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I. Maternal Health Program

The Philippines is tasked to reduce the maternal mortality ratio (MMR) by three

quarters by 2015 to achieve its millennium development goal. This means a MMR of

112/100,000 live births in 2010 and 80/100,000 live births by 2015. However, the

Philippines find it hard to reduce maternal mortality. Similarly, perinatal mortality

reduction has been minimal. The percentage of pregnant women with at least four prenatal visits decreased from

77% in 1998 to about 70.4% in 2003

Women who receive at least two dose of tetanus toxoid also decreased from 38% in

1998 to 37.3% in 2003.

Only about 76.8% of pregnant women received iron supplementation during

pregnancy.

The 2000 Philippine Health Statistics revealed that these are the common causes of

maternal deaths:

o 25% die out of hypertension;

o

20.3% postpartum haemorrhage;o 9% pregnancy with abortive outcomes.

Births attended by health professionals increased from 56% (1998) to 59.8% (2003).

Women with at least one prenatal visit increased to 51% (2003) from 43% in 1998.

Only 44.6% of postpartum women received a dose of Vitamin A.

Essential Health Service Packages Available in the Health Care Facilities

A. ANTENATAL REGISTRATION- Every women has to visit the nearest health facility for

antenatal registration and to avail prenatal care services. Thisis the only way to guide her in pregnancy care to make herprepared for childbirth.

Prenatal Visits Period of Pregnancy1st Visit As early in pregnancy as possible beforefour months or during the first trimester

2nd Visit During the 2nd trimester

3rd Visit During the 3rd trimesterEvery 2 weeks After 8th month of pregnancy till delivery

B. TETANUS TOXOID IMMUNIZATION- Both mother and child are protected against neonatal tetanus.

VaccineDose

Timing of Vaccination Period of Protection

TT1 5th-6th month ofpregnancy

None

TT2 At least 4 weeks afterTT1

3 years

TT3 At the 5th to 6th month ofsucceeding pregnancyregardless of intervalfrom previous pregnancy

5 years

TT4 At the 5th to 6th month ofpregnancy regardless ofinterval

10 years

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TT5 At the 5th to 6th month ofpregnancy regardless ofinterval

lifetime

C. MACRONUTRIENT and MICRONUTRIENT SUPPLEMENTATION- Interventions for maternal health include supplementation for

folic acid, iron, Vitamin A and balanced energy and protein

intake to improve maternal and fetal outcomes.- The important years for intervention related to nutrition are

from pregnancy to two years of age.- Inability to make essential interventions available causes

irreversible damages and increases the risk of girls becomingmalnourished mothers, who then have low-birth-weight babies.

D. TREATMENT OF DISEASES and OTHER CONDITIONS- Iodine deficiency is one of the preventable cause of mental

retardation and brain damage. It is also associated withcretinism, low mean birth weight and increased infantmortality. All of 4 provinces of Northern Mindanao are high-riskIDD areas. The nurse can assess the womens thyroid gland

by palpation, based on the report that 30% of pregnant womenhave goiter.

- Malaria is the 9th leading cause of morbidity among women. Inareas where malaria is endemic the health care provider gives2 tablets of chloroquine phosphate (250mg/tablet) every weekfor the duration of pregnancy.

E. EARLY DETECTION AND MANAGEMENT OF COMPLICATIONS OFPREGNANCY

- The nurse needs to have the skill in detecting the danger signsof pregnancy. Patients manifesting these signs need toreferred to the nearest facility or physician. Interestingly, theresults of the study by ADB on 41 out of 79 provinces in the

Philippines show that only 56.6% of women were advised togo to specific public facilities in case of pregnancycomplication. The rest were not adequately informed wherethey can go if they encountered pregnancy complications.

- Prompt detection and management will help in decreasing thechances for maternal and fetal mortality and morbidity.Specifically, the nurse needs to report vaginal bleeding,edema of the face and hands, headache, dizziness, blurredvision, and pallor.

- In the prenatal check-up, the health care provider also takesthe womens fundic height, temperature, blood pressure,weight, signs of urinary infection and signs of eclampsia

especially starting the 20th week.F. FAMILY PLANNING COUNSELLING

- Family planning and fertility awareness are part of what isdiscussed in the first prenatal visit and the subsequent visits.

After delivery, the benefits of family planning, risks of apregnancy too soon and most suitable family planningmethods for a breastfeeding woman are discussed. Thechoices offered are IUD, condom, progesterone only pill,natural family planning, spermicides and permanent methods

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G. STD/HIV/AIDS PREVENTION AND MANAGEMENT- The WHO standard aims for all women during pregnancy,

childbirth and the postnatal period to be given appropriateinformation on the prevention and recognition of SexuallyTransmitted Infections (STIs) and reproductive tract infections(RTIs).

-They should be assessed for STIs/RTIs and, when required,provided with prompt and effective treatment for themselvesand, in the case of STIs, their partners.

- Effective management of STIs is the key to their control, as itprevents the development of complications and sequelae,reduces the spread of these diseases in the community andoffers a unique opportunity for targeted education on HIVprevention.

The Nursing Process in a Nurse-Managed care- A nurse-managed pregnancy care is best described as the nurse taking

ownership of the delivery of pregnancy services. Her roles include being apractitioner, health educator, and coordinator. This means that the nurse has a

level of expertise and decision making capability to work with the client andfamily in attaining the expected outcomes of care. Whether she works with theclient through a clinic or a home visit, the main responsibility of ensuring that thewoman is able to undergo a risk assessment, receive visit-specific screeningtests, education, immunizations or supplements and interventions. The use ofnurse-managed care is also part of the implementing current evidence thatwomen benefit most when there is continuity of care. The nurse will also bridgethe gap of making effective referrals so that the woman know where to go andwhat to do in the face of complications in pregnancy.

II. CHILD HEALTH PROGRAMS

A. INFANT AND YOUNG CHILD FEEDING- Issued by the WHO and UNICEF and 2002 as endorsed by consensus in the

55th World Health Assembly in May 2002 and the UNICEF Executive Board inSeptember 2002.

- The strategy calls for the promotion of breastmilk as the ideal food for thehealth growth and development of infants; and of exclusive breastfeeding forthe first 6 months of life as means to achieve optimal growth, developmentand health of newborns. Thereafter, to meet their evolving nutritionalrequirements, infants should receive nutritionally adequate and safecomplementary foods while breastfeeding continues for up to two years ofage or beyond. Since breastfeeding is also a learned behaviour, all mothersneed accurate information and skilled support and counselling within their

families, communities and health cares system to successfully breastfeed.B. EXPANDED PROGRAM ON IMMUNIZATION

Objectives of EPI- To reduce morbidity and mortality rates among infants and children from

six childhood immunizable disease Elements of EPI

- Target Setting

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- Cold chain Logistic Management- Vaccine distribution through cold chainis designed to ensure that the vaccines were maintained under properenvironmental condition until the time of administration.

- Information, Education and Communication (IEC)- Assessment and evaluation of Over-all performance of the program- Surveillance and research studies

Fully Immunized Child (FIC)- less than 12 months old child with completeimmunizations of DPT, OPV, BCG, Anti Hepatitis, Anti measles.

There is no contraindication to immunization except when the child is

immunosuppressed or is very, very ill (but not slight fever or cold). Or if the

child experienced convulsions after a DPT or measles vaccine, report such to

the doctor immediately.

Malnutrition is not a contraindication for immunizing children rather; it is an

indication for immunization since common childhood diseases are often

severe to malnourished children.

FEFO (first expiry and first out) - vaccine is practiced to assure that allvaccines are utilized before the expiry date. Proper arrangement of vaccinesand/or labelling of vaccines expiry date are done to identify those near toexpire vaccines.

The 7 immunizable diseases

- Tuberculosis

- Diphtheria

- Pertussis

- Measles

- Poliomyelitis

- Tetanus

- Hepatitis B

Health workers are vital to health care delivery system. The most criticalproblem we are facing now is the lack of nurses and other disciplines incarrying out health activities in immunization. As a nurse you need to:

- Actively masterlist infants eligible for vaccination in thecommunity

- Immunize infants following the recommended immunizationschedule, route of administration, correct dosage and following theproper cold chain storage of vaccines

- Observe aseptic technique on immunization and use one syringeand one needle per child. This reduces blood-borne disease andpromote safety of injection practices

- Disposed used syringes and needles properly by using a collector

box and disposing it in the septic vault to prevent health hazard- Inform, educate, and communicate with parents- Conduct health visits in the community to assess other health

needs of the community and be able to provide package of healthservices to targets

- Identify cases of EPI target disease per standard case definition- Manage vaccines properly by following the recommended storage

of vaccine- Record the children given with vaccination in the Target Client List

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- Submit report and record of children vaccinated, cases and deathson EPI diseases

- Identify and actively search cases and deaths of EPI targetdiseases following standard case definition.

C. MANAGEMENT OF CHILDHOOD ILLNESSES The IMCI has been established as an approach to strengthen the

provision of comprehensive and essential health package to children. Children with various health conditions although considered common

diseases, are difficult to manage. Some diseases have the samesymptoms that needs to be furthered assessed before classification andtreatment takes place.

The steps of IMCI are:1. Assess the patient. Taking the history of the patient is one

way of getting information about the disease condition.This can be done by asking and observing patientscondition to explore possible causes.

2. Classify the Disease. A thorough assessment supportedwith laboratory results is necessary for classification of

illness and confirmation of the disease.Color Code Classification Level of ManagementGreen Mild Home Care

Yellow Moderate Manage at the RHU

Pink Severe Urgent referral in Hospital

3. Treat the patient. Treatment is a curative method oftreating diseases. This vary on the condition of the patient

4. Counsel the patient. Providing health education to clientspromotes health and avoid risk of infection. These areimportant for parents/caregivers especially those who lackknowledge on health practices and risk factors thatcontribute to different ailments.

D. NUTRITION PROGRAM Micronutrient Supplementation. Includes twice a year distribution of

Vitamin A capsules through the Araw ng Sangkap Pinoy, known asGarantisadong Pambata, or Child Health Week is the approach adoptedto provide micronutrient supplements to 6-71 months old pre-schoolers ona nationwide scale

Food Fortification Program. RA 8976, is the addition of essential nutrientsto widely consumed food product at levels above its natural state in a costeffective and sustainable intervention. Provides mandatory fortification ofstaples namely: flour, with iron and vitamin A, cooking oil and refinedsugar with Vitamin A and rice with iron, and the voluntary fortification ofprocessed foods through the Sangkap Pinoy Seal.

E. ORAL HEALTH PROGRAM Primary objectives includes: a) To increase the proportion of Orally Fit

Children under 6 years old to 80% by 2010; b) To control oral health risksamong young people.

Classification of Oral Interventionso Preventive- Consists of measures which will promote oral health

and provide specific protection from the occurrence of dentalcaries and other oral diseases. Some of these interventionsinclude: oral examinations, oral hygiene (brushing of teeth), pit

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and fissure sealant program against tooth decay and FlourideUtilization Program

o Curative- are remedial measures applied to halt the progress oforal disease and restore the sound condition of the teeth andsupporting tissues. It includes: Permanent filling to restoresalvageable teeth, gum treatment and root planning, extraction

and drainage of localized oral abscesses.o Promotive- services includes health education activities directed to

priority groups thru individual or group approach using acceptedtools and media.

III. FAMILY PLANNING1. Female Sterilization. Safe and simple surgical procedure which provides

permanent contraception for women who do not want more children. Also knownas bilateral tubal ligation that involves cutting or blocking the two fallopian tubes.

2. Male Sterilization. Permanent method wherein the vas deferens (passage ofsperm) is tied and cut or blocked through a small opening on the scrotal skin. It isalso known as vasectomy.

3. Pill. Contains hormones estrogen and progesterone taken daily to preventcontraception

4. Male Condom. Thin sheath of latex rubber made to fit on a mans erect penis toprevent the passage of sperm cells and sexually transmitted disease organismsinto the vagina. It provides dual protection from STIs including HIV preventingtransmission of disease microorganism during intercourse.

5. Injectables. Contain synthetic hormone, progestin which suppresses ovulation,thickens cervical mucus, making it difficult for sperm to pass through andchanges uterine lining.

6. Lactating Amenorrhea Method or LAM. Temporary introductory postpartummethod of postponing pregnancy based on the physiological infertilityexperienced by breastfeeding women.

7. Mucus/Billings/Ovulation . Abstaining from sexual intercourse during fertile(wet) days prevents pregnancy.

8. Basal Body Temperature. BBT method is identifying the fertile and infertileperiod of a womans cycle by daily taking and recording the rise in bodytemperature before and after ovulation.

9. Symptom-thermal method. STH method is identifying the fertile and infertiledays of the menstrual cycle as determined through a combination of observationsmade on the cervical mucus, basal body temperature recording and other signsof ovulation.

10. Two day method. Is a simple fertility awareness based method of familyplanning that involves cervical secretions as indicator of fertility, women checkingthe presence of secretions everyday.

11. Standard days method. A new method of family planning method in which allusers with menstrual cycles between 26 and 32 days are counselled to abstainfrom sexual intercourse on days 8-19 to avoid pregnancy. The couples usedcolor coded cycle beads to mark the fertile and infertile days of the menstrualcycle.

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The Roles of Public Health Nurse on the Family Planning Program- Provide counselling among the clients will help increase FP acceptors and

avoid defaulterso To inform and educate and convince mothers on the

use of family planning methodso To inform and discuss the importance and

benefits/advantages/disadvantages of family planningo To inform its side effects, complications and what to do

if problems develop.o To inform its effectiveness of FP methods

- Provide packages of health services among reproductive age group in allhealth facilities

o Family planningo MCHNo Management of Reproductive Tract Infections including

STIs/HIV/AIDSo Violence against womeno Management of breast and other Reproductive

Cancers- Ensure the availability of FP supplies and logistics for the client.

IV. ENVIRONMENT AND SANITATION

A. Health and Sanitation

Environmental health and sanitation is still a health problem in the country.

Diarrheal disease ranked first in the leading cause of morbidity among the

general population. The department of health through the EOHO, has authority to

act on all issues and concerns in environment and health including the very

comprehensive Sanitation code of the phil. (PD 856, 1978).

B. Water Supply Sanitation Program

Policies:

Approved types of water supply facilities

Level 1(point source) a protected well or a developed spring with an outlet but

without a distribution system, generally adaptable for rural areas where the

house are thinly scattered.

Level 2(communal faucet system or stand-posts) a system composed of a

source a reservoir, a piped distribution network and communal faucets, located atnot more than 25 meters from the furthest house.

Level 3(waterworks system or individual house connections) a system with a

source, a reservoir, a piped distributor network and household taps.

Unapproved water type facility - water coming from doubtful sources such as

open dugs well, unimproved spring

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Access to safe and potable drinking water

Water quality and monitoring surveillance every municipality through its rural

health units must formulate an operational plan for quality and monitoring

surveillance every year.

Waterworks/water system and well construction

Well sites shall require prior approval from the secretary of health Well construction shall comply sanitary requirements

Water system shall supply safe and potable water

Water shal be made readily available

Adequate pressure and volume shall be provide in the water system distribution

line

C. Proper Excreta and Sewage Disposal Program

Approved types of toilet facilities

Level 1

non-water carriage toilet facility toilet facilities requiring small amount of water to wash the waste into the

receiving space

Level 2 on site toilet facilities of the water carriage type with water sealed and

flushed type with septic tank disposal facilities.

Level 3 water carriage types of toilet facilities connected to septic tanks and/or

sewerage system to treatment plant.

D. Food Sanitation Program

Policies:

Food establishment shall be appraised as to the following sanitary conditions:

Inspection/approval of all food sources, containers, transport vehicles.

Compliance to sanitary permit requirement for all food establishments.

Provision of updated health certificate for food handlers, cooks and cook helpers.

DOHs Administration Order no. 1 2006 requires all laboratories to use

Formalin Ether Concentration Technique (FECT) instead of direct fecal smear in

the analysis of stools for food handlers

Destruction or banning of food unfit for human consumption.

Training of food handlers and operators on food sanitation.

Food establishments shall be rated and classified as to follows:

Class A excellent

Class B very satisfactory

Class C satisfactory

Ambulant food vendors shall comply with the requirements as to the issuance of

health certificate.

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Household food sanitation are to be promoted and monitored and food hygiene

education to be intensified.

Four Rights in Food Safety:

Right source

Right preparation

Right cooking

Right storage

Hospital Waste Management Programs

Policies:

All newly constructed/authorized and existing government and private hospitals

shall prepare and implement a Hospital Waste Management Program as a

requirement for registration/renewal of license.

The use of appropriate technology and indigenous materials for HWM systemshall be adopted.

Training of all hospital personnel involved in waste management shall be an

essential part of hospital training program.

Public information campaign on health and environmental hazard arising from

mismanagement of hospital shall be the responsibility of the hospital

administration.

DOH hospital waste management guidelines/policies shall be guided by existing

legislative health and environmental protection laws policies on waste

management.

Local ordinances regarding the collection and disposal techniques shall beinstitutionalized.

V. COMMUNICABLE DISEASESA. Tuberculosis (National Tuberculosis Control Program)

Vision: A country where TB is no longer a health problem Mission: Ensure that TB DOTS services are available, accessible, and

affordable to the communities in collaboration with the LGUs and otherpartners

Goal: To reduce prevalence and mortality from TB by half by the year2015 (Millennium Development Goal)

Targets: Cure at least 85% of the sputum smear-positive TB patientdiscovered; Detect at least 70% of the estimated new suptum smear-positive TB patients

Public Health Nursing Responsibilities for Adult TBo Together with other NTP staff/workers, manage the procedures for

case-finding activitieso Assign and supervise a treatment partner for a patient who will

undergo DOTS

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o Supervise rural health midwives (RHMs) to ensure properimplementation of DOTS

o Maintain and update TB Registero Facilitate requisition of drugs and other NTP supplieso Provide continuous health education to tall TB patients under

treatment and encourage family and community participation in TB

controlo In coordination with physician, conduct training to health workerso Prepare, analyse, and submit quarterly reports to the Provincial

Health Office or City Health Office Public Health Nursing Responsibilities for Child TB

o Interview and open treatment cards for identified tuberculouschildren

o Perform tuberculin testing and reading to eligible childreno Maintain NTP records (treatment card, TB reister for children and

quarterly reports)o Manage requisition and distribution of drugso Assist the physician in supervising other health workers of the

RHU in the proper implementation of the policies and guidelineson TB in children

o Assist in the training of other health workers in Tuberculin testingand reading.

B. Leprosy (LEPROSY CONTROL PROGRAM)

Multi-Drug Therapy (MDT) is the use of 2 or more drugs in the treatmentof leprosy. It is proven effective cure for leprosy and renders patients non-infectious a week after starting treatment. Further, MDT home treatmentof leprosy patients is possible.

Public Health Nursing Responsibilities

o Prevention Health education of patients, families and the community

on the nature of the disease, etc. Advocate healthful living through proper nutrition,

adequate rest, sleep and good personal hygiene BCG vaccination especially of infants and children.

o Casefinding

Recognize early signs and symptoms of leprosy and refersuspects to RHU

Take patient and family history and fill up patient records

Conduct epidemiological investigation and report findingsto MHO

Assist physicians in physical examination Assesses health of family members and other household

contacts.

o Management and Treatment

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Promotes healthful living by teaching the value of good

personal hygiene, proper nutrition, adequate rest andsleep

Helps patient/family understand and accept the problemsbrought about by the illness and assess their capabilities to

deal with them.

C. Schistosomiasis (Schistosomiasis Control Program)

Nursing Responsibilities

Preventive Measures:-Educate the public in endemic areas regarding mode oftransmission and methods of protection.-Dispose of feces and urine so that viable eggs will not reachbodies of fresh water containing intermediate snail host.-Improve irrigation and agriculture practices: reduce snail

habitats-Treat snail-breeding sites with molluscicides- Prevent exposure to contaminated water

-Provide water for drinking, bathing and washing clothes from

sources free of the etiologic agent.

-Treat patients in endemic areas to prevent disease

progression

-Travelers visiting endemic areas should be advised of the risks

and informed about preventive measures

D. Filariasis Infectious Agents:

Human Lymphatic Filariasis is a chronic parasitic infectioncaused by nematode parasites known as Wuchereria bancrofti, Brugiamalayi and / or Brugia timori.

Mode of TransmissionThe disease is transmitted to a person through bites from an infectedfemale mosquito primarily Aedes poecilius that bites at night.

E. Malaria Malaria is produced by intraethrocytic parasites of the genus

Plasmodium; P falciparum, P. vivax, P. ovale, and P. malariae.

Prevention of Epidemic:

The following should be done in the event that an imminent epidemic

occurs:

-Mass blood smear

-Immediate confirmation and follow-up of cases

-Insecticide-treatment of mosquito nets

-Focal Spraying

-Stream Clearing

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-Intensive IEC campaign

Important education to the public:

-taking of chemoprophylaxis

-wearing of long-sleeved clothing and trousers when going

out at night.

-Application of insect repellant to skin-Use of mosquito nets

-Use of screen in doors and windows.

-Use of insecticide aerosols and pyrethroid mosquito coils

-Clearing of hanging branches of trees along the stream.

F. Dengue Hemorrhagic Fever Classification:

-Severe, frank type- with flushing, sudden high fever, severe hemorrhage,followed by sudden drop of temperature, shock and terminating inrecovery or death.

-Moderate-with high fever, but less hemorrhage, no shock.

-Mild-with slight fever, with or without petechial hemorrhage butepidemiologically related to typical cases usually discovered in the courseof investigation of typical cases.

Control Measures:

o Eliminate vector by:

changing water and scrubbing sides of flower vases once

a week. destroy breeding places of mosquito by cleaning

surroundings

proper disposal of rubber tires, empty bottles and cans

keep water containers covered

G. Measles Prevention and Control:

-Avoid exposing children to any person with fever or with acutecatarrhal symptoms.-Isolation of cases from diagnosis until 5-7 days after onset of

rash.-Disinfection of all articles soiled with secretions of nose andthroat.-Encouragement by the health department and by privatephysician of administration of measles immune globulin tosusceptible infants and children under 3 years of age in families orinstitutions where measles occurs.

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Nursing Care:

-Protect eyes of patients from glare of strong light as they are aptto be inflamed.-Keep the patient in an adequately ventilated room but free fromdrafts and chilling to avoid complications of pneumonia.

-Teach, guide and supervise correct technique of giving spongebath for comfort of patient.-Check for corrections of medication and treatment prescribed bythe physician.

H. Typhoid Fever Public Health Nursing Responsibility

Teach members of the family how to report all symptoms

to the attending physician

especially when patient is being cared for at home.

Teach, guide and supervise members of the family on

nursing techniques which willcontribute to the patients recovery

Interpret to family the nature of the disease and need for

practicing preventive and

control measures

Nursing Care

Demonstrate to family how to give bedside care, such as tepid

sponge bath, feeding, changing of bed linen, use of bedpan

and mouth care

Any bleeding from the rectum, blood in stools, sudden acuteabdominal pain,

restlessness, falling of temperature should be reported at

once to the physician or the patient should be brought at once

to the hospital

Take vital signs and teach family member how to take and

record them.

I. Hepatitis A

Infectious Hepatitis, epidemic hepatitis, catarrhal jaundice A form of hepatitis occurring either sporadically or in epidemics

and caused by

viruses introduced by fecally contaminated water or food.

Young people especially school children are most frequently

infected

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Prevention and Control

o Ensure safe water for drinking

o Sanitary method in preparing, handling, and serving food

o Proper disposal of feces and urine

o Washing hands very well before eating and after using the toilet

o Separation and proper cleaning of articles used by patient

J. Rabies Rabies is an acute viral encephalomyelitis caused by rabies virus, a

rhabdovirus of the genus lyssavirus.

It is fatal once signs and symptoms appear

2 Kinds

1. Urban or canine rabies is transmitted by dogs

2. Sylvatic rabies is a disease of wild animals and bats which sometimes

spread to dogs, cats and livestock.

Rabies remains a public health problem in the Philippines.

Approximately 300 to 600 Filipinos die of rabies every year Philippines has one of the highest prevalence rate of rabies in the

whole world

Management/Prevention

o The wound must be immediately and thoroughly washed with soap and

water.

o Antiseptic such as povidone iodine or alcohol may be applied.

o The patients may be given antibiotics and anti-tetanus immunization

o Post exposure treatment

o Active immunization -3 years

o

Passive immunization-immediate protection against rabies