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 another. 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. 3

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 community 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.
9

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)

10

Healthy People 2010

2 Goals:

Increase quality and years of healthy life Eliminate health disparities

28 Focus Areas 467 specific objectives covering all ages

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Healthy People 2010

Steps/Goals

Reducing the Burden of Disease

Obesity Diabetes Asthma Cancer Heart

Disease and Stroke

12

Healthy People 2010

Addressing Risk Factors

Physical Inactivity Poor Nutrition Tobacco Use Youth Risk Taking

13

Steps to a Healthier US

The Presidents Health and Fitness Initiative

Created by Presidential Executive Order June 2002

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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
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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 Administration

16

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
17

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 exposure Determines the risk for environmental disasters Sets policy Enforces laws that provide a safe supply of water and food
18

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 Officer

19

Community Health Assessment

A

systematic way to determine the health status, resources or needs of a population. health requires a populationbased approach with attention given to the economic, social and political environments of the community as they impact a communitys health.
20

Community

Steps of the Population-based Approach

1. Epidemiological research The first step is to gather health data about the community, analyze the data and then develop a plan. 2. 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.
21

Steps of the Population-based Approach

3. 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. 4. Evaluation A systematic inquiry to determine if the program followed its plan and met its goals.
22

Gathering Data: Epidemiology

Concerns of epidemiology include accidents, suicide, climate, toxic agents such as lead, air pollution and catastrophes due to ionizing radiation. 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.

23

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 environment

24

Epidemic vs. Pandemic

Epidemic = excessively communicable, contagious, disseminated, prevalent or widespread. 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.

25

Roles and Settings for Community-Based Nursing

Individuals Families Groups General community

School & rural nursing Public health Home health Camp nurse Parish nurse Occupation health nurse
26

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.
27

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)
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CHN Practice

Builds caring relationships with families and communities. 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 cooperation). Understands and works with diversity and differences. Focuses on populations or subpopulations rather than individual-based practice.
29

CHN Practice
(continued)

Focuses on wellness, not sickness. Focuses on prevention, not just treatment of problems. 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.

30

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.

31

CHN Practice
(continued)

CHN recognizes health as a state of complete physical, mental and social wellbeing and not merely the absence of disease and infirmity. (W.H.O.) Holistic focus; works with clients along the Wellness/Illness continuum.

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The Illness/Wellness Continuum

Photo Source: courtesy of Eastern Michigan University, http://www.emunix.emich.edu/~bogle/wellness%20continuum.jpg

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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.

34

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

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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.

36

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 healthpromoting environment: In the home In schools In public places In the workplace Includes good nutrition, adequate clothing, shelter, rest and recreation. Health education.
37

Primary Prevention

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

Promotes changes in lifestyle through behavioral therapies to those areas that represent major health risks:

(continued)

Smoking Obesity Sedentary life-styles Improper diet Alcohol and drug abuse Sexual promiscuity Not practicing safe sex Falls Preventing automobile accidents

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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
40

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

41

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
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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 diseases.

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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.

44

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 therapy. 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.

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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.

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The CHNs Role

To promote health and healthy behaviour in the community To act as a health resource person for the community

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The CHNs Role

(continued)

To identify health issues which may impact the well-being of individuals, families, groups and communities. To refer identified health issues to appropriate agencies and ensure that co-ordination of care occurs.

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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
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Infection Control from a Community Health Perspective

Modes of defence against infection:
Natural immunity Artificial immunity Active/Passive Altering the environment

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Issue of Immunity

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

1. 2. 3. 4. Source - initiator (person, animal, food, water) Reservoir - storage place and exit from source Agent - causes and effect (bacteria, virus, spirochete, etc.) 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
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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

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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
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Modes of Transmission
(continued)

Vector
External mechanical transfer (flies) Internal transmission: Mosquito - malaria Ticks - Lymess disease

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

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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 indicated Tertiary prevention - educate to prevent complications; teach side effects of therapy and prevent spread of disease

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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.
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TB Outbreak in the Community

(continued)

California law mandates the immediate reporting of outbreaks by telephone to local county health departments. 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 setting 2 or more linked cases in a vulnerable population 2 or more linked multi-drug resistant TB cases
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TB Outbreak in the Community

(continued)

For more information please refer to: Tuberculosis Outbreak Response Team World Wide Web: http://www.dhs.ca.gov/ps/dcdc/TBCB/reso urces/Outbreak%20Response%20Team%20 Fact%20Sheet.pdf

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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.
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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 bacteria Antimicrobial soaps Antiseptics Disinfectants
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Clients Healthy Environment

(continued)

Standard precautions: Use generic barrier techniques:

CDC

guidelines Blood & body fluid precautions Laundry Waste disposal Protective equipment

Hand

washing most important to prevent transmission of infection.

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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.
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Clients Healthy Environment

(continued)

Care concerned with promoting safety which is individualized, based upon: Developmental stage Lifestyle Environment

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Immunizations

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.

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Immunization Recommendations

CDC guidelines available at www.cdc.gov 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

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Home Safety
Leading cause of accidental death in the home is due to falls. Other accidental deaths include:

Poisonings Fires Burns Drowning Firearm accidents

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Assessment: Environmental Hazards in Homes and Community

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
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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.
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Disease Prevalence in Different Populations (continued)

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 populations. African-Americans have a higher incidence of colorectal cancer as compared with Caucasian populations.
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Diversity, Ethnicity and Culture

Diverse populations are different. Ethnicity is cultural differences based on heritage. 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 time.
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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
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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 practices. Be careful to use culturally sensitive language.

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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 interventions. Demonstrate respect for client and significant others. Demonstrate respect for a patients health values, practices and beliefs.

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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 safety. Teen: Auto accident & substance abuse, abstinence & unsafe sexual practices, seat belt use, helmet and safety gear use, smoking, drugs and violence.
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Health Issues by Developmental Stages

(continued)

Adult: Lifestyle habits

Smoking Obesity Exercise Motor vehicle accidents Drug Abuse Alcohol Abuse

Elderly: Physiologic changes of aging

Falls Elder abuse

Burns Auto Accidents

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Barriers to Prenatal Care

Socio demographics Insurance/financial issues Inadequate number of healthcare providers for low income Childcare unavailable Long wait for care Cultural considerations Transportation issues Attitudes regarding care
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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?

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Infant Car Safety

1. Front seat facing forward.

2. Back seat facing forward.

3. Front seat facing backward.

4. Back seat facing backward.

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Child Health Case Study

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

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Child Health Case Study

(continued)

There are abandoned cars in the empty lot next to their home. The childs health record indicates that his preschool 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.
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Questions for case study: What might be a possible reason for the childs problems?
What counseling and education would the nurse provide for the mother and child?
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Preparing for the Worst

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Types of Biological Warfare

Anthrax - bacilli causing cutaneous or pneumonia Botulism toxin - bacilli causing nerve damage and paralysis Plague - rat flea vector with high death rate Tularemia - tick, bloodsucking insect or infected waterplague-like infection Q fever - bacterium from inhaling dust and unpasteurized milk Smallpox - viral airborne pustular fatal illness Rat poison and nerve gasses
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Bioterrorism and Public Health

Magnitude Investigative process Social issues Ethical issues Biological concerns

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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
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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 damage.
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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

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Disaster Management

4 Phases: Preparedness, Response, Recovery, Mitigation

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.

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Disaster(continued) Management

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.

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Disaster(continued) Management

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 assessment Recovery - Actions taken to return to a normal situation after disaster; possibly resulting in a safer situation than existed

prior to the disaster.

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Disaster(continued) Management

Mitigation - any activity that reduces or eliminates risks to persons or property or lessens the actual or potential effects or consequences of an incident.

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Disaster(continued) Management

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.

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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.
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Nurses Role in Disaster Case Study

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?

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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. A. How would this disaster be categorized? B. What phase of disaster management will you implement?
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Housing and Homecare Challenges

Discharge Planning Homelessness

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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, etc.

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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 functions. Referral to appropriate community resources in the community and to appropriate education programs is part of the role of the RN performing discharge planning.

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Homelessness

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 homeless

Limited access to health care

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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 arrangements.

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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.
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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 years. 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. 104

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

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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

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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
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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 lowincome people has the strongest effect on lowering homelessness rates as compared to several other interventions tested.
108

Homelessness Prevention Strategies

(continued)

Supportive services coupled with permanent housing For people with serious mental illness, with or without cooccurring 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.
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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.
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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 welltargeted and therefore, efficient.
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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.
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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

113

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 population.
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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?
115

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.
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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?
117

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.
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High School Health Nurse

Case Study (continued)
Later, when preparing the clinics report of infectious 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: A. What nursing interventions are appropriate with this patient? B. What actions should be taken at the community level?
119

Public Health Nurse

Case Study
A client in a public health setting has expressed concerns 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.

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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 therapy, might be an appropriate intervention.

Questions for this Scenario:

How would the nurse introduce the idea of music therapy? What would the nurse tell the mother about music therapy and the potential benefits for her as a new nursing mother?

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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:
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School Health Nurse

Case Study (continued)
Question for Lice Scenario:
A. What should the nurse do first? Who should the nurse involve in the epidemiological investigation? B. What kinds of data should the nurse obtain during the first part of the investigation?

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Community Health Nursing

Case Study
The emergency room physician has referred a 60-yearold 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.

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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.

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Community Health Nursing

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

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NCLEX-RN Practice Question #1

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 community?
1. Having a seizure in public.

2. Operating a motor vehicle.

3. Operating machinery on the job. 4. Choking on food during a seizure.
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NCLEX-RN Practice Question #2 What level of prevention is the goal of a community health nurse in an area that has just experienced a major earthquake?
1. Primary 2. Secondary 3. Tertiary 4. Essential
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NCLEX-RN Practice Question #3

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:
1. Promote heart disease

2. Transmit trichinosis
3. Transmit enterobiasis 4. Worsen the symptoms of dementia
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NCLEX-RN Practice Question #4

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:
1. Falls 2. Poisoning 3. Aspiration/suffocation 4. Motor vehicle accidents
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NCLEX-RN Practice Question #5

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

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NCLEX-RN Practice Question #6

The nurse is teaching a community group about preventing accidental poisoning in the home. Which of the following would the nurse stress as inappropriate?
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.
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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.
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Based on this information, the nurse would assign highest priority to which of the following nursing diagnoses?
1. 2. 3. 4. Fatigue Activity Intolerance Decreased Cardiac Output Ineffective Airway Clearance

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NCLEX-RN Practice Question #8

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?
1. Providing the client with an over bed trapeze. 2. Having the client perform daily weight-bearing exercises. 3. Providing adaptive equipment to assist in activities of daily living. 4. Encouraging the client to rest for several hours, several times a day.
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Photo Acknowledgement: Unless noted otherwise, all photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.

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