The Theory of Unpleasant
Symptoms:
Clinical Application
An Acute-Care View
Alexis Farrington, BSN, RN
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).
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.
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%” (Titler et
al., 2005).
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
The Theory of Unpleasant Symptoms
Lenz & 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.
Relationship Among Influencing
Factors and Theoretical Concepts
Physiological
Psychological
Situational
• Disease
Process
•Fear
•Personal
•Finances
• New Diagnosis
•Anxiety
Distress
Intensity
Performance
/Behavior
Symptoms
Quality
T-i-m-e
Lenz & Pugh’s (1995)
Original Construct of Theoretical Model/Conceptual
Frameworks of
The Theory of Unpleasant Symptoms
Application to Practice
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.
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.
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 patientcentered 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).
Symptom
Identification/Anticipation
 According to Lenz & Pugh (1995), many
symptoms correlate to multiple disease
processes and are unique to patients
individually.
Performance/
Behavior
Consequence
Theoretical
Concepts
 The influencing factors, in most cases
exacerbate the theoretical concepts
that give rise to the response or result of
the original symptom.
Physiological
Diagnosis
Pain
 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.
Influencing
Factors
T-i-m-e
Intensity
Psychological
Loss of
independence
Anxiety
Restless/Aggression
Quality
Distress
Situational
Finances
Lack of Insurance
Fear
Nursing: The Profession That Never Sleeps
 It is largely assumed that risk for falls and
patient safety is primarily a nursing
concern (Titler et 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.
References
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