Application of the Nursing Process Assessment and Diagnosis
The following example demonstrates the process of collecting and analyzing data and deriving community diagnoses. It also exemplifies the multiple care levels within which community health nurses’ function: the individual client, the family, and the aggregate or community levels.
In this scenario, the nurse identified an individual client health problem during a home visit, which provided the initial impetus for an aggregate health education program. Data collection expanded from the assessment of the individual to a broad range of literature and data about the nature of the problem in populations. The nurse then formulated a community-level diagnosis to direct the ensuing plan. This was subsequently implemented at the aggregate level and then evaluated.
School nurses frequently address a broad range of student health problems. In the West San Antonio School District, school nurses generally reserve several hours a week for home visits. In a recent case, a teacher expressed concern for a high school junior named “John” whose brother was dying of cancer. In a health class, John shared his personal fears about cancer, which caused his classmates to question their own cancer risks and how they might reduce them.
The school nurse visited John’s family and learned that the 25-year-old son had testicular cancer. Since his diagnosis 1 year earlier, he had undergone a range of therapies that were palliative but not curative; the cancer was advanced at the time of diagnosis. The nurse spent time with the family discussing care, answering questions, and exploring available support for the entire family.
At a school nurse staff meeting, the nurse inquired about her colleagues’ experiences with other young clients with this type of cancer. Only one nurse remembered a young man with testicular cancer. The nurses were not familiar with its prevalence, incidence, risk factors, prevention strategies, or early detection approaches. The nurse recognized the high probability that high school students would have similar questions and could benefit from reliable information.
The school nurse embarked on a community assessment to answer these questions. The nurse first collected information about testicular cancer. Second, the nurse reviewed the nursing and medical literature for key articles discussing client care, diagnosis, and treatment. Epidemiological studies provided additional data regarding testicular cancer’s distribution pattern in the population and associated risk factors.
The nurse learned that young men aged 20 to 35 years were at the greatest risk. Other major risk factors were not identified. It was learned that healthy young men do not seek testicular cancer screening and regular health care; they may be apprehensive about conditions affecting sexual function.
These factors contribute to delays in detection and treatment. Although only an estimated 8850 new cases of testicular cancer will have been diagnosed in the United States in 2017, it is one of the most common tumors in young men. Furthermore, this cancer is amenable to treatment with early diagnosis (American Cancer Society, n.d.).
On the basis of these facts, the nurse reasoned that a prevention program would benefit high school students. However, to perform a comprehensive assessment, it was important that the nurse clarified what students did know, how comfortable they were discussing sexual health, and how much the subject interested them.
Therefore, the nurse approached the junior and senior high school students and administered a questionnaire to elicit this information. The nurse also queried the health teacher about the amount of pertinent cancer and sexual development information the students received in the classroom.
The nurse considered the latter an important prerequisite to dealing with the sensitive subject of sexual health. According to the health teacher, the students did receive instruction about physical development and psychosexual issues. Students expressed a strong desire for more classroom instruction on these subjects and more information on cancer prevention. However, they did not have sufficient knowledge of the beneficial health practices related to cancer prevention and early detection.
Key Assessment Data
There is an increased risk of undetected testicular cancer among young men related to insufficient knowledge about the disease and the methods for preventing and detecting it at an early stage, as demonstrated by high rates of late initiation of treatment.
Clarifying the problem and its cause helped the nurse direct the planning phase of the nursing process and determine both long-term and short-term goals.
The long-term goal was:
The short-term goals were:
Planning encompassed several activities, including the discovery of recommended health care practices regarding testicular cancer. The nurse also sought to determine the most effective and appropriate educational approaches for male and female high school students. Identifying helpful community agencies was also an essential part of the process. The local chapter of the American Cancer Society provided valuable information, materials, and consulting services. A nearby nursing school’s media center and faculty were also very supportive of the program.
After formalizing her objectives and plan, the nurse presented the project to the high school’s teaching coordinator and principal. Their approval was necessary before the nurse could implement the project. After eliciting their enthusiastic support, the nurse proceeded with more detailed plans. She selected and developed classroom instruction methods and activities that would maximize high school students’ involvement.
The nurse also ordered a film and physical models for demonstrating and practicing testicular self-examination. She prepared group exercises designed to relax students and help them be comfortable with the sensitive subject matter. The nurse scheduled two 40-minute sessions dealing with testicular cancer for the junior-level health class. In a final step of the planning phase, she designed evaluation tools that assessed knowledge levels after each class session and measured the extent to which students integrated these health practices into their lifestyles at the end of their junior and senior years.
The nurse was now ready to proceed with the implementation of a testicular cancer prevention and screening program. She initiated the assessment phase by identifying an individual client and family with a health need, and she extended the assessment to the high school aggregate. Her data collection at the aggregate level, for both the general and local high school populations, assisted in her community diagnosis. The diagnosis directed the development of a community-specific health intervention program and its subsequent implementation and evaluation.
The nurse conducted the two sessions in a health education class. At the beginning of the class period, students participated in a group exercise, and the nurse asked them about their knowledge of testicular cancer. The nurse showed a film and led a discussion about cancer screening. In the second session, she demonstrated the self-examination procedure using testicular models and supervised the students while they practiced the procedure on the models. The nurse advised the male students about the frequency of self-examination. With the females, she discussed the need for young men to be aware of their increased risk, drawing a parallel to breast self-examination.
After completing the class sessions, the nurse administered the questionnaires she had developed for evaluation purposes. Analysis of the questionnaires indicated that knowledge levels were very high immediately after the classes.
Students were pleased with the frank discussion, the opportunity to ask questions, and the clear responses to a sensitive subject. Teachers also offered positive feedback. Consequently, the nurse became a knowledgeable health resource in the high school.
Intermediate-term evaluation occurred at the end of the students’ junior and senior years. The nurse arranged a 15-minute evaluation during other classes, which assessed the integration of positive health practices and testicular self-examinations into the students’ lifestyles.
At the end of the school year, the prevalence of regular self-assessment was significantly lower than knowledge levels. However, 30% of male students reported regularly practicing self-examinations at the end of 1 year, and 70% reported they had performed self-examination at least once during the past year.
The compilation of incidence data is ideal for long-term evaluation, and it documents the reduction of a community health problem. Testicular cancer is very rare; therefore, incidence data are not reliable and may not be feasible to collect. However, for more prevalent conditions, objective statistics help reveal increases and decreases in disease rates, and these may be related to the strengths and deficiencies of health programs.
Levels of Prevention
The following are examples of the three levels of prevention as applied to this case study.