Lect.7 Community As Client: The Nursing process in the promotion of Health

June 25, 2024
0
0
Зміст

TERNOPIL STATE MEDICAL UNIVERSITY

INSTITUTE OF NURSING

DEPARTMENT OF CLINICAL IMMUNOLOGY, ALLERGOLOGY

AND GENERAL PATIENT CARE

 

Lecture 7

 

Community As Client: The Nursing process in the promotion of Health

 

 

After studying this chapter, you should be able to:

·         Identify the nursing process.

·         Discuss the steps or phases of the nursing process

·         Describe community health nursing

·         Explain what community assessment is.

 

Introduction

 The nursing process is a process by which nurses deliver care to patients, supported by nursing models or philosophies. The nursing process was originally an adapted form of problem-solving and is classified as a deductive theory.

The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the patient has, and for every element of patient care, rather than once for each patient. The nurse’s evaluation of care will lead to changes in the implementation of the care and the patient’s needs are likely to change during their stay in hospital as their health either improves or deteriorates. The nursing process not only focuses on ways to improve the patient’s physical needs, but also on social and emotional needs as well.

·         Cyclic and dynamic

·         Goal directed and client centered

·         Interpersonal and collaborative

·         Universally applicable

·         Systematic

The nursing process is not something foreign or unusually complex. On the contrary, we use the nursing process method on a daily basis without even realizing it. For example, a trip to the gas station to get fuel requires Assessing the various prices and the number of people waiting to get gas among other things. A subsequent decision, or Diagnosis, is made based on the former criteria. This may include pulling into the gas station to fuel up or going down the road for better prices and/or less of a crowd. The price is right and there’s not much of a crowd, we’re pulling in. Now the Planning can take place. This may include which pump to use, how much gas to put in the tank, whether or not to clean the windows along with other things. We’re at the pump and ready to fuel up. We must now Implement what we planned prior to pulling up to the pump. We’ve pulled up on the passenger side because the gas tank resides on this side, part of our plan. We’ve also given ourselves enough room to exit without getting blocked in by another vehicle, part of our plan also. We now unscrew the gas cap and begin fueling or Implementing what we planned. Things went well. We are fueled up and have exited the gas station without complication. Our Evaluation of the trip to the gas station would be a good one. We may choose to use this method in the future. The Nursing process is that simple in theory. However, as a nurse, the nursing process tool will be used for more complex and difficult situations but is applied the same way as the gas station analogy.

Skills

The nursing process involves skills a nurse should possess when he or she has to initiate the initial phase of the process. Having these skills contributes to the greater improvement of the nurse’s delivery of health care to the patient, including the patient’s level of health, or health status.

·         Cognitive or Intellectual skills, such as analyzing the problem, problem solving, critical thinking and making judgments regarding the patient’s needs. Included in these skills are the ability to identify, differentiate actual and potential health problems through observation and decision making by synthesizing nursing knowledge previously acquired.

·         Interpersonal skills, which includes therapeutic communication, active listening, conveying knowledge and information, developing trust or rapport-building with the patient, and ethically obtaining needed and relevant information from the patient which is then to be utilized in health problem formulation and analysis.

·         Technical skills, which includes knowledge and skills needed to properly and safely manipulate and handle appropriate equipment needed by the patient in performing medical or diagnostic procedures, such as vital signs, and medication administrations.

The following are the steps or phases of the nursing process.

  • Assessment (of patient’s needs)

  • Diagnosis (of human response needs that nurses can deal with)

  • Planning (of patient’s care)

  • Implementation (of care)

  • Evaluation (of the success of the implemented care)

Assessment

Assessment is the first stage of the nursing process in which the nurse should carry out a complete and holistic nursing assessment of every patient’s needs, regardless of the reason for the encounter. Usually, an assessment framework, based on a nursing model is used.

The purpose of this stage is to identify the patient’s nursing problems. These problems are expressed as either actual or potential. For example, a patient who has been rendered immobile by a road traffic accident may be assessed as having the “potential for impaired skin integrity related to immobility“.

Components of a nursing assessment

Nursing history

Taking a nursing history prior to the physical examination allows a nurse to establish a rapport with the patient and family. Elements of the history include:

  • health status

  • course of present illness including symptoms

  • current management of illness

  • past medical history including family’s medical history

  • social history

  • perception of illness

 Psychological and social examination

The psychological examination may include;

  • Client’s perception (why they think they have been referred/are being assessed; what they hope to gain from the meeting)

  • Emotional health (mental health state, coping styles etc)

  • Social health (accommodation, finances, relationships, genogram, employment status, ethnic back ground, support networks etc)

  • Physical health (general health, illnesses, previous history, appetite, weight, sleep pattern, diurinal variations, alcohol, tobacco, street drugs; list any prescribed medication with comments on effectiveness)

  • Spiritual health (is religion important? If so, in what way? What/who provides a sense of purpose?)

  • Intellectual health (cognitive functioning, hallucinations, delusions, concentration, interests, hobbies etc)

Physical examination

A nursing assessment includes a physical examination: the observation or measurement of signs, which can be observed or measured, or symptoms such as nausea or vertigo, which can be felt by the patient.

The techniques used may include Inspection, Palpation, Auscultation and Percussion in addition to the “vital signs” of temperature, blood pressure, pulse and respiratory rate, and further examination of the body systems such as the cardiovascular or musculoskeletal systems.]

Models for data collection

The following nursing models are conceptual models, constructed of theories and concepts. They are used to help nurses assess, plan, and implement patient care by providing a framework within which to work. They also help nurses achieve uniformity and seamless care. are used to gather the necessary and relevant information from the patient in order to effectively deliver quality nursing care. This will help the nurse determine the ranking of the problems encountered.

Gordon’s functional health patterns

Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient:

  • Health perception and management

  • Activity and exercise

  • Nutrition and metabolism

  • Elimination

  • Sleep and rest.

  • Cognition and perception

  • Self-perception and self-concept

  • Roles and relationships

  • Coping and stress management

  • Sexuality and reproduction

  • Values and beliefs

Roy’s adaptation model

Roy‘s model of nursing sees an individual as a set of interrelated systems, biological, psychological, and social. The individual tries to maintain a balance between each of these systems and the outside world. However, there is no absolute level of balance. According to Roy we all strive to live within a band where we can cope adequately. This band will be unique to an individual. The adaptation level is the range of adaptability within which the individual can deal effectively with new experiences.

 

 

Maslow’s hierarchy of needs

 Maslow’s hierarchy of needs is often depicted as a pyramid consisting of five levels: the four lower levels are grouped together as being associated with Physiological needs, while the top level is termed growth needs associated with psychological needs. Deficiency needs must be met first. Once these are met, seeking to satisfy growth needs drives personal growth. The higher needs in this hierarchy only come into focus when the lower needs in the pyramid are satisfied. Once an individual has moved upwards to the next level, needs in the lower level will no longer be prioritized. If a lower set of needs is no longer being met, the individual will temporarily re-prioritize those needs by focusing attention on the unfulfilled needs, but will not permanently regress to the lower level. For instance, a businessman at the esteem level who is diagnosed with cancer will spend a great deal of time concentrating on his health (physiological needs), but will continue to value his work performance (esteem needs) and will likely return to work during periods of remission.

How to collect data

  • Client Interview

  • Physical Examination

  • Observation

Diagnosing Phase

 A nursing diagnosis is a standardized statement about the health of a client (who can be an individual, a family, or a community) for the purpose of providing nursing care. Nursing diagnoses are developed based on data obtained during the nursing assessment.

The main organization for defining standard diagnoses in North America is the North American Nursing Diagnosis Association, now known as NANDA-International. Other international associations are AENTDE (Spanish), AFEDI (French language) and ACENDIO (Europe).

Nursing diagnoses are part of a movement iursing to standardize the terminology involved. This includes standard descriptions of diagnoses, interventions and outcomes. Nurses who support of standardized terminology believe that it will help nursing become more scientific and evidence-based. Other nurses feel that nursing diagnoses are an ivory tower mentality and neither help in care planning nor in differentiating nursing from medicine.[1]

Types of Diagnosis

·         Actual Diagnosis-a judgment on clients response to a health problem that is present

·         High Risk-based on most likely to develop

·         A Possible Nursing Diagnosis-a health problem is unclear and causative factor is unknown

·         Wellness Diagnosis-indicating a well response of the patient

Components of a Nursing Diagnosis

·         Problem Statement(diagnostic label)-describes the clients health problem

·         Etiology(related factor)-the probable cause of the health problem

·         Defining Characteristic-a cluster of signs and symptoms

Planning Phase

In agreement with the patient, the nurse addresses each of the problems identified in the planning phase. For each problem a measurable goal is set. For example, for the patient discussed above, the goal would be for the patient’s skin to remain intact. The result is a nursing care plan.

care plan

Care plans are central to the nursing process.  They are documents that outline in detail the care to be provided to a patient.  For the student nurse, preparing and writing a care plan can be very time consuming and complicated.

There are many sites and reference books that provide nursing care plan templates.  Templates are useful in providing an outline for a starting point. They can be compared to the blueprints to building a house.  Also useful for the builder (and to student nurses) are examples of the finished product.

Our member site provides a library of  “Graded Patient Care Plans”  composed by student nurses.  These graded patient care plans include rationales and instructor notes.   They are provided as case studies for review, learning, and research.  Also provided for our members are Maslow Cheat Sheets”. These are provided to help Nursing Students save time and work with their Maslow’s hierarchy of needs and Gordon’s Functional Health Patterns presentations.

care plans  A nursing care plan outlines the nursing care to be provided to a patient. It is a set of actions the nurse will implement to resolve nursing problems identified by assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.

 

“Seeing how a care plan was formatted and how instructors graded them helped me immensely“.Cathy Thomas,

 

A must have resource for the nursing student!”
Patty Smith

Implementing Phase

The methods by which the goal will be achieved are also recorded at this stage. The methods of implementation must be recorded in an explicit and tangible format in a way that the patient can understand should he wish to read it. Clarity is essential as it will aid communication between those tasked with carrying out patient care.

 Patient care is part of a nurse‘s role. Nurses use the nursing process to assess, plan, implement and evaluate patient care. Patient care is founded in critical thinking and caring in a holistic framework. Nursing care is increasingly framed in best practice, which is the application of evidence-based concepts to patient problems in a particular setting. Florence Nightingale is recognized as the first nurse researcher.

Contents

1 Infection control

2 Records

3 Vital Signs

4 Medication

5 Diet

 

Evaluating Phase

The purpose of this stage is to evaluate progress toward the goals identified in the previous stages. If progress towards the goal is slow, or if regression has occurred, the nurse must change the plan of care accordingly. Conversely, if the goal has been achieved then the care can cease. New problems may be identified at this stage, and thus the process will start all over again. It is due to this stage that measurable goals must be set – failure to set measurable goals will result in poor evaluations.The entire process is recorded or documented in an agreed format in the patient’s care plan in order to allow all members of the nursing team to perform the agreed care and make additions or changes where appropriate

 

Community Health Nursing Practice

 To describe community health nursing more clearly, a group of four nursing organizations met (Quad Council of Public Health Nursing Organizations, 1999). The four organizations were called The Quad Council and consisted of the American Nurses Association, Council of Community, Primary, and Long-Term Care; American Public Health Association—Public Health Nursing Section; Association of Community Health Nurse Educators; and Association of State and Territorial Directors of Nursing. Their definition of the scope of public health nursing practice is quoted below:

Public health nursing is the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences (American Public Health Association, Public Health Nursing Section 1996). Public health nursing is a population-based, community-oriented nursing practice. The goal of public health nursing is the prevention of disease and disability for all people through the creation of conditions in which people can be healthy.

Public health nurses most often partner with nations, states, communities, organizations, and groups, along with individuals, in completing health assessment, policy development, and assurance activities. Public health nurses practice in both public and private agencies. Some public health nurses may have responsibility for the health of a geographic or enrolled population, such as those covered by a health department or capitated health system, whereas others may promote the health of a specific population, for example, those with HIV/AIDS.

Public health nurses assess the needs and strengths of the population, design interventions to mobilize resources for action, and promote equal opportunity for health. Strong, effective organizational and political skills must complement their nursing and public health expertise (Quad Council of Public Health Nursing Organizations, 1999, p. 2).

In addition, The Quad Council explicated the eight tenets of public health (community health) nursing practice to advance the goal of promoting and protecting the health of the population

We can use these tenets to guide our practice of community health nursing, regardless of the setting. In addition to the work of the Quad Council, which underscores the population focus of public health nursing, public health nurses in Wisconsin report that their practice has become more population focused (Zahner, S.J. & Gredig, Q.N., 2005). Next, let’s discuss some of the factors that will affect our practice in this century.

 

Community assessment

  Community assessment is a process; it is the act of becoming acquainted with a community. The people in the community are partners and contribute throughout the process. Our nursing purpose in assessing a community is to identify factors (both positive and negative) that impinge on the health of the people to develop strategies for health promotion. As Hancock and Minkler (1997, p. 140) point out, “For health professionals concerned with … community building for health, there are two reasons for [conducting] community health assessments: information is needed for change, and it is needed for empowerment.” We will use the community assessment wheel (Fig. 11-1) as a framework for the assessment

 

Community-as-Partner Model

  Based on Neuman’s model of a total-person approach to viewing patient problems (1972), the community-as-client model was developed by the authors to illustrate the definition of public health nursing as the synthesis of public health and nursing. The model has been renamed the community-as-partner model to emphasize the underlying philosophy of primary health care.

Neuman’s total-person approach and, subsequently, the community-as-partner model are considered systems models. You are already familiar with several kinds of systems, for instance, body systems (endocrine, neuromuscular); social systems; and filing systems. Systems have a common purpose, interrelated parts, and boundaries. The whole system is considered greater than the sum of its parts, and there is emphasis on the interaction of those parts to make up the whole. An individual, group, or community can be considered an open system in that there is constant interaction with the environment through boundaries.

In addition to systems theory, Neuman’s model incorporates Selye’s stress adaptation theory, gestalt theory from psychology, and field theories. For application to community work, stress adaptation has been included in the community-as-partner model.

Definitions of the four concepts that are central to nursing—person, environment, health, and nursing—provide a framework for the community-as-partner model. Person is a population or an aggregate. Everyone in a defined community (total population) or aggregate (the elderly, teens, nurses) represents the person. In effect, environment may be thought of as community (i.e., a network of people and their surroundings). The links between the people in the community may be where they live, the work they do, their ethnicity or race, the way they live, and any other factors they have in common (Baum, 1998). Health in this model is seen as a “resource for everyday life, not the objective of living. [It is] a positive concept emphasizing social and personal resources, as well as physical capacities” (World Health Organization, 1986). Nursing, based on definitions of the other three concepts, is prevention. That is, all of nursing is considered preventive: primary prevention is aimed at reducing possible encounters with stressors or strengthening the lines of defense (e.g., sunscreen to prevent skin cancer; immunizations); secondary prevention occurs after a stressor crosses the line of defense and causes a reaction, and it is aimed at early detection to prevent further damage (e.g., breast self-examination); and tertiary prevention aims to maintain and restore a more-or-less healthy state (e.g., rehabilitation, meditation).

Consider the community-as-partner model. There are two central factors in this model: a focus on the community as partner (represented by the community assessment wheel at the top, which incorporates the community’s people as the core) and the use of the nursing process. The model is described in some detail to assist you in understanding its parts; this will guide your practice in the community.

The core of the assessment wheel represents the people who make up the community. Included in the core are the demographics of the population as well as their values, beliefs, and history. As residents of the community, the people are affected by and, in turn, influence the eight subsystems of the community. These subsystems are physical environment, education, safety and transportation, politics and government, health and social services, communication, economics, and recreation.

The solid line surrounding the community represents its normal line of defense, or the level of health the community has reached over time. The normal line of defence may include characteristics such as a high rate of immunity, low infant mortality, or middle income level. The normal line of defense also includes usual patterns of coping, along with problem-solving capabilities; it represents the health of the community.

The flexible line of defence, depicted as a broken line around the community and its normal line of defence, is a buffer zone representing a dynamic level of health resulting from a temporary response to stressors. This temporary response may be neighbourhood mobilization against an environmental stressor such as flooding or a social stressor such as an unwanted adult bookstore. The eight subsystems are divided by broken lines to remind us that they are not discrete and separate but influence (and are influenced by) one another. (Remember: A principle of ecology is that everything is connected to everything else. This also applies to the community as a whole.) The eight divisions both define the major subsystems of a community and provide the community health nurse with a framework for assessment.

Within the community are lines of resistance, internal mechanisms that act to defend against stressors. An evening recreational program for young people implemented to decrease vandalism and a freestanding, no-fee health clinic to diagnose and treat sexually transmitted diseases are examples of lines of resistance. Lines of resistance exist throughout each of the subsystems and represent the community’s strengths.

Stressors are tension-producing stimuli that have the potential of causing disequilibrium in the system. They may originate outside the community (e.g., air pollution from a nearby industry) or inside the community (e.g., the closing of a clinic). Stressors penetrate the flexible and normal lines of defense, resulting in disruption of the community. Inadequate, inaccessible, or unaffordable services are stressors on the health of the community.

Stressors and lines of resistance (strengths) together become part of the community nursing diagnosis by giving rise to the degree of reaction. The degree of reaction is the amount of disequilibrium or disruption that results from stressors impinging on the community’s lines of defense. For instance, if there is a case of measles (stressor) in an elementary school and the lines of resistance are strong (99% of students are up-to-date on immunizations), the degree of reaction (potential outbreak of measles) will be minimal. The degree of reaction may be reflected in mortality and morbidity rates, unemployment, or crime statistics, to name a few.

Consider the community-as-partner model once more .The goals represented by the model are system equilibrium and a healthy community, and include the preservation and promotion of community health.

 

References

·        Assessing, Fundamentals of Nursing: Concepts, Process and Practice, Second Edition, Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder, 2004, p.261

·        Critical Thinking and the Nursing Process, Fundamentals of Nursing: Concepts, Process and Practice, Second Edition, Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder, 2004, p.245-253

·        Notes on Healthcare Process, 2004

·        Anderson, S., Guthrie, T., & Schirle, R. (2002). A nursing model of community organization for change. Public Health Nursing, 19(1), 40–46.

·        Camann, M. A. (2001). Outcomes of care: The use of conceptual models to вЂ

Leave a Reply

Your email address will not be published. Required fields are marked *

Приєднуйся до нас!
Підписатись на новини:
Наші соц мережі