Textbook of Medical-Surgical Nursing 3e

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Unit 3   Applying concepts from the nursing process

homes to assist with activities of daily living (ADLs), self-care activities, including bathing, grooming, dressing, eating, toilet­ ing, and bowel and bladder care, and instrumental activities of daily living (IADLs ), the complex aspects of independence including meal preparation, grocery shopping, household man­ agement, finances and transportation. It is difficult for many people to be in a position of hiring, supervising and some­ times firing people who may be providing them with intimate physical care. The need to balance the role of recipient of care and oversight of the person providing care may lead to a blurring of role boundaries. However, this aspect of assisted care may be overcome by using agencies to supply services. In Australia, a National Disability Scheme is being trialled and it is anticipated that this will facilitate assistive support services. Nursing interventions Providing direct care Nursing care of people with chronic conditions is varied and occurs in an assortment of settings. It can include provision of direct care or supportive care. Direct care is often provided in the clinic or doctor’s office, the hospital, or the person’s home, depending on the status of the illness. Examples of direct care may include assessing the person’s physical status, providing wound care, managing and overseeing medication regimens and performing other technical tasks. The availability of this type of nursing care is one of the main reasons people can remain at home and return to a somewhat normal life after an acute episode of illness. Nurses have also used ‘telehealth’ care (use of the telephone in healthcare) to monitor patients with chronic illnesses, deliver selected nursing interventions (e.g. counselling), and provide ongoing education and support (Coyle, Duffy & Martin, 2007). Nurses often provide supportive care unless the person is hospitalised because much of the day-to-day responsibility for managing chronic conditions rests with the person and family. Supportive care may include ongoing monitoring, medication administration, elimination manage­ ment and teaching, counselling and serving as an advocate for the person, making referrals and case managing. Providing supportive care is just as important as the performance of technical care. For example, through ongoing monitoring that might take place either in the home or a nursing clinic (such as a heart failure clinic), a nurse might detect impending complications, such as signs of heart failure. The nurse might detect these signs before they are noticeable to the person and could make a referral (call the doctor or consult the medical protocol in a clinic) for medical evaluation, thereby prevent­ ing a lengthy and costly hospitalisation. Providing supportive care and case management Working with people with chronic illness or disability requires not just dealing with the medical aspects of their disorder, but also working with the whole biopsychosocial person—physi­ cally, emotionally and socially. This holistic approach to care requires nurses to draw on their knowledge and skills, includ­ ing knowledge from the social sciences and psychology in particular, and their skills in variable means of communication (see Fig 10-5). In the case of the man with COPD, for example, the lack of sufficient resources could prevent him from hiring a home health aide. For this reason, the nurse might want to explore carefully the issue of resources with the man and, if there are

Figure 10-5  Alternative communication methods and types of patient education are essential to the provision of appropriate health-related information to people with disabilities. (© Will & Deni McIntyre/Photo Researchers, Inc.)

financial constraints, enlist the services of a social worker, with the man’s consent, to explore possible community resources. Since the man is having trouble breathing, the nurse should determine whether the man is also having difficulty cooking and eating, and whether he is losing weight because of insuffi­ cient kilojoule intake to meet his nutritional needs. If cooking is a problem, then the nurse might look into community resources such as Meals on Wheels. If the man is losing weight, then the nurse should advise him to eat frequent, small meals to lessen the fatigue associated with eating and to supplement meals with high-protein drinks. In the case of the woman with stroke, the nurse might want to explore the extent of the woman’s physical limitations, when during the day she has the most difficulty with incontinence, and whether this might be related to fatigue. If fatigue is a factor, the nurse might explore the possibility of having a home health aide to help her with some of her self-care activities. This would enable the woman to conserve her energy for social activities and personal care. The nurse would also discuss with the woman the reasons for an adequate intake of fluids. If the woman is too busy or tired to make frequent trips to the sink or refrigerator to get fluids, the nurse might help the woman develop strategies for saving time and energy. For example, the woman could attach a bottle of water to her walking frame and carry it around with her, or strategically place bottles of water or other liquids around the house to increase their accessibility. The nurse might also explore with the woman the types of caffeine-free fluids that she enjoys drinking. Nurses and other healthcare professionals need to recognise the person’s ideas about the quality of their life, even though it may be difficult to see patients make unwise choices and decisions about lifestyles and illness management. People have the right to receive care without fearing ridicule or refusal of treatment, even if their behaviours (e.g. smoking, substance abuse, overeating and failure to follow healthcare