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The Nurse’s Role in Chronic Disease Management - Marian ABSN
Nurses are key to helping patients manage their chronic illnesses. Marian University’s Accelerated BSN program can help you become a chronic disease nurse.
onlineabsn.marian.edu
Nurses play a crucial role in helping patients handle the complexities of managing their long-term diseases. Nursing activities can include:
- Assessments
- Care coordination
- Education
- Medication management
- Monitoring and support
- Nutritional counseling
- Personalized care plans
- Preventive care
- Wound care
When meeting with a patient, nurses take vital signs and health histories. They listen to the patient’s needs, how they are managing their conditions, and any health-related changes. Nurses identify follow-up needs, such as whether a patient should have blood drawn, schedule an eye exam, or come in for additional visits. They help patients manage their well-being by providing basic information about their disease(s) and teaching them how to maintain a healthy lifestyle and monitor their own health.
HIGHLIGHT:
Team based primary care models are becoming more prominent in primary care offices. It is important to clearly understand the nursing contribution to chronic disease management and preventative care in primary care. There are clinical activities such as performing nurse led clinics, utilizing nurse protocols, and performing annual wellness visits, and chronic disease education that are instrumental in the management and prevention of chronic diseases.4
In addition, there are recommendations that can be considered in changing the RN role for the future, such as providing RNs with additional training in primary care and care management skills for patients with complex health care needs.7
Professional nurses have the potential for significant contributions to patient-centered, cost-effective care through the care coordination role. The ANA recommends continued nursing research, education and improvement in professional practices to explore options for nurse led care coordination models.12
The Institute of Medicine report on the future of nursing affirms that “Nurses are being called upon to fill primary care roles and to help patients manage chronic illnesses, thereby preventing acute care episodes and disease progression”1.
Primary care practices should consider utilizing nurses in patient care delivery, care coordination, and as leaders supporting office workflows. Overall, nurses play an integral role in preventing and managing chronic diseases. Utilizing nurses will improve patient outcomes, nurse and physician satisfaction, as well as patient satisfaction and improve the health of our communities.
HIGHLIGHT:
Nursing implications
The updated HF management guidelines reference nurses nine times. For example, the guidelines note the role of the nurse in patient education about medication adherence and healthy lifestyle behaviors, which, when combined with other interventions, can help reduce asymptomatic LV dysfunction. Nurse-led support for patients with HF who experience depression can improve self-care, which leads to improved clinical outcomes. In addition, nurses have successfully coached patients in restricting their daily dietary sodium intake to 2 to 3 g per day, resulting in improved function and decreased leg edema. Nurses also play a significant role in evaluating patients for LV assistive devices when HFrEF becomes too advanced for less invasive interventions.When nurses organize or take part in care coordination, case management, and early post-discharge follow-up, all-cause mortality and re-hospitalization rates decrease. Nurses are invaluable members of the interprofessional team caring for patients with HF at any stage.
Nurse-Driven Process to Improve Ambulatory Care Medication Reconciliation
Purpose: The purpose of this quality improvement project was to improve outpatient medication review and reconciliation through the introduction of nursing. It is understood that active health professional medication management assists patients in maintaining complete and correct medication lists…
library.aaacn.org
Description: Two outpatient clinical areas were selected for a 15-week intervention. One caring for primary care/infectious disease patients and the other a surgical otolaryngology practice. Between the practices, 17 nurses are employed. The reviewed encounters were primarily made up of prescriber appointments but also included nurse exclusive visits. Further, nursing telephone triage encounters were included in the intervention. Workflow changes included nurse education on proper medication review and reconciliation, establishment and instruction on the preferred workflow, and EHR workflow enhancement. Nurses during in-person clinic visits and during appropriate telephone encounters were directed to review and reconcile current EHR records. Medication reconciliation compliance was measured through the recorded completion of the activity. Those patients engaging in an in-person encounter were provided a paper version or directed to the e-version after-visit summary for an updated and valid medication list. Press Ganey© CG-CAHPs rates, specific to medication management, were also reviewed.
Impact of a 6-Month Post-BSN Residency in Primary Care in Developing Regional Capacity for RN Integration
This presentation outlines program results since 2019 of a 6-month intensive university led post-baccalaureate residency/fellowship designed to prepare practice ready RNs in primary care…
library.aaacn.org
