Community Health Nursing PDF 2023-2024

Community Health Nursing For 4th year under graduate students Prepared by Staff Member of Community Health Nursing Department 2023-2024 Faculty vision and mission Vision Aspiration of Faculty of Nursing, Minia University to be a center of excellence in nursing education and conduct scientific research for the development of performance and to provide health services and nursing distinct. Mission Faculty of Nursing, Minia University, and Its mission in being prepares its graduates to be able to give and deliver high quality nursing care, as well as play an active role in community service and development and to participate in scientific research and its applications, and self-development and continuing education. Department vision and mission Vision Community Health Nursing Department provide nursing students with the necessary knowledge and skills that provide preventive, therapeutic and rehabilitation nursing services for the individual, the family and the community supported by evidence-based practices and also provides community health services and the application of scientific research based on the health needs of the community. Mission Preparing qualified cadres in the field of community health, both scientifically and professionally, to provide health care for the individual, the family and the community, as well as a competition in the local and regional labor market, while enabling institutions and community organizations to meet the health needs of the society. Community health nursing The Community Health Nursing Department objectives The Community Health Nursing Department aims to achieve the following objectives Updating the scientific curricula assigned to the department, including teaching, teaching aids and evaluation system Strengthening the educational skills of faculty members in the department Updating research plans according to local health needs of the community and emergency health issues Communicate health, education and research activities to local and international communities Develop highly qualified nurses to provide comprehensive health care to the individual, the family and the community. Strengthen the relationship between the college and the community through participation in community activities, volunteer work and medical convoys. Collaborate with governmental and non-governmental organizations in identifying and meeting health needs. Employ scientific research to solve problems related to community health. Preparation students who are professionally qualified, skilled and professionally qualified to provide nursing care in the areas of community health in accordance with international quality standards -3-|Page Community health nursing CONTENT & INDEX Topic Page 1. Overview to Community Health Nursing. 5 2. Community Assessment and Diagnosis 16 3. School Health Nursing 28 4. Maternal and Child Health (MCH) 44 5. Communicable Diseases 75 6. Environmental sustainability and climate change 99 7. Family Health 124 8. Disabilities and Rehabilitation 136 9. Home Health Care and Home Visit 153 10. Occupational Health nursing 168 11. Primary Health Care 182 12. Women Health 193 13. Community With Disaster 206 14. Care of Elderly Client 217 15. Health Promotion 236 16. Refreneces 250 Distribution and grads Total grads 200 Clinical 40 Semester work 60 Final Written Exam 80 Final Oral Exam 20 Total 200 -4-|Page Community health nursing Overview of Community Health Nursing 5|Page Community health nursing Overview of Community Health Nursing Intended Learning Outcomes (ILOs): By the end of this lecture the student will be able to achieve the following objectives: ▪ Define community and relevant concepts. ▪ Distinguish between community health nursing and community-based nursing ▪ List characteristics and functions of community health nurse. ▪ Explain principles of community health nursing ▪ Differentiated between client, delivery, and population-oriented role performed by community health nurses. 6|Page Community health nursing Overview of Community Health Nursing Biomedical According the biomedical model, health means the freedom from concept disease, pain or defect. This model focus on the physical, processes, such as the pathology, biochemistry and physiology. Ecological the science of mutual relation between living organism and their concept environment. The ecologist put forward a hypothesis that health is a dynamic equilibrium between man and environment Psychosocial Contemporary development in social science. Revealed that health is not concept only a biomedical and ecological phenomenon but influenced by social, psychological, cultural, economic and political factors. Holistic concept Defined as unified multidimensional process involving the well-being of whole person in the contest of his environment. Definition of A collection of people who interact with one another and whose community: common interests or characteristics form the basis for a sense of unity or belonging. Examples of some communities: - Citizen of town - group of farmers - prison community - professional nurse Tiny village Community The identification of needs and the protection and improvement of collective Health: health within a geographically defined area Public health Is art and science of preventing diseases, prolonging life, promoting health, and efficacy through organized community effort. Or activities that societies, undertaken to assure the conditions in which people 7|Page Community health nursing can be healthy Aims of public health 1. sanitation of the environment 2. control of communicable diseases 3. education of individual Community Is a field of professional practice in nursing and in public health in Health which technical nursing, interpersonal, analytical, and organizational Nursing: skills are applied to problems of health as they affect the community. Is population –focused, with the goal of promoting health and preventing disease and disability for all people through the creation of conditions in which people can be healthy. Nursing: encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all setting. Nursing includes the promotion of health, prevention of illness, and care of ill, disabled, and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy. Neighborhood: A smaller, more homogeneous group than community that involves interaction and a level of identification with others living near-by. Population: the general public or society or a collection of communities Aggregates: populations with some common characteristics that frequently have common concerns, but many not interact with each other to address those concerns. 8|Page Community health nursing Objectives of Community Health Nursing: To increase capability of individuals, families, and groups and community to deal with their own health. To strengthen community resources. To control and counteract environmental hazards. To prevent and control communicable and non-communicable diseases. To provide specialized services for mothers, children, adults, workers, elderly handicapped and eligible couples etc. To conduct research that contributes to the further refinement and improvement of community health nursing practice. To participate in preparing health personnel to function in community for community health care services. To supervise, guide and help health personnel in carrying out their functions effectively. Philosophy of Community Health Nursing: Philosophy of individual’s right of being healthy. Philosophy of working together under a competent leader for the common good. Philosophy that people in the community have potential for continued development and are capable of dealing with their own problems if educated and helped. Philosophy of socialism. 9|Page Community health nursing Principles of Community Health Nursing: Community health nursing is community focused, it is therefore essential to know the defined community, make a map and essential effective working relationship. Community health nursing is based on identified community health nursing needs and functions within total community health programmes. Health education, guidance and supervision are integral part of community health nursing services. Professional relationships are essential in community health services. Individuals and families participate fully in all decision making relating to attainment of health. Continuous services are effective services and community health nurse must provide continuous health services. Well-developed system of records and reports is essential for community health services. Periodic and continuous appraisal and evaluation of health situation and health services are basic to community health. Health services should be available and accessible to all without any discrimination. Health worker should be non – political, non-sectarian in her / his relationship. Health worker must maintain professional dignity and must never accept any gift or bribe. 10 | P a g e Community health nursing Characteristics of Community Health Nursing: Integral part of community health. a specialized field of nursing. synthesizes community health with nursing. the whole community is the client. emphasizes on primary level prevention. promotes self-care responsibility. involves multidisciplinary team approach. working for people, with people and by people. seeking support from and giving support to personnel from other sectors working for welfare and development in the community. dealing with wide range of health problems and health needs and providing need based generalized health services. Community health nursing is providing continuous and not episodic care. Trends influencing community health Nursing: Community Health Nursing practice today affected by several newer developments in the field of medicine, nursing. Several trends currently influencing community health and nursing. they are: 1-Demographic trends: o Increase population o Greater percentage of elderly people 2-Technological trends: o Knowledge explosion o Environmental pollution 3-Socioculture trends: o Health insurance o Mass communication 11 | P a g e Community health nursing 4-Economic trends: o Rising cost of health care Hospital Nurse and Community Health Nurse: Hospital Nurse Community health Nurse Setting Work in hospital Work in community settings, homes, school, industries, and hospital….etc Nursing Specialized I.e. works with Generalized i.e. works with all concern specific age or disease. groups and different diseases. Interdependent within the Interdependent within the health health sector. sector and other sectors. Provide comprehensive Provide comprehensive cares to cares to individual patients individuals, families and only. community. Applies professional nursing Applies professional practice with practice. basic community health nursing Condition requiring practice. hospitalization i.e. sick Prevailing health problems and individuals and disabled community needs. Total population especially under served and high-risk groups Main principle in her Main principle in her practice is practice is curative, prevention, early case finding, prevention of complication health teaching, follow up and and health teaching i.e. focus family self-direction i,e, focus mainly on secondary and mainly on primary prevention. tertiary prevention. Improved patient, family, 12 | P a g e Community health nursing Patient well to be community health and self-care discharged. The nurse is the hostess The nurse is a guest Setting for Community Health Nursing (C.H. N) practice: Homes Ambulatory service settings It includes a variety of places for CHN. These are places where clients come for day service e.g. MCH, TB clinic School Occupational health settings Residential institution Function of community health nursing: Providing care to the ill and disabled in their homes. Maintaining healthful environments. Teaching about health promotion and prevention of disease Identify those with inadequate standards of living and untreated illnesses and disabilities and referring them Preventing and reporting neglect and abuse. Collaborating to develop appropriate, adequate, acceptable health care services. Ensuring quality of nursing care and engaging in nursing research Community based nursing: Application of the nurses process in caring for individuals, families and group were they live, work or go to school or as they move through the health care system. 13 | P a g e Community health nursing Community health nursing and community based nursing are two different Community health nursing emphasizes preservation and protection of health while community based nursing emphasize managing acute or chronic conditions. In community health nursing, the primary client is the community while in community-based nursing, the primary clients are the individual and family. Services in community based nursing are largely direct while in community health nursing services are both direct and indirect. Community health nursing roles: A. client oriented roles B. delivery oriented roles C. population oriented role A. client oriented roles Care giver: used the nursing process to provide direct nursing intervention to individuals, families, or population groups Educator: facilitates learning for positive health behavior change Counselor: teaches and assists clients in the use of problem solving process Referral resources: links clients to services to meet identified health needs Role model: demonstrate desired health related behavior Advocate: speaks or acts on behalf of clients who cannot do so for themselves Primary care provider: provide essential health services to promote health, prevent illness, and deal with existing health problems 14 | P a g e Community health nursing Case manager: coordinates and direct the selection and use of health care services to meet client needs, maximize resources utilization, and minimize the expense of care B. delivery oriented roles 1-Coordinator/ care manager: Organize and integrate services to best meet client needs in the most efficient manner 2-collaborator: engages in shared decision making regarding the nature of health problems and potential solutions to them 3-liaison: provide and maintains connections and communication between clients and health care providers or among provides C. population oriented role 1-case finder: identifies clients with specific health problems -geared toward awareness of population level problem 2-leader: influences clients and others to take action regarding identified health problems 3-change agent : initiates and facilitates change in individual or client behavior or conditions or those affecting population groups 4-community developer: mobilize residents and other segments of the population to take action regarding identified community health problems 5-coalition builder: promotes the development and maintenance of alliances of individuals or groups of people to address a specific health issue 6-researcher: conduct studies to explain health related phenomena and to evaluate the effectiveness of interventions to control them 15 | P a g e Community health nursing Community Assessment and Diagnosis 16 | P a g e Community health nursing Community Assessment and Diagnosis By the end of this lecture, the student will be able to : Describe meaning of community Needs: - Identify the goals of community assessment Describe meaning of community Assets: - Mention approaches can be used Identify important of community assessment Types of Community Needs Assessment Describe sources of community data Discuss community assessment process Explain community assessment methods 17 | P a g e Community health nursing Community Assessment and Diagnosis Introduction In order to effectively serve a community, it is important to understand the community. This understanding can be achieved through a community assessment. The findings from an assessment will define the extent of the needs that exist in a community and the depth of the assets available within the community to address those needs. This understanding of needs and assets can be used to strategically plan and deliver relevant, successful, and timely services. Definition of Community Needs: - The process of determining the real or perceived needs of a defined community of people The goals of a community assessment 1- Is to develop an informed understanding of the gaps or needs that exist within a community and their impacts upon the community‘s members. 2- Is to develop a detailed analysis of community assets, or resources, that currently exist in the community and can be used to help meet community needs. Definition of Community Assets: - Community assets are defined as ―those things that can be used to improve the quality of life. Community assets include organizations, people, partnerships, facilities, funding, policies, regulations, and a community‘s collective experience. Any positive aspect of the community is an asset that can be leveraged to develop effective solutions Two approaches can be used for community asset 1- The first approach is to identify the assets that are already known for supporting community needs. This includes community organizations and 18 | P a g e Community health nursing individuals that currently provide services to community members or have provided financial support to address the needs. Organizations that provide after-school programs to help youth graduate on time would be included in a community assessment focused on keeping kids in school. Clinics that offer free medical services to low-income seniors should be identified in a community assessment of seniors who need medical financial assistance. 2- A second approach to identifying community assets builds upon the experiences of other communities to highlight resources that may be available. The community assessment can identify communities with similar demographics that have successfully addressed similar needs, and can provide insight about the assets used in those communities. The community can then determine if similar assets can be found in its community. Why Should You Conduct a Community Assessment? There are many benefits to conducting a community assessment. Listed below are just a few. 1) You can work with your community partners to identify additional benefits in your community as an exercise to build consensus and buy-in for the process. 2) There is increased understanding within the community about its needs, why they exist, and why it is important for the needs to be addressed. 3) Community members have the opportunity to share how the needs impact the quality of life for the larger community. 4) Community engagement is increased because members from different parts of the community are included in discussions about needs, assets, and the community‘s response. 19 | P a g e Community health nursing 5) The community‘s strengths and weaknesses are identified. 6) There is an inventory of the resources currently available within the community that can be leveraged to improve the quality of life for its community members. 7) Communities identify the asset gaps that exist in their communities. 8) Community members have an increased awareness of how they can contribute to their community‘s assets. 9) Community organizations can use the information about community needs to assess their service delivery priorities. 10) There is data for making decisions about the actions that can be taken to address community needs and how to use the available assets. 11) Data can be used to inform strategic planning, priority setting, program outcomes, and program improvements. Types of assessment depends on : 1-needs 2-goals to be achieved 3-resources available Types of Community Needs Assessment 1. Familiarization or “ Windshield Survey ” It is the most necessary type Nurses drive or walk around the community ,find health , social and governmental services , obtain literature , introduce themselves as working in the area , and become familiar with the community 2. problem- oriented assessment Begins with a Problem and then assess the community in terms of that problem. 20 | P a g e Community health nursing Used when a familiarization assessment is not enough and a comprehensive is too expensive. Respond to a particular need. 3. Community Subsystem Assessment: CHN focuses on a single dimension of community life. 4. Comprehensive assessment: to discover all relevant community health information. Begins with a review of existing studies and all data available now in the community. Survey (demographics) , Key information interviewed in every major system ; then more detailed interviews and surveys to get more information on organizations and their various roles within. NB: It is seldom performed because expensive and time consuming. Community Assets Assessment : focuses on the strengths and the capacities of the community rather than the problems alone - Begins with what is present in the community. - Capacities and strengths of community members are identified ,focusing on creating relationships among local residents, associations, and institutions to multiply power and effectiveness Sources of Community Data 1. Primary Sources: Health team members obtained directly from the community. 2. Secondary Sources: Health team members, client records, community health statistics, Census Bureau Data, reference books, research reports, community health nurses. 3. International Sources: WHO,UNICEF,Internet sources. 21 | P a g e Community health nursing 4. National Sources : MOH, Bureau of the Census 5. Local Sources: chamber of commerce, hospitals, social service agencies, School districts, municipalities, universities or colleges. The community assessment process There are a six-step process for planning and conducting a community assessment: Step 1: Define the Scope Community issues are complicated. One issue is often related to many others, and it is easy to keep expanding the range of issues to include in your community assessment. Let‘s look at the following example: High school dropout rates are related to homelessness. Homelessness is related to head-of-household unemployment. Unemployment can lead to gang involvement. Gang involvement is related to high school dropout rates. Gang involvement can be prevented if efforts are targeted at middle school youth. Step 2: Decide to Go Solo or Collaborate Deciding the scope will highlight the choices available to you for conducting your community assessment. You can decide to ―go solo and carry the entire responsibility for completing all of the community assessment activities; or, you can work with community partners as a collaborative project to complete the assessment. Potential community partners include corporations, nonprofit organizations, and local community organizations, foundations that provide grants to your community, universities, and government entities. 22 | P a g e Community health nursing Benefits of Collaboration: Engages more community members in the assessment planning and implementation. Increases access to more data sources to answer the key questions. More resources are available to conduct the assessment and cover expenses. Establishes relationships that will be important for leading actions identified in the community assessment findings. Step 3: Collect Data This step will guide you through finding credible sources of information and, when necessary, 1- Developing your own data collection tools. 2- Consider the amount of time and resources you have available prior to selecting any specific method or combination of methods. 3- Prioritize your data collection needs according to what is essential to complete your community assessment. 4- Document your data collection efforts using the ―creating a data collection plan worksheet‖. In using this tool, you will list the key questions that you identified in Step 1 and then identify probable sources of information. Step 4: Determine Key Findings The data collection step will result in a lot of data and information about your community needs and assets. You can analyze the data to identify the assessment‘s key findings. Key findings serve several purposes: 1- They validate anecdotal evidence of community needs and assets. 23 | P a g e Community health nursing 2- They highlight significant trends found in the data collection process. 3- They reveal differences across segments of the community. 4- They help clarify answers to the community assessment‘s key questions. Step 5: Set Priorities and Create an Action Plan The completion of a community assessment process should allow you to make informed decisions about your goals and objectives. You are able to identify specific needs that came up in your assessment that you want to address. Step 6: Share Your Findings The last step of your community assessment is to share what you have learned with others and to disseminate your plan. Now that you have taken the time to find out information about your community, you should allow the community to benefit from your findings. Community members are more likely to support your efforts when they have a clear understanding of the work you have done and of what their community needs. Community Assessment Methods A- Surveys Method: Series of questions is used to collect data It has three phases; 1. Planning phase: to determine sampling and tools for data collection. -determine the what and why. -determine precise data to be collected. -select population (household, block, neighborhood). -select survey methods , instrument ( interview , telephone call , questionnaire ) 24 | P a g e Community health nursing -sampling size ( % of the total population in question ) 2. data collection phase : -identify and train data collectors. -pre-test and adjust instrument -supervise actual collection, planning, for non-responses or refusals. 3. data analysis and presentation phase - organize data for tabulation and analysis. - apply appropriate statistical methods - determine relationships and significance. - report the results and include implications, recommendations, and next steps, providing a feedback to the community surveyed throughout a community forum. B- Community forum / town hall meeting Method A qualitative assessment method designed to obtain community opinions. Members are invited representing all segments of the community involved with the issue Inexpensive method and results are obtained quickly ( Krueger 1994 ) Used to elicit public opinion on a variety of issues TV programs with a “yes” or “no” vote on an issue. C- Focus Groups Method Designed to obtain grassroots opinions. it is a small group process ( 5 to 15 people) Members chosen for the group are homogenous in terms of demographic variables Leadership skills are used and small group process to promote discussion the interviewer guide the discussion according to a pre-determined set of questions or topics 25 | P a g e Community health nursing Group meets for 1-3 hours and may meet in a series. Assessment data can be collected from several groups over a period of time. Efficient and low cost methods. Cornell University Cooperative Extension identifies four barriers to priority setting and offers suggestions for minimizing these barriers: 1. The Human Problem — the difficulty of getting people to focus on key issues, decisions, and conflicts Start by striving for consensus on what you are trying to accomplish by priority setting. Why are we doing this and what are the stakes? Actively recognize that there is strength in differing viewpoints and don‘t place viewpoints in value order. Build in time to allow people to reflect on information presented, digest it, and modify decisions. 2. The Process Problem — the challenge of managing information and ideas during a priority-setting process Be very specific in defining priorities to minimize multiple interpretations. Make key information available prior to decision meetings. Be aware of taking too much time to analyze information (―analysis paralysis‖) and/or rushing to meet deadlines. 3. The Structural Problem — the difficulty of priority setting across different issue areas Cultivate open communication. 26 | P a g e Community health nursing Carefully nurture relationships throughout the planning process. Keep focus on current priorities, not precedent. 4. The Institutional Problem — the challenge of translating priorities into action Build on existing strengths in implementation. Ensure that you have a well-defined implementation plan. Make sure that individuals responsible for carrying out key tasks are committed to implementing changes. 27 | P a g e Community health nursing School Health Nursing 28 | P a g e Community health nursing School Health Nursing Intended Learning Outcomes (ILOs): By the end of this lecture the student will be able to achieve the following objectives: Define coordinated school health program. List the members of a school health team. List eight components of a coordinated school health program. Describe the role of the school health nurse. Describe nutritional needs for school age children Define school health education. Explain nursing services in school Discuss role of the nurse in school health program 29 | P a g e Community health nursing School Health Nursing Introduction The schools play an important part in society and in the development of the nation. As children learn best when they are healthy, so the promotion of good health among school children will contribute to their ability to learn and participate well in all aspects of the educational program. Education and schooling Education is not just academic learning and rate learning but the most important aspects of education include: 1. Learning to take responsibility and rights in a society. 2. The development of each child’s individual talents. 3. Learning to solve problems of everyday life. 4. Learning the meaning of a good citizen Characteristics of school age period 1. It is the period of growth and development, physically, mentally, socially and emotionally. 2. Period of stress and strain. 3. During this period school plays an important role in the real structure of a community. The school health program Is a combination of many intcrrd3tcd Activities which may include health education, School health services and school environment protection services. Components of school health program 1. Healthful school environment a. Physical environment 30 | P a g e Community health nursing The standards of cleanliness, heating, lightning, and ventilation influence the children’s health, comfort and ability to learn, suitable eating and adequate spaces are also important children should be supervised and taught to keep their environment clean, pleasant and welcoming. The physical environment includes: 1. Building: easily accessible, away from noise with sufficient play area. 2. Classroom: 6x8 or 5x7 meters and number of students' 30-40 students. a. Ventilating window area is at least one-sixth of the floor area. b. Light: natural (Window) and artificial for cloudy days or evening school. c. Desks and seats: properly designed for the student’s body. 3. Water supply: Piped water in urban and underground in rural areas, presence of drinking fountains and provides soap to lavatories to prevent infection. 4. Refuse disposal: Should be collected and disposed daily, put small baskets in playground and classrooms. 5. Sewage disposal: suitable type of latrine according the area in use. 6. Insect control: application of insecticides. 7. Food sanitation: special consideration to the canteen and avoiding the food handlers around the school. The school meals should be: ▪ Nutritious and adequate. ▪ Cooked under hygienic conditions. ▪ Available to every child. 31 | P a g e Community health nursing b. Non-physical environment: 1. Good relationship between students, teachers and parents. 2. Good relationship between the children themselves. 3. Homework are properly arranged to prevent fatigue. 4. The involvement of parents in their children’s education. 5. The influence of teachers on the children. 6. Opportunities for developing talents. 2. School health services a. activities: Defined: Its mean organized activities to assess the complete health status of the pupil from the physical mental and emotional conditions. This is done through: ▪ History taken: past and present health problem ▪ Observation: signs of sickness or deviation from normal ▪ Screening tests: vision, hearing, speech, weight and height ▪ Laboratory investigation: urine, stool, blood and chest x-ray ▪ Medical examination: done at the start of each new grade, by physicians, dentists and nurse ▪ Special surveys: to detect any health problem e.g. D.M..etc. b. Follow up and counseling: done by the doctor, teacher and nurse c. Prevention and control of communicable diseases: Examples ▪ Respiratory diseases: common cold sore throat measles chicken pox, mumps...etc. ▪ Food and milk borne infection. ▪ Skin diseases: scabies ringworm. ▪ Eye infection: trachoma, conjunctivitis 32 | P a g e Community health nursing Measures of prevention 1. Healthful environment. 2. Immunization a. Booster dose of DT in 1st and 4th year of primary school. b. Vaccination in case of epidemics. c. Vaccination of meningitis 1st and 4th year of primary school 3. Daily observation of all pupils for early case findings. 4. Period of isolation of the child at home for each of the following diseases: Days 21 Hepatitis Days 18 Whooping cough Days 10 Scarlet fever Days 14 Measles Days 7 G. Measles Days 14 Chicken pox Days 14 Mumps 5. Readmission to school after sickness, for some diseases as diphtheria and typhoid three (-ve) consecutive lab. Bacteriological tests are needed before readmission to school. 6. Care of contacts by observation or given chemo prophylaxis as in meningitis. 7. Care of absence. 8. Screening for infectious diseases and source of infection. 9. Examination and treatment of food handlers particularly those working inside the school and dealing or serving food or meals to students e.g. personnel working in the school canteen. 10.Health education for communicable diseases. 33 | P a g e Community health nursing d. Early detection and correction of non-communicable diseases: Such as eve defects, acute illness as middle ear infection dental problems, malnutrition, emotional problems and parasitic diseases as oxyurids and ascaris. e. Emergency care and first aid their must be: ▪ Immediate care and referral. ▪ Notifying parents. ▪ Plans accident, fire and traffic accidents prevention. ▪ Prepare a suitable room for emergency care with suitable supplies and equipments. ▪ Trained personnel and pupils in first id procedures f. Care of handicapped children: Need medical, social, and educational care. Most specialists prefer education of handicapped children on the same school with normal children whenever possible. g. Health services for school personnel: Good health of the teacher is a pre-requisite for a good educational program as well as for prevention of spread of diseases. 3. Curative activities and health insurance, it includes ▪ Treatment of any discovered disease. ▪ Referral for specialist care. ▪ Social and health education activities. Student’s health records and recording: To provide continuing information on the health status of each child, there are 2 types of records: 1. The public health record including: a. History of illness. 34 | P a g e Community health nursing b. Immunization. c. Result of screening tests. d. Community agencies caring for child. 2. The teacher’s observing contains pertinent informality noticed by the teacher regarding the child. 4. School health education: 1. Health education is the process of providing learning experience for the purpose of influencing knowledge, attitude and changing behavior into a healthful one. 2. Health education is an essential component of any school health program. 3. It should be integrated into the overall curriculum; there are two types formal and informal. 4. As education helps children to understand the meaning of health and create health consciousness which will reflect on their behavior. 5. It provides a variety of learning experience as classroom discussion, problem solving activities demonstration, films, field trips and use of textbook. Needs of school age group 1. Nutritional needs: ▪ School age children are in a period of slow steady growth and their nutritional needs are relatively stable. They need 2400 calories /day. 15% protein, 35% fat, 50% carbohydrate, vitamins, minerals, water and salts. ▪ School age children can eat the general family diet with Exception of tea and coffee. 35 | P a g e Community health nursing ▪ Snacks are most likely to be the primary source of nutrients for the school age children. ▪ Diet should include a proper balance of protein, fat, carbohydrate, vitamin, minerals, water and salts. ▪ Eating disorder among school children such as anorexia nervosa and bulimia. ▪ Federally found programs such as School breakfast program and school lunch program were initiated to ensure that all children have access to these-two meals during the school day. Nutritional education program Nutritional education is essential and must include parents, teachers and children need to know and understand the food pyramid, how to make healthy choices for snacks, and the importance of balancing physical activity with food intake. Obesity, dental caries, anemia, and heart disease can be reduced or prevented with proper education and lifestyle changes. 2. Protection from infection 1. Booster immunization. 2. Healthful school environment. 3. Daily observation of all pupils for early detection of any disease or problem. 4. Readmission to school after sickness. 5. Care of contacts. 6. Care of absence. 7. Screening for infectious diseases, scabies, and ringworm. 3. Maintenance of health 1. Prevention of communicable disease and accidents. 2. Avoid noise, noisy places around school. 3. Building must be wide with sufficient play area. 36 | P a g e Community health nursing 4. Good ventilation of classroom and has windows. 5. Safe-Water supply and natural and artificial. 6. Light Glean baths and insect control. 4. Exercises ▪ School program should include physical training to improve the circulation of blood and help in muscle flexibility. ▪ Teach children the ideal body mechanism e.g. proper positioning while sitting, reading, writing.... etc. 5. Rest and sleep The school child needs adequate periods of rest and sleep. This differs according\to the age of the school child. 6. Curative services ▪ Treatment of any discovered cases. ▪ Referral through health insurance system. ▪ Emergency cares and first aid. 7. Psycho – social needs ▪ School age child need security, safety and peer groups. ▪ They need organized games for team play and learn how to be a leader. 8. Health education ▪ Good educational program for prevention of spread disease. ▪ The children must understand the meaning of health and create health consciousness, which will reflect on their health behavior. Main causes of morbidity and mortality among school children 1. Morbidity ▪ Parasitic diseases e.g Ascaris. ▪ Respiratory diseases: Influenza, tonsillitis, bronchopneumonia. 37 | P a g e Community health nursing ▪ Skin diseases: Scabies, ringworm, Tania. ▪ Infectious diseases: Mumps, typhoid and paratyphoid, whooping cough. ▪ Dental problems: Malocclusion, dental caries. ▪ Rheumatic fever. ▪ Eye diseases: Defective vision, conjunctivitis. ▪ Accidents: Motor vehicle, bleeding, wound, fractures broken. ▪ Diarrhea diseases. ▪ Food poisoning. ▪ Handicaps: Visual, hearing, heart disease. ▪ Emotional problems: Tears, worries, frustration, insecurity and conflict, nail biting, over aggressiveness. ▪ Deficiency diseases protein impaired growth iron lead to anemia, vit.A lead to eye manifestation, calcium and vit.D lead to dental caries. 2. Mortality ▪ Infectious diseases. ▪ Accident. ▪ Rheumatic fever. Health problems of school age children The mortality rates of school age children (5-14years) are low and decreasing they have dropped from 4 per 1000 in 1900 to 0.24 per 1000 currently. Again, this reduction can be credited to effective prevention and control of acute infectious diseases of child hood, Today motor vehicle accidents lead the list of causes of death for children aged 5-14 years, followed by all other accident, congenital anomalies, homicide heart disease, pneumonia and influenza. 38 | P a g e Community health nursing 1. Communicable disease Morbidity in school children, however, is high children of this group are most often affected by respiratory illness. followed by infection and parasitic, disease, injuries and digestive condition among school children, the incidence of measles, rubella, mumps, pertussis has dropped considerably because of widespread immunization efforts. 2. Poor nutrition and dental health Nutritional problems (primary overeating and inappropriate food choices) and poor dental health. Obesity often begins in childhood and becomes a risk factor for heart disease, hypertension and diabetes. As many as 15% to 20% of school age children are overweight. School children often unreasonably high in sugar and fat increase the incidence of coronary arteriosclerosis and dental caries in this population group. 3. Behavioral and learning problem Behavioral disorders and development disabilities are problems of this age group often becoming exacerbated when the child enters school. Approximately 10-15% of school-aged children have learning disabilities and behavioral problems 4. Juvenile delinquency A delinquent child is a child who has committed on offence e.g. theft, sexual assault, murder, burglary, inflecting injury on others. Delinquency embraces all deviations from normal youthful behavior and includes the incorrigible, ungovernable habitually disobedient and those who desert their homes and mix with in normal people. The Highest incidence is found in children aged 15vears and above the incidence among boy is 4-5 times more than girls. 39 | P a g e Community health nursing School nursing Services Definition of School nursing School nursing is a specialized practice of professional nursing that advanced the wellbeing academic success, and lifelong achievement of students. Nursing service in schools ordinarily consists of 3 overlapping areas: 1. Health supervision Included such activities as health assessments, vision and hearing screening, and health deficit identification. 2. Health counseling Involves providing interpretation of health information, guidance and counseling regarding health behavior and recommendations regarding individual and group health conditions. 3. Health education: Refers to planning, promoting, and implementing health instruction as well as providing consultation services in health-related matters. This should be integrated within the school curriculum. Teaching and counseling carried out by the school nurse differ from school to another according to the school system and different occasions. Role of the nurse in school health program 1. Healthful school environment a. Physical environment ▪ The nurse must liaise with staff in ensuring that there is a high stander of environment hygiene, (water, sanitation, latrine, dormitories). ▪ Daily rounds in the classes to be sure that there is good ventilation and good lighting. 40 | P a g e Community health nursing ▪ Daily round in the bathrooms, to ensure adequate water supply and proper sewage disposal. ▪ Write a report on the building in a special book and present it to the administrator and the physician. ▪ Be alert to environmental deficiencies and hazards and make suggestions to the maintenance department. b. Non-physical environment ▪ The nurse must involve teachers and parents in children’s problems. ▪ She must give support to teachers and parents and promote good interpersonal relationships. ▪ Promote good teacher pupil relationships. 2. School health services a. Preventive arthritis ▪ Health appraisal: Taking history (personal, family, medical history etc...). Health observation signs of sickness and deviation from normal. Prepare pupils to screening tests and laboratory investigations. Screen vision, hearing, and measure weight and height. Help in laboratory investigations. Assist in comprehensive medical examination for school children. Interpret the findings of screening tests and laboratory investigations to the teachers and parents. Conduct special surveys to detect any health problem. 41 | P a g e Community health nursing ▪ Follow up and counseling for the children deviated from normal. ▪ Prevention and control of communicable diseases: Provide immunization Daily observation of pupils for early case findings, referral and isolation Prevention and control of outbreaks of infection Care of contacts Care of absence Be sure that food handlers in the school pass through physical examination and have a healthful certificate Ensure healthful school environment ▪ Early case finding and referral of non-communicable disease and parasitic disease ▪ Emergency care and first aid: The nurse so responsible to carry our first aid treatment for the injured due to accident, and if necessary, transfer them to hospitals or clinics. Be sure that there is enough first aid equipments and supplies in the school to carry out first aid. The nurse should arrange for in-service training program for teachers interested in first aid. ▪ Care of handicapped children: Identify child with handicap (e.g. poor hearing or vision, epilepsy, mobility difficulties) and arrange referral, treatment and support. Help handicapped students to accommodate with their defects. 42 | P a g e Community health nursing ▪ Health services for school personnel according to the needs. b. Curative activities: ▪ Referral for treatment of any discovered diseases ▪ Children in need of remedial treatment or special care should be identified (as should any child with special learning problems). ▪ Filling the health record and keeping it. ▪ Interpret the finding and record available for teachers and physicians. 3. School health education ▪ The nurse can participate in the parent counsel and stimulate the interest and cooperation of parents in the school health program. ▪ Formulate health association. ▪ Conduct health conferences with teachers about student’s health problem. ▪ Assist in planning curriculum for health instruction ▪ Emphasize utilization of community resources and guides parents in selecting suitable agencies for assistance of their children. ▪ Give health education to sick children about how to prevent the re- infection. ▪ The nurse can participate in class discussion in occasions such as: immunization, medical examination and accidents. ▪ The nurse should help in planning and conducting school health projects. 43 | P a g e Community health nursing Maternal and Child Health (MCH) 44 | P a g e Community health nursing Maternal and Child Health (MCH) Intended Learning Outcomes (ILOs): By the end of this lecture the student will be able to achieve the following objectives: ▪ Describe the objectives of MCH program. ▪ Identify the functions of MCH centers. ▪ Describe the program of child-health. ▪ List 4 main reasons why mother & children health must be given top priorities in health programme ▪ Mention recent trends in MCH services ▪ Discuss the principle for MCH program ▪ Discuss the indicators for MCH programmer ▪ Identify the function of MCH centers for childcare. ▪ Identify the routine of the work in MCH center. ▪ Identify the role of the public health nurse at MCH center. ▪ List the High-risk mothers and children. ▪ Describe the maternal health indices. ▪ Identify the high-risk children. ▪ Identify the infant and preschool child mortality. ▪ Identify the neonatal mortality rate. ▪ Identify the measures to reduce infant mortality. 45 | P a g e Community health nursing Maternal and Child Health (MCH) Introduction Mothers and children constitute more than half of population (62%). They have regarded as the most vulnerable members of society because they have special risk e.g. child bearing among women susceptibility to communicable diseases, growth and development and survival among children. So, they are in need of special attention. Emphasis is placed on promotion of heath and prevention of death, disease and defects. Maternal and child health services Definition Maternal and child health (MCH) refer to a package of comprehensive health care services which are developed to meet promotive, preventive, curative, rehabilitative needs of pregnant women before, during and after delivery and of infants and pre-school children from birth to five years. There are 4 main reasons why mother & children health must be given top priorities in health programme- 1. Mother & child below the age of 15 years makeup the majority of the population in almost countries. 2. Mother & children constitutes a ‘special risk’ or vulnerable group in the case of illness, death, in the terms of pregnancy, childbirth of mothers, & growth development in the case of children. 3. by improving the health of mother & children we can improve the health of the family & community. 4. Ensuring child survival is a future investment for the family & community. 46 | P a g e Community health nursing Indicators for MCH programme Maternal & child health can be evaluated on the basis of the following indicators: 1. Maternal mortality rate: below 1 (for every 1000 live births) 2. Infant mortality rate: below 30 (for every 1000 live births) 3. Death rate of 1-4 year old age group: below 10. 4. Size o f family: 2-3 members. 5. Perinatal mortality rate: 30-35. 6. Weight of minimum 90% of total children: according to height/weight charts. Objectives of MCH program Reduce maternal mortality and morbidity. Reduce per natal and neonatal mortality and morbidity. Regulate fertility so as to have wanted and healthy children when desired. Provide basic maternal and child health care to all mother and children. Promote and protect health of mothers. Promote and protect physical growth and psycho-social development of children. Recent trends in MCH services 1. Integration of care: Earlier MCH care services were divide into antenatal, child care & family planning. Naturally it is helpful in increase the capability & effectiveness of services. 2. Risk approach: This new thought was born from the lack of resources & their availability. As per this the risk group among mother & infant is identified special care is given to them. 3. Man power changes: According to new concept, maternal & child health services should be left to traditional health workers as health 47 | P a g e Community health nursing visitor rather than specialist of field & child volunteers & workers of NGOs. 4. Primary health care: It makes available information about protection & resources for mother & child health care. 5. Reproductive & child health: As per the decision taken in world women’s conferences, Beijing (1995), maternal & child health services have been included in reproductive & child health services. Principles for MCH program The guiding principles for the M.C.H. programme are: a. Consultation & participation: Consultation with , & participation by, families id integral to the services. Services will be informed by, & seek to meet, the young needs of young children & their families. b. Access & availability: all families with young children should be able to readily access the information, services & resources that are appropriate for, & useful to them. c. Primary prevention: Prevention of harm or damage is preferable to repairing it later. Early detection of risk factors is required, & intervention, where appropriate. d. Capacity building: Promotion of resilience & capacity is preferable to allowing problems to undermine health or autonomy. e. Equity: All children should be able to grow up actively learning, healthy, sociable & safe-irrespective of their family circumstances & background. b. Family centered: The identification & management of child & family needs requires a family centered approach that focuses on strength.. 48 | P a g e Community health nursing f. Inclusion: Inclusive practices are essential for all children to get the best start, irrespective of their family circumstances, differing abilities background. g. Partnership: Quality services are achieved through integrated services delivered & partnership with other early childhood & specialist services, & with family. h. Quality: All families with young children must be confident of the quality of information, services & resources provided to them. Functions of MCH centers ▪ Premarital care. ▪ Maternity care. ▪ Infant and preschool child care. ▪ Family planning. ▪ Health education. ▪ Social care. 1. Premarital care Purposes of premarital care 1. Early detection of any health problem and treatment. 2. To provide Premarital guidance; preparation for marriage, family life education, (art of child rearing and family planning. 3. Saving parents and future off springs from health hazards (e.g. by premarital immunization against German measles and mumps if not taken) Components of premarital care 1. Premarital examination. 2. Premarital education. 3. Premarital counseling. 49 | P a g e Community health nursing A. Premarital examination it includes 1. History taking (personal and family medical history). 2. Physical examination (heart and chest to detect any disease, pelvic measurement to detect contracted or deformed pelvis) 3. Laboratory investigations a. Blood tests for was serman reaction to exclude syphilis, viral hepatitis B (VHB), viral hepatitis viral hepatitis C, AIDS. Rh factor, BL grouping and hemoglobin. b. Urine analysis for sugar and albumin to exclude DM or kidney disease. 4. Chest X-ray (to exclude pulmonary TB.) 5. Premarital immunization. B. Premarital education ▪ Premarital education should be started early during prepuberty, puberty, adolescence as well as adulthood to guide and prepare couples for marriage. ▪ The following areas of health education should be emphasized on parents' health, nutrition, and safe environment role of the father, role of the mother, childrearing, sex education and family planning. C. Premarital counseling ▪ Premarital counseling is a communication process in which the counselor tries to provide a couple with complete and accurate information on responsibility of marriage and encourage the couple to explore and communicate their individual needs, goals, values and deficiencies. ▪ It is a chance for the couple to verbalize their expectations of marriage including any fears and anxieties they may have. 50 | P a g e Community health nursing 2. Maternity Ante natal care :- Is the preventive and promotive care of pregnant women during antenatal period? Or It is the care and supervision given to a pregnant woman so that she may pass through with minimum of mental and physical discomfort and a maximum of mental and physical fitness. Aims of ante-natal care 1. Safety and welfare of the mother and her fetus. 2. Preparation of mother for labor, lactation and subsequent care of her child. 3. Early detection and appropriate treatment of high risk conditions. 4. Reduction of maternal and infant mortality, still births.premature. 5. Increase the number of breast-fed babies. Schedule of Antenatal visits 12-15 visits in normal Cases No. of Visits (1) 1 visit/month 1st trimester (3) 1 visit/month 2nd trimester (4) 2 visit/month 7th and 8th month (4) 1 visit/week 9th month MCH services for pregnant women A. Initial visit I. History taking ▪ Personal: name age occupation, address. ▪ Menstrual: LMP. EDD. Menarche and dysmenorrhea. ▪ Obstetric: parity, complications for mother or baby. 51 | P a g e Community health nursing ▪ Medical: past illness, heart conditin, DM and TB. ▪ Family: any genetic disease, hypertension, heart and TB. ▪ Social: income, family members and education. II. Examination 1. General examination ▪ Head: Ears, eyes, nose, mouth and throat. ▪ Neck: palpation of the thyroid gland. ▪ Observation of skin and hair. ▪ Heart and lungs: are auscultated for irregularities in function. ▪ Extremities: are examined for varicose veins and edema. ▪ Vital signs: temp. Pulse, and respiration, to detect any abnormalities. ▪ Blood pressure; should be 120/80 or less and not above 140/90. ▪ Body weight and height: weight should be recorded in the first visit. ▪ Then recording the weight in graph each return visit. 2. Local Examination ▪ Inspection of breast and nipples. ▪ Abdominal examination: o Inspection of hair distribution, linea nigra, stria gravidarum and scare of previous operations. o Palpation of the abdomen for: ▪ Height of the funds. ▪ Fetal lie, attitude, position and presentation using the four grips. o Auscultation of fetal heart sound (120/160/min) o Pelvic measurements to evaluate feto-pelvic accommodation. o Inspection of external genitalia. 52 | P a g e Community health nursing o Vaginal examination to rule out abnormalities of birth canal. o Cervix examination (position, size, mobility). III. Investigations Urine analysis for glucose and albumen. Blood tests include: 1. Blood group is determined because of the risk of hemorrhage. 2. Rhesus factor, if the mother is Rh-negative. Several follow up determination for the presence of irregular antibodies should be done throughout pregnancy (at 1st visit, 28 weeks, 34 weeks and at term). If the samples remain negative labor is allowed to proceed without interference. The RH of the infant should be determined and if positive, the mother should be treated with Rh \ immune globulin. 3. Hemoglobin, if HB is below 12.6 g. (85%), iron, folic acid, vit. B and C are prescribed. If HB below (70%) blood investigations is carried out. 4. Wasserman test for screening of syphilis. 5. Screening for AIDs viral hepatitis B (VHB) and viral hepatitis C (VHC) Dental exanimation V. Social services B. Return visit 1. In every visit the following should be done to pregnant women, weight, measuring the blood pressure, general observation urine analysis for sugar and albumen, at the 30 th week hemoglobin estimation, abdominal examination, and size of the uterus. Asked about general well-being, signs and symptoms of edema, bleeding, constipation, headache, or any unusual symptoms. 53 | P a g e Community health nursing 2. After routine examination every pregnant women should be educated as regards her: diet, rest, bowel movement, exercise, fresh air and sunshine bath, care of breast and nipples, clothing, dental care, sexual intercourse, travel, physiology of pregnancy and mechanism of delivery, psychological aspect, family life education, family planning, changed of mood, body drugs, micro-organisms environmental and biological factors. 3. Husband should he included in the education sessions in order to understand expected role and changes occurring to his life. 4. Immunization: in Egypt, active immunization against tetanus is done as a routine for all pregnant women attending MCH centers. Primary immunization of pregnant women consists of two doses of absorbed toxoid administered about one month apart except if the woman was actively immunized, she can take only one dose. For life long protection, the mother should receive 5 doses of-tetanus toxoid, the 1st dose should be at first contact, or as early as early as possible during pregnancy, and dose after 4 weeks (give 80% protection). 6-12 mouths after the 2nd dose or during the subsequent pregnancy, give the 3rd dose (give 95% protection). Another 2 doses given during the subsequent pregnancy or every 1-3 for the 4th dose & 1-5 years for the 5th dose (give 99% life long protection). Health teaching during first trimester 1. The family accepts this pregnancy: the first pregnancy produces a certain degree of emotional anxiety in mind of any thinking woman, emotions e.g. mother love and pride in creation, induce feeling of tranquility and gladness. 2. Physiological changes due to pregnancy: rise level of estrogen and progesterone increase number of red and white cells and platelets, increase heart rate. BP falls 5 to 10 mm, increase 54 | P a g e Community health nursing secretion of glucose, urea, amino acids, and folic acid in urine dilatation of uterus and enlarged, weight changes, pain in breast and abdomen, cognation, deep breathing. The changes affected all system. 3. Fresh air and sunshine: the pregnant woman should be advised to spend day in the fresh air if possible, away from busy streets. Baby needs a daily airing before birth as well as after. 4. Travel: long rail or care journey should not be undertaken. The jarring and excitement may induce abortion in susceptible women. 5. Rest and sleep: at least 8 hrs. Sleep should be obtained every night, relax for 2 hrs during day. 6. Cleanliness: regular and frequent washing especially in the genital region and under axilla-and breast due to increase in discharge and sweating. 7. Care of teeth: the fetal demands for calcium, that is with draw during pregnancy from mothers' teeth and bones. For tooth extraction, a local analgesic is administered to avoid cyanosis. 8. Coitus: during pregnancy is normal and depend on the mother in clination. A previous abortion might be an indication for avoiding coitus during first months. 9. Smoking: if women heavy smokers try to cut down because nicotine in excess dose causes vasoconstriction and affect placental function. 10.Bathing: avoid hot bath because may cause fainting ii daily shower is ideal, avoid tub-bath. 11.Bowels: move every day without use laxatives, regulate her habit of defecation, increase fluid intake and maintain her diet to avoid constipation. 55 | P a g e Community health nursing 12.Avoid taken any drugs: without doctor order, avoid exposure to infectious disease especially German measles. 13.Exercise and relaxation: should be simple and not to be strenuous. Walking is excellent to stimulate the circulation and feeling good appetite. 14.Warning without-frightening tell pregnant women about unusually symptoms to be treated in early stages and avoid complications. 15.Avoid x-ray, vaginal douching, catheter and enemas are contraindicated. 16.Diet: diet should contain meat, milk, vegetables and fruits 17.Minor discomfort Health education during the second trimester 1. Help family to establish their role as parents. 2. Husband can adapt to the change occurring to his wife. 3. Better family life and family planning. 4. Avoid heavy weights, may predispose to abortion, avoid constant standing lead to varicose veins avoid climb to reach high shelves because over balancing and her tendency to faint. 5. Travel avoids airlines after 32nd week as there is possibility of premature labor. 6. Rest and sleep during second half of pregnancy, the mother is carrying constant load and increase to 11 kgm. She advise to rest and sleep at least 2hrs/day. 7. Clothes: should be suitable, comfort, made from cotton. Bras should be broad shoulder straps and constricting bands on the legs should be avoided to prevent varicose veins and edema. Shoes should be short heal and broad base to maintain good posture. 8. Diet: increase fluids. 56 | P a g e Community health nursing Health education during third trimester 1. Exercise end recreation: homework, making beds, sweeping polishing brings many but not all muscles into play, so exercise have been advised to keep the muscles to be used during labour in good tone and the pelvic joints flexible. 2. Travel: avoid airline. 3. Breast care: should be massaged to milk the colostrums and prevent it from blacking the ducts. 4. Perineal care: due to frequency of urination and increase discharge. 5. Marit 6. Sexual relation: should be avoided in last 3 weeks of Pregnancy to avoid infection. 7. Avoid smoking alcohol, and drugs. 8. Preparation for herself and her home for delivery or other place for delivery. 9. Family planning; should be educated. 10.Baby care: baby rearing and feeding. 11.Diet increase iron and calcium. 12.True onset of labour. 13.Warning signs: vaginal hemorehage. Stopped fetal movement, any abnormal secretion abnormal vomiting edema, headache abdominal pain. 14.Minor discomfort B) Natal care Objectives of the natal care ▪ To assist the mother to have normal delivery. ▪ Provide emergency care if necessary. ▪ Safety for both mother and fetus. 57 | P a g e Community health nursing Place of delivery 1. In MCH centers There is an internal section with a limited number of beds for delivery of: 1. Registered mothers who preferred to deliver at the center. 2. Mothers living under poor inconvenient housing. 3. Mothers With mild difficulties. 2. Home delivery Deliveries expected to be normal can be carried out at home by qualified trained nurse midwife (assistant midwives) provided with an equipped kit. Difficult cases can be referred to the center or hospital. Home delivery Advantages 1. The mother feels happier in her home with her family around her. 2. The mother often does not want to be separated from her other children and husband. 3. The family routine can easily be rearranged when the baby is part of the family-from the beginning. 4. The mother will receive advice concerning her needs in her own home. 5. The expenses and risk of cross infection is minimal. Disadvantages 1. Normal cases may become suddenly complicated despite the best screening process. Certain complications are difficult to predict. 2. There is not constant attention for the mother and baby, and skilled help is not readily available. 3. The mother may resume her household responsibilities too soon when there is inadequate help in the home. The mother's diet may be neglected. 58 | P a g e Community health nursing Contraindications of Home Delivery Either the mother or baby is "at risk" if any of the following criteria are present The mother The baby The home Medical Obstetrical Any abnormal Cephalo-pelvic presentation or Cardiac disease Overcrowding disproportion position Infectious Gestation period Pre- eclampsia, Tuberculosis Disease less than 3p wks eclampsia present Unsanitary Hemolytic diseases Diabetes Multiple pregnancy conditions Ante partum Fetal abnormalities Venereal disease Hemorrhage Essential True post maturity Polyhydramnios hypertension Anemia Rh-lso-immunization Previous: caesarian section, difficult forceps Sub fertility delivery, postpartum hemorrhage or -adherent placenta: -stillbirths, neonatal deaths Primigravida over 30 years Multigravida over 36 years 59 | P a g e Community health nursing c. Post natal It is the period of time from the end of the third stage of labour until the time at which the pelvic organs have returned to normal about 6- 8 weeks. Goals of post partum care 1. Helping the physiological changes of this period to occur as spontaneously as possible. 2. Helping parents in adjusting to and accepting new roles. 3. Helping strengthen mother child or parent child fignding General examination 1. Measuring vital signs according to mother’s condition. It should be normal during puerperium. 2. Abdominal examination a. For any tenderness, palpable organs and swelling. b. The uterus is felt as a firm, pear shaped. c. The decrease in size is approximately 1cm daily, until the 11th or 12th day when the fund is longer palpable. d. The bladder should be emptied prior to uterine palpation. e. Complete involution occurs after 6 weeks. 3. Vulva and perineum examination a. Under aseptic condition, observe vaginal discharge, (lochia) Health education about 1. Avoiding puerperal infection. 2. Care for episiotomy. 3. Rest and sleep. 4. Diet. 5. Early ambulation. 6. Breast care. 7. Psychological changes. 60 | P a g e Community health nursing 8. The bowels. 9. Exercises. 10.Family planning. 11.Post partum examination 2ndand 6th week it includes abdominal examination obstetric examination, inspection and palpation of breast, urine analysis, hemoglobin estimation, B. P. and weight. Postpartum checks 1. 1st day; vital signs BP. general examination. level of the fundus (1/U) lochia (rubra) perineum, episiotomy. 2. 3rd flow of milk slight increase of temp lochia (rubra) level of the fundus (U/1) perineum. 3. 5th level of the fundus (U/3) lochia (serosa). 4. 7th level of the fundus (U/5) lochia (serosa) cord (bady). 5. 10th temperature (puerperal sepsis), level of the fundus (U/8) lochia (alba). 6. 15th involution of uterus lochia (alba). 7. 22nd lochia (alba), ant complication or complains. 8. 40th post-partum examination, family planning, BCG vaccination for the infant. Program of child-health Infant and preschool childcare Objectives of child health services 1. Health promotion of children. 2. Prevention and control of diseases and hazards. 3. Prevention of disability and rehabilitation. Function of MCH centers for childcare 1. Preventive services, which include: a. Prenatal and natal care. Newborn care b. Health promotion of infants and pre-school children 61 | P a g e Community health nursing c. Prevention and control of communicable diseases d. Health education e. Maintenance of health through periodic medical examination 2. Curative services. 3. Social services. 1. Preventive services Prenatal and natal care Good ante natal care for normal fetal growth and ensure safe delivery of the fetus. a. Newborn care Immediate neonatal care as.aseptic cutting of the umbilical (cord, clear airway, establish respiration. Apager scoring, protection from hemorrhage, protection from infection, eye care management of complication if present and keep warmth. b. Health Promotion ▪ Adequate nourishment of infant and children is one of the most important features in health promotion breast feeding should always be encouraged. ▪ Supplementation of milk and some food for infants and twins. ▪ Nutritional education, for the mother, how to prepare adequate diet, proper breast feeding arid weaning practices. c. Prevention and control of communicable diseases ▪ Immunization of infants and children (see booklet of immunization in practice). ▪ Good sanitation of the environment of the clinic and home. ▪ Health education about personal hygiene, food sanitation and environmental sanitation, prevention of infection. 62 | P a g e Community health nursing d. Health education The education for the mother about, feeding, weaning. Hygiene, accident, prevention, growth and development care of the baby infant care, importance of vaccination, play material and recreation. e. Maintenance of health Periodic examination of the child for checkup of the general condition, growth and development through regular visits to the MCH as the following schedule: ▪ Monthly for the first year ▪ Twice / year for the second year ▪ Every year till the age of 6 years. Every child should have his own health record, which contain information from birth till the end of preschool period. In the first visit: ▪ History is taken about birth data (date of birth, place of birth, period of gestation, type of labour) ▪ Measurement of, weight, height. chest and head circumference. ▪ A Complete physical examination and test of hearing and vision. In periodic follow up visits: ▪ Assessment of growth and development, check height, weight, teeth, etc. ▪ Immunization: compulsory vaccination on time, type and date. ▪ Any Signs of diseases or complains is recorded and treated. ▪ Health education for the mother about child growth, diet, hygiene, infant bearing, and physical, emotional needs, disease of infancy and how to cope with them. 2. Curative services MCH center provide curative services for sick children through: ▪ Case finding. 63 | P a g e Community health nursing ▪ Early diagnosis and treatment. ▪ Follow up of cases. ▪ Referral cases. Main problems facing children from birth to 5 years ▪ Congenital malformation. ▪ Prematurity. ▪ Birth injuries. ▪ Asphyxia. ▪ Infection (tetanus). ▪ Upper respiratory tract infection. ▪ Malnutrition diseases. ▪ Communicable diseases. ▪ Gastrointestinal and diarrheal diseases. ▪ Accidents. 3. Social services The social worker and the nurse together share the responsibility for preparing the family to the parenthood role, and develop a health parent-child relationship through and health education. Worker at the MCH center can carry out a social investigation about the families in need of social support and provide adequate support. Personnel working in the MCH centers ▪ Physicians ▪ Midwives ▪ Dentists. ▪ Nurses ▪ Pharmacist ▪ Social works ▪ Health educators ▪ Laboratory technicians 64 | P a g e Community health nursing ▪ Clerics ▪ Aids High-Risk Mothers and Children High-risk mothers A highly significant part of the prenatal assessment is the screening for high-risk factors. Risk factors are any findings that have a negative effect on pregnancy out come either for woman or her fetus. High-risk factors I. Biological socioeconomic and demographic factors: ▪ Age: less that 18 years or more than 35 years. ▪ Parity: fifth or more-pregnancy. ▪ Birth spacing: too short intervals (less than 2 years) and too long (more than 10 years). ▪ Education of mother: illiterate mothers are at risk. ▪ Illegitimacy. ▪ Inadequate prenatal care. ▪ Poverty: substandard housing and nutritional deprivation. ▪ X-ray irradiation, occupational hazards, pollution. ▪ Drug abuse. ▪ Migrant Family status ▪ Alcoholism ▪ Smoking ▪ History of mental illness Medical factors ▪ DM ▪ Heart disease ▪ Hypertension ▪ Renal disease ▪ Hypo or hyperthyroidism 65 | P a g e Community health nursing ▪ Malnutrition (anemia, Hb less than 9 gm) ▪ Syphilis ▪ Rubella Obstetrical factors: ▪ History of still birth ▪ Repeated abortion ▪ Previous cesarean section ▪ RH incompatibility ▪ Toxemia ▪ Multiple pregnancies ▪ Placenta previa ▪ Contracted pelvis ▪ History of difficult or prolonged labor II. Risk factors at time of labour ▪ Rupture of uterus ▪ Premature separation of placenta ▪ Difficult or prolonged labour ▪ Uterine inertia ▪ Premature labour ▪ Abnormal-Presentation III. Maternal health indices ▪ Maternal mortality rate. ▪ Perinatal mortality rate. ▪ Pregnancy outcome (abortion, still birth ratio) These indices are used to evaluate the improvement in women's health status. They reflect the quality of maternity health services. 66 | P a g e Community health nursing a. Maternal mortality Means deaths of women from cause during the maternity cycle (pregnancy, labor and puerperium). Deaths are for during labor and puerperium. Maternal mortality rate Is the number of maternal (deaths) associated with pregnancy, labour and puerperiunm in a given area in a given year per 1000 live births in the same area and year. No. of maternal deaths during pregnancy, labour and puerperium in a given area and 1000 X year = MMR Total no of live births in the same area & year MMR in Egypt is 55 / 100,000 (MOH 2008). Causes of maternal mortality ▪ Hemorrhage. ▪ Infection (puerperal sepsis). ▪ Toxemia These main causes of maternal mortality constituted 85% of all maternal deaths. The other causes are rupture uterus, cesarean section, high forceps, rheumatic heart or renal failure. Factors influencing the decrease of maternal mortality 1. Good coverage during the antenatal period, natal and post natal period. 2. Increase the use of hospitals and specialized health care centers for maternity clients. 3. Establishment of high-risk centers for mother and infant care. 4. Prevention and control of infection with antibiotics and improved techniques. 67 | P a g e Community health nursing 5. The availability of blood and blood products for transfusion. 6. Lowered rates of anesthesia related deaths. 7. Family planning. 8. In-service training programs for the personnel as well as traditional birth attendants. 9. Supervision of midwives, assistant midwives, nurses and traditional birth attendants (TB A). 10.Rising the age marriage (18 yrs) 11.Improving standard of living of mothers 12.Application of research for prevention of MM b. Perinatal mortality rate No of still births and no of neonatal deaths (less than 7 days of life) in a given area & year 1000 X = PMR Total no of births (still and live births) in the same area and year Causes of prenatal mortality ▪ Maternal diseases e.g. cardiovascular diseases, DM, hypertension, malnutrition etc... ▪ Toxemia of pregnancy. ▪ Ante partum hemorrhage. ▪ Maternal age, high parity ▪ Natal causes e.g. birth injuries, asphyxia, and prolonged, complicated labor. ▪ Post natal causes prematurity, respiratory distress, infection e.g. tetanus neonatorum septicemia, meningitis. ▪ Congenital anomalies 68 | P a g e Community health nursing c. Pregnancy out comes: 1. Abortion: early fetal death before 28th weeks of gestation (age of fetal viability) 2. Miscarriage and still-births: late fetal deaths after 28th weeks of gestation. Still birth ratio: No of still births in a given area & year 1000 X = no of live birth in the same area and year Prevention of still births ▪ Good antenatal care ▪ Early detection and treatment of predisposing factors. ▪ Family planning. ▪ Raising standard of community living. High-risk children Definition A high-risk infant is one whose health status makes him susceptible to increased morbidity or mortality. Risk factors All the factors which pose to the mother’s health affect the course of baby’s development, thus high risk babies are born to high-risk mothers. 1. Factors related to maternal health as discussed before 2. Factors related to the new born a. Prematurely (death during 1st year of life 17 times than. normal) b. Low Apgar score c. Congenital malformation. d. Birth injuries e. Prolonged hospital stay (infection poor progress) f. Mental handicaps 69 | P a g e Community health nursing g. Early stoppage of breast-feeding h. Introduction of complementary foods either too early or too late i. Frequent episodes of infection Infant and preschool child mortality Infant mortality Infant mortality rate:-it refers to the number of infant dying within 1 year of a given a year per 1000 live births in a given year. Infant mortality = Neonatal mortality and post neonatal mortality No of infant deaths (under 1 year) in a given 1000 X area & year = IMR No of live births in same area and year In Egypt IMR 24.5 per 1000 live births (EDHS 2008). o Neonatal mortality rate:-it refers to the number of infants dying within the 1st month of live (under 28 days)n a year per 1000 live births in a given year. o Post neonatal mortality rate:- it refers to number of infant deaths from 28days to 1 year of age per 1000live births in a given year. o Perinatal mortality rate;-it refers to number of still birth plus deaths within the 1st week of delivery per 1000 live births in a year. Neonatal mortality rate No of infant deaths during the 1st 4 weeks of life 1000 x in a given area and year = No of live births in the same area and year In Egypt neonatal mortality is (EDHS 2008): (16.3 /1000 live births A. Main causes of neonatal deaths 1. Per maturity 50% 2. Birth injuries 3. Congenital malformation 70 | P a g e Community health nursing 4. Infections (respiratory and tetanus) B. Specific causes of infant mortality ▪ Respiratory tract infection ▪ Gastro-entérites ▪ Pre maturity General causes ▪ Birth injuries ▪ Congenital malformation ▪ Malnutrition ▪ Infection ▪ Accident In Egypt, infant mortality rate is 23.2/1000 live birth (2003). Measures to reduce infant mortality ▪ Raising the standard of community (better housing, education, better advanced medical care, good nutrition and income). ▪ Environmental sanitation. ▪ Educate girls the art of mother craft and infant care. ▪ Good coverage during the antenatal, natal and postnatal period. ▪ Improvement of MCH services especially the educational activities. ▪ Immunization. ▪ Special care to premature infants. ▪ Prevention of gastro-enteritis and prompt-treatment of acute respiratory infections. ▪ Family planning ▪ Encourage breast feeding and proper weaning 71 | P a g e Community health nursing Preschool child mortality rate = No of child's death in age gro

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