Lesson: Health Care Process as Applied to Individual and Family

Objectives: Given an individual client, you will be able to apply beginning AKS to provide the appropriate health care
strategies accurately the steps of the health process
Lesson outline: This lesson contains the following:
1. Health Care Process Basic Concepts
- Definition
2. Steps of the health care process
a. Assessment
b. Planning
c. Intervention
d. Evaluation

Introduction: Health Care Process is a scientific and systematized approach to health care for individuals, families,
and community for health promotion and illness prevention.
Overview of Health Care Process

STEPS PURPOSE ACTIVITIES

1. Assessment  To establish baseline data  Obtain history
 Perform Physical
Assessment
 Review records (health
records, laboratory
records)
 Interview family and
support persons
 Validate assessment data

Diagnosis ( Statement of
Health Condition
2. Planning
3. Implementation
4. Evaluation
 Organize data
 To identify the client’s health care  Compare data against
needs (Utilizing Maslow’s standards (normal
Hierarchy of needs) structure; functions)
 To state the clients health  Identify gaps and
condition inconsistencies
 Determine client’s
strengths/weaknesses, risk
and problems
 Formulate statement of
health condition
 To identify the client’s health care  Formulate SMART goals
needs (utilizing Maslow’s and outcome criteria with
hierarchy of needs) the client
 To state the client’s health  Set priorities together with
condition the client
 Select appropriate health
care strategies
 Write health care plan
 To carry out health care plan  Perform planned health
 To help the client attain SMART care strategies
goals
 To determine the extent to which  Collect data about the
goals of health care have been client’s response
achieved  Analyze/draw conclusions
about goal attainment
 Modify the health care
plan.
Health Care Process as applied to Individual

Steps:
A. Assessment
 It is the collection, verification, and documentation of subjective and objective data about the client’s health
status
 It involves active participation by the client. Therefore, the health care worker should establish a helping
relationship and must communicate effectively
 Systematic observation is essential:
- Use all senses: sight, smell, hearing, touch and taste when collecting data.
- The observations of the health care worker must be validated. Interpretations of the client’s behavior
must not be used as fact. This could be done by way of being aware of their own value, beliefs, and
biases which may affect how they interpret.

Types of Data:
1. Subjective Data- are the client’s personal perceptions often gathered during the health history
2. Objective Data- are detectable by an observer. Examples of these data are those gathered during physical
assessment and review of health records.

Sources of Data:
1. Primary: Client
2. Secondary:
 Family members/ support persons
 Health personnel
 Medical records
 Other records and reports (laboratory examination, social agency’s report)
 Literature ( journals, reference texts, standard norms against which to compare findings)

Methods of Data Collection

A. Observing
- Gather data using five senses
- Be careful of faulty organization of data and misinterpretation
Example: You may interpret a client’s wish not to talk as depression when in fact the client is very hard.

B. Interviewing
- A combination of directive and non-directive approaches is used.
- The goals are establish rapport and collect data
- Begin by using open ended questions to determine areas of concern for the client. As the review
evolves, you may used closed questions to obtain data to complete health history.
Activities
1. History Taking
 Structuring data collection using Maslow’s Hierarchy of Human Needs Model
 Purpose: To obtain data systematically, the health care worker needs to use or organized assessment
framework or structure

Maslow’s Hierarchy of Human Needs

 Physiologic Needs- air, food, water, shelter, rest & sleep, activity, temperature maintenance, elimination,
pain avoidance
 Safety and Security Needs- to be safe, to feel safe, protection
 Love and Belonging – Giving and receiving love, having a family, attaining a place in a group.
 Self Esteem- self-esteem: feelings of independence, self-respect. Self esteem from others: recognition,
respect and appreciation
 Self-Actualization- guided by the basic values and principles and apply them
- Autonomous (free from parental and social pressures)

2. Physical Assessment- a way of examining the health of a client, gives objective data

Techniques of Physical Assessment:

1. Inspection- using the eyes, means assessing the general appearance of the client and the condition of
each body parts.
2. Palpation- using hands, act of feeling to detect condition of the skin and the underlying structures.
3. Percussion- using the hands also, tapping of certain areas like back, chest, and abdomen to note
vibrations and sounds.
 Tympanic- abdomen
 Resonant- chest
 Flat- muscles
4. Auscultation- using the ears, listening to client’s voice, hear heartbeat, breathing and sounds of the
intestines.

Materials: Flashlight, tape measure, watch/clock, thermometer, sphygmomanometer, stethoscope,

weighing scale.

Note: These instruments can help us more about client’s condition. However, lack of these should not
prevent a health care provider from doing good physical assessment. Since these are costly, cheap,
local substitute or alternative materials can be utilized or using one’s creativity, you may design or make
materials.

 Vitals Signs- these are indicators that tells us about the changes in a client’s, these include:
a. Temperature (36.5-37.5 degree C)
b. Respiration/breathing (at rest):
Adult- 12-20 cycles/min.
Children- 25-30 cycles/min.
Infants/babies- 30-40 cycles/min.
c. Pulse/heartbeat: Adult: 60-110 beats/mim.
Children: 80-120 beats/min.
Infant/babie: 100- 140 beats/min.
d. Blood pressure- 120/80 mmHg to 140/90 mmHG (dependent on several factors like age,
occupation, habits, food preferences)
  Weight and Height will also assess

Guidelines in Physical Assessment:

1. Make the client relaxed and comfortable
2. Provide privacy
3. Have an order for examinations:
 Head to toe
 Eyes to Mouth
 Chest to Abdomen
4. Maintain a well-lighted room
5. Always explain every steps that will be undertaken

B. Statement of a Health Condition

> a health- related response requiring strategies or interventions necessary in the promotion of health and prevention
of illness which make possible the performance of the daily essential functions of the client.
> Positively stated and with parameters
Eg: > Good skin status as manifested by smooth texture, and fair color
 Proper posture as manifested straight shoulder, head moved up, chin in , stomach in
 Good breathing pattern as manifested by a respiration rate of 16 cycles per minute.

C. Establishing Priorities: setting priorities should be based on Maslow’s Hierarchy of Needs. However,
dependent also on age, situation, setting, and number of person affected.

 Objective Setting: provides direction for determining how to help individuals in his concerns, related to
restoration, maintenance and promotion of health.

Classification of Objective:
1. Short term-weekly
2. Long term-month

Characteristics:
S- specific
M- measurable
A-Attainable
R- realistic
T- time- bounded

D. Health Care Strategies/Interventions: actions, necessary to promote health, maybe done by the health care
provider or the individual or both.

Health Care Strategies:

a. Hygiene and Comfort Measures
1. Eye care
 2. Oral care
3. Care of the hands and feet
4. Perineal care
5. Bath
6. Massage
7. Making bed
8. Hot and cold applications

b. Interventions to promote/improve nutritional status

1. Food handling and preparation

c. Spiritual care
d. Exercise, rest and sleep
e. Alternative medicine
e.1. Use of Herbal Plants/Medicine
e.2. Finger Pressure
e.3. Ventussa

f. Interventions for common signs and symptoms

f.1. fever
f.2. cough and colds
f.3. Loose bowel movement

E. Evaluation
 specifies how the health care provider will determine achievement of the outcome of care.
 Reflection of objectives