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: christopher.fowler@sbcglobal.net

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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