99218 - Infermieristica nella cronicità (BO2)

Learning outcomes

At the end of the module the student possesses knowledge relating to the methodology, organizational and clinical care models for taking charge, management and continuity of care in chronic and fragile situations. Develops knowledge related to therapeutic education. Recognizes and values the resources of the family, the community and the service network.

Course contents

1. PRINCIPLES OF CARING FOR PEOPLE WITH CHRONIC DISEASES

Evolution of health needs related to new forms of frailty and chronic conditions.

The care paradigm: from "to cure" to "to care". Meaning of care management ("care taking").

Components and models of care management for priority health issues.

Care management in practice: healthcare and social aspects, with particular reference to the importance of involving the Person, the caregiver, and the family (significant people for the Patient), as well as organizational aspects.

2. CARE SETTINGS AND MODELS FOR CHRONIC CONDITIONS

The importance of teamwork in care management within an integrated service network.

Characteristics of interventions and the organization of services as a network.

Overview of organizational structures and relevant regulatory aspects.

The transitional care model and intermediate care.

The chronic care model.

Care settings for chronic conditions (outpatient clinics, home care, intermediate care, Community Health Houses, Community Hospitals - OS.CO).

The community nurse: competencies in different care settings for assisting Patients with chronic diseases.

3. TOOLS AND PROFESSIONAL ROLES IN CARE MANAGEMENT

Management of the Person with illness within the multidisciplinary team: the tools required for personalized care.

Tools for assessment and care management, the Individualized Care Plan (ICP/PAI), and assessment scales.

4. CARE MANAGEMENT

The most prevalent chronic diseases, diagnostic, therapeutic and care pathways, therapeutic education, self-care, and therapeutic alliance.

• Nursing care planning for patients with chronic diseases:
  1. Hypertension
  2. Heart failure
  3. Liver cirrhosis in chronic disease management
  4. Chronic Obstructive Pulmonary Disease (COPD) in chronic disease management
  5. Alzheimer's disease and Parkinson's disease dementias
  6. Rheumatologic diseases
  7. Cancer as a chronic condition and palliative care

Readings/Bibliography

Texts for study

Scalorbi S., Longobucco Y., Trentin A., INFERMIERISTICA PREVENTIVA, DI FAMIGLIA E DI COMUNITÀ McGraw-Hill, Milano, 2022 Seconda edizione ISBN 8838655642

NANDA International, Inc. Diagnosi Infermieristiche: Definizioni e Classificazione 2024-2026, Casa Editrice Ambrosiana, Milano

Texts for further study

Judith M. Wilkinson, Laurie Barcus, Diagnosi infermieristiche con NOC e NIC, 2017 seconda edizione Casa Editrice Ambrosiana

Amaducci G., Artioli G., Narrare la malattia, Nuovi strumenti per la professione infermieristica, Edit.Carocci Faber, Roma, 2007

Giuseppe D'Imperio, L’organizzazione come rete di relazione, Edit.Libreria Univ. Benedetti, 2010

A.Dalponte, F.Olivetti Manoukian, “ Lavorare con la cronicità” Edit.Carrocci Faber, 2004

G.Cavazza, C.Malvi, La fragilità degli anziani, Strategie, progetti, strumenti per invecchiare bene, Maggioli Editore, 2014.

G. Maciocco, Malattie croniche: nuovi modelli assistenziali, Edit. Prospettive sanitarie e sociali, 2006

Sasso L., Gagliano C., Bagnasco A., Scienze infermieristiche generali e cliniche, Edit. McGraw-Hill Education; 3 edizione, Milano, 2016


Sasso L., Silvestro A., Rocco G., Tibaldi L.; Moggia F., Scienze infermieristiche in Area Critica, Edit. McGraw-Hill Education; 2 edizione, Milano, 2012

Valenti D., Moggia F. Le alternative possibili che il medico internista può proporre alla dimissione, rispetto all'aumento di intensità di cura e l'assistenza ospedaliera ordinaria: la rete di cure palliative. QUADERNI - Italian Journal of Medicine 2017; 5(5): 55-71

Linee di indirizzo per l’attuazione del modello organizzativo delle Case della Comunità Hub – AGENAS 2024

Parte I. Il percorso clinico e assistenziale nelle insufficienze croniche d'organo "end-stage". Recenti Prog 9 Med 2014; 105: 9-24

Teaching methods

Active teaching: presentation of prototypical cases according to the problem based learning methodology

Simulations with individual care planning

Assessment methods

Assessment Methods

The final assessment will consist of two examinations:

Written examination, followed by the oral examination during the same exam session:

Written examination: Development of a nursing care plan based on a predefined case study, including the identification of one Nursing Diagnosis and one Collaborative Problem, with their corresponding objectives and interventions (a prerequisite for admission to the oral examination).
Maximum time allowed: 20 minutes.

Oral examination: Open-ended questions related to the case study addressed during the examination session, with further discussion and in-depth analysis.

Regarding learning assessments, the use of AI is prohibited. Any use constitutes a violation of academic integrity.

Teaching tools

Computer, video projector, books, articles, videos.

Office hours

See the website of Fabrizio Moggia