COMMUNITY HEALTH NURSING

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Community Health Nursing: The 3 Broad Concepts

1. What is a community?– a group of people with

common characteristics or interests living together within a territory or geographical boundary

–  place where people under usual conditions are found

– The community is the object or focus of care in CHN, with the family as the unit of service.

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FACTS of CHN

Focus : promotion and preservation of health

Area of Content: skills and knowledge relevant to both nursing and public health

Clients : general populations (individuals, families, communities)

Time : continual, not limited to episodic care

Scope : comprehensive and general, not limited to a particular age or group

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Concepts on Community Health Nursing:

CLIENTS of Community Health NurseComposed of different levels

of clientele: Individual, family, population group, and community

• Community as a SETTING for CHN PRACTICE

School Health Nursing- School

Occupational Health Nursing- Workplace

Public Health Nursing-Home

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2. What Is Health?

A state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity (WHO, 1995).

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What is Health?

It carries the mandate that health is It carries the mandate that health is a a basic human rightbasic human right..

It is seen as a spectrum or a continuum

•The modern concept of health refers to Optimum Level of Functioning (OLOF) of individuals, families, and communities, which is influenced by the ecosystem through a myriad of factors.04/11/23 7

What influences OLOF?

• Behavioral (culture, habits, mores, ethnic customs)

• Socio-economic (employment, education, housing)

• Political (safety, oppression, people, empowerment)

• Hereditary (genetic endowment, familial, racial)

• Health Care Delivery System (promotive, preventive, curative, rehabilitative)

• Environment (air, food, water, wastes, noise, radiation, pollution, congestion)

3. What is Nursing?

The diagnosis and treatment of human responses to actual or potential health problems (ANA, 1980).

Nursing, together with public health, is one of the helping professions in the health care system which operates at three levels of clientele – individuals, families or groups, and communities

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It operates within the realm of health care both independently and interdependently.

The objective of nursing is to assist clients to achieve, maintain, or recover a high level of functioning.

Assisting sick individuals to become healthy and healthy individuals achieve optimum wellness (Henderson)

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The PHILOSOPHY of CHN

•is based on the worth

and dignity of man

(Shetland)

•Concepts and Principles

pertaining to CHN

Knowledge-base of CHN• Biological and social sciences

• Ecology

• Clinical Nursing

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•Utilizes COMMUNITY HEALTH ORGANIZATIONS

it is population-focused – “the greatest good for the greatest number” > Community diagnosis

> Vital statistics

> Priority setting

it is a promotive-preventive service

– adheres to Primary Health Care > Health education

> Preventive treatment

• It is a generalist practice – deals with all cases

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The ULTIMATE GOAL of CHN

RAISE the level

of health

of citizenry

…

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• By: help communities and

families cope with discontinuities in health and threats

Maximize their potential for high level wellness

Promote reciprocally supportive relationship between people and their physical and social environment

The PRIMARY FOCUS of CHN

health promotion wherein health teaching is the

primary responsibility of the community health nurse,

who is a generalist in terms of practice

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Principles of CHNE – ducation as primary tool and responsibilityM – ade available to all regardless of race, creed and socio-economic

statusP – olicies and objectives of the agency is fully understood by the nurseO – rganizing for health, with the family as the unit of serviceW – orks as a member of the health team (PHN)E – xisting active organizations are utilizedR – ecording and reporting are accurateM – onitoring and evaluation of services is periodically doneE – xisting indigenous resources of the community is usedN – eeds of clienteles is recognized and serves as basis for CHNT – raining and development as opportunities for continuing staff education

programs

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REMEMBER that in CHN:

1. The patient in CHN is the Community which is composed of different population groups and several families (the basic unit of care), and In turn compose of individuals.

2. Client is ACTIVE and NOT PASSIVE recipient of care

 

3. CHN practice is affected by any changes in society and environment

4. Multi-sectoral effort is the key to goal achievement

5. CHN is a part of health care system and the larger human services system. 

 

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Quick Review Exercises

(QRX)

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QRX

In terms of CHN practice, the nurse in the community is trained as

a. Certified in public healthb. Specialist in CHNc. 4-year BSN graduated. Generalist in nursing

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Ans: d. Generalist in nursing

QRX

The thrusts of CHN must be embodied in the hearts of health care providers. Which one strengthens the health care system?

a. Supporting conditions for healthy habits

b. Increasing opportunities to be healthy

c. Letting the people manage their own health

d. Financing health care program

Ans: c.Letting the people manage their own health

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Ans: c.Letting the people

manage their own health

QRX

As a Public Health Nurse, what is your primary function or responsibility?

a. Reporting of casesb. Health Promotionc. Community Diagnosisd. Health Teaching

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•Ans:

d. Health Teaching

QRX

The philosophy of CHN practice is based on the belief that the family is the smallest unit in a democratic society. Which age group should be the priority of the nurses in the community?

a. Older persons and terminally ill

b. Adolescents and adultsc. Infants and childrend. All ages regardless of status 04/11/23 27

Ans:

d. All ages regardless

of status

HIGHLIGHTS in CHN Concepts

CHN is based on the recognized needs of communities, families,

groups, ands individuals.

•CHN is a unique blend of nursing and public health practice, and is oftentimes used interchangeably

with the term “Public Health Nursing”. 04/11/23 29

Philosophy of Public HealthHealth and longevity as birthrights

Longevity – average lifespan or life expectancy• 50 years – Swaroop’s Index• Untimely death – person died without reaching

the average lifespan

Combined (M/F) – 69.6 y/o Male – 66.74 y/o Female – 72.61 y/o

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Objectives of Public Health

3 P’s:

Promote health

Prevent Disease

Prolong Life

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Basic Public Health Services

• Environmental Sanitation• Health Education• Prevention of Communicable Diseases• Medical Services• Nursing Services• Vital Statistics• Public Health Laboratories• Maternal and Child Health Services

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Basic Competencies Needed by the Public Health Nurse

• Teaching

• Management

• Critical Thinking

• Physical Caregiving

• Application of the Nursing Process

• Application of the Epidemiological Process

• Documentation04/11/23 33

Functions of the PHN

Manager> Planner, Programmer, Supervisor, Coordinator of services

Health Care Provider> Direct nursing care

Researcher> Epidemiologist, Health Monitor, Recorder, Statistician

Community Organizer> Change Agent

Trainer> Health Educator, Counselor

Role Model

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In the care of the families:

Provision of primary health care services Developmental/Utilization of family

nursing care plan in the provision of care

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In the care of the communities: • Community organizing mobilization, community development

and people empowerment

• Case finding and epidemiological investigation

• Program planning, implementation and evaluation

• Influencing executive and legislative individuals or bodies concerning health and development

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Responsibilities of CHN:

– be a part in developing an overall health plan, its implementation and evaluation for communities

– provide quality nursing services to the three levels of clientele, the standards ser for CHN practice

– maintain coordination/linkages with other health team members, NGO/government agencies in the provision of public health services

– conduct researches relevant to CHN services to improve provision of health care

– provide opportunities for professional growth and continuing education for personal growth thru staff development

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CHN Process

1.Establishing a working relationship with the client• Initiating contact• Communicating interest in the

client’s welfare• Showing willingness to help with

expressed need of the client• Maintaining a two-way

communication with the client04/11/23 38

CHN Process

2. Assessment of needs, taking into consideration personal, environmental and psycho-socio- cultural factors influencing health

• Situation and trends revealed in personal, socio- economic and environmental history

• Physical, emotional, intellectual ability to perform a function

• Attitudes, knowledge and perceptions of health and illness

• Health behavior and patterns of health care• Resources available to meet own needs• Other factors affecting health

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A. Collection of DataA. Community

Demographic data Vital statistics Community Dynamics Disease surveillance Economic, cultural , and environmental characteristics Health service utilization

B. Family and Individual- Health status/ education

- Socio-cultural factors- Occupation- Family dynamics- Environment- Patterns of coping

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B. Categories of Health ProblemA. Wellness State

B. Health Deficit

C. Health Threat

D. Foreseeable Crisis

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CHN Process

3. Planning of care

• Summarizing problems and needs

• Establishing priorities of care• Setting objectives of care• Determining approaches or

strategies to meet identified objectives04/11/23 42

CHN Process

4. Implementation of care

• Actual delivery of care• Institution of planned

interventions• Application of coordination,

supervision, social mobilization, health education,

therapeutic communication04/11/23 43

CHN Process

5. Evaluation of care

• Monitoring of status• Systematic documentation of

results• Analysis of effectiveness of

care provided(Structural elements, Process

Elements, and Outcome elements)04/11/23 44

Levels of Clientele

Individual • Basic approaches in

looking at the individual:

 – Atomistic

 – Holistic

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Family 

Models:

Developmental Stages of Family Development Stage 1 – The Beginning Family  Stage 2 – The Early Child-bearing Family  Stage 3 – The Family with Preschool Children 

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Stage 4 – The Family with School Age Children

 

Stage 5 – The Family with Teen-agers

 

 Stage 6 – The Family as Launching Center

 

Stage 7 – The Middle-aged Family

 

Stage 8 – The Aging Family 

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Structural-Functional

Initial Data Base

Family structure and Characteristics

Socio-economic and Cultural Factors

Environmental Factors

Health Assessment of Each Member

Value Placed on Prevention of Disease

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First Level Assessment

Health threats:conditions that are conducive to disease, accident or failure to realize

one’s health potential Health deficits: instances of failure in health maintenance (disease, disability,

developmental lag) Stress points/ Foreseeable crisis situation:anticipated periods of unusual demand on the individual or family in

terms of adjustment or family resources

Wellness State/ Potential 

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Second Level Assessment: 

• Recognition of the problem

• Decision on appropriate health action

• Care to affected family member

• Provision of healthy home environment

• Utilization of community resources for health care

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Problem Prioritization:

Nature of the problemWellness StateHealth deficitHealth threatForeseeable Crisis

Preventive potentialHighModerateLow

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• Modifiability

Easily modifiable

Partially modifiable

Not modifiable

• Salience

High

Moderate

Low

*Family Service and Progress Record04/11/23 52

Population Group

• Vulnerable Groups:

 

Infants and Young Children

School age

Adolescents

Mothers

Males

Old People04/11/23 53

CHN Process

Community Diagnosis

• Determining the health status of the populations in the community as

well as the factors that directly or indirectly affect their health status

• It is an integral part of the assessment phase of the CHN Process

• It is also known as community assessment or situational analysis04/11/23 54

• A process by which the people in the community and the health team assess the community’s health problems and needs as bases for health program development.

• A learning process for the community to identify their own health problems and needs.

• A profile that depicts the health problems and potentials of the community.

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2 types of Community Diagnosis:

1.Comprehensive- provides general health profile of the community

2.Specific or Problem-Oriented- yields a comprehensive profile of a particular health problem

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STEPS:Preparatory Phase 

1. site selection2. preparation of the community3. statement of the objectives4. determine the data to be collected5. identify methods and instruments for data

collection6. finalize sampling design and methods7. make a timetable

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Implementation Phase

1. data collection

2. data organization/collation

3. data presentation

4. data analysis

5. identification of health problems

6. prioritization of health problems

7. development of a health plan

8. validation and feedback

Evaluation Phase04/11/23 58

CHN Process

Parts of Community Diagnosis:

A. Demographic Variables

• Total population and population density

• Age and sex composition, Population Pyramid

• Sex Ratio

• Civil Status

• Population movement/patterns of migration

• Growth Rate, Life Expectancy

• Crude Birth Rate, Crude Death Rate04/11/23 59

CHN Process

Parts of Community Diagnosis:

B. Social Indicators

• Literacy Rate

• Educational attainment

• Communication network

• Transportation system

• Housing conditions (types, ownership, lighting, ventilation, crowding/congestion)04/11/23 60

CHN Process

Parts of Community Diagnosis:

C. Economic Indicators• Dependency Ratio

• Occupation

• Income

• Poverty index

• Unemployment Rate

• Underemployment Rate

• Types of industry present in the community04/11/23 61

CHN Process

Parts of Community Diagnosis:

D. Cultural Factors

• Ethnicity

• Race

• Language

• Religion

• Beliefs (superstitions and traditions)

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CHN Process

Parts of Community Diagnosis:

E. Environmental Indicators

• Topographical characteristics

• Water supply

• Garbage disposal/collection system

• Excreta disposal

• General sanitary condition

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CHN Process

Parts of Community Diagnosis:

F. Health Patterns• Food storage

• Infant feeding practice

• Immunization status

• Health seeking behavior

• Source of health information

• Leading causes of mortality, morbidity, infant mortality, infant morbidity, maternal mortality04/11/23 64

CHN Process

Parts of Community Diagnosis:

G. Health Resources• manpower-population ratio

• manpower distribution

• manpower policies

• health budget and policies

• sources of health funding

• categories of health institutions available

• categories of health services available04/11/23 65

CHN Process

Parts of Community Diagnosis:

H. Political and Leadership Patterns• Power structures in the community

• Confidence of people to authority

• Conditions that cause developmental conflicts

• Prevailing issues

• Practices that are usually utilized in settling concerns of the community

• Stakeholder Analysis04/11/23 66

CHN ProcessSteps in Conducting Community Diagnosis:

1. Determining the objectives

2. Defining the study population

3. Determining the data to be collected

4. Developing an instrument

• survey questionnaire

• interview schedule

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CHN ProcessSteps in Conducting Community Diagnosis:

5. Data gathering

• Records review

• Observation

• Surveys

• Interviews

6. Data collation04/11/23 68

CHN Process

Steps in Conducting Community Diagnosis:

7. Data presentation

8. Data analysis

9. Identification of CHN Problems

• Health status

• Health resources

• Health-related04/11/23 69

CHN Process

Steps in Conducting Community Diagnosis:

10. Prioritization of CHN Problems

• Nature

• Magnitude

• Modifiability

• Preventive potential

• Social concern 04/11/23 70

Biostatistics

A. Demography

A study of population size, composition, and spatial distribution as affected by births, deaths, and migration

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SOURCES OF DEMOGRAPHIC DATA:

1.Survey1. Census- De jure or De facto

2. Sample Survey

2.Continuing Population Registers

3.Other Records and Registration Systems

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COMPONENTS:Population Size

1. Natural increase2. Net migration3. Rate of natural increase

Population Composition1. Age Distribution2. Median Age3. Dependency Ratio4. Sex Ratio5. Population Pyramid6. Others: occupational groups, economic groups,

educational attainment, and ethnic groups

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Population Distribution1. Urban-Rural

• Shows the proportion of people living in urban compared to the rural areas

2. Crowding Index• Indicates the ease by which a communicable

disease can be transmitted from 1 host to another susceptible host

3. Population Density• Determines the congestion of the place

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B. VITAL STATISTICS The application of statistical measures to vital

events (births, deaths and common illnesses) that is utilized to gauge the levels of health, illness and health services of a community.

• Fertility Rate

– Crude Birth Rate– General Fertility Rate

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Mortality RatesCrude Death RateSpecific Mortality RateInfant Mortality RateNeonatal Mortality RatePost-neonatal Mortality RateMaternal Mortality RateProportionate Mortality RateSwaroop’s IndexCase Fatality RateCause-of- Death Rate

Morbidity RatePrevalence Incidence Rate

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C. EPIDEMIOLOGY

– The study of distribution of disease or physiologic condition among human population s and the factors affecting such distribution

– The study of the occurrence and distribution of health conditions such as disease, death, deformities or disabilities on human populations

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Basic Concepts:

– Epidemiologic Triad

– Transmission

– Incubation period

– Herd immunity

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Factors affecting distribution:

• PERSON– intrinsic characteristics

• PLACE– extrinsic factors

• TIME– temporal patterns

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Patterns of Disease Occurrence:• Epidemic

– a situation when there is a high incidence of new cases of a specific disease in excess of the expected.

– when the proportion of the susceptible are high compared to the proportion of the immunes

• Epidemic potential – an area becomes vulnerable to a disease upsurge due to causal

factors such as climatic changes, ecologic changes, or socio-economic changes

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• Endemic – habitual presence of a disease in a given geographic location

accounting for the low number of both immunes and susceptible

e.g. Malaria is a disease endemic at Palawan. – the causative factor of the disease is constantly available or

present to the area.

• Sporadic – disease occurs every now and then affecting only a small

number of people relative to the total population– intermittent

• Pandemic – global occurrence of a disease

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THE NATIONAL HEALTH SITUATION

Health Care Delivery System

Health Care Delivery System is

“the totality of all policies, facilities, equipments, products, human resources and services which address the health needs, problems and concerns of the people. It is large, complex, multi-level and multi-disciplinary.”

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According to Increasing Complexity of the Services

Provided

According to the Type of Service

Type Service Type ExamplePrimary Health Promotion,

Preventive Care, Continuing Care for common health problems, attention to psychological and social care, referrals

Health Promotion and illness Prevention

Information Dissemination

Secondary

Surgery, Medical services by Specialists

Diagnosis and Treatment

Screening

Tertiary Advanced, specialized, diagnostic, therapeutic & rehabilitative care

Rehabilitation

PT/OT

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The Healt

h Secto

r

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The Health Sector

Department of HealthVision: Leader and staunch advocate and model in promoting Health for ALL in the Philippines

Mission: Guarantee equitable, sustainable, and quality health for all Filipinos, specially the poor and shall lead the quest for excellence in health

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3 Major Functions:

1. LEADERSHIP in healthNational policy – formulation, monitoring and evaluationRegulatory institutionAdvocates adoption of health policies, plans and programs

2. Enabler and Capacity BuilderInnovate new strategies to improve health programsExercise oversight functionEnsure highest achievable standards

3. Administrator of Specific ServicesManage selected national health facilities and hospitalsAdminister direct services for emergent health concernsAdminister health emergency response services

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DOH ProgramsD – ental Health

O – perations for Environmental Sanitation

H – ealth Education and Community Organizing

P – revention and Control of Communicable Diseases

R – eproductive Health

O – lder Persons Health Services

G – uidelines for Nutrition

R – ehabilitation and Management of Non-communicable Dse.

A – lternative Health Care Practices (HerbalMeds/Acupressure)

M – aternal and Child Health and IMCI

S – entrong Sigla Movement

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Local Government Units (LGU)

RA 7160 Local Government Code

Private Sector

Composed of both commercial and business organizations, non-business organizations

Non-Government Organizations

Assumes the following roles:Policy and Legislative AdvocatesOrganizers, Human Rights AdvocatesResearch and DocumentationHealth Resource Development PersonnelRelief and Disaster ManagementNetworking

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PRIMARY LEVELHealth Promotion and

Illness Prevention

SECONDARY LEVELPrevention of

Complications thru Early Dx and Tx

TERTIARY LEVELPrevention of Disability, etc.

Provided at –► Health care/RHU► Brgy. Health Stations►Main Health Center►Community Hospital and Health Center►Private and Semi-private agencies

► When hospitalization is deemed necessary and referral is made to emergency (now district), provincial or regional or private hospitals

► When highly-specialized medical care is necessary► Referrals are made to hospitals and medical center such as PGH, PHC, POC, National Center for Mental Health, and other gov’t private hospitals at the municipal level

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Primary Health Care

WHO: PHC was declared in the ALMA ATA CONFERENCE(USSR) in September 6-12, 1978, as a strategy to community health development.

Philippines: Adopted through LOI 949 signed by President Marcos on October 19, 1979 with the theme-

“Health in The Hands of the People by 2020”

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Primary Health Care

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Framework

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How can PHC be possible?Control of Communicable Diseases

Offers Health Education

Maternal and Child Care

Provision of Medical Care and Emergency Treatment

Offers “Immunization”

Nutrition and Food Supply

Environmental Sanitation

N “Family Planning”

Treatment of Locally Endemic Diseases

Supply and Proper Use of Essential Drugs

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COMM.

PARTIPATION

SECTORAL

LINKAGES

PROPER

TECHNOLOGY

SUPPORT

MECHANISM

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PILLARS

A. Multi-sectoral approachIntersectoral linkages (population control,

private sectors, social welfare, public service, enrironmental, etc.)

Intrasectoral linkages (people’s empowerment; within own system)

B. Community Participation

e.g. Community Organizing04/11/23 95

C. Appropriate Technology

- method used to provide a socially and environmentally acceptable

level of service or quality product at the least economic cost.

Criteria:

Safe

Acceptable

Feasible

Effective

Scope-wise

Affordable

Complex

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10 Medicinal Plants:

Bawang-anti cholesterol

Ulasimang-Bato-lowers uric acid

Bayabas- antiseptic; diarrhea

Lagundi-cough, asthma, and colds

Yerba Buena- toothache, pain, and arthritis

Sambong- renal calculi

Ampalaya- diabetes mellitus

Niyog-niyogan- anti-helminthic

Tsaang-Gubat- diarrhea

Akapulko- fungal infection RA 8423: utilization of medicinal plants as

alternative for high cost medications04/11/23 97

D. Support mechanism made available

Village/Grassroots Health Workers

Intermediate Level Health Personnel of First-Line Hospitals

Trained CommunityHealth worker; health auxiliary volunteer; Traditional Birth Attendant

General Medical PractitionersPublic Health NursesMidwives

Physicians withspecialty areaNursesDentists

TYPES OF PRIMARY HEALTH WORKERS

Initial link, 1st contact of the community

1st source of professional healthcare

Establish close contact with the village and

intermediate level HW04/11/23 98

D – ental Health

O – perations for Environmental Sanitation

H – ealth Education and Community Organizing

P – revention and Control of Communicable Diseases

R – eproductive Health

O – lder Persons Health Services

G – uidelines for Nutrition

R – ehabilitation and Management of Non-communicable Dse.

A – lternative Health Care Practices (Herbal Meds/Acupressure)

M – aternal and Child Health and IMCI

S – entrong Sigla Movement

Strategies and Programs:

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Reproductive Health• Exercise of reproductive right & responsibility

• Vision: RH practice as a way of life for every man and woman throughout life

•Goals: 4 E’s

> Every pregnancy should be intended

> Every birth should be healthy

> Every sex act should be free of coercion

> Every family should achieve its desired size

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