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NURSING: AN ART AND A SCIENCE
Presented by: Prof. ARBY P. VILLANUEVA, RN, MSN
Nursing is a caring profession. As a unique profession, it is practiced with an earnest concern from the art of care and the science of health. The profession involves a humanistic blend of scientific knowledge and holistic nursing practice.
´ The act of utilizing the environment of the patient to assist him in his recovery (Nightingale). environment. ´ .CONCEPTS OF NURSING The four major concepts in nursing theories are the person. health and nursing.
HISTORY OF NURSING .
Period of Intuitive Nursing ´ Nursing in the Near East ´ Babylonia « Egypt « Israel « ´ Nursing in the Far East India « China « ´ Nursing in Ancient Greece .
Nursing in Rome ´ Period of Apprentice Nursing ´ Dark Period of Nursing ´ Nursing in America ´ Period of Educated Nursing ´ Period of Contemporary Nursing ´ .
It was performed out of compassion for others. out of the wish to help others . Nursing was untaught and instinctive.PERIOD OF INTUITIVE NURSING ´ Instinctive nursing was practiced since prehistoric times among primitive tribes and lasted through the early Christian era.
Provided laws that covered every facet of Babylonian life including medical practice. « Contributions to Medicine and Nursing: ² Babylonia- Code of Hammurabi. . sisters or mothers.NURSING IN THE NEAR EAST « Nursing remained the duty of slaves. wives.
the Egyptians introduced the art of embalming which enhanced their knowledge of human anatomy ² Israel- Moses is recognized as the ´Father of Sanitationµ
NURSING IN THE FAR EAST
China- the people strongly believed in spirits and demons as seen in the practices such as using girl·s clothes for male babies keep evil away from them.
India- SUSHURUTU made a list of function and qualifications of nurses. For the first time in recorded history, there was a reference to the nurse·s taking care of patients. These nurses were described as combination of physical therapist and cook.
´ Hippocrates. born in Greece. was given the title ´Father of Scientific Medicineµ ´ . the insignia of the medical profession today.NURSING IN ANCIENT GREECE Nursing was the task of untrained slave ´ The Greeks introduced the caduceus.
because illness was sign of weakness.NURSING IN ROME The transition of pagan to Christian philosophy took place. There was contrast between the materialism of pagan society and the spirituality of the converted Christians. ´ The Romans attempted to maintain vigorous health. ´ .
There was contrast between the materialism of pagan society and the spirituality of the converted Christians. .´ The Romans attempted to maintain vigorous health. because illness was sign of weakness. The transition of pagan to Christian philosophy took place.
Nursing care was performed without any formal education and by people who were directed by more experienced nurses.PERIOD OF APPRENTICE NURSING Pastor Fliedner and his wife established the Kaiserwerth Institute for the Training of Deaconesses (a training school for nurses) in Germany ´ It is called the period of ´on the job trainingµ. ´ .
DARK PERIOD IN NURSING
The unity of the Christian faith was destroyed. ´ Properties of hospitals and schools were confiscated.
PERIOD OF EDUCATED NURSING
This period began on June 15, 1860 when the Florence Nightingale School of Nursing opened at St. Thomas Hospital in London (St. Thomas Hospital School of Nursing). The development of nursing during this period was strongly influenced by trends resulting from wars, from an arousal of social consciousness, from the emancipation of women and from the increased educational opportunities offered to women.
FACTS ABOUT FLORENCE NIGHTINGALE Recognized as the ´Mother of Modern Nursingµ; she was also known as the ´Lady with a Lampµ ´ Advocated for the care of those afflicted with diseases caused by lack of hygienic practices
´ . Scientific and technological developments as well as social changes mark this period.PERIOD OF CONTEMPORARY NURSING This covers the period after World War II to the present. ´ Establishment of the WHO by the United Nations to assist in fighting disease by providing health.
HSITORY OF NURSING IN THE PHILIPPINES .
EARLY BELIEFS AND PRACTICES .
´ Beliefs about causation of disease: ´ « Another person (an enemy or a witch) « Evil spirits .Diseases and their causes and treatment were shrouded with mysticism and superstitions.
´ People believed in special gods of healing.People believed that evil spirits could be driven away by persons with powers to expel demons. ´ . If they used leaves or roots. with the priest-physician (called ´word doctorsµ as intermediary. they were called herb doctors (Herbolarios).
EARLY CARE OF THE SICK ´ The early Filipinos subscribed to superstitious beliefs and practices in relation to health amd sickness. . Persons suffering from diseases without any identified cause were believed to be bewitched by the ´mangkukulam or mangagawayµ. Difficult childbirth and some diseases (called ´pamaoµ) were attributed to ´nonosµ. Herbmen were called ´Herbicherosµ. meaning one who practiced witchcraft.
if the birth became difficult. . witches were supposed to be the cause. the ´mabuting hilotµ (good midwife) was called in. To disperse their influence.´ Midwife assisted in childbirth. During the labor. gunpowder was exploded from a bamboo came close to the head of the sufferer.
it was established mainly to care for the Spanish King·s soldiers. ´ . ´ The Earliest Hospitals Established was the following: ´ Hospital Real de Manila (1577). but also admitted Spanish civilians.HEALTH CARE DURING THE SPANISH REGIME The religious orders exerted their efforts to care for the sick by building hospitals in the different parts of the Philippines. founded by Gov. Francisco de Sande.
service was in general supported by alms and contributions from charitable persons.San Lazaro Hospital (1578).Founded by Brother Juan Clemente and was administered for many years by the Hospitalliers of San Juan de Dios. ´ Hospital de Indio (1586).Established by Franciscan Order. ´ . built exclusively for patients with leprosy.
near a medicinal spring. ´ San Juan de Dios Hospital (1596). Bautista of the Franciscan order.Founded by the brotherhood of Misericordia and administered by the Hospitalliers of San Juan de Dios. rendered general health service to the public.Established in Laguna. ´ .Hospital de Aguas Santas (1590). founded by Brother J. support was derived from alms and rents.
Installed a field hospital in an estate house in Tejeros: provided nursing care to the wounded night and day. ´ .converted their house into quarters for the Filipino soldiers. ´ Rosa Sevilla de Alvero.NURSING DURING THE PHILIPPINE REVOLUTION The prominent persons involved in nursing works were: ´ Josephine Bracken.wife of Jose Rizal. during the Philippine American War that broke out in 1899.
second wife of Emilio Aguinaldo provided nursing care to Filipino soldiers during the revolution. President of the Filipino Red Cross branch in Batangas. organized the Filipino Red Cross under the inspiration of Apolinario Mabini.wife of Emilio Aguinaldo.Dona Hilaria de Aguinaldo. ´ . ´ Dona Maria Agoncillo de Aguinaldo.
´Ina ng Biac na Bato.Melchora Aquino (Tandang Sora). ´ Trinidad Tecson.µ stayed in the hospital at Biac na bato to care for the wounded soldiers. Nursed the wounded Filipino Soldiers and gave them shelter and food. ´ .
1907) Mary Johnston Hospital and School of Nursing (Manila. 1907) San Juan de Dios Hospital School of Nursing (Manila. 1907) St. 1907) Philippine General Hospital School of Nursing (Manila. 1906) St. Paul·s Hospital School of Nursing (Manila. 1913) .HOSPITALS AND SCHOOLS OF NURSING ´ ´ ´ ´ ´ ´ Iloiolo Mission Hospital School of Nursing (Iloilo City. Luke·s Hospital School of Nursing (Quezon City.
FIRST COLLEGES OF NURSING IN THE PHILIPPINES University of Santo Tomas College of Nursing (1946) ´ Manila Central University College of Nursing (1947) ´ University of the Philippines College of Nursing (1948) ´ .
First Filipino nurse to receive a Masters degree in Nursing abroad ´ Socorro Sirilan.NURSING LEADERS IN THE PHILIPPINES Anastacia Giron-Tupas. founder of the Philippine Nurses Association ´ Cesaria Tan.pioneered in Hospital Social Service in San Lazaro Hospital where she was the Chief Nurse ´ .First Filipino nurse to hold the position of Chief Nurse Superintendent.
A pioneer in nursing education.a pioneer in school health education ´ Sor Ricarda Mendoza. ´ Socorro Diaz. Florence Nightingale of ILOILO ´ .Rosa Militar.´Dean of the Philippine Nursingµ.First full-time editor of the newly named PNA magazine ´The Filipino Nurseµ ´ Loreto Tupaz.First editor of the PNA magazine called ´The Messageµ ´ Conchita Ruiz.
the association of nurses employed in Department of Health ´ Catholic Nurses Guild of the Philippines ´ .NURSING ORGANIZATIONS Philippine Nurses Association.this is the national organization of Filipino nurses ´ National League of Nurses.
NURSING LEADERS AND THEORIES .
. Client·s environment is manipulated to include appropriate noise. nutrition. comfort.FLORENCE NIGHTINGALE (MID-1800) ´ Developed and described the first theory of nursing. socialization and hope. hygiene. She believed that in the nurturing environment. light. the body could repair itself. She focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act.
. sick or well.VIRGINIA HENDERSON (1955) ´ Introduced the nature of Nursing Model. She postulated that the unique function of the nurse is to assist the clients. She identified fourteen basic needs. in the performance of those activities contributing to health or its recovery. will or knowledge.
14 COMPONENTS OF BASIC NEEDS Breathe normally ´ Eat and drink adequately ´ Eliminate body wastes ´ Move and maintain desirable postures ´ Sleep and rest ´ Select suitable clothes ´ Maintain body temperature ´ .
Keep body clean and well groomed ´ Avoid dangers in environment and avoid injuring others ´ Communicate with others ´ Worship according to one·s faith ´ Work in such a way there is a sense of accomplishment ´ Play or participate in recreation ´ Learn. discover or satisfy curiosity that leads to normal development and health ´ .
She defined nursing as service to individuals and families. she conceptualized nursing as an art and a science that molds the attitudes.FAYE ABDELLAH (1960) ´ Introduced Patient-Centered Approaches to Nursing Model. She identified twenty-one (21) nursing problems. sick or well and cope with their health needs . Furthermore. intellectual competencies and technical skills of the individual nurse into the desire and ability to help people.
KEY CONCEPTS OF TWENTY ONE (21) NURSING PROBLEMS To maintain good hygiene ´ To promote optimal activity: exercise. rest and sleep ´ To promote safety ´ To maintain good body mechanics ´ To facilitate the maintenance of a supply of oxygen ´ To facilitate maintenance of nutrition ´ To facilitate maintenance of elimination ´ .
feelings and reactions ´ .To facilitate the maintenance of fluid and electrolyte balance ´ To recognize the physiologic response of the body to disease conditions ´ To facilitate the maintenance of regulatory mechanisms and functions ´ To facilitate the maintenance of sensory function ´ To identify and accept positive and negative expressions.
To identify and accept the interrelatedness of emotions and illness ´ To facilitate the maintenance of effective verbal and nonverbal communication ´ To promote the development of productive interpersonal relationship ´ .
To facilitate progress toward achievement of personal spiritual goals ´ To create and maintain a therapeutic environment ´ To facilitate awareness of self as an individual with varying needs ´ To accept the optimum possible goals ´ To use community resources as an aid in resolving problems arising from illness ´ To understand the role of social problems as influencing factors ´ .
According to Johnson.Taking In nourishment in socially and culturally acceptable ways. each person as a behavioral system is composed of seven subsystems namely: ´ Ingestive.Security seeking behavior.Riddling the body waste in socially and culturally acceptable ways.DOROTHY E. ´ Affiliative. JOHNSON (1960. 1980) Conceptualized the Behavioral System Model. ´ Eliminative. ´ .
Master of oneself and one·s environment according to internalized standards of excellence. ´ .Nurturance-seeking behavior.Aggressive. ´ Sexual and role identity behavior. ´ Achievement. ´ Dependence.Self-protective behavior.
maintain and restore health. nurses help individuals die with dignity. She described nursing as a helping profession that assists individuals and groups in society to attain.IMOGENE KING (1971. If this is not possible. . 1981) ´ Postulated the Goal Attainment Theory.
1984) ´ Developed the Transcultural Nursing Model. beliefs and practice) to improve or maintain a health condition. . She advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes (cultural values.MADELEINE LEININGER (1978.
She advocated that nursing is a human interaction and proposed four conservation principles of nursing which are concerned with the unity and integrity of the individual.MYRA LEVIN (1973) Described the Four Conservation Principles. The four conservation principles are: ´ Conservation of energy ´ Conservation of structural integrity ´ Conservation of personal integrity ´ Conservation of social integrity ´ .
through primary. 1989. to adjust to environmental stressors and maintain client stability. secondary and tertiary prevention modes.BETTY NEUMAN (1982. to protect the client·s basic structure and to obtain or maintain a maximum level of wellness. The nurse helps the client. . 1992) ´ Proposed the Health Care System Model. The concern of nursing is to prevent stress invasion.
1985) ´ Developed the Self-Care and Self-Care Deficit Theory.DOROTHEA OREM (1970. She defined self-care as ´the practice of activities that individuals initiate and perform on their own behalf in maintaining life. health and well-being.µ .
. She defined nursing as an interpersonal process of therapeutic interactions between an individual who is sick or in need of health services and a nurse especially educated to recognized and respond to the need for help.HILDEGARD PEPLAU (1952) ´ Introduced the Interpersonal Model.
. Unitary man is an energy field in constant interaction with the environment.MARTHA ROGERS (1970) ´ Conceptualized the Science of Unitary Human Beings.
.SISTER CALLISTA ROY (1979. functions as a whole through interdependence of its parts. She viewed each person as a unified biopsychosocial system in constant interaction with a changing environment. 1984) ´ Presented the Adaptation Model. She contended that the person as an adaptive system.
She believed that the nurse helps patients meet a perceived need that the patients cannot meet for themselves. .IDA JEAN ORLANDO (1961) ´ Conceptualized the Dynamic Nurse-Patient Relationship Model.
which generates self-knowledge. self-control. She emphasized that nursing is the application of the art and human science through transpersonal caring transactions to help persons achieve mind-body-soul harmony.JEAN WATSON (1979-1985) ´ Conceptualized the Human Caring Model. . self-care and self-healing.
CONCEPTS OF HEALTH AND ILLNESS .
It is a state of integration of the body and mind. in relation to geography and to culture.Health is a fundamental right of every human being. Meanings and descriptions of health and illness vary among people. ´ Health and illness are highly individualized perceptions. ´ .
Health is maintained through prevention of disease via environmental health factors (Nightingale) ´ . (WHO) ´ Health is being well and using ones· power to the fullest extent.Health is a state of complete physical. mental and social well-being. and not merely the absence of disease or infirmity.
´ Wellness is a way of life ´ Wellness is the integration of body. mind and spirit ´ Wellness is the loving acceptance of one·s self. ´ . It involves engaging attitudes and behaviors that enhance quality of life and maximize personal potential.WELLNESS AND WELL BEING Wellness is well-being. ´ Wellness is a choice.
´ .MODELS OF HEALTH AND ILLNESS The Health-illness Continuuum ´ Health Belief Model ´ Smith·s model of health ´ Leavell and Clark·s Agent-Host-Environment Model (Biologic nodel) ´ Health promotion model.
THE HEALTH-ILLNESS CONTINUUM Describes the interaction of the environment with well-being and illness. ´ . This concept connotes ability to perform ADL or to function independently. ´ High Level wellness (HLW) ´ An integrated method of functioning that is oriented towards maximizing one·s potentialities within the limitations of his environment.
family history for diabetes mellitus.PRECURSOR OF ILLNESS These are the factors which impinge on the individuals to lead towards the illness spectrum: ´ Heredity. cancer ´ .g. hypertension.e.
e.g.Behavioral Factors. poor sanitation.e. overcrowding. poor supply of potable water ´ .g. high animal fat intake ´ Environmental Factors. alcohol abuse. cigarette smoking.
1975 Describes the relationship between a person·s belief and behavior ´ Individual perceptions and modifying factors may influence health beliefs and preventive health behavior ´ .HEALTH BELIEF MODEL (HBM) BECKER.
diabetes mellitus is lifelong disease ² Perceived threat of an illness e.´ Individual perceptions include the following ² Perceived susceptibility to an illness e. heart. kidneys.g diabetes mellitus causes damage to the brain. eyes. blood vessels .g family history to diabetes mellitus increases risk to develop the disease ² Perceived seriousness of an illness e.g.
´ Likelihood of taking recommended preventive health action depends on : ² Perceived benefits of preventive action ² Perceived barriers to preventive action .
disease or injury ´ Role Performance Model.defines health in terms of individual·s ability to fulfill societal roles such as performing work.SMITH¶S MODEL OF HEALTH Clinical Model. ´ .views people as physiologic system with related functions and identifies health as the absence of signs and symptoms.
Focuses on adaptation. This model believes that the aim of treatment is to restore the ability of the person to adapt that is to cope. . Views health as creative process and disease as a failure in adaptation or mal-adaptation.´ Adaptive Model.
´ Eudaemostic Model.Conceptualizes that health is a condition of actualization or realization of a person·s potential. . This model avers that the highest aspiration of people is fulfillment and complete development³ actualization.
LEAVELL AND CLARK¶S AGENT-HOSTENVIRONMENT MODEL (ECOLOGIC MODEL) ´ Avers that there are three interactive factors that affect health and illness. (3) Environment.any factor or stressor that can lead to illness or disease. .any factor external to the host that may or may not predispose the person to a certain disease. The three factors are as follows: (1) Agent. (2) HostPersons who may or may not be affected by a disease.
HEALTH PROMOTION MODEL The health promotion model describes the multi-dimensional nature of persons as they interact within the environment to pursue health. The model focuses on the following areas: ´ Individual perceptions (client·s cognitive perceptual factors) ´ .
Modifying factors (demographic and social factors) ´ Participation in health.promoting behaviors (likelihood of action) ´ This model attempts to explain the reasons why individuals engage in health activities. ´ .
emotional.ILLNESS Illness is a personal state in which the person feels unhealthy ´ Illness is a state in which person·s physical. intellectual. developmental or spiritual functioning is diminished or impaired compared with previous experience ´ . social.
.DISEASE ´ An alteration in body functions resulting in reduction of capacities or shortening of the normal life span.
g. cleft palate) ´ Developmental defects (e. ultraviolet rays) ´ .g.g.COMMON CAUSES OF DISEASES Biologic Agents (e. radiation.g. hot and cold substances. microorganism) ´ Inherited genetic defects (e. imperforate anus) ´ Physical agents (e.
g. emissions from smoke-belching cars) ´ Tissue response to irritation/injury (fever.g. inadequate iodine causing goiter) ´ Emotional/physical reaction to stress (e.g. anxiety. lead. fear) ´ . inadequate insulin in diabetes mellitus. inflammation) ´ Faulty chemical/metabolic process (e.Chemical agents (e.
CLASSIFICATION OF DISEASES .
ACCORDING TO ETIOLOGIC FACTORS a.1. hereditary factors. present at birth (e.g. cleft palate) ´ . prenatal infection. Hereditary.g. diabetes mellitus.due to defect in the genes of one or other parent which transmitted to the offspring (e. cleft lip. hypertension) ´ b. Congenital.Due to a defect in the development.
results from inadequate intake or absorption of essential factors (e.g. Metabolic. which is vitamin D deficiency in adults) ´ e. diabetes mellitus. Traumatic.g.c.due to disturbances or abnormality in the intricate processes of metabolism (e. fractures) ´ .g. hyperthyroidism) ´ d. osteomalacia.due to injury (e. Deficiency.
g. (e.Due to abnormal response of the body to chemical or protein substances or to physical stimuli. asthma. Idiopathic. cancer) ´ h. self0originated. skin allergy) ´ g. Cancer) ´ .due to abnormal or uncontrolled growth of cells (e.g. Allergenic. of spontaneous origin (e. Neoplastic.Cause is unknown.g.f.
hypothyroidism after thyroid surgery. osteoporosis.results from the treatment disease (e.g. alopecia <hair loss> after chemotheraphy) ´ . Degenerative. Iatrogenic. osteaoarthritis) ´ j.i.results from degenerative changes that occur in tissue and organs (e.g.
are intense and often subside after a relatively short period.2.an acute Illness usually has a short duration and is severe. An acute illness may affect functioning in any dimension (e. acute appendicitis) .g. The signs and symptoms appear abruptly. Acute Illness. ACCORDING TO DURATION OR ONSET ´ a.
The client may fluctuate between maximal functioning and serious relapses that may be life threatening (e. It is characterized by remission and exacerbation. Chronic Illness.´ b.a chronic illness persists.g hypertension). . usually longer than 6 months and can also affect functioning in any dimension.
Remission. Exacerbation. with recurrence of pronounced symptoms ´ .the disease becomes more active again at a future time.period during which the disease is controlled and symptoms are not obvious ´ ii.i.
´ c. subacute endocarditis) .Symptoms are pronounced but more prolonged than in acute illness (e.g.Sub-acute.
3. may result from abnormal responses to stimuli (e. cancer among chemical factory workers) ´ . psychiatric illnesses) ´ b.g.g. Functional.Results from factors associated with the occupation engaged in by the patient (e. DISEASES MAY ALSO BE DESCRIBED AS: a. Occupational. OTHERS.No anatomical changes are observed to account for the symptoms present.
Epidemic. cancer) ´ d.usually acquired through sexual relation (e. SARS) ´ . Venereal.Attacks a large number of individuals in a community at the same time (e.occurs in several individuals of the same family (hypertension.c. gonorrhea) ´ e. Familial. AIDS.g.g.
a disease in which only occasional cases occur (e. Endemic. Sporadic. goiter in Mountain Province) ´ g. Palawan.an epidemic disease which is extremely widespread involving an entire country or continent ´ h.g.g. dengue during rainy season.f. leptospirosis during floods) ´ . Pandemic.present more or less continuously or recurs in a community (e.
THREE LEVELS OF PREVENTION .
Seeks to prevent a disease or condition at a prepathologic state. to stop something from ever happening ² Health promotion ² Specific prevention .PRIMARY PREVENTION ´ to encourage optimal health and to increase the person·s resistance to illness.
to prevent catastrophic effects that could occur if proper attention and treatment are not provided. ² Early diagnosis/detection/screening ² Prompt treatment to limit disability .SECONDARY PREVENTION ´ it is also known as health maintenance. Seeks to identify specific illness or conditions at an early stage with prompt intervention to prevent or limit disability.
and establishment of high-level wellness. Occurs after a disease or disability has occurred and the recovery process has begun.TERTIARY PREVENTION ´ to support the client·s achievement of successful adaptation to known risks. optimal reconstitution. intent is to halt the disease or injury process and assist the person in obtaining an optimal health status ² Rehabilitation .
BEHAVIORS ASSOCIATED WITH LEVELS OF PREVENTION .
PRIMARY PREVENTION Quit smoking ´ Avoid/limit alcohol intake ´ Exercise regularly ´ Eat well-balanced diet ´ Reduce fat and increase fiber in diet ´ .
Take adequate fluids ´ Avoid over exposure to sunlight ´ Maintain ideal body weight ´ Complete immunization program ´ Wear hazard devices in work site ´ .
SECONDARY PREVENTION Have annual physical examination ´ Regular Pap·s test for women ´ Monthly BSE for women who are 20 years old and above ´ Sputum examination for tuberculosis ´ Annual stool guiac test and rectal examination for clients over age 50 years ´ .
TERTIARY PREVENTION Self-monitoring of blood glucose among diabetics ´ Physical therapy after CVA (stroke0. participation in cardiac rehabilitation after MI (myocardial infarction or heart attack) ´ Attending self-management education for diabetes ´ Undergoing speech therapy after laryngectomy ´ .
ILLNESS BEHAVIOR .
It involves how people monitor their bodies. . define and interpret their symptoms. take remedial actions and use the health care system.´ People who are ill generally act in a way that medical sociologists called illness behavior.
. ² If clients believe that symptoms are serious or perhaps life threatening they are also more likely to seek health care assistance.VARIABLES INFLUENCING ILLNESS BEHAVIOR ´ Internal variables ² Influencing the way clients behave when they are ill are their perceptions of symptoms and the nature of the illness.
² A client with a visible symptom may be more likely to seek assistance than a client without such a visible symptom.´ External variables ² Influencing a client·s illness behavior include the visibility of symptoms. . cultural background. economic variables. accessibility of health care system and social support. social groups.
IMPACT OF ILLNESS ON CLIENT SELFCONCEPT .
Self-concept is a mental 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. ´ .
Reference: ´ Fundamentals of Nursing by Udan ´ .
.´ In the providing of care. a nurse is able to observe changes in the client·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 illness.