COMMUNITY HEALTH NURSING

Primary Goal in CHN:

- To promote self-reliance: autonomy and independence

- Health in the Hands of the People

Ultimate Goal in CHN:

- To raise the level of health of the citizens

- To raise OLOF
- Raise Health Citizenry

COMMUNITY

1. Social group of people

2. Interacting with each other
3. Determined by geographic boundaries
4. Living together
5. To attain certain and common goals and share same interest

CHARACTERISTICS OF HEALTHY COMMUNITY

H- as strong and reliable governing body

C- oncerned with own health status (members)
O- ught to work together to attain independence
M- embers aware of their own health and biologic status
M- embers give credit to governing authority
U- nited to attain Health Citizenry
N- atural and biologic resources are open to all but consumption is controlled
I- ntended environmental and physiologic needs are sustained by communities and families
T- he health needs are accessible and affordable to the public and free for the indigent
Y- outh have parents and guardians as role models

TYPES OF COMMUNITY

A. URBAN/ CITY
- High view of health
- Industrialized community
- More than 200,000
- More people, less space

B. RURAL/ OPENLANDS
- Low view of health
- Agricultural community
- Less than 200,000
- Less people, more space

C. SUBURBAN/ RURBAN/ CAPITAL

- Mixed type
- Rural setting with urban amenities

HEALTH

1. Optimum Level Of Health (OLOF)

2. State of complete physical, mental and social well-being and not merely the absence of disease (WHO, 1995)

10 Determinants of Health

GGPIEEPSCH

G- enetics
G- ender
1
P- hysical environment
I- ncome and social status
E- ducation
E- mployment
P- ersonal coping and behavior
S- ocial support network
C- ulture
H- ealth services

*6 Determinants of Health

Socioeconomic Low income= high illnesses; high income= drug abuse and lifestyle problems
Political Safety, oppression, people empowerment
Healthcare Delivery System Primary Health Care
Heredity Genetically-acquired diseases
Behavioral Lifestyle habits shaped by culture
Environmental Pollution, man-made diseases

NURSING

1. Art and science of rendering care

2. An act of assisting the sick and the well

Margaret Shetland

- Upholding the worth and dignity of man

- Philosophy of CHN

WHO

- CHN is combination of nursing skills, sociology and public health nursing

Ruth B. Freeman

- CHN is a service rendered by professional nurse to individuals, families and communities at home, health centers,
clinic, school and workplace for health promotion and disease prevention, care of the sick at home and
rehabilitation

Dr. Charles Edward Amory Winslow

- CHN is an art and science of prolonging life, preventing disease and promoting health

Dr. Araceli S. Maglaya

- CHN is utilization of nursing process

Lilian Wald

- Coined the term public health nursing

***POINT TO REMEMBER!

▪ Community- primary client in CHN

▪ Individual- point of entry in CHN
▪ Population- group of people with distinct way or pattern of life

Definition of Terms:

1. Public Health Nurse

- Refers to nurses at local or national departments whether their position is Public Nurse, Nurse or School Nurse

2. Public Health Nursing

- Community health nursing practiced in the public sector

LEVELS OF CLIENTELE:

2
I- Individual
F- Family
P- Population/ Aggregates
C- Community

A. Individual
- Entry point in CHN
- Groundwork
▪ Atomic- Biologic Being
▪ Holistic- mind, body and spirit

B. Family
- Bounded by BBAME
- B (blood)
- B (birth)
- A (adoption)
- M (marriage)
- E (emotions)

▪ B- Basic unit of society

▪ F- Focus of care
▪ U- Unit of service

Types of Family:

1. Nuclear- mother+ father with children only

2. Extended- family + relatives
3. Blended- previous relationship
4. Intergenerational- composed of 2 or more
- Lola sa tuhod
- Apo sa tuhod
5. Cohabitational- live in
6. Dyad- father and mother with no child

Types of Family:

1. Patrifocal- father is the head

2. Matrifocal- mother is the head
3. Consanguineal family- blood relationship
4. Conjugal- consisting of father, mother and children who are under-aged or unmarried

C. Community
- Primary client in the community
- Focus of CHN or patient in CHN
- Note:
1. Municipal- MAYOR
2. Provincial- GOVERNOR

*Always remember!

⮚ Focus- health promotion

⮚ Primary responsibility- health education
⮚ Right documentation- fundamental hallmark of nursing responsibilities
⮚ Role of nurses in CHN- Facilitator, Assistant, Teacher
⮚ Role of People- Leader

D. Group/ Aggregate
- Distinct way or pattern of life
- Share common developmental stage
- Share common characteristics
- Share common exposure to health problems
- Example: elderly

NOTE: In CHN, the client is considered as an ACTIVE partner NOT PASSIVE recipient of care
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 - Most of the clients are healthy

PUBLIC HEALTH NURSING

- Term used before for community health nursing

PUBLIC HEALTH as science and art by Dr. CEA Winslow:

3 P’s:

⮚ Promotion of health
⮚ Prevention of disease
⮚ Prolonging of life

Goal: To enable every citizen to realize his birth right of health and longevity

***Objectives of Public Health: “CODES”

C ontrol of Communicable Diseases

O rganization of Medical and Nursing Services
D evelopment of Social Machineries
E ducation of IFC on personal Hygiene→ Health Education is the essential task of every health worker
S anitation of the environment

CORE BUSINESS OF PUBLIC HEALTH (“DIHHP”)

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

OTTAWA CHARTER ON HEALTH PROMOTION (1986)

- Defines health promotion by enabling people to control over or improve health

Prerequisites of Health (FEE IS PASS)

F- ood
E- ducation
E- quity
I- ncome
S- helter
P- eace
A- Stable ecosystem
S- ustainable resources
S- ocial justice

Foundations of Health Promotion/ 3 Basic Strategies (MAE)

M- ediate
A- dvocate
E- nable

5 Basic Actions (BCSDR)

Build public health policy

Create supportive environment
Strengthen community action
Develop personal skills
Reorient health services

JAKARTA DECLARATION ON HEALTH PROMOTION (1997)

4
5 Priorities on Health Promotion

1. Promote social responsibility on health

2. Increase investment on health development
3. Consolidate and expand partnership in health
4. Increase community capacity and empower individuals
5. Secure infrastructure in health promotion

TARGET POPULATION

I- Individual
F- Family
P- Population
C- Community

ROLES OF THE PUBLIC HEALTH NURSE

1. Clinician, who is a health care provider, taking care of the sick people at home or in the RHU
2. Health Educator, who aims towards health promotion and illness prevention through dissemination of correct
information; educating people
3. Facilitator, who establishes multi-sectoral linkages by referral system
4. Supervisor, who monitors and supervises the performance of midwives
5. Researcher- collects data
6. Trainer- trains newbie
7. Manager- Planning, Organizing, Staffing, Directing, Controlling
8. Leader- influences people
9. Coordinator- outside health team
10. Collaborator- within health team
11. Advocate- protects rights
a. Assess needs
b. Offer alternative
c. Support decision
d. Influence healthcare team

*3 Elements considered in CHN:

# Science of Public Health (core foundation in CHN),

# Public Health Nursing Skills and
# Social Assistance Functions

TYPES OF PRIMARY HEALTH WORKERS

***Depends on the following: PAL

P- political and financial feasibility

A- Availability of health manpower resources
L- local health needs and problems

***Three Levels:

Level I: Village/ Grassroots - Non- professionals

- With honorarium only

Trained community health workers

Health auxillary volunteer
Trained hilots
Barangay health volunteers
Barangay health workers

Level II: Intermediate - Professionals

- Refer to 8 PHW below

Level III: First Line Personnel Specialists

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PUBLIC HEALTH WORKERS (PHW) PHW’s: are members of the health team who are professionals namely

1. Medical Officer (MO)-Physician

2. Public Health Nurse (PHN)-Registered Nurse
3. Rural Health Midwife (RHM)-Registered Midwife
4. Dentist
5. Nutritionist
6. Medical Technologist
7. Pharmacist
8. Rural Sanitary Inspector (RSI)-must be a sanitary engineer

LEVELS OF HEALTH CARE

PRIMARY SECONDARY TERTIARY

WHO? Healthy High-risk Post-treatment
HOW? Health education Early screening and treatment Rehabilitation
Discharge instructions
Maintenance medications
Palliative/ Supportive care
WHY? Health promotion Prevent complications Prevent further complications
Disease prevention

Examples:

1. Sex education among youth

2. Breastfeeding classes to mothers
3. Operation Timbang
4. Management of Epidemics
5. Conducting sputum microscopy
6. Male circumcision
7. Use of mosquito nets and repellants
8. Colostomy support group
9. Passive ROM exercises for trauma patient
10. Crutch walking
11. Teaching how to use a condom
12. Belly dancing for middle-aged people
13. Surgical hand washing
14. Establishing youth clubs and mothers’ organizations
15. Teaching self- injection method to a diabetic client
16. Conducting epidemiologic investigation to identify the extent of spread of disease
17. Catheterization of a client to promote urinary elimination
18. Pap smear
19. Self- breast examination for a woman with family history of breast cancer
20. Chemotherapy for a cancer patient

LEVELS OF HEALTHCARE SERVICES

PRIMARY SECONDARY TERTIARY

Private practitioners Emergency Regional hospitals
Lying-in District Medical centers
Peuriculture centers Provincial General hospitals
Rural health unit City National health services
Community health centers Specialized units
Barangay health stations

REFERRAL SYSTEM

BHS by Registered Midwife

RHU by Registered Nurse

MHO (Municipal Health Office)

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PHO (Provincial Health Office)

RHO (Regional Health Office)

NATIONAL AGENCIES

SPECIALIZED AGENCIES

*Provincial Government versus Municipal Government

Provincial Government Municipal/ City Government

Chairman: Governor Chairman: Mayor
Vice- chairman: PHO Vice- chairman: MHO/CHO
Manages secondary Manages primary

*Rural Health Unit versus Barangay Health Station

Rural Health Unit Barangay Health Station

Within municipality of 5,000 population Strategic area 3-5 km away from RHU
Complete health team Rural midwife only
Managed by Municipal Health Office Acts as a satellite station

DEPARTMENT OF HEALTH

Secretary: Dr. Paulyn Jean B. Rosell- Ubial

***Roles and Functions by EO 102 (LEA)

Leadership in health - National policy and regulatory institution

- Plans, monitors and evaluates health services

Enabler and capacity builder - Innovates new strategies in the implementation of healthcare

Administrator of specific services - Administer health services

- Manages all health institution from primary to tertiary

***Primary Function of DOH: Promotion of Health for the People

***Vision:

DOH is the LSM (Leader, Staunch Advocate, Model) of health for all in the Philippines

***Vision by 2030:

● A global leader for attaining BEM:

B- Better health outcomes

E- Equitable healthcare financing
M- More responsive healthcare systems

***Principles to attain VISION: EQA

E- Equality: equal services to all, no discrimination

Q- Quality: Quality over quantity (philosophy of DOH)
A- Accessibility: utilize strategies for delivery of health services

***Mission:

- Guarantee equitable, sustainable and quantity health for all Filipinos, especially the poor and shall lead the
quest for excellence in health

***Health Sector Reform Agenda

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 - Overriding goal of DOH
- Describe the major SOP:
S- Strategies
O- Organizations
P- Policies

***FOURmula ONE for Health

- Framework of implementation of HSRA

Goals of FOURMula ONE: BEM

B- Better health outcomes

E- Equitable and sustainable healthcare financing
M- More responsive healthcare systems

4 Elements of Strateg: “FIRE GOD”

1. Health FInancing
2. Health REgulation
3. GOod Governance
4. Health Service Delivery

Health Financing To foster greater, better and sustainable INVESTMENTS in health

PHIC (Philippine Health Insurance Corporation) through:
a. NHIP- National Health Insurance Program
b. DOH

Contribution: 200 per month or 600 per quarterly

Health regulation To ensure QUALITY AND AFFORDABILITY of health goods and services
Health Service Delivery To ensure ACCESSIBILITY AND AVAILABILITY of health services
Good governance To enhance HEALTH SYSTEM PERFORMANCE at national and local levels
T- Transparent
A- Account
E- Efficient

Roadmap for all Stakeholders in Health: National Objectives for Health (NOH) evaluated every 5 years

3 Strategies in Delivering Health Services:

1. Creation of RHCDS (Restructured Health Care Delivery System) PD 568 of 1976

2. Management of Information Systems regulated by RA 3753: Vital Statistics Law
3. Primary Health care regulated by LOI 949 (1984)

PHILIPPINE HEALTHCARE DELIVERY SYSTEM

MAJOR PLAYERS
PUBLIC SECTOR PRIVATE SECTOR
Finance: tax- based Finance: market- based
Healthcare: free Healthcare: with fee

PHILIPPINE LOCAL HEALTH SYSTEM

RA 7160 (1991)- Local Government Code, Decentralization, Devolution Code

- Refers to the act of by which the national government confers power and authority upon various local
government units to perform specific functions and responsibilities including provision and delivery of basic
health services

***Transfer of Power

National Government (Formulator)

LGU (Implementor)
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***Objectives of Local Health Systems: PEFEU

P Promote inter-LGU linkages and cost sharing schemes

E Establish local health systems
F Foster participation in public and private sectors
E Ensure quality of health service delivery at the local level
U Upgrade healthcare management and service capabilities of local health facilities

INTER LOCAL HEALTH SYSTEMS/ZONE (ILHS/Z)

- Clustering of municipalities with defined population and geographical area, a referral hospital, RHU, BHS

***Composition of Inter-Local Health Zone (ILHZ)

1. People- 100,000 to 500,000

2. Boundaries- determines the accountability and responsibility of health care providers
3. Health facilities- district, emergency or provincial hospital as an integrated health system
4. Health workers- right unit of health providers is needed to deliver comprehensive health services

PRIMARY HEALTH CARE: essential healthcare made universally accessible to individuals, families and community
by means acceptable to them through their full participation and at a cost that the community and country can afford at all
stages of development (not totally free)

***History

A. First International Conference

Venue: Alma Ata, USSR now Almaty Kazakhstan, USSR

Date: September 6-12, 1978
Sponsor: WHO, UNICEF (United Nations International Conference Emergency Fund) now: United Nations Children’s
Fund
Representative: Dr. Dizon, Dr. Villar
Theme: Health for All by Year 2000

B. Philippines

Legal basis: LOI 949

Signed by: President Marcos
Date: October 19, 1979
Theme: Health for All Filipinos by Year 2000, Health in Hands of the People by 2020
***Mission: Strengthen the healthcare system wherein people will manage their own healthcare
***Concept/Strategy: Partnership and Empowerment towards self-reliance
***Ultimate Goal: Community Developments towards Self-reliance and self-determination

***Pillars of PHC/ Four Cornerstones: AIUS

A- Active community participation- most important

I- Inter and intra-sectoral linkages
Intra-sectoral Intersectoral

Within Health Care Delivery System Outside Health Care Delivery System

1°, 2°, 3° Hospitals Government Organizations (GO)

Non-government Organizations (NGO)

U- Use of appropriate technology

S- Support mechanism available

***CHARACTERISTICS OF PRIMARY HEALTH CARE:

5A+S

ACCEPTABLE
ACCESSIBKE
AFFORDABLE
ATTAINABLE
9
AVAILABLE
SUSTAINABLE

*Criteria for appropriate technology: ACCEFS

A Affordable, accessible, acceptable, available

C Cost wise, economical
C Complex procedures which provide simple outcomes
E Effective
F Feasible- possibility of use at all times
S Scope of technology is safe and secure

ELEMENTS OF PRIMARY HEALTH CARE

E Education on health
L Locally endemic disease
E Expanded Program on Immunizations
M Maternal and Child Care
E Essential drugs and herbal plants
N Nutrition
T Treatment of communicable and non-communicable diseases
S Sanitation

D Dental health
A Access of hospitals as wellness centers
M Mental health

HEALTH EDUCATION

***Elements of Heath Education: “ICE”

- Information
- Communication
- Education

***INFORMATION

- Dissemination of ideas to keep population group knowledgeable and aware

***COMMUNICATION

- Interaction involving 2 or more persons or agencies

- 3 Elements:
Sender
Message
Receiver

***EDUCATION

- Change within individual

- 3 elements: education
K- Knowledge
S- Skills
A- Attitude

***Principles of Health Education: LBM 5C D

L Learning process
B Basic function of health workers
M Motivation
C Community resources utilization
C Considers health status of the people
C Continuous process
C Creative process

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C Cooperative work
D Doing

EPIDEMIOLOGY

⮚ Study of health and illness

⮚ Backbone in the prevention of disease
⮚ is the pattern of occurrences & distribution of diseases, defects & deaths

SPORADIC

⮚ seasonal
⮚ occasional (on and off)
⮚ intermittent/ unpredictable
⮚ Tag-ulan= leptospirosis
⮚ Tag-init= rabies

ENDEMIC

⮚ Endititigil
⮚ Constant
⮚ Continuous
⮚ disease occurs regularly, habitually, constantly affecting the population group
⮚ Schistosomiasis: Samar, Leyte, Mindoro, Davao
⮚ Malaria: Palawan & Mindanao-reasons why it’s prevalent
⮚ Forested areas
⮚ Surrounded by bodies of water
⮚ Dengue
- Day biting
- Low flying
- Stagnant
- Urban

EPIDEMIC

- Epakalit
- Sudden increase in #
- Outbreak
- Location-based
- Ex: food poisoning

PANDEMIC

⮚ Pandaigdigan
⮚ Worldwide epidemic
⮚ Ex: HIV
⮚ Worldwide, international, universal, global in occurrence
⮚ AIDS, Hepatitis B, PTB, measles, mumps, diphtheria, pneumonia

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 EXPANDED PROGRAM ON IMMUNIZATION

LAWS:

PD 996- Compulsory immunization for children 8 years below

RA 10152- Mandatory Infants and Children Health Immunization Act of 2011
PD 147- National Immunization Day: Wednesday
RA 7846- Compulsory Hepatitis B vaccination
EO 663- Bakuna ang Una sa Sanggol at Ina

***Four Major Strategies: MNOP

1. Measles-free by 2008
2. Neonatal tetanus free by 2008
3. Of at least 90% FIC (Fully Immunized Child)
4. Polio free maintenance

***Principles of EPI:

1. Epidemiologic situation
2. Mass approach
3. Basic health service
4. Vaccination should not be restarted from beginning if interval exceeded
5. Safe to give all EPI vaccines on the same day at different sites of body
6. 1 syringe: 1 Child

***Elements of EPI: SACIT

S Surveillance, Research and Studies

A Assessment and Evaluation of Programs
C Cold Chain Management
I Information, Communication, Education
T Target Setting

Administration of vaccines (PD 996)

# of
Vaccine Content Form & Dosage Doses Route

Freeze dried
Infant- 0.05ml
Live attenuated Preschool-0.1ml
BCG (Bacillus Calmette Guerin) bacteria 1 ID

DT- weakened toxin

DPT (Diphtheria Pertussis P-killed bacteria
Tetanus) liquid-0.5ml 3 IM

OPV (Oral Polio Vaccine) weakened virus liquid-2drops 3 Oral

Hepatitis B Plasma derivative Liquid-0.5ml 3 IM

Freeze dried-
Measles Weakened virus 0.5ml 1 Subcutaneous

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 Schedule of Vaccines (PD 996)

Age at 1st Interval between

Vaccine dose dose Protection

BCG is given at the earliest possible age protects against the

BCG At birth possibility of TB infection from the other family members

DPT 6 weeks 4 weeks An early start with DPT reduces the chance of severe pertussis

The extent of protection against polio is increased the earlier OPV

OPV 6weeks 4weeks is given.

An early start of Hepatitis B reduces

@birth,6th the chance of being infected and becoming a carrier.
Hepa B @ birth week,14th week

Measle 9m0s.-11m At least 85% of measles can be prevented by immunization at this

s 0s. age.
▪ 6 months – earliest dose of measles given in case of outbreak
▪ 9months-11months- regular schedule of measles vaccine
▪ 15 months- latest dose of measles given
▪ 4-5 years old- catch up dose
▪ Fully Immunized Child (FIC)– less than 12 months old child with complete immunizations of DPT, OPV, BCG, Anti
Hepatitis, Anti measles.
Tetanus Toxoid Immunization

Vaccine Minimum age interval % protected Duration of Protection

TT1 As early as possible 0% 0

TT2 4 weeks later 80% 3 years

TT3 6 months later 95% 5 years

TT4 1year later/during next pregnancy 99% 10 years

TT5 1 year later/third pregnancy 99% Lifetime

▪ There is no contraindication to immunization except when the child is immunosuppressed or is very, very ill (but not slight
fever or cold). Or if the child experienced convulsions after a DPT or measles vaccine, report such to the doctor
immediately.
▪ Malnutrition is not a contraindication for immunizing children rather; it is an indication for immunization since common
childhood diseases are often severe to malnourished children.
Cold Chain under EPI

▪ Cold Chain is a system used to maintain potency of a vaccine from that of manufacture to the time it is given to child or
pregnant woman.
▪ The allowable timeframes for the storage of vaccines at different levels are:
▪ 6months- Regional Level
▪ 3months- Provincial Level/District Level
▪ 1month-main health centers-with ref.
▪ Not more than 5days- Health centers using transport boxes.
▪ Most sensitive to heat: Freezer (-15 to -25 degrees C)
▪ OPV
▪ Measles
▪ Sensitive to heat and freezing (body of ref. +2 to +8 degrees Celsius)
▪ BCG
▪ DPT
▪ Hepa B
▪ TT
Note: Temperature monitoring 2 times a day (early morning and late afternoon)
Note: Vaccination provides active artificial immunity to infants
▪ Use those that will expire first, mark “X”/ exposure, 3rd- discard,
▪ Transport-use cold bags let it stand in room temperature for a while before storing DPT.
▪ Half life packs: 4hours-BCG, DPT, Polio, 8 hours-measles, TT, Hepa B.
▪ FEFO (“first expiry and first out”) – vaccine is practiced to assure that all vaccines are utilized before the expiry date.
Proper arrangement of vaccines and/or labeling of vaccines expiry date are done to identify those near to expire vaccines.

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 TARGET SETTING

Infants 3%
BCG School Entrants 3%
Pregnant 3.5%

12-59 Months (Measles High-Risk Area) 11.5%

0-59 Months (OPV) 14.5%

Outbreak Response Immunizations
15-44 Y/O Women In Tetanus Toxoid High-Risk Area 11.5%

RA 10152: MANDATORY INFANT AND CHILD HEALTH IMMUNIZATION OF 2011

A. ROTAVIRUS- protects child from rotaviral gastroenteritis

▪ COVERAGE: infants (6-15 weeks)

▪ SCHEDULE: 2 doses
Brand Name: Rotarix
1st dose: 6 weeks up to 15 weeks along with Penta 1, OPV 1 and Pneumococcal vaccine 1
▪ PREPARATION AND ADMINISTRATION:
No reconstitution needed
Ensure appropriate age
Ensure no allergies
Not taking any immunosuppressants
▪ STORAGE: +2 to +8 (body of refrigerator)

B. PENTAVALENT (DPT, HiB, Hep B)

▪ COVERAGE: infants from 6- 14 weeks

▪ SCHEDULE:
1st dose: 6 weeks
2nd dose: 10 weeks
3rd dose: 14 weeks
▪ PREPARATION AND ADMINISTRATION:
5 vaccines in 1 vial
More protection, less injection
Must never be frozen
▪ STORAGE: +2 to +8
Note: Hep B must be given at birth before Pentavalent can be given
Hep B should be given within 24 hours after birth or not later than 7 days

C. MEASLES-MUMPS-RUBELLA

▪ COVERAGE: 12- 15 months

▪ STORAGE: -15 to -25

Note: Anti Measles vaccine (AMV) must be given first at 9-11 months before MMR will be given
AMV is usually given at 9 months along with Vitamin A (Retinol)

UPDATED EPI: RA 10152

Vaccine Dose Route Site No. of Doses First dose Interval

BCG Infant: 0.05 ml ID Right deltoid
School-age: ID Left deltoid 2 At birth -
0.05 ml
Hep B 0.5 ml IM Right vastus 1 At birth -
lateralis
OPV 2-3 drops Oral Mouth 3 6 weeks 4 weeks
Measles 0.5 ml SQ Upper outer 1 9- 11 months -
arm
Pentavalent 0.5 ml IM Vastus lateralis 3 6 weeks 4 weeks
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 Rotavirus 2-3 drops Oral Mouth 2 6- 15 weeks 4 weeks
MMR 0.5 ml SQ Upper outer 1 12- 15 months -
arm

SUMMARY OF SCHEDULE OF VACCINES

Vaccine Age
At birth 6 weeks 10 weeks 14 weeks 9 months 12 months
BCG ✔

Hep B ✔

OPV ✔ ✔ ✔

Measles ✔

Pentavalent ✔ ✔ ✔

Rotavirus ✔ ✔

MMR ✔

MATERNAL CARE

PHILIPPINE REPRODUCTIVE HEALTH:

Determinants:
1. Socioeconomic
2. Status of women
3. Social and gender issues
4. Cultural, psychosocial and biological factor

Elements:
1. Family Planning
2. Maternal and Child Health and Nutrition
3. Prevention and Management of Reproductive Tract Infections including STI and HIV/AIDS
4. Adolescent Reproductive Health

LAWS:

PD 965- Pre-marriage counseling about Family Planning and Responsible Parenthood

RA 4244- Responsible Parenthood and Reproductive Health Act of 2002
RA 10354- amended RA 4244

***STRATEGIC THRUSTS:
1. BEMOC (Basic Emergency Obstetric Care)
2. 4 Prenatal visits
3. Responsible parenthood and provision of appropriate health package to women of reproductive age
(18-35 years)

***PRENATAL VISITS
1ST Visit Early
nd
2 Visit 2nd trimester
3rd Visit 3rd trimester
Every 2 weeks Every 2 weeks

Note: Home based Mother Record (HBMR)- color pink; used to identify risk of pregnancy

***MICRONUTRIENT SUPPLEMENTATION

A. Iron/Folic Acid

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 Normal pregnant 60 mg/ 400 ug Daily for 6 months

Lactating 60 mg/ 400 ug Daily for 3 months

B. Vitamin A (Retinol)

Normal pregnant 10, 000 IU Twice a week starting 4 months

With xerophthalmia 10, 000 IU Once day for 4 weeks

Lactating 200,000 IU 1 dose only within 4 weeks after

delivery

***DIAGNOSTIC TESTS

A. Benedict’s Test
- To detect DM
- 5 cc Benedict’s solution + 3-5 drops urine
- Results:

Blue Negative

Green +1

Yellow +2

Orange +3

Brick red +4

Noted: Bad Girls Yell On Boys

B. Acetic Acid Test

- To detect presence of urine
- 3-5 drops acetic acid + urine
- Results:

Negative No cloudiness

+1 Faint cloudiness

+2 Heavy cloudiness

+3 Opaque cloudiness

***CRITERIA FOR HOME DELIVERY

1. Full term
2. Less than 5 gravida
3. Cephalic
4. Without existing diseases
5. No history of complications
6. No previous CS
7. Imminent delivery
8. No PROM
9. Adequate pelvis
10. Abdominal enlargement is appropriate for age of gestation

***BEMONC (Basic Emergency Maternal Obstetric and Neonatal Care)

1. Administer parenteral oxytocin
2. Administer parenteral anticonvulsant
3. Administer parenteral antibiotic
4. Perform manual removal of placenta
5. Perform removal of retained products of conception
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 6. Perform assisted vaginal delivery (vacuum and forceps delivery)

***CEMONC (Comprehensive Emergency Maternal Obstetric and Neonatal Care)

- 6 interventions in BEMONC plus the following:
1. Perform Cesarean section
2. Perform blood transfusion
3. Advance life support

***POSTPARTUM PERIOD

A. POSTPARTAL VISIT

1st Visit 1st Week Postpartum (after 3-5 days) Home Visit
2nd Visit 6 weeks Postpartum Clinic Visit

B. SUPPLEMENTATION

Vitamin A 200,000 IU one dose only within 4 weeks after delivery

Iron/ Folic Acid 60 mg/ 400 ug daily for 3 months

Iodized Capsule Oil 200 mg 1 capsule for 1 year

CHILD CARE

Essential Newborn Care: DOH/ WHO Protocol

4 Core Steps of Essential Newborn Care

I- Immediate and thorough drying

II- Skin-to-skin Contact
III- Proper Cord Clamping and Cutting
IV- Non-separation of the newborn and mother for early initiation of breastfeeding

I. IMMEDIATE AND THOROUGH DRYING (within first 30 seconds)

● Call out time of birth
● Dry the NB thoroughly for at least 30 seconds
● Wipe the eyes, face, head, front, back, arms and legs
● Remove wet clothes
● Check breathing while drying
● Notes:’
a. Do not ventilate unless floppy/ not breathing
b. Do not suction unless mouth/nose are blocked withsecretions
● DON’T’S
a. No slapping
b. No hanging upside down
c. No squeezing of chest
d. Do not wipe off vernix caseosa
e. Do not do footprinting
f. Do not bathe the baby

II. EARLY SKIN-TO-SKIN CONTACT (after 30 seconds of drying)

● If the baby is breathing or crying:
a. Position NB prone to mother’s abdomen or chest
b. Cover NB back with dry blanket
c. Cover NB head with bonnet
● Avoid manipulations (routine suctioning that may cause trauma or infection)
● Place ID band on ankles, not wrist
● Skin-to-skin contact is doable for C-section babies

17
 III. PROPERLY TIMED CORD CLAMPING (1-3 minutes after)
● Remove first set of gloves
● After cord pulsation stops after 2-3 minutes, clamp cord using plastic clamp or tie at 2 cm from the base
● Clamp at 5 cm from the base
● Cut cord close to the plastic clamp so that there is no need for a second trim
● Do not milk the cord towards the baby
● After the first clamp, may strip the cord of blood before applying the second clamp
● Do not apply any substance onto the cord’

IV. NON-SEPARATION OF NEWBORN AND MOTHER FOR EARLY INITIATION OF BREASTFEEDING

(within 90 minutes)
● Leave NB in skin-to-skin contact with mother
● Observe feeding cues (tonguing, licking, rooting)
● Encourage mother to nudge NB toward breast
● Counsel on positioning
a. NB neck not flexed nor twisted
b. NB is facing breast
c. NB body close to mother’s body
d. NB whole body is supported
● Counsel on attachment and suckling
a. Chin touching the breast
b. Areola more visible above than below
c. Lower lip turned outward
d. Mouth wide open
e. Suckling is slow, deep with pauses
● Minimize handling by health workers
● Do not give sugar water, formula or other prelacteals, do not give bottles or pacifiers
● Do not throw away colostrums
● Weighing, eye care, examinations, injections (BCG, Hep B) is done after first full breastfeeding
● Postpone bathing until hours

GOOD LATCH ON DURING BREASTFEEDING

“CALMS”

C- Chin must touch the breast

A- Areola is more visible above than below
L- Lower lip turned outward
M- Mouth wide open
S- Suckling must be slow, deep and with pauses

EXPANDED NEWBORN SCREENING IN THE PHILIPPINES

RA 9288: Newborn Screening Act of 2004

▪ Article 3, Section 5: Obligation to inform

▪ Article 3, Section 6: Performance of NB screening
▪ Article 3, Section 7: Refusal to be tested

PP 540: First Week of October: “Newborn Screening Week”

5 METABOLIC DISEASES TO SCREEN:

Congenital Hypothyroidism
Congential Adrenal Hyperplasia
G6PD
Galactosemia
Phenylketonuria
18
DOH- leading agency of NB Screening Program

When to do NB screening: Not later than 3 days

If in NICU, not later than 7 days

Mail blood samples within 24 hours

INFANT AND YOUNG CHILD FEEDING

Exclusive breastfeeding- breast milk only for 6 months

Complementary feeding- with food by 6 months

*Guidelines for complementary feeding: PAST

P- Properly fed
A- Adequate
S- Safe
T- Timely

BREAST MILK DIFFERENCE FORMULA MILK

20 cal/oz 20 cal/oz
Carbohydrates > Carbohydrates
Protein: Lactalbumin < Protein: Casein
Linoleic acid = Linoleic acid
Minerals < Minerals

Benefits of Breastfeeding:

B- Best for baby and mommy

R- Reduces incidence of allergies
E- Economical, no waste
A- Antibodies
S- Sterile and pure
T- Temperature is always ideal
F- Fresh milk never spoils
E- Easy to prepare and digest
E- Eradicates feeding difficulties
D- Develops mother and child bonding
I- Immediately available
N- Nutritionally optimal
G- Gastroenteritis greatly reduced

Laws:

EO 51- Milk Code

RA 7600- Rooming-in and Breastfeeding Act of 1992
RA 8976- Food Fortification Law

Laws Affecting Elderly:

RA 7876: Senior Citizens Center Act of the Philippines

RA 9257: Expanded Senior Citizen Act of 2010

First Week of October: Elderly Filipino Week

1999- International Year of Older Persons

19
UN Principle for Older Persons- to ass life to years that have been added to life

***Campaign: Global Movement for Active Ageing (Global Embrace 1999)

Key Message:

1. CELEBRATE- celebrate ageing. Getting older is good while the alternative, dying prematurely is not
2. A SOCIETY FOR ALL- all dimensions for being active should be taken into account the physical, mental and
spiritual
3. INTERGENERATIONAL SOLIDARITY- older persons should not be marginalized

ESSENTIAL DRUGS

Laws:

RA 9502- Cheaper Medicine Act

RA 6675- Generic Act
Dr. Alfredo Bengzon- Father of Generics Act
RA 6425- Old Dangerous Drug Act
RA 915- Comprehensive Dangerous Drug Act of 2002

BOTIKA NG BARANGAY

July 5, 1996- AO 23
Criteria:
Managed by- Community Organization or Cooperative
Coverage areas: Far flung, depressed
Initial Capital Requirement: 1/3 of Community Funds
Workers: At least 2 BHWs
Available Botika ng Barangay space

LIST OF OTC DRUGS

Analgesic/Antipyretic Paracetamol
Antacid Aluminum hydroxide + Magnesium hydroxide
Anti-helminthic Albendazole, Mebendazole
Anti- allergic/ Anti-pruritic Diphenhydramine, Phenylchlorphenamine maleate
NSAID Mefenamic acid, Ibuprofen
Anti- thrombotic Aspirin (Not to be handled by PHN)
Anti- vertigo Meclizine
Bronchodilator/ Anti- cough Lagundi
Diuretic/ Anti-urolithiasis Sambong
Antitussive Dextromethorphan
Anti- motility Loperamide
Solutions ORESOL
Laxatives/ Cathartics Bisacodyl
Anti-scabies/ Anti- lice/ Anti-fungal Benzyl benzoate, sulfur
Anti-anemia Ferrous sulfate
Antifungals Benzoic acid + salicylic acid, clotrimazole, miconazole
Vitamins Ascorbic acid, Vit B1+ B6 + B 12, Vitamin A, Multivitamins
Vitamins and Minerals Folic acid+ ferrous sulfate, zinc sulphate
Minerals Calcium lactate, calcium carbonate
Disinfectants Hydrogen peroxide, ethyl alcohol, povidone- iodine
Anti-infectives Amoxicillin, cotrimoxazole
Others Metformin
Glibenclamide
Metoprolol
Captopril
salbutamol

*Oplan Walang Resetang Program- solution to absence of medical officer who prescribed the medicines so PHN are
given the responsibility to prescribe generic medicines

20
*Walong Wastong Gamot Program”- available generics in “Botika sa Baryo” and Health Center

C- Cotrimoxazole Combination of:

a. Trimethoprim (TMP)
- Bacteriostatic effect
- Inhibits/stops multiplication of bacteria
- For GUT, GIT, URTI
b. Sulfamethoxazole (SMX)
- Bactericidal action
- Kills bacteria
- For GUT, GIT, URTI, Skin infections

A- Amoxicillin/ Ampicillin From Penicillin family

Bacteriostatic action
Least sensitivity reaction
Adverse reaction: Anaphylactic shock
R- Rifampicin Side effect: Orange secretions
I- Isoniazid Side effect: Peripheral neuropathy
Should take Vitamin B6 (Pyridoxine)
P- Pyrazinamide Side effect: Hepatotoxic
P- Paracetamol Analgesic and antipyretic effect
O- Oresol
N- Nifedipine Anti-hypertensive
Calcium- channel blockers

*ORESOL

Larger volume Smaller volume

Water: 1000 mL or 1 Liter Water: 250 ml
Sugar: 8 teaspoon Sugar: 2 teaspoon
Salt: 1 teaspoon Salt: ¼ teaspoon or 1 pinch of salt
10-12 granules of rock salt

Glucose 20 grams
Sodium chloride 3.5 grams
Sodium bicarbonate 2.5 grams
Potassium chloride 1.5 grams

RA 8423- TRADITIONAL ALTERNATIVE MEDICINE ACT

L- LAGUNDI
U- ULASIMANG BATO
B- BAYABAS
B-BAWANG
Y- YERBA BUENA
S- SAMBONG
A- AKAPULKO
N- NIYUG-NIYOGAN
T- TSAANG GUBAT
A- AMPALAYA

Lagundi Vitex Negundo Ascof (Asthma, Leaves Decoction

Cough, Colds, Fever) Poultice
Pain And
Inflammation
Dysentery
Colds And Pain In
Influenza
Skin Diseases
Headache
Rheumatism, Sprain,
Contusion, Insect
Bites

21
 Aromatic Bath For
Sick Patients
Ulasimang Bato Peperonia Pellucida Gout Leaves Decoction
A.K.A Pansit- Arthritis Poultice
Pansitan Rheumatism
Bayabas Psidium Guajava Diarrhea Leaves Decoction
Toothache
Mouth And Wound
Wash
Bawang Allium Sativum Hpn Clove/Bulb Poultice
(Gastric Irritant) Lower Cholesterol Stir Fry
Toothache Babad Sa Suka
Yerba Buena/ Mentha Cordifelia Same As Lagundi Leaves Decoction
Peppermint Except For Asthma Poultice
Muscle Headache
Arthritis
Rheumatism
Cough
Sambong Blumea Balsamifera Edema Leaves Decoction
Diuretic
Anti-Stones
Akapulko/ Cassia Alata Anti-Fungal Leaves Decoction
Bayabas-Bayabasan Athletes Foot Poultice
Scabies Cream
Niyug- Niyogan Quisqualis Indica Intestinal Parasites Seeds Decoction
Poultice
Adult (8-10) Juice
7-12 Y/O (6-7)
6-8 Y/O (5-6)
4-5 Y/0 (4-5)

Taken 2 Hours After

Meals
Tsaang Gubat Carmona Retusa Diarrhea Leaves Decoction
Infantile Colic Poultice
Dental Caries
Dyspepsia
Ampalaya Mamordica Charantia Type 2 Dm Leaves Not Fruit Decoction

NUTRITION

10 NUTRITIONAL GUIDELINES FOR FILIPINOS:

1. Eat variety of foods daily

2. Breastfeed infants from birth to 4- 6 months exclusively
3. Proper feeding and growth monitoring of children
4. High protein foods (fish, lean meat, poultry, dried beans)
5. Eat more vegetables, fruits and root crops
6. Eat foods cooked in edible oil daily
7. High calcium foods
8. Iodized salt but not too much of salty foods
9. Clean and safe food, avoid food-borne diseases
10. Healthy lifestyle, good nutrition, exercise regularly

MICRONUTRIENT SUPPLEMENTATION

VITAMIN A/ RETINOL- ARAW NG SANGKAP PINOY/ GRANTISADONG PAMBATA/ CHILD HEALTH WEEK

NORMAL
AGE DOSAGE SCHEDULE
INFANT (6-11 MONTHS) 100, 000 IU 1 Dose Only Anytime 6-11 Months But
Usually 9 Months Along With Measles
12- 71 MONTHS 200, 000 IU 1 Cap Every 6 Months
PREGNANT 10, 000 IU 2x/ Week Starting 4 Months
POSTPARTUM 200, 000 IU 1 Dose Only Within 4 Weeks After
Delivery
22
 WITH XEROPHTHALMIA
6- 11 MONTHS 100, 000 IU 1 Cap Now, 1 Cap Next Day And 1
12- 59 MONTHS 200, 000 IU Cap 2 Weeks After
PREGNANT 10, 000 IU Once A Day For 4 Weeks

IRON

AGE DOSAGE SCHEDULE

PREGNANT 60 mg Iron/ 400 ug Folic Acid Once a day for 6 months (180 days)
LACTATING 60 mg Iron/ 400 ug Folic Acid Once a day for 3 months (90 days)

IODINE

200 mg (1 capsule/year)

NUTRITIONAL SURVEILLANCE SYSTEM

BODY MASS INDEX

FORMULA:

ASIA- PACIFIC OBESITY GUIDELINES

BMI INTERPRETATION
< 18.5 UNDERWEIGHT
18.6- 22.9 NORMAL
23.0- 24.9 OVERWEIGHT
25.0- 29.9 OBESE I
>30 OBESE II

IDEAL BODY WEIGHT

RULE MALE FEMALE

EVERY 5 FT 110 lbs 105 lbs
+ 1 INCH +6 +5
- 1 INCH - 6 - 5

Other Formula: Height in cm - 100

< 10%- Underweight

>10 %- Overweight
>20%- Obese

WAIST HIP RATIO

FORMULA: Waist circumference (cm)/ Hip Circumference

NORMAL:

MALE- <1.0
FEMALE- <0.85

ABNORMAL: ANDROID OR CENTRAL OBESITY

23
MALE- ≥1.0
FEMALE- ≥0.85

WAIST CIRCUMFERENCE (visceral fat)

Men < 90 cm (35 inches)

Women < 80 cm (31.5 inches)

SANITATION OF ENVIRONMENT

RA 6969- Toxic Substances and Hazardous and Nuclear Waste Control Act of 1990
RA 8749- Clean Air Act of 1999
RA 9003- Ecologic Solid Waste Management Act of 2000
RA 9275- Clean Water Act of 2004
PD 856- Code of Sanitation
PD 825- Proper Garbage Disposal

WATER SUPPLY AND SANITATION

LEVEL 1 LEVEL 2 LEVEL 3

Description Point source Communal faucet/ Stand Waterworks System with
post Individual House
Connections
Suitable Area Rural Rurban Urban
Number of Households 15-25 1/ 4-6
Distance from the farthest Not more than 250 meters 25 meters
household
Water yields or discharge 40-140 LPM 40-80 LPM

Note: Certification of an existing water source is issued by the: Secretary of Health

Unapproved Type of Water Facility:

1. Open dug wells

2. Unimproved springs
3. Wells that need priming

PROPER EXCRETA AND SEWAGE DISPOSAL PROGRAM

LEVEL 1 Non-water carriage toilet facility

LEVEL 2 Water-carriage with water-sealed, flush-type and septic tank
LEVEL 3 Water-carriage type water-sealed, flush-type with septic tank/ sewerage treatment

FOOD SANITATION PROGRAM

FOOD ESTABLISHMENT CLASSIFICATION

CLASS A Excellent Every 3 Months

CLASS B Very Satisfactory Every 2 Months
CLASS C Satisfactory Every 1 Month

Note: DOH AO #1 s. 2006= requires all laboratories to use Formalin Ether Concentration Technique (FECT) in stool
analysis and all ambulant vendors must submit health certificate

FOUR RIGHTS OF FOOD SAFETY:

RIGHT SOURCE
RIGHT PREPARATION
RIGHT COOKING
RIGHT STORAGE

24
 Right Source
Buy fresh food
Check expiry dates
Avoid canned goods with
dent
Use water from safe sources
Boil water for 30 minutes
Right Preparation
Avoid contact between raw
and cooked food
Buy pasteurized milk
Wash vegetables well
Wash hands and kitchen
utensils
Right Cooking Right Storage
Cook food thoroughly Cooked foods should be left
Eat cooked food at room temperature not
immediately more than 2 hours
Wash hands thoroughly Hot conditions ≥ 60°C
before and after cooking Cold conditions ≤ 10°C
Reheat ≥ 70°C

Golden Rule: When in doubt, throw it out!

MENTAL HEALTH

TYPES OF BURDEN:

DEFINED- effect to patient

UNDEFINED- effect to significant others
HIDDEN- stigma and violation of human rights
FUTURE- generation to generation

12 S in MENTAL HEALTH

S- SPIRITUALITY
S- SELF-AWARENESS
S- SCHEDULING: TIME MANAGEMENT
S- SIESTA
S- STRETCHING
S- SENSATION TECHNIQUES
S- SPORTS
S- SOCIALIZATION
S- SONGS
S- SPEAK TO ME
S- STRESS DEBRIEFING
S- SMILE

FIELD HEALTH SERVICE INFORMATION SYSYSTEM

COMPONENTS:

1. FAMILY TREATMENT RECORD (FTR)

- Fundamental building block
- Date, name, address of patient, symptoms or complaint, diagnosis, treatment and date of treatment

2. TARGET CLIENT LIST (TCL)

- Second building block
- Per DOH Program

3. REPORTING FORMS/ TALLY REPORT

- Transmitted from one facility to another

4. OUTPUT REPORT
- Produced at Provincial Health Office

MONTHLY FORM
BY MIDWIFE
PROGRAM REPORT (M1) DOH PROGRAMS: MATERNAL CARE, CHILD CARE,
FAMILY PLANNING AND DISEASE CONTROL
MORBIDITY REPORT (M2) DISEASES: LISTED BY AGE AND SEX
QUARTERLY FORM
BY PHN
PROGRAM REPORT (Q1) DOH PROGRAMS: MATERNAL CARE, CHILD CARE,
FAMILY PLANNING AND DISEASE CONTROL
MORBIDITY REPORT (Q2) DISEASES: LISTED BY AGE AND SEX
ANNUAL FORMS
ABHS- FORM (MIDWIFE) VITAL STATISTICS
ANNUAL FORM 1 (PHN) VITAL STATISTICS

25
ANNUAL FORM 2 MORBIDITY (DISEASES): LISTED BY AGE AND SEX
ANNUAL FORM 3 MORTALITY (DEATHS): LISTED BY AGE AND SEX

OFFICE PERSON RECORDING FORMS FREQUENCY SCHEDULE OF

TOOLS SUBMISSION
BHS MIDWIFE ITR MONTHLY FORM MONTHLY EVERY 2ND WEEK OF
TCL (M1 & M2) SUCCEEDING MONTH
RF/TR

A-BHS FORM ANNUALLY EVERY 2ND WEEK OF

JANUARY

RHU PHN RF/TR QUARTERLY FORM QUARTERLY EVERY 3RD WEEK OF 1ST
OUTPUT REPORT (Q1 & Q2) MONTH OF
SUCCEEDING
QUARTER

ANNUAL FORMS ANNUALLY EVERY 3RD WEEK OF

A1 JANUARY
A2
A3

8 MILLENIUM DEVELOPMENT GOALS

1. Eradicate extreme poverty and hunger

2. Promote universal primary education
3. Gender equality and women empowerment
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/ AIDS, malaria and other disease
7. Ensure environmental sustainability
8. Develop global partnership

17 SUSTAINABLE DEVELOPMENTAL GOALS

1. No Poverty
2. Zero Hunger
3. Good Health and Well-Being
4. Quality Education
5. Gender Equality
6. Clean Water and Sanitation
7. Affordable and Clean Energy
8. Decent Work and Economic Growth
9. Industry, Innovation and Infrastructure
10. Reduced Inequality
11. Sustainable Cities and Communities
12. Responsible Consumption and Production
13. Climate Action
14. Life Below Water
15. Life On Land
16. Peace and justice strong institutions
17. Partnership to achieve the Goal

***QUALIFICATIONS OF A PUBLIC HEALTH NURSE

Professional Qualifications in the Philippines:

Public Health Nurse (Nurse II and Nurse III) BSN, RN

Supervising Public Health Nurse/ Nurse Supervisor at the BSN, RN
Provincial/ City Level MN/ MAN
26
 5-year experience as PHN
Nurse Instructor II BSN, RN
MAN
3- year experience as PHN
Special Training on the Functions of the Nurse
Regional Nurse Supervisor/ Regional Public Health Nurse BSN, RN
(Nurse V) MPH
MAN major in PHN Administration and Supervision
5-year experience in CHN- 2 years in supervisory position
Nurse Program Supervisor (Nurse VI) BSN, RN
MPH
MAN major in PHN Administration
7-year experience in CHN/ Training
Chief Nurse VII BSN, RN
MAN major in CHN/ MPH major in CHN
5-year experience (3 years in supervisory or assistant
chief nurse position)
Occupational Nurse BSN, RN
Preferably with Training/ Units in Occupational Nursing
Regional Training Nurse BSN, RN
MAN/ MPH
6-year experience (3 years of which in training and nursing
education)
Assistant Chief Nurse BSN, RN
MAN major in CHN/ MPH
5-year experience in CHN (2 years supervisory position)

Personal Qualifications:

1. Good physical and mental health

2. Interest and willingness to work in community
3. Resourcefulness and creativity
4. Leadership potential
5. Active member in professional working organization
6. Honesty and integrity

HOME VISIT

Definition: Professional face-to-face contact made by a nurse to patient or family to provide necessary health care
activities and further attain an objective of agency

PRINCIPLES:

● Must have a purpose or objective

● Must use every available information about the patient and his family through family records
● Priority should focus on the essential needs of the individual and his family
● Should involve the individual and family
● Plan should be flexible

FACTORS INFLUENCING FREQUENCY OF HOME VISITS: “NAPOPA”

N- Nursing services used by family

A- Acceptance of the family, willingness and interest to cooperate
P- Physical, psychological and educational needs of individual and family
O- Other health agencies and number of health personnel available
P- Policy of agency
A- Ability of patient and family to recognize own needs and knowledge of available resources and abilities to use these
resources

STEPS IN HOME VISIT:

1. Greet the patient and introduce yourself

2. State the purpose of the home visit
27
 3. Observe the patient and determine health needs
4. Put the bag in a convenient place then proceed to perform the bag technique
5. Perform the needed nursing care and give health teachings
b. Bag technique
- Wash hands thoroughly
- Wear apron
- Prepare needed articles from the bag

c. Health assessment
- Start with health family member to members with health problem to prevent cross contamination
d. Health teachings
6. Wash hands thoroughly and arrange the equipment
7. Record all important data, observation and care needed
8. Make appointment for the next visit

BAG TECHNIQUE

Definition: Indispensable tool that enables the nurse to perform nursing procedures with ease and deftness, to save time
and effort with the end view of rendering effective nursing care to clients

PUBLIC HEALTH BAG

Definition: An essential and indispensable equipment of a public health nurse which should be carried along during home
visits

Baby Weigh Scale= Sallen Ming Scale

PRINCIPLES: “HAMES”

H- Hand washing
A- Avoid contamination
M- Minimize time and effort
E- Effectivity of care
S- Save time and effort

Rationale: To render effective nursing care to clients and members of family during home visit

Special Considerations:

1. The bag should contain all necessary articles, supplies and equipment, which may be used to answer emergency
needs.
2. The bag and its contents should be cleaned as often, supplies replaced and ready for use anytime.
3. The bag and its contents should be well-protected from contact with any article in home of patients. Consider bag
and its contents clean/sterile while article belonging to patient as dirty and contaminated.
4. Arrangement of bag should be one most convenient to uses to facilitate efficiency and avoid confusion
5. Hand washing is done as frequent.
6. Bag when used for communicable should be thoroughly cleaned and disinfected before keeping and using.

3 C’s

Content- arrangement is based on the uses

Cleanliness- the bag should be thoroughly cleansed after a communicable disease case

Contamination- protect the bag from any contact with any article in the patient’s home

***Work field:

Paper-lining touch

Inner surface: clean

Outer surface: Unclean

28
Materials:

Paper lining 2 pairs of scissors (surgical Adhesive plaster Medications:

and bandage)
Paper bag (waste) 2 pairs of forceps (curved Alcohol lamp Betadine
and straight)
Plastic/ linen lining Syringes Tape measure 70% Alcohol
Apron Needles (19, 22, 23, 25) Baby’s scale Ophthalmic ointment
Hand towel in plastic bag Sterile dressing (OS and 1 pair of rubber gloves Zephiran
cotton balls)
Soap and soap dish Sterile cord tie 2 test tubes Hydrogen peroxide
Thermometer with case (oral Test tube holder Spirit of ammonia
and rectal)
Acetic acid
Benedict’s solution
Note: BP apparatus and stethoscope are carried separately

STEPS:

1. Place bag on the table lined with a clean paper in which the clean side must be out and folded part touching the
table
2. Ask for basin of water
3. Open the bag and take out the towel and soap
4. Wash hands using soap and water. Wipe to dry
5. Take out the apron and put it on with right side out
6. Put out all necessary articles needed for specific care
7. Close the bag and put it in one corner
8. Perform nursing care
9. Clean all used articles and wash hands
10. Open the bag and return articles
11. Remove apron folding it away from the person
12. Fold the lining place it inside the bag and close the bag
13. Record the data that were gathered, observed, and nursing care rendered. Provide instructions for care of client in
the absence of the nurse
14. Make appointment for the next visit

After Care:

1. Clean and alcoholize articles before keeping them

2. Get bag from table, fold paper lining (insert) and place in between the flaps and cover the bag

Evaluation and Documentation:

3. Record all relevant findings about the client and member of the family
4. Take note of environmental factors which affect client’s health
5. Include quality of nurse- patient relationship
6. Assess effectiveness of nursing care given

HOME ISOLATION TECHNIQUES

Principles:

● Do not mix articles used by the patient with articles used by other members of the household
● Frequent washing and airing of beddings and other articles and disinfection of room, use of soap, water,
sunlight and some chemical disinfectants is necessary.
● Caregiver should wear protective gown that should be worn only in the patient’s room
● All discharges should be properly discarded
● Articles soiled with discharges should be boiled in water for 30 minutes before laundering. Those could be
burned should be burned

***Technique to MEMORIZE! “BASA”

B- Boiling should be done before laundering

A- All articles used by the sick member should not be mixed with others
S- Secretions should be disposed properly

29
A- Airing, disinfecting and hand washing should be done

TYPES:

A. Reverse- protect the patient

B. Strict- protect the nurse

THERMOMETER TECHNIQUE

● If mercury thermometer, set at 35°C

● Place at under the tongue (2-3 minutes), axilla (5-8 minutes), rectal (1 minute)

1. Clean from cleanest to dirtiest

Before use: Bulb to stem
After use: Stem to bulb
2. Clean thermometer in downward, spiral and rotating motion
3. Ideal ways:
3x soap- cleansing agent
3x water- rinsing agent
1x alcohol- disinfecting (wrap around bulb then put in kidney basin)
4. Wipe with dry alcohol before returning to case

PROPER BLOOD PRESSURE MEASUREMENT (DOH)

STEPS:

1. Preparatory Phase
● Introduce self to client
● Make sure client is relaxed and has rest for at least 5 minutes and should not have smoked or ingested
caffeine within 30 minutes before measurement
● Explain the procedure
● Assist to sitting or supine position

2. Applying the BP cuff and stethoscope

● Bare the client’s arm
● Apply cuff around the upper arm 2-3 cm above the brachial artery
● Apply cuff snugly with no creases
● Keep the arm at level of the heart
● Keep manometer at eye level
● Palpate the brachial pulse

3. Estimating SBP using Palpatory Method

● While palpating the brachial and radial pulse, close valve of pressure bulb and inflate the cuff until pulse
disappears
● Note the point at which pulse disappears
● This is the palpated SBP

NATIONAL VOLUNTARY BLOOD SERVICES PROGRAM (BLOOD SERVICES ACT OF 1994)

Blood Supply Eligibility

1. Weight 45 kg (100 lbs)= 250 mL & 50 kg (110 lbs)= 450 mL

2. Good health
3. Age: 16-65 years old (Note: 16-17 years old need consent)
4. BP (SBP 90-160 & DBP 60-100)
5. Hgb 12-14 for female & 14-16 for male (at least 12.5 g/dL)
6. Hematocrit 36-42% for female & 42-48% for male

Contraindications:

DM
Cancer

30
 Hyperthyroidism
STD
AIDS
Cardiovascular diseases
Severe psychiatric disorders
TB
Lung disorders
Kidney and liver disease
Epilepsy
Prolonged bleeding
Malaria
Use of prohibited drugs

***SHELF LIFE

1. WBC & RBC= 5 weeks

2. Plasma= 12 months

***Post-Blood Donation

1. Keep an eye on your dressing leave at least 3 hours but not more than 12 hours
2. Avoid carrying heavy objects with donating arm
3. Do not smoke for the next 2 hours and avoid alcohol intake for the next 12 hours
4. Eat regular meals
5. Increase fluid intake

FIELDS IN PUBLIC HEALTH NURSING

SCHOOL NURSING

- The application of nursing theories and principles in the care of the school population
- Focus: Promotion of health and wellness of students, teaching and non-teaching
- Primary Role of CHN: To ensure that educational potential is not hampered by unmet health needs
- Health and Nutrition Center (HNC) of the Department of Education has 2 Divisions:
1. Health Division
2. Nutrition Division

Functions of the School Nurse:

1. School Health and Nutrition survey

2. Putting up a functional school clinic
3. Health assessment
4. Standard vision testing
5. Ear examination
6. Height and weight measurement and nutritional status determination
7. Medical referrals
8. Attendance to emergency cases
9. Student health counseling
10. Health and nutrition education activities
11. Organization of school- community health and nutrition councils
12. Communicable disease control
13. Establishment of data bank on school health and nutrition activities
14. School plant inspection for health environment
15. Rapid classroom inspection
16. Home visitation

OCCUPATIONAL HEALTH NURSING

- The application of nursing principles and procedures in conserving the health of workers in all occupations
- Mission: To assure that every man and woman in the country is safe and in healthful working conditions

Categories of Occupational Hazards

Physical Agents within work that may cause tissue damage

Chemical
Biological Viruses, bacteria, fungi, mold, parasites
31
Mechanical Stress on musculoskeletal
Psychosocial

Occupational Injury- a cut or a fracture, sprain or amputation that results from a single incident in the work environment

Occupational Illness- any abnormal condition other than injury caused by exposure to environmental factors associated
by the environment

Protection of Health Workers

PD 442- Labor Code of the Philippines

RA 7305- Magna carta for Public Health Workers

VITAL STATISTICS

● Refers to the systematic study of vital events such as births, illnesses, marriages, divorces, separation and deaths
● Is a tool in estimating the extent or magnitude of health needs and problems in the community
● Describes the health status of the people which serves as the basis for developing, implementing and evaluating
programs and intervention strategies

Uses of Vital Statistics:

● Indices of the health and illnesses status of the community

● Serves as the basis of PIME CHN programs and services

Pertinent Laws:

RA 3753: Civil Registry Law (now RA 10625)

PD 651: Birth Registration Law within 30 days

Sources of Demographic Data:

1. Census- official and periodic enumeration of population

2 Ways of Assigning People during Census

a. De facto- people assigned to place where they usually live regardless of where they are at the time of census
b. De jure- people assigned to place where they are physically present at the time of census regardless of their
usual place of residence
2. Sample surveys
● Demographic information is collected from the sample of a given population instead of a census
● Data obtained from a small number of people proportion to the total population, the result will always be
generalized for the whole population
3. Registration systems
● Recording of vital events refer to births, deaths, marriages, divorces and the like

VITAL STATISTICS FORMULA SIGNIFICANCE

CRUDE BIRTH RATE NATURAL INCREASE

CRUDE DEATH RATE NATURAL DECREASE

INFANT MORTALITY RATE HEALTH STATUS OF

COMMUNITY

32
MATERNAL MORTALITY RATE PRENATAL CARE

FETAL DEATH RATE PREGNANCY WASTAGE

NEONATAL DEATH RATE POSTPARTUM CARE

INCIDENCE RATE ACUTE DISEASE

PREVALENCE RATE CHRONIC DISEASE

SEX RATIO BALANCE OF MALE OVER

FEMALE

SWAROOP’S INDEX LONGEVITY OF LIFE

ATTACK RATE MORE ACCURATE RISK OF

EXPOSURE

CASE FATALITY RATIO KILLING POWER OF DISEASE

GENERAL FERTILITY RATE REPRODUCTIVE HEALTH

DEPENDENCY RATIO COMPARISON OF

ECONOMICALLY DEPENDENT
TO ECONOMICALLY
PRODUCTIVE
CROWDING INDEX EASE OF COMMUNICABLE
DISEASES TO BE
TRANSMITTED
POPULATION DENSITY CONGESTION OF PLACE

PROPORTIONATE MORTALITY
RATE

33
NATIONAL EPIDEMIC SENTINEL SURVEILLANCE SYSTEM (NESSS)

● Continuous collection and analysis of data of cases and death

● Hospital-based information system that monitors the occurrence of infectious diseases with outbreak
potential

Objectives:

1. To measure magnitude of problems

2. To measure effect of control program

RA 3573: Law on Reporting of Notifiable Diseases

Laboratory Diagnosed Clinically Diagnosed

1. Cholera 1. Dengue Hemorraghic Fever

2. Hepatitis A 2. Diptheria

3. Hepatitis B 3. Measles

4. Malaria 4. Meningococcal Disease

5. Typhoid Fever 5. Neonatal tetanus

6. Non-neonatal tetanus

7. Pertussis

8. Rabies

9. Leptospirosis

10. Polio

PARTNERSHIP AND COLLABORATION

1. NETWORKING
- Relationship among organizations that consists of exchanging information about each other’s goals and objective,
services or facilities

2. COORDINATION
- Relationship where organizations modify their activities in order to provide better service to target beneficiary

3. COOPERATION
- Relationship where organizations share information and resources and make adjustments in one’s own agenda to
accommodate the other organizations’ agenda

4. COLLABORATION
- Level of organizational relationship where organization help each other enhance their capacities in performing their
tasks as well as in provision of services

5. COALITION OR MULTI-SECTORAL COLLABORATION

- Level of organizational relationship where organizations and citizens form a partnership

FAMILY HEALTH NURSING PROCESS

ASSESSMENT

- Initial contact: establish rapport and confidence

- Data collection

34
Methods and Tools of Data Collection: “PROIL”

P- Physical Examination
R- Records review
O- Observation
I- Interview
L- Laboratory/ Diagnostic Tests

INITIAL DATABASE

A. Family structure, characteristics and dynamics

B. Socioeconomic and cultural characteristics
C. Home and environment
D. Health status of each member
E. Values and practices on health promotion, maintenance and disease prevention

FIRST LEVEL ASSESSMENT : IDENTIFY EXISTING OR POTENTIAL HEALTH CONDITIONS

- Identify the “what”

1. Wellness- readiness or potential; a clinical or nursing judgment about a client in transition from a specific level of
wellness or capability to a higher level
2. Health Deficit- a gap between actual or achievable health status, failure in health maintenance
▪ Disease/ disability
▪ “nahitabo na”
▪ There is already existing problem
3. Health Threat- conditions that promote disease or injury and prevent people from realizing their health potential
▪ Risk or potential problem
▪ “mahitabo pa”
4. Foreseeable Crisis/ Stress points- stressful occurrences like death or illness of a family member, marriage,
menopause, abortion, pregnancy or hospitalization

Examples:

1. Poor lighting
2. Stroke
3. Noise pollution
4. Death of member
5. Adolescence
6. Walking barefoot
7. Loss of job
8. Inadequate rest
9. Marriage
10. Breastfeeding
11. Menopause
12. Strained marital relationship

SECOND LEVEL ASSESSMENT: IDENTIFY THE NATURE OR TYPE OF NURSING PROBLEMS

- Identify “why” are the problems

▪ Inability to recognize the presence of the condition or problem

▪ Inability to make decisions with respect to taking appropriate health action
▪ Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/ at-risk member of the
family
▪ Inability to provide a home environment conducive to health maintenance and personal development
▪ Failure to utilize community resources for health care

PLANNING

Steps:

1. Prioritize problems
2. Formulate goals and objectives of nursing care
35
 3. Develop the plan of interventions
4. Develop the plan for evaluating

PRIORITIZATION OF HEALTH PROBLEMS

Nature of Condition Is the problem a wellness condition, health deficit, health threat or
foreseeable crisis

Modifiability of Condition Probability of success in enhancing wellness state

Preventive Potential Refers to nature and magnitude of future problems that can be minimized
or totally prevented if intervention is done

Salience Refers to family’s perception and evaluation of the problems

CRITERIA SCORE WEIGHT

Nature of the Condition
● Wellness 3
● Health deficit 3 1
● Health threat 2
● Foreseeable crisis 1

Modifiability of the Condition

● Easily modifiable 2
● Partially modifiable 1 2
● Not modifiable 0

Preventive Potential
● High 3
● Moderate 2 1
● Low 1

Salience
● A condition needing immediate attention 2
● A condition not needing immediate attention 1 1
● Not perceived as a condition needing change 0

IMPLEMENTATION

- Putting nursing care to action, coordinating services, utilizing community resources, providing health education and
training, and documenting responses to nursing action

EVALUATION

● Types of Evaluation
1. Ongoing Evaluation
2. Intermittent Evaluation
3. Terminal Evaluation

● Classic Frameworks of Evaluation

1. Structural Evaluation- physical settings, instrumentalities and conditions through which nursing care is given
2. Process Evaluation- steps of nursing process itself (ADPIE)
3. Outcome Evaluation- changes in client’s health status that result from nursing intervention

QUALITY ASSURANCE: SENTRONG SIGLA MOVEMENT (SSM) of 1999

36
- Joint effort between DOH and LGU
- Before: Quality Assurance Program (QAP) of 1998

OBJECTIVES: To foster better and more effective collaboration between DOH and LGU, where DOH serves as provider
of technical and financial assistance packages for healthcare and LGU as direct implementer of health programs and
prime developer of health systems

Long-term Goal: Institutionalize SS within the health sector to generate continuous quality improvement in health care

Intermediate Goal: Improve quality of health care in outpatient health facilities, hospitals and public health services

Guiding Principles:

1. Maintain incentive in SS certification: recognition for achieving good quality

2. Quality improvement is an unending process
3. Focus shall be on core public health program proven to be most beneficial to people
4. Partnership that empowers all stakeholders; based on trust and transparency
5. DOH shall give purposive technical assistance to targeted health facilities
6. Assessment for certification shall involve other stakeholders

Level and Scope of Certification:

1. Basic SS Certification- 1st level

2. Specialty Awards- 2 nd level
3. Awards of Excellence- highest

SS Validity: 2 years

Awards for excellence: 3 consecutive

4 PILLARS:

1. Quality assurance
2. Grants and Technical Assistance
3. Health Promotion
4. Awards

A. Scope and Structure of SS Quality Standards- Level I

a. Function: Provide basic public health services

Core Public Health Programs

● Use of herbal medicine
● Botika ng Barangay
● Voluntary Blood Program
● Health Emergency Preparedness and Response Program
● Safe Motherhood and Family Planning
● Child care
● Prevention and Control of Infectious Diseases
● Promotion of Healthy Lifestyle

b. Facility and System Standards

- Ensure that the health facility is appropriately equipped with sufficient manpower, adequate logistics and organized
procedures to efficiently and effectively promote core public health programs

c. Integrated Public Health Function

- Ensure that health facility and staff promote public health programs and prevent and control public health programs
through direct client care

d. Basic Curative Function Standards

- Ensure that the health facility and staff provide basic curative services that consist of primary level outpatient and
emergency care

e. Regulatory Function Standards

37
- Ensure that the health facility and staff support and provide an environment to prevent, reduce and control risks and
hazards to the community

B. Scope and Structure of SS Quality Standards- Level II

a. Local Health System Development

Goal: To strengthen local health systems development

b. Integrated Public Health Functions Covering 5 Core Public Health Programs

Core Public Health Programs:

1. Integrated Women’s Health

2. Child Care
3. Prevention and Control of Infectious Diseases
4. Environmental Health
5. Integrated Prevention and Control of Lifestyle-related Diseases

COMMUNITY HEALTH NURSING PROCESS

Definition: A systematic, scientific, dynamic, ongoing interpersonal process in which the nurse and clients are viewed as a
system with each affecting the other and both being affected by factors within the behavior.

COMMUNITY DIAGNOSIS

Definition: A process in which the PHN and the community are identifying community problems that will serve as basis in
formulating community program

Types:

1. Comprehensive- obtaining general information about the community

Elements:
Demographic variables
Socioeconomic and cultural variables
Health-illness patterns
Health resources
Political leadership patterns

2. Problem-Oriented or Specific- obtaining particular information about the community

SOURCES OF DATA:

1. Primary Data- sources are the community people through surveys, interviews, focused-group discussion,
observations and through actual minutes of community meetings

2. Secondary Data- sources would be organization all records of the program, health center records and other public
records

LAWS AFFECTING CHN

PD 996 Expanded Program on Immunization

RA 8423 Traditional and Alternative Medicine Act
RA 9502 Cheaper Medicines Act
RA 8504 Philippine AIDS Prevention and Control Act
RA 8172 Act for Iodization Law
RA 9211 Tobacco Regulation Act
PD 856 Code of Sanitation
RA 9262 Anti-Violence Against Women and Children
RA 9482 Anti- Rabies Act of 2007
RA 6425 Dangerous Drug Act
RA 3573 Law on reporting Communicable Diseases
RA 6713 Code of Conduct and Ethical Standards for Public Officials and Employees

38
 RA 7305 Magna Carta for Public Health Workers
RA 1082 Rural Health Act
RA 8749 Clean Air Act
PD 825 Proper Garbage Disposal
RA 8976 Food Fortification Act
EO 2009 Family Code of the Philippines
RA 9255 Illegitimate Children to use surname of fathers
PD 965 Family Planning and Responsible Parenthood for Marriage
RA 7600 Rooming-in and Breastfeeding Act
RA 9288 Newborn Screening Act
RA 7875 National Health Insurance Act
RA 4073 Liberalization of Leprosy
RA 9275 Clean Water Act
RA 9003 Ecological Solid Waste Management Act of 2000
RA 7170 Organ Donation Act of 1991
RA 7277 Magna Carta for Disabled Persons

COPAR

⮚ Community Participatory Action Research

⮚ CO- identify and solve client problems
⮚ PAR- Participatory Action Research (Primary Health Care)
⮚ Essential element: Participation
⮚ Role of nurse:
- Facilitator
- Assist
- Teach
⮚ Goal: Community Health Development
⮚ Pag unlad ng isang community
⮚ Social transport for 5 years
⮚ Self- reliance

PHASES OF COPAR:

P- Pre-entry
E- Entry
S- Study (community), diagnosis
O- Organizing (People Organization)
A- Action
S- Sustenance and Strengthening
T- turnover/ Phase out
- Check the structures
- System
- Skills development

PRE-ENTRY (4 CPS)

⮚ Preliminary social investigation- gather data about barangay

⮚ Site selection
⮚ Community consultations/ dialogues
⮚ Courtesy call
⮚ Community profiling
⮚ Community assembly
⮚ Baseline- information discussion, courtesy call

Criteria for site selection:

D- depressed
O- oppressed
P- poor
E- exploited
S- struggling

ENTRY PHASE

39
 ⮚ Social preparation
⮚ Intregation with the community
⮚ Information campaign
⮚ Goal: To establish group for the organization
1. Courtesy call
2. DSI (Deepening Social Integration)- to identify needs
3. Immersion/ integration- imbide life of people in the area

Behavior: “SLAP”

S- simple
L- low profile
A- Approachable
P- participates in social act

Potential leaders (core group)

SALT (Self-Awareness Leadership Training)

Leader:

P- poor
R- respected
C-communicator
D-decisions for change
O-open minded
C-charismatic

⮚ Continuing social investigations

⮚ Core group formation
⮚ SALT

STUDY (Community)/ Diagnostics Phase

⮚ Research phase
⮚ Data/study/ research
⮚ Prioritization of community needs
⮚ PRC
1. Profile in community
2. Research team committee
3. Community Diagnosis
a. Develop instrument
b. Data collection
c. Data collation
d. Data presentation

Graph- many variables

Pie- few variables

Histogram- distribution of frequency

Line graph- distribution of time

e. Data analysis

ORGANIZATION PHASE

⮚ Capability building phase

⮚ Community health organization
⮚ Election of officers
⮚ Action reflection action session (ARAS)
⮚ Organization: plan solution for community problems
⮚

40
B- Building of organization
E- Election of officer
T- Training of officers (ARAS) Action Reflection Action Session
T- Team building of officers

ACTION PHASE

⮚ Setting up of linkages/ ntework

⮚ Referral systems
1. Training community health workers
PIME Planning, Implementation, Monitoring, Evaluation
2. Mobilization

SUSTENANCE & STRENGTHENING

⮚ Formalization of linkages
⮚ Formation and ratification of constitution and by-laws
⮚ Continuation education and training
⮚ Develops medium and long-term CHD Plans

Communicable Diseases

Types:

1. Infectious- not easily transmitted (needs direct skin inoculation)

2. Contagious- easily transmitted (usually droplet)

Characteristics:

a. Infectivity- enter and move into the body

b. Pathogenecity- cause
c. Virulence- strength of the agent
d. Invasiveness- ability to live outside the body

Acquisition

a. Community-acquired- prior to admission

b. Hospital-acquired/ Nosocomial
c. Iatrogenic- during medical or surgical procedures

Mode of Transmission

a. Contact
1. Direct- person to person
2. Indirect- person -> fomite (inanimate object) -> person

b. Droplet- more than 5 microns seen by the naked eye

(Large) drops within 3 feet
Example: sneezing, coughing, talking

c. Airborne- small particles suspended in the air

Example: droplet nuclei, aerosolized product
d. Vector borne- animals
e. Vehicle borne- food-borne, water, disease

Stages of Infection

a. Incubation period- exposure to first signs and symptoms

b. Prodromal- presence of non-specific signs and symptoms to specific signs and symptoms (Pathognomonic sign)
c. Illness/fastiga- presence of all signs and symptoms
d. Convalescent- defervescent- signs and symptoms gradually decrease

Body Defenses

41
First Line of Defense- cell-mediated response, skin, normal flora
Second line of defense- inflammatory response, leukocytosis

*Signs of Inflammation

a. Redness- rubor
Warmth- calor
Swelling- tumor
Pain- Dolor
BLOOD-BORNE DISEASES

DENGUE

1. Definition
a. Also known as Infectious Thrombocytopenia Purpura, Breakbone, Dandy Fever
b. Dengue hemorrhagic fever
c. A mosquito-borne viral disease
d. Transmitted by the bite of an infected female Aedes aegypti (Daytime), Aedes Albopictus (Nighttime), Tiger
Mosquito: Clear and Stagnant
e. Caused by 4 serotypes: Den-1, Den-2, Den-3, Den-4
f. Dengue by characterized by:
i. Fever
ii. Rash
iii. Muscle and joint pains
iv. Bleeding
g. Common during rainy seasons
h. Only through bite of an infected female
i. The vector mosquito becomes infected when it bites people with DHF following 8 to 10 days after the bite.
The infected mosquito then transmits the disease through its bite to other people
j. Characteristics of Dengue mosquito
i. Small, black and white insects
1. With stripes on its legs, body and back
2. Male feeds on plant juices and nectars
ii. Feeding
1. Female- blood meal
2. Male feeds on plant juices and nectars
iii. Generally bite biters
1. Prefers to bite just after sunrise and before sunset
iv. Can fly from 50 to 300 meters only to look for blood meal or breeding site
v. 1 female lays about 60 to 100 eggs per batch; lays about 3-4 batches of eggs in its lifetime
vi. Aedes aegypti prefers to rest at cool shaded places, dark corners, closets and drawers, clear
stagnant waters
2. Etiologic Agent: dengue virus, arbovirus, flavivirus, Chikungunya Virus
3. Incubation period: 1 week
4. Stages:
a. Dengue hemorrhagic fever
i. 1st 4 days: Febrile or invasive stage
ii. 4th to 7th day: Toxic or hemorrhagic Stage
iii. 7th to 10th day: Convalescent or Recovery Stage
5. Grade 1- Dengue Fever
- Herman’s sign (rashes)
- Abdominal pain with vomiting

Grade 2- Dengue Hemorrhagic Fever

- Bleeding

Grade 3- Circulatory collapse

Grade 4- shock, coma, death

6. What should be done?

a. All dengue suspects should be brought to the nearest health facility, do not self- medicate
b. Do not give aspirin- it may lead to bleeding and or gastric irritation

42
 c. Start oral rehydration in the early stages of fever
d. If symptoms persists for 3 or more days or if danger signs appear, refer patient immediately to the hospital
7. Diagnostic Exam
a. Tourniquet test (Rumpels Lead Test)- using the BP cuff; 1 square inch, positive if 20 or more
b. Occult Blood
8. Prevention:
a. Best way: search and destroy
b. Destroy breeding sites:
i. Cover all water containers
ii. Change water of flower vases and scrub side of containers once a week
iii. Dispose of garbage properly and remove rubbish around premises that can collect rain water
iv. Inspect and clean roof gutters
v. Properly arrange discarded tires under the shade or stock pile and place a cover on top
c. Preventing mosquito bites:
i. Install screens on windows and doors
ii. Protective clothing or repellants
iii. Use mosquito nets for infants or adults while sleeping at daytime
iv. Isolate the person sick with dengue in a screened room or by using a mosquito net
9. Modalities of Treatment
a. Paracetamol
b. Blood transfusion
c. Oxygen therapy
d. Sedatives
e. Intravenous fluids

FILARIASIS

Also known as Elephantiasis

1. Definition: a parasitic disease caused by an African eye worm

2. Etiologic agent: Wuchereria bancrofti, Brugia malayi and Brugia timori
3. Incubation period: 8 to 16 months
4. Mode of transmission: person-to-person by mosquito bites Aedes Poecillus (abaca area)
5. Stages:
a. Acute Stage
i. Lymphadenitis- inflammation of lymph nodes
ii. Lymphangitis- inflammation of lymph vessels
iii. Male genitalia affected to funiculitis, epididymitis and orchitis (redness, painful and tender scrotum)
b. Chronic Stage
i. Develop to 10-15 years from onset of first attack
ii. Hydrocele (swelling of the scrotum)
iii. Lymphedema- temporary swelling of the upper and lower extremities
iv. Elephantiasis- enlargement and thickening of the skin of the upper and lower extremities, scrotum
and breast)
6. Diagnostic Exam
a. Nocturnal blood examination (NBE)- taken at patients residence or hospital after 8 pm
b. Immunochromatographic test (ICT)- rapid assessment method; an antigen test done at daytime
c. Bentonite FLucculation test
7. Modalities of treatment
a. Diethylcarbamazine Citrate (DEC) or HETRAZAN/ BELTRAZAN- an individual treatment kills almost all
microfilaria and a good proportion of adult worms
8. Marinduque, Saranggani- provinces considered endemic for filariasis

LEPTOSPIROSIS

Also known as mud fever, Weil’s disease, flood fever

1. Definition: zoonotic infectious bacterial disease carried by animals

2. Etiologic agent: Leptospira interrogans/spirochete
3. Incubation period: 7 to 19 days; average 10 days
4. Period of communicability: 10 to 20 days after onset
5. Source of infection: contaminated food and water, vector- borne RATS
6. Mode of transmission: ingestion or contact with skin and mucous membrane with infected urine
43
 7. Signs and symptoms
a. Septic/Leptospiremic Stage
i. Febrile, lasting 4 to 7 days
ii. Remittent fever
iii. Headache
iv. Myalgia
v. Nausea
vi. Vomiting
vii. Cough
viii. Chest pain
b. Immune or Toxic Stage
i. Lasts 4 to 30 days
ii. Iritis, headache, meningeal manifestations
iii. Oliguria and anuria with progressive renal failure
iv. Shock, coma and congestive heart failure
v. Death may occur between the 9th and 16th day
8. Diagnostic Tests:
a. MAT- Microscopy Agglutination Test
b. LAT- Leptospira Antigen Antibody Test

9. Prevention and control

a. Education on how to control leptospirosis specially during rainy season
b. Protective clothing
c. Stringent community- wide rat eradication program
d. Report all cases
10. Modalities of Treatment
a. Penicillin at 2m units q6 hours IM/IV
b. Tetracycline/Doxycycline 100 mg q12 hors per orem
c. Erythromycin 500 mg q12 hours per orem in patients allergic to penicillin
d. Urine must be properly disposed- using gloves
11. Additional hosts: rat, rabbits, cattles

MALARIA

Also known as Marsh fever

1. Definition: primary vector breeds in clear slow flowing streams, vector in coastal areas
2. Etiologic agent:
a. Plasmodium falciparum- 70%, deadly
b. Plasmodium vivax- 30%
c. Plasmodium malariae- 1% very rare
d. Plasmodium ovale- not found in Philippines
3. Mode of transmission: from an infected mosquito (Anopheles mosquito)
4. Signs and symptoms:
a. Recurrent chills
b. Fever
c. Profuse sweating
d. Anemia
e. Malaise
f. Hepatomegaly
g. splenomegaly
5. Top province: Palawan
6. Diagnostic exam
a. Clinical diagnosis- but have 50% accuracy
b. Blood smear- at the peak of fever
-Thick smear: # of protozoa
-Thin smear: type of protozoa
c. Microscopic diagnosis (Gold Standard)- definite diagnosis
d. Rapid Diagnostic Test (RDT)- to detect plasmodium-specific antigens; takes about 7 to 15 minutes, very
sensitive, accurate 90%; fast to detect
7. First line drug: Arthemeter, Quinine, Chloroquine

44
 Central Nervous System

TETANUS

• Also known as lock-jaw

Etiologic Agent: Clostridium tetani- anaerobic

Incubation Period

• 3 days to 3 weeks- adult

• 3 to 30 days- neonate

Sources of Infection

• Feces
• Soil
• Dust
• Rusty materials
• Mode of Transmission
• Direct inoculation through punctured wound

Entry of Microorganism

• Rugged traumatic wounds or burns

• Umbilical stump
• Unrecognized wound
• Dental extraction
• Ear piercing
• circumcision
• Signs and Symptoms
• Spasm and tightening of the jaw muscle
• Trismus- prolonged tightening of the masseter
• Risus sardonicus- spasm of the facial muscle, lip protrusion
• Opisthotonus- arching of the back

Pathophysiology

• Entry via wound

• Bacterial proliferation
• Immune response
• Secretion of toxins
• Tetanolysin (destruction of RBC)

Spasm of muscles

• Spasm of muscles:
1. Facial muscle- risus sardonicus
2. Masseter- trismus
3. Spine- opisthotonus
4. Respi muscles- dyspnea
5. GUT- urinary retention
6. GIT- constipation
7. Abdomen- abdominal rigidit
8. Extremities- robot gait

Treatment

1. Antitoxin
2. Penicillin G
3. Surgical exploration and cleaning of the wound
4. Muscle relaxant
5. O2
6. NGT feeding
7. Tracheostomy- severe cases

Prevention and Control

● Active immunization with tetanus toxoid for adults

45
 ● Tetanus toxoid- 5 doses

Additional notes:

● Tetanospasm- muscle spasm

● Clostridium tetani- anaerobic; gram-positive; drumstick appearance
● Sources of tetanus infection in a neonate- umbilical stump or cord

Vaccine Minimum Age/ Interval % Protected Duration of Protection

TT1 As early as possible during --- ---
pregnancy
TT2 At least 4 weeks later 80% 3 years
TT3 At least 6 months later 95% 5 years
TT4 At least 1 year later 99% 10 years
TT5 At least 1 year later 99% lifetime

MENINGITIS

Definition: Inflammation of the meninges of the brain and spinal cord

Etiologic agent: Neisseria meningitides

Incubation period: 2 to 10 days

Source of Infection:

● Respiratory droplets
● Direct invasion

Signs and Symptoms:

● Severe headache
● Stiff neck
● Dislike of bright lights
● Fever/ vomiting (projectile)
● Drowsy and less responsive/ vacant (decrease LOC)
● Rashes
● Brudzinski sign- automated reflex of the hips and knees when a patient’s neck is flexed forward while lying down
● Kernig’s sign- severe stiffness and pain of the hamstrings causes an inability to straighten the leg when the hip is
flexed to 90 degrees

Pathophysiology

● Entry of causative agent to the respiratory tract

● s/sx of Upper Respiratory Tract Infection
1. cough, cold, fever, sore throat
● Blood stream, crossing the BBB
● Meninges: inflammatory response
1. Nuchal rigidity- stiff neck
2. Kernig’s sign
3. Brudzinski sign
● Decreased flow of CSF
● Increased ICP
1. Mannitol- decrease ICP, osmotic diuretic
2. Severe headache
3. Projectile vomiting
4. Widening of pulse pressure

Diagnostic Exam

● Lumbar puncture- CSF: cloudy, increased pressure, increased protein and WBC, decreased glucose
● Gram stain and culture of CSF
● Head: CT Scan

46
Modalities

● Antibiotic therapy
● Mannitol- asses urine output, I and O
● Anticonvulsants- priority: safety
● Acetaminophen

ENCEPHALITIS

Also known as brain fever

1. Definition: acute inflammatory condition of the brain

2. Etiologic agent: arboviruses
3. Incubation period: 5 to 15 days
4. Mode of transmission: transmitted to humans by bite of an infected mosquito
5. Signs and symptoms:
a. Flu-like symptoms: (Prodromal)
h. Chills
i. Headache
j. Fever
k. Nausea
l. Vomiting

b. Neurologic symptoms:
i. Confusion
ii. Drowsiness
iii. Stiff neck
iv. Seizures
v. Photophobia

6. Diagnostic Test:
a. Lumbar puncture
b. Serology tests
c. EEG
d. Brain MRI
e. CT scan of the head- to check for inflammation of the head
7. Nursing Management:
a. Symptomatic and supportive
b. Control of convulsions
c. TSB
d. Unless comatose, oral fluid should be encouraged

POLIOMYELITIS

Also known as Infantile Paralysis

1. Etiologic agent: Legio debilitans

2. Incubation period: 7 to 14 days
3. Period of communicability: 1st 3 days to 3 months of illness
4. Mode of transmission: contact transmission
5. Clinical features
a. Acute onset, flaccid paralysis
b. Fever present at onset
c. No progression after 2-3 days
d. Asymmetric
e. Legs affected most often
f. Permanent paralysis
6. Types
a. Abortive type- was exposed, able to harbor, but di nagtuloy ang sakit
b. Pre-paralytic- to bloodstream
c. Paralytic- to CNS
7. Signs and symptoms
a. Nasopharynx- tonsillitis

47
 b. Mouth- Peyer’s patches
c. Cervical lymph nodes
i. Severe muscle pain
ii. Hayne’s sign- head drop
iii. Poker’s sign- opisthotonus with head retraction
iv. Flaccid paralysis- soft, flabby, limp
8. Diagnostic Test: Pandy’s Test
9. Management:
- Treatment of fever
- Enteric isolation
- Firm mattress
- Passive ROM
- Analgesic
- Morphine: Pain reliever
- Moist heat application
- Encourage bed rest
- Dispose excreta and vomitus properly
10. Prevention
a. Salk- IPV (Inactivated Polio Vaccine)
b. Sabin- OPV

*avoid OPV in immunocompromised

RABIES

Also known as Lyssa Virus, Hydrophobia

Agent: Rhabdovirus

Mode of Transmission:

- Bite scratch
- Transplant (Example: cornea)
- Airborne

Incubation Period: 10-14 days

Signs and Symptoms:

- Salivation
- Hydrophobia
- Aerophobia
- Hallucination
- Confusion
- Restlessness
- Agitation
- Respiratory paralysis (cause of death)

Diagnostic Tests: Fluorescent Antibody Test (FAT)

CNS- presence of negri bodies

*Rabies is preventable but not curable

Management:

- Wash wound for 5 minutes (running water)

- Do not rub garlic
- Observe the dog for 10-14 days
- Proceed to hospital- assess severity and duration of bite
- Suture wound as needed, emphasize on drainage
- Anti-tetanus serum
- Anti-rabies
- Vaccination of dogs at 3 months

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 Integumentary System

CHICKENPOX

• Definition:Characterized by vesicular eruptions on the sin and mucous membrane

• Centrifugal (starts from trunk, then palabas)

Etiologic Agent

• Varicella zoster agent

Incubation Period

• 2 to weeks (3 to 17 days)

Period of Communicability

• 1 day before eruption of first lesions and 6 days after appearance of first crop or 6 days after crusting

Mode of Transmission

• Airborne or droplet
• Direct contact
• Indirect contact

Signs and Symptoms

a. Pre-eruptive Stage (Prodromal Stage)

1. Fever

2. malaise

• Signs and Symptoms

b. Eruptive Stage

1. Rashes starts from trunk

2. Initial lesions: red papules

3. Content of lesions become milky and pus-like within 4 days, fluid-filled vesicles

4. Pruritus

Pathophysiology

1. Macule

2. Papule

3. Fluid-filled vesicles

4. Crusting

Modalities

1. Zovirax

2. Acyclovir

3. Oral antihistamine

4. Calamine lotion- or baking powder paste for pruritus

5. Antipyretic

49
GERMAN MEASLES

Etiologic Agent

• Rubella virus

Incubation Period

• 14 to 21 days or 2 to 3 weeks

Mode of Transmission

• Direct contact

• Droplet method

Complication

1. Encephalitis

2. Neuritis

3. Arthritis

4. Arthralgia

Signs and Symptoms

a. Prodromal Stage

1. Low grade fever

2. Malaise
3. Headache
4. Mild coryza
5. Conjunctivitis

b. Eruptive Stage

1. Forcheimer’s spots
2. Exanthematous rash

Management

1. Isolation
2. Bed rest until fever subsides
3. Darken room- if eyes affected
4. Liquid diet
5. Eye irrigation- for conjunctivitis
6. Good ventilation

Additional Notes

• German measles- no desquamation

• Measles- with desquamation

MEASLES

Definition

• Acute exanthematous disease and symptoms referable to the upper respiratory tract

Etiologic Agent

• Rubeola

Incubation Period

50
 • 10 (fever) and 14 (rashes) days

Period of Communicability

• 4 days before and 5 days after the appearance of rashes (catarrhal stage)

Source of Infection

• Blood
• Secretion of eyes, nose and throat
• Mode of Transmission
• Direct and indirect contact
• Droplet

Complication

• Bronchopneumonia- most common

• Otitis media
• Nephritis
• Encephalitis
• Blindness

Signs and Symptoms

a. Pre-eruptive Stage (Prodromal)

1. Fever
2. Catarrhal symptoms: rhinitis, conjunctivitis, photophobia, coryza
3. Koplik’s spots- buccal cavity

• Signs and Symptoms

b. Eruptive Stage

1. rash: 4-5 days

2. Rash: cheeks, bridge of the nose, along the hairline temple or earlobe, but not on the nape
3. Anorexia and irritability
4. Pruritus

c. Stage of Convalescence

1. Rashes fade: face downwards

2. Desquamation
3. First in, first out na pagwala sa rashes

Modalities

• Penicillin- to prevent secondary infection

LEPROSY

• Also known as Hansen’s Disease

Definition

• A chronic system infection characterized by progressive cutaneous lesions

• A chronic mild communicable disease caused by Mycobacterium leprae, rod-shaped bacteria
• Mainly affects the skin, peripheral nerves, eyes, mucosa of the upper respiratory tract

Etiologic Agent

• Mycobacterium leprae

Incubation Period

• 5 ½ months to 8 years

Mode of Transmission

51
 • Contact- prolonged skin to skin contact

• Droplet- a very rare mode of transmission

Signs and Symptoms

a. Early

1. Anhdrosis
2. Reddening of the eyes
3. Light discoloration or reddish skin lesions with definite loss of sensation
4. Positive slit skin smears
5. Neonyne face

b. Late
1. Loss of eyelid reflex
2. Gynecomastia in males
3. Sunken nose bridge
4. Madarosis- falling of the eyebrows
5. Clawing and contracture
6. Chronic ulcers= sole, palm, fingers
7. Lagopthalmos

Diagnostic Exam: Slit Skin Smear, Lesion Biopsy

Management: Multi Drug Therapy

a. Paucibacillary- non-infectious/ tuberculoid/ indeterminate (6-9 months)

- Rifampicin, Dapsone
b. Multibacillary- infectious/ lepromatous/ borderline (24-30 months)
- Rifampicin, Dapsone, Clofazimine

SCABIES

Definition: Infestation of the skin produced by the burrowing action of a parasite mite resulting in irritation and the
formation of vesicles or pustules

Etiologic agent: Sarcoptes scabiei

Incubation period: within 24 hours

Period of Communicability: For the entire period the host is infected

Mode of transmission:

a. Direct contact
b. Indirect contact

Usually infected sites:

- Nipples a
- Armpits
- Wrists
- Fingers
- Belly button
- Pubic area

Signs and Symptoms:

- Itching, especially at night

- Thin, pencil-mark lines on the skin
- Rashes
- Skin abrasions

Modalities of Treatment

- Scabicide: Eurax Ointment (Crotamiton)

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 - Pediculicide: Kwell lotion (Gamma Benzene Hexachloride)- contraindicated in young children and
pregnant women
- Topical steroids
- Hydrogen peroxide: cleanliness of wound
- Lindae Lotion for Itchiness

Nursing Management:

- Apply cream at bedtime, from neck to toes

- Instruct patient to avoid bathing for 8 to 12 hours
- Dry clean or boil bedclothes- boil 30 minutes before laundering
- Report any skin irritation
- Good handwashing

MUMPS

Also known as parotitis

Definition: manifested by swelling of one or both parotid glands

Etiologic agent: Paramyxovirus

Incubation Period: 12 to 26 days

Period of communicability: before onset of parotid gland swelling until it remains

Mode of Transmission: respiratory droplets, direct contact

Signs and Symptoms:

- Sudden earache
- Face pain
- Swelling of the parotid glands
- Headache
- Fever
- Sore throat
- Swelling of the temples or jaw

Modalities of Treatment:

a. Relief of pain
b. Bed rest
c. Orchitis
- Suspensory
- Sedatives
- 300 to 400 mg Cortisone followed by 100 mg every 6 hours

d. Diet
- Soft or liquid

Respiratory System

Pertussis

Also known as whooping cough

Agent: Bordette Gengou/ Bordetella Pertussis

Mode of Transmission: Airborne

Signs and Symptoms:

a. Catarrhal Stage
- Most communicable
- Cough, coryza, frequent sneezing, fever, teary eyes
b. Paroxysmal Stage

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 - Frequent coughing ending in inspiratory whoop

Diagnostic Test: Nasal and throat swab

Drug of Choice: Erythormycin

Prevention: DPT

DIPHTHERIA

Also known as: Corynebacterum diphtheria/ Klebs Loeffler Bacillus

Mode of Transmission: droplet

Signs and Symptoms: pseudomembrane, Bull-neck appearance

Diagnostic Tests:

1. Nasal and throat test- confirmatory

2. Shick’s Test- susceptibility to Diptheria
3. Maloney’s Test- hypersensitivity to Diptheria

Management:

1. Never remove pseudomembrane- bleeding

2. Give anti-Diphtheria Serum (neutralize toxin)
3. Drug of choice: Erythromycin
4. Prevention: DPT

TUBERCULOSIS

Also known as Koch’s Disease/Consumptios/Poor Man’s Disease

Agent: Mycobacterium tuberculosis, Mycobacterium bovis- cattle

Mode of Transmission: airborne

Incubation period- 6- 8 weeks

Signs and Symptoms:

1. Afternoon fever
2. Night sweats
3. Chest pain, backpain
4. Anorexia
5. Weight loss
6. Easy fatiguability
7. hemoptysis

Diagnostic Test:

1. Presumptive Test- Mantoux Test, PPD, Tuberculin Test

ID: 48-72 hors- check induration in 48-72 hors
Immunocompromised- 5 mm induration
With risk- 10 mm
Without risk- 15 mm

2. Confirmatory Test: Direct Sputum Smear Microscopy

Acid Fast Bacilli
X-ray (determines extent of lesion)

Management: DOTS- Direct Observe Treatment Shortcourse

Intensive Phase Maintenance Phase

Category I New cases 2 RIPE 4 RI
(+) Chest X-ray
(+) Sputum
54
Category II Fall cases: Relapsing 2 RIPES 1 RIPE
5 RIE
Category III (-) Sputum 2 RIP 4 RI
(+) Chest X-ray
Category IV Multi-Drug Resistant

6 months- short

8 months- longest

Side effects:

Rifampicin- orange red secretions

Isoniazid- peripheral neuropathy

Pyrazinamide- high uric acid, hepatotoxicity

Ethambutol= eye problems

Streptomycin- ototoxic, tinnitus

Gastrointestinal System

TYPHOID FEVER

Also known as Enteric Fever

Agent: Salmonella typhi

Mode of Transmission: fecal-oral

Signs and Symptoms:

a. Rose Spots- due to Peyer’s patches

Diagnostic Test:

a. Typhi Dot
b. Widal’s Test

Management: Chloramphenicol

SCHISTOSOMIASIS

Also known as snail fever, Bilhariasis, Katayama Disease

Agent: parasite: Cercaria

Schistosoma: Japonicum- Philippines

Haematobium

Mansoni

Signs and Symptoms:

a. Fever
b. Increased abdominal girth
c. Eosinophilia
d. Cough

Diagnostic Tests: KatoKatz Test

Drug of choice: Praziquantel

Prevention: Wear Boots

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AMOEBIASIS

Also known as Amoebic Dysentery

Agent: Entamoeba Histolytica

Mode of transmission: Fecal-oral

Signs and Symptoms: bloody mucoid stool- dysentery

Drug of choice: Metronidazole (Flagyl)

CHOLERA

Also known as Eltore

Agent: Vibro cholera

Mode of Transmission: Fecal-oral

Signs and Symptoms:

a. Washer Woman’s sign- wrinkled skin due to dehydration

b. Rice, watery stool
c. Poor skin turgor

Drug of choice:

a. Tetracycline
b. Nalidixic Acid

BIRD FLU

Definition: Flu infection in birds that affects humans

Etiologic agent: Avian influenza virus

Incubation period: 2-4 days

Mode of Transmission: Handling infected bird

What is bird flu?

a. Contagious disease of birds

b. H5N1 virus- can also cause severe infections in humans
c. Bird flu can enter the country through smuggling of infected birds

How is bird flu transmitted to humans?

a. Close contact with infected birds

b. Inhalation or contamination with infected discharges or feces of infected birds
c. Feces with the virus dries up, become pulverized and can be inhaled
d. Flapping of wings of infected birds
e. One does not get bird flu from thoroughly cooked chicken meat

Signs and symptoms:

a. Fever
b. Cough
c. Body weakness and muscle pain
d. Sore throat
e. Difficulty of breathing
f. Sore eyes and diarrhea

What to do with infected humans?

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 a. Quarantine
b. Place face mask on patient
c. Protect self-using mask and goggles
d. Keep distance to 1 meter from patient- dapat more than 3 feet from the patient
e. Transport patient to DOH for referral

Treatment:

a. Osetalmivir given in the first 2 days in the onset of fever

OPLAN S4 for Bird Flu

a. Structure
b. Surveillance
c. Statements to the Public
d. Supplies

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