Community Health Nursing II

COMMUNITY HEALTH
NURSING II
PROF. RAMONA A. GALICIA
COMMUNITY The synthesis of nursing knowledge and
practice and science and practice of public
health, implemented via a systematic use of the
HEALTH NURSING nursing process & other processes to promote

health and prevent illness in population groups
(Clark, 2008).
The other processes include management,
supervision, research, advocacy and political
action

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LEVELS OF CLIENTELE IN COMMUNITY HEALTH NURSING
PRACTICE
 INDIVIDUAL  FAMILY

unit of care is the “person”
· unit of care : family members

·
· Focus: patient’s health or with medically diagnosed health
medical problem, clinical problems
management of the problem  · Focus: family members general
 · The family of the patient
may or may not be involved health or medical problem and
· Scope of service : basic to clinical management of the
comprehensive problem
 

LEVELS OF CLIENTELE IN COMMUNITY HEALTH NURSING
PRACTICE
 POPULATION GROUP  COMMUNITY

Group of people who share
· The term “community” has both
 ·
geographic and socio-cultural connotations

common characteristics,  · The community as the patient in
developmental stage or common community health nursing still focus is
exposure to environmental factors services to individuals and families
 · Interventions are planned and
and consequently common health
implemented on a community wide scale
problems, issues and concerns (e.g  · Group of people sharing common
maternal, prenatal & newborn geographic boundaries/or common values
populations, infant, toddler & interests w/in specific social system
preschool pop, 


THE FAMILY AS THE PATIENT AND UNIT OF CARE
FAMILY
Definition: refers to two or more individual joined by ties of blood, marriage or adoption and who
constitute a single household, interact with each other in their respective familial roles and who
create and maintain a common culture
Rationale :
1. The family is considered the “natural” and fundamental unit of society. It is an institution that
involves majority of the population
2. The family as a group generates, prevents, tolerates and corrects health problems within its
membership.
3. The health problems of family members are interlocking.
4. the family is the most frequent locus of health decisions and actions in personal care.
5. The family is an effective and available channel for much of the community
 health nursing effort.

Families have particular ways or process of COPING with health problems. Failure
to cope results in ILLNESS or PERSISTENCE OF AN ILLNESS and DIMINISHED
PRODUCTIVITY of the family as functioning unit.
EFFECTIVE COPING is defined as the ability to perform certain health tasks.

 1. Recognizing interruptions of health development. Ability to recognize the
presence of a health problem
 2. Making decisions about taking appropriate health action.
 3. Providing nursing care to the sick, disabled and/or dependent members of
the family.
 4. Maintaining a home environment conducive to health maintenance and
personal Development.
 5. Maintaining a reciprocal relationship with the community and health
institutions.

Family Coping Index -
 Þ When the family is unable to cope with one or another aspect of health care, it may be said
to have a “coping deficit”;
 Þ The scale enables you to place the family in relation to their ability to cope with the nine areas
of family nursing at the time observed and as you would expect it to be in 3 months or at the time
of discharge if nursing care were provided.
 Þ Coping capacity is rated from 1 (totally unable to manage this aspect of family care) to 5
(able to handle this aspect of care without help from community sources). Check “no problem” if
the particular category is not relevant to the situation. The justification consists of brief statement
or phrases that explain why you have rated the family as you have
 General Considerations:
 · It is the coping capacity and not the underlying problem that is being rated.

THE NURSE AS THE MEDIUM, CHANNEL AND PROVIDER OF
CARE
NURSING PROCESS
The use of the nursing process systematizes practice. The depth,
breadth and overall quality of performance in all the steps of the
process distinguish a professional nurse from others who can and do
provide nursing services.
 With the use of nursing process, nursing care is never a routine,
ritualistic response to problems, and neither is it based on common
sense. It is a dynamic activity that calls for the application of
synthesized knowledge and skills and the use of reflective thinking.

NURSING PROBLEM
Definition : a situation or condition which interferes with the promotion and/or
maintenance of health and recovery from illness or injury, and which is subject to
change or modification through nursing interventions.
 Problems that cannot be modified through nursing measures are referred to
other disciplines or health personnel and are not regarded as nursing problems.
 Nursing Problems in the Community go beyond the physical problems of
patients and their families. Most often, the problems are in the realm of human
behavior. Health Education therefore is an important nursing intervention.

THE NURSE’S ROLE IN FAMILY CARE
PRACTICE
1. Health Monitoring
 2. Provider of Care to a sick member
 3. Coordinator of family services
 4. Facilitator
 5. Teacher
 6. Counselor
THE FAMILY NURSING PROCESS
 1. ASSESSMENT
- includes the collection and analysis of factual information relevant to the client’s
status, and the capacity to solve health problems and his environment.
- Sources of Data :
(a) health status of family members
(b) family’s status as a functioning unit expected to promote wellness among
members
 (c) family environment

SEQUENCE OF ACTIVITIES
1. Establishes a working relationship with the family
 A) Initiate contacts
 B) Communicates interest in family’ welfare
 C) Expresses/shows willingness to help with expressed needs
 D) Maintains a two way communication with the family
2. Conducts an initial assessment to determine the presence of any
health problem TOOL: Initial Data Base for Family Nursing Practice

A. Family Structure, Characteristics and
Dynamics
 a. Members of the household and relationship to the head of the family
 b. Demographic data: age, sex, civil status, position in the family
 c. Place of residence of each member
 d. Type of family structure: according to authority, location, function
 e. Dominant family members in terms of decision-making esp. in matters of
health care
 f. General family relationships/ dynamics – presence of any obvious/ readily
observable conflict between members; characteristic communication/
interaction patterns among members

B. Socio-economic and Cultural
Characteristics
 a. Total family monthly income and breakdown of expenses
 b. Educational attainment and educational status of each member
 c. Ethnic background and religious affiliation
 d. Family traditions, events or practices affecting member’s health or
family functioning
e. Significant others: role/s they play in the family’s life
f. Relationship of the family to larger community; nature and extent of
participation of the family in community activities

C. Home and Environment
a. Housing
 a.1 Adequacy of living space (as compared to standard
 living space, crowding index and as perceived by the family)
 a.2 Sleeping arrangement
 a.3 Presence of breeding or resting sites of vectors of
 diseases: (mosquitoes, flies, cockroaches, rodents etc.)
 a.4 Presence of accidents and fire hazards
 A. 5 Food storage and cooking facilities
 a. 6 Water supply: source (level 1, 2 or 3), ownership, potability
 a. 7. Toilet facility: type/ level, ownership, sanitary condition
 a. 8 Garbage/ refuse disposal: type, sanitary condition as observed
 a. 9 Drainage system: type, sanitary condition as observed
 b. Kind of neighborhood: congested, slum, etc.
 c. Social and health facilities available: accessibility and availability
 d. Communication (how health information and announcements are received)
 and transportation facilities available (the ones used to access facilities)

D. Health status of each family member
a. Medical and nursing history indicating current or past significant illnesses
 or beliefs and practices conducive to health and illness
b. Nutritional assessment (specifically for vulnerable or at-risk members
c. Developmental assessment of infants, toddlers, preschoolers (MMDST)
d. Risk factor assessment indicating presence of major and contributing
modifiable risk factors for specific lifestyle diseases:
· Hypertension; physical inactivity; sedentary lifestyle; cigarette/ tobacco
smoking; elevated blood lipids/ cholesterol, obesity, diabetes mellitus;
inadequate fiber intake; Stress; alcohol drinking and other substance abuse
e. Physical assessment indicating presence of illness state/s (diagnosed or
undiagnosed by medical practitioners)
f. Results of laboratory/ diagnostic and other screening procedures
 supportive of assessment findings (if any)
E. Values, habits, practices on health promotion,
maintenance and disease prevention.
a. Immunization status of family members
b. Healthy lifestyle practices
c. Adequacy of:
 c.1 Rest and sleep
 c.2 Exercise/ activities
 c.3 Use of protective measures: adequate footwear in parasite- infested areas,
use of bednets and protective clothing in malaria and filariasis endemic areas
 c.4 Relaxation and other stress management activities
 c.5 opportunities w/c enhance feelings of self worth, self efficacy & sense of
connectedness to self, others & a higher power, essence of meaningfulness.
d. Use of promotive-preventive health services (maternal & child health
supervision) & use of healthy lifestyle-related services

3. Categorizes health problems into :
¨ Health threats

 ¨ Health deficits
 ¨ Forseable crisis situations/ stress points
 A. Health threats – conditions that are conducive to disease and accident, or
 may result to failure to maintain wellness or realize health potential
Example: gathering sufficient subjective and objective data to support the possible problem,
“Unhealthful lifestyle and personal habits specifically alcohol

 drinking as health threat” of an adult male client
 B. Health deficits – instances of failure in health maintenance
Example: illness states whether diagnosed or undiagnosed;failure to thrive/
develop according to normal rate; disability as health deficits
 C. Stress points/ foreseeable crisis situations – anticipated periods of unusual
 demands on the individual or family in terms of adjustment/ family resources
 Example: marriage, pregnancy, loss of job

4. Determines the nature and extent of the family’s performance of the health
tasks on each of the health problems categorized in activity no. 3 defines the family
nursing problems
TOOL :
A Typology of Nursing Problems in Family Nursing Practice :
Second Level Assessment

Second Level Assessment – defines the nature or type of nursing problems that the
family encounters in performing the 5 family health tasks with respect to a given
health condition or problem from the 1st level assessment, and the etiology/ies to
the family’s assumption of these tasks (the failed ones)

5. Determines priorities among the list of health
problems
 A. considers the nature of the problems presented
 B. evaluates the modifiability of the problem
 C. evaluates the preventive potential of the problem
 D. evaluates the family’s perception/evaluation of
each problem in terms of seriousness and urgency of
attention needed

TOOL : A Scale for Ranking Family Health
Problems According to Priorities
 ¨ Nature of condition or problem – categorized into wellness, health threat, health
deficit and foreseeable crisis
 ¨ Modifiability – refers to the probability of success in enhancing the wellness state,
improving condition, minimizing, alleviating totally eradicating the problem through
nursing interventions
 ¨ Preventive potential – refers to the nature and magnitude of future problems which
can be minimized or totally prevented if intervention is done
 ¨ Salience – refers to the family’s perception and evaluation of the condition or
problem in terms of seriousness and urgency of attention needed or family readiness

6. Ranks health problems according to priorities
7. Decides on what problems to tackle in the order of
immediacy/ urgency based on priorities set.
8. Defines nursing objectives in realistic measurable
terms jointly with the family
9. Plans approaches, strategies of action , criteria and
standards for evaluation
 (Output : Family Nursing Care Plan)

2. INTERVENTION
- during this phase, the nurse formulates the goals, objectives
and the nursing actions which hopefully will help the family
overcome the obstacles to healthy functioning.
 A. Implement the Family Nursing Care Plan
 A.1 Family Visit / Home Visit
 A.2 Community Assembly

3. EVALUATION
- the evaluation phase is done to demonstrate whether or not the intended results
did occur.
Evaluating Family Nursing Care – using criteria, evaluate if outcomes/ objectives
were achieved as well as the goal and decide whether the plan is to be terminated,
modified or continued. Evaluate whether there are changes in the health status.
Determine if problems requiring nursing care were resolved. Determine if
interventions are appropriate and adequate. Analyze how the plan was
implemented and determine what factors are related with success and what
created barriers.

SCALE FOR CRITERIA
1. Nature of the condition or problem presented
WEIGHT
1
RANKING HEALTH Scale **
Wellness state

CONDITIONS AND Health deficit
Health threat
3
3

2
PROBLEMS Foreseeable crisis
2. Modifiability of the condition or problem
Scale**
1

2
ACCDG. TO Easily Modifiable
Partially modifiable

2

PRIORITIES Not modifiable
3. Preventive potential
1
0

Scale ** 1
High
Moderate 3
SCORING: Low 2
1. Decide on a score for each of the 1
criteria. 4. Salience
2. Divide the score by the highest Scale** 1
A condition or problem
possible score and multiply by the needing immediate attention 2
weight: (score/Highest Score) X Weight A condition or problem not
needing immediate attention 1
3. Sum up the scores for all the criteria.
Not perceived as a problem or
The highest score is 5 equivalent to the condition needing change 0
total weight

* Reference: Bailon, S & Maglaya, A
(2003)

CONCEPTS OF COMMUNITY
 Classification of Community
· Urban
· Rural
 Characteristics of Community
· Environment
· Population behavior or lifestyle
· Human biology
· Systems of health care
 Types of Community may vary according to:
1. Objectives or degree of detail or depth of the assessment
2. The resources
3. The time available for the nurse to conduct the Community Diagnosis

Types of Community Diagnosis:
A. Comprehensive Community Diagnosis
· aims to obtain general information about the community with the intent of determining not only
prevalent health conditions and risk factors but also the socio-economic conditions and lifestyle
behaviors and attitudes that have effect on health
 Elements of Community Diagnosis:
· Demographic Variables
· Socio-Economic & Cultural Variables
· Health & Illness Patterns
· Health Resources
· Political/Leadership Patterns
B. Problem-oriented Community Diagnosis
· Type of assessment that responds to a particular need of a target group

Sources of Data:
A. Primary Data—Sources are the community people through
surveys, interviews, focused group discussions, observations, and
through the actual minutes of community meetings
 B. Secondary Data—Organizational records of the program, health
center records and other public records
 Components of Community:
 A. The core
 B. Population

COMMUNITY ORGANIZING
 · guiding people to understand the existing condition of their own community
 · organizing people to work collectively and efficiently on their immediate and long-term
objectives
 · mobilizing people to develop their capacity & readiness to respond and take action on their
immediate and long term needs
 · A process by which people, health services and agencies of the community are brought
together to:
 à Learn about the common problems
 à Identify these problems as their own
 à Plan the kind of action needed to solve these problems
 à Act on this basis

IMPORTANCE OF COMMUNITY
ORGANIZING
 · It provides the people with an opportunity to get involved
and identify the common health problems of their
community
 · It guides the community in decision making towards self-
reliance
 · It guides people in analyzing the strengths and weaknesses
of every possible solution offered by them
BENEFITS OF COMMUNITY
ORGANIZING
1. It contributes to the establishment with different community resources – natural,
institutional, technical, financial and human resources – and can function with maximum
effectiveness.
2. It stimulates the various groups to examine their programs to determine how well they are
meeting their problems.
3. People are given a chance to study their problems, offer solutions and give a chance to an
action.
4. As a result of this working together as a strong unity and coherence is developed among various
organizations and leaders of the community represented so that they develop a feeling of
responsibility for making the program successful. Community organization sets up action pattern to
solve problems.

PRINCIPLES INVOLVED IN COMMUNITY
ORGANIZATION
1. Planning group needs to represent all people concerned and the discussion
must include people with technical knowledge of health problems.
2. Technique of asking questions is often important in developing community
organization and group discussion.
3. Major discussion should be made by the entire group
4. Local factors and available personnel should be asked in determining what types
of organization is desirable and practicable.
A good organizational plan can succeed only when the people who operate it will
see its values which are compatible personally and not antagonistic professionally.

STEPS IN ORGANIZATION PROCESS
1. Fact Finding – Factual information serves to identify needs, determine the extent to
which needs are met and to make known gaps and overlaps in existing services.
2. Determination of needs – once the facts are assembled, the health worker helps to
define community problems and decide which problems warrant concerted community
action.
3. Program Formation – when a problem have been selected for action, a concrete
proposal must be developed containing general and specific objectives.
4. Education and interpretation - all the above steps are of little value if they do not lead
to action that will benefit the community. The fourth step is to interpret and educate the
public concerned to support the proposed program.

PHASES OF COMMUNITY ORGANIZING
A. PREPARATORY PHASE
1. Area Selection
2. Community profiling
3. Entry into the community & integration with the people
B. ORGANIZATIONAL PHASE
1. Social preparation
2. Spotting & developing potential leaders
3. Core group formation
 Setting up the community organization

PHASES OF COMMUNITY ORGANIZING
 C. EDUCATION & TRAINING PHASE
1. Conducting community diagnosis
2. Training of community health workers
3. Health services & mobilization
 Leadership-formation activities
D. INTERSECTORAL COLLABORATION PHASE
E. PHASE-OUT

Roles of the Nurse as a Community
Organizer
· Enabler
· Advocate
· Developer/Builder
COPAR
(Community Organizing Participatory Action Research)
A social development approach that aims to transform the apathetic,

individualistic and voiceless poor into dynamic, participatory and
politically responsive community.
A process by which a community identifies its needs and objectives,
develops confidence to take action in respect to them and in doing so,
extends and develops cooperative and collaborative attitudes and
practices in the community (Ross 1967)

PHASES OF COPAR
PRE-ENTRY PHASE
Ithe initial phase of the organizing process where the community/organizer looks
for communities to serve/help.
· Preparation of the Institution
· Site Selection
· Identify Potential Municipalities
· Identify Potential Barangay
· Choose Final Barangay
· Identify Host Family

PHASES OF COPAR
ENTRY PHASE
social preparation phase - activities done here includes the sensitization of the
people on the critical events in their life, motivating them to share their dreams
and ideas on how to manage their concerns and eventually mobilizing them to take
collective action on these.
· Integration with the community
· Identification of potential leaders
· Conduct of information campaign
· Provision of basic health services

PHASES OF COPAR
· ORGANIZATION BUILDING PHASE
Entails the formation of more formal structures and the inclusion of more formal
procedures of planning, implementation, and evaluating community-wide
activities. It is at this phase where the organized leaders or groups are being given
trainings (formal, informal, OJT) to develop their skills and in managing their own
concerns/programs.
· Community Health Organization
· Research Team Committee
· Planning Committee
· Health Committee Organization

PHASES OF COPAR
SUSTENANCE/STRENGTHENING PHASE
Occurs when the community organization has already been established and the community
members are already actively participating in community-wide undertakings. the different
communities setup in the organization building phase are already expected to be functioning by
way of planning, implementing and evaluating their own programs with the overall guidance from
the community-wide organization.
· Education & Training of CHO
· Networking and linkaging
· Health & Development Mobilization
· Implementation of Livelihood Programs
· Developing Secondary Leaders

STEPS IN CONDUCTING COMMUNITY
DIAGNOSIS
1. Determining the objectives
2. Defining the study population
3. Determining the data to be collected
4. Collecting the data
 Observations
 Records review
 Interviews (face to face, telephone, individual or group, key informant interview, structured or un)
 Focus group discussion
5. Developing the instrument
 Survey questionnaire
 Focus group discussion guide
 Key Informant Interview guide
 Observation checklist

DIAGNOSIS
6. Actual data gathering
 Semistructured interviews
 Analytical games
 Stories and portraits
 Diagrams
 Workshop
7. Data collation
 numerical data (age, number of children)
 descriptive data (family planning method used, gender)
8. Data presentation
 Statistical tables
 Graphs (pie chart, bar graph, line graph)
 Descriptive data
9. Data Analysis

DIAGNOSIS
10. Identifying the Community Health Nursing Problems
A. health status problems’
Described in terms of increased/decreased morbidity, mortality, fertility, or
reduced capability for wellness
B. health resources problems
Described in terms of lack of or absence of manpower, money, materials, or
institutions necessary to solve health problems
C. health-related problems
- In terms of social, economical, environmental, and political factors that aggravate
the illness-inducing situations in the community.
CRITERIA WEIGHT
Nature of the problem 1

health status 3
health resources 2
health-related 1
Magnitude of the problem 3

75%-100% affected 4
50%-74% affected 3
25%-49% affected 2
<25% affected 1
Modifiability of the problem 4

high 3
moderate 2
low 1
not modifiable 0
Preventive potential 1
high 3
moderate 2
low 1
Social concern 1
urgent community concern;
expressed readiness 2
recognized as a problem but
not needing urgent attention 1
not a community concern 0


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COMMUNITY HEALTH

HEALTH NURSING nursing process & other processes to promote

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 POPULATION GROUP  COMMUNITY

geographic and socio-cultural connotations

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“Unhealthful lifestyle and personal habits specifically alcohol

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A social development approach that aims to transform the apathetic,

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Nature of the problem 1

Magnitude of the problem 3

Modifiability of the problem 4

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