CHRONIC ILLNESS

affect people of all ages—the very young, the middle-aged, and the very old. are found in all ethnic, cultural, and racial groups, although some disorders occur

more frequently in some groups than in others (Centers for Disease Control and Prevention [CDC], 2004

account for7 of the 10 leading causes of death in the United States, including the three most frequently occurring diseases that result from preventable causes (tobacco use, improper diet and physical inactivity, and alcohol use).

occurs in all socioeconomic groups, but people who have low incomes and disadvantaged backgrounds are more likely to report poor health (RWJF, 2001).

Factors such as poverty and inadequate health insurance decrease the likelihood that people with chronic illness or disability receive health care and health screening measures such as mammography, cholesterol testing, and routine checkups(United States Department of Health and Human Services[USDHHS], 2005).

How people react to and cope with chronic illness is usually similar to how they react to other events in their lives, de-pending, in part, on their understanding of the condition and their perceptions of its potential impact on their own and their family’s lives.

Adjustment to chronic illness (and disability) is affected by various factors:•Suddenness, extent, and duration of lifestyle changes necessitated by the illness•Family and individual resources for dealing with stress•Stages of individual/family life cycle•Previous experience with illness and crises•Underlying personality characteristics•Unresolved anger or grief from the past

CHRONIC CONDITION

are often defined as medical conditionsor health problems with associated symptoms or disabilities that require long-term management (3 months or longer).

illnesses or diseases that have a prolonged course, that do not resolve spontaneously, and for which complete cures are rare.

The specific condition may be a result of illness, genetic factors, or injury; it may be a consequence of conditions or unhealthy behaviors that began during childhood and young adulthood.

MANAGEMENT OF CHRONIC CONDITIONS

includes learning to live with symptoms or disabilities and coming to terms with identity changes resulting from having a chronic condition.

It also consists of carrying out the lifestyle changes and regimens designed to control symptoms and to prevent complications.

Although some people assume what might be called a “sickrole” identity, most people with chronic conditions do not consider themselves to be sick or ill and try to live as normal a life as possible. Only when complications develop or symptoms interfere with activities of daily living (ADLs) do most people with chronic health conditions think of themselves as being sick or disabled (Nijhof, 1998).

CAUSESOF THE INCREASING NUMBER OF PEOPLE WITH CHRONIC CONDITIONS INCLUDE THE FOLLOWING:

A decrease in mortality from infectious diseases, such as smallpox, diphtheria, and other serious conditions

Longer lifespans because of advances in technology and pharmacology, improved nutrition, safer working conditions, and greater access (for some people) to health care

Improved screening and diagnostic procedures, enabling early detection and treatment of diseases

Prompt and aggressive management of acute conditions, such as myocardial infarction and acquired immuno-deficiency syndrome (AIDS)–related infections

The tendency to develop chronic illnesses with advancing age Lifestyle factors, such as smoking, chronic stress, and sedentary lifestyle, that

increase the risk for chronic health problems such as respiratory disease, hypertension, cardiovascular disease, and obesity.

CHARACTERISTICS OF CHRONIC CONDITIONS

Managing chronic illness involves more than managing medical problems. Associated psychological and social problems must also be addressed

Chronic conditions usually involve many different phases over the course of a person’s lifetime. There can be acute periods, stable and unstable periods, flare-ups, and remissions. Each phase brings its own set of physical, psycho-logical, and social problems, and each requires its ownregimens and types of management.

Keeping chronic conditions under control requires persistent adherence to therapeutic regimens. Failing to adhere to a treatment plan or to do so consistently increases the risks of developing complications and accelerating the disease process

One chronic disease can lead to the development of other chronic conditions.

Chronic illness affects the entire family. The day-to-day management of illness is largely the responsibility of people with chronic disorders and their families.

The management of chronic conditions is a process of discovery. People can be taught how to manage their conditions. However, each person must discover how his or her own body reacts under varying circumstances—for example, what it is like to be hypoglycemic, what activities are likely to bring on angina, and how these or other conditions can best be prevented and managed.

•Managing chronic conditions must be a collaborative process that involves many different health care professionals working together with patients and their families to provide the full range of services that are often needed for management at home. The medical, social, and psy-chological aspects of chronic health problems are often complex, especially in severe conditions.

The management of chronic conditions is expensive

Chronic conditions raise difficult ethcal issues for patients, health care professionals, and society. Problematic questions include how to establish cost controls, how to allocate scarce resources (eg, organs for transplantation),and what constitutes quality of life and when life support should be withdrawn.

Living with chronic illness means living with uncertainty

THE CHALLENGES OF LIVING WITH CHRONIC CONDITIONS INCLUDE THE NEED TO ACCOMPLISH THE FOLLOWING:

Alleviate and manage symptoms Psychologically adjust to and physically accommodate disabilities Prevent and manage crises and complications Carry out regimens as prescribed Validate individual self-worth and family functioning Manage threats to identity Normalize personal and family life as much as possible Live with altered time, social isolation, and loneliness Establish the networks of support and resources that can enhance quality of life Return to a satisfactory way of life after an acute debilitating episode (eg, another

myocardial infarction or stroke) or reactivation of a chronic condition Die with dignity and comfort

APPLYING THE NURSING PROCESS USING THE PHASES OF THE CHRONIC ILLNESS SYSTEM

Step 1: Identifying Specific Problems and the Trajectory Phase

The first step is assessment of the patient to determine the specific problems identified by the patient, family, nurse, and other health care providers. Assessment enables the nurse to identify the specific medical, social, and psycho-logical problems likely to be encountered in a phase.

Step 2: Establishing and Prioritizing Goals

Once the phase of illness has been identified for a specific patient, along with the specific medical problems and related social and psychological problems, the nurse helps prioritize problems and establish the goals of care. Identification of goals must be a collaborative effort, with the patient, family,

Step 3: Defining the Plan of Action to Achieve Desired Outcomes

Once goals have been established, it is necessary to identify a realistic and mutually agreed-on plan for achieving them including specific criteria that will be used to assess the patient’s progress. The identification of the person responsible for each task in the action plan is also essential. In addition, identification of the environmental, social, and psychological factors that might interfere with or facilitate achieving the desired outcome is an important part of planning.

Step 4: Implementing the Plan and Interventions

This step addresses implementation of the plan. Possible nursing interventions include providing direct care, serving as an advocate for the patient, teaching, counseling, making referrals, and case-managing (eg, arranging for resources).Nurses can help patients implement the actions that allow patients to live with the symptoms and therapies associated with chronic conditions, thus helping them to gain independence. The nurse works with each patient and family to identify the best ways to integrate treatment regimens into their ADLs to accomplish two tasks: (1) adhering to regimens to control symptoms and keep the illness stable, and(2) dealing with the psychosocial issues that can hinder illness management and affect quality of life.

Step 5: Following Up and Evaluating Outcomes

The final step involves following up to determine if the problem is resolving or being managed and if the patient and family are adhering to the plan. This follow-up may uncover the existence of new problems resulting from the intervention, problems that interfere with the ability of the patient and family to carry out the plan, or previously un-expected problems. Maintaining the stability of the chronic condition while preserving the patient’s control over his or her life and the patient’s sense of identity and accomplishment is a primary goal. Based on the follow-up and evaluation, consideration of alternative strategies or revision of the initial plan may be warranted.