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A P P E N D I X
Public Health Nursing Assessment Tool
Designed by
Sandra B. Lewenson and
Marie Truglio-Londrigan for
Public Health Nursing:
Applying and Doing
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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 A’s. When filling in these
boxes, place the most pertinent infor-
mation that you think informs the
assessment.
3. When completing Section I Part 3-
3(B-1): Access to Care, note that this
is a summary of the work that you did
in Part 1. Reflect on this information
and arrive at your decisions pertain-
ing to access to care.
4. In some instances, you need to con-
sider 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 doc-
u
ment 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 filling 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 fill in the boxes about the
number of schools in a community,
but you may also want to know the
number of students per faculty mem-
ber, if a community collaborator cited
that as a concern.
6. In some instances, there will be over-
lap of data collection. Because infor-
mation for this tool will usually be
collected by a group, in qualitative
research the overlap may be consid-
ered a saturation of data. In the
analysis section, these data will pro-
vide 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 sta-
tus; however, this is an example of how public health nurses serve individuals in the
community as well as the general population.
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Section I Part 1: Foundational Health Measures 43
Section I Part 1
A-1 Individual and Family
Source of Evidence:
Section I Part 1
B-1 Population: Vital Statistics
Source of Evidence:
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.
Census Track Community County State
#%#%#%#%
Live births
General deaths
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44 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Section I Part 1
B-2 Population: Mortality
Source of Evidence:
Section I Part 1
B-3 Population: Morbidity
Source of Evidence:
Census Track Community County State
Census Track Community County State
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Section I Part 1: Foundational Health Measures 45
Section I Part 1
B-4 Population: Life Expectancy
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:
Census Track Community County State International
Census Track Community County State International
Census Track Community County State International
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46 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Section I Part 1
B-7 Population: Physically and Mentally Unhealthy Days
Source of Evidence:
SECTION I PART 2: FOUNDATIONAL HEALTH MEASURES
Health-Related Quality of Life and Well-Being
Health-related quality of life is a complex concept and focuses on “the impact health sta-
tus 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:
Census Track Community County State International
• 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.
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Section I Part 3: Foundational Health Measures 47
SECTION I PART 3: FOUNDATIONAL HEALTH MEASURES
Determinants of Health
Section I Part 3-1
Biology and Genetics
Section I Part 3-1
A-1 Individual and Family Assessment
Section I Part 3-1
B-1 Population
Source of Evidence:
The determinants of health under biology and genetics include data that are individual/
family focused or population focused. The public health nurse gathers the informa-
tion 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 popu-
lation aggregate, data such as age, race and gender would be considered important
to gather.
In this section, when appropriate, the public health nurse includes an assessment of
the individual and family. Include the history, genogram, and ecogram. Special con-
sideration is given to analysis of genetically defined diseases such as sickle cell ane-
mia, cystic fibrosis, and BRCA1 or BRCA2.
Census Track Community County State
Population at last census
Population density
Population changes in the
last 10 years
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48 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Section I Part 3-1
B-3 Population: Race Distribution
Source of Evidence:
Section I Part 3-1
B-4 Population: Gender Distribution
Source of Evidence:
Section I Part 3-2
Social Factors
Census Track Community County State
#%#%#%#%
White
Black/African American
Hispanic
Asian
Native American
Other
Census Track Community County State
#%#%#%#%
Female
Male
Social factors, the next determinant of health to be considered, include social deter-
minants of health and physical determinants or conditions in the environment (U.S.
DHHS, 2010b). Social factors that the public health nurse assesses include the client’s
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.
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Section I Part 3: Foundational Health Measures 49
Section I Part 3-2
A-1 Social Determinants: Housing Conditions
Source of Evidence:
Section I Part 3-2
A-2 Social Determinants: Transportation
Source of Evidence:
Housing
Characteristics
Total #
of Units
Owner
Occupied
Renter
Occupied Vacant
Housing
Subsidies/Homeless
Provisions
Description of Services: Cost,
Destination of Service,
Quality of Service, Condition
of Services and/or Roads,
Handicap Accessibility
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
Train
Bus
Taxi including
private services
Major roads
Minor roads
Volunteers providing
transportation
School buses
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50 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Section I Part 3-2
A-3 Social Determinants: Workplace
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:
List Places of Employment
Description of Workplace
Professional, Industry,
Factories, Schools, Town,
City, County, Businesses
What Workplace Safety
Measures Are in Place?
What Is the Estimated
Yearly Salary Range
of Employees?
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Section I Part 3: Foundational Health Measures 51
Section I Part 3-2
A-4 Social Determinants: Recreational Facilities
Source of Evidence:
Section I Part 3-2
A-5 Social Determinants: Educational Facilities
Source of Evidence:
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 A’s will
assist with determining
adequacy or inadequacy)
# of Public # of Private (religious) # of Private (secular)
Preschool
Elementary
Junior high
Senior high
Colleges/universities
Early morning
programs
Recreational programs
within school system
After-school programs
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52 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Section I Part 3-2
A-6 Social Determinants: Places of Worship
Source of Evidence:
Section I Part 3-2
A-7 Social Determinants: Social Services
Source of Evidence:
Name/Address/Phone Denomination Services
Agency Name/Address/Phone
(food and clothing banks,
homeless shelters, adult day
care social services, child care)
Area Served/
Services Provided/
Cost of Services
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
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Section I Part 3: Foundational Health Measures 53
Section I Part 3-2
A-8 Social Determinants: Library Services
Source of Evidence:
Section I Part 3-2
A-9 Social Determinants: Law Enforcement
Source of Evidence:
Libraries
Name/Address/Phone
Area Served/Services
Provided
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
Law Enforcement
Services
Area Served/Services
Provided, Size, Equipment,
Response Time, Types of
Calls Over Past 6 Months,
Neighborhood Programs
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
Police force
Special services (SWAT,
bomb squads, emergency
response teams)
Animal enforcement
Senior watch patrols
Private security
Neighborhood watches
Vigilante groups
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54 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Section I Part 3-2
A-10 Social Determinants: Fire Department
Source of Evidence:
Section I Part 3-2
A-11 Social Determinants: Communication
Source of Evidence:
Fire Department Stations
Area Served/Services
Provided, Number of
Companies, Equipment,
Response Time, Types of
Calls Over Past 6 Months,
Community Programs
Adequate/Inadequate
(Analysis of Seven A’s
will assist with
determining adequacy
or inadequacy)
Fire fighters in company
Special fire forces
(emergency response teams)
Description of
Services (include
whether it is
community based,
state, or national)
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
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
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Section I Part 3: Foundational Health Measures 55
Section I Part 3-2
A-12 Social Determinants: Employment Distribution
Source of Evidence:
Section I Part 3-2
A-13 Social Determinants: Leading Industries in Community
(name at least two)
Source of Evidence:
#
in Census
Track
#
in
Community # in County # in State
Employed persons
Unemployed persons
Name Address Type # of Employed
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56 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Section I Part 3-2
A-14 Social Determinants: Educational Level of People Older Than 25 Years
Source of Evidence:
Section I Part 3-2
A-15 Social Determinants: Family Income
Source of Evidence:
Census Track Community County State
Ninth grade and lower
High school graduate
Some college
College graduate
(associate’s and
baccalaureate)
Median # of years of
school completed
Census Track Community County State
$0–5,000
$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%
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Section I Part 3: Foundational Health Measures 57
Section I Part 3-2
B-1 Physical Determinants: History of the Community
Source of Evidence:
Section I Part 3-2
B-2 Physical Determinants: Windshield Survey
Source of Evidence:
Write a narrative including information about the history of the community you are
assessing. Include data that describe who started the community, any interesting sto-
ries that define the community.
The windshield survey reflects what the public health nurse can view from a car win-
dow while driving through a community and contains observations of various com-
ponents in the community such as housing, open spaces, transportation, race,
ethnicity, restaurants, and stores.
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58 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Section I Part 3-2
B-3 Physical Determinants: The Built Environment
Source of Evidence:
Section I Part 3-2
B-4 Physical Determinants: Natural Environment
Source of Evidence:
The built environment describes the man-made structures in the community includ-
ing 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.
Write a narrative that includes data on factors such as topography, climate, terrain,
topographical features, and other factors in the community.
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Section I Part 3: Foundational Health Measures 59
Section I Part 3-2
B-5 Physical Determinants: Physical Barriers/Boundaries
Source of Evidence:
Section I Part 3-2
B-6 Physical Determinants: Environmental/Sanitation/Toxic Substances
Source of Evidence:
Write a narrative that includes data such as geographical boundaries and man-made
boundaries.
Description of
Services (include
whether it is
community based,
state, or national)
Adequate/Inadequate
(Analysis of Seven A’s
will assist with
determining adequacy or
inadequacy)
Water supply
Sewage supply
Solid waste disposal
Provisions or laws for recycling
Air contaminants
Vector control programs for deer,
ticks, rabid animals, rodents
Other
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60 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Section I Part 3 -3
Health Services
Source of Evidence:
Section I Part 3-3
A-1 Acute Care
Source of Evidence:
The determinant of health known as health services is more than a listing of the phys-
ical, social, and mental health programs offered to an individual/family or a popula-
tion in a particular community. It also includes an assessment of access to these
services and uses the Seven A’s. The Seven A’s 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 individu-
als or populations can access essential services that can influence their health and
well-being.
Agency Name/Address/Phone
Area Served/Services
Provided, Cost,
Hours, Population
Served
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
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Section I Part 3: Foundational Health Measures 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:
Agency Name/Address/Phone
Area Served/Services
Provided, Cost,
Hours, Population
Served
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
Agency Name/Address/Phone
Area Served/Services
Provided, Cost,
Hours, Population
Served
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
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Section I Part 3-3
A-4 Long-Term Care
Source of Evidence:
Section I Part 3-3
A-5 Rehabilitative
Source of Evidence:
Agency Name/Address/Phone
Area Served/Services
Provided, Cost,
Hours, Population
Served
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
Agency Name/Address/Phone
Area Served/Services
Provided, Cost,
Hours, Population
Served
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
62 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
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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:
Agency Name/Address/Phone
Area Served/Services
Provided, Cost,
Hours, Population
Served
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
Agency Name/Address/Phone
Area Served/Services
Provided, Cost,
Hours, Population
Served
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
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64 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Section I Part 3-3
A-8 Occupational
Source of Evidence:
Section I Part 3-3
A-9 School Health Programs
Source of Evidence:
Agency Name/Address/Phone
Area Served/Services
Provided, Cost,
Hours, Population
Served
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
Agency Name/Address/Phone
Area Served/Services
Provided, Cost,
Hours, Population
Served
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
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Section I Part 3: Foundational Health Measures 65
Section I Part 3-3
A-10 Dental
Source of Evidence:
Section I Part 3-3
A-11 Palliative
Source of Evidence:
Agency Name/Address/Phone
Area Served/Services
Provided, Cost,
Hours, Population
Served
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
Agency Name/Address/Phone
Area Served/Services
Provided, Cost,
Hours, Population
Served
Adequate/Inadequate
(Analysis of Seven A’s will
assist with determining
adequacy or inadequacy)
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66 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Section I Part 3-3
B-1 Access to Care
Section I Part 3-3
B-1 Access to Care: Using the Seven A’s
Source of Evidence:
The following Seven A’s 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, loca-
tion, 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?
Adequate/
Inadequate
Identify as a
Problem Statement
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?
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Section I Part 3: Foundational Health Measures 67
Section I Part 3-4
Policymaking
Section I Part 3-4
A-1 Local, State, and Federal Organizational Structure of Community
Source of Evidence:
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 well-
being 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 sup-
ported in the past? What are the laws that affect the individual/family, population, and
community with regard to the public’s 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 commu-
nity, 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 can-
didates if it is an election year and listen to what the community is saying. Check web-
sites, 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 learn-
ing about the 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 rep-
resents 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
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68 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
Section I Part 3-4
A-2 Political Issues in the Community
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)
Source of Evidence:
Political Issues Action Taken/Policy
Health Policies Action Taken/Policy
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Section I Part 3: Foundational Health Measures 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 popu-
lation-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.
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70 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
SECTION I PART 4: HEALTH CARE DISPARITIES
SECTION II: ANALYSIS OF HEALTH STATUS
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 indi-
vidual’s 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 informa-
tion needed is gathered throughout the PHNAT. Summarize your finding in a narra-
tive form below.
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, top-
ics, and objectives.
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Section III: Prioritize Public Health Issues in Order of Priority 71
SECTION III: PRIORITIZE PUBLIC HEALTH ISSUES
SECTION III: PRIORITIZE PUBLIC HEALTH
ISSUES IN ORDER OF PRIORITY
In determining the priority health issues, the public health nurse, using a population-
based 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).
Issues
Targeted
Population
Short-Term Goal(s) Long-Term Goal(s)
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72 Chapter 3 Appendix: Assessment: Using the Public Health Nursing Assessment Tool
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
Individual/Family/
Population Community System
Track and
Outcome
Evaluation
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
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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
41764_CH03_025_073_3PGS_66542_CH03_053_086 6/6/11 2:01 PM Page 73
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