Unit 2

 Upon completion of this unit you should be able to:  Identify and give examples of the five steps of the nursing process  Apply the steps of the nursing process to a community assessment  Define and describe the purpose of a nursing model  Identify and give examples of each component of the Community As Partner Model  Identify and give examples of the three levels of prevention

The nursing process is a model for nursing practice. It is a systematic, organized method used to identify and manage patient health problems. AssessDiagnosePlanImplementEvaluate

 Provides a plan for the practice of nursing  Based on a nursing theory developed by Ida Jean Orlando in 1958  Is a model for problem solving  Involves 5 steps  Assessment of the patient’s needs  Diagnosis of human response needs  Planning of patient’s care  Implementation of care  Evaluation of the success of implemented care An easy acronym to remember the steps is: would you like A Delicious PIE?

 Determine baseline or “normal”  Identify the presence of actual and potential problems  Includes data collection and review- the nurse must determine if the data collected is complete and accurate  Includes data analysis  Determine which problems are actual and which ones are potential  Develop a problem list  Prioritize the problems

 A statement that describes an actual or potential health problem that requires interventions  Is the basis for the nursing care plan  Reflects the nurse’s clinical judgment about the client’s health conditions or needs

 Based on the assessment and diagnosis, the nurse sets goals for the patient  The goals must be measurable and achievable  Short term and long term goals are set  These goals are also referred to as “outcomes”

 In this phase, the plan is actually carried out  Care given is based on the care plan formulated during the planning phase

 During this phase, the nurse determines if the goals were met  If the goals were not met, then determine why they were not met  The whole process may start over if goals are not achieved

Assessment: A patient recovering from abdominal surgery complains of pain. The nurse asks the patient to rate the pain on a 10 point scale. The patient responds with a score of 8. The nurse checks the vital signs and finds an elevated blood pressure and heart rate. The nurse also analyzes the data collected to identify an actual problem – pain.

Diagnosis Based on the data collected during the assessment phase, the nurse concludes that the patient is in pain and that providing relief of pain is high on the priority list for this patient. This is an actual patient problem that requires interventions

Planning: The nurse formulates a plan (interventions that can be performed) and develops a goal of pain relief. Implementation: The nurse administers the pain medication ordered by the physician and provides education on relaxation techniques

Evaluation: After administration of pain medications, the nurse checks on the patient. The patient is once again asked to rate the pain on a 10 point scale. The patient responds with a score of 4. The nurse determines that the goal was achieved and the interventions were effective. If the pain score had remained an 8, the nurse would determine why the goal was not met. This is a rather simple example of the nursing process in action. Eventually the process becomes second nature and the experienced nurse does not think about each step.

 Model- Defined by Merriam-Webster as “a description or analogy used to help visualize something that cannot be directly observed”  Nursing Model- an abstract or general statement about concepts that organize ideas or provide a framework for practice. Four concepts central to nursing models include person, environment, health, and nursing  Nursing models include health promotion and holistic aspects of care

 Based on Neuman’s Systems Model  Developed by Elizabeth T. Anderson and Judith M. McFarlane  The framework follows the nursing process  Person, environment, health, and nursing are central concepts to the Community-as-Partner Model  Person- everyone in the community (total population or aggregate)  Environment- the things that connect the people to their community ( work, where they live, ethnicity)  Health- physical, mental and social well being  Nursing- interventions that focus on prevention (primary, secondary, and tertiary)

Two central factors with this model: 1. The community is a “partner”; in other words, the involvement of the community is essential. This is represented by the large circle (the community assessment wheel) at the top of the model. 2. The model follows the nursing process

The Community–as- Partner Model begins with assessment. The concept of assessment is represented by the ‘assessment wheel’. The center of the wheel is the community core. This represents the people of the community. The areas surrounding the community core are the eight subsystems of the community.

The community core (people in the community) is influenced by the eight subsystems and the eight subsystems are influenced by the community core. Sometimes the influences are positive, sometimes they are negative. The relationship between the community core, the subsystems and the environment are illustrated by the solid and broken lines in the figure and will be discussed in further detail in the following slides.

 Represented by a solid line around the community circle  This represents the level of health of the community- what the community “normally” does to maintain health  Low infant mortality rate and high median household income are examples of normal line of defense for a community  How the community copes with every day stress and problem solving are also considered part of the normal line of defense

 Represented by a broken line around the community (outside normal line of defense)  The broken line is significant as it symbolizes the dynamic nature and changing state of the community’s defenses.  Also referred to as the “buffer zone”  It is the level of health occurring after temporary response to a stressor  These measure are temporary. They also promote and protect the overall health of the community  Offering tetanus shots, food, and clean water after a natural disaster (flood, hurricane) is an example of a flexible line of defense. The measures are temporary, but they promote and protect the overall health of the community.

 Represented by the broken lines within the community assessment wheel  The strengths of the community  Present in all eight subsystems of the community  Are the defenses in place to fight stressors  A free pregnancy help clinic in a community with high teen pregnancy rates is an example of a line of resistance.

 Represented by stars on the community assessment wheel  Stressor is a stimulus that threatens the balance of the community  Can be internal (loss of a major employer within the community results in loss of income and health insurance to many of the community members)  Can be external (air pollution from a neighboring town)  Stressors penetrate the flexible and normal lines of defense

 Degree of reaction is the amount of disequilibrium caused by a stressor  The degree of reaction will vary depending on the stressor and the community’s lines of defense  A community with a strong line of resistance (vaccination against a certain disease) will have a smaller degree of reaction from a stressor (measles or flu)  Degree of reaction is reflected in statistics such as mortality and morbidity rates, employment rates and crime statistics

 The blue shaded areas within the community assessment wheel are the eight subsystems of the community  Divided by broken lines to symbolize the connection between them  In order to assess the community, each of the eight subsystems must be thoroughly assessed

 Physical environment  Education  Safety and transportation  Politics and government  Health and social services  Communication  Economics  Recreation

 In the center of the community assessment wheel lies the community core  The community core represents the people of the community  The core is a reflection of the demographics, values, beliefs and history of the community  The people (community core) of the community have a fluid relationship with the eight subsystems. That is to say the people of the community will have an affect on the eight subsystems and the subsystems will in turn have an affect on the people in the community.

 There are 6 phases to a community assessment:  Establish contract/partnership  Assessment  Diagnosis  Planning  Implementation  Evaluation

 The people in the community are considered as “partners” in the process  Establishing a contract or partnership with leaders of the community is essential

 Collect data about the community core and the eight subsystems  Collect subjective data (interviews with community members)  Collect objective data  Observations made in the community (windshield survey)  Published data  Objective data will validate subjective data  After all data is collected, analysis can begin

Group or cluster pieces of related data  Develop a master list of problems or stressors  Determine the “degree of reaction” to stressors  Prioritize the list of problems or stressors Compare data  Identify gaps, omissions and incongruencies  Compare the data for the community to other communities within the state and nation Draw inferences from the data analysis to create a diagnosis  What does the data mean?

 The diagnosis is developed from the problem list created in the assessment/analysis phase.  The community health diagnosis describes the community’s response or need regarding a specific health issue.  Be careful not to confuse the community health nursing diagnosis with a medical diagnosis or problem such as HIV.

 Develop goals and interventions  Goals should reflect national health priorities (Healthy People 2020)  Goals are a collaboration between the nurse and the community  Interventions are specific activities that the nurse will do to help the people of the community attain the goals (health screening, educational programs, etc)  Interventions classified as primary, secondary or tertiary

 Primary interventions  Strengthen the community’s normal line of defense  Reduce encounters with stressors  Focus on prevention  Immunizations is an example  Secondary interventions  Minimize the degree of reaction from a stressor  Occurs after a stressor has crossed a line of defense  Focus is on early detection (screening) and prevention of further damage  Blood pressure screening is an example  Tertiary interventions  Applied after a stressor has penetrated the community and a degree of reaction has taken place  Promotes equilibrium and prevents further disequilibrium  Focus is on restoration of a healthy state (treatment)  Counseling students after a school shooting is an example

 Phase five – Implementation  The interventions created during the planning phase are put into action  Phase six – Evaluation  Based on feedback from the community  Did the community achieve the goals?  If not, then the nurse must figure out why the goals were not met  Involves data collection and analysis  May start the process over again – reassessment of the community  The nursing process for communities is cyclical and ongoing