community health lecture part 1
TRANSCRIPT
7/29/2019 Community Health Lecture Part 1
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Mary Ann Rosa MSN, RN, CS, GNP
Queensborough Community College
MRosa
Part I
Introduction and Overview of
Community Health Nursing
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Historical Perspective
MRosa
First written reference to care of the ill at home is found in the New Testament
Florence Nightingale, 1860s
Opened the Nightingale School of Nursing in 1860 where she stressed goodfood, clean air and sanitation
One year of training: promoting self-care and the health of the communities Also involved in developing nursing for the sick poor at home and in
workhouses
Origin of the concept of “ visiting nurse”
District public health nursing. Each nurse was assigned a specific geographicarea of London
William Rathbone:
Promoted the establishment of district nursing
Modern concept of “visiting nurse”
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Historical Perspective
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Founder of Public Health Nursing
The number of poor immigrants who had come to
America from Europe with little resources
Lived in communities on the lower east side of Manhattan
Resided in tenements
Developed many illnesses
.
Lillian Wald
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Historical Perspective
MRosa
Lillian Wald continued: Visiting Nurse Service founded by Lillian Wald and Mary
Brewster in 1893. Venture was funded entirely through private donations Started with a focus on MCH
Henry Street Settlement House, 1895 Founded by Lillian Wald; help by Mary Brewster Nurses lived in the neighborhoods where they worked
Coined the term “Public Health Nurse” Lillian Wald defined public health nursing as seeking to
cure the sick patients as well as trying to alleviate theunderlying cause of disease by improving healtheducation and public health standards.
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Historical Perspective
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1910: approx. 90% of all nursing care was provided inthe home
Shift to the Hospital after World War I
Technology and complexity Increased Access to Health Insurance An Aging Population and Increased health care
needs Injuries from war
Development of private insurance & Medicare &Medicaid
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Historical Perspective
MRosa
Shift Back to the Community in the 1980s
Escalating Health Care Costs
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Historical Perspective
MRosa
Rising Health Care Costs in the 1980s
Overuse of expensive care & procedures
Failure to promote preventive services
Increased number of uninsured people Higher insurance rates for those that can pay
Increased Health Care Salaries
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Historical Perspective
MRosa
Rising Health Care Costs in the 1980s continued: Aging Population
Survival of patients with complex problems
Expensive, sometimes, unnecessary tests – covered by
insurance Defensive Medicine
Long Hospital Stays
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1980s begins the start of
Cost Containment
MRosa
The Tax Equity and Fiscal Responsibility Act
(TEFRA) in 1982
1983 Social Security Amendments
Prospective Payment System (PPS)
Diagnosis Related Groups (DRGs) for
reimbursement
Development of PPOs, HMOs, and managed
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Managed Care
MRosa
Through the use of responsible,
effective, and cost-efficient care,Managed care refers to a system
that for a set fee, assumes
responsibility and accountability for the health of a population
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1980s begins the start of
Cost Containment
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LOS decreased
Discharged “quicker and sicker”
Increased need for services in the community
Movement of nursing care back to community
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erence e ween osp aCommunity
Factors Hospital CommunityIllness
Environment
Resources
Access to Patient
Focus
Family support
Client Role
Nursing Role
Teaching style of nurseMRosa
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Community Based Nursing
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Nursing care directed toward specific individualsand families within a community
Philosophy of care – how the nurse practices, notwhere the nurse practices
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Community Based Nursing
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Assists patients as they move among and
between health care settings
The individual & family have primary
responsibility for decisions The patient is viewed within the family and social
systems
Illness is a part of life
Purpose of care is to limit disability, improve
functional capacity and QOL
Treatment effectiveness drives decisions
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Community Health Nursing
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Subset of community based nursing
Requires specific knowledge and skill
Care provided for individuals, families, and
groups within a community
CHN defined by its role in promoting public’s
health
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NLN
MRosa
NLN recommends that all nursing education preparenurses to function in community based settings.
To also understand the business of health care
To have highly developed skills – assessment,interdisciplinary collaboration & working withculturally diverse populations
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National League for Nursing’s Essential
Components of Community Care
Self-care
Advance Directives
Living Will
Management of Illness
Prevention
Consideration of family, culture, and
community
Continuity of care through Collaboration
Essential for quality care
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Continuity of Care
Coordination of activities involving clients, providers,
and payers to promote the delivery of heath care
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Collaboration
Commits two or more persons or organizations to achieve a common goal
through enhancing the capacity of one or
more of the members to promote and protect
health
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Critical Thinking Exercises
CONTINUITY OF CARE
MRosa
1. List three examples from your clinicalexperience where you believe continuity was interrupted.
2. Indicate the steps that could have been takento ensure continuity of care in these examples.
3. Recall three examples from your clinicalexperience where continuity of care was evident.
ommun y ase urs ng s
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ommun y ase urs ng sCompetencies
MRosa
Assessment & Physical Caregiving
Critical Thinking & Problem Solving
Learner / Teacher
Management
Documentation
Communication
Culturally Sensitive Care
Being an advocate
ommun y ase urs ng s
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ommun y ase urs ng sCompetencies
MRosa
Interdisciplinary Care
Partner with communities
Improve access to care
Understanding Primary Care / Disease Management
Preventative Care
Evidenced Based Practice
Information Technology
Leadership Performance Improvement
Ethical – Legal
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Health Promotion & Disease
Prevention
MRosa
Health Promotion
Disease Prevention
Health Protection
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Levels of Prevention
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Primary Prevention
prevention of initial occurrence of disease or injury
Includes Health Promotion & Health Protection
Secondary Prevention
Early identification of disease / injury with intervention to
limit disability
Tertiary Prevention
Limit disease progress / disability
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Match each activity with the appropriate
level of prevention
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Immunizations
Physical assessment
HTN screening
Teaching re: lifestyle changes such as diet
Smoking cessation
Mammography
Support groups for caregiver
Meals on Wheels for homebound
Seat belts
Pregnancy testing
Alcohol & drug prevention
PT after stroke
Mental health counseling for rape victims
Home management after chronic illness
Hygiene teaching
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Prevention in Different Settings to
Individuals, Families, Groups &
Communities
MRosa
Examples of _________________ Prevention
Counseling and HIV testing to individual
Early prenatal care
TB screening for a family at risk
Lead screening of children in a community
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Prevention in Different Settings to
Individuals, Families, Groups &
Communities
MRosa
Examples of _________________ Prevention
Nutrition teaching to the patient with AIDS Teaching to a newly diagnosed patient with
diabetes about diet Teaching to a family member about how to
follow procedure for a dressing change Support group for children with asthma
Shelters for victims of natural disasters
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Prevention in Different Settings to
Individuals, Families, Groups &
Communities
MRosa
Examples of _________________ Prevention
Family planning to an individual in the clinic
education about infection control in the home
prenatal classes to a group of pregnant
adolescents fluoride water supplementation to the
community
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Goals of Prevention
MRosa
Improve Quality of Life
Be Cost Effective
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Screening Identifies individuals with unrecognized health
risk factors or asymptomatic disease
conditions in populations
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Outreach Locates populations of interest or populations
at risk and provides information about the
nature of the concern, what can be done
about it, and how services can be obtained
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Question
Which public health nursing intervention is seenin the following example?
Student nurses go into a neighborhood door-to-
door. They identify individuals who have not
had flu shots and direct them to the local
community center’s flu clinics.
A. Screening
B. Outreach
C. Health teaching
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Question
Which public health nursing intervention is seen
in the following example?
A group of student nurses takes blood
pressures at a senior center in the communityand provides information about hypertension,
what follow-up those with high blood pressure
require, and how they may secure health
care.
A. Screening
B. Health education
C. Outreach
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Question
Which public health nursing intervention is seenin the following example? A nurse and a physical therapist meet to plan
the care of an elderly woman who ishospitalized with a broken hip and will bedischarged from the hospital today.
A. CollaborationB. ConsultationC. Care management
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Question
Which public health nursing intervention is seenin the following example?
A nurse meets with Edna, an elderly womanwho has been hospitalized with a broken hip,
and her family. They discuss what self-careEdna can manage on her own and how thefamily may be able to assist her once shegoes home, and determine the communityresources available to assist with her care.
A. Health teachingB. Case managementC. Collaboration
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Infant Mortality
MRosa
Death Rate of infants < 1 year per 1000 births
An international measure of health status
US Infant Mortality Rate = 6.9
International Ranking = 27
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Infant Mortality
Leading Causes of Infant Death
MRosa
Congenital ailments
Pre-term / LBW
Sudden Infant Death Syndrome
Problems Due to Pregnancy
Respiratory Distress Syndrome
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The Community
MRosa
Group of people with common characteristics Geographic
Political
Race / Ethnicity
Age
Problem Based
Knowledge of the community increases qualitycare
What makes a healthy community?
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The Community & Health,
Health Care Needs Influenced by:
MRosa
Vital Statistics & Demographics
Resources & Support Services
Community Leadership
Culture
Composition of Families
Socioeconomic Status Community Boundaries
Social Systems
Social Systems & Health in the
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Social Systems & Health in the
Community
MRosa
Economy
Education
Religion
Welfare
Recreation
Health Care
Government
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Health
MRosa
Defined by the World Health Organization as
“a state of physical, mental & social well-
being and not merely absence of diseases”
Health Illness Continuum
Continuum from optimal health
to total disability
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What is Health?
MRosa
Acute CareNursing Focus
Fix the problem
Eliminate disease
Community NursingFocus
Facilitate Self Care
Improve functional ability
Enhance QOL
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Healthy People 2020
MRosa
Provide information & knowledge about how toimprove health in a format that enables diversegroups to work together
Provides science-based, 10-year national objectives
for improving the health of all Americans; Frameworkfor improving health of nation.
Road map to better health for all
Can be used by many different people, communities,groups, professional organizations whose concern isa particular population or threat to health
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Healthy People 2020
MRosa
The Office of Disease Prevention & Health Promotion
U.S. Department of Health and Human Services
coordinates
Healthy People 2020
www.health.gov/healthypeople
1-800-367-4725
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Healthy People 2020
MRosa
Vision
A society in which all people live long, healthy
lives.
Mission: Healthy People 2020 strives to:
Identify nationwide health improvement
priorities.
Increase public awareness and understanding Provide measurable objectives and goals
Engage multiple sectors
Utilize evidence based practice
D t i t f H lth
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Determinants of Health
MRosa
What makes some people healthy and othersunhealthy?
How can we create a society in which everyone
has a chance to live long healthy lives?
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MRosa
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Healthy People 2020
MRosa
Addressing “All Hazards” Preparedness as aPublic Health Issue
The Role of Health Information Technology and
Health Communication
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What Does Healthy People 2020
Say About Cultural Care?
Elimination of disparity among groups in access to
quality health care
Increase in community-based programs that areculturally and linguistically appropriate
Healthy People 2020: Focus
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Healthy People 2020: FocusAreas
MRosa
1. Access to Quality Health Services
2. Arthritis, Osteoporosis, and Chronic Back Conditions
3. Cancer
4. Chronic Kidney Disease
5. Diabetes
6. Disability and Secondary Conditions
7. Educational and Community-Based Programs 8. Environmental Health
9. Family Planning
10. Food Safety
11. Health Communication12. Heart Disease and Stroke
13. Immunization and Infectious Diseases
14. HIV
Healthy People 2020: Focus
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Healthy People 2020: Focus
Areas
MRosa
15. Injury and Violence Prevention
16. Maternal, Infant, and Child Health
17. Medical Product Safety
18. Mental Health and Mental Disorders
19. Nutrition and Overweight
20. Occupational Safety and Health 21. Oral Health
22. Physical Activity and Fitness
23. Public Health Infrastructure
24. Respiratory Diseases 25. Sexually Transmitted Diseases
26. Substance Abuse
27. Tobacco Use
28. Vision and Hearing
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Healthy People 2020
Eliminate Health Disparities
Examples of Health Disparities
Effect of income on
health status
The lower the household
income, the poorer thehealth
Effect of education on
income
The higher the education,
the more income
MRosa
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Question
What can nurses do to address disparity in their own
community?
A. Educate themselves regarding issues of disparity
B. Use evidence-based decision making
C. Identify vulnerable populations in their communitiesD. Advocate for vulnerable populations
E. All of the above
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Healthy People 2020
Increase Quality & Years of Healthy Life
Life Expectancy at Birth, 1930 –2002National Center for Health Statistics, National Vital Statistics Reports, vol. 52, no. 3
2002 77.3
2000 77.0
1995 75.8
1990 75.4
1980 73.7
1970 70.8
1960 69.7
1930 59.7MRosa
C St d 1
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Case Study 1
MRosa
. Harold is a 61-year-old bachelor who lives alone on a
farm in a rural area. His diabetes has been wellcontrolled for 40 years. Harold had lived with hismother, who cooked for him and administered hisinsulin. After his mother’s death last year, he went to theclinic three times in 3 months for problems with his
diabetes. Harold stated, “Every time I went to the clinic Isaw someone different. I would tell them the same storythree times. Don’t they ever talk to each other?” He wasadmitted for a large ulcer on his ankle and uncontrolleddiabetes last week.
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Case Study 1 continued
MRosa
This morning you interviewed him in preparation for hisdischarge. He told you that he has never cooked anddoesn’t plan to learn now. He would rather go to thebakery and get doughnuts and caramel rolls for breakfast and lunch and eat cake and ice cream for dinner. He has refused to participate in any care
related to his wound or even look at his wound.Harold seems very attached to his niece, who lives ona farm half a mile from him. She visits him everyevening and has offered to help with his care. Your first plan was to have a home health aide provide
homemaking care for Harold. When you suggestedthis he said, “No one is going to come into my houseand cook in my mother’s kitchen! That’s what family isfor!”
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Case Study 1
MRosa
a. What are the problems identified?1. Physical
2. Psychosocial
3. Family dynamics
4. Environmental5. Lifestyle
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Case Study 1
MRosa
b. How will you use the elements of community based
nursing to plan for Harold’s discharge?
• self -care
• in the context of the family and community
• preventive focus
• continuity
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Case Study 1
MRosa
c. List one goal for each problem identified.1. Physical
2. Psychosocial
3. Family dynamics
4. Environmental5. Lifestyle
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Case Study 1
MRosa
d. What nursing actions would you take to help
achieve these goals?
e. Specify community resources you can suggest to
this client.
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Case Study 2
MRosa
Anna is 85 years old and suffers from congestive heart
failure. She is not taking her medication. Her
hemoglobin is 9.0 g/dL and she complains about
constant fatigue. Her weight has remained
constant, but she states “my legs have gotten so
swollen and I am so short of breath.”
a. Determine the primary nursing role.
b. State two likely basic or physical needs and
psychosocial needs
Case Study 3
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Case Study 3
MRosa
Mrs. Nguyen is a 45-year-old woman admitted to the hospital for
spinal fusion of C5-6 & C6-7 vertebrae. She is from Vietnam &has lived in the U.S. for 15 years. She has been suffering from
degenerative disk disease & osteoarthritis for the last 4 years & has lost
some of the function in her right arm. Her plan of care was developed
around the critical pathways for cervical fusion, with an expected length
of stay in the hospital from 3 to 5 days. The surgical procedure wasuneventful, but Mrs. Nguyen suffered from nausea & vomiting until the
middle of postoperative day (POD) 1. Today is POD 2. She is able to get
to the bathroom by herself but cannot dress herself, bathe herself, or
pick up anything weighing over 3 or 4 lb. Her physician is
recommending that she be discharged tomorrow, POD 3. She will be in aPhiladelphia collar for 6 weeks, during which time she will be unable to
drive. Mrs. Nguyen lives with her husband & 2 teenage sons, ages 14 &
16. Her husband owns a restaurant & works 12 to 14 hours a day. He will
not be taking off any work time to care for her when she gets home.
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Question
Who said the nurse, through her “peculiar introduction to the patient and her organic
relationship with the neighborhood” could be the
“starting point” for wider service in the
community? A. Mary Brewster
B. William Rathbone
C. Lillian WaldD. Florence Nightingale