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(C228) ATI-Community Health <Chapter 3> <Community-Based & Home Care of the Adult Client>

Terms in this set (42)

Chapter Review
- In contrast to community health, which focuses on the health of a population, community-based care focuses on individual and family healthcare needs. Services are provided in many different settings and by various programs, including community centers and clinics, day care programs, parish nursing, and Meals-on-Wheels.
- Factors affecting health in the community include social support systems, community healthcare structures, the environment, and economic resources.
- Home care is defined as services for people who are recovering, disabled, or chronically ill and who are in need of treatment or support to function effectively in the home environment.
- Two special components of home care are hospice care and respite care.
- The home care system includes agencies, clients, referral sources, physicians, reimbursement sources, and legal considerations.
- The roles of the home care nurse include advocate, provider of direct care, educator, and coordinator of services.
- Nursing interventions to ensure competent care include those used to establish trust and rapport, proceed slowly, set goals and boundaries, assess the home environment, set priorities, promote learning, limit distractions, put safety first, and control infection.
- Rehabilitation is the process of learning to live to one's maximum potential with a chronic health impairment and its resultant disability.
Block Nursing
nursing care provided to people who live on the same block as the nurse
Community
encompassing a specific geographic area, a community may be a small neighborhood in a major urban city or a large area of rural residents. Communities have in common the characteristics of people, area, social interaction, and common ties
Community-Based Nursing
nursing centered on individual and family health care needs. The nurse practicing community-based care provides direct services to individuals to manage acute or chronic health problems and to promote self-care. The care is provided in the local community
Contracting
the negotiation of a cooperative working agreement between the nurse and client that is continuously renegotiated
Disability
the degree of observable and measurable impairment
Handicap
the total adjustment to disability that limits functioning at a normal level
Home Care
services for recovering, disabled, or chronically ill people in need of treatment or support to function effectively in the home environment (National Association for Home Care); services for the purpose of promoting, maintaining, or restoring health or of maximizing the level of independence while minimizing the effects of disability and illness, including terminal illness (U.S. Department of Health and Human Services)
Home Health Agencies
either public or private organizations engaged in providing skilled nursing and other therapeutic services in the client's home
Home Health Care
encompasses both health and social services provided to the chronically ill, disabled, or recovering person in his or her own home. Home care is usually provided when a person needs help that cannot be provided by a family member or friend
Home Health Nursing
nursing care to acute and chronically ill clients of all ages in their home while integrating community health nursing principles that focus on environmental, psychosocial, economic, cultural, and personal health factors affecting an individual's and family's health status
Hospice Care
generally refers to 'a way of caring for people near the end of their journey through life, faced with dying and in need of refuge' (Vines and Hartzell, 1981)
Impairment
a disturbance in structure or function resulting from physiologic or psychologic abnormalities
Parish Nursing
nurses work with the pastor and staff of a faith community to promote health and healing through counseling, referrals, teaching, and assessment of health care needs
Rehabilitation
the process of learning to live to one's maximum potential with a chronic impairment and its resultant functional disability
Respite Care
short-term or intermittent home care, often using volunteers. These services exist primarily to give the family member or friend who is the primary caregiver some time off from care
Differentiate community-based care from community health care.
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Discuss selected factors affecting health in the community.
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Describe services and settings for healthcare consumers receiving community-based and home care.
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Describe the components of the home healthcare system, including agencies, clients, referrals, physicians, reimbursement, legal considerations, and nursing care.
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Compare and contrast the roles of the nurse providing home care with the roles of the nurse in medical-surgical nursing discussed in Chapter 1.
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Explain the purpose of rehabilitation in healthcare.
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You are the nurse making a home care visit when the client tells you that he does not have enough money to get all of his new prescriptions filled at the pharmacy. Which of the following resources would be able to assist with the client's problem?

a. Social Support
b. Community Health Care System
c. Community Centers
d. Day Care Programs
Social Support

Rationale:
A person's social support system consists of the people who lend assistance to meet the client's financial, personal, physical or emotional needs. The nurse needs to know what support is available for health care of her clients and family with understanding of their cultural and ethnic backgrounds as well.

Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive Level: Application
Objective: Describe the components of the home health care system, including agencies, clients, referrals, nursing care, physicians, reimbursement, and legal considerations.
Strategy: Identify the core issue to prevent distraction of incorrect choices.
A home care nursing is visiting a 72 year old patient who is concerned about paying medical bills. The nurse understands this client is eligible for which benefit:

a. Medicaid.
b. Medicare.
c. Community based health services.
d. Social support group.
Medicare.

Rationale:
Medicare and Medicaid are health assistance programs created by 1965 Social Security amendments. Medicare is a federal health insurance plan for acute care needs of the disabled and those over the age of 65 years of age. This plan will be over hospitals, long term care facilities as well as the home. Medicaid is a state-run health insurance program with limited incomes.

Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive Level: Application
Objective: Describe services and settings for healthcare consumers receiving community-based and home care.
Strategy: Use nursing knowledge and the process of elimination to make the correct selection.
The nurse is assessing the following clients. Which one of these clients in the clinic would be a candidate for a day care program?

a. A client diagnosed with terminal cancer two weeks age with a poor Prognosis.
b. A client who is bed bound after a recent fractured hip.
c. A client who lives with her daughter and forgets to take her medications when her daughter is at work in the daytime.
d. A client who has diabetes and needs to have her dressing changed to her left leg three times a week.
A client who lives with her daughter and forgets to take her medications when her daughter is at work in the daytime.

Rationale:
Day care programs, such as senior centers, are usually located where people gather for social, nutritional and recreational purposes. They may provide care for older adults with physical disabilities or mild Alzheimer's disease while family caregivers are at work. These programs vary among communities. Meals may also be provided at a low cost.

Nursing Process: Evaluation
Client Need: Safe; Effective Care Environment
Cognitive Level: Analysis
Objective: Provide client care in community-based settings and the home.
Strategy: Use nursing knowledge and the process of elimination to make the correct selection.
The physician has discharged a client from the acute care facility. The client needs to have a dressing changed to his right lower extremity once a day for the next seven days. Which of the following interventions should the nurse select to plan the patient's discharge?

a. Teach the client the dressing change prior to discharge.
b. Ask the physician to cancel the discharge until the leg wound heals.
c. Notify social services to set up home care visits for the dressing changes.
d. Notify the parish nurse in the area to change the dressing in the home once the client is discharged.
Notify social services to set up home care visits for the dressing changes.

Rationale:
Home care services the disabled or chronically ill person who is in need of treatment or support to function effectively in the home environment. Home care encompasses health and social services provided to the chronically ill as well as persons recovering in his or her own home. The client could change his own dressing at home if he had good dexterity and had the supplies, but the staff would have to do extensive teaching in order to discharge him home to do the dressing. The best choice is to allow the home care agencies to start the treatments upon discharge and follow the client's progress.

Nursing Process: Evaluation
Client Need: Safe; Effective Care Environment
Cognitive Level: Analysis
Objective: Compare and contrast the roles of the nurse providing home care with the roles of the nurse in medical-surgical nursing discussed in Chapter 1.
Strategy: Identify key words in the question or stem to select the right answer.
A client is being admitted to an institutional based home care agency. Who is the responsible coordinator to the client's case?

a. Social Worker
b. Registered Nurse
c. Client and their family
d. Home care aides
Registered Nurse

Rationale:
Home care agency personnel typically include administrators, managers, care providers and business office staff. The responsibility of the case coordination remains with the registered nurse which also may be called the case manager.

Nursing Process: Assessment
Client Need: Safe and Effective Care
Cognitive Level: Application
Objective: Provide client care in community-based settings and the home.
Strategy: Identify the core issue to prevent distraction of incorrect choices.
The nurse has completed an initial visit with a home bound client in whom she has obtained biographical information during the interview; as well as collecting information regarding the client. This process applies to:

a. Assessment Process.
b. Diagnosis Process.
c. Planning Process.
d. Evaluation Process.
Assessment Process.

Rationale:
The nursing process used in home care is not different from that practiced in any other setting. The unique challenges of home care present themselves chiefly in the implementation step. Assessment in the home includes the nurse assessment, and data collection which focuses chiefly around the first home visit. During the visit, much of the assessment process centers around collecting the information, including a medication sheet; forms for pain; psychosocial database and spiritual assessment as well as financial assessment.

Nursing Process: Implementation
Client Need: Physiological Integrity
Cognitive Level: Application
Objective: Apply the nursing process to care of the client in the home.
Strategy: Use knowledge of the nursing process and the process of elimination to make the correct selection.
You are evaluating a new graduate in the home care setting. Which of the following statements made by the nurse would require further assessment of the problem prior to her next visit with the client?

a. "I see that no one wears shoes in your home, so I will remove mine also."
b. "Let's talk about your medications again before I leave to make sure you understand everything."
c. "If you have problems while at home, you need to make sure you contact the agency before the office closes at the end of the day."
d. "I am going to leave a detailed copy of all of the things we have covered today for you to review whenever you have time."
"If you have problems while at home, you need to make sure you contact the agency before the office closes at the end of the day."

Rationale:
Nursing practice in the home setting is a unique experience that differs in many ways from nursing practice in a hospital setting. Because clients and nurses most often meet during periods of vulnerability and crisis, the nurse provides a great deal of information; therefore the nurse should be well educated because the nurse is a great link between the client and the physician. The family and the client have support from the agency anytime needed because there is always someone to assist the client whenever necessary. If the new graduate tells the client that they can only notify the office during business hours, this is inaccurate, and will require more education with the graduate.

Nursing Process: Evaluation
Client Need: Physiological Integrity
Cognitive Level: Application
Objective: Compare and contrast the roles of the nurse providing home care with the roles of the nurse in medical-surgical nursing discussed in Chapter 1.
Strategy: Use communication concepts and the process of elimination to make the correct selection.
The nurse is evaluating a client's environment at home. Which of the following observations in the home would require further demonstration and education with the client?

a. Medications in a daily planner box and a list of all of his home medications.
b. A small night light in the hallway as well as an overhead light.
c. A small throw rug in the living room to cover an exposed extension cord.
d. A small pantry with a variety of non-perishable foods.
A small throw rug in the living room to cover an exposed extension cord.

Rationale:
Safety assessment in the home is a nursing responsibility and a legal requirement. Nurses cannot close their eyes to any unsafe practices in the home. Upon entering the home and on a continuing basis, it is imperative that the nurse is alert for any hazardous or unsafe conditions.

Nursing Process: Evaluation
Client Need: Safe and effective Care
Cognitive Level: Application
Objective: Apply the nursing process to care of the client in the home.
Strategy: Use Maslow's Hierarchy of needs for prioritization to choose the best selection.
When the nurse is explaining to a client the specifications for safety in the home, which of the following topics and illustrations should be discussed? Choose all that apply.

a. Electrical hazards
b. A lamp with a frayed cord
c. Monthly income with the client
d. Support system of the clients
e. Cooking habits that may precipitate a fire
f. Appropriate as well as inappropriate clothing
- Electrical hazards
- A lamp with a frayed cord
- Cooking habits that may precipitate a fire
- Appropriate as well as inappropriate clothing

Rationale:
Nurses must focus on safety and survival first. Safety assessment in the home is a nursing responsibility. Upon entering the home and on a continuing basis, it is imperative that the nurse alert the family to unsafe and hazardous conditions, suggest remedies and document in the clinical record the family's response to the nurse's suggestions.

Nursing Process: Evaluation
Client Need: Safe and Effective Care
Cognitive Level: Application
Objective: Provide client care in community-based settings and the home.
Strategy: Use Maslow's Hierarchy of needs for prioritization to choose the best selection.
A client with diabetes mellitus notifies the home health nurse that his sharps container at home is full and needs to be replaced before he gives himself another injection of insulin. The nurse tells the client that she will not be able to visit him today. What is the safest recommendation that the nurse can make to the client regarding the sharps container?

a. Instruct the client to wrap each syringe in a paper towel and put the towel at the bottom of the trash can.
b. Dispose of the syringes in a thick liquid detergent bottle after using the syringe and replace the lip on the bottle.
c. Recap the needle after using the syringe and store it in a plastic bag until the next nurses visit.
d. Wipe the needle off with an alcohol swab and re-use the syringe until the nurse returns on her next visit.
Dispose of the syringes in a thick liquid detergent bottle after using the syringe and replace the lip on the bottle.

Rationale:
Safety is very important for the client as well as those caring for the client. The disposal of toxic medications and sharp objects (such as needles used for injections) is also a safety issue in the home. The nurse should teach the client regarding safety and educate the family as well whenever. Option A is unsafe; all needles should be placed in some form of sharps containers so that people are not exposed to needlestick injuries. Options C and D are incorrect because recapping needles and wiping off needles to reuse them places the individual at risk for a needlestick injury and blood-borne diseases.

Nursing Process: Implementation
Client Need: Safe Effective Care Environment
Cognitive Level: Analysis
Objective: Provide client care in community-based settings and the home.
Strategy: Use nursing knowledge and the process of elimination to make the correct selection.
Case Study: The Case of Safety First for Home Health
Client's Name: Glenda Lidzy

Abstract: Glenda Lidzy is an 82 yr old female requiring home health following a lengthy illness. As the home health nurse, you are assigned to her initial assessment, and to develop a plan of care for her.

Objectives:
- Compare and contrast the roles of the nurse providing home care with the roles of the nurse in medical-surgical nursing.
- Explain the purpose of rehabilitation in healthcare.

Glenda Lidzy is an 82 year old female discharged home following a lengthy hospitalization due to urosepsis. Due to prolonged bed rest, she has less overall strength and stamina and will need help resuming ADLs. Her PMH is unremarkable, with the exception of diabetes which was discovered during her recent hospitalization. She has osteoarthritis, requiring the use of a walker to ambulate, and is able to move all extremities fairly well.

Glenda lives alone, and has strong family support as well. She will need IV antibiotic therapy to continue for 2 weeks. She has a PICC (peripherally inserted central catheter) in her right upper arm. You are the home health nurse assigned to care for Ms. Lidzy.
As you go to Glenda's home for the first time, describe how you will set boundaries for the nurse-client relationship.
Because nurses are invited into homes they must realize they are guests. The environment belongs to the client, who retains control. If the client has had home health before, he/she has a clearer picture of your role in their care, but if they have not, you will need to "set the stage" for your visits.

Some ways to do this: ask the client what days and times are most convenient for them. As much as possible, work around these times—be on time! Help the client understand what you will be doing each visit, and why. Involve family members who will be jointly caring for client. Allow client to ask questions, and provide a contact number for you should they need to contact you. It is important to specify when they can use that contact #, so that calls are appropriate.
What assessment will be performed to obtain a complete picture of the client's self-care status?
During the visit, much of the assessment process centers on collecting the information requested on the tools and forms contained in the agency's admission packet. These packets usually include a physical and psychosocial database; a medication sheet; forms for pain assessment, spiritual assessment, and financial assessment; and a family roster. It is extremely important that the data collected be as complete and accurate as possible and reflects subjective, objective, current, and historical information. Through interviewing, direct observation, and physical assessment, the nurse can achieve the goal of the initial visit, namely, to gain as clear and accurate a clinical picture of the client as possible.
On your initial home visit with Glenda, you notice her apartment is cluttered, with many colorful rag rugs scattered about her apartment. When you ask about them, she states, "I love the color, my house is so drab". What nursing diagnosis will help plan her safety?
Risk for injury (falls) related to clutter and use of rugs. Ms. Lidzy uses a walker, and has mobility issues. Clutter and rugs add to the problem. It is helpful to allow her to see the danger these pose, rather than come in and tell her she needs to clean the place up! Are there other ways to add color without rugs? Could you develop a plan to de-clutter (especially in terms of her route to the restroom)?
What will be your goal for Ms. Lidzy in terms of her safety while in the home?
Ms. Lidzy will have no injury (falls) while at home (timeframe).
What interventions should be implemented for Ms. Lidzy?
- Teach the importance of maintain clear uncluttered walkways throughout home.
- Encourage to remove loose rugs, and to use other sources of color (such as flowers or curtains).
- Evaluate ability to safely get from bed to toilet at nighttime. (Provide nightlight)
- Evaluate client's use of her walker and teach appropriate technique if client is using it incorrectly.
- Evaluate client for physical therapy assessment for safety in the home.
Care Plans
You are a home health nurse visiting a new client for the first time. The client, Russell Ford, is a 67-year-old male with cancer. He has refused chemotherapy and radiation, but wants care for pain management and nutrition. Mr. Ford lives with his wife, Paula, age 62. The Fords have 2 grown sons who live in the same town. Upon entering the client's home, you immediately note the house has numerous unsafe and hazardous conditions.
Assessment and Diagnosis: What further assessment of the client's home is necessary? Based on the information provided, what is the immediate priority diagnosis?
You immediately note hazardous conditions, so a thorough evaluation of the home is necessary to evaluate the presence of further hazards. Determine if the clients are aware these hazards pose a health risk. Determine if the client, spouse, or another person has experienced an injury related to the hazards.

The priority diagnosis is Risk for Injury related to unsafe and hazardous conditions of the home.
Planning and Intervention: What are the goals for the diagnosis of Risk for Injury? What interventions will you implement?
The goals are for the client and spouse to remain free from injury and to be able to identify and correct potential safety hazards.

Interventions include:

- Alert the client and spouse to the unsafe and hazardous conditions
- Offer suggestions to correct the unsafe and hazardous conditions
- Assess the client and spouse for understanding of the hazards
- Document how the client and spouse respond to the suggestions
- Maintain respect and courtesy during the instructions and suggestions to the client and spouse
- Establish a home safety list for the client.
Evaluation: How do you evaluate the progress towards achieving the goal?
Assess the client and client's spouse for understanding of the potential safety hazards. Can they now identify the risks? Is the home now free from potential hazards Have the client and spouse remained free from injury?
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