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Community Health Nursing


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Title: Community Health Nursing

Community Health Nursing
  • Module 11

Community Health Nursing (ANA, 1986)
  • The synthesis of nursing practice and public
    health practice applied to promoting and
    preserving the health of populations

Community Health Definitions
  • Community - a group of people sharing common
    needs, interests, resources and environments.
  • Population - a statistical aggregate or subgroup
    of people with similar or identical
    characteristics may or may not interact with one
  • Community Health Nursing - nursing care that
    takes place outside of acute-care settings meets
    its goals by identifying problems and supporting
    community participation in the process of
    preserving and improving the health of community.
    The focus is on the health of the larger group
    rather than the health of the individual.
  • Public Health Nursing - subset of Community
    Health Nursing goal is primarily improving the
    health of the entire community.

Communities Essential Functions
  • Production, distribution or consumption of items
  • Socialization
  • Transmission of culture
  • Provision of norms/social controls
  • Provision of mutual respect

Communities Four Critical Attributes
  • Group orientation
  • Bond among individuals
  • Human interaction
  • Collective action

7 Patterns in a Health Sustainable Community
  • Cultivates leadership everywhere
  • Creates a sense of community
  • Connects people and resources
  • Knows itself
  • Practices ongoing dialogue
  • Embraces diversity
  • Shapes its future

Goal of Community Health Programs
  • To improve the levels of health of the
  • First, identify potential and existing community
    health problems
  • Unique to each city

Community Health Programs
  • World Health Organization (WHO)
  • Healthy People 2010
  • Department of Health and Human Services (DHS)
  • Public Health Department
  • (See Study Guide 2 for more extensive list)

World Health Organization
  • Founded in 1948 to give worldwide guidance in
    health, set standards of health, cooperate with
    governments in strengthening national health
    programs, and develop and transfer health
    technology, information, and standards.

Healthy People 2010
  • 10-year plan and 10 goals for the health of the
    U.S. to promote healthy behaviors
  • Builds on original Healthy People initiative
    originated under President Carter.
  • An initiative of the Department of Health and
    Human Services (DHS)

Healthy People 2010
  • 2 Goals
  • Increase quality and years of healthy life
  • Eliminate health disparities
  • 28 Focus Areas
  • 467 specific objectives covering all ages

Healthy People 2010
  • Steps/Goals
  • Reducing the Burden of Disease
  • Obesity
  • Diabetes
  • Asthma
  • Cancer
  • Heart Disease and Stroke

Healthy People 2010
  • Addressing Risk Factors
  • Physical Inactivity
  • Poor Nutrition
  • Tobacco Use
  • Youth Risk Taking

Steps to a Healthier US
  • The Presidents Health and Fitness Initiative
  • Created by Presidential Executive Order June

Healthier US Mission
  • Focus on Health pillars
  • Be physically active
  • Eat a nutritious diet
  • Get preventative screenings
  • Make healthy choices
  • To prevent disease, disability and death and help
    Americans lead safer, healthier, long lives

Healthier US, A Collaborative Effort
  • Health and Human Services (HHS) Agencies Involved
    in Steps to a Healthier US
  • Administration on Aging
  • Administration for Children and Families
  • Agency for Healthcare Research and Quality
  • Centers for Disease Control and Prevention (CDC)
  • Centers for Medicare and Medicaid Services
  • Food and Drug Administration
  • Health Resources and Services Administration
  • Indian Health Services
  • National Institutes of Health (NIH)
  • Substance Abuse and Mental Health Services

DHHS Top 10 National Goals Targeted at Ensuring
Healthy Communities and Individuals
  • Physical activity
  • Overweight and obesity
  • Tobacco use
  • Mental health
  • Responsible sexual behavior
  • Injury and violence
  • Substance abuse
  • Environmental quality
  • Immunizations
  • Access to health care services

Public Health
  • Focuses on assessing and identifying
    subpopulations at high risk or threat of disease
    or, at high risk of poor recovery
  • Makes sure resources and services are available
    and accessible to this population
  • Includes the study and practice of techniques
    that protect communities from epidemics, toxic
  • Determines the risk for environmental disasters
  • Sets policy
  • Enforces laws that provide a safe supply of water
    and food

Public Health
  • Includes various governmental agencies
  • Center for Disease Control and Prevention (CDC)
  • Food and Drug Administration (FDA)
  • National Institutes of Health (NIH)
  • All are active in maintaining public health
  • Each of 50 states has a health department in
    which at least one physician is the Public Health

Community Health Assessment
  • A systematic way to determine the health status,
    resources or needs of a population.
  • Community health requires a population-based
    approach with attention given to the economic,
    social and political environments of the
    community as they impact a communitys health.

Steps of the Population-based Approach
  • Epidemiological research The first step is to
    gather health data about the community, analyze
    the data and then develop a plan.
  • Needs assessment This assessment includes
    systematically assessing what a community
    requires to maintain the best health for (or
    prevent or treat disease in) its members. All
    providers, clients and other key parties must be
    included in the assessment.

Steps of the Population-based Approach
  1. Program Planning Identifying the current
    situation or incident that needs improvement or
    change, indicating the desired outcome, and then
    designing a series of steps to move from the
    current situation to the desired situation.
  2. Evaluation A systematic inquiry to determine if
    the program followed its plan and met its goals.

Gathering Data Epidemiology
  • Concerns of epidemiology include accidents,
    suicide, climate, toxic agents such as lead, air
    pollution and catastrophes due to ionizing
  • Term derives from the word epidemic which is an
    outbreak of disease that suddenly affects a large
    group of persons in a geographic region or
    defined population group.

Epidemiological Perspective
  • Looks at similarities among persons or
    populations that do or do not develop an illness.
  • Studies health related issues.
  • Considers belief that health status is dependent
    on multi-factorial causes among agent, host and

Epidemic vs. Pandemic
  • Epidemic excessively communicable,
    contagious, disseminated, prevalent or
  • Pandemic an exceptionally widespread epidemic
    that affects a very high proportion of the
    population or populations throughout the world
    extraordinarily widespread diseases with global
    impact. Examples AIDs, malaria, and influenza.

Roles and Settings for Community-Based Nursing
  • School rural nursing
  • Public health
  • Home health
  • Camp nurse
  • Parish nurse
  • Occupation health nurse
  • Individuals
  • Families
  • Groups
  • General community

CHN Mission
  • Health Promotion
  • Physical health, mental health, and social and
    environmental health.
  • Includes individuals and communities abilities
    to cope with changes (environmental, social) and
    to maintain overall health and well-being.
  • Health Protection
  • Workplace safety and health, food and drug
    safety, and other health/safety areas, as well as
    the regulations that provide for them.
  • Avoiding illness and its consequences.

CHN Mission (continued)
  • Health Balance
  • A state of well-being that results from a healthy
    interaction among a persons body, mind, spirit
    and environment
  • Disease Prevention
  • Includes activities designed to protect people
    from disease and its consequences
  • Includes the three levels of disease prevention
    Primary, Secondary and Tertiary Prevention
  • Social Justice
  • Ensuring basic needs are met (adequate income and
    health protection)

CHN Practice
  • Builds caring relationships with families and
  • Acts as a participant and facilitator rather than
    just a dispenser of medications or information.
  • Fosters mutual respect from both the giver and
    the receiver of care (effective care requires
  • Understands and works with diversity and
  • Focuses on populations or subpopulations rather
    than individual-based practice.

CHN Practice (continued)
  • Focuses on wellness, not sickness.
  • Focuses on prevention, not just treatment of
  • Assists people and communities make their own
    decisions regarding health care (empowerment).
  • Assists those with existing health conditions to
    maximize their potential and prevent
    deterioration, if possible.

CHN Practice (continued)
  • Works in partnership with the community to
    address and support public health needs with
    education and referrals.
  • Responds to communicable disease needs.

CHN Practice (continued)
  • CHN recognizes health as a state of complete
    physical, mental and social well-being and not
    merely the absence of disease and infirmity.
  • Holistic focus works with clients along the
    Wellness/Illness continuum.

The Illness/Wellness Continuum
Photo Source courtesy of Eastern Michigan
University, http//
Preventative Nursing
  • A branch of nursing aimed at preventing the
    occurrence of both mental and physical illnesses
    and diseases.
  • The nurse, as a member of a team of
    professionals, has the opportunity to emphasize
    and implement health care services to promote
    health and prevent disease.

Preventative Nursing (continued)
  • Nursing expertise and general professional
    competence can also be used in supporting
    community action at all levels for the promotion
    of public health. There are three levels of
    preventative nursing
  • Primary Prevention
  • Secondary Prevention
  • Tertiary Prevention

Nurses Role In Prevention
  • Primary - prevent homelessness by identifying and
    eliminating risks for this. Refer those with
    psychiatric disorders to specialists.
  • Secondary - refer to financial assistance, food
    supplements, assist finding shelter.
  • Tertiary - prevent recurrence of poverty, health
    problems, homelessness. Make referrals, educate.

Primary Prevention
  • Is applied to a generally healthy population.
  • Aim is general health promotion.
  • Involves measures taken to keep illness or
    injuries from occurring.
  • Includes whatever intervention is required to
    provide a health-promoting environment
  • In the home
  • In schools
  • In public places
  • In the workplace
  • Includes good nutrition, adequate clothing,
    shelter, rest and recreation.
  • Health education.

Primary Prevention
  • Health education includes sex education and
    realistic plans for retirement for the aging
  • Areas of emphasis include protective measures
    such as immunizations, environmental sanitation,
    accident prevention and protection from
    environmental hazards (Occupational Safety and
    Health Administration - OSHA).

Primary Prevention (continued)
  • Promotes changes in lifestyle through behavioral
    therapies to those areas that represent major
    health risks
  • Smoking
  • Obesity
  • Sedentary life-styles
  • Improper diet
  • Alcohol and drug abuse
  • Sexual promiscuity
  • Not practicing safe sex
  • Falls
  • Preventing automobile accidents

Primary Prevention - Interventions
  • Primary prevention prevent the initial
    occurrence of the disease or injury
  • Immunization clinics
  • Smoking cessation
  • Tobacco chewing cessation
  • Sex education
  • Use of infant car seats, seat belts
  • Family planning
  • Dietary teaching and exercise
  • Water fluoridation

Secondary Prevention
  • Aimed at early recognition and treatment of
  • Includes general nursing interventions and
    teaching of early signs of disease.
  • These include but are not limited to glaucoma,
    obesity and cancer.

Secondary Prevention - Interventions
  • Secondary-early detection
  • Testicular self-exam
  • Blood pressure and cholesterol screening
  • Diabetes screening
  • HIV screening
  • Mammograms, pap smears
  • TB screening for those at risk
  • Hearing and vision screening

Tertiary Prevention
  • The goal is to prevent further deterioration of
    physical and mental functioning.
  • Individuals involved have an existing illness or
    disability whose impact on their lives is
    lessened through tertiary prevention.
  • To help maintain whatever residual function is
    available for maximum enjoyment of and
    participation in lifes activities.
  • Includes nursing care for patients with incurable

Tertiary Prevention (continued)
  • Patient education concerning how to manage and
    optimize new level of wellness associated with
    already diagnosed diseases and conditions.
    Examples include Parkinsons disease, multiple
    sclerosis and cancer.
  • Rehabilitation services are an essential part of
    tertiary prevention.

Tertiary Prevention - Interventions
  • Tertiary Prevention-maximize recovery after an
    injury or illness including rehabilitative care.
  • Dietary education on low-fat, low-sodium diet or
    other prescribed diets.
  • Post-stroke exercise, speech or occupational
  • Nutritional counseling to support clients with
    HIV or AIDS
  • Foot care, eye exams and renal function studies
    in diabetic clients.
  • Swim therapy for clients with disabilities,
    rheumatologic or musculoskeletal health issues.

Preventative Nursing Case Study
  • A group of elders living in a senior center are
    concerned about their risk for stroke. They have
    asked you, as their community health nurse, to
    address their concerns.
  • Using each of the three levels of prevention,
    identify an appropriate educational topic that
    would address these elders prevention needs.

The CHNs Role
  • To promote health and healthy behaviour in the
  • To act as a health resource person for the

The CHNs Role (continued)
  • To identify health issues which may impact the
    well-being of individuals, families, groups and
  • To refer identified health issues to appropriate
    agencies and ensure that co-ordination of care

Barriers to Referral Process
  • Attitudes of health care professionals
  • Physical accessibility of resources
  • Cost of resource services
  • Time
  • Other
  • Priorities
  • Motivation
  • Previous experiences
  • Lack of knowledge of available services
  • Cultural factors
  • Finances
  • Other

Infection Control from a Community Health
  • Modes of defence against infection
  • Natural immunity
  • Artificial immunity Active/Passive
  • Altering the environment

Issue of Immunity
  • Acquired - exposure to antigens or passive
    injection of immunoglobulins
  • Active - from invading microorganism
  • Congenital - present at birth antibodies from
  • Herd - ability of community to resist an epidemic
  • Humoral - body makes antibodies quickly when it
    encounters same organism again
  • Natural - genetically determined in specific
  • Passive - acquired by preformed antibodies
    (immunoglobulin, in utero, breastfeeding)

Components Necessary for Infection
  1. Source - initiator (person, animal, food, water)
  2. Reservoir - storage place and exit from source
  3. Agent - causes and effect (bacteria, virus,
    spirochete, etc.)
  4. Mode of transmission - airborne, direct contact,
    animal to human, etc.
  5. Portals of entry - gains access through break in
    skin, respiratory tract
  6. Susceptible new host - organism from which a
    parasite obtains its nourishment

Modes of Transmission
  • Contact
  • Direct - fecal, oral, or client contact
  • ? herpes, scabies, STDs
  • Indirect - inanimate objects, needles, dressing,
    secretions ? hep B, HIV
  • Droplet (airborne) - cough, sneeze, talk ?
    measles, influenza virus, rubella, TB

Modes of Transmission (continued)
  • Air
  • Droplet nuclei/evaporate. Droplet, suspended in
    air -TB, chicken pox
  • Vehicle
  • Contaminated items
  • H2O Cholera, drugs, solution - pseudomonas
  • Blood hep C
  • Food salmonella, e. coli

Modes of Transmission (continued)
  • Vector
  • External mechanical transfer (flies)
  • Internal transmission
  • Mosquito - malaria
  • Ticks - Lymess disease

? Transmission of Pathogens
  • Medical surgical asepsis
  • Immunization
  • Food sanitation
  • Insect rodent control
  • Appropriate disposal of human waste

Infectious Disease Outbreak
  • Primary prevention - immunize, educate on
    prevention and ways to eliminate exposure from
    the respiratory, skin and gastrointestinal routes
  • Secondary prevention - screening, case-finding,
    treatment, and legal enforcement of treatment, if
  • Tertiary prevention - educate to prevent
    complications teach side effects of therapy and
    prevent spread of disease

TB Outbreak in the Community
  • TB outbreaks typically occur in enclosed, highly
    populated places such as prisons, jails,
    shelters, hospitals, schools and nursing homes.
  • Every county in California has a Tuberculosis
    Outbreak Response Team made up of a nurse,
    physician, epidemiologist and two communicable
    disease investigators.
  • Technical assistance may be provided through
    telephone conference calls, face-to-face
    meetings, and/or onsite activities.

TB Outbreak in the Community (continued)
  • California law mandates the immediate reporting
    of outbreaks by telephone to local county health
  • Suggested triggers for reporting suspected or
    confirmed outbreaks to CDHS include, but are not
    limited to
  • 3 or more shared cases in the community
  • 2 or more active TB cases in a congregate
  • 2 or more linked cases in a vulnerable
  • 2 or more linked multi-drug resistant TB cases

TB Outbreak in the Community (continued)
  • For more information please refer to
    Tuberculosis Outbreak Response Team World Wide
    Web http//

Clients Healthy Environment
  • Presence of pathogen does not mean that an
    infection will be contracted. Infection occurs
    in the presence of factors that must all be
    present for the infection to occur.
  • An individuals own healthy immune system is a
    great defense against many infections.
  • The very young (first three months of age), the
    pregnant woman and the elderly have a depressed
    immune system.
  • Patients with AIDS or neutropenic states are also
    at risk for opportunistic infections.

Clients Healthy Environment (continued)
  • Asepsis Absence of pathogenic organisms
  • Medical asepsis Clean, reduce prevent spread
    of infection
  • Hand washing at least 10-15 sec, count 1
  • Antimicrobial soaps
  • Antiseptics
  • Disinfectants

Clients Healthy Environment (continued)
  • Standard precautions Use generic barrier
  • CDC guidelines
  • Blood body fluid precautions
  • Laundry
  • Waste disposal
  • Protective equipment
  • Hand washing most important to prevent
    transmission of infection.

Clients Healthy Environment (continued)
  • Safety risk factors
  • Immobility Impacts respiratory,cardiovascular,
    musculoskeletal and integumentary systems i.e.
    paralysis pressure ? decubiti
  • Physical limitations related to drugs and illness
    can result in falls.
  • Extrinsic environmental factors, especially in
    the elderly, can result in falls and injuries.
    Monitoring for night wandering.
  • Medication side effects can impact safety.
  • Safety awareness and planning.
  • Educational safety classes can include
  • Swim classes for preschoolers
  • Parent education for locking up medications
    cleaning supplies proper use of car seats.

Clients Healthy Environment (continued)
  • Care concerned with promoting safety which is
    individualized, based upon
  • Developmental stage
  • Lifestyle
  • Environment

  • Vaccines produce immunity by producing immune
    response in host.
  • Live attenuated vaccine - response is
    identical to disease response reaction is
    usually mild form of disease. Long immunity with
    one dose.
  • Inactivated vaccine - requires multiple doses
    and boosters to maintain immunity.

Immunization Recommendations
  • CDC guidelines available at
  • This includes
  • Recommended adult schedule
  • Recommended childhood and adolescents
  • Catch-up schedules for children and adolescents
    who start immunizations late or are more than one
    month behind schedule
  • Immunization untoward reactions also available at
    the above web site

Home Safety
  • Leading cause of accidental death in the home is
    due to falls. Other accidental deaths include
  • Poisonings
  • Fires
  • Burns
  • Drowning
  • Firearm accidents

Assessment Environmental Hazards in Homes and
  • Burns
  • Firearms
  • Cleaning products
  • Radon carbon monoxide
  • Asbestos
  • Lead and lead paint
  • Air pollution
  • Chemical poisons
  • Pesticides
  • Air pollution
  • Water pollution
  • Hazardous waste
  • Accidents
  • Radiation
  • Biological

Disease Prevalence in Different Populations
  • Rural populations are less likely to use
    preventative health services.
  • Homosexual men are most likely to have HIV.
  • Those with the least education and highest
    poverty have the most compromised health status.
  • American Indians Alaska Natives have twice the
    rate of diabetes and higher rates of injury and
    suicide as compared with Caucasian populations.

Disease Prevalence in Different Populations
  • Asians and Pacific Islanders may be one of the
    healthiest populations in U.S.
  • Heart disease death rates are 40 higher among
    African-Americans as compared with Caucasian
  • African-Americans have a higher incidence of
    colorectal cancer as compared with Caucasian

Diversity, Ethnicity and Culture
  • Diverse populations are different.
  • Ethnicity is cultural differences based on
  • Cultural care is the provision of health care
    that incorporates clients cultural beliefs about
    disease and treatment.
  • Cultural assessments provide information to
    health care providers about culture and its
    effect on communication, personal space, physical
    contact, social structure and orientation to

Possible Cultural Differences
  • Personal space
  • Family patterns
  • Time orientation
  • Nutritional choices
  • Pain response
  • Communication
  • Death and dying
  • Religion and spirituality
  • Childbirth, care of the newborn
  • Child-rearing practices

Conveying Cultural Sensitivity
  • Introduce yourself and state your role.
  • Address patients by their last name unless they
    give you permission to use other names.
  • Be honest if you lack information about cultural
  • Be careful to use culturally sensitive language.

Conveying Cultural Sensitivity (continued)
  • Dont make assumptions based upon a lack of
    response to questions, pain level or acceptance
    of health interventions.
  • Encourage questions about procedures and nursing
  • Demonstrate respect for client and significant
  • Demonstrate respect for a patients health
    values, practices and beliefs.

Health Issues by Developmental Stages
  • Infant/toddler Decrease home accidents and
    injuries, lead poisoning and child abuse.
  • School-age Home, school and sports accidents and
    injuries, bicycles skateboard injuries,
    strangers and abduction, child abuse and car
  • Teen Auto accident substance abuse, abstinence
    unsafe sexual practices, seat belt use, helmet
    and safety gear use, smoking, drugs and violence.

Health Issues by Developmental
Stages (continued)
  • Adult Lifestyle habits
  • Smoking
  • Obesity
  • Exercise
  • Motor vehicle accidents
  • Elderly Physiologic changes of aging
  • Falls
  • Elder abuse
  • Drug Abuse
  • Alcohol Abuse
  • Burns
  • Auto Accidents

Barriers to Prenatal Care
  • Socio demographics
  • Insurance/financial issues
  • Inadequate number of healthcare providers for low
  • Childcare unavailable
  • Long wait for care
  • Cultural considerations
  • Transportation issues
  • Attitudes regarding care

Infant Car Safety
  • A mother brings her 9-week-old infant to a
    community-based clinic for a well-baby visit. The
    nurse instructs the mother about infant safety
    issues. In evaluating the effectiveness of the
    teaching, the nurse would expect the mother to
    place the infant in a car seat in which of the
    following positions?

Infant Car Safety
  • 1. Front seat facing forward.
  • 2. Back seat facing forward.
  • 3. Front seat facing backward.
  • 4. Back seat facing backward.

Child Health Case Study
  • The kindergarten teacher referred a 5-year-old
    boy to the
  • school nurse. His disruptive classroom behavior
  • inability to concentrate has become increasingly
    worse. In a
  • meeting with the boys mother, the family history
  • that the boys parents have been divorced for two
    years and
  • he is living with his mother in an older urban
  • where the houses are in need of repair.

Child Health Case Study (continued)
  • There are abandoned cars in the empty lot next to
    their home. The childs health record indicates
    that his pre-school physical a year ago revealed
    a normal, healthy child with no apparent problems
    or abnormalities. The mother states that his
    behavior has gotten progressively worse over the
    last year. Upon examination, the nurse discovers
    that he has hearing and speech deficits and
    extreme difficulty in concentrating. His finger
    stick hemoglobin indicates mild anemia.

  • Questions for case study
  • What might be a possible reason for the childs
  • What counseling and education would the nurse
    provide for the mother and child?

Preparing for the Worst
Types of Biological Warfare
  • Anthrax - bacilli causing cutaneous or pneumonia
  • Botulism toxin - bacilli causing nerve damage and
  • Plague - rat flea vector with high death rate
  • Tularemia - tick, bloodsucking insect or infected
    water-plague-like infection
  • Q fever - bacterium from inhaling dust and
    unpasteurized milk
  • Smallpox - viral airborne pustular fatal illness
  • Rat poison and nerve gasses

Bioterrorism and Public Health
  • Magnitude
  • Investigative process
  • Social issues
  • Ethical issues
  • Biological concerns

Physical Clues to Bioterrorism
  • Fever with rash
  • Bleeding disorders
  • Outbreaks in animals and humans
  • Group illnesses
  • Respiratory illness with fever
  • Influenza-like symptoms with blisters, pustules
    and rash
  • Coughing up blood and dyspnea

Community Disasters What is an Emergency?
  • A community emergency is any unplanned event that
    can cause deaths or significant injuries or than
    can shut down operations, communications and
    travel into or outside of the community, or that
    can cause significant property or environmental

Community Disasters
  • Possible widespread community disasters include
  • Fire
  • Hazardous Materials Incident
  • Terrorism
  • Tornado
  • Hurricane
  • Winter storm
  • Severe Thunderstorm
  • Earthquake
  • Land slides
  • Communications Failure
  • Flood and Flash Flood
  • Civil Disturbance
  • Explosion
  • Pandemic

Disaster Management
  • 4 Phases Preparedness, Response, Recovery,
  • Nurses must be flexible, may need to use nursing
    judgment to make decisions such as where needed
    resources will be used, triaging patients to the
    appropriate level of care and care management
    within their scope of practice.

Disaster Management (continued)
  • Preparedness - plans made to save lives and to
    help prepare for rescue, evacuation, caring for
    victims, personnel training, resource gathering,
    communications, and stockpiling and maintenance
    of supplies and equipment.

Disaster Management (continued)
  • Response - Actions taken to save lives and
    prevent further damage putting disaster plan
    into action. Nurses may be active in triage,
    first aid, rescue, evacuation, recognizing and
    preventing communicable disease, first aid and
  • Recovery - Actions taken to return to a normal
    situation after disaster possibly resulting in a
    safer situation than existed prior to the

Disaster Management (continued)
  • Mitigation - any activity that reduces or
    eliminates risks to persons or property or
    lessens the actual or potential effects or
    consequences of an incident.

Disaster Management (continued)
  • Phases of emotional reaction during disaster
  • Heroic phase Excitement, people working together
    to save lives and property.
  • Honeymoon 2 weeks to 2 months after the
    disaster. Victims feel supported by government
    community. Optimism is high and plans are made
    for recovery.
  • Disillusionment Several months to 1 year after
    disaster. Frustration from unexpected delays and
    a sense of failure.
  • Reconstruction Phase Sometimes several years.
    Rebuilding the community and individuals trying
    to return to normal life.

Nurses Role in Disaster
  • Assess the community for
  • Available disaster plan
  • Level of education and knowledge
  • Risks for potential disasters such as climate,
    terrain, local industries, toxic waste, etc.
  • Personnel available to help in a disaster
  • Available resources if a disaster occurs. These
    include food, shelter, medication, water,
    clothing, volunteers, etc.

As a nurse in a newly formed home health agency,
you have been asked to develop a disaster plan
for the agency. Questions for this Scenario
What steps would you take to develop the plan,
and who would you involve?
Nurses Role in Disaster Case Study
Disaster Case Study
  • You are contacted to respond to a disaster after
    a major earthquake in southern California. The
    damage has caused power outages for over 500
    miles. About 50 people have been killed, many are
    injured. You have volunteers that are ready to
    assist you.
  • How would this disaster be categorized?
  • What phase of disaster management will you

  • Housing and Homecare Challenges
  • Discharge Planning
  • Homelessness

Discharge Planning
  • RNs in many settings may be called upon to
    provide discharge planning.
  • Home safety assessment includes stairs, adequate
    lighting, throw rugs, grab bars in the shower and
    bathroom, etc.
  • Assess need for home care supplies and equipment
    including a cane, walker, oxygen, hospital bed,
    bedside commode, elevated toilet seat, grab bars,

Discharge Planning (continued)
  • Assessment includes a functional assessment
    including patients ability to perform activities
    of daily living (ADLs) such as basic hygiene and
    dressing activities.
  • Assessment of independent activities of daily
    living (IADLs) includes ability to perform
    shopping, cooking, cleaning and financial
  • Referral to appropriate community resources in
    the community and to appropriate education
    programs is part of the role of the RN performing
    discharge planning.

  • Up to 404,914 people are homeless in California
    at any point in time. (Source HUD, 2006)
  • Families are quickly becoming the fastest growing
    group of homeless (40)
  • May be temporarily, chronically, or episodically
  • Limited access to health care

Homelessness (continued)
  • Sheltered Homeless Shelters include all
    emergency shelters and transitional shelters for
    homeless, including domestic violence shelters,
    residential programs for runaway/homeless youth
    and any hotel/motel/apartment voucher

Homelessness (continued)
  • Unsheltered Homeless Places not meant for human
    habitation include streets, parks, alleys,
    parking ramps, parts of the highway system,
    transportation depots and other parts of
    transportation systems (e.g., subway tunnels,
    railroad car), all-night commercial
    establishments (e.g., movie theaters,
    laundromats, restaurants), abandoned buildings,
    building roofs or stairwells, chicken coops and
    other farm outbuildings, caves, campgrounds,
    vehicles and other similar places.

Homelessness (continued)
  • Chronically Homeless
  • An unaccompanied individual with a disabling
    condition who has been continuously homeless for
    a year or more or has experienced four or more
    episodes of homelessness over the last three
  • A disabling condition is defined as a diagnosable
    substance abuse disorder, serious mental illness,
    developmental disability or chronic physical
    illness or disability, including the
    co-occurrence of two or more of these conditions.
  • In defining the chronically homeless, the term
    homeless means a person sleeping in a place
    not meant for human habitation (e.g., living on
    the streets) or in an emergency homeless shelter.

Health Problems of Homeless
  • The homeless population is aging.
  • As of August 2006, a study in San Francisco
    revealed the average age of their homeless
    population to be 50 years of age. Fourteen years
    ago, the average age was 37.
  • Health problems showing up relate to growing
    older and include
  • Hypertension
  • Diabetes
  • Emphysema

Health Problems of Homeless (continued)
  • All genders mental illness, bronchitis,
    pneumonia, problems caused by being outdoors,
    wound and skin infections, URI
  • Men - TB, scabies, lice, AIDS, trauma, ETOH
  • Women - assault, rape, URI

Health Problems of Homeless (continued)
  • Children - lice, scabies, skin disorders, anemia,
    asthma, poor dental health, ear infections, GI
    problems, malnutrition, developmental delays
  • Social - depression, suicide, low motivation,
    sense of shame, poor self-esteem
  • Emotional - worsening ETOH or drug abuse,
    physical violence, less able to be employed, less
    opportunity for children to attend school

Homelessness Prevention Strategies
  • Housing Subsidies Several studies have provided
    evidence that housing subsidies is a very
    effective prevention activity for homelessness.
    Studies indicate that subsidizing housing costs
    for extremely low-income people has the strongest
    effect on lowering homelessness rates as compared
    to several other interventions tested.

Homelessness Prevention Strategies (continued)
  • Supportive services coupled with permanent
    housing For people with serious mental illness,
    with or without co-occurring substance abuse,
    permanent supportive housing works to prevent
    initial homelessness, to re-house people quickly
    if they become homeless, and to help chronically
    homeless people leave the streets.

Homelessness Prevention Strategies (continued)
  • Mediation in Housing Courts Mediation under the
    auspices of the Housing Courts has the ability to
    preserve tenancy, even after the landlord files
    for eviction. For example, mediation preserved
    housing for up to 85 of people with serious
    mental illness facing eviction in the Western
    Massachusetts Tenancy Preservation Project and
    cut the proportion becoming homeless by at least
    one third.

Homelessness Prevention Strategies (continued)
  • Cash assistance for rent or mortgage arrears
    This commonly used primary prevention activity
    for households still in housing but threatened
    with housing loss can be effective the
    challenge is to administer it in a way that makes
    it well-targeted and therefore, efficient.

Homelessness Prevention Strategies (continued)
  • Rapid exit from shelter These secondary
    prevention activities are directed toward
    families just entering shelter, to ensure that
    they quickly leave shelter and stay housed
    thereafter. Using this innovative strategy,
    counties have reduced the length of stay from 60
    days to 30 days and have seen an 88 success rate
    in keeping formerly homeless families from
    returning to shelter over the next year.

NCLEX-RN Test Plan and Community Health
  • Disease Prevention
  • Health and Wellness
  • Health Promotion Programs
  • Health Screening
  • High Risk Behaviors
  • Immunizations
  • Lifestyle Choices
  • Self Care
  • Principles of Teaching and Learning
  • Human Sexuality

Community Health Questions
  • Time to put yourself in the role of a public
    health nurse (PHN) in a variety of health care
    setting with various types and ages of clients.
  • Apply relevant nursing content as indicated to
    intervene in treating an individual or

School Health Nurse
  • Scenario
  • A student has confided in the school
  • nurse that her father is sexually abusing her.
  • She does not want her mother, who is a
  • teacher at the school, to know and does not
  • want the nurse or the counselor to discuss
  • this with anyone. What should you do?

High School Nurse
  • A high school in a rural farm community has a
    disproportionately high number of pregnant
    students. Most of these young mothers choose to
    keep their babies rather than terminate their
    pregnancies or give their babies up for adoption.
    Some have assistance from their families or the
    fathers of the babies. In many of these cases,
    the young mothers are unable or unwilling to
    complete their high school education. This often
    leads to isolation, depression and financial
    dependency on others.

High School Health Nurse (continued)
  • The school nurse determines that a combination
    learning and
  • support group for these young mothers may
    alleviate some of
  • the isolation and depression and provide them
    with incentive
  • to finish school.
  • Questions for this Scenario
  • What are the first steps the nurse must take to
    establish this group?
  • Who are the key people the nurse must work with
    to make this group work?

High School Health Nurse Case Study
  • A 16-year-old female high school student is being
    treated for gonorrhea and chlamydia for the
    second time in six months. While counseling the
    young woman, the nurse learns that she has only
    one sexual partner but she suspects that her
    boyfriend might not consider their relationship
    monogamous. He refuses to wear a condom because
    he says he wants to really enjoy having sex with
    her and a condom would interfere with that. The
    client doesnt want to confront her boyfriend
    because she is afraid of losing him. She states,
    Whats the big deal anyway? Gonorrhea and
    chlamydia are curable.

High School Health Nurse Case Study (continued)
  • Later, when preparing the clinics report of
  • diseases for the public health department, the
    nurse notes
  • that there is a high incidence of gonorrhea and
    chlamydia in
  • the clinics adolescent population.
  • Questions for this Scenario
  • What nursing interventions are appropriate with
    this patient?
  • What actions should be taken at the community

Public Health Nurse Case Study
  • A client in a public health setting has expressed
  • about her stress level while nursing her newborn.
    She is
  • three weeks postpartum and the infant is a
    healthy, normal
  • newborn with normal weight gain. The client has a
  • 3-year old son who was bottle fed and she states
    that I wish I would have nursed him. I am
    determined to be successful with this baby.

Public Health Nurse Case Study (continued)
  • The nurse is aware that the client cannot use
  • pharmacological agents to reduce her anxiety and
    that a
  • complementary health practice, such as music
  • might be an appropriate intervention.
  • Questions for this Scenario
  • How would the nurse introduce the idea of music
  • What would the nurse tell the mother about music
    therapy and the potential benefits for her as a
    new nursing mother?

School Health Nurse Case Study
  • A community health nurse is contacted about a
    possible head lice outbreak in an elementary
    school in her district. The school has sent 50
    students home in the past week with suspected
    head lice. The principal is upset that parents
    are sending their children to school with unclean
    hair, which he believes is the cause of the head
    lice infestation. The children who have been sent
    home are all in the third grade. Answer the
    following questions

School Health Nurse Case Study (continued)
  • Question for Lice Scenario
  • What should the nurse do first? Who should the
    nurse involve in the epidemiological
  • What kinds of data should the nurse obtain during
    the first part of the investigation?

Community Health Nursing Case Study
  • The emergency room physician has referred a
    60-year-old man to a clinic for follow-up care of
    his hypertension. While taking his health
    history, the clinic nurse learns that the client
    has recently been released from prison after a
    twenty-year sentence. He has just started working
    as a dishwasher in a local restaurant.

Community Health Nursing Case Study (continued)
  • He is living in a low-rent housing facility and
    does not have a car, a telephone or health
    insurance. During his years of incarceration, the
    client lost all contact with family members and
    friends. Since he has only recently moved to this
    city, he has no local contacts. In reviewing
    clinic admission forms, the nurse assesses that
    the clients reading skills are very low level.


Community Health Nursing Case Study (continued)
  • Questions for this hypertensive client scenario
  • What risk factors should the nurse consider when
    providing comprehensive care for this client?
  • What other health care providers may collaborate
    in this case?
  • What community agencies may be an appropriate
    referral for this client?

The nurse is teaching a client recently diagnosed
with a seizure disorder. What information
provided by the nurse is the issue of greatest
concern to an individual who has seizures in the
NCLEX-RN Practice Question 1
  • 1. Having a seizure in public.
  • 2. Operating a motor vehicle.
  • 3. Operating machinery on the job.
  • 4. Choking on food during a seizure.

What level of prevention is the goal of a
community health nurse in an area that has just
experienced a major earthquake?
NCLEX-RN Practice Question 2
  • 1. Primary
  • 2. Secondary
  • 3. Tertiary
  • 4. Essential

The nurse is teaching a community group about
nutritional wellness. The nurse explains that the
best reason to avoid the ingestion of raw or
undercooked pork is that it can
NCLEX-RN Practice Question 3
  • 1. Promote heart disease
  • 2. Transmit trichinosis
  • 3. Transmit enterobiasis
  • 4. Worsen the symptoms of dementia

The nurse is reviewing safety information with
the parents of a toddler. The nurse should base
the information on the knowledge that most deaths
in children under age 3 are caused by
NCLEX-RN Practice Question 4
  • 1. Falls
  • 2. Poisoning
  • 3. Aspiration/suffocation
  • 4. Motor vehicle accidents

A client recovering from alcoholism joins
Alcoholics Anonymous (AA) to help maintain
sobriety. The nurse recognizes that AA is
considered to be a
NCLEX-RN Practice Question 5
  • 1. Social group
  • 2. Self-help group
  • 3. Re-socialization group
  • 4. Psychotherapy group

The nurse is teaching a community group about
preventing accidental poisoning in the home.
Which of the following would the nurse stress as
NCLEX-RN Practice Question 6
  • 1. Keep medications on the top shelf of the
    medicine cabinet.
  • 2. Place medications in unmarked containers to
    disguise them from children.
  • 3. Keep the telephone number of the poison
    control center near the telephone.
  • 4. Refrain from referring to medication as
    candy in the presence of children.

NCLEX-RN Practice Question 7
The home care nurse is visiting a homebound
client who has a history of gastrointestinal (GI)
bleeding. Upon assessment, the nurse determines
that the clients blood pressure has dropped from
128/78mm Hg to 95/58 mm Hg in 1 week, and the
resting pulse has increased from 84/min to
104/min in 1 week. The client also complains of
dizziness upon arising and shortness of breath
when walking a short distance.
Based on this information, the nurse would assign
highest priority to which of the following
nursing diagnoses?
  • 1. Fatigue
  • 2. Activity Intolerance
  • 3. Decreased Cardiac Output
  • 4. Ineffective Airway Clearance

The home health nurse is caring for a client who
has limited mobility. Which of the following
actions should the nurse include to prevent the
development of osteoporosis?
NCLEX-RN Practice Question 8
  • 1. Providing the client with an over bed trapeze.
  • 2. Having the client perform daily weight-bearing
  • 3. Providing adaptive equipment to assist in
    activities of daily living.
  • 4. Encouraging the client to rest for several
    hours, several times a day.

Photo Acknowledgement Unless noted otherwise,
all photos and clip art contained in this module
were obtained from the 2003 Microsoft Office
Clip Art Gallery.