39277 - Clinical Nursing and Rehabilitation in Chronic Disease (RN)

Course Unit Page

Academic Year 2022/2023

Learning outcomes

At the end of the module the student has the knowledge related to the methodology, the organizational and clinical assistance models for the taking charge, management and continuity of the assitance in situations of chronicity. Develops knowledge related to therapeutic education. He knows the resources of the family and the community.

Course contents

Acquire knowledge and skills related to the methodology and organizational and clinical-care models for the care and management of the person with chronic problems and permanent disabilities

Plan and manage care processes in multidisciplinary teams, from the assessment phase of the need to the definition of the therapeutic project in the pathways of chronicity, disability, based on evidence of effectiveness and using quality improvement methodologies

To develop, in the logic of a multidimensional approach, the continuity of care among the different welfare contexts.

Plan and conduct specific therapeutic education interventions, to improve the self-management of the person towards his health problem

Know the resources of the family and the community


Definition of chronicity and fragility and epidemiology

Chronic diseases and their characteristics

Innovative aspects of chronicity management

GNNN system for care planning in chronicity, with the use of international taxonomies (NANDA-I, NOC, NIC)


= paradigm of waiting medicine and of initiative medicine

= organizational models: self management, disease management and case management, chronic care model, Primary nunrsing

= integrated management of the multidisciplinary team

= concept of empowerment and mode of promotion

= Principles of welfare complexity


Services and activities guaranteed by the National Health Service: Essential Levels of Assistance (LEA)

Acute, chronic and protracted needs

Hospital and Territory Integration to guarantee continuity of care (Home care, Health houses, Community hospitals, ...)

Care pathways and nursing skills within the care network: PDTA, intermediate care.

Assisted pathways in the elderly person with femur fracture and in the myelolesa person, devices and support aids.

Palliative care: tools and processes of care evaluation

Assessment tools for the care of the fragile patient: Braden, Barthel, Brass, IADL scale, BINA


Nurse and therapeutic education

Pedagogical approach to the ETP

The phases of the educational process: methodology and application


The ICF classification (International Classification on Functioning, Disability and Health)

Effective relational models for functional relationships

Teaching methods

Interactive frontal lessons

Role playing

Narration of clinical cases

Assessment methods

The assessment of the knowledge acquired by the student is based on the administration of 50 questions concerning the teaching of clinical and rehabilitative nursing in chronicity, divided as follows: 30 questions concern the rationale of the topics covered in compliance with the published program; 30 questions require nursing planning in the chronic care pathways and the path of therapeutic education applied to the educational needs detected in the context of chronicity. The student draws 1 question by field and exposes his knowledge orally with problem solving methodology. the overall exam test includes a range of 10-15 minutes per student. the exam is considered positively overcome with the complete answer of 1 question and partial of the other, corresponding to the 18/30 vote.

Teaching tools

P.C. internet

Office hours

See the website of Antonella Dionisi