OVERVIEW OF CHRONICITY
 Carry out regimens as prescribed
1. DEFINITION OF CHRONIC CONDITIONS
• Medical conditions or health problems with
associated symptoms or disabilities that require
long-term management (3 months or longer).
• Illnesses or diseases that have a prolonged course,
that do not resolve spontaneously, and for which
complete cures are unlikely or rare.
• May be a result of illness, genetic factors, or injury;
or it could be a consequence of conditions or
unhealthy behaviours that began during childhood
or young adulthood.
• Consists of carrying out the lifestyle changes and
regimens designed to control symptoms and
prevent complications.
2. CAUSES OF CHRONIC CONDITIONS
 A decrease in mortality from infectious diseases.
 Lifestyle factors.
 Longer lifespans because of advances in
technology and pharmacology.
 Improved screening and diagnostic procedures.
3. CHARACTERISTICS OF CHRONIC CONDITIONS
 Managing chronic illness involves more than
treating medical problems.
 Chronic conditions usually involve many different
phases over the course of a person’s lifetime.
 Keeping chronic conditions under control requires
persistent adherence to therapeutic regimens.
 One chronic disease can lead to the development of
other chronic conditions.
 Chronic illness affects the entire family.
 The day-to-day management of illness is largely
the responsibility of people with chronic disorders
and their families.
• The management of chronic conditions is a process
of discovery.
• Managing chronic conditions must be a
collaborative process that involves many different
health care professionals working together with
patients and their families.
• The management of chronic conditions is
expensive.
• Chronic conditions raise difficult ethical issues for
patients, families, health care professionals, and
society.
• Living with chronic illness means living with
uncertainty.
4. IMPLICATIONS OF MANAGING CHRONIC
CONDITIONS
 Alleviate and manage symptoms
 Psychologically adjust to and physically
accommodate disabilities
 Prevent and manage crises and complications
 Validate individual self-worth and family
functioning
 Manage threats to identity
 Normalize personal and family life as much as
possible
 Live with altered time, social isolation,
 and loneliness
 Establish the networks of support and resources
that can enhance quality of life
 Return to a satisfactory way of life
 Die with dignity and comfort
5. PHASES OF CHRONIC CONDITIONS
 The course of an illness can be thought of as a
trajectory that can be managed or shaped over time,
to some extent, through proper illness management
strategies.
5.1 PRETRAJECTORY PHASE
Description: Genetic factors or lifestyle behaviors that place
a person or community at risk for a chronic condition.
Focus of Nursing Care: Refer for genetic testing and
counseling if indicated; provide education about prevention
of modifiable risk factors and behaviors.
5.2TRAJECTORY ONSET PHASE
Description: Appearance or onset of noticeable symptoms
associated with a chronic disorder.
• includes period of diagnostic workup and
announcement of diagnosis
• may be accompanied by uncertainty
Focus of Nursing Care: Provide explanations of diagnostic
tests and procedures and reinforce information and
explanations given by primary health care provider.
• provide emotional support to patient and family
5.2 STABLE PHASE
Description: Illness course and symptoms are under control
as symptoms, resulting disability and everyday life activities
are being managed within limitations of illness.
• illness management centered in the home
Focus of Nursing Care: Reinforce positive behaviors and
offer ongoing monitoring.
• provide education about health promotion and
encourage participation in health promoting
activities and health screening
UNSTABLE PHASE
Description: Characterized by an exacerbation of illness
symptoms, development of complications, or reactivation of
an illness in remission.
• Period of inability to keep symptoms under control.
 • May require more diagnostic testing and trial of
new treatment regimens or adjustment of current
regimen.
Focus of Nursing Care: Provide guidance and support.
• reinforce previous teaching
ACUTE PHASE
Description: Severe and unrelieved symptoms or the
development of illness complications necessitating
hospitalization, bed rest, or interruption of the person’susual
activities to bring illness course under control.
Focus of Nursing Care: Provide direct care and emotional
support to the patient and family members.
CRISIS PHASE
Description: Critical or life-threatening situation requiring
emergency treatment or care and suspension of everyday life
activities until the crisis has passed.
Focus of Nursing Care: Provide direct care, collaborate with
other health care team members to stabilize patient’s
condition.
COMEBACK PHASE
Description: Gradual recovery after an acute period and
learning to live with or to overcome disabilities and return to
an acceptable way of life.
FOCUS OF NURSING CARE: ASSIST IN
COORDINATION OF CARE.
• Rehabilitative focus may require care from other
health care providers.
• Provide positive reinforcement for goals identified
and accomplished.
DOWNWARD PHASE
Description: Illness course characterized by rapid or gradual
worsening of a condition.
• Physical decline accompanied by increasing
disability or difficulty in controlling symptoms.
• Requires biographical adjustment and alterations in
everyday life activities.
Focus of Nursing Care: Provide home care and other
community-based care to help patient and family adjust to
changes and come to terms with these changes.
• Assist patient and family to integrate new treatment
and management strategies.
DYING PHASE
Description: Final days or weeks before death.
• Characterized by gradual or rapid shutting down of
body processes, biographical disengagement and
closure, and relinquishment of everyday life
interests and activities.
Focus of Nursing Care: Provide direct and supportive care to
patients and their families through hospice programs.
6. APPLYING THE NURSING PROCESS USING THE
PHASES OF THE CHRONIC ILLNESS SYSTEM
The focus of care for patients with chronic conditions is
determined largely by the phase of the illness and is directed
by the nursing process, which includes assessment,
diagnosis, planning, implementation, and evaluation.
STEP 1: IDENTIFYING SPECIFIC PROBLEMS AND
THE TRAJECTORY PHASE
• Assessment enables the nurse to identify the
specific medical, social, and psychological
problems likely to be encountered in a phase.
STEP 2: ESTABLISHING AND PRIORITIZING GOALS
• The nurse helps prioritize problems and establish
the goals of care.
• Identification of goals must be a collaborative
effort, with the patient, family, and nurse working
together, and the goals must be consistent with the
abilities, desires, motivations, and resources of
those involved.
STEP 3: DEFINING THE PLAN OF ACTION TO
ACHIEVE DESIRED OUTCOMES
• Identify a realistic and mutually agreed-on plan for
achieving goals, including specific criteria that will
be used to assess the patient’s progress.
• The identification of the person responsible for
each task in the action plan is also essential.
• Identification of the environmental, social, and
psychological factors that might interfere with or
facilitate achieving the desired outcome is an
important part of planning.
STEP 4: IMPLEMENTING THE PLAN AND
INTERVENTIONS
• Help patients implement the actions that allow
patients to live with the symptoms and therapies
associated with chronic conditions, thus helping
them to gain independence.
• Work with each patient and family to identify the
best ways to integrate treatment regimens into their
ADLs to accomplish two tasks:
(1) adhering to regimens to control symptoms
and keep the illness stable
(2) Dealing with the psychosocial issues that
can hinder illness management and affect
quality of life.
STEP 5: FOLLOWING UP AND EVALUATING
OUTCOMES
 • Determine if the problem is resolving or being
managed and if the patient and family are adhering
to the plan.
• Maintaining the stability of the chronic condition
while preserving the patient’s control over his or
her life and the patient’s sense of identity and
accomplishment is a primary goal.
• Consideration of alternative strategies or revision
of the initial plan may be warranted.
7. HOME AND COMMUNITY-BASED CARE
• One of the major goals of nursing today should be
the prevention of chronic conditions and the care of
people with them.
• This requires promoting healthy lifestyles and
encouraging the use of safety and disease-
prevention measures.
• Prevention should also begin early in life and
continue throughout life.
• Patient and family teaching is an important nursing
role that may make the difference in the ability of
the patient and family to adapt to chronic
conditions.
• Learning needs change as the trajectory phase and
the patient’s personal situation change.
OVERVIEW OF DISABILITY
1. DEFINITIONS OF DISABILITY
Limitation in performance or function in everyday activities
(difficulty talking, hearing, seeing, walking, climbing stairs,
lifting or carrying objects, performing ADLs, doing school
work, or working at a job).
A severe disability is present if a person is unable to perform
one or more activities, uses an assistive device for mobility,
or needs help from another person to accomplish basic
activities.
1. CATEGORIES OF DISABILITY
Disabilities can be categorized as developmental disabilities,
acquired disabilities, and age-associated disabilities.
1.1 DEVELOPMENTAL DISABILITIES
 Occur any time from birth to 22 years of age and
result in impairment of physical or mental health,
cognition, speech, language, or self-care.
 Examples of developmental disabilities are spina
bifida, cerebral palsy, Down syndrome, and
muscular dystrophy.
 Some developmental disabilities occur as a result
of birth trauma or severe illness or injury at a very
young age.
1.2 ACQUIRED DISABILITIES
Occur as a result of an acute and sudden injury (e.g.,
traumatic brain injury, spinal cord injury, traumatic
amputation), acute nontraumatic disorders (e.g., stroke,
myocardial infarction), or progression of a chronic disorder
(e.g., arthritis, multiple sclerosis, chronic obstructive
pulmonary disease, blindness due to diabetic retinopathy).
1.3 AGE-RELATED DISABILITIES
Occur in the elderly population and are thought to be due to
the aging process.
Examples of age-related disabilities include osteoarthritis,
osteoporosis, and hearing loss.
2. MODELS OF DISABILITY
These include the medical and rehabilitation models, the
social model, the biopsychosocial model, and the interface
model.
2.1 MEDICAL MODEL
• This model equates people who are disabled with
their disabilities and views disability as a problem
of the person.
• Health care providers, rather than people with
disabilities, are viewed as the experts or authorities.
• Management of the disability is aimed at cure or
the person’s adjustment and behavior change.
• The model is viewed as promoting passivity and
dependency.
• People with disabilities are viewed as tragic.
2.2 REHABILITATION MODEL
It regards disability as a deficiency that requires a
rehabilitation specialist or other helping professional to fix
the problem.
People with disabilities are often perceived as having failed
if they do not overcome the disability.
2.3 SOCIAL MODEL
Views disability as socially constructed and as a political
issue that is a result of social and physical barriers in the
environment.
Its perspective is that disability can be overcome by removal
of these barriers.
2.4 BIOPSYCHOSOCIAL MODEL
Integrates the medical and social models to address
perspectives of health from a biologic, individual, and social
perspective. The disabling condition, rather than the person
and the experience of the person with a disability, remains
the defining construct of the biopsychosocial model.
2.5 INTERFACE MODEL
Is based on the life experience of the person with a disability
and views disability at the intersection (i.e., interface) of the
medical diagnosis of a disability and environmental barriers.
It considers rather than ignores the diagnosis.
The person with a disability, rather than others, defines the
problems and seeks or directs solutions.
3. DISABILITY VERSUS DISABLING DISORDERS
The nurse who cares for patients with preexisting disabilities
or new disabilities must recognize the impact of a disability
on current and future health and wellbeing, the ability to
participate in self-care or self-management, and the ability
to obtain required health care and health screening.
3.1 COMMUNICATION STRATEGIES
Does the patient with a disability require or prefer
accommodations (e.g., a sign interpreter) to ensure full
participation in conversations about his or her own health
care?
 Are appropriate accommodations made to
communicate with the patient?
 Are efforts made to direct all conversations to the
patient rather than to others who have accompanied
the patient to the health care facility?
3.2 ACCESSIBILITY OF THE HEALTH CARE
FACILITY
Are clinics, hospital rooms, offices, restrooms, laboratories,
and imaging facilities accessible to people with disabilities?
Is a sign interpreter other than family member available to
assist in obtaining a patient’s health history and in
conducting a physical assessment?
Does the facility include appropriate equipment to permit
people with disabilities to obtain health care (including
mammography, gynecologic examination and care, dental
care) in a dignified and safe manner?
3.3 ASSESSMENT
 Usual Health Considerations
 Disability-Related Considerations
 Abuse
 Depression
 Aging
 Secondary Conditions
 Accommodations in the Home
3.4 COGNITIVE STATUS
Is it assumed that the patient is able to participate in
discussion and conversation rather than assuming that he or
she is unable to do so because of a disability?
Are appropriate modifications made in written and verbal
communication strategies?
3.5 MODIFICATIONS IN NURSING CARE
 Are modifications made during hospital stays,
acute illness or injury, and other health care
encounters to enable a patient with disability to be
as independent as he or she prefers?
 Is “person-first language” used in referring to a
patient with disability, and do nurses and other staff
talk directly to the patient rather than to those who
accompanied the patient?
 Are all staff informed about the activities of daily
living (ADLs) for which the patient will require
assistance?
 Are accommodations made to enable the patient to
use his or her assistive devices (hearing/visual aids,
prostheses, limb support devices, ventilators,
service animals)?
3.6 PATIENT TEACHING
 Are accommodations and alternative formats of
teaching materials (large print, Braille, visual
materials, audiotapes) provided for patients with
disabilities?
 Does patient teaching address the modifications
(e.g., use of assistive devices) needed by patients
with disabilities to enable them to adhere to
recommendations?
 Are modifications made in teaching strategies to
address learning needs, cognitive changes, and
communication impairment?
3.7 HEALTH PROMOTION AND DISEASE
PREVENTION
Are health promotion strategies discussed with people with
disabilities along with their potential benefits: improving
quality of life and preventing secondary conditions (health
problems that result because of preexisting disability)?
 Are patients aware of accessible community-based
facilities (e.g., health care facilities, imaging
centers, public exercise settings, transportation) to
enable them to participate in health promotion?
3.8 INDEPENDENCE VERSUS DEPENDENCE
Is independence, rather than dependence, of the person with
a disability the focus of nursing care and interaction?
Are care and interaction with the patient focused on
empowerment rather than promoting dependence of the
patient?
3.9 INSURANCE COVERAGE
Does the patient have access to the health insurance
coverage and other services for which he or she qualifies?
Is the patient aware of various insurance and other available
programs?
RIGHT OF ACCESS TO HEALTH CARE
1. BARRIERS TO HEALTH CARE
Many people with disabilities encounter barriers to full
participation in life, including health care, health screening,
and health promotion.
1.1 STRUCTURAL BARRIERS
Barriers that make certain facilities inaccessible.
Examples of structural barriers include stairs, lack of ramps,
narrow doorways that do not permit entry of a wheelchair,
and restroom facilities that cannot be used by people with
disabilities (e.g., restrooms that lack grab bars and those that
lack larger restroom stalls designed for people using
wheelchairs).
1.2 NEGATIVE AND STEREOTYPIC ATTITUDES

(e.g., believing that all people with disabilities have a poor

quality of life and are dependent and nonproductive) on the
part of the public.

Health care providers with similar negative attitudes make it

difficult for people with disabilities to obtain health care
equal in quality to that of people without disabilities.

END OF LECTURE