Community Study Guide for the HESI

Keep in mind: This guide does not necessarily mean you will see these topics. There may
be other topics that are not included here. I just did an internet search to see which
topics are most frequently covered and have tried to give you some pointers here.
Review Healthy People 2020 objectives in the chapters of your textbook- Just
familiarize yourself with them. These are the basis for community health programs. Page
80, 201

Leading Health Indicators

1. Access to Health Services
2. Clinical Preventative Services
3. Environmental quality
4. Injury and violence
5. Maternal, Infant, and Child health
6. Mental health
7. Nutrition, physical activity, and obesity
8. Oral health
9. Reproductive and sexual health
10.Social determinants
11.Substance abuse
12.Tobacco
Population Groups across the Lifespan and their Health Risks
Infants
Number 1 cause of injury or death is suffocation followed by Motor Vehicle Accident
then Homicide.
Sudden Infant Death Syndrome
Infection is the most significant cause of illness in infants and children.
Vertical transmission of infection- Passage of a disease-causing agent

(pathogen) from mother to baby during the period immediately before

and after birth. Transmission might occur across the placenta, in the
breast milk, or through direct contact during or after birth. For
example, HIV can be a vertically transmitted pathogen. Also known
as perinatal transmission.
Children
Obesity Healthy people objectives have addressed youth fitness and obesity
Defined by using BMI which is a ratio of weight to height
Risks for childhood obesity were related to obesity in the parents
Obesity rates are higher in populations such as Native American, Hispanic, and
African Americans groups. Lower socioeconomic groups in urban settings

have been associated with higher rates.

Injuries and Accidents- Number one cause of death in ages 1 24 yrs.
Motor vehicles accidents are the leading cause of death among children and teenagers.
Toddlers experience a large number of falls, poisonings, and motor vehicle accidents
Lead poison from lead based paint in older homes is a health concern.
Lead has detrimental effects particularly on the neuro system.
Can decrease IQ. If on WIC and have lead poisoning the program will provide additional
foods high in calcium and iron.
Review treatment of lead poison. Chelation therapy and a diet high in calcium, vitamin
C and iron. Dont want BLL > 5mcg/dL
Infant Mortality Rate: the measure most commonly used around the world as an
indicator of overall health and availability of health services. May want to review how to
calculate it. #of infants <1 who die/ # of live births in same year
School age children have the lowest injury death rate; however, this group has difficulty
judging speed and distance, placing them at risk for pedestrian and bicycle accidents.
Vision screening in young children would match shapes or colors.
Adolescents: Injury accounts for 75% of all deaths and risk-taking becomes more
conscious at this time especially among males.
Suicide is the second leading cause of death among youths between the ages of 15
and 24. Suicide is the third leading cause of death among youth between the ages of
10 and 24 years. Community health programs for adolescents should focus on
suicide prevention.
Developing a smoking program for adolescents- first want to determine the incidence of
smoking among the teenagers in the community.
Menomune vaccine given to adults younger than 30. It prevents infection by certain
groups of meningococcal bacteria. Discharge teaching- give Tylenol, watch for signs and
symptoms of reaction such as fever, behavior change, seizures or difficulty breathing.
Acute Illness- also a significant cause of illness in children.
Chronic Health Problems- improved medical technology has increased the number of
children surviving with chronic health problems. Examples: Down Syndrome, spina
bifida, cerebral palsy, asthma, diabetes, congenital heart disease, cancer, hemophilia,
broncopulmonary dysplasia, and AIDS
Routine immunizations have been very successful in preventing selected diseases.
Immunization rates are the amount of people that get scheduled vaccines. These
rates are used as quality indicators of the health of the population. Review the
immunization schedule in children.**

Good nutrition is essential for healthy growth and development and influences disease
prevention in later life. e.g. Children and adolescents calcium intake affects if they
develop osteoporosis in adulthood.
Women
The womens health movement was pivotal in bringing national recognition to womens
health issues.
Women have a longer life expectancy than men
Women are more likely to have acute and chronic conditions that require them to use
more services than men.
African-American or black women are statistically more likely to have poor health
outcomes because of poor understanding of health, lack of access to health care, and
lifestyle practices.
Heart disease leading cause of death in women
Lung Cancer leading cause of cancer in women and 2nd leading cause of death
Men
Men are physiologically the more vulnerable gender, shorter life span and higher infant
mortality rate
Life expectancy of men in the US is one of the lowest in the developed countries
Men engage in more risk-taking behaviors than women
Men tend to avoid diagnosis and treatment of illnesses that may result in serious health
problems
Elderly
Steadily growing population
Increase in chronic conditions, demand for services, and strained health care budgets
More older adults live in the community- Age in place
Nurses address the chronic health concerns of elders with a focus on maintaining or
improving self-care and preventing complications to maintain the highest possible
quality of life.
Assessing the elderly incorporates physical, psychological, social, and spiritual domains.
Individual and community focused interventions involve all three levels of prevention
through collaborative practice.
What vaccines should the elderly receive and how often?
-Tetanus diphtheria every 10 years
-Influenza vaccine annually
-Pneumonia vaccine once after age 65 (ask physician about booster every 5 years)
-Herpes Zoster (shingles) one time dose at age 60.
-Hep A and B for those at risk
U.S. Healthcare problems
More than 43 million people in the United States are uninsured, and many more simply
lack access to adequate health care.

Health care reform measures seek to make changes in the cost, quality, and access of the
present system. Review TQM and Quality Assurance
TQM: consists of organization-wide efforts to install and make permanent a climate in
which an organization continuously improves its ability to deliver high-quality products
and services to customers. (long term success through customer satisfaction)
Quality assurance: the maintenance of a desired level of quality in a service or product,
especially by means of attention to every stage of the process of delivery or production.
The integration of primary care and public health is necessary for the future health of the
nation. We must have more emphasis on primary prevention.
To achieve the specific health goals of programs such as Healthy People 2010, primary
care and public health must work within the community for community-based care.
Target approach focuses on a certain group of individuals and their health needs (e.g.
Hispanic pregnant women with STDs). The approach looks at spiritual, cultural and
leadership aspects.
The most sustainable individual and system changes come when people who live in the
community have actively participated. Important to involve community leaders in
program planning. Community stakeholders
Nurses are more than able to fill the gap between personal care and public health because
they have skills in assessment, health promotion, and disease and injury prevention;
knowledge of community resources; and ability to develop relationships with community
members and leaders.
Home Visits- give a more accurate assessment of the following than do clinical visits:
- the family structure
- the natural or home environment
- behavior in that environment
Home visits provide opportunities to identify both barriers and supports for reaching
family health promotion goals.
Home visits afford the opportunity to gain a more accurate assessment of the family
structure and behavior in the natural environment.
Home visits also provide opportunities to observe the home environment and to identify
both barriers and supports to reducing health risks and reaching family health goals.
Home Health Nurses Delegation- What must RNs do and what can they delegate?
Home health RNs must do the initial assessment of the patient. ADLs can be
delegated to a nursing care aide.

Parish nurses: nurses who respond to health and wellness needs within the faith context
of population of faith communities and are partners with the church in fulfilling the
mission of health ministry.
Parish nursing: a community-based and population-focused professional nursing
practice with faith communities to promote whole person health to its parishioners
usually focused on primary prevention.
Parish nurse coordinator: a parish nurse who has completed a certificate program
designed to develop the nurse as a coordinator of a parish nursing service.
Parish nurse services respond to health, healing, and wholeness within the context of the
church. Although the emphasis is on health promotion and disease prevention throughout
the life span, the spiritual dimension of nursing is central to the practice.
The parish nurse partners with the wellness committee and volunteers to plan programs
and consider health-related concerns within faith communities
To promote a caring faith community, usual functions of the parish nurse include personal
health counseling, health teaching, facilitating linkages and referrals to congregation and
community resources, advocating and encouraging support resources, and providing
pastoral care.
Parish nurses collaborate to plan, implement, and evaluate health promotion activities
considering the faith communitys beliefs, rituals, and polity. Healthy People 2010
guidelines are basic to the partnering for the programs.
Nurses working in the parish nursing specialty must seek to attain adequate educational
and skill preparation for the accountability to those served and to those who have
entrusted the nurse to serve
Nurses are encouraged to consider innovative approaches to creating caring communities.
These may be in congregations as parish nurses, among several faith communities in a
single locale, or regionally; or in partnership with other community agencies or models
such as block nursing.
To sustain oneself as a parish nurse healer, the nurse takes heed to heal and nurture self
while supporting individuals, families, and congregation communities in their healing
process.
Hospice: palliative system of health care for terminally ill people; takes place in the
home with family involvement under the direction and supervision of health
professionals, especially the visiting nurse. Hospice care takes place in the hospital when
severe complications of terminal illness occur or when family becomes exhausted or does
not fulfill commitments. A patient admitted into hospice usually is expected to die within
6 months. The care in hospice is palliative care for the dying patient.

Disaster Preparedness
Professional Preparedness

Requires nurses and other personnel to be aware of and understand the disaster
plans at their workplace and community- participate in mock drills

Adequately prepared nurses will function in leadership capacity and assist

towards smoother recovery phase

Fieldwork, shelter management requires creativeness and willingness

American Red Cross provides training for health professionals to adapt existing
skills to disaster setting
Role of Community Health Nurse

Can initiate or update disaster plans at workplace and community and ensure
education, drill participation

Knowledge of vulnerable populations, available community resources

Assessing and reporting of environmental hazards, unsafe equipment, faulty

structures, disease outbreaks, e.g., measles, flu
Before anything happens: Prepare for Safety in a Disaster: Four steps
1. Find out what could happen to you:
a. Determine what types of disasters are most likely to happen
b. Learn about warning signals in community
c. Ask about care for pets
d. Review the disaster plans at workplace, and other places where families
spend time together
e. Determine how to help the elderly or disabled
2. Create a disaster plan
a. Discuss types of disasters that are likely to happen and review what to do
b. Pick 2 types of places to meet
c. Choose an out-of-state friend to contact
d. Review evac. Plans
3. Complete this checklist
a. Post emergency numbers next to phone
b. Teach how to call 911
c. Determine when and how to turn off water, gas, and electricity
d. Check adequacy of insurance coverage
e. Locate and review use of fire extinguishers
f. Install and maintain smoke detectors
g. Conduct a home hazard hunt
h. Stock emergency supplies
i. CPR certification
j. Locate all escape routes
k. Find safe spots

4. Practice and maintain your plan

a. Review every 6 mos.
b. Conduct drills
c. Replace stored water every 3 mos. and stored food every 6 mos.
d. Test and recharge fire extinguisher
e. Test smoke detectors
Personal Preparedness
Nurses who are disaster victims themselves and provide care to others will experience
considerable stress.
American Red Cross and Federal Emergency Management Agency (FEMA) are two
well known authorities on disaster preparedness, response, and recovery
Three levels
1st level Personal Preparedness
2nd level- Professional Preparedness
3rd level- Community Preparedness
Most states and counties have an Office of Emergency Management (OEM) that is
responsible for developing and coordinating emergency response plans within their
defined area. The state office supports local OEMs and other state agencies that
participate in disaster response. It provides planning and training services to local
governments, including financial and technical assistance. During an actual
emergency or disaster, the state OEM coordinates a state response and recovery
program if necessary. County OEMs are in charge of creating a comprehensive, allhazard plan that should address realistic dangers to the community and list
available resources.
**Nurses need to review the disaster history of community, including how past
disasters have affected the health care delivery system, how their particular
organizations fit into the plan, and what role they and their organizations are
expected to play in a disaster.
Stages: Preparedness, Response, and Recovery
Preparedness: Know who is at risk, Personal, Professional and Community
Preparedness
Personal Preparedness

Entails plan for keeping oneself ready for disaster, both mentally and physically

Individuals not personally prepared will have less to give to family, community,
job, and other disaster victims

Nurses can be disaster victims- personal preparation needed to attend to patients

Checklist helpful to prepare

Professional Preparedness

Requires nurses and other personnel to be aware of and understand the disaster
plans at their workplace and community- participate in mock drills

Adequately prepared nurses will function in leadership capacity and assist

towards smoother recovery phase

Fieldwork, shelter management requires creativeness and willingness

American Red Cross provides training for health professionals to adapt existing
skills to disaster setting

American Red Cross: Founded in 1881 by Clara Barton

Different from FEMA or OEM because it is a nongovernmental

volunteer agency.

Manages blood service and bone marrow registry

Assist with military leaves

Provides disaster training for healthcare professionals

Takes part in disaster preparedness, response, and recovery.

Responsibilities during disaster: operates shelters, provides feeding

services, provides individual and family assistance, provides disaster
health services, handles inquiries from concerned families, coordinates
relief efforts with other agencies and the government, seeks contributions
Community Preparedness

Level of preparedness only as high as people/ organizations in the community

make it

Well-prepared communities have written disaster plans, conduct drills, have

adequate warning system, and backup evacuation plan

Office of Emergency Management- state/ county office coordinating regional

plans

Understanding past disasters can influence planning for future, liabilities in

resources
Response
The primary objective of disaster response is to minimize morbidity and mortality.
The level of disaster determines FEMAs response. Levels are not determined by the
number of casualties but by the amount of resources needed.
FEMA Levels of Disaster Response

Level III- a minor disaster, involves a minimal level of damage but could result in
the president declaring an emergency. A minimal request for federal help

Level II- moderate disaster- likely to result in major disaster being declared.
Regional federal resources engaged, other outside area may be called on

Level I- massive disaster, severe damage or multistate scope. Full engagement of

federal regional and national resources

Citizens and health professionals must be attached to official agencies with

disaster management responsibilities to avoid further risk

American Red Cross

3 ways to classify a disaster:

Type- agent that caused the event, such as hurricane, hazmat, transportation

Level- anticipated or actual Red Cross response and relief costs

Level I. costs less than $10,000
Level II costs $10,000 or more, but less than $50,000
Level II costs $50,000 or more, but less than $250,000
Level IV costs $250,000 or more but less than $2.5 million
Level V costs $2.5 million or more

Scope- magnitude of the event, units affected and responding ,e.g., single-family,
local, state, major, federally declared
Single family affects an individual or single family- occurs within the
jurisdiction of a single Red Cross chapter
Local Disaster- Affects more than one family, occurs within the jurisdiction of a
single Red Cross chapter
State Disaster- Affects multiple families, occurs within the jurisdiction of one or
More Red Cross chapters within a single state
Major Disaster- has one or more of the following characteristics
-coordinated response of multiple Red Cross units
- affects more than a single state
- creates national news
- result in emergency or disaster declaration by the President etc.

Presidentially Declared Disaster- requires full or partial implementation of the

National Response Plan

The National Response Plan

Once a federal emergency has been declared, the National Response Plan may take effect,
depending on specific needs arising from the disaster. The NRP is a concerted effort to
prevent terrorist attacks within the US; reduce Americans vulnerability to terrorism,
major disasters, and other emergencies; and minimize the damage and recover from
attacks, major disasters, and other emergencies that occur.
Role of the Nurse

Role in disaster response depends on nurses past experience, role in community

disaster preparedness, specialized training, special interest

Community health nurses valued for skills in community assessment, case

finding, prevention, education, surveillance, working with aggregates

Plans for triage must begin as soon as rescue workers arrive- highest priority
given to life-threatening injuries with high probability of survival- nurses accurate
assessment info will help match available resources to populations emergency needs.

Recovery
The recovery stage of disaster occurs as all involved agencies pull together to restore the
economic and civic life of the community. For example: the government takes the lead
in rebuilding efforts whereas the business community tries to provide economic support.
Nurses Role in Recovery

Multifaceted responsibilities- flexibility required to assist in successful

recovery

Teaching health promotion, disease prevention, assessment of physical,

psychological problems incurred in cleanup efforts, as well as threat of
communicable disease

Case finding, referral for mental distress

Assessment and reporting of environmental health hazards resulting from

event
Get community back to normal, deal with emotional matters and after effects
Assess what might be going on in community using primary, secondary and tertiary care
Terrorism
Role of the Nurse:

Help people cope with the aftermath of terrorism

Allay public concerns and fears of bioterrorism

Identify the feelings that you and others may be experiencing

Assist victims to think positively and move to the future

Prepare nursing personnel to be effective in a crisis situation

Nurses are concerned with Anthrax, Smallpox, Botulism, brucellosis, pneumonic plague
and Ricin and should have awareness of these bioterrorism agents. You need to review
the biological agents and review how anthrax exposure can occur from your textbook
outside of a biological attack. Pneumonic plague and Smallpox are transmitted from
person to person vial respiratory or inhalation exposure.
Anthrax: -cutaneous: first symptom is sore throat that develops into a blister. Blister then
develops into a skin ulcer with a black area in the center. The sore, ulcer and blister do
not hurt.
- GI: the first symptoms are nausea, loss of appetite, bloody diarrhea, and fever
followed by bad stomach pain.

Inhalation: first symptoms are cold or flu like symptoms and can include a sore
throat, mild fever and muscle aches. Later symptoms include cough, chest
discomfort, SOB, tiredness, and muscle aches.
- Exposed, but not infected: Antibiotics (Cipro, levofloxacin, doxycycline, or
penicillin) combined with the Anthrax vaccine.
- Exposed and have infection: 60 day course of antibiotics
- Cutaneous, if left untreated, 80% recover. GI is more serious; more than half die.
Inhalation is much more severe.
Smallpox: Variola virus
- transmission is direct, face-to-face, and prolonged. Can also be airborne.
- S/S: high fever, fatigue, severe headache, rash that turns to pus-filled lesions,
vomiting, delirium, excessive bleeding
- Treatment: no cure, just supportive care (hydration, pain meds, antipyretics).
- Prevention: vaccine provides 10-year immunity, but it is not really provided
anymore since smallpox has been eradicated.
- The discovery of a single case of smallpox would be an international health
emergency (Department of Homeland Security would be involved)
Botulism: spread from contaminated food
Brucellosis: comes from livestock or something
Pneumonic plague: airborne and can be spread person to person
Ricin: airborne poison. Cannot be spread person to person. Requires an antitoxin, but
there isnt one yet, so treatment would just be supportive care until one is available.
Need to have vaccine for small pox when exposed as a health care provider.

Levels of prevention r/t Disaster Management

Primary Prevention- Participate in developing a disaster management plan for the
community
Secondary Prevention- Assess disaster victims and triage for care
Tertiary Prevention- Participate in home visits to uncover dangers that may cause
additional injury to victim or cause other already harmed
Population at Greatest Risk for Disruption After a Disaster
Persons with disabilities
Persons living on a low income, including the homeless
Non-English speaking persons and refugees
Persons living alone
Single-parent families
Persons new to the area
Institutionalized persons or those with chronic mental illness
Previous disaster victims or victims of traumatic events
People who are not citizens or legally documented immigrants

Substance abusers
The five components to a comprehensive public health response to outbreaks of illness
are the following
- Detecting the outbreak
- Determining the cause
- Identifying factors that place people at risk
- Implementing measures to control the outbreak
- Informing the medical and public communities about treatments, health
consequences, and preventative measures
Triage: the process of separating casualties and allocating treatment on the basis of the
victims potentials for survival.
- Highest priority is always given to victims who have life threatening injuries but
who have a high probability of survival once stabilized
- Second priority is given to victims with injures that have systemic complications
that are not yet life threatening and could wait 45 60 minutes for treatment
- Last priority is given to those victims with local injuries without immediate
complications and who can wait several hours for medical attention.

Review the triage color system

Assess using the 1-minute guideline: 1st check for respirations, 2nd check perfusion
by pinching the nail beds and assessing reaction, 3rd check mental status by asking
simple questions like, Who are you?
Green (delayed): Injured or ill but stable and not likely to deteriorate if treatment is
delayed 2 hours or more. Commonly referred to as walking wounded. Walking,
respirations <30, cap refill <2s, able to follow commands. (Ex- minor injuries, strain
or sprain)
Yellow (urgent): Acute problem and stable, but may deteriorate. Requires treatment
within 20 min-2hrs. (Ex-open fractures, chest wound).
Red (critical): Unstable with acute problem. Immediate intervention is likely to save
life or limb. Life threatening, transport immediately. RR >30, cap refill >2s, doesnt
obey commands. (Ex- compromised airway, shock, hemorrhage).
Black (expectant): dead or unsalvageable given the available resources. Low priority
transport. (Ex- massive head injury, extensive full thickness burns).

Rationale from Saunders

In an emergency department, triage is classifying clients according to their need for care
and includes establishing priorities of care. The kind of illness, the severity of the
problem, and the resources available govern the process. Clients with trauma, chest pain,
severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits,
and those who sustained chemical splashes to the eyes are classified as emergent and are
the number 1 priority. Remember the client must be able to survive.

Clients with conditions such as a simple fracture, asthma without respiratory distress,
fever, hypertension, abdominal pain, or the client with a renal stone have urgent needs
and are classified as number 2 priorities.
Clients with conditions such as a minor laceration, sprain, or cold symptoms are
classified as non-urgent and are the number 3 priority.
Older adult health risks
Nutrition, safety, social isolation, and depression
Need to assess the health literacy of the client first before we teach
Program outcomes: smoking cessation, weight management, diabetic management
- look at the evaluation of the specific outcome
- Identifying changes in the clients health status that result from nursing care
provides nursing data that demonstrate the contribution of nursing to the health
care delivery system.
- Outcome evaluation is a change in a clients health status as a result of program
implementation.
Research studies using the tracer or sentinel method to identify clients outcomes and
client satisfaction surveys can be used to measure outcome standards.
From data, strengths and weaknesses in nursing care delivery can be determined.
The most common measurement methods are direct physical observations and
interviews.
Primary Care- refers to organized community efforts designed to prevent disease and
promote health (education).
Secondary Care- an intermediate level of health care that includes diagnosis and
treatment. Screening.
Tertiary Care- rehabilitation and return of a patient to a status of maximum usefulness
and a minimum risk of recurrence of a physical or mental disorder
Levels of Prevention
Primary Prevention- Counsel clients in health behaviors related to lifestyle
Secondary Prevention- Implement a family-planning program to prevent unintended
pregnancies.
Tertiary Prevention- Provide a self-management asthma program for children with
chronic asthma to reduce their need for hospitalization (prevent from getting worse)

Federal Agencies
Many federal agencies are involved in government health care functions. The agency
most directly involved with the health and welfare of Americans is the U.S. Department
of Health and Human Services

U.S. Department of Health and Human Services (USDHHS)

Largest health program in the world, its mission is to enhance the health and well-being
of the American people through the following:
- Alcohol, drug abuse, and mental health programs
- Disease tracking and identification
- Health care access for all and integrity of the nations health entitlement and
safety net programs
- Identification and correction of health hazards
- Medical assistance after disasters
- Medical research
- Promotion of exercise and healthy habits
- Protection of the nations food and drug supply
The Health Resources and Services Administration of the USDHHS contains the Bureau
of Health Professions, this bureau includes separate divisions for nursing, medicine,
dentistry, public health, and allied health professions
The Division of Nursing administers nurse education legislation, interprets trends and
nursing needs of the nations health care delivery system, and serves as a liaison with the
nursing community and with international, state, regional, and local health interests
Two other agencies with the DHHS:
The National Institute for Nursing Research (NINR) and Healthcare Research and
Quality (AHRQ)
This institution is the focal point of the nations nursing research activities. It promotes
the growth and quality of research in nursing and patient care, provides important
leadership, expands the pool of experienced nurse researchers, and serves as a point of
interaction with other bases of health care research
Nurses can apply for support for research, projects, or training from a variety of agencies
within the federal government besides the NINR of the Division of Nursing.
Other federal agencies: Dept. of Commerce, Dept. of Defense, Dept. of Labor (includes
OSHA), Dept. of Agriculture (includes WIC), Dept. of Justice, Food and Drug
Administration.
Review the role of the CDC: CDC works 24/7 to protect America from health, safety and
security threats, both foreign and in the U.S. Whether diseases start at home or abroad,

are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights
disease and supports communities and citizens to do the same.
CDC increases the health security of our nation. As the nations health protection agency,
CDC saves lives and protects people from health threats. To accomplish our mission,
CDC conducts critical science and provides health information that protects our nation
against expensive and dangerous health threats, and responds when these arise.

Review Medicare part A, B and D and Medicaid Social Security Act of 1965!!
-Medicare part A provides payment for hospital services, home health services, and
extended care facilities (98% of elderly covered)
-Medicare part B is available to all people who wish to pay a monthly premium for the
coverage. About 96% of elderly are covered. Provides coverage for services other than
hospitalizations such as physician care, lab, equipment, and ambulance services.
-Medicare part D covers prescription medication. There are different options and costs for
part D coverage.
-Medicaid: Provides financial assistance to states and counties to pay for medical services
for the aged poor, the blind, the disabled, and families with dependent children. The
medical indigent is required to pay a monthly premium.
Voluntary and Private Nonprofit Agencies
Voluntary and private agencies are grouped together as nonprofit home health agencies;
voluntary agencies are supported by charities such as United Way, Medicare, Medicaid,
other third-party payers, and client payment.
The amount of financial assistance the voluntary agency receives depends on the
community it serves. With Medicare, the private nonprofit agency emerged as an
alternative agency to the public-supported program. These agencies included
rehabilitation agencies, based in either rehabilitation facilities or skilled facilities.
Nurses use assessment skills to detect potential and actual exposure pathways and
outcomes for clients cared for in the acute, chronic, and healthy communities of practice.
Risk communication is an important skill and must acknowledge the outrage factor
experienced by communities with environmental hazards.
Vulnerable populations- are those groups who have an increased risk to develop adverse
health outcomes, vulnerable populations often experience multiple cumulative risks and
they are particularly sensitive to the effects of those risks.
Vulnerable populations often are more likely than the general populations to suffer from
health disparities.
Examples of areas that show health disparities across populations groups are infant
mortality, childhood immunization rates, and disease-specific mortality rates.

Vulnerable Population Groups of Special Concern to Nurses

- Poor and homeless people
- Pregnant adolescents
- Migrant workers and immigrants (will need immunizations and screening for TB)
- Severely mentally ill individuals
- Substance abusers
- Abused individuals and victims of violence
- Persons with communicable disease and those at risk
- Persons who are human immunodeficiency virus (HIV positive) or have Hep B or
sexually transmitted disease.
Behavioral (Lifestyle) Health Risk Assessment
Families are the major source of factors that can promote or inhibit positive lifestyles. It
is important to look at risks for the family as a unit.
Critical dimensions of lifestyle risks include the following:
- Value placed on behavior
- Knowledge of the behavior and its consequences
- Effect of the behavior on the family
- Effect of the behavior on the individual
- Barriers to performing the behavior
- Benefits of the behavior
It is important to assess the frequency, intensity, and regularity of specific behaviors. It
also is important to evaluate the resources available to the family for implementing the
behaviors.
Transtheoretical Change Theory-belief that people are in a stage of willingness to
change. Behavior changes like exercise, wearing seatbelts or helmets are personal
decision and cannot be forced. The community health nurse educates the client in hopes
of moving them from not engaging in a healthy behavior to at least considering doing it
in the next 6 months.
Modifiable Risk and Unmodifiable Risks
Risk factors that are "unmodifiable," are things that neither you nor your patients can do
anything about. You need to know the "unmodifiable" risk factors, because they help you
to define high-risk individuals and groups for whom treating or controlling the
"modifiable" risk factors is a priority.
If a question has modifiable risk factors and non-modifiable risk factors as choices, pick
the non-modifiable one.
Modifiable risks can be changed such as smoking.
Epidemiology how to calculate a rate

The denominator includes the numerator

Example: Crude birth rate

Attack Rate:

Number of live births during 1 year X1000

Midyear population
# of people exposed & developed disease
Population at risk

** Expressed in %
Evaluating Outcomes
Outcomes can be measured by looking at changes from before and after the intervention
to solve the problems. Changes in the following can be used to see the outcomes of the
interventions:
- Demographics
- Socioeconomic factors
- Environmental factors
- Individual and community health status
- Use of health services
In the example of infant malnutrition, one would look for the number of cases of infant
malnutrition in the community before providing education to other health providers about
assessment of infant development. A time period for evaluation would be chosen and
perhaps 1 year later (the time frame). The number of cases of infant malnutrition would
be measured to see if a change had occurred and there were fewer cases.
Incidence rate- the frequency or rate of new cases of an outcome in a populations;
provides an estimate of the risk of disease in that population over the period of
observation
Formula = # of new cases
Pop. At risk
** Population at risk is the total population minus the existing cases
**Expressed per 10,000
Prevalence: number of existing cases in a population at a given time
Formula = # of existing cases
Total population
** Expressed per 100,000
Nursing Process- Always assess before starting an intervention
Community assessment
Most nurses are familiar with the nursing process as it applies to individually
focused nursing care. Using it to promote community health makes this same
nursing process community focused.

Community assessment- the process of critically thinking about the community and
involves getting to know and understand the community as partner. The community
assessment phase involves a logical, systematic approach to the initial phase of the
nursing process. Community assessment helps as follows:
- To identify community needs
- To clarify problems
- To identify strengths and resources
Assessing the community health requires the following three steps:
- Gathering relevant existing data and generating missing data
- Developing a composite database
- Interpreting the composite database to identify community problems and strengths
Data Collection and Interpretation
The primary goal of data collection is to get usable information about the community and
its health. The systematic collection of data about community health requires the
following:
- Gathering or compiling existing data
- Generating missing data
- Interpretation of data
- Identifying community health problems and community abilities
Data gathering is the process of obtaining existing, readily available data. The following
data usually describe the demography of a community
- Age of residents
- Gender distribution of residents
- Socioeconomic characteristics
- Racial distributions
- Vital statistics, including selected mortality and morbidity data
Identify needs, problems, strengths, and resources and apply what you know.
Windshield surveys- are the motorized equivalent of simple observation. They involve
the collection of data that will help define the community, the trends, stability, and
changes that will affect the health of the community
School Nurse:
- Primary -The school nurse monitors the children for all of their state-mandated
immunizations for school entry.
- Secondary- School nurse is involved in screening children for illnesses and
providing direct nursing care
- Tertiary The school nurse cares for children with long-term health needs,
including asthma and disabling conditions

School nurses carry out catheterizations, suctioning, gastrostomy tube feedings, and other
skills in school.
The concern for health promotion of adolescents is safety because of their propensity to
take part in risky behavior.
***To effectively reach a population group you must connect with someone in the
community and establish trust.
Occupational Exposure
Job categories
Exposure
Farm workers
pesticides, infectious
Agents, gases, sunlight
Chemical workers

solvents, cleansers, etc.

Work-related diseases and conditions

HTN, mood disorders, cardiovascular
disease
Cancer, etc.

*Review the list on page 610 textbook*

Medicare
Provides hospital insurance and medical insurance to persons ages 65 years and older,
permanently disabled persons, and persons with end-stage renal failure
Part A covers: hospital care and home care (home care or hospice cant have both),
skilled nursing care
Part B- covers: (non-institutional care insurance) Medical care, diagnostic services and
physiotherapy.
To obtain payment for Medicare services, a documentation of skilled care service must
be done during the visit.
Medicaid- Financial assistance to states and counties to pay for medical services for poor
older adults, the blind, the disabled, and families with dependent children.

**Public Assistance ProgramsWIC- a special supplemental food program administered by the Department of
Agriculture through the state health departments; provides nutritious food that add to the
diets of pregnant and nursing women, infants, and children younger than 5 years.
Eligibility is based on income and nutritional risk as determined by a health professional.
**Total Quality Management
**Continuous Quality Improvement
**Workplace policies provide certainty for staff and employees as to what behavior
and conduct is appropriate in the workplace.
The Quality Assurance Committee reviews and plans policies and education about
safety in the work place.

Outreach worker: a health worker who makes a special, focused effort to find people
with specific health problems for the purpose of increasing their access to health services
-evaluate effectiveness find out if successful and use ways to measure success
Epidemiology- attempts to link the agent to the disease or conditions.
Epidemiologic triangle (or epidemiological triad) agent, host, and environment
changes in one of the elements of the triangle can influence the occurrence of disease by
increasing or decreasing a persons risk for disease. Risk is the probability that an
individual will experience an event.
- Agent: an animate or inanimate factor that must be present or lacking for a
disease or condition to develop. The toxic substance or environmental factors.
example: E. coli
- Infectious agents (bacteria, viruses, fungi, parasites)
- Chemical agents (heavy metal, toxic chemicals, pesticides)
- Physical agents (radiation, heat, cold, machinery)
Host: a living species (human or animal) capable of being infected or affected by an
agent. Host can also be viewed as a susceptible person or population.
- anything capable of being infected
- Genetic susceptibility
- Immutable characteristics (age, sex)
- Acquired characteristics (immunologic status)
- Lifestyle factors (diet, exercise)
Environment- all that is internal or external to a given host or agent and that is
influenced and influences the host and/or agent. Environmental factors are associated
with disease development.
-

anything external
climate (temperature, rainfall)
Plant and animal life (agents or reservoirs or habitats for agents)
Human population distribution (crowding, social support)
Socioeconomic factors (education, resources, access to care)
Working conditions (levels of stress, noise, satisfaction)

Relationship between the above 3 cause disease, try to break the connection, if a
break then there will be no disease.
Web of Causality- complex interrelations of factors interacting with each other to
influence the risk for or distribution outcomes.
- recognizes the complex interrelationships of many factors interacting, sometimes
in subtle ways, to increase (or decrease) the risk of disease.
- Associations are sometimes mutual, with lines of causality going in both
directions

Includes phenotype, social organization, behavior, environment, workplace,

unknown factors, genes, and microbes

Family assessment
Ecomap- represents the familys interactions with other groups and organizations,
accomplished by using a series of circles and lines.
- It is represented by a circle in the middle of the page
- Other groups and organizations are then indicated by circles
- Lines representing the flow of energy are drawn between the family circle and the
circles representing other groups and organizations
- An arrowhead at the end of each line indicates the direction of the flow of energy
(into or out of the family)
- The weight of the line indicates the intensity of the energy
Genogram- is a pictorial display of a person's family relationships and medical history. It
goes beyond a traditional family tree by allowing the user to visualize hereditary patterns
and psychological factors that punctuate relationships. It can be used to identify repetitive
patterns of behavior and to recognize hereditary tendencies. It is a tool to determine
clients risk factors for developing disease and to focus health promotion efforts. Also,
violence and abusive tendencies can be traced back over generations and nurses can help
clients to break these patterns.
Prevention Strategies for Violence
Individual and Family levels
- Assess during routine examination (secondary)
- Assess for marital discord (secondary)
- Educate on developmental stages and needs of children (primary)
- Counsel for at-risk parents (secondary)
- Teach parenting techniques (primary)
- Assist with controlling anger (secondary)
- Treat for substance abuse (tertiary)
- Teach stress-reduction techniques (primary)
Community Level
- Develop policy
- Conduct community resource mapping
- Collaborate with community to develop systematic response to violence
- Develop media campaign
- Develop resources such as transition housing and shelters
High school students and middle school students- important to steer them away
from violence and teach them to work on their own skills and build their self-esteem.
Further Review

Review care if the dying patient with emphasis on grief, depression and legal and ethical
issues.
Review signs and symptoms of Hepatitis A, B, C and know how they are transmitted.
Newborns are at risk for Hep B from an infected mother.
Hepatitis A: Person to person, fecal oral route, contaminated food, water, shellfish.
General population is at risk. Probable immunity following infection. Eliminate common
sources of infection by sanitation. Administer vaccine and IG within 2 weeks of
exposure. Use universal precautions. S/S: acute fever, anorexia, malaise, dark urine,
jaundice usually lasting 2 months. Low fatality rate, but can last up to 6 months.
Treatment is supportive care.
Hepatitis B: Highest in young adults, homosexual men, persons engaging in unprotected
sex, injection drug users, health care and public safety workers. Direct and indirect
contact with blood and serum-derived fluids, sexual contact, perinatal. Routinely
immunize infants, children, and high-risk groups. Practice safe sex, use universal
precautions, screen all donated blood and blood products. Mom can pass to baby. S/S:
insidious onset and nonspecific symptoms, anorexia, N/V, jaundice, sometimes fatal
hepatitis. Treatment is supportive care.
Hepatitis C: directly related to prevalence of injection drug use in the population, HCV
in donated blood supply, and lack of use of parenteral precautions in health care. Sexual
and mother-to-child transmission are unlikely. No vaccine exists. S/S: insidious onset,
symptoms vary from asymptomatic (80%) to fulminating, fatal disease. Treatment with
ribavirin and slow release interferons (pegylated interferons).
Role of case manager
Risks for developing community acquired pneumonia: very old and very young, crowded
places
The nurse focusing on a community health project based on a report from the WHO
would focus on number of people without access to health care.
Review MMR and other vaccines
Review poisoning from asbestos (lung cancer/respiratory issues, workplace/mold
exposure), silica dust (occupational- coal mining. Dust is inhaled and causes nodules and
inflammation in upper lobes of lungs), histoplasmosis (bat droppings), and carbon
monoxide (colorless, odorless, tasteless; emitted by burning gasoline, kerosene, propane
and charcoal; CO takes the place where oxygen is supposed to bind on RBCs) and
anthrax
Meals on Wheels
Lillian Wald was very important in the history of nursing.
Developed public health nursing practice Started the Henry Street Settlement

The Henry Street Settlement provided care to immigrants

Established the first nursing service of occupational health
Established the committee that was the forerunner of the NLN
Instituted a sliding scale fee for service
Additional Info From Power Points
-A childs life expectancy is predicted more by his zip code than genetic code
-SMART objectives: Specific as possible; measurable; achievable; relevant to the goals,
needs and interests of the community; time frame
-Two levels of evaluation:
-Formative: is instituted for the purpose of assessing the degree to which
objectives are met or planned activities are conducted. This is done along the way.
-Summative: is instituted to assess program outcomes or as a follow-up of the
results of program activities. This is what you do at the end of a program to
determine if it worked overall.
Stages of Change:
-Precontemplation: no intention to take action within the next 6 months.
-Contemplation: intends to take action within the next 6 months.
-Preparation: intends to take action within the next 30 days and has taken some
behavioral steps in this direction.
-Action: changed overt behavior for less than 6 months
-Maintenance: changed overt behavior for more than 6 months
-Asthma is the most common chronic illness for children. The most common cause is
second-hand smoke exposure.
-Poverty is the greatest threat to child health. (access to care, nutrition, safe environment)
-Medicaid is important to children. They can begin receiving care in infancy and
participate in EPSDT.
-Functional definition of aging is better measure of age than chronological age.
-Nursing care for older adults focuses on helping them to remain independent and
functional. Healthy People 2020 seeks to increase quality and years of healthy life.
-Theories of Aging:
-Stochastic: random, accumulate over time
-Error theory: accumulation of errors in protein synthesis results in
impaired cellular function
-Somatic mutation theory: when cells are exposed to x-ray radiation of
chemicals, alteration of DNA occurs.
-Free radical theory: highly reactive molecules possess an extra electric
charge (free electron) that can cause damage. The body produces
antioxidants to scavenge these free radicals.
-Cross-link theory: aging causes body chemicals to become cross-linked.
Abnormal activity develops, causing waste products to accumulate in
cells.
-Wear and tear theory: human body eventually wears out.
-Nonstochastic: predetermined
-Programmed theory: cells divide only a certain number of times, which is
proportionate to the life span.

-Immunologic theory: Alteration of B and T cells occurs. Autoaggression

(Cells are not identified by the body and are attacked by the immune
system).
-In 1850 the Shattuck Report proposed that health education was a vital component in the
prevention of disease (part of school health nursing). It is a fundamental document that is
still used today. Lillian Wald was able to show that the presence of school nurses could
reduce absenteeism by 50%.
-1893: Ada Mayo Stewart was the first industrial nurse at the Vermont Marble
Company. Betty Molder was a nurse for the coal mining company in 1888.
-For the elderly client:
-Always check bowel and bladder!
-Not all opiates are equal (dosage will need to be adjusted)
-Fentanyl patch= no heat!
-If they have nausea/vomiting caused by cancer/chemo, use Haldol.
-If SOB, cool the room and move air with a fan.
-Prevention in Disasters:
-Primary prevention:
-Aimed at preventing the occurrence of a disaster or limiting the
consequences (mitigation).
-Occurs in nondisaster and predisaster stages.
-Secondary prevention
-Include search, rescue, and triage of victims
-Assessment of destruction and devastation
-Implemented once the disaster occurs
-Tertiary prevention
-Focuses on recovery and restoring the community to previous levels of
functioning.
-Aimed at preventing a recurrence of minimizing the effects of future
disasters.
-Triage is the process of separating casualties and allocating treatment based on the
victims potential for SURVIAL!
-START triage system: Simple triage and rapid treatment
-Used in mass casualties
-To occur in less than one minute
-Uses people with minor injuries to assist
-Person is tagged with a colored triage tag and victims are moved to the
treatment area
-Bioterrorism agents can be easily disseminated or transmitted from person to person.
They result in high mortality rates and have the potential for major public health impact.
It might cause public panic and social disruption and require special attention for public
health preparedness. Detecting the outbreak is the most crucial aspect in minimizing
damage from the attack (and determining the cause).
-History of Environmental Health:
-Florence Nightingale: cleaned environment and reduced infection during the
Crimean War

-Mary Brewster worked to improve the environment of the Henry Street

neighborhood and aimed to improve physical environment and social conditions
that affected health. She helped Lillian Wald.
-Lead:
-remains in the body for decades (stored in the bone)
-interferes with RBC production (may present with anemia)
-May cause damage to the brain, liver, and other vital organs.
-BLL >5 is considered abnormal. There is no safe level; even low levels can cause
neurological damage
-Common symptoms: vomiting, intermittent abdominal cramps, headaches,
irritability, weakness, and constipation
-Blacks experience more environmental lead exposure than whites
-4.4% of child <5 have blood levels high enough to cause declining intelligence
and this figure doubles for children in poverty
-Need to increase iron, calcium, and vitamin C in their diet (nurse cannot change a
childs environment, so recommend dietary changes)
-IPV: identify high-risk situations; give safety plans and community resources
-John Snow is the father of epidemiology
-Calculation of rates: rates are arithmetic expressions that help practitioners consider a
count of an event relative to the size of the population from which it is extracted
-Incidence rate is better applied to acute disease and outbreaks, while prevalence rates are
better applied to the study of chronic disease.
-Screening: secondary prevention
-Reliability: how precise is the measurement? Is it consistent and repeatable? Do
you get the same measure every time?
-Validity: is the measurement really measuring what we think it is? Exactly how?
-Evaluated by sensitivity and specificity
-Framingham Heart Study: study by the United States Public Health Service on factors
related to the development of heart disease. Done by a town in Connecticut that followed
people every year and collected data that helped define the cardiovascular risk factors. It
has now expanded to include diabetes, HTN, and other chronic diseases. It is the largest
public health surveillance study post WWII. Infectious disease is now moving toward
cardiovascular risk.
-Spectrum of infection: not all contact with an infectious agent leads to infection; not all
infection leads to an infectious disease.
-Subclinical infection: no overt symptomatic disease
-Infections: entry and multiplication of infectious agent in host
-Infectious disease and communicable disease: pathophysiological responses of
the host to the infectious agent, manifesting as an illness (considered a case)
-Carriers: people who continue to shed infectious agent without any symptoms of
disease
-Vector transmission: occurs when an infectious agent is carried by a vector (non human
carrier such as an animal or an insect). Indirect transmission.
-Lyme disease:
-Most at risk: people who live, work, or play in wooded areas

-S/S: red, circular rash at site of bite. Clear center with bulls-eye pattern.
Tiredness, fever, chills, joint pain, muscle aches, headache, stiff neck, and swollen
lymph nodes
-Prevention: use an insect repellant when in tick-infested areas; keep arms and
legs covered; wear high rubber boots because ticks are usually found close to
ground; tuck shirt into pants and pants into socks or boots; wear a hat and keep
long hair pulled back; shower and wash clothing after being in tick-infested areas;
inspect skin and hair once inside
-Treatment: few weeks of antibiotics. If untreated, can affect joints, heart, and
nervous system.
-Anthrax is often transmitted through drum circles (animal skin). This can cause the GI
form.
-Sheppard Towner Act: the law that has had the most significant impact on public health
policy, community health nursing, and social welfare policy in the US. This act made
nurses available to provide services for women and children, offered well-child
development services, provided adequate hospital services and facilities for women and
children, and provided grants-in-aid for the establishment of maternal and child welfare
programs.