NCM 104 & 113: Community Health Nursing

CHAPTER 1: FUNDAMENTAL CONCEPT OF CHN

f. Rene Dubos (book: Man Adapting): a quality of life, involving
DEFINITION OF CHN social emotional, mental, spiritual & biological fitness on the
part of the individual, which results from adaptations to the
– direct goal oriented and adaptable to the needs of the individual,
environment.
the family and community during health and illness (ANA)
g. Dunn: illness, health, and peak wellness are on a continuum;
– area of human services directed toward developing and
health is fluid and changing. Consequently, within a social
enhancing the health capabilities of people (John Henrich, 1981)
environment, state of health depends on the goals, potentials,
– utilization of nursing process in different level of clientele
& performance of individuals, families, communities, &
concerned with promotion of health, prevention of disease and
societies.
disability and rehabilitation (Aracelli Maglaya).
– synthesis of nursing practice and public health practice.
– activities focus on health promotion and disease prevention. SOCIAL
– of or relating to living together in organized groups or similar
• Community health nurses assist in the transition of the health close aggregates (American Heritage College Dictionary, 1997)
care system from disease-oriented system to health-oriented – units of people in communities who interact with each other.
system.
SOCIAL HEALTH
MAJOR GOAL OF CHN – connotes community vitality and is a result of positive interaction
• To preserve the health of the community and surrounding among groups within the community with an emphasis on health
populations by focusing on health promotion and health promotion and illness prevention.
maintenance of individuals, families, and groups within the
community. COMMUNITY
– seen as a collection of locality-based individuals, interacting in
CHN/PHN is associated with health and the identification of social units, and sharing common interests, characteristics, values,
populations at risk rather than with an episodic response to patient goals.
demand. – Baldwin: outlined the evolution of the definition of community.
They determined that, before 1996, definitions of community
MISSION OF PUBLIC HEALTH focused on geographical boundaries, combined with social
• Social justice that entitles all people to necessities, such as attributes of people.
adequate income and health protection, and accepts collective – Maurer & Smith addressed concept of community and identified
burdens to make this possible. 4 defining attributes:
• People • Interaction
• Place • Common characteristics, interests, or
DEFINITION OF HEALTH, ACCORDING TO:
goals
a. WHO: a state of complete physical, mental, and social well-
being and not merely the absence of disease or infirmity.
b. Murray: a state of well-being in which the person is able to DEFINITION OF COMMUNITY, ACCORDING TO:
use purposeful, adaptive responses and processes physically, a. Allender: A collection of people who interact with one
mentally, emotionally, spiritually, and socially. another and whose common interests or characteristics
c. Pender: actualization of inherent and acquired human form the basis for a sense of unity or belonging.
potential through goal-directed behavior, competent self- b. Lundy & James: A group of people who share something in
care, and satisfying relationship with others. common and interact with one another, who may exhibit a
d. Orem: a state of person that is characterized by soundness commitment with one another and may share a geographic
or wholeness of developed human structures and of bodily boundary.
and mental functioning. c. Clark: A group of people who share common interests, who
e. WHO (1986): expanded the definition to include socialized interact with each other, and who function collectively within
conceptualization of health: “The extent to which an individual a defined social structure to address common concerns.
or group is able, on the one hand, to realize aspirations and d. Shuster and Goeppinger: A locality-based entity, composed
satisfy needs; and, on the other hand, to change or cope of systems of formal organizations reflecting society's
with the environment. Health is seen as a resource for institutions, informal groups, and aggregates.
everyday life, not the objective of living; it is a positive
concept emphasizing social & personal resources, & physical TYPES OF COMMUNITY
capacities.” Maurer & Smith (2009) noted two main types of communities:
Saylor: considers several dimensions of health, a. Geopolitical/ Territorial communities
including physical (structure/ function), social, role, mental – formed by both natural and manmade boundaries (barangay,
(emotional and intellectual), and general perceptions of city, province, region, nation, neighborhood).
health status. It conceptualizes health from a macro
perspective, as a resource to be used rather than a goal b. Phenomenological/functional communities
in and of itself.

Community Health Nursing

 – refers to relational, interactive groups, in which the place or b. control of communicable infections
setting is more abstract, and people share a group perspective c. education of the individual in personal hygiene
or identity based on culture, values, history, interests, and goals d. organization of medical and nursing services for
(school, college, church, organizations [community of solution]). the early diagnosis and preventive treatment of
disease
Population e. development of the social machinery to ensure
– typically used to denote a group of people having common everyone a standard of living adequate for the
personal or environmental characteristics (elders in a rural region) maintenance of health, so organizing these
benefits as to enable every citizen to realize his
Aggregates birthright of health and longevity" (Hanlon).
– subpopulations that have some common characteristics or
concerns (pregnant teens within a school district). • Key phrase of public health: through organized community
effort.
DETERMINANTS OF HEALTH & ILLNESS connotes organized, legislated, & tax-supported efforts
1. Income and social status – higher income and social status are through health departments/related governmental
linked to better health. The greater the gap between the agencies.
richest and poorest people, the greater the differences in
health. Institute of Medicine of the United States (1988) identified 3 primary
2. Education – low education levels are linked with poor health, functions of public health: assessment, assurance, & policy
more stress and lower self-confidence. development.
3. Physical environment – safe water and clean air, healthy Core Public Health Functions
workplaces, safe houses, communities, and roads all contribute Assessment
to good health. • Regular collection, analysis, and information sharing about
4. Employment and working conditions – people in employment health conditions, risks, and resources in a community.
are healthier, particularly those who have control over their • Data are used for program planning and policy development.
working conditions. Policy development
5. Social support networks – greater support from families, • Use of information gathered during assessment to develop
friends and communities is linked to better health. local and state health policies and to direct resources toward
6. Culture – customs and traditions, and the beliefs of the family those policies.
and community all affect health. • Involves advocacy & political action to develop policies in
7. Genetics – inheritance plays a part in determining lifespan, various levels of decision making.
healthiness, and the likelihood of developing illnesses. Assurance
8. Personal behavior and coping skills – balanced eating, keeping • Focuses on the availability of necessary health services
active, smoking, drinking and how we deal with life’s stresses throughout the community. It includes maintaining the ability
and challenges all affect health. of both public health agencies and private providers to
9. Health services – access and use of services that prevent and manage day-to-day operations and having the capacity to
treat disease influences health. respond to critical situations and emergencies.
10. Gender – men and women suffer from different types of • Making sure health services are effective, available, accessible.
diseases at different ages.
• Public health efforts focus on prevention and promotion of
INDICATORS OF HEALTH AND ILLNESS population health at the national and local levels.
• The National Epidemiology Center of DOH, PSO, and local a) national level: concentrate on providing support &
health centers/offices/departments advisory services to public health structures at the local
o provide morbidity, mortality, and other health status level.
related data. b) local level: provide direct services to communities
• Local health centers/offices/departments through 2 avenues:
o responsible for collecting morbidity & mortality data & i) Environmental health services – protect public
forwarding the information to higher-level health facility. from hazards ( polluted water, tainted food).
• Nurses participate in investigative efforts to determine what is ii) Personal health care services – immunization &
precipitating the increased disease rate and work to remedy family planning services, well-infant & maternal
the identified threats or risks. care, & treatment prevalent health conditions
(communicable and noncommunicable).
DEFINITION & FOCUS OF PUBLIC HEALTH &
COMMUNITY HEALTH ESSENTIAL PUBLIC HEALTH FUNCTIONS
Definition of Public Health Drafted by World Health Organization Regional Office for the
• C. E. Winslow: Public health is the science and art of: Western Pacific
1. preventing disease 1. Health situation monitoring and analysis.
2. prolonging life 2. Epidemiological prevention and control surveillance/disease.
3. promoting health and efficiency through organized 3. Development of policies and planning in public health.
community effort for: 4. Strategic management of health systems and services for
a. sanitation of the environment population health gain.
5. Regulation and enforcement to protect public health.

Community Health Nursing

 6. Human resources development and planning in public health.
7. Health promotion, social participation, and empowerment. Level 1: Primary Prevention Activities - Prevention of
8. Ensuring the quality of personal and population-based health problems as they occur.
service. Example: Immunization
9. Research, development, and implementation of innovative
public health solutions. Level 2: Secondary Prevention - early detection and
intervention
HEALTH PROMOTION & LEVELS OF PREVENTION Example: Screening for STD
• Medical care focuses on disease management and cure. Level 3: Tertiary Prevention - correction and
• Public health focus health on promotion and disease prevention. prevention of deterioration of a disease state.
Example: Teaching insulin administration in the home
Health Promotion
– activities enhance resources directed at improving well -being.

Disease Prevention DEFINITION AND FOCUS OF CHN, PHN, &

– activities protect people from disease and the effects of disease. COMMUNITY-BASED NURSING
Community Health Nursing
LEVELS OF PREVENTION (LEAVELL & CLARK, 1958) • CHN: global/umbrella term.
1. Primary Prevention • ANA: synthesis of nursing practice and public health practice
– relates to activities directed at preventing a problem before applied to promoting and preserving the health of populations”.
it occurs by altering susceptibility or reducing exposure for • It is a broader and more general specialty area that
susceptible individuals. encompasses subspecialties including PHN, school nursing,
– consists of 2 elements: general health promotion and specific occupational health nursing, and other developing fields of
protection. practice, such as home health, hospice care, and independent
a. General Health promotion: efforts enhance resiliency and nurse practice.
protective factors and target essentially well populations.
(promotion of good nutrition, and encouraging regular Public Health Nursing
exercise) • PHN: component or subset of CHN
b. Specific protection: efforts reduce or eliminate risk
• It is the synthesis of public health and nursing practice.
factors (immunization and water purification).
• Freeman: PHN may be defined as a field of professional
practice in nursing and in public health in which technical
2. Secondary Prevention
nursing, interpersonal, analytical, and organizational skills are
– early detection and prompt intervention during the period of
applied to problems of health as they affect the community.
early disease pathogenesis. (mammography, blood pressure
These skills are applied in concert with those of other persons
screening, newborn screening, and mass sputum examination)
engaged in health care, through comprehensive nursing care
– implemented after a problem has begun but before signs and
of families and other groups and through measures for
symptoms appear and targets those populations who have risk
evaluation or control of threats to health, for health education
factors
of the public, and for mobilization of the public for health action.
– directed toward prompt intervention to prevent worsening
• In the Philippines, it is seen as a subspecialty nursing practice
conditions of the affected population.
generally delivered within official or governmental agencies.
3. Tertiary Prevention • American Public Health Association: PHN is the practice of
– targets populations have experienced disease and focuses on promoting and protecting the health of populations using
limitation of disability and rehabilitation (teaching insulin injection knowledge from nursing, social, and public health sciences.
techniques, referring a patient with spinal cord injury for • ANA: PHN practice is population focused, with the goals of
occupational and physical therapy) promoting health and preventing disease and disability for all
.– Aim: to reduce the effects of disease and injury and to restore people through the creation of conditions in which people can
individuals to their optimal level of functioning. be healthy.

Standards for Public Health Nursing Practice (ANA, 2007).

Standards of Care
Standard 1: Assessment PHN collects comprehensive data pertinent to the health status of the populations
Standard 2: Population Diagnosis and priorities PHN analyzes the assessment data to determine the population diagnoses and priorities.
Standard 3: Outcomes Identification PHN identifies expected outcomes for a plan that is based on population diagnoses and priorities.
Standard 4: Planning PHN develops a plan that reflects best practices by identifying strategies, action plans, and
alternatives to attain expected outcomes.
Standard 5: Implementation PHN implements the identified plan by partnering with others.
a. Coordination Coordinates programs, services, and other activities to implement the identified plan.
b. Health Education and Health Promotion Employs multiple strategies to promote health, prevent disease, and ensure a safe environment
for populations.
c. Consultation Provides consultation to various community groups and officials to facilitate the implementation
of program and services.

Community Health Nursing

 d. Regulatory Activities Identifies, interprets, and implements public health laws, regulation, and policies.
Standard 6: Evaluation PHN evaluates the health status of the population.
Standards of Professional Performance
Standard 7: Quality of Practice PHN systematically enhances the quality and effectiveness of nursing practice.
Standard 8: Education PHN attains knowledge and competency that reflects current nursing and public health practice.
Standard 9: Professional Practice Evaluation PHN evaluates one’s own nursing practice in relation to professional practice standards and
guidelines, relevant statutes, rules, and regulations.
Standard 10: Collegiality and Professional PHN establishes collegial partnerships while interacting with representatives of the population,
Relationships organizations, and health and human services professionals, and contributes to the professional
development of peers, students, colleagues, and others.
Standard 11: Collaboration PHN collaborates with the representatives of the population, organizations, and health and human
services professionals in providing for and promoting the health of the population
Standard 12: Ethics PHN integrates ethical provisions in all areas of practice.
Standard 13: Research PHN integrates research findings in practice.
Standard 14: Resource Utilization Population PHN considers factors related to safety, effectiveness, cost, and impact of practice and in the
planning of delivery of nursing and public health programs, policies, and services.
Standard 15: Leadership PHN provides leadership in nursing and public health.

Community-Based Nursing CHN Population focused practice

• McEwen and Pullis: application of the nursing process in caring • responsible for • concerned with many distinct and
for individuals, families, and groups where they live, work, or specific overlapping community
go to school or as they move through the health care system. subpopulation in subpopulations.
• It is a setting specific; emphasis is on acute and chronic care. It community • focus on many subpopulations that
includes practice areas: home health and nursing in outpatient. make up the entire community.
• involves concern for those who do,
DIFFERENCE BETWEEN COMMUNITY-BASED and do not, receive health services
NURSING AND CHN
Zotti et al. (1996) compared community-based nursing and A population focus involves a scientific approach to CHN:
CHN. They explained that the goals of the two are different. community assessment and diagnosis are necessary and basic to
planning, intervention, and evaluation.
CHN Community-based Nursing • Community health nursing practice requires the following types
• Emphasizes preservation • Emphasizes managing acute of data for scientific approach and population focus:
and protection of health. chronic or conditions. a. the epidemiology, or body of knowledge, of a particular
problem and its solution
• Primary client: • Primary clients: individual &
community. family. b. information about the community.
• Services: direct and • Services: largely direct.
Information useful for population focus
indirect.
Type of Examples Sources
Information
Distinguishing Features of Community Health Nursing Practice
Demographic Age, gender, Vital Statistics; census
• In addition to its preventive approach to health, CHN is
Data socioeconomic status,
characterized by its being population- or aggregate-
education level.
focused, its developmental nature, and the existence of a
Groups at high Health status and health Health statistics;
prepayment mechanism for consumers of community
risk indicators of various disease statistics
health nursing services.
subpopulations in the
community
POPULATION-FOCUSED APPROACH & CHN Services/provi Official (public) health City directors, phone
INTERVENTIONS ders available departments, healthcare books, social
Population-focused Nursing providers for low- workers, list of low-
• Baldwin: concentrates on specific groups of people and income individuals and income providers,
focuses on health promotion and disease prevention, families, community community health
regardless of geographical location. service agencies nurse
• Goal: to promote healthy communities.
• Population focused practice (Minnesota DOH, 2003): LEVELS OF CLIENTELE OF THE COMMUNITY HEALTH
o Focuses on the entire population. NURSE
o Is based on assessment of the populations' health status.
• Community health nurses focus on the care of several levels
o Considers the broad determinants of health.
of clientele:
o Emphasizes all levels of prevention.
o Individual – focus of nurse in the clinic or health center.
o Intervenes with community, system, individuals, and
o family – basic unit of care in CHN.
families.
o group/aggregate

Community Health Nursing

 o community as a whole in many settings (homes, clinics, INTERVENTION WHEEL
schools). Public Health Intervention Model
• When the nurse uses community organizing as a strategy for • initially proposed in the late 1990s by nurses from the Minnesota
health promotion and disease prevention, the focus of care is DOH.
the entire community. • describe the breadth and scope of public health nursing
• For community analysis, nurse conducts interviews with practice.
families as the units of data collection. • model was revised and termed Intervention Wheel.
• recognized as a framework for CHN and PHN practice.
Clients of Community Health Nurse
• contains 3 important elements:
• Individual o population based.
o CHN deals with individuals (sick or well). o contain 3 levels of practice (community, system, and
o considered as an "entry point" in working with these individual/family)
clients. o identifies and defines 17 public health intervention (group
• Family in 5 wedges).
o defined as a collection of people who are integrated,
interacting and interdependent (Hunt, 1997).
• Population group
o group of people who share common characteristics
developmental stage or common exposure to
environmental factors, and consequently common health
problems, issues, and concerns.
o population groups are the usual targets or beneficiaries
of social services and health programs.
• Community
o A group of people sharing common geographic
boundaries and/or common values and interests within a
specific social system.
• Behringer and Richards: community as webs of people shaped
by relationships, interdependence, mutual interests, and
patterns of interaction.
• Anderson and McFarlane: developed community-as-client
model and was renamed to community-as-partner model. The
two elements of the model are focus on the community as
partner and the use of the nursing process.

Public Health Interventions and definitions

Public Health Definition
Interventions
Surveillance Monitors health events through systematic collection analysis, and interpretation of health data for the purpose of
planning, implementing, and evaluating public health interventions.
Disease and other health Systemically gathers and analyzes data regarding threats to the health of populations, ascertains the source of the
event investigation threat, identifies cases and others at risk, and determines control measures.
Outreach Locates populations of interest or populations at risk and provides information about the nature of the concern,
what can be done about it, and how services can be obtained.
Screening Identifies individuals with unrecognized health risk factors or asymptomatic disease conditions.
Case finding Locates individuals and families with identified risk factors and connects them with resources.
Referral and follow-up Assist individuals and families, groups, organizations, and/or communities to identify and access necessary resources
to prevent or resolve problems.
Case management Optimizes self-care capabilities of individuals and families and the capacity of systems and communities to coordinate
and provide services.
Delegated functions Are direct care tasks that RN carries out under the authority of a HCP as allowed by law.
Health teaching Communicates facts, ideas, and skills that change knowledge, attitudes, values, beliefs, behaviors, and practices of
individuals, families, systems, and/or communities.
Counseling Establishes an interpersonal relationship with a community, system, family or individual, with the intention of increasing
or enhancing their capacity for self-care and coping.
Consultation Seeks information and generates optional solutions to perceived problems through interactive problem solving
with a community, system, family, or individual.
Collaboration Commits 2 or more persons or organization to achieve a common goal through enhancing capacity of one or
more of the family to promote and protect health.

Community Health Nursing

 Coalition building Promotes and develops alliances among organizations for a common purpose
Community organizing Helps community groups to identify common problems or goals, mobilize resources, and develop and implement
strategies for realizing the goals they collectively have set.
Advocacy Pleads someone’s cause or acts on someone’s behalf, with a focus on developing the community, system, and
individual/family’s capacity to plead their own cause or act on their own behalf.
Social Marketing Utilizes commercial marketing principles and technologies for programs designed to influence the knowledge,
attitudes, values, beliefs, behaviors, and practices of the population of interest.
Policy development and Places health issues in decision maker’s agenda, acquires a plan of resolution, and determines needed resources,
enforcement resulting in law, rules, regulation, ordinances, and policy. Policy reinforcement compels others to comply with ules,
regulations, ordinances, and policies.

EMERGING FIELDS OF CHN IN THE PHILIPPINES 11 Key Areas of Responsibility

Home health care 1. Safe and quality nursing care
– practice involves providing care to individuals and families in their • Knowledge of health/illness status of client; sound decision
own places of residence mainly to minimize the effects of illness making; safety, comfort. and privacy; priority setting based
and disability. on client's needs; administration of medications and health
therapeutics; use of the nursing process.
Hospice home care
– home care rendered to the terminally ill to provide comfort, 2. Management of resources and environment
improve quality of life, and provide support as they go through the • Organization of workload; use of financial resources for client
processes of dying and grieving. care; mechanism to ensure proper functioning of
– Palliative care is particularly important in hospice care. equipment; and maintenance of a safe environment.

EntrepreNurse 3. Health education

– project initiated by DOLE, in collaboration with the Board of • Assessment of client's learning needs; development of a
Nursing of the Philippines, DOH, PNA, and other stakeholders to health education plan and learning materials; and
promote nurse entrepreneurship by introducing a home health implementation and evaluation of the health education plan.
care industry in the Philippines.
– purpose: to deliver home health care services. 4. Legal responsibility
– It aims to: • Adherence to nursing law and relevant laws, national, local,
a. Reduce the cost of health care for the country's indigent and organizational policies (documentation of care given to
population by bringing primary health care services to poor clients).
rural communities.
b. Maximize employment opportunities for the country's 5. Ethicomoral responsibility
unemployed nurses. • Respect for rights of client; responsibility and accountability
c. Utilize country's unemployed human resources for health for for own decisions and actions; and adherence to international
the delivery of public health services and the achievement of and national codes of ethics for nurses.
the country's MDGs on maternal and child health (DOLE,
2013). 6. Personal and professional development
• Identification of own learning needs; pursuit of continuing
Faith Community/Parish Nursing education; involvement in professional and civic activities;
– practice of art and science of nursing combined with spiritual projection of a professional image; positive attitude toward
care. change and criticism; and adherence to professional
– focuses on health promotion and provision of holistic care to standards.
members of the faith community.
– nurses assume roles of health educator, personal health 7. Quality improvement
counselor, developer, and coordinator of support groups in faith • Data gathering for quality improvement; participation in
community. nursing audits and rounds; identification and reporting of
– integrator of health and healing, they recognize spirituality as the variances in client care; and recommendation of solutions to
core of practice of nursing. identified problems related to client care.

Competency Standards in Community Health Nursing 8. Research

▪ 11 key areas of responsibility determined by Committee on • Research-based formulation of solutions to problems in client
Core Competency Standards Development for the Board care and dissemination and application of research findings.
of Nursing of the Philippines and the Commission on Higher
Education Technical Committee on Nursing Education 9. Records management
(2005). • Accurate and updated documentation of client care while
▪ The Nursing Core Competency Standards were revised observing legal imperatives in record keeping.
in 2012, building on the same set of key areas of
responsibility. 10. Communication
• Use therapeutic communication techniques for establishment
of rapport, identifies verbal and nonverbal cues, and

Community Health Nursing

 responds to clients' needs, using formal and informal channels • 1958:
of communication and appropriate information technology. o regional health offices were created as a result of
decentralization efforts.
11. Collaboration and teamwork • 1970s
• Establishment of collaborative relationships with colleagues o Health care delivery system was reconstructed. Paved
and other members of the health team; collaborative the way for the health care system that exist to this day
planning with the other members of the health team. where health services are classified as primary,
secondary, and tertiary. It also brought the redefinition
HISTORY OF PUBLIC HEALTH AND PHN IN and expansion of the roles of public health nurses and
PHILIPPINES the midwives in health centers and RHUs.
• 1577 • 1991
o Franciscan Friar Juan Clemente opened medical o RA 7160 (Local Government Code) enacted to amended
dispensary in Intramuros for the indigent. devolution of basic health services including health
services, to LGUs and the establishment of a local health
• 1690
board in every province and municipality. (To enable local
o Dominican Father Juan de Pergero worked toward
governments to attain fullest development as self -reliant
installing a water system in San Juan del Monte and
communities and make them more effective partners in
Manila.
the attainment of national goals. )
• 1805
• September 2000
o smallpox vaccination was introduced by Francisco de
o Philippines, commit to attain the 8 Millennium
Balmis, personal physician of King Charles IV of Spain.
Development Goals. DOH commit to the attainment of
• 1876
MDGs to reduce child mortality, improve maternal health,
o first medicos titulares (worked as provincial health
combat HIV/AIDS, malaria, and other diseases.
officers) were appointed by the Spanish government.
• 1999
• 1888
o DOH launched directed efforts towards comprehensive
o 2-year courses consist of fundamental medical & dental
reform in health care with the Health Sector Reform
subjects offered in UST. Graduated were known as
Agenda launched.
“cirujanos ministrantes” and serve as male nurses &
• 2005
sanitation inspectors.
o Implementation of framework FOURmula One for health
• 1901
• 2010
o U.S. Philippines Commission, through Act 157, created
o Universal Health Care which aims to achieve health
Board of Health (now: DOH) of the Philippine Islands with
system goals of better health outcomes, sustained health
a Commissioner of the Public Health, as its chief
financing, and responsive health system that will provide
executive officer.
equitable access to health care.
• 1912
o Fajardo Act of 1912 created sanitary divisions made up of
1 – 4 municipalities. Each sanitary division had a president
who had to be a physician.
• 1905
o Lagota de Leche founded by Asociacion Feminista
Filipina, first center dedicated to the service of the
mothers and babies.
o Puericulture centers provided maternity and infant care.
• 1915
o PGH extend PHN services in the homes of patients by
organizing a unit called Social and Home Care services.
• 1947
o DOH was reorganized into bureaus: quarantine, hospitals
that took charge of the municipal and charity clinics and
health with the sanitary divisions under it.
• 1954
o Congress passed RA 1082 (Rural Health Act) that
provided the creation of RHU in every municipality.
• 1957
o RA 1891 was enacted to amend certain provisions (for a
more equitable distribution of health personnel) in the
Rural Health Act. The law created 8 categories of rural
health units corresponding to the population size of the
municipalities.

Community Health Nursing

 NCM 104 & 113: Community Health Nursing

CHAPTER 2: THEORETICAL FOUNDATIONS OF CHN REVIEW OF THEORETICAL APPROACHES

PRACTICE 1. General System Theory
– viewed as an open system
HISTORICAL PERSPECTIVES ON NURSING THEORY o Client: set of interacting elements that exchange energy,
matter, or information with the external environment to
• Florence Nightingale
exist.
o first nurse to formulate conceptual foundation for
o Individual: set of dimensions – physical, social, psychological,
nursing practice.
and spiritual that are interdependent and interrelated.
o believed that clean water, clean linen, access to adequate
o family and aggregate are set of interrelated individuals.
sanitation and a quiet environment would improve health
o a geographic community is composed of a set of families.
outcomes.
– useful in analyzing interrelationships of elements within client and
environment.
Years after her leadership, nursing practice became
– has boundaries that separate from its environment
atheoretical and was based primarily on reacting to the
o Culture and Family Code dictate the boundaries of Filipino
immediacy of patient situation and demands of medical staff.
Family
– regulate its exchange of matter, energy, and information with its
Some early nursing theories were extremely narrow and
environment.
depicted health care situations that involved only one nurse and
o Family environment constitutes everything outside its
one patient. Family and other health care professionals were
boundaries that affect it; family home, community and its
absent from the context of the theories.
institutions make up the immediate environment and is
considered in the assessment of family health status.
1980 onwards, nursing theorists including, Dorothy Johnson,
o Family gets inputs of matter (food, water), energy (sunlight,
Sister Callista Roy, Imogene King, Betty Neuman and Jean
electricity), and information (news on community events,
Watson have included community perspectives in their definition
health teachings) – resources taken from its environment.
of health.
o Outputs are material products, energy and information that
result from the family’s processing of inputs.
Nola Pender developed the Health Promotion Model in the
▪ Example: health practices and health status of family
1980s, then revised in 1996.
members.
o Feedback is the information from the environment
HOW THEORY PROVIDES DIRECTION TO NURSING directed back to the system, which allows the system to
• Goal of theory: to improve nursing practice. make the necessary adjustments for better functioning.
• Chinn & Kramer (2008): using theories or parts of theoretical ▪ Example: Nurse’s feedback to a mother that her
frameworks to guide practice best achieves this goal. child is underweight makes her aware of her child’s
• Theory-based practice guides data collection and interpretation needs and allows her to take action.
in a clear and organized manner.
Subsystems
DEFINITION OF THEORY, ACCORDING TO: – components of a system (Family members)
a. Barnum: A theory is like a map of a territory as opposed to – interact to accomplish their own purpose.
an aerial photograph. The map does not give the full terrain;
instead it picks out those parts that are important for its Suprasystems
given purpose. – bigger system composed of families who interrelate with and
affect one another (Community)
Nursing Theorist:
b. Woods & Cantanzaro (1988): A systematic vision of reality; a 2. Social Learning Theory
set of interrelated concepts that is useful for prediction and – based on belief that learning takes place in a social context;
control. people learn from one another, and learning is promoted by
c. Dickoff & James (1968): A conceptual system or framework modeling or observing other people.
invented for some purpose; and as the purpose varies, so – environment affects learning but learning outcomes depend on
too must the structure and complexity of the system. the learner’s individual characteristics.
d. Chinn & Krammer (1999): A creative and rigorous structuring – anchored on the fact that persons are thinking beings with self-
of ideas that projects a tentative, purposeful, and systematic regulatory capacities, capable of making decisions and acting
view of phenomena. according to expected consequences of their behavior.
e. Pryjmachuk (1996): A set of ideas, hunches, or hypotheses – application of the theory can be done by:
that provides some degree of prediction and/or explanation o Attention: Catching attention with different strategies
of the world. o Retention: Promoting retention of learning
f. Torres (1986): Theory organizes the relationship between o Reproduction/Imitation: Providing opportunities for
the complex events that occur in a nursing situations so that reproduction of procedures
we can assist human beings. Theory provides a way of o Motivating: Motivating person by explaining the benefits
thinking about and looking at the world around us. possible by practicing the behavior.

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3. Health Belief Model o diseases associated with excess occurred in affluent societies
– initially proposed in 1958 (obesity). Diseases that result from inadequacies in food,
– provides basis for practice of health education and promotion. shelter and water afflict the poor. Poor people in affluent
– information alone is rarely enough to motivate people to act for societies experience least desirable combination of factors.
their health. Individuals must know what to do and how to do it – personal (individual’s awareness, knowledge, health beliefs,
before they can take action. money, and time) and societal resources affect range of health
– based on assumption that the major determinant of preventive promoting or damaging choices available to individuals.
health behavior is disease avoidance – humans make easiest choices available to them most of the time.
– major limitation: it places burden of action exclusively on client Health promoting choices must be more readily available and less
costly than health damaging options for individuals to gain health.
Key Concepts and Definitions of the Health Belief Model – provides inclusion of economic, political, and environmental health
Concept Definition determinants
Perceived One’s belief regarding the chance of getting a
Susceptibility given condition. 5. Pender’s Health Promotion Model
Perceived One’s belief regarding the seriousness of a given – developed in 1980s and revised in 1996.
Severity condition. – explores biopsychosocial factors that influence individuals to
Perceived One’s belief in the ability of an advised action to pursue health promotion activities
Benefits reduce health risk or seriousness of a given – depicts complex multidimensional factors which people interact
condition. with as they work to achieve optimum health.
Perceived One’s belief regarding the tangible and
Barriers psychological cost of an advised action.
Cues to Strategies or conditions in one’s environment that
action activate readiness to take action.
Self-efficacy One’s confidence in one’s ability to take action to
reduce health risk.

4. Milio’s Framework for Prevention

– provides a complement to HBM and a mechanism for direction
attention upstream.
– Nancy Milio outlined 6 propositions that relate individual’s ability
to improve healthful behavior to society’s ability to provide
accessible and socially affirming options for health choices.
– believed national-level policy making was the best way to
favorably impact health of most people rather than concentrating
efforts on imparting information to change patterns of behavior.
– health deficits often result from an imbalance between
population’s health needs and its health sustaining resources.

Variables of Health Promotion Model

Individual Characteristics Person’s unique characteristics and experiences affect his actions. Effect depends on the behavior in question.
and Experiences
Prior Related Behavior Prior behaviors influence subsequent behavior through perceived self-efficacy, benefits, barriers and affects
related to that activity. Habit is also a strong indicator of future behavior.
Personal Factors Personal factors that may influence behavior are biological factors such as age, BMI, strength, and agility;
psychological factors include self-esteem, self-motivation, and perceived health status; sociocultural factors include
race, ethnicity, acculturation, education, and socioeconomic status.
Behavior Specific Significant in behavior motivation. They are a “core” for intervention because they may be modified through
Cognitions and Affect nursing actions assessment of the effectiveness of interventions is accomplished by measuring the change in
these variables.
Perceived Benefits of Perceived benefits of a behavior are strong motivators of that behavior. Motivate the behavior through intrinsic
Action and extrinsic benefits. Intrinsic benefits: increased energy and decreased appetite. Extrinsic benefits: social
rewards such as compliments and monetary rewards.
Perceived Barriers to Action Barriers are perceived unavailability, inconvenience, expense, difficulty, or time regarding health behaviors.

Community Health Nursing

 Perceived Self-Efficacy Self-efficacy is one’s belief that he or she is capable of carrying out a health behavior. If one has high self-efficacy
regarding a behavior, one is more likely to engage in that behavior than if one has low self-efficacy.
Activity Related Affect Feelings associated with a behavior will likely affect whether an individual will repeat or maintain the behavior.
Interpersonal Influences Feelings or thoughts regarding beliefs or attitudes of others. Primary influences are family, peers
Situational Influences Perceived options available, demand characteristics, and aesthetic features of the environment where the
behavior will take place. Example: a lovely day will increase the probability of one taking a walk; the fire code will
prevent one from smoking indoors.
Commitment to a Plan of Pender states that “commitment to a plan of action initiates a behavioral event”. This commitment will compel
Action one into the behavior until completed unless a competing demand or preference intervenes. Pender states that
“commitment to a plan of action initiates a behavioral event”.
Immediate Competing Alternative behaviors that one considers as possible optional behaviors immediately prior to engaging in the
Demands and intended, planned behavior. One has little control over competing demands, but one has great control over
Preferences competing preferences.
Health Promoting Goal or outcome of the HPM. The aim of health promoting behavior is the attainment of positive health outcome.
Behavior

6. Transtheoretical Model Decisional Balance

– combines several theories of intervention. Pros benefits of behavior change
– based on the assumption that behavior change takes place over Cons costs of behavior change
time, and progresses through stages
– each stage is stable and is open to change; one may stop in one 7. PRECEDE-PROCEED Model
stage, progress to the next stage or return to a previous stage. – Developed by Dr. Lawrence W. Green
– change is difficult.. Change may be: – provides a model for community assessment, health education
o unpleasant (exercising) planning, and evaluation.
o require giving up pleasure (eating desserts) – PRECEDE: Predisposing, Reinforcing, and Enabling Constructs in
o painful (undergoing insulin injections) Educational diagnosis and evaluation, used for community diagnosis
o stressful (eating new foods) – PROCEED: Policy, Regulatory, and Organizational Constructs in
o jeopardize social relationships (meeting family/friends Education and Environmental Development, model for
during gathering involving food) implementing and evaluating health programs based on PRECEDE.
o not seem important anymore (among older individuals) • Predisposing factors: people’s characteristics that motivate
o require change in self-image (couch potato to an athlete) them toward health-related behavior.
• Enabling factors: conditions that facilitate or impede health
related behavior.
• Reinforcing factors: feedback given by support resulting
from performance of health-related behavior

Constructs Description
Stages of Change
Pre No intention to take action toward behavior
contemplation change in the next 6 months due to a lack of
information about the consequences of the
behavior or due to failure on previous attempts
Contemplation Has some intention to take action toward
behavior change in the next 6 months.
Weighing pros and cons to change.
Preparation Intends to take action within the next month
and has taken steps toward behavior change.
Has a plan of action.
Action Has changed overt behavior for less than 6
months. changed behavior sufficiently to reduce
risk of disease
Maintenance Has changed overt behavior for more than 6
months. Strives to prevent relapse.

Community Health Nursing

 NCM 104 & 113: Community Health Nursing

CHAPTER 3: PRIMARY HEALTH CARE S – Safe water and sanitation

KEY PRINCIPLES OF PRIMARY HEALTH CARE
BRIEF HISTORY OF PRIMARY HEALTH CARE Key principles that set PHC apart from traditional mode of health
• September 6 – 12, 1978 care delivery:
o first International Conference for PHC at Alma Ata, USSR, a. Accessibility, affordability, acceptability, and availability
Russia initiated by WHO and UN Children’s Fund. • Accessibility
o Alma Ata Conference made the following declarations: – physical distance of health facility or travel time
▪ Health is a basic fundamental right. required to get health services.
▪ There exists global burden of health inequalities – WHO guideline: health care facilities must be within
among populations. 30 minutes from the communities.
▪ Economic and social development is of basic – barangay health stations are facilities intended to
importance for full attainment of health for all. provide accessible health services at community level.
▪ Governments have a responsibility for the health • Affordability
of their people. – consideration of individual, family’s capacity to pay for
• PHC strategy was adopted in Philippines by virtue of LOI 949. health services.
• Letter of Instruction 949 of 1979 – a matter of whether community or government can
– legal basis for PHC in the Philippines afford these services.
– signed by Pres. Ferdinand Marcos – factors WHO considers in determining affordability is
– theme: Health in the Hands of the People by 2020 the out-of-pocket expenses for health care.
– in the Philippines, government insurance is covered
through PhilHealth
DEFINITION OF PRIMARY HEALTH CARE
• Acceptability
• Alma Ata Declaration: PHC is essential health care based on
– health services are compatible with the culture and
practical, scientifically sound, and socially unacceptable methods
traditions of the population.
and technology made universally accessible to individuals and
• Availability
families in the community through their full participation and at
– a question whether health services are offered in
a cost that the community and country can afford to maintain
health care facilities or is provided on regular and
at every stage of their development in the spirit of self-reliance
organized manner.
and self-determination.
• Universal goal: Health for all by the year 2000.
Example:
o Health for all: acceptable level of health for all people of
1. Botika ng Bayan and Botika ng Barangay
the world through community and individual self-reliance.
– established by Philippines government to promote equity
o Policy agenda of health for all by the year 2000 was a
in health by ensuring availability and accessibility of affordable,
global strategy employed for achieving 3 main objectives:
safe, and effective, quality essential drugs, with priority to
▪ Promotion of health lifestyles
marginalized, underserved, critical, and hard-to-reach areas.
▪ Prevention of disease
– make available low-priced OTC drugs, and selected,
▪ Therapy for existing conditions.
known prescription antibiotic drugs (DOH AO 23A, 1996)
– operated by nongovernment institutions, churches
5 KEY ELEMENTS 0F WHO 2.. Ligtas sa Tigdas ang PInas
WHO identified 5 key elements to achieve goal of health for all: – mass measles immunization campaign.
1. Reducing exclusion & social disparities in health (universal – children aged 9 months to below 8 years old were
coverage). vaccinated against measles and rubella.
2. Organizing health services around people’s needs and
expectations (health service reforms). b. Support mechanisms.
3. Integrating health into all sectors (public policy reforms). – resources for essential health services from 3 major
4. Pursuing collaborative models of policy dialogue (leadership entities:
reforms). • people
5. Increasing stakeholder participation. • government
• private sector (NGOs, socio-civic, and faith groups)
8 ESSENTIAL HEALTH SERVICES
Alma Ata Declaration listed eight essential health services: c. Multisectoral approach
E – Education for health – health and disease are outcomes of multiple interrelated
L – Locally endemic disease control factors
E – Expanded program for immunization – PHC requires communication, cooperation, and
M – Maternal and child health including responsible parenthood collaboration within sectors.
M – Mental Health – exemplified through intrasectoral and intersectoral linkages.
E – Essential drugs
N – Nutrition
T – Treatment of communicable and noncommunicable diseases

Community Health Nursing

 Intrasectoral linkages Criteria for Appropriate Health Technology
– communication, cooperation, and collaboration within • Safety
health sector: members of health team and health agencies – technology results in minimal risk to the user and
(two-way referral system) intended positive outcome of the use of a technology
– exemplified by team approach utilized by personnel of far outweigh its unintended negative effects.
health center dealing with health conditions and problems Example: Pertussis Vaccine is not recommended
to be given to a child aged 7 or older because at
Intersectoral linkages this age, vaccine is more hazardous than disease.
– encompass communication, cooperation, & collaboration • Effectiveness
between health sector and sector of society like education – technology accomplish what it is meant to accomplish
– Rabies Prevention and Control Program, a collaborative Example: Medicinal herbs endorsed by DOH have
effort of: been tested and clinically proven to have medicinal
DOH: immunization for victims of animal bites value in relief and treatment of ailments
DA: outreach rabies immunization for dogs • Affordability
DepEd: in charge of information campaign in schools – measures for health promotion and disease prevention
LGUs: information campaign in communities are cost-effective in comparison to treatment of disease.
Example: Childhood conditions (cough, , diarrhea,
d. Community participation fever) often require home intervention only.
– a process in which people, in partnership with those who • Simplicity
are able to assist them, identify problems, and needs and – technology requires readily available simple materials
assume responsibilities to plan, manage, control, and assess and process that can be more easily adopted by people.
collective actions. Example: Oral rehydration for management for
– health is achieved through self-reliance and self- diarrhea is a technology administered at home
determination • Acceptability
– individuals, families, and communities are not recipients of – technology is effective when it is used by those who
care but active participants in achieving their health goals need it.
– true or active participation: should be knowledgeable about • Feasibility and reliability
health problems and identify needs for solutions and draw – technology must be easy to apply considering natural
out action plans according to priority and resources available; setting and supplies must be constantly available.
organize and implement programs and monitor and control Example: Sputum examination is feasible in more
progress and evaluate for getting feedback and reprogram. areas compared to CXR.
• Ecological effects
e. Equitable distribution of health resources
– important consideration in choosing or rejecting
– PHC advocates for care that is community-based and particular technology.
preventive in orientation. It calls for an inventory and analysis
Example: DOH AO no. 21 s. 2008 mandated gradual
of health resources, facilities, and manpower. phase out of mercury in health care facilities.
– DOH has 2 programs to ensure equitable distribution of
• Potential to contribute to individual and community
manpower to rural areas
development.
– promotes self-sufficiency on the part of those using it.
Doctor to the Barrios (DTTB) Program
– deployment of doctors to municipalities without doctors.
– manage RHU or health centers in unserved, economically TRADITIONAL AND ALTERNATIVE HEALTH CARE
depressed 5th or 6th class municipalities for 2 years. Republic Act 8423
– offered competitive compensation by DOH and LGU – Traditional and Alternative Medicine Act
– Signed to law through efforts of Secretary of Health, Juan Flavier.
Registered Nurses Health Enhancement and Local Service – created Philippine Institute of Traditional and Alternative Health
– training and deployment program for unemployed nurse Care: promote & advocate use of traditional & alternative health
– deployed to unserved, economically depressed care modalities through scientific research & product development.
municipalities for 1 year.
– offered competitive compensation by DOH and LGU Traditional Medicine
– sum of total knowledge, skills, and practice on health care, not
f. Appropriate technology necessarily explicable in the context of modern, scientific
– refers to technology suitable to community that will use it. philosophical framework, but recognized by the people to help
– people’s technology and indigenous technology are used maintain and improve their health towards the wholeness of their
in reference to appropriate technology. being, the community and society, and their interrelations based
– health technology includes: on culture, history, heritage, and consciousness.
• tools
• drugs Alternative Health Care Modalities
– forms of nonallopathic, occasionally nonindigenous or imported
• methods
healing methods, though not necessarily practice for centuries
• procedures
nor handed down from one generation to another.
• technique

Community Health Nursing

 – some alternative health care modalities include, reflexology,
acupressure, chiropractic, nutritional therapies
DOH through its Traditional Health Program endorsed medicinal plants to be used due to proven health benefits as attested by National Science
and Development Board.
Medicinal Plant Use/Indication Preparation
Lagundi Asthma, cough and colds, fever, dysentery, pain Decoction
Skin disease (scabies, ulcer, eczema), wounds Wash affected site with decoction
Yerba Buena Headache, stomachache Decoction
Cough and colds. Infusion
Rheumatism, Arthritis Massage sap
Sambong Antiedema/anti-urolithiasis Decoction
Tsaang Gubat Diarrhea Stomachache Decoction
Niyog-niyogan Antielminthic Seeds are used
Bayabas Washing wounds Decoction
Diarrhea, gargle, toothache
Akapulko Antifugal Poultrice
Ulasimang Bato/ Lowers blood uric acid (rheumatism and gout) Decoction
Pansit-pansitan Eaten raw
Bawang Hypertension; lowers blood cholesterol. Eaten raw/fried.
Toothache Apply on part
Ampalaya Diabetes mellitus (mild non-insulindependent) Decoction/Steamed

Medicinal Plan Preparation

Preparation Procedure for Preparation
Decoction boil the recommended part of the plant in water for 20 minutes (recommended boiling time)
Infusion plant material is soaked in hot water for 10 - 15 minutes (recommended period of soaking)
Poultice directly apply plant material on the affected part, usually in bruises, wounds, and rashes
Tincture mix the plant material in alcohol.

Alternative Health Care Modalities Practiced

Term Definition
Acupressure Application of pressure on acupuncture points without puncturing the skin
Acupuncture Uses special needles to puncture and stimulate specific anatomical points on the body
Aromatherapy Art and science of the sense of smell; Combines essential aromatic oils then applied to the body
Chiropractic Discipline of the healing arts concerned with pathogenesis, therapy, and prophylaxis of functional disturbances, pain
syndromes and path mechanical states related to the static and dynamics of the locomotor system (spine & pelvis)
Phytomedicine Herbal medicine; finished, labeled, medicinal products that contain active ingredients of the plant.
Massage Superficial soft parts of the body are rubbed, stroked, tapped for remedial, aesthetic or limited therapeutic purposes.
Nutritional Therapy Use of food as medicine to improve health enhancing nutritional value of food components that reduce risk of disease
Pranic Healing Follows the principle of balancing energy.
Reflexology Application of therapeutic pressure on the body’s reflex points.

DIFFERENCE BETWEEN PHC AND PRIMARY CARE PHC Primary Care

Primary Care Focus client Family and community Individual
– American Association of Family Medicine: it includes health Focus of Promotive and Curative provided by
promotion, disease prevention, health maintenance, counseling, care preventive through health professionals
patient education, and diagnosis and treatment of acute and community participation
chronic illness in variety of health care setting. Decision- Community-centered Health worker driven
– refers to the first contact of a person with health professional. making Consultative-participative
process
Primary Health Care Outcome Self-reliance/Self-help Reliance on health
– strategy for delivery of health programs workers to regain
health
Primary Nursing Setting for Rural-based satellite Mostly urban places;
– model of nursing care that emphasizes continuity of care by services clinics; community health hospital, clinics
having one nurse providing care for small group of inpatients within centers
a nursing unit of a hospital. Goal Development and Absence of disease
preventive care

Differences between PHC and Primary Care

Community Health Nursing

NCM 104 & 113: Community Health Nursing

CHAPTER 4: COMMUNITY ORGANIZING: ENSURING CORE PRINCIPLES IN COMMUNITY ORGANIZING

HEALTH IN THE HANDS OF THE PEOPLE Anchored on basic values of, human rights, social justice, social
responsibility.
DEFINITION OF COMMUNITY ORGANIZING
a. CO is People-Centered
• Community Organizing (CO)
– basic premise of CO endeavor is that people are the means
– a process consists of steps that instill and reinforce
and ends of development, and community empowerment is the
people’s self-confidence on their own collective strengths
process and outcome (Felix, 1998).
and capabilities (Manalili, 1990)
– process of critical inquiry is informed by and responds to
– development of community’s collective capacities to
experiences and needs of marginalized sectors.
solve its problems and aspire for development through its
– not meant for person-to-person interaction, with only a few
own efforts.
who will benefits from any undertakings and activities.
– continuous process of educating community to develop
– a people-centered strategy, emphasis on development of
its capacity to assess and analyze situation (involves
human resources necessitating education.
process of consciousness raising), plan and implement
– process that promotes development of people’s autonomy
interventions (mobilization), and evaluate.
and self-reliance, leading to people empowerment.
– a process of educating and mobilizing members of
– organizers serve as facilitators guiding through the process.
community to enable them to resolve problems.
– people take lead, make decisions for themselves
– means to build community’s capacity to work for
common good and health goals.
b. CO is Participative
– CO and CHN practice have common goals:
– participation of community in entire process-assessment,
o People empowerment
planning, implementation, and evaluation-should be ensured.
o Development of self-reliant community
– community is considered as prime mover and determinant,
o Improved quality of life.
rather than beneficiaries and recipients of development efforts.
– community organizing is a process for development.
– for people empowerment, community participation is critical
– emphases of community organizing in PHC:
condition for success (Reid, 2000).
o People from community working together to solve
– in community participation decision making and responsibility
their problems.
are in the hands of ordinary people.
o Internal organizational consolidation as a prerequisite
to external expansion
c. CO is Democratic
o Social movement first before technical change
– CO should empower disadvantage population.
o Health reforms occurring within context of broader
– a process that allows majority of people to recognize and
social transformation.
critically analyze their difficulties and articulate their aspiration.
– a value-based process, tracing its roots to three basic
– decision must reflect the will of whole, will of common people.
values: human rights, social justice, and social responsibility
– effort must be exerted to achieve a consensus. This requires
(LOCOA, 2005).
a participative and consultative approach.
o Human rights
– based on worth and dignity inherent to all human:
d. CO is Developmental
right to life, right to development as person & as
– CO is directed toward changing current undesirable conditions.
community, freedom to make decisions for self.
– organizer desires change for the betterment of community
o Social Justice
and believes that community shares these aspirations and
– entails fairness in distribution of resources to
changes can be achieved.
satisfy basic needs and maintain dignity as human.
– CO affords empowerment of the marginalized people.
o Social Responsibility
– CO seeks authentic human development.
– offshoot of ethical principle of solidarity, people
being part of community and is reflected in
e. CO is Process-oriented.
concern for one another; society has responsibility
– CO goals of empowerment and development are achieved
to ensure an environment for fullest development
through a process of change.
of its members.
– CO is dynamic. With evolving community situation, monitoring
and periodic review of plans are necessary.
• Community Development
– means improvement access to resource (including
health resources) that enable people to improve their PHASES OF COMMUNITY ORGANIZING
standards of living and overall quality life. 1. Pre-Entry
– it is the end goal of CO and all efforts towards uplifting • involves preparation on the part of organizer and choosing
status of poor and marginalized. a community for partnership.
– entails process of assessment of current situation, • preparation includes:
identification of needs, deciding on appropriate courses of o knowing the goals of community organizing activity.
actions, mobilization of resources to address needs, and o delineate criteria or guidelines for site selection.
monitoring and evaluation by people

Community Health Nursing

 o list sources of information & facility resources Integration Styles of Manalili (1990)
(government & private) • Now you see, now you don’t style
o novice organizers: review of basic concepts of CO. o visits the community as per schedule but is not able
• Proper selection community to transcend the guest status.
• Identify possible barriers, threats, strengths, opportunities: o cannot break down the barrier and does not get the
determinant of overall outcome of CO. chance to understand their way of life.
• Communities may be identified through: • Boarder style
o Initial data gathered through an ocular survey. o rents a room in the village, lives his own life, and does
o Review of records of health facility not share the life of the community.
o Review of barangay/municipality profile o regarded as guest or boarder in the house.
o Referrals from other communities, institutions or • Elitist style
through a series of meetings o lives with the barangay chairman or other prominent
o Consultation from LGUs or private institutions. person in the community.
• Ocular survey is done at this stage. o frequently seen in the company of local officials.
o Does the community meet GIDA criterion of DOH? o makes the integration with the community difficult.
(geographically isolated and in a disadvantaged area)
o Do community members perceive the need for People-centered approach in integration
assistance? (resistance or reluctance is expected) • organizers enter the community with well-conceived plan.
o Does the community show signs of willingness or • allows organizers to develop a deeper relationship with the
hostility towards the organizers? whole community through various techniques.
o Is there no obvious threat to the safety of community
organizers? Techniques that facilitate community integration
o Are there other groups working in the area? • Occasional home visits (Pagbabahay-bahay)
o Is partnership among the possible stakeholders o effective way of developing a close relationship with
(community, LGU, agencies) possible and feasible? the community
o must observe the daily schedule of activities to avoid
2. Entry to the Community inconvenience on the family.
• formalizes the start of organizing process. • Huntahan
• organizer gets to know the community and vice versa. o informal conversations
• make courtesy call to local formal leaders (mayor and o done in basketball court, sari-sari store.
municipal council, barangay chairperson, council members) o participation in the production process and livelihood
• visit to informal leaders (elders, local health workers, church activities (farming)
leaders) recognized in the community. o allows to gain understanding the production process
and economic system within the community and to
Considerations in entry phase: share daily experience of the community people.
• community organizer’s responsibility to introduce • Participation in Social Activities
themselves and their institution to community. o to get to know through face-to-face encounters.
• explanation of vision and mission, goals, programs, and o remain a role model and avoid activities and situations
activities must be given in all initial meetings and contacts that may undermine the reputation of the community.
with the community.
• Preparation for initial visit includes: • Social Analysis
o gather information on socioeconomic conditions. o process of gathering, collating, and analyzing data to
o traditions including religious practices. gain understanding of community conditions, identify
o overall physical environment community problems, and determine its root cause.
o general health resources. o also referred as social investigation, community study,
• goal of process: build up confidence & capacities of people. community needs assessment, community analysis. In
nursing practice, it is called community diagnosis
Manalili: 2 strategies for gaining entry into a community: (emphasis on health and health-related problems).
• Padrino – a patron, (barangay, LGU official). To boost o requires comprehensive analysis of:
organizer’s image, tends to preset intended project ▪ demographic; sociocultural; environmental;
output, creating false hopes. economic data
• Bongga – easiest way to catch attention and gain ▪ data on health patterns (morbidity, morality,
“approval” of community. Exploits weaknesses and involves fertility)
doles-out (free medicines). It reinforces dole-out mentality, ▪ data on health resources
which contradicts the essence of CO.
• Identifying potential leaders
3. Community Integration (Pakikipamumuhay) o organizing is not a job of one person.
• organizers live in the community to understand it better o identify partners and potential leaders who will help
and imbibe community life. lead the people.
• establishment of rapport indicates successful integration. o interactions provide opportunity to identify
• integration requires immersion in community life. prospective allies in the organizing efforts.
o CO is participative and developmental in nature.

Community Health Nursing

 o identified potential leaders should be trained and be • process is as important as the output. A project may fail,
a part of CO team. but as long as they gain valuable experience and learns
o challenge of CO: training and preparation of potential from the process, it is not a failure.
leaders. • Regular monitoring and continuing community formation
o the key is to allow them to develop and gradually program.
assume the leadership role.
• Evaluation
• Core Group Formation o systemic, critical analysis of organizations/projects’
o recruits must share same problem the group seeks state compared to planned goals & objectives.
to correct, and believes to the core values, principles, o done periodically:
and strategies employed. ▪ during mobilization (formative evaluation) to
o keep group size manageable (8 – 12 members). allow revision of strategies if needed
o focal point of CO: formation of a viable, functioning ▪ at the end of prescribed project period
core group. (summative evaluation)
o requires a series of training sessions to transfer the o in CO, there are two major areas of evaluation:
technology of CO. ▪ program-based evaluation (the success of the
o essential component: reinforcement of social program)
consciousness of members, in analyzing root causes ▪ organizational evaluation (the closeness of the
of community problems. members of the organization)
o formation program focuses on self-awareness and o general evaluation parameters are used as guides for
development of community health leaders. evaluation of organizing activities.
o core group will serve as the foundation of CO.
Area of evaluation General Evaluation Parameters
• Community Organization Program-based • Were the goals and objectives of the
o in information dissemination, core group, with the project achieved?
organizers’ assistance, instills awareness of common • What strategies were implemented? What
concerns among community members. worked? What did not?
o conducts series of assembly with the goal of arriving • What is the overall impact of the project
at a common understanding of community concerns on the community?
and formulation of action plan. • How were the resources of the
o collective decision-making dictate what projects and organization and community utilized?
strategy to be undertaken. Organizational • Were the mission, vision, and goals of the
o if they decide to formalize the organization, it must organization achieved?
have the following characteristics: • How are the organizational policies being
▪ organizational name and structure implemented?
▪ set of officers recognized by the community. • What is the level of participation in the
▪ constitution & bylaws stating vision, mission, affairs of the community organization?
and goals, rules & regulations of organization, • How were the resources of the
duties & responsibilities of officer and member. organization utilized and managed?
▪ may seek legal recognition by registering with • What type of interpersonal relationship is
government agencies (Securities & Exchange shared among organization members,
Commission, Cooperative Development among leaders, & members of community
Agency). Recognition of LGU completes the organization?
process.
o Gaining legal recognition paves the way for 4. Exit and Expansion Phase
organization’s participation in the barangay, municipal, • Manalili: the best entry plan is an exit plan.
or city development council as provided in the Local • from the start: have a clear vision of the end with general
Government Code (RA 7160). time frame in mind.
o may establish linkages & network with government • time required for CO depends on organizer’s diligence and
agencies/NGOs, or other people’s organizations, acceptance by the community.
facilitating the attainment of its goals and objectives. • time of exit: determined by organizer & community during
meeting for monitoring and evaluation.
• Action/Mobilization Phase • indication of readiness for exit by the organizer:
o implementation of planned projects and programs. o attainment of set goals of CO efforts
o important considerations during mobilization phase: o demonstration of capacity of people’s organization to
▪ allow the community to determine the pace lead the community in dealing common problems.
and scope of project implementation. o people empowerment as manifested by collective
▪ start with simple projects (tapat ko, linis ko) involvement in decision-making & community action
▪ as they gain experience and develops, move on matters that impact their lives.
toward more complex programs (community • stay in touch with the community as a friendly consultant.
recovery facility) • sustained relationship between organizer and community.

Community Health Nursing

 GOALS OF COMMUNITY ORGANIZING Comparison of traditional research approach and COPAR
1. People Empowerment Points of Traditional Research COPAR
• CO is aimed at achieving effective power for the people. comparison Approach
Decision-making • Top-down • Bottom-up
• people learn to overcome powerlessness and develop
their capacity to maximize control over the situation and Emphasis • Expert/nurse- • Community-driven
start to place the future in their hands. driven process process
• Premium is placed • Premium is placed
2. Building relatively permanent structures and people’s on data and output on the process.
organization Roles • Researchers: • Researchers:
Nurse Community
• CO aims to establish and sustain permanent organizational
• Subjects/objects members
structures that serve the needs and aspirations of the
of research: • Facilitator &
people.
Community Recorder: Nurse
• ensures people’s maximum participation while they provide members • Data analysis is
venue through, they can link up with other groups. (respondents of done collectively by
research the community.
3. Improved quality of life instrument):
• CO seeks to secure short- and long-term improvements • Data analysis done
in the quality of life of the people. by the nurse and
• in long-term, it must create a conducive environment for presented to the
the development of human creativity and solidarity through community.
equitable distribution of power and resources. Methodology • Research tools and • Research tools and
methodologies: methodologies:
COMMUNITY ORGANIZING PARTICIPATORY ACTION predetermined by identified and
nurse-organizer. developed by the
RESEARCH community.
• introduced in the mid-1990s.; it is an approach to research that Output • Upon completion, • Conclusions and
aims to promote change among participants. study is packaged, recommendations
• members being studied participate as partners in research submitted to the are made by the
phases (design, data collection, analysis, and dissemination) agency, and community, lead to
• approach utilized mostly in social psychology that encourages published. agreed community
the researchers and those who will benefit from the research • Recommendations actions.
(family, policy makers) to work together as full partners in all are made by the • Whole research
phases of research. researcher based cycle continues until
• COPAR is a community development approach that allows on the findings of it becomes a part
community (participatory) to systematically analyze situation the study. of community life,
(research), plan solution, and implement project (action) utilizing leads to community
process of CO. development.
• Community
• acceptance of paradigm shift in relationship and roles of
members formulate
external agent and community is a key to success in COPAR.
recommendations.

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NCM 104 & 113: Community Health Nursing
• to succeed, nurse-researcher must adopt creative, interesting, • COPAR breaks practice of making people passive recipients
and easy to apply methodologies at community level (plus of service. It passes responsibility for health to the people.
factors: fun, utilize local resources, create excitement). • Active community participation is a deliberate process of
• major role in COPAR: to facilitate & guide community in critical education and building community capacities.
assessment of situation. • The essence of Primary Health Care and Community
• requires nurse to use techniques that provide wealth of Organizing is the development of self-reliant communities, fully
relevant information and allow meaningful participation. responsible for their health decisions. And that is health in the
“hands of the people”

Participatory data-gathering methods for COPAR

Methods Procedures
Transect Walk • For making an ocular survey, ask a group from community to come along and join. Nurse requests community
members to take the lead in the inspection (pasyal), ask them critical questions about the community, and allow
them to analyze and draw conclusions.

Mapping • Nurse asks some members to draw a detailed map of the community emphasizing certain aspects of the
community. It allows people to view their community from different perspective and provide them insights as how
they can deal with community concerns.

Resources map
o Show sources of livelihood (farming areas, specific plants planted in particular areas, fishing grounds)
o Show physical resources (health center, barangay health station, church/chapel, barangay halls)

Health Map
o Health worker respondents (BHW/midwife) may draw a spot map, highlighting households with identified
health problems (diabetes, tuberculosis, malnutrition) and household with vulnerable members (pregnant
mother, infants, differently able persons, elderly)

Seasonal Map/Calendar
o Shows various activities and events significant to the community.
o focus on livelihood (planting, harvest, and fishing season), social events (fiesta, Christmas, religious activities),
historical mapping of significant disasters that they experienced (floods, drought, fire, food shortage)

Ven Diagram • Focuses on the relationships within the community between community and outside agencies/groups.
• Provides them a visual representation of social support systems and a clear idea of social resources that can be
tapped in the future.
• Draw a big circle (represents community), then smaller circles inside the big circles (organizations/groups in the
community). At the center place the most active or influential organization. Smaller circle outside the big circle
(institutions outside the community). The proximity/distance outside circles in relation to the big circle symbolizes
the outside institutions’ degree of support and influence among their community.

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NCM 104 & 113: Community Health Nursing

CHAPTER 5: HEALTH PROMOTION, RISK REDUCTION, RELATIONSHIP OF RISK TO HEALTH AND HEALTH
& CAPACITY-BUILDING STRATEGIES PROMOTION ACTIVITIES
• Types of risk factors
DEFINITION OF HEALTH PROMOTION ACCORDING TO: o Modifiable risk factors
• Green and Kreuter: any combination of health education and ▪ aspect of risk over an individual has some control.
related organizational, economic, & environmental supports for ▪ examples: Smoking, food eaten
behavior of individual, groups/communities conducive to health o Non-modifiable risk factors
• Parse: behavior that is motivated by the desire to increase ▪ aspect risk which one has little or no control.
wellbeing and to reach the best possible health potential ▪ examples: Genetic makeup, age, gender
• Risk Reduction
DEFINITION OF HEALTH PROTECTION ACCORDING TO: – a proactive process individuals participate in behaviors
that enable them to react to actual/potential health threat.
• Parse: behaviors in which one engages with the specific intent
• Risk Communication
to prevent disease, detect disease in the early stages or to
– process through which public receives information
maximize health within constraints of disease
regarding possible threats to health.
• Examples: immunizations, cervical cancer screening
• Internet is a new source of risk communication for community.
• Newspaper, periodicals, radio, TV, and billboards are long-
RISK AND HEALTH standing sources of health information in public health.
• Risk (Oleckno)
– probability that a specific event will occur in a given time
DIET AND HEALTH
frame.
• Diet: one of the most modifiable or risk factors.
• Risk Assessment
– determine health risks to individuals, groups & • Healthy diet contributes to prevention of chronic diseases (DM
populations. type I , HTN, heart disease).
– systematic way of distinguishing risks posed by potentially • Obesity affecting Filipino adults is known as android or apple-
harmful exposures. shaped type
• Abdominal fat accumulation is measured using waist-to-hip ratio
Steps of Risk Assessment • WHR criterion recommended by WHO is considered as a
▪ Hazard identification sensitive measure for risk to cardiovascular diseases.
▪ Risk description. • Person with WHR of ≥ 1.0 in men and ≥ 0.85 in women is
▪ Exposure assessment considered android or apple-shaped obese.
▪ Risk estimation. • Relative risk associated with apple-type obesity:
o 2x risk of developing CAD.
• Risk Factor (Friis) o 3x developing cardiovascular disease (stroke).
– an exposure that is associated with a disease. • Body weight is determined by complex interplay (metabolism,
genetic, behavior, environment, culture, socioeconomic status).
Criteria establishing a risk factor: • The 10 Nutritional Guidelines for Filipinos were developed to
▪ frequency of the disease varies by category or facilitate dissemination simple and practical messages to
amount of factor. encourage healthy diet and lifestyle.
o Cigarette smokers & heavy smokers are 1. Eat variety of foods everyday
more likely to develop lung cancer than 2. Breastfeed infants exclusively from birth to 4-6 months
nonsmokers & those who smoke a little. and give foods while continuing breastfeeding.
▪ risk factor must precede the onset of the 3. Maintain child’s normal growth through proper diet and
disease. monitor their growth regularly.
o Cigarette smoker has lung cancer after 4. Consume fish, lean meat, poultry, or dried beans.
smoking for a while. 5. Eat more vegetables, fruits, and root crops.
▪ association of concern must not be due to any 6. Eat foods cooked in edible/cooking oil daily.
source of error. 7. Consume milk and milk products and calcium rich
o Sources of error: study design, data foods (small fish and dark leafy vegetables every day.)
collection methods, and data analysis. 8. Use iodized salt; avoid excessive intake of salty foods.
o Other criteria 9. Eat clean and safe food 1
▪ Strength of association 10. For healthy lifestyle & good nutrition, exercise regularly,
▪ Consistency with repetition do not smoke and avoid drinking alcoholic beverages.
▪ Specificity • Daily Nutritional Guide Pyramid provides Filipinos an eating plan
▪ Plausibility for health living.
• Portion distortion is when individuals unknowingly eat larger
amounts that they would usually eat.
• Portion control is an important aspect of weight management.

Community Health Nursing

 PHYSICAL ACTIVITY AND HEALTH • Nurse must provide information and referrals to help clients
• One’s surrounding impact whether one will choose to exercise. access resources to help them to get off and to stay oof of
• One’s environment is a significant factor in health promotion. tobacco.
• The need to increase physical activity depends on the age, • For implementation & management of tobacco control, WHO
physical condition, and gender of the client. Tobacco Free Initiative formulated MPOWER strategy:
o Monitor tobacco use and prevention policies.
o Protect people from tobacco smoke.
SLEEP
o Offer help to quit tobacco use.
• Sleep is an essential component of chronic disease prevention o Warn about the dangers of tobacco.
and health promotion. o Enforce bans on tobacco advertising, promotion, and
sponsorship.
How much sleep do we really need? o Raise taxes on tobacco.
Age Sleep Needs • To highlight the need to control tobacco use, World No
Newborn (1 – 2 months) 10.5 – 18 hours Tobacco Day is celebrated yearly on May 31.
Infants (4 – 12 months ) 12 – 16 hours (including naps) • Republic Act No. 9211 or the Tobacco Regulation Act of 2003
Toddlers (1 – 2 years) 11 – 14 hours (including naps) o prohibits smoking in public places and sale of tobacco
Preschool (3-5 years) 10 – 13 hours(including naps) products to minors.
School-age (6 – 12 years) 9 – 12 hours o requires a printed warning on cigarette packages and
Teens (13 – 17 years) 8 – 10 hours prohibits all forms of advertising mass media and
Adults (18 years and older) 7 hours or more regulates other forms of promotions.
o undertake National Smoking Cessation Program and
• Insufficient sleep is associated with diabetes, heart disease, establish smoking withdrawal clinics.
obesity, depression, and motor vehicle accidents.
• The need for sleep is regulated by 2 processes. ALCOHOL CONSUMPTION AND HEALTH
o The longer we are awake, the stronger the desire to • A drink is the amount of any alcoholic beverage that delivers
sleep. a half ounce (around 15 mL) of pure ethanol, which is equivalent
o Circadian biological clock in the brain to the following:
▪ Suprachiasmatic nucleus responds to light. This o Wine: 4 – 5 oz. (120 – 150 mL)
makes us tend to be sleepy at night and active o Wine Cooler: 10 oz. (around 300 mL)
during the day when it is light. o Beer: 12 oz. (360 mL)
▪ Circadian rhythm is why we are sleepiest o Distilled liquor (80 proof of whiskey, scotch, rum, vodka):
between 2:00 – 4:00 am and in the afternoon 1.25 oz. (around 40 mL)
(1:00 – 3:00 pm) • Moderation: not more than 2 drinks a day for average-sized
▪ Circadian rhythm regulates the 24-hour cycle of man and not more than 1 drink a day for average-sized woman.
the body. • Liver can process about a half ounce ethanol per hour,
• Sleep Hygiene (National Sleep Foundation 2010) depending on the body size, previous drinking experience,
1. Avoid caffeine and nicotine close to bedtime. food intake, and general health.
2. Avoid alcohol as it can cause sleep disruptions. • Heavy drinking
3. Retire and get up at the same time every day. – consuming more than two drinks a day for men and
4. Exercise regularly but finish exercise and vigorous more than one drink a day for women.
activity at least 3 hours before bedtime.
• Binge drinking.
5. Establish regular relaxing bedtime routine (warm bath,
– consuming five or more drinks on a single occasion for
reading a book).
men or four or more drinks for women.
6. Create a dark, quiet, cool sleep environment.
• Excessive drinking
7. Have comfortable beddings.
– take the form of heavy drinking, binge drinking, or both.
8. Use the bed for sleep only. Do not read, listen to music,
or watch TV in bed.
Risks of Alcohol Consumption
9. Avoid large meals before bedtime. Short-term Intermediate Long-term risk
risk effect
TOBACCO AND HEALTH RISK • Risky sexual • Miscarriage • Neurologic conditions: dementia
• Smoking cessation is an important step in achieving optimum behavior • Stillbirth & stroke
health. • Violence • Alcohol • Cardiovascular problems: MI,
• Smokers who are trying to quit experience withdrawal • Unintentional poisoning HTN, cardiomyopathy
symptoms (anxiety, increased appetite, irritability, difficulty injuries • Psychiatric problems: depression,
concentrating) • Falls anxiety, social problems
• Drowning (unemployment),
• American Cancer Society recommends the following Steps to • Others: cancer of the mouth,
Quit Smoking: throat, liver, and breast; liver
1. Make decision to quit. disease (cirrhosis & hepatitis), GI
2. Set a date to quit and choose a plan. consequences (pancreatitis &
3. Deal with withdrawal through. Avoid temptation. gastritis)
4. Staying off tobacco is a lifelong process. Remind
yourself of the reasons why you quit.

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 OTTAWA CHARTER FOR HEALTH PROMOTION 5. Reorient Health Services
• Organized by WHO, the 1 International Conference on Health
st o Responsibility for health promotion in health services is
Promotion was held at Ottawa, Canada on November 17 – 21, shared.
1986. o Work together towards a health care system that
• It calls for commitment to health promotion to achieve the goal contributes to the pursuit of health.
of Health for All by the year 2000 and beyond.
6. Moving into the Future
o Health is created and lived by people within the settings
• Definition of Health Promotion
o Ottawa Charter: Health promotion as the process of of their everyday life.
enabling people to increase control over and improve o Caring, holism, and ecology are essential issues in
their health. developing strategies for health promotion.
o WHO: It is not just the responsibility of health sector but
goes beyond healthy lifestyles to well-being. HEALTH EDUCATION
• Maurer and Smith distinguish health education from patient
• The Charter identifies prerequisites for health. education as:
Prerequisites for health o Health promotion
Fundamental conditions and resources for health are: – process of changing people’s knowledge, skills and
• Peace • Income attitudes for health promotion and risk reduction.
• Shelter • Stable Ecosystem – nurse participates by empowering people for
them to achieve optimum health and prevent
• Education • Sustainable Resources
disease by bringing out lifestyle changes and reducing
• Food • Social justice and Equity
exposure to health risk in the environment
– includes risk communication.
• The Charter identifies 3 basic strategies for health promotion.
o Advocacy for health to provide for the conditions and o Patient education
resources essential for health. – series of planned teaching-learning activities
o Enabling all people to attain their full health potential. designed for individuals, families, groups with an
o Mediating among different sectors of society in efforts identified alteration in health.
to achieve health. – purpose: to aid client in coping with the event, to
prevent complication or deterioration of condition.
• WHO: 6 priority action areas provide support to these 3
strategies:
EFFECTIVE NURSE EDUCATOR
1. Build Healthy Public Policy
o Health promotion puts health on the agenda of policy • Based on Knowle’s theory on adult learning, Stanhope and
makers. Lancaster listed following basic principles that guide the
o Health promotion policy effective nurse educator
▪ a coordinated action that combines diverse but o Message
complimentary approaches (legislation, fiscal ▪ Send a clear/understandable message to the
measures, taxation, and organizational change). learner.
▪ requires identification of obstacles to the adoption o Format
of health public policies in non-health sectors and ▪ Select most appropriate learning format/strategy.
ways of removing them. ▪ Strategy must match objectives of learning activity
and the characteristics of learner.
2. Creative Supportive Environments o Environment
o inextricable links between people and their environment ▪ Create best possible learning environment.
constitute the basis for socioecological approach to ▪ Create a therapeutic and supportive relationship
health. with the learner.
o Overall guiding principle: need to encourage reciprocal o Experience
maintenance – to take care each other. ▪ Organize positive and meaningful learning
o Health promotion generates living, and working experience.
conditions that are safe, stimulating, and enjoyable. ▪ Sequence the materials in logical manner (simple
to complex concepts).
3. Strengthen Community Actions o Participation
o Health promotion works through concrete and effective ▪ Engage learner in participatory learning.
community actions in setting priorities, making decisions, ▪ Nurse engages learners’ participation by involving
planning strategies, implementing them for better health. them in discussions, soliciting feedback, and return
o Heart of this process: empowerment of communities demonstration.
o Evaluation
4. Develop Personal Skills ▪ Evaluate and give objective feedback to learners.
o Health promotion supports personal and social ▪ Knowing the degree of attainment of learning
development by providing information, education for objectives motivates learners to go on.
health, and enhancing life skills.

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 EFFECTIVENESS OF HEALTH EDUCATION
• Strategies and tools: printed materials, audiovisual
presentations, face-to-face discussions, return demonstration
and online resources.
• Presence of support systems reinforces the practiced of
learned health behaviors.

COMPETENCY-BASED TRAINING OF
COMMUNITY/BARANGAY HEALTH WORKERS
• PHC emphasized the role of the community in promotion,
maintenance, and restoration of health of its members.
• Important aspect of the community in capacity building for
health: training of CHWs.
• Their training does not constitute tertiary education.
• As the supervisor of nursing auxiliary personnel, the PHN
participates in training volunteers who can work as BHWs.
• Goal of training program: volunteers’ development of
competencies that will enable them to provide primary care
services to their community.
• The book ‘Where There is no Doctor: A Village Health Care
Handbook’, provides practical guide for BHWs and BHW
training.

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NCM 104 & 113: Community Health Nursing

CHAPTER 6: FAMILY HEALTH NURSING o It involves transmission of culture of a social

group.
THE FAMILY o Family: 1st teacher, instructing children in
societal rules.
• National League for Nursing has emphasized the importance
▪ Status Placement:
of family nursing in standard curriculum guides for schools in
o Society is characterized by hierarchy of its
nursing since 1917.
members into social classes.
▪ Economic Function:
DEFINITION OF HEALTH PROTECTION ACCORDING TO: o Rural family: unit of production; family
• National Statistical Coordination Board: Family is a group of works as a team.
persons usually living together and composed of the head and o Urban family: unit of consumption;
other persons related to the head by blood, marriage, or economically productive members work
adoption. to earn wages.
• Johnson: It is a social unit interacting with the larger society. o Meet the needs of individual family members.
• Allan: It is characterized by people together because of birth, ▪ Physical Maintenance
marriage, adoption, or choice. o Provides for the survival needs of its
• Friedman: It is two or more persons who are joined together dependent members.
by bonds of sharing and emotional closeness and who identify ▪ Welfare and Protection
themselves as being part of the family. o Supports spouses or partners by providing
for companionship and meeting affective,
FORMS OF FAMILY sexual, and socioeconomic needs.
• Nuclear Family o Source of motivation and morale for its
– family of marriage, parenthood, or procreation members.
– composed of husband, wife, and their immediate children o Gives children emotional gratification and
• Dyad Family psychological security.
– consisting of only husband and wife (empty nesters)
• Extended Family FAMILY AS A CLIENT
– consisting of three generations. • Family is a critical resource. It can improve individual member’s
• Blended Family health through health promotion and wellness activities.
– results from a union where one or both spouses bring • Ripple effect: any dysfunction (illness, injury, separation) that
a child from previous marriage into new living arrangement affects one or more family members will affect the members
• Compound Family and unit as a whole.
– man has more than one spouse. • Case Findings: identify a health problem that necessitates
– approved by Philippine authorities only among Muslims identifying risks for the entire family.
by virtue of PD no. 1083, Code of Muslim Personal Laws of • Improving Nursing Care: provide better and more holistic care
the Philippines. by understanding the family and its members.
• Cohabiting Family • Freeman & Heinrich: Family provides feedback and influences
– live-in arrangement between unmarried couple who are health services.
called common-law spouses and their children
• Single Parent FAMILY AS A SYSTEM
– death of spouse, separation, pregnancy (wedlock). • General Systems Theory has been applied to the study of
• Gay or Lesbian Family families. A way to explain how the family as a unit interacts with
– made up of a cohabiting couple of the same sex in a larger units outside the family and with smaller units inside the
sexual relationship. family.
– Family Code in the Philippines (EO no. 209): Marriage is • Family may be affected by disrupting force acting on a system
a special contract of permanent union between man and outside family (suprasystem). It is embedded in social systems
woman entered in accordance with the law for the that have influence on health (education, employment, housing)
establishment of conjugal and family life. • Parke stated that there are three subsystems of the family:
o Parent-child subsystem
FUNCTION OF THE FAMILY o Marital subsystem
• Family is the buffer between individuals and society. o Sibling-sibling subsystem
• The family fulfills two important two important purposes.
o Meet the needs of society.
▪ Procreation
o institution for reproductive function and
child rearing.
▪ Socialization of family members
o Socialization: process of learning how to
become a productive member of society.

Community Health Nursing

 DEVELOPMENTAL STAGES OF THE FAMILY CHARACTERISTICS OF A HEALTHY FAMILY
• Duvall, a forerunner of focus on family development. She • Otto & Pratt: healthy families as energized families.
identified stages that family transverse from marriage to death. • DeFrain & Montalvo:
o Members interact with each other.
Family Life Cycle o Healthy families can establish priorities.
1. Beginning family through marriage or commitment as a o Healthy families can affirm, support, and respect each
couple relationship. other.
2. Parenting the first child o Members engage in flexible role relationships, share
3. Living with adolescent power, respond to change, support growth and
4. Launching family (youngest child leaves home) autonomy of others, and engage in decision-making that
5. Middle-aged family (remaining marital dyad to retirement) affects them.
6. Aging family (retirement to death of both spouses) o Family teaches family and societal values and beliefs and
shares spiritual core.
Stages and Tasks of the Family Life Cycle o Healthy family foster responsibility and value service to
1. Marriage: Joining of Families others,
a. Formation of identity as a couple o Healthy families foster responsibility and value service to
b. Inclusion of spouse in realignment of relationships with others.
extended families o Health families have a sense of play and humor and share
c. Parenthood: making decisions leisure time.
2. Families with Young Children o Healthy families have the ability to cope with stress and
a. Integration of children into family unit crisis and grow from problems.
b. Adjustment of task: child rearing, financial, and household
c. Accommodation of new parenting and grandparenting FAMILY NURSING AND THE NURSING PROCESS
roles • Maurer & Smith: Family nursing is the practice of nursing
3. Families with Adolescents directed towards maximizing the heath and well-being of all
a. Development of increasing autonomy for adolescents individuals within a family system.
b. Midlife reexamination of marital and career issues • Primary consideration: family’s willingness to utilize nursing
c. Initial shift towards concern for the older generation services.
4. Families as launching centers
a. Establishment of independent identities for parents and FAMILY HEALTH ASSESSMENT
grown children
• Assessment of the family helps practitioners identify their health
b. Renegotiation of marital relationship
status and aspects of family composition, function, and process.
c. Readjustment of relationships to include in-laws and
grandchildren. • Process of family assessment requires objectivity and
professional judgement to attach practical meaning to
d. Dealing with abilities and death of older generation.
information being acquired.
5. Aging families
a. Maintaining couple and individual functioning while o Family health assessment guidelines
– information about the environment, or community
adapting to the aging process
b. Support role of middle generation context and information about the family.
– modify content and adapt to fit the individual family.
c. Support and autonomy of older generation.
d. Preparation for own death and dealing with the loss of – serves as a guide and a means to record pertinent
information about the family.
spouse and/or siblings and other peers.
– can be obtained through:
o interview with 1 or more family members
FAMILY HEALTH TASKS o interview of subsystems within the family
• Family serves as a source for its members by carrying out (dyads of mother-child, parent-parent,
health tasks. sibling-sibling)
• 1st family health task: providing members with means for health o group interview (more than two family
promotion and disease prevention. members)
• The health tasks of the family, according to Freeman & o observation to family & their environment
Heinrich (1981): o physical examination (anthropometry)
o Recogniing interruptions of health or development. o secondary data: review of records
▪ Requisite step: to be able to deal purposefully with o Household
an unacceptable health condition. – a social unit consisting of people living alone or a
o Seeking health care. group of persons who sleep in the same housing
o Managing health and nonhealthy crises. unit and have a common arrangement in the
o Providing nursing care to sick, disabled, or dependent preparation and consumption of food.
members of the family.
o Maintaining a home environment conducive to good GENOGRAM
health and personal development. • a tool that helps to outline the family’s structure; way to
o Maintaining a reciprocal relationship with the community diagram a family.
and its health institutions.
• Includes 3 generations of family members.

Community Health Nursing

 FAMILY HEALTH TREE ▪ Data on family structure can be visualized
• Mechanism for recording family’s medical and health histories. through graphic tools (genogram, ecomap, family
• Note the following points: tree)
o Cause of death of deceased family members o Socioeconomic characteristics
o Genetically linked disease ▪ Data on social integration (ethnic origin,
o Environmental and occupational diseases languages & dialects spoken, social networks)
o Psychosocial problems ▪ Educational experiences and literacy
o Infectious disease ▪ Work history
o Familial risk factors from health problems ▪ Financial resources
o Risk factors associated with family’s method of illness ▪ Leisure time interests
prevention. ▪ Cultural influences
o Lifestyle related risk factors. ▪ Spirituality or religious affiliation
o Family Environment
▪ physical environment inside the family’s
ECOMAP
home/residence and its neighborhood.
• Used to depict family’s linkages to its suprasystems. o Family Health and Health Behavior
• Portrays an overview of family in their situation. ▪ Family’s activities of daily living
• Depicts important nurturant or conflict-laden connections ▪ Self-care
between family members and the world. ▪ Risk behaviors.
• Demonstrates the flow of resources, or the lack and ▪ Health history
deprivations. ▪ Current health status
• Highlights the nature of the interfaces and points to conflict to ▪ Health care resources (home remedies & health
be mediated, bridges to build, and resources to be sought and services)
mobilized.
FAMILY NURSING DIAGNOSIS
FAMILY INTERVIEWING • NANDA-International: It serves as a common framework of
• Medium for providing family intervention. expressing human responses to actual and potential health
• Uses general systems and communication concepts to problems.
conceptualize the health needs of families and to assess their • Family Coping Index
responses to events (birth, retirement, chronic illness) – alternative tool for nursing diagnosis
• Critical components of family interview: – based on premise that nursing action may help a family in
o Manners providing for a health need or resolving a health problem by
– common social behaviors that sets the tone for promoting the family’s coping capacity.
the interview and begin the development of – focuses on identifying coping patterns of the family in 9
therapeutic relationship. areas of assessment.
o Therapeutic questions – Freeman & Heinrich: 9 areas of assessment of the Family
– key questions that facilitates the interview Coping Index
o Therapeutic conversations 1. Physical Independence
– focused, planned, and engages the family. o Family members’ mobility and ability to perform
– initiate discussion that brings the family together on ADLs and activities necessary for personal
issues. hygiene.
o Genogram and ecomap 2. Therapeutic Competence
– provide essential information on family structure. o Ability to comply with prescribed/recommended
o Commending family or individual strengths procedures and treatments to be done at home.
– reinforces immediate and long-term positive 3. Knowledge of Health Condition
relationships. o Understanding of the health condition or
essentials of care according to the
FAMILY DATA ANALYSIS developmental stages of family members.
• Data synthesis: organizes data into clusters. 4. Application of Principles of Personal and General
• Data analysis: done by comparing findings with accepted Hygiene
standards for individual family members and for the family unit. o Practice of general health promotion &
• The following is a system of organizing family data: recommended preventive measures.
o Family structure and characteristics 5. Health Care Attitudes
▪ Data on household membership o Family’s perception of health care in general.
▪ Demographic characteristics o Observed in family’s degree of responsiveness
▪ Family members living outside the household to promotive, preventive, & curative efforts of
▪ Family mobility health workers.
▪ Family dynamics (emotional bonding, authority 6. Emotional Competence
and power structure, autonomy of members, o Degree of emotional maturity of family members
division of labor, patterns of communication, according to their developmental stage.
decision making, problem and conflict resolution).

Community Health Nursing

 7. Family Living Patterns 3. Developmental Interventions
o Interpersonal relationships among members o aim to improve the capacity of family to provide
o Management of family finances for its own health needs (guiding the family to
o Type of discipline in the home. make responsible health decisions).
8. Physical Environment
o Home, school, work, and community Plan should be based on the:
environment that influence the health of family a. Principle of mutuality: the family is given the opportunity to
members. decide for itself how they can best deal with a health
9. Use of Community Facilities situation.
o Ability of family to seek and utilize government- b. Principle of personalization: NCP fits the unique situation of
run, private health, & community services. a family (needs, style, strengths, & patterns of functioning)
c. Coordination with other members of health care team and
FORMULATING CARE OF PLAN agencies involved in the care of the family maximizes
• Planning involves: resources by preventing duplication of services.
o priority setting d. Nurse’s capacity of defining self: nurse has to delineate the
o establishing goals & objectives purpose, resources, and limitations.
o determining appropriate interventions to achieve goals &
objectives. IMPLEMENTING THE PLAN OF CARE
• Stancope & Lancaster: nurse’s role at this stage consists of • Implementation is the step when the family or nurse execute
offering guidance, providing information, and assisting the family the plan of action.
in the planning process.
• Priority Setting EVALUATION
– determining the sequence in dealing with identified family • To evaluate is to determine or fix the value.
needs and problems. • Determining the value of nursing care that has been given.
– the following factors need to be considered: • Product of evaluation: terminate, continue, modify interventions.
1. Family safety • Goals and objectives: framework of evaluation.
o life-threatening situation: top priority. • Formative Evaluation
2. Family perception – judgment about effectiveness of nursing interventions
o Priority is given to the need that the family as they are implemented.
recognizes as urgent.
• Summative Evaluation
3. Practicality
– determining the end results of family nursing care and
o looks into existing resources and constraints.
involves measuring outcomes or degree to which goals
4. Projected effects
have been achieved.
o immediate resolution of a family concern gives
• Aspect of Evaluation:
them sense of accomplishment and confidence.
o Effectiveness
▪ determination of whether goals and objectives
ESTABLISHING GOALS AND OBJECTIVES were attained.
• Goal o Appropriateness
– desired observable family response to planned ▪ suitability of goals/objectives and interventions
interventions in response to mutually identified family need. ▪ accurate assessment of family health needs: basis
• Objectives for appropriate goals, objectives, interventions.
– desired step-by-step family responses as they work o Adequacy
toward a goal. ▪ degree of sufficiency of goals/objectives and
– workable, well stated objectives should be SMART: interventions in attaining the desired change.
S: Specific (objective clearly articulates) o Efficiency
M: Measurable (observable, quantifiable) ▪ relationship of resources used to attain desired
A: Attainable (objective: realistic; conformity with outcomes.
available resources, existing constraints, family traits)
R: Relevant (objective is appropriate for family need) FAMILY-NURSE CONTACTS
T: Time bound (have a specified target time or date)
• Family-nurse relationship is developed through family-nurse
contacts, which may take the form of a:
DETERMINING APPROPRIATE INTERVENTIONS o Clinic Visit
• Freeman & Heinrich: categorize nursing interventions into 3 – takes place in private clinic health center,
types: barangay health station.
1. Supplemental interventions – advantage:
o actions that nurse performs on behalf of the family ▪ family member takes initiative of visiting
when it is unable to do things for itself. professional health worker (indicating
2. Facilitative Interventions family readiness to participate in the health
o actions that remove barriers to appropriate health care process).
action (assisting family to avail of maternal and early ▪ nurse has greater control over the
childcare services). environment, distractions are lessened.

Community Health Nursing

 o Group Conference b. In-home Phase
– provides opportunity for initial contact • Begins as nurse seeks permission to enter and lasts until
– appropriate for developing cooperation, she leaves the family’s home.
leadership, self-reliance, community awareness • It consists of initiation, implementation, and termination.
– opportunity to share experiences and practical o Initiation
solutions to common health concerns. ▪ Customary to knock.
o Telephone Contact ▪ In reasonably loud but nonthreatening voice
– provides easy access between nurse/health introduce self
worker and the family. ▪ On entering the home, acknowledge the family
o Written Communication members with a greeting and introduces self
– used to give specific information to families and the agency he represents.
o Home Visit ▪ Observes environment for his own safety and
sits as the family directs him to sit.
HOME VISITS ▪ Establish rapport by initiating a short
– professional, purposeful interaction that takes place in the family’s conversation.
residence aimed at promoting, maintaining, and restoring the health ▪ States the purpose of visit the source of
of the family or its members. information.
– advantages: o Implementation
o allows first-hand assessment of home situation. ▪ Involves the application of nursing process.
o nurse can seek out previously unidentified needs. o Termination
o gives nurse opportunity to adapt interventions according ▪ Consists of summarizing with the family the
to family resources. events during the home visit and setting a
o promotes participation and focuses on the family as a unit. subsequent home visit or another form of
o teaching family members is made easier by the familiar family-nurse contact.
environment and the recognition of need to learn as they c. Post-visit Phase
are faced by the actual home situation. • Takes place when the nurse has returned to health facility.
o gives family sense of confidence in themselves and in the • Involves documentation of the visit.
agency.
– disadvantages: THE NURSING BAG
o cost in terms of time and effort. – frequently called PHN bag
o more distractions (unable to control the environment). – tool used by the nurse to provide care safely and efficiently
o nurse’s safety. – has the following contents:
• Articles for infection control
PHASES OF HOME VISITS • Articles for assessment of family members.
a. Pre-visit Phase • Articles for nursing care
• Nurse contacts the family, determines the willingness for a o Sterile items
home visit, and sets an appointment with them. o Clean articles
• Plan for the home visit is formulated during this phase. o Pieces of paper
• Following are specific principles in planning for a home visit:
o Being a professional contact with the family, the Use of Nursing Bag
home visit should have a purpose. Other purposes: • Bag technique helps the nurse in infection control.
▪ To have more accurate assessment • Allows the nurse to give care efficiently.
▪ To educate family about measures of health • Saves time and effort by ensuring that the articles needed for
promotion, disease prevention and control of nursing care are available.
health problems. • Bag technique should not take away the nurse’s focus on the
▪ To provide supplemental interventions for patient and the family.
the sick, disabled or dependent family • Bag technique may be performed in different ways, principles
member. of asepsis are of the essence and should be always practiced.
▪ To provide family with greater access to
health resources in the community. For infection control, the following activities should be practiced
o Use information about the family collected from all during home visits:
possible sources. • Proceed from “clean” to “contaminated”.
o Home visit plan focuses on identified family needs, • The bag and its contents should be well protected from
particularly needs recognized by the family as contact with any article in the patient’s home.
requiring urgent attention.
• Line the flat surface with paper on which the bag and articles
o The client and family should actively participate in
to be used are placed.
planning for continuing care.
o Plan should be practical and adaptable. • Wash your hands before and after physical assessment and
physical care of each family member.
• Bring out only the articles needed.
• Do not put any family’s articles on the paper lining.
• Wash articles before putting them back into the bag.

Community Health Nursing

 NCM 104 & 113: Community Health Nursing

CHAPTER 7: THE NURSING PROCESS IN THE CARE CHARACTERISTICS OF A HEALTHY COMMUNITY

OF COMMUNITY • Shared sense of being a community based on history & values.
• General feeling of empowerment and control over matters
COMMUNITY that affect the community.
• Nies & McEwen: Community is the focus of nursing care. • Existing structures that allow subgroups within the community
• Community is a group of people who: to participate in decision making in community matters.
o Have a common interest or characteristics. • Ability to cope with change, solve problems, manage conflicts
o Interact with one another. within community through acceptable means.
o Have sense of unity or belonging. • Open channels of communication.
o Function collectively within a defined social structure to • Equitable and efficient use of community resources.
address common concerns.
• Community: phenomenological (functional; school) or Ottawa Charter (WHO): Healthy community is the process of
geopolitical (territorial; barangay ) enabling people to increase control over, and to improve their health.

Ottawa Charter was one of the documents that paved the way
PRINCIPLES OF CHN
for Healthy Settings movement (Healthy Cities movement).
1. Community is the focus of care; nurse responsibility is to the
community as a whole.
Healthy city
2. Give priority to community needs.
– continually creating and improving physical and social
3. Work with the community as equal partner of health team.
environments and expanding community resources that enable
4. Focus on primary prevention for appropriate activities.
people to mutually support each other in performing all functions
5. Promote healthful physical and psychosocial environment.
of life and developing their maximum potential.
6. Reach out to all who may benefit from a specific service.
– it aims to:
7. Promote optimum use of resources.
o achieve good quality of life.
8. Collaborate with others working in the community health.
o create health-supportive environment.
o provide basic sanitation and hygiene needs.
CONDITIONS IN THE COMMUNITY AFFECTING o supply access to health care.
HEALTH
• Community has 3 features: people, location, social system The Philippines is a member nation of WHO Western Pacific
Region, which has advocated for the Healthy Cities and Healthy Island
a. People movement.
• Population variables that affect community health: size, density,
composition, rate of growth and decline, cultural characteristics, COMMUNITY ASSESSMENT
mobility, social class, educational level • Nurse collects data on 3 categories: people, place, social
system.
b. Location • Community database for Planned Approach to Community
• Community health is affected by natural and man-made Health (PATCH), a community health planning model based on
variables related to location. Green’s PRECEDE model.
• Natural factors: climate, flora, and fauna
• Man-made variables: presences of open spaces, quality of soil, Data collected for PATCH process for health planning
water, and air, location of health facilities. 1. Community profile: demographic, educational, & economic data.
• National Statistical Coordination Board of the Philippines: 2. Morbidity and mortality data, including unique health events.
o Redefined an urban area as a barangay that has: (typhoon that caused flooding)
– a population of 5,000 or more 3. Behavioral data focusing on behavioral risk factors (smoking,
– at least 1 business establishments with a minimum of drinking, leading a sedentary life)
10 employess 4. Opinion data from community leaders
– 5 or more facilities within 2 km radius from barangay
hall Comprehensive Needs Assessment
c. Social System – gathers information about the community using a systematic
• It is a patterned series of interrelationships existing between process where data is collected regarding all aspects of the
individuals, groups, and institutions and forming a coherent community to identify actual and potential health problems.
whole. – most useful when health assessment of the community is being
• Components that affect health: family, economic, educational, done for the first time.
communication, political, legal, religious, recreational, and health – data are collected about a random sample of the population
systems.
Problem-oriented Assessment
– focused on a particular aspect of health.
– workable when nurse is familiar with the community
– purposive sampling is indicated.

Community Health Nursing

 TOOLS FOR COMMUNITY ASSESSMENT who attended the delivery) is responsible for
• Data sources are grouped into primary and secondary data. registering births that occur outside a facility.
• Community itself is the primary sources of data. o The birth of a child should be registered with 30 days
• Primary data: observation (participant observation, from the occurrence of birth at the Local Civil
ocular/windshield survey), informant interview, community Registry Office.
forum, focus group discussion.
• Secondary data: existing data sources, vital registries, health • PD 856 (Sanitation Code) requires a death certificate
records and reports, disease registries, publications. before the burial of the deceased.
o The physician who lasts attended the deceased:
Collecting Primary Data responsible for preparing death certificate, certifying
a. Observation cause of death, and forwarding it to the health officer
– rapid observation of a community may be done through within 48 hours.
an ocular survey. o If death occurred without medical attention: nearest
– participant observation is a purposeful observation of relative or anyone who has knowledge of the death
shall report to health officer within 48 hours. Health
formal and informal community activities by sharing the life in
the community. officer certifies the cause of death and direct its
registration.
– helps in determining community values, beliefs, norms,
power structure. o Absence of health officer: death will be reported to
the mayor, municipal secretary, member of
b. Survey Sangguniang Bayn, who shall issue the death
– consuming and expensive certificate for purposes of burial.
– necessary when there is no available information about the o Registration of death shall be made within 30 days
from the occurrence of death at the Local Civil
community or specific population to be studied.
– made up of a series of questions for systematic collection Registry Office where the birth occurred.
of information.
– used by the nurse in identifying patterns of utilization of 2. Health records and reports
health services. • EO no. 352, the Field Health Service and Information
System (FHSIS) is the official recording and reporting
c. Informant interview system of DOH and used by NSCB to generate statistics.
– purposeful talks with key informants of ordinary
community members. Field Health Service and Information System
– key informants; formal and informal community leaders of – essential tool in monitoring the health status of the
position and influence. populations at the different levels.
– basis for:
d. Community forum • priority setting of local governments.
– open meeting of the members of the community • planning and decision-making at different levels
– pulong-pulong sa barangay (barangay, municipal, district, provincial, national).
– effective in providing people with a medium for expressing • monitoring and evaluating health program
their views and developing their capacity to influence decision implementation.
makers. – standardized, facility-level database for in-depth studies
– used as a venue for data validation – composed of recording and reporting tools

e. Focus group Records

– made of much smaller group, 6-122 members inly – facility-based; kept at BHS, RHU, health center.
– effective in the assessment of health needs of specific – services delivered are the basis of the data entered in the
groups records; basis of reports
– focus group of first-time pregnant women
Recording tools
Secondary data sources FHIS Manual of operations describes the following
1. Registry of vital events recording tools:
• RA 3753 (Civil Registration Law), enacted in 1930, establish
the civil registry system; requires registration of vital events a. Individual Treatment Record (ITR)
(births, marriages, deaths.) – building block of the FHIS.
• RA 7160 (Local Government Code) assigned the function – contains date, name, address of patient, presenting
of civil registration to local governments and mandated the symptoms or complaint of the patient on consultation,
appointment of Local Civil Registrars. and the diagnosis, treatment, and date of treatment.
o Birth & death rate are sources of fertility & mortality
data. b. Target Client Lists (TCLs)
o Facility-based births: the facility administrator shall be – second building block of FHSIS.
responsible for the registration of the event. Birth – purposes:
attendants (physician, midwife, nurse, or anybody • to plan and carry out patient care and service
delivery.

Community Health Nursing

 • to facilitate monitoring and supervision of service ii. Morbidity report (Q2)
delivery activities. – 3- month consolidation of existing cases or
• to report services delivered. morbidity report (M2) in the community.
• to provide a clinical-level database
– TCLs maintained in RHU and health centers c. Annual forms
• TCL for Prenatal Care i. A- BHS
• TCL for Postpartum Care – report by the midwife; contains demographic,
• TCL for Under 1 year old children environmental, and natality data.
• TCL for Family planning
ii. Annual form 1 (A-1)
• TCL for Sick children
– prepared by the nurse and is the report of the
• National Tuberculosis Program TB Register
RHU or health center.
• National Leprosy Control Program Central – contains demographic, environmental data, data
Registration Form on natality and mortality for the entire year.
c. Summary table iii. Annual form 2 (A-2)
– accomplished by the midwife. – prepared by the nurse; yearly morbidity report
– a 12-column table in which columns correspond to the by age and sex.
12 months of the year.
– kept at BHS and has 2 components: iv. Annual form 3 (A-3)
• Health Program Accomplishment – prepared by the nurse; yearly report of all deaths
• Morbidity/ Diseases. (mortality) by age and sex.
– supposed to be updated monthly.
– health program accomplishment provides the midwife 3. Disease Registries
of a tool for assessment of accomplishments and a ready • listing of persons diagnosed with a specific type of disease
source of reports. in defined population.
– source of data for any survey or research. • data collected through disease registries serve as basis for
monitoring, decision- making, and program management.
d. Monthly Consolidation Table (MCT)
– accomplished by the nurse based on summary table. 4. Census data
– serves as the source document for the quarterly form
• made by BHWs; periodic governmental enumeration of
and the output table of the RHU or health center.
population.
• Batas Pambansa Blg. 72, provides for a national census of
Reporting Forms
population and other related data every 10 years.
The reporting forms, as enumerated in the FHSIS manual
of Operations are the following: • Philippine Statistical System (PSS): provides statistical
information and services to the public.
o NSCB: policy -making and coordinating body of PSS.
a. Monthly forms
– regularly prepared by the midwife and submitted to o NSO: the PSS arm that generates general-purpose
statistics: population, employment, family
the nurse, who then uses the data to prepare the
Quarterly forms. income/expenditures.
• During a census, people may be assigned to a locality by
i. Program report (M1) de jure or de facto method.
– contains health indicators categorized as o De jure assignment: based on the legally established
maternal care, childcare (vaccines), family planning place of residence of people.
(methods), and disease control. o De facto: according to the actual physical location of
the people.
ii. Morbidity report (M2)
– contains list of all cases of disease by age & sex. METHODS TO PRESENT COMMUNITY DATA
Community data are presented to the health team and
b. Quarterly forms community members for the following purposes:
– prepared by the nurse. • To inform the health team and community members of
– there should only be one quarterly form for the existing health and health-related conditions in the community
municipality/ city. in the understandable manner.
– in municipalities/cities with 2 or more RHUs or health • To make community members appreciate the significance and
center, consolidation is done under the direction of relevance of health information to their lives.
Municipal/City Health Officer. • To solicit broader support and participation in the community
– submitted to the Provincial Health Office health process
• To validate findings
i. Program report(Q1) • To allow for a wider perspective in the data analysis
– contains 3-month total of indicators categorized • To provide a basis for better decision making.
as maternal care, family planning, childcare, dental
health, and disease control.

Community Health Nursing

Graphs for presenting community data and their uses Domains and Problems of the Problem Classification Scheme
Bar Graph a. Environmental Domain
• To compare values across different categories of data. – material resources and physical surroundings both inside and
outside the living area, neighborhood, and broader community.
Line Graph • Income • Residence
• To have a visual image of trends in data over time and age. • Sanitation • Neighborhood/workplace safety

Pie Chart b. Psychosocial Domain

• To show percentage distribution or composition of a – patterns of behavior, emotion, communication, relationships, and
variable, such as population or households. development.
• Communication with • Mental health
Scatter Plot or Diagram community resources • Sexuality
• To show correlation between 2 variables. • Social contact • Caretaking/parenting
• Values of both variables in subjects are plotted in a graph • Role change • Neglect
with an x-axis and a y- axis. • Interpersonal relationship • Abuse
• Spirituality • Growth and
COMMUNITY DIAGNOSIS • Grief development
– process of determining the health status of the community and
the factors responsible for it. c. Physiological Domain
– a quantitative and qualitative description of the health of citizens – functions and processes that maintain life
and the factors that influence their health. • Hearing • Urinary function
– allows identification of problems and areas of improvement, • Respiration • Pain
thereby stimulating action • Circulation • Reproductive function
• Neuro-Musculoskeletal • Oral health
Format for community diagnosis. function • Pregnancy
a. Shuster and Goppinger • Vision • Cognition
• proposed a practical adaptation of a format of nursing • Digestion • Postpartum
diagnoses for population groups previously presented by • Hydration • Speech and language
Green and Slade. • Consciousness • Communicable/
• three- part statement consist of: • Bowel function Infectious condition
o health risk or specified problem to which the
• Skin
community is exposed.
o specific aggregate or community with whom the nurse
d. Health-related Behaviors Domain
will be working to deal with the risk or problem.
– patterns of activity that maintain or promote wellness, promote
o related factors that influence how the community will
recovery, and decrease the risk of disease.
respond to the health risk or problem.
• Nutrition • Substance use
• Sleep & rest patterns • Family planning
b. OHAMA System
– used as a framework for the care of individuals, families, and • Physical activity • Health care supervision
communities by health care providers. • Personal care • Medication regimen
– comprehensive and research-based classification system for
client problems that exists in the public domain PLANNING COMMUNITY HEALTH INTERVENTIONS
– has 3 components that are to be used together: • Planning for community health interventions is based on
findings during assessment and formulated nursing diagnosis.
Problem classification scheme (client assessment)
– serves as a guide in collecting, classifying, analyzing, documenting, Planning
and communicating health and health- related needs and – logical process of decision making to determine which
strengths. identified health concerns requires immediate consideration and
– model for practice, education, and research. what actions may be undertaken to achieve goals and objectives.
– a phase that involves priority setting, formulating goals and
Areas of concern are classified in 4 levels: objectives, and deciding on community interventions.
• 1st level: 4 domains
• 2nd level: areas of concern under the 4 domains Priority Setting
• 3rd level: area of concern is categorized into health promotion, – provides nurse and health team with a logical means of
potential problem or actual problem. establishing priority among the identified health concerns.
• 4th level: clusters of sign and symptoms that describe actual – WHO suggested the following criteria to decide on:
problem. • Significance of the problem
o based on the number of community people
affected by the problem.
o Disease Condition: estimated in terms of its
prevalence rate

Community Health Nursing

 o Potential Problem: its significance is determined by Repeat the process on all identified health problems, compare
estimating the number of people at risk of total priority scores of the problems. The problem with the highest
developing the condition. total priority score is assigned top priority.
• Level of community awareness and the priority its
members give to the health concern. FORMULATING GOALS AND OBJECTIVES
o community motivation to deal with the condition. Goals
o major consideration – desired outcomes at the end of interventions
• Ability to reduce risk.
o related to the availability of expertise among health Objectives
team and the community. – short-term changes in the community that are observed as the
• Cost of reducing risk health team and the community work towards the attainment of
o consider economic, social, and ethical requisites and goals.
consequences of planned actions. – serves as instructions, defining what should be detected in the
• Ability to identify the target population. community as interventions are being implemented.
o intervention is a matter of availability of data – specific, measurable, attainable, relevant, and time-bound
sources,( FHSIS, census, survey reports, and case- (SMART) objectives provide a solid basis for monitoring and
finding or screening tools). evaluation.
• Availability of resources.
o to intervene reduction of risk entails technological, DECIDING ON COMMUNITY INTERVENTIONS
financial, and other material resources of the • The group analyzed the reasons for people’s health behavior
community, nurse, and health agency. and directs strategies to respond to the underlying causes.
• In the process of developing the plan, the group takes into
For a realistic and useful outcome, priority-setting process consideration the demographic, psychological, social, cultural,
requires joint effort of the community, nurse, and other stakeholders and economic characteristics of the target population and the
available health resources.
• The group defines guidelines for discussion, particularly on
the manner of reconciling differences of opinion. IMPLEMENTING THE COMMUNITY HEALTH
• Shuster and Goeppinger suggested flexible process using
INTERVENTIONS
nominal group technique (each group member has equal Implementation (action phase)
voice in decision making, avoiding control of the process – most exciting phase for most health workers.
by the dominant members of the group). – entails coordination of plan with community and other members
of the health team.
– deal with the recognized priority health concern
• The technique is appropriate for brainstorming and ranking
ideas, when consensus building is desired over making a – entire process is intended to enhance the community’s capability
choice based on the opinion of the majority. in dealing with common health conditions/problems.
– nurse’s role: to facilitate the process rather than directly
implement the planned interventions.
• The group makes a list of the identified community health
problems or conditions. Identified problems is treated
separately according to a set of criteria agreed upon by EVALUATION OF COMMUNITY HEALTH
the group. INTERVENTIONS
Evaluation approaches:
As suggested by Shuster and Goeppinger (2004), the following steps a. Structure Evaluation
are carried out: – looking into manpower and physical resources of the
1. From a scale of 1 to 10, 1 being the lowest, the members agency responsible for community health interventions.
give each criterion a weight based on their perception of
a weight based on their perception of its degree of b. Process Evaluation
importance in solving the problem. – examining how nursing process (ADPIE) were undertaken.

2. From a scale of 1 to 10, 1 being the lowest, each member c. Outcome Evaluation
rates the criteria in terms of the likelihood of the group – determining the degree of attainment of goals &
being able to influence or change the situation. objectives.

3. Collate the weights (from step 1) and ratings (from step 2) Ongoing evaluation or monitoring
made by the members of the group. – done during implementation
– provide feedback on compliance to the plan and the need for
4. Compute the total priority score of the problem by changes in plan to improve process and outcomes of interventions.
multiplying collated weight and rating of each criterion.

5. The priority score of the problem is calculated by adding

the products obtained in step 4

Community Health Nursing

Standards of Evaluation
The bases for a good evaluation are:

Utility
– value of the evaluation in terms of usefulness of results.
– helps the group gain insight into strengths and weaknesses
of the plan and the manner of its implementation.

Feasibility
– answers the question of whether the plan for evaluation is
doable or not, considering available resources (facilities, time,
expertise for conducting the evaluation).
– feasible evaluation plan will yield data worthy of the resources
needed to collect and process them.

Propriety
– involves ethical and legal matters.
– respect for the worth and dignity of the participants in data
collection should be given due consideration.
– results of evaluation should be truthfully reported to give
credit where it is due and to show the strengths and
weaknesses of the community

Accuracy
– validity and reliability of the results of evaluation.
– accurate evaluation begins with accurate documentation
while the community health process is ongoing.
– high degree of validity and reliability: choosing and properly
utilizing right evaluation tools.

Community Health Nursing

 NCM 104 & 113: Community Health Nursing

CHAPTER 8: APPLICATIONS OF EPIDEMIOLOGY IN housing, number of persons per room, availability, & distribution
COMMUNITY HEALTH of food supplies.

g. Environmental indicators
EPIDEMIOLOGY • Quantity of suspended particulate matter (hydrocarbons,
• Last: study of distribution and determinants of health-related oxidants), portability of drinking water (turbidity, contamination
states or events in specified populations, and the application of of surface water with sewage and industrial wastes)
this study to the prevention and control of health problems
• terms of epidemiology: h. Disability indicators
o Study: surveillance, observation, hypothesis testing, • DALYs, indicators of restricted activity, indicators of long-term
analytic research, and experiments disability
o Distribution: analysis by time, places and classes of
people affected i. Health policy indicators
o Determinants: biological, chemical, physical, social, • Allocation of manpower & financial resources, mechanisms for
cultural, economic, genetic, and behavioral factors that community participation, collaboration between government
influence health. and NGOs, equity in distribution of resources among special
o Health related states or events: disease, cause of death, target groups, availability of public policy statement & health
behaviors (use of tobacco), positive health states, plan.
reactions to preventive regimens and, provision and
used of health services,
ASSESSMENT OF THE HEALTH STATUS OF THE
o Specified populations: identifiable characteristics
(occupational groups) COMMUNITY (COMMUNITY DIAGNOSIS)
o Application to prevention and control: aim of public Health indicators
health. – to promote, protect, restore good health. – quantitative measures expressed as rates, ratio, or proportions
that describe and summarize aspects of health status of population.
PRACTICAL APPLICATIONS OF EPIDEMIOLOGY – used to determine factors that may contribute to a causation
1. Assessment of the health status of the community or and control of diseases, indicates priorities for resource allocation,
community diagnosis monitors implementation off health programs, and evaluates
2. Elucidation of the natural history of disease outcomes oh health programs.
3. Determination of disease causation – a tool to assess the health status of the population
4. Prevention and control of disease o determining factors that may contribute to causation and
5. Monitoring and evaluation of health interventions control of disease.
6. Provision of evidence for policy formulation o identifying public health problems and needs
o indicating priorities for resources allocation
o monitoring implementation of health program
TYPES OF HEALTH INDICATORS & THEIR EXAMPLES o evaluating outcomes of health programs
a. Health status indicators (Morbidity)
• Prevalence, incidence
MORBIDITY INDICATORS
b. Health status indicators (Morality) • based on disease specific incidence or prevalence for the
common and severe diseases (malaria, diarrhea, leprosy).
• Crude and specific death rates, maternal mortality, infant
mortality, neonatal mortality, postnatal mortality, child mortality,
Prevalence proportion (P) = (no. of existing cases of a disease
proportionate mortality, case fatality, life expectancy at birth,
at particular point in time / no. of people examined at that point
disability-adjusted life years (DALYs).
in time) x F [no. of the base 10, most common F used is 100]
c. Population indicators
Factors affecting Prevalence
• Age-sex structure of the population, population density,
Increased by Decreased by
migration, population growth (crude birth rate, fertility rate)
Longer duration of disease Shorter duration of disease
Prolongation of life of patients High case-fatality rate from
d. Indicators for the provision of health care without care disease
• Access to health programs and facilities, availability of health Increase in new cases Decrease in new cases
resources (facilities, health manpower, finances) In-migration of cases In-migration of healthy people
Out-migration of healthy people Out-migration of cases
e. Risk reduction indicators In-migration of susceptible Improved cure rate of cases
• Cases consulting health provider., infants exclusively breast-fed people
for the first 6 months, children fully vaccinated. Improved diagnostic facilities

f. Social and economic indicators

• Level & distribution of economic wealth, types & levels of
employment, school enrollment & adult literacy, availability of

Community Health Nursing

Incidence Factors that affect the Crude death rate
– measures number of new cases, episodes, or events occurring • Age and sex composition of the population
over a specified period of time within a specified population at risk. • Adverse environmental and occupational conditions
– best indicator of whether a condition is decreasing, increasing, • Peace and order conditions of a place
or remaining static.
– best measure to use to evaluate health interventions Age-standardized death rate: better measure for comparison.
effectiveness; derived from cohort study.
Specific mortality rates
Types of Incidence measures – show rates of dying in specific population groups.
a. Cumulative incidence (Incidence proportion)
– measures the average risk of probability of developing Specific mortality rate = (no. of death in a specified group in a
disease within a specified period of time (risk period). calendar year / midyear population of the same specified
group) x F
CI = (no. of new cases that developed during the period / no.
of persons followed-up) x F Cause of death rate
– rate of dying due to a specific cause.
Attack Rate is used instead of CI if risk period for occurrence of – Identifies the greatest threat to the survival of the people
the disease is short.
Cause of death rate = no. of deaths from a certain cause in a
AR = (no. of people who ate the food item ad developed calendar year / midyear population) x F
diarrhea / total no. of people who ate the food item) x 100
Factors affecting the cause of death rate:
b. Incidence density rate • Completeness of the registration of deaths
– computed using total person-time at risk for entire cohort as • Composition of the population
denominator. • Accuracy of ascertaining the cause of death
– measures average instantaneous rate of disease occurrence.
– must always include a unit of time (cases per 100 000 person- Infant Mortality Rate
years) – good index of health in a community (infants are very sensitive
to adverse environmental conditions.)
ID = (no. of cases during the period / average population x – high IMR: low level of health standards, secondary to poor
duration of follow-up) x F maternal & child health care, malnutrition, poor environmental
sanitation, deficient health service delivery.
ID = (no. of cases during the period / sum of person-time at
risk) x F IMR = (deaths under 1 year of age in a calendar year / number
of live births in the same year) x 1 000
Cohort
– group of people who share a common defining characteristics. Neonatal mortality and post neonatal mortality add up to the IMR.
Deaths among infants less than 28 days are due mainly to prenatal
At risk group or genetic factors, while those in later months are influenced by
– members of group are free of disease but have the potential environmental and nutritional factors.
for developing a particular disease within specific period of time.
Neonatal mortality rate = no. of deaths among those under 28
Specific Morbidity rates days of age in calendar year / no. of live births in the same
– show how disease rates in specific population groups (age, sex, year) x 1 000
occupation, education, exposure to risk factors, place of residence)
– answers who are affected, where do they occur, or when do Post neonatal mortality rate = number of deaths among those
they occur or increase. 28 day to less than 1 year of age in a calendar year / number
of live births in the same year.) x 1 000
Example: (No. of TB cases among those aged 20-24 years /
midyear population aged 20-24 years) x 100 000 Maternal Death
– death of a female from any cause related to or aggravated by
MORTALITY INDICATORS pregnancy or its management (excluding accidental or incidental
• provides important information of the health status of the causes) during pregnancy and childbirth or within 42 days of
people in the community. termination of pregnancy, irrespective of the duration and the site
of the pregnancy.
Crude death rate
– rate which mortality occurs in a given population. Maternal mortality ratio
– ideal denominator: number of pregnancies, but due to the
CDR = (no. of deaths in a calendar year / midyear population) unavailability of data, the number of live births is used.
x 1 000 – measure of obstetric risk and is affected by maternal health
practices, diagnosis ascertainment, completion of registration of
birth.

Community Health Nursing

 MMR = (no. of deaths due to pregnancy, delivery, puerperium POPULATION INDICATORS
in a calendar year / no. of live births in the same year) x 100 • include population growth indicators (CBR, GFR, total fertility
rate, annual growth rate), population dynamics (migration) that
Case Fatality Rate affect age-sex structure of the population and vice versa.
– proportion of cases that end up fatally. Crude birth rate
– risk of dying among persons afflicted with a particular disease. – measures how fast people are added to the population through
– quantifies the risk of dying among those who have disease, while births.
incidence proportion quantifies the risk of developing disease with – High fertility: CBR ≥ 45 / 1 000 live births
a specified period of time. – Low fertility: CBR ≤ 20 / 1 000 live births
– magnitude of CFR depends on the nature of the disease itself,
diagnostic ascertainment, level of reporting in the population. CBR = (no. of registered live births in a year / midyear
population) x 1 000
CFR = (no. of deaths from a specified cause / no. of cases if
the same disease) x 100

Goal /
Health Targets Health indicators
Target
Goal 4: Reduce child mortality. Under-five mortality rate
Target 5: Reduce by 2/3 between 1990 and 2015, the under-five Infant mortality rate
mortality rate. Proportion of 1-year old children immunized against measles
Goal 5: Improve maternal health. Maternal mortality ratio
Target 6: Reduce by three quarters between 1990 and 2015 the Proportion of births attended by skilled personnel
maternal mortality ratio.
Goal 6: Combat HIV/AIDS, malaria, and other diseases. HIV prevalence among pregnant women aged 15 24 years
Target 7: Have halted by 2015 and begun to reverse the spread Condom use rate of the contraceptive prevalence rate
of HIV/AIDS Ratio of school attendance of orphans to school attendance of non-
Target 8: Have halted by 2015 and begun to reverse the orphanage aged 10-14 years.
incidence of malaria and other diseases. Prevalence and death rates associated with malaria.
Proportion of population in malaria risk areas using effective malaria
prevention and treatment measures.
Prevalence and death rates associated with TB.
Proportion of TB cases detected and cured under DOTS.

General fertility rate Public Health Surveillance

– more specific rate than CBR, births are related to the segment – WHO: ongoing, systematic collection, analysis and interpretation
of the population deemed to be capable of giving birth (women in of health-related data needed for planning, implementation, and
the reproductive age groups.). evaluation of public health practice.
– High fertility: GFR ≥ 200 / 1 000 live births
– Low fertility: CBR ≤ 60 / 1 000 live births Surveillance Systems
– developed for:
GFR = (no. of registered live births in a year / midyear • monitoring high burden diseases
population of women 15 – 44 years of age) x 1 000 • detecting disease outbreaks that could escalate into
epidemic proportions.
Population Pyramid • monitoring progress toward attainment of targets for the
– graphical representation of age-sex composition of population control, elimination of a specific disease
examined during assessment of the health status of the community. – new public health paradigm for surveillance advocate inclusion of
– its shape provides insights into the fertility and mortality patterns detection of toxins, hazardous chemicals, genetically modified
of a community as well as the most probable health problems that products, and risky behaviors
needs health services.
Philippine Integrated Behavioral and Serologic Surveillance:
SOURCES OF DATA FOR CALCULATION OF HEALTH monitors seropositivity among most at-risk groups for HIV infection
INDICATOR and their behaviors that put them at risk.
Disease Notification
– integral part of disease surveillance. Disease Surveillance
– RA 3573: Law on Reporting of Communicable Disease to report a. Passive Surveillance
notifiable diseases (dengue, rabies, leptospirosis, HIV/AIDS) to local – system by which public health staff receives reports from
and national health authorities. hospitals, clinics, public health units.
Disease Registry
– compilation of information about a particular disease. b. Active Surveillance
– aim: to include all cases of disease in registry without duplication. – system in which public health staff members actively and
regularly contact health care providers or population to obtain
information about the disease of interest.

Community Health Nursing

 Philippine Integrated Disease Surveillance and Response • Expanded Program on Immunization Surveillance System
integrates health statistics generated through major disease • HIV-AIDS registry
surveillance.
• Notifiable Disease Reporting System Bureau of Animal Industry of the DA is aiming for the elimination
• Field Health Service Information System of rabies as mandated by RA 9482.
• National Epidemiology Sentinel Surveillance System

Priority disease, syndromes, and conditions targeted for surveillance by DOH

Disease targeted for Other diseases of public
Epidemic-prone disease
eradication health importance
• Acute bloody diarrhea • Influenza-like illness • Poliomyelitis (acute • Adverse events
• Acute encephalitis • Leptospirosis flaccid paralysis) following immunization.
• Acute hemorrhagic fever syndrome • Malaria • Measles • Diphtheria
• Acute viral hepatitis • Meningococcal disease • Neonatal Tetanus • Non-neonatal tetanus
• Anthrax • Paralytic shellfish poisoning • Pertussis
• Cholera • Severe acute respiratory • Rabies
• Dengue syndrome
• Human avian influenza • Typhoid and paratyphoid fever

CONSIDERATIONS IN THE ANALYSIS & c. There should be correspondence in time and geographical
INTERPRETATION OF HEALTH INDICATORS location of the events in the numerator and population in the
denominator.
a. Is the denominator of the rate the most appropriate one?
d. Time specifications are usually on annual basis.
b. Is the numerator an accurate count of the number of
e. Factors used in the computation of the different rates may
events? Inaccuracies are due to under registration, under
be any number of the base 10.
reporting, duplication.
ELUCIDATION OF NATURAL HISTORY OF DISEASE

Stages in the natural history of disease and the level of prevention

Stage of Susceptibility (Pre-
Stage of Subclinical Disease Stage of Clinical Disease Resolution Stage
pathogenesis Stage)
Person is not yet sick but may be Person is still apparently healthy since Patient manifests recognizable signs Patient either
exposed to the risk factors of the clinical manifestations of the disease are and symptoms (vaginal bleeding). recovers
disease. (multiple sex partners in the not yet shown, although pathologic completely from
case of cervical cancer). changes have already occurred. the disease,
Primary Level of Prevention Secondary Level of Prevention Tertiary Level of Prevention becomes a
• Health education • Papanicolaou smear • Applicable to limit the disability chronic case with
• Immunization and restore the functional or without
capability of the patient. disability or dies.

Disease outbreak Evaluation

– occurrence of cases of disease in excess of what would normally – process that systematically and objectively assesses compliance
be expected in a defined community, geographical area or season. to design of the program, performance, relevance and success of
– occurrence of 1 case of CD is considered an outbreak provided a project, extent to which project accomplishes its intended results
that the disease: and achieves measurable impacts.
• a previously unknown disease. – to provide feedback on the results and impact of the project to
• never occurred in the area where the case is observed. inform lawmakers about the efficacy of the intervention.
• has been absent from the population for a long time.

Monitoring
– ongoing activity during program implementation to assess
current status of its implementation in terms of compliance of
design, timeline, attainment of goals.

Community Health Nursing

NCM 104 & 113: Community Health Nursing

CHAPTER 9: HEALTH CARE DELIVERY SYSTEM immunization, practices in maternal and childcare,
and environmental conditions.
HEALTH SYSTEM
4. Articulating ethical and evidence-based policy options
– consist of all organizations, people, and actions whose primary
o Through its Department of Ethics and Social
intent is to promote, restore, or maintain health.
Determinants, WHO is involved in issues on
– has 6 building blocks:
health ethics in collaboration with other
o service delivery.
governmental and NGOs.
o health workforce
o WHO has worked on bio-ethical concerns
o information
(human organ and tissue transplantation),
o medical products, vaccines, and technology
reproductive technology, and public health
o financing
response rates of infectious diseases.
o leadership and governance or stewardship
5. Providing technical support, catalyzing change, and
WORLD HEALTH ORGANIZATION building sustainable institutional capacity
– global leader in health matters. o WHO offers technical support and training, its
came into force in April 7, 1948 (World Health Day) member countries in the fields of maternal and
– headquarters: Geneva, Switzerland child. Control of diseases and environmental
– has 147 country offices, and 6 world regional offices: health services.
o Africa o WHO is involved in monitoring the health situation
o America and assessing health trends.
o Eastern Mediterranean o WHO has developed guidance and tools of
o Europe measurement, monitoring, and evaluation.
o Southeast Asia
o Western Pacific
MILLENNIUM DEVELOPMENT GOALS
– Philippines is a member of the Western Pacific Region.
– established in Millennium Summit of the United Nations in
– objective: attainment by all people of the highest possible level
September 6-8, 2000.
of health.
– world leaders recognize their collective responsibility to uphold
– core functions:
the principles of human dignity, equality and equity at the global
1. Providing leadership on matters critical to health and
level. To uphold these principles is their duty to all the people of
engaging in partnerships where joint action is needed.
the world, especially the most vulnerable and in particular, the
o WHO have 193 member countries and 2
children.
associate members.
1. Eradicate extreme poverty and hunger.
o WHO Country Focus is directed towards
2. Achieve universal primary education.
providing technical collaboration with member
3. Promote gender equality and empower women.
states, in accordance with each country's needs
4. Reduce child mortality.
and capacities.
Targets:
a. Reduce by two-thirds, between 1990 and 2015,
2. Shaping the research agenda and stimulating the
the under-five mortality rate
generation, translation and dissemination of valuable
5. Improve maternal health.
knowledge. WHO strategy on research for health ahs 5
Targets:
goals
a. Reduce by three quarters, between 1990 and
o Capacity: to strengthen national health research
2015, the maternal mortality ratio.
system
b. Achieve universal access to reproductive health.
o Priorities: to focus research on priority health
6. Combat HIV/AIDS, malaria, and other diseases.
needs
Targets:
o Standards: to promote good research practice
a. Have halted by 2015 and begun to reverse the
and enable the greater sharing of research
spread of HIV/AIDS.
evidence, tools, and materials.
b. Achieve, by 2010, universal access to treatment
o Translation: to ensure that quality evidence is
for HIV/AIDS for all those who need it.
turned into products and policy
c. Have halted by 2015 and begun to reverse the
o Organization: to strengthen research culture and
incidence of malaria and other major diseases.
improve the management and coordination of
7. Ensure environmental sustainability.
WHO research activities.
8. Develop a global partnership for development.
3. Setting norms and standards and promoting and
monitoring their implementation
o WHO develops norms and standards for health
and health related issues, such as pharmaceutical
products, vaccines, biological products use in

Community Health Nursing

 PHILIPPINE HEALTH DELIVERY CARE SYSTEM As administration of specific services, DOH is tasked to:
Department of Health • Serve as administrator of selected health facilities at
– main governing body of health services in the country. subnational health levels act as referral centers for local health
– provides guidance and technical assistance to LGUs through systems, that is tertiary and special hospitals, reference
Center for Health Development. laboratories, training centers, centers for health promotion,
disease control and prevention, and regulatory offices.
Provincial Government • Provide specific program components for conditions that
– responsible for administration of provincial and district hospitals. affect large segments of the population.
• Develop strategies for responding to emerging health needs.
Municipal and City Governments • Provide leadership in health emergency preparedness and
– in charge of primary care through RHU or health centers. response services, including referral and networking systems
for trauma, injuries, and catastrophic events.
Satellite outpost (BHS)
– provide health services in the periphery of the municipality or Core Values of the DOH
city. 1. Integrity
• The Department believes in upholding truth and pursuing
RA 7160: Local Government Code honesty, accountability, and consistency in performing its
– mandated the devolution of basic health services. functions.
– LGUs have the autonomy and responsibility to plan and
implement basic health services. 2. Excellence
• DOH continuously strive for the best by fostering
RA 7875: National Health Insurance Act of 1995 innovation, effectiveness, efficiency, dynamism, and
– Created Philippine Health Insurance Corporation (PhilHealth) openness to change.
– A tax-exempt government corporation attached to the DOH for
policy coordination and guidance and aims for universal health 3. Compassion and Respect for Human Dignity
coverage of all Filipino citizens. • DOH upholds quality of life, respect for human dignity is
encouraged by working with sympathy and benevolence
DEPARTMENT OF HEALTH for the people in need.
Department of Health
– national agency mandated to lead the health sector towards 4. Commitment
assuring quality health care for all Filipinos. • the Department commits to achieve its vision for the
– Vision: global leader for attaining better health outcomes, health and development of future generations.
competitive and responsive health care system, and equitable
health financing. 5. Professionalism
– Mission: To guarantee equitable, sustainable and quality health for • DOH performs its functions in accordance with the
all Filipinos, especially the poor, and to lead the quest for excellence highest ethical standards, principles of accountability, and
in health. full responsibility.
– major roles
o Leader in Health 6. Teamwork
o Enabler and Capacity Builder • DOH employees work together with result-oriented
o Administrator of Specific Services mindset.

Leadership role of DOH is specifically elucidated in EO 102 s. of 1999 7. Stewardship of the Health of the People
• Planning and formulating policies of health programs and • Department shall pursue sustainable development and
services. care for environment since it impinges on health of the
• Monitoring and evaluating the implementation of health Filipinos.
programs, projects, research training, and services.
• Advocating for health promotion and healthy lifestyle.
• Serving as technical authority in disease control and
prevention
• Providing administrative and technical leadership in health
care financing and implementing National Health Insurance
Law.

As enabler and capacity builder, DOH performs:

• Providing logistical support to LGUs, private sector, and other
agencies in implementing health programs and services
• Serving as the lead agency in health and medical research
• Protecting standards of excellence in the training and
education of health care providers at all levels of health care
system.

Community Health Nursing

 LEVEL OF HEALTH CARE DELIVERY

DOH AO 2012-0012: Rules and Regulations Governing the New • Without in-patients’ beds (health centers, out-patient clinics,
Classification of Hospitals and Other Health Facilities in the Philippines dental clinics)
– provides a new classification scheme of health facilities • With in-patient beds (short-stay facility where the patients
spend 1-2 days before discharge; infirmaries and birthing
General Hospital facilities)
– provides services for all kinds of illnesses, injuries, or deformities
Category B: Custodial Care Facility
Specialty Hospital • provides long-term care to patients with chronic conditions
– offers services for specific disease, or type of patient (children, requiring ongoing health and nursing care due to impairment
elderly, women) and reduced degree of independence in ADLs and in need
of rehabilitation.
DOH AO 2012-0012 classifies other health facilities as follows: • custodial psychiatric facilities, substance/drug abuse
Category A: Primary Care Facility treatment and rehabilitation centers, sanitaria/leprosaria,
• first contact health care facility that offers basic services nursing homes
(emergency services and provision for normal deliveries)

Community Health Nursing

 Category C: Diagnostic/Therapeutic Facility ▪ exception of the use of sealed radiation sources
• facility for examination of human body, specimens from in radiotherapy as in internal therapy.
human body for diagnosis, water for drinking water analysis.
• covers preanalytical, analytical, postanalytical phases of Category D: Specialized Outpatient Facility
examination. It is further classified into: • performs highly specialized procedures on outpatient basis.
o Laboratory facility: • dialysis, ambulatory surgical clinic, cancer chemotherapeutic
▪ Clinical laboratory ▪ Drug testing laboratory center, cancer radiation facility, physical medicine, and
▪ HIV testing ▪ Newborn screening rehabilitation center
laboratory laboratory
▪ Blood service ▪ Laboratory for Hospitals Other Health Facilities
facility drinking water analysis General Primary Care Facility
o Radiologic facility • Level 1 Custodial Care Facility
▪ X-ray ▪ MRI • Level 2 Diagnostic/Therapeutic Facility
▪ CT scan ▪ UTZ • Level 3 (teaching/training)
▪ Mammography Specialty Specialized Outpatient Facility
o Nuclear medicine facility
▪ Regulated by Philippine Nuclear Facility Research
Institute utilizing applications of radioactive
materials in diagnosis, treatment, medical
research.
Hospitals Level 1 Level 2 Level 3
Clinical Consulting specialist in: Medicine, Level 1 plus: Level 2 plus:
services Pediatrics, Obstetrics-Gynecology, Surgery
for Emergency and outpatient services Departmentalized clinical services Teaching/training with accredited residency
inpatients Respiratory unit training program in 4 major clinical services
Isolation facilities General ICU Physical medicine and rehabilitation unit
Surgical/maternity facilities High-risk pregnancy unit Ambulatory surgical clinic
Dental clinic NICU Dialysis clinic
Ancillary Secondary clinical laboratory Tertiary clinical laboratory Tertiary clinical laboratory with histopathology
services Blood station Blood bank
First-level X-ray Secondary-level X-ray with mobile Third-level X-ray
unit
Pharmacy

RURAL HEALTH UNIT Implementing Rules and Regulations of RA 7305: Magna Carta of
Rural Health Unit Public Health Workers. 1 Rural Health Physician: 20 000 population and
– health center; primary level health facility in the municipality 1 PHN: 10 000 population. Public Health Nurses:
– focus: preventive and promotive health services and supervision • Supervises and guides RHM in municipality.
of BHS • Prepares FHSIS quarterly and annual reports of municipality
– 1 RHU: 20 000 population for submission to PHO.
• Utilizes nursing process in responding to health care needs
Barangay Health Station (needs for health education and promotions)
– fist contact health care facility; satellite station of RHU • Collaborates with members of health team, government
– manned by volunteer BHWs under the supervision of RHM. agencies, private businesses, NGOs, people’s organizations
to address community health problems.
RURAL HEALTH UNIT PERSONNEL
Municipal Health Officer (Rural Health Physician) 1 RHM: 5 000 population, RHM:
– heads the health services at municipal level and carries out: • Manages BHS and supervises and trains BHWs.
• Administrator of RHU • Provides midwifery services and executes health care
o Prepares the municipal health plan and budget. programs and activities for reproductive age (family
o Monitors the implementation of basic health services. planning counseling and services)
o Management of RHU staff • Conducts patient assessment and diagnosis for referral or
• Community Physician further management.
o Conducts epidemiological studies. • Performs health information, education, communication
o Formulates health education campaigns on disease activities.
prevention. • Organizes the community.
o Prepares and implements control measures or • Facilitates barangay health planning and other community
rehabilitation plans. health services.
• Medico-legal officer of the municipality

Community Health Nursing

Rural Sanitation Inspector (RSI) Devolution
– functions: ensuring healthy physical environment in the – act by which national government confers power and authority
municipality by advocating, monitoring, and regulating activities upon LGU to perform specific functions and responsibilities.
(inspection of water supply and unhygienic household conditions).
Local Health Boards
Barangay Health Worker (BHW) • Chairman of the board: Governor/Mayor
– considered the interface between community and RHU. • Vice chairman: Provincial/Municipal/City Health Officer
– trained in preventive health care with emphasis on maternal and • Members: Chairman of the committee on health of
childcare, family planning and reproductive health, nutrition, and Sanggunian, Representative from private sector or NGO
sanitation. involved in health services, DOH representative.
– equipped with basic skills for prevention and management of Functions of Local Health Board
common illness. • Proposing to the Sanggunian annual budgetary allocations for
– assist in providing basic services at the BHS and RHU. the operation and maintenance of health facilities and services
within the province, city, or municipality.
Barangay Health Workers’ Benefit and Incentive Act (RA 7883) • Serve as advisory committee to Sanggunian on health matters.
– entitles BHW to hazard and subsistence allowances and • Creating committees that shall advise local health agencies on
other benefits. various matters related to health service operation.

LOCAL HEALTH BOARDS HEALTH REFERRAL SYSTEM

RA 7160: Local Government Code Referral
– enacted to bring about genuine and meaningful local autonomy. – set of activities undertaken by HCP or facility in response to its
– enable LGU to attain their fullest development as self-reliant inability to provide the necessary health interventions to satisfy a
communities and make effective partners in the attainment of patient’s need.
national goals – ensures continuity and complementation of health and medical
– mandates devolution of services, including health services. services.
– provided the creation of Provincial or Local Health Boards.

Community Health Nursing

Two-way referral system Strategic Thrusts
– when hospital intervention has been completed, patient is Attainment of the goal of UHC is through the pursuit of 3
referred back to the health center. strategic thrusts:
a. Financial risk protection through expansion in NHIP enrollment
Types of Referrals and benefit delivery
1. Internal Referral b. Improved access to quality hospitals and health care facilities
– occurs within the health facility; from one health personnel c. Attainment of the health-related MDGs
to another.
– made to request for an opinion or suggestion, co- To achieve the 3 strategic thrusts, 6 strategic instruments shall
management, or further management of specialty care. be optimized:
1. Health Financing
2. External Referrals – instrument to increase resources for health that will be
– movement of a patient from one health facility to another. effectively allocated and utilized to improve financial protection
It may be vertical (lower to higher level of health facility) or of the poor and vulnerable sectors.
horizontal (similar different catchment areas).
2. Service Delivery
INTER LOCAL HEALTH ZONE – instrument to transform health service delivery structure to
Inter-Local Health Zone address variations in health service utilization and health
– based on the concept of District Health System, an integrated outcomes across socioeconomic variables.
health management and delivery system based on defined
administrative and geographical area 3. Policy, Standards, and Regulation
–.has a defined catchment population within defined geographical – instrument to ensure equitable access to health services,
area. It has a central or core referral hospital and a number of essential medicines, technologies of assured quality, availability,
primary care facilities (RHUs and BHSs). and safety.
– has the following components:
a. People 4. Governance for Health
• ideal population size of health district: 100,000 – – instrument to establish mechanisms for efficiency,
500,000, number of people vary from zone to zone, transparency, and accountability, and prevent opportunities for
taking consideration the number of LGUs that will fraud.
decide to cooperate and cluster.
b. Boundaries 5. Human Resources for Health
• establish accountability and responsibility of health – instrument to ensure that all Filipinos have access to
service providers. professional health care providers the appropriate level of care.
c. Health facilities.
6. Health Information
• RHUs, BHSs, and other health facilities that decide to
work together as an integrated health system and a – instrument to establish a modern information system that
district or provincial hospital, serving as central shall:
referral hospital, make up health facilities of an ILHZ. a. Provide evidence for policy and program development.
d. Health workers. b. Support for immediate and efficient provision of health
care management of province-wide health systems.
• ILHZ health workers include personnel of DOH,
district or provincial hospitals, RHUs, BHSs, private
Public Health Programs
clinics, volunteer health workers from NGOs, and
1. Reproductive and Maternal Health - Pre-pregnancy services
community-based organizations.
and care during pregnancy, delivery, and postpartum period
2. Expanded Garantisadong Pambata (child health)
HEALTH SECTOR REFORM: UNIVERSAL HEALTH CARE a. Advocacy for exclusive breastfeeding in the first 6
Universal Health Care (Aquino Health Agenda) months of life
– launched through AO 2010-0036 b. newborn screening program
– latest in a series of continuing efforts of the government to c. immunization
bring about health sector reforms. d. nutrition services
– built upon strategies of two previous platforms of reform: e. integrated management of childhood illness.
• initial Health Sector Reform Agenda 3. Control of communicable disease
• FOURmula One for health 4. Control of Noncommunicable or Lifestyle Diseases
– planned for implementation until 2016 5. Environmental Health

Goals and Objectives

a. Better health outcomes
b. Sustained health financing, and
c. A responsive health system by ensuring that all Filipinos,
especially the disadvantaged group, have equitable access to
affordable health care.

Community Health Nursing

 NCM 104 & 113: Community Health Nursing

CHAPTER 10: MATERNAL, NEWBORN, AND CHILD

HEALTH AND NUTRITION (MNCHN) MNCHN CORE PACKAGE OF SERVICES
– paradigm shift from risk approach that focuses identifying
MNCHN SITUATION pregnant women at risk of complications to one that considers all
pregnant women at risk of such complications.
Leading cause of maternal deaths:
o Pregnancy complications occurring during labor, delivery, and
A. Pre-pregnancy package
postpartum period.
1. Nutrition
o Hypertension
a. Nutritional counselling
o Postpartum hemorrhage
b. Promotion of use of iodized salt
o Severe infections
c. Provision of micronutrient supplementation
o Medical problems arising from poor birth spacing, maternal
i. Iron and folate: 60 mg elemental iron. 400 ug
malnutrition, unsafe abortion, presence of concurrent
folic acid 1 tab daily for 3 – 6 months
conditions (TB, malaria, STIs, diabetes, hypertension)
ii. Vit. A: 5 000 IU weekly or daily multivitamin
supplement (if Vit. A is not available)
Leading cause of neonatal deaths within 1st week of life:
2. Promotion of healthy lifestyle (advice relative to smoking
o Asphyxia, prematurity, severe infections, congenital anomalies,
cessation, diet, exercise, moderate alcohol intake)
neonatal tetanus
3. Advice on family planning and provision of family planning
services
Delays that lead to maternal and neonatal deaths:
4. Prevention and management of lifestyle-related diseases
o Delay in identification of complications.
5. Prevention and management of infection (deworming of
o Delay in referral.
women of reproductive age; reduce other causes of IDA)
o Delay in management of complications.
6. Counselling on STD/HIV/AIDS, nutrition, personal hygiene,
and consequences of abortion
Likelihood of maternal & neonatal deaths increases with risk factors:
7. Adolescent health services
o Having mistimed, unplanned, unwanted, and unsupported
8. Provision of oral health services
pregnancy
o Not securing adequate care during pregnancy
B. Prenatal Package
o Delivering without skilled birth attendance and not having
1. Prenatal visits
access to emergency obstetric and neonatal care
a. At least four visits throughout the course of pregnancy
o Not having proper postpartum and postnatal care for mother
(1 in 1st and 2nd; at least 2 visits in 3rd trimester)
and newborn.
b. Prenatal assessment (weight & BP monitoring, fundal
height measurement, fetal heartbeat and movement
• FHSIS data are obtained from administrative reports furnished
count, diagnostic exams [CBC, blood typing, urinalysis,
by government hospitals, local government health units.
STIs screening, blood sugar screening, pregnancy test,
• Maternal and Child Health Survey is conducted by NSO annually. cervical cancer screening using acetic acid, Pap smear])
• Family Planning Survey conducted every 5 years. 2. Micronutrient supplementation
• Census of Population and Housing conducted every 10 years. a. Iron & folate (60 mg/400 ug) OD for 6 months or 180
tabs.
MNCHN STRATEGY b. Vit. A: 10 000 IU 2x a week from 4th pregnancy week.
Key Strategies of MNCHN c. Elemental iodine: 200mg given once during pregnancy.
1. Ensuring universal access to and utilization of MNCHN core 3. Tetanus toxoid immunization
package services and interventions directed not to individual a. 0.5 mL of TT given IM on deltoid muscle
women of reproductive age and newborns at different stages
of life cycle. Dose Interval Percent Duration of Protection
2. Establishment of a service delivery network at all levels of care. Protected
3. Organized use of instruments for health systems development TT1 As early as
4. Rapid build-up of institutional capacities of DOH and PhilHealth. possible during
1st pregnancy
TT2 At least 4 80 Infants: protected against
MNCHN aims to achieve the following intermediate results: weeks later neonatal tetanus
1. Every pregnancy is wanted, planned, and supported. Mother: 3-year protection
2. Every pregnancy is adequately managed throughout its course. TT3 At least 6 95 Infants: protected against
3. Every delivery is facility-based and managed by skilled birth months later neonatal tetanus
attendants or skilled health professionals. Mother: 5-year protection
4. Every mother-and-newborn pair secures proper postpartum TT4 At least 1 year 99 Infants: protected against
and newborn care with smooth transition to women’s health later neonatal tetanus
care package for the mother and child survival package for Mother: 10-year protection
the newborn. TT5 At least 1 year 99 Infants: protected against
later neonatal tetanus
Mother: Lifetime protection

Community Health Nursing

 4. Promote exclusive breastfeeding, NBS, infant immunization. E. Newborn (1st Week of Life) Care Package
5. Counseling on healthy lifestyle (focus: smoking cessation, diet 1. Interventions within first 90 minutes
and nutrition, exercise, STI & HIV prevention, and oral health). • Immediate thorough frying
6. Early detection & management of pregnancy complications. o Protect against cold stress and hypothermia.
7. Prevention and management of other conditions: HTN, o Stimulates breathing.
anemia, DM, TB, malaria, schistosomiasis, and STI/HIV/AIDS o Immediate first action for newborns.
8. Birth planning and promotion of facility-based delivery. • Skin-to-skin contact between mother and newborn.
o Provide warmth; opportunity to bond; helps in
Home Based Mother’s Record stabilizing the baby; promotes successful
– simplified record of history of present and past pregnancy breastfeeding by facilitating colostrum feeding;
– provides a mean of promoting continuity of care through plays a part in protection of newborn against
woman’s reproductive life. infection and hypothermia.
• Promotes early recognition of who are at risk of • Cord clamping 1-3 minutes after birth is recommended.
developing conditions (severe anemia, HTN, bleeding, o Allows placental transfusion which increases
moderate to severe edema) blood volume, iron reserves.
• Encourage self-care and referral suited to woman’s needs. o Reduce likelihood of IDA; reduce need for blood
• Initiation of care according to women’s identified needs transfusion in preterm infants & lowers incidence
• Serves as a record of care and information and source of of brain hemorrhage.
health statistics. • Early initiation of breastfeeding (within 1 hour after birth)
• Guides HCP in providing health education needs about risk o Reduce infant deaths attributed to diarrhea and
& care during pregnancy, newborn care, & postpartum. lower RTI.
o Stimulates oxytocin secretion resulting in uterine
C. Childbirth Package contraction.
1. Skilled birth attendant/ skilled health professional- assisted • Non-separation of baby from the mother (rooming-in)
delivery and facility-based deliveries including the use of o Promotes bonding.
partograph. o Allows to breastfeed on demand.
• Strategy: promote facility-based childbirth with skilled 2. Essential newborn care after 90 minutes to 6 hours
health professional attendant • Vit. K prophylaxis
2. Proper management of pregnancy, & delivery & newborn • Hep B and BCG vaccination
complications. • Examination of baby: birth injury, malformation, defects
• DOH, PhilHealth, & WHO recommend EINC (Unang • Additional care for a small baby (< 2 500 g) or twin
Yakap) practices in hospitals & birthing facilities. 3. Care prior to discharge; (after 90 min)
• Recommended EBP: • Support unrestricted, per demand breastfeeding day
o Continuous maternal support. and night.
o Freedom of movement during labor • Ensure warmth of the baby.
o Monitoring progress of labor Kangaroo Mother Care (KMC)
Partograph – meet baby’s needs for warmth, breastfeeding,
– graphic recording of the progress of protection from infection, stimulation, love, and
labor & condition of mother & fetus. safety.
– detect deviations from normal and in • Washing and bathing (hygiene)
early decision-making in referral. • Look for danger signs and start resuscitation, if
o Non-pharmacological pain relief before labor necessary, keep warm, give first doses of IM antibiotics
anesthesia give oxygen.
o Position of choice during labor and delivery • Look for signs of jaundice and infection.
o Spontaneous pushing in semi-upright position
• Perform newborn screening (blood spot) and newborn
o Hand hygiene hearing screening.
o Nonroutine episiotomy
• Provide instruction on discharge.
o Active management of 3rd stage of labor
3. Access to basic emergency obstetric & newborn care
F. Childcare Package
(BEmONC) or comprehensive emergency obstetric &
1. Immunizations
newborn care (CEmONC) services.
2. Nutrition
D. Postpartum Package • Exclusive breastfeeding up to 6 months
1. Postpartum visits: within 72hours and on 7th day postpartum • Sustained breastfeeding up to 24 months with
check for conditions like bleeding or infections complementary feeding
2. Micronutrient supplementation • Micronutrient supplementation
a. Iron & folate (60 mg/400 ug) OD for 3 months or 3. Integrated Management of Childhood Il nesses
90 tabs. 4. Injury prevention
b. Vit. A: 200 000 IU within 4 weeks after delivery 5. Oral health
3. Counseling on nutrition, childcare, family planning & other 6. Insecticide-treated nets for mothers and children in malaria-
available services endemic areas

Community Health Nursing

 – constellation of methods, techniques, and services that contribute
MNCHN SERVICE DELIVERY NETWORK to reproductive health and well-being by preventing and solving
Levels of care in the MNCHN service delivery network: reproductive health problems.
1. Community Level Service Providers (Community Health Team) Republic Act 9710: Magna Carta of Women
– gives primary health care services; include RHUs & BHS – enacted in 2009; in provision for comprehensive health services,
– basic functions due respect shall be accorded to religious conviction, demands of
a. Navigation functions responsible parenthood, & right of women to protection from
• informing about health risk and needs assessment. hazardous drugs, devices, interventions, & substances.
• assist to develop and use health plans.
Republic Act 10354: Responsible Parenthood and Reproductive Health
• facilitate access to critical health services
(emergency transport, communication outreach – State recognizes & guarantees human rights to sustainable
service) and financial sources (PhilHealth) human development, health, education and information, right to
b. Basic Delivery functions choose & make decisions; in accordance with one’s religious
convictions, ethics, cultural beliefs, & demands of responsible
• Advocate for birth spacing & family planning
parenthood.
services.
– directs DOH to procure, distribute to LGUs, and monitor the
• Master listing: pregnant and women of
usage of family planning supplies for the country.
reproductive age, children below 1 year of age
• Early detection and referral of high-risk Reproductive Health Program of the Philippines
pregnancies – adopts life-span approach.
• Report maternal and neonatal deaths. – recognizes reproductive health is a concern that affects different
age brackets.
2. BemONC-capable facility – client will be provided with services they need.
– 6 signal obstetric function
• Parenteral administration of oxytocin in 3rd stage of labor Framework of Philippine Reproductive Health Program: 10 Elements
• Parenteral administration of loading dose of of Reproductive Health Care
anticonvulsant 1. Family planning
• Parenteral administration of initial dose of antibiotics 2. Maternal & child health and nutrition
• Perform assisted deliveries (imminent breech delivery) 3. Prevention & control of RTI, STIs & HIV/AIDS
• Removal of retained products or conception. 4. Adolescent reproductive health
• Manual removal of retained placenta. 5. Prevention & management of abortions & its complications
– able to provide emergency newborn interventions 6. Prevention & management of breast & reproductive tract
• Newborn resuscitation cancers &other gynecological conditions.
• Treatment of neonatal sepsis 7. Education &counseling on sexuality & sexual health
• Oxygen support 8. Men’s reproductive health & involvement
– able to provide blood transfusion services 9. Prevention & management of violence against women &
– can be operated by midwife under supervision by RHU children
physician or has referral arrangements with hospital or doctor 10. Prevention &treatment of infertility and sexual dysfunction
trained in management of maternal and newborn emergencies
– should have at least 1 midwife or nurse with a physician on call. PHILIPPINE FAMILY PLANNING PROGRAM
– 1 BEmONC facility per 125 000 population Family Planning Program
– started in 1970s as family planning service delivery component to
3. CemONC-capable facility achieve fertility reductions.
– can perform – evolve to improving the health of women and children and has
• 6 signal obstetric function been integrated with other RH programs
• Provide cesarean delivery services. Country’s commitment in International Conference in
• Blood banking and transfusion services Population and Development, held in Cairo in 1994, and 4 th
• Other highly specialized obstetric interventions. World Conference on Women, held in Beijing in 1995.
• Capable of providing neonatal emergency interventions
• Management of low birth weight or preterm newborn National Family Planning Policy
• Other specialized newborn services. – articulated through AO 50A, s. 2001, asserts that FP as a health
– 1 CEmONC facility per 500 000 population. intervention made available to men & women of reproductive age.

Family Planning
REPRODUCTIVE HEALTH PROGRAM – means to prevent high- risk pregnancies brought about by the
Reproductive Health following conditions:
– based on the right to access to appropriate health care services 1. Being too young (< 18) or too old (> 34)
that enable women to go safely through pregnancy and childbirth 2. Having had too many (4 or more) pregnancies
and provide couples with best chance of having healthy infants. 3. Having closely spaced pregnancies (<36 months)
4. Being too ill or unhealthy or having an existing disease
Reproductive Health Care
Administrative Order 132, s 2004

Community Health Nursing

 – created DOH-National Family Planning (NFP) Program
– in recognition of modern NFP methods subjected to extensive
testing to ascertain its efficacy and scientific validity.
BENEFITS OF FAMILY PLANNING
Administrative Order 2012-2009
a. Benefits to mothers
– national strategy to reduce unmet need for modern family
planning as a means of achieving MDGs in maternal health • Enables her to regain her health after delivery.
emphasized the implementation of FP program integrated and • Gives enough time and opportunity to love and provide
synchronized with other public health programs like Maternal attention to her husband and children.
Newborn and Child Health Program and Garantisadong Pambata in • Give more time for her family & own personal advancement.
the broader context of Kalusugan Pangkahalatan Execution Plan. • When suffering from an illness, gives enough time for
– pushed for the enrollment of poor families into the National treatment and recovery.
Health Insurance Program and education on the use of PhilHealth
benefits for FP. b. Benefits to children
• Healthy mothers produce health children.
4 PILLARS OF PFPP (GUIDING PRINCIPLES OF FPP) • Will get all the attention, security, love and care they deserve.
1. Responsible parenthood
– will and ability to respond to family’s needs and aspirations. c. Benefits to fathers
– promotes freedom of responsible parents to decide the timing • Lightens the burden and responsible in supporting his family.
and size of their family in pursuit of better life. • Enables him to give his children their basic needs.
• Gives him time for his family and own personal advancement.
2. Respect for life • When suffering from an illness, gives enough time for
– 1987 Constitution protects the life of the unborn from the treatment and recovery.
moment of conception.
– FP aims to prevent abortions, saving lives of women & children. NATURAL FAMILY PLANNING
Natural Family Planning
3. Birth spacing – WHO: methods for planning and avoiding pregnancies by
– proper spacing: 3-5 years from a recent pregnancy to recover observation of natural signs and symptoms of the fertile and
from pregnancy and improve her well-being, health of child, and infertile phase of menstrual cycle.
relationship between spouse and between parents and children. • Modern Natural Family Planning: LAM and FAB methods
• Traditional methods of withdrawal and calendar/rhythm
4. Informed choice method are no longer recommended, found to be
– couples decide and choose methods based on informed choice ineffective and not evidence based.
and to exercise responsible parenthood in accordance with their
religious ethical values and cultural background, subject to Advantages of Natural Family Planning
conformity with universally recognized international human rights. • Effective when used correctly.
• No physical side effects.
CLIENT COUNSELING AND ASSESSMENT • Inexpensive since it does not involve surgery of the use of
Family Planning Counseling medications or supplies.
– client centered, face to face, interactive communication between • No need for follow-up medical appointment.
health service provider and client to make free and informed • Develops better understanding on sexual physiology &
choices about one’s fertility intention. reproductive function.
– enables client to know more about the benefits, advantages, and • Promotes shared responsibility for family planning.
disadvantages of different FP methods and what to do if problems • Fosters better communication between spouses,
develop. strengthening marriage and family.
• May utilize signs and symptoms of woman’s fertility to either
Family Planning Counselor avoid or achieve pregnancy based on their decision.
– must:
a. possess knowledge about the client, their needs, and the 1. Lactation Amenorrhea Method (LAM)
different FP methods. – based on natural effect of breastfeeding on mother’s fertility,
b. have positive attitude towards work. there is delay in return of fertility after childbirth.
c. be sensitive, understanding, and helpful. – secretion of GnRH by hypothalamus, inhibit pituitary secretion
– role nurses assume as provider of community health services. of gonadotropin and development of ovarian follicle. End effect:
low estrogen level in blood and transient infertility.
Essential content of nurse-client interaction about chosen method: – encourages best breastfeeding practice.
1. Effectiveness
2. Advantages and disadvantages Breastfeeding is 98-99.5% effective for birth spacing if all the
3. Possible side effects, complications & signs that require an following criteria are met:
immediate visit to health facility. a. Mother’s menstrual period has not returned.
4. How to use the chosen method b. Full (100%) or nearly dull (85%) feeding of the baby with
5. Prevention of STIs breast milk.
6. When to return to the health facility c. Baby is less than 6 months.

Community Health Nursing

2. Fertility Based Awareness Methods
– based on scientific analysis of fertile time in menstrual cycle. 3. Changing pattern of Fertility
– involves recognition of physiologic markers indicating woman’s – vaginal discharge becomes thinner and clearer.
fertility. – there is sensation of being wet and slippery.
– feeling of fullness or swelling of the tissue of vulva.
2a. Billings’ Ovulation Method (BOM) (Cervical Mucus Method) – last day is the peak of the fertility.
– developed by Drs. John and Evelyn Billings
– fertility management based on cervical mucus, body’s sign 4. Peak of Fertility
of fertility. – last of slippery sensation.
– applicable to women in all stages of reproductive life, with – day after the peak if fertility, confirmed by loss of
irregular menstrual cycles, perimenopausal women and slippery sensation the next day.
nursing mothers
– effectiveness: 95 – 97% in preventing pregnancies. 5. Postovulatory Infertile Phase
– requires observing and record phases in menstrual cycle: – last for about 14 days.
1. Menstruation – woman may feel dry again or have some
discharges, no slippery sensation.
2. Basic Infertile Pattern (BIP) – phase before start of menstruation.
– observed after menstruation.
– woman feels dry around genital area and does not To avoid pregnancy, they must follow 4 rules of BOM:
have vaginal discharge or have unchanging pattern 1. Avoid intercourse on menstrual days.
of vaginal discharge. 2. During BIP period, they may intercourse every other evening
– has no fixed number of days. to allow for observation of passage of fertile mucus.
3. Avoid intercourse during days of changing pattern of fertility
until 4th day after the peak.

Community Health Nursing

 4. May have intercourse at any time after 4th day after the
peak until next menstruation.

2b. Basal Body Temperature (BBT)

– influenced by illness, stress, changes in sleep pattern and
intake of alcohol
– least effective NFP method.
– better used in combination with symptothermal method.
– one’s body temperature when one is fully at rest, that is,
upon rising from sleep and before eating.
– at ovulation, BBT goes down slightly around 0.3°C (surge of
LH) followed by rise in temperature not higher than normal
(secretion of progesterone by corpus luteum) maintained over
a period of several days until the next menstruation.

If chosen for fertility regulation, following instructions are given:

a. Take BBT every morning before arising using same digital oral
thermometer, have at least 3 hours of continuous sleep.
b. Record daily BBT and look for a pattern.
Slight increase (< 0.5°C) sustained for 3 days or more
indicates ovulation has taken place and may be fertile. 2e. Two-Day Method
c. Most fertile 2-3 days before BBT rises. – uses cervical secretions as an indicator of fertility.
To avoid pregnancy, abstain from start of – requires checking presence of secretion every day.
menstruation up to 3-4 days after BBT rises. – if the woman notices any secretion the day or the day
before, she should consider herself fertile and avoid intercourse
2c. Symptothermal Method on those days.
– all signs of fertility are taken note of (racking cervical mucus,
BBT) other signs of ovulation are observed such as: Disadvantages of FAB
a. Mittleschmerz • .Except SDM, couple needs training and time to use the
– one sided, lower abdominal pain occurs around the method effectively. It takes about two to three cycles to
time of ovulation. accurately identify the fertile period.
b. Spinnbarkeit • .Except SDM, require consistent & accurate record keeping.
– cervical mucus capacity to stretch before breaking.
• Require high level of diligence and motivation by the couple.
c. Breast tenderness
• Require periods of abstinence from intercourse which may be
d. Increase libido
difficult for some couples.
e. Mood changes (depression and mood swings)
• Offer no protection against STIs/HIV/AIDS
2d. Standard Days Method (SDM)
– appropriate for couple where her menstrual cycle lasts from ARTIFICIAL FAMILY PLANNING METHODS
26 -32 days. 1. Combined Oral Contraceptives (COCs) (pills)
– 1st day of menstruation is counted as Day 1. Days 8 through 19 – contain hormones (estrogen and progesterone)
are notes as fertile days when the couple abstain from – prevent conception mainly by suppressing ovulation.
intercourse if they want to avoid pregnancy. – cause changes in endometrium and thicken cervical mucus
– a necklace, SDM beads, is used as memory aid for woman. making sperm transport inside the uterus difficult or unfavorable.
– effectiveness: 95%, with typical use, it is 88%.
Advantages
• Convenient and easy to use.
• Makes menstrual cycle more regular and predictable.
• Reduce symptoms of gynecologic conditions (dysmenorrhea
and endometriosis).
• Reduces risk of ovarian and endometrial cancer.
• Reversible, rapid return to fertility.
• Does not interfere with intercourse.
• Safe as proven

Disadvantages
• Effectiveness is lowered with incorrect use and intake of
some drugs (rifampicin and most anticonvulsant).
• Can suppress lactation.
• Requires regular resupply.
• Offers no protection against STIs, including HIV .
• Has side effects: nausea, dizziness, or breast tenderness.

Community Health Nursing

 • May pose health risk for some women. • < 6 weeks postpartum
o Increased risk of cardiovascular disease (blood clots, • History of and current ischemic heart disease or stroke
heart attack, stroke) • Smoking 15 or more cigarettes per day in woman aged 35.
o Increased risk of benign liver tumors • Raised BP (> 160/ >100 mmHg)
o Slightly higher risk of breast cancer • DM with vascular complications of > 20 years of duration
o Long term use (≥ 5 years): increased risk of cervical • DVT
cancer (sexually active women have higher risk of • Breast cancer within the past 5 years
being infected with HPV, which causes cervical cancer)
• Liver conditions: active viral hepatitis, benign or malignant
liver tumor, decompensated cirrhosis
Contraindications
• Breastfeeding

2. Depot Medroxyprogesterone Acetate – almost all IUDs have 1 or 2 strings that hang through cervical
– known by its brand name Depo–Provera, is a progesterone- opening into the vagina.
only preparation injected IM q3 months. – types of IUD: hormone releasing and copper-bearing IUD
– hormone is released then slowly into the blood stream – effectiveness: 99% (copper-bearing IUD)
– main action: suppression of ovulation, but it also changes the – optimum time for IUD insertion: while having menstrual
cervical mucus and endometrial lining. bleeding
– effectiveness: 99% with perfect use; 97% with typical use – optimum time for IUD insertion (after childbirth): 48 hours after
NSD and 8 week after CS delivery.
Advantages
• Does not interfere with intercourse.
• Can be used while breastfeeding a baby 6 months and older. Advantages
• May help protect against endometrial cancer, PID, and IDA. • Local action
• Has no effect on amount or quality of breast milk.
Disadvantages • Low cost
• Delayed return to fertility for about 1-4 months after use. • Does not interfere with sexual intercourse.
• Irregular vaginal bleeding is common. • One time application.
• Gradual weight gain. • Immediate return to fertility upon removal.
• Does not protect against STIs. • Can be inserted immediately after childbirth or after abortion
and can be removed by trained provider.
Contraindications • Long-lasting: copper-bearing IUD lasts for 10 years or more.
• Liver conditions: liver cirrhosis, hepatitis, tumor
• HTN (> 160/ >100 mmHg) Disadvantages
• DM with vascular complications of > 20 years of duration • Has common side effects: pain, cramping, longer and heavier
• Cardiovascular problems (stroke, M) menstrual bleeding and irregularities.
• DVT • Device may be expelled, possibly without knowing it.
• History of Brast Cancer • Requires pelvic exam before insertion/removal of IUD.
• Does not protect against STIs and increase incidence of PID .
3. Intrauterine Device (IUD) • Possible uterine perforation (occurs at time of insertion).
– small plastic or metal device inserted inside a woman’s uterus • Requires self-checking of IUD strings from time to time.
to prevent pregnancy.
– releases copper or hormone. 4. Barrier methods

Community Health Nursing

 – involves use of devices that mechanically or chemically prevent • Scrotal hematoma
fertilization. • Wound infection
– devices includes: • Epididymitis
• Male condoms • Sperm granuloma, caused by leakage of sperm from
• Diaphragms cut ends of vas causing inflammation.
• Cervical caps
• Spermicide 5b. Bilateral Tubal Ligation (BTL)
– effectiveness: 70% (cervical caps & spermicides) to 85% – involves cutting or blocking 2 fallopian tubes.
(male condoms) – standard procedure: mini-laparotomy under local
– generally easy to use, except for diaphragm & cervical cap anesthesia and light sedation
(require pelvic manipulation) – prevents conception by blocking the passage of the
– cannot be used if allergic to latex rubber (condoms, ovum through fallopian tube, preventing fertilization.
diaphragms, cervical caps) or to spermicide ingredients – can be performed immediately after giving birth or after
– diaphragm & cervical cap: left in place for 6 hours after abortion.
ejaculation. – kept NPO for 4 hours
– not removing diaphragm for > 24 hours and the cervical cap – involves risks: infection, bleeding at the incision site, injury
for > 48 hours may result in toxic shock syndrome. to internal organs and anesthesia risk.
– rarely, ectopic pregnancy may result after a BTL.

NEWBORN SCREENING
5. Permanent Methods – procedure to find out if a baby has congenital metabolic disorder
5a. Vasectomy that may lead to mental retardation or death.
– surgical procedure where vas deferens is tied and cut – ideally done on 48th – 72nd hours of life; may be done after 24
or blocked through a small opening on scrotal skin, hours from birth but not later than 3 days from delivery of
resulting in absence of sperm in seminal fluid. newborn.
– done either through a traditional/incisional vasectomy – newborns who need intensive care may be exempted from the
small incision is done in scrotal skin using scalpel or 3-day requirement but must be tested by 7 days of age
through non-scalpel vasectomy (NSV),
NSV: puncture wound using vas dissecting Republic Act 9288: Newborn Screening Act of 2004
forceps is made at the midline of scrotal skin to reach – prior to delivery, health practitioner who delivers or assists in
both vas on either side. delivery of newborn has the obligation to inform the parents or
– NSV: procedure of choice in the country. legal guardian of the availability, nature, and benefits of NBS.
– effectiveness: 100% 3 months after the procedure – copy of refusal document shall be made part of the newborn’s
(seminal fluid no longer contains sperms) medical record. It shall also be indicated in national NBS database.

Possible complications
Disorders Definition Long term Effects
Congenital Hypothyroidism • Inability to produce thyroid hormone • Severe Mental Retardation
Congenital Adrenal • Inability of adrenal gland to secrete cortisol or aldosterone, or both. • Death
Hyperplasia
Galactosemia • Unable to metabolize galactose & unable to tolerate any form of milk. • Death
• Cataracts
Phenylketonuria • Inability to properly break down phenylalanine (amino acid) • Severe Mental Retardation
Glucose-6 phosphate • RBCs break down when the body is exposed to certain drugs, food, • Severe Anemia
dehydrogenase (G6PD severe stress, or severe infection. • Kernicterus
Deficiency)
Maple Syrup Urine • Genetic defect • Death
Disease • Unable to break down leucine, isoleucine, and valine.
• Urine of affected person smells like maple syrup

NEWBORN SCREENING PROCEDURE • If there is no specialist in the area, NBS Secretariat office
– specimen for NBS is obtained through heel prick, blotted on a will assist the baby’s attending physician.
special absorbent filter card and then sent to NSC.
– blood sample may be obtained by doctors, nurses, medical Newborn Screening Reference Center (NSRC)
technologist, trained midwife. – responsible for national testing database and case registries,
– available in hospitals, lying-in clinics, RHUs, health centers, some training, technical assistance, & CE for laboratory staff.
private clinics. – located at the following sites:
• Normal (Negative) NBS results are available by 7 – 14 1. NSC-NIH for NCR and Luzon: National Institute of Health,
working days from the time samples are received at NSC. University of the Philippines Manila, Pedro Gil St., Ermita,
• Positive results are relayed to the parent immediately by Manila
the health facility.

Community Health Nursing

 2. NSC-Central Luzon for Region I, I , I I and CAR: Angeles – repealed Presidential Decree 996.
University Foundation Medical Center, Angeles City.
3. NSC-Visayas: West Visayas State University Medical Center, 2. Republic Act 7846
Iloilo City – provided for compulsory immunization against hepatitis b
4. NSC-Mindanao: Southern Philippines Medical Center, Davao for infants and children below 8 years old.
City – provided for Hepatitis B immunization within 24 hours after
5. NSC-Southern Luzon: Daniel Mercado Medical Center, birth of babies of women with Hepatitis B.
Tanauan City, Batangas – specific goals of the program:
6. NSC-Northern Luzon: Mariano Marcos Memorial Hospital • To immunize all infants/children against most
and Medical Center, Batac City, Ilocos Norte common vaccine-preventable diseases
7. NSC-Central Visayas: Eversley Child Sanitarium and General • To sustain polio-free status of the Philippines
Hospital, Cebu City • To eliminate measles infection.
o PP No. 4, s. 1998: launched the Philippine
NEWBORN HEARING SCREENING Measles Elimination Campaign
Republic Act 9709: Universal Newborn Hearing Screening and • To eliminate maternal and neonatal tetanus.
Intervention Act of 2009 o PP No. 1066, s. 1997: declared nation
– established Universal Newborn Hearing Screening Program for neonatal tetanus elimination campaign.
early detection of congenital hearing loss and referral for early • To control diphtheria, pertussis, hepatitis B, and
intervention services to infants with hearing loss. German measles.
– established Newborn Hearing Screening Reference Center at • To prevent extrapulmonary TB among children.
NIH
EXPANDED PROGRAM ON IMMUNIZATION (EPI) IMMUNIZATION SCHEDULE FOR INFANTS AND YOUNG
– established in 1976, to ensure that infant/children and mothers have CHILDREN
access to routinely recommended vaccines. • Immunization: health intervention for eligible children and women
– 6 vaccine preventable diseases were initially included.
and available in all health facilities providing health services for
• TB • Diphtheria • Pertussis women and children nationwide.
• Poliomyelitis • Tetanus • Measles • Wednesday: designated immunization day in government health
facilities unless revised by local traditions, customs, and other
LAWS RELATED TO EPI exception.
1. Republic Act 10152: Mandatory Infant and Children Health • 2012: 2 new vaccines were introduced as part of EPI: Rotavirus
Immunization Act of 2011 and Hib vaccine.
– mandates basic immunization covering the vaccine- o Rotavirus infects the large intestine, most common cause
preventable diseases. of severe diarrhea in infants and children. 6 – 24 months
– added to the 6 vaccine preventable diseases are Hepatitis are at greatest risk for developing Rotavirus.
B, mumps, rubella, diseases caused by Haemophilus o Hib can cause meningitis and pneumonia, with almost all
influenzae type B cases younger than 5 years, with those between 4 and 18
– gives directive to government hospitals and health centers months vulnerable.
to provide for free mandatory basic immunization to infants
and children below 5 years old.
Antigen Age Dose Route Site
1. BCG vaccine At birth 0.05 mL IM Right deltoid region
2. Hepatitis B vaccine At birth 0.5 mL IM Anterolateral thigh muscle
3. DPT-HepB-Hib vaccine 6 weeks; 10 weeks; 14 weeks 0.5 mL IM Anterolateral thigh muscle
4. OPV 6 weeks; 10 weeks; 14 weeks 2 drops PO Mouth
5. IPV 4 weeks 0.5 mL IM Outer part of the upper arm
6. AMV 9 – 12 months 0.5 mL SQ Outer part of the upper arm
7. MMR vaccine 12 – 15 months 0.5 mL SQ Outer part of the upper arm
8. Rotavirus vaccine 6 weeks; 10 week 0.5 mL PO Mouth
9. PCV 6 weeks; 10 weeks; 14 weeks 0.5 mL IM Outer part of the upper arm

The following are important consideration related to the • Recommended sequence of coadministration of vaccine: OPV
schedule and manner of administering infant immunizations: then Rotavirus vaccine then other appropriate vaccines.
• Use only one sterile syringe and needle per client. • OPV administration: putting drops of vaccine straight from
• No need to restart vaccination series regardless of time dropper onto child’s tongue.
elapsed between doses. o Do not let the dropper touch the tongue.
• EPI antigens are safe and effective, can administered • Monovalent Hepatitis B vaccine must be used for birth dose.
simultaneously but at different sites. Pentavalent must not be used at birth (DPT & Hib vaccine
o > 1 injection given on same limb: injection sites should should not be given at birth).
be 2.5 – 5 cm apart to prevent overlapping of local o Monovalent – contains antigen against 1 disease.
reactions.

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 o Hepatitis B vaccine: given 24 hours after birth • Administer Rotavirus vaccine slowly down 1 side of the mouth
with a mother that is positive with Hepatitis B. If (between cheek and gum) with tip of the applicator directed
not, given at baby’s 6 weeks of age. toward the back of infant’s mouth. To prevent spitting of
o Pentavalent – contains antigens in 5 diseases. 5 vaccine, stimulate rooting and sucking reflex of young infant.
in 1 vaccine. Diphtheria, Tetanus, Hepatitis B, For 5 months older, slightly stroke the throat downward to
Hemophiles influenza type B, whooping cough. It stimulate swallowing.
can be given after 6 weeks, 2nd dose is given
at 10 weeks, & 3rd dose is given at 14 weeks.
• Child who does not received AMV1 as scheduled or caregivers
do not know whether the child have received AMV1 shall be EPI VACCINES
given AMV1 as soon as possible then AMV2, 1 month after. • Preparations used in EPI: inactivated (killed) microorganism,
• Children entering day care centers/preschool and Grade I shall attenuated microorganism, fragments from microorganism
be screened for measles immunizations. Without immunization or toxoids.
shall be referred to a health facility for immunization. • Attenuated vaccines: live microorganism that are altered
• 1st dose of Rotavirus vaccine is administered only to infants aged and no longer pathogenic but still antigenic.
6 weeks to 15 weeks. 2nd dose is given at aged 10 – 32 weeks. • Toxoids: inactivated or altered bacterial exotoxins.

Vaccine Contents Form

Bacillus Calmette-Guerin Live, attenuated bacteria Freeze-dried, reconstituted with special diluent
Hepatitis B vaccine RNA-recombinant, using Hepatitis B Cloudy, liquid in an auto-disable injection syringe, if available
surface antigen (HBs Ag)
DPT-HepB-Hib (Pentavalent Diphtheria toxoid Liquid in an auto-disable injection syringe
vaccine) Inactivated pertussis bacteria
Recombinant DNA surface antigen
Synthetic conjugate of Haemophilus
influenza B bacilli
OPV Live, attenuated virus Clear, pinkish liquid
Anti-Measles vaccine Live, attenuated virus Freeze-dried, reconstituted with special diluent
Measles, mumps, rubella vaccine Live, attenuated viruses Freeze-dried, reconstituted with special diluent
Rotavirus vaccine Live, attenuated virus Clear, colorless liquid, in a container with an oral applicator.
Tetanus toxoid Weakened toxoid Clear, colorless liquid, sometimes slightly turbid.

TARGET SETTINGS AND VACCINE REQUIREMENTS • Formulas to Estimate Eligible Population:

• 1st specific goal of EPI: indicates a target of 100% immunization o Estimated no. of infant = total population x 2.7%
of infants/children against most common vaccine-preventable o Estimated no. 12–59-month-old children = total population
diseases. x 10.8%
• PHN: responsible for preparing vaccine requirements and o Estimated no. of pregnant women = total population x
overseeing vaccine allocation. 3.5%

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 NCM 104 & 113: Community Health Nursing

MAINTAINING THE POTENCY OF EPI VACCINES o Stored in freezer.

• Vaccines confer immunity when they are potent and to retain o In vaccine bag: placed in contact with cold packs.
potency, it must be properly stored, handled, & transported. • MMR, & Rotavirus Vaccine:
o stored in refrigerator at +2 to +8 °C.
MAINTAIN THE COLD CHAIN o stocked neatly on refrigerator shelves.
o do not stock at the refrigerator door shelves.
Cold chain
– system for ensuring vaccine potency from manufacture time to • Hepatitis B vaccine, Pentavalent vaccine, Rotavirus vaccine, &
the time given to eligible client. TT:
o damaged by freezing.
Cold Chain Officer o wrap the containers of the vaccines with paper before
– responsible for cold chain management at each level putting them in vaccine bag with cold packs.
– RHU/health center: PHN acts as the Cold Chain Officer. • Diluents: storing them in lower or door refrigerator shelves.
• in charge of maintaining cold chain equipment and supplies
(freezer/refrigerator, transport box, vaccine bag/carriers, COLD CHAIN PRINCIPLES
cold chain monitors, thermometers, and cold packs.) System to maintain vaccine potency.
• implements emergency plan in the event of electrical • Regional level – 6 months
breakdown or power failure. • District level – 3 months
• Municipal level – 1 month
Cold chain requirements. • Transport boxes – 5 days.
• OPV
o -15 to -25 °C. REFRIGERATOR AND TEMPERATURE LOG

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• Monitor temperature twice a day: Early Morning & Late • Abide open vial policy.
Afternoon o Multidose vial may be opened for 1 – 2 clients if client
• Freezer cannot come back for the next immunization schedule.
o -15 to -25 °Celsius o Multidose liquid vaccines: OPV, Penta, HepB and TT
o -20 °Celsius – maintenance taken following standard sterile procedure, may be used
o Measles, OPV, MMR in the next immunization schedule up to maximum of 4
• Body weeks if all the following conditions are met:
o +2 to +8 °Celsius ▪ Expiry date has not passed.
o +5 average temperature ▪ Vaccine has not been contaminated.
• Defrost freezer 1 inch or 2-3cm ice build-up. ▪ Vials have been stored under appropriate cold
• Distance of refrigerator to wall – 12 inches/ 1 ft. chain conditions.
• Bottles of water – place at the bottom of the refrigerator ▪ Vaccine vial septum: not submerged in water.
• Avoid frequent door opening. ▪ VVM: do not reached the discard point.
• Avoid medication and food inside. • Reconstitute freeze-dried vaccines (BCG , AMV & MMR) only
with the diluents supplied with them.
• Most sensitive to heat: placed in the freezer (-15 to -25 °C)
o Oral Polio Virus (OPV) • Discard reconstituted free-dried vaccines 6 hours after
o Measles reconstitution or at the end of the immunization session,
o MMR whichever comes sooner.
• Least sensitive to heat - placed at the body of refrigerator • Protect bacille Calmette-Guerin (BCG) from sunlight.
(+2 to +8 °C)
o DPT/Penta
o Hep B
o bacille Calmette-Guerin
o Tetanus Toxoid

OTHER CONSIDERATIONS TO MAINTAIN POTENCY

• Observe first expiry-first out (FEFO) policy; return vials in
refrigerator twice only.
o 1st exposure – mark “X”
o 2nd exposure – mark “XX”
o 3rd exposure – discard
• Comply with recommended duration of storage and transport.
o Health center/RHU: do not exceed 1 month.
o Transport boxes: kept only up to max of 5 days.
• Take note if vaccine container has a vaccine vial monitor
(VVM) and act accordingly.
o VVM: round disc of heat-sensitive material placed on a
vaccine vial to register cumulative heat exposure (the
slower the temperature, the slower the color change)
IMMUNIZATION: SIDE EFFECTS & ADVERSE REACTIONS
• BCG injection results in the formation of a wheal that disappears within 30 minutes. After 2 weeks, small red tender swelling appears at
injection site, which may develop into small abscess which ulcerates. The ulcer heals by itself and leaves a scar. Whole course of vaccination
to formation of scar takes about 12 weeks (expected response and does not require management)

Vaccines Side Effects Management

BCG Koch’s phenomenon: acute inflammatory reaction within 2 -4 No management needed
days after vaccination. It indicates previous exposure to
tuberculosis.
Deep abscess at vaccination site; invariably due to Refer to physician for incision and drainage
subcutaneous or deeper injection
Indolent ulceration (ulcer that persist after 12 weeks from Treat with INH powder
vaccination date)
Glandular enlargement (enlargement of lymph glands draining If suppuration occurs, treat as deep abscess
the injection site)
Hepatitis B Local soreness at injection site No treatment necessary
DPT-HepB- Fever that last for 1 day. Fever beyond 24 hours is not due Advise to give antipyretic
Hib to the vaccine but to other causes.
(Pentavalent Reassure parents & instruct to give antipyretic Reassure parents that soreness will disappear after 3 -4 days
vaccine) Abscess after a week or more indicates that the injection Incision and drainage may be necessary
was not deep enough, or the needle was not sterile.

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 Convulsions may occur in children > 3 months caused by Proper management of convulsions; pertussis vaccine should
pertussis vaccine not be given anymore
OPV None
AMV Fever 5 – 7 days after vaccination; mild rash Reassure parents & instruct to give antipyretic
MMR Local soreness, fever, irritability, and malaise Reassure parents & instruct to give antipyretic
Rotavirus Some develop mild vomiting and diarrhea, fever, and irritability Reassure parents & instruct to give antipyretic & Oresol
TT Local soreness at injection site Apply cold compress, no other treatment needed.

Principles • at least 3 doses of TT any time prior to pregnancy with

• Measles vaccine: when given at 9 months provide 85% this child
protection against measles infection. When given at 1 year
and older provides 95% protection INFANT AND YOUNG CHILD FEEDING
• Moderate fever, malnutrition, mild respiratory infection, Legislative Efforts:
cough, diarrhea, and vomiting are not contraindications to Executive Order No. 51: Milk Code
vaccination. Generally, one should immunize unless the child – prohibits advertising, promotion or other marketing materials
is so sick that he needs to be hospitalized. that imply or create a belief that bottle feeding is equivalent or
• Giving dose of vaccine less than 4 weeks interval may superior to breastfeeding.
lessen antibody response. Lengthening interval between
doses of vaccine leads to higher antibody levels. Executive Order No. 382
• False contraindications to immunization: malnutrition, low – observance of National Food Fortification Day on November 7.
grade fever, mild respiratory infection and diarrhea should – fortification involves addition of nutrients to food. It is the
not be considered a contraindication to OPV vaccination. improving of the nutritional status of population.
o Children with diarrhea who are due for OPV should
receive a dose, but the dose is not counted and Republic Act 7600: Rooming-in and Breastfeeding Act
should return when the next dose is due. – promotes bonding between the mother and the baby.
• Repeat BCG vaccination if the child does not develop a – newborn infants must be put to the breast of mother
scar after the 1st injection. immediately after birth and roomed-in within 30 minutes after
NSD and within 3 - 4 hours after birth by Caesarian delivery.
CONTAINDICATIONS TO IMMUNIZATIONS
Do not give: Republic Act 8172: ASIN Law (Act for Salt Iodization Nationwide).
• Pentavalent vaccine/DPT to children over 5 years of age. – requires producers of food-grade salt to iodize the salt that
• Pentavalent vaccine/DPT to a child with recurrent they produce, import, trade or distribute.
convulsions or active neurological disease of the CNS
• Pentavalent vaccine 2 or 3/DPT 2 or 3 to a child who had Republic Act 8976: Philippine Food Fortification Act
– mandates fortification of rice with iron, wheat flour with Vitamin
convulsions or shock within 3 days of the most recent
dose. A and iron, refined sugar with Vitamin A and cooking oil with
o Vaccines containing whole cell pertussis component Vitamin A.
should not be given to a child with evolving – promotes fortification of food products through Sangkap Pinoy
neurological disease. Seal Program.
• Rotavirus when the child has a history of hypersensitivity to
Republic Act 10028: Expanded Breastfeeding Promotion Act
previous dose, intussusception, intestinal malformation,
– mandates setting up of lactation stations in all health and non-
acute gastroenteritis.
health facilities, establishments, or institutions.
• Live vaccines like BCG to a child who has signs and
– grant break intervals for nursing employees to breastfeed or
symptoms of AIDS or other immune deficiency conditions,
express milk (Breastfeeding Area).
immunosuppressed. or irradiation (exposure of radiation)
Administrative Order. 36, s2010: Garantisadong Pambata
EPI RECORDING AND REPORTING – comprehensive & integrated package of services and
EPI recording and reporting are accomplished using FSHIS communication on health, nutrition, and environment for children
available every day at various setting.
Fully Immunized Child/dren (FIC)
– given BCG, 3 doses of OPV, 3 doses of DPT and HepB or 3 NUTRITIONAL ASSESSMENT
doses of Penta and 1 dose of AMV before reaching 1 year old.
1. History taking
• Dietary and health history
Completely Immunized Child/dren
– completed their immunization schedule at the age of 12-23 • Recent episode of infection (measles)
months.
2. Terms:
a. Exclusive Breastfeeding
Child protected at birth (CPAB)
– a child whose mother has received – infant receives breastmilk including expressed breastmilk
and allows infant to receive oral rehydration salt, drops,
• 2 doses of TT during this pregnancy provided that the
syrups (vitamins, minerals, medicines) but nothing else.
second dose was given at least a month prior to delivery
b. Predominant Feeding

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 – infant’s predominant source of nourishment has been 3b. Length/ height for age
breastmilk – attained growth in length or height in relation to
– have received liquids, water and water-based drinks, fruit child’s age at a given time
juice, ritual fluids, ORS, and syrups – to determine those who are short/ stunted

c. Bottle Feeding 3c. Mid-upper Arm Circumference (MUAC)

– child is given food/ drink including breastmilk from a – used for rapid screening for malnutrition to identify
bottle with a nipple/teat. children who need referral for further assessment/
treatment.
d. Early Initiation of Breastfeeding – below 115 mm: severe malnutrition in children aged
– initiation of breastfeeding of newborn after birth within 6-59 months
90 minutes in accordance with essential newborn protocol. – always taken on left arm.

3. Anthropometry To measure MUAC:

– measurement of physical dimensions and gross composition of • Find the midpoint between top of the shoulder
the body and tip of the elbow while the left arm is bent.
– used to determine nutritional status include: • Wrap a measuring tape around the upper arm
at the level of the midpoint.
3a. Weight for age • Read the MUAC while the arm is hanging down
– reflects body weight relative to the child’s age the side of the body and relaxed.
– used to determine underweight

3d. Clinical Examination • Early initiation of breastfeeding

– recognize signs of malnutrition (micronutrient • Exclusive for the first 6 months of life
deficiency) • Extend breastfeeding up to two years and beyond.
– data from PA (eye exam, history taking) • Complementary feeding with the use of locally available and
– useful in detecting micronutrient deficiencies and culturally acceptable foods.
sever forms of malnutrition. • Food fortification
• Micronutrient supplementation
3e. Biochemical Examination o Diet Diversification is added to its strategy
– assessment of specific components of blood or urine
• Universal salt iodization
samples of an individual in order to measure specific
aspects of one’s metabolism.
• blood test- serum retinol determination
(detect and determine severity of VAD)
BENEFITS OF BREASTFEEDING
To Infants
• hemoglobin determination (determination of
IDA). • Provides all nutrients needed for growth in the first 6 months.
• urine examination (detect and determine • Carries antibodies from mother to help combat disease.
severity of Iodine deficiency) • Prevents diarrhea due to reduce risk from contaminated
formula as well as of the antibodies in the breast milk.
Secretory IgA, most abundant type of antibodies that
INFANT & YOUNG CHILD: RECOMMENDED FEEDING
protects mucosal membrane in the gut against pathogen.
PRACTICES

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 • Lowers risk of developing later in life chronic conditions,
(allergies, asthma, obesity, diabetes, and heart disease). 2. Cross-cradle hold
• Provides benefit for intellectual and motor development of – same to the cradle hold, except the mother cradles her infant
the infant. with arm on the opposite side of the nursing breast.

To Mother 3. Football, clutch, or underarm hold

• Early initiation of breastfeeding helps to contract the uterus – mother sits, hold the infant between her flexed arm and body,
and therefore reduce bleeding. positions the infant facing her, and supports the infant’s head
• Help in the return to pre-pregnancy weight. with her open arm. Twins may be fed at the same time using
• Exclusive breastfeeding delays the return of fertility. the double-football hold.
• Long-term benefit: lower risk of premenopausal breast
cancer and ovarian cancer. 4. Side-lying hold
– mother lies on her side with one arm supporting her head.
The infant lies aside beside the mother, facing the breast. The
TECHNIQUES OF BREASTFEEDING
mother grasps and offers her breast to the infant with the other
1. Cradle hold hand. Once the infant has latched on, she supports her infant’s
– the mother sits with her arms supported and, using her arm body.
on the same side as the nursing breast, cradle the infant of her
body.

To achieve proper latching • Baby finishes the feed and releases the breast by himself and
• Provide support by positioning her fingers against her chest looks contented.
wall below and her thumb above the breast. Other points included in the breastfeeding education sessions:
• Stimulates rooting reflex by touching infant’s lip with her nipple. • Putting the infants to breast stimulates oxytocin release making
• Wait for infant’s mouth to open wide. the mother’s uterus to contract that helps to reduce bleeding.
• Quickly moves her infant to her breast. • During lactation, intake should be increased to cover the
• Aims her infant’s lower lip below her nipple so that the infant’s energy cost of breastfeeding.
chin will touch her breast. • By 10% if the woman is not physically active, by 20% or more
if she is moderately or very active.
Signs that the baby latched on to the breast properly: o Lactating mother uses 500 kcal to make 750 mL of
• Mouth is wide open. breastmilk.
• Lower lip is turned out. o Malunggay (Moringa oleifera) as a galactagogue, an
• Chin is touching the breast. agent that promotes flow of milk and rich in iron.
• More areola is visible above the baby’s mouth than below. • Breast do not need to be washed before or after feeds.
• Regular emptying of the breast is important to maintain
Signs that the baby is sucking effectively: lactation.
• Baby’s swallowing can be seen or heard. • Breast changes occur during pregnancy due to hormones. Not
• Baby’s cheeks are full and not drawn inward during a feed. breastfeeding.

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COMPLIMENTARY FEEDING PRACTICES

Complementary Feeding
– introducing foods to complement breastmilk after 6 months
– should be timely, adequate, safe, and properly fed
Target Schedule
a. Timely population
– introduced when need for energy and nutrients Vitamin 6 – 11 months 100,000 IU once only
exceeds what can be provided through exclusive & A 12 – 71 months 200,000 IU every 6 months
frequent breastfeeding. capsule
2 – 6 months 0.3 ml OD to start at 2 months
b. Adequate with LBW (2 until 6 months.
– provide sufficient energy, protein, and micronutrients to 500 g) Preparation: 15 mg elemental
meet growing child’s need. Iron iron/0.6 mL
Anemic children 1 tsp OD for 3 months or 30mg
c. Safe 2 – 59 months once a week for 6 months with
– hygienically stored and prepared and fed with clean hands old supervised administration
using clean utensils and not bottles and teats.
FOOD FORTIFICATION
d. Properly Fed – addition to micronutrient to staple foods (rice, sugar, cooking oil,
– given consistent with child’s signal of hunger and that flour, salt)
meal frequency and feeding methods are suitable for the – Sangkap Pinoy seal is affixed to the packaging of food products
child’s age. that is certified as fortified in combination of micronutrients (Vitamin
MICRONUTRIENT SUPPLEMENTATION A, iron, iodine)
– short term intervention for correcting high level of micronutrient
deficiencies until more sustainable food-based approaches can be DEWORMING
used effectively. – done every 6 months in the aged 1 – 12 years.
– purpose: to add to the vitamins and minerals provided by a – aged 12 – 24 months: albendazole 200 mg (half tab) or
normal diet. Mebendazole 500 mg tab. Both require intake on full stomach.
– given to 0-59 months, in addition to regnant and lactating women – possible effects of anti-helminthic drugs:
and other women of reproductive age, or within 15 – 49 years old. • Local sensitivity/ allergy – give an antihistamine.
Zinc Supplementation • Mild abdominal pain- give an anti-spasmodic.
– given to 0-59 months, and who are having diarrhea. • Diarrhea- give oral solution (ORS)
• < 6 months: 10mg elemental zinc per day • Erratic worm migration – pull out worms from mouth/
• 6-59 months: 20mg elemental zinc per day for 10-14 days. nose or from other body orifices.
– giving it 10-14 days lowers the incidence of diarrhea following 2- – not advised if the child is known to have any of the following:
3 months. • Serious illness
• Abdominal pain
• Diarrhea

Community Health Nursing

 • History of hypersensitivity – enable body to produce enzymes, hormones, and other
• Severe malnutrition substances essential for proper growth and development.

MALNUTRITION IN CHILDREN Vitamin A deficiency

• Detect PEM: Measurement of height, weight, MUAC – ill effects on eyes and diminishes ability to fight infections.
– detected through serum retinol determination.
• Sign (severe case): baggy pants and edema.
– serum retinol determination: <20 μg or 0.70 μmol/L; < 10 μg or
• Baggy pants: loose skin on buttock (loss of subcutaneous and
0.35 μmol/L (severe VAD)
muscle tissues). It helps in detecting severe wasting.
– prevention & management: eat variety of Vitamin A rich sources:
plants (dark green leaves, orange or yellow colored fruits &
Protein Energy Malnutrition
vegetables) and animals (milk, egg yolk, liver)
a. Underweight
– weight for age < -2 standard deviations of the WHO Child
Xeropthalmia
Growth Standard median.
– signs and symptoms affecting the eye that can be attributed to
VAD night blindness (mildest); keratomalacia (potentially blinding).
b. Stunting
– height for age < -2 standard deviations of the WHO Child
Signs and symptoms
Growth Standard median.
Night blindness
– result of recurrent infections or poor diet
– difficulty seeing in the dark
– associated with delayed mental development, poor school
– responds rapidly (24 – 48 hours) to treatment with a
performance, and reduced intellectual capacity.
high dose of Vitamin A.
c. Wasting
– weight for height < -2 standard deviations of the WHO Child
Conjuctival xerosis
Growth Standard median.
– marked dryness of the affected conjunctiva
– symptom of acute undernutrition
– appears roughened, with fine droplets or bubbles in the
– consequence of insufficient food intake or high incidence of
surface.
infectious disease, especially diarrhea
– usually appears with Bitot’s spots.
– respond 2 – 5 days to treatment with high dose of
d. Overweight
Vitamin A.
– weight for height < +2 standard deviations of the WHO Child
Growth Standard median
– high probability of obesity and can lead to variety of disabilities
and diseases (DM and Cardiovascular diseases)
Bitot’s spots
Severe Acute Malnutrition in children 6 – 59 months
– foamy, soapy, whitish patches seen in scleral conjunctiva
– weight for height < -3 SD of the WHO Growth Standard median
(white part of the eye)
– presence of edema of both feet
– can be removed but reaccumulate if VAD is not
– MUAC: <115 mm
corrected.
– <6 months old: SAM is detected by the presence of clinical
signs of visible severe wasting, edema, and difficulty in
Corneal xerosis
breastfeeding
– cloudy, dry cornea with orange peel appearance.
– indication: pitting edema of both feet.
– vision is diminished even in daytime.
Verify by applying thumb pressure for 3 seconds on top of
– respond 2 – 5 days to treatment with high dose of
both feet. (not bilateral: not malnutrition)
Vitamin A.
– cornea regains its normal appearance in 1 – 2 weeks.
Grades of edema
• Grade + (mild): both feet/ankles Corneal ulceration/Keratomalacia
• Grade ++ (moderate): both feet, lower legs, hands or – soft, bulging cornea with large perforation in the surface.
lower arms – children with prolonged diarrhea and measles frequently
• Grade +++ (severe): generalized edema (both feet, progress to this stage.
legs, hands, arms face) – may result in perforation, blindness, collapse of the
eyeball.
MICRONUTRIENT MALNUTRITION – emergency treatment with a high dose of Vitamin A may
Micronutrient still save the other eye.
– present in the body in amount <0.005% of body weight.
– all vitamins are micronutrients.
– calcium, sodium, potassium, chlorine are not micronutrients

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 NCM 104 & 113: Community Health Nursing

IMCI Case Management

Preparation Vitamin A dosage and
Diagnosis
per capsule schedule of administration IMCI protocol guides the health worker in:
1 capsule upon diagnosis • Assessing signs that indicate severe disease.
regardless of the last dose • Assessing child’s nutrition, immunization and feeding.
Measles 100,000 IU
for infants
of Vitamin A capsule • Teaching parents how to care for a child at home.
(VAC) was given • Counseling parents to solve feeding problems.
6 – 11
1 capsule upon diagnosis • Advising parents about when to return to a health facility.
Severe pneumonia, months
except if he was given
persistent diarrhea
VAC <4 weeks before IMCI case management process involves the following elements:
or malnutrition 200,000 IU
diagnosis 1. Assess by checking first for danger signs (possible bacterial
for children
1 capsule immediately upon infection), nutrition and immunization status, & other problems.
Cases with signs of 12 – 71
diagnosis. 2. Classify child’s illness using a color-coded triage system. Each
VAD months
1 capsule the next day illness is classified according to whether it requires:
(xerophthalmia)
1 capsule 2 weeks after. • Pink: Urgent referral treatment and referral
• Yellow: Specific medical treatment and advice.
Iron deficiency Anemia • Green: Simple advice on home management
– in children < 5 years old and pregnant women: Hgb of < 110 g/L. 3. Identify specific treatments for the child.
– finger prick blood sample test is done.
• Requires urgent referral, give essential treatment
– simple method: assess for palmar pallor.
before transfer.
• Hold child’s palm open by grasping it gently from side.
• Needs treatment at home, develop integrated
• Do not stretch the fingers backward. treatment plan and give the 1st dose at the clinic.
• Compare child’s palm with your own palm. 4. Provide practical treatment instruction.
– most common cause of anemia • Teach mother how to give oral drugs, how to feed
and give fluids during illness, and how to treat local
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS infections at home.
– initiated by WHO/UNICEF; offers simple and effective methods • Ask to return for follow-up.
for child survival, healthy growth, and development • Teach how to recognize signs that indicate immediate
– based on combined community, health facility, and health system. return to health facility.
– IMCI process includes preventive and curative measures. 5. Assess feeding, including breastfeeding practices. Counsel to
solve any feeding problems found. Then counsel the mother
Main components of IMCI strategy: about her own health.
1. Improvements in case management skills of health care 6. When a child is brought back to the clinic as requested, give
staffs. follow-up care and, if necessary, reassess the child for new
2. Improvements in health systems needed for effective problems.
management of childhood illness.
3. Improvements in family and community practices.

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 NCM 104 & 113: Community Health Nursing

CHAPTER 11: NONCOMMUNICABLE DISEASE CONTROL RISK FACTORS FOR NCDS

1. Physical Inactivity
NONCOMMUNICABLE DISEASE • < 5 times of 30 minutes of moderate exercise/week or
– WHO reports NCDs to be the leading cause of mortality. < 3 times of 20 minutes of vigorous activity/week.
• key determinant of energy expenditure.
Noncommunicable Disease • fundamental to energy balance and weight control.
– noninfectious and nontransmissible. • risk of getting cardiovascular disease increases 1.5 times for
– referred as lifestyle related disease noncompliance for physical activity.

CARDIOVASCULAR & CEREBROVASCULAR DISEASE 2. Cigarette smoking

Cardiovascular disease (heart disease) • primary risk factor for development of NCDs.
– used to refer to diseases that involve the heart or blood vessels. • smoking cigarettes damages blood vessels lining and
reduces HDL and oxygen in the blood.
Cerebrovascular disease (Stroke)
– group of brain dysfunction related to disease of the blood vessels 3. Unhealth eating (Obesogenic)
supplying the brain. • one of the major factors responsible for global increase of
– most common cause: cardiovascular disease, cancer, diabetes, and obesity.
• Atherosclerosis
– disease of the blood vessels; deposition of fats & 4. Excessive alcohol drinking
cholesterol within arterial wall. • lead to metabolic & physiological effects on organ system.
– screening for elevated cholesterol: blood sample • may cause malabsorption, inflammation to GI tract, liver
for lipid profile test. problems, and cancer.
▪ Prior to testing, NPO for at least 8 hours.
▪ ≥20-year-old: Lipoprotein profile every 5 5. Viruses
years. • Oncoviruses: viruses capable of causing cancer.
• Hypertension (High blood pressure) • cause mutation by breaking the normal cell’s DNA chain
– systolic ≥ 140 mmHg; diastolic BP ≥ 90 mmHg. during infection.
– screening: measurement of blood pressure. • Human Papilloma Virus: cervical and vulvar cancer
• Epstein Barr Virus: Nasopharyngeal, anal cancer
Screening • Human T-lymphotropic Virus (HTLV-1): non-Hodgkin
– identification of unrecognized disease by application of test or Lymphoma, Hepatitis B and C virus: Liver cancer
procedures that can be applied rapidly to help identify one’s chance
of becoming ill. 6. Radiation
• Energy emitted and transferred though matter and space.
CANCER (MALIGNANT NEOPLASM) o UV radiation
– group of various disease involving unregulated cell growth. ▪ adversely affects the genes and cell enzymes
– screening: early detection of warning signs. causing DNA mutations
• Change in bowel or bladder habits ▪ primary source: Solar radiation (major cause of
• A sore throat that does not heal skin cancer)
• Unusual bleeding or discharge o Ionizing radiation
• Thickening or lump in the breast ▪ cause tissue and cell damage by breaking DNA
• Indigestion or difficulty of swallowing molecule
• Obvious change in mole (ABCDE assessment) ▪ X-ray, gamma rays, particulate radiation from
• Nagging cough or hoarseness nuclear accidents, occupational exposure,
• Unexplained anemia
• Sudden weight loss PREVENTION OF NCDS
1. Promote physical activity and exercise
CHRONIC OBSTRUCTIVE PULMONARY DISEASE Physical activity
– bodily movement produced by skeletal muscles that results
– includes chronic bronchitis and emphysema
in the expenditure of energy.
– risk factor: smoking; secondhand smoking and pollution
aggravate the problem.
Exercise
– subcategory of physical activity that is planned, structured,
DIABETES repetitive, aimed, at improving or maintaining physical fitness.
– group of metabolic disease
– has high blood glucose level because the pancreas is not Physical fitness
producing enough insulin, or the cells do not respond to the insulin – measure of one’s ability to perform activities with vigor and
produced. alertness without undue fatigue.
• Insulin: hormone that regulates blood sugar.

Community Health Nursing

 Levelsof Physical Activity (Physical Activity Guidelines) • Adults below 65 years of age should have at least 150
• Inactive minutes per week of structured moderate intensity activity
• Low: < 150 minutes/week or 75 minutes of structured of vigorous activity
• Medium: 150 – 300 minutes of moderate intensity/week
or 75 – 150 minutes of vigorous intensity/week 2. Promote healthy diet and nutrition
• High: > 300 minutes of moderate intensity/week • Good nutrition is a primary determinant of good health.
• Healthy diet is the cornerstone of preventing NCDs
Metabolic Equivalent (METs) • ABCs of good nutrition
– ratio of rate of energy expenditure during activity to the rate o Aim for physical fitness
of energy expenditure at rest. o Build a healthy base of nutrition practices
• Light (<3.0 METs) o Choose food sensibly.
• Moderate (3.0 – 6.0 METs)
• Vigorous (> 6.0 METs) Methods used to assess healthy weight
1. Body Mass Index: weight (kg)/ Height m2
• Minimum of 60 minutes of moderate or rigorous activity 2. Waist Circumference: assess central fat distribution and the
every day for adolescents and children. degree of abdominal obesity.

Disease risk relative to weight and waist circumference

Classification BMI Waist Circumference Waist Circumference
Men ≤40 in; Women ≤35 in Men ≥40 in; Women ≥35 in
Underweight
Severe < 16 kg/ m2
Moderate 16.0 – 16.99 kg/ m2
Mild 17.0 – 18.49 kg/ m2
Normal 18.50 – 24.99 kg/ m2
Overweight 25.0 – 29.9 kg/ m2 Increased High
Obese
Class 1 30.0 – 34.99 kg/ m2
Class 2 35.0 – 39.99 kg/ m2 High Very High
Class 3 > 40.0 kg/ m2

• Recommended adolescent fat intake should be < 30% of NCDS PREVENTION AND CONTROL PROGRAM
calories per day with less animal fat and cholesterol to < Goal: Reduce the toll of morbidity, disability, and premature deaths
300 mg daily due to chronic, non-communicable lifestyle-related disease.
• Overweight and obesity is a result of imbalance energy due
to excessive intake of calories within the number of calories Objectives:
burned. 1. Analyze the social, economic, political, and behavioral
determinants of NCD.
3. Promote a smoke free environment 2. Reduce exposure of individuals and population to major
• Smoking is a major risk factor for developing determinants of NCD while preventing emergence of
cardiovascular and cerebrovascular disease, lung cancer, preventable common risk factors.
and chronic lung disease. 3. Strengthen health care for people with NCD through health
• Guide for treating tobacco use and dependence sector reforms and cost-effective interventions.
o Ask
o Advise MENTAL HEALTH
o Assess – WHO: state of social well-being in which every individual realizes
o Assist his or her own potential (self-image), can cope with the normal
o Arrange follow-up stresses of life (resiliency), can work productively and fruitfully
(productivity and creativity), and is able to make a contribution to
4. Stress Management her or his community (sense of purpose).
• Stress is the nonspecific response of the body to any
demand on it. Mental health problems have 4 facets as public health burden:
• Managing stress involves understanding one’s reaction to 1. Defined or direct burden
stress. – burden affecting persons with mental disorders (cost of
• Overall aim: minimize frequency of stress inducing treatment, quality of life, disability).
situations, increase resistance, avoid physiologic arousal
resulting from stress. 2. Undefined or indirect burden
– burden relating to the impact of mental health problems to
others (family member, community who care for the patient).

Community Health Nursing

 3. Hidden burden Rule IV, Sec. 4 of the IRR of Republic Act 7277, addresses the health
– stigma and violations of human rights to persons affected concerns of 7 different categories of disability:
with mental health problems. • Psychosocial and behavioral illnesses
• Chronic illness with disabilities
4. Future or health burden • Learning disabilities
– burden resulting for aging population or increasing social • Mental disabilities
problems (development of complication or illnesses, death.) • Visual disabilities
• Orthopedic deficits
NATIONAL MENTAL HEALTH PROGRAM • Communication deficit
Vision: Better quality of life through total health care for all Filipinos
Mission: A rational and unified response to mental health NATIONAL HEALTH PROGRAM FOR PWDs
Goal: Quality mental health care Vision: Improve the total well-being of persons with disabilities
(PWDs)
DISABILITY
– general term for impairments, activity limitations, and participation Mission: DOH shall ensure the development, implementation, and
restrictions. monitoring of relevant and efficient health programs and systems
for PWDs that are available, affordable, and acceptable.
Impairment
– problem in body function or structure. Goals:
1. Reduce the prevalence of all types of disabilities.
Activity limitation 2. Promote and protect the human rights and dignity of PWDs
– difficulty encountered in executing task and their caregivers.

Participation restriction Objectives:

– problem experienced with regard to the involvement of lie 1. Develop integrated national health & human rights program
situations. & local models to serve special health needs.
2. Pursue implementation & monitoring of laws and policies for
Disability PWDs (accessibility law, human rights, and other related laws).
– negative aspects of the interaction between individuals with 3. Ensure health facilities and services are equitable, available,
a health condition, personal, and environmental factors. accessible, acceptable & affordable to PWDs through
development and implementation of essential health
Barriers packages that suitable to their special needs and enrollment
• Inadequate policies and standards for PWDs into National Health Insurance Program.
• Negative attitude of people 4. Initiate and strengthen collaboration and partnership among
• Lack of provision of services for PWDs stakeholders to improve facilities devoted to management
• Poor service delivery and rehabilitation of PWDs & upgrade capabilities of health
• Inadequate funding professionals & frontline workers to cater their special needs.
• Lack of accessibility 5. Continue & fast-track registration of PWDs to generate data
• Lack of involvement for accurate planning and implementation of programs.
• Lack of data and evidence on disability
VISUAL IMPAIRMENT
Convention on the Rights of Persons with Disabilities (CPRD) Classification of Visual Impairment
– United Nations on December 13, 2006, adopted the CRPD Low vision
– supersedes the United Nations Standard Rules on the Equalization – visual acuity of < 6/18, but equal to or > 3/60, or corresponding
of Opportunities for Person with Disabilities in 1993. visual field loss to < 20 degrees in better eye with best possible
– Aim: promote, protect and ensure the full and equal enjoyment correction
of all human rights and fundamental freedoms by all persons with
disabilities, and to promote respect for their inherent dignity. Blindness
– become the foundation for the paradigm shift toward – visual acuity of < 3/60, or corresponding visual field loss to
understanding disability. < 10 degrees in the better eye with best possible correction.

Republic Act 7277: Magna Carta for Disabled Persons Vision 2020: The Right to Sight
– addresses the needs of individuals with physical disability is the – launched by WHO in 1999
National Health Program for Persons with Disabilities. – global initiative for elimination of avoidable blindness
– requires: – aim: to develop a sustainable comprehensive health care system
• national health program for PWDs that will ensure the best possible vision for all, thus improving their
• establishment of medical rehabilitation centers in provincial quality of life.
hospitals – has 3 essential components of the action plans
• integrated and comprehensive program for the health • cost-effective disease control interventions
development of PWDs that shall make essential health • human resource development
services available to them at affordable cost. • infrastructure development

Community Health Nursing

 NATIONAL PREVENTION OF BLINDNESS PROGRAM 4. Work toward poverty alleviation in Philippines through the
Guidelines in the implementation of the National Prevention of provision of quality eye care.
Blindness Program are in A.O. no. 179, s. 2004.
Goal: Reduce the prevalence of avoidable blindness in the
Vision: All Filipinos enjoy the right sight by year 2020. Philippines through the provision of quality eye care.

Mission: The DOH, local health units, partners, and stakeholder Objectives:
commit to: 1. Increase cataract surgical rate from 730 to 2,500 by the year
1. Strengthen partnership among and with stakeholders to 2010.
eliminate avoidable blindness in the Philippines. 2. Reduce visual impairment due to refractive errors by 10% by
2. Empower communities to take proactive roles in promotion the year 2010.
of eye health and prevention of blindness. 3. Reduce the prevalence of visual disability in children from
3. Provide access to quality eye care services for all. 0.30% to 0.20% by the 2010.

Law Description
Executive Order No. 958 National Healthy Lifestyle Advocacy Campaign. Declaring the years 2005- 2015 as the decade of healthy lifestyle.
Republic Act 1054 Free emergency medical and dental treatment for employees.
Republic Act 9211 Tobacco Regulation Act of 2003. Regulates the packaging, use, sale, distribution, and advertisements of tobacco
products.
Republic Act 6425 Penalties for Violations of the Dangerous Drug Act of 1972.
Republic Act 9165 Comprehensive Dangerous Drug Act of 2002.
Republic Act 8423 Traditional and Alternative Medicine Act of 1997.
Department Personnel Creation of a Program Management Committee for the National Prevention of Blindness Program
Order No. 2005-0547
A.O. No. 179 series of 2004 Guidelines for the Implementation of the National Prevention of Blindness Program.
Proclamation No. 40 Declaring the month of August every year as “Sight Saving Month”.
Republic Act 7277 Magna Carta for Disabled Persons. An act providing for the rehabilitation and self-reliance of disabled persons and
their integration into the mainstream of society and for other purposes.
Republic Act 10352 An act restructuring the Excise Tax on Alcohol and Tobacco, which prescribes higher tax rates on tobacco and
alcohol products. The law imposes higher taxes on cigarette and alcohol products for the next five years. It aims
to restructure the existing taxes imposed on alcohol and tobacco goods, which are potential revenue source that
will help fund Universal Health Care Program of the government, and to discourage people from engaging in vices.

Community Health Nursing

 NCM 104 & 113: Community Health Nursing

CHAPTER 12: COMMUNICABLE DISEASE CONTROL • WHO initiative to eradicate:

o yaws started in 1954
EPIDEMIOLOGIC TRIANGLE MODEL o malaria in 1955
– explains the development of communicable disease. o smallpox in 1980
– recognizes three major components: o dracunculiasis and paralytic poliomyelitis in 2000
1. Agent o measles in 2015
– organism involved in the development of a disease.
– bacteria, viruses and rickettsiae, rickettsial agents, • Smallpox is the only disease that has been successfully
fungi, protozoa, helminths, and arthropods that act as eradicated worldwide in 1977.
vectors to agents from their reservoirs to humans.
Philippines: National Objectives for Health 2011-2016 identified the
2. Host following as diseases targeted for elimination.
– organism that harbors & provides nutrition for agent. • Rabies
– ability of host to fight the agent causing the infection o one of the most acute fatal infections
is influenced by age, gender, socioeconomic, ethnicity, o goal of National Rabies Prevention and Control Program:
nutritional & immune status, genetic makeup, hygiene. eliminate rabies as public health problem at less than 0.5
cases/million population & declare Philippines rabies-free
3. Environment by 2020.
– condition in which agent survive/originate; comprises: o 2010: DOH reported Siquijor, Batanes, Camotes Island,
• Physical environment: temperature, weather, Apo Island, and Malapascua Island as rabies free.
soil, water, food sources.
• Biological environment: animals, insects, flora, • Leprosy
and other human beings that act as reservoir o Philippines has the highest prevalence of leprosy among
or foster the survival of organisms. the countries in the Western Pacific region.
• Socioeconomic environment: behavior, o Leprosy Program target is to eliminate leprosy as a
personality, attitudes, cultural characteristics, public health problem at a level of one case per 10,000
occupation, urbanization. population in identified endemic areas (Eastern Visayas,
locos, Zamboanga peninsula, Central Visayas, and
Northern Mindanao).
DISEASES TARGETED FOR ERADICATION
• Ultimate goal in the control of CDs: elimination and eradication • Filariasis
so that it is no longer considered a public health problem o 43 out of 80 endemic provinces have not reached the
target level due to lack of awareness and
Eradication understanding about the disease and its elimination.
– permanent reduction to zero of the worldwide prevalence of o goal of National Filariasis Elimination Program (NFEP):
a disease caused by a specific agent. eliminate filariasis as a public health problem by 2015
with a prevalence rate of microfilaremia of less than 1%.
Elimination
– reduction to zero prevalence of a disease in a single country, WHO classification for endemicity is based on elimination level
continent, or other limited geographical area of microfilaria rate of less than 1%, and antigen rate of less than 1%
– control of manifestations so that it is no longer a public health per implementing unit.
problem by reducing its incidence below 1 case/10,000 population
– intervention measures are still needed in elimination since the
• Schistosomiasis
disease is still present elsewhere o endemic in 12 regions in the country.
o national prevalence rate: 2.5% and peaking at 15-49
International Task Force for Disease Eradication (ITFDE) years of age
– established in 1988 to systematically review potential candidate o goal of Schistosomiasis Control Program: to eliminate
diseases for eradication and to provide leadership and advocacy schistosomiasis as a public health problem with the
for the concept of eradication where appropriate and useful. prevalence rate of less than 1% for the last five
– identified diseases consecutive years.
For global eradication For global elimination
Smallpox Dracunculiasis Hepatitis B Rabies Focus of communicable disease control: directed toward
Poliomyelitis (guinea worm Malaria Trachomatis eradicating the disease, because it can reduce/eliminate burden of
Measles disease), Neonatal Onchocerciasis disease and its associated mortality.
Rubella Taeniasis tetanus Iodine
Lymphatic (tapeworm) Chagas deficiency
filariasis disease Yaws.

Community Health Nursing

 COMMUNICABLE DISEASES • Incubation period: 2-7 days

DENGUE HEMORRHAGIC FEVER (HEMORRHAGIC • Clinical manifestation

o First 4 days: Febrile or Invasive stage
FEVER, BREAK BONE OR DANDY FEVER, DENGUE ▪ high grade fever, headache, body malaise,
SHOCK SYNDROME) conjunctival infection, vomiting, epistaxis or gum
• CA: Dengue virus (DEN), single stranded RNA virus of 4 bleeding, positive torniquet test.
types (DEN-1, 2, 3, 4) genus Flavivirus, family Flaviviridae.
o 4th – 7th day: Toxic/Hemorrhagic Stage
• Vector: Infected female Aedes mosquitoes. ▪ complication of dengue is expected to come out:
abdominal pain, melena, Unstable BP, narrow
• Aedes aegypti (yellow fever mosquito or tiger mosquito) pulse pressure and shock.
– principal vector predominant in urban areas seen in
tropical and subtropical countries. o 7th – 10th day: Convalescent/Recovery stage
▪ BP is stable and platelet count and bleeding
• Aedes albopictus (Asian tiger mosquito) parameters begin to normalize.
– secondary vector predominant in rural areas
– the only mosquitoes transmit chikungunya virus Classification of Dengue Fever According to Severity
1. Grade I – Dengue fever: saddleback fever + constitutional
• MoT: transmitted through infected Aedes mosquito bite signs and symptoms plus + torniquet test
2. Grade I – Stage I +spontaneous bleeding, epistaxis, GI,
• Susceptible: cutaneous bleeding
o all individuals regardless of age, gender 3. Grade I I – Dengue Shock Syndrome: all of the following signs
o children between 0-9 years are commonly affected and symptoms + evidence of circulatory failure
o populated areas with poor environmental conditions 4. Grade IV – Grade I I + irreversible shock & massive bleeding
conducive for vector breeding.
Dengue Case Classification
Warning signs
Probable dengue Severe dengue
(strict observation & medical intervention)
Live in/travel to dengue endemic area. 1. Abdominal pain Severe plasma leakage leading to:
Fever and two of the following criteria: 2. vomiting 1. Shock (DSS)
1. Nausea, vomiting 3. Fluid accumulation 2. Fluid accumulation with respiratory distress
2. Rashes 4. Mucosal bleeding
3. Aches and pains 5. Lethargy Severe bleeding
4. Torniquet test (+) 6. Liver enlargement >2cm
5. Leukopenia 7. Increase in HCT concurrent with rapid decrease in Severe organ involvement
6. Any warning sign platelet count 1. Liver: AST/ALT ≥1,000
2. CNS: Impaired consciousness
3. Heart and other organs

Diagnostic Laboratory Procedures

1. Tourniquet test or Rumpel-Leads test. 1. Platelet count & hematocrit (HCT) count.
– measures coagulability of the blood. – rapid decrease in platelet count (150,000 to 400,000
– applying a tourniquet on a client's extremity and observing cu.mm) in parallel with a rising hematocrit (F=36-46%,
amount of petechiae produced. M=41-53%) is suggestive of progress to the critical phase
– presumptive test for capillary fragility. of dengue.
– assess bleeding tendencies – no proper laboratory services available: minimum
• Contraindication: with fistula, with arteriovenous shunt, standard is point-of-care testing of hematocrit by capillary
and those who have undergone a mastectomy (finger prick) blood sample with the use of a
• Inflates the cuff to a point midway between systolic & microcentrifuge.
diastolic pressure for 5 minutes. Release cuff & make 2. Hemagglutination-inhibition (HI) test.
1-inch square below the cuff, at antecubital fossa. – require paired sera; based on the ability of dengue virus
• Count number of petechiae (positive result: presence antibodies to inhibit agglutination
of 20 or more petechiae per inch square). 3. CBC
4. Bleeding Parameters
2. Capillary refill test/Nail blanch test. 5. Serologic test
– rate at which blood refills empty capillaries. 6. Dengue blot, Dengue Igm
– measures dehydration and decreased peripheral perfusion. 7. Other :
– measured by holding a hand higher than heart-level o Prothrombin Time
– warning sign: refill time of more than 3 seconds. o Activated Partial Thromboplastin Time
o Bleeding time
o Coagulation time

Community Health Nursing

Nursing Intervention
• Paracetamol every 6 hours. o Chronic Stage (10-15 years from onset of first attack)
o still has high fever, do TSB. ▪ Hydrocele (Swelling of the scrotum)
• Encourage oral intake of ORS, fruit juice, and fluids containing ▪ Lymphedema (Temporary swelling of upper and
electrolytes and sugar to replace losses from fever and lower extremities)
vomiting. ▪ Elephantiasis (enlargement & skin thickening of
o ORESOL: 75 ml/KBW in 4-6 hours to children or at 2- lower/upper extremity, scrotum, breast)
3L in adults.
o If not tolerated: IVF of 0.9% saline or Ringer's lactate Laboratory
with or without dextrose at maintenance rate. 1. Circulating filarial antigen (CFA) - finger prick
• Avoid dark-colored foods (can mask bleeding). 2. Nocturnal Blood Examination: blood taken after 8:00 pm
• Low fat, low fiber, nonirritating, and noncarbonated diet. 3. Immunochromatographic Test: rapid assessment; antigen test
• Strict bed rest that can be done at daytime
• Do not give IM injections to avoid hematoma.
• Bleeding of gums: ice chips & use soft-bristled toothbrush. Treatment
• GI bleeding: NPO. • Diethylcarbamazine citrate (Hetrazan): 6mg/KBW in divided
doses for 12 consecutive days
• Blood transfusion: given as soon as severe bleeding is
suspected/recognized. Given with care due to risk of fluid
overload. • Ivermectin (Mectizan)
o best taken as single dose with a full glass of water in
• Shock: place in dorsal recumbent (promote circulation).
empty stomach.
o cannot be used in patient with asthma
Preventive measures: 4 S in dengue prevention
• Search and destroy breeding places
Surgical Treatment
• Seek early consultation
• Elephantiasis and hydrocoele can be handled through surgery.
• Say no to indiscriminate defogging
• Mild cases of lymphedema: treated by lymphovenous
• Self-protection anastomosis distal to the site of lymphatic destruction.
• Chyluria: operated by ligation and stripping of lymphatics of
FILARIASIS (ELEPHANTIASIS, FILARIOIDEA the pedicle of affected kidney
INFECTION, HUMAN LYMPHATIC FILARIASIS) • Hydrocoele: managed by inversion or resection of tunica
– endemic in 45 out of 78 provinces vaginalis.
– progresses to become chronic, debilitating and disfiguring
Preventive Measures
Biological type • Environmental sanitation: proper drainage and cleanliness of
1. Nocturnal: microfilaria circulate in peripheral blood at surroundings.
night (10pm – 2am) • Measures aimed to protect individual & families
2. Diurnal: microfilaria circulate in greater concentration at o Use of mosquito nets
daytime o Use of long sleeves, long pants and socks
o Application of insect repellants Screening of houses
• CA: Wuchereria bancrofti, Bulgaria malayi, Brugia timori o Health education

• MoT: bite of infected mosquito LEPTOSPIROSIS (WEIL’S DISEASE, CANICOLA, MUD

FEVER, TRENCH FEVER, FLOOD FEVER, SPIROKETAL
• Vector: Anopheles, Mansonia, Aedes poecilus, Culex
quinquefasciatus JAUNDICE, JAPANESE SEVEN DAYS FEVER)
– rat: main host to leptospirosis; pigs, cattles, rabbits, hare, skunk
• Incubation period: 8-16 months and other wild animals can serve as reservoir hosts.

• Clinical manifestation • CA: Leptospira interrogans

o Asymptomatic Stage
▪ presence of microfilariae in peripheral blood • MoT: Inoculation into broken skin, ingestion
▪ No clinical signs and symptoms of the disease
• Source of infection: Urine & excreta of rodents and infected
o Acute stage
▪ Filarial fever and lymphatic inflammation that • Incubation period: 7-13 days
occurs frequently as 10x/year & abates
spontaneously after 7 days • Anicteric Type (without jaundice)
▪ Lymphadenitis (Inflammation of lymph nodes) o manifested by fever, conjunctival injection
▪ Lymphangitis (Inflammation of lymph vessels) with o signs of meningeal irritation
gradual skin thickening (limbs, scrotum)
▪ funiculitis (inflammation of spermatic cord), • Icteric Type (Weil Syndrome)
epididymitis, or orchitis (redness, tender scrotum) o Hepatic and renal manifestation

Community Health Nursing

 o Jaundice, hepatomegaly ▪ splenomegaly
o Oliguria, anuria which progress to renal failure ▪ cerebral malaria
o Shock, coma, CHF ▪ changes of sensorium
o Convalescent Period ▪ severe headache
▪ vomiting
• Clinical manifestation ▪ seizures
o Leptospiremic/Septicimic phase
▪ leptospires are present in blood and CSF 1. Cold stage: 10-15 mins, chills, shakes
▪ onset of s/sx: headache, myalgia (calf pain), N/V, 2. Hot stage: 4-6 hours, recurring high grade fever,
cough, chest pain, high remittent fever 4-7 days severe headache, vomiting, abdominal pain, face is blue
3. Diaphoretic stage: excessive sweating
o Immune/Toxic phase
▪ correlates with appearance of circulating IgM Diagnosis
▪ jaundice 1. Clinical Method: based on signs and symptoms and history of
visiting malaria endemic area.
o Convalescence 2. Microscopic Method: based on blood smear examination

Diagnosis Recommended Anti-Malaria Drugs

1. Clinical history & its clinical manifestations • Blood Schizonticides - drugs acting on sexual blood stages of
2. Culture of organism the parasites which are responsible for clinical manifestations.

Treatment Treatment
• Penicillin and other related B-lactam antibiotics
• Tetracycline Treatment for P. Falciparum
• Erythromycin • Chloroquine tablet
• Sulfadoxine/Pyrimethamine
Prevention and Control • Primaquine
• Education of people at particular risk (increase awareness
and enable early diagnosis and treatment). Treatment for P. Vivax
• Use of protective clothing • Chloroquine
• Stringent community-wide rat eradication program. Remove • Primaquine
rubbish from environment to reduce rodent population.
• Segregate domestic animals potentially infected from man's Treatment for mixed
living, working and recreation areas. • Chloroquine
• Isolation of patients & concurrent disinfection of soiled articles. • Sulfadoxine/Pyrimethamine
• Chemoprophylaxis in groups at high risk of infected host. • Primaquine

MALARIA (MARSH FEVER, PERIODIC FEVER, KING OF Multi-drug resistant P. Falciparum

TROPICAL DISEASES) • Quinine + Doxycycline, or Tetracycline & Primaquine
– infectious but not contagious
Complications
Vector: (night biting) anopheles mosquito or minimus flavire • Severe anemia
• Cerebral malaria
• CA: Protozoa • Hypoglycemia
o Plasmodium vivax
▪ widely distributed Chemoprophylaxis
o Plasmodium falciparum • Doxycycline
▪ common in Philippines • Mefloquine
o Plasmodium malariae
▪ less frequent Nursing Care
o Plasmodium ovale • Consider patient with cerebral malaria as emergency
▪ rarely seen. • Administer IV quinine as IV infusion
o Plasmodium knowlesi • Watch out for jaundice (related to falciparum parasitemia
density)
• Clinical manifestation • Evaluate degree of anemia
o Uncomplicated • Watch for abnormal bleeding due to decrease production of
▪ fever, chills, sweating every 24 – 36 hours clotting factors by damage liver.
o Complicated
▪ sporulation/segmentation & rupture of Prevention and control:
erythrocytes in the brain & visceral organs. 1. Mosquito control
▪ hepatomegaly 2. Zooprophylaxis: larvae-eating fish, animals: near the house

Community Health Nursing

 3. Environmental methods: cleaning and irrigating canals
4. Screening of houses • Risk of developing rabies
5. Avoid outdoor night activities, peak biting hours: 9PM – 3AM. o Face bite: 60%
6. Use of long sleeve clothing, insect repellant, mosquito nets o Upper extremities: 15-40%
7. Mechanical methods: use of fly swats or traps o Lower extremities: 10%
8. Insecticide: treatment of mosquito net
9. House Spraying • Clinical manifestation
10. Stream Seeding o Dog
11. Stream Clearing ▪ at first withdrawn, change in mood, shows
nervousness & apprehension, unusual salivation,
SCHISTOSOMIASIS (SNAIL FEVER, BILHARZIASIS) paralysis starts on hind legs spreading towards
• CA: Schistosoma japonicum, mansoni, S. haematobium entire body, death
o Human
• Vector: Oncomelania quadrasi (snail) ▪ Incubation period
▪ Prodromal stage:
• Incubation period: 2 months • Headache
• Pain & numbness sensation at site of bite
• MoT: Vehicle (water), indirect (skin pores) • Depression
• Penile erection/spontaneous ejaculation
• Clinical manifestation ▪ Acute neurologic phase
o Rash at site of inoculation • Spastic:
o Enlargement of abdomen o Anxiety
o Diarrhea o Confusion
o Body weakness o Insomnia
o Bloody stools • Dementia:
o Spleenomegaly o Intense excitement
o Weakness o Difficulty in breathing
o Anemia o Swallowing
o Inflamed liver o Drooling
o Hydrophobia
Laboratory/diagnostic test: • Paralytic:
1. Direct stool examination o Flaccid ascending symmetric paralysis
2. COPT (Cercum Ova Precipetin Test) o Coma
3. Kato Katz Technique - gold stondard o Death

Treatment: Diagnosis
• Praziquantel (Biltricide) 1. Postmortem direct fluorescent antibody staining test
• Oxamniquine for S. mansoni and S. haematobium
Management and Prevention
Prevention: • Immediately & thoroughly washed wound with soap & water.
1. Proper disposal of feces and urine • Patients may be given antibiotics & anti-tetanus immunization.
2. Prevent exposure to contaminated water (wearing of rubber • Post-exposure treatment: (local wound treatment, active
boots) immunization and passive immunization)
3. Eradication of breeding places of snails. • Consult a veterinarian/trained personnel to observe the pet
4. Improve irrigation & agriculture practices: reduce snail habitats for 14 days for signs of rabies.
by removing vegetation or draining and filling. • Immunized pet at 3 months of age & every year thereafter
5. Treat snail-breeding sites with molluscicides. • Isolate patient.
6. Prevent exposure to contaminated water. Accidental water • Darken room and observe silence.
exposure, towel dry. Apply 70% alcohol to kill surface • Give food if patient is hungry.
cercariae.
• Keep water out of sight.
7. Inactivating cercariae: water treatment with iodine or chlorine,
• Observe universal precaution, essentially wearing gloves.
or the use of paper filters. Allowing water to stand 48-72
• Perform terminal disinfection.
hours before use also effective.
Postexposure treatment
RABIES (HYDROPHOBIA, LYSSA) A. Recommended vaccines that provide active immunity that is infiltrated
• CA: Rhabdovirus in and around the wound for the first dose of the vaccine.
PVCV (purified vero cell vaccine) = 0.1 ml
• MoT: Bite of rabid animal whose saliva has the virus PDEV (purified duck embryo vaccine) = 0.2 ml

• Incubation period: 20-90 days (humans); 1 week-7.5 months

(dogs)

Community Health Nursing

 a. Reduce multisite intramuscular (IM) (2-1-1) schedule Nursing Intervention
Schedule Site and route Dose • Maintain strict aseptic technique
Day 0 Deltoid IM 2 doses • Observe signs of increase ICP
Day 7, 21 Deltoid IM 1 dose
• Protect eyes from light and noises
b. 2 site intradermal regimen (most cost effective treatment) • Note and record amount of vomitus
Schedule Site and route Dose • Check signs of dehydration
Day 0, 3,7 Deltoid ID 2 doses • Proper disposal of secretions
Day 30 Deltoid ID 1 dose • Emphasize importance of masking and isolation
Day 90 Deltoid ID 1 dose • Prevent sudden jar of bed
• Keep patient in a dark room and complete physical rest
B. Recommended immunoglobulins
• Diversional activities and passive exercises
provides passive immunity administered IM route distant from site of
vaccine inoculation
• Equine rabies = KBW × 0.2 ml MENINGOCOCCEMIA
• Human rabies = KBW × 0.133 ml • CA: Neisseria meningitides (gram negative diplococcus)

Immunoglobulins • MoT: Airborne or Direct contact with respiratory droplets

Schedule Site and route Dose from nose and throat of infected persons.
Day 0 Deltoid (adult) 1 dose
Anterolateral (infants)
or • Incubation Period: 1-3 days
Day 7 Deltoid (adult) 1 dose
Anterolateral (infants) • Natural reservoir: human nasopharynx

Prevention of rabies • Clinical manifestation

1. Pre-exposure prophylactic treatment for high-risk individuals o Sudden onset of high-grade fever, rash and rapid
Treatment: High-risk every year (lab), 2x/year (vet) deterioration within 24 hours
• PDEV = 1.0 ml o Weakness
• PVCV = 0.5 ml o Joint and muscle pain
o Hemorrhagic rash, progressing from few petechiae to
Schedule Dose
Day 0, 7 1 dose IM
widespread purpura and ecchymoses
Day 21 1 dose ID o Meningeal irritation like headache, N/V, stiff neck, bulging
fontanel (among infants), seizure or convulsion and
sensorial changes.
MENINGITIS o Meningococcemia: spiking fever, chills, arthralgia,
• CA: N. menigitidis, H. influenza, S. pneumoniae, M. tuberculosis sudden appearance of hemorrhagic rash
o Fulminant Meningococcemia (Waterhouse
• Clinicalmanifestation Friderichsen): septic shock, hypotension, tachycardia,
o Fever o Headache enlarging petechial rash, adrenal insufficiency
o Rapid pulse o Irritability
o Soreness of skin o Fever Laboratory
and muscles o (+) Kernig’s, Babinski, 1. Blood Culture
o Convulsion/seizures Brudzinski 2. Gram stain of peripheral smear, CSF and skin lesions
3. CBC
Diagnosis
1. Lumbar puncture Chemoprophylaxis
– to obtain specimen of CSF • Rifampicin 300-600mg q 12hrs x 4 doses
– to reduce ICP • Ofloxacin 400mg single dose
– to introduce medication/anesthetic
• Ceftriaxone 125-250mg IM single dose
2. Blood C/S
Treatment:
Treatment
• Antimicrobial
• Bacterial meningitis & TB meningitis o Benzyl Penicillin
o Intensive Phase
o Chloramphenicol
o Maintenance Phase
• Fungal meningitis Nursing Care:
o Cryptococcal meningitis – fluconazole/amphotericin B 1. Patient must be given chemoprophylaxis before discharge
to assure elimination of meningococcus in nasopharynx.
Supportive/Symptomatic Management 2. Observe infection control measures and respiratory
• Antipyretic isolation especially for the first 24 hours upon admission.
• Treat signs of increased ICP 3. Other isolation technique: non-sharing of utensils, cups,
• Control of seizures lipstick, cigarettes and other water bottles, dishes, glasses.
• Adequate nutrition Don't use also musical instruments with mouth pieces,

Community Health Nursing

 mouth guards or anything else that has been in the mouth o Risus sardonicus
of the infected person. o Abdominal rigidity
4. Advice importance of check-up after one week discharge, o Localized or generalized muscle spasm
then monthly for those with complication (neurologic
deficit) till improved. Prevention
• Pregnant women should be actively immunized in regions
POLIOMYELITIS (INFANTILE PARALYSIS; HELNE- where tetanus neonatorum is prevalent.
MEDIN DISEASE)
Management
• CA: Legio debilitans
• Keep patient away from noise, bright lights or anything else
that will irritate the patient
• MoT:
o Droplet infection (early infection)
Treatment
o Body secretions (nasopharyngeal)
o Fecal oral (during late stage) • Neutralize the toxin
• Kill the microorganism
• Vector: Flies may act as mechanical vectors • Prevent and control the spasm (Muscle relaxants, Sedatives,
Tranquilizers)
• Incubation Period: 7-12 days • Tracheostomy

Treatment
• Predisposing Factors:
Tetanus Anti-Toxin (TAT)
o Children below 10 years old
o Male more often affected Adult, children, infant 40,000 IU ½ IM, ½ IV
o Poor environmental and hygienic conditions Neonatal Tetanus 20000 IU, ½IM, ½ IV

• Clinical manifestation Tetanus Immunoglobulin (TIG)

o Mild febrile illness: fever, malaise, sore throat (abortive Neonates 1000 IU, IV drip or IM
stage) Adult, infant, children 3000 IU, IV drip or IM
o Pre-paralytic stage - flaccid asymmetrical ascending
paralysis (Landry’s sign), Hayne’s sign (head drop), Control of spasms
Pofer’s sign (opisthotonus) • Diazepam
o Paralytic stage: bulbar or spinal • Chlorpromazine

Diagnostic: Nursing Care

1. Pandy’s test - CSF (increased CHON) • Patient should be in a quiet, darkened room, well ventilated.
• Minimal/gentle handling of patient
Management:
• Active: OPV (Sabin) and IPV (Salk) • Liquid diet via NGT
• Immunity is acquired for 3 strains • Prevent Injury
o Legio brunhilde (fatal)
o Legio lansing TYPHOID FEVER
o Legio leon • CA: Salmonella typhosa, typhoid bacillus

Respiratory Distress Management • Source of Infection:

a. Respirator o Feces and urine of infected persons.
b. Tracheostomy o Family contacts may be transient carrier.
c. Oxygen therapy o Carrier: common on over 40 years of age, females.
d. Rehabilitation
• MoT:
TETANUS NEONATORUM & TETANUS o Oral-fecal route
• CA: Tetanus bacillus (clostridium tetani) o Direct or indirect contact with patient or carrier.

• Source of Infection: Immediate source of infection is soil, • Principal vehicles: food and water.
street dust, animal and human feces.
• Vectors: Flies
• MoT: contamination of the unhealed stump of the umbilical
cord. • Incubation Period: | – 3 weeks.

• Incubation period 4-21 days • Period of Communicability: As long as typhoid bacilli appear in
excreta; from appearance of prodromal symptoms from first
• Clinical manifestation week throughout convalescence.
o Difficulty of opening the mouth (trismus or lockjaw)

Community Health Nursing

 HEPATITIS B
• Clinical Manifestation: – a STD; most serious due to possibility of severe complications
o Rose spot (abdominal rashes) (massive liver damage and hepatocarcinoma of the liver).
o > 7 days step ladder fever 40-41 °C – main cause of liver cirrhosis and liver cancer.
o Headache
o Abdominal pain • CA: Hepatitis B virus
o Constipation (adults)
o Mild diarrhea (children) • Incubation Period: 2 – 5 months
o Ulceration of Peyer's patches
o Enlargement of spleen • MoT:
a. From person to person through:
Laboratory b. Parental transmission through:
1. Blood examination WBC usually leukopenia with lymphocytosis c. Perinatal Transmission
Management:
• Clinical manifestation
• Chloramphenicol o Loss of appetite
• Amoxicillin o Easy fatigability
• Sulfonamides o Malaise
• Ciprofloxacin o Joint and muscle pain (similar to influenza)
• Ceftriaxone o Low grade fever
o Nausea and vomiting
HEPATITIS A (INFECTIOUS HEPATITIS, EPIDEMIC o Right-sided abdominal pain
HEPATITIS, CATARRHAL JAUNDICE) o Jaundice (yellowish discoloration of skin and sclera)
• CA: Hepatitis A virus o Dark-colored urine

• Incubation Period: 15 – 50 days Preventive Measures

• Immunization with Hepatitis B vaccine especially among
infants and high groups with negative HB sag test.
• MoT: fecal-oral route
• Wear protected clothing (gowns, mask, gloves, eye cover),
when dealing with blood semen, vaginal fluids and secretions.
• Susceptibility: Young people especially school children are
most frequently infected. • Wash hands and other skin areas after contact with these
fluids and after removing gloves and gowns.
• Avoid injury with sharp instrument as needles, scalpel, blades.
• Predisposing Factors
• Use disposable needles and syringes only once and discard
o Poor sanitation
properly or sterilize non-disposable needles and syringes
o Contaminated water supplies
o Unsanitary method of preparing and serving of food before and after use.
o Malnutrition • Sterilize instrument used for circumcision, ear holing,
o Disaster and wartime conditions tattooing, acupuncture and those used for minor surgical-
dental procedures.
• Clinical Manifestation: • Avoid sharing of toothbrush, razors and other instruments
o Influenza-like such as headache that can become contaminated with blood.
o Malaise and easy fatigability • Observe safe sex practices
o Anorexia and abdominal discomfort/pain
o Nausea and vomiting Management
o Fever • Symptomatic and supportive measures
o Lymphadenopathy o analgesic-antipyretic (pain and fever) are given.
o Jaundice accompanied by pruritus and urticaria o diet high in carbohydrates.
o Bilirubinemia with clay-colored stools
HEPATITIS C, D, E
Management Hepatitis C
• Prophylaxis: "IM" injection pf gamma globulin – Post transfusion Hepatitis
o Anti HAV IgM – active infection – MoT: percutaneous, BT
o Anti HAV IgG – old infection; no active disease – Predisposing factors: paramedical teams and blood recipients
• Complete bed rest – Incubation period: 2 weeks – 6 months
• Low fat diet but high in sugar
Hepatitis D
Prevention – Dormant type
• Ensure safe water for drinking – can be acquired only if with hepatitis B
• Sanitary method in preparing handling and serving food
• Proper disposal of feces and urine Hepatitis E
– If hepatitis E recurs at age 20-30, it can lead to liver cancer
• Washing hands before eating and after using the toilet

Community Health Nursing

 – Enteric hepatitis Prevention and Control
– MoT: Fecal-oral route • Avoid exposing children to any person with fever or with
acute catarrhal symptoms.
Management • Isolation of cases from diagnosis until about 5-7 days after
• Enteric and Universal precautions onset of rash.
• Assess LOC • Administration of measles immune globulin to susceptible
• Bed rest infants and children under 3 yrs. of age in families.
• ADEK deficiency intervention • Live attenuated and inactivated measles virus vaccines have
• High CHO, Moderate CHON, Low fat been tested and are available for use in children with no
• FVE prevention history of measles, at 9 months of age or soon thereafter.

Complication: Management
1. Fulminant Hepatitis: signs and symptoms of encephalopathy • Protect eyes from glare of strong light as they are apt to be
2. Chronic Hepatitis: lack of complete resolution of clinical signs inflamed.
and symptoms and persistence of hepatomegaly • Keep patient in ventilated room but free from drafts and
3. HBsAg carrier chilling to avoid complications of pneumonia.

MEASLES (RUBEOLA, 7 DAY FEVER, HARD RED GERMAN MEASLES (RUBELLA)

MEASLES) • CA: rubella virus
• CA: paramyxoviridae; morbilli virus
• Clinical Manifestation:
• Source of Infection: Secretion of nose & throat. o Fever
o Exanthem
• MoT: droplet spread or direct contact with infected persons, o Retroauricular adenopathy.
or indirectly through articles freshly soiled with secretions. o Forchheimer’s spot (petechial lesion on buccal cavity or
soft palate)
o Cervical lymphadenopathy
• Incubation Period: 10 days from exposure to appearance of
o Low grade fever
fever and about 14 days until rash appears.
o Oval, rose red papules about the size of pinhead
o Rashes: Maculopapular, Diffuse/not confluent, No
• Period of Communicability: During the period of coryza or desquamation, spreads from the face downwards
catarrhal symptoms - 9 days, (from 4 days before and 5 days
after rash appears).
CHICKEN POX (VARICELLA)
– one of the most readily communicable of diseases (early stages
• Clinical Manifestation
of eruption.)
o Pre-eruptive stage
▪ Coryza
▪ Conjunctivitis • CA: Herpes zoster virus (shingles), varicella zoster virus
▪ Photophobia (chicken pox)
▪ Cough
▪ Koplik’s spots • Incubation Period: 2-3 weeks
▪ Stimson’s line
o Eruptive stage • MoT: Direct contact or droplet spread. Indirect through
▪ Eruption is preceded by about 2 days of articles freshly soiled by discharges of infected persons.
coryza, during which stage grayish pecks
(Koplik spots) may be found on the inner • Source of Infection: Secretion of respiratory tract of infected
surface of the cheeks. persons. Lesions of skin are of little consequence. Scabs
▪ Morbilliform rash appears on 3rd or 4th day themselves are not infective.
affecting face, body and extremities ending in
branny desquamation. • Period of Communicability: Not more than 1 day before and
▪ Maculopapular rashes appears first on the more than 6 days after appearance of first crop of vesicles.
hairline, forehead, post auricular area the spread
to the extremities (cephalocaudal) Immunity
▪ Rashes are too hot to touch and dry • Active : Varicella vaccine
▪ High grade fever and increases steadily at the • Passive: VZIG, ZIG: (given 72-96 hours w/n exposure)
height of the rashes
• Clinical manifestation
Death is due to complication (secondary pneumonia, usually in o Sudden onset with slight fever
children under 2 years old). o Malaise
o Headache
o Eruptions: maculo-papular for few hours, vesicular for
3-4 days and leaves granular scabs.

Community Health Nursing

 o Rashes: Maculopapulovesicular, centrifugal (start: face & WHOOPING COUGH (PERTUSSIS)
trunk then spread to the body) – during attack, the child becomes cyanotic, the eyes appear to
o Leaves a pitted scar (pockmark) bulge or popping out of the eyeball and tongue protrudes

Management • CA: Hemophilus pertussis, Bordet gengou, Bacillus or

• Oral acyclovir Bordetella pertussis or pertussis bacillus.
• Tepid water and wet compresses for pruritus
• Aluminum acetate soak for VZV • Source of Infection: Discharges from laryngeal and bronchial
• Potassium Permanganate (ABO) mucous membrane of infected persons.

Prevention and Control • Clinical manifestation

• Case >15 years of age: investigated to eliminate possibility of o Invasion or catarrhal stage (7-14days) starts with ordinary
smallpox. cough
• Isolation. o Cold
• Concurrent disinfection of throat and nose discharges. o 2nd week: paroxysms of cough ending in a
• Exclusion from school for 1 week after eruption first appears characteristic whoop as the breath is drawn in.
and avoid contact with susceptible. o Spasmodic or paroxysmal 5-10 spasms of explosive
cough (no time to catch breath. A peculiar inspiratory
CHOLERA (EL TOR) crowing sound followed by prolonged expiration and a
• CA: Vibrio El Tor sudden noisy inspiration with a long high pitched “whoop”)
o Vomiting may follow spasm.
o Cough may last for several weeks and occasionally 2-3
• Sources of Infection: Vomitus and feces of infected persons
and feces of convalescent or healthy carriers. months.

• Clinical manifestation • MoT: Direct spread through respiratory and salivary contacts.
o Sudden onset of acute and profuse colorless diarrhea
o Vomiting • Incubation Period: 7-10 but not exceeding 21 days.
o Rice watery stool with flecks of mucus,
o Severe dehydration (Washerwoman’s skin, poor skin • Diagnosis
turgor) 1. WBC count: 20000-50000
o Severe dehydration 2. Culture with Bordet Gengou Agar
o Muscular cramps
o Cyanosis Prevention
o Collapse (severe) • Routine DPT immunization of all infants; started at 1 1/2
months of life and given monthly in 3 consecutive months.
• MoT: Food and water contaminated with vomitus and stools • Booster dose: given at the age of 2 years and again at 4 to
of patients and carriers; oral fecal route 6 years of age.
• Subsequent booster: every 10 years thereafter
• Diagnosis: Stool culture • Segregated until after 3 weeks from the appearance of
paroxysmal cough.
• Incubation Period: few hours to 5 days
Management
• Period of Communicability: 7-14 days after onset, occasionally • Complete bed rest to conserve energy
2-3 months. • Prevent aspiration
• High calorie, bland diet
Management • Omit milk and milk product because it increases the mucous
• IV fluids • Refeeding of infants 20 min after vomiting
• Tetracycline
• Doxycycline Treatment
• Erythromycin • Erythromycin shorten the period of communicability
• Quinolones • Ampicillin if with allergy to erythromycin
• Furazolidone • Hyperimmune pertussis gamma globulin in <2 years old (1.25
• Sulfonamides (children) mL IM)

Nursing Care Nursing Interventions:

• Continue and increase frequency of breastfeeding. • Focused on prevention and other complications: special
attention to diet is needed if patient vomits after cough
• Give additional fluids, "am", soup, cereals mashed vegetables.
paroxysms.
• Coconut water is said to be rich in potassium, one of the
• Teach parents how to pick up the infant or child during
electrolytes found in choleric stools.
paroxysmal cough, giving abdominal support.
• Give Oresol according to required amount based on age

Community Health Nursing

Complications • Vomiting: do not do procedures that may cause nausea
• Bronchopneumonia • Ice collar (reduce pain of sore throat)
• Abdominal hernia • Soft and liquid diet
• Severe malnutrition
• TB LEPROSY (HANSENOSIS, HANSEN'S DISEASE,
• Asthma LEONTIASIS)
• Encephalitis • CA: Mycobacterium leprae/Hansen's bacillus (acid fast, rod -
shaped bacillus)
DIPHTHERIA
• CA: Corynebacterium diphtheria (Klebs-Loeffler bacilus), gram • Incubation period: 5 months – 5 years
positive
• MoT: Airborne (inhalation of droplet/spray from coughing and
• Source of Infection: Discharges and secretions from mucus sneezing of untreated leprosy patient); Prolonged skin-to-skin
surface of nose and nasopharynx and from skin and other contact
lesions.
Laboratory/Diagnostic
• MoT: Contact with a patient or carrier or with articles soiled 1. Slit Skin Smear (SSS) examination – done only when
with discharges of infected persons. diagnosis is doubtful to prevent misclassification and wrong
treatment.
• Milk has served as a vehicle. 2. Skin lesion biopsy
3. Lepromin test
• Incubation Period: 2 to 6 days.
• Clinical manifestation
• Period of Communicability: Until virulent bacilli has disappeared o Early signs
from secretions and lesions: usually 2 weeks and seldom ▪ reddish or white change in skin color
more than 4 weeks. ▪ loss of sensation on the skin lesion
▪ decrease/loss of sweating
• Clinical manifestation ▪ hair growth over the lesion
o Febrile infection of the tonsil, throat, nose, larynx or a ▪ thickened and/or painful nerves
wound marked by a patch or patches of grayish ▪ muscle weakness
membrane ▪ pain or redness of the eye
o Nasal diphtheria is commonly marked by one sided ▪ nasal obstruction/bleeding
nasal discharge and excoriated nostrils. ▪ ulcers that do not heal.
o Non-respiratory or cutaneous diphtheria appears as
localized punched out ulcers. o Late signs/Lepromatous
▪ loss of eyebrow (madarosis)
Diagnosis ▪ inability to close eyelids (lagophthalmos)
1. Nose and throat swab using Loeffler’s medium ▪ clawing of fingers and toes
2. Schick test: determine susceptibility or immunity in diphtheria ▪ contractures
3. Maloney test: determines hypersensitivity to diphtheria toxoid ▪ sinking of the nose bridge
▪ enlargement of the breast in males
Methods of Prevention and Control ▪ chronic ulcers.
• Active immunization of infants (6 weeks) and children with 3
doses of DPT toxoid administered at 4-6 weeks intervals and WHO classification of Leprosy (basis of modern management or
booster doses following year after last dose of primary series Multi-Drug Therapy)
and another dose on the 4th or 5th year of age. 1. Paucibacillary (tuberculoid and indeterminate)
• Pasteurization of milk • Non-infectious types
• Duration of treatment 6-9 months
Treatment • (-) Skin slit test or five or less lesions
• Antidiptheria serum (Neutralize the toxins) 2. Multibacillary (Lepromatous and borderline)
• Penicillin (Kill the microorganism) • Infectious types
• Tracheostomy, Intubation (Prevent respiratory obstruction) • Duration of treatment- 24-30 months
• Serum therapy (Diphtheria antitoxin): early administration • (+) Skin slit test and more than five lesions
aimed at neutralizing the toxin present in general circulation
• Antibiotics: Treatment
o Penicillin G 100000mg/kg/.day • Domiciliary treatment as embodied in R.A. 4073 which
o Erythromycin 40mg/kg advocates home treatment.

Nursing Intervention Multidrug treatment therapy for leprosy

• Patient should be confined to bed for at least 2 weeks – use of two or more drugs (rifampicin, clofazimine, & dapsone)
• Prevent straining on defecation

Community Health Nursing

 – main purpose: to kill all viable organisms in a relatively short TUBERCULOSIS (PHTISIS, CONSUMPTION DISEASE,
period of time rendering the patient noninfectious. KOCH'S DISEASE)
• CA: Mycobacterium tuberculosis and M. africanum from
For Paucibacillary (PB) Leprosy Cases:
humans, occasionally by M. bours from cattle, or M. canettii.
• Adjust dose appropriately for children less than 10 years.
o Rifampicin 300 mg
• MoT:
o Dapsone 25 mg.
o Airborne droplet through inhalation of coughing,
singing, or sneezing.
Single lesion and negative skin slit smear cases
o Bovine tuberculosis: exposure to tuberculosis cattle,
Drug Adult dosage Children (10-14 year old)
by ingestion of unpasteurized milk or dairy products.
Rifampicin 600 mg 300 mg o Extrapulmonary tuberculosis, other than laryngeal, is
Ofloxacin 400 mg 200 mg not communicable, even if there is a draining sinus.
Minocycline 100 mg 50 mg
Frequency Single dose Single dose • Incubation period: 4-6 weeks.
Drugs and dosage for paucibacillary (PB) cases • Period of Communicability: as long as viable tubercle bacili are
Schedule Adult Children (10-14 year old) being discharged in the sputum.
Day 1 Rifampicin 600 mg Rifampicin 450 mg
Dapsone 100 mg Dapsone 50 mg Degree of communicability depends on number of
Days 2-28 Dapsone 100 mg Dapsone 50 mg bacilli discharged, virulence of bacilli, adequacy of ventilation,
Full course 6 blister packs to be 6 blister packs to be exposure of bacilli to sun or UV light and opportunities for
duration taken monthly within a taken monthly within a their aerosolization by coughing, sneezing, talking.
maximum period of 9 maximum period of 9
months. months. • Clinical manifestation
o low grade late o chest pain
For Multibacillary (MB) Leprosy Cases: afternoon fever o cough of two weeks or
• For children younger than 10 years old, the dose must be o loss of appetite more
adjusted according to body weight. o easy fatigability o hemoptysis or recurrent
o night sweats blood-streaked sputum
Schedule Adult Children (10-14 year old) o dry cough o significant weight loss
Drugs and dosage Drug and dosage o later productive o body malaise
Day 1 Rifampicin 600 mg Rifampicin 450 mg with hemoptysis o shortness of breath
Clofazimine 300 mg Clofazimine 150 mg
Dapsone 100 mg Dapsone 50 mg Laboratory/diagnostic test:
Day 2 - Clofazimine 50 mg Clofazimine 50 mg every 1. Direct sputum smear microscopy
28 Dapsone 100 mg other day – principal diagnostic method adopted by NTP.
Dapsone 50 mg
Full 12 blister packs to be 12 blister packs to be Guidelines for interpretation of the results of three specimens
course taken monthly within a taken monthly within a a. Smear positive (+)
duration maximum period of 18 maximum period of 18 – at least two positive (+) sputum smear results,
months months – specimen out of the smear positive (+) results with
the highest number is the final AFB quantification.
• Adjust dose appropriately for children less than 10 years. Laboratory interpretation of sputum AFB
o Rifampicin 300 mg Dapsone 25 mg and Clofazimine Laboratory diagnosis Result
100 mg once a month and 50 mg twice a week. Negative (-) No AFB seen in 100 fields
• Should patient fail to complete treatment within the prescribed Positive (+) 1-9 AFB seen in 100 fields
duration, the patient should continue treatment until he has 1+ 10-99 AFB seen in 100 fields
consumed 24 MB blister packs. 2+ 1-10 AFB seen in 50 fields
3+ > 10 AFB seen in at least 20
Prevention: fields
• BCG vaccination
b. Smear negative (-)
• Avoidance of prolonged skin to skin contact with active
– all three sputum smear results as negative (-).
untreated case
• Good hygiene c. Doubtful
– only 1 positive (+) out of the 3 specimens examined.
– in case of doubtful results, another set of 3 sputum
specimens is requested to the patient.
• If at least 1 specimen from the 2nd set of
specimen is positive (+), diagnosis is positive.
• If all 3 specimens from 2nd set of specimen
are negative (-), diagnosis is negative.

Community Health Nursing

 2. Chest X-ray Single-drug formulation (SDF)
– assumed a secondary role in the diagnosis of TB based on NTP. – each drug is prepared individually.

Prevention: FDC has several advantages over SDF:

• Bacillus Calmette-Guérin (BCG) vaccination of newborn • FDC is administered more easily than SDF
infants provides 50% protection against any TB disease, and • less chances of drug resistance
grade I/school entrants • decrease in medication errors
• improves health workers and patients adherence.
Fixed-dose combination (FDC)
– two or more anti-TB drugs are combined in one tablet, is
highly recommended.

Recommended Category of Treatment Regimen

Treatment regimen
Category Types of TB patients
Intensive phase Maintenance phase
• New smear-positive PTB,
• New smear-negative PTB with extensive parenchymal lesions on
HRZE HR
I CXR as assessed by the TBDC
(2 months) (4 months)
• Extrapulmonary TB
• Severe concomitant HIV disease
• Treatment failure (patient while on treatment, is sputum smear
positive at 5 months or later during the course of treatment)
• Relapse (patient previously treated for TB, who has been declared HRZES
cured or treatment completed, and is diagnosed with (2 months) + HRE
II
bacteriologically positive TB) HRZE (5 months)
• Return after default (RAD) (patient who returns to treatment with (1 month)
positive bacteriology, following interruption of treatment for 2
months or more)
• New smear-negative PTB with minimal parenchymal lesions on
III HRZE (2 months) HR (4 months)
chest X-ray
• Chronic (still smear-positive after supervised retreatment) (2 months)
IV Second-line generation antibiotics based on results of
culture and sensitivity test

Tuberculosis treatment regimen for children Treatment Regimen for Category I : 2HRZES/HRZE/4HRE (FDC)
Treatment regimen Continuation
Types of TB Intensive Phase
Intensive phase Maintenance phase Phase
Body
HRZ HR 3rd
Pulmonary TB Weight First 2 months E
(2 months) (4 months) month FDC-
(kg) 400
Extrapulmonary HRZS HR FDC-A FDC-A B (HR)
Streptomycin mg
TB (2 months) (10 months) (HRZE) (HRZE)
30 - 37 2 0.75 g 2 2 1
Dosage per Category of Treatment Regimen 38 - 54 3 0.75 g 3 3 2
a. Fixed-Dose Formulation (FDC) 55 - 70 4 0.75 g 4 4 3
– number of tablets per patient will depend on body weight. > 70 5 0.75 g 5 5 3
– patients must be weighed before treatment is started.
b. Single Drug Formulation (SDF)
Treatment Regimen for Categories | & I I: 2HRZE/4HR (FDC) – modify dosage within acceptable limits according to body
No. of tablets/day No. of tablets/day weight, particularly those weighing <30kg at time of diagnosis.
Intensive Phase Continuation Phase
Body Weight (kg)
(2 months) (4 months) Treatment Regimen for Categories | & I : 2HRZE/4HR (SDF)
FDC-A (HRZE) FDC-B (HR) Anti-TB Drugs No. of tablets/day No. of tablets/day
30 - 37 2 2 Intensive Phase Continuation Phase
38 - 54 3 3 (2 months) (4 months)
55 - 70 4 4 Isoniazid (H) 1 1
> 70 5 5 Rifampicin (R) 1 1
Pyrazinamide (Z) 2
Ethambutol (E) 2

Community Health Nursing

Treatment Regimen for Category I : 2HRZES/1HRZE/5HRE MUMPS (EPIDEMIC PAROTITIS)
No. of tablets or vial/day – one of the most readily communicable of diseases, especially in
Intensive Phase No. of tablets/day the early stages of eruption.
Anti-TB Drugs (3 months) Continuation Phase
First 2 (5 months)
3rd month • CA: Mumps virus, a member of family Paramyxomviridae,
months
Isoniazid (H) 1 1 1 genus Paramyxovirus, antigenically related to parainfluenza
Rifampicin (R) 1 1 1 viruses.
Pyrazinamide (Z) 2 2
Ethambutol (E) 2 2 2 • MoT: direct contact with a person who has the disease or by
Streptomycin (S) 1 vial/day (56 vials for 2 contact with articles freshly soiled with secretion from the
months) nasopharynx.

Drug Dosage per kg Body Weight • Source of Infection: mouth and nose secretion.
Drug Dose per kg body weight and maximum dose
Isoniazid 5(4 - 6) mg/kg, and not to exceed 400mg daily • Incubation Period: 12 to 26 days, usually 18 days.
Rifampicin 10(8 - 12) mg/kg, and not to exceed 600mg daily
Pyrazinamide 25(20 - 30) mg/kg, and not to exceed 2g daily • Period of Communicability: begins before glands are swollen
Ethambutol 15 (15 - 20) mg/kg, and not to exceed 1.2g daily and last as long as any localized glandular swelling remains.
Streptomycin 15 (12 - 18) mg/kg, and not to exceed 1g daily
• Clinical manifestation
National Tuberculosis Control Program o Painful swelling in front of ear, angle of jaws & down
Vision: A country where TB is no longer a public health problem the neck
o Swelling of one or both of the parotid glands
Mission: Ensure that TB DOTS services are available, accessible, o Fever
and affordable to the communities in collaboration with the LGUs o Malaise
and other partners o Loss of appetite
o Swelling of one or both testicles (orchitis) in some boys
Goal: to reduce prevalence and mortality from TB by half by the
year 2015 through its targets: Management
• cure at least 85% of the new sputum smear-positive • Prophylactic
cases discovered • Diet should be soft or liquid as tolerated.
• detection at least 70% of the estimated new sputum • Avoid sour foods/fruit juices due to burning/stinging sensation.
smear positive cases. • Soft, bland diets are prescribed if the jaws are sore.
• Ice collar/cold applications over parotid glands relieve pain.
Philippines adopted Comprehensive Unified Policy on TB control.
• Remain in bed to prevent complications.
Comprehensive Unified Policy put all TB control protocols • Inflammation of lachrymal glands, or conjunctivitis may occur.
under one umbrella and enjoined other key government agencies o doctor may prescribe cold compresses or a collyrium.
and private organizations involved in TB control to carry out their o protection from light, dark glasses may be used.
respective TB control efforts in the context of the NTP.
Medications.
NTP Objectives and Strategies • Mumps immune serum used for passive immunization.
NTP's four-pronged set of objectives calls for improvement of • Serum sickness does not follow, since it is human serum, but
access to and quality of services, enhancement of stakeholders' hepatitis has occurred.
health-seeking behavior, sustainability of support for TB control • Children as a rule require no medication.
activities, and strengthening management of TB control services
at all levels. SOIL TRANSMITTED HELMINTHIASES
– third most prevalent infection worldwide, second only to the
Patients with the following conditions shall be recommended for diarrheal diseases and tuberculosis.
hospitalization – ranked 10th among the World's Top Ten infectious diseases killer
1. massive hemoptysis according to WHO.
2. pleural effusion obliterating more than ½ of a lung field
3. miliary TB 3 major causes of intestinal parasitic infections in the Philippines:
4. TB meningitis • Ascaris lumbricoides
5. TB pneumonia • Trichuris trichiura
6. those requiring surgical intervention or with complications. • Hookworm (Ancylostoma duodenale & Necator americanus).

NTP adopted DOTS, most effective strategy for controlling TB. Classified as soil transmitted helminths (STH) because their
major development takes place in the soil.

Geofactors (temperature, humidity wind are the primary

factors which determine their distribution.

Community Health Nursing

 – anthelmintic effect occurs by blocking the glucose uptake
They do not need any intermediate host. Intestinal parasites of the organisms, reducing the energy until death
live as long as 5 years, passing out as much as 240,000 eggs
per worm per day. 2. Pyrantel pamoate
– neuromuscular blocking effect which paralyze the helminth,
With unsanitary disposal of human stools, eggs develop in the allowing it to be expelled in the feces
soil and can mechanically infect humans when fingers, food or
water are contaminated with parasite eggs from the soil or when 3. Pierazine citrate:
the infective lava of hookworms in the soil penetrate skin of – paralyze muscles of parasite, this dislodges the parasites
barefooted individuals. promoting their elimination

• Clinical manifestation Complications

o Anemia • Migration of worms to body parts (ears, mouth, nose)
o Malnutrition • Loeffler’s Pneumonia
o Stunted growth in height and body size • Energy protein malnutrition
o Decreased physical activity • Intestinal obstruction
o Impaired mental development and school performance
TAPEWORM (FLATWORMS)
Susceptibility:
• CA: Taenia Saginata (cattle), Taenia Solium (pigs)
• 2 to 5 years old: easily infected and they should be given
treatment.
• MoT: fecal oral route
• 6 to 14 years old: harbor the greatest local of infection and
are significant source of transmission (reservoir).
• Clinical manifestation
Treatment:
o neurocysticercosis
• aim to reduce the source of infection. o seizures
• frequency of treatment: 2x a year for 3 years. o hydrocephalus

HOOKWORM (ROUNDWORM) Diagnostic:

– leads to iron deficiency and hypochromic microcytic anemia • Stool Exam
– gain entry via the skin
Management:
• CA: Necator Americanus, Ancylostoma Duodenale • Praziquantel
• Niclosamide
Diagnostic:
• Microscopic exam (stool exam) PINWORM
• CA: Enterobius vermicularis
Management:
• Pyrantel Pamoate and Mebendazole
• MoT: fecal oral route
• Don’t give drug without (+) stool exam
• Members of the family must be examined and treated also • Clinical manifestation
o Itchiness at the anal area d/t eggs of the agent
ASCARIASIS Diagnostic:
– greatest frequency in tropical countries. • tape test at nighttime (agents release their eggs during
– infection rate of 70-90% in rural areas nighttime)

• Worms reach maturity 2 months after ingestion of eggs. Management:

• Adult worms live > 10 months (18 months maximum.) • Pyrantel Pamoate
• Female can produce up to 200 000 eggs per day • Mebendazole
• Eggs may be viable in soils for months or years
• Worms can reach 10-30cm in length Management:
• Promote hygiene
• MoT: ingestion of embryonated eggs (fecal-oral) • Environmental Sanitation
• Proper waste and sewage disposal
• Clinical manifestation • Anthelmintic medications repeated after 2 weeks (entire
o loss of appetite o vomiting family)
o worms in the stool o abdominal distention
o fever o diarrhea
o wheezing o dehydration

Medical Management
1. Mebendazole

Community Health Nursing

 PARALYTIC SHELLFISH POISONING (PSP I RED TIDE
POISONING) Management:
– syndrome of characteristic symptoms predominantly neurologic • Anti-viral - acyclovir (zovirax)
which occur within minutes or several hours after ingestion of
poisonous shellfish. Compilation:
– organism that causes red tide in the seas around Manila Bay, • Meningitis
Samar, Bataan, and Zambales is the Pyromidium bahamense var. • Neonatal infection (vaginal birth)
compressum.
– poison victims who survive the first twelve hours after ingestion GENITAL WARTS (CONDYLOMA ACUMINATUM)
of the toxic shellfish have a greater chance of survival. • CA: HPV type 6 & 11, papilloma virus

• CA: dinoflagellates/plankton, single celled organism (poisonous • Clinical manifestation

after heavy rainfall preceded by prolonged summer). o Single or multiple soft, fleshy painless growth of the
vulva, vagina, cervix, urethra, or anal area
• MoT: Ingestion of contaminated bi- valve shellfish or mollusks o Vaginal bleeding, discharge, odor
during red tide season. o Dyspareunia

• Incubation Period: 30 minutes to several hours after ingestion DX:

of poisonous shellfish. • Pap smear-shows cellular changes (koilocytosis)
• Acetic acid swabbing (will whiten lesion)
• Clinical Manifestation • Cauliflower or hyperkeratotic papular lesions
o Numbness of the face especially around the mouth
o Vomiting and dizziness Treatment
o Headache • liquid nitrogen - podophylin resin
o Tingling sensation, paresthesia and eventual paralysis • Laser treatment is more effective
of hands and feet
o Floating sensation and weakness Complication
o Rapid pulse • Neoplasia
o Difficulty of speech (ataxia) and difficulty of swallowing • Neonatal laryngeal papillomatosis (vaginal birth)
(dysphagia)
o Total muscle paralysis with respiratory arrest and GONORRHEA (MORNING DROP, DRIP, TULO, CLAP,
death occurs in severe cases.
JACK)
Management and Control Measures – genitals (penis or cervix), anus, throat, and eyes can be infected.
• No definite medication indicated
• CA: Neisseria gonorrhoeae (gram positive)
• Induce vomiting
• Drinking pure coconut milk weakens toxic effect of red tide
• MoT: Sexual contact
sodium bicarbonate solution (25 grams in 1/2 glass of water).
o Drinking of coconut milk and sodium bicarbonate solution
is advised during early stage of poisoning only. • Incubation period: 3 – 7 days
o If given during late stage, it can make the patient’s
condition worse. • Clinical manifestation
o Females
• Shellfish affected by red tide must not be cooked with vinegar
▪ vaginal discharge (80% asymptomatic for
as toxin of Pyromidium increases (15x greater) when mixed
cervical infection of rectum; mild sore throat
with acid.
for gonorrhea of the throat.)
• Toxin of red tide is not totally destroyed upon cooking hence
o Male (5-10% asymptomatic)
consumers must be educated to avoid bi-valve mollusks such
▪ Mucopurulent discharge
as tahong, talaba, halaan, kabiya, abaniko when the red tide
▪ Painful urination
warning has been issued.
▪ Decreased sperm count
▪ Burning urination and pus discharges from
HERPES GENITALIS infection of urethra
• CA: HSV 2
Laboratory/Diagnostic
• Clinical Manifestation 1. Gram stain & culture of cervical secretions on Thayer Martin
o Painful sexual intercourse VCN medium
o Painful vesicles (cervix, vagina, perineum, glans penis) 2. Culture of specimen in cervix (female)
3. Gram stain (male)
Diagnostic:
• Viral culture Treatment: single dose only
• Pap smear (shows cellular changes) • Ceftriaxone (Rocephin) 125 mg IM
• Tzanck smear (scraping of ulcer for staining) • Ofloxacin (Floxin) 400 mg orally

Community Health Nursing

 • Treat concurrently with Doxycycline or Azithromycin for 50% 3. Fluorescent treponemal antibody absorption test (FTA-ABS)
infected w/ Clamydia 4. Kalm Test

Prevention Treatment
• Crede's prophylaxis (silver nitrate/ tetracycline) • Primary and secondary: Penicillin G
• Avoid contact with secretions • Tertiary: IV Penicillin G
• Practice monogamous sexual contact
Complication
Complications • Damage to nervous system and other organs, heart disease,
• Meningitis • PID insanity, brain damage, severe illness or death of newborns
• Heart damage • Ectopic pregnancy
• Kidney damage • Infertility CHLAMYDIA
• Skin rash • Peritonitis • CA: Chlamydia trachomatis, gram (-)
• Ophthalmia neonatorum • Perihepatitis
• Sepsis • Arthritis • MoT: Sexual contact; infants can become infected during
vaginal delivery.
SYPHILIS (SY, BAD BLOOD, THE POX)
• CA: Treponema pallidum, spirochete • Incubation Period: 2-10 days

• Incubation Period: 10-90 days • Clinical manifestation

o Gray white discharge
• MoT: Passed by direct contact with infectious sore. o Burning and itchiness at the urethral opening
o Females:
• Clinical manifestation ▪ slight vaginal discharge
o Primary (3 – 6 weeks after contact): nontender ▪ itching and burning of vagina
lymphadenopathy and chancre, swollen glands; most ▪ painful intercourse
infectious; resolves 4 – 6 weeks ▪ abdominal pain
▪ fever in later stages.
Chancre
– painless ulcer with heaped up firm edges o Males:
▪ discharge from penis
appears at the site where treponema enters.
▪ burning and itching of urethral opening
▪ burning sensation during urination.
Bubo
– swelling of regional lymph node
Diagnostic
o Secondary (appear 1 week to 6 months after 1. Gram stain
2. Antigen detection test on cervical smear
appearance of chancre): systemic; generalized macular
papular rash (palms and soles), painless wartlike lesions 3. Urinalysis
in vulva or scrotum (condylomata lata),
lymphadenopathy, rash, patchy hair loss, alopecia, sore Management
throat, mucous patches of the mouth and swollen • Doxycycline or Azithromycin
glands • Erythromycin and Ofloxacin

o Tertiary (6 – 40 years): neurosyphilis/permanent Complication:

damage (insanity); gumma formation (necrotic • Untreated: sterility, pre-maturity & stillbirths, infant pneumonia
granulomatous lesions), aortic aneurysm, damage to & eye infections in infants, which can lead to blindness.
body organs such as the brain and heart and liver. • PID
• Ectopic pregnancy
Primary & secondary sores will go away even without treatment, • Fetus transmittal (vaginal birth)
but germs continue to spread throughout the body.
CANDIDIASIS (MONILIASIS)
Latent syphilis may continue 5-20+ years with no symptoms, but • CA: Candida albicans (most common cause), Candida
the person is no longer infectious. tropicalis (rare cause)

Pregnant woman can transmit it to her unborn child (congenital • MoT: Contact with secretions or excretions of mouth, skin,
syphilis). vagina, and feces, from patients or carriers.
Diagnostic
• Incubation period: Variable
1. Dark-field illumination test: lesion 1st & 2nd stage
2. Nonspecific Venereal disease research laboratory (VDRL) &
RPR • Period of communicability: Presumably while lesions are
present

Community Health Nursing

 HUMAN IMMUNODEFICIENCY VIRUS INFECTION
• Clinical manifestation /ACQUIRED IMMUNE DEFICIENCY SYNDROME
o Severe vulvar pruritus (prominent feature)
• CA: Retrovirus - Human T-cell lymphotrophic virus 3 (HTLV -3);
o Vaginal discharge (scanty, whitish, yellow, thick to form Retrovirus (HIV 1 and 2)
curds, non-offensive)
o Sore vulva • MoT:
o Speculum examination: thick whitish plugs attached to o Sexual contact
vaginal wall, vaginal epithelium bleeds when plug is o Blood transfusion
removed, but cervix is normal. o Contaminated syringes, needles, nipper, razor blades
o Direct contact of open wound/mucous membrane with
Diagnosis: contaminated blood, body fluids, semen and vaginal discharges.
1. Microscopic demonstration of pseudohyphae or yeast cells in
infected tissue or body fluids (vaginal discharge) • Incubation Period: Variable. Time from infection to development of
2. KOH (wet smear indicate positive result) detectable antibodies is 1-3 months, the time from HIV infection to
diagnosis of AIDS has observed range of less than 1 year to 15 years
Treatment: or longer.
• Nystatin vaginal pessary
• Miconazole or clotrimazole creams • Clinical Manifestations
• Ketoconazole A. Physical
o Maculo-papular rashes o Kaposi's sarcoma (skin
• Fluconazole in recurrent cases
o Loss of appetite cancer)
• Imidazole
o Weight loss (major) o Pneumocystis carinii
• Monistat o Fever of unknown pneumonia
• Diflucan origin; Prolonged for 1 o Gaunt-looking,
month (major) apprehensive
Complications: o Malaise o Cough for 1 month (minor)
• Oral thrush to baby (vaginal birth) o Persistent diarrhea o Pruritic dermatitis (minor)
(major signs) o Recurrent herpes zoster
TRICHOMONIASIS (TRICH) o Tuberculosis (localized (minor signs)
• CA: Trichomonas vaginalis. and disseminated) o Candidiasis (minor)
o Esophageal candidiasis o Lymphadenopathy (minor)
• MoT:
o usually passed by direct sexual contact. B. Mental
o can be transmitted through contact with wet objects, such as Early Stage Later Stage
towels, wash clothes and douching equipment. o Forgetfulness o Confusion
o Loss of concentration o Disorientation
• Incubation: 4 to 20 days, with average being 7 days. o Loss of libido o Seizures
o Apathy o Mutism
• Clinical manifestation o Psychomotor retardation o Loss of memory
o Many women and most men have no symptoms. o Withdrawal o Coma
o Females:
▪ White or greenish-yellow odorous discharge Stages:
▪ Vaginal itching and soreness 1. Acute viral illness (1 month after initial exposure) – fever,
▪ Painful urination. malaise, lymphadenopathy
o Males: 2. Clinical latency – 8 yrs with no symptom; towards end, bacterial
▪ Slight itching of penis and skin infections and constitutional symptoms – AIDS related
▪ Painful urination complex; CD4 counts 400-200
▪ Clear discharge from penis. 3. AIDS – 2 yrs; CD4 T lymphocyte < 200 w/ (+) ELISA or
Western Blot and opportunistic infections
Diagnosis:
1. Microscopic slide of discharge Diagnosis:
2. Culture tests • Enzyme Linked Immuno-Sorbent Assay (ELISA) presumptive test
• Western blot- confirmatory test
Management o HIV
• Metronidazole ▪ 2 consecutive positive ELISA
▪ 1 positive Western Blot Test
Complications: o AIDS
• PROM ▪ CD4 is less than 200/ml

Treatment
• Anti-retroviral Therapy (ART) – ziduvirine (AZT)

Prevention:
• Maintain monogamous relationship

Community Health Nursing

• Avoid promiscuous sexual contact • Use of condoms and other protective device.
• Sterilize needles, syringes and instruments • Abstinence
• Proper screening of blood donors • Be faithful
• Rigid examination of blood and other products for transfusion • Condoms
• Avoid oral, anal contact and swallowing of semen • Don’t use drugs
Laws for the Control of Communicable Diseases
Laws Description
Republic Act 3573 Reporting of Communicable Diseases: Requires individuals and health facilities to report notifiable diseases to local and national
public health authorities. Pursuant to Section 3 of Act 3573, the lists of notifiable disease are epidemic-prone diseases, which are
targeted for eradication or elimination, and subject to international health regulation.

Category I (Immediately notifiable): acute flaccid paralysis, adverse event following immunization, anthrax, human avian influenza,
measles, meningococcal disease, neonatal tetanus, paralytic shellfish poisoning, rabies, and Severe Acute Respiratory Syndrome

Category II (Weekly Notifiable) includes acute nloody diarrhea, acute encephalitis syndrome, acute hemorrhagic fever syndrome,
acute viral hepatitis, bacterial meningitis, cholera, dengue, diphtheria, influenza-like illness, leptospirosis, malaria, non-neonatal
tetanus, pertussis, typhoid and paratyphoid fever.
Republic Act 4073 Act Liberalizing the Treatment of Leprosy: No persons afflicted with leprosy shall be confined in a leprosarium provided that
such person shall be treated in any government skin clinic, rural health unit or by a duly licensed physician.
Republic Act 8504 Philippines AIDS Prevention and Control Act of 1998: Act promulgating policies and prescribing measures for the prevention and
control of HIV/AIDS in the Philippines, instituting a nationwide HIV/AIDS information and educational program, establishing a
comprehensive HIV/AIDS monitoring system, strengthening the Philippine National AIDS Council and for other purposes.
Republic Act 9482 Rabies Act of 2007: Rabies control ordinances shall be strict implemented and the public shall be informed on the proper
management of animal bites and/or rabies exposures.
Republic Act 1136 Tuberculosis Law of 1954: Creation of the Division of Tuberculosis under an appointed Director of the National Tuberculosis
Center of the Philippines (NTCP) established at the DOH compound.
Memorandum Circular Pronounced the National Tuberculosis Control Programs as the highest priority public health program of the LGUs.
No. 98-155
Presidential Proclamation Reaffirming the commitment to the Universal Child and Mother Immunization goal by launching the Polio Eradication Project,
No. 46 of 1992 which aims to make the Philippines polio-free by 1995.
Presidential Proclamation Declaring month of June as National Dengue Awareness Month, and formulation of the National Dengue Prevention and Control
No. 1204 of 1998 Program to reduce morbidity and mortality due to dengue so that it will no longer be a public health problem.
Administrative Order National Tuberculosis Control Program adopted Directly Observed Treatment, Short-Course (DOTS) in the management of TB.
No. 24 series of 1996.

Community Health Nursing

 NCM 104 & 113: Community Health Nursing
CHAPTER 13: ENVIRONMENTAL HEALTH Environmental health indicators that need to be monitored are
as follows:
ENVIRONMENTAL HEALTH 1. Households with access to improved or safe water - stratified
to Levels 1, Il, and I I
In 1998, DOH, in its IRR of Chapter XX (Pollution of the
2. Households with sanitary toilets
Environment) of the Code of Sanitation of the Philippines (P.D. 856)
3. Households with satisfactory disposal of solid waste
4. Households with complete basic sanitation facilities
Environmental health
5. Food establishments
– characteristics of its conditions that affect quality of health.
6. Food establishments with sanitary permits
– aspect of public health that is concerned with those forms
7. Food handlers
of life, substances, forces, and conditions in the surroundings
8. Food handlers with health certificates
or person that exert influence on human health & well being

In 1993, WHO described environmental health through • 2nd week of January, midwife submits Annual Barangay Health
consultation in Sofia, Bulgaria: Station Report "A-BHS" form to city/municipal health nurse.

Environmental Health • City/municipal health nurse consolidates A-BHS forms to annual

– comprises of those aspects of human health, including quality report using "Al" form that is due by 3rd week of January.
of life, that are determined by physical, chemical, biological,
social, and psychosocial factors in the environment. • Provincial health nurse performs same task and submits a
– theory and practice of assessing, correcting, controlling, and consolidated "Al" report form of all municipalities to DOH
preventing factors in environment that can potentially affect Regional FHSIS Coordinator on 4th week of January.
adversely the health of present and future generations.
• Consolidated regional annual reports are submitted to DOH
Environmental health National Office on 2nd week of March that year.
– component of individual's well-being that is determined by
interactions with physical, chemical, biological, social, & psychosocial Households with access to improved or safe water supply
factors external to him or her. – have access to any levels of safe water sources that conforms
to national standards for drinking water.
Executive Order No. 489: Institutionalizing the Inter-Agency
Committee on Environmental Health (IACEH) Level I: Point source
– DOH Secretary (chairperson); DENR Secretary (vice chairperson). – protected well (shallow/deep well), improved dug well, developed
– task of coordinating, monitoring, and evaluating environmental spring, rainwater cistern with outlet but without distribution system.
health programs initiated by the government and private agencies – adaptable for rural areas where houses are thinly scattered.
to achieve environmental protection for health promotion. – serve 15-25 households and its outreach must not be more than
– to perform these roles, National Environmental Health Action Plan 250 meters from the farthest user.
(NEHAP) had been developed – yield or discharge: 40 to 140 liters/minute.
– point of consumption is at source itself, placing water reservoir
Components of Environmental Health (NEHAP) at higher risk of contamination.
Assigned to the leadership of members of lACEH
1. Solid waste In FHSIS, if Level I reservoir (protected rainwater cistern) is piped
2. Water into the tap of households, they are then considered to have a Level
3. Air Ill access as the risk of reservoir contamination is minimized.
4. Toxic and hazardous waste
5. Occupational health Level Il: Communal faucet system or Standpost
6. Food safety – has source, reservoir, piped distribution network, & communal
7. Sanitation faucet located not more than 25 meters from farthest house.
– suitable for rural and urban areas where houses are clustered
In July 2010, this has been expanded to include climate change. densely enough to justify a simple piped water system.
– include communal faucet where group of households get their
ENVIRONMENTAL HEALTH RECORDS MANAGEMENT water supply even if the faucet is connected to Level Ill source.
– designed to deliver 40-80 liters per capita/day to an average of
• Maintenance of environmental health records is a responsibility
100 households, with one faucet per 4-6 households.
given to city, municipal, and provincial health nurses.
– piped distribution network takes point of consumption away
• Field Health Service Information System: Data management from reservoir, decrease risk of pollution coming from consumers.
system being used by the DOH.
• Data collection begins with midwife and BHWs. Level I I: Waterworks system
• Midwife is tasked to maintain monthly record of environmental – system with a source, transmission pipes, a reservoir, and a piped
health program accomplishments in Summary Table form. distribution network for household taps.
– suited for densely populated areas.
– requires minimum treatment of disinfection.

Community Health Nursing

Households with complete basic sanitation facilities d. Chemical wastes
– satisfy the presence of the following basic sanitation elements: – varied states of chemical matter from clinical or
• access to safe water, laboratory, housekeeping, & disinfecting procedures.
• availability of a sanitary toilet – has any of the five properties of hazardous wastes:
• satisfactory system of garbage disposal. hazardous chemical wastes.

Sanitary permit e. Sharps

– certification of city health officer or sanitary engineer that they – biomedical wastes cause cuts or puncture wounds.
comply with minimum sanitation requirements upon inspection in – include needles, broken glass, and scalpels blades.
accordance with P.D. No. 522 & 856 and local ordinances.
f. Radioactive wastes
REPUBLIC ACT 9003: ECOLOGICAL SOLID WASTE – include sealed radiation sources, liquid, & gaseous
materials contaminated with radioactivity, excreta of
MANAGEMENT ACT OF 2000 patients who underwent radionuclide diagnostic and
– activities that reduce, & eliminate, potentially recyclable materials therapeutic applications, together with related
in waste stream before they end up as undesirable on the land. paraphernalia and tap water washings.
– discipline associated with control of generation, storage,
collection, transfer & transport, processing, & disposal of solid 3. Industrial waste
wastes in accordance with best principles of public health, – arise from production & agricultural, and mining industries.
economics, engineering, conservation, aesthetics, & other
environmental considerations, and responsive to public attitudes. 4. Hazardous wastes
– substances that pose immediate/long-term danger,
Health-supporting functions of land, such as: possessing any of the following properties:
1. Platform for human activities: Polluted soil is contaminated with • toxic
disease-causing parasites and microbes.
• corrosive (acids of pH <2; bases of pH >12)
2. Agricultural production: Alteration of soil composition can make
• flammable
land unsuitable for growing crops and threaten food security.
3. Habitat of members of the food chain: • reactive (can cause explosions)
• As hazardous materials accumulate; they affect lower • genotoxic (cytostatic drugs).
life-forms in a process: Bioaccumulation.
• Hazardous chemicals increase in concentrations in the • Pathway of municipal solid waste (solid waste stream) begins
food chain in a process: Biomagnification. with waste generation.
4. Filter for surface water: bodies of water percolate through soil • Waste reduction can be done through the reuse of materials.
layers until it finds its way to groundwater.
Color coding of hospital waste bins
Classification of Solid Waste • Black or colorless: Nonhazardous & nonbiodegradable wastes
1. Municipal waste • Green: Nonhazardous biodegradable wastes
– discarded nonhazardous household commercial and • Yellow with biohazard symbol: Pathological/ anatomical wastes.
institutional waste, street sweepings, and construction debris. • Yellow with black band: Pharmaceutical, cytotoxic, or chemical
wastes (labeled separately)
2. Health care waste (biomedical wastes) • Yellow bag that can be autoclaved: Infectious wastes
– generated in diagnosis, treatment, or immunization. • Orange with radioactive symbol: Radioactive wastes
– classified as follows:
a. Infectious wastes Recyclable wastes such as metals, plastics, paper, and glass can
– suspected to contain pathogens in sufficient be sent to MRF to generate recycled raw materials for producers.
concentration to cause a disease in susceptible hosts.
– include: laboratory cultures, contaminated wastes Biodegradable and organic wastes can be sent to a composting
from clients with infectious disease, and materials that unit for processing and subsequent agricultural use.
have been in contact with the infected.
Only residual wastes (if any) should be dumped into the sanitary
b. Pathological wastes landfill.
– tissues, organs, body parts, human fetuses, animal
carcasses, and blood and body fluids. IRR of Republic Act 9003 declared the following as prohibited acts:
– recognizable human body parts: anatomical waste. • Open burning
• Open dumping
c. Pharmaceutical wastes • Burying in flood-prone areas
– pharmaceutical products (drugs, vaccines, sera) • Squatting in landfills
that are no longer required and need to be disposed. • Operation of landfills on aquifer, groundwater reservoir,
– includes discarded items used in handling watershed
pharmaceuticals (bottles/boxes with residues, gloves, • Construction within 200 meters from dump/landfill
masks, connecting tubings, and drug vials).

Community Health Nursing

 WATER SANITATION o Settlement
DOH had set standards of quality of drinking water through DOH ▪ allow it to stand undisturbed in the dark for a day.
Administrative Order No. 2007-0012: Philippine National Standards for ▪ causes death to >50% of most harmful bacteria
Drinking Water of 2007. and settling of suspended solids.
General requirements of safe drinking water: ▪ repetition of settlement in another container
1. Microbial quality increases its effectiveness
– tested through parameters of total coliform, fecal o Filtration
coliform, & heterotrophic plate count. ▪ utilize filters to block particles while allowing water
2. Chemical and physical quality to pass through (clean cloth, sand, ceramics).
– tested through parameters of pH, chemical-specific
levels, color, odor, turbidity, hardness, total dissolved solids. • Disinfection Processes:
3. Radiological quality o Boiling
– tested through parameters of gross alpha activity, gross ▪ very effective method for water disinfection.
beta, and radon. ▪ water should be brought to "rolling boil" and kept
in that state for at least 1 minute at sea level.
DOH AO 2007-0012 directs drinking water processors to create a ▪ at higher altitudes, it should be kept in rolling boil
water safety plan. The key components of water safety plans include: state for 3 minutes.
1. System assessment ▪ causes water to change taste and be improved by
– determine if drinking water supply chain can deliver performing aeration after it has been cooled.
water of quality that meets health-based targets. o Chemical disinfection
2. Operational monitoring ▪ using various chemicals (most widely: chlorine as it
– identify control measures in drinking water system that can kill all viruses & bacteria).
collectively control identified risks & ensure health-based ▪ some species of protozoa & helminths are
targets met, detect deviation from required performance. resistant to chlorination.
3. Management plans o Solar disinfection (SODIS)
– describe actions to be taken during normal operations ▪ follows the principle that ultraviolet rays from the
or incident conditions. sun destroy harmful organisms in water.
▪ done by filling transparent plastic containers 1 to 2L
Republic Act 9275: Philippine Clean Water Act of 2004 with clear water & exposing to direct sunlight for
– national law on water quality management. 5 hours. If cloudy, exposed for 2 consecutive days.
– DENR as lead agency in law implementation & enforcement.
– DOH primarily responsible for promulgation, revision, & Water Storage and Consumption
enforcement of drinking water quality standards. • Wide-necked containers with tight-fitting lids are best for
water storage (easy to clean between use).
DOH has produced IRR of P.D. 856 Chapter I : Water Supply. Some
of the provisions include: AIR PURITY
1. Washing & bathing within radius of 25 meters from well or Air pollutant
other source of drinking water is prohibited. – DENR A.O. 2000-81: any matter in atmosphere other than natural
2. No artesians, deep, or shallow well shall be constructed within concentrations of oxygen, nitrogen, water vapor, CO2, and inert
25 meters from source of pollution (septic tanks & gases that may be detrimental to health or the environment.
sewerage systems). Drilling wells within 50-meters distance
from a cemetery is also prohibited. • As the altitude increases, oxygen percentages decrease.
3. No radioactive source or material shall be stored within radius
of 25 meters from well or source of drinking water unless Troposphere
it is adequately & safely enclosed by proper shielding. – temperature is warmest at sea level; coolest at higher altitudes.
4. No dwellings shall be constructed within catchment area of – as the air gets cooler, the less water vapor it is able to carry.
protected spring water source, and it shall be off limits to
people and animals. • Particulate matter that is of public health concern is ~10 pm in
size (PM10) as they can be suspended in air.
EMERGENCY WATER TREATMENT
Technical Notes on Drinking Water, Sanitation, & Hygiene in DENR AO 2000-81: IRR for RA 8746 identified pollutants that
Emergencies created by Water, Engineering, & Development should concern communities
Center (WHO, 2011), provides prescriptions for emergency treatment • ozone-depleting substances
of drinking water: • chlorofluorocarbons
• particulate matter that refers to any material that exists in
• Pretreatment Processes: a finely divided form as a liquid or solid other than water,
o Aeration greenhouse gases that can potentially induce global
▪ remove volatile substances, reduce CO2 content, warming such as carbon dioxide, methane, and oxides of
& oxidize dissolved minerals in preparation for nitrogen, chlorofluorocarbons, and fuel components
sedimentation and filtration. (aromatics, benzene, sulfur).
▪ rapidly shake a container that is partially full of water
for 5 minutes.

Community Health Nursing

Stratosphere • Public health nurses serve as an expert resource for mayors
– ozone layer is found. and governors and for "Airshed" to whom the city belongs.
– has inverted vertical-temperature profile.
– gets warmer as altitude increases. Airshed
– layer where most airplanes fly and emit most of the products of – area with common weather or meteorological condition and
jet fuel combustion. common source of air pollution.

Emission Pursuant to the principles of R.A. 9275, following rights of citizens

– AO 2000-81: any measurable pollutant gas or unwanted sound are sought to be recognized:
from a known source, which is passed into the atmosphere. 1. Right to breathe clean air.
2. Right to utilize and enjoy all natural resources according to the
Major sources of Air Pollution principle of sustainable development.
Mobile source 3. Right to participate in formulation, planning, implementation, &
– machine through oxidation/reduction reactions monitoring of environmental policies & programs & decision-
– include combustion of carbon-based /other fuel, constructed making process.
& operated principally for conveyance of persons or 4. Right to participate in decision-making process concerning
transportation of goods, that emit air pollutants as a reaction development policies, plans, & programs projects or activities
product. that have adverse impact on environment and public health.
5. Right to be informed of the nature and extent of potential
Stationary source hazard of activity, undertaking, or project and to be served
– building/fixed structure, facility that emits air pollutant. timely notice of any significant rise in level of pollution &
accidental or deliberate release into atmosphere of harmful or
• American Conference of Governmental Industrial Hygienists hazardous substances.
defined a criteria depending on efficiency of particle sizes in 6. Right of access to public records which a citizen may need to
entering respiratory tract: exercise his or her rights effectively under this Act.
o inhalable particulate matter: start at 100-um diameter 7. Right to bring action in court or quasi-judicial bodies to enjoin
o thoracic particulate matter: start at 10-um diameter all activities in violation of environmental laws and regulations,
o respirable particulate matter: start at 4-um diameter. to compel rehabilitation and cleanup of affected area, & to
• Pollution Prevention and Abatement Handbook by World Bank: seek imposition of penal sanctions against violators of
the particles likely to cause adverse health effects are the fine environmental laws.
particulates PM10 and PM2.5, particles smaller than 10 & 2.5 pm. 8. Right to bring action in court for compensation of personal
• Prevention of exposure: use of high-efficiency particulate filters damages resulting from the adverse environmental and public
(N-95 Mask). health impact of a project or activity.

Air Quality Management Section of DENR-EMB TOXIC & HAZARDOUS WASTE CONTROL
– monitors air quality. • Controlled chemicals: asbestos, cyanide, mercury,
polychlorinated biphenyls, ozone-depleting substances.
• Healthy air has a TSP that does not exceed 90 ug/m3. • Top causes of poisons: jewelry cleaners (high cyanide),
• Direction of air quality monitoring is toward building technical pesticides, button batteries, Watusi firecracker, Jatropha seeds,
capacity to monitor PM10 and PM2.5. multivitamins, malathion and xylene, camphor with methyl ASA,
• DENR-EMB (chairperson) of air management and turpentine.
• DOTC (vice chairperson). • Interventions:
o gastric aspiration and lavage of adults
Programs initiated to address air pollution: o induced emesis of children
1. Bantay Tsimineya Program o administration of high dose of activated charcoal into
– monitors point-source air pollution from industries. the stomach
o administration of protective agents such as:
2. Bantay Tambutso Program and Standard Setting ▪ Atropine: for carbamate & organophosphate
– adopted Euro-II emission standards for motorized vehicles. pesticides
– penalizes vehicle owners who fail to meet the set- ▪ Methylene blue: for chlorates and nitrites
standards. ▪ Acetylcysteine/methionine: paracetamol overdose
▪ Hydroxocobalamin/sodium thiosulfate: for cyanide
3. Improved Fuel Quality Program in silver cleaners
– phased out leaded gasoline, and regulated the sulfur,
benzene, and aromatic content of fuels. Toxic and Environmental Health Working Group
– headed by DENR (chairperson) and Department of Agriculture
4. National Research & Development Program for the Prevention (vice chairperson).
and Control of Air Pollution
– development was directed by DENR A.O.2000-81 to the FOOD SAFETY
DENR-EMB, in coordination with DOST. – assurance that food will not cause any harm to the consumer
when it is prepared and eaten according to its intended use
(NEHAP).

Community Health Nursing

 • DOH formed interagency committee that is led by FDA. Primary barriers
– structures and facilities that prevent the fecal contamination of
Republic Act 9711: Food and Drug Administration Act fingers, fluids, flies, and fields/floors.
– strengthened FDA in safeguarding the safety and quality of
processed foods, drugs, diagnostic reagents, medical devices, Secondary barriers
cosmetics, and household substances. – practices that prevent contaminated fingers, fluids, flies,
fields/floors from coming in contact with food or the new host.
DOH published IRR of Chapter I I of P.D. 856 to define the – include handwashing practices, insect and vermin control, water
sanitation requirements for the operation of a food establishment. treatment, and proper food handling.
• Establishment must have sanitary permit from the city that has
jurisdiction over the business. Sanitation facilities have four components
• In food-establishments on-board sea-crafts, application must be 1. Toilet
filed in vessel's port of origin. – bowl where the user sits down or a squatting plate.
• No person shall be employed in food establishment without
health certificate issued by city/municipal health officer. 2. Collection systems (sewerage systems)
• No person shall be allowed to work on food handling if afflicted – transport the wastewater for treatment or disposal.
with a communicable disease.
• Food preparation and storage rooms should never be used or 3. Treatment
directly connected to sleeping apartment or toilet. – process of reducing liquid & solid waste to nonpolluting
• No animals can be kept in the food areas. matter.
• Floors, walls, and ceilings must be made of materials that can
4. Disposal or reuse
be cleansed
– releases the treated waste to the environment.
• Utensils must be scrapped from all food particles and be
– discharge to water bodies such as rivers, application to soils,
washed in warm water (49°C) with soap.
or release to the atmosphere in the form of gas.
• Utensils are subjected to one of the following bactericidal
treatments: Classification of sanitation systems according to water reliance.
o Immersion at least 30 seconds in clean hot water (77°C). 1. Water-reliant systems
o Immersion at least 1 minute in lukewarm water containing – make use of water to flush and transport the waste material
55-100 ppm of chlorine solution. to the collection system, thus requiring a continuous supply of
o Exposure to steam at least 15 minutes to 77°C, or for 5 water.
minutes to at least 200°C.
2. Nonwater-reliant systems
• It is the duty of Sanitation Inspector to perform inspection and – make use of "dry" storage for urine and feces.
evaluation of compliance of food establishments to set – treat or store the materials on-site as they are not connected
standards at frequency specified by IRR to sewerage systems.
• Ambulant food vendors shall sell only bottled drinks, and
prepacked food. They are prohibited from selling food that Privy
requires the use of utensils. – toilet system that is not connected to a sewerage system.
• Monitored by FHSIS, all food handlers must maintain an
updated health certificate. IRR of the Sanitation Code of the Philippines developed by the
DOH describes three components of a sanitary privy,
SANITATION • earthen pit
– hygienic and proper management, collection, disposal, or reuse • floor covering the pit
of human excreta and community liquid wastes to safeguard health • water-sealed bowl
of individuals and communities (Philippines Sanitation Sourcebook
and Decision Aid developed by DENR, DOH, and Local Water • Flooring should cover the pit tightly and joined to the bowl with
Utilities Administration, 2005). a water-tight and insect-proof joint.
• Pit should be at least 1 m wide.
• DOH is the chair of sanitation sector
• DILG serves as the vice chair. Sanitation facilities
1. Box-and-can privy (bucket latrine)
In 2005, Sanitation and Hygiene Promotion Programming – fecal matter is collected in a can or bucket, periodically
Guidelines developed the F-Diagram, proposed 6 Fs that form part removed for emptying and cleaning
of means to transmit microorganisms in fecal materials to new host
• Feces 2. Pit latrine (pit privy)
• Fingers – fecal matter is eliminated into a hole in the ground that
• Fluids leads to a dug pit. Latrine is toilet facilities without a bowl.
• Flies
• Fields/ floors 3. Antipolo toilet
• Food. – made up of elevated pit privy that has a covered latrine.

Community Health Nursing

 4. Septic privy Unsanitary facilities:
– fecal matter is collected in a built septic tank that is not 1. Water-sealed toilet connected to sewer/septic tank, shared
connected to a sewerage system. with other households.
2. Water-sealed toilet connected to other depository type, shared
5. Aqua privy with other households.
– fecal matter is eliminated into a water-sealed drop pipe 3. Closed pit, shared with other households.
that leads from the latrine to a small water-filled septic tank 4. Open pit.
located directly below the squatting plate. 5. Hanging toilet.
6. Other unsanitary types of practice.
6. Overhung latrine 7. Open defecation.
– fecal material is directly eliminated into a body of water
such as a flowing river that is underneath the facility. VERMIN AND VECTOR CONTROL
DOH prepared the IRR of Chapter XVI Vermin Control of P.D. 856.
7. Ventilated-improved pit (VIP) latrine: Vermin
– a pit latrine with a screened air vent installed directly over – group of insects or small animals (flies, mosquitoes,
the pit. cockroaches, fleas, lice, bedbugs, mice, rats), which are vectors
– filled pits are then covered with soil for composting, and of diseases.
the facility is redirected or relocated to another pit.
Insects:
8. Concrete vault privy – flies, mosquitoes, cockroaches, bedbugs, fleas, lice, ticks, ants,
– fecal matter is collected in a pit privy lined with concrete and other arthropods.
in such a manner so as to make it water tight.
Pest
9. Chemical privy – destructive or unwanted insect or other small animals (rats,
– fecal matter is collected into a tank that contains a caustic mice, etc.) that cause annoyance, discomfort, nuisance, or
chemical solution, which in turn controls and facilitates the transmission of disease to humans and damage to structures.
waste decomposition.
Rodent
10. Compost privy – small mammals (rats and mice)
– fecal matter is collected into a pit with urine and anal – characterized by constantly growing incisor teeth used for
cleansing materials with the addition of organic garbage such gnawing or nibbling.
as leaves and grass to allow biological decomposition and
production of agricultural or fishpond compost (or nightsoil). Vector
– organism that transmits infection by inoculation into skin or
11. Pour-flush latrine mucous membrane by biting; or deposit of infective materials
– has a bowl with a water-seal trap similar to the conventional on skin, food, or other objects; or biological reproduction within
tank-flush toilet except that it requires only a small volume organism.
of water for flushing.
DOH identified strategies of vermin abatement program
12. Tank-flush toilet 1. Community-wide and community-participated.
– feces are excreted into a bowl with a water-sealed trap. 2. Technically coordinated.
3. Continuing.
13. Urine diversion dehydration toilet (UDDT) 4. Basically a partnership between private & government sectors.
– a waterless toilet system that allows the separate collection 5. Preferably utilize indigenous technology and resources to attain
and on-site storage or treatment of urine and feces. self-reliance.
– made up of urine separation toilet with urine side leading
to a collecting container for agricultural use and fecal side Vermin control and disinfestation methods
leading to a ventilated vault. 1. Environmental sanitation control
– fecal vault is kept "dry" and, the feces are left to dehydrate – maintenance of cleanliness of immediate premises and
for agricultural use. proper building construction and maintenance.
– clean-up drives are aimed at altering or eliminating the
In 2010, DOH published Philippine Sustainable Sanitation Roadmap breeding sites of the vectors.
and defined the 3 sanitation facilities that are considered sanitary
under the DOH and NSO definitions: 2. Naturalistic control
1. Water-sealed toilet connected to a sewer or septic tank, used – pest control method that utilizes nature and nature's
exclusively by the household. systems without disturbing the balance of nature.
2. Water-sealed toilet connected to other depository type, used
exclusively by the household. 3. Biological and genetic control
3. Closed pit used exclusively by the household. – utilizes living predators, parasites, and other natural
enemies of the pest to reduce or eliminate pest populations.
– aimed killing larvae without polluting the environment.

Community Health Nursing

 4. Mechanical and physical control
– method that utilizes mechanical devices (rodent traps, fly
traps, mosquito traps, air curtain, and ultraviolet light).

5. Chemical control
– utilizes rodenticides, insecticides, larvicides, and pesticides.

6. Integrated control
– controls pests using different methods and procedures
that are used to complement each other.

BUILT ENVIRONMENTS
– man-made structures that provide a setting for human activities.

Presidential Decree no. 1096: National Building Code of the Philippines

– governs the design of built environments.

In 2004, DPWH developed the Revised IRR of National Building

Code of the Philippines. Some of the provisions enacted to protect
public health are as follows:
• Minimum air space shall be provided as follows:
o School rooms: 3m3 with 1m2 of floor area/person.
o Workshops, factories, & offices: 12m3 of air space/person.
o Habitable rooms: 14m3 of air space/person.

• Minimum sizes of rooms and their least horizontal dimensions

shall be as follows:
o Rooms for human habitations: 6m2 with a least horizontal
dimension of 2m.
o Kitchen: 3m2 with a least horizontal dimension of 1.50 m.
o Bath & toilet: 1.20m2 with a least horizontal dimension of
900 mm.

• Ceiling height of habitable rooms:

o Rooms with artificial ventilation shall have ceiling heights
not less than 2.40 m (8 ft) measured from floor to ceiling.
o Rooms with natural ventilation shall have ceiling heights
of not less than 2.70 m (9 ft).
o Mezzanine floors shall have clear ceiling height not less
than 1.80 m above and below it.

• Minimum window sizes:

o Rooms intended for any use, not provided with artificial
ventilation system, shall be provided with a window or
windows with a total free area of openings equal to at
least 10% of the floor area of the room, provided that
such opening shall be not less than 1.00 m2.
o Toilet and bathrooms, laundry rooms, and similar rooms
shall be provided with windows with an area not less than
1/20 of the floor area, provided that opening shall not be
less than 240 mm2.
o Windows shall open directly to court, yard, public street
or alley, or open watercourse.

Community Health Nursing

 NCM 104 & 113: Community Health Nursing
CHAPTER 14: DISASTER MANAGEMENT Societal hazard
– results from the interaction of varying political, social, or economic
DISASTER MANAGEMENT factors, which may have a negative impact on the community.
– examples: stampedes, armed conflicts, terrorist activities, riots
Emergency
– event endangering life or health of significant number of people
NA-TECH (natural-technological) disaster
and demanding immediate action.
– natural disaster that creates/results in technological problem.
– example: earthquake that causes structural collapse of roadways,
Disaster
in turn, brought down electrical wires and caused subsequent fires.
– event that causes level of destruction, death, or injury that affects
community’s ability to respond to incident using available resources.
Types of Disasters
Natural Disasters Man-Made Disasters
Mass casualty
Communicable disease outbreaks Civil unrest/Riots
– 100 or more individuals are involved Droughts Explosions/Bombings
Earthquakes Fires
Multiple casualty Floods Mass transit accidents
– more than 2 but fewer than 100 individuals are involved. Heat waves Mining accidents
Landslides Pollution
Casualties Classification Mudflow/Debris flow (lahar) Stampedes
1. Direct victim Red tide phenomena Structural failures (bridges)
– individual who is immediately affected by the event Tsunamis Terrorist/terrorist-related events
– displaced persons and refugees are special categories of Volcanic activities Toxic or hazardous spills
direct victims. Weather disturbances (typhoons) Wars/Open armed conflicts

2. Indirect victim Terrorism

– family member or friend of the victim or a first responder. – criminal acts, including against civilians, committed with intent to
cause death/serious bodily injury, or taking of hostages, with the
3. Displaced persons purpose to provoke state of terror in general public or in group
– who have to evacuate their home, school, or business as a of persons, intimidate population or compel government or
result of a disaster international organization to do or to abstain from doing any act"

4. Refugees Acts of terrorism

– group of people who have fled their home or country as a • Threats of terrorism • bomb scares & bombings
result of famine, drought, natural disaster, war, or civil unrest. • Assassinations • Computer-based attacks
• Kidnappings • Use of chemical, biological,
TYPES OF DISASTERS • Hijackings nuclear, & radiological weapons
Natural hazard
– physical force (typhoon, flood, landslide, earthquake). Weapons of mass destruction
– any weapon
Biological hazard • intended to cause death/serious bodily injury through
– process/phenomenon of organic origin or conveyed by biological release, dissemination, impact of toxic or poisonous
vectors (exposure to pathogenic microorganisms, toxins). chemicals, or its precursors
– examples: disease outbreaks and red tide poisoning. • involving a disease organism
• designed to release radiation/radioactivity at dangerous
Technological hazard level to human life.
– arises from technological/industrial conditions (accidents,
dangerous procedures, and infrastructure failures).

Biological weapons of mass destruction

Biological organism Lethality Prevention Treatment Potential for use
Symptomatic; secondary One person could possibly cause a national
Smallpox (incubation 1-5 days) High Vaccine
infections epidemic
Anthrax (incubation 2-60 days) Very high Vaccine Antibiotics early; if late, nothing Likely agent; resistant to weather; can be stored
Plague (Yersinia pestis) Very high; 100% Not considered a likely agent; difficult to turn into
No vaccine Antibiotics
(incubation 1-3 days) if untreated a weapon
Vaccine being Antitoxin; requires intensive
Botulism High Not considered a likely weapon
tested supportive care
Vaccine being
Tularemia Moderate Antibiotics Difficult to stabilize for use as a weapon
studied
Not considered a likely weapon; difficult to acquire;
Ebola Very high No vaccine Minimal
poorly understood

Community Health Nursing

 Brucellosis (incubation 5-21 Antibiotics; begin upon
Low No vaccine Not considered a likely weapon; low lethality
days) suspicion of disease
Q fever (Coxiella burnetil) Antibiotics; begin in
Low Vaccine Not considered a likely weapon; low lethality
(incubation 14-26 days) incubation period
Other potentials: Viral Venezuelan equine encephalitis, cholera, salmonella, influenza, and staphylococcal enterotoxin B

Chemical agents of mass destruction

Chemical agent Lethality Treatment Impact
Sarin (nerve agent) High Move to fresh air; wash skin; drugs limited effectiveness Likely nerve agent; chemicals needed to produce are
banned by International Chemical Weapons Convention
VX (nerve agent) Very high Move to fresh air; wash skin; drugs limited effectiveness Not likely weapon; difficult to manufacture
Tabun (nerve agent) High Move to fresh air; wash skin; drugs limited effectiveness Easy to manufacture nerve agent; likely agent to be
used
Chlorine (pulmonary Low Move to fresh air; wash skin; no antidote Readily available; likely agent because of availability;
agent) breaks down with water
Hydrogen cyanide Low to Move to fresh air; wash skin; some drugs mitigate effects Industrial product; some chemicals used to produce
(blood agent) moderate are banned; likely agent because of availability

CHARACTERISTICS OF DISASTERS 4. Imminence

1. Frequency – speed of onset of impending disaster and relates to the extent
– refers to how often disaster occurs. of forewarning possible and anticipated duration of incident.

2. Predictability • Typhoons are announced to the public in terms of Public

– relates to ability to tell when and if a disaster event will occur. Storm Warning Signals (PSWS).

3. Preventability PSWS
– actions can be taken to avoid a disaster. – raised to warn the public of an incoming weather disturbance.
– flooding can be prevented through proper refuse disposal,
maintenance of waterways, control of indiscriminate logging Philippine Atmospheric, Geophysical & Astronomical Services
Administration (PAGASA)
Primary prevention – service institute under DOST, issues the PSWS.
– aimed at preventing occurrence of disaster or limiting
consequences when the event itself cannot be prevented. 5. Scope and number of casualties
– occurs in non-disaster & pre-disaster stage refers to period – indicates the range of its effect.
immediately before disaster or when a disaster is pending. – scope is described in terms of geographic area involved and
– preventive actions: assessing communities to potential in terms of the number of individuals affected, injured, or killed.
disaster hazards, developing disaster plans, conducting drills, – location, type, and timing of a disaster event are predictors of
training volunteers & HCP, providing educational programs, the types of injuries and illnesses that might occur.
notifying appropriate officials, warning the population, and
advising what response to take 6. Intensity
– describing level of destruction & devastation of disaster event.
Secondary prevention – tropical cyclones that affect the country are categorized
– strategies are implemented once the disaster occurs. according to intensity in terms of wind speed near the center of
– secondary prevention actions: search, rescue, triage of the cyclone
victims and assessment of the destruction and devastation
of area involved Classification of tropical cyclones according to strength of associated
winds
Tertiary prevention 1. Tropical disturbance
– focuses on recovery of community, restoring the – weak tropical cyclone; wind speed: 35 – 64 kph near the
community to its previous level of functioning and its center.
residents to their maximum functioning.
– aimed at preventing a recurrence or minimizing the effects 2. Tropical storm
of future disasters. – moderate tropical cyclone; maximum wind speed: 65 – 118
kph near the center.
• To respond effectively, nurses need to know the:
o kind of disasters that threaten the communities 3. Typhoon
o injuries to expect from different disaster scenarios – intense tropical cyclone; wind speed: 119 – 200 kph near
o evacuation routes the center.
o location of shelters or evacuation centers
o warning systems 4. Super typhoon
– most intense category of tropical cyclones with wind speed
greater than 200 kph.

Community Health Nursing

Factors contributing to the amount of damage from a disaster event At work and school
• distance from the zone of maximum winds • Schools, day care providers, workplaces, apartment
• degree of exposure of the location to the disaster buildings, and neighborhoods should have site-specific
• building standards emergency plans.
• vegetation type In a high-rise building
• resultant flooding • Note where the closest emergency exit is.
• Be sure you know another way out in case your first
DISASTER MANAGEMENT choice is blocked.
– requires interdisciplinary, collaborative team effort and involves • Take cover against a desk or table if things are falling.
network of agencies and individuals to develop a disaster plan that • Face away from windows and glass.
covers the multiple elements necessary for an effective plan. • Move away from exterior walls.
• Do not use elevators.
Disaster management stages • Stay to the right while going down stairwells to allow
1. Prevention stage emergency workers to come up.
– first stage in disaster management occurs before a disaster Water
is imminent and is known as the non-disaster stage. • Store at least 3-day supply; 1 gallon per day per person.
– potential disaster risks should be identified, risk maps created. Supply checklist
• flashlight, batteries, radio, garbage bags, map, moist
• DENR spearheaded the creation of the geohazard maps towelettes, whistle, clothing, bedding, and tools.
through its Mines and Geosciences Bureau Special needs items
• Primary prevention measures: educating public regarding • Prescription medications; special items for infants
what actions to take to prepare for disasters (diapers, formula), elders, or persons with disabilities.
In a moving vehicle
Guidelines for early detection of biochemical terrorist incidents • If the vehicle becomes difficult to control, pull over.
• Rapidly increasing disease incidence (within hours or days) • Avoid road hazards.
in a normally healthy population. • Obey barriers and signs.
• Unusual increase in the number of people seeking care, Deciding to stay or go
especially with fever, respiratory, or GI complaints. • Depending on your circumstances and the nature of
• Endemic disease rapidly emerging at an uncharacteristic the attack, the first important decision is whether you
time or in an unusual pattern. stay put or get away.
• Clusters of patients arriving from a single locale.
• Large numbers of rapidly fatal cases—patients who die All community disaster plans should address the following elements:
within 72 hours after admission to the hospital. • Authority
• Any patient presenting with a disease that is relatively • Communication
uncommon & has bioterrorism potential (pulmonary • Control
anthrax, smallpox, or plague). • Logistical coordination of personnel
• Supplies and equipment
2. Preparedness and planning stage • Evacuation and rescue
– individual & family preparedness: first aid training, disaster • Care of the dead.
emergency kit, establishing predetermined meeting place
away from home, and making communication plan. Authority
• Designated by title, it should not specify a person by name.
Advice on disaster preparedness • plan should indicate who has the power to declare that there
Emergency Supplies
is a disaster and to initiate the disaster plan.
Food Communication
• Store at least a 3-day supply of nonperishable food. • Analysis of the population during non-disaster stage should
• Have a manual can opener. identify groups that need special attention as to the process
• Keep disposable plates/cups and utensils. of notification.
Clean air • Reliance on telephone systems or cell phones should not be
• Store snugly fitting face masks. the sole planned means of communicating because these
• Store plastic sheeting, duct tape, and scissors to seal may not work, or the systems might be overloaded.
off a room. • important element: early warning stage.
First aid kit
• sterile gloves, dressings, soap, antibiotic ointment, Logistical section
bandages, eye wash, and nonprescription medications • should specify where supplies and equipment are located or
Make a plan where additional supplies and equipment can be obtained
Create a family plan from, where these will be stored or found, and how these
• Plan on how to contact one another if the family is will be transported to the disaster site.
separated.

Community Health Nursing

 Essential human resources • While the area is being checked and then cleared of potential
• emergency and disaster specialists, officials of governmental threats, a staging area can be set up at or near the site of
and voluntary agencies, engineers, weather specialists, and the incident to direct on-site activities.
community leaders should be identified and tracked where • Begin once clearance is given, disaster triage area is
they will be located. established, and an emergency treatment area is set up to
provide first aid until transportation for victims to hospitals or
Evacuation and rescue health care facilities for treatment can be coordinated
• Plan should include information about transportation for
evacuation and rescue, documentation and record keeping, Staging area
and evaluation of success or failure of the plan. • On-site incident command station.
• Disaster responders should report to this area to "check in"
• Disaster plan is a dynamic entity. so that everyone is accounted for & be given an assignment.
• Planning is a continuous process, and plans change with • No one should go to the disaster site unless directed to do
circumstances and when gaps are identified. so by the staging area commander.
• Plans should follow the disaster planning principles: • Where the authority rests for decisions as to additional
resources to be called to the area to manage the disaster
Disaster planning principles incident.
1. Measures usually taken are not sufficient for major disasters.
2. Plans should be adjusted to people's needs. Disaster triage
3. Planning does not stop with development of written plan. • Focus of disaster triage: do as little as possible, for the
4. Lack of information causes inappropriate responses by greatest number, in the shortest period of time.
community members.
5. People should be able to respond with or without direction. START triage system
6. Plans should coordinate efforts of entire community, so large – triage system that is used by first responders.
segments of the citizenry should be involved in the planning. – stands for "simple triage and rapid treatment."
7. Linked to surrounding areas. – describes what to do when first arriving at a
8. General to cover potential disaster events. multicausality or mass casualty incident.
9. Based on everyday work methods & procedures. – disaster triage of an injured person should occur in
10. Specify a person's responsibility for implementing segments less than 1 minute.
by position or title rather than by name. – describes how to enlist people with minor injuries to
11. Develop record-keeping system before disaster occurs: assist.
o Supplies and equipment
o Records of all present at any given time (to account As a decision is made regarding the status of an
for everyone and to identify the missing) individual, the person is tagged with a colored triage tag
o Identification of victims & deceased, conditions &
treatment, & which facility victims are sent. Green
12. Backup plans need to be in place for the following: – walking wounded or with minor injuries (cuts and
o Disruption of telephone and cell phone lines abrasions) who can wait several hours for treatment
o Disruption of computer data (should be downloaded
weekly and stored off-site) Yellow
o Protecting essential public health functions (vital – systemic but not yet life-threatening complications
records and communicable disease data). who can wait 45 to 60 minutes (simple fractures)

3. Response stage Red

– begins immediately after the disaster incident occurs. – top priority or immediate and is for those with life-
– community preparedness plans that have been developed are threatening conditions but who can be stabilized and
initiated. have a high probability of survival (amputations)

Evacuation Black
• Have established evacuation routes for residents to use if – for deceased or injuries are extensive that nothing
evacuation from the area is necessary. can be done to save them (multiple severe injuries)
• Education to potential damage, deaths, and injuries that will
be incurred from the potential disasters that may affect their New classification of victim, those who are
community needs to be done in the preparedness stage and contaminated, will require a hazmat (for "hazardous
not when evacuation is ordered. materials") tag.

Search and rescue To assess individual within 1-minute guideline, the

• Before this should begin, safety must be considered. system uses three characteristics. ("30-2-can do”)
• If criminal action is suspected, law officials will be among the
first to respond to secure area and possibly gather evidence. 1. Respirations
• if they are over 30 per minute, the
individual is tagged red or immediate.

Community Health Nursing

 • If the individual has fewer than 30 cpm, Public health officials have the responsibility of detecting
then move to the second step—perfusion. outbreaks, determining cause of illness, identifying risk factors for the
population, implementing interventions to control the outbreak, and
Perfusion informing the public of health risks and preventive measures that
• Pinch the nail bed and observing the need to be taken.
reaction are done to check perfusion
PHILIPPINE RED CROSS
Checking mental status. – officially founded in 1947, the PRC carried out two main functions:
• Ask the individual simple questions (Who blood provision and disaster-related services.
are you?). – embodying fundamental principles of International Red Cross and
Red Crescent Movement (humanity, impartiality, neutrality,
Following triage, victims are moved to treatment area independence, voluntary service, unity & universality)
where their condition is checked again. First aid may be – present-day Red Cross offers six major services:
provided, until transportation is available. 1. National Blood Services - provision of safe blood for
medical purposes.
While search and rescue is going on, public health 2. Safety Services - conduct of training in first aid, BLS,
agencies are checking for threats (contaminated water, water safety, accident prevention.
vectors, and air quality) and disseminate data and relate 3. Social Services - relevant to disaster and post-disaster
information to officials, media, & public as appropriate. situations include:
• Guidance and counseling.
4. Recovery stage • Psychosocial support program/critical incident
– begins when danger from disaster has passed and concerned stress management: help in stress during disasters.
local and national agencies are present in the area to help victims • Tracing service: assists locating displaced/missing
rebuild their lives and help the community restore public services. person(s) during disaster where normal channels
– cleanup of damage and repair of homes and businesses begin. of communication have become difficult for the
– evaluation and revision of the disaster plans based on lessons families concerned.
learned from the experience are made. • Referral service.
• Early livelihood recovery program: support
Understanding financial impact on community & agencies restoration of livelihood after a disaster.
involved is essential in developing future public health policy. • Hot meals: facilitate feeding program to prevent
malnutrition among calamity victims.
GOVERNMENT RESPONSIBILITIES 4. Volunteer services: provide training course.
• They are responsible for the safety and welfare of its citizens. 5. Community health and nursing services: offer training
• Emergencies and disaster incidents are handled at the lowest programs in Basic Health Education Program and Primary
possible organizational and jurisdictional level. Health Care (Community-Based Health Program) for
• Police, fire, public health, public works, and medical emergency professional nurses and student nurses.
services: first responders responsible for incident management 6. Disaster management services: disaster relief operations
at the local level. and services of identifying hazard-prone areas and
• Local government manages events during incident by carrying making vulnerability assessment of these areas. PRC
out evacuation, search, and rescue and maintaining public offers courses on Disaster Management, including
health and public works responsibilities. Community-Based Disaster Management Training.
• Local communities should have contingency operation plans Specific disaster management services offered include:
for multiple disaster situations & for various aspects of the plan. • Relief operations
• Deployment of disaster response teams
Emergency telephone number for the Philippines is 1 7, also called • Organization of barangay disaster action team
Patrol 117, under the management of DILG. • Preposition of relief supplies

Executive Order No. 226, s. 2003 institutionalized Patrol 117 as PRC is one of the major nongovernmental agencies
nationwide emergency hotline number for police assistance, fire that work with government agencies in disaster risk
protection, PRC, among others. reduction. This purpose of PRC is specifically stated in R.A.
10072: Philippine Red Cross Act.
PUBLIC HEALTH SYSTEM
– mission: promotion of health, prevention of disease, and NATIONAL DISASTER RISK REDUCTION AND
protection from threats to health. MANAGEMENT PLAN
– describe all of the governmental and NGOs and agencies that • 2010, R.A. 10121: Philippine Disaster Risk Reduction and
contribute to the improvement of the health of populations. Management Act, brought paradigm shift from disaster
preparedness and response to DRRM.
Preparedness includes vigilance & reporting of suspicious
illnesses (signs and symptoms of biological agents, food-borne
• NDRRM framework envisions a country that has "safer,
diseases, & CDs) in the community by physicians and nurses in local
adaptive and disaster-resilient Filipino communities toward
health care facilities or private offices and clinics.
sustainable development."

Community Health Nursing

 • Goal: to shift from reactive to proactive in DRRM. o Networking and partnership building between and among
stakeholders, media, and the different levels of
• This means the focus is on government
o building individual, collective, and institutional capacities to
adjust to situations (increased resilience) R.A. 10121 has designated the Office of Civil Defense, an attached
o decreasing vulnerabilities. bureau of DND, as the operating arm and the Secretariat of the
NDRRMC.
• NDRRMP aims to:
o strengthen government capacity (national & local) A focal agency has been assigned to each of the four priority
together with partner stakeholders areas, and the heads of these agencies shall serve as Vice
o build disaster resilience of communities Chairperson in the NDRRMC.
o institutionalize arrangements & measures for reducing
disaster risks Lead agencies in the NDRRMC and their priority areas
DILG Secretary Vice Chairperson, Disaster Preparedness
• The plan has four priority areas: DSWD Secretary Vice Chairperson, Disaster Response
DOST Secretary Vice Chairperson, Disaster Prevention &
o Disaster prevention and mitigation
Mitigation
▪ reducing vulnerabilities & exposure & enhancing
NEDA Director- Disaster Rehabilitation and Recovery
capabilities of communities General
▪ examples: geohazard mapping, construction of
dams or embankments to eliminate flood risks, NDRRMC provides national leadership. Disaster Risk Reduction and
regulations that do not permit any settlement in Management Councils exist at the regional, provincial, city, and
high-risk zones, improved environmental policies, municipal levels.
and increased public awareness
o Disaster preparedness NDRRMP is the document formulated and implemented by the
▪ capacity to effectively anticipate, respond to, and Office of Civil Defense, the agency that sets out goals and specific
recover from the impacts of hazardous events objectives for reducing disaster risks together with related actions
▪ examples: contingency planning, stockpiling of to accomplish these objectives.
supplies, development of arrangements for
coordination, evacuation drills, & associated training. Community-Based Disaster Risk Reduction and Management
– describes the process of DRRM in which at-risk communities
o Disaster response actively engaged in identification, analysis, treatment, monitoring,
▪ provision of emergency services & public and evaluation of disaster risks to reduce vulnerabilities & enhance
assistance during or immediately after disaster to their capacities.
save lives, reduce health impacts, ensure public – the people are at the heart of decision-making & implementation
safety, and meet the basic subsistence needs of of DRRM activities.
the people affected.
▪ sometimes called "disaster relief."
INCIDENT COMMAND SYSTEM
o Rehabilitation and recovery – standardized, on-scene, all-hazard incident management concept.
▪ ensure the ability of communities to restore their – allows users to adopt integrated organizational structure to
normal level of functioning by rebuilding livelihood match complexities and demands of single /multiple incidents
& damaged infrastructure & increasing their without being hindered by jurisdictional boundaries.
organizational capacity – nonpermanent organization and is activated only in response to
disasters or emergencies.
Implementation strategies and mechanisms – establishment of ICS was provided for by the IRR of R.A. 10121
National Risk Reduction and Management Plan
o Advocacy and information, education, and communication If possible, local DRRMCs manage incidents with their own
(IEC) emergency teams and material resources. The following criteria are
o Competency-based capability building through conduct of used in defining which level of DRRMC should take charge of a
customized training programs particular incident:
o Contingency planning • Barangay Development Committee (BDC), if a barangay is
o Institutionalization of Disaster Risk Reduction and affected
Management Councils and Local Risk Reduction and • City/municipal DRRMC, if two or more barangays are affected.
Management Offices • Provincial DRRMC, if two or more cities/municipalities are
o Mainstreaming of DRR in all plans of the government affected.
(national and local) including the private sector groups and • Regional DRRMC, if two or more provinces within the region
other members of the community are affected.
o Research, technology development, and knowledge • NDRRMC, if two or more regions are affected.
management to keep up with changes in the climate and
technological advances NDRRMC and intermediary local DRRMCs act as support to LGUs
o Monitoring, evaluation, and learning that have primary responsibility as first disaster responders to incident
occurring within their jurisdictions.

Community Health Nursing

 DRRMC, through its chairperson, provides Incident Commander DRRMC Emergency Operations Center
the mission and authority to achieve overall priorities of on-scene – located away from the disaster site
disaster response operations: life safety, incident stabilization, & – supports Incident Commander by making executive/policy
property/environmental conservation and protection. decisions, coordinating interagency relations, mobilizing & tracking
resources, collecting, analyzing, & disseminating information, &
Incident Command continuously providing alert advisories/ bulletins & monitoring of
– responsible for the overall management of the incident. obtaining situation.
– headed by Incident Commander and made up of the Command – does not command on-scene level of the incident.
Staff and the General Staff. – Incident Command takes charge of the operations at the scene.

Command function may be done either as: RESPONSES TO A DISASTER

1. Single Incident Command Classic four phases of a community's reaction to a disaster:
– applied when incident occurs within single jurisdiction & there 1.. Heroic phase
is no functional agency overlap. – nearly everyone feels the need to rush to help people
survive the disaster.
2. Unified Command – medical personnel may work hours without sleep, under
– applied when disaster/emergency affects several areas or very dangerous and life-threatening conditions to take care of
jurisdictions or requires multiagency engagement. their patients.
– agencies work together through designated members of Unified
Command to establish common set of objectives & strategies and 2. Honeymoon phase
a single Incident Action Plan – people begin to tell their stories and review over and over
again what has occurred.
Command Staff, composed of people who report directly to the – bonds are formed among victims and health care workers.
Incident Commander, usually includes: – gratitude is expressed for being alive.
• Public Information Officer
o responsible for providing public, media, other agency 3. Disillusionment phase
with required information related to the incident. – when time has elapsed and delay in receiving help /failure to
• Safety Officer: receive promised aid has not occurred, feelings of despair arise.
o monitors operations related to incident – medical personnel & other responders may experience
o advises Incident Command on matters of operational depression due to exhaustion from long days of long hours.
safety (health and safety of responding personnel). – people realize the way things were before the disaster is
o responsibility: safe conduct of incident management not the way things are now and may never be the same again.
and has the authority to stop any unsafe act.
• Liaison Officer 4. Reconstruction phase
o coordinating with representatives from cooperating – once the community has restored some of the buildings, and
and assisting agencies or organizations. services, and some sense of normalcy is returning, feelings of
• General Staff despair will subside.
o responsible for functional aspects of incident – counseling support for victims and helpers may need to be
command structure. initiated to help people to recover more fully.
o consists of operations, planning, logistics, & finance/ – people begin to look to the future
administration.
Common responses to a traumatic event
Biological Emotional Physical Behavioral
• Poor concentration • Shock • Nausea • Suspicion
• Confusion • Numbness • Lightheadedness • Irritability
• Disorientation • Feeling overwhelmed • Dizziness • Arguments with friends and loved ones
• Indecisiveness • Depression • GI problems • Withdrawal
• Shortened attention span • Feeling lost • Rapid heart rate • Excessive silence
• Memory loss • Fear of harm to self and/or loved ones • Tremors • Inappropriate humor
• Unwanted memories • Feeling nothing • Headaches • Increased/decreased eating
• Difficulty making decisions • Feeling abandoned • Grinding of teeth • Change in sexual desire or functioning
• Uncertainty of feelings • Fatigue • Increased smoking
• Volatile emotions • Poor sleep • Increased substance use or abuse

Posttraumatic stress disorder

– reactions mentioned usually resolve in 1 to 3 months after the
disaster but, in some cases, it may lead to PTSD.
– psychiatric disorder that can occur following an individual's
experiencing or witnessing a life-threatening event, such as a
disaster.

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 NCM 104 & 113: Community Health Nursing
CHAPTER 15: eHEALTH IN COMMUNITY SETTING Benefits of a well-managed Patient Information System
1. Data are readily mapped, enabling more targeted interventions
eHEALTH and feedback.
Information and communication technologies • With a system that delivers a real time and accurate
– diverse set of technological tools & resources used to patient and community information, health care
communicate and to create, disseminate, store, and manage practitioners are able to deliver patient centered care
information and targeted disease prevention.
• Facility and staff are provided feedback on their
eHealth performance through computer alerts, enabling them to
– use of ICT for health. continually comply with standard guidelines and monitor
– overall umbrella term health targets.
– May 25, 2005, during the Fifty – Eight World Health Assembly, • They can track the frequency and locale of disease in
a resolution was adopted by WHO recognizing member states real time through an EMR & Geographic Information
recognizing eHealth as cost -effective way using ICT in health care System (GIS) like Philippine Health Alas of DOH.
service, health surveillance, health literature, health education and • GIS technology enables detailed maps to be generated
research with relative speed and ease. This provides health
practitioners with the ability to provide quick responses
Given the extensive capabilities of ICT, eHealth can be considered in to questions or concerns.
any of, but not limited to, the following:
• Communicating with a patient through teleconference, email, 2. Data can be easily retrieved and recovered.
short message service. • In the event of force majeure, retrieval of patient
• Providing patient teaching with aid of electronic tools (radio, information is not a problem since data are backed up
television, computers, smartphones, and tablets) in a server.
• Recording, retrieving, and mining data in electronic medical
record (EMR). 3. Redundancy of data is minimized
• Patient data that are frequently required in various forms
ehealth encompasses 3 main areas (WHO): need to be only recorded once. These can be linked and
• Delivery of the health information, for health professionals and organized automatically into related record types through
health consumers, through internet and communications. database. It allows a better record management and ease
• Using the power of information technology and e-commerce of use. .
to improve public health services. (education and training of
health workers). 4. Data for clinical research becomes more available.
• Use of e-commerce & e-business practice in health systems • Having quality data stored in databases provides faster
management and more reliable research outputs.

5. Resources are used efficiently

POWER OF DATA AND INFORMATION
• Making patient information more readily available, EMR
.Data reduce cost related to chart pulls as well as supplies
– fundamental elements of cognition. needed to maintain paper charts.
– unanalyzed raw facts that do not imply meaning.

Information GOOD DATA QUALITIES

– when meaning is attributed to data Data must have the following characteristics
– when data are processed and analyzed. 1. Accuracy.
• Ensures that documentation reflects the event as it
Paper based method happened.
• Inconvenience to interoperability of health services. Information 2. Accessibility
backup and instant data access. • Ascertains data availability should the patient or any
• Continuity and interoperability of care stops in the unlikely member of the health care staff needs.
event that a record gets misplaced. 3. Comprehensiveness.
• Illegible handwriting poses misinterpretation of data. • Data inputted should be complete.
• Patient privacy is compromised. 4. Consistency/Reliability
• Data are difficult to aggregate. • Having no discrepancies in data recorded makes it
consistent
• Actual time for patient care gets limited.
5. Currency
Internal and external changes affecting health care informatics • All data must be up-to-date and timely.
1. Ability to manipulate large amounts of data. 6. Definition
2. Ability to relate data to cohorts of people who shares similar • Data should be properly labeled and clearly defined.
health problems
3. Ability to link to genomic data.

Community Health Nursing

 eHEALTH SITUATION IN THE PHILIPPINES 1. Financial risk protection through program enrolment and
DOH introduced several health information systems that aim to benefit delivery.
improve the access of health data. 2. Improved access to quality hospitals and health care facilities.
1. Electronic Field Health Service Information System 3. Attainment of the health- related Millennium Development
Goals
2. Online National Electronic Injury Surveillance System
3. Philippine Health Atlas
National eHealth Strategic Framework for 2010-2016
4. Unified Health Management Information System
– drafted by the DOH, with the vision of ICT supporting UHC to improve
health care access, quality, efficiency, and patient’s safety and satisfaction,
FACTORS AFFECTING eHEALTH IN THE PHILIPPINES for reducing cost and enabling policy makers, providers, individuals, and
1. Limited health budget communities to make the best possible health decisions.
2. The emergence of free and open source software
• Free Open-Source Software: makes the source code Electronic medical records
of a program freely available to all. – comprehensive patient records that are stored and accessed from a
3. Decentralized government computer or server.
• RA 7160: Local Government Code of 1991
o LGUs are autonomous. They are in control of their Telemedicine
own basic health services, including the budget. – One of the 5 strategic goals of DOH’s National eHealth Strategic
▪ Tarlac: Wireless Access for Health (WAH) Framework for 2010-2016 is to capitalize on ICT. In order to reah and provide
▪ Iloilo: Secured Health Information and better health services to GIDAs, to support MDG attainment, and to
Network Exchange (SHINE) disseminate information to citizens and providers through telemedicine and
4. Target users are unfamiliar with the technology mobile health.
• Along with software development and hardware – WHO: “delivery of health care services, where distance is a critical factor,
procurement, staff training, and maintenance of the by all health care professionals using information and communications
system are key factors in determining its effectiveness. technologies for exchange of valid information for diagnosis, treatment and
• Recognition of community’s cultural aspects is important prevention of disease and injuries, research and evaluation and for the
in starting them off into a new direction such as continuing education of the health care providers, all in the interests of
computerization and automation. advancing the health of individuals and their communities”
• eHealth implementation’s success depends on the end
user’s willingness to learn and accept the technology. WHO underscores 4 elements that are specific for telemedicine
5. Surplus of “digital native” registered nurses. 1. Its purpose is to provide clinical support.
2. It is intended to overcome geographical barriers, connecting users
• Digital native: a person who grew up and is familiar with
who are not in the same physical location.
digital technologies and who uses them in daily living.
3. It involves the use of various types of ICT.
4. Its goal is to improve health outcomes.
USING eHEALTH IN THE COMMUNITY
Universal Health Care and ICT eLearning
DOH Administrative Order No. 2010-0036
– use of electronic tools to aid in teaching.
– outlined the policy directions of universal health care. – useful in correcting misconceptions about health and health care.
– known as Kalusugan Pangkaahatan. One of its aim is to attain – permits access reliable to information about health
efficiency by using IT in all aspects of health care.
– can be used to educate fellow health professionals.
– this reform agenda has three priority health directions:

EXAMPLES OF eHEALTH PROJECTS IN THE COMMUNITY

Health projects in the Philippines used in community health practice

Name Type Key information
– Implemented in 2004 by University of the Philippines Manila -National Telehealth Center through
Telemedicine eGovernment Fund of the Commission on information and Communications Technology
BuddyWorks
& elearning – Allowed RHU physicians in geographically isolated and disadvantaged areas (GIDAs) to send telereferrals
to medical specialists at Philippine General Hospital via short message service and e-mail.
– Developed in 2004 by Dr. Herman Tolentino of UPM College of Medicine Medical Informatics Unit
(MIU). Project initially began in Pasay health centers and has been implemented in more than 48 health
Community Health Information
EMR centers since then.
Tracking System (CHITS)
– Program is divided into different modules based on existing DOH programs (EPI, NIP, etc) and is a
Free and Open Source Software (FOSS).
Electronic Field Health Service
HIS & – An online version of the FHSIS developed by the DOH where you can upload FHSIS data.
electronic
(eFHSIS) Information System
reporting
Electronic Integrated – Developed in 2009 by Ateneo Innovation Center.
Management of Childhood eLearning – An electronic version of IMCI accessible in mobile devices.
lines (elMCI)
– Funded by United States Agency for International Development and developed by UPM-NTHC.
NTHC eLearning videos eLeaming
– Created eLearning videos on tuberculosis, stroke, bird flu, and child poisoning

Community Health Nursing

 – Funded by DOST-PCHRD and developed through collaborative efforts of University of the Philippines
Manila-Electrical and Electronics Engineering institute (UP-EEED, University of the Philippines Manila -
National institute of Physics (UPM - NIP) and UPM-NTHC
RxBox Telemedicine
– It is a mobile computer connected with medical devices (ECG, pulse oximeter, electronic blood
pressure and heart rate monitors) that is intended for mobile deployment to rural health centers.
– It can store and send patient information and allow video & chat conferencing with medical specialist.
– An EMR created for rural health units.
Segworks Rural Health
Information System (SEGRHIS)
EMR – Developed by Segworks, a local software company based in Davao.

Secure Health Information EMR & SMS - An EMR developed by Smart Communications.
Network Exchange (SHINE) reporting
Synchronized Patient Alert via SMS alert - Add-on to WAH; it is an SMS reminder system for patients who are due for follow-up.
SMS (SPASMS) system
– A project of WHO and DOH- Health Emergency Management Staff (DOH-HEMS).
Disaster
Surveillance in Post Extreme
management
– Allows community health nurses to submit daily reports of prevalent diseases immediately after
Emergencies and Disasters disasters via SMS, e-mail, and other information and communication technologies.
& SMS
(SPEED) – It sends immediate notification alerts (INAs) to CHNs for possible outbreaks based on available data.
reporting

– Implemented in 2010 in the Tarlac province through the Public-Private Partnership (PPP) of Qualcomm,
Health
UPM-NTHC, USAID, Smart, DOH-IMS, Center for Health Development (CHD) Region Ill, RTI International,
Wireless Access for Health information
National Epidemiological Center (NEC), Tarlac State University, and the local government.
(WAH) system (HIS)
& EMR – WAH augmented the existing CHITS by connecting health centers through broadband Internet access.

ROLES OF COMMUNITY HEALTH NURSES IN eHEALTH • Guarantee that all eHealth interventions are performed
1. Data and records manager in a safe and ethical manner, making sure that the
• Monitors the trends of diseases through EMR, allowing personnel involved in eHealth are competent and have
targeted interventions for health promotion, disease training/certification.
prevention, curative services, or rehabilitation.
• Maintain the quality of data inputs in the EMRS, making 6. Researcher
sure that information is accurate, complete, consistent, • Responsible for identifying possible points for research
correct and current. and developing a framework, based on data aggregated
• Participate in regular data audits. by the system.

2. Change agent
• Working closely with community and implementing
eHealth with them and not for them.
• Do not force technology on the community but inform
and guide them in selecting & applying appropriate ICT
tools.
• Collaborate with health leaders, policy makers,
stakeholders, and other community health professionals
to determine their knowledge and awareness on eHeatlh
and appropriate ICT tools.

3. Educator
• Provide health education to individual and families through
ICT tools.
• Participate in making eLearning videos on specific
diseases.
• Use scheduled text messages to patients among
catchment population to send important health
information or reminders.

4. Telepresenter
• Needs may need to present the patient’s case to a
remote medical specialist, noting salient points for case
assessment, evaluation, and treatment.
• Usually occurs via teleconference.
5. Client Advocate
• Safeguard patient records, ensuring that security,
confidentiality, and privacy of all patient information are
being upheld.

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 NCM 104 & 113: Community Health Nursing
CHAPTER 16: SCHOOL HEALTH Integrated School Health and Nutrition Program (ISHNP)
– designed to maintain and improve the health of school children
HISTORICAL DEVELOPMENT OF SCHOOL HEALTH by preventing diseases and promoting health related knowledge,
skills, and practices.
PROGRAMS
• School nurse visits 4 – 6 schools per month, each visit lasting SCHOOL HEALTH SERVICES
for 3 days or more, depending on type of school, location, and
Health Education
population.
– culture sensitive and based on identified educational needs of
• School nurse is responsible for planning and conducting training target population.
programs for teachers on health and nutrition.
• Health concepts are introduced according to the development
Components of Health Programs
level of school children.
1. Health education
• Health concepts integrated in the curriculum from
2. Physical education
Kindergarten to Senior High School:
3. Health services
o Nutrition
4. Nutrition services
o Personal & oral hygiene (WASH: water, sanitation,
5. Counseling, psychological and social services .
hygiene)
6. Healthy school environment
o Prevention of soil borne helminthiasis, mosquito borne
7. Health Promotion for Staff
disease, and other prevalent CDs (acute respiratory
8. Family and community involvement
infections, diarrhea, TB)
o Use of traditional and alternative care in the
Republic Act 124: An Act to Provide for Medical Inspection of Children
management of common heath conditions
Enrolled in Private Schools, Colleges, and Universities in the Philippines
– first school health program required by law
Areas of concern for health education:
– stated that the duty of school heads of private school with a total
1. Oral Hygiene
enrollment of 300 or more to provide a part- or full-time physician
for annual medical examination. • oral hygiene education: 7 o‘clock toothbrushing habit
– physicians were to render reports of their school health activities activity.
at the end of every quarter of each school year to the Director of 2. Injury prevention & developing safety conscious behavior
Health. • in the use of school playground, while engaging in
– physicians were place under the supervision of Bureau of Health, sports, and the like.
forerunner of DOH. 3. Tobacco Use
• Smoking is a major problem in this country.
Redesigned Approach in School Health Nursing (RASHN) 4. Substance Abuse
– adopted through Department of Education, Culture and Sports • National Drug Education Program: directed toward
(DECS) memorandum no. 37, s. 1991. raising consciousness of primary & secondary
– based on the philosophy that the academic performance of the students on the perils of using illicit drugs.
pupils and instructional outcomes are determined by the quality of • random drug testing is carried as part of this
health of school population and the community where they came program.
from. 5. HIV, AIDS and other STDs
• School-base HIV and AIDS Education and Prevention
DepEd Order no. 43, s. 2011 Program: information dissemination campaign to
– on the subject Strenghtening the School Health and Nutrition educate the general population on the risks of HIV
Programs for the achievement of Education for All and MDGs eeks and AIDS.
to strengthen School Health and Nutrition Program (SHNP) through
a seamless alignment of SHNP activities with other key school PHYSICAL EDUCATION
programs, thus the title, Integrated School Health and Nutrition • Sedentary lifestyle is associated with obesity, hypertension,
Program (ISHNP) heart disease and diabetes.
– outlines a matrix of activities for ISHNP designed to address FEA • Regular Physical activity helps build and maintain healthy bones
goals, which are: and muscles.
• Expand early childhood care and education
• Improve quality of education Guidelines for School and Community programs: Promoting lifelong
• Provide learning and life skills to young people and adults physical activity
– SHNP activities are also intended to address MDG goals: 1. Establish policies that promote enjoyable, lifelong physical
• To eradicate extreme poverty and hunger activity.
• To reduce child mortality rate 2. Provide physical & social environments that encourage &
• To combat HIV/AIDS, malaria, and other diseases. enable them to engage in safe & enjoyable physical activity.
• To ensure environmental sustainability 3. Implement sequential physical activity education curricula and
instruction in grades K to 12.
4. Implement health education curricula.

Community Health Nursing

 5. Provide extracurricular physical activity programs that offer NUTRITION
diverse, developmentally appropriate activities (noncompetitive • Identifying nutritional problems, counseling, and making
and competitive) for all students. appropriate referrals are important in the school setting.
6. Encourage parents to support children's participation in physical • School-Based Feeding Program (SBFP), previously Breakfast
activity, be physically active role models, and include physical Feeding Program, DepEd aims to rehabilitate at least 70% of
activity in family events. the identified severely wasted school children to normal
7. Provide training to enable teachers, coaches, recreation and nutritional status at the end of 100-120 feeding days.
health care staff, and other school and community personnel
• Beneficiaries of SBFP are provided with hot meals following
to promote enjoyable, lifelong physical activity. the developed standardized recipes using malunggay and 20-
8. Assess physical activity patterns, refer appropriate physical day cycle menu utilizing locally produced/ grown foods.
activity programs, and advocate for physical activity instruction
• Provided additional 300 calories/day (address nutritional
and programs for young people.
deficiencies).
9. Provide a range of developmentally appropriate community
• Schools are encouraged to develop vegetable gardens.
sports & recreation programs attractive to young people.
10. Regularly evaluate physical activity instruction, programs, & • Food preparation is undertaken by home economics/ feeding
facilities. teachers or homeroom PTA on a rotation basis.

HEALTH SERVICES EATING DISORDERS

• Health care provided include preventive services: health • Self-perceptions begin early in life; education and counseling
screening (screening for completeness of immunizations) must begin in elementary school.
• Services include emergency care, management of acute and • Prevention should concentrate on eliminating misconceptions
chronic conditions, appropriate referrals, & regular deworming surrounding nutrition, dieting, and body composition.
as part of Integrated Soil Transmitted Helminthiasis Prevention • Binge eating: recurrent, out-of-control eating of large amounts
and Control Program. of food whether a person is hungry or not.
• Anorexia: severely restricted intake of food based on extreme
fear of weight gain.
HEALTH SCREENINGS
• Bulimia: form of anorexia; chaotic eating pattern with recurrent
One of the objectives of School Health Nursing Program: detect
episodes of binge eating followed by purging.
early signs & symptoms of illness, disabilities, & deviations from normal.
To achieve this objective, the school nurses do: • Health consequences: reduction of bone density, severe
dehydration, tooth decay, and fatal electrolyte imbalances.
• Annual health assessment
o PE of eyes, ENT, neck, mouth, skin, extremities, posture,
Female athlete triad
nutritional status, heart, and lungs.
– syndrome consist of eating disorders, amenorrhea, osteoporosis.
o Visual acuity test (vision screening): use of Snellen's chart,
– result in menstrual irregularities, premature osteoporosis, and
E-chart, or symbol chart.
decreased bone mineral density.
o Ballpen click test (auditory screening): test for hearing
acuity.
o Health examination of prospective Grade 1 entrants is OBESITY
performed during summer • Not considered an eating disorder
• Height and weight measurement • Associated with development of DM, dyslipidemia, HTN, and
o done at the beginning and end of school year other disorders (osteoarthritis, sleep apnea, cholelithiasis).
o accomplished for nutritional assessment and growth
monitoring using the WHO Child Growth Standards, NUTRITIONAL EDUCATION PROGRAMS
Tables, and Charts. • Children need to know and understand what the food pyramid
• Rapid classroom inspection is how to make healthy snack choices, and why balancing
o done to detect illness, particularly when there is outbreak physical activity with food intake is important.
o carried out to assess children’s general state of hygiene. • Obesity, dental caries, anemia, & heart disease can be reduced
or prevented with proper education and lifestyle changes.
EMERGENCY CARE • Adolescents and school-aged children should receive
• Schools are a frequent site for student injuries that range from counseling regarding the intake of saturated fat.
minor injuries to serious injuries, and to life-threatening injuries
• Include natural events and man-made disasters. COUNSELING, PSYCHOLOGICAL, & SOCIAL SERVICES
• Basic first aid equipment should be available. • They see problems as a sign of weakness or lack of control.
• Important role of school nurse: act as counselor and confidante.
CARE OF THE ILL CHILD • Major depressive disorders often have their onset in
• School nurse is responsible for monitoring the health of all adolescence and are associated with increased risk of suicide.
students. • Most events occurred at the beginning or end of the school
day or during the lunch period
STUDENT RECORD
• Health records should be maintained for all students according Warning signs of stress
to the policies of the DepEd. • Difficulty eating or sleeping
• Use of alcohol or other substances (sedatives, sleep enhancers)

Community Health Nursing

 • Difficulty in making decisions • Advocacy campaign and capability building to enable schools to:
• Persistent angry or hostile feelings o Apply positive and nonviolent discipline,
• Inability to concentrate o Provide conflict resolution or peer mediation, including
• Increased boredom referral to appropriate service providers
• Frequent headaches and ailments o Formulate and implement guidelines for prevention and
• Inconsistent school attendance reporting of cases of bullying.

Truths about adolescent suicides HEALTHY SCHOOL ENVIRONMENT

1. Most adolescents who attempt suicide are ambivalent and torn • It should consist of (WHO, 1997):
between wanting to die and wanting to live. o Physical, psychological, and social environment that is
2. Any threat of suicide should be taken seriously. developmentally oriented & culturally appropriate, and
3. There are warning signs preceding a suicide attempt enables students to achieve their potential
4. Suicide is more common in adolescents than homicide. o Healthy organizational culture within the school
5. Education concerning suicide does not lead to increased o Productive interaction between school and community.
number of attempts.
6. Females are likely to consider or attempt suicide, and males Possible signs of abuse
are more likely to complete a suicide attempt. • Physical abuse
7. One suicide attempt is likely to result in subsequent attempt. o Unexplained burns, bites, bruises, broken bones
8. Firearms and strangulation are predominant modalities of o Shrinks at the approach of adults
completed suicides in children and adolescents. o Appears frightened and cries when it is time to go home
9. Most adolescents who have attempted or completed suicide • Neglect
have not been diagnosed as having a mental disorder. o Frequent absenteeism from school
10. All socioeconomic groups are affected by suicide. o Steals food or money
o Lacks adequate medical or dental care
• School nurse may help the child learn how to solve problems, o Appears dirty or disheveled or is underweight
how to cope, and how to build self-esteem. o Does not have proper seasonal clothing
• Family is an integral part of child's well -being; the nurse need • Sexual abuse
to work closely with families to develop appropriate health plan. o Has difficulty walking or sitting
o Reports new onset of nightmares or bedwetting
Psychosocial Intervention Project o Refuses to change into gym attire or participate in
– effort to promote healthy psychosocial environment in school. physical activities
– enhance knowledge and skills of school health personnel o Runs away from home
– allows training of school personnel on crisis management (war- o Becomes pregnant or develops STls
torn and calamity-stricken areas) • Emotional abuse
o Exhibits behavior changes (acting out, extreme passivity)
Factors common in those who commit violent acts in school: o Exhibits delay in physical or emotional development
• Male o Attempted suicide
• Poor socio-economic status o Exhibits inappropriate adult or infantile behavior
• Have history of abuse
• Instant gratification HEALTH PROMOTION FOR SCHOOL STAFF
• Easy access to guns • Staff that participate in health promotion programs increase
• Have a history of discipline problems. health knowledge and positively change attitudes and behaviors
relative to smoking practices, nutrition, physical activity, stress,
To curb violence in schools, DepEd Order No. 40, s. 2012 on the and emotional health.
DepEd Child Protection Policy was issued. In the order, DepEd • School nurses play important role in all levels of prevention
promotes a zero-tolerance policy for any form of child abuse, through assessment, planning, intervention, and evaluation.
violence, discrimi-nation, bullying, and other forms of child abuse. • School nurse can assist faculty and staff by giving workshops
on exercise & nutrition, screening for increased BP, &
Child Protection Policy establishing weight management programs.
– aims to ensure school discipline is administered in a manner
consistent with the child's human dignity. Teachers' Health Welfare Enhancement Program
– protection shall be provided to children who are gravely – offered by Department of Health and Nutrition Service
threatened or endangered by circumstances, which affect their – school health personnel conduct health examination and health
normal growth and development and over which they have no profiling of all teachers and nonteaching personnel.
control.

Plan to translate Child Protection Policy into action includes:

• Consciousness raising; mobilization; and education of students,
parents, teachers, LGUs, and other stakeholders in addressing
child abuse and bullying
• Development of system of standard reporting of incidents of
child abuse and bullying

Community Health Nursing

 Standards of practice
Standard 1. Assessment Collects comprehensive data pertinent to client's health or situation.
Standard 2. Diagnosis Analyzes assessment data to determine the diagnoses or issues.
Standard 3. Outcomes identification Identifies expected outcomes for a plan individualized to client.
Standard 4. Planning Develops a plan that prescribes strategies and alternatives to attain expected outcomes.
Standard 5. Implementation Implements the identified plan.
Standard 5A: Coordination of care Coordinates care delivery.
Standard 5B: Health teaching and health Provides health education and employs strategies to promote health and a safe environment.
promotion
Standard 6. Evaluation Evaluates client's progress towards attainment of outcomes.
Standards of professional performance
Standard 7. Quality of practice Systematically enhances quality and effectiveness of nursing practice.
Standard 8. Education Attains knowledge and competency that reflects current school nursing practice.
Standard 9. Profession practice evaluation Evaluates one's own nursing practice in relation to professional standards and guidelines, relevant statutes,
rules, and regulations.
Standard 10. Collegiality Interacts with, and contributes to the professional development of, peers and school personnel as colleagues.
Standard 11. Collaboration Collaborates with client, family, school staff, and others in the conduct of school nursing practice.
Standard 12. Ethics Integrates ethical provisions in all areas of practice.
Standard 13. Research Integrates research findings into practice.
Standard 14. Resource utilization Considers factors related to safety, effectiveness, cost, and impact on practice in planning and delivery of
school nursing services.
Standard 15. Leadership Provides leadership in professional practice setting and profession.
Standard 16. Program management Manages school health services.

FAMILY AND COMMUNITY INVOLVEMENT • Nurse help develop physical activity programs in the community
• School nurses are often asked to provide health content to that include the child and family.
families, parents, & communities on variety of topics, (sexuality, • Nurses should become adept at working in public sphere by
STIs, HIV, CDs, and substance abuse). increasing visibility and becoming skilled in working with media
• School nurses are ready resource to community if health- and legislators.
related problems arise. • Media can be a useful tool in assisting school nurses with health
• Programs aimed at adolescent weight control may also need education advocacy.
to be targeted to the parents.
ROLE OF THE NURSE IN SCHOOL SETTING

Example Nurse's role

Primary prevention
Nutrition education Provide education to children and parent; consult with dietary staff.
Immunizations Provide for or refer to source(s) for immunizations; offer consultation for immunization in special circumstances.
Safety Provide safety education; inspect playgrounds and buildings for safety hazards.
Health education Facilitate healthy lifestyle education programs; develop health education curriculum for appropriate grade levels; provide
health education to parents, faculty, and staff; develop suicide prevention programs and sex education materials.
Secondary prevention
Screenings Schedule routine screenings for scoliosis, vision and hearing problems, eating disorders, obesity, depression, anger, dental
problems, and abuse.
Case finding Identify at-risk students.
Treatment Administer medications; develop individualized health plan; implement procedures and tasks necessary for student with
special health needs; administer first aid.
Home visits Assist with family counseling and assess special and at-risk students.
Tertiary prevention
Referral of student for substance Serve as an advocate; assist with resource referrals; assist parent, faculty, and staff; consult with neighborhood and law
abuse or behavior problems enforcement officials; initiate outreach programs.
Prevention of complications and Follow-up and referral for student with eating disorders and obesity; participate with faculty and staff to reduce
adverse effects recurrence and risk factors; serve as a case manager.
Faculty and staff monitoring Follow-up for faculty and staff experiencing chronic or serious illness; follow-up of work-related injuries and accidents.

Community Health Nursing

 NCM 104 & 113: Community Health Nursing
CHAPTER 17: OCCUPATIONAL SAFETY AND HEALTH – explore influences of various environments (work & home),
relationships, & lifestyle factors on worker health and determine
OCCUPATIONAL HEALTH NURSING the interactions affecting worker health.
Article 23 of United Nations Universal Declaration of Human
Environmental health
Rights states,
– systematically examine interrelationships between worker and
Every-one has the right to work, to free choice of
extended environment as basis for development of prevention
employment, to just and favorable conditions of work.
and control strategies.
Occupational safety and health (OSH)
Legal and ethical issues
– DOLE: lead government agency; has been
– ensure compliance with regulatory mandates and contend with
– given rulemaking and rule-enforcement powers to implement
ethical concerns that arise in competitive environments.
stipulations of Philippine Constitution and Philippine Labor Code.
– discipline involved in promotion and maintenance of highest
degree of physical, mental and social well-being of workers. EVOLUTION OF OCCUPATIONAL HEALTH NURSING
Ms. Magdalena Valenzuela
Occupational health nursing – instituted Industrial Nursing Unit (INU) of PNA on November 11,
– union of PHN to the thrust of government for OSH gave rise to 1950.
a public health nursing subspecialty.
– focuses on promotion, prevention, and restoration of health Ms. Perla Gorres
within the context of safe & healthy environment. – from Philippine Manufacturing Company (PMC) served as the 1st
– includes prevention of adverse health effects from occupational chairperson.
and environmental hazards.
Ms. Anita Santos
Elements of Occupational health nursing – from Jardine Davies; elected as 1st president on August 19, 1964.
Nursing science – paved way to the modification in the name of the organization
– provide context for health care delivery & recognize the needs to Occupational Health Nurses Association of the Philippines, Inc. on
of individuals, groups, and populations within the framework of November 12, 1966.
prevention, health promotion, & illness & injury care management
(risk assessment, risk management, and risk communication). • June 5 – 6, 1970 – first annual convention was held.
• September 25, 1979 – the organization was registered with
Medical science the Securities and Exchange Commission.
– specific to treatment & management of occupational health • OHNAP remains dynamically involved in programs of DOLE,
illness, integrated with nursing health surveillance activities. Bureau of Working Conditions, OSHC, and DOH.

Occupational health sciences OCCUPATIONAL HEALTH STRATEGIES: ASSESSMENT

– including AND CONTROL OF HAZARDS IN THE WORKPLACE
• toxicology: recognize routes of exposure, examine Classification of occupational health concerns
relationships between chemical exposures in workplace 1. Health hazards
and acute and latent health effects, and understand dose- – elements in the environment that can cause work-
response relationships related diseases to the worker.
• industrial hygiene: identify & evaluate workplace hazards 2. Safety hazards
for control mechanism to be implemented for exposure – unsafe conditions or acts that significantly increase the
reduction. risk of a worker to be injured.
• safety: identity & control workplace injuries through active
safeguard & training & education program about job safety Begins with risk anticipation & assessment by creating job-safety
• ergonomics: match the job to the worker, emphasizing analysis done through reviews of records, process & equipment
capabilities and minimizing limitations. reviews, chemical inventories, interviews, focused group discussions,
surveys, observations, & walk-through methods.
Epidemiology
– study health & illness trends and characteristics of the worker OHT categorize identified health hazards in the workplace as follows:
population, investigate work-related illness & injury episodes, and 1. Biological-infectious hazards
apply epidemiological methods to analyze & interpret risk data to – infectious-biological agents (bacteria, viruses, fungi,
determine causal relationships & participate in epidemiological parasites) that may be transmitted via contact with infected
research. clients or coworkers, and contaminated materials.

Business and economic theories, concepts, and principles 2. Chemical hazards

– strategic & operational planning, valuing quality & cost-effective – forms of chemical agents (medications, solutions, and
services, management of occupational health & safety programs. gases), that interact with body tissues and cells and are
Social and behavioral sciences potentially toxic or irritating to body systems.

Community Health Nursing

 3. Enviromechanical hazards Control measures for occupational hazards can be categorized into:
– factors encountered that cause accidents, injuries, strain, 1. Administrative control
discomfort (poor equipment/lifting devices & slippery floors). – development and implementation of policies, standards,
trainings, job design, and the like.
4. Physical hazards
– agents (radiation, electricity, extreme temperatures, noise) 2. Engineering
that can cause tissue trauma through transfer of energy – adoption of physical, chemical, or technological
from these sources. improvements to limit the exposure of workers to the
hazards of the workplace.
5. Psychosocial hazards
– factors and situations encountered that create stress, 3. Materials provision
emotional strain, or interpersonal problems. – providing workers with supplies or supplements that can
decrease their exposure or susceptibility to occupational
hazards.
Examples of occupational hazards and associated health effects
Category Exposures Health effects
Biological Blood or body fluids Bacterial, fungal, and viral infections (e.g., hepatitis B)
Solvents Headache and central nervous system dysfunction
Lead Central nervous system disturbances
Chemical
Asbestos Asbestosis lung disease
Acids Burns
Static or nonneutral postures Back injuries
Repetitive or forceful exertions Musculoskeletal disorders
Enviromechanical Shift work Sleep disorders
Poorly matched furniture Strained muscles
Slippery floors Injury
Electricity Electrocution
Noise Hearing loss
Radiation Reproductive effects and cancer
Physical
Lighting Headache and eye strain, slips and falls
Vibration Raynaud's disease
Heat Heat exhaustion and heat stroke
Unhealthy stress Fatigue and burnout
Psychosocial
Work-home imbalance Anxiety reactions and a variety of physical symptoms

FRAMEWORK AND SCOPE OF OHN PRACTICE • AAOHN's standards of occupational and environmental health
• OHN collaborates with workers, employers, other professionals nursing practice form the basis by which the profession
to identify health problems, prioritize interventions, develop and describes its responsibilities and accountabilities.
implement programs, and evaluate services delivered.
Standards of occupational and environmental health nursing
Standard I: Assessment Systematically assesses health status of the client(s).
Standard II: Diagnosis Analyzes assessment data to formulate diagnoses.
Standard Ill: Outcome Identifies outcomes specific to the client’s identification.
Standard IV: Planning Develops goal-directed plan that is comprehensive and formulates interventions to attain expected outcomes.
Standard V: Implementation Implements interventions to attain desired outcomes identified in the plan.
Standard VI: Evaluation Systematically & continuously evaluates responses to interventions & progress toward the achievement of desired outcomes.
Standard VII: Resource Secures and manages resources that support occupational health and safety programs and services.
Standard VIII: Professional Assumes accountability for professional development to enhance professional growth and maintain competency.
Standard IX: Collaboration Collaborates with client for promotion, prevention, & restoration of health within the conduct of safe & healthy environment.
Standard X: Research Uses research findings in practice & contributes to scientific base to improve practice and advance the profession.
Standard XI: Ethics Uses ethical framework for decision making in practice,
sc

In the Philippines, Rule 1965.04 of the Amended OSHS published 4. Participating in maintenance of occupational health & safety by
by DOLE (1996) stipulated the expected duties and functions to be giving suggestions in improvement of working environment
performed by OHN: affecting the health and well-being of the workers.
1. Organizing & administering health service program integrating 5. Maintaining a reporting and records system and, if a physician
occupational safety in the absence of physician; activities of is not available, preparing & submitting annual medical report,
the nurse shall be in accordance with the physician. using prescribed form to employer as required by this standard.
2. Providing nursing care to injured or ill workers.
3. Participating in health maintenance examination. If a physician is • Ethical framework that guides the practice of occupational
not available, performing work activities that are within the health nursing is made explicit in the AAOHN code of ethics
scope allowed by nursing profession, and if extensive
examinations are needed, referring to a physician.

Community Health Nursing

Occupational health nurses Types of nonoccupational programs
– encourage and enable individuals to make informed decisions • cardiovascular health • accident prevention
about health care concerns. • cancer awareness • retirement health
– worker advocate and has the responsibility to uphold professional • personal safety • stress management
standards and codes. • immunization • relaxation techniques
– responsible to management, is usually compensated by • prenatal & postpartum health
management, and must practice within a framework of company
policies and guidelines. Occupational health programs topics
– as advocates for workers, foster equitable and quality health care • emergency response
services and safe and healthy work environments.
• first aid and CPR training
• right-to-know training
Code of Ethics of the American Association Of Occupational Health
• immunization programs for international business travelers
Nurses:
Occupational and environmental health nurses: • prevention of back injury through knowledge of proper lifting
techniques, ergonomics
• provide health, wellness, safety, other related services to
clients with regard to human dignity & rights, unrestricted • other programs targeted to the specific hazards identified in
by consideration of social/economic status, personal the workplace
attributes, or nature of health status.
Women's health and safety issues:
• as licensed health care professionals, accept obligations to
society as professional & responsible community members. • maternal-child health • stress management
• strive to safeguard clients' rights to privacy by protecting • reproductive health • work-home balance issues
confidential information & releasing information as required • breast cancer education &
or permitted by law. early detection
• promote collaboration with other professionals, community
agencies, & stakeholders to meet health, wellness, safety, OHN:
and other related needs of the client. • plays key role in the development and delivery of prenatal,
• maintain individual competence in nursing practice, based postpartum, and childhood programs in the workplace.
on scientific knowledge, & recognize & accept • primary importance: ability to serve as change agent to initiate
responsibility for individual judgments & actions, while needed programs in the work environment.
complying with appropriate laws and regulations. • plays critical role in shaping of supportive policies and practices
to accommodate the needs of families (flexible working hours,
parental leave, and on-site child care).
LEVELS OF PREVENTIVE CARE AND OHN
• Promotion, protection, maintenance, restoration of worker's Secondary prevention
health are priority goals set forth in occupational health nursing. – aimed at early diagnosis, early treatment interventions, and
attempts to limit disability.
• OHN had overall responsibility for program management, and – identification of health needs, health problems, employees at risk.
the majority performed surveillance, screening, and prevention
functions as independent practice. • Secondary prevention efforts: preplacement, periodic, and job
transfer evaluations to ensure that the worker is being placed
Primary prevention or is continuing to work in a job that is safe for that worker.
– involved health promotion and disease prevention.
Preplacement evaluation
Health promotion – performed before worker begins employment in a new
– art and science of helping people discover the synergies company or is placed in a different job.
between their core passions and optimal health, enhancing
– baseline examination that consists medical history, occupational
motivation to strive for optimal health, and supporting them
health history, and physical assessment that target type of work he
in changing lifestyle to move toward a state of optimal health. will be performing.
– optimal health is a dynamic balance of physical, emotional,
social, spiritual and intellectual health.
• Occupational health nurse will be expected to document the
return on investment for these and other related activities.
Disease prevention
– begins with recognition of health risk, disease, or
Tertiary prevention
environmental hazard and followed by measures to protect
– rehabilitation & restoration of worker to optimal level of
from harmful consequences of that risk.
functioning based on limitations imposed by disability or illness.
Performing walk-through surveys in workplace, recognizing
potential & existing hazards, & maintaining communications with • Strategies: case management, negotiation of workplace
accommodations, counseling and support for workers who will
safety and industrial hygiene resources to prevent illness and injury.
continue to be affected by chronic disease
• Process of returning an individual to work begins with the
onset of injury or illness

Community Health Nursing

 • Regardless of being an occupational or nonoccupational – work habits tend to emphasize consistency rather than
condition, OHN is the center of case management. routinely tailoring care to encompass individual differences

Physical demands analysis Proficient

– tool in objectively assessing the physical demands of any job. – has increased ability to perceive client situations as a whole
based on past experiences, focusing on relevant aspects of the
• Nurse is often the driving force behind employer's duty of situation.
creating a transitional duty pool. Goal of this program: provide – predict expected events in particular situation and recognize
temporary work that is less physically demanding in nature than protocols sometimes must be altered to meet client’s needs
the employee's regular work.
• They usually work with other occupational health and safety Expert
specialists who may or may not be employed by the company. – has extensive experience and a broad knowledge base and is
able to grasp a situation quickly and initiate appropriate action.
Toxicologist – has sense of salience grounded in practice, guiding actions and
– studies and identifies toxic properties of agents used priorities
in work which the workers might be exposed to.
EXAMPLES OF SKILLS AND COMPETENCIES FOR OHN
Industrial hygienist Examples of skills according to 9 defined areas of competence.
– identifies, evaluates, and controls toxic exposures and 1. Clinical and primary care
hazards in the work environment. • Applying nursing process in delivery of care
• Providing first aid and primary care according to treatment
Safety specialist protocols
– prevents occupational injuries and evaluates safety • Conducting physical assessment
practices and protocols in the workplace. • Taking occupational and environmental health history
• Diagnosing and treating
Ergonomist • Being knowledgeable about immunization protocols
– design specialist who helps promote healthy interface
• Identifying employees' emotional needs and providing
of humans and their tools.
support and counseling
• Using multidisciplinary problem-solving approach to
Epidemiologist
occupational health illness and injury
– conducts research studies on the patterns of disease
and history of occupational diseases and injuries. • Maintaining records
• Clinical testing and monitoring
SKILLS AND COMPETENCIES OF THE OHN • Responding to medical emergencies
• Being knowledgeable about trends in health-related issues
• OHN must possess competencies necessary to recognize and
evaluate potential and existing health hazards.
2. Case management
• Management and budgeting skills and knowledge of legal and
• Identifying need for case management services
regulatory requirements, toxicology, ergonomics, epidemiology,
• Conducting case management assessments using
environmental health, safety, counseling, and health promotion
multidisciplinary framework
and education are essential to meet the demands of OHN
practice. • Developing case management care plans
• Evaluating resources and vendors for case management
Competency categories in occupational & environmental health • Implementing early return-to-work programs
nursing • Monitoring and evaluating outcome
1. Clinical and primary care • Developing policies and program for case management
2. Case management • Analyzing trends for case management services
3. Workforce, workplace, and environmental issues • Designing disability management systems
4. Regulatory and legislative/Legal and ethical responsibilities • Conducting research based on case management
5. Management/Management and Administration outcomes.
6. Health promotion and disease prevention
7. Occupational and environmental health and safety education 3. Workforce, workplace, and environmental issues
and training • Having knowledge of worksite operations, manufacturing
8. Research processes, and job tasks
9. Professionalism • Identifying and monitoring potential and existing workplace
exposures
Each competency delineates comprehensive performance criteria at • Influencing appropriate and targeted recommendations for
the competent, proficient, and expert levels. control of workplace hazards
Competent • Having knowledge of toxicological, epidemiological, and
– gain confidence & mastered perception of role and ability to ergonomic principles
cope with specific situations. • Understanding appropriate engineering and administrative
– less need to rely on peer judgments & of other professionals. controls and PPE specific to preventing workplace health
hazard exposures

Community Health Nursing

 • Understanding roles and collaboration with other cross- • Applying adult learning theory and principles to health
functional groups as an integral part of a core education programs
multidisciplinary team • Integrating all levels of prevention into company culture
• Performing risk assessments
• Managing health surveillance programs 7. Occupational and environmental health and safety education
• Creating effective professional and technical support
4. Legal and ethical responsibilities networks both functionally and cross-functionally
• Being knowledgeable of: • Developing and implementing training programs for
o state nursing practice acts and ability to practice workers and professionals
occupational health nursing within state guidelines
o federal, state, and municipal regulations pertaining to 8. Research
occupational and environmental health • Identifying researchable problems
o associated guidelines, and other relevant occupational • Systematically collecting, analyzing, and interpreting data
and environmental health laws from different sources
o all aspects of medical record-keeping practices in • Recognizing trends in health outcomes by department,
compliance with nursing practice, state law, and work area, or work process
standards of practice • Planning, developing, and conducting research
o current legal trends related to negligence and • Developing and testing models and theories relative to
malpractice cases in professional nursing and in the occupational and environmental health nursing practice
occupational health setting
o confidentiality parameters 9. Professionalism
• Influencing regulatory and legal processes related to • Engaging in a lifelong learning plan
occupational and environmental health • Maintaining currency in practice
• Acting as a professional role model for students and
5. Management and administration
colleagues
• Managing budgets
• Advancing the specialty through knowledge and science
• Hiring staff and management of staff performance
• Fostering professional development plans
IMPACT OF LEGISLATION ON OCCUPATIONAL HEALTH
• Developing program goals and objectives
DOLE possesses legislative and rule-making powers with regard to
• Developing business plans through knowledge of internal the following laws and standards:
and external resources
• P.D. 442: Philippine Labor Code on prevention compensation
• Providing comprehensive on-site services and programs
• Administrative Code on Enforcement of Safety and Health
• Knowing needs of business and employees Standards
• Writing reports • Occupational Safety and Health Standards (OSHS)
• Performing audits and quality assurance • E.O. 307: Creating the Occupational Safety and Health Center
• Handling workers' compensation and disability (OSHC) under the Employees Compensation Commission
• Performing cost-benefit analyses, cost-effectiveness • PD 626: Employees Compensation and State Insurance Fund
analyses, and outcomes monitoring • Hazard-specific laws regarding antisexual harassment
• Allocating appropriate staff resources • R.A. 9165: Comprehensive Drugs Act of 2002
• Providing leadership in health-related issues • R.A. 8504 National HIV/AIDS Law of 1998
• Negotiating • Laws and regulations under jurisdiction of government
• Facilitating work accommodations & return-to-work organizations other than DOLE
processes • DOH: Sanitation Code
• Coordinating medical response activities and site disaster • DA: Fertilizer and Pesticides Act
planning
• DENR: RA 6969, Ratification of Stockholm Convention,
• Being a resource expert on health issues for employees Chemical Control
and management
• R.A. 9185: Comprehensive Dangerous Drugs Act of 2002
• Participating in strategic operations planning
• R.A. 6541: National Building Code of the Philippines
6. Health promotion and disease prevention • R.A. 6969: Toxic Substances Act
• R.A. 9231: Special Protection of Children against Child Abuse,
• Conducting needs assessments
Exploitation and Discrimination Act
• Recognizing cultural differences and their relationship with
health issues
P.D. 442: Philippine Labor Code
• Using effective communication styles to match diverse – aims to protect every citizen desiring to work locally or overseas
employee and management audiences by securing the best possible terms and conditions of employment.
• Making effective presentations
• Planning, developing, implementing, and evaluating health Article 6: all rights & benefits granted to workers shall, except
programs designed to meet the needs of specific as may otherwise be provided, apply alike to all workers,
employee groups or organizations whether agricultural or nonagricultural. This includes
• Evaluating health promotion outcomes fundamental right to health and safety in workplace.

Community Health Nursing

Working conditions and rest periods Article 158. When Emergency Hospital is Not Required.
Article 83. Normal hours of work. • requirement for emergency hospital or dental clinic shall not
• Shall not exceed 8 hours a day. be applicable in case there is a hospital or dental clinic which
is accessible from the employer’s establishment and makes
In the case of health personnel with a population of at least arrangements for the reservation necessary beds and dental
one million or in hospitals with a bed capacity of at least 100, facilities for the use of his employees.
they shall hold regular office hours for 8 hours a day, for 5 days
a week, exclusive of time for meals, except when demands Article 159. Health Program.
of service require work for 6 days or 48 hours, in which case, • the physician engaged by an employer shall, in addition to his
they are entitled to additional compensation of at least 30% of duties under this Chapter, develop and implement a
their regular wage on the 6th day. comprehensive occupational health program for the benefit
of the employees of his employer.
Article 84. Hours of work
• all time during which an employee is: Article 160. Qualifications of Health Personnel
o required to be on duty/to be at prescribed workplace • physicians, dentists, and nurses employed by employers shall
o suffered or permitted to work. have the necessary training in industrial medicine and
• Rest periods of short duration during working hours shall be occupational safety and health.
counted as hours worked.
Article 161. Assistance of Employer
Article 85. Meal Periods. • duty of employer to provide all the necessary assistance to
• Regular meal periods of no less than 60 minutes. ensure the adequate and immediate medical and dental
attendance and treatment to an injured or sick employee in
Medical, dental, and occupational safety case of an emergency.
Article 156. First-aid treatment.
• Requires employer shall keep in the establishment such first- Compensation
aid medicines and equipment as the nature and conditions of Article 86. Night shift differential
work may require. • Not less than 10% of a worker's regular wage must be paid
• Training of sufficient number of employees in first-aid for every hour of work done between 10 o'clock in the
treatment is a responsibility of employer. evening and 6 o'clock in the morning.
• Overtime work has a different rate.
Article 157. Emergency medical and dental services.
• Duty of employer to furnish employees with free medical Article 87. Overtime
and dental attendance and facilities consisting of: • additional of at least 25% percent of a worker's regular
o services of full-time registered nurse when number of wage for every hour worked beyond the regular 8 hours.
employees is 50 – 200 except when employer does • Work greater than 8 hours during a holiday or rest day, a
not maintain hazardous workplaces, services of worker must be paid an additional compensation equivalent
graduate first-aider shall be provided for protection of to the rate of the first 8 hours on a holiday or rest day plus
workers, where no registered nurse is available at least 30% of regular wage.

o services of a full-time registered nurse, a part-time Article 88. Undertime not offset by overtime
physician and dentist, and emergency clinic when the • Undertime may not be offset by an overtime on any other
number of employees is 200 – 300. day.

o services of a full-time physician, dentist, and full-time Article 89. Emergency overtime work.
registered nurse as well as a dental clinic and infirmary • It may be possible that an employer may require any
or emergency hospital with one bed capacity for every employee to perform emergency overtime work.
100 employees when the number of employees o when country is at war or local emergency has been
exceeds 300. declared by National Assembly or Chief Executive

• Hazardous workplaces: no employer shall engage the o when it is necessary to prevent loss of life or property
services of a physician or a dentist who cannot stay in the in case of imminent danger to public safety due to an
premises of the establishment for at least 2 hours, (part-time actual or impending emergency in the locality caused
basis), and not less than 8 hours (employed on full-time basis). by serious accidents, fire, flood, typhoon, earthquake,
epidemic, or other disaster or calamity
• Where the undertaking is nonhazardous in nature, the
physician and dentist may be engaged on retainer basis, o when there is urgent work to be performed on
subject to such regulations as the Secretary of Labor and machines, installations, or equipment, in order to avoid
Employment may prescribe to ensure immediate availability serious loss or damage to the employer or some other
of medical and dental treatment and attendance in case of cause of similar nature
emergency.
o when the work is necessary to prevent loss or
damage to perishable goods

Community Health Nursing

 abortion. She must receive her full pay based on her regular
o where the completion or continuation of work started or average weekly wages.
before 8th hour is necessary to prevent serious • When she applies for maternity leave, she may be required
obstruction or prejudice to the operations of employer. by employer to produce medical certificate stating that the
delivery will probably take place within two weeks.
• Maternity leave shall be extended without pay on account of
Article 91. Right to Weekly rest day illness medically certified to arise out of the pregnancy,
• It must not be less than 24 consecutive hours after every 6 delivery, abortion, or miscarriage, which renders the woman
consecutive normal workdays. unfit for work, unless she has earned unused leave credits
• It is the employer who determines and schedules the weekly from which such extended leave may be charged.
rest day of the employees. • Employer shall only pay the maternity leave for the first four
• exception: employer shall respect the preference of deliveries by the woman employee.
employees as to their weekly rest day when such
preference is based on religious grounds. Article 134. Family Planning Services
• establishments that are required by law to maintain a clinic
Article 92. When employer may require work on a rest day or infirmary must provide free family planning services.
• If any of the following happens: Services shall include application or use of contraceptive pills
o in case of actual/impending emergencies caused by and intrauterine devices (IUDs).
serious accident, fire, flood, typhoon, earthquake, • DOLE, in coordination with other agencies of the
epidemic or other disaster/calamity to prevent loss of government engaged in the promotion of family planning,
life and property, or imminent danger to public safety shall develop and prescribe incentive bonus schemes to
encourage family planning among female workers in any
o in cases of urgent work to be performed on the establishment or enterprise.
machinery, equipment, or installation, to avoid serious
loss which the employer would otherwise suffer Article 139. Minimum employable age
• No child below 15 years of age shall be employed, except
o in the event of abnormal pressure of work due to when the child works under the sole responsibility of parents
special circumstances, where the employer cannot or guardian, and employment does not in any way interfere
ordinarily be expected to resort to other measures with the schooling.
• Any person between 15 and 18 years of age may be
o to prevent loss or damage to perishable goods employed for such number of hours and such periods of day
as determined by the Secretary of Labor and Employment
o where the nature of work requires continuous in appropriate regulations.
operations, and stoppage of work may result in • A person below 18 years of age shall in no case be allowed
irreparable injury or loss to the employer to undertake employment that is hazardous or deleterious in
nature as determined by the Secretary of Labor and
o under other circumstances analogous or similar to the Employment.
foregoing as determined by the Secretary of Labor
and Employment. TRENDS AND ISSUES CONCERNING OCCUPATIONAL
HEALTH
Article 93. Compensation for rest day. • Exposure of workers to hazardous substances, processes, and
• If work is made/permitted to be done on scheduled rest working conditions tends to increase the risk of workers to
day/holiday work, mandates that worker must be paid develop work-related diseases (cancers, renal and chronic
additional compensation of at least 30% of his regular wage. respiratory diseases, pneumoconiosis, and asthma).
• An employee is entitled to such additional compensation for • Highest rates of occupational deaths occur in agriculture,
work performed on Sunday only when it has been forestry, mining, and construction
established as a rest day.
• If employee has no regular workdays & no regular rest days, Concerns of some groups are commonly overlooked, thus, placing
additional compensation of at least 30% of the regular wage them at higher risk:
must be given for work performed on Sundays and holidays. • Gender division of labor poses an impact on women's safety
• During special holidays, additional 30% of regular wage must and health in the workplace. Safety standards are based on the
be given. model of a male worker
• If holiday work falls on scheduled rest day, worker is entitled • Some countries do not include home-based workers under
to additional compensation of at least 50% of the regular safety and health legislation.
wage. • Part-time workers suffer from not being covered by safety
and health provisions.
Working conditions for special groups of employees • Economically active migrants have been exposed to working
Article 133. Maternity leave benefits. conditions that are abusive and exploitative.
• For pregnant woman employed, who rendered aggregate • Workers in informal economy are much likely to be exposed
service of at least 6 months for the last 12 months, employer to poor working environments, low safety & health standards,
shall grant her leave at least 2 weeks prior to expected date
of delivery and another 4 weeks after normal delivery or

Community Health Nursing

 and environmental hazards, and to suffer poor health because
they have little/no knowledge of the risks and how to avoid it.
• Many children are involved in hazardous work.
• Aging of the global workforce raises many concerns
• Accident rate of contract workers: 2x of permanent workers.
• Road accidents usually involve people in the course of their
work, but the deaths are treated as road traffic accidents
rather than work-related fatalities.

The employee has a right to privacy and be protected from

unauthorized and inappropriate disclosure of information. Exemption
is made in life-threatening emergency, authorization by employee to
release information (insurance, HCP), workers' compensation
information, and compliance with government laws and regulations.

AAOHN identifies levels of confidentiality of health information.

1. Level I
– relates to information required by law (data on occupational
illness and injuries, exposure data).

2. Level I
– covers information that will assist in management of human
resources (information obtained from job placement and
other health examinations to determine workability status of
the employee).

3. Level I I
– focuses on personal health information (non-job-related
health problems or health counseling).

• Disclosure of Levels I and I information to management is

allowed only on need-to-know basis, with reference to
workability status and regulatory compliance.
• Disclosure of Level I I information to management and
regulatory agencies should only be allowed as required by law.

Community Health Nursing