Nursing Process in Home Setting

1
Nursing Process in Home Setting

• N312 - Home Health Nursing

2
Home Health Focus

• Patient health care needs
• Familial factors
• Socio-cultural factors
• Economic factors
• Environmental factors

3
Nursing Assessment

• Data collected assists physician with plan of
  care and development of nursing care plan.
• Plan of care vs. patient care plan
• discipline oriented care plans

4
Components of Assessment Phase

• Initial telephone call
• Assessment interview
• Historical database
• Nursing health history
• Medication assessment
• Physical assessment
• spiritual, mental, functional status

5
Nursing Diagnosis

• Common ones used in home care
• knowledge deficit
• activity intolerance
• self-care deficit

6
Nursing Planning

• Plan of care
• multidisciplinary - care paths
• Patient care plan
• medical treatment plan
• interventions
• projected outcomes of care
• long term goals
• has specific aim/purpose regarding patient care

7
Nursing Planning (cont)

• Outcomes of care
• goals and outcomes reflect nursing diagnosis and
  overall plan of care
• patient centered
• goals are long term and should occur by discharge
• outcomes are precise and measurable steps to
  achieve goals

8
Nursing implementation

• Identify specific interventions to achieve goals
  and outcomes
• Interventions are often improvisational in home
  setting
• trial and error

9
Nursing implementation (cont)

• Case management
• exchanging information with patients/caregivers
• coordinating referrals
• faciitating multidisciplinary conferences
• seeking resources within the community
• integration of care plan with caregivers/patients

10
Nursing implementation (cont)

• Guidelines for implementation of care plan
• agency policies and procedures
• inclusive of multidisciplinary team and
  patients/caregivers
• collaboration and cooperation
• improvisation and individualization
• reimbursement regulations

11
Nursing evaluation

• measure effectivenss of nursing actions,
  multidisciplinary care and appropriate
  utilization of resources
• determine progress in meeting outcomes of care
  and achieving long-term goals
• discharge planning
• continuum of care