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Module Seven: The Nursing Process in Chronic Illness

This module explores nursing process as it relates specifically to chronic illness

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The essential nature of a comprehensive assessment is highlighted. Root cause analysis and continuity of care are visited.

Module Objectives.

1) Describe the importance of a comprehensive assessment for the individuals who live with chronic illness.

2) Examine evidence-based assessment tools that could be valuable in assessing an individual in chronic illness situations.

3) Examine the significance of continuity of care and safe transitions in safe and quality outcomes.

4) Appraise communication as it relates to nursing process and continuity of care.

Required readings:

American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.).

https://ssuproxy.mnpals.net/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=nlebk

&AN=2935865&scope=site

Review Standards One – Six (pages 75 – 89) in the American Nurses Association Scope and Standards of Practice (4th ed.). Note this is available via the McFarland Library – see the required resources section of your course syllabus. A brief outline is linked into this module, but is not designed to replace reading through Standards One – Six.

Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., & Naylor, M. D. (2015). Continuity of Care: The Transitional Care Model. Online Journal of Issues in Nursing, 20(3), 1.

https://ssuproxy.mnpals.net/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&

AN=120383226&scope=site

(this is dated, but excellent. I also loaded this into the module as table one is a good outline before you start reading the article. The table is harder to get to in the copy from the McFarland Library)

Ljungholm, L., Edin-Liljegren, A., Ekstedt, M., & Klinga, C. (2022). What is needed for continuity of care and how can we achieve it? – Perceptions among multiprofessionals on the chronic care trajectory. BMC Health Services Research, 22(1), 1–15.

https://doi

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org.ssuproxy.mnpals.net/10.1186/s12913

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The Joint Commission (2015, September 28). Sentinel Event Alert. Issue 5.sea_55_falls_4_26_16

(jointcommission.org)

https://www.jointcommission.org/

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/media/tjc/documents/resources/patient

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safety

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topics/sentinel

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event/sea_55_falls_4_26_16

World Health Organization. (2018).
Continuity and Coordination of Care.

http://apps.who.int/iris/bitstream/handle/10665/274628/9789241514033

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eng ?ua=1

This document is long (but excellent). Start with the Executive Summary (p. 9); then go to pages 18 – 20. Priority Three (p. 31) is particularly applicable to chronic illness situations. (the direct link is also in the module)

World Health Organization. (2016).
Transitions of Care.

https://apps.who.int/iris/bitstream/handle/10665/252272/9789241511599-eng

This is long as well, but provides the best definitions of care transitions I have found and includes some practical interventions. (the direct link is in the module)

Optional Readings:

Backman, C., Chartrand, J., Dingwall, O., & Shea, B. (2017). Effectiveness of person- and family-centered care transition interventions: a systematic review protocol.
Systematic reviews, 6(1), 158.

https://doi.org/10.1186/s13643

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017

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Davis, K. M. (2020). Continuity of care for people with multimorbidity: the development of a model for a nurse-led care coordination service. Australian Journal of Advanced Nursing, 37(4), 7–19.

https://doi

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org.ssuproxy.mnpals.net/10.37464/2020.374.123

Feil Weber, L. A., Dias da Silva Lima, M. A., Marques Acosta, A., & Quintana Maques, G. (2017). Care Transition from Hospital to Home: Integrative Review. Cogitare Enfermagem, 22(3), 6–15.

https://doi

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org.ssuproxy.mnpals.net/10.5380/ce.v22i3.47615

(the abstract is included in multiple languages, but the body of the article is in English)

Jingjing Hu, Yuexia Wang, & Xiaoxi Li. (2020). Continuity of Care in Chronic Diseases: A Concept Analysis by Literature Review. Journal of Korean Academy of Nursing, 50(4), 513–522.

https://doi

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org.ssuproxy.mnpals.net/10.4040/jkan.20079

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Ljungholm, L., Edin-Liljegren, A., Ekstedt, M., & Klinga, C. (2022). What is needed for continuity of care and how can we achieve it? – Perceptions among multiprofessionals on the chronic care trajectory. BMC Health Services Research, 22(1), 1–15.

https://doi

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org.ssuproxy.mnpals.net/10.1186/s12913

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Ljungholm, L., Klinga, C., Edin, L. A., & Ekstedt, M. (2022). What matters in care continuity on the chronic care trajectory for patients and family carers?—A conceptual model. Journal of Clinical Nursing (

John Wiley & Sons, Inc.), 31(9/10), 1327–1338.

https://doi

org.ssuproxy.mnpals.net/10.1111/jocn.15989

Souza de Oliveira, L., Neves Alonso da Costa, M. F. B., Vieira Hermida, P. M., Regina de Andrade, S., Oliveira Debetio, J., & Novaes de Lima, L. M. (2021). Practices of nurses in a university hospital for the continuity of care for primary carea. Anna Nery School Journal of Nursing / Escola Anna

Nery Revista de Enfermagem, 25(5), 1–7.

https://doi

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org.ssuproxy.mnpals.net/10.1590/2177

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9465

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EAN

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2020

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Welch, M.L., Hodgson, J.L., Didericksen, K.W. et al. Family-Centered Primary Care for Older Adults with Cognitive Impairment. Contemp Fam Ther 44, 67–87 (2022).

https://doi.org/10.1007/s10591

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Wrotny, C., Bradley, D., & Brulé, M. (2021). Back So Soon? Part 2: Use of the 5 “Whys” Process in Unplanned Hospital Readmissions. Professional Case Management, 26(4), 186–193.

https://ssuproxy.mnpals.net/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&

AN=150667049&scope=site

Key Points

·

Evidence based

assessment tools are valuable as you assess any individual, especially those who are living with chronic illness. Utilization of these types of tools help you pick up important assessment data that could be easily overlooked.

· Utilization of evidence-based assessment tools help with tracking progression of the health concern in a more specific and quantifiable way.

· A care plan is only as good as the assessment it is built on!

· Continuity of care is important and often challenging

“
Managing chronic illness raises the nursing practice bar, challenging nurses to apply a patient-focused, systematic, outcome based, cost effective, quality care model” (Gies, p. 144).

Introduction to assignment

As you know well, caring for individuals and families who live with chronic illness is complex! The difference is vast between caring for an individual with a single health problem in an acute care situation as opposed to caring for an individual with multiple morbidities and their family for years. Each situation is unique.

It can be easy to make assumptions when caring for individuals with chronic illness. For example, it is easy to think that all individuals with dementia benefit from similar plans of care. Or that teaching is always a good intervention – remember that it is not always possible for individuals (ex. with dementia) to learn new skills. Don’t make the assumption that individuals with COPD are more alike than unique! A “cookie cutter” approach is not helpful when caring those in chronic illness situations!!

Below are links to a variety of evidence based assessment tools. Choose one of them.

Choose one of the following evidence based assessment tools. If you have another you would like to address, please email me with the tool. I will let you know if it will work for this assignment

Braden Scale

https://www.in.gov/health/files/Braden_Scale

Caregiver Strain Index.

http://www.npcrc.org/files/news/caregiver_strain_index

Geriatric Depression Scale https://geriatrictoolkit.missouri.edu/cog/GDS_SHORT_FORM.PDF

https://geriatrictoolkit.missouri.edu/cog/GDS_SHORT_FORM.PDF

John Hopkins Fall Risk Assessment

https://www.hopkinsmedicine.org/institute_nursing/models_tools/jhfrat_acute%20care%20original_6_

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Mini Nutrition Assessment – Short Form

https://www.mna

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elderly.com/sites/default/files/2021

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10/mna

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guide

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english

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sf

STEADI fall risk tool.

https://www.cdc.gov/steadi/pdf/STEADI

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Form

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RiskFactorsCk

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508

Remember to determine what factors are contributing to the concern before trying to intervene!! For example, if a person is at risk for falling due to orthostatic hypotension, removing throw rugs (although good) is probably not the optimal intervention.

A patient and family centered care plan is only as good as the assessment it is based on. Using evidencebased assessment tools, relevant to the unique situation can help the nurse uncover data and contributing factors that can be easily overlooked. If the root of the problem is not identified, it likely will not be addressed. Positive outcomes may not be achieved. The Joint Commission recommends use of these tools when assessing risk for some things – ex. falls (The Joint Commission).

Part One: Choose one of the tools included above and respond to the following questions adhering to the criteria in the rubric.

After reviewing the tool of your choice: Respond to the following questions. Your responses must demonstrate critical thinking and careful analysis to earn full points.

1) State which tool you are reviewing.

2) What contributing/risk factors are assessed by the assessment tool?

3) What are the risks and possible consequences of an incomplete assessment?

4) Describe how you would approach development of goals and interventions, considering root causes and principles of patient and family centered care following your assessment?

Part Two:

Remember that one purpose of care planning is to promote continuity of care. Those who live with chronic illness typically receive care from a number of professionals, unlicensed staff, and family members. It is not uncommon that important information is lost during transitions from one caregiver and/or one healthcare setting to another. Omitting significant information can impact outcomes quickly. These transitions of care are as important as ‘passing the baton’ in a relay race. If information is ‘dropped’ the outcome may be impacted.

After reviewing the documents/articles addressing continuity of care included in this module, address the following.

5) Explain in a minimum of three paragraphs how you would develop the plan of care to facilitate continuity of care. Incorporate at least four of the Transitional Care Model (TCM) Components as your facilitate continuity of care. Hint: Table One in the article by Hirschman, et al. (linked into the module) would serve as a good place to start your response.

Please submit your assignment to the assignment box and share with your peers in the discussion forum adhering to the following criteria.

Please refer to the Nursing process in chronic illness folder for more guidance

Incomplete or inaccurate (0 points)

Criterion		Excellent	Competent	Not satisfactory
1. includes name of tool and lists	Includes summary of factors that are evaluated/measured by the assessment tool.	Summary of factors incomplete	Summary of factors not included (0 points)
contributing risk factors assessed	(2 points)	(1 point)
2.Consequences of incomplete assessment	Explores necessity of identifying causative factor during assessment (exploration requires more than three well written sentences) (6 points)	Exploration is limited. (3 points)		Incomplete or inaccurate (0 points)
3. Plan development and person and family centered care	Discusses approach to development of goals and interventions, considering principles of patient and family centered care. (6 points)	Approach to development of goals and interventions is limited. (3 points)
4. Continuity and person and family centered care	Discusses effective strategies to facilitate continuity of care delivery while adhering to principles of person and family centered care. (10 points)	Strategies to facilitate continuity of care delivery while facilitating person centered care minimally addressed. (5 points)	Not complete or incorrect (0 points)
Evidence based	At least one professional citation/reference pair supports responses to criteria three, four, and five. Resource(s) must be integrated, cited, and referenced per APA style. See criteria for professional references on p. 9 of syllabus. Rare APA style errors. (3 pts)	Provides evidence-based, professional reference using incorrect APA format. Or provides nonscholarly references with correct APA format intext. (1.5 points)	Provides no scholarly reference to support position/ideas in postings/discussion and /or uses no APA format (0 points)
Writing quality	Punctuation, spelling, spacing, capitalization and writing mechanics errors are rare. Writing is clear, succinct, focused, organized. Easy to understand main ideas. (2 points)	Fewer than 5 writing mechanics errors. Writing is focused and organized. (1 point)	Five or more writing mechanics errors. Clarity, focus lacking. (0 points)
Posted/ submitted	Posted in both the discussion forum and the assignment box. (1 point)	Not posted in both the discussion forum and the assignment box (0 points)	Not posted as directed. (0 points)