Nursing Path

CARING is the essence of NURSING. -Jean Watson

Nursing Path

Knowing is not enough, we must APPLY. Willing is not enough, we must DO. -Bruce Lee

Nursing Path

Treat the patient as a whole, not just the hole in the patient.

Nursing Path

Success is not final. Failure is not fatal. It is the courage to continue that counts. -Winston Churchill

Nursing Path

A problem is a chance for you to do your best. -Duke Ellington

Control of Diarrheal Diseases (CDD)

Management of the Patient with Diarrhea
A. No Dehydration
  • Condition – well, alert
  • Mouth and Tongue – moist
  • Eyes – normal
  • Thirst – drinks normally, not thirsty
  • Tears – present
  • Skin pinch – goes back quickly
Three Rules for Home Treatment
  1. Give the child more fluids than usual
    • use home fluid such as cereal gruel
    • give ORESOL, plain water
  2. Give the child plenty of food to prevent under nutrition
    • continue to breastfeed frequently
    • if child is not breastfeed, give usual milk
    • if child is less than 6 months and not yet taking solid food, dilute milk for 2 days
    • if child is 6 months or older and already taking solid food, give cereal or other starchy food mixed with vegetables, meat or fish; give fresh fruit juice or mashed banana to provide potassium; feed child at least 6 times a day. After diarrhea stops, give an extra meal each day for two weeks.
  3. Take the child to the health worker if the child does not get better in 3 days or develops any of the following:
    • many watery stools
    • repeated vomiting
    • marked thirst
    • eating or drinking poorly
    • fever
    • blood in the stool
Oresol Treatment
 Age  Amount of ORS to give after each loose stool
 Amount of ORS to provide for use at home
 < 24 months  50-100 ml  500 ml/day
 2-10 years  100- 200 ml  1000 ml/day
 10 years up  As much as wanted  2000 ml/day

B. Some Dehydration
  • Condition – restless, irritable
  • Mouth and Tongue – dry
  • Eyes – sunken
  • Thirst – thirsty, drinks eagerly
  • Tears – absent
  • Skin pinch – goes back slowly
Approximate amount of ORS to give in 1st 4 hours
 Age  Weight (kg)  ORS (ml)
 4 months  5  200- 400
 4- 11 months  5- 7.9  400- 600
 12-23 months  8- 10.9  600- 800
 2-4 yrs.  11- 15.9  800- 1200
 5-14 yrs.  16- 29.9  1200- 2200
 15 yrs. up  30 up  2200- 4000
  1. If the child wants more ORS than shown, give more
  2. Continue breastfeeding
  3. For infants below 6 mos. who are not breastfeed, give 100-200 ml clean water during the period
  4. For a child less than 2 years give a teaspoonful every 1-2 min.
  5. If the child vomits, wait for 10 min, then continue giving ORS, 1 tbsp/2-3 min
  6. If the child’s eyelids become puffy, stop ORS, give plain water or breast milk, Resume ORS when puffiness is gone
  7. If ( -) signs of DHN- shift to Plan A
Use of Drugs during Diarrhea
  • Antibiotics should only be used for dysentery and suspected cholera
  • Antiparasitic drugs should only be used for amoebiasis and giardiasis
C. Severe Dehydration
  • Condition – lethargic or unconscious; floppy
  • Eyes – very sunken and dry
  • Tears – absent
  • Mouth and tongue – very dry
  • Thirst- drinks poorly or not able to drink
  • Skin pinch – goes back very slowly
  • Treatment PLAN C- treat quickly
  1. Bring pt. to hospital
  2. IVF – Lactated Ringers Solution or Normal Saline
  3. Re-assess pt. Every 1-2 hrs
  4. Give ORS as soon as the pt. can drink

Role of Breastfeeding in the Control of Diarrheal Diseases Program

Two problems in CDD
  1. High child mortality due to diarrhea
  2. High diarrhea incidence among under fives
  • Highest incidence in age 6 – 23 months
  • Highest mortality in the first 2 years of life
  • Main causes of death in diarrhea :
    • Dehydration
      • To prevent dehydration, give home fluids “am” as soon as diarrhea starts and if dehydration is present, rehydrate early, correctly and effectively by giving ORS
    • Malnutrition
      • For under nutrition, continue feeding during diarrhea especially breastfeeding.
Interventions to prevent diarrhea
  1. breastfeeding
  2. improved weaning practices
  3. use of plenty of clean water
  4. hand washing
  5. use of latrines
  6. proper disposal of stools of small children
  7. measles immunization
    1. Risk of severe diarrhea 10-30x higher in bottle fed infants than in breastfed infants.
    2. Advantages of breastfeeding in relation to CDD

            a. Breast milk is sterile
            b. Presence of antibodies protection against diarrhea
            c. Intestinal Flora in BF infants prevents growth of diarrhea causing bacteria.

    3. Breastfeeding decreases incidence rate by 8-20% and mortality by 24- 27% in infants under 6 months of age.
    4. When to wean?
  • 4-6 months – soft mashed foods 2x a day
  • 6 months – variety of foods 4x a day

Summary of WHO-CDD recommended strategies to prevent diarrhea
    1. Improved Nutrition
  • Exclusive breastfeeding for the first 4-6 months of life and partially for at least one year.
  • Improved weaning practices
    2. Use of safe water
  • collecting plenty of water from the cleanest source
  • protecting water from contamination at the source and in the home
    3. Good personal and domestic hygiene
  • handwashing
  • use of latrines
  • proper disposal of stools of young children
    4. Measles immunization

Control of Acute Respiratory Infections (CARI)

A. No Pneumonia: Cough or Cold
  1. No chest in drawing
  2. No fast breathing ( <2 mos. - <60/min,2-12 mos. – less than 50 per minute; 12 mos. – 5 years – less than 40 per minute)
  1. If coughing more than 30 days, refer for assessment
  2. Assess and treat ear problems/sore throat if present
  3. Advise mother to give home care
  4. Treat fever/wheezing if present
Home Care:
1. Feed the Child
  • Feed the child during illness
  • Increase feeding after illness
  • Clear the nose if it interferes with feeding
2. Increase Fluids
  • offer the child extra to drink
  • Increase breastfeeding
3. Soothe the throat and relieve the cough with a safe remedy
4. Watch for the following signs and symptoms and return quickly if they occur
  • Breathing becomes difficult
  • Breathing becomes fast
  • Child is not able to drink
  • Child becomes sicker
B. Pneumonia
  1. No chest in drawing
  2. Fast breathing (less than 2 mos- 60/min or more ; 2-12 mos. – 50/min or more; 12 mos. – 5 years – 40/min or more)
  1. Advise mother to give home care
  2. Give an antibiotic
  3. Treat fever/wheezing if present
  4. If the child’s condition gets worst, refer urgently to hospital; if improving, finish 5 days of antibiotic.
Antibiotics Recommended by WHO
  • Co-trimoxazole,
  • Amoxycillin, Ampicillin, (p.o)
  • or Procaine penicillin (I.M.)
C. Severe Pneumonia
  1. Chest indrawing
  2. Nasal flaring
  3. Grunting ( short sounds made with the voice)
  4. Cyanosis
  • Refer urgently to hospital
  • Treat fever ( paracetamol), wheezing ( salbutamol)
D. Very Severe Disease
  1. Not able to drink
  2. Convulsions
  3. Abnormally sleepy or difficult to wake
  4. Stridor in calm child
  5. Severe undernutrition
  • Refer urgently to hospital

Assessment of Respiratory Infection
Ask the Mother
  1. How old is the child?
  2. Is the child coughing? For how long?
  3. Age less than 2 months: Has the young infant stopped feeding well?
  4. Age 2 months up to 5 years: Is the child able to drink?
  5. Has the child had fever? For how long?
  6. Has the child had convulsions?
Look, Listen        1. Count the breaths in one minute.

 Age  Fast Breathing
 Less than 2 months  60/minute or more
 2 months- 12 months  50/minute or more
 12 months – 5 years  40/minute or more
    2. Look for chest in drawing.
    3. Look and listen for stridor. Stridor occurs when there is a narrowing of the larynx, trachea or epiglottis which interferes with air entering the lungs.
    4. Look and listen for wheeze. Wheeze is a soft musical noise which shows signs that breathing out (exhale) is difficult.
    5. See if the child is abnormally sleepy or difficult to wake. (Suspect meningitis)
    6. Feel for fever or low body temperature.
    7. Check for severe under nutrition

Community Organizing Participatory Action Research (COPAR)

Definitions of COPAR

  • A social development approach that aims to transform the apathetic, individualistic and voiceless poor into dynamic, participatory and politically responsive community.
  • A collective, participatory, transformative, liberative, sustained and systematic process of building people’s organizations by mobilizing and enhancing the capabilities and resources of the people for the resolution of their issues and concerns towards effecting change in their existing oppressive and exploitative conditions (1994 National Rural Conference)
  • A process by which a community identifies its needs and objectives, develops confidence to take action in respect to them and in doing so, extends and develops cooperative and collaborative attitudes and practices in the community (Ross 1967)
  • A continuous and sustained process of educating the people to understand and develop their critical awareness of their existing condition, working with the people collectively and efficiently on their immediate and long-term problems, and mobilizing the people to develop their capability and readiness to respond and take action on their immediate needs towards solving their long-term problems (CO: A manual of experience, PCPD)

Importance of COPAR
  1. COPAR is an important tool for community development and people empowerment as this helps the community workers to generate community participation in development activities.
  2. COPAR prepares people/clients to eventually take over the management of a development programs in the future.
  3. COPAR maximizes community participation and involvement; community resources are mobilized for community services.

Principles of COPAR
  1. People, especially the most oppressed, exploited and deprived sectors are open to change, have the capacity to change and are able to bring about change.
  2. COPAR should be based on the interest of the poorest sectors of society
  3. COPAR should lead to a self-reliant community and society.

COPAR Process
  • A progressive cycle of action-reflection action which begins with small, local and concrete issues identified by the people and the evaluation and the reflection of and on the action taken by them.
  • Consciousness through experimental learning central to the COPAR process because it places emphasis on learning that emerges from concrete action and which enriches succeeding action.
  • COPAR is participatory and mass-based because it is primarily directed towards and biased in favor of the poor, the powerless and oppressed.
  • COPAR is group-centered and not leader-oriented. Leaders are identified, emerge and are tested through action rather than appointed or selected by some external force or entity.

COPAR Phases of Process
1. Pre-entry Phase
  • Is the initial phase of the organizing process where the community/organizer looks for communities to serve/help.
  • It is considered the simplest phase in terms of actual outputs, activities and strategies and time spent for it
        Activities include:
    • Designing a plan for community development including all its activities and strategies for care development.
    • Designing criteria for the selection of site
    • Actually selecting the site for community care
2. Entry Phase
  • Sometimes called the social preparation phase as to the activities done here includes the sensitization of the people on the critical events in their life, innovating them to share their dreams and ideas on how to manage their concerns and eventually mobilizing them to take collective action on these.
  • This phase signals the actual entry of the community worker/organizer into the community. She must be guided by the following guidelines however.
    • Recognizes the role of local authorities by paying them visits to inform them of their presence and activities.
    • The appearance, speech, behavior and lifestyle should be in keeping with those of the community residents without disregard of their being role models.
    • Avoid raising the consciousness of the community residents; adopt a low-key profile.
3. Organization Building Phase
  • Entails the formation of more formal structures and the inclusion of more formal procedures of planning, implementation, and evaluating community-wide activities. It is at this phase where the organized leaders or groups are being given trainings (formal, informal, OJT) to develop their skills and in managing their own concerns/programs.
4. Sustenance and Strengthening Phase
  • Occurs when the community organization has already been established and the community members are already actively participating in community-wide undertakings. At this point, the different communities setup in the organization building phase are already expected to be functioning by way of planning, implementing and evaluating their own programs with the overall guidance from the community-wide organization.
        Strategies used may include:
    • Education and training
    • Networking and linkaging
    • Conduct of mobilization on health and development concerns
    • Implementing of livelihood projects
    • Developing secondary leaders

Community Health Nursing: An Overview

Definition of Terms

  • a group of people with common characteristics or interests living together within a territory or geographical boundary
  • place where people under usual conditions are found
  • Derived from a latin word “comunicas” which means a group of people.
  • OLOF (Optimum Level of Functioning)
  • Health-illness continuum
  • High-level wellness
  • Agent-host-environment
  • Health belief
  • Evolutionary-based
  • Health promotion
  • WHO definition
Community Health
  • Part of paramedical and medical intervention/approach which is concerned on the health of the whole population
  1. Health promotion
  2. Disease prevention
  3. Management of factors affecting health
  • Both profession & a vocation. Assisting sick individuals to become healthy and healthy individuals achieve optimum wellness
Community Health Nursing
  • “The utilization of the nursing process in the different levels of clientele-individuals, families, population groups and communities, concerned with the promotion of health, prevention of disease and disability and rehabilitation.” ( Maglaya, et al)
  • Goal: “To raise the level of citizenry by helping communities and families to cope with the discontinuities in and threats to health in such a way as to maximize their potential for high-level wellness” ( Nisce, et al)
  • Special field of nursing that combines the skills of nursing, public health and some phases of social assistance and functions as part of the total public health program for the promotion of health, the improvement of the conditions in the social and physical environment, rehabilitation of illness and disability ( WHO Expert Committee of Nursing)
  • A learned practice discipline with the ultimate goal of contributing as individuals and in collaboration with others to the promotion of the client’s optimum level of functioning thru’ teaching and delivery of care (Jacobson)
  • A service rendered by a professional nurse to IFCs, population groups in health centers, clinics, schools , workplace for the promotion of health, prevention of illness, care of the sick at home and rehabilitation (DR. Ruth B. Freeman)
Public Health
  • “Public Health is directed towards assisting every citizen to realize his birth rights and longevity.”“The science and art of preventing disease, prolonging life and efficiency through organized community effort for:
  1. The sanitation of the environment
  2. The control of communicable infections
  3. The education of the individual in personal hygiene
  4. The organization of medical and nursing services for the early diagnosis and preventive treatment of disease
  5. The development of a social machinery to ensure every one a standard of living, adequate for maintenance of health to enable every citizen to realize his birth right of health and longevity (Dr. C.E Winslow)

Mission of CHN
  • Health Promotion
  • Health Protection
  • Health Balance
  • Disease prevention
  • Social Justice

Philosophy of CHN
  • “The philosophy of CHN is based on the worth and dignity on the worth and dignity of man.”(Dr. M. Shetland)

Basic Principles of CHN
  1. The community is the patient in CHN, the family is the unit of care and there are four levels of clientele: individual, family, population group (those who share common characteristics, developmental stages and common exposure to health problems – e.g. children, elderly), and the community.
  2. In CHN, the client is considered as an ACTIVE partner NOT PASSIVE recipient of care
  3. CHN practice is affected by developments in health technology, in particular, changes in society, in general
  4. The goal of CHN is achieved through multi-sectoral efforts
  5. CHN is a part of health care system and the larger human services system.

  • Clinician, who is a health care provider, taking care of the sick people at home or in the RHU
  • Health Educator, who aims towards health promotion and illness prevention through dissemination of correct information; educating people
  • Facilitator, who establishes multi-sectoral linkages by referral system
  • Supervisor, who monitors and supervises the performance of midwives
  • Health Advocator, who speaks on behalf of the client
  • Advocator, who act on behalf of the client
  • Collaborator, who working with other health team member
*In the event that the Municipal Health Officer (MHO) is unable to perform his duties/functions or is not available, the Public Health Nurse will take charge of the MHO’s responsibilities.

Other Specific Responsibilities of a Nurse, spelled by the implementing rules and Regulations of RA 7164 (Philippine Nursing Act of 1991) includes:
  • Supervision and care of women during pregnancy, labor and puerperium
  • Performance of internal examination and delivery of babies
  • Suturing lacerations in the absence of a physician
  • Provision of first aid measures and emergency care
  • Recommending herbal and symptomatic meds…etc.
In the care of the families:
  • Provision of primary health care services
  • Developmental/Utilization of family nursing care plan in the provision of care
In the care of the communities:
  • Community organizing mobilization, community development and people empowerment
  • Case finding and epidemiological investigation
  • Program planning, implementation and evaluation
  • Influencing executive and legislative individuals or bodies concerning health and development

Responsibilities of CHN
  • be a part in developing an overall health plan, its implementation and evaluation for communities
  • provide quality nursing services to the three levels of clientele
  • maintain coordination/linkages with other health team members, NGO/government agencies in the provision of public health services
  • conduct researches relevant to CHN services to improve provision of health care
  • provide opportunities for professional growth and continuing education for staff development

Standards in CHN
  1. Theory
    • Applies theoretical concepts as basis for decisions in practice
  2. Data Collection
    • Gathers comprehensive, accurate data systematically
  3. Diagnosis
    • Analyzes collected data to determine the needs/ health problems of IFC
  4. Planning
    • At each level of prevention, develops plans that specify nursing actions unique to needs of clients
  5. Intervention
    • Guided by the plan, intervenes to promote, maintain or restore health, prevent illness and institute rehabilitation
  6. Evaluation
    • Evaluates responses of clients to interventions to note progress toward goal achievement, revise data base, diagnoses and plan
  7. Quality Assurance and Professional Development
    • Participates in peer review and other means of evaluation to assure quality of nursing practice
    • Assumes professional development
    • Contributes to development of others
  8. Interdisciplinary Collaboration
    • Collaborates with other members of the health team, professionals and community representatives in assessing, planning, implementing and evaluating programs for community health
  9. Research
    • Indulges in research to contribute to theory and practice in community health nursing

Community Health Nurse Roles and Functions


  1. Bachelor of Science in Nursing
  2. Registered Nurse of the Philippines

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

Provider of Nursing Care
  1. Provides direct nursing care to sick or disabled in the home, clinic, school, or workplace
  2. Develops the family’s capability to take care of the sick, disabled, or dependent member

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

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

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

Health Monitor
  • Detects deviation from health of individuals, families, groups, and communities through contacts/visits with them

Role Model
  • Provides good example of healthful living to the members of the community

Change Agent
  • Motivates changes in health behavior in individuals, families, groups, and communities that also include lifestyle in order to promote and maintain health

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

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

Community Assessment

Community Assessment
  • Status
  • Structure
  • Process

Types of Community Assessment
1. Community Diagnosis
  • A process by which the nurse collects data about the community in order to identify factors which may influence the deaths and illnesses of the population, to formulate a community health nursing diagnosis and develop and implement community health nursing interventions and strategies.
2 Types:

Comprehensive Community Diagnosis  Problem-Oriented Community Diagnosis
  • aims to obtain general information about the community
  • type of assessment responds to a particular need


    Preparatory Phase
  1. site selection
  2. preparation of the community
  3. statement of the objectives
  4. determine the data to be collected
  5. identify methods and instruments for data collection
  6. finalize sampling design and methods
  7. make a timetable
    Implementation Phase
  1. data collection
  2. data organization/collation
  3. data presentation
  4. data analysis
  5. identification of health problems
  6. prioritization of health problems
  7. development of a health plan
  8. validation and feedback
    Evaluation Phase

  • DEMOGRAPHY ­- study of population size, composition and spatial distribution as affected by births, deaths and migration.
  • Sources: Census – complete enumeration of the population
2 Ways of Assigning People
  1. De Jure - People were assigned to the place where assigned to the place they usually live regardless of where they are at the time of census.
  2. De Facto - People were assigned to the place where they are physically present at are at the time of census regardless, of their usual place of residence.
  1. Population size
  2. Population composition
    • Age Distribution
    • Sex Ratio
    • Population Pyramid
    • Median age - age below which 50% of the population falls and above which 50% of the population falls. The lower the median age, the younger the population (high fertility, high death rates).
    • Age – Dependency Ratio - used as an index of age-induced economic drain on human resources
    • Other characteristics:
      • occupational groups
      • economic groups
      • educational attainment
      • ethnic group
  3. Population Distribution
    • Urban-Rural - shows the proportion of people living in urban compared to the rural areas
    • Crowding Index - indicates the ease by which a communicable disease can be transmitted from 1 host to another susceptible host.
    • Population Density - determines congestion of the place

Vital Statistics
  • The application of statistical measures to vital events (births, deaths and common illnesses) that is utilized to gauge the levels of health, illness and health services of a community.
Types of Vital Statistics

Fertility Rate

    1. Crude Birth Rate

        Total # of livebirths in a given calendar year                         X 1000  Estimated population as of July 1 of the same given year

    2. General Fertility Rate

        Total # of livebirths in a given calendar year                     X 1000                  Total number of reproductive age

Mortality Rate
    1. Crude Death Rate

       _Total # of death in a given calendar year_                        X 1000   Estimated population as of July 1 of the same calendar year

    2. Infant Mortality Rate
       Total # of death below 1 yr in a given calendar year             X 1000
Estimated population as of July 1 of the same calendar year

    3. Maternal Mortality Rate
        Total # of death among all maternal cases in a given calendar year         X 1000
              Estimated population as of July 1 of the same calendar year

Morbidity Rate
1. Prevalence Rate

        Total # of new & old cases in a given calendar year                     X 100
Estimated population as of July 1 of the same calendar year

2. Incidence Rate

        Total # of new cases in a given calendar year_                            X 100      Estimated population as of July 1 of the same calendar year

3. Attack Rate
        Total # of person who are exposed to the disease                        X 100
    Estimated population as of July 1 of the same calendar year

  • the study of distribution of disease or physiologic condition among human population s and the factors affecting such distribution
  • the study of the occurrence and distribution of health conditions such as disease, death, deformities or disabilities on human populations
1. Patterns of disease occurrence
  • A situation when there is a high incidence of new cases of a specific disease in excess of the expected.
  • when the proportion of the susceptible are high compared to the proportion of the immunes
    Epidemic potential
  • an area becomes vulnerable to a disease upsurge due to causal factors such as climatic changes, ecologic changes, or socio-economic changes
  • habitual presence of a disease in a given geographic location accounting for the low number of both immunes and susceptibles.E.g. Malaria is a disease endemic at Palawan. 
  • The causative factor of the disease is constantly available or present to the area.
  • disease occurs every now and then affecting only a small number of people relative to the total population
  • intermittent
  • global occurrence of a disease
    Steps in Epidemiological Investigation:
  1. Establish fact of presence of epidemic
  2. Establish time and space relationship of the disease
  3. Relate to characteristics of the group in the community
  4. Correlate all data obtained
2. Role of the Nurse
  • Case Finding
  • Health Teaching
  • Counseling
  • Follow up visit

Communicable Diseases (Chronic)


1. Tuberculosis

  • TB is a highly infectious chronic disease that usually affects the lungs.
Causative Agent: Mycobacterium Tuberculosis

  • cough
  • afternoon fever
  • weight loss
  • night sweat
  • blood stain sputum
  • ranks sixth in the leading causes of morbidity (with 114,221 cases) in the Philippines
  • Sixth leading cause of mortality (with 28507 cases) in the Philippines.
Nursing and Medical Management
  • Ventilation systems
  • Ultraviolet lighting
  • Vaccines, such as the bacillus Calmette Guerin (BCG) vaccine
  • drug therapy
Preventing Tuberculosis
  • BCG vaccination
  • Adequate rest
  • Balanced diet
  • Fresh air
  • Adequate exercise
  • Good personal Hygiene
National Tuberculosis Control Program – key policies
  • Case finding – direct Sputum Microscopy and X-ray examination of TB symptomatics who are negative after 2 or more sputum exams
  • Treatment – shall be given free and on an ambulatory basis, except those with acute complications and emergencies
  • Direct Observed Treatment Short Course – comprehensive strategy to detect and cure TB patients.
DOTS (Direct Observed Treatment Short Course)
  • Category 1- new TB patients whose sputum is positive; seriously ill patients with severe forms of smear-negative PTB with extensive parenchymal involvement (moderately- or far advanced) and extra-pulmonary TB (meningitis, pleurisy, etc.)
    • Intensive Phase (given daily for the first 2 months) - Rifampicin + Isioniazid + pyrazinamide + ethambutol.
    • If sputum result becomes negative after 2 months, maintenance phase starts. But if sputum is still positive in 2 months, all drugs are discontinued from 2-3 days and a sputum specimen is examined for culture and drug sensitivity. The patient resumes taking the 4 drugs for another month and then another smear exam is done at the end of the 3rd month.
    • Maintenance Phase (after 3rd month, regardless of the result of the sputum exam)-INH + rifampicin daily
  • Category 2-previously-treated patients with relapses or failures.
    • Intensive Phase (daily for 3 months, month 1, 2 & 3)-Isioniazid+ rifampicin+ pyrazinamide+ ethambutol+ streptomycin for the first 2 months Streptomycin+ rifampicin pyrazinamide+ ethambutol on the 3rd month. If sputum is still positive after 3 months, the intensive phase is continued for 1 more month and then another sputum exam is done. If still positive after 4 months, intensive phase is continued for the next 5 months.
    • Maintenance Phase (daily for 5 months, month 4, 5, 6, 7,& 8)-Isionazid+ rifampicin+ ethambutol
  • Category 3 – new TB patients whose sputum is smear negative for 3 times and chest x-ray result of PTB minimal
    • Intensive Phase (daily for 2 months) – Isioniazid + rifampicin + pyrazinamide
    • Maintenance Phase (daily for the next 2 months) - Isioniazid + rifampicin

2. Leprosy
  • Sometimes known as Hansen's disease
  • is an infectious disease caused by , an aerobic, acid fast, rod-shaped mycobacterium
  • Gerhard Armauer Hansen
  • Historically, leprosy was an incurable and disfiguring disease
  • Today, leprosy is easily curable by multi-drug antibiotic therapy
Signs & Symptoms

Early stage (CLUMP)                                              Late Stage (GMISC)
Change in skin color                                        Gynocomastia
Loss in sensation                                            Madarosis(loss of eyebrows)
Ulcers that do not heal                                    Inability to close eyelids (Lagopthalmos)
Muscle weakness                                            Sinking nosebridge
Painful nerves                                                Clawing/contractures of fingers & nose

Prevalence Rate
  • Metro Manila, the prevalence rate ranged from 0.40 – 3.01 per one thousand population.
  • Dapsone, Lamprene
  • clofazimine and rifampin
  • Multi-Drug-Therapy (MDT)
  • six month course of tablets for the milder form of leprosy and two years for the more severe form
Leprosy Control Program
  • WHO Classification – basis of multi-drug therapy
    • Paucibacillary/PB – non-infectious types. 6-9 months of treatment.
    • Multibacillary/MB – infectious types. 24-30 months of treatment.
  • Multi-drug therapy – use of 2 or more drugs renders patients non-infectious a week after starting treatment
    • Patients w/ single skin lesion and a negative slit skin smear are treated w/ a single dose of ROM regimen
    • For PB leprosy cases- Rifampicin+Dapsone on Day 1 then Dapsone from Day 2-28. 6 blister packs taken monthly within a max. period of 9 mos.
  • All patients who have complied w/ MDT are considered cured and no longer regarded as a case of leprosy, even if some sequelae of leprosy remain.
  • Responsibilities of the nurse:
    • Prevention – health education, healthful living through proper nutrition, adequate rest, sleep and good personal hygiene;
    • Casefinding
    • Management and treatment – prevention of secondary injuries, handling of utensils; special shoes w/ padded soles; importance of sustained therapy, correct dosage, effects of drugs and the need for medical check-up from time to time; mental & emotional support
    • Rehabilitation-makes patients capable, active and self-respecting member of society.

Feeding and Eating Disorders of Infancy and Early Childhood


Feeding disorder of infancy or early childhood is characterized by the failure of an infant or child under six years of age to eat enough food to gain weight and grow normally over a period of one month or more. The disorder can also be characterized by the loss of a significant amount of weight over one month. The disorders of feeding and eating included in this category are persistent in nature and are not explained by underlying medical conditions. They include the following:
  1. Pica
  2. Rumination disorder
  3. Feeding disorder
Pica is an eating disorder typically defined as the persistent ingestion of nonnutritive substances for a period of at least 1 month at an age at which this behavior is developmentally inappropriate (eg, >18-24 mos). It is seen more in young children than adults. Between 10 and 32% of children ages 1 – 6 have these behaviors.
Children with Pica may eat:
  1. Animal feces
  2. Clay
  3. Dirt
  4. Hairballs
  5. Ice
  6. Paint
  7. Sand
This pattern of eating should last at least 1 month to fit the diagnosis of pica. It is not yet known what causes pica, but research indicates that it may be related to mineral deficiencies such as an iron deficiency. However, often the non-food items that an individual chooses to consume will not contain the mineral of which they are deficient, so pica is not an alternative means of obtaining nutrients.

The term rumination is derived from the Latin word ruminare, which means to chew the cud. Rumination disorder is the repeated regurgitation and re-chewing of food. With this disorder, the child brings the partially digested food up into the mouth and usually re-chews and re-swallows the food. This regurgitation appears effortless, may be preceded by a belching sensation, and typically does not involve retching or nausea.
In rumination, the regurgitant does not taste sour or bitter. To be considered a disorder, this behavior must occur in children who had previously been eating normally, and it must occur on a regular basis, usually daily, for at least one month. The child may exhibit the behavior during feeding or right after eating.
Symptoms of rumination disorder in babies and young kids include:
  1. Repeated regurgitation of food
  2. Repeated re-chewing of food
  3. Weight loss
  4. Bad breath and tooth decay
  5. Repeated stomach aches and indigestion
  6. Raw and chapped lips
This disorder is relatively uncommon and occurs more often in boys than in girls. It results in malnutrition, weight loss, and even death in about 25% of affected infants.

Feeding disorder of infancy or early childhood is characterized by persistent failure to eat adequately, which results in significant weight loss or failure to gain weight. This disorder is equally common in boys and girls. It occurs most often during the first year of life.

Electroconvulsive Therapy (ECT)


Electroconvulsive therapy or the shock treatment is used to treat depression in clients who do not respond to antidepressants or those patients who have intolerable adverse reactions at administered therapeutic doses. Despite the controversy about the therapy, it is proven to be effective for certain patients. Many depressed (major) clients, particularly those with psychotic symptoms, don’t respond to medications but do respond to ECT.

Nowadays, ECT is not only used for major depression, but also for the treatment of:
  • mania (in bipolar disorder)
  • catatonia
  • quick relief for self-destructive behavior (suicide attempts)
ECT may only be indicated for the treatment of severely depressed clients that needs fast relief. Suicidal clients may be given ECT. Giving antidepressant medication may take weeks before the full effects to occur. That is an enough time for a self-destructive client to harm himself.
Can pregnant women undergo ECT?
Pregnant clients can also undergo an electroconvulsive therapy. The treatment poses no harm or injury to the fetus. Thus, pregnant self-destructive women may undergo ECT to provide quick relief of depression and self-directed violence. This prevents a fetus from suffering if an untreated the mother tries to hurt herself while waiting for the medication to take full effect.

Contraindications and precautions
ECT stimulates a seizure episode to occur, however it does not cause a seizure disorder and patient with a seizure disorder may undergo the therapy. No absolute contraindications are noted with ECT but a few conditions have been associated with morbidity and mortality rate which includes the following:
  • recent myocardial infraction
  • stroke
  • sever hypertension
  • presence of intracerebral mass

Mechanism of action
The therapy induces a therapeutic tonic seizure (a seizure where the person loses consciousness and has convulsions) which lasts for about 15 seconds. To do this, electrodes are applied to the head of the client which will deliver an electrical impulse in the brain that causes a seizure. It is believed that the shock intensifies brain chemistry to correct the chemical imbalance in depression (decrease serotonin and norepinephrine).
Frequency of treatment
A series of about 6-15 treatments are scheduled three times a week. Six treatments are needed to observe a sustained improvement of depressive symptoms. Maximum effect or benefit is achieved in 12 to 15 treatments.

Side Effects
  • Confusion or Disorientation
  • Fatigue
  • Headache
  • Short-term memory impairment (temporary)

Nursing Interventions
Before ECT
  1. Informed consent should be signed.
  2. NPO post midnight.
  3. Remove fingernail polish.
  4. IV line initiation.
  5. Administration of short-acting anesthetic.
  6. Administration of a sedative or muscle relaxant (succinylcholine).  Atropine is also given to decrease bronchial secretions which could block the airways during seizures.
  7. Let the client void before the procedure.
During ECT
  1. Place electrodes on the client’s head on one side (unilateral) or both (bilateral).
  2. Brain monitoring through electroencephalogram (EEG).
  3. Oxygen administration with an Ambu-bag.
After ECT
  1. When the client is awake, reorient the client.
  2. Obtain vital signs.
  3. Assess client for the return of gag reflex.
  4. Allow the client to eat (with a positive gag reflex).

Eating Disorders

Eating is very important in every human being. Not only that it is necessary for survival but it is also a social activity and has been part of many occasions all around the world. For some individuals, eating is one source of their worries, anxiety and problems.
Many people are worried and apprehensive about how they look. Most of the time, they can feel self-conscious about their bodies. Amongst the population, the teens are the ones most concerned about their body figure. This can be true, especially that they are going through puberty and they undergo dramatic physical changes and face social pressures.

Eating disorders refer to a group of conditions that are described and typified by the abnormal eating habits that are involved. The food intake in this case are either insufficient or excessive that results to detriment of an individual’s physical and emotional health.

List of Common Eating Disorders
  • Anorexia Nervosa (AN). AN is a life-threatening eating disorder. It is characterized by the client’s refusal or inability to maintain a minimally normal weight and an intense fear of gaining weight. Clients with anorexia nervosa have a disturbed perception of the size and shape of their body. These people have body weight that is 85% or less of that expected for their age and height. Anorexia can cause menstruation to stop, and often leads to bone loss, loss of skin integrity, etc. It greatly stresses the heart, increasing the risk of heart attacks and related heart problems. The risk of death is greatly increased in individuals with this disease.
  • Bulimia Nervosa. Bulimia is characterized by recurrent binge eating followed by compensatory behaviors such as purging (self-induced vomiting, excessive use of laxatives/diuretics, or excessive exercise). The amount of food consumed during a binge episode is quite larger than a person would normally eat. Bulimics may also fast for a certain amount of time following a binge. Clients with bulimia binge because of strong emotions which are then followed by guilt and shame.
  • Binge Eating Disorder. This type of eating disorder is characterized by a compulsive overeating. However, unlike bulimia nervosa no compensatory behavior is noted after the binge episode.
  • Purging Disorder. Individuals who are eating normally but are recurrently purging to promote weight loss are under this category.
  • Pica. Individuals who cannot distinguish between food and non-food items have PICA. In this type of eating disorder, a person is craving to eat, chew or lick non-food items or foods containing no nutrition. These things include chalk, paper, plaster, paint chips, baking soda, starch, glue, rust, ice, coffee grounds and cigarette ashes.

Erik Erikson’s Theory of Psychosocial Development

AKA Erik Homburger Erikson

Born: June 15, 1902
Birthplace: Frankfurt am Main, Germany
Died: May 12, 1994
Location of death: Harwich, MA
Cause of death: unspecified
Religion: Jewish
Race or Ethnicity: White
Occupation: Psychologist

United States
Executive summary: Eight Stages of Childhood

Psychosocial development as articulated by Erik Erikson describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future.

Psychosocial Development Stages Summary

 Stage  Basic Conflict  Important Events  Outcome
 Infancy (birth to 18 months)  Trust vs. Mistrust  Feeding Children develop a sense of trust when caregivers provide reliabilty, care, and affection. A lack of this will lead to mistrust.
 Early Childhood (2 to 3 years)  Autonomy vs. Shame and Doubt  Toilet Training Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt.
 Preschool (3 to 5 years)  Initiative vs. Guilt  Exploration
Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt.
 School Age (6 to 11 years)  Industry vs. Inferiority  School
Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority.
 Adolescence (12 to 18 years)  Identity vs. Role Confusion  Social Relationships Teens needs to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self.
 Young Adulthood (19 to 40 years)  Intimacy vs. Isolation  Relationships Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation.
 Middle Adulthood (40 to 65 years)  Generativity vs. Stagnation  Work and Parenthood Adults need to create or nurture things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world.
 Maturity(65 to death)  Ego Integrity vs. Despair  Reflection on Life Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair.

Psychosocial Development Stages

Infancy (Birth -18 months)
  • Psychosocial Crisis: Trust vs. Mistrust
Developing trust is the first task of the ego, and it is never complete. The child will let its mother out of sight without anxiety and rage because she has become an inner certainty as well as an outer predictability. The balance of trust with mistrust depends largely on the quality of the maternal relationship.
  • Main question asked: Is my environment trustworthy or not?
  • Central Task: Receiving care
  • Positive Outcome: Trust in people and the environment
  • Ego Quality: Hope
  • Definition: Enduring belief that one can attain one’s deep and essential wishes
  • Developmental Task: Social attachment; Maturation of sensory, perceptual, and motor functions; Primitive causality.
  • Significant Relations: Maternal parent
Erikson proposed that the concept of trust versus mistrust is present throughout an individual’s entire life. Therefore if the concept is not addressed, taught and handled properly during infancy (when it is first introduced), an individual may be negatively affected and never fully immerse themselves in the world. For example, a person may hide themselves from the outside world and be unable to form healthy and long-lasting relationships with others, or even themselves. If an individual does not learn to trust themselves, others and the world they may lose the virtue of hope, which is directly linked to this concept. If a person loses their belief in hope they will struggle with overcoming hard times and failures in their lives, and may never fully recover from them. This would prevent them from learning and maturing into a fully-developed person if the concept of trust versus mistrust was improperly learned, understood and used in all aspects of their lives.

Younger Years (1 1/2 - 3 Years)
  • Psychosocial Crisis: Autonomy vs. Shame & doubt
If denied independence, the child will turn against his/her urges to manipulate and discriminate. Shame develops with the child's self-consciousness. Doubt has to do with having a front and back -- a "behind" subject to its own rules. Left over doubt may become paranoia. The sense of autonomy fostered in the child and modified as life progresses serves the preservation in economic and political life of a sense of justice.
  • Main question asked: Do I need help from others or not?

Early Childhood (3-6 Years)
  • Psychosocial Crisis: Initiative vs. Guilt
Initiative adds to autonomy the quality of undertaking, planning, and attacking a task for the sake of being active and on the move. The child is learning to master the world around them, learning basic skills and principles of physics; things fall to the ground, not up; round things roll, how to zip and tie, count and speak with ease. At this stage the child wants to begin and complete their own actions for a purpose. Guilt is a new emotion and is confusing to the child; she may feel guilty over things which are not logically guilt producing, and she will feel guilt when her initiative does not produce the desired results.
  • Main question asked: How moral am I?

Middle Childhood (7-12 Years)
  • Psychosocial Crisis: Industry vs. Inferiority
To bring a productive situation to completion is an aim which gradually supersedes the whims and wishes of play. The fundamentals of technology are developed. To lose the hope of such "industrious" association may pull the child back to the more isolated, less conscious familial rivalry of the oedipal time.
  • Main question asked: Am I good at what I do?

Adolescence (12-18 Years)
  • Psychosocial Crisis: Identity vs. Role Confusion
The adolescent is newly concerned with how they appear to others. Ego identity is the accrued confidence that the inner sameness and continuity prepared in the past are matched by the sameness and continuity of one's meaning for others, as evidenced in the promise of a career. The inability to settle on a school or occupational identity is disturbing.
  • Main question asked: "Who am I, and what is my goal in life?"

Early Adulthood (19-34 years)
  • Psychosocial Crisis: Intimacy vs. Isolation
Body and ego must be masters of organ modes and of the other nuclear conflicts in order to face the fear of ego loss in situations which call for self-abandon. The avoidance of these experiences leads to openness and self-absorption.

Middle Adulthood (35-60 Years)
  • Psychosocial Crisis: Generativity vs. Stagnation
Generativity is the concern of establishing and guiding the next generation. Simply having or wanting children doesn't achieve generativity. Socially-valued work and disciplines are also expressions of generativity.
  • Main question asked: Will I ever accomplish anything useful?...

Later Adulthood (60 years - Death)
  • Psychosocial Crisis: Ego integrity vs. despair
Ego integrity is the ego's accumulated assurance of its capacity for order and meaning. Despair is signified by a fear of one's own death, as well as the loss of self-sufficiency, and of loved partners and friends.

Developmental Theories

Theorists consider that emotional, social, cognitive and moral skills develop in stages.

  1. Psychosocial – Erik Erikson’s theory of psychosocial development is most widely used. At each stage, children confront a crisis that requires the integration of personal needs and skills with social and cultural expectations. Each stage has two possible components, favorable and unfavorable.
  2. Psychosexual – Sigmund Freud considered sexual instincts to be significant in the development of personality. At each stage, regions of the body assume prominent psychologic significance as source of pleasure.
  3. Cognitive – Jean Piaget proposed four major stages of development for logical thinking. Each stage arises from and builds on the previous stage in an orderly fashion.
  4. Moral – Lawrence Kohlberg’s theory of moral development is based on cognitive development and consists of three major levels, each containing two stages.
(birth to 1 year)
Trust vs. mistrust
Sensorimotor (birth to 2 years)
(1-3 years old)
Autonomy vs. same and doubt
Sensorimotor (1-2 years); preoperational (preconceptual) (2-4 years)
(3-6 years old)
Initiative vs. guilt
Preoperational (preconceptual) (2-4 years); preoperational (intuitive) (4-7 years)
School Age
(6-12 years)
Industry vs. inferiority
Concrete operations
(7-11 years)
(12-18 years)
Identity vs. role diffusion (confusion)
Formal operations
(11-15 years)

Defense Mechanisms

People use defense, or coping, mechanisms to relieve anxiety. The definitions below will help you determine whether your patient is using one or more of these mechanisms.
  1. 1. Acting Out
    • Acting out refers to repeating certain actions to ward off anxiety without weighing the possible consequences of those action.
    • Example: A husband gets angry with his wife and starts staying at work later.
  2. Compensation
    • Also called substitution.
    • It involves trying to make up for feelings of inadequacy or frustration in one area by excelling or overindulging in another.
    • Example: An adolescent takes up jogging because he failed to make the swimming team.
  3. Denial
    • A person in denial protects himself from reality – especially the unpleasant aspects of life – by refusing to perceive, acknowledge, or face it.
    • Example: A woman newly diagnosed with end-stage-cancer says, “I’ll be okay, it’s not a big deal”.
  4. Displacement
    • In displacement, the person redirects his impulses (commonly anger) from the real target (because that target is too dangerous) to a safer but innocent person.
    • Example: A patient yells at a nurse after becoming angry at his mother for not calling him.
  5. Fantasy
    • Fantasy refers to creation of unrealistic or improbable images as a way of escaping from daily pressures and responsibilities or to relieve boredom.
    • Example: A person may daydream excessively, watch TV for hours on end, or imagine being highly successful when he feels unsuccessful. Engaging in such activities makes him feel better for a brief period.
  6. Identification
    • In identification, the person unconsciously adopts the personality characteristics, attitudes, values, and behavior of someone else (such as a hero he emulates and admires) as a way to allay anxiety. He may identify with a group to be more accepted by them.
    • Example: An adolescent girl begins to dress and act like her favorite pop star.
  7. Intellectualization
    • Also called isolation.
    • Intellectualization refers to hiding one’s emotional responses or problems under a fa├žade of big words and pretending there’s no problem.
    • Example: After failing to obtain a job promotion, a worker explains that the position failed to meet his expectations for climbing the corporate ladder.
  8. Introjection
    • A person introjects when he adopts someone else’s values and standards without exploring whether they fit him.
    • Example: An individual begins to follow a strict vegetarian diet for no apparent reason.
  9. Projection
    • In projection, the person attributes to others his own unacceptable thoughts, feelings, and impulses.
    • Example: A student who fails a test blames his parents for having the television on too loud when he was trying to study.
  10. Rationalization
    • Rationalization occurs when a person substitutes acceptable reasons for the real or actual reasons that are motivating his behavior.
    • The rationalizing patient makes excuses for shortcomings and avoids self-condemnation, displacements, and criticisms.
    • Example: An individual states that she didn’t win the race because she hadn’t gotten a good night’s sleep.
  11. Reaction Formation
    • In reaction formation, the person behaves the opposite of the way he feels.
    • Example: Love turns to hate and hate into love.
  12. Regression
    • Under stress, a person may regress by returning to the behaviors he used in an earlier, more comfortable time in his life.
    • Example: A previously toilet-trained preschool child begins to wet his bed every night after his baby brother is born.
  13. Repression
    • Repression refers to unconsciously blocking out painful or unacceptable thoughts and feelings, leaving them to operate in the subconscious.
    • Example: A woman who was sexually abused as a young child can’t remember the abuse but experiences uneasy feelings when she goes near the place where the abuse occurred.
  14. Sublimation
    • In sublimation, a person transforms unacceptable needs in acceptable ambitions and actions.
    • Example: He may channel his sex drive into his sports or hobbies.
  15. Undoing
    • In undoing, the person tries to undo the harm he feels he has done to others.
    • Example: A patient who says something bad about a friend may try to undo the harm by saying nice things about her or by being nice to her and apologizing.