Nursing 619: Patient Interview

Upon entering a patient’s room, one tends to see the patient only in the specific time frame with only the current issues at hand. Instead of seeing the patient as an individual with a personal story, he or she may be seen as another case of whatever disease it is that may be exhibited. It is difficult to put a client into context when one does not know the entire story behind the present illness. This is why it is crucial for nurses to know and clearly understand a patient’s health history along with his or her current health status. The application of the transition and trajectory theories can help nurses to place patients in a greater story to understand how the patients got where they are, the issues patients may encounter, and where they will go as far as their health status is concerned.

The trajectory theory can tell a nurse about a patient’s progression of illness and their experience with this progression. As a nurse, one would particularly care about the progression of illness and a patient’s experience with it, because it assists the nurse in developing a more specific and individualized plan of care for that patient. By looking at a patient’s trajectory, a nurse can tell where a patient is at any given time in his or her health status. By finding this particular stage in the trajectory, a nurse can determine which needs are essential for the patient at that time. The trajectory theory can also assist nurses in looking at the picture as a whole. The nurse can examine a trajectory, learn the appropriate outcomes and focus the plan of care on achieving these outcomes. It is important as a nurse to realize that any intervention performed will have an affect on the patient’s outcome making it much easier as a nurse, to fit reliable interventions with predetermined outcomes.

The trajectory theory is the idea that there is a particular course of action for any person experiencing a situation in his or her life whether it be biographically, in reference to work, or in relation to an illness (Corbin). A trajectory experienced biographically may be one encountered through a person’s life such as leaving one stage of life and entering into another. This can be found when a person goes from a lifestyle where working was a main duty to becoming retired and finding other things to do with one’s time. A trajectory in reference to work may be working one’s way from a low-end job to a much higher level job where one is given more responsibilities and tasks to become involved with. The illness trajectory is more commonly used by nurses and other health care providers. The illness trajectory can assist health care providers in determining a patient’s health progress or decline, and where he or she stands in this trajectory. With this tool, the stage of the illness can be concluded, such as the time before symptoms began, the onset of symptoms, the acute illness, stable and unstable phases, the deterioration phase and the dying phase or the alternate route of regression to patient’s pre-illness state (Shippee-Rice).

The transition theory is based on the idea that when one encounters a change in life or something different, one may make an alteration in his or her current lifestyle to progress to a higher or newer state of being (Meleis). The ability to realize that a change is occurring is important for nurses and all health care providers alike. Knowing that there is an upcoming change or being able to recognize signs of an already occurring change, allows the nurse to find ways in assisting the patient in making his or her transition to the next phase of their life or trajectory (Selder). With assistance and support, patients may feel more at ease during their transition and may also have better outcomes.

Both the transition theory and the trajectory theory have a strong relationship with one another. The trajectory theory is a path that consists of different stages. When a patient is at one stage and moving into another, a transition is required. This is so, because the patient is reaching a different phase from the one he or she was currently in. For example, a patient may go from a stable phase in which the patient may think that his or her health may be improving, but instead, the patient enters into a phase of deterioration. The transition made here may be the patient coming to terms with the fact that the disease has not completely finished its course and that he or she may remain ill longer or may need to stay in the hospital longer than had been planned, keeping the patient from getting back to his or her normal routine in life.

The interview with my patient went very smoothly despite my fear of having a difficult time accomplishing what needed to be done. Once I was finished assisting my patient with her morning care, I requested her permission to ask some questions about her health and the factors surrounding it, and she agreed to answer any questions I had, to the best of her ability. Before starting this interview, I had written down a few questions to ask, thinking that it would be the best way to start conversations which may lead to other questions. I had taken a chair to the patient’s bedside and sat down so that I was at eye level with her. It was then that I began to ask my questions. Some questions that I had asked included; what is your perception of your health status at this moment, how has your health been in the past, what do you feel will be the outcome of your illness, and how do you cope with your illness or keep yourself healthy. These questions led to further questions such as; where do you live, where does your family live, what kinds of activities do you enjoy, when did you first start to notice you were ill, what brought you into the hospital and many more while trying to stay focused on patient’s health. The interaction progressed very nicely and continued as more of a conversation between the two of us rather than a question and answer interview.

The patient I had interviewed was very open about her illness. Although her diagnosis may have appeared simple at first, because it was Pneumonia, she had a lot to share with me about her illness and her life. The patient had shared that she felt miserable and not like herself, she had previously been fairly healthy and without any issues besides a minor case of Pneumonia which she had the previous month, but was treated for. She has four children and lives in a nursing home. She told me that while at the nursing home, she was independent and was able to do many things on her own, but since she became diagnosed with Pneumonia, she has felt very weak and unable to be as active as she may have been in the past.

When looking at my patient in terms of her trajectory, I found her to be in the acute phase. In the acute phase, the patient is hospitalized with an acute illness. This phase follows the trajectory onset, when signs and symptoms first begin to appear (Shippee-Rice). Typically, in an elderly patient, Pneumonia is diagnosed when signs and symptoms such as general deterioration, weakness, abdominal symptoms, anorexia, confusion, tachycardia and tachypnea are present. Chest x-rays are obtained to differentiate a diagnosis of Pneumonia from chronic heart failure which may cause similar signs and symptoms. Treatment is provided by means of adequate hydration, supplemental oxygen therapy, assistance with deep breathing and coughing, frequent position changes and early ambulation (Smeltzer). These treatment options may provide the patient with the strength to reach a more stable phase and return to his or her pre-illness state where as they may also provide no benefit to the patient and he or she may begin to deteriorate and possibly die. This branch between deterioration or becoming well again may be seen as the stable or unstable phase of a patient’s illness trajectory where as the complete decline to death or incline to a pre-illness state may be seen as the final stages of the trajectory.

A major transition that the patient will have to make is relying on health care workers, and others to assist her in completing her activities of daily living or at least providing more assistance than she otherwise would have required. This is something that the patient has not needed to allow in the past because she has been fairly independent. This is a transition that the patient will need to make in order to allow herself to be taken care of because she is too weak and unable to do so appropriately. The patient stated that she does not experience many ups and downs with her illness although she has not been diagnosed with Pneumonia for long. One up for her may have been being treated for her first diagnosis of Pneumonia and being free from the illness, although a down would have been contracting the illness again only a month later which had brought her into the hospital at this time. The patient is Catholic and believes that praying each day and having her family who supports her, has made being ill easier to handle because she is not alone. The patient states that very few things bother her, she is very easy-going and does not experience many stressors or things that make her illness more difficult to deal with. She keeps her head up in any situation and always looks at the positive aspect of any issue she is up against. The patient does expect that her condition will be treated and she will return to her pre-illness state rather than the condition worsening. She is very optimistic and follows doctors and nurses orders closely to better improve her current health status and outcomes.

Three variables that are affecting this patient’s trajectory are adherence to treatment regimen, family support, and her attitude and belief system, all of which have a positive affect on her trajectory. These three factors also affect a patient’s transition within his or her trajectory. Adherence to treatment regimen is important with any condition. The more likely a patient is to adhere to his or her treatment, the better chances a patient has of a positive outcome, leading the patient to a more positive path on his or her illness trajectory. Family support is also important because it gives the patient motivation to stick with the treatment being prescribed by doctors and nurses, and it also lets the patient know that there is somebody there who cares for him or her. Without any support from her family, this patient may have given up on following her treatments or may not have cared about her health or treatments at all. A positive attitude is great to have in any situation. When people have a negative attitude, they may become depressed because they see no good side to the situation which may lead to incoherence to treatment and worsening of a condition. An optimistic attitude gives the patient high hopes and a more positive outlook on his or her trajectory, seeing only that a good outcome will arise from the situation rather than a poor one. Having a belief system may also apply the same benefits to an illness trajectory as does a family and a strong support system. Having a certain belief can give one faith in both his or herself, and the outcome of the trajectory of the disease.

With a better view on the patient’s trajectory and transitions, nursing care can be much improved. When looking at where a patient is and where a patient may be going, a nurse can focus his or her care on that specific time period as well as preparing for what may be ahead. As a nurse, it is important to focus on the future of a client’s condition, but most importantly, his or her present health status because the interventions that are provided now will be the ones which affect the future outcomes. It is also important for the nurse to look at the past stages of the patient’s illness trajectory in order to understand how the patient got where he or she is. This way, the nurse can assist the patient in changing the things that may have caused his or her illness to begin with. The transitions patients are making is also important for a nurse to pay attention to. If a specific transition is being made by the patient, or needs to be made in order to enhance his or her health, it is the nurse’s job to find the best way to make this possible. It is the responsibility of the nurse to assist the patient in identifying and altering the poor health habits that a patient may have in a way that will be most successful for the patient.

This patient’s trajectory was similar to that found in theory. The illness trajectory for this patient had a pre-trajectory phase, a trajectory onset phase, an acute phase, and so far, also a stable or unstable phase (Shippee-Rice). Also, as stated in Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, the elderly population with Pneumonia may be more difficult to treat and in turn resulting in a higher mortality rate. It is here that I also see my patient following the assumed trajectory of Pneumonia. Because this patient had been 84 years old and had already been diagnosed with Pneumonia but contracted it again, I found it to be more likely that she would have many more complications. Seeing this patient case and knowing the risks of Pneumonia within the elderly population has shown a consistency with the expected trajectory.

These models and theories are very useful in practice. Nurses are more likely to see the patients as a whole and not just as a case when he or she looks at the patient’s trajectory and entire story. Many times, a nurse may go into a patient’s room only to examine the current situation on hand rather than considering many of the underlying variables that have a large impact on the patient’s current and future health status. All nurses should be examining their patients by using the trajectory and transition theories in order to best provide care for their patients.



References
Corbin, J. R.N. (1998). The corbin and strauss chronic illness trajectory model: an update. Scholarly Inquiry for Nursing, 12, 33-41.
Meleis, A., Schumacher, K. (1994). Transitions: a central concept in nursing. IMAGE: Journal of Nursing Scholarship, 26, 119-127.
Selder, F. Life transition theory: the resolution of uncertainty. Nursing and Health Care, 10, 437-451.
Shippee-Rice, R. Ph.D., R.N. (2007). Clinical Decision Making 1: Transition and Trajectory. Unpublished presentation.
Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever, K.H. (2008). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. Philedelphia: Lippincott, Williams & Wilkins, a Wolter Kluwer Business (11th ed., Vol. 2).