CHAPTER
6
A wise man should consider that health is the
greatest of human blessings, and learn how
by his own thought to derive benefit from his
illnesses.
—Hippocrates
LEARNING OUTCOMES
1. Describe how the factors changing the health care delivery system
are influencing the shift of patient care from hospitals to community-
based settings.
2. Differentiate community-based nursing from public health nursing.
3. Compare community-based patient care settings and the services
provided in these settings.
KEY TERMS
ambulatory care home health care
case management intermediate care facilities, Table 6-3
community-based nursing long-term carepreferred provider
family caregivers organizations (PPOs)
health maintenance organizations (HMOs)
Major changes in nursing practice and patient care are
occurring as a result of numerous factors affecting the health
care system. Social, economic, technologic, and health factors
are driving the delivery of health care from hospitals to com-
munity settings. In response to these factors, the practice of
professional nursing has moved from an almost exclusively
hospital-based practice to practice opportunities in commu-
nity-based settings. Community settings can be described as
local health centers and other health agencies, barangay health
centers, student health services, occupational services, and
school health. Nurses are providing patient care in a wide vari-
ety of health care settings outside of the hospital. A majority
of nurses work in hospitals, but many nurses work in a com-
munity setting.
Nursing practice that occurs in the community has
taken on a variety of meanings, creating confusion among
terms such as community-based nursing and public health
­nursing.1 For the purpose of this chapter, home care nurses
are engaged in community-based nursing practice. The goals
of ­community-based nursing are to help individuals and
families promote health, prevent illness, and manage acute or
chronic health conditions in community and home settings as
opposed to hospital settings. By contrast, public health nurs-
ing can be described as nurses who improve health through a
Reviewed by Theresa A. Petersen, RN, MSN, FNP, Assistant Professor, Montana State University–Northern, Haure, Mont.; Regina McFerren, RN,
BA, MSN, Assistant Professor, College of Nursing, University of Southern Nevada, Henderson, Nev.; and Elizabeth Madigan, RN, PhD, FAAN,
Associate Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.
Community-Based Nursing
and Home Care
Teri A. Murray
Annabelle R. Borromeo
4. Describe the roles and challenges of nurses working in community-
based settings.
5. Describe the characteristics of family caregivers, the challenges they
have, and the optimal approach for you to use when partnering with
family caregivers.
residential care facilities, Table 6-3
skilled nursing facilities, Table 6-3
transitional care
population focus. Public health nursing is distinguished from
other specialties by the following eight tenets:
1. Focuses on a population rather than an individual
although the nurse might provide care to an individual
2. Uses a utilitarian approach to achieve the greater good
for the greatest number
3. Provides nursing care in partnership with the popula-
tion
4. Provides primary prevention as the focus of care rather
than tertiary care
5. Embraces an ecologic framework rather than the use of
the nursing process as a framework for care
6. Seeks services for those individuals and populations at
risk who may not seek care
7. Uses the core principles of public health (assessment,
policy development, and assurance)
8. Collaborates with multiple stake holders (health related
and non–health related) to ensure the public’s health.2
This chapter presents an overview of the changing health
care system and discusses nursing care in community-based
settings rather than public health nursing. Although long-
term care and rehabilitation facilities are not typically con-
sidered community-based settings, they are included in this
chapter.
73
74 SECTION 1  Concepts in Nursing Practice
CHANGING HEALTH CARE SYSTEM
Factors Influencing Change
Socioeconomic Considerations. The changes in health care have
been largely initiated by the continued efforts of the govern-
ment, employers, insurance companies, and regulating agencies
to provide the most cost-effective health care. Historically, the
most notable event related to changing reimbursement patterns
was the institution of case-rate payment systems in the Phil-
Health program. With these changes, hospitals were no longer
reimbursed for all costs. Instead, payment for hospital services
to PhilHealth patients was based on flat fees determined by the
diseases and problems treated during the admission. Because
this payment structure was implemented in hospitals, it is often
considered to have contributed to a shift toward home- and
community-based care.
Private and other public health care systems are following the
lead of the PhilHealth program. Health maintenance organiza-
tions (HMOs)1 and preferred provider organizations (PPOs)2
evolved as a means of offering cost-effective health care deliv-
ery.3 In these managed care systems, charges are negotiated in
advance of the delivery of care using predetermined reimburse-
ment rates or capitation fees for medical care, hospitalization,
and other health care services. Like the PhilHealth program,
these organizations are causing a shift in the delivery of care
from the acute care hospital setting to less expensive commu-
nity settings.
Universal Health Care. Universal Health Care or Kalusugan
Pangkalahatan is the health reform agenda of the Department of
Health (DOH). The goal of Universal Health Care is to ensure
that every Filipino, especially the poor, receives quality health
care that is affordable through enrollment of every Filipino in
the PhilHealth program
Changing Demographics. Of the total Philippine population,
about 4.3% (4 million) are aged 65 years or older. The growth
of the population age 65 and over affects all aspects of society
and particularly challenges health care providers to meet the
needs of an aging society. Aging Filipinos may have disabilities
that compromise their ability to remain functional in their own
homes without supportive community or professional help. The
elderly may also have complex medical and health care needs,
experiencing multiple chronic conditions that compromise
their ability to remain independent. Physical and functional
problems, dementia, fixed incomes, and limited family or com-
munity support put the elderly at an increased need for social
and health care assistance. (Health care needs of the older adult
are discussed in Chapter 5.)
Inability to pay for health care is associated with a tendency
to delay seeking care, resulting in more serious illnesses. The
need to identify and meet health care needs of this population
1An HMO consists of an association of health care professionals and
facilities that provide a specified package of health care for a fixed sum
of money paid in advance for a specified period of time. The HMO con-
tracts with health care professionals and facilities to provide the speci-
fied care. Generally a patient cannot seek care outside of the health care
providers and/or hospitals under contract with the HMO.
2A PPO is a group of health care professionals and/or hospitals who
contract with an employer, insurance company, or third-party payer
to provide medical care to a specified group of potential patients. The
services offered are not prepaid or fixed. There is typically more choice
in a PPO than in an HMO, and thus it is more costly.
requires reaching into the community where these individuals
live and work. (Cultural factors affecting health care are dis-
cussed further in Chapter 2.)
Nature and Prevalence of Illness. The increased life expectancy
of the population and lifestyle factors contribute to increases
in the number, severity, and duration of chronic conditions.
Chronic diseases are the major cause of death and disability
worldwide and are responsible for 57% of all deaths in the Phil-
ippines.4 The leading causes of death from chronic diseases,
including cardiovascular disease, cancer, diabetes, and chronic
obstructive pulmonary diseases, are related to lifestyle behav-
iors. Tobacco use, lack of physical activity, and poor nutrition
(including obesity) are the major contributors to cardiovascu-
lar disease and cancer.5 The focus of health care is now shift-
ing from intervention in the acute phase of diseases toward
health promotion and disease prevention. Nursing practice
directed toward the prevention and management of chronic
illness occurs in community-based settings through (1) pro-
motion of regular screening, (2) education about the effects of
lifestyle choices and their relationship to health and illness, and
(3) assisting individuals and families to manage chronic illness
in the home.
Technology. Surgical innovations, such as advances in cardiac
surgery, and medical interventions, such as new drugs for can-
cer treatment, have allowed individuals to live longer, shifting
both acute and long-term care to community-based settings.
New technology has improved diagnostic procedures and man-
agement of patient care. Computers, lifesaving drugs, and tele-
health interventions have simplified diagnosis and treatment
and shortened hospital stays.
Patient care has moved to outpatient settings such as surgical
centers, providing services that have been traditionally deliv-
ered only in hospitals. Complex patient care treatments, such
as intravenous (IV) antibiotic therapy and parenteral nutrition
therapy, are increasingly being delivered through home infu-
sion services. Evolving technology, the focus on reducing rap-
idly increasing health care costs, and patient preference to be at
home have stimulated the movement to provide health care in
community and home settings.
Increasing Consumerism. Health care is becoming a more
consumer-focused business. Patients are becoming more inter-
ested and active participants in their health care. Many patients
eagerly seek out information about their health from the media
and Internet sources. They also expect that information will be
provided so that they may collaborate with health care providers
in making the appropriate decisions about their health care. In
addition, the public has come to view health care as an entitle-
ment or a human right. Health care legislation emphasizes equal
access to health care services, regardless of the ability to pay.
As increasing demands are made on scarce and costly health
care resources, nurses are becoming more active partners with
patients in promoting self-care through education and ­advocacy.
COMMUNITY-BASED CARE
Role: Client Care: 2.4.10.4, 2.5 (Appendix A)
Continuum of Patient Care
Depending on an individual’s health status and the cost of
care required, patients can move among different health care
settings. There is a continuum of care whereby different settings
accommodate the varying needs of the patient. Within this con-
tinuum, many persons today are cared for in community-based
 Chapter 6  Community-Based Nursing and Home Care
settings that include home health care. For example, a person
may be hospitalized in a trauma unit of an acute care hospital
following a motor vehicle accident. After the person is stabi-
lized, he or she may be transferred to a general medical-surgical
unit and then to an acute rehabilitation facility. After a period of
rehabilitation, the person may be discharged to his or her home
to continue with outpatient rehabilitation and to be followed
by home health care nurses and/or cared for in an outpatient
clinic.
The continuum of care does not always include hospital-
ization. Most patients receive community-based care with-
out experiencing an acute problem requiring hospitalization.
Health problems may be identified in a variety of outpatient
settings. In addition, individuals or families may seek specific
assistance from health care resources in the community.
For example, a patient may be screened for diabetes mellitus
in a community-based screening program and, when indicated,
referred to a clinic where a diagnosis of diabetes can be estab-
lished. A diabetes educator may function as a case manager to
coordinate the diabetes management team consisting of nurses,
dietitians, pharmacists, physicians, and other health care pro-
fessionals. Services may include care and education at a variety
of settings, as well as follow-up by home health care nurses.
Patients can be treated in a multitude of settings, opting
for the one most appropriate for their health care needs but
within the constraints of health care insurance plans and the
cost of care. Today health care is increasingly constrained by
third-party payer cost containment efforts. At the same time
third-party payers are demanding outcome-based quality care.
Although the hospital remains the mainstay for acute care inter-
ventions, settings such as extended care facilities, assisted liv-
ing centers, and home health care offer patients the opportunity
to live or recover in settings that maximize their independence
and preserve human dignity.
Community-based settings where nursing care is provided
include ambulatory care (Table 6-1), and long-term care.
Long-term care refers to the care of patients for a time period
greater than 30 days. It may be required for individuals who
are severely developmentally disabled, are mentally impaired,
or have physical deficits requiring continuous medical or nurs-
ing management, such as those who are ventilator dependent
or those with Alzheimer’s disease. Long-term care facilities
include skilled nursing facilities, intermediate care facili-
ties, retirement communities, and residential care facilities
(Table 6-2).
As noted at the beginning of the chapter, some of these set-
tings are not typically considered community-based settings.
However, they do include areas where nurses practice ­outside
of the hospital and constitute many of the less expensive com-
munity settings used in managed care.
Table 6-1 CHARACTERISTICS OF
AMBULATORY CARE SETTINGS
• Provide health care services on an outpatient basis.
• Include physician offices, clinics, outpatient surgical or diagnostic
centers, churches, schools, day care centers, and occupational or
work sites.
• Nurses in ambulatory care settings assess patients’ problems,
evaluate need for resources and information, and provide appropriate
interventions that allow patients to care for themselves.
• Patient teaching and telephone follow-up are routine practices.
75
Long-Term Care Facilities. Unlike other community-based
options, placement in long-term care is rarely considered to
be a cost-saving measure. Many patients and families initially
express concerns about the possibility of entering long-term
care. In the face of high cost and family concerns, three fac-
tors appear to precipitate placement in a long-term care facility:
(1) rapid patient deterioration, (2) caregiver inability to con-
tinue care because of “burnout”—too much and too long, and
(3) an alteration in or loss of a family support system. Changes
in orientation (e.g., increased confusion), incontinence, or a
major health event (e.g., stroke) can accelerate placement.
The conflicts and fears faced by the family and patient make
placement a transition time. Common caregiver concerns
include the following: (1) the process of admission will be
resisted by the patient; (2) the level of care given by staff will be
insufficient; (3) the patient will be lonely; and (4) financing of
nursing care will not be adequate.
This time of disruption is increased by the physical reloca-
tion of the patient, which may result in adverse health effects
for the patient. Relocation stress syndrome is a nursing diag-
nosis that is associated with the disruption, confusion, and
challenges that the patient faces when moving from one envi-
ronment to a new environment. The move results in patient
anxiety, depression, and disorientation. Appropriate interven-
tions to reduce the effects of relocation should be used. When-
ever possible, involve the patient in the decision to move. The
caregiver can share information, pictures, or a videotape of
the new location. New health personnel can send a welcome
message. On arrival, the new resident can be greeted by a staff
member to provide orientation. To bridge the relocation, the
new resident can be “buddied” with a seasoned resident.
Community-Based Nurses
Nurses practicing in community-based settings care for a
broad spectrum of individuals with different needs.6 Nursing
roles include home health care nurses, long-term care nurses,
school nurses, occupational nurses, and nurses working in out-
patient clinics and ambulatory care centers. Nurses in nurse-
managed clinics provide direct care to patients in an ambulatory
setting. Faith community nurses (also called parish nurses)
practice holistic health care within a faith community, empha-
sizing the relationship between spiritual faith and health. Faith
community nurses complement the work of other health care
workers, acting as a liaison with congregational and community
resources.7
In contrast to nurses in acute care settings, community-based
nurses must take great effort to integrate their care into the daily
lives of their patients. In long-term care settings, the structure
of the environment must support the necessary clinical care of
the residents while still providing a homelike atmosphere for
them. In home care, the challenge may be to provide excellent
care in the face of noise, clutter, interruptions, and other family
needs. In clinics and other ambulatory settings, the nurse must
complete the nursing process in an extremely efficient manner,
minimizing the length and number of visits necessary to pro-
vide effective care.
HOME HEALTH CARE
Role: Client Care: 2.4.10.4, 2.5 (Appendix A)
Home health care refers to health care delivered in the
home setting. Home care is defined as the broad spectrum of
76 SECTION 1  Concepts in Nursing Practice
health care and social services provided in the home environ-
ment to recovering, disabled, or chronically ill patients.8 Home
health care may include health maintenance, education, illness
prevention, diagnosis and treatment of disease, palliative care,
and rehabilitation. Care may be delivered in assisted living situ-
ations when no other skilled nursing professionals are avail-
able for patient care needs. Patients receiving home health care
may require intermittent services or full-time, 24-hours-a-day
assistance.
In the past decade there has been an explosive growth in
home health care services, coupled with a steady decline in hos-
pital bed occupancy and length of hospital stay. The growth in
home health care has been stimulated by hospital prospective
payment, the increase in managed care, and the patient’s prefer-
ence to be cared for at home. Home health care is one of the most
rapidly growing segments in health care today, with the primary
motivation being to shift health care to less costly services.3
Nurses and home health aides provide most home health
care services. Registered nurses are the coordinators of patient
care, being accountable both for the supervision of personal
care services by home health aides, including all aspects of
care in the home. Other services commonly provided by home
health agencies include physical therapy, occupational therapy,
and social worker services.
Patient Care in the Home
Some of the most common diagnoses of home care patients
are diabetes mellitus, hypertension, heart failure, osteoarthri-
tis, stroke, acute and chronic wounds, chronic obstructive
pulmonary disease, heart disease, and cancer. Skilled nursing
care may include observation, assessment, management, evalu-
ation, teaching, training, administration of medications, wound
care, tube feedings, catheter care, and behavioral health inter-
ventions (Table 6-3). Commonly performed treatments in the
home include administration of infusion therapy (e.g., antibi-
otic administration), patient-controlled analgesia for pain con-
trol, enteral feedings, parenteral nutrition, chemotherapy, and
hydration therapy. The nurse and a rehabilitation team member
may also provide medical equipment in the home to facilitate
medical treatment and safety. These may include electrical beds,
wheelchairs, commodes, walkers, and other assistive devices.
Patients have benefited from sophisticated technology in
the home care setting. The miniaturization of infusion pumps
makes it possible for patients to go to work while receiving anti-
biotics, parenteral nutrition, or chemotherapy. The use of cen-
tral venous catheter devices and peripherally inserted central
catheters has eliminated many problems associated with short-
term and less reliable IV therapy, although it has also necessi-
tated great vigilance regarding infection. Tabletop ventilators
allow patients who are dependent on mechanical ventilation
to be cared for in the home setting, allowing for even greater
mobility when the equipment is strapped to the back of a wheel-
chair. Oxygen delivery in a variety of forms is also frequently
provided in the home (see Chapter 29).
Common assessed needs of patients requiring home care
are presented in Table 6-4. Examples of nursing diagnoses for
patients requiring home care are presented in Table 6-5.
Although the patient is the focus of care, nursing care in
the home must be family centered. An illness experienced by
one family member will affect the entire family and alter fam-
ily interactions. Families often provide care for ill members
and assist in decision making about the type and extent of care
Table 6-2 PRACTICE SETTINGS
FOR LONG-TERM CARE
Setting Characteristics
Residential care • Supervisory care homes or assisted living
facilities arrangements.
• Residents generally must be able to care for
themselves and move about without the help
of another person.
• Residents often live in care homes to obtain
additional assistance for their ADLs, such as
grooming and meal preparation, or supervision
with their medications.
Intermediate care • Provide convalescent care and regular medi-
facilities cal, nursing, social, and rehabilitative services
in addition to room and board for people not
capable of independent living.
• Offer a mix of medical care, nursing and
rehabilitative care, and personal and residential
care services.
• Special care units in these facilities have been
developed for individuals with cognitive impair-
ments (e.g., Alzheimer’s disease) who may
require special assistance.
• Although these units are appropriate for
patients with early- to middle-stage demen-
tia, they may not be appropriate for those in
advanced stages of dementia.
Community- • Coordinated plans of medical, nursing,
based and rehabilitative care provided at home to
long-term care ­disabled persons who would otherwise be
(CBLTC) placed in a hospital.
• Programs offer patients an alternative to
institutionalization.
• Services may include all those available in an
institution like a hospital.
ADLs, Activities of daily living.
provided. Care provided by health professionals is usually epi-
sodic, leaving the family with the burden of care day in and day
out.
Teaching needs to involve both the patient and the family.
Family members who are providing care should learn how to
administer treatments and manage equipment. For example,
diet modification is a cornerstone of diabetes management.
Although an elderly diabetic person may be the patient, it may
be the patient’s spouse or daughter who does the grocery shop-
ping and cooking. Dietary teaching that does not include the
family may not be successful.
Nursing in the home involves a very different set of dynam-
ics than that of care provided in the hospital. In the hospital,
the health care team has the dominant role and the environ-
ment is controlled. In the home, the family and/or the patient
play the dominant role, and the nurse is a visitor in the health
care setting. Home health care is delivered within the context
of the family’s and the patient’s cultural values and beliefs. In
the home, the nurse is more likely to encounter the patient’s use
of healing practices arising from cultural beliefs and the use of
home remedies and complementary and alternative therapies.
The home care nurse must be knowledgeable about cultural
practices and complementary and alternative therapies to guide
the patient and family in their safe and effective use. (Culture
is discussed in Chapter 2, and complementary and alternative
therapies are discussed in Chapter 7.)
 Chapter 6  Community-Based Nursing and Home Care
Table 6-3 EXAMPLES OF HOME HEALTH CARE NURSING ACTIVITIES
Assessment
• Performance of in-depth holistic assessment of patient, family,
and home environment.
• Assessment of community services as a source of referral for
patient/caregiver needs.
• Ongoing evaluation of patient’s progress.
Wound Care
• Assessment and culture of wounds, debridement and irrigation
of wounds, application of wound care products, dressing change.
• Instructing patients and caregivers in wound care management
and nutrition.
• Documentation (written and photographic).
Respiratory Care
• Management of oxygen therapy, mechanical ventilation, chest
­physiotherapy.
• Suctioning and care of tracheostomies.
Vital Signs
• Measuring blood pressure and pulse, assessment of cardiopulmo-
nary status.
• Teaching patients and caregivers to take blood pressure and pulse.
• Teaching patients and caregivers signs and symptoms to monitor and
emergency measures to take if signs and symptoms are exhibited.
Elimination
• Assistance with colostomy irrigation and skin care procedures.
• Insertion of urinary catheters, irrigation, and evaluation of signs and
symptoms of infection.
• Instruction of patient and caregivers in intermittent catheterization and
insertion, replacement, and irrigation of urethral and suprapubic catheters.
• Bowel and bladder training.
Rehabilitation
• Teaching patients and families to use assistive devices, range-
of-motion exercises, ambulation, and transfer techniques.
• Referral of patients for physical therapy and occupational therapy
services.
Patients seen by home health care nurses are most often
discharged from hospital settings. However, they may also be
referred directly from a physician’s office or nursing care facili-
ties, or the patient may request this service. PhilHealth and
other types of insurance do not cover home health services at
this time, but there are studies to explore its cost-effectiveness
compared to hospital care. Home health visits are intended to
assess and monitor the patient’s condition. These visits may
also be characterized by a predetermined routine or treatment
regimen, such as prefilling insulin syringes, prepouring oral
medications, administering injected cobalamin (vitamin B12),
or performing wound care and dressing changes.
Home Health Care Team
The home health care team includes many members, includ-
ing the patient, family, nurses, physician, social worker, physi-
cal therapist, occupational therapist, speech therapist, home
health aide, pharmacist, respiratory therapist, and dietitian
(Table 6-6). The members of the home health care team work
collaboratively with the home health care nurse to plan and
evaluate the patient’s progress. This is done on a regular basis
with a significant emphasis placed on teaching and counseling.
Nursing care is one of the primary services in the home setting.
Home care nurses focus on empowering the patient and family
77
Nutrition
• Assessment of nutrition and hydration status.
• Nutritional counseling, teaching, reinforcement about prescribed thera-
peutic diet.
• Administration of nasogastric (NG) and percutaneous tube feedings,
including gastrostomy and jejunostomy tubes, and teaching families
about tube feedings.
• Placement and replacement of NG tubes and ongoing management
and evaluation of all tubes.
Medications
• Teaching patients and families about administration and side effects of
medications.
• Evaluating adherence to drug regimen and effectiveness of ­prescribed
drugs.
• Administration of and teaching about injectable medications
(e.g., cobalamin [vitamin B12]).
• Weekly preparation of medications that are self-administered
(e.g., insulin, oral medications).
Intravenous Therapy
• Assessment and management of dehydration.
• Administering antibiotic drugs, parenteral nutrition, blood products,
and analgesic and chemotherapeutic agents.
• Flushing peripheral and central lines and ports and changing dressings.
• Instructing patients and families on line care, flushing, and dressing
changes.
Pain Management
• Assessment of pain, including location, characteristics, precipitating
factors, and impact on life.
• Teaching patient and family about nonpharmacologic techniques
(e.g., relaxation, imagery) for pain management.
• Providing optimal pain relief with prescribed analgesics.
Selected Laboratory Studies
• Drawing blood for studies related to monitoring disease processes or
therapy (e.g., drug levels).
to meet their own needs so they can feel in control of their
lives. Goals aim for long-term rather than short-term results.
Decision making and priority setting become shared activities
among the patient, family, and nurse.
Hospice
Hospice exists to provide support and care for people in the
last phases of terminal illnesses.9 Hospice care represents a
return to previous times when dying individuals were helped to
remain at home and to die at home, if possible, surrounded by
familiar sights, sounds, and smells and by the love of those who
care. Although hospice can be provided by agencies that also
provide other forms of community-based care, it is important
to remember the unique philosophical orientation that guides
hospice care. (Hospice and end-of-life care are discussed in
Chapter 11.)
FAMILY CAREGIVERS
While clinicians in all settings strive to create partnerships
with a patient’s family and loved ones, such relationships are
particularly important in home and community-based settings.
Family caregivers are spouses, adult children, other relatives,
and friends who (1) give and/or assist with direct patient care,
78 SECTION 1  Concepts in Nursing Practice

Table 6-4 COMMON ASSESSED NEEDS Table 6-5 NURSING DIAGNOSES

OF PATIENTS REQUIRING Patients Requiring Home Care
HOME CARE*
Acute pain related to tissue damage, therapy, decreased joint mobility
Health Perception–Health Cognitive-Perceptual Pattern Caregiver role strain related to 24-hr care responsibilities, marginal
Management Pattern • Need for sensory prosthetic coping patterns, unrealistic expectations
• Risk factors for potential health devices Chronic pain related to actual or potential tissue damage, disease
problems • Memory and learning problems progression
• Difficulty understanding • Acute and/or chronic pain Constipation related to decreased fluid intake, lack of mobility, opioid
­prescribed therapy • Sensory impairments analgesics
Deficient fluid volume related to inadequate nutrition and hydration,
Nutritional-Metabolic Self-Perception– dysphagia, and confusion
Pattern Self-Concept Pattern Fatigue related to disease process and therapy
• Chewing, swallowing, • Body image and esteem Imbalanced nutrition: less than body requirements related to ­inability
and ­eating problems ­disturbances to ingest or digest food, inability to absorb nutrients
• Skin impaired integrity • Feelings of powerlessness Impaired home maintenance related to decreased mobility, decreased
• Diet restrictions or endurance
­modifications Role-Relationship Pattern Impaired skin integrity related to physical immobility, radiation,
• Changes in living arrangements ­pressure
Elimination Pattern • Social isolation Risk for aspiration related to enteral tube feedings, impaired gag reflex
• Lack of bowel and bladder • Altered roles and responsibilities or swallowing, inability to expectorate sputum
control Risk for infection related to inadequate primary or secondary defenses,
• Need for assistive devices Sexuality-Reproductive impaired immune status, malnutrition
Pattern Risk for injury related to altered mobility, confusion, fatigue
Activity-Exercise Pattern • Changes in sexuality patterns Self-care deficit (any combination of the following):
• Lack of endurance during • bathing, dressing, feeding, or toileting related to pain, musculo-
activities Coping–Stress Tolerance skeletal impairment, decreased ­endurance
• Impairments in mobility Pattern Social isolation related to physical immobility, alteration in physical
• Dealing with change and loss appearance
Sleep-Rest Pattern • Exhaustion of adaptive abilities
• Altered sleep patterns
Value-Belief Pattern
• Value or belief conflict contribute to social isolation. Stress can progress to burnout
and result in negligence and abuse of the family member by the
*Organized by Functional Health Patterns. caregiver.
Adult children are often caregivers. The impact of the care-
(2) provide emotional and social support for the patient, and giving role can be overwhelming for adult children caregivers.
(3) manage and coordinate health care services. ­Family care- They may need to relocate their family or their parent(s), juggle
giving is sometimes called informal caregiving because it is care employment and family responsibilities, face financial strain,
given without pay and occurs in a community setting. These and realize the “loss” of their own lives. They have lost their par-
caregivers often sacrifice their own health to care for a loved one ents as they knew them before the illness, they have lost or had
dealing with a debilitating disease. A typical family caregiver is to deal with job changes, and they have lost or had to drastically
an older, married woman who often has chronic diseases and/ change their social networks.
or disabilities and is poor. An illness experienced by one family member will affect
Caregiving responsibilities are usually taken on gradually the entire family and alter family interactions. Family conflicts
with the progression of the illness of the patient. As the caregiv- regarding the changes needed or disagreements about how to
ing responsibilities become more demanding, caregivers often deal with the changes can develop. Often family members do
realize that changes have taken place in their lives related to the not communicate with each other about the needs of the patient,
experiences of being a caregiver. The intensity and complex- and this results in tension.
ity of caregiving put caregivers at risk for high levels of stress. At the same time, many family members involved in direct
Some common caregiver stressors are listed in Table 6-7. Care- caregiving activities also identify rewards associated with
giver stressors vary based on the intensity of the caregiving this role. Positive aspects of caregiving include (1) knowing
role. For example, a caregiver may need to adjust work sched- that their loved one is receiving good care (often in a home
ules to accommodate patient health care appointments, or the environment), (2) learning and mastering new tasks, and
caregiver may need to be available to monitor the cognitively (3) finding opportunities for intimacy. The tasks involved in
impaired patient’s safety 24 hours a day, 7 days a week. caregiving often provide opportunities for family members
Caregiving is an experience for which most people are not to gain greater insights into each other and strengthen their
prepared. It is common for caregivers to become physically, relationships.
emotionally, and economically overwhelmed with the respon-
sibilities and demands of caring for a family member. The stress
of caregiving may result in emotional problems such as depres-
NURSING MANAGEMENT
sion, anger, and resentment. Signs of caregiver stress include
FAMILY CAREGIVERS
irritability, inability to concentrate, fatigue, and sleeplessness. NURSING ASSESSMENT
The caregiver often experiences reduced social interactions and The first step in helping family caregivers is to identify them.
may be at risk for social isolation. Time commitments, fatigue, They must first be identified either by health care professionals
and, at times, socially inappropriate behaviors of the patient or self-identified. Caregivers have been referred to as “hidden
 Chapter 6  Community-Based Nursing and Home Care
Table 6-6 ROLES OF ADDITIONAL
MEMBERS OF THE HOME
CARE TEAM
Team Member Description of Services Provided
Physical therapist Will work with patients on strengthening and
(PT) endurance, gait training, transfer training,
and developing a patient education program.
Physical conditions or diagnoses that may
trigger a referral to a physical therapist
include orthopedic conditions, such as hip or
knee surgeries or neuromuscular deterio-
ration commonly seen with multiple sclerosis,
amyotrophic lateral sclerosis, and stroke.
Occupational May assist patient with fine motor coordination,
therapist (OT) performance of activities of daily living,
cognitive-perceptual skills, sensory testing,
and the construction or use of assistive or
adaptive equipment.
Speech therapist Focuses on various speech pathologies
for those who have suffered speech or
swallowing disorders seen in patients with
stroke, laryngectomy, or progressive neuro-
muscular diseases.
Social worker Assists patients with coping skills, caregiver
concerns, securing adequate financial
resources or housing assistance, or making
referrals to social service or volunteer
agencies.
Home health Assists patients with their personal care needs,
aide such as bathing, dressing, hair washing,
or some homemaking activities (e.g., meal
preparation or light housekeeping).
Pharmacist Prepares medications and infusion products.
Respiratory May assist with oxygen therapy in the home,
therapist provide specialized respiratory treatments,
and instruct patient or caregiver regarding the
proper use of respiratory equipment.
Dietitian Is available for dietary consultation regarding
health promotion or specialized diets.
patients” because a common characteristic of caregivers is pri-
marily having concern for their loved one and ignoring their
own needs.
The assessment of any patient needs to include an assessment
of the caregiver. You are a key person in this process. Areas that
should be assessed are presented in Table 6-8. Listen attentively
to the caregivers’ stories. They provide clues as to what their
lives are like, and these clues should be explored.
After you do an assessment, ask family caregivers if they need
help. Find out what specific types of help they need. Caregivers
are often reluctant to ask for help because they do not want to be
a burden or they feel they may be rejected. It is very important
to be supportive and encouraging of caregivers. Many caregiv-
ers suffer in silence because they may not know how to ask for
help, they may not know where to look for help, or they do not
know what help is available for them.
NURSING DIAGNOSES
Nursing diagnoses for family caregivers may include, but are
not limited to, the following:
• Caregiver role strain
• Social isolation
• Anxiety
• Ineffective health maintenance
79
Table 6-7 CAREGIVER STRESSORS
• Change in roles and relationships within family unit
• Lack of respite or relief from caregiving responsibilities
• Juggling day-to-day activities, decisions, and caregiving
• Change in living conditions to accommodate family member
• Conflict in the family unit related to decisions about caregiving
• Lack of understanding of the time and energy needed for caregiving
• Inability to meet personal self-care needs, such as socialization,
sleep, eating, exercise, and rest
• Financial depletion of resources as a result of a caregiver’s inability
to work and the increased cost of health care
• Inadequate information and/or skills related to specific caregiving
tasks, such as bathing, drug administration, wound care
PLANNING
The overall goals are that the caregiver will (1) have reduced
stress levels; (2) maintain personal, emotional, and physical
health; and (3) cope with the long-term effects of caregiving.
NURSING IMPLEMENTATION
You need to help family caregivers understand and cope with
changing roles, responsibilities, and stresses. You can communi-
cate a sense of empathy to the caregiver by allowing discussion
about the burdens and rewards of caregiving.
SAFETY ALERT
When differences exist, efforts to improve communication among the
patient, the family caregiver, and health care providers can improve deci-
sion making and alleviate stress for all parties.
Monitor the caregiver for indications of declining health
and emotional distress. It is important to remember that family
caregivers can have misperceptions about their relative’s prefer-
ences for care. These perceptions need to be clarified.
To reduce stress, help caregivers acknowledge their feelings
of stress and plan self-care activities. Discuss the potential that
support groups, networks of family and friends, and commu-
nity resources have for reducing stress. Support groups help by
sharing experiences and information, offering understanding
and acceptance, and suggesting solutions to common problems
and concerns. Encourage the caregiver to seek help from the
Table 6-8 ASSESSMENT OF FAMILY
CAREGIVERS
Assess family caregivers using the following questions:
1. What is your level of stress?
2. What are you doing to cope and how well are you coping?
3. How well do you maintain your own nutrition, rest, and exercise?
4. What is your level of social interaction vs. social isolation?
5. How much support do you get from outside sources (e.g., other
family members, friends, church members)?
6. How well are you taking care of your own health care needs (espe-
cially those with chronic illnesses of their own)?
7. Are you aware and do you use community and Internet resources?
For example: community resources, such as disease-specific profes-
sional organizations (e.g., Alzheimer’s Association, American Heart
Association), local adult day care centers, and Internet sites such as
www.caregiver.org.
8. Do you know about resources available for respite (someone caring
for your loved one while you have time to yourself)?
9. What kind of help or services do you need now and in the near
future?
80 SECTION 1  Concepts in Nursing Practice

formal social support system on matters such as respite care,
housing, health coverage, and finances. Respite care, which is
planned temporary care for the patient, can allow the caregiver
to regain a sense of equilibrium. Respite care includes adult day
care, in-home care, and assisted living services.
Family caregivers need to be encouraged to take care of
themselves. Keeping a journal can help the caregiver express
feelings that may be difficult to express verbally. Eating a
balanced diet at regular times will provide for the caregiver’s
well-being. Physical contact with others provides emotional
support and acknowledgment of the caregiver’s own need for
physical comfort. Exercise can help relieve stress. Maintenance
of regular activities and interests is also important to help the
caregiver. Humor is important, and its use from time to time in
some situations can provide distraction and relieve stress-filled
situations.

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*Evidence-based information for clinical practice.