The purpose of this direct care project is for learners to apply the nursing process to a community health problem determined by their observations and data collection of vulnerable populations in their community. This is Part 1 of 4 in the Direct Care Project.

Direct Care Project Overview

There are four parts to the Direct Care Project.
There will be graded Project Check-ins that correlate to each part.
The topic selected in Part 1 will be the same one used in Parts 2 through 4. Your choice is either Air Quality OR Substance Use.
Review the table below for an overview and due dates for each topic.
Carefully review the instructions, tutorials, templates, and rubrics for each of the four parts as you begin this Direct Care Project.

Course Outcomes

This direct care project enables the student to meet the following course outcomes:

CO2 Assess the health of populations, aggregates, and communities (PO4)
CO3 Apply the nursing process to vulnerable populations with professional clinical judgment and evidence-based practice (PO4 & 8)
CO5 Utilize a collaborative approach to address factors that influence population health (PO2)
CO6 Examine collaborative trends in community health nursing (PO2)

Part 1 enables the student to meet the following course outcomes:

CO2 Assess the health of populations, aggregates, and communities (PO4)
CO3 Apply the nursing process to vulnerable populations with professional clinical judgment and evidence-based practice (PO4 & 8)

Substance Use Assessment and Diagnosis Template

Directions: Collect the data outlined in this template. Fill in the blanks in the tables provided. There are two parts – online data collection and a modified windshield survey data collection. You will then identify a nursing problem in a vulnerable population and write a nursing diagnosis. See the assignment directions for suggestions and best practices. For full credit, all information in a category must be completed. This will be the topic of your Assessment and Nursing Diagnosis Template and also Parts 2 through 4 of your course project.


Name:                                                                         Date:


Online Data Collection

  1. Community Information
  Your Community Data
Name of city or town and state
Nature of this community (rural, suburban, urban)
Describe your community in 2-3 sentences


  1. Community Demographics
    1. Go to https://www.census.gov/quickfacts/fact/table/US/PST045218
      1. The US data should automatically populate
      2. Input your zip code or county/township name
  • Then input your state for comparison data
  1. Enter the data into the table below
  2. Compare the county, state, and US data
  County Data State Data U.S. Data
Population total
Male (subtract female % from 100)
Persons under 5
Persons over 65
Race and origin data
  County Data State Data U.S. Data
White alone
Black or African Americans alone
American Indian and Alaska Natives alone
Asian alone
Native Hawaiian and Other Pacific Islanders alone
Two or more races
Hispanic or Latino
White alone, not Hispanic or Latino
Significant population characteristics
  County Data State Data U.S. Data
Foreign born persons
Housing overview
  County Data State Data U.S. Data
Housing units
Owner-occupied housing unit rate
Median selected monthly owner costs with a mortgage
Median selected monthly owner costs without a mortgage
The median value of owner-occupied housing units
Median gross rent
Family and living arrangements
  County Data State Data U.S. Data
Persons per household
Living in the same house 1 year ago
Language other than English spoken at home
Computer and Internet Use
  County Data State Data U.S. Data
Households with a computer
Households with a broadband internet subscription
  County Data State Data U.S. Data
High school graduate or higher
Bachelor’s degree or higher
  County Data State Data U.S. Data
With a disability under the age of 65 years
Persons without health insurance under the age of 65 years
  County Data State Data U.S. Data
Civilian labor workforce ages 16+
Transportation-mean travel time to work (minutes)
Income and poverty
  County Data State Data U.S. Data
Median household income
Persons in poverty


  1. Community Epidemiological Data
    1. Go to: https://www.countyhealthrankings.org/
    2. Click on your state
      1. Start with Overall Rankings in Health Outcomes
      2. Then choose your county


**you will need to use the “+” to see all of the data**

  County Data State Data
Health Outcomes Percentile N/A
Health Factors Percentile N/A
Premature death
Low birth weight
Adult smoking
Adult obesity
Physical inactivity
Excessive drinking
Alcohol-impaired deaths
Teen births
Drug overdose deaths
Children in poverty
Violent crime
Air pollution
Drinker water violations
Long commutes


  1. Substance Use
    1. Go to: https://www.samhsa.gov/data/report/behavioral-health-barometer-state-barometers-volume-6?page=0
      1. Find your state and download the report.
      2. Review the report and document the following:
        1. Go to the Substance Use, Misuse, and Use disorders section. This will be the area that discusses those 12 and older (near end of the report).
  • Find the following percentages:
  State Average    Regional Average National Average
Tobacco use
Marijuana use disorder
Heroin use
Misuse of prescription pain reliever
Opioid use disorder
Illicit drug use disorder
Alcohol use disorder
Substance use disorder




Windshield Survey

It is recommended that you have someone drive you around your community at least 2 times, ideally at different times of day and on weekends vs. weekdays.

Look at the people in your community.


Did you observe:

No Yes If Yes, provide a number of states “many” “some” or “few”
·         *pregnant women
·         *pregnant adolescents
·         *infants (under the age of 1 year old)
·         *young children (1-5 years old)
·         *school-age children (6-18 years old)
·         adults (18 – 60 years old)
·         *older adults (over the age of 60 years old)
·         people exercising
·         people driving
·         people walking
·         people biking
·         people congregating in groups on the street
·         *people that had hygiene issues or were unkempt
·         people that were appropriately dressed
·         people that were physically fit
·         people that were obese
·         *people that were undernourished, thin
·         people that appear healthy
·         *people that have obvious physical disabilities, such as those using walkers or wheelchairs
·         *people with apparent mental/emotional disabilities
·         *people who appeared homeless or unemployed

 *Represents vulnerable populations

Social and Economic Conditions


Did you observe:

No Yes If Yes, provide a number of state “many” “some” or “few”
·         housing that was run down or dilapidated
·         areas undergoing renewal
·         public housing
·         public transit (subway, train, buses, taxis, etc)
·         transportation to health care resources
·         landfills
·         restaurants
·         any political signs
·         any evidence of health education on billboards, advertisements, or signs
·         any efforts to improve the neighborhood’s health such as advertisements for health-related events, health fares, clinics, or lectures
·         any group efforts in the neighborhood to improve the living conditions or the neighborhood
·         churches, synagogues, and other places of worship



Health Resources


Did you observe:

No Yes If Yes, provide a number of states “many” “some” or “few”
·         hospitals
·         community clinics
·         family planning clinics
·         generalist doctors
·         dentist offices
·         pharmacies
·         urgent care clinics
·         skilled nursing facilities
·         mental health or counseling clinics
·         homeless or abuse shelters
·         public health department office
·         substance abuse treatment center
·         alternative medicine practices, botanicals, or herbal medicine shops

Answer the following question:



If some of the above health resources were not observed, approximately how far away would a person need to travel to find these resources?





Environmental Conditions


Did you observe:

No Yes If Yes, provide a number of states “many” “some” or “few”
·         evidence of anything that might make you suspicious of ground, water, or air pollutants
·         poor road conditions with potholes, or poor drainage
·         adequate traffic lights, signs, sidewalks, and curbs
·         railroad crossings fitted with warnings and barriers
·         streets and parking lots well lit
·         handicapped access to buildings, sidewalks, and streets
·         recreational facilities, playgrounds, and/or facilities like the YMCA
·         children playing in the streets, alleys, yards, or parks
·         evidence of nuisances such as ants, flies, mosquitoes, rodents, or stray animals observed



Identify a nursing problem based on your data and observations. The problem must be related to substance use. Example: Alcohol use



Problem Identification: _________________

Vulnerable Population

Identify the vulnerable population that is most impacted by this problem. Example: Adolescents


Vulnerable Population Identification: _________________


Write a nursing diagnosis based on your problem from above. Fill in the blanks below.

Example: Increased risk for alcohol use among adolescents related to lack of sufficient knowledge about the long and short-term impacts demonstrated in increased county data compared to state/national averages.

*See chapter 6 in the Nies and McEwen (2019) textbook for more examples of composing a community health nursing diagnosis.

Nursing Diagnosis: Increased risk of____________(problem from above) among ____________ (vulnerable population from above) related to ___________(etiological statement) as demonstrated in _______(health indicators/community data from above)


If you need a similar but plagiarism-free “assessment and diagnosis”, then feel free to contact us!