The Theory of Unpleasant Symptoms: Clinical Application

1. The Theory of Unpleasant Symptoms:Clinical Application An Acute-Care View Alexis Farrington, BSN, RN

2. Background • In the acute-care setting, nurses are responsible for managing clinical symptoms, effects of medications and behaviors that place patients at risk for falls. • Nurses are also responsible for reporting to primary care providers and immediate level management changes in patients’ symptoms that increase the risk for potential injury (Rochefort, Ward, Ritchie, Girard and Tamblyn, 2011). • Frequent assessments are necessary to determine changes in patients’ mental status, gait stability and levels of anxiety and should be communicated during shift reports (Kerzman, Chetrit, Brin and Toren, 2004). • In some cases, falls may be a reflection of increased patient-care ratios (Titler, et al., 2005).

3. Problem Statement Elderly-related falls in the acute-care setting remains an ongoing and costly concern in health care. Although many institutions have implemented action plans geared toward multidisciplinary approaches for prevention, the majority of safety reliance remains on nursing and its interventions.

4. Significance The Centers for Disease Control reports that one in three adults greater than the age of 65 will fall annually (CDC, 2013). According to the CDC (2013), costs for falls involving the elderly ranged well over $30 billion in 2010 and is expected to double within the next ten years. “Patient falls that included risk factors were preventable and predictable up to 78%” (Titleret al., 2005).

5. Specific Aims • Implementation of the concepts of the theory of unpleasant symptoms to reduce falls through: • Early identification of risk factors • Anticipate symptoms • Aid in development of preventative interventions

6. The Theory of Unpleasant SymptomsLenz &Pugh (1995) • Classification: Middle Range Theory (MRT) • Purpose: Proposes to integrate previously existing knowledge regarding what is known about varying symptoms based on the premise that similarities exist among them and is experienced in a variety of clinical settings and circumstances. • Foundational concepts: • Symptoms-sensations that are professed or perceived personally by an individual. • Symptom expressions: Duration, intensity, time and quality. • Influencing factors: Physiologic, psychologic and situational.

7. Relationship Among Influencing Factors and Theoretical Concepts Performance/Behavior

8. Lenz & Pugh’s (1995) Original Construct of Theoretical Model/Conceptual Frameworks ofThe Theory of Unpleasant Symptoms

9. Application to Practice Disadvantages No preset identified list of interventions specified for particular group of symptoms to guide practice. Observations and identification of symptoms are dependent on the skills of the clinician to determine assessment of needs. Advantages • May be applied to multiple areas of nursing practice. • May address symptoms individually or in “clusters” to meet the needs of one individual. • Symptoms may be perceived objectively by the clinician (observation of performances) by patient.

10. Application to the Acute-Care Setting Communication • Shift reporting: that is concise and up-to-date is necessary for continuity in the identification of symptoms (Dykes, 2012). • Management: Consistent and timely communication with upper-level management is critical to navigate the patient’s location at all times. (Symptoms may suggest need for adjustment in clinical status or level of care)(Rochefort, Ward, Ritchie, Girard and Tamblyn, 2011). • Primary care providers: (PCP’s: MD/ARNP/PA) need to be aware of patient’s change in symptoms to adequately adjust current treatment modalities) (Rochefort, Ward, Ritchie, Girard and Tamblyn, 2011). • Team work: Nursing and non-nursing staff working within the same areas should communicate consistently to avoid potential patient-related mishaps. Many falls result secondary to a lapse in communication among team members (Dykes, 2012). Education • Patient Priority: Nursing, non-nursing staff and families are essential components in patient-centered care. Awareness of the anticipation of symptom changes is necessary to identify alterations in influencing factors, symptoms or behaviors that may result in a fall or other untimely event (AGS, 2010). • Evidence-based data: should be easily accessible to nursing staff that may facilitate constant education material for clinicians and families to ensure safety (Kerzman, Chetrit, Brin and Toren, 2004). • Clinical Competence: It is essentially important for nurses to be clinically cognizant of potential susceptibility secondary to medications, sedatives, diuretics, urinary incontinence, anxiety and disease processes that may lead to unsafe changes in cognition that place patients at risk (Murphy, 2011).

11. Symptom Identification/Anticipation According to Lenz & Pugh (1995), many symptoms correlate to multiple disease processes and are unique to patients individually. The influencing factors, in most cases exacerbate the theoretical concepts that give rise to the response or result of the original symptom. In the case of the provided example: Pain is a physiological sensation that could manifest in one behavior; however, given the significance of the influencing factors, may potentially affect the severity of the sensation of the unpleasant symptom. Nursing may overcome this cycle by working with families, increasing knowledge of clinical symptoms that employ critical thinking that will promote anticipation of needs. Communication with family and other consulting disciplines will assist in management of addressable influencing factors that may enable the patient to focus more on healing with less of a sense of helplessness.

12. Nursing: The Profession That Never Sleeps • It is largely assumed that risk for falls and patient safety is primarily a nursing concern (Titleret al., 2005). • While nursing carries the bulk of patient care and is responsible for care, all disciplines play a vital role in the safety and satisfaction of our patients (as we all benefit). • Active participation and involvement is a vital role in all of the of the disciplines within the area whether clinically or not. • The clinical environment is not only a business, but we are in business to provide consistent, safe and support across the continuum to all. • Nurses use your judgment, advocate and exercise your clinical expertise to ensure the best possible outcomes for your patients. • Don’t forget to communicate. Nursing is a 24 hour duty. We do more with less and can usually make something of nothing at all.

13. References • Graham, B. C. (2012). Examining evidence-based interventions to prevent inpatient falls. Medsurg Nursing, 21(5), 267-270. • Hutchinson, S., & Wilson, H. (1998). The theory of unpleasant symptoms and Alzheimer's disease... including commentary by Lenz ER and Gift AG. Scholarly Inquiry for Nursing Practice, 12(2), 143-162. • Kerzman, H., Chetrit, A., Brin, L., & Toren, O. (2004). Characteristics of falls in hospitalized patients. Journal of Advanced Nursing, 47(2), 223-229. http://dx.doi.org/10.1111/j.1365-2648.2004.03080.x • Lenz, E., Pugh, L., Milligan, R., Gift, A., & Suppe, F. (1997). The middle-range theory of unpleasant symptoms: an update. Advances in Nursing Science, 19(3), 14-27. • Lovallo, C., Rolandi, S., Rossetti, A., & Lusignani, M. (2010). Accidental Falls in hospital inpatients: evaluation of sensitivity and specificity of two risk assessment tools. Journal of Advanced Nursing, 66(3), 690-696. http://dx.doi.org/10.1111/j.1365-2648.2009.05231.x • Murphy, W. (2012). Improved patient safety and quality: a focus on falls. Home Health Care Management & Practice, (24)1, 62-64. http://dx.doi.org/10.1177/10884822311422822 • Nazarko, L. (2012). How to reduce risk of injury if a person remains at risk of falls. British Journal of Healthcare Assistants, (6)9, 432-437. • Rochefort, C. M., Ward, L., Ritchie, J. A., Girard, N., & Tamblyn, R. M. (2012). Patient and nurse characteristics associated with high sitter use costs. Journal of Advanced Nursing, (68)8, 1758-1767. http://dx.doi.org/10.1111/j.1365-2648.2011.05864.x • Titler, M., Dochterman, J., Picone, D., Everett, L., Xie, X., Kanak, M., & Fei, Q. (2005). Cost of hospital care for elderly at risk of falling. Nursing Economics, (23)6, 290-306.