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CHN by: JOMAR P.

MALLONGA, RN, LLB, MAN must know Yesterday is best memory, tomorrow is a dream, but today is gift. Thats why it is called present, for what the Lord value is today Your commitment now. DOH is the lead agency in health New Vision: DOH is the leader staunch advocate and model in promoting Health for all in the Philippines.

. New Mission: Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor and shall lead the quest for excellence in health. Goal: Partnership with LGU, private sector, other government sectors and NGOs toward self reliance in the provision of basic health services in the localities. The Health Sector Reform Agenda (HSRA) Health Sector Reform is the overriding goal of the DOH Rationale for Health Sector Reform Slowing down in the reduction in the IMR and MMR. Persistent of large variations in health status across population groups and geographic areas. High burden from infectious diseases. Rising high burden from chronic and degenerative diseases Unattended emerging health risks from environmental and work related factors. Burden of disease is heaviest on the poor. Four elements of the strategy are: 1. Health financing 2. Health regulation 3. Health service delivery

4. Good governance BASIC PRINCIPLE: 1. Universal access to basic health services 2. Prioritizing health education to vulnerable groups 3. Managing epidemiologic shift from infections to degenerative diseases 4. Enhancing performance of the health sector PRIMARY STRATEGIES: 1. Development of national standards and objective for health 2. Assurance of quality health care 3. Support to local health system 4. Increase investment for PHC 5. Support for frontline health workers Primary Health Care Primary Health Care (PHC) An essential health care made universally accessible to the individuals and families in the community by means acceptable to them through their full participation at a cost that the community can afford. September 12, 1978 (International conference)(WHO)Alma Ata, Russia Called in response to the crises confronting the health system goal conceptualization of PHC HFA by 2000 (Philippines) adoption of PHC D.O.H. Leads the implementation of PHC in the Philippines L.O.I 949 Legal basis of PHC in the Philippines GOAL: Health for all by the year 2000 & Health in the hands of the people by the year 2020 GOALS OF PHC

1. Health for all by the year 2000 & Health in the hands of the people by the year 2020 2. Self-Reliance L.O.I No. 949 (October 19, 1979) Legal basis of the adoption of PHC in the Philippines. KEY CONCEPTS OF PHC 1. PHC IS AN ESSENTIAL HEALTH CARE 2. PHC IS MADE UNIVERSALLY ACCESSIBLE TO INDIVIDUALS, FAMILIES AND COMMUNITY. 3. PHC MUST BE ACCEPTABLE TO THE COMMUNITY. 4. PHC MUST INVOLVE FULL COMMUNITY PARTICIPATION. 5. PHC MUST BE AN INTEGRAL PART OF THE COUNTRYS HEALTH SYSTEM. 6. PHC IS AN INTEGRAL PART OF THE OVERALL SOCIAL AND ECONOMIC DEVELOPMENT OF THE COUNTRY CRITERIA OF PHC: 1. PHC MUST BE COMMUNITY BASED 2.PHC MUST BE ACCEPTABLE TO THE PEOPLE 3. PHC MUST BE ACCESSIBLE 4.PHC MUST BE AFFORDABLE ELEMENTS OF PHC E- EDUCATION FOR HEALTH L- LOCALLY ENDEMIC DISEASE CONTROL E- EXPANDED PROGRAM OF IMMUNIZATION M-MATERNAL AND CHILD HEALTH E- ESSENTIAL DRUGS N- NUTRITION T- TREATMENT OF COMMUNICABLE DISEASE

S- SAFE WATER ANDSANITAION C- CENTER FOR HOSPITAL WELLNESS M- MENTAL HEALTH O- ORAL AND DENTAL HEALTH PILLARS OF PHC A. COMMUNITY PARTICIPATION PROCESS BY WHICH INDIVIDUALS AND FAMILIES ASSUME RESPONSIBILITY FOR THEIR OWN HEALTH AND WELFARE AND FOR THOSE OF THE COMMUNITY AND DEVELOP THE CAPACITY TOCONTRIBUTE TO THEIR COMMUNITY AND COMMUNITY DEVELOPMENT B.MULTISECTORAL APPROACH 1.INTERSECTORAL LINGKAGES -PHC FORMS AN INTEGRAL PART OF HE HEALTH SYSTEM AND THE OVERALL SOCIAL AND ECONOMIC DEVELOPMENT OF THE COMMUNITY AGRICULTURE,EDUCATION, PUBLIC WORKS,LOCAL GOVT,SOCIAL WELFARE,POPULATION CONTROL,PRIVATE SECTORS 2.INTRASECTORAL LINGKAGES -IN THE HEALTH SECTOR, THE ACCEPTANCE OF PRIMARY HEALTH CARE NECESSITATES THE RESTRUCTURING OF THE HEALTH SYSTEM TO BROADEN HEALTH COVERAGE AND MAKE HEALTH SERVICES ACCESIBLE TO ALL. -IN TERMS OF HEALTH SERVICES, PHC FACILITIES FOCUS ON THE TREATMENT OF PREVALENT DISEASE IN THE COMMUNITY. THERE ARE SECONDARY AND TERTIARY FACILITIES WHERE MORE SERIOUS AND MORE COMPLEX HEALTH PROBLEM ARE ATTENDED TO. C. APPROPRIATE TECHNOLOGY METHOD OR TECHNIQUE WHICH PROVIDE A SOCIALLY ENVIRONMENTALLY ACCEPTABLE LEVEL OF SERVICE OR QUALITY PRODUCTION LEAST ECONOMIC COST THE FOLLOWING CITERIA CAN BE USED IN DETERMINING APPROPRIATENESS OF TECHNOLOGY: EFFECTIVENESS AND SAFETY, COMPLEXITY, COST, ACCEPTABILITY, SCOPE OF THE TECHNOLOGY, AND FEASIBILTY

D.SUPPORT MECHANISM 1. HC SERVICES AND FACILITIES ARE MAINLY CONCENTRATED IN URBAN AREAS LIVING THE RURAL AREA VERY MUCH DEPRIVED OF HC. 2. OUR HEALTH MANPOWER ARE MAINLY ABOARD AND IF THEY ARE IN THE COUNTRY THEY ARE IN THE CITIES 3. OVER DEPENDENCECY ON IMPORTANT HEALTH TECHNOLOGIES. 4. OUR PHARMACEUTICALS INDUSTRIES IS DOMINATED BY FOREIGN MULTI NATIONAL COMPANIES. 5. THE PRE PAID MEDICAL INSURANCE IS LIMITED ONLY TO THE FEW WHO ARE REGULARLY EMPLOYED. 6. THE DOHS SHARE IN THE NATIONAL BUDGET HAS BEEN VERY SMALL AND THE HEALTH BUDGET IS SPENT MORE ON THE CURATIVE OF THE COUNTRY RATHER THAN THE PREVENTIVE HC. Sentrong Sigla The Birth of Sentrong Sigla Quality Assurance Program (QAP) Goal: To make DOH and LGUs active partners in providing quality health services Key Strategies: 1. Certification/Recognition Program CRP 2. Continuous Quality Improvement - CQI Sentrong Sigla Movement Goal: Quality Health Objectives: Better and more effective collaboration between DOH and LGUs DOH: as provider of technical and financial assistance packages for health care LGU: prime developers of health systems and direct implementers of health programs FRAMEWORK FOR COMMUNITY HEALTH NURSING Community health nursing is the totality of its philosophy and beliefs, principles and processes. These are underscored in the roles and functions of community health nurses.

Community health nursing is influenced by its immediate context the health care delivery system and the overall economic, political, socio cultural and environmental factors. The primary goal of community health nursing is the promotion and preservation of health of its different clients, individual, family, population, group and community. A. Individual The PHW deals with individual sick or well on a daily basis. These are the people who consult at the health center and receive health services such as prenatal supervision, well-child follow-ups and morbidity services. These also include client with chronic illnesses such as diabetes mellitus and hypertension who go to the health center for blood sugar and blood pressure monitoring. B. Family The family is very important social institution that performs two major functions reproduction and socialization. It is generally considered as the basic unit of care in community health nursing for many reasons. It may contribute knowingly or unknowingly to the development of health and nursing problems of its members. C. Population group A population group or aggregate is a group of people who share common characteristics, developmental stage or common exposure to particular environmental factors, and consequently common health problems. Some of these groups are: children, men, women, farmers, factory workers, commercial workers, prisoners, military men, and elderly. D. Community The community is a group of people sharing common geographic boundaries and/or common values and interest. Its functions within a particular socio cultural context, which means that no two communities are alike. The physical environment varies, and so with the peoples way of behaving and coping. The people are different from each other, thus the dynamics in one community differs from that of the other. 1. ESTABLISHING A WORKING RELATIONSHIP WITH THE CLIENT A. initiating contact B. communicating interest with the client C. expressing and showing willingness to help with the expressed need

D. maintaining a two-way communication with the client. 2. ASSESSMENT OF NEEDS

Taking into consideration personal, environmental and psycho-social-cultural factors influencing Hx. A. situations and trends revealed in personal and social history B. physically, emotionally and intellectually ability to function C. attitudes, knowledge and perception of health and illness D. health behaviors and patterns of health care E. resources available to meet own needs F. other factors associated with risk of prevailing Hx. Problems 3. PLANNING AND IMPLEMENTATION OF CARE

Summarizing needs problems establishing priorities of care, determining objectives, approaches strategies and intervention to meet identifies needs and objectives for care. STATEGIES AND INTERVENTION MUST BE: A. directly related to the needs and underlying causes of the problems identified B. Based on scientifically, technically sound principle and health promotion, disease prevention, treatment and rehabilitation adapted to local conditions and situations. C. Planned in term of desired outcomes of individuals, family, group health, and health related behaviors. 4. EVALUATION OF CARE

The analysis of the effectiveness of care provided based on systematic documentation, monitoring and observation in relation to: A. accuracy, competence and regularity of assessment B. individual, family and community participation C. quality, scope and interpretation of observed differences with suggested changes Basic concepts and principles in the practice of CHN

1. The family is the unit of care in CHN. 2. The community is the patient in CHN, viewed either physically in terms of geographical boundaries or time-space dimension or a group sharing commons characteristics, needs, interest and / or values. 3. The goal or improving community health is realized through multidisciplinary effort. 4. The CH nurse shares the responsibility for the delivery of health in a community with other health workers in the team and works with them in a spirit of teamwork.

5. The community health nurse works with and not for the individual pt. family group or community. 6. The practice of CHN is affected by changes in society in general and by developments in the health field in particular. The CH nurse is serving and in congruence with the changes in the health care technology. 7. CHN is part of the community health system, which is turn is part of the larger human services system.

The Philippine Health Situation 1. Analysis of the nations state of health 2. Forces that impinge on the countries state of health A. Social factors: status and role of education system on health; religion B. Cultural Factors C. Political Factors D. Economic factors: GNP, employment, recession, inflation, global trends Health Policies and Programs Improvement of Health Care Delivery System Health Care Delivery System - The network of health facilities and personnel, which carry out the tasks of rendering health care to the people

PRIMARY PREVENTION

Health education Good standard of nutrition adjusted to developmental phase of life Attention to personality development Provision of adequate housing, recreation and agreeable working conditions Marriage counseling and sex education Genetics Periodic selective examinations SPECIFIC PROTECTION Use of specific immunizations Attention to personal hygiene Use of environmental sanitation Protection against occupational hazards Protection from accident Use of specific nutrients Avoidance of allergens SECONDARY PREVENTION EARLY DIAGNOSIS AND PROMPT TREATMENT Case finding measures, individual and mass Screening surveys Selective examinations

DISABILITY LIMITATIONS TERTIARY PREVENTION

REHABILITATION Provision of hospital &community facilities for retraining and education for maximum use of remaining capacities Education of the public & industry to utilize the rehabilitated as full employment as possible Selective placement Work therapy in hospitals Use of sheltered colony Immunization: process by which an individuals immune system becomes fortified against an agent (immunogen) Vaccination: administration of antigenic material (vaccine) by a pathogen.

Considered to be the most effective & cost-effective method of preventing infectious diseases EXPANDED PROGRAM ON IMMUNIZATION Launched July 1976 Began July 1979 By Department of Health In Cooperation with World Health Organization and UNICEF. EXPANDED PROGRAM ON IMMUNIZATION OBJECTIVE: To reduce the morbidity & mortality among infants and children caused by the 6 childhood immunization disease. PRINCIPLES OF E.P.I. The program is based on epidemiological situation; schedules are drawn on the basis of the occurrence and characteristic epidemiological features of the disease. The whole community rather than just the individual is to be protected thus mass approach is utilized. Immunization is a basic health service and such it is integrated in to the health services being provided for by the Rural Health Unit.

PD 996: compulsory basic immunization to 8 years and below Remember! Basic immunization completed on or before the childs first birthday I. Coverage a) b) Fully Immunized Child (FIC) receives 11 doses of vaccine Target Setting

b1. Target Population group meant to benefit from EPI programs; - DOHs Responsibility Infants, School Entrants and Pregnant women b2. Illegible Population those qualify to receive specific immunizations a) Wastage Allowance Cold Chain SystemTemperature-controlled supply chain designed to maintain potency of vaccines when being transported from the manufacturer to the clients. First Expiry First Out vaccine is practiced to assure that all vaccines are utilized before its expiry date Temperature monitoring of vaccines is done in all levels of facilities. Temperature is plotted everyday in a temperature monitoring chart. General Considerations 1. Maintenance and potency a. Avoid break in the cold chain 1. Appropriate storage temperature a. OPV and measles vaccine are kept frozen (-15 to -25C), sensitive to sunlight and fluorescent light b. Other are refrigerated (+2C to +8C) most

2. Use of vaccine bag with cold pack (cold dogs)

a. Place frozen ice packs on table for 5-10 with DPT and TT 3. Diluents are refrigerated 4. HEPA B most sensitive to cold b. Discard unused 1. BCG and AMV 6 hours after reconstitution 2. Other vaccines at the end of the working

minutes before packing

day

c. Maximum duration of storage/transport of biological regional level 6 months, provincial level 3 months, district level 3 months, health center (with refrigerators) 1 month, using transport boxes: 5 days 2. Contraindications a. In general condition serious illness to require a hospitalization are contraindications b. Convulsion within 3 days following DPT immunization (indicate of hypersensitivity to pertussis vaccine) are definite contraindication to subsequent doses c. BCG should not be given to children who have signs and symptoms of AIDS and other auto immune deficiency diseases or those who are immunosuppressed due to malignant disease, therapy immunosuppressive agents or irradiation

d. The following condition are not considered as contraindication: 1. Mild upper respiratory infection 2. Simple diarrhea 3. Low Grade Fever 4. Malnutrition considered an indication e. Both measles vaccine and OPV should be given with HIV and AIDS Tetanus Toxoid Immunization Schedule for Pregnant Women EPI logistics 1. Auto disable Syringe with needle are disposable injection devices that re especially made to prevent reuse and are therefore less likely than standard

disposable syringes to cause person-to-person transmission of blood-borne diseases. 2. Mixing syringe is used to withdraw the diluent content from the ampoule and inject into the vaccine vial for mixing prior to vaccination. 3. Safety collector box is where to store used syringes with needle for safe disposal. The number of syringes accommodated depends on the volume of the box. Objective To reduce mortality from diarrhea particularly among children under five through extensive case management utilizing oral rehydration therapy (ORT), environmental sanitation, maternal and child health education activities. Preventive interventions that are effective and affordable: Breastfeeding Improved weaning practices Use plenty of clean water Hand washing Use of latrines Proper disposal of babies stools Measles immunization Task of Health Workers The health workers must convince and help community members to adopt the practices and to continue to practice them on an on-going basis. A health worker can teach, encourage, and set a good example MANAGEMENT OF THE PATIENT WITH DIARRHEA TREATMENT PLAN A TO TREAT DIARRHEA AT HOME USE THIS PLAN TO TEACH THE MOTHER: Continue to treatment at home her childs current episode to diarrhea

Give early treatment for future episodes of diarrhea EXPLAIN THE THREE RULES FOR TREATING DIARRHEA AT HOME 1. GIVE THE CHILD MORE FLUIDS THAN USUAL TO PREVENT DEHYDRATION Use recommended home fluid, such as cereal gruel, if this is not possible, give plain water. Use ORS solution for children.Give as much of these fluids as the child will take. Use the amounts shown below for ORS as a guide Continue giving these fluids until the diarrhea stops. 2. GIVE THE CHILD PLENTY OF FOOD TO PREVENT UNDERNUTRITION Continue to breast feed frequently If the child is not breast fed, give the usual milk. If the child is less than 6 months old and not yet taking solid food, dilute milk or formula with an equal amount of water for 2 days. 3. TAKE YOUR CHILD TO HEALTH WORKER IF THE CHILD DOES NOT GET BETTER IN 3 DAYS OR DEVELOPS ANY OF THE FOLLOWING: Many watery stools Eating or drinking poorly Repeated vomiting Fever Marked thirst Blood in the stool

CHILDREN SHOULD BE GIVEN ORS SOLUTION AT HOME , IF They have been on treatment plan B or C They cannot return to the health worker if the diarrhea gets worse It is national policy to give ORS to all children who see a health worker for diarrhea.

IF THE CHILD WILL BE GIVEN ORS SOLUTION AT HOME, SHOW THE MOTHER HOW MUCH ORS TO GIVE AFTER EACH LOOSE STOOL AND GIVE HER ENOUGH PACKETS FOR 2 DAYS: TREATMENT PLAN B TO TREAT DEHYDRATION APPROXIMATE AMOUNT OF ORS SOLUTION TO GIVE IN THE FIRST 4 HOURS * Use the patients age only when you do not know the weight. The approximate amount of ORS required(in ml) can be calculated by multiplying the patients weight (in grams) times 0.075

AFTER 4 HOURS, REASSESS THE CHILD USING THE ASSESSMENT CHART THEN SELECT PLAN A, B OR C TO CONTINUE TREATMENT If there are NO SIGNS OF DEHYDRATION, shift to Plan A when dehydration has been corrected, the child usually passes urine and may also be tired and fail asleep. If signs indicating SOME DEHYDRATION are still present, repeat Plan B, but start to offer food, milk and juice as described in Plan A If signs indicating SEVERE DEHYDRATION have appeared, shift to Plan C. New Developments in the Management of Acute Diarrhea Rules on Treatment of Diarrhea Give extra fluids, ORS solution or recommended home fluids Give zinc supplementation Continue feeding, encourage on going breastfeeding when applicable Advise mother when to return to the health facility immediately

CARI Program Goal: to decrease pneumonia morbidity Trends: 1. No cough prep unless in allergic pertussoid cases 2. Home care:

a. increase fluid intake b. soothing throatremedy: calamansi c. limited to PRN use of AB Sample chart: 1. Child w/ cough / dyspnea 2. Child w/ ear discomfort 3. child w/ sore throat Maternal health Program Maternal Health Program The Philippines is tasked to reduce the maternal mortality ratio(MMR). The maternal mortality ratio has declined from an estimated 209 per 1000,00 live births in 1987-93 to 1998. o 77%(1998)-70.4%(2003)-% of pregnant women with at least four prenatal visits is decreased 38%(1998)-37.3%(2003)-% of pregnant women who received at least 2 doses of tetanus toxoid

2000 Philippine Health Statistics revealed the causes of all maternal death: 25% hypertension 20.3% postpartum hemorrhage 9% pregnancy with abortive outcomes

Common causes of Maternal death: delays in taking critical actions delays in seeking care delay in making referral delay in providing appropriate medical management

Other factors include:

closely spaced births frequent pregnancies poor detection and management of high-risk pregnancies.

poor access to health facilities brought about by geographic distance and cost of transportation

Health care and health staff who lacks competence in handling obstetrical emergencies.

The overall goal program is to improve the survival, health and well being of mothers and unborn through a package of services for the pre pregnancy, prenatal, natal and post natal stages. Strategic thrusts for 2005-2010 launch and implement the Basic Emergency Obstetric Care(BEMOC) =establishment of facilities that provide emergency obstetric care for every 125,00 population improve the quality of prenatal and postnatal care reduce women's exposure to health risk

LGUs, NGOs and other stakeholder must advocate for health

Health service package before, after pregnancy and Antenatal registration Tetanus toxoid immunization Micronutrient supplementation

Treatment of disease and other conditions Clean and safe delivery Support for breast feeding Family planning counselling Basic Prenatal Services The basic prenatal services at the hospitals, RHU, and BHS should include the following: 1. History taking 2. Physical examination 3. Treatment of diseases 4. Tetanus toxoid immunization, iron supplementation 5. Health education 6. Laboratory examination 7. Oral and dental examination ( except for BHS ) 8. Proper referral to next higher level when applicable A Must for All Pregnant Women Shall be given Tetanus Toxoid Immunization which is according to the WHO Iron Supplement shall be given from the 5th month of pregnancy up to 2 months postpartum which is equivalent to 210 days (100 to 200 mg orally per day) In Goiter Endemic Areas, all pregnant women shall be given one iodized oil capsule every year In Malaria Infested Areas, all pregnant women shall be given prophylaxis in the form of Chloroquine ( 150 mg/tablet ) 2 tablets per week for the whole duration of pregnancy Education for Parenthood Provision of information about pregnancy, labor and delivery, the postpartum period and lactation Usually taught in small groups, may be individualized

Topics can be grouped into early and late pregnancy, labor and delivery, and post delivery/newborn care Labor and Delivery Process Intrapartal Care Goals of Intrapartal Care Responsibilities Care During Childbirth Home deliveries for normal pregnancies attended by licensed health personnel shall be encouraged Trained Hilots may be allowed to attend home deliveries only in the following circumstances: 1. in areas where there are no licensed health personnel on maternal care 2. When, at the time of delivery, such personnel is not available NOTE: at risk pregnancies and mothers who develop obstetrical complications during labor should be immediately referred to the nearest facility but obstetric first aid should be administered first before transport Actively practicing but untrained birth attendants ( hilots ) should be identified, trained and supervised by a personnel of the nearest BHS/RHU trained on Maternal Care The following are qualifiers for a Home Delivery: 1. Full term 2. Less than 5 pregnancies 3. Cephalic presentation 4. Without existing diseases 5. No history of difficult deliveries and prolonged labor ( more than 24 hour primi; more than 12 hours multigravida ) 6. No previous CS 7. Imminent deliveries 8. No premature rupture of BOW

9. Adequate pelvis 10.Abdominal enlargement is appropriate for age of gestation Home Delivery Kit The kit should contain the following: 1. At least 2 pairs of clamps ( or strings ) 2. A pair of scissors ( or boiled razor blade ) 3. Antiseptic ( 70% alcohol or Povidone Iodine ) 4. Soap and hand brush 5. Clean towel ( or piece of cloth ) 6. Flashlight 7. Sphygmomanometer and stethoscope OPTIONAL: Plastic sheet Suction bulb Weighing scale Ophthalmic ointment Sterile gloves Thermometer

Pointers During Home Deliveries The three Cleans should be practiced namely: 1. Clean hands 2. Clean surface 3. Clean cord NOTE: should be emphasized to prevent maternal and neonatal infection Safe Delivery: attendant must be aware of early signs of complications to be able to refer properly and timely Postpartum Care

Postpartum care refers to the medical and nursing care given to a patient from the time of delivery until her body returns to near its nonpregnant state The puerperium is the 6-week period after delivery, beginning with the termination of labor and ending with the return of the reproductive organs to the nonpregnant state It is also a physical and psychological adjustments to the process of childbearing Involution refers to the progressive changes in the uterus after delivery, leading to its return to prepregnant size and condition This period is sometimes referred to as the fourth trimester of pregnancy One aspect of care that commonly suffers with the trend toward earlier discharge is support in breastfeeding Factors that Increase the Risk of Complications 1. Preeclampsia or eclampsia 2. Diabetes 3. Cardiac problems 4. Uterine overdistension due to multiple births or hydramios 5. Abruptio placenta or placenta previa 6. Precipitous or prolonged labor, difficult delivery, extended period of time spent in stirrups CARE OF THE NEWBORN Care of the Newborn MAINTAINING PATENT AIRWAY a. Suctioning: start with mouth then the nose; nose can lead to aspiration * should not be more than 1 minute because it can irritate the larynx which can cause obstruction thus can lead to respiratory distress * will result to a hoarse cry * prolonged suctioning can irritate the vagal nerve that can affect the heart leading to bradycardia * 30 RR/minute can cause brain damage

b. Positioning * to promote drainage should be modified trendelenburg position * to aid in the closure of foramen ovale head should be lower to the right side * in the presence of increase intracranial pressure, position the NB at Fowlers ** signs of ICP: shrill cry, bulging fontanelle, vomiting * change position every 2 hours to provide equal circulation and promote lung expansion * Harlequin sign * rub the back or sole to stimulate the CNS for breathing monitor respiratory rate, failure to establish respiration in 5 minutes means asphyxia neonatorum can lead to irreversible brain damage Characteristic of normal respiration must be quiet, irregular, abdominal, rapid but shallow * with short period of apnea but must be without cyanosis 2. PROVIDE WARMTH * dry the NB immediately, place under a drop light or isollete * NB does not know how to shiver if temperature drops below 34 degree Celsius can lead to chills * danger of chills: hypoglycemia, acidosis and apnea * normal temperature is 37.2; after birth usually drops as low as 34; but must be maintained between 35.5 to 36.5 - and must be established within 8 hours * initial temperature is taken rectally to rule out imperforate anus

3. CORD CARE * cord is clamped after pulsation which could still deliver 50 to 100 ml of blood to the NB * pulsation stops within 1 to 5 minutes * check the cord every 15 minutes for primary signs of bleeding

* blood loss of 30 ml is considered hemorrhage ( total blood volume of NB is 300 ml thus 10% is considered hemorrhage ) * check for 1 vein and 2 arteries * absence of one artery is indication of CHD or renal anomalies * additional blood is harmful if it would be added by force of milking * added blood should only be by pulsation and gravity What is Newborn Screening? New born Screening (NSB) is a sample procedure to find out if a baby has a congenital metabolic disorder that may lead to mental retardation or even death if left untreated. Why is Newborn Screening Important? Most babies with metabolic disorders look normal at birth. By doing NSB, metabolic disorders maybe detected even before clinical signs and symptoms are present. And as a result of this, treatment can be given early to prevent consequences of untreated condition. When is Newborn Screening Done? NSB is ideally done on the 48th-72nd hour of life. However, it may also be done 24 hours from birth. Who will collect the sample of newborn screening? The blood sample for NSB may be collected by the ff: physician, nurses, medical technologist or trained midwife. Where is Newborn Screening Available? NSB as available in Hospitals, Lying-ins, Rural Health Unit and Health Centers. What is the meaning of the Newborn Screening result? A negative screen means that the Newborn Screening is normal. A positive screen means that the newborn must be brought to his or her health practitioner for further testing. What should be done if a baby has a positive Newborn Screening?

Babies with positive results should be referred at once to a specialist for confirmatory testing and further management. What are the disorders included in the Philippine newborn screening program? Currently, there are five disorders being screened, There are: 2. Congenital Adrenal Hyperplasia (CAH)

3. Galactosemia (GAL) GAL is a condition in which babies are unable to process galactose, the sugar present in the milk. Accumulation of excessive galactose in the body can cause many problems, including liver damage, brain damage, cataracts. 4. Phenylketonuria (PKU) PKU is a rare condition in which the baby cannot properly use one of the building blocks of protein called phenylalanine. Excessive accumulation of phenylalanine in the blood cause brain damage. 5. Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD def) G6PD deficiency is a condition where the body lacks the enzyme called G6PD. Babies with this deficiency may have hemolytic anemia resulting from exposure to oxidative substances found in drugs, foods and chemicals. Reminders: G6PD def is the most common condition among NBS panel of disorders. Napthalene or moth ball, and some drugs including herbal medicine should be avoided by people with G6PD def. While waiting for the NBS results, parents are advised not to exposed their baby to napthalene or moth balls. More so, all medications that will be given to the baby must be prescribed by the doctor If the NBS result is G6PD def. consult the babys doctor and proceed with confirmation test. Refer the result to your physician 1. Concept: Exclusive BF in 1st 4-6 months of life

2. Program related Laws a. EO 51 (Milk Code) anti commercialization b. R A 7600 Rooming in c. RA 766 Baby Friendly Hospital Initiative 3. Strategies for a successful Baby friendly and BF program a. BF policy b. Health worker training on BF c. Information dissemination of the advantages of BF d. Teach mothers on proper BF: - R-breast x 10 mins: hunger satisfaction - L-breast x 10 mins: psychoal satisfaction - slow, deep breathing of baby while taking milk - proper burping of baby post BF - BF on demand - BF 30 mins post NSD; 3-4 hrs post CS - discourage pacifier use - BF support Benefits of Breastfeeding FAMILY PLANNING FAMILY PLANNING A national mandated priority public health program to attain the country's national health development A health intervention program and an important tool for the improvement of the health and welfare of mothers, children and other members of the family FAMILY PLANNING It also provides information and services for the couples of reproductive age to plan their family according to their beliefs and circumstances through legally and medically acceptable family planning methods

BASIC PRINCIPLES Responsible Parenthood Responsible Parenting Respect for Life The 1987 Constitution states that the government protects the sanctity of life Abortion is NOT a FP method Birth Spacing Informed Choice Goal: family welfare improvement of quality of life Policies 1. Non coercion 2. Integration 3. Multi sectoral approach 4. Unacceptability of abortion INTENDED AUDIENCE Men and women of reproductive age (15-49) years old) including adolescents TYPES OF FAMILY PLANNING Permanent Temporary 1. Natural Method 2. Barrier Method 3. Hormonal Method 4. Emergency Pill PERMANENT FP: VASECTOMY TUBAL LIGATION TEMPORARY FP: NATURAL METHOD Cervical Mucus

Basal Body Temperature Calendar/Rhythm Method Standard Days Method Lactational Amenorrhea Method Withdrawal TEMPORARY FP: BARRIER METHOD Cervical Cap Condoms Female Condoms Diaphragm with Spermicide Spermicides Sponge TEMPORARY FP: BARRIER METHOD TEMPORARY FP: BARRIER METHOD TEMPORARY FP: BARRIER METHOD TEMPORARY FP: BARRIER METHOD TEMPORARY FP: BARRIER METHOD TEMPORARY FP: BARRIER METHOD TEMPORARY FP: BARRIER METHOD TEMPORARY FP: BARRIER METHOD TEMPORARY FP: BARRIER METHOD TEMPORARY FP: HORMONAL METHOD Injectibles IUD Norplant Implants The Patch

Pills Vaginal Ring TEMPORARY FP: HORMONAL METHOD TEMPORARY FP: HORMONAL METHOD TEMPORARY FP: HORMONAL METHOD TEMPORARY FP: HORMONAL METHOD TEMPORARY FP: HORMONAL METHOD PHILIPPINE NUTRITION PROGRAM Goal The goal of the 2020 Nutritional Guidelines for Filipinos is the improvement of the nutritional status, productivity and quality of life of the population, through adoption of desirable dietary practices and healthy lifestyle. General Objectives 1. To reduce the morbidity and mortality rates due to Avitaminoses and other nutritional deficiencies among the population, particularly among infants and pre schoolers. 2. To reduce PEM among infants and pre schoolers 2. To reduce vitamin A deficiency use among infants and pre schoolers using Bitots spot as indicators 4. To reduce the prevalence of IDA among pregnant mothers and infants. 5. To identify IDD endemic areas using clinical indicators and classify severity using laboratory indicators 6. To reduce significantly the magnitude and severity of IDD through provision of iodine supplements using goiter grade and laboratory indicators Policies: I. II. III. IV. Nutritional Surveillance (NS) Food Production Nutrition Education Nutrition Rehabilitation

V.

Nutritional Surveillance (NS) to detm victims of malnutrition

A. Anthropometric Measurement study of measurements of human dimensions 1. Age for weight best for use - If weight is not appropriate with the age: a. Stunting: growth retardation b. Wasting: muscle wasting connotes malnutrition 2. Age for Height - If height is not appropriate with the age: Stunting 3. Weight for height Gomez Table Reference 4. Skin Folds Test - pinch the external oblique m. (bilbil) w/ your palm Normal: 1 inch Overweight: > 1 inch

5. Middle Upper Arm Circumference (MUAC) - used in children below 5 yrs. Old - measure middle upper arm using tape measure Normal: 13 cm. & above Malnutrition: < 13 cm. Schedule for receiving Vitamin A supplement to infants, preschoolers and mother: Protein Energy Malnutrition (PEM) - refers to a range of clinical disorder due to deficient of protein or calories or both. These maybe manifested by 2.1 Marasmus carbohydrates deficiency (energy giving food) 2.2 Kwashiorkor protein deficiency II. Food Production

1. Fortification products w/o any nutrient are added w/ nutrients

* RA 8172 (Asin Law) - FIDEL Salt (Fortification of iodine Deficiency Elimination) = Iodized salt Patak Asin, Dec 1-5, 2003 * RA 832 (Rice Fortification) - FVR (Fortified Vitamin Rice) - Erap Rice - Gloria Rice 2. Enrichment adding more nutrients to products already w/ nutrients - Canned Goods - Noodles - Junk foods III. Nutrition Education sharing of information to mothers whose children are malnourished. 3 basic food groups: Go CHO Grow CHON Glow Vitamins, minerals and fats Reproductive Health Definition A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity in all matters relating to the reproductive system and to its functions and processes. Exercise of reproductive life with responsibility. Concepts A married couple has the capability to reproduce. Reproductive health is the exercise of reproductive right with responsibility.

RH includes several sexual health for the purpose of enhancement of life and personal relations. RH means safe pregnancy and delivery. Concepts RH includes protection from unwanted pregnancy by having access to safe and acceptable methods of family planning of their choice. RH includes protection from harmful reproductive practices and violence. RH assures access to information on sexuality to achieve sexual enjoyment. Vision Reproductive health practice as a way of life for every man and woman through life. Goals To achieve healthy sexual development and maturation. To achieve their reproductive intention. To avoid illness/disease, injuries disabilities related to sexuality and reproduction. To receive appropriate counseling, and care for RH problem. Goals 3 Es Every pregnancy should be intended. Every birth should be healthy. Every sex act should be free of coercion and infection. Achieve a desire family size. Framework International Focus on womans health

Ultimate Goal: Quality of Life

Local Focus on : Both men and Women; based on its elements. Components/ Elements of RH 1. Maternal and Child Health 2. Family Planning 3. Prevention and Control of RTI including STDs/ HIV/AIDS 4. Adolescent Sexual & Reproductive Health 5. Prevention of Abortion & Management of its complications Components/ Elements of RH 6. Mens Reproductive Health 7. Prevention of Reproductive Tract Cancer and other Gynecological Problems 8. Counseling and Education for Human Sexuality 9. Infertility Management 10. Violence against Women Leprosy Control Program Goals A. Provide MDT to all leprosy cases B. Identify, correct deformities and institute appropriate action C. strengthen education campaign to lower stigma attached to the disease. Coverage A. Paucibacillary (tuberculoid & indeterminate) non Infectious type 6-9 mos. treatment duration

B. Multibacillary (lepromatous & borderline) infectiousType 24-30 mos. Treatment duration.

C. Ambulatory chemo treatment thru use of D. Domiciliary Treatment: RA 4073 for home E. Drugs given free on a monthly supply basis F. PB Regimen (6 mos.)

MDT treatment c/o BHS

a. Supervised: Rifampicin 600mg & Dapsone 100mg once a month b. Self administration: Dapsone 100mg OD G. MB Regimen (24 mos.) a. Supervised: Rifampicin 600mg, Lamprene 300mg , Dapsone 100mg once monthly. b. Self administration: Lamprene 50mg, Dapsone 100mg The Strengthened NTBCP Goals: a. To control TB at year 2000 by reducing: a1. Annual risk of infection from 2.5 % to 1.0% a2. Prevalence rate from 6-7 / 1000 to under 1/1000 pop. b. To adequately & effectively treat all sputum (+) Including those with mod. to far advanced X-ray with Cavitations for the last 6 mos. With SCC use. Coverage A: case finding A1. Direct sputum microscopy for identified TB Symptomatic A2. X-ray of TB symptomatic who are (-) after 2 More sputum exam A3. All DOH services outlets serves as collection Points for sputum of all TB Symptoms. B: Screening : Complete X-ray, Sputum C. Treatment: C1. Free & shall be on ambulatory domiciliary basis except ERs or Ambulatory or exam, Mantoux

C2. All shall sputum (+) and cavitary given priority for SCC for 6mos. C3. Regimen: SR, SCC National Tuberculosis Control Program

cases Shall be

One of the 22 high burdened countries (WHO TB watchlist) 3rd (151/100,000) in the Western Pacific Case notification of all cases 6th leading cause of deaths (2002) 6th leading cause of morbidity (2002) Prevalence of Sm(+) cases 3.1/1,000

NTP objectives Case detection rate of 70 % or more Cure rate of 85 % or more

Directly observed treatment short course Political commitment Quality microscopy service Regular availability of drugs Standardized records & reports Supervised treatment

PTB cases category Category 1 1. Prescribed for: New pulmonary smear (+) cases New seriously ill pulmonary smear (-) cases with extensive parenchymal involvement New severely ill extra-pulmonary TB cases

2. Drugs and duration of treatment: Intensive Phase: 2 months Rifampicin 450 mg Isoniazid 300 mg Pyrazinamide 2 tablets 500 mg Ethambutol 2 tablets 400 mg

Maintenance phase: 4 months Rifampicin 450 mg Isoniazid 300 mg

Category 2 1. Prescribed for: Failure cases Relapse cases RAD (smear +) Other (smear +)

2. Drugs and Duration of treatment: Intensive Phase 2 months

Rifampicin 450 mg Isoniazid 300 mg Pyrazinamide 2 tablets 500 mg Ethambutol 2 tablets 400 mg Streptomycin 1 gm Intensive phase 1 month

Rifampicin 450 mg Isoniazid 300 mg

Pyrazinamide 2 tablets 500 mg Ethambutol 2 tablets 400 mg Maintenance pahse 5 months

Rifampicin 450 mg Isoniazid 300 mg Ethambutol 2 tablets 400 mg Category 3 1. Prescribed for: New smear (-) but within minimal pulmonary TB on radiography as confirmed by a medical officer New extra pulmonary TB (not serious)

2. Drugs and Duration of treatment: Intensive phase 1 month

Rifampicin 450 mg Isoniazid 300 mg Pyrazinamide 2 tablets 500 mg Maintenance pahse 5 months

Rifampicin 450 mg Isoniazid 300 mg Care Older Person Nursing care of older persons is domain of gerontological / geriatric nurse. However;since most older persons are in the community, Community Health Nurses plays an important role in their care. Major cause of morbidity for 50 and above years is influenza Major cause of mortality for 60 and above years is Diseases of the heart Nurses priority concern: ADL, nutrition, safety and security Resolution 46: to add life to years that have been added to life.

ESENTIAL DRUGS THIS PROGRAM FOCUSES ON THE INFORMATION CAMPAIGN ON THE PROPER UTILIZATION AND ACQUISITION OF DRUGS. THE GENERIC ACT OF THE PHILIPPINES IS IN RESPONSE TO THIS CAMPAIGN EIGHT ESSENTIAL DRUGS AT THE HEALTH CENTER (COINRAPP) 5 Alternative Medicine Categories Alternative Medical System Mind-Body Techniques Biologically Based Therapies Body-Based Therapies Energy Therapies TRADITIONAL AND ALTERNATIVE HEALTH CARE PRACTICE As part of primary health care and because of the increasing cost of drugs, the use of locally available medicinal plants has been advocated by the Department of Health. Many local plants and herbs in the Philippine backyard and field have been found to be effective in the treatment of common ailments. L lagundi (five leaved chaste tree), cough U ulasimang-bato / pansit-pansitan, uric acid B bawang (garlic), decrease cholesterol level B bayabas (guava), antiseptic, diarrhea Y yerba buena (peppermint), pain relief S sambong (ngai campor), anti edema A ampalaya (bitter gourd, bitter melon), bld sugar N niyog-niyogan, anti helmintic T tsaang gubat (tsa), diarrhea A akapulko (ringworm bush), anti fungal EPIDEMIOLOGY AND VITAL STATISTICS DEFINITION OF EPIDEMIOLOGY The study of the distribution and determinants of health-related states or events in a specified population FACTORS DEFINING EPIDEMIOLOGY

Study : Surveillance , observation, hypothesis testing, analytic research, experiments. Distribution : analysis by time, place and person. Determinants : Physical, biological, social, cultural and behavioral factors that influence health. AIMS OF EPIDEMIOLOGIC RESEARCH Describe the health status of a population Explain the etiology of disease Predict the disease occurrence Control of disease distribution VITAL STATISTICS Vital Statistics refers to the systematic study of vital events such as births, illnesses, marriages, divorces/separation and deaths. SOURCES OF DATA Population Census Registration of vital data Health surveys Studies and researches

CRUDE OR GENERAL RATES These rates are referred to the total living population. It must be presumed that the total population was exposed to the risk of the occurrence of the event. SPECIFIC RATE the relationship is for a specific population class or group. It limits the occurrence of the event to the portion of the population definitely expose to it Crude Birth Rate a measure of one characteristic of the natural growth or increase of a population. Total # of livebirths registered in a CBR = --------------------------------x1,000 given calendar year

Estimated population as of July of same year Crude Death Rate A measure of one mortality from all causes which may result in a decrease of population

Total No. of deaths registered in a given calendar year CDR = --------------------------------------X1,000 Estimated Population as of July 1 of the same year Infant Mortality Rate - Measures the risk of dying during the 1 st year of life. It is a good index of the general health condition of a community since it reflects the changes in the environmental and medical condition of the community. Total No. of deaths under 1yr of age registered in a given calendar year IMR = ------------------------------------ x1,000 Total number of registered live births of same calendar year

Maternal Mortality Rate It measures the risk of dying from causes related to pregnancy, childbirth and puerperium. It is an index of the obstetrical care needed and received by women in the community. Total no. of deaths from maternal for a given year MMR = --------------------------------------- x1,000 Total no. of livebirths registered for Same year causes registered

Fetal death rate Measures pregnancy wastage. Death of the product of conception occurs prior to its complete expulsion, irrespective of duration of duration of pregnancy. Total no. of fetal deaths registered in a given calendar year

FDR = ------------------------------------ x1,000 Total no. of livebirths registered of year Neonatal Death Rate Measures the risk of dying on the 1st mo of life. May serve as index of the effects of prenatal care and obstetrical management of the newborn. No. of deaths under 28 days of age year NDR = -------------------------------------- x1,000 No. of livebirths registered in the same year registered in a given calendar same

Specific Death Rate Describes more accurately the risk of exposure of certain classes or groups to particular diseases. To understand the forces of mortality, the rates should be made specific provided the data available for both the population and the event in their specifications. The specific rates render more comparable thus reveal the problems of public health. Deaths in specific class or group calendar year Specific = ---------------------------------------x100,000 D.R. Estimated population as of July 1 in the class of group of said year same specified registered in a given

Incidence Rate Measures the frequency of occurrence of the phenomenon during a given period of time. Deals only with new cases. No. of new cases of a particular specified period of time IR = ----------------------------------- x100,000 Estimated population as of July of the same year Prevalence Rate Measures the proportion of the population which exhibits a particular disease at a particular time. This can only be determined following a survey of the population concerned. Deals with total (old and new) number cases. No. of new and old cases of a certain given time PR = ------------------------------------------- x100 Total No. of persons examined at same given time disease registered at a disease registered during a

Attack Rate A more accurate measure of the risk of exposure. Useful in epidemiological investigations No. of persons acquiring a disease AR = ----------------------------------------- x100 No. of exposed to same disease in 2002 Philippine Health Situation Projected Population As of 2005 Life expectancy at Birth (Both sexes) Male Female Crude birth rate (2002) 69.6 yrs. 66.9 yrs. 1,666,773 21.0 Crude death rate (2002) 396,297 5.0 Infant Death rate/1000 Lv 23,778 14.8 Maternal death rate/1000 Lv 1,801 1.1 Fetal death rate 9,341 5.1 Leading Cause of Morbidity Philippines, 2002 1. Pneumonias 2. Diarrheas 3. Bronchitis/ bronchiolitis 79,503,675 84,241,341 same year registered in a given year

4. Influenza 5. HPN (hypertension) 6. TB ( respiratory ) 7. Heart Disease 8. Malaria 9. Chicken Pox 10.Measles Leading Cause of Mortality Philippines, 2002 1. Diseases of the Heart 2. Diseases of Vascular System 3. Malignant Neoplasm 4. Pneumonia 5. Accidents 6. TB, all forms 7. COPD 8. Certain conditions originating in the perinatal period 9. DM 10.Renal: Nephritis, nephrosis, nephrotic syndrome Maternal Mortality Philippines, 2002 1. Other complication related to pregnancy occurring in the course of labor, delivery and puerperium 2. Hypertension complicating pregnancy, childbirth and puerperium 3. Postpartum hemorrhage 4. Pregnancy with abortive outcome 5. Hemorrhage related to pregnancy

Infant Mortality Philippines, 2002 1. Other perinatal conditions 2. Pneumonia 3. Bacterial sepsis of newborn 4. Diarrhea and gastroenteritis of presumed infectious origin 5. Congenital malformation of the heart 6. Other Congenital malformation 7. Disorders related to short gestation and low birth weight 8. Septicemia 9. Measles Home visit Purpose: a. Provide prioritized care to the family, new born & sick b. Assess living conditions c. To fit in history teaching needs d. To discover & report CD cases (notifiable disease) - MOH care number 2 inclusion of AIDS as Reportable disease. - RA 3513 requires all PH workers to report CD Principles for a Home Visit A home visit should have a purpose or objective Planning for a home visit should make use of all available information about the patient and his/her family health records: knowledge of the health center personnel, including those from other agencies that may have rendered services to this particular patient or family. Planning should revolve around the essential needs of the individual and his/her family but priority should be given to those needs recognized by the family itself. Planning of a continuing care should involve the individual and his/her family.

Planning should be flexible and practical. BAG TECHNIQUE A tool making use of public health bag through which the nurse, during his/her visit, can perform nursing procedures with ease and deftness, saving time and effort with the end in view of rendering effective nursing care. Public health bag is an essential and indispensable equipment of the public health nurse which he/she has to carry along when he/she goes out home visiting. It contains basic medication and articles which are necessary for giving care. Principles The use of the bag technique should minimize if not totally prevent the spread of infection from individuals to families, hence, to the community. Bag technique should save time and effort on the part of the nurse in the performances of nursing procedures. Bag technique should not overshadow concern for the patient rather should show the effectiveness of total care given to an individual or family. Bag technique can be performed in variety of ways depending upon agency policies, actual home situation, etc., as long as principles of avoiding transfer of infection is carried out. Clinic Visit Definition: health center visit Phase: A. Pre consultation (assessment) 1. Pre clinic lectures 2. Admission of client vital signs, history 3. Initial history taking, physical assessment B. Consultation phase (intervention) 1. Rx and treatment C. Post consultation phase (evaluation) 1. Interpret Rx and treatment 2. Setting of appointment date

3. Intensive health teachings 4. Completion of records 5. Selection of priority groups for home visits Group Contact Types: a. Mother class - series of lectures w/ mothers - increase10 sessions, informal - decrease 10 sessions, informal - household teachings audience is the family b. Community assembly - verbalization of problems - planning solutions to their problems FAMILY HEALTH NURSING Level of community health nursing practice directed or focused on the family as the unit of care, with health as the goal and nursing as the medium, channel or provider of care Family Case Load the number and kind of families a nurse handles at any given time; it varies with time, as cases are added or dropped based on the need for nursing care and supervision NURSES ROLE IN FHN HEALTH MONITOR PROVIDER OF CARE TO A SICK FAMILY MEMBER COORDINATOR OF FAMILY SERVICES FACILITATOR TEACHER COUNSELOR FNCP

ASSESSMENT: 1ST level identifying health threath deficit, foreseeable crises (identifying health problem) 2nd level identifying family nursing problem based on family task FAMILY TASK ABILITY TO RECOGNIZE PROBLEM ABILITY TO MAKE DECISION ABILITY TO PERFORM NURSING CARE ABILITY TO MAINTAIN ENVIRONMENT CONDUCIVE TO HEALTH ABILITY TO USE COMMUNITY RESOURCES PLANNING should be based on the prioritized and recognized needs of the family. Problem could be: a. Actual health problem b. Potential or high risk health problem c. Possible health problem PRIORITY SETTING 1. Nature of the problem 2. Modifiability of the problem ( current knowledge, resources of the family, nurses and community) 3. Preventive potential (gravity or severity of the problem, duration, current management, exposure of any high risk group) 4. Salience familys perception and evaluation of the problem in terms of urgency and seriousness of attention needed