C2: concepts ,definitions of community health nursing

Objective:
1. Define community and distinguish it from public health
2. Describe the four stages of community health development.
3. Describe the eight characteristic of community health nursing.

The concept of community:

• Community is collection of people who, live together in same geographical area, who share some important feature of their lives
and share same interest, who interact with one another and whose common characteristic and holding the same right and
privileges.

Community and public health:

• Community health and public health share many features .both are organized community effort aimed at the promotion
,protection and preservation of the public’s health. Historically s a practice specialty public health has bee associated primarily
with the effort of official or Govemental entities for example federal ,state, or local tax-supported health agencies that target a
wide range health issues. In contrast ,private health effort or non- governmental organization such as those of society work toward
solving selected health problems. Such as American lung cancer . Bothe terms are interchangeable.
• Currently community health practice encompasses both approach and works collaboratively with all health agencies and NGO
which are concerns with public’s health.
• Community health practice refers to a focus on specific designed communities .It is a part of larger public health effort and
recognized the fundamental concepts and principle of public heath as its birthright and foundation of practices.
• Public health is the science and arts of preventing disease ,prolonging the life and promoting healthy through organized
community effort for the sanitation of the environment , the control of communicable infections ,hygiene ,the education of the
population
•Community Health: Is the identification of needs along with the protection and improvement of collective health ,within a
geographically defined area.

Historical development of community health nursing:

• Before the nature of community health nursing can be fully grasped or it is necessary to understand its root and factors that shape
its growth . Community practice has developed to accommodate the needs of a changing society. Yet it has always maintaining its
initial goal of improving community health .
Stages:
1- Early home-care nursing (before mid-1800s
• The origins of early nursing care: The early root of home care nursing began with religious and charitable group.
• The early nightingale years :Much of the foundation of modern community heath nursing practice was laid through Florence
nightingale. She started to give care for the sick and injured people in the war (Grimean War). Thousand of injured people lay in
street without bed, cleaned covering food. Florence organized competent nursing care and established kitchen for those people .
•Later she demonstrated that nursing intervention could prevent illness and improve the health of population .
• Mrs. nightingale concern for population at risk also she give care for people in their home.
• In addition she helped in establishment first nonreligious school for nurses 1860 at St. Thomas Hospital in London. She
promoted a stander for proper education and supervision of nurses in practice known as nightingale model.

2- District Nursing (Mid 1800s-1900)

• Nightingale’s continued influence : the next stage is the establishment of formal organization of visiting nursing or district
nursing .
• in 1859 ,William Rathbone an England philanthropist became convinced of the value of home nursing as result of private care
given to his wife. He employed Mary
Robinson the nurse who give care to his wife to visit poor people and teach them the proper hygiene and sanitation .
• In 1861 with Florence Nightingale’s help and advise Rathbone opened a training school for nurses connected with Royal
Liverpool infirmary. Also a nurse training Institute of district nursing established in Manchester in 1864, nurse were train to
dispensed food and medicine.

Home Visiting Takes Root:

• Home visit takes root ( in District Nursing): in the united states the first community health nurse, France Root ,hired by the
Women’s Brach of New York Mission in 1877,pioneered home visit to the poor in New York City .District nursing association
were founded in Buffalo in 1885 and in Boston. These district association served only sick and poor people because rich people
have their won private home nurse. The work of district nurse is focus on mostly on the care of individual. They check
temperature, pulse rate and give simple treatment as directed by physician.

3- Public health nursing (1900 to 1970)

• Nurses making a difference: by the beginning of 20the century ,district nursing had broadened its focus to include the health and
welfare of the general public not just for poor
• In this stage a specialized program such as infant welfare, tuberculosis clinics and venereal disease were developed. .
• The role of district nurses has expand in this stage, while caring for sick people ,health teaching ,disease prevention and health
promotion has pioneered
4- Community health nursing (1970 to present)
• The emergence of the term community health nursing foreshowed a new era. By late 1920 and early 1970 while public health
nurses continued their work ,many other nurses who were not practicing public health were based in community. Their practice
setting include community clinic, doctor offices, schools, primary health care
• This term was not university accepted and many people had difficulty distinguishing community health form public health .
• Confusion also arose regarding the question of whether community health nursing was generalized or specialized.
• Confusion also arose regarding the role and functions of community health nurses.

Eight characteristics of community health nursing:

1. Population focused:
Means it is concerned for the health status of population group and their living environment. A population may consist of the
elderly living through community. Or it may be scattered group with common characteristics such as people at high risk of
developing heart diseases. Population could be children or pregnant women at risk of health problem...ect.

2. The greatest good for the greatest number of-2 people

• A population –oriented focus involves a new outlook and set of attitudes individualized care is important but prevention of
aggregate problem in community health reflect more accurately its philosophy and benefits more people. furthermore because
community health nurses are concerned about several aggregate at the same time ,service will of necessity be provided to multiple
an overlapping group .

3. Client as equal partners

• The goal of public health is to increase quality and years of life and eliminate health disparities “ this goal requires a partnership
effort .just as learning cannot take place in the school without students participation ,the goal of the public cannot take without
consumers participation. Client health status and health behavior cannot be change unless people accept and apply the proposal
presented by the community health nurse. Public health nurse can encourage individuals’ participation by promoting their
autonomy rather than permitting dependency.
• The quality of care is affected when the consumer dose not understand and cannot participate in the health care process. Health
literacy or the ability to obtain process and understanding basic health information services need to make appropriate health
decision .
• Self care. The process of taking responsibility for developing one’s own health potential .
• Self Care deficit: when people’s ability to continue self-care activities drops below their needs.

4. Prioritizing primary prevention

• In community health nursing the promotion of health and prevention of illness are a first order priority .less emphasis is place on
curative care .
• Another distinguishing characteristic of community health is its emphasis on positive health and wellness .community health
nurses concentrate on the wellness end of the health continuum in a variety of ways. They teach proper nutrition ,promote
immunization among school preschool children ,encourage regular exercise .

5. Selecting strategies that create health condition in which population may thrive:
• With our population focus , it prudent for community health nurses to design intervention for the whole community ,not limiting
it “ to those seek service or otherwise vulnerable “ but directed toward the entire population within a community and the system
that may affect the health of those individual ,families and population. We do this by having “social and health care trend
,changing concerns and policy and legislation activities”

6. Actively reaching out

• We know that some client are more prone to develop disability (poor, no access to heath care services ,homeless) outreach
efforts are needed to promote the health for theses clients and prevent disease .

7. Optimal use of available resource

• It is our duty to wisely use the resources we are given. For most public health agencies ,budgets are critically stressed .tertiary
health are sues up the greatest percentage of our health care dollar ,leaving.
8. Interprofessional collaboration
• Community health nurses must work in cooperation with other team members ,coordination services and addressing the needs of
population group .other health care works and organization and client is essential for establishing effective services and program.
 CS 3: Population And Community Health

Objectives:
1. Describe Community Meaning And Dimensions Of Community As Client.
2. Apply Nursing Process In The Community As A Framework In The Community.
3. Describe Community Based Initiative (CBI) In Oman.
4. Identify The Objectives And Responsibilities Of CBI Department In Oman.

Community As A Client:
•Community As A Client Refers To A Group Or Population Of People As The Focus Of Nursing Services . It Is Population
Focuses- Practice That Distinguished Community Health Nursing From Other Nursing Specialty.

Dimension Of The Community As Client:

•Community Having Three Dimension.
1- People/Status: The Most Common Measure Of The Health Of The Community.
•It Typically Comprises Morbidity And Mortality Data Identifying The Physical ,Emotional ,Social Determination Of The Heath.
•Physical And Social Indices Include Vital Statistics ,Leading Causes Of Death ,Illness, Suicide Rate And Rate Of Drug And
Alcohol Addition.
•Social Determination Can Be Identify By Crime Rate, Functional Ability Level Or By High School Dropout .
•Other Demographic Characteristics Such As Single Female Headed Household Can Help Status Measures.
2- Structure : Its Refers To Services And Resources.
•Community Association Group And Organization Provide A Means For Accessing Needed Services.
•Adequacy And Appropriateness Of Health Services Can Be Determined By Examine The Pattern Of The Use ,Number And
Types Of Health And Social Services And Quality Measures.
•Demographical Data Such As Socioeconomic And Racial Distribution ,Age , Gender And Education Level Are Also Important
Indicators Of Community Structure.
3- Process: Reflect The Community Ability To Function Effectively.
•It Include Process Within The Community (Collaboration Between Subsystems Of Education And Health .For Instance Between
Community And State Of National Level. In A Classic Work, Cottrell (1976) Describe Community Competency As A Key
Component Of Process Dimension.
•A Competent Community Can : Collaborate Effectively In Identifying Community Needs, achieve working according to a set
goals, agree on ways and means implement the set goals and Collaborate Effectively To Take Required Action.

Features Of The Community

•Community Having Three Features:
1- Location Includes:
Community Boundaries:
•Location Of Health Services • Geographic Feature •Climate
•Flora And Fauna •Human Made Environment . • Refer to page 464.
2- Population:
•Size •Density •Composition /Demographic
•Rate Of Growth Or Decline- Mortality • Cultural Characteristic •.Education Level
3- Social System:
•The Concepts Of A Social System (People Who Made Up The Community Such As Parent, Spouse ,Employee, Citizen
•The Health Care Delivery System As Part Of The Social System.
E.G What Is The Level Of Health Promotion Is Carried Out By The Health System.

Apply Nursing Process To The Community:

•The nursing process provides a framework or structure on which community health nursing action are based.
•Application of the process varies with each situation but the nature of process remain the same.
•Certain characteristic of that process are important for community health nurse to emphasis in their practice.

Characteristics Of Community Process Deliberative:

The Nursing Process Like The Research Process In EBP.
IT Is Deliberative- Purposefully Rationally And Carefully Thought out.
It Requires The Use Of Sound Judgement That Is Based On Adequate Information.
Further More For Deliberative Problem Solving Is Necessary Skills For Working With Community Health Team To Address The
Need And Health Problem Of The Community.

• Adaptable:
The Nursing Process Is Adaptable.
Its Dynamic Nature Enable The Community Health Nurse To Adjust Appropriately To Each Situation And To Be Flexible In
Applying The Process To Aggregate Health Needs. Furthermore Its Flexibility Is A Reminder To The Nurses That Each
Community Situation Is Unique .
• Cyclical:
•The Nursing Process Is Cyclical And In Constant Progression . Steps Are Repeated Over And Over In The Nurse Aggregate
Client Relationships. The Nurse Engage In Continual Interaction ,Data Collection Analysis ,Intervention And Evaluation .

• Client Focused:
•The Nursing Process Is Client Focused.
•It Is Used For And With Client.
•Community Health Nurse Use The Nursing Process For The Express Purpose Of Addressing The Health Of Population . They
Are Helping Client Directly Or Indirectly.

• Interactive:
•In That Nurse And Client Are Engage In A Process Of Ongoing Interpersonal Communicated.
•Giving And Receiving Accurate Information Is Necessary To Promote Understanding Between Nurse And Client And Foster
Effective Use Of The Nursing Process.

• Need Oriented:
Community Nurse Used Nursing Process To Anticipate The Need Of The Of Population And Anticipate Strategy On How To
Prevent Health Problem.
The Nurse Should Think Of Nursing Diagnosis As Ranging From Health Problem ,Identification Of The Needs To Primary
Prevention And Health Promotion.

• Interaction With Community:

All Steps Of Nursing Process Depend On Interaction. Reciprocal Exchange And Influence Among People. For Example Listening
To A Group Of Elderly People ,Reaching A Class Of Expectant Mother ,Working With The Parents To Set Up A Dental
Screening, All These Involve Communication, Relationship And Interaction.

Types Of Community Needs Assessment:

•After Considering The Importance Of Community Partnerships And Coalitions, The Community Nurse Is Ready To Determine
The Community’s Needs.
•Assessmet Is The Key Initial Steps Of The Nursing Process .
•Community Needs Assessment Is The Process Of Determining The Real Or Perceived Needs Of A Defined Community.

Types Of Community Needs Assessment:

1. Familiarizing Or Windshield Survey
2. Problem-Oriented Assessment
3. Community Subsystem Assessment.
4. Comprehensive Assessment
5. Community Assets Assessment

Community Assessment Methods:

•Survey
•Descriptive Epidemiology Studies •Geographic Information Systems •Community Forums Or Town Hall Meeting •Focus Group

Survey:
•A Surveys Is An Assessment Method In Which A Series Of Questions Is Used To Collect Data For Analysis For Specific Group
Of People.

Descriptive Epidemiologic Studies:

•Which Examines The Amount And Distribution Of A Certain Disease Or Health Condition In A Population By Person (Who Is
Affected ) Time (When Dose The Cases Occur) And Place Where Does The Condition Occur).Descriptive Epidemiology Studies
Are Useful To Determine Individual At Risk ,Where And When Might Occur.

Geographic Information System Analysis:

•GIS Was Introduced As A Health Information Technology. It Mapping And Visualization Of The Health Disparities And Their
Relationship To The Geographical Location Of The Health Services. Which Allow For Better Resources Allocation To Disparate
And Underserved Population.

Community Forum Or Town Hall Meeting:

•The Method Is Designed To Obtain Community Opinion. This Method Is Use To Elicit Public Opinion On Varity Of Issues Such
As Health Care Concern, Feeling About Issues In The Community Such As Gangs.

Focus Group:
•This Is Similar To Community Forum It Designed To Obtain Opinion Of Community .However Only A Small Group Of
Participant.
Sources Of Community Data:
•Primary And Secondary (Formal And Informal Leaders ,Community
Members Because The Data Are Obtain Directly Form The Community.
•International Sources (Data Collected By Several Agencies Such As Who, Health Organization ,American Health Organization)
•National Sources.
•State And Local Sources.(The Most Significant State Source Of Assessment Data Comes From The State Health Department For
Collecting Vital Statistics And Morbidity Rate.

Data Analysis And Diagnosis:

Data Analysis Process.
•First The Data Must Be Validated .Are They Accurate ,Complete And Representative Of The Community .Several Validation
Process May Use.
•Date Can Be Rechecked By Other.
•Subjective And Objective Data Should Be Compared.
Then Data Should Be Separated Into Categories As Physical , Social And Environment. Some Computer Program Cab Be Used
To Analysis Assessment Data ( SPSS)

Community Diagnosis Formation

Please Refer To Chn Course Syllabus Practicum Pp.42-45

Community Base Initiative In Oman Community Health Nursing:

•The Ministry Of Health ,Oman Has Realized The Important Of The Holistic Approach In Addressing The Determination Of
Health Through The Community Based Initiatives(CBI),such As The Healthy Cities, Health Villages And Neighborhoods, Health
Lifestyle Program And Community Support Group .Therefore In August 2006 A Fully –Fledged Department Was Established In
MOH/DGHA To Provide Technical Support ,Management And Leadership To Regions/Sites Implementing Various CBI Program

Objectives And Responsibility Of Cbi Department In Oman:

•Achieve Health Promotion Through CBI Project In Healthy Lifestyle And Environment.
•Promote Inter-sector Collaboration And Make People Partners I Development.
•Provide Support To Achieve Self-reliance To Improve The Socio-economic And Health Status Of Some Societies.

Responsibility Of The Department

•Establishing Policies Related To The Program Of Community Based Initiative For Health Support By Liaising With The Parties
Related To The Health Sector.
•Monitor The Implementation Of The Yearly Plan For Programs Of Community Based Initiative And Related Activities.
•Training Qualifying National Teams In Health Community Management
•Preparing Revising And Developing Work And Measurement Guideline For The Implementation Of Cbi.
• Provide Technical Support To Areas Implementing Community Based Initiative
•Seeking Funds For Implementation Of Projects.
 CS 4: Definitions, Principles & Activities Of Primary Health Care

Objective:
1. Define the term Primary Health Care
2. Discuss the various elements constituting Primary Health Care.
3. Identify the objectives of Primary Health Care
4. Describe the principles of Primary Health Care
5. Discuss the vision of Quality Assurance Improvement and Patient Safety program in PHC.

Primary Health Care- Definition:

“ PHC is an essential health care based on practical, scientifically sound and socially acceptable methods and technology made
universally accessible to individuals and families in the community through their full participation at a cost that community and
country can afford to maintain at every stage of their development in the spirit of Self-Reliance and Self- Determination”
- It forms an integral part of:
- the country's health system
- the overall social and economic development of the community.
- It is the first level of contact of individuals and the family with the national health system
- Brings health care as close as possible to where people live and work.

Elements OF primary health care:

1. Education concerning prevailing health problems and preventive and control methods.
2. Promotion of food supply and proper nutrition
3. Adequate supply of safe water and basic sanitation
4. Maternal and child health care including family planning
5. Immunization against the major infectious diseases
6. Prevention and control of locally endemic diseases
7. Appropriate treatment of common diseases and injuries
8. Provision of essential drugs

1-Education and information concerning prevailing health problems and methods of preventing and controlling them
-Education to make the individual able to think and decide about his health, accept health measures, having healthy environment.
-Education based on socio-economic conditions,
politics, culture and religion.

2- Promotion of food supply and proper nutrition

Focus is on:
-Under nutrition.
-Child and maternal malnutrition.
-Promotion of better nutrition.
-Correction of faulty feeding practices
-Prevention of infectious diseases which are nutrition-related eg: Diarrhea.

3- Adequate supply of safe water and basic sanitation

- Safe, adequate and accessible supplies of water.
- Proper sanitation.
The main objectives of this PHC elements are:
- To prevent disease
- Improve the quality of life and well being by:
 Promoting personal and community hygiene,
 Ensuring the availability of safe water supply and sanitation facilities
 Associating water supply and sanitation with other health and/or development programs.

4- Maternal and child health including family planning

-Aims at promoting and protecting the health of children and women of childbearing age, so that
-All children have the possibility for healthy growth and development and
-Reproductive life of women is compatible with a state of health and well being.
MCH/FP care includes at least five main functions:
a. Antenatal care
b. Delivery care
c. Post natal care
d. Child care
e. Family planning care
5- Immunization against the major infectious diseases
- To reduce morbidity and mortality against the major killers of children.
- Priority is given to the following diseases:.
1. Diphtheria, 2. Whooping cough, 3. Tetanus,
4. Measles& Rubella, 5. Polio myelitis, 6. Tuberculosis,
7. Hepatitis B, 8. Mumps and 9. Pneumococcal infections
-The goal: to provide immunization for all children of the world with special priority given to those in developing countries.
- In addition, children are protected in the first year of life.
-Tetanus immunization for pregnant mothers.

6- Prevention and control of locally endemic diseases

MALARIA
- NMEP(National Malaria Eradication Programme)
- Launched in Al Sharquiya governorates in 1990 with main objectives of stopping local transmission and eliminate the reservoir
of infected cases.
- Strategies applied were:
- vector control(larviciding) - early case detection - prompt radical treatment.

7- Treatment of common diseases and injuries

A. Diarrheal Diseases:
Prevention of diarrheal morbidity and mortality is a vital part of national strategies of PHC. Diarrheal disease control includes at
least three main functions namely;
a. Diagnosis of diarrheal disease
b. Provision of appropriate treatment
c. Management of outbreaks of diarrheal diseases and its prevention
To achieve these appropriate information, appropriate technologies, equipments and supplies, improved communication,
supervision and technical support is required.
B. Common Accidents in the home
- Accidents are among the highest causes of death in most countries.
-The aim:
-To provide first aid on the spot
-To provide adequate treatment at the appropriate level of care
-To prevent the occurrence of similar accidents in the future
-To provide programs for active rehabilitation of disabled persons, children as well as adults.
Three types of home accidents have been chosen :
-a. Cuts -b. Burns& scalds -c. Poisoning

8- Provision of essential drugs

Aim:
- Making drugs available to users of the health systems at all levels of PHC, all over the country, at all times by
-Instituting an efficient system of drug acquisition, storage, distribution and utilization.
- Drug management in primary health care is an integral part of the overall drug management plan for a country wide health
system.
1. Provision of an accessible, comprehensive as well as specialized PHC service to the community.
2. Advanced capacity building to the health professionals in leadership, management and clinical skills.
3. Implementing PHC policies.
4. To strengthen the screening in Primary Health Care through defaulter tracing and early detection of diseases and its
management among above 40 years.
5. Implementing effective and accredited CPD training Program for PHC workers.

Principles of PHC (Course Book):

A. Universal coverage of the population with care provided according to need.
B. Services should be promotive, preventive, curative and rehabilitative.
C. Services should be effective, culturally acceptable, affordable and manageable.
D. Community should be involved to promote self-reliance.
E. Approaches to health should be related to other sectors of development.

Quality Assurance / improvement and patient safety program:

- VISION: The vision of Quality Assurance /improvement is to provide a health service that is accessible, acceptable, efficient,
effective and safe that is continuously evaluated and improved.
- It is worth mentioning that the absence of quality systems in health care organizations lead to increase and irrationalized
expenses of health services, users dissatisfaction as well as high rates of medication and medical errors.
- In its endeavor to improve the quality of health services, The MOH has adopted a Total Quality strategy to establish and
maintain quality management systems in Health care institutions.
-The effective implementation of quality systems requires joint work between all health care workers in one side and different
community sectors on the other.
 CS5: Primary Health Care Services In Oman
Objectives:
1. Identify the main primary health care services that are implemented in Oman.
2. List the objectives of each primary health care services.
3. Describe the various activities that are provided by each service.
4. Specify the roles of community health nurse in providing primary health care service.
5. Differentiate between the various types of referral system in Oman.
6. Discuss the roles & responsibilities of health team members during the process of referral.

Services of PHC:
1. Health Education 2. Promotion of Proper Nutrition 3. Environment Health
4. Maternal Health 5. Child Health 6. School Health
7. Immunization Against Childhood Diseases 8. Control Of Diseases 9. Mental Health
10. Eye Health 11. Oral Health 12. Community Participation
13. Adequate Supply And Rational Uses of Essential Drugs 14. Inter-sectoral Cooperation
15. Treatment of Common Diseases And Injuries

1. Health education:
- It is a process by which people learn and as a result of their learning, they can change their attitude toward health.
- It motivates and help people to adopt and maintain healthy practices and lifestyles

Who are the health educators?

- Each individual of a health team is responsible about health education. - Clear plan
- It should be given in every hospital, health center, school, home. - Using different methods

2. Promotion of proper nutrition

Nutrition plays important role on quality of life.
- Maternal malnutrition cause of poor health of women and their infants.
- Malnutrition in adults can reduces their work capacity, therefore interferes with their personal and professional development.

Promotion of proper nutrition According to WHO (2020):

– 47 million children < 5 years of age are wasted (weight-for-height z score < −2 SD), 14.3 million are severely wasted and 144
million are stunted (low height-for-age), while 38.3 million are overweight or obese.
– Around 45% of deaths among children < 5 years of age are linked to undernutrition.

Promotion of proper nutrition Diarrhea and Malnutrition:

- Frequent diarrhea leads to malnutrition - Children with diarrhea must continue to be fed properly

PHC Objectives Regarding Nutrition:

– Promotion of activities that can improve food supply at the family level
– Correction of faulty feeding habits
– Treatment and prevention of anemia, vitamin A deficiency
– Prevention and early management of diarrhea and acute respiratory infections

Role of PHC team:

1. Assessing and defining the problem by survey, making a plan of work, this should include:
 Availability of nutritious food materials.
 Customs and traditions with food handling, storage practices.
 Environmental and personal hygiene.
 Voluntary organizations that can support promotion of nutritional status in the community.
 Socio-economic situation of different families.
2. Determining nutritional status of children by growth monitoring.
3. Knowing and minimizing the risk factors which may lead to malnutrition.
4. Detecting early signs of malnutrition and taking appropriate actions (anemia, Kwashiorkor, marasmus).

At family level, family should be educated on:

❖ Selection of right kind of local food
❖ Planning of a nutritionally adequate diet according to the family budget
❖ Correction of wrong dietary practices
❖ Breast feeding for infants and correct feeding practices
❖ Nutritional needs of pregnant and lactating women
❖ Encourage food production by the family (kitchen garden, poultry and cattle).
At individual level:
❖ Organize health clinics related to motherhood (ANC/PNC)
❖ Organize well baby clinics (Immunization, growth monitoring)
❖ Organize health education activities related to nutrition
 3. Environmental health:
The main aims in PHC are:
- To prevent diseases related to unsafe drinking water, lack of sanitation and poor hygiene
- To improve quality of life and health of the population by promoting personal and community hygiene

Activities related to environmental health:

– Promotion of personal and community hygiene – Provision of safe drinking water
– Proper system of excreta disposal – Food quality control
– Control of vectors, flies, mosquitoes and cockroaches – Training of local workers and health volunteers
– Participation in arranging village cleaning campaigns – Inter-sectoral coordination

Community education relate to environment:

– Assess their environmental health needs – Identify resources to meet those needs
– Implement plan – Continue and monitor the newly initiated activities
– Periodically evaluate environmental health activities

4. Maternal health
Objectives:
❖ To promote health of the mother by maintaining the healthy growth of the fetus and the mother.
❖ To reduce maternal mortality and morbidity
The main activities
– Antenatal care – Intranatal care – Post natal care

Antenatal care activities:

– Identify pregnant women in community – Follow the pregnancy
– Identify risk factors in mother and fetus – Educate them
– Administer tetanus toxoid – Decide about the place of delivery

Aim of Intra Partum Care:

- To conduct the delivery under aseptic technique - Minimum injury for both
- Efficient dealing with complications and timely referral - Baby should be given to the mother immediately after birth

Postnatal Care Objectives:

– To prevent complications of post partum period – To restore and maintain the health of the mother and new born
– To provide health education to the mother and family with stress on breast feeding, personal hygiene and family planning

Postnatal Care Activities:

– Physical examination, at PNC 2 weeks and 6 weeks. – Health education on diet, exercise, baby care, importance of BF
– Anemia should be treated – Focus on immunization (inj. TT)

5. Child Health:
Objectives:
– To protect and promote the health of children by meeting special biological and psychological needs during the rapid process of
human growth and development.
– To reduce the infant and child morbidity and mortality.

Common problem in new born:

– Low birth weight. – Difficulty in breathing. – Neonatal tetanus.
– Infection of any injury. – Head or brain injury. – Conjunctivitis.

Common problem in Infant and children:

– Malnutrition – Diarrhea – Respiratory infection – Infectious diseases (Mumps, Whooping cough, Chicken pox,,ect)

Main activities of child health care:

– Promote breast feeding – Growth monitoring – Immunization against childhood diseases
– Weaning – HE – Nutritional surveillance and prevention of malnutrition

6. School health program:

Objectives:
– To meet comprehensively the physical and social health needs and problems of school age children.
– Safe guarding the health of should children is extremely important so that they grow educated ,physically and mentally health
adult.
– Conversant with principle of health protection and promotion and thus ultimately provide healthy environment to their own
families.
Activities in school health:
– Screening of school children to detect any diseases or abnormality.
– Health education to school children on personal hygiene, diseases prevention and health promotion.
– Immunization against childhood disease.

7. Immunization against childhood disease.

Objectives:
– To sustain and consolidate high immunization coverage of children under one year of age against the ten preventable childhood
disease (diphtheria, pertussis, tetanus, poliomyelitis , tuberculosis, measles and viral ,hepatitis B and HIB).
– To eradicate poliomyelitis
– To immunize all pregnant women with two doses of tetanus toxoid in order to eradicate neonate tetanus.
Objectives of vaccination:
– To minimize the morbidity and mortality due the preventable disease among children.
– To promote the growth and development of new generation of children that comprise the future of the nation.
– To ensure that all children 0-10 year of age are protected against childhood disease by completing the vaccination in time.
– To continue the protection against children disease by giving booster doses at the right time to children who are vaccinated.
– To vaccinate all pregnant women at the child bearing age with tetanus toxoid.

PHC workers MUST be knowledgeable and skilled about:

– The vaccine for target diseases
– The correct technique of giving vaccine
– Prepare and conduct immunization sessions.
PHC must ensure:
 Availability of vaccine
 Availability of equipment
 Vaccines are kept in proper condition and maintain cold chain till vaccines are used.
– Cold Chain is the system which ensures that vaccines remain potent from the moment of manufacture to the time of
immunization.
– A vaccine is potent if it is in good condition. Heat ,sunlight and freezing can destroy the vaccines. Heat and sunlight damage live
vaccine. Freezing damage killed vaccine and toxoids.
– VACCINES TEMPERATURE BETWEEN +2 TO +8 C AT ALL TIME.

8. Control of diseases
– Objectives:
– To maintain epidemiological surveillance of health problems, communicable and non-communicable diseases in the country.

Communicable diseases:
Control Communicable diseases by:
❖ Providing information about diseases
❖ Advising people to adopt personal hygiene habit ❖ Promote immunization
❖ Follow up treatment

Non-Communicable diseases Objectives

1. Cardiovascular diseases
2. Management and control of diabetes
3. Prevention and control of cancer
-To prevent and reduce the prevalence and incidence of cardiovascular diseases
through:
– Primary prevention of coronary heart diseases by control preventable risk factors.
– Early detection and control of hypertension
– Follow up: maintenance therapy can be continued at health center
– To prevent, control and implement comprehensive management program of
diabetes and its complication.
– Diagnosis and treatment at PHC.
– Heath education on controlling diabetes.
– To prevent and reduce the incidence of cancer.
– Refer the suspected cases to the regional hospital
– Educate people on prevention of certain types of risk factors.

9. Mental health
Objectives:
– To promote mental health, prevent mental illness, provide treatment to mentally ill person and rehabilitate them as necessary.
– To promote mental health awareness in community.

Function of health workers at PHC level:

– Detection of mentally ill person in community
– Assessing ten mental health condition
– Give proper treatment or refer to hospital
Mental health education:
1. Mental diseases are preventable and treatable
3. Mental illness are not infectious
5. Treatment in hospital
7. Alcohol use can lead to mental problem.
2. After successful treatment a person can live a normal life
4. Magic and supernatural power has nothing to do with mental illness.
6. Treat than married

10. Eye health care

Objectives:
– To prevent and control avoidable blindness
– To reduce blindness due to Cataract, Glaucoma, ect These can be achieved by:
– Conducting health education activities.
– Proper assessment of eye problem, treatment of minor eye problems and referral of serious problems to specialists.

Eye diseases that are seen in PHC can be classified as:

1. Eye diseases which can be treated by trained PHC workers, such as Conjunctivitis, Trachoma, Subconjunctival Hemorrhages.
2. Eye diseases in which treatment initiated and referred to specialist for further treatment, such as corneal ulcers, laceration to
eyeball, burns.
3. Eye problems which need immediately referred to ophthalmologist, such as acute attack of glaucoma, cataract, retinal
detachment

11. Oral health

Objectives:
– To reduce the oral health problems (dental caries and periodontal disease) through balanced and integrated curative and
preventive dental health program.

Role of health workers in promotion of oral health:

– Oral health education (parents and children)
– Holding toothbrush drills for school children
– Screening: 6-7 years old children annually, pre-school children and mothers as part of MCH program.
– Referral and follow up

12. Community participation

Objectives:
– Involvement of community in process of self-care, health promotion and disease prevention.
- Effective PHC implementation can not be achieved without community involvement.
How to stimulate community involvement?
(education, communication, religious leaders, influential person)

13. Inter-sectoral cooperation

Objectives:
– To involve other sectors like education, social welfare, ect and addressing themselves to uplift the quality of human life.
Wilayat health committee is established to perform:
– Suggest future expansion of health service.
– Plan and implement inter-sectoral activities such as environmental health.
– Community involvement in health promotion.

14. Treatment of common diseases and injuries

Objective:
– Proper management of common diseases and injuries.
Aim:
– Immediate diagnosis and treatment of common diseases and injuries.
– Refer patient to hospital if diagnostic facilities are not available in health center.
– Follow up maintenance therapy

15. Adequate supply and rational use of essential drugs

Objectives:
– To ensure the regular supply to all people of safe and effective drugs of acceptable quality with adequate control.
– Essential drugs are those drugs that achieve the widest possible coverage of population with proven efficacy and safety.
Criteria of Essential drugs:
– Less toxic – Cost of combination product is less than the sum of individual product.
– Has greater therapeutic effect – Compliance is improved.
Role of PHC team:
– Educate community about drug misuse. – Keep dangerous drugs in separate cabinet with separate register.
– Management of drugs – Keep a small stock of life saving drugs in separate and easy reach place.
– In charge should make sure that vaccines are kept under right storing condition and right temperature.
Study page 66
Roles of nurses in providing PHC service (SLA)
- Assessing health status of individual, families, community - Providing integrated health care (emergency treatment)
- Training and supervising health workers. - Monitoring record reports of vital statistics

Current practice of CHN in Oman: (SLA)

– Patient who found to have complications and don’t meet criteria for admission, are referred back to the physician for further
investigations.
– Patients who found to meet admission criteria, are admitted into service and individualized patient and family centered care
delivered to him/her in their home.
– Three more healthcare programs were integrated into community health service in Oman ( elderly care program, palliative care
(prevention and relief of suffering), heart failure service)

Referral:
With increasing specialization, the referral hospitals would function well only with organized referral system, thus avoiding direct
access.
Referral: Process in which the treating physician at lower level of health service, who has inadequate skills or lesser facilities at
his level to manage a clinical condition, seeks the assistance of better equipped and specially trained person with better resources.
Types of referral :
1. Routine referral: Facilities could be availed by PHC institution for laboratory, radiological
2. Emergency referral: made in emergency cases which can not be totally managed at primary health institution.
Reasons for referral:
– Expect opinion – Admission and management of patient – For investigation

Health Care Team:

Role & Interrelationship
Main characteristics of team:
- Have common goals and objectives - Cooperation between members
- Have a leader - Follow set of rules and norms

Health personnel in health team in PHC:

- Medical officer -Administrative officer -Health assistant
- Nursing staff - Sanitary inspector - Sanitary assistant
- Midwife - Assistant pharmacists - Laboratory technician / X ray technician
- Spray man, drivers

Role & Interrelationship:

The level of manpower and skills should match the tasks to be carried out and the staff is adequately distributed throughout the
wilayat health centers.

Role of medical officer:

– Responsible for functioning of health center and overall supervision of PHC team.
– Ensure implementation of national policies and strategies of health services delivery.
– Assign work among the staff members according to the work needs.
– Arrange for training and retraining of members of PHC team.

Role of administrator:
– Ensure proper maintenance of building, furniture and equipment and arrange replacement when needed.
– Supervise all members in PHC team attendance in time and absence.
– Participate in promoting community involvement.
– Supervise cleanliness of health center.

Role of senior staff nurse:

– Perform nursing duties in health center according to standard.
– Prepare well balanced duty schedule ensuring utilization of nursing skills 24 hours/ day based on patient needs, staff capabilities
and recourses availably.
– Administer medications, treatment and patient care according to policy.
– Participate in outreach program.

Role of staff nurse:

– Perform nursing duties in health center according to standard.
– Assume in charge duties as directed by superiors.
– Administer medications, treatment and patient care according to policy.
– Participate in patient education.
 CS6: NATIONAL CONTROL PROGRAM (NCP)
Objectives:
1. Identify the main issues that necessitate the emergence of communicable disease control program
2. Identify the evolution history of communicable disease control.
3. Describe the CHN’s role in the process of investigating reportable
4. Explain the strategies used for the three levels of prevention in communicable disease control.
5. Discuss the issues and challenges of the national control programs as practiced in MoH (Refer course syllabus pg17 )
6. Discuss the role of CHN during the nursing process for the communicable disease control .

Issues Related To Emergence Of CD:

- Numerous changes in issues related to public health nationally and globally since last century.
- Achievement in health, safety, longevity and disease control improved lives of many population.
- Ongoing work of the public health nurse in advocating for the communities through disease prevention and health promotion.

Ongoing Issues:
- Higher morbidity of various age group related to communicable diseases rather than death.
- Continuing disproportionate morbidity and mortality among lower socioeconomic populations.
- Emergent, newly identified resurging diseases related to changing environments, global mobility and need for space.(eg: H1N1)
- Development of antibiotics resistant strains of bacteria leads to occupational health challenges .eg: MDRTB
- Potential terrorists attacks utilizing biological agents.
- Ongoing public empowerment through education regarding healthy life practices, and current health research about disease,
cancer prevention through diet and immunization and the environment.

Evolution Of Communicable Disease Control:

communicable disease those of epidemic and pandemic disease such as TB, influenza, or AIDS.
the first documented global threat from communicable disease began in the 13th century .
• it was responsible for killing 25% of population in European countries. not until 1700 and 1800 were the causative organisms for
various infectious disease recognized through the assistance of increasingly sophisticated microscopy.
• with these discoveries came early attempts to create ways to prevent the spread of such organisms.
• WHO came into existence as the arm of united nations in 1948 . it was established to tackle world health issues.
• it has evolved into multifaceted agency provide services ongoing health /illness research, education, medical responds and
disease control
• one disease , smallpox is an example of communicable disease control success story
• smallpox first responded to a crude vaccine was that developed in 18th century. the vaccine was studied perfected and used
globally for decades.

Community Health Nurse’s Role: Process Of Investigating Reportable Communicable Diseases

Process of investigating reportable communicable diseases:
Each state has a state health department, but not all states have local level sites like a county health department. Some of the state
or local health department utilize a combination of nurses, epidemiologists, and communicable disease investigators. The CDC
and WHO provide guidance documents that assist state public health agencies develop investigation policy and procedures for
local level investigator to use.
State health departments commonly specify two other circumstances that must be reported:
1- any outbreak or unusually high incidence of any disease.
2- any occurrence of an unusual disease of public health importance.
The local health department/agency is the initial point of notification of communicable disease investigation.
In most states, reporting known or suspected cases of a reportable disease is generally considered to be an obligation of:
• Physicians, dentists, nurses, and other health professionals.
• Medical examiners
• Administrators of hospitals, clinics, nursing homes, schools, and nurseries.
-Some states also request reporting from
• Laboratory directors.
• any individual who knows of or suspects the existence of a reportable disease.
These steps include interviewing individuals, contact and additional case finding, analyzing information gathered from
surveillance, intervening to control the disease, and elimination or eradication.

Interview:
Prior to contacting an individual for an interview:
- review the information received from mandated reporters for completeness.
- clarify that the disease is suspect or lab confirmed.
- review the case definition. A case is the individual who ether has a laboratory confirmed reportable disease or meets the clinical
definition in an investigation.
- many disease has specific questionnaires that are useful when interviewing the client.
The interview:
• Maintaining a neutral and nonjudgmental attitude during the interview process will elicit information more readily, especially
when discussing an STD.
• The interview may be by telephone or in person.
• Introduction of self and purpose of the confidential nature of the
interview is essential.
• Eliciting what the individual knows about the disease may give the nurse an idea of the individual’s knowledge base.
• Gathering the information by using a disease-specific questionnaire may lead to a possible source of the disease, or to additional
infected contacts.
• The nurse will contact individuals identified as possibly infected by the identified case.
Surveillance of reportable disease is the next step.
Effective surveillance and control can lead to elimination and eradication of disease in many cases.
Elimination is stopping of a disease in a defined geographical region (An example; No natural cases of measles in US), whereas
eradication is the extinction of naturally occurring disease. By maintaining high levels of immunization, only imported cases of
measles have occurred for years. An example of eradication of disease is smallpox.

Primary Prevention:
• In the context of communicable disease control, two approaches are useful in achieving primary prevention :
• Education using mass media with targeting health massages to aggregates
• Immunization

Education:
• Health education in primary prevention is directed both at helping individuals understand their risk and promoting healthy
behaviors.
• Targeting meaningful health message to aggregates:
To deliver effective health promotion and disease prevention message, the message must reach the target group (at risk)
population. This requires correct identification of characteristics of the target audience in terms of educational level, salience of
the issue, involvement of the target audience with the issue, and their access to the media channel used.
• Cultural issues affect people’s interpretation of messages.

4 Principles for adapting health messages to specific population subgroups:

1. Develop educational materials from the community perspective, reflecting respect for the community values and traditions,
relevance to community needs and interests, and participation to of the community in the preparation and use of the materials.
2. Materials must be related to the delivery of the health services that are available, accessible, and acceptable to the target
population.
3. All materials must be pretested and have demonstrated attractiveness, comprehension, acceptability, ownership, and
persuasiveness.
4. Materials must have a readability level for the intended audience.

• Ways to communicate:
The use of traditional and new communication technologies can serve the global population. Radios, television, in person
interaction, and print/ signage have been used for years to promote health messages. Internet has been used for some time now as
a repository of information.
The use of cell phones, Internet, texting, tweeting, and the use of social networking like Facebook are examples of new ways to
send messages to communicate to and with people.

Immunization:
• It is process to stimulate the individual’s immune system to create antibodies the particular infectious disease.
• Vaccine-Preventable Diseases:
Hepatitis A and B, H. influenza type b, measles, polio, diptheria, pertussis, influenza, and chickenpox are examples of diseases
that can be prevented through immunization. Immunity may be either passive or active.
Passive immunity is short-term resistance to specific disease-causing organism, it may be acquired naturally like the newborns or
artificially through inoculation with pooled human antibody that gives temporary protection.
Active immunity is long term resistance to a specific disease causing organism, it also can naturally or artificially acquired.
A vaccine is a preparation made from a live organism or an inactivated form of the organism.

• Schedule of recommended immunization:

A schedule for the administration of childhood vaccination, based on recommendations by the ACIP, the American Academy of
Pediatrics, the American Academy of Family Physicians, and the CDC. (Table 8-4)
• The CDC also provides “catch up” schedules for children not receiving
their first immunization at birth according to the standard schedule.
• Factors influencing the recommended age at which vaccines are administered include the age specific risks of the disease, the
age specific risks of complications, the ability of persons of a given age to produce an adequate and lasting immune response, and
the potential for interference with the immune response acquired from passively transferred maternal antibodies.
• In general, vaccines are recommended to the youngest age group at risk whose members are known to develop an acceptable
antibody response to vaccination.
• Recommendations for vaccine administration may revised in light of specific circumstances, ex, it is now recommended that
infants receive HBV at birth, whether the mothers have positive or negative response to HB surface antigen.
Herd Immunity:
• It is the immunity level present in a particular population of people.
• In case of few immune individuals exist within a community, herd
immunity is low, and the spread of disease is more likely.
• Whereas immunization of more individuals in the community contributes to high proportion with acquired resistance to the
infectious agent, playing a role in higher herd immunity.

Assessing immunization status of the community:

• Determining the immunization status of children in a community can be a time-consuming but worthwhile task.
• Public health nurses can access the children and school entry immunization data through their state’s immunization agency as
well as state immunization registries.
• Other community sitting in which the public health nurse identify under immunization children include homeless shelter and
other public service setting.

Barriers to immunization coverage:

• Improving immunization coverage requires examination of the reasons why children are not immunized.
• There are many barriers consider as challenges the community health nurse may have to deal with when working with the
community and trying to effect adequate immunization coverage for the general public and protection from VPDs (Vaccine-
Preventable Diseases)

• There are five barriers:

1. Religious Barriers
2. Financial Barriers
3. Social and Cultural barriers
4. Philosophical Objections
5. Provider Limitations

• Religious Barriers:
- The right to religious freedom gives individuals the constitutional right to exemption from immunization if they object to
vaccination on religious ground.
- Problems arise when members of exempted groups are found together in community settings, raising the risk of disease spread
because of a lower herd immunity.

• Financial barriers:
Access to affordable immunization programs may be a significant factor for immunization delays in families with limited
incomes. Such families may have had more priorities than vaccinations for otherwise well child.

• Social and Cultural Barriers:

Education levels, transportation problems, as well as access to the health facilities can pose essential barriers to immunization
coverage for children and all family members. The paperwork involved in obtaining the informed consent of parents may be
intellectually intimidating for some parents.
Working parents may find it difficult, if not impossible to reach an immunization clinic with child during working hours.
• Meeting immunization needs for minority groups involves understanding
cultural concepts related to health care and preventive measures.
• Language barriers may lead parents to feel confused, overwhelmed, and unable to access the services.

• Philosophical Objections
- Many caring parents have philosophical objections to immunization because they fear harming their children.
- This puts the child “behind” on immunizations, according to the AAP schedule.
- Community/public health nurses should be aware that caring parents are talking about these issues, reading about them, and
trying to make informed decisions.
- It may be helpful to offer information or websites that address many myths surrounding childhood immunization.

• Provider Limitations
- Health care providers may contact with an eligible child, yet fail to offer vaccination.
- There are some limitations for the provider to be aware of, example:
1. Reviewing child’s immunization record.
2. Maintaining safety and efficacy of administering multiple vaccines on the same occasion.
3. Deferring administration of vaccine based on condition.
4. Recalling and notifying parents for the next immunization.

Planning and implementing an immunization campaign:

Immunization campaigns targeting specific subgroups can be effective if they include the following:
a. Community assessment for the target groups
b. Assessment of and planning for the needs of the target groups, such as transportation, need for language interpreters, provision
of child care, or dealing with high illiteracy rates.
Adult Immunization:
• Adults are at as great a risk for a VPD as is a child if they are unimmunized.
• Some of the immunizations given for adults are tetanus, pertussis, influenza, and pneumococcal.
• Adults may require immunizations to prevent occupational exposure to blood, blood products, or other potentially contaminated
body fluids.
• History of high-risk conditions promote adult vaccination.

• Factors that may contribute to low vaccination levels among adults:

1. Limited comprehensive vaccine delivery system.
2. No such requirements exist for all adults.
3. Health care providers may not be current with the adult-recommended immunizations.
4. Comprehensive vaccination programs have not been established in siting where healthy adults congregate.
5. Clients and providers may fear adverse effects after vaccination.

International travelers, Immigrants, refugees:

• As Americans interact more with their neighbors in other parts of the world, the incidence of Americans with tropical or
imported diseases rises. An average flight can be equal to incubation period infectious diseases, ad microbial agents could be
spread to the globe.
• At a minimum, all the international travelers should take steps to be adequately immunized as required by international health
practice.
These steps include being immunized with recommended vaccines for the particular area of the world, being knowledgeable about
food and water precautions as well as the basic first aid for the care of simple injuries.
The travelers who neglect to take the recommended travel vaccines end up with generally preventable illnesses, which can cost
them time, money, and their health.

Secondary prevention:
Two approaches of communicable diseases:
1. Screening 2. Disease case and contact investigation

1.Screening:
Is used in community health and disease prevention to describe programs that provide disease testing opportunities to detect
diseases in group of asymptomatic apparently healthy individuals .

Common screening measures can include:

1.Prenatal hepatitis B 2.Urine chlamydia and gonorrhea 3.Monteux tuberculin skin test

There are several screening tests available for HIV :

• Oral fluids testing • Rapid finger stick • Enzyme immunoassay (more sensitive screening)

The HIV screening test confirmed by supplemental test such as :

A. Western blot B. Immunofluorescence assay

Criteria for screening tests:

•Validity and Reliability •Predictive value and yield

1. Validity and Reliability :

Validity : refers to test’s ability to accurately identify those with the disease .
Reliability: refers to test’s ability to give consistent results when administered on different occasions by different technicians .

2. Predictive value and yield

Predictive value of screening test: is important for determining whether screening intervention is justified .
Yield : refers to number of positive results found per number tested.

*Epidemiologic criteria for screening intervention for detection of health problems (p.277)

The ethics represented by these statement include :

• Clear and unwavering respect for dignity and worth of individuals across racial .
• Gender. • Religious. • Sexual. • Tribal. • Ethnic.

2. Disease case and contact investigation:

Are fundamental public health strategies for controlling and preventing the spread of infectious diseases. (MPH and Michael, 2021)

Tertiary Prevention:
1. Care and treatment
2. Isolation and quarantine
2 methods for keeping infected person and noninfected persons apart to prevent the spread od a disease
1. isolation 2. quarantine

- Isolation- separation of the infected persons (or animals) from others for the period of communicability to limit the transmission
of the infectious agent to susceptible persons.
- Quarantine- restrictions placed on healthy contacts of an infectious case for the duration of the incubation period to prevent
disease transmission if infection should develop

What is the different between the two methods?

Safe handling and control of infectious :
Control of infectious in community health also relies upon the proper disposal of contaminated wastes.
The CDC supports and encourages universal precautions

universal precautions includes the following:

 Hand washing
 Bagging and discarding articles contaminated with infectious material
 Use of proper personal protective equipment
 Waste capable of producing an infectious diseases requirements for medical waste disposal are for waste to be segregated into
categories of:
1. Used and unused sharp
2. Cultures and stocks of infectious agents
3. Human blood and blood product
4. Human pathologic, isolation, and animal waste.

4 key elements of an infectious waste management program are applicable to community practice:
1. Health professionals must be able to correctly distinguish waste that poses a significant infections hazard from other biomedical
waste that poses no greater risk than general municipal waste and such infectious waste must be clearly defined.
2. the waste management program must have administrative support and authority to institute practice guidelines and provide the
containers and other resources needed for safe disposal of infectious wastes.
3.Handling of the infectious wastes must be minimized.
4.An enforcement or evaluation mechanism must be in place to insure that the goal or reducing the potential for exposure to
infectious waste in the community is met.

A. Control of Communicable Disease

1. Vector borne diseases
Issues & challenges:
- The vector-borne disease included in the list of priority disease in Oman are:
1-leishmaniosis 2- Malaria 3- Acute-hemorrhagic fevers including ( CCHF, WNV,RVF,DF & 171-1F),
-According to Annual Health Report 2020 of Oman, 310 acute Hemorrhagic Fever cases were reported in 2020. also, the cases
were increased in these recent years.)
In 2008 consultancy visit from WHO was conducted to review the leishmaniosis situation
-An independent vertical program for Malaria eradication exists Within the Ministry of Health which has a vector control section.
-The bionomics of vectors other than malaria is currently under study that includes:
1- identification of the species 2- seasonal
3- spatial distribution(density mapping) 4- efficiency for transmission.

Viral Hemorrhagic Fevers:

- No human cases due to West Nile Virus fever (WNV) were reported in Oman.( - Similarly Rift Valley fever (RVF) was also not
reported in humans or animals.
- One indigenous case of Dengue was reported in 2000.
-According to Annual Health Report 2020 of oman,300 cases of Dengue were reported in 2020.
- Travel associated dengue cases continue to be diagnosed among the expatriate population in Oman.

Schistosomiasis Control in Dhofar:

-Science 1979, Dhofar governorate was a low transmission area for intestinal Schistosomiasis.
-Beginning of elimination process of Schistosomiasis in (2003) with objective to strengthen and sustain control of indigenous
transmission of S.mansoni.
-Two outbreaks of Schistosomiasis infection occurred in 1982 and 1999.
- Following the recent outbreak in 1999, the annual surveillance of the Schistosomiasis among school children showed increasing
of stool positive cases in 2000 to 2003 and then dramatically decrease in 2004.
- from 2017-2020, zero cases of Schistosomiasis were reported as annual health report 2020 said.

Brucellosis Control In Dhofar:

-Brucellosis is one of the major zoonotic infectious diseases in the Governorate of Dhofar.
-316 cases were reported in 2000 as against 94 cases in 2008. -
-From 2003 animal population is being immunized by Ministry of Agriculture against brucellosis that might have also contributed
to the reduction of the number of cases.
- as annual health report 2020; the cases were declined in the last five years, 130 cases of Brucellosis were reported in 2020.
What are the reasons of the decline:
- Laboratory diagnostic techniques.
- Expansion of laboratory diagnostic facilities.
-Improved awareness of community against high risk behavior.
What are the Challenges and constraints facing human Brucellosis control:
1- long term commitment(12 years) by the Ministry of Agriculture for animal vaccination program.
2- Maintain high immunization coverage and cold chain.
3- Non-availability of brucellosis program manager.

2. Infection Control Program:

- Standard precautions; encompass all the basic principles of infection control that are mandatory in all health care facilities. Their
application extends to every hospitalized patient, regardless of their diagnosis, risk factors and presumed infectious status, to
reduce the risk to patient and staff of acquiring an infection.
- Hand hygiene is very much at the core of standard precautions and is the most effective infection control measure.
-These precautions essentially to provide a clean environment and promote patient safety at a very basic level.
-Transmission-based Precautions; (airborne, droplet and contact precautions).
-prevention of site-specific or device-related infections, in particular urinary tract infections, surgical site infections, pneumonia
and bloodstream infections

Organizational Structure: Infection control section..........by the epidemiologist.

-A restructuring proposal .......to improve line of authority and communication between infection control team, committee and
other bodies within regional and referral hospitals.
- Policies and guidelines: The gulf cooperation council (GCC) Infection Control Manual (‫ المجلس‬approved by the GCC Health
Ministers is under print by the Executive Board .of the Health Ministers Council of the GCC‫)التنفيذي‬
- Availability and specifications of medical supplies: Adequate specifications of critical supplies related to infection control is to
be developed in with input from clinicians, infection control experts and department of specification and supplies in the medical
store.
- Occupational safety of Health care workers: -to protect health care workers by HBV and influenza vaccine.
- A standardized blood and body fluid exposure reporting system has been proposed to capture the root causes of needle stick
injures and other forms of exposures.
-Ongoing education is to be conducted to the health care workers about standard precautions to prevent occupational hazards.

- Supervision and monitoring system: a preliminary auditing check lists were developed, and regular visits were made to health
care facilities.
- Networking:
-Information is exchanged with GCC countries through the GCC IC (gulf cooperation council Investigating Committee)
committee.
-Links are established with the regional and international organizations working in infection control.
-More efforts and resources needed to be channeled to facilitate infection control professionals attend local, regional and
international meetings/ conferences.

3.STI control Program

background:
-STI is not considered to be a significant problem in Oman. STI published in 1996.
Issues:
-Burden of STI diseases -Surveillance in STI needs to strengthen
-Guidelines -Training
Challenges:
*Private sector involvement *Burden of disease in expatriates
 Seven acute encephalitis syndrome cases were recorded according to annual health report 2020.

4. HIV control program

-In 1984 first HIV case was reported from Oman.
-Major mode of transmission is heterosexual contact. Males are predominantly affected and 15-49 age group patients make +12
major part of the total HIV cases.
- Universal screening for antenatal mothers was started in 2009
-Surveillance
-Mother to child transmission -Treatment monitoring
-Creation of system of treatment monitoring so as program can monitor this aspect and amend strategies for better management
and control of the HIV.
-HIV counselors' needs to be trained or retrained for all aspects related to program.
-147 Omani cases of positive HIV in 2020, as annual health report 2020.
-The cascade of HIV care in Oman, 2015-2018: A population-based study from the Middle East.
-All cases of Omani people living with HIV (>12 years old) who were reported to the NAP from 1984 through December 2018
were included.
-To evaluate the programmatic success in Oman and improvement in care, retention in care, ART coverage and viral suppression
was observed among people living with HIV in 2015-2018.
- Population-based data on all diagnosed people living with HIV reported to the National AIDS .Programmed in 1984–2018 were
used
-Study showed the cascade of HIV care to evaluate the programmatic success in Oman that a significant improvement in linkage
to care and HIV viral suppression among people living with HIV in Oman in 2015-2018. (Elgalib,2020)

B. Control of chronic non-communicable diseases

1. National Cancer Control Program
2. National Tobacco Control Program
3. Mental health & Drug ControlProgram
4. National non- communicable Screening Program

1. National Cancer Control Program

- Introduction:
- Every year, more than a thousand cancer cases are diagnosed in the Sultanate of Oman, which poses a major challenge to the
health and patient care sector.
- According to Al-Bahrani et al., (2019) Cancer may be a critical open wellbeing issue in all nations. The worldwide burden of
cancer is assessed in 2018 to be 18.1 million unused cancer cases. It is fourth cause of patient mortality in Oman. Notably, there
was an increment of 10.2% in the whole frequency cases in 2016 (n=1780) compared to 2015 (n=1,615).

The strategic areas of work of the national control program are:

1-Data collection, analysis and reporting ( Oman National Cancer Registry ).
2-Comprehensive management of cancer cases in the National Oncology center with chemotherapy being made available in
regional oncology satellite unite.
3-The MOH is the central focal point for dissemination of information on cancer, liaising with other institution (MOH and other)
dealing with cancer.
1985-----Establishing the Omani national cancer registry.
1996----- Establishing the department for monitoring and control of non-communicable disease of the general directorate of health
affairs.
2001----- compulsory reporting of the first by decree issued the minister of health. non-communicable disease(cancer)

Issues and challenges:

The annual reports of ONCR :
- shows that incidence of cancer remains more or less the same over the past ten years.
- The challenge every year is to collect the data from all sources.
- Very often physicians do not complete the notification forms.
- Active reporting the major method of data collection.
- Collecting information from all the Ministry of Health hospitals.
- In 2006 we have liaised the major private hospitals in Muscat to collect cancer data.
- Data on mortality is necessary for a cancer registry for which a vital registration
system would be very useful.
- Mortality statistics are an indicator of the duration of survival of pts and the cause of death and will enable the cancer registry to
take part in some international research studies.
- Availability of mortality data will make Omani's data more comprehensive and easily accepted in publication of the International
Agency for Research on Cancer.
- All modalities of treatment for cancer are available in Oman an important component in the care for patient pain and palliative
care.

2.The National Tobacco Control Program

Introduction
 The WHO’s Tobacco Free Initiative (TFI) is conducted from headquarters in Geneva and regional and national offices around
the world.
 The Framework Convention on Tobacco Control (FCTC) was developed after prolonged deliberation by member countries of
WHO, in response to the global tobacco epidemic.
 In March 2005, 59 countries have ratified the FCTC. The Sultanate of Oman has also ratified the FCTC on 9 March 2005.
 The success of the FCTC as a tool for public health will depend on the energy, and poetical commitment that we devote to
implementing it, in countries in the coming year.
Issues and challenges:
- There is an increasing lobbying for the banning of smoking in enclosed public places and various steps have been taken towards
this goal.
- Meetings with key policy makers are being conducted with the aim of drafting a national law for the control of tobacco use in
accordance with the FCTC.
-Theprocessofprintinghealthwarningsintheformofpictureswhichshould occupy at least 50% of the space on the cover of any
cigarette packet is ongoing.
- communicated with the Canadian authorities since they have Tread -y made this practice mandatory. also received 10 pictures
from WHO.

3.Mental health & Drug Control Program

Introduction:
-The Sultanate of Oman has a keen interest in the reflected by the Ministry of Health, using the development of health care, which
is five-year development plans in the development of health services
Mental health hospitals:
 Al-Rahma hospital in 1975 is The first mental health unit.
 IbnSina hospital in 1983; it was the only hospital Specializing in the treatment of
psychological diseases.
 Al-Masra hospital was launched in Muscat Governance to cater the needs and services of mental health in Oman.( lunched in
1/1/2013).
There are 15 psychiatric OPD distributed in different regions & covered the mental health & drug abuse issues.
Issues; challenges:
A-Mental Health:
1-The national mental health policy was formulated in 1992 and it has not been updated.
2-No national mental health law to protect human rights of the patients.
B-Drug abuse:
1- very limited services.
2-Severe shortage of expertise on this field at all levels. 3- lack of integration with AIDS program.
4- lack of integration with primary health services

4.National non-communicable Screening Program.

Introduction:
• The national screening program for non communicable is a pioneer project
• Is intended to provide a screening service for all Omanis aged 40 years and above who have never been previously diagnosed
with diabetes, hypertension or chronic kidney disease
• The program targets five common conditions(DM, HTN, chronic renal impairment, obesity, & hypercholesterolemia)
• This program has ben given a high priority by top-level policy markers at the ministry following an evaluation of the results of
the pilot project that took place between July and December 2006.
The 3 main objective of this program:
1- Early detection of the disease cases & subsequent early intervention aiming at reduction
2- Enhancing community awareness about current health challenge.
3- Promoting and helping people attain health through health education that forms a part of the program.
Issues & challenges:
-Improving the client active participation rates, screening setting (Drugs/ Lab facilities), and health professional adoption &
acceptance.
-Capacity building of the well –being team with regard to risk, pre-disease & chronic disease management.
-There is a shortage of manpower especially nutritionists and qualified health educators.
-Extending the availability of the electronic screening module to all health centers and improving the reporting system.
-Ensuring good compliance from pts with risk factors & pre-disease.
-Equity in the service availability and care delivered to the clients.

C. Malaria Eradication Program

Introduction:
• Malaria was one of the major public health problems in Oman.
• In seventies; The endemicity(‫( توطن‬of the disease reached its peak, when about 300,000 clinical
cases were recorded annually.
• To reduce the incidence of malaria cases (to a level of not a public health problem)..... the government was compelled(forced) to
introduce a malaria control program.
This graphs shows the Number of imported malaria cases in GCC countries. The graphs were made using data adopted from
WHO, World Malaria Reports, 2019 and 2020 and the Malaria Atlas Project 2019
According to annual health report 2020:
There is 79% decrease in the number of malaria cases reported in 2020 when compared to 2019. just 276 confirmed cases of
malaria were recorded in 2020 in oman.
• Due to the emergence of resistance of falciparum malaria ....to chloroquine and the Anophline mosquitoes to insecticide plus
other technical factors.
• the control program did not achieve the goal of stopping malaria from being a public health problem.
• Ministry of Health decided to move from control to eradication.
• the National Malaria Eradication program (NM EP) was launched in Al- Sharquiya (North and South) Governorate ,,,,,,as a pilot
project(experimental project) in 1991,,,,,,,, to: 1.stop local transmission
2.eliminate the reservoir of infection.
• After the successful achievements of the pilot project in reducing the number of malaria cases, it was extended to the other
Governorate in phases, with the following objectives:
1. To interrupt malaria transmission and deplete(minimize) the reservoir of infection to reach to an Annual Parasite Incidence
(API) of 0.1/1000 population by the year 2000.
2. To eliminate residual infections and prevent re-establishment of transmission by the year 2005.
3. Maintenance of the incidence indigenous malaria cases at zero level by the year 2010.
The strategies applied to achieve the objectives of the NMEP were:
• Integrated vector control (chemical larviciding and biological control in addition to imagociding through indoor residual
spraying (IRS). and space spraying,).
• Early case detection and prompt radical treatment of cases (through Surveillance, Active and Passive Case Detection (ACD &
PCD) involving both public and private health sectors and distribution of chemoprophylaxis for travelers to endemic countries).
• The interruption of malaria transmission was achieved in 2004 and maintained till September 2007 when a focus of local
transmission was detected in Dakhiliya Governance (MOH 2013). In 2008, another outbreak of local transmission was reported in
north Batinah Governance which was due to the increase in the number of imported cases.
• In 2013 a total of 1451 malaria cases were recorded, most of these cases were imported except 11 were locally transmitted which
were secondary to an imported case. The majority (94.1%) of the diagnosed cases in 2013 were Plasmodium vivax and 5.9% of
the cases were Plasmodium falciparum.
Issues and challenges:
1. The increase in the development projects lead to the increase in the influx of imported malaria cases through the labor force
from the malaria endemic countries.
2. Illegal migration from some of the source countries.
3. The climate change in the favor of vector breeding and survival.

The role of community health nurse in using the nursing process for communicable disease control
-Assessment is the first step in nursing process.
-Community health nurse must use all assessment skills and tools available during contact with client , so as not to overlook the
possibility of a communicable disease.
-Assessment must be comprehensive , producing physical, social , and environmental data
-The planning step in the nursing process involves different activities , depending on whether the intervention is for an individual,
family, group , or entire community.
-The nurse may assist a client or family to obtain an immunization or definitive treatment.
- The nurse may assist the client through education about self-care related to disease symptoms that provide relief and in reducing
the chance of transmission the disease to other in the family or community.
-The implementation step, the nurse actually takes the action that was identified as necessary during assessment and planning.
-In implementation step, the nurse may actually deliver the service or may supervise other staff or volunteers , as with a large
immunization event.
-Evaluation is an essential step in the nursing process.
-It is the most important to determine whether actions have achieved the established goal.
-EX. Have the outcomes been accomplished?
 CS7: health education in the community
Objectives:
• Define the term health education
• Define the various learning domains
• Explain the community health nurse’s role in teaching at three level.
• Review the back group history of HE department in Oman.
• Explain the responsibility of the HE information department in Oman
• Highlights the main activities achieve by health education department since its establishment.

The HE Defined:
• The education process is a systematic ,sequential ,logical ,scientifically based ,planned course of action consist of two major
interdependent operation :teaching and learning .this process form a continues cycle that also involves two interdependent players
:teacher and the learner .Together ,they jointly perform teaching and learning activities , the outcome of which lead to mutually
desired behavior change.

Domains of learning:
• Cognitive • Affective • Psychomotor.

Cognitive domain:
• Cognitive domain of learning involve the mid and thinking process. When the meaning an relationship of series facts.
• Cognitive domain deals with knowledge recalling and recognition ,development of intellectual abilities and skills.
• There are six major level in cognitive domain (knowledge ,comprehension ,application ,analysis ,synthesis and evaluation .

Knowledge:
• Knowledge is the lowest level of learning according to Blooms’s taxonomy . Involve recall. If students remember
material previously learned they have acquired knowledge .This level can be use with client who unable to understand underlying
reason or rationales such as children or people who have strokes .for example stroke patient need to remember to take medication
daily that regular exercise restores function. Although they may be not grasp the reason behind these measures.

Comprehension:
•The second level of cognitive learning comprehension combine remembering with understanding and example of comprehension
•‘female leady will describe a well-balance diet”

Application:
• In this level the learning should not only describe the and understand material but also be able to apply it to new
situation . For example diabetic client write down glucometer reading and to show the nurse at the next day. A school nurse could
aske adolescent in a weight –loos group t keep a diet record for a week and share it with the group. Construction worker who
understand the hazard has to transfer knowledge and comprehension into practice.

Analysis:
• At this level the learner breakdown the learning material into parts distinguishing between elements and understand the
relationship between elements .This level become preliminary in the solving problem. For example the mother analyze when she
seeks to determine the cause of infant crying .after viewing the total situation she break it down into variables such hunger , pain
she examine these parts and drown conclusion.

Synthesis:
• Synthesis is the combination of all other previous mention level. The learner who achieve the learning not only analyze
their problem but also able to production plan of situation and implement it. For example a young couple who want to toilet
training their 2 year child may learning physical and psychological dimensions of toilet training analyze their situation and then
develop plan for training the child.

Evaluation:
• The high-test level of learning is evaluation .the learning can judges and evaluate the usefulness of masteries learned.
With state purpose of learning ,learning able to judge their won health behavior by comparing with standers such as maintain of
normal weight . Another example client at nutrition class will be able to measure the cholesterol content in one portion of the now
–cholesterol dish .

How to measure cognitive learning:

• Cognitive learning can be measure in term of client behavior. For instance that client have achieve teaching objective for the
application of knowledge if their behavior demonstrate actual use of information taught .

Affective domain:
• Affective domain in which learning occurs involves emotion feeling, behavior or affect. For example nurse want client to
develop ability to accepts ideas that promote health even if those ideas conflict with the client own values.
• Attitude and value are learned .They develop gradually as the way an individual feels and respond is molded by family ,peers
,experience and culture.
• Affective learning occurs in several level .
• At first level the individual are simply receptive learns ,just listen ,show awareness and attentive.
• At the second level learner become active particularly by respond to information in some ways for example willing to read
education material and to participate in discussion .
• At the third level attach value to information .for example a nurse taught members of therapy group several principle to improve
certain skills, members showed acceptance when they acknowledge important of these ideas .They shows appreciation to ideas by
starting to practice them.

Psychomotor domain:
• Psychomotor domain include visible demonstrable performance skills that require some kind of neuromuscular
coordination .for example client in the community need to learning baby bathing.

For psychomotor learning to take place some condition must be met:

• Learner must be capable of the skills.
• Learner must be has a sensory image of how to perform skills
• Learner must be practice the skill.
• The nurse must be certain that the learner is physically ,intellectually and emotionally capable of performing the skills

Community health nurse roles at three level of prevention:

• Teaching at three level of prevention . Please read page 371 at your required text

Health education in community (Oman)

• The department of health education and information was stablished primarily 1975 with only 7 staff , the number of health
educators has now reached to 156 who are distributed in health care facilities in different governances. .
• The department works in collaboration with various heath department ,movement and private sectors in order to deliver health
education service to the public.
Organization structure of department • Page 84 C/S

The objective of the department:

• Raise public awareness in coordination with different health department and sectors
• Plan preventive measures and strategies in order to fight different health problem.
• Educated and encourage individual and communities about taking are of their health
• Eliminate possible health risk to foster positive practice.

The department consists mainly of two sections: Programs Section and Legends Section.
• The program Section is specialized in the following:
1. Planning, following up and evaluating health education activities in the Ministry of Health to follow the health education
activates in all governorates that include (programs, campaigns, exhibitions, during national and international occasions).
2. Develop the skills of the workers in the field of health education
3. Cooperate with different governmental and private sectors in order to set health plans and projects.
4. Follow the progress of the health indicators of the strategic plan.

• The Legends Section is specialized in the production of health education materials through coordination with different health
sectors in the Sultanate and liaises with different media resources available aiming to increase the health awareness among public.

• The responsibilities of Health Education Department

1. Produce of IEC (Information, Education, Communication) materials.
2. Follow up and evaluate health education activities in all the regions in the Sultanate.
3. Broadcast health education programs in mass media. Train health educators.
4.Activate world, international, regional, and national days and occasions related to health issues by implementing different
activities and campaigns.
5. Organize different health exhibitions.

Highlights of the department activities in 2012:

• In 2012 many activities were achieved by different sections. The department organized and participated in five exhibitions for
different purpose including the
department's participation in the "Board of Health Ministers of the Gulf Cooperation Council conference" in its thirty seven
session and the participation in the future vision conference for the health system 2050 "Elegant Care and Sustainable Health".
• In addition, 21 Health Education materials were produced in different health topics, and different health subjects and messages
were broadcast in different TV and video.
• The department also, has achieved some of the objective indicators of the 8thFive Year Health plan such as, production of
educational materials in the
fields of chronic kidney disease and health life style and has developed a training program for health educators.
• In addition, the department organized two workshops during 2012, to enrich the health workers in the field of health education,
and three staff from
Health Education department participated in different meetings, conferences and workshops locally and internationally.
 CS8: FAMILY HEALTH
Objectives:
1. Define the term family and family health nursing.
2. Explain important family characteristics to be recognized by community health nurses.
3. Analyze the role of the community health nurse in caring and promoting the health of the family.

Definition of family:
•Family as a basic unit of society (united nation)
•Views family as“ a householder and one or more other person living in the same household who are related to the household by
birth , marriage , or adoption” (U.S.CensusBureau,2011)
•Define family as “tow or more individuals who depend on one another for emotional , physical, and economical support”
(Kaakinen, 2010)

Definition of family health:

•Define family health as a “dynamic changing relative state of wellbeing which include the biological, psychological, spiritual,
sociological and culture factors of the family system ( Kaakinen, 2010)
•Family health concerned with how well the family function together as a unit.

Family health nursing:

•Nurses can provide care to the individuals within the family or to the family as the client or to the family as a system. Some
nurses view family nursing as part of other specialties such as community health nursing , maternal child nursing or mental health
nursing.
•Nurses work with individuals within families every day. Most often, the individual is the recipient of care. While assessing the
needs of the individual, the nurse needs to include the family in the assessment, as the family is the pivotal provider of care.

Universal characteristics of families:

Five of the most important family characteristics for community health nurses to recognize are as follows:
1-Every family is a small social system. 2- Every family moves through stages in its life cycle.
3-Every family has its own culture values and rules. 4- Every family has structure.
5-Every family has certain basic functions.

1.Families as social system:

• Interdependence among members • Family Boundaries • Energy Exchange
• Adaptive Behavior • Goal-Oriented Behavior

a. Interdependence among members:

All the members of a family are interdependent; each member’s actions affect the other members, and what affects the family
system affects each family member.
Example: A father might consider some changes to reduce his risk of coronary heart disease.
-If he cuts back over time the family income will reduce.
-If he begins to eat different foods, food preparation and patterns of eating will change

b. Family Boundaries:
-Families as systems set and maintain boundaries:
(ego-boundaries, generation boundaries, and familycommunity boundaries) that can include outside influences (permeable) or not
(limiting).
-These boundaries, which result from shared experiences and expectations.
-Also, a greater concentration of energy exists within the family than between the family and its external environment, thereby
creating a family system boundary

c. Energy Exchange:
As open systems, in order to function adequately, families exchange materials or information with their environment. This process
is called energy exchange.

d. Adaptive Behavior:
Families are adaptive, equilibrium-seeking systems. In accordance with their nature, families never stay the same. They shift and
change in response to internal and external forces.

e. Goal-Oriented Behavior
Families as social system are goal directed. Families exist for a purpose to establish and maintain a milieu that promotes the
development of their members. To fulfill this purpose, a family must perform basic functions, such as providing love, security,
identity, a sense of belonging.

2.Family life cycle:

Family growth and develop continuously and adaptive to change(developmental stages).
a. Stages of the family life cycle:
There are two broad stages in the family cycles:
1. Expansion: as new members are added ,roles and relationships increase.
2. Contraction: as family members leave to start lives of their own, age, or die.
- There are phases that are more specific in framework of the expanding-contracting family, such as launching of children and
retirement of parents.

b. Family developmental tasks:

-All families, for instance, must provide for the physical needs of their members at every stage.
-Physical maintenance for example parent’s ability to accept responsibility and procure necessary resources to provide food,
clothing, and shelter.
-Some function requires greater emphasis at certain stages, socialization for example consume much a family time during the
early stages of child Development.
See table 18.1 page 573

3. Family culture
-Family culture is acquired knowledge that family members use to interpret their experiences and generate their behaviors that in
turn influence their actions.
-Three aspects of family culture deserve special consideration:
1. Shared values and their effect on behavior 2. Roles 3. Distribution and use of power

a. Shared values and their effect on behavior:

-Although families share many broad cultural values drawn from the larger society in which they live ,they also develop unique
characteristic. Every family has its own set of values and rules for operation that can be considered as family culture. These
values, often not verbalized, become powerful, determinants of what the family believes, feels, thinks, and does.
-According to Sandip S Jogdand and JD Naik study which is (Study of family factors in association with behavior problems
amongst children of 6-18 years age group) shows that The behavior problems have good prognosis if they are recognized earlier.
Family has great role in prevention of behavior problems in children, so parental counseling may be helpful.(Sandip S Jogdand
and JD Naik,2014)

b. roles:
-Roles the assigned or assumed parts that members play during day-to-day family living .for instance, the father role may be
assigned as an authoritative one that includes establishing rules, judging behavior, and administering punishment for violation of
rules. In another family, the father role maybe defined primarily as that of a breadwinner and supporting the mother’s decisions in
day-to-day childrearing. If there is an absence of a male parent, a grandfather, uncle, friend, or even the mother may take over the
father role.
-Families distribute among their members all the responsibilities and tasks necessary to conduct family living.

C. Distribution and use of power:

Power is the possession of control, authority, or influence over others-assuming patterns in each family. In some families, power
is concentrated primarily in one member, in other families, it is distributed on a more egalitarian basis.

4. Families structures:
For many people in the United States, the term family used to describe a picture of a husband, wife, and children living under one
roof, with the man as breadwinner and the woman as homemaker.
In the past (Traditional) Today(Contemporary)
-this nuclear family was often seen as the norm for everyone family may include: divorced couples.
-Man as breadwinner and the woman as homemaker To see more example refer to book please p.575
-In Mexico, families remain close, are large, and extend into multiple
generation
-In Japan and Germany, the families are small and tend to the needs of their
elders at home.

-Families come in many shapes and sizes.

-McGoldrick, Carter and Garcia-Preto (2011) find changes in family structure related to societal changes such as:
-increased divorce rates
- two-income households
- increase in work time, especially for women.

5. Family functions:
Families in every culture throughout history have engaged in similar functions:
-families have produced children. -physically maintained their members.
-protected their health. -encouraged their education or training.
-given emotional support and acceptance. - provided supportive and nurturing care during illness.
Family function:
Functions Tasks
Providing affection 1.Meeting physical needs (food, shelter, clothing, health care)
2. Provides dependability
Providing security and acceptance 1.Provide need fulfillment
2. Offers a safe retreat
Instilling identity and satisfaction 1. Teaching roles
2. Instilling values and goals
Promoting affiliation 1. To give a sense of belonging
2. Provide a connection to a family
Providing socialization 1. Transmit their culture
2. Learn roles within the family
Establishing controls 1. Maintain order
2. Learn right and wrong
3. Teach division of labor.

SOCIAL CLASS:
-Social class often shapes a family access and choices to work, educational, and health care opportunities (McGoldrick et al.,
2011).
-Their overall health is often determined by their class position “The biggest predictor of one’s health is one’s wealth” (Unnatural
Causes, 2011)
-according to study (Family Influence on Children's Nutrition and Physical Activity Patterns in Oman) , which the researchers find
children's nutrition intake was significantly associated with parental education level, family income, family nutrition and physical
activity patterns .(AlYazeedi,B.berry,D.crandell,J. Walya,M. 2021).

Traditional families:
Type of family Description
Nuclear family -Husband, wife, and children living together in the same household.
-The work distribution between two adult can vary.
Nuclear dyad family Two adults living together who have no children or who have grown children living outside the home.
Single adult family -One adult is living alone by choice or because of separation from husband or children.
-Separation may be the result of divorce, death, or distance from children
Kin-network -Several nuclear families live in the same household or near one another and share goods and services
-They may own and operate a family business, sharing work and child care responsibilities, income and
expenses, and even meals
Blended family -Single parents marry and raise the children.
To read more about that, please refer to book p.576

Analyze the role of the community health nurse in caring and promoting the health of the family
-Implication for community health nurses. Community health nurse can no longer hold to a myth to traditional nuclear family.
They must be prepared to work with all of family and accept them as valid Unless the community health nurse accept the full
array of family lifestyle and address the special need of each family may not able to help the family to meet their needs.
-The structure of an individual family may change several time ,a girl may be born to into nuclear family and then become part of
a single parent when parents divorces ,as she mature she may become a single adult living along and then she may marry and
become mother. Therefore the community nurse must address client need in all life change of individual.

Role of the CHN:

1. She needs to be prepared to take care of not only nuclear family but also the other types of family.
2. Learn to address clients’ needs throughout the life changes, equipping people with the skills needed to deal the inevitability of
changing structures.
-according to Moreira’s study which is (assessment of infrastructure of family health units and equipment used in primary care
action), shows that assessing the quality of infrastructure in family health units and of the equipment used in primary care actions
is one of the important roles of nurse in caring and promoting the health of the family
3. The CHN must consider that variations in structure create variations in family strengths and needs.
 C9: Home visit
Objectives:
• Describe the components of the nursing process as they apply to enhance family health.
• Identify the steps in a successful family health intervention
• Identify five family health practice guideline
• Describe and demonstrate home visit technique and bag technique.

Nursing process components applied to families as client:

Working with families where they live:
• Depending on the setting for community health nursing practice ,the nurse encounters most client at their home and neighbors.
• Regardless of the families location ,the client is the family ,the family is the unit of service in family nursing.

The home visit:

• Working in the community and being able to visit families in their home is a privilege. In this unique setting you are permitted
into the most intimate of space we as human being have.
• Our homes are our creation ,our private space ,they hold our personal treasures takes a certain amount of trust to enter a client
home also takes trust on the part of nurse.
• Therefore confidentiality and respect are highly necessary

Nursing skills used during home visit:

• May skills in addition to expert nursing skills are needed when assessing ,planning ,implementation and evaluation .
Special skills are required when making home visit:
1. Acute observation skills
2. Assessment of home environment condition
3. Assessment of body language and other nonverbal communication .

steps in a successful family health intervention (component of the family visit)

• Pre-visit preparation .( assessment and planning)
Community health nurse designs a plan for the initial family health visit based on a referral coming into the agency. Referral is a
request for service from another agency or person.
Referral may be formal made from complementary agency or informal result from verbal or telephone referring from friends or
relative who believe somebody needs help.
Making the visit (implementation ) • Read page 589

Concluding and documenting the visit (Evaluation)

• In here you are terminating the visit and retrieving items needed for next visit.
• The documentation of each home visit is completed as soon as possible the nurse return to the agency. Some agency provide the
nurse with laptop ,computer and electronic charting forms.
• Sometime it is allow for the nurses to chart at their home.
• Most the agency expected for charting to be complete by the end of each working day or not later that the end of the work week.

Focus of family health visit:

Family health visit are deigned to educational ,to provide anticipatory guidelines and to focus on health promotion and prevention.
• Family education and anticipatory guidance. • Family promotion and illness prevention .

Family education and anticipatory guidance.

• Official agencies such as country or city health department ,distribute their service based on the broader population according to
their need.
• Eg. In community with large population of teen pregnancies and high-risk infants, the health department will contact the hospital
and agencies to provide clinic and or home visit to all teens and women.
• on this visit the nurse teaches prenatal and newborn care and provides anticipatory guideline (information needed in the future
for infant care)

Family promotion and illness prevention:

• Can be done through immunization and teaching people how to prevent illness and how to remain health is basic to community
health.
• In addition health promotion may include screening program ,nutritional ,safety

Personal safety on home visit:

• Personal safety while traveling and in the neighborhood. • Arriving at the home.
• Friction between family members • Family members under the influence
• The presence of strangers.

Guidelines for making home visit:

• Assessment • Planning • Implementation • Evaluation
Refer to page 588 display 19.1 (important)
Family health practice guidelines:
Work with the family collectively.
• As much as possible community health nurses want to involve all the family’s members during nurse-client interaction.
• This approach reinforce the important of each individual members contribution to total family functioning.
• Nurse want to encourage everyone participation in the work that the nurse and the family jointly agree to do.

Start where the family is:

• the community health nurses begin at the present not the ideal level of functioning
• Conduct a family assessment to ascertain the members needs and level of health and then determine collective interest ,concerns
and priority .

Adapt nursing intervention to the family’s stage of development:

• .Awareness of the family’s development stage enable the nurse to assess the appropriate of the family’s level of function and to
tailor intervention according.

Recognize the validity of family structure variations:

• There are two important principles to remembers .
• first what is normal for one family is not necessary normal for another. Each family is unique in its combination of structure
,composition ,roles and behavior .as long as family carries out its function effectively and demonstrate the characteristics of a
healthy family one
• Second families are constantly changing. (marriage)

Empowering families.
• Throughout the family visit ,you must remember that the ultimate goal is to assist ,the family in becoming independent of your
services. Many families have strengths that some middle-class nurses may overlook or interpret as weakness .it is nurse job to
recognize the strengths in families and help the family to recognize
 CS9: Home visit
Components of Nursing process:
-Assessing, planning, implementing, and evaluating nursing care are steps used to deliver care to clients in acute care settings and
in the extensive clinic system.
-Same steps are used in the community health settings.
-Steps don’t change but the context and client focus are different along with the consideration of external variables.

Working with families in CH settings:

1. Family visits need not be limited to homes. Family members may be visited in school or at work during a lunch break, in a day
care or senior center in a group home or myriad after work or after school and recreational settings.
2. Nurse must be creative in accommodating various family schedules and routines.
3. Families appreciate the individualized effort and respond more positively when nurses are willing to work with family member
schedules.
4. Family respond more positively and cooperative when nurses are willing to work with family member schedules.
5. When we visits in the public places (School and work) we need to be careful of confidentiality and respect the family’s wishes.
6. In day care or In adult day care program, assessment of the individual’s ability to manage, participate and interact in the
situation can give insight into problems the family is referring to when you make a home visit.
7. Visiting schools gives insight into health problems are good for nurses as well as parents. This is an excellent opportunity to
consult with the principal, teachers, school nurse, counselor and school psychologist.
8. She can act a s liaison and client advocate between parents and school professional.

Working with families where they live:

-Depending on the setting for CHN practice, the nurse encounters most clients in their homes and neighborhoods.
-Families migrate some are living on the streets, in homeless shelters or with relatives or friends.
-Irrespective of the family’s location, the client is the family: the family is the unit of service in family nursing.
1. Home Visit – is a privilege
2. Nursing skills used during home visits – (Nursing Process, Interview, Communication)
A. Acute observation skills- (Environment, Neighborhood, travel safety, Home conditions, Number of households, Client
demeanor, Body language, and Nonverbal cues)
B. Assessment of home environmental conditions – (Resources and barriers encountered by family like neglectful landowner,
narrow pathway, living room condition)
C. Assessment of body language and other nonverbal cues – (Greeting on the doorway is already a gathering data, If members are
absent inquire about them)

Steps in successful family health intervention:

1.The greatest barrier to a successful family health visit is lack of planning and preparation.
2.A visit is not successful just because the nurse enters a home or other setting where clients are present
3.A successful family health visit takes much planning and preparation and requires accurate documentation and follow up.
4.Safety measures must be followed not only while traveling in the neighborhood, but also in the home.

Components of the Family health visit:

It is divided into 4 components
1. Previsit preparation : ( Assessment & Planning)
2. Making the visit: (Implementation)
3. Concluding and Documenting the visit: ( Evaluation)

1. Previsit Preparation Referral : Formal and informal

Nurses should have physical place to work with access to telephone, other supportive materials, Health education materials,
Resource directory
CHN bag with necessary supplies
2. Making the Visit (See page 589 for following guidelines for initial contact)
3. Concluding and Documenting the visit
After planning for the next visit, saying goodbye to the family members terminates the home visit.
This is a good time to put away the paperwork, materials, and supplies from this visit and retrieve items needed for the next visit
on your schedule.
Documentation of each home visit is completed as soon as the nurse returns to center.
Laptop computers and electronic charting forms, and charting is encouraged at the end of visit before leaving for the next one.

Focus of Family health visits:

-Family education and anticipatory guidance.
-Family promotion and illness prevention Personal Safety on the Home Visit
-Personal Safety while travelling and in the neighborhood
-Arriving at the home
-Friction between family members
-Family members under the influence of drug and alcohol
-The presence of strangers
Family health practice guidelines:
Family nursing is a kind of nursing practice in which the family is the unit of service.
Five Family Health Practice Guidelines (For Detailed Discussion, See Page 597-601)
1. Work with the family collectively
2. Start where the family is
3. Adapt nursing interventions to family stage of development
4. Recognize the validity of family structural variations
5. Empowering families

Home Visiting Technique Aims:

• To provide family health services to prevent diseases, promote and to maintain health of the family members.
• To carry out simple nursing care at home for the needy clients.
• To provide treatment for minor ailments.
• To rehabilitate the sick and the disabled members of the family.
• To help the family to help themselves to maintain their health.

Home Visiting Technique Principles:

1. Should be made according to the needs of the family.
2. Be sensitive to the member’s feelings and needs at the time of visiting.
3. Accept useful suggestions made by the family members.
4. Be scientific when discussing the subjects.
5. Use safe technical skills and nursing procedures.
6. Have a full understanding of the agency’s policies.
7. Be aware of the community resources and use them wisely.
8. Collect information about the client, home and the environment and make objective analysis.
9. Include the client and family in planning.
10. Be kind and courteous and show concern for the family with a view to gain their confidence.

Equipment And Logistics

1. Prepare and keep ready all the needed equipment for home visit- Home visit kit or bag.
2. Keep ready all the documents and records needed for home visit and for family assessment.
3. Obtain transport if needed.
4. Make a survey and prepare a map of the area with details of topography, location of villages, population, roads, house
members, different land marks, etc.

Home Visiting Procedure:

A. Preparation: 1. Identify the purpose of the visit. And make a work plan for the visit.
2. Get the family folder and records.
3. Collect all the equipment for family assessment and home visiting.
4. Consult the map to identify the area and the family.
B. During the visit: 5. Greet the client and family members courteously and state the purpose of the visit.
6. Conduct the visit and perform the services according to the purpose and plan.(If there is risk
case/priority case discuss situation with mother taking care not to offend her or appear critical)

C. Family Assessment:
D. Plan and implement the care:
E. Home Environment:
F. Health Education:
G. Follow-up:
H. Evaluation:
I. Documentation:
7. Obtain information(talk should be informal) about the health services received from the
health center/hospital. (Eg. Immunization, Antenatal, postnatal and child care)
8. Examine and screen every member of the family, especially the under 5 children weaned
and sick.
9. Plan with the family.
10. Provide treatment for minor ailments.
11. Make referrals when necessary.
12. Observe environmental conditions – sanitation.
13. Discuss with the family members.
14.Provide suggestions to correct the conditions.
15.Based on the needs of the family.
16. Follow the principles of teaching- learning.
17. Provide follow up services to evaluate the effects of instructions given or previous
teachings.
18. To reinforce the most important actions.
• What is achieved from the goal?
• How far the visit was useful?
• What were the difficulties?
• What more needs to be done?
• Record all the information in the family folder: Assessment data, Needs and problems
identified, and Plan of action.
Nursing Bag & Bag Technique
Purposes:
1. To have clean and readily accessible equipment to provide client care.
2. To enhance the nurse to provide client care at home.

The bag:
1. Must be made of leather or some light material.
2. Must be carried by hand or on the shoulder.
3. Must have outside pockets for keeping a note book, tape measure, news paper or plastic sheet, towel/ tissues, soap in a dish and
a nail brush.

Equipment
1.Hand washing articles:
- Soap with dish, nail brush and towel.
2. Articles for recording vital signs:
- thermometer (rectal and Oral) stethoscope, BP apparatus.
3. Equipment for first aid and dressings:
- Artery forceps, dressing forceps, bowl, kidney basin, sterile dressing pack, scissors, slings, band aids and adhesive tape.
4. Spring balance/ baby weighing scale.
5. Glucometer, strips for urinalysis, tongue depressor, flash light.
6. Syringes, cotton swabs.
7. Fetoscope/fetal heart monitor.
8. Prescribed medications/solutions, spirit, paraffin oil, eye and ear drops, antiseptic solutions.
9.Water proof bags for receiving used equipment, paper bag to received soiled swabs.

Bag technique:
-Keep the bag as clean as possible as this is the same bag used to several homes.
-Spread the newspaper or plastic sheet on a flat surface in a clean area and place the bag on it.
-Wash hands with soap and water.
-Open the external flap of the bag with out touching the outer side.
-Remove only what is needed.
-Carry out the nursing procedure.
-Wash and boil all the instruments after finishing the procedure; wash hands, open the bag and replace them. When this is not
possible, place them in a separate bag.
-Dispose the soiled dressing.
-Wash hands after procedure.
-Upon completion of home visit after taking the bag, fold the newspaper/plastic sheet with the used part inside and keep it in the
outside pocket.
-Care of the equipment.

Why regular care of equipment is necessary?

1.To prevent any possible cross-infection by carrying contaminated articles from house to house.
2.To preserve the equipment(s) for use as long as possible.
3.To keep the contents of the bag clean and in good condition but not necessarily sterile.
- On return to health center the nurse clean and sterilize all equipment, reset the bag and replace it and keep it ready for the next
use.
 CS10: Home Health/ Hospice & Palliative Care

Overview of home health care:

* Due to drastic changes in financing and more people living with complex illness have contributed to the need for health care at
home.
- Early hospital discharges
- Growing population survives & yet suffers from complex illness.
- Advanced technologies that are available for home care - Aging population

Obj1: Summarize the historical evolution of home health and hospice care:
*Throughout human history, health care has been provided at home by family members
*In USA, the Ladies Benevolent Society in Charleston, South Carolina, made the earliest known 1813 organized effort to care for
the sick poor at home.
*In 19th century it became possible for women to become nurses trained in the manner of Florence Nightingale.
* In 1893, Lillian Wald began home visiting in New York City
*One of Wald’s famous innovations was the establishment of insurance coverage for home care.
*Between 1909 and 1952, 100 million home visits were made to the policy holders of Metropolitan Life Insurance Company
*In the later half of the 20th century, as hospitals became increasingly effective in providing acute more people survived to live
with debilitating chronic illness and disability and referral to home care was used to discharge those non acute patients from the
hospital .
*The Medicare home health benefit was established with certain goals in mind.
*It was designed to provide intermittent home visits in which nurses and therapists would instruct clients and families in self care .
*Home health nursing was clearly differentiated from longer nursing shifts in which nurses stayed in the home for several hours at
a time .
*The period of visiting was to be brief and provide direct personal care just temporality until patients and families could care for
themselves.
* Families were expected to manage long term care alone.
* Nurses had previously controlled their own practice, services under the new benefit were viewed as extensions of medical care
with physicians certifying needed services for short –term treatment of sickness
*The number of Medicare –certified home care agencies grew rapidly until enactment of the Balanced Budget Act of 1997
*Payment to providers was changed from reimbursement for each visit to the Medicare prospective payment system
*Medicare payment rates based on patient characteristics and need for services .
*The BBA resulted in a closure of 30% to 36% of the nation’s Medicare –certified home health agencies and a dramatic decline in
the number of patients served with particular impact on the most vulnerable patients over 85 years old who needed intensive
services
*The shift in service provision also impacted home health nurses, who are most satisfied when they have control over their
practice and able to provide quality patient care
For more information please refer to the text book page 1043

Evolution of hospice care:

* In medieval Europe, hospices were refuges for the sick and dying.
* The contemporary hospice movement originated in England, where Dame Cicely Saunders founded St. Christopher's Hospice in
1967.
* Dr. Saunders was credentialed as a nurse, social worker and physician.
* She developed a unique program based on compassion and skillful relief of physical discomfort through around the clock
analgesics administered by mouth
*The first hospice in the US was established in 1974 in Branford, Connecticut, by Florence Wald, Dean of the Yale School of
Nursing.
*Hospices in the United States came to focus on providing care in the home.
*To that end Congress established the Medicare hospice benefit in 1982 with the intention of keeping people at home, yet
receiving comprehensive services that are less expensive than hospitalization.
*Hospice characteristics have changed over time
*Initially, nearly all clients suffered from terminal cancer but presently, people with a variety of end –stage diseases are admitted.
*Move from charity to business in hospice with highly reliable Medicare payment – “ market share”.

Obj2: Home Health nursing practice

* The practice of home health nursing has roots in community /public health nursing.
* The nurse provides home health nursing care to acute, chronic and terminally ill clients of all ages in their homes.
- The home health nursing care integrating public health nursing principles that focus on:
1. Environmental 2. Psychosocial 3. Economic 4. Cultural
5. Personal health factors affecting a client’s and family’s health status and well being

Definition of Home Health and Home Healthcare Nurse:

Home health - is a unique field of nursing practice that requires a synthesis of public health nursing principles with the theory and
practice of medical/surgical, geriatric, mental health and other nursing specialties.
Home Healthcare Nurse – is the primary source of up-to-date nursing knowledge in this rapidly changing field of practice.
The effective home health nurse must:
1. Determine how to keep unstable client safe until the next visit
2. Thoughtfully maintain boundaries between personal and professional life
3. “Make do” with limited supplies
4. Face immense challenges with time management and paperwork demands
5. Constantly think of personal safety in neighborhoods and homes
6. Deliberately build trust
7. Sense “where people are” and suspend judgment
8. Develop a connection at the first visit
9. Develop “giant antennae to detect cues in the home
10. Face persistent distractions during home visits
11. Help people solve their own problems
12. Keep priorities fluid

Practice Competencies Of Home Health Nurses:

A. Locating the Client and Getting Through the Door
- Use map, get transport, careful with vague directions, will encounter clients with unstable family, face a challenging family
situations.
- Always remember you are a guest in the home. Respect and attentive listening are foundations. Agendas must be laid aside
initially as nurse focuses on concerns and realities of client and family.
- Nursing approaches that build the initial therapeutic nurse–client connection include:
1. Helping with immediate problems that the family identifies.
2. Start where they want in ways that make sense to them.
3. Emphasize positives to the extent possible, rather than telling people what they are doing wrong and need to change.
4. Autonomy should be respected, and the family should be empowered by actions recognizing that they are in charge of their
lives.
5. Nurse must be up front and truthful regarding the medical and nursing problems that need resolution.

B. Hub of the Family Caregiving Wheel: Promoting Self- Management

- Promote independence rather than dependence
- Lasting health improvement is possible when nurse works with client/family to make
decisions truly their own
- Financial incentives minimize nurse’s visits and duration of service, pressuring a client/family adopt agency agenda, denies any
sense of partnership and can backfire, resulting in non-adherence to the therapeutic regimen. This can place a nurse in a no-win
situation.
- Effort is made to develop capacity for self-care, so that the home team can safely withdraw.

C. Rim of the Home Health Caregiving Wheel: Detecting

- is an all-encompassing, never-ending assessment process as the nurse seeks to understand the client’s health in the context of
home.
- Much to investigate and many distractions to ignore.
- The nurse keeps her ears and eyes “wide open.”
- The home environment surrounds the nurse with sounds, sights, and scents that need to be comprehended in light of the client’s
needs.
- Investigate number of people, caregivers, care, culture and religion, environment safety and security...
The practice competencies of home health nurses can be illustrated with the Home Health Nursing Caregiving Wheel. Figure 32-1

D. Spokes of the Home Health Caregiving Wheel: Collaborating, Mobilizing, Strengthening, Teaching, Solving Problems
- Promotion of self-care and family care include collaborating with multiple team members and mobilizing resources in the
community that can sustain the client after discharge. The nurse is the coordinator of all other home health team members working
with social worker, and proposes needed connections with community services.
- The home health nurse is constantly teaching clients and/or family caregivers through concrete explanation, discussion, and
modeling behavior. Though teaching is no assurance of behavior change and improved management of a health problem.
- Finally, home health nursing competency requires flexibility and creativity in solving health care problems and the challenges of
everyday living. All outcomes of care can be achieved only by adapting to the skills and resources available in the home.

Obj.4 Family Caregiver Burdens Of Providing Home Care

- Caregivers assume a considerable physical, psychological and economic burden in the care of their loved one at home.
- Caregiver tasks compete for time, energy and attention.
- Caregivers often describe themselves as emotionally and physically drained and may very much need information about
resources to assist them.
- Economic cost of providing home care places a significant burden on informal caregivers.
- Out-of-pocket expenditures include medications, transportation, home medical equipment, supplies, and respite services.
- These costs may be non-reimbursable and are often invisible, but they are very real to families struggling to provide care on a
fixed income.
 Obj.5 Differences Between Home Health & Hospice
Home Health
Emphasis is on rehabilitation and physiological stabilization
Focus is on health of client
Plan of care is determined by medical need
Nurse is a case manager until home health discharge
Priority is given to correct physiologic imbalances
Intermittent visits decrease in frequency as client stabilizes
Symptom control is domain of physician with some nurses
having expertise
Sedatives and opioids are used hesitantly to reduce suffering
End of life problems tend to be seen as medical crises
Client is brought to hospital for unmanaged symptoms
Spiritual needs are met by own clergy
No bereavement support is provided
Hospice
Emphasis is quality of life and comfort
Focus is on health of whole family
Plan of care is guided by client choice
Nurse is a case manager until death
Client chooses how to live his last days
Intermittent visits increase in frequency as death become
imminent
Nurses are expert in symptom control
Sedatives and opioids are expertly adjusted to eliminate
suffering
End of life disease course is managed to avoid crises
Symptoms to be managed at home if possible at end of life
Spiritual care is focus of whole team
Survivors have bereavement support

Obj.6 Hospice Nursing Practice:

-The hospice nurse’s role is central in the hospice interdisciplinary team, functions as case manager, visits the client more
frequently, work in close collaboration with physicians to assure management of symptoms often change rapidly as the end of life
nears.
-Hospice nurses rotate through 24 hour call 7 days a week to assure continuous availability by telephone and visits for emergent
problems reported by client or family.
- ANA in collaboration with other groups has published standards of practice for hospice and palliative nursing (2007) and pain
management (2005)
- Through the ANCC (American Nurses Credentialing Center 2012) hospice nurses can receive board certification in pain
management.
-There is no current certification for hospice or home health nursing . -The practice standards and certification process provide
guidance in this
specialized field of nursing .
-Hospice caregiving can be illustrated as a tree, strongly rooted in the process of nurses deliberately practicing self-care for
themselves.
1. Roots of Hospice Nursing: Sustaining Oneself
2. The Trunk Reaching Upward: Connecting, Speaking Truth, and Encouraging Choice
3. Collaborating
4. Strengthening the Family
5. Comforting
6. Spiritual Practice and Letting Go

1. Roots of Hospice Nursing: Sustaining Oneself

• Effective hospice nurses understand that to care for others, they must care for themselves. Without strong healthy roots, the tree
will not thrive.
• Sustaining oneself requires deliberate effort to maintain one’s own physical, emotional, and spiritual well-being.
• Knowing oneself, identifying sources of stress, and learning how to care for oneself are important.
• Expert hospice nurses keep themselves healthy by maintaining a balance between giving and receiving, letting go of
predetermined agendas and idealistic hopes to achieve more than is humanly possible, being emotionally open and clear, and
deliberately replenishing themselves to restore their energy

2. The Trunk Reaching Upward: Connecting, Speaking Truth, and Encouraging Choice
• Rooted in self-care, hospice nurses practice connecting, which refers to the centrality of relationships in providing hospice care.
The hospice nurse seeks to understand the emotional and spiritual distress common to the end of life, particularly the progressive
experience of loss after loss.
• Guided by that understanding, hospice nurses emphasize attentive listening to understand each individual’s unique story.
Quieting your own thoughts to truly hear what is being expressed. Sometimes listening involves simply being present in the
moment, paying attention.
• It is important for hospice nurses to speak honestly when other professionals and family feel obliged to keep being cheerful and
positive. Hospice nurses openly seek to speak truthfully about many issues that can be painful to discuss. Speaking truth is
visualized as encircling the entire top of the caregiving tree. Hospice nurses bring up difficult subjects, so that the client is freed to
speak about his greatest fears and concerns.
• Sometimes it leads to joint problem solving and encouraging choice through informed decision-making. After truth has been
discussed and the client has made a decision, the hospice nurse often advocates for client wishes against the resistance of various
authorities. Remember that these are the final decisions in a dying person’s life.
 3. Collaborating
• Interdisciplinary teamwork is an essential branch on the tree. Hospice team members communicate and are constantly consulting
each other, share information and work interdependently, coordinates the plan of care and day-to-day efforts to provide physical
and psychosocial comfort.
• Hospice nurse supervises practical nurses and nursing assistants. The physician is responsible for medical care and serves as
liaison with the client’s primary care physicians.
• Social workers, spiritual counselors, and volunteers are integral members of the hospice team. The hospice interdisciplinary
team is constantly challenged to work creatively together to find solutions for complex end of-life suffering with emotional,
spiritual, and physical components.

4. Strengthening the Family

• The death of a family member causes great disruption for all involved. When family members are in a caregiving role in the
home, they experience significant personal suffering. They are vulnerable to physical and emotional illness themselves.
• The process of taking care involves managing the illness and all practical assistance, seeking information and resources, and
preparing for death itself. Family members often are caught up with family issues and struggles with the health care system.
• An extremely important hospice nursing role involves strengthening family members’ abilities as caregivers. Teaching
caregiving requires creative teaching methods and flexibility.
• Often the hospice nurse is able to help family members communicate with each other, gather them together, and act as an
intermediary if necessary.

5. Comforting
• Hospice nurses develop extensive expertise in pain and symptom management.
• Contemporary medical/ surgical nursing textbooks discuss the essentials in this field, and advanced knowledge is developed
through experience, continued education, and reading.

6. Spiritual Practice and Letting Go

• As death draws near, spiritual needs intensify, with the final search for meaning, reconciliation, hope, and transcendence beyond
the limits of human lived experience.
• Hospice nurses recognize spiritual distress and practice spiritual caring interventions that include respect for beliefs and spiritual
practices and fostering reconciliation if there is a problem with estrangement from family, friends, and faith tradition.
• They deliberately try to keep their minds uncluttered by distracting preoccupations, so that they can listen attentively and
promote life review. Cassidy (1998) states that spiritual care at the end of life involves being a companion on the dying person’s
journey, even when we would rather escape walking with them along the frightening path through darkness.
• Guiding letting go is a truly unique nursing practice that involves helping the client to let go of former activities and hopes,
including life itself. This involves listening to intense emotions and helping the person and family find resolution. Sometimes it
involves participating in a vigil at the bedside of the dying person and encouraging loved ones to say their final words of farewell.

Obj.7 Ethical Challenges In Hospice Nursing

• The hospice nurse confronts striking ethical challenges at the end of life.
• To nurse at the end of life, you need to become conscious of how value - aden the choice of medical and nursing interventions
can be.
• Naming and clarifying ethical issues is a prominent nursing role.
• We must strengthen our voice and ask, Is what we are doing good for this person and family?
• Wide ranging issues include respect or disregard for client autonomy, relief or disregard for client suffering and avoidance of
killing at the very end of life.
• The hospice nurse needs to develop their own knowledge of nursing and medical ethics in order to question the ethical
implication of interventions and to advocate for client and family.
 C11: School Health
History of School Nursing:
• Beginning in the mid-1800 and continuing through the early years of the 20th century, mandatory education was instituted in the
US
• The early years included health services often conducted by medical inspectors (physicians)
• In New York City, where communicable disease was rampant, inspectors sent notes home with children with the message “you are
sick-go home” and citing the reason for their exclusion from the school
• Parents did not receive these notes or could not read them and because families lacked resources, most children were left untreated
and simply remained out of schools as truants
• No efforts were made by medical inspectors to follow up on excluded children
• As these excluded children played with healthy children after school hours, the levels of contagious illness actually worsened
• As noted in Woodfill and Beyrer’s classic text (1991), the absentee children promoted the spread of various communicable diseases
• In 1902, the New York Board of Education contracted with Lillian Wald’s Henry Street Settlement to provide a PHN to work with
the families and schools to facilitate the return of healthy children to school
• Lina Rogers made home visits to follow up on excluded children and was assisted by other Henry Street nurses in providing care,
educating families about diseases and the need for hygiene
• In the first month of the school nurse experiment, 98% of children previously excluded from school for medical reasons were
treated and readmitted
• The board hired 12 more school nurses, and over the next few years other cities and states began hiring nurses to work in the
schools
• School health nurses have historically advocated for hot lunches, breakfast programs and the need for increased health education in
schools and for families
• School nurses continue as a specialty branch of professional nursing that serves the school-age population
• More than 73,000 school nurses are estimated to be working in schools today
• According to the most recent (2006) School Health Polices and Program Study (SHPPS), many school nurses oversee multiple
schools and less than half of the schools had the nationally recommended ratio of one school nurse for every 750 students
• Most schools (86.3%) had at least a part-time nurse • Although some schools still report not having any
school nursing services
• School nurses deliver services to students from birth through age 21 years
• They also work with students’, families and the school community in regular and special education schools as well as other
educational settings e.g. preschools, court and other community schools
• The role of the school nurse has expanded over the years, along with the increase in chronic conditions and challenges in accessing
health care.
• Federal law requires school systems to provide care for children with disabilities
• The Individuals with Disabilities Education Act, the Rehabilitation Act of 1973 and Title 11 of the Americans with Disabilities Act
all mandate equal educational opportunities for all students including children with complex medical conditions
• Lack of access to health care has added extra burdens on schools as children come to schools sick or miss additional days of school
resulting from complications of illnesses that could have been easily treated in earlier stages
• In 2010, almost 6 million children in the US (8%) did not have health insurance
• Many children can access health care services only at school
• National health survey indicate indicate that 5% of children missed 11 days of school or more in the past year because of illness
• School nurses are also involved in emergency preparedness and disaster planning

Key Roles of the School Nurse:

Liaison with the Interdisciplinary School Health Team
• The nurse collaborates with counseling and psychological services as well as physical education and nutrition services working to
provide a healthy school environment with family and community involvement
• Although the school nurse plays a central role, collaboration with many other individuals is important

The components of school health program:

1. School health services (preventive services, referral)
2. Health education for students
3. Health promotion for faculty and staff
4. Counseling, psychological and social services
5. School nutrition services
6. Physical education programs
7. Health school environment
8. Family and community involvement (partnership among school, families, community groups)

Key Roles of the School Nurse:

Positive Working Relationship with Administrators and Teachers
• The school principal influences all phases of the school health program by promoting good school health through active support of
the school’s health services , participation in setting health related policies and tapping into community resources
• The principal can reinforce positive efforts within the school ranging from the health teaching in the classroom to the cleaning
activities of the custodian
• The school nurse and teachers must collaborate constantly as the school nurse provides information and guidance to teachers
regarding students in their classrooms with specific health conditions and concerns and teachers report on students’ health concerns
and behaviors
• For more information refer to text book page number 993-994

Responsibilities of the School Nurse:

• The primary responsibilities of the school nurse are to prevent illness and to promote and maintain the health of the school
community
• The school nurse serves not only individuals, families and groups within the context of school health but also the school as an
organization and its membership (students and staff) as aggregates
• The school nurse identifies health related barriers to learning, serves as a health advocate for children and families and promotes
health while preventing illness and disability
• School care activities include care of children with special health needs, including nasogastric tube feedings , catheterization,
insulin pumps and suctioning
• General and emergency first aid, vision, hearing, scoliosis and TB screening
• Height, weight and BP monitoring
• Oral health and dental education
• Immunization assessment and monitoring
• Medication administration and assessment of acute health problems and health examination
• Training school staff in CPR, universal precautions and first aid as well as overseeing the health and wellness of school staff
members
• Each school nurse must assess and prioritize how to address the specific needs in each individual school and determine the order
• This largely autonomous practice requires specific skills and training

Three Main Functions of School Nursing Practice:

1. Health Services 2. Health education 3. Promotion of a healthy school environment

1. Health Services
Health services include caring for individual students who have chronic conditions or acute situations. The school nurse observes an
increase in the number of students diagnosed with asthma and investigates ways to help all students with asthma.
Chronic conditions:
• Sinusitis • Tonsillitis • Diabetes • Hearing difficulties
• Dermatitis • Asthma • Seizure disorders • Hay fever
Acute conditions:
• Stomachaches • Headaches • Flu • Colds

A. Health Services for Chronic Conditions: Page 996-999

• Asthma • Diabetes • Seizure disorders • Food allergies
• Behavioral problems and learning disabilities • Medication administration
B. Health Services to Prevent Illness and Injury
• Immunization • Safety

Asthma :
- is the most common chronic disease of childhood.
-School nurses work with students, their families, and their doctors to develop an asthma action plan to control, prevent, or minimize
untoward effects of acute asthma episodes.
- Nurses acting as case managers have been found to decrease the number of ER visits and hospitalizations of school-age children
with asthma.
- Monitoring asthma medications and teaching proper methods of inhaler use are also vital school nursing functions.
- Students with asthma do not miss more days of school, if there is a nurse available to assist with management.

Diabetes:
- is another common chronic illness in young people: approximately under age 20 have diabetes.
- Working with families and health care providers, school nurses assess and develop a care plan for students with diabetes. Maintain
confidentiality and at the same time ensure that the school is a safe environment for the child.
- Both type 1 and type 2 diabetes mellitus are found in school-age children.
- Training for teachers and fellow classmates is also important. Teachers are often called upon to assist students with their insulin
pumps or food management. If the child has an insulin reaction, fellow students should be taught to quickly get the teacher.
- However, many school nurses do not feel comfortable delegating tasks such as administration of insulin or glucagon.
- Testing blood sugar and taking insulin at school can be frustrating and can cause children to feel singled out or different from their
peers, develops depression than those without diabetes
- It is important for school nurses to understand each child’s concerns and to alert teachers and school personnel to the signs and
symptoms (as well as the treatment) of hypoglycemia.
 Seizure disorders :
- Epilepsy is a disorder of the brain in which neurons sometimes give abnormal signals. A person who suffers from epilepsy may
have comorbidities including autism, depression, and anxiety. seizures can usually be controlled with medication (e.g., antiepileptic
drugs specific to the pediatric population), surgical treatment, or a diet rich in proteins and fats and low in carbohydrates (a ketogenic
diet).
-It is important for school nurses to develop care plans to address seizure concerns during school hours. Care plans include
monitoring medication compliance and teaching school staff about first aid measures for seizure victims.
- Children and adolescents with seizure disorders may feel embarrassed or be the victims of teasing or bullying. They may exhibit
signs of school avoidance.
- Nurses need to work with these children and to teach all students about the disease process and the need for empathy and
understanding.

Food allergies :
- Another leading chronic condition found in school settings is severe food allergies that can lead to anaphylactic shock.
-Eight common foods account for 90% of severe food allergies. They are fish, shellfish, soy, milk, egg, wheat, peanuts, and tree nuts
(e.g., cashews, walnuts).
-Many common foods and school supplies (e.g., play dough) can contain hidden allergens, and care must be taken to prevent
exposure.
- School nurses coordinate and work with students and their families, along with school personnel, to raise awareness and enlist
caution. They also work with families and health care providers to ensure that epinephrine via an autoinjector (EpiPen) is available
for the child in case of emergencies. Epinephrine reverses the body’s allergic reaction to the allergen
- School nurses coordinate and ensure that proper protocol is followed.
- School nurses also work with teachers and lunch room personnel to alert them of the allergy, explain what can happen in a case of
anaphylaxis, and provide training on how to use the EpiPen or other needed medication.

Behavioral problems and learning disabilities :

-Other chronic childhood health problems are those of emotional, behavioral,
and intellectual development. These are not always easy to detect and measure, and they can be debilitating.
-The causes of learning disabilities and emotional behavioral problems appear to have genetic, environmental, and cultural
influences. The number of children with learning disabilities in the lowest economic group is twice that in the highest group.
- High-risk children often come from families with a high incidence of child abuse (physical and sexual) and neglect.
-ADHD is a cluster of problems related to hyperactivity, impulsivity, and inattention.
- School nurses must be aware of the signs and symptoms and serve as an advocate for these children and their families.
- Collaboration is needed between the child’s family, the school, and the child’s health care provider to diagnose ADHD and
effectively plan appropriate interventions and educational accommodations. Teacher confirmation of ADHD-related behaviors is
very important.

Medication administration :
-Medication administration for a variety of conditions is an important responsibility for school nurses. In schools where a nurse is
present every day, she can personally oversee medication administration. Unfortunately, many nurses cover more than one school
and so other school personnel (e.g., secretaries, health aides) oversee medication administration.
-It is ideal for school nurses to provide training and audit records to ensure that proper guidelines are followed.
- Problems commonly occur with omission of doses because students fail to come to the office for medication administration.
- This is especially problematic with students taking insulin or antidiabetic drugs, antibiotics, and medication for ADHD.
- School nurses must understand their own state’s act and the legal implications regarding their decisions.

Immunization:
- Among schoolchildren, the incidence rates of measles (rubeola), rubella (German measles), pertussis (whooping cough),
infectious parotitis (mumps), and varicella (chickenpox) have dropped considerably because of widespread immunization efforts,
although these communicable diseases do still occur and sometimes with serious complications such as birth defects from rubella and
nerve deafness from mumps.
- School nurses are deeply involved in each of these preventive activities. Health departments and schools often work collaboratively
to provide immunization services and it is a compulsory immunization laws for school entrance.
- School nurses often oversee and ensure that children are in compliance with school entrance laws regarding immunizations.
-They may call parents directly when they note that the student is out of compliance. They may also arrange to help the student get
immunized by facilitating appointments or, in some school districts, by directly providing the immunizations..

Safety :
- Emphasis on a healthful physical environment includes proper selection, design, organization, operation, and maintenance of the
school building and playground equipment.
- School nurses are also involved in ensuring that injury prevention efforts are encouraged.
- Custodial personnel assist in the maintenance of school grounds, but school nurses must be aware of conditions and make
recommendations to remedy unsafe situations.
- As school nurses provide first aid treatment for playground injuries, they may observe trends (e.g., a high number of injuries where
faulty playground equipment or other factors influence higher injury rates) and request action.
- When injury trends are noted, school nurses work with maintenance departments and administration to advocate change and prevent
future injury.
- School nurses also assist with physical adaptations for students with special needs (e.g., ramps, electric doors); mindful of visual,
thermal, and acoustic factors in school buildings; promote sanitation and the safety of the school bus system as well as food services;
natural disasters or emergency situations; earthquakes and potential bioterrorism events may impact schools or not permit children to
return home at the end of a school day. School nurses are ideal persons to assist in disaster/emergency relief.

2. Health Education and Health Promotion:

Health Education and Health Promotion includes planned and incidental teaching of health concepts and health curriculum
development.
School nurse teach regarding:
• Proper hand hygiene
• School nurses are trusted by students, students listen to them. Nurse must use creativity and autonomy to identify and prioritize
needs.
• Severe food allergy - allergies are not contagious, what to do in the case of an allergic reaction, and importance of not sharing foods
that may contain potential allergens.
• Nurse also teach about basic first aid, nutrition, physical exercise, and seat belt safety, or provide information about careers in the
health care professions.
• In addition to lecture or verbal teaching, education may also be in the form of bulletin board notices, newsletters, or in-service
presentations for educators and parents.

A. Screenings: Opportunities for Teaching Page 1000-1001

• Vision • Hearing • Miscellaneous Health Screenings
B. Oral and Dental Health: Teaching and Referral

Vision :
- schools offered vision screening
-School nurses often oversee routine vision screenings at periodic intervals so that vision problems that can interfere with learning
may be detected and treated early (e.g., nearsightedness, farsightedness, strabismus, amblyopia).
-School nurses also are involved in follow-up to ensure that corrective eyewear is obtained.

Hearing :
- mass screenings are done to detect any serious hearing deficits that may be related to recurrent ear infections or some type of
sensorineural hearing loss.
-Sensorineural hearing loss involves the inner ear or the nerves leading from the inner ear. It is permanent and cannot be surgically or
medically corrected.

Miscellaneous Health Screenings:

- Height, weight, and sometimes blood pressure and cholesterol screenings are done on a regular basis to monitor normal growth and
development and allow for early intervention with populations who are especially susceptible to hypertension and heart disease.
-In some areas, scoliosis screening is also done, frequently during middle school years or in fifth grade, to permit early detection and
referral for medical intervention (e.g., bracing, surgery).

3. Promotion of a Healthful School Environment

It includes maintaining and promoting a healthful school environment and school living which emphasizes planning a daily schedule
for monitoring healthful classroom experiences, extracurricular activities, school breakfasts and lunches, emotional climate,
discipline programs, and teaching methods.
It also includes screening, observing, and assessing students to identify needs early and to report illegal drug use, bullying, suspected
child abuse, and violations of environmental health standards.
Health promotion also involves the nurse in supporting the physical, mental, and emotional health of school personnel by being an
accessible resource to teachers and staff regarding their own health and safety.

A. Proper nutrition and exercise

• Obesity • Under nutrition • Eating disorders
B. Adolescent High-Risk Behaviors
• Sexual Activity: Teen Pregnancy and Sexually Transmitted Diseases • Substance Abuse • Mental Health Issues and Suicide
C. Abuse

Obesity :
- Obesity rates have increased for all children. Since 1980, they have doubled for children between ages 2 to 5 and adolescents (ages
12 to 19). Rates have tripled for those between ages 6 and 11 years. the number of children diagnosed with type 2 diabetes continues.
-As children become older, families have less impact on food choices, and peers begin to have more influence.
- School nurses can do many things to assist with the obesity epidemic. They can advocate for health and physical activity classes.
Nurse-implemented, parent- directed program in the school decreased obesity among students.
- Parents are supportive of increasing physical exercise and emphasizing nutritional foods in the school setting.
- A number of weight control programs for overweight children and adolescents are available through schools, health departments,
community health centers, health maintenance organizations (HMOs), and private groups.
 Under nutrition :
- Poor nutrition and obesity are not uncommon among adolescents, whose diets often consist of snacks with limited nutritional value
interspersed among unhealthful meals.
- Undernutrition serious consequences, with an impact on the academic performance. Irritability, lack of energy, and difficulty
concentrating are only some of the problems that arise from skipped meals or consistently inadequate nutrition.
- Infection and illness that lead to loss of school days can affect academic progress and interfere with the acquisition of basic skills,
such as reading and mathematics.
- Undernutrition is frequently associated with poverty and hunger, but social pressure to be thin can also spark purposeful
undernutrition.
- School nurses can advocate for better nutritional choices in the lunchroom and vending machines.
- Legislative approaches: Limit soft drink sales in public schools.
- Teach all grade levels regarding proper nutrition, and they can educate students and parents alike about nutritious snacks in contrast
to snacks with little food value.
- School nurses may also work with staff to provide nutrition and exercise programs.

Eating disorders :
- Eating disorders are another area of concern. Issues with body image and control are at the heart of anorexia nervosa and bulimia
nervosa, common problems for adolescent girls.
- These diseases have emotional causes that pose complex challenges to treatment.
-School nurses must be aware of the signs and symptoms of eating disorders and be proactive in identifying students at risk.
- Scoliosis screenings are an optimal time to also observe for eating disorders, as examination of the spine allows for visualization of
the body core.
-School nurses can work with students to develop a healthier self-concept and identify outside treatment resources.

Obj. 4 - School Health Strategies

1. Preparation of the peer education manual with the guidance of a UNICEF staff/expert. The manual will be a guide for peer
educators in 5 health topics:
a. Nutrition b. Tobacco use c. Violence d. Road safety e. STI & AIDS
2. Sharing the MOE in preparation of adolescent’s health package supported by UNFPA (United Nations Fund for Population
Activities).
3. Sharing in health promotion workshop conducted by health education department.
4. Sharing in health promotion strategy taskforce. 5. Sharing in dietary guidelines taskforce.
6. Sharing in a workshop on production of health education materials for youth.
7. Participating in the GCC school health committee meeting in March 2008.
8. Conduction of two meetings of the central joint school health committee.
9. Conduction of two meetings of the central joint facts for life committee,
10. Sharing in preparation of the manual of school canteen with MOE.

Obj. 5 - School Health Education Activities in Oman

1. Health education program is the main activity in the schools. Routine health education activities continued as per education
schedule.
2. The eleventh edition of “Facts of life” book was distributed in 2008.
-The book was updated and seven new topics were added for the two parts of the book. Part two will be distributed to students in
grade 10 instead of grade 11 as per the request from the health services and schools.
-Request for translation and printing of the English version was submitted (waiting for approval).
3. Anti-smoking project was being implemented in 393 schools in the academic year 2007/2008 in addition to another 222 schools
started in September 2008.
-Health education materials were produced and distributed to all target schools.
4. Conduction of the art competition in the world health day 2008 with the slogan “Protecting health from climate changes”.
-About 211 students participated and two girls won. One with fourth level and the second with certificate of merit.

Obj. 6 - Activities for Health Promoting Schools

1.Continuation of school health website for the national network of HPS through www.schoolhealthoman.com
2. Conduction of the Second HPS Forum in Salalah in 28-30 January 2008 in coordination with the school health joint committee-
Dhofar region and world organizations, about 300 health and education staff participated.
3. Field visit to all schools implementing HPS initiative was taken in April and May 2008. A team from the National HPS taskforce
was formulated. 15 out of 19 schools were declared health promoting schools. The 4 schools failed to win were scheduled for re-
evaluation in 2009.
4. Conduction of Training for trainers (TOT) in Health Promoting Schools Initiative. It was conducted in 15-17 November 2008 and
was participated by regional training teams. A meeting of the national health promoting schools taskforce was held in June 2008.
-Implementation of health promoting schools in 10% of schools in all regions as a phase of expansion.
 Cs12: Occupational Health
Introduction:
-Business & industry
-Employee health
- Organizations:
-Traditional health benefits, safe & healthy environment
-Offer healthy snacks / promote jogging / exercise facilities
- Increasing number of companies have recognized the benefits of occupational and environmental health nurses as part of the
overall health promotion & wellness efforts.

Obj1: Occupational and Environmental health nursing:

- Occupational : job
- Environment : is everything that is around us
Factors in the work environment that can affect worker health & safety
- Specialty practice that focuses on the promotion, prevention and restoration of health within the context of a safe and healthy
environment.
- It includes the prevention of adverse health effects from occupational & environmental hazards.
- It provides for & delivers occupational & environmental health & safety services to workers, worker populations & community
groups.
- An autonomous specialty, and nurses make independent nursing judgments in providing
health care services
- 1895 :
– Vermont Marble Company
– hired the 1st industrial nurse in the US
– free nursing service: home visiting & care of the sick
- World War II : illness prevention & health education
- Occupational Safety & Health Act of 1970 > Occupational Safety & Health Administration(OSHA)

- 3 Main Categories of OHN:

1. Compliance : hearing tests, physical exam, immunizations, TB testing.
2. Care:
 1st person to evaluate an injury.
 Provide guidance, counseling, education & coaching for employees to improve their health.
3. Health promotion :
- primary prevention
1. Importance of physical activity to control weight
2. Flu vaccine
3. Safe-lifting demonstration
-Secondary prevention : 1. Cholesterol checks 2. BMI screening

- Occupational & environmental health nurses – need to apply strategies to reduce job stress & potential job strain
 Modeling health-affirming choices
 Networking with other nurses
 Professional organizations
 Setting occupational health standards

OHN ROLES:
1. Clinician 2. Researcher 3. Case manager 4. Educator 5. Coordinator
6. Consultant 7. Health Promotion Specialist 8. Manager 9.Corporate Director 10. Nurse Practitioner

Roles of Occupational health nurses:

A. Occupational Health Nurse Clinician
-provides direct care for both occupational and non occupational illness and injuries using established protocols.
-performs health assessment, screenings, surveillance, and counseling
-conducts workplace walkthroughs / assessments and exposure follow ups.

B. Occupational Health Nurse Case Manager

- coordinates healthcare services for the employee from the onset of injury or illnesses to a safe return to work or an optimal
alternative.
- quality outcome- focused care is delivered in a cost effective manner.

C. Occupational Health Nurse Coordinator

- functions as the single occupational health nurse for a company responsible for the occupational and environmental health &
safety services.
- conducts needs assessments of the patient population & worksite.
- develops programs to address needs.
D. Occupational Health Nurse Health Promotion Specialist
- has primary responsibility for the overall management of the health promotion program.
-Exercise, nutrition / smoking cessation programs

E. Occupational Health Nurse Manager

- responsible for setting occupational health unit policy and directing , administering & evaluating an occupational and
environmental health & safety service.
-Operational management -Financial management -Quality improvement

F. Occupational Health Nurse Practitioner

- uses independent and collaborative critical judgments in conducting health assessments, making differential diagnoses.
- promoting optimal health , and providing pharmacological and non pharmacological treatments in the direct management of
acute or chronic illness & injuries within the scope of state regulations.

G. Occupational Health Nurse Corporate Director

- functions as a policy maker at the corporate level and develops and directs the overall occupational & environmental health &
safety programs in consultation with other health & safety specialists & corporate management.

H. Occupational Health Nurse Consultant

- provides advice for developing occupational and environmental health and safety services for structuring the delivery of
services, including managed care and case management.

I. Occupational Health Nurse Educator

- plans curricula appropriate to various levels of educational preparation & has responsibilities for occupational & environmental
health nursing curricula & clinical experiences in college or university.

J. Occupational Health Nurse Researcher

- develops researchable questions, design studies, conducts research, writes grants & disseminates research findings to improve
practice and build knowledge in the discipline.

Obj 4: Settings for Occupational & Environment Health Nursing:

- Occupational health nurses provide their services to any number of settings, including business, industry, schools, and clinics,
and hospitals, just to name a few.
- Companies
Acute care setting : Occupational & environmental health

Obj 5: EBP & Educational preparation to be an OHN:

- Evidence-Based Practice
 Nursing education graduate level programs  Continuing education programs
- National Institutes for Occupational Safety & Health (NIOSH), part of the CDC
 Responsible for conducting research related to worker health & safety, & for educating health & safety professionals
- RN, BSN
- Previous experience :Occupational health Public health Emergency care
- Certification
 American Board for Occupational Health Nursing :
▪ Educational qualification ▪ Experience ▪ Continuing education ▪ Examination

Obj 6: Types of adverse working conditions that impact the health status of the workers:
- Hospital based nurses
 Physical hazards – lifting patients
 Biological hazards – blood & body fluids, infectious diseases
 Chemical exposures – OR gases, chemotherapy
 Radiation hazards – radiation therapy
- PPEs – not use / not effective
- Repeated exposure to loud noise – hearing loss
- Shift work – impact sleep & rest cycle
- Low-paying jobs – get a 2nd or even a 3rd job
- Personal stressors / balancing work / family demands

Obj 7: Standard Occupational Health Nurse activates & the emerging Occupational Health Nurse activates:
- Standard OHN Activities:
1. Supervising care for emergencies & minor illnesses
2. Counseling employees about health risks
3. Follow up the employees’ compensation
4. Performing periodic health assessments
5. Evaluating the health status of employees returning to work
- Emerging OHN Activities:
1. Analyzing trends (health promotion, risk reduction, health expenditures)
2. Developing programs suited to corporate needs
3. Recommending more efficient & cost-effective in- house health services
4. Determining cost-effective alternatives to health programs & services
5. Collaborating with others to identify problems & propose solutions

Obj 8: Objectives of OHP in Oman:

1. To promote & maintain the highest possible degree of physical, mental and social well being of workers in all occupations.
2. To promote the safety and health at workplace. 3. To increase awareness among employees and communities regarding
occupational safety & health aspects.
4. To prevent occupational related health problems arising from the work environment among others.
5. To reduce the morbidity and mortality due to occupational disease and injuries.

Strategies:
1. Integration of occupational health in healthcare services
2. Training of staffs on occupational health
3. Enhancing the surveillance for occupational diseases.
4. Occupational health promotion in workplace.
5. Enhancing the intersectoral cooperation among agencies.

Components of injury prevention and safety promotion program:

1. Review the existing surveillance systems within health and related sectors.
2. Develop a feasible and sustainable surveillance program including coordination.
3. Conduct training program on data collection, management & analysis.
4. Develop a framework for mechanisms towards monitoring.
5. Strengthen dissemination and data application practices.
6. Implement interventions that are based on data and evidence.
7. Evaluate impact of interventions.
 C13: Maternal & Child Health

1. Maternal & Child population have always been priorities for public health & CHN.
2. US spends more money on health care per capita than any other country in the world, yet has the highest rates of child poverty
& the lowest levels of child health & safety of the rich countries.

• Global Overview Of The Health Status Of Women & Infants:

1. Maternal Health is one of the indicators of population health. It is often measured by Maternal Mortality Rate ( MMR ) .
-MMR- a measure of obstetric risk and it is determined by : (Maternal deaths / Live births) x 100,000
• Causes of Maternal Deaths :
1- direct causes ( complications of pregnancy, labor and delivery ) 3 - hypertensive disorder
2- intervention omissions or incorrect treatment 4 - unsafe abortions
• Further reading is required for students re the percentages of MMR in other countries.

2. Infant Mortality – another critical health indicator .

- Globally, 3.3 to 4 million neonatal deaths and 6 million deaths of children under age 1 in 2009.
• Causes of Infant Mortality:
1- poor maternal health 4 - poor post natal care for mothers and babies
2- poor hygiene, LBW , malnutrition 5 - infections e.g. pneumonia & sepsis
3-HIV/ AIDS , malaria, diarrheal infectious diseases ( 2008 )
• The lowest percent of neonatal deaths occurred in the African region; but got the highest malarial, HIV/ AIDS for children under
5 years old.
• Further reading required for students re Infant Mortality.

3. HIV/ AIDS:
- 34 million adults and children living with HIV virus. 60% of cases are found in sub Saharan Africa ( WHO 2011b)
- Rates are rising faster in Eastern Europe and Central Asia ( WHO ,2011a) - 16.6 million children were orphaned from
HIV/AIDS and most of them with AIDS are children of HIV positive mothers.
-Mother to Child Transmission ( MTCT ) can be reduced by 67% with a single antiretroviral drug taken for a short time &
combination therapies.
-To reduce MTCT, women must seek prenatal care early enough in their pregnancies for the antiretroviral drug to be effective.
-Antiretroviral therapy was provided to 6.6 million persons in 2010. with 45,000 of them are children.
-Most population favors routine HIV testing & women are more likely to be tested & understand the benefit of the treatment to her
& to her unborn child.

Categories of the major risk factirs affecting mothers' & infants' health: ( pls refer to page 662)
Lifestyle Sociodemographic Medical & Gestational History
• Inadequate nutrition, alcohol consumption, substance • Low maternal age, • Primiparity , multiple gestation,
abuse, poor prenatal care, environmental toxins. poverty, low educational premature rupture of membrane,
level, unmarried status diabetes, short interpregnancy intervals ,
• Stress, violence, lack of social support & bed sharing genetic, etc

Maternal, Infant & Child Health Care:

GOAL: Improve the health & well being of women, infants, children and families
Please refer to page 661-662 for more information

Role of CHN in providing care for Maternal & Child Population:

- CHN focuses on health promotion , health protection & early intervention.
- CHN provides educational interventions for the young child it that includes nutrition teaching.
- Encourages parents to act responsibly on behalf of their children to assist in health habit formation.
- Encouraging age appropriate immunizations , cessation of smoking during pregnancy.
-Encouraging appropriate use of child safety devices.
-Providing interventions that motivate people into adherence to laws that require certain immunizations or mandate to report child
abuse & environmental health standards violations .

National significance & magnitude of pregnant & child's problems:

- Oman has made significant achievement in reducing the infant mortality rate that has dropped from 64 in 1980 to 9.5/1000 live
births in the year 2012.
- Maternal mortality ratio since its initiation of monitoring by MOH in 1995, has also shown drop from 22in 1995 to 17.8/
100,000 live births in 2012.

Oman's current success story can be summarized as an outcome of 3 proven interventions:

1) Provision of antenatal service within easy access
2) Strengthening the services and systems
3) Sustaining the standards of the health care delivery.
Reasons of Mother and child considered as one unit of care :
1. During antenatal period fetus is part of the mother and the fetus receive all the building materials from mother’s blood
2. Child health is closely related to maternal H. A healthy mother gives birth to a healthy baby.
3. Certain diseases as syphilis, German measles, drug intake, AIDS and etc are likely to have their effects upon the fetus.
4. After birth the child is dependent upon the mother for feeding, mental and social development, Sickness and even loss of
mother can have an adverse effect on the child growth due to maternal deprivation syndrome.
5. Post-partum care is inseparable from the neonatal care.
6. The mother is the first teacher of the child.

Objectives Of Maternal & Child Care:

MOTHER CHILD
1. Maintain good health during pregnancy and lactation 1. Lives and develops within a healthy family environment
2. Learn the art of motherhood 2. Enjoys love and security
3. Normal childbirth enjoyment 3. Obtains adequate nutrition
4. Give birth to a healthy baby 4. Obtains adequate medical care
5. Reduce maternal morbidity and mortality 5. Learns the principle of a healthful living
6. Reduce infant and child morbidity and mortality

Factors Influencing the Health of Pregnant Women and Infants:

1. Genetic and largely beyond the individual\s control
2. Socioeconomic and resistance to change
3. Factors related to lifestyle choices, that individual woman have made.

Categories of Factors
A. Risk before Birth ( factors associated with high risk pregnancies ):
Demographic Past Pregnancy History Medical History Current Danger S/ S
- Low socioeconomic status, - Pre-eclampsia/ Eclampsia - Hypertension - Severe pallor
disadvantages ethnic group - Caesarean section - Diabetes Mellitus - Persistent headache
- Marital status --unwed mothers - Preterm labor - Renal diseases - Blurring of vision
- Maternal age : - Premature rupture of - Cardiac diseases - Generalized edema
1) Gravida ˂ 15 years of age membranes - Sickle cell disease - Convulsion
2) Primigravida35 years of age or - Three or more - Thalassemia major - Unilateral leg edema
older consecutive abortions - Chronic Hepatitis - Calf tenderness
3) Gravida 40 years of age or older during 1st trimester - HIV - Difficult breathing
- Maternal weight: Non pregnant - 2nd trimester abortion -Psychiatric disorders - Vaginal bleeding/leaking
weight ˂ 100 lb or ˃ 200lb(45kg to - Postpartum Hemorrhage - Epilepsy - Persistent or severe
90kg). - Refer to p. 77 for more - Genetic disorders abdominal pain
- Stature: Height -1.5 m examples - Thyroid disease - Unexplained persistent fever

B. Risk Factors after birth:

1. Problems developing before the infant reaches one month of age are usually related to gestational age and birth weight and in
utero problems.
2. Problems after one month are often related to environment factors. Here the community health nurse plays a significant role in
prevention, especially in relation to morbidity.

Roles of Community Health Nursing in Maternal & Child Health:

-Maternal services start from infanthood of the mother to promote her health, increase her safety, and prepare her as a successful
future mother knowing the principles of healthy life , importance of family and her responsibility as a community member.
►Care given to mother does not only affect the health of the baby but also reflects on the whole family. She is the one who cares
for the family and house.
►Pregnancy and delivery as well as the health problems that affect the community affect maternal health.

Maternal Care Phases:

1. Premarital or Preconceptual > 2. Antenatal > 3. Natal care > 4. Post Natal

1- Premarital or Preconceptual :
1.1 Physical examination: - examination from head to toe
1.2 Investigations:
- Chest X -ray for detection of tuberculosis - Blood investigation of hemoglobin and Rh factor
- Urine test for sugar and albumin - Test to detect sexually transmitted diseases
1.3 Health education and Counseling:
-Teaching about suitable age for marriage. Very young mothers under the age of 20 years might be exposed to problems during
pregnancy and labor.
-Health education about personal hygiene, some facts about antenatal care, and importance and principles of child care
-Genetic counseling , encouraging the people to avoid consanguineous marriages to prevent hereditary diseases.
2- Antenatal Care Tasks:
2.1. Record personal information:
- At the first visit all the personal information should be documented as per the maternal health card
2.2 History taking:
- At the first visit the history as per the Maternal Health Record parameters which includes current and previous obstetrical &
gynecological risks, medical history, current danger signs and symptoms, birth spacing history and family medical history should
be documented.
Women should also be asked about ( in the present pregnancy):
• Exposure to radiation • Drugs in 1st trimester
• Fever, rash in 1st trimester • Current medication
2.3. Clinical Examination of pregnant women:
- Measurement of weight and body mass index (BMI) - Measurement of blood pressure
- Systemic examination - Breast examination - Obstetric examination
2.4. Risk grading:
2.5. Ultrasonography in ANC 2.6. Laboratory tests
2.7. Immunization
2.8. Health Education
2.9. Drug Prescription
Frequency of Antenatal Visits:
-At Booking: -12-14 weeks -22-24 weeks -28-30 weeks -32-34 weeks -36-38 weeks -40 weeks

3- Natal care:
- The main role of the nurse is to assist the midwife and support the mother, preparation for labor.
4- Post natal Care:
- The post natal mother is expected to have a post natal checkup after 6 weeks of delivery and the new born baby checkup is
scheduled after 2 weeks.

The nurse uses nursing process to give care to the mother and child .
Assessment :
-Examination of the mother, head to toe using the check list or guide sheet
-Breast and nipple are examined for the presence of cracks or inflammation or retracted nipple
-Observe the milk secretion
-Assess the uterine involution and after pains
-Observe the lochia for color, amount and smell

Nursing Interventions:
1. Provide postnatal care: Care of the perineum, hygienic care, care of the breast, proper diet, and meeting the elimination needs.
2. Care of the newborn: bathing, care of the umbilical cord, feeding
3. Health education about:
-Breast care and breast feeding -Personal hygiene - Nutrition
-Postnatal exercises -Follow up examinations -Birth spacing
-Care of the newborn, immunization schedule, accident prevention, clothing, growth and development

Evaluation of Care:
1. Evaluate the health status of mother and child e.g.: weight gain in the child
2. Successful involution of uterus
3. Mother resumes normal functioning
4. Visit the postnatal and child health clinic as per the schedule -Attains a normal puerperium
5. Records the necessary information regarding the mother and child

Child Health:

Common causes of morbidity & mortality:

A. Neonates & Infants

1. Immaturity & Prematurity:
-Premature or preterm infant is the one born before the end of 37 weeks of gestation regardless of the birth weight.
- generally immature gestationally and of low birth weight (LBW) = less than 2500 gm regardless of the gestational age.
-LBW infants are highly vulnerable to disease and death. Hence this is a major public health problem

2. Congenital Anomalies:
- Congenital anomalies of the cardiovascular, circulatory, and nervous system pose the greatest mortality threats.
- Genetic disorders e.g.: Down's syndrome, sickle cell anemia, cystic fibrosis, and diseases due to exposure to toxic agents during
pregnancy e.g.: maternal rubella, radiation, chemicals maternal alcohol abuse etc.
3. Sudden Infant Death Syndrome (SIDS )
-SIDS accounts for more than one third of all neonatal deaths.
-More frequently in male child, LBW infant, twins, low socioeconomic groups, infants with CNS disorders.
-It often occur during sleep periods associated high incidence of upper respiratory diseases.
-Majority occurs in cases where maternal or paternal intravenous drug use, maternal AIDS, maternal promiscuity.
-Children with AIDS are infected in utero.
-Children with HIV commonly demonstrate signs of failure to thrive, infectious otitis media, pneumonia, septicemia, oral
candidacies and chronic diarrhea, hepato- splenomegaly

4. Sepsis (Septicemia):
- Neonates are particularly susceptible to a variety of infections and sepsis.
- The following symptoms should prompt the nurse to take an appropriate action:
- Full anterior fontanel that lacks normal pulsation - Hypothermia/ Hyperthermia
- Lethargy / Irritability, Tremors, Seizures - ( Refer further to course book for more symptoms )

B. Toddlers and Preschools:

-Morbidity and mortality among these group is attributable to accidents and infectious diseases
1. Accidents:
-Motor vehicle accidents, drowning, burns, poisoning, choking and falls. Segments of this population most at risk are boys. The
annual death rate recorded shows males are at higher risk than females.
2. Infectious Diseases
-Infection remains the primary cause of both illness and restricted activity in children ages 1-5 years.

Role Of Nurse In Promotion Of Health Of The Mother And Child

-Identifying areas where families and larger groups can increase the state of their health where they are working towards
maximizing their potential, is one of the most challenging aspects of community health nursing.
-Health promotion in 0-5 year group is important because this period provides the foundation of physical, intellectual and
emotional health for the rest of the child's life.

While planning for health promotion activities the nurse must understand the following for effective and appropriate
intervention:
-Behavior changes with age in a patterned predictable manner.
-All growth physical or emotional, implies organization.
-Norms of various age groups can be dangerous if they are used as absolute standards because each child develops with different
rhythm.
-It requires a team effort, comprising school nurses, social worker, teacher, nutritionist, doctor, family etc.

Health Promotion Before Birth:

-Good health begins before a child is conceived. Children need to be wanted and planned and parents need to learn how to be
parents.
Parent Education:
-to include information regarding physical aspect of child care, nutrition for mother and child, intellectual and emotional
development of child and the stresses of role change of the parents.
-It should promote nurturing parenting skills. The nutrition to the female child is important as it will affect her future children.
-Education on adolescent preferences and the value of eating a balanced diet need to be emphasized.

Health Promotion during Pregnancy:

-Parents need support throughout pregnancy because they do have negative, positive or ambivalence feelings about pregnancy.
-Supportive intervention efforts during pregnancy and the few months following child birth can improve maternal and child health
outcome.

Health Promotion after Birth:

-Assistance in postnatal care following discharge from the hospital at home can help mother regain her health and also take the
responsibility of infant care and adjust to role's changes.

Preventive Health Care

New Born Assessment
-Done for early case finding and preventive care.
-Obtain a base line data about the infant's surface features, movement patterns, and general health for comparisons with future
examinations.
-Systemic periodic assessment over a period of time is important.
-Parental involvement in the assessment process helps the nurse to see how the family interacts.
Child Care:
-The child care starts from birth until school age.
-Afterwards health care is the responsibility of the school health program. The health of the infant at birth is dependent upon the
care he received while fetus in utero.
-Care of healthy infants and preschool takes place in well baby clinics and nurseries while care of the sick ones takes place in
hospitals OPD.

Child Care and the Role of the Nurse:

A. In Baby Clinics
Assessment:
-Taking history of birth, risk at birth such as Poor apgar score at birth, prolonged hospital stay, congenital malformation, Twins or
multiple birth etc.
-History of growth and development, feeding and weaning, diseases
-Immunization, psychological problems, problems with elimination pattern etc.
-Assessment of risk factors: Malnutrition, iron deficiency, PEM

Intervention:
1. Immunization
2. Health education

Examination:
-Temperature, pulse and respiration
-Anthropometric measurement
-Growth and development
-Signs and symptoms of diseases
-Malformations or deviations
-Other physical and mental changes, poor home environment

Health education regarding:

1. Breast feeding and weaning, complementary feeding 2. Growth and development
3. Prevention of accident, diarrheal diseases 4. Promotion of sleep
5. Need and importance of play 6. Toilet training 7. Care during infectious diseases

Child care & the role of the nurse:

-Carry out laboratory investigations.
-Home visits to identify home situation and family relations and help mothers to solve the problem.
-Encourage the use of all family potentials to meet the health needs.

Role of the nurse in child health clinic:

-Welcome the mother -Weigh the baby and measure height and plot on the growth chart
-take history and check immunization schedule -Assist in examination -Assess development
-Detect at risk children -Refer to doctor as necessary -Give health education according to the need of the child
 CS 14: Client With Disabilities And Chronic Illness

 At some point in our lives, most of us diagnosed e a chronic illness or develop some type of disability.
 Some become temporarily incapacitated &unable to manage daily lives, & require assistance from others
 Estimated 36 million Americans (12% of pop.) live with some ongoing level of disability (U.S. Census Bureau, 2012).
 In 2010, over 38 million persons reported limitations in their usual activities as the result of chronic conditions
 Costs of disability and chronic illness:(direct medical care &indirect annual costs related to disability are significant burdens on
those affected, on public & health & social insurance.
 disabled Individual have higher H care costs: (more chronic conditions & poorer H status requires more health care services
 Reducing costs is by (H promotion & preventive services, & expanding coordinated care and targeted disease management
programs (Anderson et al., 2011).

Differentiation of Terms:
A. Disabled (adj.)– incapacity to do something because of a handicap–physical , mental ,etc.
( Morehead & Morehead, 1995 )
B. Disability ( noun ) – linked to inability ; the lack of ability to do something, whatever the reason , but usually through
incompetence, weakness, lack of training , etc.
- impairments, activity limitations or participation restrictions
C. Functioning – encompasses all body functions, activities and participations.
D. Handicap–any encumbrance or disadvantage (strain) E. Chronic Disease – any illness prolonged, does not resolve
spontaneously & is rarely cured completely.
- Preventable and pose a significant burden on morbidity, mortality and personal & societal cost ( CDC , 2007 )

ICF – International Classification of Functioning, Disability and Health:

 a universal classification system with standardized language and a way to view the domains of health from a holistic vantage
point.
It takes into account body functions and structures, activities &participation, environmental factors& personal factors.
Allows a multi-dimensional evaluation of individual’s circumstances in terms of functioning, disability and health.

ICF: 1- biopsychosocial approach to assess people disabilities

2- people with same disease or disability have same level of fuctioning

Aim:
1. Provide a scientific basis for understanding and studying health- related states, outcomes & determinations.
2. Establish a common language for describing health and H related states to improve communication between different users: H
care workers ,researches ,policy makers ,public & disabled people
3. Permit comparison of data across countries, health car disciplines, services and time.
4. Provide a systematic coding scheme for health information systems

World Report on disability:

-Every citizen needs to participate in their country’s development.
-People with disabilities must advocate to remove barriers that prevent their full participation in their communities e.g.(access to
education , health, employment, transport & information services).

Recommendations :
1. Enable access to all mainstream systems and services.
2. Invest in specific programs services for people with disabilities.
3. Adopt a national disability strategy and plan of action
4. Involve people with disabilities.
5. Improve human resource capacity.
6. Provide adequate funding & improve affordability.
7. Increase public awareness and understanding.
8. Improve disability data collection.
9. Strengthen & support research on disability

Impact of Disability & Chronic Illness on Families:

1. The need for normalcy & certainty , information &partnership .
2. Emotional Stress/ Emotionally draining
3. Self- blaming as a coping strategy. ( depression )
4. Financial & technology Struggle
5. Employment opportunities maybe limited
6. Compromised physical & mental health of caregivers.
Role of the PHN:
- Select appropriate interventions to address the health needs of all the members.
- Advocate for the needed care , services and equipment.
-Must view the family holistically .
- Must include assessment of caregiver and family work patterns.

Family’s Role in Advocacy:

- Navigate a health care system.
-Demand assistance from health care agencies , social services and transportation access to achieve a level of care needed by the
family members.

Role of CHN / PHN:

1. Public Health Nurses are in prime position to advocate for the health needs of the disabled & chronically ill.
2. Collaborate with other professionals in reaching the goal of improved health for the handicapped clients.
Please refer to page 865 for the scenario reflecting the roles of a PHN/ CHN.

Role of CHN / PHN:

-Clinician -Educator -Advocate -Manager -Collaborator -Leaders -Researcher

Institutions Supervised By Ministry Of Social Development:

• Disabled Care and Rehabilitation Center ( Arabic Only ) - It is the first institution that was established to take care of disabled
members of society and qualifying them to handle some jobs and tasks assigned to them.
• Care Home for Disabled Children in Muscat ( Arabic Only ) - it was established in 1997 as a division in the Disabled Care and
Rehabilitation Center.Then, it became a separated Directorate in 2002 and it covered the field of medical rehabilitation, social
skills development programs for disabled children.

Private Rehabilitation Centers:

Muscat Center for Autism
• It is the first institution crated and designed to children with autism disorder in 2007.The Center provides care and services to
children of 3-14 years old and tries to include them fully in society. It is mainly concerned in their issues and improvement of
skills. It also prepares a rehabilitation training program for children of 14-18 years old.

• Creative Center for Rehabilitation

It was established in Muscat in 2007. It is aiming at taking care of the disabled persons who have cerebral palsy (CP), Down
syndrome, autism, severe learning disabilities, mental retardation and other disabilities.The Center receives members of 4-30
years old.The Center has 4 sections:
1. Montessori section: For 4-13 years old children who suffer from mental retardation, Down syndrome and autism.
2. Educational delayed section: For 5-18 years old children with severe learning disabilities that cannot function in
mainstream schools.
3. Male adolescent section: For male students of 16-30 years old, who suffer from Down syndrome, autism, mental
retardation, and other disabilities.
4. Female adolescent section: For male students of 16-30 years old, who suffer from Down syndrome,
autism, mental retardation, and other disabilities.

• Rawa Rehabilitation Center

- It was established in Muscat in February 2011. It provides rehabilitation services to those who suffer from disabilities or
behavior disorders. It gives sufficient training and rehabilitation for those who have attention defects and hyperactivity disorders
in order to fulfill an integrated inclusion with the other students in the mainstream schools. It also provides rehabilitation after
cochlear implants, and for the ones who are suffering from hearing impairment.

Rehabilitation Centers related to the Association for the Welfare of the Handicapped Children
• These centers were established since 1991 in different parts of the Sultanate.These Centers serve many types of disabilities that
some children have (i.e. mild hearing impairment, mental disabilities and double disabilities) from the ages of 5-13 years old. By
2011, there were 10 -Centers distributed in different parts of Oman.
Community Rehabilitation Centers Care centers outside Oman

Assisting and rehabilitation services (life-support)

Community associations for disabled persons:
1. The Association for the welfare of handicapped children- was established in 1991 and it focuses on supporting disabled
children with mild disabilities (mental and hearing) and double disabilities. It aims at embracing their potentials in order
to develop their role in building society. It also provides better opportunities and means for interaction with different
parts and members of society.
2. The Oman association for Disabled - was established in Muscat in 1995 to serve disabled individuals and highlight their
potentials among other participants in constructing society. It ensures that their rights are being given fairly and approves
their participation in various activities and sport events to enrich their opportunities in winning different competitions. In
addition, it works in building their skills and uplifting their talents and work potentials.
 • AL Noor Association for the Blind - was established in in 1997 with its headquarter located in Muscat. It has 3 other branches
in Dhofar governorate, Dakhiliya region and Batinah region. It is handling a pioneer role in looking after the blind and guiding
him/her to fulfill the highest achievements he/she got the skill to do. It provides the educational, vocational, social and cultural
support for them
and is devoted to give the attention, supplement and aid needed to these people to deal with technology and contemporary
lifestyles.
• The Association of Early Intervention for Children with Disabilities - was established to avoid the extending affects for
disabilities. It prevents some of the damages resulted on neglecting disabilities or treating them with low levels of care

• Employment of disabled people

A. Institutional employment: Many ministries and private agencies work on providing a share of their job opportunities to the
disabled members of society.This process is preceded and supervised by the Ministry of Social Development and the Ministry of
Manpower who takes the responsibility of finding a proper job for the disabled candidates according to their qualifications and
skills.
B. Self-employment :As some disabled members wish to start their own projects, there are interest-free loans offered by the
Ministry of Social Development and given to the disabled individual who is capable of having his/her own business or project in
order to assist them to raise their incomes and live independently.

• Other facilities: According to Article (12) of the Disabled Persons Welfare and Rehabilitation Act
every disabled individual has the right to have a “Disabled Person’s Card” that entitles them to enjoy many facilities, privileges
and rights such as the Exemption from housemaid recruitment fees and vehicle registration and renewing registration fees, special
discounts on some types of cars and household items.

Translation and signs language interpretations:

People with hearing impairments have got the chance to receive information, knowledge and news through sign language that is
the bridge between these persons and the other members of society .To enhance this mean of communication, many workshops
and training courses were carried out to give the community the chance to acquire this language and thereby deal normally with
the disabled individuals.
 CS15: Care of vulnerable population: Older Adult

Leading causes elderly inpatient morbidity:

-ischemic heart disease -Diabetes mellitus -hypertensive diseases
-Cataract and disorders of lens heart failure -Heart failure
-Fracture of bones and dislocations -pneumonia - Bronchial asthma

In Oman, 7 Major Health Problems By The Eldelry In Oman

1. Hypertension (68.3%)
2. High total cholesterol (53%)
3. Osteoarthritis (48.6%)
4. Overweight and obesity (46.1%)
5. Blindness and low vision (40.3%)
6. Anemia (35.2%)
7. Diabetes mellitus (29.1%)

Social Challenges And Health Difficulties

- Widowhood = 29.7% much higher among females (54.1%) than males (7.4%).
- Living Alone ( 6.8% )
- Illiterate ( 80% )
- Households With Elderly :belonged to the lowest income and lower middle classes ( 43% )
- Elderly Suffering From Five Or More Difficulties : (moderate to severe) ( 45.5% )

Factors affecting the health of the elderly:

- Life style - Life experience - Personality traits - Physical health - Societal support
Being able to adapt, to continue to handle stress, and to be active and involved.

Alternatives to institutionalizing:
-Day care -Day hospital -Respite care -Congregate housing

Elderly Care Service Programme Ministry Of Health, Sultanate Of Oman:

-By the year 2050 it is expected that 21% of the population in Oman will be above 60 years old.
-The situation will create a health problem if planning and preparedness to meet its consequences are not done early.

THE 8TH 5 -YEAR HEALTH DEVELOPMENT PLAN (2011-2015)

* The plan targets three categories of the elderly namely:
1. Those who can reach the facilities 2. Those who cannot 3. Those who are bedridden
*Main Objectives:
1. Provide promotive and curative health care
2. Physiotherapy, rehabilitation through primary health care
3. Preparing family members to meet the needs of the elderly
4. Disseminate public awareness in the society to promote community participation in the care of the elderly.

The Elderly Care Service Programme

-First initiative came from the Directorate General of Health Services, Al Dakhiliya Governorate (August 2003) with a small pilot
phase of 97 elders.
-The issue was raised to the higher official and labeled it as a “Home Project for Elderly Care in Nizwa”
-The preliminary focused were on strategy that satisfies the elderly needs with indicators such as:
1-demographic indicators 2-health indicators 3-social indicators
-Followed by a research study in the same governorate ( households of Nizwa), with a total of 2040 elders with the objective of
exploring the profile and needs of the elderly population.
-Wider service pilot phase was implemented in 13 PHC institutions (same governorate and included 2476 elders )
-(2006) First community based survey for the elderly was carried out (Nizwa district) .It reflected poor nutritional knowledge and
nutritional imbalance.
-(2008) Old age citizens were studied in national household survey entitled “National Elderly Health Survey” along with the
Oman World Health Survey (OWHS)
-( March 2010) the program was implemented in the national level in four (4) phases that will cover all elders in Oman by the end
of year 2014 totaling to 101,145.

National Geriatric Care Programme :March/2011

Main Goal target:
“Improve the quality of life through promoting healthy lifestyles and active ageing within the family”
 Benefits Of The Programme To The Elderly Population And Health System:
1. Cost of health services can be saved by providing early intervention such as screening through comprehensive elderly
assessment.
2. Non-Communicable diseases in elderly populations are best managed if early diagnosing and intervention are made.
3. Management of elders and care for them within the family by training the caregivers to deal with their needs helps in saving
health expenditure
4. Social authorities are important co-workers in order to access the social benefits for the elders
5. PHC provides health care which is cheaper than other levels of care and more appropriate for the elders being nearer to home
and walk in clinics, and most times no transportation or escort is needed to reach them

4 Phases Of The Elderly Program Implementation

1. Phase One (Establishment)
2. Phase Two ( Planning )
3. Phase Three ( The Inputs )
4. Phase Four (Implementation)

The Comprehensive Elderly Assessment

Phase III, Step 20. The Comprehensive Elderly
1. History 2. Medical Examination
3. Diagnostic tests and scales 4. Investigations Assessment

Vertical Packages:
• Package 1: The Active Elders
• Package 2: The Elders In Health Institutions
• Package 3: Retirement Elders

Package1: The Active Elders ( 60% ) :(Elders With Health Problem Not Recognized)
Categories Of Active Elderly:
A. In good health and has no chronic illness
B. In good general condition but has mild chronic illness
C. In moderate state of health

PACKAGE 2: The Elders in Health Institutions ( 35% )

• (Primary, Secondary, Tertiary: Health
• Problems is Relatively Recognized)
-In 2011, the total number of elderly visits to the PHC
• institutions in Oman was 412,358

Two Groups Of Patients:

1. OPD Elderly patient in health institution 2. Discharged Elderly Patients
• Have chronic problems. • Admitted in secondary or tertiary care with referral letter or
• May or may not be active discharged summary
• No disabling mobility problems but with less quality of life

PACKAGE 3 :Retirement Elders ( 5% ): (Health problem is related to Frailty)

“Retirement Elders are elders whose state of health is severely impaired and the quality of life is markedly affected specially in
the areas of activity and mobility”

1. Horizontal Package 1 Service :

(Provided in the PHC Centre) -Covers vertical package 1 and 2
2. Horizontal package II Service:
-Covers vertical package 3
-Provided by a team (doctor, nurse, medical orderly, physiotherapist, and social worker ), upon request from the team leader after
assessment of the elder actual needs.

Criteria for effective services:

- Comprehensiveness - Coordination -Accessibility -Quality
 C16: Epidemiology

Obj1: Define the following terms:

1- Epidemiology is “concerned with the distribution and determinants of health and diseases, morbidity, injuries, disability and
mortality in populations”.
- A specialized form of scientific research that can provide health care workers, including community health nurses, with a body
of knowledge on which to base their practice and methods for studying new and existing problems.
- The knowledge or study of what happens to people.
2- Epidemic refers to a disease occurrence that clearly exceeds the normal or expected frequency
in a community or region.
EX: Cholera, Bubonic Plague or Pneumonic Plague (Black Death), and Small pox.
3- Pandemic refers to a disease occurrence which is worldwide.
EX: Bubonic Plague or Pneumonic Plague (Black Death), HIV/ AIDS
4- Endemic refers to a continuing presence of a disease or infectious agent in a given geographic area .
EX: Plague in Vietnam, Malaria in the tropics of Brazil

Obj2: Importance of epidemiology:

Ultimate goals of epidemiology are:
1. To determine the extent of disease in a population
2. To identify patterns and trends in disease occurrence
3. To identify the causes of disease
4. To valuate the effectiveness of prevention and treatment options

- Epidemiology offers community health nurses a specific methodology for assessing the health of aggregates.
- It also provides a frame of reference for investigating and improving clinical practice in any setting.
* Frame of reference: a set of criteria or stated values in relation to which measurements or judgments can be made.
Ex: CHN Nurse’s goal is to lower incidence of STD in a community, prevention plans requires information about population
groups:
- How many STD cases have been reported in this community for the past year?
- What is the expected number of STD cases or morbidity rate?
- Which members of the community are at highest risk of contracting STDs?

Obj3: Host , Agent, & Environment model:

- Also known as epidemiologic triad/epidemiologic triangle.
- Interactions among these 3 elements explained infectious and other disease patterns.
-In this model, disease results from the interaction between the agent and the susceptible host in an environment that supports
transmission of the agent from a source to that host.

- Host is a susceptible human or animal who harbors and nourishes a disease–causing agent.
-Factors such as physical, psychological and lifestyle influence the host’s susceptibility & response to an agent and these includes:
Physical : Age, sex, race and genetic influences on the host’s vulnerability or resistance.
Psychological : Outlook & response to stress.
Lifestyle: Diet, exercise, healthy & unhealthy habits, sleep patterns.
- The concept of resistance is important for public health nursing practice. People sometimes have an ability to resist pathogens
this is called inherent resistance.
- People have inherited or acquired characteristics that makes them less vulnerable.
- Resistance can be promoted through preventive interventions that supports healthy lifestyles.

- An Agent is a factor that causes or contributes to a health problem or condition.

Causative agents can be factors that are present or lacking
Types of agents:
1. Biologic agents -bacteria, viruses, fungi, protozoa, worms, and insects. Ex: influenza virus or HIV
2. Chemical agents in the form of liquids, solids, gases, dusts, or fumes. Ex: are poisonous sprays used on garden pests and
industrial chemical wastes.
3. Nutrient agents include essential dietary components that can produce illness conditions if they are deficient or are taken
in excess. Ex: deficiency of niacin can cause pellagra, and too much vitamin A can be toxic.
4. Physical agents include anything mechanical (e.g., chainsaw, automobile), material (rock slide), atmospheric (ultraviolet
radiation), geologic (earthquake), or genetically transmitted that causes injury to humans. The shape, size, and force of
physical agents influence the degree of harm to the host.
5. Psychological agents are events that produce stress leading to health problems (war).

Agents may also be classified as :

1- Infectious agents cause communicable diseases such as AIDS or TB. Certain characteristics are important for CHN to
understand such as:
-Extent of exposure to the agent -The agent’s pathogenicity -Infectivity -Virulence
-Toxigenicity -Resistance -Antigenicity
2- Non infectious agents have similar characteristics in that their relative abilities to harm the host vary with type of agent and
intensity and duration of exposure

- Environment refers to all the external factors surrounding the host that might influence vulnerability or resistance.
- Physical environment includes factors such as geography, climate and weather, safety of buildings, water and food supply, and
presence of animals, plants, insects, and microorganisms that have the capacity to serve as reservoirs (storage sites for disease-
causing agents) or vectors (carriers) for transmitting disease.
- Psychosocial environment refers to social, cultural, economic and psychological influences and conditions that affect health,
such as access to health care, cultural health practices, poverty, and work stressors, which can all contribute to disease or health.

1. Ex: Lyme disease:

AGENT: Spirochete Borrelia burgdorferi - bacteria
HOSTS: Humans of all ages, along with dogs, cattle, and horses.
- Ticks that feed on wild rodents and deer transfer the spirochete to human hosts after feeding on them for several hours.
ENVIRONMENTAL: working or playing in tick-infested areas.

2. Ex: Encephalitis-causing disease

AGENT: Virus
HOSTS: Humans.
- Virus survives winter in the body of the adult Culex mosquito. The infected mosquito bites a bird and infects it. Other
mosquitoes who are not yet infected, bite the bird and in turn become infected. The infected mosquitoes now pass the virus onto
birds, humans, or horses.
ENVIRONMENTAL: Staying outdoors; staying indoors at dawn, dusk, and in the early evening; working or playing near
standing water sources where mosquitoes lay their eggs; and reported dead birds in the area.

Obj4: Natural History of a disease or health condition:

- Refers to events that occur before its development, during its course and during its conclusion.
- This process involves the interactions among a susceptible host, the causative agent and the environment.
- Natural progression of a disease occurs in four stages as they affect a population:
1. Susceptibility 2. Preclinical (subclinical) disease 3. Clinical disease 4. Resolution (includes recovery, disability, or death)
SEE FIGURE (7-6)

- Susceptibility Stage: the disease is not present and individuals have not been exposed.
However, host and environmental factors could very likely influence people’s susceptibility to a causative agent and lead to
development of the disease.
Ex. College students with poor eating habits and fatigue from lack of sleep during final examinations present risk factors that
promote the occurrence of the common colds.
Ex. “If exposure to an agent occurs at this time, a response will take place. Initial responses reflect the normal adaptation response
of the cell or functional system (e.g., the immune system). If these adaptation responses are successful, then no disease occurs and
the process is arrested”
- Subclinical Disease Stage: begins when individuals have been exposed to a disease but are as yet asymptomatic. It is followed by
an incubation period during which the organism multiplies to sufficient numbers to produce a host reaction and clinical symptoms.
Ex. Vulnerable children who have been exposed to chickenpox (varicella) but do not yet display signs of fever or Lesions.
For diseases caused by infectious agents, the incubation period is relatively short, hours to months. One noteworthy exception to
this is infection with HIV, which has an incubation period of 1 to 3 months, with progression to AIDS from 1 to 15 years or
longer.
- Incubation period - The period between exposure to an infection and the appearance of the first symptoms.

- Clinical Disease Stage: signs and symptoms of the disease or condition develop.
- In the early phase of this period, the signs may be evident only through lab test findings such as tubercular lesions on
radiographs or premalignant cervical changes evident on Pap smears.
- Later in this stage acute symptoms are clearly visible as in the case of widespread enterocolitis in a salmonellosis (food
poisoning) outbreak.
- In this early clinical stage or early discernible lesions stage, evidence of the disease or condition is present and diagnosis occurs.

- Resolution Stage: the disease or health condition causes sufficient anatomic or functional changes to produce recognizable signs
and symptoms.
- Disease severity may vary from mild to severe.
- The disease may conclude with a return to health, a residual or chronic
form of the disease with some disabling limitations or death.
- This can also be called the advanced disease stage because the disease or condition has completed its course.
- Community health nurses can intervene at any point during these four stages to delay, arrest, or prevent the progression of the
disease or condition. Primary, secondary, and tertiary prevention can be applied to each of the stages.
Level of prevention Pyramid:
SITUATION: Apply the levels of prevention during the four stages of the natural history of a disease to eradicate or reduce risk
factors (examples of possible conditions provided)
GOAL: Using the three levels of prevention, negative health conditions are avoided, or promptly diagnosed and treated, and the
fullest possible potential is restored.

Primary Prevention Secondary Prevention Tertiary Prevention

Health Promotion & Education :
May include:
• Nutrition counseling-diabetes
• Sex education=pregnancy
• Smoking cessation–lung cancer
Health Protection:
May include:
• Improved housing and sanitation–
waterborne diseases
• Immunizations–communicable
diseases • Removal of
environmental hazards-accidents
Early Diagnosis: Rehabilitation:
The third stage in the natural • Reduce the extent and severity of a health problem
history of disease, the early to minimize disability
pathogenesis or onset stage: • Restore or preserve function
• Screening programs–breast and
testicular cancer, vision and hearing
loss, hypertension, tuberculosis,
diabetes
Prompt Treatment: Primary Prevention
• Initiate prompt treatment Health Promotion & Health Protection :
• Arrest progression Education: • Health services
• Prevent associated disability • Training for employment - • Immunizations as
homeless population needed exercise
• Group treatment and
rehabilitation–adolescent
drug users
• Food, shelter, rest/sleep,

Q:
1. Which of the following levels of prevention emphasizes the importance of early detection and treatment?
A. Primary B. Secondary C. Tertiary D. Intermediate
2.What is the aim of primary level of prevention?
A. Aims to make ill people get well B. Prevents complete disability
C. Aims to help well individual stay well D. None of the above
3.The following are tertiary levels of prevention, except:
A. Referring a client to a support group B. Referring a client to a rehabilitation center
C. Teaching a client who has diabetes to prevent complications D. Teaching a client how to do breast self- exam

Obj5: Sources of Information for Epidemiologic Study

- Epidemiologic investigators may draw data from any of three major sources:
A. Existing data B. Informal investigations C. Scientific studies
- The public health nurse will find all three sources useful in efforts to improve the health of aggregates.

Sources of Example
Information for
Epidemiologic
Study
A. Existing Vital Statistics- refers to information gathered from ongoing registration of births, deaths, adoptions, divorces
Data and marriages.
Census data- refers to data from population census taken every 10 years in many countries are the main source
of population statistics.
Reportable diseases- refer to the reporting of the communicable diseases to their local health authority.
Disease Registries- some areas or states have disease registries or rosters for conditions with major public
health impact.
(TB ,Rheumatic fever & Cancer)
Environmental Monitoring- state governments through health departments monitor health hazards found in
the environment. Pesticides, industrial wastes, radioactive or nuclear materials, chemical additives in foods,
and medicinal drugs have joined the list of pollutants.
National Center for Health Statistics Health Surveys- provides a continual source of information about the
health status and
needs of the entire nation. Ex. National health survey, Nursing home survey, Nutrition survey, Family growth
survey, morbidity and mortality surveys.
B. Informal -Second information source in epidemiologic study.
Observation -If several cases of diabetes come to the attention of a nurse, a widespread might come to light through
and informal inquiries about the incidence and age at onset of the disease among them.
Description -Informal observational study often raises questions and suggests hypotheses that form the basis for designing
larger-scale epidemiologic investigations.
C. Scientific -Third source of information in epidemiologic inquiry involves carefully designed scientific studies. Nursing
Studies profession has recognized the need to develop a systematic body of knowledge on which to base nursing
 practice. Systematic research is becoming an accepted part of the community health nurse’s role. Findings from
epidemiologic studies conducted by or involving nurses are appearing more frequently in the literature.
Ex. Maternal chronic disease and preterm birth.

Obj6: Difference between prevalence & incidence in health & illness states:
Descriptive epidemiology:
1. Counts – figures, numbers, data from the period prior to and following
2. Rates - are statistical measures expressing the proportion of people with a given health problem among a population at risk.
The total number of people in the group serves as the denominator for various types of rates. To express a count as a proportion,
or rate, the population to be studied must first be identified.
-The most important for the public health nurse to understand are the prevalence rate, the period prevalence rate, and the incidence
rate.
-Prevalence refers to all of the people with a particular health condition existing in a given population at a given point in time.
-Prevalence rate- describes a situation at a specific point in time.
- Prevalence rat e= Number of person with a characteristic / Total number in population
Ex:
If a nurse discovers 50 cases of measles in an elementary school, that is a simple count. If that number is divided by the number
of students in the school, the result is the prevalence of measles. For instance, if the school has 500 students, the prevalence of
measles on that day would be 10% (50 measles/500 population).
Ex. 50/500 = 0.1 or 10 or 10%

-Incidence refers to all new cases of a disease or health condition appearing during a given time.
-Incidence rate- describes a proportion in which the numerator is all new cases appearing during a given period of time and the
denominator is the population at risk during the same period.
-Incidence rate = Number of person developing a disease / / Total number at risk per unit of time
Ex:
Some childhood diseases give lifelong immunity. The school children who have had such diseases would be removed from the
total number of children at risk in the school population. Three weeks after the start of a measles epidemic in a school, the
incidence rate describes the number of cases of measles appearing during that period in terms of the number of persons at risk:
Ex. 200/1,000 = 0.2 or 20 or 20%
Note: In prevalence rate, not everyone in a population is at risk for developing a disease. But the incidence rate recognizes this
fact.

-Computing Rates - To make comparisons between populations, epidemiologists often use a common base population in
computing rates.
For example, instead of merely saying that the rate of an illness is 13% in one city and 25% in another, the comparison is made
per 100,000 people in the population. This population base can vary for different purposes from 100 to 100,000.
- To describe the morbidity rate, which is the relative incidence of disease in a population, the ratio of the number of sick
individuals to the total population is determined.
- The mortality rate refers to the relative death rate, or the sum of deaths in a given population at a given time.

Common Epidemiologic Rate :

- Crude Mortality Rate=
(Number of Reported Deaths During 1 Year/ Estimated Population as of July 1 of Same Year) x 1,000
- Crude Birth Rate=
(Number of Live Birth During 1 Year / Estimated Population of July 1 of Same Year) x 100,000
- Case Fatality Rate=
(Number of Deaths From a Particular Disease/ Total Number with the Same Disease (Diagnosed with the same disease)) x 100
- Age –Specific Mortality Rate=
(Number of Persons in a Specific Age Group Dying During 1 Year/ Estimated Population of the Specific Age Group as of July 1
of Same Year ) x 100000
-General Fertility Rate=
(Number of Live Births During 1Year /Number of Females Aged 15-44 as of July 1 of Same Year) x1000
- Maternal Mortality Rate =
(Number of Deaths from Pueperal Causes During 1 Year/Number of Live Births During Same Year) x 100,000
- Infant Mortality Rate=
(Number of Deaths under 1 Year of Age for Given Year /Number of Live Birth Reported for Same Year) x 1000
- Perinatal Mortality Rate=
(Number of Fetal Deaths Plus Infant Deaths under 7 Days of Age during 1 Year /Number of Live Births Plus Fetal Deaths During
Same Year) x 1000
Exercise:
1-In Wilayat “Y” there are 80,648 population reported as Mid year population of 2011- 2012. There are 1512 Live births during
this particular period is reported.
-Calculate the Crude Birth Rate and compare with Oman’s CBR as per 2010 statistics.
Answer: ( 1512/80,648) x 1000, CBR = 18.74 / 1000

2-In Wilayat “Y” there are 80,648 population reported as Mid year population of 2011-2012. There are 293 deaths reported in the
same year. Calculate the Crude Death Rate.
-Compare the above result with Oman’s CDR, 2010 statistics and write your interpretation.
Answer: (293/ 80,648 )x 1000, CDR = 3.63 / 1000

3-In Wilayat “Y” there are 80,648 population reported as Mid year population of 2011-2012. There are 1512 Live births during
this particular period is reported. The total number of death of children between 0-1 year of age group is 23. Calculate the IMR for
Wilayat “ Y
Answer: (23/1512) x 1000, IMR = 15.21 / 1000

4- In Wilayat “Z” there are 183,345 population reported as Mid year population of 2011-2012. There are 15450 births reported
during this particular period. The number of deaths of mothers reported as follows.
• One died of ante partum hemorrhage, one died during delivery, one mother died due to post natal complication one died due to
road traffic accident. Please calculate the MMR.
Answer: (3/ 15450) x 100,000 , MMR = 19.41/100,000

Student’s Note:
• Please note that objectives 8, 9,10 & 11 all of them are SLA.
 C17: Environmental Health

Definition of Environment:
• WHO defines environment, as it relates to health, as “ all the physical, chemical, and biological factors external to a person and
all the related behaviors” WHO (1948/2011)

Upstream Approach to Health Impact and Environmental Health:

• The “up stream approach "emerged from the publication by John McKinley in 1979, “ A Case for Focusing Upstream” that
identifies root causes of disease and manufacturers of illness
• Identifies origin of disease from: 1– socioeconomic factors 2– environmental origins of disease
• In an upstream approach, we think of those factors that are at the institutional and system level rather than looking solely at
healthy lifestyle issues.
• Eg; Improvement of heart health:
– Regular approach- healthy diet, physical activity, smoking cessation
– Upstream approach- social factors- second hand smoke in public places, unhealthy food choices in schools, how building
impede outdoor physical activity......
• Butterfield reminds us that public health nurses are often the “ sentinels of surveillance” who detect unusual illness patterns and
respond to environmental emergencies in work and community settings.
• 33% of disease occurrence is due to environmental exposures.
• Prevalence of environmentally linked health problems such as asthma, neurological problems, certain cancers and birth defects
are all on the rise.
• Thus, nurses must use an upstream framework to assess, monitor, educate , advocate and create policy to reduce environmental
health risk .
• Butterfield identified three specific opportunities for nurses to impact these health threats:
1. By presence in hospitals, clinicians’ worksites, schools and home settings
2. Nurses haves kills to translate technical information into messages that non health professionals can understand
3. Nurses have skills to promote health at both the individual and community level

Strategic actions that can be considered as part of an upstream framework are to include:
1. Using an environmental health history in nursing assessments in order to create better tracking of environmental exposures.
2. Embedding environmental health information into nursing practice settings.
3. Increasing educational efforts to inform individuals and families of environmental health hazards.
4. Knowing information.
5. Engaging in environmental health research to advance our understanding of etiology and prevention.
6. Advocating for individuals and groups who are at specific risks.

Environmental Health Principles for Public Health Nursing:

1. Safe and sustainable environments are essential conditions for the public's health.
2. Environmental health is integral to the role and responsibilities of all public health nurses.
3. All public health nurses should possess environmental health knowledge and skills.
4. Environmental health decisions should be grounded in sound science.
5. The precautionary principle is a fundamental tenet for all environmental health endeavors.
6. Environmental justice is a right of all populations.
7. Public awareness and community involvement are essential in environmental health decision making.
8. Communities have a right to relevant and timely information for decisions on environmental health.
9. Environmental health approaches should respect diverse values, beliefs, cultures, and circumstances.
10. Collaboration is essential to effectively protecting the health of all people from environmental harm.
11. Environmental health advocacy must be rooted in scientific integrity, honesty, respect for all persons, and social justice.
12. Environmental health research addressing the effectiveness and public health impact of nursing interventions should be
conducted and disseminated.

Application of Core Functions of Public Health to the Environmental Health for Public Health Nursing:
• In 1988, the Institute of Medicine convened “ the disarray of public health” and developed the mission , role of government in
fulfilling this mission and specific responsibilities for level of government
• This resulted in the core functions of public health and the ten essential services
Assessment includes: Policy development relies upon: Assurance:
• Investigation of health hazards • Science for decision making • Seeks innovative solutions to health issues,
• Surveillance of health issues(Eg; • Educating people to create • Guarantees necessary services are provided,
disease or injury) community involvement to • Provides oversight to policy implementation
• Examining causes develop polices
• Assessing needs

• Public health nurses extend these functions by strong emphasis upon education for:
– Health promotion
– Disease prevention
– Advocacy by integrating nursing knowledge and practice into these functions
• Public health nurses work collaboratively with other in the community to promote health for the people they serve.
Places where nurses address environmental impacts:
Schools Homes Occupational settings Broad community- built environment
• Indoor air quality( • Healthy Home • Enforce safety standards at workplace • Reduce pediatric obesity
Asthma prevention) Initiative(HHI) • Educate workers • Safe walking path
• Integrated Pest • Monitor health • Recreational areas with reduced
Management(IPM) • Advocate for workers’ health exposure to pesticides in playgrounds.

Application of Core Functions in PHN:

Assessment Policy Development Assurance
• Assessment role of PHN and Knowledge base • Home
• PHN assessment: • Severe weather events
• Individual • Food safety
• Home • Environmental Justice
• Community
• Built environment
• Sustainable community
• Land use
• Toxic exposure:
• Air
• Water
• Food
• Toxic waste
• Radiation

Application of Core Functions to EHN:

Assessment Role of PHN and Knowledge Base
Environmental health sciences include:
Environmental Toxicology Risk assessment Risk management
epidemiology
A branch of “study of harmful interactions Uses scientific information by identifying and Judgments be made
epidemiology that between chemical agents and evaluating adverse events to aid in judgments about the
focuses on biological systems” about hazards in the environment. significance of those
environmental Biomonitoring The process uses risks
exposures and the 1. hazard identification,
risks that contribute 2. dose response assessment
to adverse health. 3. exposure assessment

Environmental Health Assessment "I PREPARE"

Example of Question Mnemonic Cue
Do you have symptoms that occur in one setting? Investigate potential exposures
What chemicals are you exposed to in your work setting? Present work
When was your residence built What chemicals are stored on your property? Residence
Are the environmental concerns in your neighborhood? Environmental concerns
What work have you done in the past Location? past work
What was your hobbies? Use of pesticides Activities
EPA, ASTDR, NLM, www.envirn.org Referrals and resources
Are materials available for education Educate? Environmental Health

Public Health Nursing Assessments:

1. Individual assessment:
 Part of every health visit/ workplace assessment
 IPREPARE(Table 9.3, pg 295)
 Sick building syndrome (Pg 295)- schools
2. Home assessment:
 Home Environmental Health and Safety Assessment tool
 Water, gas appliance, asbestos, lead paint
 Safe disposal of mercury devices
 Varnishes, fertilizers, pesticides management
 Air fresheners
 Mold., pets
 Coal
3. Community assessment:
 Built environment
  Windshield/walking survey
 Exhausts, Industries, Incinerators
 Sources of drinking water
 Stagnant water
 Superfund – Love Canal, Times Beach
 Brownfield sites
4. Built environment
 Physical structures( building, dams, roads)
 Location of schools, homes
 Public transportation
 Many diseases
5. Sustainable communities
 Climate change
 Global warming
 Emergency preparedness
6. Land use:
 Transport
 Soil health
 Community design
7. Toxic exposure
 Air
 Water
 Food
 Toxic waste

Sustainable communities:
(1) be personally prepared
(2) comprehend state and local disaster plans
(3) conduct a rapid needs assessment
(4) investigate outbreaks
(5) perform public health triages
(6) communicate risk effectively

Application of Core Functions to Environmental Health Nursing

• Individual Assessment & Home Assessment
• Community Assessment & Built Environment
• Sustainable Communities &Land Use
• Types of Toxic Exposures Air , Water & Food
• Vulnerable Groups, Toxic Waste & Radiation
Refer to your text book page 294-303

Policy Development:
– addresses the need for legislation to protect human health
– Addresses opportunities for nurses to engage communities to address their own health and create policy specific to their needs.
• Nurses must be a catalyst for change in order to protect community members for hazards in the environment

1. Public health
nurses must be informed about the hazards in the community, existing legislation that protects people in the community
2. Public health nurses can organize public educational programs in schools and agencies in their community to inform the public
about local hazards in their homes, schools and communities and to learn about resources to help reduce their exposures
3. They also serve on local and national committees and boards to advocate for change

Assurance:
• The regulatory function for policy ensures that appropriate services are provided
• Public health nurses must incorporate environmental health principles into practice
• Eg; A CHN can educate families to reduce their risks from environmental hazards in the home, an OHN will ensure that safety
regulations are followed in the work settings.
- Assurance guarantees that policy and regulatory functions are followed through the provision of essential services.
- Nurses are vital to assuring that essential services are provided in the community.
(4) Examples how community nurses fulfill the assurance functions:
1- Home. 2- Severe Weather Events. 3- Food Safety in the Community. 4- Environmental Justice.
 Home:
- Environmental risks contribute to serious adverse health effects that may lead to death.
- Nurses who work with families and communities are involved in many research programs and projects that can affect the home
environment.
- The home assessments or concerns for environmental health risks addressed by the Healthy Homes Initiative are (Lead, asthma
triggers, carbon monoxide, radon, pesticide use, environmental tobacco smoke as well as source of heating in the home).

Severe Weather Events:

-A second area for nurses to assure that essential services are provided to community members is in response to severe weather
events.
-There are some specific issues related to environmental risks that occur after severe weather events and include power outages,
potable water, food supplies, sewage, mold and toxic exposures.

Food Safety in the Community:

-Food safety is another area for nurses where health and safety can be assured of environmental health risks in the community.
-One specific area in which nurses have been involved in education, advocacy and policy efforts is with fish warnings.
-Bioaccumulation refers to the process where toxins accumulate in greater concentration in an organism than the rate of
elimination.

Environmental Justice:
-The EPA defines environmental justice as the fair treatment and meaningful involvement of all people regardless of race, color,
national origin, or income with respect to the development, implementation, and enforcement of environmental laws, regulations,
and policies.

Global environmental health:

-Nurses must think globally in order to be effective locally.
-Broadening thinking to consider foods imported from countries
around the world , toy made in other countries.
-Nurses who work for “green nursing “ by promoting more ecological and environmentally safe practices in their workplace are
making an impact upon global environmental health.

MOH strategies to reduce mortality and morbidity related to environmental factors :

1. Conducting comprehensive studies to evaluate drinking water resources and the diseases resulting from its contamination.
2. Implementations of integrated vector control & rational use of pesticide as a national policy.
3. Early detection and appropriate management of chemical poisoning cases.
4. Development& implementation of occupation health & safety program.
5. Qualifying and training of national staff in field of environment health ,poisoning, and occupational health.
6. Conducting studies and field research with the objectives of evaluation and development.
7. Development & implementation of a national policy for safe management of medical waste in co-ordination with related sectors
8. 1-8 Health impact assessment of the developmental project before and after being establish.
9. 1-9 Implementation of WHO initiative to provide healthy environment for children.
 C18: Disaster in the Community
Definition:
● Disaster is any natural or man made event that causes a level of destruction or emotional trauma exceeding the abilities of those
affected to respond without community assistance.

Types of Disaster:
● Two categories: Natural disaster and Man made disaster
● Natural Events such as the earthquake and tsunami.
● A Man made disaster is caused by human activity shootings(Iraq and Iran), bombing ( Yemen, Iraq), riots (Bahrain, Libya and
Egypt) and wars (Kuwait, Iran and Iraq). Others include nuclear reactor meltdowns: industrial accidents; oil spills; construction
accidents and air, train, bus and subway crashes.
● Many at times, man made disasters can and frequently do follow natural disasters as occurred with the nuclear reactors in Japan
following the earthquake and tsunami in 2011.
● A casualty is a human being who is injured or killed by or as a direct result of an accident. Disasters are commonly
characterized by the number of casualties involved
1.Multi casualty incident: more than two people but fewer than 100.
2.Mass casualty incident: involving 100 or more casualties.

Types of Disaster: Others

● Two categories: Natural disaster and Man made disaster
● NATURAL DISASTER:
1. Meteorological : Hurricanes, tornados, hailstorms, snowstorms, and droughts.
2. Topological: landslides, avalanches, mudslides, and floods.
3. Disaster originates from underground: earthquakes, volcanic eruptions, and tidal waves.
4. Bacteriological: communicable disease epidemics e.g. Ebola virus and insect swarms e.g. Locusts

Man made or Human Generated Disaster:

● Warfare:
1. Conventional warfare( Bombardment, blockage and siege)
2. Non conventional warfare: nuclear, chemical and biological : acts of terrorism
3. Civil disasters: riots and demonstrations .

● Scope: Disaster is the range of its effect, either geographically or in terms of the number of people impacted. The collapse of a
500 unit high rise apartment building has a greater scope than the collapse of a bridge that occurs while only two cars are crossing.
● Intensity: of a disaster is the level of destruction and devastation it causes. For instance, an earth quake centered in a large
metropolitan area and one centered in a desert may have the same numeric rating on the Richter scale, yet have very different
intensities in terms of the destruction they cause.

Role of community Health Nurse

1. Primary Prevention : a. Preparing for Disasters
2. Secondary Prevention : b. Responding to Disasters
3. Tertiary Prevention :c. Supporting Recovery from Disasters
Refer text book from 547-555 and plan for a Role play.