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