Chapter 1: Nursing Practice and Nursing Process

NURSING PRACTICE
BASIC CONCEPTS IN NURSING PRACTICE

Understanding basic concepts in nursing practice, such as roles of nursing, theories of nursing, licensing, and legal issues, helps enhance performance.

Definition of Nursing

• Nursing is an art and a science.
• Earlier emphasis was on the care of sick patient; now the promotion of health is stressed.
• American Nurses Association definition, 1980: Nursing is the diagnosis and treatment of human responses to actual and potential health problems.

Roles of Nursing

Whether in hospital-based or community health care setting, nurses assume three basic roles:

• Practitioner involves actions that directly meet the health care and nursing needs of patients, families, and significant others; includes staff nurses at all levels of the clinical ladder, advanced practice nurses, and community-based nurses.
• Leader involves actions such as deciding, relating, influencing, and facilitating that affect the actions of others and are directed toward goal determination and achievement; may be a formal nursing leadership role or an informal role periodically assumed by the nurse.
• Researcher involves actions taken to implement studies to determine the actual effects of nursing care to further the scientific base of nursing; can include all nurses, not just academicians, nurse scientists, and graduate nursing students.

History of Nursing

• The first nurses were trained by religious institutions to care for patients; no standards or educational basis.
• In 1873, Florence Nightingale developed a model for independent nursing schools to teach critical thinking, attention to the patient's individual needs, and respect for the patient's rights.
• During the early 1900s, hospitals used nursing students as cheap labor and most graduate nurses were privately employed to provide care in the home.
• After World War II, technological advancements brought more skilled and specialized care to hospitals, requiring more experienced nurses.
• Development of intensive and coronary care units during the 1950s brought forth specialty nursing and advanced practice nurses.
• Since the 1960s, greater interest in health promotion and disease prevention along with a shortage of physicians serving rural areas, helped create the role of the nurse practitioner.

Theories of Nursing

• Nursing theories help define nursing as a scientific discipline of its own.
• The elements of nursing theories are uniform nursing, person, environment, and health; also known as the paradigm or model of nursing.
• Nightingale was the first nursing theorist; she believed the purpose of nursing was to put the person in the best condition for nature to restore or preserve health.
• More recent nursing theorists include:
  • Levine - Nursing supports a person's adaptation to change due to internal and external environmental stimuli.
  • Orem - Nurses assist the person to meet universal, developmental, and health deviation self-care requisites.
  • Roy Nurses manipulate stimuli to promote adaptation in four modes physiologic, self-concept, role function, and interdependence relations.
  • Neuman - Nurses affect a person's response to stressors in the areas of physiologic, psychological, sociocultural, and developmental variables.
  • King - Nurses exchange information with patients, who are open systems to attain mutually set goals.
  • Rogers - Nurses promote harmonious interaction between the person and environment to maximize health; both are four-dimensional energy fields.

Nursing in the Health Care Delivery System

• Technology, education, society values, demographics, and health care financing have an impact on where and how nursing is practiced.
  • By the year 2030, the over age 65 population will more than double to about 70 million.
  • Almost 50% of the U.S. population has one or more chronic conditions.
  • The annual cost of medical care in the United States is greater than $900 billion and growing at twice the rate of inflation.
• Current trends to use health care dollars for primary care of many, rather than specialized care for a few, have shifted nursing care out of the acute care hospital and into the home and outpatient setting.
• Inpatient staff nurses are now responsible for a greater number of patients who may be older, more acutely ill, and hospitalized for shorter stays.
  • Diagnosis-related groups (DRGs), implemented in 1983, set rates for Medicare payment for inpatient services, fixing reimbursement based on diagnosis, not on actual charges. This set the standard for shorter hospital stays and other cost-cutting measures.
  • During the 1990s, hospital mergers, reengineering efforts, and other cost-cutting efforts led to a decrease in nursing care hours and registered positions, replacing nurses with less-skilled personnel.
  • From late 1990s through mid-2000, nursing school enrollment began to decline and has yet to reverse. Health care employers are experiencing a shortage in the supply of new nurses and the aging of the registered nurse workforce. By 2010, the average age of the practicing nurse in the United States is projected to be age 45½.
  • Research indicates that the number of registered nurses directly and positively affects patient outcomes. Health care organizations are attempting to increase nursing positions during a shortage.
• The concept of managed care has expanded for health maintenance organizations (HMOs) and preferred provider organizations to case management and reimbursement control for most insurance plans. Therefore, more nurses are working in utilization management or for hospitals or insurance companies to determine the need for specialist consultations, costly procedures, surgeries, and hospitalizations.
• More nurses are working for large outpatient centers run by hospitals or HMOs; responsibilities include less hands on care, but more assessment and health education for patients and their families.
• The nursing role has expanded to meet health care challenges more efficiently with certification in a variety of specialties to provide direct care or support and educate other nurses in their roles

Advanced Practice Nursing

• Registered professional nurses with advanced training, education, and certification are allowed to practice in expanded scope.
• This includes nurse practitioners, nurse midwives, nurse anesthetists, and clinical nurse specialists.
• Scope of practice and legislation vary by state.
  • Clinical nurse specialists are included in advanced practice nurse (APN) legislation in at least 25 states (some of these include just psychiatric/mental health clinical nurse specialists).
  • Nurse practitioners have some type of prescriptive authority in all 50 states and the District of Columbia.
  • Nurse practitioners are now eligible for Medicare reimbursement across the United States at 85% of the physician fee schedule in most cases and are eligible for Medicaid reimbursement in some states.
  • Most states give authority to APNs through the Board of Nursing with some degree of physician collaboration/supervision required.
• Master's degree preparation is becoming the requirement for most APN roles; however, many certificate programs have trained APNs in the past 30 years.
• Regulation of Canadian APNs has been slower than in the United States, except for midwives, so practice of APNs has been restricted.
• The number of APNs, particularly nurse practitioners, is growing. It is predicted that by 2005 there will be approximately as many nurse practitioners as family physicians in the United States.
• Some acute care teaching hospitals are also increasing the number of nurse practitioners to fill gaps in patient care coverage created by the resident duty hour guidelines (80 hour rule, Accreditation Commission for Graduate Medical Education).

Licensing/Continuing Education

• Every professional registered nurse must be licensed through the state board of nursing in the United States to practice in that state or the College of Nursing to practice in a Canadian province.
• Continuing education requirements vary depending on state laws, institutional policies, and area of specialty practice/ certification. Continuing education units can be obtained through a variety of professional nursing organizations and commercial educational services.
• Many professional nursing organizations exist to provide education, certification, support, and communication among nurses; for more information contact your state nurses' association, state board of nursing, or the American Nurses Association, 600 Maryland Avenue S.W., Suite 100, Washington, DC 20024-2571, 202-554-4444

ANCC Certification Examinations

ADVANCED PRACTICE

Nurse practitioners

• Adult Nurse Practitioner
• Family Nurse Practitioner
• Gerontological Nurse Practitioner
• Pediatric Nurse Practitioner
• Acute Care Nurse Practitioner
• Adult Psychiatric and Mental Health Nurse Practitioner
• Family Psychiatric and Mental Health Nurse Practitioner
• Advanced Diabetes Management Nurse Practitioner

Clinical specialists

• Clinical Specialist in Adult Psychiatric and Mental Health Nursing
• Clinical Specialist in Child/Adolescent Psychiatric & Mental Health Nursing
• Clinical Specialist in Gerontological Nursing
• Clinical Specialist in Medical-Surgical Nursing
• Clinical Specialist in Home Health Nursing
• Clinical Specialist in Pediatric Nursing
• Clinical Specialist in Community Health
• Advanced Diabetes Management Clinical Specialist

Other disciplines

• Palliative Care
• Advanced Diabetes Management Pharmacist
• Advanced Diabetes Management Dietitian

BACCALAUREATE AND HIGHER SPECIALTIES

• Psychiatric and Mental Health Nurse
• Medical-Surgical Nurse
• Pediatric Nurse
• Gerontological Nurse
• Perinatal Nurse
• Community Health Nurse
• College Health Nurse
• Cardiac/Vascular Nurse
• Informatics Nurse
• Home Health Nurse
• Nursing Professional Development
• Nursing Administration
• Nursing Administration, Advanced

DIPLOMA/ASSOCIATE DEGREE SPECIALTIES

• Psychiatric and Mental Health Nurse
• Medical-Surgical Nurse
• Pediatric Nurse
• Gerontological Nurse
• Perinatal Nurse
• Cardiac/Vascular Nurse

MODULAR EXAMINATIONS

• Nursing Case Management
• Ambulatory Care Nurse

SAFE NURSING CARE

Patient Safety

• Patient safety has moved to the forefront of health care as a result of the Institute of Medicine's (IOM) report, To Err is Human: Building a Safer Health Care System, published in 2000.
  • In reviewing studies of adverse events and patient deaths in hospitals across the country, the report found that approximately half were due to medical error and could have been prevented.
  • In studying the cause for these errors, the report identified the current health care system as complex and error prone. Errors are not caused by bad health care workers, but are due to the badsystems.
  • The IOM offered recommendations for improving systems and processes to improve patient safety in health care organizations.
• The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is also committed to improving safety for patients in health care organizations. Many of JCAHO standards focus on patient safety.
  • In 2001, JCAHO introduced standards that require organizations to determine the cause of an event by using a Root Cause Analysis to analyze errors retrospectively. They also established standards to analyze high-risk processes using a Failure Mode and Effects Analysis procedure and to alter processes as needed to improve safety.
  • In 2002, JCAHO introduced National Patient Safety Goals in accreditation requirements. The goals focused on patient identification, verbal orders, dangerous abbreviations, surgical site marking and time-out for patients, procedure, and site verifications, infusion pumps, and clinical alarms.
  • In 2004, JCAHO established goals related to hand washing and hospital-acquired infections. Nurses play a key role in building and modifying patient care practice to achieve the JCAHO patient safety goals.
  • JCAHO's National Patient Safety Goals for 2005 expand to include:
    • Timeliness of reporting and receipt of critical test results and values.
    • Identification of and action to prevent error related to look-alike, sound-alike drugs.
    • Accurate and complete reconciliation of medication across the continuum of care.
      
      
      
      
    • Reduced risk of patient harm from falls, reduced risk of influenza and pneumonia, and reduced risk of surgical fires.
• In 2003, the IOM published a companion report to To Err is Human, titled Keeping Patients Safe: Transforming the Work Environment for Nurses. Recognizing nursing as the largest segment of the health care work force, the report calls for changes in nursing staffing levels and limits on nurses' work hours, in addition to changes in nurse work space, work processes, and organizational culture.

Personal Safety

• Nurses may be at risk for personal harm in the workplace. The American Nurses Association (ANA) has sponsored initiatives to improve nurses' personal safety.
• The Centers for Disease Control and Prevention estimates that 384,325 health care workers are injured by needles and other sharps each year. Nurses sustain the largest percentage of these injuries. The ANA's Safe Needles, Save Lives campaign was key in promoting the use of safety devices. Nurses and other health care workers are now protected by the Needlestick Safety and Prevention Act (P.L. 106-430). The law requires health care organizations to use needleless or shielded-needle devices, obtain input from clinical staff in the evaluation and selection of devices, educate staff on the use of safety devices, and have an exposure control plan.
• The physical work environment, which includes patient handling tasks, such as manual lifting, transferring, and repositioning patients, can also place nurses at risk for musculoskeletal disorders such as back injuries and shoulder strains. The ANA's Handle with Care campaign aims to prevent such injuries and to promote safe patient handling through the use of technology and assistive patient handling equipment and devices.

Culturally Sensitive Care

The changing demographics of the United States and other countries bring a diverse array of individuals with varying cultures and beliefs into nursing practice. Nurses must provide culturally competent care by expanding their knowledge about different cultures. Many print and online resources are available to provide information about the values, beliefs, and traditions of various cultures. However, the nurse must always use caution and avoid generalizing and stereotyping patients. Culturally sensitive care begins with an individualized patient assessment, including his or her definition of health and expectations for care. Based on this assessment, the nurse can develop an individualized care plan.

Leininger (2002) offers guidelines for providing care to patients from different cultures. Consider cultural care preservation, which allows patients to continue cultural practices that do not cause harm or interfere with treatment. In cultural care negotiation, the patient and health care staff negotiate the inclusion of cultural practices in treatment. If the patient is engaging in harmful practices, the nurse can help the patient select a substitute practice within the patient's cultural values.

THE NURSING PROCESS

The nursing process is a deliberate, problem-solving approach to meeting the health care and nursing needs of patients. It involves assessment (data collection), nursing diagnosis, planning, implementation, and evaluation, with subsequent modifications used as feedback mechanisms that promote the resolution of the nursing diagnoses. The process as a whole is cyclical, the steps being interrelated, interdependent, and recurrent.

STEPS IN THE NURSING PROCESS

Assessment. systematic collection of data to determine the patient's health status and to identify any actual or potential health problems. (Analysis of data is included as part of the assessment. For those who wish to emphasize its importance, analysis may be identified as a separate step of the nursing process.)

Nursing diagnosis. identification of actual or potential health problems that are amenable to resolution by nursing actions.

Planning. development of goals and a care plan designed to assist the patient in resolving the nursing diagnoses.

Implementation. actualization of the care plan through nursing interventions or supervision of others to do the same.

Evaluation. determination of the patient's responses to the nursing interventions and of the extent to which the goals have been achieved.

The ANA has recognized several standardized languages for nursing to document the nursing process and nursing care. Standardized languages are important for computerized documentation systems, for tracking care over the continuum, andfor studying the impact of nursing care.

Assessment

• The nursing history
  • Obtain subjective data by interviewing the patient, family members, or significant other and reviewing past medical records.
  • Provides the opportunity to convey interest, support, and understanding to the patient and to establish a rapport based on trust.
• The physical examination
  • Objective data obtained to determine the patient's physical status, limitations, and assets.
  • Should be done in a private, comfortable environment with efficiency and respect.

Nursing Diagnosis

• Organize, analyze, synthesize, and summarize the assessment data.
• Identify the patient's health problem, its particular characteristics and etiology.

BOX 1-2 North American Nursing Diagnosis Association Accepted Nursing Diagnoses

• Activity intolerance
• Acute confusion
• Acute pain
• Adult failure to thrive
• Anticipatory grieving
• Anxiety
• Autonomic dysreflexia
• Bathing or hygiene self-care deficit
• Bowel incontinence
• Caregiver role strain
• Chronic confusion
• Chronic low self-esteem
• Chronic pain
• Chronic sorrow
• Compromised family coping
• Constipation
• Death anxiety
• Decisional conflict (specify)
• Decreased cardiac output
• Decreased intracranial adaptive capacity
• Defensive coping
• Deficient diversional activity
• Deficient fluid volume
• Deficient knowledge (specify)
• Delayed growth and development
• Delayed surgical recovery
• Diarrhea
• Disabled family coping
• Disorganized infant behavior
• Disturbed body image
• Disturbed personal identity
• Disturbed sensory perception (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)
• Disturbed sleep pattern
• Disturbed thought processes
• Dressing or grooming self-care deficit
• Dysfunctional family processes: Alcoholism
• Dysfunctional grieving
• Dysfunctional ventilatory weaning response
• Effective breast-feeding
• Effective therapeutic regimen management
• Energy field disturbance
• Excess fluid volume
• Fatigue
• Fear
• Feeding self-care deficit
• Functional urinary incontinence
• Health-seeking behaviors (specify)
• Hopelessness
• Hyperthermia
• Hypothermia
• Imbalanced nutrition: Less than body requirements
• Imbalanced nutrition: More than body requirements
• Impaired adjustment
• Impaired bed mobility
• Impaired dentition
• Impaired environmental interpretation syndrome
• Impaired gas exchange
• Impaired home maintenance
• Impaired memory
• Impaired oral mucous membrane
• Impaired parenting
• Impaired physical mobility
• Impaired religiosity
• Impaired skin integrity
• Impaired social interaction
• Impaired spontaneous ventilation
• Impaired swallowing
• Impaired tissue integrity
• Impaired transfer ability
• Impaired urinary elimination
• Impaired verbal communication
• Impaired walking
• Impaired wheelchair mobility
• Ineffective airway clearance
• Ineffective breast-feeding
• Ineffective breathing pattern
• Ineffective community coping
• Ineffective community therapeutic regimen management
• Ineffective coping
• Ineffective denial
• Ineffective family therapeutic regimen management
• Ineffective health maintenance
• Ineffective infant feeding pattern
• Ineffective protection
• Ineffective role performance
• Ineffective sexuality patterns
• Ineffective therapeutic regimen management
• Ineffective thermoregulation
• Ineffective tissue perfusion (specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral)
• Interrupted breast-feeding
• Interrupted family processes
• Latex allergy response
• Nausea
• Noncompliance (specify)
• Parental role conflict
• Perceived constipation
• Posttrauma syndrome
• Powerlessness
• Rape-trauma syndrome
• Rape-trauma syndrome: Compound reaction
• Rape-trauma syndrome: Silent reaction
• Readiness for enhanced communication
• Readiness for enhanced community coping
• Readiness for enhanced coping
• Readiness for enhanced family coping
• Readiness for enhanced family processes
• Readiness for enhanced fluid balance
• Readiness for enhanced knowledge (specify)
• Readiness for enhanced management of therapeutic regimen
• Readiness for enhanced nutrition
• Readiness for enhanced organized infant behavior
• Readiness for enhanced parenting
• Readiness for enhanced religiosity
• Readiness for enhanced self-concept
• Readiness for enhanced sleep
• Readiness for enhanced spiritual well being
• Readiness for enhanced urinary elimination
• Reflex urinary incontinence
• Relocation stress syndrome
• Risk for activity intolerance
• Risk for aspiration
• Risk for autonomic dysreflexia
• Risk for caregiver role strain
• Risk for constipation
• Risk for deficient fluid volume
• Risk for delayed development
• Risk for disorganized infant behavior
• Risk for disproportionate growth
• Risk for disuse syndrome
• Risk for dysfunctional grieving
• Risk for falls
• Risk for imbalanced body temperature
• Risk for imbalanced fluid volume
• Risk for imbalanced nutrition: More than body requirements
• Risk for impaired parent/infant/child attachment
• Risk for impaired parenting
• Risk for impaired religiosity
• Risk for impaired skin integrity
• Risk for infection
• Risk for injury
• Risk for latex allergy response
• Risk for loneliness
• Risk for other-directed violence
• Risk for perioperative-positioning injury
• Risk for peripheral neurovascular dysfunction
• Risk for poisoning
• Risk for posttrauma syndrome
• Risk for powerlessness
• Risk for relocation stress syndrome
• Risk for self-directed violence
• Risk for self-mutilation
• Risk for situational low self-esteem
• Risk for spiritual distress
• Risk for sudden infant death syndrome
• Risk for suffocation
• Risk for suicide
• Risk for trauma
• Risk for urge urinary incontinence
• Sedentary lifestyle
• Self-mutilation
• Sexual dysfunction
• Situational low self-esteem
• Sleep deprivation
• Social isolation
• Spiritual distress
• Stress urinary incontinence
• Toileting self-care deficit
• Total urinary incontinence
• Unilateral neglect
• Urge urinary incontinence
• Urinary retention
• Wandering

State nursing diagnoses based on the North American Nursing Diagnosis Association (NANDA) list. Nursing diagnoses continue to be developed and refined.

Further work is being done through the University of Iowa College of Nursing to refine, extend, validate, and classify the NANDA taxonomy, called the Nursing Diagnosis and Extension Classification (NDEC) project.

Planning

• Assign priorities to the nursing diagnoses. Highest priority is given to problems that are the most urgent and critical.
• Establish goals or expected outcomes derived from the nursing diagnoses.
  • Specify short-term, intermediate, and long-term goals as established by nurse and patient together.
  • Goals should be specific, measurable, and patient focused and should include a time frame.
• Identify nursing interventions as appropriate for goal attainment.
  • Include independent nursing actions as well as medical orders.
  • Should be detailed to provide continuity of care.
  • Nursing Interventions Classification (NIC) is a standardized language describing treatments performed by nurses in all settings and specialties. More than 480 NIC interventions have been developed through the University of Iowa College of Nursing. NIC is organized into 30 classifications and 7 domains and includes physiologic and psychosocial interventions and interventions for illness prevention and treatment. NIC interventions may serve a role in documentation, coding, and reimbursement for nursing care in the future.
• Formulate the nursing care plan. The nursing care plan may be a component of the interdisciplinary/collaborative care plan for the patient.
  • Include nursing diagnoses, expected outcomes, interventions, and a space for evaluation.
  • May use a standardized care plan check off appropriate data and fill in target dates for expected outcomes and frequency and other specifics of interventions.
  • May use a protocol that gives specific sequential instructions for treating patients with a particular problem, including who is responsible and what specific actions should be taken in terms of assessment, planning, interventions, teaching, recognition of complications, evaluation, and documentation.
  • May use a care path or clinical pathway (also called care map or critical pathway) in which the nurse as case manager is responsible for outcomes, length of stay, and use of equipment during the patient's illness; includes the patient's medical diagnosis, length of stay allowed by DRG, expected outcomes, and key events that must occur for the patient to be discharged by that date. Key events are not as specific as nursing interventions but are categorized by day of stay and who is responsible (nurse, physician, other health team member, patient, family).
  • May also use a computerized care plan that is based on assessment data and allows for the selection of nursing interventions and establishment of expected outcomes.

Implementation

• Coordinate activities of patient, family, significant others, nursing team members, and other health team members.
• Delegate specific nursing interventions to other members of the nursing team, as appropriate.
  • Consider the capabilities and limitations of the members of the nursing team.
  • Supervise the performance of the nursing interventions.
• Record the patient's responses to the nursing interventions precisely and concisely.

Evaluation

Determines the success of nursing care and the need to alter the care plan.

• Collect assessment data.
• Compare patient's actual outcomes to expected outcomes to determine to what extent goals have been achieved.
  
  
  • Nursing Outcomes Classification (NOC) is a standardized language of patient outcomes used to evaluate the effects of nursing interventions. More than 200 outcomes are organized into 29 classifications and 7 domains. Disciplines other than nursing have found NOC useful in evaluating the effectiveness of their interventions.
• Include the patient, family, or significant other, nursing team members, and other health team members in the evaluation.
• Identify alterations that need to be made in the goals and the nursing care plan.

NURSING CARE PLAN 1-1

Example of a Nursing Care Plan

Mr. John Preston, a 52-year-old businessman, was admitted with chest pain; rule out myocardial infarction. He had experienced substernal chest pain and weakness in his arms after having lunch with a business associate. The pain had lessened by the time he arrived at the hospital. The nursing history revealed that he had been hospitalized 5 months previously with the same complaints and had been told by his physician to go to the emergency department if the pain ever recurred. He had been placed on a low-fat diet and had stopped smoking. Physical examination revealed that Mr. Preston's vital signs were within normal limits. He stated that he had feared he was having a heart attackuntil his pain subsided and until he was told that his electrocardiogram was normal. He verbalized that he wanted to find out how he could prevent the attacks of pain in the future. The physician's orders on admission included activity as tolerated, low-cholesterol diet, and nitroglycerin 0.4 mg (1/500 gr) sublingually as needed.

NURSING DIAGNOSIS

Acute Pain related to angina pectoris/rule out myocardial ischemia

GOALS

Short-term: Relief of pain

Long-term: Altered lifestyle to include measures that decrease myocardial oxygen demands Compliance with therapeutic regimen

Nursing Interventions Expected Outcomes Critical Time* Actual Outcomes (Evaluation) Monitor blood pressure (BP), pulse (P), respirations (R) q4h. BP, P, R will remain within normal limits. 24 h BP: stable at 116 to 122/72 to 84 P: stable at 68 to 82 R: stable at 16 to 20 Assess frequency of chest pain and precipitating events. Patient will remain free from chest pain. 24 h Denies chest pain; able to walk length of hall, eat meals, and visit with family and friends without chest discomfort. Encourage food and fluid intake that promotes normal nutrition, digestion, and elimination and that does not precipitate chest pain: light, regular meals; foods low in cholesterol; 1,500 to 2,000 mL fluid/day. Will tolerate dietary regimen. Will not experience chest pain after meals. Will maintain normal bowel elimination. Will have intake of 1,500 to 2,000 mL fluid/day. 24 h Denies chest pain after meals; no constipation or diarrhea; fluid intake 1,700 to 2,100 mL/day. Request consultation with dietitian. Reinforce diet teaching. Will identify foods low in cholesterol and those foods that are to be avoided. Will select well-balanced diet within prescribed restrictions. 48 h Dietitian reviewed diet restrictions with patient and wife; wife counseled in meal planning. Patient selects and eats a balanced diet consisting of foods low in cholesterol. Encourage alterations in activities and exercise that are necessary to prevent episodes of anginal pain. Will identify activities and exercises that could precipitate chest pain: those that require sudden bursts of activity and heavy effort. Will identify emotionally stressful situations; will explain the necessity for alternating periods of activity with periods of rest. 48 h Patient and wife have identified activities and situations that should be avoided; patient and wife have studied their usual daily routine and have made plans to alter the routine to allow for rest periods; teenage son has volunteered to assist with strenuous home-maintenance chores. Teach nitroglycerin regimen. Will describe action, use, and correct administration of nitroglycerin. 24 h Accurately stated action, use, and dosage of nitroglycerin; demonstrated correct administration. * These times have not been standardized, but are individualized according to the patient's needs.

Continuation of the Nursing Process

• Continue all steps of the nursing process: assessment, nursing diagnosis, planning, implementation, and evaluation.
• Continuous evaluation provides the means for maintaining the viability of the entire nursing process and for demonstrating accountability for the quality of nursing care rendered.

COMMUNITY AND HOME CARE NURSING

HOME HEALTH CONCEPTS

The home care nurse functions in the home and community, outside the walls of a hospital or other health care facility. The role is more independent and the basic concepts of home health are different from hospital or outpatient nursing.

Roles and Duties of the Home Care Nurse

• The home care nurse maintains a comprehensive knowledge base of the health of the patient.
• The home care nurse performs an extensive evaluation of the patient's medical history, physical condition, psychosocial well-being, living environment, and support systems.
• The home care nurse functions independently, recommending to the primary or specialty health care provider what services are needed in the home.
• The home care nurse coordinates the services of other disciplines such as physical therapy, occupational therapy, nutrition, and social work.
• The home care nurse oversees the entire treatment plan and keeps the health care provider apprised of the patient's progress or lack of progress toward goals.
• The home care nurse acts as a liaison between patient, family, caregivers, and the primary health care provider and other members of the health care team.
• The home care nurse may function as supervisor of home health aides who provide direct daily care for the patient.
• The home care nurse must honor patient rights as in the hospital (see page 13).

Skills for Home Care Nursing

• Good rapport building to engage the patient, family, and caregivers in goal attainment.
• Clear communication to provide effective teaching to family and caregivers, to relate assessment information about the patient to the health care provider, and to share information with the home care team.
• Cultural competence knowledge and appreciation of the cultural norms being practiced in the home. Cultural practices may affect family structure, communication, and decision making in the home; health beliefs, nutrition, and alternative health practices; and spirituality and religious beliefs.
• Accurate documentation record keeping in home care is used for reimbursement of nursing services, accreditation and regulatory review, and communication among the home care team.

Reimbursement Issues

• Home health care services are reimbursed by Medicare, Medicaid, and a variety of commercial insurances and managed care plans.
• Some patients are willing to pay out of pocket for additional services not covered by insurance because of the well-established value of home care services compared with more expensive hospital and nursing home services.
• Services are reimbursed by Medicare if they meet the following criteria:
  • Services are ordered by a physician (or, more recently, by a nurse practitioner).
  • Services are intermittent or needed on a part-time basis.
  • The patient is homebound.
  • The services required are skilled (need to be provided by a licensed nurse, physical therapist, or speech therapist, or by an occupational therapist, social worker, or home health aide along with the service of a nurse).
  • The services requested are reasonable and medically necessary.
• The home health nurse must evaluate the case and ensure that these criteria apply. This information must be documented so reimbursement will not be denied.

HOME HEALTH PRACTICE

The nursing process is carried out in home care as it is in other nursing settings. Patient interactions are structured differently than in the hospital because the nurse will interact with the patient for a limited time. Many procedures and nursing interventions are implemented in a similar manner as other nursing settings, as outlined in the rest of this book. Major concerns of the home care nurse are patient teaching, infection control, and maintenance of safety.

The Home Care Visit

• The initial home care visit to a patient should be preceded by information gathering and an introductory phone call.
• Extensive assessment is carried out at the first visit, including complete medical and psychosocial history, physical
  

  
  

  
  examination, assessment of the home environment, nutritional assessment, medication review, and review of current treatment plan.
• Once assessment (gathered from multiple sources) is complete, nursing diagnoses are formed.
• Outcome planning (goal setting) is done with the patient, family, and caregivers involved.
• The plan is implemented over a prescribed time period (the certified period of service). Interventions may be:
  • Cognitive patient teaching.
  • Psychosocial reinforcing coping mechanisms, supporting caregivers, reducing stress.
  • Technical procedures such as wound care, catheter insertion.
• Evaluation is ongoing at every visit and by follow-up phone calls to adjust and refine the care plan and frequency of service.
• Recertification for continued service, discharge, or transfer (to a hospital or nursing home) ultimately occurs.

Patient Teaching

• Patient teaching is directed toward the patient, family, caregivers, and involved significant others.
• Patient teaching is usually considered skilled and is therefore reimbursable. Topics may include:
  • Disease process, pathophysiology, and signs and symptoms to monitor treatment.
  • Administration of injectable medication or complex regimen of oral medications.
  • Diabetic management for a newly diagnosed diabetic.
  • Wound or ostomy care.
  • Catheterization.
  • Gastrostomy and enteral feedings.
  • Management of peripheral or central I.V. catheters.
  • Use of adaptive devices for carrying out activities of daily living and ambulation.
  • Transfer techniques and body alignment.
  • Preparation and maintenance of therapeutic diet.
• Barriers to learning should be evaluated and removed or compensated for.
  • Environmental barriers, such as noise, poor lighting, distractions
  • Personal barriers, such as sensory deficits, poor reading skills, drowsiness
• The teaching plan should include the three domains of learning:
  • Cognitive sharing facts and information
  • Affective address the patient's feelings about the disease and treatment
  • Psychomotor performance of desired behavior or steps in a procedure
• Documentation of patient teaching should be specific and include the degree of patient competence of the procedure.
• Patient teaching plans may take several sessions to implement successfully.

Infection Control

• Nosocomial infection rates are much lower in home care, but patients are still at risk for infection due to weakened immune systems and the variability of a clean or sterile environment at home.
• The nurse should assess and maintain a clean environment.
  • Make sure that clean or sterile supplies are readily available when needed.
  • Make sure that contaminated supplies are disposed of promptly and properly.
    • Needles should be disposed of in a sharps container (usually kept in the home), which can be disposed of through the home health agency or the patient's pharmacy.
    • Supplies, such as dressings, gloves, and catheters, should be securely bagged and disposed of in small amounts through the regular trash collection at the patient's home. However, biohazardous waste disposal may be necessary in some cases.
• The nurse should be aware of all methods of transmission of infection and implement and teach preventive practices.
• The nurse must perform ongoing assessment for signs and symptoms of infection, and teach the patient, family, and caregivers what to look for.
• The nurse should be aware of community-acquired infections that may be prevalent in certain populations, such as tuberculosis, human immunodeficiency virus infection, hepatitis, and sexually transmitted diseases.
  • Teach preventive practices.
  • Encourage and institute screening programs.
  • Report infections according to the local public health department policy.
• Encourage and provide vaccination for the patient and household contacts for influenza, pneumococcal pneumonia, hepatitis B, and others as appropriate.

NURSING ALERT

Above all else, model and teach good hand-washing practice to everyone in the home.

Ensuring Safety

• Continually assess safety in the home, particularly if the patient is very ill and the care plan is complex.
• Assess for environmental safety issues cluttered spaces, stairs, throw rugs, slippery floors, poor lighting.
• Assess for patient's personal safety issues sensory deficits, weakness, problems with eating or swallowing.
• Assess safety in the bathroom handrails, bath mat, raised toilet seat, water temperature.
• Assess safety in the kitchen proper refrigeration of food, ability to shop for and cook meals, oven safety.
• Be alert for abuse and neglect, especially of children, dependent elders, and women.
• Check equipment for electrical and fire safety and that it is being used properly.
  
  
  
  
• Be continually cognizant of your own safety get directions, travel during daylight hours, wear seat belts, do not enter suspicious areas without an escort, be alert to your surroundings.