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managed care
organizations
Medicaid
Medicare
morbidity
mortality
nurse-managed care
nursing team
preferred provider
organizations
primary care
primary illness
primary nursing
remission
secondary care
secondary illness
sequelae
team nursing
terminal illness
tertiary care
values
wellness
HEALTH
The World Health Organization (WHO) is globally committed to Health for All. In the preamble to its constitution, WHO defines health as a state of complete physical,
mental, and social well-being, not merely the absence of
disease or infirmity. Each person perceives and defines
health differently. Nurses must recognize the importance
of respecting such differences rather than imposing standards that may be unrealistic for the person.
CHAPTER 4
Levels of health
Good Health
Normal Health
Illness
Critical Illness
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this chapter). If all are equally deserving of health, it follows that the nation in general and nurses in particular
have a duty to protect and preserve the health of those
who may be unable to assert this right for themselves.
Death
Time span (life span)
WELLNESS
Holism
Holism (the sum of physical, emotional, social, and spiritual health) determines how whole or well a person
feels. Any change in one component, positive or negative,
Physical
Emotional
Health: A Right
The United States was established on the principle that
everyone is equal and entitled to life, liberty, and the pursuit of happiness. Based on this premise, everyone, regardless of age, gender, level of education, religion, sexual
orientation, ethnic origin, social position, or wealth, is
entitled to equal services for sustaining health. Unfortunately, as will be discussed later, health disparities exist
among various groups within the United States. These
groups include the poor, racial and ethnic minorities,
those affected by gender differences, older adults, and people with disabilities. Efforts are underway, however, to
eliminate health barriers and to promote equal access to
health care (see discussion of Healthy People 2010 later in
Social
Spiritual
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ILLNESS
Illness (a state of discomfort) results when disease, deterioration, or injury impairs a persons health. Several
terms are used commonly when referring to illnesses:
morbidity and mortality; acute, chronic, and terminal;
primary and secondary; remission and exacerbation; and
hereditary, congenital, and idiopathic.
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TABLE 4.1
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RANK
CAUSE OF DEATH
NUMBER
1
2
3
4
5
6
7
8
9
10
710,760
553,091
167,661
122,009
97,900
69,301
65,313
49,558
37,251
31,224
29.6
23.0
7.0
5.1
4.1
2.9
2.7
2.1
1.5
1.3
Source: Anderson, R. N. (2002). Deaths: Leading causes for 2000. Division of Vital Statistics, Centers for Disease Control and
Prevention, 50(16), 8.
Hereditary, Congenital,
and Idiopathic Illnesses
A hereditary condition (disorder acquired from the
genetic codes of one or both parents) may or may not produce symptoms immediately after birth. Cystic fibrosis, a
lung disease, and Huntingtons chorea, a neurologic disorder, are examples of inherited illnesses. The first is diagnosed soon after birth; the second is not manifested until
adulthood.
Congenital disorders (those present at birth but
which are the result of faulty embryonic development)
cannot be genetically predicted. Maternal illness, such as
rubella (German measles) or exposure to toxic chemicals
or drugs especially during the first 3 months of pregnancy,
often predisposes the fetus to congenital disorders. Several decades ago, many pregnant women took the drug
thalidomide and subsequently gave birth to infants with
missing arms and legs. There is a great deal of concern
about the role of alcohol in producing fetal alcohol syndrome, a permanent but preventable form of retardation,
and the effects of exposure to other environmental toxins. Although the etiologies for some congenital disorders
are well established, they can occur randomly.
An idiopathic illness is an illness whose cause is
unexplained. Treatment focuses on relieving the signs
and symptoms because the etiology is unknown. Examples of idiopathic conditions include hypertension for
which there is no known cause or a fever of undetermined origin (FUO).
The health care system (network of available health services) involves agencies and institutions where people
seek treatment for health problems or assistance with
maintaining or promoting their health. The health care
system, clients, and their diseases have drastically changed
during the past 25 years (Box 4-1). Advances in technology and discoveries in science have created more elaborate
methods of diagnosing and treating diseases, creating a
need for more specialized care. What was once a system in
which people sought medical advice and treatment from
one physician, clinic, or hospital has developed into a complex system involving primary, secondary, tertiary, and
extended care.
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BOX 4-1
Access to Care
An estimated 43.4 million U.S. citizens do not have access
to health care because of the economic burden it poses.
Another 25 million U.S. citizens have inadequate health
care coverage (U.S. Census Bureau, 1998). Groups such
as children, older adults, ethnic minorities, and the poor
are likely to be underserved. Many of these people delay
seeking early treatment for their health problems because
they cannot afford to pay for services. When an illness
becomes so severe that the only choice is to seek medical
attention, many turn to their local hospital emergency
departments for care. Inappropriate use of emergency
departments is expensive and involves long waits and
often no follow-up care.
Extended Care
Extended care (services that meet the health needs of
clients who no longer require acute hospital care) includes
rehabilitation, skilled nursing care in a persons home
or a nursing home, and hospice care for dying clients.
Extended care is an important component of the health
care system because it allows earlier discharge from sec-
CHAPTER 4
Although Medicare is primarily used by older Americans, it does not cover long-term care and limits coverage
for health promotion and illness prevention. It also does
not cover prescription medications until the new Medicare
prescription benefit goes into effect in 2006, which are significant expenses for older adults and those with chronic
illnesses. Consequently some purchase private Medigap
insurance to cover additional health-related expenses.
Medicaid (a state administered program designed to
meet the needs of low-income residents) is supported by
funds from federal, state, and local sources. Each state
determines how the funds will be spent. In general, Medicaid programs cover hospitalization, diagnostic tests,
physician visits, rehabilitation, and outpatient care. They
also may cover long-term care when a person exhausts his
or her private funds.
Managed Care
Managed care organizations (private insurers who
carefully plan and closely supervise the distribution of
their clients health care services) control costs of health
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BOX 4-2
BOX 4-3
GOALS
Increase quality and years of healthy life
Eliminate health disparities
LEADING HEALTH INDICATORS
Physical activity
Overweight and obesity
Tobacco use
Substance abuse
Mental health
Injury and violence
Environmental quality
Immunizations
Improve occupational safety and health
Access to health care
U.S. Department of Health and Human Services. (2000). Healthy people 2010.
Washington, DC: U.S. Government Printing Office.
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3. Physical
Activity
4. Nutrition
5. Sexual Health
HIV Infection
STDs
6. Unintentional Injuries
7. Tobacco
8. Substance Abuse
1. Mental and
Physical Impairment
and Disability
2. Chronic Diseases
Heart Diseases
Cancer
Stroke
Lung Disease
Diabetes
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ELIMINATE
HEALTH
DISPARITIES
INCREASE
QUALITY AND YEARS
OF HEALTHY LIFE
FOCUS AREAS
SPECIAL POPULATIONS*
Low Income
Race/Ethnicity
Gender
Age
People with Disabilities
FOCUS AREAS
* Special population groups need to be
considered as objectives are developed
in all focus areas.
NURSING TEAM
Licensed
Practical/
Vocational
Nurse
Registered
Nurse
Functional Nursing
The Client
and
Family
Nursing
Assistant
Nursing
Students
Nursing
Volunteer
types of professionals as well as allied health care workers with special training such as respiratory therapists,
physical therapists, and technicians.
Nurses use their unique skills in the hospital as well
as other employment areas. Because they have skills that
assist the healthy, the dying, and all in between, nurses
work in various settings such as health maintenance
organizations, physical fitness centers, diet clinics, public health departments, home health agencies, and hospices. Wherever nursing personnel work together, they
use one of several patterns for managing client care. The
five common management patterns are functional nursing, case method, team nursing, primary nursing, and
nurse-managed care. Each has advantages and disadvantages. Students are likely to encounter one or all of these
methods in their clinical experience.
One method used when providing client care is functional nursing (pattern in which each nurse on a client
unit is assigned specific tasks). For example, one is
assigned to give all the medications, another performs all
the treatments (such as dressing changes), and another
works at the desk transcribing physicians orders and
communicating with other nursing departments about
client care issues. This pattern is being used less often
because its focus tends to be more on completing the task
rather than caring for individual clients.
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Case Method
The case method (pattern in which one nurse manages
all the care a client needs for a designated period of time)
should not be confused with managed care, which is discussed later. The case method is most often used in home
health and public health nursing.
Team Nursing
Team nursing (pattern in which nursing personnel
divide the clients into groups and complete their care
together) is organized and directed by a nurse called the
team leader. The leader may assist with but usually supervises the care that other team members provide. All team
members report the outcomes of their care to the team
leader. The team leader is responsible for evaluating if the
goals of client care are met.
Conferences are an important part of team nursing.
They may cover a variety of subjects but are planned
with certain goals in mind such as determining the best
approaches to each clients health problems, increasing the
team members knowledge, and promoting a cooperative
spirit among nursing personnel.
Primary Nursing
In primary nursing (pattern in which the admitting
nurse assumes responsibility for planning client care and
evaluating the clients progress), the primary nurse may
delegate the clients care to someone else in his or her
absence but is consulted when new problems develop or
the plan of care requires modifications. The primary nurse
remains responsible and accountable for specific clients
until they are discharged.
Nurse-Managed Care
A new type of nursing-care delivery system is being
implemented in several areas of the United States. It is
called nurse-managed care (pattern in which a nurse
manager plans the nursing care of clients based on their
type of case or medical diagnosis) by some and case management by others. A clinical pathway typically is used
in a managed care approach (see Chap. 1 for more information on managed care and an example of a clinical
pathway).
This innovative system was developed in response to
several problems affecting health care delivery today such
as the nursing shortage and the need to balance the costs
of medical care with limited reimbursement systems.
Nurse-managed care is similar to the principles used by
successful businesses. In the business world, corporations
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