Promoting self-care through symptom management: A theory-based approach for nurse practitioners
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Transcript of Promoting self-care through symptom management: A theory-based approach for nurse practitioners
PRACTICE
Promoting self-care through symptom management:A theory-based approach for nurse practitionersChristopher Fowler, RN, PhD(c), ACNP (Acute Care Nurse Practitioner)1, Michelle Kirschner,RN, MSN, ACNP (Acute Care Nurse Practitioner)2, Debra Van Kuiken, RN, PhD(c) (Senior Research Assistant)3,& Linda Baas, RN, PhD, ACNP (Professor)4
1 Liver Institute at Methodist Dallas Medical Center, Dallas, Texas
2 Cardiovascular Consultants of Cincinnati, Cincinnati, Ohio
3 Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
4 Department of Adult Health, University of Cincinnati College of Nursing, Cincinnati, Ohio
Keywords
Common sense model; illness representation;
symptom management; self-care.
Correspondence
Christopher Fowler, RN, PhD(c), ACNP, 2133
Weatherbee Street, Fort Worth, TX 76110.
Tel: 214-947-4417 (office); Fax: 214-947-1828;
E-mail: [email protected]
Received: November 2005; accepted: April
2006
doi:10.1111/j.1745-7599.2007.00218.x
Abstract
Purpose: To present a theory of illness representation useful in clinical practice
along with two case studies as examples of theory implementation.
Data sources: Literature review of relevant theory and associated literature,
case studies from clinical practice.
Conclusions: An individual asks several questions when experiencing a phys-
ical sensation: ‘‘Am I sick, stressed, or is this a sign of aging? If I’m sick, is the
symptom connected with a disease label?’’ After asking these questions, the
individual develops a cognitive and emotional illness representation that
includes the dimensions of identity, cause, consequences, control, and timeline.
This representation is guided by personal, cultural, and environmental contexts
and determines coping strategies. By assessing the individual’s cognitive and
emotional representations of the illness, the nurse practitioner (NP) can use the
common sense model of illness representation (CSM) to establish interventions
and action plans helpful in decreasing distress in the management of symptoms.
Implications for practice: NPs frequently care for patients who present with
very severe symptoms related to their health problem. This becomes a major
challenge in effective disease management. Leventhal’s CSM can be used as a
framework to identify the cognitive and emotional illness representations
individuals develop when acute and chronic symptoms are presented. By
assessing the individual’s cognitive and emotional representations of the illness,
the NP will be able to use the CSM to establish interventions and action plans
that will be helpful in decreasing the patient’s distress in the management
of symptoms.
Introduction
Nurse practitioners (NPs) frequently see patients who pres-
ent with such severe symptoms related to their health
problem that it becomes a major challenge to manage
the disease. Many of these patients either have difficulty
recognizing an increase in the number and severity of
symptoms or do not seek treatment when they know that
symptoms are worsening (Baas, Beery, Allen, Wizer, &
Wagoner, 2004; Noble & Robertson, 1996). This poses
a major challenge for the clinician who would like to
optimize the patient’s self-management of the illness. Ulti-
mately, if symptoms are recognized early and if the indi-
vidual then takes the appropriate self-care action, hospital
and/or emergency department visits could be avoided and
better care outcomes achieved (Grady et al., 2000).
Johnson (1999, p. 444) stated that ‘‘theory is useful to
practitioners because when the process through which an
intervention effects outcomes is understood, there is a basis
Journal of the American Academy of Nurse Practitioners 19 (2007) 221–227 ª 2007 The Author(s)Journal compilation ª 2007 American Academy of Nurse Practitioners
221
for decisions about the applicability of the process to
situations other than those used in the research.’’ The
common sense model of illness representation (CSM)
was developed to explain how a person processes an illness
threat (Cameron & Leventhal, 2003). By understanding
the elements that are a part of a person’s representation,
the NP can best determine interventions that are appro-
priate and useful. This article will discuss problems that
interfere with symptom recognition and subsequent self-
care actions. The CSM and case studies involving acute and
chronic symptomswill bedescribed.Finally, the implications
of using this theory to promote self-care will be discussed.
Recognizing physical symptoms
Two distinctly different problems arise when an indi-
vidual recognizes physical symptoms. The first is aware-
ness that the physical sensation is associated with a health
problem. The second problem is determining when the
sensation is getting worse and the person needs to seek
help. These problems are common in persons with acute or
chronic illness and require different strategies.
Recognizing new physical sensations
Just as it takes a skilled clinician to identify symptoms
and formulate a diagnosis, it takes skill on the patient’s part
to recognize symptoms and appropriately attribute cause
(Cioffi, 1991; Leventhal, Brown, Shacham, & Engquist,
1979). The physical sensations associated with symptoms
are often vague, may be unique to the individual, and may
not fit a textbook description. A physical sensation may be
normal in one situation but not in another. For instance,
shortness of breath is normal after heavy exertion, but it is
abnormal when sitting or lying down. While we may have
textbook patterns for some problems, in reality there is
often wide variation in the way a symptom presents. At
times, these differences are based on gender and age or
may be mediated by comorbidities. Adding to the chal-
lenge is that any given symptom can be associated with
many causes.
For example, chest pain has many etiologies and ways in
which it can present (Braunwald, Zipes, Peter, & Bonow,
2004). Causes of chest pain range from cardiovascular and
pulmonary disorders to gastrointestinal and musculoskel-
etal problems. Recent research has demonstrated a pro-
nounced difference in the manner in which men and
women experience chest pain (McSweeny, Lefler, &
Crowder, 2005). Persons with diabetes mellitus experience
less severe chest pain and more shortness of breath and
fatigue during a myocardial infarction (MI) (Seller, 2000).
This is enough to confuse a healthcare professional; it can
render the layperson bewildered by the experience and
unsure of what to do (Cioffi, 1991).
Recognizing worsening of symptoms
The second problem in symptom recognition occurs
when the person has difficulty recognizing worsening of
the symptom and/or determining when the symptom is
severe enough to take action (Cioffi, 1991). This can
happen even when the person has experienced the symp-
tom before and is relatively sure of what to do when the
symptom occurs. The symptom or sensation may begin as
a mild sensation and build slowly in a crescendo pattern
that may occur slowly over weeks or months or rapidly
over days or hours. From 1 h to the next or 1 week to the
next, the increase in severity may be so small and gradual
that it becomes impossible to detect the difference.
Initiating self-care actions
Once symptoms are recognized, the individual needs to
take some form of self-care action (Cioffi, 1991). Two
problems can occur at this point. The person may not have
enough information to know what to do or may fear taking
action. Again, these are two distinct problems with differ-
ent strategies for management.
Deciding upon an action
A new symptom leaves most people unsure of what to
do. While some people seek professional advice, many
turn to family and friends for advice on when to seek
attention from the medical community. The advice given
by the lay sector often determines initial health actions in
response to a new symptom (Leventhal, Leventhal, &
Robitaille, 1998). Lay advice is greatly influenced by past
personal experiences as well as media campaigns about
health issues. If lay advice fails to demonstrate an improve-
ment, then the person frequently turns to a healthcare
professional. Once sensations or symptoms are recognized
as part of a pattern of illness, the individual has a template
for future comparison.
Fearing the outcomes of action
Fear may be the reason a person recognizes the symptom
and knows that it is worsening yet does not seek treatment.
The person may believe that the underlying disease is
progressing or may fear ‘‘bad news,’’ hospitalization, or
more intense treatment. Clinicians have known for some
time that fear can have both adaptive and maladaptive
consequences.A little fear canbe a motivator, but too much
fear can render the person paralyzed from taking appro-
priate action (Christman, Kirchhoff, & Oakley, 1992).
Patients with both acute and chronic illnesses are taking
amoreactive role in theirhealthcareand expect their beliefs
regarding their illness to be considered in consultation and
Self-care through symptom management C. Fowler et al.
222
treatment. A variety of theoretical models have been devel-
oped to incorporate the patient’s cognitive processing when
dealing with the impact of acute and chronic illnesses. The
CSM addresses both cognitive and emotional processing in
a social and environmental context (Cameron & Leventhal,
2003). It is the focus of this article to apply the CSM to two
case studies in an attempt to demonstrate successful strat-
egies for increasing self-care in clinical practice.
Common sense model of illness representation
In the early 1970s, studies of the effect of fear messages
on health-related behaviors demonstrated that develop-
ment and implementation of an action plan were related
not only to the fear but also to the individual’s changed
thinking with regard to the health threat (Leventhal et al.,
1979). This work led to the development of the CSM in the
1980s. This theory, previously referred to as the theory of
self-regulation, has been refined and widely studied from
the perspective of many disciplines over the past two
decades (Diefenbach & Leventhal, 1996; Johnson, 1999;
Leventhal et al., 1998). The CSM provides an overall
framework for describing health-related behaviors; it inte-
grates social and contextual factors with an individual’s
cognition (knowledge and thoughts) and affect (emotions)
(Leventhal et al., 1979). The cognitive and affective factors
are taken together to form the overall illness representa-
tion. In this model, health and illness behaviors are the
product of the combined action of the illness representa-
tion (cognitive and emotional perceptions), of specific
illness threats, and of the coping processes used in the
situation (Brownlee, Leventhal, & Leventhal, 2000).
In the CSM, the individual is an active problem solver
who selects coping strategies to control perceived risks
(Leventhal, Diefenbach, & Leventhal, 1992). This individ-
ual deals with two phenomena simultaneously: (a) the
perceived reality of the health threat and (b) the emotional
reactions to that threat. Both personal and sociocultural
factors influence the representation of the disease threat,
the perceived availability of treatment and prevention,
and the criteria used for evaluating the outcome of treat-
ment. Personal and environmental factors such as prior
illnesses, an individual’s somatic self, depression, activity
level, and personality traits (i.e., type A personality, opti-
mism–pessimism, defensive or attributional styles) influ-
ence the development of cognitive and emotional illness
representations. Social and cultural factors include the
ease with taking on the sick role, the consistency of the
individual’s beliefs with the main cultural environment,
and the consistency of the individual’s beliefs with those of
the healthcare provider in determining which symptoms
will be reported and the expectations for treatment
(Leventhal et al., 1992; Leventhal et al., 1998).
Stimulus
According to the CSM, an internal or external stimulus is
interpreted and elaborated upon by the individual to form
a more complete picture of the illness threat. These rep-
resentations change over time and guide subsequent
actions (Leventhal et al., 1998). When the stimulus is
internal (i.e., a somatic sensation or symptom), the indi-
vidual attempts to assign meaning to that sensation. The
meaning of the stimulus depends upon its similarity or
dissimilarity to prior illness episodes or upon the patient’s
beliefs about another illness such as cancer or multiple
sclerosis. When the stimulus is external (i.e., a news report
or the occurrence of an illness in a loved one), the illness
representations are checked against the individual’s sense
of his or her health and perceived susceptibility to disease
(Leventhal et al., 1998).
Illness representation
When developing a cognitive illness representation, an
individual considers five components: (a) identity, (b)
cause, (c) timeline, (d) consequences, and (e) controlla-
bility/cure (see Figure 1). The identity component includes
the disease label and the individual’s perception of the
physical or somatic aspects of that disease. Identity is an
essential component of the illness representation and
emphasizes the importance of physical cues or somatic
sensations as a trigger for cognitive and emotional process-
ing. The cause component defines the patient’s beliefs
regarding what caused the illness (i.e., genetic causes, poor
lifestyle choices, bacteria). It is important to remember that
it is the patient’s perception of cause, not the healthcare
provider’s, which influences the illness representation.
The timeline component includes the individual’s beliefs
about the duration and frequency of illness episodes.
Timeline includes whether the illness is acute, chronic,
or cyclical in nature. Furthermore, it includes patterns of
illness occurrence. The consequences component includes
the individual’s beliefs about the impact of the illness on
Stimulus
CognitiveRepresentation
CauseConsequencesControllability/Cure Identity Timeline
Emotional Representation
CopingStrategies
CopingStrategies
AppraisalProcess
AppraisalProcess
Figure 1 Graphical representation of Leventhal’s CSM.
C. Fowler et al. Self-care through symptom management
223
the person. Consequences include personal experiences,
economic hardships, emotional stress, social role, and
quality of life. The controllability/cure component includes
the individual’s beliefs regarding the responsiveness of the
stimulus to interventions implemented by the individual
and by healthcare providers (Leventhal et al., 1992;
Leventhal et al., 1998).
Emotions are an integral component of the CSM.
The emotional representation of the illness develops
simultaneously with the cognitive illness representation.
This emotional representation develops as a more sub-
jective experience and creates feeling states such as annoy-
ance, anger, depression, and anxiety (Leventhal et al.,
1992). Emotion functions in either a positive or a negative
way. If the emotion is accompanied by an action plan, it
can motivate the individual to engage in healthcare activ-
ities. However, if the emotion is overwhelming, less action
is taken. Emotional states can influence cognitive illness
representations in multiple ways, including: (a) affecting
the onset and progression of an existing disease, (b)
increasing the difficulty of self-diagnosis and the decision
to seek care, (c) altering attention to and interpretation of
the physical states, and (d) affecting health-related behav-
ioral decisions in response to physical or somatic changes
(Leventhal et al., 1998).
Coping
The categorization of the stimulus and the individual’s
development of the cognitive and emotional illness rep-
resentations lead to the selection and implementation of
coping strategies directed toward management of the
cognitive and/or the emotional illness representations
(Leventhal & Mosbach, 1983). Coping strategies are aimed
at decreasing the emotional distress and alleviating or
ending the threat of the illness. If emotional distress is
overwhelming, coping will be focused on emotional com-
fort. If emotional distress is not overwhelming, the person
will be able to focus coping strategies on behaviors that are
aimed at eliminating the illness threat (Taylor et al., 1992).
Appraisal
The final stage of the CSM is the appraisal stage. The
illness representations and subsequently selected coping
strategies will lead to certain expectations that play a crit-
ical role in the appraisal of the effectiveness of these coping
strategies (Leventhal & Mosbach, 1983; Leventhal et al.,
1992; Taylor et al., 1992). At this point, the individual
appraises if barriers and facilitators to the performance,
efficiency, and effectiveness of coping strategies exist.
Evaluation of the coping procedure will include compar-
ison of the anticipated outcome with the actual outcome,
such as ‘‘Did the treatment have the desired effects?’’ The
appraisal process functions as a feedback loop. A treatment
that does not have the desired effect may cause the person
to alter his or her representation (shortness of breath is
not because of exertion) or may lead to new or modified
coping strategies (calling a healthcare provider or taking
a diuretic).
A theoretical framework similar to the CSM is the theory
of modeling and role modeling (Erickson, Tomlin, &
Swain, 1988). The core similarity is that it is the person’s
model of the world or the experience that must be
explored. Each individual comes to a situation with a dif-
ferent set of past experiences that shape the current situ-
ation, perceptions of health and what will make the
situation better, and coping resources that are perceived
to be available. To assist the individual, the healthcare
provider must understand these representations.
Johnson has conducted research in patient education
that is based on the CSM. This approach to patient edu-
cation is sometimes called concrete objective teaching and
in other sources called sensory preparatory teaching. In
this model, teaching focuses on factual information while
also preparing the person for possible physical and emo-
tional responses surrounding the event. For instance,
when teaching the patient who is preparing to undergo
a cardiac catheterization, the nurse would describe what
the patient will see, hear, and feel during the test.
Johnson’s (1999) work has been widely studied and ap-
plied to clinical practice.
Case studies
The following two case studies are of two patients who
present with similar symptoms. The first is a patient with
new symptoms and illustrates an acute illness scenario.
The second case involves a patient who has a chronic
condition with an exacerbation of a recurring symptom.
These cases are similar to those NPs see routinely in
practice.
First case study: Susan
Susan is a 28-year-old teacher who has had seasonal
allergic rhinitis every autumn for the past 3 years. She had
frequent episodes of atopic dermatitis as a child. She is
married without children. She recently found a stray cat
and has been keeping it in her apartment. Her postnasal
drip has worsened but she is in good health. She is not
sleeping well and frequently awakens because of trouble
breathing. She attributes her sleep disturbance to her
‘‘sinus problems.’’
Susan finds that she is more fatigued and blames it on
her interrupted sleep. Her coworkers tell her that they are
concerned. She has a constant dry cough and cannot speak
more than a few words at a time without coughing. She is
Self-care through symptom management C. Fowler et al.
224
also not able to walk up the steps without uncontrollable
coughing midflight. She identifies that her symptoms have
been getting progressively worse for the past 3 weeks and
decides to see the NP.
Susan’s respiratory rate is 36 breaths per minute on
exam. She is wheezing throughout her lungs and has
diminished breath sounds. Susan’s peak flow is 60% of
predicted for a woman of her age and weight. The NP
makes a diagnosis of reactive airway disease versus
asthma, which may have been precipitated by exposure
to the cat. Treatment consists of inhaled bronchodilators,
oral and inhaled corticosteroids, and education about
reactive airway disease and asthma; goals of therapy
include minimal or no chronic symptoms with no limi-
tations on activities and maintenance of near-normal
pulmonary function. Education will involve use of the
peak flow meter to monitor response to medications, as
recommended in most general guidelines for treatment
(National Asthma Education and Prevention Program
Expert Panel Report, 2002).
This is the first experience that Susan has had with
wheezing and shortness of breath. She had no knowledge
of what the symptoms might mean or when she was in
danger (Cioffi, 1991). She will now need particular infor-
mation about the nature of the illness, cause, timeline,
consequences, and controllability of asthma. This will
include how to recognize symptoms, how to monitor
her peak flow, and when to call for worsening signs and
symptoms. She will need to learn how to reduce allergens
in her environment. The most emotional of the decisions
that she may face will be giving her cat to someone else, as
she may not be able to tolerate living with the animal.
Should she decide to keep the pet, she will need to make
changes in her home to lessen the risk of symptom exac-
erbations. Follow-up visits with Susan can be shaped by an
assessment that is based on the CSM.
Second case study: James
The second case study is also of a person experiencing
shortness of breath. However, this patient has a chronic
problem and has previously experienced the symptoms.
He has been given information about his illness but has not
monitored the symptoms nor has he followed instructions.
James is a 68-year-old retired male who presents to the
hospital with an episode of decompensated heart failure
(HF). Two years ago, James suffered an anterior wall MI
and has been hospitalized several times for HF exacerba-
tion. Because his symptoms occur with less than usual
activities, he is rated as having New York Heart Association
Class III severity (moderate). Four days ago, he noticed
increasing shortness of breath and peripheral edema that
has progressively worsened. Thinking that the symptoms
would resolve, he did not call his cardiologist. He was
subsequently hospitalized.
During his hospitalization, James is treated in the inten-
sive care unit with aggressive diuresis and symptom man-
agement. Once James’ baseline knowledge is assessed, the
NP can begin teaching about the identification of physical
symptoms such as dyspnea, fatigue, and swelling that
represent a worsening of his physical condition.
The evaluation and teaching plan for this patient takes
into account personal and sociocultural factors that could
influence his evaluation of symptoms and response. Dur-
ing an initial interview, James is unsure of his medications
or when he was last seen by the cardiologist. He states that
his wife of 41 years has a pivotal role in monitoring and
managing his care, including dispensing medications and
making medical appointments. She needs to be involved in
the education as James relies on his wife’s ability to help
him in processing symptoms and determining an accurate
illness representation. Social beliefs as to the acceptability
of a symptom may also influence whether James will seek
help. Other social and cultural beliefs that prevent treat-
ment of symptoms also need to be explored.
The NP’s individualized patient education plan focuses
on gathering essential data and teaching the most vital
concepts during hospitalization. The period of decompen-
sation is most useful for initiating sensory teaching, and
this may be of greatest importance (Grady et al., 2000). The
process begins in the hospital and needs to continue in the
outpatient setting. Potential venues could include NP-
managed HF clinics, support groups, or cardiac rehabilita-
tion classes.
Discussion
In discussing the application of theory to practice, it is
important to define the assumptions underlying the the-
ory. The CSM posits that individuals are active problem
solvers and that the individual’s representation of the
illness will guide coping actions and behavior. It is also
assumed that these representations may not be in agree-
ment with medical ‘‘facts’’ (Leventhal et al., 1998). There-
fore, it is important for the NP to note the individual’s
representation of the illness. Susan attributed her fatigue
to trouble sleeping and her trouble sleeping to sinus
problems. This is an indication that Susan has not linked
her symptoms to either her cat or asthma or a reactive
airway. By giving her information that links the symptoms
with the underlying illness, the NP will provide symmetry
between the disease label and the symptoms (coughing,
fatigue, wheezing, shortness of breath). The symmetry
rule is crucial in both understanding the recognition of
the symptom as a sign of illness and determining the
actions needed. For example, if James is not feeling any
C. Fowler et al. Self-care through symptom management
225
symptoms of his HF or hypertension, he may decide that he
does not need to take his medication. Or if James were to
take a diuretic and still have trouble breathing, he may
adjust his representation and attribute the dyspnea to
another source.
Recognition of symptoms can be further delayed or
hindered by the attribution of symptoms to stress or aging.
For instance, Susan may attribute the fatigue to stress
at work, or James may interpret his low activity tolerance
to signs of stress or aging and therefore feel there is no
treatment. Horowitz, Rein, and Leventhal (2004) found
that many patients with heart disease did not link their
symptoms with the diagnosis of HF. Building the link
between symptoms and illness label (identity) can moti-
vate the individual to be vigilant in monitoring for symp-
toms and adhering to treatment (Diefenbach & Leventhal,
1996). Reinforcing education on the link between short-
ness of breath, weight gain, and edema with the label of HF
will help James and his wife to recognize these as treatable
symptoms attributable to a specific diagnosis.
Recognizing worsening of symptoms is often a problem
for those with a chronic disease. The timeline aspect of the
illness representation addresses some of the confusion. In
a study of 50 patients with known HF, some patients saw
their HF as episodic, not as a chronic condition (Horowitz
et al., 2004). Rather than having a representation of HF as
an ever-present chronic condition, many patients viewed
their HF as acute in nature and therefore did not con-
tinuously monitor symptoms. Without monitoring, the
symptoms may develop slowly or quickly, often not being
recognized until severity warrants a visit to the emergency
department. Having incomplete knowledge of the symp-
toms and the timeline can lead to an inaccurate represen-
tation and a delay in seeking treatment.
The insidious nature of worsening symptoms compli-
cates a procedure that is already hampered by the distress
of having a chronic disease. Johnson (1999) and Cioffi
(1991) have highlighted the advantage of education that is
focused on concrete sensations, as experienced by the
individual. This allows the patient to assign a meaning
to the sensation based on a cognitive illness representation
and lessens the emotional response to the situation.
Leventhal posited that instructing an individual to focus
on the sensory aspects of the sensation, a process he called
sensory monitoring, can divert the patient from a destruc-
tive emotional response (Leventhal et al., 1992). Sensory
awareness training is one method that can be taught to
James to increase identification of physical sensations.
Several approaches to sensory perception training can
be used. Allowing patients to rate dyspnea on a visual
analogue scale before and after diuretic or bronchodilator
administration can encourage focusing on sensory percep-
tion during times of greatest fluctuation. Optimally,
a patient can identify a specific treatment that can relieve
negative symptoms and institute a pattern of self-manage-
ment. In an ideal scenario, James would identify early
sensory changes that are associated with worsening HF
and make appropriate adjustments in treatment to include
taking additional diuretics and reducing sodium and fluid
intake as taught.
Sensory teaching for James could focus on the early
identification of dyspnea. Evidence indicates that changes
in distress or intensity of dyspnea may serve as an impor-
tant trigger for emergency department visits and subse-
quent hospitalization. The use of sensory perception
teaching in HF patients may allow for early identification
of prodromal changes in the character of dyspnea. This
early warning system, accompanied by objective measures
of volume overload such as weight gain, potentially moti-
vates individuals with HF to alter their treatment in
a timely manner. This potentially prevents costly care
and unnecessary hospital stays.
Assisting patients in appropriately establishing the five
components that make up the cognitive illness represen-
tation serves as a guide for a cognitive evaluation of
symptoms rather than an emotional schema. In the case
of James, the initial step is helping him to identify symp-
toms of worsening HF. The next component is outlining
potential causes of worsening symptoms such as increased
salt intake or noncompliance with medications. The NP
can assist James and his wife in understanding the timeline
of his illness and the chronic nature of HF, including the
cyclic waxing and waning of symptoms. An individualized
education plan addresses the positive benefits of early
response to symptoms and the consequences of a delayed
response. This includes the beliefs of the patient and his
wife regarding how HF is controlled. Creating accurate
constructs of these five components can be helpful in
producing effective coping strategies and self-care.
Susan’s reactive airway and probable asthma will
require many of the same representations of chronic illness
with periods of little or no symptoms. However, her cur-
rent perception of her conditions is one of acute onset and
nature. The NP will need to listen for Susan’s perceptions
and assist her in forming representations that are accurate
and will help Susan in her self-care.
Even with recognition of symptoms, self-care may be
delayed or avoided because of fear or confusion as to what
course of action needs to be taken. By helping the patient
form representations that are accurate, both of these
elements will diminish. As James and his wife begin to
see HF as a condition that must be monitored daily
(chronic timeline) and are aware of the symptoms that
are associated with HF (dyspnea, edema, weight gain),
they will be alert to the sensory cues and know what
actions to take and avert the fear response. When James
Self-care through symptom management C. Fowler et al.
226
is able to recognize and treat symptoms successfully, he
will see the condition as one that can be self-monitored
and treated. As James treats symptoms, his representation
of those symptoms will be altered based upon success of
treatment or negative outcomes.
Interventions must incorporate all components of the
self-regulation system to be successful (Leventhal et al.,
1998). The potential use of nursing interventions to pro-
mote specific outcomes exists in the illness representation,
coping, and appraisal phases of the model. Irrelevant past
experience and social myths can dominate in the inter-
pretation of stimuli and generate illness representations
and self-regulative systems that are false (Leventhal et al.,
1992). From the perspective of the CSM, successful treat-
ment requires the replacement of a self-regulative system
that is false with one that is coherent and valid (Leventhal
et al., 1992).
Conclusions
The usefulness of the CSM in two clinical scenarios has
been presented. The individual will ask several questions
when experiencing a physical sensation: ‘‘Am I sick,
stressed, or is this a sign of aging? If I’m sick, is the symptom
connected with a disease label?’’ After asking these ques-
tions, the individual will develop an illness representation
that will include identity, cause, consequences, control,
and timeline. This representation will be guided by per-
sonal, cultural, and environmental contexts and will
determine the coping strategies. As coping strategies are
appraised for effectiveness, the representation may change
and coping strategies be adjusted. By assessing the indi-
vidual’s cognitive and emotional representations of the
illness, the NP will be able to use the CSM to establish
interventions and action plans that will be helpful in
decreasing distress in the management of symptoms.
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