Community Health Nursing Review

Community Health Nursing
Mark Anthony F. Rosario

BSN.,RN.,MAN
Asst. Secretary of
Operating Nurses
Association of the
Philippines

Definitions
• “Public Health is the science and art of
preventing disease, promoting life,
and promoting health…”
- Dr. C.E. Winslow
• “Public Health Nursing is the practice of
nursing in national and local
government health departments. …
community health nursing practiced
in the public sector.”
- Standards of Public Health Nursing in
the Philippines, 2005

• Community Health Nursing is “the
utilization of the nursing process in
the different levels of clientele-
individual, families, population groups
and communities… promotion of
health, prevention of disease and
disability, and rehabilitation”
- Dr. Araceli Maglaya, et. al.

Need to Remember
• Individual, Family, Population Groups,
and Community are the four LEVELS
of clientele
• Community is the patient in CHN
• Family is the unit of care
• Goal of CHN is achieved through
multisectoral efforts
• CHN is part of Health Care System and
the Larger Human Services System
Special Note:
• The Public Health Nurse will take
charge of the Municipal Health
Officer’s responsibilities in the event
that the MHO is unable to perform his
duties or is not available

Role of Public Health
Nurse
• Clinician
• Health Educator
• Coordinator and collaborator
• Supervisor
• Leader and Change Agent
• Manager
• Researcher

Health Care Delivery
System
• The Public Sector
• Department of Health
– Vision: The DOH is the leader, staunch
advocate, and model in promoting
health for all in the Philippines.
– Mission: Guarantee equitable,
sustainable, and quality health for all
Filipinos, especially the poor and lead
the quest for excellence in health.
– Goal: Health Sector Reform Agenda
• EO 102 identifies the DOH as the
national health authority
• FOURmula ONE for Health
– Framework for the implementation of
the Health Sector Reform Agenda
• Four Elements
– Good Governance
– Health Financing
– Health Regulation
– Health Service Delivery

Local Government Units
• RA 7160 or Local Government Code of
1991
– Devolution of powers, functions and
responsibilities
– Provincial and municipal level
• District Health System – smallest
manageable unit in areas which are
small enough to be managed without
being bogged down by bureaucracy,
yet large enough to be feasible
Primary Health Care
“Essential health care made
universally accessible to
individuals and families in the
community by means acceptable
to them through their full
participation and at a cost that
the community can afford at
every stage of development.”
 World Health Organization
Things to Remember:
• PHC Goal: HEALTH FOR ALL BY THE
YEAR 2000
– Alma Ata, USSR, First International
Conference on PHC, September 1978
• Legal Basis: LETTER OF INSTRUCTION
949 signed by Pres. F. Marcos
• Underlying Theme: HEALTH IN THE
HANDS OF THE PEOPLE BY 2020

Primary Health Care
• Four Pillars of PHC
 Support mechanism made
available
 Active community
participation
 Intra- and inter-sectoral
linkage
 Use of appropriate
Levels of Health Care
• Two Levels of Primary Health Care
Workers
– Village or Barangay Health Workers
• Trained CHW
• Health auxiliary volunteers
• Traditional birth attendants
– Intermediate Level Health Workers
• General medical practitioner
• Public health nurses
• Rural sanitary inspectors
• Midwives
Three Levels of Health Care
Services
Primary Secondary Tertiary
Barangay Health Emergency or Regional Health
Station District Hospitals Services
Rural Health Units Provincial or City Regional Medical
Community Hospitals Centers and
Hospitals Training Hospitals
National Health
Services Medical
Centers

Levels of Disease
Prevention
• Primary Level Disease Prevention
– Directed at individuals at risk; specific
protection against risks
– Immunizations
– Food supplementation
– Malaria chemoprophylaxis

• Secondary Level of Prevention
– Directed for individuals in the subclinical
asymptomatic and symptomatic stage;
aims to diagnose and treat existing
health problems
– Screening
– Casefinding
– Surveillance
– Treatment of communicable disease

• Tertiary Level Disease Prevention
– Directed towards individual in the
pathogenic stage of disease; deals
with the reduction of the magnitude
and severity of the residual effects of
communicable and non-communicable
diseases
– Rehabilitation
– Control of measles during an epidemic


Primary Health Care
• Education for Health
• Locally Endemic and Communicable
Disease Control
• Expanded Program on Immunization
• Maternal and Child Health
• Essential Drugs
• Nutrition
• Treatment
• Safe Water and Sanitation
• Dental Health
Family Health Nursing
Process
• First Level Assessment
– Wellness Condition
– Health Deficit are instances of failure in
health maintenance
– Health Threat are conditions that are
conducive to disease, accident, or
failure
– Foreseeable crisis or stress points are
anticipated periods of unusual demand
on the individual or family in terms of
adjustment
• Second Level Assessment
– Inability to recognize the existence of a
health condition or problem
– Inability to make decisions with respect
to taking appropriate health action
– Inability to provide nursing care to the
sick, disable, or dependent member of
the family
– Inability to provide a home environment
that is conducive to health
maintenance and personal
development
– Failure to utilize community resources
Scale of Ranking Health
Conditions
Criteria Score Weight
Nature of the Condition 1
Wellness
Modifiability of the Condition 3 2
Health Deficit
Easily modifiable
Preventive Potential 32 1
Health 231
SalienceThreat
Partially
High modifiable 1
Foreseeable
Not crisis immediate
modifiable
Moderate 012
A condition needing
Low
attention 1
A condition not needing immediate 0
attention
Not perceived as a condition
Home Visit
Principles
• Must have a purpose
• Makes use of all available information about
a patient
• Consider and give priority to needs of clients
• Involve clients
• Should be flexible
•
Guidelines to consider about frequency of
visits
• Need of the client
Steps in Conducting Home
Visits
1.Greet the client and introduce self
2.State the purpose of the visit
3.Assess the health needs
4.Perform the bag technique
5.Perform nursing care and give health
teachings
6.Record all data (observation and care
rendered)
7.
Bag Technique
• Is a tool used by the nurse to enable
her to perform a nursing procedure
with ease and deftness
• PHN Bag is an essential and
indispensable equipment of a public
health nurse which she has to carry
along during home visits
• The BP Apparatus is part of the PHN
Bag
Bag Technique
Principles
• Minimize, if not prevent the spread of
infection
• Saves time and effort of the nurse
• Should show effectiveness of total care given
to an individual or family
• Can be performed in a variety of ways
Important Points
• Should contain all necessary articles/supplies

• Should be cleaned very often and supplies
are replaced Community Health Nursing
Community Diagnosis
• An in-depth process in finding out the
profiles, health status of the community
and the factors affecting the present status
1.Preparation for Community Diagnosis
2.Data gathering (spot map, key informant
interview, community survey, records
review)
3.Data presentation
4.Problem identification
5.Preparation of an action plan
Community Organizing
• Is a process by which people, health
services and agencies of the
community are brought together to:
a.Learn about common problems
b.Identify these problems are their own
c.Plan the kind of action to solve
problems
d.Ac on this basis

Community Organizing
Participatory Action
Research
• Principles:
– People have the capacity to change
– COPAR should be based on the interest
of the poorest sectors of society
– COPAR should lead to the development
of self-reliance
• Methods:
– Action-Reflection-Action-Session
– Consciousness-Raising

COPAR Phases
• I. Pre-Entry Phase
– Site Selection
• Must be DOPE
• Health services are inaccessible or
inadequate
• Poor health status
• Area has no serious peace and order
problem
• No strong resistance
• Area is free from relatively similar
programs
– Preliminary Community
Social Investigation
Health Nursing
• II. Entry Phase
– Integration
– Conduct of Information Campaign
– Deepening Social Investigation
– Identification of Potential Leaders
– Provision of Health Services
– Core Group Formation

• III. Organization-Building Phase
– Preparing the community for
organization-building
– Organizing the CHO
– Training and Education for the CHO
– Setting up the CHO

• IV. Sustenance and Strengthening
Phase
– Education and Training
– Networking and Linkages
– Community Mobilization on Health and
Development Concerns
– Development of Secondline Leaders

Expanded Program on
Immunization
Vaccine Minimum Number of Amount Route Interval
BCG Agebirth
At Doses
1 0.05 mL ID
Hepatitis B At birth 3 0.5 mL IM (thigh) 10th and
DPT 6 weeks 3 0.5 mL IM (thigh) th week
414weeks
OPV 6 weeks 3 2 drops PO 4 weeks
Measles 9 months 1 0.5 mL IM (arm)
If ch ild h a s co n vu lsio n s, D o N O T g ive D P T

If ch ild is im m u n o co m p ro m ise d , D o N O T g ive
Po lio , M e a sle s, a n d B C G ! ! !
Immunize every sick child
Tetanus Toxoid
Vaccin Minimum Time and Percent Duration of Protection
e
TT1 Interval
As early during 0Protection
TT2 4pregnancy
weeks 80 3 years; Infants protected
TT3 6 months 95 from NTInfants protected
5 years;
TT4 1 year 99 from NT Infants protected
10 years;
TT5 1 year 99 from NT ALL Infants
Lifetime;
protected from NT

EPI: Cold Chain
• Storage:
–6 months Regional Level
–3 months Provincial/District Level
–1 month Main Health Centers
–5 days Health Centers

Family Planning
• Principles:
– Responsible Parenthood
– Respect for Life
– Birth Spacing
– Informed Choice
• Mandate: EO 119 and EO 102

Contraceptive Methods
• Natural
– Abstinence
– Calendar Method
– Basal Body Temperature
– Cervical Mucus (Billings)
– Symptothermal method
– Lactation Amenorrhea Method
– Coitus Interruptus
– Standard Days Method – Cycle Beads
• Surgical Methods
Contraceptive Methods
• Hormonal
– Progestin-Only Oral Contraceptives
– Low-Dose Combined Oral Contraceptives
– Injectables
– Norplant Implants

• Barrier
– Intrauterine Device
– Diaphragm
Malnutrition
• Vitamin A Supplementation
– Infants (6 to 11 months) 100,000 IU – 1
dose
– Children (12 to 72 months) 200,000 IU –
1 capsule every 6 months
– For Pregnant women given starting 4th
Month 10,000 IU twice a week until
delivery
• Iron Supplementation
– For Pregnant women 60 mg Iron and 400
mcg Folic Community
acid 1 tablet OD for 6
Health Nursing
months or 2 tabs per day if started in
• Iron Supplementation
– For Low Birth Weight - drops 15 mg
Iron/0.6 mL, 0.3 mL once a day to start
2 months until 6 months
– For 1 to 5 y/o – syrup 30 mg Iron/5 mL, 1
tbsp OD for 3 months or 1 tsp once a
week for 6 months
– For 6 to 11 years anemic and
underweight – syrup 30 mg/5 mL, 2
tbsp OD for 6 months
• Iodine Supplementation
– Iodized capsule with 200 mg iodine 1
IMCI
• Assess, Clasify, Identify, Treat
• CUVA
•

Garantisadong Pambata
• Campaign to support various health
programs that will reduce childhood
illnesses
• Vit. A and iron supplementation
• Catch-up immunization
• Done twice a year (one week in April,
and one week in October)

Newborn Screening
Disorder Effects
Congenital Hypothyroidism Mental Retardation
Congenital Adrenal Hyperplasia Death
Galactosemia Death and cataracts
Phenylketonuria Mental Retardation
G6PD Deficiency Anemia and Kernictirus
D o n e a fte r 2 4 , 4 8 th to 72 nd hour after birth;

scre e n e d a g a in a fte r 2 w e e ks fo r m o re
a ccu ra te re su lts
U se s h e e lp rick m e th o d a n d a n a b so rb e n t
filte r p a p e r a n d d rie d fo r 4 h o u rs
R e p o rt p o sitive re su lts im m e d ia te ly
Environmental Sanitation

DOH Herbal Medicines
• BAYABAS
• ULASIMANG BATO
• BAWANG
• LAGUNDI
• YERBA BUENA

• SAMBONG
Isolation Precautions
• Universal Precautions or Standard
Precautions
– Apply to blood, all body fluids,
secretions, and excretions; skin that is
not intact; and mucus membranes
• Hand Hygiene or Handwashing
– Best way to prevent spread of
pathogens
– May use alcohol based when hands are
not visibly soiled
– Handwashing is for visibly soiled hands
Transmission Based Precautions
Airborne Precaution Droplet Precaution Contact Precaution
For PTB, measles, For influenza, Skin to skin contact or
varicella meningitis, diptheria, through fomites
Must use a particulate rubella Requires gloves, a
filter mask Safe 3 feet and more mask, gown, and
personal equipment
D o N O T R E C A P N E E D LE S !

Tuberculosis
• TUBERCULOSIS
– CA: Mycobacterium tuberculosis
– MOT: Airborne droplet through coughing
and sneezing
– Direct Sputum Smear Microscopy is the
PRIMARY diagnostic tool
– PPD:
• (+) >5 years (-) HIV 10 mm
induration
• (+) <5 years (+) HIV 5 mm
induration
Tuberculosis
• TUBERCULOSIS
– CA: Mycobacterium tuberculosis
– MOT: Airborne droplet through coughing
and sneezing
– Direct Sputum Smear Microscopy is the
PRIMARY diagnostic tool
– PPD: Detects presence of antibodies;
Results after 48 to 72 hours
• (+) <5 y/o (+) BCG ≥10 mm is
positive
• (+) >5Community
y/o (-) BCG ≥5 mm is
Health Nursing
Directly Observed
Treatment - Shortcourse
Category Type of TB Patient Intensive Continuatio
I New smear-positive; 2Phase
RIPE 4n RI
Phase
II With extensive
Treatment parenchymal lesion
failure 2 RIPES/ 5 RIE
III EPTB
Relapse
New smear-negative PTB with 1RIPE
2 RIPE 4 RI
IV Severe
Chronicconcomitant
minimal parenchymalHIV disease
lesions Refer

Antimycobacterials
• Rifampicin – take with meals; protect
from light
• Isoniazid – take before meals; give 10
to 100 mg of Pyridoxine
• Pyrazinamide – caution for gouty
arthritis; protect from light
• Ethambutol – not given to children
below 6 years
• Streptomycin – given IM
• Community Health Nursing
Leprosy
• LEPROSY (Hansen Disease)
– CA: Mycobacterium leprae
– MOT: Direct skin contact; prolonged
– Dx: Slit Skin Smear
– Types:
• Paucibacillary: Treat with Rifampicin
and Dapsone for 6 to 9 months
• Multibacillary: Treat with Rifampicin,
Clofazimine, and Dapsone for 24
to 30 months
– Community Health Nursing
Malaria
• MALARIA
– CA: Plasmodium (vivax, ovale, malariae,
falciparum)
– MOT: Bite of anopheles mosquito
– DX: Quantitative Buffy Coat
– Treatment: Quinine, Sufadoxine,
Chloroquine, Mefloquine
– Prophylaxis: Chloroquine, weekly
intervals, start 1 to 2 weeks prior to
entering endemic area.
– Update: Artemeter-Lumefantrine
Dengue Hemorrhagic
Fever
• DENGUE HEMORRHAGIC FEVER
– CA: Dengue virus (I, II, III, IV) and
Chikungunya virus
– MOT: Bite of Aedes aegypti virus
– Dx: Tourniquet test (capillary fragility or
Rumpel Leads test)
– Treat:
• Fluids
• Paracetamol
• WOF bleeding
Filariasis
• FILARIASIS
– CA: Wuchereria brancrofti, Brugia
malayi, Brugia timor
– MOT: Bite of Aedes poecilius
– Dx: symptomatology: obvious
lymphadenitis, lymphangitis,
lymphedema, elephantiasis, orchitis
– Treat:
• Diethylcarbamazinecitrate
(Hetrazan)
Schistosomiasis
• SCHISTOSOMIASIS (Bilhariasis, Snail
Fever)
– CA: Schistosoma japonicum,
Schistosoma mansoni, Schistosoma
haematobium
– Intermediate Host: Oncomelania
quadrasi
– MOT: Skin contact to contaminated
water
– Treat:
• Praziquantel (Biltricide)
Measles
• MEASLES
– CA: Paramyxovirus
– MOT: Airborne droplet (1 to 2 days
before onset of s/s; 4 to 5 days after
disappearance of rash)
– Pathognomonic Sign: Koplik’s spots
– PVT: Measles vaccine
– Mgt:
• Vitamina A Supplementation
• Ibuprofen or Paracetamol
• Supportive
Chicken Pox
• CHICKEN POX
– CA: Varicella-Zoster Virus
– MOT: Direct contact (1 to 2 days prior to
appearance of rashes; 5 to 6 days onset
of vesicular crusting)
– S/S: Vesicular rash starts from the trunk to
peripheries
– Mgt:
• Acyclovir 800mg TID
• Paracetamol
• Keeping fingernails short
• Oatmeal bath
Mumps / Parotitis
• MUMPS / PAROTITIS
– CA: Mumps Virus
– MOT: Airborne droplet (1 to 2 days
before onset of parotitis; 5 days after
onset of swelling)
– Compli: orchitis, oophoritis, infertility,
meningoencephalitis
– PVT: MMR at 12 to 15 M; Booster at 4 to
6 years
– Mgt:
• Bedrest
• Antipyretics
Diphtheria
• DIPHTHERIA
– CA: Corynebacterium diphtheria (Klebs-
Loeffler bacillus)
– MOT: Contact with ill or contaminated
articles
– Pathognomonic Sign: Pseudomembrane on
throat and tonsils
– Dx: Culture of membrane
– PVT: DPT vaccine
– Mgt:
• Diphtheria antitoxin, penicillin,
erythromycin
Tetanus
• NEONATAL TETANUS and TETANUS OF
OLDER AGE GROUPS
– CA: Clostridium tetani
– MOT: Contamination of unhealed cord
stump
– Treat:
• Penicillin I.V.
• Tetanus antiserum or tetanus
immunoglobulin
– PVT:
• TetanusCommunity
vaccine Health Nursing
Influenza
• INFLUENZA
– CA: Influenza virus (A, B, C)
– MOT: Droplet
– PVT: Inactivated (IM) for 6 months and
older; Live, attenuated (Nasal Spray)
for 2 to 49 years
– Mgt:
• Supportive


Influenza A H1N1

Pneumonia
• PNEUMONIA
– CA: a lot!
– MOT: mainly respiratory droplet
– Treat:
• Anti-infectives (Antibiotics,
Antivirals, Antifungals)
• Antipyretics
– Mgt:
• Supportive

Cholera
• CHOLERA (EL TOR)
– CA: Vibrio cholerae
– MOT: Fecal-oral route
– S/S: Rice-water stool
– Treat:
• Tetracycline
– Mgt:
• OReSol, coconut water, “am”, soap,
cereals, BF

• Community Health Nursing

Typhoid Fever
• TYPHOID FEVER
– CA: Salmonella typhi
– Note: Rose spots on abdomen or chest
– Treat:
• Chloramphenicol
– Mgt:
• Rehydration
• Proper food preparation
–
Shigellosis
• SHIGELLOSIS (Bacillary dysentery)
– CA: Shigella (dysenterae, flexneri,
boydii, soneii)
– Treat:
• Trimethoprim-sulfamethoxazole
– Mgt:
• Rehydration

Amebiasis
• AMEBIASIS (Amebic dysentery)
– CA: Entamoeba histolytica
– Treat:
• Metronidazole
– Mgt:
• Rehydration

Soil-Transmitted
Helminthiasis
• SOIL-TRANSMITTED HELMINTHIASIS
– CA: Ascaris lumbricoides, Trichuris
trichiura, Ancylostoma duodenale &
Necator americanus (Hookworn)
– MOT: Contact with contaminated soil
– Treat:
• Mebendazole
• Albendazole

Paragonimiasis
• PARAGONIMIASIS
– CA: Paragonimus westermani (subsp.
philippinensis), Paragonimus
siamenses
– MOT: ingestion of raw crab
(Sundathelpusa philippina, Varona
litterata)
– Treat:
• Praziquantel
• Bithionol
– Mgt:
• ProperCommunity
food Health
preparation
Nursing
Hepatitis A
• HEPATITIS A (Infectious Hepatitis,
Epidemic Hepatitis, Catarrhal
Jaundice)
– CA: Hepatitis A virus
– MOT: Fecal-oral route, parenteral
– Treat:
• IM injection of gamma globulin
– Mgt:
• Environmental sanitation
Paralytic Shellfish
Poisoning
• PARALYTIC SHELLFISH POISONING (Red
Tide Poisoning)
– CA: Dinoflagellates (Pyromidium
bahamense var. compressum in Manila
Bay, Samar, Bataan, Zambales)
– MOT: Eating contaminated bivalve
shellfish
– Treat/Mgt:
• Induce vomiting
• Pure coconut milk and sodium
bicarbonate
Leptospirosis
• LEPTOSPIROSIS (Weil’s Disease, Trench
Fever, Mud Fever, Flood Fever,
Japanese Seven Days Fever,
Spiroketal Jaundice)
– CA: Leptospira interrogans
– MOT: Skin contact to contaminated
water or moist water
– Treat:
• Penicillin
• Tetracycline
• Erythromycin
Rabies
• RABIES (Hydrophobia)
– CA: Rabies virus
– MOT: Bite of a rabid animal, or through
scratches on the skin
– Treat/Mgt:
• Wash area with soap and water
• Rabies immunoglobulin and active
immunization

Scabies
• SCABIES
– CA: Sarcoptes scabiei
– MOT: Direct contact with infected person
or through fomites
– Treat:
• Benzyl benzoate
• Permethrin (Kwell)
– Mgt:
• Personal hygiene
• Environmental sanitation

Anthrax
• ANTHRAX (Woolsorter Disease,
Ragpicker Disease)
– CA: Bacillus anthracis
– MOT: Ingestion, inhalation or cutaneous
contact with spore
– Treat:
• Penicillin
• Erythromycin
• Tetracycline
–
Sexually Transmitted
Infections
• GONORRHEA (GC, Clap, Drip)
– CA: Neisseria gonorrheae
– MOT: Sex, Mother to child during
delivery
– Treat:
• Ceftriaxone
• Azithromycin
• Doxycycline

• SYPHILIS
– CA: Treponema pallidum
– MOT: Sex
– 4 Stages (First, Second, Latent, Late)
– Complications:
• Neurosyphilis
• Cardiovascular syphilis
– Treat:
• Penicillin, Tetracycline, Doxycycline
–
• TRICHOMONIASIS (Trich)
– CA: Trichomonas vaginalis
– MOT: Sex
– Treat:
• Metronidazole

• Hepatitis B
– CA: Hepatitis B virus
– MOT: Sex and blood, mother to child
– PVT:
• Hepatitis B vaccine
• Safe sex practice
– Treat:
• Hepatitis B immunoglobulin

• HIV/AIDS
– CA: Human Immunodeficiency Virus
– MOT: Sex and blood and body fluids
– Dx: EIA and Western Blot
– Note: 6 months window period
– Treat: Highly Actice AntiRetroviral
Therapy (HAART)
• Reverse Transcriptase Inhibitors,
Protease Inhibitors, Nucleosides,
Fusion Inhibitors
– Community Health Nursing
Meningococcemia
• MENINGOCOCCEMIA
– CA: Neisseria meningitidis
– MOT: Droplet spread
– Treat:

Severe Acute Respiratory
Syndrome
• SARS
– CA: Coronavirus
– MOT: Droplet spread
– Note: Isolation!
– Treat:

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Community Health Nursing

Mark Anthony F. Rosario