COMMUNITY HEALTH NURSING CARE PLANS, DIAGNOSIS AND INTERVENTION

COMMUNITY HEALTH NURSING
CARE PLANS, DIAGNOSIS AND
INTERVENTIONS
By: ROMMEL LUIS C. ISRAEL III

ADPIE CARE
PLAN FOR
COMMUNITY
HEALTH
PROBLEMS
References: Community Health Nursing Diagnosis and Nursing Care Plan. (2022, February 20). NurseStudy.net.
https://nursestudy.net/community-health-nursing-diagnosis/ and NurseStudy.net (2022). ADPIE Nursing Process. [online]
NurseStudy.net. Available at: https://nursestudy.net/adpie-nursing-process/. 2

ADPIE : THE 5
STAGES OF THE
NURSING
PROCESS
References: Community Health Nursing Diagnosis and Nursing Care Plan. (2022, February 20). NurseStudy.net. https://nursestudy.net/community-health-
nursing-diagnosis/ and NurseStudy.net (2022). ADPIE Nursing Process. [online] NurseStudy.net. Available at: https://nursestudy.net/adpie-nursing-process/. 3
ASSESSMENT
DIAGNOSIS
PLANNING
IMPLEMENTATION
EVALUATION

ASSESSMENT
INCLUDES THE FOLLOWING:
• Vital Signs taking
• Head-to-Toe Assessment
• Patient's Medical History
• Subjective complaints and objective Physical
observation from a patient

ASSESSMENT
1. DATA COLLECTION
• Interview patients and/or family
members having a keen
observation of their behavior and
conducting a physical
examination
• Concentrates on relevant data
collection, evidence validation,
and recording the noted
abnormalities

ASSESSMENT
2. OBJECTIVE VERSUS SUBJECTIVE
DATA
• Objective data are the pieces of information
that you can see, hear, feel, smell, and
measure. Includes body temperature, Blood
Pressure, Heart Rate, tremors, pallor,
diaphoresis, weight and height. We often
refer to this data as "signs."
• Subjective data are pieces of information
that are immeasurable. They are spoken
information such as emotion, level of
pain, itchiness, tinnitus, and others which are
often referred to as "symptoms."

DIAGNOSIS
Nurses establish nursing diagnosis to aid the patient
in their current or potential health problems
Nurses can identify patient's response to disease and
modify nursing care plans to meet the patient's
needs.
Nursing diagnosis also helps in facilitating better
communication between medical team members.
The comprehensive judgement of nurses, which are
evidenced based, could determine the actual and
potential health risks to their patients.

DIAGNOSIS
1. NANDA
• The taxonomy created by the North American
Nursing Diagnosis Association (NANDA) is where
the nursing diagnoses as based
• Example for Pain, use impaired comfort or acute
pain as the nursing diagnosis.
• After the diagnosis is established, identified risk
that may cause harm or complications to the
patient must be placed in order.
• Life-threatening risks shall be listed as top priority
followed by other risks in descending order with
the most minor as the lowest priority

DIAGNOSIS
2. ABRAHAM MASLOW'S
HEIRARCHY OF NEEDS
• The bottom level needs to be
met before an individual can
move on to the next level of
the pyramid.
• Develop by Abraham Maslow,
an American Psychologist

DIAGNOSIS
2. ABRAHAM MASLOW'S HEIRARCHY OF NEEDS
• The bottom level needs to be met before an individual
can move on to the next level of the pyramid.
• First Level – Basic Physiological Needs
• Second Level - Safety and Security Needs
• Third Level - Love and Belongingness Needs
• Fourth Level - Self-Esteem Needs
• Fifth Level - Self-Actualization Needs

DIAGNOSIS
FIRST LEVEL: BASIC PHYSIOLOGICAL
NEEDS
• This is the level at the bottom part of the pyramid
• Includes air, water, food, shelter, rest, clothing,
reproduction, and elimination
• These are the highest priority and the most basic
human survival needs
• The concept of ABC (Airway, Breathing,
Circulation) in nursing belongs to the highest
priority. It has the most vital role in the
prioritization of care and nursing diagnosis.

DIAGNOSIS
SECOND LEVEL: SAFETY AND SECURITY
NEEDS
• This pertains to protection from violence or theft,
emotional stability and well-being, health and
financial security
• In the hospital setting, nurses provides instruction
on using guard rails and call lights to prevent falls,
the importance of hygiene, and frequent
handwashing to prevent infection, to name a few.
How about in the community setting?
• Making a patient feel safe and secure before a
surgical operation or when facing serious medical
situation is also part of this level

DIAGNOSIS
THIRD LEVEL: LOVE AND
BELONGINGNESS NEEDS
• This social needs involve human interaction.
• Friendships and family relationship are
among these needs.
• The need of the individual to accept
themselves and to also feel accepted by the
family, friends, friends, and colleagues.
• Nurses support this by actively listening to
their patients and encouraging them in an
activity that keeps them from avoiding
social isolation.

DIAGNOSIS
FOURTH LEVEL: SELF ESTEEM NEEDS
• The primary concept is self-respect and self-
confidence
• The belief of being valuable and confident and being
capable of personal growth and accomplishments.
• Hospitalized patients who are dependent on
others or sometimes feel not useful are difficult to
attain this level. Hence, nurses should listen and
encourage the patient to feel significant to the lives
of their family, friends and their workplace.
• For patients who may not be able to return to
work, the nurse can gather information about
personal achievements and focus on them. These
patients can feel delighted and encouraged to feel
good about themselves.

DIAGNOSIS
FIFTH LEVEL: SELF-ACTUALIZATION
NEEDS
• This is the highest spot in the pyramid.
• All the other levels must be met before they
can be fulfilled.
• Involves the fulfillment of full potential as a
person.
• There are cases where in this level cannot be
reached at all.
• Nurses should assist the patients to reach
their other goals to reach their maximum
potential in time.

PLANNING
Developing for a plan on how to achieve the desired goal /s
for the patient. The goal should always be S.M.A.R.T.:
SPEFICIC
MEASURABLE
ATTAINABLE
REALISTIC/RELEVANT
TIME-BOUND

PLANNING
Example of S.M.A.R.T. Plans:
A patient who has mobility problem should have
a nursing care plan that can allow them to move
from the bed to a chair at least 3x a day and sit
there for a certain amount of time.
A patient diagnosed by a nursing professional
with a lack of adequate nutrition may have a plan
that entails eating several small meals a day
instead of 3 large meals.

PLANNING
• Aside from creating SMART goals, a nursing care
plan and intervention strategies must be developed
and communicated to the patient and the rest of the
medical team, as a part of the treatment. This will
surely help in achieving the success of the goals.
19

IMPLEMENTATION
It is commonly executed using a combination
of direct care and indirect care.
1. DIRECT CARE
• The provision of hands-on care to help the patient meet
their goals.
• Carrying out of nursing interventions such as wound
care, administering medications or oxygen, applying a
cardiac monitor, repositioning or assisting in a patient's
ambulation.
• Includes the patients working individually. The nurse
provides feedback about the patient's development and
discuss modification in the care plan for them to meet
the desired goals.

IMPLEMENTATION
It is commonly executed using a
combination of direct care and indirect
care.
1. INDIRECT CARE
• Involves monitoring the other health care staffs to
make sure that they are working harmoniously to
carry out the goals of the nursing care plan.
• It is anything that transpired in the patient care
that is completed while the nurse is away from
the patient.

EVALUATION
The Health Care Professional weighs the
outcome of the nursing actions done in the
implementtain stage .
Did the plans work successfully?
Did the plans are still in the process of
being effective?
Did the plans failed and therefore need to
be changed?
23

EXAMPLE OF ADPIE:
Patient with
Osteomyelitis
References: Community Health Nursing Diagnosis and Nursing Care Plan. (2022, February 20). NurseStudy.net. https://nursestudy.net/community-health-nursing-
diagnosis/ and NurseStudy.net (2022). ADPIE Nursing Process. [online] NurseStudy.net. Available at: https://nursestudy.net/adpie-nursing-process/. 24

ASSESSMENT
OBJECTIVE DATA:
Fever (39.5C) and Flushed Skin
Erythema, swelling, warmth on the left arm
Compromised mobility of the affected site and limb and Range of
Motion (ROM)
Complete Blood Count showing elevated White Blood Cell (WBC)
SUBJECTIVE DATA:
10/10 level of pain as verbalized by the patient

PLANNING (Expected Outcome)
Tient will verbalize an acceptable pain level of 5or less on a 0 to 10 pain
scale, as confirmed by normal signs, and relaxing effect, and body posture.
The patient will sustain a normal body temperature measurement of less
than 39C, dry skin and normal respiration rate.
References: Community Health Nursing Diagnosis and Nursing
Care Plan. (2022, February 20). NurseStudy.net.
https://nursestudy.net/community-health-nursing-
diagnosis/ and NurseStudy.net (2022). ADPIE Nursing Process.
26

IMPLEMENTATION
FOR ACUTE PAIN RELATED TO INFECTIOUS PROCESS AND
SWELLING:
Assess the patient's pain level being 10 as the highest
and 0 as the lowest pain. Note the characteristics of
pain.
Monitor vital signs at least every 4 hours or as ordered
by the physician
Administer pain medication according to the physician's
orders.
Encourage bed rest to lessen the movement of the
affected area and alleviate the pain.

IMPLEMENTATION
FOR ACUTE PAIN RELATED TO INFECTIOUS PROCESS AND SWELLING:
• Be considerate during wound care and use appropriate timing
through administration and wound care during peaks of pain
medication.
• Elevate the involved area to reduce the swelling and ease the pain.
• Provide hot and cold packs if not contraindicated by the attending
physician.
• Provide activities to help with distractions such as listening to music,
reading books, or watching television.
References: Community Health Nursing Diagnosis and Nursing Care Plan. (2022, February 20). NurseStudy.net.
https://nursestudy.net/community-health-nursing-diagnosis/ and NurseStudy.net (2022). ADPIE Nursing Process. [online] NurseStudy.net.
Available at: https://nursestudy.net/adpie-nursing-process/.
28

IMPLEMENTATION
FOR HYPERTHERMIA RELATED TO INFLAMMATORY RESPONSE TO INFECTION:
• Monitor the patient's temperature at appropriate times and as clinically
specified.
• Obtain temperature measurement from the same site and with the same
tool for more accurate results.
• Administer antipyretics as ordered to reduce fever for some time.
• Remove warm clothing and adjust the room temperature which affects the
patient's body temperature.
• Offer sponge bath and provide temperature lowering measurements such
as fan or cold clothe to the forehead.
29

EVALUATION
1. T patient verbalizes an acceptable pain level of 5 at the end of the
shift.
2. The patient maintains a normal body temperature as evidenced by
consistent temperature measurement of 37.5C, a cool and dry skin.
30

ADPIE CARE PLAN FOR COMMUNITY HEALTH
PROBLEMS
diagnosis/ and NurseStudy.net (2022). ADPIE Nursing Process. [online] NurseStudy.net. Available at: https://nursestudy.net/adpie-nursing-process/.
31

THE NURSING PROCESS IN THE COMMUNITY
• The nursing process in the community involves health planning.
• It is a continuous social process in which data in a certain area is
collected and analyzed in order to establish a strategy for generating
new ideas , meeting identified requirements, resolving health
issues and guiding changes in the delivery of health care.
• Community health nurses are required to design strategies and
actions for the entire community health needs, not just for the health
of a single person.
• It involves the process of problem solving which is centered on a
certain group of people.
nursing-diagnosis/ and NurseStudy.net (2022). ADPIE Nursing Process. [online] NurseStudy.net. Available at: https://nursestudy.net/adpie-nursing-process/.
32

• Assessments in the community are made, needs and problems are
prioritized.
• Goals are set and methods for achieving them are developed.
• When planning care for a group or a population, the term program
planning is frequently used to refer to the process of planning care for
a community.
• CHNurses conduct health assessments that collect a broader range of
data than nurses in other fields: information on both the
individuals and families within the community.
33

• CHNurses look at the data to see if it can be utilized to determine a
population's health, resources or needs.
• They also look into how a range of community factors affect
the health of the people who live there.
• Collaborating with the members of the community to to validate
nursing diagnosis based on the assessment and enlisting community
members' support and cooperation and accomplishing change are all
essential tasks
34

• The program may not be successful if the community is not involved
from the start.
• Incorporate the community in the assessment and planning phases.
35

COMMUNITY HEALTH NURSING DIAGNOSIS
References: Community Health Nursing Diagnosis and Nursing Care Plan. (2022, February 20). NurseStudy.net. https://nursestudy.net/community-
health-nursing-diagnosis/ and NurseStudy.net (2022). ADPIE Nursing Process. [online] NurseStudy.net. Available at: https://nursestudy.net/adpie-
nursing-process/. 36

COMMUNITY HEALTH NURSING CARE PLAN
ALTERED HEALTH-SEEKING BAHAVIORS
ASSESSMENT:
The older adults are expanding rapidly in ABC community, a sub-urban
community. According to the records, there is only one taxicab service
in the area, which causes limited public transportation.
37

NURSING DIAGNOSIS:
Altered health-seeking behaviors related to insufficient transport
services for senior citizens.
38

DESIRED OUTCOME:
The community, particularly the senior citizens, will improve their
health-seeking behaviors through participation in organized health
activities and programs.
39

40
INTERVENTIONS
RATIONALE
Conduct a comprehensive review of the
health records in the community
Establishing a baseline makes it easier to
set realistic goals which are the basis for
effective planning.
Coordinate with the health care
organizations and community leaders.
Collaboration with relevant
organizations is necessary to have the
resources required to putc up health
programs and activities.

41
INTERVENTIONS
RATIONALE
Arrange Home Visits to selected Senior
Citizens and identify the most significant
health concerns that need to be
addressed as soon as possible.
Home visits can put an individual's mind
at ease and make them feel important in
society. It will be expected that they will
want to participate in the health
activities that will be launched.
Identifying the most pressing health
issues might assist the CHNurses in
prioritizing health related problems and
activities.

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