Florida University: Chapter 1-11|NUR 3125 Med-surg exam 1,100% CORRECT

Florida University: Chapter 1-11|NUR 3125 Med-surg exam 1 Chapter 1 ANA Nursing: the protection, promotion, and optimization of health and abilities, prevention of injury, facilitation of healing, alleviation of suffering though the diagnosis and treatment of human response, and advocacy in the care of individuals, groups, communities, and populations Florence nightingale: the goal of nursing is “to put patient in best condition for nature to act upon him” Patient needs: vary depending on problems, circumstances, and past experiences. ● Nurses identify patient’s immediate, ongoing, and long-term needs and work with patient to address them ● Basic Needs: Maslow’s Hierarchy ○ Physiologic needs (food, water, shelter, warmth) ○ Safety and Security (security, order, law) ○ Belongingness and affection (family, social) ○ Esteem and self-respect (achievement) ○ Self actualization (meaning, growth) ● Wellness: being proactive and involves in self-care activities aimed towards a state of physical, psychological and spiritual well being; four components ○ Capacity to perform at best of ability ○ Ability to adapt ○ Feeling of wellbeing ○ Feeling harmonious Health: WHO- state of complete physical, mental, and social well-being; not merely the absence of disease and infirmity ● Health is ever changing ● Health promotion: focuses on changing habits, lifestyle, and environment to reduce risk and enhance health and well-being; promotes disease prevention, wellness, self-care ○ Healthy people 2020: list of goals for the nation to improve health; attempt to reduce or eliminate illness, disability, and premature death; 26 leading health indicators or goals ■ LHIs aimed at improving access to healthcare, improving environment, preventative services, improving nutrition, etc ○ Technology: websites, chat groups, social media, computer tech, wearables ● Changing patterns: chronic diseases such as cardiovascular, cancer, diabetes, and lung diseases cause 7/10 of the leading causes of death; nearly half of all adults have a diagnosed chronic condition, 60 million have 2 or more ● Major health concerns: tobacco use, substance abuse, poor physical activity and nutrition habits, obesity Influences on Delivery of Healthcare ● Population demographics ○ Minorities triple in US by 2030 ○ Five races, according to census: white, black, asian, native american, native hawaiian or pacific islander ■ Asian race largest growth rate ■ Hispanics half of the population growth ○ Increasing number and proportion of older americans ● Sensitivity to cultural differences ○ Patients from diverse sociocultural groups bring various health care beliefs, values, and practices to the healthcare setting ○ They also bring unique risk factors for some diseases and unique reactions to treatment Technological advances ● Precision medicine: focuses on preventing and curing cancers, idifies unique characteristics of individual persons to mine and analyze datasets and improve treatment ● Health informatics: using health information technology (HIT) to improve quality, efficiency, delivery of healthcare ○ Technology informatics guiding reform (TIGER): provides expert panel reports and guidelines for incorporating HIT into nursing practice ○ International classification of diseases (ICD-WHO)” provides common nomenclature and tracking of the incidence and prevalence of various diseases globalls ○ EHR incentive program: use EHR by 2018 or face reductions in reimbursement ○ Telehealth: uses technology to deliver healthcare, information, or education at a distance Providing Quality, safe, and evidence-based care ● Evidence based practice bundles measurably improve patient outcomes ● Institute of Medicine (IOM): To Err is Human report (2000) noted an alarming breakdown in quality control and safety in the american healthcare system ○ 100,000 americans die annually from preventable errors ○ Follow up report Crossing the Quality Chasm (2001) envisioned reformed system that is evidence-based, safe, effective, patient centered, timely, efficient and equitable ○ Lead to ACA and pay performance measures (meeting or exceeding, cost efficient and of best quality); aims for all americans to have access to quality, affordable healthcare programs ● Triple aims of effective healthcare systems ○ Improve population health ○ Improve patient care experience ○ Reduce per capita costs ● TJC national patient safety goals ● QSEN Quality and Safety Education for Nurses: curriculum of knowledge, skills, and attitudes that future nurses must learn ○ Patient centered care ○ Teamwork and collaboration ○ Evidence based practice ○ Safety ○ Informatics ● Coordinating care: seamless transitioning of care from hospital to community setting improves patient’s health outcomes ○ Nurses: case management, clinical nurse leaders Nursing Practice Today ● ANA policy statement: The depth and breadth in which individual registered nurses and advanced practice registered nurses engage in the total scope of nursing practice is dependent on education, experience, role, and the population served ● Standards of practice: basic competencies in delivering nursing care and using the nursing process ● Standards of Professional Performance/ Code of ethics: expectations for behavioral competencies Medical Surgical nursing: provides services to patients from adolescence to end of life in a variety of inpatient and outpatient clinical settings Advanced nursing rolls/ Advanced practice registered nurses: have more education and can treat and coordinate special patient care ● Certified nurse practitioners: practice autonomously in diagnosing, treating individual patients with undifferentiated clinical manifestations and confirmed diagnoses; can prescribe medications that are not restricted in nature ● Certified nurse midwives ● CRNAs ● Clinical nurse specialist: influences patient, nurse, and healthcare system ● Clinical nurse leader: help patients navigate the healthcare system ● Doctor of nurse practicing ● Case managers The Future of Nursing: the future of nursing as a profession is inextricably tied into the future of health care in the nation ● Campaign: begin implementation of recommendations by fostering the development of national and state Action Coalition (pg 13) Chapter 2: Community Based Nursing practice Community: an interacting population of individuals living together within a larger social structure Factors that have increased the need for community healthcare ● Shift from inpatient to outpatient ● New population trends ○ Growing number of older adults has increased the demand for medical, nursing, and social services within the public health system ● Tighter insurance regulations ● Decreasing hospital revenues ● Changes in federal legislation Role of nurse in community: expanding due toz ● Transitions in the healthcare industry ● changing patterns of disease and wellness ● Changes within the nursing profession ● Patients moving from acute care to community in early stages of recovery Community Based Nursing: targeted at improving the health status of groups of patients or the community at large; promotes health and wellness, reduces spread of disease or illness, improves health status for the whole community; families and individuals; acute and chronic illness interventions ● Occurs in a variety of settings, directed toward people and families; needs related to illness, injury, or disability; acute illness and interventions for chronic illness ● Home healthcare is a major aspect of community-based care and elderly clients are the most frequent users ● Community settings: public health departments, ambulatory health clinics, long-term care facilities, schools, faith communities, hospice centers (6 months EOL), industrial environments (occupational nursing), homeless shelters and clinics, nursing centers, home health agencies, urgent care centers, same-day surgical centers, short-stay facilities, patient’s homes ● Ambulatory settings: medical clinics, ambulatory care units, urgent care, rehab, mental health centers, student health centers, community outreach programs, affordable accessible healthcare ● Organizing interventions ○ Primary: health promotion and prevention of illness or disease ■ Bike helmets, tobacco cessation, immunizations ○ Secondary: early detection, prevent or minimize loss of function and independence, health maintenance ■ Health screenings and health risk appraisal, newborn screenings, mammographies ○ Tertiary: focuses on minimizing deterioration and improving quality of life ■ Rehab, medications, therapies Public health nursing: combines discipline of public health with nursing; considered specialty practice within community-oriented nursing; focus on population health Community nurses ● Self directed, flexible, adaptable, and accepting of various lifestyles and living conditions ● Must have expertise in decision making, critical thinking, assessment, health education, community resources, and competency in basic nursing care ● Must be culturally competent, especially in community where nurse culture is different from population being treated ○ Developing cultural competencies: ■ Awareness and self reflection ■ Willingness to explore cultural expressions in health and illness ■ Delivery of interventions that are congruent with the patient’s culture Discharge Planning: begins on admission to acute care to assist with transitioning from acute care to community or home care setting ● Development involves identifying needs and collaboration between discharging agency and community agencies ● Communication with family to ensure understanding and cooperation is vital ● Community Resources: a community based nurse must be knowledgeable about community resources available to patients as well as services provided by local agencies, eligibility requirements, and possible charges for the services ○ Most communities have directories or resource booklets that list local health and social service agencies and their offerings to meet client needs ○ Includes referral to other team members, continuous coordination to avoid duplication of services; grocery/drug stores, banks, social service agencies, senior citizen programs, physicians, dentists, etc Home health care ● Holistic care is provided in the home through the collaboration of a interdisciplinary team that includes professional nurses, home health aides, social workers, physical, speech, and occupational therapists, and physicians ● Most are reimbursed by sources like medicare/caid, private insurance, and direct payment ● Skilled nursing, follow up care, teaching, and hospice care are common nursing services ● Telehealth facilitates exchange of information between patients and nurses regarding health information such as blood glucose readings, vitals, and cardiac parameters ● Nurse is a guest in the home ○ Delivers care regardless of conditions ○ Nurse may need to work by improvising such as using a normal bed when an adjustable bed is not available and working without a bedside table ○ Infection control is more difficult and can include hand hygiene in homes without running water ○ Must plan for visit: review referral, schedules visit with permission, verifies time and address, assures supplies and equipment are available, discuss supplies needed ■ Routine visits, wound care improvisation, central line dressing changes ● Is still a confidential setting ● Home health agency policy manual: identifies agency’s philosophy and procedures and defines the services provided ● Conducting a home visit ○ Ensure personal safety- don’t drive an expensive car or wear expensive jewelry during visits ○ Initial visit: includes evaluating the patient and home environment, establish plan of care characterics of home environment ○ Determine needs for future visits, frequency ○ Ending visits: summarize point of visit for patients, point out positive attributes to give sense of accomplishment, ensure recap of teaching/treatment plan, who to call/when to call for help, when/if a return visit will take place ○ Documentation Caring for the Homeless ● Mostly underinsured or uninsured with little to no access to healthcare ○ Will seek health care late in the course of a disease because of these barriers, deteriorate more quickly ● Lower life expectancy, high rates of disease and illness, disease more easily spread ● Nurse role: skilled in dealing with various health problems, individualized treatment for unpredictable environments, non judgemental care Chapter 3: Critical Thinking, Ethical Decision making, and the Nursing Process Critical thinking: reasoning and judgement used to develop conclusions, solutions, and alternatives appropriate to a situation; used in all practice settings ● Includes cognitive and metacognitive skills, logical reasoning ○ Metacognition: the examination of one’s own reasoning or thought process to help refine thinking skills ● Development of critical thinking requires experiential learning and practice, developed over time ● A deliberate, outcome oriented activity that is logical, organized, and iterative; occurs through inquiry; formulation of conclusions ● Used for clinical reasoning, or the process used to gather and analyze client info, evaluate relevance, and decide on nursing actions ● Skills: interpretation, analysis, inference, explanation, evaluation, self-reflection, self- regulation ● Components: identifying priorities, gathering and validating information, analyzing info, drawing on past experience and knowledge, maintaining flexibility, consider alternatives, and formulate decisions Ethics: formal systematic study of moral belief to understand right and wrong ● Theories ○ Deontology/formalist: ethical standards exist independently of consequences, sense of duty principle; do the right thing ○ Teologic/Consequentialism: focuses on consequences of actions ■ Utilitarianism: greatest good for greatest number of people ● Meta ethics (understanding concepts of ethics) in healthcare: analysis of concept of informed consent ○ Nurse questions if a patient was truly informed (by understanding what is it to be informed) ● Applied ethics: identification of ethical problems; addresses the implications of actions/practice in terms of moral permissibility ○ Nursing ethics is a form of applied ethics, moral situations specific to nursing care ● Common ethical issues: confidentiality, restrains use, truth-telling, refusal to provide care, end of life decisions, palliative care Morals: specific values, characters, or actions whose outcomes are examined through systematic ethical analysis ● Ethics and morals are often used interchangeably ● Moral situations ○ Dilemmas: clear conflict inexists between 2 or more principles or competing morals (lesser of two evils) ○ Problems: competing moral claims but one is clearly dominant ○ Uncertainty: a feeling of something not being right but not being able to point out the problem or conflicting value ○ Distress: institutional constraints stand in the way of pursuing correct action Ethical standards ● International Council of Nurses (ICN): code of ethics for nurses (2012), globally applicable ● American Nurses Association (ANA) Code of Ethics for Nurses (refer to Chart 3-4) ● ANA sponsors: Center for Ethics and Human rights- position statements that can be used to guide nursing practice Patient Self-Determination Act of 1991 ● Advanced Directives ● Identification of health care representative or power of attorney (decision maker if patient unable to make own decisions) ● Living will: wishes for care in the event they are unable to decide themselves, helps health care providers make decisions; before hospitalization ● Physician orders for life-sustaining treatment (POLST) Ethical decision making: dilemmas are common and diverse in nursing; no clear solutions, situations vary ● Approach to ethical decision making- follow steps of nursing process ● Ethical analysis Chart 3-3: autonomy, beneficence, nonmaleficence, double effect, distributive justice ○ Autonomy: entails the right of patients to receive adequate and accurate info so that they can make an informed decision free from external constraints Examples of nursing interventions: reposition patient every 2 hours around the clock, teach and reinforce the use of guided imagery to reduce pain prior to invasive procedures, monitor oral and intravenous fluid intake to ensure that 2000 mL of fluids has been received, position the client in an upright position in a chair for 15 minutes before meals, apply lanolin to the patient’s lips every 2 hours and as needed (i.e., pro re nata [prn]), teach the patient and family the correct way to apply a wedge splint prior to sleep, promote a therapeutic relationship, Ambulate client The Nursing Process ● Assessment: health history, physical assessment, ongoing observation, relevant information from family, team, records, recording data to EHR; basis for identifying diagnoses and collaborative problems ○ EHR provides means of communication among team members and facilities to coordinate planning and continuity of care ○ Recording data provides continuity of care ● Diagnosis: part of ANA scope of practice, NANDA-I (nursing diagnosis taxonomy), based on collection and assessment of data, addresses both actual and potential health problems, not medical diagnosis, collaborative problems ● Planning: prioritizing (maslow hierarchy as one framework used to prioritize), establish expected outcome and goals (SMART), long-term, intermediate, short term goals, determine interventions, use standardized interventions (nursing interventions classification) ● Implementation: carrying out plan of care through nursing interventions, nurse responsibility, attempt to achieve goals, constant assessment, making revision; patient focused interventions abased on planned outcomes/goals; direct or indirect actions (Examples above) ● Evaluation: final step of the nursing process, allows nurse to assess patient response to interventions and extent of objective and goal achievement Individualized Care Plan chart 3-10 Chapter 4: Health education and promotion Health education: tool to assist patients and families in developing effective health behaviors ● supports nursing care that is directed toward the “promotion, maintenance, and restoration of patient health; preventing illness; helping people adapt to the residual effects of illness ● Affects the abilities of people and families to perform self-care activities ● Supports informed decision making ● Promotes adherence to therapeutic regimens Factors influencing adherence ● Demographic variables: age, gender, race, socioeconomic status, education level ● Illness variables: illness severity and relief of symptoms given by therapy ● Therapeutic regimen: uncomfortable side effects, complexity, treatment fatigue ● Psychosocial variables: support, intelligence, motivation, competing demands, attitude towards illness and professionals, substance abuse, religious and cultural beliefs ● Financial variables: direct and indirect costs of regimen ● Health literacy: communication, cultural skills, mathematical skills, education, understanding ● Gerontologic considerations: non-adherence in adults leads to increased morbidity, mortality, and cost of treatment. Collaborated, continuous, coordinated care needed between professionals. ○ One or more multiple chronic illnesses; periodic acute episodes ○ Multiple medications, side effects ○ Inadequate adjustment to stress and change, lack of support systems ○ Forgetfulness ○ Sensory impairments ○ Mobility issues ○ Cognitive impairments: drawing inferences, applying information, understanding teaching points Teaching and Learning ● Teaching: helping another person learn; active process ● Learning: acquiring knowledge, attitudes, skills, and behavior changes ○ Factors affecting learning ■ Learning readiness: based on culture, personal values, physical and emotional status, past experience (experiential readiness) ● Appropriately incorporate a patient’s social and cultural patterns ● “Teachable moments” and positive feedback ■ Learning environment: room temp, lighting, noise levels, distractions, etc ● Formal vs informal ● Interpersonal aspects ● Physical environment: comfort ● Timing: avoid times when a patient is fatigued, uncomfortable, anxious, or otherwise occupied ■ Teaching techniques: lectures, group teaching, demonstration and practice, reinforcement and follow-up, motivational interviewing, electronic, online, or internet resources, teach-back, and teaching aids (books, pamphlets, pictures, films, tapes, models, etc) ● Teaching patients with disabilities ○ Physical, emotional, or cognitive: adapt information to the person’s abilities; give clear written and oral information, highlight significant information; avoid jargon ○ Hearing impairment: slow, directed, deliberate speech; use interpreters; make sure the patient can see your mouth; written materials, visual aids, telecommunication devices; captions on electronic resources; sue the “good ear”; use direct eye contact, use demonstration and return demonstration ○ Visual impairment” ensure the patient has their optical devices; use proper lighting and color contrast on materials and equipment; use auditory and tactile formats for materials; explain noises associated with teaching materials; arrange materials in a clockwise pattern; encourage them to verabilize information back ○ Learning disabilities ■ Input: see above ■ Output: use all senses as appropriate, provide written, audio, and computerized information, review information and give time to interact and ask question, use hand gestures and motions ■ Developmental: Base information on developmental stage, use nonverbal cues, gestures, and signalling; use simple explanations with concrete examples and repetition; encourage active participation; teach-back methods ● Teaching plans and the nursing process ○ Assessment: assess needs, readiness, internal and external variables around ability to learn, what they need to learn, expectations ○ Diagnosis: deficient knowledge; “ineffective health maintenance, ineffective self-health management, decisional conflict” ○ Planning: preparing teaching strategies, prioritizing, choosing goals and outcomes, selecting aids, involving family ○ Implementation: teaching methods, aids, equipment, recording responses, providing feedback ○ Evaluation: teachbacks, follow ups, analyzing understanding, making changes Health promotion: common goal with health teaching to encourage achievement of a high level of wellness ● Cornerstone of health policy because of need to control costs and reduce unnecessary sickness and death ● Maximize healthy lives and prevent illness ● Healthy people 2020: establish goals for the nation, defines current health promotion and disease prevention initiatives; increasing quality of years and elimination of health disparities ● Health promotion models: serve as organizing frameworks to help understanding of health promotion behaviors; used in clinical work and research ○ Health belief model: fosters understanding of why some people choose healthy actions and some do not ■ Four principles: demographic and disease factors; factors that lead to unavailability or difficulty in accessing specific health promotion alternatives; factors such as financial and social support; factors in self-perception of illness, health status, and self-efficacy ○ Resource model of preventative health behavior: addresses the use of resources in promoting health ■ Emphasizes motivational factors; cognitive- perceptual factors; perceived control of health, health status, benefits and barriers ○ Achieving health for all (canada): 12 determinants of health that provide a framework for assessing and evaluating a population’s health ○ Awareness, motivation, skills, and opportunity model: addresses organizational and individual health behavior change; focuses on empowerment, individual priorities, assisting changes in behavior to promote optimal health to create a balance among the five dimensions ■ Five dimensions of optimal health: physical, emotional, social, intellectual, spiritual ○ Transtheoretical model for change: Stages of change model’ focuses on motivation of person to make decisions that promote healthy changes; precontemplative, contemplative, decision making, action, maintenance, termination ● Components of health promotion ○ Self responsibility: personal accountability for one’s actions or behavior; depends on desires and inner motivations ○ Nutritional awareness: understanding the importance of a healthy diet and relationship between diet and disease; the single most significant factor in determining health status, longevity, and weight control ○ Stress management: behaviors and techniques an individual uses to strengthen resistance and resources against stress ○ Physical fitness: condition of being physically healthy ● Health promotion throughout the lifespan ○ Starts before birth, ends at death ○ Yearly health screenings ○ Counseling ○ Immunizations ○ Preventative medications and procedures ○ Adolescents: focus on creating healthy habits to prevent negative outcomes of risky behaviors ○ young/middle adults: focus on healthy behaviors (general wellness, smoking cessation, exercise, physical conditioning, weight control, conflict resolution, stress management) pregnancy and the family, cancer screenings, chronic illness, workplace activities offered ○ Old people: very health conscious, benefit from activities and education that help them maintain independence and achieve optimal health ● Role of the nurse: every interactions is an opportunity to promote healthy attitudes and behaviors that foster: ○ Well being: long established credibility with the public allows them to play a vital role in health promotion ○ Self-actualization ○ Personal fulfillment Chapter 5: Adult Health and Nutritional Assessment Role of the nurse: ● Collaborative effort: all members of the healthcare team collaborate and use their unique skills and knowledge to the contribute to the resolution of patient problems by first obtaining some level of history and assessment ● Healthy history: the collection of subjective data about a patient’s health status ● Physical assessment: collection of objective data about a patient’s health status ● Nursing process guides care: nursing diagnoses are used to determine the appropriate plan of care for the patient and drive nursing interventions and patient outcomes ● Electronic medical record: nursing diagnoses provide standard nomenclature for the use in EHR, enabling clear communication among team members and the collection of data for continuous improvement in patient care Effective communication ● Establish rapport: put the patient at ease, encourage honest communication, make eye contact, and listen carefully to the patient’s responses to questions about health issues ● Be aware of nonverbal communication, yours and the patient’s ● Consider patient’s educational and cultural background, and language proficiency ● Avoid technical terms/medical jargon, questions and interactions should be phrased so that they are easily understandable ● Summarize at end of visit, answer questions, correct misinformation Ethical considerations ● Explain the purpose of the health history and physical examination, how the information will be used, and who it will be shared with ● Explain the procedures of the health history and physical, how participation is voluntary ● Private setting to encourage honesty and trust ● HIPAA 1996: established national standards to protect individuals medical records and other personal health information ● Electronic Health Record: offers convenient access to health data for the patient and providers, can be used to improve quality, efficiency, and continuity of patient care Assessment in the Home or Community: Assessment of people in community settings, including the home, consists of collecting information specific to existing health problems, including data on a patient’s physiologic and emotional status, the community and home environment, the adequacy of support systems or care given by family and other care providers, and the availability of needed resources. Components of health history: ● Biographical data: patient’s name, address, age, gender, marital status, occupation, and ethnic origins ● Chief complaint: the issue that caused the patient to seek the care of a healthcare provider ● Present health concern/illness: includes information such as date and type of onset which the problem occured, manifestations of the problem, and the course of illness. It should also include self-treatment, medical interventions, progress and effects of treatment, and patient’s perceptions of the cause or meaning of the problem. ● Past health history: needs may be for nursing care ○ Immunization status, childhood illnesses, psychiatric illnesses, injuries- burns, factures, head injuries, traumatic injuries, hospitalizations, surgical and procedures, allergies, previous exams and diagnostic testing ● Family history: used to identify diseases that may be genetic, communicable, or possibly environmental in origin; cancer, hypertension, heart disease, diabetes, epilepsy, mental illness, tuberculosis, kidney disease, arthritis, allergies, asthma, alcoholism, and obesity; results of genetic testing and screenings ● Review of systems: can be organized as a formal checklist which is easily audited and less subject to error; overview of general health as well as symptoms related to each body symptoms; negative and positive answer should be recorded ● Patient profile: composite profile of patient that includes past life events, current medications, education and occupation, financial resources, environment (physical, spiritual, interpersonal), lifestyle patterns, presence of physical or mental disability, self-concept, sexuality, risk for abuse, and stress and coping response Components of the Physical exam ● General observations ○ Posture: provides valuable information; ex: patients with abdominal pain from peritonitis prefer to lie still ○ Body movements ■ Generalized disruption of voluntary or involuntary movement (tremors, seizures) ■ Asymmetry of movement: usually occurs with disorders of the CNS or cerebrovascular disease (stroke); dropping, weakness, paralysis, etc ○ Speech patterns: can indicate CNS disease, damage to larynx, etc ○ Nutritional status: obesity from diet or disease, loss of weight by diet or disorders ● Vital signs and pain ○ BP, HR, RR, Temp, Pain ● Focussed assessment of body systems: skin, head and neck, thorax and lungs, breasts, cardiovascular system, abdomen, rectum, genitalia, neurologic system, musculoskeletal system Assessment techniques ● Inspection: observation of each relevant body system in more detail; skin color, presence of lesions, edema, erythema, symmetry, pulsations ● Palpation: assessment of structures of the body with light and deep pressure; examples include superficial blood vessels, lymph nodes, thyroid, organs of the abdomen, pelvis, and rectum ● Percussion: use of sound to examine different body organs; a skill that require much practice ● Auscultation: listening to sounds produced within the different body structures created by movement of air or fluid; happens before palpation on abdomen; classified by intensity, pitch, duration, quality ○ Listen with stethoscope/diaphragm firmly on skin Nutritional assessment: provides information about obesity, undernutrition, and malnutrition ● Disorders caused by nutritional deficiency, overeating, or eating unhealthy meals are among the leading causes of illness and death in the United States; obesity, osteoporosis, cirrhosis, diverticulitis, and eating disorders among them ● Obesity: leading risk factor for global deaths; contributes to diabetes, coronary artery disease, certain musculoskeletal disorders, and cancer ● Lifespan considerations ○ Adolescence: time of critical growth, lifelong eating habits; obesity is a rising concern ■ Girls are at risk for deficit in iron, folate, and calcium ○ Older adults: may maintain specific diets for improving or maintaining health ■ Mini nutritional assessment: identified adults ages 65 or older who are malnourished or at risk of becoming malnourished; has food intake declined over the past 3 months, weight loss, mobility, psychological stress or acute disease, neuropsychological problems and BMI are all assessed. 12-14pts no risk, 8-11 at risk, 0-7 malnourished ● Components of the Nutritional assessment ○ BMI: weight (kg) / [Height (m) squared]; must take ethnicity into account; 30 or more is obese ■ Low BMI associated with higher mortality rate among hospitalized patients and community-dwelling older adults; Less than 18.5 at increased risk for problems associated with poor nutrition ○ Waist circumference: measured at level of iliac crest; greater than 40 inches in men or 35 in women indicated excess abdominal fat; increased risk for diabetes, dyslipidemias, hypertension, heart attack, and stroke ○ Biochemical measurements ■ Serum prealbumin and albumin: low levels measure protein deficit but may not decrease until malnutrition is severe; can also be caused by liver disease, overhydration, excessive loss due to burns, major surgery, infection, or cancer; serum prealbumin used to assess effectiveness of nutritional therapy ■ Serum transferrin and retinol-binding protein: transferrin depletes more quickly than albumin, low levels can cause iron deficiency, anemia; ■ CBC ■ Electrolytes: electrolyte balance and kidney function ■ Urine tests: 24 hour urine collection to calculate creatinine/height index that assesses metabolically active tissue and indicated the degree of protein depletion; low values may indicate loss of lean body mass and protein malnutrition ○ Clinical findings: other tissues can serve as indicators of general nutrition status; teeth, hair, skin, gums, mucous membrane, mouth, tongue, muscles, abdomen, lower extremities, and thyroid gland ○ Dietary data: food record, 24 hour recall, and interview; used to help estimate whether intake is adequate and appropriate; religious and cultural considerations ■ Dietary interview: individuals’ ethnicity of their personal beliefs include which foods are eaten and how they are prepared and served ○ Evaluating the data ■ Collaborative approach ■ Compare food intake with dietary guidelines (MyPlate): fruits, grains, vegetables, protein, dairy; recommendations based on different age groups and activity levels ■ Fat intake and cholesterol levels: increased amounts have been associated with increased risk for heart disease and stroke ○ Factors influencing nutritional status ■ Hospitalization: illness or disorder that caused hospital stay may cause inadequate dietary intake ■ Physical problems or limitations: fatigue, illness, disease ■ Limited or fixed incomes: medications may cost so much that they result in insufficient money to buy nutritious foods ■ Cultural influence ■ Medications: side effects such as nausea, vomiting, irritating oral or gastric mucosa, GI symptoms, suppressing appetite, influencing bacterial flora in the intestines, affecting nutrient absorption (secondary malnutrition) ■ Complex treatments ○ Chapter 6: Individual and Family Homeostasis, Stress, and Adaptation Claude Bernard: a 19th century French physiologist who first developed the biologic principle that for life there must be a constancy or “fixity of the inter milieu” despite changes in the external environment ● “Constancy” in this case is homeostasis: a steady state within the body, in which stress or changes initiate processes to restore and maintain dynamic balance ○ When the compensatory mechanisms are not adequate steady state (homeostasis) is threatened Stress and adaptation ● Stress: a state produced by change in the environment that is perceived ad as threatening to a person’s dynamic equilibrium ○ Stressors: an internal or external event or situation that upsets equilibrium; can be physical, physiologic, or psychosocial in nature ■ Create potential for physiologic, emotional, cognitive, or behavioral changes ■ Physical: cold, heat, chemical agents, etc ■ Physiologic: pain, fatigue ■ Psychosocial: normal life transitions that require some adjustment such as going from childhood into puberty, getting married, or giving birth ● negative emotions such as fear and anger accompany harm/loss appraisals, positive emotions accompany challenge ● Adaptation: adjustment to the change so that the person is in equilibrium again ○ Seyle’s General Adaptation Syndrome: theory of adaptation to biologic stress ■ Alarm: sympathetic nervous system fight- or flight response; catecholamines released; onset of ACTH response; self-limiting ■ Resistance: adaptation occurs to stressors; cortisol activity is still increased vs electating and returning to a normal range ■ Exhaustion: endocrine activity continues, body will fail if exposure to stressor is prolonged ● Coping: a compensatory process that has physiologic and psychological components ● Interpretation by the brain ○ Parts of the brain ■ Hypothalamus: regulates emotions and many visceral behaviors necessary for survival; eating, drinking, temperature control, reproduction, defense, aggression ■ Cerebral hemispheres: concerned with cognitive functions; thought processes, learning, memory ■ Limbic system: cerebral hemispheres and brainstem connections ■ Reticular activating system: controls alert or waking state of the body; connects brainstem, midbrain, and limbic system ○ Sympathetic nervous system response: increase in function of vital organs and a state of general body arousal ■ heart rate increases, peripheral vasoconstriction occurs which raises blood pressure raises; blood glucose is increased to supply more readily available energy; pupils dilate, mental activity increases ■ Person is more likely to experience cold feet, clammy skin and hands, chills, palpitations, and knots in the stomach, person may appear tense ○ Sympathetic nervous system also stimulates adrenal medulla to release hormones epinephrine and norepinephrine into the bloodstream; sustain and prolong sympathetic actions, stimulate the nervous system, and produce metabolic effects that increase blood glucose and metabolic rate ○ Hypothalamic-pituitary pathway: longest acting phase of the physiologic response, more likely to occur in persistent stress ■ Hypothalamus secretes corticotropin-releasing factor, which stimulates anterior pituitary to produce ACTH, which stimulates the adrenal cortex to produce glucocorticoids like cortisol; cortisol stimulates protein catabolism, releasing amino acids which the liver converts into glucose, and inhibits glucose uptake by many body cells ■ The cortisol-induced metabolic effects provides the body with a ready source of energy during stress; can cause a person with diabetes under stress to need more insulin ● Maladaptive response to stress: chronic, recurrent response to stress that does not promote the goals of adaptation ○ Include faulty appraisals and inappropriate coping ○ A precursor to disease: any stressor elicits a state of disturbed physiologic equilibrium, leads to illness if the response to stress is prolonged or excessive ■ Immune response decreases, allowing for tumors and infections to develop ○ Seyle’s list of disorders of maladaptation: hypertension, cardiovascular disease, renal disease, rheumatoid arthritis, allergic diseases, nervous and mental disorders, sexual dysfunction, digestive/metabolic disease, cancer ● Stress at the cellular level ○ Negative feedback: mechanisms throughout the body monitor the internal environment and sense deviations from predetermined set point or range; trigger a response to offset the deviation and restore homeostasis ■ Compensatory mechanisms: blood pressure, body temperature, acid-base balance, blood glucose, fluid and electrolyte balance ■ Major organs affected: heart, lungs, kidneys, liver, GI tract, and skin ■ Net result is homeostasis (steady state): achieved by the continuous, variable action of organs involved in making adjustments and by continuous exchange of chemical substances among cells, interstitial fluid, and bloos ● Ex: Increased CO2 in ECF leads to increased pulmonary ventilation, which decreases CO2 ○ Positive feedback: perpetuates the chain of events set in motion by the original disturbance instead of compensating for it; ex: blood clotting ○ Cellular adaptation: cells can adapt to environmental stress through structural and functional changes ■ Hypertrophy: result of prolonged, increased workload ■ Atrophy: results from decreased use, decreased blood supply, loss of nerve supply, inadequate nutrition ■ Hyperplasia: increase in the number of new cells, can be reversible when stimulus is removed ■ Dysplasia: bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same tissue type; tend to become malignant ■ Metaplasia: cell transformation in which one type of mature cell is replaced or converted into another type of cell; the other cell may more resistant the the stress that stimulated the change but can have damaging consequences ○ Causes of cellular injury: may arise from internal or external environment; presence of one injury makes the system susceptible to other types ■ Hypoxia, chemical injury, infectious agents are the most common; also include nutritional imbalance, physical agents, chemical agents, immune mechanisms, genetic disorders, temperature, radiation, electric shock, and mechanical trauma ○ Inflammation: a localized reaction intended to neutralize, control, or eliminate the offending agent to prepare the site for repair; nonspecific, intended to serve as a protective function ■ Not the same as infection ■ Sequence of events: trigger, transient vasoconstriction, then vasodilation, increased vascular permeability, leukocytic cellular infiltration ■ Five cardinal signs: warmth, redness, swelling, pain, and loss of function ○ Cellular healing: the reparative process begins at the same time as injury, proceeds after inflammatory debris has been removed ■ Regeneration or replacement ● Regeneration: defect is gradually repaired by proliferation of the same cell types that were destroyed ● Replacement: cells of another type fill in the tissue defect and result in scar formation ○ Condition of the host, environment, and the nature and severity of the injury affect the processes of inflammation, repair, and replacement Nursing management: early identification of stressors is key ● Assessment: vitals; emotional distress; other indicators of homeostasis deviation; problems with movement or sensation; problems with affect, behavior, speech, cognitive ability, orientation, or memory; obvious impairments or lesions; diagnostic studies ● Diagnoses: anxiety, ineffective coping, defensive coping, ineffective denial (indicate poor adaptive responses); social isolation, risk for spiritual distress, readiness for enhanced family processes, decisional conflict, risk for compromised resilience, impaired resilience, risk for powerlessness, etc ● Interventions ○ Promoting a healthy lifestyle: provides internal resources that aids in coping, uffers of cushions impact of stressors ■ single most important factor for determining health status is social class, and within a social class research suggests that the major factor in influencing health is level of education ○ Enhancing coping strategies ■ other ways of coping include seeking information, prioritizing needs and roles, lowering expectations, making compromises, comparing oneself to others, planning activities to conserve energy, taking things one step at a time, listening to one’s body and using self- talk for encouragement ○ Teaching relaxation techniques: produce response that counters the stress response; guided imagery, meditation, progressive muscle relaxation, breathing techniques, biofeedback, massage, use of humor ○ Educating about stress management: giving patients info also reduces emotional response so that they can concentrate and solve problems more effectively ○ Promoting family health ○ Enhancing social support: provides a positive social identity, emotional support, material aid and tangible services, access to information, and access to new social contacts and social roles ○ Recommending support and therapy groups: exist for people in similar situations Chapter 7: Transcultural Nursing Transcultural nursing: providing care to patients and families across cultural variations ● Acknowledging, respecting and adapting to the cultural needs of patients, families, and communities ● Facilitating access to culturally appropriate health care is critical to ensuring holistic nursing care ● Madeleine Leninger (2002): founder of transcultural nursing, initiated field in mid 1950s ○ Culture care accommodation: professional actions and decisions that nurses make on behalf of those in their care to help people of a designated culture achieve a beneficial or satisfying health outcome ○ Culture care restructuring: repatterning, professional actions and decisions that help patients reorder, change, or modify their lifestyles towards more beneficial health patterns ○ Acculturation: members of a cultural group adapt or take the behaviors of another group ○ Cultural blindness: the inability of people to recognize their own values, beliefs, and practices and those of others because of strong ethnocentric tendencies (the tendency to judge others based on one’s own culture) ○ Cultural imposition: the tendency to impose one’s cultural beliefs, values, and patterns of behavior on a person or people from a different culture ○ Cultural taboos: activities or behaviors that are avoided or prohibited by a particular cultural group Culture: the knowledge, belief, morals, laws, customs, and any other capabilities and habits acquired by humans as members of society; guides thinking, doing, being, and biomes patterned expression of who that person is and becomes ● Ethnic culture ○ Learned from birth through language and socialization ○ Shared by members of the same cultural group, includes internal sense and external perception of distinctiveness ○ Influenced by specific conditions related to environmental and technical factors and to the availability of resources ○ Dynamic and ever changing ● Subculture: large groups of people who share characteristics that identify them as a distinct entity ● Minority: group of people whose physical or cultural characteristics differ from the dominant culture or majority of people in a society ● Health disparities: higher rates of morbidity, mortality, and burden of disease in a population or community than found in the overall population; significant in ethnic and racial minorities ○ Significant gap in health status between overall American population and people of specific ethnic backgrounds ○ Occur with women, LGBT, as well as people who have disabilities ○ Include higher rates of cancer, heart disease, diabetes, HIV, AIDs, and other conditions Cultural humility: addressing one’s cultural knowledge deficits by exploring the patient’s needs from the patient’s cultural perspective and exploring one’s own cultural cultural beliefs and how they might conflict with the patient's beliefs Culturally competent nursing care: effective, individualized care that demonstrates respect for the dignity, personal rights, preferences, beliefs, and practices of the person receiving care while acknowledging the biases of the caregiver and preventing these disease biases from interfering with care provided ● Incorporates delivery of interventions congruent with a given culture, care of clients with different values ● Agency policies that promote culturally competent care: developed to promote an environment in which the traditional healing, spiritual, and religious practices of patients are respected and encouraged, and to recognize the special dietary practices of patients from selected cultural groups ○ Visitation regulations ○ Translation services for non-english speaking patients ○ Dietary practices ○ Train staff to provide care for patients with different cultural values ● Transcultural assessment model (Giger and Davidhizar 2012): individual is culturally unique with different experiences, cultural beliefs, and cultural norms; identifies communication, space, time orientation, social organization, environmental control, and biologic variations as relevant phenomena ● Cross-cultural communication: occurs not only throughout words, but also body language, and other cues such as voice, tone, and loudness ○ Approx 150 different languages in the US; spanish #2 ○ Interpreters: should be professionals who are unfamiliar with the patient but fluent in language and culture ○ Signs of ineffective communication ■ Efforts to change the subject: may indicate listener is attempting to talk about something more familiar because they don't understand what was said ■ Absence of questions ■ Inappropriate laughter: disguise embarrassment around poor comprehension ■ Nonverbal cues Cultural awareness or sensitivity: awareness of cultural differences that might be present in the healthcare delivery process Culturally mediated characteristics ● Information disclosure: patients have the right to full disclosure concerning their disease and prognosis and belief that full advocacy means working to provide that king of disclosure; collaborate to reach culturally appropriate solution ● Space and distance: differs by culture; see items like wheelchairs as an extension of culture and ask for permission before entering the personal space ● Eye contact: some culture such as asians, native americans, indo-chinese, arabs, and appalachians may consider direct eye contact as impolite or aggressive and may avert their eyes as a sign of paying attention, respect, etc ● Time: punctuality and variations in the use of time are culturally determined ● Touch: central to the human communication process ○ Among many asians it is impolite to touch a person’s head because the spirit is believed to reside there ○ Same-sex exams may be a requirement for certain parts of the body ● Observance of holidays: nurse should familiarize themselves with major observances for the groups they serve; efforts should be made to accommodate them ● Diet: especially significant in patients with diabetes, hypertension, GI disorders, obesity, and other issues; varies culturally ● Biologic variations: genetic predispositions to rates of metabolism cause some patients be more prone to adverse reactions or reduced/enhanced effect to standard doses of medications Different health therapies ● Complimentary: used to supplement conventional medicine ● Alternative: used to replace conventional medicine ● Integrative: comprehensive, interdisciplinary approach to preventing and treating illness and promoting health that brings together complimentary, alternative, and conventional therapies ● National center for complementary and integrative medicine (NCCIH): nurses must be accepting of a patient’s beliefs and right to autonomy ○ Two integrative health therapy classifications ■ Natural products ■ Mind and body practices Views on illness and causes ● Biomedical or scientific: scientific worldview, embraced by most of health care professionals, cause and effect; pathogenic explanation of communicable diseases ● Natural or holistic: nature must be kept in harmony; common in Native Americans, Asians, and other cultures; breaking the laws of nature creates imbalances, chaos, and disease ○ Yin/Yang theory: belief held by many asian groups, the basis for eastern or chinese medicine; female and negative forces such as darkness, emptiness, and cols are yin; yang are positive, make, emitting warmth and fullness ; cold foods, hot foods ○ Many hispanic, african, and arab groups also embrace the hot/cold theory of illness ● Magico-religious: world is an arena in which supernatural forces dominate, fate of the world and those in it depends on the action of supernatural forces for good and evil ○ Faith healing (christian religions) ○ Voodoo, witchcraft (african and carribean cultures) Cultural nursing assessment: systematic appraisal or examination of individuals, families, groups, and communities in terms of their cultural beliefs, values and practices; assess space, social organization, time, biological variations, environmental control and communication; note whether they have assimilated or observe their own practices, incorporate into care Know thyself ● Know your own cultural attitudes, values, beliefs, and practices. ● Recognize that despite “good intentions,” everyone has cultural “baggage” that ultimately results in ethnocentrism ● Acknowledge that it is generally easier to understand those whose cultural heritage is similar to your own, while viewing those who are unlike you as strange and different. ● Maintain a broad, open attitude. Expect the unexpected. Enjoy surprises. ● Avoid seeing all people as alike—that is, avoid cultural stereotypes, such as “all Chinese like rice” or “all Italians eat spaghetti.” ● Try to understand the reasons for any behavior by discussing commonalities and differences with representatives of ethnic groups different from your own. ● If a patient has said or done something that you do not understand, ask for clarification. Be a good listener. Most patients will respond positively to questions that arise from a genuine concern for and interest in them. ● If at all possible, speak the patient’s language (even simple greetings and social courtesies are appreciated). Avoid feigning an accent or using words that are ordinarily not part of your vocabulary. ● Be yourself. There are no right ways or wrong ways to learn about cultural diversity. Future of transcultural nursing: majority-minority crossover in 2050 ● Efforts to increase minority nurses at the rate in which increasing percentage of ethnic minorities is occuring ● Culturally diverse nurses: facilitate recruitment and program completion of nursing students who are members of ethnic minorities ● Use of simulation role-play in nursing education: prepare nurses to deliver culturally competent care ● Nursing programs are exploring creative ways to promote cultural competence and humanistic care in nursing students, including offering multicultural health studies in their curricula Chapter 8: Genetics and Genomics in Nursing Human Genome Project: and international research effort aimed at identifying and characterizing the order of every base in the human genome Precision medicine: a major national initiative that supports both short-term and long-term research initiatives aimed and facilitating genetic and genomic advances in healthcare ● Goals are to further advance personalized medicine using genetic make-up or genomic profiles Nursing Competencies for genetics and genomics ● Recognition of attitudes and beliefs related to genetic and genomic science ● Advocacy for genetic and genomic services ● Incorporation of genetic and genomic technologies and information into practice ● Demonstration of personalizing genetic and genomic information and services ● Providing autonomous and informed genetic and genomic related decision making ● Role of the nurse: ○ Collect and interpret relevant family and medical histories ○ Link between patient and services, identify clients who would benefit from specific genetic services, resources, or tech; facilitate referral ○ Collaborate with specialists ○ Understand role of genetics and genomics as it relates to inheritance patterns ○ Include genomics and genetics in health assessments and in devising nursing diagnoses ○ Planning/implementing nursing interventions that are specific to the patient’s diagnosis and genetic makeup ○ Participate in management and coordination of care of patients with genetic conditions ○ Evaluating responses to medications based on pharmacogenetics Genetic mutations: changes in gene structure that permanently change the sequence of DNA; can me inherited or acquired and occur in the body often ● Single nucleotide polymorphisms (SNPs): genetic variations that occur commonly in the human genome ○ Mostly harmless, but can alter function of genes and influence disease development ● Inheritance pattern/types of genetic mutations ○ Mendelian conditions: present on one or both chromosomes of a pair, result from gene mutations ■ Classified according to pattern of inheritance ● Autosomal dominant ○ Affect male/females equally ○ Follows vertical pattern of inheritance ○ Present with variable expression ○ Penetrance: percent of people with the gene to show the trait ■ BRCA gene presence vs breast cancer incidence ● Autosomal recessive ○ Pattern is more horizontal ○ Relatives of a single generation tend to present the conditions ○ More likely to present within ethnic groups, children of related parents ○ Carriers only have one copy, do not present; have 25% chance of passing on the condition if with another carrier ● Sex-linked ○ X: recessive or dominant, if recessive all males will inherit ■ Females with one gene affected have 50% chance of passing it on to males, 50% chance of daughters being a carrier assuming partner is not ○ Multifactorial, nontraditional, and complex inheritance ■ Result from multiple gene mutations and environmental influences ● Ex: heart disease, high BP, cancer, diabetes, spina bifida, anencephaly ■ May occur more often in families but no discernable patterns ○ Chromosomal difference: major cause of birth defects, intellectual disabilities and malignancies ■ Aneuploidy: extra or missing chromosomes ● Most pregnancies will self-terminate ● Trisomy 21 ● Turner syndrome ■ Cause 50% of all spontaneous first semester losses ■ FISH detects small abnormalities and characterizes rearrangement ○ Deletions, loss, insertions, duplications, translocations of genetic segments Genetic testing is the primary tool available to identify individuals predisposed to genetic diseases ● Provides information leading to diagnosis or inherited conditions or conditions with a known genetic contribution ● Genotypic: analysis directly of chromosomes and genes ● Phenotypic: examine familial or biological presentation of the disease and include assessment of patient’s family or personal history, medical factors influencing disease, as well as testing for gene products such as proteins or diseases tissues Genetic Screenings is testing populations or groups independent of positive family history or symptom manifestation ● Aim to improve management and identification of treatable conditions that could prove dangerous to health ○ Newborn screening: PKU, congenital hypothyroidism, galactosemia ● Provides reproductive options to people with high probability of having children with severe, untreatable diseases ● Screen pregnant women to detect birth defects such as neural tube defects and down syndrome Nursing Assessment ● Ongoing ● Gathering genetic information by obtaining family and health history, conducting comprehensive physical and developmental assessments ● Physical assessment ○ Neurofibromatosis/:Café-au-lait spots as hallmark of the disease ● Psychosocial assessment ○ Educational level and understanding of the genetic condition or concern in the family ○ Desired goals or outcomes ○ Family rules regarding disclosure of information ○ Family rules, boundaries, cultural practices, and personal preference about knowing the information ○ Past coping mechanisms and social support ● Family history: ○ Assess risk ○ Decide on testing strategies ○ Establish inheritance patterns ○ Identify family members at risk ○ Identify shared environmental risks ○ Calculate total risk ○ Assess risk of passing onto children ○ Make recommendations to modify risk (treatments) ○ Make decisions about surveillance and management ○ Develop patient rapport ○ Educate patients ● Advocacy ○ Pre Counseling information ○ Prepping for evaluations of genetics ○ Communicating information ○ Providing support Ethical issues ● Patient’s right to self-determination and autonomy ● Right to privacy, confidentiality ● Risk for discrimination ○ GINA (2008): law that protects individuals from genetic discrimination ■ Prohibits health insurers from denying coverage or charging higher rates to those who are healthy but have a genetic predisposition ■ Protection around employment but not applied to employers with less than 15 employee or military, federal employees health benefits programs Genetic counseling across the lifespan ● Prenatal Issues ○ Understanding prenatal screening and diagnosis testing ○ Implications of reproductive choices ○ Potential for anxiety and emotional distress ○ Effects on partnership, family, and parental–fetal bonding ● Newborn Issues ○ Understanding newborn screening results ○ Potential for disrupted parent–newborn relationship on diagnosis of a genetic condition ○ Parental guilt ○ Implications for siblings and other family members ○ Coordination and continuity of care ● Pediatric Issues ○ Caring for children with complex medical needs ○ Coordination of care ○ Potential for impaired parent–child relationship ○ Potential for social stigmatization ● Adolescent Issues ○ Potential for impaired self-image and decreased self-esteem ○ Potential for altered perception of family ○ Implications for lifestyle and family planning ● Adult Issues ○ Potential for ambiguous test results ○ Identification of a genetic susceptibility or diagnosis without an existing cure ○ Effect on marriage, reproduction, parenting, and lifestyle ○ Potential impact on insurability and employability Chapter 9: Chronic Illness and Disability Chronic disease: noncommunicable diseases, chronic conditions, or chronic disorders ● Long term health conditions that affect one’s well-being and function in an episodic, continuous, or progressive way over many years of life ● Account for 7 of the 10 leading causes of death in the united states; responsible for ⅔ deaths globally; prevalence is increasing in lower income populations; Occur in people of every age, socioeconomic level, culture ● Chronic conditions: medical problems with associated symptoms that require long term (>3mos) management; persist for months or years ● Do not resolve or complete cures are rare, usually management for control is the only option; unlikely to resolve spontaneously ● Ex: cardiovascular diseases, cancer, diabetes, chronic lung diseases Chronic illness: the human experience of living with a chronic disease or condition ● Includes the individual’s perception and the individuals and other’s responses to it Disability: a restriction or lack of ability to perform an activity in a normal manner Multiple Chronic Conditions ● Half of all adults (117 million people) have one or more chronic health conditions; 1 in 4 have two or more ● Increase the complexity of care Increase risk for conflicting medical advice, adverse effects of medications, unnecessary and duplicative tests, preventable hospitalizations ● Cost of care increases with the number of chronic conditions Causes of increase in chronic diseases ● Decrease in mortality from infectious diseases ● Lifestyle factors: lack of exercise, poor nutrition, tobacco use, alcohol use ● Obesity ● Longer lifespans ● Improved screenings, d