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Chapter: Medical Surgical Nursing: Community-Based Nursing Practice

Other Community-Based Health Care Settings

Ambulatory Settings - Occupational Health Programs - School Health Programs - Care for the Homeless -

Other Community-Based Health Care Settings


Ambulatory health care is provided for patients in community or hospital-based settings. The types of agencies that provide am-bulatory health care are medical clinics, ambulatory care units, urgent care centers, cardiac rehabilitation programs, mental health centers, student health centers, community outreach programs, and nursing centers. Some ambulatory centers provide care to a specific population, such as migrant workers or Native Americans. Neighborhood health centers provide services to patients who live in a geographically defined area. The centers may operate in free-standing buildings, storefronts, or mobile units. Agencies may provide ambulatory health care in addition to other services, such as offering an adult day care or health program. The kinds of services offered and the patients served depend on the agency’s mission.


Nursing responsibilities in ambulatory health care settings include providing direct patient care, conducting patient in-take screenings, treating patients with acute or chronic illnesses or emergency conditions, referring patients to other agencies for additional services, teaching patients self-care activities, and offering health education programs that promote health main-tenance. A useful tool for the community-based nurse might be the classification scheme developed by the Visiting Nurses Association of Omaha, which contains patient-focused prob-lems that are in one of four domains: environmental, psy-chosocial, physiologic, and health-related behaviors (Cookfair, 1996).

Nurses also work as clinic managers, direct the operation of clinics, and supervise other health team members. Nurse practi-tioners, educated in primary care, often practice in ambulatory care settings with a focus on gerontology, pediatrics, family or adult health, or women’s health. Constraints imposed by federal legislation and ambulatory payment classifications (APCs) re-quire efficient and effective management of patients in ambula-tory settings. Nurses can play an important part in facilitating the function of the ambulatory care facility.




Federal legislation, especially the Occupational Safety and Health Act (OSHA), has had a major impact on health conditions in the workplace. The law is directed at creating safer and healthier work conditions. It is in an employer’s interest to try to provide a safe working environment, because the result is reduced costs associated with employee absenteeism, hospitalization, and disability.


Occupational nurses may work in solo units in an industrial setting, or they may serve as consultants on a limited or part-time basis. They may also be members of an interdisciplinary team composed of a variety of health care workers such as nurses, physicians, exercise physiologists, health educators, counselors, nutritionists, safety engineers, and industrial hygienists. The oc-cupational health nurse functions in several ways and may pro-vide direct care to employees who become ill or injured, conduct health education programs for company staff members, or set up health programs aimed at establishing specific health behaviors, such as eating properly and getting enough exercise. The nurse must also be knowledgeable about federal regulations pertaining to occupational health and familiar with other pertinent legisla-tion, such as the Americans with Disabilities Act. The occupa-tional health nurse may monitor employees’ hearing, vision, blood pressure, or blood glucose levels (Capriotti, Kirby, & Smeltzer, 2000). Exposures to radiation, infectious diseases, and toxic substances are also tracked and reported to government agencies as required.




School health programs provide valuable services for students and may also serve the school’s community. School-age children and adolescents with health problems are at major risk for under-achieving or failing in school. The leading health problems of elementary-school children are injuries, infections (including in-fluenza and pneumonia), malnutrition, dental disease, and can-cer. The leading problems for high-school students are alcohol and drug abuse, injuries, homicide, pregnancy, sexually trans-mitted disease, sports injuries, dental disease, and mental and emotional problems. Ideally, school health programs have an interdisciplinary health team consisting of physicians, nurses, dentists, social workers, counselors, school administrators, par-ents, and students. The school may serve as the site for a family health clinic that offers primary health and mental health services to children and adolescents as well as to all family members in the community. Many school nurses have baccalaureate degrees, and advanced practice nurses are ideally suited to provide the primary care in these settings. Some school nurse programs provide com-munity care. Physical examinations are performed by advanced practice nurses who then diagnose and treat students and fami-lies for acute and chronic illnesses. These clinics are cost-effective and are especially beneficial for students from low-income families who lack access to traditional health care or have no health insurance.


The roles of the school nurse are care provider, health educa-tor, consultant, and counselor. The school nurse collaborates with students, parents, administrators, and other health and so-cial service professionals regarding a student’s health problems. Nurses perform health screenings, give basic care for minor in-juries and complaints, administer medications, monitor the im-munization status of students and families, and identify children with health problems. They need to be knowledgeable about state and local regulations affecting school-age children, such as ordi-nances for excluding students from school because of communi-cable diseases or parasites such as lice or scabies.


The school nurse is also a health education consultant for teachers. In addition to providing information on health prac-tices, teaching health classes, or participating in the development of the health education curriculum, the school nurse educates the teacher and class when one of the students has a special problem, a disability, or a disease such as hemophilia or acquired immuno-deficiency syndrome (AIDS).




No exact figures exist on the number of homeless people in the United States. Homelessness is a growing problem, and the homeless population includes increasing numbers of women with children (often victims of abuse) and elderly people. The home-less are a heterogeneous group, including members of dysfunc-tional families, the unemployed, and those who cannot find affordable housing. A large number of homeless persons, about 85%, are chronically mentally ill or abuse alcohol or other drugs (Walker, 1998). Some are temporarily homeless as a result of catastrophic natural disasters.


The homeless often have difficulty affording or gaining access to health care. Because of numerous obstacles, they seek health care late in the course of a disease and deteriorate more quickly than other patients. Many of the health problems they experience are related in large part to their living situations. Street life ex-poses homeless persons to the extremes of hot and cold environ-ments and compounds their health risks.


Homeless persons have high rates of trauma, tuberculosis, upper respiratory tract infections, poor nutrition and anemia, lice, scabies, peripheral vascular problems, sexually transmitted diseases, dental problems, arthritis, hypothermia, skin disorders, and foot problems. Common chronic health problems of the homeless include diabetes, hypertension, heart disease, AIDS, and mental illness. These problems are made more difficult by living on the street and by being discharged to a transitory, home-less situation in which follow-up is unlikely (Hunter, Crosby, Ventura, & Warkentin, 1997; Walker, 1998). Homeless persons who live in shelters frequently encounter overcrowded, unventi-lated quarters that provide an ideal environment for the spread of communicable diseases such as tuberculosis.


Community-based nurses who work with the homeless must be nonjudgmental, patient, and understanding. They must be proficient in dealing with many different kinds of people who have a wide variety of health problems and needs. Nursing inter-ventions are aimed at attempting to obtain health care services for the homeless and evaluating the health care needs of those who reside in the shelters.


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