NURSING PROCESS - DIAGNOSIS

• Diagnosing is the 2^nd phase of nursing process
• Nurse uses critical thinking skills to interpret assessment data
• All the activities preceding this phase are directed toward formulating nursing diagnosis.
• The use of the nursing process and nursing diagnoses is rapidly becoming an integral part of an effective system of nursing practice.
• Identification & Development of Nursing Diagnosis began in year 1973.
• It is derived from actual or potential problems.
• Derived from physiological, social, cultural, developmental and spiritual dimensions of client.

NANDA INTERNATIONAL

• NANDA -North American Nursing Diagnosis Association
• a professional organization of nurses interested in standardized nursing terminology.
• Officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses.
• In 2002 Taxonomy II, which was a revised version of Gordon's functional health patterns, was released.
• The current structure of NANDA's nursing diagnoses is referred to as Taxonomy II and has three levels: Domains (13), Classes (47) and (206)Diagnosis labels.

Taxonomy II

Domain

Health promotion

Nutrition

Elimination/ Exchange

Activity/ Rest

Perception/ Cognition

Self- perception

Role relationship

Sexuality

Coping/Stress tolerance

Life principles

Safety/ Protection

Comfort

Growth/ Development

Class 1

Health awareness

Ingestion

Urinary function

Sleep/Rest

Attention

Self-concept

Caregiving roles

Sexual identity

Post-trauma responses

Values

Infection

Physical comfort

Growth

Class 2

Health management

Digestion

Gastrointestinal function

Activity/ Exercise

Orientation

Self-esteem

Family relationships

Sexual function

Coping responses

Beliefs

Physical injury

Environmental comfort

Development

Class 3

Absorption

Integumentary function

Energy balance

Sensation/ Perception

Body image

Role performance

Reproduction

Neuro-behavioral stress

Value/Belief/ Action congruence

Violence

Social comfort

Class 4

Metabolism

Respiratory function

Cardio-vascular/ Pulmonary responses

Cognition

Environmental hazards

Class 5

Hydration

Self-care

Communi- cation

Defensive processes

Class 6

Thermo- regulation

MEANING

• The word “diagnosis” is singular and “diagnoses” is plural.
• The nursing diagnoses are involved with human responses to stressors or other factors that adversely effect achievement of optimum health.
• Treatment is directed towards causes of the responses or factors influencing it.
• Nursing diagnoses are different from medical diagnoses.

Differences between nursing and medical diagnosis

S. No.	Nursing	Medical
1.	Diagnose and treat human responses	Diagnose and treat disease
2.	Care for client	Cure disease
3.	Holistic-effects on whole individual	Biological, physical effects
4.	Teach clients to do selfcare and become more independent in daily activities	Teach clients about treatments for their disease

DEFINITION

• Nursing diagnosis is a statement or conclusion of a client’s potential or actual health problem resulting from analysis of data.
• Nursing diagnosis is a statement of client’s potential or actual alterations/changes in his health status.
• A statement that describes a client’s actual or potential health problems that a nurse can identify and for which she can order nursing interventions to maintain the health status, to reduce, eliminate or prevent alterations/changes.
• Nursing diagnosis is the problem statement that the nurse makes regarding a client’s condition which she uses to communicate professionally.
• A Nursing diagnosis is a statement of a patient problem that is arrived at by making inferences from the collected data (Mundiger and Jauron, 1975),
• American Nurses’ Association has implied nursing diagnosis in the definition of nursing: Nursing is the diagnosis and treatment of human responses to actual or potential health problems (ANA, 1980).
• “A clinical judgement about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.” (NANDA, March 1990).

USE/PURPOSE OF NURSING DIAGNOSES
General

• Gives Nurses a Common Language
• Promotes Identification of Appropriate Goals
• Provides Acuity Information
• Can Create a Standard for Nursing Practice
• Provides a Quality Improvement Base

Specific

• For client:
• Individualization of care
• Appropriate selection of interventions
• Establishment of goal
• For Nursing:
• Facilitates communication, documentation
• Continuity of care among health care provider

CHARACTERISTICS OF NURSING DIAGNOSIS

• It states a clear and concise health problem.
• It is derived from existing evidences about the client.
• It is potentially amenable to nursing therapy.
• It is the basis for planning and carrying out nursing care.

TYPES OF NURSING DIAGNOSES
Actual Nursing Diagnoses

• A client problem that is present at the time of the nursing assessment.
• It is based on the presence of signs and symptoms.
• Actual Nursing Diagnoses defined as “a clinical judgment that the nurse has validated because of the presence of major defining characteristics.”
• EXAMPLES
• Ineffective breathing pattern related to bacterial / viral inflammatory Process.
• Anxiety related to changes in the environment and routines, threat to socio economic status.
• Body image disturbance related to temporary presence of a visible drain/ tube.

Risk Nursing Diagnoses

• A clinical judgment that a problem does not exist, therefore no S/S are present, but the presence of risk factors is indicates that a problem is only is likely to develop unless nurse intervene or do something about it.
• A clinical judgment that an individual/group is more vulnerable to develop the problem than others in the same or a similar situation because of risk factors.
• Describes human responses to health conditions / life processes that may develop in a vulnerable individual / family / community.
• EXAMPLES
• Risk for impaired skin integrity related to immobility.
• Risk for impaired skin integrity related to edema and neuropathy
• Risk for injury related to generalized weakness
• Risk for Impaired skin integrity (left ankle) related to decrease peripheral circulation in diabetes.
• Risk for Impaired skin integrity related to loss of pain perception

Wellness Nursing Diagnoses

• Also known as Health-promotion Nursing Diagnosis
• A clinical judgment about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness (NANDA-I, 2012).
• Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement.
• A clinical judgment about a person's, family’s or community's motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviours, and can be used in any health state.
• Health-promotion nursing diagnosis are one part statement includes diagnostic label.
• EXAMPLES
• Readiness for Enhanced Self-Esteem.
• Readiness for enhanced spiritual well being
• Readiness for enhanced family coping.

Syndrome Nursing Diagnoses

• A syndrome diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to present because of a certain situation or event.
• A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.
• Example –
• Rape-trauma syndrome as manifested by anger, genitourinary discomfort, and sleep pattern disturbance.

Potential/ Possible Nursing diagnosis

• Possible nursing diagnosis is not a type of diagnosis as are actual, risk, and syndrome.
• A possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear. It requires more data either to support or to refuse it.
• Possible nursing diagnoses are a diagnostician’s option to indicate that some data are present to confirm a diagnosis but are insufficient at this time.
• One in which evidence about a health problem is incomplete or unclear therefore requires more data to support or reject it; or the causative factors are unknown but a problem is only considered possible to occur.
• For Eg.
• Possible social isolation R/t unknown etiology
• Potential risk of constipation as a result of enforced bed rest.
• Potential risk of pressure sore development from enforced bed rest.

COMPONENTS OF A NURSING DIAGNOSIS STATEMENT
A nursing diagnostic statement consists of four parts:

1. Label
2. Problem
3. The Related Factor
4. Defining characteristics

LABEL

• It is a concise term or phrase that represents a pattern of related clues.
• It may include Qualifiers and modifiers.
• Describes the client's health problem or response for which nursing therapy is given.
• It describes the client's health status clearly and concisely in few words.
• Each diagnostic label approved by NANDA carries a definition that clarifies its meaning.

Purpose:

• Is to direct the formation of client goals and desired outcomes.
• It may also suggest some Nursing interventions.

Qualifiers and Modifiers - these are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement.

• Qualifiers for e.g.
• “Deficient” – inadequate in amount, quality, degree, insufficient, incomplete
• “Impaired” – made worse, weakened, damaged, reduced, deteriorated
• “Decreased” – lesser in size, amount, degree
• “Ineffective” – not producing the desired effect
• “Compromised” – to make vulnerable to threat
• Modifiers for e.g. –
• “Acute” – sever, serious, intense, critical
• “Chronic” - constant, persisting, ever present
• “Depleted” - exhausted, tired, useless
• “Disturbed” - troubled, uneasy, unbalanced, bothered
• “Dysfunctional” - inability to function, organ or part of body unable to function
• “Enhanced” - improved, better
• “Excessive” - extreme, too much, unnecessary, disproportionate
• “Increased” - greater than before, improved
• “Intermittent” - irregular, alternating, discontinuous
• “Potential for” - likely to occur, may or might

PROBLEM

• The problem in the statement is as identified by the nurse during the assessment phase. The nurse needs to consider two areas while identifying the problem.
• Provides a clear, precise description; delineates its meaning and helps differentiate it from similar diagnoses.
• Based on data collected
• Must be approved NANDA format begin with qualifier or modifiers
• Use the exact NANDA wording to state the problem
• Examples
• Poor sleep pattern/ Sleep Pattern, disturbed
• Poor circulation / Tissue perfusion, ineffective (cardiopulmonary)

Problem Identification

• What is the problem that is inferred by assessment data?
• For example:
• Client worried about surgery planned for the next day.
• High glucose level due to lack of knowledge about right selection of food items.
• Pupil dilated with medicine for eye testing.
• Not able to sleep in changed setting of hospital.
• Feeling of loneliness.
• To what degree is the problem present ?
• A degree of problem can be explained as:
• Post-operative patient on first day require assistance to brush his teeth.
• A malnourished child is at risk for acquiring infection, hypothermia.
• A nurse observes indifferent behaviour of mother towards the child.

THE RELATED FACTOR/ ETIOLOGY

• The related factors are “conditions or circumstances that can cause or contribute to the development of a diagnosis.”
• The factors contributing to or causing the problem
• It can't be a medical diagnosis
• Must be modifiable by nursing intervention
• Nurse must be able and license to do something about it.
• The etiology component of a nursing diagnosis identifies one or more probable cause of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client's care.
• Examples of related factors are given below:
• Environmental – Excessive noise, light, fumes, pollutants.
• Psychological – Fear of death, feeling of loneliness, impaired parent-child bonding.
• Socio-cultural – Inability to procure food, lack of support system, lack of finances, literacy level.
• Physiological – Abnormal fluid loss, sensory deficit, loss of skin integrity, breathing difficulty.
• Spiritual – Inability to practice religious rituals, conflict between religious beliefs and prescribed health regimen.

DEFINING CHARACTERISTICS

• Defining Characteristics are the cluster of signs an symptoms that indicate the presence of a particular diagnostic label
• For Actual Nursing Diagnosis- The Defining Characteristics are the client's signs and symptoms
• For Risk Nursing Diagnosis- No subjective and objective signs are present Thus the factors that cause the client to be more than ''Normally'' vulnerable

WRITING THE DIAGNOSTIC STATEMENT
Most Nursing Diagnoses are written as two part or three part statements, but there are variations of these.

1. One part statements
2. Two part statements
3. Three part statements

One-Part Statements

• Wellness nursing diagnoses will be written as one-part statements.
• e.g., Readiness for Enhanced Parenting
• Related factors are not present for wellness nursing diagnoses because they would all be the same: motivated to achieve a higher level of wellness.
• Syndrome diagnoses, such as Rape-Trauma Syndrome, have no “related to” designations.

Two-Part Statements

• The basic two part statement includes the following.
• Problem (P) :- Statement of the client's response (NANDA Label)
• Etiology (E) :- Factors contributing to or probable cause of responses.
• The two parts are joined by the words related to rather than due to.
• The phrase due to implies that one part causes or is responsible for the other part.
• By contrast, the phrase related to merely implies a relationship.
• Risk and possible nursing diagnoses have two parts. The validation for a risk nursing diagnosis is the presence of risk factors. The
• Risk factors are the second part, as in:
• Risk Nursing Diagnosis Related to Risk Factors
• Possible nursing diagnoses are suspected because of the presence of certain factors.
• For Examples -
• Risk for Impaired Skin Integrity related to immobility secondary to fractured hip
• Possible Self-Care Deficit related to impaired ability to use left hand secondary to IV

Three-Part Statements

• The three part Diagnostic Statements called the PES format and includes the following:
• Problem (P) :- Statement of the client's response (NANDA Label)
• Etiology (E) :- Factors contributing to or probable cause of the response.
• Signs and Symptoms (S) :- Defining characteristics manifested by the client.
• Diagnostic label(Problem) related to contributing factors (Etiology) as evident by signs and symptoms
• The presence of major signs and symptoms (defining characteristics) validates that an actual diagnosis is present. This is the third part.
• Actual nursing diagnoses can be documented by using the three part statement because the signs & symptoms have been identified.
• It is not possible to have a third part for risk or possible diagnoses because signs and symptoms do not exist.
• Examples
• Anxiety related to unpredictable nature of asthmatic episodes as evident by statements of “I’m afraid I won’t be able to breathe”
• Urge Incontinence related to diminished bladder capacity secondary to habitual frequent voiding as evident by inability to hold off urination after desire to void and report of voiding out of habit, not need.

GUIDELINES TO FORMULATE NURSING DIAGNOSTIC

• First write an actual or high-risk health problem and not an environmental problem. State environmental factors in the second part.
• For e.g.:
• Wrong: Excessive environmental stimuli related to monitoring equipment
• Right: Sensory perceptual alterations (auditory and visual) related to excessive environmental stimuli
• Do not write several unrelated problems in the first part even though the related factor of the problem may be the same.
• Judge the problems as unrelated when the nursing plan requires separate interventions for each problem.
• For e.g.:
• Wrong: Anxiety and activity intolerance related to frequent episodes of chest pain
• Right: Activity intolerance related to frequent episodes of chest pain
• Right: Anxiety related to frequent episodes of chest pain
• Write the diagnostic statement in a manner that both the problem and related factors refer to different findings.
• For e.g.:
• Wrong: Self-feeding deficit related to inability to feed self.
• Right: Self-feeding deficit related to muscle weakness.
• Write the diagnosis in legally advisable terms.
• For e.g.:
• Wrong: Ineffective airway clearance related to inadequate suction.
• Right: Ineffective airway clearance related to effects of sedation.
• Write the nursing diagnosis in terms of response rather than the need.
• For e.g.:
• Wrong: Need for maintenance of nutritional intake.
• Right: Altered nutrition (less than body requirements) related to nausea and vomiting.
• The purpose of nursing diagnosis is to keep the planning care focused on problems that are amenable to nursing interventions.

VERIFICATION OF THE DIAGNOSIS
The accuracy of nursing diagnosis is verified by the nurse asking the following questions.

1. Is the data base sufficient and accurate?
2. Does a pattern exist?
3. Is the nursing diagnosis based on nursing knowledge?
4. Can the nursing diagnosis be altered by independent nursing actions?

DOCUMENTATION

• After developing and verifying nursing diagnosis the nurse documents the statements on the chart and care plan.
• The statement must also be included on nurses notes or progress notes, discharge summary and referral forms.
• Diagnostic statements are reviewed and revised when it is necessary.

BIBLIOGRAPHY

1. BNS-101 Nursing Foundation, Published By -IGNOU; 2017 [cited 2018 Feb 25].
2. “Birpuri” S Sharma. Principles and practice of nursing, Published By -Jaypee Publication, 2012
3. Burton M, Ludwig LJM. Fundamentals of nursing care: concepts, connections & skills. Second edition. Philadelphia, PA: F.A. Davis Company; 2014.
4. Kozier B, Berman A, editors. Kozier & Erb’s fundamentals of nursing: concepts, process, and practice. 9th ed. Boston: Pearson; 2012.
5. Nugent PM, Vitale BA. Fundamentals of nursing: content review plus practice questions. 2014.
6. Perry AG, Potter PA, Ostendorf W. Clinical nursing skills & techniques. 8th edition. St. Louis, Missouri: Elsevier; 2014.
7. Potter PA, Perry AG, Hall A, Stockert PA. Fundamentals of nursing. Eighth edition. St. Louis, Mo: Mosby Elsevier; 2013.
8. Treas LS, Wilkinson JM. Basic nursing: concepts, skills, & reasoning. Philadelphia, PA: F.A. Davis Company; 2014.

NURSING PROCESS - ASSESSMENT

• Assessment is the foundation step of nursing process.
• It consists of systematic and orderly collection of information pertaining to and about the health status of the client.
• It includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles.
• The information obtained helps to make nursing diagnoses and to develop a plan of care.

PURPOSE OF ASSESSMENT

• To establish a data base (all the information about the client) such as -
• Nursing health history
• Physical assessment
• The physician’s history & physical examination
• Results of laboratory & diagnostic tests
• Material from other health personnel

TYPES OF ASSESSMENT

1. Initial assessment – Assessment performed within a specified time on admission. To establish a complete database for problem identification, reference and future comparison. Ex: nursing admission assessment
2. Problem-focused assessment – Ongoing process integrated with nursing care, To use to determine status of a specific problem identified in an earlier assessment. Ex: problem on urination-hourly assessment of fluid intake & urine output hourly
3. Emergency assessment – Rapid assessment done during any physiologic/physiologic crisis of the client, to identify life threatening problems. Ex: Rapid assessment of a client’s airway, breathing status & circulation after a cardiac arrest; Assessment for suicidal tendency or potential for the violence.
4. Time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the client’s current status to baseline data previously obtained. Ex: Follow-up assessment.

COMPONENTS OF ASSESSMENT PHASE

1. Collection of data
2. Organization of data
3. Validation of data
4. Analyzing of data
5. Documentation of data

COLLECTION OF DATA

• Collection of data is the process of gathering of information about the client’s health status.
• It includes accumulation of comprehensive information about the client on initial assessment.
• It must be both systematic and continuous to prevent the omission of significant data and reflect a client’s changing health status.
• Database is the all information about a client; It includes –
• The nursing health history, physical assessment, primary care provider’s history, and physical examination, result of laboratory and diagnostic tests and material contributed by the other health care personnel.
• Current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now)
• Past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods)
• Physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status
• The gathering of information about the client’s well-being status includes:
• Strengths as well as weaknesses of patient,
• Response of patient to his health concerns,
• Analysis of the circumstances associated with patient’s well-being status,
• Knowledge related to health and well-being,
• Beliefs and values about health,
• Life-style,
• Health-related goals, and
• Support system.

TYPES OF DATA
Subjective data

• Also referred to as Symptom/Covert data
• Information from the client’s point of view or are described by the person experiencing it.
• Information supplied by family members, significant others and other health professionals are considered subjective data.
• Example: pain, dizziness, ringing of ears/Tinnitus

Objective data

• Also referred to as Sign/Overt data
• Those that can be detected observed or measured/tested using accepted standard or norm.
• Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin

SOURCE OF DATA

• Primary source - Data directly gathered from the client using interview and physical examination.
• Secondary source - Data gathered from client’s family members, significant others, client’s medical records/chart, other members of health team, and related care literature/journals.

METHODS OF DATA COLLECTION
a) Interview

• Interview is a planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling.
• It is used while taking the nursing history of a client.
• The client interview is conducted to gather specific information about the client.
• The purposes of interview in this phase of assessment are:
• To collect specific information required for diagnosis and planning.
• To establish a trusting nurse-client relationship.
• The allow the client to participate in identification of problems and goal setting.
• The assist nurse to determine areas for specific investigation during the process of assessment.
• To assist nurse to gain insight into client’s ability to function, severity of his illness and his behavior.

b) Observation

• Observation is a method of data collection through the conscious use of 5 senses — sight, smell, hearing and feeling (touch) and instruments.
• Observation is a skill that requires practice.
• Through the use of senses, the nurse collects data about client, his family and his environment.
• Through observation, nurse can also understand the interaction between the client and the environment.
• Each observation finding requires further investigation to confirm the impression.

c) Examination

• Systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results.
• Substantial data are also obtained by physical examination of the client.
• Nurse uses physical examination with the following purposes:
• To define the client’s response to the disease process.
• To establish baseline data to evaluate the nursing interventions.
• To compare the efficiency of medical and nursing interventions.
• To substantiate subjective data obtained during interview and other nurse-client interaction.
• Physical examination includes various techniques such as inspection, palpitation, percussion, auscultation.
• Physical examination Should be conducted systematically:
• Cephalocaudal approach – head-to-toe assessment
• Body System approach – examine all the body system
• Review of System approach – examine only particular area affected

ORGANIZATION OF DATA

• Data is organize systematically –
• Either in written or computerized format such as Nursing Health History, Nursing Assessment, Or Nursing Data-base Form.
• These all formats are based on the conceptual models. These are Maslow’s basic needs, Body System Model and Gordon’s 11 Functional Health Patterns.

VALIDATION OF DATA

• The information gathered during assessment phase must be complete, factual, and accurate because the nursing diagnoses and interventions are based on this information.
• Validation is 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 overlooked
• Avoid jumping to conclusion
• Differentiate cues and inferences
• Cues – Subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure.
• Inferences – The nurse interpretation or conclusion based on the cues.
• For Example:
• A nurse observes the cues that are an incision is red, hot and swollen wound = nurse make inference that the incision is infected.
• A nurse observes the cues that the client’s skin is dry = nurse make inference that the client is dehydrated.

ANALYZE DATA

• Compare data against standard and identify significant cues.
• Standard/norm are generally accepted measurements, model, pattern.
• For Ex:
• Normal vital signs,
• Standard weight and height,
• Normal laboratory/diagnostic values,
• Normal growth and development pattern.

DOCUMENTING DATA

• The documentation is recording of data accumulated during the assessment.
• It is the integral part of all the phases of the nursing process.
• Nurse records all data collected about the client’s health status
• Data are recorded in a factual manner not as interpreted by the nurse
• Record subjective data in client’s word; restating in other words what client says might change its original meaning.

Purposes of Documentation

• To communicate the information to the other members of the health team and thereby prevent repetition of asking same questions by other personnel.
• To facilitate the delivery of quality client care. The information collected allows the nurse to develop preliminary nursing diagnoses, outcomes and nursing interventions, which later on can be updated, clarified to provide quality care.
• To provide a mechanism for the evaluation of individual client care.
• To provide a legal record of the care provided to the client.
• To serve as a source for identification of research topics for nursing practice.

Guidelines for Documentation for a Nurse

1. Make entries very objectively without personal opinion, biases. Use quotation marks to clearly identify the statements. For e.g. client’s description of illness: “I have a lump in the abdomen and have come to get it operated”.
2. Support description or interpretations of objective data by specific observation. For e.g. nurse interprets excessive crying as - Subjective data -moderate hypothermia in a baby; Objective data: Baby looking pale, skin mottled, skin temperature 35º C.
3. Avoid using generalised terms like “good”, “fair”, “normal”. These descriptions do not mean same to everyone. What is “good” for one person may mean “fair” to another. For e.g. instead of writing bowel pattern - normal, record “bowels moved everyday without the use of laxatives.”
4. Avoid using superfluous information. For e.g. “The child had swallowed kerosene, one year back and was taken to nursing home, there the child was kept in ICU and discharged after one week.” This information can be written as “History of kerosene poisoning one year back, treated in private agency and discharged after one week.”
5. Record the findings with description like size and shape. These kinds of descriptions are important to evaluate the effectiveness of nursing intervention at a later date. For e.g. description of wound will include information related to colour, size, location, drainage.
6. Write legibly and correct any errors by drawing a line so that the original entry is also readable e.g. Pain chronic
7. Use correct language and spelling.
8. Use abbreviations approved for use.

BIBLIOGRAPHY

1. BNS-101 Nursing Foundation, Published By -IGNOU; 2017 [cited 2018 Feb 25].
2. “Birpuri” S Sharma. Principles and practice of nursing, Published By -Jaypee Publication, 2012
3. Burton M, Ludwig LJM. Fundamentals of nursing care: concepts, connections & skills. Second edition. Philadelphia, PA: F.A. Davis Company; 2014.
4. Kozier B, Berman A, editors. Kozier & Erb’s fundamentals of nursing: concepts, process, and practice. 9th ed. Boston: Pearson; 2012.
5. Nugent PM, Vitale BA. Fundamentals of nursing: content review plus practice questions. 2014.
6. Perry AG, Potter PA, Ostendorf W. Clinical nursing skills & techniques. 8th edition. St. Louis, Missouri: Elsevier; 2014.
7. Potter PA, Perry AG, Hall A, Stockert PA. Fundamentals of nursing. Eighth edition. St. Louis, Mo: Mosby Elsevier; 2013.
8. Treas LS, Wilkinson JM. Basic nursing: concepts, skills, & reasoning. Philadelphia, PA: F.A. Davis Company; 2014.

NURSING PROCESS - INTRODUCTION

• Practice of nursing is caring which is directed by the way the nurses view the client, the client’s environment, health and the purpose of nursing.
• To nurses the nursing process provides a useful description of how nursing should be performed.
• As nurses remain in constant interaction with their clients, professional colleagues, medical and health care team members, they have the best opportunity to assess the patient’s needs and provide evidence-based care.

HISTORY OF NURSING PROCESS

• The term ‘Nursing Process’ was first used/mentioned by ‘Lydia Hall’, a nursing theorist, in 1955 wherein she introduced 3 STEPs: Observation, Administration of care and Validation.
• In 1967, Yura and Walsh added assessment to the three steps and described a four phase process (APIE).
• In the mid-1970s an addition of diagnostic phase resulted into a five step process (ADPIE).
• The use of nursing process in clinical practice was started in 1973 by the American Nurses Association (ANA) in Standards of Nursing Practice.
• After 1980 the nursing process was added to the General Nursing Curriculum in India.
• In 1991, revisions were made to the standards to incorporate outcome identification in the planning phase. now a 6-step process (ADOPIE) Assessment, Diagnosis, Outcome Identification, Planning, Implementation and Evaluation.

DEFINITION

• The two words of nursing process are significant - Nursing and Process.
• Nursing - caring the clients during times of illness and assisting the client to achieve maximum health potential throughout the life cycle.
• Process - a series of rational thoughts, decisions and acts to achieve a goal. It implies a movement which has beginning, middle and an ending.
• “The nursing process is systematic, goal directed, Client-centered method for structuring the delivery of nursing care.”
• Nursing Process (NP) is defined as a systematic, continuous and dynamic method of providing care to clients. It comprises series of sequential phases built upon the preceding step. Each phase logically leads to the next. As one step leads to the next step it results into ultimate achievement of mutually determined nursing outcomes/goals.

CHARACTERISTIC OF NURSING PROCESS

• It is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care.
• Goal-oriented – Nurse make her objective based on client’s health needs.
• Note: Goals and plan of care should be base according to client’s problems / needs NOT according to your own problem as the nurse.
• Organized / Systematic – The nursing process is composed of 6 sequential and interrelated steps and these 6 phases follow a logical sequence.
• Individualized & Humanistic care - plan to care is developed and implemented taking into consideration the unique needs of the individual client in providing care, it involves respect of human dignity. Therefore, it is individualized (no 2 person has the same health needs even with same health condition/illness).
• OTHER  (ASIDE FROM GOSH)
• Cyclic and Dynamic in nature – data from each phase provides the input into the next phase so that is becomes a sequence of events (cycle) that are constantly changing (dynamic) base on client’s health status.
• Involves skill in Decision-making – nurse makes important decisions related to client care, she choose the best action/steps to meet a desired goal or to solve a problem. She must make decisions whenever several choices or options are available.
• Uses Critical Thinking skills – the nurse may encounter new ideas or less-than-routine or non-ordinary situations where decisions must be made using critical thinking.

PURPOSE OF NURSING PROCESS

• General
• To help the nurse provide goal-directed, client-cantered care
• Specific
• To identify a client’s health status; his Actual/Present and potential/possible health problems or needs.
• To establish a plan of care to meet identified needs.
• To provide nursing interventions to meet those needs.
• To provide an individualized, holistic, effective and efficient nursing care.

PHASES OF NURSING PROCESS

1. Assessment - involves collection of information or details about the client obtained from different sources, e.g., through interview, physical examination using different methods and clinical examination.
2. Nursing Diagnosis- identify the client’s problem(s).
3. Outcome identification & Planning - development of strategies to alleviate client’s problem identified in nursing diagnosis through a series of steps.
4. Implementation - starting and completing the strategies planned with help of client, family members and health care team members.
5. Evaluation - assessment of strategies planned to alleviate the clients’ suffering or otherwise re-plan and revise the care.

BIBLIOGRAPHY

1. BNS-101 Nursing Foundation, Published By -IGNOU; 2017 [cited 2018 Feb 25].
2. “Birpuri” S Sharma. Principles and practice of nursing, Published By -Jaypee Publication, 2012
3. Burton M, Ludwig LJM. Fundamentals of nursing care: concepts, connections & skills. Second edition. Philadelphia, PA: F.A. Davis Company; 2014.
4. Kozier B, Berman A, editors. Kozier & Erb’s fundamentals of nursing: concepts, process, and practice. 9th ed. Boston: Pearson; 2012.
5. Nugent PM, Vitale BA. Fundamentals of nursing: content review plus practice questions. 2014.
6. Perry AG, Potter PA, Ostendorf W. Clinical nursing skills & techniques. 8th edition. St. Louis, Missouri: Elsevier; 2014.
7. Potter PA, Perry AG, Hall A, Stockert PA. Fundamentals of nursing. Eighth edition. St. Louis, Mo: Mosby Elsevier; 2013.
8. Treas LS, Wilkinson JM. Basic nursing: concepts, skills, & reasoning. Philadelphia, PA: F.A. Davis Company; 2014.

HEALTH CARE SYSTEMS IN INDIA

INTRODUCTION

Health has been at the centre of human concern since ancient times. Civilisations developed and perished due to wars, conflicts and raging diseases, which left none untouched, save those whose health was taken care of by an organized system. Ancient civilisations that developed in Indus valley, Greece, Rome and Mesopotamia had fairly advanced health systems for their times and the medical practitioners enjoyed a high status in the society due to their practice.

Two renowned medical systems developed in India in ancient times; Ayurveda and Siddha, which were quite similar in concept and practice. Indian systems sought knowledge by which life could be prolonged and some of the popular medical treatises of those times were the Charaka Samhita and the Sushruta Samhita.

The practice of medicine has come a long way since the time of magic, religion and supernatural thoughts to a modern science following evidence-based practice with a range of services extending from preventive, promotive, curative to rehabilitative offered to the individual and community.

DEFINITIONS

Health

• Health is defined as," a dynamic state of complete physical, mental and social well-being and not merely an absence of disease or infirmity." (WHO)

Health Care

• Health care is defined as," multitude of services rendered to individuals, families or communities by the agents of the health services or professions for the purpose of promoting , preventing, maintaining, monitoring or restoring health." (OXFORD DICTIONARY)

System

• A set of interrelated and independent parts designed to achieve a set of goals.

HEALTH CARE SYSTEM

• Health care delivery system is a system in which the services related to health care delivered to the target population.
• Health care delivery system is an integral part of the government, responsible to central authority and interrelated in its activities with a general conduct to governmental affairs

Health System

• Health system covers a whole extent of health activities, health programmes, institutions providing medical care such as hospitals, clinics and primary health care centres and the policies enunciated by governments to provide optimal health care for its citizens.
• In general health system defines as "Complex of facilities, organizations, and trained personnel engaged in providing health care within a geographical area."
• Health System as described by WHO is the "sum total of all the organisations, institutions and resources whose primary purpose is to improve health."
• Health systems should be accessible, efficient, affordable and of a good quality.
• Health systems usually include the following -
  • Development of health policies, plan for their implementation and development of a system of regulation of health services.
  • Define and develop the institutional framework to deliver the health services within the purview of this system.
  • Allocate and mobilise financial and human resources for its functioning.
  • Plan, manage and deliver the health services.

aim of Health systems

• Ultimately aim of Health systems is to improve, maintain and restore the health status of the community at a cost that an individual and the community can afford to spend without substantial change in their financial status.

Goals of Health care System

• A health system has to provide for much more than routine delivery of services. It has to protect the health of its community, treat them with dignity and ensure that it responds fairly to the expectations of the population. The WHO has thus identified three overall goals for the health systems to be -
  • Effective in contributing to better health throughout the entire population.
  • Responsive to people's expectations, including safeguarding patient's dignity, confidentiality and autonomy and being sensitive to the specific needs and vulnerabilities of all population groups.
  • Fair in how individuals contribute to funding the system so that everyone has access to the services available and is protected against potentially impoverishing levels of spending.

functions Health System

• Health care systems fulfill three main functions:
  • Health care delivery,
  • Fair treatment to all, and
  • Meeting non health expectations of the population

Determinants of Health System

• Economic
  • Affordability
  • Availability
• Political
  • Priorities
  • Appropriateness
  • Accessibility
  • Equity
• Cultural
  • Acceptability
  • Utilization
  • Participation

Forces influence the Health System

• New emerging diseases,
• Changing disease profile,
• Technical and diagnostic advances,
• Longevity of life,
• Expectations of people,
• Subsidies and cross-subsidies
• Increasing non-plan expenditure,
• Competing priorities and
• Improving awareness among people, and
• Rising Cost of health care delivery

HISTORY OF HEALTH CARE SYSTEM

Early history

India is one of the ancient civilizations of the Indus valley. The excavations in the Indus valley especially Harappa and Mohenjodaro showed planned cities with drainage, house and public baths built of baked bricks suggesting the practice of environmental sanitation in 3000 B C. The art of Health Care in India can be traced back nearly 3500 years, when India was invaded by Aryans, Ayurveda and siddha systems of medicine came into existence.

The hospital system was developed during the rule of Emperor Ashoka (third century BCE), schools of learning in the healing arts were created. Many valuable herbs and medicinal combinations were created. Even today many of these continue to be used.

The Emperor Ashoka was the first leader in world history to attempt to give health care to all of his citizens, thus it was the India of antiquity which was the first state to give its citizens national health care. There were hospitals not only for people but also for animals.

During the eleventh century The Arabic system known as "Unani" was introduced in India by the Arabs and Persians.

Pre independence Era

The British had established their rule in India in 1757. A Royal Commission was appointed to investigate the causes of the extremely unsatisfactory condition of health in the British army stationed in India. The commission pointed out the need for the protection of water supplies, construction of drains and prevention of epidemics in civil population for safeguarding the health of the British army.

An epidemic of plague in 1896 awakened the government to the urgent need of improving public health. The All India Institute of Hygiene and Public Health, was established in Calcutta with aid from the Rockefeller foundation. The Health survey and Development Committee (Bhore Committee) was appointed by the government of India to survey the existing position in regard to health conditions and health organization in the country and to make recommendations for the future development. In 1946 the Bhore committee recommended a short term and long-term programme for the attainment of reasonable health services based on concept of modern health practice.

Post-independence Era

India became independent in 1947 with new concept of establishing a welfare state. The burden of improving the health of people and widening the scope of health measures fell upon the center and states. Government appointed various committees for health analysis in the country.

The Alma Ata deceleration of 1978 launched concept of "Health for All 2000 A.D." and introduced the concept of primary health care. It was totally state's responsibility to provide primary health care to the people and led to the formulation of the first National Health Policy.

In 1983, 1st National Health Policy was introduced. The major goals of the policy was to provide universal, comprehensive primary health services and articulated the need to encourage private initiative in health care service delivery.

1980-90 the period of Neoliberal economic and health sector reform that were aimed at increasing the importance of the private sector and desire to utilize private sector resources for addressing public health goals, and Liberalization of insurance sector to provide health financing system.

In the year of 2000, the national population policy (NPP) was announced to address the unmet need of contraception, health care infrastructure, and health personnel, and to provide integrated delivery for basis reproductive and child care services.

Near 20 years after the first health policy, the 2nd National Health Policy was introduced in 2002. The NPH was set a new policy framework to achieve public health goals by the increasing access to the decentralized public health system by establishing new infrastructure indifferent area and upgrading the infrastructure of existing institutions.

Recently in 2005, The Government of India has launched the National Rural Health Mission with the goal of improving the availability of and access to quality health care by people, especially for rural areas. NRHM provide great strength to the rural health care delivery system.

Most recently in 2007, telemedicine and the medical tourism were introduced in the health care system of India.

Model of HEALTH CARE DELIVERY system

The challenge that exists today in many countries is to reach the whole population with adequate health care services and to ensure their utilization. For that the numerous models have been developed for the delivery of health care services. One of the simplest model is –

• The" inputs" are the health status or health problems of the community; they represent the health needs and health demands of the community. Since sources are always limited to meet the many health needs, priorities have to be set.
• The "health care services" are designed to meet the health needs of the community through the use of available knowledge and resources. The services provided should be comprehensive and community-based.
• The "health care system" is intended to deliver the health care services; it constitutes the management sector and involves organizational matters.
• The final outcome or output is the changed health status or improved health status of the community which is expressed in terms of lives saved, deaths averted, diseases prevented, etc.

Organization & administration of health system in india

Health administration is the science of the organizing and coordinating government agencies whose purpose is to improve the physical, mental and social well-being of the people of the country. It is a part of the public administration.

India is a Union of 28 States and 7 Union territories. Under the Constitution of India, the States are largely independent in matters relating to the delivery of health care to the people. Each State has developed own system of health care delivery, independent of the Central Government.

The Central responsibility of an organization of policy making, planning, guiding, assisting, evaluating, and coordinating the work of the State Health Ministries, so that health services cover every part of the country, In order to achieve the goal to "Health for All – 2020". Health administration governed in India at 4 levels -

1. National level (Central level)
2. State level
3. District level
4. community level

CENTRE level Health Care Administration

The official "organs" of the health system at the national level consist of:

1. The Ministry of Health and Family Welfare;
2. The Directorate General of Health Services; and
3. The Central Council of Health and Family Welfare

1. Union Ministry of Health and Family Welfare

ORGANIZATION

The Union Ministry of Health and Family Welfare is headed by a Cabinet Minister, a Minister of State and a Deputy Health Minister. The Union Ministry has three departments-

1. Departments of health
2. Departments of family welfare
3. Departments of Indian Systems of Medicine and Homoeopathy (ISM&H)

FUNCTIONS of the Union Health Ministry

• The functions of the Union Health Ministry are set out in the seventh schedule of Article 246 of the Constitution of India under

1. The Union list and
2. The Concurrent list

• Union list
• The functions given in the Union list are:
  • International health relations and administration of port quarantine
  • Administration of central institutes such as the All India Institute of Hygiene and Public Health, Kolkata; National Institute for the Control of Communicable Diseases, Delhi, etc.
  • Promotion of research through research centers and other bodies
  • Regulation and development of medical, pharmaceutical, dental and nursing professions
  • Establishment and maintenance of drug standards
  • Census, and collection and publication of other statistical data
  • Immigration and emigration
  • Regulation of labour in the working of mines and oil fields and
  • Coordination with States and with other ministries for promotion of health.
• Concurrent list
• The functions listed under the concurrent list are the responsibility of both the Union and State governments.
• The concurrent list includes:
  • Prevention of communicable diseases
  • Prevention of adulteration of foodstuffs
  • Control of drugs and poisons
  • Vital statistics
  • Labour welfare
  • Ports other than major
  • Economic and social planning, and
  • Population control and Family Planning

Functions of Department of Medical & Public Health

• The functions of the Department of Medical & Public Health are –
  • Health Policy preparation
  • National Health Programs conduction
  • Drug Control
  • PFA enforcement
  • Diseases control-
  • Communicable/Non-communicable
  • Supplies & Disposal Maintenance
  • CME & Trainings
  • Medical Education & Research
  • Vital statistics & Health intelligence
  • International support

Functions of Department of Family Welfare

• The functions of the Department of Family Welfare are –
  • Policy preparation & Planning
  • Information collection & Evaluation
  • Contraceptive-Research /Supply
  • Seeking International support for Family Welfare
  • EPI/UIP/CSSM/RCH/ARI/ORT-Trainings & area development
  • Maternal and Child Health Services.
  • IEC - Information, Education and Communication.
  • Rural Health Services
  • Paraprofessional training
  • NGO support
  • Development of Sub-center

Functions of Department of IMS&H

• The functions of the Department of IMS&H are –
  • Upgrade the educational standards in the Indian Systems of Medicines and Homoeopathy colleges in the country;
  • Strengthen existing research institutions and ensure a time-bound research programme on identified diseases for which these systems have an effective treatment;
  • Draw up schemes for promotion, cultivation and regeneration of medicinal plants used in these systems;
  • Evolve Pharmacopoeial standards for Indian Systems of Medicine and Homoeopathy drugs

1. The Directorate General of Health Services

ORGANIZATION

Directorate General of Health Services [DGHS] is the principal adviser for the Union Govt. in both medical and public health matters. He is assisted by additional director, a team of deputies and a large administrative staff. It comprises of three units – medical care and hospital, public health and general health.

functions

• The general functions are surveys, planning, coordination, programming and appraisal of all health matters in the country.
• The specific functions are -
• International health relations and quarantine: All the major ports in the country and international air ports are directly controlled by the Directorate General of Health Services. All matters relating to the obtaining of assistance from International agencies and the coordination of their activities in the country are undertaken by the Directorate General of Health Services.
• Control of drug standards: The DGHS is headed by the Drugs Controller. Its primary function is to lay down and enforce standards and control the manufacture and distribution of drugs through both Central and State Government Officers.
• Medical store depots: The Union Government runs medical store depots. These depots supply the civil medical requirements of the Central Government and of the various State Governments. These depots also handle supplies from foreign agencies. The Medical Stores Organization endeavors to ensure the highest quality, cheaper bargain and prompt supplies.
• Post graduate training: The DGHS is responsible for the administration of national institutes, which also provide post-graduate training to different categories of health personnel.
• Medical education: The Central Directorate is directly in charge of the following medical colleges in India: the Lady Harding, the Maulana Azad and the medical colleges at Pondicherry, and Goa. Besides these, there are many medical colleges in the country which are guided and supported by the Centre.
• Medical Research: Medical Research in the country is organised largely through the Indian Council of Medical Research, founded in 1911 in New Delhi. The funds of the Council are wholly derived from the budget of the Union Ministry of Health.
• Central Govt. Health Scheme
• National Health Programmes: Health programmes of this kind can hardly succeed without the help of the Central Government. The Central Directorate plays a very important part in planning, guiding and coordinating all the national health programmes in the country.
• Central Health Education Bureau: An outstanding activity of this Bureau is the preparation of education material for creating health awareness among the people. The Bureau offers training courses in health education to different categories of health workers.
• Health Intelligence: The Central Bureau of Health Intelligence was established in 1961 to centralize collection, compilation, analysis, evaluation and dissemination of all information on health statistics for the nation as a whole. It disseminates epidemic intelligence to States and international bodies. The Bureau has an Epidemiological Unit, a Health Economics Unit, a National Morbidity Survey Unit and a Manpower Cell.
• National Medical Library: The Central Medical Library of the Directorate General Health Services was declared the National Medical Library in 1966. The aim is to help in the advancement of medical, health and related sciences by collection, dissemination and exchange of information.

1. Central Council of Health

The Central Council of Health was set up by a Presidential Order on 9 August, 1952 under Article 263 of the Constitution of India for continuous consultation, mutual understanding and cooperation between the Centre and the States in the implementation of all the programmes and measures pertaining to the health of the nation.

ORGANIZATION

• The Union Health Minister is the Chairman and the State Health Ministers are the members.

FUNCTIONS

• The functions of the Central Council of Health are:
  • To consider and recommend broad outlines of policy in regard to matters concerning health in all its aspects such as the provision of remedial and preventive care, environmental hygiene, nutrition, health education and the promotion of facilities for training and research.
  • To make proposals for legislation in fields of activity relating to medical and public health matters and to lay down the pattern of development for the country as a whole.
  • To make recommendations to the Central Government regarding distribution of available grants-in-aid for health purposes to the States and to review periodically the work accomplished in different areas through the utilization of these grants-in-aid.
  • To establish any organisation or organizations invested with appropriate functions for promoting and maintaining cooperation between the Central and State Health administrations

STATE level Health Care Administration

• Organizational structure at the state level is on the similar pattern as that as that as the central level. Health being a state subject, the state govt. has autonomy in dealing with health matters.
• At present there are 28 States in India, with each state having its own health administration.

State Ministry of Health and Family Welfare

• The State Ministry of Health is headed by a Minister of Health and Family Welfare and a Deputy Minister of Health and Family Welfare. These are political appointments and they are elected members of legislative assembly.
• They have political responsibilities, responsibilities towards their constituencies as per their political agenda, and responsibilities for administration and management of Health and Family Welfare services in their state.

Health Secretariat

• The State Health and Family Welfare Minister is assisted for all administrative aspects of health care by the Health Secretariat, that is the official organ of his Ministry.
• The Health Secretariat is headed by the secretary who is assisted by Additional, Deputy and Assistant Secretaries and other hierarchy of administrative staff.

Functions

• The major functions which are performed by the secretariat include helping minister in:-
  • Formulation, review and modification of broad policy outlines.
  • Execution of policies programmes etc.
  • Coordination with Government of India and other state Governments.
  • Control for smooth and efficient functioning of administrative machinery.

State Health Directorate

• The State Health Directorate is the technical wing of state Ministry of Health and Family Welfare.
• Before independence, the Medical and Public Health Services at the State level like at the Centre were also administered by two separate departments headed by surgeon General and Inspector General of civil hospitals and Director of Public Health Services respectively.
• After independence these two departments medical health and public health were integrated into State Directorate of Health Services as recommended by Dr. Bhore committee report in 1946.
• State Health Directorate is headed by Director of health services. In some States he is designated as Director of Health and Family Welfare.
• He is the chief technical advisor to the stale Government on all matters of Medical, Public Health and Family welfare.
• He is assisted by a number of Deputy and Assistant Directors to plan and provide health care services to meet health care needs of the State as per Govt. health policy.
• The Deputy and Assistant Directors of Health may be of two types - regional and functional. The Regional Directors inspect all the branches of public health within their jurisdiction, irrespective of their specialty. The Functional Directors are usually specialists in a particular branch of public health such as mother and child health, family planning, nutrition, tuberculosis, leprosy, health education etc.

Functions

• It studies in department of the health problem and need of the state and planning for health services in the state.
• Implementation of national health programmes and evaluating their achievements.
• Promoting providing and supervising all types of health services in the state such as primary health services; school health services; family planning services; MCH; occupational health services etc.
• Collection of vital statistics.
• Encouraging reproductive and child health (Family welfare. maternal health etc.)
• Improvement of nutrition programme and Controlling food adulteration and also sanitation in milk and edibles.
• Medical and nursing education, training of nurses, female health workers and other health workers.
• Controlling rural and urban health services through district medical officer.
• Providing feedback to the state health ministry regarding health.
• Following the directives of union ministry of health/state health ministry.

District level Health Care Administration

District - An Administrative unit Defined Geographical boundary and Population. Within each district again, there are 6 types of administrative areas -     Sub – divisions, Tehsils (Talukas), Community Development Blocks, Municipalities and Corporations (urban area), Panchayats (Villages)

• District is Peripheral most Planning unit
• It is a self-contained segment of National Health System
• Middle level management organisation
• The principal unit of administration in India is the district under a Collector.
• It is a link between the State/ regional structure on one side and the peripheral level structures such as PHC/ Sub-Centre on the other side.

Organization

Chief Medical and Health Officer (CM & HO)

Chief Medical and Health Officer - CM & HO is a Director of health and family welfare service at the district in rural area and are overall in-charge of the health and family welfare programmes in the rural area. CM&HO is assisted by Dy. CMO, rhc officer and programme officers. Dy. CMO and rhc officer are assisted by Block CMOs.

Principle Medical Officer (PMO)

Principle Medical Officer – PMO is a Director of health and family welfare service at the district in urban area and is overall in-charge of the health and family welfare programmes in urban area.

Functions of District Health System

• Liaison between Field units & Headquarter
  • Field reports
  • Inspections
  • Meetings
• Implementation of Policy & Programs
• District level planning & Action Plans
• Rationale use of Finance & Resources
• Communication Management
  • Plans/Schedules/Progress/Problems
• Control & Monitoring

community level Health Care Administration

Organization

Centre	Population Norms
	Plain Area	Hilly/Tribal/Difficult Area
CHC	1,20,000	80,000
PHC	30,000	20,000
Sub-Centre	5000	3000

COMMUNITY HEALTH CENTRE

Community health Centre (CHC) has been established for every 80,000 to 120,000 population and this centre provides the basic specialty services in general medicine, Pediatric, surgery, obstetrics and gynecology.

Functions of Chc

• Care of Routine and emergency cases in medicine
• Care of Routine and emergency cases in surgery.
• 24 hour delivery services, including normal and assisted deliveries.
• Essential and emergency obstetric care
• FP services including laparoscopic services
• New born care
• Routine and emergency care of sick children
• Other management including nasal packing, tracheotomy, foreign body removal etc.
• All the national health programmes (NHP) should be delivered through the CHC.
• Other:-
  • Blood Storage Facility
  • Essential laboratory Services
  • Referral Services

Staffing Pattern at CHC

• Existing Clinical manpower
  • General Surgeon            1
  • Physician                 1
  • Obstetrician/ Gynecologist     1
  • Pediatrician             1
• Existing Support Manpower
  • Nurse- Mid wife            7+2
  • Dresser                 1
  • Pharmacist/ Compounder    1
  • Lab technician            1
  • Radiographer            1
  • Ophthalmic assistant        1
  • Ward boy/ nursing orderly    2
  • Sweepers                2
  • Chownkidar            1
  • OPD attendant            1
  • Data Entry Operator        5
  • OT attendant            1
  • Registration Clerk        1

Primary health centre level

At present there is one primary health centre covering about 30,000 (20,000 in hilly, desert and difficult terrains) or more population. Many rural dispensaries have been upgraded to create these PHCs. The bed strength of Primary health centre is 6. (but can be raised up to 10)

Functions of Phc

• Medical Care
• MCH including Family Planning
• Safe water supply and basic sanitation
• Prevention and control of locally endemic diseases.
• Collection and reporting of vital statistics.
• Education about health
• National health programmes as relevant
• Referral services
• Training of health guides, health workers local dais and health assistants.
• Basic laboratory services.

Staffing Pattern of PHC

• Medical Officer            1
• Pharmacist            1
• Nurse Mid-wife            1
• Health Worker (female)/ANM 1
• Block Extension Educator    1
• Health Assistant (Male)     1
• Health Assistant (Female)    1
• U.D.C (Upper Division clerk) 1
• L.D.C (Lower Division Clerk) 1
• Lab. Technician          1
• Driver                1
• Class IV                4
• Total                 15

Sub – Centre Level

The sub center is the peripheral outpost of exiting health care delivery system in rural areas. it provides interface with community at the grass root level ,providing all the primary health services. one sub-centre for every 5000 population in general and one for every 3000 population in hilly, tribal and backward areas. Each sub – centre is manned by one male and one female multipurpose health worker.

Functions of Sub- Centre

• Mother and child health care
• Family planning and immunization
• It is proposed to extend the facilities at all sub- centers for IUD insertion, and simple laboratory investigation like routine examination of urine for albumin and sugar.
• The work at sub-centers is supervised by male and female health assistants.
• According to the revised norm, one female HA will supervise the work of 6 female Health Workers.

Staffing Pattern of Sub- Centre

• Health Worker (Female)/ ANM    1
• Health Worker (Male)            1
• Voluntary Worker            1
• Total                     3

HEALTH CARE DELIVERY SYSTEM in india

Health care services in general are rendered by the government through a network of health centres from the grassroots areas to the block level in the rural areas and through hospitals, dispensaries, maternal, child health and family welfare centers in the urban areas. The hospitals in the sub divisional, Talukas level, district level etc. provide referral services to the infrastructure in the rural area.

There are also voluntary and private agencies which are functioning to deal with the health problems of people. The delivery system is-

1. Public or Govt. sector

Public sector is govt. sponsored system. It is funded by the public funds which are generated through general taxes. The services are rendered to the people at large in rural and urban areas by three tier system developed at the block level, district and state level.

1. Rural Health service

The health services in the rural areas are rendered through a network of infrastructure developed from within the village and in continuum up to block level. The major emphasis is on promotive and preventive health care services and comprises primary health care.

At the village level, elementary services are rendered by trained village health guides, birth attendants (local Dias) and anganwari workers. They belong to the village they serve and are non-governmental functionaries. They are included in the health care delivery system to promote and encourage community participation and to have a link between the community and the health functionaries.

The village health guide provide simple treatment for common minor ailments, first aid during accidents and emergency, care to mother and children including family planning, health education etc.

The trained birth attendants work under the supervision and guidance of female health worker and provide personal and skillful care during prenatal period, give health education on child care, immunization, nutrition, and family planning.

Anganwari workers work in Anganwaries and carry on the responsibility of health check-ups, supplementary nutrition, immunization, non-formal education of children enrolled in Anganwardi. They coordinate with the ANMs in their areas for some of the functions eg. Immunization and health check-up of children. Each one serves a population of 1000 in the village.

The continuum of health centres which provide primary health care services include subcentres, primary health centres and community health centres. The sub centre serve a population of 5000 in plain area and 3000 in hilly, tribal and backward areas. The limited primary health care services which are provided from sub centres include; maternal and child health, family planning, prevention and control of communicable diseases, treatment of minor ailments, record of vital events, emergency care, maintenance of record and reports, supervision and training of dais and village health guides. The services are rendered by ANMs i.e. health workers (F) and health worker (M) under the supervision and guidance of health supervisor (F and M) respectively.

1. Urban Health Services

The services in the urban areas are rendered through district hospitals and medical college hospitals. There are also hospitals and institutes of higher education and research which are under Central Govt. and provide general as well as referral services. In addition to these hospital services, there are maternal and child health , family welfare centers, family planning clinics, dispensaries, maternity homes, community hospitals run by local Govt. to provide specific primary level services to defined population.

1. Health insurance system

In India health insurance system is restricted to factory/industrial workers and their families and central govt. employees and their families. They are covered by 2 different very well organized health insurance schemes. This are-

1. Employees State Insurance - The ESI scheme was started under the parliament Act in 1948 to provide medical benefits in kind and cash during sickness, employment injury, maternity etc. the scheme is based on the contributions from the employer, employees and the government.
2. Central Govt. Health scheme - This scheme is for the Central Government Employers. To start with it was introduced in Delhi in 1954 to provide comprehensive health care to central govt. employees. Gradually it was extended to other cities not only to central govt. employees and their family members but also other autonomous organizations employees, members of parliament, retired central govt. servants, widow receiving family pensions, Governors and retired judges.
   The scheme is on the cooperative efforts and contribution basis from the employees and employer for their mutual benefits. The services are given through a network of dispensaries, governmental hospitals, and identified private specialized hospitals in various systems of medicine.
   The CGHS provides outdoor, domiciliary, indoor, specialists consultations, emergency, maternal and child welfare and family welfare services. It also supplies optical and dental aids at reasonable rates.

1. Other Agencies - Railway Hospitals & Military Hospitals

The services to these people and their families are rendered by specially organized armed forces medical services and railways health services respectively. Comprehensive preventive, promotive, curative and rehabilitative services are rendered through specially organized health units, clinics, hospitals etc.

1. Indigenous system of medicine [AYUSH]

The indigenous systems of medicine form an important part of public system of health care delivery in both rural and urban areas. Services are rendered through out-patient departments, dispensaries and hospitals.

1. National health programme

In addition to various levels of health care services through public system, the govt. of India has put in lot of efforts to deal with various health problems at the national level. These problems are related to communicable and non- communicable diseases, environmental sanitation problem, nutritional problems, population problems etc.

The govt. of India through its ministry of health and family welfare have launched ongoing various national health programmes in successive five year plans since independence. The technical and material assistance have also been obtained by various international and bilateral agencies in planning and implementation of these programmes. These organizations include WHO, UNICEF, Word bank, UNFPA, DANIDA etc.

1. Voluntary health agencies

There are varieties of non- governmental organizations which are voluntary in nature and contribute tremendously in furthering the public health by providing health services, or health education, by advancing research etc.

The NGOs complement and supplement role of govt. agencies. There are also "not for profit" voluntary hospitals which generate funds to sustain and provide charitable services e.g. Holy Familya Hospital.

1. Private sector

Like voluntary health sector, the private health sector also occupies an important place in health care delivery system in the country. There has been extensive growth in the private owned facilities since independence but more so during the last decade, there has been significant increase in the number of medical practitioners. They range from herbal and witch doctors to modern unqualified or quasiqualified "quacks" to qualified practitioners of different system of medicine, many of whom also indulge in quackery.

The different system of medicine includes Allopathy or Modern Medicine, Homeopathy, Ayurveda, Unani And Siddha. Apart from these, there are other like Yoga, Naturopathy and Chiropractice. There are large numbers of practitioners who have not qualified in any of the recognized systems. It is this diversity and complexity which is in part responsible for lack of regulation and quality control in private practice.

Further, those who are qualified in modern medicine tend to locate themselves in urban areas and all others are equally locate themselves in urban areas and all others are equally located in urban and rural areas. There are three times more allopathic in urban than in rural areas.

There has been increase in the number of private hospitals including those owed by the voluntary agencies. The private consultants are attached to these hospitals. They participate in the services organized by the hospital as well as they have their own private OPD/clinics and cases in hospital. The fee which is charged for the services varies depending upon the level, standard, popularity etc. of the hospital; consultant; locality etc. there is no uniform pattern and there is no control over this. The system is beyond the reach of even an average middle class family. It is not an organized system of providing health care services. Efforts are being put into maintain the standards through legislation related to nursing homes and hospitals and consumer protection act.

The various diagnostic facilities are on the increase to assist in making diagnosis but these are very expensive and often exploited liberally. The govt. is putting in efforts to involve Medical Council of India and Indian Medical Association to regulate the system etc.

1. Medical Truism and Telemedicine

Medical tourism is one of the major external drivers of growth of the Indian healthcare sector. This is a developing concept whereby people from world over visit India for their medical and relaxation needs. Most common treatments are heart surgery, joint replacement, orthopedic surgery, gastroenterology, ophthalmology, transplants, urology, cosmetic surgery and dental care. Hospitals groups like The Global Hospitals Group, MIOT Hospitals, Fortis Healthcare, Apollo hospitals, Max Hospitals, Dharamshila Cancer Hospital and Research Centre have increased their presence in international market for medical tourism.

In the current rapidly changing healthcare scenario the magnitude of the problem associated with healthcare delivery is enormous and extremely dynamic. However, present day technology has the solution for this problem. User-friendly equipment with compatibility to integrate technologies like telemedicine makes the solution simpler.

Telemedicine system is growing rapidly in India, nearing 700 million rural populations of India will benefit enormously from digital data transmission related to healthcare. Both public and private entities are aggressively pursuing the use of telemedicine to hasten diagnostics and treatment of a variety of diseases. Private hospitals such as Apollo Hospital Group, Escorts Heart Institute and Fortis Healthcare are provide these services in India.

Challenges in health system

• Manpower- Number & Norms
• Rural / Urban differential
• Geographical divide across States
• S-E groups –accessibility/ reach
• Gaps between Policy & Action
• Health sector expenditure
• Newer Infections

Role of nurse in health care delivery system

• Care-Provide
• Planner
• Sensitive Observer
• Educator Manager
• Organizer
• Evaluator
• Controller And
• Administrator

BIBLIOGRAPHY

1. http://en.wikipedia.org/wiki/Healthcare_in_India
2. http://www.americanprogress.org/issues/2008/10/health_care_delivery.html
3. http://research.microsoft.com/enus/collaboration/fourthparadigm/4th_paradigm_book_part2_robertson_heckerman.pdf
4. K.park 'textbook of preventive and social medicine 'published by Banarsidas .Bhanot edition 2009,p765-775
5. J.kishore 'national health programs of India' published by century publications edition 2010 pp 63 to 69..
6. TNAI; Textbook of manual of community health,(3):141-143.
7. J.kishore;national health programs of india;7 ed;2007:58-61.
8. George S.Health care delivery system;www.social science research network.2005(5):19-21.
9. Diwakar G.health care delivery system in India. The Heinz school review.2006;3(2):34-36.
10. Madura G. India launches national rural health mission. British medical journal. 2005;4(3):33-35.