Community Health Nursing Lecture Three

Community Health Nursing - NUR 804

• Course offered by Dr. Margaret Pau, Associate Professor of Practice at Saint Francis University
• Focuses on comprehensive assessment in home care nursing and managing common medical conditions at home

Lecture Three

• Covers comprehensive assessment in home care nursing
• Addresses management of common medical conditions at home
• Includes cardiovascular disease, respiratory disease, diabetic mellitus, and other conditions

Learning Outcomes

• Students will understand the importance of comprehensive assessment in home care nursing
• They will learn how to perform comprehensive assessments in home care settings
• They will identify health care needs of clients with specific conditions
• Students will understand social, cultural, economical, and environmental factors influencing client health
• They will identify intervention and treatment plans for managing various specific conditions in home care nursing

Comprehensive Assessment in Community Care

• Aims to evaluate all aspects of physical, mental, and social wellbeing of clients
• Identifies health care needs requiring additional support
• Determines if clients are safe and able to cope at home
• Integrates assessment findings into the care plan and appropriate client care
• Engages clients in the assessment process for better participation in care

Assessment Process

• Assessment is an ongoing process
• Focus on specific health issues
• Gather information from different sources
• View from multiple perspectives
• Take an in-depth look at diversity

Goals of Comprehensive Assessment

• Manage client's health at home for an extended period
• Prevent unnecessary hospital admissions and service utilization

Sources of Information

• Referrals, patient discharge summaries, nursing discharge summaries, patient files
• Clients, family members, carers
• Multidisciplinary health care team, other community partners (e.g., RCHE staff, NGOs)

Guiding Principles for Assessment

• Demographic characteristics (sex, age, family background)
• Physical health (medical history, mobility, ADLs, present health problems)
• Mental health (psychological state, behavioral risk)
• Socioeconomic characteristics (financial status, neighborhood relationship)
• Environmental health (infectious disease outbreak)
• Important issues and follow-up appointments

Comprehensive Assessment at First Home Visit

• Categorizes assessment into Initial and Focused Assessment
• Initial assessment includes general assessment (vital signs, consciousness, cognition), medication, communication, nutrition, disease management, psychological, pain, elimination, mobility, social, falls, and skin
• General condition assessment involves vital signs, consciousness level, mental status, and cognition (including AMT)

Communication

• Vision: Normal / Blurred
• Language/Dialect
• Speech: Clear / Slurring
• Hearing: Left ear (normal/loud voice/hearing aids), Right ear (normal/loud voice/hearing aids)
• Communication Aids: Communication chart / Sign language

Pain

• Presence of pain
• Site of pain
• Pain scale used
• Use of pain relief

Mobility

• Independent/ ambulatory with aids/ chairbound/ bedbound
• Muscle strength (upper/lower limbs)
• Walking aids (stick/quadripod/tripod/frame/rollator/crutch/wheelchair)
• Assisted by person(s)
• Balance and gait (including Barthel Index (BI)/20)
• Modified Functional Ambulatory Category (MFAC)

Barthel Index (BI)

• Includes assessment scores for bowel, bladder, dressing, grooming, feeding, mobility, dressing, and transfer

Modified Functional Ambulatory Category (MFAC)

• Stages of function, ranging from those who are completely immobile to those who are fully ambulatory with and without aids.

Fall

• History of fall within recent 3 months
• Number of falls
• Hospitalizations due to falls

Nutrition

• Diet (normal/special diet)
• Oral feeding (self-help/with assistance/feed by caregiver)
• Tube feeding (nasogastric tube / PEG, milk regime, tube type/size, due date for change)
• Knowledge and skill on tube care, including feeding technique, cleansing of utensils, storage of milk, blockage/misplacement/slip out of tube

Elimination - Urinary

• Normal/Frequent/Dysuria/Incontinence
• Use of aids (commode/diaper/urinal/bedpan)
• Ileal conduit
• Percutaneous nephrostomy tube (PCN)
• Urinary catheter (urethral/suprapubic, type/size of catheter, due date for renewal)
• Knowledge and skills related to caring for the conduit, PCN, or catheter. Includes amount and color of urinary output, and management of blockage/slipout of catheter

Elimination - Bowel

• Normal
• Constipation/use of laxatives
• Incontinence
• Diarrhea
• Stoma (color of stoma, knowledge and skill on care of stoma, colostomy bag change)

Skin Condition

• Intact/dry/fragile/edema
• Rash/skin redness (location)
• Risk of pressure injury (Braden Scale)
• Pressure injury/wound assessment (site, size, stages, amount/color of discharge)
• Knowledge and skills on skin/wound care

Braden Scale

• Assesses factors contributing to pressure risk (sensory perception, moisture, activity, mobility, nutrition, and friction and shear) in the context of a patient's particular circumstances

Medication

• Number of drug items
• Herbs/over-the-counter drugs
• Self-help/care giver help/RCHE staff help
• Drug storage

Psychological & Spiritual

• Concerns and worries
• Emotional and behavioral problems
• Suicidal thoughts

Social

• Marital status, family member/main caregiver/household member
• Accommodation
• Educational level
• Occupational history
• Financial status
• Use of community resources (e.g., home help service, day care centre)

Disease Management

• Assessment and management of specific conditions in the community
• Cardiac Care, Diabetic Care, Respiratory Care, Postnatal and Infant Care

Common Types of Cardiovascular Disease

• Coronary heart disease
• Ischemic heart disease (IHD)
• Myocardial Infarction (MI)
• Congestive heart failure (CHF)

Case One (Mrs. Lee)

• Female, 78 years old
• Lives with husband in a public estate
• Suffered from congestive heart failure (CHF)
• Referred to CNS for cardiac care on discharge

Home Care Plan for Different Diseases

• Details of 10 care elements to incorporate, including Physical Status, Psycho-social status, Home environment, Medication, Nutrition, Elimination, Hygiene, Activity & Exercises, Consultation, referral, follow-up schedule, and Community resources.

Focus History

• Past medical history (previous angina, MI, chest/heart surgery)
• Family history of cardiovascular disease
• Current medical problems (HT, DM, hyperlipidemia)
• Medication history, drug allergies, current medications
• Lifestyle (smoking, alcohol, diet, exercise)

Cardiovascular Assessment

• General appearance (color, clubbing, tobacco staining)
• Vital signs (BP, Pulse, Respiration Rate, Temperature, SpO2)
• Body weight, BMI
• Inspection (scars over chest, pacemaker, jugular vein pressure)
• Palpation
• Auscultation
• Client complaints (chest pain, breathing difficulties, cough, fatigue, cyanosis, syncope, edema)

Psycho-social Status Assessment

• Patient living situation, support system
• Patient/Caregiver attitude (co-operating, indifferent/resistant)
• Emotional status, stress, anxiety
• Identification of suicidal risk
• Stress-relieving techniques

Risk Factor Assessment

• Family history, health status of all first-degree relatives
• Substance use (alcohol, tobacco, illicit substances)
• Quantity/duration of substance use (drinks per day/cigarette pack-years)
• Other risk factors are also listed

Physical Activity

Drug Compliance and Use of Devices

• Drug compliance (good/fair/poor)
• Drug administration (self/caregiver)
• Use of TNG
• Use of oxygen therapy

Proper use of Nitroglycerin (TNG) Sublingual

• Instructions on how to use nitro for chest discomfort

Patient Empowerment

• Improved patient ability to manage health and illness
• Empowering patients with knowledge, skills, attitudes, and self-awareness

Empower Client On

• Addressing physical care/self-management skills
• Psycho-social support/coping skills
• Medication effects/storage/compliance
• Lifestyle modifications/healthy diet/stress management/quitting smoking/alcohol/regular bowel habits/exercise regime with precaution

Tips for Maintaining Health

• Personal hygiene, avoid skin breakdown
• Environmental hygiene, ventilation/avoid dust
• Home safety, oxygen concentrator use
• Regular exercise/energy saving technique
• Community support/rehab center/smoking cessation
• Influenza/Covid-19 vaccination

Self-Management Skills

• Monitoring blood glucose (SMBG), blood pressure, pulse rate
• Medication management and correct injection technique
• Monitoring for early signs and symptoms of hypoglycemia/hyperglycemia attacks and managing symptoms
• Managing hypoglycemia/hyperglycemia
• Early detection of diabetes complications (poor eye vision, foot ulcer) and preventative care
• Proper sharps disposal

Management of Diabetic Emergency

• Treatment for hypo/hyperglycemia episodes, including recommendations for glucose level stabilization.

CNS Visit for Respiratory Disease

• Includes COPD, TB, and pneumonia
• Includes relevant assessment needs

COPD

• Chronic Obstructive Pulmonary Disease as a progressive disease of the airways, characterized by inflammation, thickened and swollen walls, increased mucus production, and distorted/suppressed lung tissue, leading to difficulty in breathing
• Relevant clinical features, including systemic (weight loss, fatigue, fever, night sweats), respiratory (cough, hemoptysis, pleural effusion), and other findings such as hilar lymphadenopathy.

Case Study Three (Mr. Wong)

• Male, 78
• COPD, long-term oxygen therapy (LTOT)
• Hospitalization due to exacerbation
• Referred to CNS for pulmonary care on discharge

Focused History (Pulmonary Disease)

• Family history of pulmonary disease
• Past medical history (asthma, pneumonia, TB, chest injury, chest/heart surgery)
• COPD exacerbation or other current health problems
• Medication history and drug allergies
• Lifestyle (smoking, alcohol, diet, exercise)
• Occupational history and Covid/Influenza vaccination
• Any other risk factor consideration also listed

Physical Examination (Pulmonary Disease)

• General appearance
• Vital signs (BP, Pulse, Respiration Rate, Temperature, SpO2)
• Body weight
• Chief complaint (cough type, difficulty breathing, associated pain, duration)
• Cyanosis presence (yes/no)
• Cough (productive/non-productive, color, amount, consistency)
• Exercise/activity tolerance
• Chest sounds (clear/crepitation/rhonchi/wheeze)
• COPD exacerbation, chest infection
• Other signs (ankle edema, muscle wasting)
• Palpation/Percussion/Auscultation

Assessment of COPD Medication Compliance and Use of Devices

• Assessment of medication compliance (good/fair/poor), drug administration
• Standby drugs for COPD exacerbation
• Inhaled bronchodilators\steroid use (with/without mask)
• Home oxygen therapy (yes/no, L/min, hours/day)
• Related compliance to various aspect

Home Care Management of COPD

• Four components of patient empowerment (ability to assess/monitor COPD; risk factor reduction; managing stable COPD; self-managing COPD exacerbation)

Patient Empowerment (COPD)

• Physical care/self-management skills
• Psycho-social support/coping skills
• Important aspects of good medication compliance and proper storage
• Breathing/purse-lip respiration techniques
• Energy conservation techniques
• Knowledge and skill on inhaler/home oxygen therapy
• Personal hygiene reminder, mouth rinsing
• Smoking/alcohol cessation
• Health diet
• Stress management
• Regular bowel habits, bronchodilator use

Risk Factors (COPD)

• Avoidance of environmental tobacco smoke
• Avoiding occupational dust exposure
• Avoiding indoor\outdoor air pollution/irritants
• Other risk factor consideration also listed

Managing Environmental Hygiene in COPD Care

• Maintain personal and environmental hygiene
• Proper ventilation, avoidance of dust/other respiratory irritants
• Ensuring home safety (oxygen concentrator placement/use)

Self-Management Skills (COPD)

• Self-monitoring of body temperature, BP/P
• Early identification of chest infection signs\symptoms
• Symptom control management and exacerbation management

Medication and Use of Devices (COPD)

• Identifying medication/device problems
• Education on medication/device purpose, administration, effects/side effects
• Proper use of inhaled bronchodilators/spacers
• Importance and proper use of oxygen concentrator. How to properly disinfect devices/equipment
• Mechanical ventilator support (e.g., home Bipap) assessment of needs if needed

Signs and Symptoms of COPD Exacerbation

• Increased shortness of breath
• Chest pain/burning/tightness
• Fever (presence/absence)
• Cough with yellowish/viscous sputum
• Palpitations
• Activity intolerance

CNS visit for Tuberculosis (TB)

• Relevant considerations for TB, including case studies, signs/symptoms, medications, treatment, and patient education

TB Disease

Signs/Symptoms (TB)

• Cough lasting >3 weeks
• Purulent sputum/bloody sputum
• Chest/breathing pain, unintentional weight loss
• Fever, fatigue, loss of appetite, night sweats, chills

Medications (TB)

• Four-drug regimen (isoniazid, rifampicin, pyrazinamide, ethambutol) for the first two months
• Two-drug regimen (isoniazid, rifampicin) for the remaining four months
• Treatment provided by the TB and Chest Service free of charge
• Directly Observed Treatment (DOT) given by health-care professionals
• Importance of DOT
• Consequences of irregular treatment

Common Side Effects (TB medications)

• Nausea, vomiting
• Decreased appetite
• Fever
• Dizziness
• Ringing in ears (tinnitus)
• Blurred vision
• Skin itchiness/rash
• Other complications are also listed

Directly Observed Therapy (DOT)

• DOT aims to improve TB cure rates and prevent drug resistance
• Essential for maximizing efficacy and success of TB treatment
• Includes frequent supervision of medication taking and monitoring treatment compliance to improve successful cure

Education (TB)

• Stay at home for the initial several weeks of treatment
• Mask-wearing practice
• Maintaining hygiene (coughing/sneezing, tissue disposal, ventilation)
• Importance of completing the entire treatment course

Postnatal Care

• Maternal assessment (vital signs, general appearances, emotional status, breast examination, uterus involution)

Lochia Assessment

• Colour, amount, any foul smell of lochia

Personal hygiene

• Personal hygiene practices
• Practices for wound healing

Dietary Intake

• Appropriateness and sufficiency
• Intake monitoring and assessment

Wound Condition

• Appropriate care for wound healing
• Assessment of wound care compliance

Compliance to Perform Postnatal Exercises

• Compliance of performing postnatal exercises

Baby Assessment

• Vital signs (RR, Temp)
• General appearance (active/dull/color/pallor/jaundice)
• Feeding (breast/bottle, intake amount)
• Umbilical cord (status, abnormalities)
• Buttock (skin redness, sores)
• Baby safety
• Sterilization of bottles
• Cord care and bath technique
• Immunization record

Baby Care

• Jaundice observation and management
• Baby feeding technique (breast/bottle)
• Sterilization of feeding bottles
• Cord care (cleaning, observing amount/color of discharge)
• Skin care (redness of buttock, lotion application)

References

This quiz focuses on comprehensive assessment techniques in home care nursing, specifically addressing the management of common medical conditions such as cardiovascular diseases and diabetes mellitus. Students will learn about the importance of understanding patient needs and the various factors that influence health outcomes in a home care setting.