Early detection of functional and cognitive decline after hospital discharge: the role of community nursing and multidisciplinary teams.

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.