Term
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Definition
* CH nurses play lg role in maintaining continuity of care as they transition from inpatient to outpatient setting
* CH nurses us technology to maintain continuity of care
* partnerships among individuals, families, community-based agencies |
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Term
| Issues that partnering entities may address |
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Definition
* info mgt
* cultural values
* health care system improvement
* physical envronment |
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Term
| Groups partnering to elicit needed change in the community |
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Definition
| more powerful than nurse working independently |
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Term
| CH nurses facilitate continuity of care thru case mgt services |
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Definition
* focused supervision for individualized care
* follow-up
* referrals to appropriate resources |
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Term
| establishment of ongoing relationship betwn individual and health care provider |
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Definition
| leads to improved health outcomes |
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Term
| Nurse's role with regard to consultations |
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Definition
* initiate necessary consults or notify PCP so consult can be initiated
* provide consultant with pertinent info
* incorporate consultant's recommendations into POC
* facilitate coordination of consultant's recommendations with other health care providers' recommendations
* protect client from conflicting / potentially dangerous orders |
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Term
| Nurse's role in referrals |
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Definition
* assist in restoring, maintaining, or promoting health
* link client with community resources
* have knowledge of individuals and organizations that serve as resources
* educate client about resources and self-care measures |
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Term
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Definition
* physicians
* acute-care settings
* primary care sites
* health departments
* Long-term facilities
* home care services
* Rehab services
* PT services
* OT services
* specialty service agencies
* pharmacies |
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Term
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Definition
* psyc services
* churches
* support groups
* life care planners
* medical equipment providers
* meal delivery services
* transportation services |
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Term
| Steps in referral process |
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Definition
* engage in working relationship with client
* establish criteria for referral
* explore resources
* accept client's decision to use given resource
* make referral
* facilitate referral
* eval outcome |
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Term
| Barriers to referral process: Client barriers |
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Definition
* lack of motivation
* inadequate info about community resources
* inadequate understanding of need for referral
* accessibility needs
* priorities
* finances
* cultural factors |
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Term
| Barriers to referral process: Resource barriers |
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Definition
* attitudes of health care personnel
* costs of services
* physical accessibility of resources
* time limitatios
* limited expertise working with culturally diverse populations |
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Term
| Follow-up considerations in referral |
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Definition
* monitoring to determine if referral was completed
* assessing whehter referral outcomes were met
* determining if client was satisfied with the referral |
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Term
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Definition
* essential component of continuum of care
* ongoing assessment that anticipates future needs of client
* ongoing communication betwn client, nurse, physicians, family, other health care providers
* goal to enhance well-being of client by establishing appropriate options for meeting health care needs
* Joint Commission requires initation of DC planning at time of admission |
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Term
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Definition
* promote interdisciplinary services and increased client / family involvement
* decrease cost by improving client outcomes
* provide education to optimize health participation
* advocate for services and client rights |
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Term
| Successful mgt of client's health care needs |
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Definition
| collaboration betwn client, family, community, payer, other health care professionals |
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Term
| Excellent communication skills |
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Definition
| needed for case mgt nurse in order to facilitate communication |
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Term
| Nsg Process in Case Mgt: Assessment |
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Definition
| Clarify problem by evaluating physical needs, psychosocial issues, functional ability, and financial constraints |
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Term
| Nsg Process in Case Mgt: Diagnosis |
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Definition
* determine cause and precipitating factors
* ID applicable nsg diagnoses by using above assessment |
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Term
| Nsg Process in Case Mgt: Planning |
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Definition
In conjunction with client and family, determine:
* possible outcomes for client
* advantages and disadvantages of possible outcomes
* what role each participant will play
* impact on client in each area listed for assessment |
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Term
| Nsg Process in Case Mgt: Intervention |
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Definition
Case manager
* contacts service providers
* provides referral info
* coordinates all services to be provided
* monitors client to dtermine if services are still appropriate |
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Term
| Nsg Process in Case Mgt: Evaluation |
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Definition
Monitor care provided by different agencies, comparing against
* original projected outcomes
* physical needs
* psychosocial needs
* financial needs
* client and family satisfaction |
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Term
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Definition
| combination of nursing science with information and communication technologies in the delivery of nsg care |
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Term
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Definition
delivery of quality health care thru use of telecommunication technologies
* allows for delivery of education
* increase awareness of health issues
* particularly useful in rural areas |
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Term
| Telecommunication technologies can transmit |
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Definition
* physical data (VS, wt, ECG)
* audio data (voice, heart sounds)
* visual data (images of wounds) |
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Term
| CIRCLE model of spiritual care |
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Definition
C aring
I ntuition
R espect religious beliefs/practices
C aution
L istening
E motional support |
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Term
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Definition
* personal ealth counseling
* health education
* liason betwn faith community and local resources
* facilitator support groups, change in congregation, volunteer training
* spiritual support |
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Term
| Occupational health nurse develops partnerships with |
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Definition
* workplace admin
* industrial hygienists
* safety specialists
* occupational medicine docs
* HR
* union reps
* health insurance agencies |
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Term
| Occupational Health and Safety Administration (OSHA) of 1970 established |
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Definition
* develops and enforces workplace health regulations to protect safety and health of workers
* National Advisory Committe on Occupational Safety (NIOSH) -- gathers and disseminates data on occupational illness and injury |
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Term
| Workers compenstations acts |
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Definition
| state-level legilation that regulates financial compensation to workers suffering from injuries or illness resulting from the workplace |
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Term
| Nursing's role in health policy |
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Definition
* change agents -- advocate for needed change at local, state, or federal level
* lobbyists -- persuade or influence legislators
* coalitions -- facilitation of goal achievement through collaboration of 2 or more groups
* public office -- serving society and advocating for change by influencing policy dev thru public service |
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