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Chapter: Medical Surgical Nursing: Chronic Illness

Phases of Chronic Illness

Over the years, chronic conditions can pass through several dif-ferent phases.


Over the years, chronic conditions can pass through several dif-ferent phases (Corbin & Cherry, 1997; Strauss & Corbin, 1988). Nine phases have been identified (Chart 10-1):

1.        The pretrajectory phase describes the stage at which the person is at risk for developing a chronic condition because of genetic factors or lifestyle behaviors that increase sus-ceptibility to chronic illness.


2.        The trajectory phase is characterized by the onset of symptoms or disability associated with a chronic condition. Since symptoms are being evaluated and diagnostic tests are performed, this phase is often accompanied by uncer-tainty as the person awaits a diagnosis. Nursing care often involves preparing patients for diagnostic tests and offering emotional support


3.        The stable phase of the trajectory indicates that symptoms and disability are being managed adequately. Although the patient is doing well, nursing care is still important at this time to reinforce positive behaviors and to offer ongoing monitoring.


4.        The unstable phase is characterized by an exacerbation of illness symptoms, development of complications, or reac-tivation of an illness in remission. During this phase, a per-son’s everyday activities may be temporarily disrupted because symptoms are not well controlled. There may also be more diagnostic tests and a trial of new regimens until some degree of control over symptoms is achieved. During this time of uncertainty, patients look to nurses for guid-ance and support.


5.       The acute phase is characterized by sudden onset of severe or unrelieved symptoms or complications that require hos-pitalization for their management. This phase may require major modification of the person’s usual activities for a pe-riod of time. Nurses are intensely involved in the care of the chronically ill patient during this period, providing di-rect care and emotional support to the patient and family members.


6.        The crisis phase is characterized by a critical or life-threat-ening situation that requires emergency treatment or care. During this phase patients and their families depend upon the skill, knowledge, and support of nurses and other pro-fessionals to stabilize their conditions.


7.        The comeback phase is the period in the trajectory marked by recovery after an acute period. It includes learn-ing to live with or to overcome disabilities and a return to an acceptable way of life within the limitations imposed by the chronic condition. Although aspects of care may shift to other health care providers during the rehabilitative phase, the role of nurses as organizers of care and collaborators in the recovery of patients is essential.

8.        The downward phase marks the worsening of a condition. Symptoms and disability continue to progress despite attempts to gain some control through treatment and management regimens. A downward turn does not necessarily mean imminent death; the downward trend can be arrested and an illness restabilized. Since patients are not yet acute or dying but usually are living at home during this time, their contact with nurses is often limited. The supportive presence of nurses is needed, however, because of adjustment issues. Nurses working in clinics and physicians’ offices can play an important role in helping patients understand and come to terms with what is happening to them.

9.        The dying phase is characterized by the gradual or rapid decline in the trajectory despite efforts to halt the disorder or slow the decline through illness management; it is characterized by failure of life-maintaining body functions. During this phase nurses provide direct and supportive care to patients and their families through hospice programs


Nursing Management

Nursing care of patients with chronic conditions is varied and oc-curs in an assortment of settings. It can include provision of di-rect care or supportive care. Such care is often provided in the clinic or physician’s office, the hospital, or the patient’s home, de-pending on the status of the illness.


Examples of direct care may include assessing the patient’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 patients can remain at home and return to a somewhat normal life after an acute episode of illness.


Because much of the day-to-day responsibility for managing chronic conditions rests with the patient and family, nurses often provide supportive care unless the patient is hospitalized. Sup-portive care may include ongoing monitoring, teaching, counsel-ing, serving as an advocate for the patient, 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 im-pending complications, such as signs of heart failure. The nurse might detect these signs before they are noticeable to the patient and could make a referral (call the physician or consult the med-ical protocol in a clinic) for medical evaluation, thereby prevent-ing a lengthy and costly hospitalization.


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