Community

Health Nursing I
Course Description

Community Health Nursing emphasizes care of the client/client system

utilizing community health services in a variety of home agency
settings. The students are introduced to professional aspects of nursing
in the community including historical developments and nursing
practice, legal and ethical issues, strategies and tools promoting health,
nursing care of at-risk aggregates across the life span, and issues and
concerns in community health nursing. Community health concepts
and skills for promoting individual, family, and community wellness are
stressed.

Dear students
This module is dedicated to the students of Southern Luzon State
University at College of Allied Medicine in support to distant learning
during this time of pandemic, we hope that the students who read this
book will prepare you to shape your future in health care.

Southern Luzon State

University Brgy Kulapi,
Lucban Quezon

vcasin@slsu.edu.ph

0998-9505875

NCM 104 COMMUNITY HEALTH NURSING| Prepared by: VIRGINIA G. CASIN, RN, MSN 2021-2022
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NCM 104 COMMUNITY HEALTH NURSING| Prepared by: VIRGINIA G. CASIN, RN, MSN 2021-2022
 MODULE 1: OVERVIEW OF PUBLIC HEALTH
NURSING IN THE PHILIPPINES

This module will give an idea about public health nursing in the Philippines, as to the definition of public
health, community health, public health nursing, and community health nursing. Furthermore, it will
explain the standard and evolution of public health nursing in the Philippines, and the roles and functions
of the community health nurse. The nurse’s aim is to improve the health status of the community in
general – thus, nurses have several roles and functions in order to achieve healthy community. In a
nutshell, the learners will be able to understand the different roles and functions of community health
nurse.

At the end of this module, the student will be able to:

● Define public health, community health, public health nursing, and community health nursing.
● Enumerate the different standard of Public Health Nursing in the Philippines
● Discuss the evolution of Public Health nursing in the Philippines
● Identify the different roles and functions of community health nurse

PUBLIC HEALTH

C.E. Winslow defined public health as the science and art of preventing disease, prolonging life and
promoting health and efficiency through organized community effort for:

1. Sanitation of the environment

2. Control of communicable infections
3. Education of the individual in personal hygiene
4. Organization of medical and nursing services for the early diagnosis and preventive treatment of
disease
5. Development of the social machinery to ensure everyone a standard of living adequate for the
maintenance of health, so organizing these benefits as to enable every citizen to realize his
birthright of health and longevity.

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COMMUNITY HEALTH

Extend the realm of public health to include organized health efforts at the community level through both
government and private efforts

PUBLIC HEALTH NURSING

WHO defined as a special field of nursing that combines the skills of nursing public health and some
phases of social assistance and functions as part of the total public health program for the promotion of
health, the improvement of the conditions in the social and physical environment, rehabilitation of illness,
and disability.

Freeman defined as a field of professional practice in nursing and in public health in which technical
nursing, interpersonal, analytical, and organizational skills are applied to problems of health as they affect
the community.

It is the practice of promoting and protecting the health of populations using knowledge from nursing,
social, and public health sciences (American Public Health Association, 1996).

It is a population focused with the goals of promoting health and preventing diseases and disability for all
people through the creation of conditions in which people can be healthy (ANA, 2007).

COMMUNITY HEALTH NURSING

Ruth B. Freeman defined as a service rendered by a professional nurse with communities, groups, families,
individuals at home, in a health centers, in clinics, in schools, in place of work – for the promotion of
health, prevention of illness, care of the sick at home and rehabilitation.

American Nurses Association (ANA) defined as the synthesis of nursing practice and public health practice
applied to promoting and preserving the health of population.

PUBLIC HEALTH NURSE (PHN)

Refer to the nurses in the local/national health departments of public school whether their official
position title is Public Health Nurse, or nurse, or school nurse.

PHILOSOPHY

According to Dr. Margaret Shetland, the philosophy of Community Health Nursing is based on the worth
and dignity of man.

CONCEPTS

Concepts basic to nursing are used in working with the clients: individuals, families, groups, and
communities. Some concepts of community health nursing are:

1. The primary focus of community health nursing practice is on health promotion

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 2. Community Health Nursing practice is extended to
benefit not only the individual but the whole family
and community
3. Community health nurse are generalists in
terms of their practice through life’s continuum – its full range of health problems and needs.
4. Contact with the client and/or the family may continue over a long period of time which includes
all ages and all types of health care.
5. The nature of community health nursing practice requires that current knowledge derived from
the biological and social sciences, ecology, clinical nursing, and community health organizations be
utilized.
6. The dynamic process of assessing, planning, implementing, and intervening, provide periodic
measurement of progress, evaluation and a continuum of the cycle until the termination of
nursing is implicit in the practice of community health nursing.

GOAL

● The ultimate goal of community health services is to raise the level of health of the citizenry
● The goal of community health nursing is to help communities and families to cope with the
discontinuities in health and threats in such a way as to maximize their potential for high level
wellness, as well as to promote reciprocally supportive relationship between people and their
physical and social environment.

OBJECTIVES

1. To participate in the development of an overall health plan for the community and its
implementation and evaluation
2. To provide quality nursing services to individuals, families, and communities, utilizing as basis, the
standards set for community health nursing practice.
3. To coordinate nursing services with various members of the health team, community leaders, and
significant others, government and non-government agencies/organizations, in achieving the aims
of public health services within the community.
4. To participate in and/or conduct researches relevant to community health and community health
nursing services and disseminate their results for improvements of health care.
5. To provide community health nursing personnel with opportunities for continuing education and
professional growth through staff development.

PRINCIPLES

The following principles of Community Health Nursing were adapted from those formulated by Mary S.
Gardner and by Leahy, Cobb, and Jones.

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 1. Community Health Nursing is based on recognized
needs of communities, families, groups, and
individuals.
2. The community health nurse must understand
fully the objectives and policies of the agency she represents.
3. In Community Health Nursing, the family is the basic unit of service.
4. Community Health Nursing must be available to all regardless of race, creed, and socio-economic
status.
5. Health teaching is a primary responsibility of the community health nurse.
6. The community health nurse works as a member of the health team.
7. There must be provision for periodic evaluation of community health nursing services.
8. Opportunities for continuing staff education program for nurses must be provided the Community
Health Nursing Agency. The community health nurse also has a responsibility for his/her own
professional growth.
9. The community health nurse makes use of available community health resources.
10. The community health nurse utilizes the already existing active organized groups in the
community.
11. There must be provision for educative supervision in Community Health Nursing.
12. There should be accurate recording and reporting in Community Health Nursing.

STANDARDS OF PUBLIC NURSING PRACTICE

Standards of Care
Standard 1. Assessment The public health nurse collects comprehensive data pertinent to the
health status populations
Standard 2. Population The public health nurse identifies expected outcomes for a plan that is
diagnosis and priorities based on population diagnoses and priorities
Standard 3. Outcome The public health nurse identifies expected outcomes for a plan that is
identification based on population diagnoses and priorities
Standard 4. Planning The public health nurse develops a plan that reflects best practices by
identifying strategies, action plans, and alternatives to attain expected
outcomes
Standard 5. Implementation The public health nurse implements the identified plan by partnering
with others
1. Coordination Coordinates programs, services, and other activities to implement the
identified plan
2. Health Education and Employs multiple strategies to promote health, prevent disease,
Health Promotion ensure a safe plan
3. Consultation Provides consultation to various community groups and officials to
facilitate the implementation of programs and services
4. Regulatory activities Identifies, interprets, and implements public health laws, regulations,
and policies
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Standard 6. Evaluation The public health nurse evaluates the health
status of the population
Standard of professional performance
Standard 7. Quality of The public health nurse systematically
practice enhances the quality and effectiveness of nursing practice
Standard 8. Education The public health nurse attains knowledge and competency that
reflects current nursing and public health practice
Standard 9. Professional The public health nurse evaluates one’s own nursing practice in
practice evaluation relation to professional practice standards and guidelines, relevant
statuses, rules and regulations
Standard 10. Collegiality and The public health nurse collaborates with the representatives of the
professional relationships population, organizations, and health and human services
professionals, and contributes to the professional development of
peers, students, colleagues, and others
Standard 11. Collaboration The public health nurse collaborates with the representatives of the
population, organizations, and health and human services
professionals in providing for and promoting the health of the
population
Standard 12. Ethics The public health nurse integrates ethical provisions in all areas of
practice
Standard 13. Research The public health nurse integrates research findings in practice
Standard 14. Resource The public health nurse considers factors related to safety,
Utilization population effectiveness, cost, and impact on practice and in the planning and
delivery of nursing and public health programs, policies, and services.
Standard 15. Leadership The public health nurse provides leadership on nursing and public
health

EVOLUTION OF PUBLIC HEALTH NURSING IN THE PHILIPPINES

The history of public health nursing in the Philippines is embedded in the history of Department of Health,
which was first established as Department of Public Works Education and Hygiene in 1989.

1912

Fajardo Act. (Act No. 2156) created Sanitary Divisions. The president of the sanitary division
(forerunners of the present Municipal Health Officers) took charge of two or three municipalities.
Where there were no physicians available, male nurses were assigned to perform the duties of the
president, Sanitary Division.

1914

School Nursing was rendered by a nurse employed by the Bureau of Health in Tacloban, Leyte.

In the same year, Recognization Act No. 2462 created the Office of General Inspection.

Two graduate Filipino nurses, Mrs. Casilang Eustaquio and Mrs. Matilde Azurin were employed
for Maternal and Child Health Sanitation in Manila under an American nurse, Mrs. G. D. Schudder.

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1916-1918

Miss Perlita Clark took charge of the public health

nursing work staff was composed.

● 1 American nurse supervisor

● 1 American dietician
● 36 Filipino nurses working in the provinces
● 1 nurse and 1 dietician assigned in two sanitary department

1917

Four graduate nurses paid by the City of Manila were employed to work in the City Schools

1918

The office of Miss Clark was abolished due to lack of funds

1919

The first Filipino nurse supervisor under the Bureau of Health, Miss Carmen del Rosario was
appointed. She succeeded Miss Madel Dabbs. There was gradual increase of public health nurses
and expansion of services.

1923

Two government schools of Nursing were established:

1. Zamboanga General Hospital School of Nursing in Mindanao

2. Baguio General Hospital in Northern Luzon

July 1, 1926

Miss Carmen Leogardo resigned, and Miss Genara S. Manongdo, a ranking supervisor of the
American Red Cross - Philippine Chapter, was appointed as her replacement.

1928

The first convention of nurses was held followed by yearly convention until the advent of World
War II. Pre-service training was initiated as a pre-requisite for appointment.

1933

Reorganization Act No. 4007 transferred the division of Maternal and Child Health of the Office of
Public Welfare Commission to the Bureau of Health.

October 7, 1947
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The newly created Section of Puericulture
Center of the Bureau of Hospitals had Mrs. Teresa
Malgapo as Chief.

1948

The first training center of the Bureau of Health was organized in cooperation with Pasay City
Health Department. Physicians and nurses undergoing pre-service training in public health nursing
as well as nursing students on affiliation were assigned to the above training center.

1953

Philippine Congress approved Republic Act No. 1082, or the Rural Health Law. It created the 81
Rural Health Units. Each unit had a physician, a public health nurse, midwife, a sanitary inspector,
and a clerk driver.

1957

Republic Act 1891 was approved amending Sections 2, 3, 4, and 8 of R.A. 1082 “Strengthening
Health and Dental Services in the Rural Areas and Providing Funds”

1967

In the merged Bureau of Disease Control and Mental Health, Mrs. Zenaida Panlilio-Nince was
appointed as Nursing Program Supervisor and served as consultant on the nursing aspects of the 5
special diseases: TB, Leprosy, Venereal Disease, Cancer, Filariasis. She was involved in program
planning, monitoring, evaluation, and research.

1987

Executive Order No. 119 reorganized the Department of Health and created several offices and
services within the Department of Health

1990-1992

Aside from the usual services for mother and children, these nurses were involved in the following
programs: expanded program on immunization, Control of Diarrhea, and control of acute
respiratory infections.

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ROLES AND FUNCTIONS OF PUBLIC HEALTH NURSE

I. PLANNER / PROGRAMMER
● Identifies needs, priorities, and problems of individual, families, and community
● Formulates nursing competed of health plan. In doctorless area, he/she is responsible for
the formulation of the municipal health plan

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 ● Interprets and implements the nursing plan,
program policies, memoranda, and circular
for the concerned
staff/personnel.
● Provides technical assistance to rural health midwives in health matter like target setting,
etc.
II. PROVIDER OF NURSING CARE
● An inherent function of the nurse; cares for individuals, families, and communities toward
health promotion and disease prevention
● Provides direct nursing care to the sick, disabled, in the home, clinic, school, or place of
work.
● Develops the family’s capability to take care of the sick, disabled, or dependent member
● Provides continuity of patient care
III. MANAGER / SUPERVISOR
● Formulates individual, family, group, and community-centered care plan
● Interprets and implements program policies, memoranda, and circulars
● Organizes work force, resources, equipment and supplies, and delivery of health care at
local levels
● Requisitions, allocates, distributes materials (medicine and medical supplies, records and
reports equipment)
● Provides technical and administrative support to rural health midwife (RHM)
● Conducts regular supervisory visits and meeting to different RHMs and gives feedback on
accomplishment/performance
● Organizing nursing service of the local health agency, the PHN responsible for the delivery
of the services provided by the program to the target clientele.
● PHN is a supervisor of the midwives and other auxiliary health workers, whom formulates
a supervisory plan and conducts supervisory to implement the plan.
IV. COMMUNITY ORGANIZER
● Responsible for motivating and enhancing community participation in terms of planning,
organizing, and implementing, and evaluating health programs/services.
● Initiates and participates in community development activities
V. COORDINATOR OF SERVICES
● Coordinates with individuals, families, and groups for health and related health services
provided by various members of health team and Government
● Brings activities or group activities systematically into proper relation or harmony with
each other
● Coordinates nursing programs as environmental sanitation, health education, dental
health, and mental health

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VI. TRAINER / HEALTH EDUCATOR / COUNSELOR
● Identifies and interprets training
needs of the RHMs, barangay health
workers (BHWs), and “hilots”
● Formulates appropriate training program designs for RHMs, BHWs, and “hilots”
● Provides and arranges learning experience for RHMs, affiliates (nursing and midwife), and
other health workers
● Conducts training for RHMs and “hilot” on health promotion and disease prevention
● Facilitates training for Barangay Health Workers
● Organizes orientation/training of concerned groups including non-government
organization
● Provides information that allows clients to make healthier choices and practices
● Acts as a resource speaker/person on health and health-related services
● Participates in the development and distribution of information education and
communication (IEC) materials
● Conducts IEC orientation for selected group on specific programs/projects
● Initiates the use of tri-media: radio/TV, and cinema plugs, print ads, and other indigenous
resources for health education purposes
● Conducts pre-marital counseling
VII. HEALTH MONITOR
● Detects deviation from health of individuals, families, groups of the community through
contacts/visits with them
● Uses symptomatic and objectives observation and other forms of data gathering like
morbidity, registry, questionnaire, checklist, and anecdotal report/record to monitor
growth and development, and health status of individuals, families, and communities
VIII. ROLE MODEL
● Provides good example/model of healthful living to the public/community
IX. CHANGE AGENT
● Motivates changes in health behavior of individuals, families, groups, and community,
including lifestyle, in order to promote and maintain health
X. RECORDER / REPORTER / STATISTICIAN
● Prepares and submits required reports and records
● Maintains adequate, accurate, and complete recording and reporting
● Reviews, validates, consolidates, analyzes, and interprets all records and reports
● Prepares statistical data/charts, and other data presentations for display and of
presentations in staff meeting conferences and seminars/workshops

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EVALUATION

1. Make a reflection paper on Global and National Health Situation.

a. Global Health Situation
● Introduction: (present and give the idea or thoughts)
● Reflection: (tell what you learned from the idea, your realizations, effects, and
lessons you learned from it)
● Conclusion/s: (summary of your thoughts, wrap up your ideas, highlight the main
points)
b. National Health Situation of the Philippines
● Introduction: (present and give the idea or thoughts)
● Reflection: (tell what you learned from the idea, your realizations, effects, and
lessons you learned from it)
● Conclusion/s: (summary of your thoughts, wrap up your ideas, highlight the main
points)
2. Make an interview of a public health nurse (PHN), (if face-to-face is not possible, you can call or
message him/her), in your locality to determine the roles and functions he/she performs as a
PHN.

REFERENCE/S:

● Famorca et al., Nursing Care of the Community: A Comprehensive text on Community and Public
Health Nursing in the Philippines, 2013

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MODULE 2: HEALTH CARE DELIVERY SYSTEM

WORLD HEALTH ORGANIZATION (WHO)

Public health works to improve health and quality of life through prevention and treatment of disease and
through promotion of healthy behaviors. Public health is a basic component of health care systems.
However, to many people, the definition and role of public health are not clear.

The definition of health care systems are organizations or policies in place that are designed to plan and
provide medical care for people. Providers of health care insurance are examples of health care systems.
Hospitals, clinics and community health centers are examples of health care systems.

The nurse is an essential member of the health workforce in the country. For the nurse to work efficiently
within the health care delivery system, an understanding of the dynamic relationships among its
components is needed. For example, a nurse who understands the referral system will be able to refer
patients to the appropriate facility or health personnel.

This module highlighted the nation’s health care delivery system has a great impact not only on the health
of its people, but also on their total development, including their socio-economic status. In health care
delivery system involves issues of cost and challenges.

This module describes the health care delivery system in the Philippines, beginning with the World Health
Organization (WHO), as specialized agency of the United Nations (UN) provides global leadership on
health matters. The Philippine health care delivery system provided by the government and the private
sector-profit, as well as non-profit, with the latter frequently referred to as non-government organizations
or NGOs. The national level direction is set by the Department of Health (DOH).

At the end of module 2, the learners are expected to achieve the following:

3. Discuss how the World Health Organization (WHO) affects issued in the Philippines
4. Identify the Millennium Development Goals (MDGs) and the targets of the health-related MDGs.

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DELIVERY SYSTEM means any system, device, or
technology that improves, enables, or constitutes the delivery of a Compound or Product to a patient.

HEALTH CARE DELIVERY – the provision of health care delivery.

A health system, also sometimes referred to as health care system or as healthcare system, is the
organization of people, institutions, and resources that deliver health care services to meet the health
needs of target populations.

HEALTH CARE DELIVERY SYSTEM is an integrated health services encompasses the management and
delivery of quality and safe health services so that people receive a continuum of health promotion,
disease prevention, diagnosis, treatment, disease-management, rehabilitation, and palliative care
services, through the different levels and sites of care within the health system, and according to their
needs throughout the life courses.

THE WORLD HEALTH ORGANIZATION

The World Health Organization (WHO) is a specialized agency of the United Nations responsible for
international public health. The WHO established by constitution on April 7, 1948, since then, April 7 has
been celebrated each year as World Health Day. With its headquarters in Geneva, Switzerland, WHO has
147 country offices and 6 world regional offices for Africa, the Americas, Eastern Mediterranean, Europe,
Southeast Asia, and the Western Pacific. The Philippines is a member of the Western Pacific Region, which
holds office in Manila.

WHO is supporting countries in implementing people-centered and integrated health services by way of
developing policy options, reform strategies, evidence-based guidelines, and best practices that can be
tailored to various country settings.

The WHO’s Constitution states that its objective “is attainment by all peoples of the highest possible level
of health.”. To attain its objectives, WHO core functions:

1. Providing leadership on matters critical to health and engaging in partnership where joint action is
needed. The WHO Country Focus is directed toward providing technical collaboration with
member states in accordance with each country’s needs and capacities (WHO, 2013c).
2. Shaping the research agenda and stimulating the generation, translation, and disseminating
valuable knowledge.
Five Goals of WHO strategy on Research for Health (WHO, 2013c):

a. Capacity in reference to capacity-building to strengthen national health research systems;

b. Priorities to focus research on priority health needs particularly in low and middle-income
countries.
c. Standards to promote good research practice and enable to greater sharing research
evidence, tools, and materials.
d. Translation to ensure that quality evidence is turned into products and policy, and

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 e. Organization to strengthen the research
culture within WHO and improve the
management and coordination
of WHO research activities.
3. Setting norms and standards and promoting and monitoring their implementation. WHO develops
norms and standards for various health and health-related issues, such as pharmaceutical
products including vaccines and other biological products used in immunization, practices in
maternal and child care, and environmental conditions.
4. Articulating ethical and evidence-based policy options. Through its Department of Ethics and
Social Determinants, WHO is involved in various issues on health ethics (WHO, 2013d). in
collaboration with other governmental and non-governmental organizations. WHO has worked on
bioethical concerns such as those related to human organ and tissue transplantation, reproductive
technology, and public health response to threats of infectious diseases like AIDS, influenza, and
tuberculosis (WHO, 2013e).
5. Providing technical support, catalyzing change, and building sustainable institutional capacity.
WHO offers technical support and training to its member countries in the fields of maternal and
child health, control of diseases, and environmental health services. WHO involved in monitoring
the health situation and assessing health trends. WHO has developed guidance and tools on
measurement, monitoring, and evaluation (WHO, 2013f).

We know that Philippines is a member of a global system of nations interacting with each other at
different levels and in different ways. Events that happen in other countries can affect the health status of
Filipinos. Travel from one part of the country to another makes transmission of communicable diseases
likewise easy. This has been proven by events as the emergence and spread of diseases like HIV/AIDS,
SARS (Severe Acute Respiratory Syndrome), and AH1N1 influenza (swine flu) to cite a few. As of now, all
over the world suffering of pandemic disease of Covid-19. WHO provides the environment that facilitates
cooperation and sharing of resources to promote and protect health and to resolve health problems and
alleviate their effects. WHO worked as a partner of the Philippine DOH in the development and provision
of services towards the attainment of health-related Millennium Development Goals (MDGs).

What do you mean by Millennium Development Goal? What was a success of Millennium Development
Goal? What are the eight Millennium Development Goal?

THE MILLENNIUM DEVELOPMENT GOALS

World leaders in the United Nation General Assembly participated in the Millennium Summit last
September 6 to 8, 2000. The result of the summit was the resolution entitled United Nations Millennium
Declaration (UN, 2013) in this declaration, the world leaders recognized their collaborative responsibility
to support the principles of human dignity, equality and equity at the global level. To support these
principles is their duty to all the people of the world, especially the most vulnerable and, particular, the
children (UN General Assembly, 2000).

The Philippines is a member of the 191 states expressed commitment in the declaration, to reduce
extreme poverty and achieve seven other targets – now called the Millennium Development Goals (MDGs)
– by the year 2015 (UN, 2013).

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The following are the eight MDGs and the target’s
corresponding to health-related MDGs 4, 5, and 6 (UN,
2008).

Target: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate

● Under-five mortality rate

● Infant (under 1) mortality rate
● Proportion of 1-year-old children immunized against measles

Target 5A: Reduce by three quarters the maternal mortality ration

● Maternal mortality ratio

● Proportion of births attended by skilled health personnel
Target 5B: Achieve universal access to reproductive health

● Contraceptive prevalence rate

● Adolescent birth rate
● Antenatal care coverage
● Unmet need for family planning

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Target 6A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS

● HIV prevalence among population aged 15-24 years

● Condom use at last high-risk sex
● Proportion of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS
Target 6B: Achieve by 2010, universal access to treatment for HIV/AIDS for all those who need it

● Proportion of population of advanced HIV infection with access to anti-retroviral drugs

Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases

● Prevalence and death rates associated with malaria

● Proportion of children under 5 sleeping under insecticide-treated bed nets
● Proportion of children under 5 with fever who are treated with appropriate anti-malarial drugs
● Incidence, prevalence, and death rates associated with tuberculosis
● Proportion of tuberculosis cases detected and cured under DOTS (Directly Observed Treatment
Short Course)

Of the eight MDGs, five are not considered as strictly health issues. However, these five MDGs are
health-related issues because they are goals toward upgrading socio-economic conditions. These
socio-economic conditions are, in themselves, health determinants.

SUSTAINABLE DEVELOPMENT GOALS

The sustainable development goals (SDGs) are a new, universal set of goals, targets, and indicators that UN
members states will be expected to use to frame their agendas and political policies over the next 15
years. The Sustainable Development Goals are the blueprint to achieve a better and more sustainable
future for all. They address the global challenges we face, including those related to poverty, inequality,
climate change, environmental degradation, peace and justice. The 17 Goals are all interconnected, with
their 169 targets form the core of the 2030 agenda. They balance the economic, social, and ecological
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dimensions of sustainable development and place the
fight against poverty and sustainable development
on the same agenda for the first time.

The goals within a goal: Health targets for SDG 3

GOAL 3: GOOD HEALTH AND WELL-BEING

● Ensure healthy lives and promote well-being for all

● SDG 3 aspires to ensure health and well-being for all, including a bold commitment to end the
epidemics of AIDS, tuberculosis, malaria, and other communicable diseases by 2030.
● Aims to achieve universal health coverage, and provide access to safe and effective medicines and
vaccines for all. Supporting research and development for vaccines is an essential part of this
process as well as expanding access to affordable medicines.

Target 3.3
By 2030, end the epidemic of HIV in Southeast Asia and the Pacific which has resulted from injecting
drug use-related transmissions continuing to be a significant driving factor. Provide increased
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 access to HIV prevention, treatment and care
services among people who use drugs and
prisoners.
Target 3.4
By 2030, reduce by one third premature mortality from non-communicable diseases through
prevention and treatment and promote mental health and well-being.
Target 3.5
Strengthen the prevention and treatment of substance abuse, including narcotic, drug use such as
opium and heroin.

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EVALUATION

a. In a present situation, choose a news item about the recent agreement of WHO that you think
will impact on the health situation in the Philippines. Discuss the potential effects of these
agreement on the local health situations.
b. What are the 3 health problems related to MDG? Give nursing interventions to these
problems?
c. Quiz

1. Who created the Millennium Development Goal and when?

a. The NGO global network in 1995
b. The United States Senate in 2010
c. The United Nations in 2000
d. The University of Dallas in 1956
2. Which of the following is not a Millennium Development Goal?
a. Improve Maternal Health
b. Ensure Environmental Sustainability
c. Reduce Child Mortality
d. Dig more wells for water in developing countries
3. What does the first goal in MDG?
a. Reduce child mortality rate
b. Promote gender equality and empower women
c. To eradicate extreme poverty and hunger
d. To improve maternal health
4. What year is the deadline for MDG to be accomplished?
a. 2015
b. 2020
c. 2016
d. 2000
5. MDG #5 is very important to pregnant mother:
a. Nutrition
b. Medical care at birth
c. Medical advice and pregnancy planning
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 d. All of the above
6. In MDG #6, what are the three key diseases to
fight?
a. Polio, Heart disease, HIV/AIDS
b. Malaria, Tuberculosis, and HIV/AIDS
c. Tuberculosis, Cancer, and HIV/AIDS
d. Malaria, Diabetes, and Cholera
7. How many SDG and targets are there?
a. 50 goals and 100 targets
b. 17 goals and 169 targets
c. 17 goals and 196 targets
d. 24 goals and 10 targets
8. What are the three dimensions of the SDG?
a. Economic, Social, and Environmental
b. Education, Poverty, and Justice
c. Presales stores, Gardening, Hipster
d. Recycling food waste, Renewable energies
9. What is the date goal for SDG?
a. Full implementation by 2030
b. Fully completed by 2040
c. Partial completion by 2025
d. Completed by 2010
10. Which of the following are the 17 new Sustainable Development Goals?
1. Ensure healthy lives and promote well-being for all at all ages
2. End 80% poverty in all its forms everywhere
3. Make cities and human settlements inclusive, safe, resilient, and sustainable
a. 1, 2
b. 1, 3
c. 2, 3
d. All of the above

REFERENCE/S

● Famorca, 2013, et al., Nursing Care of the Community

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● https://www.unodc.org/documents/SDGs/UNODC-SDG_brochure_LORES.pdf
● https://www.thefreedictionry.com/healthcare+delivery”>healthcare delivery</a>
● https://www.un.org/sustainabledevelopment/sustainable-development-goals/

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 MODULE 3: HEALTH CARE DELIVERY
SYSTEM
DEPARTMENT OF HEALTH (DOH)

The Department of Health (abbreviated as DOH; Filipino: Kagawaran ng Kalusugan) is the executive
department of the Government of the Philippines, responsible for ensuring access to the basic public
health services by all Filipinos through the provision of quality health care and the regulation of all health
services and products. It is the government’s over-all technical authority on health. It has its headquarters
at the San Lazaro Compound, along Rizal Avenue in Manila.

The head of the department is led by the Secretary of Health, currently Francisco Duque, nominated by
the President of the Philippines, and confirmed by the Commission on Appointments. The Health
Secretary is a member of the cabinet. Francisco Tiongson Duque III (Tagalog: [fren’sisko ‘duke]; born
February 13, 1957) is a Filipino physician, government official serving as Secretary of Health since 2017 in
the Cabinet of President Rodrigo Duterte, a position he had previously held from 2005 to 2010 in the
Cabinet of President Gloria Macapagal Arroyo.

The Department of Health (DOH) is the country’s principal health agency. It is responsible for ensuring
access to basic public health services through the provision of quality healthcare and the regulation of
providers of health goods and services.

In this module, you will understand the function of this agency, the healthcare personnel, and the referral
system.

At the end of module 3, the learners are expected to achieve the following:

● Discuss the Philippine health care delivery system in terms of the different levels of services
● Describe how the Department of Health (DOH) provides health leadership in the Philippines
● Explain the functions of the members of the health team in the rural health unit/health center
● Understand the referral system from the inter-local health zone

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THE DEPARTMENT OF HEALTH

Executive Order No. 119, Section 3, states that the “Department of Health shall be responsible for the
following – in relation to its main function of promotion, protection, and preservation or restoration of the
health of the people through the provision and delivery of providers of health goals and services.”

VISION

To be a global leader for attaining better health outcomes, competitive, and responsive health
care system, and equitable health financing.

MISSION

To guarantee equitable, sustainable, and quality health for all Filipinos, especially the poor, and to
lead the quest for excellence in health (DOH, 2012b)

Major Roles and Functions

1. Leadership in Health
The leadership role of the DOH is specifically elucidated in Executive Order 102, series of 1999 in
terms of the following functions:

a. Planning and formulating policies of health programs and services

b. Monitoring and evaluating the implementation of health programs, projects, research,
training, and services
c. Advocating for health promotion and healthy lifestyles
d. Serving as a technical authority in disease control and prevention, and
e. Providing administrative and technical leadership in health care financing and
implementing the National Health Insurance Law
2. Enabler and Capacity Builder
As Enabler and Capacity Builder, the DOH performs the following functions (Office of the President,
1999)
a. Providing logistical support to LGUs, the private sector, and other agencies in
implementing health programs and services
b. Serving as the lead agency in health and medical research, and
c. Protecting standards of excellence in the training and education of health care providers
at all levels of the health care system
3. Administrator of Specific Services
As administrator of specific services, the DOH is tasked to (Office of the President, 1999):
a. Serve as administrator of selected health facilities at subnational levels that act as referral
centers for local health systems, that is tertiary and special hospitals, reference
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 laboratories, training centers, centers for
health promotions, centers for disease
control and prevention, and regulatory
offices
b. Provide specific program components for conditions that affect large segments of the
populations, such as tuberculosis, malaria, schistosomiasis, HIV/AIDS, and micronutrient
deficiencies
c. Develop strategies for responding to emerging health needs, and
d. Provide leadership in health emergency preparedness and response services, including
referral and networking systems for trauma, injuries, and catastrophic events.
CORE VALUES

1. Integrity
2. Excellence
3. Compassion and Respect for Human Dignity
4. Commitment
5. Professionalism
6. Teamwork
7. Stewardship of the Health of the People

LEVEL OF HEALTH CARE DELIVERY

The DOH issued Administrative Order 2012-0012 (Rules and Regulation Governing the New Classification
of Hospitals and other Health Facilities in the Philippines) that provides for a new classification scheme of
health facilities

HOSPITALS OTHER HEALTH FACILITIES

General a. Primary Care Facility
● Level 1 b. Custodial Care Facility
● Level 2 c. Diagnostic/Therapeutic Facility
● Level 3 (teaching/training) d. Specialized Outpatient Facility
● Specialty

DOH Administrative Order 2012-0012 classifies other health facilities as follows:

● Category A Primary Care Facility – a first-contact health care facility that offers basic health
services including emergency services and provision for normal deliveries.
o Without in-patient beds like health centers, out-patient clinics, and dental clinics.
o With in-patient beds – a short-stay facility where the patient spends on the average of one
to two days before discharge.
▪ Examples are infirmaries and birthing (lying-in) facilities

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 ● Category B Custodial Care Facility – a health facility
that provides long-term care, including basic
services like food and shelter, to patients with
chronic conditions requiring on-going health and
nursing care due to impairment and a reduced degree of independence in activities of daily living,
and patients in need of rehabilitation.
o Examples are custodial psychiatric facilities, substance/drug abuse treatment and
rehabilitation centers, sanitarian/leprosaria, and nursing homes.
● Category C Diagnostic/Therapeutic Facility – a facility for the examination of the human body,
specimens from the human body for the diagnosis, sometimes treatment of disease, or water for
drinking water analysis.
The test covers the pre-analytical, analytical, and post-analytical phases of examination.

This category is further classified into:

o Laboratory Facility, such as, but not limited to the following:

▪ Clinical Laboratory
▪ HIV testing
▪ Blood service facility
▪ Drug testing laboratory
▪ Newborn screening laboratory
▪ Laboratory for drinking water analysis
o Radiologic facility providing services such as X-Ray, CT Scan, Mammography, MRI, and
Ultrasound.
o Nuclear machine facility – a facility by the Philippines Nuclear Research Institute utilizing
applications of radio-active materials in diagnosis, treatment, or medical research, with
the exception of the use sealed radiation sources in radio therapy as in internal radiation
therapy.
● Category D Specialized Outpatient Facility – a facility that performs highly specialized procedures
on an outpatient basis
o Examples are dialysis clinic, ambulatory surgical clinic, cancer chemotherapeutic
center/clinic, cancer radiation facility, and physical medicine and rehabilitation
center/clinic.

THE RURAL HEALTH UNIT

● RHU is a primary level health facility in the municipality and commonly known as a health center
● The focus of the RHU is preventive and promotive health services and the supervision of BHS
under its jurisdiction (DOH, 2001).
● The ratio of RHU to catchment population is 1 RHU:20,000 population

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THE BARANGAY HEALTH STATION

● The BHS is the first-contact health care facility that

offers basic services at the barangay level
● It is manned by volunteer BHW under the supervision of the Rural Health Midwife (RHM)

THE RURAL HEALTH UNIT PERSONNEL

a. MUNICIPAL HEALTH OFFICER (MHO) OR RURAL HEALTH PHYSICIAN – heads the health services at
the municipal level and carries out the following roles and functions:
1. Administrator of the RHU
i. Prepares the municipal health plan and budget
ii. Monitors the implementation of basic health services
iii. Management of the RHU staff
2. Community Physician
i. Conducts epidemiological studies
ii. Formulates health education campaigns on disease prevention
iii. Prepares and implements control measures or rehabilitation plans
3. Medico-legal officer of the municipality

RA 7305 or Magna Carta of the Public Health Workers stipulate that there be:

● One (1) rural health physician to a population of 20,000

● Nurse-population ratio – 1:20,000
● RHM recommended ratio of 1 for every 5,000 population

b. PUBLIC HEALTH NURSE (PHN)

1. Supervises and guides all RHMs in the municipality
2. Prepares the FHSIS quarterly and annual reports of the municipality for submission to the
Provincial Health Office
3. Utilizes the nursing process in responding to health care needs, including needs for health
education and promotions of individuals, families, and catchment community
4. Collaborates with the other members of the health team, government agencies, private
business, NGO, and people’s organizations to address the community’s health problems
c. RURAL HEALTH MIDWIFE

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 1. Manages the BHS and supervises
and trains the BHW
2. Provides midwifery services and executes
health care programs and activities for
women of reproductive age, including family planning counseling and services
3. Conduct patient assessment and diagnosis for referral or further management
4. Performs health information, education, and communications activities
5. Organizes the community
6. Facilitates barangay health planning and other community health services
d. RURAL SANITARY INSPECTOR
1. The functions of the RSI are directed towards ensuring a healthy physical environment in
the municipality
2. This entails advocacy, monitoring, and regulatory activities, such as inspection of water
supply and unhygienic household conditions
e. BARANGAY HEALTH WORKERS (BHW)
1. They are trained in preventive health care, with a strong emphasis on maternal and child
care, family planning, and reproductive health, nutrition, and sanitation
2. They are also equipped with basic skills for prevention and management of common
diseases
3. They assist in providing basic services at the BHS and the RHU
4. The recommended ratio of BHW to catchment population is 1 BHW:20 Households

HEALTH CARE PERSONNEL ORGANIZATION CHART

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 BASIC PRINCIPLES TO ACHIEVE IMPROVEMENT IN HEALTH

1. Universal access to basic health services must be ensured

2. The health and nutrition of vulnerable groups must be prioritized
3. The epidemiological shift from infection to degenerative diseases must be managed
4. The performance of the health sector must be enhanced

PRIMARY STRATEGIES OF DOH

1. Support to local health systems and front liners

2. Assurance of health care
3. Increased investment of PHC
4. Development of national standards and objectives for health

RHM Roles in the Health Care Delivery System of the Department of Health

● As an RHM assigned to a specific BHS covering several barangays, you work under the supervision
of the Public Health Nurse (PHN)
● The midwives are the frontline level where come in direct contact with the community and the
individual client, responding the best can do to their health needs and problem. It is the duty of
the midwife to make sure that all the DOH services are available to the people in her catchment
area
● If the client’s condition or problem is beyond the capability to help solve or is not within your
function and responsibilities, please refer to the PHN or RHP or to any appropriate facility in the
community

LOCAL HEALTH BOARDS

RA 7160 or Local Government Code – was enacted to bring about genuine and meaningful local
autonomy

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 ● Under this law, all structures, personnel,
and budgetary allocations from the provincial
health level down to the barangay were
devolved to the local government units to
facilitate health service delivery
● Provided the creation of Provincial Health Board and the City/Municipal Health Boards or Local
Health Boards
● At the City and Municipal level, the local health board is composed of the following:
o Mayor (chair)
o Municipal Health Officer (vice chair)
o Chairman of the Committee on Health of Sangguniang Bayan
o DOH representative
o NGO representative
Devolution

● This refers to the act by which the national government confers power and authority upon various
LGUs to reform specific functions and responsibilities
● Aims to transform LGUs into self-reliant communities and active partners in the attainment of
national goals through a more responsive and accountable local government structure instituted
through a system of decentralization

The function of Local Health Boards

1. Proposing to the Sanggunian annual budgetary allocations for the operation and maintenance of
health facilities and services within the province/city/municipality.
2. Serving as an advisory committee to the Sanggunian on health matters
3. Creating committee that shall advise local health agencies on various matters related to health
services operations

HEALTH REFERRAL SYSTEM

● Referral in the health system is a set of activities undertaken by a health care provider or facility in
response to its inability to provide the necessary health intervention to satisfy a patient’s need.
● It engages all health facilities from the lowest to the highest level.
● A patient is first cured for by the family which may or may not seek the assistance of the barangay,
from either these two entities, the case referred to the barrio health station, barangay health
workers refer cases to the rural health team, who in turn refer more serious cases to either the
district hospital, then to provincial, regional, or the whole health care system
● Figure 1 is a representation of the two-way referral system in the Philippines

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INTER-LOCAL HEALTH ZONE

● It is a system of health care similar to a district health system in which individuals, communities,
and all other health care providers in a well-defined geographical area, participate together,
providing quality, equitable, and accessible health care with Inter-Local Government Unit
partnership as the basic framework.
● The ILHZ does not only cover government health services but includes all other sectors involved in
the delivery of health services. It includes community-based NGOs and the private-sector – both
local and foreign.

Components of ILHZ

1. People – the ideal population size of health district between 100,000 and 500,000, the
number of people may vary from zone to zone, especially when taking into consideration the
number of LGUs that will decide to cooperate and cluster.
2. Boundaries – clear boundaries between ILHZs establish accountability and responsibility of
health service providers/
3. Health Facilities – RHUs, BHSs, and other health facilities that decide to work together as an
integrated health system and a district or provincial hospital, serving as the central referral
hospital
4. Health workers – to deliver comprehensive services of the DOH, district or provincial hospitals,
RHUs, BHSs, private clinics, volunteer health workers from NGOs and community-based
organizations.

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Figure 2 shown the diagram illustrating an ILHZ. The
governments of three adjacent municipalities and an NGO offering custodial care to a person have granted
to consolidate their health systems into a health cluster. The cluster provides primary services and
custodial care to a total population. The cluster has recognized a linkage with the district hospital, which
serves as the central referral hospital of the ILHZ.

Expected Achievement of the Inter-Local Health System

1. Universal coverage of health insurance

2. Improved quality of hospital and rural health unit service
3. Effective referral system
4. Integrated planning
5. Appropriate health information system
6. Improved drug management system
7. Developed human resources
8. Effective leadership through inter-LGU corporation
9. Financially visible or self-sustaining hospitals
10. Integration of public health and curative hospitals sectors
11. Strengthened cooperation between LGU and health sectors

Guiding Principles in Developing the Inter-Local Health System

1. Financial and administrative autonomy of the provincial and municipal administrations

2. Strong political support
3. Strategic synergies and partnership
4. Community participation
5. Equity of access to health services by the population, especially the poor
6. Affordability of health services
7. Appropriateness of health programs
8. Decentralized management
9. Sustainability of health initiatives
10. Upholding of standards of quality health services

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EVALUATION

1. Make an organizational structure of your RHU personnel on your respective places

2. Interview a Public Health Nurse in their locality and ask them the referral system of a
suspected covid patient. How they manage PUM, PUI, and positive covid patients?
QUIZ

I. IDENTIFICATION
1. Is the totality of all policies, infrastructures, facilities, equipment, products, human resources,
and services that address the health needs, problems, and concerns of all people
2. The national health authority providing health care for all Filipinos.
3. Partner of the Philippine DOH that provides global leadership on health matters.
4. Framework for the implementation of HSRA
5. A law that mandates devolution of basic services from the national government to LGUs.
6. Refers to the act by which the national government confers power and authority upon the
various LGUs to perform specific functions and responsibilities
7. A set of activities undertaken by a health care provider or facility in response to its inability to
provide the necessary health intervention to satisfy a patient’s need.
8. A type of referral wherein the patient moves from one health facility to another.
9. A referral that occurs within the health facility from one personnel to another.
10. A set of 17 goals for the World’s future through 2030.
II. ENUMERATION
1. Roles and Functions of DOH (4)
2. DOH Core Values (5)
3. Areas that need to be Reformed (5)
4. Rationale for Health Sector Reform (2)
5. Elements of Strategy (4)
6. Component of Local Health Board (5)
7. Rural Health Unit Personnel (5)

REFERENCE/S

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● Famorca et. al., Nursing Care of the Community:
A Comprehensive text on Community and Public
Health Nursing in the Philippines, 2013

● https://en.wikipedia.org/wiki/Department_of_Health_(Philippines)

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MODULE 4: HEALTH CARE DELIVERY SYSTEM

PRIMARY HEALTH CARE

Primary Health Care is a philosophy and a strategy. It is not one single program or project rather it is the
overarching strategy for the whole health program. All DOH programs are anchored on the key principles
of Primary Health Care. These programs seek to correct the inequities in health, ensuring health care for
the most vulnerable population groups in the country. For these programs to be effective and sustainable,
these require genuine partnership of different sectors. And more importantly, these PHC programs should
be a partnership between the health care providers and the community. And by so doing, these programs
fulfill the vision of making all essential health services accessible, affordable, available and acceptable,
therefore achieving our goal of “health for all”.

This module highlighted the nation’s health care delivery system has a great impact not only on the health
of its people but also on their total development, including their socio-economic status. In health care
delivery system involves issues of cost and challenges.

This module describes the health care delivery system in the Philippines, beginning with the World Health
Organization (WHO, as specialized agency of the United Nations (UN) provides global leadership on health
matters. The Philippine health care delivery system provided by the government and the private
sector-profit as well as non-profit, with the latter frequently referred to as non-government organizations
or NGOs. The national level direction is set by the Department of Health (DOH).

The nurse is a member of the health care team in the community. For the nurse work efficiently within the
health care delivery system, an understanding of the dynamic relationship among its components is
needed. A nurse who understands the referral system will be able to refer patients to the appropriate
personnel or facility. In valuing the nurse’s role in the system provides motivation to work despite
sometimes seemingly overwhelming odds. This module provides a realization of the nurse’s position in the
scheme of health care delivery in the Philippines.

At the end of the module 4, the learners are expected to achieve the following:

● Relate the application of PHC key principles in the implementation of public health programs.
● Identify and to familiarize traditional and alternative health care modalities that may be applied in
communities.
● Differentiate the level of prevention.

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 THE PHILIPPINE HEALTH CARE DELIVERY SYSTEM

PRIMARY HEALTH CARE

According to WHO, it is essential care made universally accessible to individuals and families in the
community by means acceptable to them through their full participation and at cost that the community
and country can afford at every stage of development.

It is the partnership approach among community; the government and the private sector or
non-government organizations.

It focuses on the importance of community participation in the identification of health and health-related
problems in seeking their solutions to improve the socio-economic development plays in the development
of individual.

HEALTH

Health is a state of complete physical, mental, and social well-being and not merely the absence of disease
or infirmly.

The WHO has put equal emphasis on the social dimensions of health that wellness can be achieved by
considering different factors that independently influence the health of the population, such as
environment, education, social services, and politics/leadership.

RATIONALE FOR PHC

● Magnitude of health problem

● Inadequate and unequal distribution of health resources
● Increasing cost of medical care
● Isolation of health care activities from other development activities

PHC – was declared during the First International Conference held at Alma Ata, USSR on Sept 6-12, 1978
by WHO.

LEGAL BASIS

● This was adopted in the Philippines through Letter of Instruction 949 signed by former President
Ferdinand E. Marcos, on October 19, 1979, and has an underlying theme of “Health in the Hands
of the People buy 2020”
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 ● Sept 11, 1981 – PHC was launched nationwide
in the Philippines, upon the
recommendation of the former minister of
health Dr. Jesus C. Azurin. The
implementation of PHC then started.

GOAL: “Health for All by the Year 2020” and “Health in the Hands of the People by the Year 2020”

FIVE KEY ELEMENTS TO ACHIEVING THE GOAL OF “Health for All”

1. Reducing exclusion and social disparities in health (universal coverage)

2. Organizing health services around people’s needs and expectations (health service reform)
3. Integrating health into all sectors (public policy reforms)
4. Pursuing collaborative models of policy dialogue (leadership reforms)
5. Increasing stakeholder participation

The Alma Ata Declaration listed eight essential health services, using the acronym ELEMENTS as a
memory aid:

● E – Education for health

● L – Locally endemic disease control
● E – Expanded program for immunization
● M – Maternal and child health including responsible parenthood
● E – Essential drugs
● N – Nutrition
● T – Treatment of communicable and non-communicable diseases
● S – Safe water and sanitation

KEY PRINCIPLES OF PRIMARY HEALTH CARE

1. Accessibility, affordability, acceptability, and availability (The 4As of PHC)

● Accessibility usually refers to the physical distance of a health facility or the travel time
required for people to get the needed or desired health services. The WHO guideline states
that for these health care facilities to be considered accessible, they must be within 30
minutes from the communities. BHS (Barangay Health Station) are facilities intended to
provide accessible health services at the community level.

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 ● Affordability is not only in
consideration of the individual or family’s
capacity to pay for basic health services. The
WHO considers in determining affordability
of health care is the out-of-pocket expenses for health care
● Acceptability means that the health care offered as in consonance with the prevailing culture
and traditions of the population
● Availability is a question of whether the basic services required by the people are offered in
the health care facilities or is provided on a health care facility or is provided on a regular and
organized manner.

Consider the following health programs and analyze them according to the 4As as defined above.

● Botika ng Bayan and the Botica ng Barangay

These drugstores were established by the Philippine government to promote equity in
health by ensuring the availability and accessibility of affordable, safe, and effective
quality essential drugs to all, with priority given to the marginalized, underserved, critical,
and hard-to-reach areas.

● “Ligtas sa Tigdas ng Pinas” a mass measles immunization campaign. Children aged 9

months to below 8 years old were vaccinated against measles and rubella.
2. Support mechanism
Health programs and projects provide better outputs when these three entities; the people, the
government, and the private sectors.
3. Multi-sectoral approach
The PHC requires communication, cooperation, and collaboration within and among various sectors.
4. Community participation
Health is achieved through self-reliance and self-determination and that individuals, families, and
communities are not considered as recipients of care but active participants in achieving their
health goals.
5. Equitable distribution of health resources
The DOH is spearheading two programs to ensure equitable distribution of manpower to the rural
areas, these programs are:
● Doctor to the Barrios (DTTB) Program – is the deployment of doctors to municipalities
that are without doctors. DTTB volunteers are fielded to manage the RHU or health
centers in unserved economical expressed fifth or sixth municipalities for 2 years.
● Registered Nurse Health Enhancement and Local Service (RN HEALS) – is a training and a
deployment program for unemployed nurses, RN HEALS volunteers are deployed to
underserved, economically depressed municipalities for 1 year to address the inadequate
nursing workforce in rural communities and health facilities
6. Appropriate technology

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 Appropriate technology refers to the technology
that is suitable to the community that will use it. To
better capture its essence, the terms “people’s
technology” and “indigenous technology”
are also used in reference to appropriate technology. Criteria for appropriate health technology:

● Safety
● Effectiveness
● Affordability
● Simplicity
● Acceptability
● Feasibility and reliability
● Ecological effects
● Potential to contribute to individual and community development

RA 8423 or the Traditional and Alternative Medicine Act of 1997

● It was signed into law through the efforts of then Secretary of Health Juan Flavier
● This created the Philippine Institute of Traditional and Alternative Health Care, which is tasked to
promote and advocate the use of traditional and alternative health care modalities through
scientific research and product development.
● DOH endorsed 10 medicinal plants to be used as herbal medicines in the Philippines due to their
proven health benefits as attested by the National Science and Development Board.

The 10 Medicinal Plants endorsed by the DOH

Medicinal Plants Use / Indication Preparation

1. Sambong Anti-edema Decoction
Anti-urolithiasis
2. Ampalaya Diabetes Mellitus Decoction
(Mild / Non-Insulin Dependent) Steamed
3. Niyug-niyugan Anti-helminthic Seeds are used
4. Tsaang Gubat Diarrhea Decoction
Stomachache
5. Akapulko Anti-fungal Poultice
6. Lagundi Asthma, cough, and colds, fever, Decoction
dysentery, pain Wash affected site with
Skin diseases (scabies, ulcer decoction
eczema, wounds)
7. Ulasimang Bato / Lower blood uric acid Decoction
Pansit-pansitan (rheumatism and gout) Eaten raw

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8. Bawang Hypertension, lower blood Eaten raw / fried
cholesterol, toothache Apply on part
9. Bayabas Washing wounds Decoction
Diarrhea
Gargle, toothache
10. Yerba Buena Headache, stomachache Decoction
Cough and colds Infusion
Rheumatism, arthritis Massage sap

AKAPULKO AMPALAYA

BAWANG BAYABAS

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LAGUNDI NIYUG-NIYOGAN

SAMBONG TSAANG GUBAT

ULASIMANG BATO / PANSIT-PANSITAN YERBA BUENA

MEDICINAL PLANT PREPARATIONS

Preparation Procedure for Preparation

Decoction Boil the recommended part of the plant material in water. Recommended
boiling time is 20 minutes.
Infusion Plant material is soaked in hot water, much like making a tea
Recommended period of soaking is 10-15 minutes
Poultice Directly apply recommended plant material on the part affected, usually
used on bruises, wounded or rashes
Tincture Mix the plant material in alcohol

ALTERNATIVE HEALTH CARE MODALITIES PRACTICED

Preparation Procedure for Preparation

Acupressure A method of healing and health promotion that uses the application of
pressure on acupuncture points without puncturing the skin
Acupuncture A method of healing using special needles to puncture and stimulate
specific anatomical points on the body

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Aromatherapy The art and science of the sense of smell
whereby essential aromatic oils are combined
and then applied to the body in some form of
treatment
Chiropractic A discipline of the healing arts concerned with the pathogenesis,
diagnosis, therapy, and prophylaxis of functional disturbances,
pathomechanical states, pain syndromes, and neurophysiological effects
related to the static and dynamics of the locomotor system, especially of
the spine and pelvis
Herbal Medicine / Finished, labeled, medicinal products that contain as active ingredients
Phytomedicine aerial or underground parts of the plants or other material or combination
thereof, either in the crude state or as plant preparation.
Massage A method wherein the superficial soft parts of the body are rubbed,
stroked, kneaded, or tapped for remedial, aesthetic, hygienic, or limited
therapeutic purposes
Nutritional therapy The use of food as medicine and to improve health by enhancing the
nutritional value of food components that reduces the risk of a disease. It
is synonymous with nutritional healing.
Pranic healing A holistic approach of healing that follows the principle of balancing
energy
Reflexology The application of therapeutic pressure on the body’s reflex points to
enhance the body’s natural healing mechanisms and balance body
functions. It is based on the principle that internal glands and organs can
be influenced by properly applying pressure to the corresponding reflex
area on the body.

PRIMARY HEALTH CARE VERSUS PRIMARY CARE

DIFFERENCES BETWEEN PRIMARY HEALTH CARE AND PRIMARY CARE

Point of comparison Primary health care Primary care

Focus client Family and community Individual
Focus client Promotive and preventive through Curative, provided by health
community participation professional
Decision-making process Community-centered / Health worker driven
consultative-participative
Outcome Self-reliance / self-help Reliance on health professionals to
restore/regain health
Setting for services Rural-based satellite clinics,

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EVALUATION

1. Make an interview with your parent, grandparent, aunt, or uncle about herbal medicines. Ask
them their experience in using these herbal medicines.
2. Choose 2 among the eight essential health services and then base on our previous discussion
relate these services in relation to implement on your respective locality
REFERENCES

● Famorca et. al., Nursing Care of the Community: A Comprehensive text on Community and Public
Health Nursing in the Philippines, 2013
● https://www.unodc.org/documents/SDGs/UNODC-SDG_brochure_LORES.pdf

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MODULE 5: HEALTH CARE DELIVERY SYSTEM
UNIVERSAL HEALTH CARE

Universal Health Care (UHC), also referred to as “Kalusugan Pangkalahatan (KP)”, is the “provision to
every Filipino of the highest possible quality of health care that is accessible, efficient, equitably
distributed, adequately funded, fairly financed, and appropriately used by an informed and empowered
public”.

At the end of module 5, the learners are expected to achieve the following:

● Correlate the strategic thrusts of Universal Health Care to the current health situation and the goal
and objectives of Universal Health Care.
● Differentiate the 3 levels of prevention

THE PHILIPPINE HEALTH CARE DELIVERY SYSTEM

Health Sector Reform: Universal Health Care

● Universal Health Care (UHC) (Kalusugan Pangkalahatan), also called the Aquino Health Agenda,
is the latest in a series of continuing efforts of the government to bring about health sector
reforms
● UHC – was built upon the strategies of two previous platforms of reform: the initial Health Sector
Reform Agenda (1999-2004) and FOURmula One (F1) for Health (2005-2010). UHC is planned for
implementation until 2016.

RATIONALE:

● Health sector reforms are intended to bring about equity in health service delivery
● DOH and PhilHealth review highlighted the need to improve health-related financial risk
protection among Filipinos.

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 ● PhilHealth benefit delivery was found to be lowest
among the target population – the poorest
quintile. The concern on inequitable access to
health resources has not been resolved.
● Neglect of public hospitals and health facilities due to inadequate health targets has been
observed.
● Renewed efforts to achieve health-related MDGs are in order.

UHC was launched through Administrative Order 2010-0036 to address these challenges

GOAL and OBJECTIVES:

UHC is detected towards ensuring the achievement of the health system goals of:

1. Better health outcomes

2. Sustained health financing, and
3. A responsive health system by ensuring that all Filipinos, especially the disadvantages group, have
equitable access to affordable health care. (DOH, 2010)
Strategic thrusts:

a. Financial risk protection through expansion in NHIP enrollment and benefit delivery
b. Improved access to quality hospitals and health care facilities
c. Attainment of the health-related MDGs
d. To achieve the three strategic thrusts, six strategic instruments shall be optimized:
1. Health financing – instruments to increase resources for health that will be effectively
allocated and utilized to improve the financial protection of the poor and the vulnerable
sectors.
2. Service delivery – instrument to transform the health service delivery structure to address
variations in health service utilization and health outcomes across socio-economic variables.
3. Policy, standards, and regulation – instrument to ensure equitable access to health services,
essential medicines, and technologies of assured quality, availability, and safety.
4. Governance for health – instrument to establish the mechanisms for efficiency, transparency,
and accountability, and prevent opportunities for fraud.
5. Human resources for health – instrument to ensure that all Filipinos have access to
professional health care providers capable of meeting their health needs at the appropriate
level of care.
6. Health information – instrument to establish a modern information that shall:
i. Provide evidence for policy and program development
ii. Support for immediate and efficient provision of health care and management of
province-wide health system (DOH, 2010)

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LEVELS OF PREVENTION

1. Primary Prevention
It relates to activities directed at preventing a problem before it occurs by altering susceptibility or
reducing exposure for susceptible individuals.

Two Elements:
a. General health promotion – efforts enhance resiliency and protective factors and target
essentially well populations. Example promotion of good nutrition, provision of adequate
shelter, and encouraging regular exercise.
b. Specific protection – efforts reduce or eliminate risk factors and include such measures as
immunization and water purification.
2. Secondary prevention
● It refers to early detection and prompt intervention during the period of early disease
pathogenesis
● It is implemented after a problem has begun but before signs and symptoms appear and
targets those populations who have risk factors. Example: mammography, blood pressure
screening, newborn screening, and mas sputum examination for pulmonary tuberculosis
● It is also directed toward prompt intervention to prevent worsening of conditions of the
affected population. Example: teaching a mother how to give oresol to her child suffering
from diarrhea to prevent dehydration and administering Vit A capsules to children with
measles.
3. Tertiary prevention
● It targets population that have experienced disease or injury and focuses on limitation of
disability and rehabilitation
● Aims are to reduce the effects of disease and injury and to restore individuals to their
optimal level of functioning
Example:
o Teaching how to perform insulin injection techniques
o Disease management to a patient with diabetes
o Referring a patient with spinal cord injury for physical therapy

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EVALUATION

Direction: classify the following if it is Primary, Secondary, or Tertiary Level of Prevention

1. Medications
2. Safe Sex
3. Cancer screening
4. Genetic counselling
5. Maintenance of diet
6. Cessation of smoking
7. Breast self-examination
8. TB screening
9. Physical therapy
10. Exercise
11. Limit alcohol consumption
12. Job training
13. Mammograms
14. Immunizations
15. Rehabilitations
16. Testicular examinations
17. Avoid exposure to sunlight

REFERENCE/S

● Famorca et. al., Nursing Care of the Community: A Comprehensive text on Community and Public
Health Nursing in the Philippines, 2013
● Kozier & Erb’s, Fundamental of Nursing Concepts, Process and Practice, Berman, Synder, et. al.,
2018, Philippine, Pearson Education Spith Asia 10th edition, Volume 1 & 2

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 MODULE 6: FAMILY HEALTH NURSING
PROCESS

This module highlighted the community health nurse’s work with families. Although the nature of the
family is changing and challenging traditional definitions and configuration, the family remains the basic
unit of care in public health and the core of society. For this reason, approaches to meeting the health
needs of the families must go beyond that of the traditional health healthcare system. Which tends to
address the individual as the unit of care. This module will provide tools for assessing the family and the
application of the rest of the steps of the nursing process in the health care. For this reason, you are
expected to apply these basic concepts in improving the individual and family health.

Upon completion of this module, you will be able to:

● State of definition of family

● Describe the different types of family
● Determine the different functions of family
● Identify the characteristics of a family as a client and as a system
● Identify the different types and purpose of family-nurse contact

00

I know that we have different definition of family. So, for you, what family means to you? What type of
family do you have? How will you describe your family?

The family as the Basic Unit of the Society

● Family is a group of persons usually living together and composed of the head and other persons
related to the head by blood, marriage, or adoption. (NSCB, 2008)
● Social unit interacting with the larger society (Johnson, 2000)
● Characterized by people together because of birth, marriage, adoption, or choice (Allen, 2000)
A family is two or more persons who are joined together by bonds of sharing and emotional closeness and
who identify themselves as being part of the family (Friedman, et. al., 2003)

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TYPE OF FAMILY

A. Structure
● NUCLEAR – the family of marriage, parenthood, or procreation; composed of a husband
and wife and their immediate children – natural, adopted, or both
● EXTENDED – composed of two or more nuclear families economically and socially related
to each other. Multi-generational, including married brothers and sisters, and the families.
● SINGLE PARENT – divorced or separated, unmarried, or widowed male or female with at
least one child.
● BLENDED/RECONSTITUTED – a combination of two families with children from both
families and sometimes children of the newly married couple. It is also a remarriage with
children from previous marriage.
● DYAD – husband and wife or other couple living alone without children
● GAY/LESBIAN – homosexual couple living together with or without children
● FOSTER – substitute family for children whose parents are unable to care for them
● COMPOUND – one man/woman with several spouse
● COHABITING/LIVE-IN – unmarried couple living together
B. Decisions in the Family (Authority)
● PATRIARCHAL – full authority on the father or any male member of the family. e.g., father,
eldest son, grandfather
● MATRIARCHAL – full authority of the mother or any female member of the family. e.g.,
mother, eldest daughter, grandmother
● EGALITARIAN – husband and wife exercise a more or less amount of authority, father and
mother decides.
● DEMOCRATIC – everybody is involved in decision-making
● AUTHOCRATIC
● LAISSEZ-FAIRE – “full authority”
● MATRICENTRIC – the mother decides/takes charge in absence of the father (e.g., father is
working overseas)
● PATRICENTRIC – the father decides/takes charge in absence of the mother
C. Decent (cultural norms, which affiliate a person with particular group of kinsmen for certain social
purposes)
● PATRILINEAL – affiliates a person with a group of relatives who are related to him through
his father
● BILATERAL – both parents
● MATRILINEAL – related through mother
D. Residence
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 ● PATRILOCAL – family resides/stays
with/near domicile of the parents of
the husband
● MATRILOCAL – live near the domicile of
the parents of the wife

The family performs several essential functions for society. The family fulfills two important purposes are
to meet the needs of the society and to meet the needs of the individual family members.

FUNCTIONS OF THE FAMILY

The family meets the needs of the society through:

1. Procreation
2. Socialization of family members
3. Status placement
4. Economic function

The family meets the needs of individual through:

1. Physical maintenance
2. Welfare and protection

Rationale for considering the Family a Unit of Care

● The family is considered the natural and fundamental unit of society

● The family as a group generates, prevents, tolerates, and corrects health problems within its
membership
● The health problems of the family members are interlocking
● The family is the most frequent focus of health decisions and actions in personal care
● The family is an effective and available channel for much of the effort of the health worker

1. Family as a client
● The family meets individual needs through provision of basic needs (foods, shelter, clothing,
affection, and education)
● The family supports spouses or partners by meeting affective, sexual and socio-economic needs

The Reasons why it is important to for the Nurse to Work with the Family

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 1. The family is critical resource
2. In a family unit, any dysfunction (illness,
injury, separation) that affects one or more
family members will affect the members
and unit as a whole
3. Case finding
4. Improving nursing care

2. Family as a System
● The General System Theory has been applied to the study of families.
● It is a way to explain how the family as a unit interacts with larger units outside the family
● Each member of the system is, to a certain extent, independent of other members, yet, the
members are in so many ways dependent on each other. Thus, the family is certainly more than
just the sum of its members.

FUNCTION DEVELOPMENT STAGE

Family life cycle

● Beginning family through marriage or commitment as a couple relationship

● Parenting the first child
● Living with adolescents
● Launching family (youngest child leaves home)
● Middle-aged family (remaining marital DYAD to retirement)
● Aging family (from retirement to death of both spouses)

Stages and task of family life cycle

A. Marriage: joining of families

● Formation of identify as a couple
● Inclusion of spouse in realignment of relationships with extended families
● Parenthood: making decisions

B. Families with young children

● Integration of children into family unit
● Adjustment of tasks: child rearing, financial, and household
● Accommodation of new parenting and grandparenting

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 C. Families with adolescents
● Development of increasing autonomy
for adolescents
● Mid-life re-examination of marital and career issues
● Initial shift towards concern for the older generation

D. Families as launching centers

● Establishment of independent identities for parents and grown children
● Re-negotiation of marital relationship
● Re-adjustment of relationships to include in-laws and grandchildren
● Dealing with disabilities and death of older generation

E. Aging families
● Maintaining couple and individual functioning while adopting to the aging process
● Support role of middle generation
● Support and autonomy of older generation
● Preparation for own death and dealing with the loss of spouse and/or siblings and other peers

Characteristics of a Healthy Family

● Members interact with each other; they communicate and listen repeatedly in many context
● Healthy families can establish priorities. Members understand that family needs are priority
● Healthy families affirm, support, and respect each other
● The members engage in flexible role relationships, share power, respond to change, support the
growth, and autonomy of others and engage in decision making that affects them
● The family teaches family and societal values and beliefs and shares a spiritual core
● Healthy families foster responsibility and value service to others
● Healthy families have sense of play and humor and share leisure time
● Healthy families have the ability to cope with stress and crisis and grow from problems. They
know when to seek help from professionals.

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 FAMILY-NURSE CONTACTS

The family-nurse relationship is developed through

family-nurse contacts, which may take the form of a
clinic visit, group conference, telephone contact, written communication or home visit. The nurse uses the
type of family-nurse contact that is most suitable to the purpose or situation at hand.

A. CLINIC VISIT
It takes place in a private clinic, health center, barangay health station, or in an ambulatory clinic
during a community outreach activity.
Advantages
● Family member takes the initiative of visiting the professional health worker, usually
indicating the family’s readiness to participate in the health care process.
● Allows the nurse to maximize resources (time other health care providers to whom the
client can be referred as needed and material resources such as supplies and equipment)
● The nurse has greater control over the environment, distractions are lessened.
Disadvantages

● Unable to transport, the family member requiring nursing care

● The family may feel less confident to discuss family health concern

B. GROUP CONFERENCE
Such as conference of mothers in the neighborhood, provides an opportunity for initial contact
between the nurse and target families of the community.
It may take place at a health facility or in the community.
Appropriate for developing cooperation, leadership, self-reliance and/or community awareness
among group members
Advantage: There is an opportunity to share experience and practical solutions to common health
concerns
Disadvantage: The nurse may not able to reach the families in greatest need of help through a group
conference.

C. TELEPHONE CONTACT
Advantages:
● It provides easy access between the nurse/health worker and the family
● Provides the nurse and the family with opportunities to contact each other through calls
or short messaging services
● Encouraging the family to communicate with the clinic or health center when they feel the
need for it cultivates the family’s confidence in the health agency
Disadvantage: Information transmitted through the telephone is limited
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D. WRITTEN COMMUNICATION
It is used to give specific information to families such
as instructions given to parents through
school children. Although there is a potential for
reaching many families, being a one-way method requiring literacy and interest, the nurse cannot
be certain that the information will reach the intended recipient.

E. HOME VISIT
It is a professional, purposeful interaction that takes place in the family’s residence aimed at
promoting, maintaining, or restoring the health of the Filipino or its members. It is a family-nurse
contact where instead of the family going to the nurse, the nurse goes to the family. the nurse
makes a home visit upon the family’s request, as a result of case finding, in response to a referral
or to follow up clients who have utilized services of a health facility such as a health center,
lying-in clinic, or hospital.

A home visit has following advantages:

a. It allows first-hand assessment of the home situation: family dynamics, environmental
factors affecting health and resources within the home
b. The nurse is able to seek out previously unidentified needs
c. It gives the nurse an opportunity to adapt interventions according to family resources
(David et. al., 2007)
d. It promotes family participation and focuses on the family as a unit (Maurer and Smith,
2009)
e. Teaching family members in the home is made easier by the familiar environment and the
recognition of the need to learn as they are faced by the actual home situation (Maurer
and Smith, 2009)
f. The personalize nature of a home visit gives the family a sense of confidence in
themselves and in the agency (David et. al., 2007)
The major Disadvantage of a home visit relates to efficiency:

a. There are more distractions in the home

b. Nurse is not safe

THREE PHASES OF HOME VISIT

1. Pre-Visit Phase
If possible, the nurse contacts the family, determines the family’s willingness for a home visit,
and set an appointment with them. The plan for the home visit is formulated during this
phase.

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 Principles in planning a home visit:
a. Should have a purpose
● To have more accurate assessment of the family’s living conditions and
adapt intervention accordingly
● To educate the family about measures for health promotion, disease
prevention, and control of health problems
● To prevent the spread of infection among family members and within the
community
● To provide supplemental interventions for the sick, disabled, or
dependent family member and, whenever possible, guide the family on
how to give care in the future
● To provide the family with greater access to health resources in the
community by establishing a close relationship with them, providing
information and making referrals as necessary
b. Use information about the family collected from all possible sources
c. Home visit plan focuses on identified family needs, particularly needs recognized
by the family as requiring urgent attention
d. The client and the family should actively participate in planning for continuing
care
e. The plan should be practical and adaptable

2. In-Home Visit
This phase begins as the nurse seeks permission to enter and lasts until he or she leaves the
family’s home. It consists of initiation, implementation, and termination.

a. Initiation
● It is customary to knock or ring the doorbell
● Upon entering the home, the nurse acknowledges the family members
with a greeting and introduces himself or herself
● Establish rapport
● State the purpose and the source of information
b. Implementation
● Apply nursing process
c. Termination
● Summarizing with the family the events during the home visits and setting
a subsequent home visit or another form of family nurse contact such as a
clinic visit
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 ● Recording

3. Post-Visit Phase
a. The nurse has returned to the health facility
b. Documentation of the visit during which the nurse records event that transpired
during the visit, including personal observations and feelings of the nurse about
the visit
c. If appropriate, referral may be made
d. Plan for the next visit

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 INTERPROFESSIONAL CARE IN THE
COMMUNITY

Interprofessional collaboration is defined “when

multiple health workers multiple health workers from different professional backgrounds work together
with patients, families, carers (caregivers), and communities to deliver the highest quality of care.”

Benefits:

Interprofessional collaboration leads to better patient outcomes by:

● Empowers team members

● Closes communication gaps
● Enables comprehensive patient care
● Minimizes re-admission rates

1. Rural Health Unit Personnel

2. Local Government Unit (LGU)
It is an administrative and political government unit subsidiary to the national government which could
itself consist of sub-units as in the case of a province or a municipality

3. Government Organizations
● Department of Social Welfare and Development (DSWD)
● Kagawaran ng Kagalingan at Pagpapaunlad Panlipunan DSWD is the executive
department of the Philippine Government responsible for the protection of the social
welfare of the rights of Filipinos and to promote social development
● DSWD provides welfare programs and services to the Persons with Disabilities, social
security for the aged and destitute through the network of residential care homes and
non-institutional services

MISSION

To develop, implement, and coordinate social protection and poverty reduction solutions for
and with the poor, vulnerable, and disadvantaged

FUNCTIONS

Provides assistance to other national government agencies, LGUs, NGOs, and members of civil
society in the implementation of programs, projects, and services.

It is mandated by law to develop, administer, and implement comprehensive social welfare

programs designed to uplift the living conditions and empower the disadvantaged children,
youth, women, older persons, with disabilities, families in crisis or at risk.
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 Example:

4Ps – Pantawid Pamilyang Pilipino

Program

● Formerly known as Ahon Pamilyang Pilipino

● A conditional cash transfer program of the Philippine government under DSWD

● National Nutrition Council (NCC)

● Pambansang Kapulungan ng Nutrisyon
● NCC is an agency of the Philippine government under the DOH, responsible for creating
conducive policy environment for national and local nutrition, planning, implementing,
monitoring and evaluating, and surveillance using state of the art technology and
approaches

● Commission of Population (POPCOM)

● POPCOM is a government agency mandated as the over-all coordinating, monitoring, and
policy-making body of the population program
● It is the lead agency promoting activities

Functions:
Providing data for national planning. It has statutory powers to collect, analyze, and disseminate
population data in the country.

4. Non-Government Organizations
● Civil and Social Organization
● Civic organization means an organization that provides services to its community
● Civic organizations are comprised of people who join together to provide a service or
services to the community
● Non-profit organization are considered civic organizations because they formed for the
purpose of profits for its owners or investors
● Civic organization such as the Kiwanis, rotary, etc., may be identified on group display
structures in accordance with the standards

● Religious Organization
● Religious organizations include, but not limited to, churches, mosques, temples

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● Schools

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 RECORDS IN FAMILY HEALTH NURSING PRACTICE

Fields Health Information System (FHSIS)

Importance of uses:

● To provide summary of data on health services delivery and selected program accomplished
indicators at the barangay, municipality/city, district, provincial, regional, and national levels
● To provide data which when combined with data from other sources, can be used for program
monitoring and evaluation purposes
● To provide a standardized, facility level database which can be accessed for a more in-depth study
● To ensure that the data reported to the FHSIS are useful and accurate and are disseminated in a
timely and easy to use fashion
● To minimize the recording and reporting burden at the service delivery level in order to allow
more time for patient care and promotive activities

Types of Records and Reports

● Family Treatment Record

● Target Client List
● Reporting Forms
● Output Reports

Treatment Record

● The fundamental building block or foundation of the FHSIS

● The document, form, or pieces of paper upon which the presenting symptoms or complaints of
the patient or consultation and the diagnosis (if available), treatment and date of treatment is
recorded

Target Client list

● To plan and carry out patient care and service delivery

● The primary advantage of maintaining the TCL is the MW/Nurse does not have to go back to
individual patient/family records as frequently in order to monitor patient treatment or services to
beneficiaries
● To facilitate the monitoring and supervision for services
● To report services delivered
● To provide a clinic-level database which can be accessed for further studies, e.g., follow up and
special prospective studies, record surveys, etc.

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 o TCL for Expanded Program on
Immunization
o TCL of children 0-59 months (Risk UFC)
o TCL for Pre-natal Care
o TCL for post-partum care
o TCL for Family Planning
o Lists for TB Symptomatic
o TCL for TB Cases under SCC
o TCL for TB Cases under SR

Tally / Reporting Forms

● FHSIS reports are prepared and submitted monthly, quarterly, and annually
● Reports are prepared and submitted by the unit/person responsible for the service/activity being
provided and sent directly to the PHO
● Undertaken or are the responsibility of MW/Nurses

Output Reports or Table

● Produced at the PHO the data reported in FHSIS disseminated down to the RHU/MHC and up
through the DOH system to the Regional Health Office

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EVALUATION

1. Make a complete personal genogram.

What are the high-risk factors? Categorize
current risk-factors as physical, interpersonal, and environmental.
2. Classified the following according to Health Problems
a. Broken stairs
b. Pointed/sharp objects, poison, and medicines improperly kept
c. Poor personal hygiene
d. Alcohol drinking
e. Poor lighting and ventilation
f. Divorce or separation
g. Marriage
h. Unemployment
i. Faulty eating habit
j. Noise pollution
3. Case scenario:
a. Identify the initial database for family according to:
i. Family structure, characteristics, and dynamic
ii. Socio-economic and cultural characteristics
iii. Home environment
iv. Health status of each family member
v. Values, habits, practices on health promotion, maintenance and disease
prevention
b. Identify and prioritize the problem
c. Make a family nursing care plan (top 2 problem)

Mr. and Mrs. Rosario are living together for almost 15 years at Brgy. Masikap, Lucban,
Quezon. They have five children - three girls and two boys. Three of them are studying,
and their eldest is an out-of-school youth. Mrs. Rosario is currently pregnant and she's on
her sixth month. The couple are both high school graduates. Mrs. Rosario is a vendor,
while her husband is a tricycle driver.

According to Mrs. Rosario, her pregnancy is unplanned and unwanted as they are facing
financial issues due to their daily expenses and school requirements of their children.
They depend on their small and unstable income, and sometimes receive support coming
from their in-laws. As of current, she has no pre-natal check-up due to financial

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 constraints. Their estimated monthly
family income, when combined, is
Php 5,000.00. Mrs. Rosario manages and
able to allocate budget for their food,
and school expenses of their three children. But according to her, it is not enough for
them but she managed it appropriately so that they can eat three times a day.

Their house is made up of light materials, like pieces of plywood. It measures

approximately 25 square meters. Living room is situated as soon as you enter the house,
just beside that is the area where they usually sleep, change clothes, eat, and for the
privacy of the couple. They use charcoal for cooking, electricity is not available due to the
limited resources, instead they use gas lamp. Water source is from the deep well, where
they need to get 25 meters away from their house. They use plastic containers to store
water for drinking purposes. Toilet facility is not available; thus, public toilet is being
shared among the neighborhood. Waste materials are not being segregated, and are just
being thrown at the river.

Mrs. Rosario's youngest, who is 10-month-old now, is very sickly and does not have any
immunization as the mother verbalize that she wasn't able to bring the child to the health
center. Last week, a health worker visited and assess the child, hence confirmed
underweight.

REFERENCE/S:

● Famorca et. al., Nursing Care of the Community: A Comprehensive text on Community and Public
Nursing in the Philippines, 2013
● Maglaya, Arceli S, Nursing Practice in the Community, 4th Edition Argaunata Corporation 2005

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 MODULE 7: MATERNAL,
NEWBORN, AND CHILD HEALTH
AND NUTRITION STRATEGY

The health of the Filipino mothers and children determines the health of the next generation of Filipinos.
It is given that socio-economic development can happen only when people are able to attain and maintain
a certain level of health. Understandably to attain the first Millennium Development Goal (MDG) to
eradicate extreme poverty and hunger), maternal and under five mortality rates have to be drastically
reduced and diseases that take a heavy toll on human capital like malaria and HIV/AIDS have to be
controlled.

Access to adequate and good quality maternal, newborn, and child health, and nutrition services is
expected to impact on the national situation in general. Therefore, improving maternal and child health
condition is imperative is being given top priority by health planners in the country. Vigorous efforts
toward this direction are evidenced by statements from the DOH leadership urging health workers to be
committed to the attainment of MDG 4 and 5 (reduction of maternal and under five mortality rates
respectively) and various documents containing evidence-based directives on MNCHN.

This module deals mostly with DOH policies and guidelines on maternal and child services. If quality
maternal and child health goals are to be made accessible to the target populations, LGU have to exert all
efforts towards compliance with these directives.

The nurse being in direct contact with health care clients, is at the forefront in the delivery of public health
services. In addition, the nurse has administrative/managerial functions. Therefore, public health nurses
are in the unique position of being in the unique position of being in the “middle” of delivery of services
to mothers, neonates, and young children. The health status of mothers, particularly during pregnancy,
the postpartum period and the period of lactation, is a major affecting the health status of their children.
Understandably, MNCHN services yield effects that carry a tremendous impact on the well-being and
ultimately, the development of the nation.

Upon completion of this module, you will be able to:

● Describe the current maternal and child health situation in the Philippines
● Explain the components of the core package of services in the Maternal, Newborn and Child
Health and Nutrition Strategy
● Recognize the role of the nurse in the delivery of the core package of services in the MNCHN
Strategy

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The Current Maternal and Child Health and Nutrition Situation

Leading Causes of Maternal Death (DOH, 2011)

1. Complications related to pregnancy occurring in the course of labor, delivery and puerperium
2. Hypertension complicating pregnancy, childbirth and puerperium
3. Postpartum hemorrhage
4. Pregnancy with abortive outcomes

Leading Causes of Neonatal Deaths (DOH, 2011)

1. Asphyxia
2. Prematurity
3. Severe infections
4. Congenital anomalies
5. Newborn tetanus
6. Other causes

Three Delays that lead to Maternal and Neonatal Deaths

1. Delay in identification of complications

2. Delay in referral
3. Delay in the management of complications

Risk Factors of Maternal and Neonatal Deaths

1. Having mistimed, unplanned, unwanted, and unsupported pregnancy

2. Not securing adequate care during the pregnancy
3. Delivering without skilled birth attendance, i.e., attendance by skilled midwives, nurses, or
physicians and not having access to emergency obstetric and neonatal care
4. Not having proper postpartum and postnatal care for the mother and the newborn

Leading Causes of Infant Deaths (DOH, 2011)

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 1. Bacterial sepsis of newborn
2. Respiratory distress of newborn
3. Pneumonia
4. Disorders related to short gestation and low birth weight
5. Congenital malformations of the heart
6. Congenital pneumonia
7. Neonatal aspiration syndromes
8. Other congenital malformation
9. Intrauterine hypoxia and birth asphyxia
10. Diarrhea and gastroenteritis of presumed infectious origin

The MNCHN Core Package Services

The maternal and newborn care package is characterized by a paradigm shift from the risk approach that
focuses on identifying pregnant women at risk of complications to one that considers all pregnant women
at risk of such complications.

Four Key Strategies

1. Ensuring universal access to and utilization of an MNCHN core package of services and
interventions directed not only to individual women of reproductive age and newborns at
different stages of the life cycle
2. Establishment of a service delivery network at all levels of care to provide the package of services
and interventions
3. Organized use of instruments of health systems development to bring all localities to create and
sustain their service delivery networks, which are crucial for the provision of health services to all
4. Rapid buildup of institutional capacities of DOH and PhilHealth being the lead national agencies
that provide support to local planning and development through appropriate standards capacity
buildup of implementers and financing mechanisms

Aims of MNCHN Strategy

1. Every pregnancy is wanted, planned, and supported

2. Every pregnancy is adequately managed throughout its course
3. Every delivery is facility-based and managed by skilled birth attendants or skilled health
professionals

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 4. Every month-and-newborn pair secures
proper postpartum and newborn care with smooth
transitions to the women’s health care package for
the mother and child survival package for the
newborn

The MNCHN Core Package of Service

A. Pre-pregnancy Package
1. Nutrition
● Nutrition counseling
● Promotion of the use iodized salt
● Provision of micronutrient supplements
a. Iron and folate: 60 mg elemental iron/400 ug folic acid 1 tablet daily 3-6
months
b. Vitamin A at least 5,000 IU every week or a daily multivitamin supplement
may be taken as option when the required Vitamin A is not available
2. Promotion of healthy lifestyle
3. Advice on FP and provision of FP services
4. Prevention and management of lifestyle-related diseases
5. Prevention and management of infection
6. Counseling on STD/HIV/AIDS, nutrition, personal hygiene, and the consequences of
abortion
7. Adolescent health services
8. Provision of oral health services
B. Pre-natal Package
1. Pre-natal visits (at least 4 through pregnancy) and pre-natal assessment
At least four visits throughout the course of pregnancy: at least one visit in the first and
second trimesters and at least two visits in the third trimesters
Pre-natal assessment includes:
● Weight and blood pressure monitoring measurement of fundic height against the
age of gestation
● Fetal heart beat and fetal movement count to assess the adequacy of fetal growth
and well-being
2. Micro-nutrient supplementation
● Iron and folate (60 mg/400 ug) once a day for 6 months or 180 tablets
● Vitamin A 10,000 IU twice a week from the fourth month of pregnancy; and

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 ● Elemental iodine 200 mg given
once during pregnancy
3. Tetanus toxoid immunization
● 0.5 ml of TT is injected intramuscularly on the deltoid muscle
Toxoid
Diphtheria Interval Percent Duration of Protection
(TD) Protection
Dose
TD1 As early possible
during first
pregnancy
TD2 At least 4 weeks 80 Infants born to the mother are
later protected against neonatal
status
Gives 3-year protection to the
mother
TD3 At least 6 months 95 Infants born to the mother are
protected against neonatal
status
Gives 5-year protection to the
mother
TD4 At least 1 year later 99 Infants born to the mother are
protected against neonatal
status
Gives 10-year protection to
the mother
TD5 At least 1 year later 99 Infants born to the mother are
protected against neonatal
status
Gives lifetime protection to
the mother

4. Promotion of exclusive breastfeeding, newborn screening, and infant immunization

5. Counseling on healthy lifestyle
6. Early detection and management of complications of pregnancy
7. Prevention and management of other conditions where indicated: hypertension, anemia,
diabetes, tuberculosis, malaria, schistosomiasis, STI/HIV/AIDS
8. Birth planning and promotion of facility-based delivery

Home-based Mother’s Record (HBMR)

● HBMR is a simplified record of history of present and past pregnancies, and measures of
the TBA, BHW, or health professional
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 ● HBMR has been concluded to:
o Provides a means of promoting
continuity of care through a woman’s
reproductive life
o Promotes early recognition of women who are at risk of developing conditions
o Encourages self-care where appropriate and referral suited to the needs of the woman
o Supports initiation of appropriate care
o Serves as a useful record of care and health information and source of health statistics
o Guides the health workers in providing for the health education needs of the client

C. Childbirth Package
1. Skilled birth attendance/skilled health professional-assisted delivery and facility-based
deliveries including the use of partograph. Most maternal deaths occur during labor or
the first 24 hours postpartum, and the most complications cannot be predicted or
prevented. It is logical that the best strategy to prevent maternal deaths is to promote
facility-based childbirth with a skilled health professional attendance.
2. Proper management of pregnancy and delivery complications and newborn complications
● The DOH, PhilHealth, and WHO recommend essential intrapartum and newborn
care (EINC) practices in hospitals and other birthing facilities in the country
● EINC is called Unang Yakap. EINC practice during the intrapartum period consist of
measures that based on scientific evidence, are necessary for safe and quality
care of the woman during childbirth.
3. Access to Basic Emergency Obstetric and Newborn Care (BEmONC) or Comprehensive
Emergency Obstetric and Newborn Care (CEmONC) services.

D. Post-partum Package
1. Post-partum visits: within 72 hours and on the 7th post-partum check
2. Micro-nutrient supplementation
● Iron and folate (60 mg/400 ug) once a day for 3 months or 90 tablets
● Vitamin A 200,000 IU within 4 weeks after delivery
3. Counseling on nutrition, child care, FP, and other available services

Newborn (1st week of life) Care Package

A. Intervention within the first 90 minutes

● Immediate and thorough drying
● SSC between mother and NB

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 ● Cord clamping 1-3 minutes after
birth
● Early initiation of BF within an
hour after birth
● Non-separation of baby from the mother, also known as rooming-in
B. Essential newborn care after 90 minutes to 6 hours
● Vitamin K prophylaxis
● Hepatitis B and BCG vaccination
● Examination of the baby for birth injuries, malformations, or defects
● Additional care for a small baby (a baby with a birth weight of < 2,500 gms) or
twin
C. Care prior to discharge: after the first 90 minutes
● Support for unrestricted, per demand breastfeeding, day and night
● Ensuring warmth of the baby
● Washing and bathing (hygiene)
● Monitoring for danger signs and resuscitation, if necessary
● NBS (blood spot) and NB hearing screening (if available)
● Discharge teachings
E. Child Care Package
1. Immunization
2. Nutrition
3. Exclusive BF up to 6 months
4. Sustained BF up to 24 months with complementary feeding
5. Micro-nutrient supplementation
6. IMCI
7. Injury prevention
8. Oral health
9. Insecticide – treated net for mothers and children in malaria endemic areas

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EVALUATION

1. Make an interview of a pregnant woman or a

post-partum mother, and assess obstetrical,
history, vaccination, and pre-natal check-up. Relate it to our discussion.
2. Discuss the importance of micro-nutrients supplementation in pregnant woman
3. Discuss the importance of SSC between the mother and NB.
4. Why and how Vitamin K administered to a newborn?

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 CHILD HEALTH PROGRAM

Goals of the Child Health Program

● Every child grows up in a family with love and security, lives in healthy surroundings, receives
adequate nourishment, health supervision, and medical attention, and is taught the elements of
healthy living.

Objectives of the Child Health Program

● To reduce significantly global mortality and morbidity associated with the major causes of deaths
in children and to contribute to healthy growth and development of children.

Framework for Children’s Rights

● The Philippine National Strategic Framework for Development for Children of CHILD 21 is a
strategic framework for planning programs and interventions that promote and safeguard the
rights of Filipino citizen.
● Covering the period 2000-2005, it paints in board strokes a vision for the quality life of Filipino
children in 2025 and a roadmap to achieve the vision

Other Relevant Legal Framework include the following:

1. RA 7610 – Anti-Child Abuse Act

2. RA 7658 – an act prohibiting the employment of children below 15 years of age
3. RA 6809 – Emancipation law lowered majority age from 21 to 18 years old

Children’s Health 2025

● Children’s Health 2025, a subdocument of CHILD 21, realizes that health is a critical and
fundamental element in children’s welfare. However, health programs cannot be implemented in
isolation from the other component that determines the safety and well-being of children in
society

Vision for Children’s Health

A health Filipino child is:

● Wanted, planned, and conceived by healthy parents

● Carried to term by healthy mother
● Born into a loving, caring, stable family capable of providing for his or her basic needs

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 ● Delivered safety by a trained attendant
● Screened for congenital defects these defects are
implemented at the appropriate time
● Exclusively breastfed for at least 6 months, and continued breastfeeding up to two years
● Introduced to complementary foods at about 6 months of age, and gradually to a balanced,
nutritious diet
● Protected from the consequences of protein-calorie and micro-nutrient deficiencies through good
nutrition and access to fortified foods and iodized salt
● Provided with safe, clean, and hygienic surroundings free from accidents
● Properly cared for at home when sick and brought to a health facility for appropriate management
when needed
● Offered equal access to good quality curative, preventive, and promotive health care services as a
member of the Filipino society
● Regularly monitored for proper growth and development, and provided with adequate
physio-social, and mental stimulation
● Screened for disabilities and development delays in early childhood; if disabilities are found,
interventions are implemented to enable the child to enjoy a life of dignity at the highest level of
function attainable.
● Protected from discrimination, exploitation, and abuse
● Afforded the opportunity to reach his or her full potential as adult

Children’s Health Program

Goal: The ultimate goal of Children’s Health 2025 is to achieve good health for all Filipino children by the
year 2025

Garantisadong Pambata

● Is a package of health services that has traditionally been given to children below six years old in
April and October but will now be offered all year-round and will appropriate services and
promotion even for school-aged children.
● GP highlights health-promoting behaviors that parents, caregivers, teachers, leaders, and children
themselves can do in their respective spheres of influence.
● Among the behaviors being promoted are breastfeeding, completion of immunization, regular
Vitamin A supplementation, and deworming, handwashing, toothbrushing, proper toilet use, and
prevention of smoking at home.
1. Newborn Screening
● NBS – is a simple procedure to find out if the newborn has a congenital metabolic disorder that
may lead to mental retardation and even death if left untreated.
● The signs and symptoms of these metabolic disorders are manifested when the ill effects are
already irreversible.
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Newborn Screening in the Philippines

RA 9288 also known as Newborn Screening

Act of 2004

● This law states that, prior to deliver, any health practitioner who delivers, or assists in the
delivery, of a newborn in the Philippines has the obligation to inform the parents or legal
guardian of the newborn of the availability, nature, and benefits of NBS.

Schedule and Method of Screening

● Ideally done on the 48th to the 72 hours of life, NBS may also be done after 24 hours from
birth
● Some disorders are not detected if the test is done earlier than 24 hours
● The baby must be screened again after 2 weeks for more accurate results

Results

● A negative results screen means that the result of the test is normal and the baby is not
suffering from any of the disorders being screened
● In case of a positive screen the NBS nurse coordinator will immediately inform the coordinator
of the institution where the sample was collected to recall patients for confirmatory testing
● NBS can be done by a physician, a nurse, a midwife, or medical technologists in participating
health institutions (hospital, lying-ins, RHUs, and Health Centers)
● If babies are delivered at home, babies may be brought to the nearest institution offering
newborn screening

NEWBORN SCREENING POSSIBLE RESULTS

1. Congenital Hypothyroidism (CH)

a. CH results from lack or absence of thyroid hormone, which is essential to growth of
the brain and the body
b. If the disorder is not detected and hormone replacement is not initiated within (4)
weeks, the baby’s physical growth will be stunted and she/he may suffer from mental
retardation
2. Congenital Adrenal Hyperplasia (CAH)
a. CAH is an endocrine disorder that causes severe salt loss, dehydration, and
abnormally high levels of male sex hormone in both boys and girls
b. If not detected and treated early, babies may die within 7-14 days
3. Galactosemia (GAL)

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 a. GAL is a condition in which the
body is unable to process galactose,
the sugar present in milk
b. Accumulation of excessive galactose in
the body can cause many problems, including liver damage, brain damage, and
cataracts.
4. Phenylketonuria (PKU)
a. PKU is a metabolic disorder in which the body cannot properly use one of the building
blocks of protein called phenylalanine.
b. Excessive accumulation of phenylalanine in the body causes brain damage
5. Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)
a. G6PD deficiency where the body lacks the enzymes called G6PD.
b. Babies with this deficiency may have hemolytic anemia resulting from exposure to
certain drugs, foods, and chemicals.
c. Babies with positive NBS results should be referred at once to the nearest hospitals or
specialist for confirmatory testing and further management.

2. NEWBORN HEARING SCREENING

RA 9709, also known as the Universal Newborn Screening and Intervention Act of 2009
● It established a Universal Newborn Hearing Screening Program (UNHSP) for the early
detection of congenital hearing loss among newborns and referral for early intervention
services to infants with hearing loss
● The law places on any health care practitioner who delivers or assists in the delivery of a baby
in the Philippines. The obligation to inform the parents or legal guardian of the newborn of
the availability. Nature and benefits of hearing loss screening among newborns or infants 3
months old below
● Parents or legal guardians of newborns who refuse to test shall sign a waiver indicating their
understanding of the risks of undiagnosed congenital hearing loss
● Early detection and intervention facilitate speech development and prevent future learning
and psycho-social difficulties of the child with hearing impairment

Laws to Improve the Nutritional Status of Infants and Young Children in the Country

● Executive Order No. 51 – also known as the Milk Code, among other provisions, prohibits
advertising promotion, or other marketing materials that shall imply or create a belief that
bottle feeding is equivalent or superior to breastfeeding
● Executive Order No. 382 – provided for the observance of the National Food Fortification Day
every November 7
● RA 7600 – also known as the Rooming-in and Breastfeeding Act, among other provisions,
states that newborn infants be put to the breast of the mother immediately after birth and

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 roomed-in within 30 minutes after normal
spontaneous deliveries and within 3-4 hours
after birth by caesarian delivery.
● RA 8172 – also known as ASIN (Act for Salt
Iodization Nationwide) Law; requires all procedures of food-grade salt to iodize the salt that
they produce, import, trade, or distribute
● RA 8976 – also known as the Philippine Food Fortification Act; mandates the fortification of
rice with iron, wheat flour with Vitamin A and iron, refined sugar with Vitamin A, and cooking
oil with Vitamin A; and promotes fortification of food products through the Sangkap Pinoy Seal
Program
● RA 10028 – also known as the Expanded Breastfeeding Promotion Act; among other
provisions, mandates the setting up lactation stations in all health and non-health facilities,
establishments, or institutions; and also grants break intervals for nursing employees to
breastfeed or express milk.
● AO 36, s2010 – also known as Expanded Garantisadong Pambata (GP); a comprehensive and
integrated package of services on health, nutrition, and environment for children available
every day at various settings such as homes, schools, health facilities, and communities by
government and non-government organizations, private sectors, and civic groups.

3. NATIONAL IMMUNIZATION PROGRAM

The National Immunization Program was established in 1976 to ensure that infants/children and months
have access to routinely recommended infant/childhood vaccines.

Goals of the National Immunization Program and Supporting Legislation

● To reduce the morbidity and mortality among children against the most common
vaccine-preventable diseases

Laws have given mandate of protecting children through immunization to the DOH and LGUs
● RA 10152, also known as Mandatory Infants and Children Health Immunization Act of 2011,
mandates basic immunization covering the vaccine-preventable diseases
● RA 7846 provided for compulsory immunization against Hepatitis B for infants and children
below 8 years old
o It is also provided for Hepatitis B immunization within 24 hours after birth of babies of
women with Hepatitis B (Congress of the Philippines, 1994a)

Specific Goals of the Program

1. To immunize all infants/children against the most common vaccine-preventable diseases.
2. To sustain the polio-free status of the Philippines

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 3. To eliminate measles infection. Presidential
Proclamation No. 4, 1998 launched the
Philippine Measles Elimination Campaign
4. To eliminate maternal and neonatal
tetanus. Presidential Proclamation No. 106, s 1997 declared a national neonatal tetanus
elimination campaign starting 1997.
5. To control Diphtheria, Pertussis, Hepatitis B, and German Measles
6. To prevent extrapulmonary TB among children

Immunization Schedule for Infants and Young Children

● Wednesday is the designated immunization day in government health facilities unless,
otherwise, revised by local traditions, customs, and other exceptions

⮚ In 2012, two new vaccines were introduced as part of NIP: Rotavirus vaccine and Hib vaccine
⮚ Rotavirus infects the large intestines. It is the most common cause of severe diarrhea in infants
and children. Children between ages of 6 and 24 months are at greater risk in developing severe
Rotavirus infection

Schedule and Manner of Administration of Infant Immunization

c Age Dose Route Site

BCG Vaccine At birth o any 0.05 ml Intra-dermal Right deltoid
time after birth region (arm)
Hepatitis B At birth 0.5 ml Intramuscular Anterolateral
vaccine thigh muscle
DPT-Hepa-Hib 6 weeks 0.5 ml Intramuscular Anterolateral
(Pentavalent 10 weeks thigh muscle
vaccine) 14 weeks
Oral polio vaccine 6 weeks 2 drops Oral Mouth
10 weeks
14 weeks
Anti-measles 9-11 months 0.5 ml Sub-cutaneous Outer part of the
vaccine (AMV1) upper arm
Measles-mumps-r 12-15 months 0.5 ml Sub-cutaneous Outer part of the
ubella vaccine upper arm
(AMV2)
Rotavirus vaccine 6 weeks 1.5 ml Oral mouth
10 weeks

Important Considerations related to the Scheule and Manner of Administering Infant Immunization

● Use of one sterile syringe and needle per client

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 ● There is no need to restart a vaccination
series regardless of the time that has elapsed
between doses
● All the EPI antigens are safe and effective
when administered simultaneously, that is during the same immunization session but at
different sites
o It is not recommended however, to mix different vaccines in one syringe before
injection, or to use a fluid vaccine for reconstitution of a freeze-dried vaccine
o When a vaccine is administered to an infant at the same time with another injectable
vaccine, the vaccines should be administered on different sites
● If more than one injection has to be given on the same limb, the injection sites should be
2.5-5 cm apart to prevent overlapping of local reactions
● The recommended sequence of the co administration of vaccines is OPV first followed by
Rotavirus vaccine, then other appropriate vaccines
● OPV is administered by putting drops of the vaccine straight from the dropper onto the child’s
tongue. Do not let the dropper touch the tongue.
● Only monovalent Hepatitis B vaccine must be used for the birth dose. Pentavalent vaccine
must be used for the birth dose because DPT and Hib vaccine should not be given at birth
● A monovalent vaccine is one that contains an antigen a single disease. Pentavalent vaccine
contains antigens against five diseases: Diphtheria, Pertussis, Tetanus, Hepatitis B, and
Hemophilus Influenza B
● Children who have not received AMV1 as scheduled and children whose parents or caregivers
do not know whether they have received AMV1 as soon as possible, then AMV2 one month
after AMV1 dose
● All children entering day care centers/pre-school and Grade 1 shall be screened for measles
immunization. Those without the immunization shall be referred to the nearest health facility
for immunization
● The first dose of Rotavirus vaccine is administered only to infants aged 6 weeks to 15 weeks.
The second dose is given only to infants aged 10 weeks up to a maximum of 32 weeks.
● Administer the entire dose of the Rotavirus vaccine slowly down one side of the mouth
(between the cheek and gum) with the tip of the applicator directed toward the back of the
infant’s mouth. To prevent spitting or failed swallowing, stimulate the rooting and sucking
reflex of the young infant. For infants aged 5 months or older, lightly stroke the throat in a
downward motion to stimulate swallowing.

NIP Vaccines

Preparations used in NIP

a. Inactivated (killed) microorganisms, attenuated microorganisms like Hepatitis B vaccine, or

toxoids

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b. Attenuated vaccines are live
microorganisms that have been altered so
that they are no longer pathogenic, but are still
antigenic
c. Toxoids are inactivated or altered bacterial exotoxins

c Contents Form
BCG (Bacillus, Calmette, Live, attenuated bacteria Freeze-dried, reconstituted with
Guerin) a special diluent
Hepatitis B vaccine RNA-recombinant, using Cloudy, liquid, in an auto-disable
Hepatitis B surface antigen (HBs injection syringe, if available
Ag)
DPT-HepaB-Hib Diphtheria toxoid, inactivated Liquid, in an auto-disable
(Pentavalent vaccine) pertussis bacteria, tetanus injection syringe
toxoid, recombinant DNA
surface antigen, and synthetic
conjugate of Hemophilus
Influenzae B vaccine
Oral polio vaccine Live, attenuated virus (trivalent) Clear, pinkish liquid
Anti-measles vaccine Live, attenuated virus Freeze-dried, reconstituted with
(AMV1) a special diluent
Measles-mumps-rubella Live attenuated viruses Freeze-dried, reconstituted with
vaccine (AMV2) a special diluent
Rotavirus vaccine Live attenuated virus Clear, colorless liquid, in a
container with an oral applicator
Tetanus toxoid Weakened toxin Sometimes slightly turbid in
appearance: clear, colorless
liquid;

Cold Chain Consideration

1. OPV and AMV are the most sensitive to heat with storage temperature of -15oC to -25oC
2. BCG, DPT, HBV, TT are sensitive to heat and freezing with storage temperature of 2oC to 8oC;
use of cold packs during transport.

c Type/Form of Vaccines Storage Temperature

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Most Sensitive to Heat Oral Polio (live attenuated) -15oC to -25oC (at the freezer)
Measles (freeze dried) -15oC to -25oC (at the freezer)
Least Sensitive to Heat DPT/Hepa B +2oC to +8oC (in the body of the
“D” Toxoid which is a weakened refrigerator)
toxin
“P” Killed Bacteria
“T” Toxoid which is a weakened
toxin
Hepa B +2oC to +8oC (in the body of the
BCG (freeze dried) refrigerator)
Tetanus Toxoid

Side Effects of Vaccination and their Management

Vaccines Side Effects Management

BCG Koch’s phenomenon; an acute No management is needed
inflammatory reaction within 2-4 days
after vaccination; usually indicates
previous exposure to tuberculosis
Deep abscess at vaccination site; Refer to the physician for
almost invariably due to subcutaneous incision and drainage
of deeper injection
Indolent ulceration: an ulcer which Treat with INH power
persists after 12 weeks from
vaccination date
Glandular enlargement of lymph glands Its suppuration occurs, treat as
draining the injection site deep abscess
Local soreness at the injection site
Hepatitis B Local soreness at the injection site No treatment as necessary
vaccine
DPT-HepaB-Hib Fever that usually lasts for only 1 day Advise parents to give
(Pentavalent Fever beyond 24 hours is not due to antipyretic
Vaccine) the vaccine but to other causes
Local soreness at the injection site Reassure parents that soreness
will disappear after 3-4 days
Abscess after a week or more usually Incision and drainage may be
indicates that the injection was not necessary
deep enough or the needle was not
sterile
Convulsion: although very rare, may Proper management of
occur in children older than 3 months, convulsions: pertussis vaccines
caused by pertussis vaccine should not be given anymore
OPV None

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Anti-measles Fever 5-7 days after vaccination in Reassure parents and instruct
vaccine some children; sometimes, there is a them to give antipyretic to the
mild rash child
MMR Local soreness, fever, irritability, and Reassure parents and instruct
malaise in some children them to give antipyretic to the
child
Rotavirus Some children develop mild vomiting Reassure parents and instruct
vaccine and diarrhea, and irritability them to give antipyretic to the
child
Tetanus toxoid Local soreness at the injection site Apply cold compress at the site
No other treatment is needed

Contraindication to immunization

a. There are no contraindications to immunization of a sick child if the child is well enough to go
home.
b. Sending children away and telling mothers to bring them back for immunization
c. Bringing the child back to the RHU/health center for immunization at another time may not
be easy for the mother, leaving the child at risk getting sick of an immunizable disease.

There are few absolute contraindications to the NIP vaccines. Do not give:

1. Pentavalent vaccine/DPT to children over 5 years of age

2. Pentavalent vaccine/DPT to a child with recurrent convulsions or another active neurological
disease of the central nervous system
3. Pentavalent vaccine 2 or 3/DPT 2 or 3 to a child who has had convulsions or shock within 3
days of the most recent dose
4. Rotavirus vaccine when the child has a history of hypersensitivity to a previous dose of the
vaccine, intussusceptions or intestinal malformation, or acute gastroenteritis
5. BCG to a child who has signs and symptoms of AIDS or other immune deficiency conditions or
who are immunosuppressed

Conditions Considered as False Contraindications

1. Malnutrition, which should be considered as an indication that the child especially needs the
protection conferred by immunization;
2. Low-grade fever;
3. Mild respiratory infection; and
4. Diarrhea. Children with diarrhea who are due for OPV should receive a dose of OPV during
the visit. However, the dose is not counted. The child should return when the next dose of
OPV is due.

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QUIZ:

1. A mother brings her 4-month-old infant to a baby clinic for immunization. A nurse would prepare
to administer which of the following immunization to this infant?
a. Penta vaccine and IPV
b. MMR and Hib
c. AMV and Vitamin A capsule
d. Hepatitis B vaccine and OPV
2. A clinic nurse prepares to administer an MMR vaccine to a 12-month-old infant. The nurse
administers this vaccine:
a. Intramuscularly in the anterolateral aspects of the thigh
b. Intramuscularly and Vitamin A capsule
c. Subcutaneously in the outer aspect of the upper arm
d. Subcutaneously in the gluteal muscle
3. A 2-month-old baby boy was brought by his mother to the health center for immunization. He was
given BGC and Hepatitis B right after birth. The nurse is about to give him several immunizations.
Which of the following should be given first?
a. Penta
b. OPV
c. Rotavirus vaccine
d. MMR
4. Some vaccines contain attenuated or live microorganisms. Among the following vaccines, which
contain live viruses? (1) – BCG; (2) – OPV; (3) – AMV; (4) – MMR

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 a. 1, 2, 3
b. 1, 3, 4
c. 2, 3, 4
d. All of these
5. Appropriate storage and transport temperatures of vaccines help in maintaining their potency.
Which vaccine has to be stored in the freezer?
a. BCG
b. OPV
c. AMV
d. Pentavalent
6. During assessment of a baby for immunization, the nurse noted that the baby has a temperature
of 38oC. Which of the following is the nurse’s best course of action?
a. Give paracetamol before the immunization
b. Go ahead and give the immunization
c. Refer the baby to the physician for future assessment
d. Refrain from giving pentavalent vaccine as this causes fever
7. Which of the following vaccines is not administered by intramuscular (IM) injection?
a. Measles vaccine
b. Hepa B vaccine
c. Tetanus toxoid
d. Pentavalent vaccine
8. Which of the following conditions is not true about contraindication to immunization?
a. Do not give BCG if the child has known AIDS
b. Do not give BCG if the child has known hepatitis
c. Do not give pentavalent 2 or pentavalent 3 to a child has recurrent convulsions within 3
days of Penta immunization
d. Do not give pentavalent vaccine to a child who has recurrent convulsions or active
neurologic disease
9. This is vaccine needed before a child reaches one year in order to him/her to qualify as a “fully
immunized child”
a. Measles
b. Pentavalent
c. Hepa B vaccine
d. BCG
10. Hepatitis vaccine is given IM at a dose of 0.5 ml. it can be given as early as:

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 a. 9 months
b. 6 months
c. At birth
d. At school entrant
11. BCG provides protection from the following infections, except:
a. Leprosy
b. TB
c. Meningitis
d. Pneumonia
12. Which is not true of measles vaccine?
a. It can be given at the same time as Pentavalent
b. It should be given at nine months because it provides higher protection than if it is given
at 12 months
c. It is given subcutaneously
d. It is alright to give measles vaccine to a child with diarrhea and low-grade fever
13. Which of the following dose of tetanus is given to the mother to protect her infant from neonatal
tetanus and likewise provide 10 years protection for the mother?
a. TT3
b. TT2
c. TT5
d. TT4
14. The vaccines most sensitive to heat are:
a. Penta and Hepa B
b. BCG and TT
c. OPV and measles
d. BCG ad measles
15. The temperature of the refrigerator where the vaccines are stored should be checked how many
times a day?
a. Two times a day, in the morning and afternoon before going home
b. Three times a day, in the morning, at 12 NN, and at 5PM
c. Once a day as long as the refrigerator is not frequently opened to keep temperature inside
it stable
d. It is not needed to monitor temperature because the refrigerator’s thermostat is
maintained at the desired temperature

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16. A new mother asked the nurse why he must
immunize her baby at so young an age against
hepatitis B when they do not have family history
of the disease. The nurse explains to the mother
that:
a. Hepatitis B infection is easily spread nowadays by droplet and kissing of the baby by
adults
b. Even if the mother is immune against Hepatitis B, the immunity is never transferred to the
baby so all newborns are susceptible
c. Even if no family members have the disease, it is possible that they are carriers and can
still transmit the microorganisms causing Hepatitis to the newborn
d. Hepatitis vaccine contains modified virus that will stimulate antibody production in her
body to provide life-long immunity
17. If the child spits the OPV vaccine administered, the nurse:
a. Should ask the mother to return the child after two days to be given another dose
b. Should give the child another dose immediately
c. Should not give another dose because OPV vaccine is absorbed by the glands in the
tongue immediately after giving it
d. Should ask the child if he swallowed the medication before giving another dose
18. The following two vaccines are easily damaged by heat but not destroyed by freezing
a. DPT and BCG
b. BCG and Hepatitis B
c. TT and BCG
d. Polio and measles vaccine
19. The correct temperature to store vaccines in a refrigerator is:
a. Between +2oC and +8oC
b. Between -4oC and +8oC
c. Between -8oC and 0oC
d. Between -8oC and +4oC
20. You should see to it that measles vaccine is administered as follows:
a. 0.1 ml intradermally
b. 0.5 ml intramuscularly
c. 0.5 ml subcutaneously
d. 2 drops orally
21. In order for a child to be classified as Fully Immunized Child (FIC), he should have received the
following immunizations before he reaches the age of one:

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 a. 3 doses Penta, single dose measles, 5
doses TT, single dose BCG, 3 doses OPV, 3
doses Hepa B
b. Single dose BCG, 3 doses each of Penta,
OPV, measles vaccine, and Hepa B
c. Single dose BCG, 3 doses OPV, one dose Measles vaccine, 3 doses Penta
d. 3 doses OPV, one dose BCG, 3 doses Measles vaccine, 3 doses DPT, single dose Hepa B
22. Measles vaccine is given at what age?
a. Nine months
b. At birth
c. 4-6 weeks
d. Six months
23. Protection against polio is increased if given earlier. When is the right age?
a. Birth
b. 2 weeks
c. 4 weeks
d. 6 weeks
24. How many doses should pentavalent vaccine be given with an interval of 4 weeks?
a. 4
b. 3
c. 5
d. 6
25. Which of the following vaccines is given at birth for protection as part of protection from other
members of the family?
a. Measles
b. BCG
c. DPT
d. OPV
26. BCG is given to protect the baby from infection at what age?
a. At birth
b. At 1 month
c. At 2 months
d. At 9 months
27. Tetanus toxoid is to be given to pregnant mothers. Which immunization gives a 5-year protection
for the mother and 90% protection against neonatal tetanus to infants born from them?

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 a. TT2
b. TT3
c. TT4
d. TT5
28. Which vaccine is a requirement for school entrants regardless of the presence of scar?
a. Penta
b. BCG
c. Anti-tetanus
d. Hepa B
29. At what age of the child should the 7 EPI immunizable diseases be scheduled to provide immunity
to the child?
a. At 2 years old
b. At 8 months old
c. Before child’s first birthday
d. After the child’s first birthday
30. Which of the following is not element of EPI?
a. Target setting
b. Presidential decrees and proclamations
c. Cold chain logistic management
d. Surveillance studies and research
31. The following statement refers to the objective of EPI:
a. Reduce the morbidity and mortality among infants and children
b. Reduce morbidity among children
c. Reduce mortality among children
d. Reduce maternal mortality
32. Which public health law provided the legal basis for the mandatory immunization for infants and
children below 8 years of age?
a. Presidential proclamation no. 6
b. RA 7846
c. RA 10152
d. Presidential decree no. 996

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4. NUTRITIONAL ASSESSMENT ON INFANT AND YOUNG
CHILD

The child’s dietary and health history, such as a recent episode of infections like measles, may point to
key factors that may have influenced the child’s current nutritional status.

Terms to describe different feeding practices

● Exclusive Breastfeeding – this means that the infant receives breast milk (including expressed
breast milk or breast milk from a wet nurse) and allows the infant to receive oral rehydration
salt (ORS), drops, syrups (vitamins, minerals, medicine), but nothing else.
● Predominant Breastfeeding – infant’s predominant source of nourishment has been
breastmilk, including milk expressed or from a wet nurse as the predominant source of
nourishment. However, the infant may also have received liquids – water and water-based
drinks, fruit juice, ritual fluids, and Oresol drops or syrups, such as vitamins, minerals, and
medicines.
● Complementary Feeding – process of giving the infant foods and liquids, along with
breastmilk, when breastmilk is no longer sufficient to meet the infant’s nutritional
requirements.
● Bottle Feeding – this means that the child is given food or drink (including breastmilk) from a
bottle with a nipple/teat. Information on bottle feeding is useful because of the potential
interference of bottle feeding with optimal breastfeeding practices and the association
between bottle feeding and increased diarrheal morbidity and mortality.
● Early initiation of breastfeeding – initiating breastfeeding of the newborn after birth within
90 minutes of life in accordance to the essential newborn care protocol.

NUTRITIONAL ASSESSMENT

Anthropometry – measurement of physical dimensions and gross composition of the body.

Anthropometric assessment of a child to determine nutritional status include:

a. Weight-for-age – reflects body weight relative to the client’s age. This measurement is
used to determine underweight.
b. Length-height-for-age – reflects attained growth in length or height in relation to child’s
age at a given time.
This can help identify children who are short or stunted due to prolonged under nutrition or
repeated illness. However, one must consider the effect of hereditary when using this
measurement.
c. Mid-upper arm circumference (MUAC) – can be used for rapid screening for malnutrition
to identify assessment or treatment. MUAC below 115 mm is an accurate indicator of
severe malnutrition in children aged 6-59 months.
▪ The MUAC is always taken on the left arm.

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 ▪ To measure MUAC, find the
midpoint between the top of the
shoulder and the tip of the elbow
while the child’s left arm is bent.
Wrap a measuring tape around the upper arm at the level of the midpoint. Read
the MUAC while the arm is hanging down the side of the body and relaxed.

d. Clinical examination involves recognition of signs of malnutrition

▪ Data may come from physical examination, such as eye examination for lesions in
VAD, or history taking, such as the mother’s description of her child’s night
blindness.
▪ Clinical examination is useful in detecting micronutrient deficiencies and severe
forms of malnutrition like kwashiorkor and marasmus.
e. Biochemical examination – is the assessment of specific components of blood or urine
samples of an individual in order to measure specific aspects of one’s metabolism. These
are not routinely done in RHUs/health centers because of the cost the tests entail.
▪ A blood test-serum retinol determination – to detect and determine severity of
VAD;
▪ Hemoglobin determination for iron deficiency anemia (IDA) detection;
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 ▪ Urine examination for iodine levels
to detect and determine
severity of iodine deficiency
(ID).

Recommended Infant and Young Child Feeding Practices

1. Early initiation of breastfeeding

2. Exclusive BF for the first 6 months, which is possible, except for a few medical conditions, such
as galactosemia. Infants suffering from phenylketonuria or maple syrup urine disease may still
be breastfed with monitoring of the infant blood level of the non-tolerated amino acids;
3. Extended BF up to 4 years and beyond, which recommended even if the infant’s consumption
of breastmilk declines as complementary foods.
4. Appropriate complementary feeding with use of locally available and culturally acceptable
foods.
5. Micronutrient supplementation.
6. Universal salt iodization since ordinary salt contains very little iodine that cannot provide for
the needs of the human body.
7. Food fortification.

Enhanced Child Growth Strategy

A community-based intervention that aims to improve the health and nutritional status of
children through improved caring and seeking behaviors.

Mother and Baby-Friendly Hospitals Initiative

● Realizing optimal maternal and child health nutrition is the ultimate concern of the Promotion
of Breastfeeding Program.
● Exclusive breastfeeding in the first four (4) to six (6) months after birth is encouraged as well as
enforcement of legal mandates
● It is the main strategy to transform all hospitals with maternity and newborn services into
facilities which fully protect, promote, and support breastfeeding and rooming-in practices.

Guidelines (MBFHI)

1. Counsel pregnant women on the merits of breastfeeding starting at the first encounter, and
reinforced with every subsequent visit.
2. Prescribe non-human milk only when there are valid medical reasons and with information on
the inherent hazards and risks of non-human milk.

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 3. Strongly advocate for the adoption of essential
newborn care, rooming-in, and
breastfeeding standards as mandated by
law.

5. BREASTFEEDING
Promoting Breastfeeding
● Preparation for breastfeeding begins during pregnancy
● To promote the practice of breastfeeding providing mothers and families with adequate,
accurate, and timely information and opportunities for developing necessary skills for good
breastfeeding practices is essential.

Breastfeeding benefits to the child

● Breastmilk provides all of the nutrients an infant need for growth in the first 6 months.
● Breastmilk carries antibodies from the mother that help combat disease. This is particularly
true of colostrum.
● Breastmilk prevents diarrhea because of reduced risk from contaminated formula as well as
of the antibodies in breastmilk. The most abundant type is secretory IgA that protects the
mucosal membrane in the baby’s gut against pathogens.
● Compared to artificially fed infants, breastfed infants have a lower risk of developing later in
life chronic conditions like allergies, asthma, obesity, diabetes, and heart disease.
● Breastfeeding provides benefits for intellectual and motor development of the infant. Many
studies confirm that breastfed children do better on tests of cognitive and motor
development.

Technique of Breastfeeding

● While teaching a woman about the breastfeeding technique, she may express concern about
certain breast and nipple conditions
● If the woman lacks confidence in her capacity to breastfeed because of small breast, the
nurse/midwife must explain to her that the size of her breasts does not affect her capacity to
produce milk.
● Woman has flat or inverted nipples, the nurse/midwife builds the woman’s confidence and
explains that the shape of the nipples is not important.
● When the infant has latched properly to the breast during feeding, he or she suckles the
breast and not the nipple.

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 ● Management of flat or inverted nipples is not
helpful; for example, stretching nipples or
wearing nipple shields does not help.
● The nurse/midwife teaches the mother to
position herself comfortably for breastfeeding, holding the infant does to her body, tummy to
tummy.

Positions when breastfed

1. Cradle hold – the mother sits with her arms supported and, using her arm on the same side as
the nursing breast cradles the infants in front of her body.

2. Cross-cradle hold – similar to the cradle hold, except that the mother cradles her infants with arm on
the opposite side of the nursing breast.

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3. Football, clutch, o underarm hold – the mother sits, holds the infant between her flexed arm
and body, position the infant facing her and supports the infant’s head with her open hand.
Twins may be fed at the same time using the double-football hold.

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 4. Side-lying hold – the mother on her wide with one arm supporting her head. The infant lies
beside the mother, facing the breast. The mother grasps and offers her breast to the infant
with the other hand.

For successful breastfeeding, the infant must properly latch on the mother’s breast. To achieve this,
the mother:
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 1. Provides support by positioning her fingers
against her chest wall below and her thumb
above the breast.
2. Stimulates the rooting reflex by touching her
infant’s lips with her nipple
3. Waits for the infant’s mouth to open wide
4. Quickly moves her infant’s breast (she brings her infant to the breast she does not move
herself on her breast to the infant)
5. Aims her infant’s lower lip below her nipple so that infant’s chin will touch her breast.

The mother is informed of signs that the baby has latched on to the breast properly

a. The baby’s mouth is wide open

b. The lower lip is turned out
c. The chin is touching the breast (or nearly so)
d. More areola is visible above the baby’s mouth than below

Signs that the baby is getting enough milk

a. The baby’s swallowing can be seen or heard

b. You can see or hear the baby swallowing
c. The baby’s cheeks are full and not drawn inward during a feed
d. The baby finishes the feed and releases the breast by himself/herself and looks contented

Associated Problems with Breastfeeding

1. Engorgement – usually the 3rd postpartum day, accompanied by fever (milk fever) and may last
for 24 hours. Recommend a firm fitting brassiere for good support. Apply cold compress if
mother will not be breastfeeding and warm compress if mother will breastfeed.
2. Sore nipples – not contraindication to breastfeeding.
● Teach the mother to expose the nipples to air by leaving the bra unsnapped 10-15
minutes after feeding
● Exposing to 20 watts bulb, 12-18 inches away if exposure is not effective, may also be
performed
● Use nipple shiel but not plastic liners
3. Mastitis – localized pain, swelling, redness in breast tissue, (+) lump.
● Give antibiotics as ordered
● Teach on the application of ice compress including proper breast support
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 ● Discontinue breastfeeding on affected
breast
4. Nutrition – mother should increase intake of all
nutrients
5. Advise mother on family planning methods and responsible spacing of children

6. COMPLEMENTARY FEEDING PRACTICES

From the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is provided
breastmilk, and complementary feeding becomes necessary to fill the energy and nutrient gap.

Ensure that Nutritional Needs are met requires that complementary foods be:
a. Timely – complementary foods are introduced when the need for energy and nutrients
exceeds what can provided through exclusive and frequent breastfeeding
b. Adequate – they should provide sufficient energy, protein, and micronutrients to meet a
growing child’s nutritional needs;
c. Safe – foods are hygienically stored and prepared, and fed with clean hands using clean
utensils and not bottles and artificial nipples.
d. Properly fed – foods are given consistent with a child’s signal of appetite and satiety, and that
meal frequency and feeding method – actively encouraging the child, even during illness, to
consume sufficient food using fingers, spoon, or self-feeding – are suitable for age.

7. MICRONUTRIENT SUPPLEMENTATION

The value of micronutrient supplementation in the attainment of MDG targets is emphasized in

Administrative Order 2010-0010.

Micronutrient supplementation – (vitamins and minerals) is a short-term intervention for correcting high
levels of micronutrient deficiencies until more sustainable food-based approaches can be used
effectively.

The common nutritional deficiencies are:

1. Vitamin A
2. Iron
3. Iodine
● These deficiencies lead to a serious physical, mental, social, and economic condition
among children and women.
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Micronutrient Supplementation for Children
Micronutrient Target population Schedule
Vitamin A Infants 6-11 months old 100,000 once only
Children 12-71 months old 200,000 IU every 6 months
Iron Infants 2-6 months with low 0.3 ml once a day to start at
birth weight (<2,500 g) 2 months until 6 months
when complementary
foods are given

Preparation is 15 mg
elemental iron/0.6 ml
Anemic children 2-5 months 1 tsp. once a day for 3
old months or 30 mg once a
week for 6 months with
supervised
administration

Zinc Supplement
Is also given to children aged 0-59 months and who are having diarrhea.
✔ For infants less than 6 months the dose is 10 mg elemental zinc per day;
✔ For children 6-59 months, 20 mg elemental zinc per day for 10-14 days
✔ Given to children with diarrhea, zinc reduces the duration and severity of the episode
✔ Giving zinc supplements for 10-14 days lower the incidence of diarrhea in the following 2-3
months.

8. FOOD FORTIFICATION

● An addition of micronutrient to staple food such as rice, sugar, cooking oil, flour, and salt.
● This is also mean the addition of micronutrients to processed foods at level above the natural
state.

SANGKAP PINOY SEAL

● is conferred by the DOH and affixed to the packaging of food products that have been
certified as fortified either singly or in combination of the micronutrients, Vitamin A, iron,
and iodine.

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 ● The seal guarantees that the food was
processed in compliance with the
fortification standards of the government.

● Deworming of children aged 1-12 years is done every 6 months

● Children aged 12-24 months are given Albendazole 200 mg or half tablet or Mebendazole 500
mg tablet
● Children older than 2 years are given Albendazole 400 mg or Mebendazole 500 mg tablet.
Both of these drugs require on a full stomach.

Adverse Effects of the Anti-helminthic Drugs and their Respective Management

a. Local sensitivity or allergy - or give an anti-histamine

b. Mild abdominal pain – give an anti-spasmodic
c. Diarrhea – give oral rehydrating solution
d. Erratic worm migration – pull out worms from mouth/nose or from other body orifices

Deworming is not advised if the child is known to have any of the following conditions:

a. Serious illness, such as an illness that requires to a hospital

b. Abdominal pain
c. Diarrhea
d. History of hypersensitivity to the drug, or
e. Severe malnutrition

9. MALNUTRITION IN CHILDREN

1. Protein Energy Malnutrition

● Protein energy malnutrition consists of underweight, stunting, wasting, and
overweight
● Measurement of weight, height, and/or MUAC is important in the detection of these
conditions
● Severe cases
● Present signs as edema and the so-called “baggy pants”

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 Points to Remember about Protein
Energy Malnutrition

● Underweight – as weight for age < -2

standard deviations (SD) of the WHO Child Growth Standards median; mortality risk
of children who are even mildly underweight children are even greater risk

Source: https://www.downtoearth.org.in/news/child-malnutrition-is-down-survey-42484

● Stunting – height for age < -2 SD of the WHO Child Growth Standards median;
stunting is growth retardation with delayed mental development, poor school
performance, and reduced intellectual capacity.

Source: https://africa.cgtn.com/2020/02/09/58-5-million-children-in-africa-suffering-from-stunting/

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 ● Wasting – weight for height < -2
SD of the WHO Child Growth
Standards median; a symptom of
acute under nutrition, usually as a
consequence of insufficient food intake or a high incidence of infectious diseases,
especially diarrhea

Source: https://www.unicef.org/rosa/press-releases/additional-39-million-children-under-5-could-suffer-wasting-south-asia-year-due

● Overweight – defined as weight for height > +2 SD of the WHO Child Growth
Standards median; associated with a higher probability of obesity in adulthood,
which can lead to a variety of disabilities and diseases such as diabetes and
cardiovascular diseases.

Source: https://www.smartparenting.com.ph/health/your-health/waistline-size-normal-bmi-a00286-20190829?ref=article_related

● Severe acute malnutrition (SAM) in children 6-49 months of age – is defined as

weight-for-height less than -3 SD of the WHO Child Growth Standards median, or the
presence of edema of both feet, or a MUAC < 115 mm.

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 Source: https://medium.com/@unicefphils/treating-filipino-children-with-severe-malnutrition-a304afc714d9

● Children with a MUAC < 115 mm should be treated for severe malnutrition
regardless of their weight-for-height
● Pitting edema of both feet is an indication of SAM
o It is verified by applying thumb pressure for 3 seconds on top of both
feet
o The pit will remain in both feet for several seconds
o Both feet have to be examined
o If the edema is not bilateral, it is not an indication of malnutrition
There are three grades of edema, indicated by plus (+) signs:
● Grade + (mild) – both feet/ankles
● Grade ++ (moderate) – both feet, lower legs, or lower arms
● Grade +++ (severe) – generalized edema including both feet, legs, hands,
arms, and face
“Baggy pants” is term used to describe loose skin on the buttocks because of
subcutaneous and muscle tissues.

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 Source: https://www.slideshare.net/csnvittal/protein-energy-malnutrition-for-medicos

● “Baggy pants” helps in detecting visible severe wasting

● For infants less than 6 months old, SAM is detected by the presence of clinical
signs of visible severe wasting and edema, together with difficulties in
breastfeeding.
● Micronutrient Malnutrition
● All Vitamins are micronutrients
● Some minerals like calcium, sodium, potassium, and chlorine are abundantly
present in the body and are therefore not micronutrients.
● Micronutrients enable the body to produce enzymes, hormones, and other
substances essential for proper growth and development.
● Iodine, Vitamin A, and iron are most important in global public health terms;
their lack represents a major threat to the health and development of
populations the world over particularly children and pregnant women.
● Vitamin A deficiency
● Aside from the ill effects of VAD on the eyes, it also diminishes the ability to
fight infections
● Even a mild, subclinical deficiency can be a problem, as it may increase
children’s risk for respiratory and diarrheal infections, decrease growth rates,
slow bone development and decrease the likelihood of survival from serious
illness.
Xerophthalmia – refers to all signs and symptoms affecting the eye that can be
attributed to VAD.

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 Source: https://www.slideshare.net/Jbcshare/xerophthalmia

The following are the eye symptoms of VAD progressing from the mildest, that is, night
blindness, to the potentially blinding condition keratomalacia:

a. Night blindness – difficulty in seeing in the dark with the child refusing to
play after dusk, stumbling on furniture, grouping for food, and asking
questions at dusk, indicating difficulty in seeing.
Night blindness responds rapidly, usually within 24-48 hours to treatment with a
high-dose Vitamin A.

Source: https://www.slideshare.net/Jbcshare/xerophthalmia

b. Conjunctival xerosis – marked dryness of the affected area in the

conjunctiva.
● The area appears roughened, with fine droplets or bubbles on the
surface.
● Conjunctival xerosis usually appears with Bitot’s spots.
● These symptoms respond within 2-5 days to treatment with a
high-dose Vitamin A

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 Source: https://www.slideshare.net/Jbcshare/xerophthalmia

c. Bitot’s spot – foamy, soapy, whitish patches seen in the white part of eye
(scleral conjunctiva). This can be removed but may reaccumulate later if VAD
is not corrected.

Source: https://www.slideshare.net/Jbcshare/xerophthalmia

d. Corneal xerosis – cloudy, dry cornea with an orange-peel appearance.

● Some people call this fish scale
● The child’s vision is diminished even at daytime
● Corneal xerosis responds within 2-5 days to treatment with a
high-dose of Vitamin A
● A corneal regains its normal appearance in 1-2 weeks.

Source: https://www.slideshare.net/Jbcshare/xerophthalmia

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 e. Corneal

ulceration/keratomalacia – soft, bulging cornea with large perforation or

holes in the surface
● Children with prolonged diarrhea and measles frequently prolonged
to this stage
● This may result in perforation, collapse of the eyeball, and blindness
● Emergency treatment with a high-dose of Vitamin A may still save the
other eye.

Source: https://www.slideshare.net/Jbcshare/xerophthalmia

Schedule of high-dose of Vitamin A for high-risk children

Diagnosis Preparation per capsule Vitamin A dosage and schedule

of administration
Measles ● 100,000 IU for infants 6-11 Give one capsule upon diagnosis
months old regardless of when the last dose
● 200,000 IU for children of VAC was given
12-71 months old
Severe pneumonia, persistent ● 100,000 IU for infants 6-11 Give one capsule upon
diarrhea, or malnutrition months old diagnosis, except when the child
● 200,000 IU for children was given VAC less than 4 weeks
12-71 months old before diagnosis
Cases with signs of Vitamin A ● 100,000 IU for infants 6-11 Give one capsule immediately
deficiency (xerophthalmia) months old upon diagnosis
● 200,000 IU for children Give one capsule the next day
12-71 months old and 1 capsule 2 weeks after

Feeding to child with a variety of vitamin A – rich sources, both animal (e.g., milk, egg
yolk, and liver) and plant (dark green leaves and orange – or yellow-colored fruits and
vegetables).

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 2. Iron Deficiency Anemia
● WHO defines anemia in children
under 5 years of age and pregnancy
women as a hemoglobin value > 100
g/liter.
● The finger-prick blood sample test may be done to detect anemia

A simple method of detection of anemia is to assess the child for palmar pallor.

● To detect this sign, hold the child’s palm open by grasping it gently from the side.
Do not stretch the fingers backward as this may cause pallor by blocking the blood
supply.
● Comparing the child’s palm with your own palm of other children helps in
detecting palmar pallor.
● If the skin of the palm is very pale or so pale that it looks white, the child has
severe palmar pallor.
● Iron deficiency is probability the most common cause of anemia
● Other causes include acute and chronic infections that result in inflammation and
hemorrhages, such as Dengue fever, deficiencies of other vitamins and minerals,
especially folate, Vitamin B12, and Vitamin A; and genetically inherited traits, such
as G6PD deficiency.

Micronutrient Supplementation for Children

Micronutrient Target Population Schedule

VAC Infants 6-11 months old 100,000 IU once a day
Children 12-71 months old 200,000 IU every 6 months
Iron Infants 2-6 months with low 0.3 ml once a day to start 2
birth weight (< 2,500 g) months, until 6 months when
complementary foods are given.

Preparation is 15 mg elemental
iron/0.6 ml
Anemic children 2-59 months 1 tsp once a day for 3 months or
old 30 mg once a week for 6 months
with supervised administration

EVALUATION

1. Differentiate food fortification from micronutrient supplementation. Cite an example and explain.
2. If you have a 2-year-old little brother or sister that has iron deficiency anemia, make a health teaching
plan for him/her.

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10. INTEGRATED MANAGEMENT OF CHILDHOOD
ILLNESS
● IMCI has been established as an approach to
strengthen the provision of essential and
comprehensive health package to children.
● It is a simple and effective methods for child survival, healthy growth, and development and is
based on the combined delivery of essential interventions at community, health facility, and
health systems levels.
● The top three leading causes of mortality among children aged 1-4 years were:
o Pneumonia
o Accidents
o Diarrheas and gastroenteritis of presumed infectious origin
IMCI Strategy

1. Improvements is case management skills of health care staff

2. Improvements in the health system needed for effective management of childhood illness
3. Improvements in family and community practices
● It even integrates nutrition, immunization, vitamin supplementation, and counselling
the mother

IMCI Case Management

● IMCI clinical guidelines are meant to be used by the health worker in the management of
sick children from age 1 week up to 5 years.
● They are based on expert clinical opinion and research results

IMCI Protocol Guides for health worker

1. Assessing signs that indicate severe disease

2. Assessing a child’s nutrition, immunization, and feeding
3. Teaching parents how to care for a child at home
4. Counseling parents to solve feeding problems; and,
5. Advising parents about when to return to a health facility

Elements in IMCI Case Management

1. Assess a child by checking first for danger signs (or positive bacterial infection in a
young infant), asking questions about common conditions, examining the child, and

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 checking nutrition and
immunization status. Assessment
includes checking the child for
other health problems.
2. Classify a child’s illnesses using a color-coded triage system. Many children have more
than one condition. Each illness is classified according to whether it requires:
● Urgent pre-referral treatment and referral (PINK)
● Specific medical treatment and advice (YELLOW), or
● Simple advice on home management (GREEN)
3. Identify specific treatments for the child. If a child requires urgent referral, give
essential treatment before the patient is transferred.
● If the child needs treatment at home, develop an integrated treatment plan for
the child and give the first dose of drugs in the clinic
● If a child should be immunized, give immunizations
4. Provide practical treatment instructions, including teaching the mother or caretaker
on how to give oral drugs, how to feed and give fluids during illness, and how to treat
local infections at home.
● Ask the mother or caretaker to return for follow-up on a specific date, and teach
her how to recognize signs that indicate that the child should return immediately
to the health facility.
5. Assess feeding, including assessment of BF practices, and counsel to solve any feeding
problems found. Then counsel the mother about her own health.
6. When a child is brought back to the clinic as requested, give follow-up care and if
necessary, re-assess the child for new problems.

Color-Coded System Uses in the Management of Childhood Illnesses

IMCI Strategy

1. Focused Assessment
Danger Signs

✔ Unable to drink or breastfeed

✔ Vomits everything taken in
✔ Has convulsions, abnormally sleepy, or difficult to awaken

Main Symptoms

✔ Cough or cold, Fast breathing, Stridor, chest indrawing

✔ Diarrhea, signs of dehydration
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 ✔ Fever, S/S associated with malaria,
measles, dengue
✔ Ear pain, mastoiditis

Color Presentation Classification of Diseases Level of Management

Green Mild Home Care
Yellow Moderate Managed at the RHU
Pink Severe Urgent referral to hospitals

Nutritional Status

Immunization Status

Other Problems

✔ Stridor – is a harsh noise made when the child breaths IN

✔ Wheezing noise – when the child breaths OUT
✔ Chest Indrawing – if the lower chest wall goes in when the child breaths IN

2. Classification
● Urgent Referral (Pink/Red)
● Specific Treatment (Yellow)
● Home Management (Green)

3. Treatment
● Treatment includes identifying the treatment, treating counseling and follow-up,
and counseling the caretakers and follow-up.

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EVALUATION

IMCI Integrated Management of Childhood Illness

Comprehensive Examination

1. What is NOT true in IMCI

a. It is a strategy whose goal is to decrease child mortality
b. It is a strategy that targets the most common causes of illness in children
c. It is a strategy that is done only by nurses
d. It is a strategy that is based on a color-coded classification
2. The following are steps in the IMCI strategy with the exception of:
a. Focused assessment
b. Treating the illness
c. Diagnosing the illness
d. Counselling and follow up of cases
3. Classifying the client under the PINK code means what?
a. Treatment will be done in the center
b. The child has pneumonia
c. The child has general danger sign
d. Child is sent home without treatment
4. Which is included in the pink classification?
a. Mastoiditis
b. Measles with eye or mouth complication
c. Persistent diarrhea
d. Malaria
5. A child with diarrhea with some dehydration is classified under what color code?
a. Pink
b. Yellow
c. Green
6. Classifying the client under the GREEN code means:
a. Treatment will be done in the center and continued at home

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 b. The child has a general danger sign
c. The child has pneumonia
d. Child is started on appropriate
antibiotic ASAP
7. When checking for general danger signs, the following questions are asked EXCEPT:
a. Is the child having convulsions?
b. Does the child have diarrhea?
c. Does the child vomit everything?
d. Is the child not able to eat?
8. When checking for general danger signs, the following questions are asked EXCEPT:
a. Is the child eating or breastfeeding less?
b. Has the child had convulsion?
c. Does the child vomit everything?
d. Is the child having cough?
9. The following are the MAIN SYMPTOMS to ask, except:
a. A cough or difficult breathing
b. Fever
c. Feeding problem
d. Diarrhea
10. A child with cough or difficult breathing may have pneumonia. He is assessed for:
a. Rales
b. Nasal flaring
c. Wheezing
d. Chest indrawing
11. Fast breathing is when the respiratory rate of a 12 months old child is:
a. 46
b. 50
c. Both a & b
d. Neither a & b
12. In assessing respiratory status, it is important that:
a. Child must be calm and quiet
b. Is not feeding (sucking)
c. Is not crying
d. All of the above

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13. What are considered as safe throat
remedies in treating cough and colds in
IMCI?
a. Tamarind, calamansi, ginger,
breastmilk
b. Orange juice, sugar water, diluted milk
c. Antiseptic lozenges, antitussive, mucolytics
d. Diluted vinegar, honey with lemon, warm tea with milk
14. A 9 months old child came in has the following symptoms: cough for 4 days with fever of same
duration. She has no general danger signs. Her respiration is counted as 46 per minute. She
has no chest indrawing, no stridor. Her classification would be:
a. Severe pneumonia or very severe disease
b. Pneumonia
c. No pneumonia: cough or cold
d. Allergy
15. A child has classified as severe pneumonia or very severe disease of:
a. He has fast breathing
b. Both A & C
c. He is abnormally sleepy
d. Neither A & C
16. In LOOKING and FEELING for signs of dehydration, which among the following parameters is
not included?
a. Child is abnormally or difficult to awaken
b. Fontanels are sunken
c. Child is restless and irritable
d. Skin pinch goes back slowly
17. If the child has diarrhea for 8 days but he has no dehydration, the following is TRUE except:
a. He is drinking normally
b. He has severe persistent diarrhea
c. His skin pinch went back immediately
d. He is classified in the green row
18. If a febrile child has measles, we:
a. Look for clouding of the cornea
b. See petechiae all over his body
c. Do a blood smear to rule out malaria
d. Classifies the child as in need of urgent referral
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19. We classify the child as mastoiditis,
if:
a. There is tender swelling behind the
ear
b. There is pus draining from the ear for 14 days or more
c. There is ear pain for 14 days or more
d. All of the above
20. What is done if there is ear discharge
a. Wick the ear
b. Air dry the canal by blowing on it
c. Plug the ears with cotton balls
d. Nothing, just let it drip out
21. In the IMCI treatment plan, what is used to clean the mouth if child has measles with mouth
complication/
a. Diluted hydrogen peroxide
b. Diluted betadine
c. Diluted gentian violet
d. Sterile water only
22. What drug is avoided in the control of fever among patients with DHF?
a. Paracetamol
b. Aspirin
c. Acetaminophen
d. Tempra
23. What sign/symptoms would classify a child as Severe Dengue Hemorrhagic Fever?
a. Epistaxis, cold clammy extremities, abdominal pain, hypertension
b. Petechia, abdominal pain with vomiting, and diarrhea, headache
c. Cold clammy skin, persistent abdominal pain, persistent vomiting, gum bleeding
d. Black tarry stools, warm and flushed skin, pallor, dyspnea
24. In giving Vitamin A, the following are true except:
a. Given to patients with severe classification
b. Not given if child is for referral
c. Not given to children younger than 6 months
d. Given a prophylaxis for prevention of complications of IMCI classified conditions
25. The following conditions are treated with oral antibiotic except:
a. Pneumonia
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 b. Eye infection
c. Dysentery
d. Cholera
26. To prevent low blood sugar, she can be given the following treatment except:
a. Ask mother to breastfeed her
b. Giving her expressed breastmilk if she refuses to suck
c. Giving a mixture of condensed milk and water
d. Giving small sips of sugar water
27. In giving ORS, the following are TRUE except:
a. If child vomits while giving it, wait for 10 minutes then give more slowly
b. Stop breastfeeding while giving it
c. May be given with clean water if child is not breastfed
d. May be replaced if not available by mixing sugar and salt with water
28. A child was brought to the center because of ear pain and foul-smelling discharge for almost 3
weeks. He will be classified as:
a. Mastoiditis
b. Acute ear infection
c. Chronic ear infection
d. Vertigo
29. Any sick child should be brought back to the center when:
a. Not able to drink or breastfeed
b. Becomes sicker
c. Develops a fever
d. All of the above
30. A child with ear problem should be assessed for the following except:
a. Is there any fever?
b. Ear discharge
c. If discharge is present, how long?
d. Ear pain
31. An ear discharge that has been present for more than 14 days can be classified as:
a. Chronic ear infection
b. Mastoiditis
c. Acute ear infection
d. Complicated ear infection

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32. If the child has severe classification
because of ear problem, what would be the
best thing that you as the nurse can do?
a. Instruct mother when to return
immediately
b. Refer urgently
c. Give antibiotic for 5 days
d. Dry the ear by wicking
33. If child with no dehydration needs home treatment, which of the following is not included in
the rules for home treatment in this case?
a. Continue feeding the child
b. Give oresol every 4 hours
c. Know when to return to the health center
d. Give the child extra fluid
34. A child who has had diarrhea for 14 days but no signs of dehydration is classified as:
a. Severe persistent diarrhea
b. Dysentery
c. Severe dysentery
d. Persistent diarrhea
35. The IMCI guidelines target which of the following groups of children
a. 0-24 months
b. Under school age children
c. Less than 5 years old
d. Infants
36. Which of the following will be the first action of the nurse in managing childhood illnesses?
a. Assess the patient
b. Classify the disease
c. Treat the patient
d. Counsel the patient
37. The nurse should be able to identify danger signs. Which of the following is considered in IMCI
as a danger sign?
a. Diarrhea
b. Fever
c. DOB
d. Convulsions

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38. If a child is classified in the yellow card, what
will be the level of management to be utilized?
a. Home care
b. Manage at RHU
c. Urgent referral in hospital
d. Any of the above
39. During home visit, the nurse assessed the child with ARI. Which of the following signs indicate
immediate medical attention?
a. Inability to drink
b. Restlessness
c. Fever
d. Cough
40. What vitamin should be given to a child with severe complicated measles?
a. Vitamin A
b. Vitamin B
c. Vitamin C
d. Vitamin D
41. If a child living in malaria-risk area stopped feeding well, vomits everything, is abnormally
sleepy with stiff neck, the child will be classified under what color?
a. Green
b. Yellow
c. Pink
42. If a child was noted to have no dehydration, in what card will she be categorized?
a. Green
b. Yellow
c. Pink
43. A child with any of the general danger signs is classified under what color?
a. Green
b. Yellow
c. Pink
44. A 3-year-old child with cough, respiratory rate of 28, no chest indrawing is under what card?
a. Green
b. Yellow
c. Pink
45. A child with stridor is classified under what color?
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 a. Green
b. Yellow
c. Pink
46. A child is classified to have measles with eye or mouth complications, in what color will he be
classified?
a. Green
b. Yellow
c. Pink
47. A child with sunken eyes, poor skin turgor, sleepy, and does not want to drink is under what
card?
a. Green
b. Yellow
c. Pink

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