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Lewiss

MedicalSurgical Nursing
Assessment and Management
of Clinical Problems
3rd edition
Mosby
is an imprint of Elsevier
Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
This edition 2012 Elsevier Australia
1st edition 2005; 2nd edition 2008 Elsevier Australia
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National Library of Australia Cataloguing-in-Publication Data
___________________________________________________________________
Lewis`s medical-surgical nursing assessment and management
of clinical problems / Diane Brown ; Helen Edwards.
3rd ed.
9780729539951 (hbk.)
Includes index.
Nursing.
Surgical nursing.
Brown, Diane.
Edwards, Helen.
610.73
___________________________________________________________________
Publisher: Libby Houston
Developmental Editor: Elizabeth Coady
Publishing Services Manager: Helena Klijn
Editorial Coordinator: Natalie Hamad
Edited by Caroline Hunter
Proofread by Tim Learner
Indexed by Michael Ferreira
Cover and internal design by Darben Design
Typeset by Midland Typesetters
Printed in China by China Translation and Printing Services
Funding 76
Care alternatives for older adults 77
Legal and ethical issues 78
Culturally competent care: older adults 79
Nursing management: older adults 80
6 Community-based nursing care 92
Teri A Murray (US); Debbie Kralik (ANZ)
Factors infuencing change in the healthcare system 93
Community-based nursing 95
Community care settings 96
Client care 99
Community-based nursing skills and attributes 102
Hospice care 102
7 Complementary and alternative therapies 105
Virginia Shaw (US); Lesley Cuthbertson (ANZ)
Complementary and alternative medicine 105
Alternative medical systems 107
Mind-body interventions 111
Biological-based therapies 113
Manipulative and body-based methods 115
Energy and biofeld therapies 117
Nursing management: complementary and alternative
therapies 119
Summary 121
8 Pain management 126
Mary Ersek, Gordon A Irving (US); Di Brown (ANZ)
Magnitude of the pain problem 126
Pain experience 126
Defnitions and dimensions of pain 127
Cognitive, affective, behavioural and sociocultural responses
to pain 128
Pain mechanisms 129
Classifcation of pain 133
Pain assessment 134
Pain treatment 139
Nursing and collaborative management: pain 151
Institutionalising pain education and management 152
Ethical issues in pain management 152
Patients unable to self-report pain 154
International perspectives 154
9 Palliative care 158
Margaret McLean Heitkemper, Cheryl Ross Staats (US);
Ann Harrington, Meg Hegarty (ANZ)
Introduction 158
Palliative care defnitions 158
Palliative care contexts 159
Physical manifestations at the end of life 160
Psychosocial manifestations at the end of life 161
Grief 161
Culturally competent palliative care 162
Spiritually appropriate palliative care 163
Legal and ethical issues affecting palliative care 163
Standards and guidelines for palliative care practice 164
Nursing management: end of life 165
Special needs of caregivers in palliative care 170
10 Substance use and dependency 173
Patricia Graber OBrien (US); Charlotte de Crespigny,
Peter Athanasos (ANZ)
Overview of addictive behaviours 174
The Suite 00
Navigate by Colour/How to use this Book 00
Preface 00
Acknowlegdements 00
Contributors 00
Reviewers 00
SECTION ONE
Concepts in nursing practice
Paul Morrison
1 The importance of nursing 2
Patricia Graber OBrien (US); Mary FitzGerald,
John Field (ANZ)
The evolution of nursing as an essential service in Australia
and New Zealand 3
Professional teamwork 4
Nursing knowledge 9
Nursing research 12
Nursing care planning 14
Conclusion 19
2 Culturally competent care 22
Cory A Shaw, Margaret M Andrews (US);
Frances Hughes, Lesley Seaton (ANZ)
Culture 22
Cultural competence 24
Health disparities and the social determinants of health 27
Cultural and ethnic differences in illness and treatment 28
Social and spiritual elements of health and illness care 30
Nursing assessment: providing safe, culturally competent
care 32
The role of the nurse in reducing health disparities 33
The importance of documenting nursing care 34
3 Health history and physical examination 36
Patricia Graber OBrien (US); Jan Thompson (ANZ)
Data collection 36
Nursing history: subjective data 38
Physical examination: objective data 42
Problem identifcation and nursing diagnoses 47
4 Health promotion and patient education 49
Patricia Graber OBrien (US); Pauline Glover (ANZ)
Defning health 49
Determinants of health 50
Health for all 50
Teaching-learning process 51
Process of patient education 54
5 Older adults 64
Margaret Wooding Baker, Margaret McLean Heitkemper
(US); Lynn Chenoweth (ANZ)
Demographics of ageing 64
Attitudes towards ageing 65
Adult development 65
Biological ageing theories 67
Age-related physiological changes 69
Special older adult populations 72
Social support and the older adult 75
Social services for the older adult 76
Contents
vi CONTENTS
Stimulants 176
Nicotine 176
Cocaine 180
Amphetamines 181
Caffeine 182
Depressants 183
Alcohol 183
Sedatives 185
Opioids 186
Cannabis 188
Hallucinogens 189
Inhalants (solvents) 189
Nursing management: substance-related health
problems 189
11 Rural and remote area nursing 208
Sue Kruske, Sue Lenthall, Sue Kildea, Sabina Knight,
Beverley Mackay, Desley Hegney (ANZ)
Introduction 208
Defnitions of rural and remote areas 208
Remote area and rural nursing 209
History of remote area healthcare services in Australia 210
Indigenous health in New Zealand 211
Health defnitions and determinants 211
Primary Health Care approach 213
Characteristics of remote area and rural nursing 213
Advanced practice 215
Collaborative practice 217
Professional support for rural and remote area nurses 217
Remote area nurse model of consultation 217
Rewards of working in rural and remote area nursing 218
Education pathways for remote and rural nurses 218
Future of remote area and rural nursing 219
SECTION TWO
Pathophysiological mechanisms of disease
Patsy Yates
12 Nursing management: inammation and wound
healing 224
Russell Zaiontz, Sharon L Lewis (US); Patsy Yates (ANZ)
Infammatory response 224
Nursing and collaborative management: infammation 228
Healing process 230
Nursing and collaborative management: wound healing 234
Pressure ulcers 239
Nursing and collaborative management: pressure ulcers 241
13 Genetics, altered immune responses and
transplantation 246
Sharon L Lewis (US); Patsy Yates (ANZ)
Genetics 246
Nursing management: genetics 250
Stem cells 251
Normal immune response 251
Altered immune response 258
Allergic disorders 262
Nursing management: immunotherapy 265
Nursing and collaborative management: latex allergies 266
Autoimmunity 266
Immunodefciency disorders 268
Human leucocyte antigen system 269
Organ transplantation 269
Graft-versus-host disease 274
14 Nursing management: infection and human
immunodeciency virus infection 277
Jeffrey Kwong, Lucy Bradley-Springer (US);
Patsy Yates (ANZ)
Infections 277
Human immunodefciency virus infection 282
Nursing management: HIV infection 293
15 Cancer 306
Jormain Cady, Joyce Marrs (US); Patsy Yates (ANZ)
Biology of cancer 308
Classifcation of cancer 314
Prevention of cancer 316
Diagnosis of cancer 317
Multidisciplinary care 318
Nursing management: patients undergoing chemotherapy
and radiation therapy 328
Nursing management: biological and targeted therapy 338
Haematopoietic growth factors 338
Haematopoietic stem cell transplantation 338
Gene therapy 340
Complications resulting from cancer 340
Management of cancer pain 343
Psychological support 344
Cancer survivorship 344
16 Nursing management: uid, electrolyte and acid
base imbalances 349
Audrey J Bopp (US); Patsy Yates (ANZ)
Homeostasis 349
Water content of the body 349
Electrolytes 350
Mechanisms controlling fuid and electrolyte movement 352
Fluid movement in capillaries 353
Fluid movement between extracellular fuid and intracellular
fuid 354
Fluid spacing 354
Regulation of water balance 354
Fluid and electrolyte imbalances 356
Extracellular fuid volume imbalances 357
Nursing management: extracellular fuid volume
imbalances 357
Sodium imbalances 359
Nursing and collaborative management: hypernatraemia 360
Nursing and collaborative management: hyponatraemia 361
Potassium imbalances 361
Nursing and collaborative management: hyperkalaemia 363
Nursing and collaborative management: hypokalaemia 364
Calcium imbalances 365
Nursing and collaborative management:
hypercalcaemia 366
Nursing and collaborative management: hypocalcaemia 366
Phosphate imbalances 367
Magnesium imbalances 368
Acid-base imbalances 368
Assessment of fuid, electrolyte and acid-base
imbalances 373
Oral fuid and electrolyte replacement 375
Intravenous fuid and electrolyte replacement 375
Central venous access devices 376
Nursing management: central venous access devices 378
SECTION THREE
Perioperative care
Sonya Osborne
17 Nursing management: preoperative care 384
Janice A Neil (US); Carolyn Naismith (ANZ)
Surgical settings 384
Patient interview 385
Nursing assessment of the preoperative patient 385
Nursing management: the preoperative patient 393
Culturally competent care: preoperative patient 399
CONTENTS vii
18 Nursing management: intraoperative care 402
Anita J Shoup, Maureen Reilly, Jack R Kless (US);
Sonya Osborne (ANZ)
The physical environment of the operating room suite 402
Surgical team 403
Nursing management: the patient before surgery 406
Nursing management: the patient during surgery 407
Nursing management: the patient after surgery 410
Anaesthesia 410
Catastrophic events in the operating room 417
New and future considerations 418
19 Nursing management: postoperative care 421
Debra J Smith (US); Carolyn Naismith (ANZ)
Postoperative management in the postanaesthesia recovery
unit 421
Fast-tracking 421
Postanaesthesia recovery unit admission 421
Potential alterations in respiratory function 423
Nursing management: respiratory complications 424
Potential alterations in cardiovascular function 426
Nursing management: cardiovascular complications 427
Potential alterations in neurological function 427
Nursing management: neurological complications 427
Pain and discomfort 428
Nursing management: pain 428
Hypothermia 428
Nursing management: hypothermia 428
Nausea and vomiting 429
Nursing management: nausea and vomiting 429
Surgical-specifc care of the patient in the PARU 429
Discharge from the PARU 429
Care of the postoperative patient in the surgical unit 430
Potential alterations in respiratory function 430
Nursing management: respiratory complications 430
Potential alterations in cardiovascular function 433
Nursing management: cardiovascular complications 433
Potential alterations in urinary function 434
Nursing management: urinary complications 435
Potential alterations in gastrointestinal function 435
Nursing management: gastrointestinal complications 435
Potential alterations of the integument 436
Nursing management: surgical wounds 436
Pain and discomfort 437
Nursing management: pain 437
Potential alterations in temperature 438
Nursing management: altered temperature 438
Potential alterations in psychological function 438
Nursing management: psychological function 439
Planning for discharge and follow-up care 439
SECTION FOUR
Problems related to altered sensory input
Nick Santamaria
20 Nursing assessment: visual and auditory
systems 444
Sarah C Smith, Sherry Neely (US); Karen Twyford (ANZ)
The visual system 444
Structures and functions of the visual system 444
Assessment of the visual system 448
Diagnostic studies of the visual system 457
The auditory system 458
Structures and functions of the auditory system 458
Assessment of the auditory system 460
Diagnostic studies of the auditory system 463
21 Nursing management: visual and auditory
problems 468
Sarah C Smith, Sherry Neely (US); Karen Twyford (ANZ)
Visual problems 468
Correctable refractive errors 468
Uncorrectable vision impairment 472
Nursing management: vision impairment 472
Eye trauma 474
Extraocular disorders 474
Infammation and infection 474
Nursing management: infammation and infection in
the eye 477
Dry eye disorders 478
Strabismus 478
Corneal disorders 478
Intraocular disorders 478
Cataracts 478
Nursing management: cataracts 481
Retinopathy 482
Retinal detachment 483
Age-related macular degeneration 485
Glaucoma 486
Nursing management: glaucoma 489
Intraocular infammation and infection 490
Enucleation 491
Ocular manifestations of systemic diseases 491
Auditory problems 491
External ear and canal 491
Trauma 491
External otitis 491
Nursing management: external otitis 492
Cerumen and foreign bodies in the external ear canal 492
Malignancy of the external ear 494
Middle ear and mastoid 494
Acute otitis media 494
Nursing management: acute otitis media 494
Chronic otitis media and mastoiditis 494
Chronic otitis media with effusion 496
Otosclerosis 496
Nursing management: otosclerosis 497
Inner ear problems 497
Mnire`s disease 497
Nursing and collaborative management: Mnire`s
disease 497
Labyrinthitis 498
Benign paroxysmal positional vertigo 498
Acoustic neuroma 498
Hearing loss and deafness 499
Nursing and collaborative management: hearing loss
and deafness 500
22 Nursing assessment: integumentary system 507
Barbara Sinni-McKeehen (US); Nick Santamaria (ANZ)
Structures and functions of the skin and appendages 507
Assessment of the integumentary system 509
Diagnostic studies of the integumentary system 516
23 Nursing management: integumentary problems 518
Barbara Sinni-McKeehen, Elise F Hazzard (US);
Nick Santamaria (ANZ)
Health promotion 518
Malignant skin neoplasms 520
Risk factors 520
Non-melanoma skin cancers 520
Malignant melanoma 522
Dermatological problems 524
Skin infections and infestations 524
Allergic dermatological problems 528
Benign dermatological problems 529
Diseases with dermatological manifestations 529
viii CONTENTS
Multidisciplinary care: dermatological problems 529
Nursing management: dermatological problems 535
Cosmetic procedures 538
Nursing management: cosmetic surgery 540
Skin grafts 540
24 Nursing management: burns 543
Judy A Knighton (US); Joy Fong (ANZ)
Health promotion 543
Types of burn injury 543
Classifcation of burn injuries 546
Phases of burn management 548
Pre-hospital care 548
Emergent phase 548
Nursing and collaborative management: emergent
phase 552
Acute phase 559
Nursing and collaborative management: acute phase 561
Rehabilitation phase 564
Nursing and collaborative management: rehabilitation
phase 565
Emotional needs of the patient and family 566
Special needs of the nursing staff 566
SECTION FIVE
Problems of oxygenation: ventilation
Bridie Kent
25 Nursing assessment: respiratory system 572
Jane Steinman Kaufman (US); Bridie Kent (ANZ)
Structures and functions of the respiratory system 572
Assessment of the respiratorysystem 580
Diagnostic studies of the respiratory system 589
26 Nursing management: upper respiratory tract
problems 597
Valerie Bender Howard (US); Jane Clarke (ANZ)
Structural and traumatic disorders of the nose 597
Deviated nasal septum 597
Nasal fracture 597
Rhinoplasty 598
Nursing management: nasal surgery 598
Epistaxis 598
Nursing and collaborative management: epistaxis 598
Inammation and infection of the nose and paranasal
sinuses 599
Allergic rhinitis 599
Nursing and collaborative management: allergic rhinitis 599
Acute viral rhinitis 602
Nursing and collaborative management: acute viral
rhinitis 602
Infuenza 602
Nursing and collaborative management: infuenza 603
Sinusitis 604
Nursing and collaborative management: sinusitis 604
Diseases and disorders of the paranasal sinuses 605
Polyps 605
Foreign bodies 605
Problems related to the pharynx 605
Acute pharyngitis 605
Nursing and collaborative management: acute
pharyngitis 605
Peritonsillar abscess 605
Obstructive sleep apnoea 605
Nursing and collaborative management: sleep apnoea 606
Problems related to the trachea and larynx 607
Airway obstruction 607
Tracheostomy 607
Nursing management: tracheostomy 607
Laryngeal polyps 614
Head and neck cancer 614
Nursing management: head and neck cancer 617
27 Nursing management: lower respiratory tract
problems 625
Janet T Crimlisk (US); Jane Clarke (ANZ)
Lower respiratory tract infections 625
Acute bronchitis 625
Pneumonia 626
Nursing management: pneumonia 630
Tuberculosis 633
Nursing management: tuberculosis 638
Atypical mycobacteria 640
Pulmonary fungal infections 640
Bronchiectasis 641
Nursing management: bronchiectasis 641
Lung abscess 642
Nursing and collaborative management: lung abscess 642
Environmental lung diseases 643
Lung cancer 643
Nursing management: lung cancer 648
Other types of lung tumours 650
Chest trauma and thoracic injuries 650
Pneumothorax 651
Fractured ribs 653
Flail chest 653
Chest tubes and pleural drainage 654
Nursing management: chest drainage 656
Chest surgery 656
Restrictive respiratory disorders 660
Pleural effusion 660
Pleurisy 662
Atelectasis 663
Interstitial lung diseases 663
Idiopathic pulmonary fbrosis 663
Sarcoidosis 663
Vascular lung disorders 663
Pulmonary oedema 663
Pulmonary embolism 663
Nursing management: pulmonary embolism 666
Pulmonary hypertension 666
Primary pulmonary arterial hypertension 666
Secondary pulmonary hypertension 668
Cor pulmonale 668
Lung transplantation 669
28 Nursing management: obstructive pulmonary
diseases 673
Jane Steinman Kaufman (US); Bridie Kent (ANZ)
Asthma 673
Nursing management: asthma 689
Chronic obstructive pulmonary disease 693
Nursing management: COPD 713
Cystic fbrosis 719
Nursing management: cystic fbrosis 722
Bronchiectasis 723
Nursing management: bronchiectasis 724
SECTION SIX
Problems of oxygenation: transport
Maryanne Hargraves
29 Nursing assessment: haematological system 730
Brenda K Shelton, Sandra Irene Rome, Sharon L Lewis
(US); Maryanne Hargraves (ANZ)
Structures and functions of the haematological system 730
Assessment of the haematological system 737
Diagnostic studies of the haematological system 743
CONTENTS ix
30 Nursing management: haematological problems 751
Sandra Irene Rome (US); Maryanne Hargraves (ANZ)
Anaemia 751
Nursing management: anaemia 753
Anaemia caused by decreased erythrocyte production 755
Iron-defciency anaemia 755
Nursing management: iron-defciency anaemia 757
Thalassaemia 757
Megaloblastic anaemias 758
Nursing management: megaloblastic anaemias 759
Anaemia of chronic disease 760
Aplastic anaemia 760
Nursing and collaborative management: aplastic
anaemia 761
Anaemia caused by blood loss 761
Acute blood loss 761
Nursing management: acute blood loss 762
Chronic blood loss 762
Anaemia caused by increased erythrocyte destruction 762
Sickle cell disease 762
Nursing and collaborative management: sickle cell
disease 765
Acquired haemolytic anaemia 766
Haemochromatosis 766
Polycythaemia 767
Nursing management: polycythaemia 768
Problems of haemostasis 768
Thrombocytopenia 768
Nursing management: thrombocytopenia 772
Haemophilia and von Willebrand`s disease 774
Nursing management: haemophilia 777
Disseminated intravascular coagulation 777
Nursing management: disseminated intravascular
coagulation 780
Neutropenia 780
Nursing and collaborative management: neutropenia 782
Myelodysplastic syndrome 784
Nursing and collaborative management: myelodysplastic
syndrome 784
Leukaemia 784
Nursing management: leukaemia 788
Lymphomas 790
Hodgkin`s lymphoma 790
Nursing and collaborative management: Hodgkin`s
lymphoma 791
Non-Hodgkin`s lymphomas 793
Nursing and collaborative management: non-Hodgkin`s
lymphoma 794
Multiple myeloma 795
Nursing management: multiple myeloma 796
Disorders of the spleen 797
Blood component therapy 797
SECTION SEVEN
Problems of oxygenation: perfusion
Robyn Gallagher
31 Nursing assessment: cardiovascular
system 808
Angela J DiSabatino, Linda Bucher (US);
Linda Soars (ANZ)
Structures and functions of the cardiovascular system 808
Assessment of the cardiovascular system 813
Diagnostic studies of the cardiovascular system 821
32 Nursing management: hypertension 831
Elisabeth G Bradley (US); Robyn Gallagher (ANZ)
Normal regulation of blood pressure 832
Hypertension 834
Nursing management: primary hypertension 846
Hypertensive crisis 850
Nursing and collaborative management: hypertensive
crisis 851
33 Nursing management: coronary artery disease and
acute coronary syndrome 854
Linda Griego Martinez, Linda Bucher (US); Robyn
Gallagher (ANZ)
Coronary artery disease 854
Risk factors for coronary artery disease 855
Nursing and collaborative management: coronary artery
disease 863
Clinical manifestations 868
Multidisciplinary care 870
Diagnostic studies 873
Acute coronary syndrome 874
Clinical manifestations 875
Diagnostic studies 877
Multidisciplinary care 878
Nursing management: chronic stable angina and acute
coronary syndrome 882
Sudden cardiac death 890
Nursing and collaborative management: sudden cardiac
death 890
34 Nursing management: heart failure 894
Mary Ann House-Fancher, Hatice Y Foell (US);
Linda Soars (ANZ)
Heart failure 894
Nursing and collaborative management: acute heart failure
and pulmonary oedema 901
Nursing management: chronic heart failure 905
Cardiac transplantation 910
35 Nursing management: ECG monitoring and
arrhythmias 914
Linda Bucher (US); Robyn Gallagher (ANZ)
Rhythm identifcation and treatment 914
ECG changes associated with acute coronary syndrome 934
Syncope 935
36 Nursing management: inammatory and structural
heart disorders 939
Nancy Kupper, De Ann Mitchell (US);
Robyn Gallagher (ANZ)
Inammatory disorders of the heart 939
Infective endocarditis 939
Nursing management: infective endocarditis 943
Acute pericarditis 945
Nursing management: acute pericarditis 947
Chronic constrictive pericarditis 948
Nursing and collaborative management: chronic constrictive
pericarditis 948
Myocarditis 948
Nursing management: myocarditis 949
Rheumatic fever and heart disease 949
Nursing management: rheumatic fever and heart disease 951
Valvular heart disease 952
Mitral valve stenosis 953
Mitral regurgitation 954
Mitral valve prolapse 954
Aortic stenosis 955
Aortic regurgitation 955
Tricuspid and pulmonic valve disease 955
Nursing management: valvular disorders 957
Cardiomyopathy 959
Dilated cardiomyopathy 960
Nursing and collaborative management: dilated
cardiomyopathy 962
Hypertrophic cardiomyopathy 963
x CONTENTS
Nursing and collaborative management: hypertrophic
cardiomyopathy 963
Restrictive cardiomyopathy 964
Nursing and collaborative management: restrictive
cardiomyopathy 964
37 Nursing management: vascular disorders 967
Deidre D Wipke-Tevis, Kathleen Rich (US);
Linda Soars (ANZ)
Peripheral arterial disease 967
Carotid artery disease 968
Disorders of the aorta 968
Aortic aneurysms 968
Nursing management: aortic aneurysms 971
Aortic dissection 973
Nursing management: aortic dissection 975
Peripheral arterial disease of the lower extremities 975
Nursing management: lower extremity peripheral arterial
disease 979
Acute arterial ischaemic disorders 981
Thromboangiitis obliterans 982
Raynaud`s phenomenon 983
Disorders of the veins 983
Venous thrombosis 983
Superfcial thrombophlebitis 985
Deep vein thrombosis 985
Nursing management: venous thrombosis 988
Varicose veins 990
Nursing management: varicose veins 991
Chronic venous insuffciency and venous leg ulcers 991
Nursing management: venous leg ulcers 993
SECTION EIGHT
Problems of ingestion, digestion, absorption and
elimination
Ann Framp
38 Nursing assessment: gastrointestinal system 998
Anne Croghan (US); Marie Verschoor (ANZ)
Structures and functions of the gastrointestinal system 998
Assessment of the gastrointestinal system 1005
Diagnostic studies of the gastrointestinal system 1012
39 Nursing management: nutritional problems 1023
Peggi Guenter (US); Di Brown (ANZ)
Nutrition 1023
Normal nutrition 1023
Special diets: vegetarian diet 1027
Malnutrition 1028
Nursing management: malnutrition 1033
Types of specialised nutrition support 1037
Nursing management: total parenteral nutrition 1046
Eating disorders 1048
Culturally competent care: nutrition 1049
40 Nursing management: obesity 1052
Jennifer Kretzschmar, Paula Blackwell, Sharon L Lewis
(US); Brighid McPherson (ANZ)
Obesity 1052
Health risks associated with obesity 1056
Nursing management: the obese patient 1057
Multidisciplinary care 1059
Collaborative surgical therapy 1063
Nursing management: the obese patient undergoing
surgery 1067
Metabolic syndrome 1069
Nursing and collaborative management: metabolic
syndrome 1070
41 Nursing management: upper gastrointestinal
problems 1073
Margaret McLean Heitkemper (US); Ann Framp (ANZ)
Nausea and vomiting 1073
Nursing management: nausea and vomiting 1075
Oral infammations and infections 1078
Oral cancer 1079
Nursing management: oral cancer 1080
Oesophageal disorders 1081
Gastro-oesophageal refux disease 1081
Nursing management: gastro-oesophageal refux
disease 1085
Hiatus hernia 1086
Nursing and collaborative management: hiatus hernia 1086
Oesophageal cancer 1087
Nursing management: oesophageal cancer 1088
Other oesophageal disorders 1089
Disorders of the stomach and upper small intestine 1091
Gastritis 1091
Nursing and collaborative management: gastritis 1093
Upper gastrointestinal bleeding 1094
Nursing management: upper gastrointestinal bleeding 1097
Peptic ulcer disease 1099
Nursing management: peptic ulcer disease 1106
Nursing management: surgical therapy for peptic ulcer
disease 1112
Gastric cancer 1113
Nursing management: gastric cancer 1114
Food poisoning 1116
42 Nursing management: lower gastrointestinal
problems 1121
Marilee Schmelzer (US); Stephanie Buckton (ANZ)
Diarrhoea 1121
Nursing management: acute infectious diarrhoea 1123
Faecal incontinence 1125
Nursing management: faecal incontinence 1126
Constipation 1127
Nursing management: constipation 1130
Acute abdominal pain 1131
Nursing management: acute abdominal pain 1132
Chronic abdominal pain 1133
Irritable bowel syndrome 1133
Abdominal trauma 1133
Nursing and collaborative management: abdominal
trauma 1135
Inammatory disorders 1135
Appendicitis 1135
Nursing management: appendicitis 1136
Peritonitis 1136
Nursing management: peritonitis 1137
Gastroenteritis 1137
Nursing management: gastroenteritis 1137
Infammatory bowel disease 1137
Nursing management: infammatory bowel disease 1145
Intestinal obstruction 1148
Nursing management: intestinal obstruction 1150
Polyps of the large intestine 1150
Colorectal cancer 1152
Nursing management: colorectal cancer 1156
Ostomy surgery 1157
Nursing management: ostomy surgery 1159
Diverticulosis and diverticulitis 1165
Nursing and collaborative management: diverticulosis and
diverticulitis 1166
Hernias 1166
Nursing and collaborative management: hernias 1167
Malabsorption syndrome 1167
Coeliac disease 1168
CONTENTS xi
Lactase defciency 1170
Short-bowel syndrome 1170
Gastrointestinal stromal tumours 1170
Anorectal problems 1171
Haemorrhoids 1171
Nursing management: haemorrhoids 1172
Anal fssure 1172
Anorectal abscess 1172
Anal fstula 1173
Pilonidal sinus 1173
43 Nursing management: liver, pancreas and biliary
tract problems 1176
Margaret McLean Heitkemper, Anne Croghan,
Paula Cox-North (US); Ann Framp (ANZ)
Jaundice 1176
Disorders of the liver 1177
Hepatitis 1177
Nursing management: hepatitis 1185
Toxic and drug-induced hepatitis 1188
Autoimmune/metabolic/genetic liver diseases 1189
Cirrhosis of the liver 1190
Nursing management: cirrhosis 1200
Fulminant hepatic failure 1204
Nursing management: fulminant hepatic failure 1205
Liver cancer 1205
Nursing and collaborative management: liver cancer 1206
Liver transplantation 1206
Disorders of the pancreas 1207
Acute pancreatitis 1207
Nursing management: acute pancreatitis 1211
Chronic pancreatitis 1214
Nursing management: chronic pancreatitis 1215
Pancreatic cancer 1215
Nursing management: pancreatic cancer 1216
Disorders of the biliary tract 1217
Cholelithiasis and cholecystitis 1217
Nursing management: gall bladder disease 1220
Gall bladder cancer 1222
SECTION NINE
Problems of urinary function
Ann Bonner
44 Nursing assessment: urinary system 1226
Vicki Y Johnson (US); Ann Bonner (ANZ)
Structure and function of the urinary system 1226
Assessment of the urinary system 1232
Diagnostic studies 1236
45 Nursing management: renal and urological
problems 1249
Vicki Y Johnson (US); Ann Bonner (ANZ)
Infectious and inammatory disorders of urinary
system 1249
Urinary tract infections 1249
Nursing management: urinary tract infections 1253
Acute pyelonephritis 1255
Nursing management: acute pyelonephritis 1256
Chronic pyelonephritis 1257
Urethritis 1257
Urethral diverticula 1257
Interstitial cystitis/painful bladder syndrome 1258
Nursing management: interstitial cystitis/painful bladder
syndrome 1259
Renal tuberculosis 1259
Immunological disorders of the kidney 1259
Glomerulonephritis 1259
IgA mesangioproliferative glomerulonephritis 1260
Acute post-streptococcal glomerulonephritis 1260
Nursing and collaborative management: acute
post-streptococcal glomerulonephritis 1260
Goodpasture`s syndrome 1261
Nursing and collaborative management: Goodpasture`s
syndrome 1261
Rapidly progressive glomerulonephritis 1261
Chronic glomerulonephritis 1261
Nephrotic syndrome 1261
Nursing and collaborative management: nephrotic
syndrome 1262
Obstructive uropathies 1262
Urinary tract calculi 1263
Nursing management: urinary tract calculi 1267
Strictures 1268
Renal trauma 1270
Renal vascular problems 1270
Nephrosclerosis 1270
Renal artery stenosis 1270
Renal vein thrombosis 1270
Hereditary renal diseases 1270
Polycystic kidney disease 1270
Nursing and collaborative management: polycystic kidney
disease 1272
Medullary cystic disease 1272
Alport`s syndrome 1272
Renal involvement in metabolic and connective
tissue diseases 1272
Urinary tract tumours 1272
Kidney cancer 1272
Nursing and collaborative management: kidney cancer 1273
Bladder cancer 1273
Nursing and collaborative management: bladder
cancer 1274
Urinary retention 1275
Nursing management: urinary retention 1276
Urinary incontinence 1276
Nursing management: urinary incontinence 1281
Instrumentation 1281
Surgery of the urinary tract 1284
Renal and ureteral surgery 1284
Urinary diversion 1284
Nursing management: urinary diversion 1286
46 Nursing management: acute kidney injury and
chronic kidney disease 1292
Carol M Headley (US); Ann Bonner (ANZ)
Acute kidney injury 1292
Nursing management: acute kidney injury 1299
Chronic kidney disease 1301
Nursing management: conservative therapy of chronic
kidney disease 1310
Dialysis 1313
General principles of dialysis 1314
Peritoneal dialysis 1314
Haemodialysis 1317
Continuous renal replacement therapy 1322
Kidney transplantation 1324
Nursing management: kidney transplant recipient 1326
SECTION TEN
Problems related to regulatory and
reproductive mechanisms
Jenny Sando
47 Nursing assessment: endocrine system 1336
JoAnne Konick-McMahan (US); Valerie Cheetham (ANZ)
Structures and functions of the endocrine system 1336
Assessment of the endocrine system 1344
Diagnostic studies of the endocrine system 1349
xii CONTENTS
48 Nursing management: diabetes mellitus 1357
Nancy C Robbins, Cory A Shaw, Sharon L Lewis (US);
Bronwyn Davis (ANZ)
Diabetes mellitus 1357
Normal glucose metabolism 1358
Type 1 diabetes mellitus 1359
Type 2 diabetes mellitus 1360
Gestational diabetes 1361
Secondary diabetes 1362
Complications 1362
Diagnostic studies 1362
Multidisciplinary care 1362
Drug therapy: insulin 1362
Drug therapy: oral agents 1368
Nutritional therapy 1371
Exercise 1373
Monitoring blood glucose 1373
New developments in diabetic therapy 1375
Culturally competent care: diabetes mellitus 1375
Nursing management: diabetes mellitus 1375
Acute complications of diabetes mellitus 1381
Diabetic ketoacidosis 1382
Hyperosmolar hyperglycaemic non-ketotic syndrome 1384
Nursing management: diabetic ketoacidosis and
hyperosmolar hyperglycaemic non-ketotic syndrome 1385
Hypoglycaemia 1385
Nursing and collaborative management:
hypoglycaemia 1386
Chronic complications of diabetes mellitus 1386
Angiopathy 1388
Diabetic retinopathy 1389
Nephropathy 1389
Neuropathy 1389
Complications of the feet and lower extremities 1391
Integumentary complications 1391
Infection 1392
49 Nursing management: endocrine problems 1396
JoAnne Konick-McMahan (US); Valerie Cheetham (ANZ)
Disorders of the anterior pituitary gland 1396
Growth hormone excess 1396
Nursing management: growth hormone excess 1398
Excesses of other trophic hormones 1399
Hypofunction of the pituitary gland 1399
Nursing management: hypofunction of the pituitary
gland 1400
Disorders associated with antidiuretic hormone
secretion 1400
Syndrome of inappropriate antidiuretic hormone 1400
Nursing management: syndrome of inappropriate
antidiuretic hormone 1401
Diabetes insipidus 1402
Nursing management: diabetes insipidus 1403
Disorders of the thyroid gland 1403
Thyroid enlargement 1403
Thyroid nodules 1404
Thyroiditis 1404
Hyperthyroidism 1404
Nursing management: hyperthyroidism 1408
Hypothyroidism 1412
Nursing management: hypothyroidism 1414
Disorders of the parathyroid glands 1416
Hyperparathyroidism 1416
Nursing management: hyperparathyroidism 1418
Hypoparathyroidism 1418
Nursing and collaborative management:
hypoparathyroidism 1419
Disorders of the adrenal cortex 1419
Cushing`s syndrome 1419
Nursing management: Cushing`s syndrome 1422
Adrenocortical insuffciency 1424
Nursing management: Addison`s disease 1425
Corticosteroid therapy 1425
Nursing and collaborative management: corticosteroid
therapy 1426
Hyperaldosteronism 1427
Nursing and collaborative management: primary
hyperaldosteronism 1427
Disorders of the adrenal medulla 1428
Phaeochromocytoma 1428
Nursing and collaborative management:
phaeochromocytoma 1428
50 Nursing assessment: reproductive system 1431
Shannon Ruff Dirksen (US); Julie Parry (ANZ)
Structures and functions of the male and female reproductive
systems 1431
Assessment of male and female reproductive systems 1438
Diagnostic studies of reproductive systems 1446
51 Nursing management: breast disorders 1453
Cynthia Matthews (US); Marion Strong (ANZ)
Assessment of breast disorders 1453
Benign breast disorders 1456
Mastalgia 1456
Breast infections 1456
Fibrocystic changes 1457
Nursing and collaborative management: fbrocystic
changes 1457
Fibroadenoma 1457
Nursing and collaborative management: fbroadenoma 1457
Nipple discharge 1458
Gynaecomastia 1458
Breast cancer 1458
Nursing management: breast cancer 1467
Culturally competent care: breast cancer 1472
Mammoplasty 1473
Nursing management: breast augmentation and
reduction 1473
52 Nursing management: sexually transmitted
infections 1479
Shari Goldberg (US); John Rolley (ANZ)
Sexually transmitted infections 1479
Bacterial infections 1480
Gonorrhoea 1480
Syphilis 1482
Chlamydia infections 1485
Viral infections 1487
Genital herpes 1487
Genital warts 1489
Nursing management: sexually transmitted infections 1490
53 Nursing management: female reproductive
problems 1496
Nancy J MacMullen, Laura Dulski (US);
Julie Parry (ANZ)
Infertility 1496
Nursing and collaborative management: infertility 1497
Abortion 1498
Problems related to menstruation 1500
Premenstrual syndrome 1500
Dysmenorrhoea 1501
Nursing management: dysmenorrhoea 1501
Abnormal vaginal bleeding 1502
Nursing management: abnormal vaginal bleeding 1503
Ectopic pregnancy 1503
Nursing and collaborative management: ectopic
pregnancy 1504
Perimenopause and postmenopause 1505
CONTENTS xiii
Culturally competent care: menopause 1507
Nursing management: perimenopause and
postmenopause 1507
Conditions of the vulva, vagina and cervix 1508
Nursing management: conditions of the vulva, vagina and
cervix 1509
Pelvic infammatory disease 1509
Nursing management: pelvic infammatory disease 1510
Endometriosis 1511
Nursing management: endometriosis 1512
Benign tumours of the female reproductive system 1512
Leiomyomas 1512
Cervical polyps 1513
Benign ovarian tumours 1513
Cancers of the female reproductive system 1514
Cervical cancer 1514
Endometrial cancer 1515
Ovarian cancer 1516
Vaginal cancer 1517
Vulvar cancer 1517
Surgical procedures 1518
Radiation therapy 1518
Nursing management: cancers of the female reproductive
system 1519
Problems with pelvic support 1522
Uterine prolapse 1522
Cystocele and rectocele 1523
Nursing management: problems with pelvic support 1523
Fistula 1524
Nursing management: fstulas 1524
Sexual assault 1524
Nursing management: sexual assault 1525
54 Nursing management: male reproductive
problems 1530
Shannon Ruff Dirksen (US); John Rolley (ANZ)
Problems of the prostate gland 1530
Benign prostatic hyperplasia 1530
Nursing management: benign prostatic hyperplasia 1535
Prostate cancer 1539
Nursing management: prostate cancer 1544
Prostatitis 1545
Nursing and collaborative management: prostatitis 1546
Problems of the penis 1546
Congenital problems 1547
Problems of the prepuce 1547
Problems of the erectile mechanism 1547
Cancer of the penis 1547
Problems of the scrotum and testes 1548
Infammatory and infectious problems 1548
Congenital problems 1548
Acquired problems 1548
Testicular cancer 1549
Nursing and collaborative management: testicular
cancer 1549
Sexual functioning 1550
Vasectomy 1550
Erectile dysfunction 1551
Nursing management: erectile dysfunction 1554
Infertility 1554
SECTION ELEVEN
Problems related to movement and coordination
Jacqueline Baker
55 Nursing assessment: nervous system 1560
Sherry Garrett Hendrickson (US);
Jacqueline Baker (ANZ)
Structure and function of the nervous system 1560
Assessment of the nervous system 1574
Diagnostic studies of the nervous system 1580
56 Nursing management: acute intracranial
problems 1588
Linda Laskowski-Jones (US); Jacqueline Baker (ANZ)
Intracranial pressure 1588
Increased intracranial pressure 1590
Nursing management: increased intracranial pressure 1596
Head injury 1602
Nursing management: head injury 1606
Brain tumours 1608
Nursing management: brain tumours 1611
Cranial surgery 1612
Nursing management: cranial surgery 1613
Inammatory conditions of the brain 1615
Bacterial meningitis 1615
Nursing management: bacterial meningitis 1616
Viral meningitis 1618
Encephalitis 1618
Nursing and multidisciplinary care: viral encephalitis 1619
Brain abscess 1619
57 Nursing management: the patient with a stroke 1622
Julie T Sanford (US); Sonia Matiuk (ANZ)
Stroke 1622
Nursing management: stroke 1633
58 Nursing management: chronic neurological
problems 1646
Sherry Garrett Hendrickson, Stephanie A Elms,
Virginia Shaw (US); Jacqueline Baker (ANZ)
Headache 1646
Tension-type headache 1646
Migraine headache 1647
Cluster headache 1648
Other types of headaches 1648
Nursing management: headaches 1650
Chronic neurological disorders 1652
Seizure disorders and epilepsy 1652
Nursing management: seizure disorders and epilepsy 1657
Multiple sclerosis 1660
Nursing management: multiple sclerosis 1664
Parkinson`s disease 1666
Nursing management: Parkinson`s disease 1670
Myasthenia gravis 1671
Nursing management: myasthenia gravis 1672
Restless legs syndrome 1673
Nursing and collaborative management: restless legs
syndrome 1674
Other neurological disorders 1674
Motor neuron disease 1674
Huntington`s disease 1675
59 Nursing management: delirium, dementia and
Alzheimers disease 1678
Virginia Shaw, Sharon L Lewis (US); Wendy Moyle (ANZ)
Delirium 1678
Collaborative and nursing management: delirium 1679
Dementia 1680
Collaborative and nursing management: dementia 1682
Alzheimer`s disease 1682
Nursing management: Alzheimer`s disease 1689
Other neurodegenerative diseases 1694
60 Nursing management: peripheral nerve and
spinal cord problems 1698
Linda Laskowski-Jones (US); Anna Brown (ANZ)
Cranial nerve disorders 1698
Trigeminal neuralgia 1698
Nursing management: trigeminal neuralgia 1700
xiv CONTENTS
Bell`s palsy 1701
Nursing management: Bell`s palsy 1702
Polyneuropathies 1703
Guillain-Barr syndrome 1703
Nursing management: Guillain-Barr syndrome 1704
Botulism 1705
Nursing management: botulism 1705
Tetanus 1706
Nursing management: tetanus 1706
Neurosyphilis 1707
Spinal cord problems 1707
Spinal cord trauma 1707
Nursing management: spinal cord trauma 1715
Spinal cord tumours 1729
Nursing and collaborative management: spinal cord
tumours 1730
Post-polio syndrome 1730
Nursing and collaborative management: post-polio
syndrome 1731
61 Nursing assessment: musculoskeletal system 1734
Dottie Roberts (US); Aileen Wyllie (ANZ)
Structures and functions of the musculoskeletal
system 1734
Assessment of the musculoskeletal system 1739
Diagnostic studies of the musculoskeletal system 1743
62 Nursing management: musculoskeletal trauma and
orthopaedic surgery 1749
Sharon G Childs (US); Aileen Wyllie (ANZ)
Soft-tissue injuries 1749
Sprains and strains 1749
Nursing management: sprains and strains 1750
Dislocation and subluxation 1752
Nursing and collaborative management: dislocation 1752
Repetitive strain injury 1752
Carpal tunnel syndrome 1753
Nursing and collaborative management: carpal tunnel
syndrome 1753
Rotator cuff injury 1754
Meniscus injury 1754
Nursing and collaborative management: meniscus
injury 1755
Bursitis 1755
Muscle spasms 1755
Fractures 1755
Nursing management: fractures 1761
Complications of fractures 1769
Infection 1769
Compartment syndrome 1769
Venous thrombosis 1771
Fat embolism syndrome 1771
Types of fractures 1772
Colles` fracture 1772
Fracture of the humerus 1772
Fracture of the pelvis 1772
Fracture of the hip 1773
Nursing management: hip fracture 1773
Femoral shaft fracture 1775
Fracture of the tibia 1775
Stable vertebral fractures 1776
Facial fractures 1776
Mandible fracture 1777
Nursing management: mandibular fracture 1777
Amputation 1778
Nursing management: amputation 1779
Common joint surgical procedures 1782
Indications for joint surgery 1782
Types of joint surgery 1782
Nursing management: joint surgery 1785
63 Nursing management: musculoskeletal
problems 1789
Colleen R Walsh (US); Aileen Wyllie (ANZ)
Osteomyelitis 1789
Nursing management: osteomyelitis 1791
Bone tumours 1793
Nursing management: bone cancer 1795
Muscular dystrophy 1796
Low back pain 1796
Acute low back pain 1797
Nursing management: acute low back pain 1797
Chronic low back pain 1800
Intervertebral lumbar disc damage 1800
Nursing management: spinal surgery 1804
Neck pain 1805
Foot disorders 1805
Nursing management: foot disorders 1806
Metabolic bone diseases 1807
Osteomalacia 1807
Osteoporosis 1808
Nursing and collaborative management: osteoporosis 1809
Paget`s disease 1811
64 Nursing management: arthritis and connective tissue
diseases 1815
Dottie Roberts (US); Di Brown (ANZ)
Arthritis 1815
Osteoarthritis 1815
Nursing management: osteoarthritis 1823
Rheumatoid arthritis 1824
Nursing management: rheumatoid arthritis 1830
Spondyloarthropathies 1834
Ankylosing spondylitis 1834
Nursing management: ankylosing spondylitis 1836
Psoriatic arthritis 1836
Reactive arthritis 1836
Septic arthritis 1836
Tick-borne infection 1837
Gout 1837
Nursing management: gout 1840
Systemic lupus erythematosus 1840
Nursing management: systemic lupus erythematosus 1843
Systemic sclerosis 1846
Nursing management: systemic sclerosis 1847
Polymyositis and dermatomyositis 1848
Nursing and collaborative management: polymyositis and
dermatomyositis 1849
Mixed (overlapping) connective tissue disease 1849
Sjgren`s syndrome 1849
Soft-tissue rheumatic syndromes 1850
Myofascial pain syndrome 1850
Fibromyalgia syndrome 1850
Nursing management: fbromyalgia syndrome 1851
Chronic fatigue syndrome 1852
Nursing and collaborative management: chronic fatigue
syndrome 1852
SECTION TWELVE
Nursing care in specialised settings
Thomas Buckley and Christopher Gordon
65 Nursing management: critical care
environment 1858
Linda Bucher, Maureen A Seckel (US);
Thomas Buckley (ANZ)
Critical care nursing 1858
Culturally competent care: critical care patients 1864
Haemodynamic monitoring 1864
CONTENTS xv
Nursing management: haemodynamic monitoring 1874
Circulatory assist devices 1874
Nursing management: circulatory assist devices 1877
Artifcial airways 1877
Nursing management: artifcial airway 1880
Mechanical ventilation 1886
Nursing management: mechanical ventilation 1894
66 Nursing management: shock and multiple organ
dysfunction syndrome 1898
Kathleen M Geib (US); Margherita Murgo (ANZ)
Shock 1898
Nursing management: shock 1916
Systemic infammatory response syndrome and multiple
organ dysfunction syndrome 1920
Nursing and collaborative management: systemic
infammatory response syndrome and multiple organ
dysfunction syndrome 1921
67 Nursing management: respiratory failure and acute
respiratory distress syndrome 1926
Richard B Arbour (US); Christopher Gordon (ANZ)
Acute respiratory failure 1926
Nursing and collaborative management: acute respiratory
failure 1934
Acute lung injury/acute respiratory distress syndrome 1941
Nursing and collaborative management: acute respiratory
distress syndrome 1945
68 Nursing management: emergency care
situations 1950
Linda Bucher (US); Elizabeth Leonard (ANZ)
Assessment of the emergency patient 1950
Environmental emergencies 1958
Heat-related emergencies 1959
Environmental hyperthermia 1959
Environmental hypothermia 1961
Localised cold injury 1962
Submersion injuries 1963
Bites and stings 1964
Envenomation 1965
Poisonings/toxicology 1969
Major incident and disaster preparedness 1972
Chemical, biological and radiation hazards 1974
69 Chronic illness and complex care 1979
Linda Soars, Robyn Gallagher (ANZ)
Chronic illness 1979
The complexity of chronic illness 1979
Patient and family assessment 1981
Management of chronic illness 1981
Developing the health workforce to meet chronic illness
needs 1989
Conclusion 1991
APPENDICES
A Cardiopulmonary resuscitation and basic life
support 1995
B Nursing diagnoses 2001
C Answer key to review questions 2003
Picture credits 2005
Index 0000
1950
C
h
a
p
t
e
r

6
8
Presentations to emergency departments (EDs) range across
a wide spectrum of cases of all ages, encompassing medical,
surgical, obstetric and psychological emergencies. These cases
may present as immediate or potentially life-threatening cases,
such as major trauma, acute cardiac and/or respiratory disease
or acute psychological distress, or as less urgent cases, such as
minor wounds or localised infections. Emergency nurses must
be prepared to assess the range of cases and have sufficient
clinical knowledge to determine the priorities of care. In
ED, medical and nursing staff work collaboratively to ensure
effective and efficient patient assessment and management. In
many EDs nurses now assume advanced practice roles where
they are responsible for advanced assessment and patient
management strategies undertaking activities that, in the past,
were considered solely the domain of medicine. This chapter
examines both nursing care and multidisciplinary care.
In addition to the variety of presentations, EDs are faced
with increasing numbers of presentations. The number of
visits to the ED and the acuity of patient illnesses have
increased signifcantly over the past decade. This is due to
several reasons, which include:
Population and social change . For example, Australia`s
population grew from 16.9 million in 1989 to 22.2
million by 2010.

This increase is predominantly the
result of immigration rather than the birth rate;
consequently, the population in general is ageing, which
increases the burden on health services.
1-3
In 2010, New
Zealand`s population was approximately 4.4 million.

New Zealand is facing a different problem to Australia
due to a negative migration rate; however, this has also
led to an ageing of the population.
4
Cost and access . EDs provide a 24-hour a day service,
which is funded through the public taxation system.
(Australia and New Zealand have reciprocal agreements
for the provision of emergency services to citizens and
permanent residents.) Since many general practitioners
now charge fees on top of the government rebates, this
increases the attractiveness of attending EDs, which are
free at the point of service. Furthermore, ED services
are supported by the entire services of the hospital and
are therefore able to offer a wider range of health
services than general practitioners. EDs in local
hospitals may be the only after-hours services available
in some rural and remote regions.
This chapter focuses on the initial assessment and
management of the emergency patient and emergency
conditions, including heat- and cold-related emergencies,
submersion injuries, toxicology management, envenomation
and a brief discussion about non-accidental injuries and major
incidents and disaster preparedness. Table 68-1 provides a
summary of where the management of various emergency
situations can be found in this textbook.
Assessment of the emergency
patient
The initial assessment of patients presenting to emergency
begins with triage, a process of identifying the primary
LEARNING OBJECTIVES
1 Understand the principles of patient assessment in the emergency department,
including triage, primary survey and secondary survey.
2 Differentiate between the various types and victims of violence: accidental versus
abuse (domestic violence and children at risk).
3 Recognise the significance of mechanism of injury and initial signs and symptoms
for identifying actual or potential traumatic injury.
4 Describe the pathophysiology, assessment and multidisciplinary care of select
environmental emergencies, including hyperthermia, hypothermia and submersion
injury.
5 Identify a selection of Australias venomous creatures and discuss the principles of
management for envenomation.
6 Explain the principles of care for select toxicology emergencies.
7 Explore the strategies of preparedness for the management of major incidents,
emergency and/or disaster.
8 Describe the toxic agents and the principles of management for chemical, biological
and radiation hazards.
KEY TERMS
chemical, biological and radiation (CBR)
hazards, p 1974
children at risk, p 1956
disaster, p 1972
domestic violence, p 1956
emergency, p 1972
envenomation, p 1965
frostbite, p 1962
heat cramps, p 1959
heat exhaustion, p 1960
heat stroke, p 1961
hyperthermia, p 1959
hypothermia, p 1961
jaw-thrust or chin-lift manoeuvre, p 1953
major incident, p 1972
mechanism of injury, p 1956
primary survey, p 1951
rapid-sequence induction, p 1953
secondary survey, p 1954
submersion injury, p 1963
toxicology, p 1969
triage, p 1950
NURSING MANAGEMENT:
emergency care situations
Written by Linda Bucher
Adapted by Elizabeth Leonard
1972 SECTION 12 Nursing care in specialised settings
The solution is administered every 4-6 hours until stools are
clear. This process can be effective for swallowed objects such
as cocaine-filled balloons or condoms or substances such as iron
tablets that are not absorbed by charcoal. Complications include
nausea, vomiting and abdominal bloating, metabolic acidosis
and pulmonary aspiration. There is a high risk of electrolyte
imbalance due to fluid and electrolyte losses with this procedure.
39

Intravenous maintenance of fluids may be required to support
hydration. The process is time-consuming and requires a nurse
to stay with the patient.
Haemodialysis and haemoperfusion
Haemodialysis and haemoperfusion are invasive techniques
that simply remove the toxic substance and metabolites from
the circulation and correct electrolyte disturbances. They are
effective in cases of severe toxicity secondary to intoxication
from alcohol, lithium and phenobarbitone.
39
Patients undergoing
these procedures often require intensive care monitoring.
Haemoperfusion is a similar process to haemodialysis but
utilises the adsorptive properties of charcoal to bind drugs
or toxins as the patient`s blood is passed through a charcoal
membrane or filter; it is more effective than simple dialysis.
Antidote administration
A limited number of true antidotes are available, and many of
these agents are themselves toxic.
39
In addition, their use in
cases of acute-on-chronic overdose requires caution. Patients
who have developed dependence on drugs such as opiates or
benzodiazepines are much more likely to develop significant
withdrawal with the administration of an antidote. The
administration of either flumazenil or naloxone (as appropriate)
should be limited to the dose required to maintain respiration
and not to fully reversing the effects of the respective drug.
The role of, choice of method of and indications for
gastric decontamination remain controversial, although
there are patients who are likely to beneft from this form of
treatment. Innovations for the treatment of poisonings, such
as digoxin-Fab fragments, currently used for the treatment of
digoxin poisoning, must be available at the appropriate time
to be effective.
55
It is important, however, to remember that
antidotes themselves are drugs and frequently cause adverse
effects. Administration is based on risk-beneft analysis. It is
recommended that antidotes be used only under strict clinical
supervision, in the correct dose, with the correct route and with
appropriate monitoring.
39,56
PSYCHOLOGICAL SUPPORT
Education and support to avoid any subsequent toxic
emergencies focuses on how the poisoning occurred and
safety. A mental health professional should assess patients
whose poisoning is the result of a suicide attempt. Patients
who have a history of substance abuse may be referred for
alcohol or drug detoxification if they consent. Patients who
have suffered accidental poisoning of prescribed medications
require pharmacological education and, in some cases, may
benefit from the introduction of pre-packaged medication to
reduce the risk of confusion with medication doses.
Major incident and disaster
preparedness
A major incident is an incident that involves or has the potential
to involve a large number of casualties and can be adequately
managed by available resources, but requires a significant
coordinated response. The most recognised recent global
disasters include the destruction of the World Trade Center by
hijacked aeroplanes on 11 September 2001, the 2004 Boxing
Day tsunami and the devastating tsunami in Japan in March
2011. Disasters have also occurred closer to home: Australia
experienced the Victorian bushfires in February 2009 and the
Queensland and Victorian floods in January 2011, while New
Zealand faced two earthquakes in Christchurch and the Pike
River Mine disaster in 2010. New Zealand was also heavily
involved in the response to the Samoan tsunami in 2009.
As a result of the frst Bali bombing in 2002, which tested
the coordination of the disaster response in Australia and
New Zealand, emergency response and management in both
countries have been refned. In New Zealand, the management
of major incidents and disasters is coordinated via the New
Zealand Civil Defence Emergency Management (CDEM)
Strategy. The National Crisis Management Centre (NCMC)
facilitates crisis management arrangements, links the various
agencies and ensures that there are suffcient resources to
deal with any type of event or crisis. The CDEM Strategy
contains four goals: (1) increasing community awareness,
understanding, preparedness and participation in civil defence
emergency management; (2) reducing the risks from hazards
to New Zealand; (3) enhancing New Zealand`s capability
to manage civil defence emergencies; and (4) enhancing
New Zealand`s capability to recover from civil defence
emergencies.
57
Disaster management is governed by the Civil
Defence Emergency Management Act 2002.
In Australia, major incidents and disasters are managed under
the National Health Emergency Management (NHEM) Plan.
Both the Commonwealth and state agencies are responsible for
coordinating responses to major incidents, emergencies and/
or disasters. These agencies include Emergency Management
Australia (EMA), state emergency management committees,
emergency services (e.g. police, fre brigade, ambulance),
State Emergency Services (SES), the Red Cross and Defence
authorities. The roles and responsibilities for these agencies
are legislated by the Commonwealth and the states. The EMA
is Australia`s leading agency in the coordination of disaster
management and is responsible for the development of several
Australian government disaster response plans assisting with
disaster response both nationally and abroad.
58
The terms emergency and disaster may be used inte r-
changeably depending on the country and local terminology.
Disaster, as defned in the Community Welfare Act 1987
(Australia), is an occurrence, whether or not due to natural
causes, that causes loss of life, injury, distress or danger to
people, or loss of, or damage to, property. An emergency/
disaster is an event that is actual or imminent (e.g. fre, food,
storm, earthquake, explosion, accident, epidemic or war-like
action) that:
endangers, or threatens to endanger, the safety or health
of people in the state or territory, or
destroys or damages, or threatens to destroy or damage,
any property in the state, being an emergency that
requires a significant and coordinated response.
In New Zealand, where both disasters and emergencies are
referred to as civil defence emergencies, an emergency/disaster
is defined as a situation that:
(a) is the result of any happening, whether natural or
otherwise, including, without limitation, any
explosion, earthquake, eruption, tsunami, land
CHAPTER 68 NURSING MANAGEMENT: emergency care situations 1973
movement, flood, storm, tornado, cyclone, serious
fire, leakage or spillage of any dangerous gas or
substance, technological failure, infestation, plague,
epidemic, failure of or disruption to an emergency
service or a lifeline utility, or actual or imminent
attack or warlike act; and
(b) causes or may cause loss of life or injury or illness or
distress or in any way endangers the safety of the
public or property in New Zealand or any part of New
Zealand; and
(c) cannot be dealt with by emergency services, or
otherwise requires a significant and coordinated
response under the Act. [CDEM Act 2002 section 4]
57
EMERGENCY SERVICES
Staff in the ED need to be prepared to deal with unexpected and
severe injuries occurring as a result of disasters and terrorist
attacks. Their own communities may have been affected and
staff themselves have to confront uncertainty and fear while
providing care for those who have been injured. For example,
in New Zealand the severity of the Christchurch earthquake
meant that staff working in EDs were looking after victims
while at the same time being unsure whether their own families
and homes were safe (see Figs 68-8 and 68-9). Similarly, in
Australia the devastation of the Victorian fires meant that ED
staff were caring for injured members of their own communities
while trying to deal with the personal effects of the catastrophe.
Although Australia and New Zealand have so far avoided a
terrorist attack within their borders, the Bali terrorist attacks
in 2002 and 2004 affected many local hospitals when victims
were flown back to Australia for treatment.
Staff in EDs, in common with the rest of the community,
suffer from shock and disbelief when disasters such as these occur
but, because they are on the front line of clinical management,
it is important that they still practise the fundamental principles
of assessment and management. Staff efforts are often focused
on the management of complex patient injuries following such
incidents (see Fig 68-10). Triaging of patients based on the
seriousness and extent of injuries is crucial (see Fig 68-11).
Injuries of patients involved in disasters are varied but may
involve extensive penetrating injuries when bomb blasts occur
(see Fig 68-12). Materials used in homemade bombs present
unusual injuries requiring inventive and sometimes unusual
treatment. For instance, ball bearings used in terrorist bomb
attacks scatter widely and cause extensive, serious injuries
(see Fig 68-13).
Figure 68-8 Transferring an injured person to hospital.
Source: Photolibrary.
Figure 68-9 Severe crush injuries may result from the damage
caused by an earthquake, such as the recent Christchurch
earthquake.
Source: Photolibrary.
Figure 68-10 Emergency management of victims from the Bali terrorist attack.
Source: Used with permission. Royal Darwin Hospital, Clinical Photo Library.
1974 SECTION 12 Nursing care in specialised settings
Chemical, biological and radiation
hazards
Chemical, biological and radiation (CBR) hazards may result
from industrial accidents, epidemics or agricultural pesticide
exposure. In addition to accidental exposure, the world currently
faces the threat of terrorism. Terrorism involves overt actions,
such as the dispensing of disease pathogens or other agents
(e.g. chemical, biological and/or radiological) as weapons for
the express purpose of causing harm. Prompt recognition and
identification of potential health hazards is essential in the
preparedness of healthcare professionals.
53
Chemicals agents that pose major health risks are categorised
according to their target organ or effect (see Table 68-10).
Agents include:
nerve agents (e.g. organophosphates)
blister agents (e.g. mustard gas, lewisite and phosgene
oxime)
choking/pulmonary agents (e.g. chlorine, phosgene)
blood agents (e.g. hydrogen cyanide).
Even though these chemicals may be used industrially, they
also have the potential to be used in terrorist acts.
Radiation exposure may occur through occupational
exposure, diagnostic procedures such as X-ray and CT scans
or nuclear medicine, treatments such as those used in radiation
oncology or via radioactive materials used in war or terrorist
actions. Exposure to radiation may or may not include skin
contamination with radioactive material. If external radioactive
contaminants are present, decontamination procedures must be
initiated. Acute radiation syndrome develops after a substantial
TABLE 68-10 Chemical agents of terrorism by target organ or effect
Nerve Blood Pulmonary Blister/vesicants
Sarin (isopropyl methylphosphonofluoridate)
Tabun (ethyl N,N-dimethylphosphoramido-
cyanidate)
Soman (pinacolyl methylphosphonofluoridate)
GF (cyclohexyl methylphosphonofluoridate)
VX (O-ethyl S-[2-diisopropylaminoethyl]
methylphosphonothiolate)
Hydrogen cyanide
Cyanogen chloride
Phosgene
Chlorine
Vinyl chloride
Nitrogen and sulfur mustards
Lewisite (an aliphatic arsenic
compound, 2-chlorovinyl-
dichloroarsine)
Phosgene oxime
Figure 68-11 Patient injuries from the Bali terrorist attack. Note
triage assessment.
Source: Used with permission. Royal Darwin Hospital, Clinical Photo Library.
Figure 68-12 Penetrating wounds received as a result of a
bomb blast.
Source: Used with permission. Royal Darwin Hospital, Clinical Photo Library.
Figure 68-13 Chest X-ray showing ball-bearing bomb injury.
Source: Used with permission. Royal Darwin Hospital, Clinical Photo Library.
exposure to radiation and follows a predictable pattern (see
Table 68-11).
53
Exposure to CBR agents requires specifc decontamination
to avoid the risk of secondary contamination of staff and/or
other patients within the ED and hospital. Planning for the
response and recovery from a CBR incident is considered a
major focus in emergency management planning, not only due
to the threat of terrorist acts but also due to the risks of exposure
in general industry and within hospitals.
CHAPTER 68 NURSING MANAGEMENT: emergency care situations 1975
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1976 SECTION 12 Nursing care in specialised settings
6. A chemical spill has occurred in a nearby industrial
site. The first responders report that approximately
20 victims need to be transported to the emergency
department after decontamination at the site. This is
an example of:
A a major incident
B a natural disaster
C a disaster
D an emergency
7. Which of the following biological agents has no effective
treatment?
A anthrax
B botulism
C smallpox
D Ebola virus
References
1. Australian Bureau of Statistics (ABS). Australian demographic
trends, 2010. Canberra: ABS; 2010. Available at www.abs.gov.au/
ausstats/abs@.nsf/mf/3101.0, accessed 22 October 2010.
2. Trewin D. Australian social trends, 2006. Canberra: ABS; 2006.
3. Australian Bureau of Statistics (ABS). Australian migration
statistics, 2008-2009. Canberra: ABS; 2010.
4. Department of Foreign Affairs and Trade. New Zealand country
brief-February 2007. Available at www.dfat.gov.au/geo/new_
zealand/nz_country_brief.html, accessed December 2010.
5. Australasian College of Emergency Medicine. Guidelines on the
implementation of the Australasian Triage Scale in emergency
departments, 2000. Still current. Available at www.acem.org.au/
media/policies_and_guidelines/G24_Implementation_ATS.pdf,
accessed December 2010.
6. The National Education Framework for Emergency Triage Working
Party. Department of Health and Ageing: emergency department
triage education kit. Canberra: Commonwealth Government; 2009.
7. Jacobs B, Hoyt KS, eds. Trauma nursing core course: provider
manual. 6th edn. Des Plaines, IL: Emergency Nurses Association;
2007.
8. Ollerton JE. Adult trauma clinical practice guidelines, emergency
airway management in the trauma patient. Sydney: Institute of
Trauma and Injury Management; 2007.
9. Armstrong B, Reid C, Heath P, Howard S, Kitching J et al.
Rapid sequence induction anaesthesia: a guide for nurses in the
emergency department. Int Emerg Nurs 2009; 17:161-168.
Review questions
1. An elderly man arrives at the emergency department. He is
tachypnoeic and disoriented, and his skin is hot and dry.
The priority for treatment at this point is to:
A assess his airway, breathing and circulation
B obtain a detailed medical history from his family
C obtain a urine specimen for urinalysis
D start oxygen administration and medical assessment
2. A patient has presented with a core temperature of 32.2C.
The most appropriate rewarming technique would be:
A passive rewarming with body-to-body contact
B active core rewarming using warmed intravenous fluids
C passive rewarming using air-filled warming blankets
D active external rewarming by submersing in a warm
bath
3. The recommended management for reducing the
absorption of many ingested poisons is:
A ipecac syrup
B milk dilution
C gastric lavage
D activated charcoal
4. What is the recommended immediate management for a
funnel-web spider bite?
A tourniquet above the bite site to prevent venom
reaching the central circulation
B ice pack to the bite site to reduce pain and decrease
circulation to the bite area, immobilising the venom
C direct pressure over the bite site and a firm crepe
bandage over the site then up the entire limb
D two ampoules of funnel-web spider antivenom,
administered with prophylaxis for possible allergic
reaction
5. In the absence of significant clinical signs and symptoms,
what information would lead nursing and medical staff to
suspect the potential for underlying injury and the need
for trauma team management?
A an adult falling 2 m
B motor cyclist in a collision with a car at 40 km/h
C burns to 10% body surface area
D pedestrian killed by a car
CASE STUDY
The trauma patient
Patient profile
A 20-year-old female trauma patient is brought to the emergency
department in an ambulance. She was the driver in a motor vehicle
collision and was not wearing a seat belt. Two children in the car were
pronounced dead at the scene. The paramedics stated that there was
significant damage to the car on the drivers side.
Subjective data
Patient asks, What happened? Where are the children?
Complains of shortness of breath and abdominal pain
Objective data
Physical examination
4 cm head laceration
Badly deformed right lower leg with a pedal pulse by Doppler only
Glasgow Coma Scale score = 14, unequal pupils
Decreased breath sounds on left side of chest
Asymmetrical chest movement
Vital signs: blood pressure 90/40 mmHg, heart rate 130 beats/min,
respiratory rate 36 breaths/min
O 2 saturation 82%
CRITICAL THINKING QUESTIONS
1. What life-threatening injury does this patient probably have?
2. What is the priority of care?
3. What interventions are needed immediately?
4. What other interventions should the nurse consider?
5. Several family members have arrived in the emergency
department, including a woman who states her child was in the
car (one of the children who died). The second child who died was
the patients child. How should the nurse approach the family?
6. Based on assessment data presented, write one or more nursing
diagnoses. Are there any collaborative problems?
1979
C
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6
9
Chronic illness
Chronic illnesses differ from acute illnesses because they are of
long duration, tend to progress slowly and have a protracted,
unpredictable course.
1
The most prevalent chronic diseases
internationally are heart disease, stroke, cancer, chronic
respiratory diseases and diabetes mellitus. Together, these
five diseases are the leading causes of mortality in the world,
representing 60% of all deaths. These diseases, along with
depression, are also the most prevalent chronic illnesses in
Australia and New Zealand.
2,3

Multiple factors are involved in the development of chronic
illnesses, such as heredity, lifestyle factors (in particular,
societal changes relating to eating and exercise habits) and
environmental factors. Although numerous chronic illnesses
arise with ageing (discussed in Ch 5), half of those who
die from chronic illnesses every year are under 70 years of
age.
1
Importantly, people with chronic illness tend to develop
comorbid conditions, so that they not only have multiple
chronic illnesses but also may accumulate more conditions
as they age.
2,4,5
Additional factors that have contributed to the
rapid increase in the prevalence of chronic illnesses are the
dramatic improvements that have been made in healthcare and
health technology enabling people to survive previously fatal
illnesses, meaning that more people are living with chronic
illness and developing other chronic illnesses. Indigenous
Australians, Mori and Pacifc Islanders are strikingly
overrepresented in all chronic illness data in Australia and
New Zealand, suggesting the presence of multiple risk factors
and highlighting potential issues with equity and access to
healthcare and concerns about health literacy

in Indigenous
populations.
2,3
This reinforces the need for prevention strategies to occur
at both the individual and the population level. A recent 5-year
study found that a limited number of cost-effective public
health interventions can have a large impact on improving a
population`s health status. These interventions include:
taxing tobacco, alcohol and unhealthy foods
placing mandatory limits on the amount of salt added
during production of three basic food items (bread,
cereals and margarine)
improving the efficiency of blood pressure and
cholesterol-lowering drug management by using an
absolute risk approach and choosing the most cost-
effective generic drugs (or potentially introducing a
low-cost polypill that combines three blood-pressure-
lowering drugs and one cholesterol-lowering drug in
a single pill)
using gastric banding for severe obesity
undertaking an intensive campaign highlighting the
harmful effects of ultraviolet radiation on the skin.
6
Regardless of the cause, chronic illness results in
limitations in physical functioning, work productivity and
quality of life for those affected and can profoundly affect the
lives and identities of patients, carers and families. Chronic
illnesses place substantial demands on the health system too;
7

they currently comprise 70% of the current health burden
and this is expected to increase to 89% by 2020.
5
Financing
the healthcare costs and developing the personnel needed
for chronic illnesses have been identifed as some of the top
challenges facing the health systems in New Zealand and
Australia.
3,8

This chapter addresses generic issues in chronic illness
for the individuals affected and for the nurses who care for
them. Detailed discussion about specifc chronic illnesses,
including prevalence in Indigenous populations, is provided
in various chapters throughout this book.
The complexity of chronic illness
Chronic illness is often associated with complexity in its
causes, effects and consequences. There are three main factors
that contribute to this complexity. First, chronic illness is
characterised by periods of exacerbation; second, as time
passes, a chronic illness and its treatments may generate
further issues; and third, the individual with chronic illness
may experience unequal access to care and support.
Chronic illnesses often have acute exacerbations in which
the individual moves from a level of optimum functioning,
with the illness in good control, to a period of instability
where the individual may need assistance. Chronic illnesses
can be described as following a trajectory (see Fig 69-1)
LEARNING OBJECTIVES
1 Describe the major causes of chronic illnesses.
2 Explain the characteristics of a chronic illness across the life span.
3 Explore complex illnesses and the assessment of comorbidities in adults.
4 Describe self-management and self-care principles relating to chronic illness
management.
5 Evaluate the models of care used to manage chronic and complex illnesses.
6 Identify the workforce requirements for health workers in meeting needs for chronic
illness management.
KEY TERMS
care coordination, p 1986
care navigation, p 1985
case management, p 1989
chronic illnesses, p 1979
disease management, p 1982
exacerbation, p 1979
self-efficacy, p 1985
self-management, p 1982
social cognitive theory, p 1982
Chronic illness and complex care
Written by Linda Soars and Robyn Gallagher
1980 SECTION 12 Nursing care in specialised settings
in the general population,
10
while Mori life expectancy for
men and women is at least 8 years less than for their non-
Mori counterparts.
3
People from a culturally and linguistically
diverse (CALD) background (i.e. people whose frst language
is not English) often have poorer rates of health literacy and
may be excluded by their language and cultural preferences
from attending chronic illness management and rehabilitation
services.
11

The Australian Institute of Health & Welfare has found that
even though age-specifc prevalence rates of disability appear
relatively stable in Australia, the ageing of the population and
the greater longevity of individuals have led to growing numbers
of people, especially older people, suffering disabilities and
severe or profound limitations in core activities.
2
Within New
Zealand there is not a lot of research into chronic illnesses (also
known locally as 'long-term conditions`) as a discrete entity,
but it is estimated that, in 2008, 2 in every 3 New Zealand
adults were diagnosed with at least one chronic condition.
12

A recent analysis of Australian data showed that a male`s life
expectancy at age 65 increased by 1.5 years between 1988 and
2003 but, of this gain, 67% (1 year) was spent with disability,
including 27% spent with profound or severe core activity
limitation. Females increased their life expectancy at age 65 by
1.2 years over the same period, and for them more than 90%
of the gain was estimated to be spent with disability, including
58% spent with profound or severe limitation.
2
Indeed, hospital
admissions are a common feature of the years gained. Of the
2.5 million hospital episodes of care completed in Australian
hospitals in one year, people aged 65 years and over represented
35% of the total cases admitted.
13
Furthermore, the level of
disability experienced by older patients increases the likelihood
that they will need invasive technologies such as biventricular
pacemakers, implantable cardiac defbrillators and specifc
drugs. These provide patients with a number of complex issues
to consider in managing their lifestyle.
Depression frequently accompanies or precipitates chronic
illness and has been noted as a very important symptom to
manage. Depression is also a chronic illness itself. Therefore,
screening for depression has been recommended as part of
with overlapping phases (see Table 69-1).
9
This trajectory
characterises the common course of most chronic illnesses. The
increasing number of people with multiple chronic illnesses and
the changes in levels of acuity in those with chronic disease
have led to the need to develop local and regional systems to
manage and integrate care for people with chronic illnesses.
Indigenous Australians and Mori both have poorer health
outcomes across a range of chronic illnesses than their non-
Indigenous counterparts. In addition, Indigenous Australian
men have a life expectancy that is 11.5 years less than men
Stable
Health
Illness Months
TIME
Onset
Stable Stable
Stable
C
r
i
s
i
s
Downward
D
y
i
n
g
C
o
m
e
b
a
c
k
Comeback
Acute
Figure 69-1 The chronic illness trajectory is a theoretical model of chronic illness. The trajectory model of chronic illness recognises
that chronic illness will have many phases (see Table 69-1).
TABLE 69-1 Chronic illness trajectory
Phase Description
Onset Signs and symptoms are present
Disease diagnosed
Stable Illness course/symptoms controlled by regimen
Individual maintains everyday activities
Acute Active illness with severe and unrelieved
symptoms or complications
Hospitalisation required for management
Comeback Gradual return to an acceptable way of life
Crisis Life-threatening situation occurs
Emergency services are necessary
Unstable Unable to keep symptoms/disease course
under control
Life becomes disrupted while working to regain
stability
Hospitalisation not required
Downward Gradual and progressive deterioration in
physical/mental status
Accompanied by increasing disability and
symptoms
Continuous alterations in everyday life activities
Dying Individual has to relinquish everyday life
interests and activities, let go and die peacefully
Immediate weeks, days, hours preceding death
Source: Woog P. The chronic illness trajectory framework: the Corbin
and Strauss nursing model. New York: Springer; 1992.
CHAPTER 69 Chronic illness and complex care 1981
work together to establish the most important illness symptoms
and management plans to follow, thereby ensuring that the
patient understands the priority steps in their health action plan.
Managing multiple medical problems simultaneously can be
a challenge for both healthcare professionals and the patient,
and sometimes makes for a very confusing set of options for
patients to navigate.
Management of chronic illness
MODELS OF CHRONIC ILLNESS CARE
Given the complexity of chronic illnesses there is a corresponding
need to provide care that allows for a connection with multiple
health professional groups and specialists, while also supporting
patients` efforts at self-management. Health system planning and
redesign have led to a number of different standardised service
delivery models that can be used to meet the ongoing care needs
of people with chronic diseases requiring hospital care.
18
By
optimising service delivery systems and testing redesigned models
of care, local health services are aiming to meet the increased
care needs of the community using more flexible service delivery
models. Commonly reported models that offer the chance to
redesign parts of the existing health system are outlined in Table
69-2. New models of care are being introduced to improve patient
and carer outcomes, especially around the crisis points of the
chronic care journey, such as unplanned hospital admissions and
acute exacerbations of the chronic illness.
A recent systematic review of disease management
interventions for patients with chronic heart failure (see
Box 69-2) found that there are three intervention models:
(1) multidisciplinary interventions (holistic approaches that
bridge the gap between hospital admission and discharge,
delivered by a team); (2) case management interventions
(intense monitoring of patients following discharge, often
involving telephone follow-up and home visits); and (3) clinic
interventions (follow-up in a chronic heart failure clinic).
19

These models are summarised in the Table 69-3. The review
found weak evidence that case management interventions are
associated with a reduction in readmissions for heart failure,
although the authors concluded that it was diffcult to identify
the effective components of case management interventions.
A randomised controlled trial that examined the management
of heart failure using multidisciplinary interventions showed
reduced heart failure-related readmissions in the short term.
20

Using strategies that promote self-management may mean
that nurses are able to implement care planning that ensures
each patient with a chronic illness has a structured plan that
all chronic illness management programs. A range of chronic
illnesses have been associated with depression, including
asthma, heart disease, stroke, arthritis, diabetes mellitus,
cancer, dementia, chronic pain and Parkinson`s disease. In fact,
beyondblue suggests that more than 40% of Australians with a
mental disorder have a chronic physical illness and that having
a chronic illness puts a person at greater risk of developing
depression.
14
For people with a chronic illness, depression
makes recovery and management more diffcult. It can make
it harder to fnd the energy to eat healthily, exercise and take
medications regularly, making adherence to, and compliance
with, health action plans more diffcult.
Patient and family assessment
Care provision for the initial diagnostic and acute exacerbation
phases of a chronic illness is often managed in a hospital setting,
but the majority of care is usually, and appropriately, provided
outside of the acute care setting. This means that usually the
individuals affected, and their families, provide the majority
of care while they live in their own homes or in assisted-living
or residential aged-care facilities, with intermittent support
from ambulatory care settings. Thus the patient and family
must manage the effects of the chronic illness on their daily
functioning. This impact can be diverse and it is important to
assess for each individual.
15
Functional health assessment for
chronic illness should cover activities of daily living (ADLs)
such as bathing, dressing, eating, toileting and transport, as
well as the patient`s level of social support. It is also important
to include instrumental ADLs, such as using a telephone,
shopping, preparing food, housekeeping, doing laundry,
arranging transportation, taking medications and handling
finances. The assessment should take into account the person`s
age and life demands, as well as their capacity to manage
multiple comorbidities. The assessment and monitoring of
these functions is often used to predict the level of supportive
health, personal and domestic care required. An inability to
perform any of these activities safely or efficiently can affect
the patient`s quality of life and the level of support they need
in order to live independently in the community.
Few individuals can manage their chronic illness without the
support and care provided by family and friends.
15
Carer strain
and burden vary with complex chronic illnesses, but usually
include stress and worry related to social, fnancial and physical
aspects. These concerns need to be assessed and considered as
part of the patient`s health assessment and action planning to
manage their chronic illness. The tasks of an informal carer
may include: (1) assuming an increased physical burden of
work because of the need to add tasks previously undertaken
by the chronically ill person; (2) dealing with the changes in
the progression of the disease; (3) coping with feelings of
being overwhelmed both psychologically and physically; and
(4) dealing with changes in social roles and identity for both
themselves and the patient because of the illness. The role of the
carer in supporting the person with heart failure to provide better
self-care has been explored by Gallagher and colleagues,
16
and
their recommendations for using carer support in improving
self-care capacity are summarised in Box 69-1.
Carer strain and social support affect care needs and
management strategies.
17
A review of domestic support needs
and carer factors will enable the patient`s case manager to
effectively plan interventions that meet the goals and needs of
the patient and their family during the different phases of the
chronic illness. The case manager, patient and family should
BOX 69-1 Social support and self-care
recommendations to improve outcomes using carers
Social support provided by partners of a quality and content that
matches heart failure patients needs is associated with better
self-care, particularly in the key areas of taking medications,
managing fluid intake, consulting health professionals for weight
gain, having a flu shot and taking regular exercise.
When assessing heart failure patients capacity for self-care, the
partners relationship with the patient should also be assessed.
Carers, especially partners, should be considered as integral to
the treatment and care of heart failure patients.
New teaching or counselling strategies are needed to optimise
self-care in heart failure patients and their partners.
Source: Gallagher R, Luttik M, Jaarsma T. Social support and self-care in
heart failure. J Cardiovasc Nurs 2011; 2.
1982 SECTION 12 Nursing care in specialised settings
drives their care. A care plan should be the cornerstone of
chronic disease management and it should receive input from all
the healthcare team members who assist the patient in planning
their care. A sample care plan is provided in Figure 69-2.
PRINCIPLES OF SELF-MANAGEMENT
While the trajectory of most chronic illnesses includes hospital
admissions, the mainstay of healthcare for chronic illnesses
is self-management. Self-management is an umbrella term
that encompasses not only self-care-that is, the specific
tasks that people carry out on a day-to-day basis to manage
their condition-but also disease management, which
refers specifically to the use of health interventions, such
as medications, to treat the illness.
21,22
It is estimated that
70-80% of older individuals living with a chronic condition
can reduce their disease burden and prevent hospital admissions
through the implementation of appropriate self-management
strategies.
23
People who have participated in self-management
programs and learned strategies to manage their condition
experience a reduction in symptoms and hospital admissions,

as well as increased participation in healthy activities.
24-26

The key requirements for individuals to self-manage their
chronic illness appropriately include:
a clear understanding of the illness and the health
outcomes sought
active engagement in their own disease management
processes
self-management skills
a high level of self-efficacy (confidence in one`s own
ability to do what is required to reach a goal)
health literacy.
27
It is crucial for successful self-management that individuals
see themselves as their own main carers and use health
professionals as support. This process of engagement is best
explained by social cognitive theory. In this theory three central
factors (outcome expectancies, self-effcacy and decision
making) contribute to the individual`s level of engagement, or
TABLE 69-2 Models of care
Service type Model Rationale for use
Emergency department Fast-track for lower triage categories
Admission using 3-2-1 time limit
Clinician initiative nurses (CINs)
Nurse practitioners
Aged care services in emergency team
Nurse protocols
Emergency medical unit
Psychiatric emergency care centre
A large number of models have been tried around the
world to improve the flow of people with an
unplanned health crisis through the emergency
system. A triage process is used in all emergency
departments to ensure care by need, but there is also
benefit in treating and discharging people with
problems that can be managed in the community via
alternative care pathways.
Inpatient services Chest pain
Clinical decision
Short stay
Assessment unit: medical/aged care/surgical
Once admitted, patients receive targeted assessments,
reviews and interventions designed to be given within
a time-limited period. They are discharged earlier and
receive appropriate ongoing care at home.
Hospital-in-the-home services Acute short-term medical, nursing and allied
health services.
Slow stream rehabilitation servicestransitional
care support.
Patients receive care in their own homes that would
usually be delivered in a hospital setting.
Community-based services Chronic disease rehabilitation
Self-management programs
Short-term support services offering 23 services
(e.g. NSW Compacks)
Offered to individuals and groups to support, educate
and rehabilitate people experiencing exacerbations of
their chronic illness.
BOX 69-2 Avoiding hospital admissions: what does the
evidence tell us?
Interventions with evidence of a positive effect
Reducing admissions
Continuity of care with a general practitioner
Hospital at home as an alternative to admission
Assertive case management in mental health
Self-management
Early senior review in the emergency department
Multidisciplinary interventions and telemonitoring in heart
failure
Integration of primary and secondary care
Reducing readmissions
Structured discharge planning
Personalised healthcare programs
Interventions with evidence of little or no beneficial effect
Pharmacist home-based medication review
Intermediate care
Community-based case management (generic conditions)
Early discharge to hospital at home on readmissions
Nurse-led interventions pre- and post-discharge for patients with
chronic obstructive pulmonary disease
Interventions for which further evidence is needed
Increasing the size of general practice surgeries
Changing out-of-hours primary care arrangements
Chronic care management in primary care
Telemedicine
Cost-effectiveness of general practitioners in the emergency
department
Access to social care in the emergency department
Hospital-based case management
Rehabilitation programs
Rapid response teams
Source: Purdy S. Avoiding hospital admissions: what does the research
evidence say? The Kings Fund response to the Department of Healths
public consultation on an information revolution. London: Kings Fund;
2010.
CHAPTER 69 Chronic illness and complex care 1983
participation, in the learning that is needed and the behavioural
changes that are necessary to self-manage their condition.
28
In
terms of outcome expectancies, the individual must perceive
a threat in their illness situation and believe that they have the
capacity to somehow reduce this threat. They must consider
that they have the skills and confdence necessary to undertake
the behaviours required (self-effcacy). They must then weigh
up the balance between the effort required and the reduction in
risk they may achieve (decision making). Engagement is vital
because people with chronic illness must undertake potentially
complex behaviours and make unwelcome changes to their
lives while at the same time experiencing an array of disabling
symptoms.
REQUIREMENTS FOR SELF-MANAGEMENT
The skills required to self-manage a chronic illness may be
grouped into those needed to deal with the illness, those needed
to continue as normal a life as possible and those needed to
deal with emotions.
15

Dealing with chronic illness
To deal with the illness the individual needs to understand the
disease and the treatments, and the sequelae of both. Monitoring
key signs and symptoms of the disease, interpreting changes
in these symptoms, initiating treatments and determining when
help is needed are essential. So too is taking medications and
undertaking treatments to manage the symptoms of the illness
and then assessing the relative benefits and costs of these
treatments. Learning how to prevent and manage a crisis is
also a vital skill to develop, as most chronic illnesses have the
potential for acute exacerbations of symptoms that may result
in further disability or even death.
9
A major task for the patient and family is to learn to prevent
and manage a crisis. Preventing a crisis involves understanding
what the potential for the crisis is and then learning how to
prevent or modify the threat. This often comprises adhering
to a prescribed medical regimen. Patients also need to know
the signs and symptoms of the onset of a crisis. Depending on
the chronic illness, these may occur suddenly (e.g. seizure in a
patient with seizure disorder) or slowly (e.g. heart failure in a
patient with hypertension). It is equally important for the patient
and family to develop a plan to manage the crisis. For example,
a person with chronic obstructive pulmonary disease (COPD)
must have some understanding of their disease, the potential
for exacerbations, the signs and symptoms of exacerbations,
their medications and treatments. They must regularly assess
their level of dyspnoea and be alert for the frst signs of a
respiratory tract infection. When these signs occur, they must
begin following their crisis action plan. Finally, they must decide
whether their signs and symptoms warrant medical care.
Maintaining a normal life
The self-management skills needed to maintain a relatively
normal daily life within the boundaries of chronic illness include
managing regular aspects of life such as housekeeping, food
purchasing and preparation, social roles and relationships.
15
It is
important that the individual learns about the pattern of disease
symptoms such as typical onset, duration and severity so that
lifestyle patterns can be changed accordingly.
A key component of maintaining a relatively normal daily
life is ensuring good general health, which can be achieved
by following a healthy diet and taking exercise. Considerable
problem-solving skills may also be required to balance illness
management requirements and the symptoms that occur on a
daily basis, and to garner resources and support. For example,
an individual with COPD may plan their day very carefully to
spread out energy-consuming activities in order to avoid intense
periods of dyspnoea. They may have to arrange transport with a
friend or family member to a social event to minimise walking
and to avoid exposure to potential sources of infection on
public transport. All of these activities depend on their ability
to negotiate and manage their plans with family and friends.
Dealing with emotions
People with chronic illness may attempt to normalise their
interactions with others by managing their symptoms and hiding
their disability or disfigurement.
9
They may try to demonstrate
that they can function the same as someone without a disability
or chronic illness-a common example of this is the individual
with chronic lung disease who stops walking to catch their
breath but appears to be inspecting a plant or looking in a shop
window. Managing chronic illness requirements and skills is
demanding-the more so when compounded by the changing
emotions that people experience with chronic disease. These
emotions are likely to include sadness, isolation, anger and
frustration. An important self-management skill is the ability
TABLE 69-3 A systematic review of disease management interventions for patients with chronic heart failure
Intervention Approach Evidence
Multidisciplinary interventions A holistic approach bridging the gap
between hospital admission and
discharge, delivered by a team
Overall concept embedded in multidisciplinary teams
supports an interprofessional, collaborative approach to
health service provision.
Case management interventions Intense monitoring of patients
following discharge, often involving
telephone follow-up and home visits
Case management in the community and in hospital is not
effective in reducing generic admissions. There is limited
evidence to suggest that it may be effective for patients with
heart failure. Assertive case management is beneficial for
patients with mental health problems.
Clinic interventions The general practitioner deals only
with chronic diseases for that clinic
Specialised clinics or mini-clinics (where a group delegates a
general practitioner to deal with only chronic diseases for
that day) were also found to be beneficial. Larger clinics in
practices are not necessarily associated with lower levels of
emergency admissions.
Source: Purdy S. Avoiding hospital admissions: what does the research evidence say? The Kings Fund response to the Department of Healths public
consultation on an Information Revolution. London: Kings Fund; 2010.
1984 SECTION 12 Nursing care in specialised settings
Heart & lung health team
Multidisciplinary community chronic heart care plan
Patient name ______________________________________________
Date of birth _______________
AUTHORITY TO PROCEED WITH CARE PLAN: My GP/health professional has explained the purpose of a care plan. I give my permission to prepare
a care plan and discuss my medical history and diagnosis with the members of a multidisciplinary team. I do/do not request specifc medical or
other information to be withheld from other participants (noted in medical records). I am aware that there is a fee for the preparation of this care
plan and a Medicare rebate will be payable.
Patient signature ___________________________________________
Date _____________________
Assessment of health needs Management goals Action required Provider Review date
Symptom management To understand and encourage
self-management of symptoms
Education about heart failure
Symptom monitoring
Refer to cardiologist for
assessment for cardiac
rehabilitation
Flexible diuretic regimen
General
practitioner, clinical
nurse specialist and
heart & lung health
team
Management of fluid retention To encourage self-monitoring
of increased fluid retention
Education about
daily weights
decreased sodium intake
fluid restriction
Dietician, clinical
nurse specialist and
heart & lung health
team
Modification of activities of
daily living (ADLs)
To encourage independence in
ADLs
Occupational therapy
assessment
Community nursing assessment
Occupational
therapist and
community nurse
Medication management To understand and comply with
medication regimen
Community pharmacist or
specialist nurse assessment
General
practitioner and
pharmacist
Psychosocial support To manage anxiety and avoid
significant depression
Counselling
Refer to positive living group
Social worker and
group coordinator
Increase physical activity To gradually increase activity
tolerance
Education about daily graded
exercise
Refer to CCF/COPD group
Exercise
physiologist,
clinical nurse
specialist and heart
& lung health team
Patient health goals and
motivation
Patient to provide health goals
in own words
Discuss and write patients goals
to allow measurement over time
Exercise
physiologist,
clinical nurse
specialist and heart
& lung health team
Additional needs
I agree to the above care plan and understand the recommendations.
Patient signature ___________________________________________
GP signature _______________________________________________
Date __________________________
SERVICE PROVIDERS: I have received and agree with this care plan.
Name and contact details __________________________________________________________________________________________________
Date ___________________________________________
Name and contact details __________________________________________________________________________________________________
Date ___________________________________________
Name and contact details __________________________________________________________________________________________________
Date ___________________________________________
Name and contact details __________________________________________________________________________________________________
Date ___________________________________________
Copy to patient YES/NO Copy to service providers YES/NO
CARE PLAN REVIEW DATE ____________________________
Figure 69-2 Sample care plan for a patient with chronic heart disease.
CHAPTER 69 Chronic illness and complex care 1985
alongside health coaching interventions and case management.
For chronic illnesses there is now a big emphasis on using
telephony-based services. These services can take incoming
telephone calls from patients that report problems or seek advice
and generate regular outgoing calls to establish a patient`s
current health status and to work to prevent any relapses or
exacerbations.
Support for patient self-management requires the health
organisation to take a standardised and consistent approach,
such as the Stanford method championed by Lorig.
15
Health
staff preparing to teach self-management principles to patients
may beneft from using a model or an approach that fts in with
their own health beliefs and resources. When choosing a model,
the organisation needs to consider the following questions:
Which model fits our overall aim for chronic disease
care?
What is our training budget? What training can we afford
to implement?
Who should use this model?
Who will we target?
What skills do we have as a team?
What challenges are we likely to face? How can we
overcome them?
What post-training support will we need?
Planning the approach allows the organisation to take
account of local factors such as resource level, geographical
challenges and the availability of enabling factors such as
telephones, transport and the support of general practitioners
and specialists.
In Australia and New Zealand a range of models are used,
the most common being the Flinders University Model for
Chronic Condition Self-Management and the Chronic Disease
Self-Management Programme (known in Australia as the Better
Health Self-Management Program) from Stanford University.
29-31

In addition, various health behaviour change theories have
been developed such as motivational interviewing and health
coaching, with various delivery strategies including group-
based programs and expert peer leadership.
32
These approaches
can be offered to patients from a variety of healthcare settings,
including general practices, community health centres and local
council or leisure centres, often without the need for supervision
by health professionals. However, reinforcing the principles of
the chosen approach and encouraging self-monitoring to ensure
that patients are successful in their self-management may be
part of the nurse`s monitoring and surveillance role as a case
manager. Nurses who take such roles may also be known as
care navigators (professionals who fnd the right point of care
at the right time).
CARE NAVIGATION
Care navigation is a system of care that is designed to improve
patient experiences and health outcomes for the most at risk,
vulnerable, frail aged and chronic illness sufferers with complex
care needs. It is achieved using a system redesign process to
improve integration and coordination of care across and between
services, both in the hospital and in the community.
33
Care
navigation programs help steer patients to the most appropriate
point of care. They offer ongoing community coordinated
care (often through the patient`s general practitioner), which
includes support and help to avoid unnecessary visits to the
emergency department and inpatient treatment. Patient and carer
engagement is a key component of this approach and the model
is designed to improve satisfaction with, and use of, agreed
to counter, and work with, negative emotions. Social isolation
is a common consequence of chronic illness, so maintaining
social interaction is essential.
SELF-EFFICACY IN SELF-MANAGEMENT
The concept of self-efficacy in social cognitive theory helps to
explain how individuals develop the complex self-management
skills required to manage their chronic illness, what they are
prepared to do to help themselves and their persistence in the
face of adversity. To put it simply, self-efficacy is what people
think they can do with their knowledge, skills and experience
in a variety of circumstances. Self-efficacy is not confidence.
It relates to specific domains-for example, a person can be
very competent in driving a car but need assistance in driving
to the correct location. Thus they need support with developing
sequenced skills that lead to independent driving behaviour.
With an understanding of self-efficacy, nurses can support the
patient`s development of self-management skills with their
chronic illness.
There are four ways that individuals develop self-effcacy:
(1) by experiencing success; (2) seeing others experience success,
especially following failures; (3) being persuaded that they can
succeed; (4) and experiencing the physical and emotional feelings
that accompany skill development.
28
Nurses can help patients
with chronic illness to experience success by breaking down the
components of self-management into achievable units and by
providing positive feedback when achievements occur. Nurses
can also provide positive role models through support groups, so
that patients can learn by watching the efforts, corrections and
successes of others with similar illnesses. People with chronic
illness gauge their self-effcacy on how they feel physically
and emotionally when they think about or undertake an action.
It is the nurse`s role to help guide these interpretations. As an
example, the increased dyspnoea that occurs with exercise can
be interpreted as a positive indication of effort rather than proof
of decline in function.
It is important for nurses to be alert for negative persuaders,
because social persuasion can have a powerful negative effect
on self-effcacy. In addition, given the important role of
interpreting emotion in building resilient self-effcacy, it is vital
that depression is detected and managed promptly. Depression
leads to more negative interpretations of the development
of self-management skills and the impact of these skills on
outcomes.
28
Depression decreases the motivation to engage and
make the effort required both to learn self-management skills
and to self-manage.
ENCOURAGING SELF-MANAGEMENT
Self-monitoring strategies for patients include developing an
early warning system, such as daily weights to detect fluid
overload for patients with heart failure. Self-monitoring
strategies work when the patient knows the range of the physical
attribute they are measuring (e.g. blood sugar level) and has an
action plan that assists in interpreting the results and providing
appropriate action to manage any variation from the reference
range (e.g. a rise in blood sugar level). Figure 69-3 contains
an example of a care plan to encourage self-management of
blood sugar levels.
A range of patient self-monitoring activities can be reported
back to the specialist nurse in either a clinic or a practice
setting and may be enhanced by telehealth using computers,
telephone or direct feedback from the device to the supervising
health practitioner. Self-monitoring activities can be supported
1986 SECTION 12 Nursing care in specialised settings
Patient name ___________________________________________________________________
Date of birth ___________________________
AUTHORITY TO PROCEED WITH CARE PLAN: My GP/health professional has explained the purpose of a care plan. I give my permission to prepare
a care plan and discuss my medical history and diagnosis with the members of a multidisciplinary team. I do/do not request specifc medical or
other information to be withheld from other participants (noted in medical records). I am aware that there is a fee for the preparation of this care
plan and a Medicare rebate will be payable.
Patient signature _________________________________________________________________
Date __________________________
Assessment of health
needs Management goals Action required Provider
Appointment
date
Discuss patient self-
management goals for
diabetes
To define the patients goals Discuss current health plan
Write patients health goals
Diabetes nurse or
general
practitioner
Assess patients confidence
and skills to manage
diabetes
To observe the patients skill set
for diabetes management tasks
Assist to set test frequency and
ranges for blood sugar level
Diabetes nurse or
general
practitioner
Assess patients lifestyle
risks (SNAPW: smoking,
nutrition, alcohol intake,
physical activity, weight)
To set goals to manage
identified risks
Discuss plan and timeframe to
manage each risk identified
Diabetes nurse or
general
practitioner
Assess patients coping
skillsemotional impact
and social support
To measure anxiety and
depression levels
Discuss treatment plans
Access psychological services
Psychologist/
counsellor
Prepare multidisciplinary
team care plan as needed
To define the needs for allied
health services to support the
plan
Refer to allied health workers to
collaborate with the care plan
General
practitioner
I agree to the above care plan and understand the recommendations.
Patient signature ________________________________
GP signature _________________
Date __________________________
SERVICE PROVIDERS: I have received and agree with this care plan.
Name and contact details __________________________________________________________________________________________________
Date ___________________________________________
Name and contact details __________________________________________________________________________________________________
Date ___________________________________________
Name and contact details __________________________________________________________________________________________________
Date ___________________________________________
Name and contact details __________________________________________________________________________________________________
Date ___________________________________________
Copy to patient YES/NO Copy to service providers YES/NO
CARE PLAN REVIEW DATE ____________________________
healthcare plans. Patients and carers generally welcome their
general practitioner`s greater involvement in their healthcare
planning and delivery, and report a better healthcare experience
when their hospital admissions are guided and monitored by a
care navigation system.
33
The care navigation process between
the community and acute care service sectors is illustrated in
Figure 69-4.
Improved outcomes for patients with chronic illnesses are
achieved with care navigation that directs those who are frail
and vulnerable to the most effective point of care. This active
navigation enables patients to be treated appropriately when
they have an acute exacerbation. Care may be provided at home,
and emergency department or inpatient care may be substituted
with a specialist chronic care or hospital-in-the-home service.
CARE COORDINATION
Care coordination is a key attribute of successful case management.
Patients with multiple chronic illnesses move through increasingly
specialised parts of the health system, which can leave them
having to manage conflicting advice for their complex symptoms
and needing to choose which health action plan to follow to
improve their outcome.
34

Figure 69-3 Sample self-management care plan for blood sugar levels.
CHAPTER 69 Chronic illness and complex care 1987
target populations. The bottom line is healthier patients, more
satisfed healthcare providers and cost savings.
One of the most important aspects of care coordination is
the classifcation of risk for future emergency readmission.
At present, this assessment occurs in three ways: clinical
knowledge, threshold modelling and predictive modelling.
Clinical knowledge is the default position in most health
services whereby clinicians identify those they consider
to be at risk. Although clinicians may be able to identify
those patients currently at high risk, they are less able to
identify those who may be at risk in the future.
37

Threshold modelling , which is rules based, identifies
those at high risk who meet a set of criteria. Case
finding has usually been based on threshold modelling,
such as identifying patients with repeated emergency
admissions as a marker for high risk of future
admissions. An example of this type of model is the
Hospital Admission Risk Profile (HARP) calculator
shown in Box 69-3.
38

Predictive modelling uses data such as the patient`s age,
gender and sociodemographic characteristics in a
statistical model to calculate the risk of future admission.
Predictive modelling is thought to be the best available
technique and good examples include the Patients at Risk
of Re-Hospitalisation (PARR)

model and the Scottish
Patients at Risk of Readmission and Admission
(SPARRA)

model from the UK.
37,39

Transitions and care coordination in chronic
illness care
Traditionally, chronic illness care has been provided by
independent health specialist groups targeting individual
conditions, with limited collaboration occurring between
groups for comorbid conditions. However, many changes are
being made to this traditional pattern of care to provide more
support for patients as they transition between different phases
of their illness and between different specialist groups.
40
Care
planning and case management now offer patients support
in navigating between sectors of the healthcare system. The
current health systems in Australia and New Zealand use a
range of approaches and models of care that site these services
in the acute, community and primary healthcare sectors. The
sharing of accurate and current health information between
these sectors is vital to quality of care for patients with
chronic illness and varies according to the local level of trust,
integration and collaboration between health and community
partners. During an acute unplanned admission a patient`s
health summary needs to be current and available at the point of
care-usually the emergency department or assessment unit-
or to the outreach acute health staff. The ability to do this while
observing privacy and access concerns has limited the use
and sharing of electronic tools and plans in Australia. In New
Zealand, all general practitioners have electronic clinical notes
and all patients have a unique National Health Index (NHI)
number. In addition, the New Zealand Privacy Act does not
limit the sharing of clinical details between providers who are
caring for patients in common. In all health domains the goal
should be the greater integration of information technology
systems between all sectors; this will mean a more accurate
and timely transfer of health information from patient records
and care plans.
In Australia, there have been ongoing discussions regarding
the use of electronic health records, shared care planning, and
Key defciencies in care coordination include: (1) rushed
practitioners not following established practice guidelines;
(2) lack of active follow-up to ensure the best outcomes for
patients; and (3) patients being inadequately trained to manage
their illnesses.
35
Overcoming these defciencies requires nothing
less than the transformation of the healthcare system from one
that is essentially reactive, responding mainly when people are
sick, to one that is proactive and focused on keeping people
as healthy as possible.
33
To address these defciencies, the
McColl Institute for Healthcare Innovation has created the
chronic care model,
36
which summarises the basic elements for
improving healthcare at the community, organisation, practice
and patient levels (see Fig 69-5). Key elements of the model
include the community, the health system, self-management
support, delivery system design, decision support and clinical
information systems. Evidence-based change concepts under
each element, in combination, foster productive interaction
between informed patients, who take an active part in their care,
and providers with resources and expertise. The model can be
applied to a variety of chronic illnesses, healthcare settings and
Care navigationguided to the right point of care
Community-based rehab and education Acute hospital services
Seek out alternative
pathways to hospital
admission
Emergency department
Assertive discharge
planning for
hospital-in-the-home
services, transitional
care services
Chronic
disease team
General
practitioner
Social and
personal
support
services
Chronic disease self-care
Family and
carers
High-risk
patient with
chronic and
complex
disease
Figure 69-4 The care navigation process.
Community Health systems
Improved outcomes
Resources and policies Organisation of healthcare
Delivery
system
design
Decision
support
Clinical
information
systems
Self-
management
support
Productive
interactions
Informed,
active
patient
Prepared,
proactive
practice team
Figure 69-5 The chronic care model.
Source: The Group Health Research Institute. Available at www.
improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2,
accessed 14 January 2011.
1988 SECTION 12 Nursing care in specialised settings
telecare and telehealth systems to improve communication
about patients with chronic illnesses and their care needs.
Current discussions are based on improving the effectiveness
of sharing data from assessment tools (such as the Ongoing
Needs Identifcation [ONI] tool) and using the data to inform
staff of patient needs for community support services on
leaving hospital.
41
Effective planning for the transfer of care
when patients leave the acute health system is summarised in
Box 69-4.
An example of the increased management of the transition
between acute and community healthcare in Australia is the
Chronic Care for Aboriginal People (CCAP) program, which
was developed from a number of established New South Wales
Department of Health initiatives in an attempt to address the
gaps in healthcare provision and to improve access to, and
use of, chronic care services for Aboriginal people in New
South Wales.
42
The components of the model are presented in
Figure 69-6. This model has been used to provide the framework
for a 48-hour follow-up after discharge from hospital to enable
appropriate ongoing care.
BOX 69-3 Hospital Admission Risk Profile (HARP) calculator
Part A: clinical assessment
1. Presenting clinical symptoms
Diagnosis of chronic respiratory condition (1)
Diagnosis of chronic cardiac condition (1)
Diagnosis of complex care needs in frail aged, such as dementia, falls
or incontinence (1)
Diagnosis of complex care needs in people less than 55 years of age,
such as mental health illness (1)
Comorbid diagnosis of diabetes and/or renal failure and/or liver
disease (1)
Score: /5
2. Service access profile
Acute admission/presentation (more than once in the last 12
months) (4)
No regular GP follow up (regular medical check-ups 2 times a year)
(3)
Reduced ability to self-care (to the extent it impacts on disease
management) (3)
Score: /10
3. Risk factors
Smoking (1)
Overweight (guide BMI 2635) (1)
Underweight (guide BMI <19) (1)
High cholesterol (total cholesterol >5.5 mmol/L, HDL <1.0 mmol/L,
LDL >2.0 mmol/L) (1)
High blood pressure (>140/90 mmHg or on medication for high
blood pressure) (1)
Physical inactivity (less than 30 mins/day and 4 days/week) (1)
Polypharmacy (>5 medications with difficulty managing them) (1)
Score: /7
4. Extenuating factors
Use of services previously (1)
Carer stress issues (1)
No carer available (1)
Cognitive impairment (1)
Change to drug regimen (1)
Chronic pain (1)
Compromised skin integrity (e.g. wounds, pressure area, cellulitis) (1)
Exposure to triggers for asthma (1)
Score: /8
Total score clinical assessment (A) /30
Part B: factors impacting on self-management
5. Psychosocial factors and demographic issues
Mental health (depression, anxiety or psychiatric problems) Y/N
Disability (intellectual, physical, visual, hearing) Y/N
Access to suitable transport to care services Y/N
Financial issues (inability to afford health services and/or
medications) Y/N
CALD or Aboriginal health beliefs Y/N
Illiterate and/or limited English Y/N
Unstable living environment Y/N
Socially isolated Y/N
Drug and alcohol problems Y/N
Rate the impact these combined factors have on the persons ability
to self-manage their condition:
No impact (on ability to self-manage) (0)
Low impact (on ability to self-manage) (7)
High impact (on ability to self-manage) (15)
Score /15
6. Readiness to change assessment (choose one only)
No capacity for self-management (cognitive impairment, end-stage
disease) (4)
Pre-contemplation (not ready for change) (3)
Contemplation (considering but unlikely to change soon) (3)
Preparation (intending to take action in the immediate future) (2)
Action (actively changing health behaviours but having difficulties
maintaining plan) (1)
Maintenance (maintained behaviour for >6 months) (1)
Relapse (a return to the old behaviour) (3)
Score: /4
Total score for self-management impact (B) /19
Overall risk: add part A and part B /49
The higher the score, the higher the risk of readmission.
Source: Taylor S, Bestall J, Cotter S, Falshaw M, Hood S et al. Clinical service organisation for heart failure. Cochrane Database Syst Rev 2005; (2).
BOX 69-4 Planning for discharge: essential attributes
of discharge interventions that can potentially reduce
readmissions
Early and complete assessment of discharge needs and
medication reconciliation.
Enhanced patient (and carer) education and counselling
specifically focused on gaining an understanding of the patients
condition and its self-management.
Timely and complete communication of management plan
between clinicians at discharge when patient care is transferred
from hospital staff to primary care teams.
Early post-acute follow-up within 2472 h for high-risk patients
with either doctor or nurse.
Early post-discharge nurse (or pharmacist) phone calls or home
visits to confirm understanding of management and follow-up
plans in high-risk patients.
Appropriate referral for home care and community support
services when needed.
Source: Scott I. Preventing the rebound: improving care transition
in hospital discharge processes. Australian Health Review 2010;
34:445451.
CHAPTER 69 Chronic illness and complex care 1991
4. Depression frequently accompanies or may precipitate
chronic illness. Depression makes recovery and
management more difficult because it can make it harder
for people:
A to find the energy to eat healthily
B to exercise or take medication regularly
C as it can reduce initiative and affect adherence and
compliance with health action plans
D all of the above
5. Measuring carer strain and completing social care
assessments are an important part of assessing the impact
of these factors for different phases of the chronic illness
journey. This is because:
A carers have become too focused on their own needs
and have neglected those of the patients under
assessment
B there are so many government programs for patient
social support that a different assessment has to be
completed for each one
C a review of the domestic support needs and carer
factors enables the case manager to effectively plan
interventions that meet the patients goals and needs
D all of the above
information but also supported to make and sustain long-term
behaviour changes.
Workforce training and development are an important part
of building system capacity to manage the increasing wave of
people with chronic illnesses. The core skills needed by health
professionals to enable them to effectively support patients in
self-management training have been identifed as problem-
solving, targeting, goal setting, planning, identifying follow-
up needs, refective listening, asking open-ended questions,
identifying a person`s readiness to change, assertiveness skills,
depression screening and assessing suicide risk.
45
Conclusion
Nurses play a valuable role in assisting patients to manage
their chronic illnesses. Patients and their carers require a
variety of levels of support, empowerment and education from
nurses during the different phases of their chronic illnesses.
Patients who require support in learning how to self-manage
their condition make up 70-80% of the population with
chronic conditions. Nurses can develop their own skills and
competencies to enable patients and their carers to take on
effective self-management. High-risk patients with complex
chronic illnesses who need their condition actively managed
to prevent further complications and promote wellbeing may
need specialist disease management from multidisciplinary
teams.
46
Patients with complex and multiple conditions need
high-quality, evidence-based case management in which their
needs are identified and met by skilled practitioners, often
nurses, working within an integrated care system.
Review questions
1. Vos and Carter found that a large impact on improving a
populations health can be achieved by:
A taxation of tobacco, alcohol and unhealthy foods
B mandatory limits on salt added during production of
three basic food items (bread, cereals and margarine)
C gastric banding for severe obesity
D all of the above
2. Many factors contribute to chronic disease complexity and
these are characterised by:
A periods of exacerbation
B the chronic illness and its treatments generating
further issues
C the individual with chronic illness experiencing
unequal access to care and support
D all of the above
3. Australian and New Zealand evidence suggests that most
of the recent gain in life expectancy for individuals:
A is a result of better preschool education and
preparation-for-life classes
B is spent accompanied by disability in the final years,
and that much of the extra life years gained are spent
with a profound or severe core activity limitation
C is needed to expand the taxation base to pay for
healthcare
D is expected by the population due to their higher taxes
CASE STUDY
The patient with chronic illness
Patient background
Mrs Clare Giardini is a 69-year-old woman who has had three
presentations in the last several months with shortness of breath.
She lives in her own home with her 2 adult children, one of whom
is a specialist paediatric nurse. Mrs Giardini has a history of
osteoarthritis, non-insulin-dependent diabetes and asthma. A
recent echocardiogram showed systolic dysfunction and a poor
left ventricular ejection fraction, and Mrs Giardini is noted to have
chronic controlled atrial fibrillation.
Objective data
Temperature: 36.8 C
Heart rate: 116 beats per min
Blood pressure: 92/60 mmHg
Cardiac rhythm: atrial fibrillation
Cardiac system: S 1 and S2 present, no murmurs
Respirations: 32 shallow
Lung sounds: crackles in both bases
Daily weight: increased by 5 kg over last 2 days
CRITICAL THINKING QUESTIONS
1. What social factors and assessment questions or tools would
be useful to use with this patient?
2. Identify the community health and support services that are
available in your health district for this patient.
3. What planning and assessments around the transition process
from hospital to home would allow this patient to effectively
self-manage her conditions at home?
1992 SECTION 12 Nursing care in specialised settings
7. Aspin C, Jowsey T, Glasgow N, Dugdale P, Nolte E, O`Hallahan
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6. A holistic assessment tool for the patient with chronic
illness needs to:
A include standardised assessment of the range of carer
and social aspects in the patients circle of support
B account for the conflicting symptoms and strategies of
multiple illnesses
C be determined by the case manager over time to
establish and advise the patient of priority steps in
their health action plan
D all of the above
7. Self-management is an umbrella term that encompasses:
A self-care, the specific tasks that people carry out on a
day-to-day basis to manage their condition
B disease management provided by specialist health
staff to control palliative symptoms
C the use of health interventions, such as medications,
without the need to consider the prescribers
intentions
D only natural therapies that are known to treat the
illness
8. Preventing and managing a crisis are vital skills to develop
and the patient and family are expected to:
A understand how a health crisis can alter their usual
health state
B know ways to prevent or modify a threat to their health
C adhere to a prescribed medical regimen
D all of the above
9. People with chronic illnesses need to know the signs and
symptoms of the onset of a health crisis. Depending on the
chronic illness, these signs and symptoms may include:
A seizures in a patient with seizure disorder
B heart failure in a patient with untreated hypertension
C a change in sputum colour to yellow/green in a person
with emphysema
D all of the above
10. Self-monitoring strategies include the development of an
early warning system such as:
A calling or visiting the medical practitioner daily in case
something is wrong
B measuring daily weights to detect fluid overload for
people with heart failure
C not measuring the blood sugar level when feeling well
D all of the above
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