Community Health Nursing Review

Community Health Nursing
najarrieta, rn, rm, ctn, manc drdmc

Definitions
• “Public Health is the science and art of
preventing disease, promoting life, and
promoting health…”
- Dr. C.E. Winslow
• “Public Health Nursing is the practice of nursing
in national and local government health
departments. …community health nursing
practiced in the public sector.”
- Standards of Public Health Nursing in the
Philippines, 2005
• Community Health Nursing is “the utilization of
the nursing process in the different levels of
clientele-individual, families, population groups
and communities… promotion of health,
prevention of disease and disability, and
rehabilitation”
- Dr. Araceli Maglaya, et. al.

Need to Remember
• Individual, Family, Population Groups, and
Community are the four LEVELS of clientele
• Community is the patient in CHN
• Family is the unit of care
• Goal of CHN is achieved through multisectoral
efforts
• CHN is part of Health Care System and the
Larger Human Services System

Special Note:
• The Public Health Nurse will take charge of the
Municipal Health Officer’s responsibilities in the
event that the MHO is unable to perform his
duties or is not available

Role of Public Health Nurse
• Clinician
• Health Educator
• Coordinator and collaborator
• Supervisor
• Leader and Change Agent
• Manager
• Researcher

Health Care Delivery System
• The Public Sector
• Department of Health
– Vision: The DOH is the leader, staunch advocate, and
model in promoting health for all in the Philippines.
– Mission: Guarantee equitable, sustainable, and quality
health for all Filipinos, especially the poor and lead the
quest for excellence in health.
– Goal: Health Sector Reform Agenda
• EO 102 identifies the DOH as the national
health authority

• FOURmula ONE for Health
– Framework for the implementation of the Health Sector
Reform Agenda
• Four Elements
– Good Governance
– Health Financing
– Health Regulation
– Health Service Delivery

Local Government Units
• RA 7160 or Local Government Code of 1991
– Devolution of powers, functions and responsibilities
– Provincial and municipal level
• District Health System – smallest manageable
unit in areas which are small enough to be
managed without being bogged down by
bureaucracy, yet large enough to be feasible

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 a cost that the community can afford
at every stage of development.”
World Health Organization

Things to Remember:
• PHC Goal: HEALTH FOR ALL BY THE YEAR
2000
– Alma Ata, USSR, First International Conference on
PHC, September 1978
• Legal Basis: LETTER OF INSTRUCTION 949
signed by Pres. F. Marcos
• Underlying Theme: HEALTH IN THE HANDS
OF THE PEOPLE BY 2020

Primary Health Care
• Four Pillars of PHC
Support mechanism made available
Active community participation
Intra- and inter-sectoral linkage
Use of appropriate technology

Levels of Health Care
• Two Levels of Primary Health Care Workers
– Village or Barangay Health Workers
• Trained CHW
• Health auxiliary volunteers
• Traditional birth attendants
– Intermediate Level Health Workers
• General medical practitioner
• Public health nurses
• Rural sanitary inspectors
• Midwives

Three Levels of Health Care
Services
Primary Secondary Tertiary
Barangay Health Emergency or Regional Health
Station District Hospitals Services
Rural Health Units Provincial or City Regional Medical
Community Hospitals Centers and
Hospitals Training Hospitals
National Health
Services Medical
Centers

Levels of Disease Prevention
• Primary Level Disease Prevention
– Directed at individuals at risk; specific protection against
risks
– Immunizations
– Food supplementation
– Malaria chemoprophylaxis

• Secondary Level of Prevention
– Directed for individuals in the subclinical asymptomatic
and symptomatic stage; aims to diagnose and treat
existing health problems
– Screening
– Casefinding
– Surveillance
– Treatment of communicable disease

• Tertiary Level Disease Prevention
– Directed towards individual in the pathogenic stage of
disease; deals with the reduction of the magnitude and
severity of the residual effects of communicable and
non-communicable diseases
– Rehabilitation
– Control of measles during an epidemic

Primary Health Care
• Education for Health • Nutrition
• Locally Endemic and • Treatment
Communicable • Safe Water and
Disease Control Sanitation
• Expanded Program on • Dental Health
Immunization • Access to Sentrong
• Maternal and Child Sigla
Health • Mental Health
• Essential Drugs
Family Health Nursing
• First Level Assessment
– Wellness Condition
– Health Deficit are instances of failure in health
maintenance
– Health Threat are conditions that are conducive to
disease, accident, or failure
– Foreseeable crisis or stress points are anticipated
periods of unusual demand on the individual or family in
terms of adjustment

• Second Level Assessment
– Inability to recognize the existence of a health condition
or problem
– Inability to make decisions with respect to taking
appropriate health action
– Inability to provide nursing care to the sick, disable, or
dependent member of the family
– Inability to provide a home environment that is
conducive to health maintenance and personal
development
– Failure to utilize community resources for health care

Scale of Ranking Health
Conditions
Criteria Score Weight
Nature of the Condition
Wellness 3
Health Deficit 3 1
Health Threat 2
Foreseeable crisis 1
Modifiability of the Condition
Easily modifiable 2
2
Partially modifiable 1
Not modifiable 0
Preventive Potential
High 3
1
Moderate 2
Low 1
Salience
A condition needing immediate attention 2
A condition not needing immediate attention 1 1
Not perceived as a condition 0

Home Visit
Principles • Need of the client
• Must have a purpose • Acceptance of the family
• Makes use of all available • Policy of a specific agency
information about a patient • Other health agencies
• Consider and give priority present
to needs of clients • Past services given
• Involve clients • Ability of clients to
• Should be flexible recognize own needs
Guidelines to consider about

frequency of visits
Steps in Conducting Home Visits
1. Greet the client and introduce self
2. State the purpose of the visit
3. Assess the health needs
4. Perform the bag technique
5. Perform nursing care and give health teachings
6. Record all data (observation and care
rendered)

Bag Technique
• Is a tool used by the nurse to enable her to
perform a nursing procedure with ease and
deftness
• PHN Bag is an essential and indispensable
equipment of a public health nurse which she
has to carry along during home visits
• The BP Apparatus is part of the PHN Bag

Bag Technique
Principles • Should contain all
• Minimize, if not prevent the necessary articles/supplies
spread of infection • Should be cleaned very
• Saves time and effort of the often and supplies are
nurse replaced
• Should show effectiveness • Should be well-protected
of total care given to an • Arranged according to
individual or family convenience
• Can be performed in a
variety of ways
Important Points
Community Diagnosis
• An in-depth process in finding out the profiles, health
status of the community and the factors affecting the
present status
1. Preparation for Community Diagnosis
2. Data gathering (spot map, key informant interview,
community survey, records review)
3. Data presentation
4. Problem identification
5. Preparation of an action plan

Community Organizing
• Is a process by which people, health services
and agencies of the community are brought
together to:
a. Learn about common problems
b. Identify these problems are their own
c. Plan the kind of action to solve problems
d. Act on this basis

Community Organizing
Participatory Action Research
• Principles:
– People have the capacity to change
– COPAR should be based on the interest of the poorest
sectors of society
– COPAR should lead to the development of self-reliance
• Methods:
– Action-Reflection-Action-Session
– Consciousness-Raising

COPAR Phases
• I. Pre-Entry Phase
– Site Selection
• Must be DOPE
• Health services are inaccessible or inadequate
• Poor health status
• Area has no serious peace and order problem
• No strong resistance
• Area is free from relatively similar programs
– Preliminary Social Investigation
– Identification of Potential Barangays

• II. Entry Phase
– Integration
– Conduct of Information Campaign
– Deepening Social Investigation
– Identification of Potential Leaders
– Provision of Health Services
– Core Group Formation

• III. Organization-Building Phase
– Preparing the community for organization-building
– Organizing the CHO
– Training and Education for the CHO
– Setting up the CHO

• IV. Sustenance and Strengthening Phase
– Education and Training
– Networking and Linkages
– Community Mobilization on Health and Development
Concerns
– Development of Secondline Leaders

Expanded Program on
Immunization
Vaccine Minimum Age Number of Amount Route Interval
Doses
BCG At birth 1 0.05 mL ID

10th and 14th
Hepatitis B At birth 3 0.5 mL IM (thigh)
week
DPT 6 weeks 3 0.5 mL IM (thigh) 4 weeks
OPV 6 weeks 3 2 drops PO 4 weeks
Measles 9 months 1 0.5 mL IM (arm)
If child has convulsions, Do NOT give DPT

If child is immunocompromised, Do NOT give Polio,
Measles, and BCG!!!
Immunize every sick child

Tetanus Toxoid
Vacci Minimum Time Percent Duration of Protection
ne and Interval Protection
As early during
TT1 0
pregnancy
3 years; Infants protected
TT2 4 weeks 80
from NT
TT3 6 months 95
from NT
TT4 1 year 99
from NT
Lifetime; ALL Infants
TT5 1 year 99
protected from NT
EPI: Cold Chain
• Storage:
– 6 months Regional Level
– 3 months Provincial/District Level
– 1 month Main Health Centers
– 5 days Health Centers

Family Planning
• Principles:
– Responsible Parenthood
– Respect for Life
– Birth Spacing
– Informed Choice
• Mandate: EO 119 and EO 102

Contraceptive Methods
• Natural – Standard Days Method –
Cycle Beads
– Abstinence
– Calendar Method • Surgical Methods
– Basal Body Temperature – Tubal Ligation
– Cervical Mucus (Billings) – Vasectomy
– Symptothermal method
– Lactation Amenorrhea
Method
– Coitus Interruptus

Contraceptive Methods
• Hormonal • Barrier
– Progestin-Only Oral – Intrauterine Device
Contraceptives – Diaphragm
– Low-Dose Combined – Cervical Cap
Oral Contraceptives
– Condoms
– Injectables
– Norplant Implants

Malnutrition
• Vitamin A Supplementation
– Infants (6 to 11 months) 100,000 IU – 1 dose
– Children (12 to 72 months) 200,000 IU – 1 capsule
every 6 months
– For Pregnant women given starting 4th Month 10,000 IU
twice a week until delivery
• Iron Supplementation
– For Pregnant women 60 mg Iron and 400 mcg Folic
acid 1 tablet OD for 6 months or 2 tabs per day if
started in the 2nd or 3rd trimester

• Iron Supplementation
– For Low Birth Weight - drops 15 mg Iron/0.6 mL, 0.3 mL
once a day to start 2 months until 6 months
– For 1 to 5 y/o – syrup 30 mg Iron/5 mL, 1 tbsp OD for 3
months or 1 tsp once a week for 6 months
– For 6 to 11 years anemic and underweight – syrup 30
mg/5 mL, 2 tbsp OD for 6 months
• Iodine Supplementation
– Iodized capsule with 200 mg iodine 1 capsule for 1 year

Garantisadong Pambata
• Campaign to support various health programs
that will reduce childhood illnesses
• Vit. A and iron supplementation
• Catch-up immunization
• Done twice a year (one week in April, and one
week in October)

Newborn Screening
Disorder Effects
Congenital Hypothyroidism Mental Retardation
Congenital Adrenal Hyperplasia Death
Galactosemia Death and cataracts
Phenylketonuria Mental Retardation
G6PD Deficiency Anemia and Kernictirus
• Done after 24, 48th to 72nd hour after birth; screened again
after 2 weeks for more accurate results
• Uses heel prick method and an absorbent filter paper and
dried for 4 hours
• Report positive results immediately

DOH Herbal Medicines
• BAYABAS • SAMBONG
• ULASIMANG • AKAPULKO
BATO • NIYUG-NIYOGAN
• BAWANG • TSAANG GUBAT
• LAGUNDI • AMPALAYA
• YERBA BUENA

IMCI
• Assess, Clasify, Identify, Treat
• CUVA

Isolation Precautions
• Universal Precautions or Standard Precautions
– Apply to blood, all body fluids, secretions, and
excretions; skin that is not intact; and mucus
membranes
• Hand Hygiene or Handwashing
– Best way to prevent spread of pathogens
– May use alcohol based when hands are not visibly
soiled
– Handwashing is for visibly soiled hands

Transmission Based Precautions
Airborne Precaution Droplet Precaution Contact Precaution
For PTB, measles, For influenza, Skin to skin contact

varicella meningitis, diptheria, or through fomites
Must use a rubella Requires gloves, a
particulate filter mask Safe 3 feet and more mask, gown, and
personal equipment
Do NOT RECAP NEEDLES!

Tuberculosis
• TUBERCULOSIS
– CA: Mycobacterium tuberculosis
– MOT: Airborne droplet through coughing and sneezing
– Direct Sputum Smear Microscopy is the PRIMARY
diagnostic tool
– PPD: Detects presence of antibodies; Results after 48
to 72 hours
• (+) <5 y/o (+) BCG ≥10 mm is positive
• (+) >5 y/o (-) BCG ≥5 mm is positive

Directly Observed Treatment -
Shortcourse
Category Type of TB Patient Intensive Continuation
Phase Phase
New smear-positive;
With extensive parenchymal lesion
I EPTB 2 RIPE 4 RI
Severe concomitant HIV disease
Treatment failure 2 RIPES/
II Relapse 1RIPE 5 RIE
New smear-negative PTB with minimal

III parenchymal lesions 2 RIPE 4 RI
Chronic Refer
IV

Antimycobacterials
• Rifampicin – take with meals; protect from light
• Isoniazid – take before meals; give 10 to 100
mg of Pyridoxine
• Pyrazinamide – caution for gouty arthritis;
protect from light
• Ethambutol – not given to children below 6
years
• Streptomycin – given IM

Leprosy
• LEPROSY (Hansen Disease)
– CA: Mycobacterium leprae
– MOT: Direct skin contact; prolonged
– Dx: Slit Skin Smear
– Types:
• Paucibacillary: Treat with Rifampicin and Dapsone for
6 to 9 months
• Multibacillary: Treat with Rifampicin, Clofazimine, and
Dapsone for 24 to 30 months

Malaria
• MALARIA
– CA: Plasmodium (vivax, ovale, malariae, falciparum)
– MOT: Bite of anopheles mosquito
– DX: Quantitative Buffy Coat
– Treatment: Quinine, Sulfadoxine, Chloroquine,
Mefloquine
– Prophylaxis: Chloroquine, weekly intervals, start 1 to 2
weeks prior to entering endemic area.
– Update: Artemeter-Lumefantrine

Dengue Hemorrhagic Fever
• DENGUE HEMORRHAGIC FEVER
– CA: Dengue virus (I, II, III, IV) and Chikungunya virus
– MOT: Bite of Aedes aegypti virus
– Dx: Tourniquet test (capillary fragility or Rumpel Leads
test)
– Treat:
• Fluids
• Paracetamol
• WOF bleeding

Filariasis
• FILARIASIS
– CA: Wuchereria brancrofti, Brugia malayi, Brugia timor
– MOT: Bite of Aedes poecilius
– Dx: symptomatology: obvious lymphadenitis,
lymphangitis, lymphedema, elephantiasis, orchitis
– Treat:
• Diethylcarbamazine citrate (Hetrazan)

Schistosomiasis
• SCHISTOSOMIASIS (Bilhariasis, Snail Fever)
– CA: Schistosoma japonicum, Schistosoma mansoni,
Schistosoma haematobium
– Intermediate Host: Oncomelania quadrasi
– MOT: Skin contact to contaminated water
– Treat:
• Praziquantel (Biltricide)

Measles
• MEASLES
– CA: Paramyxovirus
– MOT: Airborne droplet (1 to 2 days before onset of s/s;
4 to 5 days after disappearance of rash)
– Pathognomonic Sign: Koplik’s spots
– PVT: Measles vaccine
– Mgt:
• Vitamina A Supplementation
• Ibuprofen or Paracetamol
• Supportive

Chicken Pox
• CHICKEN POX
– CA: Varicella-Zoster Virus
– MOT: Direct contact (1 to 2 days prior to appearance of
rashes; 5 to 6 days onset of vesicular crusting)
– S/S: Vesicular rash starts from the trunk to peripheries
– Mgt:
• Acyclovir 800mg TID
• Paracetamol
• Keeping fingernails short
• Oatmeal bath

Mumps / Parotitis
• MUMPS / PAROTITIS
– CA: Mumps Virus
– MOT: Airborne droplet (1 to 2 days before onset of
parotitis; 5 days after onset of swelling)
– Compli: orchitis, oophoritis, infertility,
meningoencephalitis
– PVT: MMR at 12 to 15 M; Booster at 4 to 6 years
– Mgt:
• Bedrest
• Antipyretics

Diphtheria
• DIPHTHERIA
– CA: Corynebacterium diphtheria (Klebs-Loeffler
bacillus)
– MOT: Contact with ill or contaminated articles
– Pathognomonic Sign: Pseudomembrane on throat and
tonsils
– Dx: Culture of membrane
– PVT: DPT vaccine
– Mgt:
• Diphtheria antitoxin, penicillin, erythromycin

Tetanus
• NEONATAL TETANUS and TETANUS OF
OLDER AGE GROUPS
– CA: Clostridium tetani
– MOT: Contamination of unhealed cord stump
– Treat:
• Penicillin I.V.
• Tetanus antiserum or tetanus immunoglobulin
–PVT:
• Tetanus vaccine

Influenza
• INFLUENZA
– CA: Influenza virus (A, B, C)
– MOT: Droplet
– PVT: Inactivated (IM) for 6 months and older; Live,
attenuated (Nasal Spray) for 2 to 49 years
– Mgt:
• Supportive

Pneumonia
• PNEUMONIA
– CA: a lot!
– MOT: mainly respiratory droplet
– Treat:
• Anti-infectives (Antibiotics, Antivirals, Antifungals)
• Antipyretics
– Mgt:
• Supportive

Cholera
• CHOLERA (EL TOR)
– CA: Vibrio cholerae
– MOT: Fecal-oral route
– S/S: Rice-water stool
– Treat:
• Tetracycline
– Mgt:
• OReSol, coconut water, “am”, soap, cereals, BF

Typhoid Fever
• TYPHOID FEVER
– CA: Salmonella typhi
– Note: Rose spots on abdomen or chest
– Treat:
• Chloramphenicol
– Mgt:
• Rehydration
• Proper food preparation

Shigellosis
• SHIGELLOSIS (Bacillary dysentery)
– CA: Shigella (dysenterae, flexneri, boydii, soneii)
– Treat:
• Trimethoprim-sulfamethoxazole
– Mgt:
• Rehydration

Amebiasis
• AMEBIASIS (Amebic dysentery)
– CA: Entamoeba histolytica
– Treat:
• Metronidazole
– Mgt:
• Rehydration

Soil-Transmitted Helminthiasis
• SOIL-TRANSMITTED HELMINTHIASIS
– CA: Ascaris lumbricoides, Trichuris trichiura,
Ancylostoma duodenale & Necator americanus
(Hookworn)
– MOT: Contact with contaminated soil
– Treat:
• Mebendazole
• Albendazole

Paragonimiasis
• PARAGONIMIASIS
– CA: Paragonimus westermani (subsp. philippinensis),
Paragonimus siamenses
– MOT: ingestion of raw crab (Sundathelpusa philippina,
Varona litterata)
– Treat:
• Praziquantel
• Bithionol
– Mgt:

Hepatitis A
• HEPATITIS A (Infectious Hepatitis, Epidemic
Hepatitis, Catarrhal Jaundice)
– CA: Hepatitis A virus
– MOT: Fecal-oral route, parenteral
– Treat:
• IM injection of gamma globulin
– Mgt:
• Environmental sanitation

Paralytic Shellfish Poisoning
• PARALYTIC SHELLFISH POISONING (Red
Tide Poisoning)
– CA: Dinoflagellates (Pyromidium bahamense var.
compressum in Manila Bay, Samar, Bataan, Zambales)
– MOT: Eating contaminated bivalve shellfish
– Treat/Mgt:
• Induce vomiting
• Pure coconut milk and sodium bicarbonate

Leptospirosis
• LEPTOSPIROSIS (Weil’s Disease, Trench
Fever, Mud Fever, Flood Fever, Japanese
Seven Days Fever, Spiroketal Jaundice)
– CA: Leptospira interrogans
– MOT: Skin contact to contaminated water or moist water
– Treat:
• Penicillin
• Tetracycline
• Erythromycin

Rabies
• RABIES (Hydrophobia)
– CA: Rabies virus
– MOT: Bite of a rabid animal, or through scratches on the
skin
– Treat/Mgt:
• Wash area with soap and water
• Rabies immunoglobulin and active immunization

Scabies
• SCABIES
– CA: Sarcoptes scabiei
– MOT: Direct contact with infected person or through
fomites
– Treat:
• Benzyl benzoate
• Permethrin (Kwell)
– Mgt:
• Personal hygiene
• Environmental sanitation

Anthrax
• ANTHRAX (Woolsorter Disease, Ragpicker
Disease)
– CA: Bacillus anthracis
– MOT: Ingestion, inhalation or cutaneous contact with
spore
– Treat:
• Penicillin
• Erythromycin
• Tetracycline

Sexually Transmitted
• GONORRHEA (GC, Clap, Drip)
– CA: Neisseria gonorrheae
– MOT: Sex, Mother to child during delivery
– Treat:
•Ceftriaxone
•Azithromycin
•Doxycycline

• SYPHILIS
– CA: Treponema pallidum
– MOT: Sex
– 4 Stages (First, Second, Latent, Late)
– Complications:
• Neurosyphilis
• Cardiovascular syphilis
– Treat:
• Penicillin, Tetracycline, Doxycycline

• TRICHOMONIASIS (Trich)
– CA: Trichomonas vaginalis
– MOT: Sex
– Treat:
• Metronidazole

• Hepatitis B
– CA: Hepatitis B virus
– MOT: Sex and blood, mother to child
– PVT:
• Hepatitis B vaccine
• Safe sex practice
–Treat:
• Hepatitis B immunoglobulin

• HIV/AIDS
– CA: Human Immunodeficiency Virus
– MOT: Sex and blood and body fluids
– Dx: EIA and Western Blot
– Note: 6 months window period
– Treat: Highly Actice AntiRetroviral Therapy (HAART)
• Reverse Transcriptase Inhibitors, Protease Inhibitors,
Nucleosides, Fusion Inhibitors

Meningococcemia
• MENINGOCOCCEMIA
– CA: Neisseria meningitidis
– MOT: Droplet spread
– Treat: Ciprofloxacin

Severe Acute Respiratory
Syndrome
• SARS
– CA: Coronavirus
– MOT: Droplet spread
– Note: Isolation!

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Community Health Nursing

najarrieta, rn, rm, ctn, manc drdmc