Chapter 12- Collaborative practice and care coordination across settings

An 82-year-old client is being discharged from the hospital following a bowel resection. The client lives alone and the client's family is out of town. Which factor will have the greatest effect on the client's home care management?

Support system 283

Which qualities are essential for a community-based nurse? Select all that apply.

Strong knowledge foundation Effective communication skills Keen physical assessment skills 267

The home care nurse asks the client and family about their socioeconomic status, culture, and beliefs. Which is the best response by the nurse when the family asks why those questions are being asked?

"I want to understand what your desires are" 269

A home health care nurse is explaining to an emergency room nurse how nursing care in the home setting differs from that in the hospital setting. Which statement by the home health care nurse would be more appropraite?

"The client and family are in control of the setting, not the nurse" In home health care, the nurse is a "guest" in the client's home. Thus, the client and family retain the power and control that they normally relinquish to providers in other settings, such as an acute care facility. A generalist background and focus are useful, as well as broad assessment skills and a knowledge base to provide clients with appropriate education that will keep them as independent as possible. A graduate degree or high-level critical care skills are not necessary. Collaboration among team members is essential. 268

A nurse has been asked to chair an action team tasked with prioritizing a list of possible new equipment purchases. Which statements, made by this nurse, will help the team be most effective? Select all that apply.

-"Our goal is to prioritize this list of potential equipment purchases, offering rationale for our choices." -"Before our next meeting, each of us will ask the nurses on the unit what their priority purchase would be." -"Once we have completed the list and rationale, I will compile our recommendations for us all to sign before submission." 271

A nurse is caring for a client who will be discharged home but will have a complex medication regimen and follow-up with several providers. Which strategies will the nurse employ to provide discharge teaching? Select all that apply.

-Divide the content into several short sessions. -Be prepared to review and repeat information. -After teaching have the client repeat back the key points. -Use visual aids to help explain teaching. Short amounts of information are easier to comprehend because the client does not become as tired. Reviewing and repeating information is essential. Teach-back is a valid technique for evaluating learning. Visual aids are helpful in explaining content. The nurse should use common, nonmedical language as much as possible when teaching. 281

The home health nurse is beginning the entry phase of the home visit. What important outcomes will the nurse achieve in this phase of the process? Select all that apply.

-The nurse develops rapport with the client and the family -The nurse completes a physical and psychosocial assessment -The nurse teaches the client and the family members about wound care 288

The nurse is meeting a new client on arrival to the unit. What is the nurse's responsibility(ies) during the admission process? Select all that apply.

-Welcoming the client as if to the client's home -Assessing the family's need to be present during the admission -Asking the client whether the client wants the family to remain during the admission process -Communicating the rules about visiting hours, the cafeteria, and other services 279

A nurse is covering all aspects of admission procedures for a client who is receiving home health services. The nurse explains what procedures will be covered during the nurse's visits. Which aspect of the admission process does this represent?

Clearly defining the purpose and expectations of the admission 269

The home health care nurse is providing information to a client and family on medication changes. What role is the nurse performing?

Client and family educator Nurses providing home health care educate clients and families about all the aspects of care in the home, including the disease process or treatment, nutrition, medications, or treatment of care of wounds. As a caregiver, the nurse develops and implements a plan of care. As a client advocate, the nurse protects and supports the rights of another person. As a coordinator of services, the nurse must use effective communication skills with other health care providers while coordinating services for the client. 269

One significant change in the health care delivery system in recent years is earlier hospital discharges. What is one result of earlier hospital discharges?

Clients with high home care needs are being discharged into the community 283

A single parent age 17 years, with one child and pregnant with a second, has the mental age of a 12-year-old. The home care nurse's greatest concern in caring for this client should be the client's ability to do which?

Cognitively understand how to care for the children Regarding all aspects of survival, the cognitive ability of this young client is the greatest concern. The cognitive ability to understand how to organize work, manage financial responsibilities, and ensure safety within the home is essential to a single parent of two young children 288

A 16-year-old client has been injured in an accident and is receiving home care due to fractures and multiple trauma-related injuries. The client states, "I don't know why I survived and not my best friend." It is most important for the home care nurse to encourage the client to:

Communicate these feelings to family and friends The home health care nurse can assist in coordinating care needs and encouraging family, teachers, schoolmates, and friends to understand the client's struggles and help support the client's needs 283

A pregnant client is on bed rest at home, and a nurse will soon come to the home to assess the client. Which type of nursing is this nurse practicing?

Community-based nursing Community-based nursing focuses on individuals and families within the community and is practiced in non-hospital settings. 265

A successful discharge includes effective planning. Identifying and meeting client needs beyond the acute care facility reduce readmissions. Which nursing role is of great importance to this success?

Coordinator 274

In anticipation of discharge, a nurse is teaching the daughter of an older adult client how to change the dressing on the client's venous ulcer. Which teaching strategy is most likely to be effective?

Demonstrate and explain the procedure and then have the daughter perform it 269

In anticipation of discharge, a nurse is teaching the daughter of an older adult client how to change the dressing on the client's venous ulcer. Which teaching strategy is most likely to be effective?

Demonstrate and explain the procedure and then have the daughter perform it. 269

Which activity by the nurse exhibits the role of family educator?

Demonstrating how to suction the oropharynx The home healthcare nurse provides teaching, such as demonstration of a skill, to the family as a client educator. The home healthcare nurse develops and implements the plan of care in the caregiver role, such as obtaining a sputum specimen. As a client advocate, the home healthcare nurse protects and supports the client's rights. The home healthcare nurse coordinates direct care to the client and services of other healthcare providers. 269

Which activity by the nurse exhibits the role of family educator?

Demonstrating how to suction the oropharynx 269

The nurse is working with a client's family and social worker to select a home health care agency. Which question does the nurse state should be the family's priority when interviewing potential home health agencies?

Does the agency meet uniform standards for licensing, certification, and accreditation by state agencies and/or federal programs? 284

Which role is the home health nurse exhibiting when demonstrating how to suction the oropharynx of the client?

Educator The home healthcare nurse provides teaching, such as demonstration of a skill, to the family as a client educator. The home healthcare nurse develops and implements the plan of care in the caregiver role, such as obtaining a sputum specimen. As a client advocate, the home healthcare nurse protects and supports the client's rights. The home healthcare nurse coordinates direct care to the client and services of other healthcare providers. 269

The nurse is assigned to care for a middle-aged client who is agitated and wants to go home. The client states that the client does not have time to waste in the hospital, and no one is doing anything anyway. Which action by the nurse is more appropriate if the client insists on leaving the hospital against medical advice (AMA)?

Have the client sign the AMA form 283

A client is having an increasing amount of difficulty caring for oneself in the home alone. The client states to the nurse, "I need more help. What am I going to do?" Which action would be the most appropriate for the nurse to take?

Have the social worker visit the client to discuss care options Services to manage health care needs in the home can involve a team of interdisciplinary professionals, including social workers. The social worker is able to broadly identify resources to meet the client's needs. As no specific needs are indicated in this case, such as the need for rehabilitation, bathing, or adaptive devices, it would be more appropriate for the nurse to refer the client to the social worker than to a physical therapist, home health aide, or occupational therapist. 269

When educating clients in the community on health promotion and prevention of disease, it is important to stress:

Health education can benefit individuals and groups 265

A client living alone has degenerative joint disease, hypertension, and neuropathy. It is difficult for the client to bathe, and the client's blood pressure is unstable. Which type of care would-this client benefit from most?

Home care Home health care services are delivered to persons at home who are recovering from illness, are disables, or are chronically or terminally ill and need various services to progress, maintain function, or perform their activities of daily living. Acute and ambulatory care are delivered on a short-term basis, and respite care's focus is on the caregiver. 283

A client living alone has degenerative joint disease, hypertension, and neuropathy. It is difficult for the client to bathe, and the client's blood pressure is unstable. Which type of care would this client benefit from most?

Home care Home health care services are delivered to persons at home who are recovering from illness, are disabled, or are chronically or terminally ill and need various services to progress, maintain function, or perform their activities of daily living. 283

A nurse is caring for a 17 year old pregnant client who is unable to afford health care. Which resources will the nurse access to obtain assistance for this client?

Make a referral to the social services department 280

A nurse is caring for a 17-year-old pregnant client who is unable to afford health care. Which resources will the nurse access to obtain assistance for this client?

Make a referral to the social services department 280

Which nursing action is appropriate when assuming the role of client case manager for a home health agency?

Managing client care from admission through discharge or resolution of illness When assuming the role of a client case manager, the nurse collaborates with the interdisciplinary team while managing care for a client (or group of clients) for a designated period of time throughout the course of the illness. 274

Which is the largest single source of reimbursement for home health care services?

Medicare Medicare is the largest single source of reimbursement for home health care services. Other sources of reimbursement may include Medicaid, private insurance, self-pay, and other public funding. 284

Home health care nurses are required to complete the Outcome and Assessment Information Set (OASIS) by which entity?

Medicare OASIS provides standardized guidelines for admission and care, as well as a national database for evaluation, reimbursement, and quality improvement. The OASIS system of data collection is required by Medicare, not by Medicaid, insurance companies, or any other third-party payer. 288

The client is being discharged to the home setting following a stroke. The client requires assistance in relearning how to cook safely. To which home health care team member should the nurse refer the client?

Occupational therapist The occupational therapist can evaluate the functional level of the client and teach activities to promote self-care in activities of daily living, such as cooking. 281

Which type of home healthcare agency is a local health department?

Official or public agency 284

Which measure should a home health care nurse integrate into routine practice to minimize the potential for lawsuits?

Perform thorough, accurate, and timely documentation The need for thorough documentation is especially high in home health care settings, both to ensure continuity of care and to provide a legally acceptable record of what occurred during nurse-client interactions. The nurse should not implement more conservative interventions solely to minimize liability. A waiver of rights is not a component of home health care. The client's learning needs and goals should indeed be integrated into plans of care, but this action does not protect against lawsuits. 287

When doing discharge planning for an older adult client who had a stroke, what is the nursing priority?

Plan reachable goals with the client and family. Goals are best met when mutually set by both the client and the nurse, with input from the family. If the client is involved in setting the goals, it is more likely that the expected outcomes of the plan will be met. The goals should be reachable by the client 281

Prior to the discharge of a client who is recovering from a stroke from an acute care facility, the nursing case manager has the nursing staff, client, client's family, physical therapist, and home health nurse meet. The most likely purpose of this meeting is to:

Prepare the client for home care 284

When preparing to transfer an older adult client back to the long-term care facility where the client has been for several years, it is the primary responsibility of the nurse to:

Provide for the coordination and continuity of care by the health care providers 269

The nurse is admitting a client for outpatient surgery. When the nurse asks what the client has been told about self-care following discharge, the client says, "No one has told me anything." Which nursing intervention is indicated?

Provide the teaching. The nurse assesses what has been done prior to the day of surgery and tailors the care plan to meet the client's needs. In this case, the client should receive information about postoperative self-care, including written instructions. The nurse, not the surgeon or charge nurse, should provide the teaching. There is no need to delay the client's surgery; moreover, it would be the surgeon's responsibility to decide whether to delay the surgery, not the nurse's.278

Public health nursing is the branch of nursing that:

Provides health care for the community Public health nursing focuses on the whole population and the health of the community at large, not just on assessing or providing care to individuals. Community-based nursing, not public health nursing, involves administering care for a defined geographic community 265

Public health nursing is the branch of nursing that

Provides health care for the community 265

A client with severe congestive heart failure (CHF) has been referred to a long-term care facility. The nurse is transferring care from the hospital setting to a long-term care facility. Which action is a priority to ensure continuity of care for this client?

Providing accurate and complete communication to the new facility 269

A client with severe congestive heart failure (CHF) has been referred to a long-term care facility. The nurse is transferring care from the hospital setting to a long-term care facility. Which action is a priority to ensure continuity of care for this client?

Providing accurate and complete communication to the new facility. To ensure continuity of care for the client, the nurse should send a detailed assessment and care plan from the hospital to the extended care facility. Frequently, the nurse at the hospital provides a verbal report to the nurse at the new facility using the approved handoff technique. Other departments at the hospital should be notified of the client's discharge, but this does not affect the client's continuity of care. Discussing the move with the client and family is important, but this does not ensure continuity of care. The family members are asked to meet with the social worker but, again, this does not ensure continuity of care. 269

In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning?

Providing client education The nurse is teaching the client important information about self-care at home prior to the client's discharge. The initial step in discharge planning is collecting and organizing data about the client, as this provides information on the client's health care needs. Home referrals may be made after the education process, based on orders provided by the physician. Developing goals may occur after the education process, as the goals need to be realistic. 227

In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning?

Providing client education 227

The nurse understands that planning for discharge actually begins at admission to the facility. The purpose of discharge planning is best described as:

Providing continuity of care that is goal directed 269

A client diagnosed with terminal leukemia is receiving home health care services to assist in the client's care. After assessing the client, the home health care nurse determines that client is unable to afford needed medical supplies. Which is the best strategy for the nurse to implement to assist the client?

Refer the client to a social worker to determine eligibility for assistance 208

A client diagnosed with terminal leukemia is receiving home health care services to assist in the client's care. After assessing the client, the home health care nurse determines that the client is unable to afford needed medical supplies. Which is the best strategy for the nurse to implement to assist the client?

Refer the client to a social worker to determine eligibility for assistance. Social workers assist in finding and connecting the client with community resources or financial resources and provide counseling and support. 208

A nurse working in a primary health care facility would most likely provide which service?

Screening Screening falls within the category of primary health care. Acute care and treatment are a part of secondary health care. Rehabilitation falls under tertiary health care. 278

A hospital has begun to expand home health services to its clients. Which reason is the most likely cause for the expansion of these services?

The change to shorter hospital stays 277

Which are examples of factors the nurse would assess to determine a client's functional abilities? Select all that apply.

The client's ability to ambulate The client's comprehension Whether the client wears eyeglasses To determine functional abilities, the nurse must assess the client's ability to care for oneself and what devices or assistance the client needs to do so. 282

One of the fastest growing venues of practice for the nurse is home health care. What is the basis for the growth in this health care setting?

The discharge home of clients who are more critically ill 283

It is important for home health care nurses to remember which point?

The nurse is the guest in the client's home 288

A nurse is preparing for handoff communication for a client who is being discharged from the hospital to home health care. Which example is not an action performed during this process?

The nurse prepares the new room for the client 269-270

The nurse is met in the staff lounge by the nurse who has been caring for the client team on this shift. The off-going nurse says, "Sorry, but I have to get out of here." The nurse then gives a quick overview of each client on the team and says, "All the rest is in the chart if you need anything." Which essential part of the handoff is missing?

The opportunity for the oncoming nurse to ask questions Handoffs should always include a chance for the oncoming nurse to ask questions and to clarify anything that is unclear. The nurse should not expect an opportunity to assess the clients, check IV sites, or meet new clients prior to the previous nurse leaving. In instances where bedside report is given, the nurse may have some of these opportunities, but they are not required in a handoff. 269

When a multidisciplinary team is involved in meeting the home care needs of a client, who is the person responsible for the coordination of the care provided?

The registered nurse Regardless of the number of providers for home health care, the responsibility for care coordination remains with the registered nurse, not with the social worker, chaplain or minister, or home health care aide. 284

A nurse is caring for a client who decides to leave the hospital against medical advice (AMA). The nurse knows that the client must sign a form before leaving. What is the purpose of the AMA form?

To release the physician and the institution from any legal responsibility 283

When would it be appropriate for the nurse to initiate discharge planning with a client who will be discharged the next morning?

When providing preoperative education related to a scheduled cataract extraction Discharge planning prepares a client to move from one level of care to another within or outside of the current health care facility. Traditionally, this process involved discharge from the hospital to the home. In the current health care system, discharge planning occurs in all settings, including ambulatory surgical centers, rehabilitation units, drug treatment centers, and childbirth centers. 280

On admission to the hospital, each client is asked whether the client has a living will or a durable power of attorney. If not, the admitting staff person provides a sample form to the client if wanted. The purpose of this inquiry is to determine:

Whether the client has a document describing wishes for care when the client is no longer able to make decisions 278

Continuity of care for a particular client is most important to prevent:

fragmentation of services. Continuity of care is the provision of health care services without disruption, regardless of movement between settings. It is most important in preventing fragmentation of health care services. It does not prevent a client from needing the services of multiple providers, although it can ensure better communication and coordination among these providers, resulting in improved outcomes for the client. 274

A new client arrived on the unit while the nurse was obtaining the end-of-shift report from the night nurse. This client is admitted walking and is here for a cardiac workup; the client is assigned to the nurse. The nursing assistant has settled the client in the room and oriented the client to the surroundings, call system, bathroom, bedside supplies, and where to place clothes. The priority nursing action is to:

gather information and complete the admission database. The nurse's priority is to complete the admission of the client and perform the history, assessment, and documentation. Additional interventions that can be completed after the assessment include asking the nursing assistant to obtain vital signs, retrieving the admission orders from the prescriber, and following up with dietary if warranted. 277