Community-Based Community-Based Nursing PracticeNursing Practice

Community-Based NursingCommunity-Based Nursing

Focused on individual and family Focused on individual and family health needshealth needs

Moving from traditional settings to Moving from traditional settings to community/neighborhood locationscommunity/neighborhood locations

Integrated system of health care Integrated system of health care including institutions, providers, including institutions, providers, agencies, policies, payment plans, agencies, policies, payment plans, families and of course patients families and of course patients

Community-Based NursingCommunity-Based Nursing

Provides health services where Provides health services where people spend their timepeople spend their time

Traditionally such as: home (home Traditionally such as: home (home care nursing), work (occupational care nursing), work (occupational nursing), school (school nurse)nursing), school (school nurse)

Community-Based Community-Based ServicesServices

Evolved to include Evolved to include various settingsvarious settingsSenior centersSenior centersDay care centersDay care centersStorefront clinicsStorefront clinicsHomeless sheltersHomeless sheltersMental health Mental health centerscenters

Drug rehab Drug rehab programsprograms

Ambulatory care Ambulatory care centerscenters

Outreach centersOutreach centers

Institution-based Institution-based centerscenters

Parish nursingParish nursing

HospitalsHospitals

Vulnerable PopulationsVulnerable Populations

ImmigrantsImmigrants

Poor/Homeless personsPoor/Homeless persons

Abused clientsAbused clients

Substance abusersSubstance abusers

Severely mentally ill personsSeverely mentally ill persons

Older adultsOlder adults

Developmental AssessmentDevelopmental Assessment

Four stepsFour steps::1.1. Determine family’s developmental stageDetermine family’s developmental stage

2.2. Consider family member’s health problems in Consider family member’s health problems in context of tasks of their developmental stagecontext of tasks of their developmental stage

3.3. Determine if family members are meeting the Determine if family members are meeting the tasks at their tasks at their individual levels of developmentindividual levels of development

4.4. Identify nursing interventions that would Identify nursing interventions that would facilitate family meeting their developmental facilitate family meeting their developmental taskstasks

Limitations of the Developmental Limitations of the Developmental Assessment ApproachAssessment Approach

Changing demographicsChanging demographics, variations in family structures , variations in family structures (not all families fit neatly into stages)(not all families fit neatly into stages)

Nurse’s viewpoint has to take structure into account, Nurse’s viewpoint has to take structure into account, thus, assessment becomes more thus, assessment becomes more complicatedcomplicated

Family conflictsFamily conflicts cause difficulty, compounded by cause difficulty, compounded by individuals’ role disruption from illnessindividuals’ role disruption from illness

Structural Family AssessmentStructural Family Assessment

Considers composition of familyConsiders composition of family

Can be very helpful to nurse in many situationsCan be very helpful to nurse in many situations

May be a good assessment to start withMay be a good assessment to start with

Functional Family AssessmentFunctional Family Assessment

Six family functions:Six family functions:

1.1. AffectiveAffective

2.2. Healthcare and physical necessitiesHealthcare and physical necessities

3.3. EconomicsEconomics

4.4. ReproductionReproduction

5.5. Socialization and placementSocialization and placement

6.6. Family copingFamily coping

Nursing ProcessNursing Process

The purpose of writing a The purpose of writing a family nursing diagnosisfamily nursing diagnosis is is to help the family promote health through the life cycle to help the family promote health through the life cycle and prevent disease through low-risk-taking behaviorsand prevent disease through low-risk-taking behaviors

In planning phase, delineate expected outcomes for In planning phase, delineate expected outcomes for family health; Use family health; Use mutual goal-settingmutual goal-setting with family with family

Process of collaborative goal-setting should have Process of collaborative goal-setting should have positive influence on nurse’s interactions with familiespositive influence on nurse’s interactions with families

Also facilitates adherence to agreed-upon plan of careAlso facilitates adherence to agreed-upon plan of care

Remember: Assessment is a two-way enterprise; the Remember: Assessment is a two-way enterprise; the family is assessing you, as wellfamily is assessing you, as well

Examples of Family Nursing Examples of Family Nursing DiagnosisDiagnosis

TheoreticalTheoretical ModelModel

StageStage HealthHealth StatusStatus

PatternPattern ProblemProblem

DevelopmentalDevelopmentalFamily withFamily withPreschoolersPreschoolers

Potential forPotential forphysical injuryphysical injury

Health-Health-Perception-Perception-HealthHealthManagementManagement

Medications &Medications &poisonous poisonous cleaningcleaningsubstances substances within reach of within reach of childrenchildren

Family withFamily withadolescentsadolescents

PotentialPotentialalteration inalteration inparentingparenting

Roles-Roles-relationshipsrelationshipspatternpattern

Value systems Value systems ofofParents & Parents & adolescent adolescent members in members in conflictconflict

Risk FactorsRisk Factors Young coupleYoung couple Compromised &Compromised &ineffectiveineffective

Coping-Coping-stress-stress-tolerance tolerance patternpattern

Teenage Teenage marriagemarriagePregnancy Pregnancy before age 16before age 16

From: C. Edelman & C. Mandle (2002) Health promotion throughout the lifespan. St. Louis: Mosby.

Steps in the Planning ProcessSteps in the Planning Process

1.1. Prioritize problems & potential problemsPrioritize problems & potential problems

2.2. Determine which items can be handled by the nurse Determine which items can be handled by the nurse and the family, and items that must be referred to and the family, and items that must be referred to othersothers

3.3. Decide on actions and expected outcomesDecide on actions and expected outcomes

GoalsGoals

Goals describe a desired outcomeGoals describe a desired outcome

Goal statements include:Goal statements include:– The expected behaviors of the familyThe expected behaviors of the family– The circumstances under which the behaviors will be The circumstances under which the behaviors will be

demonstrateddemonstrated– Criteria by which to determine when and how the Criteria by which to determine when and how the

behaviors will be performedbehaviors will be performed

Health promotion goals reflect a desire to function Health promotion goals reflect a desire to function at a higher level of health and to grow beyond at a higher level of health and to grow beyond maintaining health or preventing diseasemaintaining health or preventing disease

Implementation With The FamilyImplementation With The Family

Family nursing interventionsFamily nursing interventions aim to assist family aim to assist family members in carrying out functions that the members members in carrying out functions that the members cannot perform for themselvescannot perform for themselves– Health promotion: Health promotion: the nurse assists the family in the nurse assists the family in

improving their capacity to act on its own behalfimproving their capacity to act on its own behalf

Three Broad Categories of Interventions with Three Broad Categories of Interventions with FamiliesFamilies– Cognitive interventionsCognitive interventions– Affective interventionsAffective interventions– Behavioral interventionsBehavioral interventions

Four Types of Interventions are Four Types of Interventions are Found in Health Found in Health

Promotion/Disease PreventionPromotion/Disease Prevention

Increasing knowledge and skillsIncreasing knowledge and skills

Increasing strengthsIncreasing strengths

Decreasing ExposureDecreasing Exposure

Decreasing susceptibilityDecreasing susceptibility

Evaluation With The FamilyEvaluation With The Family

Purpose of evaluation is to determine how the family has Purpose of evaluation is to determine how the family has responded to the planned interventions. Concrete objectives are responded to the planned interventions. Concrete objectives are easier to measureeasier to measure

Family’s baseline data needs to be used as comparative criteria Family’s baseline data needs to be used as comparative criteria in evaluationin evaluation

Five measures of family functioning that can be used to Five measures of family functioning that can be used to determine effectiveness of interventionsdetermine effectiveness of interventions

1.1. Changes in interaction patternsChanges in interaction patterns2.2. Effective communicationEffective communication3.3. Ability to express emotionAbility to express emotion4.4. Responsiveness to needs of members as individualsResponsiveness to needs of members as individuals5.5. Problem-solving abilityProblem-solving ability

If goals are not met, review processIf goals are not met, review process

Health Promotion/Prevention Health Promotion/Prevention Strategies as Applied to the FamilyStrategies as Applied to the Family

Primary PreventionPrimary Prevention Completing a family genogram and assessing health risks Completing a family genogram and assessing health risks

with the family to contract for family health activities to with the family to contract for family health activities to prevent diseases from developingprevent diseases from developing

Secondary PreventionSecondary Prevention Using a behavioral health risk survey and identifying the Using a behavioral health risk survey and identifying the

factors leading to obesity in the familyfactors leading to obesity in the family

Tertiary PreventionTertiary Prevention Developing a contract with the family to change nutritional Developing a contract with the family to change nutritional

patterns to reduce further complications from obesitypatterns to reduce further complications from obesity

Three Levels of PreventionThree Levels of Prevention

Adults age 65 and over who ever received Adults age 65 and over who ever received pneumococcal vaccination, 1999-2006pneumococcal vaccination, 1999-2006

Source:Source: Centers for Disease Control and Prevention, National Center for Centers for Disease Control and Prevention, National Center for

Health Statistics, National Health Interview Survey, 1999-2006Health Statistics, National Health Interview Survey, 1999-2006. .

Components of a Community Components of a Community AssessmentAssessment

Community:Community: an entity made up of people, a place, and an entity made up of people, a place, and social systemssocial systems

The characteristics of a The characteristics of a “healthy community”“healthy community” can be can be used to assess a community’s healthused to assess a community’s health

Community assessment is a Community assessment is a problem-solving processproblem-solving process similar to the nursing processsimilar to the nursing process

Community AssessmentCommunity Assessment

Community-based vs community-oriented Community-based vs community-oriented nursingnursing

All three dimensions of community are assessed:All three dimensions of community are assessed:– The peopleThe people– The placeThe place– The social systemsThe social systems

Community assessments vary in scope and Community assessments vary in scope and complexity; nurse’s role depends on nurse’s complexity; nurse’s role depends on nurse’s educational preparation and expertiseeducational preparation and expertise

PeoplePeople

Demographic characteristics: Demographic characteristics: number, number, composition by age, rate of growth and decline, composition by age, rate of growth and decline, social class and mobility of people in the social class and mobility of people in the communitycommunity

Other vital statistics: Other vital statistics: birth rate, overall death birth rate, overall death rate, death rate by cause and age, and rate, death rate by cause and age, and infant infant mortality ratemortality rate• Infant mortalityInfant mortality rate rate is considered to be the is considered to be the

most important statistical indicator of maternal-most important statistical indicator of maternal-infant health in the communityinfant health in the community

PlacePlace

Where Where the community is located and its boundariesthe community is located and its boundaries

Type Type of community (e.g., rural or urban)of community (e.g., rural or urban)

Location of health servicesLocation of health services

Climate: Climate: flora, fauna & topographyflora, fauna & topography

Social SystemsSocial Systems

EconomicEconomic

EducationalEducational

ReligiousReligious

PoliticalPolitical

LegalLegal

Human servicesHuman services

RecreationRecreation

CommunicationCommunication

systemssystems

Epidemiology:Epidemiology:

““The study of the distribution and determinants of health-The study of the distribution and determinants of health-related states or events in specified populations, and the related states or events in specified populations, and the application of this study to control of health problems”application of this study to control of health problems”

Descriptive Epidemiology:Descriptive Epidemiology:

Study of the distribution of disease and other health-Study of the distribution of disease and other health-related states in terms of:related states in terms of:

– personal characteristics personal characteristics (person)(person)

– geographical distribution geographical distribution (place)(place)

– temporal patterns temporal patterns (time)(time)

Analytic epidemiology:Analytic epidemiology:

Studies the origins and causal factors of disease and Studies the origins and causal factors of disease and other health-related states and eventsother health-related states and events

The Epidemiologic TriangleThe Epidemiologic Triangle

Represents complex Represents complex relationships among:relationships among:

– causal agentscausal agents

– susceptible personssusceptible persons

– environmental environmental factorsfactors

Stages of Health and PreventionStages of Health and Prevention

SusceptibilitySusceptibility Primary Primary

preventionprevention

AsymptomaticAsymptomatic Secondary Secondary

diseasedisease prevention prevention

ClinicalClinical Tertiary Tertiary

manifestationsmanifestations prevention prevention