Community Health Nursing Diagnosis & Care Plan

Overall health and well-being are greatly impacted by the communities in which patients live and work. Access to care is influenced by economic, social, and political issues. Depending on the needs of the individual and the population, it may be a major factor in determining physical, mental, and emotional health as well as morbidity and mortality.

Race and ethnicity, educational attainment, gender, and income are examples of structural characteristics that may be significantly predictive of overall health. These kinds of variables reveal risk factors for chronic health conditions and present opportunities for community-based treatments.

The Nursing Process

Acute and chronic care are prioritized in community-based nursing, which encompasses practice settings such as:

  • Home health
  • School nursing
  • Case management
  • Outpatient clinics and health departments

The focus of nursing practice includes wellness promotion, prevention, maintenance, and disease control. At the disease end of the continuum, acute and chronic disorders have traditionally received the majority of attention in healthcare. Nursing care aimed at prevention and education can improve health outcomes and reduce healthcare burden, resources, and costs.

Nursing Care Plans Related to Community Health

Deficient Knowledge Care Plan

Deficient Knowledge associated with community health can be caused by inadequate knowledge of resources, access to the healthcare system and programs, and an understanding of individual and community health risks.

Nursing Diagnosis: Deficient Knowledge

Related to:

  • Inadequate knowledge of community support and resources
  • Inadequate access to healthcare professionals
  • Lack of financial and social resources
  • Program budget, outcome information, or evaluation plan deficiencies
  • Inability of existing programs to address health concerns

As evidenced by:

  • Community members’ verbalization of confusion/concern
  • Community members’ noncompliance with the health program
  • Community members’ inquiries about a certain topic
  • Community members’ misconceptions
  • Community members’ exacerbation of health symptoms
  • Health program’s inability to address the health concern
  • Preventable hospital readmissions
  • Increased incidence of physiological or psychological conditions

Expected outcomes:

  • Community will be able to identify the programs’ advantages and disadvantages in achieving health-related objectives.
  • Community will be able to create a plan to meet the community’s recognized health needs.
  • Community will be able to demonstrate behavior and lifestyle modifications towards the improvement of community health.

Deficient Knowledge Assessment

1. Assess healthcare providers’ knowledge and practices related to the community’s health.
Having the same knowledge and using the same verbiage makes it easier for those working in the community to recognize one another and communicate ideas more effectively.

2. Assess the community’s existing and potential health problems.
By identifying particular issues, population-based treatments can focus on the existing problem that may be solved by primary prevention and proactive intervention.

3. Assess the community’s resources.
Knowing what resources are currently accessible and how the community accesses them helps to identify potential gaps. Resources may not be meeting the needs of the community or the community may not be aware they exist.

4. Note the community members’ complaints/ concerns.
Taking note of the members’ concerns presents a realistic image of issue areas through feedback from those who are affected most.

Deficient Knowledge Interventions

1. Promote a cooperative community spirit without undermining the uniqueness of its individuals or groups.
People are more likely to cooperate to create plans for identifying and improving healthcare for the community when they feel respected and valued.

2. Involve the community in selecting healthcare objectives and priorities.
Involving the community members in assessing the problem, and creating goals and priorities that are important to them will increase collaboration and adherence.

3. Connect the community members to available resources.
Assure the best possible delivery of healthcare and connect people to the services they need through transportation support, 2-1-1 programs, and free clinics.

4. Collaborate with the community in creating solutions.
Collaboration encourages a sense of control and involvement, which aids in more efficient problem-solving.


Ineffective Community Coping Care Plan

Ineffective community coping can be caused by unsatisfactory community efforts to adapt and solve problems in a way that satisfies community desires or needs.

Nursing Diagnosis: Ineffective Community Coping

Related to:

  • Insufficient resources for problem-solving
  • Inadequate community resources (emergency services, transportation)
  • Lack of social support services

As evidenced by:

  • Community members’ expression of lack of support or excessive stress
  • Higher rates of illness
  • High rates of crime, abuse, unemployment, and poverty
  • Community members’ expression of powerlessness or hopelessness

Expected outcomes:

  • Community will report an identifiable improvement in coping such as decreased crime rates or increased employment
  • Community will be able to choose appropriate alternatives to undesirable activities for problem-solving and adaptability

Ineffective Community Coping Assessment

1. Assess the community’s needs.
A needs assessment is essential to identify the gaps preventing it from achieving its targeted objectives.

2. Assess disaster plans and response to emergencies.
Evaluate the policies of local and regional efforts in the face of epidemics, threats, terrorist attacks, and natural catastrophes to assess preparedness.

3. Identify the availability, accessibility, and usage of community resources.
Even when resources are accessible, they are not always utilized properly or to their full potential. Evaluate programs and resources available, referral processes, and follow-up measures.

4. Identify unmet community expectations.
Establishing shortcomings is the first step in overcoming gaps. Communication is crucial to understanding the perspective of the community.

Ineffective Community Coping Interventions

1. Collaborate and create plans together with the community members.
Organize interactions inside the community to manage interactions and meet needs. This encourages long-term participation and adherence.

2. Assist the community in creating partnerships both inside the community and with the rest of society.
Creating partnerships between the community and society encourages the community’s long-term development and constant improvement to address both present and upcoming issues.

3. Educate on the benefits of resources and activities.
Help the community recognize the benefits of improvement efforts and how their safety, health, and happiness depend on a cohesive community working together.

4. Provide access to information at the community level.
Meet them where they are. Use TV, flyers, radio, social media, and more to disseminate resource information. Information needs to be geared toward all educational and cultural levels.


Readiness for Enhanced Community Coping Care Plan

Readiness to meet improved community adaptation and problem-solving through activities, management, and communication.

Nursing Diagnosis: Readiness for Enhanced Community Coping

Related to:

  • Motivation to improve health and stress management
  • Desire to increase social change
  • Responsiveness of possible community transformation

As evidenced by:

  • Positive communication among groups
  • Addition of health programs (nutrition, exercise, immunizations)
  • Community planning events

Expected outcomes:

  • Community will be able to effectively manage stressors through community resources
  • Community will be able to verbalize appropriate coping techniques

Readiness for Enhanced Community Coping Assessment

1. Review the community’s plan for coping with problems.
Reviewing the community’s plan for coping with problems will help in the improvement of the plan according to the current needs of the community.

2. Assess the stressors of the community.
When preparing interventions to improve coping skills, it is important to accurately identify unique community stressors to know which interventions are relevant.

3. Assess the community members’ social support.
Community leaders can assist in supporting healthy coping to enable the community to move forward and improve current situations.

4. Assess the community’s current coping strategies.
Determining the current community coping strategies will assist in recognizing negative coping mechanisms and which techniques are needed.

Readiness for Enhanced Community Coping Interventions

1. Provide monthly meetings to discuss concerns.
Discuss existing stressors and upcoming or future concerns for effective intervention and planning.

2. Provide active listening and reflection.
Actively listening to the community members and reflecting on how they perceive their current situation can offer insight. The nurse will also gain more data to establish an accurate plan.

3. Develop programs and outlets for expression.
Coping can be enhanced through art, music, exercise, meditation, and more. Provide classes and stress-management programs to educate on proper coping.

4. Promote problem-solving as well as the acceptance of limitations.
Problem-solving skills can be taught but successful coping also involves recognizing and accepting when situations cannot be changed.


References and Sources

  1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
  2. Institute of Medicine (US) Committee. (1988). Public health as a problem-solving activity: Barriers to effective action – The future of public health – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK218227/
  3. Nies, M. A., & McEwen, M. (2019). Community/Public Health Nursing: Promoting the health of populations (7th ed.). Saunders.
  4. Rector, C. (2018). Community and Public Health Nursing : Promoting the Public’s Health (9th ed.). Wolters Kluwer Law & Business.
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Kathleen Salvador, MSN, RN

Kathleen Salvador is a registered nurse and a nurse educator holding a Master’s degree. She has more than 10 years of clinical and teaching experience and worked as a licensed Nursing Specialist in JCI-accredited hospitals in the Middle East. Her nursing career has brought her through a variety of specializations, including medical-surgical, emergency, outpatient, oncology, and long-term care.