PRAYER BEFORE STUDYING

Dear Lord, as I take this exam, I thank you that my value is not based on my performance, but on
your great love for me.
Come into my heart so that we can walk through this time together.
Help me not only with this test, but the many tests of life that are sure to come my way.
As I take this exam, bring back to my mind everything I studied and be gracious with what I have
overlooked. Help me to remain focused and calm,confident in the facts and in my bility, and firm
in the knowledge that no matter what happens today you are there with me. Amen

SCOPE OF NURSING LICENSURE EXAMINATION (NLE)

Nursing Board Exam/Nursing Licensure Exam Coverage (Nursing Practice I)
NURSING BOARD EXAM SCOPE/COVERAGE
NURSING PRACTICE I
TEST DESCRIPTION: Theories, concepts, principles and processes basic to the
practice of nursing with emphasis on health promotion and health maintenance. It
includes basic nursing skills in the care of clients across age groups in any setting.
Moreover, it encompasses the varied roles, functions and responsibilities of the
professional nurse in varied health care settings.
TEST SCOPE:
I. Personal and Professional Growth and Development

A. Historical Perspective in Nursing

HISTORICAL FOUNDATION OF NURSING

The Four Great Periods of Nursing

1. INTUITIVE NURSING
*This untaught nursing was instinctive.
*Dated from pre-historic times.
*Practice among primitive tribes and lasted through Christian era.
*Performed out of feeling of compassion to others.
*Out of wish to do good- HELPING

2. APPRENTICE NURSING
*Extends from the founding of religious orders in the 6 th century through the
crusades which began in the 11th century to 1836.
*The Deacons School of Nursing at Kaisserwerth, Germany established by
pastor Fliedner and his wife.
*Period of on the job training- desired of person to be trained

3. EDUCATED NURSING
*Began in 1860.
*Florence Nightingale School of Nursing opened at St. Thomas in London.
First program of formal education for nurses started.
 4. CONTEMPORARY NURSING
*Began at the end of World War II (1945)
*Scientific and Technological developments of many social changes occurs.

INTUITIVE NURSING
*Cause of illness was believed to be the invasion of the victims body by an evil
spirit.
*Uses black magic or voodoo to harm or driven out by using supernatural power.
*Believed in medicine man (shaman or witch doctor) that had the power to heal
by using white magic.
They made use of hypnosis, charms, dances, incantations, purgatives,
massage,fire, water, herbs or other vegetations and even animals.
*Performing a trephine
Drilling a hole in the skull with a rock or stone without benefit of anesthesia.
Goal of this therapy is to drive the evil spirit from the victims body.
*Nurses role was instinctive directive toward comforting, practicing midwifery
and being wet nurse to a child.
*Act performed without training and direction.

Babylonia
*Practice of medicine is far advanced.
*Code of Hammurabi.
-Legal and Civil measures is establish
-Regulate the practice of physicians
-Greater safety of patient provided
*No mention of Nurses or nursing this time

Egypt
*Art of embalming enhance their knowledge of human anatomy
*Developed the ability to make keen clinical observations and left a record of 250
recognized diseases.
*Control of health was in the hands of Gods. The first acknowledged physicians
was Imhotep.
*Made great progress in the field of hygiene and sanitation.
*Reference to nurses in Moses 5th book is a midwife and wet nurse.

Palestine
*The Hebrews book of genesis emphazised the teachings of Judaism regarding
hospitality to the stranger and acts of charity.
*Implementation of laws like
-controlling the spread of communicable disease
-cleanliness
-preparation of food
-purification of man (bathing and his food.
*The ritual of circumcision of the male child on the 8th day
*The established of the High Priest Aaron as the physician of people.

China
*Culture was imbued with the belief in spirits and demons.
*Gave the world the knowledge of material medica (pharmacology); method of
treating wounds, infection and muscular afflictions.
*Chan Chun Ching Chinese Hippocrates.
*Emperor Shen Nung said to be the father of Chinese medicine and the
inventor of acupuncture technique.
*No mention of nursing in Chinese writings so it is assumed that care of the sick
will fall to the female members of the household.

India
*First recorded reference to the nurses taking care of patients on the writings of
shushurutu.
*Functions and Qualifications of nurse includes:
- Knowledge in drug preparation and administration.
- Cleverness.
- Devotedness to the patient.
- Purity of both mind and body.
*King Asoke, a Buddhist, published an edict to established hospitals throughout
India where nurses were employed.

Greece
*Made contribution in the area aesthetic arts and clinical medicine, but nursing
was the task of the untrained slave.
*Aesculapius, The Father of Medicine in Greek mythology to whom we associate
the Caduceus, (known insignia of medical profession today)
*Hippocrates, the Father of Medicine insisted that magic and philosophical
theories had no place in medicine.
*The work of women was restricted to the household. Where mistress of the
mansion gave nursing care to the sick slaves.

Rome
*Acquired their knowledge of medicine from the Greeks.
*Emperor Vespasian opened schools to teach medicine.
*Developed military medicine First aid, field ambulance service and hospitals for
wounded soldiers.
*Translated Greek medical terminologies into Latin terms which has been used in
medicine ever since.

APPRENTICE NURSING
*Religious orders of Christian Church played a major role in this kind of nursing.

The Crusades (11th Century)

*Series of holy wars were conducted by Christian in an attempt to recapture the
Holy land from the Turks.
*Military religious orders founded during the crusades established hospitals and
staffed them with men who served as nurses. Among these were:
- The knights of St. John of Jerusalem served both as warriors in battle and
nurses in the hospital and was called Knights Hospitallers.
- The Teutonic Knights built hospitals cared for sick and denfended the faith.
- The Knights of St. Lazarus established primarily for the nursing of lepers,
forerunners of our now known communicable diseases hospital (also called
lazarettos).

The Rise of Religious Nursing Orders

* The Regular Orders established monasteries to house travelers, paupers and
patient under one roof. Later as society became better organized hospitals
tended to become separate institutions apart from monsteries.
*The Secular Orders developed for the primary purpose of nursing; were similar
to the regular orders by their temporary vows, uniformity in dress and religious
observation.
*The Nursing Orders definitely organized. The sisters advanced the stage of
probationer to wearing the white robe to receiving the hood; They were all under
the superintendent of nurses or director of nursing; later adopted a uniform dress
that eventually became entirely standardized.

Nursing Saints
* St. Hildegarde a Benedictine abbess in Germany, actually prescribed cures in
her 2 books on medicine and natural history.
* St. Francis and Clara took vows of poverty, obedience, service and chastity
and took care of the sick and the afflicted; founders of the Franciscan Order and
the Order of the Poor Clares respectively.
* St. Elizabeth of Hungary the patroness of nurses; built a hospital for the sick
and the needy.
* St. Catherine of Siena the 1st lady with a lamp; became a tertiary of St.
Dominic and engaged in works of mercy among the sick and of the Church.

The Reformation
* St. Vincent de Paul set up the first program of social service in France and
organized the Community of the Sisters of Charity. His 1st superior and co-
founder was Louise de Gras (nee de Marillac).

The Intellectual Revolution (17th Century)

 Characterized by the development of natural science, medicine, arts and as
well as interest in human beings and their welfare. Among the leaders for reform
were:
* St. John of God founder of the Brother Hospitallers and declared the patron
of all hospitals and sick folk by Pope Leo XIII in 1930.
* George Fox founder of the sect known as the Soicety of Friends (Quakers)
who advocated equality of men and women, thus making it easier for women to
become active in Nursing.
* John Howard introduced prison reforms (fresh air and plenty of water).
* Philippe Pinel introduced his modern open-door treatment of the mentally ill.
* Elizabeth Fry greatly improved prison conditions by developing work fo the
prisoners and the segregations of sexes, later established the Insitute of Nursing
sisters, the first organization of women to be trained as private duty nurse.
* Mother Mary Catherine MccAuley founder of the Order of the Sisters of
Mercy, 2nd largest of the Roman Catholic Orders.
* Theodor Fliedner and his wife Friederike Mumster established the Institute of
Kaisserwerth on the Rhine for the practical training of Deaconesses (1836), which
is considered as the 1st Organized training school for nurses. It was here where
Florence Nightingale received some of her training and the inspiration for the
establishment of her school of nursing. Some of its features includes:
1. A rotating 3 year experience in cooking and housekeeping, laundry and linen
and nursing care in the womens and mens wards; and
2. A preliminary and probationary 3 months period of trial and error for both
school and student.

The Dark Period of Nursing (17th 19th Century)

* Many hospitals were closed; the wealth took care of their sick at home; the
indigent sick were taken care of by uneducated, illiterate women who had no
background for nursing.
* Charles Dickens in his book entitled Martin Chuzzleswit published the selfish and
cruel conduct of 2 private duty nurses namely Sairey Gamp and Betsy Prig.

THE PERIOD OF EDUCATED NURSING

England
* June 15, 1860 marked the day when 15 probationers entered St. Thomas
Hospital in London to establish the Nightingale system of Nursing, founded
by Florence Nightingale (May 12, 1820). Among the highlights in her life are the
following:
- At age of 31, obtained parental consent to enter the Deaconess School at
Kaisserwerth.
- Had 3 months training at Kaisserwerth; later superintendent of the
Establishment for Gentlewomen During Illness (1853) during which time she
initiated the policy of admitting and visiting the patients of all faiths.
 - In 1854 a Volunteered for Crimean war service together with 38 women at
Scutari in the Crimea upon the request of Sir Sidney Herbert, Minister of War in
England. At first their work is not accepted because it consisted of cleaning the
area, thus reducing the infections, clothing for the men, writing letters to their
families; their work served as inspiration for the Red Cross later on.
- In 1860 started the Nightingale System of Nursing at the St. Thomas Hospital
in London believed that schools should be self-supporting; that schools of nursing
should have decent living quarters for their student; that they should have paid
nurse instructors; that the school should correlate theory to practice and these
students should be taught the why not just how in nursing.
- 2 books written Note on Nursing and Notes on Hospital, contain many
timely portions applicable in the 1970s as they were in 1859.

United States
* At the time that Florence Nightingale was opening her school in London; the U.S
was on the brink of the civil war. However though the country was in a condition of
chaos, nursing had many supporters and the needs to train nurses were
recognized.
- Linda Richards is the first graduate nurse in the U.S completed her training at
the New England Hospital for Women and Children in Boston, Massachusetts,
patterned after the DeaconessesSchool of Kaisserwerth.
- In 1873 3 schools of nursing opened, patterned after the Nightingale plan
the Bellevue Training School for Nurse in the New York City , the Connecticut
training. School in New Haven and the Massachusetts General Hospital in Boston.
- In 1881 founding of American Red Cross by Clara Barton.
- In 1889 John Hopkins hospital opened a school of Nursing with Isabel
Hampton Robb as its 1st principal and the person most influential in directing the
development of nursing in the U.S.
- In 1893 the groundwork for the estimate of the 2 new nursing organization
was lad:
1. The Associated Alumnae, later known as the American Nurses Association
was begun at the Chicago Worlds fair and
2. The American Society of Superintendent of Training Schools for Nurses, later
known as the National League for Nursing Education, also began.
- During the Spanish American War (1898 1899) nurse were concerned with
the care of the wounded as well as care of those inflected with malaria and yellow
fever.
Nurse Clara Louise Maas gave her life for the advancement of medical science in
the search for control yellow fever.

The 20th Century

*In 1900 1912
 - advancement in hospital nursing, private duty nursing, public health nursing,
school nursing, government service and pre-maternal nursing;
- there was a growing awareness for the preventive measures that could be
uses to maintaing the heath of the nation;
- There was beginning specialization in medicine.

* 1913 1937
- a standard curriculum for schools of nursing was prepared by the National
League for Nursing Education.
- the practice of nursing was gradually infiltrated with educational objectives.

* Worl War I (1917 1918)

- Private duty nurses were now nursing in the hospitals rather than in homes.
- Opening of more nursing schools as a result of the construction of more
hospitals.
- Increase demand for public health nurse for preventice aspects of care.
- Awareness of the need for military ranking among nurses for which a bill was
later introduced and passed.
Julia Stimson was the first woman to hold rank of major.

* World War II (1942 1945)

- the start of Aero-medical nursing (flight nursing)
- Creation of the U.S Cadet Nurses Corps with Mrs. Lucille Ptery Leone as
director and later the 1st woman to serve as assistant surgeon of the U.S public
Health Service.
- granting of permanent commissioned rank for both army and navy nurses.
- the concept of family centered care as methods to help patient help
themselves.
- concept of psychosomatic medicine and early ambulation.
- consept of creative nursing, which has necessitated the need for laundering
definitive studies of all aspects of nursing thus helping to raise the standards to a
professional level.

CONTEMPORARY NURSING
* Creation of United Nations in San Francisco California in 1945.
2 folds purpose are:
- International peace and international security with provisions for equal justice,
Machinery for peaceful disputes and provisions.
- Provisions for assuring human rights, social justice and economic progress.

World Health Organization (WHO)

- Special agency of U.N, established in Geneva, Switzerland in 1948
- providing health information in fighting diseases and improving the nutrition,
living standards and environmental conditions of all people.
 - Scientific and Technical Research used in disease prevention and health
care.
- Social Force affecting Nursing Legislation, prepared health care, technology
efficiency and nursing involvement with minority groups.

NURSING IN THE PHILIPPINES

Early Care of the Sick

* Early life of Filipinos had been more or less mixed with superstitious belief.
- believed in the powers of witch.
- belief in the powers of herbolarios (albularyo)
* Hospitals existed as early as 15th Century, which were established by the
religious and also by Spanish administration.
* Franciscan Order is more than any other religious group. Among their early
hospitals are:

The Earliest Hospitals Established were the following:

HOSPITAL REAL de MANILA (1577) established primarily for kings soldiers
and Spanish civilians. Founded by Gov. Francisco de Sande.
SAN LAZARO HOSPITAL (1578) exclusively for the service of leprous patients.
Named after San Lazaro, patron saint of lepers. Founded by Brother Juan
Clemente.
HOSPITAL de INDIOS (1586) established by the Franciscan Order: offered
general services, supported purely by alms and contributions from charitable
persons.
HOSPITAL de AGUAS SANTAS (1590) convalescent hospital in Pansol,
Laguna; this was near medicinal spring, which cured several patients. Founded by
Brother J. Bautista of the Franciscan Order.
SAN JUAN de DIOS HOSPITAL (1596) founded by brotherhood of misericordia;
administered by the hospitallers of San Juan de Dios.
HOSPITAL de DULAC (1602 1603) located in Paco and existed only for 1
year.
HOSPITAL de NUEVA CACERES (1655) general hospital located in Bicol.
HOSPITAL de CONVALENSCECIA (1656) estimated by the Brotherhood of San
Juan de Dios on the little island on the Pasig River, where the Hospicio de San
Jose now stands; patients of San Juan de Dios Hospital who were in the
convalescent stage were sent there for their complete recovery.
HOSPITAL de ZAMBOANGA (1842) this is a governement military hospital run
and finance by Spanish governement.
HOSPITAL de CAVITE (1842) a general hospital estimated and managed by
Brotherhood of San Juan de Dios.
HOSPITAL de SAN GABRIEL (1866) exclusively for Chinese patients .
*Fray Juan Clemente was one of the 1st members of the Mission of the Order of
St. Francis in the Philippines in 1578.
- Collected native herbs for medicine later set a little pharmacy which he filled
with various medical remedies.
- Performed both the function of a physician and those of a nurse.
*Persons who really did nursing care of the sick were religious group (called
hospitallers) but they were assisted by Filipino attendants.
*In the early development of nursing, the work of the nurse and those of the
physician were not clearly defined.

Nursing Service during the Philippine Revolution

* The women during the Philippine revolutions took active part in nursing the
wounded soldier. They dress wounds, alleviate pains, prepared food and gave
comfort even without previous trainings.
* These were the prominent women who volunteered and gave nursing service.
Josephine Bracken wife of Jose Rizal Installed a field hospital in an estate
house in tejeros, Provided nursing care to the wounded night and day.
Mrs. Rosa Sevilla de Alvaro volunteered her service for the wounded soldier at
age of 18; he work hand in hand with Dona Hilaria de Aguinaldo and they led other
Filipino women to form the Filipino Red Cross in 1899.
converted their house into quarters for the Filipino soldier, during the Philippine
American war that broke out in 1899.
Dona Hilaria de Aguinaldo wife of Emilio Aguinaldo; Organized the Filipino
Red Cross under the inspiration of Apolinario Mabini.
Dona Maria de Aguinaldo second wife of Emilio Aguinaldo. Provided nursing
care for the Filipino soldier during the revolution. President of the Filipino Red
Cross branch in Batangas.
Melchora Aquino (Tandang Sora) Nurse the wounded Filipino soldiers and
gave them shelter and food.
Captain Salome A revolutionary leader in Nueva Ecija; provided nursing care to
the wounded when not in combat.
Agueda Kahabagan Revolutionary leader in Laguna, also provided nursing
services to her troop.
Trinidad Tecson Ina ng Biac na Bato, stayed in the hospital at Biac na Bato
to care for the wounded soldier.

* The Filipino Red Cross had its own constitution approved by the revolutionary
government. This was founded on February 17, 1899 with Dona Hilaria
Aguinaldo as president and Dona Sabina Herrera as secretary.

The Rise of Hospital and Nursing Schools

*The need for hospitals, dispensaries and laboratories led to the establishement of
the Board of Health in July 1901;
*A small dispensary in Manila opened for civil officers and employees, called Civil
Hospital.
*The need for doctors and nurses to help eradicate the epidemics of cholera and
smallpox led to the employment of U.S physicians and graduate nurses.
*In 1906 the idea of training Filipino girls to become nurses intiated the growth of
nursing schools.
1. Iloilo Mission Hospital School of Nursing (Iloilo City, 1906)
- It was ran by the Baptist Foreign Mission Society of America.
- Miss Rose Nicolet, a graduate of New England Hospital for woman and
children in Boston, Massachusetts, was the first superintendent.
- Miss Flora Ernst, an American nurse, took charge of the school in 1942.

2. St. Pauls Hospital School of Nursing (Manila, 1907)

- The hospital was established by the Archbishop of Manila, The Most
Reverend Jeremiah Harty, under the supervision of the Sisters of St. Paul
de Chartres.
- It was located in Intramuros and it provided general hospital services.
-First trained nursing student graduated after 3 years.
-No standard requirements for admission except willingness to work.

3. Philippine General Hospital School of Nursing (1907)

- In 1907, with the support of the Governor General Forbes and the Director
of Health and among others, she opened classes in nursing under the
auspices of the Bureau of Education.
- Anastacia Giron-Tupas, was the first Filipino to occupy the position of
chief nurse and superintendent in the Philippines, succeeded her.

4. St. Lukes Hospital School of Nursing (Quezon City, 1907)

- The Hospital is an Episcopalian Institution. It began as a small dispensary
in 1903. In 1907, the school opened with three Filipino girls admitted.
- Mrs. Vitiliana Beltran was the first Filipino superintendent of nurses.

5. Mary Johnston Hospital and School of Nursing (Manila, 1907)

- It started as a small dispensary on Calle Cervantes (now Avenida)
- It was called Bethany Dispensary and was founded by the Methodist
Mission.
- Miss Librada Javelera was the first Filipino director of the school.

6. Philippine Christian Mission Institute School of Nursing.

- The United Christian Missionary of Indianapolis, operated Three schools
of Nursing:
1. Sallie Long Read Memorial Hospital School of Nursing (Laoag,
Ilocos Norte,1903)
2. Mary Chiles Hospital School of Nursing (Manila, 1911)
3. Frank Dunn Memorial Hospital
7. San Juan de Dios Hospital School of Nursing (Intramuros, Manila, 1913)
- Was destroyed during the war with a new hospital built along Dewey
Boulevard.

8. Emmanuel Hospital School of Nursing (Capiz, 1913)

9. Southern Island Hospital School of Nursing (Cebu, 1918)

- The hospital was established under the Bureau of Health with Anastacia
Giron-Tupas as the organizer.

10. Zamboanga general Hospital School of Nursing (1921)

11. Chinese General Hospital School of Nursing (1921)

12. Baguio General Hospital School of Nursing (1923)

13. Manila Sanitarium and Hospital School of Nursing (1930)

14. Quezon Memorial Hospital School of Nursing (1957)

15. North General Hospital School of Nursing (1946)

16. Siliman University School of Nursing (Dumaguete, 1947)

17. Occidental Negros Provincial Hospital School of Nursing (1946)

18. Cebu (Velez) General Hospital School of Nursing (1951)

19. Brokenshire School of Nursing (Nueva Ecija, 1960)

20. De Ocampo Memorial School of Nursing (1954)

21. Marian School of Nursing (1960)

22. St. Rita Hospital and School of Midwifery (1956) and Nursing (1960)

Advantages of University Hospitals over Hospital Schools of Nursing:

1. students are treated as students and not as employees.
2. adequate financial support.
3. The head of the school is responsible only for the education of students in
nursing and;
4. The environment for the university school of nursing school education.

The First Colleges of Nursing in the Philippines

a. University of Santo Tomas .College of Nursing (1946)
- The first basic collegiate school for Nursing in the Philippines.
b. Manila Central University College of Nursing (1948)
 c. University of the Philippines College of Nursing (1948). Ms.Julita Sotejo
was its first Dean
d. Southwestern College College School of Nursing (Cebu, 1947)
e. Philippine Union College of Nursing (1947)
f. Central Philippine College of Nursing (1947)
g. Siliman University College of Nursing (1947)
h. Philippine Womens University College of Nursing (1951)
i. FEU Institute of Nursing (1955)
j. UE College of Nursing (1958)
k. Saint Paul College of Nursing (Manila, 1958)

Nursing Leaders in the Philippines

*Anastacia Giron-Tupaz First Filipino nurse to hold the position of Chief Nurse
Superintendent; Founder of PNA (Philippine Nurses Association)
*Cesaria Tan First Filipino to receive a masters degree abroad.
*Socorro Sirilan Pioneered in Hospital Social Service in San Lazaro Hospital
where she was the Chief Nurse.
*Rosa Militar Pioneered in School Health Education.
*Sor Ricarda Mendoza Pioneer in Nursing Education.
*Socorro Diaz First Editor of the PNA magazine called The Message
*Conchita Ruiz First full-time editor of the PNA magazine called The Filipino
Nurse.
*Loreta Tupaz Dean of the Philippine Nursing, regarded as the Florence
Nightingale of Iloilo.

Some Highlights in the History of Nursing in the Philippines

*1906 at the Union Mission Hospital (now Iloilo Mission Hospital) in Iloilo City, 4
women started training in nursing; 3 female graduated in 1909 as Qualified
Surgical and Medical Nurses.
*1907 19 students admitted to a preliminary course in nursing as the Philippine
Normal College.
*1909 A nursing school was established under the Bureau of Education by
Authority of Act No. 1931.
*1910 Act No. 1975 recognized the school under the Bureau of Health. The
school continued as one of the activities of the newly opened Philippine General
Hospital and became known as the Philippine General Hospital School of Nursing.
*1915 Act No. 2468 authorized the granting of the titles of graduate in nursing
and graduate in midwifery to nursing midwifery students of the PGHSN.
- Public Health Nursing in the Bureau of Health began in accordance with Act
No. 2468.
*1919 Act No. 2808 (Nurses Law) was passed, enacted regulating the practice
of the nursing profession in the Philippines Islands.It also provided the holding of
exam for the practice of nursing on the 2nd Monday of June and December of each
year. This act was later amended in 1922, 1933 and 1950.
*1920 1st Board Examination for Nurse was conducted by the Board of
Examiners, 93 candidates took the exam, 68 passed with the highest rating of
93.5% - Anna Dahlgren.
- theoretical exam was held at the UP Amphitheater of the College of
Medicine and Surgery. Practical Exam at the PGH Library.
*1922 Filipino Nurses Association was established (now PNA) as the National
Organization of Filipino Nurses.
First President Rosario Delgado
Founder Anastacia Giron-Tupas
*1924 A standard curriculum for school of Nursing was published by the PNA.
*1948 UP College of Nursing was established.
- First attempt to offer a 4 year basic nursing course leading to a B.S
Nursing Degree
- The 1st attempt to elevate nursing as profession by enriching and
broadening the preparation of nurses and by educating them in a University
Setting.
- The idea was conceived by Julita V. Sotejo, a Nurse and Lawyer, who later
became the 1st Dean of the School.
- A program was opened for graduate of the 3 year hospital nursing course
to obtain a B.S Nursing Degree at the U.P College of Nursing. This program ended
in 1975.
*1951 Republic Act 649 provided for the standardization of nurses salaries both
in institution and in public health.
*1953 Republic Act No. 877 (Nursing Practice Law) was approved. Minor
revisions were incorporated in 1957, 1966 1970 and 1972.
*1955 The UPCN offered a Master of Arts in (Nursing) Degree program to
prepare BSN holders of demonstrated competence and scholarship for senior
positions in nursing and to encourage nursing research.
- A one-year course leading to a certificate of Public Health Nursing was
opened at the UPCN. This program ended in 1969.
*1965 The Academy of Nursing of the Philippines (ANPHI) approved its
constitution.
- Among its objectives are initiate, promote, sponsor, encourage, and/or
conduct nursing studies and research, and to serve as a medium of exchange
through conference, seminar, institute and workshops.
*1966 R.A 4704, amending R.A 877 was approved.
*1968 A movement toward accreditation of Nursing Schools in the Philippines
was started.
*1970 WHO started an ongoing project in nursing education on family planning
to prepare faculty members to introduce family planning in basic nursing curricula.
- R.A 6136 amending R.A 877 and 4704 was approved.
*1972 A national seminar on Public Health Nursing Education was held with
WHO technical assistance.
*1975 A national seminar on Public Health Nursing Education was held with
WHO technical assistance.
*1975 A National Health Plan was formulated.
 - It redefined the functions and responsibilities of nurses and other health
workers with implication for Nursing Education and Community Health Nursing.
- The Psychiatric-Nursing Specialists, Inc. (PNSI), the 1 st independent Nurse
Practitioners groups, was established.
*1976 A National Workshop on the Proposed Nurse-Midwife Curriculum of
Schools of Nursing in the Ministry of Health was sponsored by the Ministry. The
Workshop drafted an experimental 4-year Nurse-Midwifery curriculum.
*1977 ILO convention 149 and recommendations 157, concerning the
employment of Nursing Personnel and the conditions of their life and work, were
adopted in Geneva.
*1978 The Declaration of the Economic and School Welfare of Filipino Nurses
was passed by the PNA.
*1979 The 1st National Nurse Congress was held, its theme Nursing Issues in
the 80s.
- The 1st National Tripartite Conference on employment and conditions of life
and work of Nursing and other Health Personnel was held.
- Labor, management and government were involved.
*2002 Philippine Nursing Act of 2002 (R.A 9173)

1. Nursing Leaders
Florence Nightingale (1820-1910)
-recognized as nursings first scientist-theorist for her work, Notes on
Nursing: What It is, and What It is Not
-considered the founder of modern nursing.
-developed the Nightingale Training School of Nurses, which operated in
1860. The scchool served as a model for other training schools. Its
graduates traveled to other countries to manage hospitals and institute
nurse-training programs.
-Nightingales vision of nursing, which include public health and healt
promotion roles for nurses, was only partially addressed in the early days of
nursing. The focus tended to be on developing the profession within
hospitals.
Clara Barton (1812-1921)
-organized the American Red Cross, which linked with the International
Red Cross when the U.S Congress ratified the Geneva Convention in 1882.
Lilian Wald (1867-1941)
-considered the founder of Public Health Nursing.
Lavinia L. Dock (1858-1956)
-active in the protest movement for womens right that resulted in the U.S
Constitution amendment in 1920, allowing women to vote.
Margaret Sanger (1879-1966)
-a nurse activist; considered the founder of planned Parenthood, was
imprisoned for opening the first birth control information clinic in Baltimore in
1916.
Lydia Hall
 -developed the Care, Core, and Cure Theory
-Goal: To Care, and Cure Cores disease.
-Care for the patients BODY. Cure the DISEASE. Treat the PERSON ( or
patient) as the Core.

B. Nursing as a Profession
NURSING AS A PROFESSION

Profession is a calling that requires special knowledge, skill and preparation.

An occupation that requires advanced knowledge and skills and that it grows out
societys needs for special services.

Criteria of Profession:
1. To provide a needed service to the society.
2. To advance knowledge in its field.
3. To protect its memebers and make it possible to practice effectively.

Characteristics of a Profession:
1. A basic profession requires an extended education of its members, as well as a
basic liberal foundation.
2. A profession has a theoretical body of knowledge leaing to defined skills,
abilities and norms.
3. A profession provides a specific service.
4. Members of a profession have autonomy in decision-making and practice.
5. The profesion has a code of ethics for practice.

NURSING
- is a desciplined involved in the delivery of health care to the society.
- is a helping profession.
- is service-oriented to maintain health and well-being of people.
- is an art and science.

NURSE originated from a Latin word NUTRIX, to nourish.

Characteristics of Nursing:
1. Nursing is caring.
2. Nursing involves close personal contact with the recipient of care.
3. Nursing is concerned with services that take humans into account as
physiological, psychological, and sociological organism.
4. Nursing is committed to promoting individual, family, community, and national
health goals in its best manner possible.
5. Nursing is committed to personalized services for all persons without regard to
color, creed, social or economic status.
6. Nursing is committed to involvement in ethical, legal, and political issues in the
delivery of health care.

Personal Qualities of a Nurse:

1. Must have a Bachelor of Science degree in Nursing.
2. Must be physically and mentally fit.
3. Must have a license to prac tice nursing in the country.

- A professional nurse therefore, is a person who has completed a basic nursing

education program and is licensed in his country to practice professional nursing.

Roles of a Professional

1. Caregiver/Care provider
- the traditional and most essential role.
- functions as nurturer, comforter, provider.
- mothering actions of the nurse.
- provides direct care and promotes comfort of client.
- activities involves knowledge and sensitivity to what matters and what is
important to clients.
- show concern for client welfare and acceptance of the client as a person.

2. Teacher
- provides information and helps the client to learn or acquire new knowledge and
technical skills.
- encourages compliance with prescribed therapy.
Promotes healthy lifestyle.
- interprets information to the client.

3. Counselor
- helps client to recognize and cope with stressful psychologic or social problems;
to develop an improve interpersonal relationships and to promote personal growth.
- Encourages the client to look at alternative behaviors recognize the choices and
develop a sense of control.

4. Change agent
- initiate changes or assist clients to make modifications in themselves or in the
system of care.

5. Client advocate
- involves concern for and actions in behalf of the client to bring about a change.
- promotes what is best for the client, ensuring that the clients needs are met and
protecting the clients right.
- provides explanation in clients ;anguage and support clients decisions.
6. Manager
- makes decisions, coordinates activities of others, allocate resource evaluate care
and personnel.
- plans, give direction, develop staff, monitor operations, give the reward fairly and
represent both staff and administrations as needed.

7. Researcher
- participates in identifying significant researchable problems.
- participates in scientific investigation and must be a consumer of research
findings.
-must be aware of the research process, language of research, a sensitive to
issues related to protecting the rights of human subjects.

Expanded role as of the Nurse

1. Clinical Specialists
- is a nurse who has completed a masters degree in specialty and has
considerable clinical expertise in that specialty. She provides expert care to
individuals, participates in education health care professionals and ancillary, acts
as a clinical consultant and participates in research.

2. Nurse Practitioner
-is a nurse who has completed either as a certificate program or a masters degree
in a specialty and is also cerified by the appropriate specialty organization. She is
skilled at making nursing assessments, performing P.E., counselling, teaching and
treating minor and self-limiting illness.

3. Nurse-Midwife
- a nurse who has completed a program in midwifery; provides prenatal and
postnatal care and delivers babies to woman with uncomplicated pregnancies.

4. Nurse Anesthetist
- a nurse who completed the course of study in an anesthesia school and carries
out pre-operative status of clients.

5. Nurse Educator
- a nurse usually with advanced degree, who beaches in clinical or educational
settings, teaches theoretical knowledge, clinical skills and conduct research.

6. Nurse Entrepreneur -
- a nurse who has an advanced degree, and manages health-related business.
7. Nurse Administrator
- a nurse who functions at various levels of management in health settings;
responsible for the management and administration of resources and personnel
involved in giving patient care.

Fields and Opportunities in Nursing

1. Hospital/Institutional Nursing a nurse working in an institution with patients.

Example: rehabilitation, lying-in, etc.

2. Public Health Nursing/Community Health Nursing usually deals with

families and communities. ( no confinement, OPD only ).
Example: brgy, Health Center.

3. Private Duty/Special Duty Nurse privatey hired.

4. Industrial/Occupational Nursing a nurse working in factories, office,

companies.

5. Nursing Education nurses working in school, review center and hospital as a

C.I.

6. Military Nurse nurses working in a military base.

7. Clinic Nurse nurses working in a private and public clinic.

8. Independent Nursing Practice private practice, BP monitoring, home

service.
- Independent Nurse Practtioner.

Nursing Theory and Theorists

4 Essential concepts common among nursing theories:

- Individual
- Health
- Environment
- Nursing

FLORENCE NIGHTINGALES ENVIRONMENTAL THEORY

- Defined Nursing: The act of utilizing the environment of the patient to assist
him in his recovery.
- Focuses on changing and manipulating the environment in order to put the
patient in the best possible conditions for nature to act.
- Identified 5 environmental factors: fresh air, pure water, efficient drainage,
cleanliness/sanitation and light/direct sunlight.
- Considered a clean, well-ventilated, quiet environment essential for recovery.
- Deficiencies in these 5 factors produce illness or luch of health but with a
nurturing environment, the body could repair itself.

DOROTHEA OREMS SELF-CARE THEORY

- Defined Nursing: The act of assisting others in the provision and
management of self-care to maintain/improve human functioning at home
level of effectiveness.
- Focuses on activities that adult individuals perform on their own behalf to
maintain life, health and well-being.
-Has a strong health promotion and maintainance focus.

C. Theoretical Foundation of Nursing Applied in Health Care Situations

THEORETICAL FOUNDATION OF NURSING
I. Philosophy
Specifies the definition of the metaparadigm concepts (person, environment,
health, and nursing) in each of
the conceptual models of nursing.
Sets forth meaning through analysis, reasoning, and logical argument. It provides
a broad understanding and
direction.

Florence Nightingale - Modern Nursing; Environmental Theory

*Disease is a reparative process, and that the manipulation of the environment -
ventilation, warmth, light, diet, cleanliness, and noise - would contribute to the
process and health of the patient.
*Did not agree with the germ theory of disease although she accepted the ill
effects of contamination from organic materials from the patients and the
environment hence found sanitation as important.
*Also renowned for pioneering statistical analysis of healthcare.

Ernestine Wiedenbach - Helping Art of Clinical Nursing

* nursing is nurturing or caring for someone in a motherly fashion.
*Proposed that nurses identify patients need-for-help by:
o Observing behaviors regarding comfort.
o Exploring meanings of the behavior.
o Knowing the cause of discomfort.
o Knowing if they can solve on their own or need help.

Virginia Henderson - Definition of Nursing; 14 Basic Needs

*The unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or to recovery (or to a
peaceful death) that he would perform unaided if he had the necessary strength,
will, or knowledge and to do this in such a way as to help him gain independence
as rapidly as possible

*14 Basic Needs:

1. Breathe 8. Clean body and intact integument
2. Eat and drink 9. Safe environment
3. Eliminate 10. Communicate
4. Motion and position 11. Worship
5. Rest and sleep 12.Work
6. Clothing 13.Play
7. Temperature 14.Learn

Faye Glenn Abdellah - 21 Nursing Problems

*Problem solving was seen as the way of presenting nursing(patient) problems as
the patient moved towards health.
*Contributed to nursing theory development through the systematic analysis of
research reports to formulate the 21 nursing problems that served as an early
guide for comprehensive nursing care.

Lydia Hall - Care, Core, and Cure

*The theory consists of 3 major tenets:
o The nurse functions differently in the 3 interlocking aspects of the patient:
-Cure (Disease) shared with doctors
-Core (Person) addressed by therapeutic use of self; shared with
psychiatry/psychology, religious ministry, etc.
-Care (Body) exclusive to nurses; involves intimate bodily care like feeding,
bathing and toileting
o As the patient needs less medical care, he needs more professional nursing care
o Wholly professional nursing care will hasten recovery

Jean Watson - Philosophy and Science of Caring; Carative Factors

*Caring is a universal social phenomenon that is only effective when practiced
interpersonally. Nurses should be sensitized to humanistic aspects of caring
*10 Carative Factors
1. Form humanistic-altruistic values 6. Scientific problem-solving method for
decisions
2. Instill faith-hope 7. Promote interpersonal teaching-learning
3. Cultivate sensitivity 8. Provide supportive, protective, or
corrective environemnt
4. Develop helping-trust relationship 9. Assist gratifying human needs
5. Promote and accept expression
of positive and negative 10. Allowance for existential-phenomeno-
logical forces

Patricia Benner - Novice to Expert

*Validated the Dreyfus Model of Skill Acquisition in nursing practice with the
systematic description of the 5 stages (Novice, Advanced beginner, Competent,
Proficient, and Expert).
BENNERS STAGES OF NURSING EXPERTISE
STAGE I, Novice
*Has no experience (e.g., Nursing Student)
*Performance is limited inflexible, and governed by context-free rules and
regulations rather than experience.
*Novices have no life experience in the application of rules.
*Just tell me what I need to do and I do it.
STAGE II, Advanced Beginner
*Demonstrate marginally acceptable performance.
* Recognizes the meaningful aspect of a real situation.
*Has experienced enough real situations to make judgement about them.
*Principles to guide actions begin to be formulated and are focused on experience.
STAGE III, Competent
*Has 2 to 3 years of experience.
*Demonstrates organizational and planning abilities.
*Differentiates important factors from less inportant aspects of care.
*Coordinates multiple complex care demands.
*Develops when the nurse begins to see his or her actions in terms of long-range
goals or plans which he or she is consciously aware of.
STAGE IV, Proficient
*Has 3 to 5 years of experience.
*Perceives situations as a whole rather than in terms of parts as in Stage II.
*Uses maxims as guides for what to consider in a situation.
*Has holistic understanding of the client, which improves decision making.
*Focuses on long-terms goals.
STAGE V, Expert
*Performance is fluid, flexible, and highly proficient; no longer requires rules
guidelines, or maxims to connect an understanding of the situation to appropriate
action.
*Demonstrates highly-skilled intuitive and analytical ability in new situations.
*Is inclined to take a certain action because it felt right.

II. Conceptual Models

*Frameworks or paradigms that give a broad frame of reference for systematic
approaches to the concerned phenomena.
*Concepts that specify their interrelationship to form an organized perspective for
viewing the phenomena
Grand Theories
*Derived from models but as theories, they propose testable truths or outcomes
based on use of the model in Practice.

Dorothea Orem - Self- Care Deficit Theory

*Composed of 3 Theories:
o Theory of Self Care
o Theory of Self-Care Deficit
o Theory of Nursing Systems - 3 Types:
Wholly Compensatory - do for the patient.
Partly Compensatory - help the patient do for himself.
Supportive Educative - help the patient learn to do for himself; nurse has
important
role in designing nursing care.

Myra Estrin Levine - Conservation Model

*Major Concepts:
o Wholism (Holism)
o Adaptation - process whereby patients retain integrity; establish body economy
to safeguard stability:
Environment
Organismic Response - (1)Fight or flight, (2)inflammatory response,
(3)response to stress, (4)perceptual awareness
Trophicogenesis - alternative to nursing diagnosis
o Conservation - 4 principles of conservation - Nursing intervention is based on
the conservation of the patients:
Energy
Structural Integrity
Personal Integrity
Social Integrity
*Composed of 3 Theories- (1) conservation (2) redundancy (3) therapeutic
intention.

Martha Rogers - Unitary Human Beings

*Principles of Homeodynamics
Helicy - spiral development in continuous, non-repeating, and innovative
patterning.
Resonancy - patterning changes with development from lower to higher
frequency(intensity).
Integrality - continuous mutual process of person and environment.
*Theoretical Assertions
Energy - Man as a whole is more than the sum of his parts.
Openness - Man and environment continuously exchange matter and energy.
Helicy - Life evolves irreversibly and unidirectionally along space and time.
 Pattern and organization identify man and reflect his innovative wholeness.
Sentient, thinking being - man has capacity for abstraction and imagery,
language and thought, sensation and emotion.

Dorothy Johnson - Behavioral Systems Model

*Considered attachment or affiliative subsystem as cornerstone of social
organizations
*Nursing problems arise because there are disturbances in the structure or
function of the subsystems:
Dependency
Achievement
Aggressive
Ingestive
Eliminative
Sexual

Sister Callista Roy - Adaptation Model

*Proposed that humans are biophychosocial beings who exist within an
environment
*Environment and self provides 3 types of stimuli: (1) focal (2) residual (3)
contextual
*Human stimuli create needs in adaptation modes, such as physiological self-
concept, role function, and interdependence
*Through adaptive mechanisms, regulator and cognator, a person shows adaptive
or ineffective response that need nursing intervention.

Imogene King - Interacting Systems Framework; Goal Attainment Theory

*Nursing is a process of human interaction between nurses and patients who
communicate to set goals, explore means of attaining goals, and agree on what
means to use
*Perceptions, judgement and actions of nurse and patient lead to reaction,
interaction and transaction
*Interacting systems:
Personal System - perception, self, body image, growth and development
Interpersonal System - role, interaction, communication, transaction, and stress
Social System - organization, power-authority status, decision making.

Roper, Logan, and Tierney - Model for Nursing Based on a Model of Living
Conceptual Components
o 12 Activities of Living (AL) - complex process of living in the view of an amalgam
of activities
1. Maintain safe environment 7. Temperature
2. Communicate 8. Mobility
3. Breathe 9. Work and play
4. Eat and drink 10. Express sexuality
5. Eliminate 11. Sleep
6. Personal cleansing and dressing 12. Dying

Life span - concept of continuous change from birth to death

Dependence-independence continuum
5 factors influencing AL: Biological, Psychological, Socio-cultural,
Environmental,
Politicoeconomic.
*The individuality of living is the way in which the individual attends to ALs in
regard to place on life span and dependence-independence continuum and as
influenced by the 5 factors.

III. Theories
*Group of related concepts that proposes actions that guide practice. May be
broad but limited only to particular aspects
Middle-range Theories
*The least abstract level because they include specific details in nursing practice
like population, condition and location.

Hildegard Peplau - Psychodynamic Nursing; Mother of Psychiatric Nursing

*Stressed the importance of the nurses ability to understand ones own behavior
to help others identify felt difficulties.
*4 Phases of Nurse-Patient Relationship
Orientation
Identification
Exploitation
Resolution
*6 Nursing Roles
1. Stranger 4. Leader
2.Resource Person 5. Surrogate
3. Teacher 6. Counselor
*4 Psychobiological Experiences that compel destructive or constructive
responses
Needs
Frustrations
Conflicts
Anxieties

Ida Jean Orlando - Nursing Process; Dynamic Nurse-Patient Relationship

*Focused on patients verbal and nonverbal expressions of need and the nurses
reactions to the behavior
*3 Elements of a Nursing Situation
Patient behaviors
 Nurse reactions
Nurse actions
*Used the nursing process to meet patients needs through deliberate action;
advanced nursing beyond automatic response to disciplined and professional
response.

Joyce Travelbee - Human-to-Human Relationship Model

*Nursing was accomplished through human-to-human relationship:
1. Original encounter
2. Emerging identities
3. Developing empathy
4. Developing sympathy
5. Rapport

Katherine Kolcaba - Theory of Comfort

*Defined healthcare needs as those needs for comfort including physical, psycho-
spiritual, social, andenvironmental needs
*Intervening factors influence clients perception of comfort: age, attitude,
emotional support, experience, finance, prognosis
*Types of comfort:
1. Relief when specific need is fulfilled
2. Sense of ease, calm, and contentment
3. Transcendence or rising above the problems of pain

Erikson, Tomlin and Swain - Modeling and Role-Modeling

*Synthesis of multiple theories related to basic needs, developmental tasks, object
attachment, and adaptive coping potential
*Views nursing as self-care based on the persons perception of the world and
adaptation to stressors
*Promotes growth and development while recognizing individual differences
according to worldview and inherent endowment.

Ramona Mercer - Maternal Role Attainment

*Focused on parenting and maternal role attainment in diverse populations.
*Developed a complex theory to explain the factors impacting the maternal role
over time.

Kathryn Barnard - Parent-Child Interaction; Child Health Assessment Interaction

Theory
*Individual characteristics of each member influence the parent-infant system and
that adaptive behavior modifies those characteristics to meet the needs of
the system
*The theory is based on scales developed to measure feeding, teaching, and
environment.
Madeleine Leininger - Transcultural Care Theory; Ethnonursing
*Some of the major concepts are care, caring, culture, cultural values, and cultural
variations
*Caring is seen as the central theme in nursing care, knowledge and practice.
*Caring includes assistive, supportive, facilitative acts towards people with actual
or anticipated needs
*3 types of Nursing Actions
Cultural Care Preservation or Maintenance - retention of relevant care values
unique to culture
Cultural Care Accommodation or Negotiation - adapting culture with
professional care providers
Cultural Care Repatterning or Restructuring - changing life-ways while still
respecting culture for a healthier outcome.

Rosemarie Rizzo Parse - Human Becoming

*A unique, humanistic approach instead of a physiological basis for nursing
*Nursing is a human science that is not dependent on medicine or any discipline
for its practice
*Major concepts include:
Imaging Connecting-separating
Valuing Powering
Languaging Originating
Revealing-concealing Transforming
Enabling-limiting

Merle Mishel - Uncertainty in Illness

*Researched into experiences with uncertainty as it relates to chronic and life-
threatening illness.
*Later reconceptualized to accommodate the responses to uncertainty over time in
people with chronic conditions who may not resolve the uncertainty.

Margaret Newman - Model of Health

*Major concepts are movement, time, space and consciousness. Movement is a
reflection of consciousness.
Time is a function of movement. Time is a measure of consciousness.
*The goal of nursing is not to promote wellness or to prevent illness, but to help
people use the power within them as they evolve toward a higher level of
consciousness.

Evelyn Adam - Conceptual Model for Nursing

*Used a model from Dorothy Johnson and definition of nursing from Virginia
Henderson
*Identified assumptions, beliefs, and values, and major units
*Included goal of the profession, beneficiary of the professional service, role of the
professional, source of the beneficiarys difficulty, the intervention of the
professional, and the consequence.

Nola Pender - Health Promotion Model

*The goal of nursing care is the optimal health of the individual
*Developed the idea that promoting optimal health supersedes disease prevention
*Identifies cognitive-perceptual factors of a person, like importance of health-
promotion behavior and its perceived barriers, and these factors are modified by
demographics, biology, interpersonal influences, and situational and behavioral
factors.

D. Continuing Professional Education

E. Professional Organizations in Nursing

F. The Nurse in Health Care

1. Eleven Key Areas of Responsibility

ELEVEN KEY AREAS OF RESPONSIBILITY

A. SAFE AND QUALITY NURSING CARE

1. Demonstrate knowledge based on the health/Illness status of indiidual groups.
2. Provides sound decision making in the care of individuals/groups.
3. Promote wholeness and well-being including safety and comfort of patients.
4. Sets priorities in nursing care based on patients need.
5. Ensures continuity of care..
6. Administersmedications and other health therapeutics.
7. Utilizes the nursing process as framework for nursing.
8. Formulates a plan of care in collaboration with patients and other members of
the health team.
9. Implements planned nursing care to achieve identified outcomes.
10. Evaluates progress toward expected outcomes.
11. Responds to the urgency of the patients condition.

B. MANAGEMENT OF RESOURCES AND ENVIRONMENT

1. Organizes work load to facilitate patient care.
2. Utilizes resources to support Patient care.
3. Ensures availability of human resorces.
4. Checks proper functioning of equipment/facilities.
5. Maintains a safe and therapeutic environment.
6. Practices stewardship in the management of resources.

C. HEALTH EDUCATION
1. Assess the learning needs of the patient and family.
2. Develops health education plan based on assessed and anticipated needs.
3. Develops learning materials for health education.
4. Implements the healtheducation plan.
5. Evaluates the outcome of health education.

D. LEGAL RESPONSIBILITY
1. Adheres to practice in accordance with the nursing law and other relevant
legislation including contracts, informed consent.
2. Adheres to organizational policies and procedures, local and national.
3. Documents care rendered to patients.

E. Ethico-Moral Responsibility
1. Respects the rights of individuals/groups.
2.Accepts responsibility and accountability for own decisions and actions.
3. Adheres to the national and international code pf ethics for nurses.

F. Personal and Professional Development

1. Identifies own learning needs.
2. Pursues continuing education.
3. Gets involved in professional organizations and civic activities.
4. Projects a professional image of the nurse.
5. Possesses positive attitude towards change and criticism.
6. Performs function according to professional standards.

G. Quality Improvement
1. Utilizes data for quality improvement
2. Participtaes in nursing audits and rounds.
3. Identifies and reports variances.
4. Recommends solutions to identified causes of the problems.
5. Recommends improvement of systems and processes.

H. Reasearch
1. Utilizes varied methods of inquiry in solving problems.
2. Recommends actions for implementation.
3. Disseminates results of research findings.
4. Applies research findings in nursing practice.

I. Record Management
1. Maintains accurate and updated documentation of patient care.
2. Records outcome of patient care.
3. Observes legal imperatives in record keeping.
4. Maintains an effective recording and reporing system.
J. Communication
1. Utilizes effective communication in relating with clients, members with the team
and the public in general.
2. Utilizes effective communicationin therapeutic use of self to meet the needs of
clients.
3. Utilizes formal and informal channels.
4. Responds to needs of individuals, families, groups and communities.
5. Uses appropriate information technology to facilitate communication.

K. Collaboration and Teamwork

1. Establishes collaborative relationship with colleagues and other members of the
health team for the health plan.
2. Functions effectively as a team player.

2. Fields of Nursing
3. Roles and Functions

II. Safe and Quality Care

A. The Nursing Process
NURSING PROCESS
Definition
- It is a systematic, client-centered method for structuring the delivery of nursing
care.

B. Basic Nursing Skills

1. Vital Signs
2. Physical Examination and Health Assessment
3. Administration of Medications
4. Asepsis and Infection Control
5. First Aid Measures
6. Wound Care
7. Perioperative Care
8. Post-operative Care
9. Post-mortem Care
C. Measures to meet physiological needs
1. Oxygenation
2. Nutrition
3. Activity, Rest and Sleep
4. Fluid and Electrolyte Balance
5. Urinary Elimination
6. Bowel Elimination
7. Safety, Comfort and Hygiene
8. Mobility and Immobility
III. Health Education
A. Teaching and Learning Principles in the Care of Client
B. Health Education in All Levels of Care
C. Discharge Planning

IV. Ethico-Moral Responsibility

A. Bioethical Principles
1. Beneficence
2. Non-maleficence
3. Justice
4. Autonomy
5. Stewardship
6. Truth Telling
7. Confidentiality
8. Privacy
9. Informed Consent
B. Patients Bill of Rights
C. Code of Ethics in Nursing

V. Legal Responsibility
A. Legal Aspects in the Practice of Nursing
B. The Philippine Nursing Law of 2002 (R.A 9173)
C. Related Laws Affecting the Practice of Nursing

VI. Management of Environment and Resources

A. Theories and Principles of Management
B. Nursing Administration and Management
C. Theories, Principles and Styles of Leadership
D. Concepts and Principles of Organization
E. Patient Care Classification
F. Nursing Care Systems
G. Delegation and Accountability

VII. Records Management

A. Anecdotal Report
B. Incident Report
C. Memorandum
D. Hospital Manual
E. Documentation
F. Endorsement and End of Shift Report
G. Referral

VIII. Quality Improvement

A. Standards of Nursing Practice
B. Nursing Audit
C. Accreditation/Certification in Nursing Practice
D. Quality Assurance

IX. Research
A. Problem Identification
B. Ethics and Science of Research
C. The Scientific Approach
D. Research Process
E. Research Designs and Methodology
1. Qualitative
2. Quantitative
F. Utilization and Dissemination of Research Findings

X. Communication
A. Dynamics of Communication
B. Nurse-Client Relationship
C. Professional-Professional Relationship
D. Therapeutic Use of Self
E. Use of Information Technology

XI. Collaboration and Teamwork

A. Networking
B. Inter-agency Partnership
C. Teamwork Strategies
D. Nursing and Partnership with Other Profession and Agencies
Nursing Board Exam/Nursing Licensure Exam Coverage (Nursing Practice II)
NURSING BOARD EXAM SCOPE/COVERAGE
NURSING PRACTICE II
TEST DESCRIPTION: Theories, concepts, principle and processes in the care of
individuals, families, groups and communities to promote health and prevent
illness, and alleviate pain and discomfort, utilizing the nursing process as
framework. This includes care of high risk and at-risk mothers, children and
families during the various stages of life cycle.
TEST SCOPE:
Part I: CHN

I. Safe and Quality Care, Health Education and Communication, Collaboration and
Team work
COMMUNITY HEALTH NURSING
HISTORY OF CHN
Date
1901 Act # 157 (Board of Health of the Philippines) ;
Act # 309 (Provincial and Municipal Boards of Health) were created.
1095 Board of Health was abolished; functions were transferred to the Bureau of
Health.
1912 Act # 2156 or Fajardo Act created the Sanitary Divisions, the forerunners of
present MHOs; male nurses performs the functions of doctors.
1919 Act # 2808 (Nurses Law was created)
- Carmen del Rosario, 1st Filipino Nurse supervisor under Bureau of Health.
October 22, 1922 Filipino Nurses Organization (Philippines Nurses
Organization) was organized.
1923 Zamboanga General Hospital School of Nursing and Baguio General
Hospital were established; other government schools of nursing were organized
several years after.
1928 1st Nursing convention was held
1940 Manila Health Department was created.
1941 Dr. Mariano Icasiano became the first ciy health officer; Office of Nursing
was created through the effort of Vicenta Ponce (Chief Nurse) and Rosario Ordiz
(assistant chief nurse)
December 8, 1941 Victims of World War II were treated by the nurses of Manila.
July 1942 Nursing Office was created; Dr. Eusebio Aguilar helped in the release
of 31 Filipino Nurses in Bilibid Prison as Prisoners of War by the Japanese.
February 1946 Number of Nurses decreased from 556 308.
1948 First training center of the Bureau of Health was organized by the Pasay
City Health Department. Trinidad Gomez, Marcela Gabatin, Constancia Tuazon,
Ms. Bugarin, Ms. Ramos, and Zenaida Nisce composed the training staff.
1950 Rural Health Demonstration and Training Center was created.
1953 The first 81 Rural Health Units were organized.
1957 RA 1891 Ammended some sections of RA 1082 and created the eight
categories of Rural Health Unit causing an increase in the demand for the
community health personnel.
1958 1965 Division of Nursing was abolished (RA 977) and Reorganization
Act (EO 288)
1961 Annie Sand organized the National Nurses of DOH.
1967 Zenaida Nisce became the nursing program supervisor and consultant on
the six special diseases (TB, Leprosy, V.D., Cancer, Filariasis, and Mental Health
Illness).
1975 Scope of responsibility of nurses and midwives became wider due to
restructuring of the health care delivery system.
1976 1986 The need for Rural Health Practice Program was implemented.
1990 1992 Local Government Code of 1991 (RA 7160)
1993 1998 Office of Nursing did not materialize in spite of persistent
recommendation of the officers, board members, and advisers of the National
League of Nurses Inc.
January 1999 Nelia Hizon was positioned as the nursing adviser at the Office of
Public Health Services through Department Order # 29.
May 24, 1999 EO # 102, which redirects the functions and operations of DOH,
was signed by former President Joseph Estrada.

Laws Affecting Public Health andPractice of Community Health Nursing

R.A 7160 or the Local Government Code. This involves the devolution of
powers, functions and responsibilities to the local government both rural and
urban. The Code aims to transform local government unit into self-reliant
communities and active partners in the attainment of national goals thru a more
responsive and accountable local government structure instituted thru a system of
decentralization. Hence, each province, city and municipality has a LOCAL
HEALTH BOARD ( LHB ) which is mandated to propose annual budgetary
allocations for the operation and maintenance of their own health facilities.

Composition of Local Health Board ( LHB )

Provincial Level
1. Governor Chair
2. Provincial Health Officer vice chair
3. Chair, Committee on Health of Sangguniang Panlalawigan.
4. DOH Representative.
5. NGO Respresentative.
City and Municipal Level
1. Mayor Chair
2. MHO vise chair
3. Chair, Committee on Health of Sangguniang Bayan.
4. DOH Representative
5. NGO Representative
Effective LHS Depends on:
1. The LGUs financial capability.
2. A dynamic and responsive political leadership
3. Community Empowerment

R.A 2382 Philippine Medical Act. This act defines the practice of medicine in the
country.
R.A 1082 Rural Health Act. It created the 1st 81 Rural Health Units.
- amended by R.A 1891; more physicians, dentists, nurses, midwives
and sanitary inspectors will live in the rural areas where they are assigned in order
to raise the health conditions of barrio people, hence help decrease the high
incidence of preventable diseases.
R.A 6425 Dangerous Drugs Act. It stipulates that the sale, administration,
delivery, distribution and transportation of prohibited drugs is punishable by law.
R.A 9165 The New Dangerous Draug Act of 2002.
P.D No. 651 requires that all Health Workers shall identify and encourage the
registration of all births within 30 days following delivery.
P.D No. 996 requires the compulsary immunization of all children below 8 years
of age against the 6 childhood immunizable diseases.
P.D No. 825 provides pernalty for improper disposal of garbage.
R.A 8749 Clean Air Act of 2000
P.D No. 856 Code of Sanitation. It provides for the control of all factors in mans
environment that affect health including the quality of water, food, milk, insects,
animal carriers, transmitters of disease, sanitary and recreation facilities, nilse,
pollution and control of nuisance.
R.A 6758 Standardizes the salary of government employees including the
nursing personnel.
R.A 6675 Generics Act of 1988 which promotes, requires and ensures the
production of an adequate supply, distribution, use and acceptance of drugs and
medicines identified by their generic name.
R.A 6713 Code of Conduct and Ethical Standards of Public Officials and
Employees. It is thepolicy of the state to promote high standards of ethics in public
office. Public officials and employeesshall at all times be accountable to the people
and shall discharges their duties with utmost responsibility, integrity, competence
and loyalty, act with patriotism and justice, lead modest lives uphold public interest
over personal interest.
R.A 7305 Magna Carta for Public Health Workers. This act aims: To promote and
improve the social and economic well-being of health workers, their living and
working conditions and terms of employment; to develop their skills and
capabilities in order that they will be more responsive and better equipped to
deliver health projects and programs; and to encouragethose with proper
qualifications and excellent abilities to join and remain in government service.
R.A 8423 Created the philippine Institute of Traditional and Alternative Health
Care.
P.D No. 965 requires applicants for marriage license to receive instructions on
family planning and responsible parenthood.
P.D No. 79 defines, objectives, duties, and functions of POPCOM.
R.A 4073 advocates home treatment for lepsrosy.
Letter of Instruction No. 949 legal basis of PHC dated october 19, 1979.
-- promotes development of health programs on the
community level.
R.A 3573 requires reporing of all cases of communicable diseases and
administration of prophylaxis.
Misnistry Circular No. 2 of 1986 includes AIDS as notifiable disease.
R.A 7875 National Health Insurance Act
R.A 7432 Senior Citizens Act
R.A 7719 National Blood Services Act
R.A 8172 Salt Iodization Act ( ASIN LAW)
R.A 7277 Magna Carta for PWDS, provides their rehabilitation, self-
development and self-reliance and integration into the mainstream of society.

*A.O No. 2005 0014 National Policies on Infant and Young Child Feeding:
1. All newborns be breastfeed within 1 hour after birth.
2. Infants be exclusively breastfeed for 6 months.
3. Infants be given timely, adequate and safe complementary foods
4. Breastfeeding be continued up to 2 years and beyond.

E.O 51 Philippine Code of Marketing of Breastmilk Substitutes.

R.A 7600 Rooming In and Breastfeeding Act of 1992.
R.A 8976 Food Fortification Law
R.A 8980 Promulgates a comprehensive policy and a national system for ECCD.

A.O. No. 2006 0015 Defines the Implementing guidelines on Hepatitis B

Immunization for infants.
R.A 7846 Mandates Compulsary Hepatitis B Immunization among infants and
children less than 8 years old.
R.A 2029 Mandates Liver Cancer and Hepatitis B Awareness Month Act
( February ).
A.O No. 2006 0012 Specifies the Revised Implementing Rules and
Regulations of E.O 51 or Milk Code, Relevant International Agreements,
Penalizing Violations thereof and for other purposes.

I. Definition of Terms
Community derived from a latin word communicas which means a group of
people.
- a group of people with common characteristics or interests living together within
a territory or geographical boundary.
- place where people under usual conditions are found.
HEALTH is the OLOF (Optimum level of Functioning).
(WHO)- state of complete physical, mental and social well being, not merely the
absence of disease or infirmity.
-It primarily affects the physical well-being of people in a society.
-Health is a fundamental human right.
-A personal and social responsibility.
-A multifactorial approach.

1. HEALTH ILLNESS CONTINUUM

- A predictive grid that displays the Likelihood of a person to participate in
preventive health care.
- A Degree of client wellness ranging from optimum wellness to death.
- Dynamic state, matters as a person adopts to change in internal and a
holistic well being.

HIGH-LEVEL GOOD NORMAL ILLNESS DEATH

WELLNES HEALTH HEALTH

HEALTH ILLNESS CONTINUUM, as shown here, represents the

process of achieving HIGH LEVEL OF WELLNESS or the consequences of
unhealthy lifestyle. In this figure, there are three parameters on how to
achieve high level of wellness.
These are: (A) Awareness, (E) Education, and (G) Growth.
Otherwise, an individual who continuously live an unhealthy lifestyle, will be
on the other side of the grid, and would develop the following: (S) Signs
and Symptoms (S) Syndrome, and (D) Disorder or disability which may
lead disease or premature death.

2. AGENT HOST ENVIRONMENT MODEL

- Primarily used to predict an illness
AGENT Any environmental factor or stressor, chemical,
mechanical, physical, psychosocial, that by its presence or absence can
lead to illness or disease.
- Causative etiologic factor
HOST Persons who may or may not be at risk of acquiring the
disease.
- with intrinsic factor
ENVIRONMENT All factors external to the host that may or may not
predispose the person to the development of the disease.

-Requires the individual to maintain a continuum of balance and purposeful

direction with environment.
Ex: Etiologic factor of Dengue? --- Virus
 AGENT HOST

A. Etiologic Factors: B. Intrinsic Factors &

1. Biological infections----virus, Environmental Factors
bacteria 1. Age
- fungi, protozoa, 2. Sex (m or f)
helminthes, ectoparasites F - Weak emotional; morbidity:
2. Chemical- carcinogens, poisons, common diseases
allergens M - Mortality ( killer
Ex. GMOs carcinogen diseases)
MSG- poison 3. Behavior
3. Mechanical- car accidents, etc 4. Educational attainment-
4. Environmental/physical- occupation
heatstroke 5. Prior immunologic- response
5. Nutritive- excess or deficiency
6. Psychological C. Extrinsic Factors
1. Natural boundaries- physical,
geography
2. Biological environment
3. Socioeconomic envt.-
political boundary

3. HEALTH BELIEF MODEL

- Helps determine whether an individual is likely to participate in disease
prevention and promotion activities.
- Useful tools in developing programs for helping people change to healthier
lifestyles and develop a more positive attitude toward preventive healthier
measures.

COMPONENTS:
INDIVIDUAL PERCEPTIONS: Includes perceived susceptivility,seriousness
and threat. Seriousness of an illness.
MODIFYING FACTORS: Includes demographic variables, sociophysiologic
variables, structural variable, and cues to action. Susceptibility to an illness.
LIKELIHOOD TO ACTION: Depends on the perceived benefit versus the
perceived barriers. Benefits of taking actions.

Ex. Male infected w/ STD & female non-infectious----- Increase

susceptibility of transmission
HIV infection (commercial sex farers, sex workers, medical team
Susceptibility, possible MOT--- unprotected sex- occupational hazard
 Prevention: Safer Sex Practices
Abstinence
Be faithful
Correct, consistent, continuous use of condom
Do not penetrate (SOP)

HIV infected age groups

Males age 40-49 seafarers ratio: 1: 5 anal sex- wont get pregnant,
common in rural

Vaginal: 1: 1000

Females 20-29 Anal: 1: 200-----highest risk

Oral lowest risk

4. EVOLUTIONARY BASED MODEL

illness & death serve an evolutionary function- based on Darwins Survival
of the fittest theory
Elements:
a. Life events developmental variables & those associated with changes
b. Lifestyle determinants personal & learned adaptive strategies a
person uses to make lifestyle changes
c. Evolutionary viability within the social context extent to which a
person fx to promote survival
d. Control perceptions
e. Viability emotions affective reactions developed from life events
f. Health determinants

5. HEALTH PROMOTION MODEL

* Directed at increasing clients well being.
* All efforts increasing well being ( no threat ) ex. Sex education
Combating any possible disease ( no existing disease )

Illness Highly subjective feeling of being sick or ill.

PUBLIC HEALTH ( Dr. C.E. Winslow ) the science and art of preventing
disease, prolonging life, promoting health and efficiency through organized
community effort for the sanitation of the environment, control of communicable
diseases, the education of individuals in personal hygiene, the organization of
medical and nursing services for the early diagnosis and preventive treatment of
diseases and the development of social machinery to ensure everyone a
standard of living adequate for the maintenance of health, so organizing these
 benefits as to enable every citizen to realize his birthright of birth and longevity.
( Dr C.E Winslow ).
Art of Applying Science in the context of Politics so as to reduce Inequalities in
Health while ensuring the best health for the greatest number.

COMMUNITY HEALTH part of paramedical and medical intervention/approach

which is concerned on the health of the whole population.

Aims:
1. health promotion
2. disease prevention
3. management of factors affecting health.

INDIVIDUAL CLIENT: APPLIED STUDY: COMMUNITY AS CLIENT:

Anatomy Structure Demographic study of population
Physic Function Sociology
Pathos Malfunction Epidemiology study of disease

NURSING both profession and a vocation. Assisting sick individuals to become

healthy and healthy individuals achieve optimum wellness.

1. Virginia Henderson
- Assisting sick individuals to become healthy and healthy individuals achieve
optimum wellness

2. Dorothea Orem
- Providing assistance to clients to achieve self-care towards optimum wellness.
Early years- fetus- 12 years/ younger adults- 12-24 years
Orem- self care, autonomy----independent patient

3. Florence Nightingale
- Placing an individual in an environment. that will promote optimum capacity for
self-reparative process
- individual capable of self-repair and there is something to repair in an individual.

COMMUNITY HEALTH NURSING

-Synthesis of public and nursing practice.

(WHO Expert Committee of Nursing)

- special field of nursing that combines the skills of nursing, public health and
some phases of social assistance and functions as part of the total public health
program for the promotion of health, the improvement of the conditions in the
social and physical environment, rehabilitation of illness and disability.
- a specialized field of nursing practice.
1. Utilitarianism: greatest good for the greatest number.
2. Nursing Process.
3. Priority of health-promotive and disease-preventive strategies over curative
interventions.
4. Tools for measuring and analyzing Community Health problems.
5. Application of principles of management and organization in the delivery of
health services to the community.

(Maglaya)
- The Utilization of the nursing process in the different levels of clientele
individuals, families, population groups and communities, concerned with the
promotion of health, prevention of disease and disability and rehabilitation.

(Jacobson)
- is a learned practice disciplined with the ultimate goal of contributing as individual
and incollaboration with others, to the promotion of clients optimum level of
functioning through teaching and delivery of care.

(Dr. Ruth B. Freeman)

- a service rendered by a professional nurse to IFCs population groups in health
centers, clinics schools, workplace for the promotion of health, prevention of
illness, care of the sick at home and rehabilitation.
- Technical nursing, interpersonal, analytical and organizational skills are applied to
problems of health as they affect the community.
-Unique blend of nursing & public health practice aimed at developing & enhancing
health capabilities of the people , service rendered by a professional nurse with
the comm., grps, families, and indiv at home, in H centers, in clinics, in school, in
places of work for the ff:
1. Promotion of health
2. Prevention of illness
3. Care of the sick at home and rehab - self-reliance

Factors affecting Optimum Level of Functioning (OLOF)

1. Political
2. Behavioral
3. Hereditary
4. Health Care Delivery System
5. Environmental Influences
6. Socio economic Influences
Concepts
1. The primary focus of community health nursing practice is on health promotion
and disease prevention.
Primary goal self reliance in health or enhanced capabilities.
Ultimate goal raise level of number of citizenry.
Philosophy of CHN Worth and dignity of man.
2. CHN practices to benefit the individual, family, special groups, and community
*CHN is integrated and comprehensive
3. Community Health Nurses are generalist in terms of their practice through life
but the whole community its full range of health problems and needs.
4. Community Health Nurses are generalist in terms of their practice through life
continuity in its full range of health problems and needs.
5. The nature of CHN practice requires that current knowledge derived from the
biological, social science, ecology, clinical nursing and community health
organizations be utilized.
6. Contact with the client and or family may continue over a long period of time
which includes all ages and all types of health care.
Levels of Health Care:
Primary Health Care: Management at the level of community
Secondary Health Care: Regional, District, Municipal, and Local Hospital
Tertiary Health Care: Sophisticated Medical Center Heart Center, KI
7. The dynamic process of assessing, planning, implementing and intervening
provide measurements of progress, evaluation and a continuum of the cycle until
the termination of nursing is implicit in the practice of Community Health Nursing.
Nursing Function:
Independent without supervision of MD
Collaborative in collaboration with other Health team
( interdisciplinary, intrasectoral )

II. Community Health Nursing

- The utilization of the nursing process in the different levels of clientele-
individuals, families, population groups and communities, concerned with the
promotion of health, prevention of disease and disability and rehabilitation.

Goal: To raise the level of citizenry by helping and families to cope with the
discontinuities in and threats to health in such a way as to maximize their potential
for high-level wellness. Nisce, et al
To elevate the level health of the multitude.

MISSION OF CHN ( FIVE FOLD MISSION )

*Health Promotion activities related to enhancement of health.
*Health Protection activities designed to protect the people.
*Health Balance activities designed to maintain well being.
*Disease Prevention activities relate to avoid complication = primary, secondary,
tertiary.
*Social Justice activities related to practice practice equity among clients.

PHILOSOPHY OF CHN
*The philosophy of CHN is based on the worth and dignity of man.

Roles of COMMUNITY HEALTH NURSE / PUBLIC HEALTH NURSE

CLINICIANS - who is a health care providers, taking care of the sick people at
home or in the RHU.
HEALTHEDUCATOR who aims towards health promotion and Illness prevention
through dissemination of correctr information; educating people.
ADVOCATOR acts on behalf of the client.
FACILITATOR who establishes multi sectoral linkages by referral system.
SUPERVISOR who monitors and supervises the performance of midwives.
COLLABORATOR working with other health team member.

-In the event that the Municipal Health Officer ( MHO ) is unable to perform his
duties/functions or is not available, the Public Health Nurse will take charge of the
MHOs responsibilites.
-Other Responsibilities of a Nurse, spelled by the implementing rules and
regulations of RA 7164 ( Philippine Nursing Act of 1991 ) includes:
*supervision and care of women during pregnancy, labor, and puerperium.
*Performance of Internal Examination and Delivery of Babies.
*Suturing lacerations in the absence of a Physicians.
*Provisions of First aid measures and Emergency Care.
*Recommending Herbal and Symptomatic Meds... Etc.

In the Care of the Families:

-Provision of Primary Health Care Services.
-Developmental/Utilization of Family Nursing Care Plan in the provision of Care.

In the Care of the Communities:

-Community organizing mobilization, Community development, and People
empowerment.
-Program planning, Implementation, and Evaluation.
-Influencing executive and legislative individuals or bodies concerning health and
develoment.

ROLES OF THE COMMUNITY HEALTH NURSE

1. Planner/ Programmer- identifies needs, priorities & problems if individual, family,
& comm.
- Formulates nursing component of H plans
In doctorless areas, she is responsible for the formulation of the
municipal health plan
Provides technical assistance to rural health midwives in health matters
like target setting.
2. Provider of Nursing care- provides direct nsg care to the sick, disabled in the
homes, clinics, schools,
or places of work
provide continuity of patient care
3. Manager/ Supervisor- formulates care plan for the:
4 Clientele:
a. Requisitions, allocates, distributes materials (meds & medical supplies &
records & reports equips
b. Interprets and implements programs, policies, memoranda, & circulars
c. Conducts regular supervisory visits & meetings to diff RHMs & gives
feedbacks on accomplishments
4. Community Organizer- motivates & enhance community participation in terms
of planning, org, implementing
and evaluating Health programs/ services.
5. Coordinator of Health Services- coordination with other health team & other
govt org (GOs & NGOs) to other
health programs as envt. sanitation health education, dental health &
mental health.
6. Trainer/ Health educator/ counselor- conducts training for RHMs, BHWs, hilots
who aim towards H promo & illness prevention through dissemination of correct
info;
educating people
7. Researcher- coordinates with govt. & NGOs in the implementation of studies/
researches
participates in the conduct of surveys studies & researches on Nsg and
H related subjs.
8. Health Monitor----evaluating what deviates from normal
9. Manager ---under the nurse---midwives
10. Change Agent
11. Client Advocate

Responsibilities of COMMUNITY HEALTH NURSE

-Be a part in developing an overall health plan, it is implementation and evaluation
for communities.
-Provide quality nursing services to the three levels of clientele.
-Maintain coordination/linkages with other health team members,
NGO/government agencies in the provision of public health services.
-Conduct researches relevant to CHN services to improve provision of health care.
-Provide opprotunities for professional growth and continuing education for staff
development..

PUBLIC HEALTH

1. WINSLOW
- The science & art of preventing disease, prolonging life, promoting health
& efficiency through
organized community effort
To enable each citizen to realize his birth right of health & longevity.
Major concepts:
1. Health promotion
2. Peoples participation towards self-reliance
2. HANLON
- Most effective goal towards total development and life of the individual &
his society

3. PURDOM
- Applies holism in early years of life, young, adults, mid year & later
- Prioritizes the survival of human being

PUBLIC HEALTH NURSING

(Cuevas, 2007)
-In the light of the changing national and global helath situation and the
acknowledgement that nursing is a significant contributor to health, the public
health nurse is strategically positioned to make a difference in the health outcomes
of individuals, families, and communities cared for.

Concepts
1. Science and Art of Preventing diseases, prolonging life, promoting health and
efficiency through organized community effort for the:
a. sanitation of the environment.
b. control of communicable diseases.
c. the education of individuals in personal hygiene.
d. organization of medical and nursing services for early diagnosis and preventive
treatment of disease, and the development of social machinery to ensure
everyone a standard of living adequate for the maintenance of health, so
organizing these benefits as to enable every citizen to realize his birthright of
health and longevity.

Determinants of Health
*Factors that can affect health
a. Income and social status - socioeconomic
b. Education - socioeconomic
c. Physical Environment - Environment
d. Employment and working conditions - socieconomic
e. Social support networks - socioeconomic
f. Culture, Customs and Traditions - Behavior
g. Genetics - Heredity
h. Personal Behavior and coping skills - Behavior
i. Health Services Health Care Delivery System
j. Gender Heredity
-ECOSYSTEM influence on OLOF ( Blum 1974 ).

CORE Busyness of Public Health:

1. Disease control
2. Injury Prevention
3. Health Protection
4. Health public policy including those in relation to environmental hazards such as
in the work place, housing, food, water, etc.,
5. Promotion of health and equitable health gain.

In response to above trends, the global community, represented by the United

Nations General Assembly, decided to adopt a common vision of poberty reduction
and sustainable development in september 2000.
This vision is exemplified by the Millenium Development Goals (MDGs) which
are based on the fundamental values of:
FREEDOM
EQUALITY
SOLIDARITY
TOLERANCE
HEALTH HEALTH: MILLENIUM DEVELOPMENT
GOALS
RESPECT FOR NATURE MDG 1: Eradicate extreme poverty and hunger
Target: Halve, between 1990 and 2015, the
proportion of people whose income is
less than one dollar a day.
Target: Halve, between 1990 and 2015, the
proportion of people who suffer from
hunger.

SHARED RESPONSIBILITY MDG 2: Achieve universal primary education

Target: Ensure that, by 2015, children
everywhere, boys and girls alike, will
 be able to complete a full course of
primary schooling.

MDG 3: Promote gender equality and women

empowerment
Target: Eliminate gender disparity in primary
and secondary education preferably
by 2005 and to all levels of education
no later than 2015.

MDG 4: Decreased child mortality

Target: Reduce by 2/3, between 1990 and
2015, the under five mortality rate.

MDG 5: Increased maternal health

Target: Reduce by three quarters, between
1990 and 2015, the maternal mortality
ratio.

MDG 6: Combat HIV/AIDS, Malaria and other

diseases
Target: Have halted by 2015 and begun to
reverse the spread of HIV / AIDS
Target: Have halted by 2015 and begun to
reverse the incidence of malaria and
other major diseases.

MDG 7: Ensure environmental sustainability

Target : Integrate the principles of sustainable
development into country policies and
programmes and reverse the loss of
environmental resources.
Target : Halve, by 2015, the proportion of
people without sustainable access to
safe drinking water
Target: By 2020, to have achieved a
significant improvement in the lives of
at least 100 million slum dwellers.

MDG 8: Develop a global partnership for

development.
Target : Develop further an open, rule-based,
predictable, non-discriminatory trading
and financial system.
 Target: Address the special needs of the least
developed countries.
Target: Address the special needs of
landlocked countries and small
island developing States.
Target: Deal comprehensively with the debt
problems of developing
countries through national and
international measures in order to
make debt sustainable in the long
term.

COMMUNITY HEALTH NURSING PUBLIC HEALTH NURSING

( ART ) and Science
*Synthesis of nursing practice and
public health practice applied to
promoting and preserving the health
of the populations.
*Directs care to individuals, families,
or groups; this care, in turn
contributes to the health of the total
population.
*knowldge = nursing and PHN
*More General Specialty area that
encompasses subspecialties that
include Public Health Nursing and
other developing fields of practice
such as home health, hospice care,
and independent nursing practice.
( SCIENCE ) and Art
*Synthesis of public health and
nursing practice.
*Specific/subspecialty nursing
practice.
*Defined as the practice of
promoting and protecting health of
populations using knowledge from
nursing social and public health
sciences.
*CORE FUNCTIONS:
a. Assessment
b. Policy development
c. Assurance
*Essential Functions:
-Heart monitoring and analysis.
-Epidemiological
surveillance/disease prevention
and control and all.

A. Principles and Standards of CHN

PRINCIPLES AND STANDARD OF CHN

PRINCIPLES
1. The need of the community is the basis of community health nursing.
2. The community health nurse must understand fully the objectives and policies of
the agency she represents.
3. The family is the unit of service.
4. CHN must be available to all regardless of race, creed and socioeconomic
status.
5. The CHN works as a member of the health team
6. There must be provision for periodic evaluation of community health nursing
service.
7. Opportunities for continuing staff education programs for nurses must be
provided by the community health nursing agency and the CHN as well.
8. The CHN makes use of available community health resources.
9. The CHN taps the already existing active organized groups in the community.
10. There must be provision for educative supervision in community health
nursing.
11.There should be accurate recording and reporting in community health nursing.
12. Health teaching is the primary responsibility of the community health nurse.

STANDARDS IN CHN
I. Theory
Applies theoretical concepts as basisfor decisions in practice.
II. Data Collection
Gathering comprehensive, accurate data systematically.
III. Diagnosis
Analyzes collected data to determine the needs / health problems of Individual,
Family, Community.
IV. Planning
At each level of prevention, develops plans that specify nursing actions unique
to needs of clients.
V. Intervention
Guided by the plan, intervenes to promote, maintain or restore health, prevent
illness and institute rehabilitation.
VI. Evaluation
Evaluates responses of clients to interventions to note progress toward goal
achievement, revise data base, diagnose and plan.
VII. Quality Assurance and Professional Development
Participates in peer review and other means of evaluation to assure quality of
nursing practice.
Assumes professional development.
Contributes to development of others.
VIII. Interdisciplinary Collaboration
Collaborates with other members of the health team, professionals and
community representatives in assessing, planning, implementing and evaluating
programs for community health.
IX. Research
Indulges in research to contribute to theory and practice in community health
nursing.
B. Levels of Care
LEVELS OF CARE/PREVENTION
a. The Three Levels of Helath Care Sevices
PRIMARY
-Is devolved to the cities and the municipalities. It is health care provided by center
physicians, public health nurses, rural health midwives, barangay health workers,
traditional healers and others at the barangay health stations and rural health
units. The primary health facility is usually the first contact between the community
members and the other levels of health facility.
- activites that prevent a problem before it occurs. Example: Immunization.
SECONDARY
-Secondary care is given by physicians with basic health training. This is usually
given in health facilities and district hospitals and out-patient departments of
provincial hospitals. This serves as a referral center for the primary health facilities.
Secondary facilities are capable of performing minor surgeries and perform some
simple laboratory examinations.
- activities that provide early detection/diagnosis and treatment and Intervention.
Example: Breast self-examination, HIV screening, Operation timbang.
TERTIARY
-Is rendered by specialists in health facilities including medical centers as well as
regional and provincial hospitals, and specialized hospitals such as the Philippine
Heart Center. The tertiary health facility is the referral center for the secondary
care facilities. Complicated cases and intensive care requires tertiary care and all
these can be provided by the tertiary care facility.
- activities that correct a disease state and prevent it from further deteriorating.
Example: Teaching Insulin Administration in the home

b. Three Levels of Health Care Services and the Two Way Referral System

*There are TWO LEVELS OF PRIMARY HEALTH CARE WORKERS, namely:

1. Village or Barangay Health Workers: refers to trained community health
workers or health auxiliary volunteers or traditional birth attendants or healers.
2. Intermediate Level Health Workers: refers to general medical practitioners or
their assistants, public health nurse, rural sanitary inspectors, and midwives.

c. Types of Primary Health Workers

Village / Intermediate Health

Grassroots Health Level Personnel of
Workers First-Line
Hospitals
E - trained -general medical -physicians
X community practitioners -nurses
A -health worker -public health -dentists
 M -auxiliary health nurses
P volunteer -midwives
L -traditional birth
E attendant
C -initial link, first -first source of -establishes close
H contact of the professional contact with the
A community health care village and
R intermediate
A -works in liaison -attends to health level health
C with the local problems beyond workers to
T health service the competence promote the
E workers of village health continuity of care
R workers from hospital to
I -provides community to
S elementary -provides support home
T curative and to the frontline
I preventive health workers in -provides back-up
C health care terms of health services
S measures supervision, for cases
training, referral requiring hospital
services and or diagnostic
supplies thru facilities not
linkages with available in
other sectors health care

C. Types of Clientele
TYPES OF CLIENTELE

INDIVIDUAL
- People who visits the health center.
- People who receives health services.
e.g., Prenatal Supervision
Well Child Follow ups.
Morbidity Service
Teaching Client on Insulin Administration
Basic approaches in looking at the individual:
1. atomistic the basic constituents of an individual, use concepts of biology which
in turn refers to essentialism --- behavior --- psychological --- human behavior s
dictated by experience.
2. holistic suprasystems sociological in nature social constructionism
nurture behavior
SEX --- a biological concept (male / female)
--- a sociological concept --- gender --- musculinity or femininity --- based
on culture.
--- on sexual orientation: attracted to Opposite sex heterosexual
 Same sex homosexual
Both bisexual

Perspective in understanding the individual:

1. BIOLOGICAL
a. unified whole
b. holon
c. diporphism
2. ANTHROPOLOGICAL
a. Essentialism
b. Social constructionism
c.Culture
3. PSYCHOLOGICAL
a. Psychosexual
b. Psychosocial
c. Behaviorism
d. Social learning
4. SOCIOLOGICAL
a. Family and kinship
b. Social groups

FAMILY
- 2 or more individuals who commit to live together for an extended period of time
not necessarily with marital affinity or blood relations.
- Considered as the basic unit of care.
a. Nuclear
b. Extended with lolos and lalas, titios and titas
c. Cohabiting live-in, Not married but with kids.
d. Dyad married but without kids.

MODELS:
Stages of Family Development by Evelyn Duvall
STAGE 1 The Beginning Family ( newly wed couples ).
TASK: Compliance with the PD 965 and acceptance of the new member of the
family.

STAGE 2 The Early Child Bearing Family ( 0 30 months ).

TASK: Emphasize the importance of pregnancy and immunization and learn the
concept of parenting

STAGE 3 The Family with Preschool Children ( 3 6 years old ).

TASK: Learn the concept of Responsible Parenthood.

STAGE 4 The Family with School Age Children ( 6 -12 years old).
TASK: Reinforce the concept of Responsible Parenthood.

STAGE 5 The Family with Teenagers (13 25 years old ).

TASK: Parents to learn the concept of let go system and understand the
generation gap.

STAGE 6 Launching Center ( 1st Child will get married upto the last child ).
TASK: Compliance with the PD 965 and acceptance of the new member of the
Family.

STAGE 7 Family with Middle Adult Parents ( 36 60 years old ).

TASK: Provide a Healthy Environment, adjust with a new lifestyle and adjust with
the financial aspect.

STAGE 8 The Aging Family ( 61 years old upto death ).

TASK: Learn the concept of Death Positively.

8 Family Tasks or Basic Tasks of Developmental Model:

Physical maintenance
Allocation of resources- income given to wife
Division of labor joint parenting
Socialization of family members
Reproduction, recruitment & release
*Maintenance of order- high crime rate
Placement of members in larger society- Indication familys success
Maintenance of motivation & morale
Criticisms: very limited & cannot apply to all situation

STRUCTURAL FUNCTIONAL
Initial Data Base
a. Family Structure and Characteristics
Nuclear basic family
Extended in-law relations, or grandparents relations
*members of household in relation to head
*demographic data ( sex male or female, age, civil status )
Live in = married/ common law WIFE
Male Patriarchal Female Matriarchal
*types and structure of family
*dominant members in health
*general family relationship

Assessment: Family
-Initial data base
-1st level assessment
-2nd level assessment

b. Socio-economic and cultural Factors

*resources and expenses
*educational attainment
*ethnic background
*religious affiliation
*SO ( do not live with the family but influences decision )
*Influences to larger communities

c. Environmental Factors
*housing- number of rooms for sleeping
*kind of neighborhood
*social health facilities available
*comm. And transportatx facilities

d. Health Assessment of Each Member PE

e. Value Placed on Prevention of Disease

*Immunization
*Compliance behavior

First Level Assessment

*Health Threats:
-Conditions that are conducive to disease, accident or failure to realize ones
health potential
-Example:
Family history of illness hereditary like DM, HPN
Nutritional problem eating salty foods
Personal behavior smoking, self medication, sexual practices, drugs,
excessive drinking
Inherent personality characteristics short temperedness, short attention span
Short cross infection
Poor home environment
Lack / Inadequate immunization
Hazards fire, falls, or accidents-
Family size beyond what resources can provide -

*Health Deficits:
-Instances of failure in health maintenance ( disease, disability, developmental
lag )
3 TYPES:
a. Disease / Illness URTI, marasmus, scabies, edema
b. Disabilities blindness, polio, colorblindness, deafness
c. Developmental Problem like mental retardation, gigantism, hormonal, dwarfism

*Stree points / Forseeable Crisis Situation:

-Anticipated periods of unusual demand on the individual or family in terms of
adjustment or family resources ( nature situations )
-Example:
Entrance in school
Adolescents (circumcision, menarche, puberty)
Courtship (falling inlove, breaking up)
Marriage, pregnancy, abortion, puerperium
Death, unemployment, transfer or relocation, graduation, board exam

Second Level Assessment (Family tasks involved)

Family tasks that cant be performed

*Recognition of the problem
*Decision on appropriate health action
*Care to affected family member
*Provision of health home environment
*Utilization of community resources for health care

Problem Prioritization:
*Natur eof the Problem
Health Deficit
Health Threat
Forseeable Crisis
*Preventive Potential
High
Moderate
Low
*Modifiability
Easily modifiable
Partially modifiable
Not modifiable

*Salience
High
Moderate
Low
Family Service and Progress Record

Family Coping Index

Physical Independence ability of the family to move in and out of bed and
performed activities of daily living.
Therapeutic Independence abilty of the family to comply with the therapeutic
regimen ( diet, medication and usage of appliances ).
Knowledge of Health Condition wisdom of the family to understand the
disease process.
Application of General and Personal Hygiene ability of the family to perform
hygiene and maintain environment conducive for living.
Emotional Competence ability of the family to make decision maturely and
appropriately ( facing the reality of life ).
Family Living Pattern the relationship of the family towards each other with
love, respect and trust.
Utilization of Community Resources ability of the family to know the function
and existence of resources within the vicinity.
Health Care Attitude relationship of the family with the health care provider.
Physical Environment ability of the family to maintain environment conducive
for living.

COMMUNITY Patient
- Defined by geographic boundaries with certain identifiable characteristics, with
common values and interests.

POPULATION GROUPS-
-Aggregation of people who share common chaaracteristics, developmental stage
or common exposure to particular environmental factors thus resulting in common
health problems ( Clark, 1995: 5 ) e.g. children, elderly, women, workers, etc.

- Vulnerable Groups: or High Risk Groups ( before )

*Infants and Young Children dependent to caretakers
*School age most negected
*Adolescents identify crisis, HIV
*Mother 1/3 of population health problem ( pregnancy, delivery, puerperium )
*Males too macho to consult
*Old People degenerative disease

*Population Pyramid shows the age, sex, and structure

- Specialized Fields:
*COMMUNITY MENTAL HEALTH NURSING a unique process which includes
an integration of concepts from nursing, mental health, social psychology,
psychology, community networks, and the basic sciences.
Focus: Mental Health Promotion no need to identify disease, increase mental
wellness of people.
Nursing: Strengthening the support mechanism
Psychiatric Nursing-Focus: Mental Disease Prevention
Focus: Mental Disease Prevention identify disease and shorten disease process

*OCCUPATIONAL HEALTH NURSING the application of nursing principles and

procedures in conserving the health of workers in all occupations.
Aims: Health promotion and prevention of disease and injuries, risk minimization,
ensuring safe work place from industrial to service

*SCHOOL AND HEALTH NURSING the application of nursing theories and

principles in the care of the school population.
Components:
School Health Services- maintain school clinic, screening all children- visual,
hearing, scoliosis

Health Instruction- health education/ counselor direct & undirect

Healthful School Living- health monitor

Mental health- substance abuse, sexual H

Environmental health- food sanitation, water supply, safe environment,

safe toilet

School community- linkage- comm. Organizer

D. Health Care Delivery System

PHILIPPINE HEALTH CARE DELIVERY SYSTEM

The Philippine health care delivery system is composed of two sectors: (1) the
public sector, which largely financed through a tax-based budgeting system at
both national and local levels and where health care is generally given free at the
point of service and (2) the private sector (for profit and non-profit providers)
which is largely market-oriented and where health care is paid through user fees at
the point of service.

The public sector consists of the national and local government agencies
providing health services. At the national level, the Department of Health (DOH) is
mandated as the lead agency in health. It has a regional field office in every region
and maintains specialty hospitals, regional hospitals and medical centers. It also
maintains provincial health teams made up of DOH representatives to the local
health boards and personnel involved in communicable disease control,
specifically for malaria and schistosomiasis. Other national government agencies
providing health care services such as the Philippine General Hospital are also
part of this sector.
With the devolution of health services, the local health system is now run by Local
Government Units (LGUs). The provincial and district hospitals are under the
provincial government while the city/municipal government manages the health
centers/rural health units (RHUs) and barangay health stations (BHSs). In every
province, city or municipality, there is a local health board chaired by the local chief
executive. Its function is mainly to serve as advisory body to the local executive
and the sanggunian or local legislative council on health-related matters.

The private sector includes for-profit and non-profit health providers. Their
involvement in maintaining the peoples health is enormous. This includes
providing health services in clinics and hospitals, health insurance, manufacture of
medicines, vaccines, medical supplies, equipment, and other health and nutrition
products, research and development, human resource development and other
health-related services.

1. PRIMARY LEVEL FACILITIES

2. SECONDARY LEVEL FACILITIES
3. TERTIARY LEVEL FACILITIES

Classify as to what level the following belong

1. Teaching and Training Hospitals _______________
2. City Health Services _______________
3. Emergency and District Hospitals _______________
4. Private Practitioners _______________
5. Heart Institutes _______________
6. Puericulture Centers _______________
7. RHU Primary Level Facilities

Primary RHU, Brgy health centers

Secondary District Hospitals
Tertiary Provincial Hospitals, City Hospitals

A. THE PUBLIC SECTOR

1. THE DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH
-Lead agency in the Health Sector
-Sets the goals for the nations health status
-Establishes PARTNERSHIP

DOH MANDATE
1. Formulation
2. Support
3. Issuance
4. Promulgation
5. Development

Roles of DOH:
1. Leadership in Health
*Serve as the national policy and regulatory institution.
*Provide leadership in the formulation, monitoring and evaluation of the national
health policies, plans and programs.
*Serve as advocate in the adoption of health policies, plans and programs
2. Enabler and Capacity builder
*Innovate new strategies in health.
*Exercise oversight functions and monitoring and evaluation of national health
plans, program and policies.
*Ensure the highest achievable standards of quality health care, promotion and
protection
3. Administrator of specific services
*Manage selected national health facilities and hospitals with modern and
advanced facilities.
*Administer direct services for emergent health concerns that require new
complicated technologies.

Primary Function of DOH

-Promotion
-Protection
-Preservation
-Restoration

***VISION:
Old: Health for all Filipinos
New: The Leader of health for all in the Philippines
New: The DOH is the leader, staunch advocate and model in promoting Health for
all in the Philippines.

New: A global leader for attaining better health outcomes, competetive and
responsive health care system, and equitable health financing by 2030.

***MISSION:
-Old: Ensure accessability and quality of health care services to improve the
quality of life of all Filipinos, especially the poor.
-New:To guarantee equitable, sustainable and quality health for all Filipinos,
especially the poor, and to lead the quest for excellence in health.

Important CONCEPT!!!
In the community setting, the marginalized refers to...
D
O
P
E
A
S

PHILOSOPHY OF DOH:
-Quality is above Quantity!

PRINCIPLES OF DOH
P Performance of health sector must be enhanced.
U Universal Access to basic health services.
S Shifting from infectious to degenerative diseases must be managed.
H Health, and nutrition of vulnerable group must be prioritized.

***STRATEGIES OF DOH
SAID!!!
S support the local health system and front line workers.
A assurance of health care for all.
I increase investment of PHC.
D development of national standards, and objective for health.

Five Major Functions of the DOH

- Ensure equal access to basic health services
- Ensure formulation of health policies for proper division of labor and proper
coordination of operations among agencies
- Ensure maximum level of implementation nationwide of services regarded
as public health goods
- Plan and establish arrangements for public health systems to achieve
economics of scale
- Maintain a medium of regulation and standards to protect consumers and
guide providers

GOAL: Heal Sector Reform Agenda ( HSRA ).

Rationale for HSRA:

*Slowing down in the reduction of Infant Mortality and Maternal Mortality Rates.
*Persistence of large variations in health status across population groups and
geographic areas.
*High burden from infectious diseases.
*Rising burden from chronic and degenerative diseases.
*Unattended emerging health risks from environmenmental and work related
factors.
*Burden of disease is heaviest on the poor.

Framework for the 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

Elements of the Strategy:

1. Health financing to foster greater, better and sustained investments in health.
2. Health regulation to ensure 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 in both public and private facilities
and services.
4. Good governance to enhance health system performance at the national and
local levels.

Roadmap for All Stakeholders in Health: National Objectives for Health 2005
2010.

National Objective for Health: sets the target and the critical indicators, current
strategies based on field experience, and laying down new avenues for improved
interventions.

Goals and Objectives of the Health Sector:

- to facilitate understanding the objective of the health sector could be divided into
4 general objectives, namely:
Improve Health Status of the Population
a. Improve the general health status of the population.
b. Reduce morbidity and mortality from certain diseases.
c. Eliminate certain diseases as public health problems.
d. Promote health lifestyle and environmental health.
e. Protect vulnerable groups with special health and nutritional needs.
Ensure Quality Service Delivery
a. Strengthen national and local health systems to ensure better health service
delivery.
b. Pursue public health and hospital reforms.
c. Reduce the cost and ensure the quality and safety of health goods and
services.
d. Strengthen health governance and management support systems.
Improve Support system for the Vulnerable and Marginalized Groups
a. Institute safety nets for the vulnerable and marginalized groups.
Implement Proper Resource Management
a. Expand the coverage of social health insurance.
b. Mobilize more resources for health.
c. Improve efficiency in the allocation, production and utilization of resources for
health.

Major Helath Plans towards Health in the Hands of the People in the year
2020
A Healthy BARRIO should be:
a. Residents actively participate in attaining good health; they are
PARTNERS in health care.
b. Highlight Project: BOTIKA SA PASO CAMPAIGN
c. Goal: to maintain herbal plants in pots for family use
A Healthy CITY should be:
a. The physical environment in the workplace, streets, and public
places promote health, safety, order and cleanliness through
structural manpower support
b. Health- Related Strategies: Construction of well-maintained, income
generating public toilets; designation of a pook-sakayan, pook-
babaan
A Healthy EATING PLACE should be:
a. Eating place where:
- safe and properly prepared, stored and transferred foods
- nutritious foods and drinks are served.
b. Complies with the following sanitation standards:
- safe, environment-friendly
- with clean restrooms
- food handlers are medically fit
A Healthy MARKET should be:
a. Adequate water supply
b. Proper drainage
c. Well-maintained toilet facilities
d. Proper garbage and waste disposal
e. Cleanliness maintained
f. Affordable quality foods
A Healthy HOSPITAL should be:
a. A Center of Wellness
b. Promotes Preventive care
c. Patient-centered
A Healthy STREET should be:
a. Well-maintained roads and public waiting areas
b. Clean and obstruction free sidewalks
c. With minimal traffic problems
d. With adequate strict law enforcement
e. Project: Pook Tawiran
f. Goal: to promote and reorient people especially erring pedestrians
on the use of pedestrian crossings
GOALS AND OBJECTIVES OF DOH
GREEPPP!!!
G general health status of Filipino must improve
R reduce morbidity, mortality and disability to different diseases
E eradicate poliomyelitis
E eliminate certain endemic disease
P promote the health and nutrition of the family
P promote healthy lifestyle
P promote environmental sanitation

Basic Principles to Achieve Improvement in Health

1. Universal access to basic health servicesmust be ensured.
2. The health and nutrrition of vulnerable groups must be prioritized
3. The epidemiological shift from infection to degenerative diseases must be
managed.
4. The performance of the health sector must be enhanced.

Primary Strategies to Achieve Goals

1. Increasing investment for primary Health Care.
2. Development of national standards and objectives for health.
3. Assurance of health care.
4. Support to the local system development.
5. Support for frontline health workers.

2. LOCAL GOVERNMENT UNITS

- the Local Government Code of 1991 or RA 7160 transformed local government
units into self-reliant communities and active partners in the attainment of national
goals through a more responsive an accountable government structure instituted
through a system of decentralization.
B. THE PRIVATE SECTOR
- composed of both commercial and business organizations with its
market or profit orientation and non-business organizations with its
service orientation

E. PHC as a Strategy
PHC as a Strategy

PRIMARY HEALTH CARE (PHC)

*May 1977 30th World Health Assembly decided that the main health target of
the government and WHO is the attainment of a level of health that would permit
them to lead a socially and economically productive life by the year 2000.

*September 6 12, 1978 First International Conference on PHC in Alma Ata,

Russia ( USSR ) the Alma Ata Declaration stated that PHC was the key to attain
the health for all goal.

*October 19, 1979 Letter of Instruction ( LOI 949 ), the legal basis of PHC was
signed by President Ferdinand E. Marcos, which adopted PHC as an approach
toward the design, development and implementation of programs focusing on
health development at community level.
LOI 949 signed by President Marcos with an underlying theme: Health in the
hands of the People by 2020.

Rationale for Adopting PRIMARY HEALTH CARE:

*Magnitude of Health Problems.
*Inadequate and unequal distribution of health resources.
*Increasing cost of medical care.
*Isolation of health care activities from other development activities.

DEFINITION OF PRIMARY HEALTH CARE

*Essential health care made universally accessible to individuals and families in
the community by means acceptable to them, through their full participation and at
cost that the community can afford at every stage of development.
*A practice approach to making health benefits within the reach of all people.
*An approach to health development, which is carried out through a set of
activities and whose ultimate aim is the continuous improvement and maintenance
of health status of the community.

Goal of PRIMARY HEALTH CARE:

*Health for all Filipinos by the year 2000 and health in the Hands of the people by
the year 2020.

An improved state of health and quality of life for all people attained through
SELF-RELIANCE.

Concept of PHC
KEY STRATEGY TO ACHIEVE THE GOAL:
- characterized by partnership and empowerment of the people that shall
permeate as the core strategy in the effective provision of essential health service
that are community based, accessible, acceptable and sustainable at a cost, which
the community and the government can afford.

OBJECTIVES OF PRIMARY HEALTH CARE

*Improvement in the level of health care of the community.
*Favorable population growth structure.
*Reduction in the prevalence of preventable, communicable and other disease.
*Reduction in morbidity and mortality rates especially among infants and children.
*Extension of essential health services with priority given to the underserved
sectors.
*Improvement in Basic Sanitation.
*Development of the capability of the community aimed at self reliance.
*Maximizing the contribution of the other sectors for the social and economic
development of the community.

MISSION:
*To strengthen the health care system by increasing opportunities and supporting
the conditions wherein people will manage their own health care.
Two levels of PRIMARY HEALTH CARE WORKERS
1. Barangay Health Workers trained community health workers or health
auxiliary volunteers or traditional birth attendants or healers.
2. Intermediate Level Health Workers include the Public Health Nurse, Rural
Sanitary Inspector and Midwives.

Levels of Health Care and Referral System

1. Primary Level of Care Health care provided by center physicians, PHN, Rural
Health Midwives,Barangay Health Workers and other at the Baragay Heath Station
and Rural Health Units.
2. Secondary Level of Care Given by physicians with Basic Health Training;
given in Health Facilities which are privately owned or government operated such
as infirmaries, municipal and district hospitals and OPD of Provincial Hospitals;
serves as the Referral Center for Primary Health Facilities.
3. Tertiary Level of Care Care rendered by Specialists in Health Facilities
including Medical Centers as well as Regional and Provincial Hospitals and
specialized Hospitals.

PRINCIPLES OF PRIMARY HEALTH CARE

1. 4 As = Accessibility, Availability, Affordability and Acceptability,
Appropriateness of Health Services. The Health Services should be
present where the supposed recipients are. They should make use of the
available resources within the community wherein the focus would be more
on health promotion and prevention of illness.
2. Community Participation = Heart and Soul of Primary Health Care.
3. People are the center, object and subject of development =
- Thus, the success of any undertaking that aims at serving the people is
dependent on peoples participation at all levels of decision - making;
planning, implementing, monitoring and evaluating. Any undertaking must
also be based on the peoples needs and problems ( PCF, 1990 ).
- Part of the peoples participation is the partnership between the
community and the agencies found in the community; social mobilization
and decentralization.
- In general, health work should start from where the people are and
building on what they have. Example: Scheduling of Barangay Health
Workers in the Health Centers.

Barriers of COMMUNITY INVOLVEMENT

- Lack of motivation
- Attitude
- Resistance to change
- Dependence on the part of community people
- Lack of managerial skills
4. SELF RELIANCE

5. Partnership between the community and the health agencies in the

provision of quality of life = Providing linkages between the government and the
non government organization and peoples organization.

6. Recognition of interrelationship between the health and development =

HEALTH
- is not merely the absence of disease. Neither it is only a state of physical and
mental well being.
- Health being a soical phenomenon recognizes the interplay of political, socio
cultural and economic factors as its determinant.
- Good Health therefore, is manifested by the progressive improvements in the
living conditions and quality of life enjoyed by the community residents (PCF,
DEVELOPMENT is the quest for an improved quality of life for all.
-Development is mulit dimentional. It has a political, social, cultural, institutional
and environmental dimensions ( Gonzales 1994 ). Therefore, it is measured by the
ability of people to satisfy their basic needs.

7. SOCIAL MOBILIZATION =
- It enhances people participation or governance, support system provided by the
Government, networking and developing secondary leaders.

8. DECENTRALIZATION

Strategies of PRIMARY HEALTH CARE

1. Reorientation and reorganization of the national health care system.
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.
5. Organization of communities.
6. Increase opportunities for community participation.
7. Development of intra intersectoral linkages.
8. Emphasizing partnership.

MAJOR STRATEGIES OF PRIMARY HEALTH CARE

A. ELEVATING HEALTH TO A COMPREHENSIVE AND SUSTAINED NATIONAL
EFFORT
- Attaining Health for all Filipino will require expanding participation in health and
health related programs whether as service provider or beneficiary. Empowerment
to parents, families and communities to make decisions of their health is really the
desired outcome.
- Advocacy must be directed to National and Local policy making to elicit support
and commitment to major health concerns through legislations, budgetary and
logistical considerations.
B. PROMOTING AND SUPPORTING COMMUNITY MANAGED HEALTH CARE
- The Health in the hands of the people brings the government closest to the
people. It necessitates a process of capacity builiding of communities and
organization to plan, implement and evaluate health prgrams at their levels.
C. INCREASING EFFICIENCIES IN THE HEALTH SECTOR
- Using appropriate technology will make services and resources required for their
delivery, effective, affordable, accessible and culturally acceptable. The
development of human resources must correspond to the actual needs of the
nation and the policies it upholds such as PHC. The DOH will continue to support
and assist both public and private institutions particularly in faculty development,
enhancement of relevant curricula and development of standard teaching
materials.
D. ADVANCING ESSENTIAL NATIONAL HEALTH RESEARCH
-Essential National Health Research ( ENHR ) is an integrated strategy for
organizing and managing research using intersectoral, multi disciplinary and
scientific approach to health programming and delivery.

Translated into action, the PHC APPROACH focuses on:

Partnership with the community
Equitable distribution of health resources
Organized and appropriate health system infrastructure
Prevention of disease and promotion of health as focus
Linked multisectorally
Emphasis on appropriate technology

*PHC as a service delivery policy of the DOH permeates all strategies and thrusts
of government health programs from the national to the local and community
levels
Dimension Commercialized Primary Health Care
Health Care
Goal Absence of disease Prevention of disease
for the individual Socio-economic
development
Focus of Sick Sick and well
Care individuals
 Setting for Hospital-based Satellite Health
Services Urban-Centered Centers
Community Health
Accessible only to a Centers
few people Rural-Based
Accessible to all
People Passive recipients of Active participants in
health care health care
Structure Health is isolated Inter- and intra-
from other sectors of sectoral linkaging
society allows health to be
integrated with over-
all socio-economic
development efforts
Process Decision-making from Decision-making from
top-down bottom-top
Technology Curative services Promotive and
based on modern preventive services
medicine and blend traditional
sophisticated medicine with modern
technology medicine
Physician dominated Appropriate
technology for
frontline health care
Outcome Reliance on health People empowerment
professionals or self-reliance

FOUR CORNERSTONES/PILLARS IN PRIMARY HEALTH CARE

1. Active community participation
2. Intra Intersectoral linkages
3. Use of appropriate technology
4. Support mechanism made available

HERBAL MEDICINES ENDORSED BY THE DEPARTMENT OF HEALTH

NAME INDICATIONS DOSAGE
1. Five leaf Chaste tree 1. Asthma *Divide the decoction into
LAGUNDI (Vitex negundo) 2. Cough 3 parts:
3. Body Pain -For asthma and cough,
4. Fever drink 1 part 3 times a day.
-For fever and body
pains,drink 1 part every 4
hours.
2. Marsh Mint; 1. Body aches and pain, *Divide decoction into 2
Peppermint e.g., rheumatism, parts and drink 1 part
YERBA BUENA headache, swollen every 3 hours.
(Mentha cordifolia) gums,toothache,
(Clinopodium douglasii) menstrual and gas pain.
3. Blumea camphora 1. Swelling *Divide decoction into 3
SAMBONG (Blumea 2. Inducing diuresis parts and drink 1 parts 3
balsamifera) ( anti urolithiasis ) times a day.
4. TSAANG GUBAT 1. Effective in treating *Drink the warm
(Ehretia microphylla Lam). intestinal motility and decoction. If it persists,
also used as a mouth or if there is no
wash since the leaves of improvement an hour
this shrub has high after drinking the
flouride content. decoction, consult a
doctor.
5. ULASIMANG BATO 1. Effective in fighting *The leaves can be eaten
(Peperomia pellucida). arthritis and gout. fresh (about a cupful) as
-also known as PANSIT- a salad or decocted and
PANSITAN. drunk as tea. For the
Decoction, boil a cup of
clean chopped leaves in 2
cups of water. Boil for 15
to 20 minutes. Strain, let
cool and drink a cup after
meals (3 time a day).
6. Garlic 1. Reduces cholesterol *Eat 6 cloves of garlic
BAWANG (Allium sativum) in the blood and hence, together with meals.
helps control blood
pressure.
(Hypertension,
Hyperlipidemia)
7. Chinese honeysuckle 1. Elimination of *Chew and swallow only
NIYOG NIYOGAN Intestinal worms, dried seeds 2 hours after
(Quisqualis Indica L.) particularly the ascaris dinner according to the
and trichina. following:
ADULTS = 8 -10 seeds
9 12 years old = 6 7
seeds
6 8 years old = 5 6
seeds
4 5 years old = 4 5
seeds
8. Guava 1. ANTISEPTIC (to *For wound cleaning, use
BAYABAS (Psidium clean/disinfect wounds) decoction for washing the
Guajava) 2. Mouth wash infection, wound 2 times a day.
 sore gums and tooth *For tooth decay and
decay. swelling of gums, gargle
with warm decoction 3
times a day.
9. Ringworm bush Treatment of ringworms *Apply the juice on the
AKAPULKO also known and skin fungal affected area 1 to 2 times
as bayabas bayabasan infections. a day.
(Cassia alata) 1. Ring worm *If the person develops
2. Athletes foot an allergy while using the
3. Scabies above preparation,
prepare the following:
= Put 1 cup of chopped
fresh leaves in an earthen
jar. Pour in 2 glasses of
water and cover it.
= Boil the mixture until the
2 glasses of water
originally poured have
been reduced to 1 glass
of water.
= Strain the mixture. Use
it while it is warm.
= Apply the warm
decoction on the affected
area 1 to 2 times a day.
10. Bitter gourd or Bitter 1. Mild Non Insulin *Drink cup of cold or
melon Dependent Diabetes warm decoction 3 times a
AMPALAYA (Momordica Meelitus day after meals.
Charantia) = Lowers Blood Sugar
Levels.

11. Ginger (Zingiber 1. Motion Sickness, sore *An abortifacient if taken

officinale) throat, nausea and in large amounts; should
vomiting, migraine not be used by persons
headaches, arthritis. with cholelithiasis unless
directed by the physician;
may increase the risk of
bleeding when used
concurrently with
anticoagulants and
antiplatelets.
*Chop and Mash a piece
of ginger root, and mix in
 a glass of water.
*Boil the mixture.
*Drink the cold or warm
decoction as needed.

*AC 196 A: Ampalaya was deleted in 10 herbal plants advised by DOH in

October 9, 2003
Reminders on the Use of Herbal Medicine:
1. Avoid the use of insecticides
2. Use a clay pot and remove cover while boiling at low heat.
3. Use only the part being advocated
4. follow accurate dose of suggested preparation.
5. Use only one kind of herbal plant for each type of symptom or sickness.
6. Stop giving the herbal medication in cases of untoward reactions.
7. If signs and symptoms are not relieved after 2-3 doses, consult a doctor.

Policies to abide:
1. Know indications
2. Know parts of plants with therapeutic value: roots, fruits, leaves
3. Know official procedure/preparation
Procedures/Preparations:
a. Decoction
Gather leaves & wash thoroughly, place in a container the washed
leaves & add water
Let it boil without cover to vaporize/steam to release toxic substance
& undesirable taste
Use extracts for washing
b. Poultice
Done by pounding or chewing leaves used by herbolaryo
Example: Akapulko leaves-when pounded, it releases extracts
coming out from the leaves contains enzyme (serves as anti-
inflammatory) then apply on affected skin or spewed it over skin
For treatment of skin diseases
c. Infusion
To prepare a tea (use lipton bag), keep standing for 15 minutes in a
cup of warm water where a brown solution is collected, pectin which
serves as an adsorbent and astringent
Used for diarrhea and for pneumonia so PHN discourages to buy
commercially prepared cough syrup expectorant: Nature of Cough
1) Dry mucolytic liquefy mucus
Example: Carbocisteine, Guafenesin
2) Productive expectorant irritants to the mucus gland
Example: Bromhexine (Bisolvon)
3) Non stop coughing antitussive
Example: Dextromethorpan (Robitussin) contains codeine
 Robitussin AC contains atropine & codeine

d. Juice/Syrup
To prepare a papaya juice, use ripe papaya & mechanically mashed
then put inside a blender & add water
To produce it into a syrup, add sugar then heat to dissolve sugar &
mix it
For problems of constipation
Example: papaya, mango & caimito
e. Cream/Ointment-for topical use
Cream is water based & used for wet skin lesions
Ointment is oil based & used for dry lesions
Example: Akapulko Leaves
start with poultice (pound leaves) to turn it semi-solid
add flour to keep preparation pasty & make it adhere to skin
lesions
to make it into an ointment: add oil (mineral, baby or any oil-
serves as moisturizer) to the prepared cream to keep it lubricated
while being massage on the affected area

Elements/Components of Primary Health Care: E L E M E N T S D A M

*Education For Health
-Is one of the potent methodologies for information dissemination. It promotes the
partnership of both the family members and health workers in the promotion of
health as well as prevention of illness.
*Locally Endemic Disease Prevention and Control
-The control of endemic disease focuses on the prevention of its occurrence to
reduce morbidity rate. Example Malaria Control and Schistosomiasis Control.
*Expanded Program of Immunization
-This program exists to control the occurrence of preventable illnesses especially
of children below 6 years old. Immunizations on poliomyelitis, measles, tetanus,
diphtheria and other preventable disease are given for free by the government and
ongoing program of the DOH.
*Maternal and Child Health and Family Planning
-The mother and child are the most delicate members of the community. So the
protection of the mother and child to illness and other risks would ensure good
health for the community. The goal of Family Planning includes spacing of children
and responsible parenthood.
*Environmental Sanitation and Promotion of Safe Water Supply
-Environmental Sanitation is defined as the study of all factors in the mans
environment, which exercise or may exercise deleterious effect on his well being
and survival.
-Water is a basic need for life and one factor in mans environment. Water is
necessary for the maintenance of healthy lifestyle.
-Safe Water and Sanitation is necessary for basic promotion of health.
*Nutrition and Promotion of Adequate Food Supply
-One basic need of the family is food. And if food is properly prepared then one
may be assured healthy family. There are many food resources found in the
communities but because of knowledge regarding proper food planning,
Malnutrition is one of the problems that we have in the country.
*Treatment of Communicable Diseases and Common Illness
-The diseases spread through direct contact pose a great risk to those who can be
infected. Tuberculosis is one of the communicable diseases continuously occupies
the top ten causes of death. Most communicable diseases are also preventable.
The Government focuses on the prevention, control and treatment of these illness.
*Supply and Proper Use of Essential Drugs and Herbal Medicine
-This focuses on the information campaign on the utilization and acquisition of
drugs.
-In response to this campaign, the GENERIC ACT of the Phiippines is enacted. It
includes the following drugs: Cotrimoxazole, Paracetamol, Amoxycillin, Oresol,
Nifedipine, Rifampicin, INH (isoniazid) and Pyrazinamide, Ethambutol,
Streptomycin, Albendazole,Quinine.
*Dental Health Promotion
*Acces to and Use of Hospitals as Centers of Wellness
*Mental Health Promotion

Functions of the PRIMARY HEALTH NURSING:

1. Management Function
2.Training Function
3.Supervisory Function
4.Health Care Provider Nursing Care Function
5. Health Promotion and Education Function
6. Collaborating and Coordinating Function
7.Research Function

F. Family-based Nursing Services (Family Health Nursing Process)

FAMILY BASED NURSING SERVICES (FAMILY HEALTH NURING PROCESS)
FAMILY HEALTH NURSING

FAMILY Basic unit of society, a primary entity of health care or institution

responsible for the physical, emotional, and social support of its members.
Two Types:
- Family of Orientation
- Family of Procriation

Family Nurse Contact: Definition

- An activity with or on behalf of a particular family or individual.
 - A crucial approach in delivering community health nursing service for the
family.

Family Nurse Contact: Objectives

- Assess health needs and problems of the family;
- Ensure familys understanding and acceptance of their problems;
- Provide the needed support and assistance to the family;
- Develop the individuals and/or familys competence to cope with their
health problems, and;
- Contribute to the personal and social development of the family through
varied health activities.

FAMILY HEALTH NURSING

*Is a special field in nursing in which the family is the unit of care, health as its goal
and nursing as its medium or channel of care.

Family Case Load

*the number and kind of families a nurse handles at any given time.
*variable for cases are added or dropped based on the need for nursing care and
supervision.

FAMILY NURSING PROCESS

*It is a means by which the health care provider addresses the health needs and
problems of the client.
*It is a logical and systematic, way of processing information gathered from
different source and translating into meaningful actions or interventions.

Concept of Family as a Basic Unit of Society

*The Universal Declaration of Human Rights in Article 16 states that the family is
the natural and fundamental unit of society and is entitled to protection both by
society and the State.

STEPS:
1. RELATING
- Establishing a working relationship. Results in positive outcomes such as good
quality of data, partnership in addressing identified health need and problems, and
satisfaction of the nurse and the client.
2. ASSESSMENT
- Data Collection, Data Analysis and Data Interpretation and Problem definition or
Nursing Diagnosis.
TWO TYPES OF ASSESSMENT
a. First Level Assessment Data on status / conditions of family household
members.
 b. Second Level Assessment Data on family assumption of health tasks on
each problem identified in the First Level Assessment.

3. PLANNING
- Determination of how to assist client in resolving concerns related to restoration.
Maintenance or promotion of health.
- Establishment of priorities, set goals / objectives, selects strategies, describe
rationale.
4. IMPLEMENTATION
- The carring out of plan of care by client and nurse, make ongoing assessment,
update / revise plan, document responses.
5. EVALUATION
- A systematic, continuous process of comparing the clients response with written
goal and objective.
-Determines progress and evaluate the implemented intervention as to:
1. Effectiveness
2. Efficiency
3. Adequacy
4. Acceptability
5. Appropriateness

I. NURSING ASSESSMENT
-Involves a set of actions by which the nurse measures the status of the family as
a client, their ability to maintain wellness, prevent and control or resolve problems
in order to achieve health and well being among its members.

Steps in Nursing Assessment

1. Data Collection
- The process of identifying the types or kinds of data needed.
- Specify the methods necessary to collect such data.

Methods of Data Collection

a. Observation is use of all sensory capacities. The familys status can be
inferred from the manifestations of problem areas reflected in the following:
1. Communication and interaction pattern expected, used and tolerated by
family members.
2. Role perceptions / tasks assumptions by each member including
decision making patterns.
3. Conditions in the home and environment
b. Physical Examination is done through inspection, palpation, percussion,
and auscultation.
c. Interview by completing health history for each member. Health history
determines current health status.
 d. Record Review is the review existing records and reports pertinent to the
client / family such as diagnostic reports and immunization records.
e. Laboratory / Diagnostic Tests

5 Types of Date in Family Nursing Assessment (Initial Data Base)

A. Family Structure, Characteristics and Dynamics
1. Members of the household and relationship to the head of the family
2. Demographic data - age, sex, civil status, position in the family
3. Place of residence of each member - whether living with the family or
elsewhere.
4. Type of family structure - e.g. matriarchal or patriarchal, nuclear or
extended
Nuclear
Extended
Three generational
Dyad
Single Parent
Step Parent
Blended or Reconstituted
Single adult living alone
Cohabiting / Living in
No kin
Compound
Gay
Commune

Stages of Family Life Cycle

Newly married couple
Childbearing
Preschool age
Teenage
Launching
Middle aged (empty nest retirement)
Period from retirement to death of both spouses.

*HEALTH TASKS OF THE FAMILY (Freeman, 1981)

1. recognizing interruptions of health or development
2. seeking health care
3. managing health and non-health crises
4. providing nursing care to the sick, disabled and dependent member
of the family
5. maintaining a home environment conducive to good health and
personal development
 6. maintaining a reciprocal relationship with the community and health
institutions

5. Dominant family members in terms of decision-making, especially in

matters of health care.
6. General family relationship / dynamics - presence of any obvious /
readily observable conflict between members; characteristic,
communication / interaction pattern among members.

B. Socio-economic and Cultural Characteristics

1. Income and expenses
a. Occupation, place of work and income of each working member
b. Adequacy to meet basic necessities (food, clothing, shelter)
c. Who makes decisions about money and how it is spent
2. Educational attainment of each member
3. Ethnic background and religious affiliation
4. Significant Others - role(s) they play in family's life
5. Relationship of the family to larger community - Nature and extent of
participation of the family in community activities.

C. Home and Environment

1. Housing
a. Adequacy of living space
b. Sleeping arrangement
c. Presence of breeding or resting sites of vectors of disease (e.g.
mosquitoes, roaches, flies, rodents, etc)
d. Presence of accident hazards
e. Food storage and cooking facilities
f. Water supply - source, ownership, sanitary condition
g. Garbage/ refuse disposal - type, sanitary condition
h. Drainage system - type, sanitary condition
2. Kind of neighborhood, e.g. congested, slum
3. Social and health facilities available
4. Communication and transportation facilities available

D. Health Status of each Family Member

1. Medical and nursing history indicating current or past significant illnesses or
beliefs and practices conducive to health and illness.
2. Nutritional assessment ( specially for vulnerable or risk at-risk
members)
a. Anthropometric data: Measures of nutritional status of children- weight,
height, mid-upper arm circumference.
b. Dietary history specifying quality and quantity of food/ nutrient intake per
day
 c. Eating/feeding habits /practices
3. Developmental assessment of infants, toddlers, and preschoolers -
e.g., Metro Manila Developmental Screening Test (MMDST)
4. Risk factor assessment indicating presence of major and contributing
modifiable risk factors for - e.g. hypertension physical inactivity,
sedentary lifestyle, cigarette/ tobacco smoking, elevated blood lipids/
cholesterol, obesity, diabetes mellitus, inadequate fiber intake, stress,
alcohol drinking and other substance abuse.
5. Physical assessment indicating presence of illness state/s (diagnosed
or undiagnosed by medical practitioners.
6. Results of laboratory / diagnostic and other screening procedures
supportive of assessment findings.

E. Values, Habits, Practices on Health Promotion, Maintenance and Disease

Prevention Such as:
1. Immunization status of family members.
2. Healthy lifestyle practices.
3. Adequacy of :
a. rest and sleep
b. exercise / activities
c. Use of protective measures - e.g. adequate footwear in parasite-
infested areas; use of bednets and protective clothing in malaria and
filariasis endemic areas.
d. Use of relaxation and other stress management activities
4. Use of promotive-preventive health services.

2. Data Analysis
Steps:
1. Sorting of data for broad categories (such as those related with health
status or practices about home and environment).
2. Clustering of related cues to determine relationship among data.
3. Distinguishing relevant from irrelevant data. This will help in deciding what
information is pertinent to the situation at hand and what information is
immaterial.
4. Identifying patterns such as physiologic function, developmental,
nutritional/dietary, coping/adaptation or communication patterns.
5. Compare patterns with norms or standards of health, family functioning
and assumption of health tasks.
6. Interpreting results of comparisons to determine signs and symptoms or
cues of specific wellness state/s, health deficit/s, health threat/s,
foreseeable crises/stress point/s and their underlying causes or associated
factors.
 7. Making conclusions about the reasons for the existence of the health
condition or problem, or risk for non-maintenance of wellness state/s which
can be attributed to non-performance of family tasks.

3. Problem Definition/Nursing Diagnosis

End result of 2 major types of assessment.

*Family Nursing Problem - Stated as an inability to perform specific health task

and the reasons / etiology) why the family cannot perform such task.

Consists of 2 parts: main category of problem (coming from unattained

health task) and specific problems (statement of factors contributory for the
existence of the main problem.
Example: (general): Inability to utilize resources for health care due to lack
of adequate family resources, specifically: (specific)
a. financial resources
b. manpower resources
c. time
The more specific the problem definition, the more useful
is the nursing diagnosis in determining the nursing
intervention. Therefore, as many as three or four levels
of problem definition can be stated.

*Nurses Roles in Family Health Nursing

1. Health Monitor
2. Provider of Care to a sick Family Member
3. Coordinator of Family Services
4. Facilitator
5. Teacher
6. Counselor

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE

*FAMILY STRUCTURE, CHARACTERISTICS, AND DYNAMICS
1. Members of the household and relationship to the head of the family
2. Demographic data age, sex, civil status, position in the family
3. Place of residence of each member whether living with the family or
elsewhere.
4. Type of family structure e.g. matriarchal or patriarchal, nuclear or extended.
5. Dominant family members in terms of decision making, especially in matters
of health care.
6. General family relationship / dynamic presence of any readily observable
conflict between members; characteristics communication patterns among
members.
*SOCIO ECONOMIC AND CULTURAL CHARACTERISTICS
 1. Income and Expenses
Occupation, place of work and income of each working members
Adequacy to meet basic necessities
Who makes decisions about money and how it is spent
2. Educational attainment of each other
3. Ethnic background and religious affiliation
4. Significant Others role(s) they play in familys life
5. Relationship of the family to larger community Nature and extent of
participation of the family in community activities.

*HOME AND ENVIRONMENT

1. Housing
Adequacy of living peace
Sleeping arrangement
Presence of breeding or resting sites of vectors of diseases
Presence of accidents hazards
Food storage and cooking facilities
Water supply source, ownership, portability
Toilet facility type, ownership, sanitary condition
Drainage system type, sanitary condition
2. Kind of neighborhood, e.g. congested, slum, etc.
3. Social and health facilities available
4. Communication and transportation facilities available
*HEALTH STATUS OF EACH FAMILY MEMBER
1. Medical and nursing history indicating current or past significant illnesses or
beliefs and practices conducive to health illness
2. Nutritional assessment
Anthropometric data: Measures of nutritional status of children,
weight, height, mid-upper arm circumference: Risk assessment
measures of obesity: body mass index, waist circumference, waist
hip ratio
Dietary history specifying quality and quantity of food/nutrient intake
per day
Eating/ feeding habits/ practices
3. Developmental assessments of infants, toddlers, and preschoolers e.g.,
Metro Manila
4. Risk factor assessment indicating presence of major and contributing
modifiable risk factors for specific lifestyles, cigarette smoking, elevated blood
lipids, obesity, diabetes mellitus, inadequate fiber intake, stress, alcohol drinking
and other substance abuse
5. Physical assessment indicating presence of illness state/s
6. Results of laboratory/ diagnostic and other screening procedures supportive
of assessment findings
*VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE
AND DISEASE PREVENTION
Examples include:
1. Immunization status of family members
2. Healthy lifestyle practices. Specify.
3. Adequacy of:
rest and sleep
exercise
use of protective measures- e.g. adequate footwear in parasite-
infested areas;
relaxation and other stress management activities
4. Use of promotive-preventive health services

Typology of Nursing Problems in Family Nursing Practice

1. First Level of Assessment process whereby existing potential health

conditions/problems of the family are determined.

a. Presence of Wellness Condition states as potential or readiness

a clinical or nursing judgement about a client in transition from a
specific level of wellness or capability to a higher level.

b. Presence of Health Deficits - Instances of failure in health

maintenance.
A. Illness States, regardless of whether it is diagnosed or undiagnosed by
medical practitioner
B. Failure to thrive/ develop according to normal rate
C. Disability - whether (1) congenital or (2) arising from illness.

c. Presence of Health Threats - Conditions that are conducive to

disease, accident or failure to realize one's health potential.
A. Family history of hereditary condition / disease
B. Threat of cross infection from a communicable disease case
C. Family size beyond what family resources can adequately provide
D. Accident hazards .
1. broken stairs
2. pointed /sharp objects, poisons, & medicines improperly kept
3. fire hazards
4. fall hazards
5. others (specify):________
E. Faulty / unhealthy nutritional / eating habits or feeding techniques /
practices.
1. inadequate food intake both in quality and quantity
2. excessive intake of certain nutrients
 3. faulty eating habits
4. ineffective breastfeeding
5. faulty feeding techniques
F. Stress-provoking factors
1. strained marital relationship
2. strained parent-sibling relationship
3. interpersonal conflicts between family members
4. care-giving burden
G. Poor home / environmental condition/ sanitation
1. inadequate living space
2. lack of food storage facilities
3. polluted water supply
4. presence of breeding or resting sites of vectors of diseases
5. improper garbage / refuse disposal
6. unsanitary waste disposal
7. poor lightning and ventilation
8. noise pollution
9. air pollution
H. Unsanitary food handling and preparation
I. Unhealthy lifestyle and personal habits /practices
1. alcohol drinking
2. cigarette / tobacco smoking
3. walking barefooted or inadequate footwear
4. eating raw meat or fish
5. poor personal hygiene
6. self-medication/ substance abuse
7. sexual promiscuity
8. engaging in dangerous sports
9. inadequate rest or sleep
10. lack of / inadequate exercise / physical activity
11. lack of / inadequate activities
12. non-use of self-protection measures (e.g. non-use of bednets in
Malaria and Filariasis endemic areas)
J. inherent personal characteristics - such as poor impulses control
K. Health history which may precipitate / induce the occurrence of a health
deficit, e.g. previous history of difficult labor.
L. Inappropriate role assumption - e.g. child assuming mother's role, father
not assuming his role
M. Lack of immunization / inadequate immunization status specially of
children
N. Family disunity - e.g. self-oriented behavior of members (s), unresolved
conflicts of members(s), intolerable disagreement
O. Others, specify : _____________
 d. Presence of Stress Points / Foreseeable Crisis - Anticipated periods
of unusual demand on the individual or family in terms of adjustment /
family resources.
A. Marriage
B. Pregnancy, labor, puerperium
C. Parenthood
D. Additional member - e.g. newborn, lodger
E. Abortion
F. Entrance at school
G. Adolescence
H. Divorce or separation
I. Menopause
J. Loss of Job
K. Hospitalization of a family member
L. Death of a Member
M. Resettlement in a new community
N. Illegitimacy
O. Other, Specify ______________

2. Second Level of Assessment defines the nature or type of nursing

problems that the family encounters in performing health.

I. Inability to recognize the presence of the condition or problem due to:

A. Lack of or inadequate knowledge
B. Denial about its existence or severity as a result of fear of
consequences of diagnosis of problem, specifically :
1. social-stigma, loss of respect of peers / significant others
2. economic / cost implications
3. physical consequences
4. emotional / psychological issues / concerns
C. Attitude / philosophy in life which hinders recognition / acceptance of a
problem.
D. Others, specify __________

II. Inability to make decisions with respect to taking appropriate health

action due to:
A. Failure to comprehend the nature/ magnitude of the problem / condition
B. Low salience of the problem / condition
C. Feeling of confusion, helplessness and / or resignation brought by
perceived magnitudes / severity of the situation or problem, i.e., failure
to break down problems into manageable units of attacks
D. Lack of / or inadequate knowledge / insight as to alternative courses of
action to take
E. Inability to decide which action to take among the list of alternatives
 F. Conflicting opinions among family members / significant others
regarding action to take
G. Lack of / or inadequate knowledge of community resources for care
H. Fear of consequence of action, specially:
social consequences
economic consequences
physical / psychological consequences
I. Negative attitude towards the health problem By negative attitude is
meant one that interferes with rational decision making
J. Inaccessibility of appropriate resources for care, specifically:
1. physical inaccessibility
2. cost constraints or economic / financial inaccessibility
K. Lack of trust / confidence in the health personnel / agency
L. Others, specify______________

III. Inability to provide adequate nursing care to sick, disabled, dependent or

vulnerable / at-risk member of the family due to:
A. Lack of / inadequate knowledge about the disease / health condition
(nature, severity, complications, prognosis and management );
B. Lack of / inadequate knowledge about the child development and care;
Lack of / inadequate knowledge of the nature and extent of nursing care
needed;
C. Lack of the necessary facilities, equipment and supplies for care;
D. Lack of or inadequate knowledge and skill in carrying out the necessary
interventions / treatment / procedure / care (e.g., complex therapeutic
regimen or healthy lifestyle program);
E. Inadequate family resources for care, specifically:
Absence of responsible member
Financial constraints
Limitations / lack of physical resources e.g. isolation room
F. Significant persons unexpressed feelings (e.g. hostility / anger, guilt,
fear / anxiety, despair, rejection) which disable his / her capacities to
provide care.
G. Philosophy in life which negates / hinder caring the sick, disabled,
dependent, vulnerable / At risk member
H. Members preoccupation with own concerns / interests
I. Prolonged disease or disability progression which exhausts supportive
capacity of family members
J. Altered role performance specify :
a. role denial or ambivalence
b. role strain
c. role dissatisfaction
d. role conflict
e. role confusion
 f. role overload
K. Others, specify _________________

IV. Inability to provide a home environment conducive to health maintenance

and personal development due to :
A. Inadequate family resources, specifically:
a. financial constraints / limited financial resources
b. limited physical resources e.g. lack of space to construct facility
B. Failure to see benefits (specifically long-term ones) of investment in
home environment improvement
C. Lack of / inadequate knowledge of importance of hygiene and sanitation
D. Lack of / inadequate knowledge of preventive measures
E. Lack of skill in carrying out measures to improve home environment
F. Ineffective communication patterns within the family
G. Lack of supportive relationship among family members
H. Negative attitude / philosophy in life which is not conducive to health
maintenance and personal development
I. Lack of / inadequate competencies in relating to each other for mutual
growth and maturation (e.g. reduced ability to meet the physical and
psychological needs of other members as a result of
J. familys preoccupation with current problem or condition)
K. Others, specify --------------------------

V. Failure to utilize community resources for health care due to :

A. Lack of / inadequate knowledge of community resources for health care
B. Failure to perceive the benefits of health care / services
C. Lack of trust / confidence in the agency / personnel
D. Previous unpleasant experience with health worker
E. Fear of consequences of action (preventive, diagnostic, therapeutic.
Rehabilitative ), specifically :
a. physical / psychological consequences
b. financial consequences
c. social consequences e.g. , loss of esteem of peer / significant
others
F. Unavailability of required care / service
G. Inaccessibility of required care / service due to:
a. cost constraints
b. physical inaccessibility, i.e. location of facility
H. Lack of or inadequate family resources, specifically ;
a. manpower resources e.g. baby sitter
b. financial resources e.g., cost of medicine prescribed
I. Feeling of alienation to / lack of support from the community, e.g.,
stigma due to mental illness, AIDS, etc.
 J. Negative attitude / philosophy in life which hinders effective / maximum
utilization of community resources for health care
K. Others, specify----------------

II. PLANNING
- The step in the process which answers the following questions:
*What is to be done?
*How is to be done?
*When it is to be done?
-It is actually the phase wherein the health care provider formulates a care plan.

Steps in developing a Family Nursing Care Plan

1. Prioritized problems
2. Goals and Objectives of the Nursing Care
3. Plan of Intervention
4. Plan for Evaluating Care.

Prioritizing Health Problems

1. Nature of the Problem Presented - Categorized into wellness state, health
threat, health deficit and foreseeable crisis.

2. Modifiability of the Problem/Condition - Refers to the probability of

success in enhancing, improving, minimizing, alleviating or totally
eradicating the problem through intervention.

3. Preventive Potentials - Refers to the nature and magnitude of future

problems that can be minimized or totally prevented if intervention is done
on the problem under consideration.

4. Salience - Refers to the family's perception and evaluation of the problem

in terms of seriousness and urgency of attention needed or family
readiness.
Scoring
1. Decide a score for each of the criteria
2. divide the score by the highest possible & multiply by the weight
Score x weight
Highest score
3. Sum up the score of all criteria. The highest score is 5 equivalent to the total
weight.

CRITERIA Weight
1. Nature of the problems Presented 1
Scale:
-Health deficit / Wellness 3
-Health threat 2
-Foreseeable crisis 1
2. Modifiability of the problem 2
Scale:
-Easily modifiable 2
-Partially modifiable 1
-Not modifiable 0
3. Preventive potential 1
Scale:
-High 3
-Moderate 2
-Low 1
4. Salience 1
Salience:
-A condition / problem needing Immediate 2
attention
*A condition / problem not needing 1
Immediate attention
*Not perceived as a problem or condition 0
needing change.

Factors affecting priority setting:

The nurse considers the availability of the following in determining the modifiability
of a health condition or problem.
1. Current Knowledge, Technology and Interventions
2. Resources of the family Physical, Financial and Manpower
3. Resources of the nurse Knowledge, Skills and Time
4. Resources of the Community Facilities and Community organization or
support.

Factors in Deciding Appropriate Score for Preventive Potential

1. Gravity or severity of the problem - Refers to the progress of the disease/
problem indicating extent of damage on the patient / family. Also indicates the
prognosis, reversibility of the problem
2. Duration of the problem - refers to the length of time the problem has been
existing
3. Current Management - refers to the presence and appropriateness of
intervention
4. Exposure of any high risk group

Family Nursing Care Plan

* It is the blueprint of care that the nurse designs to systematically minimize or
eliminate the identified family health problem through explicitly formulated
outcomes of care (goal and objectives) and deliberately chosen set of
interventions/resources and evaluation criteria, standards, methods and tools.

Characteristics of Family Nursing Care Plan

1. It focuses on actions which are designed to solve or alleviate & existing
problem.
2. It is a product of deliberate systematic process.
3. The FNCP as with other plans relates to the future.
4. It revolves around identified health problems.
5. It is a mean to an end and not a end to itself.
6. It is a continuous process, not one shot deal.

Desirable Qualities of Family Nursing Care Plan

1. It should be based on a clear definition of the problem.
2. A good plan is realistic, meaning it can be implemented with reasonable chance
of success
3. It should be consistent with the goals and philosophy of the health agency.
4. Its drawn with the family.
5. Its best kept in written form.

Setting/ Formulating Goals & Objectives

This will set direction of the plan.
This should be stated in terms of client outcomes whether at the individual,
family or community level.
The mutual setting of goals which is the cornerstone of effective planning
consists of:
1. Identifying possible resources.
2. Delineating alternative approaches to meet goals.
3. Selecting specific interventions.
4. Operationalizing the plan - setting of priorities.

Goal
* It is a general statement of the condition or state to be brought about by
specific courses of action.

Cardinal Principle in Goal setting

* It must be set jointly with the family. This ensures family commitment to
their realization.
* Basic to the establishment of mutually acceptable goal in the familys
recognition and acceptance of existing health needs and problems.

Barriers to Joint Goal Setting

 1. Failure in the part of the family to perceive the existence of the problem.
2. Sometimes the family perceives the existence of the problem but does not
see it as serious enough to warrant attention.

Characteristics of Goals/ Objectives

1. Specific
2. Measurable
3. Attainable
4. Realistic
5. Time bound

Objective
Refers to a more specific statement of desired outcome of care.
They specify the criteria by which the degree of effectiveness of care is to
be measured.

Types of Objective
1. Short term or Immediate Objective
Formulated for problem situation which require immediate attention &
results can be observed in a relatively short period of time.
They are accomplished with few HCP-family contacts & relatively less
resources.
2. Medium or Intermediate objective
Objectives which is not immediately achieved & is required to attain the
long ones.
3. Long Term or Ultimate Objective
This requires several HCP-family contacts & an investment of more
resources.

Plan of Actions/ Interventions

Its aim is to minimize all the possible reasons for causes of the familys
inability to do certain tasks.

It is highly dependent on 2 Major Variables:

1. nature of the problem
2. the resources available to solve the problem

Typology of Interventions
1. Supplemental - the HCP is the direct provider of care.
2. Facilitative - HCP removes barriers to needed services.
3. Developmental - improves clients capacity.

III. Implementation
 Actual doing of interventions to solve health problems.

IV. Evaluation
Determination whether goals / objectives are met.
Determination whether nursing care rendered to the family are effective.
Determines the resolution of the problem or the need to reassess, and
re-plan and re-implement nursing interventions.

According to Alfaro-LeFevre:

Evaluation is being applied through the steps of the nursing process:

Assessment changes in health status.

Diagnosis if identified family nursing problems were resolved,
improved or controlled.
Planning are the interventions appropriate & adequate enough to
resolve identified problems.
Implementation determine how the plan was implemented, what
factors aid in the success and determine barriers to the care.

Types of Evaluation:
On-going Evaluation analysis during the implementation of the activity,
its relevance, efficiency and effectiveness.

Terminal Evaluation undertaken 6-12 months after the care was

completed.

Ex-post Evaluation undertaken years after the care was provided

Steps in Evaluation:
1. Decide what to Evaluate.
Determine relevance, progress, effectiveness, impact and efficiency
2. Design the Evaluation Plan
Quantitative a quantifiable means of evaluation which can be done
through numerical counting of the evaluation source.
Qualitative descriptive transcription of the outcome conducted
through interview to acquire an in-depth understanding of the
outcome.
3. Collect Relevant Data that will support the outcome
4. Analyze Data - What does the data mean?
5. Make Decisions
If interventions are effective, interventions done can be applied to
other client / group with the similar circumstances
If ineffective, give recommendations
 6. Report / Give Feedbacks

Dimensions of Evaluation
1. Effectiveness focused on the attainment of the objectives.
2. Efficiency related to cost whether in terms on money, effort or
materials.
3. Appropriateness refer its ability to solve or correct the existing
problem, a question which involves professional judgment.
4. Adequacy pertains to its comprehensiveness.

Tools Being used during Evaluation

Instruments are tools are being used to evaluate the outcome of the
nursing interventions:

Thermometer
Tape measure
Ruler
BP apparatus
Weighing scale
Checklist
Key Guide Questionnaires
Return Demonstrations

Methods of Evaluation
1. Direct observation
2. Records review
3. Review of questionnaire
4. Simulation exercises
1.1 Family Based Nursing Services (Family Health Nursing Process)
Nursing Assessment of Family:
First Level Assessment:
1. Family structure, characteristics and dynamics
2. Socio-economic and cultural characteristics
3. Home and environment
4. Health status of each member
5. Values and practices on health promotion/maintenance
and disease prevention
Second Level Assessment data include those that specify or describe the
familys realities, perceptions about and attitudes related to the assumption or
performance of family health tasks on each health condition or problem
identified during the first level assessment.
Developing the Nursing Care Plan
 Steps in developing a family care plan:
1. The prioritized condition/s or problems
2. The goals and objectives of nursing care
3. The plan of interventions
4. The plan for evaluating care
Implementing the Nursing Care Plan
During this phase the nurse encounters the realities in family nursing practice
which can motivate her to try out creative innovations or overwhelm her to
frustration or inaction. As the nurse practitioner works with clients she
experiences varying degrees of demands on her resources. A dynamic attitude
on personal and professional development is, therefore, necessary if she has
to face up to challenges of nursing practice.
Evaluation of Family Health Services.

G. Population Group-based Nursing Services

POPULATION FOCUSED APPROACH
- Concentrates on specific groups of people and focuses on health promotion and
disease prevention, regardless of geographical location (Baldwin et al, 1998).
- In short (Minesota Department of Health, 2003)
*Focuses on the entire population
*Is based on assessment of the population health status.
*Considers broad determinants of health.
*Emphasizes all levels of prevention.
*Intervenes with communities, systems, individuals and families.

GOAL: To promote Healthy Communities

*A population focused involves concern for those who do, and for those who do
not receive health services (social jusctice)
*SCIENTIFIC APPROACH AND POPULATION FOCUS =
1. Epidemiology 2. Information about the community.

H. Community-based Nursing Services/ Community Health Nursing Process

COMMUNITY HEALTH NURSING PROCESS
1. Assessment/Diagnosis
- assessment: purpose is to identify the health needs of the people.
a. Collection of data ( subjective: expressed by client or;
objective: measurable- interview & observations, senses)
b. Categories of health problems

2. Planning
- purpose is to act on determined needs of the community people.

3. Implementation
- purpose is to achieve the optimum level of health of the community people.
4. Evaluation-
- to determine the effectiveness of health care programs.
3 elements : structural , process & measurable outcome or objective

4 Tools/ Instruments for Data Collection:

1. Nursing history subjective
2. PE- Objective
3. Lab- Objective
4. Process recording- objective (analyzed by RN)

NURSING PROCEDURES
Clinic visit
- patient visits the Health center to avail of the services there to offered by the
facility primarily for consultation on matters that ailed them physically.
-Process of checking the clients health condition in a medical clinic.

PURPOSE: (C.U.R.E)
-Consult about signs and symptoms of illness.
-Utilize service of a health agency.
-Render some treatment procedures.
-Evaluate through some diagnostic procedures

PRE CONSULTATION CONFERENCE (CuTe PaLa We?)

-Take Clinical History after greeting and making client at ease.
-Take Temperature, BP, Height, Weight.
-Perform a through Physical Assessment
-Do Selective Laboratory Exams: Urinalysis, Sputum Exam, Fecalysis.
-Write Findings on clients record.

MEDICAL EXAMINATION (A IWan PO!)

-Assist before, during and after exam by Physician.
-Inform Physician of relevant findings.
-Work with Physician during Exam.
-Ensure Privacy, safety and comfort of patient.
-Observe Confidentiality of Exam result.

POST CONSULTATION CONFERENCE (E..R.A)

-Explain Findings and needed care or intervention.
-Refer patient to other health agency in necessary.
-Make Appointment for next client or home visit.

Standard procedures performed during clinic visits:

I. Registration/ Admission
1. Greet client and establish rapport
2. Prepare the family record or retrieve records of old clients
 3. Elicit and record the clients chief complaint and clinical history
4. Perform physical examination on the client and record it accordingly

II. Waiting time

1. Give priority numbers to clients
2. Implement the first come, first served policy except for emergency
cases

III. Triaging
1. Manage program-based cases (like the IMCI)
2. Refer all non-program based cases to the physician
3. Provide first aid treatment to emergency cases and refer to the next
level when necessary

IV. Clinical evaluation

1. Validate clinical history and physical exam
2. Nurse arrives at evidence-based diagnosis and provides rational
treatment based on DOH programs
3. Inform the client on the nature of the illness, appropriate treatment and
prevention and control measures

V. Laboratory and other diagnostic examinations

1. Identify a designated referral laboratory when needed

VI. Referral system

1. Refer patient if he needs further management following the 2-way
referral system
2. Accompany the patient when an emergency referral is needed

VII. Prescription/dispensing
1. Give proper instructions on drug intake

VIII. Health education

1. Conduct one-on-one counseling with the patient
2. Reinforce health education and counseling messages
3. Give appointments for the next visit

Blood pressure measurement

Procedure:
1. Preparatory phase
Introduce self to client
Make sure client is relaxed and has rested for at least 5 minutes
Explain the procedure
Assist to a seated or supine position
 2. Applying the BP cuff and stethoscope
Bare clients arm
Apply cuff around upper arm 2-3 cm above brachial artery
Keep manometer at eye level
Keep arm level with his heart by placing it on a table or a chair arm or by
supporting it
Palpate brachial pulse correctly just below or slightly medial to the
antecubital area

3. Obtaining the BP reading by using palpatory method

While palpating the brachial or radial pulse, close valve or pressure bulb
and inflate cuff until pulse disappears
Note point at which pulse disappeared palpated systolic BP
Deflate cuff fully
Wait 1-2 minutes before inflating cuff again

Obtaining the BP reading by auscultation

Place earpieces of stethoscope in ears and stethoscope head over the
brachial pulse
Use the bell of the stethoscope to auscultate pulse
Watching the manometer, inflate the cuff rapidly by pumping the bulb until
the column reaches 30 mmHg above the palpatd SBP
Deflate the cuff slowly at a rate of 2-3 mmHg per beat
While the cuff is deflating, listen for pulse sounds (Korotkoff sounds) (1 st
clear tapping sound Systolic BP and disappearance of sound Diastolic
BP

4. Recording BP and other guidelines

For every visit, take the mean of 2 reading, obtained at least 2 minutes
apart
If first visit, repeat procedure with other arm. Subsequent BP readings
should be performed on the arm, with a higher BP reading

Home visit
- family nurse contact which allows the health worker to assess the home and
family situations in order to provide the necessary nursing care and health related
activities.
- a professional face to face contact made by the nurse with a patient or the
family to provide necessary health care activities and to further attain the
objectives of the agency.
-PRIORITY during HOME VISITS: Newborn (First), Post-Partum, Pregnant
Mother, Morbid Individual (Last).

Purpose of Home Visit:

1. To give nursing care to the clients
 2. To assess living conditions of the patient and his family and their health
practices
3. To give health teachings regarding prevention and control of diseases
4. To establish close relationships between the health agencies and the public
5. To make use of the inter-referral system and to promote the utilization of
community services

Principles involve in Preparing for a Home visit:

1. Must have a purpose or objective
2. Should make use of all available information about a patient
3. Should consider and give priority to needs of clients
4. Should involve the clients
5. Should be flexible

Guidelines to consider regarding the Frequency of Home Visits

1. Needs of the client (Physical, Psychological, and Educational needs)
2. Acceptance of the family
3. Policy of a specific agency
4. Other health agencies and personnel involved in care of family
5. Past services given to families
6. Ability of clients to recognize own needs

Steps in conducting home visits

1. Greet the patient and introduce yourself
2. State the purpose of the visit
3. Observe the patient and determine the health needs
4. Put the bag in a convenient place then proceed to perform the bag
technique
5. Perform nursing care needed and give health teachings
6. Record all important data, observation and care rendered
7. Make an appointment for a return visit

Bag Technique: tool by which the nurse, during her visit will enable her to perform
a nursing procedure with ease and deftness, to save time and effort
- a tool making of the public health bag through which the nurse during the home
visit can perform nursing procedures with ease and deftness saving time and effort
with the end in view of rendering effective nursing care.

*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:

1. Minimize, if not prevent the spread of infection
2. Saves time and effort of the nurse
3. Should show effectiveness of total care given to an individual or family
4. Can be performed in a variety of ways
Important points to consider in the use of the bag technique: HANDWASING
1. The bag should contain all necessary articles, supplies and equipments that
will be used
2. The bag and its contents should be cleaned very often, supplies replaced
and ready for use anytime
3. The bag and its contents should be well-protected from contact with any
article in the patients home.
4. The arrangement of the contents of the bag should be the one most
convenient for the user, to facilitate efficiency and avoid confusion.

-Contents of the BAG:

*BP Apparatus , Stethoscope and umbrella are carried separately
*Medicines include: Betadine, 70% alcohol, Benedicts solution

SOLUTION:
1. Benedicts Solution For sugar detection
2. Acetic Acid For Albumin Detection
3. Zephiram Solution Soaking Solution
4. Alcohol, Betadine
5. Ammonia
-Placed waste paper bag outside of work area to prevent contamination of clean
area.
-RATIONALE IN THE USE OF PHN BAG :
*Technique during home visit
- It helps render effective nursing care.

Nursing care in the Home

- giving to the individual patient the nursing care required by his / her specific
illness or trauma to help him / her reach a level of functioning at which he / she
can maintain himself / herself or die peacefully in dignity.

Principles in Nursing Care:

1. Nursing care utilizes a medical plan of care and treatment
2. Performance of nursing care utilizes skills that would give maximum comfort
and security to the individual
3. Nursing care given at home should be used as a teaching opportunity to the
patient or to any responsible member of the family
4. Performance of nursing care should recognize dangers in the patients over-
prolonged acceptance of support and comfort
5. Nursing care is a good opportunity for detecting abnormal signs and
symptoms, observing patients attitude towards care given and the progress
of the patient

Isolation technique in the home

Done by:
1. Separating the articles used by a client with communicable disease to prevent
the spread of infection:
2. Frequent washing and airing of beddings and other articles and disinfections of
room.
3. Wearing a protective gown, to be used only within the room of the sick member.
4. Discarding properly all nasal and throat discharges of any member sick with
communicable disease.
5. Burning all soiled articles if could be or contaminated articles be boiled first in
water 30 minutes before laundering.

Intravenous Therapy
- Insertion of a needle or catheter into a vein to provide medication and fluids
based on physicians written prescription
- Can be done only by nurses accredited by ANSAP(Association of Nursing
Service Administration of the Philippine.)
- INDICATIONS:
*Maintenance /Correction of dehydration in patient unable to tolerate adequate
volume of oral fluid medications
*Parenteral Nutrition
*Administration of Drugs
*Blood Transfusion
- CONTRAINDICATIONS:
*Administration of irritant fluids / drugs through peripheral access (e.g., Sodium
Chloride, Hypertonic Potassium Chloride).

Specimen Collection
-URINE Sterile Bottle, Midstream Collection
-FECES Clean Container, Small amount of feces only.
-SPUTUM NPO midnight first collection early AM then submit at the health
center immediately, then second collection following day early in the AM then
submit at the health center then collect the third sputum; instruct the patient to take
a deep breath four times then cough out.

PRINCIPLES OF HEALTH EDUCATION

-It considers the health status of the people, which is determined by the economic
and social conscience of the country.
-It is a process whereby people learn to improve their personal habits and
attitudes, to work responsibly for the improvement of health conditions of the
family, community, and nation.
-It involves motivation, experience, and change in conduct and thinking, while
stimulating active interest. It develops and provides experience for change in
peoples attitudes, customs, and habits in relation to health and everyday living.
-It should be recognized as the basic function of all health workers.
-It takes place in the home, in the school, and in the community.
-It is a cooperative effort requiring all categories of health personnel to work
together in close teamwork with families, groups, and the community.
-It meets the needs, interests, and problems of the people affected.
-It finds means and ways of carrying out plans by encouraging individual and
community participation.
-It is a slow, continuous process that involves constant changes and revisions until
objectives are achieved.
-Makes use of supplementary aids and devices to help with the verbal instructions.
-It utilizes community resources by careful evaluation of the different services and
resources found in the community.
-It is a creative process requiring methods and techniques with various
characteristics, not following a rigid and flexible pattern.
-It aims to help people make use of their own efforts and education to improve
their conditions of living.
-It makes careful evaluation of the planning, organization, and implementation of
all health education programs and activites.

THE COMMUNITY HEALTH NURSE

QUALIFICATIONS
1. BSN
2. RN of the Philippines

PLANNER / PROGRAMMER
1. Identifies needs, priorities, and problems of individuals, families, and
communities.
2. Formulates municipal health plan in the absence of medical doctor
3. Interprets and implements nursing plan, program policies, memoranda, and
circular for the concerned staff personnel.
4. Provides technical assistance to rural health midwives in health matters.

PROVIDER OF NURSING CARE

1. Provides direct nursing care to sick or disabled in the home, clinic, school, or
workplace.
2. Develops the familys capability to take care of the sick, disabled, or dependent
member.

MANAGER / SUPERVISOR
1. Formulates individual, family, group, and community centered plan.
2. Interprets and implements programs, policies, memoranda, and circulars.
3. Organizes work force, resources, equipment, and supplies at local level.
4. Provides technical and administrative support to Rural Health Midwives (RHM)
5. Conducts regular supervisory visits and meetings to different RHMs and gives
feedback on accomplishments.

COMMUNITY ORGANIZER
1. Motivates and enhances community participation in terms of planning,
organizing, implementing, and evaluating health services
2. Initiates and participates in community development activities.
COORDINATOR OF SERVICES
1. Coordinates with individuals, families, and groups for health related services
provided by various members of the health team.
2. Coordinates nursing program with other health programs like environmental
sanitation, health education, dental health, and mental health.

TRAINER / HEALTH EDUCATOR

1. Identifies and interprets training needs of the RHMs, Barangay Health Workers
(BHW), and hilots.
2. Conducts training for RHMs and hilots on promotion and disease prevention
3. Conducts pre and post consultation conferences for clinic clients; acts as a
resources speaker on health and health related services.
4. Initiates the use of tri media (radio / TV, cinema plug, and print ads ) for health
education purposes.
5. Conducts pre marital counseling.

HEALTH MONITOR
1. Detects deviation from health of individuals, families, groups, and communities
through contracts / visits with them.

ROLE MODEL
1. Provides good example of healthful living to the members of the community.

CHANGE AGENT
1. Motivates changes in health behavior in individuals, families, groups, and
communities that also include lifestyle in order to promote and maintain health.

RECORDER / REPORTER / STATISTICIAN

1. Prepares and submits required reports and records.
2. Maintain adequate, accurate, and complete recording and reporting.
3. Reviews, validates, consolidates, analyzes, and interprets all records and
reports.
4. Prepares statistical data / chart and other data presentation.

RESEARCHER
1. Participates in the conduct of survey studies and researches on nursing and
health related subjects.
2. Coordinates with government and non government organization in the
implementation of studies / research.

CHN NOTES:
1. Primary Goal in CHN Self-reliance in health
2. Ultimate Goal in CHN Raise the level of health of the citizenry
3. Unit of care - Family
4. Levels of Clientele Individual, Family, Special Population & Community
5. Primary Focus Health Promotion & Disease Prevention
6. Philosophy Of CHN Uphold the worth & dignity of man
7. Theoretical Bases of CHN Practice Theories & Principles of Nursing & Public
Health
8. CHN as : People-oriented, comprehensive & integrated, focus on
health

I. Community Organizing
COMMUNITY ORGANIZING
Maglaya DOH
Preparatory Phase Community Analysis
Organizational Phase Design and Initiation
Education and training Implementation
Collaboration Phase Program Maintenance
Consolidation
Phase Out Dissemination Reassessment

COMMUNITY ORGANIZING a continuous and sustained (i.e. never-ending)

process of awareness-raising, organizing, and mobilizing. Awareness primary
motivation to action
Basic Concepts and Principles
Based on concrete analysis of actual situation
Basic trust on the people
By, for, with, and among the people
Anyone is capable of change
Self-willed changes have more meaning than imposed ones

Context of Community Organizing (CO): Current situation

towards the poor, deprived, oppressed (i.e. not all) but
struggling segments of the society

Goal of Community Organizing (CO): Community Development the creation of

a society that provides equal access to all benefits and opportunities the society
can offer to the people

Application of CO in Health: PRIMARY HEALTH CARE

PRIMARY HEALTH CARE
- Essential care (i.e. not alternative)
- Based on scientifically sound and socially acceptable methods and technology
- Made universally available to individuals, families, and communities
- At a cost they can afford at any given stage of their development
- Through their full participation
- Towards self- reliance and self-determination

Major Pillars of Primary Health Care

a. Multi-sectoral approach (inter- and intra-sectoral linkages)
b. Peoples participation
Partnership or shared leadership; minimum level of peoples participation
COMMUNITY ORGANIZING IN HEALTH

Two types of community:

a. Organized community with peoples organization
b. Virgin community without peoples organization

Phases of CO:
1. SOCIAL INVESTIGATION
Preliminary Investigation
- done before entry to community
- secondary data sources are utilized
- baseline information from secondary data sources (e.g. Records
Review)
Deepening Social Investigation
- continuous appraisal of community situation through primary data
sources
2. ENTRY low-key or low-profile approach
Upon entry, start the following:
a. Deepening Social Investigation
b. Social Preparation
c. Community Integration
3. SOCIAL PREPARATION tampering the grounds for setting up health
programs

Target: community leaders

- Establish rapport, develop trust, clarify intentions and
expectations
- Starts upon entry, ends with launching
Methods: courtesy call and attendance to meetings
4. COMMUNITY INTEGRATION imbibing the community way of life
Target: community
- Deepen rapport, develop mutual trust, draw objectives
Methods: house-to-house, going to places where people are, direct participation
in the production process (best method)
5. SMALL GROUP FORMATION
- cluster of 8-15 households
 - manageable units
- data processing of community diagnosis is being done
6. ELECTION OF CHWs
7. LAUNCHING social preparation ends
8. COMMUNITY DIAGNOSIS
Outcome: Problems and needs of the people
9. TRAINING AND SERVICES
Advanced community health workers have the leadership traits
10. CORE GROUP FORMATION
- Group of advanced CHWs
11. PHASE OUT so that people can practice self-reliance
- Provide opportunity for the health workers to stand on their own
Indicator of Phase-out: Advanced CHWs are able to assume staff level
functions

COMMUNITY ORGANIZING PROCESS (COPAR)

PRE-ENTRY
1. Site selection
2. Preliminary Social Investigation
ENTRY
1. Social preparation
2. Community integration
3. Deepening social investigation
ORGANIZATION FORMATION PHASE
1. Small group formation
2. Election of CHW (women; middle-aged; married)
3. Organizational meetings - to clarify matters
TRAINING PHASE
1. Training needs assessment COMMUNITY DIAGNOSIS
2. Curriculum development based on problems identified
3. Actual training
4. Training evaluation
SERVICES PHASE
1. Community clinics
2. Other services
LEADERSHIP FORMATION PHASE
1. Core group formation
2. Advanced training
CONSOLIDATION PHASE
1. Evaluation session
2. Staff development
SUSTENANCE AND MAINTENANCE PHASE
1. Endorsement to sectoral organizing
 2. Formation of regional coordinating bodies

1. Community analysisThe process of assessing and defining needs,

opportunities and resources involved in initiating community health action
program. This process may be referred to as community diagnosis, community
needs assessment, health education planning, and mapping.

5 components
Demographic, social and economic profile of the community
derived from secondary data
Health risk profile
Health/wellness outcome profile
Survey of current health promotion programs
Studies conducted in certain target groups
Steps in community analysis
Define the community - Determine the geographic boundaries of the
target community. This is usually done in consultation with representatives of
the various sectors.
Collect data As earlier mentioned, several types of data have to
be collected and analyzed.
Assess community capacity This entails and evaluation of the
driving forces which may facilitate or impede the advocated
change. Current programs have to be assessed including the
potential of the various types of leaders/influential, organization
and programs.
Assess community barriers Are there features of the new
program which run counter to existing customs and traditions? Is
the community resilient to change?
Assess readiness for change _ Data gathered will help in the
assessment of community interest, their perception on the
importance of the problem.
Synthesis of data and set priorities This will provide a
community profile of the needs and resources, and will become
the basis for designing prospective community interventions for
health promotion.

2. Design and initiation

In designing and initiating interventions the following should be done:
Establish a core planning group and select a local organizer -
Five to eight committed members of the community may be
selected to do the planning and management of the program.
Choose an organizational structure - There are several
 organization structures which can be utilized to activate
community participation. These include the following:
Leadership board or council existing local leaders working for
a common cause
Coalition linking organizations and groups to work on
community issues.
Lead or official agency a single agency takes the primary
responsibility of a liaison for health promotion activities in the
community.
Grass-roots informal structures in the community like the
neighborhood residents.
Citizen panels a group of citizens (5-10) emerge to form a
partnership with a government agency
Networks and consortia Network develop because of certain
concerns.
Identify, select and recruit organizational members - As much as
possible, different groups, organizations sectors should be
represented. Chosen representative have power for the groups
they represent.
Define the organization mission and goals - This will specify the
what, who, where, when and extent of the organizational
objectives.
Clarify roles and responsibilities of people involved in the
organization - This is done to establish a smooth working
relationship and avoid overlapping of responsibilities.
Provide trainings and recognition - Active involvement in planning
and management of programs may require skills development
training. Recognition of the programs accomplishment and
individuals contribution to the success of the program and boost
morale of the members.

3. Implementation
Implementation put design phase into action. To do so, the following
must be done:
Generate broad citizen participation - There are several ways to
generate citizen participation. One of them is organizing task
force, who, with appropriate guidance can provide the necessary
support.
Develop a sequential work plan - Activities should be planned
sequentially. Oftentimes, plan has to be modified as events
unfold. Community members may have to constantly monitor
implementation steps.
Use comprehensive integrated strategies - . Generally the
program utilize more than one strategies that must complement
 each other.
Integrate community values into the programs, materials and
messages. The community language, values and norms have to
be incorporated into the program.

4. Program maintenance consolidation

The program at this point has experienced some degree of success and
has weathered through implementation problems. The organization and
program is gaining acceptance in the community.
Integrate intervention activities into community networks - This
can be affected through implementation problems. The
organization and program is gaining acceptance in the
community.
Establish a positive organizational structure - A positive
environment is a critical element in maintaining cooperation and
preventing fast turnover of members. This is the result of good
group based on trust, respect, and openness.
Establish an ongoing recruitment plan- It should be expected that
volunteers may leave the organization. This requires a built in
mechanism for continuous recruitment and training of new
members.
Disseminate results - Continuous feedback to the community on
results of activities enhances visibility and acceptance of the
organization. Dissemination of information is vital to gain and
maintain community support.

5. Dissemination reassessment
Continuous assessment is part of the monitoring aspect in the
management of the program. Formative evaluation is done to provide
timely modification of strategies and activities. However, before any
programs reach its final step, evaluation is done for future direction.
Update the community analysis - Is there a change in leadership,
resources and participation? This may necessitate reorganization
and new collaboration with other organizations.
Assess effectiveness of interventions/programs - Quantitative
and qualitative methods of evaluation can be used to determine
participation, support and behavior change level of decision-
making and other factors deemed important to the program
Chart future directories and modifications - This may mean
revision of goals and objectives and development of new
strategies. Revitalization of collaboration and networking may be
vital in support of new ventures.
Summarize and disseminate results - . Some organizations die
because of the lack of visibility. Thus, a dissemination plan
 maybe helpful in diffusion of information to further boost support
to the organizations endeavor.

GUIDE ON HOW TO DO AN EFFECTIVE COMMUNITY DIAGNOSIS

Community Diagnosis: an in-depth process of finding out the profiles, health

status of the community and the factors affecting the present status

Contents:
1. Introduction
1.1 Rationale accurate, valid, timely and relevant information on the
community profile and health problems are essential so that resources can be
maximized
1.2 Purpose to analyze the data in order to develop responsive
intervention strategies that address the root cause of the problem
1.3 Statement of Objective what are to be accomplished to attain the
study
1.4 Methodology and tool used a description of the adoption,
construction and administration of instruments
1.5 Limitation of the study state any limitations that exist in the
reference or given population or area of assignment

2. Target Community Profile

2.1 Geographical Identifiers historical background, location,
boundaries, population, physical features, climate, spot map
2.2 Population Profile Total estimated population of Barangay,
Population Density,
2.3 Socio-demographic Profile total population of families surveyed,
number of households, age and sex distribution, sex ratio, dependency ratio,
civil status, types of families, religious distribution, place of origin, length of
residency
2.4 Socio-economic indicators educational attainment, literacy rate,
occupation, income, housing, ventilation
2.5 Environmental indicators Water supply, excreta disposal, garbage
disposal, pet ownership, domestic animals
2.6 Health profile food storage, infant feeding practices, immunization,
community facilities, health seeking behaviors, communication resource and
family planning
2.7 Morbidity and mortality data leading cause of morbidity, mortality,
infant mortality and maternal mortality

3. Analysis of Data
3.1 Identification of health problems
3.2 Prioritized problems identified
4. Action plan based from prioritized problem identified
4.1 Intervention strategies

5. Conclusion

6. Recommendation

Community Diagnosis
1. Preparation of Community Diagnosis
a. Identify barangay to survey or required by the health center
b. Ocular survey
c. Community assembly
2. Conduct of survey proper using the format/survey form
a. Random sampling or saturation
b. Guidelines in filling survey form
c. Data collection techniques
3. Make graph or chart of each data gathered
4. Data analysis and interpretation
5. Preparation of action plan /project plan

HRDP CO-PAR
COMMUNITY ORGANIZING
A continuous process of awareness building, organizing and mobilizing
community members towards community development.

PHASES AND ACTIVITIES

I. PRE-ENTRY PHASE
Preparation of the staff
Site selection
II. ENTRY PHASE
integration with the community
Courtesy calls
Information campaigns
Identification of potential leaders
III. CORE-GROUP FORMATION & MOBILIZING
integration with core group
IV. ORGANIZATION-BUILDING
Organizing Barrio Health committees
Setting up community organization
V. CONSOLATION & EXPANSION PHASE
Networking, linkages
 Implementation of livelihood projects
developing secondary leaders

J. Public Health Programs

PUBLIC HEALTH PROGRAMS

FAMILY HEALTH
Aims to:
1. Improve the survival, health and well-being of mothers and the unborn through a
package of services for the pre-pregnancy, prenatal, natal and postnatal packages.
2. Reduce morbidity and mortality rates for children 0-9 years.
3. Reduce mortality from preventable causes among adolescents and young
people.
4. Reduce mortality and morbidity among Filipino adults and improve their quality
of life.
5. Reduce morbidity and mortality of older persons and improve their quality of life.

The Maternal Health Program

Strategic thrusts for 2005-2010

Launch and implement the Basic Emergency Obstetric Care or BEMOC

strategy in coordination with the DOH.
Improve the quality of prenatal and postnatal care
Reduce womens exposure to health risks through the institutionalization of
responsible parenthood and provision of appropriate health care package to
all women of reproductive age
LGUs, NGOs and other stakeholders must advocate for health through
resource generation and allocation for health services to be provided for the
mother and the unborn

a. Antental Registration
Prenatal Visits Period of Pregnancy
1st visit As early as possible before 4 months or during the 1 st
trimester.
nd
2 visit During the 2nd trimester.
3rd visit During the 3rd trimester.
Every 2 weeks After 8th month until 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 the baby from neonatal tetanus.
*3 booster dose shots are needed to complete the five doses following the
recommended schedule to provide full protection for both mother and child.
*mother is then called as a fully immunized mother.
 c. Micronutrients Supplementation
Vit A: 10,000 IU 2x a week starting on 4th month of pregnancy
Iron: 600mg/400ug tablet daily

d. Treatment of Diseases and other Conditions ????

e. Clean and safety delivery.

1. Do a quick check upon admission for emergency signs.
2. Make the woman comfortable/
3. Assess the woman in labor.
4. Determine the stage of labor.
5. Decide if the woman can safely deliver.
6. Give supportive care throughout labor.
7. Monitor and manage labor.
8. Monitor closely within one hour after delivery and give supportive care.
9. Continue care after one hour postpartum.
10. Educate and counsel on Family Planning and provide Family Planning Method
if available and decisions made by the woman.
11. Inform, teach and counsel the woman on important MCH messages:
*birth registration
*importance of breastfeeding
*Newborn Screening for babies delivered in RHU or at home within 48 hours
up to 2 weeks after birth
*Schedule when to return for consultation for post partum visits
1st visit 1st week post partum preferably 3 - 5
days
2nd vist 6 weeks post partum

The Family Planning Program

FAMILY PLANNING
The concept of enhancing the quality of families which includes:
*Started 1960s
*2 3 years spacing of child
*2 3 years children is ideal
*5 pregnancy is a risk factor
*COUPLES FOR CHRIST DOH Partner
*Regulating and spacing childbirth
*Helping subfertile couples beget children
*Counseling parents and would-be parents
*The privilege and the obligation of the (married) couple exclusively to decide
w/ love when andhow many children provided:
the motive is justified and the means are moral.
*Involves personal decisions based on each individuals background,
experiences andsociocultural beliefs. It involves thorough planning to be
certain that the method chosen isacceptable and can be used effectively.

Function of the Health Professional in Family Planning

*To counsel, reassure, give information and allow an individual/couple
to decide his/her/their course of action according to what he/she think is
appropriate for them and in accordance to their own personal,societal,
religious beliefs & values

Goal: Provide universal access to family planning information and

services wherever and whenever these are needed.
FAMILY PLANNING Aims to contribute to:
- Reduced infant deaths
- Neonatal deaths
- Under five deaths
- Maternal deaths
Objectives:
-Addresses the need to help couples and individuals achieve their
desired family size within the context of responsible parenthood and
improve their reproductive health to attain sustainable development.
-Ensure that quality Family Planning services are available in DOH
retained hospitals, LGU managed health facilities, NGOs and private
sector.
Strategies:
*Focus service delivery to urban and rural poor
*Reestablish the FP outreach program
*Strengthen FP provision in regions with high unmet needs
*Promote frontline participation of hospitals
*Mainstream modern natural family planning
*Promote and implement CSR strategy
MISSION:
-To provide the means and opportunities by which married couples of
reproductive age desirous of spacing and limiting their pregnancies can
realize their reproductive goals.

FAMILY PLANNING SERVICES

*Temporary conception control
-Methods used to prevent conception
-Methods used to prevent ovulation
-Methods used to prevent implantation

*Sterilization / Permanent conception control

-Tubal occlusion / Bilateral Tubal Ligation
 -Vasectomy or Vas Ligation (never advice a permanent method of
planning).

Family Planning: 4 Pillars

BIRR!!!
B-
I-
R-
R-

Important Concept!!!
COUPLE Decision maker
DOH Regulator
Community Health Nurse Facilitator

Important Concept!!!
High risk Pregnancies
-Too early
-Too late
-Too Frequent
-Too many

The family planning methods:

Natural Family Planning
1. BBT (Basal Body Temperature)
- 91 99% effective
- Observe temperature for six (6) months or more
- Taken per mouth or per axilla
- Take temperature upon waking up
- Graph
- Mark coitus schedule
- Mark time of menstruation
Important Concept!!!
Progesterone CAUSES AN INCREASE IN TEMPERATURE
Estrogen CAUSES A DROP IN TEMPERATURE

2. Cervical Mucus / Billing Method

- Spinbarkeit Test
- 91 99% effective
- Clear, stretchable and mucus is abundant Fertile
- Cervical mucus is pasty Not Fertile

3. Sympto Thermal method

- 91 -99% effective
- Combination of basal body temperature and billing method
4. Lactational Amenorrhea Method (LAM)
- 98% effective
- Done for six (6) months
- Three Criteria for LAM:
* Child less than six (6) months
* Menses are still absent
* Pure Breast Feeding
- No pacifier, water, supplementary food

Artificial Family Planning

1. Pills
- % effective
- Usually taken at night
- COCs (Combine Oral Contraceptives)
* Not given on breast feeding mother
* With estrogen and progesterone
- POCs (Progestin Only Contraceptives)
* Taken by breastfeeding mothers

2. Intrauterine Device (IUD)

- 98% effective
- Sterile plastic device
- Best time for insertion
- During the second (2nd) day of menses
- You know you are not pregnant
- Cervix is slightly open
- ABSOLUTE CONTRAINDICATION
* When you have abnormal uterine bleeding.
* Nulliparous
* History of Pelvic Inflammatory Disease
* History of Sexually Transmitted Disease

3. Condom
- 97% effective
- Mother is most responsible in inserting the condom.

4. Depo Medroxyl Progesterone Acetate (DMPA)

- 98% effective
- Injectable; every 3 months
- Fertility after 6 months

Permanent Family Planning

1. Tubal Ligation
- 99% effective
- Best time:
 * Post partum
* Within four (4) to six (6) hours after delivery
- Do not engage in coitus three (3) days before and after the procedure
- Restrict lifting of objects heavier than newborn

2. Vasectomy
- 99% effective
- Vas deferens is cut
- Does not give immediate sterility
- There is a waiting time of six (6) months
- Sperm is still stored
- After six months, patient can engage in unprotected coitus.
- Not Popular among Filipinos

Nursing Alert!!!
Methods that are not part of Natural Family Planning: (not accepted by the
DOH)
- Withdrawal
- Calendar Method

Misconception about Family Planning Methods:

*Some family planning methods cause abortion
*Using contraceptives will render couples sterile
*Using contraceptive methods will results to loss of sexual desire

The Child Health Programs (Newborns, Infants and Children)

Newborns, infants and children are vulnerable age group for common
childhood diseases. The risk of infection among children is higher when not
screened for metabolic disorder, not exclusively breastfed, unvaccinated, not
properly managed when sick, not given with vitamin supplementation and many
others. To address problems, child health programs have been created and
available in all health facilities which includes:
Infants and Young Child Feeding
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 exclusion and extended breastfeeding and complementary
feeding
Key Messages on infant and young child feeding
* Initiate breastfeeding within 1 hour after birth
* Exclusive for the first 6 months of life
* Complemented at 6 months with appropriate foods, excluding milk
supplements
* Extend breastfeeding up to 2 years and beyond.
 Breastfeeding benefits
To Infants:
Provides a nutritional complete food for the young infant
Strengthens infants immune system
Safely rehydrates and provides essential nutrients
Reduces infants exposure to infection
Increase IQ points

To Mother:
Reduces womans risk of excessive blood loss after birth
Provides natural methods of delaying pregnancies
Reduces the risk of ovarian and breast cancers and osteoporosis

To Household and the Community:

Conserve funds that would be spent on breastmilk substitute
Saves medical cost to families

Newborn Screening??????

Expanded Program on Immunization

Goal of EPI: Reduction of morbidity and mortality of immunizable diseases
Not all diseases are immunizable
Principles in Vaccinating Children:
*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 9m/o.
*Vaccination schedule should not be restarted from beginning even if interval
exceeds recommended interval.
*Moderate fever, malnutrition, mild respiratory infection, cough, diarrhea and
vomiting are not contraindications to vaccination.
*Absolute contraindications: DPT 2 or DPT3 to a child who had convulsions or
shock within 3 days after DPT administration; BCG to immunosuppressed clients
*Giving doses of a vaccine at less than the recommended 4 weeks interval may
lessen antibody response
*False contraindications: malnutrition, low-grade fever, mild respiratory infections,
and other minor illnesses and diarrhea

Vaccine Minimum age # of Minimum Route, Storage Type/ form

at 1st dose Doses interval Dosage, temp of vaccine
between Site
doses
BCG Birth or anytime 1 ID 2-8 C in Freeze dried,
after birth 0.05 ml body of live
Right ref attenuated
arm bacteria
DPT 6 weeks 3 4 weeks IM 2-8 C in D
 0.5 ml body of weakened
Thigh ref toxin
(vastus P killed
lateralis) bacteria
T toxin
OPV 6 weeks 3 4 weeks Oral -15 to Live
2 drops -25C attenuated
Mouth (freezer) virus
Hepa B At birth 3 6 weeks IM 2-8 C in RNA
interval 0.5 ml body of recombinant
from 1st Thigh ref
dose to 2nd (vastus
dose, 8 lateralis)
weeks
interval
from 2nd to
3rd dose
Measles 9 months 1 SQ -15 to Freeze dried,
0.5 ml -25C live attenua-
Outer (freezer) ted virus
part of
upper
arm

Types and Schedule of Vaccines:

AT BIRTH 1 months 2 3 months 9-12
months months
st
1 BCG DPT1 DPT2 DPT3 MEASLES
OPV1 OPV1 OPV3
HEPB 1 HEPB 2 HEPB 3

BCG: Infant 0.05ml ID Will not totally eliminate TB

School entrants 0.1 ml ID (double dose) Will inhibit Leprosy

DPT:
HepB 5 ml IM destroyed by freezing
TT

Measles .5ml. SQ Most sensitive to heat & destroyed by heat

OPV 2 gtts/ P.O. - Trivalent ( 3 types)
SIDE-EFFECTS OF BCG:

a. Kochs Phenomenon (Nisie)

- Inflammation of the site of injection after 2-4 days
- 2 to 3 wks. Abscess will ulcerate then heals leaving a scar (12 wks.)
- Warm complex after vaccination

b. Deep abscess at site even after 12 wks.: Incision & drainage

Treatment: Powedered INH

c. Indolent ulceration- ulcer after 12 weeks

Treatment: Powedered INH

d. Glandular enlargement- abscess (2-3 weeks abscess will leave scar 12 weeks
after)

SIDE-EFFECTS OF DPT:

- Fever for a day (always bring antipyretic)-----------------------Normal

Soreness at site within 3-4 days Treatment: Warm compress-----
Normal
Abscess after a week or more- incision & drainage ------Not normal
Convulsions-----Emergency: post-pone giving of next dose

SIDE-EFFECT OF MEASLES:

- Fever 5-7 days after within 1-4 days------Normal

Mild rashes --------if it does not disappear-----Roseola

Remember the Principles:

* Even if the interval exceeded that of the expected interval, continue to give the
doses of the vaccine.
* Immunization can still be given until the child reaches 6 y/o
* If there has been a reported epidemic of measles, measles vaccine can be given
as early as six months
* BCG booster dose must be given to school entrants regardless of presence of
BCG scar.
* There is no contraindication to immunization, EXCEPT when the child had
convulsions upon giving the 1st dose of DPT.
* MALNUTRITION is not a contraindication, but RATHER AN INDICATION for
immunization since common childhood disease are often severe to malnourished
children.
*COLD CHAIN

A system used to maintain the potency of a vaccine from that of manufacturer to

the time it is given to child or pregnant woman.

Principles:

I. Storage- it should not exceed:

- 6 months @ the regional level

- 3 months @ the provincial/ district level
- 1 month @ main health centers (with refrigerators)
- Not more than 5 days @ health centers (using transport boxes)

Important Points To Remember:

Arranging of stored vaccine according to:

Type
Expiration date
Duration of storage
# of times they have been brought out to the field

The vaccine stored the LONGEST & THOSE THAT WILL EXPIRE
FIRST should be distributed or used 1st.

It is a MUST to mark ampules/vials with an X mark each time they are

carried to the field, because if a VACCINE IS NOT USED on the 3 rd trip,
it must already BE DISCARDED.

II. Transport

Use of cold dogs

III. Handling

Once opened or reconstituted, vaccines must be placed in a special cold

pack during immunization sessions.

Vaccine Half life

BCG 4 hours
DPT
Polio
Measles 8 hours
TT
HepaB
TARGET SETTING:

Involves the calculation of the eligible population.

ELIGIBLE POPULATION consists of any group of people targeted for

specific immunizations due to susceptibility to one or several of the EPI
diseases.

Management of Childhood Illnesses (IMCI)

INTEGRATED MANAGEMENT AND CHILDHOOD ILLNESSES
Definition: The Integrated Management of Childhood Illness (IMCI) is a strategy
to address the most common causes of illness (morbidity) and deaths(mortality)
among children under 5 which was developed and initiated by the World Health
Organization (WHO) in collaboration with UNICEF in 1995.

Goal: By 2010, to reduce the infant and under five mortality rate at least one third,
in pursuit of the goal of reducing it by two thirds by 2015.

AIM: To reduce death, illness and disability, and to promote improved growth and
development among children under 5 years of age.
IMCI includes both prventive and curative elements that are implemented by
families and communities as well as by health facilities.

Objective: Aims to reduce death, illness and disability, and to promote improved
growth and development among children under five years old.
*To reduce SSIGNIFICANTLY global mortality and morbidity
associated with the major causes of disease in children.
*To contribute to healthy gorth and development of children.

IMCI Components of Strategy:

*Improving case management skills of health workers.
*Improving the health systems to deliver IMCI.
*Improving family and community practices.

***For many sick children a single diagnosis may not be apparent or appropriate.

Presenting Complaint:
*Cough and / or fast breathing
*Lethargy / Unconsciousness
*Measles rash
*Very sick young infant
Steps in IMCI Process
-
-
-
-
-
-

Principles of the Integrated Care

o Assess for General Danger Signs
* Vomits everything
* Convulsion / Seizure
* Difficulty drinking / breastfeeding
* Drowsiness / Lethargy / Difficulty to awaken

o Assess for Main Symptoms

* Cough / DOB
* Diarrhea
* Ear Problem
* Fever
*M

Color Classification Classification of Disease Level of Management

*Green - Mild--- Home Care
*Yellow - Moderate--- Managed at the RHU
*Pink --- Sever--- Urgent Referral in Hospital

Assess and Identify Classifications

A. Cough and Difficulty

Micronutrient Supplementation
Dental health Early Child Development
Child Health Injuries

Its main goal is to reduce morbidity and mortality rates for children 0-9
years with the strategies necessary for program implementation.
 Essential Packages of Health Services for Newborn, Infant and Child

The Adolescent Health Program

The Adult Men Health Program

The Adult Women Health Program

The Older Person Health Program

Philippine Reproductive Health

NON-COMMUNICABLE DISEASE PREVENTION AND CONTROL

AIM: Preventing the four major non communicable / Chronic / Lifestyle related
disease, cancer, chronic obstructive pulmonary diseases and diabetes mellitus,
through the promotion of healthy lifestyle aimed at preventing the three
commonly shared major risk factors; unhealthy diet. Physical inactivity and
smoking.

I. Integrated Community Based Non-Communicable Disease

Prevention and Control Program
FOUR MAJOR NON COMMUNICABLE DISEASES
1. Cardiovascular diseases
2. Cancer
3. Chronic Obstructive Pulmonary Diseases
4. Diabetes Mellitus

2005 It was estimated that 35 million deaths would have occurred due to these
diseases, contributing 60% of deaths worldwide. As well as a high death toll,
chronic diseases also caused disability, often for decades of a persons life.
The most widely used summary measure of the burden of disease is the
disability adjusted life year or DAILY, which combines the number of years of
healthy life lost to premature death with time spent in less than full health. One
DAILY can be thought of as one lost healthy year of life. The projected burden
of disease of these diseases is approximately half or 48% of the global burden
of disease.
2020 The diseases are expected to account for 73% of deaths and 60% of the
disease burden.
2002 Life expectancy of Filipinos has gone up to 69.6 years.
- MORTALITY statistics showed that 7 out of 10 leading causes of
deaths in the country are diseases which are lifestyle related:
diseases of the heart and the vascular system, cancers, chronic
obstructive pulmonary diseases, accidents, diabetes, kidney
problem.
 - MORBIDITY statistics also showed that hypertension and
diseases of the heart are among the top 10 leading causes of
illnesses in the country.
2003 The result of the National Nutrition and Health Survey conducted that
recently 90% of Filipinos has one or more risk factors associated with chronic,
non-communicable diseases.

THE RISK FACTORS WITH THE CORRESPONDING PREVALENCE RATES:

a. Physical Inactivity 60.5%
b. Smoking 34.8%
c. Hypertension 22.5% (SBP > 140 or DBP > 90)
d. Hypercholesterolemia 8.5% (TC > 240)
e. Obesity 4.9% (BMI > 30)
f. Diabetes 4.6%

HEALTHY LIFESTYLE defined as a way of life that promotes and protects

health and well-being. This would include practices that promotes healthy such as
healthy diet and nutrition, regular and adequate physical activity and leisure,
avoidance of substances that can be abused such as tobacco, alcohol and other
addicting substances, adequate stress management and relaxation; and practices
that offer protection from health risks such as safe sex and immunization.

GOAL:
Reduce the toll of morbidity, disability and premature deaths due to chronic, non-
communicable lifestyle related disease.

OBJECTIVES:
1. Analyze the social, economic, political and behavioral determinants of NCD that
will serve as bases for:
a. Developing policy guidelines;
b. Setting legislative and political directions, and
c. Providing financial measures to support NCD prevention and control.

2. Reduce exposure of individuals and population to major determinants of NCD

while preventing emergence of preventable common risk factors. To hasten this,
the health sector lobby for a healthy protective environment by:
a. Proposing healthy public policies that encouraged health promoting settings in
school, workplaces and communities.
b. Encouraging government to provide protection against activities by industry and
commerce that promote unhealthy products and lifestyles.
c. Communicating the consequences of major risk factors of NCD, paying
particular attention to the most vulnerable population.

3. Strengthen health care for people with NCD through health sector reforms and
cost effective interventions. In order to contribute health status individuals and
respond to the communitys basic health care needs, there must be enhance
capability to take action to address these major NCD risk factors.

To achieve significant reduction in morbidity and mortality from major NCDs, the
following approaches should characterize the program:
1. Comprehensive Approach Focused on Primary Prevention
2. Community Based Approach
3. Integrated Approach

KEY INTERVENTION STRATEGIES

1. Establishing program direction and infrastructure
2. Changing environments
3. Changing Lifestyle
4. Reorienting health services

THE ROLE OF PUBLIC HEALTH NURSE IN NCD PREVENTION AND

CONTROL

Health Advocate
Public Health Nursing promote active community participation in NCD prevention
and control through advocacy work. As a health advocate, the PHN helps the
people toward optimal degree of independence in decision making and in
asserting their right to their right to a safer and better community. This involves:
1. Informing the people about the rightness of the cause. It is important to convey
the problem, show it affects people in the community and describe possible
actions to take.
2. Thoroughly discussing with the people the nature of the alternatives, their
content and consequences. In this manner, needs demands of the people are
amplified and eventually become the framework for decision making.
3. Supporting peoples right to make a choice and to act on the choice. The people
must be assured that they have the right responsibility to make decisions and that
they do not to change their decisions because of others objections.
4. Influencing public opinion. The advocate affirms the decision made by the
people by getting powerful individuals or groups to listen, support and eventually,
make substantial changes to solve the problem.

Health Educator
Health Education is an essential tool to achieve community health. In non-
communicable disease prevention and control, health education focuses on
establishing or inducing changes in personal and group attitudes and behavior that
promote healthier living. PHNs, as well as educators and media personel, should
conduct healthier education in a variety of settings.

The health educator aims to:

1. Inform the people. Health education creates an awareness of health needs and
problems which consequently make the people become conscious of their own
responsibilities towards their own healthy. Misconceptions and ignorance will be
corrected by disseminating scientific knowledge about causes, factors, prevention
and control of non-communicable diseases.
2. Motivate the people. Telling people about health is not enough. They should be
motivated to make own choices and decisions about habits and practices that are
determined to health, such as cigarette smoking, indulgence in alcohol, physical
inactivity and fat and sugar rich diet.
3. Guide people into action. Oftentimes, people need to supported in their effort to
adopt or maintain healthy practices and lifestyles.

Health Care Provider

The Public Health Nurse is a care provider to individuals, families and
communities rendering primary, secondary and tertiary health care services in any
setting including the community and workplace.

As care provider, emphasis of care is on health promotion and disease

prevention focusing on promotion of rational diet and physical activity and
cessation of smoking and alcohol drinking. In addition, action is directed towards
the reduction of risk factors of non communicable diseases. Primary prevention
must be family oriented because the family members live and eat together and
the roots of chronic diseases are related to personal habits and lifestyle.

Community Organizer
As an organizer, the ultimate goal of the PHN is community health
development and empowerment of the people. This is achieve by:
*Raising the level of awareness of the community regarding non communicable
diseases, its causes, prevention and control;
*Organizing and mobilizing the community in taking action for the reduction of risk
factors;
*Influencing executive and legislative bodies to create and enforce policies that
favor a healthy environment.

Healthy Trainer
The PHN provides technical assistance in the assessment of the skills of
auxiliary health workers in NCD prevention and control; teaching and supervision
on clinical management of non communicable diseases and other community
based services and recording, reporting and utilization of health information
related to non communicable diseases.

Researcher
Research is an integral part of a primary health care approach to non
communicable disease prevention and control program. It is inextricably related to
community health practices since it provides the theoretical bases for developing
appropriate and responsive intervention programs and strategies.
 II. Causes and Risk Factors of Major NCDs

A. Diseases of the Heart and Blood Vessels

1. Hypertension
Description
*Hypertension or high blood pressure is defined as a sustained elevation in mean
arterial pressure.
*It is not a single disease state but a disorder with many causes, a variety of
symptoms, and a range of responses to therapy.
*Hypertension is also a major risk factor for the development of others CVDs like
coronary heart disease and stroke.

ETIOLOGY / CAUSE
*In terms of etiology, hypertension is classified into primary and secondary
hypertension.
Primary hypertension has no definite cause. It is also called essential
hypertension. Secondary hypertension is usually the result of some other primary
diseases leading to hypertension such as renal disease. For the rest of these
session, we will be focusing on primary hypertension, which is more common.
*Although exact cause is unknown, primary hypertension is attributed to
atherosclerosis.

RISK FACTORS
*There is no single cause for primary hypertension but several risk factors have
been implicated in its development.
*Risk factors include family health history, advancing age, race and high salt
intake.
*Other lifestyle factors interact with these risk and contribute to the development of
hypertension such as obesity, excess alcohol consumption, intake of potassium
(diet high in sodium is generally low in potassium; increasing potassium in diet
increase elimination of sodium), calcium, and magnesium, stress, and use of
contraceptive drugs.
*FAMILY HISTORY
-People with a positive family history of hypertension are twice at risk than those
with no history.
*AGE
-Older person are at greater risk for hypertension than younger persons.
-The aging processes that increase BP include stiffening of the arteries,
decreased baroreceptor sensitivity, increase peripheral resistance and decreased
renal blood flow.
-For years, systolic hypertension common in older persons was considered
benign and, therefore, not treated. However, the Framingham study showed that
there was two to five times increased in death from CVD associated with isolated
systolic hypertension.
*HIGH SALTH INTAKE
-Excessive salt intake does not cause hypertension in all people, nor does
reducing salt intake, reduce BP in all hypertensives. Some people are more
susceptible than others to effects of increased salt intake.
*OBESITY
-Risk for hypertension is two times greater among overweight / obese persons
compared to people of normal weight, and three times more than that of
underweight persons.
-Fat distribution is more important risk factor than actual weight as measured by
waist to hip ratio.
-The exact mechanism of how obesity contributes to the development of
hypertension is unknown. Whatever the cause, weight loss is effective in reducing
BP in obese hypertensive patients.
-Weight loss or sodium restriction in hypertensives, controlled for 5 years, more
than doubled the success of withdrawal of drug therapy.
*EXCESSIVE ALCOHOL INTAKE
-As much as 10% of hypertension cases could be related to alcohol consumption.
Regular consumption of 3 or more drinks per day increased risk of hypertension.
Systolic pressures were more markedly affected than diastolic pressure.

KEY AREAS FOR PREVENTION OF HYPERTENSION

*Encouraged proper nutrition reduce salt and fat intake.
*Prevent becoming overweight or obese weight reduction through proper
nutrition and exercise.
*Smoking cessation tobacco use promotes atherosclerosis that may contribute
to hypertension; quitting smoking anytime is beneficial; this refers to both active
and passive smokers.
*Identify people with risk factors and encouraged regular check ups for possible
hypertension and modification of risk factors.

2. Coronary Artery Disease

Description
*Coronary Artery Disease (CAD) is heart disease cause by impaired coronary
blood flow. It is also known as Ischemic Heart Disease.
*When the coronary arteries become narrowed or clogged, supply of blood and
oxygen to the heart muscle is affected.
*When there is decreased oxygen supplied to the heart muscle, chest pain (called
ANGINA) occurs.
*CAD can cause myocardial infarction (heart attack), arrhythmias, heart failure,
and sudden death.

ETIOLOGY / CAUSES
*The most common cause is atherosclerosis. This is the thickening of the inside
wall of arteries due to deposition of a fat like substance. This thickening narrows
the space through which blood can flow, decreasing and sometimes completely
cutting off the supply of oxygen and nutrients to the heart. It affects large and
medium sized arteries like the aorta, coronary arteries and the large vessels that
supply the brain.
*Atherosclerosis usually occurs when a person has high level of cholesterol in the
blood. When the level of cholesterol in the blood is high, there is a greater chance
that it will be deposited onto the artery walls.
*In diabetes mellitus, atherosclerosis is accelerated, often resulting in coronary
artery disease, myocardial infarction and stroke.

RISK FACTORS OF CAD

a. Elevated blood lipids and cholesterol level (hyperlipidemia)
b. Hypertension
c. Smoking
d. Diabetes mellitus
e. Obesity
f. Physical inactivity/ sedentary lifestyle
g. Stress

ELEVATED BLOOD LIPIDS/ CHOLESTEROL

-Increased blood cholesterol is an important risk factor in the development of CAD.
Reports have shown that modest reduction in total cholesterol can significantly
lessen CVD morbidity and mortality.
-High LDL(low- density lipoprotein) level is a risk factor of CAD. It is called the
bad cholesterol because it is the main carrier of cholesterol and contributes to
atherosclerosis. LDL level is increased by saturated fat intake, obesity, sedentary
lifestyle, smoking, androgens and certain drugs.
-Not all cholesterol is bad. HDL (high density lipoprotein) is now acknowledged
as a protective factor against coronary heart disease. HDL facilitates reverse
transport of cholesterol to the liver where it may be excreted and therefore prevent
atherosclerosis. When HDL level is below normal, this becomes a risk factor
for CAD. It is decreased in smoking, obesity and diabetes mellitus. Regular
exercise and moderate alcohol consumption increased HDL levels.

SMOKING/TOBACCO USE
-Risk of death from CAD is 70-200 times greater for men who smoke one or more
packs of cigarettes per day compared to those who do not smoke. This risk is most
seen in young people, particular those younger than 50 years old.

KEY AREAS FOR PREVENTION OF CAD

Promote regular physical activity and exercise; exercise increases HDL, prevent
obesity and improves optimum functioning of the heart.
 Encourage proper nutrition particularly by limiting intake of saturated fats that
increased LDL, limiting salt intake and increasing intake of dietary fiber by
eating more vegetables, fruits, unrefined cereals and wheat breads.
Maintain body weight and prevent obesity through proper nutrition and physical
activity/ exercise.
Advise smoking cessation for active smokers and prevent exposures to second-
hand smoke by family members, friends and co-workers of active smokers. In
general, promote a smoke- free environment through advocacy and community
mobilization.
Early diagnosis, from prompt treatment and control of diabetes and
hypertension; these diseases are risk factors and contribute to the development
of coronary artery disease.

3. Cerebrovascular Disease or Stroke

Description
*Stroke is the loss or alteration of bodily function that result from insufficient supply
of blood to some parts of the brain. For human brain to function at emboli. Cocaine
use has been closely related to strokes, heart attacks and a variety of other
cardiovascular complications. Some of them have been fatal even in first time
cocaine users.

KEY AREAS FOR PREVENTION OF STROKE

*Treatment and control of hypertension - many people believe that effective
treatment of high blood pressure is a key reason for the rapid decline in the death
rates for stroke.
*Smoking cessation and promoting a smoke-free environment.
*Prevent thrombus formation in rheumatic heart disease and arrhythmias with
appropriate medications. These medications are usually taken on a daily basis.
Health workers need to remind these persons to take their medications as
prescribed.
*Limit alcohol consumption for women, not more than one drink per day, and for
men, not more than two drinks per day.
*Avoid intravenous drug abuse and cocaine.
*Prevent all other risk factors of atherosclerosis.

B. Cancer
-cancer is not a single disease.
-cancer develops when cell in a part of the body begin to grow out of control.
-they compete with normal cells for the blood supply and nutrients that normal
cells need thus causing weight loss.
-cancer cells often travels to the other part of the body where they begin to grow
and replace normal tissue. This process is called metastasis. It occurs as the
cancer cells get into the bloodstream or lymph vessels of our body.
-the immune system seems to play a role in the development and spread of
cancer. When the immune system is intact, isolated cancer cells will usually be
detected and removed from the body. When the immune system is impaired as in
people with immunodeficiency diseases, people with organ transplant who are
receiving immunosuppressant drugs, or in AIDS, there is usually an increase in
cancer incidence.

CAUSES OF CANCER
-Normal cells transform into cancer cells because of damage to DNA. People can
inherit damage DNA which account for inherited cancers. Many times though, a
persons DNA becomes damaged by exposure to something toxic in the
environment such as chemicals, radiation or viruses.
Carcinogens
*a carcinogen is an agent capable of causing cancer. This maybe a chemical, an
environmental agent, radiation and viruses.
*Effect of carcinogenic agents usually depend on the dose or amount of exposure;
the larger the dose or the longer the exposure, the greater the risk of cancer.
*Many cancers are associated with lifestyle risk factors such as smoking, dietary
factors and alcohol consumption.
Chemicals and Environmental Agents
*Polycyclic hydrocarbons are chemicals found in cigarette smoke, industrial
agent, or in food such as smoke foods. Polycyclic hydrocarbons produced from
animal fat in the process of broiling meats and are present in smoked meats and
fish.
*Aflatoxin is found in peanuts and peanut butter.
*Other includes benzopyrene, nitrosamines, and a lot more.
Benzopyrene
*Produced when meat and fish are charcoal broiled or smoked (e.g tinapa or
smoked fish). Avoid eating burned food and eat smoked foods in moderation.
*Also produced when food is fried in fat that has been reused repeatedly. Avoid
reusing cooking oil.
Nitrosamines
*These are powerful carcinogens use as preservatives in food like tocino,
longganisa, bacon and hotdog.
*Formation of nitrosamines may be inhibited by the presence of antioxidants such
as Vit. c in the stomach. Limit eating preserved food and eat more vegetables and
fruits that are rich in dietary fiber.
Radiation
*Radiation can also cause cancer including ultraviolet rays from sunlight, x-rays,
radioactive chemicals and other forms of radiation.
Viruses
* a virus can enter a host cell and cause cancer. This is found in cervical
cancer(human papilloma virus), liver cancer( hepatitis B virus), certain leukemias,
lymphoma an nasopharyngeal cancer( epstain barr virus).

RISK FACTORS OF CANCER

- risk factors for cancer include a person's age, sex and family medical
history. Other are linked to cancer thus causing factors in the environment. Still
others are related to lifestyle factors such as tobacco and alcohol use, diet and
sun exposure.

CANCER RISK FACTOR

Lung Cancer *Tobacco use, including cigarettes,
cigar, chewing tobacco and snuf.
*Radiation exposure
*Second hand smoke
Oral Cancer *Tobacco use (cigarette, cigar, pipes,
smokeless tobacco)
*Excessive alcohol use
*Chronic Irritation (e.g, Ill fitting
dentures)
*Vitamin A deficiency
Laryngeal Cancer *Tobacco used (cigarette, cigar, pipe,
smokeless tobacco)
*Poor nutrition
*Alcohol
*Weakened immune system
*Occupational exposure to wood dust,
paint, fumes
*Gender: 4 5 times more common in
man
*Age: more than 60 years.
Renal Cancer *Tobacco used (cigarette, cigar, pipe,
smokeless tobacco): increase risk by
40%.
*Obesity
*Diet: well cooked meat
* Occupational exposure: asbestos
organic solvents.
*Age: 50 70 years old.
Cervical Cancer *Tobacco use (cigarette, cigar, pipe
smokeless tobacco).
*Human papillomavirus infection
*Chlamydia infection
*Diet: low in fruits and vegetables.
*Family history of cervical cancer.
Bladder Cancer *Tobacco use (cigarette, cigar, pipe,
smokeless tobacco)
*Occupational exposure: dry solvents,
*Chronic bladder inflammation.
Esophageal Cancer *Tobacco use (cigarette, cigar, pipe,
smokeless tobacco)
*Gender: 3 times more common in man
*Alcohol
 *Diet: low in fruits and vegetables.
Breast Cancer *early menarche or late menopause
*Age changes in hormone levels
throughout life, such as age at first
menstration, number of pregnancies,
and age at menopause.
*High fat diet
*Obesity
*Physical inactivity
*Some studies have also shown a
connection between alcohol
consumption and an increase risk of
breast cancer.
Prostate Cancer *While all man are at risk, several
factors can increase the chances of
developing the disease, such as
advancing age, race and diet.
*Race: more common among African
American man than among white man
*High fat diet.
*Man with a father or brother who has
had prostate cancer are more likely to
get prostate cancer themselves.
Liver Cancer *Certain types of viral hepatitis
*Cirrhosis of the liver
*Long term exposure to aflatoxin
(carcinogenic substance produced by a
fungus that often contaminates peanuts,
wheat, soybeans, corn and rice.
Skin Cancer *Unprotected exposure to strong
sunlight.
*Fair complexion.
*Occupational exposure.
Colonic Cancer *Personal or family history of polyps.
*High fat diet or low fiber diet
*History of ulcerative colitis.
*Age: > 50 years.
Uterine endometrial Cancer *Estrogen replacement therapy.
*Early menarche / late menopause.

KEY AREAS FOR PRIMARY PREVENTION OF CANCER

*Smoking Cessation.
*Encourage Proper Nutrition.
*Drink alcohol beverages in moderation.
*Avoid / control obesity through proper nutrition and exercise.
*The sooner a cancer is diagnosed and treatment begins, the better the chances
of living longer and enjoying a better quality of life.

C. Diabetes Mellitus
Diabetes Mellitus (DM) is one of the leading causes of disability in persons over
45. More than half of diabetic persons will die of coronary heart disease. CAD
tends to occur at an earlier age and with greater severity in persons with diabetes.
It also increases the risk of dying of cardiovascular disease like heart attack or
stroke among women.
Description
*Diabetes mellitus is not a single disease. It is genetically and clinically
heterogeneous group of metabolic disorders characterized by glucose intolerance,
with hyperglycemia present at time of diagnosis.

ETIOLOGY / CAUSES
*Specific cause depends in the type of diabetes, however it is easier to think of
diabetes as an interaction between two factors: Genetic Predisposition
(diabetogenic genes) and Environment / Lifestyle (obesity, poor nutrition, lack of
exercise).

TYPES OF DIABETES
Type 1 Diabetes is insulin dependent diabetes mellitus (IDDM) and Type 2
is noninsulin dependent diabetes mellitus (NIDDM) Gestational Diabetes is
diabetes that develops during pregnancy. It may develop into full blown diabetes.
NIDDM is more common, occurring in about 90 95% of all persons with diabetes.
It is also more preventable because it is associated with obesity and diet.

Type 1 DM
*Characterized by absolute lack of insulin due to damaged pancreas, prone to
develop ketosis, and dependent on insulin injections.
*Genetic, environment, or may be acquired due to viruses (e.g. mumps, congenital
rubella) and chemical toxins (e.g. Nitrosamines).
Type 2 DM
*Characterized by fasting hyperglycemia despite availability of insulin.
*Possible causes include impaired insulin secretion, peripheral insulin resistance
and increased hepatic glucose production.
*Usually occurs in older and overweight persons (about 80%).

Risk Factors of Type 2 DM

*Family history of diabetes (i.e., parents or siblings with diabetes)
*Overweight (BMI 23 kg/m ) and obesity (BMI > 30 kg/m )
*Sedentary lifestyle
*Hypertension
*HDL cholesterol < 35 mg/dl (0.90 mmol/L) and/or triglyceride level > 250 mg/dl
(2.28mmol/L)
*History of Gestational Diabetes Mellitus (GDM) or delivery of a baby weighing 9
Ibs (4.0 Kgs)
*Previously identified to have Impaired Glucose Tolerance (IGT)

Complications
*Acute complications include diabetic ketoacidosis (DKA), hyperosmolar
hyperglycemic nonketotic coma (HHNK) and hypoglycemia especially in type 1
diabetic.
*Chronic complications cause most of the disability associated with disease. These
include chronic renal disease (nephropathy), blindness (retinopathy) coronary
artery disease and stroke, neuropathy and foot ulcers.

KEY AREAS FOR PREVENTION AND CONTROL OF DIABETES

*Maintain body weight and prevent obesity
*Encourage proper nutrition
*Promote regular physical activity and exercise
*Advise smoking cessation for active smokers and prevent exposure to
secondhand smoke.

D. Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of chronic
morbidity and mortality throughout the world. COPD is currently the fourth leading
cause of death in the world, and more cases and deaths due to COPD can be
predicted in the coming decades because of smoking.
Description
*COPD is a disease state characterized by airflow limitation that is not fully
reversible.

CAUSES AND RISK FACTORS

*COPD is usually due to chronic bronchitis and emphysema, both of which are due
to cigarette smoking. Cigarette smoking is the primary cause of COPD.

DIAGNOSIS
*A diagnosis of COPD should be considered in any patient who has symptoms of
cough, sputum production, or dyspnea, and / or a history of exposure to risk
factors for the disease. The diagnosis is confirmed by spirometry.

COMPLICATIONS
-Respiratory failure In advanced COPD, peripheral airways obstruction,
parenchymal destruction, and pulmonary vascular abnormalities reduce the lungs
capacity for gas exchange, producing hypoxemia and, later on, hypercapnea.
-Cardiovascular disease Pulmonary hypertension, which develops late in the
course of severe COPD), is the major cardiovascular complication of COPD), and
is associated with the development of cor pulmonale and a poor prognosis.

E. Bronchial Asthma
Asthma is a chronic disease. It is an inflammatory disorder of the airways in which
many cells and cellular elements play a role. Chronic inflammation causes an
associated increase in airway hyper responsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest tightness and coughing, particularly
at night or in the early morning.

These episodes are usually associated with widespread but variable airflow
obstruction that is often reversible either spontaneously or with treatment.

CAUSES AND RISK FACTORS

Asthma development has both genetic and environment component.
a. Host Factors: predispose individuals to protect them from developing asthma.
*Genetic Predisposition
*Airway hyperresponsiveness
*Gender
*Race / Ethnicity
b. Environmental Factors:
*Indoor allergens
*Outdoor allergens
*Occupational sensitizers
*Tobacco smoke
*Air pollution
*Respiratory infections
*Parasitic infections
*Socioeconomic factors
*Family size
*Diet and drugs
*Obesity

Asthma triggers
Triggers are risk factors for asthma exacerbations. These cannot cause asthma to
develop initially, but can exacerbate established asthma. They induce inflammation
and / or provoke acute bronchoconstriction. It involves further exposure to causal
factors (allergens and occupational agents) that have already sensitized the
airways of the person with asthma.

Other form of triggers are irritant gases and smoke, house dust mite found in
pillows, mattresses, carpets; respiratory infection, inhaled allergens, weather
changes, cold air, exercise, certain foods, additives and drugs.

KEY AREAS FOR PRIMARY PREVENTION AND EXACERBATION OF ASTHMA

*Recognize triggers that exacerbate asthma
*Avoid these triggers if possible, particularly smoking
*Promote exclusive breastfeeding as long as possible; early introduction to cows
milk may predispose baby to allergens and possible asthma.
 RISK FACTORS
*Elevated blood lipid
(Hyperlipidemia)
*High intake of fatty foods
*Inadequate intake of
dietary fiber
*Overweight and obesity.
*Sedentary lifestyle
*Smoking, both active or
passive / second hand
*Excessive use of alcohol
*Hyperlipidemia,
Hypertension, Diabetes
Mellitus
KEY AREAS FOR PREVENTION
PROMOTE PROPER NUTRITION
*Limit intake of fatty, salty and
preservative foods.
*Increase intake of vegetable and
fruits.
*Avoid high caloric low nutrient
value food like junk food, Instant
noodles, softdrinks.
*Start developing healthy habits in
children.
ENCOURAGE MORE PHYSICAL
ACTIVITY AND EXERCISE
*Moderate physical activity of
atleast 30 minutes for most days.
*Integrate physical activity and
exercise into regular day -to- day
activities.
*Walking is one form of exercise
that is possible for including older
persons with cardiovascular
disease.
PROMOTE SMOKE FREE
ENVIRONMENT
*Smoking cessation for active
smokers to reduce risk.
*Prohibit smoking inside living
areas, houses and closed areas.
DISCOURAGE EXCESSIVE
DRINKING OF ALCOHOLIC
BEVERAGES
*EARLY DIAGNOSIS AND
PROMPT TREATMENT.

III. Risk Assessment and Screening Procedures

The basis of non-communicable disease (NCD) prevention is the identification
of the major common risk factors and their prevention and control. A risk
factors refers to any attribute, characteristics or exposure of an individual,
which increases the likelihood of developing NCD. Assessment of these risk
factors and screening for NCDs in individuals and communities important in
preventing and controlling future diseases.

Risk Factor Assessment:

A. Cigarette Smoking
* Assess smoking status by asking individuals whether they smoke
or not. In order to monitor trends, collect information not only on
smoking status but also on age of onset, amount smoked by current
and former smokers, and quit attempts. Every client should be asked
about tobacco use. Smoking status should be recorded and updated
at regular intervals.

B. Nutrition/Diet
* Diet is a combination of related behaviors, which are often culture
specific. Comprehensive nutritional assessment involves detailed
recall methods (e.g., 24 hours food diary) or extensive food
frequency, questionnaires and estimation of nutrients based on food
composition tables. At the very least, the following questions should
be ask to determine the contribution of the patients nutrition to NCD
development. These include:
*Vegetables Number of servings of vegetables per day and usual
types of vegetables eaten.
*Fruits Number of fruits per day.
*Fat
Number of servings of meat and poultry.
Which part (e.g. skin of chicken)
How often fried foods are eaten
How often fast foods / restaurants are visited.
*Sodium / Salt
How often preserved, canned and instant foods are
eaten per weak.
How much salt is added when cooking food.

GUIDELINES FOR ADEQUATE VEGETABLE AND FRUIT INTAKE

*Eat 2 3 servings of vegetables each day, one serving of which is
green or yellow leafy vegetables. One serving means:
Raw vegetables 1 cup
Cooked vegetables cup

*Eat at least 2 serving of fruit per day, 1 serving is a vitamin C rich

fruit. One serving of fruit depends on type of fruit.

C. Overweight/Obesity
* Body fat can best be assessed using Body Mass Index (BMI) and
waist circumference. BMI correlates closely with total body fat in
relation to height and weight. However, this does not compensable
for frame size, does not indicate fat distribution, and cannot be
adjusted for age.
 Weight In children and adults, regular weighing is the simplest way
of knowing if energy balance is being achieved. The use of weight
for age or weight for height tables will help determines the
desirable weight either according to age (children) or height (adults).

Body Mass Index (BMI) BMI is calculated using the following

formula:
BMI = Weight in kgs / Height in meters.

GUIDELINE
Based on Asia Pacific Obesity Guidelines:
BMI Interpretation
<18.5 Underweight
18.6 22.9 Healthy weight
>23.0 Overweight
23.0 24.9 At risk
25.0 29.9 Obese 1
>30.0 Obese 2

Waist Circumference (WC) This alone is an accurate measure of

the amount of visceral fat. Remember that the central obesity is a
significant risk factor to heart disease and stroke.

ASSESSING DEGREE OF RISK CO MORBID CONDITIONS

BASED ON BMI AND WC
Measuring Waist Circumference
Procedure: Subject should be unclothed at the waist, and standing
with abdomen relaxed, arms at the sides, feet together. Use non
stretchable, measure and do not compress the skin.
Clinical Thresholds:
Men <90 cm (35 inches)
Women <80 cm(31.5 inches)
Greater than these value is not normal and the person is at risk even
if BMI is normal.

Waist Hip Ratio (WHR) Another useful measures of obesity is the

waist to hip ration by dividing the waist circumference at the
narrowest point by the hip circumference at the widest point.
WHR = Waist circumference (cm) / Hip circumference (cm)
WHR Interpretation:
*Less than 1.0 (men); less than 0.85 (women) = normal WHR
*Equal to or greater than 1.0 (men) and 0.85 (women) = android or
central obesity.
D. Physical Inactivity/Sedentary Lifestyle
 *Assessment of physical activity includes on type of work, means of
transportation and leisure time activities like sports and formal
exercise.
Minimum Recommended amount of physical activity needed to
achieve health benefit:
Regular Physical Activity: Minimum 30 minutes per day most days of
the week preferably daily.
If moderate intensity: 5 or more days of the week.
If vigorous intensity: 3 or more days of the week.

Guideline:
At least 30 minutes of cumulative physical activity moderate in
intensity for most days of the week.

E. Excessive Alcohol Drinking

*Assess habitual alcohol intake and risky behavior, such as driving or
operating machinery while intoxicated.

Screening Guidelines and Procedures:

According to WHO, screening is the presumptive identification of
unrecognized disease or defect by the application of tests, examination
or other procedures which can be applied rapidly. The primary goal of
screening is to detect a disease in its early stages to be able to treat it
and prevent further development of the disease. Screening programs
are usually disease specific and thus may be called hypertension
screening or diabetes screening.
A. Screening for Hypertension
*Hypertension is defined as a sustained systolic BP of 140 mmHg or
more and sustained diastolic BP of 90 mmHg or more based on
measurements done during at least 2 visits taken at least 1 week
apart.

B. Screening for Elevated Cholesterol in the Blood

*The recommended screening test for cholesterol is taking a small
blood sample and testing for total blood cholesterol. Prior to testing,
make sure that the person has not eaten any food nor taken any
drinks containing calories for at least eight hours. Drinking water is
acceptable.

C. Screening for Diabetes Mellitus

*The hallmark of diagnosis of diabetes mellitus is the presence of
Hyperglycemia.
For those with family history and symptoms of DM, advise blood test
for serum or plasma glucose.
 **Fasting Blood Sugar (FBS) Fasting is defined as no caloric
intake for at least eight hours; this include no food, juices, milk; only
water is allowed.
**Two hour Blood Sugar Test Performed two hours after using
75g glucose dissolved in water or after a good meal. Oral Glucose
Tolerance Test (OGTT) is not recommended for routine clinical use
nor screening purposes.

D. Screening for Cancer

*Early detection and prompt treatment are keys to curing cancer.
WARNING SIGNS FOR CANCER (CAUTION US)
C Change in bowel or bladder habits
A A sore that does not heal
U Unusual bleeding or discharge
T Thickening or lump in the breast or elsewhere
I Indigestion and difficulty swallowing
O Obvious change in wart or mole
N Nagging cough of hoarseness in voice

U Unexplained anemia
S Sudden weight loss

SPECIFIC GUIDELINES FOR EARLY DETECTION OF COMMON

CANCERS
1. Breast Cancer
a. Warning Signs includes skin changes (Edema, Dimpling or
inflammation peau, de orange orange peal like skin, Ulceration, Prominent
venous pattern), Nipple abnormalities (Retraction, Rashes or Discharge),
Abnormal Contours (Variation in size and shape of breasts).
b. Early Detection
*Breast Self-Examination cheapest and most affordable screening procedure for
breast cancer. The best time to do BSE is one week after menstrual period while
taking a shower, facing the mirror standing up or lying down.
*Breast mammography Baseline, mammogram is suggested for all women
between the ages of 35 39 and yearly mammogram after age 40. If with family
history of breast cancer, mammogram should be started at age 30. Put in mind
that BSE does not take the place of mammogram or vice versa.
2. Cervical Cancer
a. Warning Signs includes often asymptomatic and Abnormal
vaginal bleeding (e.g., Post Coital bleeding)
b. Early Detection
*Paps Smear Primary screening tool for women over age 18
- should be done in between menses (two weeks after menses).
- for persons at high risk, it should be done yearly. These include
those who are.
:Sexually active,
:Have multiple partners
 :Commercial sex workers.
3. Colon - Rectal Cancer
a. Warning Signs include change in stool, rectal bleeding, pressure
on the rectum, abdominal pai.
b. Early Detection
*Annual digital rectal exam starting at age 40.
*Annual stool blood starting at age 50.
*Annual inspection of colon.
4. Prostate Cancer
a. Warning Signs
*Symptoms of urethral outflow obstruction:
-Urinary frequency
-Nocturia
-Decrease in stream
-Post void dribbling
b. Early Detection
*Digital Rectal Exam for mean
*Prostate Specific Antigen (PSA) determination a blood test,
confirms diagnosis.
5. Lung Cancer
a. Early Warning Signs are those with a long history of smoking
and / or smoking two or more packs or cigarette per day, chronic
cough or nagging cough, dull intermittent, localized pain, history of
weight loss.
b. Early Detection
*Chest X-ray every six months for patients who have history of
smoking two packs per day.
*Sputum cystology.

E. Screening for COPD

*Characteristics and symptoms:
-cough
-sputum production
-dyspnea upon exertion
*SPIROMETRY done to determine degree of obstruction.

F. Screening for Asthma

*Suspect Asthma in Persons with the following:
1. One or a combination of cardinal symptoms ( dyspnea, cough,
wheezing, chest discomfort).
2. Temporal waxing and waning and /or nocturnal occurrence of
symptoms.
3. A history of any of the following:
*Symptoms triggered by exogenous factors.
*A family history of Asthma, Allergic rhinitis or atopy.
*An improvement of symptoms with bronchodilator use.
 ROLE OF PUBLIC HEALTH NURSE IN RISK ASSESSMENT AND
SCREENING
1. Educate as many people and in every opportunity on the warning
signs of NCDs and other risk.
2. Educate people on how to prevent the NCD risk factors through a
healthier diet, engaging in moderate physical activity and not smoking.
3. Every client not only the patient seeking consultation, should be
assessed for the presence of risk factors and early signs of NCD. This includes the
mother bringing her newborn infant for immunization, the grandmother or aunt
bringing a sick child for consultation, or members of the household during home
visits.
4. Train other health workers, even the barangay health workers and
barangay nutrition scholars on performing risk factor assessment. It will be good to
periodically check their skills like BP taking, measurement of height and weight,
using BMI table.

IV. Promoting Physical Activity and Exercise

Health Benefits of Regular Physical Activity
*Reduces the risk of dying from coronary heart disease (CHD).
*Reduces the risk of having a second heart attack in people who have already
experienced one heart attack.
*Lowers both total blood cholesterol and triglycerides and many increase
high density lipoprotein (HDL or the good cholesterol).
*Lowers the risk of developing high blood pressure.
*Helps reduce blood pressure in people who already have hypertension.
*Lowers the risk of developing non insulin dependent (Type 2) diabetes
mellitus.
*Reduces the risk of developing colon cancer.
*Helps people achieve and maintain a healthy body weight.
*Reduces feeling of depression and anxiety.
*Promotes psychological well being and reduces feelings of stress
*Helps build and maintain healthy bones, muscles, and joints.
*Helps older adults become stronger and better able to move about without
falling or becoming excessively fatigued.

UNDERSTANDING PHYSICAL ACTIVITY AND EXERCISES

*Physical Activity is something done at home, like washing the dishes,
sweeping the floor, and cleaning the house. It is also what is done outside the
house, like sweeping or raking leaves in the yard or gardening, or walking to
the neighborhood store or jeepney terminal instead of riding the tricycle. It is
something that one might be avoiding doing in the office, like instead of
climbing the stairs one takes the elevator, or instead of walking around while
using the phone one opts to sit down.
*Exercise is a planned, structured and repetitive movement done to
improve or maintain one or more components of physical fitness. It involves
energy expenditure and planning. Walking or jogging for three kilometers each
day before or after work is a structured exercise. Another example is attending
a regular aerobics class 3 times a week is structured exercise.

ROLE OF PUBLIC HEALTH NURSE

*The public health nurse play a big role in motivating individuals and groups to
prevent living sedentary lifestyles that increase their risk for NCD. She has the
responsibility of increasing their knowledge and skills needed to engage in
physical activities and exercise as well as motivating them enough to start
being physically active and to encourage them to main.

V. Promoting Proper Nutrition ?????

VI. Promoting a Smoke-Free Environment ?????

VII. Promoting Stress Management

*Stress is an everyday fact of life and everyone experience stress from
time to time. Stress is any change that one must adapt to, ranging from the
negative extreme of actual physical danger to exhilaration of falling in love or
achieving some long desired success. And in between, day to day living
confronts even the most well managed life with continuous stream of potentially
stressful experiences. Thus, stress is not only inevitable and essential; but also
normal part of life. However, normal does not necessarily mean healthy.
*Fortunately, stress management is largely a learnable skill. Everybody
can learn effectively handle stress even when pressures persist. It is not
possible to live without stress. But one can learn ways to handle the stress of
daily life efficiently, and to manage reactions to stress and minimize its negative
impact. However, it is important to remain attentive to negative stress
symptoms and to learn to identify the situations that evoke them. When these
symptoms persist, the risk for serious health problems is greater because
stress can exhaust the immune system. Recent research demonstrates that
90% of illness is stress related.
*People respond to stressful situations in different ways. Stressful
situations can trigger different types of responses. These will vary between
individuals. Some may be physical, some may be psychological and some
maybe behavioral.
STRESS MANAGEMENT TECHNIQUES
12 Stress Management Techniques
1. SPIRITUALITY
-is a state or quality of being spiritual. It is pure, holy, relating to matters of
sacred nature, not wordly, ecclesiastica, possessing the nature of qualities of a
spirit.
Mediation is a way of reaching the world beyond the senses. It is very
effective method of relaxation. The idea of mediation is to focus ones thoughts
on one relaxing thing for a sustained period of time.
Mediation can have the following effects:
-Lowers blood pressure
-Slows breathing, helps muscle relax
-Gives the body time to eliminate lactic acid and other waste products
-Eliminates stressful thoughts
-Helps with clear thinking
-Helps with focus and concentration
-Reduces stress headaches

2. SELF AWARENESS
-it means knowing ones self, getting in touch with ones feelings, or being
open to experiences. It increases sensitivity to the inner self and
relationship with the world around.

3. SCHEDULING: TIME MANAGEMENT

-time is a resource. A resource is something that lies ready for use, or
something that can be drawn upon for aid. Time is a tool that can be drawn
upon to help accomplish results, an aid that can take care of a need, an
assistant in solving problems. Managing time really refers to managing
ones self in such a way as to optimize the time available in order to achieve
gratifying results.

4. SIESTA
-it means taking a nap, short rest, a break or recharging of battery in order
to improve productivity. It helps relax the mind and body muscles. It had
been proven thru a study that siesta invigorates ones body. Performance of
an individual scored high when siesta is observed with a 15 30 minutes
nap. It relieves stress tension and one wakes up invigorated and set for the
next activity.

5. STRETCHING
-are simple movements performed at a rhythmical and slow pace executed
at the start of a demanding activity loosen muscles, lubricate joints, and
increase bodys oxygen supply. It requires no special equipment, no special
clothes, and no special skills and can be done anywhere and anytime.

6. SENSATION TECHNIQUE
-The sense of touch is a powerful and highly sensitive forms of
communication. It is a natural reaction to reach out and touch whether to
feel the shape or texture of something or to respond to another person,
perhaps by comforting them. Massage helps to soothe away stress,
unknotting tensed and aching muscles, relieving headaches and helping
sleep problems. But massage is also invigorating; it improves the
functioning of many of the bodys systems, promotes healing and tones
muscles, leaving with a feeling of renewed energy.

7. SPORTS
 -Engaging in sports and in physical activities like these have been known to
relieve stress. It also gives the body the exercise it badly needs.

8. SOCIALS
-a man is a social being who exist in relationships with his physical
environment and in relationship with people and society.
Socialization plays a very important role in the development of intrapersonal
relationships. Through socialization life becomes meaningful, happy and
worthy. On the contrary without socialization life will be boring and empty.

9. SOUNDS AND SONGS

-music plays an important part in the everyday life of a person. It provides a
medium of expression for thoughts and emotions. It also a way to relieve
tension. Music adds to the quality of life of a person.

10. SPEAK TO ME
-the world is designed as a mutual support system in which all things relate
to each other. Communication is the means by which people make their
needs known. It is the way they obtain understanding, reinforcement and
assistance from others. Communication is aimed at a goal, so it must
remain open until the goal is reached. Interpersonal conflicts generally are
resolved most effectively by open communications that accept the feelings
of the persons involved and leas to better resolution of problems. Talking to
someone when feeling overwhelmed or unable to deal with stress or feeling
helpless is often the best way of coping with stress.

11. STRESS DEBRIEFING

-Critical Incident is any usually strong or overwhelming emotional reactions
which have potential to interfere with work during the event or thereafter in
the majority of those exposed.
-Critical Incident Stress Debriefing means to assist crisis workers/ team
member to deal positively with the emotional impact of a severe event/
disaster and to provide education about current and anticipated stress
responses, as well as information about stress management.

12. SMILE
- It has been observed that people who always smile are healthy people.
Smile is an expression of pleasure. It has been found out through research
that it relieves all kinds of stresses, physical, or mental. It is also considered
one of the ingredients or factors that motivates and encourages people to
work harder and improve their level of performance in anything they do.
 VIII. Programs for the Prevention and Control of other non-
communicable diseases
-The following are some of the programs that addresses other non-
communicable diseases particularly blindness, mental disorders, renal disease
and programs for disables persons.

A. National Prevention of Blindness Program

VISION 2020: The Right to Sight is a global initiative to eliminate avoidable
blindness by the year 2020. The program is a partnership between the World
Health Organization (WHO) and the International Agency for Prevention of
Blindness (IAPB), which is the umbrella organization for eye care professional
groups and non governmental organizations (NGOs) involved in eye care.

VISION/ MISSION/ GOALS/ OBJECTIVS

Vision All Filipinos enjoy the right to sight be year 2020.
Mission The Department of Health, Local Health Units, partners and stake
holders commit to:
1. Strengthen partnership among and with stakeholders to eliminate avoidable
blindness in the Philippines.
2. Empower communities to take proactive roles in the promotion of eye health
and prevention of blindness.
3. Provide access to quality eye care services for all.
4. Work towards poverty alleviation through preservation and restoration of sight to
indigent Filipinos.
Goal:
-Reduce the prevalence of avoidable blindness in the Philippines through the
provision of quality eye care.
Objectives:
*General Objective no. 1: Increase Cataract Surgical Rate from 730 to 2,500 by
the year 2010.
*General Objective no.2: Reduce visual impairment due to refractive errors by
10% by the year 2010.
*General Objective no.3: Reduce the prevalence of visual disability in children
from 0.43% to 0.20% by the year 2010.

INTERVENTIONS BY EYE DISORDER:

1. Cataract
The pacification of the normally clear lens of the eye, is the most common
cause of blindness worldwide.
Interventions will therefore consist of increasing awareness about cataract and
cataract surgery; as well as improving the delivery of cataract services.
2. Errors of Refraction
It is the most common cause of visual impairment in the country (prevalence is
2.06% in the population).
It is corrected either with spectacle glasses, contact lenses or surgery.
3. Childhood Blindness
The prevalence of blindness among children (up to age 19) is 0.06% while the
prevalence of visual impairment in the same age group is 0.43%.
Screening of children for any sign of visual impairment can be done by
pediatricians, school clinics and health workers.

Vision 2020 Philippines envisions to eliminate avoidable blindness though

three strategies:
*Ensuring that cataract surgery is available, accessible, and affordable to
everyone.
*Reduction of the prevalence of cataract, blinding error of refraction and vitamin A
deficiency thru enhanced services.
*Pooling of resources of government and non government agencies to address
the problem of cataract, blinding error or refraction, and Vitamin A deficiency.

B. Mental Health and Mental Disorders

-World Health Organization (WHO) defines mental health as a stage of
well being where a person can realize his or her own abilities to cope
with normal stresses of life and work productively.
FOUR FACETS AS A PUBLIC HEALTH BURDEN:
Defined Burden Refers to the burden currently affecting persons with mental
disorders and is measured in terms of prevalence and other indicators such as the
quality of life indicators and disability adjusted life years (DALY).
Undefined Burden The portion of the burden relating to the impact of mental
health problems to persons other than the individual directly affected.
Hidden Burden of Mental Illness Refers to the stigma and violations of
human rights. Stigma is a mark of shame, disgrace or disapproval that results in a
person being shunned or rejected by others.
Future Burden Refers to the burden in the future resulting from the aging of
the population, increasing social problems and unrest inherited from the existing
burden.

Mental Health Sub Programs

A. Wellness of Daily Living
The process of attaining and maintaining mental well being across the life
cycle through the promotion of healthy life style with emphasis on coping with
psychosocial issues.
Objectives:
*To increase awareness among the population on mental health and psychosocial
issues.
*To ensure access of preventive and promotive mental health services.
B. Extreme Life Experience
An extreme life experience is one that is out the ordinary and which threatens
personal equilibrium.
Objectives:
*To differentiate between critical incident and extreme life experiences.
*To identify situations which may be extreme life experiences.
*To categorize / prioritize the extreme life experiences which may be the concern
of mental health.
*To identify programs that could address psychosocial consequences and mental
health issues of persons with extreme life experiences.
C. Mental Disorder
Objectives:
*Promotion of mental health and prevention of mental illness across the lifespan
and across sectors (children and adolescents, adults, elderly, and special
population such as military, OFWs, refugees, persons with disabilities).
D. Substance Abuse and Military Other Forms of Addiction
Objectives:
*To provide implementers for advocacy accurate, technical information about the
psychosocial effects of drugs.
*To promote protective factors against the development of substance abuse/
addition in the following key settings (Family, School, Workplace, Community,
Health Care Setting, Industry) through existing DOH programs and responsible
agencies.
*To rationalize and enhance the drug program to different key settings as a form of
deterring factor.
Nursing Responsibilities and Functions
1. In Mental Health Promotion
*Participate in the promotion of mental health among families and the
community,
*Utilize opportunities in his / her everyday contacts with other members of the
community to extend the general knowledge on mental hygiene.
*Help people in the community understand basic emotional needs and the
factors that promote mental well - being.
*Teach parents the importance of providing emotional support to their children
during critical periods in their lives as first day in school graduation, etc.
2. In Prevention and Control
*Recognize mental health hazards and stress situations as unemployment,
divorce or abandonment of children, vices, long standing physical illness, all of
which may make heavy demands on the emotional resources of the persons
concerned.
*Recognized pathological deviations from normal in terms of acting, thinking,
and feeling and make early referral so that diagnosis and treatment could be done
early.
*Be aware of the potential causes of breakdown and when necessary take
some possible prevention action.
*Help the family to understand and accept the patients health status and
behavior so that all its members may offer as much support in the readjustments to
home and community.
*Help patient assess his / her capacities and his / her handicaps in working
towards a solution of his / her problem.
 *Encourage feeling of achievement be setting health goals that patients can
attain.
*Encouraged patients to express his / her anxieties so that fears and
misconceptions can be cleared up.
*Impairment information and guidance about the treatment scheme of the
patients, the desired and undesirable effect of the tranquilizers, psychiatric
emergency management and other basic nursing care.
3. Rehabilitation
*Initiate patient participation in occupational activities best suited to patients
capabilities, education, experience and training, capacities and interest.
*Encourage and initiate patients to partake in activities of CIVIC organization in
the community through the cooperation of patients family.
*Advice the family about the importance of regular follow up at the clinic.
*Make regular home visits to observe patients conditions during conversation
and follow up of medication.
4. In Research and Epidemiology
*Participate actively in epidemiology survey to be aware of the size and extent
of mental health problems of the community and organize a program for better
preventive, curative and rehabilitative measures.
POINTERS FOR HAVING MENTAL HEALTH
*Maintain good physical health
*Undergo annual medical examination or more often as needed
*Develop and maintain a wholesome lifestyle (balanced die, adequate rest,
exercise, sleep, recreation).
*Avoid smoking, substance abuse and excessive alcohol.
*Have a realistic goal in life.
*Have a friend in whom you can confide and ventilate your problems.
*Dont live in the past and avoid worrying about the future.
*Live one day at a time.
*Avoid excessive physical, mental and emotional stress.
*Develop and sustain solid spiritual values.

C. Renal Disease Control Program

It is started as a Department of Health (DOH) Preventive Nephrology Project
(PNP) in June 1994, with the National Kidney and Transplant Institute(NKTI) as
the main implementing agency.
THE GOALS OF THE PROGRAM ARE AS FOLLOWS:
1. To conduct researches / studies that will establish the true incidence of existing
renal problems and its sequel in the country.
2. To assist the existing health facilities, both local and national through:
*Conduct training on nephrology, urology, and related specialties to enhance
the expertise of medical practitioners and related professions.
*Facilitation of sourcing out of funds for the development and upgrading of
manpower, equipment, etc.
*Internal and external quality assurance.
3. To formulate guidelines and protocols on the proper implementation of the
different levels of prevention and care of renal diseases, for use of medical
practitioners and other related professions.
4. To give recommendations to lawmakers for health for policy development,
funding assistance and implementation.
5. To assist in the development of dialysis and transplant centers / units in strategic
locations all over the Philippines.
6. To establish an efficient and effective networking system with other programs
and agencies, both GOs and NGOs.
IMPORTANT INFORMATION ABOUT KIDNEY DISEASES AND ORGAN
TRANSPLANTATION
Kidney diseases rank as the number 10 killer in the Philippines, causing death to
about 7,000 Filipinos every year.
Kidney Diseases
Chronic glomerulonephritis
Diabetic kidney disease
Hypertensive Kidney Disease
Chronic and repeated kidney infection(Pyelonephritis)
These often lead to End-Stage Renal
Disease (ESRD) due to the inability to recognize them in the early
stages.

D. Community-based Rehabilitation Program ???

COMMUNICABLE DISEASE PREVENTION AND CONTROL

COMMUNICABLE DISEASE
*It is an illness caused by an infectious agent or its toxic products that are
transmitted directly or indirectly to a well person through an agent, vector, or
inanimate object.

TWO TYPES
INFECTIOUS DISEASE
*Not easily transmitted by ordinary contact but require a direct inoculation through
a break in the previously intact skin or mucous membrane
CONTAGIOUS DISEASE
*Easily transmitted from one person to another through direct or indirect means
TERMINOLOGIES
DISINFECTION destruction of pathogenic microorganism outside the body
by directly applying physical or chemical means
Concurrent method of disinfection done immediately after the
infected individual discharges infectious material/secretions. This
method of disinfection is when the patient is still the source of
infection
Terminal applied when the patient is no longer the source of
infection.
Disinfectant -chemical used on non living objects
 Antiseptic chemical used on living things.
Bactericidal kills microorganism
Sterilization complete destruction of all microorganism

General Principles
Pathogens move through spaces or air current
Pathogens are transferred from one surface to another whenever objects
touch
Hand washing removes microorganism
Pathogens are released into the air on droplet nuclei when person speaks,
breaths, sneezes
Pathogens are transferred by virtue of gravity
Pathogens move slowly on dry surface but very quickly through moisture
INFECTION
invasion and multiplication of microorganisms on the tissues of the host
resulting to signs and symptoms as well as immunologic response
injures the patient either by:
o competing with the hosts metabolism
o cellular damage produced by the microbes intracellular multiplication
Factors of severity of infection
o disease producing ability
o the number of invading microorganism
o The strength of the hosts defence and some other factors.
Epidemiological triad:
o Agent
o Host
o Environment

Classification according to incidence:

SPORADIC - disease that occur occasionally and irregularly with no
specific pattern
ENDEMIC those that are present in a population or community at times.
EPIDEMIC diseases that occur in a greater number than what is expected
in a specific area over a specific time.
PANDEMIC is an epidemic that affects several countries or continents

Causes of INFECTION
Some bacteria develop resistance to antibiotics
Some microbes have so many strains that a single vaccine cant protect
against all of them ex. Influenza
Most viruses resist antiviral drugs
Opportunistic organisms can cause infection in immunocompromised
patients
Most people have not received vaccinations
Increased air travel can cause the spread of virulent microorganism to
heavily populated area in hours
 Use of immunosupressive drugs and invasive procedures increase the risk
of infection
Problems with the bodys lines of defense

Three Lines of Defense

FIRST LINE OF DEFENSE
o MECHANICAL BARRIERS
o CHEMICAL BARRIERS
o BODYS OWN POP. OF MICROORGANISM - microbial
antagonism principle
SECOND inflammatory response
o Phagocytic cells and WBC to destroy invading microorganism
manifesting the cardinal signs
THIRD immune response - Natural/Acquired: active/passive

RISK FACTORS
Age, sex, and genes
Nutritional status, fitness, environmental factors
General condition, emotional and mental state
Immune system
Underlying disease ( diabetes mellitus, leukemia, transplant)
Treatment with certain antimicrobials (prone to fungal infection), steroids,
immunosuppresive drugs etc.

Mode of Transmission
Contact transmission
Direct contact - person to person
Indirect - thru contaminated object
 o Droplet spread - contact with respiratory secretions thru cough,
sneezing, talking. Microbes can travel up to 3 feet.
Airborne Transmission
Vector Borne Transmission
Vehicle Borne Transmission

Emerging problems in infectious diseases

Developing resistance to antibiotics eg: anti tb drugs, MRSA, VRE
Increasing numbers of immunosuppressed patients.
Use of indwelling lines and implanted foreign bodies has increased.

INFECTION CONTROL MEASURES

UNIVERSAL PRECAUTION All blood, blood products and secretions from
patients are considered as infected.
WORK PRACTICE CONTROL
Handwashing
o Before and after using gloves, after hand contact with patients,
patients blood and other potentially infected materials.
Protective Equipment shall be removed immediately upon leaving the work
area. Like apron, mask, gloves etc.
o Place in designated area.
Used needles and sharps shall not be bent, broken, recapped. Used
needles must not be removed from disposable syringes.
Eating, drinking, smoking, applying cosmetics or handling contact lenses
are prohibited in work areas.
Foods and drinks shall not be stored in refrigerators, freezers where blood
or other infectious materials are stored.
All procedures involving blood or other potentially infectious materials shall
be performed in such a manner as to minimize splashing, or spraying.

Control Measures
Masking Wear mask if needed. Patient with infectious respiratory
diseases should wear mask.
Handwashing Practice it with soap and water.
Gloving Wear gloves for all direct contact with patients. Change gloves
and wash hands every after each patient.
Gowning - Wear gown during procedures which are likely to generate
splashes of blood or sprays of blood and body fluids, secretions or excretions.
Eye protection (goggles) wear it to prevent splashes.
Environmental disinfection Clean surfaces with disnfectant 70%
alcohol,diluted bleach)
Ex. Normal clean clean the room post discharge, final clean- MRSA and
infectious pts.

ISOLATION PRECAUTIONS
 Separation of patients with communicable diseases from others so as to
reduce or prevent transmission of infectious agents.
7 Categories Recommended in isolation
Strict isolation prevent spread of infection from patient to patient/staff.-
handwashing, infectous materials must be discarded, use of single room,
use of mask, gloves and gowns and (-) pressure if possible
Contact isolation prevent spread by close or direct contact
Respiratory isolation prevent transmission thru air.
TB isolation for (+) TB or CXR suggesting active PTB.
Enteric Isolation direct contact with feces
Drainage/secretion precaution- prevents infection thru contact with
materials or drainage from infected person.
Universal Precaution for handling blood and body fluids. (Bloods, pleural
fluid, peritoneal fluid etc.)
PREVENTION
Health Education educate the family about
Immunization
MOT
Environmental sanitation breeding places of mosquito, disposal of feces
Importance of seeking medical advice for any health problem
Preventing contamination of food and water.
Environmental Sanitation
o Water Supply Sanitation Program DOH thru EHS (Environmental Health
Services)
o Policies on Food Sanitation Program
o Policies on Hospital Waste Management
The Community Health Nurse is in the best position to do health education
such as
o > development of materials for environmental sanitation
o > providing group counselling, holding community assemblies and
conferences.
o > create programs for sanitation
o > be a role model
Immunization introduction of specific antibody to produce immunity to certain
disease.
o Natural passive (from placenta), active (thru immunization & recovery
from diseases)
o Artificial passive (antitoxins), active (vaccine, toxoid)
Maintain vaccine potency by preventing:
o Heat and sunlight
o Freezing
Antiseptic/ disinfectants/ detergents lessen the potency of vaccine. Use
water only when cleaning fridge/ref.
COLD CHAIN SYSTEM maintenance of correct temperature of vaccines,
starting from the manufacturer, to regional store, to district hospital, to the health
center to the immunizing staff and to the client.
Disease Acquired Thru the Respiratory tract
TUBERCULOSIS
Chronic respiratory disease affecting the lungs characterized by formation
of tubercles in the tissues---> caseation --> necrosis ---> calcification.
AKA: Phthisis, Consumption, Kochs, Immigrants disease
Etiologic agent: Mycobacterium tuberculosis
Incubation period: 2 10 wks.
Period of communicability: all throughout the life if not treated
MOT: Droplet
Sources of infection sputum, blood, nasal discharge, saliva

Classification
1. Inactive asymptomatic, sputum is (-), no cavity on chest X ray
2. Active (+) CXR, S/S are present, sputum (+) smear
Classification 0-5
A. Minimal slight lesion confined to small part of the lung
B. Moderately advanced one or both lungs are involved, volume affected
should not extend to one lobe, cavity not more than 4 cm.
C. Far advance more extensive than B

MANIFESTATIONS
Primary Complex: TB in children: non contagious, children swallow phlegm,
fever, cough, anorexia, weight loss, easy fatigability
Adult TB
o afternoon rise in temperature
o night sweats
o weight loss
o cough dry to productive
o Hemoptysis
o sputum AFB (+)
Milliary TB - very ill, with exogenous TB like Potts disease
Primary Infection
o Asymptomatic
o No manifestations even at CXR, Sputum AFB
Primary Complex
o Minimal manifestations
o Lymphadenopathy
DX
Tuberculin testing
CXR
Sputum AFB

Prevention
BCG
Avoid overcrowding
Improve nutritional status

TX
DOTS
6 months of RIPE
Respiratory isolation,
Take medicines religiously prevent resistance
Stop smoking
Plenty of rest
Nutritious and balance meals, increase CHON, Vit. A, C

MENINGITIS
Inflammation of the meninges usually some combination of headache,
fever, stiff neck, and delirium
Meningococcemia: cerebrospinal fever
o Etiologic agent: Neisseria meningitidis
o Incubation: 2-10 days
o MOT: droplet
Acute meningococcemia - with or without meningitis
o Waterhouse Friederichsen Syndrome
Diagnostic exams:
o Lumbar tap, CSF - high WBC and CHON, low glucose
Manifestations:
o Sudden onset of fever x 24h
o Petechiae, Purpuric rashes
o Meningeal irritation
Stiff neck
Opisthotonus
Kernigs sign
Brudzinski sign
o ALOC (Altered level of consciousness)
o S/S of Increase ICP

Nursing Mgt:
Administer prophylactic antibiotics: Rifampicin - drug of choice
Aquaeous Pen
Mannitol
Dexamethasone
Priority: AIRWAY, SAFETY
Maintain seizure precaution
Respiratory precaution
Handwashing
Suction secretions

DIPTHERIA
Acute contagious disease characterized by generalized toxemia coming from
localized inflammatory process
Etiologic agent: Corynebacterium Diptheria (Klebs loffer bacillus)
Incubation period: 2-5 days
Period of communicability: variable, ave:2-4 weeks
MOT Droplet, direct or intimate contact, fomites, discharge from nose, skin,
eyes
Manifestation
PSEUDOMEMBRANE - grayish white, smooth, leathery and spider web
like structure that bleeds when detached
Types of Respiratory Diptheria
NASAL
o serous to serosanginous purulent discharge
o Pseudomebrane on septum
o Dryness/ excoriation on the upper lip and nares
PHARYNGEAL
o pharyngeal pseudomembrane
o bull neck ( cervical adenitis)
o Difficulty swallowing
LARYNGEAL
o Sorethroat, pseudomembrane
o Barking, dry metallic cough

Complications
o Due to TOXEMIA
Toxic endocarditis
Neuritis
Toxic nephritis
o Due to Intercurrent Infection
Bronchopneumonia
Respiratory failure

DX
Nose and throat swabs - culture of specimen form beneath membrane
Virulence test
SHICKs TEST: test for susceptibility to diptheria
MOLONEYs TEST: test for hypersensitivity to diphtheria

MANAGEMENT
1. Penicillin, Erythromycin
2. Diptheria Antitoxin after skin test if (+), fractional dose
3. Supportive
O2, if laryngeal obstruction tracheostomy
CBR for 2 weeks
Increase fluids, adequate nutrition- soft food, rich in Vit C
Ice collar
4. Isolation till 3 NEGATIVE cultures

Prevention
DPT

PERTUSSIS (whooping cough)

 Repeated attacks of spasmodic coughing with series of explosive expirations
ending in long drawn force inspiration
Etiologic agent: Bordetella pertusis or Haemiphilus pertussis
Incubation period: 7-14 days
Period of communicability: 7 days post exposure to 3 wks post disease onset
MOT Droplet

Manifestation
o rapid cough 5-10x in one inspiration ending a high pitched
whoop.
Catarrhal slight fever in PM, colds, watery nasal discharge, teary
eyes, nocturnal coughing, 1-2 weeks
Paroxysmal Spasmodic stage; 5-10 successive forceful coughing
ending with inspiratory whoop, involuntary micturition and defecation,
choking spells, cyanosis
Convalescent 4th- 6th week; diminish in severity, frequency

Complications:
Otitis media
Acute bronchopneumonia
Atelectasis or emphysema
Rectal prolapse, umbilical hernia
Convulsions (brain damage - asphyxia, hemorrhage)

Dx:
Elevated WBC
Nasopharyngeal swab
Nursing Management
Prevention:
o DPT
 Parenteral fluids
Erythromycin - drug of choice
Prone position during attack
Abdominal binder
Adequate ventilation, avoid dust, smoke
Isolation
Gentle aspiration of secretions

MEASLES
Acute viral disease with prodromal fever, conjunctivitis, coryza, cough
and Kopliks spots
AKA: Rubeola, 7-day measles
Etiologic agent: Morbilli Paramyxoviridae virus
Incubation period: 10-12 days
Period of communicability: 3 days before and 5 days after the
appearance of rashes. Most communicable during the height of rash.
MOT: Airborne
Sources of infection secretions from eyes, nose and throat

Pathognomonic sign: Kopliks spots

Manifestations
1.Pre eruptive stage / Prodromal (10-11 days)
o Coryza, Cough, Conjunctivitis
o Kopliks Spots, whitish spot at the inner cheek
o Fever, photophobia
2. Eruptive stage
o Maculopapular rashes
o Rash is fully developed by 2nd day
 o High grade fever on and off
o Anorexia, throat is sore
3. Convalescence (7-10 days)
o Desquamation of the skin

Diagnostics
Nose and throat swab

Treatment
1. Antiviral drugs- Isoprenosine
2. Antibiotics if with complications
3. Supportive O2, IVF
Complications bronchopneumonia, otitis media, encephalitis

Nursing Management
Preventive measles vaccine at 9 months, MMR 15 months and
then 11-12; defer if with fever, illness
Isolation - contact/respiratory
TSB , Skin care daily cleansing wash
Oral and nasal care
Plenty of fluids
Avoid direct glare of the sun- due to photophobia

GERMAN MEASLES
Mild viral illness caused by rubella virus.
AKA: Rubella; 3-Day Measles
Incubation period from exposure to rash 14 -21d
Period of communicability one week before and and 4 days after onset
of rashes. Worst when rash is at its peak.
MOT: Droplet, nasal ceretions, transplacental in congenital
Manifestations
1. Prodromal low grade fever, headache , malaise, colds, lymph node
involvement on 3rd to 5th day
2. Eruptive FORSCHEIMERS SPOTS: pinkish rash on soft palate, rash
on face, spreading to the neck, arms and trunk
o lasts1-5 days with no pigmentation or desquamation
o muscle pain
Treatment
o symptomatic treatment
Complications
1. Encephalitis, neuritis
2. Rubella syndrome microcephaly, mental retardation, deaf mutism,
congenital heart disease

RISK for congenital malformation

1. 100% when maternal infection happens on first trimester of pregnancy.
 2. 4% - second/third trimester

Nursing Management
1. Isolation. Bed rest
2. Room darkened photophobia
3. Encourage fluid
4. Like measles tx

PREVENTION;
MMR, Pregnant women should avoid exposure to rubella patients
Administration of Immune serum globulin one week after exposure to rubella.

CHICKEN POX
Acute and highly contagious viral disease characterized by vesicular eruptions
on the skin
Infectious agent Herpes zoster virus or Varicella zoster
Incubation period 10 -21 days
Period of communicability: 1 day before eruption up to 5 days after the
appearance of the last crop
MOT: airborne, direct, indirect
o Direct contact thru shedding vesicles,
o Indirect thru linens or fomites

Manifestations
Pre eruptive: Mild fever and malaise
Eruptive: rash starts from trunk
Lesions - red papules then becomes milky and pus like within 4 days,
Pruritis

Stages of skin affectations

o Macule flat
o Papule elevated above the skin diameter about 3 cm
o Vesicle
o Pustule
o Crust scab , drying on the skin
Complications
o pneumonia, sepsis
Treatment
Zovirax 500mg tablet 1 tab BID X 7 days
Acyclovir
Oral antihistamine
Calamine lotion
Antipyretics

NURSING MANAGEMENT
Strict isolation until all vesicles scabs disappear
 Hygiene of patient
Cut finger nails short
Baking soda - pruritus
PREVENTION: Live attenuated varicella vaccine
VZIG - effective if given 96h post exposure

Herpes Zoster
Acute inflammatory disease known to be caused by herpes virus varicellae or
VZ virus
Infection of the sensory nerve charac by extremely painful infection along the
sensory nerve pathway
Occurs as reinfection of VZ virus
MOT
o Direct
o Indirect airborne
Incubation: 1-2 weeks

Diagnostic procedure
o Hx of chickenpox
o Pain and burning sensation over lesions of vesicles along nerve
pathway
o Smear of vesicle fluid- giant cells
o Viral cultures of vesicle fluid
o Electron microscopy
o Giemsa-stained scraping multinucleate giant epithelial cells
S/S
o Burning, itching, pain then erythematous patches followed by crops
of vesicles
o Eruptions are unilateral
o Lesions may last 1-2 weeks
o Fever, regional lymphadenopathy
o Paralysis of cranial nerve, vesicles at external auditory canal
 o Paralytic ileus, bladder paralysis, encephalitis

Complications
o Opthalmia herpes blindness because of damage of gasserian
ganglion
o Geniculate herpes deafness because of infection of 7 th CN (AKA:
Ramsay Hunt Syndrome)

Nursing Intervention
o Compress of NSS or alluminum acetate over lesions
o Analgesics, sedatives weeks to mos
o Steroids
o Keep blister covered with sterile powder esp after break
o Prevent bacterial invasion
o Encourage proper disposal of secretions and usage of gown and
mask

MUMPS
Acute viral disease manifested by swelling of one or both of the parotid
glands, with occasional involvement of other glandular
structures,particularly testes in male.
Etiologic agent filterable virus of paramyxovirus group usually found in
saliva of infected person.
AKA: Epidemic/ infectious parotitis
Incubation period: 14 -25 days.
Period of communicability 6d before and 9d post onset of parotid gland
swelling.
o 48 hrs immediately preceding the onset of swelling is the highest
communicability.
MOT: direct, indirect - droplet, airborne
CLINICAL MANIFESTATIONS
1. Sudden headache, earache, loss of appetite
2. Swelling of the parotid gland
3. Pain is related to extent of the swelling of the gland which reaches its peak in 2
days and continues for 7-10 days.
4. Fever may reach 40 C during acute stage,
5. One gland may be affected first and 2 days later the other side is involved

COMPLICATIONS
1. Orchitis testes are swollen and tender to palpation.
2. Oophoritis- pain and tendeness of the abdomen
3. Mastitis
4. Deafness may happen
5. Meningo-encephalitis -possible

DIAGNOSTIC PROCEDURES
1. Viral culture
2. WBC Count

PREVENTION: MMR Vaccine

TREATMENT MODALITIES
1. Antiviral drugs
2. NSAIDS - Acetaminophen
Nursing Interventions
o Symptomatic
o Application of warm/ cold compress
o Oral care, warm salt water gargle
o Diet semi solid, soft food easy to chew
Acid foods/fluids fruit juices may increase discomfort

Diseases Acquired thru GIT

Diseases caused by Bacteria
o Typhoid Fever
o Cholera
o Dysentery
Diseases caused by Virus
o Poliomyelitis
o Infectious Hepatitis A
Diseases caused by Parasites
o Amoebiasis
o Ascariasis

TYPHOID FEVER
 Infection of the GIT affecting the lymphoid tissues(ulceration of Peyers
patches) of the small intestine
Etiologic Agent: Salmonella typhosa and typhi, Typhoid bacillus
Incubation period: 1-2 weeks
Period of communicability: as long as the patient is excreting the
microorganism,
MOT: fecal-oral route, contaminated water, milk or other food
Sources of Infection
o A person who recovered from the disease can be potential carrier.
o Ingestion of shellfish taken from waters contaminated by sewage
disposal
o Stool and vomitus of infected person are sources of infection.

CLINICAL MANIFESTATIONS
ONSET
Ladderlike fever
Nausea, vomiting and diarrhea
RR is fast, skin is dry and hot, abdomen is distended
Head-ache, aching all over the body
Worsening of symptoms on the 4th and 5th day
Rose spots
TYPHOID STATE
Tongue protrudes- dry and brown
sordes
(coma vigil)
(subsultus tendinus)
 (Carphologia)
Always slip down to the foot part of the bed,
Severe case - delirum sets in often ending in death

Complications
o Hemorrhage, Peritonitis, Pneumonia, Heart failure, Sepsis

DIAGNOSTIC PROCEDURES
1. WBC elevated
2. Blood Culture (+) S. typhosa
3. Stool Culture (+)
4. Widal test blood serum agglutination test
O antigen active typhoid
H antigen- previously infected or vaccinated
Vi antigen - carrier

TREATMENT
1. Chloramphenicol drug of choice
2.Paracetamol

NURSING MANAGEMENT
1. Restore FE balance
2. Bedrest
3. Enteric precaution
4. Prevent falls/ safety prec
5. Oral/personal hygiene
6. WOF intestinal bleeding-bloody stool, sweating, pallor
7. NPO, BT

CHOLERA
An acute bacterial disease of the GIT characterized by profuse diarrhea,
vomiting, loss of fluid.
Etiologic agent: Vibrio cholerae, V. comma
Pathognomonic sign: rice watery stool
Incubation period: 2-3 days
Period of Communicability: entire illness, 7-14d
MOT: fecal oral route
Clinical manifestations
o Acute, profuse, watery diarrhea.
o Initial stool is brown and contains fecal material becomes rice water
o Nausea/ Vomiting
Signs and symptoms of Dehydration
o poor tissue turgor, eyes are sunken
o Pulse is low or difficult to obtain, BP is low and later unobtainable.
o RR rapid and deep
o Cyanosis later
o Voice becomes hoarse speaks in whisper
Oliguria or anuria
Conscious, later drowsy
Deep shock
Death may occur as short as four hours after onset.
Usually first or 2nd day if not treated.

Principal deficits
1. Severe dehydration - circulatory collapse
2. Metabolic acidosis loss of large volume of bicarbonate rich stool. RR rapid
and deep
3. Hypokalemia massive loss of K. abdominal distention paralytic ileus

DIAGNOSTIC EXAMS
Fecal microscopy
1. Rectal swab
2. Stool exam

Treatment
1. IVF- rapid replacement
2. Oral rehydration
3. Strict I and O
4. Antibiotics Tetracycline, Cotrimoxazole.
NURSING MANAGEMENT
1. Medical Asepsis
2. Enteric precaution
3. VS monitoring
4. Intake and Output
5. Good personal hygiene
6. Proper excreta disposal
7. Concurrent disinfection.
8. Environmental sanitation

PREVENTION
1. Protection of food and water supply from fecal contamination.
2. Water should be boiled/ chlorinated.
3. Milk should be pasteurized.
4. Sanitary disposal of human excreta
5. Environmental sanitation.

DYSENTERY
Acute bacterial infection of the intestine characterized by diarrhea and
fever
Etiologic Agent: Shigella group
o Shigella flesneri - commmon in the Philippines
o Shigella boydii, S. connei,
o S. dysenteria most infectious, habitat exclusively in man, they
develop resistance to antibiotics
Incubation period 7 hrs. to 7 days
Period of communicability during acute infection until the feces are (-)
MOT fecal-oral route, contaminated water/ milk/ food.

Clinical manifestations
Fever esp. in children
Nausea, vomiting and headache
Anorexia, body weakness
 Cramping abdominal pain (colicky)
Diarrhea bloody and mucoid
Tenesmus
Weight loss

DIAGNOSTICS
Fecalysis
Rectal Swab/culture
Bloods WBC elevated
Blood culture

TREATMENT
Antibiotics- Ampicillin, Cotrimoxazole, Tetracycline
IVF
Anti diarrheal are Contraindicated

NURSING MANAGEMENT
1. Maintain fluid and electrolyte balance
2. Restrict food until nausea and vomiting subsides.
3. Enteric precaution
4. Excreta must be disposed properly.
5. Prevention- food preparation, safe washing facilities, fly control.

POLIOMYELITIS
An acute infectious disease caused by any of the 3 types of poliomyelitis virus
which affects mainly the anterior born cells of the spinal cord and the medulla,
cerebellum and the midbrain
AKA: Acute anterior poliomyelitis, heinmedin disease, infantile paralysis
Etiologic Agent: Poliovirus (Legio Debilitans)
3 Types of Poliovirus
Type I - most paralytogenic, most frequent
Type II - next most frequent
Type III - least frequent associated with paralytic disease

3 Strains
o Brunhilde
o Laasing
o Leon
MOT: Fecal-Oral
Incubation period: 7-14 days ave (3-21 days)
Period of communicability:
o 7-16 days before and few days after onset of s/s
Signs and Symptoms:
o Febrile episodes with varying degrees of muscle weakness
o Occasionally progressive Flaccid Paralysis
3 Types of Paralysis
Spinal Paralytic
o Flaccid paralysis
o Autonomic involvement
o Respiratory difficulty
Bulbar Form
o Rapid & serious
o Vagus and glossopharyngeal nerves affected
o Cardiac and respiratory reflexes altered
o Pulmo edema
o Hypertension, impaired temp regulation
o Encephalitic s/s
Bulbospinal
o Combination
Minor Polio
o Inapparent / subclinical
o Abortive: recover within 72 hours; flulike; backache; vomiting
Major Polio
o Paralytic: asymmetrical weakness, paresthesia, urinary
retention, constipation
o Non paralytic: slight involvement of the CNS; stiffness and
rigidity of the spine, spasms of hamstring muscles, with paresis
o Tripod position: extend his arms behind him for support when
upright
o Hoynes sign: head falls back when he is in supine position with
the shoulder elevated
o Meningeal irritation: (+) Brudzinski, Kernigs sign

Diagnostic tests:
 Throat swab, stool exam, LP

Nursing Interventions:
Supportive, Preventive Salk and Sabin Vaccine
NO morphine
Moist heat application for spasms
AIRWAY: tracheotomy
Footboard to prevent foot drop
Fluids, NTN, Bedrest
Enteric and strict precautions

HEPATITIS A
Inflammation of the liver caused by hepatitis A virus
AKA: infectious hepatitis
Incubation period: 2-6weeks
MOT: oral-fecal/ enteric transmission
Diagnostic test: liver function (SGOT/SGPT)

Clinical manifestations
Prodromal/ pre icteric
S/S of URTI
Weight loss
Anorexia
RUQ pain
Malaise
Icteric
Jaundice
Acholic stool
 Bile-colored urine

Diagnostic tests: HaV Ag, Ab, SGOT, SGPT

Nursing Interventions:
o Provide rest periods
o Increase CHO, mod Fat, low CHON
o Intake of vits/minerals
o Proper food preparation/handling
o Handwashing to prevent transmission

AMOEBIASIS
Involves the colon in general but may involve the liver or lungs as well
Etiologic agent: Entamoeba histolytica
Incubation: 3-4 weeks
Period of communicability: duration of illness
MOT: fecal oral route
Indirect - Ingestion of food contaminated with E.Histolytica cysts,
polluted water supply, exposure to flies, unhygienic food handlers.
Direct contact sexual, oral, or anal, proctogenital

Clinical manifestations
Intermittent fever
Nausea, vomiting, weakness
Later : anorexia, weight loss, jaundice
Diarrhea watery and foul smelling stool often containing blood streaked
mucus.
Colic and abdominal distention
Intestinal perforation bleeding

DIAGNOSTIC EXAM
Stool Exam ( cyst, amoeba+++)
WBC elevated
TREATMENT
o Amoebacides Metronidazole(Flagyl) 800mg TID X 7days
o Bismuth gylcoarsenilate combined with Chloroquine
o Antibiotic Ampicillin, Tetracycline, Chloramphenicol
o Fluid replacement IVF, oral

NUSING MANAGEMENT
Enteric precaution
Health education- boil drinking water (20-30 mins), Use mineral water.
Cover leftover food.
Avoid washing food from open drum/pail.
Wash hands after defecating and before eating.
Observe good food preparations.
Fly control

ASCARIASIS
Helminthic infection of the small intestine caused by ASCARIS
LUMBRECOIDES
MOT: fecal-oral
Incubation period: 4-8 weeks
Communicability: as long as mature fertilized female worms live in intestine

Diagnostic exams: Microscopic identification of eggs in stool, CBC, Hx of passing

out of worms (oral or anal), X-ray.

Signs and Symptoms

o Stomachache
o Vomiting
o Passing out of worms
o Complications
o Energy / Protein malnutrition, Anemia
o Intestinal obstruction

Treatment:
o Pyrantel Pamoate
o Piperazine Citrate
o Mebendazole, Tetramizole
o Dicyclomine Hcl, NSAIDS for abdominal pain
o For intestinal obstruction
Decompression
Fluid and electrolyte therapy
If persistent, laparotomy
o Follow-up stool exam 1-2 weeks after treatment

Nursing Intervention:
 o Isolation- not needed
o Enteric precaution
o Handwashing
o Proper nutrition
o Maintenance of hydration / fluid balance / boil of water
o Improve personal hygiene
o Proper food prep/handling
o Administer meds (NSAIDS, MEBENDAZOLE).

Diseases Acquired thru the Skin

Diseases caused by Trauma and Inoculation
o Tetanus
o Rabies
o Malaria
o DHF
o Leptospirosis
o Schistosomiasis
Diseases acquired thru contact
o Leprosy

TETANUS
An acute, often fatal, disease characterized by generalized rigidity and
convulsive spasms of skeletal muscles caused by the endotoxin released by
C. Tetani
AKA: Lockjaw

Etiologic Agent: Clostridium Tetani

o Anerobic
o Spore forming, gram positive rod

Sources:
o Animal and human feces
o Soil and dust
o Plaster, unsterile sutures, rusty scissors, nails and pins

MOT:
o Direct or indirect contact to wounds
o Traumatic wounds and burns
o Umbilical stump of the newborn
o Dirty and rusty hair pins
o GIT- port of entry rare
o Circumcision/ ear pearcing

Incubation period: 3d-3week (ave:10days).

Signs and symptoms:
persistent contraction of muscles in the same anatomic area as the
injury
Local tetanus
Cephalic tetanus - rare form
o otitis media (ear infections)
Generalized tetanus
o trismus or lockjaw
o stiffness of the neck
o difficulty in swallowing
o rigidity of abdominal muscles
o elevated temperature
o sweating
o elevated blood pressure episodic rapid heart rate
Neonatal tetanus - a form of generalized tetanus that occurs in
newborn infants

Complications:
o Laryngospasm
Hypostatic pneumonia
Hypoxia
Atelectasis

o Trauma
Fractures
o Septicemia
Nosocomial infections
o Death
Diagnostic procedure:
entirely clinical
CSF normal
WBC - normal or slight elevation

Treatment:
Wounds should be cleaned
Necrotic tissue and foreign material should be removed
Tetanic spasms - supportive therapy and maintenance of an adequate
airway
Tetanus immune globulin (TIG)
o help remove unbound tetanus toxin
o cannot affect toxin bound to nerve endings
o single intramuscular dose of 3,000 to 5,000 units
o Contains tetanus antitoxin.
Oxygen
NGT feeding
Tracheostomy
Adequate fluid, electrolyte, caloric intake
During convalescence
o Determine vertebral injury
o Attend to residual pulmonary disability
o Physiotherapy
o Tetanus Toxoid
Nursing Interventions:
Prevention
DPT
o Adverse Reactions
o Local reactions (erythema, induration)
o Fever and systemic symptoms not common
o Exagerated local reactions

Nursing interventions:
Prevention of CV and respiratory complications
o Adequate airway
o ICU ET- MV
Provide cardiac monitoring
KVO
Wound care (TIG, Debridement, TT)
Administer antibiotics as ordered
o Penicillin
Care during tetanic spasm/ convulsion
o Administer Diazepam muscle rigidity/spasm
 o Administer neuromuscular blocking agents (metocurin iodide) relax
spasms and prevent seizure
Keep on seizure precaution
Parenteral nutrition
Avoid complications of immobility (contractures, pressure sores)
WOF urinary retention, fractures

RABIES
A viral zoonotic neuroinvasive disease that causes acute encephalitis
Etiologic agent: Rhabdovirus
AKA: Hydrophobia, Lyssa
Negri bodies in the infected neurons pathognomonic
Incubation period: 4-8 weeks; 10d-1yr
Period of communicability: 3-5 days before the onset of s/s until the
entire course of disease
MOT: contamination of a bite of infected animals
Diagnostic procedures
O History of exposure
O PE/ assessment of s/s
O Microscopic examination of Negri bodies using Sellers May-Grunwald
and Mann Strains
O Fluorescent Rabies Antibody technique / Direct Immunofluorescent test.

Clinical Manifestations
Prodromal Phase / Stage of Invasion
Fever, anorexia, malaise, sorethroat, copious salivation, lacrimation,
perspiration, irritability, hyperexcitability, restlessness, drowsiness, mental
depression, marked insomia
Sensitive to light, sound, and changes in temp
Myalgia, numbness, tingling, burning or cold sensation along nerve
pathway; dilation of pupils
Stage of Excitement
Marked excitation, apprehension
Delirium, nuchal stiffness, involuntary twitching
Painful spasms of muscles of mouth, pharynx, and larynx on
attempting to swallow food or water or the mere sight of them
hydrophobia
Aerophobia
Precipitated by mild stimuli touch or noise
Death spasm from or from cardiac / respiratory failure
Terminal Phase or Paralytic Stage
Quiet and unconscious
Loss of bowel and bladder control
Tachycardia, labored irregular respiration, steady rising temp
Spasm, progressively increasing paralysis
Death due to respiratory paralysis

TREATMENT:
No cure
No specific symptomatic/ supportive directed toward alleviation of
spasm
Employ continuing cardiac and pulmonary monitoring
Assess the extent and location of the bite biting incident/ status of
the animal
o Severe exposure
o Mild exposure
Wound treatment (local care)
o Cleanse thoroughly with soap and water (or ammonium
compounds, betadine, or benzalkonium cl)
o Anti - rabies serum
o Tetanus prophylaxis
o Antibiotics
o Suturing should be avoided
Antirabies sera
o Heterologous serum obtained by hyperimmunization of
different animal species i.e. horses
o HRIG Homologous reabies immunoglobulin human origin
Rabies Vaccine
Active immunization
o Administered 3 years duration
o Used for lower extremity bites
o Lyssavac (purified protein embryo), Imovax, Anti-rabies
vaccine
Passive immunization
o 3 months
o Rabuman, Hyper Rab, Imogam
Nursing Intervention:
o Isolation of patient
o Provide comfort for the patient by:
Place padding of bedside or use restraints
Clean and dress wound with the use of gloves
Do not bathe the patient, wipe saliva or provide sputum
jar
o Provide restful environment
Quiet, dark environment
Close windows, no faucets or running water should be
heard
IVF should be covered
No sight of water or electric fans

MALARIA
Acute and chronic disease transmitted by mosquito bite confined mainly to
tropical areas.
Etiologic agent Protozoa of genus Plasmodia
Plasmodium Falciparum (malignant tertian)
o most serious, high parasitic densities in RBC with tendency to agglutinate
and form into microemboli. Most common in the Philippines
P. Vivax - non life threatening except for the very young and old.
o Manifests chills every 48 hrs on the 3rd day onward if not treated,
P. malarie (Quartan) less frequent, non life threatening, fever and chills occur
every 72 hrs on the 4th day of onset
P. ovale - rare
Incubation period:
o 12days P. falciparum, 14 days P vivax and ovale, 30 days P. malariae
Period of communicability:
o If not treated /inadequate more than 3 yrs. P malariae, 1-2 yrs. P. vivax, 1
yr- P. falciparum
Mode of transmission
o Mosquito bite

VECTOR female Anopheles mosquito

DIAGNOSTICS
Malarial smear film of blood is placed on a slide, stained and examined.
Rapid diagnostic test (RDT) done in field. 10 -15 mins result blood test.
Clinical Manifestions:
Rapidly rising fever with severe headache
Shaking chills
Diaphoresis, muscular pain
Splenomegaly, hepatomegaly
Hypotension
o May lasts for 12 hours daily or every 2 days.
Complicated Malaria
GIT
o Bleeding from GUT, N/V, Diarrhea, abdominal pain, gastric, tyhoid, choleric,
dysenteric
CNS or Cerebral Malaria
o Changes in sensorium
o Severe headache
o N/V
Hemolytic
Blackwater fever
o Reddish to mahogany colored urine due to hemoglobinuria
o Anuria death
Malarial lung disease

MANAGEMENTS:
Antimalarial drugs Chloroquine (all but P. Malarie), quinine, Sulfadoxine
(resistant P falciparum) Primaquine (relapse P vivax/ovale)
RBC replacement/ erythrocyte exchange transfusion

Nursing management:
Isolation of patient
Use mosquito nets
Eradicate mosquitos
 Care of exposed persons case finding
I and O
BUN & creatinine dialysis could be life saving
ABG
TSB, ice cap on head
Hot drinks during chilling, lots of fluid
Monitoring of serum bilirubin
Keep clothes dry, watch for signs of bleeding
PREVENTION
o Mosquito breeding places should be destroyed
o Insecticides, insect repellant
o Blood donor screening.

DENGUE FEVER
Is an acute febrile disease cause by infection with one of the serotypes of
dengue virus which is transmitted by mosquito (Aedes aegypti).
Dengue hemorrhagic fever fatal characterized by bleeding and
hypovolemic shock
Etiologic agent Arbovirus group B
AKA: Chikungunya, O nyong nyong, west nile fever
Mode of Transmission: Bite of infected mosquito AEDES AEGYPTI
Incubation period 3-14 days
Period of communicability mosquito all throughout life
Sources of infection
Infected person- virus is present in the blood and will be the reservoir
when sucked by mosquitoes
Stagnant water = any

Diagnostic Tests:
Torniquet test
Platelet Count
Hematocrit
Manifestations
PRODROMAL symptoms
o malaise and anorexia up to 12 hrs.
o Fever and chills, head-ache, muscle pain
o N &V
FEBRILE Phase
o Fever persists (39-40 C)
o Rash - more prominent on the extremities and trunk
o (+) torniquet test- petechia more than 10.
o Skin appears purple with blanched areas with varied sizes (
Hermans sign)
o Generalized or abdominal pain
o Hemorrhagic manifestations epistaxis, gum bleeding
CIRCULATORY Phase
o Fall of temp on 3rd to 5th day
o Restless, cool clammy skin
o Profound thrombocytopenia
o Bleeding and shock
o Pulse - rapid and weak
o Untreated shock --- coma death
o Treated recovery in 2 days
CLASSIFICATION
Grade 1
Grade 2
Grade 3
Grade 4

Treatment:
No specific antiviral therapy for dengue
Analgesic not aspirin for relief of pain
IV fluid
BT as necessary
O2 therapy

NURSING MANAGEMENT
1. Kept in mosquito free environment
2. Keep pt. at rest
3. VS monitoring
4. Ice bag on the bridge of nose and forehead.
5. Observe for signs of shock VS (BP low), cold clammy skin

PREVENTION:
Mosquito net
Eradication of breeding places of mosquito-
 o house spraying
o change water of vases
o scrubbing vases once a week
o cleaning the surroundings
o keep water containers covered
o avoid too many hanging clothes inside the house

LEPTOSPIROSIS
Infectious bacterial disease carried by animals whose urine contaminates water
or food which is ingested or inoculated thru the skin.
Etiologic agent: spirochete Leptospira interrogans
o found in river, sewerage, floods
AKA: Weils disease, mud fever, Swineherds disease
Incubation Period: 6 -15 days
Period of Communicability found in urine between 10-20 days
MOT contact with skin of infected urine or feces of wild/domestic animals;
ingestion, inoculation
Diagnostic tests:
o Clinical manifestations
o Culture

SOURCE OF INFECTION
o Rats, dogs, mice

MANIFESTATIONS
o Septic Stage
Early
Fever (40 C), tachycardia, skin flushed, warm, petechiae
Severe
Multiorgan
Conjunctival affectation, jaundice, purpura, ARF, Hemoptysis,
head-ache, abdominal pain, jaundice
 o Toxic stage with or w/o jaundice, meningeal irritation, oliguria
shock, coma , CHF
o Convalescence recovery

MANAGEMENT
1. IV antibiotic
Pen G Na
Tetracycline
Doxycycline
2. Dialysis peritoneal
3. IVF
4. Supportive
5. Symptomatic

Nursing Interventions
o Isolation of patient urine must properly disposed
o Care of exposed persons keep under close surveillance
o Control measures
Cleaning of the environment/ stagnant water
Eradicate rats
Avoid bathing or wading in contaminated pool of water
vaccination of animals (cattles,dogs,cats,pigs)

SCHISTOSOMIASIS
Parasitic disease caused by Schistosomiasis japonicum, Schistosomiasis
mansoni, Schistosomiasis Hematobium.
AKA: Bilharziasis, Snail fever.
Incubation Period: 2 6 weeks
MOT: Bathing, swimming, wading in water.
Vector: Oncomelania quadrasi
o Cercariae: most effective stage
Diagnostic test: Ova seen in fecalysis
Diagnostic procedures:
Fecalysis
Identification of eggs
Liver and rectal biosy
Immunodiagnostic tests / circumoval precipitin test and cercarial envelope
reactions.
Signs and symptoms:
o Swimmers itch
Itchiness
Redness and pustule formation at site of entry of cercariae
Diarrhea
Abdominal pain
hepatosplenomegaly

CLINICAL MANIFESTATIONS:
Abdominal pain
Cough
Diarrhea
Eosinophilia - extremely high eosinophil granulocyte count.
Fever
Fatigue
Hepatosplenomegaly - the enlargement of both the liver and the spleen.
Colonic polyposis with bloody diarrhea (Schistosoma mansoni mostly)
Portal hypertension with hematemesis and splenomegaly (S. mansoni, S.
japonicum);
Cystitis and ureteritis with hematuria bladder cancer;
Pulmonary hypertension (S. mansoni, S. japonicum, more rarely S.
haematobium);
Glomerulonephritis; and central nervous system lesions.
Complications:
O Pulmonary hypertension
 O Cor pulmonale
O Myocardial damage
O Portal cirrhosis

Treatment:
Trivalent antimony
o Tartar emetic administered thru vein
o Stibophen (FUADIN) given per IM
PRAZIQUANTEL per orem
Niridazole

Nursing Interventions:
o Administer prescribed drugs as ordered
o Prevent contact with cercaria-laden waters in endemic areas like streams
o Proper sanitation or disposal of feces
o Creation of a program on snail control chemical or changing snail
environment

LEPROSY
Chronic systemic infection characterized by progressive cutaneous lesions
Etiologic agent: Mycobacterium leprae
o Acid fast bacilli that attack cutaneous tissues, peripheral nerves producing
skin lesions, anesthesia, infection and deformities.
Incubation period 5 1/2 mo - eight years.
MOT respiratory droplet, inoculation thru break in skin and mucous
membrane.

Diagnosis:
1. Identification of S/s
2. Tissue biopsy
3. Tissue smear
4. Bloods inc. ESR
5. Lepromin skin test
6. Mitsuda reaction

MANIFESTATIONS
Corneal ulceration, photophobia blindness
Lesions are multiple, symmetrical and erythematous macules and papules
Later lesions enlarge and form plaques on nodules on earlobes, nose
eyebrows and forehead
Foot drop
Raised large erythemathous plaques appear on skin with clearly defined
borders. rough hairless and hypopigmented leaves an anesthetic scar.
Loss of eyebrows/eyelashes
Loss of function of sweat and sebaceous glands
Epistaxis
TREATMENT
multiple drug therapy
sulfone
rehab
occupational Health
isolation
moral support

PREVENTION
1. Report cases and suspects of leprosy
2. BCG vaccine may be protective if given during the first 6 months.
3. Nursing Interventions:
1. Isolation of patient until causative agent is still present
2. Care of exposed persons
1. Household contact Diaminodiphenylsulfone for 2 years
2. Observe carefully for symptoms of the disease.

Disease Acquired Thru Sexual Contact

HIV /AIDS
Chronic disease that depresses immune function
Characterized by opportunistic infections when T4/CD4 count drops <200
MOT sexual contact with infected unprotected, injection of blood/products,
placental transmission.

History of HIV / AIDS

1959 - African man
1981- 5 homosexual men
1982-Designated as disease by CDC
1983- HIV 1 discovered
1987- 1.5 million HIV-infected in USA
1994- WHO reports 8-10 mil. Worldwide & protease inhibitors introduced
1999-First clinical trials for HIV vaccine
The immune system
o Macrophages
Humoral response
Cell-mediated response

The HIV
RNA virus
Retrovirus
Reverse transcriptase
Protease

Diagnostic Tests
ELISA
Western Blot
CD4 count
Viral load testing
Home test kits

Manifestations
o Minor signs cough for one month, general pruritus, recurrent herpes zoster,
oral candidiasis, generalized lymphadenopathy
o Major signs loss of weight 10% BW, chronic diarrhea 1month up, prolonged
fever one month up.
Persistent lymphadenopathy
Cytopenias (low)
 PCP
Kaposis sarcoma
Localized candida
Bacterial infections
TB
STD
Neurologic symptoms

Criteria for Diagnosis of AIDS

CD4 counts of 200 or less
Evidence of HIV infection and any of
o Thrush
o Bacillary angiomatosis
o Oral hairy leukoplakia
o Peripheral neuropathy
o Vulvovaginal candidiasis
o Shingles
o Idiopathic thrombocytopenia
o Fatigue, night sweats, weight loss.
o Cervical dysplasia, carcinoma in situ.
Evidence of HIV infection and any one of the following:
O Bronchial candidiasis
O Esophageal candidiasis
O CMV disease
O CMV retinitis
O HIV encephalopathy
O Histoplasmosis
O Kaposis Sarcoma
O Herpes simplex ulcers, bronchitis, pneumonia
O Primary brain lymphoma
O Pneumocystis Carinii Pneumonia
O Recurrent pneumonia
O Mycobacterium infection
O Progressive multifocal leukoencepalopathy
O Salmonella septicemia
O Toxoplasmosis
O Wasting syndromes

Treatment
Started in CD4 counts of <200
Viral load >10,000 copies
All symptomatic regardless of counts
Note: CD4 reflects immune system destruction. Viral load- degree of viral
activity
Nucleoside Reverse Transcriptase Inhibitors
Blocks reverse transcriptase
NRT
Acts by binding directly to the reverse transcriptase enzyme
Not used alone
Rapid development of resistance
Acts by binding directly to the reverse transcriptase enzyme
Not used alone
Rapid development of resistance

Generic Trade Dose Notes

Zidovudine AZT, ZDV, 300 mg. Taken with food

Retrovir Bid

Didanosine ddI, Videx 200 mg Peripheral

bid neuropathy

Zalcitibine ddC,Hivid .75 mg No antacids

TID

Stavudine d4T, Zerit 400 mg Peripheral

bid neuropathy

Lamivudine 3TC, Epivir 150 mg Used as

bid resistance
develops

Lamiduvine/Zido Combivir 150/300 Bone marrow

vudine mg toxicity

Protease Inhibitors
Introduced in 1995
Acts by blocking protease enzyme
Indinavir (Crixivan)

CDC Guidelines
o Combination of 2 NRTI + PI
Nursing Management
o Administer Antiviral meds as ordered
o Universal precaution
o Reverse isolation
gloves, needle stick injury prevention
o Assist in early diagnosis and management of complications
4 Cs
o Compliance info, + drugs
o Counselling education
o Contact tracing tracing out and tx for partners
o Condoms safe sex

GONORRHEA
 A curable infection caused by the bacteria Neisseria gonorrhoea
AKA: Clap, Drip, G. vulvovaginitis
MOT: transmitted during vaginal, anal, and oral sex
Incubation period: 3-10 days initial manifestations
Period of communicability: considered infectious from the time of
exposure until treatment is successful
Manifestations:
Urethritis both male and female
Signs and Symptoms: dysuria and purulent discharge
Cervicitis
Upper Genital Tract females (PID)
Endometritis, Salpingitis,
Pelvic Abscess
Complications :
PID
Infertility

Complications:
Upper Genital Tract male
o Epididymitis, Prostatitis, Seminal Vesiculitis
Disseminated Gonococcal Infection (DGI)
o Tenosynovitis or Polyarthritis, skin lesions and fever
Anorectal Infection
Pharyngeal Infection
Gonococcal Conjuctivitis
o Opthalmia Neonatorum
Meningitis, Endocarditis

Diagnosis:
Culture & Sensitivity
Blood tests for N. gonorrhoeae antibodies

Treatment:
ANTIBIOTICS
Penicillin
Single dose Ceftriaxone IM + doxycycline PO BID for 1 week
Prophylaxis: Silver nitrate, Tetracycline, Erythromycin

Nursing Interventions:
o Case finding
o Health teaching on importance of monogamous sexual relationship
o Treatment should be both partners to prevent reinfection
o Instruct possible complications like infertility
o Educate about s/s and importance of taking antibiotic for the entire
therapy
SYPHILIS
a curable, bacterial infection, that left untreated will progress through four
stages with increasingly serious symptoms.
Etiologic agent: Treponema pallidum
AKA: Lues, The pox, Bad blood
Type of Infection: Bacterial
Modes of transmission :
o Through sexual contact/ intercourse, kissing
o abrasions
o Can be passed from infected mother to unborn child (transplacental)
Symptoms:
o Primary syphilis (10 90 days after infection)
Chancre a firm, painless skin ulceration localized at the
point of initial exposure to the bacterium appear on the
genitals
can also appear on the lips, tongue, and other body
parts.
o Secondary syphilis (last 2 6 weeks)
syphilis rash - an infectious brown skin rash that typically
occurs on the bottom of the feet and the palms of the hand
condylomata lata - flat broad whitish lesions
Fever, sore throat, swollen glands, and hair loss can also be
experienced
Third stage
o Will manifest 1 10 years after the infection
o characterised by gummas - soft, tumor-like growths
seen in the skin and mucous membranes occurs in bones
o joint and bone damage
o increasing blindness
o Numbness in the extremities, or difficulty in coordinating movements.

Neurosyphilis
generalized paresis of the insane which results in personality
changes, changes in emotional affect, hyperactive reflexes
cardiovascular syphilis
aortitis, aortic aneurysm, Aneurysm of sinus of valsalva and aortic
regurgitation, - death

Consequences in Infants
Congenital syphilis
extremely dangerous
Deformities
Seizures
Blindness
Damage to the brain, bones, teeth, and ears.
Test and diagnosis
Venereal Disease Research Laboratory (VDRL) test
Flourescent treponemal antibody absorption (FTA Abs)
Micro hemagglutination test (MHA - TP)
CSF examination
Treatment
Syphilis is easily treatable when early detected
Penicillin & other antibiotics

Prevention:
Abstinence
Mutual monogamy
Latex condoms for vaginal and anal sex
Nursing interventions
o Case finding
o Health teaching and guidance along preventive measures
o Utilization of community health facilities
o Assist in interpretation and diagnosis
o Reinforce ff up treatment
o VD control program participation
o Medical examination of patients contacts

HEPATITIS B
serious disease caused by a virus that attacks the liver
Etiologic agent: hepatitis B virus (HBV)
Source of infections: Blood and body secretions

Risk factors
multiple sex partners or diagnosis of a sexually transmitted disease
Sex contacts of infected persons
Injection-drug users
Household contacts of chronically infected persons
Infants born to infected mothers
Infants/children of immigrants from areas with high rates of HBV infection
Health-care and public safety workerr
Hemodialysis patients

Complications:
Lifelong infection
Liver cirrhosis
Liver cancer
Liver failure
Death
Signs and symptoms:
Jaundice
Pruritus
Fatigue
RUQ - Abdominal pain
Loss of appetite
Nausea, vomiting
Joint pain

Prevention:
Hepatitis B vaccine has been available since 1982.
o Routine vaccination of 0-18 year olds
o Vaccination of risk groups of all ages
Immune globulin if exposed

MEDICAL MANAGEMENT:
Interferon alfa-2b
Lamivudine
Telbivudine
Entecavir
Adefovir dipivoxil

Nursing Interventions:
o Blood and body secretions precautions
o Prevention- Hepa B vaccine
o Proper rest periods
o Prevent stress physio/psychological
o Proper NTN, increase in CHO, high in CHON, low fats, Vit. K rich
foods and minerals
o Assistance to prevent injury, promote safety AAT
o WOF signs and symptoms bleeding, edema
o Health education on safe sex.

SEVERE OF ACUTE RESPIRATORY SYNDROME

An acute and highly contagious respiratory disease in humans
Etiologic agent: SARS coronavirus
November 2002 and July 2003, with 8,096 known infected cases and 774
deaths
Incubation period: 2-3days
MOT: Airborne

Signs and symptoms:

o flu like: fever, myalgia, lethargy, gastrointestinal symptoms, cough,
sore throat
o fever above 38 C (100.4 F)
 o Shortness of breath
o Symptoms usually appear 210 days following exposure
o require mechanical ventilation

Diagnostic Test:
Chest X-ray (CXR)- abnormal with patchy infiltrates
WBC and PLT CT. - LOW
ELISA test detects antibodies to SARS
o but only 21 days after the onset of symptoms
Immunofluorescence assay, can detect antibodies 10 days after the onset
of the disease.
o labour and time intensive test
Polymerase chain reaction (PCR) test that can detect genetic material of
the SARS virus in specimens ranging from blood, sputum, tissue samples
and stools
CXR - increased opacity in both lungs, indicative of pneumonia
SARS may be suspected
fever of 38 C (100.4 F) or more AND
Either a history of:
o Contact (sexual or casual) with someone with a diagnosis of SARS
within the last 10 days OR
o Travel to any of the regions identified by the WHO as areas with
recent local transmission of SARS (affected regions as of 10 May
2003 were parts of China, Hong Kong, Singapore and the province
of Ontario, Canada).
probable case of SARS has the above findings plus positive chest x-ray
findings of atypical pneumonia or respiratory distress syndrome

Treatment
Supportive with antipyretics, supplemental oxygen and ventilatory support
as needed.
Suspected cases of SARS must be isolated, preferably in negative pressure
rooms, with full barrier nursing precautions taken for any necessary contact
with these patients
steroids
antiviral drug
SARS vaccine
 Tuberculosis*
Leprosy*
Schistosomiasis*
Filariasis
Malaria*
Dengue Hemorrhagic Fever (H-Fever)*
Measles*
Chicken Pox (Varicella)
Mumps (Epidemic Parotitis)*
Diptheria
Whooping Cough (Pertussis)
Tetanus Neonatorum and Tetanus among older age groups*
Influenza
Pneumonias
Cholera (El Tor)*
Typhoid Fever*
Bacillary Dysentery (Shigellosis)*
Soil Transmitted Helminthiases
Paragonimiasis
Hepatitis A*
Paralytic Shellfish Poisoning (PSP I RED TIDE POISONING)
Leptospirosis*
Rabies*
 Scabies
Anthrax
Sexually Transmitted Infections
i. Gonorrhea*
ii. Syphilis*
iii. Chlamydia
iv. Gardianella Vaginitis
v. Trichomoniasis
vi. Hepatitis B*
HIV/AIDS*
Meningococcemia
Bird Flu or Avian influenza
SARS Severe Acute Respiratory Syndrome*

Comprehensive Maternal and Child Health Program

*EPI ( EXPANDED PROGRAM ON IMMUNIZATION )
*CDD ( CONTROL OF DIARRHEAL DISEASES )
*CARI (CONTROL OF ACUTE RESPIRATORY INFECTIONS )
*UFC (UNDER FIVE CLINICS )
*MC ( MATERNAL CARE )
*BF ( BREAST FEEDING )
*MRP ( MALNUTRITION REHABILITATION PROGRAM )
*VAD (VITAMIN A DEFICIENCY )
*IDD / IDA ( IODINE DEFICIENCY DISORDERS / IRON DEFICIENCY ANEMIA )
*FP ( FAMILY PLANNING )

*EPI (EXPANDED PROGRAM ON IMMUNIZATION )

PD 996 Compulsory Basic Immunization to all
children before reaching 8 years old
Started in 1976 by MOH
Target Population:
A. Infants (0-12 months):
BCG, DPT, OPV& Measles
HBV (1996)
B. School Entrants:
MECS: Grade 1=7 years old
DECS: Grade 1=6 yrs. old (1993)
Booster of BCG
RA 7846 Compulsory HBV before 8 years
old:1996
PP 4 Measles Elimination Program
(September & October) 1994-
1997-Ligtas Tigdas (6 months-8
years)

PP 6 Universal Mother & Child Immunization

Law advocated by WHO from 1996 and
onwards: 5 vaccines + Tetanus Toxoid
Strengthens the EPI Program
1. Pregnant mothers-Tetanus Toxoid
2. Children:
Infants-5 vaccines
School entrants-BCG booster dose
3. Before EPI total immunization-5
After EPI total immunization-6
(Tetanus
toxoid was included)
4. OPV was given to all children under
5 years old irregardless of the # of
doses & the time OPV was given

PP 147 Declaring the National Immunization

Day Plus (NIDs Plus) initiated by
former Sec. Flavier in 1993-95
Initially every 3rd Wednesday of
January & February (1993-1995)
1996 to present: Still being practiced
but not every 3rd Wednesday of
January & February
2002: 2nd Tuesday of March & April
At present: depends on the Secretary
PP 773 Launched the Polio Elimination
Program (PEP) 1995-2000: Zero Polio
Philippines, 1. Knock Out Polio (KOP)
2. Zero Polio Philippines (1996-2000)
3. Patak Polio (< 5 years old)
PP 1064 AFP (Acute Flaccid Paralysis)
Elimination Program-an adverse effect
of Polio
PP 1066 Neonatal Tetanus Elimination
Morbidity
Mortality
*RSI locates a venue for immunization called Patak Center and composed of 1
organizer, 1 runner, 1 vaccinator, 1 recorder and 1 health educator catering to a
population of 1,000

Policies of EPI:
I. Coverage--------------------------------------
A. Target Setting
B. FIC ( Full Immunized Child )
C. Wastage Allowance
OBJECTIVES OF EPI: To reduce morbidity and mortality rates among infants and
children from 6 or 7 immunizable disease
II. Cold Chain
III. Immunization Technical Responsibilities of PHN
IV. Surveillance--------------------------------
Planning, Supervision, and Training---
Mobilization, Monitoring and Health Education Administrative and
Supportive Role of PHN
Referral, Research and Evaluation ---

I. Coverage
A. Target Setting:
1. Target Population is the population group meant to be benefited by the EPI
Programs where DOH is responsible.
a. Infants ( 0 12 ) get the 3% of population
b. School Entrants get the 3% of population ( dictum of DOH ) = 6 years
c. Pregnant Women get the 3.5 % of population ( MWKA ) = 15 49 years
2. Eligible Population ( EP ) rae those qualified to receive specific immunizations
where PHW is responsible PHN, RHM, MO
*3 Population Groups to benefit
a. Infants (I) BCG, DPT, OPV, HBV, MV
b. School Entrants (S.E) Booster of BCG
c. Pregnant Women (PW) Tetanus Toxoid
*To determine Eligible Population:
EP = Population of the Community x 0.03 (Infants and School Entrants) or
X 0.035 (Pregnant Women)
*Example: Lanting Community with a population of 7000
a.) DPT = for infants
EP = 7000 X 0.03 = 210 to receive DPT
b.) Tetanus Toxiod = for pregnant women
EP = 7000 X .035 = 245 to receive TT
c.) Booster BCG = for school entrants
EP = 7000 X 0.03 = 210 to receive booster BCG
 B. Fully Immunized Child ( FIC ) is a child who receives the 5 sets of
vaccines (BCG, DPT, OPV, Hepa B and Measles and who receives 11
doses of vaccines.

Vaccine (# of Doses) Infants (0-12 months) School Entrants

Right age to receive the
vaccine
BCG-1 dose 0 age (at birth)-12 1 booster dose (6 years
months old)
DPT-3 doses 1st Dose-6 wks./1 mos.
OPV-3 doses 2nd Dose-10 wks./2
HBV-3 doses mos.
3rd Dose-14 wks./3
mos.
MV-1 dose 9-12 months

*MV may be given 6 months if there is an epidemic.

c. Wastage Allowance
- DOH doesnt ptoduce vaccines biologically and therefore dependent on suppliers
abroad: Germany and Switzerland to economize:
1. Be aware of the availability of vaccines:
Example: BCG
CHN: vial Private Practice: ampule
Frozen powder with a diluent
( 1 ml per content )

2. How many receipients = ?????

-Follow DOH Dictum: On the day of immunization, if 50% and above of computed
recipents arrive in the health center, open a vial but if less than 50%, dont open.
Example: In 20 recipients, 10 arrive = open a vial
-Half life of Vaccines is the duration of potency:
a. Vaccine with 4 hours half life: BCG, MV ( need to mix )
*If open at 8:00 am, its good till 12:00 noon
At 12:30 pm, dont give anymore because its not potent anymore.
b. Vaccine with 8 hours half life: DPT, OPV, HBV, TT (already in solution / liquid
form ready to administer)

Table of Reference for Requesting Vaccines from DOH

Vaccine Availability Dosage # of Doses to Wastage Number of
complete Allowance Recipients per
immunization Multiplier Vaccines
Factor (MF)
BCG Vial:
1. I Frozen .05 ml 1 dose 60% 2.5 20
2. SE Powder .1 ml 1 dose 40% 1.67 10
with
1ml diluent
DPT Vial: 10 ml .5 ml 3 doses 40% 1.67 20
liquid
OPV Plastic 2-3 gtts 3 doses 40% 1.67 25(1ml=15gtts)
(Sabin) bottle: 5 ml
slightly
pink
Liquid
HBV Vial: .5, 1, <10 y/o: .5 3 doses 10% 1.2 .5 ml=1
10 ml >10 y/o: 1 .5 ml
MV Vial: .5 ml 1 dose 50% 2 10
Frozen
Powder
with
Diluent
Soln=5ml
per content
TT Vial: 10 ml .5 ml 5 doses 40% 1.67 20
liquid
*Parenteral = Salk vaccine ( sinasaksak ) has 5 ml per content
*Oral Polio Vaccine (OPV) = Sabin (sa bibig)
For OPV: 5 ml (availability) 1 ml = 15 gtts 1 ml = 15 gtts = 5 recipients
3 gtts (dosage) 2 ml = 30 gtts = 10 recipients
3 ml = 45 gtts = 15 recipients
4 ml = 60 gtts = 20 recipients
5 ml = 75 gtts = 25 recipients

Right Time for Pregnant Women to receive Tetanus Toxoid

Primary Dose TT1 Anytime during ? Immunity
Pregnancy (5th-6th
months)
Primary Dose TT2 4 weeks after TT1 3 years immunity
st
1 Booster TT3 6 months after 5 years immunity
TT2
2nd Booster TT4 1 year after TT3 10 years immunity
3rd Booster TT5 1 year after TT4 Lifetime immunity

Examples:
1. Mrs Dela Cruz received the 1st booster dose (TT3) on November 20, 2004.
When is the 2nd booster? November 20, 2005
2. As a child, you have 3 doses of DPT. Now you become pregnant. What you
need to receive are the 3 booster doses only-TT3, TT4 & TT5 respectively.
3. If as a child, only 1 dose of DPT was given, is there a definite immunity?
Theres no definite # of years of immunity. If until 3 years she failed to receive
vaccine, she got to start with the 1st dose.

Wastage Allowances of DOH Multiplier Factors

BCG (I) 60% 2.5
MV 50% 2.0
BCG (SE) 40% 1.67
DPT
OPV
TT
HBV 10% 1.2

Steps to Compute the Number of Vaccine to be Requested from DOH

1. Determine the Eligible Population (EP)
EP=Population of the Community x 0.03 (I & SE) or 0.035 (PW)
2. Determine the Annual Dose (AD)
AD=EP x # of doses of the vaccine
3. Determine the Wastage Allowance (WA)
WA=computed AD x MF of the vaccine
4. Determine the Complete Coverage (CC)
CC=WA # of recipients per vaccine
5. Determine the Overall Total in Allowance (OT)
OT=CC x 1.25 (constant), DOH usually grants an allowance of 25% of the CC

Example: Determine the # of vaccines to be requested from DOH of DPT for

Lanting Community with a population of 4000
1. EP=4000 x 0.03=120
2. AD=120 x 3 doses=360
3. WA=360 x 1.67=601
4. CC=601 20=30
5. 30 x 1.25=37.5 or 38 vials to be given by DOH (or 8 vials allowance)

II. Cold Chain

-Tools or Procedures to follow to keep vaccine potent ( expected desired
effect ).
Policies:
1. Proper Storage: store vaccines in refrigerators

RHO 3 Given 6 months to store vaccines

MHO PHO 2 Given 3 months to store vaccines

BHS RHU 1 Given 1 month to store vaccines
 RHCDS

- Freezer OPV: most sensitive to heat

-15 C to -20 C MV

Body of Refrigerator BCG

2 C to 8 C DPT
HBV
TT: least sensitive to heat
OPV & MV: highly sensitive to heat
OPV, MV & BCG: Not damage by freezing
DPT, HBV & TT: Damaged by freezing so not placed in the freezer

2. Proper Transport
- Vaccines are to be transported from the health center to the area of
immunization (community: focused, based & oriented)
- Tools provided by DOH: Vaccine Carrier which maybe
a. Black: use by staff of HC during epidemic & needs 5 cold dogs
b. White: use by student affiliates & needs 4 cold dogs
- Cold Dogs: 4 plastic containers filled with water which is placed in the
freezer a day before immunization which is used as freezant to keep
vaccine potent

3. Proper Handling of Vaccine (After Care of Vaccine): Dictum of DOH

a. Vaccines which are opened, though not consumed, should be discarded
Reasons: cant be used for future program because vaccines have half -
life (duration of potency of vaccine)
BCG -4 hours half life
MV
Other vaccines -8 hours half life

BCG, OPV & MV are composed of live attenuated bacteria & virus so
before discarding them, disinfect 1 st with 1% Hcl or any disinfectant like
zonrox, chlorox or dumex
BCG (Bacilli Calmette-Guerin Vaccine): live attenuated bacteria
OPV & Measles Vaccine: live attenuated virus

DPT, HBV & TT can be readily discarded if not consumed

DPT:
Diphtheria-weakened toxoid treated with chemical solution to weaken
microorganism
Pertussis-killed bacteria
Tetanus-weakened toxoid
HBV: plasma derived, identified to be RNA & DNA recombinant from
blood
 TT: weakened toxoid
b. Vaccines which are taken out from Health Center for 3x or more are
considered overly exposed & not potent anymore therefore it should be
discarded
Put notation (state the date) on the unopened vaccine as to when it was
taken out from health center May 19, 2006
Jun. 19, 2006
Jul. 19, 2006-cant be used anymore after this

I. Immunization
Guiding Principles for HW in Administering Vaccines & Screening of Children
for Immunizations:
1. No BCG for a child born clinically positive to AIDS because they have a
damage immune system & introducing bacteria will further aggravate their
condition
2. There are no contraindications such as slight fever, LBM, cough & colds
and malnutrition, in giving the immunization unless upon assessment of the
practitioner that the child has serious medical problems that warrants
hospitalization
3. In giving immunization with multiple doses such as DPT, OPV & HBV,
continue counting in giving the doses. Never count back even though the
interval exceeds weeks, months or years. As long as the child is on the
eligible age
Example: DPT, OPV & HBV
1st dose: At 6 weeks (1 months), the child was given vaccination
2nd dose: The mother brought back the child when he was 8 months old
instead at 10 weeks (2 months). PHN should still give the 2 nd dose
3rd dose: The mother brought back the child at 2 years old. PHN should still
give the vaccine because child is still at the eligible age (0-59 months or 4
years & 11 months or 5 years old) to receive vaccine

4. DPT: it is a normal reaction for a child to develop high grade fever because
of the pertussis component (killed bacteria)
SOP Management:
Paracetamol q 4 hours RTC for the 1st 2 days (or 3, 4 days if still febrile)
If after 1st dose of DPT, the child develops high grade fever with convulsion,
DPT 2 & 3 are not given anymore because convulsion affects the brain cells
resulting to brain damage
DPT vaccine is only for prophylactic/ preventive use

5. Things to consider in administering vaccines:

a. Vaccine
b. Dosage
c. SOA (Site of Administration)
d. ROA (Route of Administration)
e. Side Effect: patterns of reaction that is considered normal
Vaccines Dosage SOA ROA Conferred
Immunity
BCG I=.05 ml I=R deltoid Intradermal Artificial Active
SE=.1 ml SE=L deltoid (needle is
parallel to
site=10-15
angle
Side Effects: Wheal=10 mm that disappears after 30 minutes
1st week : develops soreness and inflammation
nd th
2 -11 week : develops abscess and ulceration
12th week (3 months): heals and develops permanent scar

Age of Consultation BCG Site of Injection

Right Age (0-12 months) Right Deltoid
Wrong Age but still eligible Left Deltoid
Example: 4 years old
Booster Dose at Age 6 Left Deltoid
*If after BCG, there is no soreness & inflammation, no abscess & ulceration
and no scar developed, there is wrong preparation of site where PHW used
alcohol that kills the microorganism contained in the BCG vaccine. Thus,
repeat the dose on same site but a little lower.
*Site preparation: Use clean cotton ball & wet with sterile water only
*For non-healing abscess & ulceration:
BCG was wrongly administered by IM or SQ by PHW so incision & drainage
should be done by MD only and INH tablet, an anti-bacterial, pounded,
pulverized & applied on the site. Then repeat the dose again but not on the
same site.

Vaccine Dosage SOA ROA Conferred

Immunity
DPT .5 ml Thigh (vastus Intramuscular Artificial
lateralis) (Z tract) Active
where muscle
is grasped
and squeezed
Side Effects:
1. High grade fever due to Pertussis Component which contains killed bacteria
2. Soreness and inflammation
SOP Management:
Paracetamol (anti-pyretic & analgesic) q 4 hours RTC for 1 st 3 days or till with
fever
Nursing Care: 1st Day=apply cold compress on site
2nd , 3rd & 4th Day=apply alternating cold & warm compress
Adverse Effect: If convulsion occurs on 1 st dose, discontinue DPT 2 & DPT 3
because of the sensitivity to DPT Component but private MD gives DT which is
not available in DOH

Vaccine Dosage SOA ROA Conferred

Immunity
OPV 2-3 gtts Mouth Oral: Artificial Active
Sabin by Dr.
Albert Sabin
Salk
(parenteral
polio vaccine)
by Dr. Jones
Salk
Side Effect: None
Nursing Care:
1. NPO for 1st 20-30 minutes after receiving vaccine to prevent nausea &
vomiting
2. In case the child vomits after vaccination, repeat giving the vaccine because it
requires 30 minutes to absorb the OPV
HBV .5 ml Thigh (vastus Intramuscular Artificial Active
lateralis)
Side Effects: Soreness and inflammation on site
SOP Management: Paracetamol q 4 hours RTC for 1 st 2 days or till with fever
HBV & DPT are given together but never administer these 2 vaccines in one site:
DPT HBV
st
1 Dose Right Left
2nd Dose Left Right
3rd Dose Right Left
MV .5 ml Posterior Subcutaneous Artificial Active
aspect of (45 angle)
Deltoid
Side Effect: High grade fever
SOP Management: Paracetamol q 4 hours RTC for 1 st 2 days
MV given on same site with BCG but MV is given at 9 months while BCG at birth
In case, rashes develop after vaccination which makes the child irritable due to
itchiness,
give anti-histamines: Diphenydramine (Benadryl) syrup or
Apply Caladryl or Calamine Lotion which has anti-histamine
and cooling effect to relieve itchiness
TT .5 ml Deltoid or Intramuscular Artificial Active
Gluteal
muscle
Side Effect: Soreness and inflammation on the site which is tolerable by pregnant
woman so no need to take medicines. Just apply cold compress on site to relieve
discomfort
2 Forms of Immunization Conferring Immunity:
1. Natural
a. Active
b. Passive
2. Artificial

IMMUNITY
Natural Artificial
Provided by nature Accepts vaccine
No vaccine was given
Duration is longer/even for a lifetime Duration is shorter period
Example:
BCG-vaccine for protection from TB
gives 7-10 years immunity so booster
is needed
HBV-after 3 doses booster is needed
after 1 year
Active=person himself is involved in Active=person himself has no
the production of antibodies participation and done by another
1. Carrier (person harbors the disease person
but asymptomatic) of the disease Upon receiving vaccine (antigen) for
2. Constant exposure to disease immunizable diseases such as BCG,
3. Acquired or experienced the disease DPT, OPV, MV and HBV

Passive
1. Breastfeeding IgA (present in 1. Serum (Blood):
colostrums)
2. Perinatal immunity is acquired
during the term of pregnancy
Passive
HBV
ATS (Anti-Tetanus Serum)
ADS (Anti-Diptheria Serum)
2. Antitoxin: poison or causes infection
TAT (Tetanus Antitoxin)
DAT (Diptheria Antitoxin)
3. Immunoglobulins: IgA, IgD, IgE, IgG
& IgM where IgG is most predominant

IV. Surveillance--------------- To be discussed unde r Communicable Diseases.

Planning, Supervision and Training
Mobilization, Monitoring, and Health Education
Referral, Research and Evaluation

*CDD ( CONTROL OF DIARRHEAL DISEASES )

Policies to implement CDD:
1. Health Education on Personal Hygiene
- washing of hands before eating and after use of toilet
2. Breastfeeding ( BF )
 - Two ( 2 ) Beneficiaries of BF Program:
a. Mother regulated by R.A. 7600: Breastfeeding and Rooming In Act.
*Beastfeeding is an effective contraceptive method because it stimulates the
anterior pituitary gland to produce prolactin hormone putting the female in an
anovulatory stage theres amenorrhea for 6 months form the time she gave
birth.
*Rooming in ( RI ) is putting together of mother and the newborn and it
stimulates the posterior pituitary gland to release oxytocin hormone stimulates
the uterine muscle contraction that inhibits the implantation of fertilized zygote in
the endometrium no pregnancy occurs.
b. Children regulated by EO 51: Milk Code of the Philippines
Dictum of Milk Code: Never commercialized a brand name of milk.
- 3 Principles to make breastfeeding effective: 3 Es
a. Early: start Breastfeeding as early as possible
Normal Spontaneous Delivery (NSD): after 30 minutes
CS: after 3 4 hours
b. Exclusive: for the 1st six months; never alternate Breastfeeding with any
supplementary feeding.
c. Extensive: Breastfeeding can be extended to 2 years.
- Advantages of Breastfeeding:
Breast milk: EO 51 best for babies
Reduced allergy
Easily established
Always available
Safe making stool soft
Temperature: right teemperature 24C body reference if to be frozen,
preservation is minimum of 3 months and maximum of 6 months

Fresh always
Emotional bonding
Economical
Digestible: contains lactalbumin, a protein substance
Immunity: colostrum contains Ig A that protects baby for the 1st 3 months
Nutritious ( optional )
GIT diseases such as diarrhea is minimize / lessen because its sterile
3. Measles: immunization preventive and prophylactic
4. Oresol: a management for diarrhea to prevent dehydration
2 Concepts of Diarrhea:
a. Frequency of passing out stool = 3x/day
b. Consistency of the stool = watery
ROLE OF BREASTFEEDING IN THE
CONTROL OF DIARRHEAL DISEASES
PROGRAM
1. Two problems in CDD
 1. High child mortality due to
diarrhea
2. High diarrhea incidence among under fives
2. Highest incidence in age 6 23 months
3. Highest mortality in the first 2 years of
life
4. Main causes of death in diarrhea :
DEHYDRATION
MALNUTRITION
5. To prevent dehydration, give home fluids
am as soon as diarrhea starts and if
dehydration is present, rehydrate early,
correctly and effectively by giving ORS
6. For undernutrition, continue feeding
during diarrhea especially breastfeeding.
7. Interventions to prevent diarrhea
1. breastfeeding
2. improved weaning practices
3. use of plenty of clean water
4. hand washing
5. use of latrines
6. proper disposal of stools of
small children
7. measles immunization
8. Risk of severe diarrhea 10-30x higher in
bottle fed infants than in breastfed
infants.
9. Advantages of breastfeeding in
relation to CDD
1.Breast milk is sterile
2.Presence of antibodies protection against
diarrhea
3.Intestinal Flora in BF infants prevents growth
of diarrhea causing bacteria.
10. Breastfeeding decreases incidence
rate by 8-20% and mortality by 24-27% in
infants under 6 months of age.
11. When to wean?
4-6 months soft mashed foods 2x a day
6 months variety of
foods 4x a day
12. Summary of WHO-CDD recommended
strategies to prevent diarrhea
1. Improved Nutrition
 - exclusive breastfeeding for the first 4-6 months
of life and partially for at least one year.
- Improved weaning practices
2.Use of safe water
- collecting plenty of water from the cleanest
source
- protecting water from contamination at the
source and in the home
3.Good personal and domestic hygiene
- handwashing
- use of latrines
- proper disposal of stools of young children
4.Measles immunization.

Contents of One Pack Oresol Dissolved in One Liter drinking Water

Glucose 20 grams 1 Significance:
For re-absorption of Na
Facilitates assimilation of
Na
2 Significance:
Provides heat & energy
Sodium Chloride/NaCl 3.5 grams For retention of
water/fluid
Sodium 2.5 grams Buffer content of solution
Bicarbonate/NaHCO3 Neutralizer content of
solution
Potassium Chloride/KCl 1.5 grams Stimulates smooth
muscle contractility
especially the heart &
GIT
*Never advice mother to buy brandnames like pedialyte or gatorade

Preparation of Proper Homemade Oresol

A volume or one liter homemade oresol Smaller volume or a glass homemade
oresol
Water 1000 ml. or 1 liter 250 ml.
Sugar 8 teaspoon 2 teaspoon
Salt 1 teaspoon teaspoon or a pinch of salt=10-12
granules of rock salt: iodized salt=tips
of thumb & index finger are penetrated
with salt
*For making solutions = use 250 ml of water
*For drinking medicines = a glass is 240 ml of water.

3 Categories of Dehydration:
a. No dehydration-uses oresol
b. Some dehydration-uses oresol
c. Severe dehydration-uses IVF
Objectives/Plan/Policies of the Use of the following Program:
a. Plan A: for prevention of dehydration
b. Plan B: for treatment of dehydration-mild & moderate
c. Plan C: for treatment of dehydration-severe

CDD MANAGEMENT CHART

Assessment Category Treatment

1. Condition No dehydration Plan A-prevention of

a. Normal DHN
b. Well
c. Alert 3 Principles/3 Fs:
2. Fontanel-normal 1. Increase fluid: Tea-
3. Eyeballs-normal Tears- lipton tea bag left
present standing in a cup of
4. Mouth, Tongue & Lips: water for 15 minutes &
moist or wet Thirst: there is brownish
drinks normally discoloration
5. Skin Turgor-returns =pectin, a diuretic & has
back quickly which is an absorbent effect
done at forearm Fruit Juices-not from
highly fibrous fruits like
pineapple, mango,
guyabano.

Oresol-am or buko where

3 electrolytes are
present: Na, K & Ca
which are lost in diarrhea

Oresol is given/LBM or
every time stool is
passed out:
< 2 years old: 50-100ml.
always give the
maximum amount
2-10 years old: 100-200
 ml.
10 years old & above: as
much as tolerated &
desired

2. Increase feeding:
3. Fast referral
1. Condition Some dehydration Plan B-Treatment of mild
a. Restless & Moderate DHN using
b. Irritable oresol
2. Sunken fontanel
3. Sunken eyeballs & If less than 2 years old:
absent tears use age in months
4. Dry mouth, tongue & If < 4 months: 200-400
lips ml.
Eagerness to drink 5-11 months: 400-600 ml.
5. Skin returns back 12-23 months: 600-800
slowly ml.
2-4 y/o: 800-1200 ml.
5-14 y/o: 1200-2200 ml.
15 & above: 2200-4000
ml.

Treatment Plan: 1st 4

hours always give the
maximum
1. Condition Severe dehydration Plan C-treatment of
a. Unconsciousness severe DHN using IVF
b. Lethargic Priority-choice of IVF:
c. Floppy-apathetic or 1. D5LRS-best or 1st
passive choice if available for
2. Very sunken fontanel severe DHN since
3. Very sunken eyeballs dextrose gives additional
& absent tears source of
4. Very dry mouth, energy & improves
tongue & lips appetite D5-is glucose
Refuses to drink orally LRS-has 3 chlorides
5. Skin returns back very, 2. LRS-Lactate Ringers
very slowly best done at or Hartman solution is
the abdomen the most appropriate
choice if no D5LRS
3. Plain NSS or 0.9 NaCl
4. D5W
 5. D10W

2 Victims of Severe Dehydration:

a. Child: give 100 mg/kg body weight in the 1st 4 hours
Example: 8 kg=800 ml. IVF to be infused on the 1 st 4 hours for patient with severe
dehydration (8 am-12 noon)
b. Adult: give 3-4 liters of IVF in 1st 4 hours
Example: 9am-1pm=4 liters=1 liter/hour
If still severe dehydration, 2-6pm=infuse 4 liters IVF
Fruits for Diarrhea:
Apple: has pectin & tarum which has an absorbent property, eat the skin
Banana: has K+
Caimito: eat the flesh in cases of constipation but in diarrheal cases, eat the
extracts, milky substances (dagta) found on the inside of the skin
Duhat: wash first the fruit then sprinkle with rock salt & shake, notice extracts to
come out of the fruit, eat both skin & flesh
Fruits to avoid during diarrhea: Papaya flesh, pineapple flesh, mango,
guyabano & kaimito flesh
BRAT Diet: Banana, Rice, Apple, Tea, toasted bread or toasted rice beads which
has activated charcoal that acts as absorbent
Direction: In a cup of warm water, add 1 tablespoon of toasted rice or bread &
allow to stand for 20-30 minutes produces a blackish discoloration which is
pectin
 TYPES OF DIARRHEA
o ACUTE : < 14DAYS
o PERSISTENT: 14 DAYS or more
o DYSENTERY: Blood in the stool; with or without mucus *CARI
CLASSIFY DEHYDRATION
SEVERE DEHYDRATION
Two of the following:
Abnormally sleepy
Sunken eyes
Drinks poorly
Skin pinch goes very slowly
Treat PLAN C: Referral to hospital for IVF!!!

SOME DEHYDRATION
Two of the following:
Restless, irritable
Sunken eyes
THIRSTY: drinks eagerly
Skin pinch goes back
Treat PLAN B
O.R.S: first 4hours after assessment
200-400ml 0-4mos
400-700ml 4-12mos
700-900ml 1-2 yrs
900ml-1L 2-5yrs
NO DEHYDRATION
Not enough signs to classify some or severe
Treat PLAN A
Give extra fluids
50-100ml after each watery stool (0-2y/o)
100-200ml (2 y/o & above)
as tolerated (10y/o & above)
Continue feeding
Return if with danger sign/s.
(CONTROL OF ACUTE RESPIRATORY INFECTIONS )
Goal: Morality and Morbidity reduction of Pnuemonia.
Target groups: very young: <2 months
Older child: 2 months 5 years old
Child with cough and colds

Program:
1. Assessment:
History: Subjective
Age
Cough and Duration
Able to Drink or stop feeding
Fever ---- duration
Convulsion
Physical Examination: Objective
Weight, Height
Respiratory Rate one whole minute
Fast Breathing
*Less than 2 months 60/min or >
*2 months 1 year 50/min or >
*1- 5 years old 40/min or >
Observe for :
- Chest in drawing
- Stridor during inhalation
- LOC
- Wheeze during exhalation
- Fever
- Malnutrition
- Level of Consciousness

2. STANDARD CLASSIFICATION OF ILLNESS:

I. Infants 2 months to 5 years old

1. VERY SEVERE DISEASE:
If any 3 of the 5 Danger signs are present
Signs and Symptoms:
f. Not able to drink
g. Convulsion
h. Sleepy
i. Stridor
j. Severe Malnutrition

Treatment:
1. Refer urgently to hospital
2. 1st dose of antibiotics
3. Treatment of Fever ( TSB ) * Wheeze (NEBULIZE)
4. Antimalarial

2. PNEUMONIA:
Signs and Symptoms:
a. Chest in drawing
b. Nasal flaring
c. Grunting
d. Cyanosis

2 Types:
a. Severe Pneumonia
 Symptoms: Chest indrawing, cyanosis, nasal flaring, grunting.
Treatment: Same with very severe but anti malarial is not given.

b. Not Severe Pneumonia

Symptoms: No chest in drawing and fast breathing.
Treatment: 1. Home care TSB, Nutrition, Steam inhalation
2. Antibiotics for 2 days and follow up after 2 days.
a. If it improves, consume all meds finish the course of
the treatment.
b. If worse, refer.

3. NO PNEUMONIA
Assess for other problems and provide home care.
No Chest indrawing, No fever
If with sore throat in children: Mild, warm tea with syrup.
If chronic, refer.

II. Infants lessthan 2 months

1. VERY SEVERE DISEASE
Symptoms: Stopped feeding well
Convulsions
Abnormally sleepy
Stridor
Wheeze
Severe malnutrition and Fever of 38C or Hypothermia
(<35.5C)
Treatment: Refer urgently to hospital
Keep warm
Give first doses of antibiotic

2. PNEUMONIA
Symptoms: Severe Chest indrawing and Fast Breathing
Treatment: Same as severe.

*UFC (UNDER FIVE CLINICS )

The first five years of life form the foundations of the childs physical and
mental growth and development. Studies have shown the mortality and morbidity
are high among this age group. The Department of Health established the Under
Five Clinic Program to address this problem.

Program Objectives and Goals:

*Monitor growth and development of the chiild until 5 years of age.
*Identify factors that may hinder the growth and development of the child.
Activities and Strategies:
1. Regular height and weight determination / monitoring until 5 years old.
0 1 year old = monthly
1 year old and above = quarterly
2. Recording of immunization, vitamins, supplementation, deworming and feeding.
3. Provision of IEC materials ( ex. Posters, charts, toys ) that promote and
enhance childs proper growth and development.
4. Provision of a sagfe and learning oriented environment for the child.
5. Monitoring and Evaluation.

**BREASTFEEDING / LACTATION MANAGEMENT EDUCATION TRAINING**

-Breastfeeding practices has been proven to be very beneficial to both mother and
baby thus the creation of the following laws support the full implementation of this
program.
Executive Order 51
Republic Act 7600
The Rooming in and Breastfeeding Act of 1992.

Program Objectives and Goals:

-Protection and promotion of breastfeeding and lactation management education
training.

Activities and Strategies:

1. Full Implementation of Laws supporting the Program
A. EO 51 THE MILK CODE protection and promotion of breastfeeding to ensure
the safe and adequate nutrition of infants through regulation of marketing of infant
foods and related products. (e.g. breast milk substitute, infant formulas, feeding
bottles, teats etc.)
B. RA 7600 THE ROOMING IN AND BREASTFEEDING AC T OF 1992
-An act providing incentives to government and private health institutions
promoting and practicing rooming in and breast feeding.
-Provision for human milk bank.
-Information, education and re education drive.
-Sanction and Regulation.

3. Conduct Orientation / Advocacy meetings to Hospital / Community.

ADVANTAGES OF BREASTFEEDING:
MOTHER:
*Oxytocin helps the uterus contracts
*Uterine involution
*Reduce incidence of Breast Cancer
*Promote Maternal Infant Bonding
*Form of Family planning method ( Lactational Amenorrhea )

BABY:
*Provide Antibodies.
*Contains Lactoferin ( Binds with Iron )
*Leukocytes
*Contains Bifidus factor
Promotes growth of the Lactobacillus inhibits the growth of
pathogenic bacilli.

Positions in BF THE BABY:

1. Cradle Hold head and neck are supported
2. Football Hold
3. Side Lying Position
Best for Babies
Reduce Incidence of Allergens
Economical
Antibodies Present
Stool Inoffensive ( Golden Yellow )
Temperature always ideal
Fresh Milk never goes off
Emotionally Bonding
Easy once established
Digested easily
Immediately available
Nutritionally optimal
Gastroenteritis greatly reduced

Garantisadong Pambata ( GP )
-Garantisadong Pambata is a biannual week long delivery of a package of
health services to children between the ages of 0 59 months old with the
purpose of reducing morbidity and mortality among under fives through the
promotion of positive Filipino values for proper children growth and development.

1. WHAT ARE THE HEALTH SERVICES OFFERED IN GP AND WHO ARE THE
TARGETS?
GP offers the following:
1.1 Routine Health Services:

Health Service Dosage Route of Target

Administration Population
Vitamin A 200,000 IU or Orally by drops 12 59 months
Capule capsule 100,000 old, nationwide
 IU or cap or 3 9 -12 months old
drops infants receiving
AMV nationwide.
Ferrous Sulfate 0.3 ml ( 2 6 Orally by drops. 2 -11 months old
( 25 mg elemental months ) once a infants in
Iron per ml; 30 ml day Mindanao area,
Bottle as taken including
home medicine 0.6ml ( 6- 11 evacuation
with instructions ) months) centers in armed
conflict areas.
Routine
Immunization
-BCG 0.05 ml Intradermal on 0 11 months
right deltoid.
-DPT 0.5 ml Intramuscularly 0 11 months
on anterior thigh
-OPV 2 drops Orally 0 11 months

-AMV 0.5 ml Subcutaneously

on deltoid
-Hepa B ( If 0.5 ml Intramuscularly 0 11 months
available )
Deworming drug 1 tablet as single Orally 36 59 months,
( If available ) dose nationwide
Weighing 0 59 months
nationwide

-*The child should not have received megadose of Vitamin A above the
recommended dosage within the past 4 weeks except if the child has measles or
signs and symptoms of Vitamin A deficiency.
-**For any between 12 23 months, who missed any of his routine immunization,
the health worker should give the child the necessary antigen to complete FIC and
shall be recorded as such.

Garantisadong Pambata ( GP )
Sangkap Pinoy
-Vitamin A, Iron and Iodine
-Sources: green leafy and yellow vegetables, fruits, liver, seafoods, iodized, salt,
pan de bida and other fortified foods.
These micronutrients are not produced by the body, and must be taken in the
food we eat; essential in the normal process of growth and development:
a.) Helps the body to regulate itself
b.) Necesary in energy metabolism
c.) Vital in brain cell formation and mental developmet
d.) Necessary in the body immune system to protect the body from severe
infection.
e.) Eating Sangkap Pinoy rich foods can prevent and control:
1. Protein Energy Malnutrition
2. Vital A deficiency
3. Iron Deficiency Anemia
4. Iodine Deficiency Disorder

Breastfeeding
-Breast milk is best for babies up to 2 years old. Exclusive breastfeeding is
recommended for the first six minths of life. At about six months, give carefully
selected nutritious foods as supplements.
-Breastfeeding provides physical and psychological benefits for children and
mothers as well as economic benefits for families and societies.
BENEFITS:
For INFANTS
a. Provides a nutritional complete food for the young infant.
b. Strengthens the infants immune system, preventing many infections.
c. Safely rehydrates and provides essential nutrients to a sick child, especially to
those suffering from diarrheal diseases.
d. Reduces the infants exposure to infection.

For the MOTHER

e. Reduces a womens risk of excessive blood loss after birth.
f. Provides a natural method of delaying pregnancies.
g. Reduces the risk of ovarian and breast cancers and osteoporosis.

For the FAMILY AND COMMUNITY

h. Conserves funds that otherwise would be spent on breast milk substitute,
supplies and fuel to prepare them.
i. Saves medical costs to families and governments by preventing illnesses and by
providing immediate postpartum contraception.

Complementary Feeding for Babies 6 11 moths old

*What are Complementary Foods?
a. foods introduced to the child at the age 6 months to supplement breast milk
b. given progressively until the child is used to three meals and in between
feedings at the age of one year.

*Why is there a need to Give Complementary Foods?

c. Breast milk can be a single source of nourishment from birth up to six months of
life.
d. The childs demands for food increases as he grows older and breastmilk alone
is not enough to meet his increased nutritional needs for rapid growth and
development.
e. Breastmilk should be supplemented with other foods so that the child can get
additional nutrients.
f. Introuction of complementary foods will accustom him to new foods that will also
provide additional nutrients to make him grow well.
g. Breastfeeding, however, should continue for as long as the mother is able and
has milk which could be as long as two years.
*How to Give Complementary Foods for Babies 6 11 Months Old?
a. Prepare mixture of thick lugao / cooked rice, soft cooked vegetable. Egg yolk,
mashed beans, flaked fish / chicken / ground meat and oil.
b. Give mixture by teaspoons 2 4 times daily, increasing the amount of
teaspoons and number of feeding until the full recommended amounts is
consumed.
c. Give bite sized fruit separately
d. Give egg alone or combine with above food mixture.

*FP ( FAMILY PLANNING )

The Philippine Family Planning Program is a national program that
systematically provides information and services needed by women of
reproductive age to plan their families according to their own beliefs and
circumstances.
Goal and Objective:
* Universal access to family planning information education and services.

Mission:
*To provide the means and opportunities by which married couples of reproductive
age desirous of spacing and limiting their pregnancies can realize their
reproductive goals.

TYPES OF METHODS:
A. NATURAL METHODS
1. Calendar or Rhythm Method
2. Basal Body Temperature Method
3. Cervical Mucus Method
4. Sympto Thermal Method
5. Lactational Amennorhea

B. ARTIFICIAL METHODS
I. CHEMICAL METHODS
1. Ovulation suppressant such as PILLS
2. Depo Provera
3. Spermicidals
4. Implant
II. MECHANICAL METHODS
1. Male and Female Condom
2. Intrauterine Device
3. Cervical Cap / Diaphragm
III. SURGICAL METHODS
1. Vasectomy
2. Tubal Ligation

*MC ( MATERNAL CARE )

*BF ( BREAST FEEDING )
*MRP ( MALNUTRITION REHABILITATION PROGRAM )
*VAD (VITAMIN A DEFICIENCY )
*IDD / IDA ( IODINE DEFICIENCY DISORDERS / IRON DEFICIENCY ANEMIA )
*FP ( FAMILY PLANNING )

II. Research and Quality Improvement

A. Research in the Community
RESEARCH IN THE COMMUNITY
Research is an important activity in public health but it is misconceived to be primarily
an activity of professional researchers and academicians. Although it is not commonly
included in the PHNs statement of duties and responsibilities, research is nonetheless
included in the scope of functions of the nurse as defined by the Nursing Law.

Research in community health serves a number of purposes, among which are: (1)
improve our understanding of clients and their specific contexts;
(2) provide data needed for program and policy development and evaluation;
(3) improve the delivery of health services and implementation of existing programs;
(4) improve cost-effectiveness of programs; and (5) project a good image of nurses.

The PHN can initiate small researches on the major concerns in health service
delivery and in the management of the health facility. Research topics that could be
studied by the PHN by himself/herself include, among others, socio-demographic
profile of those who utilize health services, client waiting time, referral from and to the
health center, perception of clients on the delivery of health services, response of
clients to different health or nursing interventions, supply management and effects of
specific health education activities.

Research also contributes to what is called evidence-based practice. The practices

that were passed on and were considered as gospel truth in the past should be
examined and tested through research. The challenge, not only PHNs but to major
decision makers in the local health system is to integrate research into the
management and operation of the health facility.

B. National Health Situation

NATIONAL HEALTH SITUATION
Philippine Scenario:
*In the past 20 years some infectious degenerative diseases are on the rise.
*Many Filipinos are still living in remote and hard to reach areas where it is difficult
to deliver the health services they need.
*The scarcity of doctors, nurses and midwives add to the poor health delivery
system to the poor.

VITAL HEALTH STATISTICS 2005

PROJECTED POPULATION :
MALE - 42,874,766
FEMALE - 42,362,147
 BOTH SEXES - 85,236,913
LIFE EXPECTANCY
FEMALE - 70 yrs. Old
MALE - 64 yrs. Old

LEADING CAUSES OF MORBIDITY

*Most of the top ten leading causes of morbidity are communicable disease
*These include the diarrhea, pneumonia, bronchitis, influenza, TB, malaria and
varicella
*Leading non CD are heart problem, HPN, accidents and malignant neoplasms

LEADING CAUSES OF MORTALITY

*The top 10 leading causes of mortality are due to non CD
*Diseases of the heart and vascular system are the 2 most common causes of
deaths.
*Pneumonia, PTB and diarrheal diseases consistently remain the 10 leading
causes of deaths.

-HEALTH INDICES
I. Basic Health Indicators
2 Indicators to assess a national health situation
A. Nutrition
B. Disease Patterns
Context of CHN: Health Situation
**Leading Causes of Morbidity**
10 Leading Causes of Morbidity
1. Pneumonia -- Bacterial
2. Diarrhea
3. Bronchitis
4. Influenza -- Respiratory
5. Hypertension
6. TB Respiratory
7. Diseases of the Heart
8. Malaria
9. Chickenpox
10. Measles

**Leading Causes of Mortality**

10 Leading Causes of Mortality
1. Disease of the Heart
2. Diseases of the Vascular System
3. Malignant neoplasm
4. Pneumonia
5. Accidents
 6.TB all forms
7. COPD
8. Conditions originating in perinatal
period
9. Diabetes Mellitus
10. Nephritis, Nephrotic Syndrome

III. Other Indicators

A. Infant Mortality Rate
*2002 --- 21/1000 rated based on WHO global indicator >50 high
Increase IMR decrease MCHS ( poor nutrition and child health service )

INFANT MORTALITY RATE

Total # of death below 1 yr in a given calendar year X 1000
Estimated population as of July 1 of the same calendar year

10 Leading Causes of Infants Deaths

1. Other perinatal conditions
2. Pneumonia
3. Bacterial Sepsis of Newborn
4. Diarrhea & Gastroenteritis of presumed infectious origin
5. Congenital Pneumonia
7. Other congenital malformations
8. Disorders r/t short gestation & LBW
9. Septicemia
10. Measles
*Increase IMR = decrease MCHS
*Poor maternal childs service

B. Maternal Mortality Rate

MMR= # of maternal deaths x 1000

RLB

Leading Causes Of Maternal Deaths:

1. Normal delivery and other complications r/t pregnancy occurring in the course of
labor, delivery & puerperium
2. HPN complicating pregnancy, childbirth & puerperium
3. Postpartum hemorrhage
4. Pregnancy with abortive outcome
5. Hemorrhage related to pregnancy

*Life expectancy at birthlife span either: age specific or sex specific

 *Median Age- 20.1 years
*The Philippines is an agricultural country- 55%

C. Life Expectancy at Birth

D. Median Age
E. Crude Rates
1. Crude Birth Rate
2. Crude Death Rate

-Health Care Delivery System the totality of all policies, equipment, products,
human resources and services whichaddress the health needs, problems and
concerns of the people. It is large, complex, multi level and multi disciplinary.

Categories:
According to Increasing According to the Type of Service
Complexity of the Services
Provided
Type Service Type Service
Primary Health Promotion, Health Information
Preventive Care, Promotion Dissemination
Continuing Care for and illness
common health prevention
problems, attention
to psychological and
social care, referrals
Secondar Surgery, Medical Diagnosis Screening
y services by and
specialists Treatment
Tertiary Advanced, Rehabilitation PT/OT
specialized,
diagnostic,
therapeutic and
rehabilitative care
- The
Health Sector

GOVERNMENT SECTORS
DEPARTMENT OF HEALTH (DOH)
VISION:
-Health for all by year 2000 and Health in the Hands of the People by 2020(OLD).
-A global leader for attaining better health outcomes, competitive and responsive
health care system, and equitable health financing(NEW VISION by 2030).

MISSION:
-In partnership with the people, provide equity, quality and access to health care
especially the marginalized.(OLD)
-To guarantee equitable, sustainable and quality health for all Filipinos, especially
the poor, and to lead the quest for excellence in health.(NEW)

5 Major Functions:
1. Ensure equal access to basic health services
2. Ensure formulation of national policies for proper division of labor and proper
coordination of operations among the government agency jurisdictions
3. Ensure a minimum level of implementation nationwide of services regarded as
public health goods
4. Plan and establish arrangements for the public health systems to achieve
economies of scale Phil Health.
5. Maintain a medium of regulations and standards to protect consumers and
guide providers Sentrong Sigla = Training and infrastructure

-LOCAL GOVERNMENT UNIT / NON GOVERNMENT SECTORS

R.A. 7160 Local Govt Code Local health board- Governor
Municipal health officer- mayor
Assistant - municipal
Provincial health officer

Health Promotion- no threats, no risk- approach behavior

Health Prevention- identified health problem- avoidance behavior

-Private Sector
-Composed of both commercial and business organization, non
business organizations

Commercial/Business Non-commercial
Profit-oriented Orientation to social development, relief
and rehabilitation, community
organizing
Manufacturing Socio-civic groups
companies Religious organizations/foundations
Advertising agencies
Private practitioners
Private institutions

NGOs assumes the following roles:

Policy and Legislative Advocates
Organizers, Human Rights Advocates
Research and Documentation
 Health Resource Development Personnel
Relief and Disaster Management
Networking

PRIMARY STRATEGIES TO ACHIEVE HEALTH GOALS

*Support for health goal
*Assurance of health care
*Increasing investment for PHC
*Development of National Standard

MILESTONE IN HEALTH CARE DELIVRY SYSTEM

*RA 1082 - RHU Act
*RA 1891 - Strengthen Health Services
*PD 568 - Restructuring HCDS
*RA 7160 - LGU Code

NATIONAL HEALTH PLAN

*National Health Plan is a long-term directional plan for health; the blueprint
defining the countrys health PROBLEMS, POLICY, STRATEGIES, THRUSTS

GOAL:
*To improve health indicators through access.
*To enable the Filipino population to achieve a level of health which will allow
Filipino to lead socially and economically productive life, with longer life
expectancy, low infant mortality, low maternal mortality and less disability through
measures that will guarantee access of everyone to essential health care.

BROAD OBJECTIVES:
*promote equity in health status among all segments of society
*address specific health problems of the population
*upgrade the status and transform the HCDS into a responsive, dynamic and
highly efficient, and effective one in the provision of solutions to changing the
health needs of the population
*promote active and sustained peoples participation in health care

MAJOR HEALTH PLANS TOWARDS HEALTH IN THE HANDS OF THE

PEOPLE IN THE YEAR 2020

23 IN 1993
Refers to the 23 programs, projects, activities of the
DOH for the year 1993, which marks the beginning
of its journey towards DOG vision.
 Health for more in 94
Activities in 1994 focused on Cancer prevention,
reproductive health, mental health, and
maintenance of a safe envt.

Health Focus in 1995 Think Health, Health Link

A national & multi-sectoral health promotion

strategy aimed at conveying health messages to
people wherever they are aimed at building
supportive environments through advocacy,
community action & networking.

Health Sector Reform Agenda

Emphasizing on improvements in health care

delivery by maximizing peoples participation in
health

Sentrong Sigla Movement

Pertains to development & implementation of

standards to provide quality health services to the
people.

C. Vital Statistics
VITAL STATISTICS
Statistics refers to a systematic approach of obtaining, organizing and analyzing
numerical facts so that conclusion may be drawn from them.
Vital Statistics refers to the systematic study of vital events such as births,
illnesses, marriages, divorce, separation and deaths.
Statistics of disease (morbidity) and death (mortality) indicate the state of
health of a community and the success or failure of health work.
Health Indicators a list of information which would determine the health of a
particular community like population. Crude birth rate, crude death rate, infant and
maternal death rates, neonatal death rates and tuberculosis death rate
Health Indicators
Birth
Death
Marriages
Migration

Use of Vital Statistics:

*Indices of the health and illness status of a community
*Serves as bases for planning, implementing, monitoring and evaluating
community health nursing programs and services.

Sources of Data:
*Population census
*Registration of Vital Data
*Health Survey
*Studies and researches

Rates and Ratios:

Rate shows the relationship between a vital event and those persons exposed to
the occurrence of said event, within a given area and during a specified unit of
time, it is evedent that the person experiencing the event (Numerator) nust come
from the total population exposed to the risk of same event (Denominator).

Ratio is used to describe the relationship between two (2) numerical quanitities
or measures of events without taking particular considerations to the time or place.
These quantities need not necessarily represent the same entities; although the
unit of measure must be the same for both numerator and denominator of the
ratio.

Crude or General Rates referred to the total living population. It must be

presumed that the total population was exposed to the risk of the occurrence of
the event.

Specified Rate - the relationship is for a specific population class or group. It

limits the occurrence of the event to the portion of the population definitely
exposed to it.

Crude Birth Rate a measure of one characteristic of the natural growth or

increase of a population.

Used often because of availability of data

a. Measures how fast people are added to the population through birth
b. Crude since it is related to the total population including men, children and
elderly who are not capable of giving birth

Crude Death Rate a measure of one mortality from all causes which may result
in a decrease of population.
a. Crude because death is affected by different factors
b. Widely used because of availability of data

Infant Mortality Rate measure the risk of dying during 1st year of like. It is a
good index of the general health condition of a community since it reflects the
changes in environment and medical condition of a community.

a. SENSITIVE INDEX of level of health in a community

b. HIGH IMR means LOW LEVELS of health standards secondary to poor
maternal and child health care, malnutrition, poor environmental sanitation
or deficient health service delivery
c. May be artificially lowered by improving the registration of births

Maternal Mortality Rate measures the risk of dying from causes related to
pregnancy, childbirth, and puerperium. It is an index of the obstetrical care needed
and received by women in a community.

a. Measures risk of dying from causes associated with childbirth

b. Affected by:
Maternal health practices
Diagnostic ascertainment of maternal condition or cause of death
Completeness of registration of birth

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 measures the risk of dying the 1st month of life. It serves
as an index of the effects of prenatal care and obstetrical management of the
newborn.

Specific Death Rate describes more accurately the risk of exposure of certain
classes of groups to particular diseases. To understand the forces of mortality, the
rates should be made specific provided the data are available for both the
population and the event in their specifications. Specific rates render more
comparable and thus reveal the problem of public health.

Incidence Rate measures the frequency of occurrence of the phenomenon

during a given period of time.

Prevalence Rate measures the proportion of the population which exhibits a

particular disease at a particular time. This can only be detremined following a
survey of the population concerned, deals with the total (new and old) number of
cases.

Proportionate Mortality (Death Ratios) - shows the numerical relationship

between deaths from all causes (or group of causes), age (or group of age) etc.
and the total no. of deaths from all causes in all ages taken together.

a. Used in ranking cause of death by magnitude of frequency

b. Expressed in PERCENTAGE.

Swaroops Index

a. LOW INDEX implies that life expectancy is short

b. Directly proportional to the health status of a population, where developed
countries have higher Swaroops Index than developing countries

Case Fatality Rate

a. Measures the killing power of a disease or injury

b. A HIGH CFR means a more fatal disease
c. Rate depends on:
Nature of the disease
Diagnostic ascertainment
Level of reporting in the population
d. CFR from hospitals HIGHER than from the community

Morbidity Rate
*Incidence Rate
a. Measures the development of a disease in a group exposed to the risk of the
disease in a period of time
b. Can be made specific for age and sex
*Attack Rate

a. Used for a limited population group and time period, usually during an outbreak
or epidemic

Prevalence Rate
a. Useful in describing the occurrence of chronic conditions and as basis for
making decisions in the administration of health services
b. Useful also in computing for carrier rates and antibody levels
A. Point Prevalence

B. Period Prevalence

Adjusted or Standardized Rate to render the rates of 2 communities

comparable, adjustment for the differences in age, sex, and any other factors
which influence vital events have to be made.

Methods:
*By applying observed specific rates to some standard population.
*By applying specific rates of standard population to corresponding classes or
groups of the local population.

Presentation of Data
The following are most commonly used graphs in presenting data:
Line or Curved graphs shows peaks, valleys and seasonal trends.
Also used to show the trends of birth and death rates over a period of time.
Bar graphs each bar represents or expresses a quantity in terms of rates or
percentages of a particular observation like causes of illness and deaths.
For comparison of data.
Area diagram (Pie Charts) shows the relative importance of parts of the
whole.

Functions of the Nurse:

*Collects data
*Tabulates data
* Analyzes and interprets data
*Evaluates data
*Recommends redirection and / or strengthening of specific areas of health
programs as needed.

INTERPRETATION OF VITAL STATISTICS

Sources of Data
Vital Registration Records
a. Civil Registry Law or Republic Act No. 3753 requires the registration
of all births and death c/o National Census and Statistics Office

b. PD 651 requires all health workers to register births within 30 days

following delivery

Weekly Reports from Field Health Personnel

Population Censuses done every 5 years c/o the National Census and
Statistics Office.

GUIDELINES IN THE CLASSIFICATION OF DATA

1. Reckoning of Vital Events all vital events are registered and reported by
place of occurrence, NOT by place of residence
2. Reckoning of Age age is recorded as of Last Birthday
3. Classification of Disease and Causes of Death
a. Definition/ Classification of the event in either numerator or
denominator for consistency
b. Accuracy of the count of event or population concerned
c. Use of correct numerator
d. Magnitude / Nature of the rate

D. Epidemiology
EPIDEMIOLOGY-
-**The study of distribution of disease or physiologic conditions such as
deformities or disabilities and even death among human populations. And the
factors affecting such distribution.
 -**Study of occurrences and distribution of diseases as well as the
distribution and determinants of health state or events in a specified population,
and the application of this study to the control of health problems. This
emphasizes that epidemiologist are concerned not only with deaths, illness and
disability, but also with more positive health states and with the means to improve
health.
-**Epidemiology is the backbone of the prevention of diseases.

Aim: To identify factors of causation as basis for determining preventive and

control measures.

Uses of Epidemiology:
According to Morris, epidemiology is used to:
1. Study the history of the health population and the rise and fall of diseases and
changes in their character.
2. Diagnose the health of the community and the condition of people to
measure the distribution and dimension of illness in terms of incidence,
prevalence, disability and mortality, to set health problems in perspective and to
define their relative importance and to identify groups needing special attention.
3. Study the work of health services with a view of improving them. Operational
research shows how community expectations can result in the actual provisions of
service.
4. Estimate the risk of disease, accident, defects and the chances of avoiding
them.
5. Identify syndromes by describing the distribution and association of clinical
phenomena in the population.
6. Complete the clinical picture of chronic disease and describe their natural
history.
7. Search for causes of health and disease by comparing the experience of groups
that are clearly defined by their composition, inheritance, experience, behavior,
and environment.

Epidemiological triangle: Agent, Host and Environment.

Agents of Disease:
*Nutritive elements in excess or in deficiencies.
*Chemical Agents
*Physical Agenta
*Infectious Agnets
Host Factor (intrinsic factors) influence exposure, susceptibility or response to
agents.
*Genetics
*Age
*Sex
*Ethnic group
*Physiologic functioning
*Immunologic experience
*Inter current to pre existing disease
*Human behavior
Environmental factors (extrinsic factors) influence existence of the agent,
exposure or susceptibility to agents.
*Physical environment
*Biologic environment
*Socio economic environment

The Epidemiologic Triangle consists of three component host, environment and

agent. The model implies that each must be analyzed and understood for
comprehensions and prediction of patterns of a disease. A change in any of the
component will alter an existing equilibrium to increase or decrease the frequency
of the disease.

Preventive strategies:
1.Change the peoples behavior to manipulate the environment and reduce their
exposure to biological and non biological disease agents.
2. Manipulate the environment and prevent production or presence of disease
agents.
3. Increase mans resistance or imunity to disase agents.

DESCRIPTIVE PHASE - Deals with the collection, organization, and analysisof

data regarding the occurrence of disease other health conditions.

A. VERIFICATION OF DIAGNOSIS
-Stating ones definition of a disease / diagnosis based on the presenting signs
and symptoms.
Consider Two Factors:
1. Sensitivity indicates the strength of association between a sign / symptom
and the disease; picks up most cases and avoids FALSE NEGATIVES.
2. Specificity shows the uniqueness of the association between a sign /
symptoms and the disease; excludes non cases or avoids FALSE POSITIVES.

B. DESCRIPTION OF THE DISEASE / CONDITION

*Factors affecting distribution:
1. Place extrinsic factors.
2. Person intrinsic characteristics such as age, sex, genetic endowment and
other factors such as occupation, place of residence, income are analyzed to
identify susceptible groups in a certain locality.

Factors Affecting the Communitys Reaction to Disease Agent Invasion

a. Herd Immunity state of resistance of a population group to a particular
disease at a given time; level of immunity of the group.
b. Susceptibility Status determined by the number of individuals with little or no
immunity.

Patterns of Disease Occurrence

Epidemic a situation when there is a high incidence of new cases of a specific
disease in excess of the expected.
Endemic habitual presence of disease in a given geographic location
accounting for the low number of both immunes and susceptible.
Sporadic disease occurs every now and then affecting only a small number of
people relative to the total population.
Pandemic global occurence of a disease.

3. Time temporal patterns; expressed on a daily, weekly, monthly, or yearly

basis.

C. ANALYSIS OF DISEASE PATTERN

-one tries to find out if there is a statistical relationship between a disease and
biological or social factors.

*Causal when there is evidence that shows that certain factors increase the
probability of occurrence of a disease and a change in one or more of these
factors produces a change in the occurrence of the disease
*Non Causal
a. Spurious due to chance or bias caused by certain procedures / aspects
involved in study.
b. Indirect when a factor and disease are associated only because both are
related to some common underlying condition.

Types of Epidemiological Study Designs

Descriptive VS Analytical
Provides information on patterns of Test Hypothesis about of disease.
disease in terms of person, place and
causes characteristics.
*Correlational *Case Reports Observational Intervention
*Ecologic *Case Series (Experimental)
*Cross Sectional
surveys
*Case control *Trials
*Cohort
Experimental Non - Experimental
With manipulation Mere observation of study conditions
*Clinical Trials *Cohort
*Field Trials *Case Control
*Community Intervention Trials *Proportional Mortality Studies
*Cross Sectional
*Ecologic

Common Epidemiologic Studies:

Retrospective Cross Sectional Prospective Cohort

Outline of Plan for Epidemiological Investigation:

1. Establish fact of presence of epidemic.
-Verify diagnosis do clinical and laboratory studies to confirm the data.
2. Establish time and space relationship of the disease.
-Are the cases limited to or concentrated in any paricular geographical
subdividion of the affected community?
-Relation of cases by days of onset to onset of the first known cases maybe
done by days, weeks or months.
3. Relations to characteristic of the group of community.
-Relation of cases to age, group, sex, color, occupation, school attendance, past
immunization.
-Relation to milk and food supply.
-Relationof cases and known carrier if any.
4. Correlation of all data obtained.
-Summarize the data clearly with the aid of such tables and charts which are
necessary to give a clear picture of the situation.
-Build up the case for the final conclusion carefully utilizing all the evidence
available.

STAGES OF A DISEASE: BACKBONE TO CONTROL A DISEASE

Incubation period-
-exposure to an infection to the appearance of the firstsymptom
Prodromal period
-from the appearance of the first symptom to theappearance of a pathognomonic
sign
Stage of illness
-a stage where the patient manifest most of the signs andsymptoms
Convalescence
- stage of recovery, and a gradual decrease of symptomsmanifested

National Epidemic Sentinel System (NESS)

-hospital-based information system that monitors the occurrence of
infectiousdiseases with outbreak potential.

Why is there a need to investigate an outbreak?

1.Control and prevention measure
2.Severity and risks to others
3.Research opportunities
4.Public, political and legal concerns
5.Program consideration
6.training

Steps in Outbreak Investigation:

1.Prepare for field work
2.Establish existence of an outbreak
3. Verify diagnosis
4. Define and Identify cases
5. Perform descriptive epidemiology
6. Developing hypotheses
7. Evaluate hypotheses
8. Refine hypotheses and execute additional studies
9. Implement control and prevention measures
10. Communicate findings
11. Follow up Recommendations

E. Demography
DEMOGRAPHY
-The emprical, statistical and mathematical study of human population; derived
from two Greek word snyos, which means people and ypagly which means to
draw or write.
-Focus on three common and observable human events:
a. Population compposition or structure
b. Distribution of population in space
c. Population size
-Sources of Demographic Data
a. Census complete enumeration of the population.
b. Sample Surveys
c. Registration system
 Two ways of Assigning People
1. De Jure people are assigned to places where they usually live regardless of
where they are at the time of the census.
2. De Facto people are assigned to the place where they are physically
present at the time of the census, regardless of their usual place of residence.

COMPONENTS
1. Population Composition pertains to all measurable characteristics of the
people who make up a given population.
a. Sex Ratio

b. Age dependency Ratio used as an index of age induced economic drain

of human resources

c. Age and Sex Composition graphical presentation of the age and sex
composition of a population through the use of a POPULATION PYRAMID

d. Median Age age below which 50% of the population fall and above which
50% of the population fall.

e. Life Expectancy at Birth average number of years an infant is expected to

live under the mortality conditions for a given year.

2. Population Distribution
a. Urban Rural Distribution shows the proportion of people living in urban
compared to the rural areas.

b. Crowding Index indicates the ease by which a communicable disease can be

transmitted from one host to another susceptible host.

c. Population Density determines congestion of the place.

3. Population Size
a. Natural Increase difference between the number of births and the number of
deaths that occurred in a specific population within a specified period of time.
b. Rate of Natural Increase difference between CBR and CDR of a specific
population within a specified time.

III. Management of Resources and Environment and Records Management

A. Field Health Services and Information System ( FHSIS )

FIELD HEALTH SERVICES AND INFORMATION SYSTEM (Cuevas, 2007)

Objectives:
- To provide summary of data on health services delivery and selected program
accomplished indicators at the barangay municipality / city, district, provincial,
regional and national events.
-To provide data which when combined with data from other sources, ca be used
for program monitoring and evaluation purposes.
-To provide a standardized, facility level data base which can be assessed for a
more in depth study /studies.
-To ensure that the data reported to the FHSIS are useful and accurate and are
disseminated in a timely and easy to use fashion.
-To minimize the recording and reporting burden at the service delivery level in
order to allow more time for patient care and promotive activities.

Importance of FHSIS
- Helps local government determine public health priorities.
- Basis for monitoring and evaluatinghealth program implementation.
- Basis for planning, budgeting, logistics and decision making at all levels.
- Source of data to detect unusual occurrence of a disease.
- Needed to monitor health status of the community.
- Helps midwives in following up clients.
- Documentation of RHM / PHN day to day activities.

Components:
*FAMILY TREATMENT RECORD (Cuevas, 2007) /
INDIVIDUAL RECORD (Famorca, 2013) / *INDIVIDUAL TREATMENT RECORD
*TARGET CLIENT LIST
*REPORTING FORMS / SUMMARY TABLE
*OUTPUT REPORTS /MONTHLY CONSOLIDATION TABLE (MCT)

Concept:
*TREATMENT RECORD Fundamental building block or foundation of FHSIS.
This is the document, form or pieces of paper upon which the presenting
symptoms or complaints of the patient on consultation and the diagnosis,
treatment and date of treatment if recorded.
*CLIENT LIST Second building block of the FHSIS and are intended to serve
several purposes.
First is to plan and carry out patient care and service delivery. Such lists
will be of considerable value to midwives / nurses in monitoring service delivery to
clients in general and in particular to groups of patients identified as targets or
eligibles for one or another program of the Department.
The second purpose of Target Client Lists is to facilitate the monitoring
and supervision of service delivery activities.
The Third purpose is to report services delivered.
The fourt purpose of the Target Client Lists is to provided a clinic level
data base which can be accessed for further studies.

TARGET CLIENT LISTS TO BE MAINTAINED IN

THE FHSIS
1. Target Client List for Prenatal Care
2. Target Client List for Post-Partum Care
3. Target Client List of Under 1 Year Old Children
4. Target Client List for Family Planning
5. Target Client List for Sick Children
6. NTP TB Register
7. National Leprosy Control Program Form 2-Central Registration
Form

*TALLY / REPORTING FORMS Submitted monthly or quarterly (majority).

One report is prepared weekly several
annually, and in some instances, every few
minutes as relevant events occur, e.g., maternal
and neonatal deaths.

FHSIS Manual of Operations has the following

RECORDING TOOLS:
1. INDIVIDUAL TREATMENT RECORD (ITR)
- Date, Home address of patient
- Presenting symptoms or complaint of the patient on consultation.
- Diagnosis (if available)
- Treatment and Date of treatment.

2. TARGET CLIENT LIST (TCL)

- To carry / plan out care for patient.
- Facilitate monitoring / supervision of service delivery activities.
- To report services delivered.
- To provide clinic level data base.
e.g., TCL for prenatal care; TCL for postpartum care.
3. SUMMARY TABLE
- Accomplished by Midwife
- 12 column table = 12 months of calendar year
- monthly summary of morbidity / monthly trends of disease
- serves as a source for the 10 leading causes of morbidity.

4. MONTHLY CONSOLIDATION TABLE

- Accomplished by the Nurse
- Source document for the Quarterly form and the Output Table of the RHU or
Health Center.
- Based on the Summary Table.
(Famorca, 2013)

FHSIS Manual of Operations

REPORTING FORMS:
- These are summary data that are transmitted or submitted on a monthly,
quarterly and on annual basis to higher level. The source of data for this
components is dependent on the records.
1. MONTHLY FORMS
- Prepared by the Midwife
- Submitted to the Nurse
a. Program Report (M1)
- Maternal Care
- Child Care
- Family Planning
- Disease Control
- Summary Table Data are copied into this report; program report.
b. Morbidity Report (M2)
- Contains list of all cases of disease by age and sex.
2. QUARTERLY FORMS
- Prepared by the Nurse
- Only one quarterly form for every Municipality / City
- If there are 2 RHU / Centers for the Municipal Health Officer / Mayor.
- Quartely Forms are submitted to the provincial health officr / Office.
a. Program Report (Q1)
- 3 months total indicators: Maternal Care, Family Planning, Child Care,
Dental Health and Disease Control.
(Famorca, 2013)
b. Morbidity Report (Q2)
- 3 months consolidation of Morbidity Report (M2)
3. ANNUAL FORMS
a. A BHS
*Report by the Midwife Demographic
- Environmental
 - Natality Data

b. Annual Form 1 (A-1)

- Prepared by the Nurse
- Report of the RHU / Health Center
- Demographic, Environmental,Natality and Mortality for the entire year.
c. Annual Form 2 (A-2)
- Prepared by the Nurse
- Yearly Report for morbidity by age / sex
d. Annual Form 3 (A-3)
- Prepared by the Nurse
- Yearly Report of all deaths (mortality) by age and sex.

FLOW OF REPORT
OFFIC PERSO RECORDING FORMS FREQUENCY SCHEDULE OF
E N TOOLS SUBMISSION
BHS Midwife -ITR Monthly Monthly Every 2nd week
-TCL Form (M1 of the
-ST AND M2 ) succeeding
month
A-BHS Annually
Form Every 2nd week
of january
RHU PHN -ST Quarterly Quarterly Every 3rd week
-MCT Form (Q1 of the 1st month
AND Q2) of succeeding
quarter
Annual Every 3rd week
Forms of January
-A1
-A2
-A3

B. Target-setting
TARGET SETTING
-Involves the calculation of the eligible population for immunization services. Since
the Universal Child Immunization goal of 80% was achieved in 1989, the target for
immunizations since 1992 onwards has increased to 90%. The two most important
goals are the following:
Sustainability of the high coverage and,
Maintenance of quality immunization Services

a. Eligible Population
 1. Infants for EPI in a barangay, municipality, district, province/city and region,
target setting is based on 3% of the total population.
2. BCG School Entrants use 3% of the total population in calculating the
number of children entering first grade in one year.
3. Pregnant Women All pregnant women are eligible for EPI. Target Setting
must include the number of pregnancies that will terminate in live births (3% of the
total population) plus the number of the pregnancies (0.5 % of the total
population): thus, the percentage of eligible women in the total population is 3.5%.

b. Calculating Vaccine Needs

*How to Calculate Vaccine Needs
-Step One: Determine the eligible population.
-Step Two: Determine the number of doses required in a year by multiplying the
eligible population with the number of doses for complete immunization.

-Step Three: Determine the wastage rate of antigen or use the wastage multiplier.
From step two, multiply the product with the wastage multiplier to get the annual
needs including the wastage allowance.

-Step Four: Determine the number of ampoules or vials needed by dividing the
annual dose by the dose per vial or ampule
ANNUAL VACCINE NEEDS PER VIAL DOSE = Annual Vaccine / Dose per vial or ampule

-
Step Five: Determine the vaccine need per month or quarter
MONTHLY VACCINE NEEDS QUARTERLY VACCINE NEEDS

= Total Vials or ampules / 12 = Total Vials or ampules / 4

months quarters

Step Six: Determine the vaccine need per month or quarter with reserve stock
MONTHLY VACCINE NEEDS

= (Total Vials or ampoules / 12 months) X 1.25

C. Determining Needle and Syringe Requirements

*How to Calculate Needle and Syringe Requirements
Step One: Determine the eligible population
Step Two: Determine the monthly eligible population
MONTHLY ELIGIBLE POPULATION = Annual eligible population / 12 months

Step Three: Multiply the monthly eligible population by the number of doses
required for each antigen
MONTHLY INJECTIONS = Monthly eligible population X doses required per antigen

Step Four: Determine the total requirement including additional allowance for
syringes and needles.
TOTAL REQUIRED SYRINGES = Monthly injections X 1.25 for syringes

TOTAL REQUIRED NEEDLES = Monthly injections X 1.50 for needles

C. Environmental Sanitation
ENVIRONMENTAL SANITATION
-is defined as the study of all factors in mans physical environment which may
exercise a deleterious effect on his health, well being and survival.

Goal: to eradicate and control environmental factors in disease transmission

through the provision of basic services and facilities to all house holds.

COMPONENTS:
Water Supply Sanitation Program
Proper Excreta and Sewage Disposal Program
Insect and Rodent Control
Food Sanitation Program
Hospital Waste Management Program
Strategies on Health Risk Minimization due to Environmental Pollution

a. Water Supply Sanitation Program

Three Types of Approved Water Supply and Facilities
Level I Level II Level III
Point Source Communal Faucet System Waterworks System or
or Stand Posts Individual House
Connections
A protected well or a A system composed of a A system with a source, a
developed spring source, a reservoir, a piped reservoir, a piped distributor
with an outlet but distribution network and network and household taps
without a distribution communal faucets, located at that is suited for densely
system for rural not more than 25 meters from populated urban areas
areas where houses the farthest house in rural
are thinly scattered areas where houses are
clustered densely
Water must pass the National Standards for Drinking Water set by the DOH

b. Proper Excreta and Sewage Disposal Program

Three Types of Approved Toilet Facilities
Level 1 Level 2 Level 3
Non- water carriage On site toilet facilities of Water carriage types of
toilet facility the water carriage type toilet facilities connected
Pit latrines. with water sealed and to septic tanks and/or
Reed Odorless Earth flushed type with septic sewerage system to a
closet. vault/ tank disposal treatment plant
Bored Hole. facilities
Compost.
Ventilated improved pit

Toilet requiring small

amount of water to wash
waste into receiving
space.
-Pour flush, Aqua Privies.

Rural Areas blind drainage type of wastewater collection and disposal facilities
shall be emphasized until such time that sewer facilities and off site treatment
facilities are available.

c. Proper Solid Waste Management

-refers to satisfactory methods of storage collection and final disposal of solid
water.
REFUSE is a general term applied to solid and semi solid waste materials other
than human excreta. Waste material in refuse may be divided into:
1. Garbage refers to leftover vegetable, animal, and fish material from
kitchen and food establishments. These materials have the tendency to
decay, thus, giving off foul odor and sometimes also serve as food for
flies and rats
2. Rubbish refers to waste materials such as bottles, broken glass, tin
cans, waste paper, discarded textile materials, porcelain wares, pieces
of metal and other wrapping materials
3. Ashes are leftover from burning of wood and coal. Ashes may become
a nuisance because of the dust associated with them
4. Stable Manure is animal manure collected from stables
 5. Dead Animals include dead dogs, cats, rats, pigs and chicken that were
killed by vehicles on streets and public highways.

TWO WAYS OF EXCRETA DISPOSAL

Household Community
Burial Sanitary Landfill or
>Deposited in 1 m x 1m Controlled Tipping
deep pits covered with >Excavation of soil
soil, located 25m away deposition of refuse and
from water supply. compacting with a solid
Open Burning cover of 2 feet
Animal Feeding -Incineration.
Composting
Grinding and disposal
sewer

d. Food Sanitation Program

Policies:
1. Food establishments are subject to inspection.
2. Comply with sanitary permit requirement for all food establishments.
3. Comply with updated health certificates for food handlers, helpers,
cooks.
4. All ambulant vendors must submit a health certificate to determine
presence of intestinal parasite and bacterial infection.
3 Points of Contamination
*Place of production processing & source of supply
*Transportation and storage
*Retail & distribution points

e. Hospital Waste Management Program

Goal: to prevent the risk of contracting nosocomial infection and other diseases
from the disposal of infectious, pathological and other hospital wastes.
Policies:
1. The use of appropriate technology and indigenous materials for HWM system
shall be adopted.
2. Training of all hospital personnel involved in waste management shall be an
essential part of the hospital training program.
3. Local ordinances regarding the collection and disposal techniques, especially
incinerators, shall be institutionalized.

f. Strategies on Health Risk Minimization due to Environmental Pollution

These include the following:
a. Anti-smoke belching campaign and air pollution campaign
b. Zero solid waste management
c. Toxic, chemical and hazardous waste management
d. Red tide control and monitoring
e. Integrated pest management and sustainable agriculture
f. Pasig river rehabilitation Management

g. Education of prevailing health problems

-Accepted activity at all levels of public health used as a means of improving
the health of the people through techniques w/c may influence peoples thought
motivation, judgment & action.

3 Aspects of Health Education:

*Information provision of knowledge
*Communication exchange of information
*Education change in knowledge, attitudes and skills.

Sequence of Steps in Health Education

*Creating awareness.
*Creating motivation.
*Decision making action.

IV. Ethico-Moral-Legal Responsibility

A. Socio-cultural Values, Beliefs and Practices of Individuals, Families, Groups and
Communities
B. Code of Ethics for Government Workers
THE CODE OF ETHICS FOR GOVERNMENT WORKERS
C. WHO, DOH, LGU Policies on Health
D. Local Government Code
E. Issues

V. Personal and Professional Development

A. Self-assessment of CHN Competencies, Importance, Methods, Tools
B. Strategies and Methods of Updating Ones Self, Enhancing Competence in
Community Health Nursing and Related Areas.

VI. Part II: MCN

VII. Safe and Quality Care, Health Education, and Communication, Collaboration
and Teamwork
A. Principles and Theories of Growth and Development (Pediatric Nursing)
PRINCIPLES OF GROWTH AND DEVELOPMENT
PRINCIPLES
Growth and development are
continuous processes from conception
until death
Growth and development proceed in an Growth in height occurs in only one
orderly sequence.
Different children pass through the
predictable stages at different rates. of time rather than a certain point at
All body systems do not develop at the Certain body tissues mature more
same rate.
EXAMPLES
Although there are highs and lows in
terms of the rate at which growth and
development proceed, a child grows
new cells and learns new skills at all
times. An example of how the rate of
growth changes is a comparison
between that of the first year and later
in life. An infants triples birthweights and
increases height by 50% during the first
year of life. If this tremendous growth
rate were to continue, the 5 ye-old
child, when ready to begin school,
would weigh 1,600 Ib. And be 12 ft. 6 in.
Tall.
sequence from smaller to larger.
Development also proceeds in a
predictable order. For example, the
majority of children sit before they
creep, creep before they stand, stand
before they walk, and walk before they
run. Some children may skip a stage
( or pass through it so quickly that the
parents do not observe the stage) or
progress in a different order, but most
children follow a predictable sequence
of growth and development.
All stages of development have a range
which they are usually accomplished.
Two children may pass through the
motor sequence at different rates. For
example, one child begins walking at 9
months while another at 14 months.
Both are developing normally. They are
both following the predictable
sequence; they are merely developing
at different rates.
rapidly than others. For example,
neurologic tissue experiences its peak

Development is cephalocaudal.
Development proceeds from proximal to
distal body part.
Development proceeds from gross to
refined skills.
growth during the first year of life,
whereas genital tissues grows little until
puberty.
Cephalo is a Greek word meaning
head; Caudal means tail.
Development proceeds from head to
tail. A newborn can lift only his or her
head off the bed when he or she lies in
a prone position. By age 2 months., the
infant can lift his or her head and chest
off the bed; by 4 months., he or she can
lift his or her head, chest, and part of
the abdomen; by 5 months., the infant
has enough control to turn over ; by 9
months., he or she can control the legs
enough to crawl; and by 1 year., the
child can stand upright and perhaps
walk. Motor development has
proceeded in a cephalocaudal order
from the head to the lower extremities.
This principle is closely related to
cephalocaudal development. It can be
illustrated by tracing the progress of
upper extremity development. A
newborn makes ;ittle use of the arms or
hands. Any movement, except to put a
thumb in the mouth, is a flailing motin.
By age 3 or 4 months., the infant has
enough arm control to support the
upper body weight on the forearms, and
the infant can coordinate the hand to
sccop up objects. By 10 months., the
infant can coordinate the arm, thumb,
and index fingers, sufficiently well to use
a pincer-like grasp or be able to pick up
an object as fine as a piece of breakfast
cereal on a high-chair train.
This principle parallels the proceeding
one. Because the child is able to control
distal body parts such as fingers, he or
she is able to perform fine motor skills
( a 3-year- old colors best with a large
crayon; a 12 yr-old can write with a fine

There is an optimum time for initiation of
experiences or learning.
Neonatal reflexes must be lost before
development can proceed.
A great deal of skill and behavior is
learned by practice.
THEORIES OF DEVELOPMENT
1. Definition of Theories
Theory a systematic statement of principles that provides a framework for
explaining some phenomenon. Developmental theories provide road maps for
explaining human development.
Developmental Task a skill or a growth responsibility arising at a particular time
in an individuals life, the achievement of which will provide a foundation for the
pen).
A child cannot learn a task until his or
her nervous system is mature enogh to
allow that particular learning. A child
cannot learn to sit, for example, no
matter how much thechilds
parentshave him or her practice, until
the nervous system has matured
enough to allow back control. A child
who is not given the opportunity to learn
developmental tasks at the appropriate
or targert times for such tasks may
have ,ore difficulty than the usual child
learning the tasks later on. A child who
is confined to a body cast at 12
months., which is the time he or she
would normally learn to walk, may take
a long time to learn this skill once free
of the cast at, say, age 2 years old. The
child has passed the time of optimal
learning fo that particular skill.
An infant cannot grasp with skill until the
grasp reflex has faded nor stand
steadily until the walking reflex has
faded. Neonatal reflexes are replaced
by purposeful movements.
An infants practices taking a first step
over and over before he or she
accomplishes this securely. If a child
falls behind the normal growth and
development rate because of illness, he
or she is capable of catch-up growth
to bring him or her on equal footing
again with his or her age group.
accomplishment of future tasks. It is not so much chronological as the completion
of developmental tasks that defines whether a child has passed from one
developmental stage of childhood to another. For example, a child is not a toddler
just because he or she is 1 year plus 1 day old; he or she becomes a toddler when
he or she has passed through the development stage of infancy.

2. Basic Division of Childhood

Stage Age Period
Neonate From 28 days of life
Infant 1 month 1 year
Toddler 1 3 years
Preschooler 3 5 year
School-age child 6 12 years
Adolescent 13 20 years

3. Freuds Stages of Childhood (Psychosexual Development)

Stage Psychosexual Stage Nursing Implications
Infant ORAL STAGE: Child explores the Provide oral stimulation
world by using his or her mouth, by giving pacifiers; do not
especially the tongue. discourage thumb
sucking. Breastfeeding
may provide more
stimulation than formula
feeding because it
requires the infant to
expend more energy.
Toddler ANAL STAGE: Child learns to Help children achieve
control urination and defecation. bowel and bladder control
without undue emphasis
on its importance. If at all
possible, continue bowel
and bladder training while
child is hospitalized.
Preschooler PHALLIC STAGE: Child learns Accept childs sexual
sexual identity through awareness interest,such as fonding
of genital area. his or her own genitals,
as a normal area of
exploration. Helps
parents answer the childs
questions about birth or
sexual differences.
School-age child LATENT STAGE: Childs Help the child have
personality development appears positive experiences as
 to be non-active or dormant.
Adolescent GENITAL STAGE: Adolescent
develops sexual maturity and
learns to establish satisfactory
relationships with the opposite sex.
his or her self-esteem
continues to grow and as
he or she prepares for the
conflicts of adolescence.
Provide appropriate
opportunities for the child
to relate with opposite
sex; allow the child to
verbalize feelings about
new relationships.

Eriksons Stages of Childhood (Psychosocial Development)

Stage Developmental Task Nursing Implications
Infant Developmental task is to Provide a primary
form a sense of trust caregiver.Provide
versus mistrust. Child experiences that add to
learns to love and be security such as soft
loved. sounds and touch.
Provide visual stimulation
for active child
involvement.
Toddler Developmental task is to Provide opportunities for
form a sense of autonomy decision makingsuch as
versus shame. Child offering choicesof clothes
learns to be independent to wear or toys to play
and make decisions for with. Praise ability to
himself or herself. make decisions rather
than judge or correct the
childs decision.
Preschooler Developmental task is to Provide opportunities for
form a sense of initiative exploring new places or
versus guilt. Child learns activities. Allow play to
how to do things (basic include activities involving
problem solving) and that water, clay (for modeling),
doing things is desirable. or finger paints.
School-age child Developmental task is to Provide opportunities
form a sense of industry such as allowing child to
versus inferiority. Child assemble and complete a
learns how to do things short project so that the
well. child feels rewarded for
the accomplishement.
Adolescent Developmental task is to Provide opportunites for
form a sense of identity the adolescent to discuss
 versus role confusion. feelings about events
Adolescent learns who he important to him or her.
or she is and what kind of Offer support and praise
person he or she will be for decision making.
by adjusting to a new
body image, seeking
emancipation from
parents, choosing a
vocation, and determining
a value system.

Piagets Stages of Cognitive Development

Stage of Development Age Span Nursing Implication

Sensorimotor neonatal 1 month Stimuli are assimilated
reflexes into beginning mental
images.Behavior is
entirely reflexive.
Primary circular reaction 1 4 months Hand mouth and ear
eye coordination develop.
Infant spends much time
looking at objects and
separating self from them.
Beginning intention of
behavior is present ( the
infant brings thumb to
mouth for a purpose: to
suck it ). An enjoyable
activity for the period: a
rattle or a tape of parents
voice.
Secondary circular 4 8 months Infant learns to initiate,
reaction recognize, and
repeatpleasurable
experiences from
environment. Memory
traces are present; infants
anticipates familiar events
( a parent coming near
him will pick him up ).
Good toy for this period:
mirror; good game: peek
a boo.
Coordination of
secondary reaction
Tertiary circular reaction 12 18 months
Invention of new means 18 24 months
through mental
combination
Pre operational thought 2 7 years
8 12 months Infant can plan activities to
attain specific goals; can
perceive that others can
cause activity and that
activities of own body are
separate from activity of
objects; can search for
and retrieve toy that
disappears from view; and
can recognize shapes and
sizes of familiar objects.
Because of increased
sense of separateness,
infant experiences
separation anxiety when
primary caregiver leaves.
Good toy for this period:
nesting toys ( e.g., colored
boxes ).
Child is able to experiment
to discover new properties
of objects and events and
is capable of space and
time perception as well as
permanence. Object
outside seff are
understood as causes of
actions. Good game for
this period: throw and
retrieve.
Transitional phase to the
pre operational thought
period. Child uses
memory and imitation to
act, solves basic
problems, and foresees
maneuvers that will
succeed or fail. Good toys
for this period: those with
several uses such as
blocks and colored plastic
rings.
Thought becomes more
 sympbolic. Child can
arrive at answers mentally
instead of through
physical attempt and can
comprehend simple
abstractions, although
thinking is basically
concrete and literal. Child
is egocentric (unable to
see the viewpoint of
another) and displays
static thinking (inability to
remember what he or she
started to talk about, so
that at the end of a
sentence, the child is
already talking about
another toipc). Concept of
time is now, and concept
of distance is only as far
as he or she can see.
Centering or focusing on a
single aspect of an object
causes distorted
reasoning. No awareness
of reversibility (for every
action there is an opposite
action) is present. Child is
unable to state cause
effect relationships,
categoris or abstractions.
Good toy for this perio:
Items that require
imagination such as
modeling clay.
Concrete operational 7 12 years Concrete operations
thought include systematic
reasoning. Uses memory
to learn broad concepts
(e.g. fruit) and subgroups
of concepts (e.g., apples,
oranges). Objects are
sorted according to
 attributes such as color;
seriation, in which objects
are ordered according to
increasing or decreasing
measures such as weight;
and multiplication, in
which objects are
simultaneously classified
and seriated using weight.
Child is aware of
reversibility, An opposite
operation or continuation
of reasoning back to a
starting point (follows a
route through a maze and
then reverses steps);
understands conservation;
and sees constancy
despite transformation
(mass or quantity remains
the same even if it
changes shape or
position). Good activity for
this period: collecting and
classifying natural objects
such as native plants, sea
shells, etc. Expose child to
other view points by
asking questions like How
do you think youd feel if
you were a nurse and had
to tell someone to stay in
bed?
Formal operational 12 years Adolescent can solve
thought hypothetical problems with
scientific reasoning, can
understand causality, and
can deal with the past,
present, and future. Adult
or mature thought. Good
activity for this period: talk
time to sort through
attitudes and opinions.
From Piaget, J. (1961). The growth of logical thinking from childhood to
adolescence. New York: Basic Books, with permission.

Kohlbergs Stages of Moral Development

Age Stage Description Nursing Implications

(Year
)
Pre conventional (Level I)
2-3 1

B. Nursing Care in the Different stages of Growth and Development including

1. Nutrition
2. Safety
3. Language Development
4. Discipline
5. Play
6. Immunization
7. Anticipatory guidance
8. Values formation
C. Human Sexuality and Reproduction including Family Planning
D. Nursing Care of Women during Normal Labor, Delivery and Postpartum
E. Nursing Care of the Newborn
1. APGAR Scoring
2. Newborn Scoring
3. Maintenance of Body Processes (oxygenation, temperature)
F. Nursing Care of Women with Complications of Pregnancy, Labor, Delivery and
Postpartum Period (High-risk conditions)
G. Nursing Care of High-risk Newborn
1. Prematurity
2. Congenital defects
3. Infections
H. Nursing Care of Women with Disturbances in Reproduction and
Gynecology

VIII. Research and Quality Improvement

A. Fertility Statistics
B. Infant Morbidity and Mortality
C. Maternal Mortality
D. Standards of Maternal and Child Nursing Practice

IX. Ethico-Moral-Legal Responsibility

A. Socio-Cultural Values, Belief, and Practices of Individuals, Families related to
MCN.
B. WHO, DOH, LGU Policies on Health of Women and Children
C. Family Code
D. Child and Youth Welfare Code
E. Issues related to MCN

X. Personal and Professional Development

A. Self-assessment of MCN Competencies, Importance, Methods, Tools
B. Strategies and Methods of Updating Ones self, Enhancing Competence in
MCN and Related Areas.
Nursing Board Exam/Nursing Licensure Exam Coverage (Nursing Practice
III, IV and V)
NURSING BOARD EXAM SCOPE/COVERAGE
NURSING PRACTICE III, IV, V
TEST DESCRIPTION: Theories, concepts, principles and processes in the care of
clients with altred health patterns, utilizing the nursing process and integrating the
key areas of nursing competencies.
TEST SCOPE:
I. Safe & Quality Care, Health Education, Management of Environment &
Resources, and Quality Improvement.

A. TEST III
1. Client in Pain
CLIENT IN PAIN

GLOSSARY
addiction: a behavioral pattern of substance use characterized by a compulsion
to take the substance (drug or alcohol) primarily to experience its psychic effects.
agonist: a substance that when combined with the receptor produces the drug
effect or desired effect.
Endorphins and morphine are agonists on the opioid receptors.
algogenic: causing pain.
antagonist: a substance that blocks or reverses the effects of the agonist by
occupying the receptor site without producing the drug effect.
balanced analgesia: using more than one form of analgesia concurrently to
obtain more pain relief with fewer side effects.
breakthrough pain: a sudden and temporary increase in pain occurring in a
patient being managed with opioid analgesia.
dependence: occurs when a patient who has been taking opioids experiences a
withdrawal syndrome when the opioids are discontinued; often occurs with opioid
tolerance and does not indicate an addiction.
endorphins and enkephalins: morphinelike substances produced by the body.
Primarily found in the central nervous system, they have the potential to reduce
pain.
intractable pain: pain not relieved by conventional treatment.
neuropathic pain: pain caused by neurologic disturbance; may not be associated
with tissue damage.
nociception: activation of sensory transduction in nerves by thermal, mechanical,
or chemical energy impinging on specialized nerve endings; the nerves involved
convey information about tissue damage to the central nervous system.
nociceptor: a receptor preferentially sensitive to a noxious stimulus.
non-nociceptor: nerve fiber that usually does not transmit pain.
opioid: a morphinelike compound that produces bodily effects including pain
relief, sedation, constipation, and respiratory depression.
pain: an unpleasant sensory and emotional experience resulting from actual or
potential tissue damage.
pain threshold: the point at which a stimulus is perceived as painful.
- minimum amount of stimulus required to cause sensation of pain.
pain tolerance: the maximum intensity or duration of pain that a person is able to
endure.
- maximum pain a client is willing or able to endure.
patient-controlled analgesia (PCA): self-administration of analgesic agents by a
patient instructed about the procedure.
Phantom pain: pain experienced in missing body part.
placebo effect: analgesia that results from the expectation that a substance will
work, not from the actual substance itself.
prostaglandins: chemical substances that increase the sensitivity of pain
receptors by enhancing the pain-provoking effect of bradykinin.
radiating pain: pain experienced at source and extending to other areas.
referred pain: pain perceived as coming from an area different from that in which
the pathology is occurring.
- pain experienced in an area different from site of tissue trauma.
sensitization: a heightened response seen after exposure to a noxious stimulus.
Response to the same stimulus is to feel more pain.
tolerance: occurs when a person who has been taking opioids becomes less
sensitive to their analgesic properties (and usually side effects); characterized by
the need for increasing doses to maintain the same level of pain relief.

Pain
-Is defined as an unpleasant sensory and emotional experience associated with
actual or potential tissue damage (Merskey and Bogduk, 1994).
-Dimensions includes: Physical, Emotional, Cognitive, Socio-cultural and
Spiritual aspects.
-Pain occurs as the result of many disorders, diagnostic tests, and treatments; it
disables and distresses more people than any single disease.
1. Referred to as fifth vital sign.
2. Subjective; pain is whatever client says it is.
3. Perception of the clients pain is influenced by multiple factors (e.g., previous
pain experience and emotional, physical, and psychological status)
-The International Association for the Study of Pain (IASP) defines pain as an
unpleasant sensory and emotional experience associated with actual or potential
tissue damage, or described in terms of such damage. Although there are many
definitions and descriptors of pain, the one most relevant for nurses is that pain
is whatever the person experiencing it says it is, and existing whenever the
person says it does (McCaffery, 1979).

Types of PAIN
1. According to LOCATION
a. Referred pain
-perceived pain in an area but the source in another area.
-because fibers innervating this areas are close to innervating some tissues.
b. Visceral Pain
-usually diffuse, poorly localized, dull, pain, vague
-visceral organs are innervated by the sympathetic nerves to the spinal cord.
-rarely causes severe pain.

2. According to DURATION
a. Acute pain: mild to severe pain lasting lessthan 6 months.
-usually associated with specific injury; involves sympathetic nervous system
response.
-leads to increased pulse rate and volume, rate and depth of respirations, blood
pressure (BP), and glucose level.
-urine production and peristalsis decrease.
b. Chronic pain: mild to severe pain lasting longer than 6 months.
-associated with parasympathetic nervous system.
-client may not exhibit signs and symptoms associated with acute pain.
-may lead to depression and decreased functional status.
3 TYPES OF CHRONIC PAIN:
1. Chronic Nonmalignant Pain
- > than 6 months, no foreseeable end
- Makes it difficult to live a normal life
2. Chronic Intermittent Pain
- Refers to exacerbation & recurrence of chronic condition.
- pain occurs at specific periods
- Ex. Migraine, Sickle cell
3. Chronic Malignant Pain
- have qualities of both Acute and Chronic Pain
c. Cancer related Pain: Pain associated with cancer may be acute or chronic.
-Pain resulting from cancer is so ubiquitous that when cancer patients are asked
about possible outcomes, pain is reported to be the most feared outcome (Munoz
Sastre, Albaret, Maria Raich Escursell, et al., 2006).
-Pain in patients with cancer can be directly associated with the cancer (eg, bony
infiltration with tumor cells or nerve compression), a result of cancer treatment (eg,
surgery or radiation), or not associated with the cancer (eg, trauma). However,
most pain associated with cancer is a direct result of tumor involvement.

3. According to INTENSITY
- clients report of pain MOST important indicator of the existence & intensity of
pain.
- Assess of what level of comfort is acceptable
- Use of Pain Intensity Scale, Pain Rating Scale, Visual Analog Scale (VAS)
Factors Affecting Perception of Pain:
1. Amount of perception
2. State of Consciousness
3. The Level of Activities
4. The Clients Expectation
4. According to ETIOLOGY
b. Physiologic Pain
- Experienced when an intact, properly functioning nervous system sends signals
that the tissues are damaged, requiring attention and proper care.
- Subcategories: Somatic and Visceral
c. Neuropathic Pain
- experienced by people who have damaged or malfunctioning nerves
- may be due to: Illness, Injury, Undetermined reasons

CONCEPTS ASSOCIATED WITH PAIN

Y Pain Threshold
- lowest intensity of a painful stimulus that is perceived by a person as pain
- generally the same for all persons
Y Pain Tolerance
- the amount of pain a person is willing to endure
- Different for each person
- An only be determine by the client

FOUR PROCESS IN NOCICEPTION

1. Transduction
- the conversion of mechanical, thermal and chemical stimulus into a neural action
potential.

A delta fibers
- transmits signals more rapidly
- delivers information on pain producing stimulus
- determine the location, severity and type of pain
- perceived as sharp, cutting, stubbing sensation
A beta fibers
- thicker neurons that release inhibiting neurotransmitters
- Dominant stimulation causes gating mechanism to close
C fibers
- conducted more slowly along pain pathway
- characterized as dull, burning sensations, associated with sufferings
- engages brain stem and cerebral regions contributing to emotional,
cognitive and situational components of pain

2. Transmission
I. Pain impulses travels from peripheral nerve fibers to the spinal cord
PAN membranes become depolarized

Action potential spreads along the entire neuron

Delivers the signals to cells in the spinal cord

II. Ascension via spinothalamic tracts to the brain stem & thalamus
PAN neurotransmitters

Release into the synoptic cleft of the spinal cord

Bind the receptors

III. Transmission of signals between the thalamus and somatic sensory cortex
Spinothlamic Tract (STT) segregates

Medial branch Lateral Branch

Medial thalamus Lateral thalamus

4 thalamic nuclei

Projection to the cortex

Perception

Somatosensory cortex interpret the sensory

Frontal cortex interpret the affective

3. Perception
- client becomes conscious of the pain
- occurs in cortical structures

4. Modulation
- descending system
-descending fibers release substance which inhibits the ascending noxious
impulses in the dorsal horn

STIMULATION OF NOCICEPTORS
Mechanical instruments, and equipment
Thermal flames, hot liquids, steam
Chemical noxious substances

CHEMICAL MEDIATORS OF PAIN

1. Bradykinin a powerful vasodilator that increased capillary permeability &
constrict smooth muscle
2. Histamine a compound found in all cells. It is release in allergic inflammatory
reactions
3. Acetylcholine a neurotransmitter substance widely distributed in body tissues
& functions as vasodilators and cardiac depressants
4. Substance P stimulant at pain receptor sites involved in inflammatory
response in local tissue
5. Prostaglandin chemical substance thought to increase the sensitivity of pain
receptors by enhancing the pain provoking effect of Bradykinin.
6. Endorphin/ Encephalin reduce or inhibit transmission of pain. Both are found
in heavy concentration nit the CNS.

GATE CONTROL THEORY ( Melzack and Wall, 1965)

- pain impulses can be regulated or even blocked by gating mechanism along the
CNS.
- Substancia gelatinosa in the dorsal horn of the spinal cord where gating
mechanism is found.
- Open gate pain passes through
- Close gate pain impulses are blocked
- How to close the gate? By rubbing the back, acupressure, relaxation, deep
breathing.
- Substance P promote transmission of pain to higher nerve
- A delta fibers and C neurons release substance P to transmit impulse to the
gating system

PAIN REACTION
Factors that Decsrease an Individuals Tolerance to Pain
- Prolonged pain that is sufficiently relieved
- Fatigue accompanied by inability to sleep
- Increase fear and anxiety
- Unresolved anger
- Depression / Isolation
Physiologic reaction to Pain
- Involved the activation of the sympathetic Nervous System
- Evoked the fight and flight reaction
- With catecholamine release from the adrenal medulla
Physical Responses
- Moving away
- Protecting body area
- Restlessness
- Facial expressions biting lips,grimace, staring
- Voluntary and involuntary protective body movements

Psychological Responses
- Verbal statements praying, swearing, cursing, repeating
- Non sensual phrases
- Altered response to environment
- Vocal behaviors moan, scream, sighing, crying
- Body movements rocking, rubbing, pounding, biting
- Physical contact to others
- Facial expressions grimace, tight lips, clenched teeth
FACTORS THAT INFLUENCING PAIN PERCEPTION AND INTERPRETATION
1. Situational factors
S situation associated with pain
S formal or crowded situations
S Ex. Type of illness or tumor or disease
2. Socio-cultural factors
S We learn to respond to pain from our family & ethnic group
S Pain response tends to reflect the mores of the culture
S Can affect pain management
3. Age
S Transmission of pain may be slowed to adults
S Physical actors, affecting doses
4. Gender
S Men are expected to express <pain than women do
S Men report < pain than women
S Does not mean men feel pain less, only assumes to show it less
5. Meaning of Pain
S Meaning of pain of a person influences his/her response to pain
S Known vs unknown cause of pain
S Meaning of experience: negative or positive
6. Anxiety
S It intensifies the pain
7. Past experiences with Pain
S Affects the way we perceived our current pain
S Negative experience with pain as children have reported greater difficulties
managing pain
S Impact of pain experience may not be predictable
S Earlier pain experience allow us to adopt coping mechanism

8. Expectation and the Placebo effect

S Clients expectations plays a major role in a persons pain perception and
effectiveness pain relief intervention
S PLACEBO EFFECT
- may initiate the bodys endogenous opiate system activated by the
expectation of relief
- placebo response does not indicate absence of real pain
- deceptive use of placebo is considered unacceptable in pain
management

NURSING PROCESS IN THE CARE OF CLIENTS WITH PAIN

A. ASSESSMENT
- the cause of pain must be sought
- the person with pain is he expert about the location, intensity, quality and pattern
of the pain
PAIN CARE BILL OF RIGHTS
- Have your report of pain taken seriously & be treated with dignity & respect
- Have your pain thoroughly assessed & promptly treated
- Be informed by your health care about what may be causing the pain,
possible treatments & the benefits, risks, & cost of each
- Participate actively in decisions about how to manage your pain
- Have your pain reassessed regularly & your treatment adjusted if your pain
has not been eased (assess after)
- Be referred to a pain specialist if your pain persists.

NURSING MANAGEMENT OF PAIN

- Pain as the fifth vital sign makes pain assessment a routine aspects of care
of all clients
- Give the highly objective nature of pain, a comprehensive assessment of
the pain experiences provides the necessary foundation for optional pain
control.

MAJOR COMPONENTS OF PAIN ASSESSMENT

- Pain history to obtain facts from client
- Direct observation of behaviors, physical signs

PAIN HISTORY
- Previous pain treatment and effectiveness
- When and what analgesics were last given
- Other meds being taken
- Allergies to medication or food

ASSESSMENT
P Provoking factors (what makes pain worst/relieved)
Q Quality or quantity (dull, sharp, crushing, stabbing)
R Region and Radiation (diffused/ all over)
S Severity or intensity
T Timing (onset, duration, frequency, cause)

C Characteristics
O Onset
L Location
D Duration
E Exacerbation (what makes it worst?)
R Radiation (whether t spreads)
R Relief

P Provoking factors
A Alleviating factors/area
I Intensity
N Nature (characteristics)
MEASUREMENT OF PAIN
A Pain reporting is the single best measure of pain
A Pain location
U Drawing on the body, point & mark all areas where the pain is felt
A Pain intensity
U Numerical scale (0-10)
U Wong-Bakers Faces pain Rating (1-6 faces)
U Visual analogue scale (horizontal mark
A Pain quality
U Use of verbal descriptor scale
A Pain pattern
U Precipitating factors: what initiates (physical exertion, environmental
& emo factors)
U Alleviating factors: herbal teas, meds, test, hot or cold application,
prayer, distraction
U Associated symptoms: N/V, dizziness, diarrhea
U Effect on ADL
U Coping Resources
U Affecting responses: Anxiety, fear, exhaustion, depression or sense
of failure
U The use of the standardized assessment tools help make the pain
less abstract for the patient
U When the pain is a more concrete experience, the patient feels
empowered to cope

B. DIAGNOSIS
1) Pain
2) Activity intolerance
3) Altered family processes
4) Anxiety
5) Chronic pain
6) Constipation
7) Fear
8) Risk for altered thought processes
9) Risk for self- harm
10)Hopelessness
11) Ineffective individual coping
12)Powerlessness
13)Sleep pattern disturbance

C. NURSING CARE MANAGEMENT OF PAIN

KEY STRATEGIES IN THE MANAGEMENT OF PAIN
Y Acknowledgement and Accepting Clients pain
a. Acknowledge the possibility of pain
b. Listen attentively to what the client says about the pain
c. Convey the need to ask about the pain
d. Attend to the clients need promptly
Y Assert support persons
Y Reduce misconceptions about pain & its treatment
Y Reducing fear & anxiety
Y Preventing pain by providing measures to treat pain before it occurs or
before it becomes severe

PHARMACOLOGIC PAIN MANAGEMENT

The WHO 3 steps analgesic ladder

STEP 1: drugs for mild pain (1-3) non-opioid drugs

- Aspirin & NSAIDS = blocks prostaglandin synthesis
- Acetaminophen = acts through central mechanisms (ex. Paracetamol- Not
> 4000mg)
- Cyclooxydase-2 (COX-2) = inhibitors which selectively block the COX-2
enzymes responsible for inflammation & the production of substances
associated with pain.
- Adjuvant drugs = are not usually used for analgesia (depressants Prozac)

STEP 2: drugs for moderate (4-6) / mild but persistent pain

Y Opioid-agonist (Codeine, Hydrocodone, Meperidine)
- Bind to opioid receptors (mu, delta, kappa) in the CNS to block transmission
of nociceptive signals.

Y Opioid-agonist antagonist (Pentazocine)

- Produce effect at kappa receptors (agonist) but block the drugs effect at the
mu receptors (antagonist)

STEP 3: drugs for moderate to severe pain (7-10)

Y Opioid drugs (morphine sulfate, naloxonarcan, hydromorphane, methadone)
- Morphine = respi arrest; M-6G (metabolite of morphine)
- Meperidine = should not be used longer than 48 hours because its
metabolic by-product is toxic to the CNS

ADVERSE EFFECT OF OPIOID ANALGESICS

- constipation related to increase smooth muscle tone and motility of the GIT
- nausea and vomiting related to action on the brain stem centers
- respiratory depression related to diminished sensitivity to the respiratory center to
CO2

ADJUVANT MEDICATIONS
- may be used with an analgesic or be used alone
- blocks cellular reuptake of serotonin /& epinephrine via descending pain
inhibitory system
- Selective Serotinin Reuptake Inhibitors:
Y Fluoxetine (Prozac)
Y Paroxtine (Foxil)
Y Sertraline (Zoloft)
- Anti- anxiety agents:
Y Diazepham mediate pain by allowing the movement of chloride inos
result to hyperpolarization of postsynaptic membrane, making it less
receptive to incoming nociceptive stimuli.
Y Anti- convulsants - situations associated with nerve injury ex. Phenetoin
Y Corticosteroids - reduce edema & inflammation

APPROACHES IN THE USE OF ANALGESICS

Balanced Analgesia simultaneous use of agents for maximum relief while
minimizing the potentially toxic effects of any one agents.
Preventive approach most effective drug is administered at set intervals before
pain becomes severe or before the drug is at sub therapeutic levels.

METHODS OF ADMINISTRATION OF ANALGESICS

1. Nurse administered analgesia as PRN meds or on schedule
2. Oral
3. IM
4. IV
5. Ommaya Reservoir
- catheter is inserted into the anterior horn of the lateral ventricles
- PATIENT CONTROLLED ANALGESIA (PCA) PUMPS
U Use of a W or SC infusion pump that contains the analgesic & is
controlled by the patient.
U Uses a portable infusion pump delivers a small preset safe dose
U Has a lock system to avoid tempering by the client or family
U Patient feels in control & can decrease anxiety
U C/I: confused & unresponsive
U For persistent pain
U PCA pump is electrically controlled by a timing device delivering a
persistent of the meds.
U Pain should be brought under control before PCA starts
6. Rectal route patient who cant tolerate PO.
7. Cream & lotion
8. Transdermal route: skin patch for up to 72 hours
9. Transmucosal route: sublingually or the use of lozenges especially for
breakthrough pain
10. Nasal route: nasal mucosa
11. Topical: CAPSAICIN, EMLA (venipuncture,debridement)
12. Intraspinal/ Epidural analgesia which delivers the drug through a catheter
into areas of standard receptor sites for 8 24 hours duration.
13. Nerve blocks
I. NON INVASIVE PAIN RELIEF STRATEGIES
+ Positioning
- minimize joint and muscle stiffness
- active exercise regimen
- passive range of motion exercises
- early morning stiffness
+ Cutaneous stimulation
- distract the client and focuses attention on the tactile stimuli, away from the
painful sensations.
- Interferes with the transmission and perception of pain by stimulating large
diameter A beta sensory nerve fibers that activate the descending
mechanisms reducing the intensity of pain, activate the endorphine system
- Be applied directly, proximal to or distal to contralateral to the pain
- Contraindicated to areas of skin breakdown or impaired neurologic function
- Massage decrease muscle tension
- Useful when painful area cannot be touched when it is hypertensive,
inaccessible, or whom pain is felt in a missing part (phantom)
- Immobilization/bracing, heat/cold application, acupressure

***TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)

- Delivery of electrical current through electrodes applied to the skin over the
painful region, at bigger points or even a peripheral nerve. Stimulate the nonpain
receptors or cause the release cp.

THE USE OF TENS

a Remove & clean electrodes daily
a Wash skin with soap & water
a Allow skin to dry
a Wipe skin with a prepared pad before reapplying the conductor pad
a Check the back if numbness or tingling is not felt during treatments.
a Report if sensation is either
a Heat therapy & Id therapy

II. INVASIVE PAIN RELIEF STRATEGIES

+ Acupuncture involves the insertion of the needles at specified cutaneous sites
+ Percutaneous electrical nerve stimulation involves the insertion of a needle
to which a stimulator is attached, near a large peripheral or spinal nerve.

Nerve Blocks
- temporary or permanently interrupting transmission of nociceptive input by
application of local anesthetics or neurolytic agents (alcohol or phenol)
- successful for more localized chronic pain
- injection of anesthetics close to the nerves, thereby blocking their conductivity
- commonly used for operative procedures
- Ex. Plenux block for anesthesia of an extremity: brachial plexus block,
epidural block
NEUROSURGICAL INTERVENTIONS
Rhizotomy sensory nerve roots are destroyed where they enter the spinal cord
Cordotomy pain pathways are at the midline portion of the spinal cord before

COGNITIVE BEHAVIORAL THEORIES

S Anticipatory guidance
- preparing the patient for what to expect allows the nurse to help reduce
anxiety & clarify misinformation & misinterpretation
- Distraction redirection of attention on something away from pain (visual,
auditory, intellectual, tactile)

S Imagery
- Develop sensory images that focus away from the pain sensation &
emphasize other sensory experiences & pleasant memories.

S Hypnosis
- a state of altered consciousness characterized by extreme responsiveness
to suggestion

S Relaxation techniques
- deep breathing, music, low rhythmic breathing, progressive relaxation
exercises
- biofeedback teach self control over physiologic variables that relate to
pain like muscle contraction & blood flow

S Therapeutic touch
- realign aberrant fields
- pass hands over the clients body at a distance of 2-6 inches to sense
changes in the field & return it to normal

S Spiritual intervention
- encompasses a persons innermost concerns & values
- make peace with their past, being, spiritually aware in the present & making
commitment to go forward the life despite the pain.
- Prayer, caring.

NURSING ACTIONS THAT PROMOTE EFFECTIVE RELATIONSHIP WITH A

PATIENT IN PAIN
1) Believe the client
2) Clarify responsibilities in pain relief
3) Respect the clients response to pain
4) Collaborate with the client
5) Explore the pain with the client, its meaning
6) Be with the client
TEN COMMNADMENTS OF PAIN MANAGEMENT
1) Thou shalt believe the patients report to pain
2) Thou shalt assess and reassess the patients response to pain interventions
3) Thou shalt not be afraid of prescribing or administering opioid analgesics
4) Thou shalt not prescribe inadequate amounts of any analgesics
5) Thou shalt not use the abbreviation PRN for continuous pain, but ATC
6) Thou shalt reassure the patient and family that risk of opioid addiction is rare
7) Thou shalt provide support for the whole family.
8) Thou shalt not limit thy approach simply to the use of analgesics, but also
adjuvant drugs and mind-body techniques.
9) Thou shalt prevent or treat side effects of opioid
10) Thou shalt not be afraid to ask colleagues advice.

2. Peri-operative Care
GLOSSARY
ambulatory surgery: includes outpatient, same-day, or short-stay surgery that
does not require an overnight hospital stay
informed consent: the patients autonomous decision about whether to undergo a
surgical procedure, based on the nature of the condition, the treatment options,
and the risks and benefits involved
intraoperative phase: period of time that begins with transfer of the patient to the
operating room table and continues until the patient is admitted to the
postanesthesia care unit
perioperative phase: period of time that constitutes the surgical experience;
includes the preoperative, intraoperative, and postoperative phases of nursing
care
postoperative phase: period of time that begins with the admission of the patient
to the postanesthesia care unit and ends after follow-up evaluation in the clinical
setting or home
preadmission testing: diagnostic testing performed before admission to the
hospital
preoperative phase: period of time from when the decision for surgical
intervention is made to when the patient is transferred to the operating room table

PRIORITY CONCEPT: Infection; Safety

Perioperative nursing is a specialized area of practice. It incorporates the three

phases of the surgical experience: preoperative, intraoperative, and postoperative.
The preoperative phase begins when the decision for surgery is made and ends
when the patient is transferred to the operating room.
The intraoperative phase begins with the patients entry into the operating room
and ends with admittance to the postanesthesia care unit (PACU), or recovery
room.
The postoperative phase begins with the patients admittance to the PACU and
ends with the patients complete recovery from the surgical intervention.
 Although the perioperative nurse works in collaboration with other healthcare
professionals to identify and meet the patients needs, the perioperative nurse has
the primary responsibility and accountability for nursing care of the
patient undergoing surgery.

Surgery
Surgery is an invasive medical procedure performed to diagnose or treat illness,
injury, or deformity. Although surgery is a medical treatment, the nurse assumes an
active role in caring for the patient before, during, and after surgery.
Interdisciplinary care and independent nursing care together prevent complications
and promote the surgical patients optimal recovery.

Classification of Surgical Procedures

- Surgical procedures can be classified according to purpose, risk, and urgency

Classifications of Surgical Procedures

Classification Function Examples
Purpose Diagnostic Determine or confirm a diagnosis Exploratory
Laparotomy (incision
into the peritoneal
cavity to inspect
abdominal organs),
Breast biopsy,
bronchoscopy

Ablative Remove diseased tissue, organ, or Appendectomy,

extremity Amputation

Constructive Build tissue/organs that are absent Repair of cleft palate,

(congenital anomalies) closure of atrial septal
defect in the heart

Reconstructive Rebuild tissue/organ that has been Skin graft after a burn,
/Restorative damaged total joint replacement

Colostomy,debride-
Palliative Alleviate symptoms of a disease ment of necrotic tissue,
(not curative) resection of nerve
roots(Bowel resection
in patient with terminal
cancer).

Procurement Replace organs/tissue to restore Heart, lung, liver,

 for Transplant function kidney transplant.
Risk Minor Minimal physical assault with Removal of skin
minimal risk lesions, facial plastic
surgery, dilation and
curettage (D&C),
cataract extraction,
tooth extraction

Major Extensive physical assault and/or Transplant, total joint

serious risk replacement,thoraco-
tomy, colostomy,
nephrectomy, coronary
artery bypass, removal
of larynx, resection of
the lung lobe
Urgency Elective Suggested,though no foreseen ill Cosmetic surgery,
effects if postponed cataract surgery,
bunionectomy,breast
reconstruction

Urgent Necessary to be performed within Heart bypass surgery,

1 to 2 days amputation resulting
from gangrene,
Excision of cancerous
tumor, removal of
gallbladder for stones,
vascular repair of
obstructed artery
(CABG), fractured hip

Emergency Performed immediately Obstetric emergencies,

Repair of perforated
appendix, Repair of
traumatic amputation,
control of internal
hemorrhaging, bowel
obstruction, ruptured
aneurysm, life-
threatening trauma
I. Preoperative Care
A. Obtaining informed consent***
1. The surgeon is responsible for explaining the surgical procedure to the client
and answering the clients questions. Often, the nurse is responsible for obtaining
the clients signature on the consent form for surgery, which indicates the clients
agreement to the procedure based on the surgeons explanation.
2. The nurse may witness the clients signing of the consent form, but the nurse
must be sure that the client has understood the surgeons explanation
of the surgery.
3. The nurse needs to document the witnessing of the signing of the consent form
after the client acknowledges understanding the procedure.
4. Minors (clients younger than 18 years) may need a parent or legal guardian to
sign the consent form.
5. Older clients may need a legal guardian to sign the consent form.
6. Psychiatric clients have a right to refuse treatment until a court has legally
determined that they are unable to make decisions for themselves.
7. No sedation should be administered to the client before the client signs the
consent form.
8. Obtaining telephone consent from a legal guardian or power of attorney for
health care is an acceptable practice if clients are unable to give consent
themselves. The nurse must engage another nurse as a witness to the consent
given over the telephone.

B. Nutrition
1. Review the surgeons prescriptions regarding the NPO (nothing by mouth)
status before surgery.***
2. Withhold solid foods and liquids as prescribed to avoid aspiration, usually for 6
to 8 hours before general anesthesia and for approximately 3 hours before surgery
with local anesthesia (as prescribed).
3. Insert an intravenous (IV) line and administer IV fluids, if prescribed; per agency
policy, the IV catheter size should be large enough to administer blood products if
they are required.

C. Elimination
1. If the client is to have intestinal or abdominal surgery, per surgeons preference
an enema, laxative, or both may be prescribed for the day or night before surgery.
2. The client should void immediately before surgery.
3. Insert an indwelling urinary catheter, if prescribed; urinary catheter collection
bags should be emptied immediately before surgery, and the nurse should
document the amount and characteristics of the urine.

D. Surgical site
1. Clean the surgical site with a mild antiseptic or antibacterial soap on the night
before surgery, as prescribed.
2. Shave the operative site, as prescribed; shaving may be done in the operative
area.
!Hair on the head or face (including the eyebrows) should be shaved only if
prescribed.

E. Preoperative client teaching

1. Inform the client about what to expect postoperatively.
2. Inform the client to notify the nurse if the client experiences any pain
postoperatively and that pain medication will be precribed and given as the client
requests. The client should be informed that some degree of pain should be
expected and is normal.
3. Inform the client that requesting an opioid after surgery will not make the client a
drug addict.
4. Demonstrate the use of a patient controlled analgesia (PCA) pump if
prescribed.
5. Instruct the client how to use noninvasive pain relief techniques such as
relaxation, distraction techniques, and guided imagery before the pain occurs and
as soon as the pain is noticed.
6. The nurse should instruct the client not to smoke (for at least 24 hours before
surgery); discuss smoking cessation treatments and programs.
7. Instruct the client in deep breathing and coughing techniques, use of incentive
spirometry, and the importance of performing the techniques postoperatively to
prevent the development of pneumonia and atelectasis.***

Client Teaching
Deep Breathing and Coughing Exercises
*Instruct the client that a sitting position gives the best lung expansion for coughing
and deep breathing exercises.
*Instruct the client to breath deeply 3 times, inhaling through the nostrils and
exhaling slowly through pursed lips.
*Instruct the client that the third breath should be held for 3 seconds; then the
client should cough deeply 3 times.
*The client should perform this exercise every 1 to 2 hours.
Incentive Spirometry
*Instruct the client to assume a sitting or upright position.
*Instruct the client to place the mouth tightly around the mouthpiece.
*Instruct the client to inhale slowly to raise and maintain the flow rate indicator,
usually between the 600 and 900 marks on the device.
*Instruct the client to hold the breath for 5 seconds and then to exhale through
pursed lips.
*Instruct the client to repeat this process 10 times every hour.
Leg and Foot Exercises
*Gastrocnemius (calf) pumping: Instruct the client to move both ankles by
pointing the toes up and then down.
*Quadriceps (thigh) setting: Instruct the client to press the back of the knees
against the bed and then to relax the knees; this contracts and relaxes the thigh
and calf muscles to prevent thrombus formation.
*Foot circles: Instruct the client to rotate each foot in a circle.
*Hip and knee movements: Instruct the client to flex the knee and thigh and to
straighten the leg, holding the position for 5 seconds before lowering (not
performed if the client is having abdominal surgery or if the client has a back
problem).
Splinting the Incision
*If the surgical incision is abdominal or thoracic, instruct the client to place a pillow,
or 1 hand with the other hand on top, over the incisional area.
*During deep breathing and coughing, the client presses gently against the
incisional area to splint or support it.

8. Instruct the client in leg and foot exercises to prevent venous stasis of blood and
to facilitate venous blood return
9. Instruct the client in how to splint an incision, turn, and reposition
10. Inform the client of any invasive devices that may be needed after surgery,
such as a nasogastric tube, drain, urinary catheter, epidural catheter, or IV or
subclavian lines.
11. Instruct the client not to pull on any of the invasive devices; they will be
removed as soon as possible.

Psychosocial preparation
1. Be alert to the clients level of anxiety.
2. Answer any questions or concerns that the client may have regarding surgery.
3. Allow time for privacy for the client to prepare psychologically for surgery.
4. Provide support and assistance as needed.
5. Take cultural aspects into consideration when providing care.

Preoperative checklist
1. Ensure that the client is wearing an identification bracelet.
2. Assess for allergies, including an allergy to latex.
3. Review the preoperative checklist to be sure that each item is addressed before
the client is transported to surgery.
4. Follow agency policies regarding preoperative procedures, including informed
consents, preoperative checklists, prescribed laboratory or radiological tests, and
any other preoperative procedure.
5. Ensure that informed consent forms have been signed for the operative
procedure, any blood transfusions, disposal of a limb, or surgical sterilization
procedures.
 6. Ensure that a history and physical examination have been completed and
documented in the clients record
7. Ensure that consultation requests have been completed and documented in the
clients record.
8. Ensure that prescribed laboratory results are documented in the clients record.
9. Ensure that electrocardiogram and chest radiography reports are documented
in the clients record.
10. Ensure that a blood type, screen, and crossmatch are performed and
documented in the clients record within the established time frame per agency
policy.
11. Remove jewelry, makeup, dentures, hairpins, nail polish (depending on agency
procedures), glasses, and prostheses.
12. Document that valuables have been given to the clients family members or
locked in the hospital safe.
13. Document the last time that the client ate or drank.
14. Document that the client voided before surgery.
15. Document that the prescribed preoperative medications were given.

Substances That Can Affect the Client in Surgery

Antibiotics
Antibiotics potentiate the action of
anesthetic agents.
Anticholinergics
Medications with anticholinergic effects
increase the potential for confusion,
tachycardia, and intestinal hypotonicity and Corticosteroids cause adrenal atrophy and
hypomotility.
Anticoagulants, antiplatelets, and
thrombolytics
*These medications alter normal clotting
factors and increase the risk of
hemorrhaging.
*Acetylsalicylic acid (Aspirin), clopidogrel, after surgery.
and nonsteroidal antiinflammatory drugs
are commonly used medications that can
alter platelet aggregation.
*These medications should be
discontinued at least 48 hours
before surgery or as specified by the
surgeon; clopidogrel
usually has to be discontinued 5 days
Antihypertensives
Antihypertensive medications can interact
with anesthetic agents and cause
bradycardia, hypotension, and impaired
circulation.
Corticosteroids
reduce the ability of the body to withstand
stress.
Before and during surgery, dosages may be
increased temporarily.
Diuretics
Diuretics potentiate electrolyte imbalances
Herbal Substances
Herbal substances can interact with
anesthesia and cause a variety of adverse
effects. These substances may need to
be stopped at a specific time before surgery.
During the preoperative period, the client
needs to be asked if he or she is taking an
before surgery. herbal substance.

Anticonvulsants
Long-term use of certain anticonvulsants
can alter the metabolism of anesthetic
agents.
Antidepressants
Antidepressants maylower the blood
pressure during anesthesia.
Insulin
The need for insulin after surgery in a
diabetic may be reduced because the
clients nutritional intake is decreased, or the
need for insulin may be increased because
of the stress response and intravenous
administration of glucose solutions.

Antidysrhythmics
Antidysrhythmic medications reduce
cardiac contractility and impair cardiac
conduction during anesthesia.
Adapted from Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8,
St. Louis, 2013, Mosby.

16. Monitor and document the clients vital signs.

Preoperative medications
1. Prepare to administer preoperative medications as prescribed before surgery.
2. Instruct the client about the desired effects of the preoperative medications.
!After administering the preoperative medications, keep the client in bed with the
side rails up (per agency policy). Place the call bell next to the client; instruct the
client not to get out of bed and to call for assistance if needed.

Arrival in the operating room

1. Gguidelines to prevent wrong site and wrong procedure surgery.
a. The surgeon meets with the client in the preoperative area and uses undelible
ink to mark the operative site.
b. In the operating room, the nurse and surgeon ensure and reconfirm that the
operative site has been appropriately marked.
c. Just before starting the surgical procedure, a time out is conducted with all
members of the operative team present to identify the correct client and
appropriate surgical site again.
2. When the client arrives in the operating room, the operating room nurse will
verify the identification bracelet with the clients chart.
3. The clients record will be checked for completeness and reviewed for informed
consent forms, history and physical examination, and allergic reaction information.
4. The surgeons prescriptions will be verified and implemented.
5. The IV line may be initiated at this time (or in the preoperative area), if
prescribed.
6. The anesthesia team will administer the prescribed anesthesia.
!Verification of the client and the surgical operative site is critical.
II. Postoperative Care
A. Description
1. Postoperative care is the management of a client after surgery and includes
care given during the immediate postoperative period as well as during the days
following surgery.
2. The goal of postoperative care is to prevent complications, to promote healing of
the surgical incision, and to return the client to a healthy state.

3. Alterations in Human Functioning

GLOSSARY
apnea: temporary cessation of breathing
bronchophony: abnormal increase in clarity of transmitted voice sounds
bronchoscopy: direct examination of larynx, trachea, and bronchi using an
endoscope.
cilia: short hairs that provide a constant whipping motion that serves to propel
mucus and foreign substances away from the lung toward the larynx
compliance: measure of the force required to expand or inflate the lungs
crackles: soft, high-pitched, discontinuous popping sounds during inspiration
caused by delayed reopening of the airways
diffusion: exchange of gas molecules from areas of high concentration to areas of
low concentration
dyspnea: labored breathing or shortness of breath
egophony: abnormal change in tone of voice that is heard when auscultating
lungs
fremitus: vibrations of speech felt as tremors of chest wall during palpation
hemoptysis: expectoration of blood from the respiratory tract
hypoxemia: decrease in arterial oxygen tension in the blood
hypoxia: decrease in oxygen supply to the tissues and cells
obstructive sleep apnea: temporary absence of breathing during sleep
secondary to transient upper airway obstruction
orthopnea: inability to breathe easily except in an upright position
oxygen saturation: percentage of hemoglobin that is bound to oxygen
physiologic dead space: portion of the tracheobronchial tree that does not
participate in gas exchange
pulmonary perfusion: blood flow through the pulmonary vasculature
respiration: gas exchange between atmospheric air and the blood and between
the blood and cells of the body
rhonchi: low-pitched wheezing or snoring sound associated with partial airway
obstruction, heard on chest auscultation
stridor: harsh high-pitched sound heard on inspiration, usually without need of
stethoscope, secondary to upper airway obstruction
tachypnea: abnormally rapid respirations
tidal volume: volume of air inspired and expired with eachbreath during normal
breathing
ventilation: movement of air in and out of airways
wheezes: continuous musical sounds associated with airway
narrowing or partial obstruction
a. Disturbance in Oxygenation
CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION Ref. Nclex rn 7th
ed.., brunner and suddarths medical surgical nursing 12th ed.(unit 5 pg 486-
666)
I. Anatomy and Physiology
The respiratory system is composed of the upper and lower respiratory tracts.
Together, the two tracts are responsible for ventilation (movement of air in and
out of the airways). The upper respiratory tract, known as the upper airway,
warms and filters inspired air so that the lower respiratory tract (the lungs) can
accomplish gas exchange. Gas exchange involves delivering oxygen to the
tissues through the bloodstream and expelling waste gases, such as carbon
dioxide, during expiration. The respiratory system works in concert with the
cardiovascular system; the respiratory system is responsible for ventilation
and diffusion, and the cardiovascular system is responsible for perfusion
(Farquhar & Fantasia, 2005).

A. Primary functions of the respiratory system

1. Provides oxygen for metabolism in the tissues
2. Removes carbon dioxide, the waste product of metabolism

B. Secondary functions of the respiratory system

1. Facilitates sense of smell
2. Produces speech
3. Maintains acid-base balance
4. Maintains body water levels
5. Maintains heat balance

C. Upper respiratory airway pg1123

1. Nose: Humidifies, warms, and filters inspired air
2. Sinuses: Air-filled cavities within the hollow bones that surround the nasal
passages and provide resonance during speech. A prominent function of sinuses
is to serve as a resonating chamber in speech. The sinuses are a common site of
infection.
3. Pharynx, Tonsils, and Adenoids
a. Passageway for the respiratory and digestive tracts located behind the oral and
nasal cavities
b. Divided into the nasopharynx, oropharynx, and laryngopharynx
4. Larynx
a. Located just below the pharynx at the root of the tongue; commonly called the
voice box
b. Contains 2 pairs of vocal cords, the false and true cords
c. The opening between the true vocal cords is the glottis. The glottis plays an
important role in coughing, which is the most fundamental defense mechanism of
the lungs.
5. Epiglottis
a. Leaf-shaped elastic flap structure at the top of the larynx
b. Prevents food from entering the tracheobronchial tree by closing over the glottis
during swallowing

D. Lower respiratory airway

1. Trachea: Located in front of the esophagus; branches into the right and left
mainstem bronchi at the carina.
2. Mainstem bronchi
a. Begin at the carina
b. The right bronchus is slightly wider, shorter, and more vertical than the left
bronchus.
c. Divide into secondary or lobar bronchi that enter each of the 5 lobes of the lung.
d. The bronchi are lined with cilia, which propel mucus up and away from the lower
airway to the trachea, where it can be expectorated or swallowed.
3. Bronchioles***
a. Branch from the secondary bronchi and subdivide into the small terminal and
respiratory bronchioles.
b. Contain no cartilage and depend on the elastic recoil of the lung for patency.
c. The terminal bronchioles contain no cilia and do not participate in gas
exchange.
4. Alveolar ducts and alveoli***
a. Acinus (plural, acini) is a term used to indicate all structures distal to the
terminal bronchiole.
b. Branch from the respiratory bronchioles
c. Alveolar sacs,which arise from the ducts, contain clusters of alveoli, which are
the basic units of gas exchange.
d. Type II alveolar cells in the walls of the alveoli secrete surfactant, a
phospholipid protein that reduces the surface tension in the alveoli; without
surfactant, the alveoli would collapse.
5. Lungs***
a. Located in the pleural cavity in the thorax
b. Extend from just above the clavicles to the diaphragm, the major muscle of
inspiration
c. The right lung, which is larger than the left, is divided into 3 lobes: the upper,
middle, and lower lobes.
d. The left lung, which is narrower than the right lung to accommodate the heart,
is divided into 2 lobes.
e. The respiratory structures are innervated by the phrenic nerve, the vagus
nerve, and the thoracic nerves.
f. The parietal pleura lines the inside of the thoracic cavity, including the upper
surface of the diaphragm.
g. The visceral pleura covers the pulmonary surfaces.
h. A thin fluid layer, which is produced by the cells lining the pleura, lubricates the
visceral pleura and the parietal pleura, allowing them to glide smoothly and
painlessly during respiration.
i. Blood flows throughout the lungs via the pulmonary circulation system.
6. Accessory muscles of respiration include the scalene muscles, which elevate
the first 2 ribs; the sternocleidomastoid muscles, which raise the sternum; and
the trapezius and pectoralis muscles, which fix the shoulders.
7. The respiratory process
a. The diaphragm descends into the abdominal cavity during inspiration, causing
negative pressure in the lungs.
b. The negative pressure draws air from the area of greater pressure, the
atmosphere, into the area of lesser pressure, the lungs.
c. In the lungs, air passes through the terminal bronchioles into the alveoli and
diffuses into surrounding capillaries, then travels to the rest of the body to
oxygenate the body tissues.
d. At the end of inspiration, the diaphragm and intercostal muscles relax and the
lungs recoil.
e. As the lungs recoil, pressure within the lungs becomes higher than
atmospheric pressure,causing the air, which now contains the cellular waste
products carbon dioxide and water, to move from the alveoli in the lungs to the
atmosphere.
f. Effective gas exchange depends on distribution of gas (ventilation) and blood
(perfusion) in all portions of the lungs.

Function of the Respiratory System

a. The primary function of the respiratory system is the exchange of gases
between the external environment and the blood.
b. The process of respiration involves ventilation, perfusion, diffusion, and nervous
system control.
c. Respiration refers to the mechanical and metabolic process involved with
oxygen (O2) transport from atmospheric air into the blood and carbon dioxide
(CO2) transport from the blood back to the atmospheric air.

Process of Respiration: Ventilation is the passage of gases between the

atmosphere and the lungs. Ventilation phases include inspiration and expiration.
 - Pulmonary ventilation is the total volume of gas exchange between the
atmosphere and the lungs.
- Alveolar ventilation is the volume of air that undergoes gas exchanges.
-Ventilation phases
*Inspiration The nerve impulses travel from the brain via the phrenic nerve to
contract the diaphragm, increasing the diameter of the thoracic cavity. Intrapleural
pressure increases, becoming more negative compared to atmospheric air. Air
moves from an area of higher pressure (atmosphere) to lower pressure
(respiratory system). Hence, air moves through structures of the respiratory
system to alveoli and pulmonary capillaries where gas exchange occurs.
*Expiration The diaphragm relaxes and pushes upward, decreasing the thoracic
cavity diameter. Intrapleural pressure remains negative compared to atmospheric
air, but becomes less negative than during inspiration. Intraplumonic pressure
becomes higher than atmospheric pressure, allowing passive air flow from the
lungs through the respiratory structures into the atmosphere. Smaller airways may
collapse during expiration, particularly in the supine position.

Respiratory System Pressure An atmospheric pressure of 760 mmHg serves as

the reference point for comparison to respiratory pressure.
a. Intrtapulmonary pressure, also called Intra alveolar pressure, equals
atmospheric pressure when the glottis is open and there is no air movement.
b. Intrapleural (or intrathoracic) pressure is the negative pressure produced by
opposite forces of elastic recoil between the lungs and chest wall. With the glottis
open and alveolar air in communication with the atmosphere, it measures negative
compared to intrapulmonary pressure. With the glottis closed, as in during
coughing or with forced expiration, it measures positive compared to atmospheric
air. Normally, negative intrapleural pressure prevents lung collapse. With forced
expiration against a closed glottis, intrapleural pressure becomes positive.

Respiratory Tissue Properties Respiratory vessels and airways are implanted in

elastic tissues which have the following properties:
a. Compliance is the elastic property related to elastic and collagen fibers. It
changes with the changes in respiratory system pressures and/or changes in lung
fluid content. Higer compliance occurs in a lung that is more easily distended.
Lower compliance occurs in a lung that is not easily distended
b. Elastic recoil is the ability of the lungs to return to their original shaped after air
is expelled. Recoil is present because of opposing forces created by the
movements of the lungs and chest wall.
c. Distensibility makes inflation more difficult through increased volume of lung
fluid content or consolidation of lung tissue.
d. Stiffness is the resistance of the lungs tostretch and to accommodate air
volume. Ncreasing lung stiffiness lowers compliance.
Airway Resistance refers to obstruction to airflow caused by condition of
respiratory system tissues (elastic recoil, compliance), changes in airway diameter
(bronchoconstriction, mucus obstruction)and / or pressure differences between
atmospheric air and intrapulmonary air.

Lung Volumes describe normal individual quantities of air exchanged during

specific times of the breathing cycle. Lung capacities describe combined quantities
of lung volumes during specific periods of the breathing cycle.

Tidal volume (VT): 5 10 Ml /kg (or 500 Ml total); air volume inspired and
expired during one breathing cycled.
Inspiratory reserve volume (IRV): 1,800 to 2,000mL; maximum air volume
inspired with forced inspiration ( i.e., movement of air from the atmosphere into the
respiratory system) following normal inspiration.
Expiratory reserve volume (ERV): 1,400 mL; air volume that can be expired with
force following normal expiration.
Residual volume (RV): 1,000 to 1,200 mL air volume remaining in the lungs
following forced expiration.
Total lung capacity (TLC): 5,000 to 6,000 mL; maximum capacity of the lungs.
TLC = IRV + VT + ERV + RV
Inspiratory capacity (IC): maximum air volume that can be inhaled following a
normal exhalation. IC = VT + IRV
Vital vapacity (VC): 4,500 to 4,800 mL; maximum air volume that can be exhaled
after a maximum inhalation. VC = IRV + VT + ERV
Functional residual capacity (FRC): 2,000 to 2,400 mL; residual air volume int
the lungs after a normal exhalation. FRC = ERV + RV.

Body position Gravity accountsfor greater ventilation in dependent areas of the

lungs. An upright, sitting or standing position allows for the path of least resistance
into the more compliant lung bases.

Perfusion is the quality of blood flow through the pulmonary capillary bed and to
the respiratory system structure. The respiratory system circulation includes the
pulmonary circulation and bronchial circulation.

Diffusion is the movement of gas from an area of higher pressure to lower

pressure.O2 diffuses from the atmosphere into the alveoli, across the pulmonary
capillary membrane and into the pulmonary capillaries for circulation throughout
the body. CO2 diffuses out of the pulmonary capillaries across the capillary
membrane and into the alveoli to be exhaled. Diffusion continues until pressure
differences become equal between the two areas

Parameters in the process of Breathing

a. Suitable O2 and CO2 concentration in the inspired air. Ambient air has the
greatest O2 concentration within the first 10,000 feet of the earths surface. O 2
concentration within the first 10,000 feet of the earths surface. O 2 concentration is
20.93% and exerts a parial pressure of 158 mmHg.
Normal atmospheric or barometric pressure is 760 m mHg. Pressures less than
that ambient air is called negative or or subatmospheric pressure.
-Adequate ventilation or perfusion of the alveoli.
a. Iinspiration involves descent of the diaphragm, expansion of the thorax and
decrease in the pressure in the air passages and alveoli so that air flows into the
respiratory tree.
b. Expirations is a normally passive function wherein the diaphragm rises, the
thorax relaxes and pressure in the alveoli becomes greater than atmospheric
pressure, resulting in the expulsion of air.
b. Permeable alveolar capillary membrane.The partial pressure of a gas in a
given volume is the foce it exerts against the walls of the container.
c. Adequate pulmonary and systemic circulation
- This lies primarily with the heart and buffer mechanism which act reflexly to
control BP and to maintain circulation.
- In the systemic circulation, decreased Po2 or increased Pco2 produces
vasodilation which slows the blood flow and permits more time for gas excgange
to take place.
- In the pulmonary circulation, decreased pO2 produces vasoconstriction of
capillaries and blood is shunted to capillaries in the better ventilated areas of the
lungs.
d. Ability of the blood to transport O2 and CO2 between the lungs and tissues.
e. Ability of cells to utilize O2 and eliminate CO2.

f. Neural control of respiration

The respiratory center is a widely dispersed group of neurons located bilaterally
in the reticular substance of the medulla oblongata and pons, and in the chest
wall, aorta and carotid. It is divided into 3 major areas.
Medullary rhythmically area - controls the basic rhythm of respiration.
Apneustic area prolongs and deepens inspiration.
Pneumotaxic area inhibits respiration, Both apneustic and pneumotaxic areas
are located in the pons but not necessary for the maintenanceof the basic rhythm
of respiration.
Factors affecting rate and depth of respiration:
*Central chemoreceptors in the medulla. Increased Pco 2 and or decreased blood
pH causes increased alveolar ventilation as compensatory mechanism to maintain
Pco2 and pH at normal levels.
*Peripheral chemoreceptors in the aortic arch and carotid bodies. Increased Pco 2
and / or decreased pH, and / or decreased partial pressure of arterial oxygen (Po 2)
causes increased alveolar ventilation.
*Stretch receptors in the alveolar septa, bronchi, and bronchiolesprevent
overdistention of the lungs when they are inflated.
*Proprioceptors in muscles and tendons of moveable joints stimulate ventilation
with exercise to increase oxygen supply during increased oxygen demand.
*Baroreceptors in the aortic and carotid sinus alter respiration relative to changes
in arterial blood pressure . Elevated arterial blood pressure lowers respiration.
Blood pressures below 80 mmHg increase respiration.
*External environmental factors such as cold, physical stress, air pollution,
smoking, and pain alter respiration. Infection and fever increase respiration caused
by increased oxygen demand.

II. Assessment
*Nursing and Health History
The health history focuses on the physical and functional problems and the effects
of these problems on the patient, including the ability to carry out activities of daily
living. Several common symptoms related to the respiratory system are discussed
in detail below. If the patient is experiencing severe dyspnea, the nurse may need
to modify or abbreviate the questions asked and the timing of the health history to
avoid increasing the patients breathlessness and anxiety.
In addition to identifying the chief reason why the patient is seeking health care,
the nurse tries to determine when the health problem or symptom started, how
long it lasted, if it was relieved at any time, and how relief was obtained. The nurse
obtains information about precipitating factors, duration, severity, and associated
factors or symptoms.

Common Symptoms
The major signs and symptoms of respiratory disease are dyspnea, cough,
sputum production, chest pain, wheezing, and hemoptysis. The nurse also
assesses the impact of signs and symptoms on the patients ability to perform
activities of daily living and to participate in usual work and family activities.
-Dyspnea (subjective feeling of difficult or labored breathing, breathlessness,
shortness of breath) is a symptoms common to many pulmonary and cardiac
disorders, particularly when there is decreased lung compliance or increased
airway resistance. Dyspnea may also be associated with neurologic or
neuromuscular disorders (eg, myasthenia gravis, Guillain-Barr syndrome,
muscular dystrophy, postpolio syndrome) that affect respiratory function. Dyspnea
can also occur after physical exercise in people without disease (Davis & Holliday,
2005; Porth & Matfin, 2009).
The circumstance that produces the dyspnea must be determined.
Therefore, it is important to ask the patient the following questions:
 How much exertion triggers shortness of breath? Does it occur at rest? With
exercise? Running? Climbing stairs?
Is there an associated cough?
Is the shortness of breath related to other symptoms?
Was the onset of shortness of breath sudden or gradual?
At what time of day or night does the shortness of breath occur?
Is the shortness of breath worse when laying flat?
Is the shortness of breath worse while walking? If so, when walking how far?
How fast?
How severe is the shortness of breath? On a scale of 1 to 10, if 1 is breathing
without any effort and 10 is breathing that is as difficult as it could possibly be,
how hard is it to breathe?
It is especially important to assess the patients rating of the intensity of
breathlessness, the effort required to breathe, and the severity of the
breathlessness or dyspnea. Patients use a variety of terms and phrases to
describe breathlessness, and the nurse needs to clarify what terms are most
familiar to the patient and what these terms mean. Visual analogue or other scales
can be used to assess changes in the severity of dyspnea over time (Dorman,
Byrne & Edwards, 2007; Porth & Matfin, 2009).
- Coughing is a reflex that protects the lungs from the accumulation of secretions
or the inhalation of foreign bodies. Its presence or absence can be a diagnostic
clue because some disorders cause coughing and others suppress it. The cough
reflex may be impaired by weakness or paralysis of the respiratory muscles,
prolonged inactivity, the presence of a nasogastric tube, or depressed function of
the medullary centers in the brain (eg, anesthesia, brain disorders) (Irwin,
Baumann, Bolser, et al., 2006; Porth & Matfin, 2009).
- Cough results from irritation of the mucous membranes anywhere in the
respiratory tract. The stimulus that produces a cough may arise from an infectious
process or from an airborne irritant, such as smoke, smog, dust, or a gas. A
persistent and frequent cough can be exhausting and cause pain. Cough may
indicate serious pulmonary disease or a variety of other problems as well,
including cardiac disease, medication reactions (eg, amiodarone [Cordarone],
angiotensin - converting enzyme [ACE] inhibitors), smoking, and
gastroesophageal reflux disease (Irwin, et al., 2006).
- To help determine the cause of the cough, the nurse describes the cough: dry,
hacking, brassy, wheezing, loose, or severe.
*A dry, irritative cough is characteristic of an upper respiratory tract infection of viral
origin, or it may be a side effect of ACE inhibitor therapy.
*An irritative, high-pitched cough can be caused by laryngotracheitis.
*A brassy cough is the result of a tracheal lesion.
*while a severe or changing cough may indicate bronchogenic carcinoma. Pleuritic
chest pain that accompanies coughing may indicate pleural or chest wall
(musculoskeletal) involvement.
- The nurse inquires about the onset and time of coughing. Coughing at night may
indicate the onset of left-sided heart failure or bronchial asthma. A cough in the
morning with sputum production may indicate bronchitis. A cough that worsens
when the patient is supine suggests postnasal drip (rhinosinusitis). Coughing after
food intake may indicate aspiration of material into the tracheobronchial tree. A
cough of recent onset is usually from an acute infection.
- Secretions are of different types:
a. Sputum is an aggregation of secretions from the tracheobronchial tree, mouth,
pharynx, (saliva), nose and sinuses.
b. Phlegm refers to secretions of the tracheobronchial tree and lungs. A healthy
adult may have a volume of 100mL/24 hrs.
Sputum Production A patient who coughs long enough almost invariably
produces sputum. Sputum production is the reaction of the lungs to any constantly
recurring irritant. It also may be associated with a nasal discharge. The nature of
the sputum is often indicative of its cause. A profuse amount of purulent sputum
(thick and yellow, green, or rust colored) or a change in color of the sputum is a
common sign of a bacterial infection. Thin, mucoid sputum frequently results
from viral bronchitis. A gradual increase of sputum over time may occur with
chronic bronchitis or bronchiectasis. Pink tinged mucoid sputum suggests a
lung tumor. Profuse, frothy, pink material, often welling up into the throat, may
indicate pulmonary edema. Foul-smelling sputum and bad breath point to the
presence of a lung abscess, bronchiectasis, or an infection caused by
fusospirochetal or other anaerobic organisms.
Chest Pain or discomfort may be associated with pulmonary or cardiac disease.
Chest pain asccociated iwth pulmonary conditions may be sharp, stabbing, and
intermittent, or it may be dull, aching, and persistent. The pain is usually felt on the
side where the pathologic process is located, but it may be referred elsewhere
for example to the neck, back, or abdomen.
- Chest pain may occur with pneumonia, pulmonary embolism with lung infarction,
pleurisy, or as a late symptom of bronchogenic carcinoma. In carcinoma, the pain
may be dull and persistent because the cancer has invaded the chest wall,
mediastinum, or spine.
- Lung disease does not always cause thoracic pain because the lungs and the
visceral pleura lack sensory nerves and are insensitive to pain stimuli. However,
the parietal pleura has a rich supply of sensory nerves that are stimulated by
inflammation and stretching of the membrane. Pleuritic pain from irritation of the
parietal pleura is sharp and seems to catch on inspiration; patients often describe
it as being like stabbing of a knife. Patients are more comfortable when they lay
on the affected side because this splints the chest wall, limits expansion and
contraction of the lung, and reduces the friction between the injured or diseased
pleurae on that side. Pain associated with cough may be reduced manually by
splinting the rib cage.
- Factors to consider:
a. onset, location, and radiation
 b. duration and character or quality
c. factors that precipitate that relieve pain
d. effect of the pain or the activiity.
Cyanosis is a condition wherein the Hgb is reduced to 5g / dl or more.
Normal: 15 g/dl or 6.95 vol.
- Types:
a. Peripheral cyanosis refers to the bluish discoloration of the extremities and the
nailbeds.
Causes:
- reduced oxyhemoglobin in the systematic capillaries.
- peripheral vasoconstriction.
- strenuous exercise due to increased utilization of oxygen.
- reduced blood flow which is usually physiological in nature.
b. Central cyanosis refers to the bluish discoloration of the lips, tongue, face and
mucous membrane. It results from insufficient oxygen of hemoglobin. It is always
pathologic.
c. Differential cyanosis refers to the condition wherein the upper half of the body
is pink and the lower part is blue or vice versa. It indicates severe heart disease.
Factors that alter the appearance of cyanosis:
1. Pigmentation and Thickness: Cyanosis is a subjective assessment and is
therefore not a reliable sign of the state of oxygenation.
*very thin, unpigmented skin, especially where capillaries are superficial and
numerous (e.g., the tip of the tongue, the buccal mucosa, the cutaneous surfaces
of the lips, the tips of the finger and toes, the nailbeds, the earlobes and the tip of
nose must be observed).
*Some areas are highly vascular (e.g., heels). In newborns, these afford easy
determinatin.
*The mucous membrane is an important site for detection of cyanosis in clients
with dark skin.
2. The type and amount of light used in making the assessment: Natural light is
best; fluorescent light is less desirable.
3. The absolute amount of reduced hemoglobin, rather than the relative amount of
oxyhemoglobin and reduced hemoglobin. A client who is anemic may not appear
cyanotic, even though marked degrees of desaturation exist. On the other hand, a
client with polycythemia may develop cyanosiswith a lesser degree of
dessaturation than the normal individual.
4. Observers perception: Factors to consider
*activity and environment (Does color become worse when crying?)
*duration
*distribution (Is it limited to the extremities?)
Voice quality Does the client speak in jerky sentences? Are the sounds weak? Is
hoarseness present?
Stridor is a harsh, high pitch sound usually associated with an obstruction in the
upper trachea or vocal cord. It is an emergency.
*Physical Assessment Assessment of the lower respiratory structures includes
inspection, palpation, percussion, and auscultation of the thorax.
- Inspection: deformities of the thorax, slope of the ribs, local log, rate and rhythm
of breathing.
*Chest Configuration Normally, the ration of the anteroposterior diameter to the
lateral diameter is 1:2. However, there are four main deformities of the chest
associated with respiratory disease that alter this relationship: barrel chest, funnel
chest (pectus excavatum), pigeon chest (pectus carinatum), and kyphoscoliosis.
-Barrel Chest. Occurs as a result of overinflation of the lungs. There is an
increase in the anteroposterior diameterof the thorax. In a patient with
emphysema, the ribs are more widely spaced and the intercostal spaces tend to
bulge on expiration. The appearance of the patient with advanced emphysema is
thus quite characteristic and often allows the observer to detect its presence
easily, even from a distance.
-Funnel Chest (PECTUS EXCAVATUM). Occurs when there is a depression in
the lower portion of the sternum. This may compress the heart and great vessels,
resulting in murmurs. Funnel chest may occur with rickets or marfans syndrome.
-Pigeon Chest (PECTUS CARINATUM). A pigeon chest occurs as a result of
displacement of the sternum. There is an increase in the anteroposterior diameter.
This may occur with rickets, Marfans syndrome, or severe kyphoscoliosis.
-Kyphoscoliosis. Is characterized by elevation of the scapula and a
corresponding S shaped spine. This deformity limits lung expansion within the
thorax. It may occur with osteoporosis and other skeletal disorders that affect the
thorax.
*BreathingPatterns and Respiratory Rates Observing the rate and depth of
respiration is a simple but important aspect of assessment. The normal adult who
is resting comfortably takes 12 to 18 breaths per minute. Except for occasional
sighs, respirations are regularin depth and rhythm. This normal pattern is
described as eupnea. The rate and depth of various patterns of respiration are
presented.
RATES AND DEPTHS OF RESPIRATION
Types Description
Eupnea Normal, breathing at 12 18 breaths/minute.
Bradypnea Slower than normal rate (<10 breaths/min.), with
normal depth and regular rhythm.
Associated with increased intracranial pressure,
brain injury, and drug overdose.
Tachypnea Rapid, shallow breathing >24 breaths/min.
Associated with pneumonia, pulmonary edema,
metabolic acidosis, septicemia, severe pain, or
rib fracture.
Hypoventilation Shallow, irregular breathing.
Hyperpnea Increase depth of respirations.
Hyperventilation Increased rate and depth of breathing that
results in decreased PaCO2 level.
Inspiration and expiration are nearly equal in
duration.
Called Kussmauls respiration if associated with
diabetic ketoacidosis or renal origin.
Apnea Period of cessation of breathing; time duration
varies; apnea may occur briefly during other
breathing disorders, such as with sleep apnea;
life-threatening if sustained.
Cheyne - Stokes Regular cycle where the rate and depth of
breathing increase, then decrease until
apnea (usually about 20 seconds) occurs.
Duration of apnea may vary and progressively
lengthen; therefore, it is timed and reported.
Associated with heart failure and damage to the
respiratory center (drug-induced, tumor, trauma).
Biots respiration Periods of normal breathing (34 breaths)
followed by a varying period of apnea (usually
1060 seconds).
Also called cluster breathing.
Associated with some nervous system disorders.

Certain patterns of respiration are characteristic of specific disease states.

Respiratory rhythms and their deviation from normal are important observations
that the nurse reports and documents.
Obstructive sleep apnea - Temporary pauses of breathing, or apnea, may be
noted. When apnea occur repeatedly during sleep, secondary to transient upper
airway blockage.
- Palpation: tenderness, masses, respiratory excursion, and fremitus (fremitus
refers to the palpable vibrations transmitted through the bronchopulmonary system
to the chest wall when the patients speaks).
*Respiratory Excursion is an estimation of thoracic expansion and may disclose
significant information about thoracic movement during breathing. The nurse
assess the patient for range and symmetry of excursion. For anterior assessment,
the nurse places the thumbs along the costal margin of the chest wall and instructs
the patient to inhale deeply. The nurse observes movement of the thumbs during
inspiration and expiration. This movement is normally symmetric.
Posterior assessment is performed by placing the thumbs adjacent to the spinal
column at the level of the tenth rib. The hands lightly grasp the lateral rib cage.
Sliding the thumbs medially about 2.5 cm (1 inch) raises a small skin fold between
the thumbs. The patient is in structured to take a full inspiration and to exhale fully.
 The nurse observes for normal flattening of the skin fold and feels the symmetric
movement of the thorax.
Decreased chest excursion may be caused by chronic fibrotic disease.
Asymmetric excursion may be due to splinting secondary to pleurisy, fractured
ribs, trauma, or unilateral bronchial obstruction.
*Tactile Fremitus Sound generated by the larynx travels distally along the
bronchial tree to set the chest wall in resonant motion. This is especially true of
consonant sounds. The detection of the resulting vibration on the chest wall
by touch is called tactile fremitus.
- Percussion: flatness (thigh), dullness (liver), resonance (normal lung),
tymphanic (gastric air, bubbles).
*Characteristics of Percussion Sounds
Sounds Relative Relative Relative Location Examples
Intensity Pitch Duration Example
Flatness Soft High Short Thigh Large pleural
effusion
Dullness Medium Medium Medium Liver Lobar Pneumonia
Resonance Loud Low Long Normal lung Simple chronic
bronchitis
Hyperresonance Very loud Lower Longer None Emphysema,
normally pneumothorax
Tympany Loud *High -------- Gastric air Large
bubble or pneumothorax
puffed out
check.

- Auscultation:
a. Normal breath sounds
- Vesicular sounds are heard over most of the lung inspiration > expiration.
- Bronchovesicular sounds are heard near mainstem bronchi:
Inspiration = Expiration.
- Bronchial /Tubular sounds are heard over the trachea:
Expiration > Inspiration
Breath Sounds
Duration of Intensity of Pitch of Location where
Sounds Expiratory Expiratory Heard Normally
Sounds Sound
Vesicular Inspiratory sounds last Soft Relatively low Entire lung field
longer than expiratory except over the
ones. upper sternum and
between the
scapulae.
Broncho- Inspiratory and Intermediate Intermediate Often in the 1st and
vesicular expiratory sounds are 2nd Interspaces
about equal. anteriorly and
between the
scapulae (over the
main bronchus).
Bronchial Expiratory sounds last Loud Relatively Over the
longer than inspiratory high manubrium, if heard
ones. at all.
Tracheal Inspiratory and Very loud Relatively Over the trachea in
expiratory sounds are high the neck.
about equal.
*The thickness of the bars indicates intensity of breath sounds; the steeper their
incline, the higher the pitch of the sounds.

b. Abnormal Breath sounds

- Rales are discrete, non continuous sounds produced by moisture in the
tracheobronchial tree. They are heard best on inspiration.
- Ronchi and wheezes are continuous sounds produced by airflow across the
passage narrowed by secretions, mucosal swelling or tumor. They are more
prominent on expiration.
- Friction rubs are crackling, grating sounds originating in an inflamed pleura.
ABNORMAL (ADVENTITIOUS) BREATH SOUNDS
Breath Sounds Description Etiology
Crackles
Crackles in general Soft, high pitched, Secondary to fluid in the
discontinuous popping airway or alveoli or to
sounds that occur during delayed opening of
inspiration (while usually collapsed alveoli.
heard on inspiration, they Associated with heart
may also be heard on failure and pulmonary
expiration); may or may not fibrosis.
be cleard by coughing.
Coarse crackles Discontinuous popping Associated with
sounds heard in early obstructive pulmonary
inspiration; harsh, moist disease.
sound originating in the
large bronchi.
Fine crackles Discontinuous popping Associated with interstitial
sounds heard in late pneumonia, restrictive
inspiration; sounds like hair pulmonary disease (eg,
rubbing together; originates fibrosis); fine crackles in
in the alveoli. early inspiration are
 associated with bronchitis
or pneumonia.
Wheezes
Wheezes in general Usually heard on Associated with bronchial
expiration, but may be wall oscillation and
heard on inspiration charge in airway
depending on the cause. diameter.
Associated with chronic
bronchitis or bronchiec-
tasis.
Sonorous wheezes Deep, low pitched Associated with
(rhonchi) rumbling sounds heard secretions or tumor.
primarily during expiration;
caused by air moving
through narrowed
tracheobroncial passages.
Sibilant wheezes Continuous, musical, high Associated with
pitched, whistlelike sounds bronchospasm, asthma,
heard during inspiration and and buildup of secretions.
expiration caused by air
passing through narrowed
or partially obstructed
airways; may clear with
coughing.

Friction Rubs
Pleural friction rub Harsh, crackling sound, like Secondary to
two pieces of leather being inflammation and loss of
rubbed together (sound lubricating pleural fluid.
imitated by rubbing thumb
and finger together near the
ear).
Heard during inspiration
alone or during both
inspiration and expiration.
May subside when patient
holds breath; coughing will
not clear sound.
Best heard over the lower
lateral anterior surface of
the thorax.
Sound can be enhanced by
applying pressure to the
 chest wall with the
diaphragm of the
stethoscope.

Diagnostic Tests
A. Risk factors for respiratory disorders.
* Allergies
*Chest injury
*Crowded living conditions
*Exposure to chemicals and environmental pollutants
*Family history of infectious disease
*Frequent respiratory illnesses
*Geographical residence and travel to foreign countries
*Smoking
*Surgery
*Use of chewing tobacco
*Viral syndromes

B. Chest x-ray films (radiographs)***

Description: Provides information regarding the anatomical location and
appearance of the lungs.
Preprocedure
a. Remove all jewelry and other metal objects from the chest area.
b. Assess the clients ability to inhale and hold his or her breath.
Postprocedure
a. Help the client to get dressed.

!Question women regarding pregnancy or the possibility of pregnancy before

performing radiography studies.

C. Sputum specimen***
Description: Specimen obtained by expectoration or tracheal suctioning to assist in
the identification of organisms or abnormal cells.

PRIORITY NURSING ACTIONS

Tracheal Suctioning
1. Assess the client and explain the procedure.
2. Assist the client to an upright position.
3. Perform hand hygiene and don protective garb.
4. Prepare suctioning equipment and turn on the suction.
5. Hyperoxygenate the client.
6. Insert the catheter without suction applied.
7. Once inserted, apply suction intermittently while rotating and withdrawing the
catheter.
8. Hyperoxygenate the client.
9. Listen to breath sounds.
10. Document the procedure, client response, and effectiveness.

Once the nurse has assessed the client, the nurse explains the procedure. The
client is assisted to a sitting upright position such as semi - Fowlers with the
head hyperextended (unless contraindicated). Hand hygiene is performed, and the
nurse applies appropriate protective garb, using aseptic technique. The nurse
prepares the needed suctioning equipment, turns on the suction device, and
sets it to the appropriate pressure. The nurse hyperoxygenates the client with
a resuscitation bag, increasing the oxygen flow rate, or asks the client to take
deep breaths. The nurse dons sterile gloves and lubricates the catheter with
sterile water or water soluble lubricant (per agency procedure), inserts the
catheter without the application of suction, and then applies intermittent
suction for up to 10 seconds while rotating and withdrawing the catheter.
After suctioning, the nurse hyperoxygenates the client and encourages the
client to take deep breaths if possible. During the procedure, the nurse monitors
the client for toleration of the procedure and the presence of complications.
Finally, the nurse listens to breath sounds to assist in determining effectiveness
and documents the procedure, the clients response, and effectiveness.

Reference
Ignatavicius, Workman (2016), p. 525. Perry, Potter, Ostendorf
(2014), pp. 631632, 637.

Preprocedure
a. Determine the specific purpose of collection and check institutional policy for the
appropriate method for collection.
b. Obtain an early morning sterile specimen by suctioning or expectoration after
a respiratory treatment if a treatment is prescribed.
c. Instruct the client to rinse the mouth water before collection.
d. Obtain 15 mL of sputum.
e.Instruct the client to take several deep breaths and then cough deeply to
obtain sputum.
f. Always collect the specimen before the client begins antibiotic therapy.***
Postprocedure
a. If a culture of sputum is prescribed, transport the specimen to the
laboratory immediately.***
b. Assist the client with mouth care.
 !Ensure that an informed consent was obtained for any invasive procedure.
Vital signs are measured before the procedure and monitored postprocedure to
detect signs of complications.

D. Laryngoscope and Bronchoscope

Description: Direct visual examination of the larynx, trachea, and bronchi with a
fiberoptic bronchoscope.
Preprocedure
a. Maintain NPO (nothing by mouth) status as prescribed.
b. Assess the results of coagulation studies.
c.Remove dentures and eyeglasses.
d. Establish an intravenous (IV) access as necessary and administer medication
for sedation as prescribed.
e. Have emergency resuscitation equipment readily available.
Postprocedure
a. Maintain the client in a semi Fowlers position.
b. Assess for the return of the gag reflex.
c. Maintain NPO status until the gag reflex returns.***
d. Monitor for bloody sputum.
e. Monitor respiratory status, particularly if sedation has been administered.
f. Monitor for complications, such as bronchospasm or bronchial perforation,
indicated by facial or neck crepitus, dysrhytmias, hemorrhage, hypoxemia, and
pneumothorax.
g. Notify the health care provider (HCP) if signs of complications occur.***

E. Endobrochial ultrasound(EBUS)
1. Tissue samples are obtained from central lung masses and lymph nodes, using
a bronchoscope with the help of ultrasound guidance.
2. Tissue samples are used for diagnosing and staging lung cancer, detecting
infections, and identifying inflammatory diseases that affect the lungs, such as
sarcoidosis.
3. Postprocedure, the client is monitored for signs of bleeding and respiratory
distress.

F. Pulmonary Angiography***
Description
a. A flouroscopic procedure in which a catheter is inserted through the antecubital
or femoral vein into the pulmonary artery or 1 of its branches.
b. Involves an injection of iodines or radiopaque contrast material.
Preprocedure
a. Obtain informed consent.
b. Assess for allergies to iodine, seafood, or other radiopaque dyes.
c. Maintain NPO status of the client for 8 hours before the procedure.
d. Monitor Vital Signs
e. Assess results of coagulation studies.
f. Establish an intravenous access.
g. Administer sedation as prescribed.
h. Instruct the client to lie still during the procedure.
i. Instruct the client that he or she may feel an urge to cough, flushing, nausea,
or a salty taste following injection of the dye.***
j. Have emergency resuscitation equipment available.
Postprocedure
a. Monitor Vital Signs.
b. Avoid taking blood pressurres for 24 hours in the extremity used for the
injection.
c. Monitor peripheral neurovascualr status of the affected extemity.
d. Assess insertion site for bleeding.
e. Monitor for delayed reaction to the dye.

G. Thoracentesis
Description: Removal of fluid or air from the pleural space via transthoracic
aspiration.
Preprocedure
a. Obtain Informed Consent.
b. Obtain Vital Signs.
c. Prepare the client for ultrasound or chest radiograph, if prescribed, before
procedure.
d. Assess results of coagulation studies.
e. Note that the client is positioned sitting upright, with the arms and shoulders
supported by a table at the bedside during the procedure.
f. If the client cannot sit up, the client is placed lying in bed toward the unaffected
side, with the head of the bed elevated.***
g. Instruct the client not to cough, breath deeply, or move during the procedure.
Postprocedure
a. Monitor Vital Signs.
b. Monitor respiratory status.
c. Apply a pressure dressing, and assess the puncture site for bleeding and
crepitus.
d.Monitor for signs of pneumothorax, air embolism, and pulmonary edema.***

H. Pulmonary function tests***

Description: Test used to evaluate lung mechanics, gas exchange, and acid
base disturbace through spirometric measurements, lung volumes, and arterial
blood gas levels.
Preprocedure
a. Determine whether an analgesic that may depress the respiratory function is
being administered.
b. Consult with the health care provide (HCP) regarding withholding
bronchodilators before testing.
c. Instruct the client to void before procedure and to wear loose clothing.
d. Remove dentures.
e. Instruct the client to refrain from smoking or eating heavy meal for 4 to 6 hours
before the test.
Postprocedure: Client may resume a normal diet and any bronchodilators and
respiratory treatments that were withheld before the procedure.

I. Lung Biopsy
Description:
a. A transbrochial biopsy and a transbrochial needle aspiration may be performed
to obtain tissue for analysis by culture or cytological examination.
b. An open lung biopsy is performed in the operating room.
Preprocedure
a. Obtain informed consent.
b. Maintain NPO status of the client before the procedure.
c. Inform the client that a local anesthetic will be used for a needle biopsy but a
sensation of pressure during needle insertion and aspiration may be felt.
d. Administer analgesics and sedatives as prescribed.
Postprocedure***
a. Monitor Vital Signs.
b. Apply a dressing to the biopsy site and monitor for drainage or bleeding.
c. Monitor for signs of respiratory distress, and notify the health care provider
(HCP) if they occur.
d. Monitor for signs of Pneumothorax and air emboli, and notify the health care
provider if they occur.
e. Prepare the client for the chest radioprahy if prescribed.

J. Spiral (helical) computed tomography (CT) scan***

1. Frequenlty used test to diagnose pulmonary embolism.
2. IV injection of contrast medium is used; if the client cannot have a contrast
medium, a ventilation perfusion (V/Q) scan will be done.
3. The scanner rotates around the body, allowing for a 3 dimentional picture of all
regions of the lungs.

K. Ventilation perfusion (V/Q) lung scan***

Description
a. The perfusion scan evaluates blood flow to the lungs.
b. The ventilation scan determines the patency of the pulmonary airways and
detects abnormalities in ventilation.
c. A radionuclide may be injected for the procedure.
Preprocedure
a. Obtain informed consent.
b. Assess the client for allergies to dye, iodines, or seafood.
c. Remove jewelry around the chest area.
d. Review breathing methods that may be required during testing.
e. Establish an Intravenous Access.
f. Administer sedation as prescribed.
g. Have emergency resuscitation equipment available.
Postprocedure.
a. Monitor the client for the reaction to the radionuclide.
b. Instruct the client that the radionuclide clears from the body in about 8 hours.***

L. Skin Tests: A skin test uses an intradermal injection to help diagnose various
infectious diseases.
Skin Test Procedure
1. Determine hypersensitivity or previous reactions to skin test.
2. Use a skin site that is free of excessive body hair, dermatitis, and blemishes.
3. Apply the injection at the upper third of the inner surface of the left arm.
4. Circle and mark the injection test site.
5. Document the date, time and test site.
6. Advise the client not to scratch the test site to prevent infection and possible
abscess formation.
7. Instruct the client to avoid washing the test site.
8. Interpret the reaction at the injection site 24 to 72 hours after administration of
the test antigen.
9. Assess the test site for the amount of induration (hard swelling) in millimeters
and for the presence of erythema and vesiculation (small blister like elevations).

M. Arterial blood gases (ABGs)***

Description:
1. Measurement of the dissolved oxygen and carbon dioxide in the arterial blood
helps to indicate the acid - base state and how well oxygen is being carried to the
body.
2. Preprocedure and postprocedure care, normal results, and analysis of results:
Collection of an ABG specimen
1. Obtain vital signs.
2. Determine whether the client has an arterial line in place (allows for arterial
blood sampling without further puncture to the client).

Normal Arterial Blood Gas Values

Normal Range
Laboratory Test Conventional Units SI Units
 pH 7.35 7.45 7.35 7.45
PaCO2 35 45 mm Hg 35 45 mm Hg
Bicarbonate (HCO3A) 21 28 mEq/L 21 28 mmol/L
PaO2 80 100 mm Hg 80 100 mm Hg

3. Perform the Allens test to determine the presence of collateral circulation

(Priority Nursing Actions).
PRIORITY NURSING ACTIONS
Performing the Allens Test Before Radial Artery Puncture.
1. Explain the procedure to the client.
2. Apply pressure over the ulnar and radial arteries simultaneously.
3. Ask the client to open and close the hand repeatedly.
4. Release pressure from the ulnar artery while compressing the radial artery.
5. Assess the color of the extremity distal to the pressure point.
6. Document the findings.

The Allens test is performed before obtaining an arterial blood specimen from
the radial artery to determine the presence of collateral circulation and the
adequacy of the ulnar artery. *Failure to determine the presence of adequate
collateral circulation could result in severe ischemic injury to the hand if
damage to the radial artery occurs with arterial puncture. The nurse first
would explain the procedure to the client. To perform the test, the nurse applies
direct pressure over the clients ulnar and radial arteries simultaneously. While
applying pressure, the nurse asks the client to open and close the hand
repeatedly; the hand should blanch. The nurse then releases pressure from the
ulnar artery while compressing the radial artery and assesses the color of the
extremity distal to the pressure point. *If pinkness fails to return within 6 to 7
seconds, the ulnar artery is insufficient, indicating that the radial artery should not
be used for obtaining a blood specimen. Finally, the nurse documents the findings.
Other sites, such as the brachial or femoral artery, can be used if the radial
artery is not deemed adequate.
Reference: Perry, Potter, Ostendorf (2014), pp. 10911092.

4. Assess factors that may affect the accuracy of the results, such as changes in
the O2 settings, suctioning within the past 20 minutes, and clients activities.
5. Provide emotional support to the client.
6. Assist with the specimen draw: prepare a heparinized syringe (if not already
prepackaged).
7. Apply pressure immediately to the puncture site following the blood draw;
maintain pressure for 5 minutes or for 10minutes if the client is taking an
anticoagulant.
8. Appropriately label the specimen and transport it on ice to the laboratory.
9. On the laboratory form, record the clients temperature and the type of
supplemental O2 that the client is receiving.
!Avoid suctioning the client before drawing an ABG sample because the
suctioning procedure will deplete the clients oxygen, resulting in inaacurate ABG
results.

N. Pulse oximetry***
Description
1. Pulse oximetry is a noninvasive test that registers the oxygen saturation of the
clients hemoglobin.
2. The capillary oxygen saturation (SaO2), is recorded as a percentage.
3. The normal value is 95% to 100%.***
4. After a hypoxic client uses up the readily available oxygen (measured as the
arterial oxygen pressure, PaO2 , on arterial blood gas {ABG} testing), the reserve
oxygen, that oxygen attached to the hemoglobin (SaO 2), is drawn on to provide
oxygen to the tissues.
5. A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs
occur.
6. If pulse oximetry readings are below normal, instruct the client in deep
breathing technique and recheck the pulse oximetry.
Procedure
1. A sensor is placed on the clients finger, toe, nose, earlobe, or forehead to
measure oxygen saturation, which then is displayed on a monitor.
2. Maintain the transducer at heart level.
3. Do not select an extremity with an impediment to blood flow.
! A usual pulse oximetry reading is between 95% and 100%. A pulse oximetry
reading lower than 90% necessitates HCP notification; values below 90% are
acceptable only in certain chronic conditions. Agency procedures and HCP
prescriptions are followed regarding actions to take for specific readings.

O. D dimer
1. A blood test that measures clot formation and lysis that results from the
degradation of fibrin.
2. Helps to diagnose (a positive test result) the presence of thrombus in conditions
such as deep vein thrombosis, pulmonary embolism, or stroke; it is also used to
diagnose disseminated intravascular coagulation (DIC) and to monitor the
effectiveness of treatment.
3.The normal D dimer level is less than or equal to 250ng/mL (250 mcg/L) D
dimer units (DDU); normal fibrinogen is 200 to 400 mg/dL (2 to 4 g/L).

III. Respiratory Treatments

A. Breathing retraining.
BOX 54 3 Client Education: Breathing Retraining and
 Huff Cough
Breathing Retraining
*This includes exercises to decrease use of the
accessory muscles of breathing, to decrease fatigue,
and to promote carbon dioxide (CO2) elimination.
*The main types of exercises include pursed lip
breathing and diaphragmatic breathing.
*The client should inhale slowly through the nose.
*The client should place a hand over the abdomen
while inhaling; The abdomen should expand with
inhalation and contract during exhalation.
*The client should exhale 3 times longer than
inhalation by blowing through pursed lips.

Huff Coughing
*This is an effective coughing technique that
conserves energy, reduces fatigue, and facilitates
mobilization of secretions.
*The client should take 3 or 4 deep breaths using
pursed lip and diaphragmatic breathing. Leaning
slightly forward, the client should cough 3 or 4 times
during exhalation.
*The client may need to splint the thorax or abdomen
to achieve a maximum cough.

B. Chest physiotherapy (CPT)

Description: Percusssion, vibration, and postural drainage techniques are
performed over the thorax to loosen secretions in the affected area of the lungs
and move them into more cenral airways.
Interventions
Chest Physiotherapy Procedure
a. Perform chest physiotherapy (CPT) in the morning on arising, 1 hour before
meals, or 2 to 3 hours after meals.
b. Stop chest physiotherapy (CPT) if pain occurs.
c. If the client is receiving a tube feeding, stop the feeding and aspirate for residual
before beginning chest physiotherapy.
d. Place a layer of material (gown or pajamas) between the hands or percussion
device and the clients skin.
e. Position the client for postural drainage based on assessment.
f. Percuss the area for 1 to 2 minutes.
g. Vibrate the same area while the client exhales 4 or 5 deep breaths.
h. Monitor for respiratory tolerance to the procedure.
i. Stop the procedure if cyanosis or exhaustion occurs.
j. Maintain the position for 5 to 20 minutes after the procedure.
k. Repeat in all necessary positions until the client no longer expectorates mucus.
l. Dispose of sputum properly.
m. Provide mouth care after the procedure.
Contraindications
a. Unstable vital signs
b. Increased intracranial pressure
c. Bronchospasm
d. History of pathological fractures
e. Rib fractures
f. Chest incisions

C. Incentive spirometry
Client Instruction for Incentive Spirometry
1. Instruct the client to assume a sitting or upright position.
2. Instruct the client to place the mouth tightly around the mouthpiece of the
device.
3. Instruct the client to inhale slowly to raise and maintain the flow rate indicator
between the 600 and 900 marks.
4. Instruct the client to hold the breath for 5 seconds and then to exhale through
pursed lips.
5. Instruct the client to repeat this process 10 times every hour while awake.

IV. Oxygen
A. Supplemental oxygen delivery systems.
Device Oxygen Delivered Nursing Considerations
Nasal cannula (nasal 1 6 L/min for oxygen Easily tolerated
prongs) concentration (FiO2) of Can dislodge easily.
24% (1 L/min) to 44% (at Doesnt get in the way of
6 L/min). eating or talking.
Effective oxygen concen-
tration can be delivered.
Allows the client to breath
through the nose or
mouth.
Ensure that prongs are in
the nares with openings
facing the client
Assess nasal mucosa for
irritation from drying effect
of higher flow rates.
Assess skin integrity, as
tubing can irritate skin.
 Add humidification as
prescribed and check
water levels.

Simple face mask 5 8 L/min oxygen flow Interferes with eating and
for FiO2 of 40% - 60% talking.
Minimum flow of 5L/min Can be warm and
needed to flush CO2 from confining.
mask. Ensure that mask fits
securely over nose and
mouth.
Remove saliva and
mucus from the mask.
Provide skin care to area
covered by mask.
Provide emotional
support to decrease
anxiet in the client who
feels claustrophobic.
Monitor for risk of
aapiration from inability of
client to clear mouth (i.e.,
if vomiting occurs)

Venturi mask (Ventimask) 4 10 L/min oxygen flow Keep the air entrapment
for FiO2 of 24% - 55% port for the adapter open
Delivers exact desired and uncovered to ensure
selected concentrations adequate oxygen
of O2. delivery.
Keep mask snug on the
face and ensure tubing is
free of kinks because the
FiO2 is altered if kinking
occurs or if the mask fits
poorly.
Assess nasal mucosa for
irritation; humidity or
aerosol can be added to
the system as needed.

Partial rebreather mask 6 -15 L/min oxyge flow for The client rebreathes
(mask with reservoir bag) FiO2 of 70% - 90%. one-third of the exhaled
tidal volume, which is
high in oxygen, thus

Nonrebreather mask FiO2 of 60%-100% at a
rate of flow that maintains
the bag two-thirds full.
Tracheostomy collar and The tracheostomy collar
T- bar or T-piece (face can be used to deliver
tent; face shield) the desired amount of
oxygen to a client
with a tracheostomy.
Aspecial adaptor (T-bar or
providing a high FiO2.
Adjust flow rate to keep
the reservoir bag two-
thirds full during
inspiration.
Keep mask snug on face.
Make sure the reservoir
bag does not twist or kink.
Deflation of the bag
results in decreased
oxygen delivered
and rebreathing of
exhaled air.
Adjust flow rate to keep
the reservoir bag inflated.
Keep mask snug on the
face.
Remove mucus and
saliva from the mask.
Provide emotional
support to decrease
anxiety in the client
who feels claustrophobic.
Ensure that the valves
and flaps are intact and
functional during each
breath (valves should
open during expiration
and close during
inhalation).
Make sure the reservoir
bag does not twist or kink
or that the oxygen source
does not disconnect;
otherwise, the client will
suffocate.
Ensure that aerosol mist
escapes from the vents of
the delivery system
during inspiration and
expiration.
Empty condensation from
 T-piece) can be used to
deliver any desired FiO2
to client with trache-
ostomy, laryngectomy, or
endotracheal tube.
The face tent provides 8-
12 L/min and the FiO2
varies due to environ-
mental loss.
the tubing to prevent the
client from being lavaged
with water and to promote
an adequate oxygen flow
rate (remove and clean
the tubing at least every 4
hr).
Keep the exhalation port
in the T-piece open and
uncovered (if the port is
occluded, the client can
suffocate).
Position the T-piece so
that it does not pull on the
tracheostomy or
endotracheal tube and
cause erosion of the skin
at the tracheostomy
insertion site.

1. Nasal cannula for low flow: Used for the client with chronic airflow limitation and
for longterm oxygen use.
2. Nasal high flow (NHF) respiratory therapy: Used for hypoxemic clients in mild
to moderate respiratory distress.
3. Simple face mask: Used for short term oxygen therapy or to deliver oxygen in
an emergency.
4. Venturi mask: Used for clients at risk for or experiencing acute respiratory failure
5. Partial rebreather mask: Useful when the oxygen concentration needs to be
raised; not usually prescribed for a client with chronic obstructive pulmonary
disease (COPD).
6. Nonrebreather mask: Most frequently used for the client with a deteriorating
respiratory status who might require intubation.
7. Tracheostomy collar and T bar or T piece: Tracheostomy collar is used to
deliver high humidity and the desired oxygen to the client with a tracheostomy; the
T bar or T piece is used to deliver the desired FiO 2 to the client with a
tracheostomy, laryngectomy, or endotracheal tube.
8. Face tent: Used instead of a tight fitting mask for the client who has facial
trauma or burns.

B. Continuous positive airway pressure (CPAP) and bilevel positive airway

pressure (BiPAP).
1. CPAP maintains a set positive airway pressure during inspiration and expiration;
beneficial in clients who have obstructive sleep apnea or acute exacerbations of
COPD.
2. BiPAP provides positive airway pressure during inspiration and ceases airway
support during expiration; there is only enough pressure provided during expiration
to keep the airways open; usually used if CPAP is ineffective.
3. Both CPAP and BiPAP improve oxygenation through airway support.

C. General interventions
1.Assess color, pulse oximetry reading, and vital signs before and during
treatment.
2. Place an Oxygen in Use sign at the clients bedside.
3. Assess for the presence of chronic lung problems.
4. Humidify the oxygen if indicated.
!A client who is hypoxemic and has chronic hypercapnia requires low levels of
oxygen delivery at 1 to 2 L/minute because a low arterial oxygen level is the
clients primary drive for breathing.

V. Mechanical Ventilation
Types
1. Pressure cycled ventilator: The ventilator pushes air into the lungs until a
specific airway presure is reached; it is used for short periods, as in the
postanesthesia care unit.
3. Time cycled ventilator: The ventilator pushes air int the lungs until a preset
time has elapsed; it is used for the pediatric or neonatal client.
3. Volume cycled ventilator
a. The ventilator pushes air into the lungs until a preset volume is delivered.
b. A constant tidal volume is delivered regardless of the changing compliance of
the lungs and chest wall or the airway resistance in the client or ventilator.
4. Microprocessor ventilator
a. A computer or microprocessor is built into the ventilator to allow continuous
monitoring of ventilatory functions, alarms, and client parameters.
b. This type of ventilator is more responsive to clients who have severe lung
disease or require prolonged weaning.
Mode of Ventilation
1. Noninvasive positive pressure ventilation or BiPAP.
a. Ventilatory support given without using an invasive artificial airway
(endotracheal tube or tracheostomy tube); orofacial masks and nasal masks are
used instead.
b. An inspiratory positive airway pressure (IPAP) and an expiratory positive airway
pressure (EPAP) are set on a large ventilator or a small flow generator ventilator
with a desired pressure support and positive end-expiratory pressure
(PEEP) level. This allows more air to move into and out of the lungs without the
normal muscular activity needed to do so.
c. Can be used in certain situations of COPD distress, heart failure, asthma,
pulmonary edema, and hypercapnic respiratory failure
 !A resuscitation bag should be available at the bedside for all clients receiving
mechanical ventilation.
2. Controlled
a. The client receives a set tidal volume at a set rate.
b. Used for clients who cannot initiate respiratory effort.
c. Least used mode; if the client attempts to initiate a breath, the ventilator locks
out the clients inspiratory effort.
3. Assist-control
a. Most commonly used mode***
b. Tidal volume and ventilatory rate are preset on the ventilator.
c. The ventilator takes over the work of breathing for the client.
d. The ventilator is programmed to respond to the clients inspiratory effort if the
client does initiate a breath.
e. The ventilator delivers the preset tidal volume when the client initiates a breath
while allowing the client to control the rate of breathing.
f. If the clients spontaneous ventilatory rate increases, the ventilator continues to
deliver a preset tidal volume with each breath,which may cause hyperventilation
and respiratory alkalosis.***
4. Synchronized intermittent mandatory ventilation (SIMV)
a. Similar to assist-control ventilation in that the tidal volume and ventilatory rate
are preset on the ventilator
b. Allows the client to breathe spontaneously at her or his own rate and tidal
volume between the ventilator breaths
c. Can be used as a primary ventilatorymode or as a weaning mode
d. When SIMV is used as a weaning mode, the number of SIMV breaths is
decreased gradually, and the client gradually resumes spontaneous breathing.

Ventilator controls and settings and descriptions.

Controls and Descriptions

Settings
Tidal volume The volume of air that the client receives with each breath.
Rate The number of ventilator breaths delivered per minute
Sighs The volumes of air that are 1.5 to 2 times the set tidal
volume, delivered 6 to 10 times per hour; may be used to
prevent atelectasis.
Fraction of The oxygen concentration delievered to the client;
inspired determined by the clients codition and ABG levels.
oxygen (FiO2)
Peak airway The pressure needed by the ventilator to deliver a set tidal
inspiratory volume at a given compliance.
pressure Monitoring peak airway inspiratory pressure reflects
changes in compliance of the lungs and resistance in the
ventilator or client.
Continuous The application of positive airwaypressure throughout the
positive airway entire respiratory cycle for spontaneously breathing clients.
pressure Keeps the alveoli open during inspiration and prevents
alveolar collapse; used primarily as a weaning
Modality.
No ventilator breaths are delivered, but the ventilator
delivers oxygen and provides monitoring and an alarm
system; the respiratory pattern is determined by the
clients efforts.
Positive end- Positive pressure is exerted during the expiratory phase of
expiratory ventilation, which improves oxygenation by enhancing gas
pressure exchange and preventing atelectasis.
(PEEP) The need for PEEP indicates a severe gas exchange
disturbance
Higher levels of PEEP (more than 15 cm H2O) increase the
chance of complications, such as barotrauma tension
pneumothorax
Pressure The application of positive pressure on inspiration that
support eases the workload of breathing.
May be used in combination with PEEP as a weaning
method.
As the weaning process continues, the amount of pressure
applied to inspiration is gradually decreased.

Interventions

!For a client receiving mechanical ventilation, always assess the client first and
then assess the ventilator.

1.Assess vital signs, lung sounds, respiratory status, and breathing patterns (the
client will never breathe at a rate lower than the rate set on the ventilator).
2. Monitor skin color, particularly in the lips and nailbeds.
3. Monitor the chest for bilateral expansion.
4.Obtain pulse oximetry readings.
5. Monitor ABG results.
6. Assess the need for suctioning and observe the type, color, and amount of
secretions.
7. Assess ventilator settings.
8. Assess the level of water in the humidifier and the temperature of the
humidification system because extremes in temperature can damage the mucosa
in the airway.
9. Ensure that the alarms are set.
10. If a cause for an alarm cannot be determined, ventilate the client manually with
a resuscitation bag until the problem is corrected.
11. Empty the ventilator tubing when moisture collects.
12. Turn the client at least every 2 hours or get the client out of bed as prescribed
to prevent complications of immobility.
13. Have resuscitation equipment available at the bedside.

Causes of Ventilator alarms

High-Pressure Alarm
Increased secretions are in the airway.
Wheezing or bronchospasm is causing decreased airway size.
The endotracheal tube is displaced.
The ventilator tube is obstructed because of water or a kink in the tubing.
Client coughs, gags, or bites on the oral endotracheal tube.
Client is anxious or fights the ventilator.

Low-Pressure Alarm
Disconnection or leak in the ventilator or in the clients airway cuff occurs.
The client stops spontaneous breathing.

Alarm safety and alarm fatigue

1. It is the responsibility of the nurse to be alert to the sound of an alarm because
this signals a client problem.
2. The nurse needs to respond promptly to an alarm and immediately assess the
client.
3. According to The Joint Commission (TJC), the most common contributing factor
related to alarm-related sentinel events is alarm fatigue, which results when the
numerous alarms and the resulting noise tends to desensitize the nursing staff and
cause them to ignore alarms or even disable them.
4. Some recommendations of TJC include establishing alarm safety as a facility
policy, identifying default alarm settings, identifying the most important alarms to
manage, establishing policies and procedures for managing alarms, and staff
education.
!Never set ventilator alarm controls to the off position.

Complications
1. Hypotension caused by the application of positive pressure, which increases
intrathoracic pressure and inhibits blood return to the heart.
2. Respiratory complications such as pneumothorax or subcutaneous emphysema
as a result of positive pressure.
3. Gastrointestinal alterations such as stress ulcers
4. Malnutrition if nutrition is not maintained
5. Infections
6. Muscular deconditioning
7. Ventilator dependence or inability to wean

Weaning: Process of going from ventilator dependence to spontaneous breathing.

1. SIMV
a. The client breathes between the preset breaths per minute rate of the ventilator.
b. The SIMVrate is decreased gradually until the client is breathing on his or her
own without the use of the ventilator.
2. T-piece
a. The client is taken off the ventilator and the ventilator is replaced with a T-piece
or CPAP, which delivers humidified oxygen.
b. The client is taken off the ventilator for short periods initially and allowed to
breathe spontaneously.
c. Weaning progresses as the client is able to tolerate progressively longer periods
off the ventilator.
3. Pressure support
a. Pressure support is a predetermined pressure set on the ventilator to assist the
client in respiratory effort.
b. As weaning continues, the amount of pressure is decreased gradually.
c. With pressure support, pressure may be maintained while the preset breaths
per minute of the ventilator are decreased gradually.

VI. Chest Injuries

Rib Fracture
Description
a. Results from direct blunt chest trauma and causes a potential for
intrathoracic injury, such as pneumothorax or pulmonary contusion
b. Pain with movement and chest splinting results in impaired ventilation and
inadequate clearance of secretions.
Assessment
a. Pain and tenderness at the injury site that increases with inspiration.***
b. Shallow respirations.
c. Client splints chest.
d. Fractures noted on chest x-ray.
Interventions
a. Note that the ribs usually reunite spontaneously.
b. Place the client in a Fowlers position.
c. Administer pain medication as prescribed to maintain adequate ventilatory
status.
d. Monitor for increased respiratory distress.
e. Instruct the client to self-splint with the hands, arms, or a pillow.
 f. Prepare the client for an intercostal nerve block as prescribed if the pain is
severe.

Flail chest
Description
a. Occurs from blunt chest trauma associated with accidents, which may result in
hemothorax and rib fractures.
b. The loose segment of the chest wall becomes paradoxical to the expansion
and contraction of the rest of the chest wall.
Assessment
a. Paradoxical respirations (inward movement of a segment of the thorax
during inspiration with outward movement during expiration)
b. Severe pain in the chest
c. Dyspnea
d. Cyanosis
e. Tachycardia
f. Hypotension
g. Tachypnea, shallow respirations
h. Diminished breath sounds
Interventions
a. Maintain the client in a Fowlers position.
b. Administer oxygen as prescribed.
c. Monitor for increased respiratory distress.
d. Encourage coughing and deep breathing.
e. Administer pain medication as prescribed.
f. Maintain bed rest and limit activity to reduce oxygen demands.
g. Prepare for intubation with mechanical ventilation, with PEEP for severe flail
chest associated with respiratory failure and shock.

Pulmonary contusion
Description
a. Characterized by interstitial hemorrhage associated with intraalveolar
hemorrhage, resulting in decreased pulmonary compliance.
b. The major complication is acute respiratory distress syndrome.
Assessment
a. Dyspnea
b. Restlessness
c. Increased bronchial secretions
d. Hypoxemia
e. Hemoptysis
f. Decreased breath sounds
g. Crackles and wheezes
Interventions
a. Maintain a patent airway and adequate ventilation.
b. Place the client in a Fowlers position.
c. Administer oxygen as prescribed.
d. Monitor for increased respiratory distress.
e. Maintain bed rest and limit activity to reduce oxygen demands.
f. Prepare for mechanical ventilation with PEEP if required.

Pneumothorax
Description
a. Accumulation of atmospheric air in the pleural space, which results in a rise in
intrathoracic pressure and reduced vital capacity
b. The loss of negative intrapleural pressure results in collapse of the lung.***
c. A spontaneous pneumothorax occurs with the rupture of a pulmonary bleb.
d. An open pneumothorax occurs when an opening through the chest wall
allows the entrance of positive atmospheric air pressure into the pleural space.
e. A tension pneumothorax occurs from a blunt chest injury or from mechanical
ventilation with PEEP when a buildup of positive pressure occurs in the pleural
space.
f. Diagnosis of pneumothorax is made by chest x-ray.
Assessment
a. Absent breath sounds on affected side
b. Cyanosis
c. Decreased chest expansion unilaterally
d. Dyspnea
e. Hypotension
f. Sharp chest pain
g. Subcutaneous emphysema as evidenced by crepitus on palpation
h. Sucking sound with open chest wound
i. Tachycardia
j. Tachypnea
k. Tracheal deviation to the unaffected side with tension pneumothorax
Interventions
a. Apply a nonporous dressing over an open chest wound.
b. Administer oxygen as prescribed.
c. Place the client in a Fowlers position.
d. Prepare for chest tube placement, which will remain in place until the lung has
expanded fully.
e. Monitor the chest tube drainage system.
f. Monitor for subcutaneous emphysema.
!Clients with a respiratory disorder should be positioned with the head of the bed
elevated.

VII. Acute Respiratory Failure

Description
1. Occurs when insufficient oxygen is transported to the blood or inadequate
carbon dioxide is removed from the lungs and the clients compensatory
mechanisms fail.
2. Causes include a mechanical abnormality of the lungs or chest wall, a defect in
the respiratory control center in the brain, or an impairment in the function of the
respiratory muscles.
3. In oxygenation failure, or hypoxemic respiratory failure, oxygen may reach the
alveoli but cannot be absorbed or used properly, resulting in a PaO 2 lower than 60
mmHg, arterial oxygen saturation (SaO2) lower than 90%, or partial pressure of
arterial carbon dioxide (PaCO2) greater than 50 mmHg occurring with acidemia.
4.Many clients experience both hypoxemic and hypercapnic respiratory failure and
retained carbon dioxide in the alveoli displaces oxygen, contributing to the
hypoxemia.
5. Manifestations of respiratory failure are related to the extent and rapidity of
change in PaO2 and PaCO2 .
Assessment
1. Dyspnea
2. Headache
3. Restlessness
4. Confusion
5. Tachycardia
6. Hypertension
7. Dysrhythmias
8. Decreased level of consciousness
9. Alterations in respirations and breath sounds
Interventions
1. Identify and treat the cause of the respiratory failure.
2. Administer oxygen to maintain the PaO2 level higher than 60 to 70 mm Hg.
3. Place the client in a Fowlers position.
4. Encourage deep breathing.
5. Administer bronchodilators as prescribed.
6. Prepare the client for mechanical ventilation if supplemental oxygen cannot
maintain acceptable PaO2 and PaCO2 levels.

VIII. Acute Respiratrory Distress Syndrome

Description
1. A form of acute respiratory failure that occurs as a complication of some other
condition; it is caused by a diffuse lung injury and leads to extravascular lung fluid.
2. The major site of injury is the alveolar capillary membrane.
3. The interstitial edema causes compression and obliteration of the terminal
airways and leads to reduced lung volume and compliance.
4. The ABG levels identify respiratory acidosis and hypoxemia that do not
respond to an increased percentage of oxygen.
 5. The chest x-ray shows bilateral interstitial and alveolar infiltrates; interstitial
edema may not be noted until there is a 30% increase in fluid content.
6. Causes include sepsis, fluid overload, shock, trauma, neurological injuries,
burns, DIC, drug ingestion, aspiration, and inhalation of toxic substances.
Assessment
1. Tachypnea
2. Dyspnea
3. Decreased breath sounds
4. Deteriorating ABG levels
5. Hypoxemia despite high concentrations of delivered oxygen
6. Decreased pulmonary compliance
7. Pulmonary infiltrates
Interventions***
1. Identify and treat the cause of the acute respiratory distress syndrome.
2. Administer oxygen as prescribed.
3. Place the client in a Fowlers position.
4. Restrict fluid intake as prescribed.
5. Provide respiratory treatments as prescribed.
6. Administer diuretics, anticoagulants, or corticosteroids as prescribed.***
7. Prepare the client for intubation and mechanical ventilation using PEEP.
IX. Asthma
Description
1. Chronic inflammatory disorder of the airways that causes varying degrees of
obstruction in the airways.
2. Marked by airway inflammation and hyperresponsiveness to a variety of stimuli
or triggers.

Asthma Triggers
Environmental Physiological Factors Medications Occupationa Food
Factors l Exposure Additives
Factors
*Animal danders *Gastroesophageal *Acetylsalicylic *Metal salts *Sulfites
*Cockroaches reflux disease acid (aspirin) *Wood and (bisulfites and
*Exhaust fumes (GERD) *B Adrenergic vegetables metabisulfites
*Fireplaces *Hormonal changes blockers dusts )
*Molds *Stress *Nonsteroidal *Industrial *Beer, wine,
*Perfumes or *Viral upper antiinflammatory chemical dried fruit,
other products respiratory infection drugs and plastics shrimp,
with aerosol processed
sprays. potatoes
*Pollens *Monosodium
*Smoke, including glutamate.
cigarette or cigar
smoke
*Sudden weather
changes
From Lewis S, Dirksen S, Heitkemper M, Bucher L, Camera I: Medical-surgical
nursing: assessment and management of clinical problems, ed 8, St. Louis, 2011,
Mosby.

3. Causes recurrent episodes of wheezing, breathlessness, chest tightness, and

coughing associated with airflow obstruction that may resolve spontaneously; it is
often reversible with treatment.

4. Severity is classified based on the clinical features before treatment

Classification of Asthma Severity
Severe Persistent
*Symptoms are continuous.
*Physical activity requires limitations.
*Frequent exacerbations occur.
*Nocturnal symptoms occur frequently.
Moderate Persistent
*Daily symptoms occur.
*Daily use of inhaled short-acting -agonist is needed.
*Exacerbations affect activity.
*Exacerbations occur at least twice weekly and may last for days.
*Nocturnal symptoms occur more frequently than once weekly.
Mild Persistent
*Symptoms occur more frequently than twice weekly but less often than once daily.
*Exacerbations may affect activity.
*Nocturnal symptoms occur more frequently than twice a month.
Mild Intermittent
*Symptoms occur twice weekly or less.
*Client is asymptomatic between exacerbations.
*Exacerbations are brief (hours to days).
*Intensity of exacerbations varies.
*Nocturnal symptoms occur twice a month or less.
From Ignatavicius D, Workman M: Medical-surgical nursing: patient-centered
collaborative care, ed 7, St. Louis, 2013, Saunders.

5. Status asthmaticus is a severe life threatening asthma episodes that is

refractory to treatment and may result in pneumothorax, acute cor pulmonale, or
respiratory arrest.

Triggers*
 *Allergens *Infection
*Exercise *Irritants

IgE mast cells mediated response

Release of mediators from mast cells,

eosinophils, macrophages, lymphocytes

Late phase response

Earky phase
response

Peaks in 30 Peaks in 5 to 6 hours

to 60 minutes
*Bronchial smooth *Bronchial hyperreactivity
muscle contraction
*Mucosaledema

*Mucus secretion *Infiltration with eosinophils and neutrophils

*Vascular leakage *Inflammation
Within 1 to 2 days

Infiltration with monocytes

and lymphocytes

*Air trapping
*Hypoxemia
*Obstruction of large and small airways
*Respiratory acidosis
FIGURE 54-10 Pathophysiology in asthma. Stems with asterisks are primary
processes. IgE, Immunoglobulin E.
Assessment
1. Restlessness
2. Wheezing or crackles***
3. Absent or diminished lung sounds
4. Hyperresonance
5. Use of accessory muscles for breathing
6. Tachypnea with hyperventilation
7. Prolonged exhalation
8. Tachycardia
9. Pulsus paradoxus
10. Diaphoresis
11. Cyanosis
12. Decreased oxygen saturation
13. Pulmonary function test results that demonstrate decreased airflow rates.
Interventions
1.Monitor vital signs.
2. Monitor pulse oximetry
3. Monitor peak flow
4. During an acute asthma episode, provide interventions to assist with
breathing.

Nursing Interventions During an Acute Asthma

Episodes
*Position the client in a high Fowlers position or
sitting to aid in breathing.
*Administer oxygen as prescribed.
*Record the color, amount, and consistency of
sputum, if any.
*Administer corticosteroids as prescribed.
*Auscultate lung sounds before, during, and after
treatment.

Client Education
1. On the intermittent nature of symptoms and need for long-term management.
2. To identify possible triggers and measures to prevent episodes.
3. About the management of medication and proper administration.
4. About the correct use of a peak flowmeter.
5. About developing an asthma action plan with the primary HCP and what to do
if an asthma episode occurs.

X. Chronic Obstructive Pulmonary Disease

Description
1. Also known as chronic obstructive lung disease and chronic airflow limitation
2. Chronic obstructive pulmonarydisease is a disease state characterized by
airflow obstruction caused by emphysema or chronic bronchitis.
3. Progressive airflow limitation occurs, associated with an abnormal inflammatory
response of the lungs that is not completely reversible.
4. COPD leads to pulmonary insufficiency, pulmonary hypertension, and cor
pulmonale.
Assessment
1. Cough
2. Exertional dyspnea
3. Wheezing and crackles
4. Sputum production
5. Weight loss
6. Barrel chest (emphysema)***
7. Use of accessory muscles for breathing***
8. Prolonged expiration
9. Orthopnea
10. Cardiac dysrhythmias
11. Congestion and hyperinflation seen on chest x r ay.***
12. ABG levels that indicate respiratory acidosis and hypoxemia.***
13. Pulmonary function tests that demonstrate decreased vital capacity.
Interventions
1. Monitor Vital Signs.
2. Administer a concentration of oxygen based on ABG values and oxygen
saturation by pulse oximetry as prescribed.
3. Monitor pulse oximetry.
4. Provide respiratory treatments and CPT.
5. Instruct the client in diaphragmatic or abdominal breathing techniques and
pursed-lip breathing techniques, which increase airway pressure and keep
air passages open, promoting maximal carbon dioxide expiration.
6. Record the color, amount, and consistency of sputum.
7. Suction the clients lungs, if necessary, to clear the airway and prevent
infection.
8. Monitor weight.
9. Encourage small, frequent meals to maintain nutrition and prevent dyspnea.
10. Provide a high-calorie, high-protein diet with supplements.
11. Encourage fluid intake up to 3000 mL/day to keep secretions thin, unless
contraindicated.
12. Place the client in a Fowlers position and leaning forward to aid in breathing
13. Allow activity as tolerated.
14. Administer bronchodilators as prescribed, and instruct the client in the
use of oral and inhalant medications.
15. Administer corticosteroids as prescribed for exacerbations.
16. Administer mucolytics as prescribed to thin secretions.
17. Administer antibiotics for infection if prescribed.
Client Education: (COPD)
1. Adhere to activity limitations, alternating rest periods with activity.
2. Avoid eating gas producing foods, spicy foods, and extremely hot or cold
foods.
3. Avoid exposure to individuals with infections and avoid crowds.
4. Avoids extremes in temperature.
5. Avoid fireplaces,pets, feather pillows, and other environmental allergens.
6. Avoid powerful odors.
7. Meet nutritional requirements.
8. Receive immunizations as recommended.
9. Recognize the signs and symptoms of respiratory infection and hypoxia.
10. Stop smoking.
11. Use medications and inhalers as prescribed.
12. Use oxygen therapy as prescribed.
13. Use pursed lip and diaphragmatic or abdominal breathing.
14. When dusting, use a wet cloth.

XI. Severe Acute Respiratory Syndrome (SARS)

A. Respiratory illness caused by a coronavirus, called SARS associated
coronavirus.
B. The syndrome begins witha fever, an overall feeling of discomfort, body aches,
and mild respiratory symptoms.
C. After 2 to 7 days, the client may develop a dry cough and dyspnea.
D. Infection is spread by close person to person contact by direct contact with
infectious material (respiratory secretions from infected persons or contact
with objects contaminated with infectious droplets).
E. Prevention includes avoiding contact with those suspected of having SARS,
avoiding travel to countries where an outbreak of SARS exists, avoiding
close contact with crowds in areas where SARS exists, and frequent hand
washing if in an area where SARS exists. ***

XII. Pnemonia
Description
1. Infection of the pulmonary tissue, including the interstial spaces, the alveoli, and
the brochioles.
2. The edema associated with inflammation stiffens the lung, decreases lung
compliance and vital capacity, and causes hypoxemia.
3. Pneumonia can be community acquired or hospital acquired.
4. The chest x ray film shows lobar or segmental consolidation, pulmonary
infiltrates, or pleural effusions.
5. A sputum culture identifies the organism.
6. The white blood cell count and the erythrocyte sedimentation rate are
elevated.
Assessment
 1. Chills
2. Elevated temperature
3. Pleuritic pain
4. Tachypnea
5. Ronchi and wheezes
6. Use of accessory muscles for breathing.
7. Mental status changes
8. Sputum production
Interventions
1. Administer oxygen as prescribed.
2. Monitor respiratory status.
3. Monitor for labored respirations, cyanosis, and cold and clammy skin.
4. Encourage coughing and deep breathing and use of the incentive spirometer.
5. Place the client in a semi-Fowlers position to facilitate breathing and lung
expansion.
6. Change the clients position frequently and ambulate as tolerated to mobilize
secretions.
7. Provide Chest Physiotherapy.
8. Perform nasotracheal suctioning if the client is unable to clear secretions.
9. Monitor pulse oximetry.
10. Monitor and record color, consistency, and amount of sputum.
11. Provide a high-calorie, high-protein diet with small frequent meals.
12. Encourage fluids, up to 3 L/day, to thin secretions unless
contraindicated.
13. Provide a balance of rest and activity, increasing activity gradually.
14. Administer antibiotics as prescribed.
15. Administer antipyretics, bronchodilators, cough suppressants,
mucolytic agents, and expectorants as prescribed.
16. Prevent the spread of infection by hand washing and the proper disposal
of secretions.
Client Education
1. About the importance of rest, proper nutrition, and adequate fluid intake
2. To avoid chilling and exposure to individuals with respiratory infections or
viruses
3. Regarding medications and the use of inhalants as prescribed
4. To notify the HCP if chills, fever, dyspnea, hemoptysis, or increased fatigue
occurs
5. Pneumococcal vaccine as recommended by the health care provider(HCP).
!Teach clients that using proper hand washing techniques, disposing of
respiratory secretions properly; and receiving vaccines will assist in
preventing the spread of infection.

XIII. Influenza
Description
1. Also known as the flu; highly contagious acute viral respiratory infection.
2. May be caused by several viruses, usually known as type A, B, and C.
3. Yearly Vaccination is recommended to prevent the disease, especially for
those older than 50 years of age, individuals with chronic ilness or who are
immunocompromised, those living in institutions, and health care personnel
providing direct care to clients (the vaccination is contraindicated in the
individual with egg allegies).
4. Additional prevention measures include avoiding those who have developed
influenza, frequent and proper handwashing, and cleaning and disinfecting
surface that have become contaminated with secretions.
5. Avian Influenza A(H5N1)
a. Affects birds; does not usually affect humans; however, human cases have
been reported in some countries.
b. An H5N1 vaccine has been developed for use if a pandemic virus were to
emerge.
c. Reported symptoms are similar to those associated with influenza types A, B,
and C.
d. Prevention measures include thorough cooking of poultry products, avoiding
contact with wild animals, frequent and proper hand washing, and cleaning and
disinfecting surfaces that have become contaminated with secretions.
6. Swine (H1N1) Influenza
a. A strain of flu that consists of genetic materials from swine, avian, and human
influenza viruses.
b. Signs and symptoms are similar to those that present with seasonal flu; in
addition, vomiting and diarrhea commonly occur.
c. Prevention measures and treatment are the same as for the seasonal flu.
Assessment
1. Acute onset of fever and muscle aches.
2. Headache
3. Fatigue, weakness, anorexia.
4. Sore throat, cough, and rhinorrhea.
Interventions
1. Encourage rest.
2. Encourage fluids to prevent pulmonary complications (unless
contraindicated).
3. Monitor lung sounds.
4. Provide supportive therapy such as antipyretics or antitussives as
indicated.
5. Administer antiviral medications as prescribed for the current strain of
influenza.

XIV. Legionnaires Disease

Description
1. Acute bacterial infection caused by Legionella pneumophila.
2. Sources of the organism include contaminated cooling tower water and warm
stagnant water supplies, including water vaporizers, water sonicators, whirlpool
spas, and showers.
3. Person-to-person contact does not occur; the risk for infection is increased by
the presence of other conditions.
Assessment
Ifluenza like symptoms with a high fever, chills, muscle aches, and headache
that may progress to dry cough, pleurisy, and sometimes diarrhea.
Interventions
Treatment is supportive and antibiotics may be prescribed.

XV. Pleural Effusion

Description
1. Pleural effusion is the collection of fluid in the pleural space.
2. Any condition that interferes with secretion or drainage of this fluid will
lead to pleural effusion.
Assessment
1. Pleuritic pain that is sharp and increases with inspiration
2. Progressive dyspnea with decreased movement of the chest wall on the
affected side
3. Dry, nonproductive cough caused by bronchial irritation or mediastinal shift
4. Tachycardia
5. Elevated temperature
6. Decreased breath sounds over affected area
7. Chest x-ray film that shows pleural effusion and a mediastinal shift away from
the fluid if the effusion is more than 250 mL.
Interventions
1. Identify and treat the underlying cause.
2. Monitor breath sounds.
3. Place the client in a Fowlers position.
4. Encourage coughing and deep breathing.
5. Prepare the client for thoracentesis.
6. If pleural effusion is recurrent, prepare the client for pleurectomy or
pleurodesis as prescribed.
PLEURECTOMY
1. Consists of surgically stripping the parietal pleura away from the visceral pleura.
2. This produces an intense inflammatory reaction that promotes adhesion
formation between the 2 layers during healing.
PLEURODESIS
1. Involves the instillation of a sclerosing substance into the pleural space via a
thoracotomy tube.
2. The substance creates an inflammatory response that scleroses tissue together.

XVI. Empyema
Description
1. Collection of pus within the pleural cavity.
2. The fluid is thick, opaque, and foul smelling.
3. The most common cause is pulmonary infection and lung abscess caused by
thoracic surgery or chest trauma, in which bacteria are introduced directly into the
pleural space.
4. Treatment focuses on treating the infection, emptying the empyema cavity,
reexpanding the lung, and controlling the infection.
Assessment
1. Recent febrile illness or trauma
2. Chest pain
3. Cough
4. Dyspnea
5. Anorexia and weight loss
6. Malaise
7. Elevated temperature and chills
8. Night sweats
9. Pleural exudate on chest x ray.
Interventions
1. Monitor breath sounds.
2. Place the client in a semi Fowlers or high Fowlers position.***
3. Encourage coughing and deep breathing.
4. Admminister antibiotics as prescribed.
5. Instruct the client to splint the chest as necessary.
6. Assist with thoracentesis or chest tube insertion to promote drainage and
lung expanasion.
7. If marked pleural thickening occurs, prepare the client for decortication,
if prescribed; this surgical procedure involves removal of the restrictive mass
of fibrin and inflammatory cells.

XVII. Pleurisy
Description
1. Inflammation of the visceral and parietal membranes; may be caused by
pulmonary infarction or pneumonia.
2. The visceral and parietal membranes rub together during respiration and
cause pain.
3. Pleurisy usually occurs on 1 side of the chest, usually in the lower lateral
portions in the chest wall.

Assessment
1. Knifelike pain aggravated on deep breathing and coughing.
2. Dyspnea
3. Pleural friction rub heard on auscultation.
Interventions
 1. Identify and treat the cause.
2. Monitor lung sounds.
3. Administer analgesics as precribed.
4. Apply hot or cold applcations as prescribed.
5. Encourage coughing and deep breathing.
6. Instruct the client to lie on the affected side to splint chest.***

XVIII. Pulmonary Embolism***

Description
1. Occurs when a thrombus forms (most commonly in a deep vein), detaches,
travels to the right side of the heart, and then lodges in a branch of the
pulmonary artery.
2. Clients prone to pulmonary embolism are those at risk for deep vein
thrombosis, including those with prolonged immobilization, surgery, obesity,
pregnancy, heart failure, advanced age, or a history of thromboembolism.
3. Fat emboli can occur as a complication following fracture of a long bone and
can cause pulmonary embooli.
4. Treatment is aimed at prevention through risk factor recognition and elimination.
Assessment
1. Apprehension and restlessness
2. Blood tinged sputum
3. Chest pain
4. Cough
5. Crackles and wheezes on auscultation
6. Cyanosis
7. Distended neck veins
8. Dyspnea accompanied by anginal and pleuritic pain, exacerbated by
inspiration
9. Feeling of impending doom
10. Hypotension
11. Petechiae over the chest and axilla
12. Shallow repirations
13. Tachypnea and tachycardia
Interventions
Priority Nursing Actions (Suspected Pulmonary Embolism)
1. Notify the Rapid Response Team and Health care provider (HCP).
2. Reassure the client and elevate the head of the bed.
3. Prepare to administer oxygen.
4. Obtain Vital Signs and check lung sounds.
5. Prepare to obtain an arterial blood gas.
6. Prepare for the administration of heparin therapy or other therapies.
7.Document the event, interventions taken, and the clients response to
tretment.
Signs and symptoms of a pulmonary embolism include the sudden onset of
dyspnea, apprehension and restlessness, a feeling of impending doom,
cough, hemoptysis, tachypnea, crackles, petechiae over the chest and
axillae, and a decreased arterial oxygen saturation. If suspected, the nurse
immediately notifies the Rapid Response Team and HCP.
The nurse stays with the client, reassures the client, and elevates the head
of the bed. The nurse prepares to administer oxygen and obtains the vital
signs and checks lung sounds. The nurse continues to monitor the client
closely, prepares the client for tests prescribed to confirm the diagnosis, and
prepares to obtain an arterial blood gas. When prescribed, the client is
prepared for the administration of heparin therapy or other therapies such
as embolectomy or placement of a vena cava filter if necessary. Finally, the
nurse documents the event, the interventions taken, and the clients response to
treatment.
Reference: Ignatavicius, Workman (2016), p. 606. Pg. 744 Pg. 614. 574

XIX. Lung Cancer and Laryngeal Cancer

Lung Cancer
Description
1. Lung cancer is a malignant tumor of the brochi and peripheral lung tissue.
2. The lungs are a common target for metastasis from other organs.
3. Bronchogenic cancer (tumors originate in the epithelium of the bronchus)
spreads through direct extension and lymphatic dissemination.
4. Classified according to histological cell type; types include small cel lung cancer
(NSCLC); epidermal (squamous cell anaplastic carcinoma are classified as
NSCLS because of their similar responses to treatment.
5. Diagnosis is made by a chest x ray study. CT scan, or magnetic resonance
imaging (MRI), which shows a lesion or mass, and by bronchoscopy and
sputum studies, which demonstrate a positive cytological study for cancer cells.
Causes
1. Cigarrette smoking; also exposure to passive tobacco smoke.
2. Exposure to environmental and occupational pollutants.
Assessment
1. Cough
2. Wheezing, dyspnea
3. Hoarseness
4. Hempotysis, blood tinged or purulent sputum
5. Chest pain
6. Anorexia and weight loss
7. Weakness
8. Diminished or absent breath sounds, respiratory changes
Interventions
1. Monitor Vital Signs.
 2. Monitor breathing patterns and breath sounds and for signs of respiratory
impairment;monitor for hemoptysis.
3. Assess for tracheal deviation.
4. Administer analgesics as prescribed for pain management.
5. Place in a Fowlersposition to help easebreathing.***
6. Administer oxygen as prescribed and humidification to moisten and
loosen secretions.***
7. Monitor pulse oximetry.
8. Provide respiratory treatments as prescribed.
9. Administer bronchodilators and corticosteroids as prescribed to decrease
bronchospasm, inflammation, and edema.
10. Provide a high-calorie, high-protein, high vitamin diet.
11. Provide activity as tolerated, rest periods, and active and passive range
of motion exercises.
Nonsurgical interventions
1. Radiation therapy may be prescribed for localized intrathoracic lung
cancer and for palliation of hemoptysis, obstructions, dysphagia,
superior vena cava syndrome, and pain.
2. Chemotherapy may be prescribed for treatment of nonresectable tumors
or as adjuvant therapy.
Surgical interventions
1. Laser therapy: To relieve endobronchial obstruction.
2. Thoracentesis and pleurodesis: To remove pleural fluid and relieve
hypoxia.
3. Thoracotomy (opening into the thoracic cavity) with pneumonectomy:
Surgical removal of 1 entire lung.
4. Thoracotomy with lobectomy: Surgical removal of 1 lobe of the lung for
tumors confined to a single lobe.
5. Thoracotomy with segmental resection: Surgical removal of a lobe
segment.
Preoperative interventions
1. Explain the potential postoperative need for chest tubes.
2. Note that closed chest drainage usually is not used for a
pneumonectomy and the serous fluid that accumulates in the empty
thoracic cavity eventually consolidates, preventing shifts of the
mediastinum, heart, and remaining lung.***
Postoperative interventions
1. Monitor Vital Signs.
2. Assess cardiac and respiratory status; monitor lung sounds.***
3. Maintain the chest tube drainage system, which drains air and blood
that accumulates in the pleural space; monitor for excess bleeding.
(See Chapter 20 for care of the client with a chest tube.)***
4. Administer oxygen as prescribed.
 5. Check the healthcare providers (HCPs) prescriptions regarding client
positioning; avoid complete lateral turning.
6. Monitor pulse oximetry.
7. Provide activity as tolerated.
8. Encourage active range of motion exercises of the operative shoulder as
prescribed.
!The airway is the priority for a client with lung or laryngeal cancer.

Laryngeal Cancer
Description
1. Laryngeal cancer is a malignant tumor of the larynx.
2. Laryngeal cancer presents as malignant ulcerations with underlying
infiltration and is spread by local extension to adjacent structures in the
throat and neck, and by the lymphatic system.
3. Diagnosis is made by laryngoscopy and biopsy showing a positive
cytological study for cancer cells.
4. Laryngoscopy allows for evaluation of the throat and biopsy of tissues; chest
radiography, CT, and MRI are used for staging.
Risk factors
1. Cigarette smoking.
2. Heavy alcohol use and the combined use of tobacco and alcohol.
3. Exposure to environmental pollutants (e.g., asbestos, wood dust).
4. Exposure to radiation
Assessment***
1. Persistent hoarseness or sore throat and ear pain.
2. Painless neck mass.
3. Feeling of lump in the throat.
4. Burning sensation in the throat.
5. Dysphagia.
6. Change in voice quality.
7. Dyspnea.
8. Weakness and weight loss
9. Hemoptysis.
10. Foul breath odor.
Interventions
1. Place in Fowlers position to promote optimal air exchange.***
2. Monitor respiratory status.
3. Monitor for signs of aspiration of food and fluid.
4. Administer oxygen as prescribed.***
5. Provide respiratory treatments as prescribed.
6. Provide activity as tolerated.
7. Provide a high calorie and high protein diet.
8. Provide nutritional support via parenteral nutrition, nasogastric tube feedings,
or gastrostomy or jejunostomy tube, as prescribed.
 9. Administer analgesics as prescribed for pain.
10. Encourage clients to stop smoking and drinking alcohol to increase
effectiveness of treatments.
Nonsurgical interventions
1. Radiation therapy in specified situations
2. Chemotherapy,which maybe given in combination with radiation and
surgery
Surgical interventions
1. The goal is to remove the cancer while preserving as much normal
function as possible.
2. Surgical intervention depends on the tumor size, location, and amount of
tissue to be resected.
3. Types of resection include cordal stripping, cordectomy, partial
laryngectomy, and total laryngectomy.
4. A tracheostomy is performed with a total laryngectomy; this airway
opening is permanent and is referred to as a laryngectomy stoma.
Preoperative interventions
1. Discuss self-care of the airway, alternative methods of communication,
suctioning, pain control methods, the critical care environment, and nutritional
support.
2. Encourage the client to express feelings about changes in body image and
loss of voice.
3. Describe the rehabilitation program and information about the tracheostomy
and suctioning.
Postoperative interventions
1. Monitor Vital Signs.
2. Monitor respiratory status; monitor airway patency and provide frequent
suctioning to remove bloody secretions.
3. Place the client in a high Fowlers position.
4. Maintain mechanical ventilator support or a tracheostomy collar with
humidification, as prescribed.
5. Monitor pulse oximetry.
6. Maintain surgical drains in the neck area if present.
7. Observe for hemorrhage and edema in the neck.
8. Monitor IV fluids or parenteral nutrition until nutrition is administered via a
nasogastric, gastrostomy, or jejunostomy tube.
9. Provide oral hygiene.
10. Assess gag and cough reflexes and the ability to swallow.
11. Increase activity as tolerated.
12. Assess the color, amount, and consistency of sputum.
13. Provide stoma and laryngectomy care
Stoma Care Following Laryngectomy
-Protect the neck from injury.
-Instruct the client in how to clean the incision and provide stoma care.
 -Instruct the client to wear a stoma guard to shield the stoma.
-Demonstrate ways to prevent debris from entering the stoma.
-Advise the client to wear loose fitting, high collared clothing to cover the
stoma.
-Avoid swimming, showering, and using aerosol sprays.
-Teach the client clean suctioning technique.
-Advise the client to increase humidity in the home.
-Increase fluid intake to 3000 mL / day as prescribed.
-Avoid exposure to persons with activity.
-Alternate rest periods with activity.
-Instruct the client in range of motion exercises for the arms,
shoulders, and neck as prescribed.
-Advise the client to wear a MedicAlert bracelet.
14. Provide consultation with speech and language pathologist as prescribed.
15. Reinforce method of communication established preoperatively.
16. Prepare the client for rehabilitation and speech therapy (Box 48-16).
Speech Rehabilitation Following Laryngectomy
Esophageal Speech
-The client produces esophageal speech by burping the air swallowed.
-The voice produced is monotone, cannot be raised or lowered, and carries no
pitch.
-The client must have adequate hearing because his or her mouth shapes
words as they are heard.
Mechanical Devices
-One device, the electrolarynx, is placed against the side of the neck; the air
inside the neck and pharynx is vibrated, and the client articulates.
-Another device consists of a plastic tube that is placed inside the clients mouth
and vibrates on articulation.
Tracheoesophageal Fistula
-A fistula is created surgically between the trachea and the esophagus,
with eventual placement of a prosthesis to produce speech.
-The prosthesis provides the client with a means to divert air from the
trachea into the esophagus, and out of the mouth.
-Lip and tongue movement produce the speech.

XX. Carbon Monoxide Poisoning

Description
a. Carbon monoxide is a colorless, odorless, and tatsteless gas that has an
affinity for hemoglobin 200 times greater than that of oxygen.
b. Oxygen molecules are displaced and carbon monoxide reversibly binds to
hemoglobin to form carboxyhemoglobin.
c. Tissue hypoxia occurs.
Assessment***
Blood Level (%) Clinical Manifestations
1 10 Normal level
11 20 (mild poisoning) Headache
Flushing
Decreased visual acuity
Decreased cerebral functioning
Slight breathlessness
21 40 (moderate Headache
poisoning) Nausea and vomiting
Drowsiness
Tinnitus and vertigo
Confusion and stupor
Pale to reddish purple skin
Decreased blood pressure
Increased and irregular heart rate
Depressed ST segment on electrocardiogram
41 60 (severe Coma
poisoning) Seizures
Cardiopulmonary instability
61 80 (fatal poisoning) Death
Adapted from Ignatavicius D, Workman ML: Medical-surgical nursing:
patientcentered collaborative care, ed 8, Philadelphia, 2016, Saunders.

XXI. Histoplasmosis
Description
1. Pulmonary fungal infection caused by spores of Histoplasma capsulatum.
2. Transmission occurs by the inhalation of spores, which commonly are found
in contaminated soil.***
3. Spores also are usually found in bird droppings.
Assessment
1. Similar to pnuemonia: Chills, Elevated temperature, Pleuritic pain,
Tachypnea, Rhonchi and wheezes, Use of accessory muscles for breathing,
Mental status changes, Sputum production
2. Positive skin test for histoplasmosis.***
3. Positive agglutination test
4. Splenomegaly, hepatomegaly
Interverventions
1. Administer oxygen as prescribed.
2. Monitor breath sounds.
3. Administer antiemetics, antihistamines, antipyretics, and corticosteroids as
prescribed.
4. Administer fungicidal medications as prescribed.
5. Encourage coughing and deep breathing.
6. Place the client in a semi Fowlers position.
7. Monitor Vital Signs.
8. Monitor for nephrotoxicity form fungicidal medications.
9. Instruct the client to wear a mask and spray the floor with water before
sweeping barn and chicken coops.

XXII. Sarcoidosis
Description
1. Presence of epithelioid cell tubercles in the lung.
2. The cause is unknown, but a high titer of Epstein Barr virus may be
noted.
3. Viral incidence is highest in African Americans and young adults.
Assessment
1. Night sweats
2. Fever
3. Weight loss
4. Cough and dyspnea
5. Skin nodules
6. Polyarthritis.
7. Kveim test: Sarcoid node antigen is injected intradermally and causes a local
nodular lesion in about 1 month.***
Interventions
1. Administer corticosteroids to control symptoms.
2. Monitor temperature.
3. Increase fluid intake.
4. Provide frequent periods of rest.
5. Encourage small, frequent, nutritious meals.
XXIII. Occupational Lung Disease
Description
1. Caused by exposure to environmental or occupational fumes, dust,
vapors, gases, bacterial or fungal antigens, and allergens; can result in
acute reversible effects or chronic lung disease.
2. Common disease classifications include occupational asthma
pneumoconiosis (silicosis or coal miners [black lung] disease), diffuse
interstitial fibrosis (asbestosis, talcosis, berylliosis), or extrinsic allergic
alveolitis (farmers lung, bird fanciers lung, or machine operators lung).
Assessment
1. Manifestations depend on the type of disease and respiratory symptoms.***
Interventions
1. Prevention through the use of respiratory protective devices.***
2. Treatment is based on the symptoms experienced by the client.

XXIV. Tuberculosis***
Description
1. Highly communicable disease caused by Mycobacterium tuberculosis.
2. M. tuberculosis is a nonmotile, nonsporulating, acid-fast rod that secretes
niacin; when the bacillus reaches a susceptible site, it multiplies freely.
3. Because M. tuberculosis is an aerobic bacterium, it primarily affects the
pulmonary system, especially the upper lobes, where the oxygen content
is highest, but also can affect other areas of the body, such as the brain, intestines,
peritoneum, kidney, joints, and liver.
4. An exudative response causes a nonspecific pneumonitis and the development
of granulomas in the lung tissue.
5. Tuberculosis has an insidious onset, and many clients are not aware of
symptoms until the disease is well advanced.
6. Improper or noncompliant use of treatment programs may cause the
development of mutations in the tubercle bacilli, resulting in a multidrugresistant
strain of tuberculosis (MDR-TB).***
7. The goal of treatment is to prevent transmission, control symptoms, and
prevent progression of the disease.
Risk factors***
1. Child younger than 5 years of age
2. Drinking unpasteurized milk if the cow is infected with bovine tuberculosis.
3. Homeless individuals or those from a lower socioeconomic group, minority
group, or refugee group.
4. Individuals in constant, frequent contact with an untreated or undiagnosed
individual.
5. Individuals living in crowded areas, such as long term care facilites, prisons,
and mental health facilities.
6. Older client.
7. Individuals with malnutrition, infection, immune dysfunction, or human
immunodeficiency virus infection; or immunosuppressed as a result of
medication therapy.
8. Individuals who abuse alcohol or are intravenous drug users.
Transmission***
1. Via the airborne route by droplet infection.
2. When an infected individual coughs, laughs, sneezes, or sings, droplet nuclei
containing tuberculosis bacteria enter the air and may be inhaled by others.
3. Identification of those in close contact with the infected individual is important
so that they can be tested and treated as necessary.
4. When contacts have been identified, these persons are assessed with a
tuberculin skin test and chest x-rays to determine infection with
tuberculosis.
5. After the infected individual has received tuberculosis medication for 2 to 3
weeks, the risk of transmission is reduced greatly.
Disease progression
1. Droplets enter the lungs, and the bacteria form a tubercle lesion.
2. The defense systems of the body encapsulate the tubercle, leaving a scar.
 3. If encapsulation does not occur, bacteria may enter the lymph system, travel
to the lymph nodes, and cause an inflammatory response termed
granulomatous inflammation.
4. Primary lesions form; the primary lesions may become dormant but can be
reactivated and become a secondary infection when reexposed to the
bacterium.
5. In an active phase, tuberculosis can cause necrosis and cavitation in the
lesions, leading to rupture, the spread of necrotic tissue, and damage
to various parts of the body.
Client history***
1. Past exposure to tuberculosis
2. Clients country of origin and travel to foreign countries in which the incidence
of tuberculosis is high
3. Recent historyof influenza, pneumonia, febrile illness, cough, or foul-smelling
sputum production
4. Previous tests for tuberculosis; results of the testing
5. Recent bacillus Calmette-Guerin (BCG) vaccine (a vaccine containing
attenuated tubercle bacilli that may be given to persons in foreign countries
or to persons traveling to foreign countries to produce increased resistance to
tuberculosis).
!An individual who has received a BCG vaccine will have a positive tuberculin
skin test result and should be evaluated for tuberculosis with a chest x ray.
Clinical manifestations
1. May be asymptomatic in primary infection
2. Fatigue
3. Lethargy
4. Anorexia
5. Weight loss
6. Low-grade fever
7. Chills
8. Night sweats
9. Persistent cough and the production of mucoid and mucopurulent sputum,
which is occasionally streaked with blood
10. Chest tightness and a dull, aching chest pain may accompany the cough.
Chest assessment
1. A physical examination of the chest does not provide conclusive evidence of
tuberculosis.
2. A chest x-ray is not definitive, but the presence of multinodular infiltrates with
calcification in the upper lobes suggests tuberculosis.***
3. If the disease is active, caseation and inflammation may be seen on the chest
x-ray.
4. Advanced disease
a. Dullness with percussion over involved parenchymal areas, bronchial
breath sounds, rhonchi, and crackles indicate advanced disease.
 b. Partial obstruction of a bronchus caused by endobronchial disease or
compression by lymph nodes may produce localized wheezing and dyspnea.
QuantiFERON TB Gold Test***
1. A blood analysis test by an enzyme-linked immunosorbent assay
2. A sensitive and rapid test (results can be available in 24 hours) that assists in
diagnosing the client
Sputum cultures
1. Sputum specimens are obtained for an acidfast smear.***
2. A sputum culture identifying M. tuberculosis confirms the diagnosis.
3. After medications are started, sputum samples are obtained again to
determine the effectiveness of therapy.***
4. Most clientshavenegative cultures after 3 months of treatment.
Tuberculin skin test (TST)***
1. A positive reaction does not mean that active disease is present but indicates
previous exposure to tuberculosis or the presence of inactive (dormant)
disease.***
2. Once the test result is positive, it will be positive in any future tests.
3. Skin test interpretation depends on 2 factors: measurement in millimeters of
the induration, and the persons risk of being infected with tuberculosis and
progression to disease if infected.
4. Once an individuals skin test is positive, a chest x-ray is necessary to rule
out active tuberculosis or to detect old healed lesions.
Induration 5 5 or > 5 mm Induration 5 10 or > 10 Induration 5 15 or > 15
Considered mm Considered mm Considered
Positive in: Positive in: Positive in:
HIV-infected persons. Recent immigrants from Any person, including
Recent contact of a high-prevalence countries. persons with no
person with TB disease. Injection drug users. known risk factors for
Persons with fibrotic Residents and employees TB.
changes on chest x-ray in high-risk congregate
consistent with prior TB. Settings.
Clients with organ Mycobacteriology
transplants. laboratory personnel.
Personsimmuno- Persons with clinical
suppressed for other conditions that place them
reasons. at high risk.
Children < 4 years of age
Infants, children, and
adolescents exposed to
adults in high-risk
categories.
Classification of the Tuberculin Skin Test Reaction
HIV, Human immunodeficiency virus; TB, tuberculosis. From Centers for Disease
Control and Prevention: Tuberculosis (TB) fact sheets (website):
http://www.cdc.gov/ tb/publications/ factsheets/ testing/ skintesting.htm.

The hospitalized client***

1. The client with active tuberculosis is placed under airborne isolation
precautions in a negative pressure room; to maintain negative pressure,
the door of the room must be tightly closed.
2. The room should have at least 6 exchanges of fresh air per hour and
should be ventilated to the outside environment, if possible.
3. The nurse wears a particulate respirator (a special individually fitted
mask) when caring for the client and a gown when the possibility of
clothing contamination exists.
4.Thorough hand washing is required before and after caring for the client.
5. If the client needs to leave the room for a test or procedure, the client is
required to wear a surgical mask.
6. Respiratory isolations is discontinued when the client is no longer considered
infectious.***
7. After the infected individual has received tuberculosis medication for 2 to 3
weeks, the risk of transmission is reduced greatly.

Client education: Tuberculosis***

1. Provide the client and family with information about tuberculosis and allay
concerns about the contagious aspect of the infection.
2. Instruct the client to follow the medication regimen exactly as prescribed and
always to have a supply of the medication on hand.
3. Advise the client that the medication regimen is continued up to 12 months
depending on the situation.
4. Advise the client of the side and adverse effects of the medication and ways
of minimizing them to ensure compliance.
5. Reassure the client that after 2 to 3 weeks of medication therapy, it is unlikely
that the client will infect anyone.
6. Advise the client to resume activities gradually.
7. Instruct the client about the need for adequate nutrition and a well
balanced diet (foos rich in iron, protein, and vitamin C) to promote
healing and to prevent recurrence of the infection.
8. Inform the client and family that respiratory isolation is not necessary
because family members already have been exposed.
9. Instruct the client to cover the mouth and nose when coughing or sneezing
and to put used tissues into plastic bags.
10. Instruct the client and family about thorough hand washing.
11. Inform the client that a sputum culture is needed every 2 to 4 weeks once
medication therapy is initiated.
12. Inform the client that when the results of 3 sputum cultures
 are negative, the client is no longer considered infectious and usually
can return to former employment.
13. Advise the client to avoid excessive exposure to silicone or dust
because these substances can cause further lung damage.
14. Instruct the client regarding the importance of compliance with treatment,
follow-up care, and sputum cultures, as prescribed.
b Disturbance in Metabolic and Endocrine Functioning
I. Anatomy and Physiology of Endocrine Glands
A. Functions
1. Maintenance and regulation of vital functions
2. Response to stress and injury
3. Growth and development
4. Energy metabolism
5. Reproduction
6. Fluid, electrolyte, and acid-base balance

B. Risk factors for endocrine disorders

Age
Heredity
Congenital factors
Trauma
Environmental factors
Consequence of other disorders or surgery

C. Hypothalamus
1. Portion of the diencephalon of the brain, forming the floor and part of the lateral
wall of the third ventricle
2. Activates, controls, and integrates the peripheral autonomic nervous system,
endocrine processes, and many somatic functions, such as body temperature,
sleep, and appetite

D. Pituitary gland
1. The master gland; located at the base of the brain (cranial cavity in sella turcica
of sphenoid bone; near optic chiasm
2. Influenced by the hypothalamus; directly affects the function of the other
endocrine glands
3. Anterior lobe (adenohypophysis) and posterior lobe (neurohypophysis)
4. Promotes growth of body tissue, influences water absorption by the kidney, and
controls sexual development and function
5. Pituitary Hormes
1. Hormones secreted by anterior lobe
a. Growth hormone (GH)
(1) Promotes protein anabolism
(2) Promotes fat mobilization and catabolism
(3) Slows carbohydrate metabolism
b. Thyroid-stimulating hormone (TSH): stimulates synthesis and secretion of
thyroid hormones
c. ACTH
(1) Stimulates growth of adrenal cortex
(2) Stimulates secretion of glucocorticoids; slightly stimulates mineralocorticoid
secretion
d. Follicle-stimulating hormone (FSH)
(1) Stimulates primary graafian follicle to grow and develop
(2) Stimulates follicle cells to secrete estrogen
(3) Stimulates development of seminiferous tubules and spermatogenesis
e. Luteinizing hormone (LH)
(1) Stimulates maturation of follicle and ovum; required for ovulation
(2) Forms corpus luteum in ruptured follicle following ovulation; stimulates
corpus luteum to secrete progesterone
(3) In males, LH is called interstitial cellstimulating hormone (ICSH);
stimulates testes to secrete testosterone
f. Prolactin (PRL)
(1) Promotes breast development during pregnancy
(2) Initiates milk production after delivery
(3) Stimulates progesterone secretion by corpus luteum
2. Hormones secreted by posterior lobe
a. Antidiuretic hormone (ADH, vasopressin)
(1) Increases water reabsorption by distal and collecting tubules of kidneys
(2) Stimulates vasoconstriction, raising blood pressure
b. Oxytocin
(1) Stimulates contractions by pregnant uterus
(2) Stimulates milk ejection from alveoli of lactating breasts into ducts
c. Melanocyte-stimulating hormone (MSH): stimulates synthesis and dispersion
of melanin in skin, causing darkening

E. Adrenal gland
1. One adrenal gland is on top of each kidney.
2. A Two closely associated structures, adrenal medulla and adrenal cortex,
positioned at each kidneys superior border
3. Regulates sodium and electrolyte balance; affects carbohydrate, fat, and protein
metabolism; influences the development of sexual characteristics; and sustains
the fight-or-flight response
4. Adrenal hormones
1. Adrenal cortex
a. The cortex is the outer shell of the adrenal gland.
b. The cortex synthesizes glucocorticoids and mineralocorticoids and secretes
small amounts of sex hormones (androgens, estrogens)
c. secretes the mineralocorticoid aldosterone and the glucocorticoids cortisol and
corticosterone
a. Aldosterone
(1) Markedly accelerates sodium and water reabsorption by kidney tubules
(2) Markedly accelerates potassium excretion by kidney tubules
(3) Secretion increases as sodium ions decrease or potassium ions increase
b. Cortisol and corticosterone
(1) Accelerate mobilization and catabolism of tissue protein and fats
(2) Accelerate liver gluconeogenesis (hyperglycemic effect)
(3) Decrease antibody formation (immunosuppressive, antiallergic effect)
(4) Slow proliferation of fibroblasts characteristic of inflammation
(antiinflammatory effect)
(5) Decrease adrenocorticotropic hormone (ACTH) secretion
(6) Mildly accelerate sodium and water reabsorption and potassium excretion
by kidney tubules
(7) Increase release of coagulation factors

2. Adrenal medulla
a. The medulla is the inner core of the adrenal gland.
b. The medulla works as part of the sympathetic nervous system and produces
two catecholamines, epinephrine and norepinephrine.
c. Stimulate liver and skeletal muscle to break down glycogen to produce glucose
d. Increase oxygen use and carbon dioxide production
e. Increase blood concentration of free fatty acids through stimulation of lipolysis in
adipose tissue
f. Cause constriction of most blood vessels of body, thus increasing total peripheral
resistance and arterial pressure to shunt blood to vital organs
g. Increase heart rate and force of contraction, thus increasing cardiac output
h. Inhibit contractions of gastrointestinal and uterine smooth muscle
i. Epinephrine significantly dilates bronchial smooth muscle

F. Thyroid gland
1. Located in the anterior part of the neck
2. Thyroid hormones: accelerate cellular reactions in most body cells
3. Controls the rate of body metabolism and growth and produces thyroxine (T4),
triiodothyronine (T3), and thyrocalcitonin
Thyroxine: stimulates metabolic rate; essential for physical and mental
development
Triiodothyronine: inhibits anterior pituitary secretion of thyroid-stimulating
hormone
Calcitonin (thyrocalcitonin): decreases loss of calcium from bone; promotes
hypocalcemia; action opposite that of parathormone
G. Parathyroid glands
1. Located on the thyroid gland
2. Small glands (2 to 12) embedded in posterior part of thyroid
3. Controls calcium and phosphorus metabolism; produces parathyroid hormone
(parathormone)
4. Parathyroid hormone (parathormone)
1. Increases blood calcium concentration
a. Breakdown of bone with release of calcium into blood (requires active form of
vitamin D)
b. Calcium absorption from intestine into blood
c. Kidney tubule reabsorption of calcium
2. Decreases blood phosphate concentration by slowing its reabsorption from
kidneys, thereby decreasing calcium loss in urine

H. Pancreas
1. Located posteriorly to the stomach (retroperitoneal in abdominal cavity)
2. Influences carbohydrate metabolism, indirectly influences fat and protein
metabolism, and produces insulin and glucagon
3. Pancreatic hormones: regulate glucose and protein homeostasis through
action of insulin and glucagon
Insulin: secreted by beta cells of islets of Langerhans
a. Promotes cellular uptake of glucose
b. Stimulates intracellular macromolecular synthesis, such as glycogen
synthesis (glyconeogenesis), fat synthesis (lipogenesis), and protein synthesis
c. Stimulates cellular uptake of sodium and potassium (latter is significant in
treatment of diabetic coma with insulin)
Glucagon: secreted by alpha cells of islets of Langerhans
a. Induces liver glycogenolysis; antagonizes glycogen synthesis stimulated by
insulin
b. Inhibits hepatic protein synthesis, which makes amino acids available for
gluconeogenesis and increases urea production
c. Stimulates hepatic ketogenesis and release of glycerol and fatty acids from
adipose tissue when cellular glucose level falls

I. Ovaries and testes

1. The ovaries are located in the pelvic cavity and produce estrogen and
progesterone.
2. The testes are located in the scrotum, control the development of the secondary
sex characteristics, and produce testosterone.

J. Negative-feedback loop
1. Regulates hormone secretion by the hypothalamus and pituitary gland
2. Increased amounts of target gland hormones in the bloodstream decrease
secretion of the same hormone and other hormones that stimulate its release.
II. Diagnostic Tests
A. Stimulation and suppression tests
1. Stimulation tests
a. In the client with suspected underactivity of an endocrine gland, a stimulus
may be provided to determine whether the gland is capable of normal
hormone production.
b. Measured amounts of selected hormones or substances are administered to
stimulate the target gland to produce its hormone.
c. Hormone levels produced by the target gland are measured.
d. Failure of the hormone level to increase with stimulation indicates hypofunction.

2. Suppression tests
a. Suppression tests are used when hormone levels are high or in the upper range
of normal.
b. Agents that normally induce a suppressed response are administered to
determine whether normal negative feedback is intact.
c. Failure of hormone production to be suppressed during standardized testing
indicates hyperfunction.

3. Overnight dexamethasone suppression test

a. Used to distinguish between Cushings syndrome and Cushings disease.
b. In Cushings disease the source of excess cortisol is the pituitary gland rather
than the adrenal cortex or exogenous corticosteroid administration.
c. Dexamethasone, a potent long-acting corticosteroid given at bedtime, should
suppress the morning cortisol in clients without Cushings disease by suppressing
adrenocorticotropic hormone (ACTH) production; in the client with Cushings
disease, this suppression will not occur.

B. Radioactive iodine uptake

1. This thyroid function test measures the absorption of an iodine isotope to
determine how the thyroid gland is functioning.
2. A small dose of radioactive iodine is given by mouth or intravenously; the
amount of radioactivity is measured in 2 to 4 hours and again at 24 hours.
3. Normal values are 3% to 10% at 2 to 4 hours, and 5% to 30% in 24 hours.
4. Elevated values indicate hyperthyroidism, decreased iodine intake, or
increased iodine excretion.
5. Decreased values indicate a low T4 level, the use of antithyroid
medications, thyroiditis, myxedema, or hypothyroidism.
6. The test is contraindicated in pregnancy.

C. T3 and T4 resin uptake test***

1. Blood tests are used to diagnose thyroid disorders.
2. T3 and T4 regulate thyroid-stimulating hormone.
3. Normal values (normal findings vary between laboratory settings)
a. Triiodothyronine, total T3: 70205 ng/dL (1.23.4 nmol/L)
b. Thyroxine, total T4: 512 mcg/dL (64154 nmol/L)
c. Thyroxine, free (FT4): 0.82.8 ng/dL (1036 pmol/L)
4. The T4 level is elevated in hyperthyroidism and decreased in
hypothyroidism.

D. Thyroid-stimulating hormone***
1. Blood test is used to differentiate the diagnosis of primary hypothyroidism.
2. Normal value is 210 mcU/L (210 mU/L).
3. Elevated values indicate primary hypothyroidism.
4. Decreased values indicate hyperthyroidism or secondary hypothyroidism.

E. Thyroid scan
1. A thyroid scan is performed to identify nodules or growths in the thyroid gland.
2. A radioisotope of iodine or technetium is administered before scanning the
thyroid gland.
3. Reassure the client that the level of radioactive medication is not dangerous to
self or others.***
4. Determine whether the client has received radiographic contrast agents within
the past 3 months, because these may invalidate the scan.
5. Check with the health care provider (HCP) regarding discontinuing
medications containing iodine for 14 days before the test and the need to
discontinue thyroid medication before the test.***
6. Instruct the client to maintain NPO (nothing by mouth) status after midnight
on the day before the test; if iodine is used, the client will fast for an additional 45
minutes after ingestion of the oral isotope and the scan will be performed in
24 hours.
7. If technetium is used, it is administered by the intravenous (IV) route 30
minutes before the scan.
8. The test is contraindicated in pregnancy.

F. Needle aspiration of thyroid tissue

1. Aspiration of thyroid tissue is done for cytological examination.
2. No client preparation is necessary; NPO status may or may not be prescribed.
3. Light pressure is applied to the aspiration site after the procedure.

G. Glycosylated hemoglobin
1. HgbA1C is blood glucose bound to hemoglobin.
2. Hemoglobin A1c (glycosylated hemoglobin A; HbA1c) is a reflection of how well
blood glucose levels have been controlled for the past 3 to 4 months.
3. Hyperglycemia in clients with diabetes is usually a cause of an increase in
HbA1c.
4. Fasting is not required before the test.
5. Normal reference intervals: 4.0%6.0% (4.0% 6.0%)
6. HgbA1C and estimated average glucose (eAG) reference intervals
!Poor glycemic control in a client with diabetes mellitus is usually the cause of an
increase in the HbA1c calue.

H. 24-hour urine collection for vanillylmandelic acid (VMA)

1. Diagnostic tests for pheochromocytoma include a 24-hour urine collection
for VMA, a product of catecholamine metabolism, metanephrine, and
catecholamines, all of which are elevated in the presence of
pheochromocytoma.
2. The normal range of urinary catecholamines:
a. Epinephrine: < 20 mcg/day (< 109 nmol/day)
b. Norepinephrine: 1580 mcg/day (89473 nmol/day)

III. Pituitary Gland Disorders

Anterior Pituitary
Hyperpituitarism
Hypopituitarism
Posterior Pituitary
These disorders can be caused by damage to the posterior pituitary or
hypothalamus:
Diabetes insipidus
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

A. Hypopituitarism
1. Description: Hyposecretion of 1 or more of the pituitary hormones caused by
tumors, trauma, encephalitis, autoimmunity, or stroke
2. Hormones most often affected are growth hormone (GH) and gonadotropic
hormones (luteinizing hormone, follicle-stimulating hormone), but thyroid-
stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), or antidiuretic
hormone (ADH) may be involved.
3. Assessment
a. Mild to moderate obesity (GH, TSH)
b. Reduced cardiac output (GH, ADH)
c. Infertility, sexual dysfunction (gonadotropins, ACTH)
d. Fatigue, low blood pressure (TSH, ADH, ACTH, GH)
e. Tumors of the pituitary also may cause headaches and visual defects (the
pituitary is located near the optic nerve).
4. Interventions***
a. Client may need hormone replacement for the specific deficient hormones.
b. Provide emotional support to the client and family.
c. Encourage the client and family to express feelings related to disturbed body
image orsexual dysfunction.
d. Client education is needed regarding the signs and symptoms of hypofunction
and hyperfunction related to insufficient or excess hormone replacement
B. Hyperpituitarism (acromegaly)
1. Description: Hypersecretion of growth hormone by the anterior pituitary gland
in an adult; caused primarily by pituitary tumors
Leads to conditions sunch as acromegaly and cushings disease
2. Assessment
a. Large hands and feet
b. Thickening and protrusion of the jaw
c. Arthritic changes and joint pain, impingement syndromes
d. Visual disturbances
e. Diaphoresis
f. Oily, rough skin
g. Organomegaly
h . Hypertension, atherosclerosis, cardiomegaly, heart failure
i. Dysphagia
j. Deepening of the voice
k. Thickening of the tongue, narrowing of the airway, sleep apnea
l. Hyperglycemia
m. Colon polyps, increased colon cancer risk
3. Interventions***
a. Provide pharmacological interventions to suppress GH or to block the action of
GH
b. Prepare the client for radiation of the pituitary gland or for stereotactic
radiosurgery if prescribed.
c. Prepare the client for hypophysectomy if planned.
d. Provide pharmacological and nonpharmacological interventions for joint pain.
e. Provide emotional support to the client and family, and encourage the client and
family to express feelings related to disturbed body image.
f. Provide frequent skin care.

C. Hypophysectomy (pituitary adenectomy, sublabial transsphenoidal

pituitary surgery)***
1. Description
a. Removal of a pituitary tumor via craniotomy or a sublabial transsphenoidal
(endoscopic transnasal) approach (the latter approach is preferred because it is
associated with fewer complications)
b. Complications for craniotomy include increased intracranial pressure,
bleeding, meningitis, and hypopituitarism.
c. Complications for the sublabial transsphenoidal surgery include
cerebrospinal fluid leak, infection, diabetes insipidus, and hypopituitarism.***
d. If the sublabial approach is used, an incision is made along the gum line of the
inner upper lip.
2. Postoperative interventions***
a. Initial postoperative care is similar to craniotomy care.
b. Monitor vital signs, neurological status, and level of consciousness.
c. Elevate the head of the bed.
d. Monitor for increased intracranial pressure.
e. Instruct the client to avoid sneezing, coughing, and blowing the nose.
f. Monitor for bleeding.
g. Monitor for and report signs of temporary diabtes insipidus; monitor intake and
output, and report excessive urinary output.
h. If the entire pituitary is removed, clients will require lifelong replacement of
ADH, cortisol, and thyroid hormone.
i. Monitor for and report signs of infection and meningitis.
j. Administer antibiotics, analgesics, and antipyretics as prescribed.
k. Administer oral mouth rinses as prescribed. Clients may be instructed to avoid
using a toothbrush or to brush teeth gently with an ultra soft toothbrush for 10
days to 2 weeks after surgery.
l. Instruct the client in the administration of prescribed medications.
m. As prescribed, Instruct the client to brush teeth gently with an ultrasoft
toothbrush for at least 2 weeks following surgery.
!Following transphenoidal hypophysectomy, monitor for and report postnasal drip
or clear nasal drainage, which might indicate a cerebrospinal fluid leak. Clear
drainage should be checked for glucose.

D. Diabetes Insipidus***
1. Description***
a. Hyposecretion of ADH caused by stroke or trauma or maybe idiopatic
b. Kidney tubules fail to reabsorb water.
c. In central diabetes insipidus there is decreased ADH production.
d. In nephrogenic diabetes insipidus, ADH production is adequate but the
kidneys do not respond appropriately to the ADH.
2. Assessment***
a. Excretion of large amounts of dilute urine
b. Polydipsia
c. Dehydration (decreased skin turgor and dry mucous membranes)
d. Inability to concentrate urine
e. Low urinary specific gravity; normal is 1.003 1.030 (1.005 1.030)
f. Fatigue
g. Muscle pain and weakness
h . Headache
i. Postural hypotension that may progress to vascular collapse without
rehydration
j. Tachycardia
3. Interventions***
a. Monitor vital signs and neurological and cardiovascular status.
b. Provide a safe environment, particularly for the client with postural hypotension.
c. Monitor electrolyte values and for signs of dehydration.
d. Maintain client intake of adequate fluids; IV hypotonic saline may be prescribed
to replace urinary losses.
e. Monitor intake and output, weight, serum osmolality, and specific gravity of urine
for excessive urinary output, weight loss, and low urinary specific gravity.
f. Instruct the client to avoid foods or liquids that produce diuresis
g. Vasopressin or desmopressin acetate may be prescribed; these are used
when the ADH deficiency is severe or chronic.
h . Instruct the client in the administration of medications as prescribed;
desmopressin acetate may be administered by subcutaneous injection,
intravenously, intranasally, or orally; ***watch for signs of water intoxication
indicating overtreatment.
i. Instruct the client to wear a MedicAlert bracelet.

E. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

1. Description
a. Condition of hyperfunctioning of the posterior pituitary gland in which excess
ADH is released, but not in response to the bodys need for it.
b. Causes include trauma, stroke, malignancies (often in the lungs or pancreas),
medications, and stress.
c. The syndrome results in increased intravascular volume, water intoxication, and
dilutional hyponatremia.***
d. May cause cerebral edema and the client is at risk for seizures.
2. Assessment***
a. Signs of fluid volume overload
b. Changes in level of consciousness and mental status changes
c. Weight gain without edema
d. Hypertension
e. Tachycardia
f. Anorexia, nausea, and vomiting
g. Hyponatremia
h . Low urinary output and concentrated urine
3. Interventions***
a. Monitor vital signs and cardiac and neurological status.
b. Provide a safe environment, particularly for the client with changes in level of
consciousness or mental status.
c. Monitor for signs of increased intracranial pressure.
d. Implement seizure precautions.
e. Elevate the head of the bed a maximum of 10 degrees to promote venous
return and decrease baroreceptor-induced ADH release.
f. Monitor intake and output and obtain weight daily.
g. Monitor fluid and electrolyte balance.
h. Monitor serum and urine osmolality.
i. Restrict fluid intake as prescribed.
j. Administer IV fluids (usually normal saline [NS] or hypertonic saline) as
prescribed; monitor IV fluids carefully because of the risk for fluid volume
overload.
k. Loop diuretics may be prescribed to promote diuresis but only if serum sodium
is at least 125 mEq/L(125 mmol/L); potassium replacement may be necessary if
loop diuretics are prescribed.
l. Vasopressin antagonists may be prescribed to decrease the renal response to
ADH.

IV. Adrenal Gland Disorders

A. Adrenal cortex insufficiency (Addisons disease)
1. Primary adrenal insufficiency***
a. Also known as Addisons disease, refers to hyposecretion of adrenal cortex
hormones (glucocorticoids, mineralocorticoids, and androgen); autoimmune
destruction is a common cause.
b. Requires lifelong replacement of glucocorticoids and possibly of mineralo-
corticoids if significant hyposecretion occurs; the condition is fatal if left
untreated.
2. Secondary adrenal insufficiency is caused by hyposecretion of ACTH from
the anterior pituitary gland; mineralocorticoid release is spared.
3. Loss of glucocorticoids in Addisons disease leads to decreased vascular
tone, decreased vascular response to the catecholamines epinephrine and
norepinephrine, and decreased gluconeogenesis.
4. In Addisons disease, loss of the mineralocorticoid aldosterone leads to
dehydration, hypotension, hyponatremia, and hyperkalemia.
5. Assessment
a. Lethargy, fatigue, and muscle weakness
b. Gastrointestinal disturbances
c. Weight loss
d. Menstrual changes in women; impotence in men
e. Hypoglycemia, Hyponatremia*
f. Hyperkalemia*, Hypercalcemia
g. Hypotension***
h. Hyperpigmentation of skin (bronzed) with primary disease***
6. Interventions
a. Monitor vital signs (particularly for hypotension), for weight loss, and intake
and output.
b. Monitor white blood cell (WBC) count; blood glucose; and potassium, sodium,
and calcium levels.
c. Administer glucocorticoids and/or mineralocorticoid medications as
prescribed.
d. Observe for addisonian crisis caused by stress, infection, trauma, or surgery.
7. Client education***
a. Need for lifelong glucocorticoid replacement and possibly lifelong
mineralocorticoid replacement.
b. Corticosteroid replacement will need to be increased during times of stress.
c. Avoid individuals with an infection.
d. Avoid strenuous exercise and stressful situations.
e. Avoid over-the-counter medications.
f. Diet should be high in protein and carbohydrates; clients taking
glucocorticoids should be prescribed calcium and vitamin D supplements
to protect against corticosteroid-induced osteoporosis; some clients taking
mineralocorticoids may be prescribed a diet high in sodium.
g. Wear a MedicAlert bracelet.
h. Report signs and symptoms of complications, such as underreplacement
and overreplacement of corticosteroid hormones.

B. Addisonian crisis
1. Description
a. A life-threatening disorder caused by acute adrenal insufficiency.
b. Precipitated by stress, infection, trauma, surgery, or abrupt withdrawal of
exogenous corticosteroid use
c. Can cause hyponatremia, hyperkalemia, hypoglycemia, and shock***
2. Assessment
a. Severe headache
b. Severe abdominal, leg, and lower back pain
c. Generalized weakness
d. Irritability and confusion
e. Severe hypotension
f. Shock
3. Interventions
a. Prepare to administer glucocorticoids intravenously as prescribed.
b. Administer IV fluids as prescribed to replace fluids and restore electrolyte
balance.
c. Following resolution of the crisis, administer glucocorticoid and
mineralocorticoid orally as prescribed.
d. Monitor vital signs, particularly blood pressure.
e. Monitor neurological status, noting irritability and confusion.
f. Monitor intake and output.
g. Monitor laboratory values, particularly sodium, potassium, and blood
glucose levels.
h. Protect the client from infection.
i. Maintain bed rest and provide a quiet environment.
! Clients taking exogenous corticosteroids must establish a plan with their
HCPs for increasing their corticosteroids during times of stress.
C. Cushings syndrome and Cushings disease (hypercortisolism)***
1. Cushings syndrome
a. A metabolic disorder resulting from the chronic and excessive production of
cortisol by the adrenal cortex or from the administration of glucocorticoids in
large doses for several weeks or longer (exogenous or iatrogenic).
b. ACTH secreting tumors (most often of the lung, pancreas, or gastrointestinal
[GI] tract) can cause Cushings syndrome.
2. Cushings disease is a metabolic disorder characterized by abnormally
increased secretion (endogenous) of cortisol, caused by increased amounts of
ACTH secreted by the pituitary gland.
3. Assessment***
a. Generalized muscle wasting and weakness
b. Moon face, buffalo hump
c. Truncal obesity with thin extremities, supraclavicular fat pads; weight gain
d. Hirsutism (masculine characteristics in females)
e. Hyperglycemia, hypernatremia***
f. Hypokalemia, hypocalcemia***
g. Hypertension***
h. Fragile skin that bruises easily, Reddish purple striae on the abdomen and
upper thighs.
4. Interventions***
a. Monitor vital signs, particularly blood pressure.
b. Monitor intake and output and weight.
c. Monitor laboratory values, particularly WBC count and serum glucose, sodium,
potassium, and calcium levels.
d. Prepare the client for radiation as prescribed if the condition results from a
pituitary adenoma.
e. Administer chemotherapeutic agents as prescribed for inoperable adrenal
tumors.
f. Prepare the client for removal of pituitary tumor (hypophysectomy, sublabial
transsphenoidal adenectomy) if the condition results from increased pituitary
secretion of ACTH.
g. Prepare the client for adrenalectomy if the condition results from an adrenal
adenoma; glucocorticoid replacement may be required following
adrenalectomy.
h . Clients requiring lifelong glucocorticoid replacement following
adrenalectomy should obtain instructions from their HCPs about increasing
their glucocorticoid during times of stress.
i. Assess for and protect against postoperative thrombus formation; Cushings
syndrome predisposes to thromboemboli.
j. Allow the client to discuss feelings related to body appearance.
k. Instruct the client about the need to wear a MedicAlert bracelet.
 !Addisons disease is characterized by the hyposecretion of adrenal cortex
hormones, whereas Cushings syndrome and Cushings disease are
characterized by a hypersecretion of glucocorticoids.

D. Primary hyperaldosteronism (Conns syndrome)

1. Description
a. Hypersecretion of mineralocorticoids (aldosterone) from the adrenal cortex
of the adrenal gland
b. Most commonly caused by an adenoma
c. Excess secretion of aldosterone causes sodium and water retention and
potassium excretion, leading to hypertension and hypokalemic alkalosis.
2. Assessment
a. Symptoms related to hypokalemia, hypernatremia, and hypertension
b. Headache, fatigue, muscle weakness
c. Cardiac dysrhythmias
d. Paresthesias, tetany
e. Visual changes
f. Glucose intolerance
g. Elevated serum aldosterone levels
3. Interventions
a. Monitor vital signs, particularly blood pressure.
b. Monitor for signs of hypokalemia and hypernatremia.
c. Monitor intake and output and urine for specific gravity.
d. Monitor for hyperkalemia, particularly for clients with impaired renal function or
excessive potassium intake because potassium retaining diuretics and
aldosterone antagonists Spironolactone (Aldactone) may be prescribed to
promote fluid balance and control hypertension.
e. Administer potassium supplements as prescribed to treat hypokalemia; clients
taking potassium-retaining diuretics and potassium supplementation are at risk
for hyperkalemia.
f. Prepare the client for adrenalectomy.
g. Maintain sodium restriction, if prescribed, preoperatively.
h. Administer glucocorticoids preoperatively, as prescribed, to prevent adrenal
hypofunction and prepare for stress of surgery.
i. Monitor the client for adrenal insufficiency postoperatively.
j. Instruct the client regarding the need for glucocorticoid therapy following
adrenalectomy.
k. Instruct the client about the need to wear a MedicAlert bracelet.

E. Pheochromocytoma***
1. Description
a. Catecholamine-producing tumor usually found in the adrenal medulla, but
extraadrenal locations include the chest, bladder, abdomen, and brain; typically
is a benign tumor but can be malignant
b. Excessive amounts of epinephrine and norepinephrine are secreted.
c. Diagnostic test includes a 24-hour urine collection for VMA.
d. Surgical removal of the adrenal gland is the primary treatment.
e. Symptomatic treatment is initiated if surgical removal is not possible.
f. The complications associated with pheochromocytoma include hypertensive
crisis; hypertensive retinopathy and nephropathy, cardiac enlargement, and
dysrhythmias; heart failure; myocardial infarction; increased platelet aggregation;
and stroke.
g. Death can occur from shock, stroke, renal failure, dysrhythmias, or dissecting
aortic aneurysm.
2. Assessment***
a. Paroxysmal or sustained hypertension
b. Severe headaches
c. Palpitations
d. Flushing and profuse diaphoresis
e. Pain in the chest or abdomen with nausea and vomiting
f. Heat intolerance
g. Weight loss
h . Tremors
i. Hyperglycemia
3. Interventions***
a. Monitor vital signs, particularly blood pressure and heart rate.
b. Monitor for hypertensive crisis; monitor for complications that can occur with
hypertensive crisis, such as stroke, cardiac dysrhythmias, and myocardial
infarction.
c. Instruct the client not to smoke, drink caffeine-containing beverages, or
change position suddenly.
d. Prepare to administer -adrenergic blocking agents and -adrenergic blocking
agents as prescribed to control hypertension. - Adrenergic blocking agents
are started 7 to 10 days before -adrenergic blocking agents.
e. Monitor serum glucose level.
f. Promote rest and a nonstressful environment.
g. Provide a diet high in calories, vitamins, and minerals.
h . Prepare the client for adrenalectomy.***
!For the client with pheochromocytoma, avoid stimuli that can precipitate a
hypertensive crisis, such as increased abdominal pressure and vigorous
abdominal palpation.

F. Adrenalectomy***
1. Description
a. Surgical removal of an adrenal gland.
b. Lifelong glucocorticoid and mineralocorticoid replacement is necessary
with bilateral adrenalectomy.
c. Temporary glucocorticoid replacement, *usually up to 2 years, is necessary
after a unilateral adrenalectomy.
d. Catecholamine levels drop as a result of surgery, which can result in
cardiovascular collapse, hypotension, and shock, and the client needs to be
monitored closely.
e. Hemorrhage also can occur because of the high vascularity of the adrenal
glands.
2. Preoperative interventions
a. Monitor electrolyte levels and correct electrolyte imbalances.
b. Assess for dysrhythmias.
c. Monitor for hyperglycemia.
d. Protect the client from infections.
e. Administer glucocorticoids as prescribed.
3. Postoperative interventions
a. Monitor vital signs.
b. Monitor intake and output; *if the urinary output is lower than 30 mL/hour,
notify the HCP, because this may result in acute kidney injury and indicate
impending shock.***
c. Monitor weight daily.
d. Monitor electrolyte and serum glucose levels.
e. Monitor for signs of hemorrhage and shock, particularly during the first 24 to 48
hours.
f. Monitor for manifestations of adrenal insufficiency.
g. Assess the dressing for drainage.
h . Monitor for paralytic ileus.
i. Administer IV fluids as prescribed to maintain blood volume.
j. Administer glucocorticoids and mineralocorticoids as prescribed.
k. Administer pain medication as prescribed.
l. Provide pulmonary interventions to prevent atelectasis (coughing and deep
breathing, incentive spirometry, splinting of incision).
m. Instruct the client in the importance of hormone replacement therapy following
surgery.
n . Instruct the client regarding signs and symptoms of complications such as
underreplacement and overreplacement of hormones.
o. Instruct the client regarding the need to wear a MedicAlert bracelet.

V. Thyroid Gland Disorders

A. Hypothyroidism***
1. Description***
a. Hypothyroid state resulting from hyposecretion of thyroid hormones (T3 and
T4) and characterized by a decreased rate of body metabolism
b. The T4 is low and the TSH is elevated.
c. In primary hypothyroidism, the source of dysfunction is the thyroid gland and
the thyroid cannot produce the necessary amount of hormones. In secondary
 hypothyroidism, the thyroid is not being stimulated by the pituitary to produce
hormones.
2. Assessment***
a. Lethargy and fatigue
b. Weakness, muscle aches, paresthesias
c. Intolerance to cold
d. Weight gain
e. Dry skin and hair and loss of body hair
f. Bradycardia
g. Constipation
h. Generalized puffiness and edema around the eyes and face (myxedema)
i. Forgetfulness and loss of memory
j. Menstrual disturbances
k. Goiter may or may not be present
l. Cardiac enlargement, tendency to develop heart failure
3. Interventions***
a. Monitor vital signs, including heart rate and rhythm.
b. Administer thyroid replacement; levothyroxine sodium (Synthroid) is most
commonly prescribed.***
c. Instruct the client about thyroid replacement therapy and about the clinical
manifestations of both hypothyroidism and hyperthyroidism related to
underreplacement or overreplacement of the hormone.
d. Instruct the client in a low calorie, low cholesterol, low saturated fat
diet; discuss a daily exercise program such as walking.
e. Assess the client for constipation; provide roughage and fluids to prevent
constipation.
f. Provide a warm environment for the client.
g. Avoid sedatives and opioid analgesics because of increased sensitivity to
these medications; may precipitate myxedema coma.
h . Monitor for overdose of thyroid medications, characterized by tachycardia,
chest pain, restlessness, nervousness, and insomnia.
i. Instruct the client to report episodes of chest pain or other signs of overdose
immediately.

B. Myxedema coma***
1. Description
a. This rare but serious disorder results from persistently low thyroid production.
b. Coma can be precipitated by acute illness, rapid withdrawal of thyroid
medication, anesthesia and surgery, hypothermia, or the use of sedatives and
opioid analgesics.
2. Assessment
a. Hypotension
b. Bradyardia
c. Hypothermia
d. Hyponatremia
e. Hypoglycemia
f. Genrealized edema
g. Respiratory failure
h. Coma
3. Interventions
a. Maintain a patent airway.
b. Institute aspiration precautions.
c. Administer IV fluids (normal or hypertonic saline) as prescribed.
d. Administer levothyroxine sodium intravenously as prescribed.***
e. Administer glucose intravenously as prescribed.
f. Administer corticosteroids as prescribed.
g. Assess the clients temperature hourly.
h. Monitor blood pressure frequently.
i. Keep the client warm.
j. Monitor for changes in mental status.
k. Monitor electrolyte and glucose levels.

C. Hyperthyroidism
1. Description***
a. Hyperthyroid state resulting from hypersecretion of thyroid hormones
(T3 and T4).
b. Characterized by an increased rate of body metabolism.
c. A common cause is Graves disease, also known as toxic diffuse goiter.
d. Clinical manifestations are referred to as thyrotoxicosis.
e. The T3 and T4 are usually elevated and the TSH level is low.
2. Assessment***
a. Personality changes such as irritability, agitation, and mood swings.
b. Nervousness and fine tremors of the hands.
c. Heat intolerance.
d. Weight loss.
e. Smooth, soft skin and hair.
f. Palpitations, cardiac dysrhythmias, such as tachycardia or atrial fibrillation
g. Diarrhea
h. Protruding eyeballs (exophthalmos) may be present
i. Diaphoresis
j. Hypertension
k. Enlarged thyroid gland (goiter)
3. Interventions***
a. Provide adequate rest.
b. Administer sedatives as prescribed.
c. Provide a cool and quiet environment.
d. Obtain weight daily.
e. Provide a high-calorie diet.
f. Avoid the administration of stimulants.
g. Administer antithyroid medications, such as methimazole or
propylthiouracil(PTU) that block thyroid synthesis as prescribed.***
h . Administer iodine preparations that inhibit the release of thyroid hormone as
prescribed.
i. Administer propranolol(Inderal) for tachycardia as prescribed.
j. Prepare the client for radioactive iodine therapy, as prescribed, to destroy
thyroid cells.
k. Prepare the client for subtotal thyroidectomy if prescribed.
l. Elevate the head of the bed of a client experiencing exophthalmos; in
addition, instruct on low-salt diet, administer artificial tears, encourage the use
of dark glasses, and tape eyelids closed at night if necessary.***
m. Allow the client to express concerns about body image changes.

D. Thyroid storm
1. Description***
a. This acute and life-threatening condition occurs in a client with uncontrollable
hyperthyroidism.
b. It can be caused by manipulation of the thyroid gland during surgery and the
release of thyroid hormone into the bloodstream; it also can occur from severe
infection and stress.
c. Antithyroid medications, beta blockers, glucocorticoids, and iodides may be
administered to the client before thyroid surgery to prevent its occurrence.
2. Assessment
a. Elevated temperature (fever)
b. Tachycardia
c. Systolic hypertension
d. Nausea, vomiting, and diarrhea
e. Agitation, tremors, anxiety
f. Irritability, agitation, restlessness, confusion, and seizures as the condition
progresses
g. Delirium and coma
3. Interventions***
a. Maintain a patent airway and adequate ventilation.
b. Administer antithyroid medications, iodides, propranolol, and
glucocorticoids as prescribed.
c. Monitor vital signs.
d. Monitor continually for cardiac dysrhythmias.
e. Administer nonsalicylate antipyretics as prescribed (salicylates increase free
thyroid hormone levels).
f. Use a cooling blanket to decrease temperature as prescribed.
E. Thyroidectomy
1. Description
a. Removal of the thyroid gland
b. Performed when persistent hyperthyroidism exists
c. Subtotal thyroidectomy, removal of a portion of the thyroid gland, is the
preferred surgical intervention.
2. Preoperative interventions
a. Obtain vital signs and weight.
b. Assess electrolyte levels.
c. Assess for hyperglycemia.
d. Instruct the client in how to perform coughing and deep-breathing exercises and
how to support the neck in the postoperative period when coughing and
moving.***
e. Administer antithyroid medications, iodides, propranolol, and
glucocorticoids as prescribed to prevent the occurrence of thyroid storm.
3. Postoperative interventions***
a. Monitor for respiratory distress.
b. Have a tracheotomy set, oxygen, and suction at the bedside.
c. Limit client talking, and assess level of hoarseness.
d. Avoid neck flexion and stress on the suture line.
e. Monitor for laryngeal nerve damage, as evidenced by airway obstruction,
dysphonia, high-pitched voice, stridor, dysphagia, and restlessness.
f. Monitor for signs of hypocalcemia and tetany, which can be caused by trauma
to the parathyroid gland.
SIGNS OF TETANY
Cardiac dysrhythmias
Carpopedal spasm
Dysphagia
Muscle and abdominal cramps
Numbness and tingling of the face and extremities
Positive Chvosteks sign
Positive Trousseaus sign
Visual disturbances (photophobia)
Wheezing and dyspnea (bronchospasm, laryngospasm)
Seizures
g. Prepare to administer calcium gluconate as prescribed for tetany.
h. Monitor for thyroid storm.
!Following thyroidectomy, maintain the client in a semi-Fowlers position.
Monitor the surgical site for edema and for signs of bleeding and check the
dressing anteriorly and at the back of the neck.
VI. Parathyroid Gland Disorders
A. Hypoparathyroidism
1. Description
a. Condition caused by hyposecretion of parathyroid hormone by the
parathyroid gland
b. Can occur following thyroidectomy because of removal of parathyroid tissue
2. Assessment***
a. Hypocalcemia and hyperphosphatemia***
b. Numbness and tingling in the face***
c. Muscle cramps and cramps in the abdomen or in the extremities***
d. Positive Trousseaus sign or Chvosteks sign***
e. Signs of overt tetany, such as bronchospasm, laryngospasm, carpopedal
spasm, dysphagia, photophobia, cardiac dysrhythmias, seizures
f. Hypotension***
g. Anxiety, irritability, depression
3. Interventions***
a. Monitor vital signs.
b. Monitor for signs of hypocalcemia and tetany.
c. Initiate seizure precautions.
d. Place a tracheotomy set, oxygen, and suctioning equipment at the
bedside.***
e. Prepare to administer calcium gluconate intravenously for hypocalcemia.
f. Provide a high-calcium, low-phosphorus diet.***
g. Instruct the client in the administration of calcium supplements as
prescribed.
h . Instruct the client in the administration of vitamin D supplements as
prescribed; vitamin D enhances the absorption of calcium from the GI tract.***
i. Instruct the client in the use of thiazide diuretics if prescribed, to protect the
kidney if vitamin D is also taken.
j. Instruct the client in the administration of phosphate binders as prescribed to
promote the excretion of phosphate through the GI tract.
k. Instruct the client to wear a MedicAlert bracelet.

B. Hyperparathyroidism
1. Description: Condition caused by hypersecretion of parathyroid hormone
(PTH) by the parathyroid gland
2. Assessment***
a. Hypercalcemia and hypophosphatemia.***
b. Fatigue and muscle weakness.
c. Skeletal pain and tenderness.
d. Bone deformities that result in pathological fractures.
e. Anorexia, nausea, vomiting, epigastric pain.
f. Weight loss.
g. Constipation.
h. Hypertension.***
i. Cardiac dysrhythmias.
j. Renal stones.
3. Interventions***
a. Monitor vital signs, particularly blood pressure.
b. Monitor for cardiac dysrhythmias.
c. Monitor intake and output and for signs of renal stones.
d. Monitor for skeletal pain; move the client slowly and carefully.
e. Encourage fluid intake.
f. Administer furosemide as prescribed to lower calcium levels.***
g. Administer NS intravenously as prescribed to maintain hydration.
h . Administer phosphates, which interfere with calcium reabsorption, as
prescribed.
i. Administer calcitonin(Fortical; Miacalcin) as prescribed to decrease skeletal
calcium release and increase renal excretion of calcium.***
j. Administer IV or oral bisphosphonates to inhibit bone resorption.
k. Monitor calcium and phosphorus levels.
l. Prepare the client for parathyroidectomy as prescribed.
m. Encourage a high-fiber, moderate-calcium diet.***
n . Emphasize the importance of an exercise program and avoiding prolonged
inactivity.***

C. Parathyroidectomy
1. Description: Removal of 1 or more of the parathyroid glands.
a. Endoscopic radio guided parathyroidectomy with autotransplantation is
the most common procedure.
b. Parathyroid tissue is transplanted in the forearm or near the
sternocleidomastoid muscle, allowing PTH secretion to continue.
2. Preoperative interventions
a. Monitor electrolytes, calcium, phosphate, and magnesium levels.
b. Ensure that calcium levels are decreased to near-normal values.
c. Inform the client that talking may be painful for the first day or two after surgery.
3. Postoperative interventions***
a. Monitor for respiratory distress.
b. Place a tracheotomy set, oxygen, and suctioning equipment at the bedside.
c. Monitor vital signs.
d. Position the client in semi-Fowlers position.
e. Assess neck dressing for bleeding.
f. Monitor for hypocalcemic crisis, as evidenced by tingling and twitching in the
extremities and face.
g. Assess for positive Trousseaus sign or Chvosteks sign, which indicates
tetany.
h . Monitor for changes in voice pattern and hoarseness.
i. Monitor for laryngeal nerve damage.
j. Instruct the client in the administration of calcium and vitamin D
supplements as prescribed.

VII. Disorders of the Pancreas

A. Diabetes mellitus
1. Description***
a. Chronic disorder of impaired carbohydrate, protein, and lipid metabolism
caused by a deficiency of insulin
b. An absolute or relative deficiency of insulin results in hyperglycemia.
c. Type 1 diabetes mellitus is a nearly absolute deficiency of insulin (primary
beta cell destruction); if insulin is not given, fats are metabolized for energy,
resulting in ketonemia (acidosis).
d. Type 2 diabetes mellitus is a relative lack of insulin or resistance to the action
of insulin; usually, insulin is sufficient to stabilize fat and protein metabolism but
not carbohydrate metabolism.
e. Metabolic syndrome is also known as syndrome X and the individual has
coexisting risk factors for developing type 2 diabetes mellitus; these risk factors
include abdominal obesity, hyperglycemia, hypertension, high triglyceride level,
and a lowered HDL (highdensity lipoprotein) cholesterol level.
f. Diabetes mellitus can lead to chronic health problems and early death as a
result of complications that occur in the large and small blood vessels in tissues
and organs.
g. Macrovascular complications include coronary artery disease,
cardiomyopathy, hypertension, cerebrovascular disease, and peripheral
vascular disease.
h. Microvascular complications include retinopathy, nephropathy, and
neuropathy.
i. Infection is also a concern because of reduced healing ability.
j. Male erectile dysfunction can also occur as a result of the disease.
!Obesity is a major risk factor for diabetes mellitus
2. Assessment***
a. Polyuria, polydipsia, polyphagia (more common in type 1 diabetes mellitus)
b. Hyperglycemia
c. Weight loss (common in type 1 diabetes mellitus, rare in type 2 diabetes
mellitus)
d. Blurred vision
e. Slow wound healing
f. Vaginal infections
g. Weakness and paresthesias
h. Signs of inadequate circulation to the feet
i. Signs of accelerated atherosclerosis (renal, cerebral, cardiac, peripheral)
3. Diet***
a. The diabetic clients diet should take into account weight, medication, activity
level, and other health problems.
b. Day-to-day consistency in timing and amount of food intake helps to control the
blood glucose level.
c. As prescribed by the HCP, the client may be advised to follow the
recommendations of the American Diabetic Association diet or U.S dietary
guidelines.
d. Carbohydrate counting may be a simpler approach for some clients; it focuses
on the total grams of carbohydrates eaten per meal. The client may be more
compliant with carbohydrate counting, resulting in better glycemic control; it is
usually necessary for clients undergoing intense insulin therapy.
e. Incorporate the diet into individual client needs, lifestyle, and cultural and
socioeconomic patterns.
4. Exercise
a. Exercise lowers the blood glucose level, encourages weight loss, reduces
cardiovascular risks, improves circulation and muscle tone, decreases total
cholesterol and triglyceride levels, and decreases insulin resistance and
glucose intolerance.
b. Instruct the client in dietary adjustments when exercising; dietary adjustments
are individualized.
c. If the client requires extra food during exercise to prevent hypoglycemia, it need
not be deducted from the regular meal plan.
d. If the blood glucose level is higher than 250 mg/dL (14.2 mmol/L) and urinary
ketones (type 1 diabetes mellitus) are present, the client is instructed not to
exercise until the blood glucose level is closer to normal and urinary ketones
are absent.
e. The client should try to exercise at the same time each day and should exercise
when glucose from the meal is peaking, not when insulin or glucose-lowering
medications are peaking.
f. Insulin should not be injected into an area of the body that will be exercised
following injection, as exercise speeds absorption.
!Instruct the client with diabetes mellitus to monitor the blood glucose level
before, during, and after exercising.
5. Oral hypoglycemic medications: Oral medications are prescribed for clients
with diabetes mellitus type 2 when diet and weight control therapy have failed
to maintain satisfactory blood glucose levels.***
!To prevent a serious reaction, inform the client taking sulfonylurea to avoid
consuming alcohol.
6. Insulin***
a. Insulin is used to treat type 1 diabetes mellitus and may be used to treat type
2 diabetes mellitus when diet, weight control therapy, and oral hypoglycemic
agents have failed to maintain satisfactory blood glucose levels.
b. Illness, infection, and stress increase the blood glucose level and the need for
insulin; insulin should not be withheld during times of illness, infection, or stress
because hyperglycemia and diabetic ketoacidosis can result.
c. The peak action time of insulin is important to explain to the client because of
the possibility of hypoglycemic reactions occurring during this time.***
! Regular insulin (U-100 strength) can be administered via IV injection (IV push).
Regular insulin (U-100) and the short-duration insulins (lispro, aspart, and
glulisine) can be administered via IV infusion.

B. Complications of insulin therapy

1. Local allergic reactions***
a. Redness, swelling, tenderness, and induration or a wheal at the site of injection
may occur 1 to 2 hours after administration.
b. Reactions usually occur during the early stages of insulin therapy.
c. Instruct the client to cleanse the skin with alcohol before injection.
2. Insulin lipodystrophy
a. The development of fibrous fatty masses at the injection site caused by
repeated use of an injection site; use of human insulin helps to prevent this.
b. Instruct the client to avoid injecting insulin into affected sites.
c. Instruct the client about the importance of rotating insulin injection sites.
Systematic rotation within 1 anatomical area is recommended to prevent
lipodystrophy; the client should be instructed not to use the same site
more than once in a 2 to 3 week period. Injections should be 1. inches (3.8
cm) apart within the anatomical area.
3. Dawn phenomenon
a. Dawn phenomenon is characterized by hyperglycemia upon morning
awakening
that results from excessive early morning release of GH and cortisol.
b. Treatment requires an increase in the clients insulin dose or a change in
the time of insulin administration.***
4. Somogyi phenomenon
a. Normal or elevated blood glucose levels are present at bedtime; hypoglycemia
occurs at about 2 to 3 a.m., which causes an increase in the production of
counterregulatory hormones.
b. By about 7 a.m., in response to the counterregulatory hormones, the blood
glucose rebounds significantly to the hyperglycemic range.
c. Treatment includes a decrease in the clients insulin dose and increase in the
bedtime snack, or both.***
d. Clients experiencing the Somogyi phomeneon may complain of early morning
headaches, night sweats, or nightmares caused by the early morning
hypoglycemia.

C. Insulin administration***
1. Subcutaneous injections and mixing insulin.
2. Insulin pumps
a. Continuous subcutaneous insulin infusion is administered by an externally
worn device that contains a syringe attached to a long, thin, narrow-lumen tube
with a needle or Teflon catheter attached to the end.
b. The client inserts the needle or Teflon catheter into the subcutaneous tissue
(usually on the abdomen or upper arm) and secures it with tape or a transparent
dressing; the pump is worn on a belt or in a pocket; the needle or Teflon
catheter is changed at least every 2 to 3 days.
c. A continuous basal rate of insulin infuses; in addition, on the basis of the blood
glucose level, the anticipated food intake, and the activity level, the client
delivers a bolus of insulin before each meal.
d. Both rapid-acting and regular short-acting insulin (buffered to prevent the
precipitation of insulin crystals within the catheter) are appropriate for use
in these pumps.
3. Insulin pump and skin sensor
a. A skin sensor device can be used that monitors the clients blood glucose
continuously; the information is transmitted to the pump, determines the need
for insulin, and then the insulin is injected.
b. The pump holds up to a 3-day supply of insulin and can be disconnected easily
for activities such as bathing.
4. Pancreas transplants
a. The goal of pancreatic transplantation is to halt or reverse the complications
of diabetes mellitus.
b. Transplantations are performed on a limited number of clients (in general,
these are clients who are undergoing kidney transplantation
simultaneously).
c. Immunosuppressive therapy is prescribed to prevent and treat rejection.

D. Self-monitoring of blood glucose level***

1. Self-monitoring provides the client with the current blood glucose level and
information to maintain good glycemic control.
2. Monitoring requires a finger prick to obtain a drop of blood for testing.
3. Alternative site testing (obtaining blood from the forearm, upper arm,
abdomen, thigh, or calf) is available, using specific measurement devices.
4. Tests must be used with caution in clients with diabetic neuropathy.
5. Client instructions: Self-Monitoring of Blood Glucose Level
*Use the proper procedure to obtain the sample for determining the blood
glucose level.
*Perform the procedure precisely to obtain accurate results.
*Follow the manufacturers instructions for the glucometer.
*Wash hands before and after performing the procedure to prevent
infection.
*If needed, calibrate the monitor as instructed by the manufacturer.
*Check the expiration date on the test strips.
 *If the blood glucose level results do not seem reasonable, reread the
instructions, reassess technique, check the expiration date of the test strips,
and perform the procedure again to verify results.

E. Urine testing
1. Urine testing for glucose is not a reliable indicator of the blood glucose level
and is not used for monitoring purposes.***
2. Instruct the client in the procedure for testing for urine ketones.
3. The presence of ketonesmay indicate impending ketoacidosis.
4. Urine ketone testing should be performed during illness and whenever the
client with type 1 diabetes mellitus has persistently elevated blood glucose
levels (higher than 240 mg/dL [13.7 mmol/L] or as prescribed for 2 consecutive
testing periods).

VIII. Acute Complications of Diabetes Mellitus

A. Hypoglycemia***
1. Description

Pg.658

c Disturbance in Elimination

B. TEST IV
1. Alterations in Human Functioning
a. Disturbances in Fluids and Electrolytes
b. Inflammatory and Infectious Disturbances
c. Disturbances in Immunologic functioning
d. Disturbances in Cellular functioning
2. Client Biologic Crisis
3. Emergency and Disaster Nursing

C. TEST V
1. Disturbances in Perception and Coordination
a. Neurologic Disorders
b. Sensory Disorders
c. Musculo-skeletal Disorders
d. Degenerative Disorders
2. Maladaptive Patterns of Behavior
a. Anxiety Response and Anxiety Related Disorders
b. Psycho-physiologic Responses, Somatoform, and Sleep Disorders
c. Abuse and Violence
d. Emotional Responses and Mood Disorders
e. Schizophrenia and Other Psychotic and Mood Disorders
f. Social Responses and Personality Disorders
g. Substance related Disorders
h. Eating Disorders
i. Sexual Disorders
j. Emotional Disorders of Infants, Children and Adolescents.

II. Personal and Professional Development

A. Nurse-Client Relationship
B. Continuing Education

III. Communication, Collaboration and Teamwork

A. Team approach
B. Referral
C. Network/linkage
D. Therapeutic communication

IV. Ethico-Moral-Legal Responsibility

A. confidentiality
B. Clients Rights
1. Informed Consent
2. Refusal to take medications, Treatment and Admission Procedures
C. Nursing Accountability
D. Documentation/charting
E. Culture Sensitivity