Community Health Nursing Special field of nursing that combines skills in Nursing, Public Health, and some Phases

of Social Assistance and functions as part of the total health program for the promotion of health, the improvement of the conditions in the social and physical environment, rehabilitation of illness and disability ( WHO ) ________________________________________________________________________ Community Health Nursing is a learned practice discipline with the ultimate goal of contributing, as individuals and in collaboration with others, to the promotion of the clients optimum level of functioning through teaching and delivery of care ( Jacobson) _________________________________________________________________________ Community Health Nursing is a service rendered by professional nurse with the community, groups, families and individuals at home, in health centers, in clinics, in school, in places of work for the promotion of health, prevention of illness, care of the sick at home and rehabilitation ( Freeman) ________________________________________________________________________ Philosophy Worth and dignity of man ( Dr. Margaret Shetland ) ________________________________________________________________________ Concept Clientele : individuals, families, groups and communities 1. Primary focus of community health practice is on health promotion 2. CHN practice is extended to benefit not only the individual but the whole family and community. 3. CH Nurses are generalists in terms of their practice through lifes continuum. 4. Contact with client may continue over a long period of time across all ages and type of health care. 5. Requires that current knowledge derived from biological and social sciences, ecology, clinical nursing and community health organizations be utilized. 6. The dynamic process of assessing, planning implementing and intervening, provide periodic measurements of progress, evaluation, continuum of cycle until the termination of nursing. ________________________________________________________________________ Goal The ultimate goal of CHN is to raise the level of health of the citizenry by helping communities and families to cope with the discontinuities in health. ________________________________________________________________________

Objective 1. Participate in the development of the overall health plan for the community as well as implementation and evaluation 2. provide quality Nursing service to individuals, families communities utilizing the standards set for CH Nursing practice as basis. 3. To coordinate nursing service with various members of the health team, community leaders and significant others, GOs and NGOs in achieving the aims of public health service within the community. 4. Participate and conduct researches relevant to community health and community health nursing services and disseminate their results for health care. 5. To provide community health nursing personnel with opportunities for continuing and professional growth through staff development. ________________________________________________________________________ Principles ( Gardner and by Leahy, Cobb and Jones ) 1. CHN is based on recognized needs of communities, families, groups and individuals. 2. The CH Nurse must understand fully the objectives and policies of the agency she represents. 3. Family is the unit of service 4. CH Services must be made available to all regardless of race, creed and socio economic status 5. Health teaching is a primary responsibility of the community health nurse 6. The CHN works as a member of the health team. 7. There must be provision for periodic evaluation of CHN services. 8. Continuing staff education programs for nurses must be provided by the CHN agency. 9. The community health nurse makes use of available community health resources 10. The CHN utilizes already existing active organized groups in the community. 11. There must be provision for educative supervision in CHN. 12. There should be accurate recording and reporting in CHN. ________________________________________________________________________ Global and Country Health Imperatives 1. Shifts in demographic and epidemiological trends in diseases including the emergence and re emergence of new diseases and the prevalence of risk and protective factors 2. New technologies for health care, communication and information 3. Existing and emerging environmental hazards associated with globalization 4. Health reforms ________________________________________________________________________

Millenium Development Goal Aimed at poverty reduction and sustainable development ( UNGA) and based on the fundamental values of freedom, equality, solidarity, tolerance, health, respect for nature and shared responsibility. The eight MDGs are as follows: 1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, malaria and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development ________________________________________________________________________ Qualifications Bachelor of Science in Nursing degree holder Registered Nurse in the Philippines ________________________________________________________________________ Roles of the CHN 1. Planner/ Programmer 2. Provider of Nursing Care 3. Manager/ Supervisor 4. Community Organizer 5. Coordinator of Services 6. Trainer/ Health Educator/ Counselor 7. Health Monitor 8. Role Model 9. Change Agent 10. Recorder/ Reporter/ Statistician 11. Researcher ________________________________________________________________________ Health The state of complete physical, mental and social well being, and not merely the absence of any diseases or infirmities ( WHO ) ________________________________________________________________________ Other Health Models 1. Medical Model 2. Health Illness Continuum 3. High Level Wellness Model 4. Adoptive Model 5. Role Function Model 6. Agent Host Environment Model 7. Eudaemonistic Model ________________________________________________________________________ Determinants of Health

Health of the Individuals and the Community is affected by a combination of factors. The following are some determinants listed by WHO. 1. Income and social status 2. Education 3. Physical Environment 4. Employment and working conditions 5. Social Support Networks 6. Culture 7. Genetics 8. Personal behavior and coping skills 9. Health Services 10.Gender ________________________________________________________________________ Community Classifications of a Community 1. Urban 2. Rural 3. Rurban Local Health System Department of Health The national authority on health providing technical and other resource assistance to concerned groups as mandated by EO 102. Its general functions are: 1. Leadership on Health Formulates national policy on health Regulatory Formulation, monitoring and evaluation on national health policies ,plans and programs Advocacy on policies, plans and programs 2. Enabler and capacity builder Innovates new strategies in health Oversight functions, monitoring and evaluation Protection of standards 3. Administrator of Specific Services Facility management ( hospitals ) Service delivery for emergent health concerns

 Vision Health for All

Administer health emergency response services

Mission Guarantee equitable, sustainable and quality health for all Filipinos, specially the poor. The DOH shall do this by seeking ways to establish performance standards for health human resources; health facilities and institutions, health products and health services that will produce the best health system for the country. This is in pursuit of its constitutional mandate to safeguard snd promote health for all Filipinos Regardless of Creed, status or gender with special consideration for the poor and the vulnerable who will require more assistance. Goal Health Sector Reform Agenda. Support mechanisms will be through sound organizational development, strong policies, systems, and procedures, capable human resource and adequate financial resources. Rationale: Due to inappropriate health service delivery system inadequate regulatory functions poor health care financing Slowing down in reduction of IMR and MMR Persistence of large variations in health status across population groups and geographic areas High burden of from infectious diseases Rising burden from chronic and degenerative diseases Unattended emerging health risks from environment and work related factors Burden of diseases is heaviest on the poor

which results in poor coverage of public health and primary care services inequitable access to personal health care services low quality and high cost of both public and personal health care

Health Sector Reform Agenda thru Fourmula One for Health

Goals of Fourmula One for Health 1. Better health outcomes 2. More responsive health systems 3. Equitable health care financing Four Elements of the Strategy 1. 2. 3. 4. Health Financing Health Regulation Health service delivery Good governance

Devolution Decentralization of power from the national government to the LGUs ( Local Government Code of 1991 or RA 7160) Objectives 1. Establish local health system for effective and efficient delivery of health care services 2. Upgrade health care management and service capabilities of local health facilities 3. Promote inter-LGU linkages and cost sharing schemes 4. Foster participation of the private sector, NGO and communities in local health systems development 5. ensure the quality of health service delivery at the local level 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 and country can afford at every stage of development.

First International Conference on PHC Official declaration on the importance of PHC was made known during the 1st International Conference on PHC in Alma Atta, USSR on Sep 6- 12, 1978 initiated by WHO and UNICEF with Health for All by Year 2000 as its official goal LOI 949 Signed by President Marcos on Oct. 19, 1979 in support of the declaration made in Alma Ata. The underlying there is Health in the Hands of the People by Year 2020.

PHC Concept is characterized by PARTNERSHIP and EMPOWERMENT as its core strategies in the effective provision of essential health services that are community based, accessible, acceptable, sustainable and affordable Elements Education for Health Locally endemic disease control Expanded Program on Immunization Maternal and Child Nursing Essential Drugs Nutrition and Breastfeeding Treatment of Communicable diseases Safe Water and Sanitation Strategies Reorientation and Reorganization on the national health system vis a vi Local Government Code of 1991 Effective preparation and enabling process for health action at all levels Mobilization of people Development and utilization of appropriate technology Organization of the communities arising from their expressed needs Increase opportunities for community participation Development on inter-sectoral linkages Emphasizing partnerships

4 Cournerstone/ Pillar 1. Active Community participation 2. Intra and enter-sectoral linkages 3. Use of appropriate technology 4. Support mechanisms made available Types of PHC Workers 1. Village or Barangay Health Workers ( BHW) generic to the community 2. Intermediate Level Health Workers midwives, nurses, doctors, Sis etc.. Levels of Health Care Primary - devolved to cities and the municipalities - center physicians, PHNs, RHMs, community volunteers

bridges the gap between community and other levels of health care Secondary - physicians with basic health training - infirmaries, municipal/ district hospitals, OPDs of Provincial Hospitals - referral center for primary health facilities - capable of performing minor surgeries and simple lab exams Tertiary - specialists in health facilities - medical centers, regional and provincial hospitals, specialized hospitals - referral center for secondary facilities

Nursing Skills Community Health Nursing Process

Systematic, scientific, dynamic, on-going interpersonal process in which the nurse and the client are viewed as a system with each affecting the other and both being affected by the factors within the behavior. ________________________________________________________________________ A. Assessment Is the first major phase of the nursing process. In family health nursing practice, this involves a set of actions by which the nurse measures the status of the family as a client, its ability to maintain itself as a system and functioning unit and its ability to maintain wellness, prevent, control, resolve problems in order to achieve health and wellbeing among its members. ________________________________________________________________________ Nursing Assessment includes: data collection data analysis or interpretation problem definition or nursing diagnosis ________________________________________________________________________ Levels of Assessment First Level First level assessment is a process whereby existing and potential health conditions of the family are determined. Health Threat conditions that promote disease or injury and prevent people from realizing their full health potentials Health Deficit happens when there is a gap between actual and achievable health status Forseeable Crisis- includes stressful occurrences such as deaths or illness of a family member Classification of Data Gathered in First Level Assessment 1. Family Structure, characteristics and dynamics 2. Socio economic and cultural characteristics 3. Home and environment 4. health status of each member 5. values and practices on health promotion/ maintenance and disease prevention

Second Level Defines the nature or type of nursing problems that the family encounters in performing the health tasks with respect to a given health condition or problem and the etiology or barriers to the familys assumption of this tasks.

Sub Steps in Data Analysis 1. Sorting of data for broad categories 2. Clustering of related cues to determine relationships 3. Distinguishing relevant from irrelevant data 4. Identify patterns 5. Compare patterns with norms or standards of health 6. Interpret results to determine signs, sypmptoms or cues of specific wellness state, health deficit, health threat or forceeable crisis and their underlying factor 7. Making inferences or drawing conclusions Activities in Assessment A. 1.Initiate Contact- demonstrate caring attitudes and mutual trusts and Confidence A. 2. Data Collection General Classification of Data 1. Primary 2. Secodary 3. Tertiary 1. 2. 3. 4. 5. Methodologies community surveys observation of health related behaviors review of statistics, epidemiological and relevant studies individual and family health records Lab and screening tests/ Physical Exams

A.3. Identify Health Problems * First Level Assessment Health Threat, Health Deficit, Forseeable Crisis Second Level Assessment Analysis/ Nursing Diagnosis Taxonomy of Nursing Problems

1. Inability to recognize the presence of the condition or problem 2. Inability to make decisions with respect to taking appropriate health actions 3. Inability to provide adequate nursing care to the sick, disabled, dependent, or vulnerable/ at risk members of the family 4.Inability to provide a home environment conducive to health maintenance and personal development 5. Failure to utilize community resources for health care A.4 Assess coping ability A.5. Prioritizing Problems Criteria 1. Nature of the Problem wellness state health deficit health threat foreseeable crisis 2. Modifiability of the problem Easily modifiable Partially modifiable Not modifiable 3. Preventive potential High Moderate Low 4. Salience Needing immediate attention Not needing immediate attention Not perceived as problem B. Planning Nursing Actions Health Prob Prioritizing needs Establish goal Construct action and operational plan Develop evaluation parameters Revise plan as needed Family Nursing Care Plan Goal of Objectiv Nursing Care es of Interventi Weight 3 3 2 1 2 2 1 0 1 3 2 1 1 2 1 0 Overall Weight 1

Family Nursin

Method of

Resourc es

g Proble m

Care

on

Nurse Family Contact

Require d

C. Implementation of Planned Care Put nursing plan to action Coordinate care/ services Utilize community resources Delegate tasks Supervise/ monitor health services provided Provide health education and training Documentation

D. Evaluation of Care and Services rendered Nursing audit Care outcomes Performance appraisal Estimate cost benefit ratio Assessment of problems Identify needed alterations Revise plan as necessary ________________________________________________________________________

Clinic Visit The patient visits the Health Center/ clinic to avail of the services being offered by the facility for a variety of reasons.

Standard Procedures for Clinic Visit A. Registration/ Admission Greet/ Establish Rapport Prepare records Record chief complaint/ history Perform PE ________________________________________________________________________ B. Waiting Period Priority numbers ________________________________________________________________________ C. Triage program based ( nurses may manage) non program based ( maybe referred to physician ) ________________________________________________________________________ D. Clinical Evaluation validate clinical history and PE nurse provides evidence based dx inform client about nature of illness, treatment, prevention and control ________________________________________________________________________ E. Laboratory and other Diagnostics F. Referral utilize 2 way referral escort pt if emergency referral ________________________________________________________________________ G. Prescription/ Dispensing H. Health Education conduct one on one counseling reinforce health education and counseling messages give appointments for next visit ________________________________________________________________________ Home Visit Home visit is a family- nurse contact which allows the health worker to assess the home and family situations in order to provide the necessary nursing care and health related activities. ________________________________________________________________________ Purpose of Home Visit 1. To give nursing care to the sick, post partum mother and her newborn 2. To assess the living condition of the pt and his family and their health practices 3. To give health teachings regarding the prevention and control of disease

4. To establish close relationship between health agencies and the public for health promotion 5. To make use of inter referral system and to promote the utilization of community services ________________________________________________________________________ Principles in Home Visit 1. must have a purpose or objective 2. planning should make use of all available info thru available records 3. in planning for a home visit, we should consider and give priority to the essential needs of the individual and family 4. planning and delivery of care should involve the individual and family 5. plan should be flexible ________________________________________________________________________ Guidelines for Home Visit 1. Physical, psychological and educational needs 2. acceptance of the family for the service as well as their interest and willingness to cooperate 3. policy 4. other health agencies present 5. evaluation of past services given to family 6. ability of the family to recognize their own needs, awareness of available resources and the ability to make use of these resources ________________________________________________________________________ Steps 1. greet the client 2. state purpose of visit 3. observe pt and determine needs 4. place CHN bag in a proper place/perform bag technique 5. perform nursing care/ provide health teachings 6. record important data, observation and care rendered 7. make appointments ________________________________________________________________________ The Bag Technique Tool by which the nurse during her visit will enable her to perform a nursing procedure with ease and deftness, to save time and effort with the end in view of effective nursing care to clients. ________________________________________________________________________ Principles of Bag Technique 1. performing bag technique will minimize, if not prevent the spread of any infection 2. it saves time and effort in performing procedures

3. shows total effectiveness of total care given to an individual or family 4. bag technique can be performed in a variety of ways ________________________________________________________________________ Important Points to Consider in the Use of the Bag 1. should contain the necessary articles, supplies and equipment 2. contents should be cleaned very often, supplies, replaced and ready for use anytime 3. contents should be well protected from contacts with other articles in the pts home 4. arrangement should be convenient to the user ________________________________________________________________________ Nursing Care in the Home 1. utilizes medical plan of care and treatment 2. performance of nursing care utilizes skills that would give maximum comfort and security 3. nursing care given at home should be used as teaching opportunity 4. performance of nursing care should recognize dangers on the pt over prolonged acceptance of support and comfort 5. provides opportunities for detecting abnormal signs and symptoms as well observing attitude towards care given ________________________________________________________________________ Isolation Technique in the Home 1. all articles of the pt should not be mixed with articles of the other members of the family 2. frequent washing and airing of beddings and other articles and disinfection of room is imperative 3. protective gown should be given to the one caring for the sick and should only be used within the room of the sick 4. all discharges, specially coming from the nose and throat should discarded 5. articles soiled with discharges should first be boiled in water 30 mins before laundry. Those that can be burned should be burned. ________________________________________________________________________

Public Health Science and Art of preventing diseases, prolonging life, promoting health and efficiency through organized community effort for the sanitation of the environment, control of communicable diseases. The education for personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of diseases and the development of

social machinery to ensure everyone a standard of living adequate for the maintenance of health to enable the citizens to attain their birth right of health and longevity ( Winslow ) ________________________________________________________________________ OLOF Optimum Level of Functioning Core Business of Public Health Disease Control Injury Prevention Promotion of health and equitable health gain Public Policy on Health Health protection ________________________________________________________________________ Essential Public Health Functions Health Situation Monitoring and Analysis Human Resource Development and Planning Health Promotion, social participation and empowerment Epidemiological surveillance/ disease prevention Ensuring the quality of personal and population based health services Research, development and implementation of innovative public health solutions Regulation and enforcement Development of policies in public health ________________________________________________________________________ Epidemiology Is the study of occurrences and disease distribution of disease as well as the distribution and determinants of health states or events in a specified population, and the application of this study to the control of health problems. Focus of Study a. distribution of diseases b. determinants ( causes ) Epidemiology is the backbone of diseases prevention

Uses of Epidemiology ( Morris): study the history of the health population and the rise and full of diseases and changes in their character Diagnose the health of the community and the condition of the people to measure the distribution and dimension of illness in terms of incidence, prevalence, disability and mortality, to set health problems in perspective and to define their relative importance and to identify groups needing special attention Study the work of health services with a view of improving them Estimate risk of diseases, accidents, defects and chances of avoiding them Identify syndromes by describing their distribution and association of clinical phenomena in the population Complete the clinical picture of chronic disease and describe their natural history Search for causes of health and disease by comparing the experience of groups Epidemiologic Triangle 1. Host 2. Agent a. matter b. energy c. information 3. Environment Patterns of Occurrence A. B. C. D. sporadic endemic epidemic pandemic

Outline of Plan for Epidemiologic Investigation 1. 2. 3. 4. Establish presence of epidemics establish time and space relationships relations to characteristics of community correlation of data obtained

Surveillance Provides timely and accurate inform on diseases of a certain locality Responsibilities of Surveillance Units a. surveillance of infectious diseases with outbreak potential b. assisting LGUs in investigation of outbreaks and their control c. developing information package on public health d. provide technical assistance related to epidemiology Public Health Surveillance Is an on going systematic collection, analysis, interpretation and dissemination of health data Objectives a. measure the magnitude of a problem b. measure the effect of the program Information Systems A. FHSIS B. NESSS Steps in Outbreak Investigation 1. prepare for fieldwork 2. establish existence of outbreak 3. verify diagnosis 4. define and identify cases 5. perform descriptive epidemiology 6. develop hypothesis 7. evaluate hypothesis 8. refine hypothesis/ perform additional studies 9. implement control and prevention measures 10. communicate findings 11. follow-up recommendations Functions of Epidemiology Nurse 1. implement public health surveillance

2. 3. 4. 5.

monitor local health personnel conduct/ assist in EI assist in the conduct of rapid surveys during disasters assist in the conduct of surveys, program evaluation and other epidemiologic studies 6. assist in trainings 7. assist in preparing annual report and financial plan 8. inventory and maintenance of unit Specific Role during EI maintain surveillance of notifiable diseases coordinate with other members of the health team participate in case findings and collection of lab specimen isolate cases of communicable diseases render nursing care/ health teaching/ supervision perform and teach household members methods of concurrent and terminal disinfection follow up cases and contacts Organize, coordinate and conduct community health education campaigns Referral Coordinate with other agencies Accomplish and keep records

Vital Statistics Refers to the systematic study of vital events such as births, illness, marriages, divorce, separation and deaths Uses of Vital Statistics indices of health status of a community serves as bases for PIME community health nursing problems and services Sources of Data Population Census Registration of Vital data Health Survey Studies and researches

CBR : measures on characteristic of the natural growth of population = Total number of live births registered in a given calendar year -------------------------------------------------------------------------- x 1,000 Estimated Mid Year Pop of same year CDR: measure of mortality from all causes which may result in a decrease of Population = Total number of deaths registered in a given year ----------------------------------------------------------- x 1, 000 Estimated Mid Year Population of same year IMR: measures the risk of dying during 1st year of life = Total number of deaths under 1 Yr. Old ---------------------------------------------------------- x 1, 000 Total number of Reg Live Births in same year MMR : measures the risk of dying from causes related to pregnancy ,child birth and puerperium = Total number of deaths from maternal causes reg in a given year ---------------------------------------------------------------------------- x 1, 000 Total no. of live births registered in same year FDR : measures pregnancy wastage = total no. of fetal deaths registered in a given year ----------------------------------------------------------- x 1, 000 Total number of live births same year NDR : Measures risk of dying in the 1st month of life No. of deaths under 28 deaths of age registered in a given yr

--------------------------------------------------------------------------- x 1, 000 No. of live births registered in same year Specific Death Rate : describes accurately the risk of exposure of certain classes Or groups to particular diseases Deaths in specific class/ group registered in a calendar yr ----------------------------------------------------------------------- x 100,000 Est Mid Year Population

Incidence rate : measures frequency of occurrence of a particular phenomenon No. of new cases of a particular diseases in a specific period of time ---------------------------------------------------------------------------------- x 100,000 Population at risk Prevalence rate: measures the proportion of population which exhibits a particular disease at a particular time No. of old and new cases of a certain disease registered at a given time ------------------------------------------------------------------------------------- x 100 Total number of persons examined