Newborn Screening Program in the Philippines

The following tests are mandated in the R.A. 9288 or Newborn Screening program
of 2004.Newborn screening is available in practicing health institutions (hospitals,
lying-ins, Rural Health Units and Health Centers) with cooperation with DOH. If
babies are delivered at home, babies may be brought to the nearest institution
offering newborn screening. However, now there is also a simple method by which
the Newborn Screening can be made possible even at home. The urine sample of
newborn can be absorbed on filter paper and sent to laboratories which may run the
test. The reports are simple enough to be understood by the parents. A negative
screen mean that the result of the test is normal and the baby is not suffering from
any of the disorders being screened. In case of a positive screen, the NBS nurse
coordinator will immediately inform the coordinator of the institution where the
sample was collected for recall of patients for confirmatory testing. Babies with
positive results should be referred at once to the nearest hospital or specialist for
confirmatory test and further management. Should there be no specialist in the
area; the NBS secretariat office will assist its attending physician.

Disorders Screened:

• CH (Congenital hypothyroidism) - is a condition of thyroid hormone

deficiency present at birth. Approximately 1 in 4000 newborn infants has a
severe deficiency of thyroid function, while even more have mild or partial
degrees. If untreated for several months after birth, severe congenital
hypothyroidism can lead to growth failure and permanent mental retardation.
Treatment consists of a daily dose of thyroid hormone (thyroxine) by mouth.
Because the treatment is simple, effective, and inexpensive, nearly all of the
developed world practices newborn screening to detect and treat congenital
hypothyroidism in the first weeks of life.
• CAH (Congenital adrenal hyperplasia) - refers to any of several autosomal
recessive diseases resulting from mutations of genes for enzymes mediating
the biochemical steps of production of cortisol from cholesterol by the
adrenal glands (steroidogenesis). Most of these conditions involve excessive
or deficient production of sex steroids and can alter development of primary
or secondary sex characteristics in some affected infants, children, or adults.
Approximately 95% of cases of CAH are due to 21-hydroxylase deficiency.
• GAL (Galactosemia) - is a rare genetic metabolic disorder which affects an
individual's ability to properly metabolize the sugar galactose. Lactose in food
(such as dairy products) is broken down by the body into glucose and
galactose. In individuals with galactosemia, the enzymes needed for further
metabolism of galactose are severely diminished or missing entirely, leading
to toxic levels of galactose to build up in the blood, resulting in hepatomegaly
(an enlarged liver), cirrhosis, renal failure, cataracts, and brain damage.
Without treatment, mortality in infants with galactosemia is about 75%.
• PKU (Phenylketonuria) - is an autosomal recessive genetic disorder
characterized by a deficiency in the enzyme phenylalanine hydroxylase
(PAH). This enzyme is necessary to metabolize the amino acid phenylalanine
to the amino acid tyrosine. When PAH is deficient, phenylalanine accumulates
and is converted into phenylpyruvate (also known as phenylketone), which is
detected in the urine. PAH is found on chromosome number 12.Left
untreated, this condition can cause problems with brain development,
leading to progressive mental retardation and seizures. However, PKU is one
of the few genetic diseases that can be controlled by diet. A diet low in
phenylalanine and high in tyrosine can be a very effective treatment. There is
no cure. Damage done is irreversible so early detection is crucial.
• G6PD Deficiency - is an X-linked recessive hereditary disease characterized
by abnormally low levels of the glucose-6-phosphate dehydrogenase enzyme
(abbreviated G6PD or G6PDH). It is a metabolic enzyme involved in the
pentose phosphate pathway, especially important in red blood cell
metabolism.

Newborn screening results are available within three weeks after the NBS Lab
receives and tests the samples sent by the institutions. However the time period is
too long a wait to know a disorder since the damage may already have started.
There are few laboratories which give results within 24 to 48 hours from receipt of
samples. Results are released by NBS Lab to the institutions and are released to
your attending birth attendants or physicians. Parents may seek the results from
the institutions where samples are collected.

Source: http://en.wikipedia.org/wiki/Newborn_screening

Leopold's Maneuver

In obstetrics, Leopold's Maneuvers are a common and systematic way to determine the
position of a fetus inside the woman's uterus; they are named after the gynecologist Christian
Gerhard Leopold. They are also used to estimate term fetal weight.[1]The maneuvers consist of
four distinct actions, each helping to determine the position of the fetus. The maneuvers are
important because they help determine the position and presentation of the fetus, which in
conjunction with correct assessment of the shape of the maternal pelvis can indicate whether the
delivery is going to be complicated, or whether a Cesarean section is necessary. The woman
should lie on her back with her shoulders raised slightly on a pillow and her knees drawn up a
little. Her abdomen should be uncovered, and most women appreciate it if the individual
performing the maneuver warms their hands prior to palpation.

First maneuver: Fundal Grip

While facing the woman, palpate the woman's upper abdomen with both hands. A professional
can often determine the size, consistency, shape, and mobility of the form that is felt. The fetal
head is hard, firm, round, and moves independently of the trunk while the buttocks feel softer,
are symmetric, and the shoulders and limbs have small bony processes; unlike the head, they
move with the trunk.

Second maneuver

After the upper abdomen has been palpated and the form that is found is identified, the
individual performing the maneuver attempts to determine the location of the fetal back. Still
facing the woman, the health care provider palpates the abdomen with gentle but also deep
pressure using the palms of the hands. First the right hand remains steady on one side of the
abdomen while the left hand explores the right side of the woman's uterus. This is then repeated
using the opposite side and hands. The fetal back will feel firm and smooth while fetal
extremities (arms, legs, etc.) should feel like small irregularities and protrusions. The fetal back,
once determined, should connect with the form found in the upper abdomen and also a mass in
the maternal inlet, lower abdomen.

Third maneuver: Pawlick's Grip

In the third maneuver the health care provider attempts to determine what fetal part is lying
above the inlet, or lower abdomen.[2] The individual performing the maneuver first grasps the
lower portion of the abdomen just above the symphysis pubis with the thumb and fingers of the
right hand. This maneuver should yield the opposite information and validate the findings of the
first maneauver. If the woman enters labor, this is the part which will most likely come first in a
vaginal birth. If it is the head and is not actively engaged in the birthing process, it may be gently
pushed back and forth. The Pawlick's Grip, although still used by some obstetricians, is not
recommended as it is more uncomfortable for the woman. Instead, a two-handed approach is
favored by placing the fingers of both hands laterally on either side of the presenting part.

Fourth maneuver

The last maneuver requires that the health care provider face the woman's feet, as he or she will
attempt to locate the fetus' brow. The fingers of both hands are moved gently down the sides of
the uterus toward the pubis. The side where there is the resistance to the descent of the fingers
toward the pubis is greatest is where the brow is located. If the head of the fetus is well flexed, it
should be on the opposite side from the fetal back. If the fetal head is extended though, the
occiput is instead felt and is located on the same side as the back.

Source: http://en.wikipedia.org/wiki/Leopold%27s_maneuvers

Expanded Program on
Immunization
The Expanded Program on Immunization was launched in July 1976 by the
Department of Health in cooperation with the World Health Organization and the
UNICEF.The original objective was to reduce the morbidity among infants and
children caused by the six childhood immunizable diseases.

General Principles in Infants/Children

Immunization
• Because measles kills, every infant needs to be vaccinated against measles
at the age of 9 months or as soon as possible after 9 months as part of the
routine infant vaccination schedule. It is safe to vaccinate a sick child who is
suffering from a minor illness (cough, cold, diarrhea, fever or malnutrition) or
who has already been vaccinated against measles.
• If the vaccination schedule is interrupted, it is not necessary to restart.
Instead, the schedule should be resumed using minimal intervals between
doses to catch up as quickly as possible..
• Vaccine combinations (few exceptions), antibiotics, low-dose steroids (less
than 20mg per day), minor infections with low fever (below 38.5º Celsius),
diarrhea, malnutrition, kidney or liver disease, heart or lung disease, non-
progressive encephalopathy, well controlled epilepsy or advanced age, are
not contraindications to vaccination. Contrary to what the majority of doctors
may think, vaccines against hepatitis B and tetanus can be applied in any
period of the pregnancy].
• There are very few true contraindication and precaution conditions. Only two
of these conditions are generally considered to be permanent: severe
(anaphylactic) allergic reaction to a vaccine component or following a prior
dose of a vaccine, and encephalopathy not due to another identifiable cause
occurring within 7 days of pertussis vaccination.
• Only the diluent supplied by the manufacturer should be used to reconstitute
a freeze-dried vaccine. A sterile needle and sterile syringe must be used for
each vial for adding the diluent to the powder in a single vial or ampoule of
freeze-dried vaccine.
• The only way to be completely safe from exposure to blood-borne diseases
from injections, particularly hepatitis B virus (HBV), hepatitis C virus (HCV),
and human immunodeficiency virus (HIV) is to use one sterile needle, one
sterile syringe for each child.

Routine Schedule of Immunization

Every Wednesday is designated as immunization day and is adopted in all parts of
the country. Immunization is done monthly in barangay health stations, quarterly in
remote areas of the country. The standard routine immunization schedule for
infants in the Philippines is adopted to provide maximum immunity against the
seven vaccine preventable diseases in the country before the child's first birthday.
The fully immunized child must have completed BCG 1, DPT 1, DPT 2, DPT 3, OPV 1,
OPV 2, OPV 3, HB 1, HB 2, HB 3 and measles vaccines before the child is 12 months
of age.

Immunizations for Pregnant

Women/TT Vaccines
The Tetanus Toxoid (TT) vaccine is given during pregnancy to prevent tetanus to as
well as the baby. Antibodies formed in your body, after the vaccination, are passed
on to your baby and protect her for a few months after birth. It also helps prevent
premature delivery.

Source: http://en.wikipedia.org/wiki/Expanded_Program_on_Immunization_
%28Philippines%29

Common Minor Instruments used

in ECS-OPD

a.kelly curve- to grasp small objects

b.kelly straight- to grasp small objects

c.eye sheet-to protect the eyes

d.mayo scissors-to cut sutures

e.gauze- dressing wounds

f.tissue forcep with teeth-- to grasp small objects

g.blade holder-to expose just enough edge

-to cut through

h.blades-for cutting

i.scalpel-for cutting skin and muscles

J.Sutures-used to hold body tissues together after an injury or

surgery

Types of sutures:

a.Catgut suture- is a type of surgical suture that is naturally

degraded by the body's own proteolytic enzymes.
b.barbed suture is a type of knotless surgical suture that has
barbs on its surface.

• Prolene 3-0-
• Chronic 3-0
• Vicrlyl 3-0
•

Leprosy
Leprosy or Hansen's disease (HD), named after physician Gerhard Armauer
Hansen, is a chronic disease caused by the bacteria Mycobacterium leprae and
Mycobacterium lepromatosis. Leprosy is primarily a granulomatous disease of the
peripheral nerves and mucosa of the upper respiratory tract; skin lesions are the
primary external sign.[3] Left untreated, leprosy can be progressive, causing
permanent damage to the skin, nerves, limbs and eyes. Contrary to folklore, leprosy
does not cause body parts to fall off, although they can become numb and/or
diseased as a result of the disease.

Early Signs and Symtomps

• Change in color-either reddish or white

• Loss of sensation on the skin lesion
• Decrease/loss of sweating and hair growth over lesion
• Thickened and/or painful nerves
• Muscle weakness or paralysis of extremities
• Pain and redness of the eyes
• Nasal obstruction or bleeding
• Ulcers that do not heal

Late Signs and Symptoms:

• Loss of eyebrow-madarosis
• Inability to close eyelids
• Clawing of fingers and toes
• Contractures
• Sinking of the nose bridge
• Enlargement of the breast in males or gynecomastia
• Chronic ulcers

Methods of Transmission:
• Prolonged skin-to-to-skin contact
• Droplet infection

Susceptibility

• Children especially twelve years and below are more susceptible.

Treatment:

• Ambulatory chemotherapy through use of Multi-drug therapy

• Domiciliary treatment as embodied in R.A. 4073 which advocates home
treatment.

Nursing Management:

• Promotes healthful living by teaching the value of good personal hygiene,

proper nutrition, adequate rest and sleep.
• Helps patient/family understand and accept the problems brought about by
the illness and assess their capacities to deal with them.
• Provides and arranges for provision of nursing care patients at home.
• Prevents secondary injury by teaching leprosy patients/families to protect
cases from burns and rough/sharp objects. Use of pads and wooden handles of
utensils are advised to protect hands and special shoes with padded soles should be
worn to protect the feet. Any injury to hands, feet and eyes should be treated early
to prevent deformities.
• Guides and supports patients/family throughout the treatment phase by
giving them information on the importance of sustained therapy, correct dosage,
effects of drugs and the need for medical check-up from time to time.
• Gives mental and emotional support by encouraging self-confidence and self-
reliance on the part of the patient/family and by maintaining an understanding and
objective attitude.
• Refers patient to the other health and allied workers as the physician, dentist,
social worker, physiotherapist, mental hygienist, occupational therapist as needed.

Hansen's disease may also be divided into the following types:

• Early and indeterminate leprosy

• Tuberculoid leprosy
• Borderline tuberculoid leprosy
• Borderline leprosy
• Borderline lepromatous leprosy
• Lepromatous leprosy
• Histoid leprosy
• Diffuse leprosy of Lucio and Latapí

Diagnostic Test:

• Skin testing
Source: http://en.wikipedia.org/wiki/Leprosy

Community Health Nursing Services in the Philippines

pp.215-221
 Tuberculosis
Tuberculosis or TB (short for tubercles bacillus) is a common and often deadly
infectious disease caused by various strains of mycobacteria, usually
Mycobacterium tuberculosis in humans.[1] Tuberculosis usually attacks the lungs but
can also affect other parts of the body. It is spread through the air, when people
who have the disease cough, sneeze, or spit.[2] Most infections in humans result in
an asymptomatic, latent infection, and about one in ten latent infections eventually
progresses to active disease, which, if left untreated, kills more than 50% of its
victims.

Infectious Agents:

 Mycobacterium tuberculosis
 Mycobacterium Africanum

Mode of Transmission:

• Airborne droplet method through coughing, singing, or sneezing

• Direct invasion through mucous membranes or breaks in the skin may occur,
but is extremely rare.

Signs and Symptoms:

• chest pain,
• coughing up blood,
• productive, prolonged cough for more than three weeks
• Systemic symptoms include:
• fever,
• chills,
• night sweats,
• appetite loss, weight loss,
• pallor,
• Tendency to fatigue very easily.

Diagnostic Tests:

A.Mantoux test- also known as the Mantoux screening test, Tuberculin

Sensitivity Test, Pirquet test, or PPD test for Purified Protein Derivative

- a standard dose of 5 Tuberculin units (0.1 mL) is injected intradermally

(between the layers of dermis) and read 48 to 72 hours later. A person who has
been exposed to the bacteria is expected to mount an immune response in the
skin containing the bacterial proteins.the reaction is read by measuring the
diameter of induration (palpable raised hardened area) across the forearm
(perpendicular to the long axis) in millimeters. If there is no induration, the result
should be recorded as "0 mm". Erythema (redness) should not be measured.

-If a person has had a history of a positive tuberculin skin test, or has not had a
recent tuberculin skin test (within one year), another skin test may be needed; if
negative, another test may be needed.

B.ELISA- Enzyme-linked immunosorbent assay (ELISA), also known as an enzyme

immunoassay (EIA), is a biochemical technique used mainly in immunology to
detect the presence of an antibody or an antigen in a sample.
Categories and Treatment Regimen:

Category I
This treatment regimen is prescribed to
• New pulmonary tuberculosis patients whose sputum is positive
• Seriously ill patients with severe forms of:
-Smear-negative pulmonary tuberculosis with extensive parenchymal involvement
-extra-pulmonary tuberculosis
Category I

Intensive Phase Rifampicin 450 mg

(2 months) Isoniazid 300 mg

Pyrazinamide 500 mg(2

tablets)

Ethambutol 400 mg(2 talets)

Maintenance PhaseRifampicin 450 mg

Isoniazid 300 mg

Category II Category II

This treatmentIntensive
regimen Phase Rifampicin
is to prescribed 450 mgtreated patients who
to previously
are:
(2 months) Isoniazid 300 mg
• Relapses
Pyrazinamide 500 mg(2 tablets)
• Failures
Ethambutol 400 mg(2 tablets)

Streptomycin 400 mg

Intensive Phase Rifampicin 450 mg

(1 month) Isoniazid 300 mg

Pyrazinamide 500 mg(2 tablets)

Ethambutol 400 mg(2 tablets)

Maintenance Phase Rifampicin 450 mg

(5 months) Isoniazid 300 mg

Ethambutol 400 mg(2 tablets)

For 30-50 kg. body weight

Fo
Category III

This treatment regimen is prescribed to:

• New pulmonary tuberculosis patients whose sputum is smear-negative for 3

times and a chest X-ray result of PTB minimal.
• Extra pulmonary tuberculosis

Category III

Intensive Phase Rifampicin

4 50 mg

(2 months) Isoniazid 300 mg

Pyrazinamide 500
mg(tablet)

Maintenance PhaseRifampicin 450 mg

(2 months) Isoniazid 300 mg

Nursing Management

Sources:http://en.wikipedia.org/wiki/Mantoux_test

Community Health Nursing Services in the Philippines pp.205-215

Micronutrient
Supplementation
Vitamin A is a vitamin that is needed by the retina of the eye in the form of a
specific metabolite, the light-absorbing molecule retinal. This molecule is
absolutely necessary for both scotopic and color vision. Vitamin A also functions
in a very different role, as an irreversibly oxidized form retinoic acid, which is an
important hormone-like growth factor for epithelial and other cells.

Vitamin Dose Schedule of giving

Vitamin A 10,000 IU Twice a week starting on
the fourth month of
pregnancy