title: Early detection of functional and cognitive decline after hospital discharge: the role of community nursing and multidisciplinary teams.
abstract: This article features an individual example describing the multifactorial interventions of community nursing and a multidisciplinary team as they assess an older man's progressive functional decline, changes in behavior, and loss of previous social habits after being discharged from the hospital for the treatment of community-acquired pneumonia. Such nursing evaluation should include the following aspects: social environment, home environment, neighborhood characteristics, architectural barriers, capacity to perform activities of daily living, walking difficulties, risk of falling, changes in behavior and social habits, cognitive-affective state, pharmacological management, and the existence of nearby social organizations. The different approaches of community nursing and the multidisciplinary team are discussed.
authors.affiliation: II Health Science Department, Rey Juan Carlos University, Madrid, Spain. domingo.palacios@urjc.es
authors.forename: Domingo
authors.initials: D
authors.lastname: Palacios-Ceña
authors.forename: Cristina
authors.initials: C
authors.lastname: Alvarez-López
authors.forename: Miguel
authors.initials: M
authors.lastname: Cachón-Pérez
authors.forename: Cristina
authors.initials: C
authors.lastname: Alonso-Blanco
mesh_terms: D000203:Activities of Daily Living; D000359:Aftercare / Q000379:methods*; D000368:Aged; D003072:Cognition Disorders / Q000175:diagnosis* / Q000517:prevention & control; D003152:Community Health Nursing / Q000379:methods*; D042241:Early Diagnosis; D005851:Geriatric Nursing / Q000379:methods*; D006792:House Calls; D006801:Humans; D008297:Male; D008609:Mental Status Schedule; D051346:Mobility Limitation; D024802:Nurse's Role; D009730:Nursing Assessment / Q000379:methods*; D010348:Patient Care Team / Q000458:organization & administration*; D010351:Patient Discharge; D018570:Risk Assessment; D012919:Social Behavior