Fundamentals Of Nursing PDF

FUNDAMENTALS OF NURSING 1 NURSING PROCESS - is a systematic, rational, cyclical method of planning and providing care STEPS OF THE NURSING PROCESS: ASSESSMENT Purpose: To establish a data base about the client’s perceived needs, health problems and risks, related e...

FUNDAMENTALS OF NURSING 1 NURSING PROCESS - is a systematic, rational, cyclical method of planning and providing care STEPS OF THE NURSING PROCESS: ASSESSMENT Purpose: To establish a data base about the client’s perceived needs, health problems and risks, related experiences, health practices, goals, values, and lifestyle. Stages of Interview: ✔ Opening (establish rapport - self introduction, non-verbal gestures) ✔ Body (open and close-ended questions) ✔ Closing DIAGNOSING Purpose: To identify and develop a list of nursing and collaborative problems Types of Nursing Diagnoses: ✔ Actual: the client shows manifestations of a health problem or condition. ✔ High-Risk: A health problem or condition is likely to develop as a result of risk factors being assessed unless the nurse intervenes. ✔ Wellness: The client is healthy as assessed but he wishes to achieve a higher level of functioning. ✔ Possible: a nursing diagnosis is which evidence is unclear unless further provided, but existing condition may predict a possible health problem ✔ Syndrome: a clustered nursing diagnosis. PLANNING Purpose: To develop an individualized, goal oriented and therapeutic care plan SPECIFIC How the nurse will know the client’s response has changed. MEASURABLE What the client will do, when it will be done, and to what extent. ATTAINABLE Relate with the client in formulating expected outcomes REALISTIC Includes client’s health capabilities TIMELY Time estimate for outcome attainment. IMPLEMENTATION Purpose: To assist client meet desired goals/outcomes and promote maximum level of functioning Types: 1. Independent: nurses are licensed to act related to their knowledge and skills. 2. Interdependent/ Collaborative: carried out by a nurse with collaboration of other healthcare team. 3. Dependent: carried out by a nurse in collaboration with the physician. 2 EVALUATION Purpose: To determine the effectiveness of the care plan and its corresponding actions whether to continue, terminate, or modify the care plan. Evaluation may be: ✔ Ongoing: done while or immediately after implementing the nursing intervention. ✔ Intermittent: performed at specified intervals, such as thrice a week. ✔ Terminal: performed to indicate the client’s condition at the time of discharge. PHYSICAL ASSESSMENT Technique: Inspection, Palpation, Percussion, Auscultation 1.Inspection Use of sense of sight Visual inspection/examination 2.Palpation ▪ Use of sense of touch NOTE: Finger pads and the back of the hand are the most sensitive body parts used for palpation. Types of palpation: Light palpation - detects superficial mass (1 “depth) Deep palpation - palpates organ enlargement like liver, mass and pulsations (3 - 4” in depth) 3. Percussion ▪ Assess for vibration with the use of fingers ▪ Thefinger of one hand taps the finger of the other hand to generate vibration which can be used to determine a diagnostic sound. TONE QUALITY PITCH EXAMPLE Resonance Hollow Low Healthy Lungs Hyperresonance Booming Very Loud Emphysema Tympany Drum - like High GI Bubbling, empty stomach or large intestine Dullness Thud - like High Kidney, full bladder, feces, filled intestine Flatness Very Dull Soft - Bones and muscles (very dense tissues), moderate heart, spleen, liver 4. Auscultation use of sense of hearing with the use of the unaided ear or a stethoscope frequently assessed organs: heart, lungs, abdomen, and blood vessels 3 VITAL SIGNS TEMPERATURE ALTERATIONS IN BODY TEMPERATURE: 1.Pyrexia - (hyperthermia) Above 40°C - hyperpyrexia 2.Fever Intermittent - fluctuation of body temp. at regular intervals between periods of fever and periods of normal or subnormal Temperature Remittent- fluctuations above Normal of more than 2 °C Relapsing - a fever that subsides and after few days returns. Constant - a fever with minimal temperature fluctuations 3. Hypothermia - a body temperature of 35 degrees Celsius or lower resulting from cold weather exposure or artificial induction PULSE RATE - number of beats per minute; assess this by compressing an artery with the pads of three fingers. Bradycardia: a pulse that is below normal rate. Tachycardia: a pulse that is above normal rate. NURSING ALERT: Pulse Force/ Pulse Volume Grading: +3: bounding pulse +2: normal +1: thready pulse, weak or difficult to feel 0: absent pulse Cardiac Output - 5-6 L of blood is forced out of the left ventricle per minute RESPIRATORY RATE Breathing Pattern/ Characteristics Sounds A. Kussmaul’s - Faster and deeper respiration without pauses in between panting B. Apneustic - Prolonged grasping breathing followed by extremely short inefficient exhalation C. Dyspnea - difficulty of breathing D. Orthopnea -DOB unless patient is sitting; can breathe only when in an upright position. E. Cheyne-Stokes - is the term for cycles of breathing characterized by deep, rapid breaths for about 30 seconds, followed by absence of respirations for 10 to 30 seconds. F. Wheezing - narrowing of airways, causing whistling or sighing sounds  G. Stridor - high-pitched sounds on inspiration with laryngeal obstruction H. Crackles/Rales - sound caused by air passing thru fluid or mucus in the airways usually heard on inhalation I. Gurgles/ Rhonchi - sound caused by air passing thru airways narrowed by fluids, edema, muscle spasm usually heard during exhalation ;course ,dry, wheezy or whistling sound 4 BLOOD PRESSURE - Pressure exerted by blood to the blood vessel wall TECHNIQUES The direct method (CVP) The indirect method (sphygmomanometer and stethoscope) Common site: brachial artery Contraindications for brachial artery: Venous access devices, such as an intravenous infusion or arteriovenous fistula for renal dialysis. Surgery involving the breast, axilla, shoulder, arm, or hand. Injury or disease to the shoulder, arm, or hand, such as trauma, burns, or application of a cast or bandage GENERAL MEDICAL AND NURSING PROCEDURES GASTRIC TUBE INSERTION Purposes: Administer tube feedings and medications to clients who cannot take in food per orem (Gavage) Prevent gastric distention, nausea and vomiting To remove stomach contents for laboratory analysis To lavage / wash stomach in case of poisoning or over dose of medication Procedure: 1. Gather the necessary equipment. 2. Explain procedure to the patient 3. Position the patient in a sitting position 4. Check nostrils for patency by asking the patient to breathe through one nares while occluding the other. 5. Measure length of NG tubing. 6. Don gloves and lubricate tube in water or a water soluble lubricant. (Never use petroleum jelly.) 7. Ask the patient to tilt his or her head backward, and gently advance the NG tube into an unobstructed nostril; direct tube toward back of throat and down. 8. As the tube approaches the nasopharynx, ask the patient to flex head toward  chest (to close the trachea) and allow him or her to swallow sips of water or ice chips as the tube is advanced into the esophagus (about 3 to 5 inches each time the patient swallows). NOTE: If the patient coughs or gags, check the mouth and oropharynx. If the tube is curled in the mouth or throat, withdraw the tube to the pharynx and repeat attempt to insert the tube. 9. Check for proper tube placement in the stomach by aspirating with a syringe for gastric drainage or by instilling about 20 mL of air into the NG tube while listening with a stethoscope for a gurgling sound over the stomach. 10.Secure the tube after checking for proper placement by cutting a 3-inch strip of 1- inch tape and then splitting the tape lengthwise at one end, leaving 1 inch intact at the opposite end 11.Place the intact end of the tape on top of the patient’s nose, and wrap one side of 5 the split tape end around the tube and secure on a nostril. Repeat with the other split tape end. 12.Document the size and type of tube inserted. Note the nostril used and the patient’s tolerance of the procedure. Document how placement was validated and whether tubing was left clamped or attached to other equipment. ▪ Total parenteral nutrition (TPN) - is delivered via a central venous catheterto reverse starvation and promote tissue synthesis, wound healing, and normal metabolic function. ▪ Central Venous Tunneled Catheters (CVT) - Are catheters with single, double, or triple lumens and can be used for administering drugs, blood products, and total parenteral nutrition as well as for obtaining blood samples for lab tests. - CVTCs can be used for months or years if infection does not occur - Dressing changes are made on all catheters using sterile technique. (Both nurse and patient should wear a mask during the procedure.) COMPLICATIONS: ✔ hyperglycemia- hyperosmolar (HA, Nausea and Vomiting, fever, chills, malaise) ✔ Infection (fever, redness and swelling on site ) ✔ Pneumothorax (dyspnea , ecchymosis, diminished/absent lung sound) GUIDELINES: 1. Verify central line placement after initial insertion via chest (radiograph) prior to beginning (pneumothorax or hemothorax is a risk with central line placement.) 2. Check vital signs (including blood pressure) at least every 6 hours after initiating infusion. 3. Check central line insertion site frequently for signs of infection (which may lead to sepsis) 4. Follow agency policy regarding frequency of dressing changes and procedure. 5. Change IV line setup every 24 hours. a. (TPN fluids are an excellent medium for bacterial growth.)  6. Do not administer IV piggyback or direct IV push medications through or draw blood samples from the TPN line. Only lipids may be a “piggybacked” carefully through the TPN line beyond the in line filter. 7. Monitor blood glucose every 6 hours; administer sliding scale insulin as ordered. 8. Weigh patient daily. (High glucose content of TPN can cause an osmotic diuresis and lead to dehydration.) 9. Order TPN solutions from the pharmacy in a timely manner; remove the next container from the refrigerator an hour before needed to prevent central infusion of cold solutions. 10. When a new container of TPN is needed, but is not available, follow agency policy to maintain the ordered fluid delivery rate with D10W until the TPN is available. (High glucose content of fluid stimulates release of insulin, which may cause hypoglycemia if fluids are discontinued abruptly.) 11. Do not attempt to “catch up” on fluids if rate inadvertently slows. 12. Discontinue TPN solution gradually at the end of therapy to prevent hypoglycemia. 13. Monitor lab values. (Liver complications, electrolyte imbalances, and pH changes are possible.) 6 ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS Guidelines in Administering Blood and Blood Products: 1. Verify physician’s order. 2. Check expiration date on product. 3. Verify accuracy of component with another licensed nurse or physician. Types of Blood Products: 1. Fresh Whole Blood- complete components 2. Red Blood Cells- used to replace erythrocytes, 1 unit increases hgb by 1g/dl and hct by 2 – 3 % after transfusion 3. White Blood Cells / Granulocyte Concentrate- Rarely used 4. Platelets- used to treat thrombocytopenia. Administered rapidly over 15 to 30 minutes 5. Fresh Frozen Plasma- used to provide clotting factors or for volume expanders Albumin to maintain colloid osmotic pressure 6. Check baseline vital signs (VS) and report any abnormal findings to the physician before beginning infusion of component. 7. Warm blood in approved blood warmer for use in rapid transfusions or for neonatal exchange transfusions. 8. Ascertain that the IV line is present and not infiltrated before beginning infusion. 9. Flush any solution from present IV line with 0.9% normal saline. (Flush again with saline after completion of product.) 10. Check manufacturer’s information before using any pump to administer product. (Some pumps may cause hemolysis of red cells.) 11. Initiate infusion within 30 minutes from the time the product is released from the blood bank. 12. Remain with the patient for at least 5 minutes after transfusion has begun. 13. Check VS 15 minutes after product infusion has begun, then 15 minutes later, and at least every 30 minutes until the infusion is completed. 14. Administer a maximum of 50 mL of product over the first 15 minutes of  transfusion. 15. Complete the infusion within 4 hours. 16. Validate teaching, assessment (including VS), product ID check, procedure (including time infusion begun and completed), and reaction in the patient’s record. 17. Stop infusion of blood product, maintain IV access with 0.9% normal saline, and notify the physician, send blood and blood set to the lab and reassess intensive monitoring. Oxygen Therapy Indicated to clients who need additional oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen. “NO SMOKING” sign on the door/head of bed area Avoid use of volatile and flammable materials such as alcohol, oils, greases, ether and acetone 7 O2 Delivery System: 1. Cannula Delivers low concentration of oxygen (24% to 45%) at flow rates of 2 - 6 LPM 2. Facemask Covers mouth and nose 3. Simple Face mask 40% - 60% at liters flow of 5 -8 LPM 4. Partial Rebreather Mask 60% - 90% at liters flow of 6 - 10 LPM The o2 reservoir bag allows the client to re-breathe about third of the exhaled air in conjunction with oxygen. It increases FiO2 by recycling expired oxygen 5. Non - rebreather Mask Highest oxygen concentration possible 95% - 100% at 10 - 15 LPM 6. Venturi Mask Oxygen concentrations vary from 24% - 40% - 50% at 4 - 10 LPM Has wide bore tubing and color coded jet adapters that corresponds to the exact oxygen concentration and flow liters to be delivered 7. Face Tents: Used when O2 masks are not tolerated Note: check facial skin frequently for dampness and chaffing Nursing Care: Keep the catheter patent by cleaning the catheter with Normal Saline CARING FOR CLIENTS WITH CHEST TUBES Types of Chest Tube Drainage System: Simple drainage system  a simple drainage system that can be connected to suction or to a Heimlich valve. The fluid-collection bottle would have measurement markings on it to help clinicians track the amount of fluid collected. Water Seal Drainage System addition of a water-sealed bottle to the simple drainage system. This helps to stop the problem of air moving back into the chest, and it also provides greater capacity for the collection of blood or body fluids without any clogging of the suction outlet/connection. 8 Three-bottle drainage system the system has a fluid-collection bottle and a water-sealed bottle, along with a pressure-regulating bottle. This bottle helps the system maintain a measured, constant negative pressure and negative flow. 1. Note accumulated drainage in the collection chamber at the start of each shift or more frequently if warranted by patient condition, and mark the date and time of observation on the collection chamber. 2. Check the water-seal and suction-control fluid levels at the start of each shift and replace water as necessary; water will evaporate from the suction-control chamber, especially with vigorous bubbling. To check fluid levels, temporarily turn off the wall suction. 3. Observe the water-seal chamber for fluctuations (tidaling) that occur with the patient’s ventilations; unless the patient is on a ventilator, the column of fluid rises with inhalation and falls with exhalation. 4. Observe the water-seal chamber for bubbling. Bubbling is normal on exhalation when the patient has a pneumothorax; continuous bubbling indicates an (abnormal) air leak in the system. 5. Maintain extra lengths of tubing by coiling it on the bed in order to prevent dependent loops  that may slow/stop drainage. 6. If drainage slows or stops, gently “milk” the chest tube from proximity to the patient toward the collection chamber: to milk the tube, grasp and squeeze it between the fingers and palm of one hand; release and repeat with the other hand on the next lower portion of the tube; continue toward the Collection chamber, squeezing the tube with only one hand at a time. 7. Do NOT strip the tube; stripping involves both hands with one holding the tube while the other squeezes and pulls toward the drainage chamber. (Stripping greatly increases the negative pressure applied to the pleural space and can cause tissue damage, bleeding, and pain.) 8. Document system function, including time initiated/discontinued, type and amount of drainage, patient respiratory status, details related to chest dressing, and appearance of the tube insertion site. CARING FOR CLIENTS WITH TRACHEOSTOMY Air is not filtered and humidified therefore, a mist collar or a 4 x 4 gauze may be held in place with a cotton tie over the stoma to filter the air as it enters. soak inner cannula in antiseptic soak with hydrogen peroxide, rinse well tie new tie before removing the old tie to prevent accidental dislodgement use precut gauze and perform care once a day at least. suction as needed and do oral care frequently 9 SUCTIONING Aspiration of secretions through a catheter that is connected to a suction machine or wall suction outlet Catheters: 1. Open tipped: Most effective in aspirating secretions 2. Whistle tipped: Less irritating 3. Oral suctioning: Yankauer device / oral suction tube 4. Catheter has a thumb port which serves as a controller when suctioning Points to remember: NEVER suction more 10 - 15 seconds Use aseptic technique when suctioning HYPEROXYGENATE prior to suctioning Do oral care after suctioning DO NOT suction while inserting the catheter When you close the thumb port with your finger the suctioning is done Open thumb port (no suction is done) Suction in a circular manner/ by rotating catheter (ensures all surfaces are reached and prevents trauma) Apply intermittent suction on withdrawal of the catheter Urinary Catheterization Procedure 1. Explain procedure to the patient. 2. Wash hands. 3. Position. A. female patient supine with knees flexed; B. male patient supine with legs slightly spread. 4. Place waterproof pad under buttocks. 5. Drape patient, diamond fashion, with sheet. 6. Arrange for adequate lighting. 7. Wash perineum with soap and water if soiled. 8. Open kit using sterile technique. 9. Don sterile gloves. 10. Set up sterile field (off bed if the patient may contaminate). 11. Test balloon if catheter will be indwelling. 12. With nondominant hand, spread labia (female) or retract foreskin (male). This hand is no longer sterile. Using provided antiseptic solution and cotton balls or swabs, cleanse perineum (female) from clitoris toward anus with top-to-bottom motion or retract foreskin (male) and use circular motion from meatus outward. Repeat this step at least three times. 13. Slowly insert catheter until urine is noted (2 to 3 inches for female or 7to 8 inches for male) For male patient, hold penis perpendicular to body and pull up gently during insertion. 14. Collect specimen if needed. 15. Remove catheter if it is not indwelling. 10 IF INDWELLING: 1. Inflate balloon. If patient has sudden pain, deflate balloon, advance catheter slightly and re inflate. 2. Pull catheter gently to check adequacy of balloon. 3. Attach catheter to collection tubing if not already connected by manufacturer. 4. Tape catheter to patient’s inner thigh.Allow slack for patient movement. 5. Discard gloves and equipment. 6. Wash hands. 7. Document size and type of catheter inserted, amount and appearance of urine, and patient’s tolerance of procedure. CARING FOR CLIENTS WITH COLOSTOMY OSTOMIES - divert and drain fecal material/ bowel resection Stoma - red, initial slight bleeding - normal, no redness or irritation 2 to 5 inches surrounding the area, no burning sensation Colostomy Ileostomy  ✔ Can irrigate, can be bowel trained, pouch ✔ no irrigation , wet fecal material , appliance all may not be worn and emptied after every the time , meticulous skin care, prevent skin defecation ✔ Ascending colon colostomy: liquid breakdown, constant flow not regulated, bag stool Transverse Colon Colostomy: emptied half full loose to semi formed ✔ Descending Colon Colostomy: close to normal Stool Monitor color changes in the Healthy stoma is red: a color change (dark stoma: Normal color : pink black to blue is noticeable) or red Stool is liquid Pale pink : low hgb/hct Post op drainage is dark green then yellow as Purple black: compromised circulation the client begins to eat What to Remember in Colostomy Care Avoid gas forming foods and nuts, but can have any food at tolerated after 6 weeks Dry skin before applying appliance Karaya powder - barrier to prevent contamination with excreta Appliance can be up to 2 weeks; 24-48 hours if eroded or ulcerated With deodorant (Charcoal filter Disk, Bismuth) ENEMA ADMINISTRATION Enema is a solution introduced into the rectum and large intestines. Its aim is to distend the intestine and irritate the intestinal mucosa; stimulates peristalsis and excretion of feces Position: Left Lateral ( adult) dorsal recumbent ( child) After administering the solutions, press buttocks together to prevent feces from expelling For abdominal cramps: stop temporarily Types of Enemas: 1. Carminative Enema- Aims to expel flatus. About 60mL to 180 mL of solution is administered 2. Cleansing Enema- It irritates the colon producing peristalsis by distending the colon with volume fluid 11 High enema A. Target: colon 1L of solution is introduced B. Low enema Target: rectum and sigmoid process ½ L is administered 3. Retention enema- Uses oil based solution (which acts as stool softeners and facilitates passage of feces). Administer oil into the rectum and sigmoid colon, then the oil is retained for 1 - 3 hours 4. Return flow / colonic Irrigation- Aims to expel flatus. Uses an inflow - outflow process that  is repeated 5 - 6 times. Solution container is lowered so that the fluid backs out through the rectal tube into the container. Intravenous Therapy Purposes: used to replace fluids and electrolytes provides vascular access for immediate or rapid delivery of substances or medications especially in emergency situation Isotonic Isotonic fluids have an osmolality the same as that of blood; about 310 mEq/L of electrolytes. Hypotonic Hypotonic fluids have an electrolyte content below 250 mEq/L. Lower osmolality than the body thus causing movement of solutes into the cells by osmosis. Used to prevent cellular edema Hypertonic Hypertonic fluids have an electrolyte content above 375 mEq/L. Higher osmolality than the body Movement is from cell to extracellular compartment Crystalloids Used for fluid volume replacement Contains mostly of electrolytes Colloids Or plasma expander Used in cases such as severe hemorrhage and hypovolemia Type of Solution Fluid Uses Isotonic Solutions · 0.9% saline ( NS ) Supplies calories as · 5% dextrose in water ( D5W) · 5% carbohydrates; dextrose in 0.255% saline (5% D ¼ prevents dehydration; NS) maintains · Lactated Ringers solution ( LR) water balance; promotes sodium diuresis Hypotonic · 0.45 Saline (½ NS) Replaces fluid and · 0.25% Saline (¼ NS) electrolyte loss · 0.33 % Saline (1/3 NS) 12  Hypertonic · 3% Saline ( 3% NS) Replaces fluid and · 5% Saline ( 5% NS) electrolyte loss · 10% Dextrose in water ( D10 W) · 5% dextrose in 0.9% saline ( 5% D/NS) · 5% Dextrose in 0.45% saline ( 5% D/1/2 Solution Colloid · Dextran Maintains colloid · Albumin osmotic pressure Flow rate: amount of fluid - drop factor on tubing box ÷ running time stated in total number of minutes. COMPLICATIONS OF IV THERAPY 1. Local/Phlebitis - involves only the insertion site and manifest as peri-catheter inflammation; Warm erythematous skin over an indurated or tender vein an often precedes or is associated with more severe infections. 2. Cellulitis - Warm erythematous and often tender skin surrounding the site of cannula insertion, pus is rarely detectable. 3. Infiltration - Edema, pain, and coolness at the site ( may not have back flow) 4. Circulatory Overload - distended jugular vein, high Blood Pressure, dyspnea, moist cough and crackles 5. Hematoma - ecchymosis, immediate swelling and leakage of blood at the site of insertion and painful lumps 6. Air embolism - tachycardia, dyspnea, hypotension, cyanosis, decreased LOC Wound Dressings Types of dressing: 1. Dry to Dry Trap necrotic debris and exudate 2. Wet to Dry Uses saline and anti-microbial solution this softens debris as it dries and dilute exudate 3. Wet to damp Wound debrided if gauze is removed Variation at drying WOUND DEBRIDED IF GAUZE REMOVED (VARIATION at DRYING) 4. Wet to Wet Keeps wound moist (wound is bathed) Moisture dilutes viscous exudate Notes: Use sterile gloves or clean gloves Use gauze pads (which may be lifted with sterile forceps) to cleanse the wound with prescribed antiseptic solution. Cleanse the wound from the center outward, using a new gauze pad for each outward motion. Iodine solutions may cause skin irritation if they are left on the skin between dressing changes  “Wet-to-dry dressing change” describes the technique of applying several layers (the number of layers depends on the size of the wound area and the patient) of saline-soaked dressings next to the wound and covering these with dry dressings. 13 GRIEF, LOSS, DEATH AND DYING Loss Actual or potential situation where in something valued is changed/lost/gone ▪ Actual ▪ Perceived Can be recognized by others Only the “self” can experience Cannot be verified by others Grief Anticipatory Experienced before the actual loss Loss can be situational or developmental Response or reaction to loss Bereavement ▪Subjective Response ▪ Mourning Types of Grief Responses: Abbreviated Grief o Genuinely felt grief but brief Anticipatory Grief o Grieving in advance Disenfranchised Grief o Unable to acknowledge the loss to other people o Examples are unacceptable loss that cannot be spoken about like suicide, abortion Dysfunctional Grief o Pathologic grieving Unresolved Grief o Extended / lengthy and severe grieving o May deny loss or grieve beyond expected time Inhibited Grief o Suppressed grieving Stages of Grieving Kübler Engel Sander Ross Denial Shock and Disbelief Shock “No! not me” (accepts situation but  denies emotionally) Anger “why me?” Awareness Awareness of Loss Bargaining Restitution Conservation/Withdrawal “if only I could live a lil longer.” ( do rituals of mourning) (social withdrawal/ needs to be alone) Depression - silence Resolving Loss Healing: The turning point (acceptance) 14 Acceptance Idealization Renewal “I’m ready” (new self - awareness Legal Aspects Related to Death Advance Health Care Directives Variety of legal and lay documents that allow persons to specify aspects of care they wish to receive should they become incapable of verbalizing their care preference 2 TYPES: Living Will - Provides specific instructions about what medical treatments the client choose to refuse in the event that the client is incapable of making decisions Health Care Proxy ❖ Durable Power of Attorney for Health Care -Notarized/witnessed statement appointing SOMEONE ELSE (relative or friend) to manage health care treatment and decisions. Do - Not - Resuscitate Orders DNR/no Code Ordered by physician when the client/ health care proxy has verbalized the wish for no resuscitation when the client will have respiratory or cardiac arrest DNR indicates that the goal of treatment is a comfortable dignified death and further life sustaining interventions will not be done to patients any longer. Nursing Responsibility in Dying Patients Assisting the Client to a peaceful death Maintaining humanity, consistent with the client’s values, beliefs and culture Providing spiritual support Facilitating expressions of feelings and emotions about death Arranging an appointment with a clergy or a spiritual adviser. Use of therapeutic communication for the family to be able to express feelings Post Mortem Care Do post mortem care according to hospital policy All equipment, tubes, supplies must be removed A pillow is placed under the head and shoulders to prevent discoloration in the face A complete bath is not necessary ( the mortician will do the bathing Identification band should be attached before the body is taken to the morgue A shroud is used to wrap the body Intervention Rigor Mortis Position the body naturally (in (stiffening of the body; starts in the natural/neutral manner) involuntary muscles like the heart etc.) Place dentures (if there is) Close eyes and mouth Algor Mortis (gradual decrease of temperature) Livor Mortis ( discoloration of the body) 15  COMMUNITY HEALTH NURSING 1 Definition: ❖ Focus of the community health nursing is the community as a whole, with nursing care of individuals, families and groups being provided within the context of promoting and preserving the health of the community (Association of Community Health Nursing Educators, 1990) ❖ According to Ruth B. Freeman, it refers to a service rendered by a professional nurse with communities, group, families, individuals at home, in health centers, in clinics, in schools, in places of work for the: Promotion of health Prevention of illness Care of the sick at home and rehabilitation Four Levels of Clientele:  Individuals Family Population Community Subspecialties: School Nursing Occupational Health Nursing Community Mental Health Nursing Public Health Nursing COMMUNITY – BASED NURSING ❖ It is a philosophy of care in which the care is provided as clients and their families move among various service outside of hospitals. PUBLIC HEALTH NURSING ❖ It is a special field of nursing that combines the skills of nursing, public health and some phases of social assistance (World Health Organization) ❖ Functions as part of the total public health programme for the promotion of health, the improvement of the conditions, in the social and physical environment, rehabilitation of illness and disability ❖ According to Dr. C.E Winslow, public health is the science and art of: Preventing diseases Prolonging life Promoting health and efficiency ❖ Refers to the nurses in the local/national health departments or public schools whether their official position title is public Health Nurse or Nurse school nurse ❖ Starts with a Salary Grade 15 Roles & Functions Planner/Programmer ✔ Identifies the health needs, priorities and problems of individuals, families, and community Nursing Care Provider 2 ✔ Provides nursing care to the sick, disabled in the home, clinic, school, or place of work Manager/Supervisor ✔ Formulates and implements nursing plan for individual, family, group, community ✔ Leads and encourages them to address their health needs and solve their health problems Community Organizer ✔ Motivates and enhances community participation  ✔ Initiates and participates in community development activities Service Coordinator ✔ Collaborates with individuals, families, and groups for health and health services Health Educator/Counselor/Trainer ✔ Conducts health teaching, training and counseling ✔ Trains and educates rural health midwives Acts as a resource speaker on health and health related services Health Monitor ✔ Monitors the status of the individuals, families and groups through various contacts Role Model ✔ Sets as good example of healthful, living to the individuals, families, and community Change Agent ✔ Motivates changes in the health behavior of individual, families and community Reported/ Recorder/Statistician ✔ Records every nursing interventions ✔ Updates existing data base ✔ Makes statistical analysis of data for interpretation Researcher ✔ Uses observation, interview, survey questionnaire, physical exam, and other methods in the assessment of individuals, families, and community Qualifications of Public Health Nurses Graduate of Bachelor of Science in Nursing and a Registered Nurse Good physical and mental health Interest and willingness to work in the community Capacity and ability to: ✔ Relate the practice with on-going community health and health related activities ✔ Work cooperatively with other disciplines and members of the community ✔ Accept and take actions needed to improve self and service ✔ Analyze combination of factors and conditions that influence health of populations ✔ Apply nursing process in meeting the health and nursing needs of the community ✔ Mobilize resources in the community With leadership potential Resourcefulness and creativity Active membership to professional nursing organizations 3 PHILIPPINE HEALTH CARE DELIVERY SYSTEM DEPARTMENT OF HEALTH (PUBLIC SECTOR)  Leadership Serve as national policy and regulatory institution. in Health Provide leadership in formulation, monitoring, and evaluation of national policies, plans and programs. Serve as advocate in the adoption of health policies, plans and programs Enabler Innovate new strategies in health and Exercise oversight functions and monitoring and evaluation of Capacity national health plans, programs, and policies Ensure the highest achievable standards of quality health care, health promotion, and health protection Administrato Manage selected national health facilities and hospitals with modern and r of specific advanced facilities Services Administer direct services for emergent health concerns that require new complicated technologies Administer health emergency response VISION ❖ Filipinos are among the healthiest people in Southeast Asia by 2022, and Asia by 2040 MISSION ❖ To lead the country in the development of a productive, resilient, equitable and people centered health system GOAL ❖ Health Sector Reform Agenda (HSRA) Health Sector reform is the overriding goal of DOH FRAMEWORK FOR THE IMPLEMENTATION OF HSRA ❖ FOURmula ONE for Health (2005-2010) Goals of the FOURmula One of Health ✔ Better Health Outcomes ✔ More responsive health systems ✔ Equitable health care financing Four Elements of the Strategy 1. Health Financing ✔ To foster greater, better and sustained investments in health (PHILHEALTH) 2. Health Regulation ✔ To ensure the quality and affordability of health goods and services 3. Health Service Delivery ✔ To improve and ensure the accessibility and availability of basic and essential  health care 4. Good Governance ✔ To enhance health system performance at the national and local levels. 4 LOCAL HEALTH SYSTEM ❖ RA 7160 – Local Government Code All structures, personnel, and budgetary allocations from the provincial health level down to the barangays were Devolved to the Local Government Units to facilitate health service delivery ❖ Objectives of Local Health System Establish local health system Upgrade the health care management and service capabilities of local health facilities Promote inter-LGU linkages and cost sharing schemes Foster participation of the private sector, non-government organizations and community ❖ Inter Local Health System It is a system of health care similar to a district health system System that is being espoused by the DOH in order to ensure quality of health care service Composition of Inter-Local Health Zone 1. People ✔ Ideal health district would have a population size between 100,000 to 500,000 for optimum efficiency and effectiveness 2. Boundaries ✔ Clear boundaries between inter Local Health Zones determine the accountability and responsibility of health service providers 3. Health Facilities ✔ District or provincial hospital and other health services deciding to work together as an integrated health system 4. Health Workers ✔ Right unit of health providers is needed to deliver comprehensive health services. PRIMARY HEALTH CARE 1.Adopted in the Philippines through: Letter of instruction (LOI) 949 ✔ Signed by President Marcos on October 19, 1979 Underlying theme: “Health in the Hands of the People by 2020” 2.Characterized by partnership and empowerment of the people that shall permeate as the core strategy in the effective provision of essential health services that are community- based, accessible, acceptable, and sustainable at a cost, which the community and the government can afford. Elements/Components of PHC  Education for health Locally Endemic and Communicable Disease Control and Treatment Expanded Program on Immunization Maternal and Child Health and Family Planning Essential Drugs Nutrition Treatment (Medical and Emergency Care, Non Communicable Diseases and Mental Health) Sanitation of the Environment 5 Four Cornerstones/Pillars in Primary Health Care Active community participation Intra and inter-sectoral linkages Use of appropriate technology Support mechanism made available Levels of Primary Health Care Worker 1. Village/Barangay Health Workers Refers to trained community health workers or health auxiliary volunteer or a traditional birth attendant or healer 2. Intermediate Level Health Workers General medical practitioners or their assistants. E.g. Public Health Nurse, Rural Sanitary Inspectors and Midwiwes, Rural Health Physician Levels of Health Care and Health Referral System 1. Primary Level of care Devolved to the cities and municipalities Health care provided by center physicians, public health nurses, rural health midwiwes, barangay health workers, traditional healers Example: ⮚ Barangay Health Station ⮚ Rural Health Unit ⮚ Community Hospital ⮚ Health Centers ⮚ Puericulture Center 2. Secondary Level of Care  Secondary care is given by physicians with basic health training Serves as a referral center for the primary health facilities Capable of performing minor surgeries and perform some simple laboratory examinations Example: ⮚ Emergency/ District Hospitals ⮚ Provincial/City Health Services ⮚ Provincial/City Hospital 3. Tertiary Level of Care Tertiary care is rendered by specialists in health facilities Referral center for the secondary care facilities Complicated cases and intensive care requires tertiary care Example: ⮚ Regional Health Services ⮚ Regional Medical Centers and Training Hospitals ⮚ National Health Services ⮚ Medical Centers ⮚ Teaching and Training Hospitals 6 Levels of Prevention 1. Primary Prevention Focuses on health promotion and disease prevention Examples: Immunization and Promotion of Healthy Lifestyle (Proper Diet and Exercise) 2. Secondary Prevention Focuses on early detection of disease and prompt treatment for individual experiencing health problems Examples: Breast- Self Examination, Diagnostic Test (AFB Test), Cancer Sign and Symptoms (Caution us) 3. Tertiary Prevention Rehabilitation (prevent further disability) Restore client’s optimum level of functioning Examples: Mental Health, Crutch Walking and Physical Therapy COMMUNITY HEALTH NURSING PROCESS 1. Assessment This provides: ✔ An estimate of the degree to which a family, group or community is achieving the level of health possible for them ✔ Identifies specific deficiencies or guidance needed ✔ Estimates the possible effects of nursing interventions Health Deficit ✔ A gap between actual and achievable health status  ✔ Failure in health maintenance ✔ Already developed the disease or disability, developmental lag. Health Threat ✔ Condition that promote disease or injury and prevent people from realizing their health potential Foreseeable Crisis ✔ Anticipated periods of unusual demand on the individual/family in terms of resources and adjustment Wellness Potential ✔ This refers to states of wellness and the likelihood for health maintenance or improvement to occur depending on the desire of the family 2. Planning Goal Setting ✔ Initial step ✔ Declaration of purpose/ intent that gives essential direction to action Constructing a Plan of Action ✔ Choosing from among the possible courses of action ✔ Selecting the appropriate types of nursing intervention ✔ Identifying appropriate and available resources Developing an Operational Plan ✔ Establish priorities, phase, and coordinate activities ✔ Development of evaluation parameters is done in the planning stage 7 3. Implementation Involves various nursing interventions which have been determined by the goals/objectives that have been previously set Carrying out of nursing procedures Documentation is done at this phase 4. Evaluation Three Classic Frameworks ✔ Structural elements ✔ Process elements ✔ Outcome elements MANAGEMENT FUNCTIONS OF COMMUNITY HEALTH NURSE ❖ Planning Includes assisting the organization in establishing a vision for the future Deciding what must be done and what the organization wants to achieve ❖ Organizing Helps to determine how a manager implements planning to achieve the stated goals Major concerns: ✔ Analysis of the systems ✔ Analysis of functions  ✔ Assigning job responsibilities ✔ Implementation ❖ Directing Includes conveying to the workers what has occurred in the planning and organizing phases ❖ Coordinating Linking people on the health care team together to function in such a way that objectives are achieved ❖ Controlling Process that measures and corrects the activities of the people and establishes standards so that objectives are met Step: ✔ Establishing standards ✔ Measuring performance criteria ✔ Correcting deviations from normal ❖ Evaluating Involves upon actions to determine their effectiveness in order to make decisions regarding future action Documenting the progress by comparing achievements against a performance standard CLINIC VISIT NURSING PROCEDURES ❖ Standard Procedures 1. Registration/Admission Greet the client and establish rapport Prepare family record (New Client) 8 Retrieve record (Old Client) Elicit and record the client’s chief complaint and clinical history Perform physical exam on the client 2. Waiting time Give Priority numbers to clients Implement “first come, first served” policy except for emergency cases 3. Triaging Manage program-based cases ✔ Manage according to Protocols Refer all non-program based cases to the physician Provide first-aid treatment to emergency cases 4. Clinical Evaluation Validate clinical history and physical exam Nurse arrives at the evidence-based diagnosis and provides rational treatment based on DOH programs Inform the client on the nature of the illness, appropriate treatment and prevention  and control measures 5. Laboratory and other Diagnostic Examinations Identify a designated referral laboratory when needed 6. Referral System Refer the patient if he needs further management following the two-way referral system Accompany the patient when an emergency referral is needed 7. Prescription/Dispensing Give proper instruction on drug intake 8. Health Education Conduct one-on-one counseling with the patient Reinforce health education and counseling messages Give appointments for the next visit HOME VISIT ❖ Allow the health worker to assess the home and family situations in order to provide the necessary nursing care and health related activities ❖ Principles Home visit must have a purpose or objective Planning should: ✔ Make use of all available information ✔ Involve the individual and family ✔ Give priority to the essential needs ❖ Purposes To give nursing care to the clients To assess living conditions of the patient and his family To give health teaching regarding the prevention and control of diseases To establish close relationship between health agencies and public To make use of inter referral system 9 ❖ Factors influencing Frequency of Home Visits Needs of the (most important) nd Acceptance of the family 2 most important Policy of a Specific agency Other health agencies involved Past services given to family Ability to recognize own needs ❖ Steps in conducting Home Visits 1. Greet the patient and introduce self 2. State the purpose of visit 3. Observe the patient and determine health needs 4. Put the bag in a convenient place then proceed to perform the bag technique 5.  Perform the nursing care needed and give health teachings 6. Record all important data, observation, and care rendered 7. Make appointment for a return visit BAG TECHNIQUE ❖ A tool by which the nurse will enable her to: Perform a nursing procedure with ease and deftness Save time and effort ❖ Public Health Bag An essential and indispensable equipment of a public health nurse which she has to carry along during her home visits ❖ Principles of bag Technique Minimize if not prevent the spread of any infection Saves time and effort This should show the effectiveness of total care given to an individual or family Can be performed in a variety of ways depending on the agency’s policy or home situation or as long as principles of avoiding transfer of infection is always observed ❖ Important Points to Consider in the Use of the Bag The bag should: ✔ Contain all the necessary articles, supplies, and ✔ Equipment that will be used to answer emergency needs ✔ Be cleaned very often, the supplies replaced, and ready for use any time ✔ Be well protected from contact with any article Arrangement of contents should be the one most convenient to the user Epidemiology ❖ Study of the occurrence and distribution of health conditions such as disease, death, deformities or disabilities on human populations. ❖ The nurse measures the frequency and distribution of health conditions using Vital statistics. Important Concepts related to Epidemiology: 1. The Multiple Causation Theory (the wheel, the web, the ecologic triad) 2. Natural History of Disease 10 A. Pre-pathogenesis or susceptibility B. Pathogenesis which has 3 substages: a. Pre-symptomatic b. Discernible lesions c. Advanced Disease 3. Level of Prevention of Health Problems 4. Concept of Causality and Association The Epidemiological Approach 1. Descriptive Epidemiology ❖ Concerned with disease distribution and frequency 2. Analytical Epidemiology ❖ Attempts to analyze causes or determinants of disease through hypothesis testing 3. Intervention or Experimental Epidemiology ❖ Answers questions about the effectiveness of new methods for controlling diseases or for improving underling conditions 4. Evaluation Epidemiology ❖ Attempts to measure the effectiveness of different health services and programs VITAL STATISTICS ❖ Refers to the systematic study of vital events such as births, illnesses, marriages, divorces, separation and deaths ❖ Morbidity (Disease) and Mortality (Death) Indicate the state of health of a community and the success of failure og health work ❖ Uses of Vital Statistics Indices of the health and illness status of a community Serves as bases for planning, implementing, monitoring and evaluating CHN programs and services ❖ Sources of Data Population census Registration of Vital Data Health survey Studies and researches ❖ Comparison between Rates and Rations Rate - Shown the relationship between vital event and those persons exposed to the occurrence of said event within a given area and during a specified unit of time Ratio – is used to describe the relationship between two numerical quantities or measure of events without taking particular considerations to the time or place Infant Mortality Rate ✔ Good index of the general health condition of a community Crude Birth Rate ✔ A measure of one characteristic of the natural growth or increase of population Crude Death Rate ✔ A measure of one mortality from all causes which may result in a decrease of population 11 Maternal Mortality Rate ✔ Measures the risk of dying from causes related to pregnancy, childbirth and puerperium  ✔ Index of the obstetrical care needed and received by women in a community Fetal Death Rate ✔ Measures pregnancy wastage ✔ Death of the product of conception occurs prior to its complete expulsion, irrespective of duration of pregnancy Neonatal Death Rate st ✔ Measures the risk of dying 1 month Attack Rate ✔ More accurate measure of the risk of exposure Case Fatality Ratio ✔ Index of a killing power of a disease and is influenced by incomplete reporting and poor morbidity data Incidence Rate ✔ Measures the frequency of occurrence of the phenomenon during a given period of time ✔ New cases Prevalence Rate ✔ Measures the proportion of population which exhibits a particular disease at a particular time ✔ New and old cases FIELD HEALTH SERVICES AND INFORMATION SYSTEM (FHSIS) ❖ Objectives To provide summary of data on health services delivery To provide data that can be used for program monitoring and evaluation purposes To provide a standardized, facility level database which can be accessed for more in depth studies To ensure that the data are useful and accurate To minimize the recording and reporting burden at the service delivery level ❖ Components Family Treatment Record ✔ Fundamental building block of FHSIS Target Client List ✔ Second building block of FHSIS Reporting Forms ✔ Only mechanism through which data are routinely transmitted from one facility to another ✔ Prepared and submitted either monthly or quarterly Output Reports ✔ Objective in designing the output formats: Make the reports useful for monitoring or management purposes 12 PUBLIC HEALTH PROGRAMS (Maternal Health Program) 1. Antenatal Registration PRENATAL VISITS PERIOD OF PREGNANCY 1ST Visit As early in pregnancy as possible 2nd Visit During 2nd trimester 3rd Visit During 3rd trimester Every 2 weeks After 8th month of pregnancy until delivery 2. Tetenus Toxoid Immunization VACCINE INTERVAL PROTECTION DURATION TT 1 As early as possible during ----------- --------- pregnancy TT 2 After 4 weeks 80% 3 years TT 3 After 6 months 95% 5 years TT 4 After 1 year 99% 10 years TT 5 After 1 year 99% Lifetime 3. Micronutrient Supplementation VITAMINS DOSE SCHEDULE Vitamins A 10,000 IU Twice a week starting on the 4th month of pregnancy Iron/Folic 60mg/400ug Daily (Starting 5th month of pregnancy up 2 months acid tablet postpartum) 4. Treatment of Diseases and Other Conditions 5. Clean and Safe Delivery 6. Health Teachings: Birth registration  Importance of breastfeeding Newborn screening between 48 hours up 2 weeks after birth Schedule when to return for consultation for post-partum visits st st ✔ 1 Visit – 1 week postpartum preferably 3-5 days nd ✔ 2 Visit – 6 weeks postpartum 7. Support to Breastfeeding 8. Family Planning Counseling Proper spacing of birth (3 to 5 years interval) FAMILY PLANNING ❖ Overall Goal: To provide universal access to family planning information and services wherever and whenever these are needed Aims to reduce: Infant deaths Neonatal deaths Under-five deaths Maternal deaths Objectives Addresses the need to help couples and individuals achieved their desired family size within context of responsible parenthood 13 Ensure that quality FP services are available in DOH retained hospitals, LGU managed health facilities, NGOs and private sector Family Planning Methods 1. Female Sterilization Also known as Bilateral Tubal Ligation Safe and simple surgical procedure which provides permanent contraception for women who do not want more children Involves cutting or blocking of two fallopian tubes. Advantages ✔ Permanent method of contraception ✔ Does not interfere with sex ✔ Results in increased sexual enjoyment ✔ No effect on breastfeeding ✔ No known long term side effects or health risks Disadvantages Uncommon complications of surgery: ✔ Infection or bleeding ✔ Increase risk for ectopic pregnancy ✔ Requires physical examination ✔ Reversal surgery is difficult ✔ Do not protect against sexually transmitted diseases  2. Male Sterilization Also known as Vasectomy Permanent method wherein the vas deferens is tied and cut or blocked through a small opening in the scrotal skin Advantages ✔ Very effective in 3 months after the procedure ✔ Permanent, safe, simple and easy to perform ✔ Can be performed in a clinic ✔ Person will not lose his sexual ability and ejaculation Disadvantages ✔ May be uncomfortable due to slight pain and swelling 2-3 days after the procedure ✔ Reversibility is difficult and expensive ✔ Bleeding may result in hematoma formation 3. Pill Contains hormones – estrogen and progesterone Advantages ✔ Safe as proven through extensive studies ✔ Convenient and easy to use ✔ Reduces gynecologic symptoms such as painful menses and endometriosis ✔ Does not interfere with sexual intercourse 14 Disadvantages ✔ Often not used correctly and consistently, lowering its effectiveness ✔ Has side effects such as nausea, dizziness or breast tenderness ✔ Can suppress lactation 4. Male Condom Thin sheath of latex rubber made to fit on a man’s erect penis to prevent the passage of sperm cells and sexually transmitted disease into the vagina Advantages ✔ Safe and has no hormonal effect ✔ Protects against microorganisms during intercourse ✔ Encourages male participation in family planning Disadvantages ✔ May cause allergy for people who are sensitive to latex or lubricant ✔ May decrease sensation, making sex less enjoyable 5. Injectables Contain synthetic hormone, progestin that suppresses ovulation, thickens cervical mucus and changes uterine lining.  Advantages ✔ Reversible ✔ No need for daily intake ✔ Does not interfere with sexual intercourse ✔ Has no estrogen-related side effects 6. Lactating Amenorrhea Method/LAM Temporary introductory postpartum method of postponing pregnancy based on physiological infertility experienced by Breastfeeding women Advantages ✔ LAM is universally available to all postpartum breastfeeding women ✔ No other FP commodities are required ✔ It contributes to improve maternal and child health and nutrition Disadvantages ✔ Short term FP method which is effective only for a maximum of 6 months ✔ The effectiveness of LAM may decrease if a mother and child are separated for extended periods ✔ Full or nearly full BF may be difficult to maintain up to 6 months 7. Mucus/Billing Methods Abstaining from sexual intercourse during fertile days prevents pregnancy Advantages ✔ Can be used by any woman of reproductive age as long as she is not suffering from an unusual disease or condition that results in extraordinary vaginal discharge 15 Disadvantages ✔ Cannot be used by woman with medical conditions that would make pregnancy dangerous 8. Basal Body Temperature Identifies the fertile and infertile period of a woman’s cycle by daily taking and recording of the rise in body temperature during and after ovulation. Before Ovulation: Temperature decreases 0.5 °F During Ovulation: Temperature increases 1.0°F 9. Sympto-thermal Method Identifies the fertile and infertile days of the menstrual cycle as determined through a combination of observations made on the cervical mucus, basal body temperature recording and other signs of ovulation 10. Two Day Method Simple fertility awareness based method of FP that involves: ✔ Cervical secretions as an indicator of fertility  ✔ Women checking the presence of secretions everyday Advantages ✔ Can be used by women with any cycle length ✔ No health related side effects associated ✔ Incurs very little or no cost ✔ Immediately reversible ✔ Promote male partner involvement in FP Disadvantages ✔ Needs cooperation of the husband ✔ Can become unreliable for women who have conditions that cause abnormal cervical secretions 11. Standard Days Method Couples use color coded cycle beads to mark the fertile and infertile days of the menstrual cycle Advantages ✔ No health related side effects associated with its use ✔ Increases self-awareness and knowledge of human reproduction ✔ Can be used either to avoid or achieve pregnancy ✔ Enhances self-discipline, mutual respect ✔ Can be integrated in health and family planning services Disadvantage ✔ Cannot be used by women who usually have menstrual cycle between 26 and 32 days long ❖ Misconceptions about Family Planning Causes abortion Will render couples sterile Will result to loss of sexual desire 16 ❖ Roles of Public Health Nurse on FP Program Provide counseling Provide packages of health services Ensure the availability of FP supplies and logistics CHILD HEALTH PROGRAMS ❖ Goal: To reduce morbidity and mortality rates (for children 0-9yrs) ❖ Programs: Infant and Young Child Feeding Newborn Screening Expanded Program on Immunization Management of Childhood illnesses  Micronutrient Supplementation Dental health Early Child Development Child Health Injuries 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 Initiate breastfeeding within 1hour after birth Exclusive for the first 6 months of life Complemented at 6 months with appropriate food Extend Breastfeeding up to 2 years and beyond ❖ Exclusive breastfeeding means giving a baby only breast milk, and no other liquids or solids, not even water. ❖ Complementary feeding- after six months of age all babies require other foods to complement breast milk. Complementary foods should be: ✔ Timely ✔ Adequate ✔ Safe ✔ Properly fed When not to breastfeed: ✔ AIDS LAWS THAT PROTECT INFANT AND YOUNG CHILD FEEDING 1. Milk Code (EO 51) Products covered by Milk Code consist of breast milk substitutes, including infant formula; other milk products, food and beverages, including bottle fed complementary foods. 2. Rooming-In and Breastfeeding Act of 1992 (RA 7600) To promote room-in and to encourage. Protect and support the practice of breastfeeding. 17 Compliance to the law is ensured through one of the 10 steps to Mother Baby Friendly Hospitals wherein the mother and the baby should be together for 24 hours. 3. Food Fortification Law (RA 8976) The law requires a mandatory food fortification of staple foods – rice, flour, edible oil and sugar and voluntary food fortification of processed food or food products 4. Expanded Breastfeeding Act of 2010 (RA 10028)  Exclusive breastfeeding for the first 6 months. PD 996 (EPI LAW) ❖ Principles: It is safe and immunologically effective to administer all EPI vaccines on the same day at different sites of the body Measles Vaccine should be given as soon as the child is 9 months old. If the child is living in an endemic area, give the vaccine as early as 6 months. If given at 9 months = 85% protection; if given at one year and older = 95% Vaccine schedule should not be restated Giving doses less than the recommended interval may lessen the antibody response No extra must be given to children/ mother who missed a dose of DPT/Hepa-B/OPV/TT Strictly follow the principle of never, ever reconstituting the freeze dried vaccines other than the diluents supplied with the One Syringe, One Needle per child during vaccination RA 10152 (2011) ❖ An act providing for mandatory basic immunization services for infants and children. False Contraindications: ✔ Malnutrition ✔ Low Grade Fever ✔ Mild Respiratory Infections ✔ Cough ✔ Diarrhea ✔ Vomiting Absolute Contraindications: ✔ DPT 2 or DPT 3 to a child who has had convulsions or shock within 3 days the previous dose. ✔ Patients with neurologic disease should not be given vaccines containing whole cell pertussis ✔ Live vaccines like BCG vaccine must not be given to individuals who are immunosuppressed due to a malignant disease. VACCINE MINIMUM AGE AT DOSES INTERVAL 1ST DOSE BCG At birth 1 Pentavalent 6 weeks 3 4 weeks 18  OPV 6 weeks 3 4 weeks HEPA B At birth 1 6 weeks from 1st dose MEASLES 9 months 1 MMR 12 months 1 IPV 14 weeks 1 VACCINE DOSAGE ROUTE SITE BCG 0.05 mL ID Right deltoid region DPT 0.5 mL IM Upper outer portion of thigh (Vastus lateralis) OPV 2-3 drops Oral Mouth HEPA B 0.5 mL IM Upper outer portion of thigh (Vastus lateralis) MEASLES 0.5 mL SQ Outer portion of upper arm NUTRITION PROGRAM Goal: improve quality of life of Filipinos through better nutrition, improved health, and increased productivity Common Nutritional Deficiencies Vitamin A Iron Iodine Programs and Projects: Micronutrient Supplementation Food Fortification Essential maternal and Child Health Service Package Nutrition Information, Communication, and Education Home, School and Community Food Production Food Assistance Livelihood Assistance ORAL HEALTH PROGRAMS Goal: Reduce the prevalence rate of dental caries and periodontal diseases from 92% in 1998 to 85% and from 78% in 1998 to 60% by 2010 among general population Objectives: To increase the proportion of orally fit children under 6 years old 80% by 2010 To control oral health risk among the young people To improve the oral health conditions of pregnant women by 20% and older persons by 10% every year until 2010 CLASSIFIACTION OF ORAL INTERVENTIONS Promotive Health education Service 19 Preventive Oral examination Treatment Oral hygiene Pit & Fissure Sealant Program Fluoride Utilization Program Curative Permanent Filling Gum Treatment Treatment Atraumatic Restorative Treatment Temporary Filling Extraction Treatment Post Extraction Drainage of Localized Oral abscesses PHILIPPINE REPRODUCTIVE HEALTH Overall Goal: Better Quality Life among Filipinos Main Objectives Reducing Maternal Mortality Rate Reducing Child Mortality Reversing spread of HIV/AIDS Increasing access to reproductive health information and services Elements Family Planning Maternal and Child Health Nutrition Prevention and Management of Reproductive Tract Infection Adolescent Reproductive Health Prevention and Management of Abortion and its Complications Prevention and Management of Breast and Reproductive Tract Cancers and other  Gynecological Conditions Education and Counselling on Sexuality and Sexual Health Men’s Reproductive Health and Involvement Violence against Women and Children Prevention and Management of Infertility and Sexual Dysfunction Environmental Health ❖ It is a branch of public health that deals with the study of preventing illness by managing the environment and changing people’s behavior to reduce exposure to biological and non-biological agents of disease or injury Health and Sanitation Laws PD 856 – Sanitation Code of the Philippines RA 6969- toxic Substances and hazardous and Nuclear Waste Control Act of 1990 RA 8749- Clean Air Act of 1999 RA 9003- Ecological Solid Waste Management Act of 2000 RA 9275- Clean Water Act 2004 Environmental Sanitation Study of all factors in man’s physical environment, which may exercise a deleterious effect on his health well- being and survival 20 The Development of Health through the Environment and Occupation Health Office (EOHO) has set some policies on the following areas: 1. Approved Types of Water Supply Facilities LEVEL 1 (Point Source) ✔ Protect well or developed spring with an outlet but without a distribution system ✔ Serves around 15 to 25 households ✔ Outreach must not be more than 250 meters from the farthest user ✔ Yield or discharge is generally from 40 to 140 liters per minute ✔ Generally adaptable for rural areas where the houses are thinly scattered LEVEL II (Communal Faucet System or Stand –posts) ✔ System composed of a source of reservoir, a piped distribution network and communal faucets ✔ Located not more than 25 meters from the farthest house ✔ Designed to deliver 40-80 liters of water per capital per day ✔ Average households: 100 ✔ One faucet per 4 to 6 households ✔ Suitable for rural areas where houses are clustered densely to justify a simple-piped system ❖ LEVEL III (Waterworks System or Individual House Connections) ✔ NAWASA, Maynilad 2. Unapproved type of water facility Open drug wells  Unimproved springs Wells that need priming 3. Access to sage and potable drinking water 4. Water quality and monitoring surveillance Disinfection of water supply sources is required on the following: Newly constructed water supply facilities Water supply facility that has been repaired/improved 5. Waterworks/water system and well construction Well sites shall require the prior approval of the Secretary of Health or his duly authorized representative Well construction shall comply with sanitary requirements of the Department of Health Water supply system shall supply safe and potable water in adequate quantity APPROVED TYPE OF TOILET FACILITY Level I Non-water Carriage Toilet Facility ✔ Pit Latrines ✔ Reed Oderless Earth Closet Toilet Facilities requiring small amount of water ✔ Poor Flush Toilet ✔ Aqua Privies LEVEL II Water carriage type with Water Flush type with septic vault/tank disposal facilities 21 LEVEL III Water carriage types of toilet facilities connected to septic tanks and/or sewerage system to treatment plant FOOD SANITATION PROGRAM ❖ Food Establishments shall be appraised as to the following sanitary conditions: Inspection/approval of all food source, containers, transport vehicles Compliance to sanitary permit requirements for all food establishment Provision of updated Health certificate for food handlers, cooks and cook helpers ❖ DOH’sAdministrative Order no.1 – 2006 requires all laboratories to use Formalin Ether Concentration Technique (FECT) instead of the direct fecal smear in the analysis of stools of food handlers. Food Establishment shall be rated as follows:  ❖ CLASS A – Excellent ❖ CLASS B – Very Satisfactory ❖ CLASS C – Satisfactory Four Rights in Food Safety Right Source ✔ Always buy fresh meat, fish fruits & vegetables ✔ Look at the expiry dates of processed food ✔ Avoid buying canned goods with dents, bulges, deformation, broken seals and improper seams ✔ Boil water for at least 2 minutes (running boiling) Right Preparation ✔ Avoid contact between raw food and cooked food ✔ Always buy pasteurized mild and fruit juices ✔ Wash vegetables well if to be eaten raw such as lettuce, cucumber, tomatoes & carrots ✔ Wash hands kitchen utensils before and after preparing foods ✔ Sweep kitchen floors to remove food droppings Right Cooking ✔ Cook food thoroughly (temperature on all parts of the food should reach 70 degrees centigrade ✔ Eat cooked food immediately ✔ Wash hands thoroughly before and after eating Right Storage ✔ All cooked food should be left at room temperature for not more than two hours ✔ Use tightly sealed containers for storing food ✔ Store food under hot conditions (at least or above 60°C) or in cold conditions (below or equal to 10°C) if you can plan to store it for more than 4 to 5 hours ✔ Do not overburden the refrigerator by filing it with too large quantities of warm food ✔ Food should be reheated to at least 70 degrees centigrade ✔ Rule in Food Safety: “When in doubt, throw it out!” 22 PRIORITY HEALTH PROGRAMS SENTRONG SIGLA (SS) CERTIFICATION Goal: Quality Health Care, Services, and Facilities Level and Scope of Certification 1. Basic SS Certification Minimum input, process and output standards for integrated public health services for 4 core programs, facility system, regulatory functions and basic curative services 2. Specialty Awards  Second level quality standards for selected 4 core public health programs 3. Awards for Excellence Highest level quality standards for maintaining Level 2 standards for the 4 core public health programs and level 2-facility system for at least 3 consecutive years. The SS Certification validity of certification is every two years. Facilities which did not progress to a level of certification but maintained current certification are: ❖ Given stickers to confirm the renewal of the validity of seal ❖ No other incentives given for mere renewal of SS status Facilities that slide back; seal will not be removed but not issued an SS sticker ❖ Scope and structure of the SS Quality Standards (Level I) Primary Function: Provide basic public health services Facility and System Standards ✔ Ensure that the health facility is appropriately equipped with sufficient manpower, adequate logistics and organized procedures to efficiently and effectively promote core public health programs Integrated Public Health Function Standards ✔ Ensure that the health facility and staff promote public health programs and prevent and control public health problems through direct patient/client care Basic Curative Function Standards ✔ Ensure that the health facility and staff provide basic curative services that consist of primary level outpatient and emergency care Regulatory Function Standards ✔ Ensure that the health facility and staff support and provide an environment to prevent, reduce and control risks and hazards to the community ❖ Scope and Structure of SS Quality Standards (Level II) 1. Local Health System Development Goal: To strengthen local health system development 23 2. Integrated Public Health Functions covering 5 core public health programs: Integrated Women’s Health Child Care Prevention and Control of Infectious Disease Integrated Prevention and Control of Lifestyle Related Diseases Environmental Health HERBAL MEDICINE ❖ General guidelines for the use of medicinal plants Be sure that the right king of plant is used according to the intended purpose Use the plant part suggested Use according to the dosage and direction recommended Use only one kind of medicinal plant at a time Stop the use of the plant if there is any untoward reaction or if side effects occur If there are no signs of improvement after two or three administration of the drug, consult a physician In boiling the plants, use enamel were or clay pots, not aluminum ware. Clean the pots very well before and after boiling the plant Use only the prescribed part of the plant Avoid the use of insecticides ❖ Herbal Plants 1. Lagundi (Vitex negundo) For cough and asthma Preparations ❖ Clean the leaves thoroughly and chop ❖ Measure two cups of water and boil on a low fire for 15 minutes ❖ Use the table on the amount of leaves to be used LEAVES AGE FRESH DRIED Adult 6 tbsp. 4 tbsp. 7- 12 y/o 3 tbsp. 2 tbsp. 2 – 6 y/o 1 ½ tbsp. 1 tbsp. Dosage ✔ Divide the solution into three parts. Drink one part each in the morning, noon and night For fever, drink each part every four hours 2. Yerba Buena (Mentha cordifolia Opiz ex Fresen) Forpains of the body Preparations ✔ Cleanse thoroughly and chop the leaves, then boil in two glasses of water for 15 minutes. ✔ Do not cover the pot; allow to cool and strain 24 ✔ Foradults, six tbsp. of fresh leaves or four tbsp. of dried leaves should be used ✔ For patients 7-12 years old, use half the adult dose Dosage ✔ Divide the boiled solution into three parts and drink on part each in the morning, afternoon and evening, Squeeze the fresh leaves and place on the painful part 3. Sambong (Blumea balsamifera) For swelling. Diuresis, anti-urolithiasis Preparations ✔ Cleanse thoroughly and chop leaves, boil in two glasses of water for 15 minutes ✔ Do not cover the pot; keep boiling and strain ✔ For adults, use six tbsp. fresh leaves or four tbsp. dried leaves Dosage ✔ Divide the boiled solution into three parts and drink one part each in the morning, afternoon and evening, Squeeze the fresh leaves and place on the painful part. 4. Tsaang Gubat (Ehretia microphylla Lam) Forstomachache Preparations ✔ Cleanse thoroughly and chop leaves and boil in two glasses of water for 15 minutes ✔ Do not cover the pot; keep cooking and strain ✔ For adults, six tbsp. of fresh leaves or four tbsp. of dried leaves should be used ✔ For patients 7-12 years old, use half the adult dose Dosage ✔ Divide in two parts and drink one part every four hours 5. Niyug-niyugan (Quisqualis indica) Forascaris Preparation ✔ Use newly-opened, mature and dried nuts Administration ✔ Eat the seeds two hours after supper Dosage Adult 8-10 seeds 7-12 y/o 6-7 seeds 6-8 y/o 5-6 seeds  4-5 y/o 4-5 seeds 6. Bayabas (Psidium guajava) Forcleansing or wounds, mouth infections and swollen gums Preparations ✔ Clean thoroughly and chop leaves ✔ Boil two glasses of leaves in four glasses of water on a low fire 25 Administration ✔ Clean wounds with the solution two times a day. To use as a mouthwash, use a lukewarm solution 7. Akapulko (Cassia alata) Infectedskin, skin irritation and scabies Preparation ✔ Squeeze enough leaves Administration ✔ Apply the juice of the leaves on affected parts twice a day 8. Ulasimang bato (Peperomia pellucida) Lower uric skin; for arthritis or gout Preparations ✔ Salad: Clean leaves thoroughly, Eat three times a day with meals ✔ Decoction: Clean leaves thoroughly and boil 1 ½ glasses of leaves in two glasses of water for 15 minutes. Divide into three parts and take three times a day. 9. Bawang (Allium sativum) To lower cholesterol level Preparation ✔ Saute or boil; may be infused (five minutes); be mixed with vinegar Administration and Dosage ✔ Eat two clove of garlic with meals three times a day 10. Ampalaya (Momordica charantia) For diabetes mellitus (mild-insulin dependent) Preparation ✔ Clean the leaves thoroughly and chop. Measure two cups of leaves in two glasses of water, Boil for 15 minutes on low fire. Drink ½ glass three times a day before eating HEALTH EMERGENCY PREPAREDNESS AND RESPONSE PROGRAM Goal: Promoting health emergency preparedness among the general public and strengthening the health sector capability and response to emergencies disaster. ❖ Legal Mandate Presidential Decree No 1566 (1978) – Strengthening the Philippine Disaster Control Capability and Establishing the National Program on Community Disaster Preparedness Republic Act No 7160 (Local Gov’t Code of 1991) ✔ Transfer of responsibilities from the national to the local government units (LGUs) ❖ Disaster and Health Emergency Management Disaster ✔ It a serious disruption of the functioning of a society, causing widespread human, material or environmental losses which exceed the ability of the affected society to cope, using only its own resources. 26 Classification of Disaster according to its cause 1. Natural Disaster 2. Human generated/Man-made Emergency ❖ Requires an immediate response ❖ It is the responsibility of all ❖ It should be woven into the community and administrative levels ❖ It should concentrate on process and people rather than documentation Main objective: Decrease mortality, morbidity and prevent disability Hazards ❖ Any phenomenon, which has the potential to cause disruption or damage to humans and their environment General Principles ❖ First priority: protection of the people who are at risk ❖ Second priority: protection of critical resources and systems on which communities depend ❖ Disaster management must be an integral function of national development plans and objectives ❖ Disaster management relies upon an understanding of hazard risks ❖ Capabilities must be developed prior to the impact of a hazard ❖ Disaster Management must be based upon interdisciplinary collaboration Major Risks to be Considered 1. Natural risks E.g. flood, earthquake, cyclones 2. Technological risks ✔ Chemical, radiological, other events caused by the failure of the socio-technical systems 3. Epidemics  4. Societal risks ✔ Caused by social exclusion, extreme poverty and group violence. NATIONAL VOLUNTARY BLOOD SERVICES PROGRAM (RA 7719 – Blood Services Act 1994) ❖ Objectives To promote and encourage voluntary blood donation by the citizenry and to instill public consciousness of the principle that blood donation is a humanitarian act. To provide adequate, safe, affordable and equitable distribution of supply of blood and blood products To mobilize all sectors of the community to participate in mechanisms for voluntary and non-profit collection of blood ❖ Vision Envision a network of modernized national and regional blood centers operating on a fully voluntary, non- remunerated blood donation system 27 ❖ Mission Ensure adequate, safe and accessible blood supply by: ✔ Promoting voluntary blood donation ✔ Establishing new blood service facilities ✔ Organizing association of blood donors and training medical practitioners on national blood use ❖ Requirements before donating: Weigh more than 45 kg (100 lbs) for 250 ml of donated blood; 50kg (110 lbs) for 450 ml of donated blood Be in good health Be aged 16-65 years (for ages 16 & 17, parental consent is need) Systolic BP =90-160 mm Hg Diastolic =60-100 mm Hg Hemoglobin at least 12.5g/dL ❖ Contraindications Diabetes Cancer Hyperthyroidism Cardiovascular disease Severe psychiatric disorder Epilepsy/convulsions Severe bronchitis AIDS/ Syphilis and other STI (past & present) Malaria  Kidney and Liver disease Prolonged bleeding Use of prohibited drugs ❖ Blood extracted for Donation Whole blood and red cell concentrates ✔ Shelf-life to 5 weeks Plasma ✔ Can be stored frozen for 12 months Considerations after blood donation: ✔ Leave the adhesive dressing on your arm for at least 3 hours but not more than twelve (12) hours. ✔ Bruising or discoloration may occur and will disappear in a few days ✔ Avoid carrying heavy objects with your donating arm ✔ Do not smoke for the next 2 hours ✔ Avoid alcohol intake for the next 12 hours ✔ Eat regular meals and increase fluid intake following your donation 28 BOTIKA NG BARANGAY Goal: To promote equity in health by ensuring the availability and accessibility of affordable safe and effective quality essential drugs to all, with priority for marginalized, underserved, critical and hard to reach areas. ❖ Objective: To rationalize the distribution of common drugs and medicines among intended beneficiaries To serve as mechanism for the DOH to establish partnership with Local Government Units (LGUs) To optimize involvement of the Barangay Health Workers addressing the health need of the community ❖ Criteria for Establishing a Botika ng Barangay Managed or operated by an established community organization or cooperative which is duly recognized as a judicial body Service or coverage area a barangay that is far flung, depressed, and hard to reach area as defined in the Magna Carta for public Health Workers implementing Rules and Regulations Community-sourced funds at least 1/3 of the initial capital requirements Local government unit/other government officials-sourced funds at least 1/3 of the initial capital requirement Submission of a barangay socio-economic profile and health profile including a  master list of indigents, if available Commitment form a licensed pharmacist to supervise Botika ng Barangay operations Identification and selection of at least 2 accredited Barangay Health Workers or Community Volunteer Health workers trained as botika ng barangay Aides Availability of a botika ng barangay space COMMUNITY ORGANIZING PARTICIPATORY ACTION RESEARCH (COPAR) DEFINITION ❖ The strategy used by the health Resource Development Program (HRDP) III in implementing primary health care delivery in depressed and undeserved communities for them to become self-reliant ❖ It is collective, participatory, transformative, liberate, sustained & systematic process of building people’s organizations by mobilizing and enhancing the capabilities and resources of the people for the resolution of their issues and concerns towards effecting change in their existing oppressive and exploitative conditions (National Rural CO conference, 1994) ❖ Importance: Tool for community development & people empowerment Prepares people/clients to eventually take over the management of a development programs in the future Maximizes community participation and involvement 29 PRINCIPLES People, especially the most oppressed, exploited and deprived sectors are open to change, have the capacity to change, and are able to bring about change Based on the interests of the poorest sectors of society Should lead to self-reliant community and society ❖ Process/Methods used in COPAR Progressive Cycle of Action Reflection Action ✔ Begins with small, local and concrete issues identified by the people and the evaluation and reflection of and on the action taken by them Consciousness Raising ✔ Emphasis on learning that emerges from concrete action and which enriches succeeding action COPAR i