Learning Objectives
By the end of this section, you will be able to:
- Summarize important subjective assessment questions for patients with chronic illness
- Discuss interprofessional collaboration team members through the assessment
- Identify cues to recognize and analyze for patients with chronic illness
- Plan hypotheses to prioritize and generate solutions for patients with chronic illness
Nursing care for a patient with a chronic illness is unique and challenging related to changes in the acuity of the chronic disease itself. For example, inpatient admissions may be required due to an acute exacerbation, or sudden worsening of symptoms, of a chronic disease (e.g., acute-on-chronic heart failure). In these situations, caring for patients with acute illness also requires care of the chronic diseases that afflict the patient simultaneously. The nurse must provide patient-centered care and focus management and treatment strategies specific to the patient’s needs and preferences. This section details the various components of care for patients with chronic illness.
Subjective Interview of the Patient with Chronic Illness
The assessment of a patient with a suspected or diagnosed chronic illness begins with obtaining a full subjective history and patient interview. This interview is like a typical patient history but with questions that are more focused on the specific chronic illness. For example, when assessing a patient with suspected diabetes mellitus, some of the focused questions may include
- Are you experiencing any symptoms, such as frequent urination or thirst?
- Do you ever feel lightheaded? If so, does this condition improve after eating?
- Do you have a family history of diabetes?
- Have you experienced any weight gain or loss?
- Have you had your blood glucose levels checked recently?
Questions during the subjective interview should focus on common symptoms associated with chronic illness. Asking these questions can help indicate whether the individual may have the illness and whether further testing and follow-up are necessary. These questions may also indicate improvement or worsening of the patient’s chronic conditions. For patients admitted with acute exacerbations of the underlying chronic disease, it is important for the nurse to assess for any knowledge deficits the patient may have about their condition. In many cases, patients do not know enough about their chronic disease or have enough interdisciplinary support to manage it at home. In these cases, the nurse should ask the patient questions about what they know about their condition, what treatment (if any) that they are currently receiving, and what resources they have available for managing their condition. After gathering this information, the nurse will have a better understanding of the patient’s knowledge level and can tailor their plan of action accordingly.
Interprofessional Collaboration
As with most patient care, caring for a patient with a chronic illness involves an interdisciplinary team approach. Collaboration between members of the health care team has been shown to improve patient outcomes and ensure that the patient receives thorough, high-quality care (Pannick et al., 2015). Table 9.4 lists typical members of the health care team and their roles.
| Team Member | Roles |
|---|---|
| Provider | Performs assessments and guides implementation of the treatment and management of the chronic disease; may be a physician or a nurse practitioner |
| Nurse | Coordinates care, performs assessments, implements treatment interventions, evaluates care, and serves as an educator and counselor when necessary |
| Social worker | Ensures the patient has appropriate financial and community resources to effectively care for their chronic condition |
| Physical and/or occupational therapist | Works with patient to ensure optimal physical condition and performance of ADLs so the patient can maintain the best quality of life possible, despite their condition |
| Dietitian | Counsels patient and implements dietary plan to promote healthy eating habits to prevent disease or limit its negative effects |
| Pharmacist | Coordinates prescriptions to ensure patient is receiving correct medications and dosages for their condition and symptoms |
Recognize Cues
One of the most important aspects of nursing care for a patient with a chronic illness relates to assessment and recognizing cues. If the patient has not yet been diagnosed with a chronic disease but it is suspected, the nurse must be able to recognize changes in the patient’s condition that may indicate the patient has the disease. If the patient has already been diagnosed with a chronic condition, the nurse should be able to recognize symptoms that would indicate the condition is worsening or improving. A comprehensive interview incorporating subjective data (e.g., patient- or family-reported data) and objective data (e.g., changes in vital signs) lends itself to using multiple recognized cues in understanding the impact of chronic disease.
Analyze Cues
After assessing symptoms related to the chronic condition, the nurse must determine the next step. Often, this involves suggesting further diagnostic testing to confirm the suspected diagnosis. Chronic disease progression is often identified in this step of the clinical judgement measurement model. By analyzing cues, the nurse is linking the patient’s medical history with the cues initially identified. For example, a patient with diabetes mellitus who reports fatigue and increased hunger and thirst may trigger the nurse to review the medical history and search for the presence of diabetes mellitus. The nurse may perform a medication reconciliation and learn that the patient takes insulin therapy, indicating the existence of a chronic metabolic endocrine disorder.
Prioritize Hypotheses
Prioritizing hypotheses involves organizing the assessment data collected previously and determining what the priority issues are that require intervention. If the patient’s chronic condition has become life-threatening, implementing life-saving measures is the top priority. After that, the nurse may use other models, such as Maslow’s hierarchy of needs, to determine the priorities of care.
Generate Solutions
Once the priorities for the patient have been established, the planning process begins. The nurse collaborates with the care team—which includes the family and support team—to determine appropriate outcomes for the patient based on their needs. The team uses evidence-based practice guidelines to ensure that appropriate interventions are implemented to achieve optimal outcomes. Goals are developed—using simple, measurable, attainable, realistic, and timed criteria—to evaluate the effectiveness of nursing care. For example, the nurse may elect to have the patient show competence in performing a blood glucose check with return demonstration. The solution generated, ultimately, would be for the patient to monitor their chronic diabetes mellitus correctly.
Take Action
When taking action, nursing interventions are individualized for the patient and supported by evidence-based practice. In the example of the patient with diabetes, the nurse ensures blood glucose monitoring is being done competently and that the patient self-administers the ordered insulin therapy correctly. The nurse also provides education about the complications of untreated diabetes mellitus. Interventions are focused on chronic disease and tailored to the patient.
Evaluate Outcomes
After implementation of the care plan, the nurse will evaluate outcomes. The nurse should assess not only whether the outcomes have been met but also which priorities of care need further intervention. If it is determined that the outcomes were not met, the nurse is tasked with coordinating revisions to the plan of care to address the unmet outcomes. This often involves getting the interdisciplinary team together again to make changes to the plan of care that better address the patient’s needs. For patients with diabetes, for example, nurses may have to ensure there is laboratory surveillance of hemoglobin A1c, follow up for chronic monitoring with foot care, and provide ongoing support for nutritional education. Given the longevity of chronic disease, nurses must consistently evaluate the patient’s response to the chronic disease.