Learning Objectives
By the end of this section, you will be able to:
- Analyze different healthcare considerations for chronic conditions
- Identify how to ensure quality health care for people with chronic conditions
- Explain nursing care of patients with chronic conditions
Although chronic conditions vary in severity, treatment needs, and support requirements, nursing care for individuals with chronic conditions focuses on providing access to all individuals. Nurses maintain a strong awareness of individual needs by considering various factors that affect healthcare delivery and access. By creating care plans focused on these specific needs, nurses promote autonomy by creating an atmosphere in which the patient is an expert on their own health. Caring for individuals with chronic conditions requires collaboration and knowledge of medication and therapeutic regimens. Patient-centered care and improving quality of life are also of high importance in caring for individuals with chronic conditions
Healthcare Considerations for Chronic Conditions
Many social, environmental, and personal factors affect healthcare delivery. Nurses will address considerations that affect patients on a personal level, such as psychological and ethical issues. Other considerations include environmental factors, financial concerns, and family dynamics. Other factors, such as social interactions, at-risk populations, and support services, also guide nursing care for individuals with chronic conditions.
Psychological Considerations
Psychological considerations in chronic disease relate to the person’s day-to-day experience living with a chronic disease. Individuals may experience grief related to a loss of ability over time. In addition to grief, chronic diseases pose additional mental health challenges. Chronic conditions are associated with a high rate of depression (Ma et al., 2021). Mental health conditions triggered by chronic disease may be exacerbated by fatigue, chronic pain, and fear.
Chronic pain is common in many long-term disorders and has a high correlation with depression. Up to 30 percent to 50 percent of individuals with chronic pain have coexisting depression (Meda et al., 2022). Depression may also precede chronic pain. Nurses can focus on promoting support groups and providing education on the importance of psychotherapy to help develop coping strategies for chronic illnesses. The burden of chronic disease may also cause interpersonal, family, and relationship conflicts related to caregiver strain, financial stress, loss of work ability, increased healthcare costs, and increased time burden. Common are feelings of sadness, grief, and discouragement, which can fluctuate over time depending on the immediate health condition. Grief in chronic disease is an important topic that nurses can help patients navigate. Losing ability, facing death, or developing progressive syndromes can lead to a specific grief response.
Ethical Considerations
Ethical considerations in caring for individuals with chronic diseases are an important aspect of care for nurses. The ethics of care, particularly for individuals with multimorbidity, the co-occurrence of two or more chronic disease states, revolves around patient autonomy and dependence. Studies show there is a fine line between autonomy and dependence in caring for patients with chronic disease (Coronado-Vázquez et al., 2020). Promoting quality of life and autonomy are two of the primary roles of the nurse; however, the vision of autonomy balanced with support must be shared among the healthcare team and the patient. A sense of autonomy empowers patients to feel a sense of control and produces improved well-being and measurable health outcomes and quality of life. The ethical considerations nurses must consider include the financial burden of chronic disease, particularly multimorbidity at an individual level as well as at community and societal levels. Beneficence and nonmaleficence also play a role in the nursing care of individuals with chronic disease. This is easily demonstrated by considering the effects of polypharmacy on patient health and well-being. Multiple medications meant to improve patient health can have harmful effects due to drug-drug interactions and organ system reactions. Diligence on the part of the nurse can identify problematic medication combinations, particularly in patients who, because of multiple chronic diseases, are seen by many specialty healthcare providers. In this instance, nurses take on the care coordinator role for patient wellness while maintaining treatment plans across medical specialties.
Social Considerations
Social considerations about chronic disease focus on the ethical issue of healthcare equity, fairness in healthcare access, and disparities among social and demographic groups. The nurse's role is to level the field and reduce disparities while respecting and understanding social and cultural determinants of health. Social determinants of health include social practices, lifestyle, work, living situation, and community environment. These can range from health choices such as smoking, drug or alcohol use, and poor nutrition, to violence in neighborhoods, domestic violence, pollutants in the environment, unemployment, and high-stress employment. These all point back to the toll that social constraints and factors play on an individual's health and the health of a community in which people dwell. Social determinants of health also have a significant impact on personal well-being and can affect friendships, interactions with coworkers, access to leisure activities, and participation in hobbies.
Patient Conversations
A Family in Transition
Scenario: Dara is a 39-year-old patient who is seeking care for her 14-year-old daughter, Lana, who is struggling with depression and anxiety. Lana does not want to be at the appointment today and offers little verbal interaction. They are seeking a referral to a mental health specialist as well as guidance in obtaining a social worker. Dara lost her job about a year ago and she and Lana have been sleeping in their van and staying with friends on and off since then.
Nurse: Good afternoon, I’m Finn. It looks like we’re seeing you today to discuss some emotional challenges you are dealing with.
Patient: We’ve had a lot of challenges this year and they’re starting to take a toll on Lana. I’m noticing her withdrawing and becoming increasingly anxious and angry. She’s lost some friends who seem repelled by our situation, and I think she’s being teased about being homeless, too. I don’t have much hope in changing our situation right now, either.
Nurse: It sounds like you’re really worried about Lana and maybe you are struggling as well.
Patient: Yes, I am, but I want to get Lana some help in managing depression and anxiety. I feel that if we had a social worker to help us navigate the system, we might have a better chance of finding an affordable place to live.
Nurse: It took a lot of courage for you to come in today. I know the healthcare provider can evaluate Lana today and get her on the right track to feeling better and coping with these hard times.
Patient: Can you refer us to a social worker, too?
Nurse: Yes, we can refer your family to a social worker. I think a referral for counseling that is covered by your insurance may also be beneficial for you and Lana. Are you willing to see a counselor?
Patient: Yes, I think seeing a counselor individually and together would really give us a boost. Thank you for your help today.
Nurse: Great, we’ll get the referrals going, and the healthcare provider will be in shortly to see you.
In contrast, social determinants of health can also guide disease prevention and health promotion (see 4.1 Defining Health and Wellness for more on social determinants of health). Perceived discrimination and the strength of social networks also play a role in health. Focusing on these factors, nurses must address the negative impacts of social factors on health. Focusing on positive impacts, such as strong family bonds and community support, promotes an overall sense of health and potentially reduces the risk of chronic disease among individuals in high-risk social groups (Cockerham et al., 2017).
On an individual level, nurses can encourage patients to embrace their social environment and existing support networks by:
- becoming experts in their own care
- joining support groups
- learning about their disease process
- talking to others about their illness
- understanding their medications and treatment
Financial Considerations
Chronic disease is responsible for an individual financial cost as well as an overall financial burden nationwide. Chronic and mental health disease make up 90 percent of healthcare spending in the United States each year (CDC, 2023). Treatments, medications, and interventions for chronic disease are significant expenses for individuals, particularly those with multiple chronic diseases. Additional costs are incurred with health insurance premiums as well as lost productivity when individuals are unable to work or work in the same way due to chronic illness.
Family Considerations
Chronic disease can affect families in both financial and emotional ways. The burden of care on families is high and can increase financial burden if caregivers must lose work productivity to perform care duties. Additional effects on families include emotional worry and caregiver burnout. A family-centered approach to care may be beneficial, particularly in families providing much of the caregiving. Nursing actions may include advocating for respite care, providing education to the patient and family regarding the disease process, and providing support services to ease financial burden.
Environmental Considerations
Environmental considerations include factors associated with continued exposure to risk factors and positive and stable environments to promote well-being. This may involve addressing environmental determinants of disease, including risk factors such as smoking, alcohol use, and lifestyle habits. Other environmental determinants are housing stability, nutrition, food security, financial security, and physical safety or violence. Stressful events trigger heightened emotional states and may exacerbate symptoms of chronic disease or create a scenario of limited coping. For older adults and those with disabilities, environmental considerations must include whether an individual can live independently, in an assisted living facility, or in a long-term care facility. Living situations depend on each patient’s specific abilities and safety. Nurses will help individuals cope with changes in living situations, such as moving from their family home, due to falling risk, to an assisted living facility.
Considerations of At-Risk Populations
Individuals in at-risk demographic groups may be at higher risk for chronic disease and have more difficulty accessing adequate care for chronic disease. Pregnant women and children may require increased support in obtaining healthy nutrition, accessing maintenance health care, and maintaining safe living situations. Older adults may require special care due to financial concerns, lack of support, fall and safety risks, and dementia. Veterans may have a higher risk for mental health disorders, suicide, PTSD, and chemical exposure–related diseases. Other at-risk demographic populations include individuals who:
- are unemployed
- are unhoused or have housing insecurity
- are uninsured or underinsured
- experience addiction
- experience food insecurity
- experience poverty
Due to a lack of resources, this individual may delay seeking treatment and enter the healthcare system only during a health crisis. When creating care plans, nurses must consider challenges these people face. By focusing on health promotion and disease prevention, nurses help prevent healthcare crises.
Ensuring Quality Health Care
Quality care is the responsibility of society, the individual, and the healthcare team. Collaborative teamwork is crucial in creating affordable, accessible health care for all. It is also important to focus care at an individual level to promote autonomy and discourage a sense of dependence. Quality health care must empower individuals to understand their disease and treatment plans, manage multiple disease states, and advocate for themselves to maintain the best quality of life and sense of well-being.
Therapeutic Regimens
Therapeutic regimens vary widely depending on the disease process, patient preferences, available services, and financial costs. Managing multiple chronic illnesses requires a more complex plan and more frequent follow-up and re-evaluation of the plan to maintain a positive trajectory in care. Nurses play a role in ensuring that patients fully understand their treatment plan, the purpose of treatments and medications, and expected outcomes. Nurses also are a link between healthcare providers and patients and work to coordinate appropriate specialty care and follow-up. Nurses are key in providing education regarding therapeutic plans in an understandable and clear way for patients. They are often the first to answer questions and explain patient changes and outcomes.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Informatics
Definition: Effectively apply appropriate technology to communicate, manage therapeutic regimens, and improve safety.
Knowledge: Nurses must recognize gaps in education or therapeutic regimen monitoring that may benefit from technology-based interventions. For example, an individual with difficult-to-control type 2 diabetes expresses concern about pain with finger sticks, trouble remembering to check her blood sugar, and erratic blood sugar levels throughout the day. The nurse knows the patient has been unable to tolerate many medications. The patient also expresses fear about the provider's recommendation for insulin therapy, because she is afraid of having low blood sugar while at work.
Skill: The nurse can relay the patient’s concerns to the healthcare provider and advocate for technology-based continuous glucose monitoring (CGM). The nurse can help the patient understand the benefits of CGM in monitoring and improving the outcomes of her insulin regimen. The patient can forward blood sugar logs to the office and receive prompt feedback on adjusting her long-acting insulin.
Attitude: The nurse can present these technological-based options to the patient enthusiastically to promote better health, less hassle, and improve the healthcare provider's ability to adjust her medication regimen quickly and efficiently.
Enabling Self-Management
A key to promoting health and well-being is a focus on empowerment, autonomy, and self-management. The level of self-management varies greatly depending on the type of illness, but nurses can hone their ability to identify the level of self-management possible for everyone. For example, in young adults managing type 1 diabetes, nurses can empower their patients to make healthy lifestyle choices, proper nutrition, and safe insulin management to prevent long-term complications. For older adults with multiple chronic diseases, understanding their medication regimen and maintaining daily movement and nutrition to continue independent living creates a sense of autonomy. In older adults with severe and progressive dementia, providing small choices in food and encouraging self-hygiene encourages a continued sense of autonomy even when full supervision is required for safety.
Patient-Centered Care
Patient-centered care focuses on each individual’s differences and how they experience chronic disease. Patients may have different choices regarding treatment and different views on lifestyle changes and quality of life. Regardless of a patient’s choices, offering respect and acceptance is an important role of the nurse. Patient-centered care always involves the patient and incorporates their choices in treatment plans. Active listening ensures that patients are and feel heard and empowers them to take an active role in their health. This positively affects health outcomes overall, even in the face of chronic disease. A comprehensive approach to patient care varies from person to person but includes the same important aspects (Table 42.7).
| Patient 1 | Patient 2 | |
|---|---|---|
| Disease history | 31-year-old male diagnosed with type 2 diabetes during a routine screening | 68-year-old male diagnosed with type 2 diabetes when he sought care for a foot wound |
| Lifestyle |
|
|
| Healthcare access |
|
|
| Additional medical diagnoses |
|
|
| Motivation |
|
|
| Preferences |
|
|
| Family resources |
|
|
| Patient-centered care provided by the nurse |
|
|
Managing Multiple Conditions
Multimorbidity is common in chronic disease. Managing multiple conditions is difficult for providers as well as patients. Interactions between medication and treatments and the risks and benefits of performing the treatment and beginning new medications must be considered. As noted, many chronic conditions may trigger other conditions or contribute to compounding symptoms. Managing multiple conditions requires coordination between healthcare providers and must consider patient preferences and abilities. A patient-centered approach considers that individuals have different conditions, take different medications, and choose different treatments.
Collaborative Management
Collaborative management of chronic disease includes physician specialists, nurses, and various other healthcare and ancillary team members (Table 42.8). Nurses often serve as team coordinators and patient advocate. Creating a collaborative team depends on the diseases present, patient preferences, financial resources, and availability of team members.
| Disease Type | Collaborative Team Members |
|---|---|
| Cancer, depending on type | Geneticist Hospice nurse Massage therapist Mental health professional Nutritionist Oncologist Palliative care specialist Physical therapist Plastic surgeon Radiation oncologist Surgeon |
| Cardiovascular diseases | Cardiac rehabilitation nurse Cardiologist Cardiovascular surgeon Mental health professional Physical therapist Pulmonologist |
| Respiratory | Allergist Pulmonologist Respiratory therapist Speech therapist |
| Kidney | Cardiologist Dialysis nurse Home health nurse Mental health professional Nephrologist Occupational therapist Palliative care specialist |
| Cognitive | Mental health professional Neurologist Occupational therapist Physical therapist Social worker Speech therapist |
| Neurological | Mental health professional Neurodevelopmental psychologist Occupational therapist Physical therapist Social worker Speech therapist |
| Neuromuscular | Mental health professional Neurologist Neurosurgeon Occupational therapist Physical therapist Speech therapist |
| Metabolic | Endocrinologist Mental health professional Nutritionist Physical therapist |
| Immune | Infectious disease specialist Mental health professional Nutritionist Occupational therapist Physical therapist Rheumatologist |
Nursing Care of Patients with Chronic Conditions
Nursing care of patients with chronic conditions encompasses care along the life span continuum from infancy through older adulthood. Patient-centered care is an essential component that links all aspects of nursing care for these individuals. Specific nursing actions must consider each patient's physical and functional abilities and how these change over time. Many chronic conditions require long-term medical management, including medication therapy. Nurses play a key role in helping patients manage these medication regimens to maintain the safety and efficacy of the treatment. As with all other nursing specialties, chronic disease management requires ongoing and patient-tailored education. Education is not a one-and-done nursing intervention but an ongoing and evolving process of helping patients manage and cope with chronic disease diagnosis, progression, treatment, and complications. Supportive care involves the emotional support of individuals dealing with chronic conditions. In addition, supportive care focuses on symptom management and improving quality of life rather than treating or changing the course of the disease.
Assessing Physical and Functional Status
Nurses play an important role in assessing physical changes that may signal the onset or progression of chronic conditions. Nurses perform various physical assessments depending on the hospital, outpatient, long-term care, or home care setting. These often are head-to-toe assessments during a hospital or long-term care facility admission. Head-to-toe assessments offer a baseline of current physical status and allow nurses, physicians, and other healthcare professionals to gauge changes in the patient's condition over time. This type of physical assessment includes inspection, auscultation, palpation, and measurement of vital signs. A targeted physical assessment will focus on documenting mobility, organ system abnormalities, sensory issues, and wounds and incisions.
Through a functional assessment, nurses aim to paint a picture of how individuals function in various life situations, such as self-care, activities of daily living, transportation, medication management, social interactions, and family roles. Understanding an individual's functional status allows nurses to gauge the need for specific support services for the individual and the family. Routine assessment of functional status allows nurses to make appropriate referrals to ancillary healthcare providers such as physical therapists, occupations therapists, respiratory therapists, and social workers.
Managing Medication Regimens
In the management of chronic conditions, medication management can be complex. Patients may need help understanding the function of their medications and managing the day-to-day regimen. The effectiveness and safety of medication self-management depend on cognitive function, the complexity of the regimen, and the type of medications prescribed. Nurses are frequently required to explain the function of medications to patients. Nurses must explain the details in a way that each patient can understand. This may require written or visual communication; for others, it may simply be a verbal explanation. Understanding the complex interactions between medications and monitoring for medication side effects and interactions between multiple medications is also critical. Drug-drug interactions are common; however, sometimes, the benefit of the medication outweighs the risk of an interaction. This is when nurses monitor for adverse reactions and report them to the healthcare provider. Educating and encouraging patients to report any changes in their condition or how they feel is also essential. Nurses will need to teach medication administration for injectable medications, inhaler use, topical preparations, and other nonoral medications. Nurses must also watch for high-risk knowledge gaps, such as an individual needing help understanding the reason for a medication, the timing, or the fact that it must be taken consistently to provide effective results.
Providing Education
Education encompasses all aspects of treatment and care for chronic illness. Nurses must rely on appropriate communication techniques tailored to each patient when providing education, to ensure the best possible reception of the information. Repeating the teaching multiple times may be necessary. A teach-back method is effective for teaching medication administration, the pathophysiology of the disease, and family teaching. Based on individual learning preferences, nurses may provide questions and answer discussions, handouts for visual assistance, and video learning to solidify learning.
Nurses providing education on chronic conditions must consider each individual's health literacy and the ability of an individual to understand and apply health-related information. The teach-back method allows patients to explain in their own words the information provided and demonstrate their ability to perform a medication administration such as insulin injection or inhaler use. Regardless of healthy literacy, the teach-back method gives patients an advantage in understanding their health conditions and treatments. The teach-back and show-me methods are crucial for patients with chronic conditions, due to the complex nature of these conditions and the common multimorbidity present (AHRQ, 2024).
Link to Learning
Learn how to implement the teach-back method with your patients.
Supportive Care
The supportive care nurses provide focuses on patient needs that may be directly associated with or triggered by their disease. These supportive measures focus on physical or emotional needs. Supportive measures address disease symptoms, side effects of medications, and social and emotional aspects of coping with a disease that the treating healthcare provider may not typically address. Supportive care involves a way of providing care as well as specific actions. By striving to provide a supportive atmosphere of care, nurses can exercise compassion, build confidence, identify areas for growth, and create a sense of safety. Specific actions that nurses may perform in providing supportive care include using encouraging words and actions, using active listening, engaging in educational dialogue, and collaborating with healthcare providers to provide patient-centered care (PCC).