Textbook of Medical-Surgical Nursing 3e

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Chapter 10

Chronic illness, disability and rehabilitation

providers’ recommendations) may have contributed to their chronic disorders. Self-determination is a right that should be preserved for all patients, and clinicians should work with patients, building a rapport and negotiating meaningful goals with them. CLINICAL REASONING CHALLENGE A 51-year-old man has been recently diagnosed with renal disease. He was very active in sports and involved with his peers but has become too tired to continue. He says he is not interested in learning about his condition, refuses to learn to give erythropoietin injections to himself, and eats and drinks whatever he wants. How would you approach goal setting and establishing a plan of care with this man? What mental health issues will you consider in your teaching? Psychosocial adaptation to chronic illness may include stress, crisis, loss and grief, body image, self-concept, stigma, uncer­ tainty and unpredictability, and quality of life (Lubkin & Larsen, 2013). The most frequently reported chronic illness and disability-triggered reactions include shock, which is a short-lived reaction experienced at the onset of a traumatic and sudden injury or the onset of a life-threatening or chronic and debilitating illness; anxiety, which is a panic-like state as the nature and magnitude of the event is processed; denial, which is a defence mechanism used to ward off anxiety and other intense emotions; depression, which reflects the realisa­ tion of the permanence and magnitude of the chronic illness or disability; anger and hostility that are both self-directed and externalised; and adjustment, which is exemplified by self-acceptance as a person with a chronic illness or disability and marked by reintegration into the community. Finally, chronic illness and disability-associated coping strategies are those psychological strategies that are used to decrease, modify or diffuse the impact of stressful life events. Individuals with chronic illnesses or disabilities may choose to disengage from the recovery process (e.g. through denial or substance abuse) or actively engage in activities to meet challenges associated with the chronic illness or disability (e.g. information seeking, problem solving, planning). All professionals involved in healthcare, including nurses, should recognise the emotional and psychological needs of patients and should be able to intervene by providing effec­ tive information, compassionate communication, and general psychological support. The nurse should take time to listen to patients talk about their disabilities; be respectful of their values and beliefs; and understand that grief, anger, regret, resentment and acceptance are all part of the healing process. Chart 10-3 lists concerns unique to older adults. The patient’s pre-existing coping abilities play an important role in the adaptation process. One patient may be particularly independent and determined, whereas another may be depen­ dent and feel powerless. One goal of managing disability is to help the patient gain a positive self-image through effective coping. The nurse must recognise different coping abilities and identify when a patient is not coping well or not adjusting to the disability or chronic illness. The patient and family may Managing patients’ reactions to disability in chronic illness

benefit from participation in a support group or talking with a mental health professional to achieve this goal, and the nurse may need to refer them to someone who can help them with particular challenges. Expected nursing outcomes Helping the patient and family to integrate changes into their lifestyle is an important part of the process. Change takes time, patience and creativity and often requires encouragement from the nurse. Validation by the nurse for each small increment towards goal accomplishment is important for enhancing self-esteem and reinforcing behaviours. Success may be defined as making some progress towards a goal when a patient is unable to implement rapid and dramatic changes in his or her life. If no progress is made, or if progress towards goals seems too slow, it may be necessary to redefine the goals, the inter­ vention or the timeframe. The nurse must realise and accept that some people will not change. Patients share responsibility for management of their conditions, and outcomes are as much related to their ability to accommodate the illness and carry out regimens as they are to nursing intervention. Providing continuing and collaborative care Patient and family teaching is an important nursing role that may make the difference in the ability of the patient and family to adapt to chronic conditions. Well-informed patients with good levels of health literacy are more likely than uninformed patients to do what is necessary to manage their chronic con­ dition (White, Chen & Atchison, 2008). They are also more likely to manage symptoms, recognise the onset of complica­ tions, and seek healthcare early (Weis, 2007). Knowledge is the key to making informed choices and decisions during all phases of the chronic illness trajectory. Teaching strategies and teaching materials should be adapted to the individual patient, so that the patient and healthcare providers share understand­ ing (Meehan, 2009). For instance, teaching materials should be tailored for people with low literacy levels and be available in several languages and in various alternative formats (e.g. Braille, large print, audiotapes). It may be necessary to provide sign interpreters. This is part of the National Chronic Disease Strategy, as Health Literacy Australia reports that 59% of the Australian population does not have a sufficient level of Gerontological Considerations Concerns of adults ageing with disabilities • Loss of independence, which is a source of self-respect and dignity • Increased potential for discrimination or abuse • Increased social isolation • Added burden on spouse, who may also have impaired health • Less access to community services and healthcare • Less access to religious institutions • Increased vulnerability to declining health secondary to other disorders, reduced physiological reserve, or pre-existing impairments of mobility and balance • Fears and doubts about ability to learn or relearn self-care activities, exercises, and transfer and independent mobility techniques • Inadequate support system for successful rehabilitation CHART 10-3