THE HEALTH CARE PROCESS

OBJECTIVES Upon completion of this module, you should be able to: 1. 2. 3. 4. ". %. Define the health care process in his own words. Explain at least 4 principles of the health care process. Enumerate the steps procedures in!ol!e in assessment. Discuss the components of a comprehensi!e health history. Demonstrate the be#innin# s$ills in conductin# physical assessment. &dentify common si#ns and symptoms indicati!e of physiolo#ical alteration. '. Differentiate health problems based on #i!en criteria. (. Demonstrate the ability to prioriti)e health concerns implied in a situation.

RECOMMENDED PREPARATION *his module is intended for +e!el && nursin# students ta$in# up ,rimary -ealth .are 1./. this can also ser!e as a re!iew for the health professionals. I. THE HEALTH CARE PROCESS Definition &t is a systematic, lo#ical method of plannin# and pro!idin# indi!iduali)ed nursin# care. Goals 1. 2. 3. 4. identify a client0s health status identify actual or potential health care problems establish plans to meet the identified needs deli!er specific nursin# inter!entions to meet these needs.

Five components of the nursing process: 1. 1ssessin# 2. Dia#nosin# 3. ,lannin# 4. &mplementin# ". E!aluatin# Steps and procedures involve in assessment

2ursin# assessment is the first ma3or phase of the nursin# or health care process. &f we apply this to the family health nursin# process, this in!ol!es a set of actions li$e the followin#: the nurse measures the status of the family as a client its ability to maintain itself as a system and functionin# unit its ability to pre!ent , control or resol!e problems in order to achie!e health and well4bein# amon# the members data amon# the present condition or status of the family are compared a#ainst norms or standards of personal and social health 5theses norms of standards are derived from values, beliefs, principles, rules, or expectations of the family) the family0s inte#rity and ability to resol!e health problems Nursing assessment includes: 1. data collection 2. data analysis or interpretation 3. problem definition or nursin# dia#nosis 5this is the end result of two major types of nursing assessment in family nursing practice) Two major types of nursing assessment 1. first-level assessment 4 it is the process whereby existin# and potential health conditions or problems of the family are determined. 1nd these health conditions are cate#ori)ed as6 a. wellness state s b. health threats c. health deficits d. stress points or foreseeable crisis this le!el explains the depth of data #atherin# and analysis on what health conditions or problems exist and why each health condition or problem related with maintainin# wellness exists. 2. Second level assessment - defines the nature or type of nursin# problems that the family encounters in performin# the health tas$s with respect to a #i!en health condition or problem this le!el explains the reason about the family0s problems related to maintainin# wellness and or pro!ide a home en!ironment conducti!e to health maintenance and personal de!elopment. Note: Assessment to individual families and individual clients varies. However, let us focus ourselves on assessment to individual clients.

Steps in assessment 1. collection of data 2. or#ani)in# of data 3. !alidation of data 4. recordin# data about the client0s health status to establish a database Activities in assessment include: 1. obtainin# a health history 2. performin# a physical assessment 3. re!iewin# client records 4. re!iewin# literature ". consultin# support people and health professionals PHYSICAL HEALTH EXAMINATION &t is conducted startin# from the head and mo!in# toward the toes6 howe!er, the procedure can !ary in many ways, howe!er, re#ardless what procedure is used, the client0s ener#y and time must be considered. *he physical assessment is therefore done in a systematic and efficient manner that re7uires the fewest position chan#es for the client. a#e of the indi!idual se!erity of the illness the preference of the nurse the a#ency0s priorities and procedures -ealth assessment are done in relation to the followin# 1. client complaints 2. the nurse0s own obser!ation of the problem 3. the client0s presentin# problem 4. nursin# inter!entions pro!ided ". medical therapies 2ote: &t is important that durin# the health assessment , the nurse pro!ides continuous communication and often as$ 7uestions. *hese techni7ues put the client at ease and #i!es the nurse !aluable sub3ecti!e information. Steps in health assessment 1. preparin# the client explain the procedure when and where the examination will ta$e place why is it necessary who will conduct it what will happen durin# the examination Note: he actual health assessment procedure has been discussed

earlier in !rimary Health "are #.#. THE NURSING HEALTH HISTORY *he nursin# health history inter!iew is the first part of the assessment of the client0s health status and is usually carried out before the physical examination . *his is a structured inter!iew desi#ned to collect specific health data and to obtain a detailed health record of the client. &ts purposes are: to elicit information about all the !ariables that may affect the client0s health status to obtain data that help the nurse understand and appreciate the client0s life expectations to initiate a non3ud#mental, trustin# interpersonal relationship with the client Data obtained are then used in collaboration with the client to de!elop nursin# dia#noses and subse7uent plans for indi!iduali)ed care. 8$ill in inter!iewin# is essential when obtainin# a health history. &t includes the followin#6 1. biographic data 9 name, address, a#e, sex, race, marital status, occupation , reli#ion, orientation, health care financin#, and usual source of medical care. 2. chief complaint or reason for visit 3. history of present illness 4. past history 5. family history of illness 6. review of systems 7. lifestyle . social data 5family relationship friendship, ethnic affiliation, educational history, occupational history, economic status, home and nei#hborhood conditions: !. psycho logic data 5ma3or stressors, usual copin# patterns, communication style, self4 concept, mood: "#. patterns of health care $ommon signs and symptoms 1. cou#h 2. fe!er 3. abdominal pain 4. diarrhea CLASSIFICATION OF HEALTH PROBLEMS 1. ,resence of -ealth *hreats conditions that are conducti!e to disease, accident or failure top reali)e one0s health potential. Examples of these are the followin#6 1. ;amily history of hereditary condition disease 5diabetes: 2. *hreat of cross infection from a communicable disease case.

3. ;amily si)e beyond what family resources can ade7uately pro!ide. 4. 1ccident ha)ards ". faulty unhealthful nutritional eatin# habits or feedin# techni7ues practices %. stress4pro!o$in# factors '. poor home en!ironmental condition sanitation (. unsanitary food handlin# and preparation <. unhealthful lifestyle and personal habits practices %. &resence of 'ealth (eficits &nstances of failure in health maintenance Examples include: 1. illness states, re#ardless of whether it is dia#nosed or undia#nosed by medical practitioner 2. failure to thri!e de!elop accordin# to normal rate 3. disability 9 whether con#enital or arisin# from illness, transient temporary 5aphasia or temporary paralysis after a .=1 or permanent 5le# amputation secondary to diabetes, blindness from measles, lameness from polio: $. &resence of Stress &oints)*oreseeable $risis Sit+ations 1nticipated periods of unusual demand on the indi!idual or family in terms of ad3ustment family resources. Examples of these include: 1. marria#e 2. pre#nancy, labor, puerperium 3. parenthood 4. additional member 5newborn, lod#er: ". abortion %. entrance at school '. adolescence (. di!orce or separation <. menopause 1/. loss of 3ob 11. hospitali)ation of a family member 12. death of a member 13. resettlement in a new community 14. ille#itimacy

>eferences: ?o)ier, et. al. ;undamentals of 2ursin# "th ed. 1ddison @esley +on#man, &nc. 1<<(. ?o)ier, Erb., et. al., .linical -andboo$ for ;undamentals of 2ursin# 'th ed. ,earson Education 8outh 1sia ,te. +td. 2//4.

Aa#laya, 1raceli. 2ursin# ,ractice in the .ommunity 3rd ed. 1r#onauta .orporation. 2//3