Family Health Care Process PDF

Family Health Care Process Health Care Process  Definition 1. It is an organize sequence of problem-solving steps used to identify and to manage the health problems of clients. 2. It is also a decision making process, thus, it requires critical thinking which involves having the fa...

Family Health Care Process Health Care Process  Definition 1. It is an organize sequence of problem-solving steps used to identify and to manage the health problems of clients. 2. It is also a decision making process, thus, it requires critical thinking which involves having the facts and knowing the reason, rationale or explanation behind the facts or knowledge. a.To practice critical thinking it requires complete data gathering, therefore, midwife should be curious, open minded and non judgmental. b.Critical thinking is careful, deliberate, and goal directed.  Advantage of Health Care Process a.It provides an orderly and systematic method for planning and providing care b.It facilitates documentation of care. c.It saves time and effort by enhancing communication among health personnel involved in the care of the same patient thereby promoting continuity of care and preventing duplication of interventions already rendered. d.It stresses the functions and accountability of midwife in rendering patient care e.Increases care quality through the use of deliberate actions.  Assessment 1. Assessment a.It is the process of collecting, organizing, validating and recording data about client’s health status. b.It is the most important step of the health care process 2. Two types of Assessment a.Data base assessment – it is a comprehensive information that the midwife gather on initial contact with the person to assess all aspect of health status b.Focus Assessment – this is the data the midwife gather to determine the status of a specific condition. 3. Data Collection a.It is the process of gathering information about the client’s health status. It is achieved by performing the different method of assessment b.Types of Data: Objective Subjective Objective data or signs - Also called overt data because these can be detected by an observer - Can be tested using an accepted standard. - Examples are BP, PR, RR, Temperature, Height, Weight Subjective data or symptoms - Are also called covert data because these can be perceived only by the affected person or by the patient himself. - These data is usually not measurable and observable - If these data is observed by others, its accuracy should be verified by the midwife to the patient - Examples are pain, feelings of worry, palpitation, itchiness, headache, anxious, nausea, dizziness c. Sources of Data *Primary source – the primary source of information is the client. The best source of subjective data and chief complaint is the client himself. *Secondary source – It includes information provided by family members, support persons, other health professionals, records and reports, laboratory and diagnostics analysis and relevant d. Methods of Data Collection *Review of clinical record *Interview of individuals, families, group *Health history *Physical assessment/ examination *Psychosocial assessment *Review of literature and relevant studies *Laboratory and screening test 4. Review of Clinical Method a. Clinical records of the client include past medical history, results of diagnostic test and consultation records previously collected and recorded by different health professionals who were involved in the care of the client in past and in present. b. By reviewing the client’s clinical record or chart before beginning assessment, especially interview, will help to avoid repeating questions that were already answered by the client, unnecessary repetition of diagnostic test and medical procedures. 5. Interview a.It is a planned conversation or communication with a purpose. b.The midwife conducts interview to: *Develop rapport with the client *Gather data about the client’s health history and identify problems *Have an opportunity to provide information to the client pertaining to his/ her health care *Provide client support Kinds of interview: *Directive Interview - It involves asking of close ended questions to elicit specific information - The questions usually begin with when, what, who, where, do and is - The interview is controlled by the interviewer example: When was your LMP? How old are you? *None directive Interview or Rapport building interview - it is the type of interview that is often used for counseling, problem solving and performance appraisal - The patients controls the pace, purpose and subject matter of interview - The interviewer encourages communication by asking open ended question, these are questions that encourage the patient to elaborate, explore and clarify their feelings and thought Example: "Tell me about yourself", is a common opener to a nondirective interview. Creating a friendly and less threatening environment for the client “How are you feeling lately?”; “ What would you like to talk about today”  Types Of questions Closed questions * Questions that can be answered by yes or no & provides extra responses or factual answers *Often used in directive interview *Useful in clients who are agitated, in pain, have difficulty communicating and concentrating, or in a lot of stress. Examples: How old are you? How much rice you eat in a meal? Do you feel dizzy whenever you stand up from a sitting position? Open ended questions * Questions that allow and encourage the client to express their feeling elaborate and explore their thoughts. * Client can choose what topic to talk about * Useful at the start of an interview or to change the subject Leading Questions *Questions that lead that client at a particular topic that the midwife needs to explore or that suggest what answer is expected. Example: “You have not eaten fatty food in the past week, did you? *The client may provide inaccurate data to please the interviewer or the midwife.  Stages of interview The Opening *Establishing rapport – process of creating goodwill and trust. Composed of greeting and introduction *Orientation – The interviewer explains the purpose and nature of the interview *The Body – This is the question and answer portion where the interviewer obtains the needed information from the interviewee.  * The Closing – the interviewer usually terminates the interview when the needed information is obtained. The client terminates it when the client decides not to give anymore questions or is unable to proceed with the interview for some reasons. *Example: “Well, that’s all I need to know for now” “Do you have any question before we end this interview?”  6. Health History a.The health history is the primary source of information about the patient. b.It can be obtained from the patient, relatives or existing old health records. Often it is the combination of all these that helps in making the health history of the patient. c. Usually a predetermined format is used by the different healthcare institutions. Anyone who conducts the interview should follow this format to make the assessment systematic, complete and accurate an not time consuming. d. Contents of health history *Demographic data includes information such as name, address, cellular phone number, sex, age, civil status, religion, and race. *Chief Complaint (CC) – it is the main reason for seeking healthcare or consultation to the clinic. The CC is recorded in the patient’s own words *Example: “I have been menstruating nonstop for more than two weeks already’” or “Palagi akong nahihilo” *Past history – includes childhood disease, immunizations, allergies, past hospitalization and diseases, accidents, injuries, past and current medications. * Review systems – Rundown from head to toe of the patient’s present health status. Contains only subjective data given by the patient  7. Review of Literature a. By reviewing journals, textbooks, and recent research finding, the midwife can obtain additional data about the client’s condition that can help in providing the client with better and effective care and intervention b. In addition, review of related literature can provide the midwife with continued education to maintain an up to date knowledge of the recent trends and advances in health care and the field of midwifery practice.  8. Psychosocial Assessment a. Vocation/ education/ financial b. Home and family c. Social, leisure, spiritual and cultural d. Sexual e. Activities of daily living f. Health habits g. Psychological  9. Physical Examination a. Physical assessment is the systematic data collection method that uses observation skills to detect health problems b. Preparation: Environment: *Conduct in a private and quiet area *Draw curtains or close door of examining room *Use good lighting *Conduct examination in a well equipped room where all needed equipment are available. Equipment: *Perform hand washing before preparing needed equipment and instruments *Ensure proper height of the examining table or bed *If examiner is right sided, examine from the right side of the bed  Client: *Psychological Preparation is the highest priority before performing physical examination *Develop rapport with the client to ensure cooperation and so that the client is at ease during procedure *Explain procedure to the client as the examination proceeds  Physical Preparation: *Ask the client to void or if he or she needs to use the toilet prior to the examination *Make client physically comfortable as much as the requirements of the examination allow  Positioning: *During the examination, it is important for the midwife to know in what position the client should be assisted to assume in order to facilitate the examination and ensure client’s comfort. Determine also if the client’s condition will allow him or her to assume the necessary position and what needed modification in the recommended position should be made. c. Order of Assessment – Physical Assessment should be conducted in systematic method/ Cephalocaudal or head to toe order of examination d. Inspection, Palpation, Percussion, Auscultation *Inspection – It is a purposeful and systematic observation of the client using the different senses: eyes, ears and nose to detect normal characteristics and abnormal manifestation.  *Palpation – Involves the sense of touch as examiner feels or presses a body part. The midwife uses different parts of the hand to assess a client’s body part for texture, temperature, vibration, position, size, consistency, mobility, distention, tenderness and pain. Types of Palpation: *Light touch – use pads of finger, often to identify areas of tenderness *Deep touch – Uses two hands, one hand palpates, the other supports often to press deeper into the patient’s abdominal area *Percussion – method in which a body part is struck to elicit sounds or vibrations. The vibration produced by striking specific body parts is transmitted through the body tissues and character of the sound depends on the density of the underlying tissue.  *Auscultation – is listening to sounds produced within the body to detect deviation from normal. The sound heard are those from abdomen, lungs and cardiovascular system Types of Auscultation: *Direct Auscultation – using unaided ear to listen to sounds within the body *Indirect Auscultation – using stethoscope. The bell of stethoscope is used for low pitch sounds such as murmurs and bruits. The diaphragm of stethoscope is used for high pitch sounds such as crackles, wheezes from the lungs These data are collected systematically and continuously, then are recorded in appropriate forms and kept so that retrieval of information is facilitated. Collected data are treated confidentially.  10. Common Diagnostic test a.Sputum examination - A bacterial sputum culture is used to detect and diagnose bacterial lower respiratory tract infections such as bacterial pneumonia or bronchitis. It is typically performed with a Gram stain to identify the bacteria causing a person's infection. *Most ideal after awakening before breakfast *Collect specimen before first dose of antibiotic if the test is for culture and sensitivity b. Urinalysis - is a test of your urine. A urinalysis is used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes. A urinalysis involves checking the appearance, concentration and content of urine. Abnormal urinalysis results may point to a disease or illness. *Routine Urinalysis – take initial voiding anytime of the day *Pregnancy Test – Use the first voided urine in the morning c. Fecalysis - is a series of tests done on a stool (feces) sample to help diagnose certain conditions affecting the digestive tract. *Make sure that the patient will not be taking any alcohol, vitamin C, aspirin, or ibuprofen before the fecalysis test or during the routine fecalysis * If stool specimen is to be tested for occult blood, instruct client to follow a meat free and high fiber diet for three days before the collection of specimen d. Tourniquet Test/ Rumpel Leads Test - The test is part of the WHO algorithm for diagnosis of dengue fever. A blood pressure cuff is applied and inflated to the midpoint between the systolic and diastolic blood pressures for five minutes. The test is positive if there are more than 10 to 20 petechiae per square inch.  11. Validating data a.For the assessment phase to be successful basis for planning patient care, the information gathered must be complete, factual and accurate. b.Validation is the act of “double checking” or verifying data to confirm that they are accurate and factual. c.Validation of data is achieved when the midwife: *double check personal observation * double check equipment *Check with experts and other team members *Compare subjective and objective data *Clarify statements  planning 1. Planning a.Planning is a series of steps in which the midwife and the patient set priorities and goals and select appropriate interventions to resolve or minimize the identified problems of the client b.The plan is the midwife’s guide to actions and interventions 2. Purpose of Plan of Care a. To individualize care b. To set priorities c. To help communicate among health personnel d. To promote continuity of care, discharge planning and goal setting e. To coordinate care f. To evaluate care rendered to client g. To promote professional development 3. Types of Goals a.Short term goals – have outcomes achievable in a few days or 1 week b.Long term goals – have desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems 4. Guideline: S M A R T Specific: the objective clearly articulates who is expected to do, i.e. the family or a target family member will manifest a particular behavior. Measurable: observable, whenever possible, quantifiable indication of family’s achievement as result of their effort toward a goal. Attainable: the objective has to be realistic and in conformity with available resources, existing constraints, and family traits, such as a style and functioning. Relevant: it should be appropriate for the family need or problem that is intended to be minimized, alleviate, or resolved. Time-bound: having a specified target time or dates helps the family and the healthcare worker in focusing their attention and the efforts toward the attainment of the objective. 5. Priority Setting a.Process of establishing which problem requires attention first, which is second and so on b.General guidelines for Setting Priorities *Take care of immediate life threatening issues *First priority includes any threat to the vital functions of breathing, heartbeat and blood pressure  *Medium Priority includes health threatening problems that may result in delayed development or cause destructive physical or emotional changes *Low priority includes problem that arise from normal development needs or those that require minimal nursing support 6. The Plan of Care should be client centered as much as possible. It means that it will state what the patient will experience or do at the completion of care. Example: “After an hour of demo teaching by the midwife, the patient will demonstrate how to perform tub bath to her newborn.  Implementation/ intervention Intervention – it is putting the care plan into action Kinds of intervention: a. Direct Intervention – these are actions performed through interaction with clients. For example performing TSB on a client with fever to lower body temperature b. Indirect – actions performed away from the client. For example, maintain ambient temperature in the nursery at 24◦C to prevent heat loss among newborns. 3. The midwife select strategies based on the knowledge that certain interventions produce desired effects. The selected intervention must be safe, within legal scope of midwifery practice, and compatible with medical orders. 4. Different functions of Midwife a. Independent Actions which the midwife carry on herself without the order from other person and for which she herself is responsible Example: performing TSB, examining and monitoring pregnant women b. Dependent Actions which the midwife perform while following orders from a superior Example: following doctors order c. Interdependent Actions which the midwife perform in collaboration with other members of the health team Example: Taking urine specimen and bringing it to the laboratory 5. Documentation: It is an important part of the intervention or implementation phase of the healthcare process to ensure accountability and continuity of care  Evaluation 1.Evaluate is assessing the patients response to nursing interventions and then comparing the response to the goals or outcome criteria written in the nursing phase, determining the extent to which the goals of care have been achieved. 2.During the evaluation phase, the midwife determines if the outcome criteria is completely met, partially met or not met at all. Health Care Process as applied to Family  Family Case Load Guide: Guidelines for Midwifery Student 1. Make a communication letter addressed to the head of the Barangay (Barangay Captain/ Chieftain) a week prior to the scheduled date of duty. It should be verified and approved by the Program Coordinator and the Dean of the Midwifery Department. 2. Deliver the communication letter (2 copies) to the head of the Barangay (Barangay Captain/ Chieftain). Make sure that the letter is both signed. First letter will serve as the receiving copy of the barangay while the other letter will be kept by Student Midwife as a duplicate document. 3. Student Midwife should always be punctual following the call time at the Barangay Hall. 4. Make a courtesy call to the Barangay Officials and Personnel (BHW/ Aid/ Tanod) and be familiarize with their names and faces. 5. Do an ocular survey of the area. 6. Construct a spot map with the following: Direction N,E,W,S (Similar to a compass) North should always be located at the top Resources in the community (Barangay Hall, School, Market, Church, Public faucet, Public toilet, etc.) 7. Identify qualified family client 8. Conduct a home visit Pre Visit Phase Contact the family, determine the family’s willingness for a visit and sets an appointment with them In Home Phase Seek permission to enter and lasts until the student midwife leaves the family’s home Greeting in vernacular/ other language common to the student and family Acknowledge the family member(s) with a greeting and introduce himself/herself Establish rapport thru short social conversation States the purpose of the visit Conduct assessment thru interview, physical examination, simple diagnostic exam. Ex. V/S taking Observe family dynamics and physical environment Use the standard family assessment form Make a Family Data Analysis Make a family Diagnosis Formulate the Plan of care -Planning involves priority setting, establishing goals and objectives and determine appropriate interventions to achieve goals and objectives Physical Care, Health teachings, and counseling are provided to the family according to plan Observes aseptic practices such as hand washing before and after touching the family members during assessment and physical care Teach family by visual demonstration practical methods of preventing the spread of infection. Summarize with the family the events during the home visit and set a subsequent home visit Post Visit Phase Involves documentation during which the student midwife record events that transpired during visit including personal observation and his/her feelings about the visit.  FAMILY ASSESSMENT Initial Data Base a. Family structure, characteristics and dynamics 1. Members of the household and relationship to the head of the family 2. Demographic data – age, civil status, position in the family 3. Place of residence- whether living with the family or elsewhere 4. Type of family structure 5.Dominant family members in terms of decision making especially in matters of health care 6. General family relationship /dynamics b. Socio-economic and cultural characteristics Income, occupation, place of work (of each member) Educational attainment of each member Ethnic background and religious affiliation Significant others and other roles they play in the family’s life Relationship of the family to the larger community (membership in organizations) c. Home and environment Information on housing and sanitation facilities which includes: Housing agency, sleeping arrangements, food storage, cooking facilities, water supply, source, ownership, potability, presence of accident hazards, toilet, garbage disposal Availability of social, health , communication and transportation facilities in the community. d. Health status of each member Past /current significant illness Beliefs/practices about health Nutritional and development status Decision – making on which or whom to seek advice regarding health e. Values and Practices on Health Promotion and Maintenance Preventive aspects- immunization status Adequate rest and sleep, exercise, relaxation activities Street management activities, utilization of health care facilities 0 Pre Eclampsia 2 0.5 3.5 3.5