UNIVERSIDAD DE MANILA

Republic of the Philippines

City of Manila

NCM 104
Community Health Nursing 1

Dr. Maria Charito Laarni S. Indonto

Professor
Primary Health Care
Integrate relevant principles of:
- social,
- physical,
- natural and health sciences and
- humanities in a given health and nursing situation
 Competencies for nurses working in
Primary Health care
1. Patient Advocacy and education
- empowering and supporting patients
- Securing health services relevant to community and population
needs
2. Effective communication
- interprofessional communication
- Health communication
Cont.
3. team-work and leadership
- team-based delivery of care
4. People-centered care and clinical practice
- Understanding individual’s needs
- clinical practice
5. Continuous learning and research
- Reflective research practice
- Maintaining professional expertise
Patient advocacy and education
Ability to promote patient’s entitlement to ensure the best quality of
care and empowering patients to become active participants of their
health.
 Key competencies in patient advocacy and
education
•Empowering and supporting patients.
•Provide nursing care, considering cultural and ethnic background, sexual orientation,
gender identity, socioeconomic status, physical or mental capacity and values or beliefs.
•Develop, deliver and evaluate evidence-informed teaching materials in health promotion
and disease prevention for patients and their families that reflect and protect the individual,
social and occupational determinants of health of the populations being served.
•Work towards improving health literacy and supporting self management among patients to
prevent negative effects of risk factors and diseases.
•Identify affordable health-care programmes and inform and support patients on how to
access them.
Cont.
•Securing health services relevant to community and population needs.
•Monitor, identify and set priorities for local population health needs to adjust care to
respond to the social and occupational determinants of health reflected in the
community health needs.
•Develop evidence-informed strategies and services that respond to the social and
occupational determinants of health reflected in the community health needs.
•Enable individuals and communities to positively influence the social and
occupational determinants of health through advocacy and empowerment in
collaboration with community services.
•Build partnerships with community services, general practice groups and patient care
groups to support effective population health responses and improved health outcomes.
Effective communication
Ability to quickly establish rapport with patients and their family
members in an empathetic and sensitive manner incorporating the
patients’ perceived and declared culture.
 Key competencies in effective
communication
•Interprofessional communication.
•Identify and communicate relevant nursing theory and practice within the
multidisciplinary and interdisciplinary teams tasked with caring for patients
and communities.
•Demonstrate effective interpersonal communication skills using relevant
technologies.
•Build and maintain relationships with the nursing community, general practice
groups and actors identified in caring for patients to ensure improved health
outcomes.
•Communicate effectively to prevent and resolve conflicts.
Cont.
•Health communications
•Build and maintain professional therapeutic relationships with patients
through effective, safe and appropriate (sensitive and empathetic)
communication.
Team-work and leadership
Ability to function effectively as a member of an interprofessional team
that includes providers, patients and family members in a way that
reflects an understanding of team dynamics and group/team processes in
building productive working relationships and is focused on health
outcomes.
 Key competencies in team-work
and leadership
Team-based delivery of care
• Work collaboratively with community services, and in cross-sectoral
multidisciplinary teams, to deliver people-oriented health promotion,
disease prevention and continuity of care.
• Lead and participate in complex care management teams with the goal
of helping to improve the care of patients with multiple comorbidities.
• Coordinate effectively with other actors in the health sector in relation
to hospital discharge planning or referral and facilitating patients’
access to other services.
 People-centred care and
clinical practice
Ability to create conditions for providing coordinated/integrated
services centred on the patients and their families’ needs, values and
preferences along a continuum of care and over the life course.
Key competencies in people-centred care and
clinical practice (1/3)
Understanding individuals needs
• Assess the nature of a patient’s family, social support and other socioeconomic
resources that might affect the individual’s health.
• Plan and implement care in close collaboration with the patients and their families,
friends or caregivers (if appropriate) in a non-judgmental and respectful manner.
• Assess and apply the type and intensity of services to the needs for the patient,
ensuring timely, non-redundant, safe and effective care.
• Manage alternative and conflicting views from family, caregivers, friends and
members of the interprofessional team to maintain focus on the patient’s wellbeing.
Key competencies in people-centred care and clinical practice (2/3)
Clinical practice
•Deliver preventive programmes, health assessment and screenings with the goal of
improving health outcomes, promoting self-care management and facilitating access
to services and resources.
•Provide health education and disease management for noncommunicable and
communicable diseases, sexual and reproductive health and rights and lifestyle
interventions.
•Provide safe, effective and evidence-informed nursing care and health services
consistent with current standards, clinical practice guidelines, regulations and
legislation.
•Ability to work independently, triage, assess, plan, implement and evaluate acute
and chronic care.
Key competencies in people-centred care and clinical practice
(2/3) (Cont.)

•Managing noncommunicable diseases: review patient treatments using relevant

protocols (adjust diabetes medications, support injection techniques, prevent
complications and treat diabetic wounds and asthma control and education), monitor
treatment outcome and provide counselling and support for behaviour change.
•Noncommunicable diseases tend to be of long duration and are the result of a
combination of genetic, physiological, environmental and behavioural factors. The
main types are cardiovascular diseases (such as heart attacks and stroke), cancer,
chronic respiratory diseases (such as chronic obstructive pulmonary disease and
asthma) and diabetes.
 Key competencies in people-centred care and clinical
practice (3/3)

Clinical practice
•Protect the health of women, including cervical screenings, breast screening,
menopause care and perinatal mental health problems.
•Protect child health by supporting breastfeeding and optimal early nutrition together
with promoting and providing newborn screening programmes and childhood
immunization.
•Promote sexual and reproductive health and rights through family planning,
contraceptives and sexually transmitted infection screening.
•Understand and address the social and occupational determinants of health, such as
differences in health-seeking behaviour and cardiovascular risk factors among men.
Continuous learning and research
Ability to demonstrate reflective practice, based on the best available
evidence and to assess and continually improve the services delivered as
an individual provider and as a member of an interprofessional team.
Key competencies in continuous learning and
research
•Reflective research practice
•Participate in developing, implementing and evaluating relevant
policies and procedures to improve the quality and effectiveness of
nursing care and to promote patient safety.
•Identify risk and safety issues and facilitate possible solutions.
•Lead, develop and support clinical research and quality improvement
activities and provide education and training to colleagues, students and
communities.
Maintaining professional expertise
•Maintain professional expertise and a strong evidence-informed approach
and practice in accordance with the newest evidence informed practice
guidelines, legislation and policies.
•Maintain a commitment to continuing professional development in primary
care practice, new and emerging issues and the changing needs of patient
populations.
•Engage in training to use and promote new eHealth tools when applicable,
including telehealth, telemedicine, mobile health, electronic health records
and data to support efficient and evidence-informed patient care.
Source:
• https://www.euro.who.int/__data/assets/pdf_file/0004/441868/Com
petencies-nurses-primary-health-care-eng.pdf
Overview of Family Nursing Care Plan
Integrate relevant principles of:
- social,
- physical,
- natural and health sciences, and
- humanities in planning Family Nursing Care.
Family Nursing Care Plan
DEFINITION
A Family Nursing Care Plan is the set of actions the nurse decides to
implement to be able to resolve identified family health and nursing
problems.
Characteristics
1. The nursing care plan focuses on actions which are designed to solve or alleviate
an existing problem.
• The plan is a blueprint for action; the meats of the plan are the approaches, strategies, activities, methods,
and materials by which the nurse hopes to change the problem situation.
2.The nursing are plan is a product of deliberate systematic process.
• It is not based on impulsive or spur of the moment decisions. The planning process is characterized by
logical thinking whereby relationships are put together to arrive at rational decisions. The actions the nurse
decides to implement are chosen from among alternatives after careful analysis and weighing options open
to her.
3.The nursing are plan, as with all other plans, relates to the future.
• It utilized events in the past and what is happening in the present to determine trends. It also envisions the
future if the problem situation is not corrected
Cont.
4. The nursing care plan revolves around identified health and nursing
problems.
• The problems are the starting points for the plan, and the bases for the objectives of
care and subsequent intervention measures.
5. The nursing care is a means to an end, not an end in itself.
• The goal in planning is to deliver the most appropriate care to client. If it does not serve the
purpose for which it is initiated it becomes useless and an expensive undertaking.
6. Nursing care planning is continuous process, not a one-shot deal.
• The results of the evaluation of the plan’s effectiveness pave the way for another cycle of
planning until the problems are resolved.
DESIRABLE QUALITIES OF A NURSING CARE PLAN

•It should be based on a clear definition of the problems.

•A nursing care plan takes time and effort to make. It will be a sheer
waste of resources if it does not produce the intended results because of
a vague or erroneous definition of a problem. A good plan is based on a
comprehensive analysis of the problem situation. The main as well as
the contributory causes in the perpetuation of the problem should be
identified
Cont.
2. A good plan is realistic
• It can be implemented with reasonable chance of success.
• This realism of a plan is related to the quantity and quality of
resources required in its execution.
Cont.
The nursing care plan should be consistent with the goals and philosophy of the health agency.
• If the health agency for instances, promotes self reliance of the client as one of the philosophies,
then the nurse must bear this in mind when planning her approach and intervention measures.

The nursing care plan is drawn with the family.

•  This is consistent with the principle that the nurse works with and NOT for the family. She
involves the family in determining health needs and problems, in establishing priorities, in
selecting appropriate course of action, implementing them and evaluating outcomes. Through
participatory planning, the nurse also gives the family the feeling that its dignity and integrity are
preserved because of the realization that is not totally helpless and can still do something about
the problem situation.
Cont.
•The nursing care plan is best kept in a written form.
•It is a means of communication not only among the nurse but also
between nurses and other members of the health team. Moreover, it is
impossible for a nurse to keep many family care plan in her mind and
remember the salient point of care. The development of standard forms
can help motivate nurses to write their nursing care plans. Written plans
also serve as useful administrative device for evaluating staff
performance and the quality of care provided to clients.
 Importance of planning care
They individualized care to clients
•  The recipient of care whether individual of family or the entire
community are different from each other. Nursing care, to be
appropriate should suit and be unique to a particular client. Planning
facilities the delivery of the most appropriate care by considering the
individuality of each client
The nursing care plan helps in setting priorities
• By providing information about the client as well as the nature of his
problems, the nurse set her priorities for care.
The Nursing care plan promote systematic communication among the health
care team
• Nursing care plan define the problems and details of nursing interventions
done to resolve them.
Continuity of care is facilitated
• Gaps and duplication in services provided are minimized. Gaps and
duplications of services are bound to occur in setting where there is frequent
turnover of staff or when several health workers are providing care to
the same family.
It facilitates the coordination of care
• By making known to other members of the health team what nursing care is
rendered. Coordination of care prevents fragmentation of services and
increases the efficiency of the health service delivery system.
After the data analysis, the nurse may realize that the family is faced with a number of
health nursing problems, which cannot be taken up all the same time considering the
available resources for both the family and the nurse.

Considering this situation, she can rank the identified problems into priorities.
There are four criteria for determining priorities among health problems.
These includes:
1.NATURE OF PROBLEM PRESENTED- categorized into health threat, health deficit,
and foreseeable crisis.
2.MODIFIABILITY OF THE PROBLEM- refers to the probability of success in
minimizing, alleviation or totally eradicating the problem through nursing intervention.
3.PREVENTIVE POTENTIAL- refers to the nature and magnitude of future problems that
can be minimized or totally prevented if intervention is done on the problem under
consideration.
4.SALIENCE- refers to the family’s perception and evaluation of the problem in terms
of seriousness an urgency attention needed.
FACTORS AFFECTING PRIORITY-SETTING

1. Current knowledge, technology, and interventions to manage

the problem
2. Resources of the family- physical, financial, manpower
3. Resources of the nurse- skills, knowledge, and time
4. Resources of the community- facilities and
community organization or support