BOOK2

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COMMUNITY HEALTH NURSING
Community Health Nursing
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I. SAFE AND QUALITY CARE, HEALTH EDUCATION, COMMUNICATION, COLLABORATION AND TEAMWORK.
A. Principles and Standards of CHN 1. Definitions
Community= a group of people with common interests living together

within a geographical boundary.
Health= state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity (WHO). It is HOLISTIC (Nightingale).
Nursing= assisting sick individual to become healthy and healthy individual to achieve optimum level of functioning.
Community Health= para/medical approach concerned on the health of

population (Community Medicine).
Public Health= the art and science of nursing so that every citizen may
realize his birthright to health and longevity (Preventive Approach).
Public Health Nursing= a professional practice in public health and

nursing in which technical nursing and organizational skills are applied to community health problems.
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Community Health Nursing= unique blend of public health and nursing
for human service with holistic approach.
2. Roles of Public Health Nurse
Health Educator= disseminates information to people with emphasis on health promotion and disease prevention (trimedia IEC).
Clinician= healthcare provider Supervisor= monitors midwives. Facilitator= uses multisectoral linkages (Referral System)
3. Responsibilities of Community Health Nursing Pro-development of overall health plan, its implementation and evaluation. Provide quality nursing services to 4 levels of clientele. Maintain linkages with other health or team members. Conduct CHN researches for health care development.
4. DOH Concepts of CHN a. Health Promotion: primary focus of CHN practice.
Health Teaching: Primary Responsibility of CHN Nurse.

b. Generalists: CHN nurses through lifes continuum of clients. c. Time-unbounded service: contact with all clients may continue for a long period of time. d. Nursing Process (APIE): implicit in CHN practice. 5. Philosophy of CHN: Worth and dignity of man.
Goal of CHN: To raise the health level of citizenry.
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B. Levels of Care
Primary= centers on health promotion and preventive measures. Secondary= centers on diagnoses and prompt treatments. Tertiary= centers on disability prevention and rehabilitation.
C. Types of Clientele
Individual= the least important client in CHN

but most important in hospital.
Family= unit of care in CHN and primary reference group. Population Groups= prominent groups that are vulnerable
to health problems. infants and young children Schoolage Adolescents Mothers Males Elderly
Community= the most important client in CHN.
D. Health Care Delivery System = the totality of all policies, equipments, products, human resources and services which address the health needs of people.
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1. Categories of Health Care Delivery System
According to Type of Service Level of Prevention Health Promotion Illness Prevention Example Provided at Location
According to Service Type
Services
Primary
Health Education, Preventive Care, Common Health Problems
Health education Immunization
RHU Community Hospital Puericulture
Secondary
Medical Services, Surgery
Diagnosis & Treatment Complication Prevention
Screening Case-finding Contact Tracing Prompt Treatment
District Hospital Provincial, City, Hospitals
Tertiary
Advanced and Specialized Services
Disability Prevetion Rehabilitation
PT/OT Facility Employment
Regional, Specialized Medical and National Health Centers
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2. The National Health Plan (Countrys Health Blueprint) Vision: A long term directional plan for health. Goal: To enable the Filipino to achieve a level of health that is accessible. Objectives: Equity: people health status Health problems: addressed Active: participative citizenry HCDS: upgraded
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3. Health Scenarios 10 Leading Causes of Morbidity (2003) 1. Pneumonia 2. Diarrhea 3. Bronchitis 4. Influenza 5. Hypertension 6. TB 7. Heart Diseases 8. Malaria 9. Chickenpox 10. Measles
10 Leading Causes of Mortality (2003) 1. Cardio diseases 2. Vascular diseases 3. Cancer 4. Accident 5. Pneumonia 6. TB 7. NEC 8. Chronic Lower Respiratory Diseases 9. DM 10. Perinatal Diseases
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E. PHC as a Strategy
Primary Health Care= essential health care made universally accessible and
affordable to individuals and families in the community by means acceptable to them, through their full participation.
Goal: Health for all Filipinos by the year 2000 and health in the hands of
people by the year 2020.
Key Strategy: People Empowerment and Partnership

PHC was declared in Alma Ata Conference in September 6-12, 1978.
LOI 949= legal basis of PHC, signed by Pres. Ferdinand E. Marcos (Oct. 19,
1979).
4 Pillars of PHC( M.A.P.S. ) Multisectoral Approach= 2-way referral system (inter/

intrasectoral)
Approtech= use of herbal medicines. Participation: active Support System: Available (Sentrong Sigla Movement)
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10 Medicinal Plants:
a. Lagundi *Skin Diseases (dermatitis, scabies) *Aromatic Bath: post-partum *Rheumatism, sprain, contusion, insect bites *Ascof (asthma, cough, fever), dysentery, colds *Headache, body pains c. Bawang *HPN *toothache e. Yerba-buena *second to lagundi *swollen gums g. Akapulko *fungal skin diseases i. Tsaang-gubat *diarrhea *stomach ache Note: * All uses leaves except bawang (clove) and niyug-niyogan (seeds) * Uses poultice (decoction) Reminders: *infantile colic *dental caries prevention *toothache *menstrual pains h. Niyug-niyogan *parasitism j. Ampalaya *NIDDM d. Bayabas *washing *diarrhea f. Sambong *anti-edema *diuretic *anti-urilithiasis *toothache b. Ulasimang-Bato *gouty arthritis *rheumatism
Boiling: 15 minutes, low fire, remove cover One kind of plant per symptom No insecticide Use clay pot Stop if Adverse Effects develop: 2-3 doses only
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Sentrong Sigla Movement= Certification Program: SS Seal (main component) Aim: To promote availability of quality health service. 4 pillars: a. Award
b. Health Promotion c. Quality Assurance d. Grants and Technical Assistance Principles and Strategies of PHC
a. As of Health Services (Acceptable, Affordable, Available) *Delivery of health services to where people are. *Use of indigenous volunteer workers as healthcare provider. *Use of traditional medications. b. Provision of Quality and Essential Health Services. *Evidence-based training design. c. Community Participation *Consciousness-raising on health concerns. d. Self-reliance *Use of cooperatives and community business. e. Social Mobilization *Health referrals and IEC. f. Decentralization (RA 7160) *Political will advocacy.
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Types of PHC Workers
Note: PHC Workers (2 levels) Healthcare Workers (3 levels) Auxiliary Village/grassroots TBA BHW *First contact of the community *Provide basic healthcare measures Intermediate MHO PHN PHM *First source of professional healthcare *Attend to health problems beyond VHWs competence *Higher source of professional healthcare *Back-up health services Ancillary First Line Hospitals Workers
The Department of Health (DOH)

Vision: Health for all Filipinos. (old)
Leader and staunch advocate and model in promoting health for all in the Philippines. (new)
Mission: To ensure accessibility and quality of healthcare to improve the

quality of life of all Filipinos, especially the poor. (old) * Guarantee equitable sustainable and quality health for all Filipinos especially the poor and shall lead the quest for excellence in health. (new) Primary Strategies:
Support to the Local Health System and Frontliners. Assurance of Healthcare. Increased investment for PHC. Development of National Standards & Objectives for Health.
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Nurses in the DOH
Position
Education (BSN, RN)
Experience
Responsibilities
Nursing Program Supervisor (N VI) Regional Training Nurse
MAN, MPH Major in Administration MAN, MPH
7 years (CHN)
Formulates policies and standards Assesses training needs, develops training devices Assists Nurse Supervisor, Nursing Training Staff in planning, organizing Evaluates District Nurse Supervisors Planning, Programming, Evaluating Directs and Organizes CHN Services Implements training program Provision of RA 1054- free medical
6 years (3 years training, 3 years education) 5 years (CHN) 3 years supervisory 5 years (CHN) 2 years supervisory 5 years 2 years supervisory 5 years as PHN
Chief Nurse
MAN, MPH Major in CHN Administration
Assistant Chief Nurse Regional Nurse Supervisor/ PHN V Provincial/City Nurse Supervisor Nurse Instructor Occupational Health Nurse
MAN, MPH Major in CHN MAN, MPH Major in CHN Administration and Supervision MAN, MPH
MAN
3 years (CHN) Now: 1 year
Units in OHN
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Health Services in DOH
( E. L. E. M. E. N. T. S. )
Education - Health Information & Communication Locally Endemic Diseases Expanded Program in Immunization Maternal and Child Health Programs Essential Drugs Nutrition Programs Treatment of Communicable Diseases Sanitation Mental Health Oral Health Services Drug Dependence
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Health Education= a process to change the attitude, knowledge and skills
(IEC).
Locally Endemic Diseases

1. Schistosomiasis Control Program Surveillance: endemic in Samar, Sorsogon, Leyte, Mindoro. Health Education: wear boots. Eradication of snail. 2. Malaria Control Program Case-Finding Larva-eating Fish: tilapia Anti-mosquito soap and lotion Natural Mosquito repellants: neem tree, gabi leaves 3. Filariasis Control Program Case-Finding Health Education Mosquito Net 4. Dengue Control Program Fumigation: CLAN CHM : Day-biting : Low-flying Urban (2 hours before/after sunrise/sunset) 3oclock Habit: Stagnant
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Expanded Program on Immunization
Objective: To reduce the 6 childhood immunizable diseases.Signed by Pres. Ferdinand E. Marcos (PD 996: September 16, 1976). Principles:
Epidemiological Situation Mass Approach Basic Health Service
Elements of EPI
( S.I.C.A.T. )
Surveillance and Research IEC Cold Chain: system of keeping vaccine potent Assessment and Evaluation of the programs overall performance Target Setting: Vaccine Computation
Legal Policies: 1. PD 996 (9/16/76): 2. PP 6 (4/3/86): 3. PP 46 (9/16/92): 4. PP 147 (3/3/93): EPI below 8 years of age United Nations Universal Child Immunization Day Universal Child and Mother Immunization National Immunization Day
5. RA 7846 (12/30/94): Hepa-B vaccination below 8 years of age 6. PP 773 (3/28/96): Knock Out Polio 7. PP 1066 (8/26/97): National Tetanus Elimination 8. PP 1064 (8/27/97): Acute Flaccid Paralysis Surveillance 9. PP 4 (7/29/98): Philippine Measles Elimination
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Target-Setting Table
Vaccines
Availability (D) 0.05 ml 1 40% 3 3 40% 1.67 40% 1.67 1.67 10 20 25 60% 20 0.1 ml 0.5 ml 2-3 gtts 2.5 (AD)
Dosage
(A)
No. of Doses Recipients Per Vaccine
Wastage Allowance/ Multiplier Factor
BCG ( I )
1 ml
BCG (SE)
DPT
10 ml
OPV
5 ml
HBV
0.5 ml 3 1 50% 2.0 10% 0.5 ml
0.5 ml
1.2
1 10
MV
5 ml
TT
10 ml 5
0.5 ml
40%
1.67
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Vaccine Features
Vaccines BCG (I) BCG (SE) DPT 1 2 3 6 weeks 10 weeks 14 weeks Target Age At birth 6 yo Site Route Side Effects WhealUlceratesHeal-Scar Management
R Deltoid L Deltoid Vastus Lateralis
Intradermal
Massage (-) Kochs:2-4 d Warm Compress Paracetamol every 4 hours
Intramuscular
Fever Convulsion (withhold next DPT dose)
OPV 1 2 3 HBV 1 2 3 6 weeks 10 weeks 14 weeks 6 weeks 10 weks 14 weeks
Mouth
Per Orem
Vomiting NPO for 30 minutes after giving OPV
Vastus Lateralis
Intramuscular
Inflammation Soreness
Warm Compress
MV
9 months
Upper Arm
Subcutaneous
Fever Rashes
Paracetamol every 4 hours
Note: Hepa B: 0-6-14 weeks in the new PHN book.
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Vaccine Minimum Age Interval (Old/ New) 0 Earliest as possible during pregnancy 1 month later Minimum Age Interval (Theoretic al) 5-6th month of 1st Pregnancy Percent Protecte d 80% Protection Duration Dose Consideration
TT 1
Varies 1 year
Primary Dose
TT 2
1 month after 1st Pregnancy or 2 weeks before delivery 5th -6th month on the 2nd Pregnancy 5th -6th month on the 3rd Pregnancy 5th -6th month on the 4th Pregnancy
80%
*Infant protected from Neonatorum Tetanus *Mother: 3 years
Primary Dose
TT 3
6 months later At least 1 year later At least 1 year later
90%
*(same) *Mother: 5 years
1st Booster
TT 4
99%
*(same) *Mother: 10 years
2nd Booster
TT 5
99%
*(same) *Mother: Lifetime
3rd Booster
Tetanus Toxoid Schedule

Note: If mother received 3 DPT during her infancy: TT1 and TT2. Start with TT3.
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Cold Chain = A system used to maintain the potency of the vaccine. Principles: 1. Storage: 3-6 months: Regional Level 3 months: Provincial/City/District 1 month: RHU with refrigerator <5 days: BHS with cold dogs : Vaccine out from the Health Center 3 times or more: discard 2. Transport= use Cold Bags Parts of Cold Bags: a. Vaccine Carriers= outside bag b. Cold Dogs (CD)= containers with ice, found within Vaccine Carrier. 3. Handling= once opened or reconstituted, vaccines are placed in special Cold Pack. Half-life: BCG: 2-4 hours (throw at the end of half day) DPT, OPV, HBV, MV, TT: 8 hours (throw at the end of the day)
Vaccine Storage:
Degree of Sensitivity to Heat Most Sensitive 1st 2nd 3rd 4 5th Least Sensitive 6th Note: OPV, MV, DPT, HB, BCG, TT in the new PHN book.
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-15 to -25 C -15 to -25 C 2-8 C 2-8 C 2-8 C 2-8 C
Storage Temperature
Vaccine OPV MV BCG DPT HBV TT
Form Liquid
Freeze Dried Freeze Dried

Liquid Liquid Liquid
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Maternal and Child Health Services
Maternal and Child Health Nursing= philo-mother and child relationship to one another and consideration of the entire family and socio- economic environment as framework of the patient. Goals: To ensure that every expectant mother maintains good health and bears healthy children.
1. Maternal Care Program

Schedule of Maternal Visits Visits 1st 2nd 3rd Prenatal (at least 3) 1st -7th months (1x/ month) 8th-9th months (q 2 weeks) 10th month (1x/week) (if high-risk: 2x/week) Postnatal Within 24 hours 1 week after the delivery 2-4 weeks after the 2nd visit
Note: Prenatal Visit in the PHN book requires at least 4 visits. 1 st Postnatal visit in the PHN book is within the 1st week (3-5 days) and 2nd Postnatal visit is 6 weeks after.
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Activities: A. ) Regular and quality maternal care services > Prenatal Care *History taking, Home-based Mothers Record (Pink card) *Physical Examination: Leopolds maneuver, weight pattern, BP, height *TT immunization *Iron: 5th month of pregnancy-2 months postpartum; 100-200 mg OD, PO for 210 days (old); 60 mg/400 ug (new) *Laboratory Exams: Urinalysis, Fecalysis, Benedicts and Heat and Acetic Acid Tests Benedicts Test: Sugar in urine determination 3-5 ml Benedicts solution (test tube) + 6 -8 drops urine + Heat (3 min)= Blue Green Yellow Orange Red (Brick) = (-) sugar = trace- (+) = (++) = (+++) = (++++)
Heat and Acetic Acid Test: Albumin determination in urine (Preeclampsia) 3-5 ml urine (test tube) + 6-8 drops Acetic Acid + Heat (3 min)= Clear= negative Cloudy precipitate= positive (albumin)
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>Prenatal Counseling >Safe Delivery Care : Clean (cord, hands, surface): not sterile! > Nursing Care after Delivery *Assessment of mother= 1. fundus is boggy: hemorrhage! 2.Vital signs 3. laceration 4. lochia 5. emotional response *Assessment of Newborn= 1. sucking reflex: airway, pneumonia, nutrition! 2. umbilical stump: tetanus! b.) Registration at the Civil Registrar (PD 651): within 30 days c.) Newborns should be enrolled in Under Five Care Program: 0-59 months
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2.
Reproductive Health
Vision: A way of life for every man and woman throughout life. Ultimate Goal: Quality of Life. 10 Elements of RH (MFARS BM VIA)
1. MCH and Nutrition 2. Family Planning 3. Abortion Complication Management 4. Reproductive Tract Infection Management 5. Sexual Health Education 6. Breast Cancer and gynecology 7. Mens RH 8. Violence Against Women (VAW) 9. Infertility and Sexual Disorder Tx 10. Adolescent RH Focus of RH Framework > Local: Men and Women : Occupational Safety, Water Sanitation, Employment (OWE) > International: Women *Environment: factor that affect womens health (poverty and under- employment) *Powerlessness: discrimination of women *Gender issues
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Vitamin A Supplementation (Pregnant and Postpartum Women)
Population Pregnant Dose 10,000 IU 2x a week (1 capsule) 200,000 IU (1 capsule) Duration 4th month AOG until delivery Given within 1 month after delivery Notes Not to be given if taking pre-natal Vitamin A 200,000 IU is toxic to pregnant women
Post-partum
Iron Supplementation (Pregnant and Postpartum Women)

Population Pregnant Lactating Dose 1 tablet OD (6 months/ 180 days) 1 tablet OD (3 months/90 days) Preparation 60 mg Elemental Iron with 400 mcg Folic Acid 60 mg Elemental Iron with 400 mcg Folic Acid
3. Under Five Care Program

= child health-related services focused to 0-59 months old children. Elements: * CARI: Control of Acute Respiratory Infection * Immunization * Breastfeeding * Oresol * Growth and Health Monitoring
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a.) Growth and Health Monitoring Growth Monitoring Chart (GMC)= standard tool used to record vital data about the childs growth and development to assess malnutrition. (Green Card). Schedule of Children Visits at Health Centers: Months 0-11 months (1st year) 12-23 months (2
nd rd
Frequency Every month Every 2 months Every 3 months Every 6 months Every year
year)
24-35 months (3 year) 36-47 months (4 year) 48-59 months (5 year) b.) Oresol Rehydration Therapy
th th
Policies on Control of Diarrheal Diseases: uses ORT (TAMB) 1. Tubig, Kubeta, Oresol: handwashing, hygiene, environmental sanitation 2. Antibiotic: no to it if causative agent is unknown. 3. Measles Immunization: most preventive measure for CDD in infants. 4. Breastfeeding >Oresol Composition: Glucose (20 g)= NaCl KCl Preparation: 1 L drinking water (2 minutes upon boiling) + 1 pack= 24 hours Home-made Oresol: *1:8:1 Formula= 1 L water + 8 tsp sugar + 1 tsp rock salt + 1 pinch salt *1:2:1 Formula= 1 glass water + 2 tsp sugar
for sodium absorption
(3.5 g)= for fluid and electrolyte retention (1.5 g)= for smooth muscle contraction
NaHCO3(2.5 g)= buffer system
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c.) Breastfeeding August 1= World Breastfeeding Day RA 7600= Rooming in and Breastfeeding Act Launching on= initial breastfeeding: within 30 minutes (NSD); within 4 hours (CS) = 2 minutes initially/ breast; then to achieve 10 minutes/breast EO 51= Milk Code: No to pacifiers (hampers oral needs) and milk companies!
Breast Milk vs Milk Formula

Breast Milk CHO CHON COOH (fats) Linoleic Acid Minerals Lactalbumin 3X () Milk Formula Casein
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Advantages:
Bonding: eye and skin contact while breastfeeding Reduced Allergic Reaction: less proteins Enduces delayed pregnancy (LAM), decreases hemorrhage at postpartum Always Available Stool: soft, sweet smelling, golden yellow Temperature is right Fresh Economical Easily Established Digestible: Lactalbumin Immunity: Natural Passive (IgA) Nutritious GIT diseases: prevented
Breast Milk Storage Room Temperature (25 C) = 8 hours Refrigerator Frozen (2-8 C) = 24 hours (-25 to -35 C) = 3-6 months
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d.) Immunization= NANA PAPA: AbAg AbAg Immunity
Natural Immunity (present at birth) * Physical barriers: * Inflammation * Plasma Proteins
Acquired/Specific Immunity
Natural Passive (Antibody) *Colostrum *Maternal-Cord Transfer Active (Antigen) Passive (Antibody)
Artificial Active (Antigen)
*Disease *Sub-clinical Exposure
*Anti-toxin *Rhogam
*Immunization *Toxoids
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e.) Care of Acute Respiratory Tract Infections (CARI) Goal: To decrease the mortality rate of pneumonia Target groups: very young: <2 months Older child: 2 months- 5 years old Child with cough and colds Policies: A= Assess T= Treat B-reastfeeding I-mmunization: MV V-itamin A A-void pollutants inhalation EO 110-E s. 1991= Standard CARI Case Management (Look) (Feel) C= Categorize (Listen) Prevention of ARI: (BIVA)
CARE RECOMMENDATION FOR CHILDREN

<4 MONTHS =exclusive breastfeeding (only breastfeeding: no food, no water, no fluids!) >8X/day =If the mother is using a bottle to feed the child: replace it with cup or spoon (easier to keep clean) =a breast milk substitute should be consumed within an hour to prevent spoilage =low birth weight baby takes milk into his mouth with his tongue! *Full term/ older babies: suck the milk, spilling some of it. =for any sick child: increase fluid intake (give soup, rice water, buko juice, clean water
Play: see, hear, feel, move

feeding
Communicate: look into your childs eyes, smile at him esp. during breastCommunity Health Nursing
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4-6 MONTHS =new foods can be introduced one a time at least 3 days apart! =Breastfeed as often day and night: >8X/24 hours =give small amount of lugaw with added oil, mash vegetables, beans, steamed tokwa, flaked fish, pulverized roasted dilis, finely ground meat, egg yolk, masked ripe fruits like banana, mango, avocado. *Give these foods 1-2X/day after breastfeeding (to avoid replacing breastmilk)
Play: have large, colorful thing for your child to reach out for, and new
things to see (plastic bowl & metal cap). Sensitive by tasting and touching (put things to mouth).
Communicate: Talk to the child; get a conversation going with sounds or

gestures.
6-12 MONTHS =breastfeed as often the child wants. =give adequate amount of lugaw with added oil, mashed vegetables or beans, steamed tokwa, flaked fish or chicken, pulverized roasted dilis, chopped meat, egg yolk, bite-size fruits. *3X/day if breastfed *5X/day if not breastfed =snacks like taho and fruits =by 12th month: complementary foods would become the childs main source of energy.
Play: clean, safe household things to handle, bang, drop (food tin & large
spoon).
Communicate: Respond to childs sounds and interest, tell your child the
names of things and people.
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12 MONTHS-2 YEARS OLD =breastfeed as often the child wants. =give family foods, rice, camote, potato, fish, chicken, meat, mongo, steamed tokwa, pulverized roated dilis, milk, eggs, dark GLV, yellow vegetables (malunggay, squash), fruits (papaya, banana), oil & margarine *5X/day
Play:Stack-up (colorful cups), things to put in containers and take-out

(plastic jar with stones)
Communicate: Ask child simple questions. Respond to your childs attempts

to talk. Play games like bye and clapping. They begin to understand what others are saying.
2 YEARS AND OLDER = Family foods 3X/day *2X/day: give nutritious foods between meals, such as boiled yellow camote, potato, boiled yellow corn, peanuts, boiled banana (saba), taho, fruits, juices. child.
Play: Counting, naming, comparing things, puzzles. Make simple toys for the
Communicate: Encourage him to talk. Answer his questions. Teach him stories, songs, games
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Types of Alternative Traditional Medicine (Acupuncture) ( M.A.R.C.A. )
Moxibustion= treatment of diseases by applying heat to

acupuncture points. Indications: (BAP) Bronchial Asthma Bronchitis Arthritic disorder Paralysis
Acupressure= acupuncture without the needle performed

with the fingers.
Reflexology= Variation of acupressure where the soles of feet and

ankle joints are stimulated. Indication: Treatment of internal organs diseases.
Cupping= method of stimulating acupuncture points by applying suc

tion through a glass jar. Sprain Injuries: soft tissues Pain: low back Indications: (SIP)
Auriculotherapy= ear acupuncture

Indications: (ODA) Obesity Drug addiction Alcoholism
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Acupressure (Traditional Treatment Modality) =A method of maintaining health, treat disease and alleviating pain by applying pressure on the body surfaces. (5000 years old) 3 elements: a. Qi= life energy; travels throughout the body along Meridians (special pathways which come in pairs on both sides of the body). b. Yin= negative, feminine force. c. Yang= positive, dominating and masculine force Application of Acupressure Posture: lying down, sitting up Manipulation: Thumb, Hypothenar (ulnar side of hand), Thenar (palm of hand), Elbow : 2-3 cycles/sec Frequency: (143 Rule) 1x a day, every 4 hours, 2-3x week in chronic disease Precautions: *use warm room, warm hand *no to full stomach, pregnant women and cardiac patients Foods to avoid: peanuts, iced, irritating, alcohol, sour, seafood, salty (PIAS) Acupressure Points: Ahshi Points= painful spots or nodes when a person has an illness Tsun Measurement= method of locating points in the body. *1 tsun= *2 tsun= *3 tsun= thumb forefinger, middle finger and ring finger forefinger, middle finger, ring finger and small finger *1.5 tsun= forefinger and middle finger
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Indications: (from head to toe) Headache, fainting, dizziness Common colds, sinusitis, rhinitis Toothache Stiff neck Hypertension Lung Diseases Abdominal Pain, Diarrhea Back Pain Bedwetting Joint Pains
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Nutritional Services
Goal: The improvement of the nutritional status and quality of life of the population, through the adoption of desirable dietary practices and healthy lifestyle. Villavieja et al (1996) : Rice is the main Filipino source of protein (12%). Nutrient Requirements: CHON (10-15%) COOH (20-30%) CHO (55-70%)
Water= most essential of all nutrients.

Common Malnutrition Problems in the Philippines:
1. Protein Energy Malnutrition (Macronutrient Malnutrition)

*Two types of PEM Features Etiology Kwashiorkor A disease after a newborn is born CHON Toddler (1-3 years old) Moon Face Flag Sign; Dermatosis Irritable Anorexic CHON Marasmus Starvation, Malabsorption CHO Any age (common:0-2 yo) Old Mans Face Muscle Wasting Apathetic, quiet Voracious eater Calorie
Deficiency Age affected Major signs and symptoms Hair/ Skin Behavior Treatment
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2. Micronutrient Malnutrition (VAG) *Vitamin A Deficiency *Anemia: IDA *Goiter: Iodine Deficiency *VAD
Schedule Supplement 1 Dose Give after 6 months High risk condition is present Infants (6-11 months) 100,000 IU 100,000 IU Preschoolers (12-83 months) 200,000 IU 200,000 IU Postpartum 200,000 IU (within 1 month) After delivery of each child only
Schedule Treatment Give Today Give Tomorrow Give after 2 weeks
Infants (6-11 months) 100,000 IU 100,000 IU 100,000 IU
Preschoolers (12-83 months) 200,000 IU 200,000 IU 200,000 IU
Xerophthalmia=leading cause of children blindness; affects 1-4 years old

children. twilight) Earliest sign: night blindness (frequent accidents at dusk/
Solution: Food Fortification with Vit. A, egg yolk, GLV, liver, yellow fruits *IDA Prevention Recommended Iron Requirements Infants (6-12 months) Children (12-59 months)
Dosage 0.7 mg daily 1 mg daily
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*IDA Treatment and Iodine Supplementation
IDA Treatment Children (0-59 months): 3-6/KBW/day Iodine Supplementation Children (0-59 months)= in endemic areas: Iodine capsule 200 mg Potassium Iodate in oil PO, once a year
Nutrition Surveillance System= a system of keeping close watch on nutritional state of people. Steps: 1. Compute for Ideal Body Weight (IBW)
Male +6 105-110 lbs -6 Rule For every increment of an inch above 5 feet For a height of 5 feet For every decrement of an inch below 5 feet Female +5 100-105 lbs -5
2. Determine the degree of malnutrition 3. Actual Body Weight X 100 IBW
Gomezs Table (Degree of Malnutrition)

>110% 90-109% 75-89% 61-74% <60% Obese Normal 1st degree 2nd degree 3rd degree
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Vitamins:
a. Water-Soluble * Biotin= energy and amino acid metabolism Fat-glycogen synthesis * Pantothenic Acid= for energy metabolism * Vitamin C= CIAS Collagen and bone formation Iron absorption from GIT Infection resistance AA metabolism Scurvy prevention *Vitamin B-complex= Thiamine (B1)= nerve function; beriberi prevention Riboflavin(B2)= skin health Prevents cracks at mouth corners, tongue inflammation Niacin (B3)= support skin, nervous and digestives systems Prevents pellagra Pyridoxine (B6)= BRAMP Brain functions Regulates sodium and potassium Absorption of Vitamin B12 Musculoskeletal and Nervous functions Production: HCl, Heme, AA, Mg Folic Acid (B9)= formation of DNA and rbc. Prevents anemia Cyanocobalamin (B12)= formation of new cells and nerve cells Metabolism of FA and AA
2 Types: Water-soluble and Fat-soluble
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b. Fat Soluble *A= for VIRBS; prevents xerophthalmia Vision Immune function Reproduction Bone/tooth growth Skin Health *D= enhances calcium absorption *E= INA; arteriosclerosis prevention Immune function Neuro-muscular system protection Anti-oxidant *K= Blood Clotting synthesis Bone Protein Blood Calcium Regulator
Minerals:
*Calcium= BINC Bone & Teeth mineralization Blood Clotting BP regulation Immune defenses Nerve Function Contraction/ relaxation of muscles *Chloride= fluid and electrolyte balance *Chromium= helps insulin (glucose energy release) *Copper= Hemoglobin formation, Iron absorption
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*Fluoride= bone/teeth formation *Iodine= regulates BMG Basal metabolic rate Mental function Growth *Iron= blood formation *Magnesium= for the M-I-N-D M-uscle contraction I-mmune system maintenance N-erve Impulse transmission D-evelopment of protein and bone/teeth mineralization *Manganese/Molybdenum= cell processes: facilitator *Phosphorus= Bone and Teeth mineralization Energy transfer Acid-Base balance *Selenium= works with vitamin E *Sodium= F & E balance; assists nerve impulse *Sulfur=integral part of BH-TV (biotin, hormones, thiamine, vits.) *Zinc= for GIRLS! Growth Immunity Reproduction Libido Stamina
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Treatment of Communicable Diseases National Tuberculosis Control Program
Vision: A country where TB is no longer a public health problem Mission: Ensure that TB DOTS services are available, accessible, and affordable to the communities in collaboration with the LGUs and other partners. Goal: To reduce prevalence and mortality from TB by half by the year 2015. RA 1135: TB Law Directly Observed Treatment of Short Course Chemotherapy (DOTS) =Tutok Gamutan Facts: 2 weeks upon taking anti-TB drugs: no longer communicable 1 week upon taking anti-leprosy drugs: no longer communicable How to Collect Sputum? Early AM upon waking up Gargle water (may add salt) Face wall (infection control), hands at the back (maximum lung expansion) Deep cough: tongues tip at lower central incisor Sputum: collected in sterile cup
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Category and Treatment Regimen (old) Category 1=2-4: RIPE-RI NEPS *New pulmonary TB patients whose sputum is (+). *Extra-pulmonary TB: Potts disease *Pulmonary TB *Seriously ill patients with severe forms *Smear (-) pulmonary TB with extensive parenchymal involvement Step 1: Intensive Phase: (Goal: not to communicate the disease) = given daily for 2 months Ri-fam-pi-cin I-N-H Py-ra-zi-na-mide E-tham-bu-tol Step 2: Sputum Exam Step 3: If smear (-): Maintenance Phase (Goal: kill the M. tb) = given daily for 4 months R= 450 mg I= 300 mg If smear (+): Drugs stopped for 2-3 days (Drug resistance) : Send Sputum C/S : Patient continue the same initial IP for 1 month (at end of 3rd month, repeat sputum exam) : Start MP for 4 months regardless of result 450 mg 300 mg 500 mg (2 tablets) 400 mg (2 tablets)
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Category 2= 2-1-5: RIPES-RIPE-RIE *Previously treated patients: relapses, failures, others Step 1. Intensive Phase given daily for 2 months RIPE + S (1 mg) given daily for 1 month RIPE Step 2. Sputum exam Step 3. Smear (-): Maintenance Phase =given daily for 5 months: RIE Smear (+): Continue IP for 1 month with same drugs (RIPE) : sputum exam : if still (+), continue RIPE for 5 months Category 3= 2-2: RIP-RI *New pulmonary TB patients whose sputum is smear (-) for 3X *Chest X-ray of PTB is minimal *Extra-pulmonary (not serious) Step 1. Intensive Phase =given daily for 2 months: RIP Step 2. Maintenance Phase =given daily for next 2 months: RI
Side Effects of anti-TB drugs:

R= red-orange urine I = peripheral neuritis (PiN) P= GoUty arthritis E= Optic Neuritis (EON) S= deafness, tinnitus
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Recommended Category of Treatment Regimen (new)
Category I Type of TB patient *New smear PTB (+) *New smear PTB (-) with extensive parenchymal lesions on CXR *Extra-pulmonary TB 2 months Rifampicin INH Pyrazinamide Ethambutol II *Treatment failure *Relapses *Return after default 2 months Rifampicin INH Pyrazinamide Ethambutol Streptomycin 1 month Rifampicin INH Pyrazinamide Ethambutol III *New Smear PTB (-) with minimal parenchymal lesions on CXR 2 months Rifampicin INH Pyrazinamide Ethambutol IV Chronic: still smear PTB (+) after supervised retreatment Refer to *DOTS Plus Center *City/Provincial NTP Coordinator
Intensive Phase
Continuation Phase
4 months Rifampicin INH
1 month Rifampicin INH Ethambutol
4 months Rifampicin INH
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Dosage per Category of Treatment Regimen a. FIXED-DOSE FORMULATION =number of tablets per patient will depend on the body weight (kilograms) Categories I & III Body weight (kg) No. of Tablets (2 months Intensive Phase) 30-37 38-54 55-70 >70 2 3 4 5 No. of Tablets (4 months Continuation Phase) 2 3 4 5
Category II Body weight (kg) No. of Tablets (First 2 months Intensive Phase) RIPE 30-37 38-54 55-70 >70 2 g 3 g 4 g 5 g S 0.75 0.75 0.75 0.75 No. of Tablets (Next 1 month Intensive Phase) RIPE 2 3 4 5 No. of Tablets (Last 5 months Continuation Phase) RI 2 3 4 5 No. of Tablets (Last 5 months Continuation Phase) E 1 2 3 3
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b. SINGLE DRUG FORMULATION = just add one tablet of INH (100 mg), PZA (500 mg), E (400) each for the patient weighing more than 50 kg. Category I & III
Anti-TB Drugs No. of Tablets (2 months Intensive Phase) R I P E 1 1 2 2 1 1 No. of Tablets (4 months Continuation Phase)
Category II Anti-TB Drugs No. of Tablets (First 2 months Intensive Phase) R I P E S 1 1 2 2 1 Vial/day (56 vials for 2 mos) No. of Tablets (Next 1 month Intensive Phase) 1 1 2 2 2 No. of Tablets (Last 5 months Continuation Phase) 1 1
Drug Dosage per KBW

Drug R I P E S Dose per KBW 10 mg/kg 5 mg/kg 25 mg/kg 15 mg/kg 15 mg/kg Maximum Dose 600 mg daily 400 mg daily 2000 mg daily 1200 mg daily 1000 mg daily
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Management of TB Children = BCG has 50% protective efficacy against TB disease, 64% against TB meningitis and 71% against death from TB. = All TB symptomatic children 0-9 years old, except sputum positive child shall be receive Tuberculin Testing. = Tuberculin testing is conducted once a week on Monday or Tuesday. 10 children are gathered to avoid wastage.
Exposed Infection TB Diagnosed/ Confirmed (Disease) (Any three) *Positive history of exposure to an adult/ adolescent TB case. *With s/s suggestive of TB. *Positive Tuberculin Test *Abnormal CXR suggestive of TB *Lab findings suggestive of TB TB Symptomatic (Any three)
*Exposure to an adult TB patient (should undergo Tuberculin testing & & PE) *Productive cough (should undergo Sputum Exam; if positive, treatment immediately & Tuberculin testing shall no longer performed) *Without signs & symptoms but with positive Tuberculin Test or with s/s but with negative Tuberculin Test (both referred for CXR)
*With s/s, with either known/ unknown exposure to a TB case (should undergo Tuberculin Test) *With known contact but with negative Tuberculin Test, and with unknown contact but with positive Tuberculin Test (referred for CXR) *Those with negative CXR, Tuberculin Testing will be repeated after 3 months. *INH for 3 months will be given to children less than 5 years old (Prophylaxis)
*Cough/ wheezing for >2 weeks *Unexplained fever for >2 weeks *Loss of appetite & weight; failure to gain weight *Failure to respond to antibiotic therapy for 2 weeks
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TB Children Treatment Regimen
1. Pulmonary TB
Drugs Intensive Phase R I P Continuation Phase R I

2. Extra-pulmonary TB
Daily Dose (mg/KBW) 10-15 mg/KBW 10-15 mg/KBW 20-30 mg/KBW 10-15 mg/KBW 10-15 mg/KBW
Duration 2 months
4 months
Drugs Intensive Phase R I P Then E or S Continuation Phase R I
Daily Dose (mg/KBW)
Duration 2 months
10-15 mg/KBW 10-15 mg/KBW 20-30 mg/KBW
15-25 mg/KBW 20-30 mg/KBW 10-15 mg/KBW 10-15 mg/KBW 10 months
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Leprosy Control Program
Objective: Provide Multi-Drug Therapy to all leprosy cases within 3 years and complete the treatment of 90% of all cases. Multi-Drug Therapy (MDT)= is the use of 2 or more drugs for the treatment of leprosy. 1 week after starting the treatment, it renders the patient to be non-infectious. WHO Classification: A. Paucibacillary (Indeterminate & Tuberculoid) = non-infectious; 6-9 months treatment
Adult Monthly Treatment: Day 1 (Supervised Dose) *Rifampicin *Dapsone Daily Treatment: Day 2-28 (Self Administered Dose) *Dapsone 100 mg 50 mg 25 mg Child (10-14 years old) <10 years old
600 mg 100 mg
450 mg 50 mg
300 mg 25 mg
b. Multibacillary (Lepromatous & Borderline) = infectious; 24 months treatment

ROM Regimen Rifampicin Ofloxacin Minoxycline Adult 600 mg 400 mg 100 mg Child 300 mg 200 mg 50 mg
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Multibacillary (RCD-CD)
Adult Monthly Treatment: Day 1 (SD) *Rifampicin *Clofazimine *Dapsone Daily Treatment: Day 2-28 (SAD) *Clofazimine Child (10-14 years old) <10 years old
600 mg 300 mg 100 mg
450 mg 150 mg 50 mg
300 mg 100 mg (1x/month) 25 mg
50 mg
50 mg (q other day)
50 mg (2x a week)
*Dapsone
100 mg
50 mg
25 mg
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Environmental Sanitation
= the study of all factors in mans physical environment with relations to his health. PD 856= Code on Sanitation PD 825= Anti-Littering Law Environmental Sanitation Programs: A. Water Supply Sanitation Program 3 types of approved water supply facilities: Level 1 (Point Source) = a protected well with an outlet but without a distribution system. = serves 15-25 households, <250 meters distance = yields 40-140 liters/minute Level 2 (Communal Faucet/ Stand Post) = a system composed of a reservoir, piped network and communal faucet. = serves 100 households, <25 meters distance = yields 40-80 liters/capita/day = 1 faucet: 4-6 households Level 3 (Waterworks System) = requires minimum treatment of water. Unapproved types of water facilities: * Open dug wells * Unimproved spring and well
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Types of Wells: (Sa DaKo Pa Sa Taas) * Shallow Well= taps water from above the impervious layer = soft, grossly contaminated = not long-lasting * Deep Well = taps water from below the impervious layer = hard, bacteriologically pure = constant supply * Katcha Well= Dug well = gets easily contaminated = dries early * Pucca Well= Dug well = do not easily get contaminated = do not get dried early * Step Well = people can step, enter and collect water = cause of Guinea worn infection * Tube Well = driven wells and sanitary wells = 50 feet way from likely source of contamination B. Proper Excreta and Sewage Disposal System 3 Types of Approved Toilet Facilities: Level 1 > Non-water carriage= (PRC BV) pit latrine reed odorless earth closet compost bored-hole ventilated improved pit > Small amount of water Pour flush Aqua Privies
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Level 2= on site toilet with septic tank Level 3= toilet with sewerage system Types of Toilet: (TOP CAW) * Trench Latrine= temporary toilet = digging around the ground * Over hung toilet= hangs over water body (never acceptable) * Pit Privy/ Latrine= odor and insects may get inside: always cover! * Cat hole= simplest excreta disposal: hukay-tabon * Chemical Toilets= portalets (buses, airplanes, ships) * Antipolo Type= same with pit latrine * Water real= hand flush/ pour flush C. Food Sanitation Food Establishment Rating: Class A= Excellent Class B= Very Satisfactory Class C= Satisfactory D. Hospital Waste Management= to prevent nosocomial infections: P. aeruginosa community infection: E.coli yellow: infectious green: wet/ non-infectious black: dry/ general waste red/ orange: radioactive/ chemical/ hazardous
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Mental Health Program
Goal: Promotion of Mental Health to reduce health-related effects of stressful lifestyle.
Mental Health= a state of well-being where a person can realize his own
abilities.
Mental ill Health= disturbance in persons thoughts, feelings and behavior. Mental Disorder= medically diagnosable illness, results in significant impairment of ones abilities.
Mental Hygiene= science which deals with measures employed to promote

mental health.
Psychiatric Nursing= promotion of Mental Health, prevention of mental
disorders and nursing care of patients during mental illness and rehabilitation.
Public Health Burdens: Mental Health Problems Defined Burden= currently affecting a person with mental disorder. Undefined Burden= impact of mental health problems to significant others. Hidden Burden= stigma and violations of human rights. Future Burden= anticipated problems resulting from existing burdens and
increasing social problems.
55 F. Family-Based Nursing Services (Family Health Nursing Process): APIE

I. Assessment
Steps: (DDD) 1. Data Collection
A. First Level Assessment (FLA): (PIRLO)

*Physical Examination *Interview *Review Records *Laboratory Tests *Observation B. Second Level Assessment (SLA): (PADE) *Perception *Actions taken *Decisions made *Effects of decision 2. Data Analysis 3. Diagnosis 2 Types:
a. Wellness State/ Potential Health Problems= end product of FLA Wellness State
* Wellness Potential= nursing judgment on wellness state based on clients performance, with no explicit desire. e.g. Potential for enhanced capability for health lifestyle * Readiness for enhanced wellness state= nursing judgment on well ness state based on clients performance, with explicit desire
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e.g. Readiness for enhanced parenting
Health Threat= condition conducive to disease, accident or failure to realize ones health potential. e.g. hereditary diseases
Health Deficit= failure in health maintenance.

e.g. with pneumonia
Stress Points/ Foreseeable Crisis= anticipated unusual demand

on the individual or family in terms of adjustment or resources e.g. birth of a 13th child
b. Family Nursing Problems= end product of SLA

= inability reasons (KAS) to perform health tasks by the family.
Reasons:
Problem recognition Health Action Decision Nursing Care to health-dependents Home Environment Resources in Community Utilization
II. Plan Family Nursing Care Plan

= blueprint of care to alleviate family nursing problems. Steps: (POSE) Prioritize health conditions and problems based on: Nature of the Problem (weight:1) *Wellness *Health Deficit *Health Threat 3 3 2
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*Foreseeable Crisis 1 Modifiability (weight: 2)= Can I and with the family change this problem? *Easily *Partially *No 2 1 0
Preventive Potential (weight: 1)= Can I and with the family prevent this thing from happening? *High *Moderate *Low 3 2 1 2 1 0
Salience (weight:1)= familys opinion about the problem. Problem needing immediate attention Problem not needing immediate attention Not perceived as a problem Objectives and Goals of Care Selecting Nursing Intervention Evaluate Plan
III. Implementation= intervention with KAS application: Generalists! IV. Evaluations

*Reflection-In-Action= think while you are doing it! *Reflection-On-Action= think what you have done!
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G. Population Group-Based Nursing Services = refer to vulnerable groups. Special Fields:
Community Mental Health Nursing Occupational Health Nursing= is concerned with the health and safety of
people at work, their families, and the general community. Goal: Assisting workers in all occupations to cope with actual and potential stresses in relation to their work and work environment and maintain OLOF. Benefits of OHN in business and their employers: *Productivity: maximized *Injuries: fewer *Costs: reduced for disability and sickness *Absenteeism: reduced
School Health Nursing= the focus is to strengthen and facilitate the educational process by promoting normal development; promoting health and safety; and intervening with actual and potential health problems of the students. Goal: Modification or removal of health of health related barriers to learning by providing prevention of illness and disability, the early detection and promotion of OLOF.
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H. Community-based Nursing Services/Community Health Nrsg.Process
I. Assessment
1. First Level Assessment: Data Collection >Health Status: family, groups, community >VHS (Vital Health Statistics) > Community Dynamics: Ecosystems OLOF *Behavior *Heredity *Health Care Delivery System *Environment *Political *Socio-economic >Demographic Data 2. Second Level Assessment: Health Problem Categorization
Nursing Diagnosis= interpreted and validated with individuals, family groups and members of the community concerned. status.
Health Deficit= gap between actual and achievable health

e.g. repeated infections, miscarriages
Health Threats= promote disease or injury and prevent people from realizing their health potential. e.g. inadequate immunization (defaulters)
Foreseeable Crisis= stressful occurrences.

e.g. illness and death of family member
Health Need= A health problem alleviated by medical and

social technology. = passive health action
Health Problem= a health need alleviated by actual/ potential resources.
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= active health action
II. Planning
Steps 1. Prioritize Problems
Nature (weight: 1) Health Status (fertility, morbidity, mortality) Health Resources (manpower, money, materials) Health-Related (BHHEPS that can aggravate illness in community) Magnitude (weight:3) = degree of community affected 75%-100% 50%-74% 25%-49% <25% Modifiability (weight: 4) High Moderate Low Not Preventive Potential (weight: 1) High Moderate Low Social Concern(weight: 1) Urgent Not Urgent Not a Concern 2 1 0
3 2 1
4 3 2 1 3 2 1 0 3 2 1
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Quantitative Objective One Reality: Hard Science Focus: Concise and Narrow Reduction, Control, Prediction Reasoning: Logistic, Deductive Basis of Knowing: Cause & Effect Relationships Measurable Mechanistic Parts Equal the Whole Tests Theory Uses Instruments Basic Element of Analysis: Numbers Report: Statistical Analyses Interpretive Organismic Whole is greater than the parts Develops Theory Uses Communication and Observation Basic Element of Analysis: Words Report: Rich Narrative, Individual Interpretation Generalization Researcher: Separate Subjects Context Free Uniqueness Researcher: Part of Research Process Participants Context Dependent Qualitative Subjectivity value Multiple Realities: Soft Science Focus: Complex and Broad Discovery, Description, Understanding Reasoning: Dialectic, Inductive Basis of Knowing: Meaning, Discovery
2. Objectives and Goal of Care= direction of action = with specific objectives made with the community = SMART 3. Selecting Nursing Intervention 4. Evaluate Plan
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III. Implementation
= the role of CHN nurse shifts from care giver to a teacher. Continuous Data: Collection, Analysis, NCP Validation Documentation= important communication tool for various team. >quality of care evidence >protect the agency and health care providers >data for research and education
IV. Evaluation
= Objective evaluation and reassessment of NCP 3 elements: (SPO)
> Structural Elements:

includes physical settings, instrumentalities and conditions.
> Process Elements:

Nursing Process (APIE).
> Outcome Elements:

changes in clients health status that result from health intervention.
63 I. Community Organizing Participatory Action Research

= process of change and empowerment for building the capability of people for future community action. 5 Stages (Community Health Promotion Model):
ADIC na DR! Analysis Design & Initiation Implementation Consolidation Dissemination-Reassessment

I. Community Analysis =process of assessing and defining needs for community health action plan. =Also known as
Mapping Education Planning Needs Assessment Diagnosis

5 Components:
Profile: Economic, Demographic, Social Health risk Outcome Profile (Mortality/ Morbidity Data) Survey (health promotion programs) Target group studies
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Steps: 1.
Define Community= includes geographic boundaries done in consultation

with representatives of the various sectors.
2. Data Collection 3. Capacity Assessment= includes driving forces that may facilitate or
impede change.
4. Barriers= communitys customs and traditions that may impede facing

the change.
5. Change Readiness 6. Set Priorities= basis for prospective community interventions.

II. Design & Initiation
1. Core Group Planning= 5-8 members from the community selected

to do the planning and management of the program.
2. Organizational Structure
*Leadership Board/ Council= existing local leaders *Coalition= groups working for community issues *Consortia= network specializing for certain concerns *Lead/ Official Agency= utmost responsible for health promotion activities in the locality. *Grass-roots= informal groups and neighborhood. *Panels= 5-10 citizen group together with a government Agency.
3. Recruit Organizational Members 4. Mission, Vision and Goals Definition 5. Roles and Responsibilities Definition 6. Training and Recognition
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III. Implementation
1. Citizen Participation/ Task Force 2. Work Plan 3. Strategies that is unified 4. Values of the community integrated in the program
IV. Consolidation/ Program Maintenance
1. Integrate activities into community networks 2. Positive organizational culture 3. Ongoing recruitment plan, or training of new members because some of
the volunteers may leave.
4. Disseminate results= continuous feedback to maintain community support.
V. Dissemination-Reassessment *Formative Evaluation= performed to give timely modification of activities and strategies for future direction.
1. Update the community analysis= this encourages collaboration with other organizations.
2. Effectiveness of programs evaluation 3. Modifications= revision of goals and objectives for the development of
new strategies.
4. Disseminates results= this enhances the organizations visibility in the

community
66 J. RESEARCH AND QUALITY IMPROVEMENT

A. Research in the Community 2 Types of Research Methods
Quantitative Objective One Reality: Hard Science Focus: Concise and Narrow Reduction, Control, Prediction Reasoning: Logistic, Deductive Basis of Knowing: Cause & Effect Relationships Measurable Mechanistic Parts Equal the Whole Tests Theory Uses Instruments Basic Element of Analysis: Numbers Report: Statistical Analyses Generalization Researcher: Separate Subjects Context Free Interpretive Organismic Whole is greater than the parts Develops Theory Uses Communication and Observation Basic Element of Analysis: Words Report: Rich Narrative, Individual Interpretation Uniqueness Researcher: Part of Research Process Participants Context Dependent Qualitative Subjectivity value Multiple Realities: Soft Science Focus: Complex and Broad Discovery, Description, Understanding Reasoning: Dialectic, Inductive Basis of Knowing: Meaning, Discovery
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Ethnographic Research
Ethnography= the study of culture = a written representation of a culture or a selected aspect of a culture Ethnographic Research/ Ethnographic Field Research= the systematic process of observing, detailing, describing, documenting and analyzing the life ways or particular patterns of a culture in order to grasp the patterns of the people in their familiar environment (Leininger). Principles: ABC A-ctive Participant: the researcher is included in data collection and analysis. B-ehavioral Context: Peoples behavior can only be understood within its area of activity. C-ategorical Analysis: ethnography focuses on generating categories and discovering relationship between them. C-ultural System: ethnography is holistic and contextual.
Stages of Fieldwork: (ELME) Entering the field setting. Leaning the ropes: learning how to play ones role within the setting. Maintaining and sustaining the relationships that emerged. Eventually leaving the setting.
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Fieldwork Methods (PIFeR) *Participant Observation= the investigator establishes a many-sided and long-term relationship with human association in its natural setting. Purpose: to develop a scientific understanding. *Interviews= a conversation with a purpose to access the perspective of the people. Purpose: to obtain a valid and reliable information. *Focus Group Interview= a qualitative approach utilizing various data collection techniques that is intentionally responsive to unexpected data = Incidental Methodology Purpose: to allow intensive exploration of feelings, opin ions and behaviors. *Review of Documents= includes field reports, annual reports, and published and unpublished materials on primary health care and community-based health programs in the Philippines. Ethical Considerations: Truthful but Vague: How deep should the participants know about the research studys purpose? >The participants knew the research was about the activities of CHN in PHC. >They were informed that the researcher was to participate and observe their activities and conduct interviews. > Research objectives were not elaborated but explained on a case-to-case basis if participants asked. Deception is inherent in participant observation.
>Present during the early stages of the research. >Resistance: People tend not to participate and critical to the field worker. >Solution: Confidentiality and anonymity assurance
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K. Vital Statistics = the application of statistical measures to vital events (births, deaths, illnesses) to achieve the levels of health, illness and health services of a community.
Fertility Rates a. Crude Birth Rate (CBR)
= measures natural growth or increase of a population. CBR= total number of live births registered in a given calendar year Estimated population as of July 1 of same year X 1000
b. General Fertility Rate (GFR) GFR= Live Birth Womens population (15-44 years old) X 1000
Mortality Rates
a. Crude Death Rate (CDR) = a measure of mortality from all causes which may result to a decrease in population CDR= total number of deaths registered in a given calendar year X 1000 Estimated population as of July 1 of same year
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b. Infant Mortality Rate (IMR) = measures the risk of dying during the 1st year of life. = good index of the general health condition: it reflects the changes in the environmental and medical conditions of the community. IMR= total number of death under 1 year of age registered in a given calendar year total number of registered live births of the same calendar year c. Neonatal Death Rate = measure the risk of dying during the 1st month of life. = index of the effects of prenatal care and obstetrical management on the newborn. NDR= Number of deaths under 28 days of age registered in a given calendar year Number of live births registered the same year d. Maternal Mortality Rate (MMR) = it measures the risk of dying from causes related to pregnancy, childbirth, puerperium. = index of the obstetrical care needed and received by women. MMR= Number of deaths from maternal causes registered for a given year X 1000 Total number of live births registered at same year X 1000 X 1000
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e. Swaroops Index= Death of >50 years old total death = if SI is high: indicative of greater life expectancy (not a good health status determinant). X 100
Morbidity Rates a. Prevalence Rate

= population exhibits particular disease at a particular time. = deals with total (old and new) cases. PR= number of new and old cases of a certain diseases registered at a given time total number of persons examined at same given time b. Incidence Rate = frequency of occurrence of the phenomenon during a given period of time, deals only with new cases. IR= Number of cases of a particular disease registered during a specified period of time estimated population as of July of same year (Note: In the PHN book the multiplier for PR and IR are both 1, 000.) X 100,000 X 100
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L. Epidemiology = science concerned with factors and conditions which determine occurrence and distribution of health, disease, disability and death in population. >Agent-Host-Environment (Clark-Leavell) >Etiology: Causation > Incubation Period: time interval from exposure to appearance of 1 st sign/ symptoms > Prodromal: appearance of 1st sign/ symptoms to pathognomonic sign. > Immunity: ability to resist infection > Herd Immunity: total immuned population.
Pattern of Disease Occurrence Responsibilities of the Nurse during Epidemics:
1. Carrier and Contact Control 2. Active Case Finding 3. Surveillance
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Pattern Epidemic = unexpected increase in number of disease cases e.g. dengue, cholera Endemic = regular, constant, habitual e.g. malaria, filariasis Sporadic =on/off, intermittent e.g. rabies Pandemic =global, cosmopolitan e.g. AIDS, Hepa B Outbreak =regional e.g. bird flu, Ebola virus 20% 80% 50% 50% Susceptible 80% Immuned 20%
M. Demography = study of population size, composition and spatial distribution as affected by births, deaths and migration. 3 Sources: a. Census= complete aspect of the population: composition, distribution, size b. Surveys c. Registration System: National Statistics Office (NSO)
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Components:
a. Population Size
Population composition: *Age distribution *Population Pyramid *Sex ratio *Median Age *Age-dependency ratio= 0-14 years old + >65 years old 15-64 years old c. Population Distribution *Urban or Rural *Population Density *Crowding Index= indicates the ease by which a communicable disease can be transmitted. X 100
CI= total number of persons in household Number of rooms in the house Normal: 1 person/ 70-90 square foot * >9 years old= should have one own room * 1-10 years old= 2 persons per room
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II. MANAGEMENT OF RESOURCES AND
RECORDS MANAGEMENT
Field Health Services and Information System
Objectives: To provide summary data on health service delivery accomplished at Health Care Delivery System. Components: Family Treatment Record (FTR)= fundamental building block of FHSIS = prepared daily Target/ Client List (TCL)= second building block = prepared and submitted weekly 4 purposes: * Plan and carry out patient care and service delivery * Monitoring and supervision of services * Report services delivered * Provide a clinic-level data base Tally/ Reporting Forms (TRF)= means of data treatment = prepared and submitted monthly/ quarterly Output Reports= outcome data = prepared and submitted quarterly/ annually
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List of FHSIS Reports and Forms Event Occurrence E1= Death Form Notification E2= Maternal Death E3= Perinatal Death Weekly M1= Notifiable Disease Monthly M1= Field Health Service Activity (FHSA) M2= Natality M3= Mortality M4= Laboratory M5= Dental M6= Family Planning M7= Social Hygiene Quarterly Q1= FHSA Q2= Dental Q3= Environmental Q4= Malaria Q5= Drugs Q6= Laboratory Annual (CHN) A1= CATS (Catchment Area Tally Sheet) A2= CAPS (Catchment Area Population Summary) A2A= CAOF (Catchment Area OPT Form) A3= HES A3A= HES A4= NR (Household Environmental Sanitation) (Household Environmental Survey) (Nutrition Report)
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III. ETHICO-MORAL-LEGAL RESPONSIBILITY RA 7160= Local Government Code EO 503= Roles and responsibilities transfer of personnel, assets and records to Local Government Unit RA 2382= Philippine Medical Act RA 1082= 1st Rural Health Act RA 1891= Dental Services in rural areas RA 3573= reporting communicable diseases CN 2 s 1986=AIDS as notifiable disease RA 4073= domiciliary leprosy RA 6425= Dangerous Drug Act PD 651= Birth registration within 30 days PD 996= Immunization of children <8 years old PD 825= improper disposal penalty PD 856= Code on Sanitation RA 8749= Clean Air Act RA 6365= National Policy on Population PD 79= revised POPCOM Act AO 114 s 1991= revised roles and responsibilities of MHO, PHN, RHM PD 1204= participation of secretaries from DILG, DOLE for family planning LOI 949= legal basis of PHC PD 965= marriage license: Family Planning and Responsible Parenthood RA 6758= salary of government employees RA 6675= Generics Act RA 6713= Code of Conduct And Ethical Standards for Public Officials/ Employees RA 7305= Magna Carta for Public Health Workers RA 8423= Philippine Institute of Traditional and Alternative Health Care
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IV. PERSONAL AND PROFESSIONAL
DEVELOPMENT
A. Self-Assessment of CHN competencies, importance, methods and tools. CHN Procedures and Tools
Clinic VisitPurposes: > Utilize services of a health agency > To consult about sign and symptoms of illness > To undergo some diagnostic procedures > To undergo some treatment procedures A. Pre-consultation Conference (CuTe PaLa We?) * Take clinical history after greeting and making client at ease. * Take temperature, BP, height, weight. * Perform a thorough physical assessment. * Do selective laboratory exams: urinalysis, sputum exam, fecalysis. * Write findings on Clients Record. B. Medical Examination (A IWan PO!)
* Assist before, during and after exam by Dr. * Inform physician of relevant findings. * Work with physician during exam. * Ensure privacy, safety and comfort of patient. * Observe confidentiality of exam results C. Post Consultation Conference (ERA)
* Explain findings and needed care or intervention. * Refer patient to other health agency if necessary. * Make appointment for next clinic or home visit.
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Home Visit= professional face to face contact of Nurse and patient to bring health activity to family. Principles: AFP a. Available Resources b. Family Needs c. Practical and Flexible d. Purpose (FANE) *Follow-up patient seen at health center who needs continuity care *Assess family needs, problems and environment *NCP implementation *Evaluate outcomes of nursing services previously provided Frequency Factors: NAP * Needs * Acceptance * Personnel Involved * Past Services Evaluation Steps: (Greet Papa, Haha, Baba, Wawa, PaHaWak, bRAD!) Greet client and introduce yourself. Explain purpose of home visit. Health inquiry. Bag Placement in convenient place. Wash hands, wear apron, put out needed articles. Physical assessment and nursing care. Wash hands. Health Teaching. Wash hands and close bag. Record findings and nursing care given. Make appointment. Look into more detailed information next time.
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Bag Technique= Tool making use of PHN bag through which the nurse can
perform nursing procedures.
Public Health Nursing Bag= an essential and indispensable

equipment of PHN. Principles: Cleaning every after use Cross-infection: minimize bag opening (3X) Concern for client, save time and effort in Nurse Content: No BP
PHN Bag contents and Arrangement:

>Traditional Arrangement a. Front (left to right) *Oral Thermometer *Rectal Thermometer b. Back (left to right) * 70% alcohol * 5% Acetic Acid * Aromatic Spirit of Ammonia * Cotton and Liquid soap in sterile water for cleansing thermometers c. Left Rear * Medicine glass * Baby scale * Bandage scissors d. Right Rear * Test tube * Test tube holder * Medicine dropper e. Center of Bag
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* Hemostat forceps * Sterile dressing (OS and Cotton Ball) * Tape Measure * Roller Bandage * Syringe and Needles * Applicator Cotton f. Top of Bag * Hand Towel * Soap * Paper waste bag > Modern Arrangement: The arrangement and the contents of the bag should be the one most convenient to the user to facilitate efficiency and avoid confusion. Steps in Bag Technique
1. Place bag on surface with paper lining. (protects bag from

contamination)
1. Ask for basin or glass of water. 2. Open bag (1st), take and spread plastic lining.
Take out and place at corner: *hand towel *soap dish *apron Close bag (1st) Handwashing (1st)
(for handwashing) (sterile work field) (for handwashing)
(single most effective infection control) (protects nurses uniform) (sterility concept)
6. Put apron
7. Open bag (2nd), put out and place at corner:

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*thermometer *kidney basin *cotton balls *waste paper bag 8. Waste paper bag: outside work field. 9. Close bag (2nd). 10. Nursing care and treatment, handwashing (2nd). 11. Clean and alcoholize things used. 12. Handwashing (3rd) 13. Open bag (3 ), put back all articles. 14. Remove apron: clean side out. Place in bag. 15. Fold plastic linen: clean side out. Place in bag. Close bag (3rd) 16. Health Teaching 17. Home/ clinic appointment for next visit. (for future visit) (for follow-up care)
rd
(prevents contamination) (prevents contamination) (prevents cross infection) (prevents cross infection)
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Thermometer Technique= keep thermometer aseptically clean to prevent transfer of infection. Steps: 1. Explain procedure to client 2. Leave thermometer case inside the bag (thermometer case protection) 3. Check mercury: 35 C 4. Vital Sign taking Axilla Rectum (accuracy check) *PR, RR, BP (5-8 minutes) (1 minute) ( anxiety)
*Temperature: beneath tongue (2-3 minutes)
5. Remove thermometer and wipe in twisting motion (wipe downwards stem-bulb) with 1 dry cotton ball 6. Read thermometer. 7. Clean thermometer above waste paper bag (wipe downwards stem-bulb) *1st= 3 CB (soap) *2nd=3 CB (water) *3rd= 1 CB (alcohol): wrap around bulb, lay inside kidney basin 8. After health teaching is over, remove thermometer wrapped in cotton with alcohol. Wipe it with1 dry CB (wipe upwards bulb-stem) Note: 1 CB 7 CB 1 CB 9 CB! Intravenous Therapy = compliance with PRC-BON Resolution No. 08 s. 1994; ANSAP. (from mouth/axilla/rectum) (upon cleansing thermometer) (after disinfecting thermometer)
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B. Strategies and Methods of Updating Ones Self, Enhancing Competence in Community Health Nursing and Related Areas.
Domain of Contradictions and Struggles of Community Health Nurses (Areas of Challenge for Updating Ones Self in CHN)
*Internal Factors------Personal Value System: Adjustment in Lifestyle Fear of Intellectual Stagnation Family Pressure Individualism vs Collectivity Commitment to the cause of the people -------Work Knowledge and Skills Curative vs Preventive Measures Achievement vs Process Orientation Western System vs Indigenous Practice Imposition vs Democratic Process Traditional vs New Roles to Take Scope of Health Work: Going Beyond and Health * External Factors-----Communitys Behavior Philippine HCDS Environmental Effects Socio-Economic Determinants Political Will
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To be able to perform the CHN duties, a PHN must have adequate and uplifted knowledge and skill in the following areas: 1. Public Health Principles, Methods, and practices: *Epidemiologic investigations, control and care of chronic and communicable diseases including tuberculosis, AIDS, and other sexually transmitted diseases. *Nutrition and preventive medicine. 2. Applications of nursing principles and skills for the promotion of health and the prevention of diseases and disabilities including: *Manage a caseload effectively and establish priorities. *Assess community, individual, and family-health needs and problems, exercise independent judgment to plan, organize and carry out public health nursing activities in a local area. *Perform assessment of health status of individuals determining the need for a level of nursing and medical care needed. *Analyze situations accurately, make recommendations and take appropriate action. *Make home visits in assigned geographic areas. *Prepare and maintain clear, concise and complete records, reports, and charts in a timely manner. 3. Development and utilization of community resources including: * Work cooperatively with health and other professions, the general public, and outside agencies. * Establish and maintain cooperative working relationships with others.
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4. National and local laws and regulations governing public health. 5. Current developments in health care and the principles of rehabilitation. 6. Cultural and environmental differences, and problems encountered in health care service delivery. 7. Principles of mental health, including substance use/ abuse interventions. 8. Human growth/ development and assessment including: * Prevention, detection, reporting, and treatment of child and adult abuse and neglect. *Gerontology and the sociological aspects of aging. 9. Adapt to various working environments; demonstrate willingness to accept assignments in various cultural, physical, behavioral, and environmental settings of patients including: *Work effectively with individuals and families to assist them in satisfactory solution of health problems. *Demonstrate tact, diplomacy, and compassion. *Carry out assigned tasks and meet specific deadlines.
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INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

CASE MANAGEMENT PROCESS =action-oriented classification =used by health professionals who see sick infants and children (1 week-5 years old) =relevant process for a first-level facility such as a clinic, health center and OPD of hospital
Elements: (ACIT-CF!)
A. ASSESS the child or infant *Take down his history, do PE *Check for danger signs (convulsions, lethargy, unconsciousness, inability to drink or breastfeeding, vomiting), or possible bacterial infection in an infant, immunization and nutrition. B. CLASSIFY the illness =making a decision related to severity of the illness. =uses a COLOR-CODED TRIAGE SYSTEM ( see table) C. IDENTIFY Treatment *Urgent Referal: give treatment, then transfer *Treat at home: Treatment plan, then 1st dose of drugs in the clinic D. TREAT *Give treatment in the health center *Teaching caregiver how to give fluids during illness, how to recognize danger signs E. COUNSEL mother: *How the child be fed *Foods and fluids to be given *When to bring back to health center *Her own health F. FOLLOW-UP
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COLOR-CODED TRIAGE SYSTEM
PINK (Urgent) Urgent Prereferal Treatment and Referal *Urgent Prereferal Treatment =done in OPD health facility =give prereferal treatment =advise parents =refer YELLOW (Medical) Specific Medical Treatment and Advice =Treat local infection =Give oral drugs =Advice and teach caregiver =Follow-up GREEN (Home) Simple Advice on Home Management =How to give oral drugs, treat local infections at Home =Counseling about feeding problems and fluids, when to return to health facility. *Referal =Emergency Triage & Treatment (ETAT) =Diagnosis =Treatment =Monitoring =Follow-up
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THE DANGER SIGNS: 1. INABILITY TO DRINK OR BREASTFEED =too weak to drink =not able to suck or swallow =if with nasal obstruction: clear them. If the child can be breastfed after his nostrils are cleaned: not a danger sign! 2. VOMITS EVERYTHING HE TAKES IN =vomits or not be able to hold down any food, fluids or oral drugs = a child who vomits but can hold down some fluids: not a danger sign! 3. ABNORMALLY SLEEPY/DIFFICULT TO AWAKEN =not awake and alert when he should be =drowsy, lethargic, does not show interest in what is happening around him =does not respond when touched, shaken, spoken to. 4. CONVULSION/SEIZURE =childs arms and legs stiffen because the muscles are contracting =fits, jerky, spasms
90 PNEUMONIA
=infection of the lungs =Causative Agents: (1) Streptococcus pneumonia (2) Haemophilus influenzae =children may die from hypoxia and sepsis A. ASSESS 1. Difficulty in breathing: unusual pattern of breathing, fast, noisy, interrupted =If a child has no cough or no DOB: ask next for diarrhea! =Chronic cough: if cough >30 days. May be sign of TB, asthma, whooping cough 2. Fast Breathing (FB) <2 months------->60 breaths per minute 2-12 months---->50 breaths per minute 1-5 yo------------>40 breaths per minute Note: If a child is exactly at 12 months: will have FB if >40 bpm! 3. Chest Indrawing (CI) =lower chest wall: IN when child breaths: IN! =normal: whole chest wall (upper & lower) and abdomen: OUT when child breaths IN exceptions: *Do not assess if child is crying or being fed *Intercostal Indrawing/Retractions *Abdominal Distention due to malnutrition 4. Stridor =harsh noise when child breaths in. =happens due to swelling of larynx, trachea, epiglottis: interferes with air entering the lungs
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B. CLASSIFY SIGNS *Any danger signs *CI *Stridor in a calm child *FB CLASSIFICATION VERY SEVERE DISEASE/ SEVERE PNEUMONIA TREATMENT *1st dose Antibiotic *Vitamin A *Prevent hypoglycemia *Refer urgently to hospital *Antibiotic for 5 days *Soothe throat & relieve cough *Advise caregiver when to return to HC *No signs of P or VSD NO PNEUMONIA: Cough or Colds *FF up in 2 days *If coughing persists >30 days: refer *Soothe the throat, relieve cough *Advice when to return *FF up in 5 days if no improvement is observed
PNEUMONIA
Pointers: 1. Chest Indrawing: may be a childs ONLY sign of VSD/ SP! The effort the child needs to breath is much greater than normal. 2. No pneumonia: does not need antibiotic because it will not prevent the colds from developing into pneumonia. *Advice caregiver to soothe her childs throat: tamarind, ginger, calamansi 3. A child with colds normally improves in 1-2 weeks!
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C. IDENTIFY AND TREAT
COTRIMOXAZOLE Trimethoprim Sulphamethoxazole (2X daily for 5 days) Adult TabSyrup let (40 mg T + (80 mg T + 200 400 mg S per 5 mg S) ml) 5 ml AMOXYCILLIN (3X daily for 5 days)
Tablet (250 mg)
Syrup (125 mg/5 ml)
2-12 months (4-<10 kg) 1-5 yo (10-19 kg)
5 ml
7.5 ml
10 ml
Pointers: *Cotri (1st-line antibiotic) & Amox (2nd-line antibiotic) D. ESSENTIAL CARE 1. Give Antibiotic Treatment If the child has mild CI & does not appear to be in respiratory distress: Give Oral Cotrimoxazole. If does not get any better: Give IM Chloramphenicol. If the child have general danger signs/ CI but does not have the classification Very Severe Febrile Disease (VSDF): give IM Chloramphenicol, until he improved, then continue giving oral Chloramphenicol for 10 days. If IM Chloramphenicol is not available: give IM Benzylpenicillin If neither IM Chloramphenicol nor IM Benzylpenicillin is available: give Cotri/Amox! 2. Give Bronchodilator = If the child is wheezing
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3. Treat fever = Axillary temperature of >38.5 C: give Paracetamol q 6. = Important for children with pneumonia because fever increases consumption of O2. 4. Manage fluids carefully = Breastfeeding is ok if child is not in RDS = If the child is too ill, have the mother express milk into a cup & slowly feed the breastmilk to child with spoon. = If the child is not able to drink: use dropper or syringe without a needle Fluid Management in SP or VSD Age Amount of Milk or Formula 5 ml/kg/hr 3-4 ml/kg Total Amount in 24 hours 120 ml/kg 72-96 ml/kg
<12 months 1-5 yo
5. Manage the airway =Use plastic syringe (s needle) to gently suck out any secretions from the nostrils. =Dry, thick, sticky mucus can be loosened by wiping it with a soft cloth moistened with salt water. 6. Keep the infant warm = Have the mother keep infant next to the body: between the breasts! = A hat or bonnet prevents heat loss from the head.
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E. FOLLOW-UP (Pneumonia) 1. After 2 days: check for danger signs. 2. Ask about breathing and number of loose stool evacuation per day. 3. Treat again! If there is CI or danger sign: give a dose of 2 nd line antibiotic or IM Chloramphenicol. (Rationale: Since the illness has worsened on the 1st-line antibiotic). Then refer urgently to hospital. If the breathing rate, fever, eating patterns are almost the same: shift to 2nd-line antibiotic; advice caregiver to return in 2 days or refer (esp if the child had measles within the last 3 months). If the child is breathing slower, has less fever, eating better: child to finish the 5-day dosage antibiotic The childs cough persists >30 days: refer!
DIARRHEA
A. ASSESS 1. Ask if the child have diarrhea. If no: Ask next for Fever! If yes: Assess for signs of dehydration, persistent diarrhea, dysentery. 2. Ask how long the child has diarrhea Persistent diarrhea: >14 days diarrhea 3. Check for signs of dehydration: (Also known as the danger signs) *Restlessness *Abnormally sleepy *Irritable *Difficult to awaken *Eyes sunken *Skin pinched return slowly (>2 seconds) Pointer: A child has the sign restless & irritable if the child is restless & irritable ALL THE TIME!
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4. Look for sunken eyes Pointers: *Severely malnourished child (marasmus) may always look sunken even if the child is not dehydrated. *Even though sunken eyes are less reliable in a visibly wasted child, use the sign still to classify the childs dehydration! 5. Offer the child fluid Not able to drink= not able to suck or swallow due to abnormally sleepy or difficult to awaken. Drinking Poorly= able to swallow only if the fluid is put into the mouth. Drinking eagerly or Thirsty= Grabby attitude If the child takes a drink only with encouragement and does not want to drink more: Not a sign of drinking problem!
6. Pinch the abdomens skin Steps: Put child in prone position; his arms at his side (not over his head); legs straight (or lying flat on his mothers lap). Locate halfway between umbilicus and side of abdomen using thumb and forefinger in pinching the skin (Do not use fingertips because it cause pain!) Place hand, so that when you pinch the skin, the fold on the skin will be in a vertical line on the childs body (not across the childs body). Firmly pick up all layers of skin. Pinch the skin for 1 second, then release. Decide if: *Very slowly: >2-5 seconds *Slowly: *Immediately >2 seconds
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Pointers: *A child with marasmus, the pinched skin may go back slowly even if the child is not dehydrated. *Overweight child or child with edema: The pinched skin returns immediately even if the child is dehydrated. *Even though a skin pinch is less reliable, use it to classify dehydration! B. CLASSIFY
SIGNS CLASSIFICATIONS TREATMENT
2 of the ff signs: (inactive!) *Abnormally sleepy/ Difficult to Awaken *Not able to drink/ Drinking poorly *Sunken eyes *Pinched skin goes back to its original state very slowly
SEVERE DEHYDRATION
*If the child has no other severe classification: Plan C *If the child has another severe classification: Refer, with the mother giving the child frequent sips of ORS and breastfeeding. *If the child is 2 yo, and there is cholera in your area: Give cholera antibiotic
2 of the ff signs: (active!) *Restless, irritable *Drinks eagerly, thirsty *Sunken eyes *Pinched skin goes back to its original state very slowly
SOME DEHYDRATION
*Give fluid and food: Plan B *If the child has another severe classification: Refer, with the mother giving the child frequent sips of ORS and breastfeeding. *Advise when to return to health center *FF up in 5 days if no improvement is observed
Not enough signs to classify as some or severe dehydration
NO DEHYDRATION
*Give fluid and food at home to treat the diarrhea: Plan A *Advise when to return to health center *FF up in 5 days if no improvement is observed
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Pointers: * If >2 signs from yellow row are not present, classify the child as No Dehydration. One sign of dehydration is important! Or they may have lost fluids without showing signs. *If a child has 1 sign in pink row and 1 sign in yellow row: Classify as Some Dehydration. PERSISTENT DIARRHEA
SIGNS With dehydration CLASSIFICATIONS SEVERE, PERSISTENT DIARRHEA (SPD) TREATMENT *Treat the dehydration before referral, unless the child has another severe disease *Give Vit. A No dehydration PERSISTENT DIARRHEA (PD) *Refer *Advise the mother about feeding a child who has PD. *Give Vit. A *FF up in 5 days
DYSENTERY
SIGN CLASSIFICATION TREATMENT
Blood in Stool
DYSENTERY
*Treat for 5 days with an oral antibiotic recommended for shigella in your area *FF up in 2 days
Pointers: Assume that Shigella caused dysentery because: A. Shigella causes >60% of all dysentery cases B. Shigella causes life-threatening dysentery C. Shigella requires stool culture (2 days laboratory result!)
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C. TREAT
DYSENTERY
AGE OR WEIGHT COTRIMOXAZOLE (Trimethoprim + Sulphamethoxazole) Give 2X daily for 5 days Adult 400 mg S) 2-4 months (4-<6 kg) 4-12 months (6-<10 kg) 1-5 yo (10-19 kg) Pointers: *Cotromoxazole (1st line Antibiotic) & Nalidixic Acid (2nd line Antibiotic) *Give the antibiotic for 5 days, return for ff up in 2 days! 1 Syrup 200 mg S per 5ml) 5 ml 5 ml 7.5 ml 1.25 ml (1/4 tsp) 2.5 ml (1/2 tsp) 5 ml (1 tsp) (80 mg T + (40 mg T + NALIDIXIC ACID Give 4X daily for 5 days Syrup (125 mg/5 ml)
CHOLERA
AGE OR WEIGHT COTRIMOXAZOLE (Trimethoprim + Sulphamethoxazole) Give 2X daily for 3 days 2-4 months (4-<6 kg) Adult 400 mg S) 1 Syrup 200 mg S per 5ml) 4-12 months (6-<10 kg) 1-5 yo (10-19 kg)
TETRACYCLINE Give 2X daily for 3 days Capsule (250 mg) __
(80 mg T + (40 mg T +
5 ml 5 ml 7.5 ml
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Pointers: 1. To rehydrate and prevent dehydration: Give ORS! 2. IVF: only in cases of severe dehydration and severe DHF. 3. The only diarrhea types treated with antibiotics: Severe dehydration, Cholera and Dysentery. 4. Never give antidiarrheals and antiemetics to children and infants. 5. Dangerous Drugs: Antimotility Drugs (Tincture of Opium, Diphenoxylate, Codeine, Loperamide) Anti-Vomiting (Chlorpromazine) =causes paralysis of gut; make child abnormally sleepy. Adsorbents (Attapulgite, Smectite, Kaolin, Activated Charcoal) =not dangerous but not effective diarrhea treatment
NO DEHYDRATION & DIARRHEA
PLAN A: TREATING DIARRHEA AT HOME 1. Give Extra Fluid (as much as the child will take)
a. b.
Breastfeed frequently.
If the child is exclusively breastfed: give ORS or clean water in addition to breastmilk. C. If the child is not exclusively breastfed: give 1 or more of the ff: *ORS *food-based fluids (soup, rice water, buko juice) *clean water
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d. Give oresol at home when the child has been treated with Plan B or Plan C during this visit or the child cannot return to health center if the diarrhea gets worse. e. Give 2 packets of ORS to use at Home f. Show how much fluid to give the child in addition to the childs usual fluid intake <2 yo >2 yo 50-100 ml after each loose stool evacuation 100-200 ml after each loose stool evacuation
*Give frequent small sips from a cup *If the child vomits, wait for 10 minutes. Then continue slowly. *Continue giving extra fluid until the diarrhea stops. 2. Continue feeding the child. 3. Return to the health center when needed. Signal Signs to return to HC: *Not able to drink or breastfeed *Becomes sicker *Develops fever *Has blood in stool
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SOME DEHYDRATION PLAN B: TREAT SOME DEHYDRATION WITH ORS Give the ORS over a 4-hour period in the HC.
A. Determine the amount of ORS to give during the 1 st 4 hours.
AGE <4 months 4-12 months 12 months-2 years 2-5 years WEIGHT <6 kg 6-<10 kg 10-<12 kg 12-<19 kg 200-400 400-700 700-900 900-1400 AMOUNT (ml)
Pointer: *Better to use the childs weight than the age! *Can be approximated by: Wt (in kg) X 75! *If the child wants more ORS than shown, give him more! *For infants <6 months who are not breastfed, give 100-200 ml of clean water (The breast milk and water will prevent hypernatremia) B. Show the mother how to give ORS *Give frequent, small sips from a cup. *If the child vomits, wait for 10 minutes, then continue slowly. *Continue breastfeeding the child whenever the child wants to be breastfed. C. After 4 hours *Reassess and classify for dehydration. *Select the appropriate plan for the continuation of the treatment. *Begin feeding the child in HC. D. If the mother must leave before completing the treatment. *Show her how to prepare ORS solution at home. *Show how much ORS to give *Give 2 more packets of ORS. *Explain the 3 rules of home treatment: Give extra fluid, Continue feeding child and Return to HC when needed.
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Pointers: *If the child is <2 yo: give ORS by spoon. If older: give ORS by sips from cup. *Do not give the child food during the 1st 4 hours of treatment of ORS. *Reassess before 4 hours if the child is not taking ORS solution or seems getting worse. *If the childs eyes are puffy: Overhydration! (not a danger sign or hypernatremia). Ok to give clean water or breast milk. Give ORS when puffiness is gone. *If after 4 hours, the child still has Some Dehydration: Begin feeding in HC. Offer food, milk, juice every 3-4 hours. After feeding, repeat the 4-hour Plan B Treatment again *If childs condition worsen (Severe Dehydration): begin Plan C. SEVERE DEHYDRATION
PLAN C: TREAT SEVERE DEHYDRATION QUICKLY 1. Your HC has IVF equipment and you are trained to give IVF? If yes: treat, if no: go 2! 2. IV treatment available in another HC within 30 minutes? If yes: treat, if no: go 3! 3. Your HC has NG equipment and you are trained to such? If yes: treat, if no: go 4! 4. Can the child drink? If yes: treat, if no: go 5! 5. Refer the child urgently to nearest hospital for IV or NG or constant care!
D. ESSENTIAL CARE (SEVERE, PERSISTENT DIARRHEA) 1. Treat dehydration using Plan A, B or C. 2. For infants <4 months old: exclusive breastfeeding is very important. 3. Supplementary Vitamins and Minerals everyday for 2 weeks. Double the RDA of folate, Vit. A, Zinc, Magnesium, Iron, Copper.
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4. Children with PD may have infections like pneumonia, sepsis, UTI, ear infection, dysentery and amoebiasis: give antibiotic. 5. Monitor the childs condition. =See the child every day during illness. Once the child is feeding well and has no signs of dehydration, see the child again in 2-3 days. E. FOLLOW-UP ; PERSISTENT DIARRHEA
After 5 days: Ask if the diarrhea stopped and how many loose stool/day? *If the diarrhea has not stopped (evacuating loose stool >3X a day): reassess, treat, refer. *If the diarrhea has stopped (evacuating loose stool <3X a day): usual feeding recommendation FOLLOW-UP ; DYSENTERY
After 2 days: Assess for diarrhea Ask about: loose stool evacuation, blood in stool, temperature, abdominal pain, eating *If dehydrated: treat the dehydration. *If the number of loose stool evacuations, the amount of blood in stool, fever, abdominal pain, eating pattern is the same or worse: Change to the 2nd line oral antibiotic recommended for shigella. Give it for 5 days. Advice to return in 2 days. Exceptions: Child is <12 months old, dehydrated in the 1 st visit, had measles within the last 3 months (refer) *If there are fewer stool evacuations, there is less blood in the stool, the temperature has gone down, less abdominal pain, eating better: continue the same antibiotic until 5-day dosage has been consumed. Pointers: *If after being treated with 2nd-line antibiotic for 2 days, the child has not improved: possible amoebiasis. Treat with Albendazole or refer. *Amoebiasis is diagnosed when trophozoites of E. histolytica, containing RBC are seen in a fresh stool sample.
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FEVER
MALARIA
=caused by parasites in blood Plasmodia =Plasmodium falciparum is dangerous! =signs of P. falciparum: shivering, sweating, persistent vomiting =Fever is a main symptom of malaria. =Chronic anemia (with no fever): maybe the only sign of illness =Cotrimoxazole: both antimalarial/ antibiotic. =Malaria, pneumonia, diarrhea: may come together. =Almost all provinces are at malarial risk except Aklan, Biliran, Bohol, Camiguin, Capiz, Catanduanes, Cebu, Guimaras, Iloilo, Leyte (Northern & Southern), Northern Samar, Siquijor are considered malaria-free but not absolute because of the vector presence.
A. ASSESS 1. Ask about fever *History of fever (best form of assessment): feels hot, temperature >37.5 C. *If no fever: next to ask is Ear Problem! 2. Decide if there is Malaria Risk Malaria Risk= if lives in MR area or visited a MR area within 4 weeks. *If there is MR: take blood smear & examine. 3. Ask how long had fever *If fever is due to viral illness: go away within a few days. *If fever present for >7days: a child has a more severe disease like typhoid fever. - Refer! 4. Ask if child had measles within the last 3 months. *Measles decreases the childs immune system and leaves the child at risk for other infections for many weeks. *A child with fever and history of measles within last 3 months: may have infection due to measles complication (eye infection). 5. Look and feel for stiff neck =fever and stiff neck may have meningitis: it needs urgent treatment with
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injectable antibiotics. Refer! *If child can move & bend his neck: no stiff neck *To assess stiff neck: encourage the baby to look down! >Draw childs attention to his umbilicus >Shine a flashlight on his toes or umbilicus >Tickle his toes *Lay child prone: support his back and shoulders with1 hand and the head with the other hand. Then carefully bend forward toward his chest. If bends easily: no stiff neck. If with resistance: with stiff neck, often cries! 6. Runny nose Common colds= runny nose + fever. It does not need antimalarial drugs due to common colds, not malaria! B. CLASSIFY MALARIA RISK
SIGNS *Any general danger sign *Stiff Neck CLASSIFICATIONS VERY SEVERE FEBRILE DISEASE/ MALARIA (VSD-FM) TREATMENT *1st dose of Chloroquine (under medical supervision or if a hospital is not accessible within 4 hours) *1st dose antibiotic *Treat hypoglycemia *Paracetamol for high fever (>38.5 C) *Send BS with the patient *REFER! *Blood Smear (+) *If BS was not done &: No runny nose, no measles, no other causes of fever
MALARIA
*Treat with oral antimalarial *1 dose Paracetamol in the HC for high fever *Ff up in 2 days if fever persists *If fever present >7 days: refer
*Blood Smear (-) *With runny nose, measles or other causes of fever
FEVER: MALARIA UNLIKELY (FMU)
*1 dose Paracetamol in HC for high fever. *Ff up in 2 days if fever persists *If fever present >7 days: refer
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Pointer: *A child with fever and any general danger sign or stiff neck may have meningitis, severe malaria, cerebral malaria, sepsis: Not possible to distinguish these severe diseases without laboratory tests.
NO MALARIA RISK
Pointer: SIGNS *Any general danger signs *Stiff neck CLASSIFICATIONS VERY SEVERE FEBRILE DISEASE (VSD-F)
st
TREATMENT *1 dose antibiotic *Treat hypoglycemia *Give 1 dose Paracetamol in HC for high fever *REFER! *Give 1 dose of *Paracetamol in HC for high fever *Ff up in 2 days if the fever persists *If fever present >7days: refer
*No sign of a VSD-F
FEVER: NO MALARIA (FNM)
*The risk of malaria is low if the child has signs of another infection that can cause the fever like common colds, measles, cellulites, abscess and ear infection.
C. TREAT
CHLOROQUINE (dive for 3 days) PRIMAQUINE Give single Give daily Dose in HC for 14D For P. falci for vivax Tablet (150 mg) Age Day 1 Day 2 Day 3 Tablet (15 mg) Tablet (15 mg) Tablet (500 mg sulfadoxine & 25 mg pyrimethamine) 2-5 months 5-12 months 1-3 yo 3-5 yo 1 1 1 1 1 __ __ __ __ 1 parum SULFADOXINE + PYRIMETHAMINE (give single dose in the HC)
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Pointers: *Chloroquine: Watch child for 30 minutes after giving due to potential vomiting. If child vomits: repeat dose. *Itching is a side effect of Chloroquine. *Chloroquine & Primaquine (1st line Antibiotic) *Sulfadoxine & Pyrimethamine (2 nd line Antibiotic)
PARACETAMOL (for high fever: >38.5 C or Ear Pain) AGE OR WEIGHT (give every 6 hours) 2 months- 3 years (4-<14 kg) 3-5 years (14-19 kg) 1. For children with VSD-FM who are referred: *Give 1st dose of IM Quinine, then REFER! 2. If referral is not possible: *Give the 1st dose of IM Quinine. *The child should remain lying down for 1 hour (risk for hypotension). *Repeat the Quinine injection 4 & 8 hours later, and then every 12 hours until the child is able to take an oral antimalarial. Do not continue Quinine injections for >1 week. *Do not give Quinine to a child <4 months of age. AGE OR WEIGHT 4-12 months (6-<10 kg) 1-2 yo 2-3 yo 3-5 yo Pointers: *Quinine= preferred antimalarial drug because it takes effect quickly. Safer and effective than IM Chloroquine. *Side effects: hypotension within 15-20 minutes, dizziness, tinnitus, sterile abscess *Give Quinine as deep IM in vastus lateralis (not in buttocks!) *May be given slow IV infusion over 4-8 hours. (10-<12 kg) (12-<14 kg) (14-19 kg) IM QUININE 300 mg/ml (in 2 ml ampules) 0.3 ml 0.4 ml 0.5 ml 0.6 ml 10 ml (2 tsp) TABLET (500 mg) 5 ml (1 tsp) SYRUP (120 mg/5 ml)
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TREAT HYPOGLYCEMIA
1. If the child is able to breastfeed: breastfeed! 2. If the child is not able to breastfeed but able to swallow: Give 30-50 ml of expressed breast milk, breast milk substitute or sugar water *To make sugar water: Dissolve 4 level tsp sugar (20 g) in 200 ml cup of clean water 3. If the child is not able to swallow: Give 50 ml of milk or sugar water through NG tube
Pointer: *Hypoglycemia is dangerous because it can cause brain damage! D. ESSENTIAL CARE (VERY SEVERE FEBRILE DISEASE)
1. Needs treatment for both meningitis and malaria. *For meningitis: give the child both IM Chloramphenicol and Benzylpenicillin every 6 hours. *Give both antibiotics by injection for 3-5 days. If the child has improved: switch to oral chloramphenicol. Total treatment duration is 10 days. 2. For Severe Malaria, give quinine. *If no quinine, give oral antimalarial: sulfadoxine & pyrimethamine (2 nd-line antimalarial) 3. In malaria-risk areas, never give Quinine to infants <4 months old because it is very unlikely that they have malaria! 4. If the child also has diarrhea with Severe Dehydration, but has no stiff neck and no Severe Malnutrition or Severe Anemia: give fluids according to Plan C. 5. For the child with Severe DHF and symptoms of shock and bleeding, give fluids according to Plan C, plasma expanders or whole blood. *Treatment of bleeding and shock is monitored through hematocrit, vital signs and urine output. 6. If the child rapidly loses his danger signs with rehydration, do not give quinine, benzylpenicillin and chloramphenicol 7. Fluid intake for suspected Meningitis AGE <12 months 1-5 yo AMOUNT OF MILK OR FORMULA TO GIVE 3.3 ml/kg/hr 2.5 ml/kg/hr TOTAL AMOUNT IN 24 HOURS 80 ml/kg/day 60 ml/kg/day
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E. FOLLOW UP MALARIA 1. If the fever persists after 2 days, or returns within 14 days: Reassess! *May mean that the child has a malaria parasite that is resistant to 1 st -line antimalarial, causing the childs fever to continue. *If the child had measles in the initial visit, the fever may be due to measles rather than to resistant malaria. 2. If the child has any general danger sign or a stiff neck: treat as a VSD-FM: give Quinine and Paracetamol *If it get worse: Give the 1st dose of the 2nd line antibiotic or IM Chloramphenicol. 3. If malaria is the only apparent cause of the fever: *Take a Blood Smear *Give the 2nd-line oral antimalarial without waiting for the result of BS test. *Advise to return to the HC in 2 days if fever persists. *If the fever persists after 2 days treatment with 2 nd-line oral antimalarial: refer. *If the fever is present >7 days: refer due to may have typhoid fever! The child may be taking Cotrimoxazole & Chloroquine due to probable cough and FB (pneumonia) and malaria. Cotromoxazole and Sulfadoxine-Pyrimethamine (Fansidar) are closely related drugs: the two should not be taken together.
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FEVER: MALARIA UNLIKELY 1. If fever persists after 2 days: Reassess! *Asses whether the fever & chills are related to TB, UTI, osteomyelitis, abscess. 2. If the child has any general danger sign or a stiff neck: treat as VSD-FM *If the child has any cause of fever other than malaria, provide the appropriate treatment. 3. If malaria is the only apparent cause of fever: *Take a Blood Smear *Treat the child with 1st-line oral antimalarial. Advice to return in HC in 2 days if fever persists. *If the fever persists after 2 days treatment with 2 nd-line oral antimalarial: refer. *If the fever is present >7 days: refer! FEVER: NO MALARIA 1. If fever persists after 2 days: Reasses! *Assess about travel to MR areas. *If there has been travel to MR areas: take blood smear. 2. If there has been travel to MR area and BS is positive, or if no BS: classify as having FEVER with MALARIA RISK! Treat accordingly. 3. If there has been no travel to a MR area & BS is negative: *If the child has any general danger sign or a stiff neck: treat as VSD-FM. *If the child has any apparent cause of fever: provide appropriate treatment. *If there is no apparent cause of fever: advice to return to HC in 2 days if fever persists. *If the fever is present >7 days: refer!
MEASLES
=fever & general rash (main signs of measles) =maternal antibody protect infant against measles for about 6 months. =most cases occur in children between 6 months-2 yo due to poor housing and overcrowding. =it infects the skin, layers of cells that line the lungs, gut, eyes, mouth and throat. =it damages the immune system leading the child prone to other infections. =30% of all measles cases lead to complication:
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*severe eye infection (corneal ulceration/ blindness) *ear infection *mouth ulcers *pneumonia *stridor *diarrhea (dysentery & persistent diarrhea) =contributes to malnutrition because it causes mouth ulcers, high fever and diarrhea. *1:10 malnourished children with measles may die *Encephalitis=brain infection, occurs in 1:1000 cases, have general danger signs, convulsions abnormally sleepy or difficult to awaken.
ASSESS
1. Look for General Rashes =red rashes begin behind the ears and on the neck, then spread to face next 24 hours: spread to the body, arms, legs after 4-5 days: rashes start to fade and skin peels (dark brown/ blackish) *check for fever, cough, runny nose, red eyes (redness in white part of the eye: conjunctiva) 2. Pus draining from eye =a sign of conjunctivitis =the pus forms a crust when the child is sleeping, which keeps the eye shut *open it gently with clean hands. Conjunctiva=lines the eyelids, covers white part of eye Iris= colored part of the eye Cornea= clear window of the eye; bright and transparent; through it you see iris and pupil in the middle. Pupil= the brownish-black central part of the eye. 3. Corneal Clouding =hazy, cloudy-look *Gently pull down lower eyelid to check for cornea =due to Vitamin A deficiency made worse by measles. =if not treated with Vitamin A: may ulcerate and can cause blindness =keep the eyes shut when exposed to light because it causes irritation or pain to eyes
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CLASSIFY SIGNS *Corneal Clouding *Deep, Extensive Mouth Ulcers CLASSIFICATION SEVERE, COMPLICATED MEASLES TREATMENT *Vitamin A *1st dose of antibiotic *Tetracycline eye ointment: for corneal clouding or pus draining from the eye *Refer *Pus Draining from the eye *Mouth Ulcers MEASLES WITH EYE OR MOUTH COMPLICATIONS *Vitamin A *Tetracycline eye ointment: for pus draining *Gentian Violet: for mouth ulcers *Ff up in 2 days *Measles now or within the last 3 months TREAT VITAMIN A AGE 6-12 months 12 months-5 years Treatment: 1 dose in the HC Supplementation: 1 dose in the HC if: *the child is >6 months old *the child did not receive a dose of Vitamin A in the past 6 months CAPSULE (100,000 IU) 1 capsule 2 capsules CAPSULE (200,000 IU) capsule 1 capsule MEASLES *Vitamin A
Pointers: *Vitamin A is given to child with: VSD, SPD, PD, Measles, Severe Malnutrition, VLWFA *Vitamin A: prevents measles virus infection in eyes and layers of cells that line the lungs, gut, mouth and throat. *Available as a capsule: tear, cut across, pierce it with a clean needle if a child cannot swallow it whole.
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TETRACYCLINE EYE OINTMENT 1. Clean both eyes 3X daily: *Wash your hands *Ask the child to close his eyes *Use clean cloth and water to gently wipe away the pus 2. Apply Tetracyline Eye Ointment on the inside of the lower eyelid *Ask the child to look up *Squirt a small amount of ointment on the inside of the lower eyelid *Wash your hands again 3. Treat the eyes until the redness is gone 4. Do not use other ointments or drops, or put anything else in the childs eyes.
Pointers: *The ointment will slightly sting the childs eyes Treat the mouth ulcers 2X daily (morning & evening) for 5 days: *Wash your hands. *Wipe the childs mouth with a clean, soft cloth dipped in salt water and wrapped around your finger; or cotton-tipped stick. *Paint childs mouth with half strength (0.25%) Gentian Violet. Dont let the child drink it. *Wash your hands again *Clean eyes and apply ointment 3X/day: morning, midday, evening
GENTIAN VIOLET Pointers: *GV kills the germs that cause the mouth ulcer. *Warn the caregiver than GV can stain clothes. *Tell to return in 2 days for follow-up or earlier if mouth ulcers get worse or child not able to drink or eat.
ESSENTIAL CARE SEVERE, COMPLICATED MEASLES 1. Manage Measles Complications *If the child cannot swallow, feed through NG tube. Treat with IM Chloramphenicol. *If with corneal clouding: treat with tetracycline. Keep the eye patched gently with clean gauze.
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*Treat other complications of measles: pneumonia, diarrhea, ear infection. 2. Give Vitamin A *3 doses (1st dose: 1st day, 2nd doe: 2nd day, 3rd dose: in 14 days) 3. Feed the child to prevent malnutrition.
FOLLOW-UP MEASLES WITH EYE OR MOUTH COMPLICATIONS 1. After 2 days: Look for red eyes, pus draining, mouth ulcers, smell the mouth 2. Treatment for Eye Infection *If pus is draining: ask the caregiver how she treated the eye infection Correct treatment: Refer! Incorrect treatment: Teach! *Pus is gone, but the redness remains: continue the treatment. *No pus or redness: stop the treatment. 3. Treatment of Mouth Ulcers *If mouth ulcers are worse or with very foul smell: Refer! *If the mouth ulcers are same or better: continue the 0.25% GV for 5 days Pointer: *Mouth problems due to measles could be complicated by thrush and herpes (the virus that causes cold sores).
DENGUE HEMORRHAGIC FEVER

=caused by a Chikungunya virus spread by Aedes =fever last for 2-7 days =children may bleed from mouth and nose, evacuate black stool. =the most severe signs of DHF occur on the 2nd day after the fever disappeared =shock must be treated with IVF and urgent referral =all the regions of the country are endemic but NCR is highly endemic all year round esp . 2 months after the start of rainy season .
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ASSESS 1. Ask for bleeding from nose, gums, vomitus, stool *Persistent Abdominal Pain (Abdominal pain that is continuous or without relief) *Persistent Vomiting (Vomiting that is continuous, occurring in short intervals and not associated with food intake)
2. Look for dried blood in the nostrils and skin petechiae (if you stretch the skin, they do not lose their color. Often seen on abdomen, chest, extremities).
3. Shock signs: *pale *abnormally restless *abnormally sleepy/ difficult to awaken *cold, clammy extremities *slow capillary refill +Apply a 2-second pressure on the nail bed of the thumb or big toe. +Release pressure: <3 seconds: adequate circulation >3 seconds: circulatory failure *Tourniquet Test: do this if the child is not in shock, no signs of bleeding/ petechiae, no persistent abdominal pain, no persistent vomiting, >6 months old, has fever for >3 days
CLASSIFY SIGNS *Bleeding from nose or gums *Blood in the stool or vomitus *Skin petechiae *Cold & clammy extremities *Slow capillary refill *Persistent abdominal pain *Persistent vomiting *No signs of SDHF FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY (F:DHFU) CLASSIFICATION SEVERE DENGUE HEMORRHAGIC FEVER (SDHF) TREATMENT *if petechiae, abdominal pain, TT (+), vomiting are the only positive signs: ORS! *If any other bleeding signs are positive: give fluids rapidly (within 30-60 minutes) Plan C *Treat hypoglycemia *Refer! *Ff up in 2 days if fever persists or if signs of bleeding are present
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Pointers: *Do not give Aspirin! Continue seeing the child daily until there has been no fever for 1. If the fever persists after 2 days: reassess! Do Tourniquet Test. *Assess for other possible causes of fever: TB, UTI, abscess, hepatitis 2. If the child has any sign of bleeding: SDHF Refer! 3. If the child has any other cause of the fever: provide appropriate treatment. 4. If the fever has been present >7 days: Refer! least 2 days without use of antipyretics. *When there is risk of dengue, a child with fever should be classified as having: malaria measles DHF (last priority classificaton!) *If there is no Dengue Risk, do not classify under dengue! at
TREAT: (refer to Plan A,B,C in Diarrhea Management) *If there is shock: IVF for Plan C started, then refer! *Plan B: for SDHF should be reassessed after 4 hours when referral to hospital is not possible. *If the child has no new signs: Plan A! FOLLOW-UP FEVER: DENGUE HEMORRHAGIC FEVER UNLIKELY
1. If the fever persists after 2 days: reassess! Do Tourniquet Test. *Assess for other possible causes of fever: TB, UTI, abscess, hepatitis 2. If the child has any sign of bleeding: SDHF Refer! 3. If the child has any other cause of the fever: provide appropriate treatment. 4. If the fever has been present >7 days: Refer!
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EAR PROBLEMS
=a child with an ear problem may have an ear infection (main cause of deafness in developing
countries). *Mastoiditis= infection that spread from the ear to the bone behind the ear *Meningitis= infection spread from ear to brain
Pus collects behind eardrum
Pain + Fever
If not treated: eardrum burst!
Pus discharges: child feels less pain
Fever stops
Poor hearing: due to hole in eardrum
Eardrum heals
If eardrum does not heal or discharge continues
Deaf (Learning problems in school)
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ASSESS 1. Ask about ear problem *If no: check for Malnutrition/ Anemia! *If yes: assess for ear pain 2. Ear discharge >2 weeks (Chronic Ear Infection) and <2 weeks (Acute Ear Infection) 3. Look for pus draining from ear and tender swelling behind the ear. *Infants: tenderness & swelling is above the ear. *Both tenderness and swelling must be present: Mastoiditis!
CLASSIFY
SIGNS *Tender swelling
CLASSIFICATION
TREATMENT *1 dose antibiotic (may also need surgery) *1st dose of Paracetamol for pain *Refer!
st
MASTOIDITIS
*Ear Pus <14 days *Ear Pain
ACUTE EAR INFECTION
*Antibiotic for 5 days *Paracetamol for pain *Dry ear: Wicking *Ff up in 5 days
*Ear Pus >14 days *No ear pain, no ear pus
CHRONIC EAR INFECTION NO EAR INFECTION
*Dry ear: Wicking *Ff up in 5 days *No additional Treatment
Pointers: *Antibiotics for treating pneumonia are effective against bacteria that cause ear infections. *Oral antibiotics are not effective against chronic ear infection! *The most important and effective treatment for chronic ear infection is by WICKING!
TREAT 1. ACUTE EAR INFECTION: refer to pneumonia (same Cotri/Amox) 2. WICKING
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*Dry the ear 3X daily 1. Roll a clean, absorbent cotton cloth or a sheet of soft, strong tissue paper into a wick (funnel or triangular-shape). 2. Place the wick in the childs ear. 3. Remove the wick when already wet. 4. Replace the wick with a clean one and repeat these steps until the ear is already dry.
Pointers: *Do not use a cotton-tipped applicator, a stick or tingting, a piece of flimsy paper that will fall apart in the ear. *Do not place anything (baby oil, fluid) in the ear between wicking treatments. *Do not allow the child to go swimming.
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AGE OR WEIGHT BENZYLPENICILLIN Dose: 100,000 U/kg GENTAMICIN
IM CHLORAPHENICOL Dose: 40 mg/kg
ORAL CHLORAM PHENICOL

Dose: 40 mg/kg Capsule (250 mg)
(10 mg/ml solution)

Dose: 3.0 mg/kg
(To a vial containing 1000 mg, add 5 ml sterile water= 5.6 ml at 180 mg/ ml) To a vial containing 600 mg (1,000,000 Units): Add 2.1 ml sterile water= 2.5 ml at 400,000 units/ml 0.2 ml 0.4 ml 0.6 ml 0.9 ml 1.2 ml 1.5 ml 2 ml 2.5 ml 2.8 ml 3.0 ml 3.5 ml 4.0 ml 5 ml 3 2 1 0.8 ml 1.0 ml 1.2 ml 1.8 ml 1 1 0.3 ml --
1 kg
--
2 kg
0.5 ml
3 kg
0.7 ml
4 kg
0.9 ml
5 kg
1.1 ml
4-9 mo
1.5 ml
(6-<8 kg)
9-12 mo
2 ml
(8-<10 kg)
1-3 yo
2.5 ml
(10-<14 kg)
3-5 yo
3.5 ml
(14-19 kg)
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Pointer: *If you want the drug to be given every 6 hours: just divide the doses in the table by 2.
FOLLOW-UP 1. After 5 days: assess! 2. If there is tender swelling behind the ear or a high fever (>38.5 C): Refer! 3. Acute Ear Infection: if the ear pain or discharge persists, treat with the same antibiotic for 5 more days. Continue wicking. Ff up in 5 days. 4. Chronic Ear Infection: Continue wicking. 5. If there is no more pain or discharge: consume the 5-day remaining dosage of the antibiotic.
MALNUTRITION AND ANEMIA

ASSESS: 1. Visible Severe Wasting (Marasmus) = very thin, no fat, made up of only skin and bones. = outline of childs ribs is easily seen. = the hips look small when compared with the chest and abdomen. = many folds of skin on the buttocks and thighs. = it looks as if the child is wearing baggy pants. = the face may still look normal, abdomen is large. 2. Palmar pallor = paleness of skin (sign of anemia) 3. Edema on both feet = may have nephritic syndrome. Refer! 4. Weight for age
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CLASSIFY SIGNS *Visible severe wasting *Edema on either feet *Severe palmar pallor *Some palmar pallor *Very low weight for age ANEMIA OR VERY LOW WEIGHT FOR AGE *Assess the childs feeding (Ff up in 5 days, if there is feeding problem) *For some pallor: Iron Albendazole: if the child is >2 yo and not had a dose in the previous 6 months *If the weight for age is very low: Vitamin A, ff up in 30 days *Not very low weight for age, no other signs of malnutrition NO ANEMIA AND NOT VERY LOW WEIGHT FOR AGE *Assess the childs feeding (Ff up in 5 days, if there is feeding problem) CLASSIFICATIONS SEVERE MALNUTRITION OR SEVERE ANEMIA TREATMENT *Vitamin A *Refer
Pointers: *Children having Severe Malnutrition/ Severe Anemia are at risk of dying from pneumonia, diarrhea and measles. They may need feeding, blood transfusion and antibiotic.
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TREAT IRON *Give 1 dose daily for 14 days. *Syrup if <12 months old; Iron/ Folate Tablets if >12 months old
AGE OR WEIGHT
IRON/FOLATE TABLET 200 mg FeSO4 + 250 mg folate (60 mg elemental Iron)
IRON SYRUP 150 mg FeSO4 per 5 ml (60 mg elemental iron per ml) 2.5 ml (1/2 tsp) 4 ml (3/4 tsp) 5 ml (1 tsp) 7.5 ml (1 tsp)
2-4 months (4-<6 kg) 4-12 months (6-<10 kg) 1-3 yo (10-<14 kg) 3-5 yo (14-19 kg)
-- tablet tablet
Pointers: * Iron may make the stool black. * Iron/Folate interfere with the action of antimalarial Sulfadoxine-Pyrimethamine (Fansidar), do not give them together.
ALBENDAZOLE Give Albendazole as a single dose in HC if: *Hookworm/ Whipworm infections are a problem among children in the area *>2 yo child *The child has not had a dose of Albendazole in the last 6 months.
ESSENTIAL CARE SEVERE MALNUTRITION = needs special mineral supplements =refer! 1. Give antibiotic even if he does not have signs of infection. In severe malnutrition, the usual signs of infection are often absent. Ex: Severely malnourished child with pneumonia may not breath as fast as well-nourished does.
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2. No specific signs of infection: give Oral Cotrimoxazole for 5 days 3. Low temperature (<35.5 C) or elevated temperature (>37.5 C), ear or skin infection, general danger signs, pneumonia, SP/ VSD, VSFD: give IM benzylpenicillin & IM Gentamicin. *If does not improve in 2 days: Add IM Chloramphenicol
4. Continue breastfeeding 5. Feed 1st Choice: MODIFIED MILK DIET= 25g dried skim milk (DSM) + 100g sugar + 30g vegetable oil + 1 L water Ex: *Unsweetened Evaporated Full-fat Milk (120 ml, 100g sugar, 20ml oil) *Fresh Cows Oil (300 ml, 100g sugar, 20ml oil) *Skimmed, Unsweetened Evaporated Milk (120 ml, 100g sugar, 30ml oil)
=Filipinos are mostly lactose intolerant. These modified milk feeds have reduced =Can be given to a child with severe malnutrition: who has also Persistent Diarrhea
lactose.
=Feed 2x during the night due to severe malnourished children die during the night
2nd Choice: COMPLEMENTARY FOODS= Thick Porridge + Oil *Avoid too much lactose (>40 ml whole milk/kg/day) DAYS 1-2 3-5 6-7 FREQUENCY Every 2 hours Every 3 hours Every 4 hours VOLUME/KG/FEED 11 ml 16 ml 22 ml VOLUME/KG/DAY 130 ml 130 ml 130 ml
*Do not add salt 6. Add 0.5 ml/kg of KCl (from a stock solution 100g KCl/L) to each feed. Give 2 ml of 50% MgSO4 once by IM injection. 7. Give Iron when childs appetite returns (before this, iron can make an infection worse)
8. Manage diarrhea with dehydration carefully. *ORS solution contains too much salt and too little potassium for children with severe malnutrition:
ORS pack + 2 L water (instead of 1 L) + 50 g sugar (10 level tsp) + 45 ml KCl solution *Rehydrate slowly. If heart rate increases, stop giving ORS. Resume giving fluid once the rates have slowed.
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9. If rectal temperature is below 35.5 C, place the infant on the mothers bare abdomen. Cover with blanket and wear a bonnet. SEVERE ANEMIA
= danger of heart failure 1. Give iron orally 2. Give antimalarial if the blood smear is positive. Give Albendazole if hookworm or whipworm is a problem in the area. 3. Feed the child with good complementary foods. 4. Give Paracetamol every 6 hours if with fever. 5. Let him drink as much as fluid to quench his thirst. Do not give IV or NG fluids.
FOLLOW-UP FEEDING PROBLEM After 5 days: reassess! 1. Counsel the mother about any new or continuing feeding problem. 2. If the child has very low weight for age, return after 30 days.
ANEMIA After 14 days: Asasess! 1. Give iron: return in 14 days for more iron. 2. Continue giving iron everyday for 2 months, with ff-up every 14 days. 3. If the child has palmar pallor after 2 months: refer!
VERY LOW WEIGHT FOR AGE After 30 days: *Weigh the child: assess! 1. If the child has no longer a very low weight for age: continue feeding properly 2. If the child still has a VLWFA, see the child monthly, counsel about feeding. *If you do not think that the childs feeding will improve or if the child has lost weight: refer!
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MANAGEMENT OF THE ILLNESS OF A YOUNG INFANT: 1 WEEK-2 MONTHS

BACTERIAL INFECTION
ASSESS 1. Check for signs of possible bacterial infection *Ask for diarrhea (classify for Persistent Diarrhea or Dysentery) *Check for feeding problems or low weight for age *Check for immunization 2. Ask about convulsion 3. If 1st count is >60 BPM, repeat! *Normal for infant to have apnea for few seconds, followed by faster breathing. 4. Mild Chest Indrawing is normal in young infants because their chest wall is soft. Severe CI is very deep and easy to see (sign of pneumonia) 5. Nasal flaring= widening of the nostrils when breathing IN. 6. Grunting= soft, short sounds when breathing out (a sign of trouble breathing) 7. If the fontanelle is bulging rather than flat: may be meningitis! 8. Check umbilicus: if red and extends to skin or with pus draining *umbilical cord usually drops by 1 week. 9. Fever: maybe the only sign of bacterial infection >37.5 C axilllary & >38 C rectal 10. Skin pustules: red spots/ blisters that contain pus 11. An infant that is difficult to awaken does not respond when touched or spoken to.
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CLASSIFY SIGNS *Convulsions *Fast breathing (>60 BPM) *Severe CI *Nasal Flaring *Grunting *Bulging fontanelle *Fever or low body temp. *Abnormally sleepy or difficult to awaken *Abnormal movement *Umbilical redness extending to the skin *Many severe skin pustules *Pus draining *Red umbilicus *Skin pustules *Pus draining LOCAL BACTERIAL INFECTION (LBI) *Oral antibiotic for 5 days *Treat local infection *Ff up in 2 days Pointers: * A young infant having bacterial infection may have pneumonia, sepsis, meningitis. AGE OR WEIGHT COTRIMOXAZOLE (Trimethoprim + Sulphamethoxazole) Give 2X daily for 5 dys Adult Tablet (Single-strength 80 mg Trimethoprim + 400 mg Sulphamethoxazole) Syrup (40 mg T + 200 mg S) AMOXYCILLIN (Give 3X daily for 5 days) Tablet 250 mg Syrup 125 mg per 5 ml CLASSIFICATIONS POSSIBLE SERIOUS BACTERIAL INFECTION (PSBI) TREATMENT *1st dose of IM antibiotics. *Treat hypoglycemia *Keep warm *Refer!
Birth-1 month (<3 kg) 1-2 months (3-4 kg)
--
1.25 ml*
-1/4
1.25 ml
1/4
2.5 ml
2.5 ml
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Pointers: *Avoid Cotri in infants less than 1 month of age who are premature or jaundiced. Give amoxycillin or benzylpenicillin instead.
1. Give the 1st dose of both benzylpenicillin and gentamicin IM (The combination is effective against broader range of bacteria) 2. Referral to a hospital is the best option to a young infant with POSSIBLE SERIOUS BACTERIAL INFECTION. If referral is not possible, give benzylpenicillin and gentamicin for 5 days. Give Benzylpenicillin every 6 hours and 1 dose of Gentamicin daily. IM Antibiotics
WEIGHT
GENTAMICIN (dose: 5 mg/kg)
BENZYLPENICILLIN
(dose: 50,000 Units/kg)

To a vial of 600 mg (1,000,000 units):
Undiluted 2 ml vial containing 20 mg=2 ml at 10 mg/ml Or Add 6 ml sterile water to 2 ml vial containing 80 mg=8 ml at 10 mg/ml
Add 2.1 ml sterile water=2.5 ml at 400,000 U/ml Or Add 3.6 ml sterile water=4 at 250,000 U/ml
1 kg 2 kg 3 kg 4 kg 5 kg
0.5 ml 1 ml 1.5 ml 2 ml 2.5 ml
0.1 ml 0.2 ml 0.4 ml 0.5 ml 0.6 ml
0.2 ml 0.4 ml 0.6 ml 0.8 ml 1.0 ml
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Treat Local Infections at Home 1. Do the treatment 2X daily. Return to HC if the infection worsens. 2. Skin Pustules *Wash hands *Wash off pus and crust with soap and water *Dry the infected area *Paint the infected area with 0.5% GV *Wash hands 3. Umbilical Infection *Wash hands *Clean umbilicus with 70% ethyl alcohol *Paint the umbilicus with 0.5% GV *Wash hands 4. Thrush *Wash hands *Wipe the infants mouth with a clean, soft cloth wrapped around the finger and dipped in salt water. *Paint the infants mouth with half -strength 0.25% GV *Wash hands Pointers: * Bring back the infant in 2 days. * Discontinue GV after 5 days.
ESSENTIAL CARE POSSIBLE SERIOUS BACTERIAL INFECTION 1. Give the infant IM Benzylpenicillin and IM Gentamicin =given because may have pneumonia, sepsis, meningitis *If meningitis is suspected: substitute IM Ampicillin for Benzylpenicillin. Treat the infant for 14 days or better refer! *If meningitis is not suspected, treat the infant for 5 days *When the infants condition has improved: substitute oral Amoxycillin for IM Benzylpenicillin or IM Amoxycillin. *If there is no response to the treatment after 2 days give chloramphenicol. 2. Keep warm
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3. Breastfeed frequently, or feed with expressed milk by dropper or by NG tube 6X a day. Give 20 ml of breastmilk/KBW. Give a total of 120 ml/kg/day. 1. After 2 days: assess for umbilicus and skin pustules 2. Pus or redness remains or is worse: refer! 3. Pus or redness has lessened: continue the antibiotic for 5 days 4. Treat hypoglycemia FOLLOW-UP LOCAL BACTERIAL INFECTION (LBI)
DIARRHEA
ASSESS 1. Ask how long has the infant had diarrhea and blood in stool. 2. Danger signs: abnormally sleepy, difficult to awaken, restless, irritable, sunken eyes, drinking ability, skin pinch
CLASSIFY SIGNS 2 of the ff signs: *abnormally sleepy or difficult to awaken *sunken eyes *pinched skin goes back slowly 2 of the ff signs: *restless, irritable *sunken eyes *pinched skin goes back very slowly *Not enough signs to classify *Diarrhea lasting >14 days NO DEHYDRATION SOME DEHYDRATION CLASSIFICATIONS TREATMENT *Infant has no PSBI nor dysentery: Plan C (fluid) *If the infant has PSBI or dysentery: frequent sips of ORS, breastfeeding, keep warm, refer! *Plan B (fluid & food) *If the infant has PSBI or dysentery: frequent sips of ORS, breastfeeding, keep warm, refer! *Give fluid to treat diarrhea at home (Plan A) *If dehydrated: treat dehydration except if with PSBI *Keep warm & Refer! *Blood in stool DYSENTERY *Frequent sips of ORS, breastfeeding, keep warm & Refer!
SEVERE DEHYDRATION
SEVERE, PERSISTENT DIARRHEA
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Pointer: *Give the young infant who does not breastfeed an additional 100-200 ml of clean water (for Plan B).
TREAT (refer to Plan A, B, C under dehydration)
LOW WEIGHT FOR AGE AND BREASTFEEDING PROBLEMS

ASSESS: 1. 2. 2. Breastfeeding: >8X in 1 day is normal! Infant who is not able to eat, may have a serious infection: Refer!
3. Young infant should be exclusively breastfed !
4. Use low weight for age line in assessing weight for age for infants (not VLWFA)
5. Check for 4 signs of *good attachment *Chin touching the breast or very close *Mouth wide open *Lower lip turned outward *More areola visible above than below the mouth
*Not Well Attached: may cause pain and damage to mothers nipples, infant may not be able to extract the breast milk which causes engorgement of the breast. *Chin not touching the breast *Mouth not wide open, lips pushed forward *Lower lip turned in *More areola visible below the infants mouth
*No Attachment At All: the infant is very sick that he cannot take the nipple into his mouth and suck.
6. Check if infant is suckling effectively *Suckling Effectively= slow, deep sucks, sometimes pauses. If infant is satisfied, he releases the breast spontaneously.
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CLASSIFY SIGNS *Not able to breastfeed *No attachment at all *No suckling at all *Not well attached to the breast *Not suckling effectively *<8 breastfeeds in 24 hours *Receives other foods or drinks *Low weight for age *Thrush (ulcers or white patches in the mouth) *Not LWFA and no other signs of inadequate feeding NO FEEDING PROBLEM (NFP) *Continue the home care and breastfeeding CLASSIFICATIONS POSSIBLE SERIOUS BACTERIAL INFECTION (PSBI)
st
TREATMENT *1 dose IM antibiotics *Treat hypoglycemia *Keep warm & Refer! * Advise for proper breastfeeding *treat thrush *ff up any feeding problem and thrush in 2 days *ff up LWFA in 14 days
FEEDING PROBLEMS OR LOW WEIGHT FOR AGE (FP:LWFA)
Pointer: *Not LWFA means that the infants weight for age is not below the line Low Weight for 1. After 2 days: reassess feeding patterns! 2. If the infant has a LWFA: return 14 days after 3. If you dont think that the infants feeding pattern will improve, or if the infant has lost weight: refer! Age. Not necessarily normal but at least, not in high -risk category!
FOLLOW-UP FEEDING PROBLEM
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LOW WEIGHT FOR AGE 1. After 14 days: weigh and reassess feeding patterns! 2. If the young infant has no longer a LWFA: continue feeding If still has a LWFA but is feeding well: return within 1 month, continue feeding If still has a LWFA and still has a feeding problem: return within 2 weeks, continue feeding. 3. If you dont think that the infants feeding pattern will improve, or if the infant has lost weight: refer!
PINK REFERRAL (SEVERE CLASSIFICATIONS)
SEVERE PNEUMONIA/ VERY SEVERE DISEASE SEVERE DEHYDRATION SEVERE, PERSISTENT DIARRHEA VERY SEVERE FEBRILE DISEASE/MALARIA VERY SEVERE FEBRILE DISEASE SEVERE, COMPLICATED MEASLES SEVERE DENGUE HEMORRHAGIC FEVER MASTOIDITIS SEVERE MALNUTRITION OR SEVERE ANEMIA Pointers: *Refer!= means refer urgently to a hospital (a health facility with inpatient beds, expertise to treat the child). supplies,
*Exception is SEVERE, PERSISTENT DIARRHEA! Referral is needed but not urgent!
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FOLLOW-UP VISIT (SUMMARY) Diseases: PNEUMONIA DYSENTERY MALARIA, if fever persists FEVER:MALARIA UNLIKELY, if fever persists FEVER: NO MALARIA, if fever persists MEASLES WITH EYE OR MOUTH COMPLICATIONS DHF, if fever persists PERSISTENT DIARRHEA ACUTE EAR INFECTION CHRONIC EAR INFECTION FEEDING PROBLEMS ANY OTHER ILLNESS, if no improvement is observed ANEMIA VERY LOW WEIGHT FOR AGE 14 days 30 days 5 days Return in: 2 days
Any sick child A child with No Pneumonia A child with diarrhea A child with Fever: DHF Unlikely
Not able to drink or BF, becomes sicker, develops fever FB, CI Blood in stool, drinking poorly Any sign of bleeding, persistent abdominal pain, persistent vomiting
WHEN TO RETURN TO HC IMMEDIATELY
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REFERENCES:
National league of Government Nurses, 2000. Community Health Nursing Services in the Philippines, 9th ed., Department of Health Jimenez, Carmen E., 2002. Community Organizing Participatory Action Research for Community Health Development: Helping People Grow and Glow, Sacred Heart College. Maglaya, Araceli S., 2004. Nursing Practice in the Community, 4th ed., UP-College of Nursing, Manila Bailon, Salvacion G., 1990. Family Health Nursing: The Process, UPCollege of Nursing, Manila Bailon-Reyes, Salvacion G., 2006. Community Health Nursing: The Basics of Practice, J-Creative Labels & Printing Corp., Quezon City Association of Philippine Schools of Midwifery (APSOM) 2005. Integrated Management of Childhood Illness, C&E Publishing, Inc. Palaganas, Erlinda C., 2003. Health Care Practice in the Community, 1st ed., Guani Prints House Task Force on Philippine Guidelines on Periodic Health Examination, 2004. Philippine guidelines on Periodic Health Examination (PHEX), New Associated Printing Press, Inc. Flavier, Juan M., 2003. Doctor to the Barrios, New Day Publishers Hunt, Roberta, 2000. Readings in Community-Based Nursing, 1st ed., Lippincott Williams and Williams
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Deloughery, Grace L., 1995. Issues and Trends in Nursing, 2nd ed., Mosby-Year Book, Inc. Untalan, Aaron T., 2005. Concepts and Guidelines in COPAR, 1st ed., Educational Publishing House Viet, Lydia C., 2004. Community Exposure: Family Health Management (Book 1 and 2), Trinitas Publishing, Inc. National League of Government Nurses, 1992. Community Health Nursing Services in the Philippines Department of Health, 7 th ed., Department of Health-Philippines Divinagracia, Carmelita C., 2004. Resources Units in NCM 100-105 with Clinical Focus, 1st ed., Association of Deans of Philippine Colleges of Nursing (ADPCN) Evangelista-Sia, Maria Loreto J. 2006. Nursing Law and Ethics, 2006 Ed.,RMSIA Publishing Prabhakara, G.N. 2005. Textbook of Community Health for Nurses, Peepee Publishers and Distributors Ltd. IIRR, PLAN and SCF, 2000. Indigenous Knowledge and Practices on Mother and Child Care: Experiences from Southeast Asia and China. International Institute of Rural Reconstruction, PLAN International and Save the Children Federation, Inc., Philippines DOH pamphlets, handouts, flyers
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Communicable Diseases
Communicable Disease
138
Communicable Diseases
GLOSSARY OF TERMS: Communicable Disease A disease that can be transmitted from one person to the other either by direct or indirect method of transmission. Contagious Disease A communicable disease that is easily transmitted from one person to the other.
Comm Ds. & Infection
Contagious
Diagram: All communicable diseases are contagious and infectious but not all contagious and infectious diseases are necessarily communicable.
Infection Invasion and Multiplication of pathogenic microorganisms in the body Reservoir Environment in which microorganisms live and multiply. Normal Microbial Flora Microorganisms present in the body but do not cause harm. Carrier A person with infection but does not manifest signs and symptoms of the disease. He/She is more dangerous than a person manifesting signs and symptoms.
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Contact A person known to have been in close association with a person with an infectious disease. Isolation Separation of the individual during the period of communicability.
Figure 1 GERMS in Prison Period of Communicability The time in which the patient is highly contagious and may vary according to the disease.
Contamination The presence of infectious agent on a body surface, also clothes, toys, beddings, surgical instruments, and other inanimate articles or substances.
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Vehicle Matter in or upon which pathogenic agents are present and survive until there is physical contact with persons. Vector A living carrier of pathogenic microorganisms from the sick to a well person. Antiseptic Agents that inhibits the growth of some microorganisms and safe to use in skin tissue. (e.g. Providone Iodine, Chlorhexidine gluconate) FUMIGATION Process of killing animal forms accompanied by the employment of gaseous agent.
DISINFECTION killing of pathogenic agents by physical or chemical means (does not kill spores.) (e.g. Chlorine, Isoprophyl Alcohol) Sterilization Killing of all living organisms and bacterial spores. (e.g. Autoclaving, Etylene Oxide gas, UV light, Ionizing Radiation)
141
EXPOSURE
INCUBATION
STAGES/ PERIODS OF INFECTION: A TIMELINE
PRODROMAL
ACUTE
CONVALESCENCE RESOLUTION
142
CHAIN OF INFECTION NURSEs ROLE: BREAK THE CHAIN.
CAUSATIVE AGENT:
e.g. bacteria, viruses,
SUSCEPTIBLE HOST:
e.g. Immunocompromised, Post
RESERVOIR:
e.g. Humans,plants, Animals, street dust, inanimate objects (fomites)
PORTAL OF ENTRY:
RESPIRATORY (A nurses concern), GIT, GUT, broken skin, mucous membrane
PORTAL OF EXIT:
Secretions Excretions Wound (skin)
MODE OF TRANSMISSION:
contact airborne
NURSING ALERT: The nurses primary role of knowing the six elements in the chain is to BREAK the chain in order to prevent the spread of infection. IMMUNITY The state of being resistant to diseases FIRST LINE OF DEFENSE
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External and Mechanical Barrier (Skin, Hair, Coughing, Cilia) SECOND LINE OF DEFENSE includes NONSPECIFIC response and SPECIFIC response NONSPECIFIC RESPONSE: Signs of Acute Inflammation are the SLIPR Mnemonic: What a cute pair of SLiPpeRs. Swelling Loss of function Increased Heat LOCAL INLFAMMATORY RESPONSE
SPECIFIC RESPONSE (sometimes considered as Third line of Defense) CELL MEDIATED IMMUNITY Involes T cell which synthesize and secrete lymphokines There are 5 types of immunoglobulins. They are GAMED. The most important is IgM. It is immediate in its effect and the most abundant. mnemonic M.D. The first antibodies to go at the site is IgM then IgD.
Immunoglobulin which crosses the placenta and the breast. IgG crosses the placenta during gestation.
144
TYPES OF IMMUNITY B. ACQUIRED IMMUNITY (through environmental exposure)
A. NATURAL IMMUNITY
(inherent in the body)
C. ACTIVE (short term duration)
D. PASSIVE (Antibodies is given to the individual)
(Antibodies is prod. by individual himself)
(long term duration of effectivity)
NATURAL (Vaccination)
ARTIFICIAL e.g. Live Attenuated V Inactivated V.
NATURAL (Transplacental) (Breasfeeding)
ARTIFICIAL (Antitoxin) (Antiserum) (Immunoglobulin)
(Recovery from disease)
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CONTROL MEASURES: The use of the Revised CDC(1997) Isolation Precautions TWO TIER: 1. STANDARD PRECAUTION Primary strategy for preventing Nosocomial infection designed for ALL patients. Precautions apply to: 1) blood 2) all body fluids, secretions, and excretions except sweat 3) nonintact skin 4) mucous membranes. 2. TRANSMISSION BASED PRECAUTION Designed for highly contagious cases or epidemiologically important pathogens. Nurse still use Standard Precaution in addition to this TBP.
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PRECAUTION Transmission CONTACT Skin to skin Gastrointestinal DROPLET Large particle droplets (5 mm or more) Close face to face (within 3 feet) Diseases/C.A. Skin: Diphteria (cutaneous) Impetigo Pediculosis Scabies Cellulitis ENTERIC: Shigella Hepa A Escherichia coli Rotavirus PRIVATE ROOM/ COHORT YES YES YES; negative air pressure room Yes, if I will handle secretions. PIMP Dr. Pertussis Influenza Meningitis Pneumonia Diphteria Rubella (German Measles) MTV Measles (Rubeola) Tuberculosis Varicella (**plus contact P.) AIRBORNE Airborne droplet nuclei
GLOVES (clean)
YES
Yes, if I will handle secretions
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GOWN YES Yes, if my patient is actively coughing. Yes, if Im 3 feet near my patient. Yes, if my patient is actively coughing. Yes, it should be HEPA (High Efficiency Particulat e Air) respirator mask like N - 95 ALWAYS closed
MASK
NO
DOOR
May keep open
May keep Open
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CNS DISEASES
Disease
Signs and Symptoms Medical Management Nursing Management Prevention
Tetanus 2. Immunization Passive Immunization: Equine Tetanus Antitoxin (TAT) Tetanus Immune globulin (Hyper Tet) within 72 hours.
TOR
1. Prevent Seizures 1. Wound Care
(Lockjaw)
Trismus
Opisthotonus Sedatives e.g. Diazepam 2. Promote Nutrition High Caloric Diet Fluid Diet, NGT, TPN 3. Monitor for Possible Complications: Aspiration Pneumonia 2. Kill the Bacteria Antibiotic Penicillin Cardiac Dysrhthymias DPT Tetanus Toxoid
1. Promote Airway Maintenance and Reduce Muscle Spasm Promote Rest Quiet environment Dim lights Avoid unnecessary handling
Causative Agent
Risus Sardonicus
Clostridium tetani
Anaerobic Toxigeni Spore Forming
Tetanus Neonatorum
Mode of Transmission/
EMERGENCY equipment @ bedside E.g. Tracheostomy, ET tube, Mechanical Ventilation
Active Immunization:
Incubation Period
MOT:
Difficulty in Sucking FIRST sign Excessive crying later leading to a strangled soundless voiceless noise.
3. Steriliziation of Hospital Supplies Tetanus Neonatorum 1. Active Immunization (Pregnant Mother) 2. Strict Asepsis during delivery. 3. Licensing of Health Personnel like the Midwifes, Nurses.
Break in Skin integrity
Diagnostic Test
Tetanus N.
1. Clinical Diagnosis
Contamination of unhealed stump of the umbilical cord
History of wounds Immunization Status 2. Blood Culture
3. Tetanus Antibody test
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150
Disease
Poliomyelitis 2. Relief of Muscle Spasm Hot Moist Packs 3. Monitor for Possible Complications: Respiratory Paralysis Hypertension
TYPES:
(Infantile Paralysis; Heine Medin Disease)
1. Abortive Polio
1. Relief of Painful Muscle Spasm 1. Rest
1. Immunization Trivalent Oral Polio Vaccine (TOPV)
Causative Agent
Polio Virus/Filterable Virus, Legio Debilitans 2. Ventilatory Support
Slight Fever Malaise Sore Throat 2. Nonparalytic Polio
Moderate Fever Headache Neck, back pain 3. Paralytic Polio Respirator Oxygen Therapy Tracheotomy Mechanical Ventilation
Aspirin Codeine Sedative Drugs (e.g. Phenobarbital) *Caution for Bulbar Polio
2. Prevent spread of Infection
Incubation Period
Fecal oral route
4. Promote Rehabilitation
Enteric Isolation until the end of fever. Proper disposal of Nasopharyngeal and excreta.
Direct/ Indirect Contact
Asymmetrical Flaccid Paralysis Tripod sign Hoynes Sign Pokers Spine 4. Bulbar Polio
5 to 35 days
Respiratory Paralysis Encephalitis Hypertension
Diagnostic Test
Refer to Physical and Occupational Therapy Braces, orthopedic shoes
1. Throat Culture
2. Stool Culture
Disease
Rabies Immunized pet @ 3 months of age Take care of your pet Rest Quiet Env. Dark environment. 2. Promote Safety and Prevent spread of infection Rest Restraint PRN Strict Isolation 3. Prevention of Agitation due to Hydrophobia
1. Prodromal/Invasive Stage Symptomatic Management 1. Prevent Seizure 1. Be a responsible Pet Owner
(Hydrophobia)
Chloral Hydrate
Causative Agent
Rhabdo virus
Mental Depression FIRST SYMPTOM Fever Headache Photophobia 2. Acute/Excitement Period
2. Utilization of National Rabies Prevention and Control Program of DOH. Manpower Development Social Mobilization Local Prgram Implementation Dog Immunization
Hydrophobia Excessive Salivation Maniacal behavior 3. Paralytic Period
Gradual, generalized flaccid
paralysis
3. Wound Care and Tetanus Immunization
Incubation Period
Avoid bathing the patient Turn off the faucets. Cover IVF.
MOT:
Diagnostic Test
If possible dont suture the wound and immediately stop the bleeding.
1. Clinical Diagnosis
4. Immunization Post Exposure Treatment Active Immunization
History of Animal Bite Signs and Symptoms 2. Observe the pet for 1014 days.
3. Brain Biopsy of Animal
Human Diploid Cell Vaccine (Imovax) Passive Immunization Rabies Immunoglobulin (Rabuman, Imogam)
Bite of Infected animal Scratch Airborne Droplet Infected Tissue transplant IP: 2 to 8 weeks
Negri Bodies 4. Fluorescent Rabies Antibody
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152
CIRCULATORY DISEASES
153
DISEASE OTHER NAME: Causative Agent DENGUE Hemorrhagic Fever Breakbone Fever, H Fever, Dandy Fever Dengue Virus type 1, 2, 3 and 4 (Arbo V) Chikungunya V. Onyong Yong V. Source of Infection: Female Aedes Aegyptii Mosquito CHARACTERISTIC: D ay Biting L ow Flying S tagnant Water U rban Incubation Period: Mode of Transmission: Signs and Symptoms: 6 7 days Mosquito Bite Grade I Fever, Headache, joint pain, conjunctivitis, Hermans Sign, Petechiae, Anorexia, abdominal pain, N and V. Grade II Grade I + ecchymosis, purpura, epistaxis, melena. Grade III
Grade II + SHOCK
GRADE IV
Grade III + Profound Shock

COMPLICATIONS: DIAGNOSTIC TESTS: Thrombocytopenia Hypovolemic Shock 1. Tourniquet Test/ Rumpel Lead Test. 2. Platelet Count 3. Viral Isolation 4. Serologic Test (ELISA) MEDICAL MANAGEMENT: 1. BORIC ACID/ Saline Compress. 2. Codeine, DO NOT GIVE ASPIRIN 3. Calamine Lotion 4. BLOOD TRANSFUSION ***FRESH FROZEN PLASMA. NURSING MANAGEMENT Rest Ice Packs on the forehead and abdomen Prevent and control bleeding TSB and Increase Fluid intake DIET: LOW FAT, LOW FIBER, NON irritating and High in Vit. C
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DISEASE OTHER NAME: Causative Agent
MALARIA Ague, Marsh Fever PLASMODIUM VIVAX PLASMODIUM FALCIFARUM PLASMODIUM MALARIAE PLASMODIUM OVALE
Source of Infection:
Female Anopheles Mosquito CHARACTERISTIC: Night Biting High Flying Free Flowing Water Rural
Incubation Period: Mode of Transmission: Signs and Symptoms:
10 to 12 days Mosquito Bite BT, contaminated needles and syringes COLD STAGE: chills, chatter teeth, shakes and shivering. HOT STAGE: HIGH FEVER ( >40 degree C, Headache, skin is red and HOT) DIAPHOREIC STAGE ****THESE THREE STAGES occur in a cycle usually in the THIRD DAY. LATER, patient will develop MALARIAL CACHEXIA ****SEVERE ANEMIA (due to destruction of the RBC.
COMPLICATIONS:
BLACK WATER FEVER Cerebral Malaria (common in Falcifarum) DIC (Disseminated Intravascular Coagulation)
DIAGNOSTIC TESTS: MEDICAL MANAGEMENT:
1. Malarial Smear/ Peripheral Blood Smear Taken at the height of the patients fever. 1. Use of Antimalarial Drug CLASS: Aminoquinolones These drugs are schizonticidal. e.g. Chloroquine (Aralen) Quinine
***Quinine is given in emergency situation (IV) but watch out for symptoms of neurologic toxicity like confusion, twitching, delirium, convulsions and coma. CLASS: PRIMAQUINE NOT ONLY SCHIZONTICIDAL but also destroy gametocytes. CLASS: Sulfadoxine USE for resistant P. Falcifarum strains. NURSING MANAGEMENT 1. 2. 3. TSB and increase fluid intake Monitor vital signs & abnormal bleeding Iron rich food
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DISEASE OTHER NAME: Causative Agent FILARIASIS Elephantiasis Wucheria Bancrofti Brugia Malayi Brugia timori Source of Infection: Female Aedes Poecillus CHARACTERISTIC Night Biting Dirty Water Rural Incubation Period: Mode of Transmission: Signs and Symptoms: 8 16 months Mosquito Bite Asymptomatic Stage
Acute Stage LLFOE Lymphadenitis Lymphangitis Funiculitis Epidydimitis Orchitis
Chronic Stage HEL Hydrocele Elephantiasis Lymphedema COMPLICATIONS: DIAGNOSTIC TESTS: Renal involvement Superinfection 1. Nocturnal Blood Exam (NBE) Giemsa stained thick blood film.Taken after 8:00 PM 2. Immunochromatographic Test (ICT) Rapid assessment test that can be done at daytime. MEDICAL MANAGEMENT: 1. Diethycarbamazine Citrate - DEC (Hetrazan) 2. Albendazole (Albenza) 3. Steriods Sugical Management is done to correct chronic signs and symptoms. NURSING MANAGEMENT 1. Teach patient about personal hygiene (e.g. wash affected areas with soap and water). 2. Elevate and Exercise affected part.
156
Dengue Hemorrhagic Fever Malaria Filariasis
Specific PREVENTIVE MEASURES: Blood Screening USE OF PROPHYLACTIC DRUG ZOOPROPHYLAXIS
NO VACCINE
1. Mass Treatment in endemic communities Considered as the MOST effective way to reduce or prevent morbidity and transmission.
Good environmental Sanitation Seeding Larvivarous Fish (e.g. tilapia)
COMMON PREVENTIVE MEASURES
Eradicate Mosquitoes
Eradicate its Breeding Sites
Protect Against Mosquito Bites
Use of long sleeves, long pants, socks Use of mosquito net (maybe insecticide treated) Use of repellants Use of antimosquito plant (e.g. Neem tree)
157
RESPIRATORY DISEASES
158
DISEASE Haemophilus pertussis Bordet Gengou Bacillus 7 to 21 days 1 to 3 days 3 days from onset of symptoms Direct (Droplet) Catarrhal Stage even until 3 weeks after onset of paroxysmal stage. Direct (Droplet) Invasive/ Catarrhal Stage (7 to 14 days) Fever, watery eyes Cough which is worse at night(dry and irritative) Coryza Influenza Virus A, B, C
Diphtheria
Pertussis (Whooping Cough) Influenza
Causative Agent
Corynebacterium Diphtheriae
(Klebs Loeffler Bacillus)
Incubation Peri-
2 -5 days
Period of Communicability
2 weeks
Mode of Trans-
Direct (Droplet)
Signs and Symptoms:
A. NASAL Diphtheria
Coryza
Epistaxis
Adenitis
Fever Chills Generalized Aches Coryza Marked Prostation
B. PHARYNGEAL diphtheria Spasmodic Stage (4 to 12 weeks)
Paroxysmal cough with a prolong inspiratory phase Protusion of eyeballs Swollen neck and veins Abdominal hernia
SORE throat
Tonsillitis
BULL NECK APPEARANCE
C. Laryngeal Diphtheria
Hoarseness of voice
DISEASE BRONCHOPNEUMONIA HERNIA HEMORRHAGES 1. Throat Culture 1. Viral Isolation 2. WBC decrease Pneumonia MOST common and MOST dangerous
Diphtheria
Pertussis (Whooping Cough) Influenza
COMPLICATIONS:
Bronchopneumonia
Peripheral Neuritis
CArditis
Nephritis
DIAGNOSTIC TESTS:
1. Nose and Throat Culture
2. Schicks Test
Determines susceptibility and immunity to diphtheria 3. Moloneys Test
Sensitivity to Diphtheria toxoid. 1. Antibiotics 2. Codeine

1. Respiratory Isolation (Droplet Precautions) 2. Abdominal Support 3. Rest 4. Small Frequent Feeding
MEDICAL MANAGEMENT:
1. Antibiotics
2. Passive Immunization
1. Antibiotics if with pulmonary bacterial complication.
Diphtheria antitoxin
1. Respiratory Isolation (Droplet) 2. Rest 3. Keep patient warm and free from drafts in bed. 4. TSB 1. Immunization (Influenza Vaccine) 2. Clothing contaminated with discharges should be boiled for 30 minutes before laundering.
NURSING MANAGEMENT
1. Strict Isolation (Droplet Precautions)/Contact Precaution for Cutaneous D.
Specific PREVENTIVE MEASURES:
2. Rest
3. Soft Diet
1. Pasteurization of Milk
159
160
COMMON PREVENTIVE MEASURES
1. Immunization DPT 2. Proper Disposal of Nasopharyngeal secretions 3. Cover mouth when coughing and sneezing. 4. Avoid use of common towels, glasses and eating utensils.
161
INTEGUMENTARY DISEASES
162
EXANTHEMOUS DISEASES: MEASLES, GERMAN MEASLES, CHICKEN POX DISEASE MEASLES GERMAN MEASLES Rubella Togaviridae/Rubivirus Droplet 2 3 weeks 12 days/ 1 week before and 5 days after rash appearance Varicella
CHICKEN POX
OTHER NAME
Rubeola
Causative Agent
Paramyxovirus/Morbillivirus
Varicella Zoster V. Airbone Skin to skin contact 2 -3 weeks 7 days/ 1 day before and more than 6 days after the first crop of vesicles.
MOT
Airborne
IP
1 2 weeks
POC
9 days/ 4 days before and 5 days after rash appearance
DISEASE Both would start with colds and later with conjunctivitis. Without conjunctivitis PATTERN OF RASH APPEARANCE: 1. Macule 2. Papule 3. Vesicle 4. Crust/Scab Vesicular Fluid Test is positive for Varicella Virus. PREVENTIVE: 1. Varivax Given for person more than 13 years old who never had chicken pox. SUPPORTIVE MANAGEMENT: Lymphadenopathy Cephalocaudal maculopapular rashes Confluent Rashes. Forscheimers Spots. Serologic Test PREVENTIVE: 1. Rubella Vaccine esp. for women who never had German Measles.
MEASLES
GERMAN MEASLES
CHICKEN POX
SIGNS AND SYMPTOMS
Both would start with colds and later with conjunctivitis
Kopliks Spots Cephalocaudal Maculopapular Rashes High Fever
Dx Test
Wright Staining
MANAGEMENT:
PREVENTIVE: 1. Measles Immunization
SUPPORTIVE MANAGEMENT: 2. Teach 1. Rest pregnant to avoid sick and those who receive MMR. 3. GammaGlobulin for those pregnant women who were exposed. For Pregnant Woman: Congenital Cataract Mutism Deafness Mental Retardation PIES Impetigo
Given at 9 months subcutaneously. SUPPORTIVE MANAGEMENT: Rest 2. Resp. Isolation (Airborne Precaution) 3. Darken Room 4.Antipyretic
1. Rest 2. Calamine lotion 3. Cut fingernails short 4. Baking soda with Warm Water (PASTE) Not a cure 5. Acyclovir (ZOVIRAX). but only hasten the acute stage.
COMPLICATIONS
POE
Pneumonia
Pneumonia
Otitis Media
Encephalitis
Encephalitis Secondary Bacterial Infection
163
164 GASTROENTERITIS
Description Is an inflammation of the GI; it most commonly affects the small intestine. A.K.A Travelers diarrhea, dysentery. History will differentiate from other conditions Etiology and Incidence
1. Bacterial E. Coli Travelers Diarrhea Shigellosis Bacillary Dysentery By way of fecal-oral Affects all ages Affects in warm climates Viral gastroenteretits rotavirus and parvovirus-type by way of the respiratory system. Affects primarily infants and the aged
Crowded living conditions The Pathophysiology and Manifestations: Symptoms common to all types of gastroenteritis include:
a. Nausea b. Vomiting c. Diarrhea
165
Bacterial stool specimens with high WBC, possibly high RBC Viral - high WBC and the presence of pus Fever depends on microorganism, bacterial usually causes higher temp. S/Sx of viral gastroenteritis include Headache Weakness muscle aches and pains abdominal distention and tenderness (but no rebound tenderness) Infection can last anywhere from 2 to 7 days. In diarrhea and vomiting become severe FVD Nursing Intervention
1. Drugs anti-infective agents, analgesics, and electrolyte replacement

medications (eg, potassium). No drugs to suppress gastric motility.
2. Monitor I & O 3. Watch out for F & E imbalances 4. Dietary changes intake of clear liquids initially lactose-free foods for 1 to 2 weeks (after symptoms subside) Parenteral therapy for severe cases. Collect stool specimen. Provide meticulous perianal skin care. Provide patient teaching covering: Adherence to medication regimen Appropriate sanitary methods for cooking and personal hygiene
166
GIT DISEASES
Mode of Transmission Symptoms Diagnostic Test Classic Signs and Treatment Period
Communicable Dis-
Causative Agent
Incubation
ease
TYPHOID Feces Food and Water Widal Reaction Agglutination of the organism to the patients serum. Tyohidot Rose Spots Bradycardia/ Tachcardia Fingers Fomites Fly Headache GIT manifestations Leukopenia Like Fever
Salmonella
1-3 wks CBC
5 Fs
Ladder / Step
Chloramphenicol DOC OTHERS: Ampcillin Cotrimoxazole
FEVER
typhosa
(Enteric Fever)
5 Fs Cuture Vomitus Feces Dark field Microscopy N&V Severe DHN
Tetracycline DOC
CHOLERA
Vibri
(Violent Dysentery)
Cholera
Few hours to 5 days
Colorless diarrhea/ RICE WATERY STOOL
Vascular collapse
Communicable DisIncubation Period

Fever 5 Fs N&V Tenesmus Bloody and mucoid stools Direct Immunofluorescence Stool Exam
Causative Agent Mode of TransTreatment mission toms

Chloramphenicol DOC
Diagnostic Test
Classic Signs and Symp-
ease
Shigella dysenteriae
BACILLARY DYSENTERY
Shigella Flexneri
1-4 days
Shigella Boydii
(Shigellosis/ Bloody Flux)

water containing Stool Exam Dermatitis Hepatosplenomegaly Enlargeme nt of the abdomen. B loody stool D iarrhea A nemia W eakness Kato- katz Technique free swimming larval forms in snails (snail-main host)
Shigella Sonnei
SCHISTOSOMIASIS
Schistosoma japon-
2-6 wks
PraziquantelDOC Oxamniquine M etrifonate
icum
(Bilharziasis or snail fever)
Schistosoma man-
soni
Schistosoma hae-
7-19 days Vector-Borne Transmission thru Direct contact with URINE of RATS Culture: Blood Urine CSF Phase Microscopic Agglutination Confirmatory Serologic Test.
matobium
LEPTOSPIROSIS
Leptospira
Two Clinical Phase: 1. Leptospiremic Phase:
Penicillin Tetracycline Erythromycin (IF ALLERGIC to penicilAppearance of IgM Fatal Stage lin) Fever Myalgia N&V 2.Immune Phase/Toxic
(Weils Disease)
interrogans
167
168
SEXUALLY TRANSMITTED DISEASES
Communicable Disease Diagnostic test Treatment
Incubation Period
Classic Signs and Symptoms
Causative Agent
Mode of Transmission
HIV/AIDS ELISA Presumptive Test Flu like symptoms AIDS: (+) Opportunistic infections/ Rare Cancers: Kaposis Sarcoma Pneumocystis Carinii Pneumonia Candidiasis Herpes zoster
Dark Field Exam Immediate Diagnosis VDRL Detect nonspecific antibodies Fluorescent Treponemal Antobody Absorption Test Identifies antigens of T. Pallidum
3-6mo. Up to 8-10 years HIV: Asymptomatic Zidovudine HIV:
Antiretroviral Therapy (Retrovir)
Sexual contact Western Blot/ Immunofluorescence Assay Confirmatory AIDS: CD4 T cell Count
BT
Retrovirus/ Human T-cell Lymphotropic Virus 3 (HTLV3)
Contaminated nee-
dles and syringes
Transplacental
Breastfeeding
STAGES: PRIMARY: painless CHANCRE SORE SECONDARY Lymph node enlargement Flu-like symptom Alopecia Skin rash LATENT: ASYMPTOMATIC TERTIARY SYSTEMIC (FATAL)
(Bad Blood/POX)
SYPHILIS
10 days to 3 mo.
Sexual Contact
Treponema pallidum (Spirochete)
Congenital
Penicillin - DOC Probenicid Slows down the excretion of Penicillin.
169
170
Communicable Disease Diagnostic test Treatment
Incubation Period
Classic Signs and Symptoms
Causative Agent
Mode of Transmission
Gonorrhea Burning upon urination Pus discharges
2-10 days Culture MALES:
Penicillin Probenicid
(clap, drip, morning drop)
Sexual Contact FEMALES: Asymptomatic
Same with gonorrhea.
Neisseria Gonorrheae
Congenital (Vaginal Delivery)
CHLAMYDIA
2-3 wks
Almost the SAME with gonorrhea
Doxycycline
Chlamydia trachomatis
Sexual Contact
Congenital (Vaginal Delivery)
OUTBREAK DISEASES
2-7 days up to 10 days H igh fever H eadache B ody aches Overall feeling of discomfort D ry cough D OB 2 4 days Nasal/Throat Swab Molecular test to detect the virus. Blood Culture Fever, cough, sore throat, severe respiratory distress. Symptomatic management Direct & indirect Symptomatic management
(SARS)
Corona virus
SEVERE ACUTE RESPIRATORY
SYNDROME
Reverse Transcription Polymerase Chain reaction (RTPCR)
BIRD FLU Close contact with infected birds and person to person (H5N1)
Avian influenza virus
2-10 days
Droplet .
H5N1 avian virus
MENINGOCOC-
CEMIA
Neisseria meningitidis
Penicillin G-DOC Chloramphenicol (If resistant to Pen- G)

Ceftriaxone for children Rifampicin prophylaxis Fever, petechiae (FIRST SIGN of the disease) Hemorrhage or thrombosis under the skin
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C.D. SUPPLEMENTS !!!

Antibiotics contraindicated during Pregnancy. MCAT Metronidazole Chloramphenicol Aminoglycoside Tetracycline
Common Characteristic of Aminoglycoside Active agent against gram (-) Mechanism of resitance. Modifying enzymes Inhibit protein synthesis Nephrotoxic Ototoxic
Patients who are taking Metronidazole should avoid drinking alcohol. If you forget your TB drugs, youll die and might need a PRIEST. Pyrazinamide Rifampin Izoniazid (INH) Ethambutol Streptomycin (+) Elisa test is considered as presumptive test for AIDS. Western Blot and Immunofluorescence Assay are the confirmatory test for AIDS. Mnemonic: President Elisa continue to Immunize the World.
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Mononucleosis like syndrome is the initial manifestation of HIV infection. The incubation period for infants with AIDS is shorter than Adults. Mnemonic: Infants mas lower age, faster incubation period Kaposis Sarcoma and Pneumocystis Carinii Pneumonia are two of the most common diseases associated with AIDS. Mnemonic: KAPUSO with AIDS. Purplish skin lesions are the early signs of Kaposis Sarcoma. Triad Symptoms of Amoebiasis High Fever Bloody Mucoid Diarrhea Tenesmus Mnemonic: High Blood yung Tae Ascariasis is a type of roundworm infection. A common first clue of patients with ascariasis is vomiting of worms or passing worms in the stool. Mnemonic: Ascariasis think of Ascof for COUGH the big O The primary treatment for Ascariasis is Mebendazole. Mebendazole is contraindicated in pregnancy and in heavy infections. (provoke ectopic migrations) The use of Pyrantel or Piperazine temporarily paralyze the worms. This drug is also safe for Pregnant women. Mnemonic Para sa Pregnant na may bulate. (permitting peristalsis) Pyrantel produces red stool. Mnemonic. Pare Pula yung tae. Contact Precaution is usually not applied for patient with Ascariasis. [there is no direct person to person transmission]
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X- ray of the intestine with ascariasis will show dot sign. [adult ascaris look like strands of sphaghetti] Acute symmetrical Cranial Nerve Impairment (Ptosis, Diplopia, Dysarthria) is the cardinal sign of Botulism. IV or IM botulism antitoxin the treatment of choice for Botulism. [neutralize circulating toxins] Check Skin test before administering Botulism antitoxin Avoid Antibiotics and Aminoglycoside of patient develop Botulism. [Increase risk of Neuromuscular Blockade] The most common predisposing factor for Candidiasis is the use of Broad spectrum antibiotics. Cream colored patches on the mouth is the pathognomonic sign for oral thrush (candidiasis) Nystatin (Mycostatin) is administered by instructing the patient to SWISH the solution in the mouth for one minute and then SWALLOW. The most common agents of cellulitis are Streptococcus pyogenes and Staphylococcus Aureus. The classic sign of cellulitis are (SEE) Sudden tenderness, erythema, and edema. Penicillin is the drug of choice for strepcoccal cause cellulitis. The most common symptom of Lymphogranuloma venereum (causative agent: Chlamydia trachomatis) is unilateral enlarged inguinal lymph nodes
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The main symptoms of Cholera are (HARD) hypovolemic shock, Acidosis, Rice watery stool, dirrhea (profuse). Prophylactic use of oral tetracycline is given to protect the transmission of cholera among family members. Oral or Parenteral rehydration therapy is the most important modality of treatment for patient with cholera. Patient with cholera is placed on contact precautions. The most common causative agent for common cold is rhinovirus. The patient is usually afebrile and runny nose is its classic symptom. Differential Diagnostic test for conjunctivitis. Bacterial increase neutrophils. Viral increase Lymphocytes. Allergy Increase Eosinophils Dont irrigate the eyes of the child with conjunctivitis. [promotes the spread of infection] Cytomegalovirus (CMV) is usually dangerous to immunocompromised and pregnant mothers. The pathognomonic sign of Diphtheria is patchy grayish green membrane (pseudomembrane) over the pharynx and Bull neck Appearance. Thrombophlebitis is a common adverse effect of Erythromycin. Ventricular Fibrillation is a common cause of sudden death in diphtheria patients. Penicillin Benzathine (IZA)[one single IM dose] is a preferrable prophylactic treatment for high risk diphtheria clients. Oral Erythromycin can also be used. [decrease compliance] Diphtheria toxin usually attack vital organs which include [PAK] Peripheral Nervous System, Heart (ART), Kidney.
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Differentiation between two tests for Diphtheria. Schick Test Susceptibility for diphtheria. Moloneys Test determine hypersensitivity to Diphteria toxoid (masamang reaction sa vaccine) In Ebola Virus infection, the patient remains contagious after he died. Herpetic Whitlow, an herpes virus hominis (HVH), commonly affects health care workers. Postherpetic neuralgia, a common complication among elderly patients with herpes, is characterized by intractable pain. Doxycycline, Penicillin and Streptomycin are the common drug of choice for Leptospirosis. Dapsone antibiotic is the primary treatment for Leprosy. RDL drugs for Leprosy. *Rifampin, Dapsone, Lamprene Patient who have been infected with leptospirosis should not donate blood for at least 12 months after recovery. Plasmodium Falcifarum is the most common causative agent in the Philippines and the most serious type of malaria. The three stages of malaria infection are the cold stage, hot stage and wet stage.
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REFERENCE:
Benenson, Abram S. Control of Communicable Diseases in Man, 15 th edition. C & E Publishing Co., Sampaloc, mania, 1990. Community Health Nursing Services in the Philippines, 9th edition. Department of Health, Philippines, 2000. Expanded Program on Immunization Manual, revised edition, Department of Health, Philippines, 1995. Grimes, Diana E. Infectious Diseases. Mosby-Yearbook Inc., Missouri. 1991. Handbook of Infectious Diseases, Springhouse Corporation, Pennsylvania, USA, 2001. Southwick, Frederick S. Infectious Diseases in 30 Days. McGraw-Hill Companies, Inc. 2003. Allender, Judith A. Community and Home Health Nursing, Lippincott-Raven Publishers, 1998. Carroll, Patricia. Community Health Nursing: A Practical Guide. Thompson Learning, Inc., Canada, 2004. Community Health Nursing Services, 9th edition, Department of Health, Philippines, 2000. Community Health Nursing, NSNA Review Series, Delmar Publishers, USA, 1996. Expanded Program on Immunization Manual, revised edition, Department of Health, Philippines, 1995. Fontaine, Karen Lee. Healing Practices: Alternative Therapies for Nursing. Prentice-Hall, Inc., New Jersey, 2000. Palaganas-Castro, Erlinda. Health Care Practices in the Community, first edition. Guiani Prints House, Malabon, Philippines, 2003.
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Maternal Child Nursing
Obstetric and Gynecologic Nursing
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Family A group of two or more persons who lives together in the same household, perform certain interrelated social tasks and share an emotional bond
Types: 1. Nuclear Husband, wife, children Provide support and feel affection to family members 2. Cohabitation family Heterosexual couple living together But NOT married Short or long term 3. Extended or Multigenerational family 4. Nuclear family + other family members May experience financial problems since the familys income must be stretched to accommodate other people 5. Single Parent Family 50-60% of the population Financial issues are a concern Lack of family support for childcare 6 .Blended family Two separate families joined as one as a result of marriage Jealousy, friction between members may occur Children may adapt more to the new situation 7. Communal Family Group of people who have chosen to live together who are not necessarily related by blood or marriage. Related by social or religious values 8. Gay or Lesbian Family 9. Foster Family 10. Adoptive Family
Anatomy and Physiology Female Anatomy External Genitalia ( Collectively known as vulva or pudenda) There are seven openings in the female external genitalia
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Vagina Anus Bartholins Duct (2) Urethra Skenes Duct (2)
Mons pubis/ Mons veneris pad of adipose tissues, which lives over the symphysis pubis, which protects the surrounding delicate tissue from trauma. Labia majora longitudal folds of pigmented skin extending from the mons pubis to the perineum. Contains the Bartholins gland that secretes yellowish mucus that acts as a lubricant during sexual activity. Labia minora soft longitudal skin folds between the Labia majora. Glans clitoris erectile tissue located at the upper end of Labia minora; primary site of sexual arousal.
Vestibule a narrow space seen when labia minora are separated that also contains the vaginal introitus,
Clinical Significance: Serve as landmark when inserting Urinary catheter
Bartholins gland and urethral meatus.
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Urethral Meatus small opening bet, the clitoris and vaginal orifice for the purpose of urination. Vaginal orifice/introitus/opening external opening of the vagina that contains the hymen. Hymen a membranous tissue ringing the vaginal introitus Perineum tissue between the anus and vagina. Site of episiotomy
The external genitalias blood supply: Arteries: a. pudendal artery Vein: Pudendal vein
b. inferior rectus artery.
Sexual Maturity Begins at 10 years of age in Girls / 12 years of age in boys Thelarche Adrenarche Menarche Secondary sex characteristic of girls occurs in order: 1. growth spurt 2. increase in the traverse diameter of the pelvis 3. breast development (thelarche) (The Hallmark) 4. growth of pubic hair (adrenarche) 5. onset of menstruation (menarche 12.5 y/o ave.) 6. Ovulation occurs 1 2 years after menarche 7. growth of axillary hair (adrenarche) 8. vaginal secretion
Secondary sex characteristic of boys occurs in order: 1. increase in weight 2. growth of testes (The Hallmark) 3. growth of face, axillary, and pubic hair 4. voice changes 5. penile growth 6. increase in height 7. spermatogenesis
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Tanner Sexual Maturity Rating (SMR) Stage 1 pre adolescence, no pubic hair fine body hair only Stage 2 occurs between ages 11 to 12, hair is sparse, long, slightly pigmented and curly hair at the symphysis pubis Stage 3 occurs between ages 12 to 13, hair is darker and curly at the labia Stage 4 occurs between ages 13 to 14, hair has adult appearance but not so thick Stage 5 normal adult pubic hair II. Internal Organs Vagina Female organ for copulation Divided into 3 parts: upper, middle, lower pH 4-5 pH from infancy to prepubertal and menopause pH is 7.5 Normal bacterial flora cells bacilli due to Doderlein bacillus and the vaginal epithelial environment Cells contain glycogen Rugae - permits stretching without tearing Uterus Functions: 1. To receive the ova to fallopian tube place for implantation and nourishment during fetal growth furnish protection to a growing fetus. 2. Aids in labor and delivery through myometrial contraction Hollow muscular organ Shape
non pregnant - pear shaped pregnant ovoid Multiparous - globular
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Weight non pregnant 50 -60 g pregnant 1,000g
Pregnant/ Involution of uterus: 4th stage of labor - 1000g 2 weeks after delivery - 500g 3 weeks after delivery - 300 g 5-6 weeks after delivery - 50 60g Layers of the uterus Endometrium glandular layer Myometrium muscular layer Perimetrium outer most layer Ligaments of the uterus Upper portion - broad and round ligaments Middle portion cardinal pubocervical and uterosacral ligaments Lower portion pelvic muscle floor
MEG M-enstruation E ndometrium G landular layer
Cervix Narrow neck of the uterus It is lined with ciliated columnar epithelium and near the internal os, it is abruptly changed into stratified squamous epithelium This is the transition point where cancers in the cervix usually begin squamocolumnar junction Highly elastic due to its high fibrous and collagenous content Clinical significance: For Pap Smear Landmark to determine cervical dilatation and effacement
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Fallopian Tubes Otherwise known as the Oviducts or uterine tubes Parts of the Fallopian Tube (from inside to out)
In-Is-A-If
Interstitium uterine portion Isthmus narrow and straight, site of sterilization Ampulla central portion, site of fertilization Infundibulum or the fimbriae fingerlike projection to the ovaries, longest of which is the fimbriae ovarica, site of Ectopic pregnancy Mnemonics Functions I - isthmus Provide transport for the ovum S - sterilization A - ampulla Provide site for fertilization F - fertilization Nourishes the zygote
Ovaries 3 to 4 cm long, 2 to 3 cm wide and 1 to 3 cm thick Almond shape From pubertal dull white to pitted gray organ Held in place by infundibulopelvic ligaments No peritoneal covering easy spread of malignant cells Source of primary hormones estrogen and Progesterone 3 principal divisions a. A protective layer of surface epithelium b. The cortex filled with the ovarian and graafian follicle. c. The central medulla containing nerves, blood vessels, lymphatic tissue and some smooth muscle tissue.
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Bony Pelvis Support and protect the pelvic contents Made up of 4 bone Innominate bones Sacrum Coccyx Lined with fibro cartilages and held together by ligaments Muscular floor of the bony pelvis Provides stability and support for surrounding structures Levator ani muscle makes up most of the major portion of the floor and comprises by: Iliococcygeus PuboCoccygeous PuboRectalis PuboVaginalis Pelvic Types Caldwell-Moloy Classification 1. Gynecoid Normal female pelvis. Transversely rounded or blunt, most favorable for vaginal birth
2. Android Wedge shaped or angulated, usually seen in males, not a favorable for vaginal birth
3. Anthropoid Oval shape. Adequate narrow pubic arch
outlet, with a normal or moderately
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4. Platypelloid Flat with an oval inlet. Wide transverse diameter but short Anteroposterior diameter, making the inlet inadequate
Pelvic Measurements 1. False Pelvis situated above the pelvis brim and formed by the ileum. Function: Supports the growing uterus during pregnancy and direct the fetus into the true pelvis near end off gestation. 2. True Pelvis inferior half formed by the pubis in front, the ileum and the ischium on the sides and the sacrum and the coccyx behind, It is made of of 3 parts: a. Pelvic Inlet b. Pelvic cavity c. Pelvic Outlet A. Pelvic inlet/pelvic brim -entrance way to the true pelvis Measurements: 1.True Conjugate (Conjugate Vera) from upper margin of symphisis pubis sacral promontory. (11 cm.) 2.Diagonal conjugate: from lower border of symphisis pubis to sacral promontory. (12.5-13 cm.) 3.Obstetric conjugate: from inner surface of symphisis pubis, slightly below upper border, to sacral promontory. (estimated subtracting 1.5-2cm to diagonal conjugation) Cavity space bet, the inlet and the outlet. Approx 12 cm.diameter. Outlet - inferior portion of the pelvis, bounded on the back by the coccyx, on the sides by ischial tuberosities and in front by the inferior pubis. (diamond shaped)
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Measurements:
1. Anteroposterior 13 cm- from the lower border of the
symphysis pubis to the sacrococcygeal joint. 2. Oblique 12 cm- from obturator foramen to the sacrospinous ligament. 3. Transverse 11 cm- line bet. the two-ischial spines. 4. Intertuberous diameter: - 8 cm- outlet between the inner borders of the ischial tuberosities. Physiology of Menstruation Average menstrual cycle - 28 to 30 days Average blood loss - 30 to 80 mean of 50 cc Duration - 4 6 days Menarche - first menstruation Dysmenorrhea - painful menstruation Amenorrhea - absence of menses for 3 months Menometrorrhagiaprolonged uterine bleeding at irregular intervals Menorrhagia - prolonged menses at regular intervals (hypermenorrhea) Metrorrhagia - irregular but frequent menses Polymenorrhea - regular intervals of less than 21 days Menopause cessation of menstruation within 12 months Mean age 45- 55 Premature menopause may occur before age 45 Perimenopause or the Climacterium - gradual decline of ovarian functions May occur 8 10 years before menopause Ovulation day i. occurs 14 days before the start of the next cycle Remember The 1st day of mens is always the 1st day of cycle Phases of Menstruation by Uterine Cycle Ischemic phase Menstrual Phase Proliferative Phase Secretory Phase Refer to the chart
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Breast
Each breast is composed of glandular, fibrous and adipose tissues Contains 15 20 lobes clustered acini cells Coopers ligament support the breast Montgomerys tubercle - sebaceous glands Produce sebum Lubricates the areola and nipple
Male Reproductive System External Penis - the male organ of copulation Elongated cylindrical structure Body and shaft Composed of 2 corpora cavernosa central bulbous spongiosa Erection is secondary to parasympathetic stimulate Scrotum Pouch like structure hanging in front of the anus Composed of the skin and the Dartos muscle Highly pigmented and with scattered hairs Contains 2 compartments Less than 2C than the body temp Internal Gonads Testes - two solid ovoid organs 4-5 cm long and 2-3 wide, divided into lobes containing Seminiferous tubules -produce spermatozoa. Leydig cells - testosterone production. Ejaculatory ducts The canal formed by the union of the vas deferens and the excretory duct of the seminal vesicle, which enters the urethra at the prostate gland.
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Urethra The passageway for both urine and semen, extending from the bladder to the urethral meatus. Seminal vesicle Are two convoluted pouches that lie along the lower portion of the bladder and empty into the urethra by the way of ejaculatory ducts. Prostate Gland Located just below the urinary bladder Secretes alkaline and most of the seminal fluid. Bulbourethral glands or Cowpers Gland Adds alkaline fluid to the semen.
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Sperm A total of 64 days before they reach maturity. Head made up of acrosomes and nucleus, carries the haploid chromosome of the male, enters the ovum during fertilization Tail or flagellum is for motility Aspermia(absence of sperm) Oligospermia- if < 20 million sperm/ ml 90 seconds to reach cervix 5 minutes to reach the end of fallopian tube SEMEN: Is a thick whitish fluid ejaculated by the male during orgasm, contains spermatozoa and fructose-rich nutrients. During ejaculation, semen receives contributions of fluid from Prostate gland (60%) Seminal vesicle (30%) Epididymis ( 5%) Bulbourethral gland (5%) Average pH = 7.5 The average amount of semen released during ejaculation is 2.5 -5 ml. It can live with in the female genital tract for about 24 to 72 hours. (50-200 million/ml of ejaculation average of 400 million/ ejaculation ) Male/Female Homologues Male Penis Testes Prostate Gland Cowpers Gland Scrotum Clitoris Ovaries Skenes Gland Bartholins Gland Labia Majora
Female
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Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
SIGNIFICANCE 1 day of mens (start) Estrogen -lowestlevel

st
SIGNIFICANCE Menses Menses Menses Menses Menses
OVARIAN CYCLE
UTERINE CYCLE
DRY DAYS
Safe Safe Safe Unsafe Unsafe Unsafe Unsafe
Progesterone is at Lowest level but Estrogen is at Peak Level Unsafe Ovulation day Increase BBT + Spinnbarkeit + Mittelschmerz Sign Unsafe Unsafe Unsafe Unsafe Unsafe Safe Safe Safe Safe Safe EstrogenDrops Progesterone -drops PMS PMS
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Note: Menstruation may vary from one person to another. The ff presented Data is based on the average physiology of 28 a day cycle.
Stages of Sexual Response Excitement Phase Erotic stimuli cause increase sexual tension, lasts minutes to hours. Plateau Phase Nearing orgasm. Lasts 30 seconds 3 minutes Orgasm May last 2 10 sec Most affected are is pelvic area. Resolution V/S return to normal, genitals return to pre-excitement phase Refractory Period The only period present in males, wherein he cannot be restimulated for about 10-15 minutes
Health Promotion Activities 1. Breast Self examination (BSE) For early detection and prompt treatment of breast cancer under secondary level of prevention monthly examination Beginning at the age of 20 Premenopausal women: 7 days after menstruation Menopause women: same day each month Can be done in front of the mirror or in supine position Note for any changes from previous BSE
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2. Clinical breast examination - done by Healthcare professionals (MD, Nurse, Midwife) - every 3 years from ages 20-40 and yearly after the age of 40 and up Papanicolaou (Pap) Smear - sexually active women 18 years old above should have annual examination - High risk women (smoking, exposed to DES ( Diethylstilbestrol) in uteru, having multiple sexual partner and with history of HPV infection) should have yearly examination. - Low risk women will have every three years after two consecutive negative smear of 1 year apart
3.
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Interpretation of Pap Smear result: Class 1: Normal Class 2: Slightly suspicious of malignancy Class 3: Moderately suspicious of malignancy Class 4: Highly suspicious of malignancy Class 5: Carcinoma in Situ
4. Testicular Examination - performed same day each month starting adolescent period - procedure done after a warm shower when the scrotal skin is most relaxed - report for any changes from previous examination and presence of hard lumps or nodules, change in consistency or difference in size Infertility problems Infertility couple unable to achieve pregnancy for 1 year of engaging Unprotected coitus Types: 1. Primary Infertility ho history of previous conception 2. Secondary Infertility with history of previous conception Regardless of outcome but unable to conceive for present. 3. Idiopathic infertility unable to conceive to unknown cause. Male Infertility Factors Spermatogenesis disturbance Obstruction of duct e.g seminiferous tubules, vas deferens Thus preventing mobilization of sperm Qualitative and quantitative changes in the seminal fluid Preventing sperm motility Problem with ejaculation and deposition of spermatozoa
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Associated Risk Factors in Male Infertility Cryptorchidism Varicocele Exposure to diethylstilbestrol (DES) in utero History of mumps orchitis Epididymitis History of sexually transmitted infection e.g. gonorrhea Ascending urethral infections Penile anomalies (epispadia and hypospadia) Erectile dysfunction and premature ejaculations Female Infertility Factors Anovulation Tubal Transport problems Uterine Problems Cervical problems Vaginal problems Associated Risk Factors in Female Infertility Turners Syndrome Excessive exposure to radiation History of Pelvic Inflammatory Disease (PID) History of sexually transmitted infection e.g. Chlamydia and gonorrhea Polycystic ovaries Presence of uterine tumors (myomas) Endometriosis Cervical stenosis and polyps Too much acidity of the vagina Fertilization - Union of the sperm and ova Ovum from ovulation to fertilization Zygote from fertilization to implantation Blastocyst 32 cell stage zygote Embryo from implantation to end of 7 wks Fetus from 8 weeks until term Conceptus developing embryo or fetus and placental structures throughout pregnancy
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Signs of Implantation Hartmans Sign vaginal bleeding on implantation Process of Implantation Apposition Adhesion Invasion Decidua Endometrium of Pregnancy Decidua basalis Part under the embryo, communicates with maternal blood vessels Decidua capsularis Encapsulates the surface of the trophoblast Decidua Vera Remaining portion Trophoblast has finger like projections serves to attach the Blastocyst in the walls of the endometrium It also has a role in nutrition of the forming cells and maintenance of pregnancy 2 layers; Amnion - Funis Chorion secundines
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Decidua During Pregnancy Chorionic villi Trophoblastic layer of the Blastocyst forming miniature villi at 11 12th day with the following areas Central Core contains fetal capillaries Outer covering has 2 layers: Syncytiotrophoblast (hCG, HPL, E and P), Cytotrophoblast (protects from viral infection, disappears at 20 24th week)
Embryonic Germ Layers
Ectoderm
CNS (brain/spinal cord) peripheral nervous system skin, hair, nails sebaceous glands sense organs mucous membranes of the anus, mouth, nose tooth enamel mammary glands
Mesoderm
supporting structures (bones, muscle, tendons) dentin of teeth kidneys & ureters reproductive system heart, circulatory system lymph vessels
Endoderm
lining of pericardial, pleural, peritoneal cavities lining of GIT, Respiratory Tract, tonsils, parathyroid, thyroid, thymus lower GUT (bladder, urethra)
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Fetal Developmental Milestones End of 4th week - germ membranes appear by the 2nd week - fetal membranes appear by the 2nd week - nervous system appears by the 3rd week (dizziness is said to be the
earliest sign of pregnancy
because of the depletion of the mothers glucose which the embryo needs for the proper brain development.
- All systems in rudimentary form; heart chambers formed and heart is beating. - Embryo length =0.4 cm; weight = 0.4g. End of 8th week - Some distinct features in face; head large in proportion to rest of body; some movement -all vital organs are formed by the 8th week (organogenesis) - placenta develops - sex organs (ovaries/testes) are formed by the 8th week - external genitalia present but not discernible - meconeum is formed by 5th to 8th wk visible on ultrasound -Length =2.5 cm, weight =2 g End of 12th week Heart beat audible by Doppler Sex distinguishable Ossification in most bones Kidneys secrete urine; able to suck and swallow - Length=6-8cm, Weight =19g.
Hypoglycemia therefore is the cause of dizziness
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End of 16th week - Heart beat audible by fetoscope - Meconium in bowel - Scalp hair develops. - Lanugo (fine downy hair on the body) appears - buds of permanent teeth form -rapid skeletal development visible on x-ray -Sex differentiation is completed - Length= 11.5-13.5 cm., weight 55 to 120 gms -Vernix caseosa appear -Lanugo covers entire body -Quickening - movement usually felt by mother occurs; -Heart rate audible -Bones hardening. -Length=16-18.5 cm.,Weight300 g -Start of fetal viability, -passive antibody transfer from mother to fetus - Body well proportioned; skin red and wrinkled; - hearing established. - Length=23 cm., weight= 600 g. End of 28th week -Surfactant demonstrable in the AF -Testis descend into the scrotal sac -Infant viable, but immature if born at this time. -Body less wrinkled; -appearance of nails. -Length= 27cm., weight= 1100g -Delivery position is assumed -Subcutaneous fat begin to deposit; -L/S ratio in lungs now 1.2 : 1 . -Skin smooth and pink. -Length= 31 cm., Weight =1800-2100 g.
End of 20th week
End of 24th week
End of 32nd week
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End of 36th week -Amount of lanugo diminish -Sole of the foot with creases -Body usually plump; -L/S ratio usually 2:1; -Definite sleep/wake cycle. -Length= 35 cm., Weight= 2200-2900 g -Full-term pregnancy -Baby is active, with good muscle tone; -Strong suck reflex; -If male testes in scrotum; -Little lanugo. -Length >40 cm., weight= 3200g or more
End of 40th weeks
Pregnancy
- is a normal physiology process. It is not a disease nor an illness but a wellness state. The main responsibility of nurses is to help mothers maintain the state of wellness throughout the periods of pregnancy and parenthood. Divided into trimesters 1st missed period to 12 weeks 2nd 13th 24th weeks 3rd 25th weeks onwards Length of pregnancy 266 days 294 days 38 weeks 42 weeks (average of 40 weeks) 9 calendar months and 10 lunar months Start of the period of viability 24 week Abortus is an embryo or fetus expelled less than 20 weeks Gestation age refers to the number of completed weeks based on the last menstrual period. If the LMP however is unknown, calculations using some Rules would estimate the gestational age.
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Estimate the date of confinement: Naegelles Rule - +7 days (-) 3 months from the LMP Example: LMP: December 15, 2006 12 15 2006 - 3 +7 9 22 2007 Mc Donalds Rule Fundic height is equal to weeks of gestation from 20-32 weeks 20 cm = 20 weeks 32 cm = 32 weeks
Bartholomews Rule To determine age of gestation by dividing the abdomen from the symphysis pubis to the xyphoid process into area of fourths 3 months from umbilicus to symphysis pubis 4 months from umbilicus to symphysis pubis 5 months level of umbilicus 6 months from umbilicus to xyphoid 7 months from umbilicus to xyphoid 8 months from the umbilicus to xyphoid 9 months just the xyphoid process 10 months level of 8 months due to lightening
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Diagnosis of Pregnancy - is based on pregnancy related physical and hormonal changes and are classified as: 1. Presumptive - this is subjective and usually felt by the mother - not conclusive of pregnancy 2. Probable - objective - usually noted by the healthcare worker - but still non conclusive of pregnancy 3. Positive - these signs emanate from the fetus - noted by the healthcare provider - conclusive for pregnancy Common first complains Includes dizziness and nausea and vomiting. Dizziness is due to hypoglycemia secondary to rapid depletion of maternal glucose needed for nervous system development. Nausea and vomiting is due to increasing Human chorionic Gonadotropin level in mothers body. It will resolve by the end of 1st trimester. If nausea and vomiting persist clinical investigation is needed. Role of Nurses 1. Assist the pregnant woman to cope up with physical and hormonal changes. 2. Promotion of positive self concept and expression of feelings 3. Institute measures to relieve common complains.
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Diagnosis of Pregnancy
Presumptive Breast changes Probable Serum laboratory tests, (+) hCG Positive Sonographic evidence of fetal Nausea, vomiting
Chadwicks sign bluish

discoloration of vagina and
outline
Amenorrhea
cervix
Fetal heart audible
Goodells sign softening of

Frequent urination Fatigue the cervix
Hegars sign softening of the

lower uterine segment
Fetal movement felt by examiner
Uterine enlargement
Ladins sign at 6 weeks, the

uterus softens in the anterior midline along the utero-cervical junction Fetal skeletal Outline by x-ray
Quickening
McDonalds Sign - The uterus

Linea nigra becomes flexible at the uterocervical junction at Melasma or Cholasma 7-8 weeks
Von Fernwald Sign - An irregular softening

Striae gravidarum 4-5 weeks
of the fundus overthe site of implantation at
Piskaceks sign irregular

Softening in the cornual area, it may be confused with uterine myoma or abnormal uterine development
Ballottement fetus noted to

bounce or rise against the examining hand
Braxton-Hicks sign irregular

painless contractions of the uterus, false labor
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Pre Natal Check Up Missed period to 32 weeks - 1 each month 33 36 weeks every 2 weeks 36 weeks onwards weeks Iron Supplementation begins at 20 weeks to 2 months postpartum 100 200 mg OD for 210 days Antimalarial drugs Chloroquine 150 mg 2 tabs every 7 days in Malarial infested areas Goiter may add iodized salt in the diet Laboratory Examinations: Blood typing Rh Typing Complete Blood count Urinalysis Coombs Test in Rh negative mother at 28 wks AOG Maternal Serum Alpha Feto Protein (MSAFP) Use to detect Neural Tube Defect (NTD) May indicate the following: Gastroschisis Omphalocoele Esophageal and duodenal atresia Abdominal wall defects Low birth weight Turners syndrome Placental complications Anencephaly Down syndrome Group B Streptococcus test rectal and vaginal swab TORCH test Toxoplasmosis (Protozoan) MOT: uncooked meat, cats stool S/s: body malaise, posterior cervical lymphadenopathy Complications: Infant with CNS damage, hydrocephalus, microcephaly, intracecrebral calcification, retinal deformities DOC: Non pregnant sulfonamides ( Bilirubin level in newborn) Pregnant: Pyrimethamine (anti folic drug)
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Others Hepatitis A Hepatitis B screening
Syphilis Screen with VDRL in the first Prenatal check up, repeat at 36th wks in
Patients with multiple sexual partners Rubella German measles S/s: mild rash and mild systemic illness Fetal damage: deafness, mental and motor challenges, cardiac defects (PDA, pulmonary stenosis most common) , retarded intrauterine growth (SGA), thrombocytopenic purpura, dental and facial clefts eg cleft lip and cleft palate. Rubella titer: 1:8 indicates immunity, Less that 1:8 susceptibility Vaccination: No pregnancy for three months (live virus) Infant born with rubella: ISOLATE transmittable up to 8 months Cytomegalovirus MOT: droplet infection S/s: asymptomatic to pregnant woman Fetal damage: hydrocephalus, microcephaly, spasticity, eye damage (optic atrophy, chorioretinitis) deafness, chronic liver disease Infant maybe born with large petechiae (blueberry muffin lesion).
common in daycare center
Herpes simplex virus Fetal Damage: 1st Trimester: Congenital anomalies and spontaneous miscarriage nd rd 2 and 3 Trimester: premature birth and intrauterine growth retardation If lesion is present during labor: advise CS to prevent contact of neonatal infection Lesion is usually : PAINFUL perineal lesion DOC: Oral acyclovir (Zovirax)
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Drug test in high risk group Oral Glucose Challenge test at 24-28th weeks AOG to screen Gestational Diabetes Mellitus Non Stress Test Evaluates fetal well being by measuring fetal activity and heart rate Indicated in patients who have suspected fetal distress or placental insufficiency Results may be reactive Adequate baseline FHT of 110 160 bpm Accelerations in the baseline FHT of 15 bpm in 20 sec Absence of decelerations Non reactive If NR may proceed to CST Contraction Stress test Evaluates a fetus at risk for compromise, who is a fetus that has no oxygen reserve Positive test Late deceleration pattern is displayed Negative test 3 uterine contractions in a 10 minute period without late decelerations Early deceleration: Head compression Late deceleration: Uteroplacental insufficiency Variable deceleration: Fetal cord compression Amniocentesis Sterile needle aspiration of amniotic fluid (AF) Indicated for: Patients who are >35 y.o Mother is a carrier of X linked disease A parent has an autosomal dominant inheritance A parent has an autosomal recessive inheritance It is used to: Detect fetal abnormalities like Neural tube defects (NTD) Detect hemolytic disease Diagnose metabolic disorder Determine fetal age and maturity Detect presence of meconium or blood in the AF
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Done between 16- 18th weeks Cells are cultured in the lab Takes 24 to 35 days to complete the test Nursing Intervention Prepare the client for the examination Prepare the materials needed Spinal needle g 20 Antiseptic solution Amber or foiled covered test tube Empty the bladder - BQ Position the patient on her back May give RhoGam to patients who are Rh (-) after the procedure Note: Alphafeto Protein can be simultaneously done with amniocentesis. Normal Value of AFP (2.5 MoM) Value = Neural tube disorder Value = Down Syndrome or other Trisomy
Ultrasonography Used to: 1. Use to verify pregnancy 2. Determine the condition of the fetus 3. Rule out any possibility of ectopic pregnancy 4. Determine the cause of bleeding in the ges tation 5. Locate a misplaced Intrauterine device (IUD)
Transvaginal (TVS) Ultrasound used in the first trimesterTransabdonimal (TAS) ultrasound from second trimester onwards
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Nursing Intervention: Instruct patient to take 1 to 2 liters of fluid 1 hour before the procedure in TAS - BQ Instruct the patient not to void before the test IN TVS patients, void before the exam and minimize intake of fluid prior to the exam. Danger Signs of Pregnancy B Board like abdomen abruption placenta Blurring of vision PIH Bleeding preterm labor, abortion A Abdominal pain or epigastric pain aura of impending convulsions S Sudden gush of fluid PROM, Abortion E Edema pathologic, especially upon rising C - Chills/ fever infection Cerebral disturbances (headache preeclampsia) Nutrition in Pregnancy Total Weight Gain 1st Trim 1 kg 2nd trim 5 kg 3rd Trim 5 kg Total of 11- 12 k or 25 to 35 lbs Foods to avoid No Carbonated drinks Chocolates Caffeine Recommended Dietary Allowance (RDA) Pregnant Calorie Protein Carbohydrates Fats 2100 kcal/day 15 gms/day 150 gms/day 15-25gms/day
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Immunizations During Pregnancy Vaccine Tetanus Toxoid Safe in Pregnancy? Yes Given in 5 doses TT1 as early as possible TT2 4 wks later TT3 6 months later TT4 1 year after TT3 Hepatitis B Yes TT5 1 year after TT4 Given in patients with multiple sexual partners, IV drug use, or with HbsAG partner Nursing Intervention
Mineral Requirement in Pregnancy Calcium Iodine Sodium Zinc Magnesium Iron 1000mg/day 220 mcg/day Season food to taste 11 mg/day 350 mg/day 30 mg/day
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Influenza Yes Given during the influenza season MMR No Advice women not to get pregnant within 3 months from receiving the vaccine DPT Rabies Yes Yes As a post exposure prophylaxis
Physical Changes in Pregnancy Reproductive System A. External structures: enlarged due to increased vascularity B. Ovaries: 1. No ovulation during pregnancy 2. Corpus Luteum persists in early pregnancy until development Of placenta is complete. C. Fallopian tubes: elongate as uterus rises in pelvic and abdominal cavities. D. Vagina Increased vascularity (Chadwicks sign) Estrogen-induced leukorrhea Change in pH (less acidic) may favor overgrowth of yeast like organisms Connective tissue loosens in preparation for distention of labor and delivery. E. Cervix Softens and loosens in preparation for labor and delivery (Goodells sign). Mucous production increases and plugs (Operculum) is formed as bacterial barricade.
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F. Uterus Hypertrophy and hyperplasia of muscle cells. Development of fibroelastic tissue that increases ability to contract Shape changes from pearlike to ovoid Rises out of pelvic cavity by 16th week of pregnancy Increased vascularity and softening of isthmus (Hegars sign) Mild contractions (Braxton Hicks sign) beginning in the fourth month through end of pregnancy. G. Breasts
1. Increased vascularity; sensitivity and fullness 2. Nipples and areola darkens 3. Nipples becomes more erectile
4. Proliferation of ducts and alveolar tissue evidenced by increased breast size. 5. Production of colostrum by the second trimester Cardiovascular System Blood volume expands as much as 50% to meet demand of new tissue and increased needs of all systems. Progesterone relaxes smooth muscle, resulting in vasodilatation and accommodation of increased volume RBC volume increases as much as 30%; may be slight decline in hematocrit as pregnancy progresses because o this relative imbalance (physiologic anemia). Stroke volume and cardiac output increase. WBCs increased. Greater tendency to coagulation. Blood pressure may drop in early pregnancy; should not rise during last half of pregnancy. Heart rate increases; palpitation possible Blood flow to uterus and placenta is maximized by side-lying position. Varicosities may occur in vulva and rectum as well as lower extremities.
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Respiratory System Increased vascularity of mucous membranes of this system gives rise to symptoms of nasal and pharyngeal congestion and fullness in the ears. Shape of thorax shortens and widens to accommodate the growing fetus Slight increase in respiratory rate Dyspnea may occur at end of third trimester before engagement or lightening Increased respiratory volume by 40 to 50 %. Oxygen consumption increases by 15%. Renal System Kidney filtration rate increases as much as 50%. Glucose threshold drops; sodium threshold rises. Water retention increases as pregnancy progresses. Enlarging uterus causes pressure on bladder resulting in frequency of urination, especially during first trimester; later in pregnancy relaxed ureters are displaced laterally, increasing possibility of stasis and infection. Presence of protein (not an expected component of maternal urine) indicates possible renal disease or pregnancy-induced hypertension. Integumentary System Increased pigmentation of nipples and areolas. Possible appearance of chloasma (mask of pregnancy); darkening of the areas on forehead and cheekbones Appearance of linea nigra, darkened line bisecting abdomen from symphysis pubis to top of fundus. Striae (stretch marks): separation of underlying connective tissue in breasts, abdomen, thighs and buttocks; fade after delivery. Greater sweat and sebaceous gland activity
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Musculoskeletal System Alterations in posture and walking gait caused by change in center of gravity as pregnancy progresses. Increased joint mobility as a result of action of ovarian hormone (relaxin) on connective tissue. Possible headache Occasional cramps in calf may occur with hypocalcemia. Neurologic System Few changes with a typical pregnancy Pressure on sciatic nerve may occur later in pregnancy due to fetal position. Gastrointestinal System Bleeding gums and hypersalivation may occur. Tooth loss due to demineralization should not occur. Nausea and vomiting in 1st trimester due to rising levels of HCG. Appetites usually improves. Cravings/desires for strange food combinations may occur. Progesterone-induced relaxation of muscle tones leads to slow movement of food through GI tract; may result in heat burn Constipation may occur as water is reabsorbed in large intestine. Emptying time for gallbladder may be prolonged; increased incidence of gallstones. Endocrine System Pituitary: FSH and LH greatly decreased; oxytocin secreted during labor and after delivery; prolactin responsible for initiation and continuation of lactation. Progesterone secreted by corpus luteum until formation of placenta.
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Principal source of estrogen is placenta synthesized from fetal precursor. HPL produced by placenta; similar to growth hormone, it prepares breasts for lactation: also affects insulin/ glucose metabolism; may overstress maternal pancreas Ovaries secrete Relaxin during pregnancy Slight increase in thyroid activity and basal metabolic rate (BMR). Pancreas may be stressed due to complete interaction of glucose metabolism, HPL and cortisol, resulting in diminished effectiveness of insulin and demand for
increased product
Common Complaints 1. Nausea and vomiting associated with high levels of HCG H. mole, nausea and vomiting more pronounced (hyperemesis) dehydration, electrolyte imbalance and starvation require hospitalization advice small frequent feedings 2. Backache squat when reaching down back support with pillows avoid high heeled shoes may give analgesia, heat and rest 3. Varicosities exaggerated by prolonged standing, pregnancy and advancing age noted by cosmetic blemishes on lower extremities, mild discomfort at the end of the day treatment with elevated legs and elastic stockings 4. Hemorrhoids due to increased pressure in the rectal veins relieved by stool softeners, warm soaks, topical anesthetics
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5. Heartburn (Pyrosis) caused by reflux of gastric contents into lower esophagus upward displacement of stomach by uterus relaxation of lower esophageal sphincter 6. Pica bizarre craving for strange food Ingestion of non-nutritive substance Pregnant mother is prone to anemia 7. Fatigue early in pregnancy relieved during the fourth month 8. Headache due to ocular strain treatment is symptomatic majority has no cause Other concerns: 1. Exercise no need to limit exercise aerobic exercise brisk walking is the best exercise 2. Employment with risk of preterm delivery for jobs that require prolonged standing severe physical strain should be avoided 3. Travel no harmful effect on pregnancy airline travel allowed 4. Bathing caution in taking tub bath, might slip
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5. Clothing practical and non constricting well supporting brassiers 6. Bowel Habits constipation is common greater frequency of hemorrhoids prevented by sufficient fluids and daily exercise 7. Coitus no harm before the last 4 weeks of pregnancy 8. Smoking adverse effects on fetus: decrease birth weight, premature birth, fetal limb deficiencies extensive placental calcification is doubled
9. Alcohol > pregnant should abstain 10. Caffeine > potentiates mutagenic effects of radiation and some chemicals 11. Illicit Drugs > opium derivatives, barbiturates, amphetamines are harmful to fetus fetal distress and low birth weight infants
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Psychological Task of the Mother First trimester I am Pregnant
Accepting pregnancy
Increasingly introspective and passive Mood swings Denial sign of maladaptation 1st Tri Ambivalent wanting or not wanting to be pregnant Mother is narcissistic or self centered having the baby is part of her Mother needs accurate diagnosis of pregnancy
Second trimester Im going to have a baby
Accepting the baby
Mother demonstrates growing realization of baby as a separate entity and needing person. Fantasizes about unborn child. Still introspective but makes plans for her and her childs future Third trimester Im going to be a parent Preparing for parenthood Nesting activity appears as due date approaches Desire to be finished with pregnancy. Anxiety over safe passage for self and baby through labor and delivery. Preparation of siblings varies according to their age and experience. Psychological Task of the Father First Trimester Excitement predominates his behavior Confused and left out
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May experience Couvade syndrome similar to that of Nausea and vomiting felt by the mother Second Trimester Anxiety is lessen if effective communication is being done Changed appearance of the partner is a reality check Third Trimester Rewarding time Man view pregnancy if his wife as a sign of Virility Methods of Childbirth Read Method The so-called natural childbirth method. Underlying concept: knowledge diminishes the fear that is key to pain. Classes include information as well as practice in relaxation and abdominal breathing techniques for labor. Lamaze Method Psychoprophylactic method based on utilization of Pavlovian conditioned respond theory. Classes teach replacement of usual response to pain with new, learned responses (breathing, effleurage, relaxation) in order to block recognition of pain and promote positive sense of control in labor Bradley Method Husband-coached childbirth. A modification of the Read method emphasizing working in harmony with the body. Leboyer Method Manipulation of environment to aid in birthing process. Birthing place is darkened and pleasantly warm with soft music playing while on labor. Infant is handled gently and cutting of cord is done late and given warm water bath immediately.
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Labor Preparation Pain Relief Non Pharmacologic Relaxation Technique Positioning Imagery Touch Therapy Music Therapy Breathing Techniques Effleurage light fingertip massage Hot & Cold application Transcutaneus Electrical Nerve Stimulation (TENS) > Stimulation of large diameter nerve fibers via electrical current during contractions Acupressure Yoga Pharmacologic A. Opoids > They give significant pain relief > Common agents: Meperidine (Demerol), Butorphanol (Stadol), Nalbuphine (Nubain) B. Regional Anesthesia > Block specific nerve pathways > Relieves pain by blocking nerve conduction > Lumbar Epidural anesthesia injection of an agent into the epidural space eliminates pain perception Can cause hypotension can slow down the labor process C. Spinal anesthesia > agent injected at the cerebrospinal fluid (CSF) at the level of L3-L4 > Hypotension can occur BQ > spinal headache > increase incidence of urinary retention D. Local Anesthesia > used only during actual birth of the fetus > complication may include allergic reaction
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Labor Process (5Ps of Labor) Passenger Passageway Power Placenta Psyche 1. Passenger The size, presentation and position of the fetus A. Fetal head Usually the largest part of the baby; it has found effect on the birthing process Bones of the skull are joined by membranous sutures, which allow for overlapping or molding of cranial bones during birth process. Anterior and posterior fontanels are the points of intersection for the sutures and are important landmarks Fontanels are used as landmarks for internal examinations during labor to determine position of fetus B. Fetal shoulders: may be manipulated during delivery to allow passage of one shoulder at a time C. Presentation: that part of the fetus which enter the pelvis in the birth process Types of Presentation are: 1. Cephalic: head is presenting part; usually vertex (occiput) which is the most favorable for birth. Head is flexed with chin on chest. Types of Cephalic a. Vertex presentation When the head is well flexed, the subocciptobregmatic diameter and the biparietal diameter present. When the head is not flexed but erect, the presenting diameters are occipitofrontal, and the biparietal. (95%) b. Brow presentation When the head is partially extended, the mento vertical diameter, 13.5 cm, and the bitemporal diameter, 8.2 cm. If this presentation persist, vaginal delivery is extremely unlikely
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c. Face Presentation When the head is completely extended, will distend the vaginal orifice the presenting diameters are the SOB 9.5 cm, BT 8.2 cm, the SMV diameter 11.5 cm, 2. Breech: buttocks or lower extremities present first.
Types are:
a. Frank: thighs flexed, legs extended on anterior body surface, buttocks presenting b. Full or complete: thighs and legs flexed, buttocks and feet (baby is squatting position) c. Footling: one or both feet are presenting
3. Shoulder: presenting part is the scapula and baby is in horizontal or transverse position. Cesarean birth indicated. D. Position: relationship of reference point on fetal presenting part to maternal bony pelvis. Maternal bony pelvis divided into four quadrants
(right and left anterior; right and left posterior). Most common positions are:
1. LOA (left occiput anterior): fetal occiput is on maternal left side and toward front, face is down. This is a favourable delivery position 2. ROA (right occiput anterior): fetal occiput on maternal right side toward front, face is down. This is a favourable delivery position 3. LOP (left occiput posterior): fetal occiput is on the maternal side and toward back, face is up. Mother experiences much back discomfort during labor; labor may be slowed; rotation usually occurs before labor to anterior position or health care provider may rotate at the time of delivery. 4. ROP (right occiput posterior): fetal occiput is on Maternal side and toward back, face is up. Presents problems similar to LOP
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Assessment of fetal position can be made by: Leopolds maneuvers: external palpitation (4 steps) of maternal abdomen to determine fetal contours or outlines. Maternal obesity; excess amniotic fluid, or uterine tumors may make palpitation less accurate. Vaginal examination: location of sutures and fontanels and determination of relationship to maternal bony pelvis. 6 Purpose: Determine cervical dilatation Determine cervical effacement Determine the status of bag of water
Determine the presenting part Determine fetal position Determine the station
Rectal examination: now virtually completely replaced by vaginal examination Auscultation of fetal heart tones and determination of quadrant of maternal abdomen where best heard.
(Correlate with Leopold maneuvers)
LEOPOLDS MANEUVER done to a. estimate fetal size, b. locate parts, and c. determine - presentation, - position, - engagement Presentation of client: place in dorsal recumbent position to relax the abdominal muscle palpate with warm hands because cold hands cause muscle contraction use palm not finger (will tickle the patient)
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The Four Maneuvers 1st Maneuver: Facing the head part, palpate for fetal part found In the fundus ( a hard, smooth balotable in the fundus 2nd Maneuver: Palpate sides of the uterus to determine location of fetal back 3rd Maneuver: Grasp lower portion of the abd. just above symphysis pubis to determine the degree of engagement with the use of Pawlicks Grip 4th Maneuver: Facing the feet part. Cross fingers downward on both sides of the uterus above the inguinal ligaments above the inguinal ligaments to determine attitude. II. Passageway Shape and measurement of maternal pelvis and distensibility of birth canal A. Engagement: fetal presenting part enters true pelvis (inlet). May occur two weeks before labor in Primipara; usually occurs at beginning of labor for Multipara. B. Station: measurement of how far the presenting part has Descended into the pelvis. Reference is ischial spines, palpated through lateral vaginal walls. When presenting part is :
means breech)
1. at ischial spines, station is 0 2. above ischial spines, station is negative number 3. below ischial spines, station is positive number 4.High or floating terms used to denote unengaged
presenting part. C. Soft tissue (cervix, vagina): stretches and dilates under the force of contractions to accommodate the passage of the fetus. III. Powers Forces of labor, acting in concert, to expel fetus and placenta. Major forces are: A. Uterine Contractions (involuntary) Frequency: timed from the beginning of one contraction to the beginning of the next
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Regularity: discernable pattern; better established as pregnancy progresses Intensity: strength of contraction; May be determined by the depressability of the uterus during a contraction. Describe as mild, moderate or strong. Duration: length of contraction. Contraction lasting More than 90 seconds without a subsequent period of uterine relaxation may have severe I implications for the fetus and should be reported. B. Voluntary bearing down efforts After full dilatation of the cervix, the mother can use her abdominal muscles to help expel fetus. These efforts are similar to those for defecation, but the mother is pushing out the fetus from the birth canal Contraction of levator ani muscles IV. Placenta As the placenta usually forms in the fundus of the uterus, it seldom interferes with the progress of labor. A low-lying, marginal, partial or complete placenta previa may require medical intervention to complete the birth process V. Psychologic response A woman who is relax, aware and participating in the birth process usually has a shorter, less intense labor. A woman who is fearful has
high levels of adrenaline
Which slows uterine contractions.
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THEORIES OF LABOR (Onset of Labor) 1. Prostaglandin Theory initiation of Labor is said to result from the release of arachidonic acids produces by steroid action on lipid precursors. Arachidonic acid is said to increase prostaglandin synthesis which is turn causes uterine contractions. 2. Oxytocin Theory release of oxytocin from the posterior pituitary glands causes contraction of the smooth muscles. E. g. Uterine muscles will necessarily contract and empty. 3. Uterine Stretch Theory uterus is compared to a balloon of which if the point of elasticity is met it will burst thus labor process occur. 4. Placental Degeneration Theory because of decreased blood supply and functional capacity, the uterus starts to contract. 5. Progesterone deprivation theory decreased amount of progesterone initiates uterine motility. Premonitoring Assessment Physiologic changes preceding labor: Lightening (engagement): - occurs up to two weeks before labor in Primipara; - at beginning of labor for Multipara Braxton Hicks contractions: may become more noticeable; may play a part in ripening of cervix Easier respirations from decreased pressure on diaphragm Frequent urination, from increased pressure on bladder Restlessness/ poor sleeping patterns, nesting behaviors
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Labor Process
True Labor Contractions are regular Increased intensity Pain begins lower back radiates to abdomen Pain intensified by walking Cervical effacement & dilatation * major sign of true labor. False Labor Irregular contractions No increase in intensity Pain confined to abdomen Pain relived by walking No cervical changes
THE ANTEPARTAL PERIOD ASSESSMENT Classification of Pregnancy: I. Gravida - number of time pregnant, regardless of duration, including the present pregnancy. Primagravida - pregnant for the first time Multigravida - pregnant for second or subsequent time Nulligravida - a woman whos never been pregnant Grandmultigravida woman been pregnant for six times and above - BQ II. Para - number of pregnancies that lasted more than 20 weeks, Regardless of outcome Nullipara a woman who has not given birth to a baby beyond 20 weeks gestation Primipara a woman who has given birth to one baby more than 20 weeks gestation. Multipara woman who has had two or more births at more than 20 weeks gestation twins or triplets is count as 1 para. Grandmultipara a woman having given birth beyond 20 weeks For sixth times and above Parturient woman in labor Puerpera - woman who has just given birth OB SCORING T = Number of Term infants P = Number of Preterm Infants A = Number of Abortions
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Stages of Labor First Stage - from the onset of true labor to full cervical dilatation
Phase Latent Phase (0-3 cm) Characteristics Beginning to 3 cm Contractions mild & short, 20-40 sec 6 hr in Nullipara 4-5 hrs in multi Active Phase (4-7 cm) 4 cm 7 cm Stronger contractions 40-60 sec q3-5 min 3hrs in nulli, 2 hrs in Multi Transitional Phase (8-10 cm) 9 cm to full cervical dilatation Very strong contractions 60-90 sec Tired, loss of sense of control Inform the progress of labor Restless, support her with breathing techniques Encourage Nursing Care Encourage walking Chest breathing Encourage to void q2-3 hours, full bladder inhibit contractions Support Person - Doula Medications should be readied Assess Vital Signs Abdominal Breathing Oral care
Phases of uterine Contractions Increment ( also known as crescendo) Acme ( the peak) Decrement ( also known as decrescendo) Uterine Contractions Duration start to end of one uterine contraction Intensity mild, moderate or severe Frequency from the start to the uterine contraction to the beginning of the next contraction Nursing Interventions:
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Administer perineal prep/enema if ordered/appropriate Assess V.S., B.P., FHR, contractions, bloody show, cervical changes, descent of fetus as scheduled Maintained bed rest if indicated or required Reinforced/teach breathing technique as needed Support laboring woman/couple based on their needs Have client attempt to void every 1-2 hrs Apply external fetal monitoring if indicated or ordered
Second Stage of Labor
From full cervical dilatation to birth of the fetus Cardinal Movements of Labor (EDFIEREE) E ngagement D escent F lexion I nternal rotation E xtension R estitution E xternal rotation E xpulsion Nursing Intervention: Prepare the patient for delivery Bring a multiparous patient to the DR at 7-8 cm Perineal preparation using 7 and the inverted 7 technique Assist the patient in breathing techniques Assist the physician in episiotomy and episiorrhapy Episiotomy and repair*
Characteristic Repair Healing Pain Results Blood loss Dyspareunia 4 degree laceration
th
Midline Easy Better Minimal Excellent Less Rare Common

Mediolateral More difficult Longer healing process Common Occasionally faulty More Sometimes Rare
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Third Stage of labor
Birth of the infant to placental expulsion
Phases: A. Placental Separation Signs of Placental Separation 1. Uterus becomes firm and globular Calkins sign 2. Uterus rises in the abdomen 3. Sudden gush of blood 4. Lengthening of the cord 5. Appearance of the placenta at the vaginal opening Types of Placental separation A. Schultz Separation of the placenta from the central to the periphery Silent/ Shiny Minimal Blood B. Duncan Peripheral separation to the central Dirty Bloody B. Placental Expulsion Delivery of placenta by bearing down effort Delivery of placenta by Brant Andrews maneuver > downward, sideways gentle traction of the cord Delivery by Credes maneuver > gentle pressure on the uterine fundus Nursing Interventions Palpate fundus immediately after delivery of placenta; massage gently if not firm Palpate fundus at least every 15 minutes for first 1-2 hours Observe lochia for color and amount Inspect perineum Assist with maternal hygiene as needed. a. Clean gown b. Warm blanket c. Clean perineal pads. Offer fluids as indicated
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Promote beginning relationship with baby and parents through touch and privacy Administer medications as ordered/needed methergine (Pitocin added to IV if present)
Fourth Stage of Labor
- immediate postpartum Characteristics of Lochia
Type Rubra
Color Red
Day 1-3 days
Composition Blood, WBCs Decidua & some microorganisms
Serosa
Pink
3-10 days
Blood, mucus tissues & WBCs
Alba White 10-14 days Mucus *Advice client to take note of any changes in the lochia
and report to her care provider
Nursing Intervention Palpate fundus every 15 minutes for first 1-2 hours; massage gently if not firm Check mothers blood pressure, pulse, resp. every 15 min. for first 1-2 hrs. or until stable Check lochia for color and amt. Every 15 min. for the first 1-2 hrs. Inspect perineum every 15 min. for first 1-2 hrs. Apply ice to perineum if swollen or if episiotomy Encourage mother to void, particularly if fundus not firm or displaced
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Post Partum Psychological Responses According to Reva Rubin Phase Taking IN Characteristics Dependent/ Reflection Phase 2-3 days Client is passive Dependent to Independent Phase Start to make decisions Active 4-5 days Independent Phase Redefining the new role Nursing Care Encourage to tell story about childbirth experience Encourage rest Positive reinforcement Emphasize on the care of the newborn Initiate Family planning method Encourage parental love and positive family relationships
Taking HOLD
Letting GO
Post Partum Assessment A. Breast Colostrums can be present Low grade temperature on 2-5th day can be present BUT should NOT be more than 24 hours is normal Mastitis > Inflammation of the glands or milk ducts > Results from pathogens coming from the neonates nose or pharynx > Usually seen 1 to 2 weeks after birth B. Uterus Determine size, degree of firmness and rate of descent Fundal Assessment Q15 min - 1st hour Q30 min 2-3 hours Q4hr - 1st 24 hour Q8hr - until discharge C. Bowel Bowel movement should return by 2-3 days postpartum Encourage patient to drink lots of fluids Do not use suppositories especially in 3rd and 4th degree laceration D. Bladder Assess the bladder if distended Catheterize if needed
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E. Lochia Assess the lochial flow Put patient in Sims position Remove the patients perineal pad and evaluate character amount and color of the discharge F. Episiotomy Determine the degree of laceration Note for any hematoma formation or erythema G. Homans Sign Assess for any (+) Homans sign which is calf pain on dorsiflexion of the foot May indicate DVT Assess only once Do not massage the calf muscles Advice to wear supportive panty hose H. Emotions Note for any overwhelming sadness for no discernible reason Patient may exhibit emotional lability, headache, crying for no apparent reason, insomnia, fatigue, restlessness and anger which is a component of Postpartum blues Post Partum depression > Feeling of despair and depression last longer than a few weeks > Feelings are so intense it interferes with the womans daily activity > Advice plenty of rest > Spend time with the partner > allow ventilation of feeling > provide emotional support > seek psychological counseling
233 FAMILY PLANNING

Ensures planned and wanted pregnancies thus assuring the love and care of the family Three Methods Natural family Planning or Fertility awareness method Rely on periods of temporary abstinence and requires an understanding of the changes that occur in a womans Ovulatory cycle A. Calendar Method Requires a couple to abstain from coitus on the days of a menstrual cycle when the woman is most apt to conceive 3- 4 days before and after ovulation In menstrual cycle more than 30 days monitor the menstrual cycle for 6 months and subtract 18 shortest = first fertile day and 11 longest = last fertile day B. Basal Body temperature A womans basal body temperature falls about one degree on ovulation because of progesterone C. Symtothermal /Cervical Mucus Use the changes in cervical mucus that occur naturally with ovulation Just before ovulation (peak day) > Mucus becomes thin, watery, transparent, feels slippery, stretches at least one inch before the strand breaks Artificial Method A. Oral Contraceptive Pills Use of Combination Oral Contraceptives (COCs) or Progestin only pills
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Side effects include > Nausea > Monilial vaginal infection > Weight gain > Headache > Breast tenderness > Break through bleaching > Mild hypertension and depression Contraindication > History of CVA > Woman who smoke > 35 y/o > obese > High serum level of liver enzymes > High blood pressure > Deep vein Thrombosis Discontinue with the presence of: A Abdominal pain C chest pain H - headache E eye problems S Severe leg cramps B. Intrauterine Devices Small plastic object inserted into the uterus through the vagina where it remains in place Insertion should be done on Day 7 -9 of the menstrual cycle Contraindicated in patients with Wilsons disease (inability to metabolize copper), clients with active, recent or recurrent PID Increase the risk for Ectopic pregnancy Health teaching includes checking of the string every month, advice the client to submit for pap smear every year and early treatment of vaginal and cervical Infection
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C. Barrier method Includes condoms, diaphragm, female condom and cervical cap Inexpensive and doesnt require a visit to the health worker It should be inserted 15 min to 1h prior to coitus thus it may embarrass the client and it is mess health teaching should include hygiene and checking of holes in the condom before use Surgical Method A. Vasectomy Vas deferens is cut and tied Out patient procedure and 99% effective Testes continue to produce sperm but cant pass the vas deferens advice client that additional form of contraception should be used until two negative sperm count report have been obtained B. Tubal Ligation it is a mini laparotomy incision performed after menses and before ovulation or after a delivery or an abortion, 99.6% effective tubes are ligated cut and severed it should be viewed as irreversible though reversal is successful in around 70% of cases but it is a difficult process and may cause Ectopic pregnancy
High Risk Pregnancy

1. Abruptio Placenta Premature separation of the placenta from its implantation Occur after 20th weeks AOG Can be cause by trauma, multiparity, short umbilical cord, smoking, malnutrition and medical complications like PIH
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Assessment findings Painful vaginal bleeding Tender, board-like uterus (especially if concealed hemorrhage, then no vaginal bleeding) Fetal bradycardia and late decelerations absent FHT in complete abruption Additional signs of shock Nursing Care Ensure bed rest Check maternal/fetal vital signs frequently Prepare for IV infusions of fluids/blood as indicated Monitor urinary output Anticipate coagulation problem (DIC) Ready the patient for possible cesarean birth if term pregnancy Provide support to parents as outlook for fetus is poor 2. Placenta Previa Low implantation of the placenta so that it overlays some or all of the internal cervical os Cause uncertain, but uterine factors (poor vascularity, fibroid tumors, multiple pregnancies) may be involved Amount of cervical os involved classifies placenta previa as : Low Lying Placenta previa Marginal placenta previa Partial placenta previa Total placenta previa Treatment is focused on assessing, controlling and restoring blood loss and the goal of delivering a term neonate Assessment findings Painless bright red vaginal bleeding after seventh month of pregnancy is cardinal indicator. Bleeding may be intermittent, in gushes or continuous. Uterus remains soft FHR usually stable unless maternal shock present No vaginal exam by nurse, may result in severe bleed, if done by physician, double set-up used
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Diagnostic Exam Based on clinical manifestation By ultrasound Nursing Care Ensure complete bed rest. Assessing vital signs, amount of bleeding Maintain sterile conditions for any invasive procedures (including vaginal examination) Make provisions for emergency cesarean birth (double set-up procedure) Continue to monitor maternal/fetal vital signs Measure blood loss carefully Assess uterine tone regularly Abruptio Placenta History Bleeding Pain Vaginal Exam Management Associated with PIH Single attack of bleeding Pain and tenderness present Can be performed Delivery Contraindicated Expectant Placenta Previa Not associated with any medical condition Repeated history of bleeding during gestation Painless bleeding
3. Cardiac Disease in Pregnancy Complicates about 1% of pregnancies Underlying cause is congenital defects of the heart Classification of the Patient Class 1: no limitation of activity Class 2: slight limitation of activity Class 3: considerable limitation of activity Class 4: symptoms present even at rest
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Treatment focuses on the health and safety of the mother and the fetus Medications previously being taken are continued during pregnancy, maintenance maybe increased to aid in compensating increasing blood volume Assessment Findings Evidenced of cardiac decompensation especially when blood volume peaks (weeks 28-32). Cough and Dyspnea Edema Heart Murmurs Palpitations Rales Nursing Intervention Duly classify the patient accordingly Promote frequent rest periods and adequate sleep, decreased stress. Teach client to recognize and report signs of infection, importance of prophylactic antibiotics Compare vital signs to baseline and normal value expected during pregnancy. Instruct in diet to limit weight gain to 15 lbs. Low sodium intake. Explain Rationale for anticoagulant therapy (heparin use in pregnancy) if ordered Teach danger signals for individual client 4. Ectopic Pregnancy Implantation of the fertilized ovum outside the endometrial cavity Usually due to previous history of Pelvic Inflammatory Disease (PID) which prevents or slow the passage of the fertilized ovum in the fallopian tube Triad of Abdominal pain Vaginal bleeding Amenorrhea
239
Assessment Findings History of missed periods and symptoms of early pregnancy Abdominal pain, may be localized on one side Rigid, tender abdomen; sometimes abnormal pelvic mass Bleeding: if severe may lead to shock Low hemoglobin and hematocrit, rising white cell count HCG titers usually lower than in intrauterine Diagnosis and Management Culdocentesis aspiration of non clotting blood in the cul de sac of Douglas Managed surgically with exploratory laparotomy followed by salphingoophorectomy or salpingostomy Nursing Care Assess for hypovolemic shock Check for the amount, character and odor of vaginal bleeding Assess vital signs Administer blood transfusion as ordered Prepare client for surgery Institute measures to control/ treat shock if hemorrhage severe; continue to monitor postoperatively Allow client to express feelings about loss of pregnancy and concerns about future pregnancies 5. Gestational Trophoblastic Disease (H-mole) Rapid deterioration of Trophoblastic villi cells and the embryo fails to develop past the initial stages Presence of grapelike vesicles per vagina, with soft abdomen and absent fetal parts on palpation Assessment findings Size of the uterus disproportionate to the length of pregnancy High levels of HCG with excessive nausea and vomiting Dark red to brownish vaginal bleeding after 12th week
240
Anemia often accompanies bleeding Symptoms of preeclampsia before usual time of onset No fetal heart sounds or palpitation of fetal parts Ultrasounds shows no fetal skeleton
Management suction curettage and can be followed by chemotherapy Nursing Care Provide Pre- and Postoperative care for evacuation of uterus (usually suction curettage). Assess patients vital signs including input and output Teach contraceptive use so that pregnancy is delayed for at least one year Teach client need for follow-up lab work to detect rising HCG levels indicative of choriocarcinoma. Monitor HCG level weekly for 3 months, bimonthly for the next 3 months and monthly thereafter Provide emotional support for loss of pregnancy Teach about risk for future pregnancies Stress the need for regular check up to Determine any malignant transformation 6. Abortion Loss of pregnancy before viability of fetus; may be spontaneous, therapeutic or elective (clients may use
term miscarriage for spontaneous abortion.)
Types: a. Threatened abortion cervix closed some bleeding and contractions fetus is not expelled b. Inevitable cervix open heavier bleeding and stronger contractions Loss of fetus usually not avoidable
241
c. Incomplete expulsion of fetus is incomplete membranes or placenta retained d. Complete: all products of conception expelled e. Missed: fetus dies in uterus, but is not expelled f. Habitual three pregnancy in a row culminating in spontaneous abortion may indicate need for investigation into underlying causes Assessment findings: Vaginal bleeding (observing carefully for accurate determination of amount, saving all perineal pads). Contractions; pelvic cramping, backache Lowered hemoglobin if blood loss significant Passage of fetus/tissue Nursing interventions: Save all tissue passed (Histopathology examination). Keep client at rest and teach reason for bed rest. Increased fluids PO or IV as ordered. Prepare client for surgical intervention (D & C or suction evacuation) if needed Provide discharge teaching about limited activities and coitus after bleeding ceases. Observe reaction of mothers and others, provide emotional support and give opportunity to express feelings of grief and loss. Administer Rhogam if mother is Rh negative. 7. HIV infection Sexually transmitted disease Caused by a retrovirus that targets the helper T cells containing CD4 antigen Manifestations include bacteremia, fever of unknown origin, weight loss, night sweats, vaginal yeast infection that are hard to treat
242
Laboratory examinations include ELISA and Western blot to confirm the disease, and a CD4 count less than 200 cells/l, and the presence of one or more of any opportunistic disease entity Viral load measures the amount of HIV in the blood stream Managed with anti retroviral agents like Zidovudine (AZT) Cesarean delivery lowers the risk of transplacental transmission Breastfeeding is contraindicated Nursing care Institute standard precaution Teach the woman measures to minimize risk of virus transmission Provide emotional support Monitor CD4 count Withhold blood sampling and injections in the neonate until after all the maternal blood has been removed from the neonate on the initial bath. 8. Incompetent Cervical Os (Premature Dilatation of Cervix) Painless condition in which the cervix dilates without uterine contractions and allow passage of the fetus usually the result of prior cervical trauma. Medical Management: May be treated surgically to cerclage (placement
of fascia or artificial material to constrict the cervix in a purse-string manner). When client goes into labor,
choice of removal of suture and vaginal delivery or cesarean birth. 2 Methods 1. Mcdonalds Method 2. Shrodkar Method
243
Assessment findings History of repeated, relatively painless abortions Early and progressive effacement and dilatation of cervix Bulging of membranes through cervical os Nursing interventions Continue observation for contractions, ruptures of membranes and monitor fetal heart tones Position client to minimize pressure on cervix 9. Diabetes Mellitus Hyperglycemia due to lack or inadequate insulin Caused by heredity, environment and lifestyle Screening test should be done at 24-28 weeks AOG using 50 gram load Oral glucose challenge test (OGCT) Proceed to confirmatory test if screening is positive with 100 gram load Oral Glucose Tolerance Test (OGTT) Glycosylated hemoglobin (HBA1C) is use to detect the presence of diabetes 4-8 weeks prior to the OGTT, abnormal results could indicate congenital anomalies Nursing Interventions Teach client the effects and interactions of diabetes and pregnancy and signs of hyper- and hypoglycaemia Teach client how to control diabetes in pregnancy, advise of changes that need to be made in nutrition and activity patterns to promote normal glucose levels & prevent complications. Dietary maintenance Advice client of increased risk of infection and how to avoid it. Observe and report any signs of preeclampsia Monitor fetal status throughout pregnancy Assess status of mother and baby frequently Monitor carefully fluids; calories, glucose and insulin during labor and delivery Continue careful observation in post delivery. Constant monitoring of random blood sugar
244
Referral to Ophthalmologist, Nephrologists and Neurologist to monitor any complications Administration of insulin injection 10. Pregnancy-Induced Hypertension General Information Refers to condition unique to pregnancy where vasospastic hypertension is not accompanied by proteinuria and edema; maternal or fetal condition may be compromised > Probable cause: Gradual loss of normal pregnancy-related resistance to angiotensin II > May also be related to decreased production of some vasodilating prostaglandins Onset after 20th week of pregnancy, may appear in labor or up to 48 hours postpartum. Characterized by widespread vasospasm Cause essentially unknown, but incidence is high in primigravidas, multiple pregnancies, H. mole, poor nutrition, essential hypertension; familial tendency Occurs in 5%-7% of all pregnant women Usual clinical classification of hypertensive disorders in pregnancy is as follows: 1. Pregnancy-induced hypertension (PIH) 1.1 Hypertension 1.2 Preeclampsia
2. Chronic Hypertension 3. Chronic hypertension with superimposed PIH 3.1 Superimposed preeclampsia 3.2 Superimposed eclampsia
a. Mild b. Severe 1.3 Eclampsia
245
Possible life threatening complications. HELLP syndrome (Hemolysis, Elevated Liver enzymes, LowOnly known cure is delivery BQ Triad of Symptom Edema / Weight gain Proteinuria Hypertension
ered Platelets).

A. Mild Preeclampsia
Assessment findings Appearance of symptoms between 20th and 24th week pregnancy Blood pressure of 140/90 or +30/ +15 mmHg on two consecutive occasions at least 6 hours apart Sudden weight gain (+3 lb/month in second trimester; +1 lb/week at any time) Slight generalized edema, especially of hands and face Proteinuria of 300 mg/liter in a 24-hour urine specimen (> +1) Nursing interventions Promote bed rest as long as signs of edema or proteinuria are minimal, preferably side-lying. Provide well-balanced diet with adequate protein and roughage, no Na+ restriction. Explain need for close follow-up, weekly or twice-weekly visits to physician
B. Severe Preeclampsia
Assessment findings Headaches, epigastric pain, nausea and vomiting, visual disturbances, irritability Blood pressure of 150-160/100-110 mmHg Increased edema and weight gain Proteinuria (5g/24hours)(4+)
246
Medical Management: Magnesium Sulfate Magnesuim sulfate acts upon the myoneural junction, diminishing neuromuscular transmission. It promotes maternal vasodilatation, better tissue perfusion and has anticonvulsant effect Nursing responsibilities 1. Three parameters to monitor (BQ) > Deep Tendon Reflexes (DTR ++) > Resp. rate more than 12 cpm > Urine Output more than 30cc/hr 2. Administer medications either IV or IM Antidote for excess levels of magnesium sulfate is calcium gluconate or calcium chloride Nursing interventions Promote complete bed rest, side-lying. Carefully monitor maternal/fetal vital signs Monitor I&O, results of laboratory tests Take daily weights Do daily fundoscopic examination Institute seizure precautions Instruct client about appropriate diet Continue to monitor 24-48 hours post delivery Administer medications as ordered; Peripheral vasodilator of choice usually Hydralazine (Apresoline)
C. Eclampsia
Assessment findings Increased hypertension precedes convulsion followed by hypotension and collapse Coma may ensue Labor may begin, putting fetus in great jeopardy Convulsion may recur Nursing Intervention Minimize all stimuli Check vital signs and lab values Have airway, oxygen and suction equipment available Administer medication as ordered
247
Prepare for C-section when seizures stabilized Continue observations 24-48 hours postpartum 11. HELLP Syndrome Hemolysis, Elevated Liver Enzymes, Low Platelet Count It involves changes in the liver and the blood seen in Severe Pre Eclampsia There is fragmentation of RBC on peripheral smear, thrombocytopenia of less than 100,000/ul, and elevation of serum transaminases. Managed with Magnesium sulfate, transfusions with fresh frozen plasma and possible delivery of the fetus Nursing Care > Assess maternal vital signs > Maintain a quiet dark environment to lessen the stimuli on the patient > Prepare the patient for delivery > Assess the patient carefully throughout labor and delivery for possible hemorrhage 12. Iron Deficiency Anemia Low red cell count due to malnutrition and chronic blood loss may be underlying condition May or may not be exacerbated by physiologic hemodilution of pregnancy Most common medical disorder of pregnancy Client is pale, tired, short of breath, dizzy Hemoglobin is lower than 11 gms/dl Nursing care > Instruct client to take the prenatal multivitamins, and iron supplements NR: Iron given with food and after meals -BQ > Monitor patients CBC, vital signs > Assess dietary habits > Evaluating for signs and symptoms of decreased perfusion to vital organs
248
13. Multiple Pregnancy Gestation involving more than one fetus Can be monozygotic (single ova) or dizygotic ( multiple ova) Client may experience increased fatigue and backache Can put the client at risk for developing many complications of pregnancy like preterm labor, Premature Rupture Of Membranes (PROM) And Intrauterine Growth Retardation (IUGR) During delivery there should be one nurse to one neonate Nursing Care > Close follow up of the client > Encourage rest and put the client on left lying position > Assess FHT and fundic height every visit > Explain danger signs and symptoms and report them immediately 14. Premature Rupture of Membranes (PROM) Spontaneous break or tear in the amniotic sac before the onset of regular contractions Maternal complications include amnionitis, endometritis, and septic shock Fetal complications include asphyxia, pulmonary hypoplasia, malpresentation and cord prolapse Predisposing factors include lack of proper prenatal care, poor nutrition and hygiene, maternal smoking and incompetent cervix Diagnosis is confirmed by the following > Nitrazine paper test blue stained bodies present fetal epithelial cell, orange stain may conclude urine or other discharges > Ferning test a smear of the fluid placed on the slide allowed to dry or heat under denature alcohol. If with Ferning pattern this indicates amniotic fluid Nursing Care: Provide sterile gloves and sterile lubricating jelly during examination Observe and record color, odor, amount of amniotic fluid Examine mother for signs of prolapsed cord
249
Reassure the client Perineal prep before and after the examination Watch for signs and symptoms of maternal Infection Anticipate giving of antimicrobial to the patient
15. IsoImmunization AKA Rh Incompatibility Mother is Rh negative, fetus is Rh positive Nulliparous woman doesnt exhibit any signs of the disorder. Subsequent pregnancies and fetus are affected though First prenatal check up, anti D antibody titer should be determined. A titer of 1:16 indicates Rh sensitization Treatment focuses on prevention, hence may give RhoGam as soon as possible after the birth of a Rh positive neonate Nursing care Assess the client for possible Rh incompatibility Administer RhoGam to Rh negative woman at 28 weeks as ordered Prepared the woman for planned delivery May also give RhoGam within 72 hrs after delivery, spontaneous abortion to prevent complications in subsequent pregnancies 16. Premature labor Uterine contractions that produces cervical changes after period of fetal viability before fetal maturity Causes include PIH, PROM, multiple pregnancy, Placenta previa, abruption placenta, trauma History of uterine contractions Treatment include suppression of the contraction May also give corticosteroid to enhance lung maturity Nursing Care Closely observe client Maintain on bed rest Ensure adequate hydration Observe fetal responses through fetal Monitoring
250
17. Disseminated Intravascular Coagulation (DIC) General information Also known as consumptive coagulopathy A diffuse, pathologic, form of clotting secondary to underlying disease/ pathology Occurs in critical maternity problems such as abruptio placenta, dead fetus syndrome, amniotic fluid embolism, preeclampsia/ eclampsia, hydatidiform mole and hemorrhagic shock Mechanism: 1. Precoagulant substances release in the blood trigger microthrombosis in peripheral vessels and paradoxical consumption of circulating clotting factors 2. Fibrin-split products accumulate, further interfering with the clotting process 3. Platelet and fibrinogen levels drop Assessment findings Bleeding may range from massive, unanticipated blood loss to localized bleeding (purpura and petechiae) Presence of special maternity problems Prolonged prothrombin and partial thromboplastin Nursing Interventions Assist with medical mgt. of underlying condition. Administer blood component therapy (white blood cells, packed cells, fresh frozen plasma, cryoprecipitate) as ordered. Observe for signs of insidious bleeding (oozing IV site, petechiae, lowered hematocrit). -BQ Institute nursing measures for severe bleeding or shock if needed. Provide emotional support to client and family as needed.
251 INTRAPARTUM COMPLICATIONS

1. Malpresentation Breech presentation Types Frank breech Footling Breech Complete Breech Risk Cord prolapse Traumatic injury Spinal fracture PROM Meconium aspiration 2. Ineffective uterine force A. Hypertonic uterine contractions Intensity of uterine contractions are severe but ineffective to dilate the cervix Painful but not observed in the electronic fetal monitor Promote rest and analgesia B. Hypotonic uterine contractions Frequency of uterine contractions are low increasing the hours of labor Leads to ineffective contraction increasing postpartum hemorrhage complications Lack of labor progression May augment labor with Oxytocin administration C. Uncoordinated Contractions Contractions occurring erratically Treated by Oxytocin administration 3. Umbilical Cord prolapse A loop of cord slips down in front of the presenting part May lead to immediate cord compression Management is aimed towards alleviating pressure on the cord
252
Nursing Care Anticipate cesarean delivery Place the client in knee chest or Trendelenburg position Cover the exposed cord with sterile wet os 4. Amniotic Fluid Embolism Amniotic fluid is forced into the open maternal blood sinuses after membranes ruptured or placental separation Risk factors A. Oxytocin administration B. Abruptio placenta C. Polyhydramnios Patient sits up and grasp her chest suddenly indicating air hunger Can not be prevented since it can not be predicted Prognosis is poor Quick emergency resuscitation should be given
POSTPARTUM COMPLICATIONS
1. Postpartum hemorrhage Any blood loss from the uterus exceeding 500 ml in NSD and 1000 Ml in operative delivery Can be caused by uterine atony, perineal lacerations retained placenta and disseminated intravascular coagulation (DIC) Uterine atony or relaxation is the usual culprit in early postpartum period > There is doughy boggy uterus > Uterus is not contracted Lacerations may result in profuse bleeding and usually occurs immediately after delivery of the placenta > Uterus is firm but bleeding persist Retained placenta can be partial or complete > Bleeding is slow trickle of blood, oozing or frank hemorrhage
253
Nursing care Assess the uterine fundus Initiate uterine massage to increase uterine tone and contractility Weigh perineal pads 1 gm of weight is = 1 ml of fluid Turn patient to her side and inspect buttocks for pooling of blood Assess VS to include urine output 2. Puerperal Infection Can be due to Group A, B hemolytic streptococcus, Chlamydia and other coagulase negative staphylococci Fever occurs at day 1-10 postpartum except the first 24h and last for 2 consecutive days Assess the clients episiotomy site Redness Erythema and ecchymosis Edema Drainage or discharge Approximation of wound edges Diagnosis can be confirmed by Blood culture and sensitivity Treatment includes antimicrobial treatment, pain management, isolation of the client Supportive care includes bed rest, hydration and reduction of fever Nursing care Monitor VS Place client in high Fowlers or semi fowlers position for drainage Strictly CBR High caloric, high protein diet Encourage client to void frequently 3. Mastitis Inflammation of the breast tissue disrupting lactation Infection usually comes from the neonates mouth and nares A. Staphylococcus aureus B. Group B hemolytic streptococcus
254
Begin 7 to 28 days postpartum, with high grade fever Should be differentiated with breast engorgement which typically occurring 2-5 days after initiation of lactation Treatment includes antimicrobial therapy Nursing Care Infection control with proper hand washing and universal precaution Assess and record the cause and amount of discomfort May continue with lactation with the following > offer the affected breast first to promote complete emptying and prevention of milk stasis > if there is abscess formation, may use breast pump BUT DISCARD breast milk > continue to breastfeed on the Unaffected side > wear supportive bra empty the breast as completely as possible ensure adequate hydration 4. Uterine Rupture Usually occurs when the uterus undergoes more strain than it can sustain Can be caused by > Prolonged labor > Malpresentation > Multiple gestation > Use of oxytocin > Obstructed labor > Traumatic maneuvers Presence of Pathologic Retraction Ring > Bandls Ring seen at the junction of upper and lower uterine segment > Constriction Ring can occur at any point of the myometrium Signs and symptoms > Severe abdominal pain > Halt in contractions > Absent FHT > Possible vaginal bleeding > Hypotension
255
References:
Adelle Pilliteri, Maternal & Child Health, care of the Childbearing and ChildRearing Family, 5th Ed, Lippincott, Williams & Wilkins, Vol 1 & 2 Cunningham et al, Williams Obstetrics, 21st Edition, Lippincott, Williams & Wilkins 2004 Ladewig,London, Davidson, A Look At Contemporary Maternal-Newborn Nursing Care, 6th Edition, Pearson Education South Asia PTE Ltd Baja-Panlilio et al, Textbook of Obstetrics (Physiologic & Pathologic) 2nd Edition, APMC Philippines Aurelio, L, Chatham C, et al Maternal-Neonatal Nursing Made Easy, Lippincott, Williams & Wilkins, 2003 Community Health Nursing Services in the DOH Philippines 9 th Edition 2002 Potter, P. and Perry, A. (2001) Fundamentals of Nursing (5th Edition) St. Louis Mosby Saunders Comprehensive Review for the NCLEX-RN Examination 3rd Edition, Linda Anne Silvestri (2005) Elsevier Inc. Comprehensive Review for Nursing Saxton; Nugent; Felikon; (2005) Elsevier Mosby Marieb, E. (2002). Anatomy and Physiology Coloring Book (6th Edition) Addison-Wesley Publishing Co. Inc. Kozier, B., et (2004). Fundamentals of Nursing: Concepts, Process and Practice (7th Edition) Philippines: Pearson Education South Asia PTE LTD. Devita, V.T., Jr., et al. eds. Cancer : Principles and Practices of Oncology, 6th Ed. Philadelphia: Lippincott Williams & Wilkins, 2001.

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1

COMMUNITY HEALTH NURSING

Community Health Nursing

A. Principles and Standards of CHN 1. Definitions

Community= a group of people with common interests living together

Community Health= para/medical approach concerned on the health of

Public Health Nursing= a professional practice in public health and

2. Roles of Public Health Nurse

4. DOH Concepts of CHN a. Health Promotion: primary focus of CHN practice.

Health Teaching: Primary Responsibility of CHN Nurse.

Goal of CHN: To raise the health level of citizenry.

Community Health Nursing

Individual= the least important client in CHN

Community= the most important client in CHN.

Community Health Nursing

According to Service Type

Health Education, Preventive Care, Common Health Problems

Health education Immunization

RHU Community Hospital Puericulture

Medical Services, Surgery

Diagnosis & Treatment Complication Prevention

Screening Case-finding Contact Tracing Prompt Treatment

District Hospital Provincial, City, Hospitals

Advanced and Specialized Services

Disability Prevetion Rehabilitation

PT/OT Facility Employment

Regional, Specialized Medical and National Health Centers

Community Health Nursing

Community Health Nursing

Community Health Nursing

Key Strategy: People Empowerment and Partnership

4 Pillars of PHC( M.A.P.S. ) Multisectoral Approach= 2-way referral system (inter/

Community Health Nursing

Community Health Nursing

The Department of Health (DOH)

Mission: To ensure accessibility and quality of healthcare to improve the

Education (BSN, RN)

Nursing Program Supervisor (N VI) Regional Training Nurse

MAN, MPH Major in Administration MAN, MPH

MAN, MPH Major in CHN Administration

3 years (CHN) Now: 1 year

Community Health Nursing

Health Services in DOH

Community Health Nursing

Locally Endemic Diseases

Community Health Nursing

Epidemiological Situation Mass Approach Basic Health Service

No. of Doses Recipients Per Vaccine

Wastage Allowance/ Multiplier Factor

0.5 ml 3 1 50% 2.0 10% 0.5 ml

Community Health Nursing

R Deltoid L Deltoid Vastus Lateralis

Massage (-) Kochs:2-4 d Warm Compress Paracetamol every 4 hours

Fever Convulsion (withhold next DPT dose)

OPV 1 2 3 HBV 1 2 3 6 weeks 10 weeks 14 weeks 6 weeks 10 weks 14 weeks

Vomiting NPO for 30 minutes after giving OPV

Paracetamol every 4 hours

Note: Hepa B: 0-6-14 weeks in the new PHN book.

Community Health Nursing

*Infant protected from Neonatorum Tetanus *Mother: 3 years

6 months later At least 1 year later At least 1 year later

*(same) *Mother: 5 years

*(same) *Mother: 10 years

*(same) *Mother: Lifetime

Infant protected from Neonatorum Tetanus Mother: 3 years

(same) Mother: 5 years

(same) Mother: 10 years

(same) Mother: Lifetime

Disease Sub-clinical Exposure