Community Nursing Management: Mary Tonkin Case Study, NURS 8721

This report details a community nursing management plan for a 77-year-old widow, Mary Tonkin, who lives alone and has multiple chronic conditions, including left-sided hemiparesis, diabetes, atrial fibrillation, and hypertension. The report emphasizes the role of the community nurse in assessing and managing Mary's health, focusing on fall risk assessment and environmental modifications, medication management, and health literacy development. It also addresses the importance of dietary changes and social support. Furthermore, the report explores the impact of informatics, such as electronic health records and telemedicine, on Mary's care, highlighting how these technologies can enhance care delivery and improve patient outcomes by providing easy access to information and facilitating remote monitoring and communication. The assignment draws upon research to support the interventions and recommendations for Mary's comprehensive care.

Running head: NURSING MANAGEMENT
NURSING MANAGEMENT
Name of the student:
Name of the university:
Author note:

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Introduction:
Community health nursing can be described as the discipline which incorporates
evidence based researches along with advancements in the science and new approaches for
improvement of health. This practice takes in consideration the various cultural as well as socio-
economic backgrounds of the people in the communities for ensuring appropriate interaction as
well as sensitivity when working with them (Kim et al., 2016). In this assignment, the
community nurse would be managing the health of the patient named Mary and would be
preparing a care management plan for her and apply informatics for her health management.
Chronic disorder management plan:
The patient named Mary had suffered from left sided hemiparesis after an incident of
stroke. Hemiparesis can be defined as the partial weakness on one side of the body of the
individual after the patient had experienced stroke. This weakness may be seen to involve arms,
hands, legs, face or combination. This might affect the mobility of individuals and also impact
ability to conduct daily activities of life (Zwar et al., 2017). Hence, Mary might be also facing
mobility issues and difficulty in cleaning, gardening and others. In such situation, the community
nurse should be referring her to a physiotherapist or can arrange for services where the
physiotherapist might undertake home-visit to give her services in collaboration with the nurse.
The physiotherapists mainly focus on the joint range of motion as well as strength by performing
exercises as well as re-learning functional tasks like that of bed mobility, walking, transferring
and motor gross motor functions.
Mary has restricted ability to mobilize and is currently seen to walk with aids. In such
situation, the community nurse would need to undertake fall risk assessment of the patient and

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accordingly modify the environment of her house so that her risk of fall reduces. The community
burse would use the Fall Risk assessment Tool also called the FRAT tool which comprises of
three parts. These are Part 1 - falls risk status; Part 2 – risk factor checklist; and Part 3 – action
plan. This would help the community nurse to assess the fall risk of Mary and accordingly take
interventions. The nurse would need to modify her house as well. Studies opine that nurses
caring for patients with fall risks need to arrange for bed rails, bathroom rails, hand bars on walls
and others which the patient can hold for support while moving (Arnold et al., 2019). Clutters
should be removed from floor in order to prevent any tripping over due to them. No light
furniture should be present to prevent chances of Mary from toppling over. The rooms should be
brightly lit and she should be also advised not to wear excessively loose clothes as they result in
increasing chances of fall. The nurse should also advise her to walk with non-skid slippers and
shoes to prevent chances of her fall. This would help Mary reduce her chances of fall due to
restricted ability to mobilize.
The patient is suffering from diabetes which was diagnosed 2 months ago. Diabetes
affects the ability of the cells of the body to respond to insulin and as a result for this, the cells of
the body cannot accept glucose from blood. Energy cannot be produced by cells of the body and
glucose level increases in blood along with risk of organ failures when untreated (Mosiallos et
al., 2015). Moreover, she is also seen to be suffering from symptoms of cardiovascular disorders
like that of atrial fibrillation. It is the common abnormal heart rhythms that happen when
electrical impulses fire from different regions in the heart in disorganized way causing the atria
to twitch making individuals feel irregular heartbeat or pulse. The symptoms that Mary faces like
shortness of breath, tiredness and dizziness are because of this disorder. She is also suffering
from issues of hypertension. It can be found that Mary has not been able to manage her chronic

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ailments successfully for which she has been suffering from their symptoms. The community
nurse should initially help her to manage her medications successfully so as to control the
symptoms of the disorder appropriately. Medication for diabetes like Metformin, microzide for
high blood pressure, clopidegrel for prevention for heart attacks and stroke – all should be
discussed with her in details so that she can understand why she is taking them and how the
medications act (Gazinao et al., 2015). The community nurse should discuss how digoxin and
warfarin can help her to overcome the symptoms of cardiovascular disorders she is facing. She
should help to develop health literacy of Mary. Studies opine that developing health literacy
helps patient to overcome their condition with medications, make them more serious about their
health. It also helps people to feel empowered of taking care of their own health. Hence, the
community nurse would try to develop health literacy of Mary and discuss about the doses ad
significance of her medication in details and try to develop her medication adherence.
From the case study it is also seen that Mary is keeping frozen foods which signifies she
is not aware of the negative consequences of fast foods, frozen foods and take-away foods on
health. They are high in calories which results in weight gain and ultimately obesity. Studies are
of the opinion that obesity acts as the risk factor for all chronic ailments increasing chances of
developing diabetes, cardiovascular disorders, hypertension and others. Hence, Mary would be
educated about the importance of having organic foods which are high on nutrients and low on
calories and asked to have home-cooked food (Smolowitz et al., 2015). Presently, it might be not
feasible for Mary to cook her own food and Sam might not be able to help her for long because
of conflicts in his own household. The community nurse in such situation can refer her to social
care agencies which can recruit social care aides for helping her in her home chores and also take
care for her throughout the day (McCormack et al., 2015). Moreover, undertaking physical

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exercises and not living a sedentary life are also important factors that help in preventing chronic
health ailments. Hence, community nurse treating Mary can educate her with free hand exercises
as well as brisk walking as she would not be able undertake vigorous exercises in this moment.
The community nursing professional should also educate Mary about handling glucometer
successfully. Glucometer help patients to understand their blood glucose level and finds out
whether they are within the safe zone of blood glucose level or not (Cherry & Jacob, 2016). This
helps the patient to approach professionals in adverse situations preventing them from accidents
(Steenkamer et al., 2017). The community nurses should also advise Mary to attend regular
screening sessions and undertake diagnostic tests to be free from deterioration of her health
conditions.
Impact of informatics on your client care:
Healthcare informatics can be explained as the integration of the healthcare sciences
along with computer science, cognitive science as well as information science for assisting in the
management of the healthcare information. Studies are of the opinion that healthcare as well as
nursing informatics are vastly evolving fields within the medical field and are seen to
continuously incorporating new and evolving technology (Wiley et al., 2015). Enhancement of
the delivery of care along with the improvement of healthcare outcomes and advanced patient
outcomes are some of the aspects that remain associated with the use of the informatics in client
care.
The community nurse can use the electronic health records to manage the patient records
of Mary easily and safely. Studies opine that patients no longer need to summarise their medical
past amid the stress of the different emergency situations. Family members would no longer have

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to worry about forgotten names of the GP or the nursing professionals or appointment and
vaccination records when they relocate. This system makes it easier for the patients and family
members as when they enter a facility, the medical staffs are already aware of the information
about the patient and they can initiate treatment or carry forward their consultations without
wasting time on repetition of the old information (Baptista et al., 2016). This also means less
paperwork as well as fewer and shorter forms of patients to fill out. Mary lives alone in her
house and she might face accidents and hence ready information in the electronic health records
would help community nurses to take quick actions. Moreover, such information would help
nurses to keep a follow up in every follow-up by the patients showing whether the patient health
is developing or not. Mary is also forgetting important information and hence information stored
on the EHR would reduce the requirement of the nurse to rely on Mary’s cognitive ability to
reveal information as well (Hudon et al., 2015).
Telemedicine can be described as the use of the electronic communications as well as
information technologies that help in providing clinical services when the participants are at
different locations. Studies are of the opinion that telehealth is a closely associated term with
telemedicine and is used to encompass a broader application wherein information technologies
and that of electronic communications are utilised for the supporting healthcare technologies
(Matthew et al., 2016). Some of the aspects of these systems are video-conferencing, e-health
including patient portals, transmission of still images, remote monitoring of vital signs,
continuing medical education and also different nursing call centres. The community nurse of
Mary can encourage her to undertake such services where they can video-conference with her to
provide her health education sessions, father information about her health, measure her vital
signs, and gather her glucometer reading information and others. Mary is living alone currently

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and she might not be able to travel to visit the community healthcare centre. This aspect would
ultimately help to remain connected with the professionals and remain under their guidance
without needing the support of Sam. Sam’s wife is worried about their children and Sam would
need to care for them and many not are able to accompany Mary all the times. In such situations,
nursing informatics would be of great help to the community nurse.

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References:
Arnold, E. C., & Boggs, K. U. (2019). Interpersonal Relationships E-Book: Professional
Communication Skills for Nurses. Saunders.
Baptista, D. R., Wiens, A., Pontarolo, R., Regis, L., Reis, W. C. T., & Correr, C. J. (2016). The
chronic care model for type 2 diabetes: a
Cherry, B., & Jacob, S. R. (2016). Contemporary nursing: Issues, trends, & management.
Elsevier Health Sciences.
Gaziano, T. A., Abrahams-Gessel, S., Denman, C. A., Montano, C. M., Khanam, M., Puoane, T.,
& Levitt, N. S. (2015). An assessment of community health workers' ability to screen for
cardiovascular disease risk with a simple, non-invasive risk assessment instrument in
Bangladesh, Guatemala, Mexico, and South Africa: an observational study. The Lancet
Global Health, 3(9), e556-e563.
Hudon, C., Chouinard, M. C., Diadiou, F., Lambert, M., & Bouliane, D. (2015). Case
management in primary care for frequent users of health care services with chronic
diseases: a qualitative study of patient and family experience. The Annals of Family
Medicine, 13(6), 523-528.
Kim, K., Choi, J. S., Choi, E., Nieman, C. L., Joo, J. H., Lin, F. R., ... & Han, H. R. (2016).
Effects of community-based health worker interventions to improve chronic disease
management and care among vulnerable populations: a systematic review. American
journal of public health, 106(4), e3-e28.

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Matthew-Maich, N., Harris, L., Ploeg, J., Markle-Reid, M., Valaitis, R., Ibrahim, S., ... & Isaacs,
S. (2016). Designing, implementing, and evaluating mobile health technologies for
managing chronic conditions in older adults: a scoping review. JMIR mHealth and
uHealth, 4(2), e29.
McCormick, K., & Saba, V. (2015). Essentials of nursing informatics. McGraw-Hill Education.
Mossialos, E., Courtin, E., Naci, H., Benrimoj, S., Bouvy, M., Farris, K., ... & Sketris, I. (2015).
From “retailers” to health care providers: transforming the role of community
pharmacists in chronic disease management. Health policy, 119(5), 628-639.
Smolowitz, J., Speakman, E., Wojnar, D., Whelan, E. M., Ulrich, S., Hayes, C., & Wood, L.
(2015). Role of the registered nurse in primary health care: Meeting health care needs in
the 21st century. Nursing Outlook, 63(2), 130-136.
Steenkamer, B. M., Drewes, H. W., Heijink, R., Baan, C. A., & Struijs, J. N. (2017). Defining
population health management: a scoping review of the literature. Population health
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Wiley, J. A., Rittenhouse, D. R., Shortell, S. M., Casalino, L. P., Ramsay, P. P., Bibi, S., ... &
Alexander, J. A. (2015). Managing chronic illness: physician practices increased the use
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Zwar, N., Harris, M., Griffiths, R., Roland, M., Dennis, S., Powell Davies, G., & Hasan, I.
(2017). A systematic review of chronic disease management.

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Appendix: Care plan:
Nursing priority intervention
Left side hemiparesis and restricted mobility Consult with physiotherapists and undertake
physiotherapy sessions
Walks with aids and difficulty in walking Fall risk management tool for fall-risk assessment
and modification of home environment
Unmanaged symptoms of chronic ailments  Medication management education
 Health literacy development
 Education for glucometer use
 Participation in screening sessions
 Education about importance of good
diet and proper physical activities
 Allocation of social workers to help her
with household chores and take care of
her as her son might have to look after
children