INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS As strategy deals with the management of common childhood illnesses done in an integrated manner. ‘© Includes preventive interventions, adjusts curative interventions to the capacity and fanctions of the health system (evidence based syndromic approach) and it involves the family members and the community in the health care process, Objectives © To significantly reduce global mortality and morbidity associated with major causes of disease in children, © To contribute to healthy growth and development of children. Case Management Process # Assess the child or infant Classify the illness Identify treatment Treat the child Refer wunsel the mother Give follow up care Assessing the child or Young Infant ‘© What should always be your first question to the mother? ~ What is the child’s problem? © What is the next question? = How old is the child? Age Group Classification © Young Infant - Childbirth to less than two (2) months ‘© Young child - Two (2) months to less than five (5) years Check for general danger signs Sleeping abnormally or lethargic * Inability to feed © Vomiting * Convulsions Assess main symptoms Cough Diarthea Fever Ear problem Assessing and classifying the illness of a young child+ 3 times or more watery/ loose stools + Duration ¥ Ifit is more than 14 days, it is PERSISTENT DIARRHE, J [fit is Persistent Diarrhea, with signs of dehydration, it is SEVERE PERSISTENT DIARRHEA + Blood in the stool v DYSENTERY é: there should be at least 2 or more signs before you can classify NO’ Classification Severe dehydration (Pink) + Lethargic or unconscious + Sunken eyes + Drinking poorly + Skin goes back very slowly No Dehydration (green) + Not enough signs to classify as some or severe dehydration FEVER Criteria for Fever + Byhistory + Feels hot + Axillary temp is 37.5 C or above Three (3) possible illnesses + Malaria + Measles + Dengue Hemorrhagic Fever MALARIA Risk + Resident of a malaria risk area + Travelled and stayed overnight in a malaria risk area for the past 4 weeks Stiff neck Blood smear, if not available Other causes of fever + Runny nose + Measles: FIVE POSSIBLE CLASSIFICATIONSDENGUE HEMORRHAGIC FEVER Bleeding from nose or gums, or Bleeding in stools or vomitus, or Skin petechiae, or Cold and clammy extremities, or Capillary refill more than 3 seconds, or persistent abdominal pain, or Persistent vomiting, or Positive tourniquet test SEVERE DENGUE HEMORRHAGIC FEVER (Pink) No signs of very febrile disease FEVER: NO MALARIA (Green) Bleeding from the following areas: Nose Gums Vomitus (is it black?) Stools (is it black?) Skin petechiae Signs of shock Cold clammy extre Slow capillary refill Tourniquet test Take BP using pediatric cuff. Calculate the average between systolic and diastolic pressure. Inflate the cuff to the calculated average and keep the pressure for 5 minutes. Release the pressure and draw a one sized inch square of the forearm. Count the number of petechiae inside the square. If there are 20 or more, the test is positive. Persistent abdominal pain Persistent vomiting EAR PROBLEM pain + Ear discharge + Duration: Acute or Chronic — if it is more than 14 days it is chronic + Swelling behind the ear. ‘Tender Swelling behind the ear MASTOIDITIS (Pink) Pus is seen draining from the ear and discharge is reported for less than 14 days Pus is seen draining from the ear and discharge and reported for 14 days or more No ear pain and NO EAR NFECTION (Gre ‘No pus is seen draining from the earPLANB Oral rehydration salt Give for 4 hours Use the child’s age when you don’t know the weight. ‘The approximate amount of ORS required ( in ml) can be also calculated by multiplying the child’s weight in kg x 75. If the child wants more ORS than shown give more. If the child vomits wait 10 mins then continue but slowly. For infants below 6 mos. who are not breastfed also give 100-200ml clean water during this period. After 4 hours of treatment REASSESS AND RECLASSIFY the child. ORESOL measurement for Plan B Age AMOUNT OF FLUID (ml) OVER 4 HOURS: 200-500 -450- 800 ‘12 months -< years 800-960 Dears -panse . Summary Table-is a 12 column table in which columns corresponds to the 12 months of the year -is accomplished by the midwife and is kept at the BHS -has 2 components: Program Accomplishment and Morbidity Diseases d. Monthly Consolidation Table (MCT)- is accomplished by the nurse based on the Summary Table Reports -consists of summary data that are transmitted or submitted monthly, quarterly and annually to a higher level, that is from BHS to the RHU or health center to the PHO and finally to the regional level Reports ~ summarizes the services of the nurse or the agency can be compiled monthly, quarterly and annually ~ are based on records and registries Reporting Forms: 1. Monthly forms ~ are regularly prepared by the midwife and submitted to the nurse who then uses the data to prepare the quarterly formsTables and graphs are useful in showing key information making it easier to show comparisons including patterns and trends. The choice of graphs will depend on the type of data being presented. Type of Graph Data Function Line Graph ‘Shows trend data or changes with time or age with respect to some other variable Bar Graph/Pictograph | For absolute or relative counts and rates between categories Histogram/ frequency Graphic presentation of frequency distribution or polygon measurement Proportional or ‘Shows breakdown of a group or total where the ‘component Bar Graph/ | number of categories is not too many pie chart Scattered diagram Correlation data for two variables Community Diagnosis - © isa quantitative and qualitative description of the health of the citizens and the factors which influence their health.(WHO) ‘© itis the process of determining the health status of the community and the factors responsible for it Types of Community Diagnosis 1. Comprehensive Community Diagnosis — aims to obtain general information about the community 2. Problem Oriented Community Diagnosis ~ respond to a particular need Schemes in stating Community Diagnosis © NANDA (now NANDA International) nursing diagnostic labels The North American Nursing Diagnosis Association (NANDA) defines nursing diagnosis as a clinical judgment about individual, community or family responses to community to actual or potential health problems or life processes. -although focused more on an individual rather than community responses to health conditions, have included diagnosis at the community level in more recent versions. There are 4 parts to a community diagnosis: 1. Adescription of the problem, response, or state (risk, concern, issue, potential or actual),Spirituality Grief Mental health Sexuality Caretaking/parenting Neglect Abuse Growth and development Physiologi Hearing Vision I Domain: ‘unctions and processes that maintain life Speech and language Oral health Cognition Pain Consciousness skin Neuro-musculo-skeletal function Respiration Circulation Digestion-hydration Bowel function Urinary function Reproductive function Pregnancy Postpartum Communicable/infectious condition Health-related Behaviors Domain: Patterns of activity that maintain or promote wellness, promote recovery, and decrease the risk of disease. Nutrition Sleep and rest patterns Physical activity Personal care Substance use Family planning Health care supervision Medication regimenPriority Setting The WHO has suggested the following criteria to decide on a community health concern for intervention: 1. Significance of the problem — is based on the number of people in the community affected by the problem or condition 2. Community awareness = The level of awareness and the priority its members give to the health concern 3. Ability to reduce risk ~ is related to the availability of expertise among the health team and community itself 4, Cost of reducing risk -the nurse has to consider economic, social and ethical requisites and consequences of planned actions Ability to identify the target population for intervention -is a matter of availability of data sources, such as FHSIS, census, survey reports, case findings or screening tools, 6. Availability of resources -entails technological, financial and other material resources of the community, the nurse and the health agency. Assigning criterion weight through nominal group technique Problem: Risk of maternal complications leading to maternal mortality in Barangay Bagong Silang Question: How important is the criterion in solving the problem? Nurse | Midwife | BHW | Mrs. Mr. ‘Average Criterion 3: Cruz Tan | Dionisia | Miranda* | Peralta* | weight Significance of the 8 10 7 10 6 8 problem C i ‘ommunity| 2 @ 5 5 5 é awareness ‘Ability to reduce risk | 10 10 10 10 10 10 Cost of reducing risk | 8 8 @ @ 8 @ ‘Ability to ident bility toidentify— | 5 5 6 5 6 5 target population ‘Availability of : 8 8 6 5 8 7 Community representative Criterion rating through normal group techniqueFormulating Goals and Objectives Goalls - the desired outcomes at the end of interventions Objectives ~ are the short term changes in the community that are observed as the health team and the community work towards the attainment of goals Characteristics of a good objective: Specific - clear about what, where, when, and how the situation will be changed Measurable - able to quantify the targets and benefits Achievable - able to attain the objectives Realistic - able to obtain the level of change reflected in the objective Time bound - stating the time period in which they will each be accomplished Sample Goals and Objectives of a Community Health Plan Problem: Risk of maternal complications leading to maternal mortality in Barangay Bagong Silang Goal: To reduce maternal mortality rate from 132/100,000 live births to 80/100,000 live births in the year 2025. Objectives: At the end of the year, the community of Barangay Bagong Silang will 1. Demonstrate the ability to organize groups to participate in the community health process from assessment to evaluation. Increase the proportion of facility-based births from 10% to 15%. Lower the proportion of untrained hilot attended births from 20% to 10%. Reduce the prevalence of nutritionally at risk pregnant women by 20%, Reduce the prevalence of anemia among pregnant women by 20%. D. Deciding on Community Interventions/Action Plan In the process of developing the plan, the group takes into consideration the demographic, psychological, social, cultural and economic characteristics of the target population on one hand and the available resources on the other hand, Implementing Community Health Interventions 1. Importance of Partnership and Collaboration © The nurse must plan to establish and maintain valuable working relationship with people such as people’s organization, health organization, educational institution, the local government units, financial institution, religious groups, socio-civil organizations, sectorial_ groups and the like. ©The aim of partnership and collaboration is to get people to work together in order to address problems or concerns that affect them. 2. Activities involved in Collaboration and Advocacy a. NetworkingCore Principles in Community Organizing 1. Community organizing is people-centered 2. Community organizing is participative 3. Community organizing is democratic 4, Community organizing is developmental 5. Community organizing is process-oriented Goals of Community Organizing 1. People’s empowerment 2. Building relatively permanent structures and people's organization 3. Improved quality of life Phases of Community Organizing 1. Preparatory Phase 2. Organizational Phase 3. Education and Training Phase 4, Inter-sectoral Collaboration Phase 5. Phase out Community Organizing Participatory Action Research Participatory Action Research (PAR) = _ is an approach to research that aims at promoting change among the participants - members of the group being studied participate in all phases of the research Community Organizing Participatory Action Research (COPAR) - isa community development approach that allows the community (participatory) to systematically analyze the situation (research), plan a solution and implement projects/programs (action) utilizing the process of community organizing Importance of COPAR ‘© COPARis an important tool for community development and people empowerment as this, helps the community workers to generate community participation in development activities. ‘© COPAR prepares people/clients to eventually take over the management of a development programs in the future, © COPAR maximizes community participation and involvement; community resources are mobilized for community services. Principles of COPAR ‘© People, especially the most oppressed, exploited and deprived sectors are open to change, have the capacity to change and are able to bring about change.Occurs when the community organization has already been established and the community members are already actively participating in community-wide undertakings. At this point, the different communities setup in the organization building phase are already expected to be functioning by way of planning, implementing and evaluating their own programs with the overall guidance from the community-wide organization. Basic Qualities of a Community Organizer Has exemplary professional and moral qualities Possesses good communication/ facilitation skills to be able to call and lead small group discussions/ trainings and community meetings. Has the ability to set good leadership examples for the community to emulate. Displays a charismatic personality that draws people towards organizing work and community activities. ‘Adopts and enjoys working with and living with all types of communities/ people. Can empathize with the people or community he is working with. Believes inthe vision of change, empowerment, and development. Has a personal conviction consistent with the values and principles being advocated, A schematic presentation of the process in COPAR Entry phase during the integration/immersion The community organizer trains and develops the core groups for data hase " gathering and analysis, The community organizer identifies Potential leaders who in turn recruit ,, The core group becomes the members of community research team. ‘They take the lead in:Roles Nurse as researcher: the community | Community members as members are subjects or objects of | researchers: the nurse is a research, usually respondents of the | facilitator and recorder. research instrument. Data analysis is done collectively Data analysis is done by the nurse, _| by the community. and then presented to the community. Methodology | Research tools and methodologies | Research tools and are predetermined/ prepackaged by | methodologies are identified and the nurse-organizer. developed by the community. Output Upon completion, the study is Conclusions and packaged, submitted to the agency, and published. Recommendations are made by the researcher based on the findings of the study. recommendations are made by the community. These will lead to. agreed community actions/projects. The whole research cycle continues until it becomes part of community life, leading towards community development. Community members formulate the recommendations. ‘Monitoring and Evaluating Community Health Programs Implemented Ongoing evaluation or monitoring is done during implementation to provide feedback on compliance to the plan as well as on need for changes in the plan to improve the process and outcome of interventions. Evaluation approaches: © Structure evaluation — involves looking into manpower and physical resources of the agency responsible for community health interventions © Process evaluation ~ is examining the manner by which assessment, diagnosis, planning, implementation and evaluation were undertaken © Outcome evaluation Standards of Evaluation 1. Utility ~is the value of the evaluation in terms of usefulness of results 2. Feasibility - answers the questions of whether the plan for evaluation is doable or not, considering available resources is determining the degree of attainment of goals and objectivesBasis for formulating plans Tool or medium for health education Determine needs of resources Legal documentation Means of communication Provide information of good nursing Conduct training and research work eHealth © eHealth is the use of ICT for health (World Health Organization, 2012). © On May 25, 2005, during the Fifty-Eighth World Health Assembly (WHA), a resolution was adopted by the World Health Organization (WHO) member states recognizing eHealth as then cost-effective way of using ICT in health care Services, health surveillance, health literature health education, and research (WHA, 2005) Given the extensive capabilities of ICT eHealth can be considered in any of, but not limited to, the following, = Communicating with a patient through a teleconference, electronic mail (e-mail), short message service (SMS). = Recording retrieving, and mining data in an electronic medical record (EMR) ~ Providing patient teachings with the aid of electronic tools such as radio, television, ‘computers, smartphones, and tablets. © eHealth, often confused with telehealth of telemedicine, is the overall, umbrella term ‘According to the WHO, eHealth encompasses three main areas: ~The delivery of health information for health professionals and health consumers, through the Internet and telecommunications. = _ Using the power of information technology (IT) and e-commerce to improve public health services, for example, through the education and training of health workers. The use of e-commerce and e-business practices in health systems management ‘THE STRATEGY AND CONCEPT OF eHEALTH — AREAS OF APPLICATION Nurses play an important role in providing nursing within the health and social care. The present strategy outlines nurses’ role in the development of eHealth. The strategy concerns nurses in all areas of clinical practice, management and administration as well as their colleagues within education and research, The strategy can be used + To provide discussion support in the development of clinical practice and other professional contexts, nationally as well as internationally ‘= To guide the design of curricula in nursing education at bachelor and master degree * In dialogue with employers to identify nurses’ need for education and professional development7. Enabling information exchange and communication in a standardized way between health care establishments. 8. Extending the scope of health care beyond its conventional boundaries. This is meant in both a geographical sense as well as in a conceptual sense. e-health enables consumers to easily obtain health services online from global providers. These services can range from simple advice to more complex interventions or products such a pharmaceuticals. 9. Ethics - e-health involves new forms of patient-physician interaction and poses new challenges and threats to ethical issues such as online professional practice, informed consent, privacy and equity issues. 10. Equity - to make health care more equitable is one of the promises of e-health, but at ‘the same time there is a considerable threat that e-health may deepen the gap between the "haves" and "have-nots". People, who do not have the money, skills, and access to computers and networks, cannot use computers effectively. In addition to these 10 essential e's, e-health should also be © easy-to-use, ‘© entertaining (no-one will use something that is boring!) and © exciting ‘© andit should definitely exist! ‘The health care system builds heavily on accurate recording of obtained data. Paper- based methods may bring inconvenience especially when it comes to interoperability of health services, information backup and instant data access. A number of bigger problems may also emerge: 1. Continuity and interoperability of care stops in the unlikely event that a record gets misplaced if the patient suffers from a chronic condition, previous findings supporting this diagnosis, drug allergies, pre- existing conditions, or even past accounts of the patient's previous visits may no longer be accessed unless the health providers have made several copies of the same record. The patient may also need to recount his/her condition for every transfer of care 2. Illegible handwriting poses misinterpretation of data. A direct observational study of medication administration found opportunities for errors associated with incomplete or illegible prescriptions. 3. Patient privacy is compromised. Traditional, paper-based records are vulnerable to unauthorized patient viewing since there is no audit trail of the usage of the chart. The disclosure of highly private information arising from such an incident can lead to los of trust in the health facility or even legal risks 4, Dato are difficult to aggregate. Manual data recording and tallying significantly delays implementation of interventions and targeted health programs. Health care monitoring is compromised as information is not readily available and up-to-date on a daily basis. 5. Actual time for patient care gets limited. Time spent by the community health worker searching for a paper-based record is time lost for actual care. Likewise, for both clinical and community settings, the overall impact of the problems related to manual/traditional data-gathering is articulated as follows:5. Currency. All data must be up-to-date and timely. This is exemplified when the community health nurse records data at the point-of-care or when it happened, 6. Definition. Data should be properly labelled and clearly defined. For example 36 is just an ordinary number unless it is labelled as an age of a person, eHEALTH SITUATION IN THE PHILIPPINES © The developing world suffers from inadequate health care and medical services. ‘© Lack of health care professionals and infrastructure contributes to this problem, making it more difficult to deliver health care to people in rural and remote communities of the developing, world. ©The ubiquity of mobile technologies and availability of Internet services in the Philippines create 2 promising ground for eHealth access. ICT has changed how Filipinos access information and how the government has utilized this to inform its citizenry. Examples of these include regular updates of traffic conditions, current events, and critical weather reports through various social media © The health sector has also begun utilizing ICT to improve its services. The DOH has introduced a number of health information systems that aim to improve the access of health data, such as the Electronic Field Health Service Information System (DOH, 2012b). © Online National Electronic injury Surveillance System (DOH, 2012c). The Philippine Health Atlas, and the Unified Health Management Information System (DOH, 2012d). Factors affecting eHealth in the country © Limited health budget. The budget allocation for health care is relatively small. This is one of the many reasons advancements in eHealth are postponed. ICT projects usually require a huge budget, take a long period to implement, and are occasionally seen as risky endeavors. ©The emergence of free and open source software in eHealth, the cost of software procurement or development often takes up a huge portion of the budget. In addition, using ready-made proprietary software can be limiting at times, especially when users want to modify the software to fit their workflow better, © Decentralized government Under RA 7160 or the Local Government Code of 1991, local government units (1GUS) are autonomous, and therefore in control of their own basic health services, including the budget. © Target users are unfamiliar with the technology eHealth is not only about technology. Along with software development and hardware procurement, staff training and maintenance of the system are key factors in determining its effectiveness. Recognition of the cultural aspects of community life is important in starting them off into a new direction such as computerization and automation © One possible pitfall of eHealth implementations is focusing on software development before accomplishing an assessment of the needs of health professionals in the field. © Most health center personnel are not familiar with the use of computers. Implementing an eHealth system requires training of health personnel on basic computer skills, use of software, and maintenance of the equipment. > Aterm coined by educator and writer Marc Prensky (2001). Digital native describes a person who grew up and is familiar with digital technologies, and who uses them in daily living. > The entry of digital native nurses into the profession and their nationwide deployment to communities may potentially aid the implementation of various ICT projects in health careprocessing of indicators, making it easier for nurses to focus on other important aspects of health care, Telemedicine One of the five strategic goals of the DOH's National eHealth Strategic Framework for 2010-2016 is to capitalize on ICT. This in order to reach and provide better health services to geographically isolated and disadvantaged areas (GIDAs), to support disseminate MDG attainment, and to information to citizens and providers through telemedicine and mobile health (eHealth) services (DOH, 2012e). (The WHO defines telemedicine as, "the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communications technologies for (The exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities WHO further underscores four elements that are specific to telemedicint 1. Its purpose is to provide clinical support. 2. Itis intended to overcome geographical barriers, connecting users who are not in the same physical location. 3. It involves the use of various types of ICT. 4, Its goal is to improve health outcomes. (As .can be seen from the example, telemedicine has the capacity to bridge the gaps in the health referral system. itis understandable that this is not a universal solution and may be applicable only in specific scenarios. The goal of a patient receiving the best care as soon as possible despite an unfavorable location or other adverse circumstances may be reached through telemedicine elearning (Health education, which is essential in health promotion and maintenance, can be facilitated by act. (1 elearning is basically the use of electronic tools to aid in teaching. It can be done synchronously, asynchronously, or in a combination of both. This can be in the form of simple instructional videos and information text blasts to social network help groups and interactive simulations. C etearning can be especialy useful in correcting misconceptions about health and health care. It permits access to reliable information about health. For example, control of communicable diseases frequently requires community participation Cl With the use of elearning technology, community can elicit community interest by showing instructional videos on measures to control health nurses particular disease. ROLES OF COMMUNITY HEALTH NURSES IN eHEALTH Ci Community health nurses roles are significantly diversified by eHealth. With the advent of eHealth, nurses are made available to several clients at a single time, making health care delivery more efficient.information handling through eHealth (ie., collection, storage, and transmission) is well explained. Clients must sign an informed Consent, if necessary. Nurses must also guarantee that all eHealth interventions are performed in a safe and ethical manner making sure that the personnel in the ehealth are competent and have received ehealth training and certification 6. Researcher ‘© Using eHealth tools (e.g., EMRs}, patient records can easily be retrieved and analysed retrospectively by community eHealth nurses. They are responsible for identifying possible points for research and developing a framework, based on data aggregated by the system. ‘An eHealth nurse researcher also pursues continuing nursing informatics education, with the goal of developing a research framework which will be beneficial to the community. Technically, the Philippine Health Information Exchange serves the following purposes: ‘a. Ease the unification and integration of health data and processes across different health facilities employing disparate electronic medical record systems; b. Promote interoperability by providing means for communication and coordination of electronic health data among the various health domains (i. disparate clinic information systems, and applications) without loss of semantics; ._ Increase accountability for the proper management of health information; d. Harmonize and optimize eHealth processes and workflows; e. Serve as reference in the development of integrated information systems f, Promote the implementation and use of interoperability standards. From the viewpoint of business process owners, the PHIE aims to achieve integrated healthcare services and delivery that is also seamlessly responsive, efficient, cost-effective, and real-time. Specifically, the system will aid in a. Enabling secured data sharing between authorized healthcare providers and consequently, supporting protected access to clients’ health data record across providers in many geographic areas of the country; b. Providing a single unified view of clients’ health data record across health facilities whether a hospital or clinic through an interface that is accessible anywhere and anytime; thereby, enhancing client care collaboration; c. Facilitating aggregation of health data into a longitudinal electronic medical record; and d. Generating accurate and real-time health statistical reports for monitoring and evaluation, with subsequent development of appropriate interventions, policies, and protocols. ‘The PHIE is composed of six (6) interacting components, namely: a. Client Registry manages the unique identification of citizens receiving healthcare services. b. Provider Registry - manages the unique identification of healthcare providers Health Facility Registry manages the unique identification of places where health services are administered d._ Standards Terminology Service manages the unique identification of clinical activities, standard health data sets, terminologies and formats. fe. Shared Health Record a repository of clients records with information in the exchange. f. Interoperability Layer receives communication from various application systems being used by the health facilities, and orchestrates message processing,