chapter 4 health and illness.pdf

44

Health and Illness

4c h a p t e r

acute illnessbeliefscapitationcase methodchronic illnesscongenital disordercontinuity of carediagnostic-related groupexacerbationextended carefunctional nursinghealthhealth care systemhealth maintenance

organizationshereditary conditionholismhuman needsidiopathic illnessillnessintegrated delivery

system

managed careorganizations

MedicaidMedicaremorbiditymortalitynurse-managed carenursing teampreferred provider

organizationsprimary careprimary illnessprimary nursingremissionsecondary caresecondary illnesssequelaeteam nursingterminal illnesstertiary carevalueswellness

Learning Objectives

On completion of this chapter, the reader will

● Describe how the World Health Organization (WHO) defines health.● Discuss the difference between values and beliefs.● List three health beliefs common among Americans.● Explain the concept of holism.● Identify five levels of human needs.● Define illness.● Explain the meaning of the following terms used to describe illnesses:

morbidity, mortality, acute, chronic, terminal, primary, secondary, remission, exacerbation, hereditary, congenital, and idiopathic.

● Differentiate primary, secondary, tertiary, and extended care.● Name two programs that help finance health care for the aged,

disabled, and poor.● List four methods to control escalating health care costs.● Identify two national health goals targeted for the year 2010.● Discuss five patterns that nurses use to administer client care.

Words to Know

Neither health nor illness is an absolute state; rather,there are fluctuations along a continuum throughout life(Fig. 4-1). Because it is impossible to be (or get) well andstay well forever, nurses are committed to helping peopleprevent illness and restore or improve their health. Nursesaccomplish these goals by

• Helping people live healthy lives• Encouraging early diagnosis of disease• Implementing measures to prevent complications

of disorders

HEALTH●

The World Health Organization (WHO) is globally com-mitted to “Health for All.” In the preamble to its constitu-tion, WHO defines health as “a state of complete physical,mental, and social well-being, not merely the absence ofdisease or infirmity.” Each person perceives and defineshealth differently. Nurses must recognize the importanceof respecting such differences rather than imposing stan-dards that may be unrealistic for the person.

CHAPTER 4 ● Health and Illness 45

A person’s behaviors are the outcomes of his or hervalues and belief system. Values are ideals that a personfeels are important. Examples include knowledge, wealth,financial security, marital fidelity, and health. Beliefsare concepts that a person holds to be true. Beliefs andvalues guide a person’s actions. Both health values andbeliefs demonstrate or affirm what is personally signifi-cant. When a person values health, he or she takes actionsto preserve it.

Most Americans believe one or all of the following:health is a resource, a right, and a personal responsibility.

Health: A Limited Resource

A resource is a possession that is valuable because its sup-ply is limited and there is no substitute. Given that defi-nition, health is considered quite precious. People oftensay, “as long as you have your health, you have every-thing,” and “health is wealth.”

Health: A Right

The United States was established on the principle thateveryone is equal and entitled to life, liberty, and the pur-suit of happiness. Based on this premise, everyone, regard-less of age, gender, level of education, religion, sexualorientation, ethnic origin, social position, or wealth, isentitled to equal services for sustaining health. Unfortu-nately, as will be discussed later, health disparities existamong various groups within the United States. Thesegroups include the poor, racial and ethnic minorities,those affected by gender differences, older adults, and peo-ple with disabilities. Efforts are underway, however, toeliminate health barriers and to promote equal access tohealth care (see discussion of Healthy People 2010 later in

this chapter). If all are equally deserving of health, it fol-lows that the nation in general and nurses in particularhave a duty to protect and preserve the health of thosewho may be unable to assert this right for themselves.

Health: A Personal Responsibility

Health requires continuous personal effort. There is asmuch potential for illness as there is for health. Each per-son is instrumental in the outcome. Pilch (1981) said, “Noone can do wellness to or for another; you alone do it, butyou don’t do it alone.” Nurses stand ready to provide assis-tance and to advocate on behalf of others.

WELLNESS●

Wellness means a full and balanced integration of allaspects of health. It involves physical, emotional, social,and spiritual health. Physical health exists when bodyorgans function normally. Emotional health results whenone feels safe and copes effectively with the stressors oflife. Social health is an outcome of feeling accepted anduseful. Spiritual health is characterized as believing thatone’s life has purpose. The four components are collec-tively referred to as the concept of holism (Fig. 4-2).

Holism

Holism (the sum of physical, emotional, social, and spiri-tual health) determines how “whole” or well a personfeels. Any change in one component, positive or negative,

High Level Wellness

Good Health

Normal Health

Illness

Critical Illness

Death

Time span (life span)

Leve

ls o

f hea

lth

FIGURE 4.1 The health–illness continuum shows the different levelsof health a person experiences over a lifetime.

Physical Emotional

Social Spiritual

FIGURE 4.2 Holism is a concept that considers all aspects of a person.

46 UNIT 2 ● Integrating Basic Concepts

automatically creates repercussions in the others. Take,for example, the person who has a heart attack. Obviouslyhis or her physical health is immediately impaired. Addi-tionally the heart attack affects the emotional, social, andspiritual aspects of health. For example, the client mayexperience psychological anxiety over this health change.His or her social roles may temporarily or permanentlychange. The client may explore philosophical and spiritualissues as he or she considers the potential for death.

Nurses profess to be “holistic practitioners” becausethey are committed to restoring balance in each of thefour spheres that affect health. They base their strategiesfor doing so on a hierarchy of human needs.

Hierarchy of Human Needs

In the 1960s, Abraham Maslow, a psychologist, identifiedfive levels of human needs (factors that motivate behav-ior). He grouped the needs in tiers, or a sequential hierar-chy (Fig. 4-3), according to their significance: physiologic(first level), safety and security (second level), love andbelonging (third level), esteem and self-esteem (fourthlevel), and self-actualization (fifth level).

The first-level physiologic needs are the most impor-tant. They are the activities, such as breathing and eating,necessary to sustain life. Each higher level is less impor-tant to survival than the previous levels. Maslow believedthat until humans satisfied their physiologic needs, theycould not or would not seek to fulfill other needs. Byprogressively satisfying needs at each level, however,people will realize their maximum potential for healthand well-being.

Nurses have adopted Maslow’s hierarchy as a tool forsetting priorities for client care. For example in the case of

the client with a heart attack, the nurse considers theclient’s physical needs such as managing pain as a prior-ity. The nurse addresses other needs, such as assisting theclient with a possible change in role performance or spir-itual distress, after the client’s health condition stabilizes.

ILLNESS●

Illness (a state of discomfort) results when disease, dete-rioration, or injury impairs a person’s health. Severalterms are used commonly when referring to illnesses:morbidity and mortality; acute, chronic, and terminal;primary and secondary; remission and exacerbation; andhereditary, congenital, and idiopathic.

Morbidity and Mortality

Morbidity (incidence of a specific disease, disorder, orinjury) refers to the rate or numbers of people affected.Federal statistics are compiled on the basis of age, gender,or per 1,000 people within the population. Mortality(incidence of deaths) denotes the number of people whodied from a particular disease or condition. Table 4-1 liststhe 10 leading causes of death among all Americans of allages in 2000.

Acute, Chronic, and Terminal Illnesses

An acute illness (one that comes on suddenly and lastsa short time) is one method for classifying a change inhealth. Influenza is an example of an acute illness. Manyacute illnesses are cured. Some lead to long-term prob-lems because of their sequelae (singular: sequela; illeffects that result from permanent or progressive organdamage caused by a disease or its treatment).

Chronic illness (one that comes on slowly and lasts along time) increases as people age. Arthritis, a joint dis-ease, is an example of a chronic illness. Many older adultslive with persistent health problems and disabilitiesbecause they survived acute illnesses that killed othersyears ago.

A terminal illness (one in which there is no potentialfor cure) is one that eventually is fatal. The terminal stageof an illness is one in which a person is approaching death.

Primary and Secondary Illnesses

A primary illness (one that develops independently ofany other disease) differs from a secondary illness (dis-order that develops from a pre-existing condition). Forexample, pulmonary disease acquired from smoking is aprimary illness. If pneumonia or heart failure occurs as aconsequence of smoke-damaged lung tissue, it is consid-ered a secondary problem. In essence, the primary condi-

Physiologic needs

Need for safetyand security

Need for loveand belonging

Need for esteemand self-esteem

Need for self-actualization

FIGURE 4.3 Maslow’s hierarchy of human needs.


tion predisposed the smoker, in this case, to the secondarycondition.

Remission and Exacerbation

A remission means the disappearance of signs and symp-toms associated with a particular disease. Although a re-mission resembles a cured state, the relief may be onlytemporary. The duration of a remission is unpredictable.An exacerbation (reactivation of a disorder, or one thatreverts from a chronic to an acute state) can occur peri-odically in clients with long-standing diseases. Often, re-missions and exacerbations are related to how well orpoorly the immune system is functioning, the stressorsthe client is facing, and the client’s overall health status(nutrition, sleep, hydration, etc.).

Hereditary, Congenital, and Idiopathic Illnesses

A hereditary condition (disorder acquired from thegenetic codes of one or both parents) may or may not pro-duce symptoms immediately after birth. Cystic fibrosis, alung disease, and Huntington’s chorea, a neurologic dis-order, are examples of inherited illnesses. The first is diag-nosed soon after birth; the second is not manifested untiladulthood.

Congenital disorders (those present at birth butwhich are the result of faulty embryonic development)cannot be genetically predicted. Maternal illness, such asrubella (German measles) or exposure to toxic chemicalsor drugs especially during the first 3 months of pregnancy,often predisposes the fetus to congenital disorders. Sev-eral decades ago, many pregnant women took the drugthalidomide and subsequently gave birth to infants withmissing arms and legs. There is a great deal of concern

about the role of alcohol in producing fetal alcohol syn-drome, a permanent but preventable form of retardation,and the effects of exposure to other environmental tox-ins. Although the etiologies for some congenital disordersare well established, they can occur randomly.

An idiopathic illness is an illness whose cause isunexplained. Treatment focuses on relieving the signsand symptoms because the etiology is unknown. Exam-ples of idiopathic conditions include hypertension forwhich there is no known cause or a fever of undeter-mined origin (FUO).

HEALTH CARE SYSTEM●

The health care system (network of available health ser-vices) involves agencies and institutions where peopleseek treatment for health problems or assistance withmaintaining or promoting their health. The health caresystem, clients, and their diseases have drastically changedduring the past 25 years (Box 4-1). Advances in technol-ogy and discoveries in science have created more elaboratemethods of diagnosing and treating diseases, creating aneed for more specialized care. What was once a system inwhich people sought medical advice and treatment fromone physician, clinic, or hospital has developed into a com-plex system involving primary, secondary, tertiary, andextended care.

Primary, Secondary, and Tertiary Care

Primary care (health services provided by the first healthcare professional or agency a person contacts) usually isgiven by a family practice physician, nurse practitioner, orphysician’s assistant in an office or clinic. Cost-conscioushealth care reforms advocate the provision of primary careby advanced practice nurses.

TABLE 4.1 LEADING CAUSES OF DEATH IN THE UNITED STATES IN 2000

RANK CAUSE OF DEATH NUMBER PERCENTAGE OF TOTAL DEATHS

1 Diseases of the heart 710,760 29.6

2 Malignant neoplasms (cancer) 553,091 23.0

3 Cerebrovascular disease 167,661 7.0

4 Chronic lower respiratory diseases 122,009 5.1

5 Accidents (unintentional injuries) 97,900 4.1

6 Diabetes 69,301 2.9

7 Influenza and pneumonia 65,313 2.7

8 Alzheimer’s disease 49,558 2.1

9 Nephritis, nephritic syndrome, and nephrosis 37,251 1.5

10 Septicemia 31,224 1.3

Source: Anderson, R. N. (2002). Deaths: Leading causes for 2000. Division of Vital Statistics, Centers for Disease Control andPrevention, 50(16), 8.


An example of secondary care (health services towhich primary caregivers refer clients for consultationand additional testing) is the referral of a client to a car-diac catheterization laboratory. Tertiary care (healthservices provided at hospitals or medical centers wherecomplex technology and specialists are available) mayrequire the client to travel some distance from home.The growing trend is to provide as many secondary andtertiary care services as possible on an outpatient basisor to require no more than 24 hours of inpatient care.

Stop, Think, and Respond ● BOX 4-1A friend complains she has been having frequentbouts of indigestion. Explain how primary, secondary,and tertiary care might be involved in her care.

Extended Care

Extended care (services that meet the health needs ofclients who no longer require acute hospital care) includesrehabilitation, skilled nursing care in a person’s homeor a nursing home, and hospice care for dying clients.Extended care is an important component of the healthcare system because it allows earlier discharge from sec-

ondary and tertiary care agencies and reduces the overallexpense of health care.

Health Care Services

As a whole, health care services include those that offerhealth prevention, diagnosis, treatment, or rehabilitation.As the types of health services expand, the health caredelivery system becomes more complex, costly, and inmany cases inaccessible.

Access to Care

An estimated 43.4 million U.S. citizens do not have accessto health care because of the economic burden it poses.Another 25 million U.S. citizens have inadequate healthcare coverage (U.S. Census Bureau, 1998). Groups suchas children, older adults, ethnic minorities, and the poorare likely to be underserved. Many of these people delayseeking early treatment for their health problems becausethey cannot afford to pay for services. When an illnessbecomes so severe that the only choice is to seek medicalattention, many turn to their local hospital emergencydepartments for care. Inappropriate use of emergencydepartments is expensive and involves long waits andoften no follow-up care.

Financing Health Care

Historically private insurance, self-insurance systems,and Medicare paid for health care. Hospitals and approvedproviders received payment for what they charged; morecharges increased income and profits. These plans offeredno incentives to control costs. Disparities in access tohealth care and the high costs prompted evaluation of theentire health care system. Subsequently this led to innov-ative cost-cutting approaches in government payment sys-tems and those financed by private insurers and corporatehealth plans.

Government-Funded Health Care: Medicare and Medicaid

Medicare (a federal program that finances health carecosts of persons 65 years and older, permanently disabledworkers of any age and their dependents, and those withend-stage renal disease) is funded primarily through with-holdings from an employed person’s income. Medicarehas two parts:

• Part A covers acute hospital care, rehabilitativecare, hospice, and home care services.

• Part B is purchased for an additional fee and coversphysician services, outpatient hospital care, labora-tory tests, durable medical equipment, and otherselected services.

● Increased older adult population● Greater ethnic diversity● More chronic, but preventable, illnesses● More older adults with cognitive disorders (e.g., Alzheimer’s disease)● Increased incidence of drug-resistant infections● Decreased incidence of and death rates from HIV with increased life

expectancy associated with expensive drug therapy● Expanding application of genetic engineering (treating diseases by

altering genetic codes)● Greater success in organ transplantation● Major efforts at cost containment● Continued rising costs of health care despite cost-containment measures● Fewer insured and more underinsured citizens● More outpatient or ambulatory (1-day stay) care● Shorter hospital stays● Less invasive forms of treatment● Shift to more home care● Greater focus on disease prevention, health promotion, and health

maintenance● Movement toward more self-care and self-testing● Approval of more prescription drugs for nonprescription use● Greater interest in herbal supplements and other “complementary” or

alternative treatments● Nationally linked computer information systems● Computerized medical record systems● Shift to criterion-based treatment (clients must meet established criteria

to justify treatment measures)● Increased litigation against health professionals

BOX 4-1 ● Trends in Health and Health Care


Although Medicare is primarily used by older Ameri-cans, it does not cover long-term care and limits coveragefor health promotion and illness prevention. It also doesnot cover prescription medications until the new Medicareprescription benefit goes into effect in 2006, which are sig-nificant expenses for older adults and those with chronicillnesses. Consequently some purchase private “Medigap”insurance to cover additional health-related expenses.

Medicaid (a state administered program designed tomeet the needs of low-income residents) is supported byfunds from federal, state, and local sources. Each statedetermines how the funds will be spent. In general, Med-icaid programs cover hospitalization, diagnostic tests,physician visits, rehabilitation, and outpatient care. Theyalso may cover long-term care when a person exhausts hisor her private funds.

Prospective Payment Systems

In response to escalating health care costs, the federal gov-ernment implemented a system of prospective payment in1983 for people enrolled in Medicare. A prospective pay-ment system uses financial incentives to decrease totalhealth care charges by reimbursing hospitals on a fixed ratebasis. Reimbursement is based on the diagnostic-relatedgroup (DRG) (a classification system used to group clientswith similar diagnoses). For example, all clients receivinga hip, knee, or shoulder replacement fall into DRG 209,Total Joint Replacement, and the surgeries are reimbursedat basically the same rate. If actual costs are less than thereimbursed amount, the hospital keeps the difference. Ifcosts exceed the reimbursed amount, the hospital is leftwith the deficit. Hospitals that are inefficient in managingclients’ recovery and early discharge can potentially losevast revenue, possibly leading to closure of the facility.

Since its inception, the DRG system has been largelyresponsible for marked decreases in hospital lengths ofstay. Subsequently three major criticisms have surfaced:(1) some older clients are discharged prematurely so asnot to exceed the fixed reimbursement, (2) families havehad to assume responsibility for the care of clients whocannot function independently following discharge, and(3) increased hospital care costs have been charged toclients with private insurance to make up for the lostMedicare revenues. In response to cost-shifting and othereconomic forces, private insurance companies have coun-tered by aggressively challenging hospital charges, refus-ing payment for unjustified billings, and developing theirown cost-containment reimbursement system known asmanaged care.

Managed Care

Managed care organizations (private insurers whocarefully plan and closely supervise the distribution oftheir clients’ health care services) control costs of health

care and focus on prevention as the best way to managecosts using the following techniques:

• Using health care resources efficiently• Bargaining with providers for quality care at rea-

sonable costs• Monitoring and managing fiscal and client outcomes• Preventing illness through screening and health

promotion activities• Providing client education to decrease the risk of

disease• Minimizing the number of hospitalizations of clients

with chronic illness

The two most common types of managed care systemsare health maintenance organizations (HMOs) and pre-ferred provider organizations (PPOs). Capitation is a thirdemerging Managed Care Organization (MCO) financialstrategy.

HEALTH MAINTENANCE ORGANIZATIONS. Health main-tenance organizations are corporations that charge pre-set, fixed, yearly fees in exchange for providing health carefor their members. The fee remains the same regardless ofthe type of health service required or the frequency ofcare. These organizations are able to remain fiscally soundbecause they offer preventive services, periodic screen-ings, and health education to keep their members healthyand out of the hospital.

Health maintenance organizations provide ambula-tory, hospitalization, and home care services. Some HMOshave their own health care facilities; others use facilitieswithin the community. A member of an HMO mustreceive permission for seeking additional care such as sec-ond opinions from specialists or unauthorized diagnostictests. Those members who fail to do so are responsible forthe entire bill. In this way, HMOs serve as gatekeepers forhealth care services.

PREFERRED PROVIDER ORGANIZATIONS. Preferred pro-vider organizations are agents for health insurancecompanies that control health care costs on the basis ofcompetition. PPOs create a network of a community’sphysicians who are willing to discount their fees for ser-vice in exchange for a steady supply of referred clients.The subscriber’s clients can lower their health care costsby receiving care from any of the preferred providers. Ifthey select providers outside the network, they pay ahigher percentage of the costs.

CAPITATION. An approach that is fundamentally differentfrom HMOs and PPOs is capitation, a payment system inwhich a preset fee per member is paid to a health careprovider (usually a hospital or hospital system) regardlessof whether or not the member requires services. Capita-tion provides an incentive to providers to control tests andservices as a means of making a profit. If members do notreceive costly care, the provider makes money.


Outcomes of Structured Reimbursement

In many cases, the changes in reimbursements have shiftedeconomic and decision-making power from hospitals andphysicians to insurance companies. One criticism is thatit is difficult to obtain and to provide health care free fromthe economic pressure of insurers. Many claim that theprofits of insurance companies come at the expense ofquality care. For example, hospitals are using unlicensedassistive personnel (UAPs) to perform some duties thatpractical and registered nurses once provided. Current evi-dence shows that deaths in health care agencies increaseas the numbers of licensed nurses decrease (AmericanMedical Association Science News Update, 2002).

On the other hand, cost-driven changes have had pos-itive effects as well. As concern for cost meets concernfor quality, health care institutions, nursing personnel,and other providers search for ways to ensure that allcare, teaching, and preparation before the discharge dateoccurs without overusing expensive resources.

In an attempt to reduce duplication of health care ser-vices and increase revenue, hospitals and other health carefacilities are forming networks known as integrated deliv-ery systems. Integrated delivery systems (networksthat provide a full range of health care services in a highlycoordinated, cost-effective manner) offer diverse optionsto clients (Box 4-2) resulting in shorter hospital stays,fewer complications such as hospital acquired infections,and quicker return to self-care.

NATIONAL HEALTH GOALS●

A national ongoing health-promotion effort referred toas Healthy People 2010 is a continuation of the 1979 Sur-geon General’s Report, Healthy People, and later, HealthyPeople 2000: National Health Promotion and Disease Pre-vention. The emphasis of Healthy People 2010 is improv-

ing the quality of life, not just increasing life expectancy,and improving community health services to reduce dis-parities in disadvantaged populations.

Healthy People 2010 identifies goals for improving thenation’s health in 10 areas, referred to as leading healthindicators, that are considered the major U.S. health concerns in the 21st century (Box 4-3). In all it contains28 focus areas, each of which has identified objectives forimprovement with the target date for accomplishmentbeing the year 2010 (Fig. 4-4). Examples of targetedhealth goals are as follows:

• Increase the proportion of people with health insur-ance.

• In the health professions, allied and associated healthprofessions, and nursing, increase the proportion ofall degrees awarded to members of underrepresentedracial and ethnic groups.

• Increase the proportion of health and wellness andtreatment programs and facilities that provide fullaccess for people with disabilities.

• Reduce the number of new cases of cancer as wellas the illness, disability, and death caused by cancer.

• Reduce infections caused by key food-borne patho-gens.

• Improve the visual and hearing health of the Nationthrough prevention, early detection, treatment, andrehabilitation (Healthy People 2010, http://www.health.gov/healthypeople/About/goals.htm).

The Healthy People 2010 campaign is being carried outwith the combined expertise of the Public Health Service,each state’s health department, national health organiza-tions, the Institute of Medicine of the National Academyof Sciences, and selected individuals from the public atlarge. To meet the targeted goals, health care workers are

Integrated delivery systems provide● Wellness programs● Preventive care● Ambulatory care● Outpatient diagnostic and laboratory services● Emergency care● Secondary and tertiary services● Rehabilitation● Long-term care● Assisted living facilities● Psychiatric care● Home health care services● Hospice care● Outpatient pharmacies

BOX 4-2 ● Integrated Delivery Systems’ ServicesGOALS● Increase quality and years of healthy life● Eliminate health disparities

LEADING HEALTH INDICATORS● Physical activity● Overweight and obesity● Tobacco use● Substance abuse● Mental health● Injury and violence● Environmental quality● Immunizations● Improve occupational safety and health● Access to health care

U.S. Department of Health and Human Services. (2000). Healthy people 2010.Washington, DC: U.S. Government Printing Office.

BOX 4-3 ● Healthy People 2010 Goals and Health Indicators


types of professionals as well as allied health care work-ers with special training such as respiratory therapists,physical therapists, and technicians.

Nurses use their unique skills in the hospital as wellas other employment areas. Because they have skills thatassist the healthy, the dying, and all in between, nurseswork in various settings such as health maintenanceorganizations, physical fitness centers, diet clinics, pub-lic health departments, home health agencies, and hos-pices. Wherever nursing personnel work together, theyuse one of several patterns for managing client care. Thefive common management patterns are functional nurs-ing, case method, team nursing, primary nursing, andnurse-managed care. Each has advantages and disadvan-tages. Students are likely to encounter one or all of thesemethods in their clinical experience.

Functional Nursing

One method used when providing client care is func-tional nursing (pattern in which each nurse on a clientunit is assigned specific tasks). For example, one isassigned to give all the medications, another performs allthe treatments (such as dressing changes), and anotherworks at the desk transcribing physicians’ orders andcommunicating with other nursing departments aboutclient care issues. This pattern is being used less oftenbecause its focus tends to be more on completing the taskrather than caring for individual clients.

Goals for the Nation

Health for All

INCREASEQUALITY AND YEARS

OF HEALTHY LIFE

1. Mental and Physical Impairment and Disability2. Chronic Diseases • Heart Diseases • Cancer • Stroke • Lung Disease • Diabetes

SPECIAL POPULATIONS*Low IncomeRace/EthnicityGenderAgePeople with Disabilities

* Special population groups need to beconsidered as objectives are developedin all focus areas.

3. Physical Activity4. Nutrition5. Sexual Health • HIV Infection • STDs6. Unintentional Injuries7. Tobacco8. Substance Abuse

18. Public Health Infrastructure • Surveillance and Data Systems • Training • Research

19. Educational and Community Based Programs

20. Violent and Abusive Behavior

9. Food and Drug Safety10. Environmental Health11. Occupational Health12. Infectious Diseases

13. Health Services • Clinical Preventive Services (including immunizations) • Emergency Medicine • Long Term Care14. Mental Health Services15. Oral Health16. Family Planning17. Maternal, Infant and Child Health

ELIMINATE HEALTH

DISPARITIESFOCUS AREAS FOCUS AREAS

FIGURE 4.4 Components of proposed Healthy People 2010.

Registered Nurse

NursingStudents

NursingVolunteer

NursingAssistant

LicensedPractical/

VocationalNurse

The Clientand

Family

FIGURE 4.5 The nursing team.

challenged to implement strategies to improve the overallhealth of people living in the United States.

NURSING TEAM●

The goal of the nursing team (personnel who care forclients directly) is to help clients attain, maintain, orregain health (Fig. 4-5). The team may include several

Case Method

The case method (pattern in which one nurse managesall the care a client needs for a designated period of time)should not be confused with managed care, which is dis-cussed later. The case method is most often used in homehealth and public health nursing.

Team Nursing

Team nursing (pattern in which nursing personneldivide the clients into groups and complete their caretogether) is organized and directed by a nurse called theteam leader. The leader may assist with but usually super-vises the care that other team members provide. All teammembers report the outcomes of their care to the teamleader. The team leader is responsible for evaluating if thegoals of client care are met.

Conferences are an important part of team nursing.They may cover a variety of subjects but are plannedwith certain goals in mind such as determining the bestapproaches to each client’s health problems, increasing theteam members’ knowledge, and promoting a cooperativespirit among nursing personnel.

Primary Nursing

In primary nursing (pattern in which the admittingnurse assumes responsibility for planning client care andevaluating the client’s progress), the primary nurse maydelegate the client’s care to someone else in his or herabsence but is consulted when new problems develop orthe plan of care requires modifications. The primary nurseremains responsible and accountable for specific clientsuntil they are discharged.

Nurse-Managed Care

A new type of nursing-care delivery system is beingimplemented in several areas of the United States. It iscalled nurse-managed care (pattern in which a nursemanager plans the nursing care of clients based on theirtype of case or medical diagnosis) by some and case man-agement by others. A clinical pathway typically is usedin a managed care approach (see Chap. 1 for more infor-mation on managed care and an example of a clinicalpathway).

This innovative system was developed in response toseveral problems affecting health care delivery today suchas the nursing shortage and the need to balance the costsof medical care with limited reimbursement systems.Nurse-managed care is similar to the principles used bysuccessful businesses. In the business world, corporations

pay executives to forecast trends and determine the beststrategies for making profits. In nurse-managed care, aprofessional nurse acts as a case manager who evaluateswhether or not predictable outcomes are met on a dailybasis. By meeting the outcomes in a timely manner, theclient is ready for discharge by the time designated byprospective payment systems, if not before.

Pilot studies indicate that this approach ensures thatstandards of care are met with greater efficiency and costsavings. Hospitals who are adopting case-managed carereport that they are operating within their budgets anddecreasing their financial losses.

CONTINUITY OF HEALTH CARE●

Continuity of care (maintenance of health care fromone level of health to another and from one agency toanother) ensures that the client navigates the complicatedhealth care system with a maximum of efficiency and aminimum of frustration. The goal is to avoid causing aclient, whether healthy or ill, to feel isolated, fragmented,or abandoned. All too often this occurs when one healthpractitioner fails to consult or communicate with othersinvolved in the client’s care. Chapters 9 and 10 give exam-ples of how nurses communicate among themselves andwith personnel in other institutions to ensure that theclient’s care is both continuous and goal-directed.

Critical Thinking Exercises

1. If you were asked to participate in planning the goals andstrategies for Healthy People 2010, what suggestions wouldyou make to promote health and reduce chronic illness?

2. Which pattern for managing client care seems most advan-tageous for nurses? Which pattern might clients prefer? Givereasons for your selections.

● NCLEX-STYLE REVIEW QUESTIONS

1. If all the following client problems exist, which is ofhighest priority for nursing management?

1. Low self-esteem2. Labored breathing3. Feeling powerlessness4. Lack of family support

2. The most appropriate initial nursing referral of a personwho is experiencing frequent headaches is to a

1. Drug company seeking clinical trial volunteers fora headache medication

2. Neurologic institute conducting investigationalresearch on headaches

3. Hospital’s emergency department for immediatemedical treatment

4. Family practice physician for a baseline physicalexamination



3. Which of the following is the best example of promotingcontinuity of client care? A hospital nurse refers a clientwith terminal cancer to a

1. Preferred provider organization2. Home health nursing organization3. Health maintenance organization4. Managed care organization

References and Suggested Readings

American Medical Association Science News Updates. (2002).High patient-to-nurse ratios in hospitals associated withmore patient deaths and increased nurse burnout and jobdissatisfaction. Journal of the American Medical Association,288(16), 1–2.

Anderson, R. N. (2002). Deaths: Leading causes for 2000.Division of Vital Statistics, Centers for Disease Control andPrevention, 50(16), 8.

Bernert, D. J. (2002). Healthy People 2010: Health educationimplications and recommendations for youth with disabili-ties. American Journal of Health Education, 33(3), 132–139.

Betz, C. L. (2002). Surgeon General’s report on health care needsfor individuals with mental retardation. Journal of PediatricNursing: Nursing Care of Children and Families, 17(2), 79–81.

Bierman, A. S., & Clancy, C. M. (2001). Health disparitiesamong older women: Identifying opportunities to improvequality of care and functional health outcomes. Journal of theAmerican Medical Women’s Association, 56(4), 155–159.

Brandeis, J., Pashos, C. L., & Henning, J. M. (2001). Racial dif-ferences in the cost of treating men with early-stage prostatecancer. Journal of the American Geriatrics Society, 49(3),297–303.

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Visit the Connection site at http://connection.lww.com/go/timbyFundamentals for links to chapter-related resources on the Internet.

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