* COMMUNITY HEALTH NURSING PROCESS* - Community health purpose and goals are realized through the application of a series

of steps that lead to desired result. - The nursing process is a systematic, dynamic, and on-going interpersonal process in which the nurses and the clients are viewed as a system with each affecting the other and both being affected by the factors within the behavior. ASSESSMENT - Assessment provides an estimate of the degree to which a family, group, or community is achieving the level of health possible for them, identifies specific deficiencies or guidance needed and estimates the possible effects of the nursing intervention. Collection of Data Relevant data are collected on the health status on the family, groups and community: Demographic data Vital health statistics Community dynamics power structure studies of disease surveillance economic cultural and environmental characteristics utilization of health services by the population and on the individual and families health status education socio-cultural religious and occupational background Family dynamics Environment Pattern of coping Method of collecting data: Community surveys by interview Observation of health related behaviors Review of statistics Health records Categories of Health Problems

The community heath nurse analyzes the data in accordance with the nurses conception of the source of the clients problem and need that can be met through nursing intervention. Presence of WELLNESS CONDITION Wellness potential is a nursing judgment on wellness state but NO explicit expression of client desire. Readiness for enhanced wellness state is a judgment on wellness state based on current competencies and performance, clinical data, and explicit expression of desire to achieve higher level of functioning or state. Inability to recognize the presence of condition or problem First Level Assessment Presence of Presence of HEALTH HEALTH THREATS DEFICITS Health threats -conditions that are conductive to disease, accident or failure. -conditions that promote disease or injury and prevent people from functioning. Health deficits -are instances of failure in health maintenance. -occurs when there is a gap between actual and achievable health status. Presence of STRESS POINT/ FORESEEABLE CRISIS SITUATION Stress poin/Foreseable crisis -are anticipated periods of unusual demand on the individual or family in terms of adjustment/family resources. -includes stressful occurrence such as death or illness of a family.

Second Level Assessment Inability to Inability to Inability to make provide provide a decisions adequate home with respect nursing care environment to talking to the sick, conducive appropriate disabled, for health health dependent maintenanc action or e and vulnerable/a personal

Inability to utilize community resources for health

t-risk developmen member of t the family Criteria for Ranking Health Condition and Problem according to priorities are: 1) Nature of the condition or problem presented; 2) Modifiability of condition or problem; 3) Preventive potential; 4) Salience (perception/evaluation of seriousness and urgency. Scale for Ranking Family Health Problems According to Priorities Criteria Weight 1. Nature of the problem presented 1 Scale : Health threat -2 Health deficit -3 Foreseeable crisis -1 2. Modifiability of the problem 2 Scale : Easily modifiable -2 Partially modifiable -1 Not modifiable -0 3. Preventive potential 1 Scale : High -3 Moderate -2 Low -1 4. Salience 1 Scale : A serious problem, immediate attention needed -2 A problem but not needing immediate attention -1 Not a felt need or problem -0 Scoring: 1. Decide on a score for each of the criteria 2. Divide the score by the highest possible score and multiply by the weight.

___Score___ Highest score x weight 3. Sum up the scores for all the criteria. The highest score is 5, equivalent to the total weight. The list of health problem ranked according to priorities is presented. PLANNING NURSING ACTIONS/CARE The plan for nursing action or care is based on the actual and potential problems that were identified and prioritized. Steps in Planning Nursing Action Goal Setting Constructing a Plan of Action Developing an Operation Plan Goal Setting A Goal is a declaration of purpose or intent that gives essential direction to action. THE COMMUNITY DIAGNOSIS Caring for the community as client starts with determining its health status. The nurse collects data about the community in order to identify the different factors that may directly or indirectly influence the health of the population. Then, she proceeds to analyze and seek explanations for the occurrence of health needs and problems of the community. The community health nursing diagnoses are then derived and will become the bases for developing and implementing community health nursing interventions and strategies. This process is called community diagnosis. Others call it community assessment or situational analysis. The health status of the community is a product of the various interacting elements such as population, the physical and topographical characteristics, socio-economic and cultural factors, health and basic social services and the power structure within the community. The interrelationship of these elements will explain the health and illness patterns in the community. Types of Community Diagnosis In the assessment of the communitys health status, the nurse considers the degree of detail or depth she should go into. There are times when situations call for a comprehensive assessment. Oftentimes, the nurse is confronted with a specific problem area like a

disaster situation or an outbreak of disease. In these instances, a problem-oriented assessment will have to be conducted. A nurse may decide to assess a specific population group in the community, in which case, she may opt to conduct a comprehensive assessment of that group and at the same time, focus on the specific problems of the same group. Comprehensive Community Diagnosis A comprehensive community diagnosis aims to obtain general information about the community. The following are elements of a comprehensive community diagnosis: A. Demographic Varaibles The analysis of the communitys demographic characteristics should show the size, composition, and geographical distribution of the population as indicated by the following: 1. Total population and geographical distribution including urba-rural index and population density 2. Age and sex composition 3. Selected vital indicators such as growth rate, crude birth rate, crude death rate and life expectancy at birth 4. Patterns of migration 5. Population and projections It is also important to know whether there are population groups that need special attention such as indigenous people, internal refugees and other socially dislocated groups as a result of disasters, calamities and development programs. B. Socio-Economic and Cultural Variables There are no limits of socio-economic and cultural factors that may directly or indirectly affect the health status of the community. However, the nurse should consider the following as essential information: 1. Social Indicators a. Communications network (whether formal or informal channels) necessary for disseminating health information or facilitating referral for clients to the health care system.

b. Transportation system including road networks necessary for accessibility of the people to health care delivery system. c. Educational level which may be indicative of poverty and may reflect on health perception and utilization pattern of the community d. Housing conditions which may suggest health hazards (congestions, fire, exposure to elements) 2. Economic indicators a. Poverty level income b. Unemployment and underemployment rates c. Proportion of salaried and wage earners to total economically active population d. Types of industry present in the community e. Occupation common in the community 3. Environmental indicators a. Physical/geographical characteristics of the community land areas that contribute to vector problems terrain characteristics that contribute to accidents or pose as geohazard zones land usage in industry climate/seaseon b. Water supply % population with access to safe, adequate water supply source of water supply c. Waste disposal % population served by daily garbage collection system % population with safe excreta disposal system Types of waste disposal and garbage disposal system d. Air, water and land pollution Industries within the community having health hazards associated with it Air and water pollution index 4. Cultural factors a. Variables that may break up the people into groups within the community such as:

 Ethnicity Social class Language Religion Race Political orientation b. Cultural beliefs and practices that affect health c. Concepts about health and illness C. Health and Illness Patterns In analyzing the health and illness patterns, the nurse may collect primary data about the leading causes of illness and deaths and their respective rates of occurrence. If she has access to recent and reliable secondary data, then she can also make use of these. 1. 2. 3. 4. 5. Leading Leading Leading Leading Leading causes of mortality causes of morbidity causes of infant mortality causes of maternal mortality cause of hospital admission

D. Health Resources The health resources that are available in the community is an important element of the community diagnosis mainly because they are the essential ingredients in the delivery of basic health services. The nurse needs to determine manpower, institutional and material resources provided not only by the state but those which are contributed by the private sector and other non-government organizations. 1. Manpower resources Categories of health manpower available Geographical distribution of health manpower Manpower-population ratio Distribution of health manpower according to health facilities (hospital, rural health units, etc) Distribution of health manpower according to type of organization (government, non-government health units, private) Quality of health manpower Existing manpower development/policies 2. Material resources Health budget and expenditures

 Sources of health funding Categories of health institutions available in the community Hospital bed-population ratio Categories of health services available

E. Political/Leadership Patterns The political and leadership pattern is a vital element in achieving the goal of high level wellness among the people. It reflects the action potential of the state and its people and its people to address the health needs and problems of the community. It also mirrors the sensitivity of the government to the peoples struggle for the better lives. In assessing the community, the nurse describes the following: 1. Power structure in the community (formal or informal) 2. Attitudes of the people toward authority 3. Conditions/events/issues the cause social conflict/ upheavals or that lead to social bonding or unification. 4. Practices/approaches that are effective in settling issues and concerns within the community. Problem-Oriented Community Diagnosis Spradley (1990) describes the problem-oriented community diagnosis as the type of assessment that responds to a particular need. For example: A nurse is confronted with health and medical problems resulting from mine tailings being disposed into the river systems by a mining company. Since a community diagnosis investigates the communitymeaning, the people and its environment the nurse proceeds with the identification of the population who were affected by the hazards posed by mine tailings. Then the nurse goes on to characterized the environmental factors along with the other elements which are relevant to the specific problems being investigated. Community Diagnosis: The Process

The process of CDx consist of collecting, organizing, synthesizing, analyzing and interpreting health data. Before the nurse collects the data, the objectives must be determined by the nurse as these will dictate the depth of the scope of the community diagnosis. The nurse needs to resolve whether a comprehensive or the problem-oriented community diagnosis will accomplish her/his objectives.

Steps in Conducting Community Diagnosis 1. Determining the objectives In determining the objectives of community diagnosis, the nurse decides on the depth and scope of the data she/he needs to gather. 2. Defining the Study Population Based on the objectives of the community diagnosis, the nurse identifies the population group to be included in the study. 3. Determining the Data to be Collected Whether the community diagnosis is going to be comprehensive or focused on a specific problem, the objectives will guide the nurse in identifying the specific data the nurse will collect. The nurse also decides Where, What, Whom to collect. 4. Collecting the Data In conducting CDx, different methods may be utilized to generate health data. a. Records review obtained by reviewing those that have been compiled from different sources. b. Survey and observations obtained both qualitative and quantitative data. c. Interviews can yield first hand information. d. Participant observation obtain qualitative data by allowing the nurse to actively participate in the life of the community. 5. Developing the Instrument Instrument or tools facilitates the nurses data-gathering activities. a. Survey questionnaire b. Interview guide c. Observation checklist 6. Actual Data Gathering Before the actual data gathering, it is suggested that the nurse met the people who will be involved in the data collection.

The instrument are discussed and analyzed. The data collectors must be given an orientation and training on how they are going to use the instruments in data gathering. 7. Data Collection After the data collection, the nurse is now ready to put together all the information. 2 types of data a. numerical b. descriptive

8. Data Presentation Data Presentation will depend largely on the type of data obtained. Descriptive data are presented into in narrative reports. Numerical data may be presented into table or graphs. Type of Graph Line graph Bar graph/ pictograph Histogram/frequency polygon Proportional or component bar graph/pie chart Scattered diagram Data Function Shows trend data or changes with time or age with respect to some other variables. For comparisons of absolute or relative counts and rates between categories. Graphic presentation of frequency distribution or measurement. Shows breakdown of a group or total where the number of categories is not too many. Correlation for tow variables.

9. Data Analysis Data analysis in CDx aims to establish trends and patterns in terms of health needs and problem of the community. It also allows for comparison of obtained data with standard values. Determining the interrelationship of factors will help the nurse view the significance of the problem and their implication on the health status of the community. 10. Identifying the Community Health Nursing Problems Community health nursing problem are categorized as:

11.

a. Health status problem They may be described in terms of increased or decreased morbidity, mortality, fertility or reduced capability fro wellness. b. Health resources problems They may be described in terms of lack of absence of manpower, money, materials or institutions necessary to solve health problems. c. Health-related problems They may be described in terms of existence of social, economic, environmental and political factors that aggravate the illness-including situations in the community. Priority-setting After the problem have been identified, the next task for the nurse and the community is to prioritized which health problems can be attended to considering the resources available at the moment. In priority-setting, the nurse makes use of the following criteria: a. Nature of the condition/problem presented The problems are classified by the nurse as health status, health resources or health related problem. b. Magnitude of the problem This refers to the severity of the problem which can be measured in terms of the proportion of the population affected by the problem. c. Modifiability of the problem this refers to the probability of reducing, controlling or eradicating the problem. d. Preventive potential This refers to the probability of controlling or reducing the effects posed by the problem. e. Social concern This refers to the perception of the population or the community as they are affected by the problem and their readiness act on the problem. CRITERIA SCORE 3 2 1 4 3 2 1 WEIGHT 1

Nature of the Problem Health Status Health Resources Health related Magnitude of the Problem 75%-100% affected 50%-74% affected 25%- 49% affected <25% affected

Modifiability of the problem High Moderate Low Not Modifiable Preventive potential High Moderate Low Social Concern Urgent community concern ; expressed readiness Recognized as a problem but not needing an urgent attention Not a community concern

3 2 1 0 3 2 1 2 1 0