The Nursing

Process in the
Care of the
Community
Learning Objectives
 Illustrate the principles of community health
nursing
 Describe the conditions affecting the health
of a given community
 Recognize the characteristics of a healthy
community
 Utilize
the nursing process in managing
community health concerns
Nursing Process in the
Care of the Community
 A community is a group of people who:
 Have a common interest or characteristic
 Interact with one another
 Have sense of unity or belonging
 Function collectively within a defined social
structure to address common concerns
 A community may be phenomenological
(functional) or geopolitical (territorial)
Principles of Community
Health Nursing
1. Community is the focus of care, nurse responsibility
is to the community as a whole
2. Give priority to community needs
3. Work with the community as an equal partner of the
health team
4. Focus on primary prevention for appropriate activities
5. Promote a healthful physical and psychosocial
environment
6. Reach out to all who may benefit from a specific
service
7. Promote optimum use of resources
8. Collaborate with others working in the community
health
Conditions in the
community affecting health
1. People
2. Location
3. Social system
Conditions in the
community affecting health
1. People
 Population variables that affect the health
of the community include
 Size
 Density
 Composition
 rate of growth or decline
 Characteristics
 Mobility
 social class and
 education level
Conditions in the
community affecting health
1. People
 Population and density
 influence the number and size of health
care institutions
 Negative effects of overcrowding include:
 Easy spread of communicable diseases
 Increased stress among the members of
the community
 Rapid degradation of housing facilities,
water, air and soil pollution
Conditions in the
community affecting health
1. People
 Population composition
 Health needs of communities vary
because of differences in age, sex,
occupation
 E.g. community with a large number of
women of reproductive age and young
children has different needs compared to
community with a large number of elderly
people
Conditions in the
community affecting health
1. People
 Rapid growth or decline of population
 Affects the health of the community
 Rapid population growth results from
migration of a large number of people due
to increased demand for services
 Rapid decline in population may results
from disturbance brought by
circumstances i.e. disasters, economic
changes, political instability
Conditions in the
community affecting health
1. People
 Cultural characteristics of the community
 Members of the community belong to a
similar cultural group (cultural
homogenicity) or are multicultural
 Feeling of belongingness and
participation in community action is
common in homogenous cultural
population
Conditions in the
community affecting health
1. People
 Mobility
 People move from one place to another
due to:
 Starting a family
 New job
 Joining another family member
Conditions in the
community affecting health
1. People
 Level of education and social class
 Affect health status because of:
 differences in living conditions and
 degree of access to resources and
opportunities
Conditions in the
community affecting health
2. Location
 Health of the community is affected by both
natural and man-made variables related to
location
 Natural factors consist of geographic features,
climate, flora, and fauna
 Geographic features consist of land and water
forms that influence food sources and
occupations
 Philippines has 2 seasons:
 Rainy season (tag-ulan) from June to
November
 Dry season (tag-araw) from December to
May
Conditions in the
community affecting health
2. Location
 Effects of climate change on human health
are evidenced by seasonal diseases i.e.
diarrheal diseases, conjunctivitis, heat
stroke, and skin condition
 Geographic location of Philippines is
vulnerable to natural hazards such as:
 Tropical cyclone - typhoons
 extreme rainfall, Thunderstorms
 floods
 Within ring of fire known for frequent
earthquakes and volcanic eruptions
Conditions in the
community affecting health
2. Location
 Factors that contribute to health problems
in urban communities include:
 Higher population density resulting in
congestion
 Greater exposure to health risks and
hazards
Conditions in the
community affecting health
3. Social System
 Is the patterned series of interrelationships
existing between individuals, groups and
institutions
 Social system components that affect
health include:
 Family, economic, educational,
communication, political, legal, religious,
recreational and health system
Characteristics of a Healthy
Community
1. A shared sense of being a community
based on history and values
2. General feeling of empowerment
3. Existing structures that allow subgroups
within the community to participate in
decision making
4. The ability to cope with change, solve
problems, and manage conflicts within the
community through acceptable means
Characteristics of a Healthy
Community
5. Open channels of communication
6. Equitable and efficient use of community
resources
A Healthy City is:
 Continually
creating and improving those
physical and social environments
 Expanding community resources
 People provide mutual support to each other
 Develop to their maximum potential
A Healthy City
 Aims to:
1. achieve a good quality life
2. create a health supportive environment
3. provide basic sanitation
4. supply access to health care
Community
Assessment
Community Assessment
 thedata needed to be collected depend
on the objectives of community
assessment.
 the nurse needs to collect data on the
three categories of community health
determinants:
 People
 place and
 social system.
Data Collected For P.A.T.C.H (Planed
Approach To Community Health)
PROCESS FOR HEALTH PLANING
1. Community Profile
 demographic educational and
 economic data

2. Morbidity and Mortality data

 including
unique health events(e.g.,
completion of barangay health station, a
typhoon that caused flooding of residential
areas)
Data Collected For P.A.T.C.H (Planed
Approach To Community Health)
PROCESS FOR HEALTH PLANING
3. Behavioral data
 focusing on behavioral risk factors, such as
smoking, drinking and leading a sedentary
life style
 prevailing good health practices in the
community, such as breast feeding and
getting regular exercise
4. Opinion data
 from community leaders, such as what they
think about the main health problems of the
community their causes, measures that may
alleviate or correct them
Approaches in Community
Assessment
 Comprehensive needs assessment
 The nurse gathers information about the
entire community using a systematic
process
 Data is collected regarding all aspects of
the community to identify actual and
potential health problems
Approaches in Community
Assessment
 Problem-oriented assessment
 Focused on a particular aspect of health
 The nurse collect information with a certain
community problem then proceed to gather
information from the aggregate vulnerable
to the problem
Tools In Community
Assessment
 Primary data
 data that have not been gathered before
and collected by the nurse through:
 Observation
 Survey
 informant interview
 community forum and
 focus group discussion
Tools In Community
Assessment
 Secondary data
 taken from existing data sources
 gives the nurse a picture of what is already
known about the population
 Consists of:
 Vital registries
 Health records and reports
 Disease registries
 Publications – DOH, FNRI, PSA
Collecting Primary Data
 Observation
 Rapid observation of a community through
ocular or windshield survey
 Gives the nurse chance to observe people and
take note of environmental conditions and
existing community facilities
 Participant observation
 is a purposeful observation of formal and
informal community activities by sharing life
of the community
 Helps in determining community values,
beliefs, norms, priorities, concerns and power
structures
Collecting Primary Data
 Survey
 Made up of a series of questions for
systematic collection of information from a
sample of individuals or families in a
community
 Appropriate for determining community
attitudes, knowledge, health behaviors and
perceptions of health and health services
Collecting Primary Data
 Informant Interview
 Purposeful talks with either key informants
or ordinary members of the community
 Key informants – consist of formal and
informal community leaders or persons of
position i.e. leaders in local government,
schools and business
 Interview may structured (interview guide)
or unstructured (informant guides the talk)
Collecting Primary Data
 Community Forum
 Is an open meeting of the members of the
community
 Pulong-pulong sa barangay is a good
example of community forum
 Effective tool in providing the people with a
medium for expressing their views
 Used as venue for informing the people
about secondary data
Collecting Primary Data
 Focus Group
 Made of a much smaller group, usually 6-
12 members only
 Effective in the assessment of health needs
of specific groups in the community
 E.g. focus group of first-time pregnant
women
Secondary Data Sources
 Registry of vital events
 Act 3753 (Civil Registration Law, Philippine
Legislature)
 Established the civil registry system in the
Philippines
 Requires the registration of vital events such
as:
 Birth
 Marriages
 deaths
Secondary Data Sources
 Registry of vital events
 The birth and death registries are sources
of fertility and mortality data
 The physician, nurse, midwife or anybody
who attended the delivery has the
responsibility for registering births
 Parent may also register the birth
 The birth of a child should be registered
within 30 days from the occurrence of birth
at the LOCAL CIVIIL REGISTRY OFFICE
of city or municipality
Secondary Data Sources
 Registryof vital events
 Presidential Decree 856 (sanitation code)
 Requires a death certificate before burial of
the deceased
 The physician who last attended the
deceased shall be responsible for preparing
the death certificate
 Certifying the cause of death and
submission made to the health officer within
48 hours
 Registration of death shall be made within
30 days from the occurrence of death at the
Local Civil Registry Office
Secondary Data Sources
 Healthrecords and reports
 The Field Health Service Information
System (FHSIS)
 is the official recording and reporting system
of the DOH
 Essential tool in monitoring the health status
of the population at different levels
Secondary Data Sources
 Healthrecords and reports
 The Field Health Service Information
System (FHSIS)
 Basis for:
1. Priority setting by local governments
2. Planning and decision making at different
levels (barangay, municipality, district,
provincial and national)
3. Monitoring and evaluating health program
implementation
Secondary Data Sources
 Healthrecords and reports
 The Field Health Service Information
System (FHSIS)
 Composed of recording and reporting tools
 Records are facility based; kept at the
barangay health stations (BHS) or at the
rural health unit (RHU) or health center
 Service delivered to the clients are the basis
of data in the record
 Records serve as the basis of reports
Secondary Data Sources
 Healthrecords and reports
 The Field Health Service Information
System (FHSIS)
 Reports consist of summary data that are
transmitted or submitted monthly, quarterly,
and annually
 Submission made from the BHS to RHU to
Provincial health office to Regional level
FHSIS Recording tools
1. Individual Treatment record (ITR)
 The building block of the FHSIS
 Record contains
 the date
 Name
 address of patient
 presenting symptoms or complaint and
 diagnosis,
 treatment and date of treatment
FHSIS Recording tools
2. Target Client Lists (TCLs)
 Second building block of the FHSIS
 Purposes:
 plan and carry out patient care and service
delivery
 Facilitate monitoring and supervision of
service delivery
 Report services delivered
 Provide a clinic level database
FHSIS Recording tools
2. Target Client Lists (TCLs)
 TCLs maintained in RHUs and health
centers:
1. TCL for Prenatal Care
2. TCL for Postpartum Care
3. TCL of Under 1 Year Old Children
4. TCL for Sick Children
5. National Tuberculosis Program TB
Register
6. National Leprosy Control Program
Central Registration Form
FHSIS Recording tools
3. The Summary Table
 Accomplished by the midwife
 It is a 12 column table in which columns
correspond to the 12 months of the year
 Kept at the BHS
 2 components:
 Health Program Accomplishment
 Morbidity/Diseases
FHSIS Recording tools
4. The Monthly Consolidation (MCT)
 Accomplished by the nurse based on the
summary table
 Serve as the source document for the
quarterly form and the output table of the
RHU or health center
FHSIS Reporting Forms
1. Monthly Forms
 Regularly prepared by the midwife and
submitted to the nurse, who uses data to
prepare quarterly forms
 Program Report (M1) – contains
indicators i.e. maternal care, child care,
family planning, and disease control
 Morbidity Report (M2) – contains a list of
all cases of disease by age and sex
FHSIS Reporting Forms
2. Quarterly Forms
 Usually prepared by the nurse
 There should only be one quarterly form for
the municipality/city
 Quarterly forms are submitted to the
Provincial Health Office
 Program Report (Q1) – contains the 3
months total indicators i.e. maternal care,
child care, family planning, and disease
control
 Morbidity Report (Q2) – a 3 month
consolidation of Morbidity Report (M2)
FHSIS Reporting Forms
3. Annual Forms
a. A-BHS is a report by the midwife that contains
demographic, environmental and natality data
b. Annual Form 1 (A-1) is prepared by the nurse and
is the report of the RHU or health center; contains
demographic, natality and mortality data for the
entire year
c. Annual Form 2 (A-2) – prepared by the nurse;
yearly morbidity report by age and sex
d. Annual Form 3 (A-3) – prepared by the nurse;
yearly report of all deaths (mortality) by age and
sex
Secondary Data Sources
 Disease Registries
 A disease registry is a listing of persons
diagnosed with specific type of disease in
defined population
 Basis for monitoring, decision making and
program management
 DOH has developed and maintained registries
for:
 HIV/AIDS
 Chronic noncommunicable diseases
 Obstructive pulmonary disease
 stroke
Secondary Data Sources
 Census Data
 A census is a periodic governmental
enumeration of the population
 Types of census method
 De jure – based on the legally established
place of residence of people
 De facto – according to the actual
physical location of people
Secondary Data Sources
 Census Data
 A PSA conducts the national census using
the de jure method
 The census population consists of:
 Filipinonationals – including those residing
in and out of the Philippines
 Nationals of other countries having their
usual residence in the Philippines
Methods to Present Community Data
 Purpose of community data presentation:
 To inform the health team and members of
the community of existing health and health
related conditions
 Make community appreciate the
significance and relevance of health
information
 Solicit broader support and participation in
the community
 Validate findings
Methods to Present Community Data
 Purpose of community data presentation:
 Allow for a wider perspective in the analysis
of data
 Provide a basis for better decision making
Graphs for Presenting
Community Data
 Bar Graph
 Compare values across different categories
of data
 E.g. population pyramid representing the
age structure of the male and female
population
Bar Graph
Graphs for Presenting
Community Data
 LineGraph
 To have a visual image of trends in data
over time or age
 Appropriate for time series
 E.g. trend of total fertility rate or average
number of children per woman in the
Philippines
Line Graph
Graphs for Presenting
Community Data
 PieChart
 Show percentage distribution or
composition of a variable i.e. population or
households
 Effective tool in highlighting the value of a
group in relation to the whole population
 E.g. distribution by nutritional status of
under 5 years of age
Pie Chart
Graphs for Presenting
Community Data
 Scatter plot or diagram
 Show correlation between two variables
 Values of both variables in subjects are
plotted in a graph with an x-axis and a y-
axis
 E.g. correlation between BMI and waist
circumference of males aged 18 years old
and above
Scatter plot or Diagram
COMMUNITY
DIAGNOSIS
Community Diagnosis
 is
the process of determining the health
status of the community and the factors
responsible for it
 It
is a quantitative and qualitative
description of he health of citizens and
the factors that influence their health
 Allowsidentification of problems and
areas of improvement
Community Diagnosis
 Shuster and Goeppinger (2004) proposed a
practical adaption of a format of nursing
diagnoses for population groups
 The
three part statement consists of:
1. the health risk or specific problem to
which the community is exposed.
2. The specific aggregate or community
with whom the nurse will be working to
deal with the risk or problem.
3. Related factors that influence how the
community will respond to the health risk
or problem application of this nursing
diagnosis
Community Diagnosis
 Example of Community Diagnosis:
 Health risk or specific problem - Risk of
Maternal complications leading to maternal
mortality
 Specificaggregate or community - among
pregnant women in (community)
 Related factors - related to:
 cost and inaccessibility of skilled birth attendant
and
 the community members perception that skilled
birth attendance and facility based delivery are
not necessary during childbirth
Planning
Community
Health
Interventions
Planning Community
Health Interventions
 Planning for community health
interventions is based on findings during
assessment and formulated nursing
diagnosis
 Planning is a logical process of decision
making to:
 determine which of the identified health
concerns require more immediate
consideration (priority setting)
 What actions may be undertaken to
achieve goals and objective
Planning Community
Health Interventions
 Planning phase involves:
1. Priority setting
2. Formulating goals and objectives
3. Deciding on community interventions
Priority Setting
 Provides the nurse and the health team
with a logical means of establishing priority
among the identified health concerns
 Criteria's to decide on a community health
concern for intervention according to The
World Health Organization (WHO):
1. Significance of the problem - is based
on the number of people in the community
affected by the problem or condition.
Criteria's to decide on a community health
concern for intervention according to The
World Health Organization (WHO):
1. Significance of the problem - If the
concerns are:
 DISEASE CONDITION – this may be
estimated in terms of its prevalence rate.
 POTENTIAL PROBLEM – its significance
is determined by estimating the number of
people at risk of developing the condition.
Criteria's to decide on a community health
concern for intervention according to The
World Health Organization (WHO):
2. The level of community awareness
 When people are aware of the risk
from a condition of the community,
these will allow them to deal with it and
more likely to have the motivation to
deal and prioritize the condition
Criteria's to decide on a community health
concern for intervention according to The
World Health Organization (WHO):
3. Ability to reduce risk
 related to the availability of expertise
among the health team and the
community itself.
 Involves the health team’s level of
influence in decision making related to
actions in resolving the community
health concern.
Criteria's to decide on a community health
concern for intervention according to The
World Health Organization (WHO):
4. Cost of reducing risk
 Thenurse has to consider economic,
social, and ethical requisites and
consequences of planned actions.
Criteria's to decide on a community health
concern for intervention according to The
World Health Organization (WHO):
5. Ability to identify the target
population
 For the intervention is a matter of
availability of data sources, such as
FHSIS, census, survey reports, and
case-finding or screening tools.
Criteria's to decide on a community health
concern for intervention according to The
World Health Organization (WHO):
6. Availability of resources
 tointervene the reduction of risk
entails technological, financial, and
other material resources of the
community, the nurse, and the health
agency.
Priority Setting
 Fora realistic and useful outcome, the
priority-setting process requires the joint
effort of the:
1. Community
2. The nurse, and
3. Other stakeholders, i.e. members of the
health team (Group)
Priority Setting Process
 Thegroup defines guidelines for
discussion
 Shusterand Goeppinger (2004)
suggested a flexible process using the
nominal group technique wherein each
group member has an equal voice in
decision making
Priority Setting Process
 Thistechnique is appropriate for
brainstorming and ranking ideas, when
consensus building is desired
 The
group makes a list of the identified
community health problems or conditions.
 Eachof the identified problems is treated
separately according to a set of criteria
agreed upon by the group
As suggested by Shuster and
Goeppinger (2004), the following steps
are carried out:
1. From a scale of 1 to 10, being the lowest, the
members give each criterion a weight based on their
perception of a weight based on their perception of
its degree of importance in solving the problem.
2. From a scale of 1 to 10, being the lowest, each
member rates the criteria in terms of the likelihood of
the group being able to influence or change the
situation.
3. Collate the weights (from step 1) and ratings (from
step 2) made by the members of the group.
4. Compute the total priority score of the problem by
multiplying collated weight and rating of each
criterion.
5. The priority score of the problem is calculated by
adding the products obtained in step 4
Priority Setting Process
 Compare the total priority scores of the
problems
 Theproblem with the highest total priority
score is assigned top priority
Formulating Goals And
Objectives
 Goals
 arethe desired outcomes at the end of
interventions
 Objectives
 are
the short-term changes in the
community that are observed as the
health team and the community work
towards the attainment of goals.
Formulating Goals And
Objectives
 Objectives
 serve as instructions, defining what
should be detected in the community as
interventions are being implemented.
 Specific
 measurable,
 attainable,
 relevant, and
 time-bound
 SMART) objectives provide a solid basis
for monitoring and evaluation.
Deciding on community
interventions
 The group analyzed the reasons for the
people’s health behavior and directs
strategies to respond to the underlying
causes.
 For
example, reasons for preference of
home delivery over facility-based delivery
should be identified
Deciding on community
interventions
 If
the majority of the women would choose to
have a home delivery because of cost or lack
of access of birthing facilities, strategies
should then be focused on improving facility-
based services
 But if the primary reason is sociocultural, the
planning team may opt to concentrate on
providing opportunities for skills development
of traditional birth attendants and/or exerting
effort to gain the trust and confidence of the
women and their families.
Deciding on community
interventions
 If
the majority of the women would choose to
have a home delivery because of cost or lack
of access of birthing facilities, strategies
should then be focused on improving facility-
based services
 But if the primary reason is sociocultural, the
planning team may opt to concentrate on
providing opportunities for skills development
of traditional birth attendants and/or exerting
effort to gain the trust and confidence of the
women and their families.
Deciding on community
interventions
 Inthe process of developing the plan, the
group takes into consideration the
demographic, psychological, social,
cultural, and economic characteristics of
the target population on one hand and the
available health resources on the other
hand.
Implementing
the Community
Health
Interventions
Implementing the Community
Health Interventions
 Often referred to as the action phase
 implementation is the most exciting phase
for most health workers.
 Aside from being able to deal with the
recognized priority health concern, the
entire process is intended to enhance the
community’s capability in dealing with
common health conditions/problems.
Implementing the Community
Health Interventions
 The nurses role:
 facilitate
the process rather than directly
implement the planned interventions
 Implementation also entails coordination
of the plan with the community and the
other members of the health team.
 Thisrequires a common understanding of
the goals, objectives and planned
interventions among the members of the
implementing group.
Implementing the Community
Health Interventions
 Collaboration with the other sectors such
as the local government and other
agencies may also be necessary.
Evaluation of
Community
Health
Interventions
Evaluation of Community
Health Interventions
 Evaluation approaches may be directed
structure, process, and outcome.
1. Structure evaluation involves looking into the
manpower and physical resources of the
agency responsible for community health
interventions.
2. Process evaluation is examining the manner
by which assessment, diagnosis, planning,
implementation, and evaluation were
undertaken.
3. Outcome evaluation is determining the degree
of attainment of goals and objectives.
Evaluation of Community
Health Interventions
 Ongoing evaluation or monitoring is
done during implementation to provide
feedback on compliance to the plan as
well as on need for changes in the plan to
improve the process and outcomes of
interventions.
Standard Of Evaluation
 The bases for a good evaluation are its
utility, feasibility, propriety, and accuracy.
(CDC, 2011)
 Utility
 is the value of the evaluation in terms of
usefulness of results.
 The evaluation of community health
interventions will be great use to the
community health group
 helps the group gain insight into strengths
and weaknesses of the plan and the
manner of its implementation.
Standard Of Evaluation
 Feasibility
 answers the question of whether the plan
for evaluation is doable or not, considering
available resources.
 Resources include facilities, time, and
expertise for conducting the evaluation.
Standard Of Evaluation
 Propriety
 involves ethical and legal matters.
 Respect for the worth and dignity of the
participants in data collection should be
given due consideration.
 The results of evaluation should be
truthfully reported to give credit where it is
due and to show the strengths and
weaknesses of the community
Standard Of Evaluation
 Propriety
 Results should be furnished to everyone
entitled to them especially the community
 Transparency and accountability should be
observed in all financial matters related to
community health action
Standard Of Evaluation
 Accuracy
 refers to the validity and reliability of the
results of evaluation.
 Accurate evaluation begins with accurate
documentation while the community health
process is ongoing