1

UNIT I: PROMOTING WELLNESS IN HEALTH AND ILLNESS

A. DEFINING WELLNESS IN HEALTH AND ILLNESS
1. Definitions of health
i. "Health is a state of complete physical, mental, and social well-
being and not merely the absence of disease" (WHO, 1947, p. 1)
ii. complete is controversial
iii. "Health is not a condition, it is an adjustment. It is not a state, but
a process. The process adapts the individual not only to our
physical, but also our social, environments" (Presidents
Commission, 1953, p. 4)
iv. most individuals define health as the following:
a. being able to be active and able to do what they want or
must do
b. being free of symptoms of disease and pain as much as
possible
c. being in good spirits most of the time
2. Definition of wellness
i. an active process by which an individual progresses towards
maximum potential possible, regardless of current state of health
ii. eight dimensions of wellness:
a. physical, e.g.:
i. ability to carry out daily tasks
ii. achieve fitness
iii. maintain nutrition and proper body fat
iv. avoid abusing drugs, alcohol, or using tobacco
products
v. generally to practice positive life-style habits

b. sociocultural, e.g.:
i. ability to interact successfully with people and
within the environment of which each person is a
part
i. develop and maintain intimacy with significant
others
ii. develop respect and tolerance for those with
different opinions and beliefs
c. emotional, e.g.:
i. ability to manage stress and express emotions
appropriately
i. ability to recognize, accept, and express feelings
ii. ability to accept ones limitations
d. intellectual, e.g.:
i. ability to learn and use information effectively for
personal, family, and career development
2

i. striving for continued growth and learning to deal
with new challenges effectively
ii. The creatively well person values and actively
participates in a diverse range of arts and cultural
experiences as a means to understand and
appreciate the surrounding world.
e. Spiritual, e.g.:
i. belief in some force (nature, science, religion, or a
"higher power") that serves to unite human beings
and provide meaning and purpose to life
i. includes a persons morals, values, and ethics
f. occupational, e.g.
i. abi lity to achieve a balance between work
and leisure time
ii. bel iefs about education, empl oyment
and home influence personal satisfaction and
relationships with others
iii. The professionally well person engages in work to
gain personal satisfaction and enrichment,
consistent with values, goals, and lifestyle.

g. Environmental, e.g
i. good health by occupying pleasant, stimulating
environments that support well-being
ii. influences include
a. food
b. water
c. air
h. Financial, e.g.
a. Satisfaction with current and future financial
situations
b. The financially well person is fully aware of financial
state and budgets, saves, and manages finances in
order to achieve realistic goals.

3


Wellness means overall well-being. It incorporates the mental, emotional,
physical, occupational, intellectual, and spiritual aspects of a person's life. Each
aspect of wellness can affect overall quality of life, so it is important to consider
all aspects of health. This is especially important for people with mental health
and substance use conditions because wellness directly relates to the quality and
longevity of your life.

3. Definition of disease
i. pathologic change in the structure or function of the body or mind
4. Definition of illness
i. the response a person has to a disease; it is an abnormal process
in which the persons level of functioning is changed compared
with a previous level
ii. influenced by the following:
a. self-perceptions
b. others perceptions
c. the effects of changes in body structure and function
d. the effects of those changes on roles and relationships
e. cultural and spiritual values and beliefs
iii. Types of illness
a. Acute illness
i. has a rapid onset of symptoms that lasts for a
limited and relatively short period of time
ii. e.g., typically less than six months


4

b. Chronic illness
i. has a gradual onset of symptoms that lasts for an
extended and relatively long period of time
ii. e.g., typically six months or longer
iii. characterized by periods of remission and
exacerbation
a. remission - symptoms disappear
b. exacerbation - symptoms reappear

iv. Stages of illness behavior ( Suchman)

Stage 1: Symptom Experience
i. The person is aware that something is wrong.
ii. A person usually recognizes a physical sensation or a
limitation in functioning but does not suspect a specific
diagnosis.
Stage 2: Assumption of the Sick People
i. If symptom persist and become severe, clients assume
the sick role.
ii. At this point, the illness becomes a social
phenomenon, and sick people seek confirmation from
their families and social groups that they are indeed ill
and that they be excused from normal duties and role
expectations.

Stage 3: Medical Care Contact
i. If symptoms persist despite the home remedies,
become severe or require emergency care, the person
is motivated to seek professional health services.
ii. In this stage the client seeks expert
acknowledgement of the illness as well as the
treatment.

Stage 4: Dependent Client Role
i. The client depends on health care professionals for the
relief of symptoms.
ii. The client accepts care, sympathy and protection from
the demands and stresses of life.
iii. A client can adopt the dependent role in a health care
institution, at home, or in a community setting.
iv. The client must also adjust to the disruption of a
daily schedule.
Stage 5: Recovery and Rehabilitation
i. This stage can arrive suddenly, such as when the
symptoms appeared.
ii. In the case of chronic illness, the final stage may
involve in an adjustment to a prolong reduction in
health and functioning.


5

v. Stages of illness acceptance ( Kubbler-Ross)
a. Denial
Someone in denial may believe a disease can't hurt
them. They may ignore their doctors' advice that could
help keep the disease under control.
b. Anger
What often fuels denial is anger--anger that an
individual was the "one in 1,000" to get a disease.
Anger may also be directed inward, with an individual
blaming him or herself for having the illness.
c. Fear
Often underlying anger is the fear that comes with
having a disease that can't be cured.
d. Grief
Feelings of grief and loss are common because chronic
diseases bring life restrictions that others don't have to
face.
Grief can cause feelings of inadequacy and lead to
withdrawal and isolation
e. Acceptance
Though managing a long-term illness can bring
emotional upheaval, it also brings the triumphant
feelings and strength that come with overcoming
obstacles.

vi. Effects of illness
a. Impact on Client
i. Behavioral Changes
ii. Emotional Change
iii. Physical Changes
iv. lifestyle changes

b. Impact on the Family
Factors:
i. Member of the family who is ill
ii. The seriousness and length of the illness
iii. Cultural and social customs the family follows

c. Changes in the family:
i. Role Changes
ii. Task reassignments and increased demands on
time
iii. Increased stress
iv. Financial problems
v. Loneliness as a result of loss and separation
vi. Change in social customs





6

B. MODELS OF HEALTH AND ILLNESS

1. Smiths models of health and illness
a. Clinical model
i. narrowest interpretation; medically-oriented model
ii. health is seen as freedom from disease
iii. illness is seen as the presence of disease
b. Role performance model
i. ability to perform work, that is fulfill societal roles, essential
to the model; assumption of the model is that a persons
most important role is their work role
ii. health is seen as the ability to fulfill societal roles
iii. illness is seen as the inability to fulfill societal roles
c. Adaptive model
i. ability to adapt to the environment and interact with it to
maximum advantage essential to the model
ii. health is seen as adaptation
iii. illness is seen as a failure of adaptation, or maladaptation
d. Eudaemonistic model
i. most comprehensive, holistic, view of health; ability to
become self-actualized essential to the model
ii. health is actualization or realization of ones potential
iii. illness is seen as the failure to actualize or realize ones
potential
2. Leavell and Clarks ecologic model (agent-host-environment model)



7

i. used primarily in predicting illness rather than promoting wellness
ii. model is composed of three dynamic, interactive elements
a. the agent
i. a factor (biologic, chemical, physical, mechanical,
psychosocial) that must be present or absent for an
illness to occur, e.g.:
presence of the legionella bacillus
b. the host
i. living beings (e.g., human or animal) capable of
being infected or affected by the agent, e.g.:
a Legionnaire at the Legionnaires
Conference at the Bellevue-Stratford Hotel
in Philadelphia
c. environment
i. everything external to the host that makes illness
more or less likely, e.g.:
presence of stagnant water in the air
conditioning system at the Bellevue-
Stratford Hotel in Philadelphia
iii. view of health and illness
a. health is seen when all three elements are in balance
b. illness is seen when one, two, or all three elements are not
in balance

3. Health-illness continua





8

a. Dunns High-Level Wellness Grid
i. composed of two axiss
1. a health axes which ranges from peak wellness to death
2. a environmental axes which ranges from very favorable to
very unfavorable
ii. the two axiss form four quadrants
1. high-level wellness in a favorable environment
a. e.g., a person who implements healthy life-style
behaviors and has the biopsychosocial spiritual
resources to support this life-style
2. emergent high-level wellness in an unfavorable
environment
a. e.g., a woman who has the knowledge to
implement healthy life-style practices but does not
implement adequate self-care practices because of
family responsibilities, job demands, or other
factors
3. protected poor health in a favorable environment
a. e.g., an ill person whose needs are met by the
health care system and who has access to
appropriate medications, diet, and health care
instruction
4. poor health in an unfavorable environment
a. e.g., a young child who is starving in a drought
ridden country
b. Travis Illness-Wellness Continuum

i. composed of two arrows pointing in opposite directions and joined
at a neutral point
1. movement to the right on the arrows (towards high-level
wellness) equals an increasing level of health and well-
being
a. achieved in three steps:
a. awareness
b. education
c. growth
2. movement to the left on the arrows (towards premature
death) equates a progressively decreasing state of health
a. achieved in three steps:
a. signs
b. symptoms
c. disability
9

ii. most important is the direction the individual is facing on the
pathway
1. if towards high-level health, a person has a genuinely
optimistic or positive outlook despite his/her health status
2. if towards premature death, a person has a genuinely
pessimistic or negative outlook about his/her health status
iii. compares a treatment model with a wellness model
1. if a treatment model is used, an individual can move right
only to the neutral point
a. e.g., a hypertensive client who only takes his
medications without making any other life-style
changes
2. if a wellness model is used, an individual can move right
past the neutral point
a. e.g., a hypertensive client who not only takes his
medications, but stops smoking, looses weight,
starts an exercise program, etc.
4. Rosenstock/Beckers Health-Belief Model



i. based on motivational theory
ii. composed of three components:
a. an individuals perceptions, e.g.:
i. of perceived susceptibility
ii. of perceived seriousness
b. modifying factors (factors that modify an individuals perceptions),
e.g.:
i. demographic variables
e.g., age, gender, race, ethnicity, etc.
ii. sociopsychologic variables
10

e.g., personality, social class, peer and reference
group pressure, etc.
iii. structural variables
e.g., knowledge about the disease, prior contact
with the disease, etc.
iv. perceived threat
v. cues to action
e.g., mass media campaigns, advice from others,
reminder postcard from a physician or dentist,
illness of family member or friend, newspaper or
magazine article
c. likelihood of action
i. perceived benefits of the action MINUS
ii. perceived barriers to action EQUALS
iii. likelihood of taking recommended preventive health action

C. VARIABLES INFLUENCING HEALTH STATUS, BELIEF, AND PRACTICES
1. Physical Dimension
i. Genetic make-up, age, developmental level, race and sex are all
part of an individuals physical dimension and strongly influence
health status and health practices.
ii. Examples:
a. The toddler just learning to walk is prone to fail and
injure himself.
b. The young woman who has a family history of
breast cancer and diabetes and therefore is at a
higher risk to develop these conditions.
2. Emotional Dimension
i. How the mind and body interact to affect body function and to
respond to body conditions also influences health. Long term
stress affects the body systems and anxiety affects health habits;
conversely, calm acceptance and relaxation can actually change
body responses to illness.
ii. Examples:
a. Prior to a test, a student always has diarrhea.
b. Extremely nervous about a surgery, a man
experiences severe pain following his operation.
c. Using relaxation techniques, a young woman
reduces her pain during the delivery of her baby.
3. Intellectual Dimension
i. The intellectual dimension encompasses cognitive abilities,
educational background and past experiences. These influence a
clients responses to teaching about health and reactions to health
care during illness. They also play a major role in health
behaviors.
ii. Examples:
11

a. An elderly woman who has only a third-grade
education who needs teaching about a complicated
diagnostic test.
b. A young college student with diabetes who follows
a diabetic diet but continues to drink beer and eat
pizza with friends several times a week.
4. Environmental Dimension
i. The environment has many influences on health and illness.
Housing, sanitation, climate and pollution of air, food and water
are aspects of environmental dimension.
ii. Examples:
a. Increased incidence of asthma and respiratory
problems in large cities with smog.
5. Socio-cultural Dimension
Health practices and beliefs are strongly influenced by a persons
economic level, lifestyle, family and culture. Low-income groups
are less likely to seek health care to prevent or treat illness; high-
income groups are more prone to stress-related habits and illness.
The family and the culture to which the person belongs determine
patterns of livings and values, about health and illness that are
often unalterable.
Examples:
a. The adolescent who sees nothing wrong with smoking or
drinking because his parents smoke and drink.
b. The person of Asian descent who uses herbal remedies
and acupuncture to treat an illness.
6. Spiritual Dimension
i. Spiritual and religious beliefs are important components of the
way the person behaves in health and illness.
ii. Examples:
a. Roman Catholics require baptism for both live births and
stillborn babies.
b. Jehovah Witnesses are opposed to blood transfusions.

D. HEALTH CARE ADHERENCE

Adherence
1. Extent of which an individuals behavior coincides with medical or health
advice
2. Factors influencing Adherence
a. Client motivation to become well
b. Degree of lifestyle change necessary
c. Perceived severity of the health care problem
d. Value placed on reducing the threat of illness
e. Difficulty in understanding and performing specific behaviors
f. Degree of inconvenience of the illness itself or of the regimens
g. Beliefs that the prescribed therapy or regimen will or will not help
h. Complexity, Side effects, and duration of the proposed therapy
i. Specific Cultural heritage that may make adherence difficult
j. Degrees of satisfaction and quality and type of relationship with
the health care providers
12

k. Overall cost of prescribed therapy

3. Nursing action on Non Adherence
a. Establish why the client is not following the regimen
b. Demonstrate caring
c. Encourage healthy behaviors through positive reinforcements
d. Use aids to reinforce teaching
e. Establish a therapeutic relationship of freedom, mutual
understanding and mutual responsibility with the client and
support persons

E. HEALTH PROMOTION AND WELLNESS
i. Health promotion is any activity undertaken for the purpose of achieving a
higher level of health and well-being

ii. Types of health promotion programs
a. information dissemination
health promotion programs that use a variety of media to offer
information to the public about the risk or particular lifestyle choices
and personal behavior, as well as the benefits of changing that
behavior and improving the quality of life

e.g., billboards, posters, brochures, newspaper features, books,
health fairs
b. health risk appraisal/wellness assessment programs
Health promotion programs that appraise individuals of the risk
factors inherent in their lifestyles in order to motivate them to reduce
specific risks factors and develop positive health habits
e.g., tools such as Health-Style: A Self-Test
c. lifestyle and behavioral change programs
Health promotion programs geared toward enhancing the quality of
life and extending the lifespan through implementation of a healthy
lifestyle or behavioral change in the individual

d. environmental control programs
Health promotion programs developed in response to the recent
growth in the number of contaminants of human origin that have
been introduced into our environment

F. HEALTHY PEOPLE 2020

i. is the federal government's prevention agenda for building a
healthier nation. It is a statement of national health objectives
designed to identify the most significant preventable threats to
health and to establish national goals to reduce these threats.

13

ii. The vision of Healthy People 2020 is to have a society in which all
people live long, healthy lives.
iii. The overarching goals of Healthy People 2020 are to:
a. attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death;
b. achieve health equity, eliminate disparities, and improve
the health of all groups;
c. create social and physical environments that promote good
health for all; and
d. promote quality of life, healthy development, and healthy
behaviors across all life stages.

iv. The plan contains 42 topic areas, including 13 new topic areas.
There are 24 objectives regarding heart disease and stroke
specifically, and more in related areas that are relevant to heart
disease and stroke.


G. THE NURSING PROCESS AND HEALTH PROMOTION

1. Assessment

a. Health History
b. Physical Examination
c. Physical Fitness Examination
d. Lifestyles assessment
e. Spiritual Health assessment
f. Social support System review
g. Health risk assessment
h. Health Beliefs review
i. Life stress review
j. Validating assessment data

2. Diagnosis

a. Wellness diagnosis
b. Readiness for enhanced

3. Planning

a. Identify health goals related behavior change options
b. Identify behavior or health outcomes
c. Develop Behavior change plan
d. Reiterate benefits of changeAddress environmental and interpersonal
facilitators and barriersof change
e. Determine a time for implementation
f. Commit to behavior-change goals



14

4. Implementation

i. Supporting
ii. Counseling
Individual
Telephone
iii. Facilitating
iv. Teaching
v. Consulting
vi. Enhancing behavior change
vii. Modeling

5. Evaluation

H. THE THREE LEVELS OF PREVENTION

i. Prevention, as it relates to health, is about avoiding disease before it starts.
ii. It has been defined as the plans for, and the measures taken, to prevent
the onset of a disease or other health problem before the occurrence of the
undesirable health event.
1. Primary Prevention
i. Primary prevention seeks to reduce the frequency of new cases of
disease occurring in a population and, thus is most applicable to
persons who are in the stage of susceptibility.
ii. We use primary prevention methods before the person gets the
disease. Primary prevention aims to prevent the disease from
occurring. So primary prevention reduces both the incidence and
prevalence of a disease.
iii. Encouraging people to protect themselves from the sun's ultraviolet
rays is an example of primary prevention of skin cancer.
2. Secondary Prevention
i. Secondary prevention attempts to reduce the number of existing
cases in a population and, therefore, is most appropriately aimed
those in the stage of pre symptomatic disease or the early stage of
clinical disease.
ii. Secondary prevention is used
1. after the disease has occurred, but
2. before the person notices that anything is wrong.
iii. A doctor checking for suspicious skin growths is an example of
secondary prevention of skin cancer. The goal of secondary
prevention is to find and treat disease early. In many cases, the
disease can be cured.
15

3. Tertiary Prevention
i. Tertiary prevention tries to limit disability and improve functioning
following disease or its complications, often through rehabilitation.
Therefore, it is most applicable during the late clinical stage or the
stage of diminished capacity.
ii. Tertiary prevention targets the person who already has symptoms of
the disease
iii. The goals of tertiary prevention are:
1. prevent damage and pain from the disease
2. slow down the disease
3. prevent the disease from causing other problems (These are
called "complications.")
4. give better care to people with the disease
5. make people with the disease healthy again and able to do
what they used to do



16

Examples of primary, secondary, and tertiary prevention interventions targeting
individuals and populations
Disease Intervention
level
Primary Secondary Tertiary
Colorectal
cancer
Individual Counselling on
healthy lifestyles:
dietary counselling
for people at risk of
colorectal cancer, etc.
Hemoccult
stool testing to
detect
colorectal
cancer early
Follow-up exams to
identify recurrence
or metastatic
disease: physical
examination, liver
enzyme tests, chest
x-rays, etc.
Population Publicity campaigns
alerting the public to
the benefits of
lifestyle changes in
preventing colorectal
cancers; promotion of
high fibre diets;
subsidies to help
people access
exercise
programmes; anti-
smoking campaigns
Organized
colonoscopy
screening
programs
Implementation of
health services
organizational
models that improve
access to high-
quality care
Infectious
diseases:
hepatitis C
Individual Counselling on safe
drug use to prevent
hepatitis C virus
(HCV) transmission;
counselling on safer
sex
Screening for
HCV infection
of patients with
a history of
injection drug
use
HCV therapy to cure
infection and prevent
transmission
Population HCV prevention
includes safer sex
practices,
programmes to
discourage needle
sharing among
intravenous drug
users, etc.
Establish a
universal
testing system
for HCV in
high risk
groups
(Similar to primary
prevention):
ensuring close
control of high risk
sites such as tattoo
parlours that have
been associated
with outbreaks
Metabolic
syndrome
Individual Nutrition and exercise
counselling
Screening for
diabetes
Referral to cardiac
rehabilitation clinics
Population Built environment
favourable for active
transport (walking,
bicycling rather than
using a car)
Community level
weight loss and
exercise
programs to
control
metabolic
syndrome
Implementation of
multidisciplinary
clinics
17



Unit II: HEALTH AS A MULTIFACTORIAL PHENOMENON

A. The determinants of health
Many factors combine together to affect the health of individuals and
communities. Whether people are healthy or not, is determined by their
circumstances and environment. To a large extent, factors such as where we
live, the state of our environment, genetics, our income and education level,
and our relationships with friends and family all have considerable impacts on
health, whereas the more commonly considered factors such as access and
use of health care services often have less of an impact.

The determinants of health include:
1. the social and economic environment,
2. the physical environment, and
3. the persons individual characteristics and behaviours.

The context of peoples lives determine their health, and so blaming
individuals for having poor health or crediting them for good health is
inappropriate. Individuals are unlikely to be able to directly control many of the
determinants of health. These determinantsor things that make people
healthy or notinclude the above factors, and many others:

a. Income and social status
i. Higher income and social status are linked to better health. The
greater the gap between the richest and poorest people, the greater
the differences in health.
b. Education
i. Low education levels are linked with poor health, more stress and
lower self-confidence.
c. Physical environment
i. Safe water and clean air, healthy workplaces, safe houses,
communities and roads all contribute to good health.
d. Employment and working conditions
i. People in employment are healthier, particularly those who have more
control over their working conditions
e. Social support networks
i. Greater support from families, friends and communities is linked to
better health.
f. Culture
i. Customs and traditions, and the beliefs of the family and community all
affect health.
g. Genetics
i. Inheritance plays a part in determining lifespan, healthiness and the
likelihood of developing certain illnesses.
h. Personal behavior and coping skills
18

i. Balanced eating, keeping active, smoking, drinking, and how we deal
with lifes stresses and challenges all affect health.


j. Health services
i. access and use of services that prevent and treat disease
influences health
k. Gender
i. Men and women suffer from different types of diseases at different
ages.

B. Optimum level of functioning among individuals, families and communities.

Eco-system which affect this level of functioning
1. Political
i. This factor pertains to the power and authority to regulate the
environment.
ii. Involves one's leadership how/she rules, manages and other people in
decision making.
iii. The government has the power to promulgate, promote, implement and
think of the different ways to alleviate problems regarding health.
iv. Its is written in the Philippine Constitution that the government provides
access for sustainable health
v. Political Issue provide People empowerment
vi. Example:
a. Safety- the condition of being free from harm, injury or loss of
authority or power

b. Oppression- unjust or cruel exercise of authority or power

c. People empowerment- determination to pursue something which is
for the interest of the
majority.

2. Behavioral
i. A persons level of functioning is affected directly by Culture, habits,
attitudes, mores, ethnic backgrounds and society or his environment.
ii. Culture, Habits, Ethnic customs
iii. Examples
a. Smoking
b. Intake of alcoholic drinks
c. Substance abuse
d. Lack of exercise

3. Hereditary
i. the genetic transmission of traits from parents to offspring; genetically
determined.

ii. There are certain diseases that is hereditary in nature, therefore individual
with this circumstances doesnt have any control of the situation.
19

iii. It is said therefore that inheritance plays a part in determining lifespan
and health level of an individual
iv. Genetic endowment, Defects, Strengths
v. Risks: Familial, Ethnic, Racial

4. Health Care Delivery system
i. One component of this factor is the primary health care which is a
partnership approach
ii. PHC - in Philippine setting, it is a partnership approach of the private
group and the government ; they work hand in hand to deliver effective
provision of essential health services
iii. Goal: Effective provision of health services that are community-based
and accessible
iv. Components: Promotive, Preventive, Curative, Rehabilitative

5. Environmental Influences
i. the sum of all the conditions and elements that make up the surroundings
and influence the development of the individuals.

ii. People living in urban areas are prone to hazards of health. E.g.
communicable and non-communicable diseases are rampant in urban
areas compare to those who are living in rural areas. Likewise those who
live in solitude life is prone to depression.
iii. Air, Food, Water waste, Urban/rural noise, Radiation, Pollution


6. Socio-Economic influence
i. refers to the production activities, distribution of and consumption of
goods
of an individual
ii. In Public health centers, families from lower income brackets are the
ones mostly served
iii. Families within the mid-income level can provide basic health services for
their members unlike those who are at poor sector basic health services
are deprived.
iv. Components: Employment, Education, Housing

7. Cultural
i. Relating to the representation of non-physical traits, such as values,
beliefs, attitudes and customs shared by a group of people and passed
from the generation to the next.
ii. Practices: a customary action usually done to maintain or promote health
like use of anting-anting and lucky charms.
iii. Beliefs: a state or habit of mind wherein a group of people place into
something
or a person.



20

UNIT III: PHILIPPINE HEALTH CARE DELIVERY SYSTEM

DEFINITION OF TERMS

HEALTH SYSTEM
i. Interrelated system in which a country organizes available resources for the
maintenance and improvement of the health of its citizens and communities.
ii. A health system comprises all organizations, institutions and resources
devoted to producing actions whose primary intent is to improve health.

HEALTH CARE SYSTEM
i. an organized plan of health services (Miller- Keane, 1987)

HEALTH CARE DELIVERY
i. rendering health care services to the people (Williams-Tungpalan, 1981)

HEALTH CARE DELIVERY SYSTEM (Williams- Tungpalan, 1981)
i. The network of health facilities and personnel which carries out the task of
rendering health care to the people.
ii. The totality of all policies, facilities, equipment, products, human resources
and services which address the health needs problems and concerns of the
people. It is large, complex, multi-level and multi-disciplinary.
PHILIPPINE HEALTH CARE SYSTEM
i. is a complex set of organizations interacting to provide an array of health
services (Dizon, 1977)

THE NATIONAL HEALTH SITUATION
The Philippine health care system has rapidly evolved with many challenges
through time. Health service delivery was devolved to the Local Government
Units (LGUs) in 1991, and for many reasons, it has not completely surmounted
the fragmentation issue. Health human resource struggles with the problems of
Underemployment, scarcity and skewed distribution. There is a strong
involvement of the private sector comprising 50% of the health system but
regulatory functions of the government have yet to be fully maximized.
1. Health Facilities
i. Health facilities in the Philippines include government hospitals,
private hospitals and primary health care facilities. Hospitals are
classified based on ownership as public or private hospitals. In the
Philippines, around 40 percent of hospitals are public (Department
of Health, 2009). Out of 721 public hospitals, 70 are managed by
the DOH while the remaining hospitals are managed by LGUs and
other national government agencies (Department of Health, 2009).
Both public and private hospitals can also be classified by the
service capability (see DOH AO 2005-0029). A new classification
and licensing system will soon be adopted to respond to the
capacity gaps of existing health facilities in all levels. At present,
Level-1 hospitals account for almost 56 percent of the total
number of hospitals (Department of Health, 2009; Lavado, 2010)
which have very limited capacity, comparable only to infirmaries
21

ii. NUMBER OF HOSPITALS BY CLASSIFICATION AND
OWNERSHIP, PHILIPPINES, 2009: private hospitals
outnumbered the government hospitals in all categories. The
disparity is more noticeable in tertiary hospitals where the number
of private hospitals is four times that of the government hospitals.
2. Health outcomes
i. Life Expectancy:
The projected average life expectancy of Filipinos in 2005 to 2010
is 68.8 years, with males having an average life expectancy of
66.11 years and females with 71.64 years (National Statistics
Office, 2010). It is projected that the average life expectancy of
Filipinos will increase to 70.38 years from 2010 to 2015 and 71.59
years from 2015 to 2020 (National Statistics Office).

Projected life expectancy at birth by sex at five calendar-year intervals,
Philippines, 2000 to 2040 (medium assumption)

Year Male Female expectancy*
2000-2005 64.11 70.14 67.62
2005-2010 66.11 71.64 68.88
2010-2015 67.61 73.14 70.38
2015-2020 68.81 74.34 71.59
2020-2025 70.01 75.54 72.77
2025-2030 71.01 76.54 73.77
2030-2035 72.01 77.54 74.77
Source: 2000 Census-based Population Projection
*Calculated using National Statistics Office data

3. Deaths and Births
i. Deaths and births are commonly measured to determine the
status of health and fertility dynamics of an area. The crude death
rate (CDR) has been declining since the 1960s. However, no
significant change has been noted since 2000-2009. The number
of deaths in a particular population is influenced by various
environmental factors. Global experience suggests that
decreasing CDR is a result of decreasing cases of infectious
diseases, improvement of perinatal practices and innovative
health interventions (National Statistics Office, 2009).
ii. Infant and maternal mortality are the most useful indicators since
they reflect the general condition of the health system.
iii. The decreasing trend in Infant Mortality Rate (IMR) over the last
decade. It dropped from 57 infant deaths per 1000 live births in
1990 to 25 infant deaths per 1000 live births in 2008 (National
Statistics Office, 2008). However, disaggregating IMR by socio-
economic quintiles and regions reveals performance disparities.
iv. The IMR of the poorest quintile in 2008 is similar to the national
IMR two decades ago. Regional comparison also depicts wide
variations which can be consistently observed since early 1990s
v. Infant and maternal mortality are the most useful indicators since
they reflect the general condition of the health system.
22

vi. On average, a woman under the poorest quintile is likely to have 5
births while the richest quintile is only likely to have 2 births
(National Statistics Office, 2008).

4. Disease Trends in the Philippines
i. The countrys health profile depicts a distinct epidemiologic and
demographic transition characterized by double burden of
diseases consisting of communicable diseases (which require
major public health intervention) and non-communicable diseases
(which need expensive curative and chronic-care intervention).
This scenario makes the countrys health profile a hybrid or
combination of health situations found in both developed and
developing countries. Similar to Sub-Saharan Africa, many
regions in the Philippines are still struggling to eliminate hunger
and infectious diseases while continually battling on non-
communicable diseases (NCDs) as experienced in developed
countries. The health status of the country therefore can be best
described to be at the crossroads of infectious and non-
communicable diseases.
ii. Communicable diseases
In the Philippines, eight out of the ten leading causes of morbidity
or illness can be attributed to infectious diseases. Illnesses related
to the respiratory system such as acute respiratory infection,
pneumonia and bronchitis are the top 3 leading cause of illness as
shown in Table 10. The country commits to control tuberculosis in
response to the Millennium Development Goals (MDGs). Despite
the aggressive campaigns initiated by the Department of Health
(DOH) in collaboration with donor agencies, tuberculosis remains
among the leading causes of morbidity and mortality in the
country. HIV control is also one of the countrys commitments to
the MDGs. Though HIV prevalence of the country is less than 1
percent, HIV cases are increasing exponentially. Endemic
diseases like malaria, schistosomiasis and filariasis are still
prevalent in several regions. The country has also experienced
cases of re-emerging infectious diseases, including new and
emerging diseases because of various demographic and
environmental factors. Non-communicable diseases
iii. Non-communicable diseases (NCDs) are increasing rapidly in the
Philippines. In 2009, seven of the ten leading causes of death are
non-communicable in etiology. Majority of the NCDs mortality
cases (i.e cardio-vascular diseases, cancer, chronic obstructive
pulmonary disease and diabetes) considered lifestyle-related.
Around 75 percent of the total deaths can be attributed to NCDs
which is similar to the estimates in most developing countries, and
30-50 percent occurred pre-maturely (below 60 years old) (Ulep,
2012). It is noteworthy that over-nutrition is increasing in the
country while under-nutrition remains a problem especially in rural
and poor areas.
iv. Comparing with the GATS in 2009, the prevalence rate is almost
close at 28.3%. The prevalence of smoking is significantly higher
among the poor adults. Alcohol is causally linked in varying
23

degrees to cancers, cardio-vascular diseases, liver disease and
pancreatitis. In the country, about a quarter of the adult
populations are alcohol drinkers in 2008 (Ulep, 2012). Another
study in 2009 indicates that almost half of the alcohol drinkers are
adults (Department of Health, 2009). of the adult population are
current smokers and 14 percent used tobacco in the past (Ulep,
2012).
v. Another study in 2009 indicates that almost half of the alcohol
drinkers are adults (Department of Health, 2009). c. Aggressively
promoting healthy lifestyle changes to reduce non-communicable
diseases; d. Ensuring public health measures to prevent and
control communicable diseases, and adequate surveillance and
preparedness for emerging and re-emerging diseases; and e.
Harnessing the strengths of inter-agency and inter-sectoral
approaches to health especially with the Department of Education
and Department of Social Welfare and the Department of Interior
and Local Government.

De La Salle University
Center for Social Concern and Action
July 2013, Vol. 1 Issue 1, pages 24-25
On promoting maternal health and child care development. The DOH is
implementing its EPI to meet the target of MDG in reducing infant/child mortality
as well as maternal mortality. To achieve this end, the govt supported the
passage and implementation of the cheaper medicine act. The department has
already started upgrading health facilities nationwide for the establishment of
1,278 basic and comprehensive emergency obstetrics and newborn care
facilities; the construction of potable water system; the construction3,931 Botika
ng barangay to provide low-cost and affordable medicines. Exact unit has a
monthly worth 25, 0o0 medicines specially intended for and other cases like
malaria, schistosomiasis, leprosy, filariasis, rabies, etc.
On Better Health Services. The number of Filipinos with no access to
government health services remains a grave concern. Before, four out of ten
Filipinos have never seen a health professional in their entire lifetime. While six
out of ten Filipinos die without being attended to by health professionals Due to
efficient targeting, 30,801 nurses and health professionals assisted ably by over
11,000 community health workers were deployed to remote areas where they
were most needed. In fact, the government had sent health professionals to
1,021 localities covered by the 4Ps and to the 609 poorest cities and
municipalities, as identified by National Anti-Poverty Commission

24




25

THREE STRATEGIES IN DELIVERING HEALTH SERVICES (ELEMENTS)
1. Creation of Restructured Health Care Delivery System (RHCDS) regulated by PD
568 (1976)
2. Management Information Systems regulated by R.A. 3753: Vital Health Statistics
Law
3. Primary Health Care (PHC) regulated by LOI 949 (1984): Legalization of
Implementation of PHC in the Philippines

CREATION OF RHCDS
1. RHO (National Health Agency) or existing national agencies like PGH or
specialized agencies like Heart Center for Asia,NKI
2. MHO & PHO (Municipal/Provincial Health Office)
3. BHS & RHU (Barangay Health Station/Rural Health Unit)

Referral System in Levels of the Health Care:
1. Barangay Health Station (BHS) is under the management of Rural Health
Midwife (RHM)
2. Rural Health Unit (RHU) is under the management or supervision of PHN
3. Public Health Nurse (PHN) caters to 1:10,000 population, acts as managers in
the implementation of the policies and activities of RHU, directly under the
supervision of MHO (who acts as administrator)

Philippine Health Care System Context
1. Health as a basic human right
2. Department of Health is the lead agency
3. Local Government Code
4. Access to health care hampered by high cost, physical and socio-cultural
barriers, and health workforce crisis
Three divisions of Health Care Delivery System
1. Government
2. Mixed Sectors
3. Private Sectors

The primary government agency in the field of health runs the bulk of the
government health facilities is the Department of Health
Devolution
i. In 1991 the Philippine Government introduced a major devolution of national
government services, which included the first wave of health sector reform,
through the introduction of the Local Government Code of 1991.
ii. The Code devolved basic services for agriculture extension, forest
management, health services, barangay (township) roads and social welfare
to Local Government Units.
iii. In 1992, the Philippine Government devolved the management and delivery
of health services from the National Department of Health to locally elected
provincial, city and municipal governments.


26

4 Essential Functions of Health System
1. Service provision
2. Resource generation
3. Financing
4. Stewardship

Health Care System Models
1. Private Enterprise Health Care Model
vi. Purely private enterprise health care systems are comparatively rare
vii. Where they exist, it is usually for a comparatively well off subpopulation in a
poorer country with a poorer standard of health care
viii. e.g. private clinics for a small, wealthy expatriate population in an otherwise
poor country
2. Social Security Health Model
i. Where workers and their families are insured by the state
ii. Refers to social welfare service concerned with social protection, or protection
against socially recognized conditions, including poverty, old age, disability,
unemployment and others

3. Publicly Funded Health Care Model
i. Where the residents of the country are insured by the state
ii. Health care that is financed entirely or in majority part by citizens tax payments
instead of through private payments made to insurance companies or directly to
health care providers

4. Social Health Insurance
i. Where the whole population or most of the population is a member of a sickness
insurance company
ii. SHI is a method for financing health care costs through a social insurance
program based on the collection of funds contributed by individuals, employers
and sometimes government subsidies.
iii. Characterized by the presence of sickness funds which usually receive a
proportional contribution of their members wages. With this insurance
contributions these funds pay medical costs of their members
iv. Affiliation to such funds is usually based on professional, geographic, religious,
political and/or non partisan criteria

Health Care Utilization
i. Physical barriers - geographical location patterns of health care consumers in
relation to health providers
ii. Financial factors also exists that affect health seeking patterns of the Filipinos

MULTISECTORAL APPROACH TO HEALTH (NLGNI, 8th edition, 1995)
i. The level of health of a community is largely the result of a combination of
factors.
ii. Health, therefore, cannot work in isolation. Neither can one sector or
discipline claim monopoly to the solution of community health problems.
Health has now become a multisectoral concern. Health has now become
a multisectoral concern.
iii. For instance, it is unrealistic to expect a malnourished child to
substantially gain in weight unless the familys poverty is alleviated In
27

other words, improvement of social and economic conditions need to be
attended to first or tackled hand in hand with health problems

Health System Composition
a. Health sector refers to the group of services or institutions in the community or
country which are concerned with the health protection of the population - may
be public (government), private and non-governmental health organizations
b. Health related sectors

Functions of the Health Sector
1. Direct provision of health services: promotion, prevention, diagnosis and
treatment, medical rehabilitation
2. Development and provision of manpower, drugs and medical supplies; financing
support
3. Research and development
4. Coordinating, controlling and directing organizations and activities associated
with other functions
1. Intersectoral Linkages
i. Primary Health Care forms an integral part of the health system and
the over-all social and economic development of the community. As
such, it is necessary to unify health efforts within the health
organization itself and with other sectors concerned. It implies the
integration of health plans with the plan for the total community
development.
ii. Sectors most closely related to health include those concerned with:
a. Agricultural b. Education c. Public works d. Local governments e.
Social Welfare f. Population Control g. Private Sectors
iii. The agricultural sector can contribute much to the social and
economic upliftment of the people. Demonstration to mothers of
better techniques and procedures for food preparation and
preservation can preserve the nutritive value of local foods. Through
joint efforts, agricultural technology that produces side effects unsafe
to health (for instance, insecticide poisoning) can be minimized or
prevented. The school has long been recognized as an effective
venue for transmission of basic knowledge to the community. Every
pupil or student can be tapped for primary health care activities such
as sanitation and food production activities Construction of safe
water supply facilities and better roads can be jointly undertaken by
the community with public works. Community organization (e.g.
establishing a barangay network for health) can be worked through
the local government or community structure. Likewise, better housing
through social welfare agencies, promotion of responsible parenthood
through family planning services and increased employment through
the private sectors can be joint undertakings for healthWe have to
recognize that oftentimes health actions undertaken outside the health
sector can have health effects much greater than those possible
within it
2. Intrasectoral Linkages
i. In the health sector, the acceptance of primary health care
necessitates the restructuring of the health system to broaden health
coverage and make health service available to all.
28

ii. There is now a widely accepted pyramidal organization that provides
levels of services starting with primary health and progressing to
specialty care.
iii. Primary health care is the hub of the health system.


DEPARTMENT OF HEALTH
i. The Philippine Department of Health (abbreviated as DOH; Filipino: Kagawaran
ng Kalusugan) is the executive department of the Philippine
government responsible for ensuring access to basic public health services by all
Filipinos through the provision of quality health care and the regulation of all
health services and products. It is the government's over-all technical authority
on health. It has its headquarters at the San Lazaro Compound, along Rizal
Avenue in Manila.
ii. The department is led by the Secretary of Health, nominated by the President of
the Philippines and confirmed by the Commission on Appointments. The
Secretary is a member of the Cabinet. The current Secretary of Health is Enrique
Ona.

5 MAJOR FUNCTIONS:
1. Principal agency in health in the Philippines
2. Ensuring access to basic health services to all Filipinos through the provision of
quality health care
3. Formulation and development of national health policies, guidelines, standards
and manual operation for health services and programs
4. Issuance of rules and regulations, licenses and accreditation
5. Promulgation of the national standards, goals, priorities and indicators
6. Development of special health programs and projects

BASIC HEALTH SERVICES UNDER OPHS OF DOH
E ducation regarding Health
L ocal Endemic Diseases
E xpanded Program on Immunization
M aternal & Child Health Services
E ssential drugs and Herbal plants
N utritional Health Services (PD 491): Creation of Nutrition Council of the Phils.
T reatment of Communicable & Non communicable Diseases
S anitation of the environment (PD 856): Sanitary Code of the Philippines

D ental Health Promotion
A ccess to and use of hospitals as Centers of Wellness
M ental Health Promotion

VISION BY 2030 (DREAM OF DOH)
A Global Leader, staunch advocate and model in promoting health for all in the
Philippines

MISSION
To guarantee EQUITABLE,
SUSTAINABLE and QUALITY
29

Health for all Filipinos,
Especially the poor and to lead the quest for excellence in health

Principles to attain the vision of DOH
1. Equity: equal health services for all-no discrimination
2. Quality: DOH is after the quality of service not thequantity
Philosophy of DOH: Quality is above quantity
3. Accessibility: DOH utilize strategies for delivery of health services

Health Resources
1. Rural Health Unit (RHU) and their sub-centers
2. Chest clinics, Malaria Eradication Units and Schistosomiasis Control Unit
3. Tuberculosis clinics and Hospitals of the PTBs
4. Private Clinics
5. Clinics run by PMA
6. Community Hospitals and Health services Centers run by Philippine Medical
Care Commission (PMCC)
7. Voluntary Health Facilities run by religious and civic groups.

The Department of Health Mandate:
The Department of Health shall be responsible for the following:
1. Formulation and development of national health policies, guidelines, standards
and manual of operations for health services and programs; issuance of rules
and regulations, licenses and accreditations; promulgation of national health
standards, goals, priorities and indicators; development of special health
programs and projects and advocacy for legislation on health policies and
programs.
2. The primary function of the Department of Health is the promotion, protection,
preservation or restoration of the health of the people through the provision and
delivery of health services and through the regulation and encouragement of
providers of health goods and services (E.O. No. 119, Sec. 3)

DOH Offices
i. The DOH is composed of about 17 central offices, 16 Centers for Health
Development located in various regions, 70 hospitals and 4 attached
agencies.

Center for Health Development
1. Responsible for field operations of the Department in its administrative region
and for providing catchment area with efficient and effective medical services.
2. Tasked to implement laws, regulation, policies and programs.
3. Tasked to coordinate with regional offices of the other Departments, offices and
agencies as well as with the local governments.
4. Act as main catalyst and organizer in the ILHZ formation
5. Provide technical support and advocacy for the devt of local health management
systems and their integration in the context of the ILHZ
6. Review and approve ILHZ proposals for funding
7. Integrate local health plans into regional plans
8. Undertake monitoring of the development and implementation of ILHS
30

DOH Hospitals
1. Provides hospital-based care; specialized or general services, some conduct
research on clinical priorities and training hospitals for medical specialization.

Attached Agencies
1. The Philippine Health Insurance Corporation is implementing the national health
insurance law, administers the medicare program for both public and private
sectors.
2. The Dangerous Drugs Board on the other hand, coordinates and manages the
dangerous drugs control program.
3. Philippine Institute of Traditional and Alternative Health Care
4. Philippine National AIDS Council

MIXED SECTORS
1. PTS- Philippine Tuberculosis society
2. PCS- Philippine Cancer Society
3. PNRC- Philippine National Red Cross
4. PMHA- Philippine Mental Health Association
5. PHA- Philippine Heart Association

PRIVATE SECTORS
1. Socialized Medicine- funded b general taxation, emphasis on prevention
2. Compulsory Health insurance- law requires people to subscribe to health insurance
plan, usually government sponsored; covers only curative and rehabilitative
medicine; preventive services provided by government agencies
3. Voluntary Health insurance- government only encourages people to subscribe to
health insurance
4. Free Enterprise- people have to take care of their medical needs.

District Health System
A contained segment of the national health system which comprises a well defined
administrative and geographic area either rural or urban and all institutions and sectors
whose activities contribute to improve health - World Health Organization

District Health System is subdivided into 3 levels of referral:
1. Primary barangay health stations and rural health units
2. Secondary district/provincial hospitals
3. Tertiary provincial and regional hospitals

1. PRIMARY LEVEL OF HEALTH CARE FACILITIES
i. the rural health units, their sub-centers, chest clinics, malaria eradication
units, and schistosomiasis control units operated by the DOH; puericulture
centers operated by League of Puericulture Centers; tuberculosis clinics and
hospitals of the Philippine Tuberculosis Society; private clinics, clinics
operated by the Philippine Medical Association; clinics operated by large
industrial firms for their employees; community hospitals and health centers
operated by the Philippine Medicare Care Commission and other health
facilities operated by voluntary religious and civic groups (Williams-
Tungpalan, 1981).


31

2. SECONDARY LEVEL OF HEALTH CARE FACILITIES
i. are the smaller, non-departmentalized hospitals including emergency and
regional hospitals.
ii. Services offered to patients with symptomatic stages of disease, which
require moderately specialized knowledge and technical resources for
adequate treatment.
3. TERTIARY LEVEL OF HEALTH CARE FACILITIES
i. the highly technological and sophisticated services offered by medical
centers and large hospitals. These are the specialized national hospitals.
ii. Services rendered at this level are for clients afflicted with diseases which
seriously threaten their health and which require highly technical and
specialized knowledge, facilities and personnel to treat effectively (Williams-
Tungpalan, 1981)



A PYRAMIDAL HEALTH STRUCTURE Tertiary National Health Health Services Care Regional Health
Services Secondary District Health Health Services Care Rural (Local Hospital) Services Primary Rural
Health Units Health Barangay health Stations Care



3 LEVELS OF HEALTH CARE
1. Primary-prevention of illness or promotion of health
2. Secondary-curative
3. Tertiary-rehabilitative


32



According to Increasing Complexity of the
service provided
According to the Type of Service

TYPES SERVICE TYPE EXAMPLE
Primary

Health Promotion,
Preventive Care,
Continuing Care for
common health
problems, attention
to psychological and
social care, referrals

Health Promotion
and illness
Prevention
Information
Dissemination

Secondary

Surgery, Medical
services by
Specialists

Diagnosis and
Treatment
Screening

Tertiary

Advanced,
specialized,
diagnostic,
therapeutic &
rehabilitative care
Rehabilitation PT/OT



LEVELS OF PREVENTION
PRIMARY LEVEL
Health Promotion and
Illness Prevention

SECONDARY LEVEL
Prevention of
Complications thru Early
Dx and Tx

1. TERTIARY LEVEL
Prevention of Disability,
etc.

Provided at
Health care/RHU
Brgy. Health Stations
Main Health Center
Community Hospital
and Health Center
Private and Semi-
private agencies
When hospitalization is
deemed necessary and
referral is made to
emergency (now district),
provincial or regional or
private hospitals

When highly-specialized
medical care is necessary
referrals are made to
hospitals and medical
center such as PGH,
PHC, POC, National
Center for Mental Health,
and other govt private
hospitals at the municipal
level


Inter Local Health Zone (ILHZ)
1. Unit of the health system created for local health service management and
delivery in the Philippines
2. Applied in many developing countries where responsibility for health services has
been decentralized from national to local health authorities
ILHZ
33

1. Has a defined population within a defined geographical area and comprises a
central or core referral hospital and a number of primary level facilities such as
RHUs and BHS
2. Clustering of municipalities
3. Includes all stakeholders involved in the delivery of health services including
community-based NGOs and the private sectors (foreign and/or local)
4. Provides quality, equitable and accessible health care

Composition of ILHZ
1. People community members, CHWs, NGOs, peoples organizations, local chief
executives, other govt officials, private sector
2. Boundaries clear boundaries between ILHZ
3. Health facilities
4. Health workers district health team

Importance of establishing an ILHZ
1. To re-integrate hospital and public health services for a holistic delivery of health
services
2. To identify areas of complementation of the stakeholders LGUs at all levels,
DOH, PHIC, communities, NGOs, private sector and others

Expected achievement of the ILHZ
1. Universal coverage of health insurance
2. Improved quality of hospital and RHU services
3. Effective referral system
4. Integrated planning
5. Appropriate health information system
6. Improved drug management
7. Developed human resources
8. Effective leadership through inter-LGU cooperation
9. Financially viable or self-sustaining hospital
10. Integration of public health and curative hospital

Core Referral Hospital
1. Main hospital for ILHZ and its catchment population
2. Main point of referral for hospital services from the community, private medical
practitioner and public health services at BHS and RHUs
3. Minimum services:
4. Out-patient services
5. Lab and radiological diagnostic services
6. Inpatient care
7. Surgical services sufficient to provide emergency care for basic life threatening
conditions, obstetrics and trauma

Minimum Package of Activity for PHC services
1. Pre-natal care
2. Normal delivery and post-partum care
3. Immunization
4. Family planning
5. Nutrition Vit. A & iron supplementation
6. Growth monitoring
34

7. Control of communicable diseases
8. Minor surgery suturing , draining of abscess, circumcision
9. Dental health
10. Appropriate referral
11. Environmental health services
12. Basic laboratory services
13. Health promotion and education
14. Management of public health services, coordination with NGOs and the private
medical sector, participation in ILHZ management
15. Training of human resources
16. Supervision of health services and human resources within the municipal
catchment area

Complementary Package of Activity for Core Referral Hospitals
1. Outpatient consultations for patients referred from the primary level
2. Inpatient medical and surgical care
3. Emergency room care
4. Minor surgery (placental extraction, excision, suturing , D&C
5. Anesthesia
6. Major emergency surgery (CS, trauma surgery, appendectomy)
7. Complicated deliveries
8. Basic orthopedics (ex. Setting of simple fractures
9. Nutrition services Referral of more urgent cases to a higher level of care
10. X-ray
11. Laboratory services
12. Blood transfusion
13. Pharmacy services
14. Management of hospital services and participation in ILHZ management
15. Public health promotion and education
16. Coordination with public health services
17. Transport and communication linkages

Tertiary Package of Activity for provincial Govt Referral Hospital
1. Pediatric, surgical, medical, orthopedic obstetric and gynecology departments
2. Expanded surgical capability (burns)
3. Intensive care, neonatal intensive care, coronary care
4. Ophthalmology
5. Rehabilitative medicine (physiotherapy, occupational therapy)
6. A full range of dental services
7. Advanced diagnostics
8. Public health laboratory (malaria, schistosomiasis, water analysis, referral
laboratory of RHUs and core referral hospitals
9. Blood bank and transfusion services
10. Medical social services, veterans, senior citizens medical services
11. Pharmacy services Dietary and nutrition services
12. Wellness center program
13. Hospital administration and management services
14. Emergency transport
15. In-house engineering and maintenance

35

FACTORS ON THE VARIOUS CATEGORIES OF HEALTH WORKERS AMONG
COUNTRIES AND COMMUNITIES
1. available health manpower resources
2. local health needs and problems
3. political and financial feasibility
Philippine Health Human Resource
i. Labor Force 34.2 M (42% of the total population)
ii. 8.83% comprise Health Human Resource
iii. Unemployment Rate 12.7%
iv. 1 out of 5 is underemployed/underpaid

Stock of Filipino Health Workers
i. Nurses (10,000/year) from 350 nursing colleges
ii. Doctors (2000/year) from 30 medical schools
iii. Midwives (1500/year) from 129 schools
iv. Dentists (2000/year) from 31 dental schools
v. Pharmacists (1500/year) from 35 pharmacy colleges

Philippine Health Human Resource
1. Biggest provider of overseas nurses
2. Underlying reasons affecting nurse recruitment, retention and fast turn-over: - low
pay - low morale - insufficient resources - stress - poor job prospect - poor
staffing - increase work loads

Comparative Advantage of Filipino Health Workers
1. Well trained
2. Highly skilled
3. Fluent in English
4. Postgraduate training in the US, Canada, etc.
5. Competent, caring, compassionate

Philippine Health Human Resource
Factors attributed to the migration of the professionals include:
1. Weak health systems
2. Economic need
3. Professional and career development
4. Attraction of a better quality life or a higher standard of living

THREE LEVELS OF PRIMARY HEALTH CARE WORKERS
1. VILLAGE OR GRASSROOT HEALTH WORKERS BARANGAY HEALTH
WORKERS
i. first contacts of the community and initial links of health care.
ii. Provide simple curative and preventive health care measures
promoting healthy environment.
iii. Participate in activities geared towards the improvement of the socio-
economic level of the community like food production program.
iv. Community health worker, volunteers or traditional birth attendants.
2. INTERMEDIATE LEVEL HEALTH WORKERS
i. represent the first source of professional health care
ii. attends to health problems beyond the competence of village workers
36

iii. provide support to front-line health workers in terms of supervision,
training, supplies, and services.
iv. Medical practitioners, nurses and midwives.
3. FIRST LINE HOSPITAL PERSONNEL
i. provide back up health services for cases that require hospitalization
ii. establish close contact with intermediate level health workers or
village health workers.
iii. Physicians with specialty, nurses, dentist, pharmacists, other health
professionals.

TWO-WAY REFERRAL SYSTEM (Niace, et. al. 8th edition 1995)
i. A two-way referral system need to be established between each level of
health facility e.g. barangay health workers refer cases to the rural health
team, who in turn refer more serious cases to either the district hospital, then
to the provincial, regional or the whole health care system.



HEALTH PROGRAMS
1. Adolescent and Youth Health and Development Program (AYHDP)
a. Reproductive health Sexuality , Reproductive Tract infection (STD,
HIV/AIDS)
b. Responsible parenthood, Maternal and Child health,
c. Communicable diseases, Diarrhea, DHF, Measles, Malaria
d. Mental Health Substance use and abuse
2. Botika ng Barangay
37

a. Refers to a drug outlet manage by a legitimate community organization
(CO/non-government Organization (NGO) and/or Local Government Unit
(LGU), with a trained operator and a supervising pharmacist specifically
established in accordance with Administrative Order No. 144 s. 2004.
3. Promotion of Breast feeding program/ Mother and Baby Friendly Hospital
Initiative (MBFHI)
a. The Mother and Baby Friendly Hospital Initiative is the main strategy to
transform all hospitals with maternity and new born services into facilities
which fully protect, promote, support breast feeding and rooming-in
practices
4. Cancer Control Program
a. The Philippines Cancer Control Program, begun in 1988, is an integrated
approach utilizing primary, secondary and tertiary prevention in different
regions of the country at both hospital and community levels.
b. Six lead Cancers (lung, breast, liver, cervix, oral cavity, colon and rectum)
are discussed.
5. Diabetes Control Program
a. Diabetes is a serious chronic metabolic disease characterized by an
increase in blood sugar levels associated with long term damage and
failure or organs functions, especially the eyes, the kidneys, the nerves,
the heart and blood vessels.
b. In diabetic, blood sugar reaches a dangerously high level which leads to
complications
i. Blindness
ii. Kidney failure
iii. Stroke
iv. Heart attack
v. Wounds that would not heal
vi. Impotence
c. What can you do to control your blood sugar?
i. Diet therapy
ii. Exercise
iii. Control your weight
iv. Quit smoking
6. Dengue Control Program
a. The thrust of the Dengue Control Program is directed towards
community-based prevention and control in endemic areas
b. Major strategy is advocacy and promotion, particularly the Four Oclock
Habit which was adopted by most LGUs. This is a nationwide, continuous
and concerted effort to eliminate the breeding places of Aedes aegypti.
7. Dental Health Program
a. Comprehensive Dental Health program aims to improve the quality of life
of the people through the attainment of the highest possible oral health.
b. Its objective is to prevent and control dental diseases and conditions like
dental carries and periodontal diseases thus reducing their prevalence.
8. Emerging Disease Control Program
a. Emerging infectious disease are newly identified and previously unknown
infection which cause public health problems either locally or
internationally.
b. These include diseases whose incidence in humans have increased
within the past two decades or threaten to increase in the near future.
38

9. Environmental Health
a. Environmental health is concerned with preventing illness through
managing the environment and by changing peoples behavior to reduce
exposure to biological and non-biological agents of disease and injury.
b. It is concerned primarily with effects of the environment to the health of
the people.
10. Expanded program on Immunization
a. The expanded program on immunization is one of the DOH programs that
has already been institutionalized and adopted by all LGUs in the region.
b. Its objective is to reduce infant mortality and morbidity through decreasing
the prevalence of six (6) immunizable diseases (TB, diphtheria, pertussis,
tetanus, polio and measles.
11. Family Planning
a. Responsible Parenthood which means that each family has the right and
duty to determine the desired number of children they might have and
when they might have them
b. Respect for life
c. Birth spacing refers to interval between pregnancies ( which is ideally 3-5
years)
12. Food and Waterborne Diseases Prevention and Control Program(FWBDPCP)
a. Established in 1997 but became fully operational in 1997 but became fully
operational in year 2000 with the provision of a budget amounting to PHP
551,000.00
b. The program focuses on Cholera, typhoid fever, hepatitis A and other
food borne emerging diseases (e.g. Paragonimus)
13. Knock out Tigdas
a. The Knock-out tigdas is s strategy to reduce the number or pool of
children at risk of getting measles, or being susceptible to measles and
achieve 95% measles circulation in all communities in 2008.
14. Leprosy Control program
b. Leprosy Control program envisions eliminating Leprosy as a human
disease by 2020 and is committed to eliminate leprosy as a public health
problem by attaining a national prevalence rate (PR) of less than 1 per
10,000 populations by year 2000
15. Malaria Control Program
a. 58 of 80 provinces: malaria endemic
b. Population at risk: 12 M
c. 22 provinces: maintain malaria-free* status
d. 2 4 outbreaks per year
e. malaria-free:absence of indigenous malaria case
16. National Filariasis Elimination ProgramGeneral Objectives:
a. To reduce the Prevalence Rate to <1/1000 population
17. National Mental Health Program
a. It aims at integrating mental health within the total health system, initially
within the DOH system, and local health system. Within the DOH, it has
initiated and sustained the integration process within the hospital and
public health systems, both at the central and regional level.
b. Furthermore, it aims at ensuring equity in the availability, accessibility,
appropriateness and affordability of mental health and psychiatric
services in the country.
18. Newborn screening
39

a. Newborn Screening (NBS) is a simple procedure to find out if your baby
has a congenital metabolic disorder that may lead to mental retardation
and even death if left untreated
19. Occupational Health ProgramVision/Mission Statement
a. Health for all occupations in partnership with the workers, employers,
local government authorities and other sectors in promoting self-
sustaining programs and improvement of workers health and working
environment.
b. Program Objective and Targets:
i. To promote and protect the health and well being of the working
population thru improved health, better working conditions and
workers environment
20. Health development Program for Older Persons
a. The Program intends to promote and improve the quality of life of older
persons through the establishments and provision of basic health
services for older persons, formulation of policies and guidelines
pertaining to older persons, provision of information and health education
to the public, dedicated to older person and, the conduct of basic and
applied researches.
21. Pinoy MD Program Gusto Kong Maging Doktor
a. A Medical scholarship Grant for Indigenous People, Local Health
Workers, Barangay Health workers, Department of Health employees or
their children.
b. This is a joint program of the Department of Health (DOH), Philippine
Charity Sweepstakes Office (PCSO), and several State Universities and
Medical Schools
22. Prevention of Blindness Program
a. To eliminate all avoidable blindness by preventing and controlling
diseases through the development of human resource, infrastructure, and
appropriate technology
23. Schistosomiasis Control Program
a. Goal of the National Schistosomiasis control program is to eliminate
Schistosomiasis as a public health problem (Prevalence of 1% and
below)
24. National TB Control Program
a. In 1196, WHO introduced the Directly Observed Treatment Short Course
(DOTS) to ensure completion of treatment
b. The DOTS strategy depends on five elements for its success:
c. Microscope, Medicines, Monitoring, DOT and Political Commitment.
d. If any of these elements are missing, our ability to consistency cure TB
patients slips through our fingers.
25. Republic Act 7719 is otherwise known as Blood Services Act of 1994The main
Objectives are:
a. To promote and encourage voluntary blood donation by the citizenry and
to instill public consciousness of the principle that blood donation is a
humanitarian act
b. To provide, adequate, safe, affordable and equitable distribution of supply
of blood and blood products

ISSUES AND CONCERNS

40

1. Some of the major factors affecting the countrys health status are as follows:
inappropriate health delivery system
2. inadequate regulatory mechanisms and poor health care financing


UNIVERSAL HEALTH CARE

UNIVERSAL HEALTH CARE (UHC), ALSO REFERRED TO AS KALUSUGAN
PANGKALAHATAN (KP)
is the provision to every Filipino of the highest possible quality of health care that
is accessible, efficient, equitably distributed, adequately funded, fairly financed,
and appropriately used by an informed and empowered public
The Aquino administration puts it as the availability and accessibility of health
services and necessities for all Filipinos.
It is a government mandate aiming to ensure that every Filipino shall receive
affordable and quality health benefits. This involves providing adequate
resources health human resources, health facilities, and health financing.

UHCS THREE THRUSTS

1. Financial risk protection through expansion in enrollment and benefit delivery of
the National Health Insurance Program (NHIP);

2. Improved access to quality hospitals and health care facilities; and

3. Attainment of health-related Millennium Development Goals (MDGs).

FINANCIAL RISK PROTECTION
Protection from the financial impacts of health care is attained by making any
Filipino eligible to enroll, to know their entitlements and responsibilities, to avail of
health services, and to be reimbursed by PhilHealth with regard to health care
expenditures.

IMPROVED ACCESS TO QUALITY HOSPITALS AND HEALTH CARE FACILITIES
Improved access to quality hospitals and health facilities shall be achieved in a
number of creative approaches. First, the quality of government-owned and
operated hospitals and health facilities is to be upgraded to accommodate larger
capacity, to attend to all types of emergencies, and to handle non- communicable
diseases.

The Health Facility Enhancement Program (HFEP) shall provide funds to
improve facility preparedness for trauma and other emergencies. The aim of
HFEP was to upgrade 20% of DOH- retained hospitals, 46% of provincial
hospitals, 46% of district hospitals, and 51% of rural health units(RHUs) by end
of 2011.

ATTAINMENT OF HEALTH-RELATED MDGS
Further efforts and additional resources are to be applied on public health
programs to reduce maternal and child mortality, morbidity and mortality from
Tuberculosis and Malaria, and incidence of HIV/AIDS. Localities shall be
41

prepared for the emerging disease trends, as well as the prevention and control
of non- communicable diseases.
The organization of Community Health Teams (CHTs) in each priority population
area is one way to achieve health-related MDGs. CHTs are groups of volunteers,
who will assist families with their health needs, provide health information, and
RNheals nurses will be trained to become trainers and supervisors to coordinate
with community-level workers and CHTs. By the end of 2011, it is targeted that
there will be 20,000 CHTs and 10,000 RNheals.
Another effort will be the provision of necessary services using the life cycle
approach. These services include family planning, ante-natal care, delivery in
health facilities, newborn care, and the Garantisadong Pambata package.
Better coordination among government agencies, such as DOH, DepEd, DSWD,
and DILG, would also be essential for the achievement of these MDGs.


GOAL 1: ERADICATE EXTREME POVERTY AND HUNGER
Target : Halve, between 1990 and 2015, the proportion of people whose income is
less than one dollar a day
Target : Halve, between 1990 and 2015, the proportion of people who suffer from
hunger

GOAL 2: ACHIEVE UNIVERSAL PRIMARY EDUCATION
Target : Ensure that, by 2015, children everywhere, boys and girls alike, will be
able to complete a full course of primary schooling

GOAL 3: PROMOTE GENDER EQUALITY AND EMPOWER WOMEN
Target : Eliminate gender disparity in primary and secondary education preferably
by 2005 and to all levels of education no later than 2015

GOAL 4: REDUCE CHILD MORTALITY
Target : Reduce by two-thirds, between 1990 and 2015, the under-five mortality
rate

GOAL 5: IMPROVE MATERNAL HEALTH
Target : Reduce by three-quarters, between 1990 and 2015, the maternal
mortality ratio

GOAL 6: COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES
Target : Have halted by 2015 and begun to reverse the spread of HIV/AIDS
Target : Have halted by 2015 and begun to reverse the incidence of malaria and
other major diseases

GOAL 7: ENSURE ENVIRONMENTAL SUSTAINABILITY
Target : Integrate the principles of sustainable development into country policies
and programmes and reverse the loss of environmental resources
Target : Halve, by 2015, the proportion of people without sustainable access to
safe drinking water
Target: By 2020, to have achieved a significant improvement in the lives
of at least 100 million slum dwellers

GOAL 8: DEVELOP A GLOBAL PARTNERSHIP FOR DEVELOPMENT
42

Target : Develop further an open, rule-based, predictable, nondiscriminatory
trading and financial system
Target: Address the special needs of the least developed countries
Target: Address the special needs of landlocked countries and small
island developing States
Target: Deal comprehensively with the debt problems of developing countries
through national and international measures in order to make debt
sustainable in the long term

To implement the KP thrusts and interventions, the DOH will adopt the following general
strategies:
1. Focus and engage vulnerable families, starting with provinces where most are
found;
2. Partner with poverty alleviation programs like the National Household Targeting
System-Poverty Reduction (NHTS-PR) and Conditional Cash Transfer (CCT);
3. Leverage LGU participation and performance through province-wide agreements;
and
4. Harness private sector participation

Focusing interventions on vulnerable families will be done by prioritizing provinces where
the largest number of families who are poor as identified by NHTS-PR and have unmet
needs are located. Twelve (12) areas in the country have been prioritized for having the
most number of families who are poor and have unmet needs. These areas are the
following: Metro Manila, Negros Occidental, Quezon, Cebu, Pangasinan, Iloilo, Cavite,
Maguindanao, Zamboanga del Sur, Leyte, Davao del Sur and Pampanga. Together,
these areas account for 33 percent of NHTS-PR families and about 40 percent of unmet
needs for public health services in the country.

The concentration of the target population in these areas provides the opportunity for
implementing public health interventions at a scale that can significantly impact on
national indicators. The main intervention in reaching the families especially the CCT is
through the organization and mobilization of CHTs

To reach the priority and target population, the DOH will partner with the poverty
alleviation programs like the NHTS-PR and CCT for NHIP enrolment and for availing
quality health services. The DOH shall facilitate the implementation of the KP by
influencing the manner by which Provinces and component LGUs, and Cities govern
local health systems. The DOH recognizes that LGUs have the primary mandate to
finance and regulate local health systems, including the provision of the right information
to families and health providers. Leveraging for LGU participation and performance will
be accomplished by entering into ARMM-wide, province-wide or city-wide agreements
with LGUs. The agreements shall define annual performance targets and resource
commitments by DOH, LGUs, PHIC, development partners and private sector. The
province-wide agreements will also serve as basis for the development of CHD support
plans for LGUs that will be consolidated into the annual budget proposal of DOH.

Harnessing the private sector participation in the upgrading of public clinics and
hospitals will be undertaken by upgrading DOH retained hospitals into modern medical
centers through public private partnerships (PPP). DOH will also explore other PPP
arrangements, including the outsourcing of some hospital management services. In
43

addition, hospital governing boards will also be organized to increase accountability of
DOH hospitals to the communities they serve.

Furthermore, the private sector with the stewardship of the public sector will be
mobilized to support the public health programs that will facilitate the achievement of the
MDGs. To facilitate the implementation of these strategies, the DOH adopted a
functional management structure that assigned accountability to CHDs and operations
cluster heads in achieving health outcome targets. Supporting the operations cluster will
be the technical clusters on health financing and policy and support to service delivery
as well as the administrative and financial management clusters among others. The
DOH will relate with the DOH-ARMM directly through the Office of the Secretary,
especially in the execution of the ARMM-wide investment plan. The success of the KP
shall be measured by the progress made in preventing premature deaths, reducing
maternal and newborn deaths, controlling both communicable and non-communicable
diseases, improvements in access to quality health facilities and services and increasing
NHIP coverage, benefit utilization and support value, prioritizing the poor and the
marginalized (such as the Geographically Isolated and Disadvantaged Area (GIDA)
population, indigenous population, older persons, differently-abled persons, internally-
displaced population, and people in conflict-affected areas). These performance
measures are the results of effective interaction between families and health care
providers (both public and private) in local health systems.

THE NATIONAL HEALTH PLAN
1. the blue print which is followed by the Department of Health.
2. It defines the countrys health problems, policy thrusts, strategies and targets.

POLICY THRUSTS AND STRATEGIES
1. Information, education, and communication programs will be implemented to
raise the awareness of the public, including policy makers, program planners and
decision makers;
2. An update of the legislative agenda for health, nutrition and family planning
(HNFP), and stronger advocacy for pending HNFP related legislations will be
pursued;
3. Integration of efforts in the health, nutrition and family planning sector to
maximize resources in the delivery of services through the establishment of
coordinative mechanisms at both the national and local levels;
4. Partnership between the public and the private sectors will be strengthen and
institutionalized to effectively utilize and monitor private resources for the sector;
5. Enhancement of the status and role of women as program beneficiaries and
program implementers will be pursued to enable them to substantially participate
in the development process.

Major Influences in the Health Care System
1. Environmental
2. Demographic
3. Socio-cultural
4. Political
5. Economic

44



Factors contributing to the limited capacity of the countrys health care system to
deliver better health outcomes
1. poor health care financing
2. The inappropriate health service delivery system, where there is excessive
reliance on use of high- end hospital services rather than primary care, including
an ineffective mechanism for providing public health programs
3. the brain drain of health professionals
4. the excessively high price of medicines, leading to costly out-of-pocket payments
and inadequate and irrational use;
5. inadequate enforcement of regulatory mechanisms
6. the insufficient effort expended on prevention and control of new diseases,
particularly non- communicable diseases
7. Data adequacy, accuracy and timeliness are other important and perennial
issues to be addressed. The unavailability of timely and accurate
data/information makes it difficult to make appropriate decisions on policies and
programs to improve health care.

Context of the National Health Plan:
The National Health Plan outlines the objectives, strategies and resources to reform the
health sector to effectively deliver quality health and social welfare services to the people
of Liberia. The MOHSW vision is improved health and social welfare status and equity in
health; therefore becoming a model of post-conflict recovery in the health field. The five-
year health plan (2007-2011) will operate within the framework of the Interim Poverty
Reduction Strategy (iPRS) and also guide the transition from humanitarian to
development assistance.

Components of the National Health Plan:
The National Health Policy and Plan are designed around four strategic orientations of
Primary Health Care, Decentralization, Community Empowerment and Partnerships for
Health. The operational and integrated framework for implementing the National Health
Policy and Plan is based on four key components
1) Basic Package of Health Services;
45

2) Human Resources for Health;
3) Infrastructure Development; and
4) Support Systems.
1. The Basic Package of Health Services (BPHS) is the cornerstone of the National
Health Plan. It defines an integrated minimum package of standardized
prevention and treatment services. The BPHS will be adapted for each level of
the health system community, health clinic, health centre, county hospital, and
tertiary hospital. The BPHS will be introduced incrementally to become functional
in 70% of existing health facilities by the end of 2008.
2. Human Resources for Health will ensure that the right numbers of health workers
are in the right place, at the right time, and with the right skills to delivery the
BPHS. This component will
1) Ensure a coordinated approach to human resource planning;
2) Enhance health worker performance, productivity and retention;
3) Increase the number of trained health workers and their equitable distribution;
and
4) Ensure gender equity in all aspects of employment.

3. Infrastructure Development will increase geographic access to the BPHS,
especially for clinics and health centers, which comprise 94% of facilities. County
health development plans will be prepared by County Health Teams in
collaboration with districts, health facilities, communities and local partners. The
National Health Plan in years one and two will consolidate health work in existing
health facilities. At the same time a longer-term plans for major rehabilitation and
construction will be prepared to being in year three.

4. Support Systems are the planning and management functions required to deliver
the BPHS. This includes Policy formulation & implementation; Planning &
Budgeting; Human Resources Management; Health Management Info Systems;
Drugs & Medical Supplies; Facility & Equipment Maintenance; Logistics &
Communication; Supervision, Monitoring & Evaluation; and Stakeholder
Coordination. The NH Plan will incrementally and pragmatically decentralize
decision-making, especially to the county level.

These components will be supported through health financing and implemented in
collaboration with a variety of partnerships for health. The integrated strategic National
Health Plan is like a child whose body is like a child whose head (the BPHS) guides its
heart (its capable human resources); and whose arms (its strong support systems and
partnerships) and legs (health financing and infrastructure) support the body







46

UNIT IV: PRIMARY HEALTH CARE (PHC)

LEVELS OF HEALTH CARE
1. Primary health care
i. The first level of contact between the individual and the health system.
ii. Essential health care (PHC) is provided.
iii. A majority of prevailing health problems can be satisfactorily managed.
iv. The closest to the people.
v. Provided by the primary health centers.
2. Secondary health care
i. More complex problems are dealt with.
ii. Comprises curative services
iii. Provided by the district hospitals
iv. The 1
st
referral level
3. Tertiary health care
i. Offers super-specialist care
ii. Provided by regional/central level institution.
iii. Provide training programs

Overview
i. May 1977 -30th World Health Assembly decided that the main health target of
the government and WHO is the attainment of a level of health that would
permit them to lead a socially and economically productive life by the year
2000.
ii. September 6-12, 1978 - First International Conference on PHC in Alma Ata,
Russia (USSR) The Alma Ata Declaration stated that PHC was the key to attain
the health for all goal
iii. October 19, 1979 - Letter of Instruction (LOI) 949, the legal basis of PHC was
signed by Pres. Ferdinand E. Marcos, which adopted PHC as an approach
towards the design, development and implementation of programs focusing on
health development at community level.
Rationale for Adopting Primary Health Care
i. Magnitude of Health Problems
ii. Inadequate and unequal distribution of health resources
iii. Increasing cost of medical care
iv. Isolation of health care activities from other development activities
Definitions of 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 cost that the community can afford at every stage of development.(WHO)
essential health care based on practical, scientifically sound and socially
acceptable methods and technology made universally, accessible to individuals
47

and families in the community by means of acceptable to them, through their full
participation and at a cost that community and country can afford to maintain at
every stage of their development in the spirit of self-reliance and self-
determination. It forms an integral part of both the countrys health system, of
which it is the central function and the main focus and of the overall social and
economic development of the community.( The Alma Ata Conference)
a practical approach to making health benefits within the reach of all people.
an approach to health development, which is carried out through a set of
activities and whose ultimate aim is the continuous improvement and
maintenance of health status
Primary health care (PHC) became a core policy for the World Health
Organization with the Alma-Ata Declaration in 1978 and the Health-for-All by the
Year 2000 Program.
The commitment to global improvements in health, especially for the most
disadvantaged populations, was renewed in 1998 by the World Health Assembly.
This led to the Health-for-All for the twenty-first Century policy and program,
within which the commitment to PHC development is restated.
PHC is essential health care that is a socially appropriate, universally accessible,
scientifically sound first level care provided by a suitably trained workforce
supported by integrated referral systems and in a way that gives priority to those
most in need, maximises community and individual self-reliance and participation
and involves collaboration with other sectors. It includes the following:
health promotion
illness prevention
care of the sick
advocacy
community development

Goals of Primary Health Care
i. HEALTH FOR ALL FILIPINOS by the year 2000 AND HEALTH IN THE
HANDS OF THE PEOPLE by the year 2020.
ii. An improved state of health and quality of life for all people attained
through SELF RELIANCE.
Health begins at home, in schools and in the workplace because it is there where
people live and work that health is made or broken.
It also means that people will use better approaches than they do now for
preventing diseases and alleviating unavoidable disease and disability and have
better ways of growing up, growing old and dying gracefully.
It also means that here will be even distribution among the population of
whatever resources for health are available.
It means that essential health services will be accessible to all individuals and
families in an acceptable and affordable way.




48

Key Strategy to Achieve the Goal:
Partnership with and Empowerment of the people - permeate as the core
strategy in the effective provision of essential health services that are community
based, accessible, acceptable, and sustainable, at a cost, which the community
and the government can afford.
Principles of Primary Health Care
1. 4 A's = Accessibility, Availability, Affordability & Acceptability,
Appropriateness of health services.
i. The health services should be present where the supposed recipients are.
They should make use of the available resources within the community,
wherein the focus would be more on health promotion and prevention of
illness.
2. Community Participation
i. heart and soul of PHC
3. People are the center, object and subject of development.
i. Thus, the success of any undertaking that aims at serving the people is
dependent on peoples participation at all levels of decision-making;
planning, implementing, monitoring and evaluating. Any undertaking must
also be based on the peoples needs and problems (PCF, 1990)
ii. Part of the peoples participation is the partnership between the community
and the agencies found in the community; social mobilization and
decentralization.
iii. In general, health work should start from where the people are and building
on what they have. Example: Scheduling of Barangay Health Workers in the
health center
Barriers of Community Involvement
o Lack of motivation
o Attitude
o Resistance to change
o Dependence on the part of community people
o Lack of managerial skills
4. Self-reliance
i. Through community participation and cohesiveness of peoples organization
they can generate support for health care through social mobilization,
networking and mobilization of local resources. Leadership and
management skills should be develop among these people. Existence of
sustained health care facilities managed by the people is some of the major
indicators that the community is leading to self reliance.

5. Partnership between the community and the health agencies in the
provision of quality of life.
i. Providing linkages between the government and the nongovernment
organization and peoples organization.

49

6. Recognition of interrelationship between the health and development
i. Health- Is not merely the absence of disease. Neither is it only a state of
physical and mental well-being. Health being a social phenomenon
recognizes the interplay of political, socio-cultural and economic factors
as its determinant. Good Health therefore, is manifested by the
progressive improvements in the living conditions and quality of life
enjoyed by the community residents (PCF,
ii. Development- is the quest for an improved quality of life for all.
Development is multidimensional. It has political, social, cultural,
institutional and environmental dimensions (Gonzales 1994). Therefore,
it is measured by the ability of people to satisfy their basic needs.
7. Social Mobilization
i. It enhances people participation or governance, support system
provided by the Government, networking and developing secondary
leaders.
8. Decentralization
i. This ensures empowerment and that empowerment can only be
facilitated if the administrative structure provides local level political
structures with more substantive responsibilities for development
initiators. This also facilities proper allocation of budgetary resources.

Objectives of Primary Health Care
i. Improvement in the level of health care of the community
ii. Favorable population growth structure
iii. Reduction in the prevalence of preventable, communicable and other disease.
iv. Reduction in morbidity and mortality rates especially among infants and children.
v. Extension of essential health services with priority given to the underserved
sectors.
vi. Improvement in Basic Sanitation
vii. Development of the capability of the community aimed at self- reliance.
viii. Maximizing the contribution of the other sectors for the social and economic
development of the community.

Mission
i. To strengthen the health care system by increasing opportunities and supporting
the conditions wherein people will manage their own health care.
The Basic Requirements for Sound PHC (the 8 As and the 3 Cs)
Appropriateness
Whether the service is needed at all in relation to essential human needs,
priorities and policies.
50

The service has to be properly selected and carried out by trained personnel in
the proper way.
Availability
Availability of medical care means that care can be obtained whenever people
need it.
Adequacy
The service proportionate to requirement.
Sufficient volume of care to meet the need and demand of a community
Accessibility
Reachable, convenient services
Geographic, economic, cultural accessibility
Acceptability
Acceptability of care depends on a variety of factors, including satisfactory
communication between health care providers and the patients, whether the
patients trust this care, and whether the patients believe in the confidentiality and
privacy of information shared with the providers
Affordability
The cost should be within the means and resources of the individual and the
country
AssessAbility
means that medical care can be readily evaluated
Accountability
Implies the feasibility of regular review of financial records by certified public
accountants.
Completeness of care
requires adequate attention to all aspects of a medical problem, including
prevention, early detection, diagnosis, treatment, follow up measures, and
rehabilitation
Comprehensiveness of care
means that care is provided for all types of health problems.
Continuity of care
51

requires that the management of a patients care over time be coordinated
among providers

Elements of Primary Health Care

1. Education for Health
Is one of the potent methodologies for information dissemination. It promotes the
partnership of both the family members and health workers in the promotion of
health as well as prevention of illness.
2. Locally Endemic Disease Control
The control of endemic disease focuses on the prevention of its occurrence to
reduce morbidity rate. Example Malaria Control and Schistosomiasis Control
3. Expanded Program on Immunization
This program exists to control the occurrence of preventable illnesses especially of
children below 6 years old. Immunizations on poliomyelitis, measles, tetanus,
diphtheria and other preventable disease are given for free by the government and
ongoing program of the DOH
4. Maternal and Child Health and Family Planning
The mother and child are the most delicate members of the community. So the
protection of the mother and child to illness and other risks would ensure good
health for the community. The goal of Family Planning includes spacing of children
and responsible parenthood.
5. Environmental Sanitation and Promotion of Safe Water Supply
Environmental Sanitation is defined as the study of all factors in the mans
environment, which exercise or may exercise deleterious effect on his well-being
and survival. Water is a basic need for life and one factor in mans environment.
Water is necessary for the maintenance of healthy lifestyle. Safe Water and
Sanitation is necessary for basic promotion of health.
6. Nutrition and Promotion of Adequate Food Supply
One basic need of the family is food. And if food is properly prepared then one
may be assured healthy family. There are many food resources found in the
communities but because of faulty preparation and lack of knowledge regarding
proper food planning, Malnutrition is one of the problems that we have in the
country.

52

7. Treatment of Communicable Diseases and Common Illness
The diseases spread through direct contact pose a great risk to those who can be
infected. Tuberculosis is one of the communicable diseases continuously occupies
the top ten causes of death. Most communicable diseases are also preventable.
The Government focuses on the prevention, control and treatment of these
illnesses.
8. Supply of Essential Drugs
This focuses on the information campaign on the utilization and acquisition of
drugs.
In response to this campaign, the GENERIC ACT of the Philippines is enacted. It
includes the following drugs: Cotrimoxazole, Paracetamol, Amoxycillin, Oresol,
Nifedipine, Rifampicin, INH (isoniazid) and Pyrazinamide,Ethambutol,
Streptomycin,Albendazole,Quinine
WHO Strategies of PHC
1. Reducing excess mortality of poor marginalized populations:
PHC must ensure access to health services for the most disadvantaged
populations, and focus on interventions which will directly impact on the
major causes of mortality, morbidity and disability for those populations.
2. Reducing the leading risk factors to human health:
PHC, through its preventative and health promotion roles, must address
those known risk factors, which are the major determinants of health
outcomes for local populations.
3. Developing Sustainable Health Systems:
PHC as a component of health systems must develop in ways, which are
financially sustainable, supported by political leaders, and supported by
the populations served.
4. Developing an enabling policy and institutional environment:
PHC policy must be integrated with other policy domains, and play its part
in the pursuit of wider social, economic, environmental and development
policy.

Major Strategies of Primary Health Care

1. Elevating Health to a Comprehensive and Sustained National Effort.
Attaining Health for all Filipino will require expanding participation in health and
health related programs whether as service provider or beneficiary. Empowerment
to parents, families and communities to make decisions of their health is really the
desired outcome.
53

Advocacy must be directed to National and Local policy making to elicit support
and commitment to major health concerns through legislations, budgetary and
logistical considerations.
2. Promoting and Supporting Community Managed Health Care
The health in the hands of the people brings the government closest to the people.
It necessitates a process of capacity building of communities and organization to
plan, implement and evaluate health programs at their levels.
3. Increasing Efficiencies in the Health Sector
Using appropriate technology will make services and resources required for their
delivery, effective, affordable, accessible and culturally acceptable. The
development of human resources must correspond to the actual needs of the
nation and the policies it upholds such as PHC. The DOH will continue to support
and assist both public and private institutions particularly in faculty development,
enhancement of relevant curricula and development of standard teaching
materials.
4. Advancing Essential National Health Research
Essential National Health Research (ENHR) is an integrated strategy for
organizing and managing research using intersectoral, multi-disciplinary and
scientific approach to health programming and delivery.

Four Cornerstones/Pillars in Primary Health Care
1. Active Community Participation
2. Intra and Inter-sectoral Linkages
3. Use of Appropriate Technology
4. Support mechanism made available







54


(E) EDUCATION FOR HEALTH
i. A process whereby knowledge, attitude, and practice of people are changed to improve
individual, family, and community health.

ii. Basic health service and every member of the health team shares responsibility in
providing health education.

iii. A means of improving the health of the people by employing various methods of
scientific procedures to show the most healthful ways of living Consists of
techniques that stimulate, arouse, and guide people to live healthy

iv. Sum of activities in which health agencies engage to influence the thinking,
motivation, judgment, and action of the people in the community

SEQUENTIAL STEPS
a. CREATING AWARENESS
b. MOTIVATION
c. DECISION MAKING ACTION

PRINCIPLES OF HEALTH EDUCATION
1. Health education considers the health status of the people.
2. Determined by the economic and social conscience of the country
3. Health education is learning
i. Process whereby people learn to improve their personal habits and
attitudes and to work responsibly for the improvement of health,
conditions in the family, community and nation.
4. Health education involves motivation, experience and change in the conduct
of thinking
i. Stimulates an active interest in people
ii. Develops and provides experiences for change in peoples attitudes,
customs, and habits in relation to health and everyday living.
5. Health education should be recognized as a basic function of all health workers
6. Health education takes place in the home, in the school, and the community
i. Learning about health results from a wide variety of contacts between
members of the family, between pupils and teachers and among the
community members.
7. Health education is a cooperative effort
i. Health education requires that all categories of health personnel work
together in close teamwork with families, groups, and community
8. Health education meets the needs, interests, and problems of the people
affected.
i. The expressed needs and interest of the people themselves are
important motivating influences for initiating individual, family and
community activities in solving health problems.
9. Health education is achieved by doing.
55

i. It does not only mean understanding the different health facts ,but
health education also finds means and ways of carrying out the plans.
ii. Obtains community and individual participation in the solution
of health problems
10. Health education is a slow continuous process.
i. It is a slow development, not a mushroom growth that evolves
constant changes and revisions until on kectoves are achieved
11. Health education makes use of supplementary aids and devices.
i. These education materials are aids to a cooperative health program
and not as program itself.
ii. Helps verbal instructions
12. Health education utilizes community resources
i. It involves the careful evaluation of the different services and
resources found in the community concerned with the total health and
well being of the people.
ii. Both human and natural resources are utilized.
13. Health education is a creative process
i. There is no single pattern for solving community problems, since
problem solving is essentially a creative work.
ii. \Needs a method and technique different from others with a
characteristic of its own.
iii. Does not follow a rigid and inflexible pattern
14. Health education helps people attain health through their own efforts.
i. It aims to help people make use of their own efforts and education in
improving their conditions of living, lodging, good nutrition and
prevention of diseases.
15. Health education makes careful evaluation of the planning, organization and
implementation of all health education programs and activities.
i. A long and continuous process like health education itself

HEALTH EDUCATION TEACHING METHODS AND STRATEGIES
i. Interviewing
ii. Counseling
iii. Lecture-discussion
iv. Open forum
v. Workshop
vi. Case study
vii. Role play
viii. Symposium
ix. Group work buzz sessions
x. Community assembly
xi. Nominal group technique
i. This technique is a structured variation of small group discussion
methods. The process prevents the domination of discussion by a
single person, encourages the more passive group members to
participate, and results in a set of prioritized solutions or
recommendations.
xii. Laboratory training
xiii. Use of IEC (information, education, communication) materials as leaflets,
brochures, comics, handouts, flyers
i. Use of publication
56

ii. Use of audio-visual aids, bulletin boars, billboards, posters, streamers,
radio, TV, overhead/slide projectors, multimedia presentation
iii. Use of IEC support as fans, umbrellas, T-shirts, bookmarks, bags,
hats, pens, stationaries, key chains, folder, kits

QUALITIES OF A GOOD HEALTH EDUCATOR
i. Knowledgeable/mastery of subject matter
ii. Credible
iii. Good listener
iv. Can empathize with others
v. Possess teaching skills
vi. Flexible
vii. Patience
viii. Creative and innovative
ix. Effective motivator
x. Ability to rephrase/summarize
xi. Encourages group participation
xii. Good sense of humor.














57



(L)LOCALLY ENDEMIC DISEASES PREVENTION
POLICIES FOR SCHISTOSOMIASIS CONTROL PROGRAM (SCP): CHES
C ase Finding
H ealth Education
E nvironmental Sanitation
S nail Eradication

CASE FINDING:
Aspects or Thing to Know
Disease: Schistosomiasis
Other name: Bilhariasis or Snail Fever
Causative agent: Schistosoma-a blood fluke (parasite)
3 Types of Species:
a. Schistosoma japonicum-endemic in the Philippines & affecting Indonesia, China,
Japan, Korea Vector: Oncomelania quadrasi
b. Schistosoma mansoni
c. Schistosoma haematobium
Laboratory Procedures to rule out Schistosomiasis:
a. Blood Examination: . eosinophil level indicates parasitism
b. Fecalysis: Kato Katz (plain stool exam that uses a special apparatus resembling
a feeding bottle sterilizer) Procedure:
Collect specimen
Have the test tube undergo centrifugation for 20 minutes
Get specimen from precipitate & swab it on glass slide
Observe it on microscope

Signs & Symptoms
1. CNS: High grade fever. cerebral convulsion
2. GIT: Nausea & vomiting, Diarrhea. Chronic dysentery (prolonged diarrhea of
more than 2 weeks & consistency is mucoid & bloody (with streaks of blood)
3. Liver: Presence of infection manifested by jaundice & hepatomegaly
4. Spleen: Infection of spleen. inflammation. enlargement of organ (Splenomegaly).
abdominal distension. abdominal pain on the right upper quadrant
5. Blood: Anemia & weakness
Treatment: Drug of Choice-Praziquantel (Biltricide) 60 mg/KBW/day
Example: If patient is 50 kg, 50 kg x 60 mg/KBW/day=3000 mg/day
58

Initial treatment: 1st 2 weeks=3000 mg/day, then do stool exam after 2 weeks. if
still (+), extend treatment for another 2 weeks. Repeat stool exam, if still (+) after
the extended week, continue treatment for 2 weeks again. No adverse effect or
over dosage even if extended for a year.
Length of Treatment: takes months to a year
Health Education: It affects mostly farmers so educate them to wear rubber boots
Environmental Sanitation:
1. Snail is the 1st concern
2. Water where snail thrives is the 2nd concern
3. Toilet=3rd concern
4. Food
5. Garbage
6. Snail Eradication: Use molluscicides treat the entire suspected
7. soil with chemical solution that kills snails
CASE FINDING:
Disease: Malaria
Other name: Ague
Causative Agent: Plasmodium-a protozoa
4 Types of Species:
1. Plasmodium falciparum-more fatal that affects the Philippine
Vector: Female Anopheles Mosquito (FAM)
2. Plasmodium vivax
3. Plasmodium ovale
4. Plasmodium malariae
Laboratory Procedure: Malarial smear-extract blood at the height of fever because
plasmodium is very active &ruptures at this period.
Signs & Symptoms of Malaria:
1st Stage=Cold: Chilling sensation for 1-2 hours
2nd Stage=Hot: High grade fever lasting for 3-4 hours
3rd Stage=Wet: Diaphoresis (excessive sweating/perspiration)

Treatment: Drug of Choice-Quinine
2 Forms:
a) Chloroquine (Aralen)
b) Primaquine
59

If Quinine is not available, may use Sulfadoxime-an antibacterial drug paired with
pyrinthamine

PERSONAL PROTECTION:
1. Sleep under a mosquito net
2. Sleep in a screened room
3. Sleep with long sleeve attire
4. Use repellents that contains DET (diethyl toluamide or toluene which has a
pungent odor that drives away mosquitoes & an irritant to mucous membrane of
respiratory tract when inhaled
5. Plant a Neem Tree using the leaves
CLEAN:
Chemical Method=insecticide spraying at night
Larvae eating fish=Tilapia
Environmental Sanitation & Health
Education=insect, water, trash
Anti-mosquito soap=basil citronelli
Neem tree=banana, banaba, gabi, eucalyptus provide repellent effect
























60





(E) EXPANDED PROGRAM ON IMMUNIZATION

Vaccines are administered to introduce immunity thereby causing the recipients immune
childhood system to react to the vaccine that produces antibodies to fight infection.
Vaccinations promote health and protect children from disease causing agents
Infants and newborn need to be vaccinated at an early age since they belong to
vulnerable age group.
Four Major Strategies
1. Sustaining high routine FIC coverage of at least 90% in all provinces and cities.
2. Sustaining the polio free country for the global certification.
3. Eliminating measles by 2008
4. Eliminating neonatal tetanus by 2008
General Principles in Vaccinating Children
1. It is safe and immunologically effective to administer all EPI vaccines on the
same day at different sites of the body.
2. The vaccination schedule should not be restarted from the beginning even if the
interval between doses exceeded the recommended interval by months or year.
3. Do not give more than one dose of the same vaccine to a child in one session.
Give doses of the same at the correct intervals
4. Strictly follow the principle of never, ever reconstituting the freeze dried vaccine
in anything other than the diluent supplied with them.
5. If you are giving more than one vaccine, do not use the sme syringe and duse
the same arm or leg for more than one injection

The 7 immunizable diseases

1. Tuberculosis
2. Diptheria
3. Pertussis
4. Measles
5. Poliomyelitis
6. Tetanus
7. Hepatitis B
61


Target Setting

Infants 0-12 months
Pregnant and Post Partum Women
School Entrants/ Grade 1 / 7 years old

Objectives of EPI

To reduce morbidity and mortality rates among infants and children from six
childhood immunizable disease

Elements of EPI

Target Setting
Cold chain Logistic Management- Vaccine distribution through cold chain is
designed to ensure that the vaccines were maintained under proper
environmental condition until the time of administration.
Information, Education and Communication (IEC)
Assessment and evaluation of Over-all performance of the program
Surveillance and research studies

Administration of vaccines
Vaccine Content Form & Dosage # of
Doses
Route
BCG (Bacillus
Calmette Guerin)
Live attenuated
bacteria
Freeze dried
Infant- 0.05ml

Preschool-0.1ml
1 ID
DPT (Diphtheria
Pertussis Tetanus)
DT- weakened
toxin

P-killed bacteria
liquid-0.5ml 3 IM
OPV (Oral Polio
Vaccine)
weakened virus liquid-2drops 3 Oral
Hepatitis B Plasma derivative Liquid-0.5ml 3 IM
Measles Weakened virus Freeze dried-
0.5ml
1 Subcutaneous


Schedule of Vaccines
62

Vaccine Age at 1st dose Interval
between dose
Protection
BCG At birth BCG is given at the earliest
possible age protects against the
possibility of TB infection from
the other family members
DPT 6 weeks 4 weeks An early start with DPT reduces
the chance of severe pertussis
OPV 6weeks 4weeks The extent of protection against
polio is increased the earlier
OPV is given.
Hepa B @ birth @birth,6th
week,14th week
An early start of Hepatitis B
reduces

the chance of being infected and
becoming a carrier.
Measles 9m0s.-11m0s. At least 85% of measles can be
prevented by immunization at
this age.

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

Tetanus Toxiod Immunization

Schedule for Women
Vaccine Minimum age
interval
%
protected
Duration of
Protection
TT1 As early as
possible
0% 0
TT2 4 weeks later 80% 3 years
TT3 6 months later 95% 5 years
TT4 1year later/during
next pregnancy
99% 10 years
TT5 1 year later/third
pregnancy
99% Lifetime

63

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

Cold Chain under EPI

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







64


(M) MATERNAL CARE PROGRAM
STRATEGIES:
A. Provision of Regular and Quality Maternal Care Services
1. Regular and quality pre-natal care
a. hx-taking, utilization of HBMR (Home-Based Mothers Record) as a guide in the
identification of risk factors
b. PE: weight, height, BP-taking
c. Perform head-to-toe assessment, abdominal exam
d. Tetanus Toxoid Immunization
e. Fe supplementation: given from 5th mo. of pregnancy to two months postpartum
(100-120 mg orally/day for 210 days)
f. Laboratory exam: Heat-acetic acid test. Benedicts test
g. Oral/Dental exam
2. Pre-natal counseling

B. Provision of safe, delivery care
a. All birth attendants shall ensure clean and safe deliveries at the faciltiies
(RHUs/hospitals)
b. at-risk pregnancies and mothers must be immediately referred to the nearest
institution
3. Provision of quality postpartum care
4. Proper schedule of follow-up must be followed:
a. 1st postpartum visit for home deliveries must be done within 24 hours after
delivery
b. 2nd, done at least 1 week after delivery
c. 3rd, done 2-4 weeks thereafter
Attendants must be aware of the early signs, symptoms and complications. They should
follow the 3 CLEANS:
CLEAN Hands
CLEAN Surface
CLEAN Cord
C. Improvement of the health personnels capabilities on newborn care, midwifery thru
trainings.
Note: All deliveries should be done in health care facilities ONLY
D. Improvement on the quality of care at the First Referral Level
65

1. Orientation, training should be done on the use of proper filling-up of HBMR card
2. Proper referrals/endorsements must be done for future If-ups
E. Prevention of unwanted pregnancies through family planning services
F. Prevention and management of STDs
G. Promotion of Appropriate health practices
H. Upgrade reporting services
I. Mobilize political commitment and community involvement to provide support to basic
health care delivery
GOALS:
A. Safe Pregnancy
Right age to be pregnant=20-35 years old, not less than 20 & not more than 35
Right interval of pregnancy=once in 2 or 3 years
Home Base Mothers Record (HBMR): the record used for care of mothers in
CHN
Laboratory Examinations:
Benedicts Test: test for sugar in the urine; test for diabetes
Heat test tube with 5 cc of Benedicts Solution (blue) in the burner then add 3-5
gtts of urine (amber yellow) then heat again.
Observe for the change in color:
Blue : (-) sugar in urine
Green : trace of sugar in urine +1 +
Yellow : traces of sugar in urine +2 ++
Orange : more traces of sugar in urine +3 +++
Brick Red : surely diabetic +4 ++++

Acetic Acid Test: test for albumin in urine; test for Pregnancy Induced HPN
Collect urine in test tube, heat it in burner then add 3-5 gtts of acetic solution
(clear white). Observe for change in color:
If it remains clear: (-) CHON or albumin in urine
If it turns cloudy: (+) CHON=proteinuria
POLICIES:
1. Non coercive (give freedom of choice)
66

2. Integration of Family Planning in all Curricular Program:
LOI 47 DECS states that Family Planning is to be integrated in all school
curricular programs, either baccalaureates or non-baccalaureates, enrolled
separately as one unit
3. Multi-Sectoral Approach: establish relationship with other agencies which can either
be:
Intrasectoral
Intersectoral-Local or International (WHO, Unicef, USAID, Japhiego)
METHODOLOGIES:
Biological
A. Basal Body Temperature (BBT)
Get the temperature early morning before waking up which should be monitored
daily at the same time
There should be a sudden drop of temperature between 0.3-0.6C followed by an
increase of temperature by 0.3-0.6C which means that the woman is fertile
B. Sympto-thermal
C. Cervical Mucus Test
a. Billings Method by Dr. Billing
b. Spinnbarkheit (came from a German word Spinner which means to play with the
cervical mucus with the finger) or Wet & Dry
Method:
Wet Cervical Mucus (Fertile): abundant, stretchy & transparent
Dry Cervical Mucus (Safe & Not fertile): whitish, pasty & adhesive
D. Calendar (Rhythm)
Deleted already since 1998 because its not recommended for irregular cycle of
menstruation
Menstrual cycle should be regular; obtain 4-6 months cycle
E. Lactation Amenorrhea Method (LAM): RA 7600-Breastfeeding & Rooming In Law
DOH organized Maternal & Child Family Health Institute (MCFHI) with the
following members:
1. All government hospitals
2. Private hospitals (volunteer)
Normal involution (uterus goes back to normal) of the uterus: after 45 days or 5-6 weeks
or 1 months if not breastfeeding
67

Frozen breast milk is to be put out of the freezer 2 hours before feeding ( Body of Ref: 2-
3 days / Freezer: 3-4 months)
Left over milk should be discarded & should not be re-preserved or re-frozen because it
is already contaminated
Temporary
A. Chemical
1. Oral Pills (Logentrol)-has low dose of estrogen & progesterone that inhibits
ovulation
2. Parenteral: Depot Medroxyprogesterone Acetate (DMPA)/Depoprovera- inhibits
ovulation making women amenorrheic;
1991, DMPA was found to be causing cancer of the cervix
1994, DMPA is given IM 4x a year every 3 months (90 days interval)
3. Implants: Norplant-it inhibits ovulation effective for 5 years but seldom advocated
for use because it is usually expensive; the client buys the device (consists of 5
capsules) & have it implanted at the health center by minor surgical incision in:
.upper inner arm because it is nearest to the brain
.external oblique
t high
gluteal muscles
B. Mechanical:
a. IUD - Up to 10 years protection
b. Cervical cap & Diaphragm -Prevent the sperm to pass the cervix , Works better
with spermicide , Wore 30 minutes before coitus and keep up to 6 hours after
coitus
c. Condom - Most effective way to prevent STDs / STIs
C. Behavioral
a. Abstinence
b. Withdrawal
D. Permanent
a. Vasectomy (reversible)-since year 2000 in the Philippines
b. BTL
Philosophy
Pregnancy, labor and delivery and puerperium are part of the continuum of the
total life cycle
68

Personal, cultural and religious attitudes and beliefs influence the meaning of
pregnancy for individuals and make each experience unique
MCN is FAMILY CENTERED- the father is as important as the mother

Goals
To ensure that expectant mother and nursing mother maintain good health, learn
the art of child care, has a normal delivery and bear healthy children
That every child lives and grows up in a family unit with love and security, in
healthy surroundings, receives adequate nourishment, health supervision and
efficient medical attention and is taught the elements of healthy living

Classification of pregnant women
Normal healthy pregnancy
With mild complications- frequent home visits
With serious or potentially serious complication referred to most skilled source
of medical and hospital care

Home Based Mothers Record (HBMR)
Tool used when rendering prenatal care containing risk factors and danger signs

Risk Factors
145 cm tall (4 ft & 9 inches)
Below 18 yrs old, above 35 yrs old
Have had 4 pregnancies
With TB, goiter, heart disease, DM, bronchial asthma, severe anemia
Last baby born was less than 2 years ago
Previous cesarian section delivery
History of 2 or more abortions, difficult delivery, given birth to twins, 2 or more
babies born before EDD, stillbirth
Weighs less than 45 kgs. or more than 80 kgs.

Danger Signs
1. any type of vaginal bleeding
2. headache, dizziness, blurred vision
3. puffiness of face and hands
4. pallor
69

Prenatal Care

Schedule of Visits
1st as early as pregnancy, 1st trimester
2nd - 2nd trimester
3rd & subsequent visits - 3rd trimester
More frequent visits for those at risk with complications
Tetanus Toxiod Immunization Schedule for Women
Vaccine Minimum Age
Interval
Percent
Protected
Duration of Protection
TT1 As early as possible
during pregnancy
0% None
TT2 At least 4 weeks later 80% Infants born to the mother will be
protected from neonatal tetanus. Gives
3 years protection for the mother from
the tetanus.
TT3 At least 6 months later 90% Infants born to the mother will be
protected from neonatal tetanus.

Gives 5 years protection for the mother.
TT4 At least 1 year later 99% Gives 10 years protection for the
mother
TT5 At least 1 year later 99% Gives lifetime protection for the
mothers. All Infants born to that mother
will be protected.
Dose: 0.5ml
Route: Intramuscular
Site: Right or Left Deltoid/Buttocks

Components of Prenatal Visits
History taking
Determination of obstetrical score- G, P, TPAL, AOG, EDD
U/A for Proteinuria, glycosuria and infxtn
Dental exam
Wt. Ht. BP taking
Exam of conjunctiva and palms for pallor
Abdominal exam - fundic ht, Leopolds maneuver and FHT
70

Exam of breasts, face, hands and feet for edema and neck for thyroid
enlargement
Health teachings- nutrition, personal hygiene, common complaints
Tetanus toxoid immunization
Iron supplementation from 5th mo. Of pregnancy - 2 mos. Postpartum
In goiter endemic areas iodized capsule once a year
In malaria infested areas- prophylactic Chloroquine (150 mg/tab ) 2 tabs/ wk for
the whole duration of pregnancy
Family Planning Program
Overview
The Philippine Family Planning Program is a national program that systematically
provides information and services needed by women of reproductive age to plan
their families according to their own beliefs and circumstances.

Goals and Objectives
Universal access to family planning information, education and services.

Mission
To provide the means and opportunities by which married couples of
reproductive age desirous of spacing and limiting their pregnancies can realize
their reproductive goals.

Types of Methods

1. NATURAL METHODS

a. Calendar or Rhythm Method
b. Basal Body Temperature Method
c. Cervical Mucus Method
d. Sympto-Thermal Method
e. Lactational Amennorhea

2. ARTIFICIAL METHODS
a. Chemical Methods
71

i. Ovulation suppressant such as PILLS
ii. Depo-Provera
iii. Spermicidals
iv. Implant

b. Mechanical Methods
i. Male and Female Condom
ii. Intrauterine Device
iii. Cervical Cap/Diaphragm
c. Surgical Methods
i. Vasectomy
ii. Tubal Ligation

Warning Signs

Pills
Abdominal pain (severe)
Chest pain (severe)
Headache (severe)
Eye problems (blurred vision, flashing lights, blindness)
Severe leg pain (calf or thigh)
Others: depression, jaundice, breast lumps
IUD
Period late, no symptoms of pregnancy, abnormal bleeding or spotting
Abdominal pain during intercourse
Infection or abnormal vaginal discharge
Not feeling well, has fever or chills
String is missing or has become shorter or longer
Injectables
Dizziness
Severe headache
Heavy bleeding
BTL
Fever
Weakness
Rapid pulse
Persistent abdominal pain
Vomiting
Dizziness
72

Pus or tenderness at incision
site
Amenorrhea



Vasectomy
Fever
Scrotal blood clots or excessive swelling

(E)ENVIRONMENTAL SANITATION

WATER SUPPLY SANITATION PROGRAM
Potable
Free from any particles that might cause illness to an individual
Ways to make Water Potable:
1. Boiling: minimum of 3 minutes to maximum of 10 minutes for drinking
2. Sterilization: 30 minutes after the water starts to boil
3. Filtration: makes use of filter paper or cotton cloth to separate solid particle from
liquid if water comes from river
4. Coagulation/Flocculation: uses aluminum crystal (tawas) that collects or absorbs
particles from liquid part & becomes slimy
a. In 1 gallon of water, drop tawas (the size of magi cubes) & allow to stand
for 6-8 hours
b. Initially, water appears to be cloudy then after 6-8 hours of standing, the
water becomes clear
5. Chlorination: uses 100% pure concentrated chlorine bought from botika or given
free by health centers
a. To prepare stock solution (SS): in 1 liter drinking water, add 1 tablespoon
of concentrated chlorine which is potent for 3-4 months
b. To prepare the chlorinated water: in 2 gallons of drinking water (10,000
ml=10 liters), add 1 tablespoon from the prepared stock solution & let it
stand for 30 minutes to react with water
c. Fluoridation: adding fluoride to prevent dental caries (primary
significance) & whitens enamel of teeth ( 2nd significance)
6. Aeration: exposing drinking water in air to strengthen taste within 24 hours which
is usually used in uphill areas where theres less or no pollution
3 TYPES OF APPROVED WATER SUPPLY AND FACILITIES
Level I
Point Source
73

A protected well or a developed spring with an outlet but without a distribution
system for rural areas where houses are thinly scattered.
Level II
Communal faucet system or stand posts
A system composed of a source, a reservoir, a piped distribution network and
communal faucets, located at not more than 25 meters from the farthest house in
rural areas where houses are clustered densely.
Level III
Waterworks system or individual house connections
A system with a source, a reservoir, a piped distributor network and household
taps that is suited for densely populated urban areas.

PROPER EXCRETA AND SEWAGE DISPOSAL SYSTEM
3 TYPES OF APPROVED TOILET FACILITIES
Level 1
Non-water carriage toilet facility:
a. Pit latrines
b. Reed Odorless Earth Closet
c. Bored-hole
d. Compost
Toilets requiring small amount of water to wash waste into receiving space
a. Pour flush
b. Aqua privies
Pit latrines
. most commonly observed in rural area
. has three components: the pit, a squatting plate and the super-structure
. types of pit include
1. Antipolo type, a pit type of toilet provided with concrete floor and an elevated
seat with a cover
2. Ventilated Improved Pit or VIP, pit with a vent pipe
74

3. Reed Odourless Earth Closet or ROEC, a pit completely displaced from the
superstructure and connected to the squatting plate by a curved chute.
4. Bored Hole Latrine
consists of relatively deep holes bored into the earth by mechanical or
manual earth-boring equipment
Holes are about 10-18 inches in diameter and usually 15-35 feet deep. The
hole is provided to facilitate squatting. Two types of bored-hole latrines are:

a. Wet Type - when the hole penetrates ground water table or other strata.
b. Dry Type - when he hole does not reach ground water table; fills up at a
faster rate then than the wet type.
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.
THINGS TO CONSIDER IN CONSTRUCTING A TOILET FACILITY:
1. At least 25 meters away from water sources at a lower elevation
2. It should be within your financial capability
3. It should be approved by the local health authorities
CARE AND MAINTENANCE OF YOUR TOILET FACILITY:
1. Water must be provided at all times.
2. Use toilet paper
3. Use lysol once a month for odor removal
4. Clean the bowl by muriatic acid to remove the stains.
5. Avoid depositing solid objects on the bowl to prevent clogging
6. Always check your toilet if its clean
7. Use plunger when clogging occurs. Dont use sticks or rods to
8. avoid the breakage of the trap or the bowl.
PROPER SOLID WASTE MANAGEMENT
Refers to satisfactory methods of storage, collection and final disposal of solid wastes
SOURCES OF SOLID WASTE
1. Household Waste - these are wastes generated in or discharged from household
including shops but excluding commercial activities
75

2. Commercial Waste - restaurants, stationery shops, grocery shops or any
commercial activity are the main sources of commercial waste.
3. Market Waste - only refers to waste generated in or discharged from markets
both for whole sale and retailing
4. Institutional Waste - these are wastes generated in government, state enterprise
and private firm office.
5. Street Sweeping Waste - these are wastes generated by the street sweeping
cleansing service.
6. River Waste - includes all the wastes generated by the river and creek cleansing
7. Medical Waste - these are wastes generated in hospitals.
COMPONENTS OF SOLID WASTE
1. Garbage refers to left over vegetable, animal and fish material from kitchen and
food establishments. These materials have the tendency to decay giving off foul
odors and sometimes serve as food for flies and rats.
2. Rubbish refers to waste materials such as bottles, broken glass, tin can, waste
papers, discarded textile materials, porcelain wares, pieces of metal and other
wrapping materials.
3. Ashes are left over from burning of wood and coal. Ashes may become a
nuisance because of the dust associated with them.
4. Stable manure is animal manure collected from stables.
5. Dead animals like dead dogs, cats, rats, pigs, and chickens that are killed by cars
and trucks on streets and public highways. They include small and large animals
that died from disease.
6. Street sweeping includes dust, manure, leaves, cigarette buts, waste papers and
other materials that are swept from streets.
7. Night soil is human waste normally wrapped and thrown into sidewalks and
streets. This also includes human waste from pail system of toilets.
8. Yard cuttings includes leaves, branches, grass and other
SANITARY WAYS OF TREATING GARBAGE:
1. Segregation-separating biodegradable from non biodegradable
2. Collection-adherence to the proper collection time. the City of Manila coordinates
with Leonel Waste Management (a private firm which collects garbage) where
the truck driver coordinates with the Barangay Chairman on the time they will
collect garbage so dont bring out garbage before the collection time
WAYS OF DISPOSAL
Household
1. Burial
Deposited in 1m x 1m deep pits covered with soil, located 25 m. away from
water supply
76

2. Open burning
3. Animal feeding
4. Composting
5. Grinding and disposal sewer
Community
1. Sanitary landfill or controlled tipping
2. Excavation of soil deposition of refuse and compacting with a solid cover of 2 feet
3. Incineration
Ecological Solid Waste Management: RA 9003- the use of incinerator approved
in 2000 but was implemented in 2003 because of lack of funding to purchase
FOOD SANITATION PROGRAM
POLICIES:
1. Food establishment are subject to inspection (approved of all food sources
containers and transport vehicles)
2. Comply with sanitary permit requirement
3. Comply with updated health certificates for food handlers, helpers, cooks
4. All ambulant vendors must submit a health certificate to determine present of
intestinal parasite and bacterial infection
3 POINTS OF CONTAMINATION
1. Place of production processing and source of supply
2. Transportation and storage
3. Retail and distribution points

HOSPITAL WASTE MANAGEMENT
RA 4226-Hospital Licensure Act monitors the hospital license & proper
management of wastes as well as renewal of license to operate
GOAL:
To prevent the risk of contraction contracting nosocomial infection from type disposal of
infectious, pathological and other wastes from hospital
COLOR CODING OF BIN TO KEEP WASTE:
Green: wet waste
Black : dry waste
77

Yellow: infectious/pathological waste like blood, sputum, urine, feces & gauze
Orange: toxic/hazardous waste
(N)Nutrition
Definition
Nutrition is a state of well-being achieved by eating the right food in every meal
and the proper utilization of the nutrients by the body.
Proper nutrition is important because:
o It helps in the development of the brain, especially during the first years of
the childs life.
o It speeds up the growth and development of the body including the
formation of teeth and bones
o It helps fight infection and diseases
o It speeds up the recovery of a sick person
o It makes people happy and productive
o Proper nutrition is eating a balanced diet in every meal
Goal
To improve the nutritional status, productivity and quality of life of the population
thru adoption of desirable dietary practices and healthy lifestyle

Objectives
Increase food and dietary energy intake of the average Filipino
Prevent nutritional deficiency diseases and nutrition-related chronic degenerative
diseases
Promote a healthy well-balanced diet
Promote food safety

Balanced diet
Balanced diet is made up of a combination of the 3 basic groups eaten in correct
amounts. The grouping serves as a guide in selecting and planning everyday
meals for the family.
The Three (3) Basic Food Groups are:

1. Body building food which are rich in protein and needed by the body for:
normal growth and repair of worn-out body tissues
supplying additional energy
fighting infections
78

Examples of protein-rich food are: fish; pork; chicken; beef; cheese; butter;
kidney beans; mongo; peanuts; bean curd; shrimp; clams
2. Energy-giving food which are rich in carbohydrates and fats and needed by the
body for:
providing enough energy to make the body strong
Examples of energy-giving food are: rice; corn; bread; cassava; sweet potato;
banana; sugar cane; honey; lard; cooking oil; coconut milk; margarine;
butter
3. Body-regulating food which are rich in Vitamins and minerals and needed by
the body for:
normal development of the eyes, skin, hair, bones, and teeth
increased protection against diseases
Examples of body-regulating food are: tisa; ripe papaya; mango; guava; yellow
corn; banana; orange; squash; carrot

Low Fat Tips
1. Eat at least 3 meals/day
2. Eat more fruits, vegetables, grain and cereals e.g. rice, noodles and potato
3. If you use butter or margarine, pat it on thinly
4. Choose low fat substitute i.e. replace whole milk with skimmed milk, low fat
cheese
5. Become a label reader. Look for foods that have less than 5 g /100 g of product
6. Eat less high fat snacks and take away potato chips, sausage rolls or breaded
meats
7. Cut all visible fat from meat; remove skin from chicken fat drippings and cream
sauces
8. Aim for thin palm-size serving of lean meat, poultry and fish/ meal
9. Grill, bake, steam, stew, stir fry and microwave, try not to fry
10. Drink lots of water all day- its a food quencher
11. Ambulate:
a. Start by walking for 10 min.
b. Build up to 30-40 min/day
c. Go for 3-4 times / week of any exercise you enjoy


Filipino Food Pyramid
Drink lot- water, clear broth
Eat most rice, root crops, corn, noodles, bread and cereals
Eat more vegetables, green salads, fruits or juices
Eat some fish, poultry, dry beans, nuts, eggs, lean meats, low fat dairy
79

Eat a little fats, oils, sugar, salt

Important Vitamins and Minerals
VITAMINS FUNCTIONS
Vitamin A Maintain normal vision, skin health, bone and tooth
growth reproduction and immune function; prevents
xerophthalmia.

Food sources: Breastmilk;poultry;eggs;
liver; meat;carrots;squash;
papaya;mango;tiesa; malunggay;kangkong; camotetops;
ampalaya tops
Thiamine Help release energy from nutrients; support normal
appetite and nerve function, prevent beri-beri.
Riboflavin Helps release energy from nutrients, support skin
health, prevent deficiency manifested by cracks and
redness at corners of mouth; inflammation of the tongue
and dermatitis.
Niacin Help release energy from nutrients; support skin,
nervous and digestive system, prevents pellagra.
Biotin Help energy and amino acid metabolism; help in
the synthesis of fat glycogen.
Pantothenic Help in energy metabolism.
Folic acid Help in the formation of DNA and new blood cells
including red blood cells; prevent anemia and some amino
acids.
Vitamin B12 Help in the formation of the new cells; maintain nerve
cells, assist in the metabolism of fatty acids and amino acids.
Vitamin C Help in the formation of protein, collagen, bone,
teeth cartilage, skin and scar tissue; facilitate in the
absorption of iron from the gastrointestinal tract; involve in
amino acid metabolism; increase resistance to infection,
prevent scurvy.

Food sources:
80

Guava;pomelo;lemon;orange; calamansi; tomato; cashew
Vitamin D Help in the mineralization of bones by enhancing
absorption of calcium
Vitamin E Strong anti-oxidant; help prevent arteriosclerosis;
protect neuromuscular system; important for normal
immune function.
Vitamin K Involve in the synthesis of blood clotting proteins and
a bone protein that regulates blood calcium level.

MINERALS FUNCTIONS
Calcium Mineralization of bones and teeth, regulator of many of
the bodys biochemical processes, involve in blood
clotting, muscle contraction and relaxation, nerve
functioning, blood pressure and immune defenses.
Chloride Maintain normal fluid and electrolyte balance.
Chromium Work with insulin and is required for release of energy
from glucose.
Copper Necessary for absorption and use of iron in the formation
of hemoglobin.
Fluoride Involve in the formation of bones and teeth; prevents
tooth decay.
Iodine As part of the two thyroid hormones, iodine
regulates growth, physical and mental development and
metabolic rate. Aids in the development of the brain and
body especially in unborn babies

Food sources:
Seaweeds;squids;shrimps;crabs;
fermented shrimp;mussels;snails; dried dilis; fish
81

Iron Essential in the formation of blood. It is involved in
the transport and storage of oxygen in the blood and is
a co-factor bound to several non-hemo enzymes required
for the proper functioning of cells.

Food sources:
Pork; beef; chicken; liver and other internal organs;
dried dilis; shrimp; eggs; pechay; saluyot; alugbati
Magnesium Mineralization of bones and teeth, building of
proteins, normal muscle contraction, nerve impulse
transmission, maintenance of teeth and functioning of
immune system.
Manganese Facilitate many cell processes.
Molybdenum Facilitate many cell processes.
Phosphorus Mineralization of bones and teeth; part of every Cell;
used in energy transfer and maintenance of acidbase
balance.
Selenium Work with vitamin E to protect body compound
from oxidation.
Sodium Maintain normal fluid and electrolyte balance, assists
nerve impulse insulin.
Sulfur Integral part of vitamins, biotin and thiamine as well as
the hormone.
Zinc Essential for normal growth, development reproduction
and immunity.


Malnutrition
An abnormal condition of the body resulting from the lack or excess of one or
more nutrients like protein, carbohydrates, fats, vitamins and minerals.
Primary Cause: POVERTY
1. Lack of money to buy food
82

o Majority of the victims of malnutrition comes from families of farmers,
fisherfolk, and laborers who cannot afford to buy nutritious foods.
2. Lack of food supply
3. Lack of information on proper nutrition and food values
Secondary Causes
1. Early weaning of child and improper introduction of supplementary food
2. Incomplete immunization of babies and children
3. Bad eating habits
4. Poor hygiene and environmental sanitation:
a. lack of potable water
b. lack of sanitary toilet
c. poor waste disposal


Forms of Malnutrition

Protein-Energy Malnutrition (PEM)
Is a nutritional problem resulting from a prolonged inadequate intake of
bodybuilding and/or energy-giving food in the diet.
Kinds:

1. Marasmus
This child does not get the right amount and kind of energy food.
She/he:
o is always hungry
o has the face of an old man
o is very thin
o easily gets sick
o looks weak
o THIS CHILD IS JUST SKIN AND BONES!
2. Kwashiorkor
This child does not get enough body-building food, although she/he may be
getting enough energy.
She/he:
o has swollen face, hands, and feet
o easily gets sick
o has dry, thin, pale hair
o has sores on the skin
o has thin upper arms
o looks sad
83

o has dry skin
o is underweight
o THIS CHILD IS SKIN, BONES, AND WATER!
Vitamin A Deficiency (VAD)
A condition in which the level of Vitamin A in the body is low.
Causes:
Not eating enough foods rich in vitamin A. E.g. yellow vegetables and yellow fruits
Lack of fat or oil in the diet which help the body absorb Vitamin A.
poor absorption or rapid utilization of Vitamin A during illness
Eye Signs
night blindness (early stage); total blindness (later stage)
bitots spot (foamy soapsuds-like spots on white part of the eye)
dry, hazy and rough appearing cornea
crater-like defect on cornea
softened cornea; sometimes bulging
Other Manifestations
increased cases of childhood sickness, and death and decreased resistance to
infection
susceptibility to childhood malnutrition and infection (measles, diarrhea and
pneumonia)
Prevention
eating foods rich in Vitamin A, such as liver, eggs, milk, crab meat, cheese, dilis,
malunggay, gabi leaves, kamote tops, kangkong, alugbati, saluyot, carrots,
squash, ripe mango, including fats and oils
breastfeeding the child
immunizing the child
taking correct dose of Vitamin A capsules as prescribed
Risk Factors
VAD is most common in children suffering from PEM and other infectious
diseases. Bottle-fed infants are also at risk of VAD especially if the milk formula
used is not fortified with Vitamin A.
Common among preschoolers and infants (FNRI)
Schedule for Receiving Vitamin A Supplement to Infants, Preschoolers and
Mothers
84

Schedule Infants (6-11 mos) Preschoolers
(12-83 mos)
Post Partum Mother
Give 1 Dose 100,000 IU 200,000 IU 200,000 IU
Within one month
Give after 6 months
High risk Condition
Present
100,000 IU 200,000 IU After delivery
of each child only

Schedule for Treatment of Viamin A Deficiency
Schedule Infants (6-11 mos.) Preschoolers (12-83 mos.)
Give Today 100,000 IU 200,000 IU
Give Tomorrow 100,000 IU 200,000 IU
Give After 2 Weeks 100,000 IU 200,000 IU


Anemia
A condition characterized by the lack of iron in the body resulting in paleness.
Sign/Symptoms
Paleness of the eyelids, inner cheeks, palms and nailbeds; frequent dizziness and
easy fatigability
Common cause
Inadequate intake of food rich in iron; can also be caused by blood loss during
menstruation, pregnancy and parasitic infections.
Prevention
Eating iron-rich food such as liver and other internal organs; green leafy
vegetables; and foods rich in Vitamin C
Prevention of Iron Deficiency
Recommended Iron Requirements Dosage
85

Infants ( 6-12 months) 0.7 mg. Daily
Children ( 12-59 months) 1 mg daily

Treatment of Iron Deficiency
Dosage
Children 0-59 month 3-6 mg. /kg. Body wt./day

Goiter
Enlargement of thyroid gland due to lack of iodine in the body.
Common in areas where the iodine content in the soil, water and food are
deficient.
Effect of Iodine deficiency to fetus: may be born mentally and physically retarded.
Goiter can be prevented by:
o daily intake of food rich in iodine
o use of iodized salt
Iodine Supplementation
Dosage
Children 0-59
months ( in endemic
areas)
Iodine capsules
(200mg) potassium iodate in
oil orally once a year.


Checking the Nutritional Status Weight
1. Weight is a very important indicator of a persons nutritional status. It is
measured in relation to either AGE or HEIGHT. Normally, a well nourished child
gains weight as she/he grows older.
2. On the other hand, a malnourished child either decreases in weight or maintains
his/her previous weight.
3. The nutritional status of a person can also be checked by looking for specific
signs and symptoms of the different forms of nutritional deficiencies.
Important
1. Weigh the child in minimal clothing, with no shoes, clogs or slippers on; and hands
and pockets free of objects.
2. The same type of scale should be used for subsequent weighing.
3. Observe the proper maintenance of the weighing scale.
86

4. Do not use a bathroom scale to avoid inaccurate readings of weight.
*bring the malnourished child together with the parents to the health center for
proper nutritional advice and treatment.
*visit the malnourished child regularly and monitor his/her weight.
*advise parents and the whole community about better nutrition and proper
feeding especially of infants, children and sick persons.

Nutritional Guidelines
1. Eat a variety of food everyday.
2. Breastfeed infants exclusively from birth to 4-6 months, and then, give
appropriate foods while continuing breastfeeding.
3. Maintain childrens normal growth through proper diet and monitor their growth
regularly.
4. Consume fish, lean meat, poultry or dried beans.
5. Eat more vegetables, fruits, and root crops.
6. Eat foods cooked in edible/cooking oil daily.
7. Consume milk, milk products or other calcium-rich foods such as small fish and
dark green leafy vegetables everyday. Use iodized salt, but avoid excessive
intake of salty foods.
8. Use iodized salt, avoid excessive intake of salty foods
9. Eat clean and safe food.
10. For a healthy lifestyle and good nutrition, exercise regularly, do not smoke, avoid
drinking alcoholic beverages.
Aims and Rationale of Each of the Guidelines
Guideline No. 1 is intended to give the message that no single food provides all
the nutrients the body needs. Choosing different kinds of foods from all food
groups is the first step to obtain a well balanced diet. This will help correct the
common practice of confining of choice to a few kinds of foods, resulting in an
unbalanced diet.
Guidelines No.2 is entitled to promote exclusive breastfeeding from birth to 4-6
months and to encourage the continuance of breastfeeding for as long as two
years or longer. This is to ensure a complete and safe food for the newborn and
the growing infant besides imparting the other benefits of breastfeeding. The
guideline also strongly advocates the giving of appropriate complementary food
in addition to breast milk once the infant is ready for solid foods at 6 months.
Malnutrition most commonly occurs between the ages of 6 months to 2 years,
therefore there is a need to pay close attention to feeding the child properly
during this very critical period.
Guideline No. 3 gives advise on proper feeding of children. In addition, the
guideline promotes regular weighing to monitor the growth of children, as it is a
simple way to assess nutritional status.
Guidelines No. 4, 5, 6 and 7 are intended to correct the deficiencies in the
current dietary pattern of Filipinos. Including fish, lean meat, poultry and dried
beans, which will provide good quality protein and dietary energy, as well as iron
and zinc, key nutrients lacking in the diet of Filipinos as a whole. Eating more
87

vegetables, fruits and root crops will supply the much needed vitamins, minerals
and dietary fiber that are deficient in our diet. In addition, they provide defense
against chronic degenerative diseases. Including foods cooked in edible oils will
provide additional dietary energy as a partial remedy to calorie deficiency of the
average Filipino. Including milk and other calcium-rich foods in the diet will serve
to supply not only calcium for healthy bones but to provide high quality protein
and other nutrients for growth.
Guideline No. 8 promotes the use of iodized salt to prevent iodine deficiency,
which is a major cause of mental and physical underdevelopment in the country.
At the same time, the guideline warns against excessive intake of salty foods as
a hedge against hypertension, particularly among high-risk individuals.
Guideline No.9 is intended to prevent food-borne diseases. It explains the
various sources of contamination of our food and simple ways to prevent it from
occurring.
Finally, Guideline No. 10 promotes a healthy lifestyle through regular exercise,
abstinence from smoking and avoiding consumption. If alcohol is consumed, it
must be done in moderation. All these lifestyle practices are directly or indirectly
related to good nutrition.

Nutrients in Food
Nutrients are chemical substances present in the foods that keep the body
healthy, supply materials for growth and repair of tissues, and provide energy for
work and physical activities.
The major nutrients include the macronutrients, namely; proteins, carbohydrates and
fats; the micronutrients, namely vitamins such as A, D, E and K, the B complex vitamins
and C and minerals such as calcium, iron, iodine, zinc fluoride and water.










88

(E) ESSENTIAL DRUGS

CREATION OF BOTIKA SA BARYO & BOTIKA SA HEALTH CENTER
RA 6675: Generics Act of 1988: Implementing

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

Walong Wastong Gamot Program- available generics in Botika sa Baryo & Health
Center

Father of Generics Act: Dr. Alfredo Bengzon

8 COMMONLY AVAILABLE GENERICS (CARIPPON)
1. Co-Trimoxazole:
Its a combination of 2 generics of drugs which is antibacterial

2. Trimethoprim(TMP)
Has a bacteriostatic action that stops/inhibits multiplication of bacteria
For GUT, GIT & URTI (TMP combined with SMX)

3. Sulfamethoxazole (SMX)
Has bactericidal action that kills bacteria
For GUT, GIT, URTI & Skin Infections

4. Amoxicillin/Ampicillin
An antibacterial drug that comes from the Penicillin Family
Effect is generally bacteriostatic (when source of infection is bacterial)
These 2 drugs provide the least sensitivity reaction (rashes & GI) and the
adverse effect of other antibiotics is anaphylactic shock

5. TB DRUGS:
Rifampicin (RIF)
Isoniazid (INH)
Pyrazinamide (PZA)

6. Paracetamol
Has an analgesic & anti-pyretic effect
Acetyl Salicylic Acid (ASA) or Aspirin is never kept in the Botika because of
its effects:
Anticoagulant-highly dangerous to Dengue patients thats why its not available in
Botika & Health Center

7. Oresol:
A management for diarrhea to prevent dehydration under the Control of Diarrheal
Diseases (CDD) Program

8. Nifedipine:
89

An anti-hypertensive drug
According to DOH, 16% of population belonging to 25 years old & above in the
community are hypertensive

I. HERBAL PLANTS
RA 8423: Alternative Traditional Medicine Law
A program where patient may opt to use herbal plants especially for drugs that
are not available in dosage form or patients has no financial means to buy the
drug
Traditional Medicine:
Use of herbal plants
10 ADVOCATED HERBAL PLANTS BY DOH: LUBBY SANTA

Lagundi Vitex
negundo

Asthma, cough, colds
& fever (ASCOF) Pain
and inflammation
Leaves Decoction
Poultice
Ulasimang
Bato
Peperonia
pellucida

Gout
Arthritis
Rheumatism
Leaves Decoction
Poultice
Bayabas Psidium
quajava

Diarrhea
Toothache
Mouth and wound
wash
Leaves Decoction
Bawang Allium
sativum

HPN
Toothache
Clove/Bulb

Poultice
Yerba Buena Mentha
cordifelia

Same as Lagundi
except asthma
Leaves Poultice
Decoction
Sambong Blumea
balsanifera
Edema
Diuretic
Leaves
Akapulko Cassia alata

All forms of skin
diseases

Leaves Poultice
Decoction,
cream
Niyog
niyogan
Quisqualis
indica

Intestinal Parasitism
(Nematodes)

Seeds Decoction
Poultice ,
Juice
Tsaang
Gubat
Carmona
resuta

Diarrhea Infantile colic
(Kabag)
Dental caries
Leaves Poultice
Decoction
Ampalaya Mamordica
charantia
Type II Diabetes
(NIDDM)
Leaves Decoction
POLICIES TO ABIDE:
1. Know indications
2. Know parts of plants with therapeutic value: roots, fruits, leaves
3. Know official procedure/preparation

Procedures/Preparations:
Decoction
90

Gather leaves & wash thoroughly, place in a container the washed leaves & add
water
Let it boil without cover to vaporize/steam to release toxic substance &
undesirable taste
Use extracts for washing

Poultice
Done by pounding or chewing leaves used by herbolaryo
Example: Akapulko leaves-when pounded, it releases extracts coming out from
the leaves contains enzyme (serves as anti-inflammatory) then apply on affected
skin or spewed it over skin
For treatment of skin diseases

PROCEDURES/PREPARATIONS:
Infusion
To prepare a tea (use lipton bag), keep standing for 15 minutes in a cup of warm
water where a brown solution is collected, pectin which serves as an adsorbent
and astringent
Juice/Syrup
To prepare a papaya juice, use ripe papaya & mechanically mashed then put
inside a blender & add water
To produce it into a syrup, add sugar then heat to dissolve sugar & mix it

Cream/Ointment
Start with poultice (pound leaves) to turn it semi-solid
Add flour to keep preparation pasty & make it adhere to skin lesions
To make it into an ointment: add oil (mineral, baby or any oil-serves as
moisturizer) to the prepared cream to keep it lubricated while being massage on
the affected area



II. ORESOL
Glucose 20 grams 1 Significance:
For re-absorption of Na
Facilitates assimilation of Na
2 Significance:
Provides heat & energy
Sodium Chloride/NaCl 3.5 grams For retention of water/fluid
Sodium
Bicarbonate/NaHCO3

2.5 grams Buffer content of solution
Neutralizer content of
solution
Potassium Chloride/KCl 1.5 grams Stimulates smooth muscle contractility
especially the
heart & GIT





91

PREPARATION OF PROPER HOMEMADE ORESOL

A volume or one liter homemade oresol Smaller volume or a glass homemade
oresol
Water 1000 ml. or 1 liter 250 ml.
Sugar 8 teaspoon 2 teaspoon
Salt 1 teaspoon teaspoon or a pinch of salt=10-12
granules of rock salt: iodized salt=tips of
thumb & index finger are penetrated with
salt


































92



FAMILY HEALTH NURSING

Definition of Family

Family
i. Basic unit in society, and is shaped by all forces surround it.
Values, beliefs, and customs of society influence the role and function of the
family (invades every aspect of the life of the family)
ii. Is a unit of interacting persons bound by ties of blood, marriage or adoption.
Constitute a single household, interacts with each other in their respective
familial roles and create and maintain a common culture.
iii. An open and developing system of interacting personalities with structure and
process enacted in relationships among the individual members regulated by
resources and stressors and existing within the larger community (Smith &
Maurer, 1995)
iv. Two or more people who live in the same household (usually), share a common
emotional bond, and perform certain interrelated social tasks (Spradly & Allender,
1996)
v. An organization or social institution with continuity (past, present, and future). In
which there are certain behaviors in common that affect each other.

The Filipino Family
Based on the Philippine Constitution, Family Code with focus on religious, legal,
and cultural aspects of the definition of family.
Section 1
The state recognizes the Filipino family as the foundation of the nation.
Accordingly, it shall strengthen its solidarity and actively promote its total
development
Section 2
Marriage, as an inviolable social institution, is the foundation of family and shall
be protected by the state.
Section 3

The state shall defend
93

1. the right of spouses to found a family in accordance with their religious
convictions and the demands of responsible parenthood
2. the right of children to assistance including proper care and nutrition, and special
protection from all forms of neglect, abuse, cruelty, exploitation and other
conditions prejudicial to their development
3. the right of the family to a family living wage income
4. the right of families or family associations to participate in the planning and
implementation of policies and programs of that affect them
Section 4
The family has the duty to care for its elderly members but the state may also do
so through just programs of social security
The Filipino Family and its Characteristics

The basic social units of Philippine society are the nuclear family
1. Although the basic unit is the nuclear family, the influence of kinship is felt in all
segments of social organizations
2. Extensions of relationships and descent patterns are bilateral
3. Kinship circles is considerably greater because effective range often includes the
third cousin
4. Kin group is further enlarged by a finial, spiritual or ceremonial ties. Filipino
marriage is not an individual but a family affair
5. Obligation goes with this kingship system
6. Extended family has a profound effect on daily decisions
7. There is a great degree of equality between husband and wife
8. Children not only have to respect their parents and obey them, but also have to
learn to repress their repressive tendencies
9. The older siblings have something of authority of their parents.

Types of Family
There are many types of family. They change overtime as a consequence of
BIRTH, DEATH, MIGRATION, SEPARATION and GROWTH OF FAMILY
MEMBERS
A. Structure
NUCLEAR- a father, a mother with child/children living together but apart from
both sets of parents and other relatives.
EXTENDED- composed of two or more nuclear families economically and
socially related to each other. Multigenerational, including married brothers and
sisters, and the families.
SINGLE PARENT-divorced or separated, unmarried or widowed male or female
with at least one child.
94

BLENDED/RECONSTITUTED-a combination of two families with children from
both families and sometimes children of the newly married couple. It is also a
remarriage with children from previous marriage.
COMPOUND-one man/woman with several spouses
COMMUNAL-more than one monogamous couple sharing resources
COHABITING/LIVE-IN-unmarried couple living together
DYADhusband and wife or other couple living alone without children
GAY/LESBIAN-homosexual couple living together with or without children
NO-KIN- a group of at least two people sharing a relationship and exchange
support who have no legal or blood tie to each other
FOSTER- substitute family for children whose parents are unable to care for
them
FUNCTIONAL TYPE:
FAMILY OF PROCREATION- refers to the family you yourself created.
FAMILY OF ORIENTATION-refers to the family where you came from.
B. Decisions in the family (Authority)
PATRIARCHAL full authority on the father or any male member of the family
e.g. eldest son, grandfather
MATRIARCHAL full authority of the mother or any female member of the
family, e.g. eldest sister, grandmother
EGALITARIAN- husband and wife exercise a more or less amount of authority,
father and mother decides
DEMOCRATIC everybody is involve in decision making
AUTHOCRATIC-
LAISSEZ-FAIRE- full autonomy
MATRICENTRIC- the mother decides/takes charge in absence of the father (e.g.
father is working overseas)
PATRICENTIC- the father decides/ takes charge in absence of the mother
C. Decent (cultural norms, which affiliate a person with a particular group of
kinsman for certain social purposes)
PATRILINEAL Affiliates a person with a group of relatives who are related to
him though his father
BILATERAL- both parents
MATRILINEAL - related through mother
D. Residence
PATRILOCAL - family resides / stays with / near domicile of the parents of the
husband
MATRILOCAL - live near the domicile of the parents of the wife
Ackerman States that the Function of Family are:
1. Insuring the physical survival of the species
95

2. Transmitting the culture, thereby insuring mans humanness
o Physical functions of the family are met through parents providing food,
clothing and shelter, protection against danger provision for bodily repairs
after fatigue or illness, and through reproduction
o Affect ional function the family is the primary unit in which he child test
his emotional reactions
o Social functions - include providing social togetherness, fostering self
esteem and a personal identity tied to family identity, providing
opportunity for observing and learning social and sexual roles, accepting
responsibility for behavior and supporting individual creativity and
initiative.

Universal Function of the Family by Doode
REPRODUCTION - for replacement of members of society: to perpetuate the
human species
STATUS PLACEMENT of individual in society
BIOLOGICAL and MAINTENANCE OF THE YOUNG and dependent members
Socialization and care of the children;
Social control

The Family as a Unit of Care

Rationale for Considering the Family as a Unit of Care:
The family is considered the natural and fundamental unit of society
The family as a group generates, prevents, tolerates and corrects health
problems within its membership
The health problems of the family members are interlocking
The family is the most frequent focus of health decisions and action in personal
care
The family is an effective and available channel for much of the effort of the
health worker

The Family as the Client

Characteristics of a Family as a Client
The family is a product of time and place-
o A family is different from other family who lives in another location in
many ways.
o A family who lived in the past is different from another family who lives at
present in many ways.
The family develops its own lifestyle
96

o Develop its own patterns of behavior and its own style in life.
o Develops their own power system which either be:
Balance-the parents and children have their own areas of
decisions and control.
Strongly Bias-one member gains dominance over the others.
The family operate as a group
o A family is a unit in which the action of any member may set of a whole
series of reaction within a group, and entity whose inner strength may be
its greatest single supportive factor when one of its members is stricken
with illness or death.
The family accommodates the needs of the individual members.
o An individual is unique human being who needs to assert his or herself in
a way that allows him to grow and develop.
o Sometimes, individual needs and group needs seem to find a natural
balance;
1. The need for self-expression does not over shadow consideration
for others.
2. Power is equitably distributed.
3. Independence is permitted to flourish.
The family relates to the community
o Family develops a stance with respect to the community:
1. The relationship between the families is wholesome and reciprocal;
the family utilizes the community resources and in turn, contributes to
the improvement of the community.
2. There are families who feel a sense of isolation from the community.
o Families who maintain proud, We keep to ourselves attitude.
o Families who are entirely passive taking the benefits from the
community without either contributing to it or demanding
changes to it.
The family has a growth cycle
o Families pass through predictable development stages (Duvall & Miller,
1990)
STAGES:

Stage 1: MARRIAGE & THE FAMILY
Involves merging of values brought into the relationship from the
families of orientation.
Includes adjustments to each others routines (sleeping, eating,
chores, etc.), sexual and economic aspects.
97

Members work to achieve 3 separate identifiable tasks:
1. Establish a mutually satisfying relationship
2. Learn to relate well to their families of orientation
3. If applicable, engage in reproductive life planning
Stage 2: EARLY CHILDBEARING FAMILY
Birth or adoption of a first child which requires economic and social
role changes
Oldest child: 2-1/2 years
Stage 3: FAMILY WITH PRE-SCHOOL CHILDREN
This is a busy family because children at this stage demand a great
deal of time related to growth and development needs and safety
considerations.
Oldest child: 2-1/2 to 6 years old
Stage 4: FAMILY WITH SCHOOL AGE CHILDREN
Parents at this stage have important responsibility of preparing their
children to be able to function in a complex world while at the same
time maintaining their own satisfying marriage relationship.
Oldest child: 6-12 years old
Stage 5: FAMILY WITH ADOLESCENT CHILDREN
A family allows the adolescents more freedom and prepare them for
their own life as technology advances-gap between generations
increases
Oldest child: 12-20 years old
Stage 6: THE LAUNCHING CENTER FAMILY
Stage when children leave to set their own household-appears to
represent the breaking of the family
Empty nests
Stage 7: FAMILY OF MIDDLE YEARS
Family returns to two partners nuclear unit
Period from empty nest to retirement
Stage 8: FAMILY IN RETIREMENT/OLDER AGE

Stage 9: PERIOD FROM RETIREMENT TO DEATH OF BOTH SPOUSES

98


12 Behaviors Indicating a Well Family
Able to provide for physical emotional and spiritual needs of family members
Able to be sensitive to the needs of the family members
Able to communicate thought and feelings effectively
Able to provide support, security and encouragement
Able to initiate and maintain growth producing relationship
Maintain and create constructive and responsible community relationships
Able to grow with and through children
Ability to perform family roles flexibly
Able to help oneself and to accept help when appropriate
Demonstrate mutual respect for the individuality of family members
Ability to use a crisis experience as a means of growth
Demonstrate concern of family unity, loyalty and interfamily cooperation

Family Health Task
Health task differ in degrees from family to family
TASK- is a function, but with work or labor overtures assigned or demanded of
the person
Duvall & Niller identified 8 task essential for a family to function as a unit:
Eight Family Tasks (Duvall & Niller)
1. Physical maintenance- provides food shelter, clothing, and health care to its
members being certain that a family has ample resources to provide
2. Socialization of Family- involves preparation of children to live in the community
and interact with people outside the family.
3. Allocation of Resources- determines which family needs will be met and their
order of priority.
4. Maintenance of Order- task includes opening an effective means of
communication between family members, integrating family values and enforcing
common regulations for all family members.
5. Division of Labor who will fulfill certain roles e.g., family provider, home
manager, childrens caregiver
6. Reproduction, Recruitment, and Release of family member
7. Placement of members into larger society consists of selecting community
activities such as church, school, politics that correlate with the family beliefs and
values
8. Maintenance of motivation and morale- created when members serve as
support people to each other
5 Family Health Tasks (Maglaya, A., 2004)
Recognizing interruptions of health development
Making decisions about seeking health care/ to take action
Dealing effectively health and non-health situations
Providing care to all members of the family
99

Maintaining a home environment conducive to health maintenance


Family Roles
Nurturing figure- primary caregiver to children or any dependent member.
Provider provides the familys basic needs.
Decision maker- makes decisions particularly in areas such as finance,
resolution, of conflicts, use of leisure time etc.
Problem-solver- resolves family problems to maintain unity and solidarity.
Health manager- monitors the health and ensures that members return to health
appointments.
Gate keeper-Determines what information will be released from the family or
what new information cam be introduced.

Theoretical Approaches to Family Health Care (family apgar)

Family Models
the use of family model provides a perspective of focus for understanding the
family
have categorized according to their basic focus as developmental, interactional
structural-functional, and systems model
Developmental Models

Duvalls and Stevensons Family development model
Evelyn Duvall (1977) family developmental framework provides guide to
examine and analyze the basic changes and developmental tasks common to
most families during their life cycle. Although each family has unique
characteristics normative patterns of sequential development are common to all
families
These stages and developmental tasks illustrate common family behaviors that
may be expected at specific times in the family life cycle. The stages are
marked by the age of the oldest child however some overlapping occurs in
families with several children.





100



STAGES OF DEVELOPMENT BASIC FAMILY TASK
Beginning Families

Early childbearing

Families with preschoolers

Families with school children

Families with teen-agers


Launching center families

Middle-aged families


Aging Families
Physical maintenance

Allocation of resources

Division of labor

Socialization of members.

Reproduction, recruitment and release of
Members

Maintenance of order

Placement of members in larger community

Maintenance of motivation and morale
Duvalls developmental model is an excellent guide for assessing,
analyzing and planning around basic family tasks developmental stage,
however, this model does not include the family structure or
physiological aspects, which should be considered for a comprehensive
view of the family. This model is applicable for nuclear families with
growing children and families who are experiencing health-related
problems.
Stevensons Family Developmental Model
Joanne Stevenson (1977) describes the basic tasks and responsibilities of
families in four stages.
STAGES HEALTH TASKS
Emerging family (from marriage
for 7 to 10 years)
Couple strives for independence from their parents
and to develop a sense of responsibility for family life.
Crystallizing family (with
teenage children)
To assume responsibility for growth and development
of individual members and outside organizations
101

Interacting family(children grown
and small grandchildren)
Assumption of responsibility for continued survival
and enhancement of the nation.
Actualizing family (aging couple
alone again)
Assume the responsibility for sharing the wisdom of
age, reviewing life and putting affairs in order
She views family tasks as maintaining a common household rearing
children and finding satisfying work and leisure. It also includes
sustaining appropriate health patterns and providing mutual support and
acculturation of family members.
This model is useful for nuclear families because it examines
psychosocial patterns to specific stage of development, however, it also
does not include family structure, nor it addresses health promotion and
health-related concerns that the family may face.
Structural- Functional Model

Friedmans Structural- Functional Family Model
Was developed from sociological frameworks and systems theory by Marilyn
Friedman (1986)
The family is the focus of this model as it interacts with supra-systems in the
community and with individual family members in the subsystem.
Friedmans Family Model Components
STRUCTURAL COMPONENTS FUNCTIONAL COMPONENTS
Family composition Affective
Value systems Physical necessities and care
Communication patterns Economic
Role structure Reproductive
Power structure Socialization and social placement
Family coping
Structural component examines the family unit, how it is organized and
how members relate to one another in terms of values, communication
network, role system and power while functional components refers to
the interaction outcomes resulting from family organizational structure.
The structural-functional components and parts all intimately interrelate
and interact; the others affect each component and part.
102

This model provides a broad framework for examining the interactions
among family and within the community. This incorporates physical,
psychosocial and cultural aspects of the family along with interacting
relationships.
This model is very applicable to any type of family and their health-
related problems
Systems Model

Calgarys Family Model (systems model)
Is an integrated conceptual framework of several theorists.
Model is based on three major categories: family structure, function and
development. Each is further subdivided into parts that interacts with others and
changes the whole family configuration.
Calgary Family Model

Family Structure Family Development Family Functions
Internal developmental stage daily living activities
Family composition developmental tasks allocation of tasks
Rank order of members attachments
Subsystems in family
Boundaries of family

External Expressive
Culture Communication
Religion Problem-solving
Social class status Roles
And mobility Control
Environment Beliefs
Extended family Alliances/coalitions
This model is comprehensive and incorporates three major areas, namely, the
structure, function and development of the family.
It is complex, with too many sub concepts for the health worker to explore and
focus.
It can be applied to any type of family with any health-related problems.

Family Apgar Questionnaire (SMILKESTEIN, 1978)
ALWAYS
(2 PTS.)
SOMETIMES
(1 pt.)
HARDLY EVER
(0 PT.)
I am satisfied with the help I
receive from my family when
something is troubling me.

103

I am satisfied with the way my
family discovers items of
common interest and shares
problem-solving with me.

I find that my family accepts
my wishes to take on new
activities or make changes in
my lifestyle.

I am satisfied with the way my
family expresses affection and
responds to my feelings such
as anger, sorrow and love

I am satisfied with the way my
family and I spend time
together.

Scoring:
Check one of the three choices:
Total Score:
7-10 = suggests a highly functional family
4-6 = moderately dysfunctional family
0-3 = severely dysfunctional family


Health as a Goal of Family Health Care
HEALTH DEFICIT- this refers to conditions of health breakdowns or advent of
illness in the family
HEALTH THREAT- these are the conditions that make it more likely for
accidents, disease or failure to thrive or develop to occur.
FORESEEABLE CRISIS- these are anticipated periods of unusual demand on
the family in terms of time or resources
WELLNESS POTENTIAL- this refers to states of wellness and the likelihood for
health maintenance or improvement to occur depending on the desire of the
family

Roles of Health Care Provider in Family Health Care
HEALTH MONITOR
PROVIDER OF CARE
COORDINATOR
FACILITATOR
TEACHER
COUNSELOR

Family Health Care Process
104

DATA COLLECTION: METHODS AND TOOLS
DATA ANALYSIS or INTERPRETATION
PLANNING
IMPLEMENTATION
EVALUATION PHASE
1. ASSESSMENT PHASE
first major phase of nursing process in family health nursing
Involves a set of action by which the nurse measures the status of the family as a
client. Its ability to maintain wellness , prevent, control or resolve problems in
order to achieve health and wellness among its members
Data about present condition or status of the family are compared against the
norms and standards of personal , social, and environmental health, system
integrity and ability to resolve social problems.
The norms and standards are derived from values, beliefs, principles, rules or
expectation.
TWO MAJOR TYPES
1. FIRST LEVEL ASSESSMENT- a process whereby existing and
potential health conditions or problems of the family are determined
(WS, HT, HD, SP or FC)
2. SECOND LEVEL ASSESSMENT- defines the nature or type of
nursing problem that family encounters in performing health task with
respect to given health condition or problem and etiology or barriers to
the familys assumption of the task
A) DATA COLLECTION METHODS: SELECT APPROPRIATE METHOD
OBSERVATION
o done through use of sensory capacities
o The nurse gathers information about the familys state of being
and behavioral responses
o the familys health status can be inferred from the s/sx of
problem areas
a. communication and interaction patterns expected
,used, and tolerated by family members
b. role perception / task assumption by each member
including decision making patterns
c. conditions in the home and environment
** Data gathered through this method have the advantage of being
subjected to validation and reliability testing by other observers
PHYSICAL EXAMINATION
o significant data about the health status of individual members
can be obtained through direct examination through IPPA,
105

Measurement of specific body parts and reviewing the body
systems
o data gathered from P.A form substantive part of first level
assessment which may indicate presence of health deficits
(illness state )
INTERVIEW
o Productivity of interview process depends upon the use
effective communication techniques to elicit needed
response
o PROBLEMS ENCOUNTERED:
How to ascertain where the client is in terms of
perception of health condition or problems and the
patterns of coping utilized to resolve them
Tendency of community health worker to readily give
out advice, health teachings or solutions once they
have identified the health condition or problems.
o Provisions of models for phrasing interview questions utilization
of deliberately chosen communication techniques for an
adequate nursing assessment.
o confidence in the use of communication skills
o Being familiar with and being competent in the use of type of
question that aim to explore, validate, clarify, offer feedback,
encourage verbalization of thought and feelings and offer
needed support or reassurance.
TYPES:
1. completing health history of each family member
o Health history determines current health
status based on significant
o PAST HEALTH HISTORY e.g.
developmental accomplishment, known
illnesses, allergies, restorative treatment,
residence in endemic areas for certain
diseases or sources of communicable
diseases.
o FAMILY HISTORY e.g. genetic history in
relation to health and illness.
o SOCIAL HISTORY e.g. intra-personal and
inter-personal factors affecting the family
member social adjustment or vulnerability
to stress and crisis
2. Collecting data by personally asking significant
family members or relatives questions regarding
health, family life experiences and home
environment to generate data on what wellness
condition and health problem exist in the family ( first
level assessment) and the corresponding nursing
106

problems for each health condition or problem ( 2nd
level assessment)
RECORDS REVIEW
o Gather information through reviewing existing records and
reports pertinent to the client
o Individual clinical records of the family members, laboratory
and diagnostic reports, immunization records reports about
home and environmental conditions
LABORATORY/ DIAGNOSTIC TEST
B) ANALIZE DATA TO IDENTIFY NEEDS AND PROBLEMS

CRITERIA FOR ANALYSIS:?
PROCESS FOR ANALYSIS:
SORTING OF DATA
CLUSTERING OF RELATED CUES
DISTINGUISHING RELEVANT FROM IRRELEVANT CUES
IDENTIFYING PATTERNS
COMPARING PATTERNS
INTERPRETING RESULTS OF COMPARISON
MAKING INFERENCES AND DRAWING CONCLUSIONS

Health Needs and Problems of the Family
A situation which interferes with the promotion and / or maintenance of health
It is a health problem when it stated as the familys failure to perform adequately specific
health task to enhance the wellne

FAMILY CARE PLAN
Definition
It is the blue print of the care that the nurse designs to systematically minimize or
eliminate the identified health and nursing problem through explicitly formulated
outcomes of care (goals and objectives) and deliberately chosen set of
interventions, resources and evaluation criteria, standards, methods and tools.

Characteristics, which are Based on the Concept of Planning as a Process:
1. The nursing care plan focuses on actions, which are designed to solve or
minimize existing problem.
107

o The cores of the plan are the approaches, strategies, activities, methods
and materials, which the nurse hopes, will improve the problem.
2. The nursing care plan is a product of the liberate systematic process.
3. The nursing care plan as with all other plans relate to the future.
o It utilizes events in the past and what is happening in the present to
determine patterns. It also projects the future scenario if the situation is
not corrected.
4. The nursing care plan is based upon identified health and nursing problems.
5. The nursing care plan is a means to an end, not an end in itself.
o The goal in planning is to deliver the most appropriate care to the client
by eliminating barriers to the family health development.
6. The nursing care plan is a continuous process not a one shot deal.
o The results of evaluation of the plans effectiveness trigger another cycle
of the planning process until the health and nursing problems are
eliminated.

Desirable Qualities of a Nursing Care Plan
1. It should be based on clear, explicit definition of the problem(s).
2. A good plan is realistic.
3. The nursing care plan is prepared jointly with the family.
4. The nursing care plan is most useful in written form.

Importance of Planning Care
1. They individualize care to clients.
2. The nursing care plan helps in setting priorities by providing information about
the client as well as the nature of his problem.
3. The nursing care plan promotes systematic communication among those involve
in the health care effort.
4. Continuity of care is facilitated through the use of nursing care plans.
o Gaps and duplications in the services provided are minimized, if not
totally eliminated.
5. Nursing care plans facilitate the coordination of care by making known to other
members of the health team what the nurse is doing.

Steps in Developing Care Plan
1. The prioritized conditions of the problem
2. Goals and objectives of the nursing care
3. The plan of interventions
4. The plan for evaluating care

Prioritizing Health Problems
108


Four Criteria for Determining Priorities:
1. Nature of the condition or problem categorized into wellness state/potential,
health threat, health deficit of foreseeable crisis.
2. Modifiability of the condition or problem-refers to the probability of success in
enhancing the wellness state improving the condition minimizing, alleviating or
totally eradicating the problem through intervention.
3. Preventive potential-refers to the nature and magnitude of future problem that
can be minimized or totally prevented if interventions are done on the condition
or problem under consideration.
4. Salience-refers to the familys perception and evaluation of the condition or
problem in terms of seriousness and urgency of attention needed or family
readiness.
Factors Affecting Priority Setting
Nature of the problem
The biggest weight is given to the wellness state or potential because of the
premium on clients effort or desire to sustain/maintain high level of wellness.
The same weight is given to health deficit because of its sense of clinical
urgency, which may require immediate intervention.
Foreseeable crisis is given the least weight because culture linked
variables/factors usually provide our families with adequate support to cope with
developmental or situational crisis.
Modifiability if the problem
Current knowledge, technology and interventions to enhance the wellness state
or manage the problem.
Resources of the family
Resources of the nurse
Resources of the community
Preventive potential
Gravity or severity of the problem-refers to the progress of the
disease/problem indicating extent of damage on the patient/family; also indicates
prognosis, reversibility or modifiability of the problem. In general, the more
severe the problem is, the lower is the preventive potential of the problem.
Duration of the problem-refers to the length of time the problem has existed.
Generally speaking, duration of the problem has a direct relationship to gravity;
the nature of the problem is variable that may, however, alter this relationship.
Because of this relationship to gravity of the problem, duration has also a direct
relationship to preventive potential.
Current management-refers to the presence and appropriateness of
intervention measures instituted to enhance the wellness state or remedy the
109

problem. The institution of appropriate intervention increases conditions
preventive potential.
Exposure of any vulnerable or high risk group-increases the preventive
potential of condition or problem

SCALE FOR RANKING HEALTH CONDITIONS AND PROBLEMS ACCDG. TO
PRIORITIES
CRITERIA WEIGHT

1. Nature of the condition or problem presented
Scale **
Wellness state
Health deficit
Health threat
Foreseeable crisis

2. Modifiability of the condition or problem
Scale**
Easily modifiable
Partially modifiable
Not modifiable

3. Preventive potential
Scale**
High
Moderate
Low
4. Salience
Scale**
A condition or problem needing immediate attention
A condition or problem not needing immediate attention
Not perceived as a problem or condition needing change


3
3
2
1




2
1
0



3
2
1


2
1
0

1






2





1




1
Scoring:
110

1. Decide of the score of each of the criteria
2. Divide the score by the highest possible score and multiply by the weight: (Score/ Highest
Score) X Weight
3. Sum up scores for all the criteria. The highest score is 5, equivalent to the total weight.

Formulation of Goals and Objectives
GOAL-is a general statement of condition or state to be brought about by specific
courses of action.
OBJECTIVE-refers to a more specific statement of the desired results or
outcomes of care. They specify the criteria by which the degree of effectiveness
of care is to be measured.
*A cardinal principle in goal setting states that goal must be set jointly with the family.
This ensures family commitment to realization.
* Basic to the establishment of mutually acceptable goals is the familys recognition and
acceptance of existing health needs and problems.

Barriers to Joint Goal Setting Between the Nurse and the Family:
1. Failure on the part of the family to perceive the existence of the problem.
2. The family may realize the existence of the health condition or problem but is too
busy at the moment.
3. Sometimes the family perceives the existence of the problem but does not see it
as serious enough to warrant attention.
4. The family may perceive the presence of the problem and the need to take
action. It may however refuse to face and do something about the situation.
Reasons to this kind of behavior:

a. Fear of consequences of taking actions.
b. Respect for tradition.
c. Failure to perceive the benefits of action.
d. Failure to relate the proposed action to the familys goals.

5. A big barrier to collaborative goal setting between the nurse and the family is the
working relationship.


Focus on Interventions to Help The Family Performs Health Tasks:
1. Help the family recognize the problem
o Increasing the familys knowledge on the nature, magnitude and cause of
the problem.
111

o Helping the family see the implications of the situation or the
consequences of the condition.
o Relating the health needs to the goals of the family.
o Encouraging positive or wholesome emotional attitude toward the
problem by affirming the
familys capabilities/qualities/resources and providing
information on available actions.
2. Guide the family on how to decide on appropriate health actions to take.
o Identifying or exploring with the family courses of action available and the
resources needed for each.
o Discussing the consequences of action available.
o Analyzing with the family of the consequences of inaction.
3. Develop the familys ability and commitment to provide nursing care to each
member.
o Contracting-is a creative intervention that can maximize the opportunities
to develop the ability and commitment of the family to provide nursing
care to its members.
4. Enhance the capability of the family to provide home environment conducive to
health maintenance and personal development.
o The family can be taught specific competencies to ensure such home
environment through environmental manipulation or management to
minimize or eliminate health threats or risks or to install facilities of
nursing care.
5. Facilitate the familys capability to utilize community resources for health care.
o Involves maximum use of available resources through the coordination,
collaboration and teamwork provided by effective referral system.

Criteria for Selecting the Type of Nurse Family Contact
1. Effectivity
2. Efficiency
3. Appropriateness
Types of Nurse Family Contact

Home Visit
While it is expensive in terms of time, effort and logistics for the nurse, it is an
effective and appropriate type of family nurse contact if the objectives and
outcomes of care require accurate appraisal of family relationship, home and
environment and family competencies. i.e. The best opportunity to serve the
actual care given by family members.
Clinic or Office Conference
It is less expensive for the nurse and provides the opportunity to use equipment
that cant be taken to the home. In some cases, the other team members in the
clinic may be consulted or called in to provide additional service.
112

Telephone Conference
May be effective, efficient, and appropriate if the objectives and outcomes of care
require immediate access to data given problems on distance or travel time.
Such data include monitoring of health status or progress during the acute phase
of an illness state, change in schedule of visit or family decision, and updates on
outcomes or responses to care and treatment.
Written Communication
It is another less time consuming option for the nurse in instances when there are
large number of families needing follow-up on top of problems of distance or
travel time.
School Visit or Conference
It is done to work with family and school authorities on how to appraise the
degree of vulnerability of and worked out interventions to help children and
adolescence on specific health risks, hazards or adjustment problems.
Industrial or Job Site Visit
It is done when the nurse and family need to make an accurate assessment of
health risks or hazards and work with employer or supervisor on what can be
done to improve on provisions for health and safety of workers.

Implementing the Nursing Care Plan
During this phase, the nurse encounters the realities in family nursing practice
that motivates her to try out creative innovations or overwhelm her to frustration
or inaction. A dynamic attitude on personal and professional development is,
therefore, necessary if she has to face up challenges of nursing practice.
Implementation Phase: A Phenomenological Experience
Meeting the challenges of this phase is the essence of family nursing practice.
During this phase, the nurse experiences with the family a lived meaningful world
of mutual, dynamic interchange of meanings, concerns, perceptions, biases,
emotions and skills. Just as the self aims to achieve body-mind integration to
achieve wholeness in the experience of being and becoming in expert caring.
Unless there is such a dynamic and active involvement between the nurse and
the family in understanding and making choices in this meaningful world of
coping, aspirations, emotions and skills the nurse cant hope to achieve expert
caring.
Expert Caring: Methods and Possibilities
113

Expert caring in the implementation phase is demonstrated phase is
demonstrated when the nurse carries out interventions based on the familys
understanding of the lived experience of coping and being in the world. Expert
caring is developing the capability of the family for engage care through the
nurses skilled practice, the family learns to choose and carry out the best
possibilities of caring given the meanings, concerns, emotions and
resources(skills & equipments) as experienced in the situation. While the
challenge for expert caring is a reality, the nurse is enriched as a result of such
an experience (Benner & Wrubel 1989).
By being experts in caring, nurses must takeover and transform the notions of
expertise. Expert caring has nothing to do with possessing privileged information
that increases ones control and domination of another. Rather, expert caring
unleashes the possibilities inherent in the self and the situation. Expert caring
liberates and facilitates in such a way that the one caring is enriched in the
process.
While expert caring does not happen overnight to the novice nurse, there are
methods and possibilities that can enhance learning towards expert caring. Such
methods and possibilities need to be carried out and experienced in real contexts
and real relationships to achieve skillfully comportment and excellence in the
current situation.
Two such major methods and possibilities:
1. Performance-focus learning through competency-based teaching
2. Maximizing caring possibilities for personal and professional development
Competency-Based Teaching
A substantive part of the implementation phase is directed towards developing
the familys competencies to perform the health tasks. Competencies include the
cognitive (knowledge), psychomotor (skills) and attitudinal or affective(emotions,
feelings, values). The following are examples of these family health
competencies using the corresponding health task in our case illustration:
Health Task: The family recognizes the possibility of cross-infection of scabies to
other family members.
Cognitive Competency:
1. The family explains the cause of scabies
2. The family enumerates ways by which cross-infection of scabies can occur
among the family members.
3. Health Task: The family provides a home environment conducive to health
maintenance and personal development of its members.
Psychomotor Competency:
The family carries out the agreed-upon measures to improve home sanitation
and personal hygiene of family members.
Health Task: The family decides to take appropriate health action.
114

Attitudinal or Affective Competencies:
1. Family members express feelings or emotions that act as barriers to decision-
making
2. Family members acknowledge the existence of these feelings or emotions.
o In order to systematically work towards development of the familys
competencies, such competencies need to be explicitly defined. Cognitive
and psychomotor competencies are reflected explicitly as objectives in
the family nursing care plan. The attitudinal or affective competencies
may also be translated into objective of care as feelings, emotions or
philosophy in life that enhance the familys desire or commitment to
behavior change and sustain the needed action.
Learning Principles and Teaching- Learning Methods and Techniques that the
Nurse Can Use in Competency-Based Teaching:
1. Learning is both intellectual and emotional process.
2. Learning is facilitated when experience has meaning.
3. Learning is individual matter.
Learning is Both Intellectual and Emotional Process
Six General Methods and Techniques:
1. Provide information to shape attitude
2. Provide experiential learning activities to shape attitudes
3. Provide examples or models to shape attitudes
4. Providing opportunities for small group discussion
5. Role playing exercises
6. Explore the benefits of power of silence
Learning is Facilitated When Experience Has Meaning
1. Analyze and process family members all teaching-learning based on their grasp
on the live experience of the situation in terms of the meaning for the self.
2. Involve the family actively in determining areas for teaching-learning based on
the health tasks that members made to perform.
3. Used examples or illustrations that the family is familiar with.
Learning is Individual Matter: Ensure Mastery of Competencies for Sustained
Actions:
Some Techniques to Develop Mastery:
1. Make the learning active by providing opportunities for the family to do specific
activities, answer questions or apply learning in solving problems.
2. Ensure clarity. Use words, examples, visual materials and handouts that the
family can understand.
3. Ensure adequate evaluation, feedback, monitoring and support for sustained
action by:
115

o Explaining well how the family is doing
o Giving the necessary affirmations or reassurances
o Explaining how the skill can be improved
Exploring with the family how modifications can be carried out to maximize situated
possibilities or best options.

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE
A. Family Structure Characteristics and Dynamics
1. Members of the household and relationship to the head of the family.
2. Demographic data-age, sex, civil status, position in the family
3. Place of residence of each member-whether living with the family or elsewhere
4. Type of family structure-e.g. patriarchal, matriarchal, nuclear or extended
5. Dominant family members in terms of decision making especially on matters of
health care
6. General family relationship/dynamics-presence of any obvious/readily observable
conflict between members; characteristics, communication/interaction patterns
among members.

B. Socio-economic and Cultural Characteristics

1. Income and expenses

a. Occupation, place of work and income of each working member
b. Adequacy to meet basic necessities (food, clothing, shelter)
c. Who makes decision about money and how it is spent

2. Educational Attainment of each Member
3. Ethnic Background and Religious Affiliation
4. Significant others-role (s) they play in familys life
5. Relationship of the family to larger community-nature and extent of participation of
the family in community activities


C. Home Environment

1. Housing

a. Adequacy of living space
b. Sleeping in arrangement
c. Presence of breathing or resting sites of vector of diseases (e.g. mosquitoes,
roaches, flies, rodents, etc.)
d. Presence of accident hazard
116

e. Food storage and cooking facilities
f. Water supply-source, ownership, pot ability
g. Toilet facilities-type, ownership, sanitary condition
h. Garbage/refuse disposal-type, sanitary condition
i. Drainage System-type, sanitary condition

2. Kind of Neighborhood, e.g. congested, slum etc.
3. Social and Health facilities available
4. Communication and transportation facilities available


D. Health Status of Each Family Member
1. Medical Nursing history indicating current or past significant illnesses or beliefs
and practices conducive to health and illness
2. Nutritional assessment (especially for vulnerable or at risk members)
o Anthropometric data: measures of nutritional status of children-weight,
height, mid-upper arm circumference; risk assessment measures for
obesity : body mass index(BMI=weight in kgs. divided by height in
meters2), waist circumference (WC: greater than 90 cm. in men and
greater than 80 cm. in women), waist hip ration (WHR=waist
circumference in cm. divided by hip circumference in cm. Central obesity:
WHR is equal to or greater than 1.0 cm in men and 0.85 in women)
o dietary history specifying quality and quantity of food or nutrient per day
o Eating/ feeding habits/ practices
3. Developmental assessment of infant, toddlers and preschoolers- e.g. Metro
Manila DevelopmentalScreening Test (MMDST).
4. Risk factor assessment indicating presence of major and contributing modifiable
risk factors for specific lifestyle diseases-e.g. hypertension, physical inactivity,
sedentary lifestyle, cigarette/ tobacco smoking, elevated blood lipids/
cholesterol, obesity, diabetes mellitus, inadequate fiber intake, stress,
alcohol drinking, and other substance abuse.
5. Physical Assessment indicating presence of illness state/s (diagnosed or
undiagnosed by medical practitioners )
6. Results of laboratory/diagnostic and other screening procedures supportive of
assessment findings.
E. Values, Habits, Practices on Health Promotion, Maintenance and Disease
Prevention. Examples include:

1. Immunization status of family members
2. Healthy lifestyle practices. Specify.
3. Adequacy of:
Rest and sleep
Exercise/activities
Use of protective measure-e.g. adequate footwear in parasite-infested areas; use
of bed nets andprotective clothing in malaria and filariasis endemic areas.
117

Relaxation and other stress management activities
4. Use of promotive-preventive health services

A TYPOLOGY OF NURSING PROBLEMS IN FAMILY NURSING
PRACTICE
First Level Assessment

I. Presence of Wellness Condition-stated as potential or Readiness-a clinical or
nursing judgment about a client in transition from a specific level of wellness or capability
to a higher level. Wellness potential is a nursing judgment on wellness state or condition
based on clients performance, current competencies, or performance, clinical data or
explicit expression of desire to achieve a higher level of state or function in a specific
area on health promotion and maintenance. Examples of this are the following

A. Potential for Enhanced Capability for:
1. Healthy lifestyle-e.g. nutrition/diet, exercise/activity
2. Healthy maintenance/health management
3. Parenting
4. Breastfeeding
5. Spiritual well-being-process of clients developing/unfolding of mystery through
harmonious interconnectedness that comes from inner strength/sacred
source/God (NANDA 2001)
6. Others. Specify.
B. Readiness for Enhanced Capability for:
1. Healthy lifestyle
2. Health maintenance/health management
3. Parenting
4. Breastfeeding
5. Spiritual well-being
6. Others. Specify.
II. Presence of Health Threats-conditions that are conducive to disease and accident,
or may result to failure to maintain wellness or realize health potential. Examples of this
are the following:

A. Presence of risk factors of specific diseases (e.g. lifestyle diseases, metabolic
syndrome)

B. Threat of cross infection from communicable disease case

118

C. Family size beyond what family resources can adequately provide

D. Accident hazards specify.
1. Broken chairs
2. Pointed /sharp objects, poisons and medicines improperly kept
3. Fire hazards
4. Fall hazards
5. Others specify.
E. Faulty/unhealthful nutritional/eating habits or feeding techniques/practices. Specify.
1. Inadequate food intake both in quality and quantity
2. Excessive intake of certain nutrients
3. Faulty eating habits
4. Ineffective breastfeeding
5. Faulty feeding techniques
F. Stress Provoking Factors. Specify.
1. Strained marital relationship
2. Strained parent-sibling relationship
3. Interpersonal conflicts between family members
4. Care-giving burden
G. Poor Home/Environmental Condition/Sanitation. Specify.
1. Inadequate living space
2. Lack of food storage facilities
3. Polluted water supply
4. Presence of breeding or resting sights of vectors of diseases
5. Improper garbage/refuse disposal
6. Unsanitary waste disposal
7. Improper drainage system
8. Poor lightning and ventilation
9. Noise pollution
10. Air pollution
H. Unsanitary Food Handling and Preparation

I. Unhealthy Lifestyle and Personal Habits/Practices. Specify.
1. Alcohol drinking
2. Cigarette/tobacco smoking
3. Walking barefooted or inadequate footwear
4. Eating raw meat or fish
5. Poor personal hygiene
6. Self medication/substance abuse
119

7. Sexual promiscuity
8. Engaging in dangerous sports
9. Inadequate rest or sleep
10. Lack of /inadequate exercise/physical activity
11. Lack of/relaxation activities
12. Non use of self-protection measures (e.g. non use of bed nets in malaria and
filariasis endemic areas).
J. Inherent Personal Characteristics-e.g. poor impulse control

K. Health History, which may Participate/Induce the Occurrence of Health Deficit, e.g.
previous history of difficult labor.

L. Inappropriate Role Assumption- e.g. child assuming mothers role, father not
assuming his role.

M. Lack of Immunization/Inadequate Immunization Status Specially of Children

N. Family Disunity-e.g.
1. Self-oriented behavior of member(s)
2. Unresolved conflicts of member(s)
3. Intolerable disagreement
O. Others. Specify._________

III. Presence of health deficits-instances of failure in health maintenance.

Examples include:

A. Illness states, regardless of whether it is diagnosed or undiagnosed by medical
practitioner.

B. Failure to thrive/develop according to normal rate

C. Disability-whether congenital or arising from illness; transient/temporary (e.g. aphasia
or temporary paralysis after a CVA) or permanent (e.g. leg amputation secondary to
diabetes, blindness from measles, lameness from polio)

IV. Presence of stress points/foreseeable crisis situations-anticipated periods of
unusual demand on the individual or family in terms of adjustment/family resources.
Examples of this include:

A. Marriage
B. Pregnancy, labor, puerperium
C. Parenthood
120

D. Additional member-e.g. newborn, lodger
E. Abortion
F. Entrance at school
G. Adolescence
H. Divorce or separation
I. Menopause
J. Loss of job
K. Hospitalization of a family member
L. Death of a member
M. Resettlement in a new community
N. Illegitimacy
O. Others, specify.___________

Second-Level Assessment

I. Inability to recognize the presence of the condition or problem due to:

A. Lack of or inadequate knowledge

B. Denial about its existence or severity as a result of fear of consequences of diagnosis
of problem, specifically:
1. Social-stigma, loss of respect of peer/significant others
2. Economic/cost implications
3. Physical consequences
4. Emotional/psychological issues/concerns
C. Attitude/Philosophy in life, which hinders recognition/acceptance of a problem

D. Others. Specify _________

II. Inability to make decisions with respect to taking appropriate health action due
to:

A. Failure to comprehend the nature/magnitude of the problem/condition

B. Low salience of the problem/condition

C. Feeling of confusion, helplessness and/or resignation brought about by perceive
magnitude/severity of the situation or problem, i.e. failure to breakdown problems into
manageable units of attack.

D. Lack of/inadequate knowledge/insight as to alternative courses of action open to
them

121

E. Inability to decide which action to take from among a list of alternatives

F. Conflicting opinions among family members/significant others regarding action to
take.

G. Lack of/inadequate knowledge of community resources for care

H. Fear of consequences of action, specifically:
1. Social consequences
2. Economic consequences
3. Physical consequences
4. Emotional/psychological consequences
I. Negative attitude towards the health condition or problem-by negative attitude is meant
one that interferes with rational decision-making.

J. In accessibility of appropriate resources for care, specifically:
1. Physical Inaccessibility
2. Costs constraints or economic/financial inaccessibility
K. Lack of trust/confidence in the health personnel/agency

L. Misconceptions or erroneous information about proposed course(s) of action

M. Others specify._________

III. Inability to provide adequate nursing care to the sick, disabled, dependent or
vulnerable/at risk member of the family due to:

A. Lack of/inadequate knowledge about the disease/health condition (nature, severity,
complications, prognosis and management)

B. Lack of/inadequate knowledge about child development and care

C. Lack of/inadequate knowledge of the nature or extent of nursing care needed

D. Lack of the necessary facilities, equipment and supplies of care

E. Lack of/inadequate knowledge or skill in carrying out the necessary intervention or
treatment/procedure of care (i.e. complex therapeutic regimen or healthy lifestyle
program).

F. Inadequate family resources of care specifically:
122

1. Absence of responsible member
2. Financial constraints
3. Limitation of luck/lack of physical resources
G. Significant persons unexpressed feelings (e.g. hostility/anger, guilt, fear/anxiety,
despair, rejection) which his/her capacities to provide care.

H. Philosophy in life which negates/hinder caring for the sick, disabled, dependent,
vulnerable/at risk member

I. Members preoccupation with on concerns/interests

J. Prolonged disease or disabilities, which exhaust supportive capacity of family
members.

K. Altered role performance, specify.
1. Role denials or ambivalence
2. Role strain
3. Role dissatisfaction
4. Role conflict
5. Role confusion
6. Role overload
L. Others. Specify._________

IV. Inability to provide a home environment conducive to health maintenance and
personal development due to:

A. Inadequate family resources specifically:
1. Financial constraints/limited financial resources
2. Limited physical resources-e.i. lack of space to construct facility
B. Failure to see benefits (specifically long term ones) of investments in home
environment improvement

C. Lack of/inadequate knowledge of importance of hygiene and sanitation

D. Lack of/inadequate knowledge of preventive measures

E. Lack of skill in carrying out measures to improve home environment

F. Ineffective communication pattern within the family

G. Lack of supportive relationship among family members
123


H. Negative attitudes/philosophy in life which is not conducive to health maintenance
and personal development

I. Lack of/inadequate competencies in relating to each other for mutual growth and
maturation (e.g. reduced ability to meet the physical and psychological needs of other
members as a result of familys preoccupation with current problem or condition.

J. Others specify._________

V. Failure to utilize community resources for health care due to:

A. Lack of/inadequate knowledge of community resources for health care

B. Failure to perceive the benefits of health care/services

C. Lack of trust/confidence in the agency/personnel

D. Previous unpleasant experience with health worker

E. Fear of consequences of action (preventive, diagnostic, therapeutic, rehabilitative)
specifically :
1. Physical/psychological consequences
2. Financial consequences
3. Social consequences
F. Unavailability of required care/services

G. Inaccessibility of required services due to:
1. Cost constrains
2. Physical inaccessibility
H. Lack of or inadequate family resources, specifically
1. Manpower resources, e.g. baby sitter
2. Financial resources, cost of medicines prescribe
I. Feeling of alienation to/lack of support from the community, e.g. stigma due to mental
illness, AIDS, etc.

J. Negative attitude/ philosophy in life which hinders effective/maximum utilization of
community resources for health care
124


K. Others, specify __________

FAMILY NURSING CARE PLAN (FNCP)
Definition
Is the blueprint of the care that the nurse designs to systematically minimize or
eliminate the identified health and family nursing problems through explicitly
formulated outcomes of care (goals and objectives) and deliberately chosen set
of interventions, resources and evaluation criteria, standards, methods and
tools.
Features FNCP
1. The nursing care plan focuses on actions which are designed to solve or
minimize existing problem. The plan is a blueprint for action. The cores of the
plan are the approaches, strategies, activities, methods and materials which the
nurse hopes will improve the problem situation.
2. The nursing care plan is a product of a deliberate systematic process. The
planning process is characterized by logical analyses of data that are put
together to arrive at rational decisions. The interventions the nurse decides to
implement are chosen from among alternatives after careful analysis and
weighing of available options.
3. The nursing care plan, as with all plans, relates to the future. It utilizes events in
the past and what is happening in the present to determine patterns. It also
projects the future scenario if the current situation is not corrected.
4. The nursing care plan is based upon identified health and nursing problems. The
problems are the starting points for the plan, and the foci of the objectives of care
and intervention measures.
5. The nursing care plan is a means to an end, not an end in itself. The goal in
planning is to deliver the most appropriate care to the client by eliminating
barriers to family health development.
6. Nursing care planning is a continuous process, not a one-shot-deal. The results
of the evaluation of the plans effectiveness trigger another cycle of the planning
process until the health and nursing problems are eliminated.

Steps in Making Family Nursing Care Plan
The assessment phase of the nursing process generates the health and nursing
problems which become the bases for the development of nursing care plan. The
planning phase takes off from there.
Formulating a family care plan involves the following steps:
1. The prioritized condition/s or problems
125

2. The goals and objectives of nursing care
3. the plan of interventions
4. The plan of evaluating care


This is a schematic presentation of the nursing care plan process. It starts with a list of
health condition or problems prioritized according to the nature, modifiability, preventive
potential and salience. The prioritized health condition or problems and their
corresponding nursing problems become the basis for the next step which is the
formulation of goals and objectives of nursing care. The goals and objectives specify the
expected health/clinical outcomes, family response/s, behavior of competency
outcomes.


126


UNIT V: CARING
The definition or meaning of caring is to feel and exhibit concern and empathy for
others. To treat other people with respect, and treat them like a human being.
When you show compassion
The term indirect care is used in reference to services that are concerned with
patient care but do not need contact or interaction between the patient and the
health care provider. Examples include scheduling and charting.
'Direct care' is care that is directly to the patient, this may even be on a one-to-
one basis, where care is provided directly to the patient
A caring person is someone who has both empathy and sympathy for those
around them. A caring person will go out of their way to make sure someone else
is alright physically and emotionally.
HEALTH-CARE PROVIDERS
Include therapists in all disciplines, from psychiatric to speech. Occupational and
physical therapists also provide care to patients.

THEORIES AND
AUTHOR
PROPOSITION/IDEA ASSUMPTION DEVELOPED
SKILLS
1. CULTURE
CARE
DIVERSITY AND
UNIVERSALITY
(madeleine.
Leininger)
Caring is essence of nursing
and is the distinct, central,
unifying form of control.
trans-cultural nursing
focuses on both
differences and similarities
among persons in diverse
cultures

Nurses must
understand
different cultures
in order to
function
effectively.
Culturally-
congruent care:
By preserving
clients familiar
life-ways
By re-patterning
nursing care to
help client move
toward wellness
By making
accommodations
in caring that is
satisfying to
client.
2. THEORY OF
BUREAUCRATI
C CARING
(Marilyn Anne
ray)

caring in nursing is contextual
and is influenced by
organizational structure.
Spiritual-ethical caring for
nursing does not question
whether or not to care in
complex systems, but
intimates how sincere
deliberations ad ultimately
the facilitation of choices
for the good of others can
or should be accomplished
Spiritual ethical
caring influences
each of the aspects
of the bureaucratic
system:

*political
*economic
*physical
*socio-cultural
*technological
*legal
*educational
127

3. CARING, THE
HUMAN MODE
OF BEING
(m. Simone roach)
Caring is the most common,
authentic criterion of
humanness.
Caring is not unique in
nursing, because
caring is the center of
all attributes used to
describe nursing.

Six Cs of caring in
nursing:
*compassion
*conscience
*competence
*commitment
*comportment
*confidence
4. NURSING AS
CARING
(Anne Boykin and
savinas
choenhofer)
caring is an altruistic, active
expression of love, intentional
and embodied recognition of
value and correctedness.
Purpose of profession
of nursing is to know
the persons and
nurture them as
persons living and
growing in care
1. Respect
of
personas
caring
individual
2. respect of
what
matters to
them

Knowing self as a
caring person,
nurse can be
authentic to self,
freeing oneself to
truly be with others.

5. THEORY OF
HUMAN CARE
(Jean Watson)
caring is essence of nursing
and moral ideal of nursing.
Caring is the moral ideal
of nursing whereby the end
is protection, enhancement
and preservation of human
dignity
Human care is basis for
nursings role in
society. Therefore,
nursings contribution to
society lies in its moral
commitment to human
care.
Emphasizes
nursings
commitment to
care of the whole
person as well as
a concern for
health of
individuals and
groups
The two individuals
(nurse and client) in
a caring transaction
are both in a
process of being
and becoming.
6. THEORY OF
CARING
(Kristen
Swanson)
caring is nurturing way of
relating to a valued other
toward one whom one feels a
personal sense of commitment
and responsibility.
It focuses on the caring
processes as nursing
interventions

A clients well
being should be
enhanced by
caring nurse who
understands
common human
responses to
specific health
problem
Caring processes
and sub dimensions
:knowing being with
doing for enabling
maintaining belief
7. THE PRIMACY
OF CARING
(Patricia Benner
and Judith Wrubel)
Caring is primary because it
sets up the possibility of giving
and receiving help.
Caring practice
requires attending to
the particular client
over time, determining
what matters to the
A caring
relationship
requires a certain
amount of
openness and
capacity to
respond to care
on the part of the

128

person, and using this
knowledge in
clinical judgments.

client. A caring
practice involves
client advocacy
and provides the
necessary
conditions to help
the client grow
and develop.

Watsons 10 Carative Factors (McCance, McKenna, and Boore 1999)

1. Humanistic-altruistic system of values
2. Faith-hope
3. Sensitivity to self and others
4. Helping-trusting, human care relationship
5. Expressing positive and negative feelings
6. Creative problem-solving caring process
7. Transpersonal teaching-learning
8. Supportive, protective, and/or corrective mental, physical, societal and spiritual
environment
9. Human needs assistance
10. Existential-phenomenological-spiritual forces

RN JOURNAL
Caring and nursing have always been thought of synonymously. Most individuals choose
nursing as a profession because of their desire to care for other individuals. Caring as a
central concept has led to the development of several caring theories. Two well known
theories were developed in the 1970s, Leiningers Theory of cultural care and Jean
Watsons Theory of human caring (McCance, McKenna, Boore 1999).

Jean Watson defines caring as a science. She states; Caring is a science that
encompasses a humanitarian, human science orientation, human caring processes,
phenomena, and experiences. Caring science includes arts and humanities as well as
science. A caring science perspective is grounded in a relational ontology of being-in-
relation, and a world view of unity and connectedness of all. Transpersonal Caring
acknowledges unity of life and connections that move in concentric circles of caring-from
individual, to others, to community, to world, to Planet Earth, to the universe. Caring
science investigations embrace inquiry that are reflective, subjective and interpretative
as well as objective-empirical; Caring science inquiry includes ontological, philosophical,
ethical, historical inquiry and studies. In addition, caring science includes multiple
epistemological approaches to inquiry including clinical and empirical, but is open to
moving into new areas of inquiry that explore other ways of knowing, for example,
129

aesthetic, poetic, narrative, personal, intuitive, kinesthetic, evolving consciousness,
intentionality, metaphysical-spiritual, as well as moral-ethical knowing. Caring science is
an evolving new field that is grounded in the discipline of nursing and evolving nursing
science, but more recently includes other fields and disciplines in the Academy, for
example, Women/Feminist studies, Education, Ecology, Peace Studies,
Philosophy/Ethics, Arts and Humanities, Mindbodyspirit Medicine. As such, caring
science is rapidly becoming an Interdisciplinary Transdisciplinary field of study. It has
relevance to all the health, education human service fields and professions (Watson
2003).

Caring behaviors are defined as; Behaviors evidenced by nurses in caring for patients.
The top ten caring behaviors, derived from nursing literature are; attentive listening,
comforting, honesty, patience, responsibility, providing information so the patient can
make an informed decision, touch, sensitivity, respect, calling the patient by name
(Tabers 1993).


Some Caring behaviors are evident in other professions. Law enforcement is noted for
their honesty and respect. Psychologists are comforting and require attentive listening
skills to help their patients. Teachers must possess patience, attentive listening,
sensitivity, and great responsibility to mold our children into productive adults. The lists
of professions are endless.

Madeleine Leininger subscribed to the central tenet that care is the essence of nursing
and the central, dominant, and unifying focus of nursing (Leininger 1991). Watson
describes nursing as a human science, with the major focus being the process of human
care for individuals, families, and groups. Her theory is based on a form of humanism
and has its origins in metaphysics (philosophy of being and knowing) (McCance,
Mckenna, Boore 1999).

The goal of nursing with Watsons theory is centered around helping the patient gain a
higher degree of harmony within the mind, body, and soul. It is achieved through caring
transactions. Watsons ten carative factors, referred to as interventions of the theory, are
presented in table one. (McCance, McKenna, Boore 1999). It also involves the
transpersonal caring relationship. Transpersonal caring is demonstrated in an event or
actual caring occasion.

Transpersonal conveys a concern for the inner life. The patient is viewed as whole and
complete, regardless of illness or disease (Watson 2003). The transpersonal nurse
seeks to connect with, embrace the spirit or soul of the patient, through the processes of
caring and healing (Watson 2003).


130

Caring in the nursing profession takes place every time a nurse-to-patient contact is
made. The nurse enters the world of the patient in order to come to know the patient as
a caring person, and that it is from this epistemology that the caring of nursing unfolds
(Schoenhofer 2002). That caring makes a difference to the patients sense of well being.
Caring may occur without curing but curing cannot occur without caring (Watson 2003).

It is with that belief that nurses care for patients in the hope that we contribute to the
cure or wellbeing of that patient.

Hope and commitment are ingredients of caring. Hope is described as more than mere
wishful thinking, but as an awareness of the moment alive with possibilities
(Schoenhofer 2002).
Hope may be the only crutch a patient has to keep their optimism. Nurses care enough
to honor that hope and support the patient. We view that patient as whole and complete.
The second carative factor of Jean Watsons ten carative factors is faith-hope (see table
one).

Hope is guided by our commitment as nurses to our patients. It is also clouded with
preconceived beliefs and morals that we are reared with.

I am a field nurse in a for-profit hospice organization. Caring is a central concept to the
delivery of hospice care. The patients we encounter are in a variety of settings, such as,
own home, nursing home, retirement center, family home, or a friends home. They are
often frightened with the knowledge of their imminent death and in unfamiliar
surroundings. They rely on the nurse and the delivery of care to help them feel physically
better.

As a hospice nurse we also view the patient as a spiritual being. That means reaching
out to the patient and forming a deeper connection to the spiritual self. It means
becoming one.

The one caring and the one being cared for are interconnected (Watson 1997). Its
experiencing human connection at a deeper level than a physical interaction (Watson
2003)

The nurse must have an inner peace with her own mortality. The nurse must be
comfortable with death and dying and possess a deep understanding and acceptance of
all life cycles and be prepared for their own death (Watson 2002). Caring is directed to a
pain free death with dignity and a belief of a spiritual transformation or journey after
death.
Caring centers on the person, preserving dignity and humanity. It is a commitment to
alleviate anothers vulnerabilities by providing attention and concern for each human life
(Watson 2002). Hospice is holistic focused caring. Our goal is to offer the dying patient
the opportunity to die in the comfort of their own home surrounded by those who care.
131

The dying patient in the nursing home is offered the opportunity to die with a caring
nurse holding their hand. Often the nursing home patient has no family or living relatives
that can share in the dying experience. The hospice nurse will be the one to care for the
dying patient and ease his journey. This relates to the carative factor number eight of
Jean Watsons ten carative factors, it states; supportive, protective, and/or corrective
mental, physical, societal and spiritual environment, and that is what we hope to achieve
with the dying patient (see table one).
Hospice also cares for the family. Caring approaches to nursing affect the nurse and the
family being cared for. This can be very challenging with dysfunctional families. Our
focus is always centered on the patient while dealing with the family. We must be guided
by caring, compassion, tenderness, gentleness, loving kindness, and equanimity for self
and others.

Caring in hospice goes beyond the actual death. Bereavement contact is done on a
routine basis for a year after the death. Nurses often attend services for the deceased to
say goodbye and receive closure with that patient and family.















132

Nursing Procedures in the Community
Clinic Visit
process of checking the clients health condition in a medical clinic

Home Visit
a professional face to face contact made by the nurse with a patient or the family
to provide necessary health care activities and to further attain the objectives of
the agency

Bag Technique

Definition

Bag technique-a tool making use of public health bag through which the nurse, during his/her
home visit, can perform nursing procedures with ease and deftness, saving time and effort with
the end in view of rendering effective nursing care.

Public health bag - is an essential and indispensable equipment of the public health nurse which
he/she has to carry along when he/she goes out home visiting. It contains basic medications and
articles which are necessary for giving care.


Rationale

To render effective nursing care to clients and /or members of the family during home visit.


Principles

1. The use of the bag technique should minimize if not totally prevent the spread of infection
from individuals to families, hence, to the community.
2. Bag technique should save time and effort on the part of the nurse in the performance of
nursing procedures.
3. Bag technique should not overshadow concern for the patient rather should show the
effectiveness of total care given to an individual or family.
4. Bag technique can be performed in a variety of ways depending upon agency policies,
actual home situation, etc., as long as principles of avoiding transfer of infection is carried
out.

Special Considerations in the Use of the Bag

133

1. The bag should contain all necessary articles, supplies and equipment which may be
used to answer emergency needs.
2. The bag and its contents should be cleaned as often as possible, supplies replaced and
ready for use at any time.
3. The bag and its contents should be well protected from contact with any article in the
home of the patients. Consider the bag and its contents clean and /or sterile while any
article belonging to the patient as dirty and contaminated.
4. The arrangement of the contents of the bag should be the one most convenient to the
user to facilitate the efficiency and avoid confusion.
5. Hand washing is done as frequently as the situation calls for, helps in minimizing or
avoiding contamination of the bag and its contents.
6. The bag when used for a communicable case should be thoroughly cleaned and
disinfected before keeping and re-using.

Contents of the Bag

Paper lining
Extra paper for making bag for waste materials (paper bag)
Plastic linen/lining
Apron
Hand towel in plastic bag
Soap in soap dish
Thermometers in case [one oral and rectal]
2 pairs of scissors [1 surgical and 1 bandage]
2 pairs of forceps [ curved and straight]
Syringes [5 ml and 2 ml]
Hypodermic needles g. 19, 22, 23, 25
Sterile dressings [OS, C.B]
Sterile Cord Tie
Adhesive Plaster
Dressing [OS, cotton ball]
Alcohol lamp
Tape Measure
Babys scale
1 pair of rubber gloves
2 test tubes
Test tube holder
Medicines
o betadine
o 70% alcohol
o ophthalmic ointment (antibiotic)
o zephiran solution
o hydrogen peroxide
o spirit of ammonia
o acetic acid
o benedicts solution
Note: Blood Pressure Apparatus and Stethoscope are carried separately.
134

Steps/Procedures
Actions Rationale
1. Upon arriving at the clients home,
place the bag on the table or any flat
surface lined with paper lining, clean side
out (folded part touching the table). Put
the bags handles or strap beneath the
bag.
To protect the bag from contamination.
2. Ask for a basin of water and a glass of
water if faucet is not available. Place
these outside the work area.
To be used for handwashing.
To protect the work field from being wet.
3. Open the bag, take the linen/plastic
lining and spread over work field or area.
The paper lining, clean side out (folded
part out).
To make a non-contaminated work field or area.
4. Take out hand towel, soap dish and
apron and the place them at one corner of
the work area (within the confines of the
linen/plastic lining).
To prepare for handwashing.
5. Do handwashing. Wipe, dry with towel.
Leave the plastic wrappers of the towel in
a soap dish in the bag.
Handwashing prevents possible infection from one
care provider to the client.
6. Put on apron right side out and wrong
side with crease touching the body, sliding
the head into the neck strap. Neatly tie the
straps at the back.
To protect the nurses uniform. Keeping the crease
creates aesthetic appearance.
7. Put out things most needed for the
specific case (e.g.) thermometer, kidney
basin, cotton ball, waste paper bag) and
place at one corner of the work area.
To make them readily accessible.
8. Place waste paper bag outside of work
area.
To prevent contamination of clean area.
9. Close the bag. To give comfort and security, maintain personal
hygiene and hasten recovery.
10. Proceed to the specific nursing care or
treatment.
To prevent contamination of bag and contents.
11. After completing nursing care or
treatment, clean and alcoholize the things
used.
To protect caregiver and prevent spread of
infection to others.
12. Do handwashing again.
13. Open the bag and put back all articles
in their proper places.

14. Remove apron folding away from the
body, with soiled sidefolded inwards, and
the clean side out. Place it in the bag.

15. Fold the linen/plastic lining, clean;
place it in the bag and close the bag.

16. Make post-visit conference on matters
relevant to health care, taking anecdotal
notes preparatory to final reporting.
To be used as reference for future visit.
135

17. Make appointment for the next visit
(either home or clinic), taking note of the
date, time and purpose.
For follow-up care.

After Care

1. Before keeping all articles in the bag, clean and alcoholize them.
2. Get the bag from the table, fold the paper lining ( and insert), and place in between the
flaps and cover the bag.

Evaluation and Documentation

1. Record all relevant findings about the client and members of the family.
2. Take note of environmental factors which affect the clients/family health.
3. Include quality of nurse-patient relationship.
4. Assess effectiveness of nursing care provided.



Thermometer Technique
to assess the clients health condition through body temperature reading

Nursing Care in the Home
giving to the individual patient the nursing care required by his/her specific illness
or trauma to help him/her reach a level of functioning at which he/she can
maintain himself/herself or die peacefully in dignity

Isolation Technique in the Home
Done by:
1. Separating the articles used by a client with communicable disease to prevent
the spread of infection:
2. Frequent washing and airing of beddings and other articles and disinfections of
room
3. Wearing a protective gown, to be used only within the room of the sick member
4. Discarding properly all nasal and throat discharges of any member sick with
communicable disease
5. Burning all soiled articles if could be or contaminated articles be boiled first in
water 30 minutes before laundering
136


Intravenous Therapy
Insertion of a needle or catheter into a vein to provide medication and fluids
based on physicians written prescription
can be done only by nurses accredited by ANSAP