Sunday, December 14, 2008

health and illness

INTRODUCTION

Mind and body go together ,move together, get well together and got sick together.

Through out history, philosophers and scientists have debated the nature of the relationship between mind and body. There is now a renewed interest in holistic health practices ,based on idea that mental processes influence physical well being and vice versa. Research is identifying the links between thoughts feelings and body functioning. Many believe that all illness have psycho physiological component. Physical disorders have a psychological component and mental disorders a physical one.

Illness is never an isolated event. The client and family must deal with changes resulting from illness and treatment. Each client responds uniquely to illness and therefore nursing interventions must be individualized. The client and family commonly experiences psychological changes ,environment, personal behaviours and psychosocial factors play an interactive role of illness and health. Being hospitalised for any illness or injury can create emotional problems and unacceptable behaviour in patients who, under trying circumstances are mentally sound and emotionally mature.

II. HEALTH

“Health is a state of complete physical, mental and social wellbeing and not merely absence of disease or infirmity” ( W.H.O 1946)

“Health means being well and using powers to the fullest extent. Disease is reparative process nature institutes because of some want of attention”
( Florence Nightingale)
III.ILLNESS
“Illness is a state in which a persons physical, social, developmental, or spiritual functioning is diminished or impaired compared with previous experience”
(Potter and Perry )
“Illness is the human experiences of disease”
( Kniesal and Ames -1986)
IV. PSYCHOLOGICAL CONSEQUENCES

Illness is defined as an absence of health or deteriorated rhythm of life ,diminished coping, an unsuccessful adjustment to life and a loss of the sense of well being and vitality .Most people perceive illness as threatening. Illness may impose necessary changes on the individuals life style. The common psychological consequences of illness is:-
Ø Uncooperativeness
Ø Gets too personal self centeredness
Ø Illness with negative process
Ø Dependent
Ø Demanding
Ø Hostility
Ø Ambivalence
Ø Aggression
Ø Paranoid
Ø Sense of shame
Ø Guilt ,fear, anxiety, regression etc.

A] UNCO-OPERATIVENESS
Individuals react to illness in many different ways. Some patients show reluctance and uncooperativeness towards health care. Co-operation is a subject of concern to most health professionals who work with ill patients. It means consciously carrying out duties ,taking medications as ordered and modifying life activities as adviced.Although uncooperativeness can result from lack of knowledge. ,simple forgetting may cause uncooperativeness on the part of someone with the best of knowledge and indecision. Sometimes exercise are omitted because as individual is busy or is unwilling to take time for them .Some times a person omits a prescribed care because of a wish ,feel normal and not different .Some therapies recommended are very expensive and the person may not have financial resources for them. Some times patients do not co-operate with the family members showing withdrawal and rejects and care and do the reverse of what is asked to do.
Research says that adopting appropriate health related behaviour is the result of three sets of beliefs, The first set comprises belief about the seventy of the diseases or its complicatory and effect on daily living. Secondly the set is composed of the persons beliefs about her own ability to perform the prescribed behaviour. Then thirdly beliefs related to their perception of the benefits that will occur from the prescribed health.
2] GETS TOO PERSONAL SELF CENTEREDNESS
During the second stage of illness patients are concerned about their survival and the effect of the disease in their lives. As a result their lives. As a result their behaviours are very self cantered .These behaviours are considered as adaptive for this stage of illness and are characterised by
1)Egocentricity
Patients become very subjective and judge everything in relation to him or her. If the nurse frowns or yarns while talking to the patient ,the patient thinks that the nurse doesn’t like him or her or knows some bad news about the patients condition. When people are talking in the hall ,the patient is sure that they are talking about him or her.
2) constriction of interest
This occurs because patients main concern is oneself and what is happening to ones body or going on in one’s room or in the immediate environment .At this time , one’s energies are diverted to trying to overcome the problems associated with the disease or medical condition and are not available for divers ional activities. some people may watch TV, read a paper or glance at a book but their span of attention is short. Their interest is minimal and the content is quickly forget.
3) Emotional dependency
The dependency creates feelings of ambiance in which one likes and appreciates the assistance that one is getting and at the same time resents the condition and need for the assistance.
4)Hypochondria sis
Means intense anxiety about the usual and normal functions of the body. When sick and anxious about recovering, the patient focuses attention on factors that he or she had previously noticed.

3] ILLNESS WITH NEGATIVE PROCESS
Every person responds to the threat of illness in a unique and special way. Illness may bring about the necessary changes in an individuals life style . Illness causes one to feel alone in facing ones problems.
Clients who have a progressive or terminal illness with little or no hope of recovery face continual change or loss. The client may be overwhelmed by illness related physical or neurological problems or by needs for care or limitations of self care ability. Roles and relationships may change and other people in the clients life may be uncomfortable or withdrawn from client.

Nursing care:-
Initial goal focus on ensuring that the client is safe and his or her physiological needs are met diminishing depressive or withdrawn behaviour.
1. Anticipatory grieving related to potential loss of health,abilities,or life.
Objective:- The client will demonstrate decreased suicidal ,withdrawn or depressive symptoms
- approach client and initiate interactions
- approach the client in a non-judgemental way
- as a client tolerates encourage discussion of the illness
- encourage the client to verbalize the feelings
2. Hopelessness related to depression
Objective;- The client demonstrates decreased suicidal , withdrawn or depressive symptoms
- assess the clients suicidal potentials
- encourage the client to express his feelings
- help the client to identify the resources
- encourage the client to be as independent as possible in self care activities.

4] DEPENDENT CLIENT

The individual develops from a child into an adult he is learning to become progressively more independent ,with an innate tendency to strive towards greater independence. Dependence is seen in every aspect of nature. likewise every human being is dependent on someone for some reasons. No person ever becomes entirely independent .In illness also the client depends on healthcare professionals for the relief of symptoms. The client accepts sympathy ,care, and protection. The more ill the client the more they are excused from responsibilities. The client may require assistance from others to meet basic human needs of daily living and may need emotional support.
As the patient recovers from his illness he needs to regain his independence gradually. He requires encouragement from nursing staff. This behaviour becomes maladaptive when the client does not becomes independent even though his condition does not require total care. They show extreme dependence on other people particularly need to be taken care of. They are often pre occupied with a fear of being left to take care of themselves.
Nursing care:-
Nursing goals with dependent clients include fostering the development of basic skills and confidence in the clients own abilities .Using limit setting and communicating clear, consistent expectation of the client can be useful.
1. Ineffective individual coping related to inadequate skills for daily living or next changes crisis
Objective:-The client will demonstrates decreased ,manipulative, attention seeking behaviour
-Assess the clients immediate environment and hospital room for potentially dangerous objects.
- Teach the client needed social skills
- Encourage the client to take direct action to meet personal needs
2. Powerlessness related to dependence on others to meet needs
Objectives:- The client will identify present skills and level of functioning
- Encourage the client ventilate feelings
- Encourage the client to share feelings with other clients
- Begin with a interview and works towards the goal of the clients discharge and independence from the hospital
5] DEMANDING CLIENT
The term demanding client refers to the client who puts a very firm and forceful request for something or it is a desire of the consumers for a particular product or service.
Examples:-
a) Antisocial personality disorder
It is a pattern of socially irresponsible, exploitative and guiltless behaviour that reflects a disregard for the rights of others .These individuals exploit and manipulate others for personal gain.

b) Histrionic personality disorders
It is characterised by colourful, dramatic and extroverted behaviour is excitable ,emotional people. They have difficulty maintaining long lasting relationships, although they require constant affirmation of approval and acceptance from others.

c) Narcissistic personality disorders
Person with narcissistic personality disorder have an exaggerated sense of self worth. They lack empathy and are hypertensive to the evaluation of others. They believe that they have the inalienable right to receive special consideration and that desire is sufficient justification for possessing whatever they seek.



6] HOSTILITY

Hostility is a hostile behaviour is characterised by verbal abuse ,threatened aggressive or violent behaviour,un co-operativeness and the therapeutic milieu, behaviours that have been defined as undesirable, unacceptable or in violation of established limits.
Hostility is a multidimensional construct that is thought to have cognitive, affective, and behavioural components. The cognitive component is defined as negative beliefs about and attitudes towards others ,including cynicism and mistrust .The affective component typically labelled as anger refers ton an unpleasant emotion ranging from irritation to rage and can be assessed with regard to frequency ,intensity and target ,the behavioural component is thought to result from the attitudinal and affective component and is an action intending to harm others ,either verbally or physically.

Hostile transference:-
If a patient internalizes anger and hostility ,this resistance may be expressed as depression and discouragement. The patient may ask to terminate the relationship on the grounds that there is no chance of getting well. If the hostility externalized the patient become critical ,defiant, irritable and may express doubts ,about the nurse training ,experience or competence. The patient may attempt to complete with the nurse by reading books on psychology & debating intellectual issues rather than working on real life problems.
Nursing management:-
Goal:- Preventing harm to the client and others
Limiting or diminishing hostile or aggressive behaviour
To promote the clients ability to control his or her own behaviour
To help the client to develop skills

7] AMBIVALANCE

It refers to simultaneous existence of contradictory or opposing emotions. Attitudes ,ideas or desires for the same person, thing or situation.
Eg: - Mixed love ;Hate feelings or it refers to the experiences of having two opposite feelings at the same time
The feelings make the person want to do two opposite things at one, normally everyone experiences ambivalence at some point ,but for these people it is more pervasive and they may be unable to make decisions. It sometime appears that the client is completely committed to treatment. He or she may do whatever is asked but within a short time may demand to leave ,complaining of being held against his or her will. The urges to leave & stay are both equally strong, making the persons seem erratic when infarct it is ambivalence This may be a cause of mood affect incongruence.
The client also may lack the ability and label their emotions .When asked how they will feel about a situation ,they may respond by saying “I DON,T KNOW”. These may be based on an impaired capacity to recognize and name what they are experiencing rather than avoidance or resistance.

Suicidal ambivalence :-

There is often ambivalence that accompanies thought of suicide. Some people do not really wish to die , but instead want to communicate a dramatic message to others concerning their distress .their suicidal attempts involve no lethal methods such as minimal drug ingestion or minor wrist slalshing.this group is disproportionately female in the united states perhaps because women have been socialised to feel helpless & to fantasize being rescued.
There is another subject of people who are ambivalent about dying and to leave the question of death to fate. Although loss of a love relationship, financial problems, or feelings of meaninglessness may be present, a person in this group still entertains some hope of working things out.

8] AGGRESSION

Alexander states that aggression can arise from such feeling states as anger , anxiety, tension , guilt ,frustration and hostility.

Aggressive behaviour:-
Aggression is disagreeing by feeling unpleasant and cantankerous aggressive behaviour include blaming, shaming , refusing to take no for an answer ,making belittling remarks, humiliating or embarrassing another in the presence of another sampling feet, banging doors ,cursing , stammering the receiver down and crying.
All ill person may feel angry at the impairment of abilities, activities or sensations that the illness beings about sometimes this anger is expressed directly or indirectly
Toward significant others in the health care worker. Because anger is difficult emotion to accept ill people may attribute to others using the coping mechanism of projection.

Types of aggression;-

Aggressive behaviours can be classified as mild ( e.g.; sarcasm) , moderate ( e.g.; slamming doors) ,severe (e.g.; threat of physical violence against others) or extreme (e.g.;- physical acts of violence against others)
Alexander identifies aggression by the following definers characters
· Sarcasm
· Verbal or physical threat
· Changes in voice tone
· Degrading comments
· Pacing
· Throwing or striking objects or people
· Suspiciousness
· Suicidal ideation
· Self mutilation
· Invasion of personal space
· Increase in agitation or irritability
· Disturbed thought process and perception
· Misinterpretation of stimuli
· Anger disproportionate to an event
Etiology:- Aggressive behaviour may be related to feelings of anger or hostility, homicidal ideation, fears, delusion , hallucination, or other psychotic processes, to substance use to a personality disorders or to other factors .

Assessing risk factors;-
Prevention is the key issue in the management of aggressive or violent behaviour. the individual who becomes violent usually feels an underlying helpless . three factors that have been identified as important considerations in assessing for potential violence include.
1) Past history of violence
2) client diagnosis
3) current behaviour
Course of disorder :-
Aggressive behaviour may develop gradually or occur suddenly ,especially in a client who is psychotic or intoxicated .Some signs that a client might become aggressive include restlessness ,increasing tension or psychomotor agitation ,making threats, verbal abuse or increasing voice volume.

Nursing diagnosis:-
· Risk for other directed violence
· Ineffective coping
· Risk for injury
· Non compliance
· Impaired social interactions
· Chronic low self esteem
8]PARANOID BEHAVIOUR
Paranoid behaviour is the presence of persistent delusion .the behaviour includes a tendency to expert exploitation by other ,doubling trust, worthiness of others , doubling trust, worthiness of others , bearing grudge and quick to anger .paranoid behaviour is the mechanism of projection. It is a common sociopathic
Personality ,the eccentric social isolate ,or the individual gone preoccupied with particular religious or political views. The person is called paranoid when he become suspicious of others ,complains that he is being watched ,followed and talked about ,paranoid behaviour can be understood as extreme form of defence mechanism of projection rather than face anxiety generated by recognition of his own hostility in to others ,namely it is they who are unjustly trying to harm him
For e.g.:-“ my family just want to put me out of the hospital and be done with me”

A brief in trust worthiness of others usually sets for the tones of positive interaction, doubt about trusting arise wrongly in individual circumstances ,such as promise gone unfulfilled . In such cases pronounced distortion can occur in our ability to trust others. The individual may loss self esteem, feel very insecure of him, because he is highly anxious and ultimately behave in a manner persecutory delusion or hallucination is predominant. Some describe it reasonable but suspiciousness can grow out of principal.So that the person becomes suspicious about anything.

When the dominating idea become fixed and unshakable ,is not open to reason and is followed by loss of insight, the idea is then clearly ,a delusion and a paranoid delusional state is said to be present .when it exists independently in an individual whose personality remains otherwise well preserved. It is called a paranoid psychosis ,which usually develops at the age of 30-40 and may remain for the rest of patient life.

Deafness blindness ,cultural and social isolation always enhance the possibility of a paranoid state developing . psychoanalytically paranoid ideas are thought to be the result unresolved homosexual conflict ,or once shows ideas perhaps precipitated by an assault on an individuals self esteem.

10] SENSE OF SHAME
When the patient believes that his illness was punishment for sin or wrong doing they may react with feeling of shame and guilt. Also certain disease may make an individual feel disgraced or ashamed ,depending up on his family feel disgraced or ashamed. ,depending up on his family and cultural background . some people feel that they share their family by having certain unacceptable condition E.g.;- Mental disorders ,epilepsy, venereal disease& T.B .guilt related to illness damage self concept. In some conditions such as alcoholism, others may view the patient as weak ,or he may think of himself in those terms. Then it precipitates the feelings of being, rejected. Sexually unacceptable or socially threatening diseases cause a patient to be rejected and then he may experience a sense of shame.


11] ANXITEY
It is a feeling of apprehension uneasiness ,agitation, uncertainty and fear occurring when a person anticipates threat. Anxiety is the most common emotional response to stress. Individuals feel anxious whenever they are threatened .whether the threat is perceived or actual. This worry can translate in to stress or the persons psychologic response to a stimulus such as rushing perspiring and becoming earless. It is a major component of mental health disturbances.

Level of anxiety:


LEVELS

Signs and symptoms


MILD

· increased degree of alertness
· increased vigilance
· increased motivation
· slight increase in vital sings



MODERATE

· subjective distress
· alert only to specific information
· possible headache, diarrhoea, nausea and vomiting



SEVERE

· feeling of impending danger
· selective attention
· feelings of fatigue



PANIC

· major perceptual distortion
· immobilization ;inability to function
· feeling of terror

Guidelines for managing anxiety:-
· Listen actively and focus on having the patient discuss personal feelings
· Use positive remarks and focus on the positive aspects of life
· Explain all procedures ,policies, diagnostic studies, medication, treatments or protocols for care
· Explore coping strategies and work with the patient to practice and use them effectively.
· Use distraction as indicated to ….and prevent self from being overwhelmed.
12] ANGER
Anger is a particularly complex emotion as it can have appositive or negative impact. Anger id is considered to be dysfunctional when the experience negative impact up on the person experiencing emotion.
The client or family may experience anger because of the illness. The anger of family members might be directed towards the client because the illness has disrupted their routine, their plans and , in some cases their ,economic and emotional support.
In some cases of illness people show anger in order to hide his feelings or emotions. He wanted to make other people think that illness didn’t affect him.
Ways to managing anger;-
· Positive self- talk .
· Change of environment
· Write about your feelings
· Listen to music
· Reading
· Being along
· Count to 50
· Deep breathing exercise

13] DENIAL OF ILLNESS
Denial of illness is an avoidance & self protecting mechanism , which permits the individual to either ,disregard or transform the implications of consequences of a thought or an act. Denial means fear& anxiety. In situation of permanent disability ,denial may be called hope. Denial is a defence mechanism characterised by avoidance of disagreeable realities & unconscious refusal to face intolerance thoughts, feelings or needs ,or desires.
Denial is a defence mechanism by which people void the implication of an illness. They may act as if the illness were not severe , as if it will shortly go away or as if it will have a few long term implications. In extreme cases , the patient may even deny that he or she has the illness, despite having been given clear information about the diagnosis.
Denial is the subconscious blocking out of the full realization of the reality implications of the disorder. It is a common reaction to chronic illness that has been observed among patients, with stroke, cardiac clients and cancer patients. denial of the implication of symptoms may act as a deterrent to seeking proper treatment.
Denial may be functional ,allowing time for emotional integration of overwhelming information or allowing a person to tolerate a chronic or progressive plight. During deterioration and decline , denial may be what helps the patient to face each day.
Denial may be adaptive , which helps individual get through a difficult traumatic experiences until they are better able to cope with reality.

A non instructive , questioning approaching should yield a change in the denial in a few days. If the patient or family is unable to respond and continuous to delay the illness beyond a few days or is unable to make important decisions about care. The denial is considered ineffective or maladaptive. During the rehabilitation phase of illness, denial may have adverse effects of client interference with the ability to take in necessary information that will be part of the patients treatment or self management programme.

14] STRESS
According to Hans Selye (1974) ,stress is a non-specific response to any demand made on the body selye formed such demands stressors.
Any situations, event or agent that produces stress is considered a stressor. A stressor can be internal or external. E g;- a head ache is an internal stressor , where as difficult assignment is an external stressor.
Stress is a pattern of disruptive psychological and physiological functioning that occurs when an environmental events is appraised as a threat to important goals and ones ability to cope.
Indicate feelings of
15] WITHDRAWAL
Withdrawn behaviour is a withdrawal from contact with others. Extreme withdrawn behaviour reflects a need to feel safe secure and can indicate feelings of anxiety , fear or sometimes anger. Illness , particularly long term or severe illness may cause a client to withdraw. Regardless of weather the client is in a hospital or at home , she may avoid interaction ,remain in her room or resort to solitary activities such as continuously watching television. Withdrawn behaviour is characterised by silence, failure to make eye contact, recalling from touch. Superficial conversation without any self disclosure or sharing of feelings and denial of feelings. The patient may deny a reality such ,as his own illness and its effect on his life.

IMPACT ON THE CLIENT

Ill clients may experience behavioural and emotional changes ,changes in self concept and body image , and life style changes, behavioural and emotional changes associated with short-term illness are generally mild and short lived. The individual ;for e.g.: may become irritable and lack the energy or desire to interact in the usual fashion with family members or friends. More acute responses are likely with severe ,life threatening ,chronic or disabling illness. Anxiety ,fear, anger, withdrawal, denial, a sense of hopelessness ,and feelings of powerlessness are all common responses to severe or disabling illness.
Certain illness can also change the clients body image or physical appearance. Especially if there is severe searing or loss of a limb or special sense organ. The clients self esteem and self concept may also be affected. Many factors can play a part in low self esteem, and a disturbance in self concept. Loss of body parts and function ,pain disfigurement ,dependence on others,unemployers financial problems, inability to participate in social functions, strained relationships with others and spiritual distress.
Ill individuals are also vulnerable to loss of autonomy, the state of well being independent and self directed without outside control. Family interactions may change so that the client may no longer be involved in making family decisions or even decisions about their own health care.

IMPACT ON THE FAMILY
A persons illness affects not only the person who is ill but also the family or significant others. The kind of effect and its extend depend chiefly on three factors:
a) the member of the family who is ill.
b) the seriousness and length of the illness
c) the cultural and social customs the family follows.
The changes that can occur in the family include the following .
· Role changes
· Task reassignments and increased demands on time.
· Increased stress due to anxiety about the outcome of the illness for the client and conflict about unaccustomed responsibilities.
· Financial problems
· Loneliness as a result of separation and pending loss change in social customs.

MANAGEMENT OF ABNORMAL ILLNESS BEHAVIOUR

Abnormal illness can be modified by psychological techniques. The use of cognitive therapies in the modification of illness behaviour is based on the rationale that fully or irrational pattern of thinking modulate maladaptive emotions and behaviours wooley,Blackwell and wriget (1978)reported a treatment programme that focus on enhancing the patients ability to take independent action in coping with his or her illness. Wooley et al targeted specific goals to alter a patients illness behaviour .these goals included.
1)Having the patient assume responsibility for his or her care .
2)Decreasing the care taking response by others, especially physicians and family members.
3)Altering the social contingencies that supported illness behaviour.
4)Decreasing the frequency of compliance throughout hospitalisation and illness behaviour. These goals included.
increasing achievement orientation, and finally
5)Collecting one year follow up data on the generalization of success from target to no target behaviour.
This heightened perceptual sensitivity to bodily sensations, and their subsequent misinterpretation by the patient may lead the patient to believe that he or she is the victim of some disease process. Such a conviction may often precede the development of illness behaviour. Rational emotional therapy ,their for would focus on the therapist first eliciting the precipitating external stimulus events, then determining the specific thought patterns ,that constitutes the internal response to these events that generate negative emotions ,and finally helping the patient modify these beliefs and thought patterns.
Lewinsohn et al (1982) have provided guidelines for implementing a treatment programme that attempts to assist the patient in
Ø Decreasing the frequency and the subjective aversive ness of unpleasant events in life.
Ø Increasing the frequency of pleasant events in his or her life.
The five steps suggested in accomplishing this goal include….
a) daily monitoring of pleasant and unpleasant events
b) relaxation training
c) managing aversive events
d) time management
e) increasing pleasant activities

SUMMARY
Illness causes changes in clients life styles, patterns and their behaviour .patient may express anxiety about the consequence of illness, sometimes they show anger towards others, in order to hide their .but some people go in to a depressed state, which can lead to serious consequences. Being hospitalized for any illness may also cause emotions. So both the health team members and family have to give support to the patient.

CONCLUSION When persons become ill, they progress through stages of illness behaviour, which are influenced by psychosocial and cultural factors , the accessibility of health care system and the nature of the illness itself. They shows certain behaviours to adjust with the situation. It has a effect on the client and family, including behavioural and emotional changes in roles, body image, elf concept and family dynamics

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