The Theory of Unpleasant Symptoms:Clinical ApplicationAn Acute-Care ViewAlexis Farrington, BSN, RN

Background

In the acute-care setting, nurses are responsible for managing clinical symptoms, effects of medications and behaviors that place patients at risk for falls.

Nurses are also responsible for reporting to primary care providers and immediate level management changes in patients’ symptoms that increase the risk for potential injury (Rochefort, Ward, Ritchie, Girard and Tamblyn, 2011).

Frequent assessments are necessary to determine changes in patients’ mental status, gait stability and levels of anxiety and should be communicated during shift reports (Kerzman, Chetrit, Brin and Toren, 2004).

In some cases, falls may be a reflection of increased patient-care ratios (Titler, et al., 2005).

Problem Statement

Elderly-related falls in the acute-care setting remains an ongoing and costly concern in health care. Although many institutions have

implemented action plans geared toward multidisciplinary approaches for prevention, the majority of safety reliance remains on nursing and its

interventions.

Significance

The Centers for Disease Control reports that one in three adults greater than the age of 65 will fall annually (CDC, 2013).

According to the CDC (2013), costs for falls involving the elderly ranged well over $30 billion in 2010 and is expected to double within the next ten years.

“Patient falls that included risk factors were preventable and predictable up to 78%” (Titler et al., 2005).

Specific Aims

Implementation of the concepts of the theory of unpleasant symptoms to reduce falls through:

Early identification of risk factors

Anticipate symptoms

Aid in development of preventative interventions

The Theory of Unpleasant SymptomsLenz & Pugh (1995)

Classification: Middle Range Theory (MRT) Purpose: Proposes to integrate previously existing knowledge

regarding what is known about varying symptoms based on the premise that similarities exist among them and is experienced in a variety of clinical settings and circumstances.

Foundational concepts: Symptoms-sensations that are professed or perceived

personally by an individual. Symptom expressions: Duration, intensity, time and quality. Influencing factors: Physiologic, psychologic and situational.

Relationship Among Influencing Factors and Theoretical Concepts

Physiological• Disease

Process

• New Diagnosis

Psychological• Fear

• Anxiety

Situational• Personal• Finances

Distress Intensity

Quality T-i-m-e

SymptomsPerforman

ce/Behavior

Lenz & Pugh’s (1995)

Original Construct of Theoretical Model/Conceptual Frameworks of

The Theory of Unpleasant Symptoms

Application to Practice

Advantages

May be applied to multiple areas of nursing practice.

May address symptoms individually or in “clusters” to meet the needs of one individual.

Symptoms may be perceived objectively by the clinician (observation of performances) by patient.

Disadvantages No preset identified

list of interventions specified for particular group of symptoms to guide practice.

Observations and identification of symptoms are dependent on the skills of the clinician to determine assessment of needs.

Application to the Acute-Care Setting

Communication

Shift reporting: that is concise and up-to-date is necessary for continuity in the identification of symptoms (Dykes, 2012).

Management: Consistent and timely communication with upper-level management is critical to navigate the patient’s location at all times. (Symptoms may suggest need for adjustment in clinical status or level of care)(Rochefort, Ward, Ritchie, Girard and Tamblyn, 2011).

Primary care providers: (PCP’s: MD/ARNP/PA) need to be aware of patient’s change in symptoms to adequately adjust current treatment modalities) (Rochefort, Ward, Ritchie, Girard and Tamblyn, 2011).

Team work: Nursing and non-nursing staff working within the same areas should communicate consistently to avoid potential patient-related mishaps. Many falls result secondary to a lapse in communication among team members (Dykes, 2012).

Education Patient Priority: Nursing, non-nursing

staff and families are essential components in patient-centered care. Awareness of the anticipation of symptom changes is necessary to identify alterations in influencing factors, symptoms or behaviors that may result in a fall or other untimely event (AGS, 2010).

Evidence-based data: should be easily accessible to nursing staff that may facilitate constant education material for clinicians and families to ensure safety (Kerzman, Chetrit, Brin and Toren, 2004).

Clinical Competence: It is essentially important for nurses to be clinically cognizant of potential susceptibility secondary to medications, sedatives, diuretics, urinary incontinence, anxiety and disease processes that may lead to unsafe changes in cognition that place patients at risk (Murphy, 2011).

Symptom Identification/Anticipation

Influencing Factors

Theoretical Concepts

Performance/Behavior Consequence

Restless/Aggression

T-i-m-e

PhysiologicalDiagnosis

Pain

PsychologicalLoss of

independenceAnxietyIntensity

Quality Situational Finances

Lack of Insurance

Fear Distress

According to Lenz & Pugh (1995), many symptoms correlate to multiple disease processes and are unique to patients individually.

The influencing factors, in most cases exacerbate the theoretical concepts that give rise to the response or result of the original symptom.

In the case of the provided example: Pain is a physiological sensation that could manifest in one behavior; however, given the significance of the influencing factors, may potentially affect the severity of the sensation of the unpleasant symptom.

Nursing may overcome this cycle by working with families, increasing knowledge of clinical symptoms that employ critical thinking that will promote anticipation of needs.

Communication with family and other consulting disciplines will assist in management of addressable influencing factors that may enable the patient to focus more on healing with less of a sense of helplessness.

Nursing: The Profession That Never Sleeps It is largely assumed that risk for falls and

patient safety is primarily a nursing concern (Titler et al., 2005).

While nursing carries the bulk of patient care and is responsible for care, all disciplines play a vital role in the safety and satisfaction of our patients (as we all benefit).

Active participation and involvement is a vital role in all of the of the disciplines within the area whether clinically or not.

The clinical environment is not only a business, but we are in business to provide consistent, safe and support across the continuum to all.

Nurses use your judgment, advocate and exercise your clinical expertise to ensure the best possible outcomes for your patients.

Don’t forget to communicate. Nursing is a 24 hour duty. We do more with less and can usually make something of nothing at all.

References Graham, B. C. (2012). Examining evidence-based interventions to prevent inpatient falls. Medsurg

Nursing, 21(5), 267-270.

Hutchinson, S., & Wilson, H. (1998). The theory of unpleasant symptoms and Alzheimer's disease... including commentary by Lenz ER and Gift AG. Scholarly Inquiry for Nursing Practice, 12(2), 143-162.

Kerzman, H., Chetrit, A., Brin, L., & Toren, O. (2004). Characteristics of falls in hospitalized patients. Journal of Advanced Nursing, 47(2), 223-229. http://dx.doi.org/10.1111/j.1365-2648.2004.03080.x

Lenz, E., Pugh, L., Milligan, R., Gift, A., & Suppe, F. (1997). The middle-range theory of unpleasant symptoms: an update. Advances in Nursing Science, 19(3), 14-27.

Lovallo, C., Rolandi, S., Rossetti, A., & Lusignani, M. (2010). Accidental Falls in hospital inpatients: evaluation of sensitivity and specificity of two risk assessment tools. Journal of Advanced Nursing, 66(3), 690-696. http://dx.doi.org/10.1111/j.1365-2648.2009.05231.x

Murphy, W. (2012). Improved patient safety and quality: a focus on falls. Home Health Care Management & Practice, (24)1, 62-64. http://dx.doi.org/10.1177/10884822311422822

Nazarko, L. (2012). How to reduce risk of injury if a person remains at risk of falls. British Journal of Healthcare Assistants, (6)9, 432-437.

Rochefort, C. M., Ward, L., Ritchie, J. A., Girard, N., & Tamblyn, R. M. (2012). Patient and nurse characteristics associated with high sitter use costs. Journal of Advanced Nursing, (68)8, 1758-1767. http://dx.doi.org/10.1111/j.1365-2648.2011.05864.x

Titler, M., Dochterman, J., Picone, D., Everett, L., Xie, X., Kanak, M., & Fei, Q. (2005). Cost of hospital care for elderly at risk of falling. Nursing Economics, (23)6, 290-306.