AMULATORY CARE

PRESENTED BY
IRSHAD AHMAD BHAT
MSC.NURSING IST YEAR
 INTRODUCTION:

 An ambulatory care patient as “an individual presenting

for personal health services who is neither bedridden
nor currently admitted to any health care institution”
By- National Ambulatory Medical Care Survey
(NAMCS)
• Their primary focus lies in pain management and
general health education for patients with chronic
injuries or illness. That help restore a patient’s ability to
live independently
 DEFINITON

Ambulatory care nursing includes those

clinical, management, and research
activities provided by registered nurses
for and with individuals who seek care
and assistance with health maintenance,
health promotion and/or health related
problems.
 CHARACTERISTICS:

1. Nursing autonomy
2. Client advocacy
3. Skillful, rapid assessment
4. Holistic nursing care
5. Client teaching
6. Wellness and health promotion
 CHARACTERISTICS CONTI…

1. Coordination and continuity of care

2. Long term relationships with clients and
families
3. Telephone triage, consultation, follow-up, and
surveillance
4. Collaboration with other health care providers
5. Case management
 CONCEPTUAL MODELS IN AMBULATORY
CARE NURSING PRACTICE:

1. Clinical model
2. Levels of prevention model
3. Primary health care, primary care, and managed care models
 CLINICAL MODEL

1. In this model, health is conceptualized as the absence of the clinical

manifestations of the disease.
2. It is assumed that the body is a machine and the modern medical technology can
use physical and chemical interventions to “fix the machine” whenever it is
broken
3. This has led to 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

The levels of prevention model, advocated by Leavell and Clark in 1965, has
influenced both public health and ambulatory care delivery worldwide.
This model suggests that the natural history of any disease exists on a continuum,
with health at one end and advanced disease at other.
PRIMARY HEALTH CARE, PRIMARY CARE,
AND MANAGED CARE MODELS:
1. Primary health care focuses on the universal right to basic health care.
2. Primary care focuses on integrated care coordinated by one primary provider.
3. Managed care approaches the use of health care services from a cost
containment perspectives.
 AMBULATORY CARE PRACTICE SETTINGS:

1. Physicians’ offices
2. Community hospital outpatient departments
3. Teaching hospital outpatient departments
4. Health maintenance organizations as Ambulatory
Care Delivery Sites
5. Emergency Departments
6. Other Ambulatory Care settings
 SERVICES PROVIDED IN AMBULATORY CENTERS:

1. Ambulatory surgery centers

(ASCs)
2. Catheterization labs
3. Dental practices
4. Dialysis centers
 SERVICES PROVIDED IN AMBULATORY CENTERS:

1. Urgent care centers

2. Imaging centers
3. In vitro fertilization clinics
4. Telemedicine providers
 ROLE OF NURSE

1. RNs enhance patient safety and the quality and effectiveness of care delivery
and are thus essential and irreplaceable in the provision of patient care services
in the ambulatory setting.
2. RNs are responsible for the design, administration, and evaluation of
professional nursing services within an organization in accordance with the
framework established by state nurse practice acts, nursing scope of practice,
and organizational standards of care.
 ROLE OF NURSE CONTI..

1. RNs provide the leadership necessary for collaboration and coordination of

services, which includes defining the appropriate skill mix and delegation of
tasks among licensed and unlicensed health care workers.
2. RNs are fully accountable in all ambulatory care settings for all nursing services
and associated patient outcomes provided under their direction
 ROLE OF NURSE CONTI..

1. Telehealth - Nurses in telehealth utilize a variety of technologies to triage,

conduct consultations, and deliver necessary follow-up on patient’s outcomes
and status.
2. Physician's office - In the physician’s clinic nurses are needed to assist the
doctors with patient consultations and procedures. Different specialties include
family medicine
 ROLE OF NURSE CONTI..

1. Urgent care - The Urgent Care Association of America projects more than
15,000 immediate care centers assess and treat ailments requiring treatment
beyond that of a doctor’s office but not severe enough for the hospital.
2. Community centres - In the community nurses act as patient educators,
coordinators, and advocates. In this role the ambulatory nurse may be
responsible for research to incorporate into community programs.
 ROLE OF NURSE CONTI..

1. Schools - Nurses in school facilities respond to medical emergencies within the

school area. In addition to this, they are responsible in assessing the health of the
students, faculty, and other school staff.
2. Health Insurance companies - Health insurance companies have an interest in
hiring nurses to collaborate with health care providers to ensure coverage
guidelines are followed appropriately. Nurses can also have a role as a nurse on
the 24-hour helpline.
 TRENDS IN AMBULATORY NURSING CARE:

1. Health care is changing:

2. From an illness oriented to a wellness orientation
3. From an acute care emphasis to primary care
4. From inpatient to outpatient services
 TRENDS IN AMBULATORY NURSING CARE:

1. From individual health to community well being

2. From fragmented care to managed care
3. From independent institutions to integrated system
4. From service duplication to a continuum of services
 CONCLUSIONS:

1. Ambulatory care nursing is one of the fastest growing areas of nursing speciality
practice.
2. Ambulatory care nurses are not only expert clinicians but also expert
communications.
3. They play key roles in facilitating the client’s successful progress through the
integrated delivery systems.
4. Ambulatory nurses make quality health care accesible.
ACUTE CARE
 ACUTE CARE HOSPITAL

• The American Hospital Association defines a hospital as an institution with the

primary function of providing diagnostic and therapeutic services
• Acute care hospitals are distinguished from long-term care facilities such as nursing
homes, rehabilitation centers, and psychiatric hospitals by the fact that the average
client stay is less Average stay: <30 days
• Types:
1. Government
2. Voluntary/Not-for-profit
3. For-profit
 UNDERSTANDING POST-ACUTE CARE

1. It is designed to fill the gap between acute care and long-term or home care and is
identified by a number of terms, including progressive, transitional, intermediate,
telemetry, or step-down units
Examples of post-acute clients include those recovering from myocardial infarction
(heart attack) or open heart surgery; those who must be weaned from a ventilator;
those who need wound management after burn injury or for multiple pressure ulcers;
those who require more rehabilitation after stroke or orthopedic surgery;
 ENSURING QUALITY HEALTH CARE
DELIVERY
1. Quality client care is the outcome of the integrated health care team approach,
2. Evidence-based practice is a concept used to improve: are to achieve client
outcomes.
3. Through work-redesign and skill-mix reallocation, in­stitutions are focusing goals
on achieving efficient client outcomes.
4. Work redesign involves studying a job over a fixed period to discover if and how
a certain job function might be made more efficient
 Elements of Quality Client Care

• Strategic planning
• Budgeting
• Performance improvement plans
• Risk management
• Utilization review
• Client satisfaction surveys
• Physician and census data input
 ETHICAL ISSUES

Common dilemmas
Nurse-client-physician conflicts
Ethical distress
Nurses are often called on to assist families in making informed decisions about
client care, and they must be familiar with ethical, legal, economic, and emotional
factors that affect the family's decision
 PERFORMANCE IMPROVEMENT AND
GOALS
These indicators generally include the following:
 Results of basic clinical indicators
 Continuous quality improvement
 Access to care issues
 Clinical Indicators with a Focus on High- Volume, High-Risk, and Problem-
Prone Issues
 PERFORMANCE IMPROVEMENT AND
GOALS
 The community/clinic focus includes the following:
 Communicable diseases (e.g., TB, HIV).
 Low birth weight as a percentage of live births
 Births to mothers 10 to 17 years of age as a percentage of all live births
 Percentage of women receiving prenatal care during the first trimester
 Breast cancer rates & mammography statistics
 Immunization rates
 THE FUTURE OF ACUTE CARE
HOSPITAL NURSING
The following are a few of the trends that will influence the delivery of care in
hospitals:
 As technology makes care in other settings more affordable, the acuity of clients in
hospitals will increase, which will prompt the use of master's prepared, acute care
nurse practitioners and clinical nurse specialists in the acute care setting.
 Health care will be directed at populations rather than individuals. Examples
include hospitals providing flu shots, community education programs, and
screenings.
 THE FUTURE OF ACUTE CARE
HOSPITAL NURSING
 Bioterrorism concerns will result in acute care hospitals taking the lead for disaster
preparation. The skills of nurses working in acute care will be utilized in a variety
of settings.
 The hospital work force may be a virtual work force with a core of flexible
workers and, based on acuity and census, other workers who contract for periods
of time. Examples include employee health, accounting, computer personnel, and
nursing staff.
 The length of a shift for nurses and rate of error will be examined.
 CONCLUSIONS:

• Acute care hospital-based nursing has changed. Years ago, clients could stay in the
hospital until they felt well enough to go home.
• Cost-containment issues have demanded that clients today spend as little time as
possible in acute care and quickly move to less expensive areas for care.
• Professional nurses are the cornerstone of high-quality care during these
shortened stays.
CRITICALCARE
 INTRODUCTION:

The first step inside an intensive care unit, or ICU, can be overwhelming. The
machinery is complex, medications are potent, stress and worry are visible on the
faces of the families, and alarms seem to sound endlessly.
. The reality is that the ICU is a place where skilled nurses, doctors, technologists,
pharmacists, respiratory therapists, & others competently care for the sickest clients
in the hospital. Their efforts are rewarding
 DEFINITION:

Critical care is a term used to

describe "the care of patients who
are extremely ill and whose
clinical condition is unstable or
potentially unstable
 REASONS FOR ADMISSION TO
THE INTENSIVE CARE UNIT:
 Respiratory difficulties impairing the client's ability to ventilate or oxygenate.
 These problems often include disorders such as pneumonia, pulmonary embolism,
drug overdose, and respiratory distress.
 Ventilators, also called respirators, may be required to assist with breathing.
 The use of these devices requires intense monitoring and skilled care providers to
assess both the equipment and the client's response.
 REASONS FOR ADMISSION TO
THE INTENSIVE CARE UNIT:
Hypotension or irregular heart rhythms can be life-threatening.
These clients may have had a heart attack or internal bleeding.
They are called hemodynamically unstable.
They are placed on cardiac rhythm monitors.
They may need monitoring of cardiac output and heart pressures.
 REASONS FOR ADMISSION TO
THE INTENSIVE CARE UNIT:
Loss of consciousness or mental status changes require ICU care.
Conditions include head injury, stroke, or brain/spinal surgery.
Frequent neurologic assessments are necessary.
Severe infections, like sepsis or burn wounds, need intensive care.
ICU care maintains blood pressure and organ perfusion.
These clients need fluid management and IV medications.
 REASONS FOR ADMISSION TO
THE INTENSIVE CARE UNIT:
Metabolic problems, like electrolyte imbalances or acidosis, need close
monitoring.
Causes include diabetes, renal failure, or other chronic diseases.
Medications are adjusted based on test results.
Clients who had major surgeries (heart, brain, chest, abdomen, orthopedic) go to
ICU after surgery.
Even clients with minor procedures but with cardiac or lung history may be
admitted for observation.
 NEEDS OF THE CRITICALLY ILL
CLIENT AND FAMILY
Clients in the ICU are at a most vulnerable stage.
Not only do these clients have great physical needs, but their emotional,
psychological, social, and environmental needs must be identified.
Critically ill clients often experience pain, immobility, disorientation, and sleep
deprivation.
They can feel isolated, anxious, and depressed.
Fears about their treatments, the unknown, and even death are not unusual.
 NEEDS OF THE CRITICALLY ILL
CLIENT AND FAMILY
Everything in their environment is stress producing unusual machines, loud noises,
equipment alarms, constant light,
Alteration of sleep quality and quantity in the critically ill client can have
important adverse consequences,
Characteristics' of hopelessness can actually impede recovery
Because of airway devices, medications, or physical pathology, many critically ill
clients cannot communi­cate their needs well, making their situation even more
stressful
 CRITICAL CARE NURSING
The American Association of Critical-Care Nurses (AACN) defines this
advocacy as "respecting and supporting the basic values, rights and beliefs of the
critically Ill client
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.
 ADVOCACY (AMERICAN ASSOCIATION OF
CRITICAL NURSES)
The critical care nurse will do the following:
 Respect and support the right of the patient or the pa­tient's designated Surrogate to
autonomous informed decision-making.
 Intervene when the best interest of the patient is in question.
 Help the patient obtain necessary care.
 Respect the values, beliefs, and rights of the patient.
 ADVOCACY (AMERICAN ASSOCIATION OF
CRITICAL NURSES)
 Provide education and support to help the patient or the patient's designated Surrogates
make decisions.
 Represent the patient in accordance with the patient's choices.
 Support the decisions of the patient or the patient's des­ignated surrogate, or Transfer
care to an equally qualified critical care nurse.
 Intercede for patients who cannot speak for themselves in situations that Require
immediate action.
 Monitor and safeguard the quality of care the patient receives.
 CRITICAL CARE PRACTICE SETTINGS
AND ROLES
 Critical care nursing is not limited to designated critical care units.
 In 2000 the Department of Health and Hu­man Services identified that about 31%
of all hospital nurses work with critically ill clients in ICU, PACU, emergency
room (ER) and in step-down units.
 Critical Care nursing is not nursing in a specific place; rather, it is nursing with a
specific mind-set that utilizes a specialized body of knowledge and skills.
 CRITICAL CARE PRACTICE SETTINGS
AND ROLES
 Critical thinking and clin­ical decision-making become more consistent the longer
the critical care nurse practices in the critical care envi­ronment.
 The critical care nurse must constantly keep up with the latest information and
become proficient with more complex new technologies and treatments.
 Critical care nurses are found in a variety of formal roles: bedside nurse, critical
care educator, case management, department manager, clinical nurse specialist,
and nurse practitioner.
 ADVANCE PRACTICE NURSES IN CRITICAL CARE:

 Advance practice nurses in critical care are registered nurses with a master's
degree who have a specialty in crit­ical care.
 The critical care clinical nurse specialist (CNS) uses an advanced level of
knowledge of critical care, pharmacology, and pathophysiology in completing the
role of educator, consultant, manager, researcher, and practitioner.
 The acute care nurse practitioner (ACNP) provides advanced nursing care to
acutely and critically ill clients in a wide variety of settings, including the emer­
gency department, ICUs, and step-down units.
 ADVANCE PRACTICE NURSES IN CRITICAL CARE:

 Making rounds, developing a plan of care, and performing specific advanced

procedures are all tasks the ACNP may do.
 Some ACNPs serve as intensivists and may insert central lines or chest tubes,
assist with surgery or intubation, or complete various functions once reserved for
physicians.
 RESEARCH ARTICLE

TITLE: Pressure injuries in mechanically ventilated COVID-19 patients utilising

different prone positioning techniques – A prospective observational study
AUTHOR : Cara Woolger a, Thomas Rollinson b c e, Fiona Oliphant a, Kristy Ross
OBJECTIVES :To compare the incidence and distribution of pressure injuries
(PIs) with two approaches to prone positioning for mechanically ventilated
COVID-19 patients, and to determine the prevalence of these PIs on
intensive care unit (ICU) and hospital discharge
 RESEARCH ARTICLE

DESIGN :A prospective observational study.

SETTING:Adult patients admitted to a quaternary ICU with COVID-19-associated
acute lung injury, between September 2021 and February 2022.
MAIN OUTCOME MEASURES :Incidence and anatomical distribution of PIs
during ICU stay for “Face Down” and “Swimmers Position” as well as on ICU and
hospital discharge.
 RESEARCH ARTICLE
RESULTS

We investigated 206 prone episodes in 63 patients. In the Face Down group, 26 of 34

patients (76 %) developed at least one PI, compared to 10 of 22 patients (45 %) in the
Swimmers Position group (p = 0.02). Compared to the Swimmers Position group, the
Face Down group developed more pressure injuries per patient (median 1 [1, 3] vs 0 [0,
2], p = 0.04) and had more facial PIs (p = 0.002). In a multivariate logistic regression
model, patients were more likely to have at least one PI with Face Down position (OR
4.67, 95 % CI 1.28, 17.04, p = 0.02) and greater number of prone episodes (OR 1.75,
95 % CI 1.12, 2.74, p = 0.01). Over 80 % of all PIs were either stage 1 or stage 2. By
ICU discharge, 29 % had healed and by hospital discharge, 73 % of all PIs had healed.
 RESEARCH ARTICLE

. CONCLUSION
Swimmers Position had a significantly lower incidence of PIs compared to the
Face Down approach. One-quarter of PIs had healed by time of ICU discharge
and three-quarters by time of hospital discharge.
 CONCLUSIONS:

• Critical care nursing occurs in a variety of settings. Health care will be

pressed to provide efficient and cost-effective services. Government
subsidies of health care may not be able to keep up with the demand.
• An impending shortage of nurses in the next 10 years will challenge our
health care institutions. Aging nurses are retiring or leaving critical care.
• Young or new nurses must step up to meet the exciting challenges of
critical care nursing
 REFERENCES:

1. Hinkle L. Janice & Cheever H. Kerry. “Brunner & Suddarth’s textbook of medical-surgical
nursing”. Edition 13. Published by Wolters Kluwer. P. 05-89.
2. Sharma K. Suresh. “Lippincott Manual of Medical-Surgical Nursing”. Published by Wolters
Kluwer. P. 09-50.
3. Nettina Sandra M. “Lippincott Manual of Nursing Practice”. 10th Edition. Published by Wolters
Kluwer. P. 04-35.
4. https://www.slideshare.net/dharmendraraval64/acute-and-critical-care
5. https://www.slideshare.net/AnshuYadav31/ambulatory-care-in-nursing
https://en.wikipedia.org/wiki/Ambulatory_care#:~:text=Ambulatory%20care%20or%20outpatient%2
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