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”
2
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

4
Communities:
Four Critical Attributes
Group orientation
 Bond among individuals
 Human interaction
 Collective action

5
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

6
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
7
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)

8
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
11
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 President’s Health and Fitness Initiative

Created by Presidential Executive Order – June
2002
14
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
15
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



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


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.
 Community
health requires a populationbased approach with attention given to the
economic, social and political
environments of the community as they
impact a community’s health.
20
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 person’s 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)
28
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.

32
The
Illness/Wellness
Continuum
Photo Source: courtesy of Eastern Michigan University,
http://www.emunix.emich.edu/~bogle/wellness%20continuum.jpg
33
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

35
Nurse’s 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).
38
Primary Prevention
(continued)

Promotes changes in lifestyle through
behavioral therapies to those areas that
represent major health risks:









Smoking
Obesity
Sedentary life-styles
Improper diet
Alcohol and drug abuse
Sexual promiscuity
Not practicing safe sex
Falls
Preventing automobile accidents
39
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
42
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 life’s activities.
 Includes nursing care for patients with
incurable diseases.

43
Tertiary Prevention
(continued)

Patient education concerning how to manage
and optimize new level of wellness associated
with already diagnosed diseases and
conditions. Examples include Parkinson’s
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.

45
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.
46
The CHNs Role

To promote health and healthy behaviour in
the community

To act as a health resource person for the
community
47
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.
48
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
49
Infection Control from a
Community Health Perspective
Modes of defence against infection:
Natural immunity
 Artificial immunity – Active/Passive
 Altering the environment

50
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)
51
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
52
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
53
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
54
Modes of Transmission
(continued)

Vector
External mechanical transfer (flies)
 Internal transmission:
 Mosquito - malaria
 Ticks - Lymes’s disease

55
 Transmission of Pathogens
Medical & surgical asepsis
 Immunization
 Food sanitation
 Insect & rodent control
 Appropriate disposal of human waste

56
Infectious Disease Outbreak
Primary prevention - immunize, educate on
prevention and ways to eliminate exposure from
the respiratory, skin and gastrointestinal routes
 Secondary prevention - screening, casefinding, treatment, and legal enforcement of
treatment, if indicated
 Tertiary prevention - educate to prevent
complications; teach side effects of therapy and
prevent spread of disease

57
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.
58
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
59
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%20F
act%20Sheet.pdf
60
Client’s 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 individual’s 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.
61
Client’s 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
62
Client’s 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.
63
Client’s 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.
64
Client’s Healthy Environment
(continued)

Care concerned with promoting safety
which is individualized, based upon:
 Developmental stage
 Lifestyle
 Environment
65
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.
66
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

67
Home Safety
Leading cause of accidental death in the
home is due to falls. Other accidental
deaths include:





Poisonings
Fires
Burns
Drowning
Firearm accidents
68
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
69
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.
70
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.
71
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 client’s 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.
72
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
73
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.
74
Conveying Cultural Sensitivity
(continued)
Don’t 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 patient’s health values,
practices and beliefs.
75
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.
76
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
77
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
78
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?
79
Infant Car Safety
1. Front seat facing forward.
2. Back seat facing forward.
3. Front seat facing backward.
4. Back seat facing backward.
80
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 boy’s mother, the family history reveals
that the boy’s 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.
81
Child Health Case Study
(continued)
There are abandoned cars in the empty lot next to their
home. The child’s 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.
82
Questions for case study:
What might be a possible reason for the child’s
problems?
What counseling and education would the nurse
provide for the mother and child?
83
Preparing for the Worst
84
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
85
Bioterrorism and Public Health





Magnitude
Investigative process
Social issues
Ethical issues
Biological concerns
86
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
87
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.
88
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
89
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.
90
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.
91
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.
92
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.
93
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.
94
Nurse’s 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.
95
Nurse’s 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?
96
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?
97
Housing and Homecare Challenges


Discharge Planning
Homelessness
98
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.

99
Discharge
Planning
(continued)
Assessment includes a functional assessment
including patient’s ability to perform activities
of daily living (ADL’s) 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.

100
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
101
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.
102
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.
103
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

105
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
106
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.
109
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.
110
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.
111
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.
112
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.
114
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.
116
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
doesn’t want to confront her boyfriend because she is
afraid of losing him. She states, “What’s the big deal
anyway? Gonorrhea and chlamydia are curable.”
118
High School Health Nurse
Case Study (continued)
Later, when preparing the clinic’s report of infectious
diseases for the public health department, the nurse notes
that there is a high incidence of gonorrhea and chlamydia
in
the clinic’s 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.”
120
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?
121
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:
122
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?
123
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.
124
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 client’s reading skills are very low level.
125
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?
126
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.
127
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
128
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
129
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
130
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
131
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.
132
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 client’s 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.
133
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
134
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.
135
Photo Acknowledgement:
Unless noted otherwise, all photos and clip art contained
in this module were obtained from the
2003 Microsoft Office Clip Art Gallery.
136