Community Health Nursing Review

Community Health Nursing


Mark Anthony F. Rosario BSN.,RN.,MAN

Asst. Secretary of Operating Nurses Association of the

Philippines


Definitions

• “Public Health is the science and art of preventing disease, promoting life, and promoting health…”

- Dr. C.E. Winslow• “Public Health Nursing is the practice of nursing in

national and local government health departments. …community health nursing practiced in the public sector.”

- Standards of Public Health Nursing in the Philippines, 2005


• Community Health Nursing is “the utilization of the nursing process in the different levels of clientele-individual, families, population groups and communities… promotion of health, prevention of disease and disability, and rehabilitation”

- Dr. Araceli Maglaya, et. al.


Need to Remember

• Individual, Family, Population Groups, and Community are the four LEVELS of clientele

• Community is the patient in CHN• Family is the unit of care• Goal of CHN is achieved through multisectoral

efforts• CHN is part of Health Care System and the Larger

Human Services System


Special Note:

• The Public Health Nurse will take charge of the Municipal Health Officer’s responsibilities in the event that the MHO is unable to perform his duties or is not available


Role of Public Health Nurse

• Clinician• Health Educator• Coordinator and collaborator• Supervisor• Leader and Change Agent• Manager• Researcher


Health Care Delivery System

• The Public Sector• Department of Health– Vision: The DOH is the leader, staunch advocate, and

model in promoting health for all in the Philippines.– Mission: Guarantee equitable, sustainable, and

quality health for all Filipinos, especially the poor and lead the quest for excellence in health.

– Goal: Health Sector Reform Agenda• EO 102 identifies the DOH as the national health

authority


• FOURmula ONE for Health– Framework for the implementation of the Health

Sector Reform Agenda• Four Elements– Good Governance– Health Financing– Health Regulation– Health Service Delivery


Local Government Units

• RA 7160 or Local Government Code of 1991– Devolution of powers, functions and responsibilities– Provincial and municipal level

• District Health System – smallest manageable unit in areas which are small enough to be managed without being bogged down by bureaucracy, yet large enough to be feasible


Primary Health Care

“Essential health care made universally accessible to individuals and families in the community by means acceptable to them through their full participation and at a cost that the community can afford

at every stage of development.”World Health Organization


Things to Remember:

• PHC Goal: HEALTH FOR ALL BY THE YEAR 2000– Alma Ata, USSR, First International Conference on

PHC, September 1978• Legal Basis: LETTER OF INSTRUCTION 949 signed

by Pres. F. Marcos• Underlying Theme: HEALTH IN THE HANDS OF

THE PEOPLE BY 2020


Primary Health Care

• Four Pillars of PHC

Support mechanism made availableActive community participationIntra- and inter-sectoral linkageUse of appropriate technology


Levels of Health Care

• Two Levels of Primary Health Care Workers– Village or Barangay Health Workers• Trained CHW• Health auxiliary volunteers• Traditional birth attendants

– Intermediate Level Health Workers• General medical practitioner• Public health nurses• Rural sanitary inspectors • Midwives


Three Levels of Health Care Services

Primary Secondary TertiaryBarangay Health StationRural Health UnitsCommunity Hospitals

Emergency or District HospitalsProvincial or City Hospitals

Regional Health ServicesRegional Medical Centers and Training HospitalsNational Health Services Medical Centers


Levels of Disease Prevention

• Primary Level Disease Prevention– Directed at individuals at risk; specific protection

against risks– Immunizations– Food supplementation– Malaria chemoprophylaxis


• Secondary Level of Prevention– Directed for individuals in the subclinical

asymptomatic and symptomatic stage; aims to diagnose and treat existing health problems

– Screening– Casefinding– Surveillance– Treatment of communicable disease


• Tertiary Level Disease Prevention– Directed towards individual in the pathogenic stage

of disease; deals with the reduction of the magnitude and severity of the residual effects of communicable and non-communicable diseases

– Rehabilitation– Control of measles during an epidemic


Primary Health Care

• Education for Health• Locally Endemic and

Communicable Disease Control

• Expanded Program on Immunization

• Maternal and Child Health

• Essential Drugs

• Nutrition• Treatment• Safe Water and

Sanitation• Dental Health• Access to Sentrong

Sigla• Mental Health


Family Health Nursing Process

• First Level Assessment– Wellness Condition– Health Deficit are instances of failure in health

maintenance– Health Threat are conditions that are conducive to

disease, accident, or failure– Foreseeable crisis or stress points are anticipated

periods of unusual demand on the individual or family in terms of adjustment


• Second Level Assessment– Inability to recognize the existence of a health

condition or problem– Inability to make decisions with respect to taking

appropriate health action– Inability to provide nursing care to the sick, disable, or

dependent member of the family– Inability to provide a home environment that is

conducive to health maintenance and personal development

– Failure to utilize community resources for health care

Scale of Ranking Health ConditionsCriteria Score Weight

Nature of the ConditionWellnessHealth DeficitHealth ThreatForeseeable crisis

3321

1

Modifiability of the ConditionEasily modifiablePartially modifiableNot modifiable

210

2

Preventive PotentialHighModerateLow

321

1

SalienceA condition needing immediate attentionA condition not needing immediate attentionNot perceived as a condition

210

1


Home VisitPrinciples• Must have a purpose• Makes use of all available

information about a patient

• Consider and give priority to needs of clients

• Involve clients• Should be flexible

Guidelines to consider about frequency of visits• Need of the client• Acceptance of the family• Policy of a specific agency• Other health agencies

present• Past services given• Ability of clients to

recognize own needs


Steps in Conducting Home Visits

1. Greet the client and introduce self2. State the purpose of the visit3. Assess the health needs4. Perform the bag technique5. Perform nursing care and give health teachings6. Record all data (observation and care rendered)


Bag Technique

• Is a tool used by the nurse to enable her to perform a nursing procedure with ease and deftness

• PHN Bag is an essential and indispensable equipment of a public health nurse which she has to carry along during home visits

• The BP Apparatus is part of the PHN Bag


Bag TechniquePrinciples• Minimize, if not prevent

the spread of infection• Saves time and effort of

the nurse• Should show effectiveness

of total care given to an individual or family

• Can be performed in a variety of ways

Important Points• Should contain all

necessary articles/supplies• Should be cleaned very

often and supplies are replaced

• Should be well-protected• Arrange according to

convenience


Community Diagnosis• An in-depth process in finding out the profiles, health

status of the community and the factors affecting the present status

1. Preparation for Community Diagnosis2. Data gathering (spot map, key informant interview,

community survey, records review)3. Data presentation4. Problem identification5. Preparation of an action plan


Community Organizing

• Is a process by which people, health services and agencies of the community are brought together to:

a. Learn about common problemsb. Identify these problems are their ownc. Plan the kind of action to solve problemsd. Ac on this basis


Community Organizing Participatory Action Research

• Principles:– People have the capacity to change– COPAR should be based on the interest of the poorest

sectors of society– COPAR should lead to the development of self-

reliance• Methods:– Action-Reflection-Action-Session– Consciousness-Raising


COPAR Phases

• I. Pre-Entry Phase– Site Selection• Must be DOPE• Health services are inaccessible or inadequate• Poor health status• Area has no serious peace and order problem• No strong resistance• Area is free from relatively similar programs

– Preliminary Social Investigation– Identification of Potential Barangays


• II. Entry Phase– Integration– Conduct of Information Campaign– Deepening Social Investigation– Identification of Potential Leaders– Provision of Health Services– Core Group Formation


• III. Organization-Building Phase– Preparing the community for organization-building– Organizing the CHO– Training and Education for the CHO– Setting up the CHO


• IV. Sustenance and Strengthening Phase– Education and Training– Networking and Linkages– Community Mobilization on Health and Development

Concerns– Development of Secondline Leaders


Expanded Program on ImmunizationVaccine Minimum

AgeNumber of Doses

Amount Route Interval

BCG At birth 1 0.05 mL ID

Hepatitis B At birth 3 0.5 mL IM (thigh) 10th and 14th week

DPT 6 weeks 3 0.5 mL IM (thigh) 4 weeks

OPV 6 weeks 3 2 drops PO 4 weeks

Measles 9 months 1 0.5 mL IM (arm)

If child has convulsions, Do NOT give DPTIf child is immunocompromised, Do NOT give Polio, Measles, and BCG!!! Immunize every sick child


Tetanus ToxoidVacci

neMinimum Time

and IntervalPercent

ProtectionDuration of Protection

TT1 As early during pregnancy 0

TT2 4 weeks 80 3 years; Infants protected from NT

TT3 6 months 95 5 years; Infants protected from NT

TT4 1 year 99 10 years; Infants protected from NT

TT5 1 year 99 Lifetime; ALL Infants protected from NT


EPI: Cold Chain

• Storage:– 6 months Regional Level– 3 months Provincial/District Level– 1 month Main Health Centers– 5 days Health Centers


Family Planning

• Principles:– Responsible Parenthood– Respect for Life– Birth Spacing– Informed Choice

• Mandate: EO 119 and EO 102


Contraceptive Methods

• Natural– Abstinence– Calendar Method– Basal Body Temperature– Cervical Mucus (Billings)– Symptothermal method– Lactation Amenorrhea

Method– Coitus Interruptus

– Standard Days Method – Cycle Beads

• Surgical Methods– Tubal Ligation– Vasectomy


Contraceptive Methods

• Hormonal– Progestin-Only Oral

Contraceptives– Low-Dose Combined

Oral Contraceptives– Injectables– Norplant Implants

• Barrier– Intrauterine Device– Diaphragm– Cervical Cap– Condoms


Malnutrition

• Vitamin A Supplementation– Infants (6 to 11 months) 100,000 IU – 1 dose– Children (12 to 72 months) 200,000 IU – 1 capsule

every 6 months– For Pregnant women given starting 4th Month 10,000

IU twice a week until delivery• Iron Supplementation– For Pregnant women 60 mg Iron and 400 mcg Folic

acid 1 tablet OD for 6 months or 2 tabs per day if started in the 2nd or 3rd trimester


• Iron Supplementation– For Low Birth Weight - drops 15 mg Iron/0.6 mL, 0.3

mL once a day to start 2 months until 6 months– For 1 to 5 y/o – syrup 30 mg Iron/5 mL, 1 tbsp OD for

3 months or 1 tsp once a week for 6 months– For 6 to 11 years anemic and underweight – syrup 30

mg/5 mL, 2 tbsp OD for 6 months• Iodine Supplementation– Iodized capsule with 200 mg iodine 1 capsule for 1

year


IMCI

• Assess, Clasify, Identify, Treat• CUVA


Garantisadong Pambata

• Campaign to support various health programs that will reduce childhood illnesses

• Vit. A and iron supplementation• Catch-up immunization• Done twice a year (one week in April, and one

week in October)


Newborn ScreeningDisorder Effects

Congenital Hypothyroidism Mental Retardation

Congenital Adrenal Hyperplasia Death

Galactosemia Death and cataracts

Phenylketonuria Mental Retardation

G6PD Deficiency Anemia and Kernictirus

• Done after 24, 48th to 72nd hour after birth; screened again after 2 weeks for more accurate results

• Uses heel prick method and an absorbent filter paper and dried for 4 hours

• Report positive results immediately


Environmental Sanitation


DOH Herbal Medicines

• BAYABAS• ULASIMANG BATO• BAWANG• LAGUNDI• YERBA BUENA

• SAMBONG• AKAPULKO• NIYUG-NIYOGAN• TSAANG GUBAT• AMPALAYA


Isolation Precautions

• Universal Precautions or Standard Precautions– Apply to blood, all body fluids, secretions, and

excretions; skin that is not intact; and mucus membranes

• Hand Hygiene or Handwashing– Best way to prevent spread of pathogens– May use alcohol based when hands are not visibly

soiled– Handwashing is for visibly soiled hands


Transmission Based PrecautionsAirborne Precaution Droplet Precaution Contact Precaution

For PTB, measles, varicellaMust use a particulate filter mask

For influenza, meningitis, diptheria, rubellaSafe 3 feet and more

Skin to skin contact or through fomitesRequires gloves, a mask, gown, and personal equipment

Do NOT RECAP NEEDLES!


Tuberculosis

• TUBERCULOSIS– CA: Mycobacterium tuberculosis– MOT: Airborne droplet through coughing and

sneezing– Direct Sputum Smear Microscopy is the PRIMARY

diagnostic tool– PPD:• (+) >5 years (-) HIV 10 mm induration• (+) <5 years (+) HIV 5 mm induration


Tuberculosis

• TUBERCULOSIS– CA: Mycobacterium tuberculosis– MOT: Airborne droplet through coughing and

sneezing– Direct Sputum Smear Microscopy is the PRIMARY

diagnostic tool– PPD: Detects presence of antibodies; Results after 48

to 72 hours• (+) <5 y/o (+) BCG ≥10 mm is positive• (+) >5 y/o (-) BCG ≥5 mm is positive


Directly Observed Treatment - Shortcourse

Category

Type of TB Patient Intensive Phase

Continuation Phase

I New smear-positive;With extensive parenchymal lesionEPTBSevere concomitant HIV disease

2 RIPE 4 RI

II Treatment failureRelapse

2 RIPES/ 1RIPE 5 RIE

III New smear-negative PTB with minimal parenchymal lesions 2 RIPE 4 RI

IV Chronic Refer


Antimycobacterials

• Rifampicin – take with meals; protect from light• Isoniazid – take before meals; give 10 to 100 mg

of Pyridoxine• Pyrazinamide – caution for gouty arthritis;

protect from light• Ethambutol – not given to children below 6 years• Streptomycin – given IM


Leprosy

• LEPROSY (Hansen Disease)– CA: Mycobacterium leprae– MOT: Direct skin contact; prolonged– Dx: Slit Skin Smear– Types:• Paucibacillary: Treat with Rifampicin and Dapsone

for 6 to 9 months• Multibacillary: Treat with Rifampicin, Clofazimine,

and Dapsone for 24 to 30 months


Malaria

• MALARIA– CA: Plasmodium (vivax, ovale, malariae, falciparum)– MOT: Bite of anopheles mosquito– DX: Quantitative Buffy Coat– Treatment: Quinine, Sufadoxine, Chloroquine,

Mefloquine– Prophylaxis: Chloroquine, weekly intervals, start 1 to

2 weeks prior to entering endemic area.– Update: Artemeter-Lumefantrine


Dengue Hemorrhagic Fever

• DENGUE HEMORRHAGIC FEVER– CA: Dengue virus (I, II, III, IV) and Chikungunya virus– MOT: Bite of Aedes aegypti virus– Dx: Tourniquet test (capillary fragility or Rumpel

Leads test)– Treat:• Fluids• Paracetamol• WOF bleeding


Filariasis

• FILARIASIS– CA: Wuchereria brancrofti, Brugia malayi, Brugia

timor– MOT: Bite of Aedes poecilius– Dx: symptomatology: obvious lymphadenitis,

lymphangitis, lymphedema, elephantiasis, orchitis– Treat:• Diethylcarbamazine citrate (Hetrazan)


Schistosomiasis

• SCHISTOSOMIASIS (Bilhariasis, Snail Fever)– CA: Schistosoma japonicum, Schistosoma mansoni,

Schistosoma haematobium– Intermediate Host: Oncomelania quadrasi– MOT: Skin contact to contaminated water– Treat:• Praziquantel (Biltricide)


Measles

• MEASLES– CA: Paramyxovirus– MOT: Airborne droplet (1 to 2 days before onset of

s/s; 4 to 5 days after disappearance of rash)– Pathognomonic Sign: Koplik’s spots– PVT: Measles vaccine– Mgt:• Vitamina A Supplementation• Ibuprofen or Paracetamol• Supportive


Chicken Pox

• CHICKEN POX– CA: Varicella-Zoster Virus– MOT: Direct contact (1 to 2 days prior to appearance

of rashes; 5 to 6 days onset of vesicular crusting)– S/S: Vesicular rash starts from the trunk to peripheries– Mgt:• Acyclovir 800mg TID• Paracetamol• Keeping fingernails short• Oatmeal bath


Mumps / Parotitis

• MUMPS / PAROTITIS– CA: Mumps Virus– MOT: Airborne droplet (1 to 2 days before onset of

parotitis; 5 days after onset of swelling)– Compli: orchitis, oophoritis, infertility,

meningoencephalitis– PVT: MMR at 12 to 15 M; Booster at 4 to 6 years– Mgt:• Bedrest• Antipyretics


Diphtheria

• DIPHTHERIA– CA: Corynebacterium diphtheria (Klebs-Loeffler bacillus)– MOT: Contact with ill or contaminated articles– Pathognomonic Sign: Pseudomembrane on throat and

tonsils– Dx: Culture of membrane– PVT: DPT vaccine– Mgt:• Diphtheria antitoxin, penicillin, erythromycin• Isolation


Tetanus

• NEONATAL TETANUS and TETANUS OF OLDER AGE GROUPS– CA: Clostridium tetani– MOT: Contamination of unhealed cord stump– Treat:• Penicillin I.V.• Tetanus antiserum or tetanus immunoglobulin

–PVT:• Tetanus vaccine


Influenza

• INFLUENZA– CA: Influenza virus (A, B, C)– MOT: Droplet– PVT: Inactivated (IM) for 6 months and older; Live,

attenuated (Nasal Spray) for 2 to 49 years– Mgt:• Supportive


Influenza A H1N1


Pneumonia

• PNEUMONIA– CA: a lot!– MOT: mainly respiratory droplet– Treat:• Anti-infectives (Antibiotics, Antivirals, Antifungals)• Antipyretics

– Mgt:• Supportive


Cholera

• CHOLERA (EL TOR)– CA: Vibrio cholerae– MOT: Fecal-oral route– S/S: Rice-water stool– Treat:• Tetracycline

– Mgt:• OReSol, coconut water, “am”, soap, cereals, BF


Typhoid Fever

• TYPHOID FEVER– CA: Salmonella typhi– MOT: Fecal-oral route– Note: Rose spots on abdomen or chest– Treat:• Chloramphenicol

– Mgt:• Rehydration• Proper food preparation


Shigellosis

• SHIGELLOSIS (Bacillary dysentery)– CA: Shigella (dysenterae, flexneri, boydii, soneii)– MOT: Fecal-oral route– Treat:• Trimethoprim-sulfamethoxazole



Amebiasis

• AMEBIASIS (Amebic dysentery)– CA: Entamoeba histolytica– MOT: Fecal-oral route– Treat:• Metronidazole



Soil-Transmitted Helminthiasis

• SOIL-TRANSMITTED HELMINTHIASIS– CA: Ascaris lumbricoides, Trichuris trichiura,

Ancylostoma duodenale & Necator americanus (Hookworn)

– MOT: Contact with contaminated soil– Treat:• Mebendazole• Albendazole


Paragonimiasis

• PARAGONIMIASIS– CA: Paragonimus westermani (subsp. philippinensis),

Paragonimus siamenses– MOT: ingestion of raw crab (Sundathelpusa

philippina, Varona litterata)– Treat:• Praziquantel• Bithionol

– Mgt:• Proper food preparation


Hepatitis A

• HEPATITIS A (Infectious Hepatitis, Epidemic Hepatitis, Catarrhal Jaundice)– CA: Hepatitis A virus– MOT: Fecal-oral route, parenteral– Treat:• IM injection of gamma globulin

– Mgt:• Environmental sanitation• Proper food preparation


Paralytic Shellfish Poisoning

• PARALYTIC SHELLFISH POISONING (Red Tide Poisoning)– CA: Dinoflagellates (Pyromidium bahamense var.

compressum in Manila Bay, Samar, Bataan, Zambales)– MOT: Eating contaminated bivalve shellfish– Treat/Mgt:• Induce vomiting• Pure coconut milk and sodium bicarbonate


Leptospirosis

• LEPTOSPIROSIS (Weil’s Disease, Trench Fever, Mud Fever, Flood Fever, Japanese Seven Days Fever, Spiroketal Jaundice)– CA: Leptospira interrogans– MOT: Skin contact to contaminated water or moist

water– Treat:• Penicillin• Tetracycline• Erythromycin


Rabies

• RABIES (Hydrophobia)– CA: Rabies virus– MOT: Bite of a rabid animal, or through scratches on

the skin– Treat/Mgt:• Wash area with soap and water• Rabies immunoglobulin and active immunization


Scabies

• SCABIES– CA: Sarcoptes scabiei– MOT: Direct contact with infected person or through

fomites– Treat:• Benzyl benzoate• Permethrin (Kwell)

– Mgt:• Personal hygiene• Environmental sanitation


Anthrax

• ANTHRAX (Woolsorter Disease, Ragpicker Disease)– CA: Bacillus anthracis– MOT: Ingestion, inhalation or cutaneous contact with

spore– Treat:• Penicillin• Erythromycin• Tetracycline


Sexually Transmitted Infections

• GONORRHEA (GC, Clap, Drip)– CA: Neisseria gonorrheae– MOT: Sex, Mother to child during delivery– Treat:• Ceftriaxone• Azithromycin• Doxycycline


• SYPHILIS– CA: Treponema pallidum– MOT: Sex– 4 Stages (First, Second, Latent, Late)– Complications:• Neurosyphilis• Cardiovascular syphilis

– Treat:• Penicillin, Tetracycline, Doxycycline


• TRICHOMONIASIS (Trich)– CA: Trichomonas vaginalis– MOT: Sex– Treat:• Metronidazole


• Hepatitis B– CA: Hepatitis B virus– MOT: Sex and blood, mother to child– PVT:• Hepatitis B vaccine• Safe sex practice

– Treat:• Hepatitis B immunoglobulin


• HIV/AIDS– CA: Human Immunodeficiency Virus– MOT: Sex and blood and body fluids– Dx: EIA and Western Blot– Note: 6 months window period– Treat: Highly Actice AntiRetroviral Therapy (HAART)• Reverse Transcriptase Inhibitors, Protease

Inhibitors, Nucleosides, Fusion Inhibitors


Meningococcemia

• MENINGOCOCCEMIA– CA: Neisseria meningitidis– MOT: Droplet spread– Treat:


Severe Acute Respiratory Syndrome

• SARS– CA: Coronavirus– MOT: Droplet spread– Note: Isolation!– Treat:

Community Health Nursing Review

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