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Patient Problems and Advanced Practice Nurse Interventions During Transitional Care

Authors

  • Mary D Naylor Ph.D., R.N., FAAN,

    1. Mary D. Naylor is Ralston Endowed Term Chair and Associate Professor, and Kathryn H. Bowles is Research Assistant Professor, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania. Dorothy Brooten is Dean and John Burry Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.
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  • Kathryn H Bowles Ph.D., R.N.,

    1. Mary D. Naylor is Ralston Endowed Term Chair and Associate Professor, and Kathryn H. Bowles is Research Assistant Professor, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania. Dorothy Brooten is Dean and John Burry Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.
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  • Dorothy Brooten Ph.D., R.N., FAAN

    1. Mary D. Naylor is Ralston Endowed Term Chair and Associate Professor, and Kathryn H. Bowles is Research Assistant Professor, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania. Dorothy Brooten is Dean and John Burry Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.
    Search for more papers by this author

Address correspondence to Mary Naylor, 420 Guardian Drive, Nursing Education Building, University of Pennsylvania, School of Nursing, Philadelphia, PA 19104–6096. E-mail: Naylor@nursing.upenn.edu

Abstract

This study is a secondary analysis of patient records written by advanced practice nurses (APNs) as they provided discharge planning and 4 weeks of home follow-up to elderly patients hospitalized with common medical and surgical conditions. The purposes of this study were to examine the problems experienced by elders who were hospitalized and discharged to home, the interventions used by APNs as they cared for these patients, and the linkages between patient problems and APN interventions. Care logs written by the APNs to document the patient problems and nursing interventions were content analyzed and coded using the Problem Classification Scheme and Intervention Scheme of the Omaha System. The results provided a description of the 10 most frequent problems experienced by the patients linked with the APN's interventions. The study provides a description of the nature and complexity of patient problems as they transition from hospital to home and increases our understanding of the contribution of APNs to the care of elders.

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