Pearls to

Remember in
Community Health
Nursing
Ramadan Ali Hassan
◊ A community is a collection of people live together who
interact with one another and whose common interest or
characteristics gives them a sense of unity and belonging.
◊ There are three types of communities
1. Geographic community: is defined by its geographic
boundaries e.g. community of Gaza city
2. Common interest community : A collection of people,
even if they are widely scattered geographically, can have
an interest or goal that binds the members together e.g.
diabetic community, disable community, ...
3. Community of solution: a group of people who come
together to solve a problem that affects all of them e.g.
community of solution for drug abuse in secondary schools
◊ Population: All of the people occupying an area, or to all of
those who share on e or more characteristics e.g. the
population of Palestine
◊ An aggregate is considered subpopulation e.g. Elderly
adults with diabetes
◊ A community has three features: location, population and
social system.
 Health is defined as a state of physical, mental
and social wellbeing not merely the absence of
disease or infirmity
 Physical health implies a mechanistic
functioning of the body.
 Mental health means the ability to think clearly
and coherently and has to do with your thinking
and feeling and how you deal with your problem.
 Social health refers to the ability to make and
maintain relationship with others and interact
well with people and the environment.
 The wellness- illness continuum is a visual
comparison of high level wellness and
traditional medicine’s view of wellness.
Community health practice has 6 basic elements or
functions:
1.Promotion of health: includes all efforts that seek to
move people closer to optimal well-being or higher level
of wellness.
2.Prevention of health problems
3.Treatment of disorders
4.Rehabilitation: involves efforts which seek to reduce
disabilities, as much as possible, and restore functions
5.Evaluation
6.Research
There are 3 levels of prevention of health problems :
1. Primary prevention:
• Prevention of health problem before it has a chance to occur.
• It concerned with healthy population
• Aims to improve the health and well-being of the population.
• E.g. immunization, use safety devices, healthy lifestyle, safe
water supply, isolation of infected person, using protective
measures,....
2. Secondary prevention:
• Aims for early detection and early and prompt treatment
• Disease or impairment is already present.
• All Screening activities are secondary prevention e.g. blood
test (lipids, sugar, tumor markers), Regular mammograms
and Pap smears for early detection of possible cancers,
Teaching breast self-testicular self examination.
3. Tertiary prevention: minimize disability or complication and
restore or preserve function e.g. rehabilitation programs, post
mastectomy exercises
o Community health nursing: It is defined as the synthesis of
nursing and public health practice applied to promoting and
protecting the health of population.
o Public health: is the art and science of prolonging life,
promoting health and preventing disease through organization of
community efforts.
Characteristics of community health nursing
1. It is a specialty field of nursing
2. Its practice combines public health with nursing
3. It is population focused.
4. It emphasizes on wellness and other than disease or illness
5. It involves inter-disciplinary collaboration
6. It promotes client’s responsibility and self-care
Roles of community health nurse:
7. Advocator
8. Clinician
9. Educator
10.Manager
11.Collaborator
12.Leader
13.Researcher
 Primary health care defined as 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 community and country can
afford to maintain at every stage of their development in the
spirit of self-reliance and self– determination
 Essential health care provided through PHC is basic
&indispensable
 Functions of primary health care
1. Education concerning prevailing health problems and the
methods of preventing and controlling them
2. Promotion of food supply and proper nutrition
3. An adequate supply of safe water and basic sanitation
4. Maternal and child health, including family planning
5. Immunization against major infectious diseases\
6. Prevention and control of locally endemic diseases
6. Appropriate treatment of common diseases and injuries
8. Provision of essential drugs
 Epidemiology is a science concerned with the
distribution and determinants of health and
diseases, morbidity, injuries, disability, and
mortality in populations
 An epidemic: refers to a disease occurrence
that clearly exceeds the normal or expected
frequency in a community or region e.g.
epidemics of cholera
 Pandemic: it is an epidemic of infectious disease
that has spread through human populations
across a large region; for instance multiple
continents, or even worldwide e.g. HIV, Swine
flu
 Endemic: it is the continuing presence of a
disease or infectious agent in a given geographic
area e.g. Hepatitis B in Egypt.
 Triangle of Epidemiology consist of :
1. Host 2. Environment 3. Agent

Certain ch.ch. of infectious agents are important for CHN to

understand.
1. Extent of exposure to the agent.
2. The agent’s pathogenicity (capacity to cause disease in the
host).
3. Its infectivity (capacity to enter the host and multiply).
4. Its virulence (severity of disease).
5. Toxigenicity (capacity to produce a toxin or poison).
6. Resistance (ability of the agent to survive environmental
conditions).
7. Antigenicity (ability to induce an antibody response in the
host).
8. Its structure and chemical composition all influence the
effect of the agent on the host.
Chain of Causation (infection)
Modes of transmission:
1. Direct: Occurs by immediate transfer of infectious agents
from a reservoir to a new susceptible host e.g. by touching,
coughing, sneezing secretions, biting, kissing.
2. Indirect: Occurs when the infectious agent is transported
within contaminated inanimate materials such as air, water,
or food. It is also commonly referred to as vehicle-borne
transmission.
3. Vector transmission: by a nonhuman carrier such as an
animal or insect e.g. Rabies and Hantavirus (transmitted by
animals), Malaria, plague, and Lyme disease (transmitted by
insects such as mosquitoes, fleas, and ticks)
4. Airborne transmission: Because of the small size and
weight of droplet nuclei, they can remain suspended in the
air for long periods before they are inhaled into the
respiratory system of a host.
5. Droplet transmission occurs when bacteria or viruses
travel on relatively large respiratory droplets (>5 µm) that
people sneeze, cough, drip, or exhale and projected up to
about one meter.
4 types of immunity are important in community health:
1) Passive immunity.
2) Active immunity.
3) Cross-immunity.
4) Herd immunity.
 Types of immunity
1) Passive Immunity: is the transfer of active immunity, in the form of prepared
antibodies, from one individual to another.
A. Natural passive immunity: transfer of antibodies from mother to fetus
during pregnancy or to newborn through breastfeeding. This immunity
lasts up to 1 year for certain diseases.
•Well protection against measles, rubella, and tetanus
• less protection with other diseases (e.g., polio and pertussis).
B. Artificial passive immunity: is a short-term immunization induced by the
transfer of antibodies induce protection against diseases e.g. Immune
globulin (hepatitis A and measles)
2) Active immunity: is long-term and sometimes lifelong resistance that is
acquired either naturally or artificially.
A. Naturally active immunity comes through host infection.
A person who contracts a disease often develops long-lasting antibodies that
provide immunity against future exposures.
B. Artificially active immunity is attained through vaccination.
 Types of immunity
3) Cross-Immunity: a person’s immunity to one agent provides immunity to a
related agent as well.
• The immunity can be either passive or active.
Examples:
• infection with one disease, such as cowpox, gives immunity to a related
disease, such as smallpox.
• Inoculation with a vaccine made from one disease-causing organism can
provide immunity to a related disease-causing organism.
4) Herd Immunity: is a form of indirect protection from infectious disease that
occurs when a large percentage of a population has become immune to an
infection, thereby providing a measure of protection for individuals who are
not immune.
• A population with low herd immunity is one with few immune members;
consequently, it is more susceptible to a particular disease.
• Non-immune people are more likely to contract the disease and spread it
throughout the group, placing the entire population at greater risk.
• Conversely, a population with high herd immunity is one in which the immune
people in the group outnumber the susceptible people; consequently, the
incidence of a particular disease is reduced.
 Types of vaccines:
1. Live attenuated organisms: the organism’s pathogenicity is reduced by sequential sub-
culturing
 Oral poliomyelitis
 BCG
 Yellow fever
 Measles, mumps, rubella
2. Inactivated organisms: the organisms have been inactivated by chemical means
 IPV (Inactivated Polio vaccine)
 Rabies
 Hepatitis A
3. Toxoid: the inactivated products of an organism
 Diphtheria
 Tetanus
4. Components of organisms:
 Surface proteins of the virus (Hepatitis B vaccine)
 Polysaccharide of surface capsule of certain bacteria (meningococcal,
pneumococcal vaccines)
 Conjugate antigens or toxoids from a microbe that an infant’s immune
system can recognize to the polysaccharides (Haemophilus influenzae
type b (Hib), influenza, pertussis, meningococcal, pneumococcal
vaccines)
 Administration of vaccines
Generally vaccines are administered via:
 Oral (OPV, Rotavirus vaccine)
 Intranasal: live attenuated Influenza vaccine
 Intramuscular: (IPV ,DTP, Hepatitis B, IPV, Hib, PCV)
 Subcutaneous: (Measles, MMR)
 Intradermal: BCG
 Vaccines that are not administered via the correct route may be sub-
optimal or cause harm e.g. BCG given subcutaneously instead or
intradermal can cause a local abscess.
 If the skin is cleaned with alcohol prior to the administration of a
vaccine, the alcohol should be allowed to dry first
 After the administration of each vaccine, the name of the vaccine and
its batch number should be recorded for future reference.
 All expired, partly used and spent vials, needles and syringes, should be
disposed of safely, usually in a sharps bin for incineration
 The expanded program of immunization does not recommend mixing
different vaccines in one syringe as this reduces efficacy.
Contraindications to immunization: (Immunodeficiency)
• Generally, live vaccines should not be given to immune-compromised individuals.
• Both measles and oral poliomyelitis vaccines should be given to children with
HIV/AIDS.
• Children with HIV/ AIDS should not be immunized with BCG or yellow fever.
True contraindications include: Severe adverse event following a dose of vaccine: e.g.
 Anaphylaxis
 Collapse
 Shock
 Encephalitis/ encephalopathy
 Non-febrile convulsion) .
False contraindications (not contraindications) include:
▪ Illness with fever (< 38.5°C.) ▪ Allergy & asthma
▪ Prematurity, Low birth weight ▪ Malnutrition
▪ Breast-fed infants ▪ Family history of convulsions
▪ Treatment with antibiotics or low dose steroids
▪ Dermatitis, eczema, local skin infections
▪ Chronic disease of heart, lung, kidney and liver.
 Vaccine storage
 Care must be taken to ensure that all vaccines are stored
according to the conditions stated in the manufacturer’s data
sheet.
 Failure to do so can result in the preparation becoming
ineffective.
 Correct storage of vaccines usually means maintaining the “cold
chain” , and refrigerated transportation and storage is usually
necessary, as most vaccines need to be stored at 2 - 8° C.
 Vaccines must not be allowed to freeze.
 Vaccination coverage
 Vaccination coverage is the percent of at risk or susceptible
individuals, or population who have been fully immunized
against particular diseases by vaccines or toxoids.
 To be significantly effective in prevention of disease on mass
or community level at least a satisfactory proportion (75% or
more) of the at risk population must be immunized.
Table 7.1: Abbreviations used in Palestinian vaccination schedule
Definition Acronym
Bacillus Calmette-Guerin BCG

Diphtheria, Pertussis, Tetanus DPT

Measles, Mumps, Rubella MMR
Trivalent Oral Polio Vaccine TOPV
Inactivated Polio vaccine IPV
Hemophilus influenza type b Hib
Pneumococcal Conjugate Vaccine PCV
Hepatitis B HB
Tetanus, diphtheria Td
Hib + HB + DPTl Penta
.Site of admin Route Dose Vaccine Age
Lt shoulder ID ml 0.05 BCG At birth
Rectus femoris , vastus IM ml 0.5 HB (1)
lateralis
Rectus femoris , vastus IM ml 0.5 IPV (1( month 1
lateralis
Rectus femoris , vastus IM ml 0.5 IPV (2)
lateralis
Rectus femoris , vastus IM ml 0.5 Penta (1)
lateralis
2
Rectus femoris , vastus IM ml 0.5 PCV (1) months
lateralis
Mouth PO drops 2 OPV (1)
Mouth PO ml 1.5 Rota (1)
Rectus femoris , vastus IM ml 0.5 Penta (2)
lateralis
Rectus femoris , vastus IM ml 0.5 PCV (2) 4
lateralis
months
Mouth PO drops 2 OPV (2)
Mouth PO ml 1.5 Rota (2)
Rectus femoris , vastus IM ml 0.5 Penta (3)
lateralis 6
.Site of admin Route Dose Vaccine Age
Lt arm SC ml 0.5 MMR (2)
Mouth PO drops 2 OPV (4) 18
Rectus femoris , vastus months
IM ml 0.5 DTP
lateralis
Lt arm IM 0.5 DT
years 6
Mouth PO drops 2 OPV
Lt arm IM ml 0.5 TD years 15
 Vaccination for special occupations
 Health care workers: hepatitis B, influenza, MMR, polio
 Public safety personnel (police, fire fighters) and staff of
institutions for the developmentally disabled: hepatitis B,
influenza
 Pets and animal handlers: rabies, plague and anthrax
 Food handlers: Typhoid-paratyphoid A and B vaccine (TAB)
 Sewage workers: DT, hepatitis A, polio, TAB
 Military troops and camp dwellers: pneumococcal,
meningococcal, influenza, BCG and tetanus
 Communicable diseases
◊ Tuberculosis is a diseases caused by bacteria usually attack the lungs, but TB
bacteria can attack any part of the body such as the kidney, spine, and brain.
◊ TB is caused by Mycobacterium tuberculosis
◊ Latent TB is an inactive state and cause no symptoms and it isn't contagious.
◊ Active TB is highly infectious to others
◊ Abscess formation and keloid formation are side effects for BCG
vaccine
◊ Diphtheria is a serious bacterial infection, usually of the throat;
the throat infection may obstruct breathing and cause death.
◊ In diphtheria, A false membrane forms in the throat which
obstruct the airway
◊ Pertussis (whooping cough) is a highly infectious acute
bacterial disease involving the respiratory tract.
◊ Tetanus (lockjaw) is an infection caused by bacteria called
Clostridium tetani which produces a toxin that damages the
nervous system and muscles causing painful muscle contractions
◊ Clostridium tetani can get into the body through broken skin,
usually through injuries from contaminated objects or soil
◊ Hepatitis A is transmitted via the faecal-oral route
 Hepatitis B can cause lifelong infection, cirrhosis (scarring) of the liver,
liver cancer, liver failure, and death.
 Transmission of HBV is through sexual intercourse, blood to blood
contact , from mother to baby, Percutaneous
 The icteric stage of hepatitis B is ch.ch. By jaundice
 Haemophilus influenza type b (Hib) is a bacterial infection causing
epiglottitis and croup, pneumonia and meningitis.
 Mumps is an acute viral infection usually affecting the salivary glands,
chiefly the parotid gland in 60% of cases.
 The measles virus is a paramyxovirus mainly affecting the mucous
membranes of the respiratory tract and skin producing fever and rash.
 Measles can lead to fatal complications including pneumonia, diarrhea,
and encephalitis (inflammation of the brain
 Tiny white spots (Koplik spots) inside the mouth appear two or three
days after symptoms begin.
 Rubella (German measles) is a mild febrile viral illness with a faint
rash which is only of importance given the damage it may cause to the
fetus when a mother contracts the infection during pregnancy.
 Poliomyelitis is an infection caused by one of three types of virus.
 Poliomyelitis is transmitted via fecal-oral route, particularly in areas
where there is poor food and water hygiene.
 Infection with one type of polio viruses will not provide protection
against the other two polio viruses
• NCDs are conditions that last a year or longer, limit functionality, and/or may
require ongoing medical care. Examples:
• Diabetes Mellitus
• Asthma
• Hypertension
• Cardiovascular diseases
• Allergy
• Atherosclerosis,
• Cancer,
• Mental health problems .

A. Modifiable risk factors B. Non-modifiable risk factors

• Tobacco use
• Age
• Physical inactivity
• Unhealthy diet • Sex
• Alcohol consumption • Race
• Raised blood pressure
• Family history
• Overweight/obesity
• Hyperglycemia
• Hyperlipidemia
• Ten leading cause of death in Palestine (2014) :
1) Cardiovascular diseases 29.5%.
2) Cancer 14.2%.
3) Cerebrovascular diseases 11.3%.
4) Diabetes mellitus 8.9%.
5) Respiratory system diseases 5.4%.
6) Perinatal Period Conditions 5.2%.
7) Accidents 5%.
8) Renal failure 3.9%.
9) Infectious disease 3.3%.
10) Senility 3.1%.
Characteristics of healthy families
1. Healthy interaction among members e.g.
discuss problems , confront each other , share
ideas & concern)
2. Enhancement of individual development
3. Effective structuring of relationship
4. Active coping effort
5. Healthy environment and life-style
6. Regular links with the broader community

Family members should be included in all phases of the family

assessment process
 An eco-map is a visual representation of a family
in relation to the community. It demonstrates the
nature and quality of family relationships and what
kinds of resources or energies are going in and out
of the family.
A genogram is a format for drawing a family tree
that records information about family members and
their relationships over a period of time, usually
three generations.
Stages of the family life cycle
There are (2) broad stages in the family cycle:
A. Expansion stage: as new members are added and roles and relationships are increased.
B. Contraction stage: as family members leave to start lives of their own, or age and die.

Stages of family life cycle:

1. Forming a partnership 2. Childbearing 3. Preschool-age
4. School-age 5. Teenage 6. Launching center
7. Middle-aged parents 8. Aging family members
Major targets of MCH Services
1. Women of reproductive age group (15-49 years)
2. Pregnant women
3. children less than 15 years
Major component of MCH services
• Provision of quality ANC, delivery care, and PNC
• Prevention of STIs/HIV/AIDS
• Immunization
• Growth monitoring
• Well baby clinic
• Nutrition Rehabilitation Clinic (NRC)
• Nutrition counseling and health education
• School health education
• Adolescent health service
The major cause of maternal mortality includes :
1. Direct cause – are these disease or
complications occur only during pregnancy
and child birth e.g., Hemorrhage Sepsis, Unsafe
abortion, Hypertensive disorder, Obstructed labor
2. Indirect cause – are these which are pre-
existing disease but aggravated by pregnancy
e.g. Anemia , Heart disease, Essential HTN, DM,
Kidney disease
3. Coincidental causes – are not related to
pregnancy e.g. Death from traffic accident
Perinatal mortality rate:
Number of fetal deaths plus infant deaths under 7 days of age X 1000
Number of live births plus fetal deaths

Maternal mortality rate:

Number of deaths from puerperal causes X 100,000
Number of live births

Maternal death include deaths during pregnancy, delivery, 42 days

after delivery from any cause due to pregnancy or delivery but not
accidents or other cause.
 The goal of school health is to support the educational
process by helping to keep children healthy, by teaching
students & teachers preventive health measures.
 Environmental health: is the branch of public health that
is concerned with all aspects of environment that may
affect human health
 Excessive nitrate levels in water leads to
methemoglobinemia.
 Occupational Health is the promotion and maintenance
of the highest degree of physical, mental, social well-being
of workers in all occupations by controlling risk and the
adaptation of work.
• Ergonomics means Fitting the job to the worker .
• The most occupational disease that nurses and physicians
suffer from is Low back pain
 Review questions
1) Principles of primary health care include …………………..
a. Health care services should be highly costs.
b. Health care services should be inappropriate to technology.
c. Health care services should be focus on curative rather than promotion
services.
d. Health care services should be equally accessible to all people

2) Which of the following is considered an example of secondary

prevention?
a. Immunization b. Breast self-examination
c. Post mastectomy exercised. Safe water supply

3) …… refers to all of the people occupying an area who don’t

necessarily have a common interest
a. Community b. Population c. Social system d. Community of
solution
4) …………… aims to reduce the exposure of person at
risk for developing a specific disease
a. Primary prevention b. Secondary prevention
c. Tertiary prevention d. Screening

5) ……………… involves efforts, which seek to reduce

disabilities, as much as possible, and restore functions.
b. Primary prevention b. Curative services
c. Health promotion d. Rehabilitation

6)………………is the art and science of prolonging life,

promoting health and preventing disease through
organization of community efforts.
c. Community health nursing b. Public health
c. Nursing d. Medicine
7. All of the following are the ultimate goals of epidemiology except:
a. Determine the extent of disease in a population
b. Identify the causes of disease
c. Identify patterns and trends in disease occurrence
d. Identify the pathophysiology of disease

8. …… refers to a disease occurrence that clearly exceeds the

normal or expected frequency in a community or region.
a. Endemic b. Epidemic c. Pandemic d. Demographic

10. …………….. Is a mode of transmission in which the

infectious agent is transported via contaminated inanimate
materials.
a. Direct transmission b. Vector transmission
c. Vehicle transmission d. Airborne transmission
11. Which of the following statements is true about BCG vaccine?
a. Killed vaccine
b. Should be given intradermally with a dose of 0. 5 ml in the deltoid
area for newborn
c. Should be given after negative Mantoux test result for infants less
than 3 months age
d. BCG vaccine must be given intradermally with a dose of 0.05 ml for
newborn

12. Which of the following manifestation is characteristic for

patient with diphtheria?
a. High grade fever b. Whooping cough
c. Neck rigidity d. A false membrane in the throat

13. Haemophilus influenza type “b” causes all of the following infection
except:
a. Epiglottitis b. Pneumonia c. Meningitis d. Gastroenteritis
14. Which of the following statements is true about poliomyelitis?
a. There are more than 5 types of polio virus
b. Is usually transmitted by vector
c. Causes destruction of the anterior horn cells of the spinal cord and the
brain stem.
d. There are many available drug therapies for the treatment of
poliomyelitis.

15. Which of the following is an example for artificial passive

immunity?
a. Antibodies from mother to fetus
b. Tetanus toxoid vaccine
c. Post infection antibodies
d. Anti-tetanus antibodies

16. All of the following are live attenuated vaccines except:

a. Measles b. Tetanus c. BCG d. Sabin
17. Which of the following risk factors is non-modifiable?
a. Smoking b. Gender c. Unhealthy diet d. Stress

18. Which of the following family stages is characterized by leaving of

family members out the family?
a. Launching b. Childbearing c. Preschool-age d. Middle-aged parents

19. …………… is a diagram of the connections between a family and

the other systems in its environment
a. Genogram b. Eco-map c. Family tree d. Family cycle

20. Home visit has 4 stages, the nurse should perform all of following
in the pre-visit phase except:
a. Initiate contact with family and introduce yourself.
b. Determine when a visit would be convenient for the family and the
nurse.
c. Plan with the family for the next visit.
d. Prepare all supplies needed for visit
21. All of the followings are indicators for MCH services except:
a. Infant mortality rate b. Crude death rate
c. Maternal mortality rate d. Peri-natal mortality rate

22. On the first home visit, it is important for community health

nurse to:
a. Conduct complete assessment of the family and client.
b. Perform several nursing care measures to convince the family that he
knows what he is doing.
c. Begin building a trust relationship.
d. Arrange for several more visits.

23. ……………. … is the total number of stillbirths plus the number

of deaths under one week old, per 1000 birth
a. Infant mortality rate b. Perinatal mortality rate
c. Neonatal mortality rate d. Post-neonal mortality rate