Textbook of Medical-Surgical Nursing 3e

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Unit 3   Applying concepts from the nursing process

health literacy to engage effectively with the health system and manage their own care (ADHA, 2009a). Despite the importance of teaching the patient and family, the nurse must recognise that patients recently diagnosed with serious chronic conditions and their families may need time to understand the significance of their condition and its effect on their lives. Teaching must be planned carefully so that it is not overwhelming. Furthermore, it is important to assess the impact of a new diagnosis of chronic illness on a patient’s life and the meaning of self-management to the patient (Kocaman et al., 2007). Interventions that enhance chronic illness self-management have demonstrated improved patient outcomes (Carrier, 2009). The nurse cannot assume that a patient with a long­ standing chronic condition has the knowledge necessary to manage the condition. Learning needs change as the trajectory phase and the patient’s personal situation change. The nurse must also recognise that patients may know how their body responds under certain conditions and how best to manage their symptoms. Contact with patients in the hospital, clinic, nursing centre, home or long-term care facility offers nurses the ideal opportunity to reassess patients’ learning needs and to provide additional teaching about an illness and its management. As previously noted, one of the major deficits of care of chronically ill people is the fragmentation of services. In order to avoid this, chronic illness management must be a collaborative process between the individual, family, nurse and other healthcare professionals. Collaboration is not limited to hospital settings; rather, it is important in all settings and throughout the illness trajectory. General practitioners have a major role in the management of chronic illness as they often act as a patient’s case manager. In some instances, this role may be allocated to a specialty nurse such as those nurses working with heart failure or COPD patients. Most chronic conditions can be managed in the home but may require the input of a range of independent services. Nurses in all settings should be aware of the resources and services available in a community and should make the arrangements (before hospital discharge if the person is hospi­ talised) necessary to secure those resources and services. When appropriate, home care services are contacted directly. Case management models adopted by community nurses are partic­ ularly beneficial in managing chronic illness where multiple services are involved to improve health outcomes (Hunter, 2012). Care for special populations with chronic illness When providing care and teaching, the nurse must consider a variety of factors (e.g. age, gender, culture and ethnicity, cognitive status, the presence of physical and sensory limita­ tions) that influence susceptibility to chronic illness and the ways people respond to chronic disorders. Certain populations, for example, tend to be more susceptible to certain chronic conditions. Chronic conditions are experienced at a higher rate in Indigenous communities in both Australia and New Zealand. In Australia, Indigenous peoples experience chronic condi­ tions at 36% more than the general population. There are higher mortality rates for diabetes (14 times the rate), kidney

illness (10 times) and heart illness (3 times) (AIHW, 2010a; Health InfoNet , 2012). The Ma¯ori population of New Zealand had higher rates for diabetes, cardiovascular illness, asthma and COPD. The level of disability for Ma¯ori was approximately four times higher compared with Europeans and for Pacific Islander peoples (NZMOH, 2012c). Populations at high risk for specific conditions can be targeted for special teaching and monitoring programs. People of different cultures and genders tend to respond to illness dif­ ferently; being aware of these differences is extremely import­ ant (Drew, 2008; McMurray, 2007). For cultures in which people rely heavily on the support of their families, families must be involved and made part of the nursing care plan. As Australia and New Zealand become more multicultural and ethnically diverse, and as the general population ages, nurses need to be aware of the relationship between culture, age and chronic illness management, and so be prepared to adapt the care they give accordingly. They also need to be aware of how they may be influenced by their own culture (Stein-Parbury, 2009). The outcomes of chronic illness in many cases are pain, dis­ ability and even death. The terms chronic conditions and dis­ ability are often used interchangeably according to the context and implications to the individual (Lubkin & Larsen, 2013). The next section discusses the issues related to disability in more detail. Disability Definition of disability According to the WHO, disability is an umbrella term for impairments, activity limitations, participation restrictions and environmental factors, and impairment is a loss or abnormality in body structure or physiological function, including mental function. A person’s functioning or disability is viewed as a dynamic interaction between health conditions (i.e. illness, disorders, injuries, trauma) and contextual factors (i.e. personal and environmental factors) (WHO, 2012). In Australia, a broad definition of disability is applied in conjunction with the WHO’s International Classification of Functioning (ICF). Disability is seen as ‘a multidimensional concept relating to impairment in bodily structure or function, limitation in activities, restriction in participation and the affected person’s environment’ (AIHW, 2006, p. 71). New Zealand, however, defines disability as ‘a long term limitation in the ability to carry out one or more activities’ (NZMOH, 2005, p. 95). Other terms used to describe people with disabilities that are not universally accepted or understood are ‘people who are phys­ ically challenged’, and ‘people with special needs’. Another approach to disability is described by Lutz and Bowers (2005), who stated that none of the existing definitions adequately addresses disability in everyday life. They defined disability as a multifaceted, complex experience that is integrated into the lives of people with disabilities. The degree of the integration is influenced by three disability-related factors: (1) the effects of the disabling condition, (2) others’ perceptions of disability, and (3) the need for and use of resources by the person with a disability. Therefore, a person is considered to have a disability— such as a restriction in performance or function in everyday activities—if he or she has difficulty talking, hearing, seeing,