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NUR 422: Community Health Nursing Midterm

Terms in this set (408)

Community-Oriented Nursing Practice is a philosophy of nursing service delivery that involves the generalist or specialist public health and community health nurse providing "health care" through community diagnosis and investigation of major health and environmental problems, health surveillance, and monitoring and evaluation of community and population health status for the purposes of preventing disease and disability and promoting, protecting, and maintaining "health" in order to create conditions in which people can be healthy.
Public Health Nursing Practice is the synthesis of nursing theory and public health theory applied to promoting and preserving health of populations. The focus of practice is the community as a whole and the effect of the community's health status (resources) on the health of individuals, families, and groups. Care is provided within the context of preventing disease and disability and promoting and protecting the health of the community as a whole. Public Health Nursing is population focused, which means that the population is the center of interest for the public health nurse. Community Health Nurse is a term that is used interchangeably with Public Health Nurse.
Community-Based Nursing Practice is a setting-specific practice whereby care is provided for "sick" individuals and families where they live, work, and go to school. The emphasis of practice is acute and chronic care and the provision of comprehensive, coordinated, and continuous services. Nurses who deliver community-based care are generalists or specialists in maternal-infant, pediatric, adult, or psychiatric-mental health nursing.
In our world
Meds are given on time and if they are not there ...we get them
If PT is ordered the PT is received.
If the wound care is to be done three times a day, it gets done three times a day
The patient eats when we say eat, the patient bathes when we say bathe...
Pain medications are given in an appropriate manner and the response is monitored
In their world
The meds are taken when the individual decides to take them
If they decided if was too cold to go out to CVS to pick up their meds, or they ran out of refills so the mail order did not send them out this quarter, They do not have them and subsequently do not take them
If their granddaughter had a school show the same time as PT, then often it is decided not to go to PT
If one pain pill doesn't work or if it wears off in 2 hours they can take another one and take it with a glass of wine or shot of whiskey.
If the individual's neighbor helps with wound care and she went to the shore for the weekend.... The dressing may not be changed.
Look at the perspective of the patients allowing me to provide care for them, it gives the patient rights. Rather than Im coming in and Im going to give your care today
This is why community care is so much fun and quite the challenge!
It is no longer "this is what is ordered so take it "
Need to use all your assessment skills and knowledge to provide care but also have to take into consideration everything that is happening to the patient.
Every encounter is different
Education
Socioeconomics
Health Literacy
Support System
Religion/Political Views
Culture regarding health, pain, time etc.....
A wealthy woman of German-Jewish descent attended nursing school in New York
In 1893 began home class for immigrant families in the lower east side of Manhattan
One of the children came to her in broken English and explained "mommy-blood-baby" and when she arrived realized mother having post partum complications that physician left because there was not money
Recognized nursing could provide for these people and with Mary Brewster they developed the Henry Street Settlement
Founder of Public Health Nursing
Developed what would become the Visiting Nurse Service of NYC
Started first school nursing role
Care focused on resolving disparities of health care through the social determinants
10 nurses in 1893—250 nurses in 1916
Established school nursing which focused on why children were absent or dismissed from school. Initially was a volunteer position from Henry Street after one year there were 12 nurses hired
In 1909, she began a relationship with Met Life to provide nursing visits to their policy holders .
Statistics showed lower mortality rates. Lasted until 1953.
Started the Henry Street Settlement - still existed today
Video on Henry street
https://www.youtube.com/watch?v=CZu1LHdoMUY

https://www.youtube.com/watch?v=lCPMcxNVdPU
Single family households with children is the largest population of poor in USA
Poverty level is $11,000 a year, $23,000 for a family of four They don't receive all of the services and the goal for HSS is that they get out of that situation and they can move on and they are given tools to do that
Relationship between these levels are the basis of community health
Levels of prevention are meant to protect from disease

Pre pathogenesis Pre disease
Pathogenesis Disease/Injury/Disability
Goal is to intervene before at the earliest possible stage to prevent complications, limit disability and stop any irreversible changes
Primary Prevention - What is it?
Interventions aimed at preventing disease, injury or disability
Aimed at those who might be susceptible but show no signs of disease. Strengthen the host
Call be aimed at general population as well
Health Promotion, specific protection
Examples
Sun screen
Healthy eating
Exercise
Smoking cessation
Safe sex
Bike and Motorcycle helmets
Immunizations
Secondary Prevention - What is it?
Interventions that increase the probability of a person with disease will be diagnosed at time when treatment for cure is likely/possible
Interventions which increase early detection
STOP the process
Identifying if there is a disease
Examples
Mammograms
Colonoscopy
Statin therapy after MI - will prevent another MI from occurring. Another event. Not an extension of the MI
Be careful especially with cancer
Screenings - like Pap smear
Tertiary Prevention - What is it?
Interventions to limit disability
Arrest progress of established disease
Interventions which occur when changes are irreversible
Control negative consequences
Focus on rehabilitation
Restore to highest level/optimal level of function possible for the individual
Intervention that have occurred once someone actually has the process or the incident
Identifying that the disease existed but we want to prevent the extension of it
Stroke - PT
Examples
Physical therapy
Occupational therapy
Cardiac rehab
Can be follow care in chronic illness as well if disease remains permanent
Excellent definitions on page 268, 269 and 270 which provides one of those text boxes that provide information for learning and discuses screenings
Family lacks or loses the ability to cope with a specific event or multiple events and becomes disorganized or dysfunctional
Demands of the situation exceed the resources of the family
Major Family Health Risks and Nursing Interventions
Healthy People 2020 target areas
Health protection activities
Family health risk appraisal
Biological and age-related risk
Biological health risk assessment
Environmental risk
Environmental risk assessment
Behavioral (lifestyle) risk
Behavioral (lifestyle) health risk assessment
Healthy People 2020 targets areas in health promotion, health protection, preventive services, and surveillance and data systems to describe age-related objectives (U.S. Department of Health and Human Services [USDHHS], 2010). Included in the area of health promotion are physical activity and fitness, nutrition, tobacco use, use of alcohol and other drugs, family planning, mental health, mental disorders, and violent and abusive behavior. Health protection activities include issues related to unintentional injuries, occupational safety and health, environmental health, food and drug safety, and oral health. Preventive services, designed to reduce risks of illness, include maternal and infant health, heart disease and stroke, cancer, diabetes, and other chronic disabling conditions, human immunodeficiency virus (HIV) infection, sexually transmitted diseases, immunization for infectious diseases, and clinical preventive services. The interrelationships among the various groups of risk are clear when the objectives for the nation are considered. Most of the national health objectives are based on risk factors of groups or populations in a variety of categories like age, gender, or health problem. However it is important to recognize that some of these factors also relate to and have potential effects on the individuals' families, work, school, and communities.
Home care was formerly defined as simply providing physical care to the sick in their homes, but the scope and complexity of the concept and practice have grown.
Roots of the concept can be traced to the New Testament of the Bible, which describes visiting the sick as a form of charity.
The first home health care program in the United States was organized in 1796 as the Boston Dispensary.
The first visiting nurse service in the United States was formed in Philadelphia in 1886.
Lillian Wald and Mary Brewster developed a visiting nurse service for the poor in New York City in 1893 at the Nurses' Settlement House on Henry Street.
In the 1800s and early 1900s, visiting nurse associations were formalized, and public health departments became widespread.
The Social Security Act of 1935 first provided government rather than local charitable funding for selected services such as maternal health, communicable disease, and the training of public health professionals.
When Medicare became effective in 1966, it revolutionized home care by
Changing it to a medical rather than nursing model of practice
Defining and limiting services for which it would reimburse
Changing the payment source and even changing the reason home care was provided
What is the benefit of a medical home health care model versus a nursing model?
Describe how the payment source has changed and the reason for home health care.
Diagnosis-Related Groups (DRGs)
Congress enacted this prospective payment system in 1983 as a part of the Tax Equity and Fiscal Responsibility Act for hospitals receiving Medicare reimbursement.
Based on major diagnostic categories, a set rate is paid for the hospitalized patient's care rather than the "cost" or charges traditionally billed by institutions.
Why did Congress pass this Act?
Give an example of how this changed billing.
Diagnosis-Related Groups (DRGs) (continued)
The net effect of the change was a major shift of patients out of the hospital into their homes, extended-care facilities, or skilled nursing facilities.
This created a challenge in terms of volumes of patients seen, necessity of more skilled nursing care over intensive times, and the evolution of highly technical procedures in the home.
Physical Therapy
Services must be provided by a qualified and licensed physical therapist.
A physical therapist's assistant may deliver limited services under the supervision of the licensed therapist.
The goals of treatment must be restorative for Medicare reimbursement but may be maintenance or preventive for other payer sources.
Speech-Language Therapy
Speech services must be provided by a master's-prepared clinician who has been certified by the American Speech and Hearing Association.
Therapy goals include minimizing communication disorders and their physical, emotional, and social impact.
Independent functioning and maximum rehabilitation of speech and language abilities are primary treatment goals.
Occupational Therapy
Services deal with life's practical tasks.
The therapist will choose and teach therapeutic activities designed to restore functional levels.
Services include
Techniques to increase independence
Design, fabrication, and fitting of orthotic or self-help devices
Assessment for vocational training
Medical Social Services
Services are provided by social workers prepared at the master's level.
Focus is on the emotional and social aspects of illness.
The care plan includes education, counseling, payment source identification, and referrals.
Homemaker-Home Health Aide
The aide provides the basic support services that can enable an elderly individual, disabled adult, or dependent child to remain at home.
Most aid services fall into one of three categories
Personal care
Physical assistance
Household chores
Referral
Entry point into the home health care system
Can come from the patient, family, social service agency, hospital, physician, or another agency
Admission
The initial evaluation and admission visits are made by an RN within 24 to 48 hours of the referral.
The evaluation and admission process generally includes at least the following:
Complete patient evaluation
Environmental assessment
Identification of primary functional impairments
Assessment of the family or significant other support system
Determination of knowledge and adherence to treatments and medications
Determination of desire for care and services
Involvement of the patient and family in the development of the plan of care and goals
Notification to the patient of rights as a patient, along with costs, payment sources, and billing practices
Explanation of the patient's right to self-determination
Provision of initial nursing interventions
Care Plan
The physician must be contacted for specific orders before delivery of care.
A treatment plan is drafted cooperatively with the physician.
The plan describes the current physical status of he patient, medications, treatments, the disciplines needed to provide care, the frequency and duration of services, the goals/outcomes, and the time frame for implementation.
It must be signed by the physician and serves as the traditional physical orders.
Visits
Visits for interventions by ordered disciplines are made to meet the patient-centered goals and progress toward identified outcomes.
Patients may be visited as infrequently as once a month to several times a day; several visits per week is typical.
Documentation
Concise and complete documentation is essential.
It may be hand-written, dictated, or entered into a computer.
Many agencies are beginning to use various problem classification schemes linked with nursing diagnoses, specific interventions, and defined patient outcomes.
It provides an accurate picture of the type and quality of care and reflects the effectiveness of the plan of care and progress toward goals and outcomes or the reason for lack of progress.
Discharge Planning
Planning begins with admission.
When patient goals or other specific criteria are met, the discharge occurs.
The purpose of discharge planning is to promote continuity of care in the patient's home.
Quality Assurance Assessment/Improvement
This provides documentation for outside organizations and for internal measures of improvements and refinements of policies and procedures.
Three major elements
Structural criteria
Process criteria
Outcome criteria
Quality assessment plans reflect standards, objectives, and measurable outcomes and include plans for remediation or improvement as an integral part of the process.
To learn more about the following:
Community needs
Community strengths
Locating confirmation data to address a recognized community problem
Public health nurses (PHNs) are ideal assessment leaders
Public health nursing competencies
The public health nursing competencies include eight major domains: analytic and assessment skills, policy development/program planning skills, communication skills, cultural competency skills, community dimensions of practice skills, public health sciences skills, financial management and planning skills, and leadership and systems thinking skills.
Data Sources
Health status indicators
Secondary sources of data
Websites, printed materials
Primary sources of data
Participant observation
Key informants
Focus group
Photovoice
Spatial data
Geographic information systems (GIS)
Using primary data
The basic process to incorporate Photovoice into a community assessment:
1. Train participants: Participants receive training in Photovoice methods, including the topic of interest, basic photography techniques, and ethical and safety issues. Participants may need to learn how to obtain written consent before photographing people, businesses, or other identifiable subjects. Training is especially important when the topic of interest is sensitive or illegal, such as substance abuse.
2. Take photos: Participants take the cameras into their communities and take photographs that reflect the topic. Equipment should be modified to fit the participants. For example, adolescents may be very comfortable with a variety of mobile devices, whereas older adults may prefer simpler cameras with modifications for low vision or manual dexterity (Novek et al, 2012).
3. Display photos: The photos are collected from the participants, and then printed or digitally projected for group participants, and sometimes members of the public, to view them.
4. Discuss photos: Viewing the photos is meant to spark discussions that provide additional information about the topic of interest. These discussions may take place as focus groups with the Photovoice participants. If the photos are displayed in public, the aim may be to raise awareness and to start conversations among diverse stakeholders.
5. Analyze and report results: The information gathered through these discussions, as well as the photos themselves, can be included in the data analysis phase. The photos can also be part of the report to the community about the findings of the community assessment (Catalani & Minkler, 2010).
Age
Ethnic background
Family history of heart disease


Age
The older you are, the more likely you are to develop coronary heart disease or to have a cardiac event (angina, heart attack or stroke).

Ethnic background




Family history

Your own risk of developing coronary heart disease is increased if: your father or brother was diagnosed with the disease, or had a cardiac event under the age of 55 your mother or sister was diagnosed with the disease or had a cardiac event under 65.

If you have a family history of heart disease, it may help to reduce your own risk if you look at what the risk factors affecting your family member were. Ask yourself:

Did they smoke?
Were they overweight?
Did they have a diet high in saturated fat?
Were they physically inactive?
Did they have diabetes?

If the answer is yes to one or more of these, then you can reduce your risk by making sure your lifestyle is not the same as theirs. Some risk factors, such as being overweight, are sometimes related to lifestyle habits that are passed on from one generation to the next. However, it's also likely that genes are responsible for passing on the risk of developing coronary heart disease. Genes can also pass on other conditions, such as high blood pressure orhigh cholesterol levels. Both of these conditions increase the risk of getting coronary heart disease.
Background information

Is there anything else which affects your risk?
People's income and the type of jobs they do, all appear to have an effect on how likely they are to get coronary heart disease. For example, people who work in manual jobs have a higher rate of coronary heart disease than people in other jobs, and people who live in poorer areas or are on lower incomes are also more likely to get the disease. Recent studies have also shown that individuals that lack support in their working environment may also be more at risk of developing coronary heart disease. Recognizing and dealing with stressful situations will help to prevent individuals using bad habits, such as smoking, drinking and eating more, to deal with stress.
Diabetes is classified as a modifiable risk factor. However, if you have diabetes, you cannot cure it. This means that anything that you can do to modify your lifestyle and keep your diabetes under control will help to reduce your risk of having a heart attack or developing angina. Having diabetes intensifies the effects of other risk factors that you may have, so it is important to reduce the risk of developing it.
While a family history of coronary heart disease is non-modifiable, i.e., if you have a family history of coronary heart disease, you cannot change it, making changes to your lifestyle will significantly reduce the risk of you developing coronary heart disease prematurely.
Function
Physical barrier/protection *Sensation
Temperature maintenance *Immunity
Fluid/electrolyte balance *Vitamin D synthesis
Absorption *Personal identity
Excretion *Wound repair
skin, hair, nails external structures that serve variety of functions. Skin is a physical barrier that protects underlying tissues and structures from microorganisms, physical trauma, ultraviolet radiation, dehydration; temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, Vitamin D synthesis; contributes to individual identity as big part of appearance
Epidermis-outer layer of skin, properties make the skin waterproof, melanin production; skin color depends on the amount of melanin and carotene contained in the skin and the volume of blood containing hemoglobin that circulates in the dermis
Dermis-connected to the epidermis by dermal papillae (form base of swirls or friction ridges that form unique pattern of fingerprints; ridges also appear on palms, toes , soles of feet), well vascularized, composed of connective tissue, made up of collagen, elastic fibers, nerve endings, lymph vessels; origin of hair follicles, sebaceous glands - secrete oily substance called sebum that lubricates hair and skin and reduces water loss through the skin, also has some fungicidal and bactericidal effects; sweat glands - two types; eccrine located over the entire skin surface, secrete odorless, colorless fluid, vital to regulation of body temperature; apocrine concentrated in axillae, perineum, areolae, open through a hair follicle, secrete milky sweat that interacts with skin bacteria producing body odor
Subcutaneous tissue- loose connective tissue- role in heat regulation, vascular pathways for supply of nutrients and removal of waste from the skin
How to document it?
Length x width x depth
What kind of exudate (drainage?
Color?
Oder?
Skin around the wound
Is it red, pink?
Is it blanched?
Wound itself?
Is it eschar?
Is there tunneling
Three layer structure
Epidermis
Outer layer
Provides waterproofing
Melanin (brown pigment) production
Dermis
Vascular, connective tissue layer *Lymph Vessels
Nerve endings *Hair follicles
Sebaceous (sebum/oil) glands *Sweat glands
Dermal Papillae
Subcutaneous Tissue/ Hypothermis
Epidermis: Outer layer
Provides waterproofing
Melanin (brown pigment) production
"Epidermis." Epidermis-delimited.jpg. Public Domain. Accessed 1/30/2014. URL=<<http://commons.wikimedia.org/wiki/File:Epidermis-delimited.JPG>>
Dermis
Vascular, connective tissue layer
Lymph Vessels
Nerve endings
Hair follicles
Sebaceous (sebum/oil) glands
Sweat glands
Dermal Papillae
Subcutaneous Tissue/ Hypothermis
Fat cells
Blood vessels
Nerves
Remaining portion of sweat glands