Chn Notes.pdf

COMMUNITY HEALTH NURSING

Community - a group of people with common characteristics or interest living together within a territory or geographical boundary.

Classifications of Communities: 1.URBAN - increased in population; industrial-type of work 2. RURAL - decreased in population; agricultural-type of work 3. RURBAN - combination of rural and urban 4. SUBURBAN - periphery around the urban areas 5. METROPOLITAN - expanding urban areas

4 Aspects of Community: 1.Social - communication and interaction of the people. 2. Cultural - norms, values and beliefs of the people. 3. Political - governance and leadership of the people. 4. Geographical - boundaries of the community.

Components of a Community: A. PEOPLE B. 8 SUBSYSTEMS 1. Housing 2. Education 3. Fire and Safety 4. Politics and Environment 5. Health 6. Communication 7. Economics 8. Recreation

Health - is the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (World Health Organization)

Determinants of health - factors or things that make people healthy or not. 1. Income and social status 2. Education 3. Physical environment 4. Employment and working conditions 5. Social support network 6. Culture 7. Genetics 8. Personal behavior and coping skills 9. Health services 10. Gender

New concept in determinants of health - OLOF (Optimum Level Of Functioning) Factors that affects OLOF: - Ecosystem Composition of Ecosystem: 1. Political – power, authority, empowerment, safety 2. Behavior – lifestyle related such as diet, exercise 3. Heredity – genes, familial history 4. Environment – air, water, garbage, food, noise 5. Socio-Economic – education, employment, housing 6. Health Care Delivery System – availability, accessibility and affordability of services and facilities

Nursing - an art and science of rendering care to individual, families and community. - assisting an individual, sick or well, in the performance of those activities contributing to health or its recovery in such a way as to help gain independence. (OLOF)

Community Health Nursing - a direct goal oriented and adaptable to the needs of the individual, the family and community during health and illness. - (ANA, 1973) - an area of human services directed toward developing and enhancing the health capabilities of people – either singly, as an individual or collectively as groups and communities. - (John Henrich, 1981)

- the utilization of the nursing process in different level of clientele concerned with the promotion of health, prevention of disease and disability and rehabilitation. - (Aracelli Maglaya)

*** a service rendered by a professional nurse

with the community, groups, families and individuals at home, in health centers, in clinics, in schools, in places of work for the promotion of health, prevention of illness, care of the sick at home and rehabilitation.

PRIMARY GOAL OF CHN: - Enhance people’s capability. ULTIMATE GOAL OF CHN: - “ To raise the level of health of the citizenry.” PHILOSOPHY OF CHN: - CHN is based on the worth and dignity of man. - (Margaret Shetland) EMPHASIS/FOCUS: - Health promotion and Disease prevention.

Important Concepts of CHN: 1. The primary focus of CHN is on health promotion. 2. Recognized needs of individuals, families and communities provide the basis for CHN. 3. The family is the unit of service. 4. Contact with the client may continue over a long period of time which include all ages and all types of health care. 5. CH nurses are generalists in terms of their practice throughout life’s continuum –its full range of health problems and needs. 6. CHN practice is extended to benefit not only the individual but the whole family and community

Roles and Functions of CH Nurse: 1. Advocate - defends the rights of the client for self-determination - intercedes, supports, pleads or acts as guardian of the client’s rights to autonomy and free choice for self-care 2. Supervisor - provides administrative support - oversees, monitors and evaluates the function of the subordinates 3. Counselor - encourages client to verbalize and express feelings and concerns - key task is active listening

4. Educator - teaches the client to provide skills, knowledge and attitude - primary task is to assess readiness to learn 5. Trainer - provides technical support - identifies training needs, formulates training program designs - arranges and conducts training to provide learning experiences to subordinates and clients

Levels of Clientele: 1. Individual - “point entry” 2. Family - center of delivery of care. 3. Group - point of specific care. 4. Community - point of entire care

PLACES IN CHN: A. Public Health Nursing - is a 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 health program. Public Health - the science and art of preventing disease, prolonging life and promoting life and efficiency. (C. E. Winslow) - is the art of applying science in the context of politics to reduce inequalities while ensuring the best health for the greatest number. (WHO)

B. School Health Nursing > Home Visitation – effective implementation of total school program > RA 124 – it mandates the school to provide clinics for the minor treatment and attendance to emergency cases > Assessment: 1. Arms 5. Ears 2. Eyes and Visual Acuity 6. Neck and Chest 3. Nose 7. Hair 4. Mouth and Teeth 8. Lower extremities > Feeding Program - Should run for 120 days - Deworming with consent

C. Occupational Health Nursing > RA 1054 – Occupational Health Act > Business Firm must employ an occupational health nurse when it has at least _____________? 101 employees

FAMILY – NURSE CONTACT: I. HOME VISIT - professional face to face contact done by a nurse to the family. Purposes: 1. Give nursing to the sick, post partum mother & newborn. 2. Assess living condition of client and their health practices. 3. Give health teachings. 4. Establish relationship with health agency and public. 5. Make use of inter-referral system and promote utilization of community services.

Principles: 1. Must have a purpose and objective. 2. Make use available information about the patient and his family. 3. Consider and prioritize essential needs of the individual and family. 4. Should involve the individual and family in planning and delivery of care. 5. Plan should be flexible.

Important Steps of Home Visit: 1. Greet client and family then introduce yourself. 2. Explain the purpose of the visit. 3. Observe the patient and determine the health needs. 4. Put the bag in a convenient place then perform bag technique 5. Perform nursing care and give health teachings. 6. Record all important data, observation and care rendered. 7. Make appointment for a return visit.

Phases: 1. Preparatory Phase a. review existing records of referral data of the family b. notifies the family of the intention to make a home visit 2. Home Visit Phase a. actual visits of the family b. makes plans, interventions, evaluation with the family and set schedule for the next visit 3. Post Visit Phase a. records data and plans for the next visit and referrals

Priorities During Home Visit: 1. Newborn 2. Post partum 3. Pregnant women 4. Morbid individuals Factors affecting Frequency of Home Visit: 1. Physical, psychological and educational 2. Acceptance of family 3. Policies given by the agency

Bag Technique: - a tool making use of a public health bag and which the public health nurse can perform procedures during home visits. Rationale : - Helps render effective nursing care to clients. Principles: 1. Minimize if not totally prevent the spread of infection. 2. Save time and effort. *** Open bag TWICE during home visit.

Special Consideration: B

- bag and its contents must be free from any contamination. A

- always perform handwashing. G - gather necessary equipments to render effective nursing care.

Steps in Performing The Bag Technique Actions: 1. Upon arrival, place the bag on the table lined with a clean paper. (the clean side must be out and folded part, touching the table) 2. Ask for a basin of water. 3. Open the bag and take out the towel and soap. 4. Wash hands. 5. Take out the apron and put it on with the right side. 6. Put out all the necessary articles needed for the specific care. 7. Close the bag and put it in one corner of the working area. 8. Perform nursing care and treatment.

9. After giving the treatment, clean all things that were used and perform handwashing. 10. Open the bag and return all things that were used in their proper place 11. Remove apron, folding it away fro the person, the soiled side in and the clean side out. Place it in the bag. 12. Fold the lining, place it inside the bag. Close the bag. 13. Take the record and have a talk with the mother. 14. Make an appointment for the next visit.

II. CLINIC VISIT Advantage: - it is inexpensive in time and usually in cost both for the service and for the family. Standard Procedure in Conducting Clinic Visit: I. Registration/Admission 1. Greet the client and establish rapport 2. Prepare records 3. Elicit client’s chief complaint and clinical history 4. Perform PE II. Waiting Time * Implement the “first come”, “first served” except for emergency and urgent cases

III. Triaging * Manage program-based cases * Refer all non-program based cases IV. Clinical Evaluation * Validate clinical history and PE * Inform client of the nature of the illness, treatment, prevention and control measures V. Laboratory and other diagnostic examinations * Identify a designated referral laboratory when needed

VI. Referral System 1. Refer if needs further management (BHS to RHU, RHU to RHU, RHU to Hospital) 2. Accompany patient if it is an emergency referral VII. Prescription/ Dispensing * 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

Phases: 1. Pre-consultation a. establish relationship b. assessment on chief complaint, VS, PE 2. Consultation A. Medical Consultation B. Nursing Intervention 3. Post-consultation a. explaining intervention to be done at home b. follow-up care c. referral (if possible)

PRIMARY HEALTH CARE - is an essential health care made universally accessible to individuals and families in the community by means acceptable to them. *** in Sept. 6-12, 1978 : UNICEF and WHO held the First International Conference on Primary Health Care in Alma Ata, USSR Legal Basis: LOI 949 : was signed by Pres Marcos on Oct 19, 1979 making Primary Health Care the thrust of the Department of Health.

Vision : Health for All Filipinos Goal : Health for All Filipinos and Health in the Hands of the people by the Year 2020 Mission : In partnership with the people, provide equity, access and quality health care especially to the marginalized

Principles: 1. 4 A’s; Accessibility, Availability, Affordability and Acceptability of health services 2. Community Participation - is the heart and soul of PHC 3. People are the center, object and subject of development 4. Self – reliance 5. Partnership between the community and the health agencies in provision of quality life 6. Recognition of interrelationship between the health and development 7. Social mobilization 8. Decentralization

RA 7160 : The Local government Code of 1991 which resulted in devolution, which transferred the power and authority from the national to the local government units, aimed to build their capabilities for self-government and develop them fully as self-reliant communities.

- Devolution Code (Mandate of Devolution) Local Government Code

Primary Health Care Team: 1. Local Chief Executive 2. Physician 3. Nurse 4. Medical technologist 5. Midwife 6. Sanitary Inspector 7. Auxiliaries - BHW - PHW

4 Pillars/Cornerstones: 1. Active community participation 2. Intra and inter- sectoral linkages 3. Use of appropriate technology 4. Support mechanisms made available Levels of PHC Workers: 1. Village or Brgy. Health Workers - health auxiliary or volunteers 2. Intermediate Level Health Workers - Physician - Sanitary Inspector - Nurse - Midwife

Ratios to catchment population: Public Health Worker Public Health Physician Public Health Nurse Public Health Midwife Dentist

= = = = =

1:50,000 1:20,000 1:20,000 1: 5,000 1:20,000

LEVELS OF PREVENTION 1.Primary Prevention - health promotion - specific protection Behaviors: 1. Quit smoking 2. Avoid/limit alcohol intake 3. Exercise regularly 4. Eat well-balance diet 5. Reduce fat and increase fiber in the diet 6. Complete immunization program 7. Wear hazard devices in work site

2. Secondary Prevention - early diagnosis/detection/screening - prompt treatment Behaviors: 1. Have annual physical examination 2. Regular Pap smear for women 3. Monthly BSE for women who are 20 yrs old and above 4. Sputum examination for Tuberculosis 5. Annual stool Guaiac test and rectal exam for clients over age 50 yrs old

3. Tertiary Prevention - prevention of complication - optimal health status after a disease or disability Behaviors: 1. Self-monitoring of blood glucose among diabetics 2. Physical therapy after CVA 3. Attending self-management education for diabetes 4. Undergoing speech therapy after laryngectomy

Levels of Health Care and Referral System 1. Primary Level of Care 1. Rural Health Units 2. Community Hospitals and Health Center 3. Private Practitioners (Puericulture Centers) 4. Brgy. Health Stations - is usually the first contact between the community members and the others levels of health facility. - provided by center physicians, public health nurses, rural health midwives, barangay health workers, traditional healers

2. Secondary Level of Facilities 1. Provincial/City Health Services and Hospitals 2. Emergency and District Hospitals - serves as a referral center for the primary health facilities - are capable of performing minor surgeries and perform some simple laboratory examinations

3. Tertiary Level of Facilities 1. National and Regional Health Services 2. Teaching and Training Hospitals - serves complicated cases and intensive care

ALTERNATIVE HEALTH CARE Legal Basis: RA 8423 – Traditional and Alternative Medicine Act * created the Philippine Institute of Traditional and Alternative Health Care

** S A N T A L U B B Y **

S - Sambong * anti-edema, diuretic, anti-urolithiasis

A - Ampalaya * DM

N - Niyog-niyogan * anti-helmintic

T- Tsaang Gubat * diarrhea, stomachache, mouth wash

A - Akapulko (Bayabas-bayabasan) * anti-fungal

L - Lagundi * asthma, cough, fever, dysentery, skin diseases

U - Ulasimang Bato (Pansit-pansitan) * lowers uric acid

B - Bawang * lowers cholesterol levels, hypertension, toothache

B - Bayabas * washing of wounds, diarrhea, gargle for toothache

Y - Yerba Buena * pain, rheumatism, arthritis, headache, cough and colds, swollen gums, toothache, menstrual and gas pain, nausea, fainting, insects bites and pruritus

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 of the plant being advocated. 4. Follow accurate dose of suggested preparation. 5. Use only one kind of herbal plant for each sickness. 6. Stop giving in case with untoward reaction. 7. If signs and symptoms are not relieved after 2 or 3 doses, consult a doctor.

DOH (Department of Health) Vision: - A leader, staunch advocate and model in promoting health for all in the Philippines.

Mission: - Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor and shall lead the quest for excellence in health.

3 Roles and Functions of DOH: - Executive Order 102 1. Leadership in health - serves as an advocate in the adoption of health policies, plans and programs to address national and sectoral concerns. 2. Administrator of Specific Service - administer health emergency responsive services including referral and networking system. 3. Enabler and Capacity Builder - innovates new strategies in health to improve the effectiveness of health programs.

Overriding Goal of DOH: - Health Sector Reform Agenda (HSRA) Framework for its Implementation: - FOURmula One for Health --- *Arroyo - Universal HealthCare (Kalusugan Pangkalahatan) ---*Aquino ( Executive Order 36) ---Phil. Health Agenda (Pres. Duterte)

ALL FOR HEALTH TOWARDS HEALTH FOR ALL Goals: 1. Financial Protection 2. Better Health Outcomes 3. Responsiveness

Values: 1. Equitable and inclusive to all 2. Transparent and accountable 3. Uses resources efficiently 4. Provides high quality services Strategies: 1. Advance quality, health promotion and primary care. 2. Cover all Filipinos against health-related financial risk. 3. Harness the power of strategic HRH development. 4. Invest in eHealth and data for decision-making. 5. Enforce standards, accountability and transparency. 6. Value all clients and patients, especially the poor, marginalized and vulnerable. 7. Elicit multi-sectoral and multi-stakeholder support for health.

8 MILLENIUM DEVELOPMENT GOALS 1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, malaria and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development - based on the fundamental values of freedom, equality, solidarity, tolerance, health, respect for nature and shared responsibility.

PHILIPPINE REPRODUCTIVE HEALTH Goal: - To achieve “Better Quality Life among Filipinos” *Responsible Parenthood and Reproductive Health Act of 2012 - RA 10354 Local Framework Focuses on: - Health needs of women, men, adolescents, children and underserved groups.

Main objectives:

1. Reducing maternal mortality rate. 2. Reducing child mortality. 3. Halting and reversing spread of HIV/AIDS. 4. Increasing access to reproductive health information and services.

10 Elements: 1. Family Planning 2. Maternal and Child Health and Nutrition 3. Adolescent Reproductive Health 4. Prevention and Management of Reproductive Tract Infections including STIs and HIV/AIDS 5. Prevention and Management of Abortion and its Complication 6. Education and Counseling on Sexuality and Sexual Health 7. Prevention and Management of Breast and Reproductive Tract Cancers and other Gynecological Conditions. 8. Men’s Reproductive Health 9. Violence Against Women and Children 10. Prevention and Management of Infertility and Sexual Dysfunctions

t PHILIPPINE FAMILY PLANNING PROGRAM *** Principal recipients of information, education, communication and motivation in family planning: - married couples of reproductive age *** It requires all couples who want to receive a marriage license to first undergo a seminar in family planning and responsible parenthood - PD 965 Advantages: 1. FP helps families improve their standard of living 2. FP reduces/eliminates fears of unwanted pregnancy 3. FP affords family members time to study or pursue occupational interest

t Major target (High Risk Women): 1. Women under 20 years old 2. Women over 35 years old 3. Women suffering from certain medical conditions that contradict pregnancy 4. Women who have had at least 4 deliveries

*** The Family Code of the Philippines? - Executive Order No. 209

t The Family Planning Methods: 1. Female Sterilization - safe and simple surgical procedure which provides permanent contraception for women who do not want more children. Also known as BTL that involves cutting or blocking the two fallopian tubes. - performed during first 2 weeks of her menstrual cycle or within the first 3 days after delivery. 2. Male Sterilization - permanent method wherein the vas deferens (passage of sperm) is tied and cut or block through a small opening on the scrotal skin. It is also known as Vasectomy.

t 3. Pill - contains hormones estrogen and progesteron taken daily to prevent contraceptions. Advised for women who are anemic because of the reduced menstrual flow. - taken some time everyday preferably at night. Common side effects: - dizziness, headache, nausea, spotting, weight gain, breast fullness. Adverse effects: Contraindications: 1. Abdominal pain 1. pregnancy or suspected 2. Chest pain 2. history of diabetes 3. Headache 3. high blood pressure 4. Eyes blurred 4. weak heart 5. Severe leg pain 5. CA of the breast 6. over 50 years old

Important facts to remember about a Pill 1. Pill are advised for women who are anemic because of the reduced menstrual flow 2. Take pill same time everyday 3. A packet of pills contain 28 tablets; 21 pills are “active pills”, 7 contain no hormones, only iron 4. Follow the direction of the arrows of the pill. When empty, start a new pack on the next day without missing a day 5. For 1 missed pill: take the pill as soon as possible; take regular pill at night 6. For 2 missed pill: take 2 pills next day, then take 2 pills the next day again 7. For 3 missed pill: discard and substitute method, start on next pack on next menstrual period.

t 4. Male Condom - thin sheath of latex rubber made to fit on a man’s erect penis to prevent the passage of sperm cell and sexually transmitted disease organism into the vagina. - the shelf life is 3 years in the Phils., if stored in a cool dry place. 5. Injectables - contain synthetic hormones, progestin which suppresses ovulation, thickens cervical mucus, making it difficult for sperm to pass through and changes uterine lining. 6. Basal Body Temperature - used to measure changes of temperature during ovulation. Temp. slightly decreases before ovulation and increases during ovulation day. It must be measured on the same time of the day, before rising, with the same thermometer.

t 7. Lactating Amenorhea Method or LAM - temporary introductory postpartum method of postponing pregnancy based on physiological infertility experienced by Breast Feeding women. Criteria: 1. Amenorrhea 2. Fully or nearly fully breastfeeding 3. Infant is less than 6 months 8. Mucus/Billings/Ovulation - abstaining from sexual intercourse during fertile (wet) days prevent s pregnancy. 9. Abstinence - best way to prevent pregnancy and STI’s

t 10. Sympto-Thermal Method - method in identifying the fertile and infertile days of the menstrual cycle as determined through a combination of observations made on the cervical mucus, basal body temp recording and other sign of ovulation. 11. IUD - changes the nature of internal secretions of woman’s body., disturbs transport and decreases number of viable sperms Contraindications: 1. PID 2. Septic Abortion 3. Endometritis 4. Anemia 5. Suspected pregnancy

t Adverse effects: 1. Period that is late 2. Abdominal pain 3. Increase in temperature 4. Noticeable discharge – foul smelling 5. Severe bleeding > an outpatient procedure; examined 1 month after insertion, then after 6 months then after 1 year. 12. Standard Days Method - A new method of natural family planning in which all users with menstrual cycles between 26 and 32 days are counseled to abstain from sexual intercourse on days 8-19 to avoid pregnancy. -The couples use color coded cycle beads to mark the fertile and infertile days of the menstrual cycle.

NUTRITION PROGRAMS Goal: - To improve the quality life of Filipinos through better nutrition, increased productivity and improved health.

3 Most Common Deficiencies: 1. Iron 2. Vitamin A 3. Iodine

Programs and Projects: 1. Micronutrient Supplementation - is one of the interventions to address the health and nutritional needs of infants and children and improve their growth and survival. * Araw ng Sangkap Pinoy (ASAP), Garantisadong Pambata - addresses health and nutritional needs of 6-71 months old 2. Food Fortification - to improve the nutritional status of the populace including children. - legal basis: RA 8976 4 Food Staples that require Mandatory Fortification: 1. Rice with Iron 3. Oil with Vitamin A 2. Sugar with Vitamin A 4. Flour with Iron and Vitamin A

3. Essential Maternal and Child Health Services - this ensures the right of the child to survival, development, protection and participation. 4. Nutrition, information, communication and education - promotion of 10 Nutritional Guidelines for Filipinos.

1. Eat variety of foods everyday. 2. Promoting exclusive breastfeeding from birth up to 4-6 months. 3. Giving proper advice on proper feeding of children. 4. Consume fish, lean meat, poultry or dried beans. 5. Eat more vegetables.

6. Eat foods cooked in edible/cooking oil daily. 7. Consume milk, milk products and other calcium-rich foods. 8. Use iodized salt, but avoid excessive intake of salty foods. 9. Eat clean and safe foods to prevent food-borne diseases. 10. Promoting healthy lifestyles. 5. Home, School and Community Food Production - establishment of kitchens, gardens in home, schools and in communities in urban and rural areas. 6. Food Assistance - it involves complementary feeding for wasted/stunted children and pregnant women with delivering low birthweight. 7. Livelihood Assistance - provision of credit and livelihood opportunities to poor households especially those with malnourished children through linkage with lending and financial institutions.

Control of Acute Respiratory Infection (CARI) Objective: Reduce mortality through early detection. Contributing Factors to Pneumonia: 1. Mothers failure to recognize signs and symptoms of Pneumonia. 2. Indiscriminate use of antibiotics. 3. Not standardized management to Pneumonia Sign of Severe Pneumonia: - Chest Indrawing Important Responsibility of the Nurse in preventing unnecessary death from Pneumonia: - Provision of careful assessment

National Cancer Control Program 9 Warning Signs: C – change in blood, bowel/bladder habits A – a sore that does not heal U – unusual bleeding/discharge T – thickening or lump in breast I – indigestion or difficulty in swallowing O – obvious change in wart or mole N – nagging cough or hoarseness U S

– unexplained anemia – sudden unexplained weight loss

Specific Guidelines for Early Detection of Common Cancers 1. Breast Cancer A. BSE - cheapest and most affordable - done 1 week after menstrual period while taking a shower B. Mammography - if a mass detected and confirmed 2. Cervical Cancer A. Pap Smear - primary screening tool for women over age 18

3. Colon Rectal Cancer A. Annual digital rectal exam starting at age 40 B. Annual stool blood test starting at age 50 C. Annual inspection of colon 4. Prostate Cancer A. Digital rectal exam B. PSA (prostate Specific Antigen) – confirms diagnosis 5. Lung Cancer A. Chest X-ray B. Sputum Cytology

LEVELS OF PREVENTION:

Primary Prevention: - elimination of conditions causing cancer Secondary Prevention: - Definitive Treatment and Management (a.) Chemotherapy, (b.) Radiation, (c. )Surgery Tertiary Prevention: - Supportive or Palliative Care a. Physical b. Psychological, Social, Spiritual

National Voluntary Blood Services Program - promotes voluntary blood donation to provide sufficient supply of safe blood and to regulate blood banks. Legal basis: RA 7719 “Blood Services Act of 1994” Criteria for Eligible donor: B = BP 90/60 – 160/100mmHg A = 16 – 65 years old W = 45 – 50 kgs minimum A = At least 12.5 hemoglobin S = Status in good condition

Main Objectives: 1. to promote and encourage voluntary blood donation by the citizenry and to instill public consciousness of the principle that blood donation is a humanitarian act 2. to provide adequate, safe, affordable and equitable distribution of supply of blood and blood products 3. to mobilize all sectors of the community to participate in mechanisms for voluntary and non-profit collection of blood

Steps to donate: 1. Go to the nearest center 2. Register a s a donor 3. History taking 4. Vital signs, PE taking 5. Blood test with blood type Must do after donated blood: 1. Eye on dressing at least 8 hours but not more than 12 hours 2. No lifting heavy objects 3. No smoke for 2 hours, no alcohol for 12 hours 4. Eat regular meals and increase fluids

National TB Control Program Vision: - A country where TB is no longer a public health problems. Mission: - Ensure that TB DOTS services are available, accessible and affordable to the communities.

Treatment: - Quality of SDF (Single Dose Formulation) & FDC (Fixed Dose Combination)

Case Finding: 1. DSSM ( Direct Sputum Smear Microscopy) - 3X collection 1st specimen – SPOT specimen collected on the day of consultation 2nd specimen – early morning specimen on the next day 3rd specimen – SPOT specimen collected on the 2nd day after submission of early morning specimen 2. Chest X-ray - to identify the extent of the disease 3. Tuberculin Testing/Mantoux Test/PPD Testing

TB Treatment: SDF Rifampicin Isoniazid Pyrazinamide Ethambutol Streptomycin

TB Abbreviation OLD NEW R R INH H PZA Z E E S S

# of Tablets of FDC of Patient per Body Weight

Body Weight (kg) 30-37 38-54 55-70 >70

# of Tablets 2 3 4 5

Category I: Newly Diagnosed TB Patient - - - ( + ) DSSM, ( + ) CXR Intensive Phase

2 months HRZE

Maintenance Phase

4 months HR

Category II: Previously treated patient with relapses or failure

Intensive Phase

2 months

HRZES

Intensive Phase

1 month

HRZE

Maintenance Phase

5 months

HRE

Category III: Newly TB patient - - - ( - ) DSSM, ( + ) CXR

Intensive Phase Maintenance Phase

2 months 4 months

HRZ HR

Category IV: - CHRONIC Still ( + ) smear after supervised re-treatment - refer to specialized facility - Provincial NTP Coordinator

DOTS - Direct Observed Treatment Short course - Main strategy which primary health services around the world are using to detect and cure TB patients.

Treatment partner: -watching the TB patient take medicines everyday during the whole course of treatment. a. Staff of the Health Care facilities b. LGU officials c. Family members of the patient

5 ELEMENTS OF DOTS: 1. Political will 2. Sputum microscopy service 3. Regular drug supply 4. Record of patient’s progress 5. Supervision of drug intake

Leprosy Control Program Leprosy - known as Hansen’s Disease - cause: Mycobacterium leprae - MOT: prolonged intimate skin to skin contact; droplet infection Diagnostic procedure: = Slit Skin Smear Preventive Measures: - BCG immunization - Health education on the MOT

DOMICILLARY TREATMENT: (Republic Act 4073) PAUCIBACILLARY : 6-9 months A. Intermediate type - flat, with not well defined patches, with slight to no sensory loss and pale in color. B. Tuberculoid type - flat, with some raised patches, definite sensory loss and rough to touch. Treatment: Day 1: Rifampicin and Dapsone Succeeding days (2-28 days): Dapsone

MULTIBACILLARY:

:

24-30 months

A. Borderline type - many raised patches at different sizes and shapes, usually enlarged nerves and occasionally with deformities. B. Lepromatous type - thickened skin and earlobes and with hair loss in eyebrows. Treatment: Day 1: Rifampicin, Dapsone, Clofaximine or Lamprene Day 2-28: Dapsone, Clofaximine or Lamprene

THE MATERNAL and CHILD HEALTH PROGRAM Overall Goal: - To improve the survival, health and well being of mothers and unborn through a package of services for the pre pregnancy, prenatal, natal and post natal stages.

Essential Health Service Packages: A. Prenatal Registration 1St visit – as early in pregnancy as possible before four months or during the first trimester 2nd visit – during the 2nd trimester 3rd visit – during the 3rd visit Every 2 weeks – after 8th month of pregnancy until delivery

B. Deliver Tetanus Toxoid Immunization OLD TT Immunization Schedule: TT1 = given anytime during pregnancy TT2 = 1 month after the first dose TT3 = 1st booster dose; 6 months interval from TT2 TT4 = 1 year interval from TT3 TT5 = booster dose 1 year interval from TT4

NEW TT Immunization Schedule: TT1 = 5th or 6th month of pregnancy

TT2 = after 1 month of TT1 TT3

= succeeding pregnancy (5th or 6th month pregnant) TT4

= succeeding pregnancy (5th or 6th month pregnant) TT5 = succeeding pregnancy (5th or 6th month pregnant)

Lifespan of TT Vaccines: TT1

= 0;

0

= 80% protection;

3 yrs protection

= 95% protection;

5 yrs protection

= 99% protection;

10 yrs protection

= 99% protection;

lifetime protection

TT2 TT3

TT4 TT5

C. Micronutrient Supplementation 1. Vitamin A 10,000 IU 2X a week starting on the 4th month of pregnancy 10,000 IU once a day for 4 weeks if with Xeropthalmia 200,000 IU post-partum; one dose within 4 weeks 2. Iron 60 mg/day 1st trimester 120 mg/day 2nd/3rd trimester 60 mg/day X 3 mos. Post-partum

D. Treatment of Diseases and Other Conditions - Unconscious - Difficulty of breathing - Post partum bleeding - Parasitism E. Clean and Safe Delivery - ensure hygiene during labor and delivery Qualifications for Home Care Delivery: 1. Full Term 7. No history of previous infection 2. G1-G4 8. No PROM 3. Cephalic Presentation 9. Adequate pelvis 4. No history of previous CS 10. No history of prolonged labor 5. No history of previous Complications 6. Enlargement of abdomen is equal to AOG

3 Priorities for a Safe Home Care Delivery: 1. Clean Hands 2. Clean Surface 3. Clean Cord

Post Partum Visits: 1st visit – within a week (3-5 days) 2nd visit – 6th week post delivery 3 Cardinal Signs of Post Partum Infection: 1. Board-like abdomen 2. Fever 3. Foul-smelling vaginal discharges

F. Support Breastfeeding Breastfeeding and Rooming –in ACT : RA 7600

Benefits of BF to Infants: 1. Increases immune system resistance 2. Provides complete nutrition 3. Increases IQ points Benefits of BF to mothers: 1. Prevent unplanned pregnancy 2. Prevent post partum bleeding 3. Prevent occurrence of cancer

New Breastfeeding Act…. REPUBLIC ACT 10028 Storage Full-term Room Temperature 8-10 hours Refrigerator 48 hours Freezer 3 months G. Family Planning Counseling - right choice of FP methods - birth spacing is ….. 3-5 years

Pre-term 4 hours 24 hours 3 months

Expanded Program on Immunization (EPI) Legal Basis: PD No. 996 – providing for compulsory basic immunization for infants and children below 8 yrs old. ( September 16, 1976) > launched in July 1976 > free vaccines: BCG, DPT, OPV, Measles

Mandatory Infants and Children Health Immunization of 2011 --- RA 10152 Objective: To reduce morbidity and mortality among infants and children caused by the 6 childhood immunizable diseases

Target for Immunization Program a. Infant : 12 months old b. School Entrants : 6-7 years old c. Pregnant Mother Infants: - 1 BCG - EO 663 - 3 Hepa B - RA 7846 - 3 DPT - 1 Measles - Proc. 4 - 3 OPV

School entrants: - 1 booster dose of BCG Pregnant mothers: - 5 Tetanus Toxoid - RA 1066 (tetanus elimination)

3 Principles of EPI: 1. Based on epidemiological situation 2. Main focus: eligible population 3. Immunization is a basic health service Elements of EPI: Target setting: calculation of eligible population Formula: EP = total population x constant percentage Constant percentage: Infants = 3% or .03 School Entrants = 3% or .03 Pregnant Mothers = 3.5% or .035

Cold Chain System - to maintain potency of the vaccine Refrigerator: Freezer: (-15° to -25 °C) – OPV, Measles Body: (2° to 8°C) - DPT, Hepa B, BCG, TT

2 most sensitive to heat vaccine: OPV & MEASLES 2 least sensitive to heat vaccine: BCG & TT

HOW LONG CAN VACCINE BE STORED? DOH REGIONAL HEALTH OFFICE

DISTRICT/ PROVINCIAL HEALTH OFFICE HEALTH CENTER * Health centers using cold box or transport boxes - 5 days * Check temperature 2x a day: first and last hour of the clinic

Vaccine

Age

Doses

At birth

1

Interval

ROUTE

Dosage

ID(RIGHT deltoid )

0.05 ml

ID(LEFT deltoid )

0.5 ml

BCG School Entrants DPT (Triple)

6 wks.

3

4 wks.

IM (VASTUS LATERALIS)

0.5 ml

OPV (Sabin)

6 wks.

3

4 wks.

ORAL

2-3 gtts

HEPA B

At birth

3

4 wks.

IM (VASTUS LATERALIS)

0.5 ml

MEASLES

9 mos.

1

SUBCUTANEOUS

0.5 ml

Pentavalent – Hib (Penta – hib) 1. Diptheria 2. Pertussis or whooping cough 3. Tetanus 4. Hepatitis – B 5. Hemaphilus influenza type B - to prevent pneumonia and meningitis to babies - injected intramuscularly - given at age 6 weeks up to 11 months

CONTENT OF VACCINES: BCG: - live attenuated bacteria OPV and MEASLES: - live attenuated virus DIPTHERIA & TT: - weakened bacterial toxins PERTUSSIS: - killed bacteria HEPA B: - derived from plasma (plasma derivatives) RNA recombinants

PRINCIPLES OF VACCINATION… 1. No BCG to a child born positive with HIV or AIDS 2. DPT is not given to a child who has recurrent convulsions or active neurologic disease 3. DPT2 or DPT3 is not given to a child who has had convulsions or shock w/in 3 days the previous dose but you can give DT. 4. Don’t immunize children before referral 5. Moderate fever, malnutrition, mild resp. infection, cough, diarrhea & mild vomiting aren’t contraindication to vaccination.

6. Safe to administer all EPI vaccines on the same day at different sites of the body. 7. No food 30 minutes after giving OPV. 8. Assess the child for allergy to egg before giving measles vaccine. 9. Measles vaccine should be given as soon as the child is 9 months old regardless of whether other vaccines will be given on that day. 10. Vaccination schedule should not be restarted from the beginning even if the interval between doses exceeded.

11. It is safe and effective with mild side effects after vaccination. 12. Do not repeat BCG vaccination if the child does not develop a scar after the first injection. 13. Strictly follow the principle of never, ever reconstitute the freeze dried vaccines to any diluents. 14. Use one syringe, one needle per child during vaccination. 15. During vaccination, clean the skin with cotton ball, moistened with water only (boiled H20).

Opened vaccines should be discarded after: > BCG & Measles : 4-6 hours

> DPT, OPV, Hepa B & TT : 8 hours Open OPV vials can be used for the next immunization if: a. Expiry date has not passed b. Vaccines stored at 0°C to 8°C c. Not taken out at the health center for outreach activities

ENVIRONMENTAL HEALTH AND SANITATION - the study of all factors in man’s physical environment, which may exercise a deleterious effect on his well-being and survival. FACTORS: 1. water sanitation 7. steam pollution 2. food sanitation 8. air pollution 3. refuse and garbage disposal 9. noise 4. excreta disposal 10. radiological protection 5. housing 11. institutional sanitation 6. insect vector and rodent control Legal basis: PD 856, 1978

Different Laws relating to Environmental Sanitation: 1. Garbage Disposal Law - PD 825 2. Ecological Solid Waste Management Act - RA 9003 3. Clean Air Act - RA 8749 4. Clean Water Act - RA 9275 5. Toxic Substances and Hazardous and Nuclear Waste Control Act - RA 6969

WATER SUPPLY SANITATION PROGRAM Approved type of water supply facilities: LEVEL I (Point Source) - a protected well or a developed spring with an outlet but without a distribution system. - serves 15 to 25 households - outreach must not be more than 250 meters from the farthest user

LEVEL II (Communal Faucet System or Stand-Posts) - a system composed of a source, a reservoir, a piped distribution network and communal faucets. - with one faucet per 4-6 households - located at not more than 25 meters from the farthest house LEVEL III (Waterworks System or Individual House Connections) - a system with a source, a reservoir, a piped distributor network and household taps. - generally suited for densely populated urban areas - requires minimum treatment or disinfection

PROPER EXCRETA AND SEWAGE DISPOSAL PROGRAM Approved types of toilet facilities: LEVEL I Non-water carriage toilet facility – no water is necessary to wash the waste into the receiving space. Ex. Pit latrines, Reed odorless earth closet Toilet facility requiring small amount of water to wash the waste into the receiving space. Ex. Pour flush toilet, Aqua privies LEVEL II on site toilet facilities of the carriage type with water-sealed and flushed type with septic tank/vault disposal facilities LEVEL III - water carriage types of toilet facilities connected to septic and/or to sewerage system to treatment plant

FOOD SANITATION PROGRAM FOUR RIGHTS IN FOOD SAFETY: 1. Right source - always buy fresh meat, fish, fruits and vegetables - check for expiry dates of processed foods - avoid buying canned foods with dents, bulges, deformation, broken seals and improper seams - use clean and safe water - if doubt of water source – boil water for at least 2 minutes

2. Right preparation - avoid contact between raw and cooked foods - always buy pasteurized milk and fruit juices - wash vegetables well if eaten raw - wash hands and kitchen utensils before and after preparing food - sweep kitchen floors to remove food droppings 3. Right cooking - cook food thoroughly and ensure that temperature on all parts of the food should reach 70 degrees centigrade - eat cooked food immediately - wash hands thoroughly before and after

4. Right storage - cooked foods should not left at room temperature for NOT more than 2 hours - store foods carefully: 4 -5 hours hot conditions : at least or above 60 degrees centigrade cold conditions: below or equal to 10 degrees centigrade - do not overburden the refrigerator - reheat stored food before eating --at least 70 degrees centigrade Rule in Food Safety: “WHEN IN DOUBT, THROW IT OUT”

HEALTH EMERGENCY PREPARENESS AND RESPONSE PROGRAM Legal Mandate: 1. PD 1566 (1978) - creation of the National Disaster Coordinating Council - creation of the Multi-level Organization - funding for a 2% reserve for calamities 2. RA 7160 - transfer of responsibilities from the national to local government units giving more power, authority and resources - allocation of 5% calamity fund for emergency operations

Terms: 1. Disaster - is a serious disruption of the functioning of a society, causing wide spread human, material or environmental losses 2. Emergency - as any occurrence, which requires an immediate response 3. Hazards - any phenomenon, which has the potential to cause disruption or damage to humans and their environment

4. Risk - the level of loss or damage that can be predicted from a particular hazard affecting particular place at a particular time from the point of view of the community. 2 components: A. Susceptibility - the factors which allows a hazard to cause an emergency B. Vulnerability - the factors which allows a hazard to cause a disaster

Classification of disaster A. According to its Cause 1. Natural disaster – force of nature 2. Human generated/Manmade – transportation/technological disasters B. According to Onset 1. Acute or sudden impact events 2. Slow or chronic genesis (Creeping disaster) Contributing factors to Disaster: 1. human vulnerability resulting from poverty and social inequality 2. environmental degradation resulting from poor land use 3. rapid population growth especially among the poor

General Principles of Disaster Management: 1. The first priority is the protection of people who are at risk. 2. The second priority is the protection of critical resources and systems on which communities depend. 3. Disasters management must be an integral function of national development plans and objectives. 4. Disaster management relies upon an understanding of hazard risks. 5. Capabilities must be developed prior to the impact on a hazard. 6. Disaster management must be based upon interdisciplinary collaboration. 7. Disaster management will only be as effective as the extent to which commitment, knowledge and capabilities ca be applied.

The Disaster Spectrum Cycle 1. Disaster Impact 2. Relief 3. Rehabilitation 4. Prevention 5. Mitigation 6. Readiness

More Specific within Preparedness includes: 1. vulnerability assessment and dissemination of information related to particular hazards and emergencies. 2. emergency planning 3. training and education 4. warning system 5. specialized communication system 6. resources and information databases and management systems and resource stocks 7. emergency exercises/drills

Principles of Emergency Preparedness: 1. It is the responsibility of all. 2. Should be woven into the community and administrative levels of both government and government organizations. 3. It is an important aspect of emergency management. 4. It is connected to other aspects of emergency management. 5. Should concentrate on process and people rather than documentation. 6. Should not be done in isolation. 7. Should not concentrate only on disasters but integrate prevention and response strategies for any scale of emergency. 8. Hospital plays a very vital role in the management of disaster. 9. The main objective is to decrease mortality, morbidity and to prevent disaster. 10. Every hospital should have a regular updated disaster plan.

PURPOSE OF THE DISASTER PLAN: 1. To provide policy for effective response to both internal and external disaster situations that can create impact to the operation of the hospital and may affect hospital staff, patients, visitors and the community. 2. Identify hospital capability to handle mass casualty. 3. Identify responsibilities of individuals and departments in the event of a disaster situation. 4. Identify standard operating guidelines for emergency activities and responses.

VITAL STATISTICS - refers to the systematic study of vital events such as births, illnesses, marriages, divorce, separation and deaths.

Use of Vital Statistics: 1. indices of the health and illness status of a community. 2. serves as bases for planning, implementing, monitoring and evaluating community health nursing programs and services. Sources of Data: 1. population census 2. registration of vital data 3. health survey 4. studies and researches

* statistic on population and the characteristics such as age, sex - Philippine Statistic Authority * Birth Certificate form - Form 102; Signatory: Birth Attendant 1. Physician 2. Nurse 3. Midwife * requires registration of birth within 30 days - PD 651 * requires registration of births and deaths to the Office of the Civil Registrar - RA 3753 A. Cities – City Health officer B. Municipalities – Municipal Treasurer

* Death Certificate form - Form 103; Signatory: Either of the following: 1. Health Officer (Physician) 2. Local Chief Executive (City or Municipal Mayor) 3. Licensed Embalmer and Undertaker (LEU) * reporting should be done within 2 days

COMMON VITAL STATISTICAL INDICATORS 1. Crude Birth Rate (CBR) - a measure of one characteristic of the natural growth or increase of a population. total number of live births registered in a given calendar _____________________________________________ X 1000 estimated population as of July 1 of same year 2. Crude Death Rate (CDR) - a measure of one mortality from all causes which may result in a decrease of population. total number of deaths registered in a given calendar _____________________________________________ X 1000 estimated population as of July 1 of same year

3. Infant Mortality Rate (IMR) - measures the risk of dying during the 1st year of life. It is a good index of the general health of a community. total number of death under 1 year of age registered in a given calendar _____________________________________________ X 1000 total number of registered live births of same calendar year 4. Maternal Mortality Rate (MMR) - measures the risk of dying from causes related to pregnancy, childbirth and puerperium. total number of deaths from maternal causes registered for a given year _____________________________________________ X 1000 total number of live births registered of same year

5. Fetal Death Rate (FDR) - measures pregnancy wastage. Death of the product of conception occurs prior to its complete expulsion. total number of fetal deaths registered in a given calendar _____________________________________________ X 1000 total number of live births registered on same year 6. Neonatal Death Rate (NDR) - measures the risk of dying the 1st month of life. It serves as an index of the effects of prenatal care and OB management. number of deaths under 28 days of age registered in a given calendar year _____________________________________________ X 1000 number of live births registered of same year

7. Incidence Rate (IR) - measures the frequency of occurrence of the phenomenon during a given period of time. number of new cases of a particular disease registered during a specified period of time _____________________________________________ X 1000 estimated population as of July of same year 8. Prevalence Rate (PR) - measures the proportion of the population which exhibits a particular disease at a particular time. number of new and old of a certain disease registered at a given time _____________________________________________ X 1000 total number of persons examined at same given time

9. Attack Rate (AR) - a more accurate measure of the risk of exposure. number of persons acquiring a disease registered in a given year _____________________________________________ X 100 number of exposed to same disease in the same year 10. Case Fatality Ratio (CFR) - index of a killing power of a disease and is influenced by incomplete reporting and poor morbidity data. number of registered deaths from a specific disease for a given year _____________________________________________ X 100 number of registered cases from same specific disease in same year

C O P A R COMMUNITY ORGANIZING PARTICIPATORY ACTION RESEARCH DEFINITIONS:

- A social development approach that aims to TRANSFORM the APATHETIC, INDIVIDUALISTIC, and VOICELESS POOR into DYNAMIC, PARTICIPATORY and POLITICALLY responsive community. - A process, by which a community identifies its needs and objectives, develops confidence to take action in respect to them and in doing so, extends and develops cooperative and collaborative attitude and practices in the community.

IMPORTANCE OF COPAR: > COPAR is an important tool for community development and people empowerment as this:  helps the community workers generate community participation in development activities.  maximizes community participation and involvement.  prepares people/clients to eventually take over the management of development programs in the future

PRINCIPLES OF COPAR: 1. People, especially he most OPPRESSED, EXPLOITED, AND DEPRIVED ( women sectors, children, handicapped, elderly, youth ) open to change, have the capacity to change, and are able to bring about change. 2. COPAR should be based on the interest of the POOREST SECTORS of society. 3. COPAR should LEAD TO SELF-RELIANT COMMUNITY AND SOCIETY.

PROCESS USED: A

PROGRESSIVE CYCLE OF ACTIONREFLECTION-ACTION which begins with small, local and concrete issues identified by the people and the evaluation and reflection of and on the action taken by them.

 CONSCIOUSNESS-RAISING

through experiential learning is central to the COPAR process because it places emphasis on learning that emerges from concrete action and which enriches succeeding action.

 COPAR is PARTICIPATORY AND MASS-BASED because it is primarily directed towards and biased in favour of the poor, the powerless and the oppressed.  COPAR is GROUP-CENTERED AND NOT LEADER

ORIENTED. Leaders are identified, emerged and tested through action rather than appointed or selected by some external force or entity.

COMMUNITY ORGANIZING - the process whereby the community members develop the capability to assess their health needs and problems, plan and implement actions to solve these problems.

- carried out by the nurse with the goal of motivating, enhancing and seeking wider community participation in decision-making in activities that have the potential to impact positively on community health.

STAG E S Stage 1. Community Analysis - the process of assessing and defining needs, opportunities and resources involved in initiating community health action program. 5 Components: 1. demographic, social and economic profile 2. health risk profile 3. health/wellness outcome profile 4. survey of current health promotion programs 5. studies conducted in certain target groups

Steps: 1. Define the community. 2. Collect data. 3. Assess community capacity. 4. Assess community barriers. 5. Assess readiness for change. 6. Synthesis data and set priorities

Stage 2. Design and Initiation 1. Establish a core planning group and select a local organizer. 2. Choose an organizational structure. a. Leadership board or council – existing local leaders working for a common cause b. Coalition – linking organization and groups to work on community issues c. Lead or official agency – a single agency takes the primary responsibility of a liaison for health promotion activities in the community.

d. Grass-roots – informal structure in the community like the neighborhood residents e. Citizen panels – a group of citizens (5-10) emerge to form a partnership with a government agency. f. Networks and consortia – network develop because of certain concerns. 3. Identify, select and recruit organizational members. 4. Define the organization mission and goals. 5. Clarify roles and responsibilities of people involved in the organization. 6. Provide training and recognition.

Stage 3. Implementation – put design into action. 1. Generate broad citizen participation. 2. Develop a sequential work plan. 3. Use comprehensive, integrated strategies. 4. Integrate community values into the programs, materials and messages.

Stage 4. Program Maintenance – at this point the program has experienced some degree of success and has weathered through implementation programs. To maintain and consolidate gains of the program, the following are essential: 1. Integrate intervention activities into community networks. 2. Establish a positive organizational culture. 3. Establish an ongoing recruitment plan. 4. Disseminate results.

Stage 5. Dissemination - Reassessment * continuous assessment is a part of the monitoring aspect in the management of the program. Formative evaluation is done to provide timely modification of strategies and activities.

1. Update the community analysis. Is there a change in leadership, resources and participation? 2. Assess effectiveness of interventions/programs. 3. Chart future directories and modifications. 4. Summarize and disseminate results.

PHASES OF COPAR

A. Pre-Entry Phase > Community consultation/dialogues > Setting of issues/considerations related to site location > Development of criteria for site selection 1. high percentage of the family income is below the national poverty threshold 2. high malnutrition rate 3. lack of primary or secondary hospital within a 30minute ride from the area 4. area must not have relative peace and order problem 5. acceptance of the community > Site selection > Preliminary social investigation >Networking with LGU’s, NGO’s and other departments

B. Entry Phase > Integration with the community > Sensitization of the community; information campaign > Continuing/Deepening social investigation > Core group formation 1. belongs to the poor sector of the society 2. responsible and committed 3. able to communicate > Coordination with other community organization > Self-Awareness and Leadership Training (SALT)/ Action Planning Best technique to identify potential leaders: - observe people who are active in small mobilization activities that motivate residents to start working.

C. Community Study/Diagnosis Phase > Selection of the research team > Training on data collection methods and techniques > Planning for the actual gathering of data > Data gathering > Training on data validation > Community validation > Presentation of the community study/ diagnosis and recommendations. > Prioritization of community needs/problems for action

TYPES OF COMMUNITY DIAGNOSIS 1. Comprehensive Community Diagnosis > aims to obtain a general information about the community. Elements: A. Demographic variables B. Socio-economic and cultural variables C. Health and illness patterns D. Health resources E. Political/Leadership patterns 2. Problem-Oriented Community Diagnosis > type of assessment that responds to a particular need.

D. Community Organization and Capability Building Phase > Community meetings to draw up guidelines for the organization > Election of officers > Delineation of the roles, functions and task of officers and members > Action-Reflection-Action session - tool used to develop team-building and to promote an avenue to verbalize feelings, opinions and suggestions and enable them to participate in decision-making > Team building exercises > Working out legal requirements for the establishment of the CHO > Training of the CHO officers/ community leaders

E. Community Action Phase > Organization and training of CHW’s > Setting-up of linkages/network referral system > Project Implementation Monitoring Evaluation (PIME) of health services > Initial identification and implementation of resource mobilization schemes

F. Sustenance and Strengthening Phase - begins when the community organization has already established community members who are actively participating in community wide undertakings activities. > Formulation and ratification of constitution and by-laws > Identification and development of “Secondary” leaders > Setting up and institutionalization of a financing scheme for the community health activities > Formalizing and institutionalization of linkages, networks and referral systems > Continuing education and upgrading of community leaders, CHW’s and CHO members > Development of medium/ long term community health and development plans

CRITICAL STEPS (ACTIVITIES) IN BUILDING PEOPLE AND ORGANIZATION 1. INTEGRATION ***A community becoming one with the people in order to: A. Immerse himself in the poor community B. Understand deeply the culture, economy leaders, history rhythms and life style in the community. 2. SOCIAL INVESTIGATION - a systematic process of collecting and analyzing data to draw a clear picture of the community. - a process of systematically learning and analyzing the various structures and forces in the community > Also known as the “Community Study”

3. TENTATIVE PROGRAM PLANNING - CO to choose one issue to work on in order to begin organizing the people. 4. GROUNDWORK - going around and motivating the person on a one on one basis to do something on the issue that has been chosen. 5. THE MEETING - people collectively ratifying what have already decided individually. The meeting gives the people the collective power and confidence .Problems and issues are discussed.

5. ROLE PLAYING - means to act out meeting that will take place between the leaders of the people and the government representative’s .It is the way of training the people to anticipate what will happen and prepare themselves for such eventually. 6. MOBILIZATION OF ACTION - actual experience of the people in confronting the powerful and the actual exercise of the people power. 7. EVALUATION - the people reviewing the steps 1-6 so as to determine whether they were successfully or not on their objectives.

8. REFLECTION - dealing with deeper, on going concerns to look at the positive values CO is trying to build in the organization. It gives as the people time to reflect on the starch reality of the life compared in the ideal. 9. ORGANIZATION - the people organization is the result of many successive and similar actions of the people .A final organizational structure is set up with elected officers and supporting members.

What is IMCI? Integrated Management of Childhood Illness (IMCI) is a strategy for reducing the mortality and morbidity associated with the major causes of childhood illness. IMCI is an integrated approach to child health that focuses on the well-being of the whole child.

The IMCI strategy : • promotes the accurate identification of childhood illnesses; • ensures appropriate integrated treatment of all major illnesses; • strengthens the counseling of caregivers; • identifies the need of and speeds up the referral of severely ill children.

In the home setting: • it promotes appropriate care-seeking behaviors; • improved nutrition and preventative care; • and the correct implementation of prescribed care.

2 Age Categories in IMCI: 1. Young Infant – up to less than 1 week up to 2 months (1 week up to 1 month and 29 days) 2. Young Child – 2 months up to 5 years (2 months up to 4 years and 11 months)

Principles in IMCI: 1. All sick children must be examined for GENERAL DANGER SIGNS: C > convulsions (fits, jerky movement, spasm)

U > unable to drink or breastfeed (not eat)

V > vomiting A

> abnormally sleepy (difficult to awaken)

2. Assess for MAIN SYMPTOMS: For Older children a. Cough/DOB b. Diarrhea c. Fever d. Ear problems

For Young infants: a. Local bacterial infection b. Diarrhea c. Jaundice

3. Assess for nutritional status, immunization status, vitamin A status, feeding problems and other potential problems.

4. Only a limited number of carefully-selected clinical signs are used.

5. A combination of individual signs leads to a child’s classification(s) rather than a diagnosis. × identify illness = Dx √ classify illness = classification 6. The guidelines do not describe the management of trauma or other acute emergencies d/t accidents or injuries.

7. IMCI management procedures use a limited number of essential drugs and encourage active participation of caretakers. 8. An essential component of the IMCI guidelines is the counseling of caretakers.

THE IMCI STRATEGY ASSESS THE CHILD Check the child for Danger Signs Then Ask:

For any “yes” answer

Does the child have cough or difficult breathing?

•Ask further questions

Does the child have diarrhea?

•LOOK,LISTEN, FEEL

Does the child have Fever?

•Based on this classify illness

Does the child have ear problem

Then Check the child for malnutrition and anemia Then check the child’s immunization status Then check the child for other problems

Classify Illness Pink classification Yellow classification Green classification Identify Treatment urgent pre-referral treatment and referral, or specific medical treatment and advice, or simple advice on home management

Treat the Child Teach the mother to give oral drugs at home Teach the mother to treat local infections at home Give intramuscular drugs in clinic Give Increased fluids for diarrhea and continue feeding If the child needs to be referred, give appropriate prereferral treatment

Counsel the mother Using the process: ASK, PRAISE, ADVISE, CHECK Food and feeding problem Fluid intake during illness When to return

Care for Development Her own health

Follow - up health-care provider gives appropriate follow-up care, as indicated in IMCI guidelines If necessary, reassess the child for any new problems.

Assess and Classify A Sick Child Aged 2 months to 5 years 1. Ask the mother what the child’s problems are? greet the mother appropriately use good communication skills listen carefully to what the mother tells you use words that the mother will understand give the mother time to answer questions ask additional questions if the mother is not sure about her answer 2. Determine if it is an initial visit

For ALL sick children ask the mother about the child’s problem, check for general danger signs and then

ASK: DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?

If YES If NO

IF YES, ASK: 



For how long?

Fast breathing is: 2 mos – 12 mos. 50 breaths per minute or more 12 mos – 5 yrs. 40 breaths per minute or more

LOOK, LISTEN, FEEL: 

Count the breaths in one minute.



Look for chest indrawing



Look and listen for stridor



Look and Listen for wheeze If wheezing and weather fast breathing, give a trial of rapid acting bronchodilator up to 3 times 15 – 20 mins. apart. Reassess



The child must be calm

CLASSIFY the child's illness using the colour-coded classification table for cough or difficult breathing.

Then ASK about the next main symptoms: diarrhoea, fever, ear problems. CHECK for malnutrition and anaemia, immunization status and for other problems

Classify Cough  Any general danger sign or  Lower chest indrawing or  Stridor in calm child

 Fast Breathing (if wheezing, go directly to treat wheezing)  No signs of pneumonia or very severe disease

SEVERE PNEUMONIA OR VERY SEVERE DISEASE PNEUMONIA

NO PNEUMONIA: COUGH OR COLD

Treatment

Safe remedies: - Instruct - Follow –up care after 5 days

NO PNEUMONIA: COUGH OR COLD

1. Give 3 days antibiotic.

1st line of drugs: Amoxicillin 2 times daily for 3 days 2nd line of drugs: Cotrimoxazole 2times daily for 3 days 2. Soothe the throat & relieve the cough using safe remedies: - B, T, L, C Breastmilk, Tamarind, Luya, Calamansi) •Never give cough syrup, antitussive, decongestant, mucolytics. 3. Instruct the mother when too return the baby immediately. 4. Follow up after 2 days.

PNEUMONIA

Pre-referral Treatment: 1. Give 1st dose antibiotic 2. Give Vitamin A - 2 months to 12 months: 100,000 IU (blue) -12 months to 5 y/o : 200,000 IU (red) 3. Treat the child to prevent lowering of the blood sugar (hypoglycemia)

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

How to prevent lowering of blood sugar level: *If the child is able to breastfeed: *If the child is not able to breastfeed but is able to swallow - give 30-50 ml milk or sugar H2O p.o. (sugar H2O: 4 tsp. sugar+200 ml H2O) *Not able to swallow but conscious: - Insert NGT *If the child is unconscious: - (IVF) D10W 5 ml/kg body weight for a few minutes

For ALL sick children ask the mother about the child’s problem, check for general danger signs, ask about cough or difficult breathing and then ASK: DOES THE CHILD HAVE DIARRHEA?

If NO

Does the child have diarrhea IF YES, ASK:

LOOK, LISTEN, FEEL:



For how long?

•



Is there blood in the stool

Look at the child's general condition. Is the child:



Abnormally sleepy or difficult to awaken? Restless or irritable? Look for sunken eyes.



Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty?



Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly?

CLASSIFY the child's illness using the color-coded classification tables for diarrhea.

Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition and anaemia, immunization status and for other problems.

Classify Diarrhea SIGNS

CLASSIFY AS

Two of the following signs:  Lethargic or unconscious  Sunken eyes  Not able to drink or drinking poorly  Skin pinch goes back very slowly

SEVERE DEHYDRATION

Two of the following signs:  Restless, irritable  Sunken eyes  Drinks eagerly, thirsty  Skin pinch goes back slowly Not enough signs to classify as some or severe dehydration.

Dehydration present No dehydration • Blood in the stool

SIGNS

SOME DEHYDRATION

NO DEHYDRATION

CLASSIFY AS SEVERE PERSISTENT DIARRHEA PERSISTENT DIARRHEA DYSENTERY

Treatment: Severe Dehydration PINK PLAN C

Give IVF : D5LR < 12 mos. old : 100ml/kg within 6 hrs 12 mos. up to 5 y.o. : 100ml/kg within 3 hrs

Some Dehydration YELLOW PLAN B

Give ORS for the 1st 4hrs Amount of ORS = weight (kg) x 75 = ml/cc > after 4 hours, re-assess child for signs of dehydration > if still some dehydration, continue ORS for 4 hours

Age

Amount of ORS

1 week up to 4 mos. old 4 mos. up to 12 mos. 12 mos. up to 2 years old 2 years old up to 5 years old

200-400 ml 400-700 ml 700-900 ml 900-1400 ml

Mild vomiting during ORT = stop ORS in 10 mins, after 10 mins continue ORS but give it in a slow manner Severe Vomiting during ORT = stop ORS → IVF or refer!

No Signs of Dehydration Green PLAN A Give ORS if with watery or loose stool 1 week up to 2 y/o = 50-100 ml ORS 2 y/o up to 5 y/o = 100-200 ml ORS If there’s no watery/loose stool (4 Home Rule Management): 1. Continue feeding (BRAT diet) 2. Give extra fluids; soups, milk, plain water, juice, rice water 3. Give Zinc supplement for 10-14 days to increase immune system 4. Advise mother when to return baby immediately.

PERSISTENT DIARRHEA (Young child) Yellow 1. Give Vit. A 2. Advise mother recommended feeding 3. Follow-up after 5 days → if still breastfeeding: = breastfeed day and night → if taking milk supplements: = replace milk supplements with increased breastfeeding = replace half of the milk & nutrient rich, semi-solid foods * Do not use condensed or evaporated milk = because it is high in CASEINE

SEVERE PERSISTENT DIARRHEA Pink

1. Give Vitamin A 2. Give IVF = Plan C

DYSENTERY (Young Infant)

DYSENTERY (Child)

Pink

Yellow

Referral

Ciprofloxacin 2 times daily for 3 days

Cholera: First Line Antibiotic: > Tetracycline Second Line Antibiotic : > Erythromycin

FEVER For ALL sick children ask the mother about the child’s problem, check for general danger signs, ask about cough or difficult breathing, diarrhea and then ASK: DOES THE CHILD HAVE FEVER? Does the child have fever? (by history or feels hot or temperature 37.5C** or above) IF YES: Decide the Malaria Risk: Yes or No

If No

THEN ASK:



For how long?



If more than 7 days, has fever been present every day? Has the child had measles within the last 3 months?



LOOK AND FEEL: 

Look or feel for stiff neck.



Look for runny nose.

Look for signs of MEASLES  Generalized rash and 

If the child has measles now or within the last 3 months:



 

Decide Dengue Risk: Yes or No Ask: o Has the child had any bleeding from the nose or gums, or in the vomitus or stool? o Has the child had black vomitus? o Has the child evacuated black stool? o Has the child had persistent abdominal pain? o Has the child been persistent vomiting?

One of these: cough, runny nose, or red eyes. Look for mouth ulcers. Are they deep and extensive?

Look for pus draining from the eye. Look for clouding of the cornea.

Look and Feel: •Look for bleeding from the nose or gums? •Look for skin petechiae •Feel for cold and clammy? •Check for slow capillary refill. •If none of the above ask , look and feel signs are present and the child is 6 months and older and fever has been present for more than 3 days, perform tourniquet test.

CLASSIFY the child's illness using the colour-coded classification tables for fever.

Then ASK about the next main symptom: ear problem, and CHECK for malnutrition and anaemia, immunization status and for other problems.

Malaria Risk Signs Signs

 

Any general danger signs Stiff neck

    

Blood Smear (+) If Blood smear is not done; No runny nose, and No measles, and No other cause of fever

   

Blood Smear (-) or Runny nose, or Measles, or Other cause of fever

Classification Classification

Very Severe Febrile Disease/Malaria

Malaria

Fever: Malaria Unlikely

No Malaria Risk Signs Signs

 

Any general danger sign Stiff Neck



No signs of very febrile disease

Classification Classification

Very Severe Febrile Disease

Fever: No Malaria

Malaria Risk Treatment > Give paracetamol for fever > Advise mother when to return immediately > Follow-up after 2 days > Give paracetamol for fever > Bring the child if there’s CUVAS > Follow-up after 2 days > Give antimalarial drugs First Line Antibiotic: Arthemeter + Lumefantrine Second Line Antibiotic: Chloroquine, Primaquine, Sulfadoxine and Pyremethamine Pre-referral Treatment: 1. Give first dose antibiotic 2. IM Quinine 3. Give paracetamol 4. Treat lowering of blood sugar 5. REFER!

Fever: Malaria Unlikely

Malaria

Very Severe Febrile Disease/Malaria

No Malaria Risk Treatment > Give Paracetamol for fever > Advise mother when to return immediately > Follow-up after 2 days

Fever: No Malaria

Pre-referral Treatment: > Give Paracetamol for fever > Treat lowering of blood sugar > Refer!

Very Severe Febrile Disease

Measles Signs

  

Any general danger signs or Clouding of the cornea, or Deep and extensive mouth ulcers

 

Pus draining from the eyes, or Mouth Ulcers



Measles now or within the last three months

Classification

Severe Complicated Measles Measles with Eye or Mouth Complications Measles

Dengue Hemorrhagic Fever Signs

      

Bleeding from the nose or gums, or Bleeding in stools or vomitus, or Skin petechiae, or Cold and clammy extremities, or Persistent abdominal pain, or Persistent vomiting, or Torniquet test positive



No signs of severe dengue hemorrhagic fever

Classification

Severe Dengue Hemorrhagic Fever

Fever: Dengue Hemorrhagic Fever Unlikely

Measles Treatment *Pre-referral Tx: > Give Vitamin A > Apply tetracycline on eyes if with eye complication > Give 1st dose of antibiotic > Refer! Don’t give/apply gentian violet on mouth ulcers > Give Vitamin A > Apply tetracycline on eyes QID > Apply Gentian Violet (half strength) on mouth BID > Follow-up after 2 days

Give Vitamin A

Severe Complicated Measles

Measles with Eye or Mouth Complications

Measles

Dengue Hemorrhagic Fever Treatment Pre-referral treatment: 1. Rapid fluid replacement 2. Paracetamol for fever of 38.5 ˚C without ASA 3. Treat child to prevent lowering of blood sugar 4. REFER! 1. Give Paracetamol for fever of 38.5 ˚C w/o ASA 2. Advise to bring if signs of severe dengue fever occurs 3. Follow up after 2 days

Severe Dengue Hemorrhagic Fever

Fever: Dengue Hemorrhagic Fever Unlikely

Ear Problem For ALL sick children ask the mother about the child’s problem, check for general danger signs, ask about cough or difficult breathing, diarrhoea, fever and then ASK: DOES THE CHILD HAVE AN EAR PROBLEM?

If No

If Yes IF YES, ASK:

LOOK AND FEEL:

If yes, for how long?  Is there ear pain?  Is there ear discharge?

 

Look for pus draining from the ear. Feel for tender swelling behind the ear.

CLASSIFY the child's illness using the color-coded classification table for ear problem.

Then CHECK for malnutrition and anemia, immunization status and for other problems.

Classify Ear Problem SIGNS

 Tender swelling behind the ear.  Pus is seen draining from the ear and discharge is reported for Less than 14 days, or  Ear pain.  Pus is seen draining from the ear and discharge is reported for 14 days or more.  No ear pain and No pus seen draining from the ear.

CLASSIFICATION

MASTOIDITIS

ACUTE EAR INFECTION CHRONIC EAR INFECTION NO EAR INFECTION

Ear Problem Treatment Pre-referral treatment: * Give 1st dose antibiotic * Give Paracetamol for ear pain * Refer!

MASTOIDITIS

* give 3 days antibiotic * dry the ear by wicking (roll soft cloth in a wick) * give Paracetamol for ear pain * follow-up after 5 days

ACUTE EAR INFECTION

* dry ear by wicking * follow-up after 5 days

CHRONIC EAR INFECTION

* No treatment needed

NO EAR INFECTION

Malnutrition and Anemia For ALL sick children ask the mother about the child’s problem, check for general danger signs, ask about cough or difficult breathing, diarrhoea, fever, ear problem and then CHECKFOR MALNUTRITION AND ANEMIA CHECK FOR MALNUTRITION AND AN EMIA.

If Yes

If No

Check for Malnutrition LOOK AND FEEL: For All Children  Determine the weight for age  Look for visible severe wasting.  Look for edema of both feet.  For children aged 6 mos. or more determine if MUAC I is less than 11 cm. Check for Anemia LOOK AND FEEL:  Look for palmar pallor. Is it: Severe palmar pallor? Some palmar pallor? 

CLASSIFY the child's illness using the color-coded classification table for malnutrition and anemia. Then CHECK immunization status and for other problems.

Classify Malnutrition SIGNS

CLASSIFICATION

If age up to 6 mos. - Visible severe wasting or Edema of both feet. • If age 6 months and above and MUAC less than 11 mm or - edema of both feet, Visible severe wasting

SEVERE MALNUTRITION

 Very low weight for age.

LOW WEIGHT

 Not very low weight for age and no other signs or malnutrition. Classify Anemia  Severe palmar pallor Some palmar pallor  No palmar pallor

NOT VERY LOW WEIGHT

SEVERE ANEMIA ANEMIA NO ANEMIA

Malnutrition and Anemia Severe Anemia/ Severe Malnutrition * Give Vitamin A * Refer!

Anemia * Give 30 days of 10 ml or 2 tsp Iron * Deworm: Mebendazole Albendazole * Follow up after 14 days

Low Weight

No Anemia, Not Very Low Weight

* Counsel mother * Follow up after * Assess the child’s feeding 5 days No feeding problem:

* Give Vit. A * Follow-up after 30 days

* Counsel the mother

Check Immunization Status, Vitamin A and Deworming Status For ALL sick children ask the mother about the child’s problem, check for general danger signs, ask about cough or difficult breathing, diarrhoea, fever, ear problem, and then check for malnutrition and anaemia and CHECK IMMUNIZATION STATUS.

AGE

IMMUNIZATION SCHEDULE:

Birth 6 weeks 10 weeks 14 weeks 9 months

VACCINES

BCG DPT-1 DPT-2 DPT-3 Measles

OPV-1 OPV-2 OPV-3

Hep B 1 Hep B 2 Hep B 3

DECIDE if the child needs an immunization today, or if the mother should be told to come back with the child at a later date for an immunization. Note: Remember there are no contraindications to immunization of a sick child if the child is well enough to go home.

Then CHECK for other problems. Vitamin A Prophylaxis The first dose at 6 mos. Or above and subsequent dose every 6 mos.

Routine Worm Treatment Give every child mebendazole every 6 mos. From age 1 year and record in the child’s card

Assess and Classify Sick Young Infant Aged up to 2 Mos. For ALL sick young infants check for signs of POSSIBLE BACTERIAL INFECTION.

ASK: 



LOOK, LISTEN, FEEL:

Is the infant having difficulty in feeding? Has the infant had convulsions?



  

 

Count the breaths in one minute. Repeat the count if elevated. Look for severe chest indrawing. Look at the umbilicus. Is it red or draining pus? Does the redness extend to the skin? Measure axillary temperature Look for skin pustules. Are there many or severe pustules? Look at the young infant's movements. Does the infant move on his own? Does the infant move only when stimulated? Does the infant not moving at all

CLASSIFY the infant's illness using the colour-coded classification table for possible bacterial infection.

Then ASK about diarrhoea. CHECK for feeding problem or low weight, immunization status and for other problems.

Classify Sick Young Infant Signs

• Not Feeding well or • Convulsions or • Fast breathing (60 breaths per minute or more) or • Severe chest indrawing or • Fever (37.5° C* or above or feels hot) or • low body temperature (less than 35.5°C* or feels cold) • Movement only when stimulated or no movement at all • Umbilical red or draining pus or • Skin pustules

• No signs of very severe disease or local bacterial infection

Classification

VERY SEVERE DISEASE

LOCAL BACTERIAL INFECTION

SEVERE DISEASE OR LOCAL BACTERIAL DISEASE UNLIKELY

TREATMENT

Pre-referral treatment: 1. Give first dose antibiotic: Gentamycin - (IM) Right Vastus lateralis Benzyl penicillin: Left Vastus lateralis 2. Keep warm 3. Treat child to prevent hypoglycemia 4. Refer.

VERY SEVERE DISEASE

1.Give 3 days antibiotics P.O. 2.Apply gentian violet on affected area (FULL STRENGHT) 3.Follw-up after 2 days.

LOCAL BACTERIAL INFECTION

SEVERE DISEASE OR LOCAL BACTERIAL DISEASE UNLIKELY

Assess Jaundice Look: Look for jaundice (yellow eyes and skin) Look at young infant’s palms. Are they yellow

Classify Jaundice 





Signs

Classification

Any jaundice if age less than 24 hours or Yellow palms and soles at any age

SEVERE JAUNDICE

Jaundice appearing after 24 hours of age and Palms and soles are not yellow

JAUNDICE

No Jaundice

NO JAUNCICE

Check for Low Weight Infants for Age in Breastfed Infants ASK:  Is the infant breastfed? If yes, How many times in 24 hours?  Does the infant usually receive any other foods or drinks? If yes, how often?  What do you use to feed the infant?

ASSESS BREASTFEEDING:  Has the infant breastfed in the previous hour?

Look, Listen and Feel •Determine the weight for age •Look for white ulcers or white patches in the mouth

If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. (If the infant was fed during the last hour, ask the mother if she can wait and tell you when the infant is willing to feed again.) 

Is the infant able to attach? no attachment at all not well attached

good attachment

TO CHECK ATTACHMENT, LOOK FOR:  Chin touching breast  Mouth wide open  Lower lip turned outward  More areola visible above then below the mouth (All these signs should be present if the attachment is good.)  Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)? no suckling at all not suckling effectively suckling effectively Clear a blocked nose if it interferes with breastfeeding.  Look for ulcers or white patches in the mouth (thrush).

Classify the Feeding Problem Signs

Classification

Not well attached to breast, or  Not sucking effectively, or  Less than 8 breastfeeds in 24 hours, or  Receives other foods or drinks, or  Low weight for are age, or  Thrush (ulcers or white patches in mouth).

FEEDING PROBLEM OR LOW WEIGHT FOR AGE

 Not low weight for age and no other signs of inadequate feeding.

NO FEEDING PROBLEM

RECOMMENDED FEEDING At birth up to 6 months > exclusively breastfeed > 8 times or more than 8 times within 24 hours. SIGNS OF HUNGER: 1. Beginning to fuss. 2. Sucking fingers and fist 3. Sucking movements with their lips.

>6 months up to 12 months: breastfeeding + 3 times a day complementary food. If not on breastfeeding: 5 times a day complementary food. >12 months up to 2 years old: breastfeeding + 5 times a day of complementary food.

>At birth up to 4 months: exclusive breastfeeding 8 times in 24 hrs. >4 months up to 6 months: breastfeeding with complementary food 1-2 times a day

Gentian Violet: Half strength: for mouth ulcers =15 ml GV+30-45 DW = .25% concentration Full strength: skin pustules & umbilical redness or pus =15 ml GV+15 ml DW = .5% concentration

Preparation and Application of Gentian Violet Mouth ulcers 1. Wash hands

Skin pustules 1. Wash hands

Umbilical Redness/Pus 1. Wash hands

2. Clean affected area 2. Clean affected using soft cloth area using soft dipped in salt water cloth soaked with soap & water 3. Paint GV 3. Paint GV

2. Clean affected area using 70% alcohol

4. Wash hands

4. Wash hands

4. Wash hands

3. Paint GV

.