LESSON 1: CONCEPT OF FAMILY AS A BASIC UNIT OF SOCIETY

A. Concepts of Family

FAMILY
-U.S census Bureau: a group of people related by blood, marriage, or adoption living together
-Allender and Spradley (2004): two or more people who live in the same household (usually) share a
common emotional bond, and perform certain interrelated social tasks
=better definition for HCP’s because it addresses the broad range of types of families that they
encounter
-primary institution in society that preserves and transmits culture
-MAGLAYA: a very important social institution that performs 2 major functions- reproduction and
socialization
-performs health promoting, health maintaining, and disease preventing activities
-family is the locus of decision making on health matters.
-it is the source of the most solid support and care to its members, particularly to
the young, the elderly, the disabled, and the chronically ill.
-FRIEDMAN: two or more persons who are joined together by bonds of sharing and emotional
closeness and who identify themselves as being part of the family

- PHC -family is the basic social institution and the primary group in society
-a social group characterized by common residence, economic cooperation and reproduction
-includes both sexes, at least two of who maintain a socially approved sexual relationship,
and one or two children

B. Types of Family

2 BASIC FAMILY TYPES:

1. FAMILY OF ORIENTATION
-the family one is born into; or oneself, mother, father, and siblings, if any
2. FAMILY OF PROCREATION
-a family one establishes; or oneself, spouse or significant other, and children

 THE DYAD FAMILY

-consists of 2 people living together, usually a woman and a man, without children
-generally viewed as temporary arrangements, but if the couple chooses child-free living, this
can also be a lifetime arrangement

 THE NUCLEAR FAMILY

-composed of a husband, wife, and children
-most common structure
-advantage: ability to provide support to family members, because with its small size, people
feel with genuine affection for each other

 THE COHABITATION FAMILY

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 -are composed of heterosexual couples who live together like a nuclear family but remain
unmarried
-may be temporary, may also be a long-lasting and as meaningful as a more traditional
alliance and therefore offer as much psychological comfort and financial security as marriage

 THE EXTENDED (MULTIGENERATIONAL) FAMILY

-includes not only one nuclear family but also other family members such as grandmothers,
grandfathers, aunts, uncles, cousins and grandchildren
-advantage: contains more people to serve as resources during crises and provides more role
models for behaviour and values
-disadvantage: family resources such as, financial and psychological, must be stretched to
accommodate all members.

 THE SINGLE-PARENT FAMILY

-increase is a result of both the high rate of divorce and the increasingly common practice of
women raising children outside marriage
-PROBLEMS:
>if the parent is ill, there is no back-up person for child care. If child is ill,
there is no close support person to give reassurance or second opinion on
whether the child ‘s health is worsening or improving.
>low-income: because the parent is most often women, and women’s
income are lower than men’s
>they may also have difficulty with role modelling or clearly identifying
their role in the family.( mentally and physically exhausting)
>single-parent fathers: may have difficulty with home management or child
care if they had little experience with these roles before the separation

 THE BLENDED FAMILY

-or remarriage, or reconstituted family, a divorced or a widowed person with children marries
someone who also has children
-advantages:
>increased security and resources for the new family
>children of blended family are exposed to different ways of life and may
become more adaptable to new situations
-problems:
>childrearing problems may arise- rivalry among the children for the
attention of a parent or from competition with the stepparent for the love of
the biologic parent.
>children may not welcome stepparent because they have not yet resolved their feelings of
separation of their biologic parents
-roles of nurses: offer emotional support to members of a remarriage family until the adjustments for
mutual living have been made

 THE COMMUNAL FAMILY

 THE GAY OR LESBIAN FAMILY
-individuals of the same sex live together as partners of companionship, financial security, and sexual
fulfilments

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-offers support in times of crisis comparable to that offered by nuclear or cohabitation family
-include children from previous heterosexual marriages through the use of artificial insemination,
adoption or surrogate motherhood

 THE FOSTER FAMILY

-children whose parents can no longer care for them may be placed in a foster or substitute home by
a child protection agency
-foster parents may or may not have children of their own
-they receive remuneration for their care and concern for the foster child
-foster home placement is temporary until children can be returned to their own parents
-if not possible, children may be raised to adulthood in foster care
-when caring for children from foster homes, it is important to determine who has legal responsibility
to determine who has legal responsibility to sign for health care (a foster parent may or may not
have this responsibility)

 THE ADOPTIVE FAMILY

-methods of adoption:
1. agency adoption
-a couple contacts an agency by first attending an informational meeting
-if they decide to apply to the agency, they are then put on a waiting list for processing
-the process includes extensive interviewing and a home visit by an agency social worker to
determine whether the couple can be relied on to provide a safe and nurturing environment for an
adopted child.
-once approved, the couple is placed on a second waiting list
-when a child has been located for them. The agency notifies the parent

C. Stages of Family Development

FAMILY STAGES

1. BEGINNING FAMILY
 TASKS:
-establishing a mutually satisfying marriage
-planning to have or not to have children

2. CHILD-BEARING FAMILY
 TASKS:
-having and adjusting to infant
-supporting the needs of all three members
-renegotiating marital relationships

3. FAMILY WITH PRE-SCHOOL CHILDREN

 TASKS:
-adjusting to costs of family life
-Adapting to the needs of pre-school
-coping with parental loss of energy and privacy

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 4. FAMILY WITH SCHOOL-AGE CHILDREN
 TASKS:
-adjusting to the activity of the growing children
-promoting joint decisions between children and parents
-encouraging and supporting children’s educational achievements

5. FAMILY WITH TEEN-AGERS AND YOUNG ADULTS

 TASKS:
-maintaining open communication among members
-supporting ethical and moral values within the family
-balancing freedom with responsibility of teen-agers
-releasing young adults with appropriate rituals and assistance

6. POST-PARENTAL FAMILY
 TASKS:
-strengthening marital relationships
-Maintaining supportive home base
-preparing for retirement
-maintaining ties with younger and older generations

7. AGING FAMILY
 TASKS:
-adjusting to retirement
-Adjusting to loss of spouse
-Closing family house

D. Family Structures and Functions

FAMILY STRUCTURES

BASED ON INTERNAL ORGANIZATION AND MEMBERSHIP

1. NUCLEAR
-also known as primary or elementary family
-composed of the father, mother, and children

2. EXTENDED
-composed of two or more nuclear families related to each other economically or socially
-extensions may be through the parent-child relationships , when the unmarried children
and the married children with their families live with the parents
-another extension is through the husband-wife relationship, as in polygamous marriage

BASED ON PLACE OF RESIDENCE

1. Patrilocal
-requires the newly-wed couple to live with the family of the bridegroom or near the
residence of the parents of the bridegroom

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 2. Matrilocal
-requires the newly-wed couple to live with or near the residence of the bride’s parents

3. Bilocal
-provides the newly-wed couple the choice of staying with either the groom’s parents or
the bride’s parents, depending on factors like the relative wealth of the families or their
status, the wishes of their parents, or certain personal preferences of the bride or the
groom

4. Neolocal
-permits the couple to reside independently of their parents
-they can decide on their own as far as their residence is concerned

5. Avunculocal
-prescribes the newly-wed couple to reside with or near the maternal uncle of the groom

BASED ON DESCENT
1. Patrilineal
-affiliates a person with a group of relatives through his or her father

2. Matrilineal
-affiliates a person with a group of relatives through his or her mother

3. Bilateral
-affiliates a person with a group of relatives related through both his or her parents

BASED ON AUTHORITY
1. Patriarchal
-authority is vested in the oldest male in the family, often the father

2. Matriarchal
-authority is vested in the mother or mother’s kin

3. Egalitarian
-the husband and wife exercises a more or less equal amount of authority

4. Matricentric
-prolonged absence of the father gives the mother a dominant position in the family,
although the father may also share with the mother in desicion-making

E. Functions of Family
-defined as the ability of the family to meet the needs of its members through developmental
transitions
-indicators:
1. Regulates sexual behavior and reproduction.

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 2. Biological maintenance function.
3. Socialization function.
4. The family gives its members a status.
5. Social control function.
6. Economic functions.

- Indicators:
1. Socialization of new family members.
2. Regulation of members' behaviours with performance of expected roles.
3. Adaptation to developmental transitions and unexpected crises.
4. Creation of an environment for free expression by members.
5. Support and assistance for one another.
6. Expression of loyalty to family.
7. Participation in community activities.
8. Involvement in problem solving and conflict resolution.
Acceptance of diversity among members.

F. Characteristics of Family

CHARACTERISTICS OF FAMILY:
1. The family as a social group is universal and is significant element in man’s social life.
2. It is the first social group to which the individual is exposed.
3. Family contact and relationships are repetitive and continuous.
4. The family is very close and intimate group.
5. It is the setting of the most intense emotional experiences during the life time of individual.
6. The family affects the individual’s social values, disposition, and outlook in life.
7. The family has the unique position of serving as a link between the individual and the larger
society.
8. The family is also unique in providing continuity of social life.
LESSON 2: LEVELS OF PREVENTION IN FAMILY HEALTH

Primary Prevention
Providing specific protection against disease to prevent its occurrence is the most desirable form of
prevention. Primary preventive efforts spare the client the cost, discomfort and the threat to the
quality of life that illness poses or at least delay the onset of illness. Preventive measures consist of
counseling, education and adoption of specific health practices or changes in lifestyle.
Examples:
a. Mandatory immunization of children belonging to the age range of 0 – 50 months old to
control acute infection diseases.
b. Minimizing contamination of the work or general environment by asbestos dust, silicone
dust, smoke, chemical pollutants and excessive noise.
c. Proper nutrition, proper attitude towards sickness, proper and prompt utilization of
available health and medical facilities, handwashing

Secondary Prevention
It consists of organized, direct screening efforts or education of the public to promote early case
finding of an individual with disease so that prompt intervention can be instituted to halt pathologic

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processes and limit disability. Early diagnosis of a health problem can decrease the catastrophic
effects that might otherwise result for the individual and the family from advanced illness and its
many complications.
Examples:
a. Public education to promote breast self-examination, use of home kits for detection of
occult blood in stool specimens and familiarity with the seven cancer danger signals.
b. Screening programs for hypertension, diabetes. Uterine cancer (pap smear), breast
cancer (examination and mammography), glaucoma and sexually transmitted disease.

Tertiary Prevention
It begins early in the period of recovery from illness and consists of such activities as consistent and
appropriate administration of medications to optimize therapeutic effects, moving and positioning to
prevent complications of immobility and passive and active exercise to prevent disability. Continuing
health supervision during rehabilitation to restore an individual to an optimal level of functioning.
Minimizing residual disability and helping the client learn to live productively with limitations are the
goals of tertiary prevention. (Pender, 1987)
Examples:
a. Rehabilitation therapy and physical therapy after stroke
b. Speech therapy after a laryngectomy
c. Insulin therapy for Diabetics
LESSON 3: THE FAMILY HEALTH NURSING PROCESS

FAMILY HEALTH NURSING

- Level of community health nursing practice directed or focused on the family as the unit of
care with health as the goal and nursing as the medium and the nurse as the channel or
provider of care.

3. A. Conducting Family Health Assessment

Assessment of the family helps nurses identify the health status of individual members of the
family and aspects of family composition, function and process. The nurse as much information about
a familyas is possible and practical. The process of family health assessment does not stop and
requires objectivity and professional judgment to attach practical meaning to the information being
acquired.

The nurse may use a tool called Family Health Assessment Form (Appendix A). or the initial
database to be a guide in data collection. Over time and depending on the guidelines of the agency,
the tool can be modified or updated.

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STEPS IN FAMILY NURSING ASSESSMENT
1. Data Collection
- Gathering of five types of data which will generate the categories of health
conditions or problems of the family.
2. Data Analysis
- Sort data
- Cluster/group related date
- Distinguish relevant from irrelevant data
- Identify patterns
- Compare patterns with norms or standards
- Interpret results
- Make inferences/draw conclusions
3. Formulation of Nursing Diagnoses
- Identification of Family Nursing Problems.

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE

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
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 patterns 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 diseases (e.g. mosquitoes, roaches,
flies, rodents, etc.)
d. Presence of accident hazards
e. Food storage and cooking facilities
f. Water supply – source, ownership, potability

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 g. Toilet facility – type, ownership, sanitary condition
h. Garbage/refuse dispossi – type, sanitary condition
i. Drainage system – type, sanitary condition
2. Kind of neighborhood, e.g. congested, slum, ect.
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 at – risk members)
a. Anthropometric data
 Measures of nutritional status of children – weight, height, mid – upper arm
circumference
 Risk assessment measures for Obesity – body mass index (BMI = weight in
kgs. divided by height in meters), waist circumference (WC: greater than 90
cm in men and greater than 80 cm in women), waist hip ratio (WHR = waist
circumference in cm divided by hip circumference in cm). Central obesity: WHR
equal to or greater than 1 cm in men and 0.85 cm in women.
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
specific lifestyle diseases – 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 o 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.

Examples include:
1. Immunization status of family members
2. Healthy lifestyle practices, Specify
3. Adequacy of
a. rest and sleep
b. exercise/activities
c. use of protective measures – e.g. adequate footwear in parasite infected areas, use of
bednets and protective clothing in malaria endemic areas
d. relaxation and other stress management activities
4. Use of promotive – preventive health services

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METHODS OF DATA GATHERING

1. Observation
- Method of data collection through the use of sensory capacities (sight, hearing, smell and
touch).
- Data gathered through this method have the advantage of being subjected to validation
and reliability testing by other observers.
2. Physical Examination
- Done through inspection, palpation, percussion, auscultation, measurement of specific
body parts and reviewing the body systems.
3. Interview
- Completing the health history of each family member. The health history determines
current health status based on significant past health history.
- The second type of interview is collecting data by personally asking significant family
members or relatives questions regarding health, family life experiences and home
environment to generate data on what wellness condition and health problems exist in the
family.
- Productivity of the interview process depends upon the use of effective communication
techniques to elicit the needed responses.
4. Record Review
- Reviewing existing records and reports pertinent to the client. (individual clinical records of
the family members; laboratory & diagnostic reports; immunization records; reports about
the home & environmental conditions).
5. Laboratory/Diagnostic Tests
- performing laboratory tests, diagnostic procedures or other tests of integrity and functions
carried out by the nurse herself and/or other health workers.

TOOLS USED IN FAMILY ASSESSMENT

GENOGRAM
- A genogram is a pictorial, multi-generational representation of familial relationships and
patterns of behavior.
Purpose:
- To engage the family in pictorially summarizing and illustrating familial relationships and
patterns of behavior within a family system in support of family assessment and
intervention planning.
ECOMAP
- A pictorial representation of a family’s connection to the persons and systems in their
environment. It illustrates three separate dimensions for each connection:
1.      the strength of the connection- (weak, tenuous/uncertain, strong);
2.      the impact of the connection-   (no impact, draining resources/energy, providing 
resources/energy);
3.      the quality of the connection (stressful).
Purpose:
- To support classification of family needs and decision-making about potential
interventions.  Further, it is to create a shared awareness (between a family and their

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 social worker) of the family’s significant connections, and the constructive and destructive
influences those connections may be having.

FAMILY HEALTH TREE

- Provides a mechanism for recording the family’s medical and health histories.
Purpose:
- To plan positive familial influences on factors on risk factors such as diet, exercise, coping
with stress, or pressure to have physical examination

4. B. Typology of Nursing Problems in Family Nursing Practice

FIRST LEVEL ASSESSMENT

I. Presence of Wellness Condition – stated as Potential or Readiness – a clinical or nursing

judgment about a client in transition from a specific level of wellness or capability to a
higher level.

Wellness potential
 Nursing judgment on wellness state or condition based on client’s performance, current
competencies or clinical data but no explicit expression of client desire.

Readiness for enhanced wellness state

 Nursing judgment on wellness state or condition based on client’s current competencies or
performance, clinical data and explicit expression of desire to achieve a higher level of state or
function in a specific area on health promotion and maintenance.

Examples
A. Potential for Enhanced Capability for:
1. Healthy lifestyle – e.g nutrition/diet, exercise/activity
2. Health Maintenance/Health Management
3. Parenting
4. Breastfeeding
5. Spiritual Well – being – process of a client’s developing/unfolding of mystery through
harmonious interconnectedness that comes from inner strength/sacred source/God
6. Others, specify

B. Readiness for Enhanced Capability for:

1. Healthy lifestyle – e.g nutrition/diet, exercise/activity
2. Health Maintenance/Health Management
3. Parenting
4. Breastfeeding
5. Spiritual Well – being – process of a client’s developing/unfolding of mystery through
harmonious interconnectedness that comes from inner strength/sacred source/God
6. Others, specify

II. Presence of health threats – conditions that are conducive to disease, accident or failure to
realize one’s health potential. Examples:

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A. Family history of hereditary condition/disease, e.g diabetes
B. Threat of cross infection from a communicable disease case
C. Family size beyond what family resources can adequately provide
D. Accident hazards, specify
1. broken stairs
2. pointed/sharp objects, poisons, and medicines improperly kept
3. fire hazards
4. fall hazards
5. others, specify
E. Faulty/unhealthful nutrition/eating habits or feeding techniques/practices, specify
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, specify
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, specify
1. inadequate living spaces
2. lack of food storage facilities
3. polluted water supply
4. presence of breeding or resting sites of vectors of diseases (e.g. mosquitoes,
roaches, flies, rodents, etc.)
5. improper garbage disposal
6. unsanitary waste disposal
7. improper drainage system
8. poor lighting and ventilation
9. noise pollution
10. air pollution
H. Unsanitary food handling and preparation
I. Unhealthy lifestyle and personal habits/practices, specify
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 relaxation activities
12. non – use of self – protection measures (e.g non use of bed nets in malaria
and filariasis endemic areas)

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 J. Inherent personal characteristics – e.g poor impulse control
K. Health history which may participate/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.
1. self – oriented behavior of members
2. unresolved conflicts of members
3. intolerable disagreement
O. Others, specify

III. Presence of health deficits – instances of failure in health maintenance. Examples include:
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 congenital or arising from illness; transient/temporary (e.g. aphasia
or temporary paralysis after a CVA) or permanent (e.g. leg amputation secondary to
diabetes, blindness from measles lameness from polio)

IV. Presence of stress points/foreseeable crisis situation – anticipated periods of unusual

demand on the individual or family in terms of adjustment/family resources. Examples
include:
A. Marriage
B. Pregnancy, labor, puerperium
C. Parenthood
D. Addition 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. Others, specify

SECOND LEVEL ASSESSMENT

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 peer/significant others
2. economic/cost implications

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 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 about by perceived
magnitude/severity of the situation or problem, i.e. failure to break down problems into
manageable units of attack
D. Lack of/inadequate knowledge/insight as to alternative courses of action open to them.
E. Inability to decide which action to take from among a list of alternatives.
F. Conflicting opinions among family members/significant others regarding action to take.
G. Lack of/inadequate knowledge of community resources for care.
H. Fear of consequences of action, specifically:
1. social consequences
2. economic consequences
3. physical consequences
4. emotional/psychological consequences
I. Negative attitude towards the health condition of problem –by negative attitude is
meant one that interferes with rational decision making.
J. Inaccessibility of appropriate resources of care, specifically:
1. physical inaccessibility
2. cost constraints of economic/financial inaccessibility

K. Lack of trust/confidence in the health personnel/agency

L. Misconceptions or erroneous information about proposed course(s) of action.
M. Others, specify

III. Inability to provide adequate nursing care to the 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 child development and care
C. Lack of/inadequate knowledge of the nature and extent nursing care needed
D. Lack of the necessary facilities, equipment and supplies for care
E. Lack of or inadequate knowledge and skill in carrying out the necessary
interventions/treatment/procedure/care (e.g., complex therapeutic regimen of healthy
lifestyle program)
F. Inadequate family resources for care, specially:
1. absence of responsible member
2. financial constraints
3. limitations/lack of physical resources – e.g., isolation room
G. Significant person’s unexpressed feelings (e.g., hostility/anger, guilt, ear/anxiety,
despair, rejection) which disable his/her capacities to provide care.

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 H. Philosophy in life which negates/hinder caring for the sick, disabled, dependent,
vulnerable/at-risk member
I. Member’s preoccupation with own concerns/interests
J. Prolonged disease or disability progression which exhausts supportive capacity of family
members
K. Altered role performance – specify:
1) Role denial or ambivalence
2) Role strain
3) Role dissatisfaction
4) Role conflict
5) Role confusion
6) Role overload
L. others, specify

IV. Inability to provide a home environment conductive to health maintenance and personal
development due to:
A. Inadequate family resources, specifically
1. financial constraints/limited financial resources
2. limited physical resources – e.g., lack of space to construct a family
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 conductive 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 family’s preoccupation with current problem or condition)
J. 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:
1. physical/psychological consequences
2. financial consequences
3. 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:
1. cost constraints
2. physical inaccessibility, i.e. location of facility

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 H. Lack of or inadequate family resources, specifically:
1. manpower resources –e.g., baby sitter
2. 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

STATEMENT OF FAMILY NURSING PROBLEM

TWO PARTS:
 Statement of unhealthful response
 Statement of factors which are maintaining the undesirable response and preventing the
desired change
Example
 Inability to make decisions with respect to taking appropriate health action due to lack of
knowledge as to alternative courses of action open to the family
3. C. Family Nursing Care Plan

THE FAMILY CARE PLAN

- Is the blueprint of the care that the nurse designs to systematically minimize or eliminate
the identified health and family nursing problems through explicitly formulated outcomes of
care ( goals and objectives) and deliberately chosen of interventions, resources and
evaluation criteria, standards, methods and tools.
DESIRABLE QUALITIES OF A NURSING CARE PLAN
1. It should be based on clear, explicit definition of the problems. A good nursing plan is based
on a comprehensive analysis of the problem situation.
2. A good plan is realistic.
3. The nursing care plan is prepared jointly with the family. The nurse involves the family in
determining health needs and problems, in establishing priorities, in selecting appropriate
courses of action, implementing them and evaluating outcomes.
4. The nursing care plan is most useful in written form.

THE IMPORTANCE OF PLANNING CARE

1. They individualize care to clients.

2. The nursing care plan helps in setting priorities by providing information about the client as
well as the nature of his problems.
3. The nursing care plan promotes systematic communication among those involved in the health
care effort.
4. Continuity of care is facilitated through the use of nursing care plans. Gaps and duplications in
the services provided are minimized, if not totally eliminated.
5. Nursing care plans, facilitate the coordination of care by making known to other members of
the health team what the nurse is doing.

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STEPS IN DEVELOPING A FAMILY NURSING CARE PLAN
1. The prioritized condition/s or problems based on:
a. NATURE OF CONDITION/ PROBLEM PRESENTED
- Categorized as wellness state/potential, health threat, health deficit, foreseeable crisis.
b. MODIFIABILITY OF THE CONDITION/PROBLEM
- Probability of success in enhancing the wellness state, improving the condition,
minimizing, alleviating or totally eradicating the problem through intervention.
c. PREVENTIVE POTENTIAL
- Nature and magnitude of future problems that can be minimized or totally prevented if
intervention is done on the problem under consideration.
d. SALIENCE
- Family’s perception and evaluation of the problem in terms of seriousness and urgency
of attention needed or family readiness

Scoring – this process will help the nurse in determining which among the family problems or needs
be prioritized

1. Decide a score for each of the criteria

2. Divide the score by the highest possible score in that item and multiply by the weight
 Score x weight
Highest score
3. Sum up the scores of all criteria. The highest score is 5 which is equivalent to the total weight.
4. The highest score is given the priority, and so on with depending on the next highest score

CRITERIA SCALE WEIGHT

Nature of the problems Presented
Health deficit / Wellness 3 1
Health threat 2
Foreseeable crisis 1
Modifiability of the problem
Easily modifiable 2 2
Partially modifiable 1
Not modifiable 0
Preventive potential
High 3 1
Moderate 2
Low 1
Salience
A condition / problem needing Immediate attention 2 1
A condition / problem not needing Immediate 1
attention

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 Not perceived as a problem or condition needing 0
change

Factors affecting priority setting:

The nurse considers the availability of the following factors in determining the modifiability of a
health condition or problem.

1. Current Knowledge, technology and interventions

2. Resources of the family - physical, financial & 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 w/c 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 w/ reasonable chance of success
3. It should be consistent w/ the goals & philosophy of the health agency.
4. It’s drawn w/ the family.
5. It’s best kept in written form.

Setting/ Formulating Goals & Objectives

 This will set direction of the plan.
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  This should be stated in terms of client outcomes whether at the individual, family or community
level.
 The mutual setting of goals w/c 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 family’s 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.
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 w/c require immediate attention & results can be observed
in a relatively short period of time.
 They are accomplished w/ few HCP-family contacts & relatively less resources.
2. Medium or Intermediate objective
 Objectives w/c 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

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  Its aim is to minimize all the possible reasons for causes of the family’s 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 client’s capacity.

3. D. Implementation
 Actual doing of interventions to solve health problems.
 Determined by mutually agreed goals and objectives
 It can be: direct nursing care, assisting the family to meet health needs and problems and
referrals to proper agencies

Barriers to Implementation
A. Family-related: indecision, apathy
B. Nurse-related: imposing ideas, negative labeling, overlooking family strengths and neglecting
cultural and gender implications

3. E. 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:
 Ongoing Evaluation – analysis during the implementation of the activity, its relevance,
efficiency and effectiveness.
 Terminal Evaluation – undertaken 6-12 months after the care was completed.
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  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

The goals and objectives of nursing care.

FORMULATE:
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 EXPECTED OUTCOMES
- Conditions to be observed to show problem is prevented, controlled, resolved or
eliminated.
- Client response/s or behavior
- Specific, Measurable, Client-centered Statements/Competencies
GOAL
- general statement of the condition; state to be brought about by specific courses of
action
- E.g. after nursing intervention, the family will be able to take care of the disabled child
competently

Cardinal Principle in goal-setting:

- Goals must be set jointly with the family
Barriers to nurse - patient joint goal setting:
- Failure on the part of the family to perceive existence of the problem
- The family may realize the existence of a health condition or problem but too busy at the
moment with other concerns and preoccupations
- Family perceives the existence of problem but does not see it as serious to warrant attention
- Family may perceive the presence of the problem and the need to take action
- Failure to develop working relationship
Reasons:
- Fear of consequence
- Respect for tradition
- Failure to perceive the benefits of action proposed
- Failure to relate the proposed action to the family’s goals

OBJECTIVES
- Best stated in terms of client outcomes
- Refer more specific statements of the desired results or outcomes of care

Categories of Objectives:
 LONG TERM/ULTIMATE – require several nurse – family encounters and an investment of
more resources
 SHORT TERM / IMMEDIATE – require immediate attention and results can be observed in a
relatively short period of time
 MEDIUM TERM / INTERMEDIATE – not immediately achieved and are required to attain long –
term ones

2. The plan of interventions.

 Decide on:
 Measures to help family eliminate:
 Barriers to performance of health tasks
 Underlying cause/s of non-performance of health tasks
 Family-centered alternatives to recognize/detect, monitor, control or manage health
condition or problems
 Determine Methods of Nurse-Family Contact
 Specify Resources Needed
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 3. The plan for evaluating.
 Criteria/Outcomes Based on Objectives of Care
 Methods/Tools

Categories of health care strategies and intervention

1. Preventive
2. Curative
3. Rehabilitative
4. Facilitative
5. Facilitation
6. Direct

FAMILY-NURSE CONTACTS

CLINIC VISIT
Pre-Consultation Conference
1. Take clinical history after greeting and making client at ease.
2. Take temperature, blood pressure, height and weight.
3. Perform a thorough physical assessment.
4. Do selective laboratory examinations such as urinalysis for sugar and albumin as necessary,
sputum exam, stool examination for parasites, vaginal smear for SID screening after taking the
necessary training.
5. Write findings on client's record.

Medical Examination
1. Assist client before, during and after examination by physician.
2. Inform physician of relevant findings gathered in pre-conference.
3. Work with the physician during the examination.
4. Ensure privacy, safety and comfort of patient throughout procedure.
5. Observe confidentiality of examination results.

Nursing Intervention
1. Carry out physician's orders as giving medication or injection.
2. Explain and reinforce physician's orders and advises.
3. Teach patient/client measures designed to promote and maintain health as proper diet, exercise
and personal hygiene.
4. Seek information regarding health status of other family members.
Example: immunization status of children, health and problems of elderly if any, health of
husband.
4. Counseling

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Post Consultation Conference
1. Explain findings and needed care or intervention.
2. Refer patient/client to other health of related staff/agency if necessary.
3. Make appointment for next clinic/home visit.
4. Referral as needed.
New: Standard procedures performed during clinic visits
1. registration/Admission
2. waiting time (1st come, 1st serve except for emergency)
3. triaging
a. manage program-based cases
b. refer all non-program based cases to the physician
c. provide 1st aid treatment to emergency cases
4. clinical evaluation
5. lab/ diagnostic exam
6. referral system
7. prescription/dispensing: give proper instructions on drug intake
8. health education

Blood Pressure Measurement

1. Preparatory: 5min rested, no cigar nor caffeine within 30 min prior to BP taking
2. Applying BP cuff & steth: 2-3 cm above brachial artery
3. Obtaining BP: use bell (diaphragm for obese); column reaches 30 mmHg above palpated BP;
deflate at 2-3mm Hg/beat; [pulse sound (korotkoff sounds): 1 st clear sound as korotkoff phase
I, softening/muffling sound as korotkoff phase IV, disappearance of sound as Korotkoff phase
V)
4. Recording BP: mean of 2 reading 2 min apart, if 5 min difference, do 3rd reading

Home Visit
- is a professional face to face contact made by a nurse to the client or the family to
provide necessary health care activities and to further attain an objective of e agency. It is
made to the client or to a responsible member of the family.

Principles in Preparing for Home Visit

Planning for a home visit is an essential tool in achieving best results.
1. A home visit should have a purpose or objective.
2. Planning for a home visit should make use of all available information about the patient and
his/her family through family health records; knowledge of the health center personnel, including
those from other agencies that may have rendered services to this particular patient or family.
3. Planning should revolve around the essential needs of the individual and his/her family but
priority should be given to those needs recognized by the family itself.
4. Planning of a continuing care should involve the individual and his/her family.
5. Planning should be flexible and practical.

24
Factors to be Consider in Determining the Frequency of Home Visit
 Acceptance of the family for the services offered; the willingness and interest to cooperate.
 Physical, psychological and educational needs of individual/ family.
 Take into account other health agencies and the number of health personnel already involved in
the care of a specific family
 Policy of a given agency and the emphasis placed on a given health program.
 Careful evaluation of past services given to a family and how this family made use of such
nursing services.
 Ability of the patient and his/her family to recognize their own needs, their knowledge of
available resources and their abilities to use these resources on their own accord.

Advantages Disadvantages
First hand assessment of the home situation Cost of time and effort
Nurse is able to seek out previously Environmental distractions
unidentified needs Nurse’s safety may be a concern
Opportunity to adapt interventions according
to family resources
Promotes family participation
Focused on the family
Easier family health education
Increased sense of confidence to the family
and to the agency

Phases of Home Visit

Home visit is consisting of three phases: pre-visit, in-home visit, and post-visit phases.
A. Pre-visit phase
Activities:
- Nurse contacts the family for home visit
- Determines willingness for visit
- Appointment-setting
- Planning phase
Principles:
- The home visit should have a purpose.
- Use information about the family collected from all possible sources. This is to analyze the
family’s situation.
- Focused on identified family needs, particularly needs recognized by the family.
- The family or the client should actively participate in the plan and implementation of care.
- Plan should be practical and adaptable.
Before leaving the health facility:
- The nurse must ensure the completeness of materials or resources he/she needs.
- The nurse must comply to safety protocols.
- Buddy system and a spot map is suggested.

25
 B. In-home visit phase
- Begins as the nurse seeks permission to enter the house and lasts until he/she leaves.
Activities:
B.1. Initiation:
- Knock or ring the doorbell while introducing self to the family.
- Acknowledge the family members
- Introduce self and the agency represented
- Observe the environment
- Establish rapport

B.2. Implementation:
- Assessment can be done. Depending on the type of assessment: physical examination,
interview and/or simple diagnostic procedures. Family Assessment form is suggested to
facilitate the assessment (Appendix A)
- Direct nursing care as needed. Direct and/or basic nursing care, health teachings and
counselling may be implemented. Interventions beyond the nurse’s capability or due to limited
resources may be referred.
- Observation and evaluation of health practices and family dynamics

B.3. Termination:
- Summarizing what transpired within the visit
- Setting a subsequent home visit
- Record findings

C. Post-visit phase
- Takes place when the nurse already returned to the health facility
- Documentation of the visit
- Referrals can be made
- Planning for the next visit

Steps in Home Visit

1. Greet client or household member and introduce yourself.
2. Explain purpose of home visit.
3. Inquire about health and welfare of client/patient and other family members. Ask about
any health and health-related problems.
4. Place bag in a convenient place before doing bag technique.
5. Wash hands and wear apron and put out needed articles and/or medicines, dressings from bag
6. Perform physical assessment and nursing care needed. If more than one member of the family is
for health supervision and care, start with the well member to avoid transfer of infection.
7. Give the necessary health teaching and advice based on client's patient's need and condition.

26
8. Wash hands and close bag.
9. Record findings and nursing care given.
10. Make appointment either for a clinic or home visit.
11. On succeeding home visit and when nurse has gained the family's trust and confidence, she/he
may look into more detailed aspects of the household and surroundings and other health
problems/concerns.

The Nursing Bag

- Also called PHN bag, is a tool used by the nurse during home and community visits to provide
care efficiently and safely.
- Handwashing always a must
- It supports the idea that the nurse must be prepared for different situations while in the
community or in a visit.

Bag Technique

Bag technique - a tool making use of a public health bag through which the nurse, during his/her
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 - is an essential and indispensable equipment of the public health nurse which
he/she has to carry along when he/she goes out home visiting. It contains basic medications and
articles which arc necessary for giving care.
Rationale: To render effective nursing care to clients and/or members of the family during home visit.

Principles in the use of bag technique

1. should minimize if not totally prevent the spread of infection from individuals to families,
hence, to the community.
2. should save time and effort on the part of the nurse in the performance of nursing procedures.
3. should not overshadow concern for the patient rather should show the effectiveness of total
care given to an individual or family.
4. can be performed in a variety of ways depending upon agency policies, actual home situation, etc.,
as long as principles of avoiding transfer of infection is carried out.

Special Considerations in the Use of the Bag

1. contain all necessary articles, supplies and equipment used to answer emergency needs.
2. be cleaned as often as possible, supplies replaced and ready for use at any time.
3. well protected from contact with any article in the home of the patients. Consider the bag and
its contents clean and/or sterile while any article belonging to the patient as dirty and
contaminated.
4. arrangement of the contents of the bag should be the one most convenient to the user to facilitate
efficiency and avoid confusion.

27
5. Hand washing is done as frequently as the situation calls for
6. bag when used for a communicable case should be thoroughly cleaned and disinfected before
keeping and re-using.

Contents of the bag

1. Paper lining
2. Extra paper for making bag for waste materials (paper bag).
3. Plastic/linen lining
4. Apron
5. Hand towel in plastic bag
6. Soap in soap dish
7. Thermometers in case [one oral and rectal]
8. 2 pairs of scissors [1 surgical and 1 bandage]
9. 2 pairs of forceps [curved and straight]
10.Syringes [5 ml and 2ml]
11.Hypodermic needles g19,22,23,25
12.Sterile dressings [OS, C.B]
13.Sterile Cord Tie
14.Adhesive Plaster
15.Dressing [OS, cotton ball]
16.Alcohollamp
17.Tape measure
18.Baby's scale
19.1 pair of rubber gloves
20. 2 test tubes
21.Test tube holder
22.Medicines:
a. Betadine
b. 70% alcohol
c. ophthalmic ointment (antibiotic)
d. zephiran solution
e. hydrogen peroxide
f. spirit of ammonia
g. acetic acid
h. benedict's solution

28
Note: Blood Pressure Apparatus and Stethoscope are carried separately.

TEACHER’S INSIGHTS:
Community health nurses do not only work with individuals, but work hand in hand at
least with a family. Dealing with families is likewise challenging due to its nature,
dynamics and traditions within and in the community, they live in. The family remains
to be the basic unit of a society and also the unit of care. With this reason, the health
status of the families will also dictate the health status of the community. Caring for a
family also cares for the community. This section of the learning material provided the
different accepts and tools for the application of the nursing care process on the family
level.
Community health nurses provides nursing care to individual and family which the result
will be the health of the community and the larger society.
LESSON 1: CONCEPT OF PUBLIC HEALTH

PUBLIC HEALTH
- 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 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.
 Dr. C.E. Winslow
- art of applying science in the context of politics so as to reduce inadequalities in
health while ensuring the best health for the greatest number
 WHO

PUBLIC HEALTH 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
- nursing practice in the public sector

CORE FUNCTIONS OF PUBLIC HEALTH

1. Disease control
2. Injury prevention
3. Health protection
4. Healthy public policy
5. Promotion of health and equitable health gain

29
PUBLIC HEALTH NURSE
- nurses in the local/national health departments or public schools whether their
official position title is PHN or nurse or school nurse

Roles and Functions of the Public Health Nurse

- health promotion and education function; training function; research function

 Clinician - health care provider, taking care of the sick people at home or in the
RHU
 Health Educator - aims towards health promotion and illness prevention through
dissemination of correct information; educating people
 Facilitator - establishes multi-sectoral linkages by referral system
 Supervisor- monitors and supervises the performance of midwives

*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
MHO’s responsibilities.

Other Specific 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 physician
 Provision 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
 Case finding and epidemiological investigation
 Program planning, implementation and evaluation
 Influencing executive and legislative individuals or bodies concerning health and
development

LESSON 2: CONCEPT OF COMMUNITY HEALTH NURSING

COMMUNITY
- 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

30
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

NURSING
- assisting sick individuals to become healthy and healthy individuals achieve optimum
wellness

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.”
- Maglaya, et al

GOAL
“To raise the level of citizenry by helping communities 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

OBJECTIVES:
1. To participate in development of an over-all health plan for the community
2. To provide quality nursing services
3. To coordinate nursing services with various membranes of the health team
4. To participate in and/or conduct researches relevant
5. To provide community health nursing personnel for continuing education and
professional growth

BASIC PRINCIPLES OF CHN

1. The community- the patient in CHN
the family is the unit of care and there
four levels of clientele: individual, family, population group (those who share
common characteristics, developmental stages and common exposure to health
problems – e.g. children, elderly), and the community.
2. In CHN, the client is considered as an ACTIVE partner NOT PASSIVE recipient of
care
3. CHN practice is affected by developments in health technology, in particular, changes
in society, in general
4. The goal of CHN is achieved through multi-sectoral efforts
5. CHN is a part of health care system and the larger human services system.

31
6. Based on the needs of the clients
7. CHN must be available to all
8. Health teaching is a primary responsibility
9. Use available community health resources

CONCEPTS
1. The focus is on health promotion
2. Contact with client may continue over long period of time
3. The dynamic nursing care process is implicit in the practice of CHN
4. To benefit the whole family, not only the individual
5. CHNurses are generalists

ROLES AND RESPONSIBILITIES OF COMMUNITY HEALTH NURSE

1. Planner/ Programmer- identifies needs, priorities & problems if individual, family,

& comm.
- Formulates nursing component of health 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
gov’t org (GOs & NGOs) to other health programs as environment, sanitation health
education, dental health & mental health.

Other related functions:

1. Trainer/ Health educator/ counselor- conducts training for rural health midwives
(RHMs), barangay health workers (BHWs), hilots who aim towards H promo &
illness prevention through dissemination of correct information;
- educating people

32
 2. Researcher- coordinates with government and non-government organizations
NGOs in the implementation of studies/researches
- participates in the conduct of surveys studies & researches on nursing and
health related subjects.
3. Health Monitor-evaluating what deviates from normal
4. Manager/supervisor – supervises team and subordinates such as public health
midwives
5. Change Agent
6. Client Advocate

RESPONSIBILITIES OF COMMUNITY HEALTH NURSE

1. Be a part in delivering an overall health plan; its implementation & evaluation for
comm.
2. Provide quality nursing services to 4 levels of clientele
3. Maintain coordination/ linkages of nsg service with other health team members
NGO/GO in the provision of PH services- multisectoral app
4. Conduct research relevant to CHN services to improve provision of health
service- research—to improve HC
5. Provide opportunities for professional growth and continuing education for staff
development

LESSON 3: HISTORICAL BACKGROUND OF COMMUNITY HEALTH NURSING

The following events, laws and activities make up the history of CHN in the Philippines:

Note: The student may read other references as others may present different timelines
and events of the history of CHN in the Philippines

1901 Act # 157 of the Philippine Commission created a Board of Health of the
Philippines
Subsequently, Act # 309 created Provincial and Municipal Boards of Health
1905 Act # 1407 (Reorganization Act) abolished the Board of Health and its
activities were taken over by the Bureau of Health under the Department of
the Interior.
1912  The Philippine General Hospital, then under the Bureau of Health, sent 4
nurses to Cebu to take care of mothers and their babies.
 The St. Paul’s Hospital School of Nursing in Intramuros, also assigned 2
nurses to do home visiting in Manila and gave nursing care to mothers and
newborns from the outpatient obstetrical service of the PGH.
1914 School Nursing was rendered by a Filipino nurse employed by the Bureau of
Health
1915 The Bureau of Health was renamed Philippine Health Service with a Director

33
 of Health as its head.
 In the same year, Reorganization Act # 2462 created the Office of General
Inspection under which the Office of District Nursing was organized.
 The Office was created due to increasing demands of nurses to work
outside the hospital, in the homes, and the need for direction, supervision,
and guidance of public health nurses.
1916- Ms. Perlita Clark took charge of the public health nursing work
1918
1919 The first Filipino nurse supervisor under the Bureau of Health, Ms. Carmen
del Rosario was appointed. She had a staff of 84 public health nurses
assigned in 5 health stations
1923 Establishment of 6 government Schools of Nursing:
 Zamboanga General Hospital School of Nursing, Mindanao
 Baguio General Hospital, Northern Luzon
 Quezon Province, Southern Luzon
 Cebu, Bohol, and Leyte – Visayas
These schools were primarily intended to train non-Christian women and
prepare them to render service among their people.
1927 Office of District Nursing under the Office of General Inspection, Philippine
Health Service was abolished and supplanted by the Section of Public Health
Nursing
1930 Section of Public Health Nursing was converted into Section of Nursing due
to pressing need for guidance not only in public nursing services, but also in
hospital nursing and nursing education
Dec At the outbreak of WWII, public health nurses in Manila were assigned to
8,1941 devastated areas to attend to the sick and the wounded.
June A group of public health nurses with physicians went to the internment camp
1942 in Capas, Tarlac to receive sick POWs released by the Japanese army.
July Many public health nurses joined the guerillas or went to hide in the
1942 mountains during WWII
Oct 7, E.O. #94 reorganized government offices and created the Division of
1947 Nursing under the Office of the Secretary of Health
 The Nursing Division was placed directly under the Secretary of Health so
that nursing services can be availed of by the different Bureau and units
to help carry out their health programs.
1953 Philippine Congress approved R.A. # 1082 or the Rural Health Law
 Each unit had a physician, a public health nurse, a midwife, a sanitary
inspector, and a clerk driver
1957 Approval of R.A. 1891 or the Second Rural Health Act created 8 categories
of rural health units based on population.

34
  This resulted in additional number of positions for health workers including
public health nurses and midwives.
1958- The Department of Health National League of Nurse, Inc., was founded
1965
1967 Mrs. Zenaida Panlilio-Nisce was appointed as Nursing Program Supervisor
and served as consultant on the nursing aspects of the 6 special
diseases/condition : TB, leprosy, VD, cancer, Filariasis, and Mental Health
 She was involved in program of planning, monitoring, evaluation, and
research.
1976- The Nursing Consultant and Nursing Program graduates to serve for 2
1986 months in the rural areas of the country before their license were issued by
the PRC.
1987 - E.O. #119 reorganized the DOH and created several offices and services
1989 within the department.
1990- The number of positions of Nursing Program Supervisors (Nurse VI) were
1992 increased as there were 3 or more appointed in each service: Maternal and
Child Health Service, Expanded Program on Immunization, Control of
Diarrheal Diseases, and Control of Acute Respiratory Infections.

1990- The Local Government Code of 1991 (RA#7160) was passed into law.
1992  This resulted in devolution, which transferred the power and authority
from the National Government to the Local Government Units (LGUs).
 It was aimed to build their capabilities for self-government and develop
them as self-reliant communities.
May EO#102 was signed. Most of the nursing positions of the Central Office
24,1999 were either transferred or devolved to other offices and services.

LESSON 4: SPECIALIZED FIELD IN COMMUNITY AND PUBLIC HEALTH

NURSING

1. SCHOOL HEALTH NURSING

 Type of PHN that focuses on the promotion of health and wellness OF THE
pupils/students, teaching and non-teaching personnel of the schools.

 OBJECTIVES:
o GENERAL: to promote and maintain the health of the school populace by
providing comprehensive and quality nursing care

o SPECIFIC:

35
 1. Provide quality nursing service to the school population
2. Create awareness on the importance of promotive and preventive
aspects of health through health education
3. Encourage the provision of standard functional facilities
4. Provide nursing personnel with opportunities for continuing education
and training
5. Conduct and participate in researches related to nursing care
6. Establish/strengthen linkages with government and NGO for school
community health work

 DUTIES AND RESPONSIBILITIES OF THE SCHOOL NURSE

1. Health advocacy
2. Health and nutrition assessment including other screening procedures
3. Supervision of the health and safety of the school
4. Treatment of the common ailments and attending to emergency cases
5. Referrals and follow-up of pupils and personnel
6. Home visits
7. Community outreach
8. Recording and reporting of accomplishments
9. Monitoring and evaluation of accomplishments

 FUNCTIONS OF SCHOOL NURSE

1. SCHOOL HEALTH AND NUTRITION SURVEY
- Provide data for evaluation and planning purposes
- Current health and nutritional status, situation on facilities, health
education, survey

2. FUNCTIONAL SCHOOL CLINIC

- RA 124 -> mandates creation of such

3. HEALTH ASSESSMENT
- Aims to discover the signs of illness and physical defects
- Thorough examination; give also advice on problems of the pupils/personnel

o Health assessment includes:

- Interviewing for information gathering
- Nutritional assessment (ht and wt)
- Vision acuity/hearing test
- Methods of physical examination
- Vital signs
- Appraisal of physical and mental condition
- Recording of findings

o Preparation

36
 - Well-lighted, ventilated screened room or corner of room
- Chairs, wastebasket, handwashing facilities, tongue depressor,
penlight, stethoscope and sphygmomanometer, forms and records

o Frequency
- Once a year

o Procedure
- Conduct classroom health lecture and inform the pupils on what to do
- 3-5 students should be waiting
- Assess one by one
- Cephalocaudal -> cleanliness, skin conditions and abnormalities
- Steth -> heart and lung assessment
- Record findings

o Steps:
a. Arms, hand, nails: roll sleeves, extend arms, show hands and
fingers
b. Eyes: put down lower lid and look up
c. Nose: place 2nd finger on the tip of the nose and pull up his nose
and extend his head backward
d. Teeth: open mouth, inspect also for the throat
e. Ears: push back hair behind ear and pull outer ear up (down and
back)
f. Neck and chest: inspect neck; chest and back auscultate
g. Hair: run fingers on hair; inspect nape
h. Feet and legs; inspect
i. General appearance: observe

IMPORTANT REMINDERS:
a. If the personnel is opposite sex, it must be done with the
presence of a personnel preferably with the same sex
b. Treat cases needing treatment
c. Refer cases
d. Inform parents

4. STANDARD VISION TESTING

- Very important sensory skill that affects learning and general development
- Early detection-> childhood blindness and visual disorder
- 20/20 vision-> visual task clearly and comfortably
- Screen students with poor acuity and ocular problems
- Refer diseases and refraction errors

37
 o IMPORTANT
a. School physician should validate
b. Refer visual problems to specialists
c. Parents should be informed

5. EAR EXAMINATION
- Early recognition is very important: achievement, learning process, clear
speech and social skills
- Effective treatment and rehabilitation
- Helps preserve hearing and stimulates language and speech development
and socialization
- Early detection of hearing difficulties
- Tests, observation, examination

1. HEIGHT AND WEIGHT MEASUREMENT/NUTRITIONAL STATUS

- Evaluating the tallness and shortness and heaviness
- Most acceptable and simplest way the nutritional status
- Ht for age, wt for age, BMI
- Deworming, feeding program

2. MEDICAL REFERRAL
- For further assessment, management of proper professional/agency

3. ATTENDANCE TO EMERGENCY CASES

- Attend emergency case while in school
- Parents must be informed

4. STUDENT HEALTH COUNSELLING

- Counseling and referral

5. HEALTH AND NUTRITION EDUCATIONACTIVITIES

- Health-related topics on formal and informal settings
- Enhance QOL by:
a. Plans/conducts trainings, programs, conferences
b. Acts as resource person
c. Information dissemination

6. COMMUNICABLE DISEASE PERSONNEL

- Responsibility shared by school, parents, community and DOH
- Refer and send home students until clear
- Vaccination, early detection, parental notification, referrals

7. DATA BANK

38
 - Accurate and up-to-date health records
- For monitoring and evaluation

8. RAPID CLASSROOM INVESTGATION

 LEGAL BASES

a. PD 603
- The child is one of the most important assets of the nation. Every effort
should be enacted to promote his welfare and enhance his opportunities
for a useful happy life

b. Article II – Promotion of health

- It should be the responsibility of the health, welfare and education entities
to assists the parents in looking after the child

c. Article III – Rights of the Child

- Every child has the right to balanced diet, adequate clothing, sufficient shelter,
proper medical attention, and the basic physical requirements of a healthy and vigorous
life

2. OCCUPATIONAL HEALTH NURSING

 Health of people in workplace
 Assess the health needs of working population and design healthy working
environment

FUNCTIONS OF PHN AS OCCUPATIONAL HEALTH NURSE

1. Lead team in sanitary and industrial hygiene of all industrial establishments
- Compliance with the sanitation code and IRR
2. Recommend to local health authority the issuance of license/permits,
suspensions and revocations
3. Coordinates with other government agencies
4. Attends to complaints of all establishments related to hygiene
5. Participates to provide, install and maintains in good condition all control facilities
and protective barriers for potential and actual hazards
6. Informs all affected workers regarding the nature of hazards and the reasons for
the control measures and protective equipment
7. Makes a periodic testing for physical examination of the workers and other
health examinations related to worker’s exposure to potential or actual hazards
in workplace
8. Provides control measures to reduce noise, dust, health and other hazards
9. Ensure strict compliance on the regular use and proper maintenance of PPE
10.Provide employees/workers an occupational health services and facilities

39
 11.Refers or elevates to higher authority all unsolved issues in relation to
occupational and environmental health problems
12.Prepares and submits yearly reports

THE PRIMARY FOCUS

 To assure so far as possible every working man and woman in the country is
safe and healthful working conditions
A. Occupational health and safety should be considered an integral part of all
health services
B. Occupational environment is complex and multi-dimensional. It requires an
as appreciation of the social, cultural political and economic context of work
C. Occupational health and safety affect not only the worker, but also the
worker’s family, SO and community
D. It is a population-based practice

PROFESSIONAL GOALS
A. Central mission is to promote and maintain the health and safety of workers
through systematic process of APIE
B. Occupational physicians focus on prevention, detection and treatment of
work-related diseases and injuries
C. Industrial hygienist recognizes, evaluate and control toxic exposures and
hazards in the work environment
D. Safety engineers and other safety professionals focus in the prevention of
occupational injuries and the maintenance or creation of safe workplaces and
safe work practices
E. Other professionals:
a. Epidemiologists – study occupational diseases and injuries
b. Toxicologists – study toxic properties of agents
c. Industrial engineers – design tools, equipments and machines
d. Ergonomists – study, design, and promote healthy interface
e. Health educators – promote healthy lifestyle and work practices

THE PRACTICE
A. Nurses focus on “promotion, protection and restoration of workers’ health
within the context of a safe and healthy work environment
B. Autonomy and independent nursing judgments characterize the practice
of OHN
C. It is research-based and multidisciplinary

40
 D. Occupational health nurses are advocates and encourage informed
decisions about health
E. Key to coordination to of holistic approach to the delivery of quality,
comprehensive occupational health services
F. Occupational health nurses are professionally accountable to workers and
other matters

3. MENTAL HEALTH NURSIN

- A unique process which includes an integration of concepts from nursing, mental
health, social psychology, psychology, community networks & 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 & shorten disease process

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LESSON 1: WORLD HEALTH ORGANIZATION, MILLENNIUM DEVELOPMENT GOALS AND
SUSTAINABLE DEVELOPMENT GOALS

WORLD HEALTH ORGANIZATION

When the diplomats formed the United Nations in 1945, they also decided the creation of a health
organization. It then formed the World Health Organization (WHO). It had its constitution on April 7,
1948. Since then, Aptil 7 is commemorated as World Health Day. The headquarters is in Geneva
Switzerland. It has 147 country offices and 6 regional offices. The Philippines is a member of the
Western Pacific Region. The country office is in Manila.

OBJECTIVE:
Attainment by all peoples of the highest possible level of health

CORE FUNCTIONS:
Provides leadership on matters critical to health and engaging in partnerships where joint action is
needed.
Shaping the research agenda stimulating the generation, translation, and disseminating valuable
knowledge.
Setting norms and standards and promoting and monitoring their implementation.
Articulating ethical and evidence-based policy options.
Providing technical support, catalyzing change and building sustainable institutional capacity.

MILLENNIUM DEVELOPMENTAL GOALS (MDG)

On September 6-8, 2000, world leaders who attended in the UN General assembly participated in
the Millennium Summit. A resolution was crafted during that momentous event and it was entitled,
United Nations Millennium Declaration. Collective responsibility to uphold the principles of human
dignity, equality and equity in the global level was emphasized.

The declaration expressed the commitment of 191 member states, with the inclusion of the
Philippines: to reduce extreme poverty and achieve seven other targets called Millennium Development
Goals (MDGs) by year 2015.

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SUSTAINABLE DEVELOPMENT GOALS (SDG)

When the MDG ended in 2015, the Sustainable Development Goals were crafted. The Sustainable
Development Goals are the blueprint to achieve a better and more sustainable future for all. They
address the global challenges we face, including those related to poverty, inequality, climate change,
environmental degradation, peace and justice. The 17 Goals are all interconnected, and in order to
leave no one behind, it is important that we achieve them all by 2030.

LESSON 2: COMPONENTS OF THE PHILIPPINE HEALTH CARE DELIVERY SYSTEM

Related terms and concepts:

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
SYSTEM
- A set of interrelated and independent parts that form a complex whole, and of these parts can
be viewed as a subsystem with its own set of interrelated and independent parts
HEALTH SYSTEM
- Interrelated ways in which a country organizes available resources for the maintenance and
improvement of the health of the citizens and communities
HEALTH CARE SYSTEM
- An organize plan of health services
HEALTH CARE DELIVERY
- Rendering health care services to the people
HEALTH CARE DELIVERY SYSTEM

43
- The network of health facilities and personnel which carries out the task of rendering health care to
the people
PHILIPPINE HEALTH CARE SYSTEM
- Is a complex set of organizations interacting to provide an array of health services

FIVE MAJOR FUNCTIONS:

1. Ensure equal access to basic health services
2. Ensure formulation of nat’l policies for proper division of labor & proper coordination of operations
among the government agency jurisdictions.
3. Ensure implementation nationwide of services regarded as public health goods
4. Plan and establish arrangements for the public health systems to achieve economies of scale
5. Maintain a medium of regulations and standards to protect consumers and guide providers

CHARACTERISTICS OF HEALTH CARE DELIVERY SYSTEM

• The system should encompass the entire population on the basis of equality and responsibility
• It should include components from the health sectors and from the sectors whose interrelated
actions contribute to health
• The essential elements of PHC should be delivered as the first point of contact between the
individuals and the health system
• The other level of system should support the first contact level to permit it to provide the
aforementioned essential elements on a continuing basis
• At intermediate levels, more complex problems should be dealt with more skilled and specialized
care as well as logistic support
• The central level should coordinate all parts of the system and provide planning and
management expertise, highly specialized care, teaching for specialized staff

STRUCTURE OF THE HEALTH SECTOR IN THE PHILIPPINES

 MAJOR COMPONENTS
A. PUBLIC SECTOR
- tax-based
A.1. National Level

DEPARTMENT OF HEALTH (DOH)

The Department of Health (DOH) holds the over-all technical authority on health as it is a national
health policy-maker and regulatory institution.

VISION
Filipinos are among the healthiest people in Southest Asia by 2022, and Asia by 2040
 
MISSION
To lead the country in the development of a people-centered, resilient, and equitable health system

ROLES AND FUNCTIONS OF DOH

1. LEADERSHIP IN HEALTH
Functions:
- LEADER in the formulation, monitoring and evaluation of national health policies, plans and
programs
44
 - ADVOCATE in the adoption of health policies, plans and programs to address national and
sectoral concerns
- NATIONAL POLICY AND REGULATORY INSTITUTION on which members of the health sector
anchor their thrusts and directions for health
2. ADMINISTRATOR OF SPECIFIC SERVICES
Functions:
- MANAGE selected health facilities and hospitals
- ADMINISTER direct services for emergent health concerns that require new complicated
technologies
- PROVIDE emergency health response services
- ADMINISTER special components of specific programs
3. CAPACITY BUILDER AND ENABLER
Functions:
- ENSURE the highest achievable standards of quality health care, promotion and protection
- INNOVATE new strategies in health to improve the effectiveness of health programs
- INITIATE public discussion on health issues and disseminate policy research outputs
- OVERSEE implementation, monitoring and evaluation of national health plans, programs and
policies

DOH CORE VALUES

 Integrity – The Department believes in upholding truth and pursuing honesty, accountability,
and consistency in performing its functions.
 Excellence – The DOH continuously strive for the best by fostering innovation, effectiveness
and efficiency, pro-action, dynamism, and openness to change.
 Compassion and respect for human dignity – Whilst DOH upholds the quality of life, respect for
human dignity is encouraged by working with sympathy and benevolence for the people in
need.
 Commitment – With all our hearts and minds, the Department commits to achieve its vision for
the health and development of future generations.
 Professionalism – The DOH performs its functions in accordance with the highest ethical
standards, principles of accountability, and full responsibility.
 Teamwork – The DOH employees work together with a result-oriented mindset.
 Stewardship of the health of the people – Being stewards of health for the people, the
Department shall pursue sustainable development and care for the environment since it
impinges on the health of the Filipinos.

Together with its attached agencies, the DOH – constituted of various central bureaus and services in
the Central Office, Centers for Health Development (CHD) in every region, and DOH-retained hospitals
– performs its roles to continuously improve the country’s health care system.

Central Office
The central office is composed of the Office of the Secretary and five major function clusters: Sectoral
Management Coordinating Team, Internal Management Support Team, Policy and Standard
Development Team for Regulation, Policy and Standard Development Team for Service Delivery, and
Policy and Standard Development Team for Financing.

DOH Hospitals
Provides hospital-based care; specialized or general services, some conduct research on clinical
45
priorities and training hospitals for medical specialization.

Attached Agencies
Attached agencies including the Philippine Health Insurance Corporation, Philippine National AIDS
Council, Philippine Institute of Traditional Alternative Health Care, Population Commission, Dangerous
Drugs Board, and National Nutrition Council.

Libraries and Learning Resource Centers

Research and resource centers and offices like the DOH Central Library, the National Epidemiology
Center Library, the DOH-DTTB-Pfizer Training and Learning Center other in-house resource units.

GOAL OF THE DOH:

Implementation of health sector reforms through the HEALTH SECTOR REFORM AGENDA (HSRA)
• Slowing down in the reduction in the infant mortality rate (IMR) and the maternal mortality rate
(MMR)
• Persistence of large variations in health status across population groups and geographic areas
• High burden form infectious diseases
• Rising burden from chronic and degenerative diseases
• Unattended emerging health risk from environmental and work related factors
• Burden of disease is heaviest on the poor

> The reasons why the above conditions are still seen among the population can be explained by the
following factors
• Inappropriate health care delivery system
• Inadequate regulatory mechanisms for health services
• Poor health care financing and inefficient sourcing or generation of funds for health care

 Framework in the implementation of HSRA: FOURmula ONE for health

a. Good governance – enhance health system performance at all levels
b. Health financing – foster greater, better and sustained investments in health
c. Health regulation – ensure the quality and affordability of health goods and services
d. Health service delivery – improve and ensure the accessibility and availability of basic essential
health care in both public and private facilities

NATIONAL OBJECTIVES FOR HEALTH

46
 - Roadmap for stakeholders in health and health-related sectors
- Sets the targets and critical indicators to guide policymakers and stakeholders in health
- Implementation is defined through FOURmula ONE for health

OBJECTIVES OF THE HEALTH SECTOR

1. Improve the health status of the population

- Improve the general health status of the population
- Reduce mortality and morbidity
- Eliminate certain diseases
- Promote health lifestyle and environmental health
- Protect vulnerable groups
2. Ensure quality service delivery
- Strengthen national and local health systems to ensure better health service delivery
- Pursue public health and hospital reforms
- Reduce cost and ensure the quality of essential drugs
- Institute health regulatory reforms
- Strengthen health governance and management support systems
3. Improve support system for the vulnerable and marginalized groups
4. Implement proper resource management
- Expand the coverage of social health insurance
- Mobilize more resources for health
- Improve efficiency in the allocation, production and utilization of resources

Universal Health Care (UHC) to Address Inequity in the Health System

• also referred to as Kalusugan Pangkalahatan (KP)

• “provision to every Filipino of the highest possible quality of health care that is accessible,
efficient, equitably distributed, adequately funded, fairly financed, and appropriately used by an
informed and empowered public”
• The Aquino administration puts it as the availability and accessibility of health services and
necessities for all Filipinos.
• It is a government mandate aiming to ensure that every Filipino shall receive affordable and
quality health benefits. This involves providing adequate resources – health human resources,
health facilities, and health financing.

UHC’s Three Thrusts

1) Financial risk protection through expansion in enrolment and benefit delivery of the National
Health Insurance Program (NHIP)
- Protection from the financial impacts of health care is attained by making any Filipino eligible to
enroll, to know their entitlements and responsibilities, to avail of health services, and to be
reimbursed by PhilHealth with regard to health care expenditures.
- PhilHealth operations are to be redirected towards enhancing national and regional health
insurance system. The NHIP enrollment shall be rapidly expanded to improve population

47
 coverage. The availment of outpatient and inpatient services shall be intensively promoted.
Moreover, the use of information technology shall be maximized to speed up PhilHealth claims
processing.

2) Improved access to quality hospitals and health care facilities; and

- The quality of government-owned and operated hospitals and health facilities is to be upgraded
to accommodate larger capacity, to attend to all types of emergencies, and to handle non-
communicable diseases.
- The Health Facility Enhancement Program (HFEP) shall provide funds to improve facility
preparedness for trauma and other emergencies.
- Financial efforts shall be provided to allow immediate rehabilitation and construction of critical
health facilities. In addition to that, treatment packs for hypertension and diabetes shall be
obtained and distributed to RHUs.
- The DOH licensure and PhilHealth accreditation for hospitals and health facilities shall be
streamlined and unified.

3) Attainment of health-related Millennium Development Goals (MDGs).

- Further efforts and additional resources are to be applied on public health programs to reduce
maternal and child mortality, morbidity and mortality from Tuberculosis and Malaria, and
incidence of HIV/AIDS. Localities shall be prepared for the emerging disease trends, as well as
the prevention and control of non-communicable diseases.
- The organization of Community Health Teams (CHTs) in each priority population area
- Another effort will be the provision of necessary services using the life cycle approach.

A.2. LOCAL LEVEL

LOCAL GOVERNMENT UNITS (LGU)

R.A. 7160 – “Local Government Code of 1991”

- Devolution of powers, functions and responsibilities to the local government
* Devolution – refers to the act by which national government confers power and authority

OBJECTIVES FOR LOCAL HEALTH SYSTEM

1. Establish local health systems for effective and efficient delivery of health services
2. Upgrade the health care management and services capabilities of local health care financing
3. Promote inter LGU linkages
4. Foster participation of the private sector, NGO’s and communities
5. Ensure the quality of health service delivery at the local level

COMPOSITION OF LOCAL HEALTH BOARDS

PROVINCIAL MUNICIPAL
Governor- Chairperson Mayor-Chairperson
48
 PHO- Vice Chairman MHO-Vice Chairman
Chairman of the Committee on Health of Chairman of the Committee on Health of
the Sangguniang Panlalawigan the Sangguniang Bayan
DOH Representative DOH Representative
NGO Representative NGO Representative

THE ORGANIZATIONAL STRUCTURE OF THE DOH AND LGUs AFTER DEVOLUTIION

• FUNCTIONS
1. Proposing budgetary allocations – operation and maintenance of health services
2. Advisory committee
3. Creating committees that shall advise local health agencies

B. PRIVATE SECTOR
- market-oriented

TYPE ORIENTATION EXAMPLES

Commercial or Business Profit-oriented Private Practitioners
Non-commercial Service-oriented Socio-civic groups,
religious organizations,
foundations

Private sub-sector involvement includes:

1. Inputs provision which covers supplies and equipment/treatment facilities

2. Service delivery which includes a whole range of activities from casefinding/treatment and
follow-up, counseling environmental sanitation, to manufacture and sale of health-related goods
3. Support activities mostly in the form of research, personnel training, project monitoring and
evaluation, and development of IEC materials
49
 4. Financing through financial assistance that usually comes in the form of grants from multilateral
and bilateral agencies.

C. Non-Government Organizations
NGOs play an important role in national and local development with emphasis on policy and
program reforms and people empowerment. NGOs have consistently assumed the roles of catalysts,
advocates, facilitators and enablers in people development. Heath NGOs are those that are directly
involved in health care and in reforming the present health care delivery system. Some of them have
pioneered alternative approaches in health.

The roles played by the NGOs include:

1. Direct delivery of health services

2. Policy and legislative advocacy
3. Organizing to promote and protect economic and democratic rights, interests, and general
welfare of health workers
4. Research and documentation concerning important health issues such as appropriate health
technology and PHC
5. Health resource development to respond to the severe lack of human resources especially in
depressed areas
6. Human rights advocacy to uphold and advance the basic health and human rights of the people,
especially those marginalized by socio-economic factors such as urban poor, workers on strike,
victims of torture, etc.
7. Relief and disaster management which includes activities as recruitment and organizing
volunteers as disaster response teams, regular solicitation and stockpiling of needed medicine,
medical supplies, food and other essentials
8. Networking to enable health NGOs to learn from each other, maximizing their resources, avoid
duplication of work and respond to various issues simultaneously.

LESSON 3: Levels of Health Care Facilities

HEALTH FACILITIES

Health facilities are physical infrastructures that offer health services. These include hospitals,
health centers, health stations, clinics, and laboratories. The government, private sector and NGO’s
today operate health facilities.

A. Hospitals
The Philippine Hospital System is composed of government and privately-owed hospitals.
The hospitals are further subdivided into primary, secondary, and tertiary categories
according to the level of care that is being offered. To ensure quality hospitals, it should be
equipped with functioning physical facilities and equipment, has an effective organization and
procedures/system; high quality managerial resource, able to adopt and meet changing
demands for hospital care.

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 B. Health Center and Barangay Health Stations
Health Center and barangay health stations (BHS) are government facilities that are
primarily responsible for the delivery of basic health services to communities. They are the
first point of contact between majority of the poor people and the health system.

C. Private Clinics and Laboratories

These provide service to a significant proportion of the population, particularly those
belonging to the middle- and upper-income classes. Most of these facilities are
concentrated in urban areas where they are highly in demand.

• Primary Level of Care

– devolved to the cities and municipalities and is the first contact
– in fair health, patients in early symptomatic stages
- RHU, chest clinics, malaria eradication clinics, private clinics

• Secondary Level of Care

– rendered by physicians with basic health training in district provincial and city hospitals
– capable of basic surgical procedures and simple laboratory exams; serves as the referral center
of primary health facilities
- Patients with symptomatic stages of disease; moderately specialized knowledge and technical
resources
- Emergency, provincial, district

• Tertiary Level of Care – rendered by specialists in medical centers, regional hospitals and
specialized hospitals
- – serves as the referral center of secondary health facilities
- - With diseases w/c seriously threaten their health; require higly technical and specialized
knowledge facilities and personnel

** DOH AO 2012-0012 (RULES AND REGULATIONS GOVERNING THE NEW CLASSIFICATION OF

HOSPITALS AND OTHER HEALTH FACILITIES)
LEVELS OF HEALTH CARE DELIVERY REMAINED, CLASSIFICATION HAS CHANGED

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THREE LEVELS OF HEALTH CARE

• CATEGORY A. PRIMARY CARE FACILITY

- First contact; basic services
- Emergency services and normal delivery services
a. Without in-patient beds (health centers, out-patient clinics, dental clinics)
b. With in-patient beds – short stay facilities (infirmaries, lying-in)

• CATEGORY B. CUSTODIAL CARE FACILITY

- Long term-care facility, food, shelter
- Chronic conditions requiring ongoing health and nursing care due to impairment and a reduced
degree of independence in ADLs and patients in need of rehabilitation
- Nursing home, leprosaria, rehabilitation

• CATEGORY C. DIAGNOSTIC/THERAPEUTIC FACILITY

- Examination, specimens for diagnosis, treatment, water analysis
• CATEGORY D. SPECIALIZED OUTPATIENT FACILITY
- Performs highly specialized procedures on an out-patient basis
- Dialysis, ambulatory surgical clinic, chemo clinic, radiation facility, rehabilitation clinic

TYPES OF PRIMARY HEALTH WORKERS

LESSON 4: RESTRUCTURED HEALTH CARE DELIVERY SYSTEM (RHCDS)

Rationale for RHCDS

 Healthcare system serves only small portion of rural population
 Diseases do not require sophistication
 Some problems can be handled by other postions besides MHO (Municipal Health Officer)

Solutions
 Three levels of health care provided by RHU (rural health unit) staff, with referral and supervisory
system support
 Redefinition of roles and relationships among RHU staff
 Establishment of satellite health centers in selected barangays

52
Features of DOH reorganization
 1958- RA 1082
- 1st Rural Health Act
- employment of more physicians, dentists, nurses, midwives and sanitary inspectors assigned to
RHU’s o 1st 81 rural health units
 1972- RA 5435 o defined authorities of regional directors for more meaningful decentralization
- 13 regional health offices
 1974 o IBRD- RHCDS implemented RHM were sent to BHS to man BHS o Midwives were trained and
roles expanded
 1982- EO 851 o integrated public health and hospital systems with emphasis on importance of putting
together promotive, preventive, curative and rehabilitative components of health care o utilization of
BHW o implementation of DOH impact programs

Role of Society in RHCDS

 participation in information drive of HCDS
 identifying problems
 identify sources

Rural Health Unit compositions and ratio to population:

 PHYSICIAN/MHO – 1: 20,000
 PHN – 1: 10,000 – 15,000
 RHM – 1: 5,000
 Rural Sanitary Inspector – 1:20,000
 Dentist – 1:50, 000
 Med tech – 1: 20, 000
 Pharmacist
 Nutritionist

HEALTH CARE FINANCING

- From the government
- WHO recommends 5% of the country’s GNP shall be for health. However, it was only placed on
through the following:
 Government third party schemes:
o Medicare program
o PhilHealth
o Employees Compensation Commission (ECC)
 Private sources
o Out-of-pocket
o Health Management Organizations (HMO) payments
 Company-financed health benefits
 Community-generated resources and donations of cash/material and technical services
from donors
 External sources
o WHO

53
 o UNICEF
o USAID
o World Bank

LESSON 5: TWO-WAY REFERRAL SYSTEM

Referral – set of activities undertaken by a health care provider or facility in response to its inability to
provide the necessary health intervention to satisfy a patient’s need.
- A functional referral system is one that ensures the continuity and complementation of health
and medical services
- It encompasses all types of care
- It involves movement of a patient from the health center of first contact and the hospital at first
referral level. When hospital intervention has been completed, the patient is referred back to the
health center – this is the two-way referral system.

Two types of referrals

A. Internal referral – occur within the health facility

B. External referral – movement of a patient or client from one health facility to another.

Inter Local Health System

- clustering municipalities into inter local health zone for holistic delivery of health services. It is based
on the concept of the District Health System, a term used by WHO to describe an integrated health
management and delivery system based on a defined administrative and geographical area.
- has defined catchment area with a central or core referral hospital and a number of primary level
facilities.

Composition of ILHZ:

1. People (100,000 – 500,000 population / health district)

2. Boundaries to determine accountability & responsibility of health service providers
3. Health facilities
4. Health workers

LESSON 1: DEFINITION AND CONCEPTS RELATED

PRIMARY HEALTH CARE (PHC)

- essential health care based on practical, scientifically sound and socially acceptable methods and
technology, made universally accessible to individuals and families in the community through their full
participation and at a cost that the community can afford to maintain at every stage of their
development in the spirit of self-reliance and self- determination.

CONCEPTUAL FRAMEWORK
• Health is a fundamental human right
• Health is both an individual and collective responsibility

54
 • Health should be an equal opportunity to all
• Health is an essential element of socio-economic development

FOCUS OF THE PHC APPROACH

• Partnership with the community

• Equitable distribution of health resources
• Organized and appropriate health system infrastructure
• Prevention of disease and promotion of health
• Linked multi-sectoral
• Emphasis on appropriate technology

PHC UNIVERSAL GOAL: “Health for all by the year 2000”

- An acceptable level of health for all people of the world through self-reliance

Framework:
People’s empowerment and partnership is the Key Strategy
- Alma-Ata, USSR
- September 6-12, 1978

First International Conference on PHC; sponsored by WHO and UNICEF

PHC was declared in the Alma-Ata Conference in 1978, as a strategy to community health
development. It is a strategy aimed to provide essential health care that is:
C – ommunity based
A – ccessible
P – art and parcel of the total socio-economic development effort of the nation
A – cceptable
S – ustainable at an affordable cost

LEGAL BASIS OF PHC IN THE PHILIPPINES: Letter of Instruction 949

- Signed by then President Ferdinand Marcos, with underlying theme, “Health in the Hands of the
People by 2020”
-
COMPARISON OF COMMERCIALIZED HEALTH CARE AND PRIMARY HEALTH CARE

DIMENSION COMMERCIALIZED PHC

HEALTH CARE
GOAL Absence of disease Prevention of disease
FOCUS Sick Sick and well
SETTING Hospital-based; urban; few Health centers; rural-
based; all
PEOPLE Passive recipients Active participants
STRUCTURE Health is isolated from Heath is integrated;
other sectors linkaging

55
PROCESS Decision-making (top- Bottom-top
bottom)
TECHNOLOGY Curative; physician- Promotive and preventive
dominated Appropriate technology for
frontline health care
OUTCOME Reliance on health People empowerment/self-
professionals reliance

LESSON 2: PRINCIPLES AND STRATEGIES

Principles and Strategies of Primary Health Care

PRINCIPLE STRATEGIES
Accessibility, availability, affordability and - Health services must be delivered
acceptability of health services where people are
- use indigenous/resident volunteer
workers as health care providers
(1:20)
- use traditional medicine with
essential drugs

Provision of quality, basic, and essential - Training design and curriculum

services based on community needs and
priorities
- KSA on promotive, preventive,
curative and rehabilitative health
care
- Regular monitoring and periodic
evaluation of CHW

Community participation - Awareness-building and

consciousness raising
- Planning, implementation,
monitoring and evaluation
- Selection of CHW
- Community-building and CO
- Formation of health committees
- Establishment of a community
health worker organization
- Mass health campaign and
mobilization

Self-reliance - Community generates support

- Use of local resources
- Training of community leadership
and management skills
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 - incorporation of IGP, coops,
small-scale industries

Recognition of interrelationship between - Convergence of health, food,

health and development nutrition, sanitation, etc
- integration of PHC into all level
plans
- coordination of activities to
different sectors

Social mobilization - Establishment of effective referral

system
- multisectoral and interdisciplinary
linkages
- IEC using multi-media
- Collaboration between GO and
NGO

Decentralization - Re-allocation of budgetary

resources
- Re-orientation of health
professionals on PHC
- Advocacy for political will and
support, from the national
leadership down to the barangay

FOUR CORNERSTONES OR PILLARS OF PHC

1. ACTIVE COMMUNITY PARTICIPATION

• Community Involvement
• Participation of the Community in:
- Defining the health and health-related needs
- Identifying realistic solutions
- Organizing, mobilizing its resources for health activities
- Evaluating the results of health actions

2. SUPPORT MECHANISM MADE AVAILABLE

- resources in for essential health services come from three major entities: the people, the government
and the private sector. These three groups should interplay to have better health outcomes. A multi-
sector approach is necessary.

Factors to consider:
a. Improvement of the following:
– Working conditions of health personnel such as team building, performance review and
promotion

57
 – Planning and management skills of health personnel at all levels
– Technical skills of health personnel
b. Improvement of the referral system at all levels
c. Formation and use of an information system that will continuously monitor the changing needs and
attitudes of the community.

3. APPROPRIATE TECHNOLOGY
Characteristics of an appropriate technology in PHC are the following:
Acceptability
Complexity
Cost
Effectiveness
Safety
Scope of technology
Feasibility

Examples: ORS for diarrhea, Herbal Medicine, Alternative Health care modalities practiced

4. INTRA- AND INTER-SECTORAL LINKAGE

Intrasectoral linkages – refer to communication, cooperation and collaboration within the health sector
Intersectoral linkages – refer to communication, cooperation and collaboration between the health
sector and other sectors

Local Governments
Education
Agriculture
Public works
Population control
Social welfare

LESSON 3: ELEMENTS/HEALTH PROGRAMS OF PHC

The Alma Ata Declaration listed eight essential health services in Primary Health Care, using the
acronym ELEMENTS:
Education for health
Locally endemic diseases
Expanded Program on Immunization
Maternal and Child care Program
Essential drugs
Nutrition
Treatment of communicable diseases
Sanitation

I. EDUCATION FOR HEALTH

- the sum of activities in which health agencies engage to influence the thinking, motivation,
judgment, and action of the people

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 - consists of techniques that stimulate, arouse, and guide people to live healthfully it is the process
whereby knowledge, attitude, and practice of the people are changed to improve individual, family,
and community.

Steps in Health Education:

• Creating awareness
• Motivation
• Decision-making

Aspects of Health Education

• Information – provision of knowledge
• Communication- exchange of information
• Education – change in knowledge, attitude, and skills

Principles of Health Education

• Health education considers the health status of the people
• Health education is learning
• Health education involves motivation, experience, and change in conduct and thinking
• Health education should be recognized as a basic function of health workers
• Health education takes place in the home, in the school, and the community
• Health education is a cooperative effort
• Health education meets the needs, interests and problems of the people affected
• Health education is achieved by doing.
• Health education is a slow and continuous process
• Health education makes use of supplementary aids and devices
• Health education utilizes community resources
• Health education is a creative process.
• Health education helps people attain health through their own efforts
• Health education makes careful evaluation of the planning, organization, and implementation of
health education program and activities.

General Aims of Health Education

• To persuade people to adopt and sustain healthful life practices
• To use judiciously and wisely the health services available to them
• To make their own decisions, both individually and collectively to improve their health status and
environment.

Factors Affecting the Attainment of Health Education

• Availability and accessibility of health services to which the individual have trust
• The economic feasibility of putting into practice the health measures being advocated
• Acceptability of the proposed health practice in terms of their customs and traditions that an
individual observes.

Qualities of a Health Educator

• Knowledgeable/mastery of subject matter

59
 • Credible
• Good listener
• Can empathized with others
• Possess teaching skills
• Flexible
• Patience
• Creative and innovative
• Effective motivator
• Able to rephrase and summarize
• Encourages group participation
• Good sense of humor
• Works for the joy of it

II. LOCALLY ENDEMIC DISEASES CONTROL

A. NATIONAL DENGUE PREVENTION AND CONTROL PROGRAM

VISION:                    A dengue free Philippines

MISSION:                  Ensure healthy lives and promote well-being for all at all ages

GOAL:                       To reduce the burden of dengue disease

OBJECTIVES:           1.) To reduce dengue morbidity by atleast 25% by 2022

INDICATORS:               Morbidity rate = No. of suspect, probable & confirmed cases x100,000
                                                                                 total population
                                                             (baseline: 198.1 per 100,000 population)
                                                         (2015 data: 200,145/100,981,437 x 100,000)
                               2.) To reduce dengue mortality by at least 50% by 2022
                              Mortality rate = No of dengue (probable & confirmed) deaths x 100,000
                                                                                 total population
                                                              (baseline: 0.59 per 100,000 population)
                                                             (2015 data: 598/100,981.437 x 100,100)
                               3.) To maintain Case Fatality Rate (CFR) to < 1% every year.
                                                CFR = no. of dengue (probable & confirmed) deaths x 100
                                                                   no. of probable & confirmed cases

 PROGRAM COMPONENTS

1. Surveillance
 Case Surveillance through Philippine Integrated Disease Surveillance and Response
(PIDSR)
 Laboratory-based surveillance/ virus surveillance through Research Institute for
Tropical Medicine (RITM) Department of Virology, as national reference laboratory,
and sub-national reference laboratories.
 Vector Surveillance through DOH Regional Offices and RITM Department of
Entomology
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   2. Case Management and Diagnosis
 Dengue Clinical Management Guidelines training for hospitals.
 Dengue NS1 RDT as forefont diagnosis at the h ealth center/ RHU level.
 PCR as dengue confirmatory test available at the sub-national and national
reference laboratories.
 NAAT-LAMP as one of confirmatory tests will be available at district hospitals,
provincial hospitals and DOH retained hospitals.

   3. Integrated Vector Management (IVM)

 Training on Vector Management, Training on Basic Entomology for Sanitary
Inspector, Training on Integrated Vector Management (IVM) for health workers.
 Insecticide Treated Screens (ITS) as dengue control strategy in schools.

   4. Outbreak Response
 Continuous DOH augmentation of insecticides such as adulticides and larvicides to
LGUs for outbreak response.

   5. Health Promotion and Advocacy

 Celebration of ASEAN Dengue Day every June 15
 Quad media advertisement
 IEC materials

   6. Research

STRATEGIES

 Enhanced 4S Strategy
S - earch and Destroy
S - eek Early Consultation
S - elf Protection Measures
S - ay yes to fogging only during outbreaks

B. MALARIA CONTROL PROGRAM

• Vision: Malaria-free Philippines by 2030
• Mission:  To empower health workers, the population at risk and all others concerned to
eliminate malaria in the country.
• Goal:  To significantly reduce malaria burden so that it will no longer affect the socio-economic
development of individuals and families in endemic areas.

• Objectives:
1. Ensure universal access to reliable diagnosis, highly effective, and appropriate treatment and
preventive measures;
2. Capacitate local government units (LGUs) to own, manage, and sustain the Malaria Program in their
respective localities;
3. Sustain financing of anti-malaria efforts at all levels of operation; and
4. Ensure a functioning quality assurance system for malaria operations
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Beneficiaries:
• meager-resourced municipalities in endemic provinces
• rural poor residing near breeding areas
• farmers relying on forest products
• indigenous people with limited access to quality health care services
• communities affected by armed conflicts
• pregnant women
• children aged five years old and below.

Program Strategies:
1. Early diagnosis and prompt treatment
•           Diagnostic Centers were established and strengthened to achieve this strategy. The
utilization of these diagnostic centers is promoted to sustain its functionality.
2. Vector control
•            The use of insecticide-treated mosquito nets, complemented with indoor residual
spraying, prevents malaria transmission.
3. Enhancement of local capacity
•            LGUs are capacitated to manage and implement community-based malaria control
through social mobilization.

C. NATIONAL FILARIASIS ELIMINATION PROGRAM

A major strategy of the Elimination Plan was the Mass Annual Treatment using the combination
drug, Diethylcarbamazine Citrate and Albendazole for a minimum of 2 years & above living in
established endemic areas after the issuance from WHO of the safety data on the use of the
drugs

• Vision:  Healthy and productive individuals and families for Filariasis-free Philippines
• Mission:   Elimination of Filariasis as a public health problem thru a comprehensive approach and
universal access to quality health services
• Goal:  To eliminate Lymphatic Filariasis as a public health problem in the Philippines by year
2017
• Specific Objectives:
The National Filariasis Elimination Program specifically aims to:
1. Reduce the Prevalence Rate to elimination level of <1%;
2. Perform Mass treatment in all established endemic areas;
3. Develop a Filariasis disability prevention program in established endemic areas;
62
 4. Continue surveillance of established endemic areas 5 years after mass treatment.

Target Population/Clients/Beneficiaries:
• individuals, families and communities living in endemic municipalities in 44 provinces in 12
regions (30 million targeted for mass treatment or 1/3 of the total population of the country). 
• However, 9 provinces have reached elimination level namely: Southern Leyte; Sorsogon; Biliran;
Bukidnon; Romblon; Agusan Sur; Dinagat Islands; Cotabato Province; and COMVAL.

Management Being Used:

A. Selective Treatment – treating individuals found to be positive for microfilariae in nocturnal
blood examination.
• Drug: Diethylcarbamazine Citrate
• Dosage: 6 mg/kg body weight in 3 divided doses for 12 consecutive days (usually given after
meals)
B. Mass Treatment – giving the drugs to all population from aged 2 years and above in all
established endemic areas.
• Drug: Diethlcarbamazine Citrate (single dose based on 6 mg/kg body wt) plus Albendazole
400mg given single dose given once annually to people 2 yrs & above living in established
endemic areas
C.  Disability Prevention thru home-based or community-based care for lymphedema &
elephantiasis cases. 

D. SCHISTOSOMIASIS CONTROL PROGRAM:

Goal:  To reduce the disease prevalence by 50% with a vision of eliminating the disease eventually in
all endemic areas
Objectives:
The Schistosomiasis control Program has the following objectives:
1.       Reduce the Prevalence Rate by 50% in endemic provinces; and
2.       Increase the coverage of mass treatment of population in endemic provinces.
Program Strategies:
The Schistosomiasis Control Program employs the following key interventions:
a.       Morbidity control: Mass Treatment
b.       Infection control: Active Surveillance
c.       Surveillance of School Children
d.       Transmission Control
e.       Advocacy and Promotion

E. LEPROSY CONTROL PROGRAM:

Vision:    Empowered primary stakeholders in leprosy and eliminated leprosy as a public health
problem by 2020
Mission:  To ensure the provision of a comprehensive, integrated quality leprosy services at all
levels of health care
Goal:  To maintain and sustain the elimination status

63
 Objectives:
The National Leprosy Control Program aims to:
• Ensure the availability of adequate anti-leprosy drugs or multiple drug therapy (MDT).
• Prevent and reduce disabilities from leprosy by 35% through Rehabilitation and Prevention of
Impairments and Disabilities (RPIOD) and SelfCare.
• Improve case detection and post-elimination surveillance system using the WHO protocol in
selected LGUs.
• Integration of leprosy control with other health services at the local level.
• Active participation of person affected by leprosy in leprosy control and human dignity program
in collaboration with the National Program for Persons with Disability.   
• Strengthen the collaboration with partners and other stakeholders in the provision of quality
leprosy services for socio-economic mobilization and advocacy activities for leprosy.

Beneficiaries:
The NLCP targets individuals, families, and communities living in hyperendemic areas and those
with history of previous cases.

III. EXPANDED PROGRAM ON IMMUNIZATION

The expanded program on immunization was launch in July 1976 by the department of health
in cooperation with the World Health Organization and the UNICEF.

Goal: To achieve the overall EPI goal of reducing the morbidity and mortality among children
against the most common vaccine-preventable diseases.

Laws related to Expanded Program on Immunization:

Presidential Decree 996 – the first law on Expanded Program on Immunization. It has the
original objective of reducing the morbidity and mortality among infants and children caused by
the seven childhood immunizable diseases.

Republic Act 10152 – also known as Mandatory Infants and Children Health Immunization Act of
2011. It mandates basic immunization covering the vaccine preventable diseases. It added the
vaccines for mumps, hepatitis B, rubella, diseases caused by Haemophilus influenza type B (Hib)
and other diseases determined by the Department of Health (DOH) Secretary. This law repealed
PD 996.

Republic Act 7846 - compulsory immunization against hepatitis B for infants and children below
8 years old. It also stated that Hepatitis B vaccine within 24 hours after birth of babies from
mothers with hepatitis B.

Specific goals:
a. To immunize all infants/children against the most common vaccine-preventable diseases
b. To sustain the polio-free status of the Philippines
c. To eliminate measles infection
d. To eliminate maternal and neonatal tetanus
e. To control diphtheria, pertussis, hepatitis B and German measles
64
 f. To prevent extrapulmonary TB among children

Principles:
1. The program based on the epidemiological situation
2. The whole community rather than just the individual is to be protected, thus mass approach is
utilized
3. Immunization is a basic health service and such it is integrated in to the health services being
provided for by the Rural health Unit

Elements:
1. Target setting
2. Cold chain logistic management
3. Information, education and communication
4. Assessment and evaluation of the program’s overall performance
5. Surveillance, studies and research

Importance of vaccination:
1. Immunization is the process by which vaccines are introduced into the body before infection sets in.
2. Vaccines are administered to promote immunity and to protect the children from disease-causing
agents

Schedule and manner of administration of infant immunization (EPI, Philippines)

ANTIGEN AGE DOSE ROUTE SITE
BCG At birth 0.05 ml ID RIGHT deltoid
Hepa B At birth 0.5 ml IM Vastus lateralis
DPT-HepB-HiB 6 weeks, 10 0.5 ml IM Vastus lateralis
weeks, 14
weeks
OPV 6 weeks, 10 2 gtts Oral Mouth
weeks, 14
weeks
AMV 9-11 months 0.5 ml SQ Outer part of
upper arm
MMR 12-15 months 0.5 ml SQ Outer part of
upper arm
Rotavirus 6 weeks, 10 1.5 ml Oral Mouth
weeks

Schedule and protection of administration of tetanus toxoid immunization (EPI,

Philippines)
VACCINE MINIMUM TIME PERCENT DURATION OF
INTERVAL PROTECTION PROTECTION
TT1 As early as
pregnancy
65
 TT2 At least 4 weeks 80 Infant: Neonatal
tetanus
Mother: 3 years
TT3 At least 6 months 95 Infant: Neonatal
tetanus
Mother: 5 years
TT4 At least 1 year 99 Infant: Neonatal
tetanus
Mother: 10 years
TT5 At least 1 year 99 All infants born will
be protected
Mother: lifetme

Side effect of vaccination and their management (EPI, Philippines)

Vaccines Side effects Management
BCG KOCH’S PHENOMENON No management
- Acute inflammatory reaction
DEEP ABSCESS AT VACCINATION SITE I and D
OR LYMPH NODES
INDOLENT ULCERATIONS INH powder
- Persists after 12 weeks
Ulcer more than 10 mm
GLANDULAR ENLARGEMENT Treat as deep abscess
HEPATITIS B LOCAL SORENESS No treatment is necessary
Within 24 hours
DPT-HepB-Hib FEVER Antipyretic
(Pentavalent) -usually one day TSB
LOCAL SORENESS No treatment
- At injection site 3-4 days
ABSCESS I and D
- An abscess that appear a week or
more after is due to wrong technique
CONVULSIONS Proper management
-very rare; 3 months of age Do not continue normal
course
OPV Usually none
AMV FEVER AND RASH Antipyretics
5-7 days after (1 week) TSB
MMR Local soreness, fever, irritability, Antipyretics
malaise
Rotavirus Some children develop mild vomiting Antipyretics
and diarrhea, fever and irritability Oresol
Tetanus toxoid Local soreness at the injection site Apply cold compress on
site
No other treatment

Important considerations:
66
  Use only one sterile syringe per client.
 No need to restart a series of vaccination regardless of time or doses that have been missed in
between.
 All the EPI antigens are safe and effective when administered simultaneously, that is, during the
same immunization schedule but at different sites. However, it is not recommended to mix
vaccines in a single syringe. Moreover, if the site is of the same limb, the sites should be at least
2.5-5 cm apart.
 OPV followed by Rotavirus vaccine and then other appropriate vaccines.
OPV is administered with a dropper. Do not let the dropper touch the child’s tongue.
 Only monovalent hepatitis B vaccine must be used for birth dose. Pentavalent vaccine must not
be used because DPT and Hib vaccine should not be administered at birth.
 In case, children who did not receive AMV1 or if the parent/caregiver forgets if the child received
such, AMV1 shall be given as soon as possible, followed by AMV2 one month after.
 All children entering day care centers/pre-school and Grade 1 shall be screened for measles
immunization. Children without vaccines shall be referred to nearest health facility.
 The first dose of Rotavirus vaccine is administered only to infants aged 6 weeks to 15 weeks.
Second dose is given only to infants aged 10 weeks up to a maximum of 32 weeks.

Vaccines, contents, form, exposure to heat and storage temperature

VACCINE CONTENTS FORM CONDITIONS STORAGE
WHEN TEMPERATURE
EXPOSED TO
HEAT
BCG Live, Freeze dried, Destroyed 0
2 to 8 C
attenuated, reconstituted
bacteria with special
diluent
Hepatitis B RNA- Cloudy, liquid, Damaged by 0
2 to 8 C
vaccine recombinant, in an auto- heat or
using Hepatitis disable freezing
B surface injection
antigen (HBs syringe if
Ag) available
DPT-HepB-Hib D-weakened Liquid, in an D-by 0
2 to 8 C
(Pentavalent toxin auto-disable heat/freeze
vaccine) P-inactivated injection
bacteria syringe
T-weakened
toxin
Recombinant
DNA surface
antigen
Synthetic
conjugate of

67
 HiB bacilli
OPV Live, Liquid Easily 0C
-15 to -25
attenuated destroyed by
virus heat, not by
freezing
AMV (AMV1) Live, Freeze dried, Easily 0C
-15 to -25
attenuated reconstituted destroyed by
virus heat, not by
freezing
MMR (AMV2) Live, Freeze dried, Destroyed 0
2 to 8 C
attenuated reconstituted
virus
Rotavirus Live, Liquid Destroyed 0
2 to 8 C
attenuated
virus
TT Liquid Damaged by 0
2 to 8 C
heat or
freezing

COLD CHAIN
- System used to maintain the potency of a vaccine from the time of manufacture to time it is
given

COLD CHAIN OFFICER

- Person directly responsible for cold chain management at each level is called Cold Chain officer.
At the RHU/health center, the public health nurse acts as the Cold Chain Officer.
- The officer is in charge of maintaining the cold chain equipment and supplies

** Please refer to the table above for the specific temperatures to maintain the potency of the vaccines

Considerations to maintain potency:

1. Storage of vaccines should NOT exceed:
 6 months at regional
 3 months at provincial
 1 month at main health centers*
 Not more than 5 days at health centers
2. Use of boxes/carriers in transport
3. Observe the first expiry-first out (FEFO) policy
4. Reconstitute freeze-dried vaccines such as BCG, AMV, and MMR only with the diluents supplied
with them
5. Discard reconstituted freeze-dried vaccines 6 hours after reconstitution or at the end of the
immunization session, whichever comes sooner.
6. Protect BCG from sunlight and Rotavirus from light.

Contraindications to immunization:

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There are no general contraindications to immunization of a sick child if the child is well enough to be
sent home.

Few absolute contraindications:

Do not give:
 Pentavalent vaccine/DPT to children over 5 years of age
Pentavalent vaccine/DPT to a child with recurrent convulsions or another active neurological
disease of the central nervous system
Pentavalent 2 or 3/DPT 2 or 3 to a child who has had convulsions or shock within 3 days of the
most recent dose.
 Rotavirus vaccine when the child has a history of hypersensitivity to a previous dose of the
vaccine, intussusceptions or intestinal malformation or acute gastroenteritis.
 BCG to a child who has signs and symptoms of AIDS or other immune deficiency conditions or
who are immunosuppressed.

False contraindications:
 Malnutrition: it is in fact, an indication
 Low-grade fever
Mild respiratory infection
 Diarrhea: Children with diarrhea and is scheduled for OPV, should receive one – but is not
counted. The child should return when the next dose of OPV is due.

EPI recording and reporting

 Fully immunized child (FIC) - who were given one dose of BCG, three doses of OPV, three doses
DPT and hepatitis B vaccine or three doses Pentavalent vaccine, and one dose anti-measles
vaccine before reaching one year old
 Completely immunized child (CIC) – refer to children who completed their immunization schedule
at the age of 12-23 months
 Child protected at birth (CPAB) – a term used to describe a child whose mother has received:
two doses of TT during this pregnancy, provided that the second dose was given at least a
month prior to the delivery; or at least three doses of TT anytime prior to pregnancy with this
child

IV. MATERNAL, NEWBORN AND CHILD HEALTH NUTRITION PROGRAM

In response to the maternal and child health situation, the DOH takes into consideration the
interrelatedness of (a) direct threats to life of mothers and children that necessitate
immediate health care and managing risks that tend to increase maternal and child deaths
and (b) underlying socio-economic conditions that hinder the provision and utilization of
MNCHN core packages of services.

FOUR KEY STRATEGIES OF MNCHN:

1. Ensuring universal access to and utilization of an MNCHN Core Package of services and
interventions directed not only to individual women of reproductive age and newborns at
different stages of the life cycle, but also to the community.

69
 2. Establishment of a Service Delivery Network at all levels of care to provide the package of
services and interventions.
3. Organized use of instruments for health systems development to bring all localities to create and
sustain their service delivery networks, which are crucial for the provision of health services to
all.
4. Rapid build-up of institutional capacities of DOH and PhilHealth, being the lead national agencies
that will provide support to local planning and development through appropriate standards,
capacity build-up of implementers, and financing mechanisms.

AIMS:
1. Every pregnancy is wanted, planned and supported
2. Every pregnancy is adequately managed throughout its course
3. Every delivery ia facility-based and managed by skilled birth attendants or skilled health
professionals
4. Every mother-newborn pair secures proper postpartum and newborn care with smooth transition
to the women’s health care package for the mother and child survival package for the newborn

MNCHN CORE PACKAGE OF SERVICES:

A. PRE-PREGNANCY PACKAGE
1. Nutrition: counselling, use of iodized salt, micronutrient supplements (Iron and folate: 60mg
elemental iron/400mcg folic acid, 1 tablet daily for 3-6 months; Vitamin A: at least 5, 0000 IU every
week or a daily multivitamin supplement may be taken as an option when the required vitamin A is not
available)
2. Promotion of healthy lifestyle
3. Advice on family planning and provision of family planning services
4. Prevention and management of life-style related diseases
5. Prevention and management of infection including deworming
6. Counselling on STI/HIV/AIDS, nutrition, personal hygiene and consequences of abortion
7. Adolescent health services
8. Provision of oral health services

B. PRE-NATAL OACKAGE
1. Prenatal visits:
a. at least four times throughout the course of pregnancy
b. pre-natal assessments
2. Micronutrient supplementation:
a. Iron and folate (60mg/400mcg) once a day for 6 moths or 180 tablets
b. Vitamin A: 10, 000 IU twice a week from the fourth month of pregnancy
c. Elemental iodine 200 mg given once during the pregnancy
3. Tetanus toxoid
a. 0.5 ml of TT, IM, deltoid muscle
b. Adequate immunization of women prevents tetanus in both the mother and the newborn
3. Promotion of exclusive breastfeeding, newborn screening and infant immunization
4. Counselling on healthy lifestyle
5. Early detection and management of pregnancy complications
6. Prevention and management of other conditions such as hypertension, anemia, diabetes, TB,
malaria, STI/HIV/AIDS
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C. DELIVERY PACKAGE
1. Skilled birth attendance/skilled health professional-assisted delivery and facility-based deliveries
including the use of partographs
2. Proper management of pregnancy and delivery complications Essential intrapartum and newborn
care practices is applied in hospitals and birthing centers/facilities

D. POSTPARTUM PACKAGE
1. Postpartum visits: within 72 hours and on the 7 th day postpartum check for complications like
bleeding and infections
2. Micronutrient supplementation:
a. Iron and folate (60mg/400mcg) once a day for 3 months or 90 tablets
b. Vitamin A: 10, 000 IU twice a week from the fourth month of pregnancy
3. Counseling on nutrition, child care, family planning and other available services

E. NEWBORN PACKAGE
1. Interventions within the first 90 minutes ( Essential Intrapartum and Newborn Care/EINC)
2. Essential newborn care after 90 minutes to 6 hours
3. Care prior to discharge

F. CHILD CARE PACKAGE

1. Immunization
2. Nutrition
3. Integrated management of childhood illnesses
4. Injury prevention
5. Oral health
6. Insecticide-treated nets for mothers and children in malaria-endemic areas

MNCHN SERVICE DELIVERY NETWORK:

No single facility or unit can provide the entire MNCHN Core Package of Services. It is important that
different health care providers within the locality are organized into a well-coordinated MNCHN service
delivery network to meet the varying needs of populations and ensure the continuum of care. This is
the reason for establishing the province as the basic unit for planning and implementation of the
MNCHN Strategy.

The MNCHN SDN can be a province or city-wide network of public and private health care facilities and
providers capable of giving MNCHN services, including basic and comprehensive emergency obstetric
and essential newborn care. It also includes the communication and transportation system supporting
this network.

1. Community level providers give primary health care services. These may include outpatient clinics
such as Rural Health Units (RHUs), Barangay Health Stations (BHS), and private clinics as well as their
health staff (i.e., doctor, nurse and midwife) and volunteer health workers (i.e., barangay health
workers, traditional birth attendants).

71
The CHTs provide both navigation and basic service delivery functions. Navigation functions include
informing families of their health risks, assisting families in health risks and needs assessment; assisting
families develop health use plans such as birthing plans and facilitating access by families to critical
health services (e.g. emergency transport and communication as well as outreach) and financing
sources (e.g. PhilHealth).

Their basic service delivery functions include advocating for birth spacing and counselling on family
planning services; tracking and master listing of pregnant women, women of reproductive age, children
below 1 year of age; early detection and referral of high-risk pregnancies; and reporting maternal and
neonatal deaths. The team shall also facilitate discussions of relevant community health issues
especially those affecting women and children. CHTs should be present in each priority population area
to improve utilization of services, ensure provision of services as well as follow-up care for postpartum
mothers and their newborn.

2. Basic Emergency Obstetric and Newborn Care (BEmONC)-capable network of facilities and providers
can be based in hospitals, RHUs, BHS, lying-in clinics or birthing homes. If the BEmONC is hospital
based, blood transfusion services which may or may not include blood collection and screening will be
provided. These facilities operate on a 24-hour basis with staff complement of skilled health
professionals such as doctors, nurses, midwives and medical technologists.

A BEmONC based in RHUs, BHS, lying-in clinics, or birthing homes can either be a stand-alone facility or
composed of a network of facilities and skilled health professionals capable of delivering the six signal
functions. A standalone BEmONC-capable facility is typically an RHU which has the complement of
skilled health professionals such as doctors, nurses, midwives and medical technologists. BEmONCs
operating as a network of facilities and providers can consist of RHUs, BHS, lying-in clinics, or birthing
homes operated by skilled health professionals. At the minimum, this can be operated by a midwife who
is either under supervision by the rural health physician or has referral arrangements with a hospital or
doctor trained in the management of maternal and newborn emergencies. Under this arrangement, a
midwife can provide lifesaving interventions within the intent of A. O. 2010-0014.

BEmONCs shall be supported by emergency transport and communication facilities. The provision of
blood transfusion services in non-hospital BEmONCs shall be dependent on presence of qualified
personnel and required equipment and supplies.

3. Comprehensive Emergency Obstetric and Newborn Care (CEmONC)- capable facility or network of
facilities are end-referral facilities capable of managing complicated deliveries and newborn
emergencies. It should be able to perform the six signal obstetric functions, as well as provide
caesarean delivery services, blood banking and transfusion services, and other highly specialized
obstetric interventions. It is also capable of providing newborn emergency interventions, which include,
at the minimum, the following: (a) newborn resuscitation; (b) treatment of neonatal sepsis/infection;
(c) oxygen support for neonates; (d) management of low birth weight or preterm newborn; and (e)
other specialized newborn services.

The CEmONC-capable facility or network of facilities can be private or public secondary or tertiary
hospital/s capable of performing caesarean operations and emergency newborn care. Ideally, a
CEmONC-capable facility is less than 2 hours from the residence of priority populations or the referring
facility.

72
These facilities can also serve as high volume providers for IUD and VSC services, especially tubal
ligations and no-scalpel vasectomy.

A typical CEmONC-capable facility has the following health human resource complement: 3 doctors
preferably obstetrician/surgeon or General Practitioner (GP) trained in CEmONC (1 per shift), at least 1
anesthesiologist or GP trained in CEmONC (on call), at least 1 pediatrician (on call), 3 Operating Room
nurses (1 per shift), maternity ward nurses (2 per shift), and 1 medical technologist per shift.

Alternatively, the SDN can also designate a CEMONC-capable network of facilities that has the
necessary staff, equipment and resources coming from a network in order to provide the full range of
CEmONC services. For example, a designated facility capable of doing caesarean sections may not have
incubators within its physical facility but can secure this equipment either from other providers or assign
care of premature neonates to another facility within the network.

The CEmONC capable facility or network of facilities should organize an itinerant team that will conduct
out-reach services to remote communities. A typical itinerant team is composed of at least 1 doctor
(surgeon), 1 nurse and 1 midwife.

REPRODUCTIVE HEALTH

Definition:
A state of complete physical, mental and social well-being and not merely the absence of disease or
infirmity in all matters relating to the reproductive system and its functions and process.

Concepts:
 A married couple has the capability to reproduce/ procreate
 Reproductive health is the exercise of reproductive right with responsibility
 RH includes sexual health for the purpose of enhancement of life and personal relations
 RH means safe pregnancy and delivery
 RH includes protection from unwanted pregnancy by having access to safe and acceptable
methods of family planning of their choice.
 RH includes protection from harmful reproductive practices and violence
 RH assures access to information on sexuality to achieve sexual enjoyment

Vision
Reproductive health practice as a way of life for every man and woman throughout life.

Goals
 To achieve healthy sexual development and maturation
 To achieve their reproductive intention
 To avoid illness diseases, injuries disabilities related to sexuality and reproduction
 To receive appropriate counselling and care of RH problems

Strategies
 Increase in improve the use of more effective or modern contraceptive methods
 Provision of care, treatment and rehabilitation for RH, if possible in all facilities

73
  RH care provision should be focused on adolescent, men and unmarried and other displaced
people with RH problems
 Strengthen outreach activities and the referral system
 Prevent specific RH problems

Ten Elements of Reproductive Health

1. Maternal and Child Health and Nutrition
2. Family Planning
3. Prevention and Management of abortion complications
4. Prevention and treatment of Reproductive Tract Infections including STDs, HIV and AIDS
5. Education and counselling on sexuality and sexual health
6. Breast and Reproductive Tract Cancers and other Gynecological conditions
7. Men’s reproductive Health
8. Adolescent Reproductive Health
9. Violence against Women (VAW)
10.Prevention and Treatment of infertility and sexual disorder

Factors/ Determinants of RH
1.Socio- Economic conditions
 Education
 Employment
 Poverty
 Nutrition
 Living Condition/ Environment
 Family Environment
2. Status of women
3. Social and Gender Issues
4. Biological, cultural and Psycho- Social Factors

NATIONAL FAMILY PLANNING PROGRAM

VISION:
For Filipino women and men achieve their desired family size and fulfill the reproductive health and
rights for all through universal access to quality family planning information and services.

MISSION
In line with the Department of Health FOURmula One Plus strategy and Universal Health Care
framework, the National Family Planning Program is committed to provide responsive policy direction
and ensure access of Filipinos to medically safe, legal, non-abortifacient, effective, and culturally
acceptable modern family planning (FP) methods.

OBJECTIVES:
To increase modern Contraceptive Prevalence Rate (mCPR) among all women from 24.9% in 2017 to
30% by 2022
To reduce the unmet need for modern family planning from 10.8% in 2017 to 8% by 2022
74
PROGRAM COMPONENTS:

Component A: Provision of free FP Commodities that are medically safe, legal, non-abortifacient,
effective and culturally acceptable to all in need of the FP service:
Forecasting of FP commodity requirements for the country
Procurement of FP commodities and its ancillary supplies
Strengthening of the supply chain management in FP and ensuring of adequate FP supply at the service
delivery points

Component B: Demand Generation through Community-based Management Information System:

Identification and profiling of current FP users and identification of potential FP clients and those with
unmet need for FP (permanent or temporary methods)
Mainstreaming FP in the regions with high unmet need for FP
Development and dissemination of Information, Education Communication materials
Advocacy and social mobilization for FP

Component C: Family Planning in Hospitals and other Health Facilities

Establishment of FP service package in hospitals
Organization of FP Itinerant team for outreach missions
Delivery of FP services by hospitals to the poor communities especially Geographically Isolated and
Disadvantaged Areas (GIDAs):
Provision of budget support to operations by the itinerant teams including logistics and medical supplies
needed for voluntary surgical sterilization services
FP services as part of medical and surgical missions of the hospital
Partnership with LGU hospitals for the FP outreach missions

Component D: Financial Security in FP

Strengthening PhilHealth benefit packages for F
Expansion of PhilHealth coverage to include health centers providing No Scalpel Vasectomy and FP
Itinerant Teams
Expansion of Philhealth benefit package to include pills, injectables and IUD
Social Marketing of contraceptives and FP services by the partner NGOs
National Funding/Subsidy

Partner Institutions
Local Government Units
Civil Society Organizations
Non-Government Organizations
Private Sector
Faith-based Organizations
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Development Partners

HIGH-RISK PRENACY CONDITIONS:

1. Being too young (less than 18 years old) or too old (over 34 years old)
2. Having had too many (4 or more) pregnancies
3. Having closely spaced (too close) pregnancies (less than 36 months)
4. Being too ill or unhealthy/too sick or having an existing disease or disorder

FOUR PILLARS OF FAMILY PLANNING PROGRAM

1. RESPONSIBLE PARENTHOOD
This refers to the will and ability to respond to the needs and aspirations of the family. It promotes the
freedom of responsible parents to decide on the timing and size of their families in pursuit for a better
life
2. RESPECT FOR LIFE
The 1987 Constitution protects the life of the unborn from the moment of conception. FP aims to
prevent abortions, thereby saving lives of both women and children
3. BIRTH SPACING
Proper spacing of 3-5 years from a recent pregnancy enables a woman to recover from pregnancy and
to improve her well-being, the health of the child, and the relationship between husband and wife and
between parents and children
4. INFORMED CHOICE
Couples and individuals are fully informed on the different modern FP methods. Couples and individuals
decide and may choose the methods that they will used based on informed choice and to exercise
responsible parenthood in accordance with their religious and ethical values and cultural background,
subject to conformity with universally recognized international human rights

BENEFITS OF FAMILY PLANNING

Benefits to mothers
1. Enables her to regain her health after delivery
2. Gives enough time and opportunity to love and provide attention to husband and children
3. Gives more time for her family and own personal advancement
4. When suffering from an illness, gives enough time for treatment and recovery

Benefits to children
1. Healthy mothers produce healthy children
2. Will get all attention, security, love and care they deserve
Benefits to fathers
1. Lightens the burdens and responsibility in supporting his family
2. Enables him to give his children their basic needs
3. Gives time for his family and own personal advancement
4. When suffering from an illness, gives enough time for treatment and recovery
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FAMILY PLANNING METHODS

Advantages Disadvantages

1. Female sterilization (bilateral tubal lagation) cutting/blocking 2 fallopian

tube (effectiveness: 99.5%

a. permanent a. uncommon complications:

b. no effect on breastfeeding infection/bleeding
c. minilaparotomy can be performed after ab. ectopic pregnancy if ever
woman gives birth c. reversal is difficult
d. not protective against STD
e. limitation of work only after surgery
2. Male sterilization (vasectomy): cutting vas deferense thru scrotal opening
(effectiveness: 99.9%)

a. very effective after 3 mos. of procedure a. slight pain & swelling 2-3 days after
b. permanent and safe not lose sexual procedure
ability and ejaculation b. reversibility difficult
c. not affect male hormonal function, c. bleeding may result in hematoma in the
erection & ejaculation scrotum
d. not protective against STD

3. Pill (Estrogen & Progesteron) (effectiveness: 99.7%)

a. safe a. S/E: nausea, dizziness, breast

b. menstrual cycle more regular & tenderness (not really harmful)
predictable b. Decrease effectiviness with: Rifampicin &
c. reduce painful menses and anti-convulsants
endometriosis c. Suppress lactation
d. reduce ovarian & endometrial CA
e. reversible
4. Male condom (effectiveness: 98%) use in erected penis

a. Safe a. allergy to latex or lubricant

b. protect against STD b. decrease sensation
c. encourage male participation in FP c. interrupts the sexual act
d. easily accessible d. requires a man’s cooperation for its use
e. manage premature ejaculation
1. Injectables (synthetic hormone, progestin) (effectiveness: 99.7%)
a. suppressing ovulation
b. thickens cervical mucus
a. reversible (no estrogen related S/E:
nausea, dizziness, nor serious
complications such as thromboplebitis or
pulmonary embolism)
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b. not affect breast feeding
6. Lactation Amenorrhea Method (LAM): temporary introductory postpartum
method of postponing pregnancy based on physiological infertility experienced
by breast feeding women (effectiveness = 9.5%)

a. universally available a. maximum effectiveness of 6 months

b. protection from an unplanned pregnancy postpartum (short)
begins immediately postpartum b. effectiveness decrease with separation of
c. no FP commodities are required mother & child
d. improve maternal & child health & c. difficult to maointain BF for 6 months
nutrition d. disadvantage to women who do not pass
any of the three criteria to practice
lactation amenorrhea
7. Mucus/Billing/Ovulation: abstaining from sexual intercourse during fertile
(wet) days prevents pregnancy

By: 1. recording of menstruation and dry days (effectiveness = 97%)

2. inspecting underwear regularly for presence of mucus

3. recording the most fertile observation/characterics at the end of the day

a. can be used by any women of a. not for women making pregnancy

reproductive age provided not suffering dangerous
from unusual condition resulting to
extraordinary vaginal discharge

8. Basal Body Temperature: daily taking and recording of the rise in the body
temperature during & after ovulation
Effectiveness: 99%

Thermometer is placed in axilla or under the tongue at least 3 hours of undisturbed rest
during (upon waking up and before any activity) throughout the menstrual cycle.

Cover line is being determined to identify the highest temp. from day 6-10 of the
menstrual cycle to identify thermal shift (the three consecutive temp above the cover line
labeled as days 1,2,3)

Intercourse is allowed from the 4th day of thermal shift until the end of the cycle
(absolute infertile phase days)

a. Very effective a. take BBT everyday and time to record

temperature. b. may practice abstinence
during fertile periods

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 9. Sympto-thermal method: identifying the fertile and infertile days of the
menstrual cycle as determined through a combination of observations made on
the cervical mucus, basal body temp recording and other signs of ovulation
Effectiveness: 90%

10. Two Day Method: cervical secretions as an indicator of fertility

Effectiveness: 96.5%; women checking the presence of secretions everyday

a. Can be used by women with any a. Needs the cooperation of the husband
cycle length b. Can become unreliable for women who
b. enhances self discipline mutual respect have conditions that cause abnormal
cooperation communication, and shared cervical secretions
responsibility of the couple for the FP c. Does not protect the client from
c. Acceptable to couples regardless of HIV/AIDS
culture, religion, socioeconomic status,
and education

11. Standard Days Method: new method of natural family planning in which all
users with menstrual cycles between 26 and 32 days are counseled to abstain
from sexual intercourse on days 8-19 to avoid pregnancy; use color coded cycle
beads to mark the fertile and infertile days of the menstrual cycle

Abstain from sexual intercourse during fertile period

Use color coded beads to mark the fertile and infertile periods

Effectiveness: 95%

a. Increases self awareness and knowledge a. Cannot be used by women who usually
of human reproduction and can lead to a have menstrual cycle between 26 and 32
diagnosis of some gynecologic problems days long
b. No need for counting or charting since
the standard days method makes use of
beads for tracking the cycle days
c. used either to avoid or achieve
pregnancy
d. Acceptable to couples regardless of
culture, religion, socioeconomic status,
and education

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS: AN OVERVIEW

In the Philippines, pneumonia was one of the leading causes of infant deaths while diarrhea and
gastroenteritis presumed infectious origin ranked in the top ten. Pneumonia and diarrhea were two of
the top three causes of childhood mortality. Worldwide, more than 50 countries have high childhood
mortalities. More than ten million children die from developing countries before reaching five years old.

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Seven of the ten deaths are due to: acute respiratory infections (mostly pneumonia), diarrhea, measles,
malaria or malnutrition – or combination of these illnesses.

The WHO/UNICEF initiated the Integrated Management of Childhood Illness (IMCI) strategies which
offer simple and effective methods for child survival, healthy growth and development and is based on
the combined delivery of essential interventions at community, health facility and health system levels.
The IMCI process includes preventive as well as curative measures to address the most common
conditions that affect young children

The IMCI strategy includes three main components:

a. Improvements in case management skills of health care staff
b. Improvements in the health system needed fir effective management of childhood illness
c. Improvement in family and community practices

IMCI case management

IMCI clinical guidelines are meant to be used by health worker in the management of sick children from
age 1 week up to 5 years. The IMCI guides the health worker in:
a. Assessing signs that indicate severe diseases
c. Assessing a child’s nutrition, immunization and feeding
d. Teaching parents how to care for a child at home
e. Counselling parents to solve feeding problems
f. Advising parents about when to return to a health facility

IMCI case management processes:

1. ASSESS a child by checking first for danger signs (or possible bacterial infection in a young infant),
asking questions about common conditions, examining the child, and checking nutrition and
immunization status. Assessment includes checking the child for other health problems.
2. CLASSIFY a child’s illnesses using a color-coded triage system. Many children have more than one
condition. Each illness is classified according to whether it requires:
a. Urgent prereferral treatment and urgent referral (pink)
b. Specific medical treatment and advice (yellow)
c. Simple advice on home management (green)
3. After classifying all conditions, IDENTIFY specific treatments for the child. If a child requires urgent
referral, give essential treatment before transferring. If a child is to be treated at home, make a
treatment plan and give first dose of drugs in the clinic. Give immunizations if needed or scheduled
4. Provide practical TREATMENT instructions, including teaching the mother or caretaker on how to give
oral drugs, how to feed and give fluids during illness, and how to treat local infections at home. Ask
the mother or caretaker to return for follow-up on a specific schedule. Teach her to identify untoward
signs and symptoms and when to return immediately.
5. Assess feeding, including breastfeeding practices and COUNSEL to solve any feeding problems.
Counsel the mother with her own health conditions.
6. When a child is brought back to the clinic as requested, GIVE FOLLOW-UP CARE and, if necessary,
reassess the child for possible new problems.

The case management is for two age groups: (a) children aged 2 months to 5 years and (b) 1 week to
2 months. The health worker would ask the age of the child first. If the age is “up to 5 years” the chart
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 is “sick child”. If the age is younger than 2 months, the chart would be “young infant”. These two age
brackets have different case managements. Then, the HCW will ask what is the problem of the child
and if it is an initial visit or follow-up. From there, the management continues

V. ESSENTIAL DRUGS

- are medicinal preparations necessary to fill the basic health needs of the population.
- Also are those drugs that satisfy the health care needs of the majority of the population; they
should therefore be available at all times in adequate amounts and in appropriate dosage forms,
at a price the community can afford

The 10 Medicinal plants endorsed by DOH

MEDICINAL PLANTS USE/INDICATION PREPARATION
(with scientific name)
LAGUNDI Asthma. cough and fever; Decoction
Vitex negundo Dysentery, colds and pain Wash affected site
in any part of the body as
in influenza; Skin diseases
(dermatitis, scabies, ulcer,
eczema) and wounds;
Headache, Rheumatism,
sprain, contusion, insect
bites; Aromatic bath for
sick patient
OLASIMANG BATO Lowers uric acid Decoction or
Peperomia pellucida eaten raw
BAYABAS Washing wounds, diarrhea, Decoction
Psidium guajava as gargle and to relieve
toothache.

BAWANG Hypertension; toothache; Eaten raw/fried or

Allium sativum lower cholesterol levels in Apply on part
blood
YERBA BUENA Rheumatism, arthritis and Decoction
Clinopodium douglasii headache; cough & cold, Infusion
swollen gums, Toothache, Massage sap
menstrual and gas pain,
nausea and fainting, insect
bites

SAMBONG Anti-edema, diuretic, anti- Decoction

Blumea balsamifera urolithiasis

AKAPULKO Anti-fungal: Tinea Flava, Poultice

Cassia alata ringworm, athlete’s foot,
and scabies
NIYOG-NIYOGAN Anthelminthic Seeds are used
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 Quisqualis indica L.
TSAANG GUBAT Diarrhea Decoction
Ehretia microphylla Lam.
AMPALAYA Lower blood sugar levels Decoction
Momordica charantia Diabetes Mellitus (Mild Steamed
non-insulin dependent)

Medicinal plant preparations

Preparation Procedure
Decoction Boil the recommended part of the plant
material in water (20 minutes)
Infusion Plant material is soaked in water.
Recommended soaking period is 10-15
minutes or longer
Poultice Directly apply recommended plant
material on the part affected
Tincture Mix the plant material in alcohol
Others:
Oil
Ointment
Cataplasm
Syrup

GUIDELINES
1. Avoid the use of insecticides as these may leave poison on plants.
2. In the preparation of herbal medicine, use a clay pot and remove cover while boiling at low heat.
3. Use only the part of the plant being advocated.
4. Follow accurate dose of suggested preparation.
5. Use only one kind of herbal plant for each type of symptoms or sickness.
6. Stop giving the herbal medication in case untoward reaction such as allergy occurs.
7. If signs and symptoms are not relieved after 2 or 3 doses of herbal medication, consult a doctor.

LAWS RELATED:

LAW DESCRIPTION
Generics Act of 1988 “Formally proclaims the state of
R.A. # 6675 promoting the use of generic terminology
in the importation, manufacture,
distribution, marketing, promotion &
advertising, labeling, prescribing &
dispensing of drugs.”
 
“Reinforces the NDP with regards to the
assurance of the high-quality & rational
drug use.”
Dangerous Drugs Act “ The safe administration &

82
R.A. 6425 transportation of prohibited drugs is
punishable by law.”
 
2 Types of Drugs:
 
Prohibited Regulated
Republic Act 9165 Comprehensive Dangerous Drugs Act of
2002

VI. NUTRITION PROGRAM

GOAL:
The improvement of nutritional status, productivity and quality of life of the population
through the adoption of desirable dietary practices and healthy lifestyle

OBJECTIVES:
To decrease the morbidity and mortality rates secondary to avitaminoses and other nutritional
deficiencies among the population mostly composed of infants and children

COVERAGE:
 Protein Energy Malnutrition (PEM)
 Vitamin A deficiency (VAD)
 Iron Deficiency Anemia (IDA)
 Iodine Deficiency Disorder (IDD)
 Philippine Food & Nutrition Programs
 Directed to the provision of nutrition services to the DOH’s identified priority vulnerable
groups

1. MALNUTRITION REHABILITATION PROGRAM

Targeted Food Task Nutrition Rehabilitation Akbayan sa Kalusugan
Force Assistance Ward (ASK Project)
Program
Provision of food rations of Every hospital must have a Aimed to provide rice &
bulgur wheat & green peas Nurse ward, where an corn soya blend
  adequately trained supplemented with local
Target population: nutritionist were assigned foods.
Pre-schoolers (RA 422)  
Pregnant women Target pop:
Lactating mothers 6 mos- 2 years
Moderately & severely
underweight
Pre-schoolers not served
by the DSWD and DA in
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 Regions 2,8,9,10,11,12

2. MICRONUTRIENT SUPPLEMENTATION PROGRAM

“23 in 93” FORTIFIED VITAMIN “Health for More in ‘94”

RICE “Buwan ng Kabataan, Pag-asa ng
Bayan’
National Focus: National
Micronutrient Day or “Araw ng
Sangkap Pinoy”
  -Aimed to distribute vitamin A
-A free enrichment program aimed to supplements, iodized oil for & seedlings
prevent deficiencies in vitamin A of plants rich in Fe & other minerals.
(blindness); iron (anemia); iodine (goiter,
mental retardation & delayed
development)
 
(1 cavan of rice + fistful processed, binilid
enriched with essential micronutrients)

3. FOOD FORTIFICATION PROGRAM

- Is the government’s response to the growing micronutrient malnutrition that has been prevalent
in the Philippines for the past several years
- Vitamin A, Iron, Iodine
- Sangkap Pinoy
- FIDEL salt
*whether or not they are normally contained in the food for the prevention or correction of deficiency

*Sangkap Pinoy micronutrients required by the body in very small quantities

4. NUTRITION SURVEILLANCE SYSTEM

- A system of keeping close watch on the state of nutrition & the causes of malnutrition w/n a
locality, w/ involves periodic collection of data & analysis & dissemination of analyzed information
- Tools utilized are Anthropometric measurements:
A. Weight for Age
B. Height for Age
C. Weight for Height
D. BMI

Weight for Age:

Measures degree & presence of wasting or stunting
 
Height for Age:
Measures the presence of stunting
< 90% of standard stunting or past chronic malnutrition
 
Weight for Height:
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 Determines the presence of muscle wasting:

Ideal body wt,: 135

Body mass index(BMI)= wt in kgs
Ht in meters
IBW: +6 for every increment of an inch above 5 ft +5 (males)
105-110 lbs for a height of 5 feet 100-105 lbs
-6 for every decrement of an inch below 5 ft -5

DEGREE OF MALNUTRITION INTERPRETATIONS:

110% and above – obese
90-109% - normal
75-89 % - 1st degree
60-75% - 2nd degree
59 and below – 3rd degree

TYPES OF NUTRITIONAL DEFICIENCIES

A. PROTEIN ENERGY MALNUTRITION (PEM)
1. MARASMUS
- Child lacks food rich in CHON & energy
- Usually the child is < 1 year old when malnutrition starts

MANIFESTATIONS:
• Very thin, no fat, muscle wasting
• Prominent ribs
• Very poor wt gain
• Loose & wrinkled skin
• Enlarged abdomen
• Anxious, always hungry
• “Old Man’s Face”

2. KWASHIORKOR
- Disease of older children when the next baby is born.
- Usually when the child is 1-3 y/o

MANIFESTATIONS:
- Very thin, fails to grow
- Light colored, weak hair
- Moon-shaped, Unhappy face
- Enlarged abdomen
- Muscle wasting
- Swollen legs, feet, arms & hands
- Doesn’t want to eat
- Dark spots on skin
- Skin sores & skin is peeling
- Apathetic

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TREATMENT:
Food

B. VITAMIN A DEFICIENCY
CAUSES:
-Low intake of Vitamin A rich food
- Low intake of protein
- Illnesses like measles, diarrhea

CONSEQUENCES:
Blindness
1. Night blindness
2. Nutritional blindness

SOURCES:
-Breast milk, animal sources, whole milk, eggs, liver, meat
-Yellow/orange fruits (papaya, mango)
- Plant sources yellow/orange vegetables (carrots & squash)
- Green leafy vegetables (malunggay, kangkong), Vit. A capsule
UNIVERSAL SUPPLEMENTATION OF VITAMIN A
INFANTS PRESCHOOLERS PREGNANT POSTPARTUM
WOMEN MOTHERS
100,000 IU 200,000 IU 10,000 IU twice 200, 000 IU within
One dose only One capsule every 6 a week starting four weeks after
months th delivery
at the 4 month
of pregnancy*

Vitamin A supplementation to High risk children.

Measles 100, 000 IU One capsule given upon

Infants (6 months- 200, 000 IU diagnosis, regardless of
11 months) when the last dose of VAC
Pre-school children was given
(12 months- 71 months)
Severe pneumonia 100, 000 IU One capsule given upon
Persistent Diarrhea 200, 000 IU diagnosis, except when the
Malnutrition child was given VAC less
Infants (6 months- than 4 weeks before
11 months) diagnosis
Pre-school children
(12 months – 71 months)
Malnutrition 200, 000 IU One capsule given upon
School children (6 diagnosis, except when the
years to 12 years old) child was given VAC less
than 4 weeks before
diagnosis

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C. IRON DEFICIENCY ANEMIA (IDA)
- Not enough hemoglobin in the RBC because of lack of Fe

CAUSES:
- Low intake of iron-rich foods
- Blood loss
- Poor absorption
- Increased demands

Sources:
a. best animal sources: liver, internal organs, meat, blood, fish, shellfish.
b. best plant sources: green leafy vegetables, dried beans

TREATMENT AND PREVENTION:

-provision of iron with folic acid
- pregnant: Once a day for 180 days
Lactating women: once a day for 90 days

IRON SUPPLEMENTATION FOR PREGNANT AND LACTATING WOMEN

TARGETS PREPARATIONS DOSE/DURATION
Pregnant women Tablet containing 60 mg 1 tablet once a day for 6
elemental iron with 400 mcg months 0r 180 days during
folic acid the pregnancy period
Or
2 tablets per day (120 mg) if
prenatal consultations are
nd rd
done during the 2 and 3
trimester
Lactating women Tablet containing 60 mg 1 tablet once a day for 3
elemental iron with 400 mcg months or 90 days
folic acid

D. IODINE DEFICIENCY DISORDERS (IDD)

- Abnormalities d/t low iodine intake.

CAUSES:
- Low intake of iodine-rich foods
- Goitrogens and other environmental factors

CONSEQUENCES:
Fetus – abortion/miscarriage/abnormalities/still
Infants – cretinism/delayed walking/motor activities
Children – poor academic performance
Adults – mental impairment/poor working capacity

TREATMENT:
- Women 15-45 y/o, School age children, adult males:
87
to take one iodized capsule with 200mg iodine every year

SOURCES:
a. 90%-food
b. 10% water

TERMS TO DESCRIBE DIFFERENT FEEDING PATTERNS

Exclusive breastfeeding – the infant receives breastmilk and allows the infant to receive oral rehydration
salt (ORS), drops, syrups, nothing else
Predominant breastfeeding – the infant’s predominant source of nourishment has been breast milk,
including milk expressed from the mother or wet nurse as sources. However, the infant may also have
received liquids – water, water-based drinks, fruit juice, vitamins, minerals and oresol
Complementary feeding – process of giving the infant foods and liquids, along with breast milk, when
breast milk is no longer sufficient to meet the infant’s nutritional requirements
Bottle feeding – the child is given food or drinl from a bottle with nipple/teat. Information on bottle
feeding is useful because of the potential interference of bottle feeding with optimal breastfeeding
practices and the association between bottle feeding and increased diarrheal mortality and morbidity
cases
Early initiation of breastfeeding – initiating breastfeeding of the newborn after birth within 90 minutes
of lifein accordance to the essential newborn care protocol

BREASTFEEDING

Unique characteristics of Breast milk:

B est for babies F resh

R educed allergic reaction E motional bonding
E conomical E asily established
A lways available D igestible
S afe/ maintains the stool soft I mmunity
T emperature always right N nutritious
G IT disorders are decreased

Difference of breast milk from formula milk:

Breastmilk vs. Formula

CHO > CHO
CHON (LACTALBUMIN) < CHON (CASEIN)
Fats = Fats
Linoleic acid content (3x) > Linoleic acid content
Minerals < minerals

88
LAWS RELATED:

LAW DESCRIPTION
Executive Order 51 The Milk Code. Prohibits advertising,
promotion, or other marketing materials
that shall imply or create a belief that
bottle feeding is equivalent or superior to
breastfeeding
Executive Order 382 Provided for the observance of the
National Food Fortification Day every
November 7
Republic Act 7600 Rooming-In and Breastfeeding Act. States
that the newborn be put to the breast of
the mother immediately after birth and
be roomed-in 30 minutes after normal
spontaneous delivery and within 3-4
hours after Caesarian section delivery
Republic Act 8172 ASIN (Act for Salt Iodization Nationwide)
Law. Requires all producers of food-grade
salt to iodize the salt that they produce,
import, trade or distribute
Republic Act 8976 Philippine Food Fortification Act.
Mandates the fortification of rice with
iron, wheat flour with vitamin A and iron,
refined sugar with vitamin A, cooking oil
with vitamin A; promotes fortification of
food products through the Sangkap Pinoy
seal Program
Republic Act 10028 Expanded Breastfeeding Promotion Act.
Mandates the setting up of lactation
stations in all health and nonhealthy
facilities, establishments, or institutions.
It also grant breaks for nursing
employees to breastfeed or express milk
Administrative Order 36, series 2010 Expanded Garantisadong Pambata. A
comprehensive and integrated package of
services on health, nutrition and
environment for children available
everyday at various settings such as
homes, schools, health facilities and
community by government, non-
government organizations, private groups
and civic groups

89
 TEACHER’S INSIGHTS
Primary Health Care is both a philosophy and a strategy. It is an all-encompassing strategy for all the
health services or programs. All the programs are abbreviated as ELEMENTS and all is anchored to the
pillars, principles and strategies of PHC. The programs are to correct the inequities in the nation and to
prioritize the most vulnerable communities. The success of these programs is based on the partnership
among the government, private groups and other sectors.
One of the focuses of the MDGs and SDGs is the improvement of the maternal and child health. The
MNCHN, EPI and Nutrition programs of the Philippines should continue to yield positive results. In the
long run, this is an indicator of a healthy individual, family and the community.

CONTROL OF COMMUNICABLE DISEASES

COMMUNICABLE DISEASES

Goal of WHO
1. Prevention of disease
2. Prevention of disability and death from infection
3.Prevention through immunization

LESSON 1: CHAIN OF INFECTION AND RELATED CONCEPTS

1. Pathogen, etiologic agent or causative agent

biologic agent (organism) capable of causing disease
Eliminate organism by:
 Sterilizing surgical instruments and anything that touches sterile spaces of the body
 Using good food safety methods
 Providing safe drinking water
 Vaccinating people so they do not become reservoirs of illness
 Treating people who are ill
2. Reservoir
Any person, animal, arthropod, plant, soil, or substance (or combination of these) in which an causative
agent normally lives and multiplies, on which it depends primarily for survival, and where it reproduces
in such numbers that it can be transmitted to a susceptible host
Eliminate reservoirs by:
 Treating people who are ill
 Vaccinating people
 Handling and disposing of body fluids responsibly
 Handling food safely
 Monitoring soil and contaminated water in sensitive areas of the hospital and washing hands
carefully after contact with either
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 3. Portal of exit
the way the causative agent gets out of the reservoir (body fluid or skin)
Reduce risk from portals of exit by:
 Covering coughs and sneezes with a tissue
 Handling body fluids with gloves, then doing hand hygiene
 Keeping draining wounds covered with a dressing
 Not working when you have exudative (wet) lesions or weeping dermatitis
4. Mode of transmission
any mechanism by which a pathogen is spread from a source or reservoir to a person
unwashed hands, things which are not cleaned between patients, droplets, or, for a few diseases, the
air
Eliminate the mode of transmission by:
 Hand hygiene
 Wearing gloves to minimize contamination of hands and discarding them after each patient
 Cleaning, disinfection, or sterilization of equipment used by more than one patient
 Cleaning of the environment, especially high-touch surfaces
5. Portal of entry
hole in the skin that allows the infectious agent to get into the body (mouth, nose, eyes, rashes, cuts,
needlestick injuries, surgical wounds and IV sites)
Protect portals of entry (our own and our patients) by:
 Dressings on surgical wounds
 IV site dressings and care
 Elimination of tubes as soon as possible
 Masks, goggles and face shields
 Keeping unwashed hands and objects away from the mouth
 Actions and devices to prevent needlesticks
 Food and water safety
6. Susceptible host
a person or animal lacking effective resistance to a particular infectious agent
Minimize risk to susceptible hosts by:
 Vaccinating people against illnesses to which they may be exposed
 Preventing new exposure to infection in people who are already ill, are receiving
immunocompromising treatment, or are infected with HIV
 Maintaining good nutrition
 Maintaining good skin condition
 Covering skin breaks
 Encouraging rest and balance in our lives

Related terms:
Symptoms
evidence of disease that is experienced or perceived (subjective)
subjective changes in body function noted by patient but not apparent to an observer
Signs
objective evidence of a disease the physician can observe and measure

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Syndrome
a specific group of signs and symptoms that accompany a particular disease
Incidence
the number of people in a population who develop a disease during a particular time period
Prevalence
the number of people in a population who develop a disease, regardless of when it appeared
refers to both old and new cases

Classification of Infectious Disease

Based on Behavior within host

Infectious Disease
- Any disease caused by invasion and multiplication of microorganisms
Contagious Disease
disease that easily spreads from one person to another

Based on Occurrence of Disease

Sporadic Disease
disease occurs only occasionally
i.e. botulism, tetanus
Endemic Disease
constantly present in a population, country or community
i.e. Pulmonary Tuberculosis
Epidemic Disease
acquire disease in a relatively short period greater than normal number of cases in an area within
a short period of time
Pandemic Disease
epidemic disease that occurs worldwide
i.e. HIV infection

Based on Severity or Duration of Disease

Acute Disease
develops rapidly (rapid onset) but lasts only a short time
i.e. measles, mumps, influenza
Chronic Disease
Develops slowly, milder but longer lasting clinical manifestation

Based on State of Host Resistance

Primary Infection
acute infection that causes the initial illness
Secondary Infection

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 one caused by an opportunistic pathogen after primary infection has weakened the body’s
defenses

Stages of Disease
Incubation Period
time interval between the initial infection and the first appearance of any s/sx
Prodromal Period
early, mild symptoms of disease
Period of Illness
overt s/sx of disease
WBC may increase or decrease
can result to death if immune response or medical intervention fails
Period of Decline
s/sx subside
vulnerable to secondary infection
Period of Convalescence
regains strength and the body returns to its pre diseased state
recovery has occurred

Modes of Transmission
The process of the infectious agent moving from the reservoir to the susceptible host

CONTACT TRANSMISSION
- the most important and frequent mode of transmission

Type of Contact Transmission

a. Direct Contact Transmission
 Person to person transmission of an agent by
 physical contact between its source and
 susceptible host
 No intermediate object involved
 i.e. kissing, touching, sexual contact
 Source → Susceptible Host
b. Indirect Contact Transmission
 reservoir to a susceptible host by means of a
 non living object (fomites)
 Source → Non Living Object → Susceptible Host

Susceptible Host
Recognition of high-risk patients
 Immunocompromised
 DM
 Surgery
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  Burns
 Elderly
Percentage Nosocomial Infection
 17% Surgical
 34% UTI
 13% LRI
 14% Bacteremia
 22% Other (incldng skin infection)

Factors for Nosocomial Infection

Microorganism/Hospital Environment
Most common cause
 Staph aureus, Coag Neg Staph Enterococci
 E. coli, Pseudomonas, Enterobacter, Klebsiella
 Clostridium Difficile
 Fungi ( C. Albicans)
 Other ( Gram (-) bacteria)
 70% are drug resistant bacteria
Compromised Host
One whose resistance to infection is impaired by broken skin, mucous membranes and a suppressed
immune system

Skin and Mucous Membrane

physical barrier
i.e. burns, surgical wounds, trauma, IV site, invasive procedures
Suppressed Immune System
i.e. drugs, radiation, steroids, DM, AIDS

IMMUNITY
The human body has the ability to resist almost all types of organisms or toxins that tend to damage
the tissues and organs. This is called immunity
Functions of Immune System
1. Protects the body from internal threats
2. Maintains the internal environment by removing dead or damaged cells.
3. Provides protection against invasion from outside the body.

THE IMMUNE SYSTEM

The major components of the immune system include the bone marrow which produces the white blood
cells (WBC), the lymphoid tissues which includes the thymus, spleen, lymph nodes, tonsils and
adenoids.

Natural Immunity

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Non-specific immunity present at birth. This includes;
a. Phagocytosis of bacteria and other invaders by white blood cells and cells of the tissue macrophage
system
b. Destruction by the acid secretions of the stomach and by the digestive enzymes on organisms
swallowed into the stomach.
c. Resistance of the skin invasion by organisms
d. Presence in the blood of certain chemical compounds that attach to foreign organism or toxins and
destroy them like lysozyme, natural killer cells and complement complex.

Acquired Immunity
The human body has the ability to develop extremely powerful specific immunity against individual
invading agents. It usually develops as a result of prior exposure to an antigen through immunization or
by contracting a disease.
Active Acquired Immunity - immune defense are developed by the person’s own body. This immunity
last many years or a lifetime.
Passive Acquired Immunity - temporary immunity from another source that has developed immunity
through previous disease or immunization. It is used in emergencies to provide immediate, short acting
immunity when the risk is high.

ANTIBODIES
Agglutination - clumping effect of antibodies between two antigen. It helps to clear the body of
invading organisms by facilitating phagocytosis.
Opsonization – in this process, the antigen-antibody molecule is coated with a sticky substance that
facilitates phagocytosis.
1. IgG (75%)
 Appears in serum and tissues
 Assumes a major role in bloodborne and tissue infections
 Activates the complement system
 Enhances phagocytosis
 Crosses placenta
2. IgA (15%)
 Appears in body fluids (blood,saliva, tears, breat milk)
 Protects against respiratory, GIT and GUT
 Prevents absorption of antigens from food
 Passes to neonate in breast milk for protection
3. IgM (10%)
 Appears mostly in intravascular serum
 First immunoglobulin produced in response to bacterial or viral infection
 Activates complement systems
4. IgD (.2%)
Appears in small amount in serum
5. IgE (.004%)
Allergic and hypersensitivity reactions
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Combats parasitic infections

IMMUNIZATION AND VACCINES

IMMUNIZATION
Process inducing immunity artificially by either vaccination (active) or administration of antibody
(passive)
Active : stimulates the immune system to produce antibodies, cellular immune responses to protect
against infectious agent
Passive : provides temporary protection through administration of exogenous antibody

IMMUNIZING AGENTS
Vaccines : a preparation of proteins, polysaccharides or nucleic acids of pathogens that are
administered inducing specific responses that inactivate or destroy or suppress the pathogen
Toxoid : a modified bacterial toxin that has been made nontoxic but retains the capacity to stimulate
the formation of antitoxin
Immune globulin : an antibody containing solution derived from human blood obtained by cold ethanol
fractionation of large pools of plasma and used primarily for immunodeficient persons or for passive
immunization
Antitoxin : an antibody derived from serum of human or animals after stimulation with specific antigens
used for passive immunity

INFECTION CONTROL PROCEDURE

Medical Asepsis
- CLEAN Technique
- Involves procedures and practices that reduce the number and transfer of pathogens
- Will exclude pathogens ONLY
Attain by:
- Frequent and thorough hand washing
- Personal grooming
- Proper cleaning of supplies and equipment
- Disinfection
- Proper disposal of needles, contaminated materials and infectious waste
- Sterilization

Surgical Asepsis
STERILE technique
- Practices used to render and keep objects and areas sterile
- Exclude ALL microorganism
Attain by:
- Use strict aseptic precautions for invasive procedures
- Scrub hands and fingernails before entering O.R.
- Use sterile gloves, masks, gowns and shoe covers

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 - Use sterile solutions and dressings
- Use sterile drapes and create an sterile field
- Heat –sterilized surgical instruments

Universal Precautions
Universal Precautions
- Infection control guidelines designed to protect workers from exposure to diseases spread by
blood and certain body fluids.
- For prevention of transmission of blood-borne pathogens in health care settings to prevent
contact with patient blood and body fluids
- Stress that all patients should be assumed to be infectious for blood-borne diseases such as AIDS
and hepatitis B.
- Universal Precautions
Followed when workers are exposed to blood and certain other body fluids, including:
- semen
- vaginal secretions
- synovial fluid
- cerebrospinal fluid
- pleural fluid
- peritoneal fluid
- pericardial fluid
- amniotic fluid
- Universal Precautions
do not apply to:
- feces
- nasal secretions
- sputum
- sweat
- tears
- urine
- vomitus
- saliva (except in the dental setting, where saliva is likely to be contaminated with blood)

Standard Precautions

Replaced universal precautions

Apply to all patients
Stipulate that gloves should be worn to touch any of the following:
- blood
- all body fluids
- secretions and excretions, except sweat, regardless of whether they are visibly bloody
- non-intact skin
- mucous membranes

Gloves
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 - Prevent contamination of the hands with microorganisms
- Prevent exposure of the HCW to blood-borne pathogens
- Reduce the risk of transmission of microorganisms from the hands of HCWs to the patient
- Do not replace the need for hand hygiene

Hands washed immediately after gloves are removed and between patient contacts
- For procedures that are likely to generate splashes or sprays of body fluid, a mask with eye
protection or a face shield and a gown should be worn
- Disposable gowns should be constructed of an impervious material to prevent penetration and
subsequent contamination of the skin or clothing
- Needles should not be recapped, bent, or broken but should be disposed of in puncture-resistant
containers

Hand Hygiene
- Single most important means to prevent transmission of nosocomial pathogens
- Removes the transient flora recently acquired by contact with patients or environmental surfaces
- Alcohol-based hand rubs are recommended (if hands are visibly soiled, washing with soap and
water is recommended)
- Ring removal prior to patient care

Transmission-Based Precautions
Transmission-Based Precautions
Apply to selected patients based on a suspected or confirmed clinical syndrome, a specific diagnosis, or
colonization or infection with epidemiologically important organisms
Always implemented in conjunction with standard precautions
3 types:
- Airborne
- Droplet
- Contact
Airborne Precautions
Prevent transmission of diseases by droplet nuclei (particles smaller than 5 µm) or dust particles
containing the infectious agent
- Airborne Precautions
- All persons entering the room of these patients must wear a personal respirator that filters 1 µm
particles with a n efficiency of at least 95% (N95 mask)
- Gowns and gloves are used as dictated by standard precautions
1. Disseminated zoster
2. Measles
3. Smallpox
4. SARS
5. Tuberculosis (pulmonary or laryngeal)
6. Varicella

- Patient placed in a private room with monitored negative air pressure in relation to surrounding
areas, and the room air must undergo at least 6 exchanges per hour

98
 - Door to the isolation room must remain closed
- Air from the isolation room should be exhausted directly to the outside, away from air intakes,
and not recirculated (high efficiency filters may be used also)
- Cough etiquette
- Patients should be instructed to cover his/her mouth and nose with tissue when coughing or
sneezing

Droplet Precautions
Prevent transmission by large-particle (droplet) aerosols
(unlike droplet nuclei, droplets are larger, do not remain suspended in the air, and do not travel long
distances)
Droplets are produced when the infected patient talks, coughs, or sneezes and during some procedures
(e.g., suctioning, bronchoscopy)
A susceptible host may become infected if the infectious droplets land on the mucosal surfaces of the
nose, mouth, or eye.
- Require patients to be placed in a private room, but no special air handling is necessary (patients
with same disease can be placed in the same room if private rooms are not available)
- Droplets do not travel long distances (generally no more than 3 feet), the door to the room may
remain open
- HCW should wear a standard surgical mask when working within 3 feet of the patient
- Gowns and gloves should be worn by HCWs when dictated by standard precautions
1. Diphtheria, pharyngeal
2. H. influenzae meningitis, epiglottitis, pneumonia
3. Influenza
4. Meningococcal infections
5. Multi-drug resistant pneumococcal disease
6. Mumps
7. Mycoplasma pneumonia
8. Parvovirus B19 infections
9. Pertussis
10.Plague, pneumonic
11.Rubella
12.Streptococcal pharyngitis

Contact Precautions
- Prevent the transmission of epidemiologically important organisms from an infected or colonized
patient through direct contact (touching the patient) or indirect contact (touching contaminated
objects or surfaces in the patient’s environment)
- Patients are placed in a private room or patients infected with same organism may be placed in
the same roo
- Barrier precautions to prevent contamination should be employed
- Gloves and Hand hygiene
- Gowns – worn if the HCW anticipates substantial contact of his or her clothing with the patient or
surfaces in the patient’s environment or there is an increased risk of contact with potentially
infective material

99
 - Noncritical patient care equipment should remain in the room and not used for other patients, if
items must be shared, they should be cleaned and disinfected before reuse
-
1. Acute diarrheal illnesses likely to be infectious in origin
2. Acute viral conjunctivitis
3. Clostridium difficile diarrhea
4. Ectoparasistic infections (lies and scabies)
5. HSV/Varicella/Disseminated zoster
6. MDR bacteria (MRSA, VRE, VISA, VRSA) infection or colonization
7. SARS
8. Smallpox
9. Streptococcal (group A) major skin, burn or wound infection
10.Viral hemorrhagic fevers

ISOLATION OF PATIENTS
Source Isolation
Reverse Isolation
- Protective or neutropenic isolation
- Used for patients with severe burns, leukemia, transplant, immuno deficient persons, receiving
radiation treatment, leukopenic patients
- Those that enter the room must wear masks and sterile gowns to prevent from introducing
microorganisms to the room

AFB ISOLATION
- VISITORS - report to nurses’ station before entering the room
- MASKS – worn in patient’s room
- GOWNS – prevent clothing contamination
- GLOVES – for body fluids and non-intact skin
- HANDWASHING - after touching patient or potentially contaminated articles and after removing
gloves
- articles discarded, cleaned or sent for decontamination and reprocessing
- room remains closed
- patients wear masks during transport

Personal Protective Equipment

- mask
- gloves
- gown
- shoe cover
- goggles

LESSON 2: BLOOD/VECTOR BORNE DISEASES

Prevention
Eradicate the source DOH CLEAN
100
 - C – chemically treated mosquito net
- L - larvae eating fish
- E – environmental sanitation
- A – anti-mosquito
- N – neem tree (oregano, eucalyptus)

A. Dengue Hemorrhagic Fever

- caused by dengue virus (Flaviviridae) with 4 serotypes
- transmitted to a bite of female aedes aegypti mosquito
- incubation period 2-7 days
Vectors: (day biting)
- Aedes aegypti (breeds in water stored in houses)
- Aedes albopictus
- Culex fatigans

Clinical manifestations:
> First 4 days – Febrile or Invasive stage – high grade fever, headache, body malaise, conjuctival
injection, vomitting, epistaxis or gum bleeding, positive tornique test.
> 4th – 7th day – Toxic or Hemorrhagic Stage – After the lyze of the fever, this is were the
complication of dengue is expected to come out as manifested by abdominal pain, melena, indicating
bleeding in the upper gastrointestinal tract, Unstable BP, narrow pulse pressure and shock.
> 7th – 10th day – Convalescent or recovery stage – after 3 days of afebrile stage and the patient was
properly hydrated and monitored BP will become stable and laboratory values of platelet count and
bleeding parameters will begin to normalize.

Classification of Dengue Fever according to severity

1. Grade I – Dengue fever, saddleback fever plus constitutional signs and symptoms plus positive
tornique test
2. Grade II – Stage I plus spontaneous bleeding, epistaxis, GI, cutaneous bleeding
3. Grade III – Dengue Shock Syndrome, all of the following signs and symptoms plus evidence of
circulatory failure
4. Grade IV – Grade III plus irreversible shock and massive bleeding

Diagnostics
Tourniquet test or Rumpel Leede Test – presumptive test for capillary fragility
- keep cuff inflated for 6-10 mins (child), 10-15 min (adults)
- count the petechiae formation 1 sq inch (>10-15 petechiae/sq inch)

Laboratory Procedures
- CBC
- Bleeding Parameters
- Serologic test
- Dengue blot, Dengue Igm
- Other :
- PT (Prothrombin Time)
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 - APTT (Activated Partial Thromboplastin Time)
- Bleeding time
- Coagulation time

Management: symptomatic and supportive

- Specific Therapy – none

- Symptomatic/Supportive therapy
- Intravenous Fluids (IVF)
- with hemoconcentration, 5-7 ml/kg/hr
- with shock, 10-30ml/kg in <20mins
- Use of Blood/Blood Products
- Platelet concentrate 1 unit/5-7kg
- Cryoprecipitate, 1unit/5kg
- FFP, 15ml/kg x 2-4hrs
- given in patient in impending shock and unresponsive to isotonic or colloid transfusion.
- Prolonged PT
- FWB 20cc/kg
- active bleeding
- check serum calcium
- PRBC 10cc/kg

Nursing Intervention
- Paracetamol (no aspirin)
- Giving of cytoprotectors
- Gastric Lavage
- Trendelenberg position for shock
- Nasal packing with epinephrine
- No intramuscular injections
- manage anxiety of patient and family

Preventive measures
Department of Health program for the control of Dengue Hemorrhagic Fever
Seek and destroy breeding places
Say no to indiscriminate fogging
Seek early consultation

B. Filariasis
- The disease often progresses to become chronic, debilitating and disfiguring disease since it’s
symptoms are unnoticed or unfamiliar to health workers.
- High rates in region 5(bicol), 8 (samar and leyte, II (davao)
- Wuchereria bancrofti and Bulgaria malayi
- Transmitted to the bite of infected female mosquito (Aedes, Anopheles, Mansonia)
- The larvae are carried in the blood stream and lodged in lymphatic vessels and lymph glands
where they mature in adult form

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Two biological type
>Nocturnal - microfilaria circulate in peripheral blood at night (10pm – 2am)
> Diurnal - microfilaria circulate in greater concentration at daytime

Clinical Manifestation
Acute stage
- filarial fever and lymphatic inflammation that occurs frequently as 10 times per year and usually
abates spontaneously after 7 days
- Lymphadenitis (Inflammation of the lymphnodes)
- Lymphangitis (Inflammation of the lymph vessels)

Chronic Stage (10-15 years from the onset of the first attack)
- Hydrocele (Swelling of the scotum)
- Lymphedema (Temporary swelling of the upper and lower extremities)
- Elephantiasis (enlargement and thickening of the skin of the lower or upper extremities)

Laboratory Diagnosis
- Blood smear – presence of microfilaria
- Immunochromatographic Test (ICT)
- Eosinophil count

Management:
- Specific Therapy
- Dietylcarbamazine (DEC) 6mg/KBW in divided doses for 12 consecutive days - Drug of Choice
- Ivermectine (Mectican)
- Supportive Therapy
- Paracetamol
- Antihistamine for allergic reaction due to DEC
- Vitamin B complex
- Elevation of infected limb, elastic stocking

DEC should be taken immediately after meals

It may cause loss of vision, night blindness, or tunnel vision with prolonged used.
Ivermectin is best taken as single dose with a full glass of water in en empty stomach.
Cannot be used in patient with asthma

Preventive Measures
Health teachings
Environmental Sanitation

C. Leptosiprosis (Weil’s disease)

- a zoonotic systemic infection caused by Leptospires, that penetrate intact and abraded skin
through exposure to water, wet soil contaminated with urine of infected animals.
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Types:
Anicteric Type (without jaundice)
- manifested by fever, conjunctival injection; signs of meningeal irritation

Icteric Type (Weil Syndrome)

- Hepatic and renal manifestation: Jaundice, hepatomegaly,
- Oliguria, anuria which progress to renal failure
- Shock, coma, CHF
- Convalescent Period

Diagnosis:
Clinical history and manifestation
Culture
Blood: during the 1st week
CSF: from the 5th to the 12th day
Urine: after the 1st week until convalescent period
LAAT (Leptospira Agglutination Test)
other laboratory
BUN,CREA, liver enzymes

Treatment:
Specific:
- Penicillin 50000 units/kg/day
- Tetracycline 20-40mg/kg/day
Non-specific
- Supportive and symptomatic
- Administration of fluids
- Peritoneal dialysis for renal failure
- Educate public regarding the mode of transmission, avoid swimming or wadding in potentially
contaminated waters and use proper protective equipment.

Nursing Responsibilities
1. Dispose and isolate urine of patient.
2. Environmental sanitation like cleaning the esteros or dirty places with stagnant water, eradication of
rats and avoidance of wading or bathing in contaminated pools of water.
3. Give supportive and asymptomatic therapy
4. Administration of fluids and electrolytes.
5. Assist in peritoneal dialysis for renal failure patient (The most important sign of renal failure is
presence of oliguria.)

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D. MALARIA

- “King of the Tropical Disease”

- an acute and chronic infection caused by protozoa plasmodia
- Infectious but not contagious
- transmitted through the bite of female anopheles mosquito
- Malaria Exacts Heavy Toll in Africa

Vector: (night biting)

- Female: anopheles mosquito
- or minimus flavire
Life cycle:
- Sexual cycle/sporogony (mosquito)
- sporozoites injected into humans
- Asexual cycle/schizogony (human)
- gametes is the infective stage taken up by biting mosquito

Strains:
Plasmodium Vivax
- more widely distributed
- causes benign tertian malaria
- chills and fever every 48 hours in 3 days
Plasmodium Falciparum
- common in the Philippines
- Causes the most serious type of malaria because of high parasitic densities in blood.
- Causes malignant tertian malaria
Plasmodium malaria
- much less frequent
- causes quartan malaria, fever and chills every 72 hrs in 4 days
- Plasmodium Ovale
- rarely seen.
Plasmodium ovale

Pathology
- the most characteristic pathology of malaria is destruction of red blood cells, hypertrophy of the
spleen and liver and pigmentation of organs.
- The pigmentation is due to the phagocytocis of malarial pigments released into the blood stream
upon rupture of red cells

Clinical Manifestations:
Uncomplicated
- fever, chills, sweating every 24 – 36 hrs
Complicated
- sporulation or segmentation and rupture of erythrocytes occurs in the brain and visceral organs.
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 - Cerebral malaria
- changes of sensorium, severe headache and vomiting
- seizures

Stages:
1. Cold stage – 10-15 mins, chills, shakes
2. hot stage – 4-6 hours, recurring high grade fever, severe headache, vomitting, abdominal pain,
face is blue
3. Diaphoretic Stage – excessive sweating

Diagnosis:
- Malarial smear
- Quantitative Buffy Coat (QBC)
Travel in endemic areas

Treatment:
Determine the species of parasite
Objectives of treatment
1. Destroy all sexual forms of parasite to cure the clinical attack
2. Destroy the excerythrocytes (EE) to prevent relapse
3. Destroy gametocytes to prevent mosquito infections

Treatment for P. Falciparum

1. chloroquine tablet (150mg/base/tab) Day 1,2,3 (4,4,2)
2. Sulfadoxine/Pyrimethamine 500mg/25mg/tab, 3tab single dose
3. Primaquine (15mg/tab) 3 tabs single dose
Treatment for P. Vivax
1. Choloroquine, Day 1,2,3 (4,4,2)
2. Primaquine 1 tab OD for 14 days
Treatment for mixed
- chloroquine (4,4,2)
- Sulfadoxine/Pyrimethamine 3 tabs once
- Primaquine 1 tab for 14 days

*Multi-drug resistant P. Falciparum:

quinine plus doxycycline, or tetracycline and primaquine

Complications:
- severe anemia
- cerebral malaria
- hypoglycemia

Prevention and Control:

- Eliminate anopheles mosquito vectors
- Advise travelers
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 - limit dusk to dawn outdoor exposure
- insect repellant, nets

Nursing Care
1. Consider a patient with cerebral malaria to be an emergency
- Administer IV quinine as IV infusion
- Watch for neurologic toxicity from quinine transfusion like delirium, confusion, convulsion and coma
2. Watch for jaundice – this is related to the density of the falciparum parasitemia,
3. Evaluate degree of anemia
4. Watch for abnormal bleeding that are may be due to decrease production of clotting factors by
damage liver.

Chemoprophylaxis:
- doxycycline 100mg/tab, 2-3 days prior to travel, continue up to 4 weeks upon leaving the area
- Mefloquine 250mg/tab, 1 week before travel, continue up to four weeks upon leaving the area
- Pregnant, 1st trimester, chloroquine, 2 tabs weekly, 2 weeks before travel, during stay and until
4 weeks after leaving
- 2nd and 3rd trimester, Pyrimethamine-sulfadoxine

LESSON 3: CENTRAL NERVOUS SYSTEM DISEASES

A. Inflammation of the meniges

Caused by bacterial pathogen, N. menigitidis, H. Influenza, Strep. Pneumoniae, Mycobacterium
Tuberculosis

Pathology:
Primary – spread of bacteria from the bloodstream to the meniges
Secondary – results from direct spread of infection from other sources or focus of infection.

The disease usually begins as an infection by normal body flora, of:

1.     The ear (otitis media) - Haemophilus influenzae
2.     The lung (lobar pneumoniae) - Streptococcus pneumoniae
3.     The upper respiratory tract (rhinopharyngitis) - Neisseria meningitidis, Haemophilus
           influenzae, Streptococcus, Group B
4     The skin and subcutaneous tissue (furunculosis) S. aureus
5.     The bone (osteomyelitis) - S. aureus
6.     The intestine - E. coli

Clinical manifestation:
- Fever
- Rapid pulse, respiratory arrythmia
- Soreness of skin and muscles
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 - Convulsion/seizures
- headache
- irritability
- fever
- neck stiffness
- pathologic reflexes: kernig’s, Babinski, Brudzinski

Diagnosis:
- Lumbar puncture
- Blood C/S
- other laboratories

a. Lumbar Puncture
- To obtain specimen of CSF
- To reduce ICP
- To Introduce medication
- To inject anesthetic

b. CSF Examination
- Fluid is turbid/purulent >1000cc/mm cells
- WBC count increase
- Sugar content markedly reduced
- CHON increased
- Presence of microorganism

Treatment:
Bacterial meningitis
- TB meningitis
- Intensive Phase
- Maintainance Phase
- Fungal meningitis
- cryptococcal meningitis – fluconazole or amphotericin B

2. Supportive/Symptomatic
a. Antipyretic
b. treat signs of increased ICP
c. Control of seizures
d. adequate nutrition

Nursing care:
Prevent occurrence of further complication
- Maintain strict aseptic technique when doing dressing or lumbar puncture.
- Early symptom should be recognize
- Vital signs monitoring
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 - Observe signs of increase ICP
- Protect eyes from light and noises
Maintain normal amount of fluid and electrolyte balance
- Note and record the amount of vomitus
- Check signs of dehydration
Prevent Spread of the disease
- Having proper disposal of secretions
- Emphasize the importance of masking
- Explain the importance of isolation
Ensure patient’s full recovery
- Maintain side rails up in episodes of siezures
- Prevent sudden jar of bed
- Keep patient in a dark room and complete physical rest
- Diversional activities and passive exercises

B. Meningococcemia
- caused by Neisseria meningitides, a gram negative diplococcus
- transmitted through airborne or close contact
- incubation is 1-3 days
- natural reservoir is human nasopharynx

Clinical Manifestation
sudden onset of high grade fever, rash and rapid deterioration of clinical condition within 24 hours
S/sx:
1. Meningococcemia – spiking fever, chills, arthralgia, sudden appearance of hemorrhagic rash
2. Fulminant Meningococcemia (Waterhouse Friderichsen) – septic shock; hypotension, tachycardia,
enlarging petecchial rash, adrenal insufficiency

Diagnostics:
- Blood Culture
- Gram stain of peripheral smear, CSF and skin lesions
- CBC
-
Treatment:
antimicrobial
- Benzyl Penicillin 250-400000 u/kg/day
- Chloramphenicol 100mg/kg/day
Symptomatic and supportive
- fever
- seizures
- hydration
- respiratory function

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Chemoprophylaxis
1. Rifampicin 300-600mg q 12hrs x 4 doses
2. Ofloxacin 400mg single dose
3. Ceftriaxone 125-250mg IM single dose

Nursing Intervention
- Provide strict isolation
- Wearing of PPE
- Health teaching
- Contact tracing
- Prophylaxis
- Meninggococcal vaccine for high risk patient

C. Rabies
- acute viral encephalomyelitis
- incubation period is 4 days up to 19 years
- risk of developing rabies, face bite 60%, upper extremities 15-40%, lower extremities 10%
- 100% fatal

Clinical Manifestations:
- pain or numbness at the site of bite
- fear of water
- fear of air

4 STAGES
1. prodrome - fever, headache, paresthesia,
2. encephalitic – excessive motor activity, hypersensitivity to bright light, loud noise,
hypersalivation, dilated pupils
3. brainstem dysfunction – dysphagia, hydrophobia, apnea
4. death

Diagnosis:
- FAT (fluorescent antibody test)
- Clinical history and signs and symptoms

Management:
- No treatment for clinical rabies
- Prophylaxis

Postexposure prophylaxis

A. Active vaccine (PDEV,PCEC,PVRV)

Intradermal (0,3,7,30,90)
Intramuscular (0,3,7,14,28)

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 (0,7,21)
B. Passive Vaccine
a. ERIG wt in kg x .2 = cc to be injected im (ANST)
b. HRIG wt in Kg x .1333

Pre-exposure Prophylaxis
Intradermal/Intramuscular (0,7,21)

Infection control
- Patient is isolated to prevent exposure of hospital personnel, watchers and visitors
- PPE
- Preventive Measures
- Education
- Post-exposure and Pre-exposure Prophylaxis
D. Poliomyelitis
- RNA, Polio virus
- Fecal oral route/droplets
- IP 7-12 days
- Disease of the lower motor neurin involving the anterior horn cells
- Infantile paralysis; Helne-Medin disease

Predisposing Factors
- Children below 10 years old
- Male more often affected
- Poor environmental and hygienic conditions

Causative Agent:
- Legio debilitans
- Brunhilde (permanent)
- Lansing and Leon (temporary)
- May exist in contaminated water, sewage and milk

Clinical manifestations:
1. mild febrile illness – fever, malaise, sore throat (abortive stage)
2. Pre-paralytic stage - flaccid asymetrical ascending paralysis (Landry’s sign), Hayne’s sign (head
drop), Pofer’s sign (opisthotonus)
3. Paralytic stage
bulbar or spinal

Mode of Transmission
- Droplet infection – in early infection
- Body secretions – nasopharyngeal
- Fecal oral – during late stage
- Flies may act as mechanical vectors
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 B. I – Abortive or inapparent
C. II – Meningitis (non-paralytic)
D. III – Paralytic (anterior horn of spinal cord)
E. IV – Bulbar (encephalitis)

Diagnostics:
Pandy’s test - CSF (increased CHON)

Management:
Active – OPV (Sabin) and IPV (Salk)

Immunity is acquired for 3 strains

A. Legio brunhilde (fatal)
B. Legio lansing
C. Legio leon

Respiratory distress
A. Respirator
B. Tracheostomy – life saving procedure when respiratory failure and inability to swallow are
not corrected
C. Oxygen therapy
D. Rehabilitation (Physical)

E. Tetanus
- caused by Clostridium tetani, grows anaeronically
- Tetanus spores are introduced into the wound contaminated with soil.
- Incubation period 4-21 days

Clinical manifestation:
- Difficulty of opening the mouth (trismus or lockjaw)
- Risus sardonicus
- Abdominal rigidity
- Localized or generalized muscle spasm

Treatment:
1. Neutralize the toxin
2. Kill the microorganism
3. Prevent and control the spasm
- muscle relaxants
- Sedatives
- Tranquilizers
4. Tracheostomy

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Anti-toxin:
Tetanus Anti-Toxin (TAT)
- Adult,children,infant 40,000 IU ½ IM,1/2 IV
- Neonatal Tetanus 20000 IU, 1/2IM, ½ IV
TIG
- Neonates 1000 IU, IV drip or IM
- Adult, infant, children 3000 IU, IV drip or IM
Antimicrobial Therapy
Penicillin (drug of choice) -3 mil units q 4hours
Pedia 500000 – 2mil units q 4 hrs
Neonatal 200000 units IVP q 12hrs or q8hrs
Control of spasms
- diazepam
- chlorpromazine

Nursing care
- Patient should be in a quiet, darkened room, well ventilated.
- Minimal/gentle handling of patient
- Liquid diet via NGT
- Prevent Injury
- Preventive Measures
- Treatment of wounds
- Tetanus toxoid (0,1,6,1,1)

LESSON 4: HEPATO-ENTERIC DISEASES

A. Schistosomiasis
- caused by blood flukes, Schistosoma
- has 3 species, S. haematobium, S. Mansoni, S. japonicum
- S. japonicum is endemic in the Philippines (leyte, Samar, Sorsogon, Mindoro,Bohol)
- Intermediate host, Oncomelania Quadrasi

Diagnosis:
- Schistosoma eggs in stool
- Rectal bipsy
- Kato Katz
- Ultrasound of HBT

Clinical Manifestations:
- severe jaundice
- edema
- ascites
- epatosplenomegaly
- S/S of portal hypertention

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Management:
- Praziquantrel 60mg/kg Once dosing
- Supportive and sympromatic

Methods of Control:
- Educate the public regarding the mode of transmission and methods of protection.
- Proper disposal of feces and urine
- Prevent exposure to contaminated water. To minimize penetration after accidental water
exposure, towel dry and apply 70% alcohol.
- The organism is pathogenic only in man

B. Typhoid Fever

- Spread chiefly by carriers, ingestion of infected foods

- Endemic particularly in areas of low sanitation levels
- Occurs more common in may to august

Mode of Transmission: oral fecal route

Clinical manifestations:
Rose spot (abdominal rashes), more than 7days Step ladder fever 40-41 deg, headache, abdominal
pain, constipation (adults), mild diarrhea (children)

Diagnosis:
Blood examination WBC usually leukopenia with lymphocytosis
Isolation
- Blood culture 1st week\
- Urine culture 2nd week
- Stool culture 3rd week
- Widal test O or H
- 1st week step ladder fever (BLOOD)
- 2nd week rose spot and fastidial
- typhoid psychosis (URINE & STOOL)

Management: Chloramphenicol (drug of choice), Amoxicillin, Sulfonamides, Ciprofloxacin, Ceftriaxone

Watch for complication

a. Perforation – symptoms of sharp abdominal pain, abdominal rigidity and absent of bowel
sounds.
- prepare for intestinal decompression or surgical intervention
b. Intestinal hemorrhage - withold food and give blood transfusion

Nursing Interventions:
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 - Environmental Sanitation
- Food handlers sanitation permit
- Supportive therapy
- Assessment of complication (occuring on the 2nd to 3rd week of infection ):
Typhoid psychosis, typhoid meningitis, typhoid ileitis

C. Hepatitis
- Hepa A – fecal oral route
- Hepa B – body fluids
- Hepa C – non A non B, BT, body fluids
- Hepa D – hypodermic, body fluids
- Hepa E – fecal oral route, fatal and common among pregnant women
- Hepa G – BT, parenteral

Hepatitis A
- Infectious hepatitis, epidemic hepatitis
- Young people especially school children are most commonly affected.
- Predisposing factors:
- Poor sanitation, contaminated water supply, unsanitary preparation of food, malnutrition,
disaster conditions

Incubation Period: 15-50 days

Clinical manifestations:
- Influenza
- Malaise and easy fatigability
- Anorexia and abdominal discomfort
- Nausea and vomiting
- Fever, CLAD
- jaundice

Diagnostics: Anti HAV IgM – active infection; Anti HAV IgG – old infection; no active disease

Management:
- Prophylaxis
- Complete bed rest
- Low fat diet but high sugar
- Ensure safe water for drinking
- Sanitary method in preparing handling and serving of food.
- Proper disposal of feces and urine.
- Washing hands before eating and after toilet use.
- Separate and proper cleaning of articles used by patient

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Hepatitis B
- DNA, Hepa B virus
- Serum hepa
- Worldwide distribution
- Main cause of liver cirrhosis and liver cancer

Incubation Period: 2-5 months

Mode of Transmission:
- From person to person through
- contact with infected blood through broken skin and mucous membrane
- sexual contact
- sharing of personal items
- Parenteral transmission through
- blood and blood products
- use of contaminated materials
- Perinatal transmission

High Risk group:

- Newborns and infants of infected mothers
- Health workers exposed to handling blood
- Persons requiring frequent transfusions
- Sexually promiscuous individuals
- Commercial sex workers
- Drug addicts

Possible Outcome:
- Most get well completely and develop life long immunity.
- Some become carriers of the virus and transmit disease to others.
- Almost 90% of infected newborns become carriers

Hepatitis C
- Post transfusion Hepatitis
- Mode of transmission – percutaneous, BT
- Predisposing factors – paramedical teams and blood recepients
- Incubation period – 2weeks – 6 months

Hepatitis D
- Dormant type
- Can be acquired only if with hepatitis B

Hepatitis E
- If hepatitis E recurs at age 20-30, it can lead to cancer of the liver
- Enteric hepatitis
- Fecal-oral route

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Diagnostics:
- Elevated AST or SGPT (specific) and ALT or SGOT
- Increased IgM during acute phase
- (+) or REACTIVE HBsAg = INFECTED, may be acute, chronic or carrier
- (+) HBeAg = highly infectious
- ALT – 1st to increase in liver damage
o HBcAg = found only in the liver cells
- (+) Anti-HBc = acute infection
- (+) Anti-HBe = reduced infectiousness
- (+) Anti-HBs = with antibodies (FROM vaccine or disease)
- Blood Chem. Analysis (to monitor progression)
- Liver biopsy (to detect progression to CA)

Management:
- Prevention of spread – Immunization and Health Education
- Enteric and Universal precautions
- Assess LOC
- Bed rest
- ADEK deficiency intervention
- High CHO, Moderate CHON, Low fat
- FVE prevention

Complications:
1. Fulminant Hepatitis – s/sx of encephalopathy
2. Chronic Hepatitis - lack of complete resolution of clinical sx and persistence of hepatomegaly
3. HBsAg carrier

LESSON 5: ERUPTIVE FEVER

A. Measles
- Extremely contagious
- Breastfed babies of mothers have 3 months immunity for measles
- The most common complication is otitis media
- The most serious complications are bronchopneumonia and encephalitis

Measles, Rubeola, 7 Day Fever, Hard Red Measles

- RNA, Paramyxoviridae
- Active MMR and Measles vaccine
- Passive Measles immune globulin
- Lifetime Immunity
- IP: 7-14 days

Mode of transmission: droplets, airborne

- *Contagious 4 days before rash and 4 days after rash
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Clinical Manifestations:
a. Pre eruptive stage
- Patient is highly communicable
- 4 characteristic features
A. Coryza
B. Conjunctivitis
C. Photophobia
D. Cough
E. Koplik’s spots ( Small, blue-white spots with a red base found on the buccal mucosa
-
- Stmsons line

b. Eruptive stage
- Maculopapular rashes appears first on the hairline, forehead, post auricular area the spread to
the extremities (cephalocaudal)
- Rashes are too hot to touch and dry
- High grade fever and increases steadily at the height of the rashes

c. Stage of convalescence
- Rashes fade in the same manner leaving a dirty brownish pigmentation (desquamation)
- Black measles – severe form of measles with hemorrhagic rashes, epistaxis and melena

Rashes: maculopapaular, cephalocaudal (hairline and behind the ears to trunk and limbs), confluent,
desquamation, pruritus

Complications:
- Bronchopneumonia
- Secondary infections
- Encephalitis
- Increase predisposition to TB

Managements:
1. Supportive –TSB for fever
2. Hydration
3. Proper nutrition
4. Vitamin A
5. Antibiotics
6. Vaccine

Nursing Care:
- Respiratory precautions
- Restrict to quite environment
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 - Dim light if photophobia is present
- Administer antipyretic
- Use cool mist vaporizer for cough

B. German Measles (Rubella)

- Acute infection caused by rubella virus characterized by fever, exanthem and retroauricular
adenopathy.
- Has a teratogenic potential on the fetuse of women in the 1st trimester

Clinical Manifestations:
- forschheimer’s (petecchial lesion on buccal cavity or soft palate),
- cervical lymphadenopathy, low grade fever
- “ Oval, rose red papules about the size of pinhead

Diagnostics: clinical
Complications: rare; pneumonia, meningoencephalitis
Complications to pregnant women:
- 1st tri-congenital anomalies
- 2nd tri-abortion
- 3rd tri-pre mature delivery
Rashes: Maculopapular, Diffuse/not confluent, No desquamation, spreads from the face downwards

C. Roseola Infantum,
Exanthem Subitum, Sixth disease
- Human herpes virus 6
- 3mos-4 yo, peak 6-24 mos
- MOT: probably respiratory secretions

Clinical manifestations:
Spiking fever w/c subsides 2-3 days, Face and trunk rashes appear after fever subsides, Mild pharyngitis
and lymph node enlargement

D. Chicken Pox, Varicella

- Herpes zoster virus (shingles),
varicella zoster virus(chocken pox)
- Active : Varicella vaccine
- Passive: VZIG, ZIG – given 72-96 hrs
w/n exposure
- Lifetime Immunity
- IP: 14-21 days

Mode of transmission: Respiratory route

* Contagious 1 day before rash and 6 days after first crop of vesicles

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 - S/sx:
fever, malaise, headache
- Rashes: Maculopapulovesicular (covered areas), Centrifugal, starts on face and trunk and
spreads to entire body
- Leaves a pitted scar (pockmark)
- CX furunculosis, erysipelas, meningoencephalitis
- Dormant: remain at the dorsal root ganglion and may recur as shingles (VZV)

Management:
a. oral acyclovir
b. Tepid water and wet compresses for pruritus
c. Aluminum acetate soak for VZV
d. Potassium Permanganate (ABO)
a. Astringent effect
b. Bactericidal effect
c. Oxidizing effect (deodorize the rash)

E. Small Pox, Variola

- DNA, Pox virus
- Last case 1977
- spreads from man-to-man only
- Active: Vaccinia pox virus
- IP: 1-3 weeks

Clinical Manifestations:
- Rashes:
- Maculopapulovesiculopustular
- Centripetal
- contagious until all crusts disappeared
Diagnostics:
- Paul’s test - instilling of vesicular fluid w/ small pox into the cornea; if keratitis develops, small
pox
- Cx: same with chicken pox
F. Kawasaki Disease
- Mucocutaneous lymph node syndrome
- Children younger than 5 years old are primarily affected.
- Associated with large coronary blood vessel vasculitits
- A febrile, exanthematous, multisystem illness characterized by
o Acute febrile phase manifested by high spiking fever, rash, adenopathy, peripheral edema,
conjunctivitis and exanthem
o sub acute phase, thrombocytosis, desquamation and resolution of fever.
o Convalescent stage
Manifestations:
- bilateral, non purulent conjuctivitis

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 - congested oropharynx, strawberry tongue, erythematous lymphs
- erythematous palms/soles, edematous hands/feet
- periungal desquamation, truncal rash
- CLADP ( 1node >1.5cm)
Diagnosis
- CBC: leukocytosis
- Platelet count >400000
- 2D echo (if coronary artery involvement is highly suggestive
- ESR and CRP elevated
Management
- IV Gamma globulin – 2g/kg as single dose for 10-12 hours. Effective to prevent coronary
vascular damage if given within 10 days of onset.
- Salicylates: 80-100mg/kg/24 hours in 4 divided doses
- Symptomatic and supportive therapy

LESSON 6: RESPIRATORY SYSTEM DISEASES

A. Mumps
Etiologic agent: RNA, Mumps virus
- Mumps vaccine - > 1yo
- MMR – 15 mos
- Lifetime Immunity
Incubation Period: 12-16 days
Mode of transmission: Droplet, saliva, fomites

Clinical Manifestations: Unilateral or bilateral

- parotitis, Orchitis - sterility if bilateral,
- Oophoritis, Stimulating food cause severe pain, aseptic meningitis
- Dx: serologic testing, ELISA
Management: supportive
Nursing care:
- Respiratory precautions
- Bed rest until the parotid gland swelling subsides
- Avoid foods that require Chewing
- Apply hot or cold compress
- To relieve orchitis, apply warmth and local support with tight fitting underpants
B. Diptheria
- Acute contagious disease
- Characterized by generalized systemic toxemia from a localized inflammatory focus
- Infants immune for 6 months of life
- Produces exotoxin
- Capable of damaging muscles especially cardiac, nerve, kidney and liver
- Increase incidence prevalence during cooler months
- Mainly a disease of childhood with peak at 2-5 years, uncommon in >6months

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Etiologic agent: Corynebacterium diphtheriae, gram (+), slender, curved clubbed organism “Klebs-
Loeffler Bacillus”
Incubation Period: 2-6 days
Mode of transmission: direct or indirect contact
1. Nasal – invades nose by extension from pharynx
2. Pharygeal
- sorethroat causing dysphagia
- Pseudomembrane in uvula, tonsils, soft palate (grayish-white membrane)
- Bullneck – inflammation of cervical LN
3. Laryngeal
- increasing hoarseness until aphonia
- wheezing on expiration
- dyspnea
Diagnosis:
- Nose and throat swab using loeffler’s medium
- Schick test – determine susceptibility or immunity in diptheria
- Maloney test – determines hypersensitivity to diptheria toxoid
Complications:
Toxic myocarditis – due to action of toxin in the heart muscles (1 st 10-14 days)
Neuritis caused by absorption of toxin in the nerve
- Palate paralysis (2nd week)
- Ocular palsy (5th week)
- Diapgram paralysis (6-10wk causing GBS)
- Motor and skeletal muscle paralysis
Treatment:
A. Neutralize the toxins – antidiptheria serum
B. Kill the microorganism – penicillin
C. Prevent respiratory obstruction – tracheostomy, intubation
Serum therapy (Diptheria antitoxin)
- early administration aimed at neutralizing the toxin present in the general circulation
Antibiotics
- Penicillin G 100000mg/kg.day (drug of choice)
- Erythromycin 40mg/kg
Nursing Intervention
- Rest.
- Patient should be confined to bed for at least 2 weeks
- Prevent straining on defecation
- vomiting is very exhausting, do not do procedures that may cause nausea
- Care for the nose and throat
- Ice collar to reduce the pain of sorethroat
- Soft and liquid diet
C. Whooping Cough, 100 day fever
Etiologic agent: Bordetella pertussis, B. parapertussis, B. bronchiseptica, gram (-)

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Incubation Period: 3-21 days
Mode of transmission: airborne/droplet
Clinical manifestations:
- Invasion or catarrhal stage (7-14days) starts with ordinary cough
- Spasmodic or paroxysmal
- 5-10 spasms of explosive cough (no time to catch breath. A peculiar inspiratory crowing sound
followed by prolonged expiration and a sudden noisy inspiration with a long high pitched
“whoop”
- During attack the child becomes cyanotic and the eyes appear to bulge or popping out of the
eyeball and tongue protrudes
Diagnosis:
- WBC count 20000-50000
- Culture with Bordet Gengou Agar
Treatment:
- Erythromycin shorten the period of communicability
- Ampicillin if with allergy to erythromycin
- Heperimmune pertusis gamma globulin in <2 years old (1.25ml IM)
- Control of cough with sedatives
Diagnostics:
WHO - >21 days cough + close contact w/ pertussis px + (+) culture OR rise in Ab to FHA or pertussis
toxin
* throat culture w/ Bordet gengou agar
Management:
- CBR to conserve energy
- Prevent aspiration
- High calorie, bland diet
- Omit milk and milk product because it increases the mucous
- Refeeding of infants 20 min after vomitting
- Milk should be given at room temperature
Complications:
- Bronchopneumonia
- Abdominal hernia
- Severe malnutrition
- TB, asthma
- encephalitis
Pre exposure prophylaxis for Diphtheria, Pertussis, Tetanus
DPT- 0.5 ml IM
- 1 - 1 ½ months old
2 - after 4 weeks
3 - after 4 weeks
- 1st booster – 18 mos
- 2nd booster – 4-6 yo
- subsequent booster – every 10 yrs thereafter

D. Pulmonary Tuberculosis

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 - The world’s deadliest disease and remains as a major public health problem.
- Badly nourished, neglected and fatigued individuals are more prone
- Susceptibility is highest in children under 3 years
- AKA: Koch’s disease: Galloping consumption
- Causative agent: Mycobacterium tuberculosis
Clinical manifestations:
- Wt loss
- night sweats
- low fever,
- non productive to productive cough
- anorexia,
- Pleural effusion and hypoxemia
- cervical lymphadenopathy
- hemoptysis ( blood in the sputum)
Dx:
- Chest xray - cavitary lesion in lungs
- Sputum exam/sputum culture (confirmatory)
- Tuberculin test - Mantoux test)
-Purified protein derivatives ( ID)
macrophages in skin take up Ag and deliver it to T cells
T cells move to skin site, release lymphokines
activate macrophages and in 48-72 hrs, skin becomes indurated
> 10 mm is (+)
The National Tuberculosis Control Program
- Vision: A country where TB is no longer a public health problem.
- Mission: Ensure that TB DOTS services are available to the communities.
- Goal: To reduce the prevalence and mortality from TB by half by the year 2015
Targets:
1. To cure at least 85% of the sputum smear positive TB patient discovered.
2. Detect at least 70% of the estimated new sputum smear positive TB cases.
Management:
short course – 6-9 months
long course – 9-12 months
Follow-up
 2 weeks after medications – non communicable
o 3 successive (-) sputum - non communicable
o rifampicin - prophylactic

Recommended Treatment Regimen for Adults and Children

Category of Treatment Classification and Treatment Regimen
Registration Group
Category I Pulmonary TB, new (whether
bacteriologicallyconfi rmed or
clinically-diagnosed) Extra- 2HRZE/4HR
pulmonary TB, new (whether
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 bacteriologically-confi rmed or
clinically-diagnosed) except
CNS/ bones or joints
Category Ia Extra-pulmonary TB, new 2HRZE/10HR
(CNS/bones or joints)
Category II Pulmonary or extra-pulmonary, 2HRZES/1HRZE /5HRE
previously treated drug-
susceptible TB (whether
bacteriologically-confirmed or
clinically diagnosed)
• Relapse
• Treatment After Failure
• Treatment After Lost to
Follow-up (TALF)
• Previous Treatment Outcome
Unknown
• Other
Category IIa Extra-pulmonary, Previously 2HRZES/1HRZE /9HRE
treated drugsusceptible TB
(whether
bacteriologicallyconfirmed or
clinically-diagnosed - CNS/bones
or joints)
Standard Regimen Drug- Rifampicin-resistant TB or ZKmLfxPtoCs
resistant (SRDR) Multidrug-resistant TB • Individualized once DST result
is available
• Treatment duration for at
least 18 months
XDR-TB Regimen Extensively drug-resistant TB Individualized based on DST
result and history of previous
treatment
Legend: R - Rifampicin, I - Isoniazid, E - Ethambutol, Z - Pyrazinamide, S - Streptomycin, Km - Kanamycin. Lfx -
Levofloxacin, Pto - Prothionamide. C - Cycloserine

Guide in Managing Adverse Reactions to Anti-TB Drugs

Adverse Reactions Drug(s) probably Management

responsible
Minor
1. Gastro-intestinal intolerance Rifampicin/Isoniazid/ Give drugs at bedtime or with

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 Pyrazinamide small meals.
2. Mild or localized skin Any kind of drugs Give anti-histamines.
reactions
3. Orange/red colored urine Rifampicin Reassure the patient
4. Pain at the injection site Streptomycin Apply warm compress. Rotate
sites of injection.
5. Burning sensation in the feet Isoniazid Give Pyridoxine (Vitamin B6):
due to peripheral neuropathy 50-100 mg daily for treatment,
(numbness, paresthesias, and 10 mg daily for prevention.
tingling in the extremities) (Cheese and milk –rich in Vit B6
)
6. Arthralgia due to Pyrazinamide Give aspirin or NSAID. If
hyperuricemia symptoms persist, consider gout
and request for blood chemistry
(uric acid determination) and
manage accordingly
7. Flu-like symptoms (fever, Rifampicin Give antipyretics
muscle pains, inflammation of
the respiratory tract)
Major
1. Severe skin rash due to Any kind of drugs (especially Discontinue anti-TB drugs and
hypersensitivity Streptomycin) refer to appropriate specialist.
2. Jaundice due to hepatitis Any kind of drugs (especially Discontinue anti-TB drugs and
Isoniazid, Rifampicin, and refer to appropriate specialist. If
Pyrazinamide) symptoms subside, resume
treatment and monitor clinically
3. Impairment of visual acuity Ethambutol Discontinue Ethambutol and
and color vision due to optic refer to an ophthalmologist.
neuritis
4. Hearing impairment, ringing Streptomycin Discontinue Streptomycin and
of the ear, and dizziness due to refer to appropriate specialist .
damage of the eighth cranial
nerve
5. Oliguria or albuminuria due to Streptomycin/ Rifampicin Discontinue anti-TB drugs and
renal disorder refer to appropriate specialist
6. Psychosis and convulsion Isoniazid Discontinue Isoniazid and refer
to appropriate specialist.
7. Discontinue Isoniazid and Rifampicin Discontinue anti-TB drugs and
refer to appropriate specialist. refer to appropriate specialist

Methods of Control:

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  Prompt treatment and diagnosis
 BCG vaccination
 Educate the public in mode of transmission and importance of early diagnosid
 Improve social condition

E. Pneumonia
1. Community acquired
Typical– Strep. Pneumoniae, H. Influenzae type B
Atypical Pneumonia – S. Aureus, M. Pneumoniae, L. Pneumophila, P. Cariini
2. Nosocomial – Pseudomonas, S. Aureus

Mode of transmission: aspiration, inhalation, hematogenous, direct inoculation, contiguous spread

CHILDHOOD PNEUMONIA
1. No pneumonia
- infant, 60/min and no chest indrawing
2. Pneumonia
- young infant >60/min, fast breathing without chest indrawing
3. Severe pneumonia
- fast breathing, severe chest indrawing, with one of danger signs
4. Very severe pneumonia
- below 2 mos old, fast breathing, chest indrawing, with danger signs
4 Danger Signs
1. Vomits
2. Convulsion
3. Drowsiness/lethargy
4. Difficulty of swallowing or feeding

Clinical manifestations:
1. Typical – sudden onset Fever of > 38 x 7-10 days, productive cough, pleuritic chest pain,
dullness, inc fremitus, rales
2. Atypical – gradual onset, dry cough, headache, myalgia, sore throat
Watch out for complications; In 24 hours death will occur from respiratory failure

Nursing Diagnosis:
 Ineffective airway clearance
 Ineffective breathing pattern
 Impaired gas exchange
 Risk for activity intolerance
Management:
 Antibiotics, hydration, nutrition, nebulization
 CARI-health teaching
 Nursing Interventions
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  Respiratory support
- oxygen supplementation
- mechanical ventilation
 Positioning
 Rest
 Suctioning of secretions
 Antipyretic and TSB
 Nutrition

LESSON 7: GASTROINTESTINAL SYSTEM DISEASES

A. Amoebiasis
Etiologic agent: Entamoeba Hystolitica, protozoa
- IP: few days to months to years,
- usually 2- 4 weeks
- MOT: Ingestion of cysts from fecally contaminated sources (Oral fecal route)
oral and anal sexual practices
- Extraintestinal amoebiasis- genitalia, spleen, liver, anal, lungs and meninges
Clinical manifestations:
- Blood streaked, watery mucoid diarrhea, foul smelling,
- abdominal cramps
- Pain on defecation (tenesmus)
- Hyperactive bowel sounds
Diagnostic tests:
- Stool culture of 3 stool specimens
- Sigmoidoscopy
- Recto-sigmoidoscopy and coloscopy for intestinal amoebiasis
Medical treatment:
- Metronidazole – trichomonocide and amoebicide for intestinal and extra intestinal sites (monitor
liver function test)
- Diloxanide furoate – luminal amoebicide
- Paromomycin – eradicate cyst of histolytica
- Tinidazole – hepatic amebic abscess

B. Bacillary Dysentery
Shigellosis
- Shiga bacillus: dysenteriae (fatal), flexneri (Philippines), boydii, sonnei; gram (-)
- Shiga toxin destroys intestinal mucosa
- Humans are the only hosts
- Not part of normal intestinal flora
- IP: 1-7 days
- MOT : oral fecal route

Clinical manifestations: fever, severe abdominal pain, diarrhea is watery to bloody with pus, tenesmus
Diagnostics: stool culture

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Management: Oresol, Ampicillin, Trimethoprim-Sulfamethoxazole, Chloramphenicol, Tetracycline,
Ciprofloxacin

C. Cholera
- Etiologic agent: Vibrio coma (inaba, ogawa, hikojima), vibrio cholerae, vibrio el tor; gram (-)
- Choleragen toxin induces active secretion of NaCl
- Active Immunization
- Incubation Period: few hours to 5 days
- Mode of transmission: oral fecal route
Clinical manifestations: Rice watery stool with flecks of mucus, s/sx of severe dehydration ie
Washerwoman’s skin, poor skin turgor
Diagnostics: stool culture
Management: IV fluids, Tetracycline (drug of choice), Doxycycline, Erythromycin, Quinolones,
Furazolidone and Sulfonamides (children)

D. Paragonimiasis
- Chronic parasitic infection
- Closely resembles PTB
- Endemic areas: orsogo, camarines sur, norte, samar, orsogon, leyte, albay, basilan
- Paragonimiasis
- AKA: Lung fluke disease
- causative agent: paragonimus westermani; Trematode
- Eating raw or partially cooked fish or fresh water crabs

Signs and symptoms

- Cough of long duration
- Hemoptysis
- Chest/back pain
- PTB not responding to anti-koch’s meds
Diagnosis:
- sputum examination – eggs in brown spots
Treatment:
1. Praziquantrel (biltrizide) (drug of choice)
2. Bithionol

E. Parasitic worms
Ascariasis
- Common worldwide with greatest frequency in tropical countries.
- Has an infection rate of 70-90% in rural areas
- MOT: ingestion of embryonated egss (fecal-oral)
- Worms reach maturity 2 months after ingestion of eggs.
- Adult worms live less than 10 months(18 months max.)
- Female can produce up to 200000 eggs per day
- Eggs may be viable in soils for months or years

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 - Worms can reach 10-30cm in length

Clinical manifestations:
- loss of appetite
- Worms in the stool
- Fever
- Wheezing
- Vomiting
- Abdominal distention
- Diarhea
- dehydration

Medical Management:
A. Mebendazole (antihelmintic) effect occurs by blocking the glucose uptake of the organisms,
reducing the energy until death
B. Pyrantel pamoate: neuromuscular blocking effect which paralyze the helminth, allowing it to be
expelled in the feces
C. Pierazine citrate: paralyze muscles of parasite, this dislodges the parasites promoting their
elimination
Nursing care:
- Environmental sanitation
- Health teachings
- Assessment of hydration status
- Use of ORS
- Proper waste disposal
- Enteric precautions
Complications:
- Migration of the worm to different parts of the body Ears, mouth,nose
- Loefflers Pneumonia
- Energy protein malnutrition
- Intestinal obstruction
Tapeworm (Flatworms)
- Etiologic agent: Taenia Saginata (cattle), Taenia Solium (pigs)
- Mode of transmission: fecal oral route (ingestion of food contaminated by the agent)
- Clinical manifestations: neurocysticercosis – seizures, hydrocephalus
- Diagnostics: Stool Exam
- Management: Praziquantel, Niclosamide
Pinworm
- Etiologic agent:Enterobius Vermicularis
- Mode of transmission: fecal oral route
- Clinical manifestations: Itchiness at the anal area d/t eggs of the agent
- Diagnostics: tape test at night time (agents release their eggs during night time); use flashlight
- Management: Pyrantel Pamoate, Mebendazole
Hookworm
- Etiologic agent: Necator Americanus, Ancylostoma Duodenale
- Leads to iron deficiency and hypochromic microcytic anemia
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 - Gain entry via the skin
- Diagnostics: microscopic exam (stool exam)
- Management: Pyrantel Pamoate and Mebendazole
- don’t give drug without (+) stool exam
- members of the family must be examined and treated also
Nursing Intervention:
- Promote hygiene
- Environmental Sanitation
- Proper waste and sewage disposal
- Antihelmintic medications repeated after 2 weeks (entire family)

E. PARALYTIC SHELLFISH POISONING

- A syndrome of characteristic symptoms predominantly neurologic which occurs within minutes or
several hours after ingestion of poisonous shellfish
- Single celled dinoflagellates (red planktons) become poisonous after heavy rain fall preceded by
prolonged summer
- Common in seas around Manila bay, Samar, Bataan and Zambales
-
Mode of transmission: Ingestion of contaminated bi-valve shellfish
Incubation period: within 30 minutes
Clinical manifestations:
- numbness of the face especially around the mouth
- vomiting, dizziness, headache
- tingling sensation, weakness
- rapid pulse, difficulty of speech (ataxia), dysphagia, respi paralysis, death.
Management and control measures:
- no definite medications
- induce vomiting (early intervention)
- drinking pure coconut milk (weakens toxic effect) don’t give during late stage it may worsen the
condition.
- nahco3 solution (25 grams in ½ glass of water)
- respiratory support
- avoid using vinegar in cooking shellfish affected by red tide (15x virulence)
- toxin of red tide is not totally destroyed in cooking.
- avoid tahong, talaba, halaan, kabiya, abaniko. when red tide is on the rise.

F. BOTULISM
- A True poison known to be one of the deadliest substance and usually released into the food
shortly after it has been canned
- Botulism
- Etiologic agent: Clostridium Botulinum, gram (+), spore forming
- Ingestion of contaminated foods (canned foods), wound contamination, infant botulism (most
common; ingestion of honey)
- Neurotoxins block AcH
- Incubation period: 12-36H (canned food)
- Incubation period: 4-14 days (wound)
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 - Active and passive immunization
Clinical manifestations: Diplopia, dysphagia, symmetric descending flaccid paralysis, ptosis, depressed
gag reflex, nausea, vomiting, dry mouth, respiratory paralysis
Diagnostics: gastric siphoning, wound culture, serum bioassay (food borne)
Management: respiratory support, antitoxin

LESSON 8: CONTACT TRANSMISSION

A. Pediculosis
Blood sucking lice/Pediculus humanus
p. capitis-scalp
p. palpebrarum-eyelids and eyelashes
p. pubis-pubic hair
p. corporis-body
Mode of transmission: skin contact, sharing of grooming implements
Clinical manifestations: nits in hair/clothing, irritating maculopapular or urticarial rash
Management: disinfect implements, Lindane (Kwell) topical, Permethrin (Nix) topical

B. Scabies
- Sarcoptes scabiei
- Pruritus (excreta of mites)
- Mites come-out from burrows to mate at night
- Mode of transmission: skin contact

Clinical manifestations:: itching worse at night and after hot shower; rash; burrows (dark wavy lines
that end in a bleb w/ female mite) in between fingers, volar wrists, elbow, penis; papules and vesicles
in navel, axillae, belt line, buttocks, upper thighs and scrotum
Diagnostics: biopsies/scrapings of lesions
Management: Permethrin (Nix) cream, crotamiton cream, Sulfur soap, antihistamines and calamine for
pruritus, wash linens with hot water, single dose of Ivermectin, treat close contacts
Nursing Care:
A. Administer antihistamines or topical steroids to relieve itching.
B. Apply topical antiscabies creams or lotion like lindasne(kwell), Crotamiton (Eurax), permithrin
C. d. Lindane (kwell) not used in <2 years old, causes neurotoxicity and seizures
D. e. Apply thinly from the neck down and leave for 12-14hrs then rinse
E. f. Apply to dry skin, moist skin increases absorption
F. g. All family members and close contacts
G. h. Beddings and clothings should be washed in very hot water and dried on hot dryer

C. Leprosy
- Chronic infectious and communicable disease
- No new case arises without previous contact
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 - Majority are contracted in childhood, manifestation arises by 15 yrs old and will definitely
diagnose at 20
- it is no hereditary
- Does not cross placenta
Cardinal Sign:
A. Presence of Hansen’s bacilli in stained smear or dried biopsy material.
B. Presence of localized areas of anesthesia
* Lepromatous or malignant
- many microorganisms
- open or infectious cases
- negative lepromin test
* Tuberculoid or benign
- few organism
- noninfectious
- positive reaction to lepromin test
Clinical manifestations:
• Early/Indeterminate – hypopigmented / hyperpigmented anesthetic macules/plaques
• Tuberculoid – solitary hypopigmened hypesthetic macule, neuritic pain, contractures of hand and
foot, ulcers, eye involvement ie keratitis
• Lepromatous – multiple lesions, Loss of lateral portion of eyebrows (madarosis), corugated skin
(leonine facies), septal collapse (saddlenose)
Late: gynecomastia- enlargement of breast in male
Diagnosis:
- Skin smear test
- Skin lesion biopsy
- Lepromin test -

Management:
Multidrug Therapy and home treatment-RA 4073 (home meds)

Paucibacillary - 6-9 months

1. Dapsone
2. Rifampicin

Multibacillary- 12-24 months

1. Dapsone – mainstay; hemolysis, agranulocytosis
2. Clofazimine – reddish skin pimentation, intestinal toxicity
3. Rifampicin – bactericidal; renal and liver toxicity

Nursing Intervention:
- Health teachings
- Counseling involving the family members and even the community
- Prevention of transmission ( use of mask )

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LESSON 9: SEXUALLY-TRANSMITTED DISEASES

A. Gonorrhea, Morning drop, Clap, Jack

o Etiologic agent: Neisseria gonorrheae, gram (+)
o Incubation period: 3-7 days
Clinical manifestations:
- Females: usually asymptomatic or minimal urethral discharge w/ lower abdominal pain
sterility or ectopic pregnancy
- Male: Mucopurulent discharge, Painful urination
decreased sperm count
Diagnostics:
- gram stain and culture of cervical secretions on Thayer Martin VCN medium
Management: single dose only
- Ceftriaxone (Rocephin) 125 mg IM
- Ofloxacin (Floxin) 400 mg orally
- treat concurrently with Doxycycline or Azithromycin for 50% infected w/ Clamydia
Complications:
PID, ectopic pregnancy and infertility, peritonitis, perihepatitis, Ophthalmia neonatorum, sepsis and
arthritis

B. Syphilis
Etiologic agent: Treponema pallidum, spirochete
“ Beautiful” fast moving but delicate spiral thread
Incubation period: 10-90 days
Clinical manifestations:
 Primary (3-6 wks after contact) – nontender lymphadenopathy and chancre; most infectious;
resolves 4-6 wks
Chancre – painless ulcer with heaped up firm edges appears at the site where the treponema
enters. Related to pattern of sexual behavior (genitalia, rectal, oral, lips); BUBO – swelling of the
regional lymphnode
 Secondary – systemic; generalized macular papular rash including palms and soles and painless
wartlike lesions in vulva or scrotum (condylomata lata) and lymphadenopathy
 Tertiary – (6-40 years) - neurosyphilis/permanent damage (insanity); gumma (necrotic
granulomatous lesions), aortic aneurysm
Diagnostics:
Dark-field examination of lesion- 1st and 2nd stage
Non specific VDRL and RPR
FTA-ABS
Management:
- Primary and secondary - Pen G
- Tertiary - IV Pen G

C. Chlamydia
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 - Etiologic agent: Chlamydia trachomatis, gram (-)
- Incubation period: 2-10 days
Clinical manifestations:
- Maybe asymptomatic
- Gray white discharge, Burning and itchiness at the urethral opening
Diagnostics:
- Gram stain
- Antigen detection test on cervical smear
- Urinalysis
Management:
- Doxycycline or Azithromycin
- Erythromycin and Ofloxacin
Complications:
- PID
- Ectopic pregnancy
- Fetus transmittal (vaginal birth)

D. Herpes Genitalis
Etiologic agent: Herpes Simplex Virus 2
Clinical manifestations: Painful sexual intercourse, Painful vesicles (cervix, vagina, perineum, glans
penis)
Diagnostics:
- Viral culture
- Pap smear (shows cellular changes)
- Tzanck smear (scraping of ulcer for staining)
Management:
Anti viral - acyclovir (zovirax)
Complications:
- Meningitis
- Neonatal infection (vaginal birth)

E. Genital Warts, Condyloma Acuminatum

- Etiologic agents: HPV type 6 & 11, papilloma virus
- Clinical manifestations: Single or multiple soft, fleshy painless growth of the vulva, vagina, cervix,
urethra, or anal area, Vaginal bleeding, discharge, odor and dyspareunia
Diagnostics:
- Pap smear-shows cellular changes (koilocytosis)
- Acetic acid swabbing (will whiten lesion)
- Cauliflower or hyperkeratotic papular lesions
Treatment:
- liquid nitrogen
- podophylin resin
Management:
Laser treatment is more effective

135
Complications:
- Neoplasia
- Neonatal laryngeal papillomatosis (vaginal birth)

F. Candidiasis, Moniliasis
- Etiologic agent: Candida Albicans, Yeast or fungus
- Clinical manifestations: cheesy white discharge, extreme itchiness
Diagnostics:
KOH (wet smear indicates positive result)
Management:
Imidazole, Monistat, Diflucan
Complications:
Oral thrush to baby (vaginal birth)

G. Trichomoniasis
- Etiologic agent: Trichomona vaginalis, parasite

- Clinical manifestations: Females: itching, burning on urination, yellow gray frothy malodorous
vaginal discharge, foul smelling; Males: usually asymptomatic

- Diagnostics: microscopic exam of vaginal discharge

- Management: Metronidazole (Flagyl); include partners

- Complications: Premature rupture of membranes (PROM)

H. HIV and AIDS
- Retrovirus (HIV1 & HIV2)
- Attacks and kills CD4+ lymphocytes (T-helper)
- Capable of replicating in the lymphocytes undetected by the immune system
- Immunity declines and opportunistic microbes set in
- No known cure
- HIV/AIDS Reverses Development and Poses Serious Threat to Future Generations
- Since 1980s, 60m have been infected and 25m have died
- About 40m live with HIV/AIDS – 38m in developing countries and 28m in Africa alone
- The spread is accelerating in India, Russia, the Caribbean and China
- AIDS is stretching health care systems beyond their limits
- There are 12m AIDS orphans – they are estimated to rise to 40m by 2010
- In Sub-Saharan Africa, 58% of HIV/AIDS infected adults are women. More than two-thirds of
newly infected teenagers are female.
- Life expectancy has declined by more than 10 years in South Africa and Botswana –
Swaziland faces the risk of extinction
- Most HIV/AIDS Infected Live in Africa and South Asia
Health
Health care workers often have rates of infection as high or higher than adults in general
Illness and death of skilled personnel further weakens the sector
136
Education
Education faces decimation of skilled teachers
Children of families struck by AIDS often have to leave school to help generate income or undertake
basic household tasks
Mode of transmission:
- Sexual intercourse (oral, vaginal and anal)
- Exposure to contaminated blood, semen, breast milk and other body fluids
- Blood Transfusion
- IV drug use
- Transplacental
- Needlestick injuries
High risk group:
 Homosexual or bisexual
 Intravenous drug users
 BT recipients before 1985
 Sexual contact with HIV+
 Babies of mothers who are HIV+
Clinical manifestations:
1. Acute viral illness (1 month after initial exposure) – fever, malaise, lymphadenopathy
2. Clinical latency – 8 years w/ no manifestations; towards end, bacterial and skin infections and
constitutional signs – AIDS related complex; CD4 counts 400-200
3. AIDS – 2 years; CD4 T lymphocyte < 200 w/ (+) ELISA or Western Blot and opportunistic
infections
HIV CLASSIFICATION
CATEGORY 1 – CD4+ 500 OR MORE
CATEGORY 2 – CD4+ 200-499
CATEGORY 3 – CD4+ LESS THAN 200

HIV test/Diagnostics:
- Elisa
- Western Blot
- Rapid HIV test
How to Diagnose
 HIV+
2 consecutive positive ELISA and
1 positive Western Blot Test
 AIDS+
HIV+
CD4+ count below 500/ml
Exhibits one or more of the ff: (next slide)
 Full blown AIDS
CD4 is less than 200/ml
Exhibits one or more of the ff:

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 - Extreme fatigue
- Intermittent fever
- Night sweats
- Chills
- Lymphadenopathy
- Enlarged spleen
- Anorexia
- Weight loss
- Severe diarrhea
- Apathy and depression
- PTB
- Kaposis sarcoma
- Pneumocystis carinii
- AIDS dementia
Treatment
Anti-retroviral Therapy (ART) – ziduvirine (AZT)
a. Prolong life
b. Reduce risk of opportunistic infection
c. Prolong incubation period

Prevention:
 A – ABSTINENCE
 B – BE FAITHFUL
 C – CONDOMS
 D – DON’T USE DRUGS

LAWS RELATED
Laws Description
Republic Act 3573 Reporting of Communicable diseases
Requires all individuals and health
facilities to report notifiable diseases to
local and national public health
authorities. Refer to Section 3 of the Act
for the list of diseases covered.
Republic Act 4073 An Act Liberalizing the Treatment of
Leprosy
No persons afflicted with leprosy shall be
confined in a leprosarium provided that
such person shall be treated in any
government skin clinic, rural health unit
or duly licensed physician
Republic Act 8504 Philippine AIDS Prevention and Control
Act of 1998
An act promulgating policies and
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 prescribing measures for the prevention
and control of HIV AIDS in the
Philippines, instituting a nationwide HIV
AIDS information and educational
program, establishing a comprehensive
HIV AIDS monitoring system,
strengthening the Philippine National
AIDS Council and for other purposes.
Republic Act 9482 The Rabies Act of 2007
Rabies control ordinances shall be strictly
implemented and the public shall be
informed on the proper management of
animal bites and/or rabies exposures.
Republic Act 1136 Tuberculosis Law of 1954
Creation of Division of Tuberculosis under
an appointed Director of the National
Tuberculosis of the Philippines (NTCP)
established at the DOH compound

 CONCEPTS ON HEALTH PROMOTION AND DISEASE PREVENTION

A. RELATED TERMINOLOGIES
A. HEALTH
 WHO
A state of complete physical, mental, and social well-being and not merely the
absence of disease or infirmity (WHO)
- SOCIAL - “of or relating to living together in organized groups or similar close
aggregates” and refers to units of people in communities who interact with one
another
- SOCIAL HEALTH - Connotes community vitality and is a result of positive
interaction among groups within the community with an emphasis on health
promotion and illness prevention.
- Mid-1980s, the WHO expanded the definition of health:
“the extent to which an individual or group is able, on the one hand, to realize
aspirations and satisfy needs; and, on the other hand, to change or cope with
the environment. Health is, therefore, seen as a resource for everyday life, not
the objective of living; it is a positive concept emphasizing social and personal
resources, and physical capacities.”

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 “A state of well-being in which the person is able to use purposeful, adaptive
responses and processes physically, mentally, emotionally, spiritually, and socially.”
(Murray)
 “Actualization of inherent and acquired human potential through goal-directed
behavior, competent self-care, and satisfying relationship with others.” (Pender)
*Health as a human right
 Health is a right of every human – WHO
 “The enjoyment of the highest attainable standard of health is one of the
fundamental rights of every human being without distinction of race, religion,
political belief, economic or social condition” (Dr. Ghebreyesus, WHO Director-
General 2017)
 According to the Committee on Economic, Social and Cultural Rights (United
Nations, CESCR, 2000) the right to health consists of interconnected and
indispensable components:
-Availability – operational public health and channels of service delivery, products
and services as well as programs be adequate
-Accessibility – entails that health facilities, services and goods must be made
possible and obtainable to everyone, being non-discriminatory, physically
accessible, economically accessible (affordable) and information accessible are the
four intersecting features of accessibility.
-Acceptability – corresponds to respect for the medical ethics, being culturally
appropriate and gender sensitive.
-Quality – implies that the health facilities, commodities and services must be in
accordance with scientific and medical ethics.

 Is the ability to maintain homeostasis or dynamic equilibrium. Homeostasis is

regulated by the negative feedback mechanism (Walter Cannon
 Is the ability to maintain the internal milieu (Claude Bernard)
 Is being well and using one’s own power to the fullest extent. Health is being
maintained through prevention of disease by enmvironmental health factors
(Nightingale
 Positive health symbolizes wellness. It is a value termed by the culture or individual
(Rogers)
 Is a state and a process of becoming and being an integrated and whole person
(Roy)- Is a state characterized by soundness or wholeness of developed human
structures and of bodily and mental functioning (Orem)
 Is a dynamic state in the life cycle; illness is an interference (King)
 Wellness is the condition in which all parts and subparts of an individual are in
harmony with the whole system (Neuman)
 Is an elusive, dynamic state influenced by biologic, physiologic and social factors.
(Johnson)
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 B. WELLNESS AND WELL-BEING
 Wellness is well-being. It involves engaging in attitude and behaviors that enhance
QOL and maximize personal potential
 Subjective perception of balance, harmony and vitality
 Is a choice
 Is a way of life
 Is the integration of boy, mind and spirit
 Is the loving acceptance of one’s self

C. DISEASE
 An alteration in body functions resulting in reduction of capacities or a shortening
of the normal life span
 Common causes of disease
a. Biologic agents
b. Inherited genetic defects
c. Developmental defects
d. Physical agents
e. Chemical agents
f. Response to irritation/injury
g. Faulty chemical/metabolic process
h. Emotional/physical reaction to stress

 Risk factor
- Any situation, habit, social or environmental condition, physiological or psychological condition,
developmental or intellectual condition or spiritual or other variable that increases the
vulnerability to illness or accident
- The presence will not mean that a disease will develop BUT increase the chances
1. Genetic/Physiological factors
 Heredity or genetic disposition to specific illness—major risk factor
2. Age
 Increases or decreases susceptibility
3. Environment
 Where a person lives or works – can increase the risk
4. Lifestyle
 Activities, habits and practices
 It can have a positive or negative effect

 CLASSIFICATIONS OF DISEASE
2. According to biologic factors
a. Hereditary – defect in the genes of one or two parents
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 b. Congenital – developmental defects
c. Metabolic – disturbance or abnormality in metabolism
d. Deficiency – inadequate dietary factors
e. Traumatic – injury
f. Allergic – abnormal response of body to stimuli
g. Neoplastic – abnormal cell growth
h. Idiopathic – unknown
i. Degenerative – changes
j. Iatrogenic – results from treatment of disease

3. According to duration/onset
a. Acute
 Short (6 months or less) and severe; s/sy appear abruptly, intense
b. Chronic
 Longer than 6 months
 Characterized by remission and exacerbation
c. Subacute
 Symptoms are pronounced, but longer than acute
B. Other classifications
a. Organic – changes in normal structure, anatomical changes
b. Functional – no anatomical changes, abnormal responses
c. Occupational – associated with occupation
d. Familial – same family
e. Venereal – sexual relation
f. Epidemic – attacks a large number of individuals in a community at the same time
g. Endemic – present more or less continuously; constant
h. Pandemic – nationwide
i. Sporadic – occasional cases, “on and off”

D. ILLNESS
6. a personal state in which the person feels unhealthy
7. a state in which a person’s functioning is diminished or impaired
8. NOT synonymous with disease

- Stages of illness
1. Symptom experience
 Transition stage
 Believes something is wrong
 Experiences some symptoms (physical, cognitive,emotional)
2. Assumption of sick role
 Acceptance of the illness
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  Seeks advice, support for decisions
3. Medical contact
 Seeks advice to health care professionals
 Validation, explanation, reassurance, prediction
4. Dependent patient role
7. Dependent on health professionals
8. Accepts/rejects suggestions
9. Passive, accepting, regress
5. Recovery/rehabilitation
 Gives up sick role and returns to former roles

IV. Other terminologies related

i. Morbidity – condition of being diseased
ii. Mortality – condition or quality of being subject to death
iii. Susceptibility – degree of resistance
iv. Etiologic agent – one that possesses the potential for producing disease
v. Pathogenicity –
vi. Virulence – power or degree of pathogenicity
vii. Symptom –
viii. Sign –
ix. Syndrome – set of signs and symptoms

B. HEALTH AS A MULTI-FACTORIAL PHENOMENON

 Factors that affect the level of functioning or health of an individual or of a population
1. POLITICAL – great influence
 Has the power/authority to regulate
 E.g. safety, oppression, people empowerment, safety/crime
2. BEHAVIORAL – habits, lifestyle
 Smoking, substance abuse, liquor, etc.
3.HEREDITARY – genetically influenced diseases
 Understanding, increase knowledge – preventive measure
 Anticipate and counteract
4.HEALTH CARE DELIVERY SYSTEM
 PHC >effective provision of essential health services that are available, accessible, acceptable and
affordable
 promotive and preventive, curative, rehabilitative
5. ENVIRON MENTAL INFLUENCES –pollution, sanitation, logging, waste disposal
 Diseases nowadays are man-made
6. SOCIO-ECONOMIC INFLUENCES – lower income groups/families are ones mostly served
 Low income families have greater number of illnesses or health problems
 Middle-upper income-> drug abuse and lifestyle diseases
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DETERMINANTS OF HEALTH
1. Income and Social Status
• Higher-income and social status are linked to better health. The greater the gap
between the richest and poor health, the greater differences in health.
2. Education
• Low education levels are linked with poor health, more stress and lower self-confidence.
3. Physical Environment
• Safe water and clean air, healthy workplaces, safe houses communities and
roads all contribute to good health.
4. Employment and Working Conditions
• People in employment are healthier, particularly those who have control over
their working conditions.
5. Social Support Networks
• Greater support from families, friends and communities is linked to better
health.
6. Culture
• Customs and traditions, and the beliefs of the family and community all affect
health.
7. Genetics
Nursing Care of the Community (Famorca et al., 2013) sacrodriguez2020
• Inheritance plays a part in determining lifespan, healthiness, and the likelihood
of developing illnesses.
8. Personal Behavior and Coping Skills
• Balanced eating, keeping active, smoking, drinking and how we deal with life’s
stresses and challenges all affect health.
9. Health Services
• Access and use of services that prevent and treat disease influences health.
10. Gender
• Men and women suffer from different types of diseases at different ages.

C. LEVELS OF PREVENTION

 PRIMARY PREVENTION - encourage optimum health and increase person’s resistance to illness
 Prevents disease; stop something to happen
 Health promotion and specific protection
 E.g.: quit smoking, avoid/limit alcohol intake, exercise, eat well-balanced diet, avoid overexposure
to sun, maintain IBW, complete immunization program, wear hazard devices
 SECONDARY PREVENTION – health maintenance
 Identify specific illnesses or conditions at early stage
 Prompt intervention to limit or prevent disability

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  Early diagnosis/detection/screening and prompt treatment
 E.g.: annual PE, Pap’s smear,BSE, TSE, sputum exam, stool and rectal exam
 TERTIARY PREVENTION – occurs after disease or disability
 Stop the disease or injury process and assist patient in attaining optimal health
 E,g,: self-monitoring of blood sugar, PT, rehabilitation, therapy
13. ACTIVITIES TO PROMOTE HEALTH AND PREVENT ILLNESS/DISEASE
1. Eat well-balanced diet
2. Exercise regularly
3. Do not smoke, avoid second hand smoke
4. Avoid alcohol, say no to drugs
5. Regular physical examination
6. Annual dental exam
7. Male: TSE; female: BSE, Pap’s smear
8. Maintain IBW
9. Reduce fat and increase fiber in diet
10. Sleep regularly 6-8 hours/night

B. THEORIES RELATED TO HEALTH PROMOTION/HEALTH EDUCATION

1. HEALTH PROMOTION MODEL
- Multi-dimensional nature of persons as they interact within the environment to pursue health
 Focus:
A. Individual perception
B. Modifying factors
C. Participation in health
Activities involved:
1. Efforts to assist individuals in taking control of and responsibility for their health risks and
improve QOL
2. Activities to improve the health of those who are not healthy and as well as those who are
healthy
3. Individual and community activities to promote healthful lifestyles
4. Self-responsibility, nutritional awareness, stress reduction, physical fitness
5. Health promotion activities:
6. Illness prevention activities:

2. DUNN’S HEALTH-ILLNESS CONTINUUM THEORY

- high level wellness ->integrated method of functioning that is oriented towards maximizing one’s
potentialities within the limitations of his environment
14. PRECURSOR OF ILLNESS
1. Heredity
2. Behavioral factors
3. Environmental factor

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 3. HEALTH BELIEF MODEL
 Relationship between belief and behavior
 Individual perceptions and modifying factors may influence health beliefs and preventive health
behavior
 Individual perceptions:
 Perceived susceptibility (history of disease)
 Perceived seriousness of the disease (lifelong)
 Perceived threat (complications)
 Modifying factors
 Demographic variables (age, sex, race)
 Sociophysiologic variables (social pressure on peers)
 Structural variables (knowledge on disease)
 Cues to action (internal: fatigue, symptoms; external: media, advice from others)

4. SMITH’S MODELS OF HEALTH

A. CLINICAL MODEL – views people as physiologic system with related functions and identifies health
as the absence of signs and symptoms of disease or injury
B. ROLE PERFORMANCE MODEL – defines health in terms of ability to fulfill societal roles
C. ADAPTIVE MODEL – focuses on adaptation; health is a success/creative process and illness a
maladaptation; aim is to adapt/cope
D. EUDAMONISTIC MODEL – actualization or realization of person’s potential

5. AGENT-HOST-ENVIRONMENT MODEL
 AGENT (any factor/stressor -> disease)
 HOST (may or may not be affected)
 ENVIRONMENT (external factor that may or may not predispose the person to a disease

6. SELF-EFFICACY

-based on the idea that people will do only what they think they can do

Four variables:

Performance accomplishments-mastery

Vicarious experience-observation

Verbal persuasion-coach, encouragement

Physiological state

>most important determinant of behavior change is learning a new behavior by doing it

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