The role of the Chronic Disease Nurse (RN) is to support physicians in the primary care setting in the care of their patients with one or more of the identified chronic conditions. Through collaborative care, their aim is to improve the management of these patients to optimize their health and well-being.A Chronic Disease Nurse (RN) works with the family physician to monitor the health of patients. The nurse has the ability to link two specialty services such as the diabetes, hypertension and cholesterol educators, dietitians, the Living Well program and the pain clinic.
Patient details are stored in an electronic information system that provides decision support which includes triggers for assessments, laboratory work and provides advice on clinical practice guidelines and treatment/referral recommendations.
This provides:
-proactive planned care and communication within the interdisciplinary team
-informed, empowered patients
-coordinated care including annual laboratory work, necessary annual assessments
and ongoing monitoring by phone or mail
-links to community programs and resources to help patients monitor and control
their health
Source: http://www.calgaryhealthregion.ca/programs/cdm/nursing/nursing.htm
>> It is good to know that there is a specialty in nursing that focuses on the patients with chronic diseases. Through this all of the patients with chronic diseases will be monitored and given appropriate nursing actions.
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Wednesday, April 28, 2010
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