PRACTICAL – 4

CONDUCTS NUTRITIONAL SURVEY AND ASSISTS

NUTRITIONAL PROGRAMMES:

Nutrition Surveys:

Concept:
The concept of Nutritional Surveillance is derived from disease
surveillance.

It has been defined as “keeping watch over nutrition in order to make

decisions that will lead to improvement in nutrition in population”.

Objectives:
a) To aid long – term planning in health and development
b) To provide input for programme management and evaluation and
c) To give timely warning and intervention to prevent short – term ford
consumption crisis.

Nutritional Surveillance and Growth Monitoring:

Nutritional surveillance should not be confused with growth monitoring.

Comparison of Growth Monitoring and Nutritional Surveillance:

Factors Growth Monitoring Nutritional Assessment
Strategy Prevention of normal Detection of under
growth nutrition
 Approach  Educational –  Diagnostic
motivational interventional
 Enrolment
 Age  All infants  Representative
sample
 Number
 Start before 6 months
 Weigher & continue monthly  Representative
ages at longer
 Recorder
 Small groups, intervals
 Weight card preferably between
10 and 20  Any size group 50
 Nutritional
– 100 most
emphasis
 Mothers guided by efficient
 Response
worker
 Response time  Trained worker
  Referral
 Simple emphasis  Precise, nutritional
growth status

 Maintaining good  Detect malnutrition

nutrition
 Nutritional
 Early home rehabilitation often
intervention based on with supplements
local knowledge
 Brief, resumption of  Long, regain of
normal growth good nutrition in
community
 Health system for
check up and  Malnutrition
possible brief food rehabilitation often
supplements in special center

Growth monitoring is oriented to the individual child, and is dynamic

measure of its health from month to month. It focuses on normal nutrition and
the means to promote continued growth and good health. it requires enrolment
of the infant at an early stage, preferably before 6 months. Regular monthly
participation is crucial to detect early onset of growth faltering.

Nutritional surveillance, on the other hand, can be carried out on a

representative sample of children in the community. It gives a reliable idea of the
overall nutritional condition of the village.

Nutritional Status Indicators:

Indicators that are considered useful for the surveillance of nutritional
status are given below:

Concise List of Indicators of Nutritional Status:

Phenomenon Indicator

Maternal nutrition Birth weight, proportion being breast

Infant & preschool child nutrition fed and proportion on weaning foods,
by age in months, mortality rates in
children aged 1,2,3 and 4 years, with
emphasis on 2 years old.

If age known: height for age

Weight for age
 If age unknown: weight for height
Aim circumference
Clinical signs &
syndromes

School child nutrition Height for age and weight for height at
7 years or school admission
Clinical signs

There is an increasing trend to use nutritional indicators to measure

quality of life, specially as a means of evaluating both development programmes
and health programmes. Many of the indicators used in nutritional surveillance
are the same as the socioeconomic and health status indicators recommended
for monitoring progress in health.

COMMUNITY NUTRITION:
Food means not only proteins, fats, minerals, vitamins and other nutrients
– but much more; it is part of security and civilization. Nations and civilizations
are linked together not only by ideas, but also by bread. Hunger and malnutrition
are problems everywhere and have harassed mankind and threatened peace
throughout history. It is no wonder that the growing incidence of hunger and
malnutrition should have come to the forefront of international concern.

Problem of malnutrition:
Definition: “A pathological state resulting from a relative or absolute deficiency or
excess of one or more essential nutrients”.

It is comprises four forms:

1) Under nutrition
2) Over nutrition
3) Imbalance &
4) Specific deficiency

1) Under Nutrition: This is the condition, which results when insufficient

food is eaten over an extended period of time. In extreme cases, it is
called starvation.

2) Over Nutrition: This is the pathological state resulting from the

consumption of excessive quantity of food ever an extended period of
time. The high incidence of obesity, atheroma and diabetes in western
societies is attributed to over nutrition.
 3) Imbalance: It is a pathological state resulting from a disproportion among
essential nutrients with or without the absolute deficiency of any nutrient.

4) Specific Deficiency: It is the pathological state resulting from a relative or

absolute lack of an individual nutrient.

The effects of malnutrition of the community are both direct and indirect.
The direct effects are the occurrence of frank sub clinical nutrition deficiency
disease such as Kwashiorkor, marasmus, vitamin and mineral deficiency
diseases.

The indirect effects are high morbidity and mortality among young
children, lower vitality of the people leading to lowered productivity and reduced
life expectancy. Malnutrition predispose to infection and infection to malnutrition;
and the morbidity arising therefore as a result of complications from such
infectious disease as tuberculosis and gastro enteritis is not inconsiderable. The
high rate of maternal morality, stillbirth and low – birth weight are all associated
with malnutrition.

In the more developed countries of the word nutritional problems are

same what different over nutrition is encountered much more frequently than
under nutrition. The health hazards from over nutrition are a high incidence of
obesity, diabetes, hypertension, cardiovascular and renal diseases, disorders of
liver and gall bladder. From this brief review, it is obvious that the consequences
of malnutrition are ominous.

ECOLOGY OF MALNUTRITION:
Malnutrition is a man made disease. It is a disease of human societies. It
begins quite commonly in the womb and ends in the grave.

Jelliffe (1996) listed the ecological factors related to malnutrition as

follows:

1) Conditioning influences
2) Cultural influences
3) Socio – economic factors
4) Food production &
5) Health and other services

Conditioning influences:
 Infectious diseases are an important conditioning factor responsible for
malnutrition, particularly in small children. Diarrhoea, intestinal parasites,
measles, whooping cough, malaria, tuberculosis all contribute to malnutrition.

In fact it is vicious circle – infection contributing to malnutrition, and

malnutrition causing an other wise minor childhood ailments to become killers.

Cultural influences:
Lack of food is not the only cause of malnutrition. Too often there is
starvation in the midst of plenty. People choose poor diets when good ones are
available of cultural influences, which vary widely from country to country, and
from region to region.

These may be stated as follows:

a) Food habits, customs, beliefs, traditions and attitudes

b) Religion
c) Food fads
d) Cooking practices
e) Child rearing practices

Socio – Economic Factors:

Increased food production should lead to increased food consumption.
But increased food production will not solve the basic problem of hunger and
malnutrition in much of the developing word scarcity of food, as a factor
responsible for malnutrition, may be true at the family level; but it is not true on a
global basis, normally it true for most of the countries where malnutrition is still a
serious problem. it is a problem of uneven distribution between the countries
and within the countries. It is said that there will be very little malnutrition in
India. Today, if all the food available can be equitably distributed in accordance
with physiological needs.

Health & Other Services:

The health sector can, if properly organized and given adequate
resources can combat malnutrition. Some of the premedical actions that can be
taken up by the health sector are,

1) Nutritional surveillance
2) Nutritional rehabilitation
3) Nutritional supplementation
4) Nutritional health education
Preventive & Social Measure:
 Since malnutrition is the outcome of several factors, the problem can be
solved only by taking action simultaneously at various level – family, community,
national and international levels.

Action At The Family Level:

Preventive measures:
The principal target of nutritional improvement in the community is the
family; the housewife is the “manager” to the consumption of foods in the family.
Both husband and wife need to be educated on the selection of right kinds of
local foods and in the planning of nutritionally adequate diet with in the limits of
their purchasing power. Harmful food taboos and dietary prejudices can be
identified and corrected.

The promotion of breast-feeding and improvement in the infant and child

feeding practices are the two areas where nutrition education can have a
considerable effect.

Social Measures:
Action is also needed to counter misleading commercial advertising with
regard to baby foods. Shortage of protective foods can be met to some extent
by planning a kitchen garden or keeping poultry.

Action at the Community Level:

Action at the community level should commence with the analysis of the
nutrition problem in terms of,

a) The extent, distribution and types of nutritional deficiencies

b) The population groups at risk and
c) The dietary and non – dietary factors contributing to malnutrition

Having obtained information, about the magnitude of the nutrition problem

in the community, the next important step will be plan realistic and feasible
approaches.

In India, is usual to start with supplementary feeding programmes, midday

school meals, vitamin A prophylaxis programme, but these will provide only
palliative, partial or temporary solutions.

The real permanent solutions can only come from fundamental measures
that will correct the basic causes of malnutrition. This implies, first of all,
increasing the availability of foods both in quantity and qualitative, but – much
more important – making sure that the people suffering or at risk of malnutrition
can obtain these foods.
Actions at the National Level:
The burden of improving the nutritional status of the people, by any large,
is the responsibility of the state.

Some of the strategies and approaches undertaken at the national level in

India are,

1) Rural development
2) Increasing agricultural production
3) Stabilization of population
4) Nutrition intervention programmes
5) Nutrition – related health activities

The FAO / WHO committee on Nutrition (1976) stressed that food and
nutrition programme planning must be an integral part of the overall socio –
economic development.

Action at the International Level:

Food and nutrition are global problem, just as health and sickness; and
both are interrelated. International cooperation can play an important role in
nutigating the effects of acute emergencies caused by floods and droughts.

Several international agencies such as the FAO, UNICEF, WHO, World

Bank, UNDP and CARE are working in close collaboration helping the national
governments in different parts of the world in their battle against malnutrition.

COMMUNITY NUTRITION PROGRAMMES:

The government of India has initiated several large-scale supplementary
feeding programmes, and programmes aimed at overcoming specific deficiency
diseases through various ministries to combat malnutrition.

1. Vitamin A prophylaxis programme:

This is to control of blindness is to administer a single massive dose of an
oily preparation of vitamin A containing 2,00,000 IU (110 mg of ratinol palmitate)
orally to all preschool children in the community every 6 months through
peripheral health workers.

This programme was launched by the ministry of health and family welfare
in 1970 on the basis of technology developed at the National Institute of Nutrition
at Hyderabad.

2. Prophylaxis against nutritional anemia:

 The programme consists of distribution of iron and folic acid tablets to
pregnant women and young children, mothers and child health (MCH), centers in
urban areas, primary health centers in rural areas and ICPS projects are
engaged in the implementation of this programme.

3. Control of Iodine Deficiency Disorders:

This programme was launched by the Government of India in 1962, in the
conventional goiter belt in the Himalayan region with the objective of
identification of the goiter endemic areas to supply iodized salt in the place of
common salt and to assess the impact of goiter control measures over a period
of time.

4. Special Nutrition Programme:

This programme was started in 1970 for the nutritional benefits of children
below 6 years of age, pregnant and nursing mothers and is in operation in urban
(areas) slums tribal areas, and backward rural areas. The main aim of the
special nutrition programme is to improve the nutritional status of the target
groups. This programme is gradually being merged in to the ICDS programme.

5. Balwadi Nutritional Programme:

This programme was started in 1970 for the benefit of children in the age
group 3 – 6 years in rural areas. It is under the overall change of the department
of social welfare. The programme is implemented through Balwadis, which also
provide primary education to these children. The food supplement provides 300
kcal and 10 gms of protein / child / day.

6. ICDS Programme:
This programme started in 1978 in India. There is a strong nutrition
component in this programme in the form of supplementary nutrition, vitamin A
prophylaxis and iron folic and distribution. The beneficiaries are preschool
children below 6 years, pregnant and lactating mothers. the states and union
territories are encouraged to undertake additional ICDS projects on the central
pattern to cover more beneficiaries.

The Anganwadi workers deliver the services not work of mahila mandali
has been built up in ICDS project areas to help Anganwadi workers in providing
health & nutrition services.

7. Mid – Day – Meal – Programme:

MDMP is also known, as school lunch programme has been operation
since 1961 throughout the country. The major objective of the programme is to
attract more children for admission to schools and retain so that literacy
improvement of children could be brought about.

Principles of MDMP:
a) A meal should be supplement not about substitute to the diet

b) The meal should supply at least one third of the total energy requirement,
and half of the protein need

c) The cost of the meal should be reasonably low

d) The meal should be such that it can be easily prepared in schools; no

complicated cooking process should be involved.

e) As for as possible locally available foods should be used; thus will reduce
the cost of the meal and

f) The menu should be frequently changed to avoid monotony

 PRACTICAL – 6
Demonstrate different nursing procedures by using bag
technique:

1) Hand washing
2) Urine sugar test

Area: Gavipuram, Guttahalli (Urban slum)

Date: 10/02/06
Time: 11 am to 11.30 am
Procedures: Hand washing and urine sugar test

Head of Family : Mr. Subramani

Age : 65 years
Purpose : To know whether he is suffering with diabetes
Place : Home
Supervised by : Madam Chitra R.

Aim: To teach the family the importance of hand washing and how to prevent
cross infections.

Objectives:

1) Explains the family members the importance of hand washing

2) Explains the family members how to prevent cross infection
3) Explains the family members how the micro – organisms enter through
contaminated fingers
4) Demonstrate family members how to test the urine sugar at home once in
a week
 5) Explains the family members the importance of checking urine sugar
every now and then

Hand washing:
Purpose:
 The importance of hand washing is to prevent, control and transmission of
pathogenic organisms from one person to other persons.

 For each procedure, before starting and after completing the procedure,
even in the middle of the procedure anything wants to take from the
nursing bag during procedure hand washing is very important to prevent
the cross infection.

Bag Technique:
Introduction:
The major aim of health care services in the home is to help people with
their health problems and work with them towards keeping the family healthy.
When performing home visits the community health nurse should carry the
Community Health Nursing bag.

The Community Health Nursing Bag:

The purpose of bag is to carry out nursing procedures in the home. The
nursing bag is a vehicle for carrying the materials and equipment needed during
home visit to attend family health care needs. The bag should be made of strong
but lightweight material to carry from house to house while during field visits.

Bag Technique Procedures:

1) To keep the bag or clean as possible to avoid cross infection

2) Place the bag on a clean surface or piece of clean newspaper or a plastic

sheet

3) Prepare a clean surface or piece of newspaper for placing the equipment

to be used

4) Remove the soup, towel and nailbrush and wash the hands well

5) Open the bag and remove only the needed articles and close the bag

6) Carry out the procedure, placing soiled swabs inside a news paper bag for
disposal by burning or any other suitable method

7) Wash and boil used utensils of possible or collect them and to take back
to health center for disinfection
 8) Wash hands, open the bag and replace the clean articles, close the bag
and return the soap, towel nail brush to the pocket

9) Take the bag and put it on the shoulder and fold the used paper or plastic
sheet with exposed side, innermost and keep it in the outside pocket of
the bag

10)Write a brief note of the observation procedure done or instruction given in

the card
11) Check the bag daily, washing hands before opening it and make
necessary replacement

Articles required for hand washing:

1) Soap in a soap dish (in nursing bag)
2) Water (tap or container of the home)
3) Nail brush
4) Hand towel
5) Basin or bucket to receive water
6) A mug to pouring water

Procedure:
1) Kept the bag on the newspaper and removed watch kept near to the bag

 Opened the bag took soap dish with soap, hand towel, nailbrush and
small piece of paper to make paper bag to discard the soiled swabs.
Placed hand towel on the newspaper.

 Asked the family members to pour water and moistened soap and hands.

 Applied soap to the hands and hold hands down to prevent splashing

 Rubbed the hands and fingers with soap until good lather comes and
used nailbrush for the nails to remove the dirt from the nails.

 Asked the family members to pour water to remove the soap from the
hands and fingers.

Hold the hands up to prevent water from coming back down the arms to
the hands:

 Dry the hands using hand towel and place it on the clean area
  After finished procedure again washed hands and replaced soap in soap
dish and hand towel in bag and closed the bag

 Discarded the paper on which soap dish was kept

 Explained the family members the importance of hand washing

Procedure – urine sugar test:

Articles required in the nursing bag:
1) Test tube holder or twisted paper
2) Spirit lamp with spirit
3) Match box
4) Benedicts solution (qualitative)
5) A bottle for collection of urine – 1
6) Test tube – 1
7) Medicine dropper – 1
8) Ounce glace or 5 CC syringe

Procedure:
After washed hands removed the articles from the bag necessary for the
urine sugar test and placed in on the clean newspaper and closed the bag.

 Collected the urine from the Mr. Subramani (H/F)

 Took 5 ml of benedicts solution in the test tube and heated the solution
with the help of spirit lamp

 Holed the test tube with test tube holder

 Heated the solution on the bottom of the test tube

 After boiled the solution kept the solution for few second and checked any
colour changes in the solution

 Then added 8 drops of urine again boiled the solution

 Then allow the solution to cool for 5 minutes

 The colour of urine is blue

 Explained the family members how to do urine sugar test at home

Blue - No sugar ( - )
Green - Trace of sugar (+)
Yellow - Slight amount of sugar (++)
Orange - Moderate amount of sugar (+++)
Brick red - Excessive amount of sugar (++++)

CONCLUSION:

The community health nursing bag its contents and purposes of using bag
is very importance to prevent cross infection and how to protect the bag from
dust, flies and keep the bay always clean and use any time.

 With this bag the nurse can carry out many nursing procedures in
the home including home delivery at home.

Self Evaluation:

The family members well cooperated and they were very interested to
know all these things. It was helped me to teach the family members the
importance of hand washing and the purpose of during urine sugar test in the
home.