title: Patient problems and advanced practice nurse interventions during transitional care.
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.
authors.affiliation: University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania 19104-6096, USA. Naylor@nursing.upenn.edu
authors.forename: M D
authors.initials: MD
authors.lastname: Naylor
authors.forename: K H
authors.initials: KH
authors.lastname: Bowles
authors.forename: D
authors.initials: D
authors.lastname: Brooten
mesh_terms: D000368:Aged; D003266:Continuity of Patient Care / Q000458:organization & administration*; D005260:Female; D006304:Health Status; D006701:Home Nursing / Q000458:organization & administration; D006801:Humans; D008297:Male; D009722:Nurse Practitioners; D009737:Nursing Records; D010351:Patient Discharge