AKLAN STATE UNIVERSITY

School of Arts and Sciences

Bachelor of Science in Nursing

Developed By:

Ma.Ellen N. Cortes, RN
April Justine Glen R. Elepongga, RN
Bergen Julie Fretch R. Estanislao, RN
Fides C. Fosana, RN
Joanna Grace T. Invina, RN
Lucelle Ann M. Macahilig, RN
Ma. Jemalyn R. Marcelino, RN
April Ann A. Nillasca, RN
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Introduction
Community Health Nursing is a unique blend of nursing and public health practice designed into a
human service. Its responsibilities extend to the care and supervision of individuals and families in
their homes.
Community Health Nursing is one of the two major fields of Nursing other than Hospital Nursing
which uses interchangeably with public health nursing. Its goal is to promote, protect and preserve
the health of the public. It envision to respond the needs of the community health.
This is to introduce other field of nursing, that being a nurse is not only to focus on providing
treatment to our clients, but also to promote healthy lifestyle.
In this module, we will be familiar in different aspects of being a community health nurse, to
educate the public that includes the individual, the family, population and the community, on
practicing healthy lifestyle, and preventing common diseases.
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Preface!
Change is inevitable. It’s a human nature and nursing education delivery is not exempted
from this. Nurse academicians are forced to adopt many approaches that includes modular, Open
Management System, self directed learning, problem based learning and simulation especially in
practicing Related Learning Experience of our students in the midst of this pandemic. Nursing
students exposures in the hospitals and health centers for their Nursing Skills and Related
Learning Experience will be replaced by multiple modules. Modules can help maintain connections
with our students during and in response to this COVID-19.

As per Instructor’s view, modular approach in giving quality nursing education is still
questionnable because students get minimum guidance from the skilled hands but with our
dedication to mold best nurses, modules could help build stronger student learning interest and
excitement
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TABLE OF CONTENTS

PART – I: Family Care Plan 5

PART – II: Bag Technique 37
PART – III: Clinic Visit 46
PART – IV: Home Visit 48
PART – V: Herbal Medicine 51
PART – VI: Field Health System Information System 59
PART – VII: National Immunization Program 73
PART – VIII: Integrated Management of Childhood Illnesses 112
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PART-I: Family
Nursing Care
Plan
LEARNING OBJECTIVES

After reading this module, the student must be able to:

1. Identify the different steps in family nursing care plan.
2. Identify and prioritize family health problems.
3. Understand and apply the process of FNCP.
4. Create or formulate family nursing care plan.
NURSING PROCESS
Nursing process is the means by which nurses address health needs and problems
of their client. It is a logical and systematic way of processing information gathered from
different sources and translating intentions into meaningful actions and interventions. There
are four phases: assessment, planning, implementation and evaluation.
Basic Phases of Nursing Process Elaboration of the Nursing Process
Assessment Establishing a relationship
Assessment*
Diagnosis*
Planning Planning outcomes*
Planning interventions*
Implementation Implementation*
Evaluation Evaluation*
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NURSING ASSESSMENT

Is the first major phase of the nursing process. In family health nursing practice, this
involves a set of actions by which the nurse determines the status of the family as a client,
its ability to maintain itself as a system and functioning unit, and its ability to maintain
wellness, prevent, control or resolve problems in order to achieve health and well- being
among its members. Data about the present condition or status of the family are compared
against norms or standards of personal, social and environmental health, system integrity
and ability to resolve system problems. Theses norms or standards are derived from
values, beliefs, rules or expectations.
Three major steps in nursing assessment as applied to family nursing practice:
1. Data Collection
2. Data Analysis
3. Formulation of Diagnosis
 The Assessment Phase in Family Health Nursing Practice
DATA COLLECTION
Framework: Use an organized and comprehensive approach to assessment
First Level- Data on status/ condition of:
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• Family/ Household member

• Home and environment
Second Level- Data on family’s assumption of health task on each health condition/ Problem identified in the first
level assessment.
Methods/ Sources:
First Level Assessment:
• Health status of family/ household member:
a) Health assessment
b) Laboratory/ diagnostic test results
c) Records/reports
• Home environment
a) Observation/ocular survey
• Recogniz
b) Interview
e need to
c) Laboratory/ diagnostic test results
use data
d) Records/ reports
based on Continuous data
Second-Level Assessment
evidence. validation/
• In-depth interview on realities/perceptions about attitudes towards assumption/ performance of health task.
• Ensure
• Observation: relate verbal with non-verbal cues Update for
accuracy
and adequacy of
reliability evidence to
of data. DATA ANALYSIS support
• Check for • Sort data diagnosis
inconsiste • Cluster/group related data
ncies. • Distinguish relevant data from irrelevant data
• Complete • Identify patterns (e.g. function, behavior, lifestyle)
missing • Compare patterns with norms or standards.
infor- • Interpret results
mation • Make inferences/ draw conclusions
HEALTH CONDITIONS/ PROBLEMS AND FAMILY NURSING DIAGNOSES
First Level Assessment: Define the health conditions/ problems (categorized as: wellness states, health deficits,
health threats, foreseeable crisis or stress points.
Second-Level Assessment: Define the family nursing problems/ diagnoses as statement of:
Family’s Inability to Perform health task on each health condition/problem specifying the barriers to
performance or reasons for non-performance of family health tasks.
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Nursing diagnosis is the end result of two major types of nursing assessment in the family
nursing practice:
1. FIRST LEVEL ASSESSMENT- is a process whereby data about the current health
status of individual members, the family as a system and its environment are
compared against norms or standards of personal, social and environmental health
and interactions/ interpersonal relationships within the family system as end result
of data analysis during the first level assessment, specific health conditions or
problems are identified and categorized as (a) wellness state (b) health threats (c)
health deficits and (d) stress points or forseeable crisis situations
2. SECOND LEVEL ASSESSMENT- specifies the nursing problems that the family
encounters in performing the health tasks with respect to a given health condition
or problem, and the causes, barriers or etiology of the family’s inability to perform
the health task. It also includes those that specify or describe the family’s realities,
perceptions about and attitudes related to the assumption or performance of family
health tasks on each health condition or problem identified during the first level
assessment.
STEPS IN FAMILY NURSING ASSESSMENT
1. DATA COLLECTION
Five types of data for first level assessment
1. Family structure, characteristics and dynamics - include family composition and
demographic data, type of family form and structure, decision-making patterns,
interpersonal relationships, interactional patterns/ interpersonal relationships and
communication patterns or processes affecting family relatedness (ex. Expression
of feelings or emotions particularly related with addressing converging and
diverging motivations or perceptions, such as during conflict) consistency and
congruence between intended and received messages; and, explicitness of
message for appropriateness, effectivity and efficiency of the communication
process related with role performance, individual members’ health and family
system integrity.
2. Socio- economic and cultural characteristics - include occupation, place of work
and income of each working member; educational attainment of each family
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member; ethnic background and religious affiliation; family traditions, events or

practices affecting members’ health or family functioning; significant others and
the role(s) they play in the family’s life; and the relationship of the family to the
larger community.
3. Home and environment- include information on housing and sanitation facilities;
kind of neighborhood and availability of social, health, communication and
transportation facilities in the community.
4. Health status of each member - includes current and past significant health
condition/s or illness/es; beliefs and practices conducive to health and illness;
nutritional and developmental status; physical assessment findings and significant
results of laboratory/ diagnostic tests/ screening procedures.
5. Values and practices on health promotion/ maintenance and disease prevention -
include use of promotive-preventive services as evidenced by immunization status
of at-risk members and use of other healthy lifestyle related services; adequacy of
rest/ sleep, exercise, relaxation activities, stress management or other healthy
lifestyle practices; opportunities which enhance feelings of self-worth, self-efficacy
and connectedness to self, others and a higher power; essence of
meaningfulness.
Data for Second Level Assessment
1. The family’s perception of the condition or problem
2. Decisions made and appropriateness; if none, reasons and
3. Actions taken and results; if none, reasons; and
4. Effects of decisions and actions on other family members
Data Gathering Methods And Tools
1. Observation- method of data collection is done through the use of the sensory
capacities- sight, hearing, smell and touch. Through direct observation, the nurse
gathers information about the family’s state of being and behavioral responses.
The family’s health status can be inferred from the signs and symptoms of problem
areas reflected in the following:
a. Communication, interaction patterns and interpersonal relationships
expected, used and tolerated by family members
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b. Role perceptions/ task assumptions by each member, including

decision-making patterns
c. Conditions in the home and environment
Data gathered through this method have the advantage of being subjected to
validation and reliability testing by other observers.
2. Physical Examination- this is done through inspection, palpation, percussion and
auscultation and measurement of specific body parts and reviewing the body
systems.
3. Interview- One type of interview is completing a health history for each family
member. The health history determines current health status based on significant
past health history (ex. Developmental accomplishments, known illnesses,
allergies, restorative treatment, residence in endemic areas for certain diseases or
exposures to communicable diseases); family history (ex. Genetic history in
relation to health and illness) and social history such as intrapersonal and
interpersonal factors affecting the family member’s social adjustment or
vulnerability to stress and crisis.
A second type of interview is collecting data by personally asking significant family
members or relatives questions regarding health, family life experiences or
relatives questions regarding health, family life experiences, and home
environment to generate data on what wellness condition/s and health problems
exist in the family and the corresponding family nursing problems for each health
condition or problem. Ensuring confidentiality and respect for the family’s right to
self-determination are key principles to consider during all phases of the nursing
process.
4. Record review- the nurse may gather information through reviewing existing
records and reports pertinent to the client. These include the individual clinical
records of the family members, laboratory and diagnostic reports, immunization
records, reports about the home and environmental conditions, or similar sources.
5. Laboratory/ diagnostic tests- another method of data collection is through
performing laboratory tests, diagnostic procedures or other tests of integrity and
functions carried out by the nurse herself and/or other health workers.
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2. DATA ANALYSIS
1. Sorting of data for broad categories such as those related with the health status or
practices of family members or data about home and environment.
2. Clustering of related cues to determine relationships between and among data
3. Distinguishing relevant from irrelevant data to decide what information is pertinent
to understanding the situation at hand based on specific categories or dimensions
4. Identifying patterns such as physiologic function, developmental,
nutritional/dietary, coping/adaptation or communication or interaction patterns and
lifestyle.
5. Relating family data to relevant clinical/ research findings and comparing patterns
with norms or standards of health (ex. Nutritional intake, immunization status,
growth and development, social and economic productivity, environmental health
requisites) family functioning and assumption of health tasks
6. Interpreting results based on how family characteristics, values, attitudes,
perceptions, lifestyle, communication, interaction, decision-making or role/task
performance are associated with specific health conditions or problems identified
7. Making inferences or drawing conclusions about the reasons for the existence of
the health condition or problem and risk factor/s related to non-maintenance of
wellness state/s which can be attributed to non-performance of family health
tasks.
3. NURSING DIAGNOSES: FAMILY NURSING PROBLEMS
The end result of the second level assessment is a set of family nursing problems
for each health condition or problem.
• Wellness condition- is a nursing judgment related with the client’s
capability for wellness.
• Health condition or problem- is a situation which interferes with the
promotion and/or maintenance of health and recovery from illness or
injury.
A wellness state or health condition/ problem becomes a family nursing problem
when it is stated as the family’s failure to perform adequately specific health tasks
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to enhance or sustain the wellness state or manage the health problem. This is
called the NURSING DIAGNOSIS in family nursing practice.
Typology of Nursing Problems in Family Nursing Practice
To facilitate the process of defining family nursing problems, a classification system
of family nursing problems was developed and field tested in 1978. This tool is called, A
Typology of Nursing Problems in Family Nursing Practice.
TYPOLOGY OF NURSING PROBLEMS IN FAMILY NURSING PRACTICE
FIRST LEVEL SSESSMENT
I. PRESENCE OF WELLNESS CONDITION- stated as Potential or Readiness- a clinical or
nursing judgment about a client in transition from a specific level of wellness or capability
to a higher level. WELLNESS POTENTIAL is a nursing judgment on wellness state or
condition based on client’s performance, current competencies or clinical data but NO
explicit expression of client desire. READINESS FOR ENHANCED WELNNESS STATE is
a nursing judgment on wellness state or condition based on client’s current competencies
or performance, clinical data and explicit expression of desire to achieve a higher level of
state or function in a specific area on health promotion and maintenance.
A. Potential for Enhanced Capability for:
1. Healthy Lifestyle (ex. Nutrition/ diet, exercise/ activity)
2. Health Maintenance/Health Management
3. Parenting
4. Breastfeeding
5. Spiritual well-being- process of client’s developing/ unfolding of mystery through
harmonious interconnectedness that comes from inner strength/ sacred
source/God
6. Others, specify: ___________
B. Readiness for Enhanced Capability for:
1. Healthy Lifestyle (ex. Nutrition/ diet, exercise/ activity)
2. Health Maintenance/Health Management
3. Parenting
4. Breastfeeding
5. Spiritual well-being
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II. PRESENCE OF HEALTH THREATS- conditions that are conducive to disease and
accident, or may result to failure to maintain wellness or realize health potential.
Examples of these are the ff:
A. Presence of risk factors of specific diseases (ex lifestyle diseases, metabolic
syndrome)
B. Threat of cross infection from a communicable disease case
C. Family size beyond what family resources can adequately provide
D. Accident/ fire hazards. Examples:
1. Broken stairs 3. Fire hazards
2. Pointed/ sharp objects, 4. Fall hazards
poisons and medicines
improperly kept
E. Faulty/ unhealthful nutritional/ eating habits or feeding techniques or practices- specify:
1. Inadequate food intake both in 3. Faulty eating habits
quality and quantity 4. Ineffective breastfeeding
2. Excessive intake of certain 5. Faulty feeding techniques
nutrients
F. Stress- provoking factors- specify:
1. Strained marital relationship 3. Interpersonal conflicts
2. Strained parent- sibling between family members
relationship 4. Care- giving burden
G. Poor home/ environmental condition/ sanitation- specify:
1. Inadequate living space 5. Improper garbage/ refuse
2. Lack of food storage facilities disposal
3. Polluted water supply 6. Unsanitary waste disposal
4. Presence of breeding or 7. Improper drainage system
resting sites of vectors of 8. Poor lighting and ventilation
diseases (ex. Mosquitoes, 9. Noise pollution
flies, roaches, rodents etc) 10. Air pollution
H. Unsanitary food handling and preparation
I. Unhealthful Lifestyle and personal habits/practices- specify:
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1. Alcohol drinking 9. Inadequate rest or sleep

2. cigarette./ tobacco smoking 10. Lack of/ inadequate
3. Walking barefooted or exercise/ physical activity
inadequate footwear 11. Lack of/ inadequate
4. Eating raw meat or fish relaxation activities
5. Poor personal hygiene 12. Non-use of self- protection
6. Self-medication/ substance measures (ex. Non-use of
abuse bednets in malaria and
7. Sexual promiscuity filariasis endemic areas)
8. Engaging in dangerous sports
J. Inherent personal characteristics- ex. Poor impulse control
K. Health history which may participate/induce the occurrence of a health deficit (ex.
History of difficult labor)
L. Inappropriate role assumption- ex. Child assuming mother’s role, father not assuming
his role
M. Lack of immunization/ inadequate immunization status specially of children
N. Family disunity- ex.
1. self-oriented behavior of member/s
2. Unresolved conflicts of member/s
3. Intolerable disagreement
III. PRESENCE OF HEALTH DEFICITS- instances of failure in health maintenance.
Examples include:
A. Illness states regardless of whether it is diagnosed or undiagnosed by medical
practitioner
B. Failure to thrive/ develop according to normal rate
C. Disability- whether congenital or arising from illness; transient/ temporary (ex aphasia
or temporary paralysis after a CVA) or permanent (ex leg amputation secondary to
diabetes, blindness from measles, lameness from polio)
IV. PRESENCE OF STRESS POINTS/ FORESEEABLE CRISIS SITUATIONS- anticipated
periods of unusual demand on the individual or family in terms of adjustment/ family
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resources; transitions (ex. Passage from one life phase, condition, or status to another,
causing a forced or chosen change that results in the need to construct a new reality).
Examples of these include:
A. Marriage I. Menopause
B. Pregnancy, labor, puerperium J. Chronic Illness
C. Parenthood K. Loss of job
D. Additional Member (ex. L. Hospitalization of a family
Newborn, lodger) member
E. Abortion M. Death of a member
F. Entrance at school N. Resettlement in a new
G. Adolescence community
H. Divorce or separation O. Illegitimac
SECOND LEVEL ASSESSMENT
I. INABILITY TO RECOGNIZE THE PRESENCE OF THE CONDITION OR PROBLEM
DUE TO:
A. Lack of or inadequate knowledge
B. Denial about its existence or severity as a result of fear of consequences of
diagnosis of problem, specifically:
1. Social stigma, loss of respect of peer/ significant others
2. Economic/cost implications
3. Physical consequences
4. Emotional/ psychological issues/ concerns
C. Attitude/ philosophy in life which hinders recognition/ acceptance of a problem
II. INABILITY TO MAKE DECISIONS WITH RESPECT TO TAKING APPROPRIATE
HEALTH ACTION DUE TO:
A. Failure to comprehend the nature/ magnitude of the problem/condition
B. Low salience of the problem/condition
C. Feeling of confusion, helplessness and/or resignation brought about by perceived
magnitude/severity of the situation or problem (ex. Failure to break down problems
into manageable units of attack)
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D. Lack of/inadequate knowledge/insight as to alternative courses of action open to

them
E. Inability to decide which action to take from among a list of alternatives
F. Conflicting opinions among family members/ significant others regarding action to
take
G. Lack of/ inadequate knowledge of community resources of care
H. Fear of consequences of action, specifically:
1. Social consequences
2. Economic consequences
3. Physical consequences
4. Emotional/psychological consequences
I. Negative attitude towards the health condition or problem by negative attitude is
meant one that interferes with rational decision making
J. Inaccessibility of appropriate resources for care, specifically:
1. Physical inaccessibility
2. Cost constraints or economic/ financial inaccessibility
K. Lack of trust/ confidence in the health personnel/agency
L. Misconceptions or erroneous information about proposed course/s of action
III. INABILITY TO PROVIDE ADEQUATE NURSING CARE TO THE SICK, DISABLED,
DEPENDENT, OR VULNERABLE/ AT RISK MEMBER OF THE FAMILY DUE TO:
A. Lack of/ inadequate knowledge about the disease/ health condition (nature, severity,
complications, prognosis and management)
B. Lack of/ inadequate knowledge about child development and care
C. Lack of/ inadequate knowledge of the nature and extent of nursing care needed
D. Lack of necessary facilities, equipment and supplies for care
E. Lack of or inadequate knowledge and skill in carrying out the necessary
interventions/ treatment/ procedure/ care (ex complex therapeutic regimen or
healthy lifestyle program)
F. Inadequate family resources for care specifically:
1. Absence of responsible member
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2. Financial constraints
3. Limitations/ lack of physical resources (ex. Isolation room)
G. Significant person’s unexpressed feelings (ex. Hostility/ anger, guilt, fear/ anxiety,
despair, rejection) which affect his/her capacity to provide care.
H. Philosophy in life which negates/ hinder caring for the sick, disabled, dependent,
vulnerable/ at risk member
I. Member’s preoccupation with own concerns/ interests
J. Prolonged disease or disability progression which exhausts supportive capacity of
family members.
K. Altered role performance- specify:
1. Role denial or ambivalence
2. Role strain
3. Role dissatisfaction
4. Role conflict
5. Role confusion
6. Role overload
IV. INABILITY TO PROVIDE A HOME ENVIRONMENT CONDUCIVE TO HEALTH
MAINTENANCE AND PERSONAL DEVELOPMENT DUE TO:
A. Inadequate family resources, specifically:
1. Financial constraints/ limited financial resources
2. Limited physical resources- ex. Lack of space to construct facility
B. Failure to see benefits (specifically long-term ones) of investment in home
environment improvement
C. Lack of/ inadequate knowledge of importance of hygiene and sanitation
D. Lack of/ inadequate knowledge of preventive measures
E. Lack of skill in carrying out measures to improve home environment
F. Ineffective communication patterns within the family
G. Lack of supportive relationship among family members
H. Negative attitude/philosophy in life which is not conducive to health maintenance
and personal development
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I. Lack of/ inadequate competencies in relating to each other for mutual growth and
maturation (ex. Reduced ability to meet the physical and psychological needs of
other members as a result of family’s preoccupation with current problem or
condition)
V. FAILURE TO UTILIZE COMMUNITY RESOURCES FOR HEALTH CARE DUE TO:
A. Lack of/ inadequate knowledge of community resources for health care
B. Failure to perceive the benefits of health care/ services
C. Lack of trust/ confidence in the agency/ personnel
D. Previous unpleasant experience with health worker
E. Fear of consequences of action (preventive, diagnostic, therapeutic rehabilitative)
specifically:
1. Physical/ psychological consequences
2. Financial consequences
3. Social consequences ex. Loss of esteem of peer/ significant others
F. Unavailability of required care/ service
G. Inaccessibility of required care/service due to:
1. Cost constraints
2. Physical inaccessibility ex. Location of facility
H. Lack of or inadequate family resources, specifically:\
1. Manpower resources ex. Baby sitter
2. Financial resources ex. Cost of medicine prescribed
I. Feeling of alienation to/ lack of support from the community ex. Stigma due to
mental illness, AIDS etc.
J. Negative attitude/ philosophy in life which hinders effective/ maximum utilization of
community resources for health care.

A CASE STUDY ILLUSTRATING NURSING ASSESSMENT

Situation:
On an afternoon of a prenatal clinic day, the community health nurse
was going over the record files of the patients seen in the morning. She cross
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checked this file with the prenatal appointment book and realized that Mrs. A, a 37
year-old patient, on her second trimester of her pregnancy, missed her appointment
for the day. The nurse took her family envelope and went over her record of previous
follow-up. She obtained the following data taken during the patient’s prenatal check-
up done a week ago:
𝐺! 𝑃"
Age of Gestation (AOG): 21 weeks
Blood Pressure: 140/90; Weight: 118 lbs
Abdominal Palpation:
• breech presentation
• fundic height: 14 cm
• fetal heart tone:135 beats/minute, right upper quadrant,
• regular but faint
Other significant finding:
slight pedal edema
Impression: Pregnancy uterine, 21 weeks
R/O Pre-eclampsia
Management:
• low salt diet
• urinalysis
• to come back next prenatal clinic day
Since the nurse decided to do a home follow-up on the patient, she read the clinical
records of the other members of the family who have gone to the clinic for
consultation. She noted down the following data:
• Rina, three years old, got sick of bronchopneumonia three months ago;
weight – 10 kgs.
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• Lita, four and half years old , and Andres, six years old were brought to the
clinic month ago for scabies; management included personal hygiene and
Benzyl Benzoate in two applications 12 hours apart and followed by a shower
after 12-24 hours.
The Assessment Process
The available data gathered during this first-level assessment reflected the
following possible health condition or problems:
1. Pre-eclampsia
Support Cues: 37 years-old mother of seven at 21 weeks age of gestation,
with BP 149/90 and slight pedal edema; weight: 118 lbs.
2. Scabies which may not have been fully cured
Supporting Cues: two preschoolers brought to the center for scabies one
month ago
3. Malnutrition which may not have been successfully managed
Supporting Cues: 3 year-old daughter weighted 10 kgs., 3 months ago
4. Family size beyond what family resources can adequately provide
Supporting Cues: A family with seven children; mother, 37 years old and
presently pregnant
The nurse decided to do a home follow-up on this family. As part of her preparation
for the home visit, she specified the important points that are needed to be able to do
an in-depth second-level assessment on the list of possible health condition or
problems gathered from the individual clinical records of the family members. By
going through the following questions, she aims to determine the family’s ability to
perform the tasks on the health condition or problems identified earlier:
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1. Why did Mrs. A fail to go to the clinic for check-up? What does the family think
about Mrs. A’s condition? Does the family recognize a possible complication
of pregnancy? If no, why not? If yes, what is the family doing about it?
2. How is Rina now? Does the family recognize the existence of malnutrition in
Rina? If no, why not? If yes, what has the family done about it? Where the
solutions effective?
To be able to do an adequate assessment on the other aspects of family life, the
nurse decided to also inquire about the following during the home visit:
3. How are Lita and Andres? What has the family done about scabies? Were the
solutions effective?
4. How are the three family members? How do the members relate with or affect
each other?
5. What are the goals or plans of the family for its members and/for itself as a
functioning unit?
6. How are the conditions in the home and the community environment?
The afternoon of the next day, the nurse made her home visit and obtained the
following data:
• The family lives in two-room house of light materials situated in a
congested urban community about 3 km from the health center
• Lita and Andres have varying degrees of infected and healed skin
eruptions and scabs on their hands and feet
• Rina looks pale, legarthic and apathetic: with scabies, too: markedly
underweight and undernourished.
• Mrs. A is a fish vendor in the community’s market and earns a profit of
P200.00/day. Mrs. A verbalized, “with the meager daily income of P300.00
my husband earns, I need to help increase family’s income through selling
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fish. I am so busy that I cannot find the time to have my urine examined.
But I did have problems during my previous pregnancies and even with
my present pregnancy. That’s why I seldom go for a check-up at the clinic.
It just happened that I passed by the health center on my way to my in-
laws last week, so I thought of dropping by the clinic to have my prenatal
check-up. But I actually feel right. However, the doctor mentioned that my
blood pressure was slightly elevated. She wanted me to go back to the
clinic yesterday for follow-up. She wants to see the results of my urine
examination. But my problem is I have plenty of things to do especially in
the morning. It is, indeed difficult to find the time for the urine examination
and the regular prenatal consultant at the clinic. One more thing, the clinic
is out of my way when I go to the market. But I don’t think I have to worry
because I have had seven pregnancies and they were all normal. All of
them were even more deliveries attended to by the ‘hilot’ (traditional birth
attendant)…
• …I have such a lot of things to attend to as a fish vendor that I could
hardly see to the needs of the children. The children are usually left at
home by themselves everyday, except for Manuel. Pedro and Cita who go
to school. Nieves is the only older child who is left to take care of the three
younger ones when we are not around. But I can’t expect her to do
everything. That’s the reason why the scabies of Andres and Lita have not
improved. I was able to buy the medicine prescribed by the doctor.
However, it was quite expensive that I was not able to buy another one
when it was consumed. This ‘gal is aso’ (scabies) must be due to the
weather. Quite a lot of children in the neighborhood have this. See, even
Rina got it, too.
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• …Rina is really small in built since she was a baby. She is not fond of
eating too..
• ..My husband and I would like to give the children a better future. We
would like them to finish even just a vocational educational attainment
they would not have to experience the kind of life we have now -a meager
income despite hard work. We can’t really expect to earn much since we
are just elementary school graduates. We have such a goal for our
children that’s why we don’t want additional children anymore. We have
decided on this since I have delivered my fifth child, Andres. However, we
have been hearing a lot of things about the methods of family planning
that cause abortion, cancer or other problems. We can’t decide on a
method because of fear of possible side effects. We might have more
problems to worry about due to any of these methods…”
The other members of the family include: Mr. A, 40 years old and a
construction worker; Manuel, 14 years old, in first year high school; Pedro, 12
years old, in grade six; Cita, 10 years old, in grade four; and Nieves, 8 years
old and not yet in school.
• All the other children help in the household chores after school work.
They fetch water from a public artesian well about half a kilometer from
the house.
• Mrs. A has the major responsibility in so far as the health of the family
is concerned.
• The other data that the nurse observed in so far as the conditions or
resources in the home include:
- Dimensions of each room is 3 meters by 3 meters
- Small screened cabinet for food storage
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- One-burner gas stove for cooking purposes

- Earthen jar with cover for drinking water supply
- Dining table with two benches
- Lighting: electricity
- Toilet facility: closed pit privy type situated beside the
garbage pit; foul smelling and with plenty of flies all over
- Garbage disposal: dumping in open pit situated at the back
of the house two meters away; with plenty of flies.
The results of the nurse’s in depth second level assessment on the identified
health condition or problems are presented in the following tables. Note that
the problem statements have been defined in terms so as to reflect the
family’s inability to perform certain aspects of the health tasks. Thus, the
problems are stated as family nursing problems.

FAMILY CARE PLAN

• Is the next step in nursing process after assessment, when health and family
problems have been clearly defined
• Is a blueprint of the nursing care designed to systematically enhance the family’s
capability to maintain wellness and or manage health problems through explicitly
formulated goals and objectives of care and deliberately chosen set of interventions,
resources and evaluation criteria, standards, methods and tools.
• Is regularly updated for modifications or changes based on family responses,
realities, behavioral processes and outcomes of care.
Importance of Nursing Care Plan
• It is a systematic way to guide the nurse on how to enhance the family’s capability
for health and health care resource generation, allocation, and utilization to achieve
specific desired outcomes of prioritized health conditions/ problems.
 25

• Planning enhances the nurse’s foresight for teamwork and coordination of services
to ensure adequacy and continuity of care.
• In written form, that promotes systematic communication among those involved in
the health care effort, minimizing gaps and duplication of services in settings where
there is frequent turnover of staff or when several health workers are providing care
to the same family.

STEPS IN DEVELOPING A FAMILY CARE PLAN

Prioritize the Health

Condition and Develop the Evaluation Plan
Problems based on: Specify:
• Nature of • Criteria/ Outcomes Based on
Condition or Objectives of Care
Problem • Methods/ Tools
• Modifiability
• Preventive
• Potential
• Salience

Develop the Intervention Plan

1.Decide on:
• Measures to help family
Define Goals and Objectives eliminate:
of Care a. Barriers to performance
Formulate: of health task.
1.Expected Outcomes: b. Underlying cause/s of
• Conditions to be observed non-performance of
to show problem is health task.
prevented, controlled, • Family-Centered alternatives
resolved or eliminated. to recognize/detect, monitor,
• Client response/s or control or manage health
behavior condition or problems
2.Specific, Measurable Client- 2.Determine Methods of Nurse-
centered Statements/ Family Contact
Competencies. 3.Specify Resources Needed.
 26

PRIORITIZING HEALTH CONDITIONS AND PROBLEMS

- Scale for Ranking Health Conditions And Problems According To Priorities- tool
aims to objectivize priority setting.
4 Criteria for Determining Priorities among Health Conditions or Problems
1. Nature of the condition or problem presented- categorized into wellness state/
potential, health threat, health deficit and foreseeable crisis
2. Modifiability of the condition or problem- refers to the probability of success in
enhancing the wellness state, improving the condition, minimizing, alleviating or
totally eradicating the problem through intervention.
3. Preventive potential- refers to the nature and magnitude of future problems that
can be minimized or totally prevented if intervention is done on the condition or
problem under consideration
4. Salience- refers to the family’s perception and evaluation of the condition or
problem in terms of seriousness and urgency of attention needed or family
readiness.
Factor Affecting Priority Setting
Consider the first criterion – nature of the condition or problem presented -
the biggest weight is given to wellness state or potential because of premium on client’s
efforts or desire to sustain/ maintain high level of wellness. The same weight is
assigned to a health deficit because of its sense of clinical urgency which may require
immediate intervention. Foreseeable crisis is given the least weight because culture
linked-/factors usually provide our families with adequate support to cope with
developmental or situational crisis.
The nurse considers the availability of the following factors in determining the
modifiability of a health condition or a problem:
1. Current knowledge, technology and interventions to enhance the wellness state or
manage the problem.
2. Resources of the family – physical, financial and manpower.
3. Resources of the nurse – knowledge, skills and time
4. Resources of the community – facilities and community organization support.
 27

To decide on an appropriate score for the preventive potential of a health

condition or problem, the following factors are considered:
1. Gravity or severity of the problem – refers to the progress of the disease/ problem
indicating extent of damage on the patient/ family; also indicates prognosis,
reversibility or modifiability of the problem. In general, the more severe or
advanced the problem is, the lower is the preventive potential of the problem.
2. Duration of the problem – refers to the length of time the problem has been
existing. Generally speaking, duration of the problem has a direct relationship to
gravity; the nature of the problem is a variable that may, however, alter this
relationship. Because of this, relationship to gravity of the problem, duration has
also a direct relationship to preventive potential.
3. Current management – refers to the presence and appropriateness of intervention
measures instituted to enhance the wellness state of remedy the problem. The
institution of appropriate intervention increases the condition’s preventive
potential.
4. Exposure of any vulnerable or high risk group – increases the preventive potential
of a condition or problem.
Effective health management/ health maintenance pattern and desire for or
engagement in healthy lifestyle activities increase the preventive potential of a wellness
state or condition.
To determine the score for salience, the nurse evaluates the family
perception of the condition or problem. As a general rule the family’s concerns, felt
needs and/or readiness increase the score on salience.
Scoring
After the score for each criterion has been decided on, the number is
divided by the highest possible score in the scale. The quotient is multiplied by the
weight indicated for the criterion being considered. Then the sum of the scores for all
the criteria is taken. The highest score is five (5), equivalent of the total weight. The
nurse considers as priority those conditions and problems with total scores nearer five
(5). Thus, the higher the score of a given condition or problem the more likely it is taken
 28

as a priority. With the available scores, the nurse then ranks health conditions and
problems accordingly.

CRITERIA WEIGHT
1. Nature of the condition or problem presented
SCALE** Wellness State
Health Deficit
3
Health Threat
3
Foreseeable Crisis 1
2
2. Modifiability of the Condition or problem
1
SCALE** Easily Modifiable
Partially Modifiable
Not Modifiable 2 2
3. Preventive potential 1
0
SCALE** High
Moderate
3 1
Low
2
4. Salience
1
SCALE** A condition or problem,
needing immediate
attention
A condition or problem 2
not needing immediate 1
attention
Not perceived as a 1
problem or condition
needing change
0
Scoring:

1. Decide on a score for each criteria.

2. Divide the score by the highest possible score and multiply by the weight: (
Score/ Highest score) x Weight
3. Sum up the scores for all the criteria. The highest score is 5, equivalent to the
total weight.
 29

FORMULATION OF GOALS AND OBJECTIVES OF CARE

GOAL- is a broad desired outcome toward which behavior is directed. It is a general

statement of the condition or state to be brought about by specific courses of action.
Example: After nursing intervention the family will be able to take care of the disabled child
competently.
Cardinal Principle in Goal Setting:
“Goals must be set jointly with the family.”

BARRIERS TO JOINT GOAL SETTING BETWEEN THE NURSE AND THE FAMILY
1. Failure on the part of the family to perceive the existence of the problem. In many
instances family is perfectly satisfied with the existing situation and the problem
was only acknowledged by the nurse. For example , about proper sanitation like
the use of sanitary toilet facilities instead of using this , the family use pit latrins.
2. The family may realize the existence of a health condition or problem but is too busy
at the moment with other concerns and preoccupations. For example , the working
mother forgot the schedule immunization day of her youngest.
3. The family perceives the existence of a problem but does not see it as serious
enough to warrant attention. Like having common cold inside your home or simple
presence of skin rashes in your kid was thought a simple case , but it might be a
sign of dengue.
4. The family may perceive the presence of the problem and the need to take action. It
may, however, refuse to face and do something about the situation.
Reasons:
a. Fear of consequence/s of taking action. Example: Submitting yourself in
biopsy because you think this might increase your stress level and costly.
b. Respect for tradition/ cultural beliefs. Example: A prima gravida in the barrio
was advised to undergo ultrasound but due to old practice opted to seek a “hilot”.
c. Failure to perceive the benefits of action proposed. Example: The woman
was advised to deliver the baby in the provincial hospital .Because of hearing
 30

some bad experiences of other person in that hospital you better choose giving
birth at home.
d. Failure to relate the proposed action to the family’s goals. Example: Family
in the middle class prioritize economic or financial benefits than health.
5. A big barrier to collaborative goal setting between the nurse and the family is failure
to develop a working relationship. In any collaborative works a harmonious
relationship is necessary. For example , if nurse Espina assigned to assess
Delapina family has conflict with each other. It will never be avoided to stain the
process with the family conflict.

OBJECTIVES- refer to more specific statements of the desired results or outcomes of care.
They specify the criteria by which the degree of effectiveness of care is to be measured.
Example: NURSING GOAL: the family will manage malaria as a disease and
threat in an endemic area.

CHARACTERISTICS OF GOAL/OBJECTIVES:

SPECIFIC
MEASURABLE
ATTAINABLE
REALISTIC
TIME-BOUNDED
 31

SHORT TERM/ IMMEDIATE OBJECTIVE: The sick member/s will take the drugs
accurately as to dose, frequency, duration, and drug combination. All members will use
self-protection measures at night till early morning when biting time of the mosquito vector
is expected.
MEDIUM-TERM/ INTERMEDIATE OBJECTIVE: All members will have regular medical
check-up and laboratory confirmation (ex. Blood smear) to monitor presence of malaria.
LONG-TERM OBJECTIVE: All members will carry out mosquito vector control measures.

Example: After 8 hours of nursing intervention , the family should be able to:
1. Assess the different problems inside the home.
2. Increase the knowledge about home sanitation.
3. Create home sanitation plan.

DEVELOPING THE INTERVENTION PLAN

§ This involves selection of appropriate nursing interventions based on the formulated

goals and objectives.
§ In selecting the nursing interventions, the nurse decides on appropriate nursing
actions among a set of alternatives, specifying the most effective or efficient method of
nurse- family contact and the resources needed.
Example method of nurse-family contact:
§ Home Visit
§ Clinic Conference
§ School Visit
§ Group approach or health classes
Here are the resources needed:
Materials like supplies, equipment and teaching materials.
Human like health care team members and community leaders.
 32

GENERAL DIRECTIONS IN SELECTING APPROPRIATE NURSING INTERVENTIONS

1. Analyze with the family the current situation and determine choices and possibilities
based on a lived experience of meanings and concerns. The appropriateness of
the nursing intervention depends on the family lived experiences. If their
experiences was acknowledge family becomes more active in the application of
nursing process.
2. Develop/ enhance family’s competencies as thinker, doer and feeler. Nursing
interventions that enhances and maximize the competencies of the family as :
1. Thinker – Make information or data or knowledge readily available and
accessible for ease of understanding the current situations in health and
illness.
2. Doer- Enhance the confident in carrying out the needed interventions to
initiate and sustain change for health promotion and maintenance as well as
accurate disease management.
3. Feeler- The family needs to develop or strengthen its affective
competencies in order to acknowledge and understand emotions generated
by family life or health situtions.
3. Focus on interventions to help perform the health tasks.
1. Help the family recognize the problem. Example : Helping the family see
the implications of the situation , or the consequences of the situation.
2. Guide the family on how to decide on appropriate health actions to take.This
can be done through , Identifying and exploring with the family the
courses of action available and the resources needed for each.
3. Develop the Family’s ability and commitment to provide nursing care to its
member. Like conducting demonstration and practice sessions on
basic nursing procedures like wound dressing and sponge bathing.
4. Enhance the capability of the family to provide a home environment
conducive to health maintenance and personal development. Like teaching
 33

them how to create environmental modifications to make it a safer

place , also putting nursing care facilities example siderails.
5. Facilitates the Family’s Capability to Utilize Community Resources for
Health Care. A maximum use of available resources like the non-
government organizations like Kiwanis Club or Rotary Club.

INDEX OF COMMUNITY RESOURCES:

Name of Office and E-mail Type of Client Requirements/Proc

Agency and Address/Telephone and Specific edures for Referral
Person to Number Services/Sched
Contact ule

4. Catalyze behavior change through motivation and support. It applies here the saying
“ Experiences are the best teacher”. Support is needed in order to face the
insecurities of the family.

DEVELOPING THE EVALUATION PLAN

• Specifies how the nurse will determine changes in health status, condition or
situation and achievement of the outcomes of care specified in the objectives of
the family nursing care plan.
• The evaluation plan also includes evaluation methods and tools and/or evaluation
data sources. Examples or evaluation methods include direct observation,
interview, oral or written tests, record review, health/ physical examination.
EVALUATION STANDARD- refers to the desired or acceptable condition, clinical
status or level of performance corresponding to an evaluation criterion or indicator
against which actual condition, clinical status or performance is compared.
 34

FORMULATION OF DIAGNOSIS
1. Definition of wellness state/ potential or health condition or problems as an end
product of first level assessment
2. Definition of family nursing problems as an end result of second level assessment.

REFERENCE:
Maglaya, A. S. (2004). Nursing Practice in The Community (Fourth ed.). Marikina City:
Argonauta Corporation.

ACTIVITY 1:
INSTRUCTION:
Read the following family case scenario and identify at least 3 (three) Family Health
Problem. After Identifying, rank the problem according to priorities (show your
computation and justification) and make an Family Care Plan to the No. 1 top
priority.
SITUATION:
A mother came to RHU with her 2 year old son. She complained that her son has been coughing
for 6 days with yellowish phlegm and with fever for 2 days now. He is also having difficulty in
breathing as claimed by the mother.
The nurse took her assessment as follows:
Vital signs: Temp: 38C
PR: 115cpm
RR: 45bpm
Weight: 7Kg
Height: 65cm
Upon interview, the mother claimed that her husband is smoking even at the house. The
husband knows that it could affect their health but claimed that he couldn’t stop. “Maisot manlng abi
amon nga baeay, sangka kwarto eang kaya nahuhum-gan it unga mag sigarilyo si tatay na” as
claimed by the mother. When the cough and fever of her son worsen, she got worried and hurried
to the RHU for consultation. She also claimed that her son doesn’t drink milk because they cannot
 35

afford it and but they can still eat at least 3 times a day. She sees her son normal and healthy as
she justifies that “Bukon man dun it maniwang. Gaka-on man dun it linugaw pirme. Kung amat hay
natataw-an man dun it chi-chirya ni lola na pang pamahaw. Uwa galing abi kami it kwarta pang
bakae it vitamins nana. 300 pesos manlang do kita sang asawa sa pag drive tricycle.”

Doctors Diagnosis: Bronchial Pneumonia with malnutrition.

I. Ranking Family Health Problems According to Priorities

CRITERIA COMPUTATION SCORE JUSTIFICATION

• Nature of the Problem

Scale: Health Threat 2

Health Deficits 3

Foreseeable Crisis 1

• Modifiability of the
Condition or problem
Scale: Easily Modifiable 2

Partially Modifiable 1

Not Modifiable 0

• Preventive potential
Scale: High 3

Moderate 2

Low 1

• Salience
 36

Scale: A serious prob.

Immediate

attention needed 2

A prob. But not

needing

immediate attention 1

Not a felt need/prob.

Total Score:

II. Family Nursing Process

Health Family Goal Objectives Nursing Method Resources Evaluation
Problem Nursing of Interventions of
of Care Required
Problems Care Nursing
 37

PART-II:
Bag
Technique
LEARNING OUTCOMES

On completion of the learning module, the student must be able to:

1. To define bag technique.
2. Know the purpose of bag technique.
3. Identify the instruments and equipments included in a PHN bag.
4. To arrange the contents of the PHN bag to its proper place.

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 medications and articles which
are necessary for giving care.

BAG TECHNIQUE

a tool making use of a public health bag through which the nurse, during his/her home
visit, can perform nursing procedures with ease and deftness, saving time and effort with the end
in view of rendering effective nursing care.
 38

PURPOSE / RATIONALE
To render effective nursing care to clients and/or members of the family during home visit.

PRINCIPLE
1. The use of the bag technique should minimize if not totally prevent the spread of
infection from individuals to families, hence, to the community.
2. Bag technique should save time and effort on the part of the nurse in the performance of
nursing procedures.
3. Bag technique should not overshadow concern for the patient rather should show the
effectiveness of total care given to an individual or family.
4. Bag technique can be performed in a variety of ways depending upon agency policies,
actual home situation, etc. as long as principles of avoiding transfer of infection is carried
out.

SPECIAL CONSIDERATIONS
1. The bag should contain all necessary articles, supplies and equipment which maybe use
to answer emergency needs.
2. The bag and its contents should be cleaned as often as possible, supplies replaced and
ready for use at anytime.
3. The bag and its contents should be well protected from contact with any article in the
home of the patients. Consider the bag and its contents clean and/or sterile while any
article belonging to the patient as dirty and contaminated.
4. The arrangement of the contents of the bag should be the one most convenient to the
user to facilitate efficiency and avoid confusion.
5. Hand washing is done as frequently as the situation calls for, helps in minimizing or
avoiding contamination of the bag and its contents.
6. The bag when used for a communicable case should be thoroughly cleaned and
disinfected before keeping and reusing.
 39

CONTENTS OF BAG AND ITS ARRANGEMENT

• Front of bag, left to right • Center of bag

Oral Thermometer Forceps (straight & curved)
Rectal Thermometer Roller bandage
Alcohol lamp with denatured alcohol
• On Right near end of bag Kidney basin
Test tube and holder Syringe and needles in container, 5
Medicine dropper & 2 ml
Tape measure
• On Left near end of bag Cotton applicator
Medicine glass Cord clamp
Weighing scale Rubber gloves
Bandage scissor
• On Top file center bag
• Back of bag (left & right) Hand towel
Alcohol 70% Soap on a soap dish
Acetic acid Paper waste bag in pocket of bag
Aromatic spirit of ammonia Newspaper to serve as lining
Benedict’s solution Apron
Betadine Plastic lining
Ophthalmic ointment
Hydrogen peroxide
Zepheran solution
Spirit of ammonia
Acetic solution

ACTIVITY 2
Return Demonstration of Bag Technique
 40

Aklan State University

School of Arts and Sciences
Bachelor of Science in Nursing

NAME: DATE:
COURSE & SEC: RLE GROUP:
BAG TECHNIQUE
PROCEDURES RATIONALE
1. Upon arriving at the client’s home, place • To protect the bag from contamination.
bag on the table or any flat surface lined with
paper lining clean side out (folded part
touching the table). Put bag handles or straps
beneath the bag.
2. Ask for a basin of water and a glass of • For hand washing and protect the work
water. If faucet is not available. Place these field from getting wet.
outside the work area.
3. Open the bag, take the liner/plastic lining & • To ensure asepsis in the field.
spread over work field area. The paper lining,
clean side out (folded part out).
4. Take out hand towel, soap dish and apron. • To prepare for hand washing.
Place them on one corner of the work area
(within the confines of the plastic lining).
5. Do handwashing. Wipe dry with towel. • To prevent transfer of microorganisms.
Leave the plastic wrappers of the towel in
soap dish in the bag.
6. Put on apron right side out and wrong side • To protect the health care provider
touching the body, sliding the head into the from contracting infection. Keeping the
neck strap. Neatly tie the strap at the back. crease creates aesthetic appearance.

7. Put out things mostly needed for specific
case (e.g. Thermometer, kidney basin, cotton
balls, and waste paper bag) and place at one
corner of the work area.
8. Place waste paper bag outside of work
area.
9. Close the bag.
10. Proceed to the specific nursing care
treatment.
11. After completing nursing care treatment
clean and sanitize the equipment used in the
procedure.
12. Perform hand washing again.
13. Open the bag and put back all articles in
their proper place.
14. Remove apron folding away from the body
with soiled side folded inward and the clean
side outward. Place it in between the flap
cover.
15. Fold the linen/plastic lining in between the
flaps of the bag and close the bag.
16. Make past visit conference with the
mothers relevant to the health care, taking
anecdotal notes for final reporting.
17. Record all relevant findings in client and
members of family and document all nursing
care and treatment one.
41
• To make materials readily accessible.
• To prevent contamination.
• To prevent contamination of the bag
and its contents.
• To promote efficiency of the procedure.
• To protect health care provider and
prevent spread of infection to others.
• To prevent spread of infection.
• To establish systematic procedure
during reuse.
• To prevent contamination and spread
of microorganisms.
• To prevent contamination and spread
of microorganisms
• Notes to be used as a reference for
future visit and follow-up.
• To provide data for the next visit or
follow-up care.
 42

18. Make an appointment for the next visit • To ensure client’s availability.
(either home or clinic) taking note of the date,
time, and purpose.
 43

Aklan State University

School of Arts and Sciences
Bachelor of Science in Nursing

NAME: DATE:
COURSE & SEC: RLE GROUP:

CHECKLIST ON BAG TECHNIQUE

Able to Able to Unable to

Procedure Perform Perform with Perform
Assistance
Assessment
1. Assess the completeness, neatness,
cleanliness and availability of bag
contents and its proper arrangement.
2. Determine the needs of the client on the
basis of findings during home visit.
Planning
3. Prepare all the equipment needed.
Implementation
4. Upon arriving at the client’s home, place
bag on the table or any flat surface lined
with paper lining.
5. Ask for the basin of water. Place this
outside work area.
6. Open the bag. Take out the plastic lining
and spread over the work field.
 44

7. Take out the hand towel, soap dish and

apron. Place them on one corner of the
work area.
8. Do Handwashing. Wipe dry with hand
towel.
9. Put on apron right side out and wrong side
touching the body.
10. Take out things that will be mostly needed
for a particular case and place in one
corner of the work field.
11. Place waste paper bag outside work area
12. Close the bag.
13. Proceed to the specific nursing care
treatment.
14. After completing nursing care treatment,
clean and sanitize all equipment’s used.
15. Do Handwashing again.
16. Open the bag and put back all articles in
their proper places.
17. Remove apron.
18. Fold the plastic lining. Clean and place it
in the flaps of the bag and close it.
19. Make post visit conference.
Evaluation
20. Reassess and evaluate the comfort of the
client after nursing care.
21. Look for other needs of client or family
pertaining to their living condition.
 45

Documentation
22. Record/document all the nursing care and
treatment that have been done to the
client and family.

23. Write anecdotal report pertaining to the

health status of other members of the
family if there is any.

Remarks:

Grade:
Rating Scale:

Excellent : 96-100%
Very Satisfactory : 90-95%
Very Good : 85-89%
Good : 80-84%
Fair : 75-79%
Poor : 74 & below

Clinical Instructor Student’s Signature

 46

PART-III:
Clinic Visit
PRE CONSULTATION CONFERENCE

1. Take clinical history after greeting and making client at ease.

2. Take temperature, blood pressure, height and weight.
3. Perform a thorough physical assessment.
4. Do selective laboratory examinations such as urinalysis for sugar and albumin as necessary,
sputum exam, stool examination for parasites, vaginal smear for STD, screening after taking the
necessary training.
5. Write findings on client’s record.

MEDICAL EXAMINATION

1. Assist client before, during and after examination by physician.

2. Inform physician of relevant findings gathered in pre-conference.
3. Work with the physician during the examination.
4. Ensure privacy, safety and comfort of patient throughout procedure.
5. Observe confidentiality of examination results.

NURSING INTERVENTION

1. Carry out physician’s orders as giving medication or injection.

2. Explain and reinforce physician’s orders and advices.
3. Teach patient/client measures designed to promote and maintain health as a proper diet,
exercise and personal hygiene.
4. Seek information regarding health status of other family members.
 47

Example: immunization status of children, health and problems of elderly if any, health of husband.
5. Counseling

POST CONSULTATION CONFERENCE

1. Explain findings and needed care or intervention.

2. Refer patient/client to other health of related staff/agency if necessary.
3. Make appointment for next clinic/home visit.
4. Referral as needed.

ACTIVITY 3: Check on your OMS.

 48

PART-IV:
Home Visit
LEARNING OUTCOMES

On completion of the learning module, the student must be able to:

1. Define home visit.
2. To enumerate the purposes of home visit.
3. To identify the available resources needed for a home visit.
4. To identify and prioritized the health problems of the individual family.
5. To determine the health teachings needed for each family members.
6. To plan and provide necessary health care activities for the family.
7.To apply the principles and general guidelines of home visit.

HOME VISIT

The home visit is a family – nurse contact which allows the health workers to assess the
home and family situations in order to provide necessary nursing care and health related activities.
In performing this activity, it is essential to prepare a plan of visit to meet the needs of the and
achieve the best results of desired outcome.

PURPOSE OF HOME VISIT

1. To give nursing care to the sick, to a post partum mother and her new born with the view
to teach a responsible family member to give the subsequent care.
 49

2. To assess the living condition of the patient and his family and their health practices in
order to provide the appropriate health teaching.
3. To give health teachings regarding the prevention and control diseases.
4. To establish close relationship close relationship between the health agencies and the
public for the promotion of health.
5. To make use of the inter-referral system and to promote the utilization of community
services.

PRINCIPLES INVOLVED IN PREPARING FOR HOME VISIT

When we plan to go on a home visit, it is necessary to assemble the records of the

patients and list the names to be visited, study the case and have written nursing care plan.
1. A home visit must have a purpose or objective.
2. Planning for home visit should make use of all available information about the patient
and his family records.
3. In planning for a visit, we should consider and give priority to the essential needs of the
individual and his family.
4. Planning and delivery of care should involve the individual and family.
5. The plan should be flexible.

GUIDELINES TO CONSIDER REGARDING THE FREQUENCY OF HOME VISIT

There is no definite rule to be followed frequency of home visits. The schedule of the visit
may vary according to the need of the patient of family for nursing care, but one has to consider the
following factors:
1. The physical needs, psychological needs and educational needs of the individual or
family.
2. The acceptance of the family for the services to be rendered, their interest and
willingness to cooperate.
3. The policy of the specific agency and the emphasis given towards their halth programs.
4. Take into account other health agencies and the number of health personnel already
involved in the care of a specific family.

STEPS IN CONDUCTING HOME VISIT

1. State the purpose of the visit

2. Put the bag in a convenient place then proceed to perform the bag technique.
3. Greet the patient and introduce yourself
4. Observe the patient and determine the health need.
 50

5. Record all important data, observation and care rendered.

6. Make appointment for a return visit.
7. Perform the nursing care needed and give health teachings.

ACTIVITY 4:

INSTRUCTION:
I. Plan a home visit to one of your family relatives within your village and answer the following
questions.

A. Identify and prioritize the health problems of the family.

B. Determine what are the health teaching needed for each family members.
C. Make a plan of health care activities for the family.

II. Check your OMS for a short quiz.

 51

PART-V:
Herbal Medicine
LEARNING OBJECTIVES

Upon the completion of the topic, the students will be able to gain understanding in
Herbal medicines and how to use it.

BACKGROUND ON HERBAL MEDICINE

As part of primary health care and because of the increasing cost of drugs, the use of
locally available medicinal plants and herbs in the Philippine backyard and field have been found to
be effective in the treatment of common ailments as attested to by the National Science
Development Board, other government and private agencies/ persons engaged in research. The
DOH is advocating the use of the following ten herbal plants.

REPUBLIC ACT 8423

Otherwise known as TAMA TRADITIONAL AND ALTERNATIVE MEDICINE ACT OF 1997
An act creating the Philippine Institute of Traditional and Alternative Health Care (PITAHC) to
accelerate the development of traditional and alternative health care in the Philippines, providing
for a traditional and alternative health care development fund and for other purposes.
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10 HERBAL MEDICINES APPROVED BY THE DOH

“SANTALUBBY”.

Sambong, Akapulko, Niyog-niyogan, Tsaang Gubat, Ampalaya, Lagundi, Ulasimang Bato,

Bawang, Bayabas, Yerba Buena

Reminders on the Use of Herbal Medicine

Avoid the use of insecticides as these may leave poison on plants. In the preparation of
herbal medicine, use a clay pot and remove cover while boiling at low heat. Use only the part of the
plant being advocated. Follow accurate dose of suggested preparation. Use only one kind of herbal
plant for each type of symptoms or sickness. Use only half the dosage prescribed for fresh parts
like leaves when using dried parts.
Decoctions loose potency after some time. Dispose of decoctions after one day. To keep
fresh during the day, keep lukewarm in a flask or thermos. Leaves, fruits, flowers or nuts must be
mature before harvesting. Less medicinal substances are found on young parts. Stop giving the
herbal medication in case untoward reaction such as allergy occurs. If signs and symptoms are not
relieved after 2 or 3 doses of herbal medication, consult a doctor

SAMBONG (HANILIB-ON)

A plant that reaches 1 ½ to 3 meters in height with rough hairy leaves. Young plants
around mother plant may be separated when they have three or more leaves.
Scientific Name: Blumea balsamifera
SAMBONG USES:
• Anti-edema
• Diuretic
• Anti-urolithiasis
 53

PREPARATION:
• Boil chopped leaves in water for 15 minutes until one glassful remains.
• Cool and strain.
• Divide decoction into 3 parts. Drink one part 3 times a day.
• NOTE: Sambong is not a medicine for kidney infection

AKAPULKO

Ringworm Bush Bayas-bayasan This plant is about 1 to 2 meters tall The leaves are
embraced with 8 to 20 oblongelliptical shaped leaflets It has flowers with oblong sepals
Scientific Name: Cassia alata
AKAPULKO USES
• Anti-fungal: Tinea Flava, Ringworm,
Athlete ’s Foot and Scabies
PREPARATION
• Fresh, matured leaves are pounded.
• Apply as a soap to the affected part 1 to 2 times a day.

NIYUG-NIYOGAN

Chinese Honey Suckle A vine which bears tiny fruits and grows wild in backyards. The
seeds must come from mature, dried but newly opened
fruits. Propagated through stem cuttings about 20cm in
height.
Scientific Name: Quisqualis indica L.
NIYUG-NIYOGAN USES
• Anti-helmintic (used to expel parasitic worms.)
PREPARATION
 54

• Seeds of niyug-niyogan are eaten raw two hours before the patient’s last meal of the day.
• Adults may take 10 seeds; children 4 to 7 years of age may eat up to four seeds only; ages
8 to 9 may take six seeds and seven seeds may be eaten by children 10 to 12 years old.
• Not to be given to children below four years old.

TSAANG GUBAT

Forest Tea or Wild Tea. A shrub with small, shiny nice-looking leaves that grows in wild
uncultivated areas and forests.
Scientific Name: Carmona retusa
TSAANG GUBAT USES
• Diarrhea
• Stomach ache
PREPARATION
• Boil the following amount of chopped
leaves in 2 glasses of water for 15 minutes or until amount of water goes down to 1 glass.
Cool and strain.
• Wash leaves and chop. Boil chopped leaves in 1 glass of water for 15 minutes. Cool and
filter/strain and drink.

AMPALAYA

Bitter Gourd or Bitter melon A climbing vine with tendrils

that grow up to 20 cms long. Leaves are heartshaped, which are
5 to 10 cms in diameter Fruits have ribbed and wrinkled surface
that are fleshy green with pointed ends at length and has a bitter
taste. Scientific Name: Momordica charantia
AMPALAYA USES
• Lowers blood sugar levels
 55

• Diabetes Mellitus (Mild-non insulin dependent)

PREPARATION
• Gather and wash young leaves very well. Chop. Boil 6 tablespoons in two glassfuls of
water for 15 minutes under low fire. Do not cover pot. Cool and strain. Take one third cup 3
times a day after meals

LAGUNDI

5 Leaved-Chaste Tree A shrub growing wild in vacant lots and waste land. Matured
branches are planted. The flowers are blue and bellshaped. The small fruits turn black when ripe. It
is better to collect the leaves when are in bloom.
Scientific Name: Vitex negundo
LAGUNDI USES
• Asthma and cough
• Fever, Dysentery, Colds & Pain
• Skin diseases and wounds
• Headache
• Rheumatism, sprain, contu sions,
insect bites.
• Aromatic bath for sick patients
PREPARATION
• For Asthma, cough and fever, boil chopped raw fruits or leaves in 2 glasses of water left
for 15 minutes until the water left in only 1 glass (decoction). Strain.
• For Dysentery, colds and pain, boil a handful of leaves and flowers in water to produce a
glass full of decoction 3 time a day.
• For skin diseases (dermatitis, scabies, ulcer, ecze ma) and wounds, prepare a decoction
of the leaves. Wash and clean the skin/wound with the decoction.
• For headache, crushed leaves may be applied on the forehead.
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• For rheumatism, sprain, contusions and insect bites, pound the leaves and apply on the
affected part.

ULASIMANG BATO

Silver bush or Shiny bush. Pansit-pansitan. A

weed with heartshaped leaves that grow in shady parts
of the garden and yard.
Scientific Name: Peperomia pellucida
ULASIMANG BATO USES
• Lowers uric acid (Rheumatism and Gout)
PREPARATION
• Wash the leaves well. One and a half cup leaves are boiled in two glassfuls of water over
low fire. Do not cover pot. Cool and strain. Divide into three parts and drink each part 3
times a day a day.
• May also be eaten as salad. Wash the leaves well. Prepare one and a half cups of leaves
(not closely packed). Divide into three parts and take as salad 3 times a day.

BAWANG

Garlic. A low herb and grows up to sixty cms high. Leaves are flat and linear. Bulbs consist
of several tubers.
Scientific Name: Allium sativum
BAWANG USES:
• For hypertension
• Toothache
• Lowers cholesterol levels in the blood
PREPARATION
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• May be fried, roasted, soaked in vinegar for 30 minutes, or blanched in boiled water for 5
minutes. Take two pieces three times a day after meals. For toothache, pound a small
piece and apply to affected part. CAUTION: Take on full stomach to prevent stomach and
intestinal ulcers.

BAYABAS

Guava. A tree about 4 to 5 meters high with tiny white flowers with round or oval fruits that
are eaten raw.
Scientific Name: Psidium guajava
BAYABAS USES:
• For washing wounds
• For toothache
• For diarrhea
PREPARATION
• Warm decoction is used for gargle.
• Freshly pounded leaves are used for
toothache. Guava leaves are to be washed well and chopped. Boil for 15 minutes at low
fire. Do not cover pot. Cool and strain before use.

YERBA BUENA

Peppermint. A small multibranching aromatic herb. The leaves are small, elliptical and with
toothed margin. The stem creeps to the ground, and develop roots.
Scientific Name: Mentha cordifelia
YERBA BUENA USES
• For pain in different parts of the body as head ache, stomach ache Rheumatism,
arthritis and headache Cough and cold Swollen gums & toothache Menstrual and
gas pain Nausea and fainting Insect bites & Pruritus
PREPARATION
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• For pain in diff. parts of the body, boil chopped leaves in 2 glasses of water for 15 minutes.
Cool and strain.
• For rheumatism, arthritis and headache, crush the fresh leaves and squeeze sap.
Massage sap on painful parts with eucalyptus.
• For cough and cold, get about 10 fresh leaves and soak in a glass of hot water. Drink as
tea. Acts as an expectorant.
• For toothache, cut fresh plant and squeeze sap. Soak a piece of cotton in the sap and
insert this in aching tooth cavity. Mouth should be rinsed by gargling salt solution before
inserting the cotton. To prepare salt solution: add 5g of table salt to one glass of water.
• For Menstrual pain and gas pain, soak a handful of leaves in a glass of boiling water. Drink
infusion. It induces menstrual flow and sweating.
• For nausea and fainting, crush leaves and apply at nostrils of patient. For insect bites,
crush leaves and apply juice on affected part or pound leaves until paste-like and rub this
on the affected part.

REFERENCE:
Cuevas, Francis Public Health Nursing in the Philippines. 10th Edition 2007

ACTIVITY 5:
Refer to online platform for quiz.
 59

PART-VI : FHSIS
LEARNING OBJECTIVES:

At the end of the topic, the students should be able to understand the importance of FHSIS and its
purpose and gain knowledge on how to apply it.

FIELD HEALTH SERVICE INFORMATION SYSTEM (FHSIS)

§ is a major component of the network information sources developed by the Department of

Health (DOH) to enable it to better manage in nationwide health service delivery activities.
§ intended to address the short term data needs of DOH staff with managerial/supervisory
functions in DOH facilities and in each of the program areas
§ monitors health service delivery nationwide.

Ultimate Goal To enable various health system stakeholders to make transparent and
evidence-based decision.

To produce relevant and quality information in support of health system

Objective
interventions.

Objectives:
• To provide data on health service delivery and selected program accomplishments at local
levels
• To provide data which, when combined with data from other sources, can be used for
program monitoring and evaluation
• To provide a standardized, facility – level database which can be accessed for more in -
depth studies
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• To minimize the burden of recording and reporting at the service delivery level in order to
allow more time for patient care and promotive activities.
Importance of FHSIS:
• Helps local government determine public health priorities
• Basis for monitoring and evaluating health program implementation
• Basis for planning, budgeting, logistics and decision – making at all levels
• Source of data to detect any unusual occurrence of a disease
• Needed to monitor the health status of the community
• Helps midwives in following up clients / patients
• Documentation of the midwives / nurses’ day to day activities
Uses of Information:
• Policy formulation
• Planning
• Implementation
• Monitoring
• Control
• Further studies/researchers
• “ACTION”
Sources of Information
• Epidemiological Investigation and Surveillance System
• National Health Survey
• Ad-Hoc Survey/Studies, ex. EPI Cluster Survey
• Field Health Service Information System
Demand for Information
• Program Coordinators
• Researchers
• Politicians
• Municipal Health Officers, PHN, Midwives, etc.
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FHSIS History
1987 – conceptualization stage
1988 – consultative meetings
1989 – pilot implementation (Regions 4 and 7)
1990 – nationwide implementation
1993 – devolution
1996 – 1 st modification (Modified)
2008 - 2 nd modification (FHSISv2008)

Components of FHSIS
Recording Tools Reporting Forms

a. Individual Treatment Record (ITR) a. Monthly Form

b. Target Client List (TCL) § M1 – Program

§ M2 - Morbidity
c. Summary Table
b. Quarterly Form
§ HPA
§ Q1 – Program
§ Morbidity Disease
§ Q2 - Morbidity
d. Monthly Consolidation Table (MCT)
c. Annual Forms

§ A-BHS
§ A1 – Vital Statistics Envi/Demographic
§ A2 - Morbidity
§ A3 – Mortality
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Difference of Recording and Reporting

Recording Tools Reporting Forms

• Facility Based • Transmitted / Submitted

• Detailed Data • Summary Data
• Day – to – Day • Monthly/Quarterly Annual
• Source: Services delivered to patients • Source: Dependent on the records
/ clients (Summary of Records)

OFFICIAL FHSIS DOCUMENTS

INDIVIDUAL TREATMENT RECORD (ITR)

• foundation/building block
• piece of paper
• patient consultation record
a. Complaints/presenting symptoms of the patient on consultation and the diagnosis (if
available)
b. Diagnosis
c. Treatment given and the date
d. Date, name, address of patient treatment
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TARGET CLIENT LIST (TCL)

• The TCL constitutes the second recording tool of the FHSIS

• Official recording form of services rendered
• Enables the PHN/RHM to plan and carry out service delivery
• Facilitates monitoring and supervision of services delivered
• Reports services delivered.
• Provides a clinic-level data base which can be accessed for further studies
• TCLs to be maintained are:
1. Target Client List for Prenatal Care
2. Target Client List for Post-Partum Care
3. Target Client List of Under 1 Year Old Children
4. Target Client List for Family Planning
5. Target Client List for Sick Children
6. NTP TB Register
7. National Leprosy Control Program Form 2-Central Registration Form
 64

DATE OF REGISTRATION - write in this column the month, day and year an infant was SEEN at
the clinic for health services.

DATE OF BIRTH - write in this column the month, day, and year of birth. This is important for
determining the immunization schedule.
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FAMILY SERIAL NUMBER - indicate in this column the number that corresponds to the number of
the family folder or envelope or individual treatment record. This column will help you facilitate
retrieval of the client’s record.

NHTS- write the symbol (*) to indicate that the infant is from the NHTS list provided by the DSWD.

NAME OF CHILD- write the complete name of the child.

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WEIGHT- write the weight of the child in kilograms

LENGTH/ HEIGHT- write the length of children under 2 years, and write the height of children 2
years and over in centimeters.

SEX- write the sex of infant “M” for male and “F” for female.
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COMPLETE NAME OF MOTHER- write in this column the name of the mother (Family Name, First
Name and Middle Initial)

COMPLETE ADDRESS- record the client’s permanent place of residence. This column will help
you to monitor or follow- up the client.

DATE OF NEWBORN SCREENING- this is divided into two sub-columns. The first sub-column
refers to those given with referral only. The second sub-column refers to newborn screening done
in the health center. Write the date only
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CHILD PROTECTED AT BIRTH (CPAB)- Write the Tetanus Toxoid Status of the mother in this
sub-column. TT STATUS- TT1, TT2, TT3, TT4, TT5 or Fully Immunized Mother (FIM) and if the
mother received TT2 only, write the month and year TT2 was given. Write the month and year the
child was classified as CPAB.

CPAB- child born to a mother who has received at least 2 doses of Tetanus Toxoid, provided that
the 2nd dose was given at least a month prior to delivery.
- (column 1) Indicate TT statues. If TT2 only, indicate the date below.
- (column 2) Indicate the Date the child was assessed CPAB

DATE IMMUNIZATION RECEIVED - Indicate the dates of the vaccine administration.

 69

SUMMARY TABLE

• is a form with 12-month columns retained at the facility (BHS) where the midwife
records all monthly data.
Composed of:
1. Health Program Accomplishment – the midwife records a summary of all the data
from TCL or registries
2. Morbidity Diseases – the midwife accomplished this table on a monthly basis.This
summary table can also be the source of ten leading causes of morbidity and
reportable disease
 70

The Monthly Consolidation Table (MCT)

• The Consolidation Table is an essential form in the FHSIS where the nurse at the RHU
records the reported data per indicator by each BHS or midwife.
• This is the source document of the nurse for the Quarterly Form.
• The Consolidation Table shall serve as the Output Table of the RHU as it already contains
listing of BHS per indicator.

FHSIS REPORTING

These are summary data that are transmitted or submitted on a monthly, quarterly and on
annual basis to higher level. The source of data for this component is dependent on the records.
The Monthly Form
1. Program Report (M1)
• The Monthly Form contains selected indicators categorized as maternal care, child
care, family planning and disease control.
• The indicators found in the TCL and Summary Tables are also recorded in M1.
• The midwife should copy the data from the Summary Table to the Monthly Form which
she regularly submits monthly to the public health nurse.
2. Morbidity Report (M2)
• The Monthly Morbidity Disease Report contains a list of all diseases by age and sex.
The Midwife uses the form for the monthly consolidation report of Morbidity Diseases
and is submitted to the PHN for quarterly consolidation.
The Quarterly Form
1. Program Report (Q1)
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• The Quarterly Form is the municipality/city health report and contains the three-month
total of indicators categorized as maternal care, family planning, child care, dental
health and disease control
2. Morbidity Report (Q2)
• The PHN uses the form for the Quarterly Consolidation Report of Morbidity Diseases
to consolidate the Monthly Morbidity Diseases taken from the Summary Table.

The Annual Forms (A-BHS, A1, A2 & A3)

• ABHS Form is the report of midwife which contains data on demographic,
environmental and natality.
The report of nurse at the RHU/MHC are the Annual Form 1 which is the report on vital
statistics: demographic, environmental, natality and mortality.
• Annual Form 2 is the report that lists all diseases and their occurrence in the
municipality/city. The report is broken down by age and sex.
• Annual Form 3 is the report of all deaths occurred in the municipality/city. The report is
also broken down by age and sex.

FHSIS FLOW OF REPORTS

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REFERENCE:
Cuevas, F. and Reyala, J. et.al. Public Health Nursing in the Philippnes 10th edition 2007.

ACTIVITY 6:
I. Find at least 2 case scenarios and accomplish the Individual Treatment Record (ITR) and Target
Client List (TCL) applicable for the situation. Write this on your Skills notebook.
 73

PART-VII:
National
Immunization
Program
LEARNING OBJECTIVES
Upon the completion of the topic, the students will be able to gain understanding in
National Immunization Program and its services.

BACKGROUND ON NPI

The last version of Manual of Operations for the Expanded program on Immunization (EPI)
was issued in 1995. As a reference, it guided the health workers to deliver immunization services
based on national protocols and standards. It also helped EPI managers and supervisors
coordinate different program components at various levels of the health system.

EPI eventually became National Immunization Program (NIP) which covered wider
segments of the population. To date, NIP provides immunity against 14 vaccine-preventable
diseases (VPDs) from only six in 1976

It expanded its population coverage beyond infants and pregnant women to include school
children, adolescent/youth, senior citizen and those in special situations. Advances in immunization
technology resulted in safer vaccination equipment and use of combined vaccines which are easier
 74

to administer. The national government budget for NIP increased from Php 3 million in early 2000
to almost Php4 billion in 2016.(DOH,

NATIONAL IMMUNIZATION PROGRAM GOAL OBJECTIVES, STRATEGIES

The 2016-20121 comprehensive multi-year strategic plan contains the following goal,
objectives, strategies to be pursued by the National Immunization Program.

GOAL
To reduce morbidity rates due to vaccine-preventable diseases.

Objective 1
To increase coverage of
existing vaccines for
targeted population groups
across the life-stage.
Objective 2 Objective 3
To provide additional To achieve the country’s
protection to identify commitment to priority
vulnerable groups from global immunization goals.
other VPDs through
evidence-based new
vaccines and
technologies.

Strategy 1 Strategy 2 Strategy 3 Strategy 4 Strategy 5

Expand the Generate Strengthen Build-up Institute

package of clients’ surveil-lance supervi- supportive
quality demand and and sion, governance,
immuni- multisector- response. monitoring financing
zation al support and and
services and for immuni- evaluation. regulatory
scale up zation. measures.
coverage
 75

THE BENEFITS OF IMMUNIZATION

§ Immunizations saves lives, prevents diseases and

reduces direct and indirect health cost.
§ Cost effective, and core competent of any preventive
services package.
§ Protects children from VPDs.
§ Gives protection against more diseases
§ Prevents the spread of diseases.
§ Prevents disease transmission from one generation
to another.
§ Source of high investment return to the government
CONSEQUENCES OF NON-VACCINATION

§ Unvaccinated children develop diseases resulting in prolonged or long term disabilities.

§ Sick children are unable to go to school, which can hamper their becoming fully productive
individual.
§ Prolonged treatment and out-of-pocket spending burdens families with medical expenses
and lost time at work

Wednesday is the designated

immunization day in government
health facilities unless otherwise
revised by local traditions, customs
and other exceptions.(National
Center for Disease Prevention and
Control, DOH, 2001)

Adapted from:https://depositphotos.com/
 76

BASIC PRINCIPLES IN IMMUNIZATION

Timing and Spacing of Vaccines

Timing and spacing of vaccines are the two most important considerations in ensuring optimal
results:

1. Multiple vaccines can be administered at the recommended schedule and time using
different injections sites. Consider the following: (i) the chance of clients coming back for
additional dose to prevent drop-outs; and (ii) the capacity of the client to receive multiple
doses.
2. Two to three inactivated injectable vaccines can be given in the same visit. Example:
PENTA, PCV and IPV can be given at the same immunization schedule at different
injection sites.
2.1. Simultaneous administration of 2 live vaccines can be given in a same visit. Example:
Oral Polio and MMR.
2.2. Two live parenteral vaccines can be given together, with the 2nd dose of the same
vaccines usually administered after 4 weeks. Example: MMR and JE can be given
together.
2.3. Longer interval between doses does not reduce the effectiveness of the vaccine. It is
not necessary to restart the series of any vaccine due to extended interval between
doses. Example: When the child does not come back for the 2nd dose of PENTA at 10
weeks but rather after the child is already 5months, we can still continue with the 2nd
dose and advise parents to come after a month for the 3rd dose.
2.4. Vaccines doses should not be administered at less than the recommended minimum
intervals or earlier than the indicated minimum age.
Administration of Vaccines

Appropriate method of vaccination is a critical component of the NIP. As a vaccine provider, you
must observe utmost professional care to ensure the optimal immune response of the recipient.
 77

1. Client Preparation and Care

• IMPORTANT: Always screen clients for possible contra-indications every time you
administer a vaccine.
• Explain to the client how the vaccines work, including safety and risk. Establish an
atmosphere in which client and their parents can freely evaluate information,
discuss vaccine concerns and make informed decisions regarding the vaccination.
• Make the vaccination least stressful to the client and their parents or guardians.
This can be done through:
Ø A positive attitude through your facial expression, body language and
comments.
Ø A soft and calm tone of voice.
Ø Eye contact even with small children.
Ø Explaining why vaccines are needed.
Ø An honest explanation of what to expect. Never say that injection won’t
hurt.
2. Infection control
• Wash your hands thoroughly before and after each new client contact.
• It is not necessary to wear gloves when administering vaccines unless you have
open lesions or are likely to come in contact with potentially infected body fluids.
• Properly dispose of used needles and syringes to prevent needle stick injury and
reuse.
Administering Multiple Vaccines at the Same Time

1. Do NOT use the same syringe for more than one vaccine.
2. As much as possible, do NOT inject the same arm or leg more than once. However, if it is
necessary to administer at least 2 vaccines on the same site to ensure that the injection
sites are at least 2.5 cm (about 2 finger breaths) apart (e.g. PCV, IPV).
3. Do NOT give more than one dose of the same vaccine in one session.
4. Give doses of the same vaccine at the correct intervals.
5. Wait at least 4 weeks between subsequent doses of OPV, DPT-HepB-Hib (PENTA)
 78

MILESTONES OF IMMUNIZATION PROGRAM IN THE PHILIPPINES

§ Official launching of the Expanded Program on

Immunization . 1976
§ BCG vaccination initially given to school entrants.

§ BCG and DPT provided nationwide, OPV and Tetanus

Toxoid (TT) for pregnant women provided in high risk 1979
area.

§ OPV and TT provided nationwide. 1980

§ MV provided among 35% of eligible population. 1982

§ MV provided nationwide 1983

§ Hepatitis B provided among 40% of eligible population 1992

§ Hepatitis B provided nationwide. 2005

§ MMR administered in selected areas

2010
§ PENTA: DTwP-HepB-Hib in three selected region.

§ PENTA administered Nationwide

§ Rotavirus vaccine provided among children in indigent families
§ Anti-Influenza Vaccine and PPV 23 provided for indigent senior 2012
citizens

§ MMR second dose provided for children 12-15 month of

age. 2013
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§ PCV 13 vaccine introduced in five selected regions

§ HPV vaccine introduced in pilot areas in CAR and 2014
Region 7

§ PV vaccine provided in the NCR, Region 3, 6 and 7

2015
§ Td and MR vaccine provided in 20 priority provinces
among females age 9-10y.o

§ IPV provision expanded to 6 regions 2016

§ Td and MR vaccines provided in all public schools

§ MV was replaced with MMR

§ Anti-Influenza Vaccine and PPV 23 provided for all 2017
senior at ages 60 to 65 years

LEGAL BASIS OF THE NATIONAL IMMUNIZATION PROGRAM

Presidential Decree (PD) No. 996

Providing for compulsory basic immunization for infants

and children below eight years of age.

Presidential Proclamation NO. 6

Implementing the Expanded program on Immunization (EPI), in response to United

Nations goal on Universal Child Immunization by 1990

Proclamation NO. 46 (1992)

Reaffirming the Philippines’ commitment to universal goal of eradicating polio by 2000

through child and mother immunization.

RA 7486

Provided for compulsory immunization against hepatitis B for infants and children below 8
years old amending for the purpose of PD no. 996. These include vaccination against: TB,
 80

DPT, polio, measles, rubella, Hepatitis B in newborns 24hr after birth and children below 8
years old.

DOH AO No. 39, s. 2003

Guided the nationwide implementation of the EPI

Republic Act 10152

§ An act providing for MANDATORY BASIC IMMUNIZATION services for infants and
children, repealing for the purpose Presidential Decree No 996 as amended.
§ Known as “MANDATORY INFANTS AND CHILDREN IMMUNIZATION ACT OF 2011”
§ The mandatory basic immunization shall be given for FREE at any government hospital or
health center to infants and children up to five (5) years of age. These include vaccines
against TB, DPT, polio, measles, mumps, rubella or german measles, hep b, H. influenza
type B (HIB) and other types as may be determined by the Secretary of Health.
WHAT IS FIC? (Fully Immunized Child)

A child before reaching 1 year old should receive all of the following:

ü 1 dose of BCG
ü 3 doses of DPT
ü 3 doses of OPV
ü 3 doses of Hep B
ü 2 doses of Measle Vaccine
ü
COMMON VACCINE PREVENTABLE DISEASES

§ Tuberculosis
§ Hepatitis B
§ Poliomyelitis
§ Diphteria
§ Pertussis (whooping cough)
§ Tetanus
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§ Haemophilus Influenza B Diseases

§ Pneumococcal Diseases
§ Measles
§ Mumps
§ Rubella Papilloma Virus (HPV)
§ Influenza
§ Rota Virus
§ Japanese Encephalitis

VACCINES AVAILABLE IN THE PHILIPPINES AND RECOMMENDED

BY DOH FOR USE AGAINTS VPDS

Usual No. of
Com-
Doses in Damaged
Formulation mon
Vaccine Disease Type of Vaccine Primary Series by
(1st Column) vial
and route of freezing?
Sizes
administration

Bacillus Calmette
No, but
Guérin (BCG) live
1 dose 20 diluent
BCG Tuberculosis attenuated Freeze-dried
intradermal dose should not
mycobacterium
be frozen
bovis

1
HEPA B 1 dose- dose
Hepatitis B PlasmRecombinant Monovalent YES
VACCINE intramuscular 10
dose

10
2 drops per dose dose
OPV Polio Live attenuated Liquid NO
3 doses – oral 20
dose

1
1 dose – dose
IPV Polio Inactivated Liquid YES
intramuscular
10
dose
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Diptheria,
Tetanus, 1
Pertussis, Inactivated: dose
PENTA
Hepatis B, conjugate Liquid 3 doses – 2
DPT- YES
Haemophilus polysaccharide Iyophilized intramuscular dose
HepB-Hib 10
influenzae type vaccine
b (Hib) doses
diseases

1
Inactivated 3 doses - dose
PCV Pneumonia Liquid 10 YES
Conjugated Intramuscular
dose

Inactivated 1 dose - 1
PPV Pneumonia Liquid YES
polysaccharide intramuscular dose

Freeze-dried
Monovalent,
1 NO but
Measles- measles-
1 dose dose diluent
MMR Mumps- Live attenuated rubella (MR), 10
Subcutaneous should not
Rubella and measles- dose be frozen
mumps-rubella
(MMR)

Freeze-dried
Monovalent,
1 NO but
measles-
Measles- 1 dose dose diluent
MR Live attenuated rubella (MR), 10
Rubella Subcutaneous should not
and measles- dose be frozen
mumps-rubella
(MMR)

Rotavirus Liquid oral 1

Rotavirus Live attenuated 2 doses -oral NO
Vaccine suspension dose

Freeze-dried
Monovalent,
1 NO but
measles-
JE Japanese 1 dose dose diluent
Live attenuated rubella (MR), 10
Vaccine Encephalitis Subcutaneous should not
and measles-
dose be frozen
mumps-rubella
(MMR)

Liquid SBI (2doses) IM

Td Multivalent WCBA (2dose in 10
Tetanus Inactivated:
st YES
Vaccine Diptheria Toxiod form: Td 1 pregnancy & 1 dose
Vaccine dose in each
subsequent
 83

pregnancy for 5
total doses) IM

Human
HPV 1
Papilloma Recombinant Liquid 2 doses -IM YES
Vaccine dose
Virus

1
Influenza dose
Influenza Inactivated Liquid 1 dose- IM 10 YES
Vaccine
dose

BCG (BACILLUS OF CALMETTE GUERIN) VACCINE

§ It protects against tuberculosis.

§ It is made from a special live but weakened mycobacterium.
§ BCG has a short life span and, once reconstituted, must be discarded after 6
hours or at the end of immunization session, whichever comes first.
§ Before you can use BCG, you must reconstitute the dry vaccine with an
accompanying diluent
§ BCG is damaged most easily by sunlight.

Reconstituting The Freeze Dried BCG Vaccine:

ü Always keep the diluent cold by sustaining with BCG vaccine ampules in refrigerator or
vaccine carrier.
ü Using a 5 mL syringe fitted with a long needle, aspirate 2 mL of saline solution from the
opened ampule of diluent.
ü Inject the 2 mL saline into the ampule of freeze dried BCG.
ü Thoroughly mix the diluent and vaccine by drawing the mixture back into the syringe and
expel it slowly into the ampule several times.
ü Return the reconstituted vaccine on the slit of the foam provided in the vaccine carrier.
 84

How safe is the BCG vaccine and what are its potential adverse effects?

BCG is a safe vaccine with rare adverse events. Most children do have a reaction at the
site of injection. Normally, when BCG vaccine is injected, a small raised lumped appears at the
injection site. This usually disappears within 30 minutes. After about 2 weeks, a red sore forms
about the size of the end of an unsharpened pencil. The sore remains for another two weeks and
then heals. A small scar, about 5 mm across remains. Health workers look for this to determine
whether the child has been vaccinated. However, the absence of a scar does not mean that the
vaccination did not work.

VACCINE SIDE EFFECTS MANAGEMENT

BCG Koch’s phenomenon: an acute inflammatory No management is needed

reaction within 2-4 days after vaccination;
usually indicates previous exposure to
tuberculosis

Deep abscess at vaccination site; almost Refer to the physician for

invariably due to subcutaneous or deeper incision and drainage
injection.

Glandular enlargement: enlargement If suppuration occurs, treat as

of lymph glands draining the injection site deep abscess.

Administration Summary:

Type of Vaccine Live Attenuated

No. of Doses One (1) dose only

Schedule At birth (preferably 90 minutes after birth or before 1 year of

age)

Dose 0.05mL

Injection Site Upper Arm

 85

Injection Type Intradermal

Contraindication: Known HIV infection and other immune deficiency.

Precaution for HIV:

If Mother is HIV positive, the new born must be tested for

HIV.

However if the HIV test is not available, BCG vaccine is

NOT given.

§ If the baby is positive with HIV infection, BCG vaccine

is NOT given.
§ If the baby is negative for HIV Infection, BCG is given.
Precaution FOR TB

If the newborn baby is exposed to smear positive TB

clients (mother or other first degree relative), it is
recommended that the infant be treated with Isoniazid for
6months before administering BCG Vaccine

Side Effects Local Reaction

Storage +2 to +8 °C

HEPATITIS B VACCINE

§ It protects against Hepatitis B infection.

§ It contains only one antigen (monovalent).
§ Only monovalent HepB vaccines should be used as a birth dose (within 24 hours).
It is available in combination and should not be used at birth, but may be used in
subsequent doses.
 86

§ If HepB vaccine is left standing for a long time, the vaccine may separate from the
liquid. In this state, the vaccine looks like fine sand at the bottom of the vial. Shake
the vial to mix the vaccine and liquid before using the vaccine.
§ HepB vaccine should NEVER be frozen.
§ The “shake test” will determine if the vaccine has been damaged by freezing. If the
vaccine fails the shake test, you must discard it.

Gold Standard: Within 24 hours, ideally 90 minutes after birth. If not given within
24hours, it can still be given within seven (7) days.

Administration Summary:

Type of Vaccine Recombinant DNA

No. of Doses One (1) dose only
Schedule Within 24 hours, ideally 90min after birth
Dose 0.5 mL
Injection Site Outer-mid thigh
Injection Type Intramuscular
Side Effects Local Soreness
Storage +2 to +8 °C

ORAL POLIO VIRUS (OPV)

§ It protects against polio virus.

§ It protects against 2 types of polio virus: one uses inactivated(dead), poliovirus,
and the other uses attenuated (weakened) polio virus.
§ Oral polio vaccine (OPV) is damaged very quick by heat.
§ If the child has diarrhea, give the dose now, until completion of the series. Then
give an extra dose one month after the last dose in the series.
§ Polio vaccine is a clear pink or pale orange liquid. It comes in a special small
bottle with a dropper cap.
 87

Administration Summary:

Type of Vaccines Live Attenuated Vaccine

No. of Doses Three (3) doses (one month apart)
Schedule 6, 10, 14 weeks
Dose 2 drops
Injection Site -------
Route Oral
Side Effects Usually none
Storage -15 to -25°C

INACTIVATED POLIO VIRUS (IPV)

§ Contains killed virus

§ Administered by injection
§ More expensive than OPV
§ Provides immunity through blood
§ Carries no risk of vaccine-associated polio paralysis (VAPP) or vaccine-derived poliovirus
(VDPD)
§ Given only before 1 year of age CONCURRENTLY with OPV3.

How effective is the polio vaccine?

§ In more than 95% of recipients, three doses of OPV produce immunity for all of polio virus
types in the vaccine.
§ IPV is also highly effective in preventing paralytic disease caused by all three types of polio
virus but induces low levels of immunity in the intestine. As a result, when a person is
immunized with IPV is infected with wild poliovirus, the virus can still multiply inside the
intestines and be shed in the feces, risking continued circulation.
 88

Administration Summary:

Type of Vaccines Inactivated Vaccine

No. of Doses One (1)
Schedule 14 weeks (given together with OPV3)
Dose 0.5 ml
Injection Site Outer left upper thigh
Injection Type Intramuscular
Side Effects Local reaction
Storage +2 to +8 °C (DO NOT FREEZE)

DPT-HepB+Hib COMBINATION VACCINE (PENTA)

§ Is a Pentavalent vaccine.
§ It protects against 5 diseases: diptheria, tetanus, and pertussis, hepatitis B, and
Haemuphilus influenzae type B.
Giving PENTA vaccine

§ Shake the vial before aspiration of the vaccine

§ Do not massage injection site
§ Apply pressure to the site
§ Instruct mothers for side effects management:
FEVER: Increase fluids; Paracetamol; TSB

LOCAL REACTION: Cold Compress

VACCINES SIDE EFFECTS MANAGEMENT

DPT-HepB-Hib Fever that usually lasts for only 1 Advise parents to give
day. Fever beyond 24 hours is not antipyretic.
(Pentavalent due to the vaccine but to other
Vaccine) causes.

Local soreness at the injection site Reassure parents that soreness

will disappear after 3-4 days.
 89

Abscess after a week or more Incision and drainage may be

usually indicates that the injection necessary.
was not deep enough or the needle
was not sterile.

Convulsions: although very rare, may Proper management of

occur in children older than 3 convulsions; pertussis vaccine
months; caused by pertussis vaccine should not be given anymore.

Administration Summary:

Type of Vaccine Inactivated vaccine

Component D,P,T, Hepa B, H. Influenza type B
No. of Doses Three (3) doses (one month apart)
Schedule 6, 10 14 weeks
Dose 0.5 ml
Injection Site Outer right upper thigh
Injection Type Intramuscular
Side Effects Local reaction, fever
Storage +2 to +8 °C

PNEUMOCOCCAL CONJUGATE VACCINE (PCV)

§ Is a vaccine against streptococcus pneumoniae for infants under one year of age.

Administration Summary:

Type of Vaccines Inactivated Vaccine

No. of Doses Three (3) doses (one month apart)
Schedule 6, 10, 14 weeks
Dose 0.5 ml
Injection Site Anterolateral (outer) part of left thigh (vastus lateralis)
Injection Type Intramuscular
Side Effects Local reaction, fever
Storage +2 to +8 °C
 90

PNEUMOCOCCAL POLYSACCARIDE (PPV)

§ Is a vaccine against streptococcus pneumoniae for adults aging 60 and 65 years old.

Administration Summary:

Type of Vaccines Inactivated Vaccine

No. of Doses One dose
Schedule At age 60 and 65 years old
Dose 0.5 ml
Injection Site Upper Arm (deltoid)
Injection Type Intramuscular
Side Effects Local reaction, fever
Storage +2 to +8 °C

MEASLES-RUBELLA (MR) AND MEASLES-MUMPS-RUBELLA (MMR)

COMBINATION VACCINES

§ In the Philippines, the NIP uses combination vaccines for measles, rubella (MR) and for
measles, mumps and rubella (MMR).
§ In powder form with diluents and must be reconstituted they can be used.
§ Any remaining reconstituted vaccine must be discarded after six hours or at th end of the
immunization session, which ever comes first.

Administration Summary:

Measles-Mumps and
Measles-Rubella (MR)
Rubella (MMR)
Type of Vaccine Live Attenuated Live Attenuated
Target Population Infants below 15months of School age children
age
 91

No. of Doses Two (2) doses Two (2) doses

Schedule 9 months and 12 months Grade 1 (5-6 years old)
and Grade 7 (11-12 years
old)
Dose 0.5 ml 0.5 ml
Injection Site Upper Arm Upper Arm
Injection Type Subcutaneous Subcutaneous
Side Effects Local reaction, fever, rash Local reaction, fever, rash
Storage +2 to +8 °C +2 to +8 °C

ROTAVIRUS

§ Protects children from rotaviruses, the leading causes of diarrhea among infants and
young children.

What are the forms and presentations of rotavirus?

§ Rotarix™
Rotaris is a monovalent, human, live attenuated rotavirus vaccine containing one strain of
G1P(8) specificity. ROTARIX is indicated for the prevention of rotavirus gastroenteritis
caused by G1 and non-G1 types (G3, G4 and G9) when administered as 2-dose series in
infants and children.
§ RotaTeq™
RotaTeq is a live, oral pentavalent vaccine containing five rotavirus strains produced by
reassortment.
 92

Administration Summary:

Type of Vaccines Live Attenuated Vaccine

No. of Doses Two (2) doses (Rotarix ™);
Three (3) doses (Rotateq™)
Schedule 6, 10 weeks
Dose 1 mL
Route Oral
Storage +2 to +8 °C

Special precautions:
Infants with acute gastroenteritis and moderate to severe illness should be postponed in
giving the Rota vaccine.

JAPANESE ENCEPHALITIS (JE) VACCINE

§ Protects people against viral encephalitis caused by Japanese Encephalitis Virus (JEV).
JEV is the leading cause of viral encephalitis in Asia

Administration Summary:

Type of Vaccines Live attenuated virus Vaccine

No. of Doses One dose
Schedule Less than eight months of age.
Dose 0.5 ml
Injection Site Upper Arm
Injection Type Subcutaneous
Contraindication § Known allergy to the vaccine or any of its components.
§ Pregnancy
§ Any condition that results in a decreased or abnormal
immune system response, including due to any infection
such as HIV, medication and/or congenital problems
(since birth)
§ Acute diseases, severe chronic diseases, and chronic
diseases with acute symptoms of the nervous system.
 93

Special Precaution § Medical history: caution needed for family or individual

history of siezures or other chronic diseases, allergies and
for women who are lactating
§ Postpone vaccination for at least three (3) months if the
person has been given immonuglobin

Adverse reaction High fever, redness, swelling

Storage +2 to +8 °C

TETANUS DIPTHERIA (TD) VACCINE

§ It is suitable for children older than five years old and adults, including pregnant women.
§ Td has the added advantage of protecting against diptheria and tetanus

What are the forms and presentation of Td vaccine?

The vaccine can come in either as dT or DT. The capital or small letter D signifies the
amount of diptheria toxoid in vaccine either high or low.

The table below the schedule by dose and the length of protection provided. Td can be used
instead of TT to protect against both tetanus and diptheria.

EXPECTED
PERCENT
DOSE WHEN TO GIVE DURATION OF
PROTECTED
PROTECTION
As early as possible in
pregnancy or first
May be very limited
Td1 contact when a girl
duration protection
reaches childbearing
age
At least 4 weeks after Infants born to the
Td2 80% 1-3 years
Td1 mother will be
 94

protected from
neonatal tetanus
Infants born to the
At least 6 months after
mother will be
Td3 Td2 or in next 95% At least 5 years
protected from
pregnancy
neonatal tetanus
Infants born to the
At least one year after
mother will be
Td4 Td3 or during 99% At least 10 years
protected from
subsequent pregnancy
neonatal tetanus
Gives life time
protection for the
At least one year after For all childbearing
mother
Td5 Td4 or during 99% age years and
All infants born to
subsequent pregnancy possibly longer
that mother will be
protected.

Definition of Protected
According to DOH 2001, the definition of protected mother is, if the mother has received
3 or more doses of TT at any other time in the past or mother has received 2 doses of TT during
pregnancy with the child.

Definition of Not Protected

§ Mother does not know or remember the immunization status

§ Mother has not received TT.
§ Mother has received only one dose of TT.
§ Mother received less than two doses of TT in the last pregnancy.
§ If the child is unprotected, the mother should receive a dose of TT during the same visit.
 95

How to Administer TT?

ü Two doses of 0.5 ml per dose

ü Administered intramuscularly (IM)
ü With one month interval between 1st 2 doses
ü The primary series can be given anytime during the pregnancy and up to 3 months post
partum
ü All unimmunized pregnant women regardless of age and parity shall be eligible for the
primary TT immunization series.
ü All mothers who bring their child to an immunization session will be screened for TT
immunization and will be given a dose of TT if not yet given.

Administration Summary:
Type of Vaccines Toxoid
Dose 0.5 ml
No. of Doses § Tetanus vaccine is given as five (5) – dose schedule. Three
(3) doses in infancy as Pentavalent and two (2) doses in
school age as Td.
§ Children (Grade 1 and Grade 7) who had received three
primary doses in the form of PENTA should receive at least
two doses of Td
§ Pregnant women who had received three childhood
DPT/PENTA doses should receive three doses of Td.
§ Pregnant women with no previous DPT/PENTA immunization
or unreliable immunization information should receive 5 Td.
Schedule § After receiving primary doses during infancy (three
doses in the form of PENTA), Td should be given to children
5-7 years old (Grade 1) and 12-15 years old (grade 7).
§ For pregnant women, Td vaccine should be given as early as
possible upon onset of pregnancy.
 96

§ For the prevention of tetanus in women through their

childbearing years and in newborns, women should receive
five doses of tetanus toxoid.
Injection Site Upper outer part of arm
Injection Type Intramuscular
Adverse reaction High fever, redness, swelling
Storage +2 to +8 °C

As a practical marker for the mothers to remember their TT booster doses, return visits shall
be scheduled according to the age of the baby born by the pregnancy during which the primary TT
series was given.
TT3- during the measles immunization of the baby at 9 months old
TT4- at the baby’s second birthday
TT5- at the baby’s third birthday
Mothers whose pregnancies did not result in a live birth shall also be entitled to booster
doses following the standard intervals as indicated above. Since these mothers may not come for
child consultations, special efforts may be needed to remind them of their subsequent doses.

HUMAN PAPILLOMA VIRUS

§ Is primarily used for prevention of cervical cancer for women.

§ Other benefits are prevention of ano-genital warts, vulvular, vaginal and anal cancer,
penile intraepithelial neoplasia (pre-cancerous disease of the outer skin layer of the penis).
Administration Summary

Type of Vaccines Recombinant

Dose 0.5 ml
Number of Doses Two (2) doses (six months apart)
Schedule Routinely given to females 9-10 years old.
Injection Site Upper arm (deltoid)
 97

Injection Type Intramuscular

Side effects § Local reactions
§ Fever
§ Vasovagal syncope can occur among adolescents and
adults after receiving the vaccine.
§
Special precaution § Postpone vaccination for pregnancy
§ Adolescent should be seated during injections and for 15
minutes afterwards since they sometimes faint.

Storage +2 to +8 °C. Protect from light.

SEASONAL INFLUENZA VACCINE

§ Most seasonal influenza vaccines are trivalent, containing two strains of influenza A and
one strain of influenza B, chosen based on known circulating strains.
§ The influenza vaccine, also known as flu shot is an annual vaccination using vaccine that
is specific for a given year to protect against the highly variable influenza virus.

What are the forms and presentation of Influenza vaccine?

§ Trivalent vaccine – protect againts two influenza A viruses (an H1N1 and H3N2) and an
influenza B virus
§ Quadrivalent virus – protect against two influenza A viruses and two influenza B viruses
 98

Administration Summary:

Type of Vaccines Inactivated influenza virus

No. of Doses Usually one dose annually
Schedule Adults 60 years of age or older should get vaccine as it
becomes available in the health center near you ideally before
flu season.
Dose 0.5 mL
Injection site Upper arm (deltoid)
Injection Type Intramuscular
Contraindication Known hypersensitivity (allergy) or anaphylaxis to a previous
dose or to a vaccine component such as egg protein
Adverse reaction § Mild: injection site reaction and fever
§ Severe: rare anaphylaxis, Guillain-Barré syndrome,
oculo-respiratory syndrome.
Storage +2 to +8 °C
 99

SUMMARY OF VACCINE BY
ROUTE OF ADMINISTRATION, INJECTION SITES AND SCHEDULE

Route of
No. Vaccine Injection Site Schedule
Administration
1 BCG Intradermal Upper-right arm At birth
2 HepB Intramuscular Outer-mid thigh At birth
3 OPV Oral Mouth 6-10-14 weeks
Outer left upper
4 IPV Intramuscular 14 weeks
thigh
Outer right upper
5 PENTA Intramuscular 6-10-14 weeks
thigh
Upper left upper
6 PCV Intramuscular 6-10-14 weeks
thigh
Adults 60-65
7 PPV Intramuscular Upper right arm
years old
Rotavirus
8 Oral Mouth 6-10 weeks
Vaccine
9 MMR Subcutaneous Upper right arm 9 and 12 months
10 MR Subcutaneous Upper right arm Grade 1 and 7
For children
Grade 1 and 7
For childbearing
woman:
Td1: as early as
possible in
pregnancy
Outer, left upper
11 Td Intramuscular Td2: 4 weeks
arm
after Td1
Td3: 6 months
after Td2
Td4: 1 year after
Td3
Td5: 1 year after
Td4
12 JE Subcutaneous Upper arm 9 months
Female: 9-10
13 HPV Intramuscular Outer, upper arm
years old
Influenza 60 years old and
14 Intramuscular Outer, upper arm
Vaccine above, annually
 100

COLD CHAIN MANAGEMENT

Essential Components In Immunization Program

• Vaccines
• Syringes
• Needles
• Cold Chain Equipment

Vaccines
Is sensitive to varying temperatures. Special care is therefore needed when transporting,
handling and storing in order to maintain their potency.
Syringes and Needles
Should be handled with utmost care– from the time they are obtained up to the time they are
used. Make sure that they are stored in an environment that is clean and free from moisture to
prevent damage.
Cold Chain System
• is a system for ensuring the potency of vaccines from the time of manufacture to the time
they are given to an eligible child or woman.
• necessary because vaccines are delicate substances that lose potency if they are exposed
to temperatures that are too warm or too cold.
2 Essential Elements
1. People- organize and manage the calculation, requisition and distribution of vaccines.
2. Equipment - Used for storing and transporting vaccines.
Cold Chain Officer
• person directly responsible for cold chain management at each level.
Public Health Nurse
• acts as the Cold Chain Officer at the RHU/ health center
 101

• In charge of maintaining the cold chain equipment and supplies such as freezer/ refrigerator,
transport box, vaccine bags/carriers, cold chain monitors, thermometers and cold packs
• Implements an emergency plan in the event of an electrical breakdown or power failure.

Vaccine Distribution Scheme

Supplier Central Regional

Storage Storage

District
Hospital
PHO

BHS RHU

Proper Storage of Vaccines

An effective cold chain is vital to the immunization program. Vaccines will give immunity only when
they are potent. In order to be potent, vaccines must be properly stored, handled, and transported.
 102

The following table shows the recommended storage temperature of each vaccine:

Types of Vaccines Storage Temperature

MOST SENSITIVE TO HEAT Oral Polio -15ºC to -25ºC
Measles (freeze dried) -15ºC to -25ºC
BCG (freeze dried) +2ºC to +8ºC
LEAST SENSITIVE TO HEAT DPT, Hepa B +2ºC to +8ºC
Tetanus Toxoid +2ºC to +8ºC

Proper stocking of vaccines:

a. Stock vaccines neatly on the shelves of the refrigerators. Do not stock vaccines at the door.
b. Keep diluents in the lower shelves. Do not freeze.
c. Stock the vaccine in the refrigerator so that those that are due to expire first can be identified
and used first.
d. Segregate different types of vaccines, arrange them neatly in a tray that does not hold water, or
in their boxes. See to it that their labels are not detached or defaced.
e. Label tray or box container, indicating name of vaccine and expiry date in bold letters or
numbers. Unopened ampules or vials of vaccines should be marked with an “x” each time they are
carried to the field and returned to the refrigerator.

• Single “x” indicates one trip to the field

• Double “xx” indicates two trips to the field.
• If vaccines are not used on their third trip to the field, they should be discarded.
• “Opened vials” in this context refer to multidose vials from which one or more doses of
vaccine have been used, in line with standard sterile procedures,
• Continue to use opened vials of vaccine in subsequent sessions if all these conditions are
met:
 103

ü The expiry date has not passed, and

ü The vaccines are stored under appropriate cold chain conditions (0-8 Celsius), and
ü All opened vials of vaccine which have been taken out of the health center for
immunization activities (e.g. Outreach, mobile teams, NIDs) are discarded at the end
of the day.

f. Leave spaces between rows to permit movement of cold air

g. Store bottles of water where there are spaces.
h. Measles and Oral Polio Vaccine should be properly stocked in the freezer together with frozrn ice
packs.

Observe the FIRST EXPIRY-FIRST OUT (FEFO)

A multidose vial may be opened for one or two clients if the health worker feels that a client
cannot come back for the scheduled immunization session. Multidose liquid vaccines such as OPV,
Pentavalent vaccine, Hepatitis b vaccine, and TT from which one or more doses have been taken
following standard sterile procedures, may be used in the next immunization sessions for up to a
maximum 4 weeks, provided that all the following conditions are met:

ü The expiry date has not passed.

ü The vaccine has not been contaminated.
ü The vials have been stored under appropriate cold chain conditions.
ü The vaccine vial septum has not been submerged in water.
ü The VVM on the vial, if attached, has not reached the discard point.
ü Reconstitute freeze-dried vaccines such as BCG, AMV, and MMR ONLY with the
diluents supplied with them.
ü Discard reconstituted freeze-dried vaccines 6 hours after reconstitution or at the end
of the immunization session, whichever comes sooner.
ü Protect BCG from sunlight and Rotavirus vaccine from light.
 104

Discard an opened vial immediately if any of the following conditions apply:

ü Sterile procedures have not been fully observed, or

ü There is even a suspicion that the opened vial has been contaminated, or
ü There is visible evidence of contamination (such as a change in appearance or the
presence of floating particles)

Proper Stocking of Vaccine in the Refrigerator

In the Transport Box or Vaccine Carrier

• Make sure you have enough frozen ice packs. You need twenty- four (24) ice packs for a
transport box and four (4) for the standard vaccine carrier.
• Place the measles and Oral Polio Vaccines in contact with the frozen ice packs. Wrap the
other vaccines (TT, DPT and Hep. B) with paper to prevent them from coming in contact
with the ice packs. Do not forget to leave the ice packs out of the freezer to stand for a few
minutes before packing.
 105

• Place BCG in between the wrapped vaccine (TT, DPT and Hep. B) and Measles and OPV
vaccines.

Important Points to Remember in Storing Vaccines

• Never freeze DPT, TT and Hep B vaccines

• Keep Polio and Measles vaccine in the freezer, or in the body of the refrigerator, if
modified
• If vaccine is stored above or below its safe temperature it will lose its potency. It cannot be
restored by being cooled or thawed again.
• Keep diluent in the lower shelves or refrigerator. Do not freeze the diluent.
• In case of power failure, fill the freezer with ice packs which are frozen in advance to keep
the temperature down. However, allow some spaces for air to circulate.
• Keep bottles of water in the lower shelves of the refrigerator to keep the temperature
constant.
• Never keep vaccines in the door of the refrigerator.
• Keep the door closed as much as possible to keep in the cold air.

VACCINE VIAL MONITOR (VVM)

• Is a label of heat-sensitive material which is placed on a vaccine vial or ampule to register

cumulative heat exposure over time.
• The combined effects of time and temperature cause the monitor to change color,
gradually and irreversibly.
 106

ü The lower the temperature, the slower the color change.

ü he higher the temperature, the faster the color change.

How does a VVM look like?

• The VVM is a circle with a small square inside it. It can be printed on a product label or
attached to the cap of the vaccine vial.
• In some models, the inner square is made of a heat sensitive material which is light in
color at the start and becomes darker as it is exposed to heat.
The basic guidelines for reading the monitor which are the same for both types are:

Rule 1: If the inner square is lighter than the outer circle, the vaccine may be used.
Rule 2: If the inner square is the same as, or darker than the outer circle, the vaccine must
not be used.

How to Read the Vaccine Vial Monitor?

The square is lighter than the circle.

If the expiry date is not passed, use

the vaccine.

Inner square still lighter than outer

ring.

If the expiry date has not been

passed, USE the vaccine.

The square matches the circle.

Do not use the vaccine. Inform your

supervisor.

Inner square darker than outer ring.

DO NOT use the vaccine.

 107

SYRINGES AND NEEDLES

Parts of a Syringe and Needle

Types of Syringes and Needles

• Standard disposable syringes and needles

• Auto- disabled syringes with fixed needles

SAFETY BOXES

• For collection of used syringes, needles and sharps

• For outreach immunization, the safety box should be taken to the health facility for disposal.
 108

Considerations Related to the Schedule and Manner of Administering Immunization

ü Use only one sterile syringe and needle per client.

ü There is NO NEED TO RESTART a vaccination series regardless of the time that has
elapsed between doses.
ü All the NIP antigens are safe and effective when administered simultaneously, that is,
during the same immunization session but at different sites. It is NOT recommended,
however, to mix different vaccines in one syringe before injection, or to use a fluid vaccine
for reconstitution of a freeze-dried vaccine.
ü The recommended sequence of the coadministration of vaccines is OPV first followed by
Rotavirus vaccine, then other appropriate vaccines.
ü OPV is administered by putting drops of the vaccine straight from the dropper onto the
child’s tongue. Do not let the dropper touch the tongue.
ü Only monovalent hepatitis B vaccine must be used for the birth dose. Pentavalent vaccine
must not be used for the birth dose because DPT and Hib vaccine should not be given at
birth. A monovalent vaccine is one that contains an antigen against a single disease.
Pentavalent vaccine contains antigens against 5 diseases: diphtheria, pertussis,
tetanus, hepatitis B and Haemophilus influenzae B
ü Children who have not received AMV1 as scheduled and children whose parents or
caregivers do not know whether they have received AMV1 shall be given AMV1 as soon
as possible, then AMV2 one month after the AMV1 dose.
ü All children entering day care centers or preschool and Grade 1 shall be screened for
measles immunization. Those without the immunization shall be referred to the nearest
health facility for immunization
ü The first dose of Rotavirus vaccine is administered only to infants aged 6 weeks to 15
weeks. The second dose is given only to infants aged 10 weeks up to a maximum of 32
weeks.
ü Administer the entire dose of the Rotavirus vaccine slowly down one side of the mouth
(between the cheek and gum) with the tip of the applicator directed toward the back of the
infant’s mouth. To prevent spitting or failed swallowing, stimulate the rooting and sucking
 109

reflex of the young infant. For infants aged 5 months or older, lightly stroke the throat in a
downward motion to stimulate swallowing.

REFERENCE:

1. Department of Health (2014). Expanded Program on Immunization, Basic Skills Course for
Health Workers.
2. Department of Health (2020). Manual of Operations National Immunization Program.
 110

ACTIVITY 7

INSTRUCTION: Indicate the vaccines that should be given to the infant according to his age. Then draw a
circle showing the route of the vaccine with label.

Situation no. 1: A mother came with a 4 months and 1 week old baby for immunization. The nurse
gathered the data and assessed the baby. She then prepares the following vaccines:
 111

Situation no. 2: A mother came with a 2 and a half months old baby for immunization. The nurse gathered
the data and assessed the baby. She then prepares the following vaccines:

Instruction: Fill in the blanks.

Route of
Vaccine Injection Site Schedule
Administration

BCG 1. Upper-right arm At birth

HepB Intramuscular Outer-mid thigh At birth

PPV Intramuscular 2. 3.

Rotavirus Vaccine 4. 5. 6.

JE 7. Upper arm 9 months

HPV Intramuscular 8. 9.

Influenza Vaccine Intramuscular Outer, upper arm 10.

 112

PART- VIII:
Integrated
Management Of
Childhood Illness
(IMCI)
LEARNING OBJECTIVES

Upon the completion of the topic, the students will be able to gain understanding in
Family Nursing Care Plan and Formulate a family care plan.

BACKGROUND OF IMCI
- IMCI is an integrated approach to child health that focuses on the well-being of the whole
child. IMCI aims to reduce death, illness and disability and to promote improved growth
and development among children under five years of age. IMCI include curative and
preventive elements that are implemented by families and communities and by health
facilities.
- The strategy was developed by World Health Organization and UNICEF and is used by
most countries in the world.
OBJECTIVES OF IMCI
• Reduce death and frequency and severity of illness and disability, and
• Contribute to improved growth and development
 113

WHAT ARE THE BENEFITS OF THE IMCI STRATEGY?

1. Addresses major child health problems because it systematically addresses the most
important causes of children illness and death.
2. Responds to demands.
3. Promotes prevention as well as cure because IMCI emphasizes important preventive
interventions such as immunization and breastfeeding.
4. Is cost-effective- most cost-effective interventions in low- and middle-income countries
(World Bank).
5. Promotes cost-saving.
6. Improves equity – IMCI improves inequity in global health care.

WHAT ARE THE FOCUS OF IMCI?

• Improving case management skills of health workers
• Improving over-all health systems
• Improving family and community health
practices
How to Select the Appropriate
WHO ARE THE CHILDREN COVERED BY THE Case Management Charts…

IMCI PROTOCOL? • 1ST! Decide which group the

Sick Young Infant: 0 up to 2 months child is in…
If the child is age 2 mos up to 5
Sick child young child: age 2 mos up to 5 years
years, select the chart ASSESS &
CLASSIFY THE SICK CHILD AGE 2
THE STEPS IN THE IMCI CASE MANAGEMENT MOS UP TO 5 YEARS.

PROCESS Up to 5 years means the child has

Young Infant: not yet had his 5th birthday.

1. Assess and classify. A child who is 2 mos old would be

2. Treat and counsel. in group 2 mos up to 5 years.

3. Follow-up If the child is not yet 2 mos, the

child is considered a young ifant.
 114

THE INTEGRATED CASE MANAGEMENT PROCESS

OUT-PATIENT HEALTH FACILITY

Check for GDS or GENERAL DANGER SIGNS

• Convulsions (during this illness)

• Lethargy/ unconsciousness
• Inability to drink or breastfeed
• Vomiting

Assess MAIN SYMPTOMS

(“CouDFEar”)
• Cough/ Difficulty breathing
• Diarrhea
• Fever
• Ear Problems

Assess NUTRITION and IMMUNIZATION STATUS and POTENTIAL

FEEDING PROBLEMS.

Check for OTHER PROBLEMS.

CLASSIFY CONDITION and IDENTIFY TREATMENT ACTIONS

According to color-coded treatment.

Urgent Referral Treatment at Out-Patient Home Management

Health Facility
OUT- PATIENT HEALTH FACILITY HOME
OUT- PATIENT HEALTH FACILITY
• Pre-referral Treatment Caretaker is counseled on:
• Advise parents • Treat local infection
• Refer child • Give oral drugs • Refer child
• Advise & teach caretaker • Home treatments
• Follow-up • Feeding & fluids
• When to return
immediately
• Follow-up
REFERRAL FACILITY

• Emergency Triage and

Treatment (ETAT)
• Diagnosis
• Treatment
• Monitoring & Follow-up
 115

Child:
1. Assess and classify: check for GDS; ask about main symptoms.
2. Treat.
3. Follow-up.
4. Counsel the mother.
BASIS FOR CLASSIFYING THE CHILD’S ILLNESS
The child’s illness is classified based on a color-coded triage system:
PINK- indicates urgent hospital referral or admission
YELLOW- indicates initiation of specific Outpatient Treatment
GREEN – indicates supportive home care

SICK YOUNG CHILD (AGE 2 MONTHS AND UP)

GENERAL DANGER SIGNS (GDS)

Ask for: Look for:

V- omits everything S- leepy/ is convulsing now
C- onvulsions
U- nable to drink. breastfeed
Urgent Attention!!!
Signs Classify as Treatment

Any GDS Very Severe Disease • Diazepam- if convulsing NOW.

• Quickly complete the assessment.

• Give any pre-referral treatment immediately.

• Treat to prevent blood sugar.

• Keep warm.

• Refer URGENTLY.

IF THE CHILD IS: FAST BREATHING IS:

2 months up to 12 months 50 breaths per minute or more
12 months up to 5 years 40 breaths per minute or more
 116

SICK YOUNG CHILD (AGE 2 MONTHS AND UP)

MAIN SYMPTOMS

“CouDFEar” (Cough/difficulty breathing, Diarrhea, Fever, Ear infection)

Cough and Difficult Breathing

Signs Classify as Treatment

Any General danger signs Severe Pneumonia or • 1st Dose Antibiotics

Very Severe Disease • Refer URGENTLY to hospital

Stridor in a calm child

Chest indrawing Pneumonia • Oral amoxicillin for 5 days*

• If wheezing (or disappeared

Fast Breathing
after rapidly acting
2-12 mos 12 mos-5 yrs bronchodilator)- inhaled
bronchodilator for 5
= 50 BPM = 40 BPM
days**
• Chest indrawing in HIV

exposed/infected child-
1st dose amoxicillin and
refer.
• Coughing .14 days or recurrent

wheeze-refer for
possible TB/asthma
assessment.
• Soothe throat to relieve cough

• Advise mother when to return

immediately
• Follow-up in 3 days
 117

No signs of Pneumonia or Cough or Cold • If wheezing (or disappeared

very severe disease after rapidly acting

bronchodilator)- inhaled
bronchodilator for 5
days**
• Coughing >14 days or

recurrent wheeze-refer
for possible TB/asthma
assessment
• Soothe throat & Relieve Cough

• Not improving: follow-up in 5

days
*oral amoxicillin for 3 days could be used for patients with fast breathing but no chest indrawing
in low HIV settings.

**if inhaled bronchodilator is not available, oral salbutamol may be tried but not treatment of
severe acute wheeze.

DIARRHEA

FOR DEHYDRATION

Signs Classify as Treatment

Any TWO: Severe Dehydration • PLAN C (If child has NO other

severe classification)
Sleepy (Difficult to awaken)
• Refer URGENTLY (if has
Sunken eyes another severe classification)
continue breastfeeding
Sip-less (unable to drink)
• Antibiotic for Cholera (If 2 years

old, with Cholera in area

 118

Skin Turgor Very Poor or skin

pinch goes back very slowly

Any TWO: Some Dehydration • PLAN B

Sunken Eyes • Refer URGENTLY (if has

another severe classification)

Sip-Full (drinks eagerly)
continue breastfeeding
Skin Turgor Poor or skin pinch • Advise mother when to return

gooes back slowly immediately

• Not improving: follow-up in 5
Restless
days.

Not enough Signs No Dehydration • Plan A

• Advise mother when to return

immediately
• Not improving: follow-up in 5

days.
If diarrhea of 14 days or more

Signs Classify as Treatment

Dehydration present Severe Persistent • Treat Dehydration before

Diarrhea referral unless has

another severe
classification
• Refer URGENTLY to hospital

No Dehydration Persistent Diarrhea • Advise on FEEDING

 119

• Multivitamins and
mineral (including zinc)
for 14 days.
• Follow-up in 5 days

And if there is BLOOD in stool

Signs Classify as Treatment

Blood in the stool Dysentery • Ciprofloxacin for 3 days.

• Follow-up in 3 days
PLAN A PLAN B PLAN C

Treat Diarrhea at HOME Treat Some dehydration Treat Severe Dehydration

with ORS Quickly

Counsel on the 4 rules of Give in Health Center ORS IVF

home treatment: over 4-hour period
100ml/kg LRS or NSS
1. Give extra fluid
Give Extra Fluid (as much as
child can take)

• Breastfeed
• If exclusively
breastfeed: ORS
• Not exclusively
breastfed: food-based
fluids, ORS
Additional fluid to the usual
intake:
 120

Up to 2 50-100 ml
Years after each
loose stool.

2 years or 100-200ml
more after each
loose stool.

• If vomits, wait 10
mins. Then continue,
but slowly.
• Continue giving extra
fluid until diarrhea
stops.
2. Give zinc Supplement ORS in ml= kg wt x 75 Age 30 ml/kg 70 ml/kg
(2 mos-5 yrs) in in
Reassess after 4 hours
(20mg tab)
Infant 1 hour 5 hours
(<12 mos)

Children 30 min 2.5 hrs

(12 mos-5
yrs)

3. Continue Feeding
If the mother must leave Reassess every 1-2 hrs
before completing
Give ORS (5ml/kg/hr) if can
treatment:
drinkRe-classify infant in 6 hours;
• Show how to children in 3 hours
prepare ORS at
home.
• Explain the 4 rules
of home treatment
 121

4. When to return NGT

20 ml/kg for 6 hours (total 120

ml/kg)

FEVER:

High or Low Malaria Risk (child lives in a malarious area or has traveled and stayed overnight
in a malaria area in the last 4 weeks

Signs Classify as Treatment

Any GDS or Stiff Neck
(+) Blood Smear
Very Severe Febrile Disease • First dose
ARTESUNATE or
QUININE, given in IM
• 1st dose antibiotics
• Prevent? BS
• 1 dose paracetamol
for fever 38.5 C
• Refer URGENTLY to
hospital.
Malaria • Treat with first line
Oral antimalarial
• 1 dose paracetamol
for fever 38.5C
• Advise mother when
to return immediately
• Follow-up in 3 days if
ever persists
• Refer for assessment:
fever present every
day for .7days
 122

(+) Blood Smear or Fever • 1st dose antibiotics

• 1 dose paracetamol
(+) Runny nose or measles No Malaria
for fever
or other causes of fever
38.5C
• Advise mother when
to return
immediately
• Follow-up in 3 days if
ever persists
• Refer for
reassessment:
fever present
every day for
>7 days
No Malaria Risk or no travel to malaria risk area

Signs Classify as Treatment

Any general danger sign
Stiff Neck
No Signs of very severe
febrile disease
Very Severe Febrile Disease
Fever
• 1st Dose Antibiotics
• Prevent? BS
• 1 dose paracetamol
for fever 38.5C
• Refer URGENTLY to
hospital.
• 1 dose paracetamol
for fever 38.5C
• Antibiotic (for identified
bacterial cause of
fever)
• Advise mother when
to return immediately

If MEASLES now within last 3 months
Signs
Any general danger signs or
Clouding of cornea or
Deep or extensive mouth
ulcer
Pus draining from the eye or
Mouth ulcers
Measles NOW or within last 3
months
123
• Follow-up in 2 days if
ever persists.
• Refer for assessment:
fever present
everyday for >7days
Classify as Treatment
Severe Complicated • Vit A
Measles • 1st dose antibiotic
• Tetracycline eye
ointment (if clouding
cornea or pus draining
from the eye)
• Refer URGENTLY to
hospital.
Measles with Eye or Mouth • Vit A
complications • Tetracycline eye
ointment (if pus
draining from eyes)
• Gentian violet (if
mouth ulcers)
Follow-up in 3 days
Measles • Vit A

Signs
Tender Swelling behind the
ear
Pus draining from ear for less
than 14 days or Ear Pain
Pus draining from ear for 14
days or more
No ear pain; no pus
Then check for the following:
Signs
Edema of both feet or
WFH/L* < 3 z-scores or
MUAC** < 115mm and any of
the ff:
- Medical complication
present or
124
Ear Problem
Classify as Treatment
Mastoiditis • 1st dose Antibiotic
• 1st dose paracetamol
for pain
• Refer URGENTLY to
hospital.
Acute ear Infection • Antibiotics for 5 days
• Paracetamol for Pain
• Dry the ear by wicking
• Follow-up in 5 days
Chronic Ear Infection • Dry the ear by wicking
• Topical QUINOLONE
eardrops for 14 days.
• Follow-up in 5 days
No ear infection • No treatment
Acute Malnutrition
Classify as Treatment
Complicated severe acute • 1st dose antibiotic.
malnutrition • Prevent low Blood
Sugar.
• Keep the child warm.
• Refer URGENTLY to
hospital.
 125

- Not Able to finish

RUTF*** or
- Breastfeeding
problem
WFH/L* < 3 z-scores or Uncomplicated severe acute • Oral antibiotics for 5
MUAC** < 115mm and malnutrition days.
• Give RUTF*** for a
Able to finish RUTF
child aged 6 mos.
• Counsel the mother
on feeding
• Assess for possible
TB infection.
• Advise mother when
to return immediately.
• Follow-up in 7 days.
WFH/L < 3 z-scores or Moderate Acute • Assess the child’s
malnutrition feeding and counsel
MUAC 115-125 mm
the mother on
feeding.
• If feeding problem,
follow-up in 7 days
• Assess for possible
TB infection.
• Advise mother when
too return
immediately
• Follow-up in 30 days
 126

WFH/L < 2 z-scores or No Acute Malnutrition • <2 years old, assess

the feeding and
MUAC 125 mm or more
counsel the mother
on feeding
• If feeding problem,
follow-up in 7 days.
*Weight-for-Height or Weight-for-Length determined by using the WHO growth standards
charts

**Mid-Upper-Arm Circumference measured using MUAC tape in all children 6 mos. Or older.

***Ready-to-Use-Therapeutic-Food for conducting appetite test and feeding children with

severe acute malnutrition.

Anemia

Signs Classify as Treatment

Severe palmar pallor Severe Anemia • Refer URGENTLY to

Some palmar pallor
No palmar pallor
hospital
Anemia • Iron*
• Mebendazole (if 1
year older and has
not had a dose for the
past 6 mos.)
• Advise mother when
to return immediately.
• Follow-up in 14 days.
No anemia • <2 years old, assess
the feeding and
counsel mother.

*DO NOT give iron- if child has severe acute malnutrition and is receiving RUTF because there
is already adequate amount of iron in RUTF.
Signs
(+) virological test in child or
(+) serological test in a child
18 mos. Or
Mother HIV (+) and
(-) virological test in
breastfeeding child or only
stopped <6weeks ago or
127
• If feeding problem,
follow up in 5 days.
HIV Infection
Classify as Treatment
Confirmed HIV • ART treatment and HIV
infection care.
• Cotrimoxazole prophylaxis*
• Assess feeding; counsel
the mother (feeding &
home care)
• Assess or refer for TB
assessment and INH
preventive therapy.
• Follow-up regularly as per
nat’s guidelines.
HIV exposed • Cotrimoxazole prophylaxis
• Start/continue ARV
prophylaxis
• Start/continue ARV
prophylaxis as
recommended.
• Virological test to confirm
HIV status**
 128

Mother HIV (+), child not yet • Assess feeding; counsel

tested or the mother (feeding &
home care).
• Follow-up regularly as per
(+)serological test in a child nat’l guidelines.
<18 mos.

(-) HIV test in mother or child HIV infection unlikely • Treat,counsel and follow-
up existing infections.
*Give cotrimoxazole prophylaxis to all HIV infected and HIV-exposed children until confirmed (-)
after cessation of breastfeeding.

**if virological test is (-), repeat 6 weeks after the breastfeeding has stopped; if serological test is
(+), do a virological test ASAP

SICK YOUNG INFANT ( AGE 1 WEEK UP TO 2 MONTHS)

Very Severe Disease and Local Bacterial Infection:

Signs Classify as Treatment

Any one of the ff:
Not feeding well or
Convulsion or
Fast breathing (60 BPM or
more) or
Very Severe Disease
• 1st dose of IM antibiotics
• Prevent low blood sugar
• Advise mother how to keep
infant warm on way
• Refer URGENTLY to
hospital

Severe chest indrawing or


Fever (37.5C or above) or
Low body temperature
(<35.5C) or
Movement only when
simulated or no movement at
all
Red umbilicus or draining pus
Skin pustules
None of the signs or local
bacterial infection.
Signs
Any jaundice if age <24 hours
or Yellow palms and soles
at any age
Jaundice appearing after 24
hours of age and palms and
soles not yellow.
129
Local Bacterial • Give Oral Antibiotics
Infection • Teach the mother to treat
local infection at home.
• Advise mother about Home
Care
• Follow-up in 2 days
Severe local disease or • Advise mother about Home
Care
Jaundice:
Classify as Treatment
Severe jaundice • Prevent low Blood Sugar.
• Refer URGENTLY to
hospital.
• Advise mother how to keep
infant warm on way
Jaundice • Advise the mother about
Home Care.
• Palms and soles appear
yellow-advise mother to
return ASAP
 130

• >14 days old: refer to a

hospital for reassessment.
• Follow-up in 1 day.
No jaundice No Jaundice • Advise the mother about
Home Care.

Diarrhea:

For Dehydration

Signs Classify as Treatment

TWO of any: Severe Dehydration • Plan C (if has no other

severe classification).
Movement only when
• Refer URGENTLY, if has
simulated or no movement at
another severe
all.
classification; ORS on the
Sunken eyes way; continue
breastfeeding.
Skin pinch goes back very
slowly

TWO of any: Some Dehydration • Plan B

• Refer URGENTLY, if has

Sunken eyes
another severe
Skin pinch goes back slowly. classification; ORS on the

Restless, irritable way; continue

breastfeeding.
• Advise mother when to
return immediately

Not enough signs of
dehydration
Signs
(+) virological test in young
infant
Mother HIV (+) and
(-) virological test in young
infantbreastfeeding child or
only stopped <6weeks ago or
Mother HIV (+), young infant
not yet tested or
131
• If not improving, follow-up
in 2 days.
No Dehydration • Plan A
• Advise mother when to
return immediately
• If not improving, follow-up
in 2 days.
HIV Infection
Classify as Treatment
Confirmed HIV • Cotrimoxazole prophylaxis
infection from age 4-6 weeks.
• Give HIV ART care.
• Advise mother on home
care.
• Follow-up regularly as per
nat’l guidelines
HIV exposed • Cotrimoxazole prophylaxis
from age 4-6 weeks
• Start/continue PMTCT*
ARV prophylaxis as per
nat’l recommendation.
• Do virological test at age 4-
6 weeks or repeat 6 weeks
after the child stops
breastfeeding.
• Advise mother on home
care.
• Follow-up regularly as per
nat’l guidelines.

(+)serological test in young
infant
(-) HIV test in mother or child
Feeding Problem or LOW Weight for Age:
In Breastfeed Infants:
Signs
Not well attached to breast or Feeding problem
Not sucking effectively or
<8 breastfeeds in 24 hours or
Receives other foods or drinks
or Low weight for age or
Thrush
132
HIV infection unlikely • Treat,counsel and follow-
up existing infections.
Classify as Treatment
• Teach correct positioning
and attachment (if not well
Or
attached or not sucking
Low weight effectively
• Advise to increase
frequency of feeding (if
breastfeeding <8 times in
24 hours).
• Counsel the mother about
breastfeeding more (if
receiving other foods or
drinks).
• Refer for breastfeeding
counseling and possible
relactation (if not
breastfeeding at all).
• If thrush, teach to treat at
home.
• Follow up low weight for
age in 14 days.
 133

Not low weight for age and no No feeding Problem • Advise the mother on
other signs of inadequate home care
feeding • Praise mother

In non-breastfeed infants:

Signs Classify as Treatment

Milk incorrectly or Feeding Problem • Counsel about feeding and

unhygienically prepared or home care.
Or
• Explain the guidelines of
Giving inappropriate
Low weight safe replacement feeding.
replacement feeds or
• Teach cup feeding (if using
Giving insufficient a bottle).
replacement or • If thrush, teach to treat at
home.
• Follow-up any feeding
HIV (+) mother mixing breast problem or thrush in 2
and other feeds before 6 mos. days.
or • Follow-up low weight for
age in 14 days
Using a feeding bottle or

Low weight for age or

Thrush

Not low weight for age and no No feeding problem • Advise the mother on
other signs of inadequate home care.
feeding • Praise mother
 134

REFERENCES:

Republic of the Philippines, D. (2014). Integrated Management of Childhood Illness (IMCI):

Department of Health website. Retrieved August 26, 2020, from https://www.doh.gov.ph/integrated-
management-of-childhood-illness
Department of Health. (2015). Integrated Management of Childhood Illness [Booklet]. DOH
Regional Office VI, World Health Organization: Author.
 135

ACTIVITY 8:
Case 1: Mutya

Mutya is 15 months old. She weighs 8.5 kg. Her temperature is 35.5°C. The health worker asked,
"What are the child's problems? The mother said, "Mutya has been coughing for 4 days, and she is
not eating well.” This is Mutya's initial visit for this problem. The health worker checked Mutya for
general signs. He asked, “Is Mutya able to drink or breastfeed?” The mother said, “No. Mutya does
not want to breastfeed." The health worker gave Mutya some water. She was too weak to lift her
head. She was not able to drink from a cup. Next, he asked the mother, "Is she vomiting?” The
mother said, "No." Then he asked, "Has she had convulsions?" The mother said, "No." The health
worker looked to see if Mutya was abnormally sleepy or difficult to awaken. When the health worker
and the mother were talking, Mutya watched them and looked around the room. She was not
abnormally sleepy or difficult to awaken.

a. Write Mutya's name, age, weight, and temperature in the spaces provided on top of the
line form.
b. Write Mutya's problem on the line after the question “Ask: What are the child's problems?"
c. Tick (~) whether this is the initial or follow-up visit.
d. Does Mutya have general danger signs? If yes, circle the sign on the Recording Form.
Then tick () Yes" or "No" after the question, "General danger signs present?"

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS AND UP TO 5 YEARS

Child’s Name:_________________________ Age:_______ Weight:_____kg. Temperature:____⁰C

ASK: What are the child’s problems? _____________ Initial visit? _____ Follow-up visit? _______

Assess (Circle all sign present) CLASSIFY

CHECK FOR GENERAL DANGER SIGNS General Danger

Sign Present?
NOT ABLE TO DRINK OR BREAST FEED
YES____
ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN
NO ____
VOMITS EVERYTHING

CONVULSIONS
 136

Case 2: Lupita

Lupita is 8 months old. She weighs 6 kg. Her temperature is 39°C. Her father told the health
worker. "Lupita has had cough for 3 days. She is having trouble breathing. She is very weak." The
health worker said, "You have done the right thing to bring your child today. I will examine her now.”
The health worker checked for general danger signs. The mother said, “Lupita will not breastfeed.
She will not take any other drinks I offer her.” Lupita does not vomit everything and has not had
convulsions. Lupita is abnormally sleepy. She did not look at the health worker or her parents when
they talked. The health worker counted 55 breaths per minute. He saw chest indrawing. He decided
Lupita had stridor because he heard a harsh noise when she breathed in.

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS AND UP TO 5 YEARS

Child’s Name:_________________________ Age:_______ Weight:_____kg. Temperature:____⁰C

ASK: What are the child’s problems? _____________ Initial visit? _____ Follow-up visit? _______

Assess (Circle all sign present) CLASSIFY

CHECK FOR GENERAL DANGER SIGNS General Danger

Sign Present?
NOT ABLE TO DRINK OR BREAST FEED
YES____
ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN
NO ____
VOMITS EVERYTHING

CONVULSIONS

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? YES ___ NO

___
• Count the breaths in one minute.
For how long? _____ days ___ breaths per min. Fast breathing?
• Look for chest drawing.
• Look and listen for stridor.
 137

Case 3: Fidel

The health worker checked Fidel for general danger signs. Fidel was able to drink, was not
vomiting, did not have convulsions, and was not abnormally sleepy or difficult to awaken. The health
worker asked about Fidel's cough. The mother said Fidel had been coughing for 5 days. He counted
43 breaths per minute. He did not see chest indrawing. He did not hear stridor when Fidel was calm.
Fidel did not have diarrhea. Next, the health worker asked about Fidel's fever. There is Malaria risk.
The mother said Fidel has felt hot for 2 days. Fidel did not have a stiff neck. He had a runny nose
with this illness, his mother said. The health worker did not have the facilities for examination of a
blood smear. Fidel has a rash covering his whole body. Fidel's eyes were red. The health worker
checked the child for complications of measles. There were no pus draining from the eye and no

clouding of the cornea. There have been no cases of dengue in their area.
 138

Good luck,
stay safe and God bless!