chronic disease management

Question 1

Assess

Answer 1

Subjective Data (Personal and family
history, symptoms, medications,
spirituality, sexuality)
Mental Health Assessment (mood,
affect, appearance, behavior,
cognition, perception)
Objective Data and Physical Health
(head to toe, body systems)
Functional Assessment
Lifestyle (alcohol, smoking, exercise,
nutrition, weight

Question 2

Management

Goals

Answer 2

Reduce overall
disease burden – Healthy
behaviours, decrease risk factors
Symptom
Control – Pharmacological, Psychosocial, Complementary therapies
Achievement of
wellness and QoL (that is acceptable to
the patient)
Prevention of depression, anxiety,
emotional distress
Patient Self management

Question 3

FUNCTIONAL ASSESSMENT

Answer 3

• Arrangement of a functional or occupational assessment can be done to
maintain (or improve) the patients independence and sense of control.
It is important for the nurse to recognise their assessment capability and
when specialised support is needed. Ie. OT, SP, PT

Question 4

Benefits of a functional assessment can include:

Answer 4

• Therapy to increase physical function (Rehabilitation or Physiotherapy)
• Learning different techniques to complete a task
• Provision of equipment
• Adaptation of the patient’s physical environment

Question 5

MOTIVATIONAL INTERVIEWING

Answer 5

A proven, effective approach in motivating behaviour change in individuals to improve their health
status and persuade them to follow recommended treatment guidelines or healthier lifestyles.
The goal is not to force the change but motivate the individual to adopt healthier lifestyle choices.
It should be a collaborative, client-centred discussion where the individual is encouraged to
discuss their reasons for their health behaviours and to identify personal health goals.

Question 6

Communication techniques involved include:

MOTIVATIONAL INTERVIEWING

Answer 6

• Open-ended questioning
• Reflective listening
• Affirmations
• Summary

Question 7

THE 5 A’S MODEL

Answer 7

Assess – 
Advise – 
Assist – 
Agree –
Arrange –

Question 8

Assess

Answer 8

the client’s beliefs, behaviour and knowledge.

Question 9

Advise

Answer 9

the client about health risks and benefits of behavioural

change through the provision of specific and relevant information.

Question 10

Assist

Answer 10

the client to identify personal barriers and use problem-solving
techniques to work through these.

Question 11

Agree

Answer 11

on goals based on the clients interest and confidence in the clients
own ability to change her or his own behaviour.

Question 12

Arrange

Answer 12

a specific plan for follow up, such as visits and phone calls.