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COMMUNITY HEALTH NURSING CHN BASIC CONCEPT The GOAL of CHN is promotion of OLOF through teaching and delivery

of care, to raise the level of the health of the citizenry Philosophy: According to Dr. Margaret Shetland, the philosophy of CHN is based on the WORHT & DIGNITY of man. CONCEPTS Primary FOCUS is HEALTH Promotion NURSES are Generalist in terms of their there practice to the through lifes continuum The nature of CHN practice requires that current knowledge delivered from 1. Biological ad social science 2. Ecology 3. Clinical nursing 4. Community health organizations PRINCIPLES Based on recognized needs of communities, families, groups and individuals FAMILY is the Unit of Service HEALTH TEACHING is the Primary responsibility of the community Health Nurse Nurses work as members of the health team HEALTH PRINCIPLES MODERN CONCEPT OF HEALTH: focuses on the Optimum Level of Functioning of individuals, families and communities Families from the lower income groups are the ones mostly served GOAL of Public Heath: to contribute to the most effective total development and life of the individual and his society ECO-SYSTEM influences the Optimum Level of Functioning (OLOF) FACTORS: Political Behavioral Heredity Health care delivery system Environment Socioeconomic influence Health Care Delivery System: TOTALITY of all policies, infrastructures, facilities, equipment, products, human resources and services that address the health needs problems and concern of all people. Essential health care services CAASALocal Government Code RA 7160: the Local Government Code DECENTRALIZATION

FAMILY: BASIC UNIT OF SERVICE DEFINITION: A social unit consisting of two or more people -usually related by blood, marriage or adaption -who live together by mutual consent and with a sense of common identity or shared goals. Two major functions: REPRODUCTION SOCIALIZATION MODERN CONTEXT; Families nowadays are considered to be Less structured Broader More flexible More inclusive Not rule-bounded POPULATION GROUPS CHILDREN WOMEN ELDERLY DISABLED COMMUNITY Defined by geographic boundaries Common interests/values Made up of institutions PRIMARY CLIENT in CHN COMMUNITY COMPETENCE Ability to: 1. Identify needs effectively 2. Achieve consensus 3. Agree on ways to implement goals 4. Work together to implement desired activities Categories of Health Problem HEALTH THREATS HEALTH DEFICITS FORESEEABLE CRISIS FIVE FOLD MISSION OF CHN: 1. Health Promotion 2. Health Protection 3. Health Balance 4. Disease Prevention a. Primary Prevention-

b. Secondary Preventionc. Tertiary Prevention5. Social Justice Duties and Responsibilities of the Community Health Nurse According to Jacobson, community health nursing is a discipline with the ultimate goal of contributing to the promotion of the clients optimum level of functioning through teaching and delivery of care. Our roles are: CLINICIAN ADVOCATE COLLABORATOR CONSULTANT COUNSELOR EDUCATOR RESEARCHER CASE MANAGER RURAL HEALTH MIDWIFE Under the general supervision of the PHN Works with the PHN in planning and evaluating health services at the Barangay level Plans for activities in the clinic BHS; follow-up in homes and field visit in the community Mobilizes community for health action QUALIFICATIONS: Supervising Public Health Nurse at least FIVE YEARS experience as PHN Nurse Instructor II: MAN, 3 years experience as CHN Regional Training Nurse: six years nursing experience, three of which in training or Nursing education Regional Nurse Supervisor: at least SEVEN years in CHN training Chief Nurse: at least FIVE YEARS experience in CHN 3 either as supervisor or assistant chief nurse


HOME VISIT Professional face-to-face contact made by a nurse to a patient or the family to provide necessary health care activities and to further attain an objective of the agency. Should have a PURPOSE/OBJECTIVE Planning for a home visit should make use of all available information about the patient and his/her family. BAG TECHNIQUE TOOL making use of the public health bag through which the nurse during the visit can perform nursing procedures with ease and deftness, saving time & effort at the end in view of rendering effective nursing care. PUBLIC HEALTH BAG essential & indispensable equipment

PRINCIPLES: 1. Ease and deftness 2. Save time and effort 3. Prevent/minimize spread on infection Special consideration: HAND WASHING Contents of the bag: BP apparatus & stethoscope are carried separately; Medicines include: butadiene, 70% alcohol, benedicts solution Place waste paper bag outside of work area to prevent contamination of clean area

INTRAVENOUS THERAPHY Refers to the insertion of the needle/catheter/cannula into a vein based on physicians written prescription ANSAP (Association of Nursing Service Ad ministration of the Phil) accrediting body INDICATIONS Maintenance/correction of dehydration in px unable to tolerate adequate volumes of oral fluid medications; Parental nutrition Administration of drugs Blood transfusion CONTRAINDICATIONS Administration of irritant fluids/drugs through peripheral access (e.g. Sodium chloride; Hypertonic potassium chloride) COMMUNITY ORGANIZING PRE-ENTRY PHASE ENTRY PHASE ORGANIZATION-BUILDING SUSTENANCE & STRENGTHENING PHASE OUT DEPARTMENT OF HEALTH VISION Health for all Filipinos (old) THE LEADER OF HEALTH FOR ALL IN THE PHILIPPINES (new) MISSION Enhance accessibility & quality of health care to improve the quality of life of all Filipinos, especially the poor (old) Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor, and to lead the quest for excellence in health. (new) BASIC PRINCIPLES - Ensured universal access to basic health services - Health & nutrition of vulnerable groups must be prioritized PRIMARY STRATEGIES S A I D PRIMARY HEALTH CARE Essential health care made universally accessible to individuals & families in the community by means acceptable to them. GOAL Health for all Filipinos & Health in the Hands of the People by the year 2020. MISSION

To strengthen the health care system by increasing opportunities & supporting the conditions wherein people will manage their own health care. Core Strategy: RELIANCE PARTNERSHIP & EMPOWERMENT towards SELF-

PHC cornerstones/Pillars M Multi sectoral linkage A Active community participations U Use of appropriate technology S - Support mechanism made available PRIMARY HEALTH WORKERS The higher the level the more qualified the health personnel & the more sophisticated the health equipment Concept: TEAMWORK TWO levels: Village/BHWs trained community health workers, health auxillary volunteers, traditional birth attendants, healers Intermediate Level professional group ALTERNATIVE THERAPHIES HERBAL MEDICINES 10 herbal medicines being advocated by the DOH L LAGUNDI U ULASIMANG BATO B BAWANG B BAYABAS Y YERBA BUENA S A N T A SAMBONG AMPALAYA NIYOG-NIYOGAN TSAANG GUBAT AKAPULKO

Reminders (BONUS) Boiling: remove cover One kind of plant for each type of sx No insecticides Use clay pot and plant part advocated Stop in case of untoward reactions; seek consultation if s/sx not relieved after 2-3 closes ACUPRESSURE QI Principle: traditional Chinese medicine upon birth life energy enters the boy HEALTH: state of balance of the YIN and YANG CONTRAINDICATIONS: o Pregnancy o Full stomach o Cardiac ailments ACUPUNCTURE GOAL. Manipulation of energy flow throughout the body following a thorough assessment by a practitioner PRECAUTIONS PREGNANCY HEMOPHILIA


AROMA THERAPY USE OF ESSENTIAL OILS OF PLANTS TO TREAT SYMPTOMS INDICATIONS INSOMNIA STRESS/RELAXATION INDUCE SLEEP REPUBLIC ACT NO. 8423 T.A.M.A OF 1997 (TRADITIONAL AND ALTERNATIVE MEDICINE ACT) Created PITAHC (Phil. Institute of Traditional & Alternative Health Care) - Scientific research & development of traditional & alternative health care system that have impact on public health care. Public Health Programs D - Dental Health Program O - Osteoporosis Prevention H - Health Education and Community Organization P R O G R A M S - Primary Health Care - Reproductive Health - Older Persons Health Services - Guidelines for Good Nutrition - Respiratory Infection Control - Accupressures - Maternal and Child Care - Sentrong Sigla Movement

HEALTH ACTIVITIES 1. Family planning/Reproductive Health 2. Nutrition 3. Womens Health and Safe Motherhood 4. Adolescent Health 5. Breastfeeding: Milk Code 6. Dental Health 7. Integrated Management of Childhood Illnesses (IMCI) 8. Newborn screening 9. CDD: Control of Diarrheal Diseases 10.Health Programs for Older Person 11.Environmental health 12.Occupational Health: industrial Hygiene 13.Cardiovascular Disease, Visual Health 14.Cancer, Asthma, COPD 15.Diabetes, Osteo, Arthritis, Musculoskeletal 16.Community Base Rehabilitation 17.Rabies 18.Philippine Registry for Disabled Persons LIGTAS BUNTIS 2005 CAMPAIGN GOAL To increase the visibility of FP as an essential public health service, and to dramatically improve the access of men, women an couples to FP & safe motherhood services. POINTERS 1. Assurance of womens safety 2. Advocates to assist Filipino couples to successfully plan their families 3. Shall provide appropriate services based on the clients choice of health facilities Set for February to March 2005

Brings affirmation on womens co-equal importance in nation building Prioritizing and supporting the emancipation of Filipino womens risks (too many, too frequent & unsafe pregnancy) Key success features o Good campaign plan & gender-culture sensitive IEC o Realistic target coverage o Availability of adequate logistics & health services o Competent health care providers o Effective supervision RERODUCTIVE HEALTH Exercise of reproductive right with responsibility VISION Reproductive health practice as a way of life for every man & woman throughout life for every man & woman throughout life GOALS 3Es Every pregnancy should be intended Every birth should be healthy Every sex act should be free of coercion & infection A Achieve a desired family size FRAMEWORK INTERNATIONAL Focus on WOMENS HEALTH Ultimate Goal: QUALITY OF LIFE LOCAL Both Men and Women; based on its elements FAMILY PLANNING Planning intended to determine the number of children based on a couples beliefs, health and economic circumstances Proper spacing of child Giving birth at the right age and at the right time Importance of FP For the health of the mother For the health of the new borne For the health of the entire providing Executive Order 199: created the PFPP (Philippine Family Planning Program) NATURAL FP CERVICAL MUCUS METHOD/ BILLINGS OVULATION o Sensations & mucus BASAL BODY TEMPERATURE LACTATIONAL AMENORRHEA METHOD SYMTO-THERMAL METHOD o Makes use of the womans BBT, cervical mucus at the vulva & other signs Advantages of natural FP N no physical side effects E effect is reversible E enables woman to know more about her body C can lead to early diagnosis of some gynecological disorder ARTIFICIAL FP TEMPORARY ORAL CONTRACEPTIVES: composed of synthetic hormones which when taken regularly prevents pregnancy

IUD small plastic sterile device that is introduction into the uterus to prevent pregnancy Depo-Medroxyprogesterone Acetate (DMPA) effective for 3 months Condom Diaphragm

PERMANENT Tubal ligation Blocking of fallopian tubes to prevent sperm & egg Vasectomy tying & cutting of vas deference

The ROOMING-IN & BREASTFEEDING ACT of 1992 RA 7600 ADVANTAGES of breastfeeding o Infant-material bonding o First preventive health measure to the child at birth o Economical APPLICABILITY NSD: room in the ff within 30 min. o Well infants regardless of AOG o With low birth weight but can suck Caesarean o Within 3 to 4 hours after birth NSD: outside health institutions o Immediately on admission EXEMPTIONS: mothers who are: o Seriously ill o Taking medications contraindicated to breastfeeding o Violent psychotics o Other conditions as determined by the doctor Complicated births o Sick baby/mother or both o Breastfeed first with: o EBM: expressed breast milk o Wet-nursing SICK INFANTS Breastmilk, especially colostrum: given as tolerated Newborn: no prelacteal feeds Sterile water Glucose water Milk formula Acceptable medical condition for supplemental feeding Special milk formula: inborn errors of metabolism Galactosemia; phenylketonuria o Continue breastfeeding for mild to moderate mothers illness: Malaria, STD, Diabetes, CHD, TB (-) sputum The ff DO NOT permit rooming-in & breastfeeding Seriously ill (eclampsia, CHD class IV, severe infection) Taking meds contraindicated to nursing (e.g. anticancer) Milk storage: Refrigerated- 24 hours Frozen ( -180C) a MONTH MILKCODE: E.O. 51 NOT PERMITTED USE of professional services for teaching parents/staff in promoting branded milk products. Common breastfeeding problem

Breast engorgement Sore nipples Mastitis

EXPANDED PROGRAM ON IMMUNIZATION PD 996: IMMUNIZATION SCHEDULE: Provides maximal immunity to the seven EPI diseases BEFORE CHILDS FIRST BIRTHDAY Goal: morbidity and mortality reduction of immunizable diseases Schedule: At birth: BCG 1 months: First doses of DPT, Hep B, OPV 2 months: Second doses of DPT, Hep B, OPV 3 months: Third doses of DPT, Hep B, OPV Tetanus Toxoid: First Pregnancy: TT1- 5th to 6th mo of pregnancy, after 4 weeks TT2 (3 years immunity) Second Pregnancy: TT3 (1st booster dose) 5th to 6th (5 years immunity) Third Pregnancy: TT4 (2nd booster dose) 5th to 6th (10 years immunity) Fourth Pregnancy: TT5 (3rd booster dose) 5th to 6th (life-long long immunity)

Administration: BCG: (infants) 0.05 ml intradermal (school entrants) 0.10 ml intradermal DPT: 0.5 ml intramuscular Hepa B: 0.5 ml intramuscular OPV: 2 drops per orem Measles: 0.5 ml subcutaneous Tetanus toxoid: 0.5 ml intramuscular Side Effects: BCG: inflammation at the site (Kochs phenomenon) warm compress Glandular enlargement, deep abscess, indolent ulceration: insicision and drainage and powered INH DPT: inflammation at site: warm compress; fever for a day; abscess: incision and drainage and antiseptic(betadine Measles: fever 3-5 days within a week after injection; mild rashes Frequently Asked Questions (FAQs) Q: What if the child failed to return after the first dose of the vaccine (D.O.H.), can we still give it? A: YES. It is a MUST to complete the doses Q: Is it necessary to repeat the 1st dose? A: NO. just give the REMAINING doses not given

Remember the principle: Even if the interval exceeded that of the expected interval, continue to give the doses of the vaccine.

Q: What is the eligible age for giving immunization (up to what age can we give the immunization)? A: Before the child reaches 6 years old Q: If there has been a reported epidemic of measles, is it okay to give measles vaccine at an earlier age? A: In case of measles epidemic, we can give MEASLES as early as 6 months of age * a booster dose of BCG shall also be given to all school entrants both in private and public schools REGARDLESS of presence of BCG scar. nd Q: What if the 2 dose of Tetanus Toxoid was not given to the mother, when is the best time to give the dose? A: It has to be given after birth in order to protect the mother and the succeeding pregnancies. Q: Is there any contraindication to giving DPT, OPV, Hepa-B? A: There is none, EXCEPT when the child had convulsions upon giving the st 1 dose of DPT. Mothers must be warned that the incident of CONVULSION st upon giving the 1 dose of DPT, MUST BE REPORTED Q: What if the child has fever of <38.5 C, mild respiratory infections and diarrhea, should the child be given the vaccine? A: The abovementioned conditions are not to be considered as a contraindication to immunization. Thus, vaccine can still be given. Q: What if the child Is malnourished? A: MALNUTRITION is not a contraindication, but RATHER an INDICATION for immunization since common childhood diseases are often severe to malnourished children. COLD CHAIN A system used to maintain the potency of a vaccine from that of manufacture to the time it is given to child or pregnant woman. Principles: I. Storage

Storage of vaccine should not exceed: 6 mos. @ the Regional Level 3 mos. @ the Provincial Level/District Level 1 mo. @ Main Health Centers (with refrigerators) not more than 5 days @ Health Centers (using transport boxes)

Important points to remember: Arranging of stored vaccine according to : Type

Expiration date Duration of Storage # of times they have been brought out to the field Storage Temperatu re Most Sensitive to Heat - 15 C to 25 C FREEZER Vaccine Form Dose/Conta iner Conditions when exposed to heat/freez ing Easily damaged by heat; not destroyed by freezing



20 dose/special bottle or 25 dose/special bottle 10 dose/vial 20 dose/amp 50 dose/amp


Freez e dried Freez e dried


LI Q U I D Liquid

20 dose/vial

Destroyed by heat,sunlig ht; not destroyed by freezing Destroyed by freezing; heat Damaged by heat Damaged by heat and freezing

Least Sensitive to heat Most sensitive to heat:

Hepa-B Tetanus Toxoid


20 dose/vial

Damaged by heat or freezing

Most sensitive to freezing:

The vaccine stored the LONGEST AND THOSE THAT WILL EXPIRE st FIRST should be distributed or used 1 .

It is MUST to mark ampules / vials with an X mark each time they are carried to the field, because if a VACCINE IS NOT USED on the third trip, it must already BE DISCARDED. II. Transport use cold dogs III. Handling

Once opened or reconstituted, vaccines must be placed in a special cold pack during immunization sessions. Vaccine Half life

BCG DPT Polio Measles Tetanus Toxoid Hepa-B


8 hours

LIGTAS TIGDAS 2004 Target: 9 mos - <8 y/o Main component: PMEC o PMEC- Philippine Measles Elimination Campaign o Includes continuing routine vaccination of infants @ 9 months old after LIGTASTIGDAS 2004 o May be repeated every 4 or 5 years o BAKUNADOORS: vaccination team COMMON QUESTIONS My child been vaccinated against measles. Is she exempted? Ans: NO, this will increase her protection from measles My child had measles previously is she exempted? Ans. NO, there are many measles like disease. This wont harm. Ans. NONE, Antibodies in the blood which provide protection against the disease decrease as the What will happen to my child after receiving the measles immunization? Ans. NOTHING, some develop SLIGHT FEVER (1-2days) Give Paracetamol q 4 hours Increase fluids; rest, sleep GMA 50% DOH undertaking to effect the SONA pledge of PGMA Primary goal Ensure that A Affordable S Safe H High quality E Effecitive Drugs & meds are always available, especially to the poor. NUTRITIONAL GUIDELINES FOR FILIPINOS GOAL Improvement of the nutritional status, productivity & quality of life of the population, through adoption of desirable dietary practices and healthy lifestyle GUIDELINES 1. Eat variety of food everyday 2. Breastfeed infants exclusively from birth to 4-6 mos 3. Maintain childrens normal growth 4. Consume fish, leanmeat, poultry or dired beans 5. Eat more vegetables, fruits & rootcrops 6. Eat foods cooked in edible/cooking oil daily 7. Consume milk, milk products/ other calcium-rich foods 8. Use Iodized salts but avoid excessive intake of salty food 9. Eat clean & safe food 10.HEALTHY LIFESTYLE & GOOD NUTRITION: a. Exercise regularly b. No smoking c. Avoid alcoholic beverages NUTRIENTS Chemical substances present in the food that keep the body healthy, supply materials for growth & repair of tissues, and provide energy from work & physical activities STOP TB: D.O.T.S. Most common sign of TB: Cough lasting for 2 weeks Biggest threat to economic development in the Philippines. 1997 Prevalence Survey: More than 16 million Filipinos are infected with TB and 600,000 TB cases are actively spreading the disease.

ELEMENTS: Microscopes Anti-TB drugs Health Care Providers/ Treatment Partners Reporting Books Funding & Support Quality service through DOTS S Screening; supervise sputum collection E Examination of sputum specimens R Recording, Reporting; Referral V Verbalize with Px at the level of his understanding I Instruct Px & Tx partner on the importance of compliance C Counseling on Compliance E Enlighten community Rabies: P.R.O. Pinoy Responsible Owner of Dog 350-400 Filipinos die of rabies every year WHAT TO DO IF BITTEN BY A DOG: Wash wound immediately with soap & water. Consult a health worker at the nearly health center. Observe the dog for 14 days for any change in behavior. If the dog cannot be observed (stray) or it suspected to be rabid, consult your physician immediately for immunization. If dog shows s/sx of rabies, it usually dies within 3-7 days. Pinoy Responsible Pet Owner P.R.O. - Have your pet immunized against rabies at 3 months old & every year after Current WHO guide for Rabies Pre & Post Exposure Tx - General considerations in Post-exposure Tx: WHO advocates the use of modern vaccines for PET Abandon the production of BRAIN-TISSUE VACCINES Immediate washing/flushing & disinfection of the wound Disinfecting with ETHANOL (700ml) or Iodine tincture Rapid administration of purified lg Administration of RIG Infiltrate into the depth of the wound & around the wound Any remaining amount, administer IM to distal part (e.g. anterior thigh) Quantities/vol. Of RIG 20 IU/kg for Human RIG 40 IU/kg for Equine RIG If the calculated dose is insufficient to infiltrate all wounds, sterile saline may be used to dilute it 2 to 3 fold to permit through infiltration. Post exposure Tx IM TWO IM schedule for modern vaccine Vaccine shouldnt injected into the gluteal region CLASSICAL 5 DOSE IM (Essen regimen) ALTERNATIVE: the 2-1-1 regimen Post exposure Tx Intradermal Economical: use 1ml syringe & short hypodermic needles 3 vaccines: HDCV (Human Diploid Cell Vaccine)

RABIVAC PVRV (Purified Verocell Vaccine) VERORAB, IMOVAX, Rabies vero PCECV (Purified Chick Embryo Cell Vaccine) RABIPUR 8 SITE ID METHOD: 8-0-4-0-1-1 for use with HDC (Rabivac); PCECV (Rabipur) When no RIG is available in emergency For use: Rabivac & Rabipur 0.1ml per ID site 2 SITE ID: 2-2-2-0-1-1 for use with: PVRV (Verorab, Imovax, Rabies Vero, TRC verorab) 0.1ml PCECV (Rabipur) 0.2ml ID minimum value of 2.5IU/ampule CONTROL OF ACUTE RESPIRATORY INFECTION (CARI)

OBJECTIVE: 45,000 children die every year because of pneumonia STRATEGIES (TENA) Training of workers with the standard management of ARI Enable BHW to identify & refer cases for treatment NGO mobilization Advocacy and Social Mobilization Contributory Fx to Pneumonia Mothers failure to recognize early s/sx Indiscriminate use of antibiotics Not standardized management by health workers LEPROSY CONTROL PROGRAM KILATIS KUTIS PROGRAM MOT: prolonged skin-to-skin; droplet Prev./Control & Rehab: 1. BCG 2. Avoid MOT 3. Hygiene 4. Adequate nutrition 5. Health education SCHISTOSOMIASIS CONTROL PROGRAM Endemic area o Bicol o o o Samar Leyte Davao

PREVENTION o Proper excreta disposal o o o o Toilet facilities Use of footware protection Mollucides Environmental sanitation

Drug of choice: PRAZIQUANTEL

MALARIA CONTROL PROGRAM NATIONAL SITUATION An average of 3 Filipinos die daily due to malaria despite governments intensified efforts to control the occurrence of the ailment. THREE causes of Malarial treatment failure in the Philippines o Drug resistance o Non-compliance of patients o Deficient drug absorption Other reasons: o Self-medication o Resorting to herbal remedies o Seeking help when the disease is already severe MOSTLY AFFECTED: MALE YOUNG ADULTS MOST VULNERABLE GROUPS: PREGNANT, CHILDREN CURRENT INITIATIVES o Global funding o Infectious disease control and surveillance PROGRAM THRUST: VISION: Malaria-free Philippines by the year 2020. MISSION: To empower the health workers, the population are risk, and all concerned to eliminate malaria in the Philippines. GOAL: Malaria is

TARGET-SETTING involves the calculation of the eligible population. Eligible population consists of any group of people targeted for specific immunizations due to their susceptibility to one or several of the EPI diseases. 3 Population with which the EPI is concerned. Infants School Entrants Pregnant Women For infants, target-setting should be based on the 3% of the total population, while for pregnant women, it must be based on the 3.5% of the total population.

infants Eligible Population = total population x 0.03 school entrants x 0.035 women To compute for the vaccines I. Determine Annual Dose-doses required in a year for complete coverage AD = EP x # of doses to consider that immunization is complete pregnant

II. Determine Wastage Allowance Wastage Dose = Annual Dose x % wastage allowance III. Combine complete coverage needs with wastage allowance Annual doses = annual doses (no wastage) + wastage doses with wastage IV. Determine # of ampules or vials needed per year Amp: vials = annual doses/doses per ampule (per year) V. Determine 3 of ampules/vials needed per month Amp: vials = annual amp: vials/12 months (per month) Solve: Total population = 6000, determine DPT vaccine to be used for infants. SURVEILLANCE Under Fives Care Program UFC Program (Under Five Care Program) A package of child health-related services focused to the 0-59 months old children to assure their wellness and survival

A. Growth and Health Monitoring Growth Monitoring Chart (GMC) A standard tool used in health centers to record vital information related to child growth and development, to assess signs of malnutrition. Sallen Ming Scale, Bar and Detect type scales are being used All newborns must be enrolled for UFCP B. Oresol Therapy Diarrhea (Unusual frequency of bowel movements more than 3x/day) (Marked change in the amount of stool) (Increase in stool liquidity) 3 CLASSIFICATIONS: Mild - 5 - 10 unformed stools/24 hours Moderate - 10 - 15 unformed stools/24 hours Severe - > 15 unformed stools/24 hours with associated signs/symptoms

Dehydration ORS, assess after 4 6 hours Management of Moderate and Severe Dehydration Intravenous fluids If NOT possible, assess if the child can drink (give ORS and refer for IV) If cannot drink ( give fluids via NGT) If no NGT, refer immediately!

Diarrhea Management at Home 3 Fs Fluids Oresol Rehydration Therapy Encourage/ensure intake of any fruit juices, am lugaw homemade soup

Frequent Feeding Continue breastfeeding With children over 6 mos.: Cereals/ starchy foods mixed with meat or fish and vegetables Mashed banana or any fresh fruit Feed the child at least 6x/day After diarrhea episode, feed 1 extra meal/day for 2 weeks

Fast Referral If child doesnt get better in 3 days, or if danger signs develop refer patient Danger Signs: Fever Sunken fontanel Sunken eyeball Frequent watery stool Repeated vomiting Blood in stool Poor intake of meals Weakness

ORS : 1 pack 1 L of water

Home-made Oresol: 1 L of water: or 1 glass of water 8 tsp. of sugar: 2 tsp. of sugar 1 tsp. of salt 1 pinch of salt Remember: Infant must be given - cup every after LBM Child must be given - 1 cup every after LBM Adult must be given 1 or more cup every after LBM Measures on Diarrhea Prevention: Breastfeed infants Provide appropriate supplemental feeding Handwashing Utilize clean and potable water Clean toilet and observe proper feces disposal Immunize the child with measles

* No antibiotics must be given to a diarrheic patient except in infectious diarrhea (e.g. cholera) C. Breastfeeding Unique Characteristics of Breast milk: B Reduced allergic reaction bonding Economical Always available Safe/maintains the stool soft Temperature always right GIT disorders are decreased Difference of breast milk from formula milk BREASTMILK CHO CHON (LACTALBUMIN) FATS Linoleic acid content (3x) MINERALS VS > < = > < FORMULA* CHO CHON (CASEIN) FATS Linoleic acid content MINERALS Fresh Emotional Easily established Digestible Immunity Nutritious

* the high CHON and mineral content of cows milk may overwhelm the newborns kidney, thus it still needs to be diluted. Casein is more difficult to digest. LEGAL MILESTONES: EO 51 MILK CODE OF THE PHILIPPINES RA 7600 MOTHER-CHILD FRIENDLY HOSPITAL - part of 23 in 93 which aims to sustain breastfeeding efforts immediately after delivery

D. Immunization (see EPI) E. Care of Acute Respiratory Tract Infections (CARI) Goal: treatment of pneumonia Assessment: History: Age, cough (since when), fever (since when), stop feeding?, convulsions? Physical Examination: Assess for fast breathing: RR of 60/min (below 2 months) 50/min (2months to 1 year) 40/min (1 to 5 years) stridor, wheeze level of consciousness stop feeding malnutrition

Standard ARI / PNEUMONIA Case Management (EO 110-E s, 1991) Cotrimoxazole adult tabs Injectable penicillin IM gentamycin IM chloramphenicol should be regularly available in DOH facilities

No DOH fund shall be used to regularly provide cough medicines except only for the following emergency conditions. Single ingredient cough suppressant for severe pertussis Single antihistamine fro confirmed allergic conditions such as allergic rhinitis O2 and flow meters must be regularly available in all government hospitals, with O2 delivered properly according to Standard ARI/Pneumonia Case Management Children found to have Severe Pneumonia, Very Severe Pneumonia, wheezing, otitis media, streptococcal sore throat should be referred to Municipal Health Officer (MHO) or hospital physicians for proper management according to the referral scheme Unit 8 STRATEGIES TO ADDRESS SPECIFIC HEALTH PROBLEMS Communicable Disease Prevention and Control Communicable Diseases Chronic Communicable Communicable Vector-borne

Tuberculosis Schistosomiasis (SCP) Leprosy (LCP) H-Fever (Dengue)

Diseases Malaria (MCP) Filariasis (FCP)

1. National Tuberculosis Control Program (NTBCP) Tuberculosis is a highly infectious, chronic respiratory disease caused by TB Bacilli. It is one of the 10 leading causes of morbidity and mortality in the Philippines, which is also known as Kochs Disease. Objective of the Program: To control TB by reducing the annual risk of infection (prevalence and mortality rates) Key Policies: Prevention BCG vaccination under the EPI Program Annual identification of at least 45% of its prevalence Public health education re: PTB mode of transmission, methods of control, and importance of early diagnosis Provide outreach services for home supervision of patients in MultiDrug Therapy and also for preventive treatment of contacts Case Finding Direct sputum microscopy for identified TB symptomatics X-ray exam of TB symptomatics who are (-) after 2 or more sputum exam Establishment of passive and active collection points for sputum samples of all identified TB symptomatics, as well as validation centers to ensure the standard and quality of sputum exam Case finding and treatment services shall be made available in the BHS/RHUs Treatment All TB cases must be treated for free, on ambulatory and domiciliary (home) basis, except those with acute complications and emergencies All sputum positive and cavitary cases shall be given priority for short course chemotherapy or SCC for 6 mos. Standard Regimen or SR for a year or intermittent SCC for 6 mos. shall be given to all infiltrative but sputum negative. SR: isoniazid and streptomycin sulfate SCC: Combo pack, Multi Drug Therapy

PTB TREATMENT REGIMEN Categories: 6 SCC Patient will be: Rifampicin 2 mos. on Pyrazinamide Rifampicin Isoniazid + 4 mos. Isoniazid

Indicated for patients who are

smear cases 8 SCC Patient will be: Rifampicin 2 mos. on Isoniazid Pyrazinamide Ethambulol Streptomycin

(+) sputum seriously ill --(-) sputum smear, (+) extensive lung lesion (+) radiographic lung lesion extrapulmonary

Rifampicin + 4 mos. Isoniazid + 5 mos Ethabutol

Rifampicin Isoniazid Ethambulol

Indicated for those with relapse failures others 4 SCC Patient will be: Rifampicin 2 mos. on Pyrazinamide Rifampicin Isoniazid + 2 mos. Isoniazid

Indicated for PTB minimal (-) sputum smear

3 Phases of Treating a PTB patient: Rifampicin 1 - Intensive Phase Pyrazinamide Diagnostic: Sputum Exam if (+), proceed to 2 - Maintenance Phase 2 mos. on Isoniazid

+ 4 mos.

Rifampicin Isoniazid

on if still (+) TB Colonies proceed to Rifampicin 3 - Extensive Phase on up to 12 mos. Isoniazid

What is the purpose of SCC-MDT? prevent developing resistance against the three drug combinations shorten duration of treatment usually treatment lasts from 5-10 years. With SCC-MDT. tx can be reduced to a minimum of 6 mos. eradicate and completely prevent the relapse of the disease Direct Observation Treatment of Short-Course Chemotherapy (DOTS) Tutok-Gamutan DOH Activities on NTBCP:

Part of the 23 in 93 is the integrated disease control of TB together with schistosomiasis and malaria through the formulation of a strategic plan for infectious disease control by specific DOH units. Health for More in 94 had Malakas na Baga, Malinaw na Mata as its strategy National Focus: TB Control Month laboratory and drug supplies were available to local governments in 1994 aimed to accelerate case finding and treatment Strategies done: Ensure that every microscopy and treatment center has the ff: Exnal microscope Microscopist trained within the last 3 years A 90% agreement rate in microscopy reading between the microscopist and validator Available NTP manual of procedures Drugs for at least 6 months supply Reagents, sputum cups for at least 6 months Utilization of an itinerant team composing of at least 2 microscopists, nurse, midwife, and a medical officer who will stay for 2 3 days in far flung communities to identify TB and start treatment 2. Leprosy Control Program LEPROSY is a chronic disease of the skin and peripheral nerves caused by Myobacterium Leprae WHO CLASSIFICATION OF LEPROSY: Paucibacillary (tuberculoid and indeterminate) non-infectious Duration of Treatment: 6-9 months Multibacillary (lepromatous and borderline) infectious Duration of treatment: 24-30 months Objectives of the Program: provide MDT to all leprosy cases within 3 years and complete the treatment of 90% of all cases out on MDT within the prescribed period identify all correctible deformities and institution of appropriate intervention reduce the stigma attached to the disease thru IEC formulate research proposals on topics associated with leprosy Key Policies: MDT as the core strategy for the National Leprosy Control Program Procurement and supply of MDT Drugs, IEC and Training Materials by CDCS Health education Supervision and Control of leprosy Control Activities Strategies: Prevention Health Education BCG vaccination Case Finding

Validate old registered cases Early referral of suspected leprosy patients Epidemiologic investigation Treatment Ambulatory Domiciliary chemotherapy through the use of MDT as embodied in RA 4073 which advocates home treatment MDT Treatment Regimen Paucibacillary Multibacillary Supervised dose: Supervised dose: Rifampicin 600 mg Rifampicin 600 mg Dapsone 100 mg Lamprene 300 mg Taken once/month in the clinic Dapsone 100 mg Self-administered Taken once/month in the clinic Dapsone 100 mg Self-administered dose Taken OD, daily by the patient at home Lamprene 50 mg Dapsone 100 mg Take OD, daily at home Leprosy Patients must be taught ways to prevent secondary injury caused by burns and rough sharp objects Emphasize importance of sustained therapy, correct dosage, effects of drugs and the need for medical check-up from time to time Provide mental and emotional support to the families of leprosy patients Refer patients as needed Rehabilitation: Imbibe patients participation in occupational activities Family and community health (PD 304) o non-segregation of leprosy patients o counseling and guidance Locally-endemic Disease Prevention and Control 1. Malaria Control Program Malaria a vector-borne disease caused by female Anopheles mosquito causing symptoms such a fever, sweating, intermittent chills, anemia, and splenomegaly. 2 Major Strategies of the Program I - Vector-Control Highlight In 24 in 94 Project: Kalusugan ng Kalikasan, Kalusugan ng Mamamayan National Focus: Awareness and prevention of mosquito borne disease day Community Action Campaign Acronym CLEAN Chemically treated mosquito nets Larva-eating fish Environmental clean-up of stagnant water Anti-mosquito soap Neem trees Chemoprophylaxis Chloroquine 1-2 weeks before entering an area then continuous until 4-6 weeks after leaving the area 2 - Detection and Early Treatment of Cases

Early Recognition, Prevention, and Control of Malaria epidemics a system which will recognize impending malaria epidemics Early diagnosis and prompt Treatment identification of a patient with malaria as soon as he is examined.

This may be done thru: Clinical Microscopic - Signs and symptoms - Mass Blood Smear Exam - history of visit to an endemic area In the event that an imminent epidemic occurs, the following should be done: Mass Blood Smear Collection Immediate confirmation and follow-up of cases Insecticide-treatment of mosquito nets 2. Schistosomiasis, H-fever and Filariasis Control Programs DOH measures to prevent and control in 24 in 94 Project: Kalusugan ng Kalikasan, Kalusugan ng Mamamayan National focus: Awareness and prevention of mosquito borne diseases day Community Action Campaign Acronym: CLEAN SCHISTOSOMIASIS CONTROL PROGRAM Schistosomiasis a parasitic infection caused by blood flukes inhabiting the veins of their vertebral victims transmitted thru skin penetration causing diarrhea, ascites, hepatosplenomegaly. H-FEVER (DENGUE) FILARIASIS CONTROL PROGRAM Dengue acute febrile A mosquito borne infection of sudden onset, disease caused by a caused by Aedes tissue nematode Aegypti, vector mosquito attacking the lymphatic system of humans thereby causing elephanthiasis, lymphedema, and hydrocele started in 1957 as an operational research of the malaria. Eradication Service Three Filaria Control were established and later on integrated with the Regional Health Offices

Activities: Case Fx: Surveillance of the disease Health Education encourage use of rubber boots for protection Environmental sanitation proper disposal of feces Snail Eradication use of moluscides

Activities: Case Fx Early reporting of any known case or outbreak

Activities: Case fx Early reporting of any known case of outbreak

Prevention, Control and Rehabilitation of Non-communicable Diseases 1. Philippine Cancer Control Program AO 89-A s. 1990 provided the Guidelines for the Philippine Cancer Control Program specifying its program policy, components, implementing guidelines and timetable. 6 Pillars: Public Information and Health Education Cancer Prevention and Early Detection Cancer Epidemiology and Research Cancer Treatment Cancer Pain Relief In Cancer Nursing, the aim of management is to relieve physical, mental and spiritual distress. Vital Task of the nurse: To help the patient maintain his dignity and integrity Cancer care is multidisciplinary. Who are to be prioritized for health supervision? Newly diagnosed cases Post-op case/discharge Indigent cases needing continuity of hospital care Terminal cases DOH Strategies: In Health for More in 94, Kayang-kaya ang Cancer National Focus: Cancer Awareness and Prevention Day Araw ng Pag-iwas sa Kanser Cancer Project: Public information and health education on Cancer Cancer information desk nationwide Kalusugan ng Kababaihan, Kalusugan ng Bayan Women are encourage to undergo the following screening procedures regularly Breast Self-Examination Regular Pap Smear Nationwide demonstration on how to correctly do self breastexamination Information dissemination also on Urinary Tract Infection, Sexually Transmitted Diseases, AIDS 2. Smoking Control Program Health hazards of smoking: Lung Cancer Cardiovascular diseases

Chronic Obstructive Pulmonary Diseases Cancer of other body organs Program objective: decrease the prevalence of smoking-related diseases and subsequent premature deaths Program components: Information and Education on Campaign and Social Mobilization Policy Development and Legislation Training of Counselors in Smoking Cessation Clinics for Specialty Hospitals Resource Management and Monitoring Strategies: National Anti-Smoking Campaign o World No Tobacco Day o National No Smoking Month o Yosi Kadiri Campaign Support comprehensive bill on Tobacco Advertising Warning labels be written on tobacco products and ads in compliance with the consumer code of 92 3. Renal Disease In 23 in 93 Preventive Cardiology and Nephrology Enhance public awareness thru health education regarding healthy lifestyles Improve access to basic health services Health for More in 94 Buwan ng Buhay na Bato Requires urinalysis of ALL children entering Grade I so as to detect childhood kidney infections, which may lead to Renal Failure Encourage adult Filipino to undergo urinalysis once a year 4. Cataract In accordance with the Prevention of Blindness Program, Malakas na Baga, Malinaw na Mata National Focus: Cataracts Screening Week at DOH Centers OPLAN: Sagip-Mata Eye Surgery for cataract and squint operations for cross-eyed children Nutrition and Adequate Food Supply Goal: The improvement of nutritional status, productivity and quality of life of the population through adoption of desirable dietary practices and healthy lifestyle. Coverage:

Philippine Programs




directed to the provision of nutrition services to the DOHs identified priority vulnerable groups: infants, pre-schoolers, schoolers, women of child bearing age (also included are the pregnant and lactating mothers) and the elderly Objectives: to decrease the morbidity and mortality rates secondary to Avitaminoses and other nutritional deficiencies among the population mostly composed of infants and children. 1. Malnutrition Program Rehabilitation

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

2. Micronutrient Supplementation Program 23 in 93 Fortified Vitamin Rice Health for More in 94 Buwan ng Kabataan, Pag-asa ng Bayan National Focus: National Micronutrient Day or Araw ng Sangkap Pinoy

- a free enrichment program aimed to aimed to distribute vitamin A prevent deficiencies in vitamin A supplements, iodized oil for (blindness); iron (Anemia); Iodine mothers and seedlings of plants rich (goiter, mental retardation and in Fe and other minerals delayed development) (1 cavan of rice + fistful processed, binilid enriched with essential micronutrients) 3. Food Fortification Program Fortification is the addition of a micronutrient deficient in the diet to a commonly and widely consumed food or seasoning. It involves: Incorporation of Monosodium Glutamate (MSG) with Vitamin A to reduce clinical signs of Xereopthalmia The use of FIDEL salt in lieu with the National Salt Iodization Program Fortification for Iodine Deficiency

ELimination 4. Nutrition Surveillance System - a system of keeping close watch on the state of nutrition and the causes of malnutrition within a locality, which involves periodic collection of data and analysis and dissemination of analyzed information Tools utilized measurements: are anthropometric

Weight for age measures degree and presence of wasting or stunting Height for age measures the presence of stunting < 90% of standard stunting or past chronic malnutrition Weight for height determines the presence of muscle wasting Male + 6 105 110 lbs. -6 Rule Female For every increment of an + 5 inch above 5 feet For a height of 5 feet 100 105 lbs. For every decrement of - 5 an inch below 5 feet

1. Compute for the Ideal Body Weight if height = 5 feet and 6 inches actual weight = 115 lbs. sex = Female 5 feet = 105 lbs. 6 inches = 30 lbs. IBW = 135 lbs. 2. Determine the degree of malnutrition Actual Body Weight a. Degree of Malnutrition = Ideal Body Weight Thus; Actual Body Weight (115) a. Degree of Malnutrition = Ideal Body Weight (135) = st 1 degree Malnutrition 85-18% x 100% X 100%

Degrees of Malnutrition 110% and above 90 109 % 75 89 % obese normal 1st degree

60 75 % 60% and below

nd 2 3rd

skinfold measurement indicates amount of body fat with the use of fat-caliper sites: triceps, biceps, subscapular, suprailiac MUAC estimates lean body mass or skeletal muscle reserves Legal Milestones: PD 491 Nutrition Act of the Philippines declares Nutrition as a priority of the government creates the National Nutrition Council designates duly as the Nutrition Month

RA 832 Rice Enrichment Law all milled rice have to be enriched with premix Rice governments nutrition program RA 8172 FIDEL Salt Supply and Use of Essential Drugs Essential drugs are medicinal preparations necessary to fill the basic health needs of the population. National Drug Formulary contains the list of essential drugs

23 in 93 Philippine National Drug Policy Objective: to promote access to High-quality Effective Essential Low-cost Safe Drugs and pharmaceuticals ACRONYM HEELS 4 Pillars: 1. Assurance of safe, effective and useful drugs 2. Rational drug use the practice of using only the necessary, appropriate and effective drugs in treating an illness 3. developing greater self-reliance in basic production thru DOH herbal processing plants 4. tailored drug procurement

Health for More in 94 National Focus Generics information Campaign Month Walong Wastong Gamot na Maabot - supports the Generics Act of 1998 through aggressive information campaigns on rational drug use, to provide consumers options for les expensive drugs with the use of generic labeling and prescribing. Pilot Program OPLAN WALANG RESETA Several prescription drugs were made available without a MDs prescription

Legal Milestones Generics Act of 1998 RA 6675 Formally proclaims the state policy of promoting the use of generic terminology in the importation, manufacture, distribution, marketing, promotion and advertising, labeling, prescribing and dispensing of drugs. Reinforces the NDP with regards to theassurance of high-quality and rational drug use Environmental Sanitation Environmental Sanitation is defined as the study of all factors in mans physical environment, which may exercise a deleterious effect on his health, well-being and survival. Goal: to eradicate and control environmental factors in disease transmission through the provision of basic services and facilities to all households. Components: Water Supply Sanitation Program Proper Excreta and Sewage Disposal Program Insect and Rodent Control Food and Sanitation Program Hospital Waste Management Program Strategies on Health risk immunization 1. Water Supply Sanitation Program 3 Types of Approved Water Supply and Facilities Level I Point Source Level II Level III Communal faucet system Waterworks system or or stand posts individual house connections Dangerous Drugs Act RA 6425 The safe, administration and transportation of prohibited drugs is punishable by law 2 Types of Drugs Prohibited Regulated LSD Benzodazepines Eucaine Barbiturates Cocaine/codeine Opiates

protected well A system composed of a A system with a source, a or a developed source, a reservoir, a reservoir, a piped spring with an outlet piped distribution distributor network but without a network and communal and household distribution system for faucets, located at not taps that is

are thinly scattered. 25 meters from farthest house in rural areas where houses are clustered densely.

the populated urban areas.

Water must pass the National Standards for Drinking Water set by the DOH 2. Proper Excreta and Sewage Disposal System 3 Types of Approved Toilet Facilities Level 1 Non-water carriage toilet facility: - Pit latrines - Reed Odorless Earth Closet - Bored-hole - Compost - Ventilated improved pit Toilets requiring small amount of water to wash waste into receiving space - Pour flush - Aqua privies Rural Areas Blind drainage type of wastewater collection and disposal facilities shall be emphasized until such time that sewer facilities and off-site treatment facilities are available. 3. Proper Solid Waste Management refers to satisfactory methods of storage, collection and final disposal of solid wastes 2 Major Components: Garbage Those having a tendency to decay and give off foul odor Rubbish Broken glass, bottles, papers Zero Solid Waste Management featured in 23 in 93 2 Ways of Excreta Disposal Household Burial Deposited in 1m x 1m deep pits covered with soil, located 25 m. away from water supply Open burning Animal feeding Composting Grinding and disposal sewer Community Sanitary landfill or controlled tipping Excavation of soil deposition of refuse and compacting with a solid cover of 2 feet Incineration Level 2 On site toilet facilities of the water carriage type with water sealed and flushed type with septic vault/tank disposal facilities. Level 3 Water carriage types of toilet facilities connected to septic tanks an/or to sewerage system to treatment plant.

4. Food Sanitation Program Policies: Food establishment are subject to inspection (approved of all food sources containers and transport vehicles) Comply with sanitary permit requirement Comply with updated health certificates for food handlers, helpers, cooks All ambulant vendors must submit a health certificate to determine present of intestinal parasite and bacterial infection 3 Points of Contamination Place of production processing and source of supply Transportation and storage Retail and distribution points 5. Hospital Waste Management Goal: To prevent the risk of contraction contracting nosocomial infection from type disposal of infectious, pathological and other wastes from hospital In 23 in 93, hospitals were developed to be Centers of Wellness addressing the need for preventive programs against smoking, cancer and other communicable diseases. This is further pushed through with the concept of Ospital Pinoy Style: Sentro ng Kalusugan in Health for More in 94 its major aim is to continue upgrading the curative as well as basic services in hospitals, which are available to all communities. One of its challenges is the implementation of Hospital Waste Management program as a requirement to operate 6. Programs related to health-risk minimization secondary to environmental pollution These include the following: Anti-smoke Beching Campaign and Air pollution Campaign Zero Solid Waste Management Toxic, Chemical and Hazardous Waste Management Red Tide Control and Monitoring Integrated Pest Management and Sustainable Agriculture Pasig River Rehabilitation Management 7. Education of prevailing health problems accepted activity at all levels of public health used as a means of improving the health of the people through techniques which may influence peoples thought motivation, judgment and action. Three aspects of health education: Information provision of knowledge Communication exchange of information Education change in knowledge, attitudes and skills Sequence of steps in health education: Creating awareness Creating motivation Decision making action HIV/STI Prevention and Control Operational Strategies: Promotion of health/health education Diseases detection Treatment program Contact tracing Clinical services Program components: Case-finding Case management

Training Monitoring Reporting system Operations research Ministry circular #2 s. 1986 includes AIDS as a notifiable disease AO#57 As 1989 provides the policies for the prevention and control of HIV/AIDS in the Philippines. National AIDS Program, featured in 23 in 93 Aimed to establish Surveillance program to determine groups at increased risk of acquiring AIDS Create a Philippine National AIDS Council which define policies advocacy, strategies, issues, and public health education for AIDS prevention Mental Heath -a state of well-being where a person can realize his or her own abilities, to cope with the normal stresses of life and work productively -the emotional adjustment the person achieve in which he can live with reasonable comfort, functioning acceptably in the community where she lives -involves the promotion of a healthy state of mind among the whole population through developing positive outlook in life strengthening coping mechanisms Vulnerable group to the development of Mental Illness: Streetchildren Victims of Torture or violence Internal refugees Victims of aimed conflict Victims of natural and man-made disasters Components of Mental Health Program A. Stress Management and Crisis Intervention B. Drugs and Alcohol Abuse Rehabilitation C. Treatment and Rehabilitation of Mentally-Ill Patients D. Special Project for Vulnerable Groups DOH Events: Buwan ng Kabataan, Pag-asa ng Bayan, featured in Health for More in 94 National Focus: National Mental Health Week: Linggo ng Lusog-Isip Rationale: Stresses in the environment of children such as times of disasters and national calamities, disintegration of the values, structure and functions of the family and urbanization, migration, drugs and physical and sexual abuse and poverty have direct effects on physical and mental health