NMNC-1220 Exam 1
Adaptation Model – answer Sister Callista Roy
Recognizes the Individual as a holistic being that must adapt to their environment in
response to various stimuli.
Health is a process of becoming integrated w/in the environment.
Charge for Nurses: identify the behaviors and stimuli that influence the individual's
environment and collaborate w/ them to set goals for positive adaptation.
Self-Care Deficit Model – answer Dorothea Orem
individuals want to learn and participate in self-care.
Charge of nurses: identify deficits and create an individualized plan of care that
promotes a return to self-care.
Six Levels of Health Care - answer preventative, primary, secondary, tertiary,
restorative, and continuing health care
Preventive Health Care - answerThe promotion of health and prevention of disease in
individuals through such actions:
Routine screening for serious diseases
Improved health care education
Attention to the role of diet, exercise, smoking, and other lifestyle choices.
Primary Health Care - answerHealth promotion
Diagnosis and treatment of common illnesses
Ongoing management of chronic health problems
Well-baby care
Family Planning
pt-centered medical home
Secondary Health Care - answer(Acute Care)
Urgent care
Hospital ER/ED
Acute med-surg
Ambulatory care
outpatient surgery
radiological procedures
Tertiary Care - answerHighly specialized and specialty care
Intensive care inpatient psychiatric facilities
Neurology cardiology, rheumatology, dermatology, oncology
Restorative Care - answerRehab programs
, Sports medicine, spinal cord injury programs, home care
Continuing Health Care - answerLong-term care
Psychiatric and older-adult day care
Discharge Planning - answerCoordinated, interprofessional process that develops a
plan for continuing care after a pt leaves the health care agency
Begin upon admission
Nurses role: know the pt's plan of care ASAP, provide discharge instructions as soon as
possible to the whole care team
Coleman's "care transitions program" - answerDischarge planning
The role of a transition coach in managing/facilitating the discharge of a pt to home or to
rehab center
4 pillars
Naylor's "transitional care model" - answerDischarge planning
Comprehensive discharge planning and follow-up for older adults who are chronically ill
6 components
4 pillars of Coleman's discharge planning model - answermedication self-management
pt-centered record
Follow-up
Indicators of worsening medical condition
6 components of Naylor's discharge planning model - answerIn-hospital assessment
and development of discharge care plan
Discharge preparation by an interprofessional care team
pt participation regarding the whole process
Continuity of care and communication among health care providers
Predischarge assessment
Post discharge follow-up
GRACE team care model - answerHigh-intensity care team
Headed by both the NP and social worker, to support the PCP and to fully address a
pt's health conditions
Focus on pts managing their health conditions, coordinate their health care, and
achieve optimal health
Resident Assessment Instrument (RAI) - answerMinimum data set (MDS)
A core of set screening, clinical, and functional status elements which forms the
foundation of a comprehensive assessment for all residents of nursing homes that are
Medicare- or Medicaid- certified
Adaptation Model – answer Sister Callista Roy
Recognizes the Individual as a holistic being that must adapt to their environment in
response to various stimuli.
Health is a process of becoming integrated w/in the environment.
Charge for Nurses: identify the behaviors and stimuli that influence the individual's
environment and collaborate w/ them to set goals for positive adaptation.
Self-Care Deficit Model – answer Dorothea Orem
individuals want to learn and participate in self-care.
Charge of nurses: identify deficits and create an individualized plan of care that
promotes a return to self-care.
Six Levels of Health Care - answer preventative, primary, secondary, tertiary,
restorative, and continuing health care
Preventive Health Care - answerThe promotion of health and prevention of disease in
individuals through such actions:
Routine screening for serious diseases
Improved health care education
Attention to the role of diet, exercise, smoking, and other lifestyle choices.
Primary Health Care - answerHealth promotion
Diagnosis and treatment of common illnesses
Ongoing management of chronic health problems
Well-baby care
Family Planning
pt-centered medical home
Secondary Health Care - answer(Acute Care)
Urgent care
Hospital ER/ED
Acute med-surg
Ambulatory care
outpatient surgery
radiological procedures
Tertiary Care - answerHighly specialized and specialty care
Intensive care inpatient psychiatric facilities
Neurology cardiology, rheumatology, dermatology, oncology
Restorative Care - answerRehab programs
, Sports medicine, spinal cord injury programs, home care
Continuing Health Care - answerLong-term care
Psychiatric and older-adult day care
Discharge Planning - answerCoordinated, interprofessional process that develops a
plan for continuing care after a pt leaves the health care agency
Begin upon admission
Nurses role: know the pt's plan of care ASAP, provide discharge instructions as soon as
possible to the whole care team
Coleman's "care transitions program" - answerDischarge planning
The role of a transition coach in managing/facilitating the discharge of a pt to home or to
rehab center
4 pillars
Naylor's "transitional care model" - answerDischarge planning
Comprehensive discharge planning and follow-up for older adults who are chronically ill
6 components
4 pillars of Coleman's discharge planning model - answermedication self-management
pt-centered record
Follow-up
Indicators of worsening medical condition
6 components of Naylor's discharge planning model - answerIn-hospital assessment
and development of discharge care plan
Discharge preparation by an interprofessional care team
pt participation regarding the whole process
Continuity of care and communication among health care providers
Predischarge assessment
Post discharge follow-up
GRACE team care model - answerHigh-intensity care team
Headed by both the NP and social worker, to support the PCP and to fully address a
pt's health conditions
Focus on pts managing their health conditions, coordinate their health care, and
achieve optimal health
Resident Assessment Instrument (RAI) - answerMinimum data set (MDS)
A core of set screening, clinical, and functional status elements which forms the
foundation of a comprehensive assessment for all residents of nursing homes that are
Medicare- or Medicaid- certified
