ABC's of Primary Health Care PDF

ABC’S OF Primary Health Care Comprehensive review on ABC’S of PHC (created by RSI) A. PRIMARY HEALTH CARE - As defined by the World Health Organization (WHO), Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology,...

ABC’S OF Primary Health Care Comprehensive review on ABC’S of PHC (created by RSI) A. PRIMARY HEALTH CARE - As defined by the World Health Organization (WHO), Primary health care is 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 and at a cost that the community can afford to maintain at every stage of their development in the spirit of self-reliance and self- determination. - PHC was declared in the Alma-Ata Conference in 1978, as a strategy to community health development. It is a strategy aimed to provide essential health care that is: C – ommunity based A – ccessible P – art and parcel of the total socio-economic development effort of the nation A – cceptable S – ustainable at an affordable cost - Framework : People’s empowerment and partnership is the Key Strategy to achieve the GOAL, “Health for all Filipinos by the year 2000 and Health in the Hands of the People by the year 2020”. B. Mission of PHC - PHC aims to strengthen the health care system by increasing opportunities and supporting the conditions wherein people will manage their own health care. C. Principles of PHC 1. Partnership and empowerment as the core strategy. 2. Focuses responsibility for health on the individual, his family and the community. 3. Full participation and active involvement of the community towards the development of self-reliant people. 4. Interrelationship between health and the overall political, socio-cultural and economic development of society 4 As of Primary health care A – ccessibility A – vailability A – cceptability A – ffordability D. Objectives of PHC 1. improvement in the level of health care of the community. 2. favorable population growth structure. 3. reduction in the prevalence of preventable, communicable and other diseases. 4. reduction in morbidity and mortality rates especially among infants and children. 5. extension of essential health care services with priority given to the underserved sectors. 6. improvement in basic sanitation 7. development of the capability of the community aimed to the underserved sectors. 8. development of the capability of the community aimed at self-reliance. 9. maximizing the contribution of the other sectors for the social and economic development of the community. E. Four Cornerstone/Pillars in PHC 1. active community participation 2. intra and inter –sectoral linkages 3. use of appropriate technology 4. support mechanism made available F. Strategies 1. Reorientation and reorganization of the national health care system in support of the mandate of devolution under the Local Government Code of 1991.  2. Effective preparation and enabling process for health action at all levels. 3. Mobilization of the people to know their communities and identifying their basic health needs. 4. Development and utilization of appropriate technology focusing on local indigenous resources available. 5. Organization of communities arising from their expressed needs. 6. Increase opportunities for community participation in local level planning, management, monitoring and evaluation within the context of regional national objectives. 7. Development of intra-sectoral linkages with other government and private agencies. 8. Emphasizing partnership. G. Elements of Primary Health Care (Elements Dam) E – ducation on prevailing health problems L – ocally endemic Disease Prevention and Control E – xpanded Program of immunization M – aternal and Child Health and Family Planning E – nvironmental Sanitation and Safe Water Supply N – nutrition and Food Supply T – reatment of Communicable & Non-communicable Diseases S – supply and proper use of Essential Drugs and Herbal Medicine D – ental Health Promotion A – ccess to and use of hospitals as centers of wellness M – ental health promotion H. Primary health Care Workers - Various categories of health care workers make up the primary health care team. The types vary in different communities depending upon: a. Available health manpower resources b. Local health needs and problems c. Political and financial feasibility - In general, the PHC team may consist of physician, nurses, midwives, nurse auxiliaries, locally trained community health workers, traditional birth attendants and healers. - types: 1. Village or Barangay Health Workers (V/ BHWs) - This refers to trained community health workers or health auxiliary volunteer or a traditional birth attendant or healer 2. Intermediate Level Health Workers - General medical practioners or their assistants, Public Health Nurse, Rural Sanitary Inspectors and Midwives. I. Levels of Health Care Services - Health problems that are beyond the capability of PHC units and beyond the competence of the PHC workers are referred to an intermediate health facility or Rural health Units (RHU) - The RHU team generally consists of the physician, dentist, public health nurse, midwife, sanitarian and other health workers. - The higher the level the more qualified the health personnel and the more sophisticated the health equipment. 3 levels: 1. Primary level - Barangay Health station, Private practitioners ,Community Hospitals, Health Centers and Rural Health Unit 2. Secondary Level - Emergency/ District Hospitals, Provincial/ City Hospitals and Provincial/ City Health Services 3. Tertiary Level - Teaching and Training Hospitals, Medical Centers and National Health Services J. Philippine health Care Delivery System The Health Care Delivery System (Major players)  – Composed of 2 sectors 1. PUBLIC SECTOR – financed with a tax based – budgeting system at both national and local levels and where health care is generally given for free at the point of service - Consists of the national and local government agencies providing health services - The DOH –the national level lead agency in health - has regional field office in every region - maintains specialty hospitals, regional hospitals and medical centers - LGU’s – it now run the local health system because of the devolution of health care services a. Provincial government: manages provincial and district hospitals b. City/Municipal Government: manages health centers, RHU and BHSs - every province, city or municipality has a local health board chaired by local chief executive 2. PRIVATE SECTOR (for profit and nonprofit providers) – market oriented and where health care is paid through user fees at the point of service - Includes providing health services in the clinics and hospitals, health insurance, manufacture of medicines, vaccines, medical supplies, equipment, nutrition products and other health related services K. Philippine Department of Health - Has the new role as the national authority on health providing technical and other resources assistance to concerned groups as mandated by EO 102. EO 102 – mandates the DOH to provide assistance to local government units, people’s organization and other members of civic society in effectively implementing programs, projects and services that will promote the health and well being of every Filipino; prevent and control diseases among population at risks; protect individuals, families and communities exposed to hazards and risk that could affect their health; and treat, manage and rehabilitative individuals affected by diseases and disability Roles and Functions: 1. Leadership in health a. Serve as the national policy and regulatory institution b. Provides leadership in the formulation, monitoring and evaluation of national health policies, plans and programs c. Serve as advocate in the adoption of health policies, plans and programs 1. Enabler and Capacity builder a. Innovate new strategies in health b. Exercise oversight functions and monitoring and evaluation of national health plans, programs and policies c. Ensure the highest achievable standards of quality health care, health promotion and health protection 1. Administrator of Specific Services a. Manage selected national health facilities and hospitals with modern and advanced facilities b. Administer direct services for emergent health concerns that require newly complicated technologies c. Administer health emergency response services VISION - The DOH is the leader, staunch advocate and model in promoting health for all in the Philippines MISSION – Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor and shall lead the quest for excellence in health GOAL – Health Sector Reform Agenda (HSRA) Rationale for Health Sector reform: 1. Slowing down in the reduction in the infant mortality rate (IMR) and the maternal mortality rate (MMR)  2. Persistence of large variations in health status across population groups and geographic areas 3. High burden form infectious diseases 4. Rising burden from chronic and degenerative diseases 5. Unattended emerging health risk from environmental and work related factors 6. Burden of disease is heaviest on the poor The reasons why the above conditions are still seen among the population can be explained by the following factors 1. Inappropriate health care delivery system 2. Inadequate regulatory mechanisms for health services 3. Poor health care financing and inefficient sourcing or generation of funds for health care The following are the implications of the above situation: 1. There is poor coverage of public health and primary care services 2. There is inequitable access (physical and financial) to personal health care services 3. There is low quality and high cost of both public and personal health care Framework for Implementation of HSRA: FOURmula ONE for health Goals of FOURmula ONE for health: 1. Better health outcomes 2. More responsive health systems 3. Equitable health care financing The four elements of the strategy are: 1. Health financing – the goal of this health reform area is to foster greater, better and sustained investments in health 2. Health regulation – the goal is to ensure the quality and affordability of health goods and services 3. Health service delivery – the goal is to improve and ensure the accessibility and availability of basic and essential health care 4. Good governance – the goal is to enhance health system performance at the national and local levels National Health Insurance Program (NHIP) – the main lever to effect desire changes and outcomes of the four elements implementation components in terms of financing, governance, regulation, service delivery. DOH PROGRAMS (Selected) L. Maternal Health Program: Introduction – To reduce the MMR by three quarters by 2015 to achieve its millennium development goal. This means a MMR of 112/100,000 live births in 2010 and 80/100,000 live births by 2015 – The percentage of pregnant women with at least four prenatal visits decreased from 77% in 1998 to 70.4% in 2003 – Women who received at least two doses of tetanus toxoid also decreased from 38% in 1998 to 37.3% in 2003 – The 200 Philippine health Statistics revealed that 25% of all maternal death are due to hypertension, 20.3% to postpartum hemorrhage, 9% pregnancy with abortive outcomes – Underlying causes of maternal deaths are delays in taking critical actions (the 3 delays) 1. Delay in deciding to seek medical care 2. Delay in identifying and reaching the appropriate health facility and 3. Delay in receiving appropriate and adequate care at the health facility Overall GOAL: to improve the survival, health and well being of mothers and unborn through a package of services for the pre pregnancy, prenatal, natal and post natal stages The STRATEGIC THRUSTS for 2005-2010 includes: a. Implementation of the Basic Emergency Obstetric Care (BEmOC) and Comprehensive Obstetric Care (CEmOC) strategy in coordination with the DOH. EmOC – Emergency Obstetric Care - part of essential obstetric care which includes pre and post-natal care, clean and safe delivery, neonatal care and family planning 2 functions: a. BEmOC – entails the establishment of facilities for every 125,000 population, can be reached within 30 minutes from each catchment barangay - it is an RHU or hospital facility which: 1. administer parenteral antiobiotics 2. adminster parenteral oxytocin 3. adminster parenteral anticonvulsants for pre-eclampsia/eclampsia 4. perform manual removal of placenta 5. perform removal of retained placental products; and 6. perform assisted vaginal delivery b. CEmOC – for every 500,000 popultion, referring facility, reach within 1 hour from a BEmOC facility - a hospital facility which: 1. perform the six functions of a BEmOC facility, plus 2. perform caesarean section and hysterectomy; and 3. give safe blood transfusion b. improve the quality of prenatal and postnatal care c. reduce women’s exposure to health risk health risk women: 1. All women of reproductive age especially those who are less than 18 years old and over 35 years of age 2. low educational resources 3. low financial resources 4. with unmanaged chronic illness 5. who just given birth in the last 18 months Essential health Service Packages Available in the Health Care facilities: – these are packages of services that every women has to receive before and after pregnancy and or delivery of a baby A. Antenatal registration - the standard prenatal visits that a woman has to receive during pregnancy are as follows PRENATAL PERIOD OF PREGNANCY VISITS 1st visit as early in pregnancy as possible before four months or during the first trimester 2nd visit during the 2nd trimester 3rd visit during the 3rd trimester Every 2 weeks after 8th month pregnancy till delivery B. Tetanus Toxoid Immunization - a series of 2 doses of Tetanus Toxoid vaccination must be received by a woman one month before delivery to protect baby from neonatal tetanus - the 3 booster dose shots to complete the five doses that provides full protection for both mother and child. The mother then is called as a “Fully Immunized Mother” (FIM) Tetanus Toxoid schedule for Women: Vaccine: TT1 – given as early as possible during pregnancy TT2 – at least 4 weeks later, gives 80% protection and 3 years protection for the mother TT3 – at least 6 months later, 95% protection and gives 5 years protection for the mother TT4 – at least one year later, 99% protection and gives 10 years protection for the mother TT5 – at least one year later, 99% protection and gives lifetime protection for the mother  C. Micronutrient Supplementation - these are necessary to prevent anemia, vitamin A deficiency and other nutritional disorders. Vitamins Dose Duration Remarks Vitamin A 1 capsule/tablet Twice a week Vitamin A should not be given to of 10,000 IU pregnant women before 4th Start from the 4th of month of pregnancy. It might pregnancy until delivery cause congenital problems in the baby Iron 60mg/400 ug 1 tablet OD for 6 months tablet or 180 days during the pregnancy period Contains 60 mg elemental iron OR with 400 mcg folic acid 2 tablets per day if prenatal consultations are done during the 2nd and 3rd trimester D. Treatment of Diseases and Other Conditions - these conditions may endanger her health and complication could occur Conditions/Diseases What to Do Do not give Difficulty of 1. Clear airway breathing/obstruction of airway 2. Place in her best position 3. Refer woman to hospital with EmOC capabilities Unconscious 1. Keep on her back arms at the a. Do not give Oral side Rehydration Solution to a woman who is 2. Tilt head backwards (unless unconscious or has trauma is suspected) convulsions 3. Lift chin to open airway b. Do not give IVF if you 4. Clear secretions from throat are not trained to do so 5. Give IVF to prevent or correct shock 6. Monitor blood pressure, pulse and shortness of breath every 15 minutes 7. Monitor fluid given. If difficulty of breathing and puffiness develops. Stop infusion 8. Monitor urine output Post partum bleeding 1. Massage uterus and expel a. Do not give clots ergometrine if woman has eclampsia, pre- 2. If bleeding persists: eclmapsia oor a. Place cupped palmed on hypertension uterine fundus and feel for sate of contraction  b. Massage fundus in a circular motion c. Apply bimanual uterine compression if ergometrine treatment done and postpartum bleeding still persists d. Give ergometrine 0.2 mg IM and another dose after 15 minutes Intestinal parasite 1. Give Mebendazole 500mg a. Do not give infection tablet single dose mebendazole in the first 1-3 months of 2. Give anytime from 4-9 pregnancy. This might months of pregnancy cause congenital problems in baby Malaria 1. Give sulfadoxin- pyrimethamine to women from malaria endemic area who are in 1st or 2nd pregnancy, 500 mg 2. Give 25 mg tab, 3 tabs at the beginning of 2nd to 3rd trimesters not less than one month interval Recommended Schedule of Post Partum Visits: 1st visit 1st week post partum preferable 3-5 days 2nd visit 6 weeks post partum M. Child Health Programs (newborns, infants and children) - Newborns, infants and children are vulnerable age group for common childhood diseases. - to address problems, child health programs have been created and available in all health facilities which includes: 1. Infant and Young Child Feeding - Overall objective: To improve the survival of infants and young children by improving their nutritional status, growth and development through optimal feeding. - The National Plan of Action for 2005-2010 for Infant and Young child feeding: Goal: reduce child mortality rate by 2/3 by 2015 Objective: To improve health and nutrition status of infants and young children Outcome: To improve exclusive and extended breastfeeding and complementary feeding - Key Messages on Infant and Young Child Feeding a. initiate breastfeeding within 1 hour after birth b. exclusive for the first 6 months of life (only breastmilk and nothing else) c. Complemented at 6 months with appropriate foods, excluding milk supplements d. Extend breastfeeding up to two years and beyond - Laws that protects Infant and Young Child feeding  a. Milk Code (EO 51) – consists of breast milk substitutes, including infant formula; other milk products, foods and beverages, including bottle-fed complementary foods. b. Rooming In and Breastfeeding Act of 1992 – requires both public and private health institutions to promote rooming in and to encourage, protect and support breastfeeding. - one of the 10th steps to Mother Baby Friendly Hospitals wherein the mother and the baby should be together for 24 hours and as long as both are in the hospital. c. Food fortification Law – declares a policy to improve the nutritional status of the children which is cost effective and has sustainable intervention to address micronutrient deficiencies. - requires a mandatory food fortification of staple foods – flour( with iron and Vit. A), cooking oil, refine sugar (with Vit. A), rice (with Iron) and the voluntary fortification of processed foods through the “Sangkap Pinoy Seal”. 2. Expanded program on immunization a. the expanded program on immunization was launch in July 1976 by the department of health in cooperation with the World Health Organization and the UNICEF. b. the original objective was to reduce the morbidity and mortality among infants and children caused by the seven childhood immunizable diseases c. Principles: 1. the program based on the epidemiological situation 2. the whole community rather than just the individual is to be protected, thus mass approach is utilized 3. immunization is a basic health service and such it is integrated in to the health services being provided for by the Rural health Unit d. Elements of EPI 1. target setting 2. cold chain logistic management 3. information, education and communication 4. assessment and evaluation of the program’s overall performance 5. surveillance, studies and research e. Legal basis/existing policies 1. Presidential Decree No. 996 - providing for compulsory basic immunization for infants and children below eight years of age 2. presidential proclamation No. 6 - implementing a united nations goal on “Universal Child Immunization” 3. Presidential Proclamation No. 147 - declaring every third Wednesday of January and February thereafter, for two years, as “National Immunization Days” 4. Republic Act 7846 - an act requiring compulsory immunization against Hepaptitis B for infants and children below eight years old f. Importance of vaccination 1. Immunization is the process by which vaccines are introduced into the body before infection sets in. 2. vaccines are administered to promote immunity and to protect the children from disease-causing agents g. Concepts of Vaccinations 1. it is safe and immunologically effective to administer all EPI vaccines on the same day at different sites of the body 2. measles vaccine should be given as soon as the child is 9 months old, regardless of whether other vaccines will be given on that day. Measles vaccines given at 9 months provide 85% protection against measles infection  3. moderate fever, malnutrition, mild respiratory infection, cough, diarrhea and vomiting are not contraindications to vaccination. 4. absolute contraindications to immunizations are: DPT2 or DPT3 to child who has had convulsions or shock within 3 days after the previous dose. Live vaccines like BCG vaccine must not be given to individuals who are immunosupressed due to malignant disease (e.g. child with AIDS) 5. it is safe and effective with mild side effects after vaccination. Local reaction, fever and systemic symptoms can result as part of the normal immune response 6. false contraindications to immunizations are children with malnutrition, low grade fever, mild respiratory infections and other minor illness and diarrhea should not be considered a contraindication to OPV vaccination. 7. repeat BCG vaccination if the child does not develop a scar after the first injection 8. use one syringe one needle per child during vaccination h. The EPI Target Diseases 1. vaccination among infants and newborns (0-12 months) against the seven vaccination preventable diseases. 2. these include: Tuberculosis, Diphtheria, Pertussis, Tetanus, Poliomyelitis, measles and hepatitis i. The EPI Routine Schedule of Immunization 1. every Wednesday is designated as immunization day and is adopted in all parts of the country 2. A child is said to be “Fully Immunized Child” when a child receives one dose of BCG, 3 doses of OPV, 3 doses of DPT, 3 doses of HB and one dose of measles before a child’s first birthday Vaccine Minimum Number of Minimum Reason Age of 1st Doses Interval Dose Between Doses BCG Birth of 1 BCG given at BCG given at anytime after earliest possible age protects birth the possibility of TB and other TB infections DPT 6 weeks 3 4 weeks An early start with DPT reduces the chance of severe pertussis OPV 6 weeks 3 4 weeks The extent of protection against polio is increased the earlier the OPV is given Hepa B At birth 3 6 weeks An early start of Hepa B reduces interval from the chance of being infected 1st dose to and becoming a carrier prevent second dose liver cirrhosis and liver cancer. and 8 weeks interval from second dose to third dose Measles 9 months At least 85% of measles can be prevented by immunization at this age j. Tetanus Toxoid Immunization Schedule for Women 1. tetanus toxoid vaccination for women is important to prevent tetanus in both mother and the baby 2. completing the five doses following the schedule provide lifetime immunity Vaccine Minimum Age Percent Duration of protection interval Protected TT1 As early as possible during  the pregnancy TT2 At least 4 weeks 80% Infants born to the mother will later protected from neonatal tetanus. Gives 5 years protection for the mother TT3 At least 6 months 95% Infants born to the mother will be later protected from neonatal tetanus. Gives 5 years protection for the mother TT4 At least one year 99% Infants born to the mother will be later protected from neonatal tetanus. Gives 10 years protection for the mother TT5 At least one year 99% Gives lifetime protection for the later mother. All infants born to that mother will be protected k. Administration of Vaccines Vaccine Dose Route of Site of Administration Administration BCG Infants 0.05 ml Intradermal Right deltoid region of the arm DPT 0.5 ml Intramuscular Upper outer portion of the thigh OPV 2 drops or Mouth depending on manufacturer’s instructions Measles 0.5 ml Subcutaneous Outer part of the upper arm Hepa B 0.5 ml Intramuscular Upper outer portion of the thigh Tetanus Toxoid 0.5 ml Intramuscular Deltoid region of the upper arm L. the EPI vaccines and its characteristics - Vaccines are substances very sensitive at various temperatures. To avoid spoilage and maintain its potency, vaccines need to be stored at correct temperature. Type/Form of vaccines Storage temperature Most Sensitive to Oral polio (live -15C to -25C (at the freezer) heat attenuated) Measles (freeze dried) -15C to -25C (at the freezer) Least Sensitive to DPT/Hep B +2C to +8C (in the body of temperature) heat D – toxoid which is a weakened vaccine P – killed bacteria T – toxoid which is a weakened toxin Hep B +2C to +8C (in the body of temperature) BCG (freeze dried) +2C to +8C (in the body of temperature) Tetanus Toxoid +2C to +8C (in the body of temperature) 3. Management of Childhood Illnesses - the Integrated Management of Childhood Illnesses (IMCI) has been established as an approach to strengthen the provision of comprehensive and essential health package to the children. Methods in Managing Childhood Illnesses: 1. Assess the patient – taking the history of the patient is one of getting information about the disease condition. This can be done by asking and observing the patient’s condition to explore the possible causes.  - Check for DANGER SIGNS: convulsions, abnormally sleepy, difficult to awaken, unable to drink/breastfeed, vomits everything - Assess MAIN SYMPTOMS: cough/difficulty breathing, diarrhea, fever, ear problems 2. Classify the disease Color- Presentation Classification of Diseases Level of Management Green Mild Home Care Yellow Moderate Manage at the RHU Pink Severe Urgent Referral in Hospital 3. Treat the patient 4. Counsel the patient – providing health education to client to promote health and avoid risk of infection. - Counsel about home treatments, feeding and fluids, when to return immediately, follow up 4. Nutrition Program - Malnutrition continues to be the public health concerns in the country. The common nutritional deficiencies are: VIT. A, IRON and IODINE. - GOAL: “To improve quality of life of Filipinos through better nutrition, improved and increased productivity. Nutritional Guideline for Micronutrient Supplementation: A. Universal Supplementation of Vitamin A Target Preparation Dose/Duration Remarks Infants 6-11 months 100,000 IU 1 dose only One capsule is given anytime during the 6- 11 months but usually given at 9 months during measles immunization Children 21- 71 200, 000 IU 1 capsule every six months months B. Vit. A supplementation to High risk children. Target/Illness Preparations Dose/Duration Measles One capsule given upon diagnosis, regardless of when Infants (6 months-11 100, 000 IU the last dose of VAC was months) given. 200, 000 IU Pre-school children (12 months- 71 months) One capsule given upon Severe pneumonia diagnosis, except when the Persistent Diarrhea child was given VAC less than 4 weeks before diagnosis. Malnutrition Infants (6 months- 11 100, 000 IU months) 200, 000 IU Pre-school children (12 months – 71 months)  One capsule given upon diagnosis, except when the Malnutrition child was given VAC less than School children (6 years 200, 000 IU 4 weeks before diagnosis to 12 years old) B. Vit. A supplementation for pregnant women and post partum women. Targets Preparation Dose Duration Remarks Pregnant women 10, 000 IU 1 capsule/ tablet Start from the 4th Vit. A 10, 000 IU of 10,000 IU month of should NOT be twice a week pregnancy until given to pregnant delivery women who are already taking pre-natal vitamins or multiple micronutrient tablets that also contain Vit. A Post-partum 200, 000 IU 1 capsule 200, One dose only Vit. A of 200, 000 women 000 IU within 4 weeks IU should NOT be after delivery given to pregnant women D. Iron supplementation for pregnant and lactating women Targets Preparations Dose/Duration Remarks Pregnant women Tablet containing 60 1 tablet once a day for A dose of 800 mcg of mg elemental iron 6 months 0r 180 days folic acid is still safe to with 400 mcg folic during the pregnancy the pregnant woman. acid period Or 2 tablets per day (120 mg) if prenatal consultations are done during the 2nd and 3rd trimester Lactating women Tablet containing 60 1 tablet once a day for mg elemental iron 3 months or 90 days with 400 mcg folic acid E. Iodine supplementation to specific population groups. Targets Preparation Dose/Duration Women 15-45 years old Iodized oil capsule with 200 1 capsule for 1 year mg iodine Children of school age Iodized oil capsule with 200 1 capsule for 1 year mg iodine Adult males 1 capsule for 1 year Iodized oil capsule with 200 mg iodine Elements of Primary Health Care (selected) N. Health Education - is a process whereby knowledge, attitude and practice of people are changed to improve individual, family and community health. Sequence of STEPS in health education: C – reating awareness M – otivation D – ecision making action Component of Health education: I –nformation E – ducation C – ommunication Principles: H – ealth E – ducation considers the health status of the people. A – chieved by doing L – earning T – takes the lead in helping people to attain health through their own effort H – uman and natural resources were utilized (community resources) H – ealth workers consider health education as their basic function E – ducation for health is a creative process D – evelopment is slow but continuous and creative process U – se of supplementary aids and devices C – ooperative effort T – akes place in the home, in the school and the community I – nlvolves motivation O –penly makes us of supplementary aids and devices N – eeds, interests and problems of the people affected must be met Health Education teaching methods: a. Interviewing b. Counseling c. Lecture – discussion d. Open- forum e. Workshop f. Case study g. Role Play h. Symposium i. Community assembly Qualities of a Good HEALTH EDUCATOR E – effective motivator to others D – oes have knowledge or mastery of subject matter U – tilizes the quality of Patience and flexibity  C – redible/creative A – able to emphatize with others T – teaching skills O – organizes and encourage group participation R – ephrase or summarize ability S – ense of humor O. Treatment of Communicable Diseases (common) Defining terms: Communicable Disease – is an illness caused by an infectious agent that is transmitted directly or indirectly to a well person through a vector or an inanimate object. Carrier – is an individual who harbors the organism and is capable of transmitting it to a susceptible host without showing manifestations of the disease. Contagious Disease – is a term given to a disease that is easily transmitted from one person to another through direct or indirect means. Host – is a person, animal or a plant on which parasite depends for its survival Infectious Disease – is transmitted not only by ordinary contact but requires direct inoculation of the organism through a break on the skin or mucous membrane. Isolation – is the separation from other persons of an individual suffering from a communicable disease. Quarantine – is the limitation of freedom of movement of persons or animals which have been exposed to communicable disease for a period of time equivalent to the longest incubation period of illness. Surveillance – is the act of watching. Sporadic diseases – are diseases that occur occasionally and irregularly with no specific pattern. Epidemic diseases – are diseases that occur in a greater number than what is expected in a specific area over a specific time. Pandemic diseases – is an epidemic that affects several countries or continents. Endemic diseases – are those that are present in a population or community at times involving few people during specific periods. Chain of INFECTION: 1. CAUSATIVE agent – is any microbe capable of producing a disease. E.g. bacteria, spirochete, virus, fungi. Etc. 2. RESERVOIR of Infection – refers to the environment and objects on which an organism survives and multiplies. 3. Portal of EXIT – is the path or way in which the organism leaves the reservoir. E.g. RS, GUT, GIT, skin and mm. 4. Mode of TRANSMISSION – is the means by which the infectious agent passes through from the portal of exit of the reservoir to the susceptible host. This is the easiest link to break the chain of infection. Modes: a. Contact Transmission – most common and can be transmitted through direct and indirect contact and droplet spread. b. Air-borne transmission – occurs when fine microbial particles or dust particles containing microbes remain suspended in the air for a prolong period c. Vehicle transmission – is the transmission of the infectious disease through articles or substances that harbor organism until it is ingested or inoculated into the host d. Vector-borne transmission – occurs when carriers, such as flies intermediate intermediate and mosquitoes transfers the microbes to another living organism. 5. PORTAL of Entry – is the venue where the organism gains entrance into the susceptible host. 6. SUSCEPTIBLE host – the human body has many defenses against the entry and multiplication of organism. Preventive Aspect of Care of patients with Communicable Disease: A. Health Education  a. availability and importance of prophylactic immunization b. manner in which infectious illness is spread and methods of avoiding the spread c. importance of seeking medical advice for any sign of health problem d. importance of environmental cleanliness and personal hygiene e. means of preventing contamination of food and water supply B. Immunization – is the introduction of specific protective antibodies in a susceptible person or animal, or the production of cellular immunity in such person or animal Immunity – is a condition of being secure against any particular disease. Types: 1. Natural a. Natural Passive – acquired through placental transfer b. Natural Active – acquired through immunization and or recovery from a certain disease 2. Artificial a. Artificial Passive – acquired through the administration of antitoxin, antiserum, and gamma-globulins b. Artificial Active – acquired through the administration of vaccine and toxoid Types of antigen: 1. Inactivated (killed organism) - not long lasting, multiple dose needed and booster dose is needed 2. Attenuated (live organism) - single dose needed and has long lasting immunity C. Environmental Sanitation – the DOH, through the Environmental Health Services (EHS), has the authority to act in all issues and concerns in environmental health including the Code on Sanitation (PD 856 1. Water Supply Sanitation Program a. Approved types of water facilities such as: LEVEL 1 (Point of source) – a protected well or a developed spring with an outlet but without a distribution system generally adoptable to rural areas LEVEL II (Communal Faucet System or Stand Posts) – composed of a source reservoir, a piped distribution network and communal faucet LEVEL III – waterworks system or individual house connection b. Unapproved type of water facility or water coming from doubtful source such as open dug well, unimproved spring and wells are not allowed for drinking unless treated through proper disinfection. c. Water quality and monitoring - examination of drinking water shall be performed only in private and government laboratories duly accredited by the DOH - certification of potability of an existing water source is done by the Secretary of health or his duly authorized representative - water supply sources need to be disinfected: (1)newly constructed water supply facilities, (2)water supply facility that has been repaired or improved (3)water supply sources found to be bacteriologically positive through laboratory analysis. 2. Proper Excreta and Sewage Disposal a. Approved types of toilet facilities: LEVEL I – non water carriage toilet facility (pit latrines) - toilet facility requiring small amount of water to wash the waste into receiving space (aqua privies) LEVEL II – Water sealed and flush type with septic tank disposal facilities LEVEL III – water carriage toilet connected to septic tanks or to sewerage system to treatment plant 3. Hospital Waste Management a. all newly constructed/renovated government and private hospitals shall prepare and implement HWM  b. the use of appropriate technology and indigenous materials for HWM shall be adopted c. training of hospital personnel involved in waste management shall be an essential part of hospital training program 4. Food Sanitation Program a. food establishments shall be appraised as to the following sanitary conditions: - inspection/approval of all food sources, containers, transport vehicles - compliance to sanitary permit requirements for all food establishments - provision of updated health certificates for food handlers, cook and cook helpers - training food handlers and operators on food sanitation Common Communicable Diseases: AMOEBIASIS (Amoebic Dysentery) - a protozoal infection of human beings initially involves the colon, but may spread to soft tissues, most commonly to the liver by lymphatic dissemination. - Etiologic Agent: Entamoeba Histolytica - Source: Human excreta - Incubation period: in svere infection is 3 days. - Period of communicability: communicable for the entire duration of illness - Mode of transmission: 1. Fecal oral route 2. can be transmitted through direct contact and through sexual contact ie. Orogenital, oroanal 3. Through indirect contact, the disease can infect human by ingestion of food especially uncooked leafy vegetables or foods contaminated with fecal materials containing E. hystolitica - Sign and symptoms: 1. Slight attack of diarrhea, altered with periods of constipation and often accompanied by tenesmus 2. diarrhea, watery and foul smelling stool often containing blood streaked mucus. 3. nausea, flatulence, abdominal distension and tenderness in the right iliac region over the colon - Diagnostic exam: stool exam - Treatment: Metronidazole (Flagyl) - Nursing management: 1. Observe isolation and enteric precaution 2. Provide health education such as boiling of water for drinking; avoid washing of food from open drum or pail, food preparation and food handling. BACILLARY DYSENTERY (Shigellosis) - is an acute bacterial infection of the intestine characterized by diarrhea and fever associated with the passing out of bloody mucoid stool with tenesmus. - Etiologic Agent: Shigella (flesneri, boydii, connei and dysenteriae) - Incubation period: 7 hours to7 days, average 3 to 5 days - Period of communicability: capable of transmitting the microorganism during the acute infection until the feces are negative of the organism. - Mode of transmission: 1. through ingestion of contaminated food or drinking contaminated water 2. transmitted by flies or through other objects contaminated by feces of the patient 3. fecal- oral transmission - Signs and symptoms: 1. Fever 2. tenesmus, nausea and vomiting 3. colicky or cramping abdominal pain associated with anorexia and body weakness 4. diarrhea with bloody-mucoid stool that is watery at first 5. dehydration and loss of weight  - Diagnostic exam: Fecalysis - Treatment: Ampicillin, Tetracycline and Cotrimoxazole - Nursing management: 1. Maintenance of fluid and electrolytes 2. restriction of food until nausea and vomiting subsides 3. proper disposal of excreta CHICKENPOX (Varicella) - is an acute and highly contagious disease of viral etiology characterized by vesicular eruptions on the skin and mucous membrane - Etiologic agent: Herpesvirus varicellae - Incubation period: 10-21 days - Mode of transmission: 1. Transmitted through direct contact with patients who shed the virus from the vesicles 2. Indirectly through linens or fomites 3. Droplet infection - Period of Communicability: about a day before the eruption of the first lesion up to about 5 days after the appearance of the last crop - Signs and symptoms: 1. Pre-eruptive: mild fever and malaise 2. eruptive: rashes starts from the trunk (unexposed area), then spread to other parts, very pruritic vesicular lesion, lesions are characterized by different stages such as Macule-Papule-Vesicle-Pustule-Crust - Diagnostic exam: based on the clinical symptoms - Treatment: Zoveraz, Acyclovir - Nursing management: 1. Respiratory isolation 2. proper personal hygiene 3. cut finger nails short hand washing to minimize spread of bacterial infections CHOLERA (El Tor) - is an acute bacterial enteric disease of the GIT characterized by profuse diarrhea, vomiting, massive loss of fluid and electrolytes that could result to hypovolemic shock and death. - Etiologic agent: Vibrio Cholerae/Coma - Pathognomonic sign: Rice watery stool - Incubation period: 1-3 days - Period of communicability: communicable during stool positive stage, usually a few days after recovery - Mode of transmission: 1. Fecal- oral route 2. Transmitted through ingestion of food or water contaminated with stool 3. Flies, soiled hands and utensils serve to transmit infection - Diagnostic exam: Rectal swab/ Stool exam - Treatment: 1. IVF treatment 2. Oral Rehydration Therapy by oral route such Oresol and Hydrites 3. ATBC – Tetracycline - Nursing management: 1. Hand washing 2. enteric isolation 3. VS, I/O 4. proper personal hygiene 5. proper disposal of excreta 6. health education – food/water supply, boiling of water, sanitary disposal of human excreta DIPTHERIA (Pseudo-membrane) - is an acute bacterial disease that can infect the body in two areas; the throat (respiratory diphtheria) and the skin (cutaneous diphtheria) - Etiologic agent: Corynbacterium Diptheria (Klebs leoffler Bacillus) - Incubation period: 2-5 days  - Source of infection: infection comes from discharges of the nose, pharynx, eyes or lesions on other parts of the body - Mode of transmission: transmitted through contact with a patient or a carrier, or with articles with discharges of infected persons -Types: 1. Nasal – with foul-smelling serosanguinous secretions 2. Tonsilar 3. Nasopharyngeal (more severe type) – cervical lymph adenopathy, Bull’s neck appearance 4. Wound or Cutaneous diphtheria –affects mucus membrane and any break on the skin - Sign and symptoms; 1. Fatigue, malaise, slight sore throat and fever 2. Cervical adenitis 3. Bull’s neck appearance due to swelling of the neck - Diagnostic exam: Nose and Throat swab, Schick test and Molony test - Treatment: 1. ATBC – Penicillin 2. Antitoxin – requires skin testing, given in combination with penicillin - Nursing management: 1. Absolute CBR for 2 weeks to conserve energy 2. soft food diet/ small frequent feeding 3. encourage to drink fruit juice rich in Vit. C to increase resistance 4. Ice collar for the neck GERMAN MEASLES (Rubella/Three day Measles) - is a mild viral illness caused by rubella virus. It causes mild feverish illness associated with rashes and aches in joints. It has teratogenic in fetus. - Etiologic agent: Rubella virus - Incubation Period: 14-21 days - Period of communicability: one week before and four days after the onset of rashes, but worst when the rash is at its peak - Mode of transmission: 1. direct contact with nasopharyngeal secretions 2. air droplets 3. transplacental transmission - Signs and symptoms: 1. Prodromal period: low grade fever, headache, malaise, conjunctivitis, mild coryza, post-auricular, occipital, posterior cervical lymphadenopathy (3-5 days after the onset) 2. Eruptive period: Forchheimer’s spot – a pinkish rash on the soft palate, eruption of rashes that may last for 1-5 days - Treatment: symptomatic - Risk of Congenital malformation: 100% - when maternal infection occurs on the first trimester of pregnancy, 4% - second and third trimesters and 90% of congenital rubella cases will excrete the virus at birth and are therefore infectious. - Nursing management: 1. Isolation of patient 2. Bed rest until fever subsides 3. Darkened room to avoid photophobia 4. Irrigation of eyes with normal saline to prevent irritation 5. Health education – administration of MMR, pregnant mothers should avoid exposure to patients infected with rubella virus, administration of Immune Serum Globulin one week after exposure to Rubella HERPES SIMPLEX - is a viral disease characterized by the appearance of sores and blisters anywhere on the skin. - Etiologic agent: Herpes simplex virus (HSV) – Type 1: can cause cold sores characterized by tiny, clear fluid-filled blisters most commonly affects the lips, mouth, nose, chin or cheeks last for 7-10 days, can be transmitted through kissing, sharing or kitchen utensils or towels; Type 2: causes genital sores, affecting the buttocks, penis, vagina or cervix 2 – 20 days after contact, usually get through sexual contact, skin contact and is characterized by minor rash, painful sores, fever, muscular pain and burning sensation on urination - Treatment/Nursing management: 1. Oral anti-viral drugs such as Acyclovir  2. Personal hygiene HERPES ZOSTER (Shingles) - is an acute viral infection of the sensory nerve caused by a variety of chickenpox virus. - Etiologic agent: Varicella-zoster (found to cause two diseases, varicella and herpes zoster) - Incubation period: communicable a day before the appearance of the first rash until to six days after the last crust - Mode of transmission: 1. Transmitted through direct contact, droplet infection and airborne 2. Indirectly through articles freshly soiled by secretions and discharges from the infected person - Signs and symptoms: 1. Erythematous base of the skin lesion appears first and followed by the appearance of the vesicles within 24 hours usually affects the thoracic segment including the extremities. (Last for 1-2 weeks) 2. Paroxysmal burning and stabbing pain that occurs 1-5 days prior to the development of rash (worst at night and is intensified by movement) 3. Fever, malaise, anorexia, headache and lymphadenopathy - Diagnostic exam: based on the clinical manifestations - Treatment: Symptomatic, anti-viral drugs, analgesics, anti-inflammatory - Nursing management: 1. strict isolation of patient. 2. Apply cool, wet dressings with NSS to pruritic lesions 3. Prevention of secondary infections INFLUENZA (La Grippe) - is an acute viral infectious disease affecting the respiratory system - Etiologic agent: RNA containing myxoviruses, Type A, B and C - Incubation period: 24 – 48 hours - Period of communicability: communicable until the 5th day of illness and up to seven days in children - Mode of transmission: 1. airborne transmission among crowded population 2. droplet transmission - Signs and symptoms: 1. Chilly sensation, hyperpyrexia, malaise, sore throat, coryza, myalgia, vomiting and headache - Nursing management: 1. Stay at home 2. drink plenty of fluids 3. symptomatic treatment 4. TSB 5. isolate patient to decrease risk of infecting others (respiratory isolation) 6. Health education – immunization, avoidance of crowded places, personal hygiene LEPTOSPIROSIS (Weil’s disease/ Hemorrhagic Jaundice) - is a zoonotic infectious bacterial disease carried by animals whose urine contaminates water or food which is ingested or inoculated through the skin. - Etiologic agent: Leptospira Interrogans - Incubation period: 6 – 15 days - Period of communicability: leptospira is found in the urine between 10 – 20 days after the onset - Source of infection: Domestic animals such as Rats, Mice and Dogs - Mode of transmission: 1. through ingestion or contact with the skin and mucous membrane of the infected urine 2. Transmitted through the mucous membrane of the eyes, nose and mouth and through a break on the skin - Signs and symptoms: Stages: 1. Septic stage – marked with fever lasting 4-7 days. Chills, headache, anorexia, abdominal pain and severe prostration  2. Immune or Toxic stage – can be with or without jaundice and last for 4-30 days. Headache, meningeal manifestation like disorientation, convulsion, with CSF findings of aseptic meningitis, oliguria and anuria with progressive renal failure, shock and coma in severe cases. Death may occur between 9 to the 16th day 3. Convalescence – at this stage, relapse may occur during the 4th to 5th week - Treatment: Penicillin G Na - Nursing management: 1. Isolate patient with proper disposal of urine 2. keep patient on close surveillance 3. health education – sanitation in homes, workplaces and farm, eradication of rats and rodents MEASLES (Rubeola/Morbilli) - is an acute, contagious disease that usually affects children which are susceptible to Upper Respiratory Tract Infection (URTI). The most common and serious of all childhood diseases. - Etiologic agent: Filterable virus/ Morbilli virus - Incubation period: 10 – 12 days - Period of communicability: Communicable four days before and five days after the appearance of rashes - Sources of infection: Virus has been found in the patient’s blood, as well as in the secretions from the eyes, nose and throat - Mode of transmission: 1. through direct contact with the droplets spread by coughing and sneezing 2. Indirectly through articles or fomites freshly contaminated with respiratory secretions of infected patients - Signs and symptoms: Stages: 1. Pre-eruptive stage – fever, catarrhal symptoms (rhinitis, conjunctivitis, photophpbia and coryza), Koplik’s spot 2. Eruptive stage – macula-papular rash appears first on the cheeks, bridge of the nose, along the hairline, at the ear lobe on the 4 th day, on and off high grade fever, anorexia and irritability 3. Convalescence stage – rashes fade away, fever subsides - Diagnostic exam: Nose and throat swab - Treatment: anti-viral drugs, ATBC if with complication such as Bronchopneumonia, otitis media - Nursing Management: 1. Isolation of patient 2. TSB to control high fever with daily cleansing bed bath 3. Oral and nasal hygiene and provision of eye/ear care free of secretions 4. Patient’s position should be changed every 3-4 hours 4. Health education: measles vaccine, MMR vaccine MUMPS (Infectious Parotitis) - is an acute viral disease manifested by the swelling of one or both parotid glands, with occasional involvement of other glandular structures, particularly the testes in male - Etiologic agent: Paramyxovirus found in the saliva of the infected person - Incubation period: 14 – 25 days - Period of communicability: 6 days before and nine days after the onset of parotid gland swelling - Mode of transmission: Droplet infection - Signs and symptoms: 1. sudden headache, earache, loss of appetite and swelling of the parotid gland located in front and below the ear 2. Pain reaches its peak in about and continues for about seven to ten days 3. moderately elevated fever 4. one gland maybe affected at first, and one to three days later, the other side may become involved  - Complication: Most notorious complication is Orchitis (occurs several days after the onset of parotid swelling) - Treatment: 1. Anti-viral drugs 2. hot and cold application for relief of pain - Nursing management: 1. Medical aseptic protective care 2. bed rest to avoid complication 3. diversional activities 4. offer soft and solid foods and avoid acid foods PERTUSSIS (Whooping Cough) - is an infectious disease characterized by repeated attacks of spasmodic coughing which consists of a series of explosive expirations, typically ending in a long drawn forced inspiration which produces a crowing sound, the “whoop” and usually followed by vomiting. - Etiologic agent: Bordatella Pertussis - Incubation period: 7 – 14 days - Period of communicability: starts from 7 days after exposure to three weeks after typical symptoms - Mode of transmission: 1. direct contact and droplet 2. indirectly through soiled linens and other articles contaminated by respiratory secretions - Sources of infection: secretions from the nose and throat of infected persons - Signs and symptoms: Stages: 1. Catarrhal stage – coryza. Sneezing, lacrimation and dry cough. It is the most communicable stage and last for 1-2 weeks 2. Paroxysmal stage – occurs on the 7 to the 14 th day, cough becomes spasmodic and recurrent with excessive explosive outburst in series of rapid 5 to 10 rapid coughs in one expiration, each cough ends in loud, crowing inspiratory whoop and choking on mucus that causes vomiting. Last from 4-6 weeks. 3. Convalescence stage – marked by decrease in paroxysms of coughing, both in frequency and severity, the attack subsides after about six weeks. - Diagnostic exam: Nasopharyngeal swabs - Treatmetn: 1. Supportive therapy 2. ATBC such as Erythromycin and Ampicillin - Nursing management: 1. Isolation and medical asepsis 2. Suctioning equipment must be readily available at all time for emergency 3. Decrease environmental stimuli 4. Provide warm baths and keep bed dry 5. Health education – immunization, patient isolation, case reporting RABIES (Hydrophobia/Lyssa) - is a specific, acute, viral infection communicated to man by the saliva of an infected animal - Etiologic agent: Rhabdovirus - Incubation period: 1-7 ½ months in dogs, 10 days to 15 years in human depending on the following: a. distance of the site b. extensiveness of the bite c. specie of the animal d. richness of the blood supply in the area of the bite e. resistance of the host - Period of communicability: communicable from 3-5 days before onset of symptoms until the entire course of illness - Signs and symptoms: Stages: 1. Prodromal/Invasion phase – characterized by fever, anorexia, malaise, sore throat, copious salivation, lacrimation, perspiration, irritability, restlessness, sometimes drowsy, mental depression and insomnia. Pain at the original site of the bite, sensitive to light, sound and temperature, numbness and tingling sensation along the peripheral nerves and site of the bite  2. Excitement or Neurological phase – characterized by mark excitation. There is delirium with nuchal rigidity, severe and painful spasm of the muscles of the mouth, pharynx and larynx on attempt to swallow water or food. Patient may exhibit maniacal behavior and profuse drooling of saliva. 3. Terminal phase – patient becomes unconscious and spasm ceases with progressive paralysis. Death occurs due to respiratory paralysis and circulatory collapse. - Diagnostic exam: Fluorescent rabies anti-body (FRA), presence of negri bodies in the dog’s brain - Treatment: 1. Washing of wounds from the bite and scratches of dog with soap and running water for at least 3 minutes 2. give ATS and anti-rabies vaccine - Nursing management: 1. Isolate the patient 2. give emotional, spiritual support and optimum comfort 3. patient should not be bath and there should not be any running water in the room or within the hearing distance of the patient 4. IVF should be wrapped and needle should be properly anchored 5. Health education – vaccination of all dogs, confinement of any dog that has bitten a person for 10 – 14 days TETANUS (Lockjaw) - is an infectious disease caused by Clostridium tetani which produces potent exotoxin with prominent systemic neuromuscular efforts manifested by generalized spasmodic contractions of the skeletal muscles. - Incubation period: 3 days to 3 weeks in adult, 3 – 30 days in Tetanus neonatorum - Etiologic agent: Clostridium tetani - Sources of infection: animal and human feces, soil and dust and plaster of paris, unsterile sutures, pins, rusty materials, scissors - Mode of transmission: 1. through punctured wound and burns that is contaminated by dust, soil or animal excreta 2. Umbilical stump in newborn especially for babies delivered at home with faulty cord dressing 3. Circumcision and ear piercing - Signs and symptoms: Neonate: - have feeding and sucking difficulties - Excessive and voiceless crying -Tonic and rigid muscular contractions - Cyanosis, pallor Adult: - Muscle spasm and increase muscle tone near the wound (localized) - if systemic or generalized: - Hypertonicity, hyperactive deep tendon reflexes and painful involuntary muscle contractions - neck and facial muscle rigidity (Trismus) - Grinning expression (Risus Sardonicus) - Opisthotonus - Intermittent tonic convulsions lasting for several minutes which may result in cyanosis and sudden death due to asphyxiation - Laryngospasm followed by accumulation of secretions in the lower airway resulting in respiratory distress - Treatment: Specific; 1. Patient should receive ATS within 72 hours after a punctured wound 2. tetanus toxoid IM given in standard schedule 3. Pen G to control infection 4. Musle relaxant to decrease muscle rigidity and spasm Non- specific; 1. Maintainance of adequate airway/ Trachestomy 2. feeding through NGT 3. adequate fluid, electrolyte and caloric intake  4. lower environmental stimuli 5. close monitoring of VS and muscle tone 6. health education – active immunization with TT and DPT for babies and children TYPHOID FEVER - is a bacterial infection transmitted by contaminated water, milk, shellfish or other food. It is an infection of the GIT affecting the lymphoid tissues (payer’s patches) of the small intestines. - Etiologic agent: Salmonella typhosa/typhi - Incubation period: 5 – 40 days with a mean of 10- 20 days - Period of communicability: as long as the patient is excreting the microorganism, he is still capable of infecting others - Sources of infection: 1. A person who recovered from the disease or one who took care of a patient with typhoid and was infected 2. ingestion of shellfish (oysters) taken from waters contaminated by sewage disposal 3. stool and vomits of infected individual - Mode of transmission: 1. Fecal oral transmission 2. Through 5 F’s 3. ingestion of contaminated food, water and milk - Signs and symptoms: Onset: - headache, chilly sensation, body pains, nausea and vomiting and diarrhea - symptoms worst at 4-5th day - fever is higher in the morning that afternoon - red spots on the abdominal wall on the 7-9th day Typhoid state: - symptoms decline in severity - Accumulation of dirty brown collection of dried mucus and bacteria (Sordes) - Coma vigil (blank stare) - twitching of the tendon in the wrist - Patient mutters deliriously and picks up aimlessly at bed clothes with his fingers in continuous fashion (Carphologia) - Delirium and death in severe cases - Diagnostic exam: Typhidot - Treatment: Chloramphenicol – drug of choice - Nursing management: 1. Maintain or restore fluid and electrolyte balance 2. Monitoring patient’s VS 3. Prevent further injury (fall) of patient with typhoid psychosis 4. Maintain good personal hygiene and mouth care 5. Cooling measures are necessary during febrile state 6. Watch for signs of intestinal bleeding 7. Health education – sanitary disposal of excreta, proper supervision of food handlers, enteric isolation, adequate protection or provision of safe drinking water supply