Assessment Tool

APPENDIX
Public Health Nursing Assessment Tool

Designed by Sandra B. Lewenson and Marie Truglio-Londrigan for Public Health Nursing: Applying and Doing
42 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Suggestions for Table Use: 1. Read all horizontal and vertical columns. These will give clues about the key questions to ask. 2. Fill in the vertical column for each table that requests information on the Seven As. When lling in these boxes, place the most pertinent information that you think informs the assessment. 3. When completing Section I Part 33(B-1): Access to Care, note that this is a summary of the work that you did in Part 1. Reect on this information and arrive at your decisions pertaining to access to care. 4. In some instances, you need to consider collecting data on multiple years to identify trends. You can duplicate these tables and use them to collect the data on different years using census data.
5. Remember that this is a working document that you, the public health nurse, can adjust and revise to meet the needs of the community you are assessing. The collection of data is more than lling in the boxes. You may need to collect additional data in a particular area, depending on what you learn as you go. For example, you may ll in the boxes about the number of schools in a community, but you may also want to know the number of students per faculty member, if a community collaborator cited that as a concern. 6. In some instances, there will be overlap of data collection. Because information for this tool will usually be collected by a group, in qualitative research the overlap may be considered a saturation of data. In the analysis section, these data will provide a variety of perspectives.
SECTION I PART 1: FOUNDATIONAL HEALTH MEASURES

General Health Status
Refers to information that will inform the public health nurse and partners in the health initiative about the health of the population (U.S. DHHS, 2010d). It is important to note that some of this information is not population focused such as self-assessed health status; however, this is an example of how public health nurses serve individuals in the community as well as the general population.
Section I Part 1: Foundational Health Measures
43
Section I Part 1
A-1 Individual and Family When appropriate, the public health nurse will include self-assessed health status as well as history, physical, genogram, ecogram, and any other tools used by his or her organization. Summarize your finding in a narrative form below.
Source of Evidence:
Section I Part 1
B-1 Population: Vital Statistics
Census Track # Live births General deaths % Community # % County # % # State %
Source of Evidence:
Section I Part 1
B-2 Population: Mortality
Census Track Community County State
Source of Evidence:
Section I Part 1
B-3 Population: Morbidity
Source of Evidence:
45
Section I Part 1
B-4 Population: Life Expectancy
Census Track Community County State International
Source of Evidence:
Section I Part 1
B-5 Population: Healthy Life Expectancy
Source of Evidence:
Section I Part 1
B-6 Population: Years of Potential Life Lost (YPLL)
Source of Evidence:
Section I Part 1
B-7 Population: Physically and Mentally Unhealthy Days
Source of Evidence:

Health-Related Quality of Life and Well-Being
Health-related quality of life is a complex concept and focuses on the impact health status has on quality of life (U.S. DHHS, 2010e). This portion of the PHNAT also focuses on the individual and again sheds light on those public health nurses who do practice on a one-to-one basis with clients in the community.
Section I Part 2
A-1 Individual and Family*Includes review of the following:
Patient-Reported Outcomes Measurement Information System (PROMIS) (www.nihpromis.org/default.aspx) tools to measure health outcomes from a patient perspective Well-being measures Participation measures (activities of daily living, instrumental activities of daily living) *There is no B in Section I Part 2.
47

Determinants of Health Section I Part 3-1
Biology and Genetics The determinants of health under biology and genetics include data that are individual/ family focused or population focused. The public health nurse gathers the information on the individual and family as a client using whatever health assessment tool he or she uses in the particular academic or clinical setting. Pertaining to the population aggregate, data such as age, race and gender would be considered important to gather.
Section I Part 3-1

A-1 Individual and Family Assessment In this section, when appropriate, the public health nurse includes an assessment of the individual and family. Include the history, genogram, and ecogram. Special consideration is given to analysis of genetically defined diseases such as sickle cell anemia, cystic fibrosis, and BRCA1 or BRCA2.
Section I Part 3-1

B-1 Population
Population at last census
Population density
Population changes in the last 10 years
Source of Evidence:
Section I Part 3-1

B-3 Population: Race Distribution
Census Track # White Black/African American Hispanic Asian Native American Other % Community # % County # % # State %
Source of Evidence:
Section I Part 3-1

B-4 Population: Gender Distribution
Census Track # Female Male % Community # % County # % # State %
Source of Evidence:
Section I Part 3-2

Social Factors Social factors, the next determinant of health to be considered, include social determinants of health and physical determinants or conditions in the environment (U.S. DHHS, 2010b). Social factors that the public health nurse assesses include the clients interactions and connections with family, friends, and others in their community. The second part includes physical determinants. The public health nurse must assess the physical environment of the community at large.
49
Section I Part 3-2

A-1 Social Determinants: Housing Conditions
Housing Subsidies/Homeless Provisions
Housing Characteristics
Total # of Units
Owner Occupied
Renter Occupied
Vacant
Source of Evidence:
Section I Part 3-2

A-2 Social Determinants: Transportation
Description of Services: Cost, Destination of Service, Quality of Service, Condition of Services and/or Roads, Handicap Accessibility Train Bus Taxi including private services Major roads Minor roads Volunteers providing transportation School buses Adequate/Inadequate (Analysis of Seven As will assist with determining adequacy or inadequacy)
Source of Evidence:
Section I Part 3-2

A-3 Social Determinants: Workplace
What Workplace Safety Measures Are in Place? What Is the Estimated Yearly Salary Range of Employees?
Description of Workplace Professional, Industry, Factories, Schools, Town, City, County, Businesses
List Places of Employment
Additional Questions to Ask: Do most people who reside in the community work in the community or do they commute? If they commute, what is their mode of transportation? What is the cost of that commute? What is the time of the commute? Does this commute impact quality of life? Source of Evidence:
51
Section I Part 3-2

A-4 Social Determinants: Recreational Facilities
Area Served/Services Provided, Cost, Population Served, Hours, Maintenance of Recreation Facilities (e.g., parks, playgrounds, athletic fields)
Adequate/Inadequate (Analysis of Seven As will assist with determining adequacy or inadequacy)
Recreational Facilities
Source of Evidence:
Section I Part 3-2

A-5 Social Determinants: Educational Facilities
# of Public Preschool Elementary Junior high Senior high Colleges/universities Early morning programs Recreational programs within school system After-school programs # of Private (religious) # of Private (secular)
Source of Evidence:
Section I Part 3-2

A-6 Social Determinants: Places of Worship
Name/Address/Phone
Denomination
Services
Source of Evidence:
Section I Part 3-2

A-7 Social Determinants: Social Services
Adequate/Inadequate Area Served/ Services Provided/ Cost of Services (Analysis of Seven As will assist with determining adequacy or inadequacy)
Agency Name/Address/Phone (food and clothing banks, homeless shelters, adult day care social services, child care)
Source of Evidence:
53
Section I Part 3-2

A-8 Social Determinants: Library Services
Adequate/Inadequate Libraries Name/Address/Phone Area Served/Services Provided (Analysis of Seven As will assist with determining adequacy or inadequacy)
Source of Evidence:
Section I Part 3-2

A-9 Social Determinants: Law Enforcement
Area Served/Services Provided, Size, Equipment, Response Time, Types of Calls Over Past 6 Months, Neighborhood Programs
Law Enforcement Services Police force Special services (SWAT, bomb squads, emergency response teams) Animal enforcement Senior watch patrols Private security Neighborhood watches Vigilante groups
Source of Evidence:
Section I Part 3-2

A-10 Social Determinants: Fire Department
Area Served/Services Provided, Number of Companies, Equipment, Response Time, Types of Calls Over Past 6 Months, Community Programs
Fire Department Stations Fire fighters in company Special fire forces (emergency response teams)
Source of Evidence:
Section I Part 3-2

A-11 Social Determinants: Communication
Description of Services (include whether it is community based, state, or national) Television (e.g., educational, relaxation, emergency response) Radio (e.g., educational, relaxation, emergency response) Newsprint (e.g., educational, relaxation, emergency response) Internet/social networking/ text messaging (e.g., educational, relaxation, emergency response) Newsletters Bulletin boards Telephone chains
Source of Evidence:
55
Section I Part 3-2

A-12 Social Determinants: Employment Distribution
# in Census Track Employed persons Unemployed persons # in Community
# in County
# in State
Source of Evidence:
Section I Part 3-2

A-13 Social Determinants: Leading Industries in Community (name at least two)
Name
Address
Type
# of Employed
Source of Evidence:
Section I Part 3-2

A-14 Social Determinants: Educational Level of People Older Than 25 Years
Census Track Ninth grade and lower High school graduate Some college College graduate (associates and baccalaureate) Median # of years of school completed Community County State
Source of Evidence:
Section I Part 3-2

A-15 Social Determinants: Family Income
Census Track $05,000 $5,000$9,999 $10,000$14,000 $15,000$24,999 $25,000$34,999 $50,000$64,000 $65,000$79,000 $80,000 or more 100% 100% 100% 100% Community County State
Source of Evidence:
57
Section I Part 3-2

B-1 Physical Determinants: History of the Community Write a narrative including information about the history of the community you are assessing. Include data that describe who started the community, any interesting stories that define the community.
Source of Evidence:
Section I Part 3-2

B-2 Physical Determinants: Windshield Survey The windshield survey reects what the public health nurse can view from a car window while driving through a community and contains observations of various components in the community such as housing, open spaces, transportation, race, ethnicity, restaurants, and stores.
Source of Evidence:
Section I Part 3-2

B-3 Physical Determinants: The Built Environment The built environment describes the man-made structures in the community including the kinds of stores, buildings, and sidewalks that facilitate healthy behaviors (or not). Describe your observations about this built environment and how it may be a determinant of health.
Source of Evidence:
Section I Part 3-2

B-4 Physical Determinants: Natural Environment Write a narrative that includes data on factors such as topography, climate, terrain, topographical features, and other factors in the community.
Source of Evidence:
59
Section I Part 3-2

B-5 Physical Determinants: Physical Barriers/Boundaries Write a narrative that includes data such as geographical boundaries and man-made boundaries.
Source of Evidence:
Section I Part 3-2

B-6 Physical Determinants: Environmental/Sanitation/Toxic Substances
Description of Services (include whether it is community based, state, or national) Water supply Sewage supply Solid waste disposal Provisions or laws for recycling Air contaminants Vector control programs for deer, ticks, rabid animals, rodents Other
Source of Evidence:
Section I Part 3 -3
Health Services The determinant of health known as health services is more than a listing of the physical, social, and mental health programs offered to an individual/family or a population in a particular community. It also includes an assessment of access to these services and uses the Seven As. The Seven As address more than the single concept of access. Whether or not there is access frequently depends on additional concepts of awareness, availability, affordability, acceptability, appropriateness, and adequacy of the service. Each of these is essential to assess and analyze for whether individuals or populations can access essential services that can influence their health and well-being. Source of Evidence:
Section I Part 3-3

A-1 Acute Care
Agency Name/Address/Phone
Area Served/Services Provided, Cost, Hours, Population Served
Source of Evidence:
61
Section I Part 3-3

A-2 Home Care
Source of Evidence:
Section I Part 3-3

A-3 Primary Care
Source of Evidence:
Section I Part 3-3

A-4 Long-Term Care
Source of Evidence:
Section I Part 3-3

A-5 Rehabilitative
Source of Evidence:
Section I Part 3: Foundational Health Measures 63
Section I Part 3-3

A-6 Assistive Living
Source of Evidence:
Section I Part 3-3

A-7 Mental Health Services
Source of Evidence:
Section I Part 3-3

A-8 Occupational
Source of Evidence:
Section I Part 3-3

A-9 School Health Programs
Source of Evidence:
65
Section I Part 3-3

A-10 Dental
Source of Evidence:
Section I Part 3-3

A-11 Palliative
Source of Evidence:
Section I Part 3-3

B-1 Access to Care The following Seven As questions can assist the public health nurse in analyzing his or her findings: Is the population aware of its needs and the services in the community? Can the population gain access to the services that it needs? Is the service available and convenient to the population in terms of time, location, and place for use? How affordable is the service for the population in question? Is the service acceptable to the population in terms of choice, satisfaction, and cultural congruence? How appropriate is the service for the specific population or is there a fit? Is there adequacy of service in terms of quantity or degree?
Section I Part 3-3

B-1 Access to Care: Using the Seven As
Adequate/ Inadequate Is the individual/family or population aware of its needs and services in the community? Can the individual/family or population gain access to the services it needs? Is the service available and convenient for the individual/family or population in terms of time, location, and place for use? How affordable is the service for the individual/family or population? Is the service acceptable to the individual/family or population in terms of choice, satisfaction, and congruence with cultural values and beliefs? How appropriate is the service for the individual/family or population or is there a fit? Is there adequacy of service in terms of quantity or degree for the individual/family or population? Identify as a Problem Statement
Source of Evidence:
67
Section I Part 3-4

Policymaking The public health nurse must also assess the policies that influence the health of the individual, family, community, system, and population under study. Examples include policies on seat belt use, helmet use, phone use and texting while driving, and child car seats. Each of these policies has had a positive influence on the health and wellbeing of individuals and the population at large, resulting in a decrease in disabilities and injuries. The public health nurse must be knowledgeable about how his or her community functions with regard to the political infrastructure and as such must assess this infrastructure to be familiar with how it works: who are the formal and informal political leaders? How can they be reached? What initiatives have they supported in the past? What are the laws that affect the individual/family, population, and community with regard to the publics health? Are these laws upheld? Are there issues that have not been addressed, and, if so, what can be done to address these issues? The data collected in this section include the organizational structure of the community, a description of the political issues in the community, and an identification of some of the public health laws that affect the community and its members health. As the public health nurse conducts this portion of the assessment, it is important to explore what the local newspapers report, to meet with the local government, and to check out the school boards or any of the governing bodies in that area. Meet the candidates if it is an election year and listen to what the community is saying. Check websites, social networking sites, and local blogs. Using the Internet, here and throughout the PHNAT, assists the public health nurse in obtaining the necessary data and learning about the community.
Section I Part 3-4

A-1 Local, State, and Federal Organizational Structure of Community In the following table, include organizational structure of the community including political parties of leadership: governor, senators, assemblypersons, mayor, and board. Once you collect the data, include a narrative and an organizational chart that represents a visual model of the hierarchy. Titles Names Method of contact Initiatives supported in the past and presently Interview one of the officials or go to a town board meeting Source of Evidence:
Section I Part 3-4

A-2 Political Issues in the Community
Political Issues Action Taken/Policy
Source of Evidence:
Section I Part 3-4

A-3 Health Policies (e.g., seat belts, taxes on tobacco, smoking ordinances, cell phone and texting bans)
Health Policies Action Taken/Policy
Source of Evidence:
69
Section I Part 3-5

Behavior Collect data on the individual and family that reflect their behavior, and again turn the kaleidoscope to look outward to the community and population in that community. The public health nurse gathers the information on the individual and family as a client using whatever health assessment tool he or she uses in the particular academic or clinical setting. Some of the questions that provide insight into individual or population-based behavior are as follows: What does your assessment of the client tell you about his or her behavior? What types of choices does he or she make with regard to diet, physical activity, alcohol, cigarette smoking or other drug use, and so forth? How does the family support health choices? How does the community support health choices? Have there been community-driven health promotion initiatives that support health such as weight loss or physical activity programs like a walk-to-school program? Summarize your finding in a narrative form below.
SECTION I PART 4: HEALTH CARE DISPARITIES

According to Healthy People 2020,If a health outcome is seen in a greater or lesser extent between populations, there is disparity. Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individuals ability to achieve good health (2010f, para. 1). Frequently, the public health nurse will note disparities as he or she observes within the community and analyzes the data gathered. Hence, for this foundational health measure much of the information needed is gathered throughout the PHNAT. Summarize your finding in a narrative form below.
SECTION II: ANALYSIS OF HEALTH STATUS

The public health nurse, along with other partnering members of a health initiative, analyzes the information gathered during the assessment process. Many times, the public health nurse will examine past data to see whether trends and patterns have emerged over time. This process of analysis takes time and reflection. The key here is that the public health nurse does not do this alone. It is a process that takes shape and form in the partnership. From this process the issues in a community are identified and priorities are set. Summarize your findings below identifying community needs, topics, and objectives.
Section III: Prioritize Public Health Issues in Order of Priority 71
SECTION III: PRIORITIZE PUBLIC HEALTH ISSUES

In determining the priority health issues, the public health nurse, using a populationbased focus, collaborates with other public health practitioners, key informants in the community, and any organization or agency that may have a voice with regard to the population and public health issue. In population-based care, partnerships form the necessary bonds that make sustainable change for health in particular targeted populations. Those involved in the partnership work together to form a common understanding of the issue. All involved, including the population of interest residing in the community, agree on the priority issue identified. This is essential for a positive outcome. Once the priority is noted, then the partnership will confer with the Healthy People 2020 topic areas and corresponding objectives (U.S. DHHS, 2010g).
SECTION III: PRIORITIZE PUBLIC HEALTH ISSUES IN ORDER OF PRIORITY

Issues Targeted Population Short-Term Goal(s) Long-Term Goal(s)
SECTION IV AND SECTION V: PLAN AND IMPLEMENTATION USING MINNESOTA INTERVENTION WHEEL STRATEGIES
Tracking and Evaluation
Minnesota Intervention Strategies and Levels of Practice Interventions Levels of Practice Track and Outcome Evaluation
Individual/Family/ Population Surveillance Disease and health threat investigation Outreach Screening Case-finding Referral/follow-up Case management Delegated functions Health teaching Counseling Consultation Collaboration Coalition building Community organizing Advocacy Social marketing Policy development and enforcement
Community
System
Section VI: Reflection
73
SECTION VI: REFLECTION

This final section reminds the public health nurse to be reflective in his or her practice. This section can be completed throughout the PHNAT process. Some of the questions that the public health nurse may ask include the following: What am I observing? What am I hearing? Am I seeing and hearing all that needs to be seen and heard? What am I missing? What feelings am I experiencing during this assessment process? Are these feelings facilitating this assessment or creating a barrier to the assessment? Are these feelings hindering the development of the partnership and the development of trust? Am I engaging in activities that help in mobilizing the community of interest?
A. Reflection Gained During Public Health Nursing Assessment
Date
Reflection

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APPENDIX

Public Health Nursing Assessment Tool

SECTION I PART 1: FOUNDATIONAL HEALTH MEASURES

Section I Part 1: Foundational Health Measures

Section I Part 1: Foundational Health Measures

SECTION I PART 2: FOUNDATIONAL HEALTH MEASURES

Section I Part 3: Foundational Health Measures

SECTION I PART 3: FOUNDATIONAL HEALTH MEASURES

Section I Part 3-1

Section I Part 3-1

Population at last census

Population changes in the last 10 years

Section I Part 3-1

Section I Part 3-1

Section I Part 3-2

Section I Part 3: Foundational Health Measures

Section I Part 3-2

Section I Part 3-2

Section I Part 3-2

List Places of Employment

Section I Part 3: Foundational Health Measures

Section I Part 3-2

Adequate/Inadequate (Analysis of Seven As will assist with determining adequacy or inadequacy)

Section I Part 3-2

Section I Part 3-2

Section I Part 3-2

Section I Part 3: Foundational Health Measures

Section I Part 3-2

Section I Part 3-2

Adequate/Inadequate (Analysis of Seven As will assist with determining adequacy or inadequacy)

Section I Part 3-2

Adequate/Inadequate (Analysis of Seven As will assist with determining adequacy or inadequacy)

Section I Part 3-2

Adequate/Inadequate (Analysis of Seven As will assist with determining adequacy or inadequacy)

Section I Part 3: Foundational Health Measures

Section I Part 3-2

Section I Part 3-2

Section I Part 3-2

Section I Part 3-2

Section I Part 3: Foundational Health Measures

Section I Part 3-2

Section I Part 3-2

Section I Part 3-2

Section I Part 3-2

Section I Part 3: Foundational Health Measures

Section I Part 3-2

Section I Part 3-2

Section I Part 3-3

Area Served/Services Provided, Cost, Hours, Population Served

Section I Part 3: Foundational Health Measures

Section I Part 3-3

Area Served/Services Provided, Cost, Hours, Population Served

Section I Part 3-3

Area Served/Services Provided, Cost, Hours, Population Served

Section I Part 3-3

Area Served/Services Provided, Cost, Hours, Population Served

Section I Part 3-3

Area Served/Services Provided, Cost, Hours, Population Served

Section I Part 3: Foundational Health Measures 63