NSG 152 Exam 1 Guidelines
(These suggestions provide an overview and are not all inclusive.)
Community Based Nursing
1. Know all information on the Flash cards you made.
Paying for Healthcare
Out-of-Pocket Payment
- First half of twentieth century - cash payments. Increasingly rare today.
- Most families cannot afford high costs of health care.
- Most Americans continue to believe that basic health care needs of all should be met
regardless of ability to pay.
Individual Private Insurance
- Financed through large, nonprofit, tax-exempt organizations or through smaller, private,
for-profit insurance companies.
- Members pay monthly premiums either by themselves or in combination with employer
payments.
- Called third-party payers because insurance company pays all or most of cost of care.
- Premiums tend to be higher than those for managed care plans, but members can
choose their own health care providers and services desired.
Employer-Based Private Insurance
- Most common source of health care coverage in the United States.
- In 2014, 66% of nonelderly workers received offer of coverage from their employer—
less than 71% rate in 1999.
- Employees who work part time less likely to be offered coverage from their employer
than employees working full time.
- Percentage of workers covered has declined over last 15 years, decline greatest among
families with low and modest incomes.
Government Financing
- Largest federally funded health care programs - Medicare and Medicaid.
- Other federally funded programs - Children’s Health Insurance Program (CHIP) and
Veteran’s Health Administration (VHA).
Medicare
- 1965: Medicare amendments to Social Security Act - national and state health insurance
programs for older adults under Title XVIII.
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1975: almost all citizens over 65 years of age held Medicare insurance for hospital care,
extended care, and home health care. Coverage increased in 1972 to include
permanently disabled workers and dependents, if qualified for Social Security benefits.
1983: Medicare converted to prospective payment plan based on patient classification
categories, called diagnosis-related groups (DRGs). Federal government implemented
DRGs to control rising health care costs. Plan pays hospital fixed amount predetermined
by diagnosis or specific procedure rather than actual cost of hospitalization and care.
1988: expanded to include catastrophic care costs and expensive medications.
2007: based on changes in DRGs made by CMS, criteria for reimbursement to hospitals
became severity of illness and projected cost of care. Plan pays only amount of money
pre-assigned to treatment for diagnosis (e.g., appendectomy); if cost of hospitalization is
greater than that assigned, hospital must absorb additional cost. If cost is less than that
assigned, hospital makes profit.
Medicare no longer reimburses hospitals for conditions that result from preventable
errors and lead to increased costs. Such conditions include pressure injuries, injuries
caused by falls, infections associated with indwelling urinary catheters, vascular
catheter–associated infections, infections of mediastinum after coronary artery bypass
graft, air embolisms, adverse reactions to incompatible blood infusions, and sponges or
instruments left inside patient during surgery.
People who receive Medicare pay both deductible cost and monthly premium for full
insurance coverage.
Part A pays most inpatient hospital costs; paid by federal government.
Part B (voluntary), paid by monthly premium; covers most outpatient costs for physician
visits, medications, and home health services.
Full cost of some services not covered by Medicare; supplemental insurance policy
offered by private insurance company recommended.
Medicare federally funded = benefits may change annually according to Congressional
decisions related to federal budget.
Talk about “phasing out” Medicare. National debate about whether United States can
continue to operate Medicare in same form along with other government programs and
still control spiraling health care costs.
Entitlement reform being considered for benefits paid by government to citizens in
order to improve national budget and reduce debt.
Medicaid
- Established in 1965 under Title XIX of the Social Security Act.
- Federally funded public assistance program for people of any age who have low
incomes; for blind, older adults, and disabled covered by supplemental security benefits;
and for beneficiaries of Aid to Families with Dependent Children.
- Coverage depends on individual state regulations.
- Current budgetary considerations leading state and federal facilities to trim Medicaid
expenditures.
- Rapid growth of aging population and increased number of poor people, many being
women and children, draining Medicaid budget.
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Programs implementing changes; reducing benefits or placing patients into managed
care programs.
Children’s Health Insurance Program (CHIP)
- Formerly State Children’s Health Insurance Program (SCHIP)
- Created by Balanced Budget Act of 1997; enacted as Title XXI of Social Security Act,
allocated $20 billion over 10 years to help states insure low-income children ineligible
for Medicaid yet cannot afford private insurance.
- States receive enhanced federal match (greater than state’s Medicaid match) to provide
coverage.
- 2007: program extended, and in 2009 reauthorized by Congress and signed by President
Obama.
- Medicaid and CHIP serve more than 42 million children who would otherwise not have
access to regular medical care.
- Medicaid and CHIP have helped bring rate of uninsured children to lowest level in over
two decades; many more children eligible but not covered.
Veterans’ Health Administration (VHA)
- United States’ largest integrated health care system, consisting of 152 medical centers,
nearly 1,400 community-based outpatient clinics, community living centers, veterans’
centers, and domiciliaries.
- Facilities and more than 53,000 independent licensed health care practitioners provide
comprehensive care to more than 8.3 million veterans each year.
- Annual medical care appropriation of more than $47 billion.
Qualities of the Community-Based Nurse
Knowledgeable and Skilled
- Effective communication
- Clinical skills; many facilities require minimum of 1 year of clinical practice
- Physical assessment skills
- Body mechanics
- Nursing diagnoses
- Infection control
- Legal regulations
Independent in Making Decisions
- Sound theoretical foundation for practice
- Proficiency in clinical skills
- Ability to solve problems creatively; make appropriate patient care decisions
Accountable
- To patient
- To family
- To primary health care provider (PHCP)
- Must consider important questions:
o Whom do I call if the patient’s physician or nurse practitioner is not available?
o What should I do if a family member becomes acutely ill?
o How do I learn to perform advanced procedures?
o How do I document the patient’s decisions about treatment?
o How do I work collaboratively and ensure that other providers know about and
document the care plan?
Roles of the Community-Based Nurse
Patient Advocate
- Advocacy: protection and support of another’s rights.
- Patients need help understanding complex health care system, handling insurance
problems, or dealing with state and federal regulations affecting care and environment.
E.g. - nurse may have to convince patient’s insurance carrier of need for continued
home health services.
- Patients need help understanding complex billing issues related to care.
- Nurses can often mobilize services needed to improve patient’s environment.
- Community nurses work long hours and face many challenges.
- Sometimes difficult to establish and maintain professional boundaries and to sever ties
when appropriate with families nurse has come to know and love.
- Helpful to be aware of challenges and able to discuss them with respected team leaders
and colleagues.
Coordinator of Services
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Generally coordinates all other health care providers visiting patient, and is primary
source of communication and coordination of patient’s care with primary health care
provider.
Uses effective communication skills with other health care providers while coordinating
services for patient.
Responsible for coordinating community resources needed by patient. Sound
knowledge of community resources enables nurse to provide comprehensive services.
E.g. - nurse must understand role of social worker or physical therapist to determine
need for services.
Should know about available community resources, such as Meals on Wheels, American
Cancer Society’s services, services for patients who are visually or hearing impaired, and
local services for aging.
As coordinator of care, nurse directs various services toward common goal of improving
patient’s health and promoting independence.
Patient and Family Educator
- Teach patients and families about all aspects of care, including disease processes and
treatments, nutrition, medications, and treatment and care of wounds.
- Identifies learning needs; then nurse, patient, and family mutually develop goals for
teaching information necessary to promote health.
- Family members or other caregivers may be taught any skill they are able and willing to
perform.
- Provides information necessary to keep patient safe until next visit, using methods that
work best in home or other community setting.
- Goal = increase patient’s ability to provide self-care and caregiver’s ability to care for
patient.
2. Be able to identify what tasks the nurse does in each stage of the Home Visit
The Home Visit
Pre-Entry Phase
- Referral process - provider or discharge planner of hospital contacts home care facility
and provides brief medical history, along with indications for home health services.
- During pre-entry phase, referral nurse at home care facility collects as much information
as possible about patient’s diagnoses, surgical experience, socioeconomic status, and
treatments ordered (pre-entry phase).
- Once assigned, nurse reviews information and calls patient to schedule visit.
- During conversation, nurse can determine whether patient’s caregiver can answer
questions related to patient’s and family’s needs and also learn about patient’s cognitive
abilities, orientation, and caregiver status.
- Initial information important for nurse planning of first visit.
Entry Phase
- Second phase of visit.
- Nurse develops rapport with patient and family, makes assessments, determines
nursing diagnoses, establishes desired outcomes (along with the patient and family),
plans and implements prescribed care, and provides teaching.
- Nurse must remember that he or she is guest in patient’s home and is offering services
that patient may accept or reject.
- Important considerations include negotiating and honoring visit times, establishing a
rapport with patient and family, defining what nursing care will be provided, and
teaching to promote independence in self-care.
- Nurse must gain trust of patient and family, and must recognize and respect their
values.
- Accepting the patient’s living conditions is necessary, even when they differ from those
of the nurse.
- Nurse must ask permission before using patient’s home for activities such as
handwashing.
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Nurse might believe that furniture in patient’s home or sick room needs to be
rearranged to allow use of equipment and to remove safety hazards, but patient should
give permission before any changes are made.
Nurses who provide home health care interventions do so based on an individualized
care plan for each patient, based initially on identifying individualized health care needs.
Identifying Needs and Determining Interventions
- Ability to assess patients accurately important skill for home health care nurses.
- Most of initial assessment takes place during first home visit, although ongoing focused
assessment occurs during subsequent visits.
- Nurse must be skilled not only in physical assessment but also in psychological,
socioeconomic, environmental, spiritual, and cultural assessment.
- Skilled assessment allows nurse to make appropriate diagnoses.
- Nurse must determine and provide culturally respectful care.
- Family caregivers must also be considered, taking into account various roles each family
member plays and how they contribute to patient’s health status.
- Specific interventions based on patient’s needs, but controlling infection and teaching
patient and caregiver are part of all home visits.
Teaching the Patient and Caregivers
- Home health care is meant to be short term and intermittent; nurse includes family and
friends in teaching process so they can learn how to care for patient after nurse’s home
care is no longer needed.
- Nurse designs and implements teaching plan based on patient’s and caregiver’s
readiness to learn; must be adapted to patient’s and caregiver’s physical and emotional
status, and must be understandable and “doable.”
- Teaching should identify both positive outcomes of following instruction and serious
consequences of failing to do so.
- Nurse points out major problem areas specific to care in home, focusing on information
needed to keep patient safe until nurse’s next home visit.
Documenting Care Given in the Home
- Documenting care given in home mandated by regulatory and federal facilities.
- Nurse may document visit on preprinted forms or checklists or may use a computer.
- Documented care plan, visit plan, and progress notes routinely used by regulatory
facilities and payer sources (e.g., private insurance or Medicare) to determine whether
various state and federal regulations are being met and if payment is warranted.
- Care plan establishes specific measurable goals and specifies a time frame for reaching
goals.
- Care plan accurately reflects condition of patient, patient’s functional limitations and
safety needs, need for skilled care, specific provider orders, anticipated progress,
criteria for discharge, supplies needed, visit schedule for all health care providers, and
list of support systems available.
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Nurse writes (or types) progress notes to document each visit to patient’s home; notes
must accurately describe patient’s condition, skilled care provided, patient’s response,
patient’s progress toward discharge, and ongoing plan for continued care; also include
nurse’s plan for next visit.
To meet reimbursement requirements, each progress note must indicate that care
provided requires knowledge and skills of professional nurse.
3. Identify examples of Community Based nursing and Community Health nursing.
Community-Based Nursing
“Community-based nursing is centered on the health care needs of individuals and families.”
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Home health care for sick individuals and support for their caregiver(s)
mother lacking medical insurance brings sick child to the clinic in her neighborhood.
man experiencing homelessness seeks help at community clinic when he cuts his foot
while walking barefoot on the street.
Community Health Nursing
“Community health nursing focuses on whole populations within a community.”
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meet with young mothers to provide valuable immunization information
teach a new diabetic how to give insulin injections by practicing with an orange.
4. Understand what epidemiology is and what it does.
Epidemiology - branch of medicine which deals with incidence, distribution, and possible
control of diseases and other factors relating to health.
5. Re-read the pages listed on the Lesson Plan for Ricci (Maternity/Child)
6. In all the readings, focus on Boxes and Tables if they are listed on the Lesson Plan.
7. Know the role of the RN with the Interdisciplinary Team
Educator – sharing knowledge and skills to prepare clients and caregivers for greater
independence during situations where they would previously have needed outside support.
Counselor – listening to and acknowledging issues and concerns of clients and caregivers to
place focus on ensuring delivery of quality patient care services.
Advocate – support the client's and caregivers’ best interests while respecting the family's
important role.
Case manager – work both within and outside of a hospital or medical facility to develop,
implement, and review healthcare plans for patients that are geriatric, recovering from serious
injuries, or dealing with chronic illnesses.
Change agent – individual who has formal or informal legitimate power and whose purpose is
to direct and guide change; identifies a vision and rationale for the change and is a role model
for other nurses and health care personnel.
Epidemiologist – professional who focuses on making sure that patients receive optimal care,
but who also reduces overall infection risks and focuses on prevention measures as well as on
infection control and direct patient nursing; assesses risk factors within a patient, a facility, or
even a population.
Stress and Coping
1. Know definitions of physiological stress and psychological stress.
Psychological stressors - cognitive appraisal and coping by a person (mediating process),
consciously or unconsciously, reacts to manage an internal or external situation.
Physiologic stressors - protective and adaptive mechanism to maintain the body’s homeostatic
balance.
2. Give examples of both types of stress.
Psychological stressors:
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relationship conflicts at home.
new or increasing work responsibilities.
increasing demands.
financial strain.
loss of a loved one.
health problems.
moving to a new location.
exposure to one or more traumatic incidents, such as a car accident or a violent crime.
Psychosocial Stressors:
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Environmental: housing or lack of crime-ridden neighborhood
Interpersonal relationships
Life events: death of loved one, marriage, divorce
Rapid changes in our world and the way we live
Horrors of history: 911, WW II, School shootings, Pandemics
Physiological stressors:
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Chemical agents (drugs)
Physical agents (cold, heat, trauma, infectious agents)
Nutritional imbalances
Hypoxia
Genetic or immune disorders
3. Identify what type of separation anxiety infants, toddlers and school age children experience.
Protest – Child will cry loudly, ask for his mother, show anger, and reject or cling to others
Despair – Child feels hopeless, becoming physically inactive, withdrawn and in a state of
mourning
Detachment - Child will appear to have recovered and will begin to accept and interact with
others, as well as with food, toys, etc. If the separation lasts, the child will suffer irreversible
damage, becoming superficially attached to adults, self-centered, preoccupied with material
things, food or activities.
4. Complete the Compare & Contrast Physiological Homeostasis form and use it as a study
guide.
5. Be able to identify examples of appropriate coping mechanisms.
Internal factors:
- ability to take control and be proactive
- responsibility for one’s own decisions
- understanding and acceptance of one’s own limits and abilities
- ability to be goal directed
- knowing when to continue or when to stop
External factors:
- caring relationships with a family member
- a positive, safe learning environment at school (including clubs and social organizations)
- positive influences in the community
Promoting the development of resiliency in children aids in the achievement of positive
developmental and health outcomes
6. Know what happens in the four levels of stress: Mild, Moderate, Severe, Panic.
Anxiety (most common human response to stress)
 Mild:
 present day to day
 increases alertness and perceptual fields
 motivates learning and growth
 facilitates problem solving
 usually restless and questioning
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Moderate:
 narrows perceptual field so can only focus on the problem at hand
 inattention to other communications and details
 Manifestations: “butterflies in my stomach”, increased respiratory & heart rate,
tremors, quavering voice
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Severe:
 behaviors are geared to get relief
 very narrow focus on details
 impaired learning ability and is easily distracted
 characterized by emotional distress that interferes with everyday life, avoiding
situations that cause anxiety and having an extreme fear of a danger that is not real
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Panic:
 person loses control and experiences dread and terror
 increased physical activity
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distorted perception of events
loss of rational thought
difficulty communicating
trembling, sweating, poor motor control
dyspnea, palpitations, choking sensation and chest pain
7. Be familiar with the GAS and other theories of stress that are on the PowerPoint.
Physical Illnesses Associated with Stress
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Autoimmune disorders
o Graves’ disease (hyperthyroidism)
o Myasthenia gravis
o Psoriasis
o Rheumatoid arthritis
o Systemic lupus erythematosus (SLE)
o Ulcerative colitis
Cardiovascular and Hematologic disorders
o Coronary artery disease
o Hypertension
o Sickle cell disease
Gastrointestinal disorders
o Constipation
o Diarrhea
o Esophageal reflux
Respiratory Disorders
o Asthma
Allostasis (New word coined in the 1980’s)
 Process of achieving stability or homeostasis through physiologic or behavioral change
Local Adaptation Syndrome (LAS)
 Localized response of the body to stress
 Involves a specific tissue or organ, not the whole body
 Precipitating stressor is traumatic or pathological (not psychological)
 Two types of LAS:
o Reflex Pain Response - Rapid, automatic, protective
o Inflammatory Response - Prevents spread of infection, promotes healing
General Adaptation Syndrome (GAS)
 Biochemical model developed by Selye which has three stages:
o Alarm Reaction
 Sympathetic nervous system kicks into create fight or flight response
o Stage of Resistance
 Body attempts to adapt to the stressor, VS, hormones return to normal
levels or not
o Stage of Exhaustion
 Body is unable to adapt and the defense resources (hormones,
adrenaline) run out
 Body may rest and try again or death may occur
Family Dynamics
1. Be able to define family and identify different types of families.
Family - any group of people who live together and depend on one another for physical,
emotional, and financial support.
Family Structure - two or more people, maybe related, maybe not, may be the same sex or not,
may be married or not. (See where I’m going?) There is no “typical” family structure.
2. Know how aging family members, birth of a baby, and chronic illness can affect the family.
Psychosocial Aspects of Aging
Successful psychological aging is reflected in the ability of older adults to adapt to physical,
social, and emotional losses and to achieve life satisfaction. Because changes in life patterns are
inevitable over a lifetime, older adults need resiliency and coping skills when confronting
stresses and change. A positive self-image enhances risk taking and participation in new,
untested roles.
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Older adults must adapt to physical, social and emotional losses
Need resiliency, coping skills and positive self-image
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90% of older adults live in the community
Only 3.4% live in nursing homes
81% own their own homes
Sometimes may move in with family
Ageism
 Prejudice and discrimination against older adults
 Based on stereotypes and applied to all older adults
 Develop due to fear of aging or inability to accept the aging process
 Negative images of older people at work
Birth of a Baby
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Chronic Illness
The Role of the Family
 Adult children & parents are not all socially alienated
 Adult children take care of parent(s) (17.9 billion hours of unpaid care in 2014)
 Stress may lead to psychiatric and physical morbidity
 Treat with psychoeducational skill building, cognitive behavioral therapy, education and
family meetings
3. Identify examples of the three theories discussed in class: Family systems theory, Structural
functional theory, and Family stress theory.
Family Systems Theory – Dr. Murray Bowen
Developed genograms
Eight interlocking concepts of theory:
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Triangles: The smallest stable relationship system. Triangles usually have one side in
conflict and two sides in harmony, contributing to the development of clinical problems.
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Differentiation of self: The variance in individuals in their susceptibility to depend on
others for acceptance and approval.
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Nuclear family emotional system: The four relationship patterns that define where
problems may develop in a family.
- Marital conflict
- Dysfunction in one spouse
- Impairment of one or more children
- Emotional distance
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Family projection process: The transmission of emotional problems from a parent to a
child.
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Multigenerational transmission process: The transmission of small differences in the
levels of differentiation between parents and their children.
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Emotional cutoff: The act of reducing or cutting off emotional contact with family as a
way managing unresolved emotional issues.
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Sibling position: The impact of sibling position on development and behavior.
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Societal emotional process: The emotional system governs behavior on a societal level,
promoting both progressive and regressive periods in a society.
Structural Functional Theory - Radcliffe-Brown
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developed field of "structural functionalism"
describes basic concepts relating to the social structure of primitive cultures
greatly influenced by work of Émile Durkheim; studied global social phenomena
study of primitive societies and determination of generalizations about social structures
believed social institutions should be studied like scientific objects
regarded institutions as key to maintaining global social order of society, analogous to
organs of a body
studies of social functions examined how customs aid in maintaining overall stability of a
society
Family Stress Theory
Family stress theory defines and explores the periodic, acute stressors that happen to all
families. When these stressors become frequent or if the individual or family lacks the support
of significant relationships, this build-up can lead to personal and family crises, including
physical, emotional, or relational trauma. Such family crises may include episodes of domestic
violence, recurring or chronic substance abuse, illness from weakened immune systems,
divorce, accidents, child abuse/neglect, etc.
4. Know the definitions of the psychosocial changes in Pregnancy
 Ambivalence – having two opposing viewpoints simultaneously
 Introversion – preoccupation with oneself and subsequent withdrawal from typical social
interaction
 Acceptance – eventual emotional and psychological validation of physical changes occurring
in the body
 Mood Swings – abrupt changes in one’s emotional state, typically brought about
spontaneously
 Change in Body Image – shift, or reinforcement, in/of one’s personal perspective of their
appearance as the body changes
5. Be familiar with Family Roles, Tasks and Risk Factors as well as what the nurse can do to help.
6. Understand the concept of the strain on Caregivers from the article about Family Caregivers.
7. Be able to identify the parts of the SCREEM Tool and the other Tools that are in the PPT.