Control of Non- Communicable Disease

1. Integrated Community based non-communicable disease prevention program

Description

Non-communicable diseases (NCDs) include cardiovascular conditions (hypertension,

stroke), diabetes mellitus, lung/chronic respiratory diseases and a range of cancers which are
the top causes of deaths globally and locally. These diseases are considered as lifestyle
related and is mostly the result of unhealthy habits. Behavioral and modifiable risk factors like
smoking, alcohol abuse, consuming too much fat, salt and sugar and physical inactivity have
sparked an epidemic of these NCDs which pose a public threat and economic burden.

GOAL:

Reduce the toll of morbidity, disability and premature deaths due to chronic, non-communicable
lifestyle related disease.

Objectives

1. Analyze the social, economic,political and behavioral determinants of NCD that will
serve as a bases for:

A. Developing policy guidelines;

B. Setting legislative and political directions, and

C. Providing financial measures to support NCD prevention and control

2. Reduce exposure of individuals and population to major determinants of NCD while

preventing emergence of preventable common risk factors. The NCD prevention and
control program must focus on modification of unhealthy lifestyles and behaviors that
predispose populations to NCD. To hasten this, the health sector should lobby for a
health protective environment by:

A. Proposing healthy public policies that encourage health-promoting settings in school,

workplaces and communities

B. Encouraging governments to provide protection against activities by industry and commerce

that promote unhealthy products and lifestyle

C. Communicating the consequences of major risk factors of NCD, paying particular attention to
the most vulnerable population

3. Strengthen health care for people with NCD through health sector reforms and cost
effective interventions.

To achieve significant reduction in morbidity and mortality from major NCDs, the
following approaches should characterize the program:
1. COMPREHENSIVE APPROACH FOCUSED ON PRIVARY PREVENTION

A. A comprehensive long-term strategy for control of NCDs must focus on primary prevention;

B. Specific protection from NCD by removal of the risk factors or reduction in their level

2. COMMUNITY-BASED APPROACH

 active community participation

 involvement of community leaders, community committees and other community groups;

 strong support and guidance from local governments and technical experts; and

 multi-sectoral collaboration

3. INTEGRATED APPROACH

A healthy community contributes to the socio-economic development of the community.

*KEY INTERVENTION STRATEGIES

1. Establishing program direction and infrastracture

2. Changing Environments

3. Changing lifestyle

4. Reorienting health services

The Role of Public Health Nurse in NCD and Control

1. Health Advocate

> the PHN helps the people towards optimal degree of independence in decision-making and in
asserting their right to a safer and better community.This involves:

A. Informing the people about the rightness of the cause.

B. Thoroughlydiscussing with the people the nature of the alternatives, their content and
consequences.

C. Supporting people’s right to make a choice and to act on the choice.

D. Influencing public opinion.

2. Health Educator

>is concerned with promoting health as well as reducing behavior-induced disease.

>in NCD prevention and control health education focuses in establishing or inducing changes in
personal and group attitudes and behavior that promote healthier living.
Aims:

A. Inform the people.

B. Motivate the people

C. Guide people in action

3. Health Care Provider

>as a care provider, emphasis of care is on health promotion ad disease prevention focusing on
promotion of rational diet and physical activity and cessation of smoking and alcohol drinking.

> action is directed towards the reduction of risk factors of NCD.

4. Community Organizer

>the ultimate goal of the PHN is community health development and empowerment of the
people. This is achieved by:

A. Raising the level of awareness of the community regarding NCD, its cause,prevention and
control;

B. Organizing and mobilizing the community in taking action for the reduction of risk factors;

C. Influencingexecutive and legistlative bodies to create and enforce policies that favor a
healthy environment

5. Health Trainer

>the PHN provides technical assistance in the assessment of the skills of auxiliary health
workers in NCD prevention and control

>teaching and supervision on clinical management of NCD and other community based
services and recording,reporting and utilization of health information related to NCD

6. Researcher

 is an integral part of a primary health care to NCD prevention and control program

 It is extricably related to community health practice since it provides the theoretical bases
for developing appropriate and responsive intervention program and strategies.

 the PHN conducts community assessments, epidemiological studies and intervention

studies.
II. CAUSES AND RIK FACTORS OF MAJOR NCDs

To be effective in preventing and controlling NCDs, the public health nurse need to understand
how NCDs develop and the risk factors associated with each disease,

A.) Diseases of the Heart and Blood Vessels(Cardiovascular Diseases)

1. HYPERTENSION

 is defined as a sustained elevation in mean arterial pressure

 it is not a single disease state but a disorder with many causes, a variety of symptoms, a
range of responses to therapy.

 it is also a major risk factor for the development of other CVDs like coronary heart disease
and stroke.

ETIOLOGY/Cause

A. Primary Hypertension

 has no definite cause

 Also called as eesential hypertension or idiophatic hypertension

 90% of hypertensive

 Is attributed to atherosclerosis

B. Secondary Hypertension

>is usually the result of some of the primary diseases leading to hypertension such as renal
diseases

RISK FACTORS

1. Family History

2. Age

3. High Salt Intake

4. Obesity

5. Excessive Alcohol Intake

KEY AREAS FOR PREVENTION OF HYPERTENSION

1. Encourage Proper Nutrition- reduce salt and fat intake

2. Prevent becoming overweight or obese

3. Smoking Cessation
4. Identify
people with risk factors and encourage regular check-ups for possible hypertension
and modification of risk factors.

2. CORONARY ARTERY DISEASE

Is a heart disease caused by impaired coronary blood flow. It is also known as Ischemic Heart
Disease.

Etiology/Cause

1. The most common cause is atherosclerosis.This is the thickening of the inside walls of the
arteries due to deposition of a fat like substance.

2. Diabetes Mellitus

Risk Factor of CAD

Modifiable

1. Elevated Blood Lipids and Cholesterol Lever( hyperlipidemia)

2. Hypertension

3. Smoking

4. Diabetes mellitus

5. Obesity

6. Physical inactivity

7. Stress

Non Modifiable

1. Family history

2. Male Sex

3. Increasing Age

KEY AREAS FOR PREVENTION OF HYPERTENSION

1. Promote regular physical activity and exercise

2. Encourage proper nutrition particularly by limiting intake saturated fats and salt intake
and increasing intake of dietary fiber

3. Maintain body weight and prevent obesity

4. Advised smoking cessation

5. Early diagnosis

4. CEREBROVASCULAR DISEASE OR STROKE

Is the loss or alteration of bodily function that result from an insufficient supply of blood in
some parts of the brain.It is one of the leading causes of disability. It can lead to weakness or
paralysis usually of one side of the body.

Eiology/Causes

1. There are three types of stroke based on cause

A. Thrombotic Stoke- usually occurs in atherosclerotic blood. This is usually seen in older
people and may occurs in person at rest

B. Embolic Stroke- it is cause by moving blood cloth usually from a thrombus in the left heart
that becomes lodged in a small artery through which it cannot pass. Its onset is usually sudden.

C. Hemorrhagic Stroke-the most fatal type of stroke that is due to intracerebral hemorrhage
that is rupture of intracerebral vessel.Othe cause of hemorrhage is aneurysms,trauma,erosion
of vessels by tumors,ateriovenous malformations and blood disorder.

2. Atherosclerosis

Risk Factor of Stroke

1. Increasing Age

2. Sex (Female)

3. Heredity(family History) and race

4. Hypertension

5. Cigarette Smoking

6. Diabetes Mellitus

7. Heart Disease

8. High Red Blood cell count

9. Season and Climate

10. Socioeconomic Factors

11. Excessive alcohol intake

12. Certain kind of drug abuse(iv drugs)

KEY AREAS FOR PREVENTION OF STROKE

1. Treatment and Control of HPN

2. Smoking Cessation and promoting smoke free environment.

3. Preventthrombus formation in rheumatic heart disease and arrhythmias with appropriate

medication.

4. Limit alcohol consumption

5. Avoid IV drug abuse and Cocaine

6. Prevent other risk factor of atherosclerosis

C. ) CANCER

 cancer is not a single disease. There are as many types of cancers as there are types of
tissues in the body.

 It is develops when cells in the part of the body begin to grow out of control.Normal body
cells grow,divide and die in an orderly fashion.During the early years of a person’s life,
normal cells divide more rapidly until the person becomes adult. After that, cells in the most
parts of the body divide onle to replace worn-out or dying cells and to repair injuries.

 Cancer cells, however,continue to grow and divide even when there is no need to do so.
Instead of dying, they outlive normal cells and continue to form new abnormal cells. They
compete with normal cells for the blood supply and nutrients that normal cells need thus
causing weight loss.

 Cancer cells often travel to other parts of the body where they begin to grow and begin to
replace normal tissue.This process is called metastasis.

CAUSES OF CANCER

1. Hereditary/Family History

2. Carcinogens

3. Environmental &Chemical Agents

4. Benzophyrene

5. Nitrosamines

6. Radiation

7. Viruses

RISK FACTORS OF CANCER

1. Age

2. Sex

3. Family Medical History

4. Cancer causing Factor in the environment

5. Lifestyle factors such as tobacco and alcohol use,diet and sun exposure

6. Differentkinds of cancer have different risk factors. Some of the major risk factors associated
with particular types of cancer include the following:

CANCER RISK FACTORS

Lung cancer  Tobacco use, including cigarettes,cigars,chewing tobacco
and snuff.
 Radiation Exposure
 Second-hand smoke

Oral Cancer  Tobacco use(cigarette,cigar,pipe,smokeless tobacco )

 Excessive alcohol use
 Chronic irritation(e.g. ill-fitting dentures)
 Vitamin A deficiency

Laryngeal Cancer  Tobacco use(cigarette,cigar,pipe,smokeless tobacco )

 Poor nutrition
 Alcohol
 Weakened immune system
 Occupational exposure to wood dust and paint fumes
 Gender 4-5 times more common in men
 Age:more than 60 years

Bladder Cancer  Tobacco use(cigarette,cigar,pipe,smokeless tobacco )

 Occupational exposure: dyes and solvents
 Chronic bladder inflammation

Renal cancer  Tobacco use(cigarette,cigar,pipe,smokeless

tobacco ):increase risk by 40%
 Obesity
 Diet:well cooked meat
 Occupational exposure:asbestos, organic solvent
 Age:50-70 years old

Cervical cancer  Tobacco use(cigarette,cigar,pipe,smokeless tobacco )

 Human papilloma virus infection
 Chlamydia infection
 Diet: low in fruits and vegetables
 Family history of cervical cancer

Esophageal cancer  Tobacco use(cigarette,cigar,pipe,smokeless tobacco )

 Gender:3 times more common in men
 Alcohol
  Diet: low fruits and vegetables

Breast cancer  Early menarche/late menopause

 Age-changes in hormone levels throughout life, such as
age at first menstruation, number of pregnancies, and age
menopause
 High fat diet
 Obesity
 Physical inactivity
 Alcohol consumption
 Women with mother or sister who have had breast cancer
are more likely to develop the disease


Prostate cancer  Race: more common among african-american men than

white men
 High fat diet
 Men with a father or brother who has had prostate cancer
are more likely to get prostate cancer themselves

Liver cancer  Certain types of viral hepatitis

 Cirrhosis of the liver
 Long term exposure to aflatoxin (carcinogenic substance
produce by a fungus that often contaminates
peanuts,wheat,soybeans,corn and rice)

Skin cancer  Unprotected exposure to strong sunlight

 Fair complexion
 Occupational exposure

Colonic cancer  Personal/family history of polyps

 High fat diet and low fiber diet
 History of ulcerative colitis
 Age:>50 years

Uterine/Endometrial cancer  Estrogen replacement therapy

 Early menarche/late menopause

KEY AREAS FOR PREVENTION OF CANCER

1. Smoking Cessation

2. Encourage proper nutrition

a.increase intake of dietary fiber by eating more leafy vegetables, fruits and unrefined cereals.
Beta-carotene,Vitamins A,C,E and dietary fiber potential have anti cancer substance

b. Eat less fat and fatty foods

c. Limit consumption of smoked,charcoal-broiled,salt-cured,and salt pickled foods

d. Avoid moldy foods

3. Drink alcoholic beverages in moderation

4. Avoid/Control obesity through proper nutrition and exercise

5. The sooner a cancer is diagnosed and treatment begins, the better the chances of living
longer.

D. ) DIABETES MELLITUS

It is not a single disease. It is a genetically and clinically heterogeneous group of metabolic

disorder characterized by glucose intolerance,with hyperglycemia present at a time of
diagnosis.

Etiology/Cause

2 Factors

A. Genetic Predesposition (diabetogenic genes)

B. Environment/Lifestyle (obesity,poor nutrition,lack of exercise)

TYPES OF DIABETES

A. Type I DM (insulin dependent diabetes mellitus -IDDM)

 Characterized by absolute lack of insulin due to damaged pancreas,prone to develop

ketosis, and dependent on insulin injections.

 Genetic,environment, or maybe acquired due to viruses( e.g. mumps,congenital rubella)

and chemical toxins(e.g Nitrosamines)

B. Type II DM (Non insulin dependent diabetes mellitus -NIDDM)

 Characterized by fasting hyperglycemia despite availability of insulin.

 Possible causes include impaired insulin secretion,peripheral insulin resistance and

increase hepatic glucose production.

 Usually occurs in older and overweight persons (about 80%)

RISK FACTORS OF TYPE II DM

 Family History of diabetes ( I.e.,parents or sibling with diabetes)

 Overweight(BMI 23 kg/m) and obesity (BMI>30kg/m)

 Sedentary Lifestyle

 Hypertension

 HDL cholesterol <35 mg/dl (0.90mmol/L) and/or triglyceride level >250mg/dl (2.28mmol/L)

 History of gestational diabetes Mellitus (GDM) or delivery of a baby weighing 9lbs (4.0 kgs)
 Previous identified to have impaired glucose tolerance (IGT)

COMPLICATION

ACUTE COMPLICATIONS

1. DiabeticKetoacedosis(DKA)-is a life-threatening problem that affects people with diabetes.

It occurs when the body starts breaking down fat at a rate that is much too fast. The liver
processes the fat into a fuel called ketones, which causes the blood to become acidic

2. Hyperosmolar Hyperglycemic nonketotic coma-is a metabolic complication of diabetes

mellitus characterized by severe hyperglycemia, extreme dehydration, hyperosmolar plasma,
and altered consciousness. It most often occurs in type 2 diabetes, often in the setting of
physiologic stress. Hyperosmolar hyperglycemic state is diagnosed by severe hyperglycemia
and plasma hyperosmolality and absence of significant ketosis. Treatment is IV saline solution
and insulin. Complications include coma, seizures, and death.

3. Hyperglycemia- is a metabolic complication of diabetes mellitus characterized by severe

hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered consciousness. It
most often occurs in type 2 diabetes, often in the setting of physiologic stress. Hyperosmolar
hyperglycemic state is diagnosed by severe hyperglycemia and plasma hyperosmolality and
absence of significant ketosis. Treatment is IV saline solution and insulin. Complications
include coma, seizures, and death.

CHRONIC COMPLICATIONS

1. Chronic Renal Disease (Nephropathy)

2. Blindness (Retinopathy)

3. Coronary Artery Disease

4. Stroke

5. Neuropathies

6. Foot ulcers

KEY AREAS TO PREVENT AND CONTROL DIABETES

 Maintain body weight and prevent obesity through proper nutrition and physical exercise

 Encourage proper nutrition

 Promote regular physical activity and exercise

 Advise smoking cessation for active smokers and prevent exposure to second hand
smoker.

C. )CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Is a disease state characterized by airflow limitation that is not fully reversible. The airflow
limitation is both progressive and associated with abnormal inflammatory response of the lungs
to noxious particles of gases.

The lungs undergo permanent structural change, which leads to varying degrees of hypoxemia
and hypercapnia. This explains the breathlessness and frequent cough associated with COPD.

CAUSES AND RISK FACTORS

It is usually due to chronic bronchitis and emphysema, both of which are due to cigarette
smoking, which is the primary cause of COPD.

DIAGNOSIS

1. Cough

2. Sputum production

3. Dyspnea

4. History of exposure to risk factors for the disease

5. Spirometry- confirmation diagnosis

COMPLICATIONS

A. Respiratory Failure -In advanced COPD, peripheral airways obstruction, parenchymal

destruction, and pulmonary vascular abnormalities reduces the lung’s capacity for gas
exchange, producing hypoxemia, and,later on, hypercapnia.

B.Cardiovascular disease -Pulmonary hypertension, which develops late in the course of severe
COPD where it is the major cardiovascular complication in COPD and is associated with the
development of cor pulmonale.

E) BRONCHIAL ASTHMA

It is an inflammatory disorder of the airways in which many cells and cellular elements play role.

Chronic inflammation causes an associated increase in airway hyperresponsiveness that leads

to recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at
night or in early morning.

CAUSES AND RISK FACTOR

Asthma development has both a genetic and environmental component.

A. Host factors: predispose individuals to or protect them from developing asthma

 Genetic Predisposition
 Atopy or Allergy

 Airway hyperesponsiveness

 Gender

 Race/ethnicity

B. Environmental factors: influence susceptibility to development of asthma in predisposed

individual, precipitate asthma exacerbations and/or cause syptoms to persist

 Indoor allergens

 Outdoor allergens

 Occupational sensitizers

 Tobacco smoke

 Air pollution

 Respiratory Infections

 Parasitic infections

 Socioeconomic factors

 Family size

 Diet and Drugs

 Obesity

ASTHMA TRIGGERS

 Irritant gases

 Smoke

 House dustmite found in the pillows, mattresses, carpets

 Respiratory Infection

 Inhaled allergens

 Weather changes

 Cold air

 Exercise

 Certain foods, additives and drug

KEY AREAS FOR PRIMARY PREVENTION AND EXACERBATION OF ASTHMA

a) Recognized triggers that exacerbate asthma

b) Avoid the triggers if possible, particularly smoking

c) Promote exclusive breastfeeding as long as possible,early introduction to cow’s milk may

predispose baby to allergies and possible asthma.

III.RISK ASSESSEMENT AND SCREENING PROCEDURE

A. Cigarette smoking- assess smoking status by asking individuals whether they are smoking
or not. In order to monitor trends, collect information not only on smoking status but also on age
of onset, amount smoked by current and former smoker and quit attempts.

B.Nutrition/ Diet
The following question should be ask to determine the contribution of the patient’s nutrition to
NCD development. These include:

VEGETABLES
Number of serving per day and usual types

FRUITS
Number of serving of fruits per day

FAT
 Number of serving og meat and poultry
 Which part(e.g. skin chicken)
 How often fried foods are eaten
 How often fast food/restaurant are visited

SODIUM/SALT
 How often preserved,canned and instant foods are eaten per week
 How much is added when cooking food

GUIDELINES FOR ADEQUATE VEGETABLES AND FRUITS INTAKE

 Eat 2-3 servings of vegetables per day, one serving of which is green or yellow leafy
vegetables. One serving means:Raw Vegetables 1 cup, Cooked vegetables 1/2 cup

 Eat at least 2 serving of fruit per day, 1 serving is a Vitamin C rich fruit. One serving
depends on type of fruits.

C.OVERWEIGHT/OBESITY

Body fat can be best assessed using Body MAss Index (BMI) and Waist circumference (PASSO
recommendations, 2000).

 BMI correlates closely with total body fat in relation to height and weight

BMI= Weight in Kgs /(Height in meters) 2

Guidelines:Based on Asia-Pacific Obesity Guidelines

 BMI INTERPRETATION
< 18.5 UNDERWEIGHT
18.6-22.9 HEALTHY WEIGHT
>23.0 OVERWEIGHT
23.0-24.9 AT RISK
25.0-29.9 OBESE I
>30.0 OBBESE II

 Waist Circumference- this alone is an accurate measure of the amount of visceral fat.
Remember that central obesity is a significant risk factor to heart disease and stroke.

Measuring Waist Circumference

Procedure: Subject should be unclothed at the waist, and standing with abdomen relaxed, arms
at the side,feet together.Use nonstretchable tape measure and do not compress the skin.

Clinical Thresholds:

Men <90cm(35 inches)

Women <80 cm (31.5 inches)

* Greater than these value is not normal and person is at risk even is BMI is normal.

DEGREE OF RISK BASED ON THE BODY MASS INDEX AND WAIST CIRCUMFERENCE

Classification BMI Waist Circumference (cm)

Men <90 >/=l90
Women<80 >/= 80
Underweight <18.5 Low but increased risk
of other clinical Average
problem
Normal 18.6-22.9 Average Increased
Overweight >/=23 Increased Moderate
AT RISK 23.0-24.9 Moderate Severe
OBESE I 25.0-29.9 Severe Very Severe
OBESE II >30.0

Waist Hip Ratio(WHR)- Another useful measure of obesity is the waist-to-Hip ratio. It is
obtained by dividing the waist circumference at the narrowest point of the hip circumference at
the widest point.

WHR= Waist Circumference (cm)

Hip Circumference (cm)

WHR INTERPRETATION

 Less than1.0 (men);less than 0.85(women) normal

 Equal to or greater than 1.0 (men) and 0.85 (women)=android or central obesity

D.PHYSICAL INACTIVITY/SEDENTARY LIFESTYLE

Assessment of physical activity includes information on type of work, means of transportation

and leisure-time activities like sports and formal exercise.

Minimum recommended amount of physical activity needed to achieve health benefit

(USDHHS, 1996)

Regular Physical Activity: MInimum 30 mins. Per day,most days of the week preferably

If moderate Intensity: 5 or more days of the week

If vigorous Intensity: 3 or more days of the week

Guideline: At least 30 mins of comulative physical activity moderate in intensity for more
days of the week.

E.EXCESSIVE ALCOHOL DRINKING

 Asses habitual alcohol intake and risky behavior, such as driving or operating machinery
while intoxicated. It is important to quantify the amount of drinking.

Question to ask on amount of alcohol intake.

1. In the past month, how many times did you have 5 drinks or more in one occasion?

2. In the past month, did you drive a vehicle when you perhaps had too much drink?

3. In the past month, did you operate a machinery when you perhaps had to much drink?

 Find out also specific type of beverage. Knowing the standard drink will determine the
ethanol content and volume
Type of Alcoholic Amount % Ethanol Content Amount of Ethanol
Beverages
BEER 1 glass/can/bottle 3% 10gms
(350ml)
WINE 1 glass (100ml) 10% 10gms
DISTILLED SPIRIT 1 glass (40ml) 25% 10gms
SCREENING GUIDELINES AND PROCEDURE

 According to WHO, screening is the “presumptive identification of unrecognized disease or

defect by the application of test, examination or other procedures which can be applied
rapidly.”

 The primary goal of screening is to detect a disease in its early stages to be able to treat it
and prevent further development of the disease.

 Screening is not a diagnostic measure, but it is a preliminary step in the assessment of the
health individual chances of becoming unhealthy.

 The Department of Health (DOH) recognizes certain lifestyle diseases that can be screened
in risk prone individuals and groups.

A. Screening of Hypertension

Hypertension is defined as sustained systolic BP 140 mm Hg or more and sustained DBP of 90

mm Hg or more based on measurement done during at least 2 visits taken at least 1 week a
part.

Criteria for Diagnosis

CLASSIFICATION OF BLOOD PRESSURE (BP)*(JNC 7 REPORT)
CATEGORY SBP MMHG DBP MMHG
Normal <120 and <80
Prehypertension 120-139 or 80-89
Hypertension, STage I 140-159 or 90-99
Hypertension, Stage2 >/=160 or >/= 100
Key: SBP-Systolic blood pressure DBP- diastolic blood pressure

GUIDELINES FOR ACCURATE MEASUREMENT OF BP

The most accurate and reliable technique for indirect BP measurement is the auscultatory
method using a mercury manometer. If you use an aneroid BP apparatus, make sure that the
needle points to zero(0) and that is correctly calibrated(recalibrate at least every 6 months)
B. SCREENING FOR ELEVATED CHOLESTEROL IN THE BLOOD

 The recommended screening test for cholesterol is taking small blood sample and testing
total cholesterol. Prior to testing, make sure that the person has not eaten any food nor
taken any drinks containing caloriesfor at least 8 hours. Drinking water is acceptable.
 If possible, low density lipoprotein(LDL) and high density lipoprotein(HDL) should also be
taken.Otherwise, the total cholesterol will be enough for screening.

RECOMMENDED GUIDELINES
Cholesterol Level Interpretation Frequency of test
<200 mg/100ml Normal Repeat every 5 years
200-239 mg/100 ml Elevated Repeat test,take average of
(Maybe at risk) both test
240mg/100ml and above Elevated Further test (lipid profile and
(at risk) treatment)

C. SCREENING FOR DIABETES MELLITUS

 The hallmark of diagnosis of DM is the presence of hyperglycemia.
 To screen for possible DM, the following is recommended

ASKI
For adults 20 years and older
 Family History of diabetes
 Symptoms of diabetes
 Polyuria increased and frequency and amount of urination
 Polydipsia increased thirst
 Unexpained weight loss

 If at special Risk for diabetes

 Hypertensive
 Overweight
 Women who have delivered a baby weighing over 9lbs.
 Women who have been diagnosed with gestational diabetes

For those with family history and symptoms of DM, advised blood test for serum or plasma
glucose

Fasting Blood Sugar(FBS)- fasting is defined as no caloric intake for at least eight hours;this
include no food, juices,milk;only water is allowed.
109 mg %- Normal
110-125 mg%- Impaired Glucose Tolerance (IGT)
126 mg%- Possible DM
Two-hour Blood sugar test- Performed two hours after using 75g glucose dissolved in water
or after a good meal
Oral Glucose Tolerance Test (OGTT) is not recommended for routine clinical use nor screening
purposes.

Criteria for Diagnosis of Diabetes Mellitus

Any of the following:

1. Symptoms of DM plus RBS >200 mg/dl (11.1 mmol/L)
2. FBS > 126 mg/dl (7.0mmol/L)
3. Two hours Blood Sugar >200 mg/dl (11.1 mmol/L) during an OGTT
Repeat testing on a different day should be done to confirm these criteria
SOURCE:Compendium of Philippine Medicine, 2000

D. SCREENING FOR CANCER

 Early detection and prompt treatment are keys to curing cancer (Note: “cure rate” in cancer
is relative and depends on the type of cancer. The earlier the cancer is detected, the more
likely it is to be cured.

 The acronym “CAUTION US” (American Cancer Society) provides a systematic way of
remembering the cancer Warning Signals.

C hange in bowel or bladder habits

A sore that does not heal

U nusual bleeding or discharge

T hickening or lump in the breast or elsewhere

I ndigestion or difficulty in swallowing

O bvious change in a wart or mole

N agging cough or hoarseness

U nexplained anemia

S udden weight loss

SPECIFIC GUIDELINES FOR EARLY DETECTION OF COMMON CANCERS

CANCER WARNING SIGNS EARLY DETECTION

BREAST  Skin Changes  Breast self-examination-
 Nipple abnormalities the best time to do BSE is
one week after menstrual
  Abnormal Contours period
 Breast mammography

 Suggested for all women

35-39 years old
 Yearly mammogram at the
age of 40
 30 yrs old- w/ family
history

CERVICAL  Often Asymptomatic Pap’s Smear is the primary

 Abnormal Vaginal Bleeding screening for women over age
 (e.g. post coital bleeding) 18

Colon Rectal  Change in stool  Annual digital rectal exam

 Rectal Bleeding starting at age 40
 Pressure on the rectum  Annual stool blood test
 Abdominal Pain starting at age 50
 Annual inspection of colon

Prostate Symptoms of urethral outflow obstruction:  Digital Rectal Exam for

men
 Urinary Frequency  Prostate specific antigen
 Nocturia (PSA) determination a
 Decrease in stream blood test,confirms
 Post-void dribbling diagnosis

Lung  Persons with a long history of smoking  Chest x-ray every 6

and/or smoking two or more packs of months for patients who
cigarette per day have history of smoking
 Chronic cough or nagging cough two packs per day
 Dull intermittent, localized pain  Sputum cytology
 History of weight loss

E. Screening for COPD

SPIROMETRY is done to determine degree of obstruction. Through SPIROMETRY, the client

can be categorized as having restrictive,obstructive or mixed pattern of ventilatory defect.
Sprirometric values varies on age,height,sex and race.

Suspect COPD in the person with the following:

 50 years old
 Smoking for many years
 With symptoms of progressive and increasing shortness of breath on exertion, and/or
 Chronic Productive cough

F. Screening for Asthma

 The hallmark of asthma is demonstration of reversibility of airway obstruction.

 Spirometry can aid diagnosis
 But this also can be achieved by measuring PEAK EXPIRATORY FLOW RATE(PEFR)
Using a PEAK FLOW METER before and after using a bronchodilator. Obstruction is reversed if
improvement is 15% or >200 ml.

ROLE OF THE PUBLIC HEALTH NURSE IN RISK ASSESSMET AND SCREENING

1. Educate as many people and in every opportunity on the warning signs of NCDs and other
risk factors.
2. Educate people on how to prevent the NCD risk factors through a healthier diet, engaging in
moderate physical activity and not smoking
3. Every client not only the patient seeking consultation, should be assessed for the presence of
risk factors and early signs of NCD. This include the mother bringing her new born infant for
immunization, the grandmother or aunt bringing a sick child for consultation or members of the
household during home visit.
4. Train other health worker, even the barangay health workers and barangay nutrition scholar
on performing risk factor for assessment. It will be a good to periodically check their skills as
well like BP taking, measurement of height and weight, using BMI table.

When Risk factor are present:

1. Confirm advise retesting if needed and frequency of retesting
2. Explain the significance of the finding and that this can contribute to development of disease
if not controlled.
3. Educate on how to modify risk factors and promote positive lifestyle changes
4. Monitor and follow up based on recommended schedule
5. Refer for confirmation of diagnosis specially if screening was done by a non doctor to a
medical specialist or center if condition warrants specialized diagnosis and treatment.

IV PROMOTING PHYSICAL ACTIVITY AND EXERCISE

 Sedentary Lifestyle, a life spent with little or no physical activity, has grave consequences to
ones health.

Health Benefits of Regular Physical Activity

 Reduces the risk of dying from Coronary Heart Disease
 Reduces the risk of second heart attack
 Lowers both total blood cholesterol and triglycerides and may increase high density
lipoprotein (HDL or the “good” cholesterol)
 Lower the risk of developing high blood pressure
 Lower the risk of developing non-insulin dependent (Type II) DM
 Reducing the risk of developing colon cancer
 Helps people achieve and maintain a healthy body weight
 Reduces feeling of depression and anxiety
 Promotes psychological well being and reduces feeling of stress
 Helps build and maintain healthy bones, muscle and joints
 Helps older adults become stronger and better able to move about without falling or
becoming excessively fatigue

UNDERSTANDING PHYSICAL ACTIVITY AND EXERCISE

PHYSICAL ACTIVITY - is something done at home, like washing the dishes, sweeping the floor
and cleaning the house. It is also what is done outside the house, like sweeping or raking the
leaves in the yard or gardening or walking in the neighborhood. It is something that one might
be avoiding doing in the office, like instead of climbing the stairs one takes the elevator.
EXERCISE- is a “planned, structure and repetitive movement done to improve or maintain one
or more components of physical fitness. It involves energy expenditure and planning.Walking or
jogging for three kilometers each day or regular aerobic class 3 times a week is structured
exercise.

The minimum amount of physical activity required for health benefits can be achieved through:
 At least 30 minutes,cumulative,of moderate intensity(e.g. walking briskly,dancing,swimming
or bicycling on level terrain.),most day of the week, or
 At least 30 minutes cumulative, of vigorous intensity(e.g. jogging,chopping woods,swimming
continuous laps,or bicycling uphill) 3 or more days of the week

ROLE OF PUBLIC HEALTH NURSE

 The public health nurse plays a big role in motivating individuals and groups to prevent
living sedentary lifestyle that increase their risk to NCD.
 She has the responsibility of increasing their knowledge and skills needed to engaged in
physical activities and exercise as well as motivating them enough to start being physically
active and to encourage them to maintain this behavior.

D. PROMOTING PROPER NUTRITION

 Eating balanced diet is important to health.
 Studies prove that following nutrition guidelines can prevent major non-communicable
diseases.
 Diets high in calories and fats are known to increase the risk of atherosclerosis (disease of
the arteries characterized by the deposition of plaques of fatty material on their inner
walls.)leading to cardiovascular diseases
 Diets low in fiber and complex carbohydrates are known to increase the risk of cancer and
diabetes.
 Following the nutrition guidelines of low salt, low fat and increased fiber in diet heps
decrease the risk.

Strategies to promote Healthy Nutrition-related practices

 Aim for ideal body weight

 Build healthy nutrition related practices
 Choose foods wisely

National Guidelines for Filipinos

1. Eat a variety of foods everyday
2. Breast-feed infants exclusively from birth to 4-6 months, and then,give appropriate foods
while continuing breast-feeding.
3. Maintain children’s normal growth through proper diet and monitor their growth regularly.
4. Consume fish, lean meat, poultry or dried beans
5. Eat more vegetables, fruits and root crops
6. Eat foods cooked in edible/cooking oil daily
7. Consume milk, milk products and other calcium-rich foods such as small fish and dark green
leafy vegetable everyday.
8. Use iodized salt but avoid excessive intake of salty foods
9. Eat clean and safe foods
10. For a healthy lifestyle and good nutrition, exercise regularly, do not smoke and avoid
drinking alcoholic beverages.

Role of Public Health Nurse

1. Educate as many people as possible particularly mothers, teachers and food handlers on
balanced and healthy diet.
2. Assess or weight problems and unhealthy nutrition-related practices.
3. Screen for other risk factors related to nutrition, such as blood cholesterol level and
hypertension.
4. For person found to be at risk of NCD, advise and counsel for risk modification.
5. Make referrals where appropriate
6. Advocate for a supportive environment where healthy food is available and affordable.

Nutrition Assessment
 Nutrition counseling starts with proper assessment. There are direct measures (BMI, waist
circumference,and waist-hip ratio) and indirect measurement (24 hour food recall method- it
involves asking the client the type and specific amount of food eaten in the previous 24 hrs.)
for nutritional status.

Nutrition Education and Counseling

 Providing nutrition education to individuals and groups whenever possible is an important
responsibility of the nurse. This includes clients who are well, at risk or even with disease.
Target groups for nutrition education includes mothers, food handlers and food service o
influence other like teachers, day care workers,community and civic leaders will also
achieve a lot in pushing for lifestyle changes.
 It is also not enough to perform risk assessment and screening of individuals.Whenever
screening is done, there is ethical responsibility to assist and provide support to individuals
who turn out to be at risk or positive for disease. One intervention is to provide proper
nutrition counseling.

Promoting Supportive Environment for Healthy Nutrition

The environment plays a major role in influencing nutrition related behavior,particularly in the
availability and access to healthy food

Encourage Vegetable Garden

Advise people to have plots in their backyard. Aside from being a healthy outdoor activity. It
would provide the cheapest and most accessible source of fruits and vegetables.

Campaign for Nutrition-friendly environment

 Encourage selling of farm products produced in the area, making sure they are fresh and
safe. Fresh foods are usually more nutritious and safe from all the chemical additives
present in processed foods.

Advocate for Healthy Policies for nutrition

 Some of these policies include prohibiting drinking alcoholic beverages
 Providing healthy foods options and limiting availability of soft drinks and junk foods in the
school canteen and prohibiting students from buying from street vendors during break.
 Health workers play the key roles in advocating and influencing school and local
government official.

VI. PROMOTING A SMOKE-FREE ENVIRONMENT

Smoking: A Serious Problem

 Of all major factors that lead to the development of NCDs,smoking is the most common and
poses significant danger to the health of most people.
 The danger is not only to those who are active smokers, but also those who are exposed to
second hand smoke.
 Scientific evidence has shown that smoking is related to at least 40 diseases and 20 types
of cancers.
 Smoking carries special risks for pregnant women and fetus such as miscarriages and
sudden infant death syndrome.

How Smoking Causes Harm

 Development of smoking-related diseases and mortality is dose-related. This means that
the more chemicals and toxins inhaled, the greater the risk.

Specifically, this is associated with:

 Number of cigarettes smoked
 Duration of smoking
 Age started smoking
 Pattern of inhaling

Harmful Substances in Tobacco

TAR- The particulate matter left when water and nicotine are removed from cigarette smoke,
contain hydrocarbons and other carcinogenic substances. Tar is deposited in lung passages,
paralyzes the cleaning mechanisms (cilia) and damages the air sacs (alveoli).

NICOTINE- also particulate, causes release of epinephrine and nor epinephrine,resulting to

arrhythmia, increased heart rate,blood pressure,cardiac output,stroke volume, contractility,
oxygen consumption and coronary blood flow.

CARBON MONOXIDE- may produce hypoxia of the intima and increase endothelial
permeability. It also reduces the oxygen-carrying capacity of the blood because it competes with
oxygen and has a greater affinity for hemoglobin.

The Good News: Quitting Can Reduce Risk

 For smoking-related deaths from CAD, lower death rates are reported in persons who quit
smoking than in persons who continue to smoke.
 Men under age of 65 years who stopped smoking reduced their risk by 50%.
 10 years of not smoking,the risk of death in CAD approaches that of a non smoker.

Role of the Public Health Nurse

1. Assisting smokers to quit

 For active smokers, motivate and assist them to quit.
 Advise them also to avoid smoking inside the house or enclosed areas to prevent exposing
people from second-hand smoke

Smoking Intervention Guidelines

 Every persons who smokes should be counseled on smoking on every visit to the
physician’s office. Maintenance of cessation should be frequently discussed with patients
who have quit.
 Every patient should be asked about tobacco use; smoking status should be recorded and
updated at regular intervals.
 Cessation interventions as brief as 3 minutes are effective, with more intensive intervention
being more effective.
 Clinicians should receive training on patient-centered counseling method.
 Office system that facilitate the delivery of smoking cessation intervention should be
established
 Links with other personnel and organizations should be established to provide smoking
cessation intervention (nurses,smoking cessation specialists,multiple risk factor intervention
programs, community resources.)

Strategies in Helping Smokers to quit

WHO has a simplified recommendation that any health worker can apply readily to any client
and any setting. This involves the 4 “As” in helping the smokers to quit.

A- ASK
Step 1- Assess smoking status. Identify all tobacco users at every visit

A- ADVISE TO STOP SMOKING AND THAT SMOKING CAN CAUSE DISEASE,EVEN

DEATH

Step 2- Target clients’ motivation to quit

Step 3- Encourage complete cessation
Step 4- Discuss alternatives and substitutes to smoking.

A- ASSIST

Step 5- Develop a quit plan with the smoker. Set a QUIT DATE
Step 6- Provide supplementary materials to assist the smoker
Step 7- Develop a plan to prevent relapse

A- ARRANGE FOLLOW-UP
Step 8- Set follow-up sessions to monitor progress and prevent lapses

2. Promoting Smoke-free Environment

WHO established four pillars for successful anti-tobacco programs. These four pillars may be
categorized into two simple words: education and legislation
1. Aggressive health information dissemination combined with comprehensive advertising bans
on tobacco products;
2. Government-supported and multisectoral programs to encourage and help smokers break
free of their addiction to smoking;
3. Building anti-tobacco coalitions to helps governments, individuals and sectors to rid tobacco
from their systems;and
4. The taxation of tobacco products to create an economic disincentive for the buying of higher
priced cigarettes.

The passage of the Tobacco Regulation Act in 2003 is a landmark legislation in the country
against tobacco use. It declared enclosed places and public utilities as no smoking area, limiting
access of children and youths to cigarettes (prohibiting sale of cigarettes to minors and selling
cigarettes within 50 meters of schools.)prominent labeling of cigarettes warning users of the
danger of smoking, and limiting/banning tobacco advertisements and sponsorships of activities
directed to children and youths.

VII. PROMOTING STRESS MANAGEMENT

 Stress is any change that one must adopt to, ranging from the negative extreme of physical
danger to exhilaration of falling in love or achieving some long desired success. And in
between, day to day living confronts even the most well managed life with continuous
 stream of potentially stressful experiences.Thus, stress is not only inevitable and essential
but also normal part of life. However normal does not necessary mean healthy.
 Stress triggers hormones that change the way the body works and feel. These are nature’s
way of helping the person cope with perceive threats.However, some cope with stress by
behaving in a way that is unhealthy,like drinking smoking or overeating, this is the reason
why it is important to manage stress appropriate in order to avoid the unhealthy effect of in
appropriate coping mechanisms.

Stress Management Technique

1. Spirituality - is a state or quality of being spiritual. It is pure, holy, relating to matters of

scared nature, not worldly, ecclesiastical, possessing the nature or qualities of a spirit.
- Meditation is the way of reaching the world beyond the senses.
2. Self Awareness- means knowing one’s self, getting in touch with one’s feeling or being open
to experiences. It increases sensitivity to inner self and relationship with the world around
3. Scheduling: Time Management- managing time really refers to managing one’s self in such
a way as to optimize the time available in order to achieve gratifying result.
4. Siesta- taking a nap, short rest, a break or recharging a “battery” in order to improve
productivity. It helps relax the mind and body muscles.
5. Stretching- it is a simple movements performed at a rhythmical and slow pace executed at
the start of a demanding activity to loosen muscle, lubricates joints, and increase body’s oxygen
supply.
6. Sensation technique- massage helps to soothe away stress, unknotting tensed and aching
muscle.
7. Sports- it relieves stress and gives the body the exercise it badly needed.
8. Socials- socialization plays a very important role in the development of interpersonal
relationships. On the contrary without socialization life will be boring and empty.
9. Sounds and Songs- It provides a medium of expression for thoughts and emotions. It is also
a way to relieve tension.
10. Speak to Me- communication is the means by which people make their needs known. It is a
way they obtain understanding, reinforcement and assistance from others.
11. Stress Debriefing- Critical Incident Stress Debriefing means to assist crisis workers/team
member to deal positively with the emotional impact of a severe event/ disaster and to provide
education about current and anticipated stress responses, as well as information about stress
management.
12. Smile- it is an expression of pleasure. It has found out through research that it relieves all
kind of stresses,physical or mental. It is also considered one of the ingredients or factors that
motivates and encourage people to work harder and improve their level of performance in
anything they do.