1. Chapter 16 Health and Wellness
At the turn of the nineteenth century, good health and overall wellness were defined as the absence of disease. Health and wellness were not viewed as multidimensional concepts.
During the latter half of the 20th century, with the discovery of antiinfective drugs and the rapid growth of the biomedical industry, disease was no longer the primary focus for defining a person’s health status.
In the 21st century, the concept of health has evolved into a multifaceted model focused on the need to maintain individual health and prevent chronic disease.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

2. The Concept of Health
The word health has several meanings. Individuals define health in terms of their own values, experiences, and ways of living. Organizations and businesses define health in the context of their goals and objectives.
Health is defined by the World Health Organization as: “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”
News headlines bombard the general public with topics ranging from the rise in childhood obesity to the increase of smoking among adolescents to the comparable rates in men and women of chronic conditions such as cardiovascular disease, chronic obstructive pulmonary disease, and stroke.
There has never been a more important time to focus on health and wellness in our society.
The professional nurse is poised to navigate the challenges of promoting health and wellness among patients by helping them achieve and maintain the highest level of physiologic functioning and mental well-being possible.
Capturing the total meaning of health and wellness for all people in a universal context is a challenging task.
Nurses must balance the requirements of the health care industry in which they are employed with the needs of the individuals for whom they care.
Addressing the fiscal challenges of health care in the 21st century while adequately meeting the needs of patients requires creativity and the ability to help individuals identify and achieve their wellness goals.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

3. Health Models
Several health models have been developed to guide practice using the nursing process:
Basic Human Needs Model
Maslow’s hierarchy of needs
Health Belief Model
Health Promotion Model
Holistic health models
Health models describe the relationship between health and wellness.
The models provide a foundation for defining optimal physiologic and mental status.
Patients’ beliefs, values, and attitudes about health and wellness are based on a complex series of experiences that can have positive and negative effects on their health status.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

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?]
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

5. Basic Human Needs Model Maslow’s Hierarchy of Needs
Health Models (Cont.)
Basic Human Needs Model
Maslow’s Hierarchy of Needs
Self-actualization
Self-esteem
Love and Belonging
Safety and Security
Physiologic
Basic Human Needs Model: Maslow’s Hierarchy of Needs
[You might refer students to Chapter 1, Figure 1-6.]
It is most often presented as a pyramid consisting of five levels.
The lowest level is related to physiologic needs, and the uppermost level is associated with self-actualization needs, specifically those related to purpose and identity.
According to this model, deficiency needs must be met first. This means that until basic physiologic requirements are achieved, attaining the higher levels of the pyramid will not be a priority.
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.
Physiologic needs include oxygen, fluids, nutrition, body temperature, elimination, shelter, and sex.
[This model is further discussed on the following slide.]
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

6. Health Models (Cont.)
Maslow’s hierarchy of needs describes the relationships between the basic requirements for survival and the desires that drive personal growth and development.
Self-actualization: the highest level of optimal functioning, involving the integration of cognition, consciousness, and physiologic utility in a single entity
Humanistic approach: the promotion of human welfare
In nursing, the hierarchy of needs model implies that basic physiologic needs are more immediate and therefore of greater importance in terms of survival than higher-level needs.
Maslow’s hierarchy of needs model supplies a humanistic approach. Nurses apply this model when developing interventions focused on preventive care and patient education.
A humanistic approach to health care focuses on strengths of individuals rather than weaknesses or illness.
Nurses should also consider that applying a fixed hierarchical order is not always the most accurate method for predicting patient behavior or actions concerning optimal health.
Nursing care aimed at the individual’s specific level of need during the current health care encounter is the most effective method for prioritizing patient care using Maslow’s hierarchy of needs model.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

7. Health Models (Cont.)
Health Belief Model: explores how patients’ attitudes and beliefs predict health behavior
When applied to the nursing process, this model is used as a measure for determining the patient’s readiness and motivation to act.
Self-efficacy is defined as the belief in one’s ability to perform a task.
Preventive action involves lifestyle change and information gathering about a health topic that leads to a change in behavior.
Health Belief Model
This model was developed by psychologists Hochbaum, Rosenstock, and Kegels (Rosenstock, 1974).
The model has been adapted and reorganized since its original inception.
The latest addition to the construct, self-efficacy, was added in 1988.
[This model is further discussed on a following slide.]
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

8. Health belief model (concepts 1, 2, 3)
Health Models (Cont.)
Health belief model (concepts 1, 2, 3)
CONCEPT
DEFINITION
CHANGE STRATEGIES
Perceived
susceptibility
Beliefs about the chances of getting a condition or disease
Define the populations at risk.
Tailor risk information to the individual’s characteristics or behaviors. Help the individual develop an accurate perception of his or her own risk
Perceived severity
Beliefs about the seriousness of a condition and its consequences
Specify the consequences of a condition, and recommend action or intervention.
Perceived benefits
Beliefs about the effectiveness of taking action to reduce risk or seriousness
Explain how, where, and when to take action and describe likely positive results.
There are three primary components to the health belief model that seek to predict how likely individuals are to change their health care behaviors.
In the three primary components of the health belief model, six main constructs influence an individual’s decision to take action about disease prevention, screening, and controlling illness.
[Review with students Table 16-1 on this slide and a following slide.]
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

9. Health belief model (concepts 4, 5, 6)
Health Models (Cont.)
Health belief model (concepts 4, 5, 6)
CONCEPT
DEFINITION
CHANGE STRATEGIES
Perceived barriers
Beliefs about the material and psychological costs of taking action
Offer reassurance, incentives, and assistance; correct misinformation or allegations.
Cues to action
Factors that activate readiness to change
Provide how-to information, promote awareness, and use reminder systems.
Self-efficacy
Confidence in one’s ability to take action
Provide training and guidance in performing action.
Use progressive goal setting.
Give verbal reinforcement.
Demonstrate desired behaviors.
Together, the six constructs of the health belief model provide a useful framework for implementing the nursing process.
Nurses can use measures in the model to assess the value of short- and long-term behavioral change strategies designed for optimizing patients’ health and wellness status.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

10. Case Study (Cont.)
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?
What questions would you ask Jack to determine all of his risk factors?
What is the impact of Jack’s disease on his wife?]
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

11. Quick Quiz!
According to Maslow’s hierarchy of needs, which of these needs would the patient seek to meet first?
Self-actualization
Psychological security
Shelter
Love and belonging
Answer: C
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

12. Health Models (Cont.)
Health Promotion Model: defines health as a positive, dynamic state of well-being rather than the absence of disease in the physiologic state
Health promotion is behavior motivated by the desire to increase well-being and optimize health status.
Health protection includes intentional behaviors aimed at circumventing illness, detecting it early, and maintaining the best possible level of mental and physiologic function within the boundaries of illness.
Health promotion model
This model was developed by Pender and colleagues (Pender, Murdaugh, and Parsons, 2011).
The model relies on the premise that a multidimensional interaction exists between an individual and the environment, and health promotion consists of behaviors directed at improving the individual’s level of well-being.
The model focuses on three areas:
(1) individual characteristics and experiences
(2) behavior-specific knowledge and affect, and
(3) behavioral outcomes.
The concepts that define the model are health promotion and health protection.
Patients may seek nursing care for illness or preventive health maintenance.
Through use of the nursing process, nurses can educate patients about acute, chronic, and preventive health care interventions.
[Review with students Figure 16-1: The Pender Health Promotion Model.]
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

13. Health Models (Cont.)
Holistic health models in nursing care are based on the philosophy that a synergistic relationship exists between the body and the environment.
Holistic care is an approach to applying healing therapies.
Holistic models focus on the interrelatedness of body and mind.
Holistic health models
When applied to the nursing process, holistic health models strive to include the patient as an active participant in the healing process rather than a passive receiver of therapeutic interventions.
Nurses participate in holistic care through the use of natural healing remedies and complementary interventions.
These include the use of art and guided imagery, therapeutic touch, music therapy, relaxation techniques, and reminiscence.
Eastern holistic therapists have been using techniques such as acupuncture, yoga, and tai chi for thousands of years as methods of healing and, more recently, in conjunction with modern allopathic medical therapies.
The holistic model provides nurses with strategies to help patients learn how to manage illness and optimal health.
Holistic nursing practice has rapidly expanded to meet the growing consumer demand for alternative and complementary interventions.
Consumers of health services have become more familiar with alternative care through the Internet, and they have sought alternatives because of increasing health care costs and expectations of management of their own care.
Holistic nursing interventions are more readily recognized and accepted by patients because mind-body-spirit therapies are emerging as proven, feasible options in contemporary medical treatment.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

14. Case Study (Cont.)
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.]
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

15. Health Promotion and Wellness
Dimensions of optimal health
Physical: Fitness, nutrition, medical self-care, control of substance abuse
Emotional: Care for emotional crisis; stress management
Social: Communities, families, friends
Intellectual: Education, achievement, career development
Spiritual: Love, hope, charity
Health promotion and wellness are increasingly emphasized in health care visits and outcome planning for chronic disease.
Rising health care costs have increased government and consumer demands to decrease the incidence of disease and minimize risk factors that predispose to illness.
Concepts of health promotion, wellness, and risk reduction influence individual motivation for setting and achieving health goals.
Health promotion was defined earlier as “behavior motivated by the desire to increase well-being and optimize health status.” Another definition is: “the art and science of helping people discover the synergies between their core passions and optimal health and become motivated to strive for optimal health.”
Optimal health implies a balance of physical, emotional, social, spiritual, and intellectual well-being.
Activities involved in health promotion include routine exercise, meeting nutritional and vitamin requirements, maintaining a body mass index within range for weight and height, good sleep habits, and stress reduction.
Health promotion activities are effective when the individual is consistently motivated and committed to lifestyle changes that support positive health behaviors.
[Review Figure 16-2 with students.]
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

16. Health Promotion and Wellness (Cont.)
Wellness is a process of self-care achieved by making choices leading to a healthy life.
Risk factor reduction is step-by-step improvement of individual health factors.
Healthy People 2020 initiative is designed to track, over 10-year increments, the risk factors and personal behaviors related to physical activity, access to health services, tobacco use, substance use, responsible sexual behavior, mental health, immunizations, and injury and violence prevention.
Wellness knowledge empowers a person to become more aware of bodily needs and how to meet those needs.
Individuals seeking wellness need to take environmental, occupational, intellectual, spiritual, emotional, physical, and social lifestyle choices into consideration.
An example of the step-by-step improvement of individual health factors:
An overweight, sedentary middle-aged smoker with a family history of cardiac disease has noticed a steady rise in resting blood pressure over a 3- to 4-year period. The patient is concerned about his slightly elevated blood pressure and begins walking 20 to 30 minutes in the evenings with his wife and reduces his pack-a-day cigarette habit to 10 cigarettes per day. He has taken the first steps in reducing risk factors for cardiac disease, but the threat of disease still exists unless he remains motivated to continue on a more healthful course.
Professional nurses can support all dimensions of health promotion, wellness, and risk factor reduction by helping patients understand how each dimension depends on the others.
Complete health agendas are continually evolving plans for reduction of lifestyle-related risks that nurses design with patients and periodically evaluate for maximum effectiveness.
Several evidence-based standardized tools are available to help people achieve their goals for a healthy lifestyle.
The leading health care indicators of the Healthy People 2020 initiative are intended to raise awareness about high-priority public health issues in the United States and ways of improving the health of families and communities.
The program provides information about annual checkups, medical terminology, and decision making about health concerns.
The initiative helps nurses provide educational materials for individuals, families, and communities, enabling them to lead healthier lifestyles and to make permanent changes in wellness habits.
[Review with students the Patient Education and Health Literacy box).
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

17. Levels of Prevention
Primary prevention is instituted before disease becomes established by removing the causes or increasing resistance.
Secondary prevention is undertaken in cases of latent (hidden) disease.
Tertiary prevention, also known as the treatment or rehabilitation stage of preventive care, is implemented when a condition or illness is permanent and irreversible.
Illness and disease prevention involves activities and interventions that delay or prevent clinical manifestations, complications, and death.
Health-related measures have been identified as primary, secondary, and tertiary levels of preventive care from a public health perspective.
Signs or symptoms to be prevented depend on the stage of health or disease of individuals receiving preventive care.
Primary Prevention
The goal of intervention during this phase is to modify risk factors to avoid the onset of disease and prevent pathologic processes from occurring.
Health promotion and specific protection strategies are appropriate methods of primary prevention nurses can use for patients.
Many health-promoting activities are nonmedical, such as lifestyle changes, nutrition improvement, and environmental alterations. They contribute to the prevention of many diseases and enhance patients’ overall vigor and health.
The goal at this phase is to address a specific disease or potential injury.
[You might elicit some examples from students (use of seatbelts and airbags in automobiles, helmet use when riding bicycles or motorcycles, the occupational use of mechanical devices when lifting heavy objects, immunizations against specific diseases).]
Secondary Prevention
Although the patient may be asymptomatic, the disease process can be detected by medical tests. Secondary prevention may be directed at individuals who are at risk for complications.
The goal for health intervention during this phase is early detection and diagnosis of health problems before patients exhibit symptoms of disease.
Screening tests may be used to assess for latent disease in vulnerable populations. Although screening examinations do not prevent disease or the cause of disease, they may influence progression to the symptomatic phase.
[Elicit some examples of screen tests from students (purified protein derivative (PPD) skin test for tuberculosis, fecal occult blood test for colorectal cancer, and mammograms for breast cancer).]
Nursing care implemented as secondary prevention occurs wherever nurses interact with patients, including in acute care or home care settings and during community health care functions.
While implementing secondary prevention measures, nurses can provide health education, which is considered a primary prevention effort.
Tertiary Prevention
The goal of care at this phase is to reduce the number and impact of complications and disabilities resulting from a disease or medical condition.
Interventions are intended to reduce suffering caused by poor health and assist the patients in adjusting to incurable conditions.
Nursing care is focused on rehabilitation efforts in the tertiary stage of prevention. Outcomes are evaluated on the basis of patient responses.
[Tertiary Prevention is further discussed on a following slide.]
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

18. Levels of Prevention (Cont.)
Collaboration and Delegation:
Collaboration in Preventive Care
Prevention is not solely the responsibility of the nurse; it involves active participation by the individual and the combined services of practitioners in many disciplines.
Collaborative health care partnerships are designed to deliver well-balanced care to the patient as a whole.
Collaborative preventive care can be mandated in the form of health care legislation, with rates for reimbursement of practitioners determined by the individual provider’s ability to collaborate and develop innovative methods for delivering services.
The role of the professional nurse is to collaborate and communicate health education to the patient and family, care provider, or surrogate. Patient education responsibilities are not delegated to any others.
The professional nurse assumes a leadership role in coordinating all members of the patient’s health care team with collaborative efforts to maximize health outcomes.
Collaborative efforts are a necessary function of tertiary prevention because the patient often has health needs encompassing numerous health disciplines that might not have been involved in the primary and secondary stages of illness.
The goal is to help patients attain the highest level of physical and mental health achievable within the parameters of impairment caused by disease or disability.
More information about collaborative efforts in preventive health care services that are patient centered and value driven is available at
[Review the Collaboration and Delegation box with students.]
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

19. Case Study (Cont.)
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.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

20. Illness
Illness is a state of health characterized by decreased or impaired abilities to engage in physical or mental functioning that was previously experienced.
Acute illness is typically characterized by an abrupt onset and short duration (<6 months).
Chronic illness is characterized by a loss or abnormality of body function that lasts longer than 6 months and requires ongoing long-term care.
Remission: periods of wellness
Exacerbation: worsening of clinical manifestations
People respond to illness in a variety of subjective and objective ways.
Response to illness is determined by an individual’s emotional and cognitive development and by the physiologic response to stress experienced by the body.
For example, pneumonia is an infectious disease that is highly curable when treated promptly and with patient compliance throughout therapy. One person with pneumonia identifies alterations in health status by the symptoms of illness associated with decreased function (e.g., fever, malaise, cough), seeks treatment, and has a positive physiologic response, maintaining usual daily activities. Another person may ignore or disregard physiologic alterations in health, with the possible result of increasing the duration of the illness, the length of treatment, and the severity of impairment.
Perception of illness and the experience of illness go beyond the physical dimension, and the nurse must recognize that a patient’s illness is not necessarily synonymous with disease status.
Illness can be categorized as acute or chronic depending on the clinical course and prognosis of disease.
Both acute and chronic illnesses can be lethal or cause permanent disability in the host organism.
Clinical manifestations of acute illness appear quickly. They may be severe or lethal, or they may soon resolve because they respond to treatment or are self limiting. The physiologic and psychological consequences of an acute illness can affect a patient’s immediate functional ability. Residual effects of acute illness may last beyond the course of the disease itself.
Chronic illness is of greater concern than communicable diseases in many areas of the world, including some developing countries. This focus on chronic illness results from factors such as people living longer; improved health care and medications; high-fat, high-sugar diets and sedentary lifestyles that contribute to obesity; and substance abuse, including tobacco, alcohol, and illegal drugs.
Nurses play a pivotal role in providing care, support, and education for people with chronic illness.
Nurses can help patients establish a daily routine of care by educating them about how to manage their care and the symptoms associated with the condition, including emergency or life-threatening situations.
Encouragement and positive support from a professional nurse can help individuals gain control over the alternating periods of health and illness and improve their quality of life.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

21. Stages of Illness Model
Illness (Cont.)
Stages of Illness Model
Stage I (Symptom experience): A clinical manifestation of disease is experienced, and the person acknowledges that something is wrong and seeks a cure.
Stage II (Assumption of the sick role): The person decides that the illness is genuine and that care is necessary.
Stage III (Medical care contact): Professional advice from health care providers is sought by the individual. A professional health care provider identifies and validates the illness and legitimizes the sick role.
Stage IV (Dependent patient role): The person, who is designated as a patient, usually undergoes treatment.
Stage V (Perceived recovery): The patient abandons the sick role and resumes usual tasks and roles to the greatest degree possible.
Illness Behaviors
Social and environmental factors are important components of health and illness.
Recognition that the health of an individual is more than just a biologic process related to physiologic function has increased awareness about the sociologic dimension of health that influences illness behaviors.
Several stages of illness behavior have been identified by medical sociologists to describe how people monitor their physical well-being, label and interpret their symptoms, take curative actions, and enter the health care system.
For the purpose of providing nursing care, Suchman’s stages of illness model (1965) best describes illness behavior and how individuals arrive at the coping mechanisms necessary for the management of disease conditions.
According to the model, the process of being ill comprises five components—or stages—of the illness experience. Each stage is characterized by certain decisions, behaviors, and end points comparable to parts of the nursing process.
Stage I: The outcome of stage I is that the person accepts the reality of symptoms and decides to take action in seeking care.
Stage II: This stage gives an individual permission to act sick and to be excused temporarily from typical social and personal obligations. The results of this stage are either acceptance of the sick role or rejection of its necessity.
Stage III: The condition still may be denied, or the patient may seek additional medical care or may accept the adverse condition, the medical diagnostic authority, and the plan for treatment.
Stage IV: Patients often feel dependent on others and may experience ambivalent or fearful thoughts that cause them to reject treatment, the advice of health care providers, and the illness. More often, care is accepted and administered to an ambivalent patient. In this stage, the sick individual has a significant need to be educated and provided with emotional support.
Stage V: Some people do not willingly give up the sick role; they begin to view themselves as chronically ill, or they malinger in the health care setting, acting sick for secondary gain. Patients with permanent disabilities may require therapy to assist them in making adjustments necessary for performing activities.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

22. Quick Quiz!
You will use the concept of primary prevention when instructing a patient to:
Get a flu shot every year.
Take a blood pressure reading every day.
Explore hiring a patient with a known disability.
Undergo physical therapy following a cerebrovascular accident.
Answer: A
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

23. Case Study (Cont.) 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.).
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

24. Factors Influencing Health and the Impact of Illness
Social determinants of health are variables that affect health and wellness. They are a key component in guiding health promotion activities and preventive behaviors.
Opportunistic infections are caused by harmless organisms that become pathogenic and illness from the spread of community-acquired disease.
Social Determinants of Health
These variables are affected by resource distribution throughout the world.
The value a patient assigns to a real or perceived health risk can influence health beliefs, behaviors, and practices that will ultimately determine a positive or negative health outcome.
Understanding the effects of these factors affords the nurse an opportunity to initiate the steps of the nursing process to plan and implement individualized care.
Age
The chronologic age of an individual is a strong indicator of susceptibility to disease or disabling conditions.
Assessment of the patient begins with risk factors that take into account the person’s age and the associated level of immune system function.
The very young, especially neonates and infants born prematurely, are more susceptible to infections because of the immaturity of their immune systems.
Likewise, older adults have decreased immune system function as a result of the aging process.
Older patients are at risk for opportunistic infections.
Complications from comorbidities of chronic disease may also increase in the aged population.
Nurses need to educate the parents of newborns, infants, children, and adolescents about the importance of regular, age-appropriate checkups and screening examinations.
Young adults, adults, and older adults should be instructed to undergo age-appropriate screening examinations, schedule regular health care provider visits, and receive recommended immunizations to promote wellness and prevent illness.
Nurses should encourage adults of all ages to act as role models for good health and to promote wellness behaviors.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

25. Factors Influencing Health and the Impact of Illness (Cont.)
Diversity Considerations
Lifespan
Gender
Disability
Morphology
[Review the Diversity Considerations box with students.]
A schedule of immunizations ( has been provided by the Centers for Disease Control and Prevention (CDC), and the U.S. Department of Health and Human Services (DHHS) provides links to health screening and disease prevention sites.
Nurses should encourage adults of all ages to act as role models for good health and to promote wellness behaviors.
Access to best-practice guidelines can be found at
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

26. Factors Influencing Health and the Impact of Illness (Cont.)
Age-Related Guidelines for Pap Smears
All women should begin cervical cancer screening at the age of 21 years. Women between the ages of 21 and 29 years should have a Pap test every 3 years.
Women between the ages of 30 and 65 years should have a Pap test plus a human papillomavirus (HPV) test (i.e., co-testing) every 5 years.
Women 65 years of age or older who have had normal results for previous Pap tests should no longer be screened.
Women who have had a total hysterectomy (i.e., removal of the uterus and cervix) should not be tested, unless the surgery was done as a treatment for cervical cancer or precancer.
Gender-related risk factors for disease are assessed according to the characteristics of each disease.
Nurses in primary and acute care settings are often the first health care providers to approach individuals about gender-specific health and wellness issues.
Preventive screening examinations take into account reproductive anatomy and follow the current CDC guidelines for age and sexual maturity.
An adolescent male should be assessed for testicular self-examination habits, and older males should have an annual prostate examination.
Menstrual history should be obtained from female patients, and an annual Papanicolaou (Pap) test is recommended.
[Review Box 16-1: Age-Related Guidelines for Pap Smears.]
Pregnancy and childbirth issues should be evaluated by the nurse as potential alterations in health status that may need continued monitoring.
Nurses are knowledgeable resources with whom people can discuss sensitive issues and questions about gender-specific illness and health-promotion activities.
Nurses must display sensitivity and comfort in dealing with these issues, which may be awkward or difficult for people to discuss with friends, family, or other members of the health care team.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

27. Case Study (Cont.)
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?]
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

28. Factors Influencing Health and the Impact of Illness (Cont.)
Genetic vulnerability, or risk of disease expression based on genotype, is involuntarily passed from biologic parents to their offspring.
Behavioral Risk Factor Surveillance System is an ongoing, state-based, random-digit-dialed telephone survey of the noninstitutionalized U.S. population older than 18 years of age. The survey collects data on health risk behaviors and preventive health services related to the leading causes of death.
Genetics and Inherited Traits
Preventive health care based on principles of human genetics is the next frontier for patient care.
Societal attitudes about testing and management of high-risk populations depend on the potential for expression of genetic disorders possibly triggered by environmental factors.
Controlling factors that place stress on physiologic function can reduce pathologic genetic expression and susceptibility to disease.
Diabetes, cancer, mental illness, and renal disease also have genetic components and are amenable to interventions that reduce risk.
Lifestyle
Health and wellness risk factors are inherent in the choice to engage in and continue particular behaviors.
Habitual lifestyle behaviors can produce health benefits or intensify the effects of pathologic risk factors.
Behavioral risk factors such as smoking, poor diet, physical inactivity, and excessive drinking are linked to the leading causes of death in the U.S. population.
These data are available for most areas of the United States and emphasize the need for health promotion and preventive care initiatives tailored to individual, community, and statewide levels of the health care system.
The economic impact of modifiable lifestyle-related risk factors that contribute to chronic disease is a serious concern to all communities because of the drain on health care and financial resources needed to accommodate an ailing population.
Nurses are often asked to participate in education efforts to promote health and wellness and reduce disease risk factors as part of their communities’ public health agendas.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

29. Factors Influencing Health and the Impact of Illness (Cont.)
Evidence-Based Practice and Informatics: Research Opportunities and Resources Related to Health and Wellness
Health and wellness topics for each body system offer a broad range of research opportunities.
Research that evaluates positive and negative lifestyle-behavior outcomes is constantly evolving as discoveries are made about the physiologic changes bodies experience with disease and illness.
Nurses are at the forefront of medical breakthroughs and are expected to be knowledgeable about the latest technology and pharmaceutical interventions.
Up-to-date information about government-sponsored best-practice guidelines regarding nutrition, physical activity, and healthy living is available at
For older adults, best-practice guidelines for health and wellness can be found at
Lifestyle (cont.)
Information on lifestyle behaviors that lead to disease is available at research-sponsored websites that have peer-reviewed material and expert analyses.
Website content should be easy to read and understandable for the general population.
Most websites that discuss the latest information about health risks, lifestyle behaviors, and outcomes have separate information specifically for health care providers.
[Review the Evidence-Based Practice and Informatics box with students.]
Nutrition and dietary intake have a direct link to modifiable lifestyle-related risk factors that predispose an individual to obesity, hyperlipidemia, and atherosclerosis.
Nurses can assist people with weight loss and maintenance techniques by educating them about the food choices and portion sizes suggested by the CDC’s My Plate Food Guide for daily caloric requirements.
Exercise is essential for the prevention of illness and promotion of wellness.
Environment
Where individuals live determines their access to food, water, shelter, and clean air.
Indoor and outdoor environmental factors influence most categories of disease and injury and determine the disease-producing organisms and substances to which an individual is exposed.
Nursing assessment is critical in identifying and minimizing modifiable environmental risks that can affect the health status of community members.
Nurses familiar with community resources can dramatically impact the health of individuals by making necessary referrals and exploring creative options with community members to minimize negative health factors.
The role of the nurse in addressing environmental concerns is often as a change agent and advocate for people with limited financial and educational resources.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

30. Quick Quiz!
After evaluating a patient’s external variables, the nurse concludes that health beliefs and practices can be influenced by:
Emotional factors.
Intellectual background.
Developmental stage.
Socioeconomic factors.
Answer: D
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

31. Factors Influencing Health and the Impact of Illness (Cont.)
Self-concept refers to the way in which individuals perceive unchanging aspects of themselves, such as social character, cognitive abilities, physical appearance, and body image.
If the image is positive, the person will develop strengths, compensate for weaknesses, and experience life in a healthy way.
If the image is negative (e.g., frail), the person will find life’s challenges devastating and sometimes insurmountable.
Attitudes and Emotions
Individuals respond differently to illness or the threat of illness.
Their attitudes, behaviors, and emotional reactions depend on the severity of the illness and its perceived impact on their health.
An individual’s unique illness behaviors are influenced by self-concept, opinions of peers and family, and cultural customs.
A short-term, self-limited illness that is not life threatening does not evoke emotions or actions that cause fundamental changes in daily lifestyle.
Chronic, debilitating disease and severe illness can produce a broad range of emotional or behavioral responses in patients and their families.
After assessment and diagnosis of emotional distress, nurses can plan interventions in collaboration with patients and their families to help identify coping mechanisms and support systems that are appropriate to each situation.
To promote positive patient outcomes, nurses must use their therapeutic communication skills when patients express concerns and wish to discuss their treatment options.
Self-concept
Self-concept is a mental image of self in relation to others and the surroundings.
The impact of illness on the self-concept of a patient and the patient’s family members depends on how secure the parties’ relationships are with one another.
Changed behaviors that may reflect altered self-concept when a person is faced with a severe or terminal illness range from minimally noticeable to extreme.
Extreme shifts in behaviors occur when the individual engages in an activity that was uncharacteristic before the illness, for example, a patient diagnosed with terminal cancer who takes up skydiving despite a long-held fear of heights.
Family, friends, and peers may be confused by the deviation from characteristic behaviors, including unmet social obligations, interpersonal tension, and increased interpersonal conflict.
Nurses coordinating care for patients with end-stage disease must learn to recognize subtle and blatant changes in self-concept. The nurse can assist patients and their families in developing effective coping strategies to adapt to differences resulting from alterations in health status.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

32. Case Study (Cont.) 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.]
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

33. Quick Quiz!
Mary has decided to set aside 30 minutes a day to walk after work next week. Mary is in what stage of risk factor modification?
Precontemplation
Contemplation
Preparation
Action
Maintenance
Answer: C
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

34. Factors Influencing Health and the Impact of Illness (Cont.)
Child and Adolescent Reactions to Trauma and Loss
Preschoolers: thumb sucking, clinging to parents, bedwetting, sleep disturbances, fear of the dark, loss of appetite, regression in behavior, and withdrawal from friends and routines.
Elementary school children: poor concentration, irritability, aggressiveness, clinging to parents, nightmares, school avoidance, and withdrawal from friends and activities.
Adolescents: agitation, sleeping and eating disturbances, increased conflicts, physical complaints, delinquent behavior, and poor concentration.
Developmental Level
Intellect and behavior can be attributed to genetic traits and environmental stimuli. However, an individual’s developmental level, as characterized by mastery of expected milestones and interactions with surroundings, reflects more than chronologic age and physical size.
The developmental level depends on a person’s ability to reason and learn from life experiences in predictable stages at age-appropriate intervals.
When planning care, the nurse must create strategies and integrate activities that conform to the patient’s cognitive level of development to achieve a specific outcome.
The concept of illness is different at each level of development.
Influence of Peers and Family
The value that friends and family place on health status can positively or negatively influence the health of an individual.
Typically, the developmental level of the patient determines whether peers or family members have more influence.
Nurses should stress the importance of parental or adult supervision of adolescent health care.
Supporting families and assisting parents with coping techniques when dealing with devastating illness or tragedy is a vital aspect of nursing care. It is accomplished by being a good listener and observer and being attentive to emotional cues.
[Review Box 16-2 with students.]
Traditions, Beliefs, and Values
Cultural traditions, spiritual beliefs, and the value an individual places on ethnic heritage greatly influence illness behaviors and therapeutic practices.
Some people have ethnic practices or religious beliefs that nurses must consider before treatment or diagnostic procedures are performed.
For instance, a patient may observe a day of fasting for religious reasons despite the detrimental effects the lack of nutrients has on the disease process.
To improve compliance with prescribed treatments, nurses can incorporate patients’ religious and cultural views into the plans of care.
Health Care Access and Availability
Gaining access to any type of health care can be an intimidating task for healthy and sick individuals.
Socioeconomic factors can compound the need for care if it is not affordable.
For individuals or families deciding whether to seek treatment, the cost may be a less significant issue than the availability of health care.
People living in isolated or less densely populated areas may have little or no access to health care providers or facilities within a reasonable distance.
The circumstances affecting access to care may confound nurses’ attempts to assist patients with compliance with drug therapy, diagnostic test schedules, and follow-up appointments.
Nurses have the responsibility and the expertise to help educate, enable, and encourage people of all ages to adopt healthier lifestyles and to become proactive about health care practices that can prevent or minimize illness and disease.
Day to day, nurses continue the commitment of contributing to the wellness of patients, families, and communities by supporting initiatives, programs, and projects that promote a culture of health and self-care, which improves patients’ quality of life.
Copyright © 2016 by Mosby, an imprint of Elsevier Inc.