Mary McCarthy is an 86-year-old widow with hypertension and heart failure NYHA Class III who was admitted after she slipped stepping out of the bathtub, hit her head on the sink, and fell to the floor, fracturing her right wrist. The patient has 2 adult children, a daughter who lives 2400 miles away and can’t afford to visit and a son who lives nearby but contacts her only occasionally and very briefly. Unbeknown to her children, Mrs McCarthy’s mobility is now limited to a few steps because of advanced osteoarthritis; her visual acuity has diminished owing to cataracts; her meals consist chiefly of cereal and the few foods in containers that she can open; and her cognitive function has eroded to where she often fails to take her medications, to make regular medical appointments, and to recognize her accumulating functional deficits. Now that she is cleared for discharge and her son arrives to drive her to her apartment, how well do you anticipate Mrs McCarthy will care for herself at home?
This issue of Critical Care Nurse highlights the concerns of monitoring and neuro-trauma. As every critical care nurse knows, an essential aspect of care for any acutely ill or injured patient—particularly one suffering from neurologic trauma—entails close, continuous assessment of numerous clinical parameters. In addition to patients with known neurologic deficits, however, many other critical care patients incur perhaps less dramatic, but still noteworthy impairments that have the potential to prolong, impede, complicate or completely preclude their ability to fully recover. As long as these patients are hospitalized, their limited abilities to take care of themselves at home may not be recognized. For some, those impediments may be apparent only after they are prematurely readmitted in a deteriorated state rather than in the stage of recovery they should have attained.
This editorial is a call to all acute care, progressive care, and critical care nurses to expand their patient assessments to encompass parameters that reflect the patient’s capacity for self-care once discharged to home. Some of the issues that need to be considered in this effort include clarifying what constitutes self-care, identifying factors that may affect self-care, recognizing patients at risk for self-care deficits, and specifying the clinical parameters to include in an assessment of self-care capacity. Examples will focus on 2 prevalent critical care patient groups: the elderly and those with heart failure (HF).
Description and Scope of Self-Care
Orem’s1 theory of nursing, often characterized as the self-care deficit nursing theory,2 describes self-care as comprising all of the voluntary activities that individuals undertake in order to maintain their health, life, and general well-being. For healthy individuals, self-care encompasses eating a balanced diet, exercising regularly, getting adequate sleep, and avoiding high-risk behaviors such as smoking. When individuals become critically ill or injured, however, the potential scope of self-care activities they may need to assume after hospital discharge could expand far beyond taking prescribed medications to sampling and interpreting their own blood or urinary laboratory values, changing dressings, administering parenteral nutrition, monitoring and adjusting fluid and dietary intake and output, and suctioning their airway. In addition, a patient’s willingness and ability to participate to this degree of self-care may represent an imperative rather than an option for avoiding unnecessary readmissions, preventing life-threatening complications, and succumbing to their diagnosis.
Factors That May Affect Self-Care
A patient’s ability to manage his/her own health, that is, to maintain a healthy state, to recover fully from an injury or illness, or to regain as optimal a level of function as possible, depends on numerous interrelated factors. Orem1 referred to these influences as basic conditioning factors: age, developmental state, environment, family system, gender, health care system, health status, pattern of living, resource availability and adequacy, and sociocultural beliefs.
When health changes occur, the ability to make necessary adaptations to those changes is influenced by a wide range of variables that include understanding the changes necessary, the readiness and motivation to change, and the motor and sensory abilities to execute those activities.3 In patients with HF, researchers found that although many patients indicate a readiness for instituting changes in self-care behaviors, their compliance with those behaviors is negatively influenced by deficiencies in knowledge about HF self-care.4 Among HF patients, the self-care behaviors least often performed include symptom monitoring such as daily weights, symptom management such as adjusting fluid intake, and symptom reporting to health care professionals. Actual performance of self-care behaviors was subject to factors as diverse as age, race, gender, income, living conditions, and symptom severity in addition to knowledge of self-care for HF.5 These potential influences may be focused by considering some identifiable patient attributes that heighten risk for diminished self-care.
Risk Factors for Diminished Self-Care Capacity
Much of the research related to self-care centers on targeted populations such as geriatric patients and those with HF. In its standard for assessment of hospitalized older adults, the Hartford Institute of Geriatric Nursing3 identifies the following coexisting conditions as risk factors for functional decline: acute illness or injuries, altered environment, altered routines, depression, limited mobility, malnutrition, pain, prolonged bedrest, prolonged use of Foley catheters, and side effects of medications. Many of these risk factors are experienced by HF patients (eg, use of medications with significant side effects, limited mobility, depression, cardiac cachexia). More specifically, Riegel et al6 found that poor self-care in HF patients is associated with the following factors: lack of knowledge regarding necessary self-care, misconceptions about the disorder, excessive daytime sleepiness, depression, poor family dynamics, and impaired cognition. Cameron et al7 found that even a mild degree of cognitive impairment represented one of the single most influential contributors to diminished capacity for self-care.
Some risk factors were more clearly discerned when researchers asked HF patients why they did not respond when significant symptoms first appeared; that telling list of risk factors encompassed8 :
Weak motivation, due to either insufficient patient education or motivation not strong enough to overcome other barriers to self-care
Lack of knowledge regarding self-care activities
Inability to recognize the significance of specific symptoms
Misinterpretation of symptoms
Inability to link behaviors (eg, failure to take medications) with consequences
Inability to recognize the significance of clusters of symptoms related to comorbidities
Other barriers such as fear and stress that predominated over facilitators of self-care
So, in addition to anticipated risk factors such as a lack of mobility or nearby support systems from family or friends, numerous other personal and situational influences may converge as obstacles along the patient’s path to successful self-care at home.
Parameters to Assess to Estimate Self-Care Capacity
When so many diverse influences need to be considered to gauge whether patients will be able to complete the necessary self-care activities, it becomes a challenge to distill these considerations into a list sufficiently inclusive yet as brief as possible to make its utility feasible for busy critical care nurses. With these prerequisites in mind, I have drafted a single-page checklist of parameters identified in the literature as relevant to self-care capacity. The activities in this checklist (see Figure) cluster around universal aspects of self-care and others common and specific to geriatric and HF populations. When the patient needs assistance by another person, the checklist provides a location for identifying who will be lending that support. Please feel free to use and/or improve upon this checklist, as your patients’ needs dictate.
A critical care patient’s recovery from life-threatening illness or injury is often contingent upon his/her ability to follow through—first with learning and then consistently completing an array of self-care measures designed to sustain and regain health. As acute care facilities continue to abbreviate patient lengths of stay, a patient’s readiness to be his/her own caregiver is reduced and so is the time available for providing the instruction, practice, and support needed to acquire competency in managing one’s own care. Although critical care nurses cannot unlock those constraints, one intervention we could contribute toward continued recovery after discharge is to estimate the patient’s capacity for self-care and identify the source that will be tapped for any needed support.
Some declines in a patient’s self-care capacity are inevitable, yet others may be mitigated by a combination of nursing anticipation, targeted assessment, prompt recognition, preplanning, and aggressive intervention. Once the outcomes of this appraisal are determined, critical care nurses can collaborate on devising strategies to maximize the patient’s self-care capabilities and ensure that recognized deficiencies are attended to by health care staff, family, or friends, as appropriate and available. This is hardly a definitive fix for the challenge of self-care deficits, but it could represent at least a worthwhile step in that direction.