Health care process

scientific and systematized approach to health to care for individuals,

families, and community for health promotions and illness prevention.
I.
Individual level
- A. assessment
- The collection, verification,and documentation of subjective and objective
data about the clients health status.
- ( subjective data: from the clients point of view. Objective data: can be
detected, observed or measure/tested using accepted standard or norm.)
- Involves active participation of clients.
- A systematic observation is essential.
- Assessment include :
o Observation
o Interviewing
o Organizing data
o Validating data
o Documenting data
B. Health problems
-also called diagnosis.
- The process of identifying clients problems and abnormality which he
suffering.
Methods in identifying health problems
-

Analysing data
Identifying problems, risk, and strengths
Formulating diagnostic statements.

c. Health care strategies

- hygiene and comfort measure
-

Interventions to promote/improve nutritional status.

Spiritual care
Exercise, rest and sleep
Alternative medicine
Intervention for common signs and symptoms
D. evaluation
- is a feedback mechanism for judging the reality of the care given.
- evaluation of the patients progress indicates what problems of the patient
have been solved, which need to assessed again, replanted, implemented
and re evaluated.
II. Family level

a. Assessment

Observation of the patient.

Interview of the patient and family.
Examination of the patient
Review of the medical record.

Two level of assessment

first level assessment - Process whereby existing and potential health

conditions or problems of the family are determined.
- categories of health conditions/problems
-wellness states
health threats
health deficits
health points or foreseeable crisis situation

second level assessment the nature or type of problems that the family
encounters in performing the health tasks with respect to a given health
condition or problem and the etiology or barriers to the family assumption of the
tasks.
Assessments includes:
-

Data collection
Data validation
Organization of data
Analyzing of data
Recording/documentation of data

Data collection
a. Family structure, characteristics and dynamics
Include the composition and demographic data of the members the
family/household, their relationship to the head and place of residence , the
type of family, and family interaction/communication and decision making
patterns and dynamics.
b. Socio-economic and cultural characteristics
Include the occupation, place of work and income of each working member:
educational attainment of each of family member: ethnic background and
religious affliation; significant others and the others role(s) they play in the
family life; and the relationship of the family to the larger community.
c. Home and environment
Include information on housing and sanitation facilities king of neighbourhood
and availability of social health, communication and transportation facilities
in the community.
d. Record review
Reviewing existing records and reports pertinent to the client (individual,
clinical records of the family members: laboratory and diagnostic reports;
immunization records: report about the home and environmental conditions.
e. Laboratory/diagnostic test

Performing laboratory tests. Diagnostic procedures or other test s of integrityt

and functions carried out by the burse herself and/or other health workers.

Methods of data collection

Interview
A planned, purposeful conversation/communication with the client to get
information, identity problems, evaluate change, to teach or to provide
support or counselling .
It is used while taking the history of a client.
Observation
Use to gather data by using the 5 senses and instruments.
Examinations
Systematic data collection to detect health problems using unit of
measurements, physical examination techniques , interpretation of
laboratory results.
Validation of data

The act of double checking or verifying data to confirm that it is accurate and
complete.
Purposes of data validation :
Ensure that data collection is complete
Ensure that objective and subjective data agree.
Obtain additional data that may have been over looked
Avoid jumping to conclusion
differentiate cues and inference
(cues: subjective or objective data observed by the nurse: what the client
says or what the nurse can see, hear, feel, smell, or measure. Interference:
the nurse interpretation or conclusion based on the cues.)

Organization of data
Uses a written or computerized format that organizes assessment data
systematically.
Example;
-

Maslows basic needs

Body system model
Gordons functional health patterns

Analyse data
Compare data against standard and identify significant cues.

Record/document data
-health workers records all data collected about the clients health status.
- data are recorded in a factual manner not as interpreted by the nurse
-record subjective data in clients word restating in other words what client says
might change its original meaning.

Diagnosis
To identify the family needs to stat the family conditions
Diagnosis activities includes:
-

Organizing data
Compare data against standard (normal structure functions )
Group data
Identify gaps and inconsistencies
Determine familys weaknesses, strengths, risks, and problems.
Formulate statement of health conditions.

Family health problems

A wellness condition is a judgement related with the family clients capability for
wellness.
A health condition or problem is a situation which interferes with the promotion
and/or maintenance of health and recovery from illness or injury.
The familys failure to perform adequately specific health tasks to enhance the
wellness state or manage the health problem.
Major health problems
1. Presence of wellness conditions.
-stated as potential readiness.
2. Inability to make decisions with respect to taking appropriate health action.
3. Inability to provide adequate health care provider to the sick, disabled
dependent or vulnerable/ at risk member of the family.
4. Inability to provide a home environment conducive to health maintenance
and personal development.
5. Failure to utilize community resources for health care.

Health care strategies

-

Assessment
Diagnosis
Planning
Intervention/implementation
Evaluation

Evaluation
- To appraise the extent to which goals and outcome criteria of nursing
care have been achieved.
- The continuous and ongoing phase of nursing process.
- The review of all previous phases of the nursing process and determine
whether expected outcome for the patient have been met.