I. Health-Care Delivery System
The health-care delivery system provides a variety of services across various settings to meet the health-related needs of the members of society. It is complex and continually changing because of such factors as federal and state legislation, reengineering of organizations, cost containment issues, emergence of new health-care professions, and expectations of clients and their family members. Recent changes in health care, such as the increased emphasis on the provision of care within the community rather than in hospitals and the focus on health rather than illness, have influenced the settings in which health care is provided.
A. Classification of health-care agencies
a. By state license when criteria are met.
b. By ownership. (1) Public/official: Federal, state, or local governmental control. (2) Voluntary: Nonprofit. (3) Proprietary: For profit.
c. By focus of care or by mission, such as: (1) Orthopedic. (2) Pediatric. (3) Psychiatric. (4) General medicine and surgery. (5) Rehabilitation. (6) Hospice. d. Services offered generally are determined by the license, size, location, and mission of the agency.
B. Acute care hospitals
1. Generally are involved with the diagnosis and treatment of acute and chronic illnesses.
2. Services provided may include:
- Acute inpatient medical and surgical services.
- Outpatient care, such as ambulatory care services, diagnostic tests, day surgery, rehabilitative care, and emergency department administered care.
- Specialty services, such as a burn, spinal cord, or dialysis unit.
C. Outpatient settings
1. Include such settings as clinics, primary healthcare provider’s offices, ambulatory surgery centers, schools, occupational settings, and agencies that provide home-care services.
2. Provide such services as minor surgical procedures, physical examinations, physical therapy, medical screenings, counseling, teaching, day care, and primary care.
3. Examples of specific settings.
- Schools - Provide health education, health promotion, and disease prevention interventions.
- Coordinate with health-care professionals and implement assistance to ensure a meaningful learning experience within school settings for children with disabilities or health-care needs.
- Engage in case-finding activities, such as head lice and scoliosis screening, and make referrals to other health agencies as needed.
b. Occupational settings.
- Provide programs to support safety in the work environment.
- May provide annual employee health screenings.
- May provide health education on topics such as weight reduction and hypertension.
- May provide counseling services.
- May provide follow-up care after an injury.
D. Long-term care settings
- Provide services on a continuum in a variety of inpatient and outpatient settings.
a. Independent living setting.
- Adults generally live in their own apartment, care for themselves, and may have meals and housekeeping services provided.
- Some facilities provide for leisure activities, banking hours, hairdresser services, rehabilitation services, and access to primary health-care providers at one’s own expense within the building.
b. Assisted living setting.
- Adults receive some assistance with activities such as dressing and bathing, in addition to the provision of meals and housekeeping services.
- Some facilities provide for leisure activities, banking hours, hairdresser services, rehabilitation services, and access to primary health-care providers at one’s own expense within the building.
c. Subacute unit in a skilled nursing home.
- Provides comprehensive care for a person with an acute illness, injury, or exacerbation of a disease process in lieu of hospitalization.
- Provides treatment interventions to avoid unnecessary and recurrent hospitalizations.
d. Intermediate care setting.
- Provides care for people who are disabled, older adults, and people who are not acutely ill but need less intensive care than services provided by a hospital or skilled nursing facility.
- Care generally is provided by nonskilled and unlicensed personnel.
Usually provides custodial care.
e. Skilled nursing care provided in a nursing home.
- Facilities that are certified to participate in and receive remuneration from Medicare or Medicaid.
- Requires people to meet specific criteria before admission, such as criteria regarding insurance, prescribed treatment, nursing services needed, and resources required.
- Provides long-term care for people who need ongoing medical and nursing attention.
- Provides short-term care for people discharged from a hospital who still require medical and nursing care to facilitate recovery from an acute health event.
- May specialize in services such as brain injury care or orthopedic rehabilitation.
E. Hospice
- Hospice provides interdisciplinary services that focus on maintaining comfort and quality of life of dying individuals and providing supportive care to grieving family members.
- Focuses on maintaining comfort and quality of life, not curative treatment.
- Offers care in such settings as hospitals, skilled nursing homes, intermediate care settings, freestanding hospice settings, and private homes; locations vary depending on the client’s condition and the ability of family members to provide care at home.
F. Community-based health care
- Community-based health care is associated with agencies that provide care in the home as well as outpatient services.
- Examples include urgent care centers, day-care centers, use of hospital services and equipment on an outpatient basis, and residential treatment halfway houses where no treatment interventions are provided.
G. Public health nursing
- Public health nursing focuses on meeting the health needs of populations.
- Provides services such as prenatal care, immunizations for children, screening for illnesses (e.g., tuberculosis, scoliosis) and helps to prevent individual disability and disease (e.g., correct use of automobile restraining devices for children, ways to reduce risk factors for cardiac disease).
II. Community-Based Nursing
A community consists of a group of people living in the same area or having a common characteristic or interest. Community-based nursing focuses on caring for people near where they live, work, and play. It is concerned with protecting, promoting, maintaining, and improving the health and quality of life of individuals, families, and groups.
A. Community-Based Settings
1. Mobile health clinics.
- Vans or buses with equipment and healthcare professionals who provide primary and secondary health-care services at numerous places within a geographic area.
- Bring health care to the people.
- Help to service migrant workers, who pose a unique challenge to the provision of health-care services because they move about the country according to the timing of harvests.
2. Faith-based organizations.
- Religious organizations that provide health-care services to individuals.
- Address clients’ physical, emotional, and spiritual needs.
- Activities associated with faith-based organizations.
(1) Coordination and training of volunteers who may provide such services as companionship visits and transportation to and from appointments.
(2) Development and facilitation of support groups.
(3) Referral services to community health-care facilities and programs.
(4) Presentation of programs involving health education, illness prevention, and health promotion.
(5) Discussion and education about health issues on an individual basis.
(6) Facilitation of assimilation of faith and health.
3. Correctional and prison environments.
- Provide routine examinations and screenings as well as acute care when needed.
- Generally require nurses to meet certain physical criteria and complete special training, such as weapons training and security procedures, to provide for their own safety.
4. Telehealth care.
- Telehealth care provides services to geographic areas where health care is not easily accessible.
- Allows data to be transmitted via the Internet, telephone, or fax machine to primary healthcare providers and specialists for consultation.
- Raises legal issues (e.g., who is responsible for the client, how confidentiality is protected, and whether the health-care provider must be licensed in the state in which the client lives).
B. Issues promoting the movement of health care into the community
1. Federal legislation identified a prospective payment system for Medicare based on illnesses and diseases. The introduction of diagnosis-related groups (DRGs) into the U.S. health-care system, in an effort to control costs, has resulted in clients being discharged from the hospital to the community earlier than was the practice before DRGs were introduced and often when clients are still sick.
2. The aging of the U.S. population has resulted in a larger percentage of individuals in the community having chronic illnesses and disabilities, requiring supportive care for the client and respite care for family members providing care.
3. The number of people who do not seek or cannot afford health care is increasing. Examples include vulnerable populations, such as people who are immigrants, homeless, living below the poverty level, uninsured, cognitively impaired, or abused.
4. The focus of health care is changing from treatment of diseases to health promotion and disease prevention, which emphasizes a nurse’s teaching role and requires educating children before unhealthy habits become engrained.
5. More people prefer to die at home rather than in a health-care facility, necessitating the provision of both physical and emotional care for clients and family members in the home.
C. Healthy People 2020 (www.healthypeople.gov)
1. A national initiative instituted in 1979, and updated every 10 years, that identifies health improvement goals and priorities and also includes new data on issues and progress achieved toward previous goals.
2. Healthy People 2020 contains 42 topic areas with more than 1,200 objectives; a subset of Healthy People 2020 objectives, called Leading Health Indicators, communicates high-priority health issues and actions to address them.
3. Provides objectives in a format that enables diverse groups to combine their efforts and work as a team.
4. Has a major impact on all health-care programs but especially on activities and groups concerned with community health needs.
D. Characteristics of a Healthy Community
- Has an awareness of its members, populations, and subgroups as being part of the community.
- Provides opportunities for and encourages participation of individuals and groups in decision making related to issues affecting the community.
- Ensures that communication remains open and information flows among all members and groups in every direction within the community.
- Detects, investigates, and dissects problems and collaborates and coordinates a response among members and groups to meet their identified needs.
- Ensures that community resources are available to all members and groups within the community.
- Focuses on promoting a high level of wellness and health among all members and populations within the community.
- Has a well-organized base of community resources available to meet needs and to intervene in a crisis or natural disaster.
E. Components of a Community Assessment
1. Overview of a community assessment.
- Provision of care is based on the nursing process; assessment is the most significant step because it drives the rest of nursing interventions.
- Information is collected about the physical environment and infrastructure of the community, characteristics of its population, available resources and services, and the economic and social systems within the community.
- Conducted by a community health nurse or public health nurse in collaboration with others (e.g., various members of the health-care team, members of community organizations, and government officials).
2. Physical environment of the community.
- Natural boundaries and size of the community.
- Types of housing.
- Average household income.
- Location of agencies and resources.
3. Population of the community.
- Characteristics of community members, such as age, gender, and educational level.
- Growth trends.
- Predominant ethnic and religious groups represented.
- Population density.
4. Safety and transportation systems available to the population.
- Agencies and status of services provided regarding water and sanitation.
- Air quality.
- Telephone service.
- Numbers of police and emergency services available.
- Rail and bus systems.
5. Social services available to the community.
- Schools, health-care agencies, and recreational facilities and the programs they provide.
- Number of health-care providers and services available, such as sources of health-care information, extent of primary care, and home and long-term care services.
- Number and types of spiritual institutions.
- Recreational organizations and clubs, such as playgrounds, parks, beaches, and sports centers.
6. Status of the members of the community.
- Biological, emotional, and sociological nature of the community.
- Biological statistics, including data on illness (morbidity) and death (mortality) rates and life expectancy of members of the community.
- Emotional and sociological statistics, including data on indications of the general mental health of community members and satisfaction or dissatisfaction with characteristics or features of the community.
7. Economic status of the community.
- Industries, employers, and occupations within the community.
- Economic level of the community, such as average household income.
- Number of workplace health promotion and illness prevention programs.
- Number of population receiving public assistance.
8. Social system of the community.
- Statistics related to crime and drug misuse within the community.
- Percentage of population attending school.
- Ways communication flows.
- Extent of interaction among members and groups within the community.
- Kind of government that runs the community.
- Extent of participation of members in healthcare decision making within the community.
- Availability of a welfare system to support the needy.
- Types and extent of volunteer programs.
F. Specific Roles of Community-based Nurses
1. Nurse epidemiologist.
- Provides surveillance and monitoring activities to identify trends in health and risk factors that threaten the health of specific populations or the health of members of the general community.
- Performs such activities as examining sources of information, case findings, field studies, surveys, and investigations; tracking illnesses, diseases, and death rates; and providing information and reports to appropriate local, state, or national officials.
2. Case manager.
- Ensures that an appropriate plan of care is formulated and implemented to meet the needs of clients across a continuum of care in the community setting.
- Coordinates and promotes continuity of care among health-care disciplines.
3. Advocate.
- Assists clients to work their way through the health-care system and obtain appropriate services.
- Engages in political action at the local, state, or national level to campaign on behalf of the community.
4. Change agent.
- Mediates within a family system or within the community, empowering people to effect change to better meet health-care needs.
- Utilizes information related to facilitating change and managing resistance to change to be a more effective change agent.
5. Teacher.
- Focuses on health promotion and disease prevention with individuals and groups through educational activities.
- Presents programs on such topics as prenatal classes, child safety, dental health, hypertension, and nutrition.
- Targets groups in schools, community organizations, and businesses.
G. Specific competencies of community-based nurses
1. Collaborate with others.
- Recognize that partnerships, networks, and coalitions are essential to effectively address the heath-care needs of members and groups within a community.
- Maintain collegial working relationships with other health team members to ensure consultation and cooperation in management of the delivery of care.
- Collaborate with other health-care providers in identifying the need for change in social, political, economic, or health-care systems within the community.
- Offer suggestions for changes compatible with the norms and values of the community.
2. Communicate with others.
a. Have excellent communication skills when working in a collaborative relationship with other health team members and when communicating with members and groups within a community.
b. Demonstrate respect verbally and nonverbally for the expertise that each professional brings to the team as well as for individual differences among members and groups within the community.
3. Maintain continuity of care.
a. Coordinate delivery of health-care services between settings (e.g., hospital to home, rehabilitation center to assisted-living facility, or nursing home to hospital) and between and among providers of health care within the community.
b. Be involved in discharge planning as soon as a client is admitted to a hospital or extended-care facility when the person is expected to return to the community.
c. Know the resources, agencies, and services that are available in the community and make referrals on behalf of the client to support continuity of care.
d. Ensure that, with the client’s consent, family members and significant others are included in the planning process because family members often are the main caregivers.
4. Provide care across the life span.
a. Provide services to clients of all ages from the time they are born until they die.
b. Provide health-care services to special needs populations within different age groups, such as adolescents (e.g., pregnant teens who give birth to low-birth-weight and premature infants), preschool and school-aged children (e.g., immunization programs, health screening, and nutrition services), and young adults (e.g., services for those who have sexually transmitted diseases or substance misuse problems).
c. Coordinate hospice care to assist terminally ill members of the community to die a peaceful, dignified death.
III. TYPES OF HEALTH-CARE SERVICES
Numerous types of health-care services are available to meet the complex needs of clients. These services can be categorized into primary, secondary, and tertiary care, each with its own unique focus. The complexity of care in each depends on a client’s individual needs, the primary health-care provider’s knowledge and expertise, and the setting in which the health care is provided.
A. Primary: Health promotion and illness prevention
- Primary health care focuses on maintaining an optimum level of wellness.
- Interventions decrease the risk of disease and disability.
- Activities include sanitation, immunization, and lifestyle modifications, such as dietary counseling, smoking cessation, and exercise.
B. Secondary: Diagnosis and treatment
- Secondary health care focuses on early detection and intervention to treat disease and minimize further impairment.
- Involves acute medical care and surgical intervention.
- Diagnostic activities include regular dental examinations, routine screenings (e.g., bone density testing and mammograms for women, HIV testing, blood pressure and cholesterol testing), and x-rays.
- Treatment activities include prescribing and administering antibiotics and prescribing and administering wound irrigation.
C. Tertiary: Rehabilitation
- Tertiary health care focuses on restoring function, maximizing results of treatment, and providing palliative care, such as supporting comfort and quality of life.
- Aims to maximize abilities in light of chronic or irreversible conditions.
- Activities include education and rehabilitation (e.g., learning how to use a wheelchair, learning to engage in activities of daily living to live independently, and making environmental modifications, such as installing grab bars and ramps and widening doorways in the home).
IV. HEALTH TEAM MEMBERS
Client needs are multifaceted, complex, and require a multitude of people from a variety of health-care disciplines with specific expertise to assist clients to meet these needs. Because nurses have a unique relationship with clients, function as client advocates, and, depending on the setting, provide care 24/7, they are commonly responsible for coordinating client care. Nurses must know the members of the health team and the services they provide to perform the role of coordinator effectively. Although the nurse is the coordinator of the health team, the client is the center of the health team.
A. The Client
1. The client is the center of the health team.
2. All members of the health team lend their expertise to assist the client in meeting health-care goals.
B. Nursing team members
1. Nurse administrators.
- Establish and manage achievement of organizational goals, particularly those of the department of nursing and other related agency departments.
- Examples include vice president for nursing, associate director of nursing, assistant director of nursing, nursing supervisor, nurse coordinator, and nurse manager.
2. Clinical nurse specialist (CNS).
- Functions as a resource to nurses caring for clients with complex nursing needs.
- Requires advanced education in a specific field.
- Examples include diabetic nurse educator, infection control nurse, and medical-surgical CNS.
3. Registered nurse (RN).
a. Coordinates services provided by members of the health-care team. b. Provides direct nursing care. c. Supervises unlicensed nursing personnel.
4. Licensed vocational nurse (LVN) or licensed practical nurse (LPN).
- Provides uncomplicated bedside nursing care.
- Works in a structured setting under the supervision of an RN.
5. Unlicensed assistive personnel (UAP).
- Provides direct nursing care delegated by an RN or LPN.
- Performs activities generally related to assisting clients with activities of daily living and performing noncomplex tasks.
- Examples include nursing associate and nursing assistant.
C. Other professional team members
- Primary health-care provider: Person who has a prescriptive license, such as medical doctor (MD), physician assistant (PA), and nurse practitioner (NP).
- Pharmacist (RPh).
- Dietitian (RD).
- Respiratory therapist (RT).
- Physical therapist (PT).
- Occupational therapist (OT).
- Social worker (SW).
- Dentist (DDS).
- Podiatrist (DPM).
- Audiologist (Au.D).
- Speech language pathologist (SLP).
- Laboratory and radiology professionals (x-ray, ultrasound, and laboratory technicians).
- Activity therapist (AT).
- Certified child life specialist (CCLS).
- Chaplain.
D. Supportive team members
- Family members.
- Unit secretary.
- Transport staff.
- Housekeeping personnel.
- Security personnel.
V. DELIVERY OF NURSING CARE
Nurses comprise the largest number of health-care professionals in most health-care settings. Utilization of their professional expertise requires a clear delineation of their roles and responsibilities as well as the use of a system that delivers nursing care that is safe, competent, and cost effective.
A. Nursing care delivery models
1. Nursing care delivery models are organizational systems that provide a framework for how nursing care is provided and which members of the nursing team deliver the care.
2. Continuously evolving because of societal healthcare initiatives, organizational reengineering, increasing acuity of clients, and the need to address cost containment.
3. Types of nursing care delivery models.
a. Primary nursing.
- An RN is responsible for assigned clients throughout their hospitalization, 7 days a week, 24 hours a day (primary nurse).
- The primary nurse does not deliver all care personally but is responsible for ensuring that comprehensive and individualized care is delivered.
- Primary nursing requires more registered nurses; however, it might not cost more because it improves collaboration, avoids delays, and supports comprehensive care.
- Communication is lateral; the primary nurse communicates directly with the nurses on the other shifts who are assigned to care for the client.
- Variations of primary nursing:
(a) Total client-care nursing: One nurse is responsible for the total care administered to a client, but the nurse changes from shift to shift.
(b) Modular nursing: Nurses are assigned to clients within a small segment of a nursing unit to ensure that clients receive care from the same personnel on a regular basis.
b. Team nursing.
- An RN team leader is responsible for a group of clients’ plans of care and nursing care delivered and makes assignments based on the abilities of each team member, such as RNs, LPNs, and unlicensed nursing personnel.
- Team members share the work to be accomplished for a group of clients.
- The team leader is responsible for coordinating the team, planning care, and collaborating with professionals in other disciplines and often does not provide direct client care.
- Although the focus is on client assignments rather than tasks, tasks are assigned within the team.
- Communication occurs in a matrix (i.e., between the team leader and members and among team members).
c. Functional nursing.
- Functional nursing is a task-oriented approach whereby tasks are assigned on the basis of a person’s educational preparation.
- It is based on clearly defined job descriptions, policies, and procedures.
- The focus is efficiency and productivity but can fragment care and fail to meet the emotional needs of clients.
- Communication occurs in a hierarchy from the head nurse to subordinates.
d. Case management (total care) model.
- An RN is responsible for planning, implementing, and evaluating care for a specific client.
- The case manager is responsible for client care across the continuum of practice settings to promote continuity of care and limit fragmentation and redundancy of care.
- This model commonly relies on critical pathways to ensure appropriate delivery of care and facilitate evaluation of the achievement of expected outcomes.
B. Roles of the nurse
1. A role is a set of responsibilities and expected behaviors related to a person’s position or status.
2. There are many common roles in the provision of nursing care regardless of the setting in which nurses work, and there are also differences in roles depending on the unique services provided by particular health-care settings.
3. Nurses must have the knowledge and ability to assume appropriate roles when individualizing client care and ensure that the roles are within the legal definition of the state nurse practice act of the state in which they work.
VI. CARING FOR VULNERABLE POPULATIONS
A. Commonalities of nursing care for vulnerable populations
- Provide emotional and culturally sensitive care.
- Provide dignified, respectful, and nonjudgmental care.
- Collaborate with other health-care professionals to ensure that comprehensive care is planned and implemented.
- Engage clients in the planning process to ensure that they have input and a vested interest in goal achievement.
- Involve family members in developing a plan of care to address client needs if the client gives consent or if the client is a minor.
- Establish priorities with the client’s input because what the nurse believes is most important might not be what is most important to the client.
- Promote and acknowledge client abilities to foster independence and increase self-esteem.
- Make referrals to appropriate community resources and services.
- Arrange for transportation and childcare to facilitate attendance at appointments.
- Coordinate home-based care if the client is unable to leave the home or if a vulnerable client is at risk for not attending health-care services.
- Arrange for participation in economic support programs, such as food stamps, Medicaid, and the Women, Infants, and Children (WIC) program.
- Provide assistance for vocational counseling if the client is able to maintain employment.
B. Individuals who are infants (birth to 1 year) or children
- Infants and children are dependent on others to meet their physiological and emotional needs.
- They have immature immune systems to protect themselves from infection.
- They lack depth and breadth of physiological responses to stress.
- They lack judgment, which may result in injury.
- They may be born into a hostile environment (e.g., inadequate nutrition, parents who misuse substances, poverty).
- Specific nursing care for infants and children.
- Ensure that infants and children receive immunizations.
- Ensure that they receive routine health care (e.g., initially monthly and then yearly) and dental care.
- Educate parents about positive health-care practices (e.g., nutrition, safety practices, and developmental expectations).
C. Individuals who are older adults
- Includes a rising percentage of adults over age 85 because of an increase in life span; older adults have multiple health problems, requiring comprehensive health care.
- Also includes a rising percentage of adults over age 65 because of the aging of the large number of people born between 1946 and 1960 (baby boomer generation); these people have health promotion and illness prevention needs to maintain health and independence.
- Demonstrate an increase in alcohol use in response to depression, lack of social support, and lack of companionship.
- Experience socioeconomic stressors, such as retirement, inadequate income, social isolation, downsizing of home and lifestyle, and relocation, which also can cause psychological and physiological stress.
- Live in their own homes but may have impaired mobility or lack of transportation, which may require services to be provided in the home.
- Specific nursing care for older adults.
- Provide opportunities that support the developmental task associated with older adults (integrity versus despair).
- Assess clients for substance use (e.g., polypharmacy) and alcohol and prescription drug misuse.
- Encourage clients to engage in social activities available in the community.
- Arrange for home-care services so that older adults can remain in their own homes for as long as possible.
- Arrange for respite care. Respite care temporarily relieves family members from the caregiving role; varies in duration, from as short as a few hours so a family member can go to a movie or shop to a week or more admission to a nursing home while a family attends an event or goes on vacation.
D. Individuals who are homeless or indigent
- Live in substandard housing or in hazardous conditions, such as insect- or vermin-infested environments, or live outside in the elements.
- Are less healthy because of such factors as inadequate nutrition, inaccessible facilities in which to bathe and wash clothes, inadequate rest, and absence of preventive health care, such as immunizations and health screenings.
- Are at increased risk for accidental injury, assault, abuse, and infectious diseases, such as tuberculosis and skin and respiratory infections.
- Have a higher incidence of severe mental illness, alcoholism, illegal drug use, and smoking than the general population.
- Specific nursing care for homeless and indigent individuals and families.
- Help clients find mobile health clinics, soup kitchens, shelters, thrift shops, and housing.
- Teach the importance of and ways to maintain a clean, healthy environment.
- Teach homeless people ways to avoid violence.
E. Individuals who are immigrants
- Usually do not speak English well enough to communicate needs or find resources that support health and wellness and treat illness.
- If in the country illegally, often do not seek health care until acutely ill because of a fear of being deported.
- Often cannot afford health insurance or healthcare services because of low-paying jobs or dependence on day work.
- Present with specific health problems, such as tuberculosis, intestinal parasites, dental decay, and hepatitis B.
- May have experienced a traumatic event, such as war, natural disaster, lack of economic opportunity, or oppression, and are at risk for emotional distress.
- Frequently engage in nontraditional healing practices that may or may not be helpful.
Specific nursing care for immigrant populations:
- Learn as much as possible about the client’s culture and its impact on the client’s healthcare needs.
- Be sensitive to cultural values and beliefs and demonstrate respect for nontraditional healing practices unless they are harmful to the client.
- Assess the client for signs and symptoms of specific health problems unique to the client’s history, culture, and environment.
- Use a professional interpreter so that information can be correctly translated, and confidentiality can be maintained; ensure that all questions are answered and understood to promote client participation in the planning process.
F. Individuals who engage in substance misuse
- Includes individuals who misuse illegal or prescription drugs and alcohol.
- Often have economic and legal issues as well as health problems related to substance misuse, such as the expense of supporting the habit, arrest and conviction related to illegal activities acquiring drugs, and infectious disease as a result of sharing drug supplies.
- Often experience a breakdown of the family and loss of support systems as the substance misuse becomes the focus of activities or because of abusive behavior.
- Often present with complex medical problems (e.g., cocaine use can cause nasal, sinus, and cardiac problems; alcohol misuse can cause liver cirrhosis).
- Specific nursing care for clients who engage in substance misuse:
- Observe for signs and symptoms of substance misuse, such as multiple missed appointments, chief complaint of insomnia or “bad nerves,” multiple health-care providers, medication bottles with different provider names, requests for frequent refills of sedatives or analgesics, history of frequent sexually transmitted infections, multiple abortions, gastrointestinal illnesses, chest pain or palpitations, and family history of addiction.
- Encourage client participation in a substance misuse program.
- Refer the client to appropriate legal services.
G. Individuals who are mentally ill
- Are routinely cared for in the community rather than in psychiatric facilities.
- Often refuse to take prescribed medications, which worsens their health status.
- Often unable to self-perform activities of daily living.
- Generally incapable of retaining a job, commonly resulting in their living below the poverty level and becoming homeless.
- Often have many of the same needs as indigent and homeless people have.
6. Specific nursing care for severely mentally ill individuals. a. Arrange for the client to attend a day-care program for individuals with mental illness, if appropriate. b. Arrange for admission to a psychiatric facility if the client becomes a danger to self or others.
H. Individuals who are within a stigmatized population
- A stigmatized population is a group of people who are unaccepted and discriminated against and lack status and power.
- Includes individuals who have communicable diseases (e.g., HIV, AIDS, tuberculosis, hepatitis C),
are mentally ill, or engage in behaviors that are denounced (e.g., substance misuse). - Specific nursing care for stigmatized populations:
- Teach individuals who engage in high-risk behaviors ways to protect themselves from infection, such as using condoms and avoiding needle sharing.
- Refer clients who have HIV or AIDS to an HIV coordinator because these professionals have expertise to meet the needs of this vulnerable population.
- Provide clients with choices and opportunities to participate in planning care to empower them.
