The Health Care Process

8/13/2019 The Health Care Process

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THE HEALTH CARE PROCESS

OBJECTIVES

Upon completion of this module, you should be able to:

1. Define the health care process in his own words.2. Explain at least 4 principles of the health care process.

3. Enumerate the stepsprocedures in!ol!e in assessment.

4. Discuss the components of a comprehensi!e health history.". Demonstrate the be#innin# s$ills in conductin# physical assessment.

%. &dentify common si#ns and symptoms indicati!e of physiolo#ical

alteration.'. Differentiate health problems based on #i!en criteria.

(. Demonstrate the ability to prioriti)e health concerns implied in a

situation.

RECOMMENDED PREPARATION

*his module is intended for +e!el && nursin# students ta$in# up rimary -ealth are 1./.

this can also ser!e as a re!iew for the health professionals.

I.THE HEALTH CARE PROCESS

Definition

&t is a systematic, lo#ical method of plannin# and pro!idin# indi!iduali)ednursin# care.

Goals

1. identify a client0s health status

2. identify actual or potential health care problems

3. establish plans to meet the identified needs4. deli!er specific nursin# inter!entions to meet these needs.

Five components of the nursing process:

1. ssessin#

2. Dia#nosin#

3. lannin#4. &mplementin#

". E!aluatin#Steps and procedures involve in assessment


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ursin# assessment is the first maor phase of the nursin# or health care process. &f

we apply this to the family health nursin# process, this in!ol!es a set of actions li$e

the followin#:

the nurse measures the status of the family as a client

its ability to maintain itself as a system and functionin# unit

its ability to pre!ent , control or resol!e problems in order to achie!e healthand wellbein# amon# the members

data amon# the present condition or status of the family are compared

a#ainst norms or standards of personal and social health 5theses norms ofstandards are derived from values, beliefs, principles, rules, or expectations

of the family)

the family0s inte#rity and ability to resol!e health problemsNursing assessment includes:

1. data collection

2. data analysis or interpretation3. problem definition or nursin#

dia#nosis 5this is the end result of two major types of nursingassessment in family nursing practice)

Two major types of nursing assessment

1. first-level assessment it is the process whereby existin# andpotential health conditions or problems of

the family are determined. nd these health

conditions are cate#ori)ed as6a. wellness states

b. health threats

c. health deficitsd. stress points or foreseeable crisis

this le!el explains the depth of data #atherin# and analysis on what health

conditions or problems exist and why each health condition or problem related

with maintainin# wellness exists.

2. Second level assessment - definesthe nature or type of nursin#

problems that the family encounters inperformin# the health tas$s with

respect to a #i!en health condition or

problem

this le!el explains the reason about the family0s problems related to maintainin#wellness andor pro!ide a home en!ironment conducti!e to health maintenance

and personal de!elopment.

Note: Assessment to individual families and individual clients varies.

However, let us focus ourselves on assessment to individual

clients.


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Steps in assessment

1. collection of data

2. or#ani)in# of data3. !alidation of data

4. recordin# data about the client0s health status to establish a database

Activities in assessment include:

1. obtainin# a health history

2. performin# a physical assessment3. re!iewin# client records

4. re!iewin# literature

". consultin# support people and health professionals

PHYSICAL HEALTH EXAMINATION

&t is conducted startin# from the head and mo!in# toward the toes6 howe!er, the

procedure can !ary in many ways, howe!er, re#ardless what procedure is used, theclient0s ener#y and time must be considered. *he physical assessment is therefore done

in a systematic and efficient manner that re7uires the fewest position chan#es for the

client.

a#e of the indi!idual

se!erity of the illness

the preference of the nurse

the a#ency0s priorities and procedures-ealth assessment are done in relation to the followin#

1. client complaints

2. the nurse0s own obser!ation of the problem

3. the client0s presentin# problem4. nursin# inter!entions pro!ided

". medical therapies

ote: &t is important that durin# the health assessment , the nurse pro!ides continuous

communication and often as$ 7uestions. *hese

techni7ues put the client at ease and #i!es the nurse !aluable subecti!e information.

Steps in health assessment

1. preparin# the client explain the procedure

when and where the examination will ta$e place

why is it necessary

who will conduct it

what will happen durin# the examination

Note: he actual health assessment procedure has been discussed


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earlier in !rimary Health "are #.#.

THE NURSING HEALTH HISTORY

*he nursin# health history inter!iew is the first part of the assessment of the client0s

health status and is usually carried out before the physical examination . *his is astructured inter!iew desi#ned to collect specific health data and to obtain a detailed

health record of the client. &ts purposes are:

to elicit information about all the !ariables that may affect the client0s health

status

to obtain data that help the nurse understand and appreciate the client0s lifeexpectations

to initiate a nonud#mental, trustin# interpersonal relationship with the clientData obtained are then used in collaboration with the client to de!elop nursin# dia#noses

and subse7uent plans for indi!iduali)ed care. 8$ill in inter!iewin# is essential when

obtainin# a health history. &t includes the followin#6

1. biographic data9 name, address, a#e, sex, race, marital status, occupation , reli#ion,

orientation, health care financin#, and usual source of medical care.

2. chief complaint or reason for visit

3. history of present illness

4. past history

5. family history of illness

6. review of systems

7. lifestyle

. social data5family relationshipfriendship, ethnic affiliation, educational history,

occupational history, economic status, home and nei#hborhood conditions

!. psycho logic data5maor stressors, usual copin# patterns, communication style, selfconcept, mood

"#. patterns of health care

$ommon signs and symptoms

1. cou#h2. fe!er

3. abdominal pain

4. diarrhea

CLASSIFICATION OF HEALTH PROBLEMS

. resence of -ealth *hreats

conditions that are conducti!e to disease, accident or failure top reali)eone0s health potential.

Examples of these are the followin#61. ;amily history of hereditary conditiondisease 5diabetes

2. *hreat of cross infection from a communicable disease case.


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3. ;amily si)e beyond what family resources can ade7uately pro!ide.

4. ccident ha)ards

". faultyunhealthful nutritionaleatin# habits or feedin#techni7uespractices

%. stresspro!o$in# factors

'. poor homeen!ironmental conditionsanitation(. unsanitary food handlin# and preparation


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Aa#laya, raceli. ursin# ractice in the ommunity 3rd ed.

r#onauta orporation. 2//3

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The Health Care Process