Nursing care of patients with chronic conditions is varied and occurs in a variety of settings. Care may be direct or supportive. Direct care may be provided in the clinic or physician’s office, a nurse managed clinic, the hospital or patient’s home, depending on the status of the illness.
Examples of direct care 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 may allow the patient to remain at home and return to a more normal life after an acute episode of illness. Giving supportive care is just as important as giving technical care. For example, through ongoing monitoring either in the home or in clinic, a nurse might detect early signs of impending complications and make a referral for medical evaluation.
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. This holistic approach to care requires nurses to draw on their knowledge and skills, including knowledge from the social sciences and psychology in particular.
Applying the Nursing Process Using the Phases of the Chronic Illness System
The focus of care for patients with chronic conditions is determined largely by the phase of the illness and is directed by the nursing process, which includes assessment, diagnosis, planning, implementation, and evaluation.
Step 1: Identifying Specific Problems and the Trajectory Phase
first step is assessment of the patient to determine the specific problems identified by the patient, family, nurse and other health care providers. Assessment enables the nurse to identify the specific medical, social, and psychological problems likely to be encountered in a phase. The types of direct care, referrals, teaching, and emotional support needed in each situation are different as well. But complementary and alternative therapies are often used by people with chronic illness, it is important to determine whether a patient with a chronic illness is using these regimens.
Step 2 : Establishing and Prioritizing goals
Once the phase of illness has been identified for a specific patient, along with the specific medical problems and related social and psychological problems, the nurse helps prioritize goals must be a collaborative effort , with the patient, family ,and nurse working together, and the goals must be consistent with the abilities, desires, motivations , and resources of those involved.
Step 3: Defining the Plan of Action to Achieve Desired outcomes
Once goals have been established, it is necessary to identify a realistic and mutually agreed on plan for achieving them, patient’s progress. Identifying the person responsible for each task in the action plan is also essential , as is identifying the environment , social ,and psychological factors that might interfere with or facilitate achieving the desired outcome.
Step 4 : Implementing the plan and interventions
Possible interventions include providing direct care, serving as an advocate for the patient, educating, counseling, making referrals, and case management. Nurses help the patient implement action that allow the patient to live with the symptoms and therapies associated with chronic conditions.
Step 5: Following up and evaluating outcomes
The final step involves following up to determine if the problem is resolving or being managed and if the patient and family are adhering to the plan. This follow up may uncover the existence of new problems resulting from the intervention, problems that interfere with the ability of the patient and family to carry out the plan, or previously unexpected problems. Patient need the support and encouragement from the nurses.