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Community Exam 2 Study Guide
Community/Public Health Nursing (NUR 443)
University of Rhode Island
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NUR443 Exam 2 Study Guide
Hospice and Home Health
I. Home Healthcare Home healthcare focus is on primary, secondary, and tertiary prevention o This thereby decreases client’s vulnerability o In HHC, the nurse is generally the provider and the whole family is the client o Healthcare takes place in the client’s home (wherever/whatever that may be) o Allows individuals to stay at home rather than long-term hospitalizations “Aging in place” Purposes of Home Healthcare o 1. Meets the acute and chronic needs of the patient and family in the home patient centered Home care provides all the disciplines of the hospital care to the client: Nursing, registered dietitians, PT, OT, ST, SW and HHA’s. Home care also includes hospice care Hospice care: Client with prognosis of 6 month or less Focus is on pain control, comfort of family/pt during the dying process; provide great amount of support. SW in home care: care for issues directly related to the patient/family’s social and emotional needs directly related to the patient’s medical condition Deal with housing, financing, caregiver concerns, counseling and long- term placements or arrangements. o 2. Ask any patient if he/she would rather be at home or in the hospital, (most will say home) Home gives a sense of security, independence, comfort and protection Patients do better at home feel better and feel more in control Follow their schedule as far as eating/sleeping for the most part Decrease infection rates at home o 3. Care is short term and intermittent and is based on the needs of the client. Needs are determined by the nursing assessment and MD orders. o What is home care: Think of continuum for health care Acute careExtended careAmbulatory careIndependent living Home care is the link to keep clients moving through the system or the continuum of care. Ex. allows the client with the broken hip to go to the hospital to rehab to home. History of Homecare o 1. 1960s Medicare starts to say how HC nurses will do their job and introduced regulations. o 2. Later switched from PHN focus of prevention to illness focus Focus changed somewhat from maternal-child health and prevention, to care of the elderly Home health care agencies are now able to meet the demands of many populations with a wide variety of problems IV therapy, TPN, PT
NUR443 Exam 2 Study Guide
o 3. Directives on home care/nurses/agenciesMedicare stated what they will and won’t pay for in home care. A lot of agencies were paid little and survived by donations, or received some from 3rd parties o Medicare is the #1 insurer of the elderly Medicare vs Medicaid in Homecare
o Medicaid payments to agencies and services vary state to state o Most medications are covered under Medicaid o Medicaid has programs where services, usually HHA services are not intermittent, the HHA is permanent o Under Medicare, the client must have a skilled need Home healthcare grew due to DRGs OASIS o Outcome and assessment information that gets completed on every single patient on admission 27-page document o Guides care plan and helps predict those at greatest risk o Helps capture outcomes functional and physical health o Determines payment o Required by Medicare and Medicaid—they just go ahead and use it for all insurances o 3 domains of assessment 1. Clinical (sensory, elimination, neuro, emotional, etc.) 2. Functional (ADLs—based on ability, not willingness) 3. Service utilization (what is the patient going to need?) o Domains scored 1-3, 3 being the highest risk; ex. C3, F3, S3 is the highest risk patient but also the highest you’ll get paid o Done on admission, done if they are transferred to a hospital, done when they are put back into homecare, done on discharge, done every 60 days if you realize they still need homecare Documentation in HHC o Specific each visit stands on its own o Goals must be measurable and follow the plan of care o Show progress towards goals o Must be evidence-based (ex. Braden scale) o Demonstrates compliance with Medicare for reimbursement
NUR443 Exam 2 Study Guide
o Assessment 1. Physical Assessment: a. Review of systems: VSS, eating, cp assess, elimination b. Appearance: dressed, washed c. Acute problem and chronic illness 2. Functional: a. Information on ambulating b. Ability to perform ADL’s: Pants soiled-incontinent or not able to ambulate to bathroom o Ask about meals-ask what they eat and look in their kitchen and make sure they are telling the full truth c. Ability to use assistive devices or need for a walker or cane-is client walking grabbing onto furniture or walls for support? d. Functional limitations: SOB or muscle weakness. Does client need equipment to make things easier-hospital on first floor near bathroom or bedside commode or w/c. 3. Psychosocial 4. Environmental 5. Economic o Termination Discuss plan for next visit Thank them for letting you into their house o Evaluation Evaluate both the client’s progress and the future plan II. Palliative Care Centers on providing comfort and decreasing pain Symptom management These patients may still be seeking treatment “Cloaking” helps patients be comfortable during major illnesses III. Hospice Provide support for the client and family from expectation of recovery until acceptance of death Provided for prognoses of less than 6 months Aims to improve quality of life for clients and family Addresses primary concerns of the client o Does aftercare with the family for up to one year Death and dying o Understand your patients and your own beliefs and experiences as well as religious and cultural practices regarding dying, death, grief and loss o Stages of grief o Do not use “hospice” right upfront because patients sometimes shut down o Know causes of illness and injury o Expressions about illness and injury Progressive stages of death o Lapses of consciousness o Blood is shunted to vital organs
NUR443 Exam 2 Study Guide
o Hearing is the last sense dying patient can hear you so don’t be stupid o Pulse is weak and thread o Diaphoretic, increased mucous (death rattle—give atropine to dry secretions) o Cheyne-Stokes respirations o A last “rally” Nursing interventions during death o Comforting and soothing conversations o Keep warm o Light comforting touch o Discuss with family members the option to say goodbye or give patient permission to die Major issues in homecare and hospice o Caregiver strain o Client neglect o Lack of resources Obesity and diabetes are some of the biggest epidemics, but patients often cannot afford healthy food o Ethical dilemma
Epidemiology and Biostatistics Epidemiology study of distribution and determinants of health events in human populations o Basic science of public health o Used to control health problems o Employs statistical tools and methods to quantify the distribution and determinants in groups of people rather than individuals Uses of Epidemiology o Studies the history of health—the rise and fall of diseases Ex. Leukemia spiked in Japan in the 1900s due to radiation exposure o Diagnose community health—population or community assessment o Study health services Ex. Legislation—helmets and seatbelts o Estimate individual behavioral decision-making risks and chances of avoiding them Ex. smoking o Identify syndromes Ex. Legionnaires, SARS, HIV/AIDS o Completing the clinical picture and natural history of disease o Determining causation—genetic, behavior, environment Historical Development o Religious era: disease was caused by divine intervention/ was punishment o Environmental era: disease caused by environmental substances/ miasma o Bacteriological era: disease is caused by specific bacterial or nutritive agents o Era of multiple causation: (current) disease is caused by an interaction of multiple factors
NUR443 Exam 2 Study Guide
Chemical agents heavy metals, toxic chemicals, pesticides Physical agents radiation, heat, cold, machinery o Host (generally us) Genetic susceptibility Immutable characteristics age and gender Acquired characteristics immunology status Lifestyle factors diet and exercise o Environment Climate temperature, rainfall, sun Plant and animal life may be agents or reservoirs Human population distribution crowding, social support Socioeconomic status education, resources, access to care Working conditions levels of stress, noise, satisfaction Multiple Causation o No single host, agent, or disease can cause disease on its own Interrelationships and interactions come together o Concept of multiple causation is easily understood when looking at non-infectious diseases like chronic illness and accidents Person-place-time relationships o Who? When? Where? Important to understand the factors that came together to figure out how a disease is spreading and how to control it Think about Contagion Epidemiological Process o Determine nature and extent of the problem o Formulate a tentative hypothesis o Collect and analyze further testable data o Plan for control Implement control plan Evaluate control plan o Make appropriate report o Conduct research Use of numbers o Frequency—how often something occurs o Mean—average o Median—middle often used to eliminate outliers o Mode—most common Ratios o Numerator is not included in the denominator o Ex. 1:10 asthmatics to non-asthmatics Proportion o Numerator must be included in the denominator o Each person in the denominator must be at risk for ending up in the numerator Rates
NUR443 Exam 2 Study Guide
o Method of measurement to asses the amount of disease in a population and describe groups of persons o Used to facilitate and interpret raw data and make comparisons o Fractions number of events in specified time divided by population in area in that time period o May make meaningful comparisons across districts o Incidence Rates Number of new cases of a disease in a population over a specified time period IR=number of new cases in a time period/population at risk during the same time o Prevalence Rate Number of new and old cases of a specified disease or condition existing at a given point/total population estimated Influences on prevalence rates Incidence number of new cases Duration of condition o If you die fast from it, the prevalence technically decreases Point Prevalence o Rate describing the number of persons with a disease at a specific point in time o Useful in examining disease rates at a specific time o Ex. Used when census counts the homeless one night Period Prevalence o Number of existing cases during a specified time period and includes old cases as well as new cases that develop during that time o Ex. Increase in trauma during the summer months Attack Rate o Incidence rate that identifies the number of people at risk who become ill o Ex. If our class all ate the same bad food and 50% got sick, that’s a 50% attack rate Relative Risk Rate o Traditional measure to study associations between group characteristic and disease o Ratio of the rate of incidence among those exposed as exposed to those not exposed to the disease Ex. People with lung cancer: smokers/non-smokers Infant Mortality Rate o Sensitive indicator for health statues of population Ex. Nutrition, housing, sanitation Types of Epidemiological Investigations o Descriptive studies Asks who, when, and where Identifies the types of people at risk Looks at the distribution of health problems Time of occurrence
NUR443 Exam 2 Study Guide
o Acquired immunity derived from exposure to the specific infectious agent, toxin, or vaccine o Active immunity body produces its own antibodies o Passive immunity temporary resistance that results from introduction of antibodies from another person or animal (ex. From mother at birth) o Herd immunity immunity of a group or community based on the immunity of many in the community Stages of Infection o Incubation time of invasion to time when symptoms first appear Latency: period of replication before shedding patient is asymptomatic but still can spread the disease Communicability: begins with shedding of agent and before symptoms are present o Prodromal onset of non-specific symptoms o Illness signs and symptoms of a specific type of infection o Recovery when acute symptoms disappear Notifiable diseases diseases that are required by law to be reported to government authorities so it can be tracked o Ex. Ebola, Zika Reportable disease Disease mandated by law to be reported to healthcare providers o Ex. STDs, salmonella, chicken pox, TB Ebola—spread and chain of infection o Direct contact with broken skin or mucous membranes Blood or bodily fluids of someone who is infected Objects that have been contaminated with blood or bodily fluids from someone with Ebola Not spread through water, air, or food Evidence suggests that the virus can last up to 6 days—can be killed by bleach and chlorine o Incubation period of anywhere from 2 to 21 days (average is 8 to 10) o Not infectious until symptoms develop o Early signs Fever, muscle pain, fatigue, headache, sore throat o Later signs vomiting, diarrhea, rash, bleeding (internal and external) o Patients died from dehydration and organ failure o Early detection is critical If symptoms are present—notify hospital infection control, report to health department, isolate and determine PPE needed Zika o Transmitted by sex, mosquito bites, pregnant women to fetus, blood transfusions, and breastfeeding o Intrauterine and perinatal transmission are two major concerns Can cause microcephaly and abnormal brain development o Symptoms Fever, rash, joint pain, red eyes, muscle pain, headache Can last several days to weeks o No vaccine; can only treat symptoms
NUR443 Exam 2 Study Guide
o Prevention Avoid mosquito bites Wear long sleeves and long pants Use mosquito screens on windows and doors Prevent unintended pregnancies during outbreaks
Tuberculosis o 1/3rd of the world’s population is infected with TB o TB is one of the leading killers of people with HIV o Causes Contagious infection that attacks the lungs o Transmission Airborne from infected person sneezing, coughing, laughing, talking Another person breathes in the bacteria and becomes infected o How TB develops Inhaling droplet nuclei that are infected with the bacteria and they begin to multiply and grow in the alveoli Small number of bacilli enter into the bloodstream in 2 to 8 weeks, and the body reacts to prevent the spread This person now has latent TB—cannot spread it At a higher risk of developing active TB in the first two years of having latent TB o Important to treat it even if they cannot spread it If the immune system cannot stop the spread of bacilli into the bloodstream, then that person will become symptomatic Attacks lungs, lymph nodes, bones, joints, brain, etc. This person has active TB and can spread it to others o Classified from 0 (no exposure) to 5 (TB suspected) o Symptoms Cough (mucus or blood) lasting more than 3 weeks Chest pain, chills, fatigue, night sweats, fever, loss of appetite and weight loss o Testing PPD test—can give a lot of false positives because skin is sensitive TB blood test—called interferon-gamma release assays (IGRAs) which measure how the immune systems react to bacteria Chest x-rays—cannot confirm that a person has TB, can just confirm that it does not—can get false positives from other diseases that cause lung abnormalities Sputum test—most important specimen for identification and isolation of acid fast bacilli o Treatment Antibiotic treatment and length depends on: Age, overall health, potential drug resistance, whether it is latent or active, and the location of the infection (which organs it is affecting)
NUR443 Exam 2 Study Guide
o Mother to child—breastfeeding and birth Stages of HIV o Acute infection o Clinical latency o AIDS
1. Acute infection o 2 to 4 weeks after exposure o Flu-like symptoms that may last weeks o Large amounts of virus in the blood and is very contagious o Often unaware of the presence of infection o Virus may not even show up on an HIV test o Symptoms Fever, chills, rash, night sweats, muscle aches, sore throat, fatigue, swollen lymph nodes, mouth ulcers 2. Clinical Latency o Active and replicates slowly longest period o Often asymptomatic o May last a decade or longer without treatment May last several decades for those receiving treatment o Transmission may occur with or without symptoms 3. AIDS huge drop in CD4 count (<200 is the marker for AIDS diagnosis) o Most severe phase o Immunocompromised and susceptible to opportunistic infections o Without treatment, survival is about 3 years o High viral load and extremely infectious o Symptoms Rapid weight loss Recurring fever and night sweats Extreme fatigue Diarrhea lasting longer than a week Sores in mouth, anus, and/or genitals Memory loss, depression, neurologic disorders Eventually Kaposi’s sarcoma Diagnosis o ELISA used to detect HIV infection May not detect in the first few weeks after exposure This is why they tell you to come back to get tested 3 months after exposure o If ELISA is positive, they will then do a Western Blot Test (extremely sensitive) o Two home tests are available to empower patients who may not be comfortable or may not have health insurance (Oraquick and Home Access HIV-1) o Saliva test: can confirm within 3 days, then a blood test will be needed
NUR443 Exam 2 Study Guide
o Viral load test: measures the amount of HIV in the bloodstream—utilized to monitor progress Treatment o Antiretroviral therapy (ART) recommended for everyone with HIV but urgency is higher in those with more rapidly declining CD4 counts Recovery stage o There is no cure o No vaccine o Maximizes quality of life and slowing progression to AIDS PEP (post-exposure prophylaxis) o Used in emergency situations—ex. Sexual assault o Started within 72 hours of exposure o Daily or BID for 28 days o Retested at 3 and 6 months PrEP (pre-exposure prophylaxis) o Used for people who are regularly exposed to HIV Ex. Partners of those HIV positive; IV drug users sharing needles; sex workers o Daily medication reduces risk of getting HIV by 90% o HIV test is done every 3 months o Truvada (Tenofovir) Disaster Nursing Types of Victims o Direct—individual who is immediately affected by the event o Indirect—family member or friend of the victim or first responder Ex. Family members putting up pictures of people who they could not find during 9/ o Displaced—people who have to evacuate the area due to disaster Ex. People who had to evacuate after Katrina and go to a new place with nothing Types of Disasters o Natural blizzards, epidemics, wildfires, earthquakes, tornadoes o Manmade terrorism, riots, bombings, structural collapse, hazardous spill, pollution, wars Terrorism: force or violence against people to coerce the government, population, or any segment thereof, in furtherance of political objectives Domestic terrorism: Terrorism except it’s by someone in the US to further a US political or social objective Ex. Las Vegas shooting, Boston Marathon bombings o Natural-Technological natural disaster that creates or results in widespread technological disaster Ex. Hurricane in Puerto Rico—they produce most of the IV bags that we use, and with the hurricane they are not manufacturing nearly as much which affects everywhere that uses those IV bags Characteristics of Disasters
NUR443 Exam 2 Study Guide
Substance Misuse Overdose is the leading cause of injury deaths in the US o 96 deaths per day Legitimate medical use and recreational dependence non-medical use and addiction increased tolerance (and increased cost) snorting heroin increased tolerance and increased cost IV heroin Overdose Triad o 1. Constricted pupils o 2. Respiratory depression (<8 RR) o 3. CNS depression Unresponsive to painful stimuli Risk Factors for Overdose o Medication-Related Factors Combination with other sedatives Ex. Patients on benzodiazepines—considered the number 1 risk factor for overdose and really should not be combined with opioids Diphenhydramine, gabapentin, sedating antidepressants—can all also increase risk Non-oral administration route High dose opioids Longer durations of use >90 days is considered long duration—see this in caner patients for example Longer-acting formulations Methadone Buprenorphine o Condition-Related Factors Respiratory illness COPD Asthma Sleep apnea Renal dysfunction Hepatic disease HIV/AIDS Cardiac dysfunction o Patient-Related Factors Recent relapse after period of abstinence Ex. Incarceration—people often are released and return to using the same amount as before but they no longer have a tolerance Using alone—can’t give yourself naloxone Multiple pharmacies/prescriptions 49 states have opioid-monitoring programs (lol kk thx Missouri) Rural areas and low income Illness or non-medical use Medicaid recipients History of mental illness
NUR443 Exam 2 Study Guide
Naloxone o Takes effect in 2-3 minutes o Short half-life—wears off in 30-90 minutes so it is important to go to the hospital Opioid half-life is longer than that so they may OD again o People often need 2 doses—some people will need even more
Community Exam 2 Study Guide
Course: Community/Public Health Nursing (NUR 443)
University: University of Rhode Island
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