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Community Health Nursing

Jaypee Gonzales Valenzuela,RN

Definition of terms:
Community Webster: place where people live

WHO: Comprising of group of inhabitants in an area following general rules and regulations, having common interests, functions, heads and organizations to attain objectives.

Health - absence of disease condition WHO: Dynamic state in the life cycle of an individual and not merely the absence of a disease Public Health Science and art of preventing disease, prolonging life, promoting health and efficiency through organized community effort.

Community Health Nursing MAGLAYA: Utilization of the nursing process in the different level of clientele-individuals, families, population groups and communities concerned with the promotion of health, prevention of disease and disability, and rehabilitation. Community Health part of paramedical and medical intervention or approach which is concerned on the health of the whole population.

MAGLAYA: utilization of nursing process to benefit the individual, family and community. WHO: combination of nursing skills, sociology and public health. FREEMAN: developing and enhancing health capabilities of people. JACOBSON: achievement of OLOF through teaching and delivery of care

Philosophy of CHN

Margaret Shetland: Based on worth and dignity of man

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

Basic Principles of CHN:

The community is the patient in CHN, the family is the unit of care and there are four levels of clientele: individual, family, population group and the community.

Health Care Ratio:

1 MHO : 20,000 1 PHN : 10,000 1 PHM : 5,000 2 BHW/Barangay minimum

Roles of Public Health Nurse (PHN):

Clinician takes care of sick at home Health Educator IEC campaign (Information, Education & Communication) Facilitator / Organizer establishes multisectoral linkages - COPAR Supervisor monitors and supervises midwives Additional Role: PHN takes charge in the absence of MHO

First Level Assessment

Health Threat (Knowledge Deficit) ~ conditions that are conducive to disease, accident or failure to realize ones health potential. Health Deficit ~ instances of failure in health maintenance (disease, disability developmental lack). Foreseeable Crisis / Stress Point ~ anticipated period of unusual demand on the individual or family in terms of adjustment or family resources

Second level Assessment

(Recognition of the problem) A problem not perceived is not a problem A problem too big or too obvious is not a priority Decision on appropriate health action decide what is to be done - Care to affected family member generalist - Provision of healthy home environment -Utilization of community resources for health care

Principle of Health Care for All: 3 As: A ccesibility (geographical proximity) A ffordability (economical capacity) A cceptability (in tuned with values, customs, beliefs and tradition)

Problem Prioritizing:
Nature of the problem
Health threat potential Health deficit actual Foreseeable crisis least

Preventive potential High yes Moderate it may or it may not be Low no

Modifiability Easily modifiable Partially modifiable Not modifiable

Primary Health Care

An essential health care given to individual, family, and community. September 6-12, 1978 Alma Ata Conference, Alma Ata, USSR Adopted in the Philippines in 1979 through LOI 949 by former President Marcos. GOAL: Improve state of health and good quality of life attained through self reliance

Essential services of PHC

Essential drugs Local disease EPI MCH Environmental Sanitation Nutrition Treatments Sanitation Responsible Parenthood

Cornerstones of PHC
Support mechanism Community participation Appropriate technology Multisectoral linkages



Well and early sick

Setting of service Role of community

Urban Passive recipients

Rural Active recipients

Decision making
Technology Outcome

Top to bottom
Curative-based Reliance to health professional

Bottom to top
Promotive & preventive services Self-reliance of community

Health Care Delivery System

~ totality of all policies, facilities, equipment, products, human resources and services which address the health needs, problems and concerns of the people. It is large, complex, multi-level and multidisciplinary National Health Plan -blueprint of DOH -backbone of all policies, plans and strategies.

Major players:
Public sector -National government and LGU -given free at point of service Private sector -market-oriented -paid offering of service

The Department of Health

ROLES: Leadership in Health - DOH serves as the advocate in the adoption of health policies, plans, and programs to address national and sectoral concerns. Enabler and capacity builder - innovates new strategies -ensure highest achievable standards Administrator of Specific services - administer direct services for emergent health concerns

The Department of Health

National governing agency responsible for the provision of health and quality of health services EO 119 Sec 3 is the legal basis of DOH creation Francisco Duque, III DOH Secretary

Vision: The DOH is the leader, staunch advocate and model in promoting health in the Philippines Mission: Guarantee equitable, sustainable and quality health care for all Filipinos

FOURmula ONE for Health

It intends to implement critical interventions as a single packaged packed by effective management, infrastructure, and financing arrangements. (Speed, precision,& effective coordination) GOALS: 1. Better health outcomes 2. More responsible health systems 3. Equitable health care financing

Health financing
Joined by DOH and National Health Insurance Corporation

Health regulation
Goal: assure quality and affordable health goods and services

Health service delivery

Goal: improve and ensure accessibility

Good governance
Goal: enhance health system performance

The PHN functions

Management function Supervisory function Nursing care function Collaborative/Coordinating function Health promotion function Training function Research function

DOH Programs:
Started 1993 23 in 1993 Flavier 1994 health for more Focus: Infants, mother, males, adolescents, elderly.

1. FAMILY HEALTH Family Planning Program

Goal: Universal access to family planning information and services. Policies: To improve family welfare with main focus on: Womans health Safe motherhood Child survival To promote family solidarity and responsible parenthood WHO 1978 enhanced 1983

1. FAMILY HEALTH Family Planning Program

Methods of Family Planning
Oral contraceptives DMPA, injectibles, implants (6-9months)

IUD ( copper T) Side effect: ectopic pregnancy
6 9 years During menstruation Post pregnancy up to 6 weeks Dilated cervix Contraindications: any type of STD, any type of Pelvic inflammatory Disease most reliable protection against STD most common used in the Philippines

Condom most unreliable as method of contraception

Cervical cap done facing up Foam most effective spermicidal Gel least effective

Lactation Amenorrhea Method

criteria: has just given birth exclusively breastfeeding child is below 6 months

Calendar method Basal body temperature Symphto-thermal Cervical mucus clear, stretchable, fertile Coitus interruptions

Permanent (Surgical/Reversible)
Tubal ligation Vasectomy most uncommon

2. Reproductive Health 1993

Vision: Reproductive health practice as a way of life for every man & woman throughout life. Goals:
To achieve healthy sexual development & maturation To achieve their reproductive intention To avoid illness/diseases, injuries, disabilities or sexuality & reproduction To receive appropriate counseling and care of RH problems

Principles: Every pregnancy should be intended Every birth should be healthy Every sex act should be free of coercion and infection Achieved a desired family size

3. Nutrition
Sangkap Pinoy is a term used by the DOH for micronutrients added to enclose its nutritional quality.
Vit. A, Iron, Iodine cant be synthesized by body

Fortification of foods with micronutrients is generally recognize as the most cost effective long term strategy for eliminating micronutrient nutrition Sangkap Pinoy Seal makes public awareness MSG & Vit A

FIDEL Fortification for Iodine Deficiency Elimination Nutrition Surveillance System system of keeping close watch in the state of nutrition and the causes if malnutrition within a locality. Tool utilized for Anthropometric measurements
Weight for Age most commonly used Measures degree and presence of wasting (acute malnutrition for 6 months or less) or stunting (chronic malnutrition more than 6 months).

Height for Age measures the presence of stunting

chronic malnutrition

Weight for Height determines the presence of muscle wasting

Tri-colored strip
Red severely undernourished Yellow moderately Green well nourished

Male +6 105 110 lbs -6

Rule For every increment of an inch above 5 feet For a height of 5 feet

Female +5 100 105 lbs

For every decrement of -5 an inch below 5 feet

Degrees of Malnutrition
110% and above 90 109 obese normal

75 89
60 - 75 60% and below

1st degree
2nd degree 3rd degree

4. Womens Health and Safe Motherhood

Criteria for Home delivery Regular and quality prenatal care Height below 5 feet Age below 18, above 35 Prev. Pregnancy: 5th pregnancy Diseases: cardiovascular diseases, endocrine diseases, DM, hyperthyroidism, psyche disorder
history of abortion and miscarriage

Tetanus Toxoid Schedule

1st Pregnancy:
TT1 5th 6th month of pregnancy TT2 after 4 weeks (3 years immunity)

2nd Pregnancy (1st booster dose)

TT3 5th 6th month (5 years immunity)

3rd Pregnancy (2nd booster)

TT4 5th 6th month (10 years immunity)

4th Pregnancy (3rd booster)

TT5 5th 6th month (lifetime immunity)

Fe Supplementation
5th month of pregnancy to two months post partum (100 120mg/day for 210 days) Laboratory exam: Heat-acetic acid test. Benedicts test Oral dental exam

Heat-acetic test CHO, Albumin

impending pre-eclampsia, UTI
5ml acetic acid 10 gtts of urine heat 3-5 minutes (circular motion) mouth of test tube away from the body

Positive cloudy Negative clean Expired brown Violet discard

Benedict s test
test sugar / glucose in urine
impending diabetes 5ml of benedict blue 10 gtts of urine heat 5 minutes

Benedicts test results

Blue Green

Orange Red

Benedicts test results

Blue Green negative +1 Olive green

Orange Red

+3 +4 Brick red

5. Adolescent Health
RH Drug dependence and Substance abuse Complex is nature and not only physical or psychological, also involves sociological and cultural.

Promotion of mental health among families and the community through advocacy of wholesome family living sports and other participative activities Anticipatory guidance of vulnerable age groups Recognition of mental health hazards and how to minimize them Participation in drug abuse prevention education

6. Breastfeeding (RA 7600)

Unique characteristics of Breast Milk:
B Bonding R Reduce allergic reaction E Economical A Always available S Safe / maintains the stool soft T Temperature always right

F Fresh E Emotional attachment E Easily established D Digestible I Immunity N Nutritious G GIT disorders are decreased

Storage Room Temperature Body of Ref Freezer

Fullterm 8 10 hours

Preterm 4 hours

48 hours
3 months

24 hours
3 months

Deep freezer

6 12 months

6 months

7. Dental Health
98/100 Filipinos suffered from tooth decay 50/100 gum disease
Vision: A lifetime of oral health and no tooth decay for succeeding generations.
Sang Milyong Sipilyo Monthly Dental Health services to the Philippine School for the Deaf Replacement of Fluoride with Tsaang Gubat Orientation training on Comprehensive Dental Health

8. Integrated Management Childhood Illness

Under five care A package of child health related services focused to the 0-59 months old children to assure their wellness and survival GMC (yellow card)
Nutritional status EPI standing

Past and previous illness Past and previous medication Over all health status

All newborns must be enrolled under GMC program

No pneumonia/ cough and cold
no fast breathing no stridor / wheeze cough for less than 30 days

home remedies ginger Chicken soup basic steam inhalation

fast breathing stridor, wheeze on exertion

antibiotic for 5 days observe after 2 days

Severe Pneumonia
fast breathing plus any danger signs stridor, wheeze on a calm child chest indrawing decrease LOC stops feeding malnutrition

1st dose of antibiotic Vitamin A Treat hypoglycemia Refer

10. Newborn Screening

~ is a simple procedure to find out if your baby has a congenital metabolic disorder that may lead to mental retardation and even death if left untreated. 48 hours or at least 24 hours After 2 weeks Performed by a trained person Draw inverted triangle at the heel, prick outside the imaginary triangle to be absorbed by absorbent filter

Newborn Screening
Disorder Screened CH (Congenital Hypothyroidism) CAH (Congenital Adrenal Hyperplasia) GAL (Galactosemia) PKO (Phenylketonuria) Effects if not screened Several Mental Retardation Death Death or Cataracts Several Mental Retardation Severe Anemia Kerricterus


11. Control of Diarrheal Diseases (CDD)

Diarrhea unusual frequency of bowel movements more than 3x a day
3 classifications:
mild: 5 9 moderate: 10 15 severe: > 15

Acute: 3 loose stools; less than 2 weeks Chronic: LBM on and off for more than 2 weeks

Oral Rehydration Therapy Fruit juice, AM Home made soup

Frequent Feeding
continue breastfeeding - 6 month old Cal CHO 6x a day If subsided, additional feeding for 2 weeks

Fast Referral

Treatment Plans
PLAN A (no dehydration)
home treatment follow up after 5 days

PLAN B (some dehydration)

two of the following signs:
restless, irritable sunken eyes poor skin turgor

1st day: home care / ORS 2nd day: refer

PLAN C (severe dehydration)

two of the following:
abnormally sleepy, difficult to awake sunken eyes unable to drink poor skin turgor

Refer Give ORS (frequent sips) along the way

1 pack : 1 L water Good for 24 hours Boiled water

glucose for Na absorption NaCl for fluid retention NaHCO3 buffer system KCl for smooth muscle/cardio contraction ***STOP giving ORS if there is puffiness in eyelids already

Measures of Diarrhea Prevention:

Breast feed infants Provide appropriate supplemental feeding Handwashing Utilize clean and portable water Clean toilet and observe proper feces disposal Immunize the child with measles No to antibiotic unless with cholera, thyroid, or amoebiasis

PLAN C (severe dehydration)

two of the following:
abnormally sleepy, difficult to awake sunken eyes unable to drink poor skin turgor

Refer Give ORS (frequent sips) along the way

12. Health Programs for Older Person

NTBCP National Tuberculosis Control Program
TUBERCULOSIS is a highly infectious, chronic respiratory disease caused by TB bacilli.

Objective: To control TB by reducing annual risk of infection (prevalence and mortality rate). Prevention:
BCG vaccines under EPI Annual identification of at least 45% of its prevalence Public Health Education regarding PTB mode of transmission, methods of control and importance of early diagnosis

Case Finding:
Direct sputum microscopy for identified TB symptomatic X-ray exam of TB symptomatic who are (-) after 2 or more sputum exam
Sputum culture best CXR extent Mantoux exposure AFB - communicability

Establishment of passive and active collection points Case finding and treatment services shall be made available in the BHS/RHUs

Intensive Phase to make patient non-communicable Maintenance cure Standard Regimen

SEI Intensive SEI 2 months Maintenance EI 10 months (SCC DOTS) Short Course Chemotherapy Direct Observed Treatment Short Course 6 months

New Course Category I 6 months

New PTB (+) sputum exam PTB with extensive lung damage Extra pulmonary TB Intensive RIPE 2 months Maintenance RI 4 months

Category II 8 months
TB relapse and failures Intensive RIPES 2 months RIPE 1 month Maintenance RIE 5 months

Category III 4 months

TB with sputum negative but (+) x-ray Extra pulmonary TB (not serum) Intensive RIP 2 months Maintenance RI 2 months

is a chronic disease of the skin and peripheral nerves caused by mycobacterium leprae.
leonine appearance duration of treatment 6 to 9 months

Tuberculoid, indeterminate Non infectious Treatment: 6 9 months

Lepromatous and borderline Treatment: 24 30 months

Health education BCG vaccination Case finding (SSS) Validate old regular cases Early referral of suspected leprosy patients

Ambulatory RA 4073:
Advocacy of home treatment Domiciliary chemotherapy through the case of MDT

13. Environmental Health

~ study of all factors in mans physical environment which may exercise and determines 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 households.

a. Water Supply Sanitation Program

3 Types of Approved Water Supply & Facilities:

Level I point source - developed spring - protected well

Level II Communal System on Stand Post - with reservoir - piped distribution system Level III Water works System

household taps

b. Proper Excreta and Sewage Disposal System

Level I non water carriage
- small amount of water eg. Pit latrine

Level II water carriage type with water sealed and flushed type with septic tank disposal facilities Level III connected to sewerage system

c. Proper Solid Waste Management

Refers to satisfactory methods of storage, collection and final disposal of solid waste. 2 major components:
garbage rubbish

2 ways:
Burial deposited in XXXXX deep pits covered with soil, located 25m away from water supply. Open burning animal feeding, composting, grinding and disposal sewerage.

d. Food Sanitation Program

Policies: Food establishments are subject to inspection
complete with sanitary permit requirement comply with updated health certificate for food handlers, helpers, and cooks

e. Hospital Waste Management

To prevent the risk of contraction and contracting nosocomial infection from type disposal of infectious, pathological and other waste from hospital

f. Programs Related to Health

Risk minimization secondary to environmental pollution

g. Education of Prevailing Health Problems

IEC comparison TRI media (print/see, hear, see & hear)

14. Occupational Health

(subspecialty) ~ application of nursing principles and procedures in conserving the health workers in all occupations. Goal: Promote and maintain highest degree of well being of workers.

15. Cardiovascular Disease and Visual Health

Smoking Control Program health hazards: Lung cancer Cardiovascular disease COPD (chronic bronchitis, emphysema, asthma, black lung dse, bronchiactis) Cancer of other body organs

Program Components:
IEC Mobilization Policy development and legislation Training and counselors in smoking Cessation clinics for specialty hospitals Resource management and monitoring

16. Cancer, Asthma / COPD

AO 89-A 1990 ~ Guidelines for the Philippine Cancer Control Program