CARE BY PHASE: APPLYING THE NURSING PROCESS
The focus of care for patients with chronic conditions is deter-mined largely by illness phase and directed by the nursing process, which includes assessment, diagnosis, planning, implementation, and evaluation.
The first step is assessment of the patient to determine the spe-cific phase (see Chart 10-1). 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 patient having an acute myocardial infarction are very different from those likely to be encountered with the same patient, 10 years later, dying at home of heart failure. The kinds of direct care, re-ferrals, teaching, and emotional support needed in each situation are different as well.
Once the phase of illness has been identified for a specific patient, along with the specific medical problems and related social and psychological issues, the next step involves establishing the goals of care. The establishment of goals should be a collaborative ef-fort with the patient, family, and nurse working together, for the attainment of a goal is unlikely if it is primarily the nurse’s and not the patient’s. The following are two examples of goals to be determined collaboratively, then written in the language of the nursing process.
An elderly man with severe progressive COPD reports in-creasing difficulty breathing, even with the oxygen level set at 2 liters/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 intolerance related to less than adequate intake of oxy-gen secondary to lung disease,” and the mutually agreed upon goal of care might be to increase the patient’s ability to care for himself. Nursing interventions related to this goal might include teaching the client how to pace his activities and helping him to obtain a home health aide to assist with the most demanding ac-tivities of daily living.
In another example, a 45-year-old woman with moderately advanced multiple sclerosis (MS) is hospitalized with a severe bladder infection. She reports that she has problems with self-catheterization because of her disability and that she has difficulty obtaining and consuming adequate fluids during the day. The nursing diagnosis for this problem might be “Toileting self-care deficit (in bladder care) related to decreased functional ability sec-ondary to MS,” and the mutual outcomes of care might be to de-velop strategies to facilitate the self-catheterization process and increase daily fluid intake.
Once goals have been established, the next step consists of estab-lishing a realistic and mutually agreed upon plan for achieving them and identifying specific criteria that can be used to assess the patient’s progress. A plan of care for the man with COPD who complains of a decreased ability to care for himself, for example, might include assisting him to prioritize his activities of daily liv-ing so he can carry out those that are most important to him be-fore he becomes too short of breath and tired. It might also include exploring how he feels about having someone assist him at home on a regular basis and, if he agrees to having help, check-ing on the availability and costs of such services. In many cases, people with chronic illness perceive someone helping them as athreat to their independence and self-esteem, the first step to a nursing home or rehabilitation center. Therefore, they are resis-tant to someone coming into their home to help them. Criteria to measure progress toward goal attainment and strategies to ac-complish the goals might include the following:
• At the end of the first nurse–patient session, the patient with COPD will be able to prioritize activities of daily liv-ing and agree to look over an information sheet and list of home care agencies provided by the nurse.
• By the second nurse–patient session, the patient will report that he is pacing his activities and is therefore better able to carry out important self-care activities. He will also report that he has read the information provided by the nurse about home care agencies.
• By the third nurse–patient session, the patient will have compiled a list of the self-care activities that are difficult for him to carry out and for which assistance would be benefi-cial. The patient will also have reviewed his finances and de-termined how much he can afford to pay for services.
• By the fourth nurse–patient session, the patient will have called a home care agency and made arrangements to have home health services for 2 hours each morning. If the pa-tient cannot make the arrangements, then the nurse would suggest that the family or someone else make them. The goal is to enable the patient to meet basic self-care needs and improve quality of life, thereby having enough time and en-ergy available for other activities. Home health services can help with this. Having the patient make the arrangements for home care promotes a sense of control. People with chronic illness-related disabilities often feel that they have lost a great deal of control over what happens to them; any activities that they can do for themselves, therefore, enhance psychological well being.
• By the fifth home visit the patient will report that all self-care needs are met either by self-pacing of activities or through the assistance of a home health aide.
A plan of care for the woman with MS might be to develop techniques for carrying out self-catheterization within the limita-tions imposed by her disability and to increase her daily fluid in-take to six to eight 8-oz glasses of fluid per day. Indicators that the desired goal has been achieved may include the following:
• By the end of the first nurse–patient session, the patient and nurse will identify with which steps in the self-catheteriza-tion procedure the patient is having the most difficulty. The patient will also be able to list three strategies for improving her intake of fluids.
• By the end of the second nurse–patient session, the patient will report that she is performing self-catheterization using the strategies suggested by the nurse for improving her tech-nique. She will also report that she has increased her fluid intake by three glasses.
• By the end of the third nurse–patient session, the patient will report that she can perform self-catheterization three out of four times without difficulty and that her fluid intake is now up to six to eight 8-oz glasses a day.
• By the end of the fourth nurse–patient session, the patient will be ready for discharge with the confidence that she is competent in performing self-catheterization and obtaining adequate fluid intake despite the physical limitations im-posed by her illness.
The next step involves identifying environmental, social, and psy-chological factors that might interfere with or facilitate achieving the goal. In the case of the patient with COPD, for example, not having sufficient resources could prevent him from hiring a home health aide. For this reason, the nurse might want to explore care-fully the issue of resources with the patient and, if there are fi-nancial constraints, enlist the services of a social worker, with the patient’s consent, to explore possible community resources. Since the patient is having trouble breathing, the nurse should deter-mine whether the patient is also having difficulty cooking and eating, and whether he is losing weight because of insufficient caloric intake to meet his nutritional needs. If cooking is a prob-lem, then the nurse might look into community resources such as Meals on Wheels. If the patient 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 patient with MS, the nurse might want to explore the extent of the patient’s physical limitations, how rapidly the MS seems to be progressing, when during the day she has the most difficulty doing the catheterization, and whether that difficulty might be related to fatigue. If fatigue is a factor, the nurse might explore whether the patient would consider having a home health aide to help her with some of her self-care activi-ties. This would enable the patient to conserve her energy for so-cial activities and personal care, such as self-catheterization. The nurse would also discuss with the patient why she is not taking in an adequate amount of fluids. If the patient is too busy or tired to make frequent trips to the sink or refrigerator to get fluids, the nurse might help the patient develop strategies for saving time and energy. For example, the patient could attach a bottle of water to her wheelchair or walker 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 patient the types of caffeine-free fluids that she enjoys drinking.
The fifth step is the intervention phase. Possible interventions in-clude providing direct care, serving as an advocate for the patient, teaching, counseling, making referrals, and case-managing (ar-ranging for resources). For example, if the patient with COPD reports after prioritizing his activities of daily living that shower-ing each morning is the most important self-care activity for him, then having a home health aide come early in the morning to help with the shower would be the best arrangement. The home health aide could also help with breakfast, make the bed, and straighten up the house. In this way, the man would use less energy doing these mundane tasks. After showering and dressing the patient might also want to plan a daily rest period, such as sitting down with a crossword puzzle or reading, that might help him over-come some of his sense of breathlessness and feel more rested.
If spasms or tremors are interfering with the ability of the woman with MS to catheterize herself, then the nurse would want to review the medications she is taking; if, for instance, she is tak-ing antispasmodics, the self-catheterizations could be timed to co-incide with the peak medication levels. In an effort to encourage an increased fluid intake, the nurse might want to help the woman build into her daily routine a set time in the morning andafternoon, allowing for flexibility, to take an herbal tea or juice break that would increase the amount of fluids ingested and also provide a rest period. While it is important for a patient with MS to maintain a sense of independence and accomplishment, it is equally important for the patient to learn to recognize his or her limits, through such signs as fatigue, and to manage them through proper planning.
Physicians prescribe therapies, such as medications and diet, and give directions for how much, when, and how they are to be used. Nurses, however, by virtue of their broad knowledge base, can best help patients develop the strategies needed to live with both the symptoms and therapies associated with chronic condi-tions. Because each patient is an individual, it is important to work individually with each patient and family to identify the best ways to integrate their treatment regimens into their daily living activities. Two tasks are important in managing chronic ill-ness: following regimens to control symptoms and keep the illness stable, and dealing with the psychosocial issues that can hinder illness management and affect quality of life.
Diagnosing and prescribing by physicians are important as-pects of chronic illness care, but they represent only half of the battle against disease. The other half includes the teaching, coun-seling, arranging, and case-managing that enable people to live with their disease and gain independence (Hughes, Hodgson, Muller et al., 2000). Saving the life of a patient with an acute myo-cardial infarction in the ICU, for example, is a positive outcome, but the patient will have a relapse if he or she is not supported in making the lifestyle changes necessary to reduce the probability of another heart attack. Helping patients and their families to understand and implement regimens and to carry out activities of daily living within the limits of their disabilities is one of the most important aspects of health care delivery—and nursing care—for patients with chronic illnesses and their families.
The final step is evaluating the effectiveness of the interventions. In chronic illness, maintaining the stability of the condition while at the same time preserving the patient’s control over his or her life and a sense of identity and accomplishment is the primary goal. Success may be defined, however, as merely making progress toward a goal when a patient finds it difficult to implement rapid and drastic changes in the way that he or she does things. Nurses cannot expect that the sedentary person with high blood pressure, for example, is going to develop a sudden passion for exercise. Nor can they expect that working people can easily rearrange their day to accommodate time-consuming regimens such as special diets or complex medication schedules. Bringing about change takes time, patience, creativity, and encouragement from the nurse. Validation by the nurse for each small increment to-ward goal accomplishment is important for enhancing self-esteem and reinforcing behaviors. If no progress is made or if progress toward goals seems too slow, it may be necessary to re-define the goals or the time frame. The patient may not be ready to progress toward the goals or may be ambivalent about the illness, its treatments, or both (Chin, Polonsky, Thomas & Nerney, 2000). Other conditions such as depression may also inter-fere with the patient’s ability to carry out regimens and make lifestyle changes.
Nurses must also realize that some people will not change. Some people, for example, are unwilling to give up smoking de-spite advanced COPD. Nor is it unusual to find people with thediagnosis of diabetes failing to adhere completely to their diabetic diets. When patients are having difficulty carrying out regimens or are reluctant to change their lifestyles, nurses should not feel that this is a failure on their part. Patients share responsibility for management of their conditions, and outcomes are as much re-lated to their ability to accommodate the illness and carry out reg-imens as they are to nursing intervention.