3: Healthcare in the Community and Home Flashcards
primary healthcare
health promotion, education, protection, and screening
secondary healthcare
emergency care, acute and critical care, diagnosis, and treatment
tertiary healthcare
rehabilitation, long-term care, support services, and hospice care
Community-based healthcare
design, delivery, and evaluation of healthcare services developed in partnership with communities
Community-based nursing care
nursing care directed towards individuals of a specific group or population within the context of the community where they live.
Community-based nursing
provides acute or chronic care services to the individual within the context of the individual’s community
Community health nursing
provides services to individuals, families, and groups identified by the risk factors of the community
public health nursing
the community is client with the focus of practice on primary prevention
The Pew Commission’s “agenda for action”
identifies 21 competencies that future health professionals must possess
Home healthcare
Such services are delivered to persons at home who are recovering from illness, are disabled, or are chronically or terminally ill and need various services to progress, maintain function, or perform their ADLs
OASIS
Outcome and Assessment Information Set provides standardized guidelines for admission and care as well as a national database for evaluation, reimbursement, and quality improvement
Continuity of care
provision of health services without disruption, regardless of movement between settings
Discharge planning
prepares a patient to move from one level of care to another within or outside the current health- care facility
Goal Setting
The nurse should develop goal setting in the areas of education, advocacy, and case management in collaboration with the patient and family/caregiver
Collaboration
the act of assembling and directing activities to provide services harmoniously
Facilitation
making something easier and smoother by eliminating problems and barriers
Negotiation
process by which the patient, nurse, and family determine goals
Basic Discharge Plan
The least complicated and most common discharge plan is teaching the patient about self-care for the illness
Simple referral Discharge Plan
involves referring the patient to community resources
Complex Referral Discharge Plan
involves referring the patient to the discharge planner
initiation phase
clarifying the source of referral and the purpose of the visit and initial contact with the family
previsit phase
establishing an understanding with the family for the purpose of the visit, scheduling the visit, and reviewing pertinent records and information
in-home phase
establishing the professional therapeutic relationship and implementing the nursing process
termination phase
the nurse and family summarize accomplishments of the visit and make plans for future visits
postvisit phase
recording findings and carrying out activities necessary to plan for the next visit
Standard of Care I:
Assessment
The home health nurse collects patient health data.
Standard of Care II:
Diagnosis
The home health nurse analyzes the assessment data in determining diagnoses
Standard of Care III:
Outcome Identification
The home health nurse identifies expected outcomes customized to the patient and the patient’s environment.
Standard of Care IV:
Planning
The home health nurse develops a plan of care that prescribes interventions to attain expected outcomes.
Standard of Care V:
Implementation
The home health nurse implements the interventions identified in the plan of care.
Standard of Care VI:
Evaluation
The home health nurse evaluates the patient’s progress toward attainment of outcomes.
Standards of Professional Performance I:
Quality of Care
The home health nurse systematically evaluates the quality and effectiveness of nursing practice.
Standards of Professional Performance II:
Performance Appraisal
The home health nurse evaluates his or her own nursing practice in relation to professional practice standards, scientific evidence, and relevant statutes and regulations.
Standards of Professional Performance III:
Education
The home health nurse acquires and maintains current knowledge and competency in nursing practice.
Standards of Professional Performance IV:
Collegiality
The home health nurse interacts with and contributes to the professional development of peers and other healthcare practitioners as colleagues.
Standards of Professional Performance V:
Ethics
The home health nurse’s decisions and actions on behalf of patients are determined in an ethical manner.
Standards of Professional Performance VI:
Collaboration
The home health nurse collaborates with the patient, family, and other healthcare practitioners in providing patient care.
Standards of Professional Performance VII:
Research
The home health nurse uses research findings in practice.
Standards of Professional Performance VIII:
Resource Utilization
The home health nurse assists the patient/family in becoming informed consumers about the risks, benefits, and costs in planning and delivering patient care.
advocacy
the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations
The goal of home care
allow people to regain or maintain optimal health and to function within their limitations in the home environment.
Among Pima Indians, 50% of adults have diabetes and 95% of those are overweight. Diabetes and obesity are directly correlated with rerouting of waterways, which impacted traditional farming and subsequent dietary supplementation with processed commercial foods. Which health determinants are implicated in this scenario? Select all that apply: a. Educational b. Economic c. Political d. Healthcare services
b. Economic
c. Political
A nurse is providing care on an acute care unit to a patient admitted for cellulitis of the right leg, with a history of bipolar disorder and intravenous drug use. She appropriately plans for discharge in order to address mobility issues, safety risk, and continued drug rehabilitation. Such interventions illustrate which type of nursing care?
a. Community-based healthcare
b. Community-based nursing care
c. Primary care
d. Secondary prevention
b. Community-based nursing care
Nursing care directed toward a specific group or population within the community and may be provided for individuals
A patient is discharged following a triple coronary artery bypass graft and is seen for follow-up by his cardiologist, his surgeon at the hospital, his primary care physician, and the anticoagulation clinic. He is also seen for diabetes management and renal failure by two other specialists. This patient is at risk for what problem with this health-care coordination?
a. Discontinuity
b. Schism of care
c. Fragmentation
d. Decentralization
c. Fragmentation
Results as patients move from one system of care to the next
A patient who has recently begun hemodialysis for kidney failure is discharging home from the hospital. Which of the following elements of discharge planning are integral in order to meet this patient’s healthcare needs?
Select all that apply:
a. A team meeting is planned between the physician, social worker, nurse, and family
b. Discharge planner establishes a dialysis schedule at a facility near the patient’s home
c. The nurse provides discharge paperwork as the patient is leaving
d. A tolerable renal diet is discussed between the dietician and the patient
a. A team meeting is planned between the physician, social worker, nurse, and family (collaboration)
b. Discharge planner establishes a dialysis schedule at a facility near the patient’s home (facilitation)
d. A tolerable renal diet is discussed between the dietician and the patient (negotiation)
A nurse is performing a safety assessment at the home of an elderly man who lives independently. He is returning home following hospitalization for a below-the-knee amputation and will have a wheelchair as needed for several weeks. Which of the following issues should be noted by the nurse?
Select all that apply:
a. The surrounding neighborhood has a high crime rate
b. Infrequent home health service availability in the area
c. Wide doorways and handrails on stairs d. A well-kept garden in the backyard
a. The surrounding neighborhood has a high crime rate (barriers to independence)
b. Infrequent home health service availability in the area (barriers to independence)
c. Wide doorways and handrails on stairs (adequate environment)
d. A well-kept garden in the backyard (person’s values)
Aesthetics/spirituality
Communion with families that strives to accomplish knowledge of health through the arts, exploration of alternative and complementary therapies, and experience of self-awareness, faith, hope, and love
case management
Professional approach to providing care
in which one provider coordinates a client’s services
community resources
Economic stability, social and health supports, and cultural norms
coordination
Care for a client and family that requires
development of plans of care that maximize the person’s ability to remain in a safe environment
facilitators
Examples include audiovisual materials, written handouts, repetition of material, and easily accessible and interested nursing staff.
health determinants
Social, economic, political, and educational health factors and trends that can promote positive healthcare in a community
healthy communities/healthy cities
Wellness programs, existing in integrated healthcare systems, that nurses often manage
hospice
Family-focused health service that provides care for terminally ill clients
levels of healthcare
Include primary (health promotion, education, protection, and screening), secondary (emergency care, acute and critical care, diagnosis, and treatment), and tertiary (emergency care, acute and critical care, diagnosis, and treatment)
nursing competencies for community-based care
Monitoring, treatment, teaching, prioritizing, intervention, and planning skills that nurses should possess to meet the epidemiologic and demographic needs of a community
patient education
Interactive, collaborative process between
nurse and client to progress toward the client’s goal of assuming responsibility for his or her health and self-care
