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Maternal Health Program The Philippines is tasked to reduce the maternal mortality ratio (MMR) by three quarters by 2015 to achieve its millennium development goal. This means a MMR of 112/100,000 live births in 2010 and 80/100,000 live births by 2015. However, the Philippines find it hard to reduce maternal mortality. Similarly, perinatal mortality reduction has been minimal. The percentage of pregnant women with at least four prenatal visits decreased from 77% in 1998 to about 70.4% in 2003 Women who receive at least two dose of tetanus toxoid also decreased from 38% in 1998 to 37.3% in 2003. Only about 76.8% of pregnant women received iron supplementation during pregnancy. The 2000 Philippine Health Statistics revealed that these are the common causes of maternal deaths: o 25% die out of hypertension; o 20.3% postpartum haemorrhage; o 9% pregnancy with abortive outcomes. Births attended by health professionals increased from 56% (1998) to 59.8% (2003). Women with at least one prenatal visit increased to 51% (2003) from 43% in 1998. Only 44.6% of postpartum women received a dose of Vitamin A. Essential Health Service Packages Available in the Health Care Facilities A. ANTENATAL REGISTRATION - Every women has to visit the nearest health facility for antenatal registration and to avail prenatal care services. This is the only way to guide her in pregnancy care to make her prepared for childbirth. Prenatal Visits Period of Pregnancy 1st Visit As early in pregnancy as possible before four months or during the first trimester 2nd Visit During the 2nd trimester rd 3 Visit During the 3rd trimester Every 2 weeks After 8th month of pregnancy till delivery B. TETANUS TOXOID IMMUNIZATION - Both mother and child are protected against neonatal tetanus. Vaccine Timing of Vaccination Period of Protection Dose TT1 5th-6th month of None pregnancy TT2 At least 4 weeks after 3 years TT1 TT3 At the 5th to 6th month of 5 years succeeding pregnancy regardless of interval from previous pregnancy TT4 At the 5th to 6th month of 10 years pregnancy regardless of interval

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At the 5th to 6th month of lifetime pregnancy regardless of interval MACRONUTRIENT and MICRONUTRIENT SUPPLEMENTATION - Interventions for maternal health include supplementation for folic acid, iron, Vitamin A and balanced energy and protein intake to improve maternal and fetal outcomes. - The important years for intervention related to nutrition are from pregnancy to two years of age. - Inability to make essential interventions available causes irreversible damages and increases the risk of girls becoming malnourished mothers, who then have low-birth-weight babies. TREATMENT OF DISEASES and OTHER CONDITIONS - Iodine deficiency is one of the preventable cause of mental retardation and brain damage. It is also associated with cretinism, low mean birth weight and increased infant mortality. All of 4 provinces of Northern Mindanao are high-risk IDD areas. The nurse can assess the womens thyroid gland by palpation, based on the report that 30% of pregnant women have goiter. - Malaria is the 9th leading cause of morbidity among women. In areas where malaria is endemic the health care provider gives 2 tablets of chloroquine phosphate (250mg/tablet) every week for the duration of pregnancy. EARLY DETECTION AND MANAGEMENT OF COMPLICATIONS OF PREGNANCY - The nurse needs to have the skill in detecting the danger signs of pregnancy. Patients manifesting these signs need to referred to the nearest facility or physician. Interestingly, the results of the study by ADB on 41 out of 79 provinces in the Philippines show that only 56.6% of women were advised to go to specific public facilities in case of pregnancy complication. The rest were not adequately informed where they can go if they encountered pregnancy complications. - Prompt detection and management will help in decreasing the chances for maternal and fetal mortality and morbidity. Specifically, the nurse needs to report vaginal bleeding, edema of the face and hands, headache, dizziness, blurred vision, and pallor. - In the prenatal check-up, the health care provider also takes the womens fundic height, temperature, blood pressure, weight, signs of urinary infection and signs of eclampsia especially starting the 20th week. FAMILY PLANNING COUNSELLING - Family planning and fertility awareness are part of what is discussed in the first prenatal visit and the subsequent visits. After delivery, the benefits of family planning, risks of a pregnancy too soon and most suitable family planning methods for a breastfeeding woman are discussed. The choices offered are IUD, condom, progesterone only pill, natural family planning, spermicides and permanent methods

G. STD/HIV/AIDS PREVENTION AND MANAGEMENT - The WHO standard aims for all women during pregnancy, childbirth and the postnatal period to be given appropriate information on the prevention and recognition of Sexually Transmitted Infections (STIs) and reproductive tract infections (RTIs). - They should be assessed for STIs/RTIs and, when required, provided with prompt and effective treatment for themselves and, in the case of STIs, their partners. - Effective management of STIs is the key to their control, as it prevents the development of complications and sequelae, reduces the spread of these diseases in the community and offers a unique opportunity for targeted education on HIV prevention. The Nursing Process in a Nurse-Managed care A nurse-managed pregnancy care is best described as the nurse taking ownership of the delivery of pregnancy services. Her roles include being a practitioner, health educator, and coordinator. This means that the nurse has a level of expertise and decision making capability to work with the client and family in attaining the expected outcomes of care. Whether she works with the client through a clinic or a home visit, the main responsibility of ensuring that the woman is able to undergo a risk assessment, receive visit-specific screening tests, education, immunizations or supplements and interventions. The use of nurse-managed care is also part of the implementing current evidence that women benefit most when there is continuity of care. The nurse will also bridge the gap of making effective referrals so that the woman know where to go and what to do in the face of complications in pregnancy. CHILD HEALTH PROGRAMS A. INFANT AND YOUNG CHILD FEEDING - Issued by the WHO and UNICEF and 2002 as endorsed by consensus in the 55th World Health Assembly in May 2002 and the UNICEF Executive Board in September 2002. - The strategy calls for the promotion of breastmilk as the ideal food for the health growth and development of infants; and of exclusive breastfeeding for the first 6 months of life as means to achieve optimal growth, development and health of newborns. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond. Since breastfeeding is also a learned behaviour, all mothers need accurate information and skilled support and counselling within their families, communities and health cares system to successfully breastfeed. B. EXPANDED PROGRAM ON IMMUNIZATION Objectives of EPI - To reduce morbidity and mortality rates among infants and children from six childhood immunizable disease Elements of EPI - Target Setting

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Cold chain Logistic Management- Vaccine distribution through cold chain is designed to ensure that the vaccines were maintained under proper environmental condition until the time of administration. - Information, Education and Communication (IEC) - Assessment and evaluation of Over-all performance of the program - Surveillance and research studies Fully Immunized Child (FIC)- less than 12 months old child with complete immunizations of DPT, OPV, BCG, Anti Hepatitis, Anti measles. There is no contraindication to immunization except when the child is immunosuppressed or is very, very ill (but not slight fever or cold). Or if the child experienced convulsions after a DPT or measles vaccine, report such to the doctor immediately. Malnutrition is not a contraindication for immunizing children rather; it is an indication for immunization since common childhood diseases are often severe to malnourished children. FEFO (first expiry and first out) - vaccine is practiced to assure that all vaccines are utilized before the expiry date. Proper arrangement of vaccines and/or labelling of vaccines expiry date are done to identify those near to expire vaccines. The 7 immunizable diseases - Tuberculosis - Diphtheria - Pertussis - Measles - Poliomyelitis - Tetanus - Hepatitis B Health workers are vital to health care delivery system. The most critical problem we are facing now is the lack of nurses and other disciplines in carrying out health activities in immunization. As a nurse you need to: - Actively masterlist infants eligible for vaccination in the community - Immunize infants following the recommended immunization schedule, route of administration, correct dosage and following the proper cold chain storage of vaccines - Observe aseptic technique on immunization and use one syringe and one needle per child. This reduces blood-borne disease and promote safety of injection practices - Disposed used syringes and needles properly by using a collector box and disposing it in the septic vault to prevent health hazard - Inform, educate, and communicate with parents - Conduct health visits in the community to assess other health needs of the community and be able to provide package of health services to targets - Identify cases of EPI target disease per standard case definition - Manage vaccines properly by following the recommended storage of vaccine - Record the children given with vaccination in the Target Client List

- Submit report and record of children vaccinated, cases and deaths on EPI diseases - Identify and actively search cases and deaths of EPI target diseases following standard case definition. C. MANAGEMENT OF CHILDHOOD ILLNESSES The IMCI has been established as an approach to strengthen the provision of comprehensive and essential health package to children. Children with various health conditions although considered common diseases, are difficult to manage. Some diseases have the same symptoms that needs to be furthered assessed before classification and treatment takes place. The steps of IMCI are: 1. Assess the patient. Taking the history of the patient is one way of getting information about the disease condition. This can be done by asking and observing patients condition to explore possible causes. 2. Classify the Disease. A thorough assessment supported with laboratory results is necessary for classification of illness and confirmation of the disease. Color Code Classification Level of Management Green Mild Home Care Yellow Moderate Manage at the RHU Pink Severe Urgent referral in Hospital 3. Treat the patient. Treatment is a curative method of treating diseases. This vary on the condition of the patient 4. Counsel the patient. Providing health education to clients promotes health and avoid risk of infection. These are important for parents/caregivers especially those who lack knowledge on health practices and risk factors that contribute to different ailments. D. NUTRITION PROGRAM Micronutrient Supplementation. Includes twice a year distribution of Vitamin A capsules through the Araw ng Sangkap Pinoy, known as Garantisadong Pambata, or Child Health Week is the approach adopted to provide micronutrient supplements to 6-71 months old pre-schoolers on a nationwide scale Food Fortification Program. RA 8976, is the addition of essential nutrients to widely consumed food product at levels above its natural state in a cost effective and sustainable intervention. Provides mandatory fortification of staples namely: flour, with iron and vitamin A, cooking oil and refined sugar with Vitamin A and rice with iron, and the voluntary fortification of processed foods through the Sangkap Pinoy Seal. E. ORAL HEALTH PROGRAM Primary objectives includes: a) To increase the proportion of Orally Fit Children under 6 years old to 80% by 2010; b) To control oral health risks among young people. Classification of Oral Interventions o Preventive- Consists of measures which will promote oral health and provide specific protection from the occurrence of dental caries and other oral diseases. Some of these interventions include: oral examinations, oral hygiene (brushing of teeth), pit

and fissure sealant program against tooth decay and Flouride Utilization Program Curative- are remedial measures applied to halt the progress of oral disease and restore the sound condition of the teeth and supporting tissues. It includes: Permanent filling to restore salvageable teeth, gum treatment and root planning, extraction and drainage of localized oral abscesses. Promotive- services includes health education activities directed to priority groups thru individual or group approach using accepted tools and media.

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FAMILY PLANNING 1. Female Sterilization. Safe and simple surgical procedure which provides permanent contraception for women who do not want more children. Also known as bilateral tubal ligation that involves cutting or blocking the two fallopian tubes. 2. Male Sterilization. Permanent method wherein the vas deferens (passage of sperm) is tied and cut or blocked through a small opening on the scrotal skin. It is also known as vasectomy. 3. Pill. Contains hormones estrogen and progesterone taken daily to prevent contraception 4. Male Condom. Thin sheath of latex rubber made to fit on a mans erect penis to prevent the passage of sperm cells and sexually transmitted disease organisms into the vagina. It provides dual protection from STIs including HIV preventing transmission of disease microorganism during intercourse. 5. Injectables. Contain synthetic hormone, progestin which suppresses ovulation, thickens cervical mucus, making it difficult for sperm to pass through and changes uterine lining. 6. Lactating Amenorrhea Method or LAM. Temporary introductory postpartum method of postponing pregnancy based on the physiological infertility experienced by breastfeeding women. 7. Mucus/Billings/Ovulation. Abstaining from sexual intercourse during fertile (wet) days prevents pregnancy. 8. Basal Body Temperature. BBT method is identifying the fertile and infertile period of a womans cycle by daily taking and recording the rise in body temperature before and after ovulation. 9. Symptom-thermal method. STH method is identifying the fertile and infertile days of the menstrual cycle as determined through a combination of observations made on the cervical mucus, basal body temperature recording and other signs of ovulation. 10. Two day method. Is a simple fertility awareness based method of family planning that involves cervical secretions as indicator of fertility, women checking the presence of secretions everyday. 11. Standard days method. A new method of family planning method in which all users with menstrual cycles between 26 and 32 days are counselled to abstain from sexual intercourse on days 8-19 to avoid pregnancy. The couples used color coded cycle beads to mark the fertile and infertile days of the menstrual cycle.

The Roles of Public Health Nurse on the Family Planning Program - Provide counselling among the clients will help increase FP acceptors and avoid defaulters o To inform and educate and convince mothers on the use of family planning methods o To inform and discuss the importance and benefits/advantages/disadvantages of family planning o To inform its side effects, complications and what to do if problems develop. o To inform its effectiveness of FP methods - Provide packages of health services among reproductive age group in all health facilities o Family planning o MCHN o Management of Reproductive Tract Infections including STIs/HIV/AIDS o Violence against women o Management of breast and other Reproductive Cancers - Ensure the availability of FP supplies and logistics for the client. ENVIRONMENT AND SANITATION A. Health and Sanitation Environmental health and sanitation is still a health problem in the country. Diarrheal disease ranked first in the leading cause of morbidity among the general population. The department of health through the EOHO, has authority to act on all issues and concerns in environment and health including the very comprehensive Sanitation code of the phil. (PD 856, 1978). B. Water Supply Sanitation Program Policies: Approved types of water supply facilities Level 1(point source) a protected well or a developed spring with an outlet but without a distribution system, generally adaptable for rural areas where the house are thinly scattered. Level 2(communal faucet system or stand-posts) a system composed of a source a reservoir, a piped distribution network and communal faucets, located at not more than 25 meters from the furthest house. Level 3(waterworks system or individual house connections) a system with a source, a reservoir, a piped distributor network and household taps. Unapproved water type facility - water coming from doubtful sources such as open dugs well, unimproved spring

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Access to safe and potable drinking water Water quality and monitoring surveillance every municipality through its rural health units must formulate an operational plan for quality and monitoring surveillance every year. Waterworks/water system and well construction Well sites shall require prior approval from the secretary of health Well construction shall comply sanitary requirements Water system shall supply safe and potable water Water shal be made readily available Adequate pressure and volume shall be provide in the water system distribution line Proper Excreta and Sewage Disposal Program Approved types of toilet facilities

Level 1 non-water carriage toilet facility toilet facilities requiring small amount of water to wash the waste into the receiving space Level 2 on site toilet facilities of the water carriage type with water sealed and flushed type with septic tank disposal facilities. Level 3 water carriage types of toilet facilities connected to septic tanks and/or sewerage system to treatment plant.

D. Food Sanitation Program Policies: Food establishment shall be appraised as to the following sanitary conditions: Inspection/approval of all food sources, containers, transport vehicles. Compliance to sanitary permit requirement for all food establishments. Provision of updated health certificate for food handlers, cooks and cook helpers. DOHs Administration Order no. 1 2006 requires all laboratories to use Formalin Ether Concentration Technique (FECT) instead of direct fecal smear in the analysis of stools for food handlers Destruction or banning of food unfit for human consumption. Training of food handlers and operators on food sanitation. Food establishments shall be rated and classified as to follows: Class A excellent Class B very satisfactory Class C satisfactory Ambulant food vendors shall comply with the requirements as to the issuance of health certificate.

Household food sanitation are to be promoted and monitored and food hygiene education to be intensified. Four Rights in Food Safety:

Right source Right preparation Right cooking Right storage Hospital Waste Management Programs Policies:

All newly constructed/authorized and existing government and private hospitals shall prepare and implement a Hospital Waste Management Program as a requirement for registration/renewal of license. The use of appropriate technology and indigenous materials for HWM system shall be adopted. Training of all hospital personnel involved in waste management shall be an essential part of hospital training program. Public information campaign on health and environmental hazard arising from mismanagement of hospital shall be the responsibility of the hospital administration. DOH hospital waste management guidelines/policies shall be guided by existing legislative health and environmental protection laws policies on waste management. Local ordinances regarding the collection and disposal techniques shall be institutionalized.

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COMMUNICABLE DISEASES A. Tuberculosis (National Tuberculosis Control Program) Vision: A country where TB is no longer a 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 (Millennium Development Goal) Targets: Cure at least 85% of the sputum smear-positive TB patient discovered; Detect at least 70% of the estimated new suptum smearpositive TB patients Public Health Nursing Responsibilities for Adult TB o Together with other NTP staff/workers, manage the procedures for case-finding activities o Assign and supervise a treatment partner for a patient who will undergo DOTS

Supervise rural health midwives (RHMs) to ensure proper implementation of DOTS o Maintain and update TB Register o Facilitate requisition of drugs and other NTP supplies o Provide continuous health education to tall TB patients under treatment and encourage family and community participation in TB control o In coordination with physician, conduct training to health workers o Prepare, analyse, and submit quarterly reports to the Provincial Health Office or City Health Office Public Health Nursing Responsibilities for Child TB o Interview and open treatment cards for identified tuberculous children o Perform tuberculin testing and reading to eligible children o Maintain NTP records (treatment card, TB reister for children and quarterly reports) o Manage requisition and distribution of drugs o Assist the physician in supervising other health workers of the RHU in the proper implementation of the policies and guidelines on TB in children o Assist in the training of other health workers in Tuberculin testing and reading. B. Leprosy (LEPROSY CONTROL PROGRAM) Multi-Drug Therapy (MDT) is the use of 2 or more drugs in the treatment of leprosy. It is proven effective cure for leprosy and renders patients noninfectious a week after starting treatment. Further, MDT home treatment of leprosy patients is possible. Public Health Nursing Responsibilities o Prevention Health education of patients, families and the community on the nature of the disease, etc. Advocate healthful living through proper nutrition, adequate rest, sleep and good personal hygiene BCG vaccination especially of infants and children. o Casefinding Recognize early signs and symptoms of leprosy and refer suspects to RHU Take patient and family history and fill up patient records Conduct epidemiological investigation and report findings to MHO Assist physicians in physical examination Assesses health of family members and other household contacts.

Management and Treatment

 Promotes healthful living by teaching the value of good personal hygiene, proper nutrition, adequate rest and sleep Helps patient/family understand and accept the problems brought about by the illness and assess their capabilities to deal with them. C. Schistosomiasis (Schistosomiasis Control Program) Nursing Responsibilities Preventive Measures: -Educate the public in endemic areas regarding mode of transmission and methods of protection. -Dispose of feces and urine so that viable eggs will not reach bodies of fresh water containing intermediate snail host. -Improve irrigation and agriculture practices: reduce snail habitats -Treat snail-breeding sites with molluscicides - Prevent exposure to contaminated water -Provide water for drinking, bathing and washing clothes from sources free of the etiologic agent. -Treat patients in endemic areas to prevent disease progression -Travelers visiting endemic areas should be advised of the risks and informed about preventive measures D. Filariasis Infectious Agents: Human Lymphatic Filariasis is a chronic parasitic infection caused by nematode parasites known as Wuchereria bancrofti, Brugia malayi and / or Brugia timori. Mode of Transmission The disease is transmitted to a person through bites from an infected female mosquito primarily Aedes poecilius that bites at night.

E. Malaria Malaria is produced by intraethrocytic parasites of the genus Plasmodium; P falciparum, P. vivax, P. ovale, and P. malariae. Prevention of Epidemic: The following should be done in the event that an imminent epidemic occurs: -Mass blood smear -Immediate confirmation and follow-up of cases -Insecticide-treatment of mosquito nets -Focal Spraying -Stream Clearing

-Intensive IEC campaign Important education to the public: -taking of chemoprophylaxis -wearing of long-sleeved clothing and trousers when going out at night. -Application of insect repellant to skin -Use of mosquito nets -Use of screen in doors and windows. -Use of insecticide aerosols and pyrethroid mosquito coils -Clearing of hanging branches of trees along the stream.

F. Dengue Hemorrhagic Fever Classification: -Severe, frank type- with flushing, sudden high fever, severe hemorrhage, followed by sudden drop of temperature, shock and terminating in recovery or death. -Moderate-with high fever, but less hemorrhage, no shock. -Mild-with slight fever, with or without petechial hemorrhage but epidemiologically related to typical cases usually discovered in the course of investigation of typical cases. Control Measures: o Eliminate vector by: changing water and scrubbing sides of flower vases once a week. destroy breeding places of mosquito by cleaning surroundings proper disposal of rubber tires, empty bottles and cans keep water containers covered

G. Measles Prevention and Control: -Avoid exposing children to any person with fever or with acute catarrhal symptoms. -Isolation of cases from diagnosis until 5-7 days after onset of rash. -Disinfection of all articles soiled with secretions of nose and throat. -Encouragement by the health department and by private physician of administration of measles immune globulin to susceptible infants and children under 3 years of age in families or institutions where measles occurs.

Nursing Care: -Protect eyes of patients from glare of strong light as they are apt to be inflamed. -Keep the patient in an adequately ventilated room but free from drafts and chilling to avoid complications of pneumonia. -Teach, guide and supervise correct technique of giving sponge bath for comfort of patient. -Check for corrections of medication and treatment prescribed by the physician.

H. Typhoid Fever Public Health Nursing Responsibility Teach members of the family how to report all symptoms to the attending physician especially when patient is being cared for at home. Teach, guide and supervise members of the family on nursing techniques which will contribute to the patients recovery Interpret to family the nature of the disease and need for practicing preventive and control measures Nursing Care Demonstrate to family how to give bedside care, such as tepid sponge bath, feeding, changing of bed linen, use of bedpan and mouth care Any bleeding from the rectum, blood in stools, sudden acute abdominal pain, restlessness, falling of temperature should be reported at once to the physician or the patient should be brought at once to the hospital Take vital signs and teach family member how to take and record them. I. Hepatitis A Infectious Hepatitis, epidemic hepatitis, catarrhal jaundice A form of hepatitis occurring either sporadically or in epidemics and caused by viruses introduced by fecally contaminated water or food. Young people especially school children are most frequently infected

Prevention and Control o Ensure safe water for drinking o Sanitary method in preparing, handling, and serving food o Proper disposal of feces and urine o Washing hands very well before eating and after using the toilet o Separation and proper cleaning of articles used by patient

J. Rabies Rabies is an acute viral encephalomyelitis caused by rabies virus, a rhabdovirus of the genus lyssavirus. It is fatal once signs and symptoms appear 2 Kinds 1. Urban or canine rabies is transmitted by dogs 2. Sylvatic rabies is a disease of wild animals and bats which sometimes spread to dogs, cats and livestock. Rabies remains a public health problem in the Philippines. Approximately 300 to 600 Filipinos die of rabies every year Philippines has one of the highest prevalence rate of rabies in the whole world Management/Prevention o The wound must be immediately and thoroughly washed with soap and water. o Antiseptic such as povidone iodine or alcohol may be applied. o The patients may be given antibiotics and anti-tetanus immunization o Post exposure treatment o Active immunization -3 years o Passive immunization-immediate protection against rabies