Chronic Illness
Principles and Practices of Rehabilitation
Health Care of the Older Adult.
Chronic health problems affect people of all ages—they occur in the very young, the middle-aged, and the very old. Chronic conditions do, however, increase in frequency with age, and elderly people often have multiple chronic disorders (Van den Akker, Buntinx, Metsemakers, Roos & Knottnerus, 1998). Chronic illnesses are found in all socioeconomic, ethnic, cultural, and racial groups; certain diseases, however, occur more frequently in some groups than in others (Kington & Smith, 1997). Native Americans between the ages of 45 to 64, for example, have a higher mortality rate from diabetes and cirrhosis than Caucasians in the same age range (Reeves, Remington, Nashold & Pete, 1997). Being poor and lacking adequate health care coverage decreases the likelihood of receiving preventive screening measures such as mammography, cholesterol testing, and routine check-ups (Hagdrup, Simoes & Brownson, 1997). Although some chronic conditions have little effect on quality of life, others have a considerable effect because of related disability (Kempen, Ormel, Brilman & Relyveld, 1997). Certain conditions require advanced technology for survival, as in the late stages of amyotrophic lateral sclerosis or end-stage renal disease. Some people with chronic health conditions and disability function independently with only minor inconvenience to their everyday lives; others require frequent and close monitoring or placement in long-term care facilities.
The Phenomenon of Chronicity
Although each chronic condition has its own specific physiologic characteristics, chronic conditions do share common qualities. Many chronic conditions, for example, have pain and fatigue as associated symptoms. Some degree of disability is usually present in severe or advanced chronic illness, limiting the patient’s participation in activities (Collins, 1997). Many chronic conditions require therapeutic regimens to keep them under control. Unlike the term “acute,” which implies a curable and relatively short disease course, chronic describes a long disease course and conditions that may be incurable. It is this characteristic of duration that often makes managing chronic conditions so difficult for those who must live with them. Psychological and emotional reactions of patients to acute and chronic conditions and changes in their health status are described in detail in Chapter 7. People who develop chronic conditions may react with shock, disbelief, depression, anger, resentment, or a number of other emotions. How people react and cope with chronic conditions is usually similar to how they react to other events in their lives, depending, in part, on their understanding of the condition and their perceptions of its potential impact on their own and their family’s lives. Adjustment to chronic illness is affected by various factors: • Personality before the illness • Unresolved anger or grief from the past • Suddenness, extent, and duration of lifestyle changes necessitated by the illness • Family and individual resources for dealing with stress • Stages of individual/family life cycle • Previous experience with illness and crises •Codependency in family systems (Lewis, 1998) Psychological, emotional, and cognitive reactions to chronic conditions are likely to occur at the initial onset, but they may also recur if symptoms worsen or recur after a period of remission. Symptoms associated with chronic illnesses are often unpredictable, and some are perceived as crisis events by patients and their families, who must contend with both the uncertainty of chronic illness and the changes it brings to their lives. This chapter describes some of the problems of living with chronic conditions and offers a guide to nursing assessment and intervention when providing care to people with chronic illness.
DEFINITION OF CHRONIC CONDITIONS
“Chronic conditions” are defined as medical conditions or health problems with associated symptoms or disabilities that require long-term (3 months or longer) management (Robert Wood Johnson Foundation, 1996). The condition may be due to illness, genetic factors, or injury. Management of such conditions includes learning to live with symptoms and/or disabilities and coming to terms with identity changes brought about by having a chronic condition. It also consists of carrying out the lifestyle changes and regimens that are designed to keep symptoms under control and to prevent complications. Although some people take on what might be called a “sick role” identity, most people with chronic conditions do not consider themselves to be sick or ill and try to live as normal a life as is possible. Only when complications develop or when symptoms become severe enough to interfere with performance of daily life activities do most people who are chronically ill think of themselves as being sick or disabled (Nijhof, 1998).
PREVALENCE AND CAUSES OF CHRONIC CONDITIONS
Chronic conditions occur in people of every age group, socioeconomic level, and culture. In 1995, an estimated 99 million people in the
The Characteristics of Chronic Conditions
Sometimes it is difficult for those who are disease-free to understand how lives are changed, often forever, because of chronic conditions. It is also easy for health professionals to focus on treating the illness while overlooking the person who has the disease (Hellstrom, Lindqvist & Mattsson, 1998). In all illnesses, but even more so with chronic conditions, the illness cannot be separated from the person (Soderberg, Lundman & Norberg, 1999). Chronic illness is something that people must contend with on a daily basis. Nurses are unable to relate to what people are facing or plan effective interventions unless they fully understand what it means to have a chronic illness (Carroll, 1998; Koch, Kralik & Taylor, 2000; Lubkin, 1997). Characteristic effects of chronic illness follow: 1. Managing chronic illness involves more than managing medical problems. Associated psychological and social problems must also be addressed since living for long periods of time with illness symptoms and disability can threaten identity, bring about role changes, alter body image, and disrupt lifestyles (Dean, 1999). This means that continuous adaptation and accommodation are called for, depending upon age and situation in life (Price, 1996; Sidell, 1997). Each major change or decrease in functional ability requires further physical, emotional, and social adaptation for patients and their families (Carroll, 1998; Lewis, 1998; Miller, 1999; Tappan, Williams, Fishman & Theris, 1999). 2. Chronic conditions usually involve many different phases over the course of a person’s lifetime. There can be acute periods, stable and unstable periods, flare-ups, and remissions. Each phase brings its own set of physical, psychological, and social problems, and each requires different regimens and types of management (Corbin & Strauss, 1991). 3. Keeping chronic conditions under control requires persistent adherence to therapeutic regimens. Failing to adhere to a treatment plan or to follow a regimen in a consistent manner increases the risks of developing complications and accelerating the disease process. However, the realities of daily life, including the impact of culture, values, and socioeconomic factors, affect the degree to which people adhere to a treatment regimen. Managing a chronic illness takes time, requires knowledge and planning (Baker, 1998), and can be uncomfortable and inconvenient. It is not unusual for patients to discontinue taking medications or to alter dosages because of side effects that are more disturbing or disruptive than illness symptoms. People also frequently cut back on regimens they consider overly time-consuming, fatiguing, or costly (Davis & Magilvy, 2000; Wichowski & Kubsch, 1997). 4. One chronic disease can lead to the development of other chronic conditions. Diabetes, for example, can eventually lead to neurological and vascular changes that may result in vision, cardiac, and kidney disease and erectile dysfunction (Warren-Boulton, Greenberg, Lising & Gallivan, 1999). 5. Chronic illness affects the whole family. Family life can be dramatically altered as a result of role reversals (Saiki- Craighill, 1997), unfilled roles, loss of income, time spent managing illness, decreases in family socialization activities, and the costs of treatment (Dokken & Sydnor-Greenberg, 1998). Stress and caretaker fatigue are common with severe chronic conditions, and the whole family rather than just the individual needs care (Canam & Acorn, 1999; Fisher & Weiks, 2000). 6. The major responsibility for the day-to-day management of illness falls upon the shoulders of chronically ill people and their families. In today’s health care system, especially with chronic conditions, day-to-day management, or self-care, has increasingly become a major part of the role of the patient or family. The home, rather than the hospital, is the center of care in chronic conditions since this is where day-to-day management occurs. Hospitals, clinics, doctors’ offices, nursing homes, nursing centers, and community agencies (visiting nurse services, social services, and disease-specific associations and societies) are adjuncts or back-up services to that daily home management. 7. The management of chronic conditions is a process of discovery. People can be taught how to manage their conditions. Teaching about symptoms, however, is not the same as experiencing them. Each person must discover how his or her own body reacts under varying conditions—for example, what it is like to be hypoglycemic, what activities are likely to bring on angina, and how these or other conditions can best be prevented and managed. 8. Managing chronic conditions is a collaborative process. The medical, social, and psychological problems associated with chronic problems tend to be complex, especially in severe conditions. The management of chronic conditions should therefore be thought of as a collaborative process that involves many different health care professionals working together with patients and their families to provide the full range of services that are ofteeeded to manage at home (Corbin & Cherry, 1997). 9. The management of chronic conditions is expensive. As indicated in Table 10-1, billions of dollars are spent every year on health care for people with chronic conditions. The money pays for hospitalizations and the purchase of equipment, medications, and supportive services. For example, hospital lengths of stay and charges are higher for acute pediatric conditions if a child also has a chronic condition (Hodgson & Cohen, 1999; Silber, Gleeson & Zhao, 1999). Overall health care costs are not likely to decrease until there is a substantial downward trend in the incidence of chronic conditions and the costs of chronic health care. 10. Chronic conditions raise difficult ethical issues for the patient, health care professionals, and society. No easy solutions exist to problems such as how to establish cost controls, how to allocate scarce resources (eg, kidneys and hearts for transplantation), how to determine what constitutes quality of life, and when to terminate life support. Patients, families, and society respond to ethical issues according to their own moral standards and definitions of quality of life. 11. Living with chronic illness means living with uncertainty (Mishel, 1999; Price, 1996). Although health care professionals have some notion about the usual progression of a chronic disease such as Parkinson’s disease, so many specific variables enter into each case that no one can predict with certainty an individual’s illness course (that is, how the person will respond to treatment and how quickly or even whether a disease will progress). Even when a patient is “in remission” or “disease-free,” he or she experiences a lingering doubt and dread that the illness will reactivate (Smeltzer, 1992; Wiener & Dodd, 1993).
THE PROBLEMS OF MANAGING CHRONIC CONDITIONS
Chronic conditions have implications for everyday living and management problems for individuals and their families as well as for society at large. Most importantly, individual efforts should be directed at preventing chronic conditions since many chronic conditions can be traced, at least in part, to unhealthy lifestyles or behaviors such as smoking and overeating. Thus, changes in lifestyle can result in the prevention of some chronic conditions, or at least a delay in their onset until a later age. Because of the tendency of some people to resist change, however, bringing about alterations in people’s lifestyles is one the major challenges facing nurses today. Once a chronic condition has occurred, the focus shifts from disease prevention to managing symptoms and staying well by avoiding complications (eg, eye problems in the diabetic) and the development of other acute illnesses (eg, pneumonia in a person with chronic obstructive lung disease). Quality of life, often overlooked by health professionals in their approach to care of people with chronic conditions, is also important. Health-promoting behaviors, such as exercise, are essential to quality of life even in people who have chronic illnesses and disabilities because they help to maintain functional status (Stuifbergen & Rogers, 1997). See Nursing Research Profile 10-1 for more information. Although coworkers, extended family, and health care professionals are affected by the problems of people with chronic illnesses, the problems of living with chronic conditions are most acutely experienced by patients and their immediate families. It is they who feel the greatest impact with lifestyle changes that directly affect quality of life. Nurses provide direct care, especially during acute episodes, but they also provide the teaching and secure the resources and other supports that enable people to integrate their illness into their lives and have some quality of life despite their illness (Michael, 1996). To understand what nursing care is needed, it is important to comprehend the issues that people with chronic illness and their families contend with and manage, often on a daily basis. The challenges of living with chronic conditions can be summarized as follows: • Alleviating and managing symptoms • Psychologically adjusting to and physically accommodating disabilities • Preventing and managing crises and complications • Carrying out regimens as prescribed • Validating individual self-worth and family functioning • Managing threats to identity • Normalizing individual and family life as much as possible • Living with altered time, social isolation, and loneliness •Establishing the networks of support and resources that can enhance quality of life • Returning to a satisfactory way of life after an acute debilitating episode (another myocardial infarction or stroke) or reactivation of a chronic condition • Dying with dignity and comfort
IMPLICATIONS FOR NURSING
Working with people with chronic illness or disability requires not just dealing with the medical aspects of their disorder, but also working with the whole person, physically, emotionally, and socially (Dean, 1999). This holistic approach to care requires nurses to draw upon their entire repertoire of knowledge and skills, including knowledge from the social sciences, psychology in particular. People often respond to illness, health teaching, and regimens in ways that are different from the expectations of health care providers. Although quality of life is usually affected by chronic illness, especially if the illness is severe (Schlenk, Erlen, Dunbar-Jacob et al., 1998), patients’ perceptions of what constitutes quality of life often drive their management behaviors. Nurses and other health care professionals need to recognize this, even though it may be difficult to see patients make unwise choices and decisions about lifestyles and disease management. Individuals have the right to receive care without fearing ridicule or refusal of treatment, even if they caused their medical conditions through their own indiscretions, such as smoking or failure to follow therapeutic regimens. As stated previously, chronic conditions have a course, although that course might be too uncertain to predict with any degree of accuracy. An illness course can be thought of as a trajectory— a course—that can be managed or shaped over time to some extent through proper illness management strategies (Robinson, Bevil, Arcangelo et al., 2001; Strauss & Corbin, 1988; Woog, 1992). The trajectory of an illness can also be divided into phases that enable more precise thinking about a person’s condition. This enables the nurse to put the present situation into the context of what might have happened to the patient in the past—that is, the life factors and understandings that might have contributed to the present state of the illness. In this way, nurses can more readily address the underlying issues and problems. Each phase of chronic illness brings with it different problems, both medical and psychosocial. The needs of a stroke patient who is a good candidate for rehabilitation, for example, are very different from those of a patient with terminal cancer. By thinking in terms of phases, and individual patients within a phase, nurses can target their care more specifically to each person. Not every chronic condition is necessarily life-threatening, and not every patient passes through each possible phase of a chronic condition.
PHASES OF CHRONIC ILLNESS
Over the years, chronic conditions can pass through several different phases (Corbin & Cherry, 1997; Strauss & Corbin, 1988). Nine phases have been identified (Chart 10-1): 1. The pretrajectory phase describes the stage at which the person is at risk for developing a chronic condition because of genetic factors or lifestyle behaviors that increase susceptibility to chronic illness. 2. The trajectory phase is characterized by the onset of symptoms or disability associated with a chronic condition. Since symptoms are being evaluated and diagnostic tests are performed, this phase is often accompanied by uncertainty as the person awaits a diagnosis. Nursing care often involves preparing patients for diagnostic tests and offering emotional support. 3. The stable phase of the trajectory indicates that symptoms and disability are being managed adequately. Although the patient is doing well, nursing care is still important at this time to reinforce positive behaviors and to offer ongoing monitoring. 4. The unstable phase is characterized by an exacerbation of illness symptoms, development of complications, or reactivation of an illness in remission. During this phase, a person’s everyday activities may be temporarily disrupted because symptoms are not well controlled. There may also be more diagnostic tests and a trial of new regimens until some degree of control over symptoms is achieved. During this time of uncertainty, patients look to nurses for guidance and support. 5. The acute phase is characterized by sudden onset of severe or unrelieved symptoms or complications that require hospitalization for their management. This phase may require major modification of the person’s usual activities for a period of time. Nurses are intensely involved in the care of the chronically ill patient during this period, providing direct care and emotional support to the patient and family members. 6. The crisis phase is characterized by a critical or life-threatening situation that requires emergency treatment or care. During this phase patients and their families depend upon the skill, knowledge, and support of nurses and other professionals to stabilize their conditions. 7. The comeback phase is the period in the trajectory marked by recovery after an acute period. It includes learning to live with or to overcome disabilities and a return to an acceptable way of life within the limitations imposed by the chronic condition. Although aspects of care may shift to other health care providers during the rehabilitative phase, the role of nurses as organizers of care and collaborators in the recovery of patients is essential. 8. The downward phase marks the worsening of a condition. Symptoms and disability continue to progress despite attempts to gain some control through treatment and management regimens. A downward turn does not necessarily mean imminent death; the downward trend can be arrested and an illness restabilized. Since patients are not yet acute or dying but usually are living at home during this time, their contact with nurses is often limited. The supportive presence of nurses is needed, however, because of adjustment issues. Nurses working in clinics and physicians’ offices can play an important role in helping patients understand and come to terms with what is happening to them. 9. The dying phase is characterized by the gradual or rapid decline in the trajectory despite efforts to halt the disorder or slow the decline through illness management; it is characterized by failure of life-maintaining body functions. During this phase nurses provide direct and supportive care to patients and their families through hospice programs.
Nursing Management
Nursing care of patients with chronic conditions is varied and occurs in an assortment of settings. It can include provision of direct care or supportive care. Such care is often provided in the clinic or physician’s office, the hospital, or the patient’s home, depending on the status of the illness. Examples of direct care may include assessing the patient’s physical status, providing wound care, managing and overseeing medication regimens, and performing other technical tasks. The availability of this type of nursing care is one of the main reasons patients can remain at home and return to a somewhat normal life after an acute episode of illness. Because much of the day-to-day responsibility for managing chronic conditions rests with the patient and family, nurses often provide supportive care unless the patient is hospitalized. Supportive care may include ongoing monitoring, teaching, counseling, serving as an advocate for the patient, making referrals, and case-managing. Providing supportive care is just as important as the performance of technical care. For example, through ongoing monitoring that might take place either in the home or a nursing clinic, such as a heart failure clinic, a nurse might detect impending complications, such as signs of heart failure. The nurse might detect these signs before they are noticeable to the patient and could make a referral (call the physician or consult the medical protocol in a clinic) for medical evaluation, thereby preventing a lengthy and costly hospitalization.
CARE BY PHASE: APPLYING THE NURSING PROCESS
The focus of care for patients with chronic conditions is determined largely by illness phase and directed by the nursing process, which includes assessment, diagnosis, planning, implementation, and evaluation.
Step 1: Identifying the Trajectory Phase
The first step is assessment of the patient to determine the specific phase (see Chart 10-1). Assessment enables the nurse to identify the specific medical, social, and psychological problems likely to be encountered in a phase. For instance, the problems of a patient having an acute myocardial infarction are very different from those likely to be encountered with the same patient, 10 years later, dying at home of heart failure. The kinds of direct care, referrals, teaching, and emotional support needed in each situation are different as well.
Step 2: Establishing Goals
Once the phase of illness has been identified for a specific patient, along with the specific medical problems and related social and psychological issues, the next step involves establishing the goals of care. The establishment of goals should be a collaborative effort with the patient, family, and nurse working together, for the attainment of a goal is unlikely if it is primarily the nurse’s and not the patient’s. The following are two examples of goals to be determined collaboratively, then written in the language of the nursing process. An elderly man with severe progressive COPD reports increasing difficulty breathing, even with the oxygen level set at 2 liters/min. This interferes with his ability to carry out activities of daily living and has decreased his quality of life. He asks the nurse for help. The nursing diagnosis for this problem might be “Activity intolerance related to less than adequate intake of oxygen secondary to lung disease,” and the mutually agreed upon goal of care might be to increase the patient’s ability to care for himself. Nursing interventions related to this goal might include teaching the client how to pace his activities and helping him to obtain a home health aide to assist with the most demanding activities of daily living. In another example, a 45-year-old woman with moderately advanced multiple sclerosis (MS) is hospitalized with a severe bladder infection. She reports that she has problems with selfcatheterization because of her disability and that she has difficulty obtaining and consuming adequate fluids during the day. The nursing diagnosis for this problem might be “Toileting self-care deficit (in bladder care) related to decreased functional ability secondary to MS,” and the mutual outcomes of care might be to develop strategies to facilitate the self-catheterization process and increase daily fluid intake.
Step 3: Establishing a Plan to Achieve Desired Outcomes
Once goals have been established, the next step consists of establishing a realistic and mutually agreed upon plan for achieving them and identifying specific criteria that can be used to assess the patient’s progress. A plan of care for the man with COPD who complains of a decreased ability to care for himself, for example, might include assisting him to prioritize his activities of daily living so he can carry out those that are most important to him before he becomes too short of breath and tired. It might also include exploring how he feels about having someone assist him at home on a regular basis and, if he agrees to having help, checking on the availability and costs of such services. In many cases, people with chronic illness perceive someone helping them as a threat to their independence and self-esteem, the first step to a nursing home or rehabilitation center. Therefore, they are resistant to someone coming into their home to help them. Criteria to measure progress toward goal attainment and strategies to accomplish the goals might include the following: • At the end of the first nurse–patient session, the patient with COPD will be able to prioritize activities of daily living and agree to look over an information sheet and list of home care agencies provided by the nurse. • By the second nurse–patient session, the patient will report that he is pacing his activities and is therefore better able to carry out important self-care activities. He will also report that he has read the information provided by the nurse about home care agencies. • By the third nurse–patient session, the patient will have compiled a list of the self-care activities that are difficult for him to carry out and for which assistance would be beneficial. The patient will also have reviewed his finances and determined how much he can afford to pay for services. • By the fourth nurse–patient session, the patient will have called a home care agency and made arrangements to have home health services for 2 hours each morning. If the patient cannot make the arrangements, then the nurse would suggest that the family or someone else make them. The goal is to enable the patient to meet basic self-care needs and improve quality of life, thereby having enough time and energy available for other activities. Home health services can help with this. Having the patient make the arrangements for home care promotes a sense of control. People with chronic illness-related disabilities often feel that they have lost a great deal of control over what happens to them; any activities that they can do for themselves, therefore, enhance psychological well being. • By the fifth home visit the patient will report that all selfcare needs are met either by self-pacing of activities or through the assistance of a home health aide. A plan of care for the woman with MS might be to develop techniques for carrying out self-catheterization within the limitations imposed by her disability and to increase her daily fluid intake to six to eight 8-oz glasses of fluid per day. Indicators that the desired goal has been achieved may include the following: • By the end of the first nurse–patient session, the patient and nurse will identify with which steps in the self-catheterization procedure the patient is having the most difficulty. The patient will also be able to list three strategies for improving her intake of fluids. • By the end of the second nurse–patient session, the patient will report that she is performing self-catheterization using the strategies suggested by the nurse for improving her technique. She will also report that she has increased her fluid intake by three glasses. • By the end of the third nurse–patient session, the patient will report that she can perform self-catheterization three out of four times without difficulty and that her fluid intake is now up to six to eight 8-oz glasses a day. • By the end of the fourth nurse–patient session, the patient will be ready for discharge with the confidence that she is competent in performing self-catheterization and obtaining adequate fluid intake despite the physical limitations imposed by her illness.
Step 4: Identifying Factors That Facilitate or Hinder Attainment of Goals
The next step involves identifying environmental, social, and psychological factors that might interfere with or facilitate achieving the goal. In the case of the patient with COPD, for example, not having sufficient resources could prevent him from hiring a home health aide. For this reason, the nurse might want to explore carefully the issue of resources with the patient and, if there are financial constraints, enlist the services of a social worker, with the patient’s consent, to explore possible community resources. Since the patient is having trouble breathing, the nurse should determine whether the patient is also having difficulty cooking and eating, and whether he is losing weight because of insufficient caloric intake to meet his nutritional needs. If cooking is a problem, then the nurse might look into community resources such as Meals on Wheels. If the patient is losing weight, then the nurse should advise him to eat frequent small meals to lessen the fatigue associated with eating and to supplement meals with high-protein drinks. In the case of the patient with MS, the nurse might want to explore the extent of the patient’s physical limitations, how rapidly the MS seems to be progressing, when during the day she has the most difficulty doing the catheterization, and whether that difficulty might be related to fatigue. If fatigue is a factor, the nurse might explore whether the patient would consider having a home health aide to help her with some of her self-care activities. This would enable the patient to conserve her energy for social activities and personal care, such as self-catheterization. The nurse would also discuss with the patient why she is not taking in an adequate amount of fluids. If the patient is too busy or tired to make frequent trips to the sink or refrigerator to get fluids, the nurse might help the patient develop strategies for saving time and energy. For example, the patient could attach a bottle of water to her wheelchair or walker and carry it around with her, or strategically place bottles of water or other liquids around the house to increase their accessibility. The nurse might also explore with the patient the types of caffeine-free fluids that she enjoys drinking.
Step 5: Implementing Interventions
The fifth step is the intervention phase. Possible interventions include providing direct care, serving as an advocate for the patient, teaching, counseling, making referrals, and case-managing (arranging for resources). For example, if the patient with COPD reports after prioritizing his activities of daily living that showering each morning is the most important self-care activity for him, then having a home health aide come early in the morning to help with the shower would be the best arrangement. The home health aide could also help with breakfast, make the bed, and straighten up the house. In this way, the man would use less energy doing these mundane tasks. After showering and dressing the patient might also want to plan a daily rest period, such as sitting down with a crossword puzzle or reading, that might help him overcome some of his sense of breathlessness and feel more rested. If spasms or tremors are interfering with the ability of the woman with MS to catheterize herself, then the nurse would want to review the medications she is taking; if, for instance, she is taking antispasmodics, the self-catheterizations could be timed to coincide with the peak medication levels. In an effort to encourage an increased fluid intake, the nurse might want to help the woman build into her daily routine a set time in the morning and afternoon, allowing for flexibility, to take an herbal tea or juice break that would increase the amount of fluids ingested and also provide a rest period. While it is important for a patient with MS to maintain a sense of independence and accomplishment, it is equally important for the patient to learn to recognize his or her limits, through such signs as fatigue, and to manage them through proper planning. Physicians prescribe therapies, such as medications and diet, and give directions for how much, when, and how they are to be used. Nurses, however, by virtue of their broad knowledge base, can best help patients develop the strategies needed to live with both the symptoms and therapies associated with chronic conditions. Because each patient is an individual, it is important to work individually with each patient and family to identify the best ways to integrate their treatment regimens into their daily living activities. Two tasks are important in managing chronic illness: following regimens to control symptoms and keep the illness stable, and dealing with the psychosocial issues that can hinder illness management and affect quality of life. Diagnosing and prescribing by physicians are important aspects of chronic illness care, but they represent only half of the battle against disease. The other half includes the teaching, counseling, arranging, and case-managing that enable people to live with their disease and gain independence (Hughes, Hodgson, Muller et al., 2000). Saving the life of a patient with an acute myocardial infarction in the ICU, for example, is a positive outcome, but the patient will have a relapse if he or she is not supported in making the lifestyle changes necessary to reduce the probability of another heart attack. Helping patients and their families to understand and implement regimens and to carry out activities of daily living within the limits of their disabilities is one of the most important aspects of health care delivery—and nursing care—for patients with chronic illnesses and their families.
Step 6: Evaluating the Effectiveness of Interventions
The final step is evaluating the effectiveness of the interventions. In chronic illness, maintaining the stability of the condition while at the same time preserving the patient’s control over his or her life and a sense of identity and accomplishment is the primary goal. Success may be defined, however, as merely making progress toward a goal when a patient finds it difficult to implement rapid and drastic changes in the way that he or she does things. Nurses cannot expect that the sedentary person with high blood pressure, for example, is going to develop a sudden passion for exercise. Nor can they expect that working people can easily rearrange their day to accommodate time-consuming regimens such as special diets or complex medication schedules. Bringing about change takes time, patience, creativity, and encouragement from the nurse. Validation by the nurse for each small increment toward goal accomplishment is important for enhancing selfesteem and reinforcing behaviors. If no progress is made or if progress toward goals seems too slow, it may be necessary to redefine the goals or the time frame. The patient may not be ready to progress toward the goals or may be ambivalent about the illness, its treatments, or both (Chin, Polonsky, Thomas & Nerney, 2000). Other conditions such as depression may also interfere with the patient’s ability to carry out regimens and make lifestyle changes. Nurses must also realize that some people will not change. Some people, for example, are unwilling to give up smoking despite advanced COPD. Nor is it unusual to find people with the diagnosis of diabetes failing to adhere completely to their diabetic diets. When patients are having difficulty carrying out regimens or are reluctant to change their lifestyles, nurses should not feel that this is a failure on their part. Patients share responsibility for management of their conditions, and outcomes are as much related to their ability to accommodate the illness and carry out regimens as they are to nursing intervention.
Promoting Home and Community-Based Care
Since chronic conditions are so costly to individuals, families, and society, one of the major goals of nursing in the 21st century 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, such as wearing seat belts and obtaining immunizations. Prevention should also begin early in life and continue throughout the life span. Patient and family teaching is one of the most significant aspects of nursing care and may make the difference in the ability of patients and their families to adapt to chronic health conditions. Well-informed, educated patients are more likely than uninformed patients to be concerned about their health and do what is necessary to maintain it (De Ridder, Depla, Severens & Malsch, 1997). They are also more likely to manage symptoms, recognize the onset of complications, and seek health care early: knowledge is the key to making informed choices and decisions during all phases of the chronic illness trajectory. Despite the importance of teaching the patient and family, the nurse must recognize that patients recently diagnosed with serious chronic conditions and their families may need time to grasp the significance of their condition and its effect on their life. Teaching should be planned carefully so that it provides information that is important to the patient’s well-being at the time without being overwhelming. The nurse who cares for patients with chronic conditions in the hospital, clinic, or home should assess each patient’s knowledge about the illness and its management; the nurse cannot assume that a patient with a long-standing chronic condition has the knowledge necessary to manage the condition. A patient’s learning needs change as the trajectory phase and his or her personal situation changes. The nurse must also recognize that patients may know how their body responds under certain conditions and how best to manage their symptoms (Gallo & Knafl, 1998). Contact with patients in the hospital, clinic, or home offers nurses the ideal opportunity to reassess patients’ learning needs and to provide additional information about an illness and its management.
CONTINUING CARE
Chronic illness management is a collaborative process between patient, family, nurse, and other health care professionals. Collaboration is not limited to hospital settings; rather, it is important in all settings and throughout the illness trajectory (Corbin & Cherry, 2001). Keeping an illness stable over time requires careful and continued monitoring of symptoms and attention to management regimens. Detecting problems early and assisting patients to develop appropriate management strategies can make a significant difference in outcomes. Most chronic conditions are managed in the home. Therefore, care and teaching during hospitalization should focus on what the patient needs to know about the condition in order to manage once discharged to home. Nurses in all settings should be aware of the resources and services available in a community and should make the arrangements (before hospital discharge if the patient is hospitalized) necessary to secure those resources and services. When appropriate, home care services are contacted directly. The home care nurse will reassess how the patient and family are adapting to the chronic condition and its treatment and will continue or revise the plan of care accordingly. Because chronic conditions occur worldwide and the world is increasingly interconnected, nurses should think beyond the individual level to the community and global levels. In terms of illness prevention and health promotion, this entails wide-ranging efforts to assess people for risk factors for chronic illness (eg, blood pressure and diabetes screening, stroke risk assessments) and group teaching related to illness prevention and management. The nurse should also remind the patient with a chronic illness, and the patient’s family, about the need for ongoing health promotion and the screening recommended for all people, as the chronic illness and disability often become the priority to the exclusion of other health-related issues.
NURSING CARE FOR SPECIAL POPULATIONS WITH CHRONIC ILLNESS
When providing care and teaching, the nurse must consider a variety of factors (eg, age, gender, culture, and ethnicity) that influence susceptibility to chronic illness and the ways patients respond to chronic disorders. Certain populations, for example, tend to be more susceptible to certain chronic conditions. Populations at high risk for specific conditions can be targeted for special teaching and monitoring programs. People of different cultures and genders tend to respond to illness differently; being aware of these differences is extremely important (Bates, Rankin- Hill & Sanchez-Ayendez, 1997; Becker, Beyene, Newsom & Rodgers, 1998; Thorne, McCormick & Carty, 1997). For cultures in which patients rely heavily on the support of their families, families must be involved and made part of the nursing care plan. As the United States becomes more multicultural and ethnically diverse, and as the general population ages, nurses need to be aware of how an individual’s culture and age facilitate or hinder chronic illness management, and nurses should be prepared to adapt the care they give accordingly (Becker, Beyene, Newsom & Rogers, 1998; Jennings, 1999; Rehm, 1999).
Principles and Practices of Rehabilitation
Rehabilitation is a dynamic, health-oriented process that assists an ill person or a person with disability (restriction in performance or function in everyday activities) to achieve the greatest possible level of physical, mental, spiritual, social, and economic functioning. The rehabilitation process helps the patient achieve an acceptable quality of life with dignity, self-respect, and independence and is designed for people with physical, mental, or emotional disabilities. During rehabilitation—sometimes called habilitation—the patient adjusts to the disability by learning how to use resources and to focus on existing abilities.
In habilitation, abilities, not disabilities, are emphasized. Rehabilitation is an integral part of nursing because every major illness or injury carries the threat of disability or impairment, which involves a loss of function or an abnormality. The principles of rehabilitation are basic to the care of all patients, and rehabilitation efforts should begin during the initial contact with a patient. The goal of rehabilitation is to restore the patient’s ability to function independently or at a preillness or preinjury level of functioning as quickly as possible. If this is not possible, the aims of rehabilitation are maximal independence and a quality of life acceptable to the patient. Realistic goals based on individual patient assessment are established with the patient to guide the rehabilitation program. Rehabilitation services are required by more people than ever before because of advances in technology that save or prolong the lives of seriously ill, injured, and disabled patients. Increasing numbers of patients who are recovering from serious illnesses or injuries are returning to their homes and communities with ongoing needs. Every patient, regardless of age, gender, ethnic group, socioeconomic status, or diagnosis, has a right to rehabilitation services (Chart 11-1). Approximately
Americans With Disabilities Act
Among all people age 21 to 64 (the prime employable years), approximately 33% of individuals with a severe disability and 77% of those with a nonsevere disability are employed, compared with 82% of nondisabled people. The employed person with disability, however, earns less money than the nondisabled person (U.S. Census, 1997). In 1990, the U.S. Congress passed the Americans With Disabilities Act (ADA) (PL 101-336), which constitutes civil rights legislation designed to permit those with disabilities access to job opportunities and to the community. As a result of this act, employers must evaluate an applicant’s ability to perform the job and not discriminate on the basis of a disability. Employers must also make “reasonable accommodations,” such as equipment or access ramps, to facilitate employment of a person with a disability. The
Right to Access to Health Care and Health Promotion
For years, people with disabilities have been discriminated against in employment, public accommodations, and public and private services including health care. The needs of the disabled in health care settings produce many challenges to health care providers: how to communicate effectively if there are communication deficits, the additional physical demands for mobility, and time required to provide assistance with self-care routines during hospitalization. Physicians and nurses may not know the specific needs of individuals with disability and may fail to provide services for them. For example, an obstetrician may advise a woman with a spinal cord injury not to become pregnant because the physician lacks experience and knowledge in this area of care. The physician and nurses caring for an expectant woman with disability may not know specific transfer techniques to help her onto an examining table or how to advise her on bowel, bladder, and skin care issues during pregnancy. Before labor and delivery, the medical team needs to be educated about the special needs of a woman with a cervical spinal cord injury in regard to management of autonomic hyperreflexia. Often, the person with disability must educate the health care professionals. Because of unfavorable interactions with health care providers, including negative attitudes, insensitivity, and lack of knowledge, people with disability may avoid seeking medical intervention or health promotion programs and activities. For this reason, and because the number of individuals with disability is increasing, nurses must acquire knowledge and skills and be accessible to assist these individuals in maintaining a high level of wellness. Nurses are in key positions to influence the architectural design of health care settings and the selection of equipment that promotes ease of access and health. Padded examination tables that can be raised or lowered make transfers easier for the disabled. Birthing chairs benefit women with disability during yearly pelvic examinations and Pap smears and for urologic evaluations. Ramps, grab bars, and raised and padded toilet seats benefit many persons who have orthopedic disabilities and need routine physical examination and monitoring (eg, bone density measurements). Just as people without disability should have regular screening tests, such as mammography or testicular and prostate examinations, so should people with disability. The health care professionals who provide these screening and monitoring procedures are in a position to influence decisions about how equipment and procedures can be adapted to meet the special needs of their patients, whether these needs are cognitive, motor, or communicative. Nurses can provide expert health promotion education classes that are targeted to the disabled. Classes outrition and weight management are extremely important to individuals who are wheelchair dependent and need assistance with transfers. Safe sex classes are needed by adolescents and young adults who have spinal cord or traumatic brain injury, because the threats of acquired immunodeficiency syndrome (AIDS) and unplanned pregnancy exist for these populations just as they do for the population in general. Other healthy behaviors about which neurologically disabled persons need education include avoiding alcohol and nonprescription medications while taking antispasmodic and antiseizure medications. Nurses should teach all stroke survivors and patients with diabetes how to monitor their own blood pressure or glucose levels. The warning signs and symptoms of stroke, heart attack, and cancer, as well as how to access help, should also be taught to all disabled persons. As active members of society, people with disabilities are no longer an invisible minority. An increased awareness of the needs of people with disabilities will bring about changes to improve their access and accommodate their needs. Modification of the physical environment permits access to public and private facilities and services, including health care, and nurses can serve as advocates for the disabled to eliminate discriminatory practices.
Focus of Rehabilitation
Disability can occur at any age and may result from an acute incident, such as stroke or trauma, or from the progression of a chronic condition, such as arthritis or multiple sclerosis. A person with disability experiences many losses, including loss of function, independence, social role, status, and income. A patient and his or her family members experience a range of emotional reactions to these losses. The reactions may progress from disorganization and confusion to denial of the disability, grief over the lost function or body part, depression, anger, and, finally, acceptance of the disability. The reactions may subside over time and may recur at a later time, especially if chronic illness is progressive and results in increasing losses. Not all patients experience all of the stages, although most do exhibit grief. Patients who exhibit grief should not be blithely encouraged to “cheer up.” The nurse should show a willingness to listen to the patient talk about the disability and should understand that grief, anger, regret, and resentment are all part of the healing process. See the accompanying Gerontologic Considerations box for concerns unique to older adults. The patient’s preexisting coping abilities play an important role in the adaptation process: one patient may be particularly independent and determined, while another may be dependent and seem to lack personal power. One goal of rehabilitation is to help the patient gain a positive self-image through effective coping. The nurse must recognize different coping abilities and identify when the patient is not coping well or not adjusting to the disability (Nursing Research Profile 11-1). The patient and family may benefit from participating in a support group or talking
with a mental health professional to achieve this goal. Refer to Chapter 6 for a detailed discussion of adaptive and maladaptive responses to illness.
The Rehabilitation Team
Rehabilitation is a creative, dynamic process that requires a team of professionals working together with the patient and the family. The team members represent a variety of disciplines, with each health professional making a unique contribution. Each health professional assesses the patient and identifies patient needs within the discipline’s domain. Rehabilitative goals are set. Each health professional assesses the patient, identifies patient needs within the discipline’s domain, and sets rehabilitative goals. Team members hold group sessions at frequent intervals to collaborate, evaluate progress, and modify goals as needed to facilitate rehabilitation and to promote independence, self-respect, and an acceptable quality of life for the patient. The patient is the key member of the rehabilitation team. He or she is the focus of the team effort and the one who determines the final outcomes of the process. The patient participates in goal setting, in learning to function using remaining abilities, and in adjusting to living with disabilities. The patient’s family is also incorporated into the team. The family is a dynamic system, so disability of one member affects the other family members. Only by incorporating the family into the rehabilitation process can the family system adapt to the change in one of its members. The family provides ongoing support, participates in problem solving, and learns to provide necessary ongoing care (Nursing Research Profile 11-2). The rehabilitatiourse develops a therapeutic and supportive relationship with the patient and the family. The nurse always emphasizes the patient’s assets and strengths, positively reinforcing his or her efforts to improve self-concept and self-care abilities. During nurse–patient interactions, the nurse actively listens, encourages, and shares the patient’s successes. Using the nursing process, the nurse develops a plan of care designed to facilitate rehabilitation, restore and maintain optimum health, and prevent complications. The nurse helps the patient identify strengths and past successes and develop new goals. Coping with the disability, self-care, mobility, skin care, and bowel and bladder management are frequently areas for nursing intervention. The nurse assumes the roles of caregiver, teacher, counselor, patient advocate, and consultant. The nurse is often the case manager responsible for coordinating the total rehabilitative plan, collaborating with and coordinating the services provided by all members of the health care team, including the home care nurse, who is responsible for directing the patient’s care after return to the home. Other members of the rehabilitation team may include a physician, nurse practitioner, physiatrist, physical therapist, occupational therapist, speech-language therapist, psychologist, psychiatric liaisourse, social worker, vocational counselor, orthotist or prosthetist, rehabilitation engineer, and sex counselor or therapist.
Areas of Specialty Practice
Although rehabilitation is a component of every patient’s care, there are specialty rehabilitation programs established in general hospitals, free-standing rehabilitation hospitals, and outpatient facilities. The Commission for the Accreditation of Rehabilitation Facilities (CARF) sets standards for these programs and monitors compliance with them. Specialty rehabilitation programs often meet the needs of patients with neurologic disabilities. Stroke recovery programs and traumatic brain injury rehabilitation emphasize cognitive remediation: assisting patients to compensate for memory, perceptual, judgment, and safety deficits as well as teaching self-care and mobility skills. Other goals include assisting patients to swallow food safely and to communicate effectively. In addition to stroke and brain injury, other neurologic disorders treated include multiple sclerosis, Parkinson’s disease, amyotrophic lateral sclerosis, and nervous system tumors. The number of spinal cord injury rehabilitation programs has increased since World War II. Integral components of the programs include understanding the effects and complications of spinal cord injury; neurogenic bowel and bladder management; sexuality and male fertility enhancement; self-care, including prevention of skin breakdown; bed mobility and transfers; and driving with adaptive equipment. The programs also focus on vocational assessment, training, and reentry into employment and the community. Orthopedic rehabilitation programs provide comprehensive services to traumatic or nontraumatic amputee patients, patients undergoing joint replacements, and patients with arthritis. Learning to be independent with a prosthesis or a new joint is a major goal of the program. Pain management, energy conservation, and joint protection are other goals. For patients who have had myocardial infarction, cardiac rehabilitation begins during the acute hospitalization and continues on an outpatient basis. Emphasis is placed on monitored, progressive exercise; nutritional counseling; stress management; and sexuality. Patients with restrictive or chronic obstructive pulmonary disease or ventilator dependency may be admitted to pulmonary rehabilitation programs. Respiratory therapists help the patient achieve more effective breathing patterns. The programs also teach energy conservation techniques, self-medication, and home ventilatory management. Comprehensive pain management programs are available for sufferers of chronic pain, especially low back pain. These programs focus on alternative pain treatment modalities, exercise, supportive counseling, and vocational evaluation. A comprehensive burn rehabilitation program may serve as a step-down unit from an intensive care burn unit. Although rehabilitation strategies are implemented immediately in acute care, a program focused on progressive joint mobility, self-care, and ongoing counseling is imperative for the burn patient. Children are not exempt from the need for specialized rehabilitation. Pediatric rehabilitation programs meet the needs of children with developmental and acquired disabilities, including cerebral palsy, spina bifida, traumatic brain injuries, and spinal cord injuries. As in all areas of nursing practice, nurses practicing in the area of rehabilitation must be skilled and knowledgeable about care of patients with substance abuse. For all individuals with disability, including adolescents, the nurse must assess actual or potential substance abuse. Almost 15 million Americans use illicit drugs; approximately 58 million engage in binge or heavy drinking of alcohol; and about 30% of the population uses nicotine products. Parental alcoholism is one of the strongest predictors of substance abuse. Alcohol abuse rates for people with disability may be twice as high as the general population. Forty to eighty percent of spinal cord injuries are related to substance abuse, and 40% to 80% of all traumatic brain injured patients are intoxicated at the time of injury (U.S. Department of Health and Human Services, 2000). Substance abuse is a critical issue in rehabilitation, especially for disabled individuals who are attempting to gain employment via vocational rehabilitation. Treatment for alcoholism and drug dependencies includes a thorough physical and psychosocial evaluation; detoxification; counseling; medical treatment; psychological assistance for the patient and family; treatment of any coexisting psychiatric illness; and referral to community resources for social, legal, spiritual, or vocational assistance. Length of treatment and the rehabilitation process depends on the individual’s needs. Self-help groups are also encouraged, although attendance in such groups (eg, Alcoholics Anonymous, Narcotics Anonymous) poses various challenges for the person who has neurologic deficits, is confined to a wheelchair, or must adapt to encounters with able-bodied attendees who may not understand disability. All specialty areas of rehabilitation require implementation of the nursing process as described in this chapter.
Assessment of Functional Abilities
Comprehensive assessment of functional capacity is the basis for developing a rehabilitation program. Functional capacity measures a person’s ability to perform activities of ADLs and IADLs. ADLs include activities performed to meet basic needs, such as personal hygiene, dressing, toileting, eating, and moving. IADLs include activities that are necessary for independent living, such as the ability to shop for and prepare meals, use the telephone, clean, manage finances, and travel. The nurse observes the patient performing specific activities (eg, eating, dressing) and notes the degree of independence; the time taken; the patient’s mobility, coordination, and endurance; and the amount of assistance required. Good joint motion, muscle strength, cardiovascular reserve, and an intact neurologic system are also carefully assessed, because functional ability depends on these factors as well. Observations are recorded on a functional assessment tool. These tools provide a way to standardize assessment parameters and supply a scale or score against which improvements may be measured. They also clearly communicate the patient’s level of functioning to all members of the rehabilitation team. Rehabilitation staff use these tools to provide an initial assessment of the patient’s abilities and to monitor the patient’s progress in independence. One of the most frequently used tools to assess the patient’s level of independence is the Functional Independence Measure (FIM). The FIM is a minimum data set, measuring 18 items. The self-care items measured are eating, bathing, grooming, dressing upper body, dressing lower body, toileting, bladder management, and bowel management. The FIM addresses transfers and the ability to ambulate and climb stairs and also includes communication and social cognition items. A WeeFIM instrument is used for children. For both children and adults, scoring is based on a seven-point scale with items used to assess the patient’s level of independence. The PULSES profile is used to assess physical condition (eg, health/illness status), upper extremity functions (eg, eating, bathing), lower extremity functions (eg, transfer, ambulation), sensory function (eg, vision, hearing, speech), excretory function (ie, control of bowel or bladder), and situational factors (eg, social and financial support). Each of these areas is rated on a scale from one (independent) to four (greatest dependency). The Barthel Index is used to measure the patient’s level of independence in ADLs (feeding, bathing, dressing, grooming), continence, toileting, transfers, and ambulation (or wheelchair mobility). This scale does not address communicative or cognitive abilities. The Patient Evaluation Conference System (PECS) contains 15 categories. This comprehensive assessment scale includes such areas as medications, pain, nutrition, use of assistive devices, psychological status, vocation, and recreation. There are many other assessment tools designed to evaluate function in persons with specific disabling conditions. In addition to the detailed functional assessment, the nurse assesses the patient’s physical, mental, emotional, spiritual, social, and economic status. Secondary problems related to the disability, such as muscle atrophy and deconditioning, are assessed, as are residual strengths unaffected by disease or disability. Other areas that require nursing assessment include potential for altered skin integrity, altered bowel and bladder control, and sexual dysfunction.
NURSING PROCESS: THE PATIENT WITH SELF-CARE DEFICITS IN ACTIVITIES OF DAILY LIVING
ADLs are those self-care activities that the patient must accomplish each day to meet personal needs. ADLs include personal hygiene/bathing, dressing/grooming, feeding, and toileting. Many patients are unable to perform such activities easily. An ADL program is started as soon as the rehabilitation process begins, because the ability to perform ADLs is frequently the key to independence, return to the home, and reentry into the community.
Assessment
The nurse must observe and assess the patient’s ability to perform ADLs to determine the level of independence in self-care and the need for nursing intervention. The activity of bathing requires obtaining bath water and utensils, washing, and drying the body after bathing. Dressing requires getting clothes from the closet, putting on and taking off clothing, and fastening the clothing. Self-feeding requires using utensils to bring food to the mouth, and chewing and swallowing the food. The activity of toileting includes removing clothing to use the toilet, cleansing oneself, and readjusting clothing. Grooming activities include combing hair, brushing teeth, shaving or applying makeup, and washing the hands. Patients who can sit up and raise their hands to their head can begin self-care activities. In addition, the nurse needs to be aware of the patient’s medical conditions, the effect that they have on the ability to perform ADLs, and the family’s involvement in the patient’s ADLs. This information is valuable in setting goals and developing the plan of care to maximize self-care.
Nursing Diagnosis
Based on the assessment data, major nursing diagnoses for the patient may include the following: • Self-care deficit: bathing/hygiene, dressing/grooming, feeding, toileting
Planning and Goals
The major goals of the patient include bathing/hygiene independently or with assistance, using adaptive devices as appropriate; dressing/grooming independently or with assistance, using adap- tive devices as appropriate; feeding independently or with assistance, using adaptive devices as appropriate; and toileting independently or with assistance, using adaptive devices as appropriate. Another goal is that the patient with a self-care deficit expresses satisfaction with the extent of independence in self-care activities.
Nursing Interventions
FOSTERING SELF-CARE ABILITIES
To learn methods of self-care effectively, the patient must be motivated. An “I’d rather do it myself ” attitude is encouraged. The nurse must also help the patient identify the safe limits of independent activity; knowing when to ask for assistance is particularly important. The nurse teaches, guides, and supports the patient who is learning or relearning how to perform self-care activities. Consistency in instructions and assistance given by health care providers facilitates the learning process. Recording the patient’s performance provides data for evaluating progress and may be used as a source for motivation and morale building (Chart 11-2). Often, a simple maneuver requires concentration and the exertion of considerable effort on the part of the patient with a disability; therefore, self-care techniques need to be adapted to accommodate the individual patient’s lifestyle. There is usually more than one way to accomplish a self-care activity, so common sense and a little ingenuity may promote increased independence. For example, a person who cannot quite reach his or her head may be able to do so by leaning forward. Encouraging the patient to participate in a support group may also help the patient to discover inventive or creative solutions to self-care problems.
RECOMMENDING ASSISTIVE DEVICES
If the patient has difficulty in performing an ADL, an adaptive or assistive device (self-help device) may be useful. A large variety of assistive devices are available commercially or can be fabricated by the nurse, the occupational therapist, the patient, or the family. The nurse should be alert to “gadgets” coming on the market and evaluate their potential for usefulness. Of course, the nurse must exercise professional judgment and caution in recommending devices, because unscrupulous vendors have marketed unnecessary, overly expensive, or useless items to patients in the past. A wide selection of computerized assistive devices is available, or devices can be designed to help individual patients with severe disabilities to function more independently. The ABLEDATA project (see Resources list) offers a computerized listing of commercially available aids and equipment for patients with disabilities.
HELPING THE PATIENT ACCEPT LIMITATIONS
If the patient has a severe disability, independent self-care may be an unrealistic goal; in this situation, the rehabilitatiourse teaches the patient how to direct his or her own care. The patient may require a personal attendant to perform ADLs. Family members may not be appropriate for providing bathing/hygiene, dressing/grooming, feeding, and toileting assistance, and a spouse may have difficulty providing bowel and bladder care for the patient and maintaining the role of sexual partner. If a personal caregiver is needed, the disabled person or family members must learn how to manage an employee effectively. The nurse assists the patient in accepting self-care dependency.
Evaluation
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include: 1. Demonstrates independent self-care in bathing/hygiene or with assistance, using adaptive devices as appropriate a. Bathes self at maximal level of independence b. Uses adaptive devices effectively c. Reports satisfaction with level of independence in bathing/hygiene 2. Demonstrates independent self-care in dressing/grooming or with assistance, using adaptive devices as appropriate a. Dresses/grooms self at maximal level of independence b. Uses adaptive devices effectively c. Reports satisfaction with level of independence in dressing/grooming d. Demonstrates increased interest in appearance 3. Demonstrates independent self-care in feeding or with assistance, using adaptive and assistive devices as appropriate a. Feeds self at maximal level of independence b. Uses adaptive and assistive devices effectively c. Demonstrates increased interest in eating d. Maintains adequate nutritional intake 4. Demonstrates independent self-care in toileting or with assistance, using adaptive and assistive devices as appropriate a. Toilets self at maximal level of independence b. Uses adaptive and assistive devices effectively c. Indicates positive feelings regarding level of toileting independence d. Experiences adequate frequency of bowel and bladder elimination e. Does not experience incontinence, constipation, urinary tract infection, or other complications
NURSING PROCESS: THE PATIENT WITH IMPAIRED PHYSICAL MOBILITY
Patients who are ill or injured are frequently placed on bed rest or have their activities limited. Problems commonly associated with immobility include weakened muscles, joint contracture, and deformity. Each joint of the body has a normal range of motion; if the range is limited, the functions of the joint and of the muscles that move the joint are impaired, and painful deformities may develop. Nurses must identify patients at risk for such complications. Another problem frequently seen in rehabilitatioursing is an altered ambulatory/mobility pattern. The patient with a disability may be either temporarily or permanently unable to walk independently and unaided. The nurse assesses the mobility of the patient and designs care that promotes independent mobility within the prescribed therapeutic limits. If a person is not able to exercise and move the joints through their full range of motion, contractures may develop. A contracture is a shortening of the muscle and tendon that leads to deformity and limits joint mobility. When the contracted joint is moved, the patient experiences pain; in addition, more energy is required to move when joints are contracted and deformed.
Assessment
At times, a patient’s mobility is restricted because of pain, paralysis, loss of muscle strength, systemic disease, an immobilizing device (eg, cast, brace), or prescribed limits to promote healing. Assessment of the patient’s mobility includes positioning, ability to move, muscle strength and tone, joint function, and the prescribed mobility limits. The nurse may need to collaborate with the physical therapist or other team members to assess mobility. During position change, transfer, and ambulation activities, the nurse assesses the patient’s abilities, the extent of disability, and residual capacity for physiologic adaptation. The nurse observes for orthostatic hypotension, pallor, diaphoresis, nausea, tachycardia, and fatigue. If a patient is not able to ambulate without assistance, the nurse assesses ability to balance, transfer, and use assistive devices (eg, crutches, walker). Crutch walking requires a high energy expenditure and produces considerable cardiovascular stress, so older people with reduced exercise capacity, decreased arm strength, and problems with balance because of old age and multiple diseases may be unable to use them. A walker is more stable and may be a better choice for such patients. The nurse assesses the patient’s ability to use various devices that promote mobility. If a patient uses an orthosis, an external appliance that provides support, prevents or corrects deformities, and improves function, the nurse monitors the patient for effective use and potential problems associated with its use.
Nursing Diagnosis
Based on the assessment data, major nursing diagnoses for the patient may include the following: • Impaired physical mobility • Activity intolerance • Risk for injury • Risk for disuse syndrome • Impaired walking • Impaired wheelchair mobility • Impaired bed mobility
Planning and Goals
The major goals of the patient may include absence of contracture and deformity, maintenance of muscle strength and joint mobility, independent mobility, and increased activity tolerance.
Nursing Interventions
POSITIONING TO PREVENT MUSCULOSKELETAL COMPLICATIONS
Deformities and contractures can often be prevented by proper positioning. Maintaining correct body alignment when the patient is in bed is essential regardless of the position selected. During each contact with the patient, the nurse evaluates the patient’s position and assists the patient to achieve proper positioning and alignment. The most common positions that a patient assumes in bed are supine (dorsal), side-lying (lateral), and prone. The nurse helps the patient assume these positions and supports the body in correct alignment with pillows (Chart 11-3). At times, a splint (eg, wrist or hand splint) may be fabricated by the occupational therapist to support a joint and prevent deformity. The nurse must ensure proper use of the splint and provide skin care.
Preventing External Rotation of the Hip
Patients who are in bed for any period of time may develop external rotation deformity of the hip because the ball-and-socket joint of the hip has a tendency to rotate outward when the patient lies on his or her back. A trochanter roll extending from the crest of the ilium to the midthigh prevents this deformity; with correct placement, it serves as a mechanical wedge under the projection of the greater trochanter.
Preventing Footdrop
Footdrop is a deformity in which the foot is plantar flexed (the ankle bends in the direction of the sole of the foot). If the condition continues without correction, the patient will not be able to hold the foot in a normal position and will be able to walk only on his or her toes, without touching the ground with the heel of the foot. The deformity is caused by contracture of both the gastrocnemius and soleus muscles. Damage to the peroneal nerve or loss of flexibility of the Achilles tendon may result in footdrop. To prevent this disabling deformity, the patient is positioned to sit at 90 degrees in a wheelchair with feet on the footrests or flat on the floor. When the patient is supine in bed, padded splints or protective boots are used to keep the feet at right angles to the legs. Frequent skin inspection of the feet must also be performed to determine whether positioning devices have created any unwanted pressure areas. The patient is encouraged to perform the following ankle exercises several times each hour: dorsiflexion and plantar flexion of the feet, flexion and extension (curl and stretch) of the toes, and eversion and inversion of the feet at the ankles. The nurse provides frequent passive range-of-motion exercises if the patient is unable to perform active exercises.
MAINTAINING MUSCLE STRENGTH AND JOINT MOBILITY
Optimal function depends on the strength of the muscles and joint motion, and active participation in ADLs promotes maintenance of muscle strength and joint mobility.
NURSING ALERT Prolonged bed rest, lack of exercise, incorrect positioning in bed, and the weight of bedding that forces the toes into plantar flexion are factors that contribute to footdrop.
Range-of-motion exercises and specific therapeutic exercises may be included in the nursing plan of care.
Performing Range-of-Motion Exercises
Range of motion is movement of a joint through its full range in all appropriate planes (Chart 11-4). To maintain or increase the motion of a joint, range-of-motion exercises are initiated as soon as the patient’s condition permits. The exercises are planned for the individual to accommodate the wide variation in the degrees of motion that people of varying body builds and age groups can attain (Chart 11-5). Range-of-motion exercises may be active (performed by the patient under supervision of the nurse), assisted (with the nurse helping if the patient is unable to do the exercise independently), or passive (performed by the nurse). Unless prescribed otherwise, a joint should be moved through its range of motion three times, at least twice a day. The joint to be exercised is supported, the
bones above the joint are stabilized, and the body part distal to the joint is moved through the range of motion of the joint. For example, the humerus must be stabilized while the radius and ulna are moved through their range of motion at the elbow joint. The joint should not be moved beyond its free range of motion; the joint is moved to the point of resistance and stopped at the point of pain. If muscle spasms are present, the joint is moved slowly to the point of resistance. Gentle, steady pressure is then applied until the muscle relaxes, and the motion is continued to the joint’s final point of resistance. To perform assisted or passive range-of-motion exercises, the patient must be in a comfortable supine position with arms at the sides and knees extended. Good body posture is maintained during the exercises. The nurse also uses good body mechanics during the exercise session.
Performing Therapeutic Exercises
Therapeutic exercises are prescribed by the physician and performed with the assistance and guidance of a physical therapist or nurse. Research is also underway to develop computerized robots with gentle, compliant behavior that could be used in the home setting for upper-extremity exercises (Krebs, 2000). The patient should have a clear understanding of the goal of the prescribed exercise. Written instructions about the frequency, duration, and number of repetitions, as well as simple line drawings of the exercise, help to ensure adherence to the exercise program. Exercise, when performed correctly, assists in maintaining and building muscle strength, maintaining joint function, preventing deformity, stimulating circulation, developing endurance, and promoting relaxation. Exercise is also valuable in helping to restore motivation and the well-being of the patient. Weight-bearing exercises may slow the bone loss that occurs with disability. There are five types of exercise: passive, active-assistive, active, resistive, and isometric. The description, purpose, and action of each of these exercises are summarized in Table 11-1.
PROMOTING INDEPENDENT MOBILITY
When the patient’s condition stabilizes and the physical condition permits, the patient is assisted to sit up on the side of the bed and then to stand. The patient’s tolerance of this activity is assessed. Orthostatic (postural) hypotension may develop when the patient assumes a vertical position. Because of inadequate vasomotor reflexes, blood pools in the splanchnic (visceral) area and in the legs, resulting in inadequate cerebral circulation. If indicators of orthostatic hypotension (eg, drop in blood pressure, pallor, diaphoresis, nausea, tachycardia, dizziness) are present, the activity is stopped, and the patient is assisted to a supine position in bed. Some disabilities, such as spinal cord injury, acute brain injury, and other conditions that require extended periods in the recumbent position, prevent patients from assuming an upright position at the bedside. Several strategies can be used to assist a patient to assume a 90-degree sitting position. First, a reclining wheelchair with elevating leg rests allows a slow and controlled progression from a supine position to a 90-degree sitting position. A tilt table, a board that can be tilted in 5- to 10-degree increments from a horizontal to a vertical position, may also be used. The tilt table promotes vasomotor adjustment to positional changes and helps the patient with limited standing balance and limited weightbearing activities to avoid the decalcification of bones and low bone mass associated with disuse syndrome and lack of weightbearing exercise. Elastic compression stockings are used to prevent venous stasis. For some patients, a compression garment (leotard) or snugfitting abdominal binder and elastic compression bandaging of the legs are needed to prevent venous stasis and ensuing orthostatic hypotension. When the patient is standing, the feet are protected with a pair of properly fitted shoes. Extended periods of standing are avoided because of venous pooling and pressure on the soles of the feet. The nurse monitors the patient’s blood pressure and pulse and observes for signs of orthostatic hypotension and cerebral insufficiency (eg, the patient reports feeling faint and weak), which suggest intolerance of the upright position. If the patient does not tolerate the upright position, the nurse should recline the patient and elevate the patient’s legs.
Assisting the Patient With Transfer
A transfer is movement of the patient from one place to another (eg, bed to chair, chair to commode, wheelchair to tub). As soon as the patient is permitted out of bed, transfer activities are started. The nurse assesses the patient’s ability to participate actively in the transfer and determines in conjunction with an occupational therapist or physical therapist the required adaptive equipment to promote independence and safety. A lightweight wheelchair with brake extensions, removable and detachable arm rests, and leg rests minimizes structural obstacles during the transfer. Tub seats or benches make transfers in and out of tubs easier and safer. Raised, padded commode seats may also be warranted for patients who must avoid flexing the hips greater than 90 degrees when transferring to a toilet. It is important that the patient maintain muscle strength and, if possible, perform push-up exercises to strengthen the arm and shoulder extensor muscles. The push-up exercise requires the patient to sit upright in bed; a book is placed under each of the patient’s hands to provide a hard surface, and the patient is instructed to push down on the book raising, the body. The nurse should encourage the patient to raise and move the body in different directions by means of these push-up exercises. The nurse or physical therapist teaches the patient how to transfer. There are several methods of transferring from the bed to the
wheelchair when the patient is unable to stand, and the technique chosen should be appropriate for the patient, considering his or her abilities and disabilities. It is helpful for the nurse to demonstrate the technique. If the physical therapist is involved in teaching the patient to transfer, the nurse and the physical therapist must collaborate so that consistent instructions are given to the patient. During transfer, the nurse assists and coaches the patient. Figure 11-1 shows weight-bearing and non–weight-bearing transfer. If the patient’s muscles are not strong enough to overcome the resistance of body weight, a polished lightweight board (transfer board, sliding board) may be used to bridge the gap between the bed and the chair. The patient slides across on the board with or without assistance from a caregiver. This board may also be used to transfer the patient from the chair to the toilet or bathtub bench. The nurse should make sure that the patient’s fingers do not curl around the edge of the board during the transfer, because the weight of the patient’s body can crush them as the patient moves across the board. Safety is a primary concern during a transfer: • Wheelchairs and beds must be locked before the patient transfers. • Detachable arm and foot rests are removed to make getting in and out of the chair easier. • One end of the transfer board is placed under the patient’s buttocks and the other end on the surface to which the transfer is being made (eg, the chair).
• The patient is instructed to lean forward, push up with his or her hands, and then slide across the board to the other surface. The nurse frequently assists weak and incapacitated patients out of bed. The nurse supports and gently assists the patient during position changes, protecting the patient from injury. The nurse avoids pulling on the weak or paralyzed upper extremity, to prevent dislocation of the shoulder. The patient is assisted to move toward the stronger side (Chart 11-6). In the home setting, getting in and out of bed and performing chair, toilet, and tub transfers are difficult for patients with weak musculature and loss of hip, knee, and ankle motion. A rope attached to the headboard of the bed enables the patient to pull toward the center of the bed, and the use of a rope attached to the footboard facilitates getting in and out of bed. The height of a chair can be raised with cushions on the seat or with hollowed-out blocks placed under the chair legs. Grab bars can be attached to the wall near the toilet and tub to provide leverage and stability.
Preparing for Ambulation
Regaining the ability to walk is a prime morale builder. However, to be prepared for ambulation—whether with brace, walker, cane, or crutches—the patient must strengthen the muscles required. Exercise, therefore, is the foundation of preparation. The nurse and physical therapist instruct and supervise the patient in these exercises. For ambulation, the quadriceps muscles, which stabilize the knee joint, and the gluteal muscles are strengthened. To perform quadriceps-setting exercises, the patient contracts the quadriceps muscle by attempting to push the popliteal area against the mattress and at the same time raising the heel. The patient maintains the muscle contraction until a count of five and relaxes for a count of five. The exercise is repeated 10 to 15 times hourly. Exercising the quadriceps muscles prevents flexion contractures of the knee. In gluteal setting, the patient contracts or “pinches” the buttocks together to the count of five, relaxes for the count of five, and repeats 10 to 15 times hourly. If ambulatory aids (ie, walker, cane, crutches) are to be used, the muscles of the upper extremities are exercised and strengthened. Push-up exercises are useful. While in a sitting position, the patient raises the body by pushing the hands against the chair seat or mattress. The patient should be encouraged to do push-up exercises while in a prone position also. Pull-up exercises done on a trapeze while lifting the body are also effective for conditioning. The patient is taught to raise the arms above the head and then lower them in a slow, rhythmic manner while holding weights. Gradually, the weight is increased. The hands are strengthened by squeezing a rubber ball. Typically, the physical therapist designs exercises to help the patient develop the sitting and standing balance, stability, and coordinatioeeded for ambulation. After sitting and standing balance are achieved, the patient uses parallel bars. Under the supervision of the physical therapist, the patient practices shifting weight from side to side, lifting one leg while supporting weight on the other, and then walking between the parallel bars. A patient who is ready to begin ambulation must be fitted with the appropriate ambulatory aid, instructed about the prescribed weight-bearing limits (eg, non–weight-bearing, partial weightbearing ambulation), and taught how to use the aid safely. The nurse continually assesses the patient for stability and adherence to weight-bearing precautions and protects the patient from falling. The nurse provides contact guarding by holding on to a gait belt that the patient wears around the waist. The patient should wear sturdy, well-fitting shoes and be advised of the dangers of wet or highly polished floors and throw rugs. The patient should also learn how to ambulate on inclines, uneven surfaces, and stairs.
Ambulating With Crutches
Patients who are prescribed partial weight-bearing or non– weight-bearing ambulation may use crutches. The nurse or physical therapist should determine whether crutches are appropriate for the patient, because good balance, adequate cardiovascular reserve, strong upper extremities, and erect posture are essential for crutch walking. Ambulating a functional distance (at least the length of a room or house) or maneuvering stairs on crutches requires significant arm strength, because the arms must bear the patient’s weight. Muscle groups important for crutch walking include the following: • Shoulder depressors—to stabilize the upper extremity and prevent shoulder hiking • Shoulder adductors—to hold the crutch top against the chest wall • Arm flexors, extensors, and abductors (at the shoulder)—to move crutches forward, backward, and sideways • Forearm extensors—to prevent flexion or buckling; important in raising the body for swinging gait • Wrist extensors—to enable weight bearing on hand pieces • Finger and thumb flexors—to grasp the hand piece
Preparing the Patient to Walk With Crutches
Preparatory exercises are prescribed to strengthen the shoulder girdle and upper extremity muscles. Meanwhile, crutches need to be adjusted to the patient before the patient begins ambulating. To determine the approximate crutch length, the patient may be measured standing or lying down. A standing patient is positioned against the wall with the feet slightly apart and away from the wall. Then a distance of
Teaching Crutch Walking
The nurse or physical therapist explains and demonstrates to the patient how to use the crutches. The patient learns standing balance by standing on the unaffected leg by a chair. To help the patient maintain balance, the nurse holds the patient near the waist or uses a transfer belt. The patient is taught to support his or her weight on the hand pieces. (For patients who are unable to support their weight through the wrist and hand because of arthritis or fracture, platform crutches that support the forearm and allow the weight to be borne through the elbow are available.) If weight is borne on the axilla, the pressure of the crutch can damage the brachial plexus nerves, producing “crutch paralysis.” For maximum stability, the patient first assumes the tripod position by placing the crutches about 20 to
Teaching Maneuvering Techniques
Before a patient is considered to be independent in crutch walking, he or she needs to learn to sit in a chair, stand from sitting, and go up and down stairs.
To sit down: 1. Grasp the crutches at the hand pieces for control. 2. Bend forward slightly while assuming a sitting position. 3. Place the affected leg forward to prevent weight-bearing and flexion.
To stand up: 1. Move forward to the edge of the chair with the strong leg slightly under the seat. 2. Place both crutches in the hand on the side of the affected extremity. 3. Push down on the hand piece while raising the body to a standing position.
To go down stairs: 1. Walk forward as far as possible on the step. 2. Advance crutches to the lower step. The weaker leg is advanced first and then the stronger one. In this way, the stronger extremity shares with the arms the work of raising and lowering the body weight.
To go up stairs:
1. Advance the stronger leg first up to the next step.
2. Advance the crutches and the weaker extremity.
Note that the strong leg goes up first and comes down last. A memory device for the patients is, “Up with the good, down with the bad.”
AMBULATING WITH A
A walker provides more support and stability than a cane or crutches. There are two types of walkers: pick-up walkers and rolling walkers. A pick-up walker (one that has to be picked up and moved with each step forward) does not permit a natural walking pattern and is useful for patients who have poor balance or limited cardiovascular reserve or who cannot use crutches. A rolling walker allows automatic walking and is used by patients who cannot lift or who inappropriately carry a pick-up walker. The height of the walker is adjusted to the patient. The patient’s arms resting on the walker hand grips should exhibit 20 to 30 degrees of flexion at the elbows. The patient should wear sturdy, well-fitting shoes. The nurse walks with the patient, holds him or her at the waist as needed for balance, continually assesses the patient’s stability, and protects the patient from falls. The patient is instructed to ambulate with a pick-up walker as follows: 1. Push off a chair or bed to come to a standing position. Never pull yourself up using the walker. 2. Hold the walker on the hand grips for stability. 3. Lift the walker, placing it in front of you while leaning your body slightly forward. 4. Walk into the walker, supporting your body weight on your hands when advancing your weaker leg, permitting partial weight bearing or non–weight bearing as prescribed. 5. Balance yourself on your feet. 6. Lift the walker, and place it in front of you again. Continue this pattern of walking. 7. Remember to look up as you walk.
USING A CANE
A cane helps the patient walk with greater balance and support and relieves the pressure on weight-bearing joints by redistributing weight. Quad canes (four-footed canes) provide more stability than straight canes. To fit the patient for a cane, the patient is instructed to flex the elbow at a 30-degree angle, hold the handle of the cane about level with the greater trochanter, and place the tip of the cane
The patient is taught to ambulate with a cane as follows:
Cane–foot sequence: 1. Hold the cane in the hand opposite the affected extremity to widen the base of support and to reduce the stress on the involved extremity. If the patient for some reason is unable to use the cane in the opposite hand, the cane may be used on the same side. 2. Advance the cane at the same time the affected leg is moved forward. 3. Keep the cane fairly close to the body to prevent leaning. 4. Bear down on the cane when the unaffected extremity begins the swing phase.
To go up and down stairs using the cane: 1. Step up on the unaffected extremity. 2. Place the cane and affected extremity up on the step. 3. Reverse this procedure for descending steps (“up with the good, down with the bad”). As for all patients beginning ambulation with an ambulatory aid, the nurse continually assesses the patient’s stability and protects the patient from falls. The nurse accompanies the patient, holding him or her at the waist as needed for balance. The patient is assessed for tolerance of walking, and rest periods are provided as needed.
ASSISTING THE PATIENT WHO USES AN ORTHOSIS OR PROSTHESIS
Orthoses and prostheses are designed to facilitate mobilization and to maximize the patient’s quality of life. An orthosis is an external appliance that provides support, prevents or corrects deformities, and improves function. Orthoses include braces, splints, collars, corsets, or supports that are designed and fitted by an orthotist or prosthetist. Static orthoses (no moving parts) are used to stabilize joints and prevent contractures. Dynamic orthoses are flexible and are used to improve function by assisting weak muscles. A prosthesis is an artificial body part; it may be internal, such as an artificial knee or hip joint, or external, such as an artificial leg or arm. In addition to learning how to apply and remove the orthosis and maneuver the affected body part correctly, rehabilitation patients must learn how to properly care for the skin that comes in contact with the appliance. Skin problems or pressure ulcers may develop if the device is applied too tightly or too loosely, or if it is adjusted improperly. The nurse instructs the patient to clean and inspect the skin daily, to make sure the brace fits snugly without being too tight, to check that the padding distributes pressure evenly, and to wear a cotton garment without seams between the orthosis and the skin. If the patient has had an amputation, the nurse promotes tissue healing, uses compression dressings to promote residual limb shaping, and minimizes contracture formation. A permanent prosthetic limb cannot be fitted until the tissue has healed completely and the residual limb shape is stable and free of edema. The nurse also helps the patient cope with the emotional issues surrounding loss of a limb and encourages acceptance of the prosthesis. The prosthetist, the nurse, and the physician collaborate to provide instructions related to skin care and care of the prosthesis.
Evaluation
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include: 1. Demonstrates improved physical mobility a. Maintains muscle strength and joint mobility b. Does not develop contractures c. Participates in exercise program 2. Transfers safely a. Demonstrates assisted transfers b. Performs independent transfers 3. Ambulates with maximum independence a. Uses ambulatory aid safely b. Adheres to weight-bearing prescription c. Requests assistance as needed 4. Demonstrates increased activity tolerance a. Does not experience episodes of orthostatic hypotension b. Reports absence of fatigue with ambulatory efforts c. Gradually increases distance and speed of ambulation
NURSING PROCESS: THE PATIENT WITH IMPAIRED SKIN INTEGRITY
An estimated 1.5 to 3 million patients develop pressure ulcers annually (Mayo Clinic Rochester, 2001). Both prevention and treatment of pressure ulcers are costly in terms of health care dollars and quality of life for patients at risk. Because the cost in terms of pain and suffering for a person with a pressure ulcer cannot be quantified, all possible efforts should be made to prevent skin breakdown. Patients confined to bed for long periods, patients with motor or sensory dysfunction, and patients who experience muscular atrophy and reduction of padding between the overlying skin and the underlying bone are prone to pressure ulcers. Pressure ulcers are localized areas of infarcted soft tissue that occur when pressure applied to the skin over time is greater than normal capillary closure pressure, which is about
Assessment
Immobility, impaired sensory perception or cognition, decreased tissue perfusion, decreased nutritional status, friction and shear forces, increased moisture, and age-related skin changes all contribute to the development of pressure ulcers.
IMMOBILITY
When a person is immobile and inactive, pressure is exerted on the skin and subcutaneous tissue by objects on which the person rests, such as a mattress, chair seat, or cast. The development of pressure ulcers is directly related to the duration of immobility: if pressure continues long enough, small vessel thrombosis and tissue necrosis occur, and a pressure ulcer results. Weight-bearing bony prominences are most susceptible to pressure ulcer development because they are covered only by skin and small amounts of subcutaneous tissue. Susceptible areas include the sacrum and coccygeal areas, ischial tuberosities (especially in people who sit for prolonged periods), greater trochanter, heel, knee, malleolus, medial condyle of the tibia, fibular head, scapula, and elbow (Fig. 11-3).
IMPAIRED SENSORY PERCEPTION OR COGNITION
Patients with sensory loss, impaired level of consciousness, or paralysis may not be aware of the discomfort associated with prolonged pressure on the skin and, therefore, may not change their position themselves to relieve the pressure. This prolonged pressure impedes blood flow, reducing nourishment of the skin and underlying tissues. A pressure ulcer may develop in a short period.
DECREASED TISSUE PERFUSION
Any condition that reduces the circulation and nourishment of the skin and subcutaneous tissue (altered peripheral tissue perfusion) increases the risk of pressure ulcer development. Patients with diabetes mellitus experience an alteration in microcirculation. Similarly, patients with edema have impaired circulation and poor nourishment of the skin tissue. Obese patients have large amounts of poorly vascularized adipose tissue, which is susceptible to breakdown.
DECREASED NUTRITIONAL STATUS
Nutritional deficiencies, anemias, and metabolic disorders also contribute to pressure ulcer development. Anemia, regardless of its cause, decreases the blood’s oxygen-carrying ability and predisposes a patient to pressure ulcer formation. Patients who have low protein levels or who are in a negative nitrogen balance experience tissue wasting and inhibited tissue repair. Serum albumin is a sensitive indicator of protein deficiency; serum albumin levels of less than 3 g/mL are associated with hypoalbuminemic tissue edema and increased risk of pressure ulcers. Specific nutrients, such as vitamin C and trace minerals, are needed for tissue maintenance and repair.
FRICTION AND SHEAR
Mechanical forces also contribute to the development of pressure ulcers. Friction is the resistance to movement that occurs when two surfaces are moved across each other. Shear is created by the interplay of gravitational forces (forces that push the body down) and friction. When shear occurs, tissue layers slide over one another, blood vessels stretch and twist, and the microcirculation of the skin and subcutaneous tissue is disrupted. Evidence of deep tissue damage may be slow to develop and may
present through the development of a draining tract. The sacrum and heels are most susceptible to the effects of shear. Pressure ulcers from friction and shear occur when the patient slides down in bed (Fig. 11-4) or when the patient is moved or positioned improperly (eg, dragged up in bed). Spastic muscles and paralysis increase the patient’s vulnerability to pressure ulcers related to friction and shear.
INCREASED MOISTURE
Prolonged contact with moisture from perspiration, urine, feces, or drainage produces maceration (softening) of the skin. The skin reacts to the caustic substances in the excreta or drainage and becomes irritated. Moist, irritated skin is more vulnerable to pressure breakdown. Once the skin breaks, the area is invaded by microorganisms (eg, streptococci, staphylococci, Pseudomonas aeruginosa, Escherichia coli), and infection occurs. Foul-smelling infectious drainage is present. The lesion may enlarge and allow a continuous loss of serum, which may further deplete the body of essential proteieeded for tissue repair and maintenance. The lesion may continue to enlarge and extend deep into the fascia, muscle, and bone, with multiple sinus tracts radiating from the pressure ulcer. With extensive pressure ulcers, systemic infections may develop, frequently from gram-negative organisms.
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