Contents SECTION ONE The Organizational/Systems Role of the Ambulatory Care Nurse 1 Ambulatory Care Nursing Specialty Practice . 3 2 The Ambulatory Care Practice Arena . 15 3 The Context of Ambulatory Care Nursing . 29 4 The Ambulatory Care Team. 49 5 Practice/Office Support . 59 6 Health Care Fiscal Management . 73 7 Informatics . 85 8 Legal Aspects of Ambulatory Care Nursing . 99 9 Patient Advocacy . 117 10 Staffing and Workload . 127 11 Telehealth Nursing Practice. 137 SECTION TWO The Professional Nursing Role in Ambulatory Care 12 Leadership . 153 13 Evidence-Based Practice . 165 14 Ethics . 183 15 Regulatory Compliance and Patient Safety. 191 16 Professional Development . 201 SECTION THREE The Clinical Nursing Role in Ambulatory Care 17 Application of the Nursing Process in Ambulatory Care. 215 18 MulticulturalAmerican Nursing Care in the Ambulatory Academy Care Setting. of. 237 19 Patient© Education and Counseling . 253 20 Care of the Well Patient: Screening and Preventive Care. 267 21 Care of the Acutely Ill Patient . 289 22 Care of theAmbulatory Chronically Ill Patient. .Care . .Nursing . 321 23 Care of the Terminally Ill Patient . 385 Glossary. 415 Index . 427 This file is provided as a sample only and may not be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, or via any information storage or retrieval system. XV Chapter 1 Ambulatory Care Nursing Specialty Practice Sheila A. Haas, PhD, RN, FAAN Objectives Key Points Study of the information presented in this chapter will 1. The definition of ambulatory care nursing must enable the learner to: delineate the scope and unique dimensions of 1. Discuss the characteristics of ambulatory care ambulatory care nursing practice and differentiate nursing practice. ambulatory care nursing from other areas of spe- 2. Differentiate ambulatory care nursing practice from cialty nursing practice. other forms of specialty nursing practice. 2. A simple, concise blueprint of ambulatory care 3. Discuss the ambulatory care nursing conceptual nursing practice is essential. framework. 3. Change creates opportunities for nurses in ambula- 4. Enumerate opportunities for nurses in ambulatory tory care. care nursing. 4. Standards promote effective management of 5. Discuss ambulatory care standards. increasingly complex ambulatory care nursing roles and responsibilities in a changing health care envi- ronment. mbulatory care nursing is a unique realm of Characteristics of Ambulatory Care nursing practice. It is characterized by rapid, Nursing Practice focused assessments of patients, long-term Characteristics are unique features of ambulatory Anurse/patient/family relationships, and teaching and care nursing practice. translating prescriptions for care into doable activities A. Differences between ambulatory care nursing for patients and their caregivers. Ambulatory care and inpatient nursing practice are often over- nursing is a specialty practice area that is character- looked. ized by nurses responding rapidly to high volumes of B. Assumptions are made that practice styles, poli- patients in a short span of time while dealing with cies, and approaches used in inpatient care apply issues that are not always predictable. Because equally in ambulatory care, when in fact they ambulatory care nursing spans all populations of American Academyoften do not. of patients, and care ranges from wellness/prevention C. Ambulatory care focuses on the individual to illness and support of the dying, there is a need for patient, with some population-based care proto- an ambulatory© care nursing conceptual framework cols versus population-focused public health that specifies (1) the concepts unique to ambulatory practice. care nursing, and (2) how these core concepts are D. Focus groups (Haas, 1998) of experienced linked in ambulatory care nursing practice. Ambulatory Careambulatory Nursingcare nurses identified the following Ambulatory care nursing provides multiple opportuni- characteristics of nursing practice in ambulatory ties as well as challenges for nurses. It offers great care: interdisciplinary as well as autonomous practice 1. Nursing autonomy. opportunities. It demands that ambulatory care nurs- 2. Patient advocacy. es develop processes and procedures that meet the 3. Skillful, rapid assessment. needs of ambulatory care patients. Ambulatory care 4. Holistic nursing care. standards define the structure and process of ambu- 5. Client teaching. latory care nursing. 6. Wellness and health promotion. This file is provided as a sample only and may not be reproduced3 or transmitted in any form or by any means, electronic or mechanical, including photocopy, or via any information storage or retrieval system. Regulatory Compliance and Patient Safety Chapter 15 I dation or public services because of a handicap 2. Reporting is important in controlling and pre- (USCA 12182[a]) (U.S. Congress, 1990). venting the spread of communicable dis- 1. Physicians’ offices are considered facilities eases and in assuring appropriate medical of public accommodation. therapy. 2. “Handicap” includes any disability. a. All states and U.S. territories participate E. Both programs receiving federal financial assis- in the national morbidity reporting sys- tance and programs of public accommodation tem. are required to meet some specific standards b. Forty-nine (49) infectious diseases and under the ADA. related conditions are reported either as 1. Architectural standards for new and altered individual cases or in the aggregate buildings and in newly leased facilities must through the states and territories to the be met, as described in the Architectural CDC in Atlanta, GA. Barriers Act (ABA). c. State requirements vary in terms of 2. Public accommodations must remove barri- which agency is to receive reports, what ers in existing buildings where it is easy to do is to be reported, time frames for so without much difficulty or expense, given reporting, and other factors. the public accommodation’s resources. d. Non-infectious diseases also regulated 3. Auxiliary aids must be provided to persons include diseases caused by occupational with impaired sensory, manual, or speaking exposures, environmental diseases, and skills, where necessary to afford such per- congenital or noninfectious childhood sons an equal opportunity to benefit from the conditions. service in question. e. Diseases of “unknown or unusual etiology” F. Individuals with HIV infection are intended to be which may evolve into identification of regarded as disabled under the ADA legislation, new diseases are also reportable. and this interpretation has been upheld by feder- 3. The threat of bioterrorism heightens the al courts. need to make surveillance timely, specific, and responsive (M’ikanatha, Southwell, & Lautenbach, 2003). Regulations Regarding Reportable Diseases a. Computerization of patient and clinical And Conditions laboratory data may allow for automat- A. The Centers for Disease Control and Prevention’s ed reporting to health departments. (CDC) National Center for Health Statistics b. Refinement of automated systems is receives reports of births, deaths, and termina- needed to: tions of pregnancies through state health depart- (1) Become appropriately sensitive. ments. American Academy(2) To transmit of important findings. 1. All states require reporting of a live birth (3) Avoid reporting of extraneous data. regardless© of length of gestation or weight. (4) Provide complete case information. 2. Fetal death is reportable, but the definition (5) Facilitate use of uniform nomencla- varies by state. ture and data standards. 3. Induced termination of pregnancy is (6) Indicate adequate staffing and skill reportable,Ambulatory and reporting is mandatory in 48 Care Nursinglevel to manage the system at the U.S. regions. local level. 4. Death certificates must be completed, C. Reportable drug information: including cause of death. 1. The National Childhood Vaccine Injury Act of B. Clinicians and laboratories are required to report 1986 requires health care providers who infectious diseases and other conditions (Chorba, administer vaccines and toxoids to report Berkelman, Safford, Gibbs, & Hull, 1990). selected adverse events occurring after vac- 1. Authority to require notification of cases of cination to the U.S. Department of Health diseases resides with state governments. and Human Services. This file is provided as a sample only and may not be reproduced193 or transmitted in any form or by any means, electronic or mechanical, including photocopy, or via any information storage or retrieval system. Care of the Acutely Ill Patient Chapter 21 I Table 21-4. b. Review of anatomy and physiology. Post-Anesthesia Discharge Scoring System c. Pre-procedural sedation assessment, ASA physical status classifications, and 1. Vital Signs patient selection criteria. • 2 = within 20% of preoperative value d. Moderate sedation vs. deep sedation, • 1 = 20%-40% of preoperative value general anesthesia, and local anesthesia. • 0 = 40% of preoperative value e. Medications, dosages, administration rates, onset/duration/peak, adverse 2. Ambulation and mental status effects, contraindications, and reversal • 2 = oriented ˘ 3 and has a steady gait • 1 = oriented ˘ 3 or has a steady gait agents. • 0 = neither f. Management and monitoring of patients before, during, and after moderate 3. Pain or nausea/vomiting sedation. • 2 = minimal g. Management of emergency situations. • 1 = moderate h. Competency in operating and trou-