Provide evidence-based, patient-centered care incorporating data from healthcare technologies to improve client care, as part of the

Quality and Safety Education for Nurses

Core Clinical Objective

• Provide evidence-based, patient-centered care incorporating data from healthcare technologies to improve client care, as part of the interdisciplinary health care team.

Activity Statements

• Collaborate to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health.
• Use evidence-based practice strategies and available community resources to design client/community care.
• Identify data from healthcare technologies to support community and public health.

Reflective Questions

• Give a comprehensive plan of care for the clients you served during your practicum experience that included
• (Client’s served during practicum experience; -Diabetic, obese, LGBT, Hospice, veterans, Depressed adolescents, Homeless )
• What referrals to other human service and social support agencies did you provide to clients?
• Why did you select these agencies?
• What specifically could these agencies add to the holistic care of the client?
• How might you include this agency’s services in your comprehensive plan of care if you were discharging a patient from a hospital to the community?
• How does your practicum program utilize surveillance data and databases?
• How did nursing contribute to or utilize these databases?

ANSWER

Enhancing Patient-Centered Care: A Comprehensive Plan of Care and Utilization of Surveillance Data in Nursing Practice

Plan of Care for Clients Served During Practicum Experience

Diabetic Client: a. Assess the client’s current diabetes management and lifestyle habits. b. Collaborate with the client to develop an individualized care plan that includes monitoring blood glucose levels, implementing a balanced diet, and promoting regular exercise. c. Educate the client on proper medication administration and potential complications of diabetes. d. Coordinate with a registered dietitian to provide nutritional counseling. e. Refer the client to a diabetes support group for additional education and emotional support.

Obese Client: a. Conduct a comprehensive assessment of the client’s health status, including physical activity level, dietary habits, and psychological factors contributing to obesity. b. Collaborate with the client to set realistic goals for weight management and lifestyle changes. c. Provide education on healthy eating habits, portion control, and the importance of regular physical activity. d. Refer the client to a registered dietitian for personalized nutrition counseling. e. Connect the client with a local fitness center or exercise program to support their physical activity goals.

LGBT Client: a. Create a safe and inclusive environment for the client to express their concerns and discuss their unique healthcare needs. b. Provide culturally competent care that respects the client’s gender identity and sexual orientation. c. Collaborate with LGBTQ+ community organizations to access resources and support groups for the client. d. Refer the client to LGBT-friendly healthcare providers or specialists if needed.

Hospice Client: a. Conduct a thorough assessment of the client’s physical, emotional, and spiritual needs. b. Develop an individualized plan of care in collaboration with the interdisciplinary hospice team. c. Provide pain and symptom management, as well as emotional support and counseling. d. Coordinate with community hospice agencies to arrange for home-based palliative care services (Siler et al., 2019). e. Collaborate with social workers to ensure access to necessary financial assistance programs and bereavement support.

Depressed Adolescents: a. Conduct a mental health assessment to evaluate the severity of depression and identify contributing factors. b. Develop a treatment plan that may include therapy, medication, and support from family and peers. c. Refer the client to local mental health clinics or psychologists specializing in adolescent mental health. d. Collaborate with school counselors and teachers to create a supportive environment at school.

Homeless Client: a. Perform a comprehensive health assessment and address immediate healthcare needs. b. Collaborate with local homeless shelters, social workers, and community outreach programs to provide resources for shelter, food, and clothing. c. Assist the client in accessing healthcare services, including vaccinations, screenings, and treatment for chronic conditions (Siler et al., 2019). d. Coordinate with case managers to develop a long-term plan for stable housing and connect the client with supportive housing programs.

Referrals to Human Service and Social Support Agencies

For the diabetic client, a referral to the American Diabetes Association or local diabetes support groups can provide additional education, self-management resources, and peer support.

The obese client can benefit from a referral to a registered dietitian who specializes in weight management, as well as local fitness centers or exercise programs for ongoing support and guidance.

LGBT clients may benefit from referrals to LGBTQ+ community centers, such as the LGBT National Help Center, where they can access resources, support groups, and counseling services tailored to their needs.

Hospice clients may be referred to local hospice agencies, such as Hospice and Palliative Care organizations, to access home-based palliative care services and support for both the patient and their family.

Depressed adolescents can be referred to mental health clinics or psychologists specializing in adolescent mental health, as well as local support groups for teens dealing with depression.

Homeless clients may benefit from referrals to local homeless shelters, social workers, and community outreach programs that provide resources for shelter, food, clothing, and access to healthcare services.

These agencies add to the holistic care of the client by providing specialized support, resources, and expertise in addressing the specific needs and challenges faced by each population (Jasemi et al., 2017). They can offer education, counseling, social support, and practical assistance, which contribute to improved outcomes and overall well-being.

Incorporating Agency Services in a Comprehensive Plan of Care

When discharging a patient from a hospital to the community, the comprehensive plan of care should include:

Collaboration with the agency: Communicate with the agency providing relevant services to ensure a seamless transition of care and continuity of support for the patient.

Sharing information: Provide the agency with necessary medical and social history, including any diagnoses, medications, and treatment plans, to ensure they have a comprehensive understanding of the patient’s needs.

Referral coordination: Facilitate a smooth referral process, ensuring the agency is aware of the patient’s upcoming discharge and that appropriate appointments or services are scheduled.

Follow-up care: Discuss with the agency the need for ongoing monitoring, follow-up appointments, or additional interventions required to support the patient’s continued well-being.

Practicum Program Utilization of Surveillance Data and Databases

Surveillance data and databases are essential tools in healthcare for monitoring and managing population health. In a practicum program, these resources can be utilized in the following ways:

Monitoring health trends: Surveillance data allows practitioners to identify patterns and trends in diseases, injuries, or other health-related events within a population.

Identifying priority areas: Databases help identify specific populations or geographic regions with higher disease burdens or health disparities, which can guide targeted interventions and resource allocation.

Informing public health policies: Surveillance data and databases provide evidence to support the development and implementation of public health policies, interventions, and prevention strategies.

Evaluating interventions: Practicum programs can utilize surveillance data to assess the effectiveness of implemented interventions and monitor progress toward health goals.

Nursing Contribution to Surveillance Databases

Nursing plays a crucial role in utilizing surveillance databases by:

Data collection: Nurses contribute to the collection and documentation of patient data, including demographic information, health status, and outcomes, which are then incorporated into surveillance databases (Nsubuga, 2006).

Reporting: Nurses report notifiable diseases, adverse events, or other health-related incidents to appropriate health authorities, ensuring accurate and timely data submission to surveillance systems.

Data analysis: Nursing professionals collaborate with epidemiologists and other healthcare professionals to analyze surveillance data, identify trends, and contribute to the interpretation of findings.

Interventions and education: Based on the analysis of surveillance data, nurses can develop and implement targeted interventions, education campaigns, or preventive measures to address identified health issues within their patient populations (Nsubuga, 2006).

Overall, nursing’s involvement in surveillance data and databases is vital in promoting evidence-based practice, improving public health outcomes, and contributing to the development of effective healthcare policies and interventions.

References

Jasemi, M., Valizadeh, L., Zamanzadeh, V., & Keogh, B. (2017). A concept analysis of holistic care by hybrid model. Indian Journal of Palliative Care, 23(1), 71. https://doi.org/10.4103/0973-1075.197960 

Nsubuga, P. (2006). Public Health Surveillance: A Tool for Targeting and Monitoring Interventions. Disease Control Priorities in Developing Countries – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK11770/

Siler, S., Mamier, I., Winslow, B. W., & Ferrell, B. (2019). Interprofessional Perspectives on Providing Spiritual Care for Patients With Lung Cancer in Outpatient Settings. Oncology Nursing Forum, 49–58. https://doi.org/10.1188/19.onf.49-58