CH 6 Health and Wellness
Actively engaged in strategies to change behavior; lasts up to 6 months Nursing Implications Previous habits may prevent taking action relating to new behaviors; identify barriers and facilitators of change.
Action
A chronic illness persists, usually longer than 6 months, is irreversible, and affects functioning in one or more systems. Patients often fluctuate between maximal functioning and serious health relapses that may be life threatening. A person with a chronic illness is similar to a person with a disability in that both have varying degrees of functional limitations that result from either a pathological process or an injury (Larsen, 2013a). In addition, the social surroundings and physical environment in which an individual lives frequently affect the abilities, motivation, and psychological maintenance of the person.
Acute and Chronic Illness
Acute and chronic illnesses are two general classifications of illness used in this chapter and throughout this text. Both acute and chronic illnesses have the potential to be life threatening. An acute illness is usually reversible, has a short duration, and is often severe. The symptoms appear abruptly, are intense, and often subside after a relatively short period. An acute illness may affect functioning in any dimension.
Acute and Chronic Illness
Chronic illnesses and disabilities remain a leading health problem in North America for older adults and children. Issues of coping and living with a chronic illness can be complex and overwhelming. The Centers for Disease Control and Prevention report that in 2012 about half of the adults in the United States had at least one chronic disease or health problem (CDC, 2015). Many chronic illnesses are related to four modifiable health behaviors: physical inactivity, poor nutrition, use of tobacco, and excessive alcohol consumption (CDC, 2015). A major role for nursing is to provide patient education aimed at helping patients manage their illness or disability. The goal of managing a chronic illness is to reduce the occurrence or improve the tolerance of symptoms. By enhancing wellness, nurses improve the quality of life for patients living with chronic illnesses or disabilities.
Acute and Chronic Illness
Patients with chronic diseases and their families continually adjust and adapt to their illnesses. How an individual perceives an illness influences the type of coping responses. In response to a chronic illness, an individual develops an illness career. The illness career is flexible and changes in response to changes in health, interactions with health professionals, psychological changes related to grief, and stress related to the illness (Larsen, 2013b).
Acute and Chronic Illness
Age affects a person's susceptibility to certain illnesses and conditions. For example, premature infants and neonates are more susceptible to infections. As a person ages, the risk of heart disease and many types of cancers increases. Age risk factors are often closely associated with other risk factors such as family history and personal habits. Nurses need to educate their patients about the importance of regularly scheduled checkups for their age-group. Various professional organizations and federal agencies develop and update recommendations for health screenings, immunizations, and counseling.
Age
People react differently to illness or the threat of illness. Individual behavioral and emotional reactions depend on the nature of an illness, a patient's attitude toward it, the reaction of others to it, and the variables of illness behavior.
Behavioral and Emotional Changes
Severe illness, particularly one that is life threatening, leads to more extensive emotional and behavioral changes such as anxiety, shock, denial, anger, and withdrawal. These are common responses to the stress of illness. You can develop interventions to help a patient and family cope with and adapt to this stress when the stressor itself usually cannot be changed.
Behavioral and Emotional Changes
Short-term, non-life-threatening illnesses evoke few behavioral changes in the functioning of a patient or family. For example, a father who has a cold lacks the energy and patience to spend time in family activities. He becomes irritable and prefers not to interact with his family. This is a behavioral change, but the change is subtle and does not last long. Some may even consider such a change a normal response to illness.
Behavioral and Emotional Changes
An increasing number of health care institutions and organizations are offering educational programs for the nursing staff that are designed to help decrease compassion fatigue and increase resiliency (Flarity et al., 2013; Jenkins and Warren, 2012). These programs educate nurses about compassion fatigue and its negative effects and provide resources and tools for nurses to use to prevent or cope with STS and BO (Potter et al., 2013b). Participating in debriefing sessions or a compassion fatigue support group allows nurses to identify stressors and work as a group to develop healthy coping strategies (Beck, 2011; Boyle, 2011). Health care organizations need to also provide resources for nurses such as a mental health professional to provide assistance in managing STS and BO (Beck, 2011). It is important that organizations provide nurses with the education and resources needed to care for themselves.
Caring for Yourself
Personal strategies focus on health-promoting behaviors and healthy lifestyle choices. In an effort to combat STS and BO, you need to eat a nutritious diet, get adequate sleep regularly, engage in regular exercise and relaxation activities, establish a good work-family balance, and engage in regular nonwork activities (Beck, 2011). Other strategies that can help you prevent or deal with STS and BO include developing coping skills, allowing personal time for grieving the loss of patients, and focusing on one's own spiritual health (Beck, 2011). Another strategy is to find a mentor or experienced nurse who understands the stress of the job and is able to help you identify coping strategies (Lombardo and Eyre, 2011).
Caring for Yourself
To be able to provide competent, quality and safe care, nurses need to take care of themselves to ensure they remain healthy. Nurses are particularly susceptible to the development of compassion fatigue, which is a combination of secondary traumatic stress (STS) and burnout (BO) (see Chapter 1). Secondary traumatic stress develops as a result of the relationships that nurses develop with their patients and families, whereas BO stems from conflicts or nurse job dissatisfaction within the work setting (Boyle, 2011; Potter et al., 2013a). Compassion fatigue frequently affects a nurse's health, often leading to a decline in health, changes in sleep and eating patterns, emotional exhaustion, irritability, restlessness, impaired ability to focus and engage with patients, feelings of hopelessness, inability to take pleasure from activities, and anxiety (Potter et al., 2013a). In the workplace the effects of compassion fatigue are often manifested by diminished performance, reduced ability to feel empathy, depersonalization of the patient, poor judgment, chronic absenteeism, high turnover rates, and conflict between nurses (Jenkins and Warren, 2012). It is important for nurses to engage in personal and professional strategies to help combat compassion fatigue and promote resiliency.
Caring for Yourself
Considering a change within the next 6 months Nursing Implications Ambivalence may be present, but patients will more likely accept information since they are developing more belief in the value of change.
Contemplation
The cultural backgrounds of patients shape their views of health, how to treat and prevent illness, and what constitutes good care (Narayan, 2010; Purnell, 2013). Two common beliefs of health exist: the individual, family, or community is able to influence its own health; or the individual has little control over his or her health because health is a gift from a higher being or power (Purnell, 2013). Health beliefs often vary within a cultural group; therefore it is important to assess the health beliefs of each patient and not stereotype a patient based on cultural background (Kersey-Matusiak, 2012). Cultural health beliefs influence individuals' responses to health and illness such as eye contact, response to pain and pain management, use of touch, perception and treatment of mental illness, and sick role behaviors (Narayan, 2010; Purnell, 2013). Other examples of cultural beliefs that affect health care practices include yin/yang balance, hot-and-cold foods, influence of humors, the importance of hexes, and spirits and soul loss (Giger, 2013). Recognizing a patient's health beliefs helps the nurse provide culturally competent nursing care that considers the physical, psychological, social, emotional, and spiritual needs of each patient. Nurses need to use culturally appropriate resources and be able to provide evidence-based cultural practices (Douglas et al., 2011).
Cultural Aspects of Care Cultural Health Beliefs
• Be aware of the effect of culture on a patient's view and understanding of illness. • Understand a patient's traditions, values, and beliefs and how these dimensions may affect health, wellness, and illness. • Do not stereotype patients based on their culture and do not assume that they will adopt all cultural beliefs and practices (Kersey-Matusiak, 2012). • When teaching patients about their illness and treatment regimens, you need to understand that unique cultural perceptions exist regarding the cause of an illness and its treatment. • Use a trained interpreter if possible when a patient and family do not speak English to avoid misinterpretation of information (Purnell, 2013). • Be aware of your own cultural background and recognize prejudices that lead to stereotyping and discrimination (Purnell, 2013).
Cultural Aspects of Care Implications for Patient-Centered Care
Cultural background influences beliefs, values, and customs. It influences the approach to the health care systems, personal health practices, and the nurse-patient relationship. Cultural background also influences an individual's beliefs about causes of illness and remedies or practices to restore health (Box 6-2). If you are not aware of your own cultural patterns of behavior and language, you will have difficulty recognizing and understanding your patient's behaviors and beliefs. You will also probably have difficulty interacting with patients. As with family and socioeconomic variables, you need to incorporate cultural variables into a patient's care plan (see Chapter 9).
Cultural Background
Defining health is difficult. The World Health Organization (WHO) defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity" (WHO, 1947). Many aspects of health need to be considered. Health is a state of being that people define in relation to their own values, personality, and lifestyle. Each person has a personal concept of health. Pender and colleagues (2015) define health as the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others while adjustments are made as needed to maintain structural integrity and harmony with the environment.
Definition of Health
Health and illness are defined according to individual perception. Health often includes conditions previously considered to be illness. For example, a person with epilepsy who has learned to control seizures with medication and who functions at home and work or a person fully recovered from a stroke with limited paralysis and living independently may no longer consider himself or herself ill. A nurse needs to consider the total person and the environment in which the person lives to individualize nursing care and enhance meaningfulness of the patient's future health status.
Definition of Health
Individuals' views of health vary among different cultural orientations (Pender et al., 2015). Pender (1996) explains that "all people free of disease are not equally healthy." Views of health have broadened to include not only physical well-being, but also mental, social, and spiritual well- being and a focus on health at the family and community levels.
Definition of Health
To help patients identify and reach health goals, nurses discover and use information about their concepts of health. Pender et al. (2015) suggest that for many people conditions of life rather than pathological states define health. Life conditions can have positive or negative effects on health long before an illness is evident (Pender et al., 2015). Life conditions include socioeconomic variables such as environment, diet, lifestyle practices or choices, and many other physiological and psychological variables.
Definition of Health
A person's thought and behavior patterns change throughout life. A nurse considers a patient's level of growth and development when using his or her health beliefs and practices as a basis for planning care (see Chapter 11). The concept of illness for a child, adolescent, or adult depends on the individual's developmental stage. Fear and anxiety are common among ill children, especially if thoughts about illness, hospitalization, or procedures are based on lack of information or lack of clarity of information. Emotional development may also influence personal beliefs about health- related matters. For example, you use different techniques for teaching about contraception to an adolescent than you use for an adult. Knowledge of the stages of growth and development helps predict a patient's response to the present illness or the threat of future illness. Adapt the planning of nursing care to developmental expectations and to the patient's abilities to participate in self-care.
Developmental Stage
The patient's degree of stress, depression, or fear can influence health beliefs and practices. The manner in which a person handles stress throughout each phase of life influences the way he or she reacts to illness. A person who generally is very calm may have little emotional response during illness, whereas another individual may be unable to cope emotionally with the threat of illness and may overreact or deny the presence of symptoms and not take therapeutic action (see Chapter 38).
Emotional Factors
Where we live and the condition of that area (its air, water, and soil) determine how we live, what we eat, the disease agents to which we are exposed, our state of health, and our ability to adapt. The physical environment in which a person works or lives can increase the likelihood that certain illnesses will occur. For example, some kinds of cancer and other diseases are more likely to develop when industrial workers are exposed to certain chemicals or when people live near toxic waste disposal sites. Nursing assessments extend from the individual to the family and the community in which they live focusing on the short term effects of exposure and the potential for long-term effects (Edelman and Mandle, 2014).
Environment
Economic variables influence the way a patient reacts to illness. Because of economic constraints, some patients delay treatment and in many cases continue to carry out daily activities. Patients' access to the health care system is closely related to economic factors. The health care system is a socioeconomic system that patients enter, interact within, and exit. For many patients entry into the system is complex or confusing, and some patients seek nonemergency medical care in an emergency department because they do not know how otherwise to obtain health services or do not have access to care. The physical proximity of patients to a health care agency often influences how soon they enter the system after deciding to seek care.
External Variables
External variables influencing a patient's illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. The visibility of the symptoms of an illness affects body image and illness behavior. A patient with a visible symptom is often more likely to seek assistance than a patient with no visible symptoms.
External Variables
External variables influencing a person's health beliefs and practices include family practices, psychosocial and socioeconomic factors, and cultural background.
External Variables
Patients' social groups either assist in recognizing the threat of illness or support the denial of potential illness. Families, friends, and co-workers all potentially influence patients' illness behavior. Patients often react positively to social support while practicing positive health behaviors. A person's cultural background teaches the person how to be healthy, how to recognize illness, and how to be ill. The effects of disease and its interpretation vary according to cultural circumstances. For example, ethnic differences influence decisions about health care and the use of diagnostic and health care services. Dietary practices and cultural beliefs contribute to illness and disease maintenance (Giger, 2013).
External Variables
The way that patients' families use health care services generally affects their health practices. Their perceptions of the seriousness of diseases and their history of preventive care behaviors (or lack of them) influence how patients think about health. For example, if a young woman's mother never had annual gynecological examinations or Papanicolaou (Pap) smears, it is unlikely that the daughter will have annual Pap smears.
Family Practices
• Promote healthy lifestyles by encouraging regular physical activity tailored to the individual's ability, accepting responsibility for one's own health, using stress-management strategies, focusing on self-care abilities, improving self-efficacy, and practicing relaxation exercises (Pascucci et al., 2012; Pender et al., 2015). • Consider an older adult's social environment and strengthen social support to promote health and provide access to resources (Touhy and Jett, 2012). • Injury prevention is a key strategy to promote and improve health (Touhy and Jett, 2012). • Promote community-based exercise programs to decrease social isolation and increase independence (Wallace et al., 2014). • Factors that have been reported to affect older adults' willingness to engage in health promotion activities may include socioeconomic factors, beliefs and attitudes of patients and providers, encouragement by a health care professional, specific motivation based on efficacy beliefs, access to resources, age, number of chronic illnesses, mental and physical health, marital status, ability for self-care, gender, education, and support system presence (Byam-Williams and Salyer, 2010; Pascucci et al., 2012). • Encourage frequent healthy meals that are well balanced and contain fruits, vegetables, and dairy (Pascucci et al., 2012).
Focus on Older Adults Health Promotion
Physiological risk factors involve the physical functioning of the body. Certain physical conditions such as being overweight place increased stress on physiological systems (e.g., the circulatory system), increasing susceptibility to illness. Heredity, or genetic predisposition to specific illness, is a major physical risk factor. For example, a person with a family history of diabetes mellitus is at risk for developing the disease later in life. Other documented genetic risk factors include family histories of cancer, heart disease, kidney disease, or mental illness.
Genetic and Physiological Factors
Rosenstoch's (1974) and Becker and Maiman's (1975) health belief model (Figure 6-1) addresses the relationship between a person's beliefs and behaviors. The health belief model helps you understand factors influencing patients' perceptions, beliefs, and behavior to plan care that will most effectively help patients maintain or restore health and prevent illness.
Health Belief Model
The first component of this model involves an individual's perception of susceptibility to an illness. For example, a patient needs to recognize the familial link for coronary artery disease. After this link is recognized, particularly when one parent and two siblings have died in their fourth decade from myocardial infarction, the patient may perceive the personal risk of heart disease.
Health Belief Model
The second component is an individual's perception of the seriousness of the illness. This perception is influenced and modified by demographic and sociopsychological variables, perceived threats of the illness, and cues to action (e.g., mass media campaigns and advice from family, friends, and medical professionals). For example, a patient may not perceive his heart disease to be serious, which may affect the way he takes care of himself.
Health Belief Model
The third component is the likelihood that a person will take preventive action. This component results from a person's perception of the benefits of and barriers to taking action. Preventive actions include lifestyle changes, increased adherence to medical therapies, or a search for medical advice or treatment. A patient's perception of susceptibility to disease and his or her perception of the seriousness of an illness help to determine the likelihood that the patient will or will not partake in healthy behaviors.
Health Belief Model
The health promotion model (HPM) proposed by Pender (1982; revised, 1996) was designed to be a "complementary counterpart to models of health protection" (Figure 6-2). It defines health as a positive, dynamic state, not merely the absence of disease (Pender et al., 2015). Health promotion is directed at increasing a patient's level of well-being. The HPM describes the multidimensional nature of people as they interact within their environment to pursue health (Pender, 1996; Pender et al., 2015).
Health Promotion Model
The model focuses on the following three areas: (1) individual characteristics and experiences; (2) behavior-specific knowledge and affect; and (3) behavioral outcomes, in which the patient commits to or changes a behavior. The HPM notes that each person has unique personal characteristics and experiences that affect subsequent actions. The set of variables for behavioral- specific knowledge and affect have important motivational significance. These variables can be modified through nursing actions. Health-promoting behavior is the desired behavioral outcome and the end point in the HPM. Health-promoting behaviors result in improved health, enhanced functional ability, and better quality of life at all stages of development (Pender et al., 2015) (Box 6- 1).
Health Promotion Model
• Use face-to-face dialogues when possible to encourage individuals regarding health promotion and lifestyle changes (Han and Yan, 2014). • Provide support to individuals as they work on lifestyle changes (Hornsten et al., 2014). • Determine if the individual has access to FCN—sponsored health promotion programs (Dandridge, 2014).• Use motivational interview techniques to determine an individual's concerns and motivation for change (Droppa and Lee, 2014).
Health Promotion Strategies Application to Nursing Practice
Nurses use a variety of psychosocial strategies to improve health promotion in individuals. Research shows that some are more effective than others. One growing strategy is faith community nursing (FCN). FCN is a specialized area of nursing in which parish nurses focus on the goals of holistic health promotion (Dandridge, 2014). A wide variety of health promotion programs are presented by the parish nurses in their faith communities. Further research is needed on the outcomes of these FCN programs (Dandridge, 2014). Face-to-face communication is another psychosocial strategy. Motivational interviewing (MI) is a face-to-face communication strategy that nurses use to assess an individual's readiness for change (Droppa and Lee, 2014). Through engaging individuals in communication, nurses who use MI are better able to understand their patients' motivation, help their patients work through resistance to change, empower the individual, and help support his or her self-efficacy (Droppa and Lee, 2014). MI techniques help move the individual through established targets in their health promotion journey. Han and Yan (2014) also found that face-to-face communication is effective in improving physical activity in individuals.
Health Promotion Strategies Evidence Summary
Currently, health care is more focused on health promotion, wellness, and illness prevention. In addition, changes in health care cost and insurance coverage have motivated people to seek ways to improve health, decrease incidence of disease and disability, and minimize the results of disease or disability.
Health Promotion, Wellness, and Illness Prevention
Examples of the health topics and objectives as defined by Healthy People 2020 include physical activity, adolescent health, tobacco use, substance abuse, sexually transmitted diseases, mental health and mental disorders, injury and violence prevention, environmental health, immunization and infectious disease, and access to health care (USDHHS, 2015). A complete list of topics and objectives is available on the Healthy People website (www.healthypeople.gov). These objectives and topics show the importance of health promotion, wellness, and illness prevention and encourage all to participate in the improvement of health.
Health Promotion, Wellness, and Illness Prevention
Health care professionals who work in the field of health promotion use proactive attempts to prevent illness or disease. Health promotion activities are passive or active. With passive strategies of health promotion, individuals gain from the activities of others without acting themselves. The fluoridation of municipal drinking water and the fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. With active strategies of health promotion, individuals adopt specific health programs. Weight-reduction and smoking-cessation programs require patients to be actively involved in measures to improve their present and future levels of wellness while decreasing the risk of disease.
Health Promotion, Wellness, and Illness Prevention
Health promotion is a process of helping people improve their health to reach an optimal state of physical, mental, and social well-being (WHO, 2009). An individual takes responsibility for health and wellness by making appropriate lifestyle choices. Lifestyle choices are important because they affect a person's quality of life and well-being. Making positive lifestyle choices and avoiding negative lifestyle choices also play a role in preventing illness. In addition to improving quality of life, preventing illness has an economic impact because it decreases health care costs.
Health Promotion, Wellness, and Illness Prevention
Individual practices such as poor eating habits and little or no exercise influence health. Physical stressors such as a poor living environment, work stress, exposure to air pollutants, and an unsafe environment also affect health. Hereditary and psychological stressors such as emotional, intellectual, social, developmental, and spiritual factors influence one's level of health. Total health programs are directed at individuals' changing their lifestyles by developing more health-oriented habits.
Health Promotion, Wellness, and Illness Prevention
Nurses emphasize health promotion activities, wellness-enhancing strategies, and illness- prevention activities as important forms of health care because they help patients maintain and improve health. The goal of a total health program is to improve a patient's level of well-being in all dimensions, not just physical health. Total health programs are based on the belief that many factors can affect a person's level of health (Box 6-3).
Health Promotion, Wellness, and Illness Prevention
Other programs are aimed at specific health care problems. For example, support groups help people with human immunodeficiency virus (HIV) infection. Exercise programs encourage participants to exercise regularly to reduce their risk of cardiac disease. Stress-reduction programs teach participants to cope with stressors and reduce their risks for multiple illnesses such as infections, gastrointestinal disease, and cardiac disease.
Health Promotion, Wellness, and Illness Prevention
Some health promotion, wellness education, and illness prevention programs are operated by health care agencies; others are operated independently. Many businesses have on-site health promotion activities for employees. Likewise, colleges and community centers offer health promotion and illness prevention programs. Some nurses actively participate in these programs, providing direct care, and others act as consultants or refer patients to them. The goal of these activities is to improve a patient's level of health through preventive health services, environmental protection, and health education.
Health Promotion, Wellness, and Illness Prevention
The concepts of health promotion, wellness, and illness prevention are closely related and in practice overlap to some extent. All are focused on the future; the difference among them involves motivations and goals. Health promotion activities such as routine exercise and good nutrition help patients maintain or enhance their present levels of health. They motivate people to act positively to reach more stable levels of health. Wellness education teaches people how to care for themselves in a healthy way and includes topics such as physical awareness, stress management, and self- responsibility. Wellness strategies help people achieve new understanding and control of their lives. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health. They motivate people to avoid a decline in health or functional levels.
Health Promotion, Wellness, and Illness Prevention
Healthy People 2000: National Health Promotion and Disease Prevention Objectives, published in 1990, identified health improvement goals and objectives to be reached by the year 2000 (U.S. Department of Health and Human Services [USDHHS, Public Health Service], 1990). Healthy People 2010, published in 2000, served as a road map for improving the health of all people in the United States for the first decade of the twenty-first century (USDHHS, 2000). This edition emphasized the link between individual and community health and the premise that the health of communities determines the overall health status of the nation. Healthy People 2020 was approved in December 2010. Healthy People 2020 promotes a society in which all people live long, healthy lives. There are four overarching goals: (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote quality of life, healthy development, and healthy behaviors across all life stages (USDHHS, n.d.).
Healthy People Documents
Healthy People provides evidence-based, 10-year national objectives for promoting health and preventing disease. In 1979 an influential document, Healthy People: the Surgeon General's Report on Health Promotion and Disease Prevention, was published; it introduced a goal for improving the health of Americans by 1990. The report outlined priority objectives for preventive services, health protection, and health promotion that addressed improvements in health status, risk reduction, public and professional awareness of prevention, health services and protective measures, surveillance, and evaluation. The report served as a framework for the 1990s as the United States increased the focus on health promotion and disease prevention instead of illness care. The strategy required is a cooperative effort by government, voluntary and professional organizations, businesses, and individuals. Widely cited by popular media, in professional journals, and at health conferences, it has inspired health promotion programs throughout the country.
Healthy People Documents
Health care has begun to take a more holistic view of health by considering emotional and spiritual well-being and other dimensions of an individual to be important aspects of physical wellness. The holistic health model of nursing attempts to create conditions that promote a patient's optimal level of health. In this model nurses using the nursing process consider patients to be the ultimate experts concerning their own health and respect patients' subjective experience as relevant in maintaining health or assisting in healing. In the holistic health model patients are involved in their healing process, thereby assuming some responsibility for health maintenance (Edelman and Mandle, 2014).
Holistic Health Models
Nurses use holistic therapies either alone or in conjunction with conventional medicine. For example, they use reminiscence in the geriatric population to help relieve anxiety for a patient dealing with memory loss or for a cancer patient dealing with the difficult side effects of chemotherapy. Music therapy in the operating room creates a soothing environment. Relaxation therapy is frequently useful to distract a patient during a painful procedure such as a dressing change. Breathing exercises are commonly taught to help patients deal with the pain associated with labor and delivery.
Holistic Health Models
Nurses using the holistic nursing model recognize the natural healing abilities of the body and incorporate complementary and alternative interventions such as meditation, music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery because they are effective, economical, noninvasive, nonpharmacological complements to traditional medical care (see Chapter 33). These holistic strategies, which can be used in all stages of health and illness, are integral in the expanding role of nursing.
Holistic Health Models
Illness is a state in which a person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired. Cancer is a disease process, but one patient with leukemia who is responding to treatment may continue to function as usual, whereas another patient with breast cancer who is preparing for surgery may be affected in dimensions other than the physical. Therefore illness is not synonymous with disease. Although nurses need to be familiar with different types of diseases and their treatments, they often are concerned more with illness, which may include disease but also includes the effects on functioning and well-being in all dimensions.
Illness
People who are ill generally act in a way that medical sociologists call illness behavior. It involves how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the resources in the health care system (Mechanic, 1995). Personal history, social situations, social norms, and past experiences affect illness behaviors (Larsen, 2013b). How people react to illness varies widely; illness behavior displayed in sickness is often used to manage life adversities (Mechanic, 1995). In other words, if people perceive themselves to be ill, illness behaviors become coping mechanisms. For example, illness behavior results in a patient being released from roles, social expectations, or responsibilities. A homemaker views the "flu" as either an added stressor or a temporary release from child care and household responsibilities.
Illness Behavior
Illness is never an isolated life event. The patient and family deal with changes resulting from illness and treatment. Each patient responds uniquely to illness, requiring you to individualize nursing interventions. The patient and family commonly experience behavioral and emotional changes and changes in roles, body image and self-concept, and family dynamics.
Impact of Illness on the Patient and Family
Body image is the subjective concept of physical appearance (see Chapter 34). Some illnesses result in changes in physical appearance. Patients' and families' reactions differ and usually depend on the type of changes (e.g., loss of a limb or an organ), their adaptive capacity, the rate at which changes take place, and the support services available.
Impact on Body Image
When a change in body image such as that which results from a leg amputation occurs, the patient generally adjusts in the following phases: shock, withdrawal, acknowledgment, acceptance, and rehabilitation. Initially the patient is in shock because of the change or impending change. He or she depersonalizes the change and talks about it as though it were happening to someone else. As the patient and family recognize the reality of the change, they become anxious and often withdraw, refusing to discuss it. Withdrawal is an adaptive coping mechanism that helps the patient adjust. As a patient and family acknowledge the change, they move through a period of grieving (see Chapter 37). At the end of the acknowledgment phase, they accept the loss. During rehabilitation the patient is ready to learn how to adapt to the change in body image through use of prosthesis or changing lifestyles and goals.
Impact on Body Image
As a result of the effects of illness on the patient and family, family dynamics often change. Family dynamics are the processes by which the family functions, makes decisions, gives support to individual members, and copes with everyday changes and challenges. When a parent in a family becomes ill, family activities and decision making often come to a halt as the other family members wait for the illness to pass, or the family members delay action because they are reluctant to assume the ill person's roles or responsibilities. This often creates tension or anxiety in the family. Role reversal is also common. If a parent of an adult becomes ill and is unable to carry out usual activities, the adult child often becomes the family caregiver and assumes many of the parent responsibilities. Such reversal leads to conflict responsibilities for the adult child and often direct conflict over decision making. The nurse views the whole family as a patient under stress, planning care to help the family regain the maximal level of functioning and well-being (see Chapter 10).
Impact on Family Dynamics
People have many roles in life such as wage earner, decision maker, professional, child, sibling, or parent. When an illness occurs, parents and children try to adapt to the major changes that result. Role reversal is common (see Chapter 10). If a parent of an adult becomes ill and cannot carry out usual activities, the adult child often assumes many of the parent's responsibilities and in essence becomes a parent to the parent. Such a reversal of the usual situation sometimes leads to stress, conflicting responsibilities for the adult child, or direct conflict over decision making.
Impact on Family Roles
Such a change may be subtle and short term or drastic and long term. An individual and family generally adjust more easily to subtle, short-term changes. In most cases they know that the role change is temporary and will not require a prolonged adjustment. However, long-term changes require an adjustment process similar to the grief process (see Chapter 37). The patient and family often require specific counseling and guidance to help them cope with role changes.
Impact on Family Roles
Self-concept is a mental self-image of strengths and weaknesses in all aspects of personality. Self- concept depends in part on body image and roles but also includes other aspects of psychology and spirituality (see Chapters 34 and 36). The effect of illness on the self-concepts of patients and family members is usually more complex and less readily observed than role changes.
Impact on Self-Concept
Self-concept is important in relationships with other family members. For example, a patient whose self-concept changes because of illness may no longer meet family expectations, leading to tension or conflict. As a result, family members change their interactions with the patient. In the course of providing care, you observe changes in the patient's self-concept (or in the self-concepts of family members) and develop a care plan to help them adjust to the changes resulting from the illness.
Impact on Self-Concept
A person's beliefs about health are shaped in part by the person's knowledge, lack of knowledge, or incorrect information about body functions and illnesses, educational background, traditions, and past experiences. These variables influence how a patient thinks about health. In addition, cognitive abilities shape the way a person thinks, including the ability to understand factors involved in illness and apply knowledge of health and illness to personal health practices. Cognitive abilities also relate to a person's developmental stage. A nurse considers intellectual background so these variables can be incorporated into communication and instructional approaches (Edelman and Mandle, 2014).
Intellectual Background
Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors.
Internal Variables
Internal variables such as patient perceptions of symptoms and the nature of the illness influence patient behavior. If patients believe that the symptoms of their illnesses disrupt their normal routine, they are more likely to seek health care assistance than if they do not perceive the symptoms to be disruptive. Patients are also more likely to seek assistance if they believe the symptoms are serious or life threatening. Persons awakened by crushing chest pains in the middle of the night generally view this symptom as potentially serious and life threatening, and they will probably be motivated to seek assistance. However, such a perception can also have the opposite effect. Individuals may fear serious illness, react by denying it, and not seek medical assistance.
Internal Variables
The nature of the illness, either acute or chronic, also affects a patient's illness behavior. Patients with acute illnesses are likely to seek health care and comply readily with therapy. On the other hand, a patient with a chronic illness in which symptoms are not cured but only partially relieved may not be motivated to adhere to the therapy plan. Some patients who are chronically ill become less actively involved in their care, experience greater frustration, and adhere less readily to care. Because nurses generally spend more time than other health care professionals with chronically ill patients, they are in the unique position of being able to help these patients overcome problems related to illness behavior. A patient's coping skills and his or her locus of control (the degree to which people believe they control what happens to them) are other internal variables that affect the way the patient behaves when ill (see Chapter 38).
Internal Variables
• Health and wellness are not merely the absence of disease and illness. • A person's state of health, wellness, or illness depends on individual values, personality, and lifestyle. • Multiple models of health in which persons are active participants explain relationships among health beliefs, health behaviors, health promotion, and individual well-being. • Health beliefs, practices, and illness behaviors are influenced by internal and external variables, and you need to consider them when planning care.
Key Points
• Health promotion activities help maintain or enhance health, whereas wellness education teaches patients how to care for themselves. • Illness prevention activities protect against health threats and thus maintain an optimal level of health. • Nursing incorporates health promotion activities, wellness education, and illness prevention activities rather than simply treating illness.
Key Points
• The three levels of preventive care are primary, secondary, and tertiary. • Risk factors threaten health, influence health practices, and are important considerations in illness prevention activities. • Improvement in health usually involves a change in health behaviors. • The transtheoretical model of change describes a series of changes through which patients progress for successful behavior change rather than simply assuming that all patients are in an action stage. • Illness has many effects on a patient and family, including changes in behavior and emotions, family roles and dynamics, body image, and self-concept. • Using personal and professional strategies that focus on caring for self can help to decrease or prevent compassion fatigue.
Key Points
Nursing care oriented to health promotion, wellness, and illness prevention is described in terms of health activities on primary, secondary, and tertiary levels (Table 6-1).
Levels of Preventive Care
Many activities, habits, and practices involve risk factors. Lifestyle practices and behaviors have positive or negative effects on health. Those with potential negative effects are risk factors. Some habits are risk factors for specific diseases. For example, excessive sunbathing increases the risk of skin cancer; smoking increases the risk of lung diseases, including cancer; and a poor diet and being overweight increase the risk of cardiovascular disease. Because patients often take risks, there is an increased emphasis for nurses to provide preventive care. Lifestyle choices lead to health problems that cause a huge impact on the economics of the health care system. Therefore it is important to understand the effect of lifestyle behaviors on health status. Nurses educate their patients and the public on wellness-promoting lifestyle behaviors.
Lifestyle
Stress is a lifestyle risk factor if it is severe or prolonged or if the person is unable to cope with life events adequately. Stress threatens both mental health (emotional stress) and physical well-being (physiological stress). Both play a part in the development of an illness and affect a person's ability to adapt to potential changes associated with the illness and survive a life-threatening illness. Stress also interferes with patients adopting health promotion activities and the ability to implement needed lifestyle modifications. Some emotional stressors result from life events such as divorce, pregnancy, death of a spouse or family member, and financial instabilities. For example, job-related stressors overtax a person's cognitive skills and decision-making ability, leading to "mental overload" or "burnout" (see Chapters 1 and 38). Stress also threatens physical well-being and is associated with illnesses such as heart disease, cancer, and gastrointestinal disorders (Pender et al., 2015). Always review life stressors as part of a patient's comprehensive risk factor analysis.
Lifestyle
The goal of risk factor identification is to help patients visualize the areas in their life that they can modify, control, or even eliminate to promote wellness and prevent illness. You can use a variety of available health risk appraisal forms to estimate a person's specific health threats based on the presence of various risk factors (Edelman and Mandle, 2014). Link the health risk appraisal tool with educational programs and other community resources if a patient needs to make lifestyle changes and reduce health risks (Pender et al., 2015).
Lifestyle
Sustained change over time; begins 6 months after action has started and continues indefinitely Nursing Implications Changes need to be integrated into the patient's lifestyle.
Maintenance stage
Basic human needs are elements that are necessary for human survival and health (e.g., food, water, safety, and love). Although each person has unique needs, all people share the basic human needs, and the extent to which people meet their basic needs is a major factor in determining their level of health.
Maslow's Hierarchy of Needs
For example, in a house fire, fear of injury and death takes priority over self-esteem issues. Although it would seem that a patient who has just had surgery might have the strongest need for pain control in the psychosocial area, if the patient just had a mastectomy, her main need may be in the areas of love, belonging, and self-esteem. It is important not to assume the patient's needs just because other patients reacted in a certain way. Maslow's hierarchy can be very useful when applied to each patient individually. To provide the most effective care, you need to understand the relationships of different needs and the factors that determine the priorities for each patient.
Maslow's Hierarchy of Needs
Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs (Figure 6-3). According to this model, certain human needs are more basic than others (i.e., some needs must be met before other needs [e.g., fulfilling the physiological needs before the needs of love and belonging]). Self-actualization is the highest expression of one's individual potential and allows for continual self-discovery. Maslow's model takes into account individual experiences, which are always unique to that individual (Touhy and Jett, 2012).
Maslow's Hierarchy of Needs
The hierarchy of needs model provides a basis for nurses to care for patients of all ages in all health settings. However, when applying the model, the focus of care is on a patient's needs rather than on strict adherence to the hierarchy. It is unrealistic to always expect a patient's basic needs to occur in the fixed hierarchical order. In all cases an emergent physiological need takes precedence over a higher-level need. In other situations a psychological or physical safety need takes priority.
Maslow's Hierarchy of Needs
A model is a theoretical way of understanding a concept or idea. Models represent different ways of approaching complex issues. Because health and illness are complex concepts, models explain the relationships between these concepts and a patient's attitudes toward health and health behaviors.
Models of Health and Illness
Health beliefs are a person's ideas, convictions, and attitudes about health and illness. They may be based on factual information or misinformation, common sense or myths, or reality or false expectations. Because health beliefs usually influence health behavior, they can positively or negatively affect a patient's level of health. Positive health behaviors are activities related to maintaining, attaining, or regaining good health and preventing illness. Common positive health behaviors include immunizations, proper sleep patterns, adequate exercise, stress management, and nutrition. Negative health behaviors include practices actually or potentially harmful to health such as smoking, drug or alcohol abuse, poor diet, and refusal to take necessary medications.
Models of Health and Illness
Nurses developed the following health models to understand patients' attitudes and values about health and illness and to provide effective health care. These nursing models allow you to understand and predict patients' health behavior, including how they use health services and adhere to recommended therapy. Positive health models focus on the individual's strengths, resiliencies, resources, potential, and capabilities rather than on disease or pathology (Pender et al., 2015).
Models of Health and Illness
__________________ _______ ___________offer a perspective to understand the relationships among the concepts of health, wellness, and illness. Nurses are in a unique position to help patients achieve and maintain optimal levels of health. They need to understand the challenges of today's health care system and embrace the opportunities to promote health and wellness and prevent illness. In an era of rising costs and advanced technology, nurses are a vital link to the improved health of individuals and society. Through assessment and knowledge of patients, nurses identify actual and potential risk factors that predispose an individual or a group to illness. In addition, a nurse uses risk factor modification strategies to promote health and wellness and prevent illness.
Models of health
Different attitudes cause people to react in different ways to illness or the illness of a family member; this reaction is illness behavior. _________________ who understand how patients react to illness can minimize its effects and help them and their families maintain or return to the highest level of functioning.
Nurses
Health education Good standard of nutrition adjusted to developmental phases of life Attention to personality development Provision of adequate housing and recreation and agreeable working conditions Marriage counseling and sex education Genetic screening Periodic selective examinations
PRIMARY PREVENTION Health Promotion
Use of specific immunizations Attention to personal hygiene Use of environmental sanitation Protection against occupational hazards Protection from accidents Use of specific nutrients Protection from carcinogens Avoidance of allergens
PRIMARY PREVENTION Specific Protection
• Ask the patient to repeat back the teaching on reducing risks and lifestyle changes (Ward-Smith, 2012). • Have the patient maintain an exercise and eating calendar to track adherence and provide positive reinforcement. • Ask the patient to discuss success with lifestyle changes such as minutes spent in activity or actual number of fruits and vegetables eaten.
Patient Teaching Evaluation
• Patient will reduce health risks related to poor lifestyle habits (e.g., high-fat diet, sedentary lifestyle) through behavior change.
Patient Teaching Lifestyle Changes
• Practice active listening and ask the patient how he or she prefers to learn. • Begin with determining information that the patient knows regarding health risks related to poor lifestyle. • Ask which barriers the patient perceives with the planned lifestyle change. • Help the patient establish goals for change. • In collaboration with the patient, establish time lines for modification of eating and exercise lifestyle habits. • Reinforce the process of change. • Use written resources at an appropriate reading level (Ward-Smith, 2012). • Ensure education materials are culturally appropriate (Douglas et al., 2011). • Include family members to support the lifestyle change. Evaluation • Ask the patient to repeat back the teaching on reducing risks and lifestyle changes (Ward-Smith, 2012). • Have the patient maintain an exercise and eating calendar to track adherence and provide positive reinforcement. • Ask the patient to discuss success with lifestyle changes such as minutes spent in activity or actual number of fruits and vegetables eaten.
Patient Teaching Teaching Strategies
The way people perceive their physical functioning affects health beliefs and practices. When you assess a patient's level of health, gather subjective data about the way the patient perceives physical functioning such as level of fatigue, shortness of breath, or pain. Then obtain objective data about actual functioning such as blood pressure, height measurements, and lung sound assessment. This information allows you to more successfully plan and implement individualized approaches, such as self-care and mobility.
Perception of Functioning
Not intending to make changes within the next 6 months Nursing Implications Patient is not interested in information about the behavior and may be defensive when confronted with it.
Precontemplation
Making small changes in preparation for a change in the next month Nursing Implications Patient believes that advantages outweigh disadvantages of behavior change; needs assistance in planning for the change.
Preparation
Primary prevention is true prevention; it precedes disease or dysfunction and is applied to patients considered physically and emotionally healthy. Primary prevention aimed at health promotion includes health education programs, immunizations, nutritional programs, and physical fitness activities. It includes all health promotion efforts and wellness education activities that focus on maintaining or improving the general health of individuals, families, and communities (Edelman and Mandle, 2014). Primary prevention includes specific protection such as immunization for influenza and hearing protection in occupational settings.
Primary Prevention
Socioeconomic and psychosocial factors increase the risk for illness and influence the way that a person defines and reacts to illness. Psychosocial variables include the stability of the person's marital or intimate relationship, lifestyle habits, and occupational environment. A person generally seeks approval and support from social networks (neighbors, peers, and co-workers), and this desire for approval and support affects health beliefs and practices. Socioeconomic variables partly determine how the health care system provides medical care. The organization of the health care system determines how patients obtain care, the treatment method, cost to patients, and potential reimbursement to the health care agency or patients. Economic variables often affect a patient's level of health by increasing the risk for disease and influencing how or at what point the patient enters the health care system. A person's compliance with a treatment designed to maintain or improve health is also affected by economic status. A person who has high utility bills, cares for a large family, and has a low income tends to give a higher priority to food and shelter than to costly drugs or treatment or expensive foods for special diets. Some patients decide to take medications every other day rather than every day as prescribed to save money, which greatly affects the effectiveness of the medications.
Psychosocial and Socioeconomic Factors
A risk factor is any situation, habit, or other variable such as social, environmental, physiological, psychological, developmental, intellectual, or spiritual that increases the vulnerability of an individual or group to an illness or accident. An example would be risk factors for falls, such as impaired gait, reduced vision, and lower extremity weakness. Risk factors and behaviors, risk factor modification, and behavior modification are integral components of health promotion, wellness, and illness prevention. Nurses in all areas of practice have opportunities to reduce patients' risk factors to promote health and decrease risks of illness or injury.
Risk Factors
The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. Nurses and other health care professionals are concerned with risk factors, sometimes called health hazards, for several reasons. Risk factors play a major role in how a nurse identifies a patient's health status. They also often influence health beliefs and practices if a person is aware of their presence. Risk factors are often placed in the following interrelated categories: genetic and physiological factors, age, physical environment, and lifestyle.
Risk Factors
Identifying risk factors is the first step in health promotion, wellness education, and illness prevention. Discuss health hazards with a patient following a comprehensive nursing assessment, then help the patient decide if he or she wants to maintain or improve his or her health status by taking risk-reduction actions (Edelman and Mandle, 2014). Risk-factor modification, health promotion, illness prevention activities, or any program that attempts to change unhealthy lifestyle behaviors is a wellness strategy. Emphasize wellness strategies that teach patients to care for themselves in a healthier way because they have the ability to increase their quality of life and decrease the potential high costs of unmanaged health problems.
Risk-Factor Modification and Changing Health Behaviors
Once an individual identifies a stage of change, the change process facilitates movement through the stages. To be most effective, you choose nursing interventions that match the stage of change (DiClemente and Prochaska, 1998). Most behavior-change programs are designed for (and have a chance of success when) people are ready to take action regarding their health behavior problems. Only a minority of people are actually in this action stage (Prochaska, 1991). Changes are maintained over time only if they are integrated into an individual's overall lifestyle (Box 6-4). Maintaining healthy lifestyles can prevent hospitalizations and potentially lower the cost of health care.
Risk-Factor Modification and Changing Health Behaviors
Some attempts to change are aimed at the cessation of a health-damaging behavior (e.g., tobacco use or alcohol misuse) or the adoption of a healthy behavior (e.g., healthy diet or exercise) (Pender et al., 2015). It is difficult to change negative health behavior, especially when the behavior is ingrained in a person's lifestyle patterns. The importance of nurses using a health promotion model to identify risky behaviors and implement the change process cannot be overemphasized because it is the nurse who spends the greatest amount of time in direct contact with patients. In addition, leading causes of death continue to relate to health behaviors that require a change, and nurses are able to motivate and facilitate important health behavior change when working with individuals, families, and communities (Edelman and Mandle, 2014).
Risk-Factor Modification and Changing Health Behaviors
Understanding the process of changing behaviors will help you support difficult health behavior changes in patients. It is believed that change involves movement through a series of stages. DiClemente and Prochaska (1998) describe the stages of change in the transtheoretical model of change (Table 6-2). These stages range from no intention to change (precontemplation), considering a change within the next 6 months (contemplation), making small changes (preparation), and actively engaging in strategies to change behavior (action) to maintaining a changed behavior (maintenance stage). As individuals attempt a change in behavior, relapse followed by recycling through the stages frequently occurs. When relapse occurs, a person will return to the contemplation or precontemplation stage before attempting the change again. Relapse is a learning process, and people can apply the lessons learned from relapse to their next attempt to change. It is important to understand what happens at the various stages of the change process to time the implementation of interventions (wellness strategies) adequately and provide appropriate assistance at each stage.
Risk-Factor Modification and Changing Health Behaviors
Adequate treatment to arrest disease process and prevent further complications and sequelae Provision of facilities to limit disability and prevent death
SECONDARY PREVENTION Disability Limitations
Case-finding measures: individual and mass screening activities Selective examinations to cure and prevent disease process, prevent spread of communicable disease, prevent complications and sequelae, and shorten period of disability
SECONDARY PREVENTION Early Diagnosis and Prompt Treatment
Secondary prevention focuses on individuals who are experiencing health problems or illnesses and are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention, thereby reducing severity and enabling the patient to return to a normal level of health as early as possible (Edelman and Mandle, 2014). A large portion of nursing care related to secondary prevention is delivered in homes, hospitals, or skilled nursing facilities. It includes screening techniques and treating early stages of disease to limit disability by averting or delaying the consequences of advanced disease. Screening activities also become a key opportunity for health teaching as a primary prevention intervention (Edelman and Mandle, 2014).
Secondary Prevention
Spirituality is reflected in how a person lives his or her life, including the values and beliefs exercised, the relationships established with family and friends, and the ability to find hope and meaning in life. Spirituality serves as an integrating theme in people's lives (see Chapter 36). Religious practices are one way that people exercise spirituality. Some religions restrict the use of certain forms of medical treatment. For example, persons of the Jehovah Witness faith do not receive blood transfusions. You need to understand patients' spiritual dimensions to involve patients effectively in nursing care.
Spiritual Factors
Provision of hospital and community facilities for retraining and education to maximize use of remaining capacities Education of public and industry to use rehabilitated persons to fullest possible extent Selective placementWork therapy in hospitals Use of sheltered colony
TERTIARY PREVENTION Restoration and Rehabilitation
Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration (Edelman and Mandle, 2014). Activities are directed at rehabilitation rather than diagnosis and treatment. For example, a patient with a spinal cord injury undergoes rehabilitation to learn how to use a wheelchair and perform ADLs independently. Care at this level helps patients achieve as high a level of functioning as possible, despite the limitations caused by illness or impairment.
Tertiary Prevention
Many variables influence a patient's health beliefs and practices. Internal and external variables influence how a person thinks and acts. As previously stated, health beliefs usually influence health behavior or health practices and likewise positively or negatively affect a patient's level of health. Therefore understanding the effects of these variables allows you to plan and deliver individualized care.
Variables Influencing Health and Health Beliefs and Practices
Internal and external variables influence both health and health behavior and illness and illness behavior. The influences of these variables and a patient's illness behavior often affect the likelihood of seeking health care, adherence to therapy, and health outcomes. Plan individualized care based on an understanding of these variables and behaviors to help patients cope with their illness at various stages. The goal is to promote optimal functioning in all dimensions throughout an illness.
Variables Influencing Illness and Illness Behavior
In the past most individuals and societies viewed good health, or wellness, as the opposite or absence of disease. This simple attitude ignores the states of health that exist between disease and good health. Health is a ______________________________ concept and is viewed from a broader perspective. An assessment of a patient's state of health is an important aspect of nursing.
multidimensional
