CHN 1

Public Health According to WHO Art of applying Science in the Context of  Politics so as to Reduce Reduce Inequalit Inequalities ies in Health while while ensurin ensuring g the best best health health for the greatest number. Accordin Accor ding g to Dr. Charles Charle s Edward Edwar d Wins low, Father of Public Health

the Promotion of Health, Prevention of  Disease and Disability and   Rehabilitation. Broader -includes CHNs in both public & private sectors.

Assessment (diagnosis is CHN Process: embedded) Planning Implementation Evaluation

Goal: Maglaya 1. Promotion of Health t of Preventing Preventing Disease, Prolonging Life, Promoting Health and efficiency 2. Preservation of Health

Nisc is ce, et e t. al al "To raise the level of health of the citizenry by helping communities and  Through: Organized  families to cope with the discontinuities Community Effort  in and threats to health in such a way as to maximize their potential for highlevel wellness" nvironmental nvironmentalMedical Sanitation Standard of living adequate to maintain health & Nursing services service s for 1. Early Diagnosis Setting: Community -place where people under usual or normal conditions are found 2. Preventive Treatment municable Disease Control (villages, schools, workplaces, etc.) -must be outside the institutional setting (hospitals, etc. are excluded) Practice: Comprehensive, general, continual Not limited to a particular specializ specialization ation,, not episodic, episodic, and spans the entire life cycle.

NaLongevity ture vity of le Every Citizen to Realize His Birthright to Health and Longe

Public Health Nursing Accord According ing to WHO Expert Expert Commit Committee tee on Nursing Special Field of Nursing that Combines the Skills of Nursing, Public Health, and  Some Some Phase Phases s of Social Social Assis Assistan tance ce and  Funct Function ions s as part part of the Total Total Public Public Heal Health th Progra Program m for the the pro promot motion ion of  health, the improvement of the conditions in the social and phys hysical environment, nt, rehabilitation of illness and disability.

Includes nurses in the public sector or the government.

Community Health Nursing According to Dr. Araceli Maglaya

Knowledge: Integration of nursing with public health as well as sociology, psychology, anthropology, economics and political science Important concepts to note in answering questions: 1. “Greatest good for the greatest number” 2. Health promotion & disease prevention are prioritized over curative care 3. The primary responsibility responsibility of the nurse is to the population as a whole 4. Client is an active, equal partner of the nurse, not n ot a passive recipient of care 5. CHN is affected by its immediate the healthcare delivery system, context, as well as overall political, economic, socio-cultural, and environmental factors 6. CHN is dynamic and flexible due to varying objective and subjective realities in different settings 7. Communit Comm unity y PARTICIPA PARTI CIPATION TION is key ke y!!!

  The utilization of the Nursing Nursing Process Process in the the Diff ifferen rent Leve evels of Clie lientele tele-Remember! CHN on the worth and dignity of m Ind Individ ividu uals als, Fami Famili lies es,, Pop Popula ulation ti“The on philosophy of CHN is based Groups and Communities, concerned with means Community  the client

establishes linkages and collaborative relationships with other health professionals, government agencies, the private sector, nongovernment organizations and people's organizations to address health problems

CHN is HUMANISTIC. It is guided by these beliefs:

Humanistic values of nursing are upheld Unique and distinct component component of healthcare Multiple factors of heath considered Active participation of clients encouraged encouraged Nurse considers availability of resources Interdependence among health team members practiced Scientific and up-to-date Tasks of CH nurse vary with time and place Independence or self-reliance self-reliance of the people is -

Roles Role s of a Comm Commun unit ity y Heal Health th Nurse Clinician

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monitors and supervises the performance of midwives and other auxiliary health workers; also initiates the formulation of staff development and training programs for midwives and other auxiliary health workers as part of  their training function as supervisors ■

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Supervisor

Researcher ■

Clinician or Health Care Provider

utilizes the nursing process in the care of the client in the home setting through home visits and in public health care facilities ; conducts referral of patients to appropriate levels of care when necessary ■

Health Educator

utilizes teaching skills to improve the health knowledge, skills and attitude of  the individual, family and the community and conducts health information campaigns to various groups for the purpose of health promotion and disease prevention ■

Coordinator and Collaborator

Manager organizes the nursing service component of the local health agency or local government unit (ex. Nursing service plan component of the overall municipal health plan); also, as program manager, the PHN is responsible for the delivery of the package of services provided by the health program to the target clientele (ex. The PHN is almost always the program manager of the National Tuberculosis Program)

Leader and Change Agent

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Leader and Change Agent influences people to participate in the overall process of community development

Coordinator and Collaborator Educator Manager

Supervisor

Researcher

participates in the conduct of research and utilizes research findings in practice (ex. disease surveillance or the continuous collection and analysis of  data on diseases and causes of death) In the event that the Municipal Health Officer (MHO) is unavailable or is unable to perform his duties, the

Specialized Fields in CHN ■

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Community Mental Health Nursing A unique clinical process which includes an integration of concepts from nursing, mental health, social psychology, psychology, community networks, and the basic sciences Occupational Health Nursing

 The application of nursing principles and procedures in conserving the health of  workers in all occupations ■

School Health Nursing

 The application of nursing theories and principles in the care of the school population

Three Levels of Healthcare Services Primary Level of Care - the first contact contact between between the community community people and the different different levels of health facility; refers to health care provided by the health center staff  Seco Seconda ndary ry Level Level of Care Care - render rendered ed by physic physician ians s with with basic basic health health traini training ng in distri district ct hospitals, provincial hospitals and city hospitals; these facilities are capable of basic surgical procedures and simple laboratory examinations; serves as the referral center of primary health facilities Tertiary Level of Care - rendered by specialists in medical centers, regional hospitals and specialized hospitals like the Heart Center of the Philippines; serves as the referral center of  secondary health facilities

Health problems that are beyond the capability of the primary health care units are referred to an intermediate health facility like the rural health unit (RHU). The RHU team usually u sually consists of: » Rural Health Physician or the Municipal Municipal Health Officer (MHO) »Dentist » Public Health Health Nurse (PHN) PRIMARY »Rural Health Midwife (RHM) »Sanitary Inspector »Community Volunteer Health Workers (CVHW) or Barangay Health Workers (BHW) Health problems that are beyond the capability of the RHU Team are referred to the District Hospital. Clients manifesting more complicated conditions need referral to higher levels of care. Higher levels of health services at the provincial, regional and national levels provide secondary or tertiary care to complete the health care given at the district and peripheral levels. With this, the functionality and strengths of the health care delivery system lie on the strength of the SECONDARY referral system. The two-way referral system creates and maintains the network of health services.

Two levels of Primary Healthcare Workers 1. Village or Barangay Health Workers (V/BHWs) - refers to trained community health

workers or health auxiliary volunteers 6r traditional birth attendants or healers  TERTIARY practitioners or their 2. Intermediate Level Health Workers - refers to general medical assistants, public health nurses, rural sanitary inspectors, and midwives Midwife 1:5,000 MHO 1:20,000 Dentist: 1:50,000 Nurse 1: 1:20,000 Sanitary Inspector 1:20,000

E X A M P L E C H A R A C  T E R

Village/Grassroots Health Workers • Trained community health worker • Auxiliary health volunteer • Traditional birth attendant • Initial link, 1 st contact of the community • Works in liaison with the local health service workers • Provides elementary

Intermediate Level • General medical practitioners • Public health nurses • Midwives

Health Personnel of   First-Line Hospitals • Physicians with specialization • Nurses • Dentists

• 1st source of  professional health care • Attends to health problems beyond the competence of village health workers

• Establish close contact with the village and intermediate level health workers to promote the continuity of care from hospital to community to

I S  T I C S

curative and preventive health care measures

• Provides support to the home frontline health workers • Provides back-up in terms if supervision, health services for cases training, referral services requiring hospital or and supplies thru diagnostic facilities not linkages with other available in health sectors centers, etc. Adapted from CENE Nursing

Board Exam Review Notes Volume 2

Four Levels of Clientele in the Community Indi In divi vid dual ua l -sick or well individuals in homes and health centers -considered as entry point in working with the family Family -2 or more persons bound together by blood, marriage, or adoption (traditional meaning) -2 or more persons who are joined by bonds of sharing and emotional closeness and who identify themselves as being part of the family (contemporary meaning) -2 major functions: reproduction and socialization -basic unit of care in CHN -may contribute to wellness or illness -locus of decisionmaking on health matters -solid source of  support to the young, elderly, disabled, chronically ill Population group -a group of people sharing the same characteristics, developmental stage or common

exposure to particular environmental factors thus resulting in common health problems Community -group of people sharing common geographic boundaries and/or common values and interests -no 2 communities are alike -exerts a strong influence on health of individuals, families, and communities -most service provisions are in the community level

Healthcare Delivery System MAJOR PLAYERS Public Sector tax-based generally free at point of service National level Department of  Health as lead agency Local health system - run by local government units

Private Sector – usually profitoriented but some are also non-profit

orgs e.g. NGO’s like Red Cross. THE PUBLIC SECTOR Department of  Health ■

Vision:

Leader Advocate in promoting health for all Model Mission: Equitable Sustainable Health for all Filipinos Quality

especially the poor

-Administer service for

Roles and

Commercial • Profitoriented • Manufacturing companies • Advertising agencies • Private practitioners • Private institutions

Non-Commercial • Oriented to social development, relief, rehabilitation, and community organizing Socio-civic groups Religious organizations/foundations NGO’s which assume the following roles -Policy and Legislative advocacies -Organizing, Human Rights advocacies -Research and Development -Health Resource Development Personnel -Relief and Disaster Management -Networking

Functions (based on EO 102):

LACE Leadership in health -Leader in the formulation, monitoring, and evaluation of  national health policies, plans, and programs -Advocate adoption of  health policies, plans, programs -National policy and regulatory institution Administrator of  specific services -Manage selected health facilities e.g. national centers like special or tertiary hospitals

promotion and health protection -Innovate new strategies in health to improve the effectiveness of  health programs -Initiate public discussion on health issues and disseminate policy research outputs to ensure informed public participation in policy decisionmaking -Oversee implementation , monitoring and evaluation of national health plans, programs and policies

Local Government Units ■

The Private Sector

emerging Primary health concerns Health Care the require complicated Esse Essent ntiial hea health lth technologies care made -Provide universally emergency accessible to Goal of the DOH: health response individuals and Implementation of  for families in the the HSRA (Health catastrophic community by Sector Reform events, means Agenda) epidemics, acceptable to and them, through Framework for widespread their full implemention of  public danger participation and HSRA: FOURmula upon at a cost that the One for Health authorization by community and the President country can Elements Elements of FOURmula One for Health and afford at every consultation GOod GOvernance – enhance enhan ce performance; stagekey player oisf PhilH   with the local Health FInancing – health investments development. government. --WHO Health REgulation – quality and affordable affordable health goods and ser Capacity builder Health Service Delivery – accessibility and Conceptual availability of health Framework: and Enabler a.Health is a -Ensure highest fundamental achievable human right standards of  b.Health is quality health both an care, health

individual and collective responsibilit y c. Health Health should be an equal opportunity to all d.Health is an essential element of  socioeconomic developmen t

TRANSLATED into ACTION, the PHC APPROACH focuses on:

September 6-12, 1978 through the sponsorship of  WHO and UNICEF. LEGAL BASIS OF PHC IN THE PHILIPPINES: Letter of  Instruction (LOI) 949 signed in October 19, 1979 by former President Ferdinand E. Marcos

and intersectoral linkages. Process  Technolo gy

NEW GOAL for the Philippine implementation of PHC: Health in the Hands of the People by 2020

Partnership with the community communi PHC asty a service Equitable distribution of health policy of  delivery

Intrasectoral • Decisionlinkages means making from relationship within top to bottom and between Curativedifferent levels of  case healthcare based on services… modern Sectors HCmost medicine Primary closely related ELEMENTs: and to health: sophistic Health education LEAPPS ated Communicable disease technolog Local Governments control y Education Physician Expanded program on Agriculture dominate immunization d Public Works •

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Outc utcome

• Rel Reliiance on on health professionals

Locally endemic Population Control disease treatment Social Welfare Environmental

the DOH sanitation permeates Organized and appropriate health all Maternal and child system infrastructure strategies and health and family thrusts of  planning Four Pillars of  Prevention of disease and promotion government health PHC of health is the focus Essential drugs programs from the provision Linked multisectorally national to the Use of appropriate Nutrition and adequate Em hasis on on a ro riacommunity te te technolo levels. technology food provision 5A’s of PHC Support mechanism made Dimensio Commercialized available n Healthcare DOHvailable Goal • Absence of   Approved the disease for Medicinal ccessible the individual technology Appropriate technology means…Super Capal FACES (SC ( SC FAC resources

ffordable cceptable ttainable

PHC GOAL (in 1978): Health for All by the year 2000

PHC was declared in Alma-Ata (now Almati), Kazakhstan, USSR during the First International Conference on PHC held on

Focus of  Care Setting for Services

People Struc tructu ture re

Plants Scope of technology – serves a variety of purposes omplexity – should be simple and easy to apply under local conditions •CSick Sambong Lag • HospitalAmpalaya Ula F easibility – compatible with local conditions based Niyog-niyogan •AUrbancceptability – measured in terms of the degree of utilization of the pe centered Tsaang gubat Cost – should be affordable • Accessible Akapulko  Y er er Effectiveness ffectiveness – should produce the de sired effect

only to a few people . harm SAMBONG Safety – effect of utilization should produce 1no • Passive Indications: edema recipients of  and urolithiasis healthcare (diuretic effect) • He Hea alth lth is PHC is a Preparation: isolated from Multisectoral Decoction other sectors of  Approach – 2. AMPALAYA society recognizes intra Indications: Diabetes Mellitus

Preparation: Decoction or steamed 3. NIYUGNIYOGAN Indications: Ascaris lumbricoides intestinal infestation Preparation: Prepare dried, mature niyugniyugan seeds Dosage: Consume by chewing the right amount of  seeds two hours after meals. Repeat same dose after 1 week. Side-effects: stomachache, diarrhea 4. TSAANG GUBAT Indications: Stomachache Preparation: Decoction 5. AKAPULKO Indications: Ringworm, Tinea Flava, Athlete's foot and other types of fungal infection Preparation: Poultice or ointment 6. LAGUNDI Indications: Cough, Asthma, Fever, Muscle Pain Preparation: Decoction or syrup 7.

8. BAYABAS Indications: wound cleansing, as mouthwash in cases of oral cavity infections & gingivitis (antiseptic properties) Preparation: Decoction 9. BAWANG Indications: lowers serum cholesterol Preparation: May be roasted, soaked in vinegar or used for sauteing 10.  YERBABUENA Indications: for muscle pain Preparation: Decoction In "23 in '93", the utilization of the 10 Herbal Plants was aggressively prescribed through community wide implementation of  projects such as herbal garden in communities RA 8423: utilization of  medicinal plants as alternative for high cost medications. Policies: The indications/uses of  plants The part of the plant to be used Preparation of  herbal medicines

Community Health Nursing Process ■

Assessment

-initiate contact -collect data -identify health problems -assess coping ability -analyze and interpret data 2 Levels of  Family Assessment 1. First level – determine actual and potential health problems. Answers ‘what’ questions. 2. Second level – determine barriers to family’s performance of  tasks. Answers ‘why’ questions.

achieve higher level or state of  health Health deficit – presence of  illness; gap between actual and ideal health *both are equally  considered as  priority #1 2. Health threat – condition that promote disease or injury 3. Stress point/foreseeabl e crisis – anticipated periods of unusual demands Initial Data Base 1. Family structure and characteristics 2. Socio-economic and cultural factors 3. Environmental factors 4. Health assessment of  each member 5. Value placed on prevention of  disease Family Diagnosis Point Component give n x1 Nature  (1)Defic (2)Threat, (3)Stres x2 Modifiability  p (highly, partially, o x1 Preventive pote of future problems minimized by solvi x1 Salience  family problem  Total=5

ULASIMANG Categories of  BATO Health Problems Community Indications: lowers (according to Guidelines: Diagnosis serum uric acid in  priority) Point Component gouty arthritis P roperly labelled herbal medicine m edicine containers 1. Wellness state give Preparation: Salad A ppropriate herbal plant to specific symptom only – readiness to n or decoction Palayok or clay pots and a wooden spoon are used when cooking herbal medicines

Administer only at recommended recommended dose R the potcover when the(illness, herbal preparation starts to boil x1emove Nature health status 2. Socio-economic -document Action stats), health resource and (material, cultural responses If the symptoms persists p ersists despite using the herbal medicine medic ine 2-3 times, consult the nearest nearest physici phys ician an Research) health-related variables(social, Watch manpower), out for allergic reactions ~ if observed, stop using the herbal preparation economic, political,3. environmental) Health and 2 Levels of  CO: A Manual of  lways keep out of reach of children A x4 Modifiability  illness patterns Nursing Experience; PCPD partially, or4.non-modifiable) nonHealth resources Intervention in the herbal medicine as modifiable) suggested Prepare(highly, x1

Preventive potential 5. Political and of future problems leadership that can bepatterns minimized by solving this x1 Salience  family’s Components perception ofof  the problem Community Dx x3 Magnitude of the1. problem Primary Data source of population would be severity: proportion affected by problem the community  Total=10 people through survey, interview, focused group Why Undert Und ertake ake discussions, Commun Com munity ity Dx? observation and 1. To have a clear through the actual picture of the minutes of  problems of the community community and to meetings identify the 2. Secondary resources available Data - source to the community would be people. organizational 2. Community records of the diagnosis enables program, health the nurse/program center records and coordinator to set other public priorities for records through planning and review of  developing records programs of health care for the community. The ■ Planning data gathered -goal setting through the -constructing plan process serves as of action and the material for operational plan analysis. Types of  Community Dx 1. Comprehensive Community Dx — general view 2. Problemoriented Community Dx – specific problem Components of  Community Dx 1. Demographic variables

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Implementati on -put nursing plan to action -coordinate care/services -utilize community resources -delegate and supervise -provide health education

CHN 1. Anticipatory – primary level of  prevention 2. Participatory – secondary & tertiary levels ■

Evaluation

-nursing audit -evaluate care outcomes -performance appraisal for workers -estimate costbenefit ratio (determine efficiency) -identify necessary alterations -revise plans Framework for Evaluation 1. Structural elements – physical: manpower, equipment, infrastructure 2. Process elements – actions, procedures, protocols 3. Outcome elements – changes in clients’ health status vis-àvis objectives and goals of care outcomes

COPAR (Community Organizing Participatory

A continuous and sustained process of  educating the people to understand and develop their critical awareness of  their existing conditions, working with the people collectively & efficiently on their immediate and long-term problems, and mobilizing the people to develop their capability and readiness to respond & take action on their immediate needs towards solving their long-term problems Principles of  COPAR

People, especially the most oppressed, exploited and deprived sectors are open to change, have the capacity to change, and are able to bring about change. ■

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COPAR shou hould be based on the interests interests of the poore poorest st sector sectors s of society COPAR shou hould lead to self-

reliant comm communi unity ty and and society Processes/Metho ds Used ■

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A Progr Progres essiv sive e Cycle of Action - Re Refl flec ecti tion on Action -begins with the already existing practice, experience, and concrete conditions of the people, sums practice practice up into a body of   theory, puts theory to practice…and the cycle repeats, constantly modifying for the better. Consciousness -raising through through learning learning by expe experi rien ence ce.. Related to A-R-A cycle. COPAR is Participatory and Massbased because it is primarily directed towards and biased in favor of the poor, the pow powerle erless ss and and the the oppr oppres esse sed d and seeks to empower the masses to participate in the changi changing ng of  their conditions. COPAR is Groupcent center ered ed and and not Leaderoriented. Leaders are identified, emerge and are test tested ed thro throug ugh h action rather

than than appo appoint inted ed or sele selec cted ted by som some exte extern rna al force or entity. Phases of the COPAR Process

1. Pre-entry Phase The initial • phas hase of the organizing process process where the community organizer looks for communities to serve/help • Designing criteria for the selection of  site • Actually sele select ctin ing g the the site for community care 2. Entry Phase • Sometimes called the social preparation phase hase as the the activitie activities s done here include ude the sensitization of  the the peop people le on the critical events in their life, motivating them to share their heir drea reams and idea ideas s on how to mana manage ge thei theirr conc concer erns ns and and eventually mobilizing them hem to tak take collective action on these. the • Signals actual entry of  the community worker/organiz er into the community with the

following guidelines: » recognize the role of the local authorities by paying them visits to inform them of their presence and activities » his/her appearance, speech, behavior & lifestyle shoul should d be in keepi keeping ng with with thos those e of the the community residents without disre disrega gard rd of  their being role model » avoid raising the consciousnes s of the community residents; adop adoptt a lowlowkey profile 3. OrganizationBuilding Phase the • Entails formation of  more formal struct structures ures and the inclusion of  more formal proc proced edur ures es of  planning, implementing, and evaluating communitywide activities of   • Conduct trai rainings ngs for the the orga organiz nized ed leaders or groups to deve develo lop p thei theirr skills in managing their own concerns/progr ams

4. Sustenance and Strengthening Phase • Occurs when the community organization has already been established and the community members are already actively participating in communitywide undertakings The diff differ eren entt •   The committees set-up in the organizationbuilding building phase are already expected to be functio functionin ning g by way of   planning, implementing and evaluating their own programs, with the overall guidan guidance ce from from the communitywide organization • Strategies: » Education and training » Networking and linkages » Conduct of  mobilization on health and development concerns » Developing secondary leaders