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1 COMMUNITY HEALTH NURSING Public Health Nursing: the term used before for Community Health Nursing  According to Dr. C.E. Winslow, Public Health is a science & art of 3 P’s 1. Prevention of Disease 2. Prolonging life 3. Promotion of health and efficiency through organized community effort  Public Elements are: 1. People 2. Government 3. Environment Areas/Fields of Nursing: 1. Nursing Education • To be in college of Nursing • Goal: Preparing students to become professional nurse • Dean→ Asst. Dean→ Secretary→ Coordinators→ Faculty→ Clinical Instructor Level II Level III Level IV 2. Nursing Practice • There are clients whom care is to be provided • 2 Concepts: 1. Clients 2. Provision of Care Areas Clients Community Health Nurse Individual, Family, Community Hospital Nurse Institutional clients who suffered medical problems Military Nurse Serving the government: AFP, PNP, Navy School Nurse Students, entire constituents of schools, personnel (rank and file) Occupational/Industrial/Company Employees Nurse Private Duty Nurse Private patients Independent Nurse Practitioner Operate a clinic-a venue where health services are provided Example: Immunization regulated by PD 996: Compulsory Basic Immunization to all children before reaching the age of 8 years old→ Infants (0-6 months)→ BCG, DPT, OPV, Hepatitis B and Measles vaccine School Entrants-6 years old (Grade 1)→ Booster of BCG 3. Nursing Administration • Administrator: a person in authority to supervise his levels of subordinates Nursing Service in Hospital (Nurse Practitioner) ↓ Chief Nurse/Directress of Nursing Service ↓ Asst. Chief Nurse ↓ Supervisor ↓ Head Nurse Staff Nurse Nursing Aide

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Community Health Nursing (CHN):  a specialized field of nursing practice  a science of Public Health combined with Public Health Nursing Skills and Social Assistance with the goal of raising the level of health of the citizenry, to raise optimum level of functioning of the citizenry (Characteristic of CHN) Target Population (IFC) are: 1. I ndividual 2. F amily 3. C ommunity Public Health (core foundation in Public Health Nursing Skills and Social Assistance Functions According to Nightingale, Nursing is an art and the science (4) Disciplines of Care: 1. Promotion of Health 2. Prevention of Illness/Disease 3. Curative Discipline of Care 4. Rehabilitative Discipline of Care Winslow enumerated the 5 Objectives of Public Health: CODES 1. C ontrol of Communicable Diseases 2. O rganization of Medical and Nursing Services 3. D evelopment of Social Machineries 4. E ducation of IFC on personal Hygiene→ Health Education is the essential task of every health worker 5. S anitation of the environment 3 Elements in Health Education: IEC 1. I nformation: to share ideas to keep population group knowledgeable and aware 2. E ducation: change within the individual 3 Key Elements of Education: a. K nowledge of theories/principles/facts/generalization b. A ttitude c. S kills 3. C ommunication: interaction involving 2 or more persons or agencies 3 Elements of Communication: a. Message b. Sender c. Receiver Regulatory Laws in CHN: r.a.: Re-organizational Act-formulated, approved, implemented & advocated before 1946 R.A.: Republic Act-laws approved & enacted after 1946 (WW II) P.D.: Presidential Decree P.P.: Presidential Proclamation E.O.: Executive Order LOI: Letter of Instruction A.C.: Administrative Circular H.B.: House Bill S.B.: Senate Bill Control of Communicable Diseases:

3 Elements considered in CHN: science of CHN),

3 A. Control of Communicable Disease regulated under r.a. 3573: Public Health Workers (PHW) to report any occurrence and incidence of communicable diseases PHW’s: are members of the health team who are professionals namely 1. Medical Officer (MO)-Physician------------------------ has immediate 2. Public Health Nurse (PHN)-Registered Nurse → responsibility to 3. Rural Health Midwife (RHM)-Registered Midwife-- implement r.a. 3573 4. Dentist 5. Nutritionist 6. Medical Technologist 7. Pharmacist 8. Rural Sanitary Inspector (RSI)-must be a sanitary engineer 2 Concepts of Communicable Disease: 1. Causative Agent-microorganism causing communicable disease 2. Transmission Contagious Easily transmitted through direct or indirect mode Transmitted via: a. Airborne-measles, pneumonia b. Droplet-PTB, Hepatitis A, Diphtheria Infectious Not easily transmitted Transmitted via: a. Blood Transfusion-AIDS, Hepatitis B, b. Sexual Intercourse: multiple sex partners 1) Bacterial-gonorrhea, syphilis, STD 2) Viral-AIDS, Hepatitis B 3) Fungal-Candidiasis 4) Protozoal-Trichomonas vaginalis c. Contaminated Article/Equipment -needles and syringes -Example: 1) Rabies-bite of a rabid dog→ rhabdo virus 2) Tetanus-wounds→ Clostridium tetani d. Placental Transfer

5 Communicable Diseases to be reported weekly and monthly: 1. Rabies 2. Measles 3. Polio 4. Neonatal Tetanus-children delivered at home by midwives/”hilots” 5. Sexually Transmitted Disease (STD)-all forms Diarrhea-not a disease but a symptom which should be reported by PHN monthly Treatment of Communicable Diseases: 1. TB: Program of DOH for its treatment-DOTS 2. Pneumonia: Care & Control of Acute Respiratory Infection (CARI) for under 5 children 3 Leading Infections: a. Pneumonia-a leading cause of morbidity & mortality of children under 5 b. Ear infection c. Throat infection Morbidity Report-report of diseases affecting the population group (BQ) while Mortality Report-reports of deaths

4 1. Diarrhea 2. Pneumonia 3. Bronchitis 4. Influenza 5. PTB 6. Hypertension

B. TB law or Liberalization of Treatment of TB regulated under R.A. 1136 Policies: 1. Preventive Program a. Immunization-BCG b. Strict isolation to prevent infection of the family c. Health education 2. Case Finding/Surveillance • 6 Concerns: 1) Disease 4) Diagnostic Procedure 2) Other name 5) Signs and Symptoms 3) Causative Agents 6) Treatment 3. Chemotherapy: a. Multiple Drug Therapy (MDT) • Purpose: 1) To prevent drug resistance against 3 combined drugs  if sensitive to one of the drugs, stop taking the identified drug but continue the other 2 2) To shorten the duration of treatment of TB  Minimum of 6 months Maximum of 12 months 3) To eradicate the organism preventing relapse b. Short Course Chemotherapy (SCC) 1) Intensive phase-2 months: RIP 2) Maintenance phase-4 months: RI 3) Extensive phase-2 months: RI • After 6 months of SCC: Do sputum examination to monitor the (+) tubercle bacilli: If (-), discontinue If (+), 2 months extension of RI then sputum culture recheck If (+), 2 months extension again of RI, the whole steps can be repeated for a total of 1 year treatment (from intensive to extensive phase) • After 8 months of SCC: do sputum examination If (-), stop medicines If (+), continue RI for 2 months • After 12 months of SCC, do sputum examination If still (+), do chest x-ray to determine the infiltration of MO to the lung lobes: a) Extensive infiltration-diagnosed as Far Advanced Pulmonary TB (FAPTB) & treated with Parenteral Streptomycin b) Minimal infiltration-diagnosed as Minimal Pulmonary TB (MPTB) & stay with SCC Program c. Directly Observed Treatment for Short Course Chemotherapy (DOTS)  Liberation of the Treatment of PTB wherein treatment is domiciliary (home setting)  DOTS was 1st introduced by WHO on 1998 in China & Indonesia where PTB was #3 as morbidity.  In the Philippines, WHO decided to include us in the program because PTB is #5 as morbidity and was implemented from 19982004.  In October 2002, a pre-evaluation was done and showed that Category I & II patients responded to DOTS Program, however, Category III patients did not respond to DOTS after 4 months of treatment.

5  DOTS was not terminated in 2004 but instead a replication was made known as Tuberculosis Incentives for Private Sectors (TIPS) which was funded by United States Agency International Development (USAID) and its beneficiary is the private sector 5 Elements of DOTS: 1) Sputum Microscopy: to rule out TB, PHN is a microscopist 2) Training & Health Education of Health Workers: PHN keeps the key to Botika & distributes SCC to registered PTB patients 3) Appropriate Funding: DOTS is funded by WHO & beneficiary is DOH 4) Recording and Reporting (R/R) for proper documentation:  r.a. 3753: Vital Health Statistics-PHN reports the PTB patients so that WHO will prepare the medicines for those registered & serves as baseline information 5) Chemotherapy: based on the 3 Categories of WHO WHO Categories of PTB Category I Category II & (+)/(+) (+)/(-) 3x Far PTB Advanced FAPTB who has started treatment but prematurely stopped Relapse PTB Re-treatment Extensive pulmonary infiltration 6 months regimen 8 months regimen 1st 2 months: RIPE 1st 2 months: Last 4 months: RI RIPES *E given once a 3rd month: RIPE day 4-8th month: RIE Category III (+)/(+) (+)/(-) 3x Minimal PTB

Signs Symptoms Sputum examination Diagnosis

Chest x-ray result Treatment Treatment Schedule

Minimal pulmonary infiltration 4 months regimen 1st 2 months: RIP Last 2 months: RI For SCC Treatment: 2 months RIP 4 months RI

C. Leprosy Law regulated by R.A. 4073 Policies: 1. Preventive-immunization (BCG) 2. Case Surveillance-health education 3. Chemotherapy-isolation 4. Rehabilitative-occupational therapy where P.P. #304 dictates non discrimination, non segregation of leprosy victims Chemotherapy depending on the Category: 1. Pauci-bacillary: non-contagious type (6-9 months) • Tuberculoid and Intermediate • TreatmentRifampicin once a month Diamino-diphenyl-sulfone (DDS) or Dapsone once a day 2. Multi-bacillary: contagious type (24-30 months) • Lepromatous and Borderline • TreatmentRifampicin once a month→ bactericidal DDS 100 mg once a day→ bacteriostatic Clofazimine (Lamprene) 50 mg once a day→ bacteriostatic

6 D. Compulsory Immunization of All Children before 8 years old against the 6 Childhood Immunizable Diseases regulated by PD 996 Target Population of Immunization: 1. Infants b. BCG c. DPT--d. OPV → 1st dose given at 6 weeks, 2nd dose given a month after st the 1 e. HBV-dose, 3rd dose given a month after the 2nd dose f. Measles Vaccine- 9 or 12 months and earlier at 6 months when there is epidemic 2. School Entrants at age 6 a. BCG booster b. DPT booster c. OPV booster E. Compulsory Immunization of All Children with HBV before the age 8 regulated under F. Universal Mother & Child Immunization Law regulated under P.P. # 6 2 Target Population: 1. Children: Infants and School Entrants→ 7 Immunizable Diseases 2. Pregnant Women: 5 doses of Tetanus Toxoid G. AFP Elimination Program regulated under P.P. # 1064 1. Polio Eradication Program (PEP) 2. Knock Out Polio (KOP) 3. Door to door “patak” (Feb. 2002 & Mar. 2-8 2002) H. A.C. 63A-include HBV in EPI Program I. A.C. 242-Hepatitis B is one of the reportable & reported to be immunizable Organization of Medical and Nursing Service: 1. A.C. 114-Roles & Functions/Responsibilities of PHN in the Rural Health Setting Categories: a. Administrative Role: process of administration 1) 4 Major Management Processes: Planning, Organizing, Directing & Controlling 2) 9 Integrated Traditional Management Processes: • Assessment----- integrated in Planning • Planning-------• Organizing----- integrated in Organizing • Staffing--------• Delegating----- integrated in Directing • Coordinating-• Recording & reporting (R/R)-• Budgetary → integrated in Controlling • Evaluation---------------------- Association of Nursing Services & Administrators of the Philippines (ANSAP): responsible for shortening the 9 Management Processes into 4 where members are all chief nurses of hospital (government & private) b. Technical Role:  PHN acts as a generalist or general practitioner  PHN can act as a physician except to prescribe medicines because only 3 persons are licensed to prescribe: Physician, Dentist & Veterinarian  PHN can act as a pharmacist which is made possible through the program “Oplan Walang Reseta” where PHN can dispense drugs in generics even without doctor’s order or prescription, regulated under RA 6675: Generics Act

7  PHN are allowed to assess, diagnose & provide appropriate treatment as in dispensing drugs & administering IVF  Other activities or functions (dependent, independent and interdependent) of PHN which implicates specific skills: a. Manager b. Clinician c. Health Educator d. Health Care Provider e. Community Organizer f. Environmentalist-matters related to environmental sanitation g. Epidemiologist-determine the pattern/distribution of diseases: epidemic, endemic, sporadic or pandemic h. Microscopist-acts like medical technologist as in DOTS i. Statistician-computes & reports morbidity, mortality & fertility to determine health status of the population c. Supportive Role: Characteristics/Qualifications of PHN a. Facilitator d. Coordinator b. Motivator e. Health Educator c. Counselor f. Supplementary/Complimentary 2. E.O. 119-Reorganization of the Ministry of Health to Department of Health a. 1918-Creation of Board of Health (BOH) b. 1919-BOH was abolished & was changed to Bureau of Health c. September 21, 1972 to 1986-Declaration of Martial Law by President Ferdinand Marcos where all agencies of the government were given the title Ministry under PD 1081; MOH Secretary- Dr. Jesus Azurin d. February 25, 1986 to 1992-EDSA 1 under President Corazon Aquino where reorganization of MOH to Department of Health (DOH); DOH Secretary-Dr. Alfredo Benzon e. 1992 to 1998-under President Fidel Ramos; DOH Secretaries-Flavier, Galves Tan (5 months), Hilarion Ramiro (2 years), Carmencita Rheodica (1st lady secretary of DOH) f. 1998 to January 20, 2001-EDSA 2 under President Joseph Estrada; DOH Secretary-Dr. Estrella (2 months), Dr. Alberto Romualdez g. January 21, 2001 to Present-under President Gloria Macapagal-Arroyo; DOH Secretary- Dr. Manuel Dayrit, Dr. F. Duque DOH Organizational Chart Department of Health Secretary ------------------------------------------------------------------------↓ ↓ ↓ ↓ ↓ Rules and Financial and Office of Office for Regulations Administrative Personnel Public Health RA 4226 (Med. Officer) Division Services (OPHS) ↓ ↓ National Executive Council (NEC) Center for Health Services ↓ Regional Health Officer (RHO)-under the Congressman (MD) ↓ Provincial Health Officer (PHO)-under the Governor (MD) ↓ Municipal Health Officer (MHO)-under the Mayor (MD) ↓ Rural Health Unit (RHU)-under the Mayor (PHN) ↓ Barangay Health Station-under the Mayor (Rural health Midwife)

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------------------------------------↓ ↓ Station Satellite (8H Operation) (24H Operations, an annex of Hospital) Basic Health Services under OPHS of DOH: E ducation regarding Health L ocal Endemic Diseases E xpanded Program on Immunization M aternal & Child Health Services→ Integrated Comprehensive MCHS E ssential drugs and Herbal plants N utritional Health Services (PD 491): Creation of Nutrition Council of the Phils. T reatment of Communicable & Non communicable Diseases S anitation of the environment (PD 856): Sanitary Code of the Philippines Basic Health Services of DOH: D rug Abuse Control Program O ral Health Services/Dental H ospitals are centers for wellness not for illnesses Goal of DOH: 1. Vision (Dream of DOH)→ Health for All Filipinos  Formulated by former Secretary Flavier in 1993→ Health for All Year 2000 and Beyond  Health under the Hands of the People 2020  Health for All Filipinos as edited by Dr. Romualdez 2. Mission: Principles to attain the vision of DOH a. Equity: equal health services for all-no discrimination b. Quality: DOH is after the quality of service not the quantity • Philosophy of DOH: “Quality is above quantity” c. Accessibility: DOH utilize strategies for delivery of health services Three Strategies in Delivering Health Services (ELEMENTS): 1. Creation of Restructured Health Care Delivery System (RHCDS) regulated by PD 568 (1976) 2. Management Information Systems regulated by r.a. 3753: Vital Health Statistics Law 3. Primary Health Care (PHC) regulated by LOI 949 (1984): Legalization of Implementation of PHC in the Philippines Creation of RHCDS  represented by: 3° RHO (National Health Agency) or existing national agencies like PGH or specialized agencies like Heart Center for Asia, NKI 2° MHO & PHO (Muunicipal/Provincial Health Office) 1° BHS & RHU (Barangay Health Station/Rural Health Unit)  Accredited from use of RHCDS: 1. Three levels of health care 2. Referral 3. PHN has an expanded role & responsibility (going beyond the standard function)  Standard Functions of Nurse: 1. Dependent-giving of medications 2. Independent-TSB for a highly febrile patient 3. Interdependent-involvement of 2 persons or agency; Example: doing your referral or collaboration with another person

9 For PHN, giving medicines is not a dependent function but is independent  3 Levels of Health Care: Objectives to be fulfilled 1. Primary-prevention of illness or promotion of health 2. Secondary-curative 3. Tertiary-rehabilitative  Referral System in Levels of the Health Care: • Barangay Health Station (BHS) is under the management of Rural Health Midwife (RHM) together with Traditional Birth Attendants (TBA) or “Hilots” • TBA is under the management of RHM where before were not accepted by Medical Officer (MO) but now are considered an asset especially if there’s no obstetrician, nurse or midwife • Rural Health Unit (RHU) is under the management or supervision of PHN • Public Health Nurse (PHN) caters to 1:10,000 population, acts as managers in the implementation of the policies and activities of RHU, directly under the supervision of MHO (who acts as administrator) • Referral System: BHS→ RHU→ MHO→ PHO→ RHO→ National Agencies→ Specialized Agencies 1. Intra-sectoral: used by RHCDS; referral within the DOH 2. Inter-sectoral: not used by RHCDS; referral/coordination/collaboration outside Management Information Systems (MIS) Components of FHSIS (Field Health Service Information System): I. Family/Individual Treatment Record done daily II. Target/Client Lists Record done weekly and the following Special Programs are: A. CDD (Control of Diarrheal Diseases) Program Policies to implement CDD: 1. Health Education on Personal Hygiene  washing of hands before eating & after use of toilet 2. Breastfeeding (BF)  Two (2) Beneficiaries of BF Program: a. Mother-regulated by R.A. 7600: Breastfeeding and Rooming-In Act • Breastfeeding is an effective contraceptive method because it stimulates the anterior pituitary gland to produce prolactin hormone→ putting the female in an anovulatory stage→ there’s amenorrhea for 6 months from the time she gave birth • Rooming-in (RI) is putting together of mother and the newborn and it stimulates the posterior pituitary gland to release oxytocin hormone→ stimulates the uterine muscle contraction that inhibits the implantation of fertilized zygote in the endometrium→ no pregnancy occurs b. Children-regulated by EO 51: Milk Code of the Philippines Dictum of Milk Code: Never commercialized a brand name of milk  3 Principles to make breastfeeding effective: 3 E’s a. Early : start BF as early as possible→ NSD: after 30 minutes; CS: after 3-4 hours b. Exclusive : for the 1st six months; never alternate BF with any supplementary feeding c. Extensive : BF can be extended to 2 years  Advantages of BF: Breast milk: EO 51-best for babies Reduced allergy •

10 Easily established Always available Safe making stool soft Temperature: right temperature 24°C body reference→ if to be frozen, preservation is minimum of 3 months & maximum of 6 months Fresh always Emotional bonding Economical Digestible: contains lactalbumin, a protein substance Immunity: colostrum contains Ig A that protects baby for the 1st 3 months Nutritious (optional) GIT diseases such as diarrhea is minimize/lessen because it’s sterile 3. Measles: immunization-preventive & prophylactic 4. Oresol: a management for diarrhea to prevent dehydration 2 Concepts of Diarrhea: a. Frequency of passing out stool=≥3x/day b. Consistency of the stool=watery Contents of One Pack Oresol Dissolved in One Liter drinking Water Glucose 20 grams 1° Significance: For re-absorption of Na Facilitates assimilation of Na 2° Significance: Provides heat & energy Sodium Chloride/NaCl 3.5 grams For retention of water/fluid Sodium 2.5 grams Buffer content of solution Bicarbonate/NaHCO3 Neutralizer content of solution Potassium Chloride/KCl 1.5 grams Stimulates smooth muscle contractility especially the heart & GIT  Never advice mother to buy brand names like pedialyte or gatorade Preparation of Proper Homemade Oresol A volume or one liter homemade oresol Smaller volume or a glass homemade oresol Water 1000 ml. or 1 liter 250 ml. Sugar 8 teaspoon 2 teaspoon Salt 1 teaspoon ¼ teaspoon or a pinch of salt=10-12 granules of rock salt: iodized salt=tips of thumb & index finger are penetrated with salt  For making solution=use 250 ml of water  For drinking medicines=a glass is 240 ml of water 3 Categories of Dehydration: a. No dehydration-uses oresol b. Some dehydration-uses oresol c. Severe dehydration-uses IVF Objectives/Plan/Policies of the Use of the following Program: a. Plan A: for prevention of dehydration

11 b. Plan B: for treatment of dehydration-mild & moderate c. Plan C: for treatment of dehydration-severe Assessment 1. Condition a. Normal b. Well c. Alert 2. Fontanel-normal 3. Eyeballs-normal Tears-present 4. Mouth, Tongue & Lips: moist or wet Thirst: drinks normally 5. Skin Turgor-returns back quickly which is done at forearm CDD Management Chart Category Treatment No dehydration Plan A-prevention of DHN 3 Principles/3 F’s: 1. Increase fluid: Tea-lipton tea bag left standing in a cup of water for 15 minutes & there is brownish discoloration =pectin, a diuretic & has an absorbent effect Fruit Juices-not from highly fibrous fruits like pineapple, mango, guyabano Oresol-am or buko where 3 electrolytes are present: Na, K & Ca which are lost in diarrhea Oresol is given/LBM or every time stool is passed out: < 2 years old: 50-100 ml. always give the maximum amount 2-10 years old: 100-200 ml. 10 years old & above: as much as tolerated & desired 2. Increase feeding: 3. Fast referral Plan B-Treatment of mild & Moderate DHN using oresol If less than 2 years old: use age in months If < 4 months: 200-400 ml. 5-11 months: 400-600 ml. 12-23 months: 600-800 ml. 2-4 y/o: 800-1200 ml. 5-14 y/o: 1200-2200 ml.

1. Condition a. Restless b. Irritable 2. Sunken fontanel 3. Sunken eyeballs & absent tears 4. Dry mouth, tongue & lips Eagerness to drink 5. Skin returns back slowly

Some dehydration

12 15 & above: 2200-4000 ml. Treatment Plan: 1st 4 hours always give the maximum Plan C-treatment of severe DHN using IVF Priority-choice of IVF: 1. D5LRS-best or 1st choice if available for severe DHN since dextrose gives additional source of energy & improves appetite D5-is glucose LRS-has 3 chlorides 2. LRS-Lactated Ringer’s or Hartman solution is the most appropriate choice if no D5LRS 3. Plain NSS or 0.9 NaCl 4. D5W 5. D10W

1. Condition a. Unconsciousness b. Lethargic c. Floppy-apathetic or passive 2. Very sunken fontanel 3. Very sunken eyeballs & absent tears 4. Very dry mouth, tongue & lips Refuses to drink orally 5. Skin returns back very, very slowly best done at the abdomen

Severe dehydration

2 Victims of Severe Dehydration: a. Child: give 100 mg/kg body weight in the 1st 4 hours Example: 8 kg=800 ml. IVF to be infused on the 1st 4 hours for patient with severe dehydration (8am-12noon) b. Adult: give 3-4 liters of IVF in 1st 4 hours Example: 9am-1pm=4 liters=1 liter/hour If still severe dehydration, 2-6pm=infuse 4 liters IVF Fruits for Diarrhea: Apple: has pectin & tarum which has an absorbent property, eat the skin Banana: has K+ Caimito: eat the flesh in cases of constipation but in diarrheal cases, eat the extracts, milky substances (dagta) found on the inside of the skin Duhat: wash first the fruit then sprinkle with rock salt & shake, notice extracts to come out of the fruit, eat both skin & flesh Fruits to avoid during diarrhea: Papaya flesh, pineapple flesh, mango, guyabano & kaimito flesh BRAT Diet: Banana, Rice, Apple, Tea, toasted bread or toasted rice beads which has activated charcoal that acts as absorbent Direction: In a cup of warm water, add 1 tablespoon of toasted rice or bread & allow to stand for 20-30 minutes→ produces a blackish discoloration which is pectin B. UFC (Under Five Children) Program-basic health service for children under 5 Policies to implement UFC: GOBIC G rowth Monitoring: age, weight & height O resol: CDD policies B reast feeding I mmunization C ARI Program (Care & Control of Acute Respiratory Infection (Pneumonia, Ear & Throat Infection)

13 C. CARI (Control of Acute Respiratory Infection) Program Categories of Pneumonia: < 5 years old ---------------------------------------------↓ ↓ < 2 months > 2 months-5 years old 1) Very severe disease (VSds) 1) VSds with Severe Pneumonia 2) Severe Pneumonia (SP) 2) Pneumonia 3) No pneumonia (NP) 3) NP with cough & colds CARI Management Chart: A ssessment C ategorize T reatment CARI Management Chart for < 2 Months Assessment Categorize Treatment Stops feeding VSdses Referral (Hospital): Fever: (+)/(-) convulsions 1. IF Fluids Always sleepy 2. Oxygen inhalation Stridor-noisy breathing 3. Co-trimoxazole on inhalation 4. Paracetamol Wheeze-noisy breathing 5. Phenobarbital on exhalation Chest Indrawing (CI) SP Referral (Hospital): Fast Breathing (FB) Same as above RR: 60/min and ↑ NV: 40-60/min for NB No Danger Signs of VSds NP with cough & colds Home care-↑ feeding CI (BF) FB Mother to observe child of any danger signs of (VSdses)→ refer urgently CARI Management Chart for > 2 Months-5 years old Assessment Categorize Treatment Stops eating VSdses Referral (Hospital): Malnutrition 1. IV Fluids ↑ Fever: (+)/(-) 2. Oxygen inhalation convulsions 3. Co-trimoxazole Always sleepy 4. Paracetamol Stridor, wheeze & CI 5. Phenobarbital (only sign for severe pneumonia) Fast Breathing P Home care with home RR: remedies: (2-12 months=50/min & 1. Salabat ↑) Official preparation is (1-5 years=40/min & ↑) initiated by: Poultice-pounding chewing Decoction-boiling 2. Tea-infusion: a. Honey or sugar b. Kalamansi 3. Co-trimoxazole starts at home for 5 days Tx Mother to bring child at

14 the health center after 2 days of treatment for proper evaluation No Danger Signs CI FB NP with cough & colds Home care with home remedies Mother to observe & report of danger signs Mother to report if cough persists even after 30 days

D. “Ligtas Tigdas”: Measles Elimination Program regulated by P.P. # 4 (1996) Example: Lanting Epidemic Measles-mass immunization (6 months-8 years) receive measles vaccine Eligible Age=0-59 months→ 5 years Example: BCG=booster 6 years & SE “Ligtas Buntis”: MWRA-Married Women of Reproductive Age MCRA-Married Couple of Reproductive Age FRA-Females of Reproductive Age HBMR: Home Based Mothers (BQ) Record Reproductive Age: 15-49 (New) & 15-44 (Old) 15-average age of menarche 49-average age of menopause Estimate for the age of menopause: Age of menarche + 35 (constant # of years of function of ovaries) Example: 12 + 35=age of menopause EO 209: Family Code under President Aquino-married women PD 651: Birth & Death Registration Law-PHN who attended delivery should register the attended birth at the Local Civil Registrar with a grace period of 30 days→ PHN prepares the birth certificate RA 9255: Acknowledgement of children with pregnancy out of wedlock E. SCP & MCP (Schistosomiasis & Malarial Control) Program: local endemic diseases-regular, constant & habitual=always Schistosomiasis Control Program (SCP): Region 5 (Sorsogon), 8 (Samar & Leyte) & 11 (Davao-North) Malarial Control Program (MCP): Palawan & Mindoro III. Tally Record & Reporting (R/R) prepared by PHN monthly Example: Influenza llll-llll-llll Cholera lll Amoebiasis ll Parasitism llll-llll IV. Outcome R/R done quarterly (once in 3 months/4x a year) and annually (done in December only) PHN has the responsibility to prepare & report on the following Health Indicators: 1. Fertility-Crude Birth Rate (CBR) 2. Morbidity-Illnesses affecting the population group a. Incidence Rate (IR)-reported new cases affecting the population group b. Prevalence Rate (PR)-determine sum total of new + old cases of diseases per percent population 3. Mortality-Reports causes of deaths a. Crude Death rate (CDR)-overall total reported death b. Maternal Mortality Rate (MMR)-maternal deaths due to maternal causes

15 c. Infant Mortality Rate (IMR)-# of infant deaths (0-12 months) or less than 1 year old d. Neonatal Mortality Rate (NMR)-# of deaths among neonates (newborn 0-28 days, < 1 month) e. Swaroops Index (SI)-deaths among individual in the age group of 50 and above Formulas: 1. Fertility: Crude Birth Rate (CBR) Overall total reported births per 1000 population CBR=overall total reported births x 1000 Population 2. Morbidity: a. Incidence Rate (IR): Reported new cases of disease per percent (100/population) population IR=new cases of disease x 100 Population b. Prevalence rate (PR): Reported new cases of disease + old cases of disease per percent of population PR=new cases + old cases x 100 Population 3. Mortality: a. Crude Death Rate (CDR): Overall total reported deaths per 1000 population CDR=overall total deaths x 1000 Population b. Maternal Mortality Rate (MMR): Reported maternal deaths per 1000 registered live births (RLB) MMR= # of maternal deaths x 1000 RLB 4. Infant Mortality Rate (IMR): Reported # of infant (0 to 12 months of age) deaths per 1000 RLB IMR=# of infant deaths x RLB 1000

5. Neonatal Mortality Rate (NMR): Reported # of neonatal (0 to 28 days or <1 month) deaths per 1000 RLB NMR=# of neonatal deaths x 1000 RLB 6. Swaroop’s Index (SI): Reported # of deaths among individuals> 50 years old over total deaths SI=# of deaths (individual >50 years old) Total Deaths x 100

Multiplying Factors (MF) to use: 100 : Morbidity 1000 : Fertility & Mortality except in Swaroop’s 100,000: 1. If the numerator is too small enough to represent denominator Example: Lanting Community (Population: 1,000,000), IR of measles=8 cases

16 IR= 7 100,000=.7 1,000,000 x 100,000=.000007 x

(not a significant result)

2. “Save our Ship” (SOS): if after computing, your answer is not in the choices available, substitute the MF with 100,000

Primary Health Care (PHC):  1978, WHO & UNICEF sponsored the PHC in Alma Ata, Russia during the Alma Ata Conference (AAC) Goal: Health for All for the Year 2000 & beyond to develop self-reliance BQ: PHC conference was held in Alma Ata  1979, internationally replicated the conference in Geneva, Switzerland wherein other nations were invited including the Philippines (DOH delegates attended) making the PHC international  1984, LOI 949 approves for the legalization of implementation of PHC in the Philippines  1993, DOH: Health for All Filipinos was advocated by Dr. Juan Flavier  2000, Health for All Filipinos by Dr. Romualdez & up to present  PHC as defined by WHO is an essential health care made universally accessible to IFC (Individual, Family, Community) “Sentrong Sigla Movement” (SSM) was established by DOH with LGUs having a logo of a Sun with 8 Rays and composed of 4 Pillars: 1. Health Promotion 2. Granted Facilities 3. Technical Assistance 4. Awards: Cash, plaque, certificate Characteristics of PHC: 1. Acceptable 2. Affordable 3. Sustainable 4. Accessible 5. Available 6. Attainable

Concepts of Family Health Care: 1. Community Based-community focused & oriented, that’s why the term PHN was changed to CHN 2. Utilizes Multi-Sectoral Approaches-makes referral system • 2 Modalities of Referral used by PHC: a. Intra-sectoral=RHCDS=within DOH b. Inter-sectoral=outside DOH wherein it establishes linkages with other locally based (DSWD, BFAD, DECS) or internationally based (WHO, USAID, ASAID, UNESCO & JAPHIEGO=an international organization based in Japan focused on family planning) 3. Utilizes People Empowerment-population is involved in implementing programs & making decision a. Community Immersion Program (CIP): imbibing with the community b. Community Organization Participatory Research (COPAR) 4. Utilizes Appropriate Technologies used by PHC: ACCEFS A ffordable, accessible, acceptable, available C ost wise=economical in nature C omplex procedures which provide a simple outcome E ffective F easibility of use=possibility of use at all times S cope of technology is safe & secure

17 4 Contributions of PHC to DOH & Economy: 1. Training of Health Workers 2. Creation of Botika sa Baryo & Botika sa Health Center 3. Herbal Plants 4. Oresol

Training of Health Workers 3 Levels of Training: 1. Grassroot/Village  Includes the Traditional Birth Attendants (TBA) or “Hilots” who attends to delivery, Barangay Health Volunteers (BHV) and Barangay Health Workers (BHW)  Non professionals, didn’t undergo formal training, receive no salary but are given incentive in the form of honorarium from the local government since 1993 2. Intermediate-these are professionals including the 8 members of the PHWs 3. First Line Personnel-the specialist (Oncologist, cardiologist, nephrologists) Creation of “Botika sa Baryo & Botika sa Health Center” A. RA 6675: Generics Act of 1988: implementing “Oplan Walang Reseta Program”-solution to the absence of a medical officer who prescribed the medicines so PHN are given the responsibility to prescribe generic medicines and “Walong Wastong Gamot Program”-available generics in “Botika sa Baryo” & Health Center  Father of Generics Act: Dr. Alfredo Bengzon  Generic Name-ingredients of drugs expected to provide therapeutic value Brand Name- name given by the manufacturer 8 Commonly available Generics in “Botika sa Baryo & Health Center”: CARIPPON 1. Co-trimoxazole:  it’s a combination of 2 generics of drugs which is antibacterial a. Trimethoprim(TMP) • Has a bacteriostatic action that stops/inhibits multiplication of bacteria • For GUT, GIT & URTI (TMP combined with SMX) b. Sulfamethoxazole (SMX) • Has bactericidal action that kills bacteria • For GUT, GIT, URTI & Skin Infections  The drug of choice of DOH for pneumonia is the combination of TMP & SMX (Co-trimoxazole) 2. Amoxicillin/Ampicillin  An antibacterial drug that comes from the Penicillin family  Effect is generally bacteriostatic (when source of infection is bacterial)  These 2 drugs provide the least sensitivity reaction (rashes & GI) and the adverse effect of other antibiotics is anaphylactic shock 3. Rifampicin (RIF)---------For TB Program: 4. Isoniazid (INH) → All are antibacterial (bactericidal) 5. Pyrazinamide (PZA)-----All came from Aminoglycoside  Rifampicin & Isoniazid are the only TB drugs given to children  Adverse Effect of RIF: Hepatotoxic INH: Peripheral neuritis 6. Paracetamol  Has an analgesic & anti-pyretic effect  Acetyl Salicylic Acid (ASA) or Aspirin is never kept in the “Botika” because of its effects: b. Analgesic

18 c. Anti-pyretic d. Anti-inflammatory e. Anticoagulant-highly dangerous to Dengue patients that’s why it’s not available in “Botika” & Health Center 7. Oresol: a management for diarrhea to prevent dehydration under the Control of Diarrheal Diseases (CDD) Program 8. Nifedipine • An anti-hypertensive drug • According to DOH, 16% of population belonging to 25 years old & above in the community are hypertensive • If BP level=150/90, it is normal for 25 years old & above ABCD’s or Groups of Drugs for Hypertension (HPN): A ngiotensin Converting Enzyme (ACE) Inhibitors  Mechanism: acts as an inhibitor or blocker  Angiotensin is a constrictor to blood vessels  Generics ending in -pril  Example: Captopril (Capoten), Enalapril B eta Blockers  Mechanism: a vasodilator  Generics ending in -olol  Example: Propranolol, Tinolol, Esmolol, Metropolol, Atenolol C alcium Channel Blockers  Calcium stimulates the heart muscle to contract  Generics ending in -dipine  Example: Nifedipine (Calcibloc-a gel capsule taken sublingually, commonly used & available in Botika sa Health Center), Adalat, Nicardipine, Amlodipine D iuretics  Use to ↑ elimination of fluids from tissue cells→ pressure in blood vessels→ constriction  Example: Furosemide (Lasix)-a loop diuretic which is commonly used & the safest a. Site: Loop of Henle b. Action: It dilates blood vessels→ ↓ BP S edative (optional)  Use to keep client calm & relax  Generics ending in –zepine, -zepam, -zepate  Example: Benzodiazepines Diazepam (Valium) 2 & 5 mg for HPN 10 mg as hypnotic B. RA 9165: New Dangerous Drugs Act (old RA 6425): needs S2 license and prescription pad Prohibited Drugs Regulated Drugs Contents: Contents: C ocaine/Codeine Benzodiazepines/drugs ending in – O piates zepine, M ethamphetamine (Shabu) -zepam, -zepate E ucaine/Ecstasy Barbiturates (barbital): L ysergic Acid Diethylamine (LSD) a. –thal (for anesthesia)-Pentothal b. –bital (for phenos)-Phenobarbital Side Effects: Side Effects: CO-Dizziness/drowsiness Sedative-calm/relax METH-Habit forming leading to Hypnotic-sleep addiction Example: Diazepam-2 mg LSD-Hallucinations (white)=sedative 5 mg (yellow) 10mg

19 (blue)=hypnotic Herbal Plants 1. RA 8423: Alternative Traditional Medicine Law-a program where patient may opt to use herbal plants especially for drugs that are not available in dosage form or patients has no financial means to buy the drug 2. Traditional Medicine: a. Use of herbal plants b. Use of acupressure-allowed only to those who have undergone training

10 Advocated Herbal Plants by DOH: LUBBY SANTA Plant Name Scientific Indications Plant Part Preparation Name Used Lagundi Vitex negundo Asthma, Leaves Decoction cough, colds Poultice & fever (ASCOF) Pain and inflammation Ulasimang Peperonia Gout Leaves Decoction Bato pellucida Arthritis Poultice Rheumatism Bayabas Psidium Diarrhea Leaves Decoction quajava Toothache Mouth and wound wash Bawang Allium sativum HPN Clove/Bulb Poultice Toothache Yerta Buena Mentha Same as Leaves Decoction cordifelia Lagundi Poultice except asthma Sambong Blumea Edema Leaves Decoction balsanifera Diuretic Akapulko Cassia alata All forms of Leaves Decoction skin diseases Poultice Cream Niyog niyogan Quisqualis Intestinal Seeds Decoction indica Parasitism Poultice (Nematodes) Juice Tsaang Gubat Carmona Diarrhea Leaves Decoction resuta Infantile colic Poultice (Kabag) Dental caries Ampalaya Mamordica Type II Leaves Decoction charantia Diabetes (NIDDM)  AC 196-A: Ampalaya was deleted in 10 herbal plants advised by DOH in October 9,2003 Policies to abide: 1. Know indications 2. Know parts of plants with therapeutic value: roots, fruits, leaves 3. Know official procedure/preparation  Procedures/Preparations: a. Decoction

20 Gather leaves & wash thoroughly, place in a container the washed leaves & add water • Let it boil without cover to vaporize/steam to release toxic substance & undesirable taste • Use extracts for washing b. Poultice • Done by pounding or chewing leaves used by herbolaryo • Example: Akapulko leaves-when pounded, it releases extracts coming out from the leaves contains enzyme (serves as antiinflammatory) then apply on affected skin or spewed it over skin • For treatment of skin diseases c. Infusion • To prepare a tea (use lipton bag), keep standing for 15 minutes in a cup of warm water where a brown solution is collected, pectin which serves as an adsorbent and astringent • Used for diarrhea and for pneumonia so PHN discourages to buy commercially prepared cough syrup→ expectorant: Nature of Cough 1) Dry→ mucolytic→ liquefy mucus Example: Carbocisteine, Guafenesin 2) Productive→ expectorant→ irritants to the mucus gland Example: Bromhexine (Bisolvon) 3) Non stop coughing→ antitussive Example: Dextromethorpan (Robitussin)→ contains codeine Robitussin AC→ contains atropine & codeine d. Juice/Syrup • To prepare a papaya juice, use ripe papaya & mechanically mashed then put inside a blender & add water • To produce it into a syrup, add sugar then heat to dissolve sugar & mix it • For problems of constipation • Example: papaya, mango & caimito e. Cream/Ointment-for topical use • Cream is water based & used for wet skin lesions • Ointment is oil based & used for dry lesions • Example: Akapulko Leaves  start with poultice (pound leaves) to turn it semi-solid  add flour to keep preparation pasty & make it adhere to skin lesions  to make it into an ointment: add oil (mineral, baby or any oilserves as moisturizer) to the prepared cream to keep it lubricated while being massage on the affected area BASIC HEALTH SERVICES OF DOH (E L E M E N T S) HEALTH EDUCATION: Generalized Activities where Health Education is provided 1. Family Health Nursing Care (FHNC) 2. Community Organization 3. Epidemiological Condition 4. Environmental Sanitation 5. Home Visit 3 Concepts of FHNC: Family: Focus of care •

21 Health: Goal of care Nursing: Medium/Channel of providing care Standard Definition of Nursing Process: a systematic approach of solving an existing problem/meeting the needs of family-RAPIE 1. Rapport/Relating 2. Assessment: Sub-steps a. Data Gathering: tools or instruments used during survey (windshield) 1) Interview 2) Observation 3) Questionnaires-mostly patronized & used in CHN 4) Records & Reports available b. Consolidation or Collation-collecting back the questionnaires, tabulate and summarize c. Validation: uses statistical approaches Statistical Approaches: 1) Central Tendencies: 3 M’s a) Mean=average Mean: x=Ex (summation of=sum total of variables available) N (# of existing variables) Example: Shortening of life expectancy of Females: 71 y/o & Males: 67 y/o. What is the average life expectancy of Filipinos? 71 + 67=138 ÷ 2=69 y/o average life expectancy b) Median=range Highest-lowest score=95-35=60 passing score c) Mode=frequency of occurrence of a variable, used if there’s too many variable occurring twice or more & arrange variables from highest to lowest Example: Scores of exam=95 95 85 85 70 65 65 65 50 Uni-modal: 70 & 50=1x Bi-modal: 95=2x Tri-modal: 85 & 65=3x Quadri-modal=4x 2) Standard Deviation: used if there are too many variables available to be treated which is seldom used in CHN SD=√ ∑ (x-x) n-1 ∑=summation of x=variables available x=mean (given special attention) n=# of existing variables

3) Percentile (%) Method: most commonly used in CHN by adding all cores then multiply by 100 d. Presentation of Data 1) Table/Chart Title: Variable

% (result of computation as expressed)

Analysis & Interpretation (A/I): This is the basis for problem identification 2) Graph: Pie Bar-2 variables only Line Polygon-connecting the results

22 Histograph-2 or more variables & appear adjacent to each other e. Identifying or Defining the Problem Typology of Nursing Problems: by Drs. Baylon & Magnaya (authors of Family Health Nursing Process) I. First Level Assessment: to determine problems of family Sources of Problems using IDB Family: use of Initial Data Base (IDB) Nature: Health Deficit (HD), Health Threat (HT), Foreseeable Crisis (FC) • Use of Initial Data Base (IDB): A. Family Chart Structure: Nuclear-Father, mother, children Extended (3rd generation)-Relatives staying with the family Multi-generational extended-“apo sa tuhod” or “apo sa talampakan” Dyad-Husband & wife only (childless couple) Blended-widow married another widow & have children Gay-Same sex living together Matriarchal-Mother is the decision maker Patriarchal-Father is the decision maker Communal-different families forming a community B. Socio-economic: poverty level, educational attainment & nature of occupation of members of the family (sources of income) C. Socio-cultural: different nature of religion D. Home environment: assessment according to ES, treatment of garbage, preparation of food, availability of toilet, water & food sanitation, sources of diseases E. Medical history: history of certain disease, family member with disease F. Resources available in community for use by the family: 5 Generalized M’s in resources available in community: 1. Man/Manpower 2. Money 3. Machine 4. Materials 5. Methods 5 Specific M’s: 1. Transportation 2. Hospital/Clinic 3. School 4. Market 5. Recreational Center • Define the problem after identifying it according to nature A. Health Deficit (HD)-if identified problem is an abnormality, illness or disease, there’s a gap/difference between normal status (ideal, desirable, expected) & actual status (the outcome/result/problem encountered on that actual day) During “operation timbang”, the 9 y/o child is 15 kg. (actual BW). For a 9 y/o, IBW=25-27 kg. 27 -15 12 kg. underweight (a deficit) B. Health Threat (HT)-any condition or situation which will be conducive to health alteration, health interference & health disturbance 8th pregnancy=↑ risk=toxemia, now known as PIH

23 Without immunization (BCG, OPV, DPT, HBV, Measles)=HT to have 7 immunizable diseases C. Foreseeable Crisis (FC)-stress points, anything which is anticipated/expected to become a problem Example: Jobless=no income→ no money to buy food leads to starvation Pregnancy for the 8th time Mr. Juan Dela Cruz is: Jobless Father FC Suffering from TB HD Wife is pregnant for the 8th time HT & FC 2 y/o youngest child lacks HT immunization 9 y/o eldest child is 3rd degree HD malnourished Poor environmental sanitation HT II. Second Level Assessment: coping capacity of the family using coping areas (9x) Coping Index Card 9x Coping Areas Competent Marginal Incompetent (Family Health (Adequate) (Average) (Inadequate) Tasks) (5) (3) (1) 1. Physical Independence (liberty of the family to move around) 2. Therapeutic Competence 3. Knowledge about health 4. Application of Principles on Hygiene 5. Attitude towards health maintenance 6. Family living (special competence) 7. Emotional Competence 8. Physical Competence 9. Utilization: Resources Available Example: A mother said that her 5 year old child has fever T=39.9°C & she did TSB, T=37.6°C→ tick competent for therapeutic 3. Planning  Four (4) Standard Steps: a. Prioritization-start if there are multiple identified problems b. Formulation of objectives-planning a procedure will start here if there is only one problem

24 c. Developing strategies of action d. Formulation of evaluation tools for the identified strategy developed  Example: TB, jobless, pregnant for the 8th time, child lacks immunization, malnutrition & poor environmental sanitation-there are 6 problems identified: • There are 6 problems identified, thus prioritize the problems which needs to be attended 1st • Make use of the Table of Reference to prioritize the Multiple Problems Criteria I. Nature: assess by PHW Health deficit (HD) Health threat (HT) Foreseeable Crisis (FC) II. Modifiability Easily Intermediate (moderate) Not modifiable III. Preventive Potential Highly Moderate Low IV. Salience of the Problem Problem needing urgent attention Problem not needing urgent attention Not a felt problem Criteria in Identifying the Problem Score Weight 3 2 1 1

2 1 0 3 2 1 2 1 0

2

1

1

 Steps: a. Decide on a score b. Score x weight Highest score c. Get the sum total of all the scores  Interpretation: Perfect score=5, if score nearing 5 then prioritize the problem Criteria 1, 2 & 3 has to be assessed objectively by the health worker Criteria 4 has to be assessed by the perception of the family  Example: Compute for Malnutrition Step 1: 3rd degree malnutrition=health deficit→ 3 Step 2: 3 3 x 1=1 II. Modifiability: 1 2 x 2=1 III. Preventive Potential: 2 3 x 1=.67 x 1=.67 IV. Salience Problem: 1 2 x 1=.5 Step 3: Add all scores 1 + 1 + .67 + .5=3.17 rd Hypothetical: TB =3.25→ 3 priority Jobless =2.99 th 8 pregnancy =3.45→1st priority I. Nature:

25 Lacks immunization =3.30→ 2nd priority Malnutrition =3.17 Poor ES =3.18 BQ: Prioritized the problem of the family of Mr. Santos: a. Womanizer -FC & HT c. Pneumonia -HD th b. Jobless -FC d. 9 pregnancy -FC & HT Answer: C, pneumonia  Isolate the problems according to nature: HD, HT & FC 4. Intervention or Implementation or Working Phase  Is the capacity to provide management  Is the professional phase of nursing process  Is the time when the PHN executes the standard function of an RN  Three (3) Standard Functions of RN: a. Dependent-giving of medicines b. Independent-monitor, assess, provide, educate c. Interdependent-referrals 5. Evaluation  Three (3) Things to be evaluated: SPO Structure of program & activity-what articles, equipments, supplies are utilized Process utilized-steps used Outcome of activity-results can be: a. Desirable-to be implemented, advocated, strengthen b. Undesirable-to be avoided  Two (2) Aspects to be evaluated in the Outcome: a. Quality-characteristic or kind of outcome; no numerical value, not measurable b. Quantity-from the word “quantum”, with numerical value, measurable Example: Dec 2004, 1st encounter with Dela Cruz Family Identified problem: 3rd degree malnutrition was reported to MO Feb 2005, MO asked about the family If PHN evaluation is: “Tumaba na, malakas, mapaglaro, masigla-quality Gained 5 lbs-quantity Community Organization Objectives: Patterns to be followed 1. Organize people----- Goal: to develop self-reliance or independence and changes 2. Mobilize people within the individual 3. Work with people 4. Educate people-----a. Knowledge b. Attitude c. Skills Phases: 1. Preparatory 4. Educating (training) 2. Organizing 5. Collaborating 3. Mobilizing 6. Phase out Policies: Preparatory Phase 1. Area of Selection  It should be DOPE Community: Depressed, Oppressed, Poor & Exploited, a new criteria for community organization  “Old Criteria”→ it must be a virgin community=meaning no agency has gone there.

26  This is a dangerous situation that’s why RA 7305: Magna Carta for Public Workers was provided-a PHN is to receive a hazard pay of 20-25% of monthly salary 2. Entry: the 1st thing to do upon entering the community is to have a courtesy call with the Barangay Captain, introduce self & group, purpose, present the project, activities, etc. 3. Integration/Immersion (CIP)  Immersion is imbibing the life situation/condition of the community by living, eating & sleeping with the family to be able to understand their situation  It requires 2 Qualities of PHN: a. Empathy b. Sympathy (Integration) 4. Community Study: Diagnosis of Community-COPAR  Makes use of the Nursing Process/Problem Solving Approach  Prioritized which among the problems identified is to be attended 1st like in nature, magnitude, modifiability, preventive potential, salience Prioritization of Community Problems NATURE Health Status (HS) Health Resource(s) Health Related MAGNITUDE OF THE PROBLEM: % problem 75-100% 50-74 % 25-49 % <25 % of the population MODIFIABILITY Easily Intermediate Low Not modifiable PREVENTIVE POTENTIAL Highly Moderate Low SALIENCE  First to be assessed is the nature of be prioritized 3 2 1 of population affected by the identified 4 3 2 1 3 2 1 0 3 2 1 the problem. Health status problem is to

Health Status is to be prioritized because it is from the outcome of report of health condition/status. Problem identified will be the indicator of health condition→ RA 3753: Vital Health Statistics Indicators of Health Status/Condition: a. Fertility: ↑ CBR=community is overpopulated=HS b. Morbidity: IR (new cases) & PR (old cases)=HS c. Mortality: Deaths like children dying of pneumonia=HS Health Resource(s): methods 5 M’s-Manpower/Man, money, machinery, material & (+) available facilities-Hospital/Clinic, mode of transportation, market, school & movie houses for recreation Health Related: Categories according to 5 Aspects of Man=PEMSS P hysical, P hysiological, P sychological

27 E motional M ental S ocial S piritual Organizing Phase 5. Choosing Potential Community Leaders 6. Core Group Formation 7. Community Assembly: Community Organizing Participatory Action Research (COPAR)  Attend the assembly of the family/families  Families in the community should be represented, any family members can represent his/her family as long as he/she is a RESPONSIBLE (one who also can comprehend) member of that family.  Barangay Captain/Chairman need not necessary be the leader. He can recommend 8. Mobilization-let the members of the community do the work. PHN should only SUPERVISE 9. Supervision of Health Education 10. Evaluation with Expansion-there should be a perceived change before one leaves that community. Never leave without change but be able to evaluate the population Health Education in terms of Epidemic Policies in times of Epidemic/Activities of PHN in times of Epidemic: 1. Organize a team 2. Conduct an Epidemiologic Investigation (EI)  A problem solving approach that follows a scientific step Steps in Epidemiological Investigation: a. Confirm diagnosis • Determine 1st if greater population is affected by disease • Example: Lanting Community=epidemic measles 3000: Susceptible population 1750: Affected population b. Appraise the fact • Use an empirical approach (the utilization of human senses)=naked eyes/sense of light, touch, smell & hearing • PHN needs to get out & check for the victims • Example: PHN’s sense of sight=saw the pathognomonic signs of measles→ koplik’s spot & rashes c. Formulate hypothesis • To make an intellectual guess based on theory, fact & generalization • The problem is stated in hypothetical form using 2 Variables of Hypothesis: 1) Independent-refers to the cause 2) Dependent-refers to outcome/effect • There should be an existing relationship between the 2 variables • Example: Stated problem in hypothesis: Measles is caused by rubeola virus Dependent (outcome): Measles Independent (cause): Rubeola virus d. Testing hypothesis • To prepare an assumption which is always paired with stated hypothesis • Assumption is the answer of the researcher to a stated problem

28 is the personal opinion of the researcher (pananaw) & does not need to be proven because it’s always true & correct • Example: Lanting Community has poor environmental sanitation (es) which caused the measles e. Draw a conclusion • To draw a conclusion from the statement of problem & assumption to come up with a Nursing Diagnosis • Example: Measles is caused by rubeola virus due to poor environmental sanitation 3. Collection of Specimen (optional)  Optional because it is case to case basis  Not done in measles epidemic  Done in GIT diseases like Cholera caused by bacterial agent Vibrio cholera where it is identified in stool examination 4. Treatment  RA 6675: providing drug of choice  Example: Cholera-give Tetracycline but contraindicated to pregnant women & children below 8 years old so may give Penicillin like Ampicillin 5. Immunization  Mass immunization for measles epidemic=”Ligtas Tigdas”, a DOH program  Example: The mass immunization of all children in the community (6 months to 8 years old) with measles vaccine irregardless if a 9 month old baby has just received measles vaccine, he will still be given. No overdose will result but it’s prophylactic (Patak Polio) and not for treatment 6. Health Education-on personal hygiene 7. Environmental Sanitation 8. Referral 9. Recording & Reporting (R/R)-r.a. 3753: Vital Health Statistics Law 10. Evaluation & Reasearch  Research evaluation was only started in 2001  Year 1996-2000: Zero Polio Philippine Program  In year 2000, there’s sudden mark decrement/decrease of polio cases  In year 2001, suddenly there’s an increase incidence of polio because they don’t know the cause so they consider polio to be mutagenic  3 Strains of Polio: 1) Brunhilde 2) Leon 3) Lansing Types of Epidemiological Investigation: a. Descriptive: describes or defines the characteristic pattern or occurrence of epidemic as to where-place when-date, time who-person b. Analytical: determines what could have cause the occurrence of the disease c. Interventional: therapeutic or experimental that determines the management/treatment for the victims of the occurrence of the disease d. Evaluative:  determines the efficacy of the management/treatment provided/procedure done  Efficacy refers to effectivity (qualitative) and efficiency (quantitative) Epidemiology is the pattern of occurrences & distribution of diseases, defects & deaths

29

Characteristics: Patterns 2 Population in Distribution Susceptible Immune (at risk to develop, (those that did not acquire or experience the experience the disease, disease) usually individuals develop resistance against the disease) 80% (more than 50%) 20% 50% 50% 20% 80% ---------

Epidemic Endemic Sporadic Pandemic

1. Epidemic  Greater than 50% of populations are susceptible or less immune individual  Greater % of the population is affected by the occurring disease  Example 1: Health worker reports that Community Lanting has an epidemic of measles affecting children less than 7 years old Total susceptible population: 3000 Children affected by measles: 1750 1750 3000 x 100=58% (more than 50% of susceptible population=epidemic Example 2: Epidemiological Chapter is regional Measles is considered epidemic if in: Year 2004=there are 15 cases Year 2005=there are 19 cases, because it exceeds the # of cases of previous year 2. Endemic-the disease occurs regularly, habitually, constantly affecting the population group 2 Local Endemic Diseases: where causative agent is available on those places a. Schistosomiasis: Region V -Bicol (Sorsogon) Region VIII -Samar & Leyte Region XI -Davao b. Malaria: Palawan & Mindanao-reasons why it’s prevalent 1) Forested areas 2) Surrounded by bodies of water 3. Sporadic  The pattern of occurrence is on & off where: On=available causative agent Off=no available causative agent  It’s intermittent (unpredictable) in occurrence  Disease occurs only if there’s a susceptible host like in rabies 4. Pandemic-worldwide, international, universal, global in occurrence like in AIDS, Hepatitis B, PTB, measles, mumps, diphtheria, pneumonia  SARS is categorized by WHO as an OUTBREAK only because out of 191 nations, 33 countries are reported to have it Home Visit  Is a PROFESSIONAL contact between PHN (with 8 manpower) & the family  The services provided is an extension of the Health Service Agency (Health Center) Objectives:

30 1. 2. 3. 4. 5. Assessment Nursing Care Treatment: under RA 6675 Health Education Referral (if care fails)

Priorities (in the care): to prevent cross contamination 1. Newborn 2. Post partum 3. Pregnant mothers 4. Morbid cases  The families need the assistance of the health center that’s why home visit was done to the family  The person who makes the home visit is rendering services on behalf of the health center Public Health Bag:  Indispensable tool that should be organize to save time & effort and to prevent cross infection & contamination  Guiding Principles in the use of Public Health Bag: 1. Content-should be prepared by the one who will make home visit 2. Cleaning • The inner part of the bag should be clean & sterile • Should be done every after home visit • Never endorse the bag 3. Contamination • The less one opens the bag, the lesser chance of contamination • In general, the bag is open 3x: a. Putting out materials for hand washing b. Putting out materials used for nursing care c. Returning all what have been used 4. Care of Communicable Case(s)-should be disinfected with the use of 70% isopropyl alcohol or Lysol which should be done at the health center and not at home Phases of Home Visit: 1. Planning  Starts at the health center  Makes a study on the status of the family  Statement of the problem  Formation of objective 2. Socialization-first activity is to establish rapport & to gain the trust of the family 3. Activity ( Health Teaching )  Intervention/Professional Phase  Opportunity to provide or extend health services  Standard Role of the Nurse: Independent, Dependent and Interdependent  To be effective, come in complete uniform (also bring a long umbrella with pointed end which serve as protection) 4. Summarization-ability to put into record & report (orally) about the outcome of the activity; Evaluation LOCAL ENDEMIC DISEASES: 2 Available Programs of DOH 1. Schistosomiasis Control Program (SCP) Policies for Schistosomiasis Control Program (SCP): CHES C ase Finding H ealth Education E nvironmental Sanitation S nail Eradication

31 Case Finding: 6 Aspects or Thing to Know a. Disease: Schistosomiasis b. Other name: Bilhariasis or Snail Fever c. Causative agent: Schistosoma-a blood fluke (parasite) • 3 Types of Species: 1) Schistosoma japonicum-endemic in the Philippines & affecting Indonesia, China, Japan, Korea Vector: Oncomelania quadrasi-a tiny snail that serves as an intermediate host responsible to transmit the disease to man 2) Schistosoma mansoni---------affects African nations 3) Schistosoma haematobium--• 3 Forms of Parasite: 1) Nematodes-pinworm 2) Trematodes-Schistosoma, Flatworms (Paragonimiasis) 3) Cestodes d. Laboratory Procedures to rule out Schistosomiasis: 1) Blood Examination: ↑ eosinophil level indicates parasitism 2) Fecalysis: Kato katz (plain stool exam that uses a special apparatus resembling a feeding bottle sterilizer)  Procedure: a) Collect specimen b) Have the test tube undergo centrifugation for 20 minutes c) Get specimen from precipitate & swab it on glass slide d) Observe it on microscope e. Signs & Symptoms (Pathognomonic=specific s/sxs identifiable for a disease: CNS: High grade fever→ cerebral convulsion GIT: Nausea & vomiting, Diarrhea→ Chronic dysentery (prolonged diarrhea of more than 2 weeks & consistency is mucoid & bloody (with streaks of blood) Liver: Presence of infection manifested by jaundice & hepatomegaly • Parts of Hepa B Virus: Serologic Tests 1) HBsAg-Hepatitis B Surface Antigen 2) HBcAg-Hepatitis B Core Antigen • (+) HBsAg or HBcAg indicates Hepatitis B not Schistosomiasis Spleen: Infection of spleen→ inflammation→ enlargement of organ (Splenomegaly)→ abdominal distension→ abdominal pain on the right upper quadrant Blood: Anemia & weakness f. Treatment: Drug of Choice-Praziquantel (Biltricide)60 mg/KBW/day • Example: If patient is 50 kg, 50 kg x 60 mg/KBW/day=3000 mg/day Available Preparation: 100 mg/tablet 3000 mg/day ÷ 100 mg/tablet=30 tablets/day, so 10 tablets in a.m. 10 tablets in noon 10 tablets in p.m. • Initial treatment: 1st 2 weeks=3000 mg/day, then do stool exam after 2 weeks→ if still (+), extend treatment for another 2 weeks. Repeat stool exam, if still (+) after the extended week, continue treatment for 2 weeks again. No adverse effect or over dosage even if extended for a year. • Length of Treatment: takes months to a year Health Education: It affects mostly farmers so educate them to wear rubber boots Environmental Sanitation: Source of disease=snail is the 1st concern Water=where snail thrives is the 2nd concern Toilet=3rd concern Food

32 Garbage Snail Eradication: Use molluscicides-treat the entire suspected soil with chemical solution that kills snails 2. Malarial Control Program (MCP): 2 Available Programs of DOH for MCP a. BICEP Biological Method: Bio (refers to something which has life=living organism) build fish ponds with tilapia (only fish that eats mosquito eggs) Insecticide=kill/spray source of disease at night time (7 pm) with Baygon/Raid (Bayothrin, Permithrin, Propoxur)→ “After 4 o’clock Habit” of DOH for Malaria & Dengue: 4 p.m.-remove possible venue for mosquitoes to thrive (stagnant waters) 5-5:30 p.m.-start spraying insecticide Malaria (FAM) Dengue (AA) Night Biting D ay Biting High Flying L ow Flying Running/Free Flowing S tagnant Water Rural U rban Case Finding: 6 Concerns for Surveillance 1) Disease: Malaria 2) Other name: Ague 3) Causative Agent: Plasmodium-a protozoa • 4 Types of Species: a) Plasmodium falciparum-more fatal that affects the Philippine Vector: Female Anopheles Mosquito (FAM) b) Plasmodium vivax-------population c) Plasmodium ovale d) Plasmodium malariae 4) Laboratory Procedure: Malarial smear-extract blood at the height of fever because plasmodium is very active & ruptures at this period 5) Signs & Symptoms of Malaria: 1st Stage=Cold: Chilling sensation for 1-2 hours 2nd Stage=Hot: High grade fever lasting for 3-4 hours 3rd Stage=Wet: Diaphoresis (excessive sweating/perspiration) Signs & Symptoms of Dengue: I. Hot II. Bleeding Tendencies i. Epistaxis-nose bleeding ii. Hematamesis-vomiting fresh blood iii. Melena iv. Hematochezia III. Recovery: if bleeding is controlled IV. Circulatory Collapse: if bleeding is not controlled→ Shock→ Death 6) Treatment: Drug of Choice-Quinine 2 Forms: a) Chloroquine (Aralen)-BQ b) Primaquine If Quinine is not available, may use Sulfadoxime-an antibacterial drug paired with pyrinthamine Environmental Sanitation: Source of Disease=1st concern + FAM Water=where mosquitoes thrive Garbage=3rd concern Food Toilet Personal Protection: 1) Sleep under a mosquito net 2) Sleep in a screened room

33 3) Sleep with long sleeve attire 4) Use repellents that contains DET (diethyl toluamide or toluene which has a pungent odor that drives away mosquitoes & an irritant to mucous membrane of respiratory tract when inhaled a) Vaseline oil, off lotion, “katol” b) Anti-mosquito soap has anti-histamine (provides cooling effect), anti-allergy, anti-itchiness, anti-inflammatory & repellent effect: i. Basil ii. Citronelle-resembles mentholated & eucalyptic smells iii. Vicks vaporab-has mentholated smell iv. Oil of Winter Green, omega, efficascent oil v. Zest soap-effective because the green bar has anti-histamine effect and the yellow bar acts as a repellent c) Dry skin of lanzones, dried banana trunk (saha ng saging) 5) Plant a Neem Tree using the leaves b. CLEAN: Chemical Method=insecticide spraying at night Larvae eating fish=Tilapia Environmental Sanitation & Health Education=insect, water, trash Anti-mosquito soap=basil citronelli Neem tree=banana, banaba, gabi, eucalyptus provide repellent effect EXPANDED PROGRAM ON IMMUNIZATION (EPI) PD 996 Compulsory Basic Immunization to all children before reaching 8 years old Started in 1976 by MOH Target Population: A. Infants (0-12 months): BCG, DPT, OPV& Measles HBV (1996) B. School Entrants: MECS: Grade 1=7 years old DECS: Grade 1=6 yrs. old (1993) Booster of BCG RA 7846 PP 4 Compulsory HBV before 8 years old:1996 Measles Elimination Program (September & October) 19941997-“Ligtas Tigdas” (6 months-8 years) Universal Mother & Child Immunization Law advocated by WHO from 1996 and onwards: 5 vaccines + Tetanus Toxoid Strengthens the EPI Program 1. Pregnant mothers-Tetanus Toxoid 2. Children: Infants-5 vaccines School entrants-BCG booster dose 3. Before EPI total immunization-5 After EPI total immunization-6 (Tetanus toxoid was included) 4. OPV was given to all children under 5 years old irregardless of the # of doses & the time OPV was given

PP 6

34 PP 147 Declaring the National Immunization Day Plus (NIDs Plus) initiated by former Sec. Flavier in 1993-95 Initially every 3rd Wednesday of January & February (1993-1995) 1996 to present: Still being practiced but not every 3rd Wednesday of January & February 2002: 2nd Tuesday of March & April At present: depends on the Secretary PP 773 Launched the Polio Elimination Program (PEP) 1995-2000: Zero Polio Philippines, 1. Knock Out Polio (KOP) 2. Zero Polio Philippines (1996-2000) 3. Patak Polio (< 5 years old) PP 1064 AFP (Acute Flaccid Paralysis) Elimination Program-an adverse effect of Polio PP 1066 Neonatal Tetanus Elimination • Morbidity • Mortality  RSI locates a venue for immunization called “Patak Center” and composed of 1 organizer, 1 runner, 1 vaccinator, 1 recorder & 1 health educator catering to a population of 1,000 Policies of EPI: I. Coverage---------------------------A. Target Setting B. FIC (Fully Immunized Child) C. Wastage Allowance II. Cold Chain III. Immunization → Technical responsibilities of PHN IV. Surveillance-----------------------Planning, Supervision & Training--Mobilization, Monitoring & HE → Administrative & Supportive Role of PHN Referral, Research & Evaluation---I. Coverage a. Target Setting: 1) Target Population is the population group meant to be benefited by the EPI Programs where DOH is responsible a) Infants (0-12)-get the 3% of population b) School Entrants-get the 3% of population (dictum of DOH)=6 years c) Pregnant Women-get the 3.5% of population (MWKA)=15-49 years 2) Eligible Population (EP) are those qualified to receive specific immunizations where PHW is responsible→ PHN, RHM, MO • 3 Population Groups to benefit: a) Infants (I)-BCG, DPT, OPV, HBV, MV b) School entrants (SE)-Booster of BCG c) Pregnant women (PW)-Tetanus toxoid • To determine Eligible Population: EP=Population of the Community x 0.03 (Infant & SE) or x 0.035 (PW) • Example: Lanting Community with a population of 7000 a) DPT=for infants EP=7000 x 0.03=210 to receive DPT b) Tetanus Toxoid=for pregnant women EP=7000 x .035=245 to receive TT c) Booster BCG=for school entrants

35 EP=7000 x 0.03=210 to receive booster BCG b. Fully Immunized Child (FIC)-is a child who receives the 5 sets of vaccines (BCG, DPT, OPV, Hep B & Measles and who receives 11 doses of vaccines Vaccine (# of Doses) BCG-1 dose DPT-3 doses OPV-3 doses HBV-3 doses MV-1 dose Infants (0-12 months) Right age to receive the vaccine 0 age (at birth)-12 months 1st Dose-6 wks./1 ½ mos. 2nd Dose-10 wks./2 ½ mos. 3rd Dose-14 wks./3 ½ mos. 9-12 months School Entrants 1 booster dose (6 years old)

 MV may be given 6 months if there is an epidemic c. Wastage Allowance  DOH doesn’t produce vaccines biologically and therefore dependent on suppliers abroad: Germany & Switzerland to economize: 1) Be aware of the availability of vaccines: Example: BCG CHN: vial Private Practice: ampule Frozen powder with a diluent (1 ml per content) 2) How many recipients= Availability Dosage for I=.05 ml Dosage to be given Dosage for SE=0.1 ml I=1 ml (availability) SE=1 ml .05 ml (dosage) .1 ml =20 recipients in 1 vial/1 ml =10 recipients  Follow DOH Dictum: On the day of immunization, if 50% & above of computed recipients arrive in the health center, open a vial but if less than 50%, don’t open. Example: In 20 recipients, 10 arrived=open a vial  Half life of Vaccines is the duration of potency: a. Vaccine with 4 hours half life: BCG, MV (need to mix) • If open at 8:00 am, it’s good till 12:00 noon At 12:30 pm, don’t give anymore because it’s not potent anymore b. Vaccine with 8 hours half life: DPT, OPV, HBV, TT (already in solution/liquid form ready to administer) Vaccine Table of Reference for Requesting Vaccines from DOH Availability Dosage # of Doses Wastage Number of to complete Allowance Recipients immunizatio Multiplier per n Factor Vaccines (MF) Vial: .05 ml Frozen .1 ml Powder with 1 ml diluent 1 dose 1 dose 60% 2.5 40% 1.67 20 10

BCG 1. I 2. SE

36 DPT Vial: 10 ml .5 ml 3 doses 40% 1.67 20 liquid OPV Plastic 2-3 gtts 3 doses 40% 1.67 25(1 ml=15 (Sabin) bottle: 5 ml gtts) slightly pink Liquid HBV Vial: .5, 1, <10 y/o: .5 3 doses 10% 1.2 .5 ml=1 10 ml >10 y/o: 1 .5 ml MV Vial: .5 ml 1 dose 50% 2 10 Frozen Powder with Diluent Sol’n=5 ml per content TT Vial: 10 ml .5 ml 5 doses 40% 1.67 20 liquid  Parenteral=Salk vaccine (sinasaksak) has 5 ml per content  Oral Polio Vaccine (OPV)=Sabin (sa bibig) For OPV: 5 ml (availability)→ 1 ml=15 gtts→1 ml=15 gtts=5 recipients 3 gtts (dosage) 2 ml=30 gtts=10 recipients 3 ml=45 gtts=15 recipients 4 ml=60 gtts=20 recipients 5 ml=75 gtts=25 recipients Right Time for Pregnant Women to receive Tetanus Toxoid Primary Dose TT1 Anytime during ? Immunity th th Pregnancy (5 -6 months) Primary Dose TT2 4 weeks after TT1 3 years immunity st 1 Booster TT3 6 months after 5 years immunity TT2 2nd Booster TT4 1 year after TT3 10 years immunity 3rd Booster TT5 1 year after TT4 Lifetime immunity Examples: 1. Mrs Dela Cruz received the 1st booster dose (TT3) on November 20, 2004. When is the 2nd booster? November 20, 2005 2. As a child, you have 3 doses of DPT. Now you become pregnant. What you need to receive are the 3 booster doses only-TT3, TT4 & TT5 respectively. 3. If as a child, only 1 dose of DPT was given, is there a definite immunity? There’s no definite # of years of immunity. If until 3 years she failed to receive vaccine, she got to start with the 1st dose Wastage Allowances of DOH BCG (I) 60% MV 50% BCG (SE) 40% DPT OPV TT HBV 10% Multiplier Factors 2.5 2.0 1.67

1.2

Steps to Compute the Number of Vaccine to be Requested from DOH 1. Determine the Eligible Population (EP) EP=Population of the Community x 0.03 (I & SE) or 0.035 (PW) 2. Determine the Annual Dose (AD) AD=EP x # of doses of the vaccine 3. Determine the Wastage Allowance (WA)

37 WA=computed AD x MF of the vaccine 4. Determine the Complete Coverage (CC) CC=WA ÷ # of recipients per vaccine 5. Determine the Overall Total in Allowance (OT) OT=CC x 1.25 (constant), DOH usually grants an allowance of 25% of the CC Example: Determine the # of vaccines to be requested from DOH of DPT for Lanting Community with a population of 4000 1. EP=4000 x 0.03=120 2. AD=120 x 3 doses=360 3. WA=360 x 1.67=601 4. CC=601 ÷ 20=30 5. 30 x 1.25=37.5 or 38 vials to be given by DOH (or 8 vials allowance) II. Cold Chain: tools or procedures to follow to keep vaccine potent (expected desired effect) Policies: 1. Proper Storage: store vaccines in refrigerators RHO MHO PHO BHS RHU RHCDS  Freezer -15° C to -20° C Body of Refrigerator 2° C to 8° C OPV: most sensitive to heat MV 3° 2° 1° Given 6 months to store vaccines Given 3 months to store vaccines Given 1 month to store vaccines

BCG DPT HBV TT: least sensitive to heat OPV & MV: highly sensitive to heat OPV, MV & BCG: Not damage by freezing DPT, HBV & TT: Damaged by freezing so not placed in the freezer 2. Proper Transport  Vaccines are to be transported from the health center to the area of immunization (community: focused, based & oriented)  Tools provided by DOH: Vaccine Carrier which maybe a. Black: use by staff of HC during epidemic & needs 5 cold dogs b. White: use by student affiliates & needs 4 cold dogs  Cold Dogs: 4 plastic containers filled with water which is placed in the freezer a day before immunization which is used as freezant to keep vaccine potent 3. Proper Handling of Vaccine (After Care of Vaccine): Dictum of DOH a. Vaccines which are opened, though not consumed, should be discarded Reasons: can’t be used for future program because vaccines have half life (duration of potency of vaccine) BCG -4 hours half life MV Other vaccines -8 hours half life

38 BCG, OPV & MV are composed of live attenuated bacteria & virus so before discarding them, disinfect 1st with 1% Hcl or any disinfectant like zonrox, chlorox or dumex BCG (Bacilli Calmette-Guerin Vaccine): live attenuated bacteria OPV & Measles Vaccine: live attenuated virus DPT, HBV & TT can be readily discarded if not consumed DPT: Diphtheria-weakened toxoid treated with chemical solution to weaken microorganism Pertussis-killed bacteria Tetanus-weakened toxoid HBV: plasma derived, identified to be RNA & DNA recombinant from blood TT: weakened toxoid b. Vaccines which are taken out from Health Center for 3x or more are considered overly exposed & not potent anymore therefore it should be discarded Put notation (state the date) on the unopened vaccine as to when it was taken out from health center May 19, 2006 Jun. 19, 2006 Jul. 19, 2006-can’t be used anymore after this III. Immunization Guiding Principles for HW in Administering Vaccines & Screening of Children for Immunizations: 1. No BCG for a child born clinically positive to AIDS because they have a damage immune system & introducing bacteria will further aggravate their condition 2. There are no contraindications such as slight fever, LBM, cough & colds and malnutrition, in giving the immunization unless upon assessment of the practitioner that the child has serious medical problems that warrants hospitalization 3. In giving immunization with multiple doses such as DPT, OPV & HBV, continue counting in giving the doses. Never count back even though the interval exceeds weeks, months or years. As long as the child is on the eligible age Example: DPT, OPV & HBV 1st dose: At 6 weeks (1 ½ months), the child was given vaccination 2nd dose: The mother brought back the child when he was 8 months old instead at 10 weeks (2 ½ months). PHN should still give the 2nd dose 3rd dose: The mother brought back the child at 2 years old. PHN should still give the vaccine because child is still at the eligible age (0-59 months or 4 years & 11 months or 5 years old) to receive vaccine 4. DPT: it is a normal reaction for a child to develop high grade fever because of the pertussis component (killed bacteria) SOP Management: Paracetamol q 4 hours RTC for the 1st 2 days (or 3, 4 days if still febrile) If after 1st dose of DPT, the child develops high grade fever with convulsion, DPT 2 & 3 are not given anymore because convulsion affects the brain cells resulting to brain damage DPT vaccine is only for prophylactic/ preventive use 5. Things to consider in administering vaccines: a. Vaccine b. Dosage c. SOA (Site of Administration) d. ROA (Route of Administration)

39 e. Side Effect: patterns of reaction that is considered normal Vaccines BCG Dosage I=.05 ml SE=.1 ml SOA I=R deltoid SE=L deltoid ROA Conferred Immunity Artificial Active

Intradermal (needle is parallel to site=10-15° angle Side Effects: Wheal=10 mm that disappears after 30 minutes 1st week : develops soreness and inflammation 2nd -11th week : develops abscess and ulceration 12th week (3 months): heals and develops permanent scar

Age of Consultation BCG Site of Injection Right Age (0-12 months) Right Deltoid Wrong Age but still eligible Left Deltoid Example: 4 years old Booster Dose at Age 6 Left Deltoid  If after BCG, there is no soreness & inflammation, no abscess & ulceration and no scar developed, there is wrong preparation of site where PHW used alcohol that kills the microorganism contained in the BCG vaccine. Thus, repeat the dose on same site but a little lower.  Site preparation: Use clean cotton ball & wet with sterile water only  For non-healing abscess & ulceration: BCG was wrongly administered by IM or SQ by PHW so incision & drainage should be done by MD only and INH tablet, an anti-bacterial, pounded, pulverized & applied on the site. Then repeat the dose again but not on the same site. Vaccine DPT Dosage .5 ml SOA Conferred Immunity Thigh (vastus Intramuscular Artificial lateralis) (Z tract) Active where muscle is grasped and squeezed ROA

Side Effects: 1. High grade fever due to Pertussis Component which contains killed bacteria 2. Soreness and inflammation SOP Management: Paracetamol (anti-pyretic & analgesic) q 4 hours RTC for 1st 3 days or till with fever Nursing Care: 1st Day=apply cold compress on site 2nd , 3rd & 4th Day=apply alternating cold & warm compress Adverse Effect: If convulsion occurs on 1st dose, discontinue DPT 2 & DPT 3 because of the sensitivity to DPT Component but private MD gives DT which is not available in DOH Vaccine OPV Dosage 2-3 gtts SOA Mouth ROA Oral: Sabin by Dr. Albert Sabin Salk (parenteral polio vaccine) Conferred Immunity Artificial Active

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

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

41 Passive Passive 1. Breastfeeding→ IgA (present in 1. Serum (Blood): colostrums) HBV 2. Perinatal→ immunity is acquired ATS (Anti-Tetanus Serum) during the term of pregnancy ADS (Anti-Diptheria Serum) 2. Antitoxin: poison or causes infection TAT (Tetanus Antitoxin) DAT (Diptheria Antitoxin) 3. Immunoglobulins: IgA, IgD, IgE, IgG & IgM where IgG is most predominant IV. Surveillance: to be discussed under Communicable Diseases MATERNAL AND CHILD HEALTH SERVICES Mothers: 1. MWRA (Married Women Reproductive Age):  15-49 years old=average age of reproduction for Filipino women • 15 years old=average age of menarche (start of menstruation/reproduction) • 49 years old=average age of menopause • Ovulation takes place only for 35 years • Age of menarche + 35 (constant)=average age of menopause  EO 209: Family Code by President Corazon Aquino-married women  PD 651: Birth & Death Registration Law-PHN must register the attended delivery to the Office of the Local Civil Registrar within 30 days • Prepare & accomplish the birth certificate • Ask the mother for a marriage contract, if none=use mother’s surname • According to the new House Bill stating that with the father’s blessing/consent (even without marriage), the child can still use his/her father’s surname, granting the father affix his signature on the birth certificate. 2. MCRA (Married Couple Reproductive Age): Both husband & wife play a significant role in the family Elements of Reproductive Health Act (HB 4110): I. Family Planning:  Problem of Over Population: NSO usually determines the census every 5 years • In the Philippines, approximately 85M population→ NSO predicted an increase of 1.7M/year • Among ASEAN Countries, Philippines ranked # 7 & globally ranked # 4 DOH National Family Planning Program: Goals: a. Safe Pregnancy • Right age to be pregnant=20-35 years old, not less than 20 & not more than 35 Right interval of pregnancy=once in 2 or 3 years Supportive of safe pregnancy=done in home setting, Home Base Mother’s Record (HBMR): the record used for care of mothers in CHN • Laboratory Examinations: 1) Benedict’s Test: test for sugar in the urine; test for diabetes  Heat test tube with 5 cc of Benedict’s Solution (blue) in the burner then add 3-5 gtts of urine (amber yellow) then heat again. Observe for the change in color: Blue : (-) sugar in urine Green : trace of sugar in urine +1 + Yellow : traces of sugar in urine +2 ++

42 Orange : more traces of sugar in urine +3 +++ Brick Red : surely diabetic +4 ++++  Adverse Effect of Diabetes: Macrosomia (too large baby)=teratogenic  Advise mother to take sugar in moderate 2) Acetic Acid Test: test for albumin in urine; test for Pregnancy Induced HPN  Collect urine in test tube, heat it in burner then add 3-5 gtts of acetic solution (clear white). Observe for change in color: If it remains clear: (-) CHON or albumin in urine If it turns cloudy: (+) CHON=proteinuria  2 Categories of PIH: a) Pre-eclampsia: HPN, Edema & Proteinuria (HEP) b) Eclampsia: Coma or convulsion b. Safe Motherhood: prenatal, post natal c. Healthy Reproductive Life Policies: a. Non coercive (give freedom of choice) • AC 114: Role & Function of PHW BQ: What is the role of PHN to the Family Planning Program of DOH? Answer: Facilitator • Never force/command/dictate to the couple what contraceptive method to use b. Integration of Family Planning in all Curricular Program: • LOI 47 DECS states that Family Planning is to be integrated in all school curricular programs, either baccalaureates or nonbaccalaureates, enrolled separately as one unit c. Multi-Sectoral Approach: establish relationship with other agencies which can either be: 1) Intrasectoral 2) Intersectoral-Local or International (WHO, Unicef, USAID, Japhiego) d. Unacceptability of Abortion: • Is the termination of pregnancy before reaching the age of viability • According to Church, methods of contraception III & IV are proabortion • “E” Contraceptives are used for legal cases such as rape so may give over the counter pills (pills with high amount of progesterone & estrogen) given one pack then after 12 hours another pack Methodologies: A. Biological 1. Basal Body Temperature (BBT)  Get the temperature early morning before waking up which should be monitored daily at the same time  There should be a sudden drop of temperature between 0.3-0.6°C followed by an increase of temperature by 0.3-0.6°C which means that the woman is fertile  Example: 5:30 am Mon 37.5°C---decrease by 0.4 Tues 37.1-----Wed 37.1 Thurs 37.1------increase by 0.4 Fri 37.4°C--2. Sympto-thermal 3. Cervical Mucus Test

43 a. Billing’s Method by Dr. Billing b. Spinnbarkheit (came from a German word Spinner which means to play with the cervical mucus with the finger) or Wet & Dry Method: 1) Wet Cervical Mucus (Fertile): abundant, stretchy & transparent 2) Dry Cervical Mucus (Safe & Not fertile): whitish, pasty & adhesive 4. Lactation Amenorrhea Method (LAM): RA 7600-Breastfeeding & Rooming In Law  DOH organized Maternal & Child Family Health Institute (MCFHI) with the following members: a. All government hospitals b. Private hospitals (volunteer)  Normal involution (uterus goes back to normal) of the uterus: after 45 days or 5-6 weeks or 1 ½ months if not breastfeeding  Frozen breast milk is to be put out of the freezer 2 hours before feeding  Left over milk should be discarded & should not be re-preserved or re-frozen because it is already contaminated 5. Calendar (Rhythm)  Deleted already since 1998 because it’s not recommended for irregular cycle of menstruation  Menstrual cycle should be regular; obtain 4-6 months cycle  Example: Aug 29 days Nov 28 days Sep 30 days Dec 29 days Oct 26 days Jan Fertile Short cycle: 26 days, subtract 18=26-18=8th day Longest cycle: 30 days, subtract 11=30-11=19th day Fertile Period: on the 8th -19th day from the start of menstrual cycle Mon Tues 6 13 R 20 R 27 Wed 7 14 T 21 TI 28 Thurs 1 8 15 I 22 LE 29 Fri 2 9 16 L 23 30mense Sat 3 10 17 E 24 31

Sun

4-1st day 5 of mense 11 12 F E 18 F 25 19 E 26

B. Behavioral 1. Abstinence 2. Withdrawal C. Temporary 1. Chemical a. Oral Pills (Logentrol)-has low dose of estrogen & progesterone that inhibits ovulation b. Parenteral: Depot Medroxyprogesterone Acetate (DMPA)/Depoprovera- inhibits ovulation making women amenorrheic; 1991, DMPA was found to be causing cancer of the cervix 1994, DMPA is given IM 4x a year every 3 months (90 days interval) c. Implants: Norplant-it inhibits ovulation effective for 5 years but seldom advocated for use because it is usually expensive; the

44 client buys the device (consists of 5 capsules) & have it implanted at the health center by minor surgical incision in: 2) upper inner arm because it is nearest to the brain 3) external oblique 4) thigh 5) gluteal muscles 2. Mechanical: IUD, Cervical cap, Diaphragm, Condom D. Permanent 1. Vasectomy (reversible)-since year 2000 in the Philippines 2. BLT II. Mother & Child Nutrition III. Prevention & Control of Infertility & other Reproductive/Gynecological Disease IV. Prevention & Control of Abortion & Its Complications V. Prevention & Control of Male & Female Reproductive Tract Infections: STD, HIV, Hepatitis B VI. Health Education on Human Sexuality VII. Violence Against Women ESSENTIAL DRUGS and HERBAL: RA 6675 and RA 9165 NUTRITIONAL HEALTH SERVICES PD 491: created the Nutrition Council of the Philippines Policies: I. Nutritional Surveillance (NS): to determine victims of malnutrition A. Anthropometric Measurement: study of measurements of human dimensions 1. Age for Weight-if weight is not appropriate with the age: a. Stunting: growth retardation b. Wasting: connotes malnutrition 2. Age for Height-if height is not appropriate with the age: Stunting 3. Weight for Height Rule Male Every height of 5 ft. 110 lbs. Every increment of an +6 inch above 5 ft. ADD Every decrement of an -6 inch below 5 ft. SUBTRACT Example: Female 4’11” at 100 lbs. 5 ft. =105 lbs. 1” decrement=-5 Female 105 lbs. +5 -5 105 -5 100 lbs. Ideal Body Weight (IBW) 100 x 100=100% Normal 100

Gomez Table Reference Percentile Description 110% & above Obesity (a form of Malnutrition) 90-109% Normal 76-89% 1st Degree-needs home diet care 60-75% 2nd Degree-needs hospitalization; use TPN Below 60% 3rd Degree-needs hospitalization; use TPN FORMULA: Actual Body Weight x 100= % Ideal Body Weight Example: Male 5’11” at 154 lbs. 154

45 5 ft. =110 lbs. 176 x 100=88% (1st Degree Malnutrition) 11 x 6 =66 lbs. IBW=176 lbs.-154 lbs. =22 lbs. underweight 4. Skin Folds Test-pinch the external oblique muscle (“bilbil”) with your palm Normal: 1 inch Overweight: > 1 inch 5. Middle Upper Arm Circumference (MUAC)-used in children below 5 years old by measuring the middle upper arm with a tape measure Normal: 13 cms. & above Malnutrition: <13 cms. B. Biochemical Method 1. Micronutrient Malnutrition-available in small amount in the body VADAG: Vitamin A Deficiency: • Deficiency: Xeropthalmia-opacity of cornea leading to night blindness • Infants (6-12 months) : Give 100,000 i.u. Pre-schoolers (12-83 months) : 200,000 i.u. Post partum : 200,000 i.u. • Never give Vitamin A to infants less than 6 months & pregnant women because it is toxic • Example: Infant 8 months old Patterns of treatment Vitamin A 100,000 i.u. 2/21/06 1st Dose: give today 100,000 i.u. 2/22/06 2nd Dose: give tomorrow 100,000 i.u. 3/08/06 3rd Dose: give after 2 weeks Anemia: Iron Deficiency Anemia • Target age group: 0-59 months (less than 5 years) • Give 3-6 mg/kbw/day • Always give the maximum • Example: Child weighs 8 kg 8 x 6=48 mg/day for the 1st 3 months then monitor If still anemic, continue giving but compute again 6 mg/kbw Goiter: Iodine Deficiency Disease (endemic in uphill) • Target age group: 0-59 months • Give 1 capsule (200 mg) of potassium iodate in oil once a year For a child < 5 years old, empty contents of capsule in a cup with warm water because he can’t tolerate it • Adverse Effect of Iodine Deficiency Disease that must be avoided: a. Mental retardation-intelligence quotient: idiot, moron & imbecile b. Growth retardation- cretinism (pedia) & dwarfism (adult) 2. Macronutrient Malnutrition-available in large amount in the body (Protein Energy Malnutrition or PEM) A. Kwashiorkor-protein deficiency B . Marasmus-carbohydrate deficiency (energy giving food) Etiology Deficiency Age Major Signs & Symptoms Hair Changes Kwashiorkor Disease experienced by an elder child upon the birth of a new baby CHON Toddlers (1-3 years old) Facial edema, moon facie (+) color changes from black to brown or from brown to golden yellow (+) sparse “flag sign” Dermatosis: Marasmus Muscle wasting CHO All ages Muscle wasting, man’s facie (-) hair changes

old

Skin

(-)

46 dryness, peeling off of the skin, desquamation Irritable Apathetic High CHON diet High CHO diet Total Parenteral Nutrition (TPN) Hyperalimentation process IV infusion with CHON, CHO regulated by a machine

Behavior Management Hospital Setting

II. Food Production 1. Fortification-products without any nutrient are added with nutrients  RA 8172 (Asin Law): Fidel Salt (Fortification of Iodine Deficiency Elimination)=Iodized Salt-“Patak” sa Asin” by Secretary Flavier on December 1-5, 2003 where DOH workers go to market to check if salt sold contains iodine by placing few drops of reagent: If salt color turns to blue violet→ fortified with iodine If salt color show no change→ not fortified with iodine  RA 832 (Rice Fortification): FVR (Fortified Vitamin Rice) by Secretary Flavier under FVR, Erap Rice under Erap, Gloria Rice or “Bigas ni Gloria” under PGMA

2. Enrichment-adding more nutrients to products already with nutrients Canned Goods----Noodles → written in their labels: enriched with vitamin ABC… Z Junk Foods--------- with DOH seal “Sangkap Pinoy” III. Nutritional Education-sharing of information to mothers whose children are malnourished 3 Basic Food Groups: Go -CHO Grow -CHON Glow -Vitamins, Minerals & Fats Pyramid for Healthy Filipino Food Lifestyle by Food & Nutrition Research Institute (FNRI)-another agency which is supportive of Nutrition Council of the Philippines Eat less Oils, Fats, Sugar, Salt Eat some Meat, Poultry, Peanut, Fatty dairies Eat more Vegetables, Fruits, Salad Eat most Wheat, Corn, Bread, Potato, Rice Drink a lot Water, Clear broth IV. Nutritional Rehabilitation  PP 147: declared the National Immunization Days Plus (NIDs Plus) • In 2003, it was held during the month of March & April • Immunization activities was not done at the Health Center but was held at a designated area • Rural Sanitary Inspector (RSI) will locate the venue (The Patak Center) to conduct the immunization • The Patak Center catering to the population of 1000 was composed of the following personnel: 1 Runner, 1 Recorder, 1 Organizer, 1 Vaccinator & 1 Health Educator • NIDs Plus Activities: 1. Immunization 2. Giving Multivitamins fortified with Vitamin A, Iron & Iodine for < 5 years old, pregnant women & post partum

47  Araw ng Sangkap Pinoy (ASAP): Health Centers distribute basic commodities fortified & enriched with multivitamins which is done yearly every October Example: Skim milk & canned goods donated by international organizations like UNICEF, WHO,  RA 4226: Hospital Licensure Act-creation of additional unit in every department of the hospital as Malnutrition Ward to house malnourished victims to be under the supervision of a nutritionist TREATMENT OF COMMUNICABLE & NON COMMUNICABLE DISEASES Communicable Diseases: which the DOH has special programs (other diseases under CD subject) 1. Tuberculosis: MDT, SCC & DOTS 2. Pneumonia: CARI 3. Diarrhea: CDD 4. Leprosy: RRC (MDT) ENVIRONMENTAL SANITATION (ES)  refers to all factors available in the environment affecting the health of the individual or population  the Environmental Health Service (EHS) of DOH is responsible for: 1. Promotion of healthy environmental conditions & prevention of environmental related diseases through appropriate sanitation strategies 2. Promotion & implementation of sanitation programs through the Department of Health Field Health Units 3. Conceptualization of new programs/projects to contend with emerging environmentally related health problems  regulated by PD 856: Comprehensive Sanitation Code of the Philippines Factors Covered by Sanitation Code Immediate Concern of PHN: 1. Food Sanitation 2. Garbage Disposal 3. Sources of Disease-PHN is concerned with eradication of insects, rodents, flies & mosquitoes & cockroaches 4. Toilet • Two Considerations in constructing toilets: a. Construct at a distance of 25-30 meters from identified source of water like deep well, faucet, etc. b. Construct at a level lower than the source of water • Role of RSI: a. Locate the source of water b. Construct a toilet for community use 5. Water Sanitation • Potable-free from any particles that might cause illness to an individual • Ways to make Water Potable: a. Boiling: minimum of 3 minutes to maximum of 10 minutes for drinking b. Sterilization: 30 minutes after the water starts to boil c. Filtration: makes use of filter paper or cotton cloth to separate solid particle from liquid if water comes from river d. Coagulation/Flocculation: uses aluminum crystal (tawas) that collects or absorbs particles from liquid part & becomes slimy • In 1 gallon of water, drop tawas (the size of magi cubes) & allow to stand for 6-8 hours • Initially, water appears to be cloudy then after 6-8 hours of standing, the water becomes clear e. Chlorination: uses 100% pure concentrated chlorine bought from botika or given free by health centers

48 To prepare stock solution (SS): in 1 liter drinking water, add 1 tablespoon of concentrated chlorine which is potent for 3-4 months • To prepare the chlorinated water: in 2 ½ gallons of drinking water (10,000 ml=10 liters), add 1 tablespoon from the prepared stock solution & let it stand for 30 minutes to react with water  1 gallon=4 liters  10 liters is good for use of family of 5 & good for 3 days only  On the 4th day, larvae are present to become mosquitoes that causes dengue so it’s not good for drinking  Prepare chlorinated water everyday f. Fluoridation: adding fluoride to prevent dental caries (primary significance) & whitens enamel of teeth ( 2nd significance) g. Aeration: exposing drinking water in air to strengthen taste within 24 hours which is usually used in uphill areas where there’s less or no pollution Beyond PHN Responsibilities: 6. Pollution: Water, Noise, Air: RA 8749-Clean Air Act=a program of DENR supported by MMDA (Smoke Belchers) & LTO (Emission Testing) 7. Plumbing: a responsibility of DPWH 8. Institutional Sanitation: establishments who employ professional prostitute requires license given by DOH from their employees • DOH created a center that caters for STD Prevention which requires employees who are at risk to have a certificate that they are free from STD & monitored once in 6 months • 4 C’s to prevent STD: Compliance, Counseling, Contact training & use of Condom 9. Hospital Waste Management: RA 4226-Hospital Licensure Act monitors the hospital license & proper management of wastes as well as renewal of license to operate • Color Coding of Bin to keep Waste: Green : wet waste--- non pathological waste Black : dry waste--Yellow: infectious/pathological waste like blood, sputum, urine, feces & gauze Orange : toxic/hazardous waste 10. Ecological Solid Waste Management: RA 9003-the use of incinerator approved in 2000 but was implemented in 2003 because of lack of funding to purchase • Dioxin: a toxic substance emitted from burning of solid waste when inhaled by a breastfeeding mother, her milk will be contaminated→ cancer of the blood of the child Sanitary Ways of Treating Garbage as taught to the Population: 1. Segregation-separating biodegradable from non biodegradable 2. Collection-adherence to the proper collection time→ the City of Manila coordinates with Leonel Waste Management (a private firm which collects garbage) where the truck driver coordinates with the Barangay Chairman on the time they will collect garbage so don’t bring out garbage before the collection time 3. Dumping in official site: PD 825-improper waste (garbage) disposal→ fine of P1,000 & minimum imprisonment of 7 days 4. Burying-if area is accessible 6. Composting-has dual purpose: a. Sanitary disposal b. Compost is used as fertilizer •

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