Textbook of Medical-Surgical Nursing 3e

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Chapter 10

Chronic illness, disability and rehabilitation

CLINICAL REASONING CHALLENGE A 28-year-old woman with three children younger than 4 years of age has recently been diagnosed with multiple sclerosis (MS) following vision loss secondary to optic neuritis. Her neurologist has recommended that she begin injection therapy with one of the illness-modifying agents to minimise the number and severity of MS exacerbations. She is very active in her community through the church and playgroup. She states she cannot fit learning about MS or injection therapy into her very busy life. Further, she states she doubts the diagnosis is correct, but is not inter­ ested in seeking a second opinion or in talking to anyone knowledgeable about MS. Identify approaches you would use to establish a plan of care with her. Link your teaching to the trajectory onset phase of chronic illness. How would your plan of nursing care change in the acute and crisis stages of chronic illness? Nursing management Doctors prescribe therapies, such as medications and diet, and give directions for how much, when and how they are to be used. It is important to work individually with each person and family to identify the best ways to integrate their treat­ ment regimens into their daily living activities, because each person is an individual. People with chronic illnesses often report receiving inadequate care, information, services and counselling (Chart 10-1). Some patients have five or more chronic conditions and see a range of specialists and primary care providers per year, leading to potentially fragmented services, high error rates and incidence of adverse events (ADHA, 2009a). This provides an opportunity for nurses to assume a more active role in addressing many of the issues experienced, coordinating care, and serving as an advocate for patients who need additional assistance to manage their illnesses while maintaining a quality of life that is acceptable to them. An example can be seen in the research presented in Chart 10-2. Once a chronic condition has been diagnosed, the focus shifts from illness prevention to managing symptoms and promoting wellness by avoiding complications (Boogaerts & Merritt, 2008). Assessment: Identifying the trajectory phase The first step is assessment of the person to determine the specific phase (see Table 10-2). Assessment enables the nurse to identify the specific medical, social and psychological problems likely to be encountered in a phase. For instance, the problems of a person having an acute myocardial infarction are very different from those likely to be encountered with the same person, 10 years later, dying at home of heart failure. The types of direct care, referrals, teaching and emotional support needed in each situation are different as well. Once the phase of illness has been identified, the nurse helps prioritise problems and establish the goals of care. Identification of goals must be a collaborative effort, with the patient, family and nurse working together with the multidisciplinary health­ care team, and the goals must be consistent with the abilities, desires, motivations and resources of those involved.

Nurs ing Research Prof ile : Evidence -based practice Self-medication for chronic illness in CALD groups

CHART 10-2

An example of goal setting is as follows. An older man with severe progressive COPD reports increasing difficulty breath­ ing, even with the oxygen level set at 2 L/min. This interferes with his ability to carry out activities of daily living and has decreased his quality of life. He asks the nurse for help. The nursing diagnosis for this problem might be ‘Activity intoler­ ance related to less than adequate intake of oxygen secondary to lung illness’, and the mutually agreed upon goal of care might be to increase the person’s ability to care for himself. Once goals have been established, the next step consists of establishing a realistic and mutually agreed upon plan for achieving them and identifying specific criteria that can be used to assess the person’s progress. Consider a 55-year-old woman with a dense hemiplegia following a stroke who is hospitalised with a severe bladder infection. She reports she has problems with incontinence and personal hygiene because of her disability, and that she has difficulty obtaining and con­ suming adequate fluids during the day because she believes this contributes to her incontinence. The nursing diagnosis for this problem might be ‘Toileting self-care deficit (in bladder care) related to decreased functional ability secondary to a stroke’, and the mutual expected outcomes of care might be to develop strategies to facilitate bladder retraining and self-care process and increase daily fluid intake. For many people with chronic illness, having someone to help them with intimate bodily activities is a threat to their independence and self-esteem, and perhaps the first step to a nursing home or rehabilitation centre. Therefore, they might resist someone coming into their home to help them. Even more challenging for many people with chronic illness is the need to hire and oversee carers who come into their factors were highlighted that are of interest to nurses. The pilot study demonstrated that the intervention was not feasible due to high attrition rates. However, this work emphasised the difficulties experienced by people with chronic illness, where taking medicines is a long-term feature of their management regimen. Also it showed the complexities of conducting health education and research into CALD groups, where English is not the primary language and where using interpreting services is part of the interface with health professionals. Summary A pilot study (Williams et al., 2012) using a randomised control trial (RCT) method compared a multifactorial intervention designed to improve medication self-efficacy and adherence. Seventy-eight participants (29 completed the study), who spoke Greek, Italian or Vietnamese, were recruited from nephrology outpatients’ clinics of two Australian metropolitan hospitals. The translated, multifactorial intervention consisted of a medication review, a short PowerPoint presentation and a motivational interview, with 12 months’ follow-up, post-baseline. Nursing implications Although there were no significant differences in medication self-efficacy or adherence between the intervention and control groups at 3, 6 and 12 months post-baseline, other