Clark Ch27 Lecture

Population and Community
Health Nursing
SIXTH EDITION
CHAPTER
27
Chronic Physical
Health Problems
Population and Community Health Nursing, Sixth Edition

Mary Jo Clark
Copyright 2015, 2008

Pearson Education, Inc. All Rights Reserved
Current Statistics
Largely replaced communicable
diseases as the leading causes of death
and disability in the United States and
elsewhere in the world
An estimated 145 million people in the
United States, half of the total
population, experience at least one
chronic condition
continued on next slide
Mary Jo Clark

Current Statistics
Globally, noncommunicable conditions
account for 63%

Mary Jo Clark

Chronic Disease
Chronic conditions include diseases,
injuries with lasting consequences, and
other enduring abnormalities
Chronic health problems may be either
physical or emotional

Mary Jo Clark

Goals of Chronic Disease: Prevention

and Control
Reducing incidence in the population
Delaying onset or development of
resulting functional disability
Alleviating suffering and improving the
quality and length of life

Mary Jo Clark

National and International Deficiencies for

Chronic Disease Control Efforts
Failure to use established practice
guidelines for the prevention and
treatment of chronic conditions
Lack of coordination of care
Lack of active follow-up to determine
the effects of care

Mary Jo Clark

National and International Deficiencies for

Chronic Disease Control Efforts
Inadequate education of the public and
those affected relative to prevention
and self-management of chronic health
problems

Mary Jo Clark

Individual, Family, and Societal Effects of

Chronic Physical Health Problems
Chronic health problems can arise from
a variety of sources
Congenital
Serious accident
Disease

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Individual Effects: Long-term

Consequences of Disease and Injury
Pain and suffering

Hospitalization
Disability
Diminished quality of life

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Pain
Approximately 100 million Americans
experience chronic pain; annual cost to
the United States society of $560 to
$635 million
Physical and physiologic effects
Psychological and cognitive effects
Significant contributor to poor quality of
life
Depression and possible suicide
Mary Jo Clark

WHO: Dimensions of Disability

Impairment of bodily structure or
function
Activity limitations
Consequent restrictions in participation
in normal daily activities

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Disabled Persons
An estimated 16% of U.S. adults (37.5
million people) have some form of
disability
43% experience more than one
functional limitation

Mary Jo Clark

Call to Action to Improve the Health and

Wellness of Persons with Disabilities
Promote public understanding of
disability and the capabilities of persons
with disability
Increase the capability of health care
providers to provide holistic care to
persons with disabilities

Mary Jo Clark

Call to Action to Improve the Health and

Wellness of Persons with Disabilities
Assist persons with disabilities to
promote their own health
Enhance access to the care and
services required to promote
independence among those with
disabilities (Office of the Surgeon
General, 2005)

Mary Jo Clark

David L. Bazelon Center for Mental

Health Law
A set of principles for societal
integration of people with disabilities
include:
Opportunities to live like others with
respect to residence, employment, and
social interactions
Control over their own lives and daily
schedules
Control over where and how they live
Mary Jo Clark


Health Law
A set of principles for societal
integration of people with disabilities
include:
Employment in nonsegregated
workplaces with access to supports
necessary to promote productivity
Independent housing other than group
homes
Opportunities to make informed choices
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Health Law
Government funding to support
implementation of the principles

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Health Law
Family Effects
May no longer be able to fulfill normal
family roles
Necessitating role reallocation
Possible role overload for other family
members
Affects relationships among family

members
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Health Law
Changes in self-image and anger for
the member with a chronic disease
Increases stress for other family
members
Entails considerable financial burden

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Societal Effects: Financial Costs

$400 billion in health care costs alone
Direct medical costs of care
Indirect medical costs (e.g., home
modification, special education)
Other indirect costs such as productivity
losses due to the inability to work

Mary Jo Clark

Societal Effects: Financial Costs

$400 billion in health care costs alone
Limitations on work ability
Premature death
Lost productivity may also apply to
family caretakers

Mary Jo Clark

Morbidity and Mortality:

Prevalence Figures
Probably grossly underrepresent the
extent of conditions in the U.S.
population
About half of all Americans are dealing
with some form of chronic condition in
themselves or a family member
12% of U.S. children have special care
needs
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Prevalence Figures
population
23% of those children experience
significant effects of their conditions
Approximately one-third of Americans
have hypertension

Mary Jo Clark


Prevalence Figures
population
Over 6.2 million people in the United
States have experienced a stroke
26 million people in the United States
had diabetes; another 79 million were
prediabetics in 2010
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Prevalence Figures
population
Cancer incidence across all types of
cancers was 443.1 per 100,000
population in 2010
Asthma affects about 25.7 million adults
and children in the United States
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Prevalence Figures
population
COPD is the third leading cause of death
in the United States; affects 5.1% of the
adult population
Arthritis contributes to nearly a quarter
of disability in older people
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Prevalence Figures
population
An estimated 1 in 26 people will develop
epilepsy at some point in their lives
An estimated 26 million people have
chronic kidney disease; millions more at
risk
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Prevalence Figures
population
Diabetes and hypertension are major
risk factors for CKD
Accidental injuries

Mary Jo Clark

Assessing Risks for and Effects

of Chronic Physical Health
Problems

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Biological Determinants
Age, Gender, and Race/Ethnicity
Genetic Inheritance
Physiologic Function

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Assessing Biological Determinants Affecting

Chronic Physical Health

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Psychological Determinants
Stress
Poor mental health (depression and
anxiety)
Mental health status affects:
Treatment and control of chronic health
problems
Engagement in risk behaviors or

adherence with treatment regimens
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Psychological Determinants
Social resistance
Psychological distress exacerbates
symptoms among people who have:
Asthma, Alzheimer disease, traumatic
brain injury

Mary Jo Clark

Assessing Psychological Determinants Affecting


Mary Jo Clark

Environmental Determinants
Occupational illness
Lead exposure
Urban and rural differences
Long-term sequelae of accidents,
cancer, and COPD
Road conditions, weather, dangerous
conditions for swimming
Physical safety hazards

Mary Jo Clark

Environmental Determinants
Pollutants
House dust, mites, molds, tobacco
smoke, and occupational exposures to
respiratory irritants
Global climate changes
Environmental justice in low-income
neighborhoods
Disablement process
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Assessing Environmental Determinants

Affecting Chronic Physical Health

Mary Jo Clark

Sociocultural Determinants
Policy issues
Income and employment
Discrimination, stigma, and social
isolation
Social marketing
Cultural factors

Mary Jo Clark

Assessing Sociocultural Determinants Affecting


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Behavioral Determinants
Tobacco use
Alcohol use
Physical activity
Nutrition
Other behavioral factors

Mary Jo Clark

Assessing Behavioral Determinants Affecting


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Health System Determinants
Health system capacity

Access to care
Lack of preventive focus
Evidence-based practice
Clientprovider relationships

Mary Jo Clark

Assessing Health System Determinants

Affecting Chronic Physical Health

Mary Jo Clark

Diagnostic Reasoning and Control of

Chronic Physical Health Problems
Diagnoses are derived from:
Information collected relative to the
incidence and prevalence of chronic
health problems in the population
Factors contributing to these conditions
May relate to individual clients or to the
general population

Mary Jo Clark

Planning and Implementing Control Strategies

for Chronic Physical Health Problems
Based on the understanding of
contributing factors derived from the
assessment
Particularly important to involve client,
family, community in planning solutions

Mary Jo Clark

Planning and Implementing Control Strategies

for Chronic Physical Health Problems
Presence of a chronic health problem
affects many facets of life
CDC's Healthy Communities Program
Assist local communities to reduce risk
factors for chronic diseases and attain
health equity within the population

Mary Jo Clark

The Chronic Care Model

Delineate the elements of high-quality
chronic disease care
Foster effective interaction between
informed clients and providers with the
needed expertise to address chronic
health issues

Mary Jo Clark

The Chronic Care Model

A health system designed around this
model will engage in effective care for
chronic illness control at all four levels
of health care delivery

Mary Jo Clark

Health Promotion
Focus on diet, exercise, and coping
skills
Access to healthy foods
Physical activity
Exercise
Teaching general coping skills
Technology (Internet for information
related to health)
Mary Jo Clark

Political Advocacy
Educational interventions aimed at
informing health policy maker
Promoting legislative and regulatory
strategies to control chronic illness in
the population
Focus on measures to foster access to
health promotion services

Mary Jo Clark

Political Advocacy
Create a healthful environment
Planning strategies to influence health
policy making

Mary Jo Clark

WHO "Best Buy" Prevention Strategies for

Noncommunicable Diseases
Protection from second-hand smoke
and development of smoking bans
Education on the dangers of tobacco
use
Banning tobacco advertising,
promotion, and sponsorship

Mary Jo Clark


Increasing tobacco taxes
Restricting access to retail alcohol
Instituting bans on alcohol advertising

Mary Jo Clark


Increasing alcohol taxes
Reducing salt intake and sodium
content in foods
Replacing trans fats with
polyunsaturated fats
Immunization for hepatitis and HPV
(WHO, 2011)

Mary Jo Clark

National Prevention Council: National

Prevention Strategy (2011)
Increase the number of people who are
healthy at every stage of their lives
Encompasses four strategic directions
and seven priorities

Mary Jo Clark


Strategic directions
Healthy and safe community
environments
Provision of clinical services
Community preventive services
Empowerment of people for healthful
living
Elimination of health disparities among
segments of the population
Mary Jo Clark


The seven priorities for action
Promoting tobacco-free living
Preventing drug abuse and excessive
alcohol use
Promoting healthy eating and active
living
Promoting injury and violence-free living
Reproductive and sexual health
Mental and emotional well-being
Mary Jo Clark

Preventing Obesity
Dietary changes, weight loss, and
moderate physical activity
Increasing food taxes (nutrient taxes
and category taxes)
Development of modified food products
Specific programs for reducing or
preventing obesity

Mary Jo Clark

Smoking Cessation Assistance
Increasing tobacco prices

Graphic media campaigns
Smoke-free laws
Barrier-free access to cessation
assistance

Mary Jo Clark

Smoking Cessation Assistance
Mass-reach health communications

Quitlines
Medications
Tailored interventions

Mary Jo Clark

Smoking Cessation Assistance: Population

Health Nurse Strategies
Provide tobacco cessation counseling or
in referring clients for cessation
services
Advocate for insurance coverage of
cessation services
Inclusion of free medication in
conjunction with existing tobacco
quitlines
Mary Jo Clark

Smoking Cessation Assistance: Population

Health Nurse Strategies
Involved in the development of mass
media campaigns
Involved in political activity to limit
smoking

Mary Jo Clark

Preventing Cardiovascular Disease

A priority in the United States
National programs to promote a
"healthy heart"
Million Hearts Initiative
Healthy Heart, Healthy Family
CPSTF (2013b)
Recommended reducing out-of-pocket
costs for treatment for hypertension and
hypercholesterolemia
Mary Jo Clark

Injury Prevention and Other

Prevention Strategies
Home and in occupational settings
"Click It or Ticket" campaign
Use of safety devices and other safety
precautions
Modifications of environmental
conditions

Mary Jo Clark

Injury Prevention and Other

Prevention Strategies
Clean-air legislation
Control of radon emissions and air
pollution
Selected immunizations
Innovative strategies (radio novella
series: "Promesas y Traiciones")

Mary Jo Clark

Screening and Surveillance

Screening is the first step in early
diagnosis of many chronic health
problems
Perform periodic health examinations
Periodically screen for chronic disease

Mary Jo Clark

WHO: Essential Components of

Noncommunicable Disease Surveillance
Monitoring exposures and risk factor
prevalence
Monitoring disease outcomes (e.g.,
morbidity and mortality)

Mary Jo Clark

WHO: Essential Components of

Noncommunicable Disease Surveillance
Monitoring health system response
WHO report
These components are lacking in most
national health information systems
Should be integrated into existing
systems

Mary Jo Clark

Screening and Surveillance: Population

Health Nurse Interventions
Educate public about need for health
examinations
Provide periodic examination
Educate public about need for periodic
screening
Plan and implement screening
programs for high-risk groups

Mary Jo Clark

Early Diagnosis
Effects can be minimized when they are
diagnosed and treated early in the
course of the disease

Mary Jo Clark

Early Diagnosis: Population Health Nurse

Interventions
Educate public about warning signs and
symptoms of chronic disease
Engage in case finding and refer for
diagnosis as appropriate
Prepare client for diagnostic procedures
(physically and emotionally)
Conduct diagnostic tests as appropriate

Mary Jo Clark

Prompt Treatment: Population Health

Nurse Interventions
Stabilize condition as soon as possible
Establish treatment regimen
Medication
Radiation
Chemotherapy
Surgery

Mary Jo Clark


Nurse Interventions
Provide evidence-based disease
management
Promote and support self-management
Prevent disease progression

Mary Jo Clark


Nurse Interventions
Assist with management of chronic
disease
Provide emergency care as needed
Educate public to provide emergency
care (CPR)
Refer for further treatment

Mary Jo Clark


Nurse Interventions
Prepare client for treatment procedures
(physically and emotionally)
Carry out treatment regimen
Provide supportive measures during
treatment (relief of pain)

Mary Jo Clark


Nurse Interventions
Educate clients about medications:
dosage, side effects, etc.
Encourage client compliance with
treatment
Educate providers for evidence-based
disease management
Disseminate evidence-based clinical
guidelines
Mary Jo Clark


Nurse Interventions
Advocate for pay-for-performance
reimbursement mechanisms
Educate and motivate clients for selfmanagement
Monitor therapeutic effects of treatment
Monitor side effects
Refer for follow-up as needed

Mary Jo Clark

Health Restoration
Promote the client's optimal level of
function despite the presence of a
chronic health problem

Mary Jo Clark

Preventing Loss of Function in

Affected Systems
Activities may be planned to minimize
losses or to eliminate risk factors that
might lead to adverse consequences of
the condition
Pain management

Mary Jo Clark


Unaffected Systems
Interventions directed toward
preventing both physical and social
disability
Breathing exercises
Providing good skin care
Teaching foot care
Managing fatigue

Mary Jo Clark


Unaffected Systems
disability
Immunization (some conditions)
Social disability
Encouraging clients to interact with
others
Assisting clients to maintain their
independence as much as possible
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Unaffected Systems
disability
Assisting with necessary role changes
within the family
Referring the client to appropriate selfhelp groups

Mary Jo Clark

Preventing Loss of Function in Unaffected

Systems: Aggregate Level
Advocate for and engage in political
activities to assure access to services
Develop positive attitudes to persons
with chronic or disabling conditions
Navigation services (clients with cancer)

Mary Jo Clark

Restoring Function
Assist with planning and
implementation of programs to regain
function
Bowel training, physical therapy
Teach client and others to carry out

program and evaluate effects

Mary Jo Clark

Promoting Adjustment
Changes in lifestyle necessitated by the
illness
Diet, activity patterns, restrictions (e.g.,
limiting alcohol use or caloric intake)
need to take medications
Some diseases necessitate learning

special skills
Adjustment in the work setting
Mary Jo Clark

Promoting Adjustment
Psychological adjustments
Self-esteem
Loss of independence also necessitates
adjustments in one's sense of control
Intimacy
Stigma
Caregiver burden

Mary Jo Clark

Goals of Pain Management

Preventing pain whenever possible
Reducing the severity or frequency of
pain
Improving physical function
Reducing psychological distress
Improving the overall quality of life

Mary Jo Clark

Survivorship Care
Provide assistance in dealing with
psychosocial effects of diagnosis
Give care to clients who survive lifethreatening conditions including
families, friends, and caregivers also
affected by the condition

Mary Jo Clark

Survivorship Care
Address psychological issues of anxiety
and depression
Provide special nutritional needs (if
needed)
Be aware of increased susceptibility to
infection

Mary Jo Clark

Survivorship Care
Identify survivorship care needs
Participate in developing a survivorship
Refer clients and families for
survivorship care services as needed
Advocate for insurance coverage of
survivorship care
Conduct research to identify care needs
and best practices in survivorship care
Mary Jo Clark

Palliative and End-of-life Care

Provide end-of-life care
Provide pain management

Provide comfort care
Provide palliative care
Encourage advance directives
Refer to hospice services as needed

Mary Jo Clark

Evaluating Control Strategies for Chronic

Physical Health Problems
Individual client
Status of the chronic condition and
client's adjustment
If interventions have been effective, the
condition will be controlled or may even
be improving

Mary Jo Clark


Individual client
Failing improvement: the condition will
provide the least disruption possible to
client and others
Criteria reflect both the client's
physiologic status and his or her quality
of life

Mary Jo Clark


Community or population level
Changes in morbidity and mortality
figures
Attempt other control strategies or to
continue with current measures
Healthy People 2020

Mary Jo Clark


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Population and Community

Population and Community Health Nursing, Sixth Edition

Copyright 2015, 2008

Copyright 2015, 2008

Population and Community Health Nursing, Sixth Edition

Copyright 2015, 2008

Population and Community Health Nursing, Sixth Edition

Copyright 2015, 2008

Goals of Chronic Disease: Prevention

Population and Community Health Nursing, Sixth Edition

Copyright 2015, 2008

National and International Deficiencies for

continued on next slide

Copyright 2015, 2008

National and International Deficiencies for

Population and Community Health Nursing, Sixth Edition

Copyright 2015, 2008

Individual, Family, and Societal Effects of

Population and Community Health Nursing, Sixth Edition

Copyright 2015, 2008

Individual Effects: Long-term

Pain and suffering

Population and Community Health Nursing, Sixth Edition

Copyright 2015, 2008

Copyright 2015, 2008

WHO: Dimensions of Disability

Population and Community Health Nursing, Sixth Edition

Copyright 2015, 2008

Population and Community Health Nursing, Sixth Edition

Copyright 2015, 2008

Call to Action to Improve the Health and

continued on next slide

Copyright 2015, 2008

Call to Action to Improve the Health and

Population and Community Health Nursing, Sixth Edition

Copyright 2015, 2008

David L. Bazelon Center for Mental

Copyright 2015, 2008

David L. Bazelon Center for Mental

Copyright 2015, 2008

David L. Bazelon Center for Mental

continued on next slide

Copyright 2015, 2008

David L. Bazelon Center for Mental

Affects relationships among family

Copyright 2015, 2008

David L. Bazelon Center for Mental

Population and Community Health Nursing, Sixth Edition

Copyright 2015, 2008

Societal Effects: Financial Costs

continued on next slide

Copyright 2015, 2008

Societal Effects: Financial Costs

Population and Community Health Nursing, Sixth Edition

Copyright 2015, 2008

Morbidity and Mortality:

Copyright 2015, 2008

Morbidity and Mortality:

continued on next slide

Copyright 2015, 2008

Morbidity and Mortality:

Copyright 2015, 2008

Morbidity and Mortality:

Copyright 2015, 2008