PRAYER BEFORE STUDYING

Dear Lord, as I take this exam, I thank you that my value is not based on my performance, but on your
great love for me.
Come into my heart so that we can walk through this time together.
Help me not only with this test, but the many tests of life that are sure to come my way.
As I take this exam, bring back to my mind everything I studied and be gracious with what I have
overlooked. Help me to remain focused and calm,confident in the facts and in my bility, and firm in the
knowledge that no matter what happens today you are there with me. Amen

SCOPE OF NURSING LICENSURE EXAMINATION (NLE)

Nursing Board Exam/Nursing Licensure Exam Coverage (Nursing Practice I)
NURSING BOARD EXAM SCOPE/COVERAGE
NURSING PRACTICE I
TEST DESCRIPTION: Theories, concepts, principles and processes basic to the practice
of nursing with emphasis on health promotion and health maintenance. It includes basic
nursing skills in the care of clients across age groups in any setting.
Moreover, it encompasses the varied roles, functions and responsibilities of the
professional nurse in varied health care settings.
TEST SCOPE:
I. Personal and Professional Growth and Development

A. Historical Perspective in Nursing

HISTORICAL FOUNDATION OF NURSING

The Four Great Periods of Nursing

1. INTUITIVE NURSING
*This untaught nursing was instinctive.
*Dated from pre-historic times.
*Practice among primitive tribes and lasted through Christian era.
*Performed out of feeling of compassion to others.
*Out of wish to do good- HELPING

2. APPRENTICE NURSING
*Extends from the founding of religious orders in the 6th century through the
crusades which began in the 11th century to 1836.
*The Deacons School of Nursing at Kaisserwerth, Germany established by pastor
Fliedner and his wife.
*Period of on the job training- desired of person to be trained

3. EDUCATED NURSING
*Began in 1860.
*Florence Nightingale School of Nursing opened at St. Thomas in London.
First program of formal education for nurses started.
 4. CONTEMPORARY NURSING
*Began at the end of World War II (1945)
*Scientific and Technological developments of many social changes occurs.

INTUITIVE NURSING
*Cause of illness was believed to be the invasion of the victims body by an evil spirit.
*Uses black magic or voodoo to harm or driven out by using supernatural power.
*Believed in medicine man (shaman or witch doctor) that had the power to heal by using
white magic.
They made use of hypnosis, charms, dances, incantations, purgatives, massage,fire,
water, herbs or other vegetations and even animals.
*Performing a trephine
Drilling a hole in the skull with a rock or stone without benefit of anesthesia.
Goal of this therapy is to drive the evil spirit from the victims body.
*Nurses role was instinctive directive toward comforting, practicing midwifery and being
wet nurse to a child.
*Act performed without training and direction.

Babylonia
*Practice of medicine is far advanced.
*Code of Hammurabi.
-Legal and Civil measures is establish
-Regulate the practice of physicians
-Greater safety of patient provided
*No mention of Nurses or nursing this time

Egypt
*Art of embalming enhance their knowledge of human anatomy
*Developed the ability to make keen clinical observations and left a record of 250
recognized diseases.
*Control of health was in the hands of Gods. The first acknowledged physicians was
Imhotep.
*Made great progress in the field of hygiene and sanitation.
*Reference to nurses in Moses 5th book is a midwife and wet nurse.

Palestine
*The Hebrews book of genesis emphazised the teachings of Judaism regarding
hospitality to the stranger and acts of charity.
*Implementation of laws like
-controlling the spread of communicable disease
-cleanliness
-preparation of food
-purification of man (bathing and his food.
*The ritual of circumcision of the male child on the 8th day
*The established of the High Priest Aaron as the physician of people.

China
*Culture was imbued with the belief in spirits and demons.
*Gave the world the knowledge of material medica (pharmacology); method of treating
wounds, infection and muscular afflictions.
*Chan Chun Ching Chinese Hippocrates.
*Emperor Shen Nung said to be the father of Chinese medicine and the inventor of
acupuncture technique.
*No mention of nursing in Chinese writings so it is assumed that care of the sick will fall
to the female members of the household.

India
*First recorded reference to the nurses taking care of patients on the writings of
shushurutu.
*Functions and Qualifications of nurse includes:
- Knowledge in drug preparation and administration.
- Cleverness.
- Devotedness to the patient.
- Purity of both mind and body.
*King Asoke, a Buddhist, published an edict to established hospitals throughout India
where nurses were employed.

Greece
*Made contribution in the area aesthetic arts and clinical medicine, but nursing was the
task of the untrained slave.
*Aesculapius, The Father of Medicine in Greek mythology to whom we associate the
Caduceus, (known insignia of medical profession today)
*Hippocrates, the Father of Medicine insisted that magic and philosophical theories had
no place in medicine.
*The work of women was restricted to the household. Where mistress of the mansion
gave nursing care to the sick slaves.

Rome
*Acquired their knowledge of medicine from the Greeks.
*Emperor Vespasian opened schools to teach medicine.
*Developed military medicine First aid, field ambulance service and hospitals for
wounded soldiers.
*Translated Greek medical terminologies into Latin terms which has been used in
medicine ever since.

APPRENTICE NURSING
*Religious orders of Christian Church played a major role in this kind of nursing.
The Crusades (11th Century)
*Series of holy wars were conducted by Christian in an attempt to recapture the Holy land
from the Turks.
*Military religious orders founded during the crusades established hospitals and staffed
them with men who served as nurses. Among these were:
- The knights of St. John of Jerusalem served both as warriors in battle and nurses
in the hospital and was called Knights Hospitallers.
- The Teutonic Knights built hospitals cared for sick and denfended the faith.
- The Knights of St. Lazarus established primarily for the nursing of lepers,
forerunners of our now known communicable diseases hospital (also called lazarettos).

The Rise of Religious Nursing Orders

* The Regular Orders established monasteries to house travelers, paupers and patient
under one roof. Later as society became better organized hospitals tended to become
separate institutions apart from monsteries.
*The Secular Orders developed for the primary purpose of nursing; were similar to the
regular orders by their temporary vows, uniformity in dress and religious observation.
*The Nursing Orders definitely organized. The sisters advanced the stage of
probationer to wearing the white robe to receiving the hood; They were all under the
superintendent of nurses or director of nursing; later adopted a uniform dress that
eventually became entirely standardized.

Nursing Saints
* St. Hildegarde a Benedictine abbess in Germany, actually prescribed cures in her 2
books on medicine and natural history.
* St. Francis and Clara took vows of poverty, obedience, service and chastity and took
care of the sick and the afflicted; founders of the Franciscan Order and the Order of the
Poor Clares respectively.
* St. Elizabeth of Hungary the patroness of nurses; built a hospital for the sick and the
needy.
* St. Catherine of Siena the 1st lady with a lamp; became a tertiary of St. Dominic
and engaged in works of mercy among the sick and of the Church.

The Reformation
* St. Vincent de Paul set up the first program of social service in France and organized
the Community of the Sisters of Charity. His 1st superior and co-founder was Louise
de Gras (nee de Marillac).

The Intellectual Revolution (17th Century)

Characterized by the development of natural science, medicine, arts and as well as
interest in human beings and their welfare. Among the leaders for reform were:
* St. John of God founder of the Brother Hospitallers and declared the patron of all
hospitals and sick folk by Pope Leo XIII in 1930.
* George Fox founder of the sect known as the Soicety of Friends (Quakers) who
advocated equality of men and women, thus making it easier for women to become
active in Nursing.
* John Howard introduced prison reforms (fresh air and plenty of water).
* Philippe Pinel introduced his modern open-door treatment of the mentally ill.
* Elizabeth Fry greatly improved prison conditions by developing work fo the prisoners
and the segregations of sexes, later established the Insitute of Nursing sisters, the first
organization of women to be trained as private duty nurse.
* Mother Mary Catherine MccAuley founder of the Order of the Sisters of Mercy,
2nd largest of the Roman Catholic Orders.
* Theodor Fliedner and his wife Friederike Mumster established the Institute of
Kaisserwerth on the Rhine for the practical training of Deaconesses (1836), which is
considered as the 1st Organized training school for nurses. It was here where Florence
Nightingale received some of her training and the inspiration for the establishment of her
school of nursing. Some of its features includes:
1. A rotating 3 year experience in cooking and housekeeping, laundry and linen and
nursing care in the womens and mens wards; and
2. A preliminary and probationary 3 months period of trial and error for both school
and student.

The Dark Period of Nursing (17th 19th Century)

* Many hospitals were closed; the wealth took care of their sick at home; the indigent sick
were taken care of by uneducated, illiterate women who had no background for nursing.
* Charles Dickens in his book entitled Martin Chuzzleswit published the selfish and cruel
conduct of 2 private duty nurses namely Sairey Gamp and Betsy Prig.

THE PERIOD OF EDUCATED NURSING

England
* June 15, 1860 marked the day when 15 probationers entered St. Thomas Hospital
in London to establish the Nightingale system of Nursing, founded by Florence
Nightingale (May 12, 1820). Among the highlights in her life are the following:
- At age of 31, obtained parental consent to enter the Deaconess School at
Kaisserwerth.
- Had 3 months training at Kaisserwerth; later superintendent of the Establishment
for Gentlewomen During Illness (1853) during which time she initiated the policy of
admitting and visiting the patients of all faiths.
- In 1854 a Volunteered for Crimean war service together with 38 women at Scutari in
the Crimea upon the request of Sir Sidney Herbert, Minister of War in England. At first
their work is not accepted because it consisted of cleaning the area, thus reducing the
infections, clothing for the men, writing letters to their families; their work served as
inspiration for the Red Cross later on.
 - In 1860 started the Nightingale System of Nursing at the St. Thomas Hospital in
London believed that schools should be self-supporting; that schools of nursing should
have decent living quarters for their student; that they should have paid nurse
instructors; that the school should correlate theory to practice and these students should
be taught the why not just how in nursing.
- 2 books written Note on Nursing and Notes on Hospital, contain many timely
portions applicable in the 1970s as they were in 1859.

United States
* At the time that Florence Nightingale was opening her school in London; the U.S was
on the brink of the civil war. However though the country was in a condition of chaos,
nursing had many supporters and the needs to train nurses were recognized.
- Linda Richards is the first graduate nurse in the U.S completed her training at the
New England Hospital for Women and Children in Boston, Massachusetts, patterned
after the DeaconessesSchool of Kaisserwerth.
- In 1873 3 schools of nursing opened, patterned after the Nightingale plan the
Bellevue Training School for Nurse in the New York City , the Connecticut training.
School in New Haven and the Massachusetts General Hospital in Boston.
- In 1881 founding of American Red Cross by Clara Barton.
- In 1889 John Hopkins hospital opened a school of Nursing with Isabel Hampton
Robb as its 1st principal and the person most influential in directing the development of
nursing in the U.S.
- In 1893 the groundwork for the estimate of the 2 new nursing organization was
lad:
1. The Associated Alumnae, later known as the American Nurses Association was
begun at the Chicago Worlds fair and
2. The American Society of Superintendent of Training Schools for Nurses, later
known as the National League for Nursing Education, also began.
- During the Spanish American War (1898 1899) nurse were concerned with the
care of the wounded as well as care of those inflected with malaria and yellow fever.
Nurse Clara Louise Maas gave her life for the advancement of medical science in the
search for control yellow fever.

The 20th Century

*In 1900 1912
- advancement in hospital nursing, private duty nursing, public health nursing, school
nursing, government service and pre-maternal nursing;
- there was a growing awareness for the preventive measures that could be uses to
maintaing the heath of the nation;
- There was beginning specialization in medicine.

* 1913 1937
 - a standard curriculum for schools of nursing was prepared by the National League
for Nursing Education.
- the practice of nursing was gradually infiltrated with educational objectives.

* Worl War I (1917 1918)

- Private duty nurses were now nursing in the hospitals rather than in homes.
- Opening of more nursing schools as a result of the construction of more hospitals.
- Increase demand for public health nurse for preventice aspects of care.
- Awareness of the need for military ranking among nurses for which a bill was later
introduced and passed.
Julia Stimson was the first woman to hold rank of major.

* World War II (1942 1945)

- the start of Aero-medical nursing (flight nursing)
- Creation of the U.S Cadet Nurses Corps with Mrs. Lucille Ptery Leone as director
and later the 1st woman to serve as assistant surgeon of the U.S public Health Service.
- granting of permanent commissioned rank for both army and navy nurses.
- the concept of family centered care as methods to help patient help themselves.
- concept of psychosomatic medicine and early ambulation.
- consept of creative nursing, which has necessitated the need for laundering
definitive studies of all aspects of nursing thus helping to raise the standards to a
professional level.

CONTEMPORARY NURSING
* Creation of United Nations in San Francisco California in 1945.
2 folds purpose are:
- International peace and international security with provisions for equal justice,
Machinery for peaceful disputes and provisions.
- Provisions for assuring human rights, social justice and economic progress.

World Health Organization (WHO)

- Special agency of U.N, established in Geneva, Switzerland in 1948
- providing health information in fighting diseases and improving the nutrition, living
standards and environmental conditions of all people.
- Scientific and Technical Research used in disease prevention and health care.
- Social Force affecting Nursing Legislation, prepared health care, technology
efficiency and nursing involvement with minority groups.

NURSING IN THE PHILIPPINES

Early Care of the Sick

* Early life of Filipinos had been more or less mixed with superstitious belief.
- believed in the powers of witch.
- belief in the powers of herbolarios (albularyo)
* Hospitals existed as early as 15th Century, which were established by the religious and
also by Spanish administration.
* Franciscan Order is more than any other religious group. Among their early hospitals
are:

The Earliest Hospitals Established were the following:

HOSPITAL REAL de MANILA (1577) established primarily for kings soldiers and
Spanish civilians. Founded by Gov. Francisco de Sande.
SAN LAZARO HOSPITAL (1578) exclusively for the service of leprous patients.
Named after San Lazaro, patron saint of lepers. Founded by Brother Juan Clemente.
HOSPITAL de INDIOS (1586) established by the Franciscan Order: offered general
services, supported purely by alms and contributions from charitable persons.
HOSPITAL de AGUAS SANTAS (1590) convalescent hospital in Pansol, Laguna; this
was near medicinal spring, which cured several patients. Founded by Brother J. Bautista
of the Franciscan Order.
SAN JUAN de DIOS HOSPITAL (1596) founded by brotherhood of misericordia;
administered by the hospitallers of San Juan de Dios.
HOSPITAL de DULAC (1602 1603) located in Paco and existed only for 1 year.
HOSPITAL de NUEVA CACERES (1655) general hospital located in Bicol.
HOSPITAL de CONVALENSCECIA (1656) estimated by the Brotherhood of San Juan
de Dios on the little island on the Pasig River, where the Hospicio de San Jose now
stands; patients of San Juan de Dios Hospital who were in the convalescent stage were
sent there for their complete recovery.
HOSPITAL de ZAMBOANGA (1842) this is a governement military hospital run and
finance by Spanish governement.
HOSPITAL de CAVITE (1842) a general hospital estimated and managed by
Brotherhood of San Juan de Dios.
HOSPITAL de SAN GABRIEL (1866) exclusively for Chinese patients .

*Fray Juan Clemente was one of the 1st members of the Mission of the Order of St.
Francis in the Philippines in 1578.
- Collected native herbs for medicine later set a little pharmacy which he filled with
various medical remedies.
- Performed both the function of a physician and those of a nurse.
*Persons who really did nursing care of the sick were religious group (called
hospitallers) but they were assisted by Filipino attendants.
*In the early development of nursing, the work of the nurse and those of the physician
were not clearly defined.

Nursing Service during the Philippine Revolution

* The women during the Philippine revolutions took active part in nursing the wounded
soldier. They dress wounds, alleviate pains, prepared food and gave comfort even
without previous trainings.
* These were the prominent women who volunteered and gave nursing service.
Josephine Bracken wife of Jose Rizal Installed a field hospital in an estate house in
tejeros, Provided nursing care to the wounded night and day.
Mrs. Rosa Sevilla de Alvaro volunteered her service for the wounded soldier at age of
18; he work hand in hand with Dona Hilaria de Aguinaldo and they led other Filipino
women to form the Filipino Red Cross in 1899.
converted their house into quarters for the Filipino soldier, during the Philippine
American war that broke out in 1899.
Dona Hilaria de Aguinaldo wife of Emilio Aguinaldo; Organized the Filipino Red
Cross under the inspiration of Apolinario Mabini.
Dona Maria de Aguinaldo second wife of Emilio Aguinaldo. Provided nursing care for
the Filipino soldier during the revolution. President of the Filipino Red Cross branch in
Batangas.
Melchora Aquino (Tandang Sora) Nurse the wounded Filipino soldiers and gave
them shelter and food.
Captain Salome A revolutionary leader in Nueva Ecija; provided nursing care to the
wounded when not in combat.
Agueda Kahabagan Revolutionary leader in Laguna, also provided nursing services
to her troop.
Trinidad Tecson Ina ng Biac na Bato, stayed in the hospital at Biac na Bato to care
for the wounded soldier.

* The Filipino Red Cross had its own constitution approved by the revolutionary
government. This was founded on February 17, 1899 with Dona Hilaria Aguinaldo as
president and Dona Sabina Herrera as secretary.

The Rise of Hospital and Nursing Schools

*The need for hospitals, dispensaries and laboratories led to the establishement of the
Board of Health in July 1901;
*A small dispensary in Manila opened for civil officers and employees, called Civil
Hospital.
*The need for doctors and nurses to help eradicate the epidemics of cholera and
smallpox led to the employment of U.S physicians and graduate nurses.
*In 1906 the idea of training Filipino girls to become nurses intiated the growth of nursing
schools.
1. Iloilo Mission Hospital School of Nursing (Iloilo City, 1906)
- It was ran by the Baptist Foreign Mission Society of America.
- Miss Rose Nicolet, a graduate of New England Hospital for woman and children
in Boston, Massachusetts, was the first superintendent.
- Miss Flora Ernst, an American nurse, took charge of the school in 1942.

2. St. Pauls Hospital School of Nursing (Manila, 1907)

- The hospital was established by the Archbishop of Manila, The Most Reverend
Jeremiah Harty, under the supervision of the Sisters of St. Paul de Chartres.
- It was located in Intramuros and it provided general hospital services.
 -First trained nursing student graduated after 3 years.
-No standard requirements for admission except willingness to work.

3. Philippine General Hospital School of Nursing (1907)

- In 1907, with the support of the Governor General Forbes and the Director of
Health and among others, she opened classes in nursing under the auspices of
the Bureau of Education.
- Anastacia Giron-Tupas, was the first Filipino to occupy the position of chief
nurse and superintendent in the Philippines, succeeded her.

4. St. Lukes Hospital School of Nursing (Quezon City, 1907)

- The Hospital is an Episcopalian Institution. It began as a small dispensary in
1903. In 1907, the school opened with three Filipino girls admitted.
- Mrs. Vitiliana Beltran was the first Filipino superintendent of nurses.

5. Mary Johnston Hospital and School of Nursing (Manila, 1907)

- It started as a small dispensary on Calle Cervantes (now Avenida)
- It was called Bethany Dispensary and was founded by the Methodist Mission.
- Miss Librada Javelera was the first Filipino director of the school.

6. Philippine Christian Mission Institute School of Nursing.

- The United Christian Missionary of Indianapolis, operated Three schools of
Nursing:
1. Sallie Long Read Memorial Hospital School of Nursing (Laoag, Ilocos
Norte,1903)
2. Mary Chiles Hospital School of Nursing (Manila, 1911)
3. Frank Dunn Memorial Hospital

7. San Juan de Dios Hospital School of Nursing (Intramuros, Manila, 1913)

- Was destroyed during the war with a new hospital built along Dewey Boulevard.

8. Emmanuel Hospital School of Nursing (Capiz, 1913)

9. Southern Island Hospital School of Nursing (Cebu, 1918)

- The hospital was established under the Bureau of Health with Anastacia Giron-
Tupas as the organizer.

10. Zamboanga general Hospital School of Nursing (1921)

11. Chinese General Hospital School of Nursing (1921)

12. Baguio General Hospital School of Nursing (1923)

13. Manila Sanitarium and Hospital School of Nursing (1930)

14. Quezon Memorial Hospital School of Nursing (1957)

15. North General Hospital School of Nursing (1946)
16. Siliman University School of Nursing (Dumaguete, 1947)

17. Occidental Negros Provincial Hospital School of Nursing (1946)

18. Cebu (Velez) General Hospital School of Nursing (1951)

19. Brokenshire School of Nursing (Nueva Ecija, 1960)

20. De Ocampo Memorial School of Nursing (1954)

21. Marian School of Nursing (1960)

22. St. Rita Hospital and School of Midwifery (1956) and Nursing (1960)

Advantages of University Hospitals over Hospital Schools of Nursing:

1. students are treated as students and not as employees.
2. adequate financial support.
3. The head of the school is responsible only for the education of students in nursing
and;
4. The environment for the university school of nursing school education.

The First Colleges of Nursing in the Philippines

a. University of Santo Tomas .College of Nursing (1946)
- The first basic collegiate school for Nursing in the Philippines.
b. Manila Central University College of Nursing (1948)
c. University of the Philippines College of Nursing (1948). Ms.Julita Sotejo was its
first Dean
d. Southwestern College College School of Nursing (Cebu, 1947)
e. Philippine Union College of Nursing (1947)
f. Central Philippine College of Nursing (1947)
g. Siliman University College of Nursing (1947)
h. Philippine Womens University College of Nursing (1951)
i. FEU Institute of Nursing (1955)
j. UE College of Nursing (1958)
k. Saint Paul College of Nursing (Manila, 1958)

Nursing Leaders in the Philippines

*Anastacia Giron-Tupaz First Filipino nurse to hold the position of Chief Nurse
Superintendent; Founder of PNA (Philippine Nurses Association)
*Cesaria Tan First Filipino to receive a masters degree abroad.
*Socorro Sirilan Pioneered in Hospital Social Service in San Lazaro Hospital where
she was the Chief Nurse.
*Rosa Militar Pioneered in School Health Education.
*Sor Ricarda Mendoza Pioneer in Nursing Education.
*Socorro Diaz First Editor of the PNA magazine called The Message
*Conchita Ruiz First full-time editor of the PNA magazine called The Filipino Nurse.
*Loreta Tupaz Dean of the Philippine Nursing, regarded as the Florence Nightingale of
Iloilo.

Some Highlights in the History of Nursing in the Philippines

*1906 at the Union Mission Hospital (now Iloilo Mission Hospital) in Iloilo City, 4 women
started training in nursing; 3 female graduated in 1909 as Qualified Surgical and Medical
Nurses.
*1907 19 students admitted to a preliminary course in nursing as the Philippine Normal
College.
*1909 A nursing school was established under the Bureau of Education by Authority of
Act No. 1931.
*1910 Act No. 1975 recognized the school under the Bureau of Health. The school
continued as one of the activities of the newly opened Philippine General Hospital and
became known as the Philippine General Hospital School of Nursing.
*1915 Act No. 2468 authorized the granting of the titles of graduate in nursing and
graduate in midwifery to nursing midwifery students of the PGHSN.
- Public Health Nursing in the Bureau of Health began in accordance with Act No.
2468.
*1919 Act No. 2808 (Nurses Law) was passed, enacted regulating the practice of the
nursing profession in the Philippines Islands.It also provided the holding of exam for the
practice of nursing on the 2nd Monday of June and December of each year. This act was
later amended in 1922, 1933 and 1950.
*1920 1st Board Examination for Nurse was conducted by the Board of Examiners, 93
candidates took the exam, 68 passed with the highest rating of 93.5% - Anna Dahlgren.
- theoretical exam was held at the UP Amphitheater of the College of Medicine and
Surgery. Practical Exam at the PGH Library.
*1922 Filipino Nurses Association was established (now PNA) as the National
Organization of Filipino Nurses.
First President Rosario Delgado
Founder Anastacia Giron-Tupas
*1924 A standard curriculum for school of Nursing was published by the PNA.
*1948 UP College of Nursing was established.
- First attempt to offer a 4 year basic nursing course leading to a B.S Nursing
Degree
- The 1st attempt to elevate nursing as profession by enriching and broadening the
preparation of nurses and by educating them in a University Setting.
- The idea was conceived by Julita V. Sotejo, a Nurse and Lawyer, who later
became the 1st Dean of the School.
- A program was opened for graduate of the 3 year hospital nursing course to
obtain a B.S Nursing Degree at the U.P College of Nursing. This program ended in 1975.
*1951 Republic Act 649 provided for the standardization of nurses salaries both in
institution and in public health.
*1953 Republic Act No. 877 (Nursing Practice Law) was approved. Minor revisions
were incorporated in 1957, 1966 1970 and 1972.
*1955 The UPCN offered a Master of Arts in (Nursing) Degree program to prepare BSN
holders of demonstrated competence and scholarship for senior positions in nursing and
to encourage nursing research.
- A one-year course leading to a certificate of Public Health Nursing was opened at
the UPCN. This program ended in 1969.
*1965 The Academy of Nursing of the Philippines (ANPHI) approved its constitution.
- Among its objectives are initiate, promote, sponsor, encourage, and/or conduct
nursing studies and research, and to serve as a medium of exchange through
conference, seminar, institute and workshops.
*1966 R.A 4704, amending R.A 877 was approved.
*1968 A movement toward accreditation of Nursing Schools in the Philippines was
started.
*1970 WHO started an ongoing project in nursing education on family planning to
prepare faculty members to introduce family planning in basic nursing curricula.
- R.A 6136 amending R.A 877 and 4704 was approved.
*1972 A national seminar on Public Health Nursing Education was held with WHO
technical assistance.
*1975 A national seminar on Public Health Nursing Education was held with WHO
technical assistance.
*1975 A National Health Plan was formulated.
- It redefined the functions and responsibilities of nurses and other health workers
with implication for Nursing Education and Community Health Nursing.
- The Psychiatric-Nursing Specialists, Inc. (PNSI), the 1st independent Nurse
Practitioners groups, was established.
*1976 A National Workshop on the Proposed Nurse-Midwife Curriculum of Schools of
Nursing in the Ministry of Health was sponsored by the Ministry. The Workshop drafted
an experimental 4-year Nurse-Midwifery curriculum.
*1977 ILO convention 149 and recommendations 157, concerning the employment of
Nursing Personnel and the conditions of their life and work, were adopted in Geneva.
*1978 The Declaration of the Economic and School Welfare of Filipino Nurses was
passed by the PNA.
*1979 The 1st National Nurse Congress was held, its theme Nursing Issues in the
80s.
- The 1st National Tripartite Conference on employment and conditions of life and
work of Nursing and other Health Personnel was held.
- Labor, management and government were involved.
*2002 Philippine Nursing Act of 2002 (R.A 9173)

1. Nursing Leaders
Florence Nightingale (1820-1910)
-recognized as nursings first scientist-theorist for her work, Notes on Nursing:
What It is, and What It is Not
-considered the founder of modern nursing.
-developed the Nightingale Training School of Nurses, which operated in 1860.
The scchool served as a model for other training schools. Its graduates traveled to
other countries to manage hospitals and institute nurse-training programs.
 -Nightingales vision of nursing, which include public health and healt promotion
roles for nurses, was only partially addressed in the early days of nursing. The
focus tended to be on developing the profession within hospitals.
Clara Barton (1812-1921)
-organized the American Red Cross, which linked with the International Red
Cross when the U.S Congress ratified the Geneva Convention in 1882.
Lilian Wald (1867-1941)
-considered the founder of Public Health Nursing.
Lavinia L. Dock (1858-1956)
-active in the protest movement for womens right that resulted in the U.S
Constitution amendment in 1920, allowing women to vote.
Margaret Sanger (1879-1966)
-a nurse activist; considered the founder of planned Parenthood, was imprisoned
for opening the first birth control information clinic in Baltimore in 1916.
Lydia Hall
-developed the Care, Core, and Cure Theory
-Goal: To Care, and Cure Cores disease.
-Care for the patients BODY. Cure the DISEASE. Treat the PERSON ( or patient)
as the Core.

B. Nursing as a Profession
NURSING AS A PROFESSION

Profession is a calling that requires special knowledge, skill and preparation.

An occupation that requires advanced knowledge and skills and that it grows out
societys needs for special services.

Criteria of Profession:
1. To provide a needed service to the society.
2. To advance knowledge in its field.
3. To protect its memebers and make it possible to practice effectively.

Characteristics of a Profession:
1. A basic profession requires an extended education of its members, as well as a basic
liberal foundation.
2. A profession has a theoretical body of knowledge leaing to defined skills, abilities and
norms.
3. A profession provides a specific service.
4. Members of a profession have autonomy in decision-making and practice.
5. The profesion has a code of ethics for practice.

NURSING
- is a desciplined involved in the delivery of health care to the society.
- is a helping profession.
- is service-oriented to maintain health and well-being of people.
- is an art and science.

NURSE originated from a Latin word NUTRIX, to nourish.

Characteristics of Nursing:
1. Nursing is caring.
2. Nursing involves close personal contact with the recipient of care.
3. Nursing is concerned with services that take humans into account as physiological,
psychological, and sociological organism.
4. Nursing is committed to promoting individual, family, community, and national health
goals in its best manner possible.
5. Nursing is committed to personalized services for all persons without regard to color,
creed, social or economic status.
6. Nursing is committed to involvement in ethical, legal, and political issues in the delivery
of health care.

Personal Qualities of a Nurse:

1. Must have a Bachelor of Science degree in Nursing.
2. Must be physically and mentally fit.
3. Must have a license to prac tice nursing in the country.

- A professional nurse therefore, is a person who has completed a basic nursing

education program and is licensed in his country to practice professional nursing.

Roles of a Professional

1. Caregiver/Care provider
- the traditional and most essential role.
- functions as nurturer, comforter, provider.
- mothering actions of the nurse.
- provides direct care and promotes comfort of client.
- activities involves knowledge and sensitivity to what matters and what is important to
clients.
- show concern for client welfare and acceptance of the client as a person.

2. Teacher
- provides information and helps the client to learn or acquire new knowledge and
technical skills.
- encourages compliance with prescribed therapy.
Promotes healthy lifestyle.
- interprets information to the client.

3. Counselor
- helps client to recognize and cope with stressful psychologic or social problems; to
develop an improve interpersonal relationships and to promote personal growth.
- Encourages the client to look at alternative behaviors recognize the choices and
develop a sense of control.

4. Change agent
- initiate changes or assist clients to make modifications in themselves or in the system of
care.

5. Client advocate
- involves concern for and actions in behalf of the client to bring about a change.
- promotes what is best for the client, ensuring that the clients needs are met and
protecting the clients right.
- provides explanation in clients ;anguage and support clients decisions.

6. Manager
- makes decisions, coordinates activities of others, allocate resource evaluate care and
personnel.
- plans, give direction, develop staff, monitor operations, give the reward fairly and
represent both staff and administrations as needed.

7. Researcher
- participates in identifying significant researchable problems.
- participates in scientific investigation and must be a consumer of research findings.
-must be aware of the research process, language of research, a sensitive to issues
related to protecting the rights of human subjects.

Expanded role as of the Nurse

1. Clinical Specialists
- is a nurse who has completed a masters degree in specialty and has considerable
clinical expertise in that specialty. She provides expert care to individuals, participates in
education health care professionals and ancillary, acts as a clinical consultant and
participates in research.

2. Nurse Practitioner
-is a nurse who has completed either as a certificate program or a masters degree in a
specialty and is also cerified by the appropriate specialty organization. She is skilled at
making nursing assessments, performing P.E., counselling, teaching and treating minor
and self-limiting illness.

3. Nurse-Midwife
- a nurse who has completed a program in midwifery; provides prenatal and postnatal
care and delivers babies to woman with uncomplicated pregnancies.
4. Nurse Anesthetist
- a nurse who completed the course of study in an anesthesia school and carries out pre-
operative status of clients.

5. Nurse Educator
- a nurse usually with advanced degree, who beaches in clinical or educational settings,
teaches theoretical knowledge, clinical skills and conduct research.

6. Nurse Entrepreneur -
- a nurse who has an advanced degree, and manages health-related business.

7. Nurse Administrator
- a nurse who functions at various levels of management in health settings; responsible
for the management and administration of resources and personnel involved in giving
patient care.

Fields and Opportunities in Nursing

1. Hospital/Institutional Nursing a nurse working in an institution with patients.

Example: rehabilitation, lying-in, etc.

2. Public Health Nursing/Community Health Nursing usually deals with families and
communities. ( no confinement, OPD only ).
Example: brgy, Health Center.

3. Private Duty/Special Duty Nurse privatey hired.

4. Industrial/Occupational Nursing a nurse working in factories, office, companies.

5. Nursing Education nurses working in school, review center and hospital as a C.I.

6. Military Nurse nurses working in a military base.

7. Clinic Nurse nurses working in a private and public clinic.

8. Independent Nursing Practice private practice, BP monitoring, home service.

- Independent Nurse Practtioner.

Nursing Theory and Theorists

4 Essential concepts common among nursing theories:

- Individual
 - Health
- Environment
- Nursing

FLORENCE NIGHTINGALES ENVIRONMENTAL THEORY

- Defined Nursing: The act of utilizing the environment of the patient to assist him
in his recovery.
- Focuses on changing and manipulating the environment in order to put the patient in
the best possible conditions for nature to act.
- Identified 5 environmental factors: fresh air, pure water, efficient drainage,
cleanliness/sanitation and light/direct sunlight.
- Considered a clean, well-ventilated, quiet environment essential for recovery.
- Deficiencies in these 5 factors produce illness or luch of health but with a nurturing
environment, the body could repair itself.

DOROTHEA OREMS SELF-CARE THEORY

- Defined Nursing: The act of assisting others in the provision and management of
self-care to maintain/improve human functioning at home level of effectiveness.
- Focuses on activities that adult individuals perform on their own behalf to maintain life,
health and well-being.
-Has a strong health promotion and maintainance focus.

C. Theoretical Foundation of Nursing Applied in Health Care Situations

THEORETICAL FOUNDATION OF NURSING
I. Philosophy
Specifies the definition of the metaparadigm concepts (person, environment, health,
and nursing) in each of
the conceptual models of nursing.
Sets forth meaning through analysis, reasoning, and logical argument. It provides a
broad understanding and
direction.

Florence Nightingale - Modern Nursing; Environmental Theory

*Disease is a reparative process, and that the manipulation of the environment -
ventilation, warmth, light, diet, cleanliness, and noise - would contribute to the process
and health of the patient.
*Did not agree with the germ theory of disease although she accepted the ill effects of
contamination from organic materials from the patients and the environment hence found
sanitation as important.
*Also renowned for pioneering statistical analysis of healthcare.

Ernestine Wiedenbach - Helping Art of Clinical Nursing

* nursing is nurturing or caring for someone in a motherly fashion.
*Proposed that nurses identify patients need-for-help by:
o Observing behaviors regarding comfort.
o Exploring meanings of the behavior.
o Knowing the cause of discomfort.
o Knowing if they can solve on their own or need help.

Virginia Henderson - Definition of Nursing; 14 Basic Needs

*The unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or to recovery (or to a peaceful
death) that he would perform unaided if he had the necessary strength, will, or
knowledge and to do this in such a way as to help him gain independence as rapidly as
possible

*14 Basic Needs:

1. Breathe 8. Clean body and intact integument
2. Eat and drink 9. Safe environment
3. Eliminate 10. Communicate
4. Motion and position 11. Worship
5. Rest and sleep 12.Work
6. Clothing 13.Play
7. Temperature 14.Learn

Faye Glenn Abdellah - 21 Nursing Problems

*Problem solving was seen as the way of presenting nursing(patient) problems as the
patient moved towards health.
*Contributed to nursing theory development through the systematic analysis of research
reports to formulate the 21 nursing problems that served as an early guide for
comprehensive nursing care.

Lydia Hall - Care, Core, and Cure

*The theory consists of 3 major tenets:
o The nurse functions differently in the 3 interlocking aspects of the patient:
-Cure (Disease) shared with doctors
-Core (Person) addressed by therapeutic use of self; shared with
psychiatry/psychology, religious ministry, etc.
-Care (Body) exclusive to nurses; involves intimate bodily care like feeding, bathing and
toileting
o As the patient needs less medical care, he needs more professional nursing care
o Wholly professional nursing care will hasten recovery

Jean Watson - Philosophy and Science of Caring; Carative Factors

*Caring is a universal social phenomenon that is only effective when practiced
interpersonally. Nurses should be sensitized to humanistic aspects of caring
*10 Carative Factors
1. Form humanistic-altruistic values 6. Scientific problem-solving method for decisions
2. Instill faith-hope 7. Promote interpersonal teaching-learning
3. Cultivate sensitivity 8. Provide supportive, protective, or corrective
environemnt
4. Develop helping-trust relationship 9. Assist gratifying human needs
5. Promote and accept expression
of positive and negative 10. Allowance for existential-phenomeno-
logical forces

Patricia Benner - Novice to Expert

*Validated the Dreyfus Model of Skill Acquisition in nursing practice with the systematic
description of the 5 stages (Novice, Advanced beginner, Competent, Proficient, and
Expert).
BENNERS STAGES OF NURSING EXPERTISE
STAGE I, Novice
*Has no experience (e.g., Nursing Student)
*Performance is limited inflexible, and governed by context-free rules and regulations
rather than experience.
*Novices have no life experience in the application of rules.
*Just tell me what I need to do and I do it.
STAGE II, Advanced Beginner
*Demonstrate marginally acceptable performance.
* Recognizes the meaningful aspect of a real situation.
*Has experienced enough real situations to make judgement about them.
*Principles to guide actions begin to be formulated and are focused on experience.
STAGE III, Competent
*Has 2 to 3 years of experience.
*Demonstrates organizational and planning abilities.
*Differentiates important factors from less inportant aspects of care.
*Coordinates multiple complex care demands.
*Develops when the nurse begins to see his or her actions in terms of long-range goals
or plans which he or she is consciously aware of.
STAGE IV, Proficient
*Has 3 to 5 years of experience.
*Perceives situations as a whole rather than in terms of parts as in Stage II.
*Uses maxims as guides for what to consider in a situation.
*Has holistic understanding of the client, which improves decision making.
*Focuses on long-terms goals.
STAGE V, Expert
*Performance is fluid, flexible, and highly proficient; no longer requires rules guidelines,
or maxims to connect an understanding of the situation to appropriate action.
*Demonstrates highly-skilled intuitive and analytical ability in new situations.
*Is inclined to take a certain action because it felt right.
II. Conceptual Models
*Frameworks or paradigms that give a broad frame of reference for systematic
approaches to the concerned phenomena.
*Concepts that specify their interrelationship to form an organized perspective for viewing
the phenomena
Grand Theories
*Derived from models but as theories, they propose testable truths or outcomes based
on use of the model in Practice.

Dorothea Orem - Self- Care Deficit Theory

*Composed of 3 Theories:
o Theory of Self Care
o Theory of Self-Care Deficit
o Theory of Nursing Systems - 3 Types:
Wholly Compensatory - do for the patient.
Partly Compensatory - help the patient do for himself.
Supportive Educative - help the patient learn to do for himself; nurse has important
role in designing nursing care.

Myra Estrin Levine - Conservation Model

*Major Concepts:
o Wholism (Holism)
o Adaptation - process whereby patients retain integrity; establish body economy to
safeguard stability:
Environment
Organismic Response - (1)Fight or flight, (2)inflammatory response,
(3)response to stress, (4)perceptual awareness
Trophicogenesis - alternative to nursing diagnosis
o Conservation - 4 principles of conservation - Nursing intervention is based on the
conservation of the patients:
Energy
Structural Integrity
Personal Integrity
Social Integrity
*Composed of 3 Theories- (1) conservation (2) redundancy (3) therapeutic intention.

Martha Rogers - Unitary Human Beings

*Principles of Homeodynamics
Helicy - spiral development in continuous, non-repeating, and innovative patterning.
Resonancy - patterning changes with development from lower to higher
frequency(intensity).
Integrality - continuous mutual process of person and environment.
*Theoretical Assertions
 Energy - Man as a whole is more than the sum of his parts.
Openness - Man and environment continuously exchange matter and energy.
Helicy - Life evolves irreversibly and unidirectionally along space and time.
Pattern and organization identify man and reflect his innovative wholeness.
Sentient, thinking being - man has capacity for abstraction and imagery, language
and thought, sensation and emotion.

Dorothy Johnson - Behavioral Systems Model

*Considered attachment or affiliative subsystem as cornerstone of social organizations
*Nursing problems arise because there are disturbances in the structure or function of
the subsystems:
Dependency
Achievement
Aggressive
Ingestive
Eliminative
Sexual

Sister Callista Roy - Adaptation Model

*Proposed that humans are biophychosocial beings who exist within an environment
*Environment and self provides 3 types of stimuli: (1) focal (2) residual (3) contextual
*Human stimuli create needs in adaptation modes, such as physiological self-concept,
role function, and interdependence
*Through adaptive mechanisms, regulator and cognator, a person shows adaptive or
ineffective response that need nursing intervention.

Imogene King - Interacting Systems Framework; Goal Attainment Theory

*Nursing is a process of human interaction between nurses and patients who
communicate to set goals, explore means of attaining goals, and agree on what
means to use
*Perceptions, judgement and actions of nurse and patient lead to reaction, interaction
and transaction
*Interacting systems:
Personal System - perception, self, body image, growth and development
Interpersonal System - role, interaction, communication, transaction, and stress
Social System - organization, power-authority status, decision making.

Roper, Logan, and Tierney - Model for Nursing Based on a Model of Living
Conceptual Components
o 12 Activities of Living (AL) - complex process of living in the view of an amalgam of
activities
1. Maintain safe environment 7. Temperature
2. Communicate 8. Mobility
3. Breathe 9. Work and play
4. Eat and drink 10. Express sexuality
5. Eliminate 11. Sleep
6. Personal cleansing and dressing 12. Dying

Life span - concept of continuous change from birth to death

Dependence-independence continuum
5 factors influencing AL: Biological, Psychological, Socio-cultural, Environmental,
Politicoeconomic.
*The individuality of living is the way in which the individual attends to ALs in regard to
place on life span and dependence-independence continuum and as influenced by the 5
factors.

III. Theories
*Group of related concepts that proposes actions that guide practice. May be broad but
limited only to particular aspects
Middle-range Theories
*The least abstract level because they include specific details in nursing practice like
population, condition and location.

Hildegard Peplau - Psychodynamic Nursing; Mother of Psychiatric Nursing

*Stressed the importance of the nurses ability to understand ones own behavior to help
others identify felt difficulties.
*4 Phases of Nurse-Patient Relationship
Orientation
Identification
Exploitation
Resolution
*6 Nursing Roles
1. Stranger 4. Leader
2.Resource Person 5. Surrogate
3. Teacher 6. Counselor
*4 Psychobiological Experiences that compel destructive or constructive responses
Needs
Frustrations
Conflicts
Anxieties

Ida Jean Orlando - Nursing Process; Dynamic Nurse-Patient Relationship

*Focused on patients verbal and nonverbal expressions of need and the nurses
reactions to the behavior
*3 Elements of a Nursing Situation
Patient behaviors
Nurse reactions
Nurse actions
*Used the nursing process to meet patients needs through deliberate action; advanced
nursing beyond automatic response to disciplined and professional response.

Joyce Travelbee - Human-to-Human Relationship Model

*Nursing was accomplished through human-to-human relationship:
1. Original encounter
2. Emerging identities
3. Developing empathy
4. Developing sympathy
5. Rapport

Katherine Kolcaba - Theory of Comfort

*Defined healthcare needs as those needs for comfort including physical, psycho-
spiritual, social, andenvironmental needs
*Intervening factors influence clients perception of comfort: age, attitude, emotional
support, experience, finance, prognosis
*Types of comfort:
1. Relief when specific need is fulfilled
2. Sense of ease, calm, and contentment
3. Transcendence or rising above the problems of pain

Erikson, Tomlin and Swain - Modeling and Role-Modeling

*Synthesis of multiple theories related to basic needs, developmental tasks, object
attachment, and adaptive coping potential
*Views nursing as self-care based on the persons perception of the world and adaptation
to stressors
*Promotes growth and development while recognizing individual differences according to
worldview and inherent endowment.

Ramona Mercer - Maternal Role Attainment

*Focused on parenting and maternal role attainment in diverse populations.
*Developed a complex theory to explain the factors impacting the maternal role over
time.

Kathryn Barnard - Parent-Child Interaction; Child Health Assessment Interaction Theory

*Individual characteristics of each member influence the parent-infant system and that
adaptive behavior modifies those characteristics to meet the needs of the system
*The theory is based on scales developed to measure feeding, teaching, and
environment.

Madeleine Leininger - Transcultural Care Theory; Ethnonursing

*Some of the major concepts are care, caring, culture, cultural values, and cultural
variations
*Caring is seen as the central theme in nursing care, knowledge and practice.
*Caring includes assistive, supportive, facilitative acts towards people with actual or
anticipated needs
*3 types of Nursing Actions
Cultural Care Preservation or Maintenance - retention of relevant care values unique
to culture
Cultural Care Accommodation or Negotiation - adapting culture with professional care
providers
Cultural Care Repatterning or Restructuring - changing life-ways while still respecting
culture for a healthier outcome.

Rosemarie Rizzo Parse - Human Becoming

*A unique, humanistic approach instead of a physiological basis for nursing
*Nursing is a human science that is not dependent on medicine or any discipline for its
practice
*Major concepts include:
Imaging Connecting-separating
Valuing Powering
Languaging Originating
Revealing-concealing Transforming
Enabling-limiting

Merle Mishel - Uncertainty in Illness

*Researched into experiences with uncertainty as it relates to chronic and life-threatening
illness.
*Later reconceptualized to accommodate the responses to uncertainty over time in
people with chronic conditions who may not resolve the uncertainty.

Margaret Newman - Model of Health

*Major concepts are movement, time, space and consciousness. Movement is a
reflection of consciousness.
Time is a function of movement. Time is a measure of consciousness.
*The goal of nursing is not to promote wellness or to prevent illness, but to help people
use the power within them as they evolve toward a higher level of consciousness.

Evelyn Adam - Conceptual Model for Nursing

*Used a model from Dorothy Johnson and definition of nursing from Virginia Henderson
*Identified assumptions, beliefs, and values, and major units
*Included goal of the profession, beneficiary of the professional service, role of the
professional, source of the beneficiarys difficulty, the intervention of the professional, and
the consequence.

Nola Pender - Health Promotion Model

*The goal of nursing care is the optimal health of the individual
*Developed the idea that promoting optimal health supersedes disease prevention
*Identifies cognitive-perceptual factors of a person, like importance of health-promotion
behavior and its perceived barriers, and these factors are modified by demographics,
biology, interpersonal influences, and situational and behavioral factors.

D. Continuing Professional Education

E. Professional Organizations in Nursing

F. The Nurse in Health Care

1. Eleven Key Areas of Responsibility

ELEVEN KEY AREAS OF RESPONSIBILITY

A. SAFE AND QUALITY NURSING CARE

1. Demonstrate knowledge based on the health/Illness status of indiidual groups.
2. Provides sound decision making in the care of individuals/groups.
3. Promote wholeness and well-being including safety and comfort of patients.
4. Sets priorities in nursing care based on patients need.
5. Ensures continuity of care..
6. Administersmedications and other health therapeutics.
7. Utilizes the nursing process as framework for nursing.
8. Formulates a plan of care in collaboration with patients and other members of the
health team.
9. Implements planned nursing care to achieve identified outcomes.
10. Evaluates progress toward expected outcomes.
11. Responds to the urgency of the patients condition.

B. MANAGEMENT OF RESOURCES AND ENVIRONMENT

1. Organizes work load to facilitate patient care.
2. Utilizes resources to support Patient care.
3. Ensures availability of human resorces.
4. Checks proper functioning of equipment/facilities.
5. Maintains a safe and therapeutic environment.
6. Practices stewardship in the management of resources.

C. HEALTH EDUCATION
1. Assess the learning needs of the patient and family.
2. Develops health education plan based on assessed and anticipated needs.
3. Develops learning materials for health education.
4. Implements the healtheducation plan.
5. Evaluates the outcome of health education.

D. LEGAL RESPONSIBILITY
1. Adheres to practice in accordance with the nursing law and other relevant legislation
including contracts, informed consent.
2. Adheres to organizational policies and procedures, local and national.
3. Documents care rendered to patients.

E. Ethico-Moral Responsibility
1. Respects the rights of individuals/groups.
2.Accepts responsibility and accountability for own decisions and actions.
3. Adheres to the national and international code pf ethics for nurses.

F. Personal and Professional Development

1. Identifies own learning needs.
2. Pursues continuing education.
3. Gets involved in professional organizations and civic activities.
4. Projects a professional image of the nurse.
5. Possesses positive attitude towards change and criticism.
6. Performs function according to professional standards.

G. Quality Improvement
1. Utilizes data for quality improvement
2. Participtaes in nursing audits and rounds.
3. Identifies and reports variances.
4. Recommends solutions to identified causes of the problems.
5. Recommends improvement of systems and processes.

H. Reasearch
1. Utilizes varied methods of inquiry in solving problems.
2. Recommends actions for implementation.
3. Disseminates results of research findings.
4. Applies research findings in nursing practice.

I. Record Management
1. Maintains accurate and updated documentation of patient care.
2. Records outcome of patient care.
3. Observes legal imperatives in record keeping.
4. Maintains an effective recording and reporing system.
J. Communication
1. Utilizes effective communication in relating with clients, members with the team and
the public in general.
2. Utilizes effective communicationin therapeutic use of self to meet the needs of clients.
3. Utilizes formal and informal channels.
4. Responds to needs of individuals, families, groups and communities.
5. Uses appropriate information technology to facilitate communication.
K. Collaboration and Teamwork
1. Establishes collaborative relationship with colleagues and other members of the health
team for the health plan.
2. Functions effectively as a team player.

2. Fields of Nursing
3. Roles and Functions

II. Safe and Quality Care

A. The Nursing Process
NURSING PROCESS
Definition
- It is a systematic, client-centered method for structuring the delivery of nursing care.

B. Basic Nursing Skills

1. Vital Signs
2. Physical Examination and Health Assessment
3. Administration of Medications
4. Asepsis and Infection Control
5. First Aid Measures
6. Wound Care
7. Perioperative Care
8. Post-operative Care
9. Post-mortem Care
C. Measures to meet physiological needs
1. Oxygenation
2. Nutrition
3. Activity, Rest and Sleep
4. Fluid and Electrolyte Balance
5. Urinary Elimination
6. Bowel Elimination
7. Safety, Comfort and Hygiene
8. Mobility and Immobility

III. Health Education

A. Teaching and Learning Principles in the Care of Client
B. Health Education in All Levels of Care
C. Discharge Planning

IV. Ethico-Moral Responsibility

A. Bioethical Principles
1. Beneficence
2. Non-maleficence
3. Justice
4. Autonomy
5. Stewardship
6. Truth Telling
7. Confidentiality
8. Privacy
9. Informed Consent
B. Patients Bill of Rights
C. Code of Ethics in Nursing

V. Legal Responsibility
A. Legal Aspects in the Practice of Nursing
B. The Philippine Nursing Law of 2002 (R.A 9173)
C. Related Laws Affecting the Practice of Nursing

VI. Management of Environment and Resources

A. Theories and Principles of Management
B. Nursing Administration and Management
C. Theories, Principles and Styles of Leadership
D. Concepts and Principles of Organization
E. Patient Care Classification
F. Nursing Care Systems
G. Delegation and Accountability

VII. Records Management

A. Anecdotal Report
B. Incident Report
C. Memorandum
D. Hospital Manual
E. Documentation
F. Endorsement and End of Shift Report
G. Referral

VIII. Quality Improvement

A. Standards of Nursing Practice
B. Nursing Audit
C. Accreditation/Certification in Nursing Practice
D. Quality Assurance

IX. Research
A. Problem Identification
B. Ethics and Science of Research
C. The Scientific Approach
D. Research Process
E. Research Designs and Methodology
1. Qualitative
2. Quantitative
F. Utilization and Dissemination of Research Findings

X. Communication
A. Dynamics of Communication
B. Nurse-Client Relationship
C. Professional-Professional Relationship
D. Therapeutic Use of Self
E. Use of Information Technology

XI. Collaboration and Teamwork

A. Networking
B. Inter-agency Partnership
C. Teamwork Strategies
D. Nursing and Partnership with Other Profession and Agencies

Nursing Board Exam/Nursing Licensure Exam Coverage (Nursing Practice II)

NURSING BOARD EXAM SCOPE/COVERAGE
NURSING PRACTICE II
TEST DESCRIPTION: Theories, concepts, principle and processes in the care of
individuals, families, groups and communities to promote health and prevent illness, and
alleviate pain and discomfort, utilizing the nursing process as framework. This includes
care of high risk and at-risk mothers, children and families during the various stages of
life cycle.
TEST SCOPE:
Part I: CHN

I. Safe and Quality Care, Health Education and Communication, Collaboration and Team
work
COMMUNITY HEALTH NURSING
HISTORY OF CHN
Date
1901 Act # 157 (Board of Health of the Philippines) ;
Act # 309 (Provincial and Municipal Boards of Health) were created.
1095 Board of Health was abolished; functions were transferred to the Bureau of
Health.
1912 Act # 2156 or Fajardo Act created the Sanitary Divisions, the forerunners of
present MHOs; male nurses performs the functions of doctors.
1919 Act # 2808 (Nurses Law was created)
- Carmen del Rosario, 1st Filipino Nurse supervisor under Bureau of Health.
October 22, 1922 Filipino Nurses Organization (Philippines Nurses Organization) was
organized.
1923 Zamboanga General Hospital School of Nursing and Baguio General Hospital
were established; other government schools of nursing were organized several years
after.
1928 1st Nursing convention was held
1940 Manila Health Department was created.
1941 Dr. Mariano Icasiano became the first ciy health officer; Office of Nursing was
created through the effort of Vicenta Ponce (Chief Nurse) and Rosario Ordiz (assistant
chief nurse)
December 8, 1941 Victims of World War II were treated by the nurses of Manila.
July 1942 Nursing Office was created; Dr. Eusebio Aguilar helped in the release of 31
Filipino Nurses in Bilibid Prison as Prisoners of War by the Japanese.
February 1946 Number of Nurses decreased from 556 308.
1948 First training center of the Bureau of Health was organized by the Pasay City
Health Department. Trinidad Gomez, Marcela Gabatin, Constancia Tuazon, Ms. Bugarin,
Ms. Ramos, and Zenaida Nisce composed the training staff.
1950 Rural Health Demonstration and Training Center was created.
1953 The first 81 Rural Health Units were organized.
1957 RA 1891 Ammended some sections of RA 1082 and created the eight categories
of Rural Health Unit causing an increase in the demand for the community health
personnel.
1958 1965 Division of Nursing was abolished (RA 977) and Reorganization
Act (EO 288)
1961 Annie Sand organized the National Nurses of DOH.
1967 Zenaida Nisce became the nursing program supervisor and consultant on the six
special diseases (TB, Leprosy, V.D., Cancer, Filariasis, and Mental Health Illness).
1975 Scope of responsibility of nurses and midwives became wider due to restructuring
of the health care delivery system.
1976 1986 The need for Rural Health Practice Program was implemented.
1990 1992 Local Government Code of 1991 (RA 7160)
1993 1998 Office of Nursing did not materialize in spite of persistent recommendation
of the officers, board members, and advisers of the National League of Nurses Inc.
January 1999 Nelia Hizon was positioned as the nursing adviser at the Office of Public
Health Services through Department Order # 29.
May 24, 1999 EO # 102, which redirects the functions and operations of DOH, was
signed by former President Joseph Estrada.

Laws Affecting Public Health andPractice of Community Health Nursing

R.A 7160 or the Local Government Code. This involves the devolution of powers,
functions and responsibilities to the local government both rural and urban. The Code
aims to transform local government unit into self-reliant communities and active partners
in the attainment of national goals thru a more responsive and accountable local
government structure instituted thru a system of decentralization. Hence, each province,
city and municipality has a LOCAL HEALTH BOARD ( LHB ) which is mandated to
propose annual budgetary allocations for the operation and maintenance of their own
health facilities.

Composition of Local Health Board ( LHB )

Provincial Level
1. Governor Chair
2. Provincial Health Officer vice chair
3. Chair, Committee on Health of Sangguniang Panlalawigan.
4. DOH Representative.
5. NGO Respresentative.
City and Municipal Level
1. Mayor Chair
2. MHO vise chair
3. Chair, Committee on Health of Sangguniang Bayan.
4. DOH Representative
5. NGO Representative
Effective LHS Depends on:
1. The LGUs financial capability.
2. A dynamic and responsive political leadership
3. Community Empowerment

R.A 2382 Philippine Medical Act. This act defines the practice of medicine in the
country.
R.A 1082 Rural Health Act. It created the 1st 81 Rural Health Units.
- amended by R.A 1891; more physicians, dentists, nurses, midwives and
sanitary inspectors will live in the rural areas where they are assigned in order to raise
the health conditions of barrio people, hence help decrease the high incidence of
preventable diseases.
R.A 6425 Dangerous Drugs Act. It stipulates that the sale, administration, delivery,
distribution and transportation of prohibited drugs is punishable by law.
R.A 9165 The New Dangerous Draug Act of 2002.
P.D No. 651 requires that all Health Workers shall identify and encourage the
registration of all births within 30 days following delivery.
P.D No. 996 requires the compulsary immunization of all children below 8 years of age
against the 6 childhood immunizable diseases.
P.D No. 825 provides pernalty for improper disposal of garbage.
R.A 8749 Clean Air Act of 2000
P.D No. 856 Code of Sanitation. It provides for the control of all factors in mans
environment that affect health including the quality of water, food, milk, insects, animal
carriers, transmitters of disease, sanitary and recreation facilities, nilse, pollution and
control of nuisance.
R.A 6758 Standardizes the salary of government employees including the nursing
personnel.
R.A 6675 Generics Act of 1988 which promotes, requires and ensures the production
of an adequate supply, distribution, use and acceptance of drugs and medicines
identified by their generic name.
R.A 6713 Code of Conduct and Ethical Standards of Public Officials and Employees. It
is thepolicy of the state to promote high standards of ethics in public office. Public
officials and employeesshall at all times be accountable to the people and shall
discharges their duties with utmost responsibility, integrity, competence and loyalty, act
with patriotism and justice, lead modest lives uphold public interest over personal
interest.
R.A 7305 Magna Carta for Public Health Workers. This act aims: To promote and
improve the social and economic well-being of health workers, their living and working
conditions and terms of employment; to develop their skills and capabilities in order that
they will be more responsive and better equipped to deliver health projects and
programs; and to encouragethose with proper qualifications and excellent abilities to join
and remain in government service.
R.A 8423 Created the philippine Institute of Traditional and Alternative Health Care.
P.D No. 965 requires applicants for marriage license to receive instructions on family
planning and responsible parenthood.
P.D No. 79 defines, objectives, duties, and functions of POPCOM.
R.A 4073 advocates home treatment for lepsrosy.
Letter of Instruction No. 949 legal basis of PHC dated october 19, 1979.
-- promotes development of health programs on the community
level.
R.A 3573 requires reporing of all cases of communicable diseases and administration
of prophylaxis.
Misnistry Circular No. 2 of 1986 includes AIDS as notifiable disease.
R.A 7875 National Health Insurance Act
R.A 7432 Senior Citizens Act
R.A 7719 National Blood Services Act
R.A 8172 Salt Iodization Act ( ASIN LAW)
R.A 7277 Magna Carta for PWDS, provides their rehabilitation, self-development and
self-reliance and integration into the mainstream of society.

*A.O No. 2005 0014 National Policies on Infant and Young Child Feeding:
1. All newborns be breastfeed within 1 hour after birth.
2. Infants be exclusively breastfeed for 6 months.
3. Infants be given timely, adequate and safe complementary foods
4. Breastfeeding be continued up to 2 years and beyond.

E.O 51 Philippine Code of Marketing of Breastmilk Substitutes.

R.A 7600 Rooming In and Breastfeeding Act of 1992.
R.A 8976 Food Fortification Law
R.A 8980 Promulgates a comprehensive policy and a national system for ECCD.

A.O. No. 2006 0015 Defines the Implementing guidelines on Hepatitis B

Immunization for infants.
R.A 7846 Mandates Compulsary Hepatitis B Immunization among infants and children
less than 8 years old.
R.A 2029 Mandates Liver Cancer and Hepatitis B Awareness Month Act ( February ).
A.O No. 2006 0012 Specifies the Revised Implementing Rules and Regulations of
E.O 51 or Milk Code, Relevant International Agreements, Penalizing Violations thereof
and for other purposes.

I. Definition of Terms
Community derived from a latin word communicas which means a group of people.
- a group of people with common characteristics or interests living together within a
territory or geographical boundary.
- place where people under usual conditions are found.

HEALTH is the OLOF (Optimum level of Functioning).

(WHO)- state of complete physical, mental and social well being, not merely the
absence of disease or infirmity.
-It primarily affects the physical well-being of people in a society.
-Health is a fundamental human right.
-A personal and social responsibility.
-A multifactorial approach.

1. HEALTH ILLNESS CONTINUUM

- A predictive grid that displays the Likelihood of a person to participate in
preventive health care.
- A Degree of client wellness ranging from optimum wellness to death.
- Dynamic state, matters as a person adopts to change in internal and a holistic
well being.
HIGH-LEVEL GOOD NORMAL ILLNESS DEATH
WELLNES HEALTH HEALTH

HEALTH ILLNESS CONTINUUM, as shown here, represents the process of

achieving HIGH LEVEL OF WELLNESS or the consequences of unhealthy
lifestyle. In this figure, there are three parameters on how to achieve high level of
wellness.
These are: (A) Awareness, (E) Education, and (G) Growth. Otherwise, an
individual who continuously live an unhealthy lifestyle, will be on the other side of
the grid, and would develop the following: (S) Signs and Symptoms (S)
Syndrome, and (D) Disorder or disability which may lead disease or premature
death.

2. AGENT HOST ENVIRONMENT MODEL

- Primarily used to predict an illness
AGENT Any environmental factor or stressor, chemical, mechanical,
physical, psychosocial, that by its presence or absence can lead to illness or
disease.
- Causative etiologic factor
HOST Persons who may or may not be at risk of acquiring the disease.
- with intrinsic factor
ENVIRONMENT All factors external to the host that may or may not
predispose the person to the development of the disease.

-Requires the individual to maintain a continuum of balance and purposeful

direction with environment.
Ex: Etiologic factor of Dengue? --- Virus
AGENT HOST

A. Etiologic Factors: B. Intrinsic Factors & Environmental

1. Biological infections----virus, Factors
bacteria 1. Age
- fungi, protozoa, helminthes, 2. Sex (m or f)
ectoparasites F - Weak emotional; morbidity:
2. Chemical- carcinogens, poisons, common diseases
allergens M - Mortality ( killer
Ex. GMOs carcinogen diseases)
MSG- poison 3. Behavior
3. Mechanical- car accidents, etc 4. Educational attainment- occupation
4. Environmental/physical- heatstroke 5. Prior immunologic- response
5. Nutritive- excess or deficiency
6. Psychological C. Extrinsic Factors
1. Natural boundaries- physical,
 geography
2. Biological environment
3. Socioeconomic envt.- political
boundary

3. HEALTH BELIEF MODEL

- Helps determine whether an individual is likely to participate in disease
prevention and promotion activities.
- Useful tools in developing programs for helping people change to healthier
lifestyles and develop a more positive attitude toward preventive healthier
measures.

COMPONENTS:
INDIVIDUAL PERCEPTIONS: Includes perceived susceptivility,seriousness and
threat. Seriousness of an illness.
MODIFYING FACTORS: Includes demographic variables, sociophysiologic
variables, structural variable, and cues to action. Susceptibility to an illness.
LIKELIHOOD TO ACTION: Depends on the perceived benefit versus the
perceived barriers. Benefits of taking actions.

Ex. Male infected w/ STD & female non-infectious----- Increase susceptibility of

transmission
HIV infection (commercial sex farers, sex workers, medical team
Susceptibility, possible MOT--- unprotected sex- occupational hazard

Prevention: Safer Sex Practices

Abstinence
Be faithful
Correct, consistent, continuous use of condom
Do not penetrate (SOP)

HIV infected age groups

Males age 40-49 seafarers ratio: 1: 5 anal sex- wont get pregnant, common in
rural

Vaginal: 1: 1000

Females 20-29 Anal: 1: 200-----highest risk

Oral lowest risk

 4. EVOLUTIONARY BASED MODEL
illness & death serve an evolutionary function- based on Darwins Survival of the
fittest theory
Elements:
a. Life events developmental variables & those associated with changes
b. Lifestyle determinants personal & learned adaptive strategies a person
uses to make lifestyle changes
c. Evolutionary viability within the social context extent to which a person fx
to promote survival
d. Control perceptions
e. Viability emotions affective reactions developed from life events
f. Health determinants

5. HEALTH PROMOTION MODEL

* Directed at increasing clients well being.
* All efforts increasing well being ( no threat ) ex. Sex education
Combating any possible disease ( no existing disease )

Illness Highly subjective feeling of being sick or ill.

PUBLIC HEALTH ( Dr. C.E. Winslow ) the science and art of preventing disease,
prolonging life, promoting health and efficiency through organized community effort for
the sanitation of the environment, control of communicable diseases, the education of
individuals in personal hygiene, the organization of medical and nursing services for
the early diagnosis and preventive treatment of diseases and the development of
social machinery to ensure everyone a standard of living adequate for the
maintenance of health, so organizing these benefits as to enable every citizen to
realize his birthright of birth and longevity.( Dr C.E Winslow ).
Art of Applying Science in the context of Politics so as to reduce Inequalities in Health
while ensuring the best health for the greatest number.

COMMUNITY HEALTH part of paramedical and medical intervention/approach which is

concerned on the health of the whole population.

Aims:
1. health promotion
2. disease prevention
3. management of factors affecting health.

INDIVIDUAL CLIENT: APPLIED STUDY: COMMUNITY AS CLIENT:

Anatomy Structure Demographic study of population
Physic Function Sociology
Pathos Malfunction Epidemiology study of disease
NURSING both profession and a vocation. Assisting sick individuals to become healthy
and healthy individuals achieve optimum wellness.

1. Virginia Henderson
- Assisting sick individuals to become healthy and healthy individuals achieve optimum
wellness

2. Dorothea Orem
- Providing assistance to clients to achieve self-care towards optimum wellness.
Early years- fetus- 12 years/ younger adults- 12-24 years
Orem- self care, autonomy----independent patient

3. Florence Nightingale
- Placing an individual in an environment. that will promote optimum capacity for self-
reparative process
- individual capable of self-repair and there is something to repair in an individual.

COMMUNITY HEALTH NURSING

-Synthesis of public and nursing practice.

(WHO Expert Committee of Nursing)

- special field of nursing that combines the skills of nursing, public health and some
phases of social assistance and functions as part of the total public health program for
the promotion of health, the improvement of the conditions in the social and physical
environment, rehabilitation of illness and disability.

- a specialized field of nursing practice.

1. Utilitarianism: greatest good for the greatest number.
2. Nursing Process.
3. Priority of health-promotive and disease-preventive strategies over curative
interventions.
4. Tools for measuring and analyzing Community Health problems.
5. Application of principles of management and organization in the delivery of health
services to the community.

(Maglaya)
- The Utilization of the nursing process in the different levels of clientele individuals,
families, population groups and communities, concerned with the promotion of health,
prevention of disease and disability and rehabilitation.

(Jacobson)
- is a learned practice disciplined with the ultimate goal of contributing as individual and
incollaboration with others, to the promotion of clients optimum level of functioning
through teaching and delivery of care.
(Dr. Ruth B. Freeman)
- a service rendered by a professional nurse to IFCs population groups in health centers,
clinics schools, workplace for the promotion of health, prevention of illness, care of the
sick at home and rehabilitation.
- Technical nursing, interpersonal, analytical and organizational skills are applied to
problems of health as they affect the community.
-Unique blend of nursing & public health practice aimed at developing & enhancing
health capabilities of the people , service rendered by a professional nurse with the
comm., grps, families, and indiv at home, in H centers, in clinics, in school, in places of
work for the ff:
1. Promotion of health
2. Prevention of illness
3. Care of the sick at home and rehab - self-reliance

Factors affecting Optimum Level of Functioning (OLOF)

1. Political
2. Behavioral
3. Hereditary
4. Health Care Delivery System
5. Environmental Influences
6. Socio economic Influences

Concepts
1. The primary focus of community health nursing practice is on health promotion and
disease prevention.
Primary goal self reliance in health or enhanced capabilities.
Ultimate goal raise level of number of citizenry.
Philosophy of CHN Worth and dignity of man.
2. CHN practices to benefit the individual, family, special groups, and community
*CHN is integrated and comprehensive
3. Community Health Nurses are generalist in terms of their practice through life but the
whole community its full range of health problems and needs.
4. Community Health Nurses are generalist in terms of their practice through life
continuity in its full range of health problems and needs.
5. The nature of CHN practice requires that current knowledge derived from the
biological, social science, ecology, clinical nursing and community health organizations
be utilized.
6. Contact with the client and or family may continue over a long period of time which
includes all ages and all types of health care.
Levels of Health Care:
 Primary Health Care: Management at the level of community
Secondary Health Care: Regional, District, Municipal, and Local Hospital
Tertiary Health Care: Sophisticated Medical Center Heart Center, KI
7. The dynamic process of assessing, planning, implementing and intervening provide
measurements of progress, evaluation and a continuum of the cycle until the termination
of nursing is implicit in the practice of Community Health Nursing.
Nursing Function:
Independent without supervision of MD
Collaborative in collaboration with other Health team (
interdisciplinary, intrasectoral )

II. Community Health Nursing

- The utilization of the nursing process in the different levels of clientele- individuals,
families, population groups and communities, concerned with the promotion of health,
prevention of disease and disability and rehabilitation.

Goal: To raise the level of citizenry by helping and families to cope with the
discontinuities in and threats to health in such a way as to maximize their potential for
high-level wellness. Nisce, et al
To elevate the level health of the multitude.

MISSION OF CHN ( FIVE FOLD MISSION )

*Health Promotion activities related to enhancement of health.
*Health Protection activities designed to protect the people.
*Health Balance activities designed to maintain well being.
*Disease Prevention activities relate to avoid complication = primary, secondary,
tertiary.
*Social Justice activities related to practice practice equity among clients.

PHILOSOPHY OF CHN
*The philosophy of CHN is based on the worth and dignity of man.

Roles of COMMUNITY HEALTH NURSE / PUBLIC HEALTH NURSE

CLINICIANS - who is a health care providers, taking care of the sick people at home or
in the RHU.
HEALTHEDUCATOR who aims towards health promotion and Illness prevention
through dissemination of correctr information; educating people.
ADVOCATOR acts on behalf of the client.
FACILITATOR who establishes multi sectoral linkages by referral system.
SUPERVISOR who monitors and supervises the performance of midwives.
COLLABORATOR working with other health team member.
-In the event that the Municipal Health Officer ( MHO ) is unable to perform his
duties/functions or is not available, the Public Health Nurse will take charge of the MHOs
responsibilites.
-Other Responsibilities of a Nurse, spelled by the implementing rules and regulations of
RA 7164 ( Philippine Nursing Act of 1991 ) includes:
*supervision and care of women during pregnancy, labor, and puerperium.
*Performance of Internal Examination and Delivery of Babies.
*Suturing lacerations in the absence of a Physicians.
*Provisions of First aid measures and Emergency Care.
*Recommending Herbal and Symptomatic Meds... Etc.

In the Care of the Families:

-Provision of Primary Health Care Services.
-Developmental/Utilization of Family Nursing Care Plan in the provision of Care.

In the Care of the Communities:

-Community organizing mobilization, Community development, and People
empowerment.
-Program planning, Implementation, and Evaluation.
-Influencing executive and legislative individuals or bodies concerning health and
develoment.

ROLES OF THE COMMUNITY HEALTH NURSE

1. Planner/ Programmer- identifies needs, priorities & problems if individual, family, &
comm.
- Formulates nursing component of H plans
In doctorless areas, she is responsible for the formulation of the municipal
health plan
Provides technical assistance to rural health midwives in health matters like
target setting.
2. Provider of Nursing care- provides direct nsg care to the sick, disabled in the homes,
clinics, schools,
or places of work
provide continuity of patient care
3. Manager/ Supervisor- formulates care plan for the:
4 Clientele:
a. Requisitions, allocates, distributes materials (meds & medical supplies &
records & reports equips
b. Interprets and implements programs, policies, memoranda, & circulars
c. Conducts regular supervisory visits & meetings to diff RHMs & gives feedbacks
on accomplishments
 4. Community Organizer- motivates & enhance community participation in terms of
planning, org, implementing
and evaluating Health programs/ services.
5. Coordinator of Health Services- coordination with other health team & other govt org
(GOs & NGOs) to other
health programs as envt. sanitation health education, dental health & mental
health.
6. Trainer/ Health educator/ counselor- conducts training for RHMs, BHWs, hilots who
aim towards H promo & illness prevention through dissemination of correct info;
educating people
7. Researcher- coordinates with govt. & NGOs in the implementation of studies/
researches
participates in the conduct of surveys studies & researches on Nsg and H
related subjs.
8. Health Monitor----evaluating what deviates from normal
9. Manager ---under the nurse---midwives
10. Change Agent
11. Client Advocate

Responsibilities of COMMUNITY HEALTH NURSE

-Be a part in developing an overall health plan, it is implementation and evaluation for
communities.
-Provide quality nursing services to the three levels of clientele.
-Maintain coordination/linkages with other health team members, NGO/government
agencies in the provision of public health services.
-Conduct researches relevant to CHN services to improve provision of health care.
-Provide opprotunities for professional growth and continuing education for staff
development..

PUBLIC HEALTH

1. WINSLOW
- The science & art of preventing disease, prolonging life, promoting health &
efficiency through
organized community effort
To enable each citizen to realize his birth right of health & longevity.
Major concepts:
1. Health promotion
2. Peoples participation towards self-reliance
2. HANLON
- Most effective goal towards total development and life of the individual & his
society

3. PURDOM
- Applies holism in early years of life, young, adults, mid year & later
 - Prioritizes the survival of human being

PUBLIC HEALTH NURSING

(Cuevas, 2007)
-In the light of the changing national and global helath situation and the
acknowledgement that nursing is a significant contributor to health, the public health
nurse is strategically positioned to make a difference in the health outcomes of
individuals, families, and communities cared for.

Concepts
1. Science and Art of Preventing diseases, prolonging life, promoting health and
efficiency through organized community effort for the:
a. sanitation of the environment.
b. control of communicable diseases.
c. the education of individuals in personal hygiene.
d. organization of medical and nursing services for early diagnosis and preventive
treatment of disease, and the development of social machinery to ensure everyone a
standard of living adequate for the maintenance of health, so organizing these benefits
as to enable every citizen to realize his birthright of health and longevity.

Determinants of Health
*Factors that can affect health
a. Income and social status - socioeconomic
b. Education - socioeconomic
c. Physical Environment - Environment
d. Employment and working conditions - socieconomic
e. Social support networks - socioeconomic
f. Culture, Customs and Traditions - Behavior
g. Genetics - Heredity
h. Personal Behavior and coping skills - Behavior
i. Health Services Health Care Delivery System
j. Gender Heredity
-ECOSYSTEM influence on OLOF ( Blum 1974 ).

CORE Busyness of Public Health:

1. Disease control
2. Injury Prevention
3. Health Protection
4. Health public policy including those in relation to environmental hazards such as in the
work place, housing, food, water, etc.,
5. Promotion of health and equitable health gain.
In response to above trends, the global community, represented by the United Nations
General Assembly, decided to adopt a common vision of poberty reduction and
sustainable development in september 2000.
This vision is exemplified by the Millenium Development Goals (MDGs) which are
based on the fundamental values of:
FREEDOM
EQUALITY
SOLIDARITY
TOLERANCE
HEALTH HEALTH: MILLENIUM DEVELOPMENT GOALS
RESPECT FOR NATURE MDG 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.

SHARED RESPONSIBILITY MDG 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.

MDG 3: Promote gender equality and women

empowerment
Target: Eliminate gender disparity in primary and
secondary education preferably by 2005 and
to all levels of education no later than 2015.

MDG 4: Decreased child mortality

Target: Reduce by 2/3, between 1990 and 2015, the
under five mortality rate.

MDG 5: Increased maternal health

Target: Reduce by three quarters, between 1990
and 2015, the maternal mortality ratio.

MDG 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.
 MDG 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.

MDG 8: Develop a global partnership for

development.
Target : Develop further an open, rule-based,
predictable, non-discriminatory 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.

COMMUNITY HEALTH NURSING PUBLIC HEALTH NURSING

( ART ) and Science ( SCIENCE ) and Art
*Synthesis of nursing practice and *Synthesis of public health and
public health practice applied to nursing practice.
promoting and preserving the health *Specific/subspecialty nursing
of the populations. practice.
*Directs care to individuals, families, *Defined as the practice of
or groups; this care, in turn promoting and protecting health of
contributes to the health of the total populations using knowledge from
population. nursing social and public health
*knowldge = nursing and PHN sciences.
*More General Specialty area that *CORE FUNCTIONS:
encompasses subspecialties that a. Assessment
include Public Health Nursing and b. Policy development
other developing fields of practice c. Assurance
 such as home health, hospice care,
and independent nursing practice.
*Essential Functions:
-Heart monitoring and analysis.
-Epidemiological
surveillance/disease prevention
and control and all.

A. Principles and Standards of CHN

PRINCIPLES AND STANDARD OF CHN

PRINCIPLES
1. The need of the community is the basis of community health nursing.
2. The community health nurse must understand fully the objectives and policies of the
agency she represents.
3. The family is the unit of service.
4. CHN must be available to all regardless of race, creed and socioeconomic status.
5. The CHN works as a member of the health team
6. There must be provision for periodic evaluation of community health nursing service.
7. Opportunities for continuing staff education programs for nurses must be provided by
the community health nursing agency and the CHN as well.
8. The CHN makes use of available community health resources.
9. The CHN taps the already existing active organized groups in the community.
10. There must be provision for educative supervision in community health nursing.
11.There should be accurate recording and reporting in community health nursing.
12. Health teaching is the primary responsibility of the community health nurse.

STANDARDS IN CHN
I. Theory
Applies theoretical concepts as basisfor decisions in practice.
II. Data Collection
Gathering comprehensive, accurate data systematically.
III. Diagnosis
Analyzes collected data to determine the needs / health problems of Individual,
Family, Community.
IV. Planning
At each level of prevention, develops plans that specify nursing actions unique to
needs of clients.
V. Intervention
Guided by the plan, intervenes to promote, maintain or restore health, prevent illness
and institute rehabilitation.
VI. Evaluation
Evaluates responses of clients to interventions to note progress toward goal
achievement, revise data base, diagnose and plan.
VII. Quality Assurance and Professional Development
 Participates in peer review and other means of evaluation to assure quality of nursing
practice.
Assumes professional development.
Contributes to development of others.
VIII. Interdisciplinary Collaboration
Collaborates with other members of the health team, professionals and community
representatives in assessing, planning, implementing and evaluating programs for
community health.
IX. Research
Indulges in research to contribute to theory and practice in community health nursing.

B. Levels of Care
LEVELS OF CARE/PREVENTION
a. The Three Levels of Helath Care Sevices
PRIMARY
-Is devolved to the cities and the municipalities. It is health care provided by center
physicians, public health nurses, rural health midwives, barangay health workers,
traditional healers and others at the barangay health stations and rural health units. The
primary health facility is usually the first contact between the community members and
the other levels of health facility.
- activites that prevent a problem before it occurs. Example: Immunization.
SECONDARY
-Secondary care is given by physicians with basic health training. This is usually given in
health facilities and district hospitals and out-patient departments of provincial hospitals.
This serves as a referral center for the primary health facilities. Secondary facilities are
capable of performing minor surgeries and perform some simple laboratory examinations.
- activities that provide early detection/diagnosis and treatment and Intervention.
Example: Breast self-examination, HIV screening, Operation timbang.
TERTIARY
-Is rendered by specialists in health facilities including medical centers as well as regional
and provincial hospitals, and specialized hospitals such as the Philippine Heart Center.
The tertiary health facility is the referral center for the secondary care facilities.
Complicated cases and intensive care requires tertiary care and all these can be
provided by the tertiary care facility.
- activities that correct a disease state and prevent it from further deteriorating.
Example: Teaching Insulin Administration in the home

b. Three Levels of Health Care Services and the Two Way Referral System

*There are TWO LEVELS OF PRIMARY HEALTH CARE WORKERS, namely:

1. Village or Barangay Health Workers: refers to trained community health workers or
health auxiliary volunteers or traditional birth attendants or healers.
2. Intermediate Level Health Workers: refers to general medical practitioners or their
assistants, public health nurse, rural sanitary inspectors, and midwives.

c. Types of Primary Health Workers

Village / Grassroots Intermediate Level Health Personnel of

Health Workers First-Line Hospitals
E - trained -general medical -physicians
X community practitioners -nurses
A -health worker -public health nurses -dentists
M -auxiliary health -midwives
P volunteer
L -traditional birth
E attendant
C -initial link, first -first source of -establishes close
H contact of the professional health contact with the
A community care village and
R intermediate level
A -works in liaison -attends to health health workers to
C with the local problems beyond the promote the
T health service competence of continuity of care
E workers village health from hospital to
R workers community to home
I -provides
S elementary curative -provides support to -provides back-up
T and preventive the frontline health health services for
I health care workers in terms of cases requiring
C measures supervision, training, hospital or
S referral services and diagnostic facilities
supplies thru linkages not available in
with other sectors health care

C. Types of Clientele
TYPES OF CLIENTELE

INDIVIDUAL
- People who visits the health center.
- People who receives health services.
e.g., Prenatal Supervision
Well Child Follow ups.
Morbidity Service
Teaching Client on Insulin Administration
Basic approaches in looking at the individual:
1. atomistic the basic constituents of an individual, use concepts of biology which in
turn refers to essentialism --- behavior --- psychological --- human behavior s dictated by
experience.
2. holistic suprasystems sociological in nature social constructionism nurture
behavior
SEX --- a biological concept (male / female)
--- a sociological concept --- gender --- musculinity or femininity --- based on
culture.
--- on sexual orientation: attracted to Opposite sex heterosexual
Same sex homosexual
Both bisexual

Perspective in understanding the individual:

1. BIOLOGICAL
a. unified whole
b. holon
c. diporphism
2. ANTHROPOLOGICAL
a. Essentialism
b. Social constructionism
c.Culture
3. PSYCHOLOGICAL
a. Psychosexual
b. Psychosocial
c. Behaviorism
d. Social learning
4. SOCIOLOGICAL
a. Family and kinship
b. Social groups

FAMILY
- 2 or more individuals who commit to live together for an extended period of time not
necessarily with marital affinity or blood relations.
- Considered as the basic unit of care.
a. Nuclear
b. Extended with lolos and lalas, titios and titas
c. Cohabiting live-in, Not married but with kids.
d. Dyad married but without kids.

MODELS:
Stages of Family Development by Evelyn Duvall
STAGE 1 The Beginning Family ( newly wed couples ).
TASK: Compliance with the PD 965 and acceptance of the new member of the family.
STAGE 2 The Early Child Bearing Family ( 0 30 months ).
TASK: Emphasize the importance of pregnancy and immunization and learn the concept
of parenting

STAGE 3 The Family with Preschool Children ( 3 6 years old ).

TASK: Learn the concept of Responsible Parenthood.

STAGE 4 The Family with School Age Children ( 6 -12 years old).
TASK: Reinforce the concept of Responsible Parenthood.

STAGE 5 The Family with Teenagers (13 25 years old ).

TASK: Parents to learn the concept of let go system and understand the generation
gap.

STAGE 6 Launching Center ( 1st Child will get married upto the last child ).
TASK: Compliance with the PD 965 and acceptance of the new member of the Family.

STAGE 7 Family with Middle Adult Parents ( 36 60 years old ).

TASK: Provide a Healthy Environment, adjust with a new lifestyle and adjust with the
financial aspect.

STAGE 8 The Aging Family ( 61 years old upto death ).

TASK: Learn the concept of Death Positively.

8 Family Tasks or Basic Tasks of Developmental Model:

Physical maintenance
Allocation of resources- income given to wife
Division of labor joint parenting
Socialization of family members
Reproduction, recruitment & release
*Maintenance of order- high crime rate
Placement of members in larger society- Indication familys success
Maintenance of motivation & morale
Criticisms: very limited & cannot apply to all situation

STRUCTURAL FUNCTIONAL
Initial Data Base
a. Family Structure and Characteristics
Nuclear basic family
Extended in-law relations, or grandparents relations
*members of household in relation to head
*demographic data ( sex male or female, age, civil status )
Live in = married/ common law WIFE
 Male Patriarchal Female Matriarchal
*types and structure of family
*dominant members in health
*general family relationship

Assessment: Family
-Initial data base
-1st level assessment
-2nd level assessment

b. Socio-economic and cultural Factors

*resources and expenses
*educational attainment
*ethnic background
*religious affiliation
*SO ( do not live with the family but influences decision )
*Influences to larger communities

c. Environmental Factors
*housing- number of rooms for sleeping
*kind of neighborhood
*social health facilities available
*comm. And transportatx facilities

d. Health Assessment of Each Member PE

e. Value Placed on Prevention of Disease

*Immunization
*Compliance behavior

First Level Assessment

*Health Threats:
-Conditions that are conducive to disease, accident or failure to realize ones health
potential
-Example:
Family history of illness hereditary like DM, HPN
Nutritional problem eating salty foods
Personal behavior smoking, self medication, sexual practices, drugs, excessive
drinking
Inherent personality characteristics short temperedness, short attention span
Short cross infection
Poor home environment
Lack / Inadequate immunization
Hazards fire, falls, or accidents-
Family size beyond what resources can provide -

*Health Deficits:
-Instances of failure in health maintenance ( disease, disability, developmental
lag )
3 TYPES:
a. Disease / Illness URTI, marasmus, scabies, edema
b. Disabilities blindness, polio, colorblindness, deafness
c. Developmental Problem like mental retardation, gigantism, hormonal, dwarfism

*Stree points / Forseeable Crisis Situation:

-Anticipated periods of unusual demand on the individual or family in terms of adjustment
or family resources ( nature situations )
-Example:
Entrance in school
Adolescents (circumcision, menarche, puberty)
Courtship (falling inlove, breaking up)
Marriage, pregnancy, abortion, puerperium
Death, unemployment, transfer or relocation, graduation, board exam

Second Level Assessment (Family tasks involved)

Family tasks that cant be performed

*Recognition of the problem
*Decision on appropriate health action
*Care to affected family member
*Provision of health home environment
*Utilization of community resources for health care

Problem Prioritization:
*Natur eof the Problem
Health Deficit
Health Threat
Forseeable Crisis
*Preventive Potential
High
Moderate
Low
*Modifiability
Easily modifiable
Partially modifiable
Not modifiable
*Salience
High
Moderate
Low
Family Service and Progress Record

Family Coping Index

Physical Independence ability of the family to move in and out of bed and performed
activities of daily living.
Therapeutic Independence abilty of the family to comply with the therapeutic regimen
( diet, medication and usage of appliances ).
Knowledge of Health Condition wisdom of the family to understand the disease
process.
Application of General and Personal Hygiene ability of the family to perform hygiene
and maintain environment conducive for living.
Emotional Competence ability of the family to make decision maturely and
appropriately ( facing the reality of life ).
Family Living Pattern the relationship of the family towards each other with love,
respect and trust.
Utilization of Community Resources ability of the family to know the function and
existence of resources within the vicinity.
Health Care Attitude relationship of the family with the health care provider.
Physical Environment ability of the family to maintain environment conducive for
living.

COMMUNITY Patient
- Defined by geographic boundaries with certain identifiable characteristics, with common
values and interests.

POPULATION GROUPS-
-Aggregation of people who share common chaaracteristics, developmental stage or
common exposure to particular environmental factors thus resulting in common health
problems ( Clark, 1995: 5 ) e.g. children, elderly, women, workers, etc.

- Vulnerable Groups: or High Risk Groups ( before )

*Infants and Young Children dependent to caretakers
*School age most negected
*Adolescents identify crisis, HIV
*Mother 1/3 of population health problem ( pregnancy, delivery, puerperium )
*Males too macho to consult
*Old People degenerative disease

*Population Pyramid shows the age, sex, and structure

- Specialized Fields:
*COMMUNITY MENTAL HEALTH NURSING a unique process which includes an
integration of concepts from nursing, mental health, social psychology, psychology,
community networks, and the basic sciences.
Focus: Mental Health Promotion no need to identify disease, increase mental wellness
of people.
Nursing: Strengthening the support mechanism
Psychiatric Nursing-Focus: Mental Disease Prevention
Focus: Mental Disease Prevention identify disease and shorten disease process

*OCCUPATIONAL HEALTH NURSING the application of nursing principles and

procedures in conserving the health of workers in all occupations.
Aims: Health promotion and prevention of disease and injuries, risk minimization,
ensuring safe work place from industrial to service

*SCHOOL AND HEALTH NURSING the application of nursing theories and principles
in the care of the school population.
Components:
School Health Services- maintain school clinic, screening all children- visual, hearing,
scoliosis

Health Instruction- health education/ counselor direct & undirect

Healthful School Living- health monitor

Mental health- substance abuse, sexual H

Environmental health- food sanitation, water supply, safe environment, safe toilet

School community- linkage- comm. Organizer

D. Health Care Delivery System

PHILIPPINE HEALTH CARE DELIVERY SYSTEM

The Philippine health care delivery system is composed of two sectors: (1) the public
sector, which largely financed through a tax-based budgeting system at both national
and local levels and where health care is generally given free at the point of service and
(2) the private sector (for profit and non-profit providers) which is largely market-
oriented and where health care is paid through user fees at the point of service.

The public sector consists of the national and local government agencies providing
health services. At the national level, the Department of Health (DOH) is mandated as
the lead agency in health. It has a regional field office in every region and maintains
specialty hospitals, regional hospitals and medical centers. It also maintains provincial
health teams made up of DOH representatives to the local health boards and personnel
involved in communicable disease control, specifically for malaria and schistosomiasis.
Other national government agencies providing health care services such as the
Philippine General Hospital are also part of this sector.
With the devolution of health services, the local health system is now run by Local
Government Units (LGUs). The provincial and district hospitals are under the provincial
government while the city/municipal government manages the health centers/rural health
units (RHUs) and barangay health stations (BHSs). In every province, city or municipality,
there is a local health board chaired by the local chief executive. Its function is mainly to
serve as advisory body to the local executive and the sanggunian or local legislative
council on health-related matters.

The private sector includes for-profit and non-profit health providers. Their involvement
in maintaining the peoples health is enormous. This includes providing health services in
clinics and hospitals, health insurance, manufacture of medicines, vaccines, medical
supplies, equipment, and other health and nutrition products, research and development,
human resource development and other health-related services.

1. PRIMARY LEVEL FACILITIES

2. SECONDARY LEVEL FACILITIES
3. TERTIARY LEVEL FACILITIES

Classify as to what level the following belong

1. Teaching and Training Hospitals _______________
2. City Health Services _______________
3. Emergency and District Hospitals _______________
4. Private Practitioners _______________
5. Heart Institutes _______________
6. Puericulture Centers _______________
7. RHU Primary Level Facilities

Primary RHU, Brgy health centers

Secondary District Hospitals
Tertiary Provincial Hospitals, City Hospitals

A. THE PUBLIC SECTOR

1. THE DEPARTMENT OF HEALTH

DEPARTMENT OF HEALTH
-Lead agency in the Health Sector
-Sets the goals for the nations health status
-Establishes PARTNERSHIP

DOH MANDATE
1. Formulation
2. Support
3. Issuance
4. Promulgation
5. Development

Roles of DOH:
1. Leadership in Health
*Serve as the national policy and regulatory institution.
*Provide leadership in the formulation, monitoring and evaluation of the national health
policies, plans and programs.
*Serve as advocate in the adoption of health policies, plans and programs
2. Enabler and Capacity builder
*Innovate new strategies in health.
*Exercise oversight functions and monitoring and evaluation of national health plans,
program and policies.
*Ensure the highest achievable standards of quality health care, promotion and
protection
3. Administrator of specific services
*Manage selected national health facilities and hospitals with modern and advanced
facilities.
*Administer direct services for emergent health concerns that require new complicated
technologies.

Primary Function of DOH

-Promotion
-Protection
-Preservation
-Restoration

***VISION:
Old: Health for all Filipinos
New: The Leader of health for all in the Philippines
New: The DOH is the leader, staunch advocate and model in promoting Health for all in
the Philippines.

New: A global leader for attaining better health outcomes, competetive and responsive
health care system, and equitable health financing by 2030.

***MISSION:
-Old: Ensure accessability and quality of health care services to improve the quality of life
of all Filipinos, especially the poor.
-New:To guarantee equitable, sustainable and quality health for all Filipinos, especially
the poor, and to lead the quest for excellence in health.
Important CONCEPT!!!
In the community setting, the marginalized refers to...
D
O
P
E
A
S

PHILOSOPHY OF DOH:
-Quality is above Quantity!

PRINCIPLES OF DOH
P Performance of health sector must be enhanced.
U Universal Access to basic health services.
S Shifting from infectious to degenerative diseases must be managed.
H Health, and nutrition of vulnerable group must be prioritized.

***STRATEGIES OF DOH
SAID!!!
S support the local health system and front line workers.
A assurance of health care for all.
I increase investment of PHC.
D development of national standards, and objective for health.

Five Major Functions of the DOH

- Ensure equal access to basic health services
- Ensure formulation of health policies for proper division of labor and proper
coordination of operations among agencies
- Ensure maximum level of implementation nationwide of services regarded as
public health goods
- Plan and establish arrangements for public health systems to achieve economics
of scale
- Maintain a medium of regulation and standards to protect consumers and guide
providers

GOAL: Heal Sector Reform Agenda ( HSRA ).

Rationale for HSRA:

*Slowing down in the reduction of Infant Mortality and Maternal Mortality Rates.
*Persistence of large variations in health status across population groups and geographic
areas.
*High burden from infectious diseases.
*Rising burden from chronic and degenerative diseases.
*Unattended emerging health risks from environmenmental and work related factors.
*Burden of disease is heaviest on the poor.

Framework for the Implementation of HSRA: FOURmula One for Health

Goals of FOURmula ONE for Health:

1. Better health outcomes
2. More responsive health systems
3. Equitable health care financing

Elements of the Strategy:

1. Health financing to foster greater, better and sustained investments in health.
2. Health regulation to ensure quality and affordability of health goods and services.
3. Health service delivery to improve and ensure the accessibility and availability of
basic and essential health care in both public and private facilities and services.
4. Good governance to enhance health system performance at the national and local
levels.

Roadmap for All Stakeholders in Health: National Objectives for Health 2005 2010.

National Objective for Health: sets the target and the critical indicators, current
strategies based on field experience, and laying down new avenues for improved
interventions.

Goals and Objectives of the Health Sector:

- to facilitate understanding the objective of the health sector could be divided into 4
general objectives, namely:
Improve Health Status of the Population
a. Improve the general health status of the population.
b. Reduce morbidity and mortality from certain diseases.
c. Eliminate certain diseases as public health problems.
d. Promote health lifestyle and environmental health.
e. Protect vulnerable groups with special health and nutritional needs.
Ensure Quality Service Delivery
a. Strengthen national and local health systems to ensure better health service
delivery.
b. Pursue public health and hospital reforms.
c. Reduce the cost and ensure the quality and safety of health goods and services.
d. Strengthen health governance and management support systems.
Improve Support system for the Vulnerable and Marginalized Groups
a. Institute safety nets for the vulnerable and marginalized groups.
Implement Proper Resource Management
a. Expand the coverage of social health insurance.
b. Mobilize more resources for health.
c. Improve efficiency in the allocation, production and utilization of resources for
health.

Major Helath Plans towards Health in the Hands of the People in the year 2020
A Healthy BARRIO should be:
a. Residents actively participate in attaining good health; they are PARTNERS in health
care.
b. Highlight Project: BOTIKA SA PASO CAMPAIGN
c. Goal: to maintain herbal plants in pots for family use
A Healthy CITY should be:
a. The physical environment in the workplace, streets, and public places promote
health, safety, order and cleanliness through structural manpower support
b. Health- Related Strategies: Construction of well-maintained, income generating
public toilets; designation of a pook-sakayan, pook-babaan
A Healthy EATING PLACE should be:
a. Eating place where:
- safe and properly prepared, stored and transferred foods
- nutritious foods and drinks are served.
b. Complies with the following sanitation standards:
- safe, environment-friendly
- with clean restrooms
- food handlers are medically fit
A Healthy MARKET should be:
a. Adequate water supply
b. Proper drainage
c. Well-maintained toilet facilities
d. Proper garbage and waste disposal
e. Cleanliness maintained
f. Affordable quality foods
A Healthy HOSPITAL should be:
a. A Center of Wellness
b. Promotes Preventive care
c. Patient-centered
A Healthy STREET should be:
a. Well-maintained roads and public waiting areas
b. Clean and obstruction free sidewalks
c. With minimal traffic problems
d. With adequate strict law enforcement
e. Project: Pook Tawiran
f. Goal: to promote and reorient people especially erring pedestrians on the use of
pedestrian crossings
GOALS AND OBJECTIVES OF DOH
GREEPPP!!!
G general health status of Filipino must improve
R reduce morbidity, mortality and disability to different diseases
E eradicate poliomyelitis
E eliminate certain endemic disease
P promote the health and nutrition of the family
P promote healthy lifestyle
P promote environmental sanitation

Basic Principles to Achieve Improvement in Health

1. Universal access to basic health servicesmust be ensured.
2. The health and nutrrition of vulnerable groups must be prioritized
3. The epidemiological shift from infection to degenerative diseases must be managed.
4. The performance of the health sector must be enhanced.

Primary Strategies to Achieve Goals

1. Increasing investment for primary Health Care.
2. Development of national standards and objectives for health.
3. Assurance of health care.
4. Support to the local system development.
5. Support for frontline health workers.

2. LOCAL GOVERNMENT UNITS

- the Local Government Code of 1991 or RA 7160 transformed local government units
into self-reliant communities and active partners in the attainment of national goals
through a more responsive an accountable government structure instituted through a
system of decentralization.
B. THE PRIVATE SECTOR
- composed of both commercial and business organizations with its market or profit
orientation and non-business organizations with its service orientation

E. PHC as a Strategy
PHC as a Strategy

PRIMARY HEALTH CARE (PHC)

*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.

*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.

*October 19, 1979 Letter of Instruction ( LOI 949 ), the legal basis of PHC was signed
by President Ferdinand E. Marcos, which adopted PHC as an approach toward the
design, development and implementation of programs focusing on health development at
community level.
LOI 949 signed by President Marcos with an underlying theme: Health in the hands of
the People by 2020.

Rationale for Adopting PRIMARY HEALTH CARE:

*Magnitude of Health Problems.
*Inadequate and unequal distribution of health resources.
*Increasing cost of medical care.
*Isolation of health care activities from other development activities.

DEFINITION 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.
*A practice 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 of
the community.

Goal of PRIMARY HEALTH CARE:

*Health for all Filipinos by the year 2000 and health in the Hands of the people by the
year 2020.

An improved state of health and quality of life for all people attained through SELF-
RELIANCE.

Concept of PHC
KEY STRATEGY TO ACHIEVE THE GOAL:
- characterized by partnership and empowerment of the people that shall permeate as
the core strategy in the effective provision of essential health service that are community
based, accessible, acceptable and sustainable at a cost, which the community and the
government can afford.

OBJECTIVES OF PRIMARY HEALTH CARE

*Improvement in the level of health care of the community.
*Favorable population growth structure.
*Reduction in the prevalence of preventable, communicable and other disease.
*Reduction in morbidity and mortality rates especially among infants and children.
*Extension of essential health services with priority given to the underserved sectors.
*Improvement in Basic Sanitation.
*Development of the capability of the community aimed at self reliance.
*Maximizing the contribution of the other sectors for the social and economic
development of the community.

MISSION:
*To strengthen the health care system by increasing opportunities and supporting the
conditions wherein people will manage their own health care.

Two levels of PRIMARY HEALTH CARE WORKERS

1. Barangay Health Workers trained community health workers or health auxiliary
volunteers or traditional birth attendants or healers.
2. Intermediate Level Health Workers include the Public Health Nurse, Rural Sanitary
Inspector and Midwives.

Levels of Health Care and Referral System

1. Primary Level of Care Health care provided by center physicians, PHN, Rural Health
Midwives,Barangay Health Workers and other at the Baragay Heath Station and Rural
Health Units.
2. Secondary Level of Care Given by physicians with Basic Health Training; given in
Health Facilities which are privately owned or government operated such as infirmaries,
municipal and district hospitals and OPD of Provincial Hospitals; serves as the Referral
Center for Primary Health Facilities.
3. Tertiary Level of Care Care rendered by Specialists in Health Facilities including
Medical Centers as well as Regional and Provincial Hospitals and specialized Hospitals.

PRINCIPLES OF PRIMARY HEALTH CARE

1. 4 As = Accessibility, Availability, Affordability and Acceptability,
Appropriateness of Health Services. 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 = Heart and Soul of Primary Health Care.
3. People are the center, object and subject of development =
- 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 ).
- Part of the peoples participation is the partnership between the community and
the agencies found in the community; social mobilization and decentralization.
- 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
Centers.

Barriers of COMMUNITY INVOLVEMENT

- Lack of motivation
- Attitude
- Resistance to change
- Dependence on the part of community people
- Lack of managerial skills

4. SELF RELIANCE
5. Partnership between the community and the health agencies in the provision of
quality of life = Providing linkages between the government and the non government
organization and peoples organization.

6. Recognition of interrelationship between the health and development =

HEALTH
- is not merely the absence of disease. Neither it is only a state of physical and mental
well being.
- Health being a soical 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, DEVELOPMENT
is the quest for an improved quality of life for all.
-Development is mulit dimentional. It has a 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 =
- It enhances people participation or governance, support system provided by the
Government, networking and developing secondary leaders.

8. DECENTRALIZATION

Strategies of PRIMARY HEALTH CARE

1. Reorientation and reorganization of the national health care system.
2. Effective preparation and enabling process for health action at all levels.
3. Mobilization of the people to know their communities and identifying their basic health
needs.
4. Development and utilization of appropriate technology.
5. Organization of communities.
6. Increase opportunities for community participation.
7. Development of intra intersectoral linkages.
8. Emphasizing partnership.

MAJOR STRATEGIES OF PRIMARY HEALTH CARE

A. 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.
- 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.
B. 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 builiding of communities and organization to plan,
implement and evaluate health prgrams at their levels.
C. 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.
D. 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.

Translated into action, the PHC APPROACH focuses on:

Partnership with the community
Equitable distribution of health resources
Organized and appropriate health system infrastructure
Prevention of disease and promotion of health as focus
Linked multisectorally
Emphasis on appropriate technology

*PHC as a service delivery policy of the DOH permeates all strategies and thrusts of
government health programs from the national to the local and community levels
Dimension Commercialized Health Primary Health Care
Care
Goal Absence of disease for Prevention of disease
the individual Socio-economic
development
Focus of Care Sick Sick and well individuals
Setting for Hospital-based Satellite Health Centers
Services Urban-Centered Community Health
Centers
Accessible only to a few Rural-Based
people Accessible to all
People Passive recipients of Active participants in
health care health care
Structure Health is isolated from Inter- and intra- sectoral
other sectors of society linkaging allows health to
be integrated with over-all
socio-economic
 development efforts

Process Decision-making from Decision-making from

top-down bottom-top
Technology Curative services based Promotive and preventive
on modern medicine services blend traditional
and sophisticated medicine with modern
technology medicine
Physician dominated Appropriate technology
for frontline health care
Outcome Reliance on health People empowerment or
professionals self-reliance

FOUR CORNERSTONES/PILLARS IN PRIMARY HEALTH CARE

1. Active community participation
2. Intra Intersectoral linkages
3. Use of appropriate technology
4. Support mechanism made available

HERBAL MEDICINES ENDORSED BY THE DEPARTMENT OF HEALTH

NAME INDICATIONS DOSAGE
1. Five leaf Chaste tree 1. Asthma *Divide the decoction into 3
LAGUNDI (Vitex negundo) 2. Cough parts:
3. Body Pain -For asthma and cough,
4. Fever drink 1 part 3 times a day.
-For fever and body
pains,drink 1 part every 4
hours.
2. Marsh Mint; 1. Body aches and pain, *Divide decoction into 2
Peppermint e.g., rheumatism, parts and drink 1 part every
YERBA BUENA headache, swollen 3 hours.
(Mentha cordifolia) gums,toothache,
(Clinopodium douglasii) menstrual and gas pain.
3. Blumea camphora 1. Swelling *Divide decoction into 3
SAMBONG (Blumea 2. Inducing diuresis ( anti parts and drink 1 parts 3
balsamifera) urolithiasis ) times a day.
4. TSAANG GUBAT (Ehretia 1. Effective in treating *Drink the warm decoction.
microphylla Lam). intestinal motility and also If it persists, or if there is
used as a mouth wash no improvement an hour
since the leaves of this after drinking the decoction,
shrub has high flouride consult a doctor.
 content.
5. ULASIMANG BATO 1. Effective in fighting
(Peperomia pellucida). arthritis and gout.
-also known as PANSIT-
PANSITAN.
6. Garlic 1. Reduces cholesterol in
BAWANG (Allium sativum) the blood and hence,
helps control blood
pressure.
(Hypertension,
Hyperlipidemia)
7. Chinese honeysuckle 1. Elimination of Intestinal
NIYOG NIYOGAN worms, particularly the
(Quisqualis Indica L.) ascaris and trichina.
8. Guava 1. ANTISEPTIC (to
BAYABAS (Psidium clean/disinfect wounds)
Guajava) 2. Mouth wash infection,
sore gums and tooth
decay.
9. Ringworm bush Treatment of ringworms
AKAPULKO also known as and skin fungal infections.
bayabas bayabasan 1. Ring worm day.
(Cassia alata) 2. Athletes foot
3. Scabies
*The leaves can be eaten
fresh (about a cupful) as a
salad or decocted and
drunk as tea. For the
Decoction, boil a cup of
clean chopped leaves in 2
cups of water. Boil for 15 to
20 minutes. Strain, let cool
and drink a cup after meals
(3 time a day).
*Eat 6 cloves of garlic
together with meals.
*Chew and swallow only
dried seeds 2 hours after
dinner according to the
following:
ADULTS = 8 -10 seeds
9 12 years old = 6 7
seeds
6 8 years old = 5 6
seeds
4 5 years old = 4 5
seeds
*For wound cleaning, use
decoction for washing the
wound 2 times a day.
*For tooth decay and
swelling of gums, gargle
with warm decoction 3
times a day.
*Apply the juice on the
affected area 1 to 2 times a
*If the person develops an
allergy while using the
above preparation, prepare
the following:
= Put 1 cup of chopped
 fresh leaves in an earthen
jar. Pour in 2 glasses of
water and cover it.
= Boil the mixture until the 2
glasses of water originally
poured have been reduced
to 1 glass of water.
= Strain the mixture. Use it
while it is warm.
= Apply the warm decoction
on the affected area 1 to 2
times a day.
10. Bitter gourd or Bitter 1. Mild Non Insulin *Drink cup of cold or
melon Dependent Diabetes warm decoction 3 times a
AMPALAYA (Momordica Meelitus day after meals.
Charantia) = Lowers Blood Sugar
Levels.

11. Ginger (Zingiber 1. Motion Sickness, sore *An abortifacient if taken in

officinale) throat, nausea and large amounts; should not
vomiting, migraine be used by persons with
headaches, arthritis. cholelithiasis unless
directed by the physician;
may increase the risk of
bleeding when used
concurrently with
anticoagulants and
antiplatelets.
*Chop and Mash a piece of
ginger root, and mix in a
glass of water.
*Boil the mixture.
*Drink the cold or warm
decoction as needed.

*AC 196 A: Ampalaya was deleted in 10 herbal plants advised by DOH in October 9,
2003
Reminders on the Use of Herbal Medicine:
1. Avoid the use of insecticides
2. Use a clay pot and remove cover while boiling at low heat.
3. Use only the part being advocated
4. follow accurate dose of suggested preparation.
5. Use only one kind of herbal plant for each type of symptom or sickness.
 6. Stop giving the herbal medication in cases of untoward reactions.
7. If signs and symptoms are not relieved after 2-3 doses, consult a doctor.

Policies to abide:
1. Know indications
2. Know parts of plants with therapeutic value: roots, fruits, leaves
3. Know official procedure/preparation
Procedures/Preparations:
a. Decoction
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
b. 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
c. 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
Used for diarrhea and for pneumonia so PHN discourages to buy
commercially prepared cough syrup expectorant: Nature of Cough
1) Dry mucolytic liquefy mucus
Example: Carbocisteine, Guafenesin
2) Productive expectorant irritants to the mucus gland
Example: Bromhexine (Bisolvon)
3) Non stop coughing antitussive
Example: Dextromethorpan (Robitussin) contains codeine
Robitussin AC contains atropine & codeine

d. 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
For problems of constipation
Example: papaya, mango & caimito
e. Cream/Ointment-for topical use
Cream is water based & used for wet skin lesions
Ointment is oil based & used for dry lesions
Example: Akapulko Leaves
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

Elements/Components of Primary Health Care: E L E M E N T S D A M

*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.
*Locally Endemic Disease Prevention and Control
-The control of endemic disease focuses on the prevention of its occurrence to reduce
morbidity rate. Example Malaria Control and Schistosomiasis Control.
*Expanded Program of 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.
*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.
*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.
*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 knowledge regarding proper food planning, Malnutrition is one of the
problems that we have in the country.
*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 illness.
*Supply and Proper Use of Essential Drugs and Herbal Medicine
-This focuses on the information campaign on the utilization and acquisition of drugs.
-In response to this campaign, the GENERIC ACT of the Phiippines is enacted. It
includes the following drugs: Cotrimoxazole, Paracetamol, Amoxycillin, Oresol,
Nifedipine, Rifampicin, INH (isoniazid) and Pyrazinamide, Ethambutol, Streptomycin,
Albendazole,Quinine.
*Dental Health Promotion
*Acces to and Use of Hospitals as Centers of Wellness
*Mental Health Promotion

Functions of the PRIMARY HEALTH NURSING:

1. Management Function
2.Training Function
3.Supervisory Function
4.Health Care Provider Nursing Care Function
5. Health Promotion and Education Function
6. Collaborating and Coordinating Function
7.Research Function

F. Family-based Nursing Services (Family Health Nursing Process)

FAMILY BASED NURSING SERVICES (FAMILY HEALTH NURING PROCESS)
FAMILY HEALTH NURSING

FAMILY Basic unit of society, a primary entity of health care or institution responsible
for the physical, emotional, and social support of its members.
Two Types:
- Family of Orientation
- Family of Procriation

Family Nurse Contact: Definition

- An activity with or on behalf of a particular family or individual.
- A crucial approach in delivering community health nursing service for the family.

Family Nurse Contact: Objectives

- Assess health needs and problems of the family;
- Ensure familys understanding and acceptance of their problems;
- Provide the needed support and assistance to the family;
- Develop the individuals and/or familys competence to cope with their health
problems, and;
- Contribute to the personal and social development of the family through varied
health activities.

FAMILY HEALTH NURSING

*Is a special field in nursing in which the family is the unit of care, health as its goal and
nursing as its medium or channel of care.

Family Case Load

*the number and kind of families a nurse handles at any given time.
*variable for cases are added or dropped based on the need for nursing care and
supervision.

FAMILY NURSING PROCESS

*It is a means by which the health care provider addresses the health needs and
problems of the client.
*It is a logical and systematic, way of processing information gathered from different
source and translating into meaningful actions or interventions.

Concept of Family as a Basic Unit of Society

*The Universal Declaration of Human Rights in Article 16 states that the family is the
natural and fundamental unit of society and is entitled to protection both by society and
the State.

STEPS:
1. RELATING
- Establishing a working relationship. Results in positive outcomes such as good quality
of data, partnership in addressing identified health need and problems, and satisfaction
of the nurse and the client.
2. ASSESSMENT
- Data Collection, Data Analysis and Data Interpretation and Problem definition or
Nursing Diagnosis.
TWO TYPES OF ASSESSMENT
a. First Level Assessment Data on status / conditions of family household
members.
b. Second Level Assessment Data on family assumption of health tasks on each
problem identified in the First Level Assessment.

3. PLANNING
- Determination of how to assist client in resolving concerns related to restoration.
Maintenance or promotion of health.
- Establishment of priorities, set goals / objectives, selects strategies, describe rationale.
4. IMPLEMENTATION
- The carring out of plan of care by client and nurse, make ongoing assessment,
update / revise plan, document responses.
5. EVALUATION
- A systematic, continuous process of comparing the clients response with written goal
and objective.
-Determines progress and evaluate the implemented intervention as to:
1. Effectiveness
2. Efficiency
3. Adequacy
4. Acceptability
5. Appropriateness
I. NURSING ASSESSMENT
-Involves a set of actions by which the nurse measures the status of the family as a
client, their ability to maintain wellness, prevent and control or resolve problems in order
to achieve health and well being among its members.

Steps in Nursing Assessment

1. Data Collection
- The process of identifying the types or kinds of data needed.
- Specify the methods necessary to collect such data.

Methods of Data Collection

a. Observation is use of all sensory capacities. The familys status can be inferred
from the manifestations of problem areas reflected in the following:
1. Communication and interaction pattern expected, used and tolerated by family
members.
2. Role perceptions / tasks assumptions by each member including decision
making patterns.
3. Conditions in the home and environment
b. Physical Examination is done through inspection, palpation, percussion, and
auscultation.
c. Interview by completing health history for each member. Health history
determines current health status.
d. Record Review is the review existing records and reports pertinent to the client /
family such as diagnostic reports and immunization records.
e. Laboratory / Diagnostic Tests

5 Types of Date in Family Nursing Assessment (Initial Data Base)

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. matriarchal or patriarchal, nuclear or extended
Nuclear
Extended
Three generational
Dyad
Single Parent
Step Parent
Blended or Reconstituted
Single adult living alone
Cohabiting / Living in
 No kin
Compound
Gay
Commune

Stages of Family Life Cycle

Newly married couple
Childbearing
Preschool age
Teenage
Launching
Middle aged (empty nest retirement)
Period from retirement to death of both spouses.

*HEALTH TASKS OF THE FAMILY (Freeman, 1981)

1. recognizing interruptions of health or development
2. seeking health care
3. managing health and non-health crises
4. providing nursing care to the sick, disabled and dependent member of the
family
5. maintaining a home environment conducive to good health and personal
development
6. maintaining a reciprocal relationship with the community and health
institutions

5. Dominant family members in terms of decision-making, especially in matters of

health care.
6. General family relationship / dynamics - presence of any obvious / readily
observable conflict between members; characteristic, communication / interaction
pattern 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 decisions 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 family's life
5. Relationship of the family to larger community - Nature and extent of participation
of the family in community activities.

C. Home and Environment

1. Housing
 a. Adequacy of living space
b. Sleeping arrangement
c. Presence of breeding or resting sites of vectors of disease (e.g. mosquitoes,
roaches, flies, rodents, etc)
d. Presence of accident hazards
e. Food storage and cooking facilities
f. Water supply - source, ownership, sanitary condition
g. Garbage/ refuse disposal - type, sanitary condition
h. Drainage system - type, sanitary condition
2. Kind of neighborhood, e.g. congested, slum
3. Social and health facilities available
4. Communication and transportation facilities available

D. Health Status of each Family Member

1. Medical and nursing history indicating current or past significant illnesses or beliefs
and practices conducive to health and illness.
2. Nutritional assessment ( specially for vulnerable or risk at-risk members)
a. Anthropometric data: Measures of nutritional status of children- weight, height,
mid-upper arm circumference.
b. Dietary history specifying quality and quantity of food/ nutrient intake per day
c. Eating/feeding habits /practices
3. Developmental assessment of infants, toddlers, and preschoolers - e.g.,
Metro Manila Developmental Screening Test (MMDST)
4. Risk factor assessment indicating presence of major and contributing
modifiable risk factors for - 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 Such as:
1. Immunization status of family members.
2. Healthy lifestyle practices.
3. Adequacy of :
a. rest and sleep
b. exercise / activities
c. Use of protective measures - e.g. adequate footwear in parasite- infested
areas; use of bednets and protective clothing in malaria and filariasis
endemic areas.
d. Use of relaxation and other stress management activities
 4. Use of promotive-preventive health services.

2. Data Analysis
Steps:
1. Sorting of data for broad categories (such as those related with health status or
practices about home and environment).
2. Clustering of related cues to determine relationship among data.
3. Distinguishing relevant from irrelevant data. This will help in deciding what
information is pertinent to the situation at hand and what information is
immaterial.
4. Identifying patterns such as physiologic function, developmental,
nutritional/dietary, coping/adaptation or communication patterns.
5. Compare patterns with norms or standards of health, family functioning and
assumption of health tasks.
6. Interpreting results of comparisons to determine signs and symptoms or cues of
specific wellness state/s, health deficit/s, health threat/s, foreseeable crises/stress
point/s and their underlying causes or associated factors.
7. Making conclusions about the reasons for the existence of the health condition or
problem, or risk for non-maintenance of wellness state/s which can be attributed
to non-performance of family tasks.

3. Problem Definition/Nursing Diagnosis

End result of 2 major types of assessment.

*Family Nursing Problem - Stated as an inability to perform specific health task and the
reasons / etiology) why the family cannot perform such task.

Consists of 2 parts: main category of problem (coming from unattained health

task) and specific problems (statement of factors contributory for the existence of
the main problem.
Example: (general): Inability to utilize resources for health care due to lack of
adequate family resources, specifically: (specific)
a. financial resources
b. manpower resources
c. time
The more specific the problem definition, the more useful is the
nursing diagnosis in determining the nursing intervention.
Therefore, as many as three or four levels of problem definition
can be stated.

*Nurses Roles in Family Health Nursing

1. Health Monitor
2. Provider of Care to a sick Family Member
3. Coordinator of Family Services
4. Facilitator
5. Teacher
6. Counselor

INITIAL DATA BASE FOR FAMILY NURSING PRACTICE

*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. matriarchal or patriarchal, nuclear or extended.
5. Dominant family members in terms of decision making, especially in matters of
health care.
6. General family relationship / dynamic presence of any readily observable conflict
between members; characteristics communication patterns among members.
*SOCIO ECONOMIC AND CULTURAL CHARACTERISTICS
1. Income and Expenses
Occupation, place of work and income of each working members
Adequacy to meet basic necessities
Who makes decisions about money and how it is spent
2. Educational attainment of each other
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.

*HOME AND ENVIRONMENT

1. Housing
Adequacy of living peace
Sleeping arrangement
Presence of breeding or resting sites of vectors of diseases
Presence of accidents hazards
Food storage and cooking facilities
Water supply source, ownership, portability
Toilet facility type, ownership, sanitary condition
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
*HEALTH STATUS OF EACH FAMILY MEMBER
1. Medical and nursing history indicating current or past significant illnesses or beliefs
and practices conducive to health illness
2. Nutritional assessment
 Anthropometric data: Measures of nutritional status of children, weight,
height, mid-upper arm circumference: Risk assessment measures of
obesity: body mass index, waist circumference, waist hip ratio
Dietary history specifying quality and quantity of food/nutrient intake per day
Eating/ feeding habits/ practices
3. Developmental assessments of infants, toddlers, and preschoolers e.g., Metro
Manila
4. Risk factor assessment indicating presence of major and contributing modifiable
risk factors for specific lifestyles, cigarette smoking, elevated blood lipids, obesity,
diabetes mellitus, inadequate fiber intake, stress, alcohol drinking and other substance
abuse
5. Physical assessment indicating presence of illness state/s
6. Results of laboratory/ diagnostic and other screening procedures supportive of
assessment findings
*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
use of protective measures- e.g. adequate footwear in parasite-infested
areas;
relaxation and other stress management activities
4. Use of promotive-preventive health services

Typology of Nursing Problems in Family Nursing Practice

1. First Level of Assessment process whereby existing potential health

conditions/problems of the family are determined.

a. Presence of Wellness Condition states as potential or readiness a

clinical or nursing judgement about a client in transition from a specific level of
wellness or capability to a higher level.

b. Presence of Health Deficits - Instances of failure in health maintenance.

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 (1) congenital or (2) arising from illness.

c. Presence of Health Threats - Conditions that are conducive to disease,

accident or failure to realize one's health potential.
A. Family history of hereditary condition / disease
B. Threat of cross infection from a communicable disease case
C. Family size beyond what family resources can adequately provide
D. Accident hazards .
1. broken stairs
2. pointed /sharp objects, poisons, & medicines improperly kept
3. fire hazards
4. fall hazards
5. others (specify):________
E. Faulty / unhealthy nutritional / eating habits or feeding techniques / practices.
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
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
1. inadequate living space
2. lack of food storage facilities
3. polluted water supply
4. presence of breeding or resting sites of vectors of diseases
5. improper garbage / refuse disposal
6. unsanitary waste disposal
7. poor lightning and ventilation
8. noise pollution
9. air pollution
H. Unsanitary food handling and preparation
I. Unhealthy lifestyle and personal habits /practices
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
7. sexual promiscuity
8. engaging in dangerous sports
9. inadequate rest or sleep
10. lack of / inadequate exercise / physical activity
11. lack of / inadequate activities
 12. non-use of self-protection measures (e.g. non-use of bednets in Malaria and
Filariasis endemic areas)
J. inherent personal characteristics - such as poor impulses control
K. Health history which may precipitate / induce the occurrence of a health deficit,
e.g. previous history of difficult labor.
L. Inappropriate role assumption - e.g. child assuming mother's role, father not
assuming his role
M. Lack of immunization / inadequate immunization status specially of children
N. Family disunity - e.g. self-oriented behavior of members (s), unresolved conflicts
of members(s), intolerable disagreement
O. Others, specify : _____________

d. Presence of Stress Points / Foreseeable Crisis - Anticipated periods of

unusual demand on the individual or family in terms of adjustment / family
resources.
A. Marriage
B. Pregnancy, labor, puerperium
C. Parenthood
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. Other, Specify ______________

2. Second Level of Assessment defines the nature or type of nursing problems that
the family encounters in performing health.

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 peers / 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 by perceived
magnitudes / severity of the situation or problem, i.e., failure to break down
problems into manageable units of attacks
D. Lack of / or inadequate knowledge / insight as to alternative courses of action
to take
E. Inability to decide which action to take among the list of alternatives
F. Conflicting opinions among family members / significant others regarding
action to take
G. Lack of / or inadequate knowledge of community resources for care
H. Fear of consequence of action, specially:
social consequences
economic consequences
physical / psychological consequences
I. Negative attitude towards the health problem By negative attitude is meant
one that interferes with rational decision making
J. Inaccessibility of appropriate resources for care, specifically:
1. physical inaccessibility
2. cost constraints or economic / financial inaccessibility
K. Lack of trust / confidence in the health personnel / agency
L. Others, specify______________

III. Inability to provide adequate nursing care to 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 the child development and care;
Lack of / inadequate knowledge of the nature and extent of nursing care
needed;
C. Lack of the necessary facilities, equipment and supplies for care;
D. Lack of or inadequate knowledge and skill in carrying out the necessary
interventions / treatment / procedure / care (e.g., complex therapeutic regimen
or healthy lifestyle program);
E. Inadequate family resources for care, specifically:
Absence of responsible member
Financial constraints
Limitations / lack of physical resources e.g. isolation room
F. Significant persons unexpressed feelings (e.g. hostility / anger, guilt, fear /
anxiety, despair, rejection) which disable his / her capacities to provide care.
 G. Philosophy in life which negates / hinder caring the sick, disabled, dependent,
vulnerable / At risk member
H. Members preoccupation with own concerns / interests
I. Prolonged disease or disability progression which exhausts supportive capacity
of family members
J. Altered role performance specify :
a. role denial or ambivalence
b. role strain
c. role dissatisfaction
d. role conflict
e. role confusion
f. role overload
K. Others, specify _________________

IV. Inability to provide a home environment conducive to health maintenance and

personal development due to :
A. Inadequate family resources, specifically:
a. financial constraints / limited financial resources
b. limited physical resources e.g. lack of space to construct facility
B. Failure to see benefits (specifically long-term ones) of investment 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 patterns within the family
G. Lack of supportive relationship among family members
H. Negative attitude / 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
J. familys preoccupation with current problem or condition)
K. 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 :
a. physical / psychological consequences
b. financial consequences
c. social consequences e.g. , loss of esteem of peer / significant others
 F. Unavailability of required care / service
G. Inaccessibility of required care / service due to:
a. cost constraints
b. physical inaccessibility, i.e. location of facility
H. Lack of or inadequate family resources, specifically ;
a. manpower resources e.g. baby sitter
b. financial resources e.g., cost of medicine prescribed
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
K. Others, specify----------------

II. PLANNING
- The step in the process which answers the following questions:
*What is to be done?
*How is to be done?
*When it is to be done?
-It is actually the phase wherein the health care provider formulates a care plan.

Steps in developing a Family Nursing Care Plan

1. Prioritized problems
2. Goals and Objectives of the Nursing Care
3. Plan of Intervention
4. Plan for Evaluating Care.

Prioritizing Health Problems

1. Nature of the Problem Presented - Categorized into wellness state, health
threat, health deficit and foreseeable crisis.

2. Modifiability of the Problem/Condition - Refers to the probability of success in

enhancing, improving, minimizing, alleviating or totally eradicating the problem
through intervention.

3. Preventive Potentials - Refers to the nature and magnitude of future problems

that can be minimized or totally prevented if intervention is done on the problem
under consideration.

4. Salience - Refers to the family's perception and evaluation of the problem in terms
of seriousness and urgency of attention needed or family readiness.
Scoring
1. Decide a score for each of the criteria
2. divide the score by the highest possible & multiply by the weight
 Score x weight
Highest score
3. Sum up the score of all criteria. The highest score is 5 equivalent to the total
weight.

CRITERIA Weight
1. Nature of the problems Presented 1
Scale:
-Health deficit / Wellness 3
-Health threat 2
-Foreseeable crisis 1
2. Modifiability of the problem 2
Scale:
-Easily modifiable 2
-Partially modifiable 1
-Not modifiable 0
3. Preventive potential 1
Scale:
-High 3
-Moderate 2
-Low 1
4. Salience 1
Salience:
-A condition / problem needing Immediate 2
attention
*A condition / problem not needing 1
Immediate attention
*Not perceived as a problem or condition 0
needing change.

Factors affecting priority setting:

The nurse considers the availability of the following in determining the modifiability of a
health condition or problem.
1. Current Knowledge, Technology and Interventions
2. Resources of the family Physical, Financial and Manpower
3. Resources of the nurse Knowledge, Skills and Time
4. Resources of the Community Facilities and Community organization or support.

Factors in Deciding Appropriate Score for Preventive Potential

1. Gravity or severity of the problem - Refers to the progress of the disease/ problem
indicating extent of damage on the patient / family. Also indicates the prognosis,
reversibility of the problem
2. Duration of the problem - refers to the length of time the problem has been existing
3. Current Management - refers to the presence and appropriateness of intervention
4. Exposure of any high risk group

Family Nursing Care Plan

* It is the blueprint of care that the nurse designs to systematically minimize or eliminate
the identified family health problem through explicitly formulated outcomes of care (goal
and objectives) and deliberately chosen set of interventions/resources and evaluation
criteria, standards, methods and tools.

Characteristics of Family Nursing Care Plan

1. It focuses on actions which are designed to solve or alleviate & existing problem.
2. It is a product of deliberate systematic process.
3. The FNCP as with other plans relates to the future.
4. It revolves around identified health problems.
5. It is a mean to an end and not a end to itself.
6. It is a continuous process, not one shot deal.

Desirable Qualities of Family Nursing Care Plan

1. It should be based on a clear definition of the problem.
2. A good plan is realistic, meaning it can be implemented with reasonable chance of
success
3. It should be consistent with the goals and philosophy of the health agency.
4. Its drawn with the family.
5. Its best kept in written form.

Setting/ Formulating Goals & Objectives

This will set direction of the plan.
This should be stated in terms of client outcomes whether at the individual, family or
community level.
The mutual setting of goals which is the cornerstone of effective planning consists
of:
1. Identifying possible resources.
2. Delineating alternative approaches to meet goals.
3. Selecting specific interventions.
4. Operationalizing the plan - setting of priorities.

Goal
* It is a general statement of the condition or state to be brought about by specific
courses of action.

Cardinal Principle in Goal setting

* It must be set jointly with the family. This ensures family commitment to their
realization.
 * Basic to the establishment of mutually acceptable goal in the familys recognition
and acceptance of existing health needs and problems.

Barriers to Joint Goal Setting

1. Failure in the part of the family to perceive the existence of the problem.
2. Sometimes the family perceives the existence of the problem but does not see it
as serious enough to warrant attention.

Characteristics of Goals/ Objectives

1. Specific
2. Measurable
3. Attainable
4. Realistic
5. Time bound

Objective
Refers to a more specific statement of desired outcome of care.
They specify the criteria by which the degree of effectiveness of care is to be
measured.

Types of Objective
1. Short term or Immediate Objective
Formulated for problem situation which require immediate attention & results can
be observed in a relatively short period of time.
They are accomplished with few HCP-family contacts & relatively less resources.
2. Medium or Intermediate objective
Objectives which is not immediately achieved & is required to attain the long
ones.
3. Long Term or Ultimate Objective
This requires several HCP-family contacts & an investment of more resources.

Plan of Actions/ Interventions

Its aim is to minimize all the possible reasons for causes of the familys inability
to do certain tasks.

It is highly dependent on 2 Major Variables:

1. nature of the problem
2. the resources available to solve the problem

Typology of Interventions
1. Supplemental - the HCP is the direct provider of care.
2. Facilitative - HCP removes barriers to needed services.
3. Developmental - improves clients capacity.
III. Implementation
Actual doing of interventions to solve health problems.

IV. Evaluation
Determination whether goals / objectives are met.
Determination whether nursing care rendered to the family are effective.
Determines the resolution of the problem or the need to reassess, and re-plan
and re-implement nursing interventions.

According to Alfaro-LeFevre:

Evaluation is being applied through the steps of the nursing process:

Assessment changes in health status.

Diagnosis if identified family nursing problems were resolved, improved or
controlled.
Planning are the interventions appropriate & adequate enough to resolve
identified problems.
Implementation determine how the plan was implemented, what factors aid
in the success and determine barriers to the care.

Types of Evaluation:
On-going Evaluation analysis during the implementation of the activity, its
relevance, efficiency and effectiveness.

Terminal Evaluation undertaken 6-12 months after the care was completed.

Ex-post Evaluation undertaken years after the care was provided

Steps in Evaluation:
1. Decide what to Evaluate.
Determine relevance, progress, effectiveness, impact and efficiency
2. Design the Evaluation Plan
Quantitative a quantifiable means of evaluation which can be done
through numerical counting of the evaluation source.
Qualitative descriptive transcription of the outcome conducted through
interview to acquire an in-depth understanding of the outcome.
3. Collect Relevant Data that will support the outcome
4. Analyze Data - What does the data mean?
5. Make Decisions
If interventions are effective, interventions done can be applied to other
client / group with the similar circumstances
If ineffective, give recommendations
 6. Report / Give Feedbacks

Dimensions of Evaluation
1. Effectiveness focused on the attainment of the objectives.
2. Efficiency related to cost whether in terms on money, effort or materials.
3. Appropriateness refer its ability to solve or correct the existing problem, a
question which involves professional judgment.
4. Adequacy pertains to its comprehensiveness.

Tools Being used during Evaluation

Instruments are tools are being used to evaluate the outcome of the nursing
interventions:

Thermometer
Tape measure
Ruler
BP apparatus
Weighing scale
Checklist
Key Guide Questionnaires
Return Demonstrations

Methods of Evaluation
1. Direct observation
2. Records review
3. Review of questionnaire
4. Simulation exercises
1.1 Family Based Nursing Services (Family Health Nursing Process)
Nursing Assessment of Family:
First Level Assessment:
1. Family structure, characteristics and dynamics
2. Socio-economic and cultural characteristics
3. Home and environment
4. Health status of each member
5. Values and practices on health promotion/maintenance
and disease prevention
Second Level Assessment data include those that specify or describe the
familys realities, perceptions about and attitudes related to the assumption or
performance of family health tasks on each health condition or problem
identified during the first level assessment.
Developing the Nursing Care Plan
Steps in developing a family care plan:
 1. The prioritized condition/s or problems
2. The goals and objectives of nursing care
3. The plan of interventions
4. The plan for evaluating care
Implementing the Nursing Care Plan
During this phase the nurse encounters the realities in family nursing practice
which can motivate her to try out creative innovations or overwhelm her to
frustration or inaction. As the nurse practitioner works with clients she
experiences varying degrees of demands on her resources. A dynamic attitude
on personal and professional development is, therefore, necessary if she has
to face up to challenges of nursing practice.
Evaluation of Family Health Services.

G. Population Group-based Nursing Services

POPULATION FOCUSED APPROACH
- Concentrates on specific groups of people and focuses on health promotion and
disease prevention, regardless of geographical location (Baldwin et al, 1998).
- In short (Minesota Department of Health, 2003)
*Focuses on the entire population
*Is based on assessment of the population health status.
*Considers broad determinants of health.
*Emphasizes all levels of prevention.
*Intervenes with communities, systems, individuals and families.

GOAL: To promote Healthy Communities

*A population focused involves concern for those who do, and for those who do not
receive health services (social jusctice)
*SCIENTIFIC APPROACH AND POPULATION FOCUS =
1. Epidemiology 2. Information about the community.

H. Community-based Nursing Services/ Community Health Nursing Process

COMMUNITY HEALTH NURSING PROCESS
1. Assessment/Diagnosis
- assessment: purpose is to identify the health needs of the people.
a. Collection of data ( subjective: expressed by client or;
objective: measurable- interview & observations, senses)
b. Categories of health problems

2. Planning
- purpose is to act on determined needs of the community people.

3. Implementation
- purpose is to achieve the optimum level of health of the community people.
4. Evaluation-
- to determine the effectiveness of health care programs.
3 elements : structural , process & measurable outcome or objective

4 Tools/ Instruments for Data Collection:

1. Nursing history subjective
2. PE- Objective
3. Lab- Objective
4. Process recording- objective (analyzed by RN)

NURSING PROCEDURES
Clinic visit
- patient visits the Health center to avail of the services there to offered by the facility
primarily for consultation on matters that ailed them physically.
-Process of checking the clients health condition in a medical clinic.

PURPOSE: (C.U.R.E)
-Consult about signs and symptoms of illness.
-Utilize service of a health agency.
-Render some treatment procedures.
-Evaluate through some diagnostic procedures

PRE CONSULTATION CONFERENCE (CuTe PaLa We?)

-Take Clinical History after greeting and making client at ease.
-Take Temperature, BP, Height, Weight.
-Perform a through Physical Assessment
-Do Selective Laboratory Exams: Urinalysis, Sputum Exam, Fecalysis.
-Write Findings on clients record.

MEDICAL EXAMINATION (A IWan PO!)

-Assist before, during and after exam by Physician.
-Inform Physician of relevant findings.
-Work with Physician during Exam.
-Ensure Privacy, safety and comfort of patient.
-Observe Confidentiality of Exam result.

POST CONSULTATION CONFERENCE (E..R.A)

-Explain Findings and needed care or intervention.
-Refer patient to other health agency in necessary.
-Make Appointment for next client or home visit.

Standard procedures performed during clinic visits:

I. Registration/ Admission
1. Greet client and establish rapport
2. Prepare the family record or retrieve records of old clients
3. Elicit and record the clients chief complaint and clinical history
 4. Perform physical examination on the client and record it accordingly

II. Waiting time

1. Give priority numbers to clients
2. Implement the first come, first served policy except for emergency cases

III. Triaging
1. Manage program-based cases (like the IMCI)
2. Refer all non-program based cases to the physician
3. Provide first aid treatment to emergency cases and refer to the next level when
necessary

IV. Clinical evaluation

1. Validate clinical history and physical exam
2. Nurse arrives at evidence-based diagnosis and provides rational treatment
based on DOH programs
3. Inform the client on the nature of the illness, appropriate treatment and
prevention and control measures

V. Laboratory and other diagnostic examinations

1. Identify a designated referral laboratory when needed

VI. Referral system

1. Refer patient if he needs further management following the 2-way referral
system
2. Accompany the patient when an emergency referral is needed

VII. Prescription/dispensing
1. Give proper instructions on drug intake

VIII. Health education

1. Conduct one-on-one counseling with the patient
2. Reinforce health education and counseling messages
3. Give appointments for the next visit

Blood pressure measurement

Procedure:
1. Preparatory phase
Introduce self to client
Make sure client is relaxed and has rested for at least 5 minutes
Explain the procedure
Assist to a seated or supine position

2. Applying the BP cuff and stethoscope

Bare clients arm
 Apply cuff around upper arm 2-3 cm above brachial artery
Keep manometer at eye level
Keep arm level with his heart by placing it on a table or a chair arm or by
supporting it
Palpate brachial pulse correctly just below or slightly medial to the antecubital area

3. Obtaining the BP reading by using palpatory method

While palpating the brachial or radial pulse, close valve or pressure bulb and
inflate cuff until pulse disappears
Note point at which pulse disappeared palpated systolic BP
Deflate cuff fully
Wait 1-2 minutes before inflating cuff again

Obtaining the BP reading by auscultation

Place earpieces of stethoscope in ears and stethoscope head over the brachial
pulse
Use the bell of the stethoscope to auscultate pulse
Watching the manometer, inflate the cuff rapidly by pumping the bulb until the
column reaches 30 mmHg above the palpatd SBP
Deflate the cuff slowly at a rate of 2-3 mmHg per beat
While the cuff is deflating, listen for pulse sounds (Korotkoff sounds) (1 st clear
tapping sound Systolic BP and disappearance of sound Diastolic BP

4. Recording BP and other guidelines

For every visit, take the mean of 2 reading, obtained at least 2 minutes apart
If first visit, repeat procedure with other arm. Subsequent BP readings should be
performed on the arm, with a higher BP reading

Home visit
- family nurse contact which allows the health worker to assess the home and family
situations in order to provide the necessary nursing care and health related activities.
- 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.
-PRIORITY during HOME VISITS: Newborn (First), Post-Partum, Pregnant Mother,
Morbid Individual (Last).

Purpose of Home Visit:

1. To give nursing care to the clients
2. To assess living conditions of the patient and his family and their health practices
3. To give health teachings regarding prevention and control of diseases
4. To establish close relationships between the health agencies and the public
5. To make use of the inter-referral system and to promote the utilization of
community services

Principles involve in Preparing for a Home visit:

 1. Must have a purpose or objective
2. Should make use of all available information about a patient
3. Should consider and give priority to needs of clients
4. Should involve the clients
5. Should be flexible

Guidelines to consider regarding the Frequency of Home Visits

1. Needs of the client (Physical, Psychological, and Educational needs)
2. Acceptance of the family
3. Policy of a specific agency
4. Other health agencies and personnel involved in care of family
5. Past services given to families
6. Ability of clients to recognize own needs

Steps in conducting home visits

1. Greet the patient and introduce yourself
2. State the purpose of the visit
3. Observe the patient and determine the health needs
4. Put the bag in a convenient place then proceed to perform the bag technique
5. Perform nursing care needed and give health teachings
6. Record all important data, observation and care rendered
7. Make an appointment for a return visit

Bag Technique: tool by which the nurse, during her visit will enable her to perform a
nursing procedure with ease and deftness, to save time and effort
- a tool making of the public health bag through which the nurse during the 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: an essential and indispensable equipment of a public health nurse
which she has to carry along during her home visits.

Principles of Bag Technique:

1. Minimize, if not prevent the spread of infection
2. Saves time and effort of the nurse
3. Should show effectiveness of total care given to an individual or family
4. Can be performed in a variety of ways

Important points to consider in the use of the bag technique: HANDWASING

1. The bag should contain all necessary articles, supplies and equipments that will
be used
2. The bag and its contents should be cleaned very often, supplies replaced and
ready for use anytime
3. The bag and its contents should be well-protected from contact with any article in
the patients home.
 4. The arrangement of the contents of the bag should be the one most convenient for
the user, to facilitate efficiency and avoid confusion.

-Contents of the BAG:

*BP Apparatus , Stethoscope and umbrella are carried separately
*Medicines include: Betadine, 70% alcohol, Benedicts solution

SOLUTION:
1. Benedicts Solution For sugar detection
2. Acetic Acid For Albumin Detection
3. Zephiram Solution Soaking Solution
4. Alcohol, Betadine
5. Ammonia
-Placed waste paper bag outside of work area to prevent contamination of clean area.
-RATIONALE IN THE USE OF PHN BAG :
*Technique during home visit
- It helps render effective nursing care.

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.

Principles in Nursing Care:

1. Nursing care utilizes a medical plan of care and treatment
2. Performance of nursing care utilizes skills that would give maximum comfort and
security to the individual
3. Nursing care given at home should be used as a teaching opportunity to the
patient or to any responsible member of the family
4. Performance of nursing care should recognize dangers in the patients over-
prolonged acceptance of support and comfort
5. Nursing care is a good opportunity for detecting abnormal signs and symptoms,
observing patients attitude towards care given and the progress of the patient

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.

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(Association of Nursing Service
Administration of the Philippine.)
- INDICATIONS:
*Maintenance /Correction of dehydration in patient unable to tolerate adequate volume of
oral fluid medications
*Parenteral Nutrition
*Administration of Drugs
*Blood Transfusion
- CONTRAINDICATIONS:
*Administration of irritant fluids / drugs through peripheral access (e.g., Sodium Chloride,
Hypertonic Potassium Chloride).

Specimen Collection
-URINE Sterile Bottle, Midstream Collection
-FECES Clean Container, Small amount of feces only.
-SPUTUM NPO midnight first collection early AM then submit at the health center
immediately, then second collection following day early in the AM then submit at the
health center then collect the third sputum; instruct the patient to take a deep breath four
times then cough out.

PRINCIPLES OF HEALTH EDUCATION

-It considers the health status of the people, which is determined by the economic and
social conscience of the country.
-It is a process whereby people learn to improve their personal habits and attitudes, to
work responsibly for the improvement of health conditions of the family, community, and
nation.
-It involves motivation, experience, and change in conduct and thinking, while stimulating
active interest. It develops and provides experience for change in peoples attitudes,
customs, and habits in relation to health and everyday living.
-It should be recognized as the basic function of all health workers.
-It takes place in the home, in the school, and in the community.
-It is a cooperative effort requiring all categories of health personnel to work together in
close teamwork with families, groups, and the community.
-It meets the needs, interests, and problems of the people affected.
-It finds means and ways of carrying out plans by encouraging individual and community
participation.
-It is a slow, continuous process that involves constant changes and revisions until
objectives are achieved.
-Makes use of supplementary aids and devices to help with the verbal instructions.
-It utilizes community resources by careful evaluation of the different services and
resources found in the community.
-It is a creative process requiring methods and techniques with various characteristics,
not following a rigid and flexible pattern.
-It aims to help people make use of their own efforts and education to improve their
conditions of living.
-It makes careful evaluation of the planning, organization, and implementation of all
health education programs and activites.

THE COMMUNITY HEALTH NURSE

QUALIFICATIONS
1. BSN
2. RN of the Philippines

PLANNER / PROGRAMMER
1. Identifies needs, priorities, and problems of individuals, families, and communities.
2. Formulates municipal health plan in the absence of medical doctor
3. Interprets and implements nursing plan, program policies, memoranda, and circular for
the concerned staff personnel.
4. Provides technical assistance to rural health midwives in health matters.

PROVIDER OF NURSING CARE

1. Provides direct nursing care to sick or disabled in the home, clinic, school, or
workplace.
2. Develops the familys capability to take care of the sick, disabled, or dependent
member.

MANAGER / SUPERVISOR
1. Formulates individual, family, group, and community centered plan.
2. Interprets and implements programs, policies, memoranda, and circulars.
3. Organizes work force, resources, equipment, and supplies at local level.
4. Provides technical and administrative support to Rural Health Midwives (RHM)
5. Conducts regular supervisory visits and meetings to different RHMs and gives
feedback on accomplishments.

COMMUNITY ORGANIZER
1. Motivates and enhances community participation in terms of planning, organizing,
implementing, and evaluating health services
2. Initiates and participates in community development activities.

COORDINATOR OF SERVICES
1. Coordinates with individuals, families, and groups for health related services provided
by various members of the health team.
2. Coordinates nursing program with other health programs like environmental sanitation,
health education, dental health, and mental health.

TRAINER / HEALTH EDUCATOR

1. Identifies and interprets training needs of the RHMs, Barangay Health Workers (BHW),
and hilots.
2. Conducts training for RHMs and hilots on promotion and disease prevention
3. Conducts pre and post consultation conferences for clinic clients; acts as a
resources speaker on health and health related services.
4. Initiates the use of tri media (radio / TV, cinema plug, and print ads ) for health
education purposes.
5. Conducts pre marital counseling.

HEALTH MONITOR
1. Detects deviation from health of individuals, families, groups, and communities through
contracts / visits with them.

ROLE MODEL
1. Provides good example of healthful living to the members of the community.

CHANGE AGENT
1. Motivates changes in health behavior in individuals, families, groups, and communities
that also include lifestyle in order to promote and maintain health.

RECORDER / REPORTER / STATISTICIAN

1. Prepares and submits required reports and records.
2. Maintain adequate, accurate, and complete recording and reporting.
3. Reviews, validates, consolidates, analyzes, and interprets all records and reports.
4. Prepares statistical data / chart and other data presentation.

RESEARCHER
1. Participates in the conduct of survey studies and researches on nursing and health
related subjects.
2. Coordinates with government and non government organization in the
implementation of studies / research.

CHN NOTES:
1. Primary Goal in CHN Self-reliance in health
2. Ultimate Goal in CHN Raise the level of health of the citizenry
3. Unit of care - Family
4. Levels of Clientele Individual, Family, Special Population & Community
5. Primary Focus Health Promotion & Disease Prevention
6. Philosophy Of CHN Uphold the worth & dignity of man
7. Theoretical Bases of CHN Practice Theories & Principles of Nursing & Public Health
8. CHN as : People-oriented, comprehensive & integrated, focus on health

I. Community Organizing
COMMUNITY ORGANIZING
Maglaya DOH
Preparatory Phase Community Analysis
Organizational Phase Design and Initiation
Education and training Implementation
Collaboration Phase Program Maintenance Consolidation
Phase Out Dissemination Reassessment

COMMUNITY ORGANIZING a continuous and sustained (i.e. never-ending) process of

awareness-raising, organizing, and mobilizing. Awareness primary
motivation to action
Basic Concepts and Principles
Based on concrete analysis of actual situation
Basic trust on the people
By, for, with, and among the people
Anyone is capable of change
Self-willed changes have more meaning than imposed ones

Context of Community Organizing (CO): Current situation

towards the poor, deprived, oppressed (i.e. not all) but
struggling segments of the society

Goal of Community Organizing (CO): Community Development the creation of a

society that provides equal access to all benefits and opportunities the society can offer
to the people

Application of CO in Health: PRIMARY HEALTH CARE

PRIMARY HEALTH CARE

- Essential care (i.e. not alternative)
- Based on scientifically sound and socially acceptable methods and technology
- Made universally available to individuals, families, and communities
- At a cost they can afford at any given stage of their development
- Through their full participation
- Towards self- reliance and self-determination

Major Pillars of Primary Health Care

a. Multi-sectoral approach (inter- and intra-sectoral linkages)
b. Peoples participation
Partnership or shared leadership; minimum level of peoples participation
c. Appropriate technology underwent experimentation and with high empirical basis;
e.g. herbal medicine and accupressure
COMMUNITY ORGANIZING INavailable
d. Support mechanism made HEALTH

Two types of community:

a. Organized community with peoples organization
b. Virgin community without peoples organization
Phases of CO:
1. SOCIAL INVESTIGATION
Preliminary Investigation
- done before entry to community
- secondary data sources are utilized
- baseline information from secondary data sources (e.g. Records
Review)
Deepening Social Investigation
- continuous appraisal of community situation through primary data
sources
2. ENTRY low-key or low-profile approach
Upon entry, start the following:
a. Deepening Social Investigation
b. Social Preparation
c. Community Integration
3. SOCIAL PREPARATION tampering the grounds for setting up health programs

Target: community leaders

- Establish rapport, develop trust, clarify intentions and expectations
- Starts upon entry, ends with launching
Methods: courtesy call and attendance to meetings
4. COMMUNITY INTEGRATION imbibing the community way of life
Target: community
- Deepen rapport, develop mutual trust, draw objectives
Methods: house-to-house, going to places where people are, direct participation in the
production process (best method)
5. SMALL GROUP FORMATION
- cluster of 8-15 households
- manageable units
- data processing of community diagnosis is being done
6. ELECTION OF CHWs
7. LAUNCHING social preparation ends
8. COMMUNITY DIAGNOSIS
Outcome: Problems and needs of the people
9. TRAINING AND SERVICES
Advanced community health workers have the leadership traits
10. CORE GROUP FORMATION
- Group of advanced CHWs
11. PHASE OUT so that people can practice self-reliance
- Provide opportunity for the health workers to stand on their own
Indicator of Phase-out: Advanced CHWs are able to assume staff level functions

COMMUNITY ORGANIZING PROCESS (COPAR)

PRE-ENTRY
1. Site selection
2. Preliminary Social Investigation
ENTRY
1. Social preparation
2. Community integration
3. Deepening social investigation
ORGANIZATION FORMATION PHASE
1. Small group formation
2. Election of CHW (women; middle-aged; married)
3. Organizational meetings - to clarify matters
TRAINING PHASE
1. Training needs assessment COMMUNITY DIAGNOSIS
2. Curriculum development based on problems identified
3. Actual training
4. Training evaluation
SERVICES PHASE
1. Community clinics
2. Other services
LEADERSHIP FORMATION PHASE
1. Core group formation
2. Advanced training
CONSOLIDATION PHASE
1. Evaluation session
2. Staff development
SUSTENANCE AND MAINTENANCE PHASE
1. Endorsement to sectoral organizing
2. Formation of regional coordinating bodies

1. Community analysisThe process of assessing and defining needs,

opportunities and resources involved in initiating community health action
program. This process may be referred to as community diagnosis, community
needs assessment, health education planning, and mapping.

5 components
Demographic, social and economic profile of the community
derived from secondary data
Health risk profile
Health/wellness outcome profile
Survey of current health promotion programs
Studies conducted in certain target groups
Steps in community analysis
 Define the community - Determine the geographic boundaries of the
target community. This is usually done in consultation with representatives of
the various sectors.
Collect data As earlier mentioned, several types of data have to
be collected and analyzed.
Assess community capacity This entails and evaluation of the
driving forces which may facilitate or impede the advocated
change. Current programs have to be assessed including the
potential of the various types of leaders/influential, organization
and programs.
Assess community barriers Are there features of the new
program which run counter to existing customs and traditions? Is
the community resilient to change?
Assess readiness for change _ Data gathered will help in the
assessment of community interest, their perception on the
importance of the problem.
Synthesis of data and set priorities This will provide a
community profile of the needs and resources, and will become
the basis for designing prospective community interventions for
health promotion.

2. Design and initiation

In designing and initiating interventions the following should be done:
Establish a core planning group and select a local organizer -
Five to eight committed members of the community may be
selected to do the planning and management of the program.
Choose an organizational structure - There are several
organization structures which can be utilized to activate
community participation. These include the following:
Leadership board or council existing local leaders working for
a common cause
Coalition linking organizations and groups to work on
community issues.
Lead or official agency a single agency takes the primary
responsibility of a liaison for health promotion activities in the
community.
Grass-roots informal structures in the community like the
neighborhood residents.
Citizen panels a group of citizens (5-10) emerge to form a
partnership with a government agency
Networks and consortia Network develop because of certain
concerns.
Identify, select and recruit organizational members - As much as
possible, different groups, organizations sectors should be
 represented. Chosen representative have power for the groups
they represent.
Define the organization mission and goals - This will specify the
what, who, where, when and extent of the organizational
objectives.
Clarify roles and responsibilities of people involved in the
organization - This is done to establish a smooth working
relationship and avoid overlapping of responsibilities.
Provide trainings and recognition - Active involvement in planning
and management of programs may require skills development
training. Recognition of the programs accomplishment and
individuals contribution to the success of the program and boost
morale of the members.

3. Implementation
Implementation put design phase into action. To do so, the following
must be done:
Generate broad citizen participation - There are several ways to
generate citizen participation. One of them is organizing task
force, who, with appropriate guidance can provide the necessary
support.
Develop a sequential work plan - Activities should be planned
sequentially. Oftentimes, plan has to be modified as events
unfold. Community members may have to constantly monitor
implementation steps.
Use comprehensive integrated strategies - . Generally the
program utilize more than one strategies that must complement
each other.
Integrate community values into the programs, materials and
messages. The community language, values and norms have to
be incorporated into the program.

4. Program maintenance consolidation

The program at this point has experienced some degree of success and
has weathered through implementation problems. The organization and
program is gaining acceptance in the community.
Integrate intervention activities into community networks - This
can be affected through implementation problems. The
organization and program is gaining acceptance in the
community.
Establish a positive organizational structure - A positive
environment is a critical element in maintaining cooperation and
preventing fast turnover of members. This is the result of good
group based on trust, respect, and openness.
 Establish an ongoing recruitment plan- It should be expected that
volunteers may leave the organization. This requires a built in
mechanism for continuous recruitment and training of new
members.
Disseminate results - Continuous feedback to the community on
results of activities enhances visibility and acceptance of the
organization. Dissemination of information is vital to gain and
maintain community support.

5. Dissemination reassessment
Continuous assessment is part of the monitoring aspect in the
management of the program. Formative evaluation is done to provide
timely modification of strategies and activities. However, before any
programs reach its final step, evaluation is done for future direction.
Update the community analysis - Is there a change in leadership,
resources and participation? This may necessitate reorganization
and new collaboration with other organizations.
Assess effectiveness of interventions/programs - Quantitative
and qualitative methods of evaluation can be used to determine
participation, support and behavior change level of decision-
making and other factors deemed important to the program
Chart future directories and modifications - This may mean
revision of goals and objectives and development of new
strategies. Revitalization of collaboration and networking may be
vital in support of new ventures.
Summarize and disseminate results - . Some organizations die
because of the lack of visibility. Thus, a dissemination plan
maybe helpful in diffusion of information to further boost support
to the organizations endeavor.

GUIDE ON HOW TO DO AN EFFECTIVE COMMUNITY DIAGNOSIS

Community Diagnosis: an in-depth process of finding out the profiles, health

status of the community and the factors affecting the present status

Contents:
1. Introduction
1.1 Rationale accurate, valid, timely and relevant information on the
community profile and health problems are essential so that resources can be
maximized
1.2 Purpose to analyze the data in order to develop responsive
intervention strategies that address the root cause of the problem
1.3 Statement of Objective what are to be accomplished to attain the
study
 1.4 Methodology and tool used a description of the adoption,
construction and administration of instruments
1.5 Limitation of the study state any limitations that exist in the
reference or given population or area of assignment

2. Target Community Profile

2.1 Geographical Identifiers historical background, location,
boundaries, population, physical features, climate, spot map
2.2 Population Profile Total estimated population of Barangay,
Population Density,
2.3 Socio-demographic Profile total population of families surveyed,
number of households, age and sex distribution, sex ratio, dependency ratio,
civil status, types of families, religious distribution, place of origin, length of
residency
2.4 Socio-economic indicators educational attainment, literacy rate,
occupation, income, housing, ventilation
2.5 Environmental indicators Water supply, excreta disposal, garbage
disposal, pet ownership, domestic animals
2.6 Health profile food storage, infant feeding practices, immunization,
community facilities, health seeking behaviors, communication resource and
family planning
2.7 Morbidity and mortality data leading cause of morbidity, mortality,
infant mortality and maternal mortality

3. Analysis of Data
3.1 Identification of health problems
3.2 Prioritized problems identified

4. Action plan based from prioritized problem identified

4.1 Intervention strategies

5. Conclusion

6. Recommendation

Community Diagnosis
1. Preparation of Community Diagnosis
a. Identify barangay to survey or required by the health center
b. Ocular survey
c. Community assembly
2. Conduct of survey proper using the format/survey form
a. Random sampling or saturation
b. Guidelines in filling survey form
c. Data collection techniques
3. Make graph or chart of each data gathered
4. Data analysis and interpretation
5. Preparation of action plan /project plan

HRDP CO-PAR
COMMUNITY ORGANIZING
A continuous process of awareness building, organizing and mobilizing community
members towards community development.

PHASES AND ACTIVITIES

I. PRE-ENTRY PHASE
Preparation of the staff
Site selection
II. ENTRY PHASE
integration with the community
Courtesy calls
Information campaigns
Identification of potential leaders
III. CORE-GROUP FORMATION & MOBILIZING
integration with core group
IV. ORGANIZATION-BUILDING
Organizing Barrio Health committees
Setting up community organization
V. CONSOLATION & EXPANSION PHASE
Networking, linkages
Implementation of livelihood projects
developing secondary leaders

J. Public Health Programs

PUBLIC HEALTH PROGRAMS

FAMILY HEALTH
Aims to:
1. Improve the survival, health and well-being of mothers and the unborn through a
package of services for the pre-pregnancy, prenatal, natal and postnatal packages.
2. Reduce morbidity and mortality rates for children 0-9 years.
3. Reduce mortality from preventable causes among adolescents and young people.
4. Reduce mortality and morbidity among Filipino adults and improve their quality of life.
5. Reduce morbidity and mortality of older persons and improve their quality of life.
 The Maternal Health Program
Strategic thrusts for 2005-2010

Launch and implement the Basic Emergency Obstetric Care or BEMOC

strategy in coordination with the DOH.
Improve the quality of prenatal and postnatal care
Reduce womens exposure to health risks through the institutionalization of
responsible parenthood and provision of appropriate health care package to all
women of reproductive age
LGUs, NGOs and other stakeholders must advocate for health through resource
generation and allocation for health services to be provided for the mother and the
unborn

a. Antental Registration
Prenatal Visits Period of Pregnancy
st
1 visit As early as possible before 4 months or during the 1st
trimester.
nd
2 visit During the 2nd trimester.
3rd visit During the 3rd trimester.
Every 2 weeks After 8th month until delivery.

b. Tetanus Toxoid Immunization

*A series of 2 doses of Tetanus Toxoid vaccination must be received by a woman one
month before delivery to protect the baby from neonatal tetanus.
*3 booster dose shots are needed to complete the five doses following the recommended
schedule to provide full protection for both mother and child.
*mother is then called as a fully immunized mother.

c. Micronutrients Supplementation
Vit A: 10,000 IU 2x a week starting on 4th month of pregnancy
Iron: 600mg/400ug tablet daily

d. Treatment of Diseases and other Conditions ????

e. Clean and safety delivery.

1. Do a quick check upon admission for emergency signs.
2. Make the woman comfortable/
3. Assess the woman in labor.
4. Determine the stage of labor.
5. Decide if the woman can safely deliver.
6. Give supportive care throughout labor.
7. Monitor and manage labor.
8. Monitor closely within one hour after delivery and give supportive care.
9. Continue care after one hour postpartum.
10. Educate and counsel on Family Planning and provide Family Planning Method if
available and decisions made by the woman.
11. Inform, teach and counsel the woman on important MCH messages:
*birth registration
*importance of breastfeeding
*Newborn Screening for babies delivered in RHU or at home within 48 hours up to 2
weeks after birth
*Schedule when to return for consultation for post partum visits
1st visit 1st week post partum preferably 3 - 5
days
2nd vist 6 weeks post partum

The Family Planning Program

FAMILY PLANNING
The concept of enhancing the quality of families which includes:
*Started 1960s
*2 3 years spacing of child
*2 3 years children is ideal
*5 pregnancy is a risk factor
*COUPLES FOR CHRIST DOH Partner
*Regulating and spacing childbirth
*Helping subfertile couples beget children
*Counseling parents and would-be parents
*The privilege and the obligation of the (married) couple exclusively to decide w/ love
when andhow many children provided:
the motive is justified and the means are moral.
*Involves personal decisions based on each individuals background,
experiences andsociocultural beliefs. It involves thorough planning to be certain that
the method chosen isacceptable and can be used effectively.

Function of the Health Professional in Family Planning

*To counsel, reassure, give information and allow an individual/couple to decide
his/her/their course of action according to what he/she think is appropriate for them
and in accordance to their own personal,societal, religious beliefs & values

Goal: Provide universal access to family planning information and services

wherever and whenever these are needed.
FAMILY PLANNING Aims to contribute to:
- Reduced infant deaths
- Neonatal deaths
- Under five deaths
- Maternal deaths
 Objectives:
-Addresses the need to help couples and individuals achieve their desired
family size within the context of responsible parenthood and improve their
reproductive health to attain sustainable development.
-Ensure that quality Family Planning services are available in DOH retained
hospitals, LGU managed health facilities, NGOs and private sector.
Strategies:
*Focus service delivery to urban and rural poor
*Reestablish the FP outreach program
*Strengthen FP provision in regions with high unmet needs
*Promote frontline participation of hospitals
*Mainstream modern natural family planning
*Promote and implement CSR strategy
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.

FAMILY PLANNING SERVICES

*Temporary conception control
-Methods used to prevent conception
-Methods used to prevent ovulation
-Methods used to prevent implantation

*Sterilization / Permanent conception control

-Tubal occlusion / Bilateral Tubal Ligation
-Vasectomy or Vas Ligation (never advice a permanent method of planning).

Family Planning: 4 Pillars

BIRR!!!
B-
I-
R-
R-

Important Concept!!!
COUPLE Decision maker
DOH Regulator
Community Health Nurse Facilitator

Important Concept!!!
High risk Pregnancies
-Too early
-Too late
-Too Frequent
-Too many

The family planning methods:

Natural Family Planning
1. BBT (Basal Body Temperature)
- 91 99% effective
- Observe temperature for six (6) months or more
- Taken per mouth or per axilla
- Take temperature upon waking up
- Graph
- Mark coitus schedule
- Mark time of menstruation
Important Concept!!!
Progesterone CAUSES AN INCREASE IN TEMPERATURE
Estrogen CAUSES A DROP IN TEMPERATURE

2. Cervical Mucus / Billing Method

- Spinbarkeit Test
- 91 99% effective
- Clear, stretchable and mucus is abundant Fertile
- Cervical mucus is pasty Not Fertile

3. Sympto Thermal method

- 91 -99% effective
- Combination of basal body temperature and billing method

4. Lactational Amenorrhea Method (LAM)

- 98% effective
- Done for six (6) months
- Three Criteria for LAM:
* Child less than six (6) months
* Menses are still absent
* Pure Breast Feeding
- No pacifier, water, supplementary food

Artificial Family Planning

1. Pills
- % effective
- Usually taken at night
- COCs (Combine Oral Contraceptives)
* Not given on breast feeding mother
* With estrogen and progesterone
- POCs (Progestin Only Contraceptives)
* Taken by breastfeeding mothers

2. Intrauterine Device (IUD)

 - 98% effective
- Sterile plastic device
- Best time for insertion
- During the second (2nd) day of menses
- You know you are not pregnant
- Cervix is slightly open
- ABSOLUTE CONTRAINDICATION
* When you have abnormal uterine bleeding.
* Nulliparous
* History of Pelvic Inflammatory Disease
* History of Sexually Transmitted Disease

3. Condom
- 97% effective
- Mother is most responsible in inserting the condom.

4. Depo Medroxyl Progesterone Acetate (DMPA)

- 98% effective
- Injectable; every 3 months
- Fertility after 6 months

Permanent Family Planning

1. Tubal Ligation
- 99% effective
- Best time:
* Post partum
* Within four (4) to six (6) hours after delivery
- Do not engage in coitus three (3) days before and after the procedure
- Restrict lifting of objects heavier than newborn

2. Vasectomy
- 99% effective
- Vas deferens is cut
- Does not give immediate sterility
- There is a waiting time of six (6) months
- Sperm is still stored
- After six months, patient can engage in unprotected coitus.
- Not Popular among Filipinos

Nursing Alert!!!
Methods that are not part of Natural Family Planning: (not accepted by the DOH)
- Withdrawal
- Calendar Method

Misconception about Family Planning Methods:

*Some family planning methods cause abortion
*Using contraceptives will render couples sterile
*Using contraceptive methods will results to loss of sexual desire

The Child Health Programs (Newborns, Infants and Children)

Newborns, infants and children are vulnerable age group for common childhood
diseases. The risk of infection among children is higher when not screened for metabolic
disorder, not exclusively breastfed, unvaccinated, not properly managed when sick, not
given with vitamin supplementation and many others. To address problems, child health
programs have been created and available in all health facilities which includes:
Infants and Young Child Feeding
National Plan of Action for 2005 2010 for infant and young Child Feeding
Goal: Reduce child mortality rate by 2/3 by 2015
Objective: To improve health and nutrition status of infants and young children
Outcome: To improve exclusion and extended breastfeeding and complementary
feeding
Key Messages on infant and young child feeding
* Initiate breastfeeding within 1 hour after birth
* Exclusive for the first 6 months of life
* Complemented at 6 months with appropriate foods, excluding milk supplements
* Extend breastfeeding up to 2 years and beyond.
Breastfeeding benefits
To Infants:
Provides a nutritional complete food for the young infant
Strengthens infants immune system
Safely rehydrates and provides essential nutrients
Reduces infants exposure to infection
Increase IQ points

To Mother:
Reduces womans risk of excessive blood loss after birth
Provides natural methods of delaying pregnancies
Reduces the risk of ovarian and breast cancers and osteoporosis

To Household and the Community:

Conserve funds that would be spent on breastmilk substitute
Saves medical cost to families

Newborn Screening??????

Expanded Program on Immunization

Goal of EPI: Reduction of morbidity and mortality of immunizable diseases
Not all diseases are immunizable
Principles in Vaccinating Children:
*It is safe and immunologically effective to administer all EPI vaccines on the same day at
different sites of the body.
*Measles vaccine should be given as soon as the child is 9m/o.
*Vaccination schedule should not be restarted from beginning even if interval exceeds
recommended interval.
*Moderate fever, malnutrition, mild respiratory infection, cough, diarrhea and vomiting are
not contraindications to vaccination.
*Absolute contraindications: DPT 2 or DPT3 to a child who had convulsions or shock
within 3 days after DPT administration; BCG to immunosuppressed clients
*Giving doses of a vaccine at less than the recommended 4 weeks interval may lessen
antibody response
*False contraindications: malnutrition, low-grade fever, mild respiratory infections, and
other minor illnesses and diarrhea

Vaccine Minimum age # of Minimum Route, Storage Type/ form

at 1st dose Doses interval Dosage, temp of vaccine
between Site
doses
BCG Birth or anytime 1 ID 2-8 C in Freeze dried,
after birth 0.05 ml body of live
Right ref attenuated
arm bacteria
DPT 6 weeks 3 4 weeks IM 2-8 C in D
0.5 ml body of weakened
Thigh ref toxin
(vastus P killed
lateralis) bacteria
T toxin
OPV 6 weeks 3 4 weeks Oral -15 to - Live
2 drops 25C attenuated
Mouth (freezer) virus
Hepa B At birth 3 6 weeks IM 2-8 C in RNA
interval 0.5 ml body of recombinant
from 1st Thigh ref
dose to 2nd (vastus
dose, 8 lateralis)
weeks
interval
from 2nd to
3rd dose
Measles 9 months 1 SQ -15 to - Freeze dried,
0.5 ml 25C live attenua-
Outer (freezer) ted virus
part of
upper
arm
Types and Schedule of Vaccines:

BCG: Infant 0.05ml ID Will not totally eliminate TB

School entrants 0.1 ml ID (double dose) Will inhibit Leprosy

DPT:
HepB 5 ml IM destroyed by freezing
TT

Measles .5ml. SQ Most sensitive to heat & destroyed by heat

OPV 2 gtts/ P.O. - Trivalent ( 3 types)

SIDE-EFFECTS OF BCG:

a. Kochs Phenomenon (Nisie)

- Inflammation of the site of injection after 2-4 days
- 2 to 3 wks. Abscess will ulcerate then heals leaving a scar (12 wks.)
- Warm complex after vaccination

b. Deep abscess at site even after 12 wks.: Incision & drainage

Treatment: Powedered INH

c.
AT BIRTH 1 months 2 3 months 9-12 Indolen
months months t
1st BCG DPT1 DPT2 DPT3 MEASLES ulcerati
OPV1 OPV1 OPV3 on-
HEPB 1 HEPB 2 HEPB 3 ulcer
after 12 weeks Treatment: Powedered
INH

d. Glandular enlargement- abscess (2-3 weeks abscess will leave scar 12 weeks after)

SIDE-EFFECTS OF DPT:

- Fever for a day (always bring antipyretic)-----------------------Normal

Soreness at site within 3-4 days Treatment: Warm compress-----Normal
Abscess after a week or more- incision & drainage ------Not normal
Convulsions-----Emergency: post-pone giving of next dose
SIDE-EFFECT OF MEASLES:

- Fever 5-7 days after within 1-4 days------Normal

Mild rashes --------if it does not disappear-----Roseola

Remember the Principles:

* Even if the interval exceeded that of the expected interval, continue to give the doses
of the vaccine.
* Immunization can still be given until the child reaches 6 y/o
* If there has been a reported epidemic of measles, measles vaccine can be given as
early as six months
* BCG booster dose must be given to school entrants regardless of presence of BCG
scar.
* There is no contraindication to immunization, EXCEPT when the child had convulsions
upon giving the 1st dose of DPT.
* MALNUTRITION is not a contraindication, but RATHER AN INDICATION for
immunization since common childhood disease are often severe to malnourished
children.

*COLD CHAIN

A system used to maintain the potency of a vaccine from that of manufacturer to the
time it is given to child or pregnant woman.

Principles:

I. Storage- it should not exceed:

- 6 months @ the regional level

- 3 months @ the provincial/ district level
- 1 month @ main health centers (with refrigerators)
- Not more than 5 days @ health centers (using transport boxes)

Important Points To Remember:

Arranging of stored vaccine according to:

Type
Expiration date
Duration of storage
# of times they have been brought out to the field
 The vaccine stored the LONGEST & THOSE THAT WILL EXPIRE FIRST
should be distributed or used 1st.

It is a MUST to mark ampules/vials with an X mark each time they are carried
to the field, because if a VACCINE IS NOT USED on the 3 rd trip, it must
already BE DISCARDED.

II. Transport

Use of cold dogs

III. Handling

Once opened or reconstituted, vaccines must be placed in a special cold pack

during immunization sessions.

Vaccine Half life

BCG 4 hours
DPT
Polio
Measles 8 hours
TT
HepaB

TARGET SETTING:

Involves the calculation of the eligible population.

ELIGIBLE POPULATION consists of any group of people targeted for specific

immunizations due to susceptibility to one or several of the EPI diseases.

Management of Childhood Illnesses (IMCI)

INTEGRATED MANAGEMENT AND CHILDHOOD ILLNESSES
Definition: The Integrated Management of Childhood Illness (IMCI) is a strategy to
address the most common causes of illness (morbidity) and deaths(mortality) among
children under 5 which was developed and initiated by the World Health Organization
(WHO) in collaboration with UNICEF in 1995.

Goal: By 2010, to reduce the infant and under five mortality rate at least one third, in
pursuit of the goal of reducing it by two thirds by 2015.

AIM: To reduce death, illness and disability, and to promote improved growth and
development among children under 5 years of age.
IMCI includes both prventive and curative elements that are implemented by
families and communities as well as by health facilities.
Objective: Aims to reduce death, illness and disability, and to promote improved growth
and development among children under five years old.
*To reduce SSIGNIFICANTLY global mortality and morbidity associated with
the major causes of disease in children.
*To contribute to healthy gorth and development of children.

IMCI Components of Strategy:

*Improving case management skills of health workers.
*Improving the health systems to deliver IMCI.
*Improving family and community practices.

***For many sick children a single diagnosis may not be apparent or appropriate.

Presenting Complaint:
*Cough and / or fast breathing
*Lethargy / Unconsciousness
*Measles rash
*Very sick young infant

Steps in IMCI Process

-
-
-
-
-
-

Principles of the Integrated Care

o Assess for General Danger Signs
* Vomits everything
* Convulsion / Seizure
* Difficulty drinking / breastfeeding
* Drowsiness / Lethargy / Difficulty to awaken

o Assess for Main Symptoms

* Cough / DOB
* Diarrhea
* Ear Problem
* Fever
*M

Color Classification Classification of Disease Level of Management

*Green - Mild--- Home Care
*Yellow - Moderate--- Managed at the RHU
*Pink --- Sever--- Urgent Referral in Hospital

Assess and Identify Classifications

A. Cough and Difficulty

Micronutrient Supplementation
Dental health Early Child Development
Child Health Injuries

Its main goal is to reduce morbidity and mortality rates for children 0-9 years
with the strategies necessary for program implementation.

Essential Packages of Health Services for Newborn, Infant and Child

The Adolescent Health Program

The Adult Men Health Program

The Adult Women Health Program

The Older Person Health Program

Philippine Reproductive Health

NON-COMMUNICABLE DISEASE PREVENTION AND CONTROL

AIM: Preventing the four major non communicable / Chronic / Lifestyle related disease,
cancer, chronic obstructive pulmonary diseases and diabetes mellitus, through the
promotion of healthy lifestyle aimed at preventing the three commonly shared major
risk factors; unhealthy diet. Physical inactivity and smoking.

I. Integrated Community Based Non-Communicable Disease Prevention

and Control Program
FOUR MAJOR NON COMMUNICABLE DISEASES
1. Cardiovascular diseases
2. Cancer
3. Chronic Obstructive Pulmonary Diseases
4. Diabetes Mellitus

2005 It was estimated that 35 million deaths would have occurred due to these
diseases, contributing 60% of deaths worldwide. As well as a high death toll, chronic
diseases also caused disability, often for decades of a persons life. The most widely
used summary measure of the burden of disease is the disability adjusted life year or
DAILY, which combines the number of years of healthy life lost to premature death
with time spent in less than full health. One DAILY can be thought of as one lost
healthy year of life. The projected burden of disease of these diseases is
approximately half or 48% of the global burden of disease.
2020 The diseases are expected to account for 73% of deaths and 60% of the disease
burden.
2002 Life expectancy of Filipinos has gone up to 69.6 years.
- MORTALITY statistics showed that 7 out of 10 leading causes of deaths
in the country are diseases which are lifestyle related: diseases of the
heart and the vascular system, cancers, chronic obstructive pulmonary
diseases, accidents, diabetes, kidney problem.
- MORBIDITY statistics also showed that hypertension and diseases of
the heart are among the top 10 leading causes of illnesses in the
country.
2003 The result of the National Nutrition and Health Survey conducted that recently
90% of Filipinos has one or more risk factors associated with chronic, non-communicable
diseases.

THE RISK FACTORS WITH THE CORRESPONDING PREVALENCE RATES:

a. Physical Inactivity 60.5%
b. Smoking 34.8%
c. Hypertension 22.5% (SBP > 140 or DBP > 90)
d. Hypercholesterolemia 8.5% (TC > 240)
e. Obesity 4.9% (BMI > 30)
f. Diabetes 4.6%

HEALTHY LIFESTYLE defined as a way of life that promotes and protects health and
well-being. This would include practices that promotes healthy such as healthy diet and
nutrition, regular and adequate physical activity and leisure, avoidance of substances that
can be abused such as tobacco, alcohol and other addicting substances, adequate
stress management and relaxation; and practices that offer protection from health risks
such as safe sex and immunization.

GOAL:
Reduce the toll of morbidity, disability and premature deaths due to chronic, non-
communicable lifestyle related disease.

OBJECTIVES:
1. Analyze the social, economic, political and behavioral determinants of NCD that will
serve as bases for:
a. Developing policy guidelines;
b. Setting legislative and political directions, and
c. Providing financial measures to support NCD prevention and control.

2. Reduce exposure of individuals and population to major determinants of NCD while

preventing emergence of preventable common risk factors. To hasten this, the health
sector lobby for a healthy protective environment by:
a. Proposing healthy public policies that encouraged health promoting settings in
school, workplaces and communities.
b. Encouraging government to provide protection against activities by industry and
commerce that promote unhealthy products and lifestyles.
c. Communicating the consequences of major risk factors of NCD, paying particular
attention to the most vulnerable population.

3. Strengthen health care for people with NCD through health sector reforms and cost
effective interventions. In order to contribute health status individuals and respond to the
communitys basic health care needs, there must be enhance capability to take action to
address these major NCD risk factors.

To achieve significant reduction in morbidity and mortality from major NCDs, the
following approaches should characterize the program:
1. Comprehensive Approach Focused on Primary Prevention
2. Community Based Approach
3. Integrated Approach

KEY INTERVENTION STRATEGIES

1. Establishing program direction and infrastructure
2. Changing environments
3. Changing Lifestyle
4. Reorienting health services

THE ROLE OF PUBLIC HEALTH NURSE IN NCD PREVENTION AND CONTROL

Health Advocate
Public Health Nursing promote active community participation in NCD prevention and
control through advocacy work. As a health advocate, the PHN helps the people toward
optimal degree of independence in decision making and in asserting their right to their
right to a safer and better community. This involves:
1. Informing the people about the rightness of the cause. It is important to convey the
problem, show it affects people in the community and describe possible actions to take.
2. Thoroughly discussing with the people the nature of the alternatives, their content and
consequences. In this manner, needs demands of the people are amplified and
eventually become the framework for decision making.
3. Supporting peoples right to make a choice and to act on the choice. The people must
be assured that they have the right responsibility to make decisions and that they do not
to change their decisions because of others objections.
4. Influencing public opinion. The advocate affirms the decision made by the people by
getting powerful individuals or groups to listen, support and eventually, make substantial
changes to solve the problem.

Health Educator
Health Education is an essential tool to achieve community health. In non-communicable
disease prevention and control, health education focuses on establishing or inducing
changes in personal and group attitudes and behavior that promote healthier living.
PHNs, as well as educators and media personel, should conduct healthier education in a
variety of settings.

The health educator aims to:

1. Inform the people. Health education creates an awareness of health needs and
problems which consequently make the people become conscious of their own
responsibilities towards their own healthy. Misconceptions and ignorance will be
corrected by disseminating scientific knowledge about causes, factors, prevention and
control of non-communicable diseases.
2. Motivate the people. Telling people about health is not enough. They should be
motivated to make own choices and decisions about habits and practices that are
determined to health, such as cigarette smoking, indulgence in alcohol, physical inactivity
and fat and sugar rich diet.
3. Guide people into action. Oftentimes, people need to supported in their effort to adopt
or maintain healthy practices and lifestyles.

Health Care Provider

The Public Health Nurse is a care provider to individuals, families and
communities rendering primary, secondary and tertiary health care services in any setting
including the community and workplace.

As care provider, emphasis of care is on health promotion and disease prevention

focusing on promotion of rational diet and physical activity and cessation of smoking and
alcohol drinking. In addition, action is directed towards the reduction of risk factors of non
communicable diseases. Primary prevention must be family oriented because the
family members live and eat together and the roots of chronic diseases are related to
personal habits and lifestyle.

Community Organizer
As an organizer, the ultimate goal of the PHN is community health development
and empowerment of the people. This is achieve by:
*Raising the level of awareness of the community regarding non communicable
diseases, its causes, prevention and control;
*Organizing and mobilizing the community in taking action for the reduction of risk
factors;
*Influencing executive and legislative bodies to create and enforce policies that favor a
healthy environment.
Healthy Trainer
The PHN provides technical assistance in the assessment of the skills of auxiliary
health workers in NCD prevention and control; teaching and supervision on clinical
management of non communicable diseases and other community based services
and recording, reporting and utilization of health information related to non
communicable diseases.

Researcher
Research is an integral part of a primary health care approach to non
communicable disease prevention and control program. It is inextricably related to
community health practices since it provides the theoretical bases for developing
appropriate and responsive intervention programs and strategies.

II. Causes and Risk Factors of Major NCDs

A. Diseases of the Heart and Blood Vessels

1. Hypertension
Description
*Hypertension or high blood pressure is defined as a sustained elevation in mean arterial
pressure.
*It is not a single disease state but a disorder with many causes, a variety of symptoms,
and a range of responses to therapy.
*Hypertension is also a major risk factor for the development of others CVDs like
coronary heart disease and stroke.

ETIOLOGY / CAUSE
*In terms of etiology, hypertension is classified into primary and secondary hypertension.
Primary hypertension has no definite cause. It is also called essential hypertension.
Secondary hypertension is usually the result of some other primary diseases leading to
hypertension such as renal disease. For the rest of these session, we will be focusing on
primary hypertension, which is more common.
*Although exact cause is unknown, primary hypertension is attributed to atherosclerosis.

RISK FACTORS
*There is no single cause for primary hypertension but several risk factors have been
implicated in its development.
*Risk factors include family health history, advancing age, race and high salt intake.
*Other lifestyle factors interact with these risk and contribute to the development of
hypertension such as obesity, excess alcohol consumption, intake of potassium (diet high
in sodium is generally low in potassium; increasing potassium in diet increase elimination
of sodium), calcium, and magnesium, stress, and use of contraceptive drugs.
*FAMILY HISTORY
-People with a positive family history of hypertension are twice at risk than those with no
history.
*AGE
 -Older person are at greater risk for hypertension than younger persons.
-The aging processes that increase BP include stiffening of the arteries, decreased
baroreceptor sensitivity, increase peripheral resistance and decreased renal blood flow.
-For years, systolic hypertension common in older persons was considered benign and,
therefore, not treated. However, the Framingham study showed that there was two to five
times increased in death from CVD associated with isolated systolic hypertension.
*HIGH SALTH INTAKE
-Excessive salt intake does not cause hypertension in all people, nor does reducing salt
intake, reduce BP in all hypertensives. Some people are more susceptible than others to
effects of increased salt intake.
*OBESITY
-Risk for hypertension is two times greater among overweight / obese persons compared
to people of normal weight, and three times more than that of underweight persons.
-Fat distribution is more important risk factor than actual weight as measured by waist
to hip ratio.
-The exact mechanism of how obesity contributes to the development of hypertension is
unknown. Whatever the cause, weight loss is effective in reducing BP in obese
hypertensive patients.
-Weight loss or sodium restriction in hypertensives, controlled for 5 years, more than
doubled the success of withdrawal of drug therapy.
*EXCESSIVE ALCOHOL INTAKE
-As much as 10% of hypertension cases could be related to alcohol consumption.
Regular consumption of 3 or more drinks per day increased risk of hypertension. Systolic
pressures were more markedly affected than diastolic pressure.

KEY AREAS FOR PREVENTION OF HYPERTENSION

*Encouraged proper nutrition reduce salt and fat intake.
*Prevent becoming overweight or obese weight reduction through proper nutrition and
exercise.
*Smoking cessation tobacco use promotes atherosclerosis that may contribute to
hypertension; quitting smoking anytime is beneficial; this refers to both active and
passive smokers.
*Identify people with risk factors and encouraged regular check ups for possible
hypertension and modification of risk factors.

2. Coronary Artery Disease

Description
*Coronary Artery Disease (CAD) is heart disease cause by impaired coronary blood flow.
It is also known as Ischemic Heart Disease.
*When the coronary arteries become narrowed or clogged, supply of blood and oxygen to
the heart muscle is affected.
*When there is decreased oxygen supplied to the heart muscle, chest pain (called
ANGINA) occurs.
*CAD can cause myocardial infarction (heart attack), arrhythmias, heart failure, and
sudden death.
ETIOLOGY / CAUSES
*The most common cause is atherosclerosis. This is the thickening of the inside wall of
arteries due to deposition of a fat like substance. This thickening narrows the space
through which blood can flow, decreasing and sometimes completely cutting off the
supply of oxygen and nutrients to the heart. It affects large and medium sized arteries
like the aorta, coronary arteries and the large vessels that supply the brain.
*Atherosclerosis usually occurs when a person has high level of cholesterol in the blood.
When the level of cholesterol in the blood is high, there is a greater chance that it will be
deposited onto the artery walls.
*In diabetes mellitus, atherosclerosis is accelerated, often resulting in coronary artery
disease, myocardial infarction and stroke.

RISK FACTORS OF CAD

a. Elevated blood lipids and cholesterol level (hyperlipidemia)
b. Hypertension
c. Smoking
d. Diabetes mellitus
e. Obesity
f. Physical inactivity/ sedentary lifestyle
g. Stress

ELEVATED BLOOD LIPIDS/ CHOLESTEROL

-Increased blood cholesterol is an important risk factor in the development of CAD.
Reports have shown that modest reduction in total cholesterol can significantly lessen
CVD morbidity and mortality.
-High LDL(low- density lipoprotein) level is a risk factor of CAD. It is called the bad
cholesterol because it is the main carrier of cholesterol and contributes to
atherosclerosis. LDL level is increased by saturated fat intake, obesity, sedentary
lifestyle, smoking, androgens and certain drugs.
-Not all cholesterol is bad. HDL (high density lipoprotein) is now acknowledged as a
protective factor against coronary heart disease. HDL facilitates reverse transport of
cholesterol to the liver where it may be excreted and therefore prevent atherosclerosis.
When HDL level is below normal, this becomes a risk factor for CAD. It is decreased
in smoking, obesity and diabetes mellitus. Regular exercise and moderate alcohol
consumption increased HDL levels.

SMOKING/TOBACCO USE
-Risk of death from CAD is 70-200 times greater for men who smoke one or more packs
of cigarettes per day compared to those who do not smoke. This risk is most seen in
young people, particular those younger than 50 years old.
KEY AREAS FOR PREVENTION OF CAD
Promote regular physical activity and exercise; exercise increases HDL, prevent
obesity and improves optimum functioning of the heart.
Encourage proper nutrition particularly by limiting intake of saturated fats that
increased LDL, limiting salt intake and increasing intake of dietary fiber by eating more
vegetables, fruits, unrefined cereals and wheat breads.
Maintain body weight and prevent obesity through proper nutrition and physical
activity/ exercise.
Advise smoking cessation for active smokers and prevent exposures to second-hand
smoke by family members, friends and co-workers of active smokers. In general,
promote a smoke- free environment through advocacy and community mobilization.
Early diagnosis, from prompt treatment and control of diabetes and hypertension;
these diseases are risk factors and contribute to the development of coronary artery
disease.

3. Cerebrovascular Disease or Stroke

Description
*Stroke is the loss or alteration of bodily function that result from insufficient supply of
blood to some parts of the brain. For human brain to function at emboli. Cocaine use has
been closely related to strokes, heart attacks and a variety of other cardiovascular
complications. Some of them have been fatal even in first time cocaine users.

KEY AREAS FOR PREVENTION OF STROKE

*Treatment and control of hypertension - many people believe that effective treatment of
high blood pressure is a key reason for the rapid decline in the death rates for stroke.
*Smoking cessation and promoting a smoke-free environment.
*Prevent thrombus formation in rheumatic heart disease and arrhythmias with
appropriate medications. These medications are usually taken on a daily basis. Health
workers need to remind these persons to take their medications as prescribed.
*Limit alcohol consumption for women, not more than one drink per day, and for men, not
more than two drinks per day.
*Avoid intravenous drug abuse and cocaine.
*Prevent all other risk factors of atherosclerosis.

B. Cancer
-cancer is not a single disease.
-cancer develops when cell in a part of the body begin to grow out of control.
-they compete with normal cells for the blood supply and nutrients that normal cells need
thus causing weight loss.
-cancer cells often travels to the other part of the body where they begin to grow and
replace normal tissue. This process is called metastasis. It occurs as the cancer cells get
into the bloodstream or lymph vessels of our body.
-the immune system seems to play a role in the development and spread of cancer.
When the immune system is intact, isolated cancer cells will usually be detected and
removed from the body. When the immune system is impaired as in people with
immunodeficiency diseases, people with organ transplant who are receiving
immunosuppressant drugs, or in AIDS, there is usually an increase in cancer incidence.

CAUSES OF CANCER
-Normal cells transform into cancer cells because of damage to DNA. People can inherit
damage DNA which account for inherited cancers. Many times though, a persons DNA
becomes damaged by exposure to something toxic in the environment such as
chemicals, radiation or viruses.
Carcinogens
*a carcinogen is an agent capable of causing cancer. This maybe a chemical, an
environmental agent, radiation and viruses.
*Effect of carcinogenic agents usually depend on the dose or amount of exposure; the
larger the dose or the longer the exposure, the greater the risk of cancer.
*Many cancers are associated with lifestyle risk factors such as smoking, dietary factors
and alcohol consumption.
Chemicals and Environmental Agents
*Polycyclic hydrocarbons are chemicals found in cigarette smoke, industrial agent, or
in food such as smoke foods. Polycyclic hydrocarbons produced from animal fat in the
process of broiling meats and are present in smoked meats and fish.
*Aflatoxin is found in peanuts and peanut butter.
*Other includes benzopyrene, nitrosamines, and a lot more.
Benzopyrene
*Produced when meat and fish are charcoal broiled or smoked (e.g tinapa or smoked
fish). Avoid eating burned food and eat smoked foods in moderation.
*Also produced when food is fried in fat that has been reused repeatedly. Avoid reusing
cooking oil.
Nitrosamines
*These are powerful carcinogens use as preservatives in food like tocino, longganisa,
bacon and hotdog.
*Formation of nitrosamines may be inhibited by the presence of antioxidants such as Vit.
c in the stomach. Limit eating preserved food and eat more vegetables and fruits that are
rich in dietary fiber.
Radiation
*Radiation can also cause cancer including ultraviolet rays from sunlight, x-rays,
radioactive chemicals and other forms of radiation.
Viruses
* a virus can enter a host cell and cause cancer. This is found in cervical cancer(human
papilloma virus), liver cancer( hepatitis B virus), certain leukemias, lymphoma an
nasopharyngeal cancer( epstain barr virus).

RISK FACTORS OF CANCER

- risk factors for cancer include a person's age, sex and family medical history.
Other are linked to cancer thus causing factors in the environment. Still others are related
to lifestyle factors such as tobacco and alcohol use, diet and sun exposure.
CANCER RISK FACTOR
Lung Cancer *Tobacco use, including cigarettes,
cigar, chewing tobacco and snuf.
*Radiation exposure
*Second hand smoke
Oral Cancer *Tobacco use (cigarette, cigar, pipes,
smokeless tobacco)
*Excessive alcohol use
*Chronic Irritation (e.g, Ill fitting
dentures)
*Vitamin A deficiency
Laryngeal Cancer *Tobacco used (cigarette, cigar, pipe,
smokeless tobacco)
*Poor nutrition
*Alcohol
*Weakened immune system
*Occupational exposure to wood dust,
paint, fumes
*Gender: 4 5 times more common in
man
*Age: more than 60 years.
Renal Cancer *Tobacco used (cigarette, cigar, pipe,
smokeless tobacco): increase risk by
40%.
*Obesity
*Diet: well cooked meat
* Occupational exposure: asbestos
organic solvents.
*Age: 50 70 years old.
Cervical Cancer *Tobacco use (cigarette, cigar, pipe
smokeless tobacco).
*Human papillomavirus infection
*Chlamydia infection
*Diet: low in fruits and vegetables.
*Family history of cervical cancer.
Bladder Cancer *Tobacco use (cigarette, cigar, pipe,
smokeless tobacco)
*Occupational exposure: dry solvents,
*Chronic bladder inflammation.
Esophageal Cancer *Tobacco use (cigarette, cigar, pipe,
smokeless tobacco)
*Gender: 3 times more common in man
*Alcohol
*Diet: low in fruits and vegetables.
Breast Cancer *early menarche or late menopause
 *Age changes in hormone levels
throughout life, such as age at first
menstration, number of pregnancies,
and age at menopause.
*High fat diet
*Obesity
*Physical inactivity
*Some studies have also shown a
connection between alcohol
consumption and an increase risk of
breast cancer.
Prostate Cancer *While all man are at risk, several
factors can increase the chances of
developing the disease, such as
advancing age, race and diet.
*Race: more common among African
American man than among white man
*High fat diet.
*Man with a father or brother who has
had prostate cancer are more likely to
get prostate cancer themselves.
Liver Cancer *Certain types of viral hepatitis
*Cirrhosis of the liver
*Long term exposure to aflatoxin
(carcinogenic substance produced by a
fungus that often contaminates peanuts,
wheat, soybeans, corn and rice.
Skin Cancer *Unprotected exposure to strong
sunlight.
*Fair complexion.
*Occupational exposure.
Colonic Cancer *Personal or family history of polyps.
*High fat diet or low fiber diet
*History of ulcerative colitis.
*Age: > 50 years.
Uterine endometrial Cancer *Estrogen replacement therapy.
*Early menarche / late menopause.

KEY AREAS FOR PRIMARY PREVENTION OF CANCER

*Smoking Cessation.
*Encourage Proper Nutrition.
*Drink alcohol beverages in moderation.
*Avoid / control obesity through proper nutrition and exercise.
*The sooner a cancer is diagnosed and treatment begins, the better the chances of living
longer and enjoying a better quality of life.
 C. Diabetes Mellitus
Diabetes Mellitus (DM) is one of the leading causes of disability in persons over 45. More
than half of diabetic persons will die of coronary heart disease. CAD tends to occur at an
earlier age and with greater severity in persons with diabetes. It also increases the risk of
dying of cardiovascular disease like heart attack or stroke among women.
Description
*Diabetes mellitus is not a single disease. It is genetically and clinically heterogeneous
group of metabolic disorders characterized by glucose intolerance, with hyperglycemia
present at time of diagnosis.

ETIOLOGY / CAUSES
*Specific cause depends in the type of diabetes, however it is easier to think of diabetes
as an interaction between two factors: Genetic Predisposition (diabetogenic genes) and
Environment / Lifestyle (obesity, poor nutrition, lack of exercise).

TYPES OF DIABETES
Type 1 Diabetes is insulin dependent diabetes mellitus (IDDM) and Type 2 is
noninsulin dependent diabetes mellitus (NIDDM) Gestational Diabetes is diabetes
that develops during pregnancy. It may develop into full blown diabetes.
NIDDM is more common, occurring in about 90 95% of all persons with diabetes. It is
also more preventable because it is associated with obesity and diet.

Type 1 DM
*Characterized by absolute lack of insulin due to damaged pancreas, prone to develop
ketosis, and dependent on insulin injections.
*Genetic, environment, or may be acquired due to viruses (e.g. mumps, congenital
rubella) and chemical toxins (e.g. Nitrosamines).
Type 2 DM
*Characterized by fasting hyperglycemia despite availability of insulin.
*Possible causes include impaired insulin secretion, peripheral insulin resistance and
increased hepatic glucose production.
*Usually occurs in older and overweight persons (about 80%).

Risk Factors of Type 2 DM

*Family history of diabetes (i.e., parents or siblings with diabetes)
*Overweight (BMI 23 kg/m ) and obesity (BMI > 30 kg/m )
*Sedentary lifestyle
*Hypertension
*HDL cholesterol < 35 mg/dl (0.90 mmol/L) and/or triglyceride level > 250 mg/dl
(2.28mmol/L)
*History of Gestational Diabetes Mellitus (GDM) or delivery of a baby weighing 9 Ibs (4.0
Kgs)
*Previously identified to have Impaired Glucose Tolerance (IGT)

Complications
*Acute complications include diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic
nonketotic coma (HHNK) and hypoglycemia especially in type 1 diabetic.
*Chronic complications cause most of the disability associated with disease. These
include chronic renal disease (nephropathy), blindness (retinopathy) coronary artery
disease and stroke, neuropathy and foot ulcers.

KEY AREAS FOR PREVENTION AND CONTROL OF DIABETES

*Maintain body weight and prevent obesity
*Encourage proper nutrition
*Promote regular physical activity and exercise
*Advise smoking cessation for active smokers and prevent exposure to secondhand
smoke.

D. Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of chronic morbidity
and mortality throughout the world. COPD is currently the fourth leading cause of death
in the world, and more cases and deaths due to COPD can be predicted in the coming
decades because of smoking.
Description
*COPD is a disease state characterized by airflow limitation that is not fully reversible.

CAUSES AND RISK FACTORS

*COPD is usually due to chronic bronchitis and emphysema, both of which are due to
cigarette smoking. Cigarette smoking is the primary cause of COPD.

DIAGNOSIS
*A diagnosis of COPD should be considered in any patient who has symptoms of cough,
sputum production, or dyspnea, and / or a history of exposure to risk factors for the
disease. The diagnosis is confirmed by spirometry.

COMPLICATIONS
-Respiratory failure In advanced COPD, peripheral airways obstruction, parenchymal
destruction, and pulmonary vascular abnormalities reduce the lungs capacity for gas
exchange, producing hypoxemia and, later on, hypercapnea.
-Cardiovascular disease Pulmonary hypertension, which develops late in the course
of severe COPD), is the major cardiovascular complication of COPD), and is associated
with the development of cor pulmonale and a poor prognosis.

E. Bronchial Asthma
Asthma is a chronic disease. It is an inflammatory disorder of the airways in which many
cells and cellular elements play a role. Chronic inflammation causes an associated
increase in airway hyper responsiveness that leads to recurrent episodes of wheezing,
breathlessness, chest tightness and coughing, particularly at night or in the early
morning.
These episodes are usually associated with widespread but variable airflow obstruction
that is often reversible either spontaneously or with treatment.

CAUSES AND RISK FACTORS

Asthma development has both genetic and environment component.
a. Host Factors: predispose individuals to protect them from developing asthma.
*Genetic Predisposition
*Airway hyperresponsiveness
*Gender
*Race / Ethnicity
b. Environmental Factors:
*Indoor allergens
*Outdoor allergens
*Occupational sensitizers
*Tobacco smoke
*Air pollution
*Respiratory infections
*Parasitic infections
*Socioeconomic factors
*Family size
*Diet and drugs
*Obesity

Asthma triggers
Triggers are risk factors for asthma exacerbations. These cannot cause asthma to
develop initially, but can exacerbate established asthma. They induce inflammation and /
or provoke acute bronchoconstriction. It involves further exposure to causal factors
(allergens and occupational agents) that have already sensitized the airways of the
person with asthma.

Other form of triggers are irritant gases and smoke, house dust mite found in pillows,
mattresses, carpets; respiratory infection, inhaled allergens, weather changes, cold air,
exercise, certain foods, additives and drugs.

KEY AREAS FOR PRIMARY PREVENTION AND EXACERBATION OF ASTHMA

*Recognize triggers that exacerbate asthma
*Avoid these triggers if possible, particularly smoking
*Promote exclusive breastfeeding as long as possible; early introduction to cows milk
may predispose baby to allergens and possible asthma.

RISK FACTORS KEY AREAS FOR PREVENTION

*Elevated blood lipid PROMOTE PROPER NUTRITION
(Hyperlipidemia) *Limit intake of fatty, salty and
*High intake of fatty foods preservative foods.
 *Inadequate intake of *Increase intake of vegetable and
dietary fiber fruits.
*Avoid high caloric low nutrient
value food like junk food, Instant
noodles, softdrinks.
*Start developing healthy habits in
children.
*Overweight and obesity. ENCOURAGE MORE PHYSICAL
*Sedentary lifestyle ACTIVITY AND EXERCISE
*Moderate physical activity of
atleast 30 minutes for most days.
*Integrate physical activity and
exercise into regular day -to- day
activities.
*Walking is one form of exercise
that is possible for including older
persons with cardiovascular
disease.
*Smoking, both active or PROMOTE SMOKE FREE
passive / second hand ENVIRONMENT
*Smoking cessation for active
smokers to reduce risk.
*Prohibit smoking inside living
areas, houses and closed areas.
*Excessive use of alcohol DISCOURAGE EXCESSIVE
DRINKING OF ALCOHOLIC
BEVERAGES
*Hyperlipidemia, *EARLY DIAGNOSIS AND
Hypertension, Diabetes PROMPT TREATMENT.
Mellitus

III. Risk Assessment and Screening Procedures

The basis of non-communicable disease (NCD) prevention is the identification of the
major common risk factors and their prevention and control. A risk factors refers to
any attribute, characteristics or exposure of an individual, which increases the
likelihood of developing NCD. Assessment of these risk factors and screening for
NCDs in individuals and communities important in preventing and controlling future
diseases.

Risk Factor Assessment:

A. Cigarette Smoking
* Assess smoking status by asking individuals whether they smoke or not.
In order to monitor trends, collect information not only on smoking status
but also on age of onset, amount smoked by current and former smokers,
and quit attempts. Every client should be asked about tobacco use.
Smoking status should be recorded and updated at regular intervals.
B. Nutrition/Diet
* Diet is a combination of related behaviors, which are often culture
specific. Comprehensive nutritional assessment involves detailed recall
methods (e.g., 24 hours food diary) or extensive food frequency,
questionnaires and estimation of nutrients based on food composition
tables. At the very least, the following questions should be ask to determine
the contribution of the patients nutrition to NCD development. These
include:
*Vegetables Number of servings of vegetables per day and usual types of
vegetables eaten.
*Fruits Number of fruits per day.
*Fat
Number of servings of meat and poultry.
Which part (e.g. skin of chicken)
How often fried foods are eaten
How often fast foods / restaurants are visited.
*Sodium / Salt
How often preserved, canned and instant foods are eaten
per weak.
How much salt is added when cooking food.

GUIDELINES FOR ADEQUATE VEGETABLE AND FRUIT INTAKE

*Eat 2 3 servings of vegetables each day, one serving of which is green
or yellow leafy vegetables. One serving means:
Raw vegetables 1 cup
Cooked vegetables cup

*Eat at least 2 serving of fruit per day, 1 serving is a vitamin C rich fruit. One
serving of fruit depends on type of fruit.

C. Overweight/Obesity
* Body fat can best be assessed using Body Mass Index (BMI) and waist
circumference. BMI correlates closely with total body fat in relation to height
and weight. However, this does not compensable for frame size, does not
indicate fat distribution, and cannot be adjusted for age.

Weight In children and adults, regular weighing is the simplest way of

knowing if energy balance is being achieved. The use of weight for age
or weight for height tables will help determines the desirable weight
either according to age (children) or height (adults).

Body Mass Index (BMI) BMI is calculated using the following formula:
BMI = Weight in kgs / Height in meters.

GUIDELINE
 Based on Asia Pacific Obesity Guidelines:
BMI Interpretation
<18.5 Underweight
18.6 22.9 Healthy weight
>23.0 Overweight
23.0 24.9 At risk
25.0 29.9 Obese 1
>30.0 Obese 2

Waist Circumference (WC) This alone is an accurate measure of the

amount of visceral fat. Remember that the central obesity is a significant
risk factor to heart disease and stroke.

ASSESSING DEGREE OF RISK CO MORBID CONDITIONS BASED

ON BMI AND WC
Measuring Waist Circumference
Procedure: Subject should be unclothed at the waist, and standing with
abdomen relaxed, arms at the sides, feet together. Use non stretchable,
measure and do not compress the skin.
Clinical Thresholds:
Men <90 cm (35 inches)
Women <80 cm(31.5 inches)
Greater than these value is not normal and the person is at risk even if BMI
is normal.

Waist Hip Ratio (WHR) Another useful measures of obesity is the waist
to hip ration by dividing the waist circumference at the narrowest point by
the hip circumference at the widest point.
WHR = Waist circumference (cm) / Hip circumference (cm)
WHR Interpretation:
*Less than 1.0 (men); less than 0.85 (women) = normal WHR
*Equal to or greater than 1.0 (men) and 0.85 (women) = android or
central obesity.
D. Physical Inactivity/Sedentary Lifestyle
*Assessment of physical activity includes on type of work, means of
transportation and leisure time activities like sports and formal exercise.
Minimum Recommended amount of physical activity needed to achieve
health benefit:
Regular Physical Activity: Minimum 30 minutes per day most days of the
week preferably daily.
If moderate intensity: 5 or more days of the week.
If vigorous intensity: 3 or more days of the week.

Guideline:
At least 30 minutes of cumulative physical activity moderate in intensity for
most days of the week.
E. Excessive Alcohol Drinking
*Assess habitual alcohol intake and risky behavior, such as driving or
operating machinery while intoxicated.

Screening Guidelines and Procedures:

According to WHO, screening is the presumptive identification of
unrecognized disease or defect by the application of tests, examination or
other procedures which can be applied rapidly. The primary goal of screening
is to detect a disease in its early stages to be able to treat it and prevent further
development of the disease. Screening programs are usually disease specific
and thus may be called hypertension screening or diabetes screening.
A. Screening for Hypertension
*Hypertension is defined as a sustained systolic BP of 140 mmHg or more
and sustained diastolic BP of 90 mmHg or more based on measurements
done during at least 2 visits taken at least 1 week apart.

B. Screening for Elevated Cholesterol in the Blood

*The recommended screening test for cholesterol is taking a small blood
sample and testing for total blood cholesterol. Prior to testing, make sure
that the person has not eaten any food nor taken any drinks containing
calories for at least eight hours. Drinking water is acceptable.

C. Screening for Diabetes Mellitus

*The hallmark of diagnosis of diabetes mellitus is the presence of
Hyperglycemia.
For those with family history and symptoms of DM, advise blood test for
serum or plasma glucose.
**Fasting Blood Sugar (FBS) Fasting is defined as no caloric intake for
at least eight hours; this include no food, juices, milk; only water is allowed.
**Two hour Blood Sugar Test Performed two hours after using 75g
glucose dissolved in water or after a good meal. Oral Glucose Tolerance
Test (OGTT) is not recommended for routine clinical use nor screening
purposes.

D. Screening for Cancer

*Early detection and prompt treatment are keys to curing cancer.
WARNING SIGNS FOR CANCER (CAUTION US)
C Change in bowel or bladder habits
A A sore that does not heal
U Unusual bleeding or discharge
T Thickening or lump in the breast or elsewhere
I Indigestion and difficulty swallowing
O Obvious change in wart or mole
N Nagging cough of hoarseness in voice
 U Unexplained anemia
S Sudden weight loss

SPECIFIC GUIDELINES FOR EARLY DETECTION OF COMMON CANCERS

1. Breast Cancer
a. Warning Signs includes skin changes (Edema, Dimpling or
inflammation peau, de orange orange peal like skin, Ulceration, Prominent venous
pattern), Nipple abnormalities (Retraction, Rashes or Discharge), Abnormal Contours
(Variation in size and shape of breasts).
b. Early Detection
*Breast Self-Examination cheapest and most affordable screening procedure for breast
cancer. The best time to do BSE is one week after menstrual period while taking a
shower, facing the mirror standing up or lying down.
*Breast mammography Baseline, mammogram is suggested for all women between the
ages of 35 39 and yearly mammogram after age 40. If with family history of breast
cancer, mammogram should be started at age 30. Put in mind that BSE does not take
the place of mammogram or vice versa.
2. Cervical Cancer
a. Warning Signs includes often asymptomatic and Abnormal vaginal
bleeding (e.g., Post Coital bleeding)
b. Early Detection
*Paps Smear Primary screening tool for women over age 18
- should be done in between menses (two weeks after menses).
- for persons at high risk, it should be done yearly. These include those
who are.
:Sexually active,
:Have multiple partners
:Commercial sex workers.
3. Colon - Rectal Cancer
a. Warning Signs include change in stool, rectal bleeding, pressure on the
rectum, abdominal pai.
b. Early Detection
*Annual digital rectal exam starting at age 40.
*Annual stool blood starting at age 50.
*Annual inspection of colon.
4. Prostate Cancer
a. Warning Signs
*Symptoms of urethral outflow obstruction:
-Urinary frequency
-Nocturia
-Decrease in stream
-Post void dribbling
b. Early Detection
*Digital Rectal Exam for mean
*Prostate Specific Antigen (PSA) determination a blood test, confirms
diagnosis.
 5. Lung Cancer
a. Early Warning Signs are those with a long history of smoking and / or
smoking two or more packs or cigarette per day, chronic cough or nagging
cough, dull intermittent, localized pain, history of weight loss.
b. Early Detection
*Chest X-ray every six months for patients who have history of
smoking two packs per day.
*Sputum cystology.

E. Screening for COPD

*Characteristics and symptoms:
-cough
-sputum production
-dyspnea upon exertion
*SPIROMETRY done to determine degree of obstruction.

F. Screening for Asthma

*Suspect Asthma in Persons with the following:
1. One or a combination of cardinal symptoms ( dyspnea, cough, wheezing,
chest discomfort).
2. Temporal waxing and waning and /or nocturnal occurrence of symptoms.
3. A history of any of the following:
*Symptoms triggered by exogenous factors.
*A family history of Asthma, Allergic rhinitis or atopy.
*An improvement of symptoms with bronchodilator use.
ROLE OF PUBLIC HEALTH NURSE IN RISK ASSESSMENT AND
SCREENING
1. Educate as many people and in every opportunity on the warning signs of
NCDs and other risk.
2. Educate people on how to prevent the NCD risk factors through a healthier
diet, engaging in moderate physical activity and not smoking.
3. Every client not only the patient seeking consultation, should be assessed
for the presence of risk factors and early signs of NCD. This includes the mother bringing
her newborn infant for immunization, the grandmother or aunt bringing a sick child for
consultation, or members of the household during home visits.
4. Train other health workers, even the barangay health workers and barangay
nutrition scholars on performing risk factor assessment. It will be good to periodically
check their skills like BP taking, measurement of height and weight, using BMI table.

IV. Promoting Physical Activity and Exercise

Health Benefits of Regular Physical Activity
*Reduces the risk of dying from coronary heart disease (CHD).
*Reduces the risk of having a second heart attack in people who have already
experienced one heart attack.
*Lowers both total blood cholesterol and triglycerides and many increase high
density lipoprotein (HDL or the good cholesterol).
*Lowers the risk of developing high blood pressure.
*Helps reduce blood pressure in people who already have hypertension.
*Lowers the risk of developing non insulin dependent (Type 2) diabetes mellitus.
*Reduces the risk of developing colon cancer.
*Helps people achieve and maintain a healthy body weight.
*Reduces feeling of depression and anxiety.
*Promotes psychological well being and reduces feelings of stress
*Helps build and maintain healthy bones, muscles, and joints.
*Helps older adults become stronger and better able to move about without falling or
becoming excessively fatigued.

UNDERSTANDING PHYSICAL ACTIVITY AND EXERCISES

*Physical Activity is something done at home, like washing the dishes, sweeping
the floor, and cleaning the house. It is also what is done outside the house, like
sweeping or raking leaves in the yard or gardening, or walking to the neighborhood
store or jeepney terminal instead of riding the tricycle. It is something that one might
be avoiding doing in the office, like instead of climbing the stairs one takes the
elevator, or instead of walking around while using the phone one opts to sit down.
*Exercise is a planned, structured and repetitive movement done to improve or
maintain one or more components of physical fitness. It involves energy expenditure
and planning. Walking or jogging for three kilometers each day before or after work is
a structured exercise. Another example is attending a regular aerobics class 3 times a
week is structured exercise.

ROLE OF PUBLIC HEALTH NURSE

*The public health nurse play a big role in motivating individuals and groups to
prevent living sedentary lifestyles that increase their risk for NCD. She has the
responsibility of increasing their knowledge and skills needed to engage in physical
activities and exercise as well as motivating them enough to start being physically
active and to encourage them to main.

V. Promoting Proper Nutrition ?????

VI. Promoting a Smoke-Free Environment ?????

VII. Promoting Stress Management

*Stress is an everyday fact of life and everyone experience stress from time to
time. Stress is any change that one must adapt to, ranging from the negative extreme
of actual physical danger to exhilaration of falling in love or achieving some long
desired success. And in between, day to day living confronts even the most well
managed life with continuous stream of potentially stressful experiences. Thus, stress
is not only inevitable and essential; but also normal part of life. However, normal does
not necessarily mean healthy.
*Fortunately, stress management is largely a learnable skill. Everybody can
learn effectively handle stress even when pressures persist. It is not possible to live
without stress. But one can learn ways to handle the stress of daily life efficiently, and
to manage reactions to stress and minimize its negative impact. However, it is
important to remain attentive to negative stress symptoms and to learn to identify the
situations that evoke them. When these symptoms persist, the risk for serious health
problems is greater because stress can exhaust the immune system. Recent research
demonstrates that 90% of illness is stress related.
*People respond to stressful situations in different ways. Stressful situations
can trigger different types of responses. These will vary between individuals. Some
may be physical, some may be psychological and some maybe behavioral.
STRESS MANAGEMENT TECHNIQUES
12 Stress Management Techniques
1. SPIRITUALITY
-is a state or quality of being spiritual. It is pure, holy, relating to matters of sacred
nature, not wordly, ecclesiastica, possessing the nature of qualities of a spirit.
Mediation is a way of reaching the world beyond the senses. It is very effective
method of relaxation. The idea of mediation is to focus ones thoughts on one relaxing
thing for a sustained period of time.
Mediation can have the following effects:
-Lowers blood pressure
-Slows breathing, helps muscle relax
-Gives the body time to eliminate lactic acid and other waste products
-Eliminates stressful thoughts
-Helps with clear thinking
-Helps with focus and concentration
-Reduces stress headaches

2. SELF AWARENESS
-it means knowing ones self, getting in touch with ones feelings, or being open to
experiences. It increases sensitivity to the inner self and relationship with the world
around.

3. SCHEDULING: TIME MANAGEMENT

-time is a resource. A resource is something that lies ready for use, or something
that can be drawn upon for aid. Time is a tool that can be drawn upon to help
accomplish results, an aid that can take care of a need, an assistant in solving
problems. Managing time really refers to managing ones self in such a way as to
optimize the time available in order to achieve gratifying results.

4. SIESTA
-it means taking a nap, short rest, a break or recharging of battery in order to
improve productivity. It helps relax the mind and body muscles. It had been proven
thru a study that siesta invigorates ones body. Performance of an individual
scored high when siesta is observed with a 15 30 minutes nap. It relieves stress
tension and one wakes up invigorated and set for the next activity.

5. STRETCHING
 -are simple movements performed at a rhythmical and slow pace executed at the
start of a demanding activity loosen muscles, lubricate joints, and increase bodys
oxygen supply. It requires no special equipment, no special clothes, and no
special skills and can be done anywhere and anytime.

6. SENSATION TECHNIQUE
-The sense of touch is a powerful and highly sensitive forms of communication. It
is a natural reaction to reach out and touch whether to feel the shape or texture of
something or to respond to another person, perhaps by comforting them. Massage
helps to soothe away stress, unknotting tensed and aching muscles, relieving
headaches and helping sleep problems. But massage is also invigorating; it
improves the functioning of many of the bodys systems, promotes healing and
tones muscles, leaving with a feeling of renewed energy.

7. SPORTS
-Engaging in sports and in physical activities like these have been known to
relieve stress. It also gives the body the exercise it badly needs.

8. SOCIALS
-a man is a social being who exist in relationships with his physical environment and
in relationship with people and society.
Socialization plays a very important role in the development of intrapersonal
relationships. Through socialization life becomes meaningful, happy and worthy.
On the contrary without socialization life will be boring and empty.

9. SOUNDS AND SONGS

-music plays an important part in the everyday life of a person. It provides a
medium of expression for thoughts and emotions. It also a way to relieve tension.
Music adds to the quality of life of a person.

10. SPEAK TO ME
-the world is designed as a mutual support system in which all things relate to
each other. Communication is the means by which people make their needs
known. It is the way they obtain understanding, reinforcement and assistance from
others. Communication is aimed at a goal, so it must remain open until the goal is
reached. Interpersonal conflicts generally are resolved most effectively by open
communications that accept the feelings of the persons involved and leas to better
resolution of problems. Talking to someone when feeling overwhelmed or unable
to deal with stress or feeling helpless is often the best way of coping with stress.

11. STRESS DEBRIEFING

 -Critical Incident is any usually strong or overwhelming emotional reactions which
have potential to interfere with work during the event or thereafter in the majority of
those exposed.
-Critical Incident Stress Debriefing means to assist crisis workers/ team member to
deal positively with the emotional impact of a severe event/ disaster and to provide
education about current and anticipated stress responses, as well as information
about stress management.

12. SMILE
- It has been observed that people who always smile are healthy people. Smile is
an expression of pleasure. It has been found out through research that it relieves
all kinds of stresses, physical, or mental. It is also considered one of the
ingredients or factors that motivates and encourages people to work harder and
improve their level of performance in anything they do.

VIII. Programs for the Prevention and Control of other non-communicable

diseases
-The following are some of the programs that addresses other non-
communicable diseases particularly blindness, mental disorders, renal disease and
programs for disables persons.

A. National Prevention of Blindness Program

VISION 2020: The Right to Sight is a global initiative to eliminate avoidable blindness by
the year 2020. The program is a partnership between the World Health Organization
(WHO) and the International Agency for Prevention of Blindness (IAPB), which is the
umbrella organization for eye care professional groups and non governmental
organizations (NGOs) involved in eye care.

VISION/ MISSION/ GOALS/ OBJECTIVS

Vision All Filipinos enjoy the right to sight be year 2020.
Mission The Department of Health, Local Health Units, partners and stake holders
commit to:
1. Strengthen partnership among and with stakeholders to eliminate avoidable blindness
in the Philippines.
2. Empower communities to take proactive roles in the promotion of eye health and
prevention of blindness.
3. Provide access to quality eye care services for all.
4. Work towards poverty alleviation through preservation and restoration of sight to
indigent Filipinos.
Goal:
-Reduce the prevalence of avoidable blindness in the Philippines through the provision of
quality eye care.
Objectives:
*General Objective no. 1: Increase Cataract Surgical Rate from 730 to 2,500 by the year
2010.
*General Objective no.2: Reduce visual impairment due to refractive errors by 10% by
the year 2010.
*General Objective no.3: Reduce the prevalence of visual disability in children from
0.43% to 0.20% by the year 2010.

INTERVENTIONS BY EYE DISORDER:

1. Cataract
The pacification of the normally clear lens of the eye, is the most common cause of
blindness worldwide.
Interventions will therefore consist of increasing awareness about cataract and
cataract surgery; as well as improving the delivery of cataract services.
2. Errors of Refraction
It is the most common cause of visual impairment in the country (prevalence is 2.06%
in the population).
It is corrected either with spectacle glasses, contact lenses or surgery.

3. Childhood Blindness
The prevalence of blindness among children (up to age 19) is 0.06% while the
prevalence of visual impairment in the same age group is 0.43%.
Screening of children for any sign of visual impairment can be done by pediatricians,
school clinics and health workers.

Vision 2020 Philippines envisions to eliminate avoidable blindness though three

strategies:
*Ensuring that cataract surgery is available, accessible, and affordable to everyone.
*Reduction of the prevalence of cataract, blinding error of refraction and vitamin A
deficiency thru enhanced services.
*Pooling of resources of government and non government agencies to address the
problem of cataract, blinding error or refraction, and Vitamin A deficiency.

B. Mental Health and Mental Disorders

-World Health Organization (WHO) defines mental health as a stage of well
being where a person can realize his or her own abilities to cope with normal
stresses of life and work productively.
FOUR FACETS AS A PUBLIC HEALTH BURDEN:
Defined Burden Refers to the burden currently affecting persons with mental
disorders and is measured in terms of prevalence and other indicators such as the quality
of life indicators and disability adjusted life years (DALY).
Undefined Burden The portion of the burden relating to the impact of mental health
problems to persons other than the individual directly affected.
Hidden Burden of Mental Illness Refers to the stigma and violations of human
rights. Stigma is a mark of shame, disgrace or disapproval that results in a person being
shunned or rejected by others.
 Future Burden Refers to the burden in the future resulting from the aging of the
population, increasing social problems and unrest inherited from the existing burden.

Mental Health Sub Programs

A. Wellness of Daily Living
The process of attaining and maintaining mental well being across the life cycle
through the promotion of healthy life style with emphasis on coping with psychosocial
issues.
Objectives:
*To increase awareness among the population on mental health and psychosocial
issues.
*To ensure access of preventive and promotive mental health services.
B. Extreme Life Experience
An extreme life experience is one that is out the ordinary and which threatens personal
equilibrium.
Objectives:
*To differentiate between critical incident and extreme life experiences.
*To identify situations which may be extreme life experiences.
*To categorize / prioritize the extreme life experiences which may be the concern of
mental health.
*To identify programs that could address psychosocial consequences and mental health
issues of persons with extreme life experiences.
C. Mental Disorder
Objectives:
*Promotion of mental health and prevention of mental illness across the lifespan and
across sectors (children and adolescents, adults, elderly, and special population such as
military, OFWs, refugees, persons with disabilities).
D. Substance Abuse and Military Other Forms of Addiction
Objectives:
*To provide implementers for advocacy accurate, technical information about the
psychosocial effects of drugs.
*To promote protective factors against the development of substance abuse/ addition in
the following key settings (Family, School, Workplace, Community, Health Care Setting,
Industry) through existing DOH programs and responsible agencies.
*To rationalize and enhance the drug program to different key settings as a form of
deterring factor.
Nursing Responsibilities and Functions
1. In Mental Health Promotion
*Participate in the promotion of mental health among families and the community,
*Utilize opportunities in his / her everyday contacts with other members of the
community to extend the general knowledge on mental hygiene.
*Help people in the community understand basic emotional needs and the factors that
promote mental well - being.
*Teach parents the importance of providing emotional support to their children during
critical periods in their lives as first day in school graduation, etc.
2. In Prevention and Control
 *Recognize mental health hazards and stress situations as unemployment, divorce or
abandonment of children, vices, long standing physical illness, all of which may make
heavy demands on the emotional resources of the persons concerned.
*Recognized pathological deviations from normal in terms of acting, thinking, and
feeling and make early referral so that diagnosis and treatment could be done early.
*Be aware of the potential causes of breakdown and when necessary take some
possible prevention action.
*Help the family to understand and accept the patients health status and behavior so
that all its members may offer as much support in the readjustments to home and
community.
*Help patient assess his / her capacities and his / her handicaps in working towards a
solution of his / her problem.
*Encourage feeling of achievement be setting health goals that patients can attain.
*Encouraged patients to express his / her anxieties so that fears and misconceptions
can be cleared up.
*Impairment information and guidance about the treatment scheme of the patients, the
desired and undesirable effect of the tranquilizers, psychiatric emergency management
and other basic nursing care.
3. Rehabilitation
*Initiate patient participation in occupational activities best suited to patients
capabilities, education, experience and training, capacities and interest.
*Encourage and initiate patients to partake in activities of CIVIC organization in the
community through the cooperation of patients family.
*Advice the family about the importance of regular follow up at the clinic.
*Make regular home visits to observe patients conditions during conversation and
follow up of medication.
4. In Research and Epidemiology
*Participate actively in epidemiology survey to be aware of the size and extent of
mental health problems of the community and organize a program for better preventive,
curative and rehabilitative measures.
POINTERS FOR HAVING MENTAL HEALTH
*Maintain good physical health
*Undergo annual medical examination or more often as needed
*Develop and maintain a wholesome lifestyle (balanced die, adequate rest, exercise,
sleep, recreation).
*Avoid smoking, substance abuse and excessive alcohol.
*Have a realistic goal in life.
*Have a friend in whom you can confide and ventilate your problems.
*Dont live in the past and avoid worrying about the future.
*Live one day at a time.
*Avoid excessive physical, mental and emotional stress.
*Develop and sustain solid spiritual values.

C. Renal Disease Control Program

It is started as a Department of Health (DOH) Preventive Nephrology Project (PNP) in
June 1994, with the National Kidney and Transplant Institute(NKTI) as the main
implementing agency.
THE GOALS OF THE PROGRAM ARE AS FOLLOWS:
1. To conduct researches / studies that will establish the true incidence of existing renal
problems and its sequel in the country.
2. To assist the existing health facilities, both local and national through:
*Conduct training on nephrology, urology, and related specialties to enhance the
expertise of medical practitioners and related professions.
*Facilitation of sourcing out of funds for the development and upgrading of manpower,
equipment, etc.
*Internal and external quality assurance.
3. To formulate guidelines and protocols on the proper implementation of the different
levels of prevention and care of renal diseases, for use of medical practitioners and other
related professions.
4. To give recommendations to lawmakers for health for policy development, funding
assistance and implementation.
5. To assist in the development of dialysis and transplant centers / units in strategic
locations all over the Philippines.
6. To establish an efficient and effective networking system with other programs and
agencies, both GOs and NGOs.
IMPORTANT INFORMATION ABOUT KIDNEY DISEASES AND ORGAN
TRANSPLANTATION
Kidney diseases rank as the number 10 killer in the Philippines, causing death to about
7,000 Filipinos every year.
Kidney Diseases
Chronic glomerulonephritis
Diabetic kidney disease
Hypertensive Kidney Disease
Chronic and repeated kidney infection(Pyelonephritis)
These often lead to End-Stage Renal
Disease (ESRD) due to the inability to recognize them in the early stages.

D. Community-based Rehabilitation Program ???

COMMUNICABLE DISEASE PREVENTION AND CONTROL

COMMUNICABLE DISEASE
*It is an illness caused by an infectious agent or its toxic products that are
transmitted directly or indirectly to a well person through an agent, vector, or
inanimate object.

TWO TYPES
INFECTIOUS DISEASE
*Not easily transmitted by ordinary contact but require a direct inoculation through a
break in the previously intact skin or mucous membrane
CONTAGIOUS DISEASE
*Easily transmitted from one person to another through direct or indirect means
TERMINOLOGIES
DISINFECTION destruction of pathogenic microorganism outside the body by
directly applying physical or chemical means
Concurrent method of disinfection done immediately after the infected
individual discharges infectious material/secretions. This method of
disinfection is when the patient is still the source of infection
Terminal applied when the patient is no longer the source of infection.
Disinfectant -chemical used on non living objects
Antiseptic chemical used on living things.
Bactericidal kills microorganism
Sterilization complete destruction of all microorganism

General Principles
Pathogens move through spaces or air current
Pathogens are transferred from one surface to another whenever objects touch
Hand washing removes microorganism
Pathogens are released into the air on droplet nuclei when person speaks,
breaths, sneezes
Pathogens are transferred by virtue of gravity
Pathogens move slowly on dry surface but very quickly through moisture
INFECTION
invasion and multiplication of microorganisms on the tissues of the host resulting
to signs and symptoms as well as immunologic response
injures the patient either by:
o competing with the hosts metabolism
o cellular damage produced by the microbes intracellular multiplication
Factors of severity of infection
o disease producing ability
o the number of invading microorganism
o The strength of the hosts defence and some other factors.
Epidemiological triad:
o Agent
o Host
o Environment

Classification according to incidence:

SPORADIC - disease that occur occasionally and irregularly with no specific
pattern
ENDEMIC those that are present in a population or community at times.
EPIDEMIC diseases that occur in a greater number than what is expected in a
specific area over a specific time.
PANDEMIC is an epidemic that affects several countries or continents

Causes of INFECTION
Some bacteria develop resistance to antibiotics
 Some microbes have so many strains that a single vaccine cant protect against all
of them ex. Influenza
Most viruses resist antiviral drugs
Opportunistic organisms can cause infection in immunocompromised patients
Most people have not received vaccinations
Increased air travel can cause the spread of virulent microorganism to heavily
populated area in hours
Use of immunosupressive drugs and invasive procedures increase the risk of
infection
Problems with the bodys lines of defense

Three Lines of Defense

FIRST LINE OF DEFENSE
o MECHANICAL BARRIERS
o CHEMICAL BARRIERS
o BODYS OWN POP. OF MICROORGANISM - microbial antagonism
principle
SECOND inflammatory response
o Phagocytic cells and WBC to destroy invading microorganism manifesting
the cardinal signs
THIRD immune response - Natural/Acquired: active/passive

RISK FACTORS
Age, sex, and genes
Nutritional status, fitness, environmental factors
General condition, emotional and mental state
Immune system
Underlying disease ( diabetes mellitus, leukemia, transplant)
Treatment with certain antimicrobials (prone to fungal infection), steroids,
immunosuppresive drugs etc.
Mode of Transmission
Contact transmission
Direct contact - person to person
Indirect - thru contaminated object
o Droplet spread - contact with respiratory secretions thru cough, sneezing,
talking. Microbes can travel up to 3 feet.
Airborne Transmission
Vector Borne Transmission
Vehicle Borne Transmission

Emerging problems in infectious diseases

Developing resistance to antibiotics eg: anti tb drugs, MRSA, VRE
Increasing numbers of immunosuppressed patients.
Use of indwelling lines and implanted foreign bodies has increased.

INFECTION CONTROL MEASURES

UNIVERSAL PRECAUTION All blood, blood products and secretions from
patients are considered as infected.
WORK PRACTICE CONTROL
Handwashing
o Before and after using gloves, after hand contact with patients, patients
blood and other potentially infected materials.
Protective Equipment shall be removed immediately upon leaving the work area.
Like apron, mask, gloves etc.
o Place in designated area.
Used needles and sharps shall not be bent, broken, recapped. Used needles must
not be removed from disposable syringes.
Eating, drinking, smoking, applying cosmetics or handling contact lenses are
prohibited in work areas.
 Foods and drinks shall not be stored in refrigerators, freezers where blood or other
infectious materials are stored.
All procedures involving blood or other potentially infectious materials shall be
performed in such a manner as to minimize splashing, or spraying.

Control Measures
Masking Wear mask if needed. Patient with infectious respiratory diseases
should wear mask.
Handwashing Practice it with soap and water.
Gloving Wear gloves for all direct contact with patients. Change gloves and
wash hands every after each patient.
Gowning - Wear gown during procedures which are likely to generate splashes of
blood or sprays of blood and body fluids, secretions or excretions.
Eye protection (goggles) wear it to prevent splashes.
Environmental disinfection Clean surfaces with disnfectant 70% alcohol,diluted
bleach)
Ex. Normal clean clean the room post discharge, final clean- MRSA and
infectious pts.

ISOLATION PRECAUTIONS
Separation of patients with communicable diseases from others so as to reduce or
prevent transmission of infectious agents.
7 Categories Recommended in isolation
Strict isolation prevent spread of infection from patient to patient/staff.-
handwashing, infectous materials must be discarded, use of single room, use of
mask, gloves and gowns and (-) pressure if possible
Contact isolation prevent spread by close or direct contact
Respiratory isolation prevent transmission thru air.
TB isolation for (+) TB or CXR suggesting active PTB.
Enteric Isolation direct contact with feces
Drainage/secretion precaution- prevents infection thru contact with materials or
drainage from infected person.
Universal Precaution for handling blood and body fluids. (Bloods, pleural fluid,
peritoneal fluid etc.)
PREVENTION
Health Education educate the family about
Immunization
MOT
Environmental sanitation breeding places of mosquito, disposal of feces
Importance of seeking medical advice for any health problem
Preventing contamination of food and water.
Environmental Sanitation
o Water Supply Sanitation Program DOH thru EHS (Environmental Health
Services)
o Policies on Food Sanitation Program
o Policies on Hospital Waste Management
 The Community Health Nurse is in the best position to do health education such
as
o > development of materials for environmental sanitation
o > providing group counselling, holding community assemblies and conferences.
o > create programs for sanitation
o > be a role model
Immunization introduction of specific antibody to produce immunity to certain disease.
o Natural passive (from placenta), active (thru immunization & recovery from
diseases)
o Artificial passive (antitoxins), active (vaccine, toxoid)
Maintain vaccine potency by preventing:
o Heat and sunlight
o Freezing
Antiseptic/ disinfectants/ detergents lessen the potency of vaccine. Use water only
when cleaning fridge/ref.
COLD CHAIN SYSTEM maintenance of correct temperature of vaccines,
starting from the manufacturer, to regional store, to district hospital, to the health center
to the immunizing staff and to the client.

Disease Acquired Thru the Respiratory tract

TUBERCULOSIS
Chronic respiratory disease affecting the lungs characterized by formation of
tubercles in the tissues---> caseation --> necrosis ---> calcification.
AKA: Phthisis, Consumption, Kochs, Immigrants disease
Etiologic agent: Mycobacterium tuberculosis
Incubation period: 2 10 wks.
Period of communicability: all throughout the life if not treated
MOT: Droplet
Sources of infection sputum, blood, nasal discharge, saliva

Classification
1. Inactive asymptomatic, sputum is (-), no cavity on chest X ray
2. Active (+) CXR, S/S are present, sputum (+) smear
Classification 0-5
A. Minimal slight lesion confined to small part of the lung
B. Moderately advanced one or both lungs are involved, volume affected should not
extend to one lobe, cavity not more than 4 cm.
C. Far advance more extensive than B

MANIFESTATIONS
Primary Complex: TB in children: non contagious, children swallow phlegm, fever,
cough, anorexia, weight loss, easy fatigability
Adult TB
o afternoon rise in temperature
o night sweats
o weight loss
 o cough dry to productive
o Hemoptysis
o sputum AFB (+)
Milliary TB - very ill, with exogenous TB like Potts disease
Primary Infection
o Asymptomatic
o No manifestations even at CXR, Sputum AFB
Primary Complex
o Minimal manifestations
o Lymphadenopathy

DX
Tuberculin testing
CXR
Sputum AFB

Prevention
BCG
Avoid overcrowding
Improve nutritional status

TX
DOTS
6 months of RIPE
Respiratory isolation,
Take medicines religiously prevent resistance
Stop smoking
Plenty of rest
Nutritious and balance meals, increase CHON, Vit. A, C

MENINGITIS
 Inflammation of the meninges usually some combination of headache, fever,
stiff neck, and delirium
Meningococcemia: cerebrospinal fever
o Etiologic agent: Neisseria meningitidis
o Incubation: 2-10 days
o MOT: droplet
Acute meningococcemia - with or without meningitis
o Waterhouse Friederichsen Syndrome

Diagnostic exams:
o Lumbar tap, CSF - high WBC and CHON, low glucose
Manifestations:
o Sudden onset of fever x 24h
o Petechiae, Purpuric rashes
o Meningeal irritation
Stiff neck
Opisthotonus
Kernigs sign
Brudzinski sign
o ALOC (Altered level of consciousness)
o S/S of Increase ICP

Nursing Mgt:
Administer prophylactic antibiotics: Rifampicin - drug of choice
Aquaeous Pen
Mannitol
Dexamethasone
Priority: AIRWAY, SAFETY
Maintain seizure precaution
Respiratory precaution
Handwashing
Suction secretions
DIPTHERIA
Acute contagious disease characterized by generalized toxemia coming from localized
inflammatory process
Etiologic agent: Corynebacterium Diptheria (Klebs loffer bacillus)
Incubation period: 2-5 days
Period of communicability: variable, ave:2-4 weeks
MOT Droplet, direct or intimate contact, fomites, discharge from nose, skin, eyes

Manifestation
PSEUDOMEMBRANE - grayish white, smooth, leathery and spider web like
structure that bleeds when detached
Types of Respiratory Diptheria
NASAL
o serous to serosanginous purulent discharge
o Pseudomebrane on septum
o Dryness/ excoriation on the upper lip and nares
PHARYNGEAL
o pharyngeal pseudomembrane
o bull neck ( cervical adenitis)
o Difficulty swallowing
LARYNGEAL
o Sorethroat, pseudomembrane
o Barking, dry metallic cough

Complications
o Due to TOXEMIA
Toxic endocarditis
Neuritis
Toxic nephritis
o Due to Intercurrent Infection
Bronchopneumonia
Respiratory failure

DX
Nose and throat swabs - culture of specimen form beneath membrane
Virulence test
SHICKs TEST: test for susceptibility to diptheria
MOLONEYs TEST: test for hypersensitivity to diphtheria

MANAGEMENT
1. Penicillin, Erythromycin
2. Diptheria Antitoxin after skin test if (+), fractional dose
3. Supportive
O2, if laryngeal obstruction tracheostomy
CBR for 2 weeks
Increase fluids, adequate nutrition- soft food, rich in Vit C
 Ice collar
4. Isolation till 3 NEGATIVE cultures

Prevention
DPT

PERTUSSIS (whooping cough)

Repeated attacks of spasmodic coughing with series of explosive expirations ending in
long drawn force inspiration
Etiologic agent: Bordetella pertusis or Haemiphilus pertussis
Incubation period: 7-14 days
Period of communicability: 7 days post exposure to 3 wks post disease onset
MOT Droplet

Manifestation
o rapid cough 5-10x in one inspiration ending a high pitched whoop.
Catarrhal slight fever in PM, colds, watery nasal discharge, teary eyes,
nocturnal coughing, 1-2 weeks
Paroxysmal Spasmodic stage; 5-10 successive forceful coughing ending
with inspiratory whoop, involuntary micturition and defecation, choking spells,
cyanosis
Convalescent 4th- 6th week; diminish in severity, frequency

Complications:
Otitis media
Acute bronchopneumonia
Atelectasis or emphysema
Rectal prolapse, umbilical hernia
Convulsions (brain damage - asphyxia, hemorrhage)

Dx:
 Elevated WBC
Nasopharyngeal swab
Nursing Management
Prevention:
o DPT
Parenteral fluids
Erythromycin - drug of choice
Prone position during attack
Abdominal binder
Adequate ventilation, avoid dust, smoke
Isolation
Gentle aspiration of secretions

MEASLES
Acute viral disease with prodromal fever, conjunctivitis, coryza, cough and
Kopliks spots
AKA: Rubeola, 7-day measles
Etiologic agent: Morbilli Paramyxoviridae virus
Incubation period: 10-12 days
Period of communicability: 3 days before and 5 days after the appearance of
rashes. Most communicable during the height of rash.
MOT: Airborne
Sources of infection secretions from eyes, nose and throat

Pathognomonic sign: Kopliks spots

Manifestations
1.Pre eruptive stage / Prodromal (10-11 days)
o Coryza, Cough, Conjunctivitis
 o Kopliks Spots, whitish spot at the inner cheek
o Fever, photophobia
2. Eruptive stage
o Maculopapular rashes
o Rash is fully developed by 2nd day
o High grade fever on and off
o Anorexia, throat is sore
3. Convalescence (7-10 days)
o Desquamation of the skin

Diagnostics
Nose and throat swab

Treatment
1. Antiviral drugs- Isoprenosine
2. Antibiotics if with complications
3. Supportive O2, IVF
Complications bronchopneumonia, otitis media, encephalitis

Nursing Management
Preventive measles vaccine at 9 months, MMR 15 months and then 11-
12; defer if with fever, illness
Isolation - contact/respiratory
TSB , Skin care daily cleansing wash
Oral and nasal care
Plenty of fluids
Avoid direct glare of the sun- due to photophobia

GERMAN MEASLES
Mild viral illness caused by rubella virus.
AKA: Rubella; 3-Day Measles
Incubation period from exposure to rash 14 -21d
Period of communicability one week before and and 4 days after onset of
rashes. Worst when rash is at its peak.
MOT: Droplet, nasal ceretions, transplacental in congenital
Manifestations
1. Prodromal low grade fever, headache , malaise, colds, lymph node
involvement on 3rd to 5th day
2. Eruptive FORSCHEIMERS SPOTS: pinkish rash on soft palate, rash on face,
spreading to the neck, arms and trunk
o lasts1-5 days with no pigmentation or desquamation
o muscle pain
Treatment
o symptomatic treatment
Complications
1. Encephalitis, neuritis
 2. Rubella syndrome microcephaly, mental retardation, deaf mutism, congenital
heart disease

RISK for congenital malformation

1. 100% when maternal infection happens on first trimester of pregnancy.
2. 4% - second/third trimester

Nursing Management
1. Isolation. Bed rest
2. Room darkened photophobia
3. Encourage fluid
4. Like measles tx

PREVENTION;
MMR, Pregnant women should avoid exposure to rubella patients
Administration of Immune serum globulin one week after exposure to rubella.

CHICKEN POX
Acute and highly contagious viral disease characterized by vesicular eruptions on the
skin
Infectious agent Herpes zoster virus or Varicella zoster
Incubation period 10 -21 days
Period of communicability: 1 day before eruption up to 5 days after the appearance
of the last crop
MOT: airborne, direct, indirect
o Direct contact thru shedding vesicles,
o Indirect thru linens or fomites

Manifestations
Pre eruptive: Mild fever and malaise
Eruptive: rash starts from trunk
Lesions - red papules then becomes milky and pus like within 4 days,
Pruritis

Stages of skin affectations

o Macule flat
o Papule elevated above the skin diameter about 3 cm
o Vesicle
o Pustule
o Crust scab , drying on the skin
Complications
o pneumonia, sepsis
Treatment
Zovirax 500mg tablet 1 tab BID X 7 days
Acyclovir
Oral antihistamine
 Calamine lotion
Antipyretics

NURSING MANAGEMENT
Strict isolation until all vesicles scabs disappear
Hygiene of patient
Cut finger nails short
Baking soda - pruritus
PREVENTION: Live attenuated varicella vaccine
VZIG - effective if given 96h post exposure

Herpes Zoster
Acute inflammatory disease known to be caused by herpes virus varicellae or VZ virus
Infection of the sensory nerve charac by extremely painful infection along the sensory
nerve pathway
Occurs as reinfection of VZ virus
MOT
o Direct
o Indirect airborne
Incubation: 1-2 weeks

Diagnostic procedure
o Hx of chickenpox
o Pain and burning sensation over lesions of vesicles along nerve pathway
o Smear of vesicle fluid- giant cells
o Viral cultures of vesicle fluid
o Electron microscopy
o Giemsa-stained scraping multinucleate giant epithelial cells
S/S
o Burning, itching, pain then erythematous patches followed by crops of
vesicles
o Eruptions are unilateral
o Lesions may last 1-2 weeks
 o Fever, regional lymphadenopathy
o Paralysis of cranial nerve, vesicles at external auditory canal
o Paralytic ileus, bladder paralysis, encephalitis

Complications
o Opthalmia herpes blindness because of damage of gasserian ganglion
o Geniculate herpes deafness because of infection of 7th CN (AKA: Ramsay
Hunt Syndrome)

Nursing Intervention
o Compress of NSS or alluminum acetate over lesions
o Analgesics, sedatives weeks to mos
o Steroids
o Keep blister covered with sterile powder esp after break
o Prevent bacterial invasion
o Encourage proper disposal of secretions and usage of gown and mask

MUMPS
Acute viral disease manifested by swelling of one or both of the parotid glands,
with occasional involvement of other glandular structures,particularly testes in
male.
Etiologic agent filterable virus of paramyxovirus group usually found in saliva of
infected person.
AKA: Epidemic/ infectious parotitis
Incubation period: 14 -25 days.
Period of communicability 6d before and 9d post onset of parotid gland swelling.
o 48 hrs immediately preceding the onset of swelling is the highest
communicability.
MOT: direct, indirect - droplet, airborne

CLINICAL MANIFESTATIONS
1. Sudden headache, earache, loss of appetite
2. Swelling of the parotid gland
3. Pain is related to extent of the swelling of the gland which reaches its peak in 2 days
and continues for 7-10 days.
4. Fever may reach 40 C during acute stage,
5. One gland may be affected first and 2 days later the other side is involved

COMPLICATIONS
1. Orchitis testes are swollen and tender to palpation.
2. Oophoritis- pain and tendeness of the abdomen
3. Mastitis
4. Deafness may happen
5. Meningo-encephalitis -possible

DIAGNOSTIC PROCEDURES
1. Viral culture
2. WBC Count

PREVENTION: MMR Vaccine

TREATMENT MODALITIES
1. Antiviral drugs
2. NSAIDS - Acetaminophen
Nursing Interventions
o Symptomatic
o Application of warm/ cold compress
o Oral care, warm salt water gargle
o Diet semi solid, soft food easy to chew
Acid foods/fluids fruit juices may increase discomfort

Diseases Acquired thru GIT

Diseases caused by Bacteria
o Typhoid Fever
o Cholera
o Dysentery
Diseases caused by Virus
o Poliomyelitis
o Infectious Hepatitis A
Diseases caused by Parasites
o Amoebiasis
o Ascariasis

TYPHOID FEVER
Infection of the GIT affecting the lymphoid tissues(ulceration of Peyers patches)
of the small intestine
Etiologic Agent: Salmonella typhosa and typhi, Typhoid bacillus
 Incubation period: 1-2 weeks
Period of communicability: as long as the patient is excreting the
microorganism,
MOT: fecal-oral route, contaminated water, milk or other food
Sources of Infection
o A person who recovered from the disease can be potential carrier.
o Ingestion of shellfish taken from waters contaminated by sewage disposal
o Stool and vomitus of infected person are sources of infection.

CLINICAL MANIFESTATIONS
ONSET
Ladderlike fever
Nausea, vomiting and diarrhea
RR is fast, skin is dry and hot, abdomen is distended
Head-ache, aching all over the body
Worsening of symptoms on the 4th and 5th day
Rose spots
TYPHOID STATE
Tongue protrudes- dry and brown
sordes
(coma vigil)
(subsultus tendinus)
(Carphologia)
Always slip down to the foot part of the bed,
Severe case - delirum sets in often ending in death
Complications
o Hemorrhage, Peritonitis, Pneumonia, Heart failure, Sepsis

DIAGNOSTIC PROCEDURES
1. WBC elevated
2. Blood Culture (+) S. typhosa
3. Stool Culture (+)
4. Widal test blood serum agglutination test
O antigen active typhoid
H antigen- previously infected or vaccinated
Vi antigen - carrier

TREATMENT
1. Chloramphenicol drug of choice
2.Paracetamol

NURSING MANAGEMENT
1. Restore FE balance
2. Bedrest
3. Enteric precaution
4. Prevent falls/ safety prec
5. Oral/personal hygiene
6. WOF intestinal bleeding-bloody stool, sweating, pallor
7. NPO, BT

CHOLERA
An acute bacterial disease of the GIT characterized by profuse diarrhea,
vomiting, loss of fluid.
Etiologic agent: Vibrio cholerae, V. comma
Pathognomonic sign: rice watery stool
Incubation period: 2-3 days
Period of Communicability: entire illness, 7-14d
MOT: fecal oral route
Clinical manifestations
o Acute, profuse, watery diarrhea.
o Initial stool is brown and contains fecal material becomes rice water
o Nausea/ Vomiting
Signs and symptoms of Dehydration
o poor tissue turgor, eyes are sunken
o Pulse is low or difficult to obtain, BP is low and later unobtainable.
o RR rapid and deep
o Cyanosis later
o Voice becomes hoarse speaks in whisper
Oliguria or anuria
Conscious, later drowsy
Deep shock
Death may occur as short as four hours after onset.
Usually first or 2nd day if not treated.

Principal deficits
1. Severe dehydration - circulatory collapse
2. Metabolic acidosis loss of large volume of bicarbonate rich stool. RR rapid and
deep
3. Hypokalemia massive loss of K. abdominal distention paralytic ileus

DIAGNOSTIC EXAMS
Fecal microscopy
1. Rectal swab
2. Stool exam

Treatment
1. IVF- rapid replacement
2. Oral rehydration
3. Strict I and O
4. Antibiotics Tetracycline, Cotrimoxazole.

NURSING MANAGEMENT
1. Medical Asepsis
2. Enteric precaution
3. VS monitoring
4. Intake and Output
5. Good personal hygiene
6. Proper excreta disposal
7. Concurrent disinfection.
8. Environmental sanitation

PREVENTION
1. Protection of food and water supply from fecal contamination.
2. Water should be boiled/ chlorinated.
3. Milk should be pasteurized.
4. Sanitary disposal of human excreta
5. Environmental sanitation.

DYSENTERY
Acute bacterial infection of the intestine characterized by diarrhea and fever
Etiologic Agent: Shigella group
o Shigella flesneri - commmon in the Philippines
o Shigella boydii, S. connei,
o S. dysenteria most infectious, habitat exclusively in man, they develop
resistance to antibiotics
Incubation period 7 hrs. to 7 days
Period of communicability during acute infection until the feces are (-)
MOT fecal-oral route, contaminated water/ milk/ food.

Clinical manifestations
Fever esp. in children
Nausea, vomiting and headache
Anorexia, body weakness
Cramping abdominal pain (colicky)
Diarrhea bloody and mucoid
Tenesmus
Weight loss

DIAGNOSTICS
Fecalysis
Rectal Swab/culture
Bloods WBC elevated
Blood culture

TREATMENT
Antibiotics- Ampicillin, Cotrimoxazole, Tetracycline
IVF
 Anti diarrheal are Contraindicated

NURSING MANAGEMENT
1. Maintain fluid and electrolyte balance
2. Restrict food until nausea and vomiting subsides.
3. Enteric precaution
4. Excreta must be disposed properly.
5. Prevention- food preparation, safe washing facilities, fly control.

POLIOMYELITIS
An acute infectious disease caused by any of the 3 types of poliomyelitis virus which
affects mainly the anterior born cells of the spinal cord and the medulla, cerebellum
and the midbrain
AKA: Acute anterior poliomyelitis, heinmedin disease, infantile paralysis
Etiologic Agent: Poliovirus (Legio Debilitans)
3 Types of Poliovirus
Type I - most paralytogenic, most frequent
Type II - next most frequent
Type III - least frequent associated with paralytic disease

3 Strains
o Brunhilde
o Laasing
o Leon
MOT: Fecal-Oral
Incubation period: 7-14 days ave (3-21 days)
Period of communicability:
o 7-16 days before and few days after onset of s/s
Signs and Symptoms:
o Febrile episodes with varying degrees of muscle weakness
o Occasionally progressive Flaccid Paralysis
3 Types of Paralysis
Spinal Paralytic
o Flaccid paralysis
o Autonomic involvement
o Respiratory difficulty
Bulbar Form
o Rapid & serious
o Vagus and glossopharyngeal nerves affected
o Cardiac and respiratory reflexes altered
o Pulmo edema
o Hypertension, impaired temp regulation
o Encephalitic s/s
Bulbospinal
o Combination
Minor Polio
o Inapparent / subclinical
o Abortive: recover within 72 hours; flulike; backache; vomiting
Major Polio
o Paralytic: asymmetrical weakness, paresthesia, urinary retention,
constipation
o Non paralytic: slight involvement of the CNS; stiffness and rigidity of
the spine, spasms of hamstring muscles, with paresis
o Tripod position: extend his arms behind him for support when upright
o Hoynes sign: head falls back when he is in supine position with the
shoulder elevated
o Meningeal irritation: (+) Brudzinski, Kernigs sign

Diagnostic tests:
Throat swab, stool exam, LP
Nursing Interventions:
Supportive, Preventive Salk and Sabin Vaccine
NO morphine
Moist heat application for spasms
AIRWAY: tracheotomy
Footboard to prevent foot drop
Fluids, NTN, Bedrest
Enteric and strict precautions

HEPATITIS A
Inflammation of the liver caused by hepatitis A virus
AKA: infectious hepatitis
Incubation period: 2-6weeks
MOT: oral-fecal/ enteric transmission
Diagnostic test: liver function (SGOT/SGPT)

Clinical manifestations
Prodromal/ pre icteric
S/S of URTI
Weight loss
Anorexia
RUQ pain
Malaise
Icteric
Jaundice
Acholic stool
Bile-colored urine
Diagnostic tests: HaV Ag, Ab, SGOT, SGPT

Nursing Interventions:
o Provide rest periods
o Increase CHO, mod Fat, low CHON
o Intake of vits/minerals
o Proper food preparation/handling
o Handwashing to prevent transmission

AMOEBIASIS
Involves the colon in general but may involve the liver or lungs as well
Etiologic agent: Entamoeba histolytica
Incubation: 3-4 weeks
Period of communicability: duration of illness
MOT: fecal oral route
Indirect - Ingestion of food contaminated with E.Histolytica cysts, polluted water
supply, exposure to flies, unhygienic food handlers.
Direct contact sexual, oral, or anal, proctogenital

Clinical manifestations
Intermittent fever
Nausea, vomiting, weakness
Later : anorexia, weight loss, jaundice
Diarrhea watery and foul smelling stool often containing blood streaked mucus.
Colic and abdominal distention
Intestinal perforation bleeding

DIAGNOSTIC EXAM
Stool Exam ( cyst, amoeba+++)
WBC elevated

TREATMENT
o Amoebacides Metronidazole(Flagyl) 800mg TID X 7days
o Bismuth gylcoarsenilate combined with Chloroquine
o Antibiotic Ampicillin, Tetracycline, Chloramphenicol
 o Fluid replacement IVF, oral

NUSING MANAGEMENT
Enteric precaution
Health education- boil drinking water (20-30 mins), Use mineral water.
Cover leftover food.
Avoid washing food from open drum/pail.
Wash hands after defecating and before eating.
Observe good food preparations.
Fly control

ASCARIASIS
Helminthic infection of the small intestine caused by ASCARIS LUMBRECOIDES
MOT: fecal-oral
Incubation period: 4-8 weeks
Communicability: as long as mature fertilized female worms live in intestine

Diagnostic exams: Microscopic identification of eggs in stool, CBC, Hx of passing out of

worms (oral or anal), X-ray.

Signs and Symptoms

o Stomachache
o Vomiting
o Passing out of worms
o Complications
o Energy / Protein malnutrition, Anemia
o Intestinal obstruction

Treatment:
o Pyrantel Pamoate
o Piperazine Citrate
o Mebendazole, Tetramizole
o Dicyclomine Hcl, NSAIDS for abdominal pain
o For intestinal obstruction
Decompression
Fluid and electrolyte therapy
If persistent, laparotomy
o Follow-up stool exam 1-2 weeks after treatment

Nursing Intervention:
o Isolation- not needed
o Enteric precaution
o Handwashing
o Proper nutrition
o Maintenance of hydration / fluid balance / boil of water
o Improve personal hygiene
 o Proper food prep/handling
o Administer meds (NSAIDS, MEBENDAZOLE).

Diseases Acquired thru the Skin

Diseases caused by Trauma and Inoculation
o Tetanus
o Rabies
o Malaria
o DHF
o Leptospirosis
o Schistosomiasis
Diseases acquired thru contact
o Leprosy

TETANUS
An acute, often fatal, disease characterized by generalized rigidity and convulsive
spasms of skeletal muscles caused by the endotoxin released by C. Tetani
AKA: Lockjaw

Etiologic Agent: Clostridium Tetani

o Anerobic
o Spore forming, gram positive rod

Sources:
o Animal and human feces
o Soil and dust
o Plaster, unsterile sutures, rusty scissors, nails and pins

MOT:
o Direct or indirect contact to wounds
o Traumatic wounds and burns
o Umbilical stump of the newborn
o Dirty and rusty hair pins
o GIT- port of entry rare
o Circumcision/ ear pearcing

Incubation period: 3d-3week (ave:10days).

Signs and symptoms:
persistent contraction of muscles in the same anatomic area as the injury
Local tetanus
Cephalic tetanus - rare form
o otitis media (ear infections)
Generalized tetanus
o trismus or lockjaw
o stiffness of the neck
o difficulty in swallowing
o rigidity of abdominal muscles
o elevated temperature
o sweating
o elevated blood pressure episodic rapid heart rate
Neonatal tetanus - a form of generalized tetanus that occurs in newborn
infants

Complications:
o Laryngospasm
Hypostatic pneumonia
Hypoxia
Atelectasis

o Trauma
Fractures
o Septicemia
Nosocomial infections
o Death

Diagnostic procedure:
 entirely clinical
CSF normal
WBC - normal or slight elevation

Treatment:
Wounds should be cleaned
Necrotic tissue and foreign material should be removed
Tetanic spasms - supportive therapy and maintenance of an adequate airway
Tetanus immune globulin (TIG)
o help remove unbound tetanus toxin
o cannot affect toxin bound to nerve endings
o single intramuscular dose of 3,000 to 5,000 units
o Contains tetanus antitoxin.
Oxygen
NGT feeding
Tracheostomy
Adequate fluid, electrolyte, caloric intake
During convalescence
o Determine vertebral injury
o Attend to residual pulmonary disability
o Physiotherapy
o Tetanus Toxoid
Nursing Interventions:
Prevention
DPT
o Adverse Reactions
o Local reactions (erythema, induration)
o Fever and systemic symptoms not common
o Exagerated local reactions

Nursing interventions:
Prevention of CV and respiratory complications
o Adequate airway
o ICU ET- MV
Provide cardiac monitoring
KVO
Wound care (TIG, Debridement, TT)
Administer antibiotics as ordered
o Penicillin
Care during tetanic spasm/ convulsion
o Administer Diazepam muscle rigidity/spasm
o Administer neuromuscular blocking agents (metocurin iodide) relax
spasms and prevent seizure
Keep on seizure precaution
Parenteral nutrition
Avoid complications of immobility (contractures, pressure sores)
 WOF urinary retention, fractures

RABIES
A viral zoonotic neuroinvasive disease that causes acute encephalitis
Etiologic agent: Rhabdovirus
AKA: Hydrophobia, Lyssa
Negri bodies in the infected neurons pathognomonic
Incubation period: 4-8 weeks; 10d-1yr
Period of communicability: 3-5 days before the onset of s/s until the entire
course of disease
MOT: contamination of a bite of infected animals
Diagnostic procedures
O History of exposure
O PE/ assessment of s/s
O Microscopic examination of Negri bodies using Sellers May-Grunwald and
Mann Strains
O Fluorescent Rabies Antibody technique / Direct Immunofluorescent test.

Clinical Manifestations
Prodromal Phase / Stage of Invasion
Fever, anorexia, malaise, sorethroat, copious salivation, lacrimation, perspiration,
irritability, hyperexcitability, restlessness, drowsiness, mental depression, marked
insomia
Sensitive to light, sound, and changes in temp
Myalgia, numbness, tingling, burning or cold sensation along nerve pathway;
dilation of pupils
Stage of Excitement
Marked excitation, apprehension
Delirium, nuchal stiffness, involuntary twitching
Painful spasms of muscles of mouth, pharynx, and larynx on attempting to
swallow food or water or the mere sight of them hydrophobia
 Aerophobia
Precipitated by mild stimuli touch or noise
Death spasm from or from cardiac / respiratory failure
Terminal Phase or Paralytic Stage
Quiet and unconscious
Loss of bowel and bladder control
Tachycardia, labored irregular respiration, steady rising temp
Spasm, progressively increasing paralysis
Death due to respiratory paralysis

TREATMENT:
No cure
No specific symptomatic/ supportive directed toward alleviation of
spasm
Employ continuing cardiac and pulmonary monitoring
Assess the extent and location of the bite biting incident/ status of the
animal
o Severe exposure
o Mild exposure
Wound treatment (local care)
o Cleanse thoroughly with soap and water (or ammonium compounds,
betadine, or benzalkonium cl)
o Anti - rabies serum
o Tetanus prophylaxis
o Antibiotics
o Suturing should be avoided
Antirabies sera
o Heterologous serum obtained by hyperimmunization of different
animal species i.e. horses
o HRIG Homologous reabies immunoglobulin human origin
Rabies Vaccine
Active immunization
o Administered 3 years duration
o Used for lower extremity bites
o Lyssavac (purified protein embryo), Imovax, Anti-rabies vaccine
Passive immunization
o 3 months
o Rabuman, Hyper Rab, Imogam

Nursing Intervention:
o Isolation of patient
o Provide comfort for the patient by:
Place padding of bedside or use restraints
Clean and dress wound with the use of gloves
Do not bathe the patient, wipe saliva or provide sputum jar
o Provide restful environment
 Quiet, dark environment
Close windows, no faucets or running water should be heard
IVF should be covered
No sight of water or electric fans

MALARIA
Acute and chronic disease transmitted by mosquito bite confined mainly to tropical
areas.
Etiologic agent Protozoa of genus Plasmodia
Plasmodium Falciparum (malignant tertian)
o most serious, high parasitic densities in RBC with tendency to agglutinate and form
into microemboli. Most common in the Philippines
P. Vivax - non life threatening except for the very young and old.
o Manifests chills every 48 hrs on the 3rd day onward if not treated,
P. malarie (Quartan) less frequent, non life threatening, fever and chills occur every
72 hrs on the 4th day of onset
P. ovale - rare
Incubation period:
o 12days P. falciparum, 14 days P vivax and ovale, 30 days P. malariae
Period of communicability:
o If not treated /inadequate more than 3 yrs. P malariae, 1-2 yrs. P. vivax, 1 yr- P.
falciparum
Mode of transmission
o Mosquito bite

VECTOR female Anopheles mosquito

DIAGNOSTICS
Malarial smear film of blood is placed on a slide, stained and examined.
Rapid diagnostic test (RDT) done in field. 10 -15 mins result blood test.
Clinical Manifestions:
Rapidly rising fever with severe headache
Shaking chills
Diaphoresis, muscular pain
Splenomegaly, hepatomegaly
Hypotension
o May lasts for 12 hours daily or every 2 days.
Complicated Malaria
GIT
o Bleeding from GUT, N/V, Diarrhea, abdominal pain, gastric, tyhoid, choleric,
dysenteric
CNS or Cerebral Malaria
o Changes in sensorium
o Severe headache
o N/V
Hemolytic
Blackwater fever
o Reddish to mahogany colored urine due to hemoglobinuria
o Anuria death
Malarial lung disease

MANAGEMENTS:
Antimalarial drugs Chloroquine (all but P. Malarie), quinine, Sulfadoxine (resistant P
falciparum) Primaquine (relapse P vivax/ovale)
RBC replacement/ erythrocyte exchange transfusion

Nursing management:
Isolation of patient
Use mosquito nets
Eradicate mosquitos
Care of exposed persons case finding
I and O
BUN & creatinine dialysis could be life saving
ABG
TSB, ice cap on head
Hot drinks during chilling, lots of fluid
Monitoring of serum bilirubin
Keep clothes dry, watch for signs of bleeding
PREVENTION
o Mosquito breeding places should be destroyed
o Insecticides, insect repellant
o Blood donor screening.

DENGUE FEVER
Is an acute febrile disease cause by infection with one of the serotypes of dengue
virus which is transmitted by mosquito (Aedes aegypti).
 Dengue hemorrhagic fever fatal characterized by bleeding and hypovolemic
shock
Etiologic agent Arbovirus group B
AKA: Chikungunya, O nyong nyong, west nile fever
Mode of Transmission: Bite of infected mosquito AEDES AEGYPTI
Incubation period 3-14 days
Period of communicability mosquito all throughout life
Sources of infection
Infected person- virus is present in the blood and will be the reservoir when
sucked by mosquitoes
Stagnant water = any

Diagnostic Tests:
Torniquet test
Platelet Count
Hematocrit

Manifestations
PRODROMAL symptoms
o malaise and anorexia up to 12 hrs.
o Fever and chills, head-ache, muscle pain
o N &V
FEBRILE Phase
o Fever persists (39-40 C)
o Rash - more prominent on the extremities and trunk
o (+) torniquet test- petechia more than 10.
o Skin appears purple with blanched areas with varied sizes ( Hermans
sign)
o Generalized or abdominal pain
o Hemorrhagic manifestations epistaxis, gum bleeding
CIRCULATORY Phase
o Fall of temp on 3rd to 5th day
 o Restless, cool clammy skin
o Profound thrombocytopenia
o Bleeding and shock
o Pulse - rapid and weak
o Untreated shock --- coma death
o Treated recovery in 2 days
CLASSIFICATION
Grade 1
Grade 2
Grade 3
Grade 4

Treatment:
No specific antiviral therapy for dengue
Analgesic not aspirin for relief of pain
IV fluid
BT as necessary
O2 therapy

NURSING MANAGEMENT
1. Kept in mosquito free environment
2. Keep pt. at rest
3. VS monitoring
4. Ice bag on the bridge of nose and forehead.
5. Observe for signs of shock VS (BP low), cold clammy skin

PREVENTION:
Mosquito net
Eradication of breeding places of mosquito-
o house spraying
o change water of vases
o scrubbing vases once a week
o cleaning the surroundings
o keep water containers covered
o avoid too many hanging clothes inside the house

LEPTOSPIROSIS
Infectious bacterial disease carried by animals whose urine contaminates water or
food which is ingested or inoculated thru the skin.
Etiologic agent: spirochete Leptospira interrogans
o found in river, sewerage, floods
AKA: Weils disease, mud fever, Swineherds disease
Incubation Period: 6 -15 days
Period of Communicability found in urine between 10-20 days
MOT contact with skin of infected urine or feces of wild/domestic animals; ingestion,
inoculation
 Diagnostic tests:
o Clinical manifestations
o Culture

SOURCE OF INFECTION
o Rats, dogs, mice

MANIFESTATIONS
o Septic Stage
Early
Fever (40 C), tachycardia, skin flushed, warm, petechiae
Severe
Multiorgan
Conjunctival affectation, jaundice, purpura, ARF, Hemoptysis, head-
ache, abdominal pain, jaundice
o Toxic stage with or w/o jaundice, meningeal irritation, oliguria shock,
coma , CHF
o Convalescence recovery

MANAGEMENT
1. IV antibiotic
Pen G Na
Tetracycline
Doxycycline
2. Dialysis peritoneal
3. IVF
4. Supportive
5. Symptomatic

Nursing Interventions
o Isolation of patient urine must properly disposed
o Care of exposed persons keep under close surveillance
o Control measures
Cleaning of the environment/ stagnant water
 Eradicate rats
Avoid bathing or wading in contaminated pool of water
vaccination of animals (cattles,dogs,cats,pigs)

SCHISTOSOMIASIS
Parasitic disease caused by Schistosomiasis japonicum, Schistosomiasis mansoni,
Schistosomiasis Hematobium.
AKA: Bilharziasis, Snail fever.
Incubation Period: 2 6 weeks
MOT: Bathing, swimming, wading in water.
Vector: Oncomelania quadrasi
o Cercariae: most effective stage
Diagnostic test: Ova seen in fecalysis
Diagnostic procedures:
Fecalysis
Identification of eggs
Liver and rectal biosy
Immunodiagnostic tests / circumoval precipitin test and cercarial envelope
reactions.

Signs and symptoms:

o Swimmers itch
Itchiness
Redness and pustule formation at site of entry of cercariae
Diarrhea
 Abdominal pain
hepatosplenomegaly

CLINICAL MANIFESTATIONS:
Abdominal pain
Cough
Diarrhea
Eosinophilia - extremely high eosinophil granulocyte count.
Fever
Fatigue
Hepatosplenomegaly - the enlargement of both the liver and the spleen.
Colonic polyposis with bloody diarrhea (Schistosoma mansoni mostly)
Portal hypertension with hematemesis and splenomegaly (S. mansoni, S.
japonicum);
Cystitis and ureteritis with hematuria bladder cancer;
Pulmonary hypertension (S. mansoni, S. japonicum, more rarely S.
haematobium);
Glomerulonephritis; and central nervous system lesions.
Complications:
O Pulmonary hypertension
O Cor pulmonale
O Myocardial damage
O Portal cirrhosis

Treatment:
Trivalent antimony
o Tartar emetic administered thru vein
o Stibophen (FUADIN) given per IM
PRAZIQUANTEL per orem
Niridazole

Nursing Interventions:
o Administer prescribed drugs as ordered
o Prevent contact with cercaria-laden waters in endemic areas like streams
o Proper sanitation or disposal of feces
o Creation of a program on snail control chemical or changing snail environment

LEPROSY
Chronic systemic infection characterized by progressive cutaneous lesions
Etiologic agent: Mycobacterium leprae
o Acid fast bacilli that attack cutaneous tissues, peripheral nerves producing skin
lesions, anesthesia, infection and deformities.
Incubation period 5 1/2 mo - eight years.
MOT respiratory droplet, inoculation thru break in skin and mucous membrane.

Diagnosis:
 1. Identification of S/s
2. Tissue biopsy
3. Tissue smear
4. Bloods inc. ESR
5. Lepromin skin test
6. Mitsuda reaction

MANIFESTATIONS
Corneal ulceration, photophobia blindness
Lesions are multiple, symmetrical and erythematous macules and papules
Later lesions enlarge and form plaques on nodules on earlobes, nose eyebrows
and forehead
Foot drop
Raised large erythemathous plaques appear on skin with clearly defined borders.
rough hairless and hypopigmented leaves an anesthetic scar.
Loss of eyebrows/eyelashes
Loss of function of sweat and sebaceous glands
Epistaxis

TREATMENT
multiple drug therapy
sulfone
rehab
occupational Health
isolation
moral support

PREVENTION
1. Report cases and suspects of leprosy
2. BCG vaccine may be protective if given during the first 6 months.
3. Nursing Interventions:
1. Isolation of patient until causative agent is still present
2. Care of exposed persons
1. Household contact Diaminodiphenylsulfone for 2 years
 2. Observe carefully for symptoms of the disease.

Disease Acquired Thru Sexual Contact

HIV /AIDS
Chronic disease that depresses immune function
Characterized by opportunistic infections when T4/CD4 count drops <200
MOT sexual contact with infected unprotected, injection of blood/products,
placental transmission.

History of HIV / AIDS

1959 - African man
1981- 5 homosexual men
1982-Designated as disease by CDC
1983- HIV 1 discovered
1987- 1.5 million HIV-infected in USA
1994- WHO reports 8-10 mil. Worldwide & protease inhibitors introduced
1999-First clinical trials for HIV vaccine
The immune system
o Macrophages
Humoral response
Cell-mediated response

RNA virus
Retrovirus
Reverse
transcriptase
Protease
 Diagnostic Tests
ELISA
Western Blot
CD4 count
Viral load testing
Home test kits

Manifestations
o Minor signs cough for one month, general pruritus, recurrent herpes zoster, oral
candidiasis, generalized lymphadenopathy
o Major signs loss of weight 10% BW, chronic diarrhea 1month up, prolonged fever
one month up.
Persistent lymphadenopathy
Cytopenias (low)
PCP
Kaposis sarcoma
Localized candida
Bacterial infections
TB
STD
Neurologic symptoms

Criteria for Diagnosis of AIDS

CD4 counts of 200 or less
Evidence of HIV infection and any of
o Thrush
o Bacillary angiomatosis
o Oral hairy leukoplakia
o Peripheral neuropathy
o Vulvovaginal candidiasis
o Shingles
o Idiopathic thrombocytopenia
o Fatigue, night sweats, weight loss.
 o Cervical dysplasia, carcinoma in situ.
Evidence of HIV infection and any one of the following:
O Bronchial candidiasis
O Esophageal candidiasis
O CMV disease
O CMV retinitis
O HIV encephalopathy
O Histoplasmosis
O Kaposis Sarcoma
O Herpes simplex ulcers, bronchitis, pneumonia
O Primary brain lymphoma
O Pneumocystis Carinii Pneumonia
O Recurrent pneumonia
O Mycobacterium infection
O Progressive multifocal leukoencepalopathy
O Salmonella septicemia
O Toxoplasmosis
O Wasting syndromes

Treatment
Started in CD4 counts of <200
Viral load >10,000 copies
All symptomatic regardless of counts
Note: CD4 reflects immune system destruction. Viral load- degree of viral activity
Nucleoside Reverse Transcriptase Inhibitors
Blocks reverse transcriptase
NRT
Acts by binding directly to the reverse transcriptase enzyme
Not used alone
Rapid development of resistance
Acts by binding directly to the reverse transcriptase enzyme
Not used alone
Rapid development of resistance

Generic Trade Dose Notes

Zidovudine AZT, ZDV, 300 mg. Taken with food

Retrovir Bid

Didanosine ddI, Videx 200 mg Peripheral

bid neuropathy

Zalcitibine ddC,Hivid .75 mg No antacids

TID

Stavudine d4T, Zerit 400 mg Peripheral

bid neuropathy
Lamivudine 3TC, Epivir 150 mg Used as
bid resistance
develops

Lamiduvine/Zido Combivir 150/300 Bone marrow

vudine mg toxicity

Protease Inhibitors
Introduced in 1995
Acts by blocking protease enzyme
Indinavir (Crixivan)

CDC Guidelines
o Combination of 2 NRTI + PI
Nursing Management
o Administer Antiviral meds as ordered
o Universal precaution
o Reverse isolation
gloves, needle stick injury prevention
o Assist in early diagnosis and management of complications
4 Cs
o Compliance info, + drugs
o Counselling education
o Contact tracing tracing out and tx for partners
o Condoms safe sex

GONORRHEA
A curable infection caused by the bacteria Neisseria gonorrhoea
AKA: Clap, Drip, G. vulvovaginitis
MOT: transmitted during vaginal, anal, and oral sex
Incubation period: 3-10 days initial manifestations
Period of communicability: considered infectious from the time of exposure
until treatment is successful
Manifestations:
Urethritis both male and female
Signs and Symptoms: dysuria and purulent discharge
Cervicitis
Upper Genital Tract females (PID)
Endometritis, Salpingitis,
Pelvic Abscess
Complications :
PID
Infertility

Complications:
 Upper Genital Tract male
o Epididymitis, Prostatitis, Seminal Vesiculitis
Disseminated Gonococcal Infection (DGI)
o Tenosynovitis or Polyarthritis, skin lesions and fever
Anorectal Infection
Pharyngeal Infection
Gonococcal Conjuctivitis
o Opthalmia Neonatorum
Meningitis, Endocarditis

Diagnosis:
Culture & Sensitivity
Blood tests for N. gonorrhoeae antibodies

Treatment:
ANTIBIOTICS
Penicillin
Single dose Ceftriaxone IM + doxycycline PO BID for 1 week
Prophylaxis: Silver nitrate, Tetracycline, Erythromycin

Nursing Interventions:
o Case finding
o Health teaching on importance of monogamous sexual relationship
o Treatment should be both partners to prevent reinfection
o Instruct possible complications like infertility
o Educate about s/s and importance of taking antibiotic for the entire therapy
SYPHILIS
a curable, bacterial infection, that left untreated will progress through four stages
with increasingly serious symptoms.
Etiologic agent: Treponema pallidum
AKA: Lues, The pox, Bad blood
Type of Infection: Bacterial
Modes of transmission :
o Through sexual contact/ intercourse, kissing
o abrasions
o Can be passed from infected mother to unborn child (transplacental)
Symptoms:
o Primary syphilis (10 90 days after infection)
Chancre a firm, painless skin ulceration localized at the point of
initial exposure to the bacterium appear on the genitals
can also appear on the lips, tongue, and other body parts.
o Secondary syphilis (last 2 6 weeks)
syphilis rash - an infectious brown skin rash that typically occurs on
the bottom of the feet and the palms of the hand
condylomata lata - flat broad whitish lesions
 Fever, sore throat, swollen glands, and hair loss can also be
experienced
Third stage
o Will manifest 1 10 years after the infection
o characterised by gummas - soft, tumor-like growths
seen in the skin and mucous membranes occurs in bones
o joint and bone damage
o increasing blindness
o Numbness in the extremities, or difficulty in coordinating movements.

Neurosyphilis
generalized paresis of the insane which results in personality changes,
changes in emotional affect, hyperactive reflexes
cardiovascular syphilis
aortitis, aortic aneurysm, Aneurysm of sinus of valsalva and aortic
regurgitation, - death

Consequences in Infants
Congenital syphilis
extremely dangerous
Deformities
Seizures
Blindness
Damage to the brain, bones, teeth, and ears.

Test and diagnosis

Venereal Disease Research Laboratory (VDRL) test
Flourescent treponemal antibody absorption (FTA Abs)
Micro hemagglutination test (MHA - TP)
CSF examination
Treatment
Syphilis is easily treatable when early detected
Penicillin & other antibiotics

Prevention:
Abstinence
Mutual monogamy
Latex condoms for vaginal and anal sex
Nursing interventions
o Case finding
o Health teaching and guidance along preventive measures
o Utilization of community health facilities
o Assist in interpretation and diagnosis
o Reinforce ff up treatment
o VD control program participation
o Medical examination of patients contacts
HEPATITIS B
serious disease caused by a virus that attacks the liver
Etiologic agent: hepatitis B virus (HBV)
Source of infections: Blood and body secretions

Risk factors
multiple sex partners or diagnosis of a sexually transmitted disease
Sex contacts of infected persons
Injection-drug users
Household contacts of chronically infected persons
Infants born to infected mothers
Infants/children of immigrants from areas with high rates of HBV infection
Health-care and public safety workerr
Hemodialysis patients

Complications:
Lifelong infection
Liver cirrhosis
Liver cancer
Liver failure
Death

Signs and symptoms:

Jaundice
Pruritus
Fatigue
RUQ - Abdominal pain
Loss of appetite
Nausea, vomiting
Joint pain

Prevention:
Hepatitis B vaccine has been available since 1982.
o Routine vaccination of 0-18 year olds
o Vaccination of risk groups of all ages
Immune globulin if exposed

MEDICAL MANAGEMENT:
Interferon alfa-2b
Lamivudine
Telbivudine
Entecavir
Adefovir dipivoxil
Nursing Interventions:
o Blood and body secretions precautions
o Prevention- Hepa B vaccine
o Proper rest periods
o Prevent stress physio/psychological
o Proper NTN, increase in CHO, high in CHON, low fats, Vit. K rich foods and
minerals
o Assistance to prevent injury, promote safety AAT
o WOF signs and symptoms bleeding, edema
o Health education on safe sex.

SEVERE OF ACUTE RESPIRATORY SYNDROME

An acute and highly contagious respiratory disease in humans
Etiologic agent: SARS coronavirus
November 2002 and July 2003, with 8,096 known infected cases and 774 deaths
Incubation period: 2-3days
MOT: Airborne

Signs and symptoms:

o flu like: fever, myalgia, lethargy, gastrointestinal symptoms, cough, sore
throat
o fever above 38 C (100.4 F)
o Shortness of breath
o Symptoms usually appear 210 days following exposure
o require mechanical ventilation

Diagnostic Test:
Chest X-ray (CXR)- abnormal with patchy infiltrates
WBC and PLT CT. - LOW
ELISA test detects antibodies to SARS
o but only 21 days after the onset of symptoms
Immunofluorescence assay, can detect antibodies 10 days after the onset of the
disease.
o labour and time intensive test
Polymerase chain reaction (PCR) test that can detect genetic material of the
SARS virus in specimens ranging from blood, sputum, tissue samples and stools
CXR - increased opacity in both lungs, indicative of pneumonia
SARS may be suspected
fever of 38 C (100.4 F) or more AND
Either a history of:
o Contact (sexual or casual) with someone with a diagnosis of SARS within
the last 10 days OR
o Travel to any of the regions identified by the WHO as areas with recent
local transmission of SARS (affected regions as of 10 May 2003 were parts
of China, Hong Kong, Singapore and the province of Ontario, Canada).
 probable case of SARS has the above findings plus positive chest x-ray findings of
atypical pneumonia or respiratory distress syndrome

Treatment
Supportive with antipyretics, supplemental oxygen and ventilatory support as
needed.
Suspected cases of SARS must be isolated, preferably in negative pressure
rooms, with full barrier nursing precautions taken for any necessary contact with
these patients
steroids
antiviral drug
SARS vaccine

Tuberculosis*
 Leprosy*
Schistosomiasis*
Filariasis
Malaria*
Dengue Hemorrhagic Fever (H-Fever)*
Measles*
Chicken Pox (Varicella)
Mumps (Epidemic Parotitis)*
Diptheria
Whooping Cough (Pertussis)
Tetanus Neonatorum and Tetanus among older age groups*
Influenza
Pneumonias
Cholera (El Tor)*
Typhoid Fever*
Bacillary Dysentery (Shigellosis)*
Soil Transmitted Helminthiases
Paragonimiasis
Hepatitis A*
Paralytic Shellfish Poisoning (PSP I RED TIDE POISONING)
Leptospirosis*
Rabies*
Scabies
Anthrax
Sexually Transmitted Infections
i. Gonorrhea*
ii. Syphilis*
iii. Chlamydia
iv. Gardianella Vaginitis
v. Trichomoniasis
vi. Hepatitis B*
HIV/AIDS*
Meningococcemia
Bird Flu or Avian influenza
SARS Severe Acute Respiratory Syndrome*

Comprehensive Maternal and Child Health Program

*EPI ( EXPANDED PROGRAM ON IMMUNIZATION )
*CDD ( CONTROL OF DIARRHEAL DISEASES )
*CARI (CONTROL OF ACUTE RESPIRATORY INFECTIONS )
*UFC (UNDER FIVE CLINICS )
*MC ( MATERNAL CARE )
*BF ( BREAST FEEDING )
*MRP ( MALNUTRITION REHABILITATION PROGRAM )
*VAD (VITAMIN A DEFICIENCY )
*IDD / IDA ( IODINE DEFICIENCY DISORDERS / IRON DEFICIENCY ANEMIA )
*FP ( FAMILY PLANNING )

*EPI (EXPANDED PROGRAM ON IMMUNIZATION )

PD 996 Compulsory Basic Immunization to all
children before reaching 8 years old
Started in 1976 by MOH
Target Population:
A. Infants (0-12 months):
BCG, DPT, OPV& Measles
HBV (1996)
B. School Entrants:
MECS: Grade 1=7 years old
DECS: Grade 1=6 yrs. old (1993)
Booster of BCG

RA 7846 Compulsory HBV before 8 years

old:1996
PP 4 Measles Elimination Program
(September & October) 1994-1997-
Ligtas Tigdas (6 months-8 years)

PP 6 Universal Mother & Child Immunization

Law advocated by WHO from 1996 and
onwards: 5 vaccines + Tetanus Toxoid
Strengthens the EPI Program
1. Pregnant mothers-Tetanus Toxoid
2. Children:
Infants-5 vaccines
School entrants-BCG booster dose
3. Before EPI total immunization-5
After EPI total immunization-6
(Tetanus
toxoid was included)
4. OPV was given to all children under
5 years old irregardless of the # of
doses & the time OPV was given

PP 147 Declaring the National Immunization

Day Plus (NIDs Plus) initiated by
 former Sec. Flavier in 1993-95
Initially every 3rd Wednesday of
January & February (1993-1995)
1996 to present: Still being practiced
but not every 3rd Wednesday of
January & February
2002: 2nd Tuesday of March & April
At present: depends on the Secretary
PP 773 Launched the Polio Elimination
Program (PEP) 1995-2000: Zero Polio
Philippines, 1. Knock Out Polio (KOP)
2. Zero Polio Philippines (1996-2000)
3. Patak Polio (< 5 years old)
PP 1064 AFP (Acute Flaccid Paralysis)
Elimination Program-an adverse effect
of Polio
PP 1066 Neonatal Tetanus Elimination
Morbidity
Mortality
*RSI locates a venue for immunization called Patak Center and composed of 1
organizer, 1 runner, 1 vaccinator, 1 recorder and 1 health educator catering to a
population of 1,000

Policies of EPI:
I. Coverage--------------------------------------
A. Target Setting
B. FIC ( Full Immunized Child )
C. Wastage Allowance
OBJECTIVES OF EPI: To reduce morbidity and mortality rates among infants and
children from 6 or 7 immunizable disease
II. Cold Chain
III. Immunization Technical Responsibilities of PHN
IV. Surveillance--------------------------------
Planning, Supervision, and Training---
Mobilization, Monitoring and Health Education Administrative and Supportive
Role of PHN
Referral, Research and Evaluation ---

I. Coverage
A. Target Setting:
1. Target Population is the population group meant to be benefited by the EPI Programs
where DOH is responsible.
a. Infants ( 0 12 ) get the 3% of population
 b. School Entrants get the 3% of population ( dictum of DOH ) = 6 years
c. Pregnant Women get the 3.5 % of population ( MWKA ) = 15 49 years
2. Eligible Population ( EP ) rae those qualified to receive specific immunizations where
PHW is responsible PHN, RHM, MO
*3 Population Groups to benefit
a. Infants (I) BCG, DPT, OPV, HBV, MV
b. School Entrants (S.E) Booster of BCG
c. Pregnant Women (PW) Tetanus Toxoid
*To determine Eligible Population:
EP = Population of the Community x 0.03 (Infants and School Entrants) or
X 0.035 (Pregnant Women)
*Example: Lanting Community with a population of 7000
a.) DPT = for infants
EP = 7000 X 0.03 = 210 to receive DPT
b.) Tetanus Toxiod = for pregnant women
EP = 7000 X .035 = 245 to receive TT
c.) Booster BCG = for school entrants
EP = 7000 X 0.03 = 210 to receive booster BCG

B. Fully Immunized Child ( FIC ) is a child who receives the 5 sets of vaccines
(BCG, DPT, OPV, Hepa B and Measles and who receives 11 doses of vaccines.

Vaccine (# of Doses) Infants (0-12 months) School Entrants

Right age to receive the
vaccine
BCG-1 dose 0 age (at birth)-12 1 booster dose (6 years
months old)
DPT-3 doses 1st Dose-6 wks./1 mos.
OPV-3 doses 2nd Dose-10 wks./2
HBV-3 doses mos.
3rd Dose-14 wks./3
mos.
MV-1 dose 9-12 months

*MV may be given 6 months if there is an epidemic.

c. Wastage Allowance
- DOH doesnt ptoduce vaccines biologically and therefore dependent on suppliers
abroad: Germany and Switzerland to economize:
1. Be aware of the availability of vaccines:
Example: BCG
CHN: vial Private Practice: ampule
Frozen powder with a diluent
( 1 ml per content )

2. How many receipients = ?????

-Follow DOH Dictum: On the day of immunization, if 50% and above of computed
recipents arrive in the health center, open a vial but if less than 50%, dont open.
Example: In 20 recipients, 10 arrive = open a vial
-Half life of Vaccines is the duration of potency:
a. Vaccine with 4 hours half life: BCG, MV ( need to mix )
*If open at 8:00 am, its good till 12:00 noon
At 12:30 pm, dont give anymore because its not potent anymore.
b. Vaccine with 8 hours half life: DPT, OPV, HBV, TT (already in solution / liquid form
ready to administer)

Table of Reference for Requesting Vaccines from DOH

Vaccine Availability Dosage # of Doses to Wastage Number of
complete Allowance Recipients per
immunization Multiplier Vaccines
Factor (MF)
BCG Vial:
1. I Frozen .05 ml 1 dose 60% 2.5 20
2. SE Powder .1 ml 1 dose 40% 1.67 10
with
1ml diluent
DPT Vial: 10 ml .5 ml 3 doses 40% 1.67 20
liquid
OPV Plastic 2-3 gtts 3 doses 40% 1.67 25(1ml=15gtts)
(Sabin) bottle: 5 ml
slightly
pink
Liquid
HBV Vial: .5, 1, <10 y/o: .5 3 doses 10% 1.2 .5 ml=1
10 ml >10 y/o: 1 .5 ml
MV Vial: .5 ml 1 dose 50% 2 10
Frozen
Powder
with
Diluent
Soln=5ml
per content
TT Vial: 10 ml .5 ml 5 doses 40% 1.67 20
liquid
*Parenteral = Salk vaccine ( sinasaksak ) has 5 ml per content
*Oral Polio Vaccine (OPV) = Sabin (sa bibig)
For OPV: 5 ml (availability) 1 ml = 15 gtts 1 ml = 15 gtts = 5 recipients
 3 gtts (dosage) 2 ml = 30 gtts = 10 recipients
3 ml = 45 gtts = 15 recipients
4 ml = 60 gtts = 20 recipients
5 ml = 75 gtts = 25 recipients

Right Time for Pregnant Women to receive Tetanus Toxoid

Primary Dose TT1 Anytime during ? Immunity
th
Pregnancy (5 -6 th

months)
Primary Dose TT2 4 weeks after TT1 3 years immunity
1st Booster TT3 6 months after 5 years immunity
TT2
nd
2 Booster TT4 1 year after TT3 10 years immunity
3rd Booster TT5 1 year after TT4 Lifetime immunity

Examples:
1. Mrs Dela Cruz received the 1st booster dose (TT3) on November 20, 2004. When is
the 2nd booster? November 20, 2005
2. As a child, you have 3 doses of DPT. Now you become pregnant. What you need to
receive are the 3 booster doses only-TT3, TT4 & TT5 respectively.
3. If as a child, only 1 dose of DPT was given, is there a definite immunity? Theres no
definite # of years of immunity. If until 3 years she failed to receive vaccine, she got to
start with the 1st dose.

Wastage Allowances of DOH Multiplier Factors

BCG (I) 60% 2.5
MV 50% 2.0
BCG (SE) 40% 1.67
DPT
OPV
TT
HBV 10% 1.2

Steps to Compute the Number of Vaccine to be Requested from DOH

1. Determine the Eligible Population (EP)
EP=Population of the Community x 0.03 (I & SE) or 0.035 (PW)
2. Determine the Annual Dose (AD)
AD=EP x # of doses of the vaccine
3. Determine the Wastage Allowance (WA)
WA=computed AD x MF of the vaccine
4. Determine the Complete Coverage (CC)
CC=WA # of recipients per vaccine
5. Determine the Overall Total in Allowance (OT)
OT=CC x 1.25 (constant), DOH usually grants an allowance of 25% of the CC
Example: Determine the # of vaccines to be requested from DOH of DPT for Lanting
Community with a population of 4000
1. EP=4000 x 0.03=120
2. AD=120 x 3 doses=360
3. WA=360 x 1.67=601
4. CC=601 20=30
5. 30 x 1.25=37.5 or 38 vials to be given by DOH (or 8 vials allowance)

II. Cold Chain

-Tools or Procedures to follow to keep vaccine potent ( expected desired effect ).
Policies:
1. Proper Storage: store vaccines in refrigerators

RHO 3 Given 6 months to store vaccines

MHO PHO 2 Given 3 months to store vaccines

BHS RHU 1 Given 1 month to store vaccines

RHCDS

- Freezer OPV: most sensitive to heat

-15 C to -20 C MV

Body of Refrigerator BCG

2 C to 8 C DPT
HBV
TT: least sensitive to heat
OPV & MV: highly sensitive to heat
OPV, MV & BCG: Not damage by freezing
DPT, HBV & TT: Damaged by freezing so not placed in the freezer

2. Proper Transport
- Vaccines are to be transported from the health center to the area of immunization
(community: focused, based & oriented)
- Tools provided by DOH: Vaccine Carrier which maybe
a. Black: use by staff of HC during epidemic & needs 5 cold dogs
b. White: use by student affiliates & needs 4 cold dogs
- Cold Dogs: 4 plastic containers filled with water which is placed in the freezer
a day before immunization which is used as freezant to keep vaccine potent

3. Proper Handling of Vaccine (After Care of Vaccine): Dictum of DOH

a. Vaccines which are opened, though not consumed, should be discarded
Reasons: cant be used for future program because vaccines have half - life
(duration of potency of vaccine)
BCG -4 hours half life
 MV
Other vaccines -8 hours half life

BCG, OPV & MV are composed of live attenuated bacteria & virus so before
discarding them, disinfect 1st with 1% Hcl or any disinfectant like zonrox,
chlorox or dumex
BCG (Bacilli Calmette-Guerin Vaccine): live attenuated bacteria
OPV & Measles Vaccine: live attenuated virus

DPT, HBV & TT can be readily discarded if not consumed

DPT:
Diphtheria-weakened toxoid treated with chemical solution to weaken
microorganism
Pertussis-killed bacteria
Tetanus-weakened toxoid
HBV: plasma derived, identified to be RNA & DNA recombinant from blood
TT: weakened toxoid
b. Vaccines which are taken out from Health Center for 3x or more are
considered overly exposed & not potent anymore therefore it should be
discarded
Put notation (state the date) on the unopened vaccine as to when it was taken
out from health center May 19, 2006
Jun. 19, 2006
Jul. 19, 2006-cant be used anymore after this

I. Immunization
Guiding Principles for HW in Administering Vaccines & Screening of Children for
Immunizations:
1. No BCG for a child born clinically positive to AIDS because they have a damage
immune system & introducing bacteria will further aggravate their condition
2. There are no contraindications such as slight fever, LBM, cough & colds and
malnutrition, in giving the immunization unless upon assessment of the practitioner
that the child has serious medical problems that warrants hospitalization
3. In giving immunization with multiple doses such as DPT, OPV & HBV, continue
counting in giving the doses. Never count back even though the interval exceeds
weeks, months or years. As long as the child is on the eligible age
Example: DPT, OPV & HBV
1st dose: At 6 weeks (1 months), the child was given vaccination
2nd dose: The mother brought back the child when he was 8 months old instead at
10 weeks (2 months). PHN should still give the 2nd dose
3rd dose: The mother brought back the child at 2 years old. PHN should still give
the vaccine because child is still at the eligible age (0-59 months or 4 years & 11
months or 5 years old) to receive vaccine

4. DPT: it is a normal reaction for a child to develop high grade fever because of the
pertussis component (killed bacteria)
 SOP Management:
Paracetamol q 4 hours RTC for the 1st 2 days (or 3, 4 days if still febrile)
If after 1st dose of DPT, the child develops high grade fever with convulsion, DPT 2
& 3 are not given anymore because convulsion affects the brain cells resulting to
brain damage
DPT vaccine is only for prophylactic/ preventive use

5. Things to consider in administering vaccines:

a. Vaccine
b. Dosage
c. SOA (Site of Administration)
d. ROA (Route of Administration)
e. Side Effect: patterns of reaction that is considered normal

Vaccines Dosage SOA ROA Conferred

Immunity
BCG I=.05 ml I=R deltoid Intradermal Artificial
SE=.1 ml SE=L deltoid (needle is Active
parallel to
site=10-15
angle
Side Effects: Wheal=10 mm that disappears after 30 minutes
1st week : develops soreness and inflammation
2nd -11th week : develops abscess and ulceration
12th week (3 months): heals and develops permanent scar

Age of Consultation BCG Site of Injection

Right Age (0-12 months) Right Deltoid
Wrong Age but still eligible Left Deltoid
Example: 4 years old
Booster Dose at Age 6 Left Deltoid
*If after BCG, there is no soreness & inflammation, no abscess & ulceration and no
scar developed, there is wrong preparation of site where PHW used alcohol that kills
the microorganism contained in the BCG vaccine. Thus, repeat the dose on same site
but a little lower.
*Site preparation: Use clean cotton ball & wet with sterile water only
*For non-healing abscess & ulceration:
BCG was wrongly administered by IM or SQ by PHW so incision & drainage should
be done by MD only and INH tablet, an anti-bacterial, pounded, pulverized & applied
on the site. Then repeat the dose again but not on the same site.

Vaccine Dosage SOA ROA Conferred

Immunity
DPT .5 ml Thigh (vastus Intramuscular Artificial
lateralis) (Z tract) Active
 where muscle
is grasped
and squeezed
Side Effects:
1. High grade fever due to Pertussis Component which contains killed bacteria
2. Soreness and inflammation
SOP Management:
Paracetamol (anti-pyretic & analgesic) q 4 hours RTC for 1st 3 days or till with
fever
Nursing Care: 1st Day=apply cold compress on site
2nd , 3rd & 4th Day=apply alternating cold & warm compress
Adverse Effect: If convulsion occurs on 1st dose, discontinue DPT 2 & DPT 3
because of the sensitivity to DPT Component but private MD gives DT which is
not available in DOH

Vaccine Dosage SOA ROA Conferred

Immunity
OPV 2-3 gtts Mouth Oral: Artificial
Sabin by Dr. Active
Albert Sabin
Salk
(parenteral
polio vaccine)
by Dr. Jones
Salk
Side Effect: None
Nursing Care:
1. NPO for 1st 20-30 minutes after receiving vaccine to prevent nausea &
vomiting
2. In case the child vomits after vaccination, repeat giving the vaccine because it
requires 30 minutes to absorb the OPV
HBV .5 ml Thigh (vastus Intramuscular Artificial
lateralis) Active
Side Effects: Soreness and inflammation on site
SOP Management: Paracetamol q 4 hours RTC for 1st 2 days or till with fever
HBV & DPT are given together but never administer these 2 vaccines in one site:
DPT HBV
1st Dose Right Left
nd
2 Dose Left Right
3rd Dose Right Left
MV .5 ml Posterior Subcutaneous Artificial
aspect of (45 angle) Active
Deltoid
Side Effect: High grade fever
SOP Management: Paracetamol q 4 hours RTC for 1st 2 days
MV given on same site with BCG but MV is given at 9 months while BCG at birth
In case, rashes develop after vaccination which makes the child irritable due to
itchiness,
give anti-histamines: Diphenydramine (Benadryl) syrup or
Apply Caladryl or Calamine Lotion which has anti-histamine
and cooling effect to relieve itchiness
TT .5 ml Deltoid or Intramuscular Artificial
Gluteal Active
muscle
Side Effect: Soreness and inflammation on the site which is tolerable by pregnant
woman so no need to take medicines. Just apply cold compress on site to relieve
discomfort

2 Forms of Immunization Conferring Immunity:

1. Natural
a. Active
b. Passive
2. Artificial

IMMUNITY
Natural Artificial
Provided by nature Accepts vaccine
No vaccine was given
Duration is longer/even for a lifetime Duration is shorter period
Example:
BCG-vaccine for protection from TB
gives 7-10 years immunity so booster
is needed
HBV-after 3 doses booster is needed
after 1 year
Active=person himself is involved in Active=person himself has no
the production of antibodies participation and done by another
1. Carrier (person harbors the disease person
but asymptomatic) of the disease Upon receiving vaccine (antigen) for
2. Constant exposure to disease immunizable diseases such as BCG,
3. Acquired or experienced the disease DPT, OPV, MV and HBV

Passive Passive
1. Breastfeeding IgA (present in 1. Serum (Blood):
colostrums) HBV
2. Perinatal immunity is acquired ATS (Anti-Tetanus Serum)
during the term of pregnancy ADS (Anti-Diptheria Serum)
2. Antitoxin: poison or causes infection
TAT (Tetanus Antitoxin)
DAT (Diptheria Antitoxin)
3. Immunoglobulins: IgA, IgD, IgE, IgG
 & IgM where IgG is most predominant

IV. Surveillance--------------- To be discussed unde r Communicable Diseases.

Planning, Supervision and Training
Mobilization, Monitoring, and Health Education
Referral, Research and Evaluation

*CDD ( CONTROL OF DIARRHEAL DISEASES )

Policies to implement CDD:
1. Health Education on Personal Hygiene
- washing of hands before eating and after use of toilet
2. Breastfeeding ( BF )
- Two ( 2 ) Beneficiaries of BF Program:
a. Mother regulated by R.A. 7600: Breastfeeding and Rooming In Act.
*Beastfeeding is an effective contraceptive method because it stimulates the anterior
pituitary gland to produce prolactin hormone putting the female in an anovulatory
stage theres amenorrhea for 6 months form the time she gave birth.
*Rooming in ( RI ) is putting together of mother and the newborn and it stimulates
the posterior pituitary gland to release oxytocin hormone stimulates the uterine muscle
contraction that inhibits the implantation of fertilized zygote in the endometrium no
pregnancy occurs.
b. Children regulated by EO 51: Milk Code of the Philippines
Dictum of Milk Code: Never commercialized a brand name of milk.
- 3 Principles to make breastfeeding effective: 3 Es
a. Early: start Breastfeeding as early as possible
Normal Spontaneous Delivery (NSD): after 30 minutes
CS: after 3 4 hours
b. Exclusive: for the 1st six months; never alternate Breastfeeding with any
supplementary feeding.
c. Extensive: Breastfeeding can be extended to 2 years.
- Advantages of Breastfeeding:
Breast milk: EO 51 best for babies
Reduced allergy
Easily established
Always available
Safe making stool soft
Temperature: right teemperature 24C body reference if to be frozen, preservation is
minimum of 3 months and maximum of 6 months

Fresh always
Emotional bonding
Economical
Digestible: contains lactalbumin, a protein substance
Immunity: colostrum contains Ig A that protects baby for the 1st 3 months
 Nutritious ( optional )
GIT diseases such as diarrhea is minimize / lessen because its sterile
3. Measles: immunization preventive and prophylactic
4. Oresol: a management for diarrhea to prevent dehydration
2 Concepts of Diarrhea:
a. Frequency of passing out stool = 3x/day
b. Consistency of the stool = watery
ROLE OF BREASTFEEDING IN THE
CONTROL OF DIARRHEAL DISEASES
PROGRAM
1. Two problems in CDD
1. High child mortality due to
diarrhea
2. High diarrhea incidence among under fives
2. Highest incidence in age 6 23 months
3. Highest mortality in the first 2 years of
life
4. Main causes of death in diarrhea :
DEHYDRATION
MALNUTRITION
5. To prevent dehydration, give home fluids
am as soon as diarrhea starts and if
dehydration is present, rehydrate early,
correctly and effectively by giving ORS
6. For undernutrition, continue feeding
during diarrhea especially breastfeeding.
7. Interventions to prevent diarrhea
1. breastfeeding
2. improved weaning practices
3. use of plenty of clean water
4. hand washing
5. use of latrines
6. proper disposal of stools of
small children
7. measles immunization
8. Risk of severe diarrhea 10-30x higher in
bottle fed infants than in breastfed
infants.
9. Advantages of breastfeeding in relation
to CDD
1.Breast milk is sterile
2.Presence of antibodies protection against
diarrhea
3.Intestinal Flora in BF infants prevents growth
 of diarrhea causing bacteria.
10. Breastfeeding decreases incidence
rate by 8-20% and mortality by 24-27% in
infants under 6 months of age.
11. When to wean?
4-6 months soft mashed foods 2x a day
6 months variety of
foods 4x a day
12. Summary of WHO-CDD recommended
strategies to prevent diarrhea
1. Improved Nutrition
- exclusive breastfeeding for the first 4-6 months
of life and partially for at least one year.
- Improved weaning practices
2.Use of safe water
- collecting plenty of water from the cleanest
source
- protecting water from contamination at the
source and in the home
3.Good personal and domestic hygiene
- handwashing
- use of latrines
- proper disposal of stools of young children
4.Measles immunization.

Contents of One Pack Oresol Dissolved in One Liter drinking Water

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 2.5 grams Buffer content of solution
Bicarbonate/NaHCO3 Neutralizer content of
solution
Potassium Chloride/KCl 1.5 grams Stimulates smooth
muscle contractility
especially the heart &
GIT
*Never advice mother to buy brandnames like pedialyte or gatorade
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
*For making solutions = use 250 ml of water
*For drinking medicines = a glass is 240 ml of water.

3 Categories of Dehydration:
a. No dehydration-uses oresol
b. Some dehydration-uses oresol
c. Severe dehydration-uses IVF
Objectives/Plan/Policies of the Use of the following Program:
a. Plan A: for prevention of dehydration
b. Plan B: for treatment of dehydration-mild & moderate
c. Plan C: for treatment of dehydration-severe

CDD MANAGEMENT CHART

Assessment Category Treatment

1. Condition No dehydration Plan A-prevention of

a. Normal DHN
b. Well
c. Alert 3 Principles/3 Fs:
2. Fontanel-normal 1. Increase fluid: Tea-
3. Eyeballs-normal lipton tea bag left
Tears-present standing in a cup of water
4. Mouth, Tongue & Lips: for 15 minutes & there is
moist or wet Thirst: brownish discoloration
drinks normally =pectin, a diuretic & has
5. Skin Turgor-returns an absorbent effect
back quickly which is Fruit Juices-not from
done at forearm highly fibrous fruits like
pineapple, mango,
guyabano.

Oresol-am or buko where

3 electrolytes are
 present: Na, K & Ca
which are lost in diarrhea

Oresol is given/LBM or
every time stool is
passed out:
< 2 years old: 50-100ml.
always give the
maximum amount
2-10 years old: 100-200
ml.
10 years old & above: as
much as tolerated &
desired

2. Increase feeding:
3. Fast referral
1. Condition Some dehydration Plan B-Treatment of mild
a. Restless & Moderate DHN using
b. Irritable oresol
2. Sunken fontanel
3. Sunken eyeballs & If less than 2 years old:
absent tears use age in months
4. Dry mouth, tongue & If < 4 months: 200-400
lips ml.
Eagerness to drink 5-11 months: 400-600 ml.
5. Skin returns back 12-23 months: 600-800
slowly ml.
2-4 y/o: 800-1200 ml.
5-14 y/o: 1200-2200 ml.
15 & above: 2200-4000
ml.

Treatment Plan: 1st 4

hours always give the
maximum
1. Condition Severe dehydration Plan C-treatment of
a. Unconsciousness severe DHN using IVF
b. Lethargic Priority-choice of IVF:
c. Floppy-apathetic or 1. D5LRS-best or 1st
passive choice if available for
2. Very sunken fontanel severe DHN since
3. Very sunken eyeballs dextrose gives additional
& absent tears source of
4. Very dry mouth, energy & improves
tongue & lips appetite D5-is glucose
Refuses to drink orally LRS-has 3 chlorides
5. Skin returns back very, 2. LRS-Lactate Ringers
very slowly best done at or Hartman solution is
the abdomen the most appropriate
choice if no D5LRS
3. Plain NSS or 0.9 NaCl
4. D5W
5. D10W

2 Victims of Severe Dehydration:

a. Child: give 100 mg/kg body weight in the 1st 4 hours
Example: 8 kg=800 ml. IVF to be infused on the 1st 4 hours for patient with severe
dehydration (8 am-12 noon)
b. Adult: give 3-4 liters of IVF in 1st 4 hours
Example: 9am-1pm=4 liters=1 liter/hour
If still severe dehydration, 2-6pm=infuse 4 liters IVF
Fruits for Diarrhea:
Apple: has pectin & tarum which has an absorbent property, eat the skin
Banana: has K+
Caimito: eat the flesh in cases of constipation but in diarrheal cases, eat the extracts,
milky substances (dagta) found on the inside of the skin
Duhat: wash first the fruit then sprinkle with rock salt & shake, notice extracts to come out
of the fruit, eat both skin & flesh
Fruits to avoid during diarrhea: Papaya flesh, pineapple flesh, mango, guyabano &
kaimito flesh
BRAT Diet: Banana, Rice, Apple, Tea, toasted bread or toasted rice beads which has
activated charcoal that acts as absorbent
Direction: In a cup of warm water, add 1 tablespoon of toasted rice or bread & allow to
stand for 20-30 minutes produces a blackish discoloration which is pectin

TYPES OF DIARRHEA
o ACUTE : < 14DAYS
o PERSISTENT: 14 DAYS or more
o DYSENTERY: Blood in the stool; with or without mucus

CLASSIFY DEHYDRATION

SEVERE DEHYDRATION
Two of the following:
Abnormally sleepy
Sunken eyes
Drinks poorly
 Skin pinch goes very slowly
Treat PLAN C: Referral to hospital for IVF!!!

*CARI SOME DEHYDRATION

Two of the following:
Restless, irritable
Sunken eyes
THIRSTY: drinks eagerly
Skin pinch goes back
Treat PLAN B
O.R.S: first 4hours after assessment
200-400ml 0-4mos
400-700ml 4-12mos
700-900ml 1-2 yrs
900ml-1L 2-5yrs

NO DEHYDRATION
Not enough signs to classify some or severe
Treat PLAN A
Give extra fluids
50-100ml after each watery stool (0-2y/o)
100-200ml (2 y/o & above)
as tolerated (10y/o & above)
Continue feeding
Return if with danger sign/s.

(CONTROL OF ACUTE RESPIRATORY INFECTIONS )

Goal: Morality and Morbidity reduction of Pnuemonia.
Target groups: very young: <2 months
Older child: 2 months 5 years old
Child with cough and colds

Program:
1. Assessment:
History: Subjective
Age
Cough and Duration
Able to Drink or stop feeding
Fever ---- duration
Convulsion

Physical Examination: Objective

Weight, Height
Respiratory Rate one whole minute
Fast Breathing
*Less than 2 months 60/min or >
 *2 months 1 year 50/min or >
*1- 5 years old 40/min or >
Observe for :
- Chest in drawing
- Stridor during inhalation
- LOC
- Wheeze during exhalation
- Fever
- Malnutrition
- Level of Consciousness

2. STANDARD CLASSIFICATION OF ILLNESS:

I. Infants 2 months to 5 years old

1. VERY SEVERE DISEASE:
If any 3 of the 5 Danger signs are present
Signs and Symptoms:
f. Not able to drink
g. Convulsion
h. Sleepy
i. Stridor
j. Severe Malnutrition

Treatment:
1. Refer urgently to hospital
2. 1st dose of antibiotics
3. Treatment of Fever ( TSB ) * Wheeze (NEBULIZE)
4. Antimalarial

2. PNEUMONIA:
Signs and Symptoms:
a. Chest in drawing
b. Nasal flaring
c. Grunting
d. Cyanosis

2 Types:
a. Severe Pneumonia
Symptoms: Chest indrawing, cyanosis, nasal flaring, grunting.
Treatment: Same with very severe but anti malarial is not given.

b. Not Severe Pneumonia

Symptoms: No chest in drawing and fast breathing.
Treatment: 1. Home care TSB, Nutrition, Steam inhalation
 2. Antibiotics for 2 days and follow up after 2 days.
a. If it improves, consume all meds finish the course of the
treatment.
b. If worse, refer.

3. NO PNEUMONIA
Assess for other problems and provide home care.
No Chest indrawing, No fever
If with sore throat in children: Mild, warm tea with syrup.
If chronic, refer.

II. Infants lessthan 2 months

1. VERY SEVERE DISEASE
Symptoms: Stopped feeding well
Convulsions
Abnormally sleepy
Stridor
Wheeze
Severe malnutrition and Fever of 38C or Hypothermia
(<35.5C)
Treatment: Refer urgently to hospital
Keep warm
Give first doses of antibiotic

2. PNEUMONIA
Symptoms: Severe Chest indrawing and Fast Breathing
Treatment: Same as severe.

*UFC (UNDER FIVE CLINICS )

The first five years of life form the foundations of the childs physical and mental
growth and development. Studies have shown the mortality and morbidity are high
among this age group. The Department of Health established the Under Five Clinic
Program to address this problem.

Program Objectives and Goals:

*Monitor growth and development of the chiild until 5 years of age.
*Identify factors that may hinder the growth and development of the child.

Activities and Strategies:

1. Regular height and weight determination / monitoring until 5 years old.
0 1 year old = monthly
1 year old and above = quarterly
2. Recording of immunization, vitamins, supplementation, deworming and feeding.
3. Provision of IEC materials ( ex. Posters, charts, toys ) that promote and enhance
childs proper growth and development.
4. Provision of a sagfe and learning oriented environment for the child.
5. Monitoring and Evaluation.

**BREASTFEEDING / LACTATION MANAGEMENT EDUCATION TRAINING**

-Breastfeeding practices has been proven to be very beneficial to both mother and baby
thus the creation of the following laws support the full implementation of this program.
Executive Order 51
Republic Act 7600
The Rooming in and Breastfeeding Act of 1992.

Program Objectives and Goals:

-Protection and promotion of breastfeeding and lactation management education training.

Activities and Strategies:

1. Full Implementation of Laws supporting the Program
A. EO 51 THE MILK CODE protection and promotion of breastfeeding to ensure the
safe and adequate nutrition of infants through regulation of marketing of infant foods and
related products. (e.g. breast milk substitute, infant formulas, feeding bottles, teats etc.)
B. RA 7600 THE ROOMING IN AND BREASTFEEDING AC T OF 1992
-An act providing incentives to government and private health institutions promoting and
practicing rooming in and breast feeding.
-Provision for human milk bank.
-Information, education and re education drive.
-Sanction and Regulation.

3. Conduct Orientation / Advocacy meetings to Hospital / Community.

ADVANTAGES OF BREASTFEEDING:
MOTHER:
*Oxytocin helps the uterus contracts
*Uterine involution
*Reduce incidence of Breast Cancer
*Promote Maternal Infant Bonding
*Form of Family planning method ( Lactational Amenorrhea )

BABY:
*Provide Antibodies.
*Contains Lactoferin ( Binds with Iron )
*Leukocytes
*Contains Bifidus factor
Promotes growth of the Lactobacillus inhibits the growth of pathogenic
bacilli.
Positions in BF THE BABY:
1. Cradle Hold head and neck are supported
2. Football Hold
3. Side Lying Position
Best for Babies
Reduce Incidence of Allergens
Economical
Antibodies Present
Stool Inoffensive ( Golden Yellow )
Temperature always ideal
Fresh Milk never goes off
Emotionally Bonding
Easy once established
Digested easily
Immediately available
Nutritionally optimal
Gastroenteritis greatly reduced

Garantisadong Pambata ( GP )
-Garantisadong Pambata is a biannual week long delivery of a package of health
services to children between the ages of 0 59 months old with the purpose of reducing
morbidity and mortality among under fives through the promotion of positive Filipino
values for proper children growth and development.

1. WHAT ARE THE HEALTH SERVICES OFFERED IN GP AND WHO ARE THE
TARGETS?
GP offers the following:
1.1 Routine Health Services:

Health Service Dosage Route of Target

Administration Population
Vitamin A 200,000 IU or Orally by drops 12 59 months
Capule capsule 100,000 old, nationwide
IU or cap or 3 9 -12 months old
drops infants receiving
AMV nationwide.
Ferrous Sulfate 0.3 ml ( 2 6 Orally by drops. 2 -11 months old
( 25 mg elemental months ) once a infants in
Iron per ml; 30 ml day Mindanao area,
Bottle as taken including
home medicine 0.6ml ( 6- 11 evacuation
with instructions ) months) centers in armed
 conflict areas.
Routine
Immunization
-BCG 0.05 ml Intradermal on 0 11 months
right deltoid.
-DPT 0.5 ml Intramuscularly 0 11 months
on anterior thigh
-OPV 2 drops Orally 0 11 months

-AMV 0.5 ml Subcutaneously

on deltoid
-Hepa B ( If 0.5 ml Intramuscularly 0 11 months
available )
Deworming drug 1 tablet as single Orally 36 59 months,
( If available ) dose nationwide
Weighing 0 59 months
nationwide

-*The child should not have received megadose of Vitamin A above the recommended
dosage within the past 4 weeks except if the child has measles or signs and symptoms of
Vitamin A deficiency.
-**For any between 12 23 months, who missed any of his routine immunization, the
health worker should give the child the necessary antigen to complete FIC and shall be
recorded as such.

Garantisadong Pambata ( GP )
Sangkap Pinoy
-Vitamin A, Iron and Iodine
-Sources: green leafy and yellow vegetables, fruits, liver, seafoods, iodized, salt, pan de
bida and other fortified foods.
These micronutrients are not produced by the body, and must be taken in the food we
eat; essential in the normal process of growth and development:
a.) Helps the body to regulate itself
b.) Necesary in energy metabolism
c.) Vital in brain cell formation and mental developmet
d.) Necessary in the body immune system to protect the body from severe infection.
e.) Eating Sangkap Pinoy rich foods can prevent and control:
1. Protein Energy Malnutrition
2. Vital A deficiency
3. Iron Deficiency Anemia
4. Iodine Deficiency Disorder

Breastfeeding
-Breast milk is best for babies up to 2 years old. Exclusive breastfeeding is recommended
for the first six minths of life. At about six months, give carefully selected nutritious foods
as supplements.
-Breastfeeding provides physical and psychological benefits for children and mothers as
well as economic benefits for families and societies.
BENEFITS:
For INFANTS
a. Provides a nutritional complete food for the young infant.
b. Strengthens the infants immune system, preventing many infections.
c. Safely rehydrates and provides essential nutrients to a sick child, especially to those
suffering from diarrheal diseases.
d. Reduces the infants exposure to infection.

For the MOTHER

e. Reduces a womens risk of excessive blood loss after birth.
f. Provides a natural method of delaying pregnancies.
g. Reduces the risk of ovarian and breast cancers and osteoporosis.

For the FAMILY AND COMMUNITY

h. Conserves funds that otherwise would be spent on breast milk substitute, supplies and
fuel to prepare them.
i. Saves medical costs to families and governments by preventing illnesses and by
providing immediate postpartum contraception.

Complementary Feeding for Babies 6 11 moths old

*What are Complementary Foods?
a. foods introduced to the child at the age 6 months to supplement breast milk
b. given progressively until the child is used to three meals and in between feedings at
the age of one year.

*Why is there a need to Give Complementary Foods?

c. Breast milk can be a single source of nourishment from birth up to six months of life.
d. The childs demands for food increases as he grows older and breastmilk alone is not
enough to meet his increased nutritional needs for rapid growth and development.
e. Breastmilk should be supplemented with other foods so that the child can get
additional nutrients.
f. Introuction of complementary foods will accustom him to new foods that will also
provide additional nutrients to make him grow well.
g. Breastfeeding, however, should continue for as long as the mother is able and has
milk which could be as long as two years.
*How to Give Complementary Foods for Babies 6 11 Months Old?
a. Prepare mixture of thick lugao / cooked rice, soft cooked vegetable. Egg yolk, mashed
beans, flaked fish / chicken / ground meat and oil.
b. Give mixture by teaspoons 2 4 times daily, increasing the amount of teaspoons and
number of feeding until the full recommended amounts is consumed.
c. Give bite sized fruit separately
d. Give egg alone or combine with above food mixture.

*FP ( FAMILY PLANNING )

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.
Goal and Objective:
* 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:
A. NATURAL METHODS
1. Calendar or Rhythm Method
2. Basal Body Temperature Method
3. Cervical Mucus Method
4. Sympto Thermal Method
5. Lactational Amennorhea

B. ARTIFICIAL METHODS
I. CHEMICAL METHODS
1. Ovulation suppressant such as PILLS
2. Depo Provera
3. Spermicidals
4. Implant
II. MECHANICAL METHODS
1. Male and Female Condom
2. Intrauterine Device
3. Cervical Cap / Diaphragm
III. SURGICAL METHODS
1. Vasectomy
2. Tubal Ligation
*MC ( MATERNAL CARE )
*BF ( BREAST FEEDING )
*MRP ( MALNUTRITION REHABILITATION PROGRAM )
*VAD (VITAMIN A DEFICIENCY )
*IDD / IDA ( IODINE DEFICIENCY DISORDERS / IRON DEFICIENCY ANEMIA )
*FP ( FAMILY PLANNING )

II. Research and Quality Improvement

A. Research in the Community
RESEARCH IN THE COMMUNITY
Research is an important activity in public health but it is misconceived to be primarily an
activity of professional researchers and academicians. Although it is not commonly included
in the PHNs statement of duties and responsibilities, research is nonetheless included in the
scope of functions of the nurse as defined by the Nursing Law.

Research in community health serves a number of purposes, among which are: (1) improve
our understanding of clients and their specific contexts;
 (2) provide data needed for program and policy development and evaluation;
(3) improve the delivery of health services and implementation of existing programs;
(4) improve cost-effectiveness of programs; and (5) project a good image of nurses.

The PHN can initiate small researches on the major concerns in health service delivery and
in the management of the health facility. Research topics that could be studied by the PHN by
himself/herself include, among others, socio-demographic profile of those who utilize health
services, client waiting time, referral from and to the health center, perception of clients on the
delivery of health services, response of clients to different health or nursing interventions,
supply management and effects of specific health education activities.

Research also contributes to what is called evidence-based practice. The practices that were
passed on and were considered as gospel truth in the past should be examined and tested
through research. The challenge, not only PHNs but to major decision makers in the local
health system is to integrate research into the management and operation of the health
facility.

B. National Health Situation

NATIONAL HEALTH SITUATION
Philippine Scenario:
*In the past 20 years some infectious degenerative diseases are on the rise.
*Many Filipinos are still living in remote and hard to reach areas where it is difficult to
deliver the health services they need.
*The scarcity of doctors, nurses and midwives add to the poor health delivery system to
the poor.

VITAL HEALTH STATISTICS 2005

PROJECTED POPULATION :
MALE - 42,874,766
FEMALE - 42,362,147
BOTH SEXES - 85,236,913
LIFE EXPECTANCY
FEMALE - 70 yrs. Old
MALE - 64 yrs. Old

LEADING CAUSES OF MORBIDITY

*Most of the top ten leading causes of morbidity are communicable disease *These
include the diarrhea, pneumonia, bronchitis, influenza, TB, malaria and varicella
*Leading non CD are heart problem, HPN, accidents and malignant neoplasms

LEADING CAUSES OF MORTALITY

*The top 10 leading causes of mortality are due to non CD
*Diseases of the heart and vascular system are the 2 most common causes of deaths.
*Pneumonia, PTB and diarrheal diseases consistently remain the 10 leading causes of
deaths.

-HEALTH INDICES
I. Basic Health Indicators
2 Indicators to assess a national health situation
A. Nutrition
B. Disease Patterns
Context of CHN: Health Situation
**Leading Causes of Morbidity**
10 Leading Causes of Morbidity
1. Pneumonia -- Bacterial
2. Diarrhea
3. Bronchitis
4. Influenza -- Respiratory
5. Hypertension
6. TB Respiratory
7. Diseases of the Heart
8. Malaria
9. Chickenpox
10. Measles

**Leading Causes of Mortality**

10 Leading Causes of Mortality
1. Disease of the Heart
2. Diseases of the Vascular System
3. Malignant neoplasm
4. Pneumonia
5. Accidents
6.TB all forms
7. COPD
8. Conditions originating in perinatal
period
9. Diabetes Mellitus
10. Nephritis, Nephrotic Syndrome

III. Other Indicators

A. Infant Mortality Rate
*2002 --- 21/1000 rated based on WHO global indicator >50 high
Increase IMR decrease MCHS ( poor nutrition and child health service )

INFANT MORTALITY RATE

Total # of death below 1 yr in a given calendar year X 1000
Estimated population as of July 1 of the same calendar year

10 Leading Causes of Infants Deaths

1. Other perinatal conditions
 2. Pneumonia
3. Bacterial Sepsis of Newborn
4. Diarrhea & Gastroenteritis of presumed infectious origin
5. Congenital Pneumonia
7. Other congenital malformations
8. Disorders r/t short gestation & LBW
9. Septicemia
10. Measles
*Increase IMR = decrease MCHS
*Poor maternal childs service

B. Maternal Mortality Rate

MMR= # of maternal deaths x 1000

RLB

Leading Causes Of Maternal Deaths:

1. Normal delivery and other complications r/t pregnancy occurring in the course of labor,
delivery & puerperium
2. HPN complicating pregnancy, childbirth & puerperium
3. Postpartum hemorrhage
4. Pregnancy with abortive outcome
5. Hemorrhage related to pregnancy

*Life expectancy at birthlife span either: age specific or sex specific

*Median Age- 20.1 years
*The Philippines is an agricultural country- 55%

C. Life Expectancy at Birth

D. Median Age
E. Crude Rates
1. Crude Birth Rate
2. Crude Death Rate

-Health Care Delivery System the totality of all policies, equipment, products, human
resources and services whichaddress the health needs, problems and concerns of the
people. It is large, complex, multi level and multi disciplinary.

Categories:
According to Increasing According to the Type of Service
Complexity of the Services
Provided
Type Service Type Service
Primary Health Promotion, Health Information
 Preventive Care, Promotion Dissemination
Continuing Care for and illness
common health prevention
problems, attention
to psychological and
social care, referrals
Secondary Surgery, Medical Diagnosis Screening
services by and
specialists Treatment
Tertiary Advanced, Rehabilitation PT/OT
specialized,
diagnostic,
therapeutic and
rehabilitative care

- The Health Sector

GOVERNMENT SECTORS
DEPARTMENT OF HEALTH (DOH)
VISION:
-Health for all by year 2000 and Health in the Hands of the People by 2020(OLD).
-A global leader for attaining better health outcomes, competitive and responsive health
care system, and equitable health financing(NEW VISION by 2030).

MISSION:
-In partnership with the people, provide equity, quality and access to health care
especially the marginalized.(OLD)
-To guarantee equitable, sustainable and quality health for all Filipinos, especially the
poor, and to lead the quest for excellence in health.(NEW)

5 Major Functions:
1. Ensure equal access to basic health services
2. Ensure formulation of national policies for proper division of labor and proper
coordination of operations among the government agency jurisdictions
3. Ensure a minimum level of implementation nationwide of services regarded as public
health goods
4. Plan and establish arrangements for the public health systems to achieve economies
of scale Phil Health.
5. Maintain a medium of regulations and standards to protect consumers and guide
providers Sentrong Sigla = Training and infrastructure
-LOCAL GOVERNMENT UNIT / NON GOVERNMENT SECTORS
R.A. 7160 Local Govt Code Local health board- Governor
Municipal health officer- mayor
Assistant - municipal
Provincial health officer

Health Promotion- no threats, no risk- approach behavior

Health Prevention- identified health problem- avoidance behavior

-Private Sector
-Composed of both commercial and business organization, non business
organizations

Commercial/Business Non-commercial
Profit-oriented Orientation to social development, relief
and rehabilitation, community
organizing
Manufacturing Socio-civic groups
companies Religious organizations/foundations
Advertising agencies
Private practitioners
Private institutions

NGOs assumes the following roles:

Policy and Legislative Advocates
Organizers, Human Rights Advocates
Research and Documentation
Health Resource Development Personnel
Relief and Disaster Management
Networking

PRIMARY STRATEGIES TO ACHIEVE HEALTH GOALS

*Support for health goal
*Assurance of health care
*Increasing investment for PHC
*Development of National Standard

MILESTONE IN HEALTH CARE DELIVRY SYSTEM

*RA 1082 - RHU Act
*RA 1891 - Strengthen Health Services
*PD 568 - Restructuring HCDS
*RA 7160 - LGU Code
NATIONAL HEALTH PLAN
*National Health Plan is a long-term directional plan for health; the blueprint defining the
countrys health PROBLEMS, POLICY, STRATEGIES, THRUSTS

GOAL:
*To improve health indicators through access.
*To enable the Filipino population to achieve a level of health which will allow Filipino to
lead socially and economically productive life, with longer life expectancy, low infant
mortality, low maternal mortality and less disability through measures that will guarantee
access of everyone to essential health care.

BROAD OBJECTIVES:
*promote equity in health status among all segments of society
*address specific health problems of the population
*upgrade the status and transform the HCDS into a responsive, dynamic and highly
efficient, and effective one in the provision of solutions to changing the health needs of
the population
*promote active and sustained peoples participation in health care

MAJOR HEALTH PLANS TOWARDS HEALTH IN THE HANDS OF THE

PEOPLE IN THE YEAR 2020

23 IN 1993
Refers to the 23 programs, projects, activities of the DOH
for the year 1993, which marks the beginning of its journey
towards DOG vision.

Health for more in 94

Activities in 1994 focused on Cancer prevention,
reproductive health, mental health, and maintenance of a
safe envt.

Health Focus in 1995 Think Health, Health Link

A national & multi-sectoral health promotion strategy

aimed at conveying health messages to people wherever
they are aimed at building supportive environments
through advocacy, community action & networking.

Health Sector Reform Agenda

Emphasizing on improvements in health care delivery by

maximizing peoples participation in health
Sentrong Sigla Movement

Pertains to development & implementation of standards to

provide quality health services to the people.

C. Vital Statistics
VITAL STATISTICS
Statistics refers to a systematic approach of obtaining, organizing and analyzing
numerical facts so that conclusion may be drawn from them.
Vital Statistics refers to the systematic study of vital events such as births, illnesses,
marriages, divorce, separation and deaths.
Statistics of disease (morbidity) and death (mortality) indicate the state of health of a
community and the success or failure of health work.
Health Indicators a list of information which would determine the health of a particular
community like population. Crude birth rate, crude death rate, infant and maternal death
rates, neonatal death rates and tuberculosis death rate
Health Indicators
Birth
Death
Marriages
Migration

Use of Vital Statistics:

*Indices of the health and illness status of a community
*Serves as bases for planning, implementing, monitoring and evaluating community
health nursing programs and services.

Sources of Data:
*Population census
*Registration of Vital Data
*Health Survey
*Studies and researches

Rates and Ratios:

Rate shows the relationship between a vital event and those persons exposed to the
occurrence of said event, within a given area and during a specified unit of time, it is
evedent that the person experiencing the event (Numerator) nust come from the total
population exposed to the risk of same event (Denominator).

Ratio is used to describe the relationship between two (2) numerical quanitities or
measures of events without taking particular considerations to the time or place. These
quantities need not necessarily represent the same entities; although the unit of measure
must be the same for both numerator and denominator of the ratio.
Crude or General Rates referred to the total living population. It must be presumed
that the total population was exposed to the risk of the occurrence of the event.

Specified Rate - the relationship is for a specific population class or group. It limits the
occurrence of the event to the portion of the population definitely exposed to it.

Crude Birth Rate a measure of one characteristic of the natural growth or increase of a
population.

Used often because of availability of data

a. Measures how fast people are added to the population through birth
b. Crude since it is related to the total population including men, children and elderly who
are not capable of giving birth

Crude Death Rate a measure of one mortality from all causes which may result in a
decrease of population.

a. Crude because death is affected by different factors

b. Widely used because of availability of data

Infant Mortality Rate measure the risk of dying during 1st year of like. It is a good
index of the general health condition of a community since it reflects the changes in
environment and medical condition of a community.

a. SENSITIVE INDEX of level of health in a community

b. HIGH IMR means LOW LEVELS of health standards secondary to poor maternal
and child health care, malnutrition, poor environmental sanitation or deficient
health service delivery
c. May be artificially lowered by improving the registration of births

Maternal Mortality Rate measures the risk of dying from causes related to pregnancy,
childbirth, and puerperium. It is an index of the obstetrical care needed and received by
women in a community.
a. Measures risk of dying from causes associated with childbirth
b. Affected by:
Maternal health practices
Diagnostic ascertainment of maternal condition or cause of death
Completeness of registration of birth

Fetal Death Rate measures pregnancy wastage. Death of the product of conception
occurs prior to its complete expulsion, irrespective of duration of pregnancy.

Neonatal Death Rate measures the risk of dying the 1st month of life. It serves as an
index of the effects of prenatal care and obstetrical management of the newborn.

Specific Death Rate describes more accurately the risk of exposure of certain classes
of groups to particular diseases. To understand the forces of mortality, the rates should
be made specific provided the data are available for both the population and the event in
their specifications. Specific rates render more comparable and thus reveal the problem
of public health.

Incidence Rate measures the frequency of occurrence of the phenomenon during a

given period of time.

Prevalence Rate measures the proportion of the population which exhibits a particular
disease at a particular time. This can only be detremined following a survey of the
population concerned, deals with the total (new and old) number of cases.

Proportionate Mortality (Death Ratios) - shows the numerical relationship between

deaths from all causes (or group of causes), age (or group of age) etc. and the total no.
of deaths from all causes in all ages taken together.

a. Used in ranking cause of death by magnitude of frequency

b. Expressed in PERCENTAGE.

Swaroops Index

a. LOW INDEX implies that life expectancy is short

b. Directly proportional to the health status of a population, where developed countries
have higher Swaroops Index than developing countries

Case Fatality Rate

a. Measures the killing power of a disease or injury

b. A HIGH CFR means a more fatal disease
c. Rate depends on:
Nature of the disease
Diagnostic ascertainment
Level of reporting in the population
d. CFR from hospitals HIGHER than from the community

Morbidity Rate
*Incidence Rate

a. Measures the development of a disease in a group exposed to the risk of the disease
in a period of time
b. Can be made specific for age and sex
*Attack Rate

a. Used for a limited population group and time period, usually during an outbreak or
epidemic

Prevalence Rate
a. Useful in describing the occurrence of chronic conditions and as basis for making
decisions in the administration of health services
b. Useful also in computing for carrier rates and antibody levels
A. Point Prevalence

B. Period Prevalence
Adjusted or Standardized Rate to render the rates of 2 communities comparable,
adjustment for the differences in age, sex, and any other factors which influence vital
events have to be made.

Methods:
*By applying observed specific rates to some standard population.
*By applying specific rates of standard population to corresponding classes or groups of
the local population.

Presentation of Data
The following are most commonly used graphs in presenting data:
Line or Curved graphs shows peaks, valleys and seasonal trends.
Also used to show the trends of birth and death rates over a period of time.
Bar graphs each bar represents or expresses a quantity in terms of rates or
percentages of a particular observation like causes of illness and deaths.
For comparison of data.
Area diagram (Pie Charts) shows the relative importance of parts of the whole.

Functions of the Nurse:

*Collects data
*Tabulates data
* Analyzes and interprets data
*Evaluates data
*Recommends redirection and / or strengthening of specific areas of health programs as
needed.

INTERPRETATION OF VITAL STATISTICS

Sources of Data
Vital Registration Records
a. Civil Registry Law or Republic Act No. 3753 requires the registration of all
births and death c/o National Census and Statistics Office

b. PD 651 requires all health workers to register births within 30 days following
delivery

Weekly Reports from Field Health Personnel

Population Censuses done every 5 years c/o the National Census and
Statistics Office.
GUIDELINES IN THE CLASSIFICATION OF DATA
1. Reckoning of Vital Events all vital events are registered and reported by place
of occurrence, NOT by place of residence
2. Reckoning of Age age is recorded as of Last Birthday
3. Classification of Disease and Causes of Death
a. Definition/ Classification of the event in either numerator or denominator
for consistency
b. Accuracy of the count of event or population concerned
c. Use of correct numerator
d. Magnitude / Nature of the rate

D. Epidemiology
EPIDEMIOLOGY-
-**The study of distribution of disease or physiologic conditions such as deformities
or disabilities and even death among human populations. And the factors affecting such
distribution.
-**Study of occurrences and distribution of diseases as well as the distribution and
determinants of health state or events in a specified population, and the application of
this study to the control of health problems. This emphasizes that epidemiologist are
concerned not only with deaths, illness and disability, but also with more positive health
states and with the means to improve health.
-**Epidemiology is the backbone of the prevention of diseases.

Aim: To identify factors of causation as basis for determining preventive and control
measures.

Uses of Epidemiology:
According to Morris, epidemiology is used to:
1. Study the history of the health population and the rise and fall of diseases and
changes in their character.
2. Diagnose the health of the community and the condition of people to measure the
distribution and dimension of illness in terms of incidence, prevalence, disability and
mortality, to set health problems in perspective and to define their relative importance
and to identify groups needing special attention.
3. Study the work of health services with a view of improving them. Operational research
shows how community expectations can result in the actual provisions of service.
4. Estimate the risk of disease, accident, defects and the chances of avoiding them.
5. Identify syndromes by describing the distribution and association of clinical
phenomena in the population.
6. Complete the clinical picture of chronic disease and describe their natural history.
7. Search for causes of health and disease by comparing the experience of groups that
are clearly defined by their composition, inheritance, experience, behavior, and
environment.
Epidemiological triangle: Agent, Host and Environment.
Agents of Disease:
*Nutritive elements in excess or in deficiencies.
*Chemical Agents
*Physical Agenta
*Infectious Agnets
Host Factor (intrinsic factors) influence exposure, susceptibility or response to
agents.
*Genetics
*Age
*Sex
*Ethnic group
*Physiologic functioning
*Immunologic experience
*Inter current to pre existing disease
*Human behavior
Environmental factors (extrinsic factors) influence existence of the agent, exposure
or susceptibility to agents.
*Physical environment
*Biologic environment
*Socio economic environment

The Epidemiologic Triangle consists of three component host, environment and agent.
The model implies that each must be analyzed and understood for comprehensions and
prediction of patterns of a disease. A change in any of the component will alter an
existing equilibrium to increase or decrease the frequency of the disease.

Preventive strategies:
1.Change the peoples behavior to manipulate the environment and reduce their
exposure to biological and non biological disease agents.
2. Manipulate the environment and prevent production or presence of disease agents.
3. Increase mans resistance or imunity to disase agents.

DESCRIPTIVE PHASE - Deals with the collection, organization, and analysisof data
regarding the occurrence of disease other health conditions.

A. VERIFICATION OF DIAGNOSIS
-Stating ones definition of a disease / diagnosis based on the presenting signs and
symptoms.
Consider Two Factors:
1. Sensitivity indicates the strength of association between a sign / symptom and the
disease; picks up most cases and avoids FALSE NEGATIVES.
2. Specificity shows the uniqueness of the association between a sign / symptoms and
the disease; excludes non cases or avoids FALSE POSITIVES.

B. DESCRIPTION OF THE DISEASE / CONDITION

*Factors affecting distribution:
1. Place extrinsic factors.
2. Person intrinsic characteristics such as age, sex, genetic endowment and other
factors such as occupation, place of residence, income are analyzed to identify
susceptible groups in a certain locality.

Factors Affecting the Communitys Reaction to Disease Agent Invasion

a. Herd Immunity state of resistance of a population group to a particular disease at a
given time; level of immunity of the group.
b. Susceptibility Status determined by the number of individuals with little or no
immunity.

Patterns of Disease Occurrence

Epidemic a situation when there is a high incidence of new cases of a specific disease
in excess of the expected.
Endemic habitual presence of disease in a given geographic location accounting for
the low number of both immunes and susceptible.
Sporadic disease occurs every now and then affecting only a small number of people
relative to the total population.
Pandemic global occurence of a disease.

3. Time temporal patterns; expressed on a daily, weekly, monthly, or yearly basis.

C. ANALYSIS OF DISEASE PATTERN

-one tries to find out if there is a statistical relationship between a disease and biological
or social factors.

*Causal when there is evidence that shows that certain factors increase the probability
of occurrence of a disease and a change in one or more of these factors produces a
change in the occurrence of the disease
*Non Causal
a. Spurious due to chance or bias caused by certain procedures / aspects involved in
study.
b. Indirect when a factor and disease are associated only because both are related to
some common underlying condition.

Types of Epidemiological Study Designs

Descriptive VS Analytical
Provides information on patterns of Test Hypothesis about of disease.
disease in terms of person, place and
causes characteristics.
*Correlational *Case Reports Observational Intervention
*Ecologic *Case Series (Experimental)
*Cross Sectional
surveys
*Case control *Trials
*Cohort
Experimental Non - Experimental
With manipulation Mere observation of study conditions
*Clinical Trials *Cohort
*Field Trials *Case Control
*Community Intervention Trials *Proportional Mortality Studies
*Cross Sectional
*Ecologic

Common Epidemiologic Studies:

Retrospective Cross Sectional Prospective Cohort

Outline of Plan for Epidemiological Investigation:

1. Establish fact of presence of epidemic.
-Verify diagnosis do clinical and laboratory studies to confirm the data.
2. Establish time and space relationship of the disease.
-Are the cases limited to or concentrated in any paricular geographical subdividion of
the affected community?
-Relation of cases by days of onset to onset of the first known cases maybe done by
days, weeks or months.
3. Relations to characteristic of the group of community.
-Relation of cases to age, group, sex, color, occupation, school attendance, past
immunization.
-Relation to milk and food supply.
-Relationof cases and known carrier if any.
4. Correlation of all data obtained.
-Summarize the data clearly with the aid of such tables and charts which are
necessary to give a clear picture of the situation.
-Build up the case for the final conclusion carefully utilizing all the evidence available.
STAGES OF A DISEASE: BACKBONE TO CONTROL A DISEASE
Incubation period-
-exposure to an infection to the appearance of the firstsymptom
Prodromal period
-from the appearance of the first symptom to theappearance of a pathognomonic sign
Stage of illness
-a stage where the patient manifest most of the signs andsymptoms
Convalescence
- stage of recovery, and a gradual decrease of symptomsmanifested

National Epidemic Sentinel System (NESS)

-hospital-based information system that monitors the occurrence of infectiousdiseases
with outbreak potential.

Why is there a need to investigate an outbreak?

1.Control and prevention measure
2.Severity and risks to others
3.Research opportunities
4.Public, political and legal concerns
5.Program consideration
6.training

Steps in Outbreak Investigation:

1.Prepare for field work
2.Establish existence of an outbreak
3. Verify diagnosis
4. Define and Identify cases
5. Perform descriptive epidemiology
6. Developing hypotheses
7. Evaluate hypotheses
8. Refine hypotheses and execute additional studies
9. Implement control and prevention measures
10. Communicate findings
11. Follow up Recommendations

E. Demography
DEMOGRAPHY
-The emprical, statistical and mathematical study of human population; derived from two
Greek word snyos, which means people and ypagly which means to draw or write.
-Focus on three common and observable human events:
a. Population compposition or structure
b. Distribution of population in space
c. Population size
-Sources of Demographic Data
a. Census complete enumeration of the population.
b. Sample Surveys
c. Registration system
Two ways of Assigning People
1. De Jure people are assigned to places where they usually live regardless of where
they are at the time of the census.
2. De Facto people are assigned to the place where they are physically present at
the time of the census, regardless of their usual place of residence.

COMPONENTS
1. Population Composition pertains to all measurable characteristics of the people
who make up a given population.
a. Sex Ratio

b. Age dependency Ratio used as an index of age induced economic drain of

human resources

c. Age and Sex Composition graphical presentation of the age and sex composition
of a population through the use of a POPULATION PYRAMID

d. Median Age age below which 50% of the population fall and above which 50% of
the population fall.

e. Life Expectancy at Birth average number of years an infant is expected to live

under the mortality conditions for a given year.

2. Population Distribution
a. Urban Rural Distribution shows the proportion of people living in urban compared
to the rural areas.

b. Crowding Index indicates the ease by which a communicable disease can be

transmitted from one host to another susceptible host.

c. Population Density determines congestion of the place.

3. Population Size
a. Natural Increase difference between the number of births and the number of deaths
that occurred in a specific population within a specified period of time.

b. Rate of Natural Increase difference between CBR and CDR of a specific population
within a specified time.

III. Management of Resources and Environment and Records Management

A. Field Health Services and Information System ( FHSIS )

FIELD HEALTH SERVICES AND INFORMATION SYSTEM (Cuevas, 2007)

Objectives:
- To provide summary of data on health services delivery and selected program
accomplished indicators at the barangay municipality / city, district, provincial, regional
and national events.
-To provide data which when combined with data from other sources, ca be used for
program monitoring and evaluation purposes.
-To provide a standardized, facility level data base which can be assessed for a more in
depth study /studies.
-To ensure that the data reported to the FHSIS are useful and accurate and are
disseminated in a timely and easy to use fashion.
-To minimize the recording and reporting burden at the service delivery level in order to
allow more time for patient care and promotive activities.

Importance of FHSIS
- Helps local government determine public health priorities.
- Basis for monitoring and evaluatinghealth program implementation.
- Basis for planning, budgeting, logistics and decision making at all levels.
- Source of data to detect unusual occurrence of a disease.
- Needed to monitor health status of the community.
- Helps midwives in following up clients.
- Documentation of RHM / PHN day to day activities.

Components:
*FAMILY TREATMENT RECORD (Cuevas, 2007) /
INDIVIDUAL RECORD (Famorca, 2013) / *INDIVIDUAL TREATMENT RECORD
*TARGET CLIENT LIST
*REPORTING FORMS / SUMMARY TABLE
*OUTPUT REPORTS /MONTHLY CONSOLIDATION TABLE (MCT)

Concept:
*TREATMENT RECORD Fundamental building block or foundation of FHSIS.
This is the document, form or pieces of paper upon which the presenting
symptoms or complaints of the patient on consultation and the diagnosis, treatment and
date of treatment if recorded.
*CLIENT LIST Second building block of the FHSIS and are intended to serve several
purposes.
First is to plan and carry out patient care and service delivery. Such lists will be
of considerable value to midwives / nurses in monitoring service delivery to clients in
general and in particular to groups of patients identified as targets or eligibles for one
or another program of the Department.
The second purpose of Target Client Lists is to facilitate the monitoring and
supervision of service delivery activities.
The Third purpose is to report services delivered.
The fourt purpose of the Target Client Lists is to provided a clinic level data
base which can be accessed for further studies.

TARGET CLIENT LISTS TO BE MAINTAINED IN

THE FHSIS
1. Target Client List for Prenatal Care
2. Target Client List for Post-Partum Care
3. Target Client List of Under 1 Year Old Children
4. Target Client List for Family Planning
5. Target Client List for Sick Children
6. NTP TB Register
7. National Leprosy Control Program Form 2-Central Registration
Form

*TALLY / REPORTING FORMS Submitted monthly or quarterly (majority).

One report is prepared weekly several
annually, and in some instances, every few minutes as
relevant events occur, e.g., maternal and neonatal
deaths.

FHSIS Manual of Operations has the following

RECORDING TOOLS:
1. INDIVIDUAL TREATMENT RECORD (ITR)
- Date, Home address of patient
- Presenting symptoms or complaint of the patient on consultation.
- Diagnosis (if available)
- Treatment and Date of treatment.

2. TARGET CLIENT LIST (TCL)

- To carry / plan out care for patient.
- Facilitate monitoring / supervision of service delivery activities.
- To report services delivered.
- To provide clinic level data base.
e.g., TCL for prenatal care; TCL for postpartum care.

3. SUMMARY TABLE
- Accomplished by Midwife
- 12 column table = 12 months of calendar year
- monthly summary of morbidity / monthly trends of disease
- serves as a source for the 10 leading causes of morbidity.

4. MONTHLY CONSOLIDATION TABLE

- Accomplished by the Nurse
- Source document for the Quarterly form and the Output Table of the RHU or Health
Center.
- Based on the Summary Table.
(Famorca, 2013)

FHSIS Manual of Operations

REPORTING FORMS:
- These are summary data that are transmitted or submitted on a monthly, quarterly and
on annual basis to higher level. The source of data for this components is dependent on
the records.
1. MONTHLY FORMS
- Prepared by the Midwife
- Submitted to the Nurse
a. Program Report (M1)
- Maternal Care
- Child Care
- Family Planning
- Disease Control
- Summary Table Data are copied into this report; program report.
b. Morbidity Report (M2)
- Contains list of all cases of disease by age and sex.
2. QUARTERLY FORMS
- Prepared by the Nurse
- Only one quarterly form for every Municipality / City
- If there are 2 RHU / Centers for the Municipal Health Officer / Mayor.
- Quartely Forms are submitted to the provincial health officr / Office.
a. Program Report (Q1)
- 3 months total indicators: Maternal Care, Family Planning, Child Care, Dental
Health and Disease Control.
(Famorca, 2013)
b. Morbidity Report (Q2)
- 3 months consolidation of Morbidity Report (M2)
 3. ANNUAL FORMS
a. A BHS
*Report by the Midwife Demographic
- Environmental
- Natality Data

b. Annual Form 1 (A-1)

- Prepared by the Nurse
- Report of the RHU / Health Center
- Demographic, Environmental,Natality and Mortality for the entire year.
c. Annual Form 2 (A-2)
- Prepared by the Nurse
- Yearly Report for morbidity by age / sex
d. Annual Form 3 (A-3)
- Prepared by the Nurse
- Yearly Report of all deaths (mortality) by age and sex.

FLOW OF REPORT
OFFICE PERSON RECORDING FORMS FREQUENCY SCHEDULE OF
TOOLS SUBMISSION
BHS Midwife -ITR Monthly Monthly Every 2nd week
-TCL Form (M1 of the
-ST AND M2 ) succeeding
month
A-BHS Annually
Form Every 2nd week
of january
RHU PHN -ST Quarterly Quarterly Every 3rd week
-MCT Form (Q1 of the 1st month
AND Q2) of succeeding
quarter
Annual Every 3rd week
Forms of January
-A1
-A2
-A3

B. Target-setting
TARGET SETTING
-Involves the calculation of the eligible population for immunization services. Since the
Universal Child Immunization goal of 80% was achieved in 1989, the target for
immunizations since 1992 onwards has increased to 90%. The two most important goals
are the following:
 Sustainability of the high coverage and,
Maintenance of quality immunization Services

a. Eligible Population
1. Infants for EPI in a barangay, municipality, district, province/city and region, target
setting is based on 3% of the total population.
2. BCG School Entrants use 3% of the total population in calculating the number of
children entering first grade in one year.
3. Pregnant Women All pregnant women are eligible for EPI. Target Setting must
include the number of pregnancies that will terminate in live births (3% of the total
population) plus the number of the pregnancies (0.5 % of the total population): thus, the
percentage of eligible women in the total population is 3.5%.

b. Calculating Vaccine Needs

*How to Calculate Vaccine Needs
-Step One: Determine the eligible population.
-Step Two: Determine the number of doses required in a year by multiplying the eligible
population with the number of doses for complete immunization.

-Step Three: Determine the wastage rate of antigen or use the wastage multiplier. From
step two, multiply the product with the wastage multiplier to get the annual needs
including the wastage allowance.

-Step Four: Determine the number of ampoules or vials needed by dividing the annual
dose by the dose per vial or ampule

ANNUAL VACCINE NEEDS PER VIAL DOSE = Annual Vaccine / Dose per vial or ampule
-Step Five: Determine the vaccine need per month or quarter

MONTHLY VACCINE NEEDS QUARTERLY VACCINE NEEDS

= Total Vials or ampules / 12 = Total Vials or ampules / 4

months quarters

Step Six: Determine the vaccine need per month or quarter with reserve stock

MONTHLY VACCINE NEEDS

= (Total Vials or ampoules / 12 months) X 1.25

C. Determining Needle and Syringe Requirements
*How to Calculate Needle and Syringe Requirements
Step One: Determine the eligible population
Step Two: Determine the monthly eligible population
MONTHLY ELIGIBLE POPULATION = Annual eligible population / 12 months

Step Three: Multiply the monthly eligible population by the number of doses required for
each antigen
MONTHLY INJECTIONS = Monthly eligible population X doses required per antigen

Step Four: Determine the total requirement including additional allowance for syringes
and needles.
TOTAL REQUIRED SYRINGES = Monthly injections X 1.25 for syringes

TOTAL REQUIRED NEEDLES = Monthly injections X 1.50 for needles

C. Environmental Sanitation
ENVIRONMENTAL SANITATION
-is defined as the study of all factors in mans physical environment which may exercise a
deleterious effect on his health, well being and survival.

Goal: to eradicate and control environmental factors in disease transmission through the
provision of basic services and facilities to all house holds.

COMPONENTS:
Water Supply Sanitation Program
Proper Excreta and Sewage Disposal Program
Insect and Rodent Control
Food Sanitation Program
Hospital Waste Management Program
Strategies on Health Risk Minimization due to Environmental Pollution

a. Water Supply Sanitation Program

Three Types of Approved Water Supply and Facilities
Level I Level II Level III
Point Source Communal Faucet System Waterworks System or
or Stand Posts Individual House
Connections
A protected well or a A system composed of a A system with a source, a
developed spring source, a reservoir, a piped reservoir, a piped distributor
with an outlet but distribution network and network and household taps
without a distribution
communal faucets, located at that is suited for densely
system for rural not more than 25 meters from populated urban areas
areas where houses the farthest house in rural
are thinly scattered areas where houses are
clustered densely
Water must pass the National Standards for Drinking Water set by the DOH

b. Proper Excreta and Sewage Disposal Program

Three Types of Approved Toilet Facilities
Level 1 Level 2 Level 3
Non- water carriage toilet On site toilet facilities of the Water carriage types of
facility water carriage type with toilet facilities connected to
Pit latrines. water sealed and flushed septic tanks and/or
Reed Odorless Earth type with septic vault/ tank sewerage system to a
closet. disposal facilities treatment plant
Bored Hole.
Compost.
Ventilated improved pit

Toilet requiring small

amount of water to wash
waste into receiving space.
-Pour flush, Aqua Privies.

Rural Areas blind drainage type of wastewater collection and disposal facilities shall
be emphasized until such time that sewer facilities and off site treatment facilities are
available.

c. Proper Solid Waste Management

-refers to satisfactory methods of storage collection and final disposal of solid water.
REFUSE is a general term applied to solid and semi solid waste materials other than
human excreta. Waste material in refuse may be divided into:
1. Garbage refers to leftover vegetable, animal, and fish material from kitchen
and food establishments. These materials have the tendency to decay, thus,
giving off foul odor and sometimes also serve as food for flies and rats
2. Rubbish refers to waste materials such as bottles, broken glass, tin cans,
waste paper, discarded textile materials, porcelain wares, pieces of metal and
other wrapping materials
3. Ashes are leftover 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 include dead dogs, cats, rats, pigs and chicken that were killed
by vehicles on streets and public highways.

TWO WAYS OF EXCRETA DISPOSAL

Household Community
Burial Sanitary Landfill or
>Deposited in 1 m x 1m Controlled Tipping
deep pits covered with >Excavation of soil
soil, located 25m away deposition of refuse and
from water supply. compacting with a solid
Open Burning cover of 2 feet
Animal Feeding -Incineration.
Composting
Grinding and disposal
sewer

d. Food Sanitation Program

Policies:
1. Food establishments are subject to inspection.
2. Comply with sanitary permit requirement for all food establishments.
3. Comply with updated health certificates for food handlers, helpers, cooks.
4. All ambulant vendors must submit a health certificate to determine presence of
intestinal parasite and bacterial infection.
3 Points of Contamination
*Place of production processing & source of supply
*Transportation and storage
*Retail & distribution points

e. Hospital Waste Management Program

Goal: to prevent the risk of contracting nosocomial infection and other diseases from the
disposal of infectious, pathological and other hospital wastes.
Policies:
1. The use of appropriate technology and indigenous materials for HWM system shall be
adopted.
2. Training of all hospital personnel involved in waste management shall be an essential
part of the hospital training program.
3. Local ordinances regarding the collection and disposal techniques, especially
incinerators, shall be institutionalized.

f. Strategies on Health Risk Minimization due to Environmental Pollution

These include the following:
a. Anti-smoke belching campaign and air pollution campaign
b. Zero solid waste management
c. Toxic, chemical and hazardous waste management
d. Red tide control and monitoring
e. Integrated pest management and sustainable agriculture
f. Pasig river rehabilitation Management

g. Education of prevailing health problems

-Accepted activity at all levels of public health used as a means of improving the
health of the people through techniques w/c may influence peoples thought motivation,
judgment & action.

3 Aspects of Health Education:

*Information provision of knowledge
*Communication exchange of information
*Education change in knowledge, attitudes and skills.

Sequence of Steps in Health Education

*Creating awareness.
*Creating motivation.
*Decision making action.

IV. Ethico-Moral-Legal Responsibility

A. Socio-cultural Values, Beliefs and Practices of Individuals, Families, Groups and
Communities
B. Code of Ethics for Government Workers
THE CODE OF ETHICS FOR GOVERNMENT WORKERS
C. WHO, DOH, LGU Policies on Health
D. Local Government Code
E. Issues

V. Personal and Professional Development

A. Self-assessment of CHN Competencies, Importance, Methods, Tools
B. Strategies and Methods of Updating Ones Self, Enhancing Competence in
Community Health Nursing and Related Areas.

VI. Part II: MCN

VII. Safe and Quality Care, Health Education, and Communication, Collaboration and
Teamwork
A. Principles and Theories of Growth and Development (Pediatric Nursing)
PRINCIPLES OF GROWTH AND DEVELOPMENT
PRINCIPLES
Growth and development are continuous
processes from conception until death
Growth and development proceed in an
orderly sequence.
Different children pass through the
predictable stages at different rates.
All body systems do not develop at the
same rate.
Development is cephalocaudal.
EXAMPLES
Although there are highs and lows in terms
of the rate at which growth and
development proceed, a child grows new
cells and learns new skills at all times. An
example of how the rate of growth
changes is a comparison between that of
the first year and later in life. An infants
triples birthweights and increases height
by 50% during the first year of life. If this
tremendous growth rate were to continue,
the 5 ye-old child, when ready to begin
school, would weigh 1,600 Ib. And be 12
ft. 6 in. Tall.
Growth in height occurs in only one
sequence from smaller to larger.
Development also proceeds in a
predictable order. For example, the
majority of children sit before they creep,
creep before they stand, stand before they
walk, and walk before they run. Some
children may skip a stage ( or pass
through it so quickly that the parents do
not observe the stage) or progress in a
different order, but most children follow a
predictable sequence of growth and
development.
All stages of development have a range of
time rather than a certain point at which
they are usually accomplished. Two
children may pass through the motor
sequence at different rates. For example,
one child begins walking at 9 months while
another at 14 months. Both are developing
normally. They are both following the
predictable sequence; they are merely
developing at different rates.
Certain body tissues mature more rapidly
than others. For example, neurologic
tissue experiences its peak growth during
the first year of life, whereas genital
tissues grows little until puberty.
Cephalo is a Greek word meaning head;

Development proceeds from proximal to
distal body part.
Development proceeds from gross to
refined skills.
There is an optimum time for initiation of
experiences or learning.
Caudal means tail. Development
proceeds from head to tail. A newborn can
lift only his or her head off the bed when
he or she lies in a prone position. By age 2
months., the infant can lift his or her head
and chest off the bed; by 4 months., he or
she can lift his or her head, chest, and part
of the abdomen; by 5 months., the infant
has enough control to turn over ; by 9
months., he or she can control the legs
enough to crawl; and by 1 year., the child
can stand upright and perhaps walk. Motor
development has proceeded in a
cephalocaudal order from the head to
the lower extremities.
This principle is closely related to
cephalocaudal development. It can be
illustrated by tracing the progress of upper
extremity development. A newborn makes
;ittle use of the arms or hands. Any
movement, except to put a thumb in the
mouth, is a flailing motin. By age 3 or 4
months., the infant has enough arm control
to support the upper body weight on the
forearms, and the infant can coordinate
the hand to sccop up objects. By 10
months., the infant can coordinate the arm,
thumb, and index fingers, sufficiently well
to use a pincer-like grasp or be able to
pick up an object as fine as a piece of
breakfast cereal on a high-chair train.
This principle parallels the proceeding one.
Because the child is able to control distal
body parts such as fingers, he or she is
able to perform fine motor skills ( a 3-year-
old colors best with a large crayon; a 12
yr-old can write with a fine pen).
A child cannot learn a task until his or her
nervous system is mature enogh to allow
that particular learning. A child cannot
learn to sit, for example, no matter how
much thechilds parentshave him or her
practice, until the nervous system has

Neonatal reflexes must be lost before
development can proceed.
A great deal of skill and behavior is
learned by practice.
matured enough to allow back control. A
child who is not given the opportunity to
learn developmental tasks at the
appropriate or targert times for such
tasks may have ,ore difficulty than the
usual child learning the tasks later on. A
child who is confined to a body cast at 12
months., which is the time he or she would
normally learn to walk, may take a long
time to learn this skill once free of the cast
at, say, age 2 years old. The child has
passed the time of optimal learning fo that
particular skill.
An infant cannot grasp with skill until the
grasp reflex has faded nor stand steadily
until the walking reflex has faded.
Neonatal reflexes are replaced by
purposeful movements.
An infants practices taking a first step over
and over before he or she accomplishes
this securely. If a child falls behind the
normal growth and development rate
because of illness, he or she is capable of
catch-up growth to bring him or her on
equal footing again with his or her age
group.

THEORIES OF DEVELOPMENT

1. Definition of Theories
Theory a systematic statement of principles that provides a framework for explaining
some phenomenon. Developmental theories provide road maps for explaining human
development.
Developmental Task a skill or a growth responsibility arising at a particular time in an
individuals life, the achievement of which will provide a foundation for the
accomplishment of future tasks. It is not so much chronological as the completion of
developmental tasks that defines whether a child has passed from one developmental
stage of childhood to another. For example, a child is not a toddler just because he or
she is 1 year plus 1 day old; he or she becomes a toddler when he or she has passed
through the development stage of infancy.

2. Basic Division of Childhood

Stage Age Period
 Neonate From 28 days of life
Infant 1 month 1 year
Toddler 1 3 years
Preschooler 3 5 year
School-age child 6 12 years
Adolescent 13 20 years

3. Freuds Stages of Childhood (Psychosexual Development)

Stage Psychosexual Stage
Infant ORAL STAGE: Child explores the
world by using his or her mouth,
especially the tongue.
Toddler ANAL STAGE: Child learns to control Help children achieve
urination and defecation.
Preschooler PHALLIC STAGE: Child learns sexual Accept childs sexual
identity through awareness of genital
area.
School-age child LATENT STAGE: Childs personality
development appears to be non-
active or dormant.
Adolescent GENITAL STAGE: Adolescent
develops sexual maturity and learns
to establish satisfactory relationships relate with opposite sex;
with the opposite sex.
Nursing Implications
Provide oral stimulation by
giving pacifiers; do not
discourage thumb sucking.
Breastfeeding may provide
more stimulation than
formula feeding because it
requires the infant to
expend more energy.
bowel and bladder control
without undue emphasis on
its importance. If at all
possible, continue bowel
and bladder training while
child is hospitalized.
interest,such as fonding his
or her own genitals, as a
normal area of exploration.
Helps parents answer the
childs questions about birth
or sexual differences.
Help the child have positive
experiences as his or her
self-esteem continues to
grow and as he or she
prepares for the conflicts of
adolescence.
Provide appropriate
opportunities for the child to
allow the child to verbalize
feelings about new
relationships.
Eriksons Stages of Childhood (Psychosocial Development)
Stage Developmental Task Nursing Implications
Infant Developmental task is to Provide a primary
form a sense of trust versus caregiver.Provide
mistrust. Child learns to experiences that add to
love and be loved. security such as soft
sounds and touch. Provide
visual stimulation for active
child involvement.
Toddler Developmental task is to Provide opportunities for
form a sense of autonomy decision makingsuch as
versus shame. Child learns offering choicesof clothes to
to be independent and wear or toys to play with.
make decisions for himself Praise ability to make
or herself. decisions rather than judge
or correct the childs
decision.
Preschooler Developmental task is to Provide opportunities for
form a sense of initiative exploring new places or
versus guilt. Child learns activities. Allow play to
how to do things (basic include activities involving
problem solving) and that water, clay (for modeling),
doing things is desirable. or finger paints.
School-age child Developmental task is to Provide opportunities such
form a sense of industry as allowing child to
versus inferiority. Child assemble and complete a
learns how to do things short project so that the
well. child feels rewarded for the
accomplishement.
Adolescent Developmental task is to Provide opportunites for the
form a sense of identity adolescent to discuss
versus role confusion. feelings about events
Adolescent learns who he important to him or her.
or she is and what kind of Offer support and praise for
person he or she will be by decision making.
adjusting to a new body
image, seeking
emancipation from parents,
choosing a vocation, and
determining a value
system.
Piagets Stages of Cognitive Development
Stage of Development
Sensorimotor neonatal
reflexes
Primary circular reaction
Secondary circular reaction
Coordination of secondary
reaction
Age Span Nursing Implication
1 month Stimuli are assimilated into
beginning mental
images.Behavior is entirely
reflexive.
1 4 months Hand mouth and ear
eye coordination develop.
Infant spends much time
looking at objects and
separating self from them.
Beginning intention of
behavior is present ( the
infant brings thumb to
mouth for a purpose: to
suck it ). An enjoyable
activity for the period: a
rattle or a tape of parents
voice.
4 8 months Infant learns to initiate,
recognize, and
repeatpleasurable
experiences from
environment. Memory
traces are present; infants
anticipates familiar events
( a parent coming near him
will pick him up ). Good toy
for this period: mirror; good
game: peek a boo.
8 12 months Infant can plan activities to
attain specific goals; can
perceive that others can
cause activity and that
activities of own body are
separate from activity of
objects; can search for and
retrieve toy that disappears
from view; and can
recognize shapes and sizes
of familiar objects. Because
of increased sense of

Tertiary circular reaction 12 18 months
Invention of new means 18 24 months
through mental combination
Pre operational thought 2 7 years
separateness, infant
experiences separation
anxiety when primary
caregiver leaves. Good toy
for this period: nesting toys
( e.g., colored boxes ).
Child is able to experiment
to discover new properties
of objects and events and is
capable of space and time
perception as well as
permanence. Object
outside seff are understood
as causes of actions. Good
game for this period: throw
and retrieve.
Transitional phase to the
pre operational thought
period. Child uses memory
and imitation to act, solves
basic problems, and
foresees maneuvers that
will succeed or fail. Good
toys for this period: those
with several uses such as
blocks and colored plastic
rings.
Thought becomes more
sympbolic. Child can arrive
at answers mentally instead
of through physical attempt
and can comprehend
simple abstractions,
although thinking is
basically concrete and
literal. Child is egocentric
(unable to see the
viewpoint of another) and
displays static thinking
(inability to remember what
he or she started to talk
about, so that at the end of
a sentence, the child is
 already talking about
another toipc). Concept of
time is now, and concept of
distance is only as far as he
or she can see. Centering
or focusing on a single
aspect of an object causes
distorted reasoning. No
awareness of reversibility
(for every action there is an
opposite action) is present.
Child is unable to state
cause effect relationships,
categoris or abstractions.
Good toy for this perio:
Items that require
imagination such as
modeling clay.
Concrete operational 7 12 years Concrete operations
thought include systematic
reasoning. Uses memory to
learn broad concepts (e.g.
fruit) and subgroups of
concepts (e.g., apples,
oranges). Objects are
sorted according to
attributes such as color;
seriation, in which objects
are ordered according to
increasing or decreasing
measures such as weight;
and multiplication, in which
objects are simultaneously
classified and seriated
using weight. Child is aware
of reversibility, An opposite
operation or continuation of
reasoning back to a starting
point (follows a route
through a maze and then
reverses steps);
understands conservation;
and sees constancy despite
 transformation (mass or
quantity remains the same
even if it changes shape or
position). Good activity for
this period: collecting and
classifying natural objects
such as native plants, sea
shells, etc. Expose child to
other view points by asking
questions like How do you
think youd feel if you were
a nurse and had to tell
someone to stay in bed?
Formal operational thought 12 years Adolescent can solve
hypothetical problems with
scientific reasoning, can
understand causality, and
can deal with the past,
present, and future. Adult or
mature thought. Good
activity for this period: talk
time to sort through
attitudes and opinions.
From Piaget, J. (1961). The growth of logical thinking from childhood to adolescence.
New York: Basic Books, with permission.

Kohlbergs Stages of Moral Development

Age Stage Description Nursing Implications

(Year
)
Pre conventional (Level I)
2-3 1
B. Nursing Care in the Different stages of Growth and Development including
1. Nutrition
2. Safety
3. Language Development
4. Discipline
5. Play
6. Immunization
7. Anticipatory guidance
8. Values formation
C. Human Sexuality and Reproduction including Family Planning
D. Nursing Care of Women during Normal Labor, Delivery and Postpartum
E. Nursing Care of the Newborn
1. APGAR Scoring
2. Newborn Scoring
3. Maintenance of Body Processes (oxygenation, temperature)
F. Nursing Care of Women with Complications of Pregnancy, Labor, Delivery and
Postpartum Period (High-risk conditions)
G. Nursing Care of High-risk Newborn
1. Prematurity
2. Congenital defects
3. Infections
H. Nursing Care of Women with Disturbances in Reproduction and Gynecology

VIII. Research and Quality Improvement

A. Fertility Statistics
B. Infant Morbidity and Mortality
C. Maternal Mortality
D. Standards of Maternal and Child Nursing Practice

IX. Ethico-Moral-Legal Responsibility

A. Socio-Cultural Values, Belief, and Practices of Individuals, Families related to MCN.
B. WHO, DOH, LGU Policies on Health of Women and Children
C. Family Code
D. Child and Youth Welfare Code
E. Issues related to MCN

X. Personal and Professional Development

A. Self-assessment of MCN Competencies, Importance, Methods, Tools
B. Strategies and Methods of Updating Ones self, Enhancing Competence in MCN and
Related Areas.
Nursing Board Exam/Nursing Licensure Exam Coverage (Nursing Practice III, IV
and V)
NURSING BOARD EXAM SCOPE/COVERAGE
NURSING PRACTICE III, IV, V
TEST DESCRIPTION: Theories, concepts, principles and processes in the care of clients
with altred health patterns, utilizing the nursing process and integrating the key areas of
nursing competencies.
TEST SCOPE:
I. Safe & Quality Care, Health Education, Management of Environment & Resources, and
Quality Improvement.

A. TEST III
1. Client in Pain
CLIENT IN PAIN

GLOSSARY
addiction: a behavioral pattern of substance use characterized by a compulsion to take
the substance (drug or alcohol) primarily to experience its psychic effects.
agonist: a substance that when combined with the receptor produces the drug effect or
desired effect.
Endorphins and morphine are agonists on the opioid receptors.
algogenic: causing pain.
antagonist: a substance that blocks or reverses the effects of the agonist by occupying
the receptor site without producing the drug effect.
balanced analgesia: using more than one form of analgesia concurrently to obtain more
pain relief with fewer side effects.
breakthrough pain: a sudden and temporary increase in pain occurring in a patient
being managed with opioid analgesia.
dependence: occurs when a patient who has been taking opioids experiences a
withdrawal syndrome when the opioids are discontinued; often occurs with opioid
tolerance and does not indicate an addiction.
endorphins and enkephalins: morphinelike substances produced by the body. Primarily
found in the central nervous system, they have the potential to reduce pain.
intractable pain: pain not relieved by conventional treatment.
neuropathic pain: pain caused by neurologic disturbance; may not be associated with
tissue damage.
nociception: activation of sensory transduction in nerves by thermal, mechanical, or
chemical energy impinging on specialized nerve endings; the nerves involved
convey information about tissue damage to the central nervous system.
nociceptor: a receptor preferentially sensitive to a noxious stimulus.
non-nociceptor: nerve fiber that usually does not transmit pain.
opioid: a morphinelike compound that produces bodily effects including pain relief,
sedation, constipation, and respiratory depression.
pain: an unpleasant sensory and emotional experience resulting from actual or potential
tissue damage.
pain threshold: the point at which a stimulus is perceived as painful.
- minimum amount of stimulus required to cause sensation of pain.
pain tolerance: the maximum intensity or duration of pain that a person is able to
endure.
- maximum pain a client is willing or able to endure.
patient-controlled analgesia (PCA): self-administration of analgesic agents by a patient
instructed about the procedure.
Phantom pain: pain experienced in missing body part.
placebo effect: analgesia that results from the expectation that a substance will work,
not from the actual substance itself.
prostaglandins: chemical substances that increase the sensitivity of pain receptors by
enhancing the pain-provoking effect of bradykinin.
radiating pain: pain experienced at source and extending to other areas.
referred pain: pain perceived as coming from an area different from that in which the
pathology is occurring.
- pain experienced in an area different from site of tissue trauma.
sensitization: a heightened response seen after exposure to a noxious stimulus.
Response to the same stimulus is to feel more pain.
tolerance: occurs when a person who has been taking opioids becomes less sensitive to
their analgesic properties (and usually side effects); characterized by the need for
increasing doses to maintain the same level of pain relief.

Pain
-Is defined as an unpleasant sensory and emotional experience associated with actual or
potential tissue damage (Merskey and Bogduk, 1994).
-Dimensions includes: Physical, Emotional, Cognitive, Socio-cultural and Spiritual
aspects.
-Pain occurs as the result of many disorders, diagnostic tests, and treatments; it disables
and distresses more people than any single disease.
1. Referred to as fifth vital sign.
2. Subjective; pain is whatever client says it is.
3. Perception of the clients pain is influenced by multiple factors (e.g., previous pain
experience and emotional, physical, and psychological status)
-The International Association for the Study of Pain (IASP) defines pain as an
unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage. Although there are many
definitions and descriptors of pain, the one most relevant for nurses is that pain is
whatever the person experiencing it says it is, and existing whenever the person
says it does (McCaffery, 1979).

Types of PAIN
1. According to LOCATION
a. Referred pain
-perceived pain in an area but the source in another area.
-because fibers innervating this areas are close to innervating some tissues.

b. Visceral Pain
-usually diffuse, poorly localized, dull, pain, vague
-visceral organs are innervated by the sympathetic nerves to the spinal cord.
-rarely causes severe pain.

2. According to DURATION
a. Acute pain: mild to severe pain lasting lessthan 6 months.
-usually associated with specific injury; involves sympathetic nervous system response.
-leads to increased pulse rate and volume, rate and depth of respirations, blood pressure
(BP), and glucose level.
-urine production and peristalsis decrease.
b. Chronic pain: mild to severe pain lasting longer than 6 months.
-associated with parasympathetic nervous system.
-client may not exhibit signs and symptoms associated with acute pain.
-may lead to depression and decreased functional status.
3 TYPES OF CHRONIC PAIN:
1. Chronic Nonmalignant Pain
- > than 6 months, no foreseeable end
- Makes it difficult to live a normal life
2. Chronic Intermittent Pain
- Refers to exacerbation & recurrence of chronic condition.
- pain occurs at specific periods
- Ex. Migraine, Sickle cell
3. Chronic Malignant Pain
- have qualities of both Acute and Chronic Pain
c. Cancer related Pain: Pain associated with cancer may be acute or chronic. -Pain
resulting from cancer is so ubiquitous that when cancer patients are asked about
possible outcomes, pain is reported to be the most feared outcome (Munoz Sastre,
Albaret, Maria Raich Escursell, et al., 2006).
-Pain in patients with cancer can be directly associated with the cancer (eg, bony
infiltration with tumor cells or nerve compression), a result of cancer treatment (eg,
surgery or radiation), or not associated with the cancer (eg, trauma). However, most pain
associated with cancer is a direct result of tumor involvement.

3. According to INTENSITY
- clients report of pain MOST important indicator of the existence & intensity of pain.
- Assess of what level of comfort is acceptable
- Use of Pain Intensity Scale, Pain Rating Scale, Visual Analog Scale (VAS)
Factors Affecting Perception of Pain:
1. Amount of perception
2. State of Consciousness
3. The Level of Activities
4. The Clients Expectation

4. According to ETIOLOGY
b. Physiologic Pain
- Experienced when an intact, properly functioning nervous system sends signals that
the tissues are damaged, requiring attention and proper care.
- Subcategories: Somatic and Visceral
c. Neuropathic Pain
- experienced by people who have damaged or malfunctioning nerves
- may be due to: Illness, Injury, Undetermined reasons

CONCEPTS ASSOCIATED WITH PAIN

Y Pain Threshold
- lowest intensity of a painful stimulus that is perceived by a person as pain
- generally the same for all persons
Y Pain Tolerance
- the amount of pain a person is willing to endure
- Different for each person
- An only be determine by the client

FOUR PROCESS IN NOCICEPTION

1. Transduction
- the conversion of mechanical, thermal and chemical stimulus into a neural action
potential.

A delta fibers
- transmits signals more rapidly
- delivers information on pain producing stimulus
 - determine the location, severity and type of pain
- perceived as sharp, cutting, stubbing sensation
A beta fibers
- thicker neurons that release inhibiting neurotransmitters
- Dominant stimulation causes gating mechanism to close
C fibers
- conducted more slowly along pain pathway
- characterized as dull, burning sensations, associated with sufferings
- engages brain stem and cerebral regions contributing to emotional, cognitive and
situational components of pain

2. Transmission
I. Pain impulses travels from peripheral nerve fibers to the spinal cord
PAN membranes become depolarized

Action potential spreads along the entire neuron

Delivers the signals to cells in the spinal cord

II. Ascension via spinothalamic tracts to the brain stem & thalamus
PAN neurotransmitters

Release into the synoptic cleft of the spinal cord

Bind the receptors

III. Transmission of signals between the thalamus and somatic sensory cortex
Spinothlamic Tract (STT) segregates

Medial branch Lateral Branch

Medial thalamus Lateral thalamus

4 thalamic nuclei

Projection to the cortex

Perception

Somatosensory cortex interpret the sensory

Frontal cortex interpret the affective

3. Perception
- client becomes conscious of the pain
- occurs in cortical structures
4. Modulation
- descending system
-descending fibers release substance which inhibits the ascending noxious impulses in
the dorsal horn

STIMULATION OF NOCICEPTORS
Mechanical instruments, and equipment
Thermal flames, hot liquids, steam
Chemical noxious substances

CHEMICAL MEDIATORS OF PAIN

1. Bradykinin a powerful vasodilator that increased capillary permeability & constrict
smooth muscle
2. Histamine a compound found in all cells. It is release in allergic inflammatory
reactions
3. Acetylcholine a neurotransmitter substance widely distributed in body tissues &
functions as vasodilators and cardiac depressants
4. Substance P stimulant at pain receptor sites involved in inflammatory response in
local tissue
5. Prostaglandin chemical substance thought to increase the sensitivity of pain
receptors by enhancing the pain provoking effect of Bradykinin.
6. Endorphin/ Encephalin reduce or inhibit transmission of pain. Both are found in
heavy concentration nit the CNS.

GATE CONTROL THEORY ( Melzack and Wall, 1965)

- pain impulses can be regulated or even blocked by gating mechanism along the CNS.
- Substancia gelatinosa in the dorsal horn of the spinal cord where gating mechanism
is found.
- Open gate pain passes through
- Close gate pain impulses are blocked
- How to close the gate? By rubbing the back, acupressure, relaxation, deep breathing.
- Substance P promote transmission of pain to higher nerve
- A delta fibers and C neurons release substance P to transmit impulse to the gating
system

PAIN REACTION
Factors that Decsrease an Individuals Tolerance to Pain
- Prolonged pain that is sufficiently relieved
- Fatigue accompanied by inability to sleep
- Increase fear and anxiety
- Unresolved anger
- Depression / Isolation
Physiologic reaction to Pain
- Involved the activation of the sympathetic Nervous System
- Evoked the fight and flight reaction
- With catecholamine release from the adrenal medulla
Physical Responses
- Moving away
- Protecting body area
- Restlessness
- Facial expressions biting lips,grimace, staring
- Voluntary and involuntary protective body movements

Psychological Responses
- Verbal statements praying, swearing, cursing, repeating
- Non sensual phrases
- Altered response to environment
- Vocal behaviors moan, scream, sighing, crying
- Body movements rocking, rubbing, pounding, biting
- Physical contact to others
- Facial expressions grimace, tight lips, clenched teeth

FACTORS THAT INFLUENCING PAIN PERCEPTION AND INTERPRETATION

1. Situational factors
S situation associated with pain
S formal or crowded situations
S Ex. Type of illness or tumor or disease
2. Socio-cultural factors
S We learn to respond to pain from our family & ethnic group
S Pain response tends to reflect the mores of the culture
S Can affect pain management
3. Age
S Transmission of pain may be slowed to adults
S Physical actors, affecting doses
4. Gender
S Men are expected to express <pain than women do
S Men report < pain than women
S Does not mean men feel pain less, only assumes to show it less
5. Meaning of Pain
S Meaning of pain of a person influences his/her response to pain
S Known vs unknown cause of pain
S Meaning of experience: negative or positive
6. Anxiety
S It intensifies the pain
7. Past experiences with Pain
S Affects the way we perceived our current pain
S Negative experience with pain as children have reported greater difficulties
managing pain
S Impact of pain experience may not be predictable
S Earlier pain experience allow us to adopt coping mechanism
8. Expectation and the Placebo effect
S Clients expectations plays a major role in a persons pain perception and
effectiveness pain relief intervention
S PLACEBO EFFECT
- may initiate the bodys endogenous opiate system activated by the expectation
of relief
- placebo response does not indicate absence of real pain
- deceptive use of placebo is considered unacceptable in pain management

NURSING PROCESS IN THE CARE OF CLIENTS WITH PAIN

A. ASSESSMENT
- the cause of pain must be sought
- the person with pain is he expert about the location, intensity, quality and pattern of the
pain

PAIN CARE BILL OF RIGHTS

- Have your report of pain taken seriously & be treated with dignity & respect
- Have your pain thoroughly assessed & promptly treated
- Be informed by your health care about what may be causing the pain, possible
treatments & the benefits, risks, & cost of each
- Participate actively in decisions about how to manage your pain
- Have your pain reassessed regularly & your treatment adjusted if your pain has
not been eased (assess after)
- Be referred to a pain specialist if your pain persists.

NURSING MANAGEMENT OF PAIN

- Pain as the fifth vital sign makes pain assessment a routine aspects of care of all
clients
- Give the highly objective nature of pain, a comprehensive assessment of the pain
experiences provides the necessary foundation for optional pain control.

MAJOR COMPONENTS OF PAIN ASSESSMENT

- Pain history to obtain facts from client
- Direct observation of behaviors, physical signs

PAIN HISTORY
- Previous pain treatment and effectiveness
- When and what analgesics were last given
- Other meds being taken
- Allergies to medication or food

ASSESSMENT
P Provoking factors (what makes pain worst/relieved)
Q Quality or quantity (dull, sharp, crushing, stabbing)
R Region and Radiation (diffused/ all over)
S Severity or intensity
T Timing (onset, duration, frequency, cause)

C Characteristics
O Onset
L Location
D Duration
E Exacerbation (what makes it worst?)
R Radiation (whether t spreads)
R Relief

P Provoking factors
A Alleviating factors/area
I Intensity
N Nature (characteristics)

MEASUREMENT OF PAIN
A Pain reporting is the single best measure of pain
A Pain location
U Drawing on the body, point & mark all areas where the pain is felt
A Pain intensity
U Numerical scale (0-10)
U Wong-Bakers Faces pain Rating (1-6 faces)
U Visual analogue scale (horizontal mark
A Pain quality
U Use of verbal descriptor scale
A Pain pattern
U Precipitating factors: what initiates (physical exertion, environmental & emo
factors)
U Alleviating factors: herbal teas, meds, test, hot or cold application, prayer,
distraction
U Associated symptoms: N/V, dizziness, diarrhea
U Effect on ADL
U Coping Resources
U Affecting responses: Anxiety, fear, exhaustion, depression or sense of
failure
U The use of the standardized assessment tools help make the pain less
abstract for the patient
U When the pain is a more concrete experience, the patient feels empowered
to cope

B. DIAGNOSIS
1) Pain
2) Activity intolerance
3) Altered family processes
4) Anxiety
5) Chronic pain
 6) Constipation
7) Fear
8) Risk for altered thought processes
9) Risk for self- harm
10) Hopelessness
11) Ineffective individual coping
12) Powerlessness
13) Sleep pattern disturbance

C. NURSING CARE MANAGEMENT OF PAIN

KEY STRATEGIES IN THE MANAGEMENT OF PAIN
Y Acknowledgement and Accepting Clients pain
a. Acknowledge the possibility of pain
b. Listen attentively to what the client says about the pain
c. Convey the need to ask about the pain
d. Attend to the clients need promptly
Y Assert support persons
Y Reduce misconceptions about pain & its treatment
Y Reducing fear & anxiety
Y Preventing pain by providing measures to treat pain before it occurs or before it
becomes severe

PHARMACOLOGIC PAIN MANAGEMENT

The WHO 3 steps analgesic ladder

STEP 1: drugs for mild pain (1-3) non-opioid drugs

- Aspirin & NSAIDS = blocks prostaglandin synthesis
- Acetaminophen = acts through central mechanisms (ex. Paracetamol- Not >
4000mg)
- Cyclooxydase-2 (COX-2) = inhibitors which selectively block the COX-2 enzymes
responsible for inflammation & the production of substances associated with pain.
- Adjuvant drugs = are not usually used for analgesia (depressants Prozac)

STEP 2: drugs for moderate (4-6) / mild but persistent pain

Y Opioid-agonist (Codeine, Hydrocodone, Meperidine)
- Bind to opioid receptors (mu, delta, kappa) in the CNS to block transmission of
nociceptive signals.

Y Opioid-agonist antagonist (Pentazocine)

- Produce effect at kappa receptors (agonist) but block the drugs effect at the mu
receptors (antagonist)

STEP 3: drugs for moderate to severe pain (7-10)

Y Opioid drugs (morphine sulfate, naloxonarcan, hydromorphane, methadone)
- Morphine = respi arrest; M-6G (metabolite of morphine)
 - Meperidine = should not be used longer than 48 hours because its metabolic by-
product is toxic to the CNS

ADVERSE EFFECT OF OPIOID ANALGESICS

- constipation related to increase smooth muscle tone and motility of the GIT
- nausea and vomiting related to action on the brain stem centers
- respiratory depression related to diminished sensitivity to the respiratory center to CO2

ADJUVANT MEDICATIONS
- may be used with an analgesic or be used alone
- blocks cellular reuptake of serotonin /& epinephrine via descending pain inhibitory
system
- Selective Serotinin Reuptake Inhibitors:
Y Fluoxetine (Prozac)
Y Paroxtine (Foxil)
Y Sertraline (Zoloft)
- Anti- anxiety agents:
Y Diazepham mediate pain by allowing the movement of chloride inos result to
hyperpolarization of postsynaptic membrane, making it less receptive to incoming
nociceptive stimuli.
Y Anti- convulsants - situations associated with nerve injury ex. Phenetoin
Y Corticosteroids - reduce edema & inflammation

APPROACHES IN THE USE OF ANALGESICS

Balanced Analgesia simultaneous use of agents for maximum relief while minimizing
the potentially toxic effects of any one agents.
Preventive approach most effective drug is administered at set intervals before pain
becomes severe or before the drug is at sub therapeutic levels.

METHODS OF ADMINISTRATION OF ANALGESICS

1. Nurse administered analgesia as PRN meds or on schedule
2. Oral
3. IM
4. IV
5. Ommaya Reservoir
- catheter is inserted into the anterior horn of the lateral ventricles
- PATIENT CONTROLLED ANALGESIA (PCA) PUMPS
U Use of a W or SC infusion pump that contains the analgesic & is
controlled by the patient.
U Uses a portable infusion pump delivers a small preset safe dose
U Has a lock system to avoid tempering by the client or family
U Patient feels in control & can decrease anxiety
U C/I: confused & unresponsive
U For persistent pain
U PCA pump is electrically controlled by a timing device delivering a
persistent of the meds.
 U Pain should be brought under control before PCA starts
6. Rectal route patient who cant tolerate PO.
7. Cream & lotion
8. Transdermal route: skin patch for up to 72 hours
9. Transmucosal route: sublingually or the use of lozenges especially for breakthrough
pain
10. Nasal route: nasal mucosa
11. Topical: CAPSAICIN, EMLA (venipuncture,debridement)
12. Intraspinal/ Epidural analgesia which delivers the drug through a catheter into
areas of standard receptor sites for 8 24 hours duration.
13. Nerve blocks

I. NON INVASIVE PAIN RELIEF STRATEGIES

+ Positioning
- minimize joint and muscle stiffness
- active exercise regimen
- passive range of motion exercises
- early morning stiffness
+ Cutaneous stimulation
- distract the client and focuses attention on the tactile stimuli, away from the painful
sensations.
- Interferes with the transmission and perception of pain by stimulating large diameter A
beta sensory nerve fibers that activate the descending mechanisms reducing the
intensity of pain, activate the endorphine system
- Be applied directly, proximal to or distal to contralateral to the pain
- Contraindicated to areas of skin breakdown or impaired neurologic function
- Massage decrease muscle tension
- Useful when painful area cannot be touched when it is hypertensive, inaccessible, or
whom pain is felt in a missing part (phantom)
- Immobilization/bracing, heat/cold application, acupressure

***TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)

- Delivery of electrical current through electrodes applied to the skin over the
painful region, at bigger points or even a peripheral nerve. Stimulate the nonpain
receptors or cause the release cp.

THE USE OF TENS

a Remove & clean electrodes daily
a Wash skin with soap & water
a Allow skin to dry
a Wipe skin with a prepared pad before reapplying the conductor pad
a Check the back if numbness or tingling is not felt during treatments.
a Report if sensation is either
a Heat therapy & Id therapy

II. INVASIVE PAIN RELIEF STRATEGIES

+ Acupuncture involves the insertion of the needles at specified cutaneous sites
+ Percutaneous electrical nerve stimulation involves the insertion of a needle to
which a stimulator is attached, near a large peripheral or spinal nerve.

Nerve Blocks
- temporary or permanently interrupting transmission of nociceptive input by
application of local anesthetics or neurolytic agents (alcohol or phenol)
- successful for more localized chronic pain
- injection of anesthetics close to the nerves, thereby blocking their conductivity
- commonly used for operative procedures
- Ex. Plenux block for anesthesia of an extremity: brachial plexus block, epidural
block

NEUROSURGICAL INTERVENTIONS
Rhizotomy sensory nerve roots are destroyed where they enter the spinal cord
Cordotomy pain pathways are at the midline portion of the spinal cord before

COGNITIVE BEHAVIORAL THEORIES

S Anticipatory guidance
- preparing the patient for what to expect allows the nurse to help reduce anxiety &
clarify misinformation & misinterpretation
- Distraction redirection of attention on something away from pain (visual,
auditory, intellectual, tactile)

S Imagery
- Develop sensory images that focus away from the pain sensation & emphasize
other sensory experiences & pleasant memories.

S Hypnosis
- a state of altered consciousness characterized by extreme responsiveness to
suggestion

S Relaxation techniques
- deep breathing, music, low rhythmic breathing, progressive relaxation exercises
- biofeedback teach self control over physiologic variables that relate to pain like
muscle contraction & blood flow

S Therapeutic touch
- realign aberrant fields
- pass hands over the clients body at a distance of 2-6 inches to sense changes in
the field & return it to normal

S Spiritual intervention
- encompasses a persons innermost concerns & values
- make peace with their past, being, spiritually aware in the present & making
commitment to go forward the life despite the pain.
 - Prayer, caring.

NURSING ACTIONS THAT PROMOTE EFFECTIVE RELATIONSHIP WITH A PATIENT

IN PAIN
1) Believe the client
2) Clarify responsibilities in pain relief
3) Respect the clients response to pain
4) Collaborate with the client
5) Explore the pain with the client, its meaning
6) Be with the client

TEN COMMNADMENTS OF PAIN MANAGEMENT

1) Thou shalt believe the patients report to pain
2) Thou shalt assess and reassess the patients response to pain interventions
3) Thou shalt not be afraid of prescribing or administering opioid analgesics
4) Thou shalt not prescribe inadequate amounts of any analgesics
5) Thou shalt not use the abbreviation PRN for continuous pain, but ATC
6) Thou shalt reassure the patient and family that risk of opioid addiction is rare
7) Thou shalt provide support for the whole family.
8) Thou shalt not limit thy approach simply to the use of analgesics, but also adjuvant
drugs and mind-body techniques.
9) Thou shalt prevent or treat side effects of opioid
10) Thou shalt not be afraid to ask colleagues advice.

2. Peri-operative Care
GLOSSARY
ambulatory surgery: includes outpatient, same-day, or short-stay surgery that does not
require an overnight hospital stay
informed consent: the patients autonomous decision about whether to undergo a
surgical procedure, based on the nature of the condition, the treatment options,
and the risks and benefits involved
intraoperative phase: period of time that begins with transfer of the patient to the
operating room table and continues until the patient is admitted to the postanesthesia
care unit
perioperative phase: period of time that constitutes the surgical experience; includes
the preoperative, intraoperative, and postoperative phases of nursing care
postoperative phase: period of time that begins with the admission of the patient to the
postanesthesia care unit and ends after follow-up evaluation in the clinical setting or
home
preadmission testing: diagnostic testing performed before admission to the hospital
preoperative phase: period of time from when the decision for surgical intervention is
made to when the patient is transferred to the operating room table

PRIORITY CONCEPT: Infection; Safety

 Perioperative nursing is a specialized area of practice. It incorporates the three phases
of the surgical experience: preoperative, intraoperative, and postoperative. The
preoperative phase begins when the decision for surgery is made and ends
when the patient is transferred to the operating room.
The intraoperative phase begins with the patients entry into the operating room and
ends with admittance to the postanesthesia care unit (PACU), or recovery room.
The postoperative phase begins with the patients admittance to the PACU and
ends with the patients complete recovery from the surgical intervention.
Although the perioperative nurse works in collaboration with other healthcare
professionals to identify and meet the patients needs, the perioperative nurse has the
primary responsibility and accountability for nursing care of the
patient undergoing surgery.

Surgery
Surgery is an invasive medical procedure performed to diagnose or treat illness, injury,
or deformity. Although surgery is a medical treatment, the nurse assumes an active role
in caring for the patient before, during, and after surgery. Interdisciplinary care and
independent nursing care together prevent complications
and promote the surgical patients optimal recovery.

Classification of Surgical Procedures

- Surgical procedures can be classified according to purpose, risk, and urgency

Classifications of Surgical Procedures

Classification Function Examples
Purpose Diagnostic Determine or confirm a diagnosis Exploratory
Laparotomy (incision
into the peritoneal
cavity to inspect
abdominal organs),
Breast biopsy,
bronchoscopy

Ablative Remove diseased tissue, organ, or Appendectomy,

extremity Amputation

Constructive Build tissue/organs that are absent Repair of cleft palate,

(congenital anomalies) closure of atrial septal
defect in the heart

Reconstructive Rebuild tissue/organ that has been Skin graft after a burn,
/Restorative damaged total joint replacement
 Colostomy,debride-
Palliative Alleviate symptoms of a disease ment of necrotic tissue,
(not curative) resection of nerve
roots(Bowel resection
in patient with terminal
cancer).

Procurement Replace organs/tissue to restore Heart, lung, liver,

for Transplant function kidney transplant.
Risk Minor Minimal physical assault with Removal of skin
minimal risk lesions, facial plastic
surgery, dilation and
curettage (D&C),
cataract extraction,
tooth extraction

Major Extensive physical assault and/or Transplant, total joint

serious risk replacement,thoraco-
tomy, colostomy,
nephrectomy, coronary
artery bypass, removal
of larynx, resection of
the lung lobe
Urgency Elective Suggested,though no foreseen ill Cosmetic surgery,
effects if postponed cataract surgery,
bunionectomy,breast
reconstruction

Urgent Necessary to be performed within Heart bypass surgery,

1 to 2 days amputation resulting
from gangrene,
Excision of cancerous
tumor, removal of
gallbladder for stones,
vascular repair of
obstructed artery
(CABG), fractured hip

Emergency Performed immediately Obstetric emergencies,

Repair of perforated
appendix, Repair of
traumatic amputation,
control of internal
 hemorrhaging, bowel
obstruction, ruptured
aneurysm, life-
threatening trauma

I. Preoperative Care
A. Obtaining informed consent***
1. The surgeon is responsible for explaining the surgical procedure to the client and
answering the clients questions. Often, the nurse is responsible for obtaining the clients
signature on the consent form for surgery, which indicates the clients
agreement to the procedure based on the surgeons explanation.
2. The nurse may witness the clients signing of the consent form, but the nurse must be
sure that the client has understood the surgeons explanation
of the surgery.
3. The nurse needs to document the witnessing of the signing of the consent form after
the client acknowledges understanding the procedure.
4. Minors (clients younger than 18 years) may need a parent or legal guardian to sign the
consent form.
5. Older clients may need a legal guardian to sign the consent form.
6. Psychiatric clients have a right to refuse treatment until a court has legally determined
that they are unable to make decisions for themselves.
7. No sedation should be administered to the client before the client signs the consent
form.
8. Obtaining telephone consent from a legal guardian or power of attorney for health care
is an acceptable practice if clients are unable to give consent themselves. The nurse
must engage another nurse as a witness to the consent given over the telephone.

B. Nutrition
1. Review the surgeons prescriptions regarding the NPO (nothing by mouth) status
before surgery.***
2. Withhold solid foods and liquids as prescribed to avoid aspiration, usually for 6 to 8
hours before general anesthesia and for approximately 3 hours before surgery with local
anesthesia (as prescribed).
3. Insert an intravenous (IV) line and administer IV fluids, if prescribed; per agency policy,
the IV catheter size should be large enough to administer blood products if they are
required.

C. Elimination
1. If the client is to have intestinal or abdominal surgery, per surgeons preference an
enema, laxative, or both may be prescribed for the day or night before surgery.
2. The client should void immediately before surgery.
3. Insert an indwelling urinary catheter, if prescribed; urinary catheter collection bags
should be emptied immediately before surgery, and the nurse should document the
amount and characteristics of the urine.

D. Surgical site
1. Clean the surgical site with a mild antiseptic or antibacterial soap on the night before
surgery, as prescribed.
2. Shave the operative site, as prescribed; shaving may be done in the operative area.
!Hair on the head or face (including the eyebrows) should be shaved only if prescribed.

E. Preoperative client teaching

1. Inform the client about what to expect postoperatively.
2. Inform the client to notify the nurse if the client experiences any pain postoperatively
and that pain medication will be precribed and given as the client requests. The client
should be informed that some degree of pain should be expected and is normal.
3. Inform the client that requesting an opioid after surgery will not make the client a drug
addict.
4. Demonstrate the use of a patient controlled analgesia (PCA) pump if prescribed.
5. Instruct the client how to use noninvasive pain relief techniques such as relaxation,
distraction techniques, and guided imagery before the pain occurs and as soon as the
pain is noticed.
6. The nurse should instruct the client not to smoke (for at least 24 hours before surgery);
discuss smoking cessation treatments and programs.
7. Instruct the client in deep breathing and coughing techniques, use of incentive
spirometry, and the importance of performing the techniques postoperatively to prevent
the development of pneumonia and atelectasis.***

Client Teaching
Deep Breathing and Coughing Exercises
*Instruct the client that a sitting position gives the best lung expansion for coughing and
deep breathing exercises.
*Instruct the client to breath deeply 3 times, inhaling through the nostrils and exhaling
slowly through pursed lips.
*Instruct the client that the third breath should be held for 3 seconds; then the client
should cough deeply 3 times.
*The client should perform this exercise every 1 to 2 hours.
Incentive Spirometry
*Instruct the client to assume a sitting or upright position.
*Instruct the client to place the mouth tightly around the mouthpiece.
*Instruct the client to inhale slowly to raise and maintain the flow rate indicator, usually
between the 600 and 900 marks on the device.
*Instruct the client to hold the breath for 5 seconds and then to exhale through pursed
lips.
*Instruct the client to repeat this process 10 times every hour.
Leg and Foot Exercises
*Gastrocnemius (calf) pumping: Instruct the client to move both ankles by pointing the
toes up and then down.
*Quadriceps (thigh) setting: Instruct the client to press the back of the knees against
the bed and then to relax the knees; this contracts and relaxes the thigh and calf muscles
to prevent thrombus formation.
*Foot circles: Instruct the client to rotate each foot in a circle.
*Hip and knee movements: Instruct the client to flex the knee and thigh and to
straighten the leg, holding the position for 5 seconds before lowering (not performed if the
client is having abdominal surgery or if the client has a back
problem).
Splinting the Incision
*If the surgical incision is abdominal or thoracic, instruct the client to place a pillow, or 1
hand with the other hand on top, over the incisional area.
*During deep breathing and coughing, the client presses gently against the incisional
area to splint or support it.

8. Instruct the client in leg and foot exercises to prevent venous stasis of blood and to
facilitate venous blood return
9. Instruct the client in how to splint an incision, turn, and reposition
10. Inform the client of any invasive devices that may be needed after surgery, such as a
nasogastric tube, drain, urinary catheter, epidural catheter, or IV or subclavian lines.
11. Instruct the client not to pull on any of the invasive devices; they will be removed as
soon as possible.

Psychosocial preparation
1. Be alert to the clients level of anxiety.
2. Answer any questions or concerns that the client may have regarding surgery.
3. Allow time for privacy for the client to prepare psychologically for surgery.
4. Provide support and assistance as needed.
5. Take cultural aspects into consideration when providing care.

Preoperative checklist
1. Ensure that the client is wearing an identification bracelet.
2. Assess for allergies, including an allergy to latex.
3. Review the preoperative checklist to be sure that each item is addressed before the
client is transported to surgery.
4. Follow agency policies regarding preoperative procedures, including informed
consents, preoperative checklists, prescribed laboratory or radiological tests, and any
other preoperative procedure.
 5. Ensure that informed consent forms have been signed for the operative procedure,
any blood transfusions, disposal of a limb, or surgical sterilization procedures.
6. Ensure that a history and physical examination have been completed and documented
in the clients record
7. Ensure that consultation requests have been completed and documented in the
clients record.
8. Ensure that prescribed laboratory results are documented in the clients record.
9. Ensure that electrocardiogram and chest radiography reports are documented in the
clients record.
10. Ensure that a blood type, screen, and crossmatch are performed and documented in
the clients record within the established time frame per agency policy.
11. Remove jewelry, makeup, dentures, hairpins, nail polish (depending on agency
procedures), glasses, and prostheses.
12. Document that valuables have been given to the clients family members or locked in
the hospital safe.
13. Document the last time that the client ate or drank.
14. Document that the client voided before surgery.
15. Document that the prescribed preoperative medications were given.

Substances That Can Affect the Client in Surgery

Antibiotics
Antibiotics potentiate the action of
anesthetic agents.
Anticholinergics
Medications with anticholinergic effects
increase the potential for confusion,
tachycardia, and intestinal hypotonicity and Corticosteroids cause adrenal atrophy and
hypomotility.
Anticoagulants, antiplatelets, and
thrombolytics
*These medications alter normal clotting
factors and increase the risk of
hemorrhaging.
*Acetylsalicylic acid (Aspirin), clopidogrel, after surgery.
and nonsteroidal antiinflammatory drugs
are commonly used medications that can
alter platelet aggregation.
*These medications should be
discontinued at least 48 hours
before surgery or as specified by the
surgeon; clopidogrel
Antihypertensives
Antihypertensive medications can interact
with anesthetic agents and cause
bradycardia, hypotension, and impaired
circulation.
Corticosteroids
reduce the ability of the body to withstand
stress.
Before and during surgery, dosages may be
increased temporarily.
Diuretics
Diuretics potentiate electrolyte imbalances
Herbal Substances
Herbal substances can interact with
anesthesia and cause a variety of adverse
effects. These substances may need to
be stopped at a specific time before surgery.
During the preoperative period, the client
usually has to be discontinued 5 days needs to be asked if he or she is taking an
before surgery. herbal substance.

Anticonvulsants
Long-term use of certain anticonvulsants
can alter the metabolism of anesthetic
agents.
Antidepressants
Antidepressants maylower the blood
pressure during anesthesia.
Insulin
The need for insulin after surgery in a
diabetic may be reduced because the
clients nutritional intake is decreased, or the
need for insulin may be increased because
of the stress response and intravenous
administration of glucose solutions.

Antidysrhythmics
Antidysrhythmic medications reduce
cardiac contractility and impair cardiac
conduction during anesthesia.
Adapted from Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St.
Louis, 2013, Mosby.

16. Monitor and document the clients vital signs.

Preoperative medications
1. Prepare to administer preoperative medications as prescribed before surgery.
2. Instruct the client about the desired effects of the preoperative medications.
!After administering the preoperative medications, keep the client in bed with the side
rails up (per agency policy). Place the call bell next to the client; instruct the client not to
get out of bed and to call for assistance if needed.

Arrival in the operating room

1. Gguidelines to prevent wrong site and wrong procedure surgery.
a. The surgeon meets with the client in the preoperative area and uses undelible ink to
mark the operative site.
b. In the operating room, the nurse and surgeon ensure and reconfirm that the operative
site has been appropriately marked.
c. Just before starting the surgical procedure, a time out is conducted with all members
of the operative team present to identify the correct client and appropriate surgical site
again.
2. When the client arrives in the operating room, the operating room nurse will verify the
identification bracelet with the clients chart.
3. The clients record will be checked for completeness and reviewed for informed
consent forms, history and physical examination, and allergic reaction information.
4. The surgeons prescriptions will be verified and implemented.
5. The IV line may be initiated at this time (or in the preoperative area), if prescribed.
6. The anesthesia team will administer the prescribed anesthesia.
!Verification of the client and the surgical operative site is critical.
II. Postoperative Care
A. Description
1. Postoperative care is the management of a client after surgery and includes care given
during the immediate postoperative period as well as during the days following surgery.
2. The goal of postoperative care is to prevent complications, to promote healing of the
surgical incision, and to return the client to a healthy state.

3. Alterations in Human Functioning

GLOSSARY
apnea: temporary cessation of breathing
bronchophony: abnormal increase in clarity of transmitted voice sounds
bronchoscopy: direct examination of larynx, trachea, and bronchi using an endoscope.
cilia: short hairs that provide a constant whipping motion that serves to propel mucus
and foreign substances away from the lung toward the larynx
compliance: measure of the force required to expand or inflate the lungs
crackles: soft, high-pitched, discontinuous popping sounds during inspiration caused by
delayed reopening of the airways
diffusion: exchange of gas molecules from areas of high concentration to areas of low
concentration
dyspnea: labored breathing or shortness of breath
egophony: abnormal change in tone of voice that is heard when auscultating lungs
fremitus: vibrations of speech felt as tremors of chest wall during palpation
hemoptysis: expectoration of blood from the respiratory tract
hypoxemia: decrease in arterial oxygen tension in the blood
hypoxia: decrease in oxygen supply to the tissues and cells
obstructive sleep apnea: temporary absence of breathing during sleep secondary to
transient upper airway obstruction
orthopnea: inability to breathe easily except in an upright position
oxygen saturation: percentage of hemoglobin that is bound to oxygen
physiologic dead space: portion of the tracheobronchial tree that does not participate in
gas exchange
pulmonary perfusion: blood flow through the pulmonary vasculature
respiration: gas exchange between atmospheric air and the blood and between the
blood and cells of the body
rhonchi: low-pitched wheezing or snoring sound associated with partial airway
obstruction, heard on chest auscultation
stridor: harsh high-pitched sound heard on inspiration, usually without need of
stethoscope, secondary to upper airway obstruction
tachypnea: abnormally rapid respirations
tidal volume: volume of air inspired and expired with eachbreath during normal
breathing
ventilation: movement of air in and out of airways
wheezes: continuous musical sounds associated with airway
narrowing or partial obstruction
a. Disturbance in Oxygenation
CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION Ref. Nclex rn 7th ed..,
brunner and suddarths medical surgical nursing 12th ed.(unit 5 pg 486-666)
I. Anatomy and Physiology
The respiratory system is composed of the upper and lower respiratory tracts.
Together, the two tracts are responsible for ventilation (movement of air in and out of the
airways). The upper respiratory tract, known as the upper airway, warms and filters
inspired air so that the lower respiratory tract (the lungs) can accomplish gas exchange.
Gas exchange involves delivering oxygen to the tissues through the bloodstream and
expelling waste gases, such as carbon dioxide, during expiration. The respiratory system
works in concert with the cardiovascular system; the respiratory system is responsible
for ventilation and diffusion, and the cardiovascular system is responsible for
perfusion (Farquhar & Fantasia, 2005).

A. Primary functions of the respiratory system

1. Provides oxygen for metabolism in the tissues
2. Removes carbon dioxide, the waste product of metabolism

B. Secondary functions of the respiratory system

1. Facilitates sense of smell
2. Produces speech
3. Maintains acid-base balance
4. Maintains body water levels
5. Maintains heat balance

C. Upper respiratory airway pg1123

1. Nose: Humidifies, warms, and filters inspired air
2. Sinuses: Air-filled cavities within the hollow bones that surround the nasal passages
and provide resonance during speech. A prominent function of sinuses is to serve as a
resonating chamber in speech. The sinuses are a common site of infection.
3. Pharynx, Tonsils, and Adenoids
a. Passageway for the respiratory and digestive tracts located behind the oral and nasal
cavities
b. Divided into the nasopharynx, oropharynx, and laryngopharynx
4. Larynx
a. Located just below the pharynx at the root of the tongue; commonly called the voice
box
b. Contains 2 pairs of vocal cords, the false and true cords
c. The opening between the true vocal cords is the glottis. The glottis plays an important
role in coughing, which is the most fundamental defense mechanism of the lungs.
5. Epiglottis
a. Leaf-shaped elastic flap structure at the top of the larynx
b. Prevents food from entering the tracheobronchial tree by closing over the glottis during
swallowing

D. Lower respiratory airway

1. Trachea: Located in front of the esophagus; branches into the right and left mainstem
bronchi at the carina.
2. Mainstem bronchi
a. Begin at the carina
b. The right bronchus is slightly wider, shorter, and more vertical than the left
bronchus.
c. Divide into secondary or lobar bronchi that enter each of the 5 lobes of the lung.
d. The bronchi are lined with cilia, which propel mucus up and away from the lower
airway to the trachea, where it can be expectorated or swallowed.
3. Bronchioles***
a. Branch from the secondary bronchi and subdivide into the small terminal and
respiratory bronchioles.
b. Contain no cartilage and depend on the elastic recoil of the lung for patency.
c. The terminal bronchioles contain no cilia and do not participate in gas exchange.
4. Alveolar ducts and alveoli***
a. Acinus (plural, acini) is a term used to indicate all structures distal to the terminal
bronchiole.
b. Branch from the respiratory bronchioles
c. Alveolar sacs,which arise from the ducts, contain clusters of alveoli, which are the
basic units of gas exchange.
d. Type II alveolar cells in the walls of the alveoli secrete surfactant, a phospholipid
protein that reduces the surface tension in the alveoli; without surfactant, the alveoli
would collapse.
5. Lungs***
a. Located in the pleural cavity in the thorax
b. Extend from just above the clavicles to the diaphragm, the major muscle of inspiration
c. The right lung, which is larger than the left, is divided into 3 lobes: the upper, middle,
and lower lobes.
d. The left lung, which is narrower than the right lung to accommodate the heart, is
divided into 2 lobes.
e. The respiratory structures are innervated by the phrenic nerve, the vagus nerve, and
the thoracic nerves.
f. The parietal pleura lines the inside of the thoracic cavity, including the upper surface of
the diaphragm.
g. The visceral pleura covers the pulmonary surfaces.
h. A thin fluid layer, which is produced by the cells lining the pleura, lubricates the
visceral pleura and the parietal pleura, allowing them to glide smoothly and painlessly
during respiration.
i. Blood flows throughout the lungs via the pulmonary circulation system.
6. Accessory muscles of respiration include the scalene muscles, which elevate the first
2 ribs; the sternocleidomastoid muscles, which raise the sternum; and the trapezius
and pectoralis muscles, which fix the shoulders.
7. The respiratory process
a. The diaphragm descends into the abdominal cavity during inspiration, causing
negative pressure in the lungs.
b. The negative pressure draws air from the area of greater pressure, the atmosphere,
into the area of lesser pressure, the lungs.
c. In the lungs, air passes through the terminal bronchioles into the alveoli and diffuses
into surrounding capillaries, then travels to the rest of the body to oxygenate the body
tissues.
d. At the end of inspiration, the diaphragm and intercostal muscles relax and the lungs
recoil.
e. As the lungs recoil, pressure within the lungs becomes higher than atmospheric
pressure,causing the air, which now contains the cellular waste products carbon dioxide
and water, to move from the alveoli in the lungs to the
atmosphere.
f. Effective gas exchange depends on distribution of gas (ventilation) and blood
(perfusion) in all portions of the lungs.

Function of the Respiratory System

a. The primary function of the respiratory system is the exchange of gases between the
external environment and the blood.
b. The process of respiration involves ventilation, perfusion, diffusion, and nervous
system control.
c. Respiration refers to the mechanical and metabolic process involved with oxygen (O 2)
transport from atmospheric air into the blood and carbon dioxide (CO2) transport from the
blood back to the atmospheric air.

Process of Respiration: Ventilation is the passage of gases between the atmosphere

and the lungs. Ventilation phases include inspiration and expiration.
- Pulmonary ventilation is the total volume of gas exchange between the atmosphere
and the lungs.
- Alveolar ventilation is the volume of air that undergoes gas exchanges.
-Ventilation phases
*Inspiration The nerve impulses travel from the brain via the phrenic nerve to contract
the diaphragm, increasing the diameter of the thoracic cavity. Intrapleural pressure
increases, becoming more negative compared to atmospheric air. Air moves from an
area of higher pressure (atmosphere) to lower pressure (respiratory system). Hence, air
moves through structures of the respiratory system to alveoli and pulmonary capillaries
where gas exchange occurs.
*Expiration The diaphragm relaxes and pushes upward, decreasing the thoracic cavity
diameter. Intrapleural pressure remains negative compared to atmospheric air, but
becomes less negative than during inspiration. Intraplumonic pressure becomes higher
than atmospheric pressure, allowing passive air flow from the lungs through the
respiratory structures into the atmosphere. Smaller airways may collapse during
expiration, particularly in the supine position.

Respiratory System Pressure An atmospheric pressure of 760 mmHg serves as the

reference point for comparison to respiratory pressure.
a. Intrtapulmonary pressure, also called Intra alveolar pressure, equals atmospheric
pressure when the glottis is open and there is no air movement.
b. Intrapleural (or intrathoracic) pressure is the negative pressure produced by
opposite forces of elastic recoil between the lungs and chest wall. With the glottis open
and alveolar air in communication with the atmosphere, it measures negative compared
to intrapulmonary pressure. With the glottis closed, as in during coughing or with forced
expiration, it measures positive compared to atmospheric air. Normally, negative
intrapleural pressure prevents lung collapse. With forced expiration against a closed
glottis, intrapleural pressure becomes positive.

Respiratory Tissue Properties Respiratory vessels and airways are implanted in elastic
tissues which have the following properties:
a. Compliance is the elastic property related to elastic and collagen fibers. It changes
with the changes in respiratory system pressures and/or changes in lung fluid content.
Higer compliance occurs in a lung that is more easily distended. Lower compliance
occurs in a lung that is not easily distended
b. Elastic recoil is the ability of the lungs to return to their original shaped after air is
expelled. Recoil is present because of opposing forces created by the movements of the
lungs and chest wall.
c. Distensibility makes inflation more difficult through increased volume of lung fluid
content or consolidation of lung tissue.
d. Stiffness is the resistance of the lungs tostretch and to accommodate air volume.
Ncreasing lung stiffiness lowers compliance.

Airway Resistance refers to obstruction to airflow caused by condition of respiratory

system tissues (elastic recoil, compliance), changes in airway diameter
(bronchoconstriction, mucus obstruction)and / or pressure differences between
atmospheric air and intrapulmonary air.
Lung Volumes describe normal individual quantities of air exchanged during specific
times of the breathing cycle. Lung capacities describe combined quantities of lung
volumes during specific periods of the breathing cycle.

Tidal volume (VT): 5 10 Ml /kg (or 500 Ml total); air volume inspired and
expired during one breathing cycled.
Inspiratory reserve volume (IRV): 1,800 to 2,000mL; maximum air volume
inspired with forced inspiration ( i.e., movement of air from the atmosphere into the
respiratory system) following normal inspiration.
Expiratory reserve volume (ERV): 1,400 mL; air volume that can be expired with
force following normal expiration.
Residual volume (RV): 1,000 to 1,200 mL air volume remaining in the lungs
following forced expiration.
Total lung capacity (TLC): 5,000 to 6,000 mL; maximum capacity of the lungs.
TLC = IRV + VT + ERV + RV
Inspiratory capacity (IC): maximum air volume that can be inhaled following a
normal exhalation. IC = VT + IRV
Vital vapacity (VC): 4,500 to 4,800 mL; maximum air volume that can be exhaled
after a maximum inhalation. VC = IRV + VT + ERV
Functional residual capacity (FRC): 2,000 to 2,400 mL; residual air volume int
the lungs after a normal exhalation. FRC = ERV + RV.

Body position Gravity accountsfor greater ventilation in dependent areas of the lungs.
An upright, sitting or standing position allows for the path of least resistance into the more
compliant lung bases.

Perfusion is the quality of blood flow through the pulmonary capillary bed and to the
respiratory system structure. The respiratory system circulation includes the pulmonary
circulation and bronchial circulation.

Diffusion is the movement of gas from an area of higher pressure to lower pressure.O2
diffuses from the atmosphere into the alveoli, across the pulmonary capillary membrane
and into the pulmonary capillaries for circulation throughout the body. CO2 diffuses out of
the pulmonary capillaries across the capillary membrane and into the alveoli to be
exhaled. Diffusion continues until pressure differences become equal between the two
areas

Parameters in the process of Breathing

a. Suitable O2 and CO2 concentration in the inspired air. Ambient air has the greatest O2
concentration within the first 10,000 feet of the earths surface. O 2 concentration within
the first 10,000 feet of the earths surface. O2 concentration is 20.93% and exerts a parial
pressure of 158 mmHg.
Normal atmospheric or barometric pressure is 760 m mHg. Pressures less than that
ambient air is called negative or or subatmospheric pressure.
-Adequate ventilation or perfusion of the alveoli.
a. Iinspiration involves descent of the diaphragm, expansion of the thorax and
decrease in the pressure in the air passages and alveoli so that air flows into the
respiratory tree.
b. Expirations is a normally passive function wherein the diaphragm rises, the thorax
relaxes and pressure in the alveoli becomes greater than atmospheric pressure, resulting
in the expulsion of air.
b. Permeable alveolar capillary membrane.The partial pressure of a gas in a given
volume is the foce it exerts against the walls of the container.
c. Adequate pulmonary and systemic circulation
- This lies primarily with the heart and buffer mechanism which act reflexly to control
BP and to maintain circulation.
- In the systemic circulation, decreased Po2 or increased Pco2 produces vasodilation
which slows the blood flow and permits more time for gas excgange to take place.
- In the pulmonary circulation, decreased pO2 produces vasoconstriction of capillaries
and blood is shunted to capillaries in the better ventilated areas of the lungs.
d. Ability of the blood to transport O2 and CO2 between the lungs and tissues.
e. Ability of cells to utilize O2 and eliminate CO2.

f. Neural control of respiration

The respiratory center is a widely dispersed group of neurons located bilaterally in the
reticular substance of the medulla oblongata and pons, and in the chest wall, aorta and
carotid. It is divided into 3 major areas.
Medullary rhythmically area - controls the basic rhythm of respiration.
Apneustic area prolongs and deepens inspiration.
Pneumotaxic area inhibits respiration, Both apneustic and pneumotaxic areas are
located in the pons but not necessary for the maintenanceof the basic rhythm of
respiration.
Factors affecting rate and depth of respiration:
*Central chemoreceptors in the medulla. Increased Pco2 and or decreased blood pH
causes increased alveolar ventilation as compensatory mechanism to maintain Pco2 and
pH at normal levels.
*Peripheral chemoreceptors in the aortic arch and carotid bodies. Increased Pco2 and /
or decreased pH, and / or decreased partial pressure of arterial oxygen (Po2) causes
increased alveolar ventilation.
*Stretch receptors in the alveolar septa, bronchi, and bronchiolesprevent overdistention
of the lungs when they are inflated.
*Proprioceptors in muscles and tendons of moveable joints stimulate ventilation with
exercise to increase oxygen supply during increased oxygen demand.
*Baroreceptors in the aortic and carotid sinus alter respiration relative to changes in
arterial blood pressure . Elevated arterial blood pressure lowers respiration. Blood
pressures below 80 mmHg increase respiration.
*External environmental factors such as cold, physical stress, air pollution, smoking, and
pain alter respiration. Infection and fever increase respiration caused by increased
oxygen demand.

II. Assessment
*Nursing and Health History
The health history focuses on the physical and functional problems and the effects of
these problems on the patient, including the ability to carry out activities of daily living.
Several common symptoms related to the respiratory system are discussed in detail
below. If the patient is experiencing severe dyspnea, the nurse may need to modify or
abbreviate the questions asked and the timing of the health history to
avoid increasing the patients breathlessness and anxiety.
In addition to identifying the chief reason why the patient is seeking health care, the
nurse tries to determine when the health problem or symptom started, how long it lasted,
if it was relieved at any time, and how relief was obtained. The nurse obtains information
about precipitating factors, duration, severity, and associated factors or symptoms.

Common Symptoms
The major signs and symptoms of respiratory disease are dyspnea, cough, sputum
production, chest pain, wheezing, and hemoptysis. The nurse also assesses the
impact of signs and symptoms on the patients ability to perform activities of daily living
and to participate in usual work and family activities.
-Dyspnea (subjective feeling of difficult or labored breathing, breathlessness, shortness
of breath) is a symptoms common to many pulmonary and cardiac disorders, particularly
when there is decreased lung compliance or increased airway resistance. Dyspnea may
also be associated with neurologic or neuromuscular disorders (eg, myasthenia gravis,
Guillain-Barr syndrome, muscular dystrophy, postpolio syndrome) that affect respiratory
function. Dyspnea can also occur after physical exercise in people without disease (Davis
& Holliday, 2005; Porth & Matfin, 2009).
The circumstance that produces the dyspnea must be determined. Therefore, it is
important to ask the patient the following questions:
How much exertion triggers shortness of breath? Does it occur at rest? With exercise?
Running? Climbing stairs?
Is there an associated cough?
Is the shortness of breath related to other symptoms?
Was the onset of shortness of breath sudden or gradual?
At what time of day or night does the shortness of breath occur?
Is the shortness of breath worse when laying flat?
 Is the shortness of breath worse while walking? If so, when walking how far? How fast?
How severe is the shortness of breath? On a scale of 1 to 10, if 1 is breathing without
any effort and 10 is breathing that is as difficult as it could possibly be,
how hard is it to breathe?
It is especially important to assess the patients rating of the intensity of
breathlessness, the effort required to breathe, and the severity of the breathlessness or
dyspnea. Patients use a variety of terms and phrases to describe breathlessness, and
the nurse needs to clarify what terms are most familiar to the patient and what these
terms mean. Visual analogue or other scales can be used to assess changes in the
severity of dyspnea over time (Dorman, Byrne & Edwards, 2007; Porth & Matfin, 2009).
- Coughing is a reflex that protects the lungs from the accumulation of secretions or the
inhalation of foreign bodies. Its presence or absence can be a diagnostic clue because
some disorders cause coughing and others suppress it. The cough
reflex may be impaired by weakness or paralysis of the respiratory muscles, prolonged
inactivity, the presence of a nasogastric tube, or depressed function of the medullary
centers in the brain (eg, anesthesia, brain disorders) (Irwin,
Baumann, Bolser, et al., 2006; Porth & Matfin, 2009).
- Cough results from irritation of the mucous membranes anywhere in the respiratory
tract. The stimulus that produces a cough may arise from an infectious process or from
an airborne irritant, such as smoke, smog, dust, or a gas. A
persistent and frequent cough can be exhausting and cause pain. Cough may indicate
serious pulmonary disease or a variety of other problems as well, including cardiac
disease, medication reactions (eg, amiodarone [Cordarone], angiotensin - converting
enzyme [ACE] inhibitors), smoking, and gastroesophageal reflux disease (Irwin, et al.,
2006).
- To help determine the cause of the cough, the nurse describes the cough: dry, hacking,
brassy, wheezing, loose, or severe.
*A dry, irritative cough is characteristic of an upper respiratory tract infection of viral
origin, or it may be a side effect of ACE inhibitor therapy.
*An irritative, high-pitched cough can be caused by laryngotracheitis.
*A brassy cough is the result of a tracheal lesion.
*while a severe or changing cough may indicate bronchogenic carcinoma. Pleuritic chest
pain that accompanies coughing may indicate pleural or chest wall (musculoskeletal)
involvement.
- The nurse inquires about the onset and time of coughing. Coughing at night may
indicate the onset of left-sided heart failure or bronchial asthma. A cough in the morning
with sputum production may indicate bronchitis. A cough that worsens when the patient is
supine suggests postnasal drip (rhinosinusitis). Coughing after food intake may indicate
aspiration of material into the tracheobronchial tree. A
cough of recent onset is usually from an acute infection.
- Secretions are of different types:
a. Sputum is an aggregation of secretions from the tracheobronchial tree, mouth,
pharynx, (saliva), nose and sinuses.
b. Phlegm refers to secretions of the tracheobronchial tree and lungs. A healthy adult
may have a volume of 100mL/24 hrs.
Sputum Production A patient who coughs long enough almost invariably produces
sputum. Sputum production is the reaction of the lungs to any constantly recurring irritant.
It also may be associated with a nasal discharge. The nature of the sputum is often
indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or
rust colored) or a change in color of the sputum is a common sign of a bacterial
infection. Thin, mucoid sputum frequently results from viral bronchitis. A gradual
increase of sputum over time may occur with chronic bronchitis or bronchiectasis. Pink
tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often
welling up into the throat, may indicate pulmonary edema. Foul-smelling sputum and
bad breath point to the presence of a lung abscess, bronchiectasis, or an infection
caused by fusospirochetal or other anaerobic organisms.
Chest Pain or discomfort may be associated with pulmonary or cardiac disease. Chest
pain asccociated iwth pulmonary conditions may be sharp, stabbing, and intermittent, or
it may be dull, aching, and persistent. The pain is usually felt on the side where the
pathologic process is located, but it may be referred elsewhere for example to the neck,
back, or abdomen.
- Chest pain may occur with pneumonia, pulmonary embolism with lung infarction,
pleurisy, or as a late symptom of bronchogenic carcinoma. In carcinoma, the pain may be
dull and persistent because the cancer has invaded the chest wall, mediastinum, or
spine.
- Lung disease does not always cause thoracic pain because the lungs and the visceral
pleura lack sensory nerves and are insensitive to pain stimuli. However, the parietal
pleura has a rich supply of sensory nerves that are stimulated by inflammation and
stretching of the membrane. Pleuritic pain from irritation of the parietal pleura is sharp
and seems to catch on inspiration; patients often describe it as being like stabbing of a
knife. Patients are more comfortable when they lay on the affected side because this
splints the chest wall, limits expansion and contraction of the lung, and reduces the
friction between the injured or diseased
pleurae on that side. Pain associated with cough may be reduced manually by splinting
the rib cage.
- Factors to consider:
a. onset, location, and radiation
b. duration and character or quality
c. factors that precipitate that relieve pain
d. effect of the pain or the activiity.
Cyanosis is a condition wherein the Hgb is reduced to 5g / dl or more.
Normal: 15 g/dl or 6.95 vol.
- Types:
a. Peripheral cyanosis refers to the bluish discoloration of the extremities and the
nailbeds.
Causes:
- reduced oxyhemoglobin in the systematic capillaries.
 - peripheral vasoconstriction.
- strenuous exercise due to increased utilization of oxygen.
- reduced blood flow which is usually physiological in nature.
b. Central cyanosis refers to the bluish discoloration of the lips, tongue, face and
mucous membrane. It results from insufficient oxygen of hemoglobin. It is always
pathologic.
c. Differential cyanosis refers to the condition wherein the upper half of the body is pink
and the lower part is blue or vice versa. It indicates severe heart disease.
Factors that alter the appearance of cyanosis:
1. Pigmentation and Thickness: Cyanosis is a subjective assessment and is therefore not
a reliable sign of the state of oxygenation.
*very thin, unpigmented skin, especially where capillaries are superficial and numerous
(e.g., the tip of the tongue, the buccal mucosa, the cutaneous surfaces of the lips, the tips
of the finger and toes, the nailbeds, the earlobes and the tip of nose must be observed).
*Some areas are highly vascular (e.g., heels). In newborns, these afford easy
determinatin.
*The mucous membrane is an important site for detection of cyanosis in clients with
dark skin.
2. The type and amount of light used in making the assessment: Natural light is best;
fluorescent light is less desirable.
3. The absolute amount of reduced hemoglobin, rather than the relative amount of
oxyhemoglobin and reduced hemoglobin. A client who is anemic may not appear
cyanotic, even though marked degrees of desaturation exist. On the other hand, a client
with polycythemia may develop cyanosiswith a lesser degree of dessaturation than the
normal individual.
4. Observers perception: Factors to consider
*activity and environment (Does color become worse when crying?)
*duration
*distribution (Is it limited to the extremities?)
Voice quality Does the client speak in jerky sentences? Are the sounds weak? Is
hoarseness present?
Stridor is a harsh, high pitch sound usually associated with an obstruction in the upper
trachea or vocal cord. It is an emergency.

*Physical Assessment Assessment of the lower respiratory structures includes

inspection, palpation, percussion, and auscultation of the thorax.
- Inspection: deformities of the thorax, slope of the ribs, local log, rate and rhythm of
breathing.
*Chest Configuration Normally, the ration of the anteroposterior diameter to the lateral
diameter is 1:2. However, there are four main deformities of the chest associated with
respiratory disease that alter this relationship: barrel chest, funnel chest (pectus
excavatum), pigeon chest (pectus carinatum), and kyphoscoliosis.
-Barrel Chest. Occurs as a result of overinflation of the lungs. There is an increase in
the anteroposterior diameterof the thorax. In a patient with emphysema, the ribs are more
widely spaced and the intercostal spaces tend to bulge on expiration. The appearance of
the patient with advanced emphysema is thus quite characteristic and often allows the
observer to detect its presence easily, even from a distance.
-Funnel Chest (PECTUS EXCAVATUM). Occurs when there is a depression in the
lower portion of the sternum. This may compress the heart and great vessels, resulting in
murmurs. Funnel chest may occur with rickets or marfans syndrome.
-Pigeon Chest (PECTUS CARINATUM). A pigeon chest occurs as a result of
displacement of the sternum. There is an increase in the anteroposterior diameter. This
may occur with rickets, Marfans syndrome, or severe kyphoscoliosis.
-Kyphoscoliosis. Is characterized by elevation of the scapula and a corresponding S
shaped spine. This deformity limits lung expansion within the thorax. It may occur with
osteoporosis and other skeletal disorders that affect the thorax.
*BreathingPatterns and Respiratory Rates Observing the rate and depth of respiration
is a simple but important aspect of assessment. The normal adult who is resting
comfortably takes 12 to 18 breaths per minute. Except for occasional sighs, respirations
are regularin depth and rhythm. This normal pattern is described as eupnea. The rate
and depth of various patterns of respiration are presented.
RATES AND DEPTHS OF RESPIRATION
Types Description
Eupnea Normal, breathing at 12 18 breaths/minute.
Bradypnea Slower than normal rate (<10 breaths/min.), with
normal depth and regular rhythm.
Associated with increased intracranial pressure,
brain injury, and drug overdose.
Tachypnea Rapid, shallow breathing >24 breaths/min.
Associated with pneumonia, pulmonary edema,
metabolic acidosis, septicemia, severe pain, or
rib fracture.
Hypoventilation Shallow, irregular breathing.
Hyperpnea Increase depth of respirations.
Hyperventilation Increased rate and depth of breathing that
results in decreased PaCO2 level.
Inspiration and expiration are nearly equal in
duration.
Called Kussmauls respiration if associated with
diabetic ketoacidosis or renal origin.
Apnea Period of cessation of breathing; time duration
varies; apnea may occur briefly during other
breathing disorders, such as with sleep apnea;
life-threatening if sustained .
Cheyne - Stokes Regular cycle where the rate and depth of
breathing increase, then decrease until
apnea (usually about 20 seconds) occurs.
 Duration of apnea may vary and progressively
lengthen; therefore, it is timed and reported.
Associated with heart failure and damage to the
respiratory center (drug-induced, tumor, trauma).
Biots respiration Periods of normal breathing (34 breaths)
followed by a varying period of apnea (usually
1060 seconds).
Also called cluster breathing.
Associated with some nervous system disorders.

Certain patterns of respiration are characteristic of specific disease states. Respiratory

rhythms and their deviation from normal are important observations that the nurse reports
and documents.
Obstructive sleep apnea - Temporary pauses of breathing, or apnea, may be noted.
When apnea occur repeatedly during sleep, secondary to transient upper airway
blockage.
- Palpation: tenderness, masses, respiratory excursion, and fremitus (fremitus refers to
the palpable vibrations transmitted through the bronchopulmonary system to the chest
wall when the patients speaks).
*Respiratory Excursion is an estimation of thoracic expansion and may disclose
significant information about thoracic movement during breathing. The nurse assess the
patient for range and symmetry of excursion. For anterior assessment, the nurse places
the thumbs along the costal margin of the chest wall and instructs the patient to inhale
deeply. The nurse observes movement of the thumbs during inspiration and expiration.
This movement is normally symmetric.
Posterior assessment is performed by placing the thumbs adjacent to the spinal column
at the level of the tenth rib. The hands lightly grasp the lateral rib cage. Sliding the
thumbs medially about 2.5 cm (1 inch) raises a small skin fold between the thumbs. The
patient is in structured to take a full inspiration and to exhale fully. The nurse observes for
normal flattening of the skin fold and feels the symmetric movement of the thorax.
Decreased chest excursion may be caused by chronic fibrotic disease. Asymmetric
excursion may be due to splinting secondary to pleurisy, fractured ribs, trauma, or
unilateral bronchial obstruction.
*Tactile Fremitus Sound generated by the larynx travels distally along the bronchial tree
to set the chest wall in resonant motion. This is especially true of consonant sounds. The
detection of the resulting vibration on the chest wall
by touch is called tactile fremitus.
- Percussion: flatness (thigh), dullness (liver), resonance (normal lung), tymphanic
(gastric air, bubbles).
*Characteristics of Percussion Sounds
Sounds Relative Relative Relative Location Examples
Intensity Pitch Duration Example
Flatness Soft High Short Thigh Large pleural
 effusion
Dullness Medium Medium Medium Liver Lobar Pneumonia
Resonance Loud Low Long Normal lung Simple chronic
bronchitis
Hyperresonance Very loud Lower Longer None Emphysema,
normally pneumothorax
Tympany Loud *High -------- Gastric air Large
bubble or pneumothorax
puffed out
check.

- Auscultation:
a. Normal breath sounds
- Vesicular sounds are heard over most of the lung inspiration > expiration.
- Bronchovesicular sounds are heard near mainstem bronchi:
Inspiration = Expiration.
- Bronchial /Tubular sounds are heard over the trachea:
Expiration > Inspiration
Breath Sounds
Duration of Intensity of Pitch of Location where
Sounds Expiratory Expiratory Heard Normally
Sounds Sound
Vesicular Inspiratory sounds last Soft Relatively low Entire lung field
longer than expiratory except over the
ones. upper sternum and
between the
scapulae.
Broncho- Inspiratory and Intermediate Intermediate Often in the 1st and
vesicular expiratory sounds are 2nd Interspaces
about equal. anteriorly and
between the
scapulae (over the
main bronchus).
Bronchial Expiratory sounds last Loud Relatively Over the
longer than inspiratory high manubrium, if heard
ones. at all.
Tracheal Inspiratory and Very loud Relatively Over the trachea in
expiratory sounds are high the neck.
about equal.
*The thickness of the bars indicates intensity of breath sounds; the steeper their incline,
the higher the pitch of the sounds.
b. Abnormal Breath sounds
- Rales are discrete, non continuous sounds produced by moisture in the
tracheobronchial tree. They are heard best on inspiration.
- Ronchi and wheezes are continuous sounds produced by airflow across the passage
narrowed by secretions, mucosal swelling or tumor. They are more prominent on
expiration.
- Friction rubs are crackling, grating sounds originating in an inflamed pleura.
ABNORMAL (ADVENTITIOUS) BREATH SOUNDS
Breath Sounds Description Etiology
Crackles
Crackles in general Soft, high pitched, Secondary to fluid in the
discontinuous popping airway or alveoli or to
sounds that occur during delayed opening of
inspiration (while usually collapsed alveoli.
heard on inspiration, they Associated with heart
may also be heard on failure and pulmonary
expiration); may or may not fibrosis.
be cleard by coughing.
Coarse crackles Discontinuous popping Associated with
sounds heard in early obstructive pulmonary
inspiration; harsh, moist disease.
sound originating in the
large bronchi.
Fine crackles Discontinuous popping Associated with interstitial
sounds heard in late pneumonia, restrictive
inspiration; sounds like hair pulmonary disease (eg,
rubbing together; originates fibrosis); fine crackles in
in the alveoli. early inspiration are
associated with bronchitis
or pneumonia.
Wheezes
Wheezes in general Usually heard on expiration, Associated with bronchial
but may be heard on wall oscillation and
inspiration depending on charge in airway
the cause. diameter.
Associated with chronic
bronchitis or bronchiec-
tasis.
Sonorous wheezes Deep, low pitched Associated with
(rhonchi) rumbling sounds heard secretions or tumor.
primarily during expiration;
caused by air moving
through narrowed
 tracheobroncial passages.
Sibilant wheezes Continuous, musical, high Associated with
pitched, whistlelike sounds bronchospasm, asthma,
heard during inspiration and and buildup of secretions.
expiration caused by air
passing through narrowed
or partially obstructed
airways; may clear with
coughing.

Friction Rubs
Pleural friction rub Harsh, crackling sound, like Secondary to
two pieces of leather being inflammation and loss of
rubbed together (sound lubricating pleural fluid.
imitated by rubbing thumb
and finger together near the
ear).
Heard during inspiration
alone or during both
inspiration and expiration.
May subside when patient
holds breath; coughing will
not clear sound.
Best heard over the lower
lateral anterior surface of
the thorax.
Sound can be enhanced by
applying pressure to the
chest wall with the
diaphragm of the
stethoscope.

Diagnostic Tests
A. Risk factors for respiratory disorders.
* Allergies
*Chest injury
*Crowded living conditions
*Exposure to chemicals and environmental pollutants
*Family history of infectious disease
*Frequent respiratory illnesses
*Geographical residence and travel to foreign countries
*Smoking
*Surgery
*Use of chewing tobacco
*Viral syndromes

B. Chest x-ray films (radiographs)***

Description: Provides information regarding the anatomical location and appearance of
the lungs.
Preprocedure
a. Remove all jewelry and other metal objects from the chest area.
b. Assess the clients ability to inhale and hold his or her breath.
Postprocedure
a. Help the client to get dressed.

!Question women regarding pregnancy or the possibility of pregnancy before performing

radiography studies.

C. Sputum specimen***
Description: Specimen obtained by expectoration or tracheal suctioning to assist in the
identification of organisms or abnormal cells.

PRIORITY NURSING ACTIONS

Tracheal Suctioning
1. Assess the client and explain the procedure.
2. Assist the client to an upright position.
3. Perform hand hygiene and don protective garb.
4. Prepare suctioning equipment and turn on the suction.
5. Hyperoxygenate the client.
6. Insert the catheter without suction applied.
7. Once inserted, apply suction intermittently while rotating and withdrawing the
catheter.
8. Hyperoxygenate the client.
9. Listen to breath sounds.
10. Document the procedure, client response, and effectiveness.

Once the nurse has assessed the client, the nurse explains the procedure. The
client is assisted to a sitting upright position such as semi - Fowlers with the
head hyperextended (unless contraindicated). Hand hygiene is performed, and the
nurse applies appropriate protective garb, using aseptic technique. The nurse
prepares the needed suctioning equipment, turns on the suction device, and
sets it to the appropriate pressure. The nurse hyperoxygenates the client with
a resuscitation bag, increasing the oxygen flow rate, or asks the client to take
deep breaths. The nurse dons sterile gloves and lubricates the catheter with
sterile water or water soluble lubricant (per agency procedure), inserts the
catheter without the application of suction, and then applies intermittent
suction for up to 10 seconds while rotating and withdrawing the catheter.
After suctioning, the nurse hyperoxygenates the client and encourages the
client to take deep breaths if possible. During the procedure, the nurse monitors
the client for toleration of the procedure and the presence of complications.
Finally, the nurse listens to breath sounds to assist in determining effectiveness
and documents the procedure, the clients response, and effectiveness.

Reference
Ignatavicius, Workman (2016), p. 525. Perry, Potter, Ostendorf
(2014), pp. 631632, 637.

Preprocedure
a. Determine the specific purpose of collection and check institutional policy for the
appropriate method for collection.
b. Obtain an early morning sterile specimen by suctioning or expectoration after a
respiratory treatment if a treatment is prescribed.
c. Instruct the client to rinse the mouth water before collection.
d. Obtain 15 mL of sputum.
e.Instruct the client to take several deep breaths and then cough deeply to obtain
sputum.
f. Always collect the specimen before the client begins antibiotic therapy.***
Postprocedure
a. If a culture of sputum is prescribed, transport the specimen to the laboratory
immediately.***
b. Assist the client with mouth care.
!Ensure that an informed consent was obtained for any invasive procedure. Vital
signs are measured before the procedure and monitored postprocedure to detect signs of
complications.

D. Laryngoscope and Bronchoscope

Description: Direct visual examination of the larynx, trachea, and bronchi with a fiberoptic
bronchoscope.
Preprocedure
a. Maintain NPO (nothing by mouth) status as prescribed.
b. Assess the results of coagulation studies.
c.Remove dentures and eyeglasses.
d. Establish an intravenous (IV) access as necessary and administer medication for
sedation as prescribed.
e. Have emergency resuscitation equipment readily available.
Postprocedure
a. Maintain the client in a semi Fowlers position.
b. Assess for the return of the gag reflex.
c. Maintain NPO status until the gag reflex returns.***
d. Monitor for bloody sputum.
e. Monitor respiratory status, particularly if sedation has been administered.
f. Monitor for complications, such as bronchospasm or bronchial perforation, indicated by
facial or neck crepitus, dysrhytmias, hemorrhage, hypoxemia, and pneumothorax.
g. Notify the health care provider (HCP) if signs of complications occur.***

E. Endobrochial ultrasound(EBUS)
1. Tissue samples are obtained from central lung masses and lymph nodes, using a
bronchoscope with the help of ultrasound guidance.
2. Tissue samples are used for diagnosing and staging lung cancer, detecting infections,
and identifying inflammatory diseases that affect the lungs, such as sarcoidosis.
3. Postprocedure, the client is monitored for signs of bleeding and respiratory distress.

F. Pulmonary Angiography***
Description
a. A flouroscopic procedure in which a catheter is inserted through the antecubital or
femoral vein into the pulmonary artery or 1 of its branches.
b. Involves an injection of iodines or radiopaque contrast material.
Preprocedure
a. Obtain informed consent.
b. Assess for allergies to iodine, seafood, or other radiopaque dyes.
c. Maintain NPO status of the client for 8 hours before the procedure.
d. Monitor Vital Signs
e. Assess results of coagulation studies.
f. Establish an intravenous access.
g. Administer sedation as prescribed.
h. Instruct the client to lie still during the procedure.
i. Instruct the client that he or she may feel an urge to cough, flushing, nausea, or a
salty taste following injection of the dye.***
j. Have emergency resuscitation equipment available.
Postprocedure
a. Monitor Vital Signs.
b. Avoid taking blood pressurres for 24 hours in the extremity used for the injection.
c. Monitor peripheral neurovascualr status of the affected extemity.
d. Assess insertion site for bleeding.
e. Monitor for delayed reaction to the dye.

G. Thoracentesis
Description: Removal of fluid or air from the pleural space via transthoracic aspiration.
Preprocedure
a. Obtain Informed Consent.
b. Obtain Vital Signs.
c. Prepare the client for ultrasound or chest radiograph, if prescribed, before procedure.
d. Assess results of coagulation studies.
e. Note that the client is positioned sitting upright, with the arms and shoulders supported
by a table at the bedside during the procedure.
f. If the client cannot sit up, the client is placed lying in bed toward the unaffected side,
with the head of the bed elevated.***
g. Instruct the client not to cough, breath deeply, or move during the procedure.
Postprocedure
a. Monitor Vital Signs.
b. Monitor respiratory status.
c. Apply a pressure dressing, and assess the puncture site for bleeding and crepitus.
d.Monitor for signs of pneumothorax, air embolism, and pulmonary edema.***

H. Pulmonary function tests***

Description: Test used to evaluate lung mechanics, gas exchange, and acid base
disturbace through spirometric measurements, lung volumes, and arterial blood gas
levels.
Preprocedure
a. Determine whether an analgesic that may depress the respiratory function is being
administered.
b. Consult with the health care provide (HCP) regarding withholding bronchodilators
before testing.
c. Instruct the client to void before procedure and to wear loose clothing.
d. Remove dentures.
e. Instruct the client to refrain from smoking or eating heavy meal for 4 to 6 hours before
the test.
Postprocedure: Client may resume a normal diet and any bronchodilators and respiratory
treatments that were withheld before the procedure.

I. Lung Biopsy
Description:
a. A transbrochial biopsy and a transbrochial needle aspiration may be performed to
obtain tissue for analysis by culture or cytological examination.
b. An open lung biopsy is performed in the operating room.
Preprocedure
a. Obtain informed consent.
b. Maintain NPO status of the client before the procedure.
c. Inform the client that a local anesthetic will be used for a needle biopsy but a sensation
of pressure during needle insertion and aspiration may be felt.
d. Administer analgesics and sedatives as prescribed.
Postprocedure***
a. Monitor Vital Signs.
b. Apply a dressing to the biopsy site and monitor for drainage or bleeding.
c. Monitor for signs of respiratory distress, and notify the health care provider (HCP) if
they occur.
d. Monitor for signs of Pneumothorax and air emboli, and notify the health care provider if
they occur.
e. Prepare the client for the chest radioprahy if prescribed.

J. Spiral (helical) computed tomography (CT) scan***

1. Frequenlty used test to diagnose pulmonary embolism.
2. IV injection of contrast medium is used; if the client cannot have a contrast medium, a
ventilation perfusion (V/Q) scan will be done.
3. The scanner rotates around the body, allowing for a 3 dimentional picture of all
regions of the lungs.

K. Ventilation perfusion (V/Q) lung scan***

Description
a. The perfusion scan evaluates blood flow to the lungs.
b. The ventilation scan determines the patency of the pulmonary airways and detects
abnormalities in ventilation.
c. A radionuclide may be injected for the procedure.
Preprocedure
a. Obtain informed consent.
b. Assess the client for allergies to dye, iodines, or seafood.
c. Remove jewelry around the chest area.
d. Review breathing methods that may be required during testing.
e. Establish an Intravenous Access.
f. Administer sedation as prescribed.
g. Have emergency resuscitation equipment available.
Postprocedure.
a. Monitor the client for the reaction to the radionuclide.
b. Instruct the client that the radionuclide clears from the body in about 8 hours.***

L. Skin Tests: A skin test uses an intradermal injection to help diagnose various
infectious diseases.
Skin Test Procedure
1. Determine hypersensitivity or previous reactions to skin test.
2. Use a skin site that is free of excessive body hair, dermatitis, and blemishes.
3. Apply the injection at the upper third of the inner surface of the left arm.
4. Circle and mark the injection test site.
5. Document the date, time and test site.
6. Advise the client not to scratch the test site to prevent infection and possible
abscess formation.
7. Instruct the client to avoid washing the test site.
8. Interpret the reaction at the injection site 24 to 72 hours after administration of
the test antigen.
9. Assess the test site for the amount of induration (hard swelling) in millimeters
and for the presence of erythema and vesiculation (small blister like elevations).

M. Arterial blood gases (ABGs)***

Description:
1. Measurement of the dissolved oxygen and carbon dioxide in the arterial blood helps to
indicate the acid - base state and how well oxygen is being carried to the body.
2. Preprocedure and postprocedure care, normal results, and analysis of results:
Collection of an ABG specimen
1. Obtain vital signs.
2. Determine whether the client has an arterial line in place (allows for arterial blood
sampling without further puncture to the client).

Normal Arterial Blood Gas Values

Normal Range
Laboratory Test Conventional Units SI Units
pH 7.35 7.45 7.35 7.45
PaCO2 35 45 mm Hg 35 45 mm Hg
Bicarbonate (HCO3 ) 21 28 mEq/L
A 21 28 mmol/L
PaO2 80 100 mm Hg 80 100 mm Hg

3. Perform the Allens test to determine the presence of collateral circulation

(Priority Nursing Actions).
PRIORITY NURSING ACTIONS
Performing the Allens Test Before Radial Artery Puncture.
1. Explain the procedure to the client.
2. Apply pressure over the ulnar and radial arteries simultaneously.
3. Ask the client to open and close the hand repeatedly.
4. Release pressure from the ulnar artery while compressing the radial artery.
5. Assess the color of the extremity distal to the pressure point.
6. Document the findings.

The Allens test is performed before obtaining an arterial blood specimen from the
radial artery to determine the presence of collateral circulation and the adequacy
of the ulnar artery. *Failure to determine the presence of adequate collateral
circulation could result in severe ischemic injury to the hand if damage to
the radial artery occurs with arterial puncture. The nurse first would explain the
procedure to the client. To perform the test, the nurse applies direct pressure
over the clients ulnar and radial arteries simultaneously. While applying pressure,
the nurse asks the client to open and close the hand repeatedly; the hand should
blanch. The nurse then releases pressure from the ulnar artery while compressing
the radial artery and assesses the color of the extremity distal to the pressure
point. *If pinkness fails to return within 6 to 7 seconds, the ulnar artery is
insufficient, indicating that the radial artery should not be used for obtaining a
blood specimen. Finally, the nurse documents the findings. Other sites, such as
the brachial or femoral artery, can be used if the radial artery is not deemed
adequate.
Reference: Perry, Potter, Ostendorf (2014), pp. 10911092.

4. Assess factors that may affect the accuracy of the results, such as changes in the O2
settings, suctioning within the past 20 minutes, and clients activities.
5. Provide emotional support to the client.
6. Assist with the specimen draw: prepare a heparinized syringe (if not already
prepackaged).
7. Apply pressure immediately to the puncture site following the blood draw; maintain
pressure for 5 minutes or for 10minutes if the client is taking an anticoagulant.
8. Appropriately label the specimen and transport it on ice to the laboratory.
9. On the laboratory form, record the clients temperature and the type of supplemental
O2 that the client is receiving.
!Avoid suctioning the client before drawing an ABG sample because the suctioning
procedure will deplete the clients oxygen, resulting in inaacurate ABG results.

N. Pulse oximetry***
Description
1. Pulse oximetry is a noninvasive test that registers the oxygen saturation of the clients
hemoglobin.
2. The capillary oxygen saturation (SaO2), is recorded as a percentage.
3. The normal value is 95% to 100%.***
4. After a hypoxic client uses up the readily available oxygen (measured as the arterial
oxygen pressure, PaO2 , on arterial blood gas {ABG} testing), the reserve oxygen, that
oxygen attached to the hemoglobin (SaO2), is drawn on to provide oxygen to the tissues.
5. A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs occur.
6. If pulse oximetry readings are below normal, instruct the client in deep breathing
technique and recheck the pulse oximetry.
Procedure
1. A sensor is placed on the clients finger, toe, nose, earlobe, or forehead to measure
oxygen saturation, which then is displayed on a monitor.
2. Maintain the transducer at heart level.
3. Do not select an extremity with an impediment to blood flow.
! A usual pulse oximetry reading is between 95% and 100%. A pulse oximetry reading
lower than 90% necessitates HCP notification; values below 90% are acceptable only in
certain chronic conditions. Agency procedures and HCP prescriptions are followed
regarding actions to take for specific readings.
O. D dimer
1. A blood test that measures clot formation and lysis that results from the degradation of
fibrin.
2. Helps to diagnose (a positive test result) the presence of thrombus in conditions such
as deep vein thrombosis, pulmonary embolism, or stroke; it is also used to diagnose
disseminated intravascular coagulation (DIC) and to monitor the effectiveness of
treatment.
3.The normal D dimer level is less than or equal to 250ng/mL (250 mcg/L) D dimer
units (DDU); normal fibrinogen is 200 to 400 mg/dL (2 to 4 g/L).

III. Respiratory Treatments

A. Breathing retraining.
BOX 54 3 Client Education: Breathing Retraining and
Huff Cough
Breathing Retraining
*This includes exercises to decrease use of the
accessory muscles of breathing, to decrease fatigue,
and to promote carbon dioxide (CO2) elimination.
*The main types of exercises include pursed lip
breathing and diaphragmatic breathing.
*The client should inhale slowly through the nose.
*The client should place a hand over the abdomen
while inhaling; The abdomen should expand with
inhalation and contract during exhalation.
*The client should exhale 3 times longer than
inhalation by blowing through pursed lips.

Huff Coughing
*This is an effective coughing technique that
conserves energy, reduces fatigue, and facilitates
mobilization of secretions.
*The client should take 3 or 4 deep breaths using
pursed lip and diaphragmatic breathing. Leaning
slightly forward, the client should cough 3 or 4 times
during exhalation.
*The client may need to splint the thorax or abdomen
to achieve a maximum cough.

B. Chest physiotherapy (CPT)

Description: Percusssion, vibration, and postural drainage techniques are performed over
the thorax to loosen secretions in the affected area of the lungs and move them into more
cenral airways.
Interventions
Chest Physiotherapy Procedure
a. Perform chest physiotherapy (CPT) in the morning on arising, 1 hour before meals, or
2 to 3 hours after meals.
b. Stop chest physiotherapy (CPT) if pain occurs.
c. If the client is receiving a tube feeding, stop the feeding and aspirate for residual
before beginning chest physiotherapy.
d. Place a layer of material (gown or pajamas) between the hands or percussion device
and the clients skin.
e. Position the client for postural drainage based on assessment.
f. Percuss the area for 1 to 2 minutes.
g. Vibrate the same area while the client exhales 4 or 5 deep breaths.
h. Monitor for respiratory tolerance to the procedure.
i. Stop the procedure if cyanosis or exhaustion occurs.
j. Maintain the position for 5 to 20 minutes after the procedure.
k. Repeat in all necessary positions until the client no longer expectorates mucus.
l. Dispose of sputum properly.
m. Provide mouth care after the procedure.
Contraindications
a. Unstable vital signs
b. Increased intracranial pressure
c. Bronchospasm
d. History of pathological fractures
e. Rib fractures
f. Chest incisions

C. Incentive spirometry
Client Instruction for Incentive Spirometry
1. Instruct the client to assume a sitting or upright position.
2. Instruct the client to place the mouth tightly around the mouthpiece of the device.
3. Instruct the client to inhale slowly to raise and maintain the flow rate indicator between
the 600 and 900 marks.
4. Instruct the client to hold the breath for 5 seconds and then to exhale through pursed
lips.
5. Instruct the client to repeat this process 10 times every hour while awake.

IV. Oxygen
A. Supplemental oxygen delivery systems.
Device Oxygen Delivered Nursing Considerations
Nasal cannula (nasal 1 6 L/min for oxygen Easily tolerated
prongs) concentration (FiO2) of Can dislodge easily.
24% (1 L/min) to 44% (at Doesnt get in the way of
6 L/min). eating or talking.
 Effective oxygen concen-
tration can be delivered.
Allows the client to breath
through the nose or
mouth.
Ensure that prongs are in
the nares with openings
facing the client
Assess nasal mucosa for
irritation from drying effect
of higher flow rates.
Assess skin integrity, as
tubing can irritate skin.
Add humidification as
prescribed and check
water levels.

Simple face mask 5 8 L/min oxygen flow Interferes with eating and
for FiO2 of 40% - 60% talking.
Minimum flow of 5L/min Can be warm and
needed to flush CO2 from confining.
mask. Ensure that mask fits
securely over nose and
mouth.
Remove saliva and
mucus from the mask.
Provide skin care to area
covered by mask.
Provide emotional
support to decrease
anxiet in the client who
feels claustrophobic.
Monitor for risk of
aapiration from inability of
client to clear mouth (i.e.,
if vomiting occurs)

Venturi mask (Ventimask) 4 10 L/min oxygen flow Keep the air entrapment
for FiO2 of 24% - 55% port for the adapter open
Delivers exact desired and uncovered to ensure
selected concentrations adequate oxygen
of O2. delivery.
Keep mask snug on the
face and ensure tubing is

Partial rebreather mask 6 -15 L/min oxyge flow for
(mask with reservoir bag) FiO2 of 70% - 90%.
Nonrebreather mask FiO2 of 60%-100% at a
rate of flow that maintains
the bag two-thirds full.
free of kinks because the
FiO2 is altered if kinking
occurs or if the mask fits
poorly.
Assess nasal mucosa for
irritation; humidity or
aerosol can be added to
the system as needed.
The client rebreathes
one-third of the exhaled
tidal volume, which is
high in oxygen, thus
providing a high FiO2.
Adjust flow rate to keep
the reservoir bag two-
thirds full during
inspiration.
Keep mask snug on face.
Make sure the reservoir
bag does not twist or kink.
Deflation of the bag
results in decreased
oxygen delivered
and rebreathing of
exhaled air.
Adjust flow rate to keep
the reservoir bag inflated.
Keep mask snug on the
face.
Remove mucus and
saliva from the mask.
Provide emotional
support to decrease
anxiety in the client
who feels claustrophobic.
Ensure that the valves
and flaps are intact and
functional during each
breath (valves should
open during expiration
and close during
inhalation).
 Make sure the reservoir
bag does not twist or kink
or that the oxygen source
does not disconnect;
otherwise, the client will
suffocate.

Tracheostomy collar and The tracheostomy collar
T- bar or T-piece (face can be used to deliver
tent; face shield) the desired amount of
oxygen to a client
with a tracheostomy.
Aspecial adaptor (T-bar
or T-piece) can be used
to deliver any desired
FiO2 to client with trache-
ostomy, laryngectomy, or
endotracheal tube.
The face tent provides 8-
12 L/min and the FiO2
varies due to environ-
mental loss.
Ensure that aerosol mist
escapes from the vents of
the delivery system
during inspiration and
expiration.
Empty condensation from
the tubing to prevent the
client from being lavaged
with water and to promote
an adequate oxygen flow
rate (remove and clean
the tubing at least every 4
hr).
Keep the exhalation port
in the T-piece open and
uncovered (if the port is
occluded, the client can
suffocate).
Position the T-piece so
that it does not pull on the
tracheostomy or
endotracheal tube and
cause erosion of the skin
at the tracheostomy
insertion site.

1. Nasal cannula for low flow: Used for the client with chronic airflow limitation and for
longterm oxygen use.
2. Nasal high flow (NHF) respiratory therapy: Used for hypoxemic clients in mild to
moderate respiratory distress.
3. Simple face mask: Used for short term oxygen therapy or to deliver oxygen in an
emergency.
4. Venturi mask: Used for clients at risk for or experiencing acute respiratory failure
5. Partial rebreather mask: Useful when the oxygen concentration needs to be raised; not
usually prescribed for a client with chronic obstructive pulmonary disease (COPD).
6. Nonrebreather mask: Most frequently used for the client with a deteriorating respiratory
status who might require intubation.
7. Tracheostomy collar and T bar or T piece: Tracheostomy collar is used to deliver
high humidity and the desired oxygen to the client with a tracheostomy; the T bar or T
piece is used to deliver the desired FiO2 to the client with a tracheostomy, laryngectomy,
or endotracheal tube.
8. Face tent: Used instead of a tight fitting mask for the client who has facial trauma or
burns.

B. Continuous positive airway pressure (CPAP) and bilevel positive airway pressure
(BiPAP).
1. CPAP maintains a set positive airway pressure during inspiration and expiration;
beneficial in clients who have obstructive sleep apnea or acute exacerbations of COPD.
2. BiPAP provides positive airway pressure during inspiration and ceases airway support
during expiration; there is only enough pressure provided during expiration to keep the
airways open; usually used if CPAP is ineffective.
3. Both CPAP and BiPAP improve oxygenation through airway support.

C. General interventions
1.Assess color, pulse oximetry reading, and vital signs before and during treatment.
2. Place an Oxygen in Use sign at the clients bedside.
3. Assess for the presence of chronic lung problems.
4. Humidify the oxygen if indicated.
!A client who is hypoxemic and has chronic hypercapnia requires low levels of oxygen
delivery at 1 to 2 L/minute because a low arterial oxygen level is the clients primary drive
for breathing.

V. Mechanical Ventilation
Types
1. Pressure cycled ventilator: The ventilator pushes air into the lungs until a specific
airway presure is reached; it is used for short periods, as in the postanesthesia care unit.
3. Time cycled ventilator: The ventilator pushes air int the lungs until a preset time has
elapsed; it is used for the pediatric or neonatal client.
3. Volume cycled ventilator
a. The ventilator pushes air into the lungs until a preset volume is delivered.
b. A constant tidal volume is delivered regardless of the changing compliance of the
lungs and chest wall or the airway resistance in the client or ventilator.
4. Microprocessor ventilator
a. A computer or microprocessor is built into the ventilator to allow continuous monitoring
of ventilatory functions, alarms, and client parameters.
b. This type of ventilator is more responsive to clients who have severe lung disease or
require prolonged weaning.
Mode of Ventilation
1. Noninvasive positive pressure ventilation or BiPAP.
a. Ventilatory support given without using an invasive artificial airway (endotracheal tube
or tracheostomy tube); orofacial masks and nasal masks are used instead.
b. An inspiratory positive airway pressure (IPAP) and an expiratory positive airway
pressure (EPAP) are set on a large ventilator or a small flow generator ventilator with a
desired pressure support and positive end-expiratory pressure
(PEEP) level. This allows more air to move into and out of the lungs without the
normal muscular activity needed to do so.
c. Can be used in certain situations of COPD distress, heart failure, asthma, pulmonary
edema, and hypercapnic respiratory failure
!A resuscitation bag should be available at the bedside for all clients receiving
mechanical ventilation.
2. Controlled
a. The client receives a set tidal volume at a set rate.
b. Used for clients who cannot initiate respiratory effort.
c. Least used mode; if the client attempts to initiate a breath, the ventilator locks out the
clients inspiratory effort.
3. Assist-control
a. Most commonly used mode***
b. Tidal volume and ventilatory rate are preset on the ventilator.
c. The ventilator takes over the work of breathing for the client.
d. The ventilator is programmed to respond to the clients inspiratory effort if the client
does initiate a breath.
e. The ventilator delivers the preset tidal volume when the client initiates a breath
while allowing the client to control the rate of breathing.
f. If the clients spontaneous ventilatory rate increases, the ventilator continues to deliver
a preset tidal volume with each breath,which may cause hyperventilation and respiratory
alkalosis.***
4. Synchronized intermittent mandatory ventilation (SIMV)
a. Similar to assist-control ventilation in that the tidal volume and ventilatory rate are
preset on the ventilator
b. Allows the client to breathe spontaneously at her or his own rate and tidal volume
between the ventilator breaths
c. Can be used as a primary ventilatorymode or as a weaning mode
d. When SIMV is used as a weaning mode, the number of SIMV breaths is decreased
gradually, and the client gradually resumes spontaneous breathing.

Ventilator controls and settings and descriptions.

Controls and Descriptions

Settings
Tidal volume The volume of air that the client receives with each breath.
Rate The number of ventilator breaths delivered per minute
Sighs The volumes of air that are 1.5 to 2 times the set tidal
volume, delivered 6 to 10 times per hour; may be used to
prevent atelectasis.
Fraction of The oxygen concentration delievered to the client;
inspired determined by the clients codition and ABG levels.
oxygen (FiO2)
Peak airway The pressure needed by the ventilator to deliver a set tidal
inspiratory volume at a given compliance.
pressure Monitoring peak airway inspiratory pressure reflects
changes in compliance of the lungs and resistance in the
ventilator or client.
Continuous The application of positive airwaypressure throughout the
positive airway entire respiratory cycle for spontaneously breathing clients.
pressure Keeps the alveoli open during inspiration and prevents
alveolar collapse; used primarily as a weaning
Modality.
No ventilator breaths are delivered, but the ventilator
delivers oxygen and provides monitoring and an alarm
system; the respiratory pattern is determined by the
clients efforts.
Positive end- Positive pressure is exerted during the expiratory phase of
expiratory ventilation, which improves oxygenation by enhancing gas
pressure exchange and preventing atelectasis.
(PEEP) The need for PEEP indicates a severe gas exchange
disturbance
Higher levels of PEEP (more than 15 cm H2O) increase the
chance of complications, such as barotrauma tension
pneumothorax
Pressure The application of positive pressure on inspiration that
support eases the workload of breathing.
May be used in combination with PEEP as a weaning
method.
As the weaning process continues, the amount of pressure
applied to inspiration is gradually decreased.

Interventions

!For a client receiving mechanical ventilation, always assess the client first and then
assess the ventilator.

1.Assess vital signs, lung sounds, respiratory status, and breathing patterns (the client
will never breathe at a rate lower than the rate set on the ventilator).
2. Monitor skin color, particularly in the lips and nailbeds.
3. Monitor the chest for bilateral expansion.
4.Obtain pulse oximetry readings.
5. Monitor ABG results.
6. Assess the need for suctioning and observe the type, color, and amount of secretions.
7. Assess ventilator settings.
8. Assess the level of water in the humidifier and the temperature of the humidification
system because extremes in temperature can damage the mucosa in the airway.
9. Ensure that the alarms are set.
10. If a cause for an alarm cannot be determined, ventilate the client manually with a
resuscitation bag until the problem is corrected.
11. Empty the ventilator tubing when moisture collects.
12. Turn the client at least every 2 hours or get the client out of bed as prescribed to
prevent complications of immobility.
13. Have resuscitation equipment available at the bedside.

Causes of Ventilator alarms

High-Pressure Alarm
Increased secretions are in the airway.
Wheezing or bronchospasm is causing decreased airway size.
The endotracheal tube is displaced.
The ventilator tube is obstructed because of water or a kink in the tubing.
Client coughs, gags, or bites on the oral endotracheal tube.
Client is anxious or fights the ventilator.

Low-Pressure Alarm
Disconnection or leak in the ventilator or in the clients airway cuff occurs.
The client stops spontaneous breathing.

Alarm safety and alarm fatigue

1. It is the responsibility of the nurse to be alert to the sound of an alarm because this
signals a client problem.
2. The nurse needs to respond promptly to an alarm and immediately assess the client.
3. According to The Joint Commission (TJC), the most common contributing factor
related to alarm-related sentinel events is alarm fatigue, which results when the
numerous alarms and the resulting noise tends to desensitize the nursing staff and cause
them to ignore alarms or even disable them.
4. Some recommendations of TJC include establishing alarm safety as a facility policy,
identifying default alarm settings, identifying the most important alarms to manage,
establishing policies and procedures for managing alarms, and staff education.
!Never set ventilator alarm controls to the off position.

Complications
1. Hypotension caused by the application of positive pressure, which increases
intrathoracic pressure and inhibits blood return to the heart.
2. Respiratory complications such as pneumothorax or subcutaneous emphysema as a
result of positive pressure.
3. Gastrointestinal alterations such as stress ulcers
4. Malnutrition if nutrition is not maintained
5. Infections
6. Muscular deconditioning
7. Ventilator dependence or inability to wean

Weaning: Process of going from ventilator dependence to spontaneous breathing.

1. SIMV
a. The client breathes between the preset breaths per minute rate of the ventilator.
b. The SIMVrate is decreased gradually until the client is breathing on his or her own
without the use of the ventilator.
2. T-piece
a. The client is taken off the ventilator and the ventilator is replaced with a T-piece or
CPAP, which delivers humidified oxygen.
b. The client is taken off the ventilator for short periods initially and allowed to breathe
spontaneously.
c. Weaning progresses as the client is able to tolerate progressively longer periods off
the ventilator.
3. Pressure support
a. Pressure support is a predetermined pressure set on the ventilator to assist the client
in respiratory effort.
b. As weaning continues, the amount of pressure is decreased gradually.
c. With pressure support, pressure may be maintained while the preset breaths per
minute of the ventilator are decreased gradually.

VI. Chest Injuries

Rib Fracture
Description
a. Results from direct blunt chest trauma and causes a potential for intrathoracic
injury, such as pneumothorax or pulmonary contusion
b. Pain with movement and chest splinting results in impaired ventilation and
inadequate clearance of secretions.
Assessment
a. Pain and tenderness at the injury site that increases with inspiration.***
b. Shallow respirations.
c. Client splints chest.
d. Fractures noted on chest x-ray.
Interventions
a. Note that the ribs usually reunite spontaneously.
b. Place the client in a Fowlers position.
c. Administer pain medication as prescribed to maintain adequate ventilatory status.
d. Monitor for increased respiratory distress.
 e. Instruct the client to self-splint with the hands, arms, or a pillow.
f. Prepare the client for an intercostal nerve block as prescribed if the pain is severe.

Flail chest
Description
a. Occurs from blunt chest trauma associated with accidents, which may result in
hemothorax and rib fractures.
b. The loose segment of the chest wall becomes paradoxical to the expansion and
contraction of the rest of the chest wall.
Assessment
a. Paradoxical respirations (inward movement of a segment of the thorax during
inspiration with outward movement during expiration)
b. Severe pain in the chest
c. Dyspnea
d. Cyanosis
e. Tachycardia
f. Hypotension
g. Tachypnea, shallow respirations
h. Diminished breath sounds
Interventions
a. Maintain the client in a Fowlers position.
b. Administer oxygen as prescribed.
c. Monitor for increased respiratory distress.
d. Encourage coughing and deep breathing.
e. Administer pain medication as prescribed.
f. Maintain bed rest and limit activity to reduce oxygen demands.
g. Prepare for intubation with mechanical ventilation, with PEEP for severe flail chest
associated with respiratory failure and shock.

Pulmonary contusion
Description
a. Characterized by interstitial hemorrhage associated with intraalveolar hemorrhage,
resulting in decreased pulmonary compliance.
b. The major complication is acute respiratory distress syndrome.
Assessment
a. Dyspnea
b. Restlessness
c. Increased bronchial secretions
d. Hypoxemia
e. Hemoptysis
f. Decreased breath sounds
g. Crackles and wheezes
Interventions
a. Maintain a patent airway and adequate ventilation.
b. Place the client in a Fowlers position.
c. Administer oxygen as prescribed.
d. Monitor for increased respiratory distress.
e. Maintain bed rest and limit activity to reduce oxygen demands.
f. Prepare for mechanical ventilation with PEEP if required.

Pneumothorax
Description
a. Accumulation of atmospheric air in the pleural space, which results in a rise in
intrathoracic pressure and reduced vital capacity
b. The loss of negative intrapleural pressure results in collapse of the lung.***
c. A spontaneous pneumothorax occurs with the rupture of a pulmonary bleb.
d. An open pneumothorax occurs when an opening through the chest wall allows the
entrance of positive atmospheric air pressure into the pleural space.
e. A tension pneumothorax occurs from a blunt chest injury or from mechanical
ventilation with PEEP when a buildup of positive pressure occurs in the pleural space.
f. Diagnosis of pneumothorax is made by chest x-ray.
Assessment
a. Absent breath sounds on affected side
b. Cyanosis
c. Decreased chest expansion unilaterally
d. Dyspnea
e. Hypotension
f. Sharp chest pain
g. Subcutaneous emphysema as evidenced by crepitus on palpation
h. Sucking sound with open chest wound
i. Tachycardia
j. Tachypnea
k. Tracheal deviation to the unaffected side with tension pneumothorax
Interventions
a. Apply a nonporous dressing over an open chest wound.
b. Administer oxygen as prescribed.
c. Place the client in a Fowlers position.
d. Prepare for chest tube placement, which will remain in place until the lung has
expanded fully.
e. Monitor the chest tube drainage system.
f. Monitor for subcutaneous emphysema.
!Clients with a respiratory disorder should be positioned with the head of the bed
elevated.

VII. Acute Respiratory Failure

Description
1. Occurs when insufficient oxygen is transported to the blood or inadequate carbon
dioxide is removed from the lungs and the clients compensatory mechanisms fail.
2. Causes include a mechanical abnormality of the lungs or chest wall, a defect in the
respiratory control center in the brain, or an impairment in the function of the respiratory
muscles.
3. In oxygenation failure, or hypoxemic respiratory failure, oxygen may reach the alveoli
but cannot be absorbed or used properly, resulting in a PaO2 lower than 60 mmHg,
arterial oxygen saturation (SaO2) lower than 90%, or partial pressure of arterial carbon
dioxide (PaCO2) greater than 50 mmHg occurring with acidemia.
4.Many clients experience both hypoxemic and hypercapnic respiratory failure and
retained carbon dioxide in the alveoli displaces oxygen, contributing to the hypoxemia.
5. Manifestations of respiratory failure are related to the extent and rapidity of change in
PaO2 and PaCO2 .
Assessment
1. Dyspnea
2. Headache
3. Restlessness
4. Confusion
5. Tachycardia
6. Hypertension
7. Dysrhythmias
8. Decreased level of consciousness
9. Alterations in respirations and breath sounds
Interventions
1. Identify and treat the cause of the respiratory failure.
2. Administer oxygen to maintain the PaO2 level higher than 60 to 70 mm Hg.
3. Place the client in a Fowlers position.
4. Encourage deep breathing.
5. Administer bronchodilators as prescribed.
6. Prepare the client for mechanical ventilation if supplemental oxygen cannot maintain
acceptable PaO2 and PaCO2 levels.

VIII. Acute Respiratrory Distress Syndrome

Description
1. A form of acute respiratory failure that occurs as a complication of some other
condition; it is caused by a diffuse lung injury and leads to extravascular lung fluid.
2. The major site of injury is the alveolar capillary membrane.
3. The interstitial edema causes compression and obliteration of the terminal airways and
leads to reduced lung volume and compliance.
4. The ABG levels identify respiratory acidosis and hypoxemia that do not respond to
an increased percentage of oxygen.
5. The chest x-ray shows bilateral interstitial and alveolar infiltrates; interstitial edema
may not be noted until there is a 30% increase in fluid content.
 6. Causes include sepsis, fluid overload, shock, trauma, neurological injuries, burns, DIC,
drug ingestion, aspiration, and inhalation of toxic substances.
Assessment
1. Tachypnea
2. Dyspnea
3. Decreased breath sounds
4. Deteriorating ABG levels
5. Hypoxemia despite high concentrations of delivered oxygen
6. Decreased pulmonary compliance
7. Pulmonary infiltrates
Interventions***
1. Identify and treat the cause of the acute respiratory distress syndrome.
2. Administer oxygen as prescribed.
3. Place the client in a Fowlers position.
4. Restrict fluid intake as prescribed.
5. Provide respiratory treatments as prescribed.
6. Administer diuretics, anticoagulants, or corticosteroids as prescribed.***
7. Prepare the client for intubation and mechanical ventilation using PEEP.
IX. Asthma
Description
1. Chronic inflammatory disorder of the airways that causes varying degrees of
obstruction in the airways.
2. Marked by airway inflammation and hyperresponsiveness to a variety of stimuli or
triggers.

Asthma Triggers
Environmental Physiological Factors Medications Occupational Food
Factors Exposure Additives
Factors
*Animal danders *Gastroesophageal *Acetylsalicylic *Metal salts *Sulfites
*Cockroaches reflux disease acid (aspirin) *Wood and (bisulfites and
*Exhaust fumes (GERD) *B Adrenergic vegetables metabisulfites)
*Fireplaces *Hormonal changes blockers dusts *Beer, wine,
*Molds *Stress *Nonsteroidal *Industrial dried fruit,
*Perfumes or *Viral upper antiinflammatory chemical shrimp,
other products respiratory infection drugs and plastics processed
with aerosol potatoes
sprays. *Monosodium
*Pollens glutamate.
*Smoke, including
cigarette or cigar
smoke
*Sudden weather
changes
From Lewis S, Dirksen S, Heitkemper M, Bucher L, Camera I: Medical-surgical nursing:
assessment and management of clinical problems, ed 8, St. Louis, 2011, Mosby.

3. Causes recurrent episodes of wheezing, breathlessness, chest tightness, and

coughing associated with airflow obstruction that may resolve spontaneously; it is often
reversible with treatment.

4. Severity is classified based on the clinical features before treatment

Classification of Asthma Severity
Severe Persistent
*Symptoms are continuous.
*Physical activity requires limitations.
*Frequent exacerbations occur.
*Nocturnal symptoms occur frequently.
Moderate Persistent
*Daily symptoms occur.
*Daily use of inhaled short-acting -agonist is needed.
*Exacerbations affect activity.
*Exacerbations occur at least twice weekly and may last for days.
*Nocturnal symptoms occur more frequently than once weekly.
Mild Persistent
*Symptoms occur more frequently than twice weekly but less often than once daily.
*Exacerbations may affect activity.
*Nocturnal symptoms occur more frequently than twice a month.
Mild Intermittent
*Symptoms occur twice weekly or less.
*Client is asymptomatic between exacerbations.
*Exacerbations are brief (hours to days).
*Intensity of exacerbations varies.
*Nocturnal symptoms occur twice a month or less.
From Ignatavicius D, Workman M: Medical-surgical nursing: patient-centered
collaborative care, ed 7, St. Louis, 2013, Saunders.

5. Status asthmaticus is a severe life threatening asthma episodes that is refractory to

treatment and may result in pneumothorax, acute cor pulmonale, or respiratory arrest.

Triggers*
*Allergens *Infection
*Exercise *Irritants
 IgE mast cells mediated response

Release of mediators from mast cells,

eosinophils, macrophages, lymphocytes

Earky phase Late phase

response response
Peaks in 30 Peaks in 5 to 6 hours
to 60 minutes
*Bronchial smooth *Bronchial hyperreactivity
muscle contraction
*Mucosaledema

*Mucus secretion *Infiltration with eosinophils and neutrophils

*Vascular leakage *Inflammation
Within 1 to 2 days

Infiltration with monocytes

and lymphocytes

*Air trapping
*Hypoxemia
*Obstruction of large and small airways
*Respiratory acidosis
FIGURE 54-10 Pathophysiology in asthma. Stems with asterisks are primary processes.
IgE, Immunoglobulin E.

Assessment
1. Restlessness
2. Wheezing or crackles***
3. Absent or diminished lung sounds
4. Hyperresonance
 5. Use of accessory muscles for breathing
6. Tachypnea with hyperventilation
7. Prolonged exhalation
8. Tachycardia
9. Pulsus paradoxus
10. Diaphoresis
11. Cyanosis
12. Decreased oxygen saturation
13. Pulmonary function test results that demonstrate decreased airflow rates.
Interventions
1.Monitor vital signs.
2. Monitor pulse oximetry
3. Monitor peak flow
4. During an acute asthma episode, provide interventions to assist with breathing.

Nursing Interventions During an Acute Asthma

Episodes
*Position the client in a high Fowlers position or
sitting to aid in breathing.
*Administer oxygen as prescribed.
*Record the color, amount, and consistency of
sputum, if any.
*Administer corticosteroids as prescribed.
*Auscultate lung sounds before, during, and after
treatment.

Client Education
1. On the intermittent nature of symptoms and need for long-term management.
2. To identify possible triggers and measures to prevent episodes.
3. About the management of medication and proper administration.
4. About the correct use of a peak flowmeter.
5. About developing an asthma action plan with the primary HCP and what to do if an
asthma episode occurs.

X. Chronic Obstructive Pulmonary Disease

Description
1. Also known as chronic obstructive lung disease and chronic airflow limitation
2. Chronic obstructive pulmonarydisease is a disease state characterized by airflow
obstruction caused by emphysema or chronic bronchitis.
3. Progressive airflow limitation occurs, associated with an abnormal inflammatory
response of the lungs that is not completely reversible.
4. COPD leads to pulmonary insufficiency, pulmonary hypertension, and cor pulmonale.
Assessment
1. Cough
 2. Exertional dyspnea
3. Wheezing and crackles
4. Sputum production
5. Weight loss
6. Barrel chest (emphysema)***
7. Use of accessory muscles for breathing***
8. Prolonged expiration
9. Orthopnea
10. Cardiac dysrhythmias
11. Congestion and hyperinflation seen on chest x r ay.***
12. ABG levels that indicate respiratory acidosis and hypoxemia.***
13. Pulmonary function tests that demonstrate decreased vital capacity.
Interventions
1. Monitor Vital Signs.
2. Administer a concentration of oxygen based on ABG values and oxygen saturation
by pulse oximetry as prescribed.
3. Monitor pulse oximetry.
4. Provide respiratory treatments and CPT.
5. Instruct the client in diaphragmatic or abdominal breathing techniques and pursed-
lip breathing techniques, which increase airway pressure and keep air passages
open, promoting maximal carbon dioxide expiration.
6. Record the color, amount, and consistency of sputum.
7. Suction the clients lungs, if necessary, to clear the airway and prevent infection.
8. Monitor weight.
9. Encourage small, frequent meals to maintain nutrition and prevent dyspnea.
10. Provide a high-calorie, high-protein diet with supplements.
11. Encourage fluid intake up to 3000 mL/day to keep secretions thin, unless
contraindicated.
12. Place the client in a Fowlers position and leaning forward to aid in breathing
13. Allow activity as tolerated.
14. Administer bronchodilators as prescribed, and instruct the client in the use of
oral and inhalant medications.
15. Administer corticosteroids as prescribed for exacerbations.
16. Administer mucolytics as prescribed to thin secretions.
17. Administer antibiotics for infection if prescribed.
Client Education: (COPD)
1. Adhere to activity limitations, alternating rest periods with activity.
2. Avoid eating gas producing foods, spicy foods, and extremely hot or cold foods.
3. Avoid exposure to individuals with infections and avoid crowds.
4. Avoids extremes in temperature.
5. Avoid fireplaces,pets, feather pillows, and other environmental allergens.
6. Avoid powerful odors.
7. Meet nutritional requirements.
8. Receive immunizations as recommended.
 9. Recognize the signs and symptoms of respiratory infection and hypoxia.
10. Stop smoking.
11. Use medications and inhalers as prescribed.
12. Use oxygen therapy as prescribed.
13. Use pursed lip and diaphragmatic or abdominal breathing.
14. When dusting, use a wet cloth.

XI. Severe Acute Respiratory Syndrome (SARS)

A. Respiratory illness caused by a coronavirus, called SARS associated coronavirus.
B. The syndrome begins witha fever, an overall feeling of discomfort, body aches, and
mild respiratory symptoms.
C. After 2 to 7 days, the client may develop a dry cough and dyspnea.
D. Infection is spread by close person to person contact by direct contact with
infectious material (respiratory secretions from infected persons or contact with
objects contaminated with infectious droplets).
E. Prevention includes avoiding contact with those suspected of having SARS, avoiding
travel to countries where an outbreak of SARS exists, avoiding close contact with
crowds in areas where SARS exists, and frequent hand washing if in an area where
SARS exists. ***

XII. Pnemonia
Description
1. Infection of the pulmonary tissue, including the interstial spaces, the alveoli, and the
brochioles.
2. The edema associated with inflammation stiffens the lung, decreases lung compliance
and vital capacity, and causes hypoxemia.
3. Pneumonia can be community acquired or hospital acquired.
4. The chest x ray film shows lobar or segmental consolidation, pulmonary
infiltrates, or pleural effusions.
5. A sputum culture identifies the organism.
6. The white blood cell count and the erythrocyte sedimentation rate are elevated.
Assessment
1. Chills
2. Elevated temperature
3. Pleuritic pain
4. Tachypnea
5. Ronchi and wheezes
6. Use of accessory muscles for breathing.
7. Mental status changes
8. Sputum production
Interventions
1. Administer oxygen as prescribed.
2. Monitor respiratory status.
3. Monitor for labored respirations, cyanosis, and cold and clammy skin.
 4. Encourage coughing and deep breathing and use of the incentive spirometer.
5. Place the client in a semi-Fowlers position to facilitate breathing and lung
expansion.
6. Change the clients position frequently and ambulate as tolerated to mobilize
secretions.
7. Provide Chest Physiotherapy.
8. Perform nasotracheal suctioning if the client is unable to clear secretions.
9. Monitor pulse oximetry.
10. Monitor and record color, consistency, and amount of sputum.
11. Provide a high-calorie, high-protein diet with small frequent meals.
12. Encourage fluids, up to 3 L/day, to thin secretions unless contraindicated.
13. Provide a balance of rest and activity, increasing activity gradually.
14. Administer antibiotics as prescribed.
15. Administer antipyretics, bronchodilators, cough suppressants, mucolytic
agents, and expectorants as prescribed.
16. Prevent the spread of infection by hand washing and the proper disposal of
secretions.
Client Education
1. About the importance of rest, proper nutrition, and adequate fluid intake
2. To avoid chilling and exposure to individuals with respiratory infections or viruses
3. Regarding medications and the use of inhalants as prescribed
4. To notify the HCP if chills, fever, dyspnea, hemoptysis, or increased fatigue occurs
5. Pneumococcal vaccine as recommended by the health care provider(HCP).
!Teach clients that using proper hand washing techniques, disposing of respiratory
secretions properly; and receiving vaccines will assist in preventing the spread of
infection.

XIII. Influenza
Description
1. Also known as the flu; highly contagious acute viral respiratory infection.
2. May be caused by several viruses, usually known as type A, B, and C.
3. Yearly Vaccination is recommended to prevent the disease, especially for those
older than 50 years of age, individuals with chronic ilness or who are
immunocompromised, those living in institutions, and health care personnel providing
direct care to clients (the vaccination is contraindicated in the individual with egg
allegies).
4. Additional prevention measures include avoiding those who have developed influenza,
frequent and proper handwashing, and cleaning and disinfecting surface that have
become contaminated with secretions.
5. Avian Influenza A(H5N1)
a. Affects birds; does not usually affect humans; however, human cases have been
reported in some countries.
b. An H5N1 vaccine has been developed for use if a pandemic virus were to emerge.
c. Reported symptoms are similar to those associated with influenza types A, B, and C.
 d. Prevention measures include thorough cooking of poultry products, avoiding contact
with wild animals, frequent and proper hand washing, and cleaning and disinfecting
surfaces that have become contaminated with secretions.
6. Swine (H1N1) Influenza
a. A strain of flu that consists of genetic materials from swine, avian, and human
influenza viruses.
b. Signs and symptoms are similar to those that present with seasonal flu; in addition,
vomiting and diarrhea commonly occur.
c. Prevention measures and treatment are the same as for the seasonal flu.
Assessment
1. Acute onset of fever and muscle aches.
2. Headache
3. Fatigue, weakness, anorexia.
4. Sore throat, cough, and rhinorrhea.
Interventions
1. Encourage rest.
2. Encourage fluids to prevent pulmonary complications (unless
contraindicated).
3. Monitor lung sounds.
4. Provide supportive therapy such as antipyretics or antitussives as indicated.
5. Administer antiviral medications as prescribed for the current strain of
influenza.

XIV. Legionnaires Disease

Description
1. Acute bacterial infection caused by Legionella pneumophila.
2. Sources of the organism include contaminated cooling tower water and warm stagnant
water supplies, including water vaporizers, water sonicators, whirlpool spas, and
showers.
3. Person-to-person contact does not occur; the risk for infection is increased by the
presence of other conditions.
Assessment
Ifluenza like symptoms with a high fever, chills, muscle aches, and headache that
may progress to dry cough, pleurisy, and sometimes diarrhea.
Interventions
Treatment is supportive and antibiotics may be prescribed.

XV. Pleural Effusion

Description
1. Pleural effusion is the collection of fluid in the pleural space.
2. Any condition that interferes with secretion or drainage of this fluid will lead to
pleural effusion.
Assessment
1. Pleuritic pain that is sharp and increases with inspiration
2. Progressive dyspnea with decreased movement of the chest wall on the affected
side
3. Dry, nonproductive cough caused by bronchial irritation or mediastinal shift
4. Tachycardia
5. Elevated temperature
6. Decreased breath sounds over affected area
7. Chest x-ray film that shows pleural effusion and a mediastinal shift away from the
fluid if the effusion is more than 250 mL.
Interventions
1. Identify and treat the underlying cause.
2. Monitor breath sounds.
3. Place the client in a Fowlers position.
4. Encourage coughing and deep breathing.
5. Prepare the client for thoracentesis.
6. If pleural effusion is recurrent, prepare the client for pleurectomy or pleurodesis as
prescribed.
PLEURECTOMY
1. Consists of surgically stripping the parietal pleura away from the visceral pleura.
2. This produces an intense inflammatory reaction that promotes adhesion formation
between the 2 layers during healing.
PLEURODESIS
1. Involves the instillation of a sclerosing substance into the pleural space via a
thoracotomy tube.
2. The substance creates an inflammatory response that scleroses tissue together.

XVI. Empyema
Description
1. Collection of pus within the pleural cavity.
2. The fluid is thick, opaque, and foul smelling.
3. The most common cause is pulmonary infection and lung abscess caused by thoracic
surgery or chest trauma, in which bacteria are introduced directly into the pleural space.
4. Treatment focuses on treating the infection, emptying the empyema cavity,
reexpanding the lung, and controlling the infection.
Assessment
1. Recent febrile illness or trauma
2. Chest pain
3. Cough
4. Dyspnea
5. Anorexia and weight loss
6. Malaise
7. Elevated temperature and chills
8. Night sweats
9. Pleural exudate on chest x ray.
Interventions
 1. Monitor breath sounds.
2. Place the client in a semi Fowlers or high Fowlers position.***
3. Encourage coughing and deep breathing.
4. Admminister antibiotics as prescribed.
5. Instruct the client to splint the chest as necessary.
6. Assist with thoracentesis or chest tube insertion to promote drainage and lung
expanasion.
7. If marked pleural thickening occurs, prepare the client for decortication, if
prescribed; this surgical procedure involves removal of the restrictive mass of fibrin
and inflammatory cells.

XVII. Pleurisy
Description
1. Inflammation of the visceral and parietal membranes; may be caused by
pulmonary infarction or pneumonia.
2. The visceral and parietal membranes rub together during respiration and cause
pain.
3. Pleurisy usually occurs on 1 side of the chest, usually in the lower lateral portions in
the chest wall.

Assessment
1. Knifelike pain aggravated on deep breathing and coughing.
2. Dyspnea
3. Pleural friction rub heard on auscultation.
Interventions
1. Identify and treat the cause.
2. Monitor lung sounds.
3. Administer analgesics as precribed.
4. Apply hot or cold applcations as prescribed.
5. Encourage coughing and deep breathing.
6. Instruct the client to lie on the affected side to splint chest.***

XVIII. Pulmonary Embolism***

Description
1. Occurs when a thrombus forms (most commonly in a deep vein), detaches,
travels to the right side of the heart, and then lodges in a branch of the pulmonary
artery.
2. Clients prone to pulmonary embolism are those at risk for deep vein thrombosis,
including those with prolonged immobilization, surgery, obesity, pregnancy, heart
failure, advanced age, or a history of thromboembolism.
3. Fat emboli can occur as a complication following fracture of a long bone and can
cause pulmonary embooli.
4. Treatment is aimed at prevention through risk factor recognition and elimination.
Assessment
 1. Apprehension and restlessness
2. Blood tinged sputum
3. Chest pain
4. Cough
5. Crackles and wheezes on auscultation
6. Cyanosis
7. Distended neck veins
8. Dyspnea accompanied by anginal and pleuritic pain, exacerbated by inspiration
9. Feeling of impending doom
10. Hypotension
11. Petechiae over the chest and axilla
12. Shallow repirations
13. Tachypnea and tachycardia
Interventions
Priority Nursing Actions (Suspected Pulmonary Embolism)
1. Notify the Rapid Response Team and Health care provider (HCP).
2. Reassure the client and elevate the head of the bed.
3. Prepare to administer oxygen.
4. Obtain Vital Signs and check lung sounds.
5. Prepare to obtain an arterial blood gas.
6. Prepare for the administration of heparin therapy or other therapies.
7.Document the event, interventions taken, and the clients response to tretment.
Signs and symptoms of a pulmonary embolism include the sudden onset of dyspnea,
apprehension and restlessness, a feeling of impending doom, cough, hemoptysis,
tachypnea, crackles, petechiae over the chest and axillae, and a decreased arterial
oxygen saturation. If suspected, the nurse immediately notifies the Rapid
Response Team and HCP.
The nurse stays with the client, reassures the client, and elevates the head of the
bed. The nurse prepares to administer oxygen and obtains the vital signs and
checks lung sounds. The nurse continues to monitor the client closely, prepares
the client for tests prescribed to confirm the diagnosis, and prepares to obtain an
arterial blood gas. When prescribed, the client is prepared for the administration of
heparin therapy or other therapies such as embolectomy or placement of a vena
cava filter if necessary. Finally, the nurse documents the event, the interventions taken,
and the clients response to treatment.
Reference: Ignatavicius, Workman (2016), p. 606. Pg. 744 Pg. 614. 574

XIX. Lung Cancer and Laryngeal Cancer

Lung Cancer
Description
1. Lung cancer is a malignant tumor of the brochi and peripheral lung tissue.
2. The lungs are a common target for metastasis from other organs.
3. Bronchogenic cancer (tumors originate in the epithelium of the bronchus) spreads
through direct extension and lymphatic dissemination.
4. Classified according to histological cell type; types include small cel lung cancer
(NSCLC); epidermal (squamous cell anaplastic carcinoma are classified as NSCLS
because of their similar responses to treatment.
5. Diagnosis is made by a chest x ray study. CT scan, or magnetic resonance imaging
(MRI), which shows a lesion or mass, and by bronchoscopy and sputum studies,
which demonstrate a positive cytological study for cancer cells.
Causes
1. Cigarrette smoking; also exposure to passive tobacco smoke.
2. Exposure to environmental and occupational pollutants.
Assessment
1. Cough
2. Wheezing, dyspnea
3. Hoarseness
4. Hempotysis, blood tinged or purulent sputum
5. Chest pain
6. Anorexia and weight loss
7. Weakness
8. Diminished or absent breath sounds, respiratory changes
Interventions
1. Monitor Vital Signs.
2. Monitor breathing patterns and breath sounds and for signs of respiratory
impairment;monitor for hemoptysis.
3. Assess for tracheal deviation.
4. Administer analgesics as prescribed for pain management.
5. Place in a Fowlersposition to help easebreathing.***
6. Administer oxygen as prescribed and humidification to moisten and loosen
secretions.***
7. Monitor pulse oximetry.
8. Provide respiratory treatments as prescribed.
9. Administer bronchodilators and corticosteroids as prescribed to decrease
bronchospasm, inflammation, and edema.
10. Provide a high-calorie, high-protein, high vitamin diet.
11. Provide activity as tolerated, rest periods, and active and passive range of
motion exercises.
Nonsurgical interventions
1. Radiation therapy may be prescribed for localized intrathoracic lung cancer and
for palliation of hemoptysis, obstructions, dysphagia, superior vena cava
syndrome, and pain.
2. Chemotherapy may be prescribed for treatment of nonresectable tumors or as
adjuvant therapy.
Surgical interventions
1. Laser therapy: To relieve endobronchial obstruction.
2. Thoracentesis and pleurodesis: To remove pleural fluid and relieve hypoxia.
 3. Thoracotomy (opening into the thoracic cavity) with pneumonectomy: Surgical
removal of 1 entire lung.
4. Thoracotomy with lobectomy: Surgical removal of 1 lobe of the lung for tumors
confined to a single lobe.
5. Thoracotomy with segmental resection: Surgical removal of a lobe segment.
Preoperative interventions
1. Explain the potential postoperative need for chest tubes.
2. Note that closed chest drainage usually is not used for a pneumonectomy and
the serous fluid that accumulates in the empty thoracic cavity eventually
consolidates, preventing shifts of the mediastinum, heart, and remaining
lung.***
Postoperative interventions
1. Monitor Vital Signs.
2. Assess cardiac and respiratory status; monitor lung sounds.***
3. Maintain the chest tube drainage system, which drains air and blood that
accumulates in the pleural space; monitor for excess bleeding. (See Chapter
20 for care of the client with a chest tube.)***
4. Administer oxygen as prescribed.
5. Check the healthcare providers (HCPs) prescriptions regarding client positioning;
avoid complete lateral turning.
6. Monitor pulse oximetry.
7. Provide activity as tolerated.
8. Encourage active range of motion exercises of the operative shoulder as
prescribed.
!The airway is the priority for a client with lung or laryngeal cancer.

Laryngeal Cancer
Description
1. Laryngeal cancer is a malignant tumor of the larynx.
2. Laryngeal cancer presents as malignant ulcerations with underlying infiltration
and is spread by local extension to adjacent structures in the throat and neck,
and by the lymphatic system.
3. Diagnosis is made by laryngoscopy and biopsy showing a positive cytological
study for cancer cells.
4. Laryngoscopy allows for evaluation of the throat and biopsy of tissues; chest
radiography, CT, and MRI are used for staging.
Risk factors
1. Cigarette smoking.
2. Heavy alcohol use and the combined use of tobacco and alcohol.
3. Exposure to environmental pollutants (e.g., asbestos, wood dust).
4. Exposure to radiation
Assessment***
1. Persistent hoarseness or sore throat and ear pain.
2. Painless neck mass.
 3. Feeling of lump in the throat.
4. Burning sensation in the throat.
5. Dysphagia.
6. Change in voice quality.
7. Dyspnea.
8. Weakness and weight loss
9. Hemoptysis.
10. Foul breath odor.
Interventions
1. Place in Fowlers position to promote optimal air exchange.***
2. Monitor respiratory status.
3. Monitor for signs of aspiration of food and fluid.
4. Administer oxygen as prescribed.***
5. Provide respiratory treatments as prescribed.
6. Provide activity as tolerated.
7. Provide a high calorie and high protein diet.
8. Provide nutritional support via parenteral nutrition, nasogastric tube feedings, or
gastrostomy or jejunostomy tube, as prescribed.
9. Administer analgesics as prescribed for pain.
10. Encourage clients to stop smoking and drinking alcohol to increase
effectiveness of treatments.
Nonsurgical interventions
1. Radiation therapy in specified situations
2. Chemotherapy,which maybe given in combination with radiation and surgery
Surgical interventions
1. The goal is to remove the cancer while preserving as much normal function as
possible.
2. Surgical intervention depends on the tumor size, location, and amount of tissue
to be resected.
3. Types of resection include cordal stripping, cordectomy, partial laryngectomy,
and total laryngectomy.
4. A tracheostomy is performed with a total laryngectomy; this airway opening is
permanent and is referred to as a laryngectomy stoma.
Preoperative interventions
1. Discuss self-care of the airway, alternative methods of communication, suctioning,
pain control methods, the critical care environment, and nutritional support.
2. Encourage the client to express feelings about changes in body image and loss of
voice.
3. Describe the rehabilitation program and information about the tracheostomy and
suctioning.
Postoperative interventions
1. Monitor Vital Signs.
2. Monitor respiratory status; monitor airway patency and provide frequent suctioning
to remove bloody secretions.
3. Place the client in a high Fowlers position.
4. Maintain mechanical ventilator support or a tracheostomy collar with
humidification, as prescribed.
5. Monitor pulse oximetry.
6. Maintain surgical drains in the neck area if present.
7. Observe for hemorrhage and edema in the neck.
8. Monitor IV fluids or parenteral nutrition until nutrition is administered via a
nasogastric, gastrostomy, or jejunostomy tube.
9. Provide oral hygiene.
10. Assess gag and cough reflexes and the ability to swallow.
11. Increase activity as tolerated.
12. Assess the color, amount, and consistency of sputum.
13. Provide stoma and laryngectomy care
Stoma Care Following Laryngectomy
-Protect the neck from injury.
-Instruct the client in how to clean the incision and provide stoma care.
-Instruct the client to wear a stoma guard to shield the stoma.
-Demonstrate ways to prevent debris from entering the stoma.
-Advise the client to wear loose fitting, high collared clothing to cover the stoma.
-Avoid swimming, showering, and using aerosol sprays.
-Teach the client clean suctioning technique.
-Advise the client to increase humidity in the home.
-Increase fluid intake to 3000 mL / day as prescribed.
-Avoid exposure to persons with activity.
-Alternate rest periods with activity.
-Instruct the client in range of motion exercises for the arms, shoulders, and
neck as prescribed.
-Advise the client to wear a MedicAlert bracelet.
14. Provide consultation with speech and language pathologist as prescribed.
15. Reinforce method of communication established preoperatively.
16. Prepare the client for rehabilitation and speech therapy (Box 48-16).
Speech Rehabilitation Following Laryngectomy
Esophageal Speech
-The client produces esophageal speech by burping the air swallowed.
-The voice produced is monotone, cannot be raised or lowered, and carries no pitch.
-The client must have adequate hearing because his or her mouth shapes words as
they are heard.
Mechanical Devices
-One device, the electrolarynx, is placed against the side of the neck; the air inside the
neck and pharynx is vibrated, and the client articulates.
-Another device consists of a plastic tube that is placed inside the clients mouth and
vibrates on articulation.
Tracheoesophageal Fistula
 -A fistula is created surgically between the trachea and the esophagus, with
eventual placement of a prosthesis to produce speech.
-The prosthesis provides the client with a means to divert air from the trachea
into the esophagus, and out of the mouth.
-Lip and tongue movement produce the speech.

XX. Carbon Monoxide Poisoning

Description
a. Carbon monoxide is a colorless, odorless, and tatsteless gas that has an affinity
for hemoglobin 200 times greater than that of oxygen.
b. Oxygen molecules are displaced and carbon monoxide reversibly binds to
hemoglobin to form carboxyhemoglobin.
c. Tissue hypoxia occurs.
Assessment***
Blood Level (%) Clinical Manifestations
1 10 Normal level
11 20 (mild poisoning) Headache
Flushing
Decreased visual acuity
Decreased cerebral functioning
Slight breathlessness
21 40 (moderate Headache
poisoning) Nausea and vomiting
Drowsiness
Tinnitus and vertigo
Confusion and stupor
Pale to reddish purple skin
Decreased blood pressure
Increased and irregular heart rate
Depressed ST segment on electrocardiogram
41 60 (severe Coma
poisoning) Seizures
Cardiopulmonary instability
61 80 (fatal poisoning) Death
Adapted from Ignatavicius D, Workman ML: Medical-surgical nursing: patientcentered
collaborative care, ed 8, Philadelphia, 2016, Saunders.

XXI. Histoplasmosis
Description
1. Pulmonary fungal infection caused by spores of Histoplasma capsulatum.
2. Transmission occurs by the inhalation of spores, which commonly are found in
contaminated soil.***
3. Spores also are usually found in bird droppings.
Assessment
1. Similar to pnuemonia: Chills, Elevated temperature, Pleuritic pain, Tachypnea,
Rhonchi and wheezes, Use of accessory muscles for breathing, Mental status
changes, Sputum production
2. Positive skin test for histoplasmosis.***
3. Positive agglutination test
4. Splenomegaly, hepatomegaly
Interverventions
1. Administer oxygen as prescribed.
2. Monitor breath sounds.
3. Administer antiemetics, antihistamines, antipyretics, and corticosteroids as
prescribed.
4. Administer fungicidal medications as prescribed.
5. Encourage coughing and deep breathing.
6. Place the client in a semi Fowlers position.
7. Monitor Vital Signs.
8. Monitor for nephrotoxicity form fungicidal medications.
9. Instruct the client to wear a mask and spray the floor with water before sweeping
barn and chicken coops.

XXII. Sarcoidosis
Description
1. Presence of epithelioid cell tubercles in the lung.
2. The cause is unknown, but a high titer of Epstein Barr virus may be noted.
3. Viral incidence is highest in African Americans and young adults.
Assessment
1. Night sweats
2. Fever
3. Weight loss
4. Cough and dyspnea
5. Skin nodules
6. Polyarthritis.
7. Kveim test: Sarcoid node antigen is injected intradermally and causes a local
nodular lesion in about 1 month.***
Interventions
1. Administer corticosteroids to control symptoms.
2. Monitor temperature.
3. Increase fluid intake.
4. Provide frequent periods of rest.
5. Encourage small, frequent, nutritious meals.
XXIII. Occupational Lung Disease
Description
1. Caused by exposure to environmental or occupational fumes, dust, vapors,
gases, bacterial or fungal antigens, and allergens; can result in acute reversible
effects or chronic lung disease.
2. Common disease classifications include occupational asthma pneumoconiosis
(silicosis or coal miners [black lung] disease), diffuse interstitial fibrosis
(asbestosis, talcosis, berylliosis), or extrinsic allergic alveolitis (farmers lung, bird
fanciers lung, or machine operators lung).
Assessment
1. Manifestations depend on the type of disease and respiratory symptoms.***
Interventions
1. Prevention through the use of respiratory protective devices.***
2. Treatment is based on the symptoms experienced by the client.

XXIV. Tuberculosis***
Description
1. Highly communicable disease caused by Mycobacterium tuberculosis.
2. M. tuberculosis is a nonmotile, nonsporulating, acid-fast rod that secretes niacin; when
the bacillus reaches a susceptible site, it multiplies freely.
3. Because M. tuberculosis is an aerobic bacterium, it primarily affects the pulmonary
system, especially the upper lobes, where the oxygen content
is highest, but also can affect other areas of the body, such as the brain, intestines,
peritoneum, kidney, joints, and liver.
4. An exudative response causes a nonspecific pneumonitis and the development of
granulomas in the lung tissue.
5. Tuberculosis has an insidious onset, and many clients are not aware of symptoms until
the disease is well advanced.
6. Improper or noncompliant use of treatment programs may cause the development of
mutations in the tubercle bacilli, resulting in a multidrugresistant
strain of tuberculosis (MDR-TB).***
7. The goal of treatment is to prevent transmission, control symptoms, and prevent
progression of the disease.
Risk factors***
1. Child younger than 5 years of age
2. Drinking unpasteurized milk if the cow is infected with bovine tuberculosis.
3. Homeless individuals or those from a lower socioeconomic group, minority group, or
refugee group.
4. Individuals in constant, frequent contact with an untreated or undiagnosed
individual.
5. Individuals living in crowded areas, such as long term care facilites, prisons, and
mental health facilities.
6. Older client.
7. Individuals with malnutrition, infection, immune dysfunction, or human
immunodeficiency virus infection; or immunosuppressed as a result of medication
therapy.
 8. Individuals who abuse alcohol or are intravenous drug users.
Transmission***
1. Via the airborne route by droplet infection.
2. When an infected individual coughs, laughs, sneezes, or sings, droplet nuclei
containing tuberculosis bacteria enter the air and may be inhaled by others.
3. Identification of those in close contact with the infected individual is important so that
they can be tested and treated as necessary.
4. When contacts have been identified, these persons are assessed with a
tuberculin skin test and chest x-rays to determine infection with tuberculosis.
5. After the infected individual has received tuberculosis medication for 2 to 3 weeks,
the risk of transmission is reduced greatly.
Disease progression
1. Droplets enter the lungs, and the bacteria form a tubercle lesion.
2. The defense systems of the body encapsulate the tubercle, leaving a scar.
3. If encapsulation does not occur, bacteria may enter the lymph system, travel to the
lymph nodes, and cause an inflammatory response termed granulomatous
inflammation.
4. Primary lesions form; the primary lesions may become dormant but can be
reactivated and become a secondary infection when reexposed to the bacterium.
5. In an active phase, tuberculosis can cause necrosis and cavitation in the lesions,
leading to rupture, the spread of necrotic tissue, and damage
to various parts of the body.
Client history***
1. Past exposure to tuberculosis
2. Clients country of origin and travel to foreign countries in which the incidence of
tuberculosis is high
3. Recent historyof influenza, pneumonia, febrile illness, cough, or foul-smelling
sputum production
4. Previous tests for tuberculosis; results of the testing
5. Recent bacillus Calmette-Guerin (BCG) vaccine (a vaccine containing attenuated
tubercle bacilli that may be given to persons in foreign countries
or to persons traveling to foreign countries to produce increased resistance to
tuberculosis).
!An individual who has received a BCG vaccine will have a positive tuberculin skin
test result and should be evaluated for tuberculosis with a chest x ray.
Clinical manifestations
1. May be asymptomatic in primary infection
2. Fatigue
3. Lethargy
4. Anorexia
5. Weight loss
6. Low-grade fever
7. Chills
8. Night sweats
 9. Persistent cough and the production of mucoid and mucopurulent sputum, which is
occasionally streaked with blood
10. Chest tightness and a dull, aching chest pain may accompany the cough.
Chest assessment
1. A physical examination of the chest does not provide conclusive evidence of
tuberculosis.
2. A chest x-ray is not definitive, but the presence of multinodular infiltrates with
calcification in the upper lobes suggests tuberculosis.***
3. If the disease is active, caseation and inflammation may be seen on the chest x-
ray.
4. Advanced disease
a. Dullness with percussion over involved parenchymal areas, bronchial breath
sounds, rhonchi, and crackles indicate advanced disease.
b. Partial obstruction of a bronchus caused by endobronchial disease or
compression by lymph nodes may produce localized wheezing and dyspnea.
QuantiFERON TB Gold Test***
1. A blood analysis test by an enzyme-linked immunosorbent assay
2. A sensitive and rapid test (results can be available in 24 hours) that assists in
diagnosing the client
Sputum cultures
1. Sputum specimens are obtained for an acidfast smear.***
2. A sputum culture identifying M. tuberculosis confirms the diagnosis.
3. After medications are started, sputum samples are obtained again to determine the
effectiveness of therapy.***
4. Most clientshavenegative cultures after 3 months of treatment.
Tuberculin skin test (TST)***
1. A positive reaction does not mean that active disease is present but indicates
previous exposure to tuberculosis or the presence of inactive (dormant)
disease.***
2. Once the test result is positive, it will be positive in any future tests.
3. Skin test interpretation depends on 2 factors: measurement in millimeters of the
induration, and the persons risk of being infected with tuberculosis and progression to
disease if infected.
4. Once an individuals skin test is positive, a chest x-ray is necessary to rule out
active tuberculosis or to detect old healed lesions.

Induration 5 5 or > 5 mm Induration 5 10 or > 10 Induration 5 15 or > 15

Considered mm Considered mm Considered
Positive in: Positive in: Positive in:
HIV-infected persons. Recent immigrants from Any person, including
Recent contact of a high-prevalence countries. persons with no
person with TB disease. Injection drug users. known risk factors for
Class Persons with fibrotic Residents and employees TB.
ificati changes on chest x-ray in high-risk congregate
on of consistent with prior TB. Settings.
the Clients with organ Mycobacteriology
Tube transplants. laboratory personnel.
rculin Personsimmuno- Persons with clinical
Skin suppressed for other conditions that place them
Test reasons. at high risk.
Reac Children < 4 years of age
tion Infants, children, and
HIV, adolescents exposed to
Hum adults in high-risk
an categories.
immu
nodeficiency virus; TB, tuberculosis. From Centers for Disease Control and Prevention:
Tuberculosis (TB) fact sheets (website): http://www.cdc.gov/ tb/publications/ factsheets/
testing/ skintesting.htm.

The hospitalized client***

1. The client with active tuberculosis is placed under airborne isolation precautions
in a negative pressure room; to maintain negative pressure, the door of the room
must be tightly closed.
2. The room should have at least 6 exchanges of fresh air per hour and should
be ventilated to the outside environment, if possible.
3. The nurse wears a particulate respirator (a special individually fitted mask)
when caring for the client and a gown when the possibility of clothing
contamination exists.
4.Thorough hand washing is required before and after caring for the client.
5. If the client needs to leave the room for a test or procedure, the client is required to
wear a surgical mask.
6. Respiratory isolations is discontinued when the client is no longer considered
infectious.***
7. After the infected individual has received tuberculosis medication for 2 to 3 weeks,
the risk of transmission is reduced greatly.

Client education: Tuberculosis***

1. Provide the client and family with information about tuberculosis and allay concerns
about the contagious aspect of the infection.
2. Instruct the client to follow the medication regimen exactly as prescribed and always
to have a supply of the medication on hand.
3. Advise the client that the medication regimen is continued up to 12 months
depending on the situation.
4. Advise the client of the side and adverse effects of the medication and ways of
minimizing them to ensure compliance.
5. Reassure the client that after 2 to 3 weeks of medication therapy, it is unlikely that
the client will infect anyone.
6. Advise the client to resume activities gradually.
7. Instruct the client about the need for adequate nutrition and a well balanced
diet (foos rich in iron, protein, and vitamin C) to promote healing and to
prevent recurrence of the infection.
8. Inform the client and family that respiratory isolation is not necessary because family
members already have been exposed.
9. Instruct the client to cover the mouth and nose when coughing or sneezing and to
put used tissues into plastic bags.
10. Instruct the client and family about thorough hand washing.
11. Inform the client that a sputum culture is needed every 2 to 4 weeks once
medication therapy is initiated.
12. Inform the client that when the results of 3 sputum cultures
are negative, the client is no longer considered infectious and usually can
return to former employment.
13. Advise the client to avoid excessive exposure to silicone or dust because
these substances can cause further lung damage.
14. Instruct the client regarding the importance of compliance with treatment, follow-
up care, and sputum cultures, as prescribed.
b Disturbance in Metabolic and Endocrine Functioning
I. Anatomy and Physiology of Endocrine Glands
A. Functions
1. Maintenance and regulation of vital functions
2. Response to stress and injury
3. Growth and development
4. Energy metabolism
5. Reproduction
6. Fluid, electrolyte, and acid-base balance

B. Risk factors for endocrine disorders

Age
Heredity
Congenital factors
Trauma
Environmental factors
Consequence of other disorders or surgery

C. Hypothalamus
1. Portion of the diencephalon of the brain, forming the floor and part of the lateral wall of
the third ventricle
2. Activates, controls, and integrates the peripheral autonomic nervous system,
endocrine processes, and many somatic functions, such as body temperature,
sleep, and appetite
D. Pituitary gland
1. The master gland; located at the base of the brain (cranial cavity in sella turcica of
sphenoid bone; near optic chiasm
2. Influenced by the hypothalamus; directly affects the function of the other endocrine
glands
3. Anterior lobe (adenohypophysis) and posterior lobe (neurohypophysis)
4. Promotes growth of body tissue, influences water absorption by the kidney, and
controls sexual development and function
5. Pituitary Hormes
1. Hormones secreted by anterior lobe
a. Growth hormone (GH)
(1) Promotes protein anabolism
(2) Promotes fat mobilization and catabolism
(3) Slows carbohydrate metabolism
b. Thyroid-stimulating hormone (TSH): stimulates synthesis and secretion of thyroid
hormones
c. ACTH
(1) Stimulates growth of adrenal cortex
(2) Stimulates secretion of glucocorticoids; slightly stimulates mineralocorticoid secretion
d. Follicle-stimulating hormone (FSH)
(1) Stimulates primary graafian follicle to grow and develop
(2) Stimulates follicle cells to secrete estrogen
(3) Stimulates development of seminiferous tubules and spermatogenesis
e. Luteinizing hormone (LH)
(1) Stimulates maturation of follicle and ovum; required for ovulation
(2) Forms corpus luteum in ruptured follicle following ovulation; stimulates
corpus luteum to secrete progesterone
(3) In males, LH is called interstitial cellstimulating hormone (ICSH);
stimulates testes to secrete testosterone
f. Prolactin (PRL)
(1) Promotes breast development during pregnancy
(2) Initiates milk production after delivery
(3) Stimulates progesterone secretion by corpus luteum
2. Hormones secreted by posterior lobe
a. Antidiuretic hormone (ADH, vasopressin)
(1) Increases water reabsorption by distal and collecting tubules of kidneys
(2) Stimulates vasoconstriction, raising blood pressure
b. Oxytocin
(1) Stimulates contractions by pregnant uterus
(2) Stimulates milk ejection from alveoli of lactating breasts into ducts
c. Melanocyte-stimulating hormone (MSH): stimulates synthesis and dispersion of
melanin in skin, causing darkening
E. Adrenal gland
1. One adrenal gland is on top of each kidney.
2. A Two closely associated structures, adrenal medulla and adrenal cortex, positioned
at each kidneys superior border
3. Regulates sodium and electrolyte balance; affects carbohydrate, fat, and protein
metabolism; influences the development of sexual characteristics; and sustains the fight-
or-flight response
4. Adrenal hormones
1. Adrenal cortex
a. The cortex is the outer shell of the adrenal gland.
b. The cortex synthesizes glucocorticoids and mineralocorticoids and secretes small
amounts of sex hormones (androgens, estrogens)
c. secretes the mineralocorticoid aldosterone and the glucocorticoids cortisol and
corticosterone
a. Aldosterone
(1) Markedly accelerates sodium and water reabsorption by kidney tubules
(2) Markedly accelerates potassium excretion by kidney tubules
(3) Secretion increases as sodium ions decrease or potassium ions increase
b. Cortisol and corticosterone
(1) Accelerate mobilization and catabolism of tissue protein and fats
(2) Accelerate liver gluconeogenesis (hyperglycemic effect)
(3) Decrease antibody formation (immunosuppressive, antiallergic effect)
(4) Slow proliferation of fibroblasts characteristic of inflammation
(antiinflammatory effect)
(5) Decrease adrenocorticotropic hormone (ACTH) secretion
(6) Mildly accelerate sodium and water reabsorption and potassium excretion
by kidney tubules
(7) Increase release of coagulation factors

2. Adrenal medulla
a. The medulla is the inner core of the adrenal gland.
b. The medulla works as part of the sympathetic nervous system and produces two
catecholamines, epinephrine and norepinephrine.
c. Stimulate liver and skeletal muscle to break down glycogen to produce glucose
d. Increase oxygen use and carbon dioxide production
e. Increase blood concentration of free fatty acids through stimulation of lipolysis in
adipose tissue
f. Cause constriction of most blood vessels of body, thus increasing total peripheral
resistance and arterial pressure to shunt blood to vital organs
g. Increase heart rate and force of contraction, thus increasing cardiac output
h. Inhibit contractions of gastrointestinal and uterine smooth muscle
i. Epinephrine significantly dilates bronchial smooth muscle

F. Thyroid gland
1. Located in the anterior part of the neck
2. Thyroid hormones: accelerate cellular reactions in most body cells
3. Controls the rate of body metabolism and growth and produces thyroxine (T4),
triiodothyronine (T3), and thyrocalcitonin
Thyroxine: stimulates metabolic rate; essential for physical and mental development
Triiodothyronine: inhibits anterior pituitary secretion of thyroid-stimulating hormone
Calcitonin (thyrocalcitonin): decreases loss of calcium from bone; promotes
hypocalcemia; action opposite that of parathormone

G. Parathyroid glands
1. Located on the thyroid gland
2. Small glands (2 to 12) embedded in posterior part of thyroid
3. Controls calcium and phosphorus metabolism; produces parathyroid hormone
(parathormone)
4. Parathyroid hormone (parathormone)
1. Increases blood calcium concentration
a. Breakdown of bone with release of calcium into blood (requires active form of vitamin
D)
b. Calcium absorption from intestine into blood
c. Kidney tubule reabsorption of calcium
2. Decreases blood phosphate concentration by slowing its reabsorption from
kidneys, thereby decreasing calcium loss in urine

H. Pancreas
1. Located posteriorly to the stomach (retroperitoneal in abdominal cavity)
2. Influences carbohydrate metabolism, indirectly influences fat and protein metabolism,
and produces insulin and glucagon
3. Pancreatic hormones: regulate glucose and protein homeostasis through action of
insulin and glucagon
Insulin: secreted by beta cells of islets of Langerhans
a. Promotes cellular uptake of glucose
b. Stimulates intracellular macromolecular synthesis, such as glycogen synthesis
(glyconeogenesis), fat synthesis (lipogenesis), and protein synthesis
c. Stimulates cellular uptake of sodium and potassium (latter is significant in
treatment of diabetic coma with insulin)
Glucagon: secreted by alpha cells of islets of Langerhans
a. Induces liver glycogenolysis; antagonizes glycogen synthesis stimulated by insulin
b. Inhibits hepatic protein synthesis, which makes amino acids available for
gluconeogenesis and increases urea production
c. Stimulates hepatic ketogenesis and release of glycerol and fatty acids from
adipose tissue when cellular glucose level falls

I. Ovaries and testes

1. The ovaries are located in the pelvic cavity and produce estrogen and progesterone.
2. The testes are located in the scrotum, control the development of the secondary sex
characteristics, and produce testosterone.

J. Negative-feedback loop
1. Regulates hormone secretion by the hypothalamus and pituitary gland
2. Increased amounts of target gland hormones in the bloodstream decrease secretion of
the same hormone and other hormones that stimulate its release.
II. Diagnostic Tests
A. Stimulation and suppression tests
1. Stimulation tests
a. In the client with suspected underactivity of an endocrine gland, a stimulus may be
provided to determine whether the gland is capable of normal hormone production.
b. Measured amounts of selected hormones or substances are administered to stimulate
the target gland to produce its hormone.
c. Hormone levels produced by the target gland are measured.
d. Failure of the hormone level to increase with stimulation indicates hypofunction.

2. Suppression tests
a. Suppression tests are used when hormone levels are high or in the upper range of
normal.
b. Agents that normally induce a suppressed response are administered to determine
whether normal negative feedback is intact.
c. Failure of hormone production to be suppressed during standardized testing indicates
hyperfunction.

3. Overnight dexamethasone suppression test

a. Used to distinguish between Cushings syndrome and Cushings disease.
b. In Cushings disease the source of excess cortisol is the pituitary gland rather than
the adrenal cortex or exogenous corticosteroid administration.
c. Dexamethasone, a potent long-acting corticosteroid given at bedtime, should
suppress the morning cortisol in clients without Cushings disease by suppressing
adrenocorticotropic hormone (ACTH) production; in the client with Cushings disease, this
suppression will not occur.

B. Radioactive iodine uptake

1. This thyroid function test measures the absorption of an iodine isotope to determine
how the thyroid gland is functioning.
2. A small dose of radioactive iodine is given by mouth or intravenously; the amount of
radioactivity is measured in 2 to 4 hours and again at 24 hours.
3. Normal values are 3% to 10% at 2 to 4 hours, and 5% to 30% in 24 hours.
4. Elevated values indicate hyperthyroidism, decreased iodine intake, or increased
iodine excretion.
5. Decreased values indicate a low T4 level, the use of antithyroid medications,
thyroiditis, myxedema, or hypothyroidism.
6. The test is contraindicated in pregnancy.

C. T3 and T4 resin uptake test***

1. Blood tests are used to diagnose thyroid disorders.
2. T3 and T4 regulate thyroid-stimulating hormone.
3. Normal values (normal findings vary between laboratory settings)
a. Triiodothyronine, total T3: 70205 ng/dL (1.23.4 nmol/L)
b. Thyroxine, total T4: 512 mcg/dL (64154 nmol/L)
c. Thyroxine, free (FT4): 0.82.8 ng/dL (1036 pmol/L)
4. The T4 level is elevated in hyperthyroidism and decreased in hypothyroidism.

D. Thyroid-stimulating hormone***
1. Blood test is used to differentiate the diagnosis of primary hypothyroidism.
2. Normal value is 210 mcU/L (210 mU/L).
3. Elevated values indicate primary hypothyroidism.
4. Decreased values indicate hyperthyroidism or secondary hypothyroidism.

E. Thyroid scan
1. A thyroid scan is performed to identify nodules or growths in the thyroid gland.
2. A radioisotope of iodine or technetium is administered before scanning the thyroid
gland.
3. Reassure the client that the level of radioactive medication is not dangerous to self or
others.***
4. Determine whether the client has received radiographic contrast agents within the past
3 months, because these may invalidate the scan.
5. Check with the health care provider (HCP) regarding discontinuing medications
containing iodine for 14 days before the test and the need to discontinue thyroid
medication before the test.***
6. Instruct the client to maintain NPO (nothing by mouth) status after midnight on the
day before the test; if iodine is used, the client will fast for an additional 45 minutes after
ingestion of the oral isotope and the scan will be performed in
24 hours.
7. If technetium is used, it is administered by the intravenous (IV) route 30 minutes
before the scan.
8. The test is contraindicated in pregnancy.

F. Needle aspiration of thyroid tissue

1. Aspiration of thyroid tissue is done for cytological examination.
2. No client preparation is necessary; NPO status may or may not be prescribed.
3. Light pressure is applied to the aspiration site after the procedure.

G. Glycosylated hemoglobin
1. HgbA1C is blood glucose bound to hemoglobin.
2. Hemoglobin A1c (glycosylated hemoglobin A; HbA1c) is a reflection of how well blood
glucose levels have been controlled for the past 3 to 4 months.
3. Hyperglycemia in clients with diabetes is usually a cause of an increase in HbA1c.
4. Fasting is not required before the test.
5. Normal reference intervals: 4.0%6.0% (4.0% 6.0%)
6. HgbA1C and estimated average glucose (eAG) reference intervals
!Poor glycemic control in a client with diabetes mellitus is usually the cause of an
increase in the HbA1c calue.

H. 24-hour urine collection for vanillylmandelic acid (VMA)

1. Diagnostic tests for pheochromocytoma include a 24-hour urine collection for
VMA, a product of catecholamine metabolism, metanephrine, and catecholamines, all of
which are elevated in the presence of pheochromocytoma.
2. The normal range of urinary catecholamines:
a. Epinephrine: < 20 mcg/day (< 109 nmol/day)
b. Norepinephrine: 1580 mcg/day (89473 nmol/day)

III. Pituitary Gland Disorders

Anterior Pituitary
Hyperpituitarism
Hypopituitarism
Posterior Pituitary
These disorders can be caused by damage to the posterior pituitary or hypothalamus:
Diabetes insipidus
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

A. Hypopituitarism
1. Description: Hyposecretion of 1 or more of the pituitary hormones caused by tumors,
trauma, encephalitis, autoimmunity, or stroke
2. Hormones most often affected are growth hormone (GH) and gonadotropic hormones
(luteinizing hormone, follicle-stimulating hormone), but thyroid-stimulating hormone
(TSH), adrenocorticotropic hormone (ACTH), or antidiuretic hormone (ADH) may be
involved.
3. Assessment
a. Mild to moderate obesity (GH, TSH)
b. Reduced cardiac output (GH, ADH)
c. Infertility, sexual dysfunction (gonadotropins, ACTH)
d. Fatigue, low blood pressure (TSH, ADH, ACTH, GH)
e. Tumors of the pituitary also may cause headaches and visual defects (the pituitary is
located near the optic nerve).
4. Interventions***
a. Client may need hormone replacement for the specific deficient hormones.
b. Provide emotional support to the client and family.
c. Encourage the client and family to express feelings related to disturbed body image
orsexual dysfunction.
d. Client education is needed regarding the signs and symptoms of hypofunction and
hyperfunction related to insufficient or excess hormone replacement
B. Hyperpituitarism (acromegaly)
1. Description: Hypersecretion of growth hormone by the anterior pituitary gland in an
adult; caused primarily by pituitary tumors
Leads to conditions sunch as acromegaly and cushings disease
2. Assessment
a. Large hands and feet
b. Thickening and protrusion of the jaw
c. Arthritic changes and joint pain, impingement syndromes
d. Visual disturbances
e. Diaphoresis
f. Oily, rough skin
g. Organomegaly
h . Hypertension, atherosclerosis, cardiomegaly, heart failure
i. Dysphagia
j. Deepening of the voice
k. Thickening of the tongue, narrowing of the airway, sleep apnea
l. Hyperglycemia
m. Colon polyps, increased colon cancer risk
3. Interventions***
a. Provide pharmacological interventions to suppress GH or to block the action of GH
b. Prepare the client for radiation of the pituitary gland or for stereotactic radiosurgery if
prescribed.
c. Prepare the client for hypophysectomy if planned.
d. Provide pharmacological and nonpharmacological interventions for joint pain.
e. Provide emotional support to the client and family, and encourage the client and family
to express feelings related to disturbed body image.
f. Provide frequent skin care.

C. Hypophysectomy (pituitary adenectomy, sublabial transsphenoidal pituitary

surgery)***
1. Description
a. Removal of a pituitary tumor via craniotomy or a sublabial transsphenoidal
(endoscopic transnasal) approach (the latter approach is preferred because it is
associated with fewer complications)
b. Complications for craniotomy include increased intracranial pressure, bleeding,
meningitis, and hypopituitarism.
c. Complications for the sublabial transsphenoidal surgery include cerebrospinal
fluid leak, infection, diabetes insipidus, and hypopituitarism.***
d. If the sublabial approach is used, an incision is made along the gum line of the inner
upper lip.
 2. Postoperative interventions***
a. Initial postoperative care is similar to craniotomy care.
b. Monitor vital signs, neurological status, and level of consciousness.
c. Elevate the head of the bed.
d. Monitor for increased intracranial pressure.
e. Instruct the client to avoid sneezing, coughing, and blowing the nose.
f. Monitor for bleeding.
g. Monitor for and report signs of temporary diabtes insipidus; monitor intake and output,
and report excessive urinary output.
h. If the entire pituitary is removed, clients will require lifelong replacement of ADH,
cortisol, and thyroid hormone.
i. Monitor for and report signs of infection and meningitis.
j. Administer antibiotics, analgesics, and antipyretics as prescribed.
k. Administer oral mouth rinses as prescribed. Clients may be instructed to avoid using a
toothbrush or to brush teeth gently with an ultra soft toothbrush for 10 days to 2
weeks after surgery.
l. Instruct the client in the administration of prescribed medications.
m. As prescribed, Instruct the client to brush teeth gently with an ultrasoft toothbrush for
at least 2 weeks following surgery.
!Following transphenoidal hypophysectomy, monitor for and report postnasal drip or
clear nasal drainage, which might indicate a cerebrospinal fluid leak. Clear drainage
should be checked for glucose.

D. Diabetes Insipidus***
1. Description***
a. Hyposecretion of ADH caused by stroke or trauma or maybe idiopatic
b. Kidney tubules fail to reabsorb water.
c. In central diabetes insipidus there is decreased ADH production.
d. In nephrogenic diabetes insipidus, ADH production is adequate but the kidneys do
not respond appropriately to the ADH.
2. Assessment***
a. Excretion of large amounts of dilute urine
b. Polydipsia
c. Dehydration (decreased skin turgor and dry mucous membranes)
d. Inability to concentrate urine
e. Low urinary specific gravity; normal is 1.003 1.030 (1.005 1.030)
f. Fatigue
g. Muscle pain and weakness
h . Headache
i. Postural hypotension that may progress to vascular collapse without rehydration
j. Tachycardia
3. Interventions***
a. Monitor vital signs and neurological and cardiovascular status.
b. Provide a safe environment, particularly for the client with postural hypotension.
c. Monitor electrolyte values and for signs of dehydration.
d. Maintain client intake of adequate fluids; IV hypotonic saline may be prescribed to
replace urinary losses.
e. Monitor intake and output, weight, serum osmolality, and specific gravity of urine for
excessive urinary output, weight loss, and low urinary specific gravity.
f. Instruct the client to avoid foods or liquids that produce diuresis
g. Vasopressin or desmopressin acetate may be prescribed; these are used when the
ADH deficiency is severe or chronic.
h . Instruct the client in the administration of medications as prescribed; desmopressin
acetate may be administered by subcutaneous injection, intravenously, intranasally, or
orally; ***watch for signs of water intoxication indicating overtreatment.
i. Instruct the client to wear a MedicAlert bracelet.

E. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

1. Description
a. Condition of hyperfunctioning of the posterior pituitary gland in which excess ADH is
released, but not in response to the bodys need for it.
b. Causes include trauma, stroke, malignancies (often in the lungs or pancreas),
medications, and stress.
c. The syndrome results in increased intravascular volume, water intoxication, and
dilutional hyponatremia.***
d. May cause cerebral edema and the client is at risk for seizures.
2. Assessment***
a. Signs of fluid volume overload
b. Changes in level of consciousness and mental status changes
c. Weight gain without edema
d. Hypertension
e. Tachycardia
f. Anorexia, nausea, and vomiting
g. Hyponatremia
h . Low urinary output and concentrated urine
3. Interventions***
a. Monitor vital signs and cardiac and neurological status.
b. Provide a safe environment, particularly for the client with changes in level of
consciousness or mental status.
c. Monitor for signs of increased intracranial pressure.
d. Implement seizure precautions.
e. Elevate the head of the bed a maximum of 10 degrees to promote venous return
and decrease baroreceptor-induced ADH release.
f. Monitor intake and output and obtain weight daily.
g. Monitor fluid and electrolyte balance.
h. Monitor serum and urine osmolality.
i. Restrict fluid intake as prescribed.
j. Administer IV fluids (usually normal saline [NS] or hypertonic saline) as prescribed;
monitor IV fluids carefully because of the risk for fluid volume overload.
k. Loop diuretics may be prescribed to promote diuresis but only if serum sodium is at
least 125 mEq/L(125 mmol/L); potassium replacement may be necessary if loop
diuretics are prescribed.
l. Vasopressin antagonists may be prescribed to decrease the renal response to ADH.

IV. Adrenal Gland Disorders

A. Adrenal cortex insufficiency (Addisons disease)
1. Primary adrenal insufficiency***
a. Also known as Addisons disease, refers to hyposecretion of adrenal cortex
hormones (glucocorticoids, mineralocorticoids, and androgen); autoimmune
destruction is a common cause.
b. Requires lifelong replacement of glucocorticoids and possibly of mineralo- corticoids
if significant hyposecretion occurs; the condition is fatal if left untreated.
2. Secondary adrenal insufficiency is caused by hyposecretion of ACTH from the
anterior pituitary gland; mineralocorticoid release is spared.
3. Loss of glucocorticoids in Addisons disease leads to decreased vascular tone,
decreased vascular response to the catecholamines epinephrine and norepinephrine,
and decreased gluconeogenesis.
4. In Addisons disease, loss of the mineralocorticoid aldosterone leads to
dehydration, hypotension, hyponatremia, and hyperkalemia.
5. Assessment
a. Lethargy, fatigue, and muscle weakness
b. Gastrointestinal disturbances
c. Weight loss
d. Menstrual changes in women; impotence in men
e. Hypoglycemia, Hyponatremia*
f. Hyperkalemia*, Hypercalcemia
g. Hypotension***
h. Hyperpigmentation of skin (bronzed) with primary disease***
6. Interventions
a. Monitor vital signs (particularly for hypotension), for weight loss, and intake and
output.
b. Monitor white blood cell (WBC) count; blood glucose; and potassium, sodium, and
calcium levels.
c. Administer glucocorticoids and/or mineralocorticoid medications as prescribed.
d. Observe for addisonian crisis caused by stress, infection, trauma, or surgery.

7. Client education***
a. Need for lifelong glucocorticoid replacement and possibly lifelong
mineralocorticoid replacement.
b. Corticosteroid replacement will need to be increased during times of stress.
c. Avoid individuals with an infection.
d. Avoid strenuous exercise and stressful situations.
e. Avoid over-the-counter medications.
f. Diet should be high in protein and carbohydrates; clients taking glucocorticoids
should be prescribed calcium and vitamin D supplements to protect against
corticosteroid-induced osteoporosis; some clients taking mineralocorticoids may be
prescribed a diet high in sodium.
g. Wear a MedicAlert bracelet.
h. Report signs and symptoms of complications, such as underreplacement and
overreplacement of corticosteroid hormones.

B. Addisonian crisis
1. Description
a. A life-threatening disorder caused by acute adrenal insufficiency.
b. Precipitated by stress, infection, trauma, surgery, or abrupt withdrawal of exogenous
corticosteroid use
c. Can cause hyponatremia, hyperkalemia, hypoglycemia, and shock***
2. Assessment
a. Severe headache
b. Severe abdominal, leg, and lower back pain
c. Generalized weakness
d. Irritability and confusion
e. Severe hypotension
f. Shock
3. Interventions
a. Prepare to administer glucocorticoids intravenously as prescribed.
b. Administer IV fluids as prescribed to replace fluids and restore electrolyte balance.
c. Following resolution of the crisis, administer glucocorticoid and mineralocorticoid
orally as prescribed.
d. Monitor vital signs, particularly blood pressure.
e. Monitor neurological status, noting irritability and confusion.
f. Monitor intake and output.
g. Monitor laboratory values, particularly sodium, potassium, and blood glucose
levels.
h. Protect the client from infection.
i. Maintain bed rest and provide a quiet environment.
! Clients taking exogenous corticosteroids must establish a plan with their HCPs for
increasing their corticosteroids during times of stress.

C. Cushings syndrome and Cushings disease (hypercortisolism)***

1. Cushings syndrome
a. A metabolic disorder resulting from the chronic and excessive production of cortisol by
the adrenal cortex or from the administration of glucocorticoids in large doses for
several weeks or longer (exogenous or iatrogenic).
b. ACTH secreting tumors (most often of the lung, pancreas, or gastrointestinal [GI] tract)
can cause Cushings syndrome.
2. Cushings disease is a metabolic disorder characterized by abnormally increased
secretion (endogenous) of cortisol, caused by increased amounts of ACTH secreted
by the pituitary gland.
3. Assessment***
a. Generalized muscle wasting and weakness
b. Moon face, buffalo hump
c. Truncal obesity with thin extremities, supraclavicular fat pads; weight gain
d. Hirsutism (masculine characteristics in females)
e. Hyperglycemia, hypernatremia***
f. Hypokalemia, hypocalcemia***
g. Hypertension***
h. Fragile skin that bruises easily, Reddish purple striae on the abdomen and upper
thighs.
4. Interventions***
a. Monitor vital signs, particularly blood pressure.
b. Monitor intake and output and weight.
c. Monitor laboratory values, particularly WBC count and serum glucose, sodium,
potassium, and calcium levels.
d. Prepare the client for radiation as prescribed if the condition results from a pituitary
adenoma.
e. Administer chemotherapeutic agents as prescribed for inoperable adrenal tumors.
f. Prepare the client for removal of pituitary tumor (hypophysectomy, sublabial
transsphenoidal adenectomy) if the condition results from increased pituitary
secretion of ACTH.
g. Prepare the client for adrenalectomy if the condition results from an adrenal
adenoma; glucocorticoid replacement may be required following adrenalectomy.
h . Clients requiring lifelong glucocorticoid replacement following adrenalectomy
should obtain instructions from their HCPs about increasing their glucocorticoid during
times of stress.
i. Assess for and protect against postoperative thrombus formation; Cushings
syndrome predisposes to thromboemboli.
j. Allow the client to discuss feelings related to body appearance.
k. Instruct the client about the need to wear a MedicAlert bracelet.
!Addisons disease is characterized by the hyposecretion of adrenal cortex hormones,
whereas Cushings syndrome and Cushings disease are characterized by a
hypersecretion of glucocorticoids.

D. Primary hyperaldosteronism (Conns syndrome)

1. Description
a. Hypersecretion of mineralocorticoids (aldosterone) from the adrenal cortex of the
adrenal gland
b. Most commonly caused by an adenoma
c. Excess secretion of aldosterone causes sodium and water retention and potassium
excretion, leading to hypertension and hypokalemic alkalosis.
2. Assessment
a. Symptoms related to hypokalemia, hypernatremia, and hypertension
b. Headache, fatigue, muscle weakness
c. Cardiac dysrhythmias
d. Paresthesias, tetany
e. Visual changes
f. Glucose intolerance
g. Elevated serum aldosterone levels
3. Interventions
a. Monitor vital signs, particularly blood pressure.
b. Monitor for signs of hypokalemia and hypernatremia.
c. Monitor intake and output and urine for specific gravity.
d. Monitor for hyperkalemia, particularly for clients with impaired renal function or
excessive potassium intake because potassium retaining diuretics and aldosterone
antagonists Spironolactone (Aldactone) may be prescribed to promote fluid balance
and control hypertension.
e. Administer potassium supplements as prescribed to treat hypokalemia; clients taking
potassium-retaining diuretics and potassium supplementation are at risk for
hyperkalemia.
f. Prepare the client for adrenalectomy.
g. Maintain sodium restriction, if prescribed, preoperatively.
h. Administer glucocorticoids preoperatively, as prescribed, to prevent adrenal
hypofunction and prepare for stress of surgery.
i. Monitor the client for adrenal insufficiency postoperatively.
j. Instruct the client regarding the need for glucocorticoid therapy following
adrenalectomy.
k. Instruct the client about the need to wear a MedicAlert bracelet.

E. Pheochromocytoma***
1. Description
a. Catecholamine-producing tumor usually found in the adrenal medulla, but
extraadrenal locations include the chest, bladder, abdomen, and brain; typically is a
benign tumor but can be malignant
b. Excessive amounts of epinephrine and norepinephrine are secreted.
c. Diagnostic test includes a 24-hour urine collection for VMA.
d. Surgical removal of the adrenal gland is the primary treatment.
e. Symptomatic treatment is initiated if surgical removal is not possible.
f. The complications associated with pheochromocytoma include hypertensive crisis;
hypertensive retinopathy and nephropathy, cardiac enlargement, and dysrhythmias; heart
failure; myocardial infarction; increased platelet aggregation; and stroke.
g. Death can occur from shock, stroke, renal failure, dysrhythmias, or dissecting aortic
aneurysm.
2. Assessment***
a. Paroxysmal or sustained hypertension
b. Severe headaches
c. Palpitations
d. Flushing and profuse diaphoresis
e. Pain in the chest or abdomen with nausea and vomiting
f. Heat intolerance
g. Weight loss
h . Tremors
i. Hyperglycemia
3. Interventions***
a. Monitor vital signs, particularly blood pressure and heart rate.
b. Monitor for hypertensive crisis; monitor for complications that can occur with
hypertensive crisis, such as stroke, cardiac dysrhythmias, and myocardial infarction.
c. Instruct the client not to smoke, drink caffeine-containing beverages, or change
position suddenly.
d. Prepare to administer -adrenergic blocking agents and -adrenergic blocking agents
as prescribed to control hypertension. - Adrenergic blocking agents are started 7 to
10 days before -adrenergic blocking agents.
e. Monitor serum glucose level.
f. Promote rest and a nonstressful environment.
g. Provide a diet high in calories, vitamins, and minerals.
h . Prepare the client for adrenalectomy.***
!For the client with pheochromocytoma, avoid stimuli that can precipitate a
hypertensive crisis, such as increased abdominal pressure and vigorous abdominal
palpation.

F. Adrenalectomy***
1. Description
a. Surgical removal of an adrenal gland.
b. Lifelong glucocorticoid and mineralocorticoid replacement is necessary with
bilateral adrenalectomy.
c. Temporary glucocorticoid replacement, *usually up to 2 years, is necessary after a
unilateral adrenalectomy.
d. Catecholamine levels drop as a result of surgery, which can result in cardiovascular
collapse, hypotension, and shock, and the client needs to be monitored closely.
e. Hemorrhage also can occur because of the high vascularity of the adrenal glands.
2. Preoperative interventions
a. Monitor electrolyte levels and correct electrolyte imbalances.
b. Assess for dysrhythmias.
c. Monitor for hyperglycemia.
d. Protect the client from infections.
e. Administer glucocorticoids as prescribed.
3. Postoperative interventions
a. Monitor vital signs.
b. Monitor intake and output; *if the urinary output is lower than 30 mL/hour, notify the
HCP, because this may result in acute kidney injury and indicate impending shock.***
c. Monitor weight daily.
d. Monitor electrolyte and serum glucose levels.
e. Monitor for signs of hemorrhage and shock, particularly during the first 24 to 48 hours.
f. Monitor for manifestations of adrenal insufficiency.
g. Assess the dressing for drainage.
h . Monitor for paralytic ileus.
i. Administer IV fluids as prescribed to maintain blood volume.
j. Administer glucocorticoids and mineralocorticoids as prescribed.
k. Administer pain medication as prescribed.
l. Provide pulmonary interventions to prevent atelectasis (coughing and deep
breathing, incentive spirometry, splinting of incision).
m. Instruct the client in the importance of hormone replacement therapy following
surgery.
n . Instruct the client regarding signs and symptoms of complications such as
underreplacement and overreplacement of hormones.
o. Instruct the client regarding the need to wear a MedicAlert bracelet.

V. Thyroid Gland Disorders

A. Hypothyroidism***
1. Description***
a. Hypothyroid state resulting from hyposecretion of thyroid hormones (T3 and T4)
and characterized by a decreased rate of body metabolism
b. The T4 is low and the TSH is elevated.
c. In primary hypothyroidism, the source of dysfunction is the thyroid gland and the
thyroid cannot produce the necessary amount of hormones. In secondary
hypothyroidism, the thyroid is not being stimulated by the pituitary to produce
hormones.
2. Assessment***
a. Lethargy and fatigue
b. Weakness, muscle aches, paresthesias
c. Intolerance to cold
d. Weight gain
e. Dry skin and hair and loss of body hair
f. Bradycardia
g. Constipation
h. Generalized puffiness and edema around the eyes and face (myxedema)
i. Forgetfulness and loss of memory
j. Menstrual disturbances
k. Goiter may or may not be present
l. Cardiac enlargement, tendency to develop heart failure
3. Interventions***
a. Monitor vital signs, including heart rate and rhythm.
b. Administer thyroid replacement; levothyroxine sodium (Synthroid) is most
commonly prescribed.***
c. Instruct the client about thyroid replacement therapy and about the clinical
manifestations of both hypothyroidism and hyperthyroidism related to
underreplacement or overreplacement of the hormone.
d. Instruct the client in a low calorie, low cholesterol, low saturated fat diet;
discuss a daily exercise program such as walking.
e. Assess the client for constipation; provide roughage and fluids to prevent constipation.
f. Provide a warm environment for the client.
g. Avoid sedatives and opioid analgesics because of increased sensitivity to these
medications; may precipitate myxedema coma.
h . Monitor for overdose of thyroid medications, characterized by tachycardia, chest
pain, restlessness, nervousness, and insomnia.
i. Instruct the client to report episodes of chest pain or other signs of overdose
immediately.

B. Myxedema coma***
1. Description
a. This rare but serious disorder results from persistently low thyroid production.
b. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication,
anesthesia and surgery, hypothermia, or the use of sedatives and opioid analgesics.
2. Assessment
a. Hypotension
b. Bradyardia
c. Hypothermia
d. Hyponatremia
e. Hypoglycemia
f. Genrealized edema
g. Respiratory failure
h. Coma
3. Interventions
a. Maintain a patent airway.
b. Institute aspiration precautions.
c. Administer IV fluids (normal or hypertonic saline) as prescribed.
d. Administer levothyroxine sodium intravenously as prescribed.***
e. Administer glucose intravenously as prescribed.
f. Administer corticosteroids as prescribed.
g. Assess the clients temperature hourly.
h. Monitor blood pressure frequently.
i. Keep the client warm.
j. Monitor for changes in mental status.
k. Monitor electrolyte and glucose levels.

C. Hyperthyroidism
1. Description***
a. Hyperthyroid state resulting from hypersecretion of thyroid hormones
(T3 and T4).
b. Characterized by an increased rate of body metabolism.
c. A common cause is Graves disease, also known as toxic diffuse goiter.
d. Clinical manifestations are referred to as thyrotoxicosis.
e. The T3 and T4 are usually elevated and the TSH level is low.
2. Assessment***
a. Personality changes such as irritability, agitation, and mood swings.
b. Nervousness and fine tremors of the hands.
c. Heat intolerance.
d. Weight loss.
e. Smooth, soft skin and hair.
f. Palpitations, cardiac dysrhythmias, such as tachycardia or atrial fibrillation
g. Diarrhea
h. Protruding eyeballs (exophthalmos) may be present
i. Diaphoresis
j. Hypertension
k. Enlarged thyroid gland (goiter)
3. Interventions***
a. Provide adequate rest.
b. Administer sedatives as prescribed.
c. Provide a cool and quiet environment.
d. Obtain weight daily.
e. Provide a high-calorie diet.
f. Avoid the administration of stimulants.
g. Administer antithyroid medications, such as methimazole or propylthiouracil(PTU)
that block thyroid synthesis as prescribed.***
h . Administer iodine preparations that inhibit the release of thyroid hormone as
prescribed.
i. Administer propranolol(Inderal) for tachycardia as prescribed.
j. Prepare the client for radioactive iodine therapy, as prescribed, to destroy thyroid
cells.
k. Prepare the client for subtotal thyroidectomy if prescribed.
l. Elevate the head of the bed of a client experiencing exophthalmos; in addition,
instruct on low-salt diet, administer artificial tears, encourage the use of dark glasses,
and tape eyelids closed at night if necessary.***
m. Allow the client to express concerns about body image changes.
D. Thyroid storm
1. Description***
a. This acute and life-threatening condition occurs in a client with uncontrollable
hyperthyroidism.
b. It can be caused by manipulation of the thyroid gland during surgery and the release of
thyroid hormone into the bloodstream; it also can occur from severe infection and
stress.
c. Antithyroid medications, beta blockers, glucocorticoids, and iodides may be
administered to the client before thyroid surgery to prevent its occurrence.
2. Assessment
a. Elevated temperature (fever)
b. Tachycardia
c. Systolic hypertension
d. Nausea, vomiting, and diarrhea
e. Agitation, tremors, anxiety
f. Irritability, agitation, restlessness, confusion, and seizures as the condition progresses
g. Delirium and coma
3. Interventions***
a. Maintain a patent airway and adequate ventilation.
b. Administer antithyroid medications, iodides, propranolol, and glucocorticoids as
prescribed.
c. Monitor vital signs.
d. Monitor continually for cardiac dysrhythmias.
e. Administer nonsalicylate antipyretics as prescribed (salicylates increase free thyroid
hormone levels).
f. Use a cooling blanket to decrease temperature as prescribed.

E. Thyroidectomy
1. Description
a. Removal of the thyroid gland
b. Performed when persistent hyperthyroidism exists
c. Subtotal thyroidectomy, removal of a portion of the thyroid gland, is the preferred
surgical intervention.
2. Preoperative interventions
a. Obtain vital signs and weight.
b. Assess electrolyte levels.
c. Assess for hyperglycemia.
d. Instruct the client in how to perform coughing and deep-breathing exercises and how
to support the neck in the postoperative period when coughing and moving.***
e. Administer antithyroid medications, iodides, propranolol, and glucocorticoids as
prescribed to prevent the occurrence of thyroid storm.
3. Postoperative interventions***
a. Monitor for respiratory distress.
b. Have a tracheotomy set, oxygen, and suction at the bedside.
c. Limit client talking, and assess level of hoarseness.
d. Avoid neck flexion and stress on the suture line.
e. Monitor for laryngeal nerve damage, as evidenced by airway obstruction, dysphonia,
high-pitched voice, stridor, dysphagia, and restlessness.
f. Monitor for signs of hypocalcemia and tetany, which can be caused by trauma to the
parathyroid gland.
SIGNS OF TETANY
Cardiac dysrhythmias
Carpopedal spasm
Dysphagia
Muscle and abdominal cramps
Numbness and tingling of the face and extremities
Positive Chvosteks sign
Positive Trousseaus sign
Visual disturbances (photophobia)
Wheezing and dyspnea (bronchospasm, laryngospasm)
Seizures
g. Prepare to administer calcium gluconate as prescribed for tetany.
h. Monitor for thyroid storm.
! Following thyroidectomy, maintain the client in a semi-Fowlers position. Monitor the
surgical site for edema and for signs of bleeding and check the dressing anteriorly and
at the back of the neck.

VI. Parathyroid Gland Disorders

A. Hypoparathyroidism
1. Description
a. Condition caused by hyposecretion of parathyroid hormone by the parathyroid
gland
b. Can occur following thyroidectomy because of removal of parathyroid tissue
2. Assessment***
a. Hypocalcemia and hyperphosphatemia***
b. Numbness and tingling in the face***
c. Muscle cramps and cramps in the abdomen or in the extremities***
d. Positive Trousseaus sign or Chvosteks sign***
e. Signs of overt tetany, such as bronchospasm, laryngospasm, carpopedal spasm,
dysphagia, photophobia, cardiac dysrhythmias, seizures
f. Hypotension***
g. Anxiety, irritability, depression
3. Interventions***
a. Monitor vital signs.
b. Monitor for signs of hypocalcemia and tetany.
c. Initiate seizure precautions.
d. Place a tracheotomy set, oxygen, and suctioning equipment at the bedside.***
e. Prepare to administer calcium gluconate intravenously for hypocalcemia.
f. Provide a high-calcium, low-phosphorus diet.***
g. Instruct the client in the administration of calcium supplements as prescribed.
h . Instruct the client in the administration of vitamin D supplements as prescribed;
vitamin D enhances the absorption of calcium from the GI tract.***
i. Instruct the client in the use of thiazide diuretics if prescribed, to protect the kidney if
vitamin D is also taken.
j. Instruct the client in the administration of phosphate binders as prescribed to promote
the excretion of phosphate through the GI tract.
k. Instruct the client to wear a MedicAlert bracelet.

B. Hyperparathyroidism
1. Description: Condition caused by hypersecretion of parathyroid hormone (PTH) by
the parathyroid gland
2. Assessment***
a. Hypercalcemia and hypophosphatemia.***
b. Fatigue and muscle weakness.
c. Skeletal pain and tenderness.
d. Bone deformities that result in pathological fractures.
e. Anorexia, nausea, vomiting, epigastric pain.
f. Weight loss.
g. Constipation.
h. Hypertension.***
i. Cardiac dysrhythmias.
j. Renal stones.
3. Interventions***
a. Monitor vital signs, particularly blood pressure.
b. Monitor for cardiac dysrhythmias.
c. Monitor intake and output and for signs of renal stones.
d. Monitor for skeletal pain; move the client slowly and carefully.
e. Encourage fluid intake.
f. Administer furosemide as prescribed to lower calcium levels.***
g. Administer NS intravenously as prescribed to maintain hydration.
h . Administer phosphates, which interfere with calcium reabsorption, as prescribed.
i. Administer calcitonin(Fortical; Miacalcin) as prescribed to decrease skeletal calcium
release and increase renal excretion of calcium.***
j. Administer IV or oral bisphosphonates to inhibit bone resorption.
k. Monitor calcium and phosphorus levels.
l. Prepare the client for parathyroidectomy as prescribed.
m. Encourage a high-fiber, moderate-calcium diet.***
n . Emphasize the importance of an exercise program and avoiding prolonged
inactivity.***

C. Parathyroidectomy
1. Description: Removal of 1 or more of the parathyroid glands.
a. Endoscopic radio guided parathyroidectomy with autotransplantation is the most
common procedure.
b. Parathyroid tissue is transplanted in the forearm or near the sternocleidomastoid
muscle, allowing PTH secretion to continue.
2. Preoperative interventions
a. Monitor electrolytes, calcium, phosphate, and magnesium levels.
b. Ensure that calcium levels are decreased to near-normal values.
c. Inform the client that talking may be painful for the first day or two after surgery.
3. Postoperative interventions***
a. Monitor for respiratory distress.
b. Place a tracheotomy set, oxygen, and suctioning equipment at the bedside.
c. Monitor vital signs.
d. Position the client in semi-Fowlers position.
e. Assess neck dressing for bleeding.
f. Monitor for hypocalcemic crisis, as evidenced by tingling and twitching in the
extremities and face.
g. Assess for positive Trousseaus sign or Chvosteks sign, which indicates tetany.
h . Monitor for changes in voice pattern and hoarseness.
i. Monitor for laryngeal nerve damage.
j. Instruct the client in the administration of calcium and vitamin D supplements as
prescribed.

VII. Disorders of the Pancreas

A. Diabetes mellitus
1. Description***
a. Chronic disorder of impaired carbohydrate, protein, and lipid metabolism caused by a
deficiency of insulin
b. An absolute or relative deficiency of insulin results in hyperglycemia.
c. Type 1 diabetes mellitus is a nearly absolute deficiency of insulin (primary beta cell
destruction); if insulin is not given, fats are metabolized for energy, resulting in
ketonemia (acidosis).
d. Type 2 diabetes mellitus is a relative lack of insulin or resistance to the action of
insulin; usually, insulin is sufficient to stabilize fat and protein metabolism but not
carbohydrate metabolism.
e. Metabolic syndrome is also known as syndrome X and the individual has coexisting
risk factors for developing type 2 diabetes mellitus; these risk factors include
abdominal obesity, hyperglycemia, hypertension, high triglyceride level, and a lowered
HDL (highdensity lipoprotein) cholesterol level.
f. Diabetes mellitus can lead to chronic health problems and early death as a result of
complications that occur in the large and small blood vessels in tissues and organs.
g. Macrovascular complications include coronary artery disease, cardiomyopathy,
hypertension, cerebrovascular disease, and peripheral vascular disease.
h. Microvascular complications include retinopathy, nephropathy, and neuropathy.
i. Infection is also a concern because of reduced healing ability.
j. Male erectile dysfunction can also occur as a result of the disease.
!Obesity is a major risk factor for diabetes mellitus
2. Assessment***
a. Polyuria, polydipsia, polyphagia (more common in type 1 diabetes mellitus)
b. Hyperglycemia
c. Weight loss (common in type 1 diabetes mellitus, rare in type 2 diabetes mellitus)
d. Blurred vision
e. Slow wound healing
f. Vaginal infections
g. Weakness and paresthesias
h. Signs of inadequate circulation to the feet
i. Signs of accelerated atherosclerosis (renal, cerebral, cardiac, peripheral)
3. Diet***
a. The diabetic clients diet should take into account weight, medication, activity level,
and other health problems.
b. Day-to-day consistency in timing and amount of food intake helps to control the
blood glucose level.
c. As prescribed by the HCP, the client may be advised to follow the recommendations of
the American Diabetic Association diet or U.S dietary guidelines.
d. Carbohydrate counting may be a simpler approach for some clients; it focuses on the
total grams of carbohydrates eaten per meal. The client may be more compliant with
carbohydrate counting, resulting in better glycemic control; it is usually necessary for
clients undergoing intense insulin therapy.
e. Incorporate the diet into individual client needs, lifestyle, and cultural and
socioeconomic patterns.
4. Exercise
a. Exercise lowers the blood glucose level, encourages weight loss, reduces
cardiovascular risks, improves circulation and muscle tone, decreases total cholesterol
and triglyceride levels, and decreases insulin resistance and glucose intolerance.
b. Instruct the client in dietary adjustments when exercising; dietary adjustments are
individualized.
c. If the client requires extra food during exercise to prevent hypoglycemia, it need not be
deducted from the regular meal plan.
d. If the blood glucose level is higher than 250 mg/dL (14.2 mmol/L) and urinary
ketones (type 1 diabetes mellitus) are present, the client is instructed not to exercise
until the blood glucose level is closer to normal and urinary ketones are absent.
e. The client should try to exercise at the same time each day and should exercise when
glucose from the meal is peaking, not when insulin or glucose-lowering medications
are peaking.
f. Insulin should not be injected into an area of the body that will be exercised following
injection, as exercise speeds absorption.
! Instruct the client with diabetes mellitus to monitor the blood glucose level before,
during, and after exercising.
5. Oral hypoglycemic medications: Oral medications are prescribed for clients with
diabetes mellitus type 2 when diet and weight control therapy have failed to maintain
satisfactory blood glucose levels.***
!To prevent a serious reaction, inform the client taking sulfonylurea to avoid consuming
alcohol.
6. Insulin***
a. Insulin is used to treat type 1 diabetes mellitus and may be used to treat type 2
diabetes mellitus when diet, weight control therapy, and oral hypoglycemic agents
have failed to maintain satisfactory blood glucose levels.
b. Illness, infection, and stress increase the blood glucose level and the need for insulin;
insulin should not be withheld during times of illness, infection, or stress because
hyperglycemia and diabetic ketoacidosis can result.
c. The peak action time of insulin is important to explain to the client because of the
possibility of hypoglycemic reactions occurring during this time.***
! Regular insulin (U-100 strength) can be administered via IV injection (IV push).
Regular insulin (U-100) and the short-duration insulins (lispro, aspart, and glulisine)
can be administered via IV infusion.

B. Complications of insulin therapy

1. Local allergic reactions***
a. Redness, swelling, tenderness, and induration or a wheal at the site of injection may
occur 1 to 2 hours after administration.
b. Reactions usually occur during the early stages of insulin therapy.
c. Instruct the client to cleanse the skin with alcohol before injection.
2. Insulin lipodystrophy
a. The development of fibrous fatty masses at the injection site caused by repeated
use of an injection site; use of human insulin helps to prevent this.
b. Instruct the client to avoid injecting insulin into affected sites.
c. Instruct the client about the importance of rotating insulin injection sites.
Systematic rotation within 1 anatomical area is recommended to prevent
lipodystrophy; the client should be instructed not to use the same site
more than once in a 2 to 3 week period. Injections should be 1. inches (3.8 cm)
apart within the anatomical area.
3. Dawn phenomenon
a. Dawn phenomenon is characterized by hyperglycemia upon morning awakening
that results from excessive early morning release of GH and cortisol.
b. Treatment requires an increase in the clients insulin dose or a change in the time
of insulin administration.***
4. Somogyi phenomenon
a. Normal or elevated blood glucose levels are present at bedtime; hypoglycemia
occurs at about 2 to 3 a.m., which causes an increase in the production of
counterregulatory hormones.
b. By about 7 a.m., in response to the counterregulatory hormones, the blood glucose
rebounds significantly to the hyperglycemic range.
c. Treatment includes a decrease in the clients insulin dose and increase in the
bedtime snack, or both.***
d. Clients experiencing the Somogyi phomeneon may complain of early morning
headaches, night sweats, or nightmares caused by the early morning hypoglycemia.

C. Insulin administration***
1. Subcutaneous injections and mixing insulin.
2. Insulin pumps
a. Continuous subcutaneous insulin infusion is administered by an externally worn
device that contains a syringe attached to a long, thin, narrow-lumen tube with a
needle or Teflon catheter attached to the end.
b. The client inserts the needle or Teflon catheter into the subcutaneous tissue (usually
on the abdomen or upper arm) and secures it with tape or a transparent dressing; the
pump is worn on a belt or in a pocket; the needle or Teflon catheter is changed at least
every 2 to 3 days.
c. A continuous basal rate of insulin infuses; in addition, on the basis of the blood glucose
level, the anticipated food intake, and the activity level, the client delivers a bolus of
insulin before each meal.
d. Both rapid-acting and regular short-acting insulin (buffered to prevent the
precipitation of insulin crystals within the catheter) are appropriate for use in
these pumps.
3. Insulin pump and skin sensor
a. A skin sensor device can be used that monitors the clients blood glucose
continuously; the information is transmitted to the pump, determines the need for
insulin, and then the insulin is injected.
b. The pump holds up to a 3-day supply of insulin and can be disconnected easily for
activities such as bathing.
4. Pancreas transplants
a. The goal of pancreatic transplantation is to halt or reverse the complications of
diabetes mellitus.
b. Transplantations are performed on a limited number of clients (in general, these are
clients who are undergoing kidney transplantation simultaneously).
c. Immunosuppressive therapy is prescribed to prevent and treat rejection.

D. Self-monitoring of blood glucose level***

1. Self-monitoring provides the client with the current blood glucose level and
information to maintain good glycemic control.
2. Monitoring requires a finger prick to obtain a drop of blood for testing.
3. Alternative site testing (obtaining blood from the forearm, upper arm, abdomen,
thigh, or calf) is available, using specific measurement devices.
4. Tests must be used with caution in clients with diabetic neuropathy.
5. Client instructions: Self-Monitoring of Blood Glucose Level
*Use the proper procedure to obtain the sample for determining the blood glucose
level.
*Perform the procedure precisely to obtain accurate results.
*Follow the manufacturers instructions for the glucometer.
*Wash hands before and after performing the procedure to prevent
infection.
*If needed, calibrate the monitor as instructed by the manufacturer.
*Check the expiration date on the test strips.
*If the blood glucose level results do not seem reasonable, reread the instructions,
reassess technique, check the expiration date of the test strips, and perform the
procedure again to verify results.

E. Urine testing
1. Urine testing for glucose is not a reliable indicator of the blood glucose level and is
not used for monitoring purposes.***
2. Instruct the client in the procedure for testing for urine ketones.
3. The presence of ketones may indicate impending ketoacidosis.
4. Urine ketone testing should be performed during illness and whenever the client with
type 1 diabetes mellitus has persistently elevated blood glucose levels (higher than
240 mg/dL [13.7 mmol/L] or as prescribed for 2 consecutive testing periods).

VIII. Acute Complications of Diabetes Mellitus

A. Hypoglycemia***
1. Description
a. Hypoglycemia occurs when the blood glucose level falls below 70 mg/dL (4.0
mmol/L), or when the blood glucose level drops rapidly from an elevated level.
b. Hypoglycemia is caused by too much insulin or too large an amount of an oral
hypoglycemic agent, too little food, or excessive activity.
c. The client needs to be instructed always to carry some form of fast-acting simple
carbohydrate with him or her.***
Simple Carbohydrates to Treat Hypoglycemia
Commercially prepared glucose tablets
6 to 10 Life Savers or hard candy
4 tsp of sugar
4 sugar cubes
1 Tbsp of honey or syrup
. cup of fruit juice or regular (nondiet) soft drink
 8 oz (235 mL) of low-fat milk
6 saltine crackers
3 graham crackers
d. If the client has hypoglycemic reaction and does not have any of the recommended
emergency foods available, any available food should be eaten; high fat foods slow
the absorption of glucose and the hypoglycemic symptoms may not resolve quickly.***
e. Clients who experience frequent episodes of hypoglycemia, older clients, and
client taking -adrenergic blocking agents may not experience the warning signs of
hypoglycemia until the blood glucose level is dangerously low; this phenomenon is
termed hypoglycemia unawareness.***
2. Assessment***
a. Mild hypoglycemia: The client remains fully awake but displays adrenergic
symptoms; the blood glucose level is lower than 70 mg/dL (4.0 mmol/L).
Hunger
Nervousness
Palpitations
Sweating
Tachycardia
Tremor
b. Moderate hypoglycemia: The client displays symptoms of worsening hypoglycemia;
the blood glucose level is usually lower than 40 mg/dL (2.2 mmol/L).
Confusion
Double vision
Drowsiness
Emotional changes
Headache
Impaired coordination
Inability to concentrate
Irrational or combative behavior
Lightheadedness
Numbness of the lips and tongue
Slurred speech
c. Severe hypoglycemia: The client displays severe neuroglycopenic symptoms; the
blood glucose level is usually lower than 20 mg/dL (1.1 mmol/L).
Difficulty arousing
Disoriented behavior
Loss of consciousness
Seizures
!Do not attempt to administer oral food or fluids to the client experiencing a severe
hypoglycemic reaction who is semiconscious or unconscious and is unable to
swallow. This client is at risk for aspiration. For this client, an injection of glucagon is
administered subcutaneously or intramuscularly. In the hospital or emergency
department, the client may be treated with an IV injection of 25 to 50 mL of 50%
dextrose in water.
3. Interventions***
PRIORITY NURSING ACTIONS
Suspected Hypoglycemic Reaction (the 15/ 15 rule)
1. If a blood glucose monitor is readily available, check the clients blood glucose level. If
the client is experiencing symptoms suggestive of hypoglycemia such as diaphoresis,
hunger, pallor, and shakiness, and a blood glucose monitor is not readily available,
assume hypoglycemia and treat accordingly.
2. For the client whose blood glucose is below 70 mg/dL (4.0 mmol/L), or for the client
with an unknown blood glucose who is exhibiting signs of hypoglycemia,
administer 15 g of a simple carbohydrate such as cup of fruit juice or 15 g of
glucose gel.
3. Recheck the blood glucose level in 15 minutes.
4. If the blood glucose remains below70 mg/dL(4.0 mmol/L), administer another 15 g
of a simple carbohydrate.
5. Recheck the blood glucose level in 15 minutes; if still below 70 mg/dL (4.0 mmol/L),
treat with an additional 15 g of a simple carbohydrate.
6. Recheck the blood glucose level in 15 minutes; if still below 70 mg/dL (4.0 mmol/L),
treat with 25 to 50 mL of 50% dextrose intravenously or, if no intravenous (IV)
equipment is present, treat with 1 mg of glucagon subcutaneously or intramuscularly.
7. After the blood glucose level has recovered, have the client ingest a snack that
includes a complex carbohydrate and a protein.
8. Document the clients complaints, actions taken, and outcome.
9. Explore the precipitating cause of the hypoglycemia with the client.
10. If the client is experiencing an altered level of consciousness, bypass oral treatment
and start with injectable glucagon or 50% dextrose. If the client is at home and does
not have access to injectable glucagon, the client should seek
immediate medical care.***

In the event of a suspected hypoglycemic reaction, the nurse should first check
the clients blood glucose level. If a blood glucose monitor is not available and the
client is experiencing the signs and symptoms of hypoglycemia, hypoglycemic reaction
should be suspected. If the blood glucose level is below 70 mg/dL (4.0 mmol/L), the
nurse should treat accordingly with 15 g of carbohydrate and recheck the level in 15
minutes. If the level is still below 70 mg/ dL (4.0 mmol/L), the nurse should treat with
an additional 15 g of carbohydrate. One more 15 g of carbohydrate if given if the level
remains below 70 mg/dL (4.0 mmol/L). The nurse then rechecks the blood glucose
level in another 15 minutes; if still below 70 mg/ dL(4.0 mmol/L), the nurse should treat
with an injectable form of glucose. The nurse should then have the client consume a
snack, document the occurrence, and explore the reasons the reaction occurred. If at
any point the client becomes unconscious, the nurse should administer an injectable
form of glucose to raise the blood glucose level.
Reference: Ignatavicius, Workman (2016), pp. 13301331. American Diabetes
Association. The 15/ 15rule.
B. Diabetic ketoacidosis (DKA)***
1. Description
a. Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes mellitus
that develops when a severe insulin deficiency occurs.
b. The main clinical manifestations include hyperglycemia, dehydration, ketosis, and
acidosis.
2. Assessment***
-Differences between Diabetic Ketoacidosis and Hyperglycemia Hyperosmolar
Nonketotic Syndrome

3. Interventions***
a. Restore circulating blood volume and protect against cerebral, coronary, and renal
hypoperfusion.
b. Treat dehydration with rapid IV infusons of 0.9% or 0.45% NS as prescribed; dextrose
is added to IV fluids when the blood glucose level reaches 250 to 300 mg/dL (14.2 to
17.1 mmol/L). Too rapid administration of IV fluids; use of the incorrect types of IV
fluids, particularly hypotonic solutions; and correcting the blood glucose level too
rapidly can lead to cerebral edema.
c. Treat hyperglycemia with insulin administered intravenously as prescribed.
d. Correct electrolyte imbalances (potassium level may be elevated as a result of
dehydration and acidosis).
e. Monitor potassium level closely because when the client receives treatment for the
dehydration and acidosis, the serum potassium level will decrease and potassium
replacement may be required.
f. Cardiacmonitoring should be in place for the client with DKA due to risks associated
with abnormal serum potassium levels.
4. Insulin IV administration***
a. Use short-duration insulin only.
b. An IV bolus dose of short-duration regular U - 100 insulin (usually 5 to 10 units) may
be prescribed before a continuous infusion is begun.
c. The prescribed IV dose of insulin for continuous infusion is prepared in 0.9% or 0.45%
NS as prescribed.
d. Always place the insulin infusion on an IV infusion controller.
e. Insulin is infused continuously until subcutaneous administration resumes, to prevent a
rebound of the blood glucose level.
f. Monitor vital signs.
g. Monitor urinary output and monitor for signs of fluid overload.
h. Monitor potassium and glucose levels and for signs of increased intracranial pressure.
i. The potassium level will fall rapidly within the first hour of treatment as the dehydration
and the acidosis are treated.
j. Potassium is administered intravenously in a diluted solution as prescribed; ensure
adequate renal function before administering potassium.
5. Client education: Guidelines during Illness
*Take insulin or oral antidiabetic medications as prescribed.
*Determine the blood glucose level and test the urine for ketones every 3 to 4 hours.
*If the usual meal plan cannot be followed, substitute soft foods 6 to 8 times a day.
*If vomiting, diarrhea, or fever occurs, consume liquids every 30 to 60minutes to
prevent dehydration and to provide calories.
*Notify the health care provider if vomiting, diarrhea, or fever persists; if blood
glucose levels are higher than 250 to 300 mg/ dL (14.2 to 17.1 mmol/L); when
ketonuria is present for more than 24 hours; when unable to take food
or fluids for a period of 4 hours; or when illness persists for more than 2 days.
!Monitor the client being treated for DKA closely for signs of increased intracranial
pressure. If the blood glucose level falls too far or too fast before the brain has time to
equilibrate, water is pulled from the blood to the cerebrospinal fluid and the brain, causing
cerebral edema and increased intracranial pressure.

C. Hyperosmolar hyperglycemic syndrome (HHS)

1. Description
a. Extreme hyperglycemia occurs without ketosis or acidosis.
b. The syndrome occurs most often in individuals with type 2 diabetes mellitus.
c. The major difference between HHS and DKA is that ketosis and acidosis do not
occur with HHS; enough insulin is present with HHS to prevent the breakdown of
fats for energy, thus preventing ketosis.***
2. Assessment***
-Differences between Diabetic Ketoacidosis and Hyperglycemia Hyperosmolar
Nonketotic Syndrome
3. Interventions***
a. Treatment is similar to that for DKA.
b. Treatment includes fluid replacement, correction of electrolyte imbalances, and insulin
administration.***
c. Fluid replacement in the older client must be done very carefully because of the
potential for heart failure.***
d. Insulin plays a less critical role in the treatment of HHS than it does in the treatment of
DKA because ketosis and acidosis do not occur; rehydration alone may decrease
glucose levels.

IX. Chronic Complications of Diabetes Mellitus***

A. Diabetic retinopathy
1. Description
a. Chronic and progressive impairment of the retinal circulation that eventually causes
hemorrhage
b. Permanent vision changes and blindness can occur.
c. The client has difficulty with carrying out the daily tasks of blood glucose testing and
insulin injections.
2. Assessment
a. A change in vision is caused by the rupture of small microaneurysms in retinal blood
vessels.
b. Blurred vision results from macular edema.
c. Sudden loss of vision results from retinal detachment.
d. Cataracts result from lens opacity.
3. Interventions***
a. Maintain safety.
b. Early prevention via the control of hypertension and blood glucose levels***
c. Photocoagulation (laser therapy) may be done to remove hemorrhagic tissue to
decrease scarring and prevent progression of the disease process.
d. Vitrectomy may be done to remove vitreous hemorrhages and thus decrease tension
on the retina, preventing detachment.
e. Cataract removal with lens implantation improves vision.***
B. Diabetic nephropathy
1. Description: Progressive decrease in kidney function.
2. Assessment
a. Microalbuminuria
b. Thirst
c. Fatigue
d. Anemia
e. Weight loss
f. Signs of malnutrition
g. Frequent urinary tract infections
h. Signs of a neurogenic bladder
3. Interventions
a. Early prevention measures include the control of hypertension and blood glucose
levels.
b. Assess vital signs.
c. Monitor intake and output.
d. Monitor the blood urea nitrogen, creatinine, and urine albumin levels.
e. Restrict dietary protein, sodium, and potassium intake as prescribed.
f. Avoid nephrotoxic medications.***
g. Prepare the client for dialysis procedures if planned.
h. Prepare the client for kidney transplant if planned.
i. Prepare the client for pancreas transplant if planned.
C. Diabetic neuropathy
1. Description
a. General deterioration of the nervous system throughout the body
b. Complications include the development of nonhealing ulcers of the feet, gastric
paresis, and erectile dysfunction.***
2. Classifications
a. Focal neuropathy or mononeuropathy: Involves a single nerve or group of
nerves,most frequently cranial nerves III (oculomotor) and VI (abducens), resulting
in diplopia
b. Sensory or peripheral neuropathy: Affects distal portion of nerves, most frequently
in the lower extremities.
c. Autonomic neuropathy: Symptoms vary according to the organ system involved.
d. Cardiovascular: Cardiac denervation syndrome (heart rate does not respond to
changes in oxygenation needs) and orthostatic hypotension occur.
e. Pupillary: Pupil does not dilate in response to decreased light.
f. Gastric: Decreased gastric emptying (gastroparesis)
g. Urinary: Neurogenic bladder
h . Skin: Decreased sweating
i. Adrenal: Hypoglycemic unawareness
j. Reproductive: Impotence (male), painful intercourse (female)
3. Assessment: Findings depend on the classification***
a. Paresthesias
b. Decreased or absent reflexes
c. Decreased sensation to vibration or light touch
d. Pain, aching, and burning in the lower extremities
e. Poor peripheral pulses
f. Skin breakdown and signs of infection
g. Weakness or loss of sensation in cranial nerves III (oculomotor), IV (trochlear), V
(trigeminal), and VI (abducens)
h . Dizziness and postural hypotension
i. Nausea and vomiting
j. Diarrhea or constipation
k. Incontinence
l. Dyspareunia
m. Impotence
n . Hypoglycemic unawareness
4. Interventions
a. Early prevention measures include the control of hypertension and blood glucose
levels.
b. Careful foot care is required to prevent trauma (Box 50-17).
***Preventive Foot Care Instructions***
*Provide meticulous skin care and proper foot care.
*Inspect feet daily and monitor feet for redness, swelling, or break in skin integrity.
*Notify the health care provider if redness or a break in the skin occurs.
*Avoid thermal injuries from hot water, heating pads, and baths.
*Wash feet with warm (not hot) water and dry thoroughly (avoid foot soaks).
*Avoid treating corns, blisters, or ingrown toenails.
*Do not cross legs or wear tight garments that may constrict blood flow.
*Apply moisturizing lotion to the feet but not between the toes.
*Prevent moisture from accumulating between the toes.
*Wear loose socks and well-fitting (not tight) shoes; do not go barefoot.
*Wear clean cotton socks to keep the feet warm and change the socks daily.
*Avoid wearing the same pair of shoes 2 days in a row.
 *Avoid wearing open-toed shoes or shoes with a strap that goes between the toes.
*Check shoes for cracks or tears in the lining and for foreign objects before putting
them on.
*Break in new shoes gradually.
*Cut toenails straight across and smooth nails with an emery board.
*Avoid smoking.
c. Administer medications as prescribed for pain relief.
d. Initiate bladder training programs.
e. Instruct in the use of estrogen-containing lubricants for women with dyspareunia.
f. Prepare the male client with impotence for penile injections or other possible treatment
options as prescribed.
g. Prepare for surgical decompression of compression lesions related to the cranial
nerves as prescribed.

X. Care of the Diabetic Client Undergoing Surgery***

A. Preoperative care
1. Check with HCP regarding withholding oral hypoglycemic medications or insulin.
2. Some long-acting oral antidiabetic medications are discontinued 24 to 48 hours before
surgery.
3. Metformin may need to be discontinued 48 hours before surgery and may not be
restarted until renal function is normal postoperatively.
4. All other oral antidiabetic medications are usually withheld on the day of surgery.
5. Insulin dose may be adjusted or withheld if IV insulin administration during surgery
is planned.
6. Monitor blood glucose level.
7. Administer IV fluids as prescribed.
B. Intraoperative care
1. Monitor blood glucose levels frequently.
2. Administer IV short or rapid acting insulin as prescribed to maintain the blood
glucose level lower than 200mg/dL.
C. Postoperative care
1. Administer IV glucose and insulin infusions as prescribed until the client can tolerate
oral feedings.
2. Administer supplemental short-acting insulin as prescribed based on blood
glucose results.
3. Monitor blood glucose levels frequently, especially if the client is receiving parenteral
nutrition.
4. When the client is toleratingfood, ensure that the client receives an adequate amount
of carbohydrate daily to prevent hypoglycemia.
5. Client is at higher risk for cardiovascular and renal complications postoperatively.
6. Client is also at risk for impaired wound healing.
c Disturbance in Elimination

I. Anatomy and Physiology

A. Functions of the gastrointestinal (GI) system
1. Process food substances
2. Absorb the products of digestion into the blood
3. Excrete unabsorbed materials
4. Provide an environment for microorganisms to synthesize nutrients, such as vitamin K
5. For risk factors associated with the GI system.
*Allergic reactions to food or medications
*Cardiac, respiratory, and endocrine disorders that may lead to slowed gastrointestinal
(GI) movement or constipation
*Chronic alcohol use
*Chronic high stress levels
*Chronic laxative use
*Chronic use of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs)
*Diabetes mellitus, which may predispose to oral candidal infections or other GI disorders
*Family history of GI disorders
*Long-term GI conditions, such as ulcerative colitis, that may predispose to colorectal
cancer
*Neurological disorders that can impair movement, particularly with chewing and
swallowing
*Previous abdominal surgery or trauma, which may lead to adhesions
*Tobacco use
B. Mouth
1. Contains the lips, cheeks, palate, tongue, teeth, salivary glands, muscles, and
maxillary bones
2. Saliva contains the enzyme amylase (ptyalin), which aids in digestion.
C. Esophagus
1. Collapsible muscular tube about 10 inches (25 cm) long
2. Carries food from the pharynx to the stomach
D. Stomach (capacity is 1,500ml)
1. Contains the cardia, fundus, body, and pylorus
2. Mucous glands are located in the mucosa and prevent autodigestion by providing an
alkaline protective covering.
3. The lower esophageal (cardiac) sphincter prevents reflux of gastric contents into the
esophagus.
4. The pyloric sphincter regulates the rate of stomach emptying into the small intestine.
5. Hydrochloric acid kills microorganisms, breaks food into small particles, and provides
a chemical environment that facilitates gastric enzyme activation.
6. Pepsin is the chief coenzyme of gastric juice, which converts proteins into proteoses
and peptones.
7. Intrinsic factor comes from parietal cells and is necessary for the absorption of
vitamin B12.
8. Gastrin controls gastric acidity.
9. The Glands and cells in the stomach secrete digestive enzymes:
1. Parietal cells- HCl acid and Intrinsic factor
2. Chief cells- pepsin digestion of PROTEINS!
3. Antral G-cells- gastrin
4. Argentaffin cells- serotonin
5. Mucus neck cells- mucus
E. Small intestine
1. The duodenum contains the openings of the bile and pancreatic ducts.
2. The jejunum is about 8 feet (2.4 meters) long.
3. The ileum is about 12 feet (3.7 meters) long.
4. The small intestine terminates in the cecum.
F. Pancreatic intestinal juice enzymes
1. Amylase digests starch to maltose.
2. Maltase reduces maltose to monosaccharide glucose.
3. Lactase splits lactose into galactose and glucose.
4. Sucrase reduces sucrose to fructose and glucose.
5. Nucleases split nucleic acids to nucleotides.
6. Enterokinase activates trypsinogen to trypsin.
G. Large intestine
1. About 5 feet (1.5 meters) long
2. Absorbs water and eliminates wastes
3. Intestinal bacteria play a vital role in the synthesis of some B vitamins and vitamin K.
4. Colon: Includes the ascending, transverse, descending, and sigmoid colons (most
mobile, prone to twisting) and rectum
5. The ileocecal valve prevents contents of the large intestine from entering the ileum.
6. The internal and external anal sphincters control the anal canal.
H. Peritoneum: Lines the abdominal cavity and forms the mesentery that supports the
intestines and blood supply.
I. Liver
1. The largest gland in the body, weighing 3 to 4 pounds (1.4 to 1.8 kg)
2. Contains Kupffer cells, which remove bacteria in the portal venous blood
3. Removes excess glucose and amino acids from the portal blood
4. Synthesizes glucose, amino acids, and fats
5. Aids in the digestion of fats, carbohydrates, and proteins
6. Stores and filters blood (200 to 400 mL of blood stored)
7. Stores vitamins A, D, and B and iron
8. The liver secretes bile to emulsify fats (500 to 1000 mL of bile/day).
9. Hepatic ducts
a. Deliver bile to the gallbladder via the cystic duct and to the duodenum via the
common bile duct
b. The common bile duct opens into the duodenum, with the pancreatic duct at the
ampulla of Vater.
c. The sphincter prevents the reflux of intestinal contents into the common bile duct and
pancreatic duct.
J. Gallbladder
1. Stores and concentrates bile and contracts to force bile into the duodenum during the
digestion of fats
2. The cystic duct joins the hepatic duct to form the common bile duct.
3. The sphincter of Oddi is located at the entrance to the duodenum.
4. The presence of fatty materials in the duodenum stimulates the liberation of
cholecystokinin, which causes contraction of the gallbladder and relaxation of the
sphincter of Oddi.
K. Pancreas
1. Exocrine gland
a. Secretes sodium bicarbonate to neutralize the acidity of the stomach contents that
enter the duodenum
b. Pancreatic juices contain enzymes for digesting carbohydrates, fats, and proteins.
2. Endocrine gland
a. Secretes glucagon to raise blood glucose levels and secretes somatostatin to exert a
hypoglycemic effect
b. The islets of Langerhans secrete insulin.
c. Insulin is secreted into the bloodstream and is important for carbohydrate metabolism.

BLOOD SUPPLY
- GIT recieves blood from arteries that originate along the entire length of the
thoracic and abdominal aorta
- The portal venous system is composed of 5 large veins: superior mesenteric,
inferior mesenteric, gastric, splenic, and cystic veins w/c form the vena portae
that enters the liver
- Oxygen and nutrients are supplied to the stomach by the gastric artery and to
the intestines by the mesenteric arteries.

Physiology
- Sympathetic
Generally INHIBITORY!
Decreased gastric secretions
Decreased GIT motility
Sphincters and blood vessels constrict

- Parasympathetic
Generally EXCITATORY!
Increased gastric secretions
Increased gastric motility
Sphincters relax
Terms
Digestion: phase of the digestive process that occurs when enzymes mix with
ingested food and when proteins, fats, and sugars are broken down into their
component molecules
Absorption: phase of the digestive process that occurs when small molecules,
vitamins, and minerals pass through the walls of the small and large intestine and
into the bloodstream
Elimination: phase of the digestive process that occurs after digestion and
absorption, when waste products are eliminated from the body

Digestive Processes
Chewing
- 1.5ml of saliva is secreted daily from the parotid, submaxillary and sublingual
glands
- PTYALIN or SALIVARY AMYLASE is an enzyme that begins the digestion of
starches

Swallowing begins as a voluntary act, w/c is regulated by the swallowing center in

the medulla oblongata of the CNS

Gastric Function
- stomach-secretes a highly acidic fluid in response to the presence of ingested
food
- fluid can total as 2.4L/day can have a ph as low as 1 and derives its acidity from
hydrochloric acid (HCl)
a. to breakdown food into more absorbable components
b. to aid in the destruction of ingested bacteria

Gastric Enzymes
Secreted by zymogens or chief cells
Amylase=for starch digestion
Lipase=for fat digestion
Pepsin=for protein digestion
Rennin=for milk and protein digestion

Secreted by parietal cells

HCl - maintains acidity 1.0 pH destroy some bacteria ingested aids also in digestion of
food
Intrinsic factor - aids in absorption of vit B12
* pernicious anemia

Secreted by endocrine cells

Gastrin, somatostatin and serotonin
 Small Intestine Function
- duodenal secretions come from the accessory digestive organs- pancreas, liver
and gallbladder and the glands on the intestinal walls pancreatic secretions have
alkaline pH due to the high concentration of bicarbonate- this neutralizes the acid
entering the duodenum from the stomach

Digestive enzymes secreted by the pancreas:

- trypsin aids in digesting protein
- amylase aids in digesting starches
- lipase aids in digesting fats
pancreatic secretions pancreatic duct ampulla of vater

2 Types of contractions in the small intestines

a. segmental contractions- mixing waves that move the intestinal contents back
and forth in a churning motion
b. intestinal peristalsis- propels the contents towards the colon
* both movements are stimulated by the presence of chyme
Finger like projections/villi are present throughout the small intestines- absorption-begins
in the jejunum by active transport and diffusion

Colonic Function
- bacteria make up a major component of the contents of the large intestine, assist
in completing the breakdown of waste material especially undigested and
unabsorbed proteins and bile salts

2 types of colonic secretions:

a. electrolyte solution- is chiefly bicarbonate solution that act to neutralize the end
products formed by the colonic bacterial action
b. mucus- protects the colonic mucosa

Waste Products of Digestion

- Feces - undigested foodstuff, inorganic materials, water and bacteria
- 75% fluid 25% solid material
- brown color results from the breakdown of bile
- gases- methane, hydrogen sulfide and ammonia
- Elimination begins with distention of the rectum w/c initiates contractions of the
rectal musculature and relaxes the closed internal anal sphincter
- internal anal sphincter- autonomic nervous system
- external anal sphincter- cerebral cortex; maintained in tonic contraction

II. Diagnostic Procedures

Common Gastrointestinal System Diagnostic Studies*
Capsule endoscopy
 Endoscopic retrograde cholangiopancreatography (ERCP)
Endoscopic ultrasound
Fiberoptic colonoscopy
Gastric analysis
Gastrointestinal motility studies
Hydrogen and urea breath test
Laparoscopy: Liver and pancreas laboratory studies
Liver biopsy
Paracentesis
Stool specimens
Upper gastrointestinal endoscopy or esophagogastroduodenoscopy
Upper gastrointestinal tract study (barium swallow)
Videofluoroscopic swallowing study
*Informed consent is obtained for a diagnostic study that is invasive.

A. Upper GI tract study (barium swallow)

1. Description: Examination of the upper GI tract under fluoroscopy after the client
drinks barium sulfate
2. Preprocedure: Withhold foods and fluids for 8 hours prior to the test (NPO after
midnight).
3. Postprocedure
a. A laxative may be prescribed.
b. Instruct the client to increase oral fluid intake to help pass the barium.
c. Monitor stools for the passage of barium (stools will appear chalky white for 24 to
72 hours postprocedure) because barium can cause a bowel obstruction.
B. Capsule endoscopy***
1. Description:A procedure that uses a small wireless camera shaped like a medication
capsule that the client swallows; the test will detect bleeding or changes in the lining of
the small intestine.
2. The camera travels through the entire digestive tract and sends pictures to a small box
that the client wears like a belt; the small box saves the pictures, which are then
transferred to a computer for viewing once the test is complete.
3. The client visits the health care providers (HCPs) office in the morning and swallows
the capsule, the recording belt is applied by the office staff, and then the client returns
at the end of the day so that pictures can be transferred to the computer.
4. Preprocedure: A bowel preparation will be prescribed. The client will need to maintain
a clear liquid diet on the evening before the exam; additionally,
NPO (nothing by mouth) status is maintained for 3 hours before and after
swallowing the capsule (time for NPO status is prescribed by the HCP but is usually 2
to 3 hours).
C. Gastric analysis
1. Description
a. Gastric analysis requires the passage of a nasogastric (NG) tube into the stomach to
aspirate gastric contents for the analysis of acidity (pH), appearance, and volume; the
 entire gastric contents are aspirated, and then specimens are collected every 15
minutes for 1 hour.
b. Medication, such as histamine or pentagastrin, may be administered subcutaneously
to stimulate gastric secretions; some medications
may produce a flushed feeling.
c. Esophageal reflux of gastric acid may be diagnosed by ambulatory pH monitoring; a
probe is placed just above the lower esophageal sphincter and connected to an
external recording device. It provides a computer analysis and graphic display of
results.
2. Preprocedure
a. Fasting for at least 12 hours is required before the test.
b. Use of tobacco and chewing gum is avoided for 24 hours before the test.
c. Medications that stimulate gastric secretions are withheld for 24 to 48 hours.
3. Postprocedure
a. Client may resume normal activities.
b. Refrigerate gastric samples if not tested within 4 hours.***
D. Upper GI endoscopy***
1. Description
a. Also known as esophagogastroduodenoscopy.***
b. Following sedation, an endoscope is passed down the esophagus to view the gastric
wall, sphincters, and duodenum; tissue specimens can be obtained.
2. Preprocedure
a. The client must be NPO for 6 to 8 hours before the test.
b. A local anesthetic (spray or gargle) is administered along with medication that
provides moderate (conscious) sedation and relieves anxiety, such as (IV)
midazolam, just before the scope is inserted.
c. Medication may be administered to reduce secretions, and medication may be
administered to relax smooth muscle.
d. The client is positioned on the left side to facilitate saliva drainage and to provide easy
access of the endoscope.
e. Airway patency is monitored during the test and pulse oximetry is used to monitor
oxygen saturation; emergency equipment should be readily available.
3. Postprocedure
a. Monitor vital signs.
b. Client must be NPO until the gag reflex returns (1 to 2 hours).
c. Monitor for signs of perforation (pain, bleeding, unusual difficulty in swallowing,
elevated temperature).
d. Maintain bed rest for the sedated client until alert.
e. Lozenges, saline gargles, or oral analgesics can relieve a minor sore throat (not
given to the client until the gag reflex returns).
E. Fiberoptic colonoscopy***
1. Description
a. Colonoscopy is a fiberoptic endoscopy study in which the lining of the large intestine
is visually examined; biopsies and polypectomies can be performed.
b. Cardiac and respiratory function is monitored continuously during the test.
c. Colonoscopy is performed with the client lying on the left side with the knees
drawn up to the chest; position may be changed during the test to facilitate passing of
the scope.
2. Preprocedure
a. Adequate cleansing of the colon is necessary, as prescribed by the HCP.***
b. A clear liquid diet is started on the day before the test. Red, orange, and purple
(grape) liquids are to be avoided.***
c. Consult with the HCP regarding medications that must be withheld before the test.
d. Client isNPO for 4 to 6 hours prior to the test.
e. Moderate sedation is administered intravenously.
f. Medication may be administered to relax smooth muscle.
3. Postprocedure
a. Monitor vital signs.
b. Provide bed rest until alert.
c. Monitor for signs of bowel perforation and peritonitis
Signs of Bowel Perforation and Peritonitis
Guarding of the abdomen
Increased temperature and chills
Pallor
Progressive abdominal distention and abdominal pain
Restlessness
Tachycardia and tachypnea
d. Remind the client that passing flatus, abdominal fullness, and mild cramping are
expected for several hours.
e. Instruct the client to report any bleeding to the HCP.
!The client receiving oral liquid bowel cleansing preparations or enemas is at risk for
fluid and electrolyte imbalances.
F. Laparoscopy is performed with a fiberoptic laparoscope that allows direct
visualization of organs and structures within the abdomen; biopsies may be
obtained.
G. Endoscopic retrograde cholangiopancreatography (ERCP)
1. Description
a. Examination of the hepatobiliary system is performed via a flexible endoscope
inserted into the esophagus to the descending duodenum; multiple positions are required
during the procedure to pass the endoscope.
b. If medication is administered before the procedure, the client is monitored closely for
signs of respiratory and central nervous system depression, hypotension, oversedation,
and vomiting.
2. Preprocedure
a. Client is NPO for 6 to 8 hours.
b. Inquire about previous exposure to contrast media and any sensitivities or allergies.
c. Moderate sedation is administered.
3. Postprocedure
a. Monitor vital signs.
b. Monitor for the return of the gag reflex.***
c. Monitor for signs of perforation or peritonitis***
Signs of Bowel Perforation and Peritonitis
Guarding of the abdomen
Increased temperature and chills
Pallor
Progressive abdominal distention and abdominal pain
Restlessness
Tachycardia and tachypnea
H. Endoscopic ultrasonography
1. Description: Provides images of the GI wall and digestive organs.
2. Preprocedure and postprocedure: Care is similar to that implemented for
endoscopy.
!Following endoscopic procedures, monitor for the return of the gag reflex before giving
the client any oral substance. If the gag reflex has not returned, the client could aspirate.
I. Computed tomography (CT) scan
1. Description
a. Noninvasive cross-sectional view that can detect tissue densities in the abdomen,
including in the liver, spleen, pancreas, and biliary tree.
b. Can be performed with or without contrast medium.***
2. Preprocedure
a. Client is NPO for at least 4 hours.
b. If contrast medium will be used, assess for previous sensitivities and allergies.
3. Postprocedure
a. No specific care is required.
J. Paracentesis***
1. Description: Transabdominal remaval of fluid from the peritoneal cavity for analysis.
2. Preprocedure:***
a. Have the client void before the start of procedure to empty the bladder and to move
the bladder out of the way of the paracentesis needle.
b. Measure abdominal girth, weight, and baseline vital signs.
c. Note that the client is positioned upright on the edge of the bed, with the back
supported and the feet resting on a stool (or in Fowlers position in bed).
3. Postprocedure:***
a. Monitor vital signs.
b. Measure fluid collected, describe, and record.
c. Label fluid samples and send to the laboratory for analysis.
d. Apply a dry sterile dressing to the insertion site; monitor the site for bleeding.
e. Measure abdominal girth and weight.
f. Monitor for hypovolemia, electrolyte loss, mental status changes, or encephalopathy.
g. Monitor for hematuria caused by bladder trauma.
h. Instruct the client to notify the HCP if the urine becomes bloody, pink, or red.
PRIORITY NURSING ACTIONS
Paracentesis
1. Ensure that the client understands the procedure and that informed consent has been
obtained.
2. Obtain vital signs, including weight, and assist the client to void.
3. Position the client upright.
4. Assist the health care provider (HCP),monitor vital signs, and provide comfort and
support during the procedure.
5. Apply a dressing to the site of puncture.
6. Monitor vital signs, especially blood pressure and pulse because these parameters
provide information on rapid vasodilation postparacentesis; weigh the client
postprocedure, and maintain the client on bed rest.
7. Measure the amount of fluid removed.
8. Label and send the fluid for laboratory analysis.
9. Document the event, clients response, and appearance and amount of fluid removed.

Paracentesis is the transabdominal removal of fluid from the peritoneal cavity. The
nurse first ensures that the client understands the procedure and that informed consent
has been obtained, because the procedure is invasive. The nurse next obtains
preprocedure vital signs, including weight, so that a baseline is obtained. Weight is taken
before and after the procedure to provide an indication of the effectiveness of the
procedure in fluid removal. The client is assisted to void to emptythe bladder and to move
the bladder out of the wayof the paracentesis needle. The client is positioned upright on
the edge of a bed with the back supported and the feet resting on a stool, or in a Fowlers
position in bed. The nurse assists the HCP,monitors vital signs per protocol, and provides
comfort and support to the client during the procedure. Once the procedure is complete,
the nurse applies a dressing to the site of puncture and monitors for leakage or bleeding.
The client is placed in a position of comfort, bed rest is maintained as prescribed, and
vital signs are monitored to assess for complications. The fluid removed from the client is
measured, labeled, and sent to the laboratory for analysis. The nurse documents the
event, the clients response, the appearance and amount of fluid removed, and any
additional pertinent data.
Reference Ignatavicius, Workman (2016), p. 1199.

!The rapid removal of fluid from the abdominal cavity during paracentesis leads to
decreased abdominal pressure, which can cause vasodilation and resultant shock;
therefore, heart rate and blood pressure must be monitored closely.

K. Liver biopsy***
1. Description: A needle is inserted through the abdominal wall to the liver to obtain a
tissue sample for biopsy and microscopic examination.
2. Preprocedure***
a. Assess results of coagulation tests (prothrombin time, partial thromboplastin time,
platelet count).***
b. Administer a sedative as prescribed.***
c. Note that the client is placed in the supine or left lateral position during the
procedure to expose the right side of the upper abdomen.
3. Postprocedure
a. Assess vital signs.
b. Assess biopsy site for bleeding.***
c. Monitor for peritonitis
Signs of Bowel Perforation and Peritonitis
Guarding of the abdomen
Increased temperature and chills
Pallor
Progressive abdominal distention and abdominal pain
Restlessness
Tachycardia and tachypnea
d. Maintain bed rest for several hours as prescribed.***
e. Place the client on the right side with a pillow under the costal margin for 2 hours
to decrease the risk of bleeding, and instruct the client to avoid coughing and
straining.***
f. Instruct the client to avoid heavy lifting and strenuous exercise for 1 week.
L. Stool specimens
1. Testing of stool specimens includes inspecting the specimen for consistency and color
and testing for occult blood.
2. Tests for fecal urobilinogen, fat, nitrogen, parasites, pathogens, food substances, and
other substances may be performed; these tests require that the specimen be sent to
the laboratory.
3. Random specimens are sent promptly to the laboratory.
4. Quantitative 24- to 72-hour collections must be kept refrigerated until they are taken to
the laboratory.
5. Some specimens require that a certain diet be followed or that certain medications be
withheld; check agency guidelines regarding specific procedures.
M. Urea breath test
1. The urea breath test detects the presence of Helicobacter pylori, the bacteria that
cause peptic ulcer disease.
2. The client consumes a capsule of carbon-labeled urea and provides a breath sample
10 to 20 minutes later.
3. Certain medications may need to be avoided before testing. These may include
antibiotics or bismuth subsalicylate for 1 month before the test; sucralfate and
omeprazole for 1 week before the test; and cimetidine, famotidine, ranitidine, and
nizatidine for 24 hours before breath testing.
4. H. pylori can also be detected by assessing serum antibody levels.
N. Liver and pancreas laboratory studies***
1. Liver enzyme levels (alkaline phosphatase [ALP], aspartate aminotransferase [AST],
and alanine aminotransferase [ALT]) are elevated with liver damage or bilary
 obstruction. Normal reference intervals: ALP, 0.5 to 2.0 mckat/L(35 to 120 U/L); AST,
0 to 35 U/L(0 to 35 U/L);ALT, 4 to 36 U/L(4 to 36 U/L).
2. Prothrombin time is prolonged with liver damage. Normal reference interval:11 to
12.5 seconds.
3. The serum ammonia level assesses the ability of the liver to deaminate protein
byproducts. Normal reference interval: 10 to 80 mcg/dL (6 to 47 mcmol/L).
4. An increase in cholesterol level indicates pancreatitis or biliary obstruction. Normal
reference interval: < 200 mg/dL (< 5.0 mmol/L).
5. An increase in bilirubin level indicates liver damage or biliary obstruction. Normal
reference intervals: Total, 0.3 to 1.0 mg/dL (5.1 to 17 mcmol/L); indirect, 0.2 to 0.8
mg/dL (3.4 to 12 mcmol/L); direct, 0.1 to 0.3 mg/dL (1.7 to 5.1 mcmol/L).
6. Increased values for amylase and lipase levels indicate pancreatitis. Normal
reference intervals: amylase, 60 to 120 Somogyi units/dL (30 to 220 U/L); lipase, 0 to
160 U/L (0 to 160 U/L).
III. Assessment PG 693
A. Abdomen
1. Subjective data: Changes in appetite or weight, difficulty swallowing, dietary intake,
intolerance to certain foods, nausea or vomiting, pain, bowel habits, medications
currently being taken, history of abdominal problems or abdominal surgery.***
2. Objective data***
a. Ask the client to empty the bladder.
b. Be sure to warm the hands and the endpiece of the stethoscope.
c. Examine painful areas last.
!When performing an abdominal assessment, the specific order for assessment
techniques is inspection, auscultation, percussion, and palpation.
3. Inspection
a. Contour: Look down at the abdomen and then across the abdomen from the rib
margin to the pubic bone; describe as flat, rounded, concave, or protuberant.
b. Symmetry: Note any bulging or masses.
c. Umbilicus: Should be midline and inverted
d. Skin surface: Should be smooth and even
e. Pulsations from the aorta may be noted in the epigastric area, and peristaltic waves
may be noted across the abdomen.
4. Auscultation
a. Performed before percussion and palpation, which can increase peristalsis.
b. Hold the stethoscope lightly against the skin and listen for bowel sounds in all 4
quadrants; begin in the right lower quadrant (bowel sounds are normally heard here).
c. Note the character and frequency of normal bowel sounds: high-pitched gurgling
sounds occurring irregularly from 5 to 30 times a minute.
d. Identify as normal, hypoactive, or hyperactive (borborygmus).
e. Absent sounds: Auscultate for 5 minutes before determining that sounds are absent.
f. Auscultate over the aorta, renal arteries, iliac arteries, and femoral arteries for vascular
sounds or bruits.
5. Percussion
a. All 4 quadrants are percussed lightly.
b. Borders of the liver and spleen are percussed.
c. Tympany should predominate over the abdomen, with dullness over the liver and
spleen.
d. Percussion over the kidney at the 12th rib (costovertebral angle) should produce
no pain.
6. Palpation
a. Begin with light palpation of all 4 quadrants, using the fingers to depress the skin about
1 cm; next perform deep palpation, depressing 5 to 8 cm.
b. Palpate the liver and spleen (spleen may not be palpable).
c. Palpate the aortic pulsation in the upper abdomen slightly to the left of midline;
normally it pulsates in a forward direction (pulsation expands laterally if an aneurysm is
present).
7. diagnostic tests related to the gastrointestinal system.
8. Client teaching***
a. Encourage the client to consume a balanced diet; obesity needs to be prevented.
b. Substances that can cause gastric irritation should be avoided.
c. The regular use of laxatives is discouraged.
d. Lifestyle behaviors that can cause gastric irritation (e.g., spicy foods) should be
modified.
e. Regular physical examinations are important.
f. The client should report gastrointestinal problems to the HCP.
IV. Gastrointestinal Tubes (see chapter 20 pg. 239 of nclex rn saunders 7th edition)
Care of client with tube

V. Gastroesophageal Reflux Disease

A. Description
1. The backflow of gastric and duodenal contents into the esophagus.
2. The reflux is caused by an incompetent lower esophageal sphincter )LES), pyloric
stenosis, or motility disorder.
B. Assessment
1. Heartburn, epigastric pain
2. Dyspepsia
3. Nausea, regurgitation
4. Pain and difficulty with swallowing
5. Hypersalivation
C. Interventions
1. Instruct the client to avoid factors that decrease LES pressure or cause esophageal
irritation, such as peppermint, chocolate, coffee, fried or fatty foods, carbonated
beverages, alcoholic beverages, and cigarette smoking.***
2. Instruct the client to eat a low-fat, high-fiber diet and to avoid eating and drinking 2
hours before bedtime and wearing tight clothes; also, elevate the head of the bed on
6- to 8-inch (15 to 20 cm) blocks.
3. Avoid the use of anticholinergics, which delay stomach emptying; also,
nonsteroidal antiinflammatory medications (NSAIDs) and other medications that
contain acetylsalicylic acid need to be avoided.
4. Instruct the client regarding prescribed medications, such as antacids, H2-receptor
antagonists, or proton pump inhibitors.
5. Instruct the client regarding the administration of prokinetic medications, if
prescribed, which accelerate gastric emptying.
6. Surgery may be required in extreme cases when medical management is
unsuccessful; this involves a fundoplication (wrapping a portion of the gastric fundus
around the sphincter area of the esophagus); surgery may be performed by
laparoscopy.

VI. Gastritis
A. Description
1. Inflammation of the stomach or gastric mucosa
2. Acute gastritis is caused by the ingestion of food contaminated with disease-causing
microorganisms or food that is irritating or too highly seasoned, the overuse of aspirin
or other NSAIDs, excessive alcohol intake, bile reflux, or radiation therapy.
3. Chronic gastritis is caused bybenign ormalignant ulcers or by the bacteria H. pylori,
and also may becaused by autoimmune diseases, dietary factors, medications,
alcohol, smoking, or reflux.
B. Assessment
Assessment Finding in Acute and Chronic
Gastritis
Acute Chronic
Abdominal discomfort Anorexia, nausea, and
Anorexia, nausea, and vomiting
vomiting Belching
Headache Heartburn after eating
Hiccupping Sour taste in the mouth
Reflux Vitamin B12 deficiency
C. Interventions***
1. Acute gastritis: Food and fluids may be withheld until symptoms subside; afterward,
and as prescribed, ice chips can be given, followed by clear liquids, and then solid
food.
2. Monitor for signs of hemorrhagic gastritis such as hematemesis, tachycardia, and
hypotension, and notify the HCP if these signs occur.
3. Instruct the client to avoid irritating foods, fluids, and other substances, such as spicy
and highly seasoned foods, caffeine, alcohol, and nicotine.
4. Instruct the client in the use of prescribed medications, such as antibiotics to treat H.
pylori, and antacids.
5. Provide the client with information about the importance of vitamin B12 injections if a
deficiency is present.
VII.Peptic Ulcer Disease
A. Description
1. A peptic ulcer is an ulceration in the mucosal wall of the stomach, pylorus, duodenum,
or esophagus in portions accessible to gastric secretions; erosion may extend through
the muscle.
2. The ulcer may be referred to as gastric, duodenal, or esophageal, depending on its
location.
3. The most common peptic ulcers are gastric ulcers and duodenal ulcers.
*B. Gastric ulcers
1. Description
a. A gastric ulcer involves ulceration of the mucosal lining that extends to the submucosal
layer of the stomach.
b. Predisposing factors include stress, smoking, the use of corticosteroids, NSAIDs,
alcohol, history of gastritis, family history of gastric ulcers, or infection with H. pylori.
c. Complications include hemorrhage, perforation, and pyloric obstruction.
2. Assessment***
Assessment of Gastric and Duodenal Ulcers
***Gastric
*Gnawing, sharp pain in or to the left of the mid-epigastric region occurs 30 to 60
minutes after a meal (food ingestion accentuates the pain{Ingestion of food
does not relieve pain}).
*Hematemesis is more common than melena.
***Duodenal
*Burning pain occurs in the mid-epigastric area 11/2 to 3 hours after a meal and during
the night (often awakens the client).
*Melena is more common than hematemesis.
*Pain is often relieved by the ingestion of food.
3. Interventions***
a. Monitor vital signs and for signs of bleeding.
b. Administer small, frequent bland feedings during the active phase.
c. Administer H2-receptor antagonists or proton pump inhibitors as prescribed to
decrease the secretion of gastric acid.
d. Administer antacids as prescribed to neutralize gastric secretions.
e. Administer anticholinergics as prescribed to reduce gastric motility.
f. Administer mucosal barrier protectants as prescribed 1 hour before each meal.
g. Administer prostaglandins as prescribed for their protective and antisecretory actions.
4. Client education***
a. Avoid consuming alcohol and substances that contain caffeine or chocolate.
b. Avoid smoking.
c. Avoid aspirin or NSAIDs.
d. Obtain adequate rest and reduce stress.
5. Interventions during active bleeding
a. Monitor vital signs closely.
b. Assess for signs of dehydration, hypovolemic shock, sepsis, and respiratory
insufficiency.
c. Maintain NPO status and administer intravenous (IV) fluid replacement as
prescribed; monitor intake and output.
d. Monitor hemoglobin and hematocrit.
e. Administer blood transfusions as prescribed.
f. Prepare to assist with administering medications as prescribed to induce
vasoconstriction and reduce bleeding.
6. Surgical interventions
a. Total gastrectomy: Removal of the stomach with attachment of the esophagus to the
jejunum or duodenum; also called esophagojejunostomy or esophagoduodenostomy
b. Vagotomy: Surgical division of the vagus nerve to eliminate the vagal impulses that
stimulate hydrochloric acid secretion in the stomach
c. Gastric resection: Removal of the lower half of the stomach and usually includes a
vagotomy; also called antrectomy
d. Gastroduodenostomy: Partial gastrectomy, with the remaining segment
anastomosed to the duodenum; also called Billroth I.
*The distal portion of the stomach is removed, and the remainder is anastomosed to
the duodenum.
e. Gastrojejunostomy: Partial gastrectomy, with the remaining segment anastomosed to
the jejunum; also called Billroth II.
*The lower portion of the stomach is removed, and the remainder is anastomosed
to the jejunum.
f. Pyloroplasty: Enlargement of the pylorus to prevent or decrease pyloric obstruction,
thereby enhancing gastric emptying
7. Postoperative interventions
a. Monitor vital signs.
b. Place in a Fowlers position for comfort and to promote drainage.***
c. Administer fluids and electrolyte replacements intravenously as prescribed;
monitor intake and output.
d. Assess bowel sounds.
e. Monitor NG suction as prescribed.
f. Maintain NPO status as prescribed for 1 to 3 days until peristalsis returns.
g. Progress the diet from NPO to sips of clear water to 6 small bland meals a day,
as prescribed when bowel sounds return.
h . Monitor for postoperative complications of hemorrhage, dumping syndrome,
diarrhea, hypoglycemia, and vitamin B12 deficiency.***
! Following gastric surgery, do not irrigate or remove the NG tube unless specifically
prescribed because of the risk for disruption of the gastric sutures. Monitor closely to
ensure proper functioning of the NG tube to prevent strain on the anastomosis site.
Contact the HCP if the tube is not functioning properly.
C. Duodenal ulcers
1. Description
a. A duodenal ulcer is a break in the mucosa of the duodenum.
b. Risk factors and causes include infection with H. pylori; alcohol intake; smoking;
stress; caffeine; and the use of aspirin, corticosteroids, and NSAIDs.
c. Complications include bleeding, perforation, gastric outlet obstruction, and intractable
disease.
2. Assessment***
Assessment of Gastric and Duodenal Ulcers
***Gastric
*Gnawing, sharp pain in or to the left of the mid-epigastric region occurs 30 to 60 minutes
after a meal (food ingestion accentuates the pain).
*Hematemesis is more common than melena.
***Duodenal
*Burning pain occurs in the mid-epigastric area 11/2 to 3 hours after a meal and during
the night (often awakens the client).
*Melena is more common than hematemesis.
*Pain is often relieved by the ingestion of food.**
3. Interventions
a. Monitor vital signs.
b. Instruct the client about a bland diet, with small, frequent meals.
c. Provide for adequate rest.
d. Encourage the cessation of smoking.
e. Instruct the client to avoid alcohol intake; caffeine; and the use of aspirin,
corticosteroids, and NSAIDs.
f. Administer medications to treat H. pylori and antacids to neutralize acid secretions
as prescribed.
g. Administer H2-receptor antagonists or proton pump inhibitors as prescribed to
block the secretion of acid.
4. Surgical interventions: Surgery is performed only if the ulcer is unresponsive to
medications or if hemorrhage, obstruction, or perforation occurs.
D. Dumping syndrome
1. Description: The rapid emptying of the gastric contents into the small intestine that
occurs following gastric resection
2. Assessment***
a. Symptoms occurring 30 minutes after eating
b. Nausea and vomiting
c. Feelings of abdominal fullness and abdominal cramping
d. Diarrhea
e. Palpitations and tachycardia
f. Perspiration
g. Weakness and dizziness
h. Borborygmi (loud gurgling sounds resulting from bowel hypermotility)
3. Client education***
Client Education: Preventing Dumping Syndrome
*Avoid sugar, salt, and milk.
*Eat a high-protein, high-fat, low-carbohydrate diet.***
*Eat small meals and avoid consuming fluids with meals.
*Lie down after meals.
*Take antispasmodic medications as prescribed to delay gastric emptying.

VIII. Vitamin B12 Deficiency

A. Description
1. Vitamin B12 deficiency results from an inadequate intake of vitamin B12 or a lack of
absorption of ingested vitamin B12 from the intestinal tract.
2. Pernicious anemia results from a deficiency of intrinsic factor (normally secreted by the
gastric mucosa), necessary for intestinal absorption of vitamin B12; gastric disease or
surgery can result in a lack of intrinsic factor.
B. Assessment***
1. Severe pallor
2. Fatigue
3. Weight loss
4. Smooth, beefy red tongue***
5. Slight jaundice
6. Paresthesias of the hands and feet
7. Disturbances with gait and balance
C. Interventions***
1. Increase dietaryintake of foods rich in vitamin B12 such as citrus fruits, dried
beans, green leafy vegetables, liver, nuts, organ meats, and brewers yeast if the
anemia is the result of a dietary deficiency***
2. Administer vitamin B12 injections as prescribed, weekly initially and then
monthly for maintenance (lifelong) if the anemia is the result of a deficiency of
intrinsic factor or disease or surgery of the ileum.***

IX. Bariatric Surgery

A. Description
1. Surgical reduction of gastric capacity or absorptive ability that may be performed on a
client with morbid obesity to produce long-term weight loss
2. Surgery may be performed by laparoscopy; the decision is based on the clients
weight, body build, history of abdominal surgery, and current medical disorders.
3. Obese clients are at increased postoperative risk for pulmonary and thromboembolic
complications and death.***
4. Surgerycan prevent the complications ofobesity, such as diabetes mellitus,
hypertension and other cardiovascular disorders, or sleep apnea.
5. The client needs to agree to modifyhis or her lifestyle, lose weight and keep the weight
off, and obtain support from available community resources such as the American
 Obesity Association, American Society of Bariatric Surgery, or Overeaters
Anonymous.***
B. Postoperative interventions
1. Care is similar to that for the client undergoing laparoscopic or abdominal surgery.
2. As prescribed, if the client can tolerate water, clear liquids are introduced slowly in 1-
ounce (30 mL) cups for each serving once bowel sounds have returned and the client
passes flatus.
3. As prescribed, clear fluids are followed by pureed foods, juices, thin soups, and milk
24 to 48 hours after clear fluids are tolerated (the diet is usually limited to liquids or
pureed foods for 6 weeks); then the diet is progressed to nutrient-dense regular food.
C. Client teaching points about diet
**Dietary Measures for the Client Following Bariatric Surgery**
*Avoid alcohol, high-protein foods, and foods high in sugar and fat.
*Eat slowly and chew food well.
*Progress food types and amounts as prescribed.
*Take nutritional supplements as prescribed, which may include calcium, iron,
multivitamins, and vitamin B12.
*Monitor and report signs and symptoms of complications, such as dehydration and
gastric leak (persistent abdominal pain, nausea, vomiting). pg697

X. Gastric Cancer
A. Description
1. Gastric cancer is a malignant growth of the mucosal cells in the inner lining of the
stomach, with invasion to the muscle and beyond in advanced disease.
2. No single causative agent has been identified but it is believed that H. pylori infection
and a diet of smoked, highly salted, processed, or spiced foods have carcinogenic
effects; other risk factors include smoking, alcohol and nitrate ingestion, and a history
of gastric ulcers.
3. Complications include hemorrhage, obstruction, metastasis, and dumping syndrome.
4. The goal of treatment is to remove the tumor and provide a nutritional program.
B. Assessment
1. Early:
a. Indigestion
b. Abdominal discomfort
c. Full feeling
d. Epigastric, back, or retrosternal pain
2. Late:
a. Weakness and fatigue
b. Anorexia and weight loss
c. Nausea and vomiting
d. A sensation of pressure in the stomach
e. Dysphagia and obstructive symptoms
f. Iron deficiency anemia
g. Ascites
h . Palpable epigastric mass
C. Interventions
1. Monitor vital signs.
2. Monitor hemoglobin and hematocrit and administer blood transfusions as prescribed.
3. Monitor weight.
4. Assess nutritional status; encourage small, bland, easily digestible meals with vitamin
and mineral supplements.
5. Administer pain medication as prescribed.
6. Prepare the client for chemotherapy or radiation therapy as prescribed.
7. Prepare the client for surgical resection of the tumor as prescribed.
**Surgical Interventions for Gastric Cancer**
Subtotal Gastrectomy
Billroth I
Also called gastroduodenostomy
Partial gastrectomy, with remaining segment anastomosed to the duodenum
Billroth II
Also called gastrojejunostomy
Partial gastrectomy, with remaining segment anastomosed to the jejunum
Total Gastrectomy
Also called esophagojejunostomy
Removal of the stomach, with attachment of the esophagus to the jejunum or
duodenum
D. Postoperative interventions
1. Monitor vital signs.
2. Place in Fowlers position for comfort.
3. Administer analgesics and antiemetics, as prescribed.
4. Monitor intake and output; administer fluids and electrolyte replacement by IV as
prescribed; administer parenteral nutrition as indicated.
5. Maintain NPO (nothing bymouth) status as prescribed for 1 to 3 days until peristalsis
returns; assess for bowel sounds.
6. Monitor nasogastric suction. Following gastrectomy, drainage from the nasogastric
tube is normally bloody for 24 hours postoperatively, changes to brown-tinged,
and is then yellow or clear.
7. Do not irrigate or remove the nasogastric tube (follow agency procedures); assist the
HCP with irrigation or removal.
8. Advance the diet from NPO to sips of clear water to 6 small bland meals a day, as
prescribed.
9. Monitor for complications such as hemorrhage, dumping syndrome, diarrhea,
hypoglycemia, and vitamin B12 deficiency.

XI. Hiatal Hernia

A. Description
1. A hiatal hernia is also known as esophageal or diaphragmatic hernia.
2. A portion of the stomach herniates through the diaphragm and into the thorax.
3. Herniation results from weakening of the muscles of the diaphragm and is aggravated
by factors that increase abdominal pressure such as pregnancy, ascites, obesity,
tumors, and heavy lifting.
4. Complications include ulceration, hemorrhage, regurgitation and aspiration of stomach
contents, strangulation, and incarceration of the stomach in the chest with possible
necrosis, peritonitis, and mediastinitis.
B. Assessment
1. Heartburn
2. Regurgitation or vomiting
3. Dysphagia
4. Feeling of fullness
C. Interventions***
1. Medical and surgical management are similar to those for gastroesophageal reflux
disease.
2. Provide small frequent meals and limit the amount of liquids taken with meals.***
3. Advise the client not to recline for 1 hour after eating.***
4. Avoid anticholinergics, which delay stomach emptying.

XII. Cholecystitis
A. Description
1. Inflammation of the gallbladder that may occur as an acute or chronic process***
2. Acute inflammation is associated with gallstones (cholelithiasis).
3. Chronic cholecystitis results when inefficient bile emptying and gallbladder
muscle wall disease cause a fibrotic and contracted gallbladder.
4. Acalculous cholecystitis occurs in the absence of gallstones and is caused by
bacterial invasion via the lymphatic or vascular system.
B. Assessment
1. Nausea and vomiting
2. Indigestion
3. Belching
4. Flatulence
5. Epigastric pain that radiates to the right shoulder or scapula***
6. Pain localized in right upper quadrant and triggered by high-fat or high-volume meal
7. Guarding, rigidity, and rebound tenderness
8. Mass palpated in the right upper quadrant***
9. Murphys sign (cannot take a deep breath when the examiners fingers are passed
below the hepatic margin because of pain)***
10. Elevated temperature
11. Tachycardia
12. Signs of dehydration
C. Biliary obstruction
1. Jaundice***
2. Dark orange and foamy urine***
3. Steatorrhea and clay-colored feces***
4. Pruritus***
D. Interventions
1. Maintain NPO status during nausea and vomiting episodes.
2. Maintain NG decompression as prescribed for severe vomiting.
3. Administer antiemetics as prescribed for nausea and vomiting.
4. Administer analgesics as prescribed to relieve pain and reduce spasm.
5. Administer antispasmodics (anticholinergics) as prescribed to relax smooth muscle.
6. Instruct the client with chronic cholecystitis to eat small, low-fat meals.***
7. Instruct the client to avoid gas-forming foods.
8. Prepare the client for nonsurgical and surgical procedures as prescribed.
E. Surgical interventions
1. Cholecystectomy is the removal of the gallbladder.
2. Choledocholithotomy requires incision into the common bile duct to remove the
stone.
3. Surgical procedures may be performed by laparoscopy.
F. Postoperative interventions
1. Monitor for respiratory complications caused by pain at the incisional site.***
2. Encourage coughing and deep breathing.***
3. Encourage early ambulation.
4. Instruct the client about splinting the abdomen to prevent discomfort during coughing*
5. Administer antiemetics as prescribed for nausea and vomiting.
6. Administer analgesics as prescribed for pain relief.
7. Maintain NPO status and NG tube suction as prescribed.***
8. Advance diet from clear liquids to solids when prescribed and as tolerated by the
client.
9. Maintain and monitor drainage from the T-tube, if present
**Care of a T Tube**
Purpose and Description
A T-tube is placed after surgical exploration of the common bile duct. The tube preserves
the patency of the duct and ensures drainage of bile until edema resolves and bile is
effectively draining into the duodenum. A gravity drainage bag is attached to the T-tube
to collect the drainage.
Interventions***
*Place the client in semi-Fowlers position to facilitate drainage.
*Monitor the output, amount and the color, consistency, and odor of the drainage.
*Report sudden increases in bile output to the health care provider (HCP).
*Monitor for inflammation and protect the skin from irritation.
*Keep the drainage system below the level of the gallbladder.
*Monitor for foul odor and purulent drainage and report its presence to the HCP.
*Avoid irrigation, aspiration, or clamping of the T-tube without an HCPs prescription.
*As prescribed, clamp the tube before a meal and observe for abdominal discomfort
and distention, nausea, chills, or fever; unclamp the tube if nausea or vomiting occurs.
XIII. Cirrhosis
A. Description
1. A chronic, progressive disease of the liver characterized by diffuse degeneration and
destruction of hepatocytes
2. Repeated destruction of hepatic cells causes the formation of scar tissue.
3. Cirrhosis has many causes and is due to chronic damage and injury to liver cells; the
most common are chronic hepatitis C, alcoholism, nonalcoholic fatty liver disease
(NAFLD), and nonalcoholic steatohepatitis (NASH).
B. Complications
1. Portal hypertension: A persistent increase in pressure in the portal vein that develops
as a result of obstruction to flow
2. Ascites
a. Accumulation of fluid in the peritoneal cavity that results from venous congestion of the
hepatic capillaries
b. Capillary congestion leads to plasma leaking directly from the liver surface and portal
vein.
3. Bleeding esophageal varices: Fragile, thin-walled, distended esophageal veins that
become irritated and rupture
4. Coagulation defects
a. Decreased synthesis of bile fats in the liver prevents the absorption of fat-soluble
vitamins.
b. Without vitamin K and clotting factors II, VII, IX, and X, the client is prone to bleeding.
5. Jaundice: Occurs because the liver is unable to metabolize bilirubin and because the
edema, fibrosis, and scarring of the hepatic bile ducts interfere with normal bile and
bilirubin secretion
6. Portal systemic encephalopathy: End-stage hepatic failure characterized by altered
level of consciousness, neurological symptoms, impaired thinking, and neuromuscular
disturbances; caused by failure of the diseased liver to detoxify neurotoxic agents such
as ammonia
7. Hepatorenal syndrome
a. Progressive renal failure associated with hepatic failure
b. Characterized by a sudden decrease in urinary output, elevated blood urea nitrogen
and creatinine levels, decreased urine sodium excretion, and increased urine
osmolarity
C. Assessment
Dermatological Findings
Axillary and pubic hair changes
Caput medusae (dilated abdominal veins )*
Ecchymosis; petechiae*
Increased skin pigmentation
Jaundice
Palmar erythema*
Pruritus
Spider angioma s (chest and thorax)*
 Endocrine Findings
Increased aldosterone
Increased antidiuretic hormone
Increased circulating estrogens
Increased glucocorticoids
Gyne comastia
Immune System Disturbance
Increased susceptibility to infection
Leukopenia
Neurological Findings
Asterixis
Paresthesias of feet
Peripheral nerve degeneration
Portal-systemic encephalopathy
Reversal of sleep-wake pattern
Sensory disturbances
Pulmonary Findings
Dyspne a
Hydrothorax
Hyperventilation
Hypoxemia
Gastrointestinal (GI)Findings
Abdominal pain
Anorexia
Ascites
Clay-colored s tools
Diarrhea
Esophageal varices
Hiatal hernia
Hypersplenism
Malnutrition
Nausea
Small nodular liver
Vomiting
Fetor hepaticus
Galls tones
Gastritis
Gastrointestinal ble eding
Hemorrhoidal varices
Hepatomegaly
Hematological Findings
Anemia
Disseminated intravascular coagulation
Impaired coagulation
 Splenomegaly
Thrombocytopenia
Cardiovascular Findings
Cardiac dysrhythmias
Development of collateral circulation
Fatigue
Hyperkinetic circulation
Peripheral edema
Portal hypertension
Spider angiomas
Fluid and Electrolyte Disturbances
Ascites
Decreased effective blood volume
Hypokalemia
Peripheral edema
Water retention
Hypocalcemia
Dilutional hyponatremia or hypernatremia
Renal Findings
Hepatorenal syndrome
Incre ased urine bilirubin
D. Interventions***
1. Elevate the head of the bed to minimize shortness of breath.
2. If ascites and edema are absent and the client does not exhibit signs of impending
coma, a high-protein diet supplemented with vitamins is prescribed.
3. Provide supplemental vitamins (B complex; vitamins A, C, and K; folic acid; and
thiamine) as prescribed.
4. Restrict sodium intake and fluid intake as prescribed.
5. Initiate enteral feedings or parenteral nutrition as prescribed.
6. Administer diuretics asprescribed to treat ascites.
7. Monitor intake and output and electrolyte balance.
8. Weigh client and measure abdominal girth daily
*How to measure abdominal girth. With the client supine, bring the tape measure
around the client and take a measurement at the level of the umbilicus. Before
removing the tape, mark the clients abdomen along the sides of tape on the clients
flanks (sides) and midline to ensure that later measurements are taken at the same
place.
9. Monitor level of consciousness; assess for precoma state (tremors, delirium).
10. Monitor for asterixis, a coarse tremor characterized by rapid, nonrhythmic extensions
and flexions in the wrist and fingers
***Eliciting asterixis (flapping tremor). Have the client extend the arm, dorsiflexthe wrist,
and extend the fingers.Observe for rapid, nonrhythmic extensions and flexions.
11. Monitor for fetor hepaticus, the fruity, musty breath odor of severe chronic liver
disease.
12. Maintain gastric intubation to assess bleeding or esophagogastric balloon tamponade
to control bleeding varices if prescribed.
13. Administer blood products as prescribed.
14. Monitor coagulation laboratory results; administer vitamin K if prescribed.
15. Administer antacids as prescribed.
16. Administer lactulose as prescribed, which decreases the pH of the bowel, decreases
production of ammonia by bacteria in the bowel, and facilitates the excretion of
ammonia.
17. Administer antibiotics as prescribed to inhibit protein synthesis in bacteria and
decrease the production of ammonia.
18. Avoid medications such as opioids, sedatives, and barbiturates and any hepatotoxic
medications or substances.
19. Instruct the client about the importance of abstinence of alcohol intake.
20. Prepare the client for paracentesis to remove abdominal fluid.
21. Prepare the client for surgical shunting procedures if prescribed to divert fluid from
ascites into the venous system.

XIV. Esophageal Varices

A. Description
1. Dilated and tortuous veins in the submucosa of the esophagus.***
2. Caused by portal hypertension, often associated with liver cirrhosis; are at high risk for
rupture if portal circulation pressure rises
3. Bleeding varices are an emergency.***
4. The goal of treatment is to control bleeding, prevent complications, and prevent the
recurrence of bleeding.***
B. Assessment
1. Hematemesis
2. Melena***
3. Ascites
4. Jaundice
5. Hepatomegaly and splenomegaly
6. Dilated abdominal veins
7. Signs of shock
!Rupture and resultant hemorrhage of esophageal varices is the primary concern
because it is a lifethreatening situation.
C. Interventions***
1. Monitor vital signs.
2. Elevate the head of the bed.
3. Monitor for orthostatic hypotension.
4. Monitor lung sounds and for the presence of respiratory distress.
5. Administer oxygen as prescribed to prevent tissue hypoxia.
6. Monitor level of consciousness.
7. Maintain NPO status.
8. Administer fluids intravenously as prescribed to restore fluid volume and
electrolyte imbalances; monitor intake and output.
9. Monitor hemoglobin and hematocrit values and coagulation factors.
10. Administer blood transfusions or clotting factors as prescribed.
11. Assist in inserting an NG tube or a balloon tamponade as prescribed; balloon
tamponade is not used frequently because it is very uncomfortable for the client and
its use is associated with complications.
12. Prepare to assist with administering medications to induce vasoconstriction and
reduce bleeding.
13. Instruct the client to avoid activities that will initiate vasovagal responses.
14. Prepare the client for endoscopic procedures or surgical procedures as
prescribed.
*D. Endoscopic injection (sclerotherapy)
1. The procedure involves the injection of a sclerosing agent into and around bleeding
varices.
2. Complications include chest pain, pleural effusion, aspiration pneumonia, esophageal
stricture, and perforation of the esophagus.
*E. Endoscopic variceal ligation
1. The procedure involves ligation of the varices with an elastic rubber band.
2. Sloughing, followed by superficial ulceration, occurs in the area of ligation within 3 to 7
days.
*F. Shunting procedures
1. Description: Shunt blood away from the esophageal varices
2. Portacaval shunting involves anastomosis of the portal vein to the inferior vena cava,
diverting blood from the portal system to the systemic circulation
3. Distal splenorenal shunt
a. The shunt involves anastomosis of the splenic vein to the left renal vein.
b. The spleen conducts blood from the highpressure varices to the low-pressure renal
vein.
4. Mesocaval shunting involves a side anastomosis of the superior mesenteric vein to
the proximal end of the inferior vena cava.
5. Transjugular intrahepatic portosystemic shunt (TIPS)
a. This procedure uses the normal vascular anatomy of the liver to create a shunt with
the use of a metallic stent.
b. The shunt is between the portal and systemic venous system in the liver and is aimed
at relieving portal hypertension.

XV. Hepatitis
A. Description
1. Inflammation of the liver caused by a virus, bacteria, or exposure to medications or
hepatotoxins
2. The goals of treatment include resting the inflamed liver to reduce metabolic demands
and increasing the blood supply, thus promoting cellular regeneration and preventing
complications.
B. Types of Hepatitis
1. Hepatitis A virus (HAV)
2. Hepatitis B virus (HBV)
3. Hepatitis C virus (HCV)
4. Hepatitis D virus (HDV)
5. Hepatitis E virus (HEV)
C. Stages of Viral Hepatitis
Preicteric Stage
The first stage of hepatitis, preceding the appearance of jaundice; includes flulike
symptomsmalaise, fatigue; anorexia, nausea, vomiting, diarrhea; painheadache,
muscle aches, polyarthritis; and elevated serum bilirubin and enzyme levels.
Icteric Stage
The second stage of hepatitis; includes the appearance of jaundice and associated
symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored
stools; pruritus; and a decrease in preicteric-phase symptoms.
Posticteric Stage
The convalescent stage of hepatitis, in which the jaundice decreases and the color of the
urine and stool returns to normal; energy increases, pain subsides, there is minimal to
absent gastrointestinal symptoms, and bilirubin and enzyme levels return to normal.
D. Assesment
1. Preicteric Stage
a. Flulike symptoms malaise, fatigue
b. Anorexia, nausea, vomiting, diarrhea
c. Pain headache, muscle aches, polyarthritis
d. Serum bilirubin and enzyme levels are elevated
2. Icteric Stage
a. Jaundice
b. Pruritus
c. Dark or tea colored urine
d. Clay colored stool
e. Decrease in preicteric phase symptoms
3. Posticteric Stage
a. Increased energy levels
b. Subsiding of pain
c. Minimal to absent gastrointestinal symptoms
d. Serum bilirubin and enzyme levels return to normal
E. Laboratory assessment
1. Alanine aminotransferase (ALT) level: Elevated into the thousands (normal, 10 to 40
units/L)
2. Aspartate aminotransferase (AST) level: Elevated into the thousands (normal 10 to
30 units/L)
3. Ammonia: Elevated levels may lead to encephalopathy (normal, 10 to 80 mcg/dL)
4. Total bilirubin levels: Elevated in the serum and urine (normal, lower than 1.5
mg/dL)
XVI. Hepatitis A
A. Description:
1.Formerly known as infectious hepatitis
2. Commonly seen during the fall and early winter
B. Individuals at increased risk
1. Commonly seen in young children
2. Individuals in institutionalized settings
3. Health care personnel
4. Crowded conditions (e.g., day care, nursin home)
5. Exposure to poor sanitation
C. Transmission***
1. Fecal-oral route
2. Person-to-person contact
3. Parenteral
4. Contaminated fruits or vegetables, or uncooked shellfish
5. Contaminated water or milk
6. Poorly washed utensils
D. Incubation and infectious period
1. Incubation period is 2 to 6 weeks.*
2. Infectious period is 2 to 3 weeks before and 1 week after development of jaundice.
E. Testing
1. Infection is established by the presence of HAV antibodies (anti-HAV) in the blood.
2. ImmunoglobulinM(IgM) and immunoglobulin G (IgG) are normally present in the blood,
and increased levels indicate infection and inflammation.
3. Ongoing inflammation of the liver is evidenced by the presence of elevated levels of
IgM antibodies, which persist in the blood for 4 to 6 weeks.
4. Previous infection is indicated by the presence of elevated levels of IgG antibodies.
F. Complication: Fulminant (severe acute and often fatal) hepatitis
G. Prevention***
1. Strict hand washing
2. Stool and needle precautions
3. Treatment of municipal water supplies
4. Serological screening of food handlers
5. Hepatitis A vaccine: Two doses are needed at least 6 months apart for lasting
protection.
6. Immuneglobulin: For individuals exposed toHAV who have never received the
hepatitis A vaccine; administer immune globulin during the period of incubation and
within 2 weeks of exposure.
7. Immune globulin and hepatitis A vaccine are recommended for household
members and sexual contacts of individuals with hepatitis A.
8. Preexposure prophylaxis with immune globulin is recommended to individuals traveling
to countrieswith poor or uncertain sanitation conditions.
!Strict and frequent hand washing is key to preventing the spread of all types of
hepatitis.
XVII. Hepatitis B
A. Description
1. Hepatitis B is nonseasonal.
2. All age groups can be affected.
B. Individuals at increased risk
1. IV drug users
2. Clients undergoing long-term hemodialysis
3. Health care personnel
C. Transmission***
1. Blood or body fluid contact***
2. Infected blood products***
3. Infected saliva or semen***
4. Contaminated needles***
5. Sexual contact***
6. Parenteral***
7. Perinatal period***
8. Blood or body fluid contact at birth***
D. Incubation Period: 6 to 24 weeks*
E. Testing
1. Infection is established by the presence of hepatitis B antigenantibody systems in the
blood.
2. The presence of hepatitis B surface antigen (HBsAg) is the serological marker
establishing the diagnosis of hepatitis B.
3. The client is considered infectious if these antigens are present in the blood.
4. If the serological marker (HBsAg) is present after 6 months, it indicates a carrier
state or chronic hepatitis.
5. Normally, the serological marker (HBsAg) level declines and disappears after the
acute hepatitis B episode.
6. The presence of antibodies to HBsAg (anti-HBs) indicates recovery and immunity to
hepatitis B.
7. Hepatitis B early antigen (HBeAg) is detected in the blood about 1 week after the
appearance of HBsAg, and its presence determines the infective state of the client.
F. Complication
1. Fulminant hepatitis
2. Chronic liver disease
3. Cirrhosis
4. Primary hepatocellular carcinoma
G. Prevention***
1. Strict hand washing
2. Screening blood donors
3. Testing of all pregnant women
4. Needle precautions
5. Avoiding intimate sexual contact and contact with body fluids if test for HBsAg is
positive.***
6. Hepatitis B vaccine: Adult and pediatric forms; there is also an adult vaccine that
protects against hepatitis A and B.
7. Hepatitis B immune globulin is for individuals exposed to HBV through sexual
contact or through the percutaneous or transmucosal routes who have never had
hepatitis B and have never received hepatitis B vaccine.

XVIII. Hepatitis C
A. Description
1. HCV infection occurs year-round.
2. Infection can occur in any age group.
3. Infection with HCV is common among IV drug users and is the major cause of
posttransfusion hepatitis.
4. Risk factors are similar to those for HBV because hepatitis C is also transmitted
parenterally.
B. Individuals at increased risk
1. Parenteral drug users
2. Clients receiving frequent transfusions
3. Health care personnel
C. Transmission: Same as for HBV, primarily through blood***
D. Incubation period: 5 to 10 weeks*
E. Testing: Anti-HCV is the antibody to HCV and is measured to detect chronic states of
hepatitis C.
F. Complications
1. Chronic liver disease
2. Cirrhosis
3. Primary hepatocellular carcinoma
G. Prevention
1. Strict hand washing
2. Needle precautions
3. Screening of blood donors
XIX. Hepatitis D
A. Description
1. Hepatitis D is common in the Mediterranean and Middle Eastern areas.***
2. Hepatitis D occurs with hepatitis B and causes infection only in the presence of
active HBV infection.
3. Coinfection with the delta agent (HDV) intensifies the acute symptoms of hepatitis B.
4. Transmission and risk of infection are the same as for HBV, via contact with blood
and blood products.***
5. Prevention of HBV infection with vaccine also prevents HDV infection, because
HDV depends on HBV for replication.
B. High-risk individuals
1. Drug users
2. Clients receiving hemodialysis***
3. Clients receiving frequent blood transfusions***
C. Transmission: Same as for HBV
D. Incubation period: 7 to 8 weeks***
E. Testing: Serological HDV determination is made by detection of the hepatitis D
antigen (HDAg) early in the course of the infection and by detection of anti-HDV
antibody in the later disease stages.
F. Complications
1. Chronic liver disease
2. Fulminant hepatitis
G. Prevention: Because hepatitis D must coexist with hepatitis B, the precautions that
help to prevent hepatitis B are also useful in preventing delta hepatitis.***

XX. Hepatitis E
A. Description
1. Hepatitis E is a waterborne virus.***
2. Hepatitis E is prevalent in areas where sewage disposal is inadequate or where
communal bathing in contaminated rivers is practiced.***
3. Risk of infection is the same as for HAV.
4. Infection with HEV presents as a mild disease except in infected women in the third
trimester of pregnancy, who have a high mortality rate.
B. Individuals with increased risk
1. Travelers to countries that have a high incidence of hepatitis E, such as India,
Burma (Myanmar), Afghanistan, Algeria, and Mexico
2. Eating or drinking of food or water contaminated with the virus
C. Transmission: Same as for HAV
D. Incubation period: 2 to 9 weeks***
E. Testing: Specific serological tests for HEV include detection of IgM and IgG
antibodies to hepatitis E (anti-HEV).
F. Complications
1. High mortality rate in pregnant women***
2. Fetal demise
G. Prevention
1. Strict hand washing
2. Treatment of water supplies and sanitation measures***

XXI. Client and Family Home Care Instructions for Hepatitis***

Home Care Instructions for the Client with Hepatitis

*Hand washing must be strict and frequent.

*Do not share bathrooms unless the client strictly adheres to
personal hygiene measures.
*Individual washcloths, towels, drinking and eating utensils,
and toothbrushes and razors must be labeled and used
only by the client.
 *The client must not prepare food for other family members.
*The client should avoid alcohol and over-the-counter
medications, particularly acetaminophen and sedatives,
because these medications are hepatotoxic.
*The client should increase activity graduallyto prevent fatigue.
*The client should consume small, frequent meals consisting
of high-carbohydrate, low-fat foods.
*The client is not to donate blood.
*The client may maintain normal contact with persons as long
as proper personal hygiene is maintained.
*Close personal contact such as kissing and sexual activity
should be discouraged with hepatitis B until surface antigen
test results are negative.
*The client needs to carry a MedicAlert card noting the date of
hepatitis onset.
*The client needs to inform other health professionals, such as
medical or dental personnel, of the onset of hepatitis.
*The client needs to keep follow-up appointments with the
health care provider.

XXII. Pancreatitis
A. Description
1. Acute or chronic inflammation of the pancreas, with associated escape of pancreatic
enzymes into surrounding tissue
2. Acute pancreatitis occurs suddenly as 1 attack or can be recurrent, with
resolutions.***
3. Chronic pancreatitis is a continual inflammation and destruction of the pancreas, with
scar tissue replacing pancreatic tissue.***
4. Precipitating factors include trauma, the use of alcohol, biliary tract disease, viral or
bacterial disease, hyperlipidemia, hypercalcemia, cholelithiasis, hyperparathyroidism,
ischemic vascular disease, and peptic ulcer disease.
B. Acute pancreatitis
1. Assessment
a. Abdominal pain, including a sudden onset at a mid-epigastric or left upper quadrant
location with radiation to the back***
b. Pain aggravated by a fatty meal, alcohol, or lying in a recumbent position***
c. Abdominal tenderness and guarding***
d. Nausea and vomiting***
e. Weight loss***
f. Absent or decreased bowel sounds***
g. Elevated white blood cell count, and elevated glucose, bilirubin, alkaline phosphatase,
and urinary amylase levels
h . Elevated serum lipase and amylase levels
i. Cullens sign
j. Turners sign
!Cullens sign is the discoloration of the abdomen and periumbilicalarea.
Turners sign is the bluish discoloration of the flanks. Both signs are indicative of
pancreatitis.
2. Interventions
a. Maintain (NPO) status/Withhold food and fluid during the acute period and maintain
hydration with IV fluids as prescribed.***
b. Administer parenteral nutrition for severe nutritional depletion.***
c. Administer supplemental preparations and vitamins and minerals to increase caloric
intake if prescribed.***
d. An NG tube may be inserted if the client is vomiting or has biliary obstruction or
paralytic ileus.***
e. Administer opiates as prescribed for pain.
f. Administer H2-receptor antagonists or proton pump inhibitors as prescribed to
decrease hydrochloric acid production and prevent activation of pancreatic enzymes.
g. Instruct the client in the importance of avoiding alcohol.***
h . Instruct the client in the importance of follow-up visits with the HCP.
i. Instruct the client to notify the HCP if acute abdominal pain, jaundice, clay-colored
stools, or dark-colored urine develops.***

C. Chronic Pancreatitis
1. Assessment***
a. Abdominal pain and tenderness
b. Left upper quadrant mass
c. Steatorrhea and foul-smelling stools that may increase in volume as pancreatic
insufficiency increases
d. Weight loss
e. Muscle wasting
f. Jaundice
g. Signs and symptoms of diabetes mellitus***
2. Interventions***
a. Instruct the client in the prescribed dietary measures (fat and protein intake may be
limited).
b. Instruct the client to avoid heavy meals.
c. Instruct the client about the importance of avoiding alcohol.
d. Provide supplemental preparations and vitamins and minerals to increase caloric
intake.
e. Administer pancreatic enzymes as prescribed to aid in the digestion and absorption of
fat and protein.
f. Administer insulin or oral hypoglycemic medications as prescribed to control diabetes
mellitus, if present.
g. Instruct the client in the use of pancreatic enzyme medications.
h. Instruct the client in the treatment plan for glucose management.
i. Instruct the client to notify the HCP if increased steatorrhea, abdominal distention
or cramping, or skin breakdown develops.
j. Instruct the client in the importance of follow-up visits. Pg 705

XXIII. Pancreatic Tumors, Intestinal Tumors, Bowel Obstructions

Pancreatic Cancer
A. Description
1. Most pancreatic tumors are highly malignant, rapidly growing adenocarcinomas
originating from the epithelium of the ductal system.***
2. Pancreatic cancer is associated with increased age, a history of diabetes mellitus,
alcohol use, history of previous pancreatitis, smoking, ingestion of a high-fat diet, and
exposure to environmental chemicals.
3. Symptoms usually do not occur until the tumor is large; therefore, the prognosis
is poor.***
4. Endoscopic retrograde cholangiopancreatography*** for visualization of the
pancreatic duct and biliary system and collection of tissue and secretions may be
done.
B. Assessment***
1. Nausea and vomiting
2. Jaundice
3. Unexplained weight loss***
4. Clay-colored stools***
5. Glucose intolerance***
6. Abdominal pain***
C. Interventions
1. Radiation
2. Chemotherapy
3. Whipple procedure, which involves a pancreaticoduodenectomy with removal of the
distal third of the stomach, pancreaticojejunostomy, gastrojejunostomy, and
choledochojejunostomy
4. Postoperative care measures and complications are similar to those for the care
of a client with pancreatitis and the client following gastric surgery; monitor
blood glucose levels for transient hyperglycemia or hypoglycemia resulting from
surgical manipulation of the pancreas.***
Intestinal tumors
A. Description
1. Intestinal tumors are malignant lesions that develop in the cells liningthe bowelwall or
develop as adenomatous polyps in the colon or rectum.
2. Tumor spread is by direct invasion and through the lymphatic and circulatory systems.
3. Complications include bowel perforation with peritonitis, abscess and fistula formation,
hemorrhage, and complete intestinal obstruction.
B. Risk factors for colorectal cancer
1. Age older than 50 years
2. Familial polyposis, family history of colorectal cancer***
3. Previous colorectal polyps, history of colorectal cancer***
4. History of chronic inflammatory bowel disease***
5. History of ovarian or breast, endometrial, and stomach cancers***
C. Assessment
1. Blood in stool (most common manifestation) detected by fecal occult blood testing,
sigmoidoscopy, and colonoscopy
2. Anorexia, vomiting, and weight loss
3. Anemia
4. Abnormal stools
a. Ascending colon tumor: Diarrhea
b. Descending colon tumor: Constipation or some diarrhea, or flat, ribbon-like stool
caused by a partial obstruction
c. Rectal tumor: Alternating constipation and diarrhea
5. Guarding or abdominal distention, abdominal mass (late sign)
6. Cachexia (late sign)
7. Masses noted on barium enema, colonoscopy, CT scan, sigmoidoscopy
D. General interventions
1. Monitor for signs of complications, which include bowel perforation with peritonitis,
abscess or fistula formation (fever associated with pain), hemorrhage (signs of shock),
and complete intestinal obstruction.***
2. Monitor for signs of bowel perforation, which include low blood pressure, rapid and
weak pulse, distended abdomen, and elevated temperature.
3. Monitor for signs of intestinal obstruction, which include vomiting (may be fecal
contents), pain, constipation, and abdominal distention; provide comfort measures.
4. Note that an earlysign of intestinal obstruction is increased peristaltic activity, which
produces an increase in bowel sounds; as the obstruction progresses, hypoactive
bowel sounds may be heard.
5. Prepare for radiation preoperatively to facilitate surgical resection, and postoperatively
to decrease the risk of recurrence or to reduce pain, hemorrhage, bowel obstruction,
or metastasis.
E. Nonsurgical interventions
1. Preoperative radiation for local control and postoperative radiation for palliation may be
prescribed.
2. Postoperative chemotherapy to control symptoms and the spread of disease
F. Surgical interventions: Bowel, local lymph node resection, and creation of a
colostomy or ileostomy
G. Colostomy, ileostomy
1. Preoperative interventions
a. Consult with the enterostomal therapist to assist in identifying optimal placement of the
ostomy.
b. Instruct the client in prescribed preoperative diet; bowel preparation (laxatives and
enemas) may be prescribed.
c. Intestinal antiseptics and antibiotics may be prescribed, to decrease the bacterial
content of the colon and to reduce the risk of infection from the surgical procedure.
2. Postoperative: Colostomy
a. If a pouch system is not in place, apply a petroleum jelly gauze over the stoma to keep
it moist, covered with a dry sterile dressing; place a pouch system on the stoma as
soon as possible.
b. Monitor the pouch system for proper fit and signs of leakage; empty the pouch when
one third full.
c. Monitor the stoma for size, unusual bleeding, color changes, or necrotic tissue.
d. Note that the normal stoma color is red or pink, indicating high vascularity. Cystic duct
Jejunum
Pancreas
Stomach
Common
duct
Hepa tic ducts
FIGURE 48-4 Whipple procedure, or radical pancreaticoduodenectomy.
CHAPTER 48 Hematological and Oncological Disorders 595

B. TEST IV
1. Alterations in Human Functioning
a. Disturbances in Fluids and Electrolytes
b. Inflammatory and Infectious Disturbances
c. Disturbances in Immunologic functioning
d. Disturbances in Cellular functioning
2. Client Biologic Crisis
3. Emergency and Disaster Nursing
 C. TEST V
1. Disturbances in Perception and Coordination
a. Neurologic Disorders
b. Sensory Disorders
c. Musculo-skeletal Disorders
d. Degenerative Disorders
2. Maladaptive Patterns of Behavior
a. Anxiety Response and Anxiety Related Disorders
b. Psycho-physiologic Responses, Somatoform, and Sleep Disorders
c. Abuse and Violence
d. Emotional Responses and Mood Disorders
e. Schizophrenia and Other Psychotic and Mood Disorders
f. Social Responses and Personality Disorders
g. Substance related Disorders
h. Eating Disorders
i. Sexual Disorders
j. Emotional Disorders of Infants, Children and Adolescents.

II. Personal and Professional Development

A. Nurse-Client Relationship
B. Continuing Education

III. Communication, Collaboration and Teamwork

A. Team approach
B. Referral
C. Network/linkage
D. Therapeutic communication

IV. Ethico-Moral-Legal Responsibility

A. confidentiality
B. Clients Rights
1. Informed Consent
2. Refusal to take medications, Treatment and Admission Procedures
C. Nursing Accountability
D. Documentation/charting
E. Culture Sensitivity