Running head: COMMUNITY HEALTH NURSING ASSESSMENT

Community Health Nursing Assessment
Alison C. Jessup
Saint Joseph’s College

COMMUNITY HEALTH NURSING ASSESSMENT
Abstract

COMMUNITY HEALTH NURSING ASSESSMENT
Prior to becoming a nurse five years ago I didn’t really give much thought to the community that surrounded me. I independently went about my daily life without really considering my neighbors or municipality and I certainly wasn’t geared towards thinking about how I can give back to the community. It wasn’t until I began working in a local hospital that I started to contemplate the community and those I serve not only within the confines of the brick and mortar but far beyond. I initially started to become involved in the Jordan Hospital community and today I currently participate in various committees such as our Unit Based Council, Service Excellence, Meditech 6.0 Computer Implementation and our Stroke Resource Team. Exposure to various teambuilding opportunities has enhanced my relationship with senior leadership and also allowed me to be a voice for staff nurses and implement positive change. A particular area that I saw the greatest opportunity for change with the most impact to patient care and safety was with our stroke team.
It is not unusual to have patients admitted to my floor with a diagnosis of Cerebral Vascular Accident or Transient Ischemic Attacks. Rarely do we see the inpatient stroke victim, but it does happen. The first inpatient stroke that I was involved with sparked my passion for stroke. Needless to say it did not go smoothly. There were so many flaws in our protocol. Staff education was poor, and we did not have a neurologist on call, just to name a few of our challenges. This particular patient outcome wasn’t ideal and I knew something had to change. I wanted to make a difference so I became involved in our Stroke Resource Team.

COMMUNITY HEALTH NURSING ASSESSMENT
According to Stern et al. (1999), despite progress in stroke prevention and improvements in medical care stroke remains the third leading cause of death and the major cause of long term disability in adults in the United States of America.
These facts were startling to me and I began to recognize the tremendous public and economic burden that stroke has on our health care system. I realized that could potentially improve stroke prevention and outcomes so we began to first focus our team on the protocols within our organization that would apply evidence based medicine to standardizing our methods of delivering the best possible care in the event of a stroke. We began to put systems and protocols in place to assess, treat and expedite patient flow from the arrival at the Emergency Department through diagnostic testing to treatment for patients meeting the criteria for administration of the clot busting drug tissue plasminogen activator (tPA). We implemented protocols to improve our bedside speech and swallow evaluations, we improved our method of delivering smoking cessation teaching and we improved our inpatient stroke education outcomes by initiating concurrent reviews. We hired full time staff neurologists and encouraged all nurses to become NIH Stroke Scale Certified.
Our team efforts have paid off and according to Wicked Local in 2010 Jordan Hospital received the American Heart Association/American Stroke Association Get With The Guidelines Award. The award recognizes Jordan Hospital’s commitment and success in implementing excellent care for stroke patients, according to evidence-based guidelines. Jordan Hospital achieved 85% of higher adherence to all Get With The Guidelines-Stoke Performance

COMMUNITY HEALTH NURSING ASSESSMENT
Achievement indicators for two or more consecutive twelve-month intervals and achieved 75% or higher compliance with six of ten Get With The Guideline-Stroke Quality Measures, which are reporting initiatives to measure quality of care. These measures include aggressive use of medications, such as tPA, antithrombotics, anticoagulation therapy, DVT prophylaxis, cholesterol reducing drugs and smoking cessation, all aimed at reducing death and disability and improving the lives of stroke patients.
Coordinating and improving Stroke care and education throughout Jordan Hospital has been a team effort and one that has led us to achieve the recognition of being a primary stroke center but we quickly realized that the education does not end there. We understood the impact that we could have on our community and we began to take our efforts to the streets attending community health fairs and speaking in community centers and nursing homes. Our outreach efforts have been vast yet the education is ongoing.
Collaborating with my stroke resource coordinator Maureen Moroney RN, BSN, who is also my nurse manager, we devised materials and presentations that were suitable for educating the public. The health fairs we attend generally focus on blood pressure screenings and education on stroke prevention using the National Stroke Association act FAST acronym as a reminder of how to recognize and respond to stroke signs and symptoms. We have found that take a way handouts and card size reminders are very effective in capturing peoples attention. The blood pressure screening are most effective in engaging the public in an open dialect and helping to considering the holistic needs of the person you are screening. My back round in psychology has

COMMUITY HEALTH NURSING ASSESMENT proved to be helpful when assessing someone’s physical, spiritual, psychological and social needs. I generally take a holistic approach in my nursing practice at the bedside yet there is something very different about this approach out in the community. I often have less time to engage a person and to make the connection needed to impact a person’s health so every second I can spend with them to empower them to know that they can make health improvements is precious.
Many of the patients I have screened have dangerously high blood pressure. I recently did a health fair that was specifically for the town’s employees. More than half of the people that were screened had dangerously high blood pressure and one person we sent directly to the Emergency Department because they were symptomatic complaining of headaches and dizziness. It is moments like that when you know you are making a difference in your community. In addition we have devised power point presentations that we usually present to small groups generally in Senior Health Centers or Nursing Homes. We often don’t include blood pressure screenings at these but we do allow ample time for questions and answers. This really allows me to see the lack of knowledge regarding stroke and reinforces my desire to continue my community education efforts. Today we are seeing younger and younger victims of strong and I am confident that if we can teach people to recognized the signs and act fast we can improve our outcomes. Coupled with prevention, we will win the battle.
Reflection Paper
It was May 23, 2011 and it was a typical day on the telemetry unit. I was working a 7:00 a.m. to 3:00 p.m. shift and I started my rounds. I made my way to each patient and found myself
COMMUITY HEALTH NURSING ASSESMENT in room 325. In the bed was a petite elderly women in her eighties who had been admitted with new onset of rapid atrial fibrillation (a-fib) and questions of a gastro-intestinal (GI) bleed her clinical picture in report showed that she had a low hematocrit, and a new a-fib. During report I was already questioning myself; is this a GI bleed or is the patient anemic? Maybe she is dehydrated, what is her blood pressure and is she at risk for a stroke? These are many of the clinical questions we ask ourselves; it is our responsibility as nurses to dig deeper and see more of the patient that lab values, vital signs, etc.
When I entered the room I noticed that the patient was pale, awake but looking very tired. There was an elderly man next to her bed asleep in a high-backed chair holding her hand. I whispered, “good morning, my name is Alison and I will be your nurse today.” She smiled back and told me her name was Betty and that the man next to her was Bob, her husband. My first order of business was to check her vital signs and although I do not recall her exact vital signs, I do know that she had an elevated heart rate and her blood pressure was on the lover side. By this time her husband, Bob, had awakened and was eagerly awaiting information regarding his wife’s condition. I knew they had a long day ahead of them with many procedures to be done. I explained to Betty and Bob that she would be having and electrocardiogram (EKG) of her heart, blood samples would be drawn and that she would be starting a new intravenous medication called Digoxin. They both looked puzzled as I recall so I began to explain the nature of each procedure and about the new medication. In addition to my verbal explanation I gave them handouts about the medications and testing for them to read.
The EKG technician was now at the door and I ushered her in. Bob asked if he could
COMMUNITY HEALTH NURSING ASSESSMENT stay in the room while the procedure was being done and we, of course, said yes. I left the room and began checking the morning labs that had been drawn. I noticed that her hematocrit (red blood cell count) was lower than her admission so I paged the physician.
We collaborated and between the low blood pressure and lab values, the physician ordered blood to be given as well as an upper endoscopy to rule out an acute bleed. I notified my patient and her husband and explained the blood transfusion procedure and what was involved in the upper endoscopy. Because the patient was also receiving intravenous fluids, it was necessary to place another IV access site. I left the room to get supplies and Bob followed me out. He asked me if Betty was going to be okay and also shared with me that they had not spent a night apart since they were married. I could see that he was deeply concerned and scared for Betty’s wellbeing. As I gathered my supplies, I tried to dispel his fears by explaining that she was in good hands and that we were doing the necessary procedures in order to get her well again. I remember him asking if she would be discharged home that night and when I said that I did not think she would be discharged, he looked upset. I knew he did not want to leave her at the hospital alone, and more importantly, I could see it would be important for the patient to have him by her side. After placing the IV access, hanging the blood and giving the patient her medications, I set up the room so that Bob could stay the night with Betty by making him up a fresh bed right next to her. After the patient received her blood transfusion, we sent her down to endoscopy. I had explained the procedure in depth to the patient and her husband, as it was unfamiliar to both of
COMMUNITY HEALTH NURSING ASSESSMENT them. This was challenging in the sense that they were simple every day people who were not savvy with medical terminology. It was necessary for me to use layman’s terms and explain what an upper endoscopy is and how she would feel post-procedure. I answered many questions that they both had and arranged for transport. Because Betty was nervous, I suggested that Bob follow her down for the procedure. I also called endoscopy to see if they would allow Bob to stay with Betty as long as possible and they agreed. When Betty arrived back on the floor, she was still lethargic form the sedation and her every faithful Bob was at her side. He told me what I had received in report from Endoscopy that she had done well. The nurse in endoscopy also reported that they did not see an active bleed. During my shift I had accomplished many things: The patient received blood; the doctor rounded; she started Digoxin IV; we arranged for her husband to stay overnight comfortably with guest meals; and she had her upper endoscopy. This had been a busy day for the patient, family and me. It was a demanding day in the sense that Betty was only one of five of my patients. Toward the end of my shift Betty’s heart rate had stabilized, her hematocrit had responded favorably to the blood transfusion and according to her endoscopy report she had no active bleed. The physician was made aware of all of our strides. Considering her hematocrit was stable the doctor ordered more tests for the morning: a stress test, transesophageal echocardiogram (TEE) and to change the patient to oral Digoxin. I again notified and educated the patient of the upcoming procedures for the morning and then I said goodbye.
I recall them uneasy about me leaving so I introduced the oncoming nurse to them so it would put them more at ease.
COMMUNITY HEALTH NURSING ASSESSMENT
The next day, I returned to work and Betty was my patient again. Overnight she had converted to a sinus arrhythmia. It was around nine in the morning when cardiology called for Betty. I went to the room to help her get ready for her exercise treadmill test (ETT). While Betty was having her ETT, it gave me time to review her morning labs along with those of my other patients. Betty’s Hematocrit had remained stable and all other labs were within normal limits.
After her ETT, Betty when right to her TEE; this was unexpected because it wasn’t planned until the afternoon but the doctor had an opening and wanted to move things along. I had already explained to the patient the nature of the test but unfortunately Bob was not able to attend so I escorted him back to room 325.
After the TEE, Betty was settled back into her room and I spoke with the doctor. It was good news, no clots had been detected, but because of her age and the new onset of a-fib, we would start her on Coumadin. I gathered the necessary teaching tools and the medication and explained it to Betty and her husband. I also explained that Betty would be kept overnight and most likely discharged in the morning.
They both seemed very excited about the idea of going home. I spent the remainder of the day coordinating Betty’s discharge plans and paperwork as well as care for my other patients.
Because Betty was now on Coumadin, it was necessary for me to collaborate with the continuing care nurse. We needed to set up a coumadin clinic appointment and I wanted everything to be ready for the morning, as I knew I would not be there.

COMMUNITY HEALTH NURSING ASSESSMENT
That afternoon I reported off and said goodbye to Betty and Bob. We had developed a strong line of communication and trust and I assured them that the morning nurse would be prepared for the discharge. We reviewed her new medication Digoxin and Coumadin, said a teary goodbye and I went home for the day.
As I reflect on this case now I remember thinking after report that Betty would be the typical a-fib and rule out GI bleed. Her hospital course, however, turned out to be a bit more complex.
Betty needed a lot of medical attention and education on what was happening to her at each point of her stay. Aside from the medical portion of her case, she had a lot of emotional and social needs as well. It was important that she was supported and her fears recognized. It would have been easy to just tell her that she was having a certain test and leave it at that, but that would not have given her the sense of trust and comfort I wanted her to feel. It was important to me that she was well informed of her exams and to assure her that I was available for questions. Betty also needed her husband by her side and he needed to be there as well.
Occasionally during the two days I cared for Betty, I felt a little overwhelmed. It isn’t always and easy task to have a patient such as this and still have other patients who need me just as much. Thankfully, I was able to pull from my resources on the floor in order to deliver quality nursing care. Shortly after Betty’s discharge a basket of fruit was delivered to the floor thanking me personally for providing Betty with extra special attention.

References

Benner, P. (1984). From novice to expert. Saddle River, NJ: Prentice-Hall, Inc.
Jordan hospital receives performance award. (2011, February 17). Retrieved from http://www.wickedlocal.com/plymouth/news/business/x1055395593/Jordan-Hospital-receives-performance-award#axzz1UqEeaxg5
Stern, E.B., Berman, M., Thomas, J.J., & Klassen, A. (1999). Community education for stroke awareness an efficacy study. Stroke Journal of the American Heart Association, Retrieved from http://www.strokeaha.org/content/30/4/720