Chapter 3.1 Community Health Nursing PDF

NCM 104A & B - COMMUNITY HEALTH NURSING 1 CHAPTER III. FAMILY NURSING PROCESS LESSON TITLE Related Concepts, Assessment, Family Nursing Diagnosis and Family Nursing Care Plan INTRODUCTION OF THE LESSON Family nursing is the practice of nursing directed towar...

NCM 104A & B - COMMUNITY HEALTH NURSING 1 CHAPTER III. FAMILY NURSING PROCESS LESSON TITLE Related Concepts, Assessment, Family Nursing Diagnosis and Family Nursing Care Plan INTRODUCTION OF THE LESSON Family nursing is the practice of nursing directed towards maximizing the health and well-being of all individuals within a family system. This lesson will provide you an in-depth understanding on how to assess a family with the use of the different assessment tools and formulation of family nursing diagnosis which will guide you in the care of a family through the use of a family nursing care plan. LEARNING OUTCOMES: Upon completion of this lesson, you should have: 1. Described the principles and techniques in the use of PHN bag. 2. Differentiated the types of family-nurse contact. 3. Described the different tools for assessment of a family. 4. Compared family data analysis with accepted standards. 5. Formulated family nursing diagnosis using the results of assessment. 6. Formulated a family nursing care plan. 7. Discussed the types, importance and uses of records in family health nursing. WARM-UP ACTIVITY Have you ever wondered how your family functions, how each family members interact and affect each other? Are you aware of any problems encountered by your own family? Have you ever tried to trace your family tree? These problems will be answered as you will go through the different learning inputs in the succeeding lessons. CENTRAL ACTIVITIES LEARNING INPUT 1: A. Related Concepts Family Health Assessment Assessment of the family helps practitioners identify the health status of individual members of the family and aspects of family composition, function and process. The nurse collects as much information about the family as is feasible and practical. The process of family assessment is unceasing and requires objectivity and professional judgment to attach practical meaning to the information being required. Thus, tools are developed to allow a more systematic and organized classification and analysis of data. MMSU-CHS, DEPARTMENT OF NURSING 1  NCM 104A & B - COMMUNITY HEALTH NURSING 1 Information can be obtained through interviews with one or family members individually, interviews of subsystems within the family, or group interviews with more than two members of the family. a. The nurse can also obtain information through observation of individual family members, dyads, and the entire family and observation of the environment in which the family lives, including housing, the neighborhood, and the larger community. b. Physical examination and other health assessment techniques, such as anthropometry, may be used. c. Secondary data can be derived from a review of records like charts, health center records, and/or agency records or from communication with other health workers or agencies who worked with the family. 1. Tools of Public Health Nurse Public Health Nurse Bag is an essential and indispensable equipment of a public health nurse which she has to carry along during her home visits. It contains basic medication and articles which are necessary for giving care. Principles:  Performing the bag technique will minimize, if not, prevent the spread of any infection.  It saves time and effort in the performance of nursing procedures.  The bag technique can be performed in a variety of ways depending on the agency’s policy, the home situation, or as long as principles of avoiding transfer of infection is always observed. Activity 5 – Related Learning Experience (RLE) This concept will be further discussed in your RLE with your CI. Demonstration and return demonstration on Bag Technique will be done. Evaluation tool will be provided for your guidance. LEARNING INPUT 2: 2. Types of Family-Nurse Contacts The family-nurse relationship is developed through family-nurse contacts. The nurse uses the type of family-nurse contact that is most suitable to the purpose or situation on hand. a. Clinic Visit – takes place in a private clinic, health center, barangay health station, or in an ambulatory clinic during a community outreach activity. MMSU-CHS, DEPARTMENT OF NURSING 2  NCM 104A & B - COMMUNITY HEALTH NURSING 1  Advantages: o Family member takes the initiative of visiting the professional health worker, usually indicating the family’s readiness to participate in the health care process. o Allows the nurse to maximize resources o Distractions are lessened because the nurse has greater control over the environment  Disadvantages: o Family is unable to transport the family member requiring nursing care. o Family may feel less confident to discuss family health concerns because the nurse is in control of the situation. b. Home Visit – a professional, purposeful interaction that takes place in the family’s residence aimed at promoting, maintaining, or restoring the health of the family or its members. = it is a family-nurse contact where, instead of the family going to the nurse, the nurse goes to the family. = the nurse makes a home visit upon the family’s request, as a result of a case finding, in response to a referral, or to follow-up clients who have utilized services of a health facility such as a health center, lying- in clinic, or hospital.  Advantages: o It allows firsthand assessment of the home situation: family dynamics, environmental factors affecting health, and resources within the home. o The nurse is able to seek out previously unidentified needs. o It gives the nurse an opportunity to adapt interventions according to family resources. o It promotes family participation and focuses on the family as a unit. o Teaching family members in the home is made easier by familiar environment and the recognition of the need to learn as they are faced by the actual home situation. o The personalized nature of a home visit gives the family a sense of confidence in themselves and in the agency.  Disadvantages: o Cost in terms of time and effort o More distractions at home since the nurse is unable to control the environment o Nurse’s safety  Phases of Home Visit A. Previsit Phase – the nurse contacts the family, determines the family’s willingness for a home visit, and sets an appointment with them. A plan for the home visit is formulated during this phase. MMSU-CHS, DEPARTMENT OF NURSING 3  NCM 104A & B - COMMUNITY HEALTH NURSING 1  Principles in planning for a home visit: 1. The home visit should have a purpose. a. To have a more accurate assessment of the family’s living conditions and adapt interventions accordingly. b. To educate the family about measures for health promotion, disease prevention, and control of health problems. c. To prevent the spread of infection among family members and within the community. d. To provide supplemental interventions for the sick, disabled, or dependent family member and, whenever possible, guide the family on how to give care in the future. e. To provide the family with greater access to health resources in the community by establishing a close relationship with them, providing information, and making referrals as necessary. 2. Use information about the family collected from all possible sources, such as records, other personnel and/or agency, or previous contacts with the family. 3. The home visit plan focuses on identified family needs, particularly needs recognized by the family as requiring urgent attention. 4. The client and the family should actively participate in planning for continuing care. 5. The plan should be practical and adaptable. B. In-home Phase – the nurse seeks permission to enter and lasts until he or she leaves the family’s home. a. Initiation = steps:  Knock or ring the doorbell and say in a loud but not threatening voice “Tao po. Si Jenny poi to, nurse sa health center,” or a similar greeting in the vernacular or some other language common to the nurse and the family.  On entering the home, acknowledge the family members with a greeting and introduce self and the agency he or she represents.  Start to observe the environment for own safety and sit as the family directs to sit.  To establish rapport, initiate a short social conversation, then state the purpose of the visit and the source of information. b. Implementation = involves the application of the nursing process – assessment, provision of direct nursing care as needed, and evaluation.  Assessment = consists of techniques such as interview, physical examination, and simple diagnostic examinations that can be done at home (Capillary blood glucose determination). It includes observation of family dynamics and the family’s physical environment (use Family Assessment Form as a guide).  Physical care, health teachings and counseling are provided to the family as needed or according to plan.  Evaluate with the family what has been accomplished during the visit. MMSU-CHS, DEPARTMENT OF NURSING 4  NCM 104A & B - COMMUNITY HEALTH NURSING 1 c. Termination = consists of summarizing with the family the events during the home visit and setting a subsequent home visit or another form of nurse- patient contact such as a clinic visit. C. Post-visit Phase = takes place when the nurse has returned to the health facility. This involves documentation of the visit during which the nurse records events that transpired during the visit, including personal observations and feelings of the nurse about the visit. If appropriate, a referral may be made. c. Group Conference – provides opportunity for initial contact between the nurse and target families of the community  Advantages: o Appropriate for developing cooperation, leadership, self-reliance, and/or community awareness among group members o Provides opportunity for group members to share experiences and practical solutions to common health concerns  Disadvantage: o Attendance in a group conference usually requires motivation and availability of target family members therefore the nurse may not be able to reach the families in greatest need of help. d. Telephone calls (landline or mobile/cell)  Advantages: o Provides easy access between the nurse/health worker and the family o Provides the nurse and the family with opportunities to contact each other through calls or short messaging services (text messaging) o Cultivates the family’s confidence in the health agency  Disadvantage: o Information transmitted through the telephone is limited o Accurate assessment of family conditions could not be done through telephone e. Written Communication – used to give specific information to families, such as instructions given to parents through school children.  Advantage: o Potential for reaching many families  Disadvantage: o Being a one-way method and requiring literacy and interest, the nurse cannot be certain that information will reach the intended recipient. Activity 1 (Lecture) – Short Quiz A short quiz will be uploaded in the mVLE. MMSU-CHS, DEPARTMENT OF NURSING 5  NCM 104A & B - COMMUNITY HEALTH NURSING 1 LEARNING INPUT 3: B. ASSESSMENT 1. Genogram = a tool that helps the nurse outline the family’s structure. It is a way to diagram the family. Generally, three generations of family members are included in a family tree, with symbols denoting genealogy. SAMPLE GENOGRAM* *Diagram was adapted from students’ output. MMSU-CHS, DEPARTMENT OF NURSING 6  NCM 104A & B - COMMUNITY HEALTH NURSING 1 SAMPLE ANALYSIS*: *Analysis was adapted from students’ output. 2. Family Health Tree = provides mechanism for recording the family’s medical and health histories.  Points to follow: a. Causes of death of deceased family members b. Genetically linked diseases, including heart disease, cancer, diabetes, hypertension, allergies, asthma, and mental retardation c. Environmental and occupational diseases d. Psychosocial problems, such as mental illness and obesity e. Infectious diseases f. Familial risk factors from health problems g. Risk factors associated with the family’s methods of illness prevention, such as having periodic physical examination, Pap smears, and immunizations h. Lifestyle-related risk factors (i.e., by asking what family members do to “handle stress” and “keep in shape”) MMSU-CHS, DEPARTMENT OF NURSING 7  NCM 104A & B - COMMUNITY HEALTH NURSING 1 SAMPLE FAMILY HEALTH TREE* *Diagram was adapted from exeley.com 3. Ecomap = a tool that is used to depict a family’s linkages to its suprasystems  The ecomap portrays an overview of the family in their situation; it depicts the important nurturant or conflict-laden connections between the family and the world. It demonstrates the flow of resources, or the lacks and deprivations. SAMPLE ECOMAP* *Diagram was adapted from students’ output. MMSU-CHS, DEPARTMENT OF NURSING 8  NCM 104A & B - COMMUNITY HEALTH NURSING 1 SAMPLE ANALYSIS*: *Analysis was adapted from students’ output. Activity 6 – Related Learning Experience (RLE) In your RLE schedule, utilize 4 hours to assess your own family utilizing all the assessment tools provided to you in the lecture. Use the genogram family health tree and ecomap and provide analysis for each. The remaining 2 hours will be used for processing. LEARNING INPUT 4: Initial Data Base 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 – whether living with the family or elsewhere. MMSU-CHS, DEPARTMENT OF NURSING 9  NCM 104A & B - COMMUNITY HEALTH NURSING 1 d. Type of family structure – matriarchal or patriarchal, nuclear or extended. e. Dominant family members in terms of decision-making, especially in matters of health care f. General family relationship/dynamics – presence of any obvious/readily observable conflict between members, characteristics communication/interaction patterns among members. B. Socio-economic and cultural characteristics a. Income and expenses a.1. Occupation, place of work and income of each working member a.2. Adequacy to meet basic necessities (flood, clothing, shelter) a.3. Who makes decision about money and how it is spent b. Educational Attainment of each member c. Ethnic background and religious affiliation d. Significant Others – role(s) they play in the family’s life e. 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 a.2. Sleeping arrangement a.3. Presence of breeding or resting sites of vectors of diseases like mosquitoes, roaches, flies, rodents etc. a.4. Presence of accidents hazards a.5. Food storage and cooking facilities a.6. Water supply – source, ownership, potability a.7. Toilet facility – type, ownership, sanitary condition a.8. Garbage/refuse disposal – type, sanitary condition a.9. Drainage system – type, sanity condition b. Kind of Neighborhood – congested, slum, etc. c. Social and health facilities available d. Communication and transportation facilities available. D. Health Status of each Family Member a. Medical and nursing history indicating current or past significant illnesses or beliefs and practices conductive to health and illness b. Nutritional assessment b.1 Anthropometric data: Measures of nutritional status of children weight, height, mid-upper arm circumference MMSU-CHS, DEPARTMENT OF NURSING 10  NCM 104A & B - COMMUNITY HEALTH NURSING 1 b.2. Dietary history specifying quality and quantity of food nutrient intake per day. b.3. Eating/feeding habits/practices c. Developmental assessment of infants, toddlers and preschoolers d. Risk factor assessment indicating presence of major and contributing modifiable risk factors for specific life style disease like HPN, physical inactivity, sedentary life style, obesity, diabetes mellitus, inadequate fiber intake, stress, alcohol drinking and other substance abuse. e. Physical assessment indicating presence of illness state (diagnosed and undiagnosed by medical practitioner f. Results of laboratory/diagnostic and other screening procedures supportive of assessment findings E. Values, Habits, Practices on Health Promotion, Maintenance and Disease Prevention a. Immunization Status of family members b. Healthy lifestyle practices, specify c. Adequacy of: c.1. Rest and sleep c.2. Exercise/activities c.3. Use of protective measures like 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 d. Use of promotive-preventive health services Activity 7 – Related Learning Experience (RLE) In your RLE schedule, utilize 4 hours to assess your own family using the Initial Data Base tool. Present data in tabular form. The remaining 2 hours will be used for processing. LEARNING INPUT 5: 4. Family Coping Index Purpose:  To provide a basis for estimating the nursing needs of a particular family. Health Care Need MMSU-CHS, DEPARTMENT OF NURSING 11  NCM 104A & B - COMMUNITY HEALTH NURSING 1 A family health care need is present when: 1. The family has a health problem with which they are unable to cope. 2. There is a reasonable likelihood that nursing will make a difference in the in the family’s ability to cope. Relation to Coping Nursing Need:  COPING may be defined as dealing with problems associated with health care with reasonable success.  When the family is unable to cope with one or another aspect of health care, it may be said to have a “coping deficit” Direction for Scaling  Two parts of the Coping index: 1. A point on the scale 2. A justification statement  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. 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: 1. It is the coping capacity and not the underlying problem that is being rated. 2. It is the family and not the individual that is being rated. 3. Rating should be done after 2-3 home visits when the nurse is more acquainted with the family. 4. The scale is as follows:  0-2 or no competence  3-5 coping in some fashion but poorly  6-8 moderately competent  9 fairly competent 5. Justification- a brief statement that explains why you have rated the family as you have. These statements should be expressed in terms of behavior of observable facts. Example: “Family nutrition includes basic 4 rather than good diet. 6. Terminal rating is done at the end of the given period of time. This enables the nurse to see progress the family has made in their competence; whether the prognosis was reasonable; and whether the family needs further nursing service and where emphasis should be placed. MMSU-CHS, DEPARTMENT OF NURSING 12  NCM 104A & B - COMMUNITY HEALTH NURSING 1 Scaling Cues:  The following descriptive statements are “cues” to help you as you rate family coping. They are limited to three points – 1 or no competence, 3 for moderate competence and 5 for complete competence. Areas to Be Assessed: 1. Physical independence: This category is concerned with the ability to move about to get out of bed, to take care of daily grooming, walking and other things which involves the daily activities. 2. Therapeutic Competence: This category includes all the procedures or treatment prescribed for the care of ill, such as giving medication, dressings, exercise and relaxation, special diets, use of prosthetic devices and other adaptive appliances such as wheelchairs and walker. 3. Knowledge of Health Condition: This system is concerned with understanding of the health condition or essentials of care according to the developmental stages of family members. Examples are the degree of knowledge of responsible family members in terms of communicability of a disease and its modes of transmission or that a disease is genetically transmitted, as in the case of diabetes mellitus. 4. Application of the Principles of General Hygiene: This is concerned with the family action in relation to maintaining family nutrition, securing adequate rest and relaxation for family members, carrying out accepted preventive measures, such as immunization. This includes practice of general health promotion and recommended preventive measures. 5. Health Attitudes: This category is concerned with the way the family feels about health care in general, including preventive services, care of illness and public health measures. This is observed in the family’s degree of responsiveness to promotive, preventive and curative efforts of health workers. 6. Emotional Competence: This category has to do with the maturity and integrity with which the members of the family are able to meet the usual stresses and problems of life, and to plan for happy and fruitful living. This may be observed in behaviors such as how the family members deal with daily challenges, their ability to sacrifice and think of others, and acceptance to responsibility. 7. Family Living: This category is concerned largely with the interpersonal or group aspects of family life – how well the members of the family get along with one another, the ways in which they take decisions affecting the family as a whole. This also refers to the management of family finances and the type of discipline in the home. 8. Physical Environment: This is concerned with the home, school, work and the community and the work environment as it affects family health. MMSU-CHS, DEPARTMENT OF NURSING 13  NCM 104A & B - COMMUNITY HEALTH NURSING 1 9. Use of Community Facilities: This is the ability of the family to seek and utilize, as needed, both government-run and private health, education, and other community services. 4. Family Data Analysis The nurse organizes data into clusters (data synthesis) and sets aside data that may be considered irrelevant. Seemingly inaccurate or conflicting data are validated with the family respondent. Data analysis is done by comparing findings with accepted standards for individual family members and for the family unit. Current information should be compared with previous information if available. In addition, the nurse correlates findings in the different data categories and checks for significant gaps in the information of the need for more details related to a finding. To organize family data, make use of the Initial Data Base for Family Nursing Practice: 1. Family Structure and Characteristics = are reflected in data on household membership and demographic characteristics, family members living outside the household, family mobility, and family dynamics (emotional bonding, authority and power structure, autonomy of members, division of labor, and patterns of communication, decision making, and problem and conflict resolution). Data on family structure can be visualized clearly through graphic tools such as genogram, ecomap, and/or family health tree. 2. Socioeconomic Characteristics include data on social integration (ethnic origin, languages and/or dialects spoken, and social networks), educational experiences and literacy, work history, financial resources, leisure time interests, and cultural influences, including spirituality or religious affiliation. 3. Family Environment refers to the physical environment inside the family’s home/residence and its neighborhood. 4. Family Health and Health Behavior take into account the family’s activities of daily living, self-care, risk behaviors, health history, current health status, and health care resources (home remedies and health services). Activity 8 – Related Learning Experience (RLE) In your RLE schedule, utilize 2 hours to identify problems from the result of the initial data base utilizing the template below. The remaining 2 hours will be used for processing. LEARNING INPUT 6: C.Family Nursing Diagnosis MMSU-CHS, DEPARTMENT OF NURSING 14  NCM 104A & B - COMMUNITY HEALTH NURSING 1 Nursing diagnoses may be formulated at several levels: as individual family members, as a family unit, or as the family in relation to its environment or community. In formulating the family nursing diagnosis, refer to the Second Level assessment. Select the appropriate statement which describes the reason why such problem in the family exists. TYPOLOGY OF NURSING PROBLEMS IN FAMILY NURSING PRACTICE FIRST LEVEL ASSESSMENT: 1. Presence of health threats, health deficits and foreseeable crisis or stress point in the family. A. Health Threats – conditions that are conductive to disease, accident or failure to realize one’s health potential. 1. Health history of specific condition/disease. Eg. Family history of diabetes. 2. Threat of cross infection from a communicable disease case. 3. Family size beyond what family resources can adequately provide. 4. Accident hazards a. Broken stairs b. Pointed/sharp objects, poisons and medicines improperly c. Fire hazards d. Fall hazards 5. Nutritional a. Inadequate food intake both in quantity and quality b. Excessive intake of certain nutrients c. Faulty eating habits 6. Stress provoking factors a. Strained marital relationships b. Strained parent sibling relationship c. Interpersonal conflict between family members 7. Poor environmental sanitation a. Inadequate living space b. Inadequate personal belongings and interests c. Lack of food storage facilities d. Polluted water supply e. Presence of breeding places of insects and rodents f. Improper garbage/ refuse disposal g. Unsanitary drainage system h. Poor lighting and ventilation MMSU-CHS, DEPARTMENT OF NURSING 15  NCM 104A & B - COMMUNITY HEALTH NURSING 1 i. Noise pollution j. Air pollution 8. Unsanitary food handling 9. Personal habits/practices a. Frequent drinking of alcohol b. Excessive smoking c. Walking barefooted d. Eating raw meat/fish e. Poor personal hygiene f. Self-medication g. Use of dangerous drugs and narcotics h. Sexual promiscuity 10. Inherent personal characteristics eg. Short temper 11. Health history which may precipitate/induce the occurrence of health deficit eg, previous history of difficult labor. 12. Inappropriate role assumption eg. Child assuming mother’s role: father not assuming his role. 13. Lack of immunization/inadequate immunization status especially of children. 14. Family disunity a. Self-oriented behavior of member’s b. Unresolved conflict of members c. Intolerable disagreements 15. Others B. Health Deficits – instances of failure in human maintenance 1. illness states, regardless whether it is diagnosed or undiagnosed by medical practitioner 2. failure to thrive/develop according to normal rate 3. disability arising from illness, whether transient/temporary (eg. Aphasia or temporary paralysis after CVA. Leg amputation secondary to diabetes C. Stress Points/Foreseeable Crisis Situations anticipated periods of unusual demand on the individual or family in terms of adjustment/family resources. 1. Marriage 2. Pregnancy, labor, puerperium 3. Parenthood 4. Additional members-newborn, lodge 5. Abortion 6. Entrance at school 7. Adolescence 8. Loss of job MMSU-CHS, DEPARTMENT OF NURSING 16  NCM 104A & B - COMMUNITY HEALTH NURSING 1 9. Death of a member 10. Resettlement in a new community 11. Illegitimacy 12. Others Activity 9 – Related Learning Experience (RLE) In your RLE schedule, utilize 2 hours in categorizing health problems utilizing the first level assessment. Make use of Template 1 provided below for your guidance. Template 1. First Level Assessment i. Health threats ii. Health deficits iii. Foreseeable crisis/stress points PROBLEM NATURE CUES LEARNING INPUT 7: SECOND LEVEL ASSESSMENT: I. Inability to recognize the presence of a problem due to: A. Ignorance of facts B. Fear of Consequences of diagnosis of problem 1. Social-stigma, loss of respect of peers/significant 2. Economic-cost 3. Physical/psychological C. Attitude/philosophy in life II. Inability to make decisions with respect to taking appropriate health action due to: A. Failure to comprehend the nature, magnitude/scope of the problem B. Low salience of the problem C. Feeling of confusion and/or resignation brought about by failure to break down problems into manageable units of attack D. Lack of knowledge/insight as to alternative courses of action open to them E. Inability to decide which action to take from among a list of alternatives F. Conflicting opinion among family members/significant others regarding action to take G. Ignorance of community resources for care H. Fear of consequences of action 1. Social MMSU-CHS, DEPARTMENT OF NURSING 17  NCM 104A & B - COMMUNITY HEALTH NURSING 1 2. Economic I. Negative attitude toward the health problem by negative attitude is meant one that interferes with rational decision making J. Inaccessibility of appropriate resources of care 1. Physical location 2. Cost K. Lack of trust/confidence in the health personnel/agency L. Misconceptions or erroneous information about proposed course(s) of action M. Others III. Inability to provide adequate nursing care to the sick disabled, dependent, or vulnerable/at risk members of the family due to: A. Ignorance if facts about the disease/health condition (nature, severity, complications, prognosis and management) child development and childcare B. Ignorance of the nature and extent of nursing care needed. C. Lack of necessary facilities (equipment and supplies) for care D. Lack of knowledge and skill in carrying out the necessary treatment/procedure/care E. Inadequate family resources for care 1. Responsible member 2. Financial F. Ineffective communication patterns G. Attitude/philosophy in life H. Others IV. Failure to utilize community resources for health care due to: A. Ignorance or lack of awareness of community resources for health care. B. Failure to perceive the benefits of health care/services C. Lack of trust/confidence in the agency/ personnel D. Previous unpleasant experience with health worker E. Fear of consequences of action (preventive, diagnostic, therapeutic, rehabilitative.) 1. Physical/psychological 2. Financial 3. Social-loss of esteem or peer/significant others F. Unavailability of required care/service G. Inaccessibility of require care/service H. Lack of inadequate family resources 1. Cost 2. Physical-location I. Feeling alienation to/lack from the community-mental illness J. Attitude/philosophy of life K. Others MMSU-CHS, DEPARTMENT OF NURSING 18  NCM 104A & B - COMMUNITY HEALTH NURSING 1 Activity 10 – Related Learning Experience (RLE) In your RLE schedule, utilize 2 hours to formulate family nursing diagnosis utilizing the Second Level Assessment. Make use of Template 2 provided below. The remaining 2 hours will be used for processing. Template 2. Second Level Assessment (Problem Sheet) HEALTH NURSING SUPORTING DATE PROBLEMS PROBLEMS DATA/CUES IDENTIFIED RESOLVED LEARNING INPUT 8: 1. Priority Setting = determining the sequence in dealing with identified family needs and problems. Priority setting is necessary because the nurse cannot possibly deal with all identified family needs and concerns all at once.  Factors to consider in priority setting: a. Family safety – a life-threatening situation is given top priority. Likewise, the occurrence of communicable disease requires immediate attention to promote healing and, more importantly, to prevent the spread of the communicable disease to the susceptible members of the household and the community. b. Family perception – priority is given to the need that the family recognizes as most urgent and/or important. c. Practicality – the nurse looks into existing resources and constraints, together with the family. (Are the resources required to address a particular need available to the nurse and the family? Does the nurse have the necessary competence to deal with the situation? What are the constraints that the family and the nurse have to deal with?) d. Projected effects – the immediate resolution of a family concern gives the family a sense of and confidence in themselves and the nurse. Criteria for determining priorities among health condition/s or problems: a. Nature of the condition or problem presented – categorized into wellness state/potential, health threat, health deficit and foreseeable crisis; b. Modifiability of the condition or problem – refers to the probability of success in enhancing the wellness state, improving the condition, minimizing, alleviating or totally eradicating the problem through intervention; MMSU-CHS, DEPARTMENT OF NURSING 19  NCM 104A & B - COMMUNITY HEALTH NURSING 1 c. Preventive potential – refers to the nature and magnitude of future problems that can be minimized or totally prevented if intervention is done on the condition or problem under consideration; d. 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. Scale for Ranking Health Conditions and Problems According to Priorities CRITERIA WEIGHT 1. Nature of the condition or problem presented 1 Scale: Wellness state 3 Health deficit 3 Health threat 2 Foreseeable crisis 1 2. Modifiability of the condition or problem 2 Scale: Easily modifiable 2 Partially modifiable 1 Not modifiable 0 3. Preventive potential 1 Scale: High 3 Moderate 2 Low 1 4. Salience 2 1 Scale: A condition or problem needing immediate attention 1 A condition or problem not needing 0 immediate attention Not a perceived as a problem or condition needing change Scoring: 1) Decide on a score for each of the criteria. 2) Divide the score by the highest possible score and multiply by the weight: (Score / Highest Score) x Weight 3) Sum up the scores for the criteria. The highest score is 5, equivalent to the total weight. MMSU-CHS, DEPARTMENT OF NURSING 20  NCM 104A & B - COMMUNITY HEALTH NURSING 1 Activity 11 – Related Learning Experience (RLE) In your RLE schedule, utilize 2 hours to identify 3 health problems from the assessment you made with your own family. Rank these nursing diagnoses using the ranking scale and arrange them according to priority. The problem with the highest score is considered the first priority. Make use of Template 3 provided below. The remaining 2 hours will be utilized for processing of outputs. Template 3. RANKING HEALTH CONDITIONS AND PROBLEMS ACCORDING TO PRIORITIES Problem #1 CRITERIA ACTUAL SCORE WEIGHT COMPUTED SCORE 1. Nature of the Problem 2. Modifiability of the problem 3. Preventive potential 4. Salience TOTAL LEARNING INPUT 9: D.Formulating Family Nursing Care Plan The nurse has to remember that the plan is for the family’s benefit and must never lose sight of the fact that the family has the right to self-determination. In the end, family decisions regarding health care have to be respected. The nurse’s role at this stage consists of offering guidance, providing information, an assisting the family in the planning process. 1. Establishing goals and objectives Goal = a general statement of the condition or state to be brought about by specific courses of action. (eg. After nursing intervention, the family will be able to care the disabled child competently.) *Cardinal principle in goal setting: - goals must be set jointly with the family (this ensures that the family’s commitment to their realization) MMSU-CHS, DEPARTMENT OF NURSING 21  NCM 104A & B - COMMUNITY HEALTH NURSING 1 Barriers to goal setting between the nurse and the family: a. Failure on the part of the family to perceive the existence of the problem. In many instances the problem is seen only by the nurse while the family is perfectly satisfied with the existing situation. b. The family may realize the existence of a health condition or problem but is too busy at the moment with other concerns and preoccupations. For example, a mother may perceive need for immunization for the children but her household chores take precedence over other concerns. c. Sometimes the family perceives the existence of a problem but does not see it as a serious enough situation to warrant attention. d. The family may perceive the presence of the problem and the need to take action. The reasons for this kind of behavior are: i. Fear of consequence/s of taking action – for example, diagnosis of a disease condition may mean expense or social stigma for the family. ii. Respect for tradition – In Philippine culture, elders play a part in decision making. iii. Failure to perceive the benefits of actioned proposed – this could be a function of the client’s previous experience with health workers and their services. iv. Failure to relate the proposed action to the family’s goals – families differ in their prioritizing of goals. e. A big barrier to collaborative goal setting between the nurse and the family is failure to develop a working a relationship. Nothing will be accomplished in a nurse’s work with families unless the family sees the nurse as a friend who is genuinely concerned with its welfare. The elements of mutual trust and confidence are crucial to the success of the nurse-family endeavor towards better health. Goals, like objectives, are best stated in terms of client outcomes, whether at the individual, family or community levels. Goals tell where the family is going. Ex. Nursing Goal – The family will manage malaria as a disease and a threat. Objective, in contrast to goals, refer to more specific statements of the desired results or outcomes of care. They specify the criteria by which the degree of effectiveness of care are to be measured. Objectives are the milestones to reach the destination. Workable, well-stated objectives should be:  Specific = the objective clearly articulates who is expected to do what the family or target family member will manifest a particular behavior. MMSU-CHS, DEPARTMENT OF NURSING 22  NCM 104A & B - COMMUNITY HEALTH NURSING 1  Measurable = Observable, measurable, and whenever possible, quantifiable indications of the family’s achievement as a result of their efforts toward a goal provide a concrete basis for monitoring and evaluation  Attainable = the objective has to be realistic and in conformity with available resources, existing constraints, and family traits, such as style and functioning.  Relevant = the objective is appropriate for the family need or problem that is intended to be minimized, alleviated, or resolved.  Time-bound = having a specified target time or date helps the family and the nurse in focusing their attention and efforts toward the attainment of the objective. Ex. Short-term/immediate objective – The sick member/s will take the drugs accurately as to dose, frequency, duration, and drug combination. All members will use self-protection measures at night till early morning when biting time of malaria vector is expected. Medium-term/intermediate objective – All members will have medical check-up and laboratory confirmation (blood smear) to diagnose malaria. Long-term objective – All members will carry out mosquito vector control measures. 2. Selecting Appropriate Family Nursing Interventions/Strategies Categories of Nursing Intervention: a. Supplemental interventions = are actions that the nurse perform on behalf of the family when it is unable to do things for itself, such as providing direct nursing care to a sick or disabled family member. b. Facilitative interventions = refer to action that remove barriers to appropriate health action, such as assisting the family to avail of maternal and early child care services. c. Developmental Interventions = aim to improve the capacity of the family to provide for its own health needs, such as guiding the family to make responsible health decisions. This type of intervention is directed toward family empowerment. Interventions may be a mix of two or all three of these categories, with the nurse making sure that they are appropriate to the family situation. PREREQUISITE TO DESIGNING AN EFFECTIVE FAMILY CARE PLAN:  Since the plan is aimed to benefit the family, the expected outcomes of interventions are observable changes in the family. The plan should therefore be based on the principle of mutuality = means that the family is given the opportunity to decide for itself how they can best deal with a health situation. The plan has to be mutually agreed upon by the nurse and the family based on their limitations individually or as a group. MMSU-CHS, DEPARTMENT OF NURSING 23  NCM 104A & B - COMMUNITY HEALTH NURSING 1  The principle of personalization requires that the nursing care plan fits the unique situation of a family: its needs, style, strengths, and patterns of functioning.  Coordination with the other members of the health team and other agencies involved in the care of the family maximizes resources by preventing duplication of services.  Nurse’s capacity of defining self = the nurse has to delineate the purpose, resources (competencies, time and material resources) and limitations. This process affords a realistic view of the situation, allowing the nurse to be more effective and avoiding disappointments or frustrations. 3. Implementing Family Care Plan IMPLEMENTATION = is the step when the family and/or the nurse execute the plan of action. The pattern of implementation is determined by the mutually agreed upon goals and objectives and the selected courses of action. Barriers to implementing planned interventions: a. Family-related 1. Apathy – a manifestation of family’s feelings of hopelessness and powerlessness 2. Indecision – result in the family allowing events to just happen *The nurse has to exert effort to find out what is actually happening to the family to be able to effectively deal with the situation. b. Nurse-related 1. Nurse’s behavior – imposing ideas, negative labeling, overlooking family strengths, and neglecting cultural and gender implications of family interventions. 2. Defining self promotes the nurse’s awareness of own behaviors. Categories of Intervention: 1. Promotive 2. Preventive 3. Curative 4. Rehabilitative 4.Evaluation of Family Nursing Care EVALUATION = determining the value of nursing care that has been given to a family. The product of this step is used for further decision making : to terminate, continue or modify the interventions. *Well-formulated goals and objectives in the nursing care plan serve as the framework for evaluation. MMSU-CHS, DEPARTMENT OF NURSING 24  NCM 104A & B - COMMUNITY HEALTH NURSING 1 Types of Evaluation: a. Formative evaluation = judgment made about effectiveness of nursing interventions as they are implemented. This is ongoing and continuing while family nursing care is being implemented and family-nurse interactions are taking place *Results of formative evaluation guide the nurse and the family in updating plans as necessary. b. Summative evaluation = determining the end results of family nursing care and usually involves measuring outcomes or the degree to which goals have been achieved. Aspects of evaluation useful in Family Health Care: a. Effectiveness = determination whether goals and objectives were attained. It answers the question, “Did we produce the expected results?” or “Did we attain our objectives?” b. Appropriateness = the suitability of the goals/objectives and interventions to the identified family health needs. An accurate assessment of family health needs is the basis for appropriate goals/objectives and interventions. It answers the question, “Are our goals/objectives and interventions correct in relation to the family health needs we intend to address?” c. Adequacy = the degree of sufficiency of goals/objectives and interventions in attaining the desired change in the family. It answers the question, “Were our interventions enough to bring about the desired change in the family?” d. Efficiency = the relationship of resources used to attain the desired outcomes. It answers the question, “Are the outcome of family nursing care worth the nurse’s time, effort and other resources?” STEPS IN EVALUATING NURSING CARE: a. Review the health and/or problem situation of the client/patient prior to nursing intervention. The assessment phase of the nursing process would provide the data to describe the status and condition of the client/patient before nursing care was provided. This step would answer the questions:  What health and nursing needs and problems were identified by the nurse?  In the face of multiple needs/problems, were priorities established?  Were the priority needs/problems correctly identified? b. Review the nursing care plan, particularly the objectives of nursing care. Examine the objectives if they were stated clearly, specifically and in terms of desired or expected outcomes. Clarify from the nurse any objective which is vague, general and unclear. c. Decide on what type of evaluation to conduct – quantitative, qualitative or both – and the specific dimensions of quality which will be examined and assessed. MMSU-CHS, DEPARTMENT OF NURSING 25  NCM 104A & B - COMMUNITY HEALTH NURSING 1 d. Decide what to evaluate – structure/resources/inputs, process or outcomes of care – and the specific objectives of nursing care whose achievement will be determined. e. Based on the decisions made in Step c and d, define the criteria for evaluation. For each of the criterion, define the standard against which the assessment findings will be compared. f. Decide on the method/s of data collection and identify the sources of evaluative data. Construct any data collection tool that may be needed and pre test it for validity and reliability before use. g. Gather the data based on the criteria for evaluation previously identified in Step e and using the sources, methods and tools decided upon in Step f. h. Analyze the data obtained in Step 7. i. Based on the results of the data analysis made in Step h, make a judgment or draw a conclusion. This step will answer the question: Were the objectives of nursing care achieved? j. Identify the possible causes for non- or partial achievement of nursing care objectives. k. Redefine the objectives for future care. Activity 12 – Related Learning Experience (RLE) In your RLE schedule, utilize 4 hours to formulate a family nursing care plan based on the priority nursing diagnosis you previously identified. Use Template 4 provided below: Template 4. FAMILY NURSING CARE PLAN NURSING PROBLEM OBJECTIVES OF NURSING PLAN OF INTERVENTION PLAN OF EVALUATION CARE CRITERIA/STANDARDS METHODS/TOOLS 2. Records in Family Health Nursing Health Records = a written document about a target client (individual client, family, group, whole community) which relates an event pertinent to health and healthcare services like clinic consultation, hospitalization, home visit, immunization, births, deaths, marriages, and others. MMSU-CHS, DEPARTMENT OF NURSING 26  NCM 104A & B - COMMUNITY HEALTH NURSING 1 *These health records containing all client information are maintained in the health care facility until the individual client dies or the family is relocated to another area. Health Reports = an account or summary of the services rendered to the clients and rationalizes the continued existence of the program. *It gives a description and analysis of the problems encountered, the measures or actions taken, as well as the accomplishments and the degree to which objectives are met and quality service is rendered. 1. Field Health Services Information System (FHSIS) = a network of information source developed by the DOH intended to address the short-term data needs of the DOH staff with managerial or supervising functions in the DOH facilities and in each of the program areas. 2. Family Service and Progress Record (FSPR) is a tool operationalize the concept of the family as the object of care and the second level of clientele in CHN practice. The FSPR also provides a tool to operationalize and apply the nursing process as the methodology for providing care to families. Wrap-up Activity With the above lessons presented what were the most important things you’ve learned which will help you in carrying out your duties and responsibilities as a community health nurse? What are the things you need more to enhance? Assessment Please answer the post-test uploaded in the mVLE. MMSU-CHS, DEPARTMENT OF NURSING 27