1. Chapter 6 Health and Wellness
Health is a multidimensional concept that must be viewed in a broader sense than good health, wellness, or the absence of disease. Models of health offer a perspective from which to understand the relationships between health, wellness, and illness.
Nurses who understand how patients react to illness can minimize the effects of illness and help patients and their families maintain or return to their highest level of functioning.

2. Healthy People Documents
Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention, 1979
Healthy People 2000: National Health Promotion and Disease Prevention Objectives
Healthy People 2010
Healthy People 2020
The U.S. government set national health care goals back in 1979, with the publication of Healthy People: The Surgeon General’s Report on Health Promotion and Disease. Since then, three more documents have been developed to identify and address health care needs.
The results of Healthy People 2000 demonstrate that infant mortality rates had declined, childhood immunizations had risen, and deaths from coronary heart disease and strokes had declined.
Healthy People 2010 served as a road map for improving the health of all people in the United States.
Healthy People 2020 goals are on the next slide.

3. Healthy People 2020 Goals
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death
Achieve health equity, eliminate disparities, and improve the health of all groups
Create social and physical environments that promote good health for all
Promote quality of life, healthy development, and healthy behaviors across all life stages.
[Ask the students: How do you see your role as a nurse in achieving these goals?]

4. Case Study
Jack is a 59-year-old man with a history of type 2 diabetes, hypertension, and obesity. He is married and works 50 to 60 hours per week in a computer technology position.
His wife works the same number of hours, although she tends to travel more with her job and sometimes works the night shift.
Therefore, both Jack and his wife have a hard time fitting exercise into their daily routine, and they often eat in restaurants.
[Ask the class: What hurdles need to be overcome for Jack to adopt a more healthy lifestyle?
What could you do as a nurse to encourage behavior changes?]

5. Definition of Health Health is more than the absence of disease!
A state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity (WHO, 1947)
A state of being that people define in relation to their own values, personality, and lifestyle
Individual views of health vary among age groups, genders, races, and cultures.
When considering health, you need to look at your patient holistically.

6. Models of Health and Illness
Health Belief Model
Addresses the relationship between a person’s beliefs and behaviors
Health Promotion Model
Directed at increasing a patient’s level of well-being
Models (theoretical ways of understanding a concept or idea) are used to understand the relationships between concepts and patients’ attitudes toward health and health beliefs.
Health Belief Model (see Fig. 6-1 on text p. 67) provides a way of understanding and predicting how patients will behave in relation to their health, and how they will comply with health care therapies. It helps nurses understand the many factors that influence patients’ perceptions, beliefs, and behaviors. Knowing this information enables us to help patients maintain or restore their health and perhaps prevent illness.
[Ask the class: Using the health belief model (re Case Study), identify two individual health perceptions that may be influencing Jack.]
Positive health behaviors are activities related to maintaining, attaining, or regaining good health and preventing illness.
Box 6-1 (on text p. 68) reviews Evidence-Based Practice: Mammography Practices in Asian-American Immigrant Women.
The health promotion model (see Fig. 6-2 on text p. 69), suggested by Pender, serves as a framework for integrating the perspectives of nursing and behavioral science and the factors that influence health.
See Box 6-2 (on text p. 68): Focus on Older Adults: Health Promotion.

7. Models of Health and Illness (cont’d)
Basic Human Needs Model
Attempts to meet the patient’s basic needs
Holistic Health Model
Attempts to create conditions that promote optimal health
Basic human needs are the elements necessary for survival and health.
The holistic model, as proposed by Mandle, is also known as complementary or alternative medicine. It is based on a comprehensive view of the person as a biopsychosocial and spiritual being.
Holistic health models of nursing promote optimal health by incorporating active participation of patients in improving their health state.
[Ask students which kinds of therapy this might include? ANSWERS can include use of music, reminiscence, relaxation, therapeutic touch, and guided imagery.]

8. Case Study (cont’d)
Jack comes to the clinic today for routine follow-up for his diabetes. Jack’s laboratory data reveal that his blood glucose level is consistently running high. His blood pressure is on the high side of normal.
Sally, the diabetes nurse educator, is working with Jack for the second time. Sally knows she wants to find a way to get Jack’s blood glucose levels down to avoid the long-term complications of diabetes.
[Ask the class: What do you think Sally plans to do?]
Sally plans to talk with Jack to determine his understanding of diabetes and to evaluate his readiness for the lifestyle behavior changes needed to manage his health.
[Ask the class: What risk factors can you identify that increase Jack’s susceptibility to problems with his diabetes and other diseases?]
[Ask the class: What questions would you ask Jack to determine all of his risk factors?]
[Ask the class: What is the impact of Jack’s disease on his wife?]

9. Maslow’s Hierarchy of Needs
Self-actualization
Self-esteem
Love and Belonging
Safety and Security
Physiological
This is Maslow’s hierarchy of needs. (See detailed version in Fig. 6-3 on text p. 69.)
Maslow’s hierarchy of needs model emphasizes identifying a patient’s individual needs, prioritizing those needs, and encouraging the patient’s individual discovery of self (self-actualization).
Some human needs are more basic than others. The beauty of this model is that it can provide a basis for nursing patients of all ages in all settings.
Safety and security are divided into physical safety and psychological safety.
Physiological needs include oxygen, fluids, nutrition, body temperature, elimination, shelter, and sex.

10. Variables Influencing Health and Health Beliefs and Practices
Variables influence how a person thinks and acts.
Health beliefs can negatively or positively influence health behavior or health practices.
Health beliefs and practices are influenced by internal and external variables and should be considered when planning care.
Understanding the effects of these variables allows you to plan and deliver individualized nursing care.
[Ask the students to describe variables that influence health and health beliefs and practices?]

11. Quick Quiz!
1. According to Maslow’s hierarchy of needs, which of these needs would the patient seek to meet first? A. Self-actualization B. Psychological security C. Shelter D. Love and belonging
Answer: C

12. Intellectual Background Perception of Functioning
Internal Variables
Developmental Stage
Intellectual Background
Perception of Functioning
Emotional Factors
Spiritual Factors
[Ask students how they think these five variables might influence health and health care beliefs.]
We will discuss these concepts in future chapters:
Chapter 11: Developmental Theories
Chapter 35: Spiritual Health

13. Socioeconomic Factors
External Variables
Family Practices
Socioeconomic Factors
Cultural Background
Family practices can be passed down, in both positive and negative forms. If, as a child, you had immunizations, well-child checkups, and regular dental and eye examinations, chances are you will continue to do so in your adult years.
Socioeconomic factors can greatly influence a person’s ability to make hard decisions. If I am healthy, I need to buy food, pay bills, or clothe the children.
We know from past experience that culture influences beliefs, values, and customs. As health care providers, we need to be aware of diverse cultures and to plan care accordingly if we expect patients to be compliant. We will see more of this concept in Chapter 9, Culture and Ethnicity.
See also Box 6-3 (on text p. 70): Cultural Aspects of Care Cultural Health Beliefs.

14. Case Study (cont’d)
Because Jack occasionally exercises, Sally decides to focus her teaching on the importance of routine exercise to improve Jack’s health and help with the management of diabetes.
Sally finds out that 6 months ago, Jack was using his treadmill for 20 minutes on most mornings. Since then, he has gotten out of the habit because he now tries to arrive at work 30 minutes earlier.
[Ask the class, What outcomes would you design for this encounter?]
[Example: By the end of the visit, Jack will verbalize two reasons why it is helpful for him to stay physically active and one new strategy for exercise that he is willing to try.]

15. Quick Quiz!
2. After evaluating a patient’s external variables, the nurse concludes that health beliefs and practices can be influenced by
A. Emotional factors.
B. Intellectual background.
C. Developmental stage.
D. Socioeconomic factors.
Answer: D

16. Health Promotion, Wellness, and Illness Prevention
1. Immunization Programs
2. Routine Exercise, Good Exercise
3. Physical Awareness, Stress Management, Self-Responsibility
Nursing incorporates health promotion activities, wellness education, and illness prevention activities rather than simply treating illness.
Health promotion activities help maintain or enhance health.
Wellness education teaches patients how to care for themselves.
Illness prevention activities protect against health threats and thus maintain an optimal level of health.
These activities can be passive or active. Individuals learn passive strategies from others without their own participation. Active strategies motivate the individuals to adopt health programs.
[Ask students to identify which box relates to health promotion, wellness, and illness prevention:
Box 1: Illness Prevention
Box 2: Health Promotion
Box 3: Wellness]

17. Levels of Prevention Primary Secondary Tertiary
True prevention that lowers the chances that a disease will develop
Secondary
Focuses on those who have a disease or are at risk to develop a disease
Tertiary
Occurs when a defect or disability is permanent or irreversible
Primary prevention includes health promotion, wellness education programs, immunizations, hearing protection in occupational settings, training to develop good body mechanics, and health screening for prostate, breast, and colon cancer.
Secondary prevention is provided in the home, health care facility, or skilled nursing facility.
Tertiary prevention aims to help patients achieve as high a level of functioning as possible.
Box 6-1 (on text p. 72) details the three levels of prevention.

18. Quick Quiz!
3. You will use the concept of primary prevention when instructing a patient to
A. Get a flu shot every year.
B. Take a blood pressure reading every day.
C. Explore hiring a patient with a known disability.
D. Undergo physical therapy following a cerebrovascular accident.
Answer: A

19. Risk Factors
Variables that increase the vulnerability of an individual or a group to an illness or accident
Risk factors include:
Genetic and physiological factors
Age
Environment
Lifestyle
Risk factors threaten health, influence health practices, and are important considerations in illness prevention activities.
A risk factor can be a situation, habit, social or environmental condition, physiological or psychological condition, developmental or intellectual condition, spiritual condition, or other variable.
Genetic and physiological factors, such as being overweight, affect physical functioning of the body.
Age increases susceptibility to certain diseases. [Ask students to name a few. Suggested answers: cancer, BPH, dementia, Alzheimer's disease.]
Environment includes cleanliness, heat, cold, overcrowding, and air quality. [Ask students: How does ethnicity fit in here?]
Lifestyle contains those factors that have positive or negative effects on health, such as smoking, drinking, and using drugs.
See Table 6-2 (on text p. 73) for information about Causes of Death in the United States in 2007 and Contributing Lifestyle Choices.

20. Risk Factor Modification and Changing Health Behaviors
Precontemplation
Not intending to make changes within the next 6 months
Contemplation
Considering a change within the next 6 months
Preparation
Making small changes in preparation for a change in the next month
Table 6-3 (on text p. 74) presents the five stages of health behavior change.
Identify risk factors in health promotion, wellness education, and illness prevention.
Implement risk modification, health promotion, or illness prevention activities.
Encourage patients to modify their lifestyles and adopt health promotion practices.

21. Case Study (cont’d)
Sally wants to apply the stages of behavior change with Jack. By using this model, she will work with Jack regarding what he is ready to do rather than simply telling Jack to be more active.
To do this, she first asks Jack how he feels about exercise and what his plans are. Jack states, “I know that exercise would be good for me and I should probably work on it.”
This tells Sally that Jack is at the contemplation stage.
[Ask the class: How should Sally respond to the knowledge that Jack is at the contemplation stage?]
Sally targets her teaching to help Jack see the benefits of exercise, how it could fit into his schedule, and what kinds of things he likes to do.
Sally asks Jack to bring a list of benefits of exercise for him and three or four options for exercise to their next appointment.
By this process, she hopes to move Jack into the preparation stage of behavior change for exercise at their next visit.

22. Risk Factor Modification and Changing Health Behaviors (cont’d)
Improvement in health may involve a change in health behaviors.
Action
Actively engaged in strategies to change behavior; lasts up to 6 months
Maintenance stage
Sustained change over time; begins 6 months after action has started and continues indefinitely
Implement risk modification, health promotion, or illness prevention activities.
Encourage patients to modify their lifestyles and adopt health promotion practices.
The transtheoretical model of change describes a series of changes through which patients progress for successful behavior change, rather than simply assuming that all patients are in an action stage.

23. Illness
A state in which a person’s physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired
Acute Illness
Short duration and severe
Chronic Illness
Persists longer than 6 months
At times, an experience with an illness will motivate a person to adapt positive behaviors.
It is good to remember that an illness does not always indicate that a disease is present.

24. Quick Quiz!
4. Sally has decided to set aside 30 minutes a day to walk after work next week. Sally is in what stage of risk factor modification? A. Precontemplation B. Contemplation C. Preparation D. Action E. Maintenance
Answer: C

25. Illness Behavior
Involves how people monitor their bodies and define and interpret their symptoms
Influenced by many variables and must be considered by the nurse when planning care
Internal variables
Perception of illness and nature of illness
External variables
Visibility of symptoms, social group, cultural background, economics, and accessibility to health care
For some patients, if they want to be ill, they will act ill.
At times, patients use their illness to guide behavioral responses.

26. Impact of Illness on the Patient and Family
Behavioral and emotional changes
Impact on body image
Impact on self-concept
Impact on family roles
Impact on family dynamics
Illness is never an isolated life event. The patient and the family must deal with changes resulting from illness and treatments associated with illness. Each family member and patient will react differently; that means that interventions must be individualized.
[Ask students for examples of how these changes affect patients.]
We will provide more in-depth discussion of these issues in the following chapters: Chapter 33: Self-Concept
Chapter 10: Caring for Families
Chapter 37: Stress and Coping

27. Patient Teaching: Lifestyle Changes
Objective
Patient will reduce health risks related to poor lifestyle habits through behavior change.
Teaching strategies
Provide active listening, ask about perceived barriers, assist the patient in establishing goals, and reinforce the process of change.
The importance of setting a goal should be stressed.
Use written resources at an appropriate reading level .
Ensure that educational materials are culturally appropriate .
Include family members to support the lifestyle change.

28. Case Study (cont’d) Teaching strategies:
Practice active listening and determine what Jack understands regarding health risks related to poor lifestyle.
Ask Jack what barriers and benefits he perceives with the planned lifestyle change of consistently exercising.
Help Jack set achievable goals for change.
Work with Jack to establish realistic time lines for modification of exercise habits.
[Ask the class: What are some additional teaching strategies Sally could use? Then discuss the ones below.]
Reinforce with Jack the process of change.
Use written resources at an appropriate reading level.
Include Jack’s wife to support the lifestyle change.
Identify community resources available to Jack (walking track, fitness facilities, etc.).

29. Case Study (cont’d)
At the next appointment, Jack says, “I saw there was a sale on walking shoes. If I’m going to start walking, do you think I need to get new shoes? Next week, I am taking a week of vacation, just doing things around the house, and I thought this would be a good time to start.”
[Ask the class: Which stage (of the stages of behavior model) best describes Jack’s desire to change?
What goals could Sally help Jack set during this visit?]

30. Patient Teaching: Lifestyle Changes (cont’d)
Evaluation
Have the patient maintain an exercise and eating calendar to track adherence, and provide positive reinforcement.
Ask the patient to discuss success with lifestyle changes such as minutes spent in activity or actual quantities of fruits and vegetables eaten.
•More information about teaching lifestyle changes to patients can be found in Box 6-4 (on page 74 of your textbooks).

31. Case Study (cont’d) Evaluation strategies
Have Jack maintain an exercise log to track adherence, and provide positive reinforcement.
Ask Jack to discuss his success with lifestyle changes, such as minutes spent in activity.
Have Jack identify community resources used in making a change.
[Ask the class: What other important step can you take as a nurse once Jack begins exercising? Discuss the value of positive reinforcement.]