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content Introduction Ambulatory care Definition Modules ambulatory care practice setting Dimensions unique to nursing practice in ambulatory care Nursing responsibilities. Acute care and critical care. Acute care. Types of hospitals ; Client admission to a hospital. Nurses role in hospitals Critical care. Need for the admission. Common condition necessitating ICU admissions Role of nurse.

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Long term care. Long term care facilities Nurses role.


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Home health care. patient care in the home home health care team Nurses role.
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Conclusion. Reference.

1. Introduction.

Medical field is a vast field which keeps on changing according to the needs of the clients; as a result it has given rise to development of new concepts such as ambulatory care, acute and critical care, long term care, home health care. 2. Ambulatory care. a) Definition. Ambulatory care is any medical care delivered on an outpatient basis. Many medical conditions do not require hospital admission and can be managed without admission to a hospital. Many medical investigations can be performed on an ambulatory basis, including blood tests, Xrays, endoscopies and even biopsy procedures of superficial organs. b) Modules which influence ambulation. Clinical model. :most health policy experts agree that the current health care system is based on the clinical or medical model .in this model health is conceptualized as the absence of the clinical manifestations of disease . It is assumed that the body is a machine and that modern medical technology can use physical and chemical interventions to fix the machine when ever its broken .this has led the great emphasis on expensive, acute care with high technology treatments and relatively little attention to prevention, public health, environmental measures, or personal responsibility for health. Levels of prevention model. This model suggests that the natural history of any diseases exists on continuum , with health at one end and advanced disease at the other .this model gives three levels of the application of preventive measures that can be used to promote health and arrest the disease process at different points along the continuum. The goal is to maintain a healthy state and to prevent disease or injury Primary prevention; encompasses both health promotion and specific protection. Health promotion

includes interventions such as health education, information on growth and development, nutrition, and exercise as well as the provision of adequate housing, safe working conditions, and other services. Specific protection interventions are targeted at specific health risks, injuries, and diseases .ex: seat belts reduce injuries in automobile crashes. Primary prevention may be targeted at individual clients, families, groups, communities, or population. prevention: secondary measures include early diagnosis and prompt treatment as well as disability limitation .case finding, screening, and treatment of disease by medical or surgical interventions to arrest the disease process and prevent further complications are all part of secondary prevention. An ambulatory care nurse carrying out a multiphase health screening for hypertension, diabetes, and hypercholesterolemia would be practicing secondary prevention. Tertiary prevention: it is the provision of measures to rehabilitate a person or group so they can maximize their remaining capacities .cardiac rehabilitation nurses, physical and occupational therapists and many home care nurses focus on tertiary prevention. E.g. teaching crutch walking. Primary health care, primary care, and managed care models. Primary health care focuses on the universal right to basic health care. Primary care focuses on integrated care coordinated by one primary provider .managed care approaches the use of health care services from a cost containment perspective .primary prevention of often confused with the concepts of primary care providers, such as family practice physicians and nurse practioners, in a gatekeeper function, causing further confusion.
Secondary

c) ambulatory care practice setting :health statistics

classifies ambulatory care settings into three main groups : physicians office : This is the most common site for the delivery of ambulatory care. Physicians of many specialties deliver ambulatory care. These physicians include specialists in family medicine, internal medicine, obstetrics, gynecology, cardiology, gastroenterology, endocrinology, ophthalmology, and dermatology. Physicians group practices usually operate on for a profit basis and seek fee for service payment directly from clients or through third party payers such as insurance companies etc. In a fee for service system, providers get paid separately for each service they provide, more service they give, more revenue they get. In integrated delivery system, hospitals align with several physician group practices to increase the hospital referral rate and provide increased coordination of care. The role of the ambulatory care nurse in physician group practices is evolving to meet the need for increasingly skilled technical services, especially in specialty practices such as oncology, and surgical centers.
community hospital out patient department: community hospital clinic services began in the

latter part of the 19th century and took over functions of free standing dispensaries ambulatory services may be housed adjacent to the hospital or be freestanding in the community .services may include outpatient surgery ,emergency centers, cardiac rehabilitation centers , drug and alcohol treatment programs, oncology health centers, home care, hospice ,and community health promotion .

Specialized clinics and health promotion programs

staffed by nurses also with in community hospital outpatient settings. teaching hospital out patient department : These departments of teaching were developed to fulfill the mission of academic health centers to provide medical and other health professional education, biomedical research, and client care services. university hospital outpatient departments and most large hospitals run by local governments provide learning experiences for medical, nursing , and other health science students as well as opportunities for clinical research on population s of clients with highly specialized needs .veterans administration ambulatory care departments serve a similar function. most teaching hospitals maintain a nonprofit status and provide care for those with public or private insurance as well as uncompensated care for uninsured clients Nurses play a major role in client and family teaching and as case managers for clients with catastrophic and chronic illnesses.
Emergency department :

Almost all of ambulatory care visits are provided in emergency departments (when there is no opd ).they may come in ambulance or by themselves .because emergency departments are organized according to the clinical nodal and are set up to meet acute care needs they are far from the ideal place to provide primary care services. Other ambulatory care settings. One unique type of ambulatory care organization is a nurse managed center or nursing center. these nurse staffed community centers may provide primary health care services , home care , hospice ,college health services, work site health promotion ,school nursing or wellness services .many nursing centers were developed by schools of nursing as faculty

practice sites for undergraduate and graduate students. Other settings in which ambulatory care nurses practice include government funded public health clinics, migrant and community health centers, homeless shelters, school based health centers. Dimensions unique ambulatory care. to nursing practice in

Telehealth nursing practice It is defined as nursing practice using the nursing process to provide care for individual patients or defined patient populations through telecommunications media. Criteria for the telenursing practice: o Using protocols, algorithms, or guidelines to assess and address client needs systematically. o Prioritizing the urgency of client needs. o Developing a collaborative plan of care with clients and their support systems the plan of care may include wellness promotion, prevention education, care counselling, disease state management, and care coordination. o Evaluating outcomes of practice and care. Communication by telephone for health guidance is common in pediatrics, obg, and primary care practices. According to nursing intervention classification telephone nursing intervention is of four types.
o Telephone

consultation. Here nurses assess the clients need and readiness to learn, teach clients, and provide advice based

on protocols approved for use with telephone nursing practice. o The nurse must have expert communication skills to elicit information when no visual or physical assessment cues are available .although telephone assessment has some pitfalls, there are some benefits, too.
o Telephone follow up :is used for clients

who have had ambulatory surgery or complex treatments .the nurse calls the client within a specified period to assess how well the client is recovering and to provide guidance for any problems .especially when the nurse is calling the client , the nurse must protect the confidentiality of the client and should speak with family members or significant others only if the client has given permission .and it gives the client ready access to a health professional. o Telephone triage: clients are sorted by telephone encounter based on the immediacy of the need and the type of problem .in ambulatory care ,a nurse talks with a client calling from home and assess the type of problem, how the problem should be resolved, whether the client should be seen in person and when , and who should resolve the problem. o Telephone surveillance: it is to work with data coming into a central ambulatory site from monitoring equipment used by clients at home .for ex .cardiac monitoring can be accomplished by connecting the monitoring equipment to a computer or telephone in the clients home. Here as a nurse our role is to document on the clients medical record, including

assessment, analysis, recommendations made to the client, and the clients level of understanding of instructions. Expert practice within setting Ambulatory care nurses who develop expertise with specific client populations often are in charge of nurse run clinics such as incontinence clinics, or wound care clinics. In a nurse run clinic, a nurse with at least a bachelors degree in nursing, plus experience and continuing education, works with physicians to develop protocols. Nurses monitor clients during ambulatory visits and suggest interventions for common problems that clients experience. The nurse often acts as their advocate in the health care system .nurses find this type of work rewarding because they have ling term relationships with clients and families and can see the results of their teaching ,advocacy ,and nursing interventions. Ambulatory care interdisciplinary team. Nurse working in ambulatory settings are members of an interdisciplinary team .they work collaboratively with physicians ,midlevel providers, such as nurse practioners ,nurse midwives, and physician assistants ,LPNS and licensed vocational nurse ,medical assistants ,and clerks receptionists . Professional and legal considerations. o Standards of care. There are nine standards which are developed by AAACN. i,e.ambulatory care nursing administration and practice standards .these standards are made to improve the services.

Structure and organization of ambulatory care nursing, Staffing in ambulatory care Competency Ambulatory nursing practice continuity of care ethics and patients rights environment research Quality management.

o Competence. Competence is the demonstrated knowledge, skills, and ability to effectively carry out the requirements of a given role. Ambulatory care nurses demonstrate competence in core clinical practice dimensions, such as client teaching. They also have competencies that reflect the unique clinical dimensions of ambulatory care nursing, such as telephone nursing and that correspond to the needs of the particular client populations served and the nursing interventions commonly required by such populations. o Certification , Holding certification in a specialty practice area such as ambulatory care nursing is a way of demonstrating competence to consumers and colleagues. To obtain certification, practicing nurses prepare for and take an examination that is developed by a panel of experts and administered by a recognized certification agency. o Regulatory compliance. Ambulatory settings must be licensed in the state in which they are located. Accreditation demonstrates compliance with a uniform set of standard, it allows comparisons with a uniform

set of standards .it allows comparisons with other organizations and enhances the organizations competitive edge. E.g.. JCAHO. o Multi state licensure. Multi state licensure is an issue that emerged because there are increasing numbers of national health care systems and Telehealth nursing practice is more common and people are more mobile in seeking care. The legal authority for practice is a concern for any professional nurse who provides care for people located in a state in which the nurse is not licensed. Nurses who mist be concerned about multi state licensure are Nurses working in integrated delivery systems and regional referral health care systems in which people come from other states Flight nurses and Tele health practice nurse. Nursing responsibilities. Clinical Nursing Role Patient Education Advocacy (compassion, caring, emotional support) Care Management Assess, Screen, Triage Telephone Practice Collaboration/Resource Identification and Referral Clinical Procedures Independent/Interdependent/Dependent Primary, Secondary, and Tertiary Prevention Communication/Documentation Outcome Management

Protocol Development/Usage Organization/Systems Role Practice/Office Support Healthcare Fiscal Mgmt. (reimbursement and coding) Collaboration/Conflict Mgmt. Informatics Context of Care Delivery/Models Care of the Caregiver Priority Management/Delegation/Supervision Ambulatory Culture/Cross Cultural Competencies Ongoing Political/Entrepreneurial Skills Structuring Customer-focused Systems Workplace Regulatory Compliance (EEOC, OSHA) Advocacy Inter-organizational and in Community Legal Issues Professional Role Evidence-based Practice Leadership Inquiry and Research Utilization Clinical Quality Improvement Staff Development Regulatory Compliance (risk management) Provider Self-Care 3. Acute care and critical care. a. Acute care. An institution with primary function of providing diagnostic and therapeutic client services for a variety of medical conditions, both surgical and non surgical. Types of hospitals ;

Government sponsored hospitals These hospitals receive local, state, or federal government support examples include the army, navy, public health service .state supported facilities include psychiatric hospitals, state university hospitals, and state prison hospitals. Locally

supported institutions include country and city hospitals. Voluntary or non profit agencies These are the hospitals designed to meet the health care needs of the general public. Profit hospitals Like voluntary hospitals they also serve general public but with goal of profit and business. Magnet hospitals. Such a designation is given to hospitals that have a reputation for providing excellent nursing care and for having good medical outcomes .these hospitals often provide medical services for complex problems that require a team of health care providers, which would be too expensive to replicate in multiple sites. Client admission to a hospital. Direct A client is seen in a physicians office, and it is determined that the client needs nursing care and specialized monitoring. Emergency A client is seen in emergency department and it is determined that client needs surgery, nursing care, and specialized monitoring .the disease that has been diagnosed is considered likely cannot be managed on an outpatient or self care basis. Scheduled A client has elected to undergo surgery or special diagnostic testing that requires specialized monitoring nursing care during recovery. Post acute care. Post acute care is one of the fastest growing segments of health care. It is called in different terms like progressive, transitional, step-down units. It is designed to fill the gap between acute and long term or home care.

All the clients will experience post acute care. If the client can do his own care at home, patient will be discharged. E.g. open heart surgery patients. Nurses role in hospitals Nursing is a service provided both to individual clients and to aggregates of people. E.g. families, groups. Nurses in he acute care hospital setting are providers of direct care, educators, researchers, and managers. Provider of direct care. Most people are familiar with nurses as providers of direct care. Nurses assess, care for, educate, and comfort clients. Nurses provide direct care in all settings and along all dimensions of the health illness continuum, from health promotion to critical care and death. Educator Professional nurses provide formal and informal education to their clients, individually and in groups. Informal education goes on almost continually; clients are taught about medications while the medications are being administered, about the importance of assessment parameters when wound care is being done, and so on. Formal education is usually provided to groups of clients and their families. Advantages of formal education are that the client is usually prepared for learning .some nurse who are specialized in particular field will help in rehabilitation. e.g. rehabilitation. Researcher. Most acute care hospitals have research committees that select areas for study .hospital nurses can identify topics to research , help

develop and implement a study , collect data , and present and utilize the study findings .e.g. skin care protocol, wound dressing . Manager. Term manager in this discussion means the person who coordinates human and material resources in providing care to clients. It includes The client The nurse Family Professional colleagues Support groups Resource groups B.Critical care. Critical care nursing is the field of nursing with a focus on the care of the critically ill or unstable patients. Critical care nurses can be found working in a wide variety of environments and specialties, such as emergency departments and the intensive care units
Need for the admission.

The most common cause for the admission is for intensive monitoring and life supportive care. Common condition necessitating ICU admissions.
Respiratory difficulties impairing the clients ability to

ventilate and oxygenate .e.g., pneumonia, respiratory distress .in this case ventilators will be necessary for the patients. Circulatory problems such as hypotension .clients may have had a MI in this conditions clients will be placed on cardiac monitor. Neurological changes, such as loss of consciousness or changes in mental status. e.g. head injury, brain surgery.

Life threatening infection or risk of infection such as

burn wounds or sepsis. Requires intensive care to control blood pressure and maintain perfusion of the heart, brain, lungs, and kidney. Role of nurse. Critical care nurses concentrate specifically on the care of clients with life threatening problems. Interventions for these clients must be adjusted continually based on constant monitoring of their response to treatment. Continuous nursing vigilance is the key to this nursing specialty and can make a significant difference in salient outcomes. A critical care nurse does use the latest machines to provide highly technical care. She should create environment that promotes healing. She should also provide complementary therapies such as music therapy, prayer, talking. While planning this type of care nurse should also include family members. Critical nurse must constantly keep up with the latest information and become proficient with more complex technologies and treatments. She should acts as bed side nurse, critical care educator, case manager, unit manager, clinical nurse specialist and nurse practioners. 5. Long term care. Long term care refers to the care of patients for a time period greater than 30 days .long term care may be required for individuals who are severely developmentally disabled, are mentally impaired, pr have physical deficits requiring continuous medical or nursing management, such as those who are ventilator dependent and those with Alzheimers diseases. Long term care facilities include Skilled nursing facilities :

Skilled nursing facilities provide care for patients who require 24 hour nursing supervision, many of whom are confined to bed for some portion of the day or are incontinent. And also offers a transitional level of post acute care in which the patient requires specified nursing skills and therapeutic support .it also provides an emphasis on rehabilitative therapies for convalescing patients. These patients may be too weak or ill to tolerate rapid rehabilitation .some patients are terminally ill or disabled to the degree that continuous nursing support is required. Intermediate care facilities An intermediate care facility provides convalescent care and regular medical, nursing, social, and rehabilitative services in addition to room and board for people not capable of independent living. Residents in these facilities require less intensive nursing care than that provided by skilled nursing facilities .intermediate care can be temporary care for individuals recovering from an acute illness or injury and often for those who have been discharged from the hospital. Common goals of these facilities are to assess what individuals are capable of doing and to help them achieve their potential by teaching and training them to achieve maximum independence. Retirement communities Some long term care settings may include the entire spectrum of care. Residents may reside in a continuing care retirement community .which is a blend of several options, including housing complex, activity center, and health care system. CCRCs differ from other retirement options by providing a continuum of housing, services, and health care, there is a written agreement or contract between the resident and the CCRC that is written agreement or contract between the resident and the CCRC that is generally intended to last the residents lifetime or for a specific period of time.

Residential care facilities Residential care facilities may be referred to as supervisory care homes or assisted living arrangements. both settings are generally licensed by the state to ensure that quality living ,safety ,and health care standards are met .residents generally must be able to care for themselves and move about without the help ;of another person .residents often live in these care homes to obtain additional assistance for their activities of daily living, such as grooming and meal preparation or supervision with their medications., any of these facilities also have a skilled nursing facility .this enables residents who temporarily need skilled nursing care to receive it until they can return to their own residence. Special care units. Some individuals with cognitive impairments may require special assistance in their long term care with increasing numbers of residents. With increasing numbers of residents with Alzheimers disease and other forms of dementia m special care units have been developed to address the unique needs of these individuals. Nurses role. Assessment the facility is required to assess residents within the first 14 days of admission and at least annually there is a change in their status .the minimum data set is the tool on which the assessesment is to be documented, it is a minimum assessment .here important pieces of information are not captured , such as the client s self concept , spirituality ,sense of purpose , immunity ,stress management use of alternative therapies, and attitudes regarding health status and death .because these are important areas for consideration in the long term care of residents, you may want to supplement the ,MDS with additional assessment data.

Care planning.

Regulations require that a care plan be written for each resident within 7 days after completion of the assessment. The care plan is an interdisciplinary one, nurses coordinate the input offered by each discipline and ensure that the plan is written in a correct, timely manner .even the residents and family should be involved in development of plan. Goals and actions that are no longer relevant need to be revised .all members of the team, particularly nursing assistants who perform most direct care activities, must be familiar with the care plan.
Care giving.

In LTCFs .nurses perform selected roles, such as administering medications and treatments, in others, they may be involved in total care activities .during the pre-employment interview, nurses should review the job descriptions for their specific positions to ensure that they have a realistic view of their role. Communication. Since the nurse has regular and close contact with residents, nursing assistants may be the first and only caregivers to detect changes in health status .there fore ,effective channels of communication are crucial in reporting these findings .and telephone orders should be taken care when receiving the order from physician .and should be documented.
Management .along with these roles she has to

perform management roles also. Delegating assignments Supervising other staff Evaluating performance Implementing disciplinary actions Completing reports Reviewing and auditing records

Communicating needs to other departments Handling complaints Ordering supplies Communicating with insurers, regulatory agencies, and other parties.

6. Home health care Home health care refers to health care delivered in the home setting .the national association for home care defines home care as broad spectrum of health care and social services provided in the home environment to recovering .disabled, or chronically ill patients. It includes health maintenance .education, illness prevention, diagnosis and treatment of disease .palliative care, and rehabilitation. patient care in the home The most common diagnoses for home care patients are diabetes mellitus .hypertension .heart failure .stroke .skin ulcers. Skilled nursing care may include observation, assessment, management, evaluation, teaching, administration of medications, tube feedings, catheter care, etc. Examples of home health care nursing activities. Assessment Wound care Respiratory care Vital signs Elimination Nutrition Rehabilitation Medications Intravenous therapy Pain management Selected laboratory studies. home health care team

Home health care team includes family and patient physician nurse

social worker Assists patients with coping skills, securing adequate financial resources or housing assistance or making referrals to social service or volunteer agencies occupational therapist Assist the patient with fine motor coordination, performance of the activities of daily living, cognitive perceptual skills, Sensory testing. physical therapist ; References will be given in case of orthopedic conditions, such as hip or knee surgeries or neuromuscular deterioration commonly seen with multiple sclerosis, stroke. Here therapist will work with patients on strengthening and endurance, gait training. speech therapist Focus on various speech pathologies for those who have suffered speech or swallowing disorders seen in patients with stroke, laryngectomy. home health aide Assist patients with their personal care needs, such as bathing, dressing, hair washing. pharmacist Involved in preparation of infusion products, respiratory therapist Assists in oxygen therapy in home setting Dietician. Will help in dietary consultation.

nurses role Home care nurses must have expert organizational skills, be able to make independent decisions, and know how to set priority and respond to problems promptly. She must adapt to a variety of circumstances that challenge their assessment, planning .and intervention abilities. Attributes of home health care nurses include flexibility, empathy, patient advocacy, and the ability to function independently in the home setting. Nurse must use concise and accurate documentation to ensure both legal and professional accountability. Tele visiting allows the nurse to do triage and provide advise, counseling, and referral for a patients health problem using the phone or computers with cameras. Home health care nurses must also be knowledgeable in the adaptive equipment or assistive devices used n the patients home to promote independent functioning. Continuous quality improvement is a mandate for home health care agencies and nurses. Should maintain confidentiality of patients .and should focus on empowering the patients and family to meet their own needs. 7. Conclusion: AMBULATORY CARE, ACUTE AND CRITICAL CARE, LONG TERM CARE, HOME HEALTH CARE. is now a days becoming very important role in maintaining the health status of the different age group and giving lots of choices for the family for the health benefit. 8. References Black mj ,hawks jh. medical surgical nursing,clinical management for positive outcomes.7th ed.missouri:saunders;2005.p.133-88. Lewis,heitkemper,dirksen.medical surgical nursing,assessment and management of clinical problems.6th ed.missouri:mosby;2004.p.85-91. Brunner , Suddarths. Textbook of MedicalSurgical Nursing.10th ed.lww;2004.p.45-51.

Ambulatory care wikipedia the free encyclopedia .mar 23 ,2009;available from: URL:en.wikipedia .org/wiki/ambulatory_care. Longterm care wikepedia the free encyclopedia . 2009;available from: URL:en.wikipedia.org/wiki/longterm_care. Home health care-wikepedia the free encyclopedia.2009;available from: URL:en.wikipedia.org/wiki/homehealth_care.

Journal reference.
Tejal K. Gandhi, M.D., M.P.H., Saul N. Weingart, M.D., Ph.D., Joshua Borus, B.A., Andrew C. Seger, R.Ph., Josh Peterson, M.D., Elisabeth Burdick, M.S., Diane L. Seger, R.Ph., Kirstin Shu, B.A., Frank Federico, R.Ph., Lucian L. Leape, M.D., and David W. Bates, M.D.Adverse Drug Events in Ambulatory Care, Volume 348:p.1556-1564. Adverse events related to drugs are common in primary care, and many are preventable or ameliorable. Monitoring for and acting on symptoms are important. Improving communication between outpatients and providers may help prevent adverse events related to drugs.

THE OXFORD COLLEGE OF NURSING.

SUBJECT: MEDICAL SURGICAL NURSING. TOPIC: AMBULATORY CARE, ACUTE AND CRITICAL
CARE, LONG TERM CARE, HOME HEALTH CARE.

SUBMITTED TO. MR.BABU .R PROFFESER (MSN) THE OXFORD COLLEGE OF NURSING.

SUBMITTED BY. SANDESH.K.S 1ST YEAR MSC NSG. THE OXFORD COLLEGE OF NURSING. SUBMITTED ON. 18/07/2009.

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