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
 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
population-based 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 population23group.
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  School & rural
nursing
 Families
 Public health
 Groups  Home health
 General  Camp nurse
community  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
well-being 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 health-promoting environment:
 In the home
 In schools
 In public places
 In the workplace
 Includes good nutrition, adequate clothing, shelter,
rest and recreation.
 Health education.
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  Priorities
care professionals  Motivation
 Physical accessibility  Previous
of resources experiences
 Cost of resource  Lack of knowledge
services of available services
 Time  Cultural factors
 Other  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. Source - initiator (person, animal, food, water)
2. Reservoir - storage place and exit from source
3. Agent - causes and effect (bacteria, virus,
spirochete, etc.)
4. Mode of transmission - airborne, direct contact,
animal to human, etc.
5. Portals of entry - gains access through break in
skin, respiratory tract
6. Susceptible new host - organism from which a
parasite obtains its nourishment

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,
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
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/resources/Outbreak%20Resp
onse%20Team%20Fact%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  Chemical poisons
 Firearms  Pesticides
 Cleaning products  Air pollution
 Radon & carbon  Water pollution
monoxide
 Asbestos
 Hazardous waste
 Lead and lead paint  Accidents
 Air pollution  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 Drug
Abuse
Exercise
Alcohol
Abuse
Motor vehicle accidents

Elderly: Physiologic changes

of aging
Falls Burns
Elder abuse 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 pre-school physical a year
ago revealed a normal, healthy child with no
apparent problems or abnormalities. The
mother states that his behavior has gotten
progressively worse over the last year. Upon
examination, the nurse discovers that he has
hearing and speech deficits and extreme
difficulty in concentrating. His finger stick
hemoglobin indicates mild anemia.
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
water-plague-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: Communications Failure

 Flood and Flash Flood
 Civil Disturbance
 Fire  Explosion
 Pandemic
 Hazardous Materials Incident
 Terrorism
 Tornado
 Hurricane
 Winter storm
 Severe Thunderstorm
 Earthquake
 Land slides
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

107
Homelessness – Prevention
Strategies
 Housing Subsidies – Several studies
have provided evidence that housing
subsidies is a very effective prevention
activity for homelessness. Studies
indicate that subsidizing housing costs
for extremely low-income people has
the strongest effect on lowering
homelessness rates as compared to
several other interventions tested.

108
Homelessness – Prevention
Strategies (continued)
 Supportive services coupled with
permanent housing – For people with
serious mental illness, with or without
co-occurring substance abuse,
permanent supportive housing works to
prevent initial homelessness, to re-
house people quickly if they become
homeless, and to help chronically
homeless people leave the streets.

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 well-targeted
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
121
as a new nursing mother?
 School Health Nurse
Case Study

A community health nurse is contacted about a

possible head lice outbreak in an elementary
school in her district. The school has sent 50
students home in the past week with suspected
head lice. The principal is upset that parents
are sending their children to school with
unclean hair, which he believes is the cause of
the head lice infestation. The children who
have been sent home are all in the third grade.
Answer the following questions:

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-year-old man to a clinic for follow-up care
of his hypertension. While taking his health
history, the clinic nurse learns that the client
has recently been released from prison after a
twenty-year sentence. He has just started
working as a dishwasher in a local restaurant.

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
The nurseNCLEX-RN
is teaching a Practice
client recently
diagnosed withQuestion
a seizure #1
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
What level of prevention
Question #2 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
The nurse is Practice group
teaching a community
Question
about nutritional wellness.#3
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
The nurse is Practice
reviewing safety information
Question
with the parents #4 The nurse
of a toddler.
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
A client recovering from alcoholism
Question #5 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
The nurse is teaching a community
NCLEX-RN Practice
group about preventing accidental
Question #6
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
The home care nurse is#7
Question 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. Fatigue
2. Activity Intolerance
3. Decreased Cardiac Output
4. Ineffective Airway Clearance

134
 NCLEX-RN
The home health nurse Practice
is caring for a
Question
client who has limited #8
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