Community Nursing Careplan - Population Based Change Care Plan

Community Nursing Care Plan 1 Demographic Information The San Marcos School of Nursing hosts several community clinics across the county. One of the numerous clinics is OB1 located in Ocean Beach, San Diego. The overarching goal of the clinic is to improve the health of the underserved and uninsured population, while providing excellent quality care to the patients. A Point-In-Time Count survey, conducted by the Regional Task Force on the Homeless San Diego (RTFHSD) (2016), showed approximately 8,692 homeless people residing in San Diego county. Further, the data showed that San Diego county holds the third highest number of homeless individuals when compared to all other counties across the United States (Health and Human Services Agency (HHSA), 2013). San Diego city alone holds just over 5,000 homeless members of the counties total homeless population, making the vast majority of 62% residing in the same city as OB1 clinic (RTFHSD, 2016). Of the homeless population, the majority of its members are white males making up over 60% (RTFHSD, 2016). Demographics depicted in the Point-In-Time Count survey are equally represented within the OB1 clinic, where the majority of clients seen there identify as unsheltered homeless white males. Patients are treated at OB1 with many different acute and chronic conditions, but one condition that is seen frequently amongst the patients is substance abuse. Social History The OB1 clinic serves many patients from a broad range of ethnicities and demographics. The patients seen at the clinic are of low socioeconomic status and often homeless. The largest portion of the homeless population served at OB1 consist of white males. According to the RTFHSD, there was an 18.9% increase in the unsheltered homeless, resulting SUBSTANCE ABUSE AMONGST HOMELESS MALES of the homeless living on the streets and tents instead of shelters or other transitional housing programs (2016). A good portion of the homeless live in close proximity to other homeless individuals and maintain friendly relationships with one another. Upon the patient’s arrival to the clinic, they are asked a series of questions to establish their social history including use of tobacco, alcohol, and street drugs. The majority of patients admit to alcohol use and many to marijuana use as well. In regard to transportation, most travel by foot unless able to access a temporary bus pass. There is also an increased need to access food services, but many of the churches in the area provide meals to the homeless population. Ultimately, the social factors experience by the vast majority of homeless individuals make them a high risk and vulnerable population. Needs Assessment The homeless population faces intense barriers on a daily basis that put them at risk for negative health effects. Homeless white males that attend the OB1 clinic have many health needs, however, it is important to use Maslow’s hierarchy of needs to assess the most pertinent needs. Physiological needs are the most important, which require instruments for survival such as: food, water, and a healthy physical state (Huitt, 2007). If a patients most instrumental physiological needs are not provided for, other levels such as safety cannot adequately be addressed (Huitt, 2007). Nonprofit organizations and charitable groups around the area offer meals and clothing to support homeless individual’s basic needs, especially the evening meals provided by nearby churches who also give out hygienic supplies. At OB1 we supply patients with healthcare, so they can maintain a healthy physical body to sustain life. Many of the patients have experienced difficult situations or suffer from untreated mental illnesses that resulted in poor coping skills. Self-medication through substance abuse is common amongst the population. SUBSTANCE ABUSE AMONGST HOMELESS MALES Along with chronic substance abuse, many health complications emerge such as malnutrition, risk for injury, and impulsiveness. If clients suffering from substance abuse can develop adequate coping skills to refrain from using drugs and alcohol, their physical and mental state have the opportunity to improve tremendously. The vast majority of homeless patients however have inefficient coping skills to deal with life stressors. Problem Identification One frequently seen condition amongst the homeless white male population is chronic substance abuse. Chronic substance abuse puts patients at a much higher risk for injury. Furthermore, the population is more vulnerable due to less access to hygiene supplies, poor quality of clothing, unstable housing, unsafe or unsanitary conditions, frequent exposure to crime or trauma, inadequate nutrition, increased rates of alcohol use, and poverty (National Health Care for the Homeless Counsel, 2004). According to the San Diego Alcohol and Drug Services Housing and Services Report conducted by the Health and Human Services Agency (HHSA) (2013), “thirty-seven percent of alcohol users and fifty-three percent of drug users also have a diagnosable mental illness” (p. 2). Of the unsheltered homeless population in San Diego, 34% reported a “high level of substance abuse” (HHSA, 2013, p. 2). Healthy People 2020 identifies several objectives regarding substance abuse. Two health-related objectives in particular that directly relate to our populations. First, SA-8 to increase the proportion of persons who need alcohol and/or illicit drug treatment and received specialty treatment for abuse or dependence in the past year (Healthy People 2020, 2018). Second, SA-15 to reduce the proportion of adults who drank excessively in the previous 30 days (Healthy People 2020, 2018). Ultimately, the white homeless male population in the city of San Diego are in need of education on effective coping skills and referral to appropriate support or SUBSTANCE ABUSE AMONGST HOMELESS MALES rehabilitation groups. They also need to have improved medical access, so they have the option to receive case management and assistance with their other conditions caused by chronic substance abuse. Location and Nature of Service OB1 clinic is held and ran by volunteers provided by the California State University, San Marcos Student Healthcare Project. The project hosts several clinics across the county of San Diego. The OB1 clinic is held in Ocean Beach, within the city of San Diego, and runs on Wednesdays from noon until 4pm. The clinic provides an array of services including: physical assessments, PAP smears, blood sugar checks, ECG’s, blood pressure monitoring, vision and hearing checks, urine analyses, pregnancy testing, and the majority of other medical services. Whether the patient is new or returning determines what paperwork they fill out prior to the appointment. Case management appointments consist of activities such as MediCal sign-ups, support groups, assistance finding housing, finding food resources, applying for patient assistance programs, and many other tasks to assist the patient. The patient is then brought back to the patient exam room, vital signs are taken, and a short interview of the patient is conducted by the nurse. The nurse then communicates the information to the nurse practitioner using SBAR. The NP then conducts a full head to toe assessment, diagnosis of the condition, treatment plan, educates, and prescribes appropriate medications. The clinic is vital for the uninsured and underserved populations healthcare and quality of life. Orem Self-Care Theory Universal Requisites USCR Maintaining a sufficient intake of air. Maintaining a sufficient intake of food and water. Met/Unmet & Rationale Met. The community at hand is able to take in a sufficient intake of air. Their oxygenation and respirations remain adequate and sufficient. Partially met. The inability to provide consistent meals and food is commonly seen amongst the homeless population. However, the local community SUBSTANCE ABUSE AMONGST HOMELESS MALES churches and food pantries provide meals and water to the homeless population which sustains them for the most part. Elimination and Excrement Partially met. Even though the population is able to void and defecate care. regularly, as well as clean themselves up, they have less access to bathrooms. The population has less supplies for maintaining good perineal care and clean hygienic practices. The lack of access to consistent toileted facilities makes elimination and excrement care only partially met. Balance between activity Unmet. The homeless population has difficulty sleeping due to being and rest. constantly exposed to the elements. They are awoken frequently by loud noises, cars, lights, animals, and other factors that are involved with sleeping outdoors. During the day they are forced to travel mostly by foot and have to find food, shelter, and supplies to get through their days. They have very little to no balance between activity and rest. Balance between solitude Met. The homeless population typically socializes with other homeless and social interaction. individuals across their San Diego community. They frequently camp or stay in similar areas so they are able to socialize with others. When they are out during the day they are able to sit on their own. They have a steady balance between solitude and social interaction. Hazard prevention. Unmet. The homeless are constantly exposed to trauma, crime, substance abuse, and mental illnesses. They typically lack good hygiene practices and are exposed to diseases. By not having consistent shelter, the homeless population in Ocean Beach is at a much higher risk for hazards. Normal function and Unmet. The homeless people of Ocean Beach are faced with consisten development. trauma, stress, substance abuse, and other life events that impede on the ability to develop normally and maintain normal functionality. Stages of development by Erickson may be altered due to life events. Developmental Self-Care Requisites: DSCR Met/Unmet & Rationale Maturational Unmet. The homeless population is often unable to handle changing needs associated with development. The lack of shelter and unconventional lifestyles make living situations unpredictable and make maturational changes hard to adjust. Situation Unmet. Situational events often are what caused the homeless population to be without shelter and their current status of homelessness. They often have disabilities, metal illnesses, substance abuse, and overwhelming poverty that make situational changes in development difficult. Ultimately, the lack of available resources and lifestyle make situational developmental adjustments difficult. The majority cannot cope well with situational life events. Often they will self-medicate through substance abuse to cope. Health Deviation Self-Care Requisites: HDSCR Met/Unmet & Rationale Seeking and securing Partially met. The need for available healthcare to provide for the homeless appropriate medical help. extreme and difficult to attain. The OB1 clinic provides the homeless population with quality medical services, however, it is not enough to supply for all. Most of the homeless do seek help for medical conditions once they SUBSTANCE ABUSE AMONGST HOMELESS MALES Being aware of, and taking care, of pathologic conditions. Effectively carrying out prescribed diagnostic, therapeutic, or rehabilitative measures. Being aware of, and taking care of, side effects of medical care measures. Modifying self-concept and self-image. are to a point that concerns them. They will often seek free clinics or government run facilities Partially met. The homeless are often not aware of their pathological conditions due to low levels of education or not able to attain early detection screenings. Once they are aware of pathological conditions most try to the best of their abilities to maintain their health, but often they do not have the supplies or mental capacity to adequately care for the conditions. Noncompliance is common for those who cannot attain medical supplies, but OB1 clinic does provide a place for the homeless to get evaluated and to receive supplies. Partially met. Patients come to OB1 to get diagnostic, therapeutic, and rehabilitative measure, but often are unable to hold the supplies for long periods of time. Often when people are sent to Questlabs to receive outsourced diagnostic lab testing, patients are unable to attend from a lack of transportation. Ultimately, many have the desire to carry out their therapeutic measures but lack the resources. Partially met. The population that is able to attain treatment regimens are sometimes aware of the side effects, whereas others see the side effects as too unsatisfactory and stop treatment abruptly. Since they often do not see medical professionals on a regular basis, they have less ability to discuss side effects with their physicians in order to adjust them or gain knowledge on how to manage side effects. Partially met. The homeless population has differences in their ability to adjust their self-image and self-concept. Whether health diagnoses are avoided or ignored, they do often to not attain the proper actions toward correcting the health issue. Although some people are able to adjust their selfconcept as their conditions change, many are unable to cope with the changes. When the individual is unable to cope with the changes in self-image, substance abuse can be seen as a coping mechanism and is commonly seen amongst this population. NANDA Diagnosis Patient Problem Ineffective coping r/t use of substances to cope with life events. Objective: Pt displaying s/s of alcohol Expected Outcomes 1. By the end of the appointment , the patient will use one healthy coping strategy to decrease stress. Nursing Interventions & Rationales Education 1a. Offer education and instruction regarding alternative coping strategies. Rationale: According to Rauer-Wu, Sullivan, and Rosenbaum (as cited in Ackley & Ludwig, 2014), mindfulness meditation intervention assisted patients coping with situational stressors. Advocacy 1b. Encourage the client to describe previous stressors and the coping mechanisms used. Rationale: According Oflaz, Haitpoglu, and Ayan (as Evaluation of Patient Response 1. Outcome was met. There were two clients during the shift of the homeless white male population with substance abuse disorder, and they were able to use one healthy coping strategy to decrease stress. SUBSTANCE ABUSE AMONGST HOMELESS MALES intoxication (i.e. slurring speech, imbalanced gait, and alcohol odor coming from skin), destructive behavior toward others through physical assaults resulting in contusions and wounds, and the inability to meet basic needs such as housing and food by asking for food services. Subjective: Patient selfreports of decreased use of social support, fatigue, high-risk taking behavior, and substance abuse verbally stated by patients. cited in Ackley & Ludwig, 2014), a psychoeducation intervention that included clients identification of symptoms, types of coping strategies used before and after the event, and ways to select alternative strategies was accompanied by medication intervention for participants with PTSD and significantly improved depression were found. One patient used deep breathing, and the other used journaling by writing down feelings in their personal journal. Coordination of Care 1c. Ask appropriate questions to assess whether denial (defensive coping) is being used in association with alcoholism. Make appropriate referrals if patient wishes to peruse available resources. Rationale: According to To and Vega (as cited in Ackley & Ludwig, 2014), alcohol abuse is a major problem in the United States, but individuals are not getting treatment. In this survey, denial or refusal to admit severity and fear of social embarrassment were the top two reasons for not seeking help. 2. By the end of the appointment , the patient will state one name of an appropriate substance abuse support group in close proximity to the OB1 clinic. Education 2a. Teach the client about available community resources (e.g. therapists, ministers, counselors, self-help groups) for related substance abuse. Rationale: According to Janda et. al. (as cited in Ackley & Ludwig, 2014), while research suggests that persons needing community services are interested in using them, not all who need services use them, due in part to the need for more information about resources, how to use them more effectively, or availability of services. Advocacy 2b. Encourage use of spiritual resources as desired. Rationale: According to Ross, Sawatphanit, and Suwansuarid (as cited in Ackley & Ludwig, 2014), spiritual activities such as prayer, meditation, and doing good deeds played a major role in coping with chronic conditions in a sample of Thai women practicing Buddhism. Alcoholics Anonymous utilizes religious influences to support members sobriety. Coordination of Care 2c. Identify problems with alcohol with appropriate tools and make referrals for additional or more intensive therapies as needed. Rationale: According to Green, Choi, and Kane (as cited 2. Outcome met. There were two clients during the shift of the homeless white male population with substance abuse disorder. By the end of their appointments both patients stated the Live and Let Live support group for an over 40 12-step and harm reduction meetings as an appropriate substance abuse support group close to them. They also were given the phone numbers for the facility as well as Alcoholics SUBSTANCE ABUSE AMONGST HOMELESS MALES in Ackley & Ludwig, 2014) Tools such as the Alcohol Use Disorders Identification Test (AUDIT) and the Alcohol-Related Problems Survey (ARPS) help with referrals for treatment facilities. Brief interventions have been shown to be effective in producing sustained abstinence or reducing levels of consumption, thereby decreasing hazardous and harmful drinking. More complex interventions are available to assist with coping, for example, a nurse-delivered intervention for depression. Victims of crime or trauma, as well as patients of chronic mental illness, need the assistance of a multidisciplinary team to cope and achieve a positive recovery. Anonymous meeting information. Discussion Questions Week 4: Violence and Abuse Is there an evidenced-based role for the nurse in the community? Although community public health nurses have different strategies for implementation of interventions, their role in the community is still influenced by evidence-based practice. One example of evidence-based practice in the community is in regard to child maltreatment and the need for wide-spread utilization of evidence-based practices is vital in preventing child maltreatment in at-risk families (Hanson, Self-Brown, Rostad, & Jackson, 2016). Further, child mental health interventions can enhance how successful the intervention implementations are and yield the greatest results (Hanson et. al., 2016). However, the use of evidence-based practices and training is influenced greatly by how much funding is available to the agency. Describe the influence of economics on care at your agency and with your population. OB1 clinic serves a population of mainly uninsured and often undocumented patients who are far below the poverty level. The patients who attend the clinic are usually in desperate need for care due to the lack of resources they have due to their socioeconomic level. Unfortunately, the OB1 clinic itself is not a federally funded agency, meaning that despite the great work the program provides they must rely solely on donations for services. The clinic pays SUBSTANCE ABUSE AMONGST HOMELESS MALES for patient labs on their own and relies on volunteer workers to keep the clinic operational. Due to the limitation of financial resources, the clinic can only provide what it is fiscally able to. Economics is one of the main factors that drives healthcare, and OB1 is constantly influenced by the status of current funds. Describe how laws affect the nurse’s role in the community. Laws and regulations dictate much of what a community nurse can and cannot do in their profession. For instance, there are mandatory reporter laws that make it a legal requirement to report suspected domestic violence or abuse of their patients (Hanson et. al., 2016). This mandatory reporting is sometimes complicated when it comes to maintaining a trusting relationship with your patients as well as ensuring their safety. Often people are less open to discussing their situation or hardships with healthcare professionals due to this required reporting (Hanson et. al., 2016). Laws may also require that certain diseases seen amongst the community such as tuberculosis, hepatitis A, and many others, be reported to the proper authorities. Patients have a trusting relationship with healthcare providers within the community that may be affected by the transparency public health nurses must uphold to comply with law. For the most part, the laws and regulations regarding nurse’s role in the community put necessary requirements in place to ensure the safety of the workers and the community as a whole. How do regulations affect the services clients in the community receive? There are many regulations put on what services clients can receive, much of which is dependent on socioeconomic status and resource availability. One regulation that affects the services clients receive is the limitations of space in shelters for the homeless. Currently on the 211 San Diego website it states that there is only one available bed out of the six shelters across the city. The Emergency Housing for Families St. Vincent de Paul Village also has additional SUBSTANCE ABUSE AMONGST HOMELESS MALES regulations on who may receive a bed, which restricts all available beds to referrals through the Coordinated Entry System. Ultimately, the amount of resources in communities are limited and often do not cover all the individuals who may need services. The limited resources may be the cause of such strict regulations on financial aid and other services, so they can be utilized by those in most dire need. Describe the impact that regulations and laws have on nurse case management and give an example from your clinical work. Laws and regulations limit the extent to which we can serve our patients, but also put necessary limitation on services so that the community can fiscally afford the interventions. For example, I had a patient who still had a thousand dollars in a 401K of which he drained out slowly when his rent checks were due. Even though he was unemployed and impoverished, he was still not eligible for MediCal due to the status of having a 401K. In order to be eligible for MediCal he would have to use all the money in his existing account. The impact of laws and regulations put on public health workers and patients is great and affects all patients of the community. Ultimately, the case managers have the difficult task of trying to work around existing laws and regulations of the state to find out what the patients qualify for in order to receive appropriate healthcare. Identify and give examples of 2 case management activities that you performed with any clients. The Case Management Society of America (2018) described case management as, “a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources” (p. 1). I have had the opportunity to SUBSTANCE ABUSE AMONGST HOMELESS MALES conduct many case management activities within the past semester, two of which included signing up a patient for MediCal and assisting a patient with financially covering a surgical procedure. The client I signed up for MediCal had recently lost his job and slowly depleted his entire 401K. He also was a chronic diabetic who was in need of insulin and glucometer supplies to manage his blood sugar. After signing him up for MediCal he was very thankful and stated he was relieved to know he could get his medications and care for himself again. As for my patient who had recent surgery, the hospital forgot to apply her MediCal to the final bill following her surgery. The patient was a Spanish speaker and received her bill in English, so she had difficulties understanding what was asked of her. I called the hospital and discussed the case with multiple professionals before finally saving her thousands of dollars from a billing error. QSEN Patient-Centered Care QSEN is utilized to “address the challenge of preparing future nurses with the knowledge, skills and attitudes necessary to continuously improve the quality and safety of the healthcare systems in which we work” (QSEN Institute, 2017, p.1). The competencies that QSEN represents is quality improvement, patient-centered care, teamwork and collaboration, evidence-based practice, safety, and informatics (QSEN Institute, 2017, p.1). In order to exemplify patient-centered care, the staff recognizes that the client is the person in ultimate control of their health and in-turn their healthcare. The healthcare team ensures that patients preferences and values are taken into account and attended to, no matter their demographics or socioeconomic status. Especially amongst the chronic alcoholics seen at OB1, patients are given not only the physical help they need, but also emotional comfort. When patients need care SUBSTANCE ABUSE AMONGST HOMELESS MALES beyond simple healthcare, we have case-managers on site that assist the patients through complex difficult matters. Teamwork & Collaboration Teamwork and collaboration are constantly exemplified by the OB1 staff. The nursing students on site do the intake information of the patients, conduct short patient interviews, collect vital signs, and discuss the patient information using SBAR formatting to the nurse practitioner and medical students. The nurse practitioner students then conduct their own assessments and evaluations of the patient, then they give report to a physician or nurse practitioner in order to verify and discuss their diagnoses. The staff is always extremely courteous, respectful, and efficient at working with one another. The quality patient care given to our patients is evidence to our thorough discussions and effective communication. The healthcare team analyzes their own abilities and feel comfortable asking questions without being put down by other staff members. The individuals working at OB1 collaborate well with each other and exemplify teamwork every day at the clinic. Evidence Based Practice According to QSEN (2017), evidence-based practice is the integration of best current practices backed by evidence and clinical expertise in order to deliver optimal medical care. All skills and practices preformed at OB1 clinic are fully based off of evidence-based practice in order to ensure the best quality of care for our patients. The staff follows practices that were supported by evidence when it came to wound care, treatment plans, prostate screenings, mammograms, pap smears, physical assessments, and all other aspects of healthcare preformed within the OB1 clinic. Ultimately, the work conducted at OB1 is thorough and systematic, following evidence-based practice and protocols. SUBSTANCE ABUSE AMONGST HOMELESS MALES Journal Throughout the past semester at OB1 clinic I have had many learning experiences. I have been challenged in my abilities to perform certain nursing skills, critically think, and problem solve. Many skills that I learned in the classroom were performed in the clinic such as wound care, where I was given the opportunity to practice and gain experience. I enjoyed having the opportunity to be the first person to really speak with my patients, gather their information, and evaluate in my mind what I thought might be going on. By listening to the nurse practitioners following my patient interview, I was able to find gaps in my assessments and realize questions I should ask at the beginning. For example, I had a patient who complained of diarrhea and weight loss for the past month, arm pain at her joints, and had a prior history of hypothyroidism. In my mind I thought to myself how odd the diagnosis of hypothyroidism was, especially with the weight loss she was having, and truly was puzzled on what further information to ask. Once I presented the patient to the NP, she asked my patient whether she had made any diet changes lately, where she mentioned she decided to go on a keto diet a month ago. Even further, the NP asked what kind of salt she put on her food, where she then discovered the patient was using kosher salt that had no iodine additive. After reflecting on this patient, I realized how important it is to ask about a patient’s diet and other details to a patient’s life that may be significant to diagnoses. Another thing I have realized is that my communication skills have improved tremendously within the course of this semester. It is more challenging to get an entirely new patient instead of being in the typical hospital setting with a current diagnosis. Communication skills are key to getting to know the patient, establish rapport and trust, and critically thing to pull out important information from their brief interview.