Topic outline
UNIT1:HUMAN NUTRITION AND DIETETICS
Assist adequately in preparation of a balanced diet to community, family andindividuals.
Introductory activity 1.1
Observe the Pictures below (A, B, C, D and F) and answer the questions thatfollow:
1. What do the above-mentioned pictures (A, B, C, D, E, and F) communicate
to you?
2. Differentiate the pictures A& B, from the picture E
3. What do you think is the importance of each activity that is being done by
the persons in pictures C, D, and F?4. According to you, what do you think is the focus of this topic?
1.1. Breast feeding
Learning activity 1.1
Observe the following pictures and respond to questions provided below:
1. Describe the activities the pictures above pointed out.
2. Discuss the importance of the ongoing activities in the pictures above
(A,B ).
3. What do you expect to learn in this lesson?
4. Use the fundamentals of nursing and nutrition text books taken from the
library or internet and find out the advantages of breast feeding for mother
and baby, teaching points for breast feeding and contra-indications ofbreast feeding
1.1.1. Introduction to breast feeding
The breast feeding consists of giving mother’s milk to a newborn, infant, or child.
Mature mother’s milk and its precursor, colostrum, are considered the most
balanced foods available for normal newborns and infants. Breastfeeding should be
initiated immediately after the birth of your child. Breast milk is specifically designed
to support optimal growth and development of the newborn, and its composition
makes it uniquely superior for infant feeding.
Exclusive breastfeeding is recommended for the first 6 months of life and should be
maintained until weaning is initiated (there are some exceptions: for example, Oral
iron drops may be needed before 6 months to support iron stores). Breast feeding
is considered adequate to meet the needs of healthy, full-term infants. Even after
solid foods are introduced, breastfeeding should continue for at least the first 12months of age.
1.1.2. Advantages of breastfeeding for the baby
For the first 2-4 days of a baby’s life, breasts will secrete colostrum, a yellowish
fluid rich in proteins. These valuable proteins are essential to the development of a
healthy immune system. The protein is easily digested and absorbed by the body,
especially by the rapidly developing brain. Colostrum provides factors that promote
maturation of the gut and good digestion. Colostrum is the most superior and well
designed nutrition for your baby in the first few days of life.
Breast milk provides superior nutrition to the baby and increases resistance to
infections, and therefore fewer incidents of illness and hospitalization. It decreases
the risk of lactose intolerance. Breast milk is sterile and easily digested. Breastfed
babies experience less nappy rash, they are less likely to develop allergies and
experience fewer constipation. Breastfed infants tend to have fewer cavities.
Breastfeeding promotes the proper development of baby’s jaw and teeth.
Breastfed infants tend to have higher intellectual quotients (IQs) due to good brain
development early in life. They benefit emotionally, because they are held more.
Breastfeeding promotes mother-baby bonding. In the long term, breastfed babies
have a decreased risk of malnutrition, obesity and heart disease compared to
formula fed babies.
Breastfeeding is credited with numerous potential health benefits for the infant,
including lower risks of otitis media, upper respiratory tract infection, lower
respiratory tract infection, asthma, atopic dermatitis, gastroenteritis, obesity, celiac
disease, type 1 and type 2 diabetes, certain types of leukemia, and sudden infant
death syndrome. Although many of these benefits are linked to breast feeding for 3
months or more, some benefits occur with any duration of breastfeeding, such as
the reduced risk of obesity and type 2 diabetes.
1.1.3. Advantages of breastfeeding for the mother
The baby’s sucking causes a mother’s uterus to contract and reduces the flow
of blood after delivery. During lactation, menstruation ceases, offering a form of
contraception. Mothers who breastfeed tend to lose weight and achieve their
pre-pregnancy figure more easily than mothers who bottle feed. Mothers who
breastfeed, are less likely to develop breast cancer later in life. Breastfeeding is
more economical than formula feeding. There are fewer trips to the doctor and less
money is spent on medications. Breastfeeding promotes mother-baby bonding.
Hormones released during breast-feeding create feelings of warmth and calm in
the mother.
1.1.4. Teaching points for breastfeeding
The infant should be allowed to be nursed for 5 minutes on each breast on the firstday to achieve letdown and milk ejection.
By the end of the first week, the infant should be nursed up to 15 minutes per breast.
In the first few weeks of breastfeeding, the infant may be nursed 8 to 12 times
every 24 hours. Mothers should offer the breast whenever the infant shows early
signs of hunger, such as increased alertness, physical activity, mouthing, or rooting.
After breastfeeding is well established, eight feedings every 24 hours may be
appropriate. The first breast offered should be alternated with every feeding so
both breasts receive equal stimulation and draining. Even though the infant will
be able to virtually empty the breast within 5 to 10 minutes once the milk supply
is established, the infant needs to nurse beyond that point to satisfy the need to
suck and to receive emotional and physical comfort. The supply of milk is equal to
the demand the more the infant sucks, the more milk is produced. Infants age 6
weeks or 12 weeks who suck more are probably experiencing a growth spurt and
so need more milk. Water and juice are unnecessary for breastfed infants in the first
6 months of life, even in hot climates. Early substitution of formula or introduction
of solid foods may decrease the chance of maintaining lactation. Infants weaned
before 12 months of age should be given iron-fortified formula, not cow’s milk.
Both feeding the infant, more frequently and manually expressing milk will help to
increase the milk supply. Breast milk can be pumped, placed in a sanitary bottle,
and immediately refrigerated or frozen for later use. Milk should be used within 24
hours if refrigerated or within 3 months if stored in the freezer compartment of therefrigerator.
1.1.5. Breast feeding technique
The breast feeding technique has 3 main parts: effective positioning for the mother,
effective positioning for the baby, attaching the baby to the breast.
a. Effective positioning for the mother
A comfortable position is a prerequisite of comfortable breastfeeding. A woman who
has recently given birth, especially one new to breastfeeding, may need some help
with this. After a caesarean section, or where the perineum is very painful, lying on
her side may be the only position a woman can tolerate in the first few days after
birth. It is likely that she will need assistance in placing the baby at the breast in this
position, because she has only one free hand. When feeding from the lower breast
it may be helpful to raise her body slightly by tucking the end of a pillow under her
ribs. Once the woman can do this unaided, she may find this a comfortable and
convenient position for night feeds, enabling her to get more sleep. Alternatively,
the mother may prefer to sit up to feed her baby, it is particularly important that the
mother’s back is upright at a right-angle to her lap.
Both (arms) lying on her side and sitting correctly in a chair with her back and
feet supported enhance the shape of the breast and allow ample room in which tomanoeuvre the baby.
b. Effective positioning for the baby
The baby’s body should be turned towards the mother’s body so that the baby is
coming up to her breast at the same angle as her breast is coming down to the
baby. The more the mother’s breast points down, the more the baby needs to be on
his back. The advice to have the baby tummy to tummy may be mistakenly taken
to imply that the baby should always be lying on his side. However, taking account
of the angle of the dangle might be more useful. If the baby’s nose is opposite his
mother’s nipple, being brought to the breast with the neck slightly extended, the
baby’s mouth will be in the correct relationship to the nipple.
c. Attaching the baby to the breast
The baby should be supported across the shoulders, so that slight extension of
the neck can be maintained. The baby’s head may be supported by the extended
fingers of the mother’s supporting hand or on the mother’s forearm. It may be
helpful to wrap the baby in a small sheet (Vancouver wrap), so that his hands are
by his side. If the newborn baby’s mouth is moved gently against the mother’s
nipple, the baby will open his mouth wide. As the baby drops his lower jaw and
darts his tongue down and forward, he should be moved quickly to the breast. The
intention of the mother should be to aim the baby’s bottom lip as far away from the
base of the nipple as is possible. This allows the baby to draw breast tissue as well
as the nipple into his mouth with his tongue. If correctly attached, the baby will have
formed a teat from the breast and the nipple.
The nipple should extend almost as far as the junction of the hard and soft palate.
Contact with the hard palate triggers the sucking reflex. The baby’s lower jaw
moves up and down, following the action of the tongue. Although the mother may
be startled by the physical sensation, she should not experience pain. If the baby
is well attached, minimal suction is required to hold the teat within the oral cavity.
The tongue can then apply rhythmical cycles of compression and relaxation so that
milk is removed from the ducts. The baby feeds from the breast rather than from the
nipple, and the mother should guide her baby towards her breast without distorting
its shape. The baby’s neck should be slightly extended and the chin in contact with
the breast. If the baby approaches the breast, a generous portion of areola will be
taken in by the lower jaw, but it is positively unhelpful to urge the mother to try to get
the whole of the areola in the baby’s mouth.
Notes
Many mothers who have had babies before require as much support withbreastfeeding as those who have given birth to their first baby
Reasons for this include:
• Previous unsuccessful breastfeeding.
• Breastfeeding may have gone well last time by chance rather than knowledge.
• The new baby may behave very differently, or have different needs, from the
mother’s previous baby/ babies.
• The mother may have recently fed (or still be feeding) a toddler and has
forgotten quite how much help a new baby requires to breastfeed.
• Their previous baby may have been born at a time when underpinning
information now known to be outdated was thought to be correct.
1.1.6. Contra indications to breastfeeding
It may be contraindicated to the mother to breastfeed her child in some cases. For
example: Galactosemia in the infant, illegal drug use in the mother, and active
tuberculosis. Breast feeding may be also be contraindicated in case of HIV/AIDS –
in some countries, the risk of infant mortality from not breastfeeding may outweigh
the risk of acquiring HIV through breast milk. The use of certain drugs, such as
radioactive isotopes, antimetabolites, cancer chemotherapy agents, lithium, andergotamine constitute a contraindication during breast feeding.
Self-assessment 1.1
1. Identify the advantages of exclusive breast feeding of a child until six
months?2. Outline the teaching points for breast feeding
1.2. Formula-feeding
Learning activity 1.2
Observe the following pictures and respond to questions given below it
1.2.1. Formula-feeding
It may happen that a mother lack or have not enough breast milk for her baby, so
it becomes a requirement to search for other sources of nutrients for replacement
in order to help the child to achieve normal growth and maintain normal health.
A Formula-feeding is a substitute for breast milk that can be used either as an
alternative to breastfeeding or as a way of supplementing it. This should include
proper amounts of water, carbohydrate, protein, fat, vitamins and minerals.
Manufacturers continue to modify their products in an effort to emulate human milk,
and although they provide less than the optimal benefits of human milk, they are
nutritionally adequate for the first year of life.
1.2.2. The three major classes of infant formulas:
a) Milk-based formulas prepared from cow milk with added vegetable oils,
vitamins, minerals, and iron. These formulas are suitable for most healthy
full-term infants.
b) Soy-based formulas made from soy protein with added vegetable oils (for fat
calories) and corn syrup and/or sucrose (for carbohydrate). These formulas
are suitable for infants who cannot tolerate the lactose in most milk-based
formulas or who are allergic to the whole protein in cow milk and milk-based
formulas.
c) Special formulas for low birth weight (LBW) infants, low sodium formulas for
infants that need to restrict salt intake, and “predigested” protein formulas for
infants who cannot tolerate or are allergic to the whole proteins (casein andwhey) in cow milk and milk-based formulas.
The standard formula choice is a cow’s milk-based formula, containing skim
milk powder, lactose and a variable blend of oils. These formulas are available
in two versions: low iron (similar amounts as in human milk, but with much lower
bioavailability) or iron-fortified (12 mg elemental iron/l). Use of low iron formulas is
one of several risk factors implicated in the incidence of iron deficiency anaemia,
the most common nutritional deficiency among infants and toddlers. To provide the
best guarantee of normal iron status, the use of iron-fortified formulas, not low ironformulas is recommended.
Soy-based formulas made from soy protein, vegetable oils and glucose polymers
(±sucrose) are available for infants of vegetarian families, infants with galactosaemia
or lactose intolerance, or infants with IgE-mediated allergy to cow’s milk protein. Soy
formulas are not indicated for low-birth-weight infants, prevention or management
of colic, routine treatment of gastroenteritis, or treatment of infants with non
IgEmediated allergy to cow’s milk protein (i.e. enteropathy or enterocolitis). Recent
concerns with respect to the safety of soy formulas are related to their content of
phyto-oestrogens. Different factors can lead to a low milk supply during breast
feeding or contraindicate it – mother’s disease, use same medications, waiting too
long to start breast-feeding, not breast-feeding often enough. Sometimes previousbreast surgery may affect milk production.
1.2.3. Advantages of formula-feeding
Time and frequency of feedings: Formula-fed babies usually eat less often than
breastfed babies since formula feeds take longer to digest.
Diet: Formula feeds are very important for a mom who needs to be on a medication
that might harm the baby.
Convenience and Flexibility: Your partner or anyone can feed Your Child at any
time without you having to pump, and store breast milk, especially if that isn’t an
option. You don’t need to find a private place to nurse in public.
1.2.4. Disadvantages of formula-feeding
Lack of antibodies: Formula feeds don’t have the antibodies found in breast milk.
As a result, formulas can’t provide to the child with immunity against infection and
illness the way breast milk does.
Unable to match the complexity of breast milk: Formulas can’t measure up to
the complexity of breast milk in the way it changes with baby’s needs.
There’s a need for planning and organization: Breast milk is always available
and at the right temperature, but formula feeds require planning to ensure that you
have all the things you need to prepare it. You must make sure you don’t run out ofstock to avoid making late-night trips to the store.
Also, you must ensure that all the necessary supplies (like bottles and nipples) are
clean, easily accessible, and ready to use. You will have to feed the child 8-10 times
in 24-hours, so if you’re not organized, you can easily get overwhelmed.
Formula can be expensive: Baby formula is quite expensive. The most expensive
type is ready-to-feed formulas, followed by the concentrated type. The least expensive
is the powdered formula. Special formulas, such as soy and hypoallergenic, can
cost even more than the ready-to-feed formulas.
It may cause gassy tummy and constipation: It’s more likely for formula-fed
babies to have gassy tummy and constipation than breastfed babies.
It may increase the risk of infections: Often formulas need to be mixed with
water. So if the water is not 100% free of bacteria or other germs, there is a risk of
infection, and in the first 12 months, this can lead to serious complications for thebaby.
Self-assessment 1.2
1. Identify the major classes of infant formulas.
2. Explain the disadvantages of formula feeding.3. What are the advantages of three major classes of infant formulas?
1.3. Supplementary feeding
Learning activity 1.3
Observe the following pictures and answer the given questions
1.3.1.Vitamin and mineral supplementation
With the exception of vitamins D and K, human milk from well-nourished mothers
provides all the nutrients required for the first four to six months of life. Routine
administration of intramuscular vitamin K at birth has eliminated vitamin K deficiency.
Commercial infant formulas are fortified with vitamins and minerals; therefore,
supplements are unnecessary.
a. Vitamin D
Human milk contains very little vitamin D. Therefore, an additional source is
recommended for exclusively breast-fed infants who may not be exposed to sunlight.
Vitamin D needs will be met from occasional exposure to small amounts of sunlight,
or prophylactic supplementation with 200 IU (5 μg) vitamin D/day. Infants at risk for
vitamin D deficiency and the development of nutritional rickets are those who are
dark-skinned, exclusively breast-fed, living at high northern or southern latitudes,
or weaned to vegetarian diets. Naturally occurring dietary sources of vitamin D are
rare (liver, oily fish), while only milk and margarine may be fortified with vitamin D in
some countries. With increasing use of sunscreen and avoidance of sun exposure
due to the risks of skin cancer, the potential for vitamin D deficiency may be higher.
b. Iron deficiency
Iron deficiency is most common among infants between the ages of 6 and 24 months.
The major risk factors for iron deficiency anemia in infants relate to socioeconomic
status and include the early consumption of cow’s milk, inadequate funds for
appropriate foods, and poor knowledge of nutrition. Other high-risk groups include
low birth weight and premature infants and older infants who drink large amountsof milk (1liter/day) or juice and eat little solid food. The importance of preventing
rather than treating anaemia has been accentuated by findings that iron deficiency
anaemia may be a risk factor for developmental delays in cognitive function and
that this delay is irreversible with iron therapy and persists into early childhood.
Strategies for the prevention of iron deficiency anaemia
In order to prevent iron deficiency anaemia the baby should be exclusively breast
fed during the first 4–6 months, then there will be the introduction of iron-fortified
infant cereal, other iron-rich foods (e.g. strained meats) and enhancers of iron
absorption (vitamin C, e.g. fruit) from 6 months. There is a need of using iron
fortified formula for infants weaned early from the breast or formula fed from birth.
The introduction of unmodified cow’s milk should be delayed until at least 9–12
months of age.
c. Fluoride
Fluoridation of the water supply has proven to be the most effective, cost-efficient
means of preventing dental caries. In areas with low fluoride levels in the water
source, fluoride supplements are recommended.
The increased availability of fluoride (fluoridated water, foods or drinks made with
fluoridated water, toothpaste, mouthwashes, and vitamin and fluoride supplements)
has resulted in an increasing incidence of very mild and mild forms of dental fluorosis
in both fluoridated and non-fluoridated communities.
This sign of excess fluoride intake has led to modifications in fluoride recommendations
including later introduction and lower doses of fluoride supplements, and caution
to parents of young children to use small amounts, and discourage swallowing of
toothpaste. Dental fluorosis has not been shown to pose any health risks and while
there may be mild cosmetic effects, the teeth remain resistant to caries.
d. Cow’s milk
The use of unmodified cow’s milk before 9–12 months of age is not recommended.
In comparison to human milk and iron fortified formula, cow’s milk is higher in
nutrients such as protein, calcium, phosphorus, sodium, and potassium and
significantly lower in iron, zinc, ascorbic acid, and linoleic acid. Nutrients in solid
foods emphasize these excesses and deficiencies, so that cow’s milk-fed infants
receive a higher renal solute load and are at greater risk of eating an unbalanced
diet. In particular, the risk for iron depletion and iron deficiency anaemia is higher
because the iron content of cow’s milk is low and not readily bioavailable and its
absorption may be impaired by the high concentrations of calcium and phosphorus
and low concentration of ascorbic acid in cow’s milk. In addition, intestinal loss of
(blood) iron in the stool is associated with Cow’s milk-feeding in the first six monthsof life. Whole cow’s milk (3.3% butterfat) continues to be recommended for the
second year of life. Two percent milk may be an acceptable alternative provided
that the child is eating a variety of foods and growing at an acceptable rate.Table 1.3. 1 Nutrient content of human milk, formula, and cow’s milk per liter
Self-assessment 1.3
1. Explain how to prevent iron deficiency anemia to an infant during the
weaning period?
2. Identify the nutrients which are highly found in cow’s milk in comparison
to human milk and iron fortified formula?
3. Which foods should be emphasized in order to avoid excesses and
deficiencies resulting from cow’s milk as supplementary food duringweaning period
1.4. Childhood special considerations
Learning activity 1.4
Observe the pictures below
1. What message do you get from each of the above-mentioned pictures?
2. Compare the pictures A and B in terms of the activities that are being
done and their importance.3. What do expect to study in this lesson?
1.4.1. Special considerations for childhood
Childhood is usually regarded as the period between 2 and 10 years. The linear
growth of pre-pubertal children occurs at a relatively constant rate of about 6 cm
per year. The median heights and weights of girls and boys are very similar. In
average, they increase from 87 cm and 12 kg at age 2 years, to 137 cm and 32 kg
at 10 years.
Children are a potentially vulnerable group since they are entirely dependent upon
parents or caregivers for all nutritional needs. Inadequate intakes of energy and
essential nutrients may compromise growth and development to an extent which
may have lasting consequences.
However, in most relatively affluent societies where a wide variety of foods are
available, growth and development usually occur quite satisfactorily without detailed
dietary advice. Obesity, rather than under-nutrition, is the major nutrition-related
disorder. An important consideration is that eating habits determined in childhoodmay be important determinants of chronic disease in later life.
1.4.2. Calories and Nutrients
Total calorie needs steadily increase during childhood, although calorie needs per
kilogram of body weight progressively fall. The challenge in childhood is to meet
nutrient requirements without exceeding calorie needs.
1.4.3. Eating Practices
As children get older, they consume more foods from non -home sources and have
more outside influences on their food choices. School, friends’ houses, childcare
centers, and social events present opportunities for children to make their own
choices beyond parental supervision.
Children who are home alone after school prepare their own snacks and, possibly,
meals.
The ideal of children eating breakfast, dinner, and a snack at home, with a nutritious
brownbag or healthy cafeteria lunch at school, is not representative of what most
children are eating. Children who eat dinner with their families at home tend to have
higher intakes of fruits, vegetables, vitamins, and minerals and lower intakes of
saturated and trans-fatty acids, soft drinks, and fried foods. Family meals promote
social interaction and allow children to learn food-related behaviors. Parents should
provide and consume healthy meals and snacks and avoid or limit empty-calorie
foods.
1.4.4. Nutrients of Concern
Important concerns during childhood include excessive intakes of calories, sodium,
and fat, especially saturated fat. Nutrients most likely to be consumed in inadequate
amounts are calcium, fiber, vitamin E, magnesium, and potassium. The percentage
of children with usual nutrient intakes below the Estimated Average Requirement
(EAR) tends to increase with age and is greater among females than males. It is
recommended to children who consume less than1 L/day of vitamin D–fortified milktakes a supplement of 400 IU/day.
Self-assessment 1.4
1. Identify nutrients which are excessively consumed by children and those
which are consumed in inadequate amounts.
2. What would you recommend to parents/care givers for promoting the
good eating habits of children?
3. What nutrients should be mostly recommended for promoting the growthof children
1.5. Special considerations and nutritional disorders inadolescence
Learning activity 1.5
Observe the pictures below and answer the questions given below:
1.5.1. Introduction
During adolescence physiological age is a better guide to nutritional needs than
chronological age. Energy needs increase to meet greater metabolic demands of
growth. Daily requirement of protein also increases. Calcium is essential for the
rapid bone growth of adolescence, and girls need a continuous source of iron to
replace menstrual losses. Boys also need adequate iron for muscle development.
Iodine supports increased thyroid activity, and use of iodized table salt ensures
availability. B-complex vitamins are necessary to support heightened metabolic
activity.
Many factors other than nutritional needs influence the adolescent’s diet, including
concern about body image and appearance, desire for independence, eating at
fast-food restaurants, peer pressure, and fatty diets. Nutritional deficiencies often
occur in adolescent girls as a result of dieting and use of oral contraceptives.
Skipping meals or eating meals with unhealthy choices of snacks contributes to
nutrient deficiency and obesity.
Fortified foods (nutrients added) are important sources of vitamins and minerals.
Snack food from the dairy and fruit and vegetable groups are good choices. To
counter obesity, increasing physical activity is often more important than restricting
intake.
The onset of eating disorders such as anorexia nervosa or bulimia nervosa often
occurs during adolescence. Recognition of eating disorders is essential for early
intervention. Sports and regular moderate-to-intense exercise necessitate dietary
modification to meet increased energy needs for adolescents.
Carbohydrates, both simple and complex, are the main source of energy, providing
55% to 60% of total daily kilocalories. Protein needs increase to 1 to 1.5 g/kg/day.
Fat needs do not increase. Adequate hydration is very important. Adolescents need
to ingest water before and after exercise to prevent dehydration, especially in hot,
humid environments. Vitamin and mineral supplements are not required, but intake
of iron-rich foods is required to prevent anemia.
Parents have more influence on adolescents’ diets than they believe. Effective
strategies include limiting the amount of unhealthy food choices kept at home,
encouraging smart snacks such as fruit vegetables or string cheese, and enhancing
the appearance and taste of healthy foods.
The ways to promote healthy eating include making healthy food choices more
convenient at home and at fast-food restaurants; and discouraging adolescents
from eating while watching television.
Malnutrition at the time of conception increases risk to the adolescent and her fetus.Most teenage girls do not want to gain weight. Counseling related to nutritional
needs of pregnancy is often difficult, and teens tolerate suggestions better than rigid
directions. The diet of pregnant adolescents is often deficient in calcium, iron, and
vitamins A and C. Prenatal vitamin and mineral supplements are recommended.
1.5.2. Nutritional disorders in adolescence
Adolescence is a stressful time for most young people. They are unexpectedly faced
with numerous physical changes, an innate need for independence, increased work
and extracurricular demands at school, in many cases jobs, and social and sexual
pressures from their peers. For many teens, such stress can cause one or more of
the following problems: anorexia nervosa, bulimia.
a. Anorexia Nervosa
Anorexia nervosa, commonly called anorexia, is a psychological disorder
characterized by an obsessive desire to lose weight by refusing to eat. It is more
common to women than men. It can begin as early as late childhood, but usually
begins during the teen years or the early twenties.
It causes the adolescent to drastically reduce calories, causing altered metabolism,
which results in hair loss, low blood pressure, weakness, amenorrhea, brain
damage, and even death.
The causes of anorexia are unclear. Someone with this disorder (an anorexic)
has an inordinate fear of being fat. Some anorexics have been over-weight and
have irrational fears of regaining lost weight. Some young women with demanding
parents perceive this as their only means of control. Some may want to resemble
slim fashion models and have a distorted body image, where they see themselves
as fat even though they are extremely thin. Some fear growing up. Many are
perfectionistic overachievers who want to control their body. It pleases them to deny
themselves food when they are hungry.
These young women usually set a maximum weight for themselves and become
an expert at “counting calories” to maintain their chosen weight. They also often
exercise excessively to control or reduce their weight. If the weight declines too far,
the anorexic will ultimately die.
Treatment requires the following:
Development of a strong and trusting relationship between the client and the health
care professionals involved in the case. The adolescent should learn and accepts
that weight gain and a change in body contours is normal during adolescence.
There is need to focus on nutritional therapy so that the adolescent understand the
need for both nutrients and calories and how best to obtain them. Individual and
family should be counselled in order to make sure that the problem is understood
by everyone. Close supervision should be done by the health care professional. Forachieving the desired results, there is need of time and patience from all involved.
b. Bulimia
Bulimia is a syndrome in which the adolescent alternately binges and purges by
inducing vomiting and using laxatives and diuretics to get rid of ingested food.
Bulimics are said to fear that they cannot stop eating. They tend to be high
achievers who are perfectionistic, obsessive, and depressed. They generally lack
a strong sense of self and have a need to seem special. They know their binge–
purge syndrome is abnormal but also fear being overweight. This condition is more
common among women than men and can begin any time from the late teens into
the thirties.
A bulimic usually binges on high-calorie foods such as cookies, ice cream, pastries,
and other forbidden foods. While eating, the binge can take only a few moments or
several hours—until there is no space for more food. It occurs when the person is
alone. Bulimia can follow a period of excessive dieting, and stress usually increases
the frequency of binges.
Bulimia is not usually life-threatening, but it can irritate the oesophagus and cause
electrolyte imbalances, malnutrition, dehydration, and dental caries.
Treatment usually includes limiting eating to mealtimes, portion control, and close
supervision after meals to prevent self-induced vomiting. Diet therapy helps teach
the adolescent basic nutritional facts so that he or she will be more inclined to treat
the body with respect. Psychological counselling will help to understand his or her
fears about food. Group therapy also can be helpful.
Both bulimia and anorexia can be problems that will have to be confrontedthroughout the client’s life
Self-assessment 1.5
1. Identify the most required nutritional needs during adolescence age.
2. What are the factors (other than nutritional needs) that influence the
adolescent diet?
3. What are the characteristics of anorexia nervosa?
4. What are the requirements for the treatment of anorexia nervosa?
5. Describe the characteristics of an adolescent suffering from bulimia.6. Discuss the management of bulimia.
1.6. Special nutrition in pregnancy
Learning activity 1.6
1. What are you seeing on the pictures A and B?
2. Describe the activities which are being done on the pictures A and B.
3. What do you think may be the title of today’s lesson?4. What do you think is the role of each food presented on picture C?
1.6.1. Balanced diet
A balanced diet is essential for the good health of a pregnant mother and her baby.
Eating well will provide nutrients that are needed by the mother and her baby. A
healthy diet will also help ensure a healthy weight gain, ensure get the key vitamins
and minerals needed, and reduce the risk of pregnancy complications.Poor nutrition during pregnancy and unhealthy lifestyle behaviors during pregnancy
increase the risk of developing nutrient deficiencies, birth defects and pregnancy
complications, it causes also low birth weight in infants and decreases chances of
survival. Maternal underweight is associated with an increased risk of premature
birth and maternal overweight is associated with a higher frequency of premature
birth, higher Caesarean section rates and increased risk of neural tube defects. A
healthy diet and regular physical activity may reduce the risk of negative pregnancy
outcomes associated with underweight and overweight. Many women mistakenly
believe that during pregnancy they need to “eat for two” (mother and baby).
The energy requirements of pregnancy are related to the mother’s body weight and
activity. The quality of nutrition during pregnancy is important, and food intake since
the first trimester includes balanced portions of essential nutrients with emphasis
on quality. Protein intake throughout pregnancy needs to increase to 60 g daily,
which represents an increase from 46g/d in non-pregnant states. Protein is essential
for the growth and development of fetus. In other words, this increase reflects a
change to 1.1g of protein/kg/day during pregnancy from 0.8g of protein/kg/day for
non-pregnant states.
The pregnant women should eat two to three portions of protein rich foods everyday including lean meat, poultry, seafood, eggs, legumes, tofu, nuts and seeds.
1.6.2. Calcium
Calcium intake is especially critical in the third trimester, when fetal bones are
mineralized. It is especially important for the growth of strong bones. It’s important to
consume adequate amounts of calcium in pregnancy to support the musculoskeletal,
nervous, and circulatory systems. Pregnant women who do not consume sufficient
amounts of calcium are at greater risk of developing osteoporosis later in life.
Pregnant and lactating women need 1000 mg of calcium per day. Pregnant teens
need 1300 mg of calcium per day. Foods rich in calcium include dairy products such
as milk, yoghurt, and cheese. Plant sources include tofu, green leafy vegetables
and fortified foods.
1.6.3. Iron
Iron needs to be supplemented to provide for increased maternal blood volume,
fetal blood storage, and blood loss during delivery. However, by focusing on eating
a variety of iron-rich foods, you should be able to get all the iron you need from
foods. Foods high in iron include red meat such as beef, lamb and eggs, lean beef
and poultry. Plant sources include spinach, and whole grain cereals, dark green,
leafy vegetables, citrus fruits. Iron from plant sources is less readily absorbed by
the body than those from animal foods. Iron absorption can be increased from plant
sources by eating them with foods rich in vitamin C, like fruits and vegetables.1.6.4. Folic acid
Folic acid intake is particularly important for deoxyribonucleic acid (DNA) synthesis
and the growth of red blood cells. Inadequate intake can lead to fetal neural tube
defects, anencephaly, or maternal megaloblastic anemia. Sources of folic acid
include, but not limited to liver, nuts, dried beans, lentils and eggs.
1.6.5. Special consideration
Prenatal care usually includes vitamin and mineral supplementation to ensure daily
intakes; however, pregnant women should not take additional supplements beyond
prescribed amounts. On the other hand, alcohol use during pregnancy can cause
physical and neuro-developmental problems, such as mental retardation, learning
disabilities, and fetal alcohol syndrome. A high caffeine intake is associated withlow birth weight (LBW) but not with birth defects or preterm birth.
Self-assessment 1.6
You are requested to help a pregnant woman who came to your Health Center for
antenatal care in 1st term of pregnancy, which kind of foods you will recommendto her during the remaining period.
1.7. Maternal Diet during lactation
Learning activity 1.7
Observe the pictures below
Nutritional needs during lactation are based on the nutritional content of breast milk
and the energy “cost” of producing milk. Compared with pregnancy, the need for
some nutrients increases, whereas the need for other nutrients falls. The healthy
diet consumed during pregnancy should continue during lactation.
The lactating woman needs 500 kcal /day above the usual allowance because
the production of milk increases energy requirements. Protein requirements during
lactation are greater than those required during pregnancy. The recommended
daily allowance for protein during lactation is an additional 25 g/day. The need for
calcium remains the same as during pregnancy (that is 1000mg/day). Lactating
teens need 1300 mg of calcium per day.
Requirements of many micronutrients increase compared to pregnancy, with the
exception of vitamins D and K, calcium, fluoride, magnesium, and phosphorus. As
such, it is recommended that women to continue to take a prenatal vitamin daily
while they are breastfeeding
There is an increased need for vitamins A and C. Daily intake of water-soluble
vitamins (B and C) is necessary to ensure adequate levels in breast milk.
For many vitamins and minerals, requirements during lactation are higher than
during pregnancy. In general, an inadequate maternal diet decreases the quantity
of milk produced, not the quality. The exceptions are thiamin, riboflavin, vitamin
B6, vitamin B12, vitamin A, and iodine: prolonged inadequate maternal intake of
these nutrients reduces their amount in breast milk and may compromise infant
nutrition. While maternal supplements can correct inadequacies, there are no
consistent recommendations concerning the use of supplements during lactation.
Women are encouraged to obtain nutrients from food, not supplements; however,
iron supplements may be needed to replace depleted iron stores, not to increase
the iron content of breast milk.
Another nutritional consideration during lactation is fluid intake. It is suggested
that breastfeeding mothers drink a glass of fluid every time the baby nurses and
with all meals. Thirst is a good indicator of need except among women who live in
a dry climate or who exercise in hot weather. Fluids consumed in excess of thirst
quenching do not increase milk volume.
In reality, breastfeeding is not always associated with return to preconception
weight, and some women actually gain weight during lactation.
Other considerations concerning maternal diet and breast milk are as follows:
Highly flavored or spicy foods may impact the flavor of breast milk but need only
be avoided if infant feeding is affected. Some babies are irritated by spicy foods,but others are fine with it
So, it is best to lessen the number of spices in food for lactating mother, if she
notices her baby being uncomfortable with it.
Caffeine, alcohol, and drugs are excreted in breast milk and should be avoided.
Consistent evidence shows that when a lactating mother consumes alcohol, it easily
enters breast milk and results in reduced milk production. There is no scientific
evidence to support alcohol consumption during lactation. An occasional drink of
alcohol may occur, but women should not breastfeed for at least 4 hours afterward.
The lactating mother should be aware that caffeine enters breast milk. Maternal
intake should be moderate, such as the equivalent of one to two cups of coffee
daily.
Chocolate is rich in theobromine, and when eaten, has a similar effect to that of
caffeine. Though people love having chocolate, they should cut down the quantitywhile breastfeeding.
Some babies could be intolerant to cow milk. When the mother drinks cow milk or
has dairy products, then the allergens that have entered the breast milk irritate the
baby. After consuming dairy products, if the baby shows symptoms like colic andvomiting, it means that the intake of the dairy products should stopped for a while.
The smell of garlic can affect the smell of breast milk. Some babies hate it while
others like it. Therefore, garlic may be stopped if the baby is uncomfortable while
nursing. Some babies might fuss or grimace at the breast when they encounter
the strong smell of garlic. Until you wean your baby, avoid peanuts, especially if
your family has a medical history of allergies to peanuts. Peanuts allergic proteins
might pass to the produced breast milk, and then reach the baby.
If you consume fish or any other foods having high mercury content, then this will
appear in the breast milk. When breast milk has high levels of mercury, it might
affect the neurological development of your baby. A lactating mother should not
consume fish more than twice a week. It is best to avoid fish that has high mercurycompletely.
If you had broccoli for dinner the previous day, then you should not be surprised
when your baby has gassy problems the next day. Other gassy foods like onions,
cabbage, cauliflower, and cucumber should be avoided while breastfeeding in
case the baby doesn’t tolerate them. Citrus fruits are an amazing source of Vitamin
C, but this can irritate the baby’s stomach due to their acidic components. As their
gastrointestinal tract is immature, they’re unable to deal with these acid components,
resulting in fussiness, diaper rashes, spitting up, and more. The mother doesn’t
have to remove citrus fruits completely from her diet, though. Having one grapefruit
or orange daily is fine. But if she decides to cut them out completely, then sheshould have other vitamin C-rich foods like pineapples, papayas, and mangoes.
Self-assessment 1.7
1. Identify the maternal diet recommended during lactation period.2. What will you discourage to eat or drink during lactation period?
1.8. Special geriatric nutritional needs
Learning activity 1.8
Observe the following pictures
1. What does each of the pictures A, B, C, and D communicate to you?
2. Identify the groups of foods included in picture A and their importance.3. What do you expect to learn from this lesson?
Nutrition plays an important role in health maintenance, rehabilitation, and
prevention and control of disease. When dealing with nutritional issues, nurses
who work with older adults must consider the following: (1) the basic components
of a well-balanced diet for older adults; (2) how the normal physiologic changes of
aging change nutritional needs; (3) how the normal physiologic changes of aging
may interfere with the purchase, preparation, and consumption of nutrients; and
(4) how cognitive, psychosocial, and pathologic changes commonly seen in aging
impact one’s nutritional status.
Nutrition and aging
Nutritional needs do not remain static throughout life. Like other needs, older
adults’ nutritional needs are not exactly the same as those of younger individuals.
An understanding of older adults’ nutritional needs is essential for providing good
nursing care. Good nutrition practices play a vital role in health maintenance and
health promotion. Good eating habits throughout life promote physical wellness
and mental well-being. Inadequate nutrition and fluid intake can result in serious
problems such as malnutrition and dehydration. Poor nutrition practices can
contribute to the development of osteoporosis and skin ulcers, and can complicate
existing conditions, such as cardiovascular disease and diabetes mellitus.
Good eating habits developed early in life promote health in old age. Older adults
are at risk for nutritional problems because of changes in physiology including
changes in body composition, gastrointestinal tract, metabolism, central nervous
system, renal system, and the senses. There are also changes in income, changes
in health, psychosocial changes, and memory loss (senile dementia), which may
include forgetting to eat. Other changes include sensory changes, and physical
problems like weakness, gouty arthritis and painful joints.
Some elderly people have difficulty getting adequate nutrition because of age
or disease related impairments in chewing, swallowing, digesting and absorbing
nutrients. Age-related gastrointestinal changes that affect digestion of food and
maintenance of nutrition include changes in the teeth and gums, reduced saliva
production, atrophy of oral mucosal epithelial cells, increased taste threshold,
decreased thirst sensation, reduced gag reflex, and decreased esophageal
and colonic peristalsis. Their nutrient status may also be affected by decreased
production of chemicals to digest food (digestive enzymes), changes in the cells of
the bowel surface and drug–nutrient interactions.
The presence of chronic illnesses (e.g., diabetes mellitus, end-stage renal disease,
cancer) often affects nutrition intake. Adequate nutrition in older adults is affected
by multiple causes such as lifelong eating habits, ethnicity, and socialization. It is
also affected by income, educational level, and physical functional level to meetactivities of daily living (ADLs), loss, dentition, and transportation.
Adverse effects of medications cause problems such as anorexia, gastrointestinal
bleeding, xerostomia, early satiety, and impaired smell and taste perception.
Cognitive impairments such as delirium, dementia, and depression affect ability to
obtain, prepare, and eat healthy foods.
Some elderly people demonstrate selenium deficiency, a mineral important for
immune function. Impaired immune function affects susceptibility to infections and
tumors (malignancies). Vitamin B6 helps to boost selenium levels, so a higher
intake for people aged 51–70 is recommended.
Nutritional interventions should first emphasize healthy foods, with supplements
playing a secondary role. Although modest supplementary doses of micronutrients
can both prevent deficiency and support immune functions, very high dose
supplementation (example, high dose zinc) may have the opposite effect and result
in immune-suppression. Therefore, elderly people also need special attention with
regard to nutritional care.
Older adults represent a heterogeneous population that varies in health, activity,
and nutritional status. Generalizations about nutritional requirements are lessaccurate for this age group than for others.
Generally, Calorie needs decrease with age; attributed in large part to progressive
decreases in physical activity (a decrease in physical activity directly lowers calorie
expenditure. Indirectly, a decrease in physical activity leads to a loss of lean body
mass).
Requirements for older people increase for calcium and vitamin D. For example,
in order to reduce the risk for age related bone loss and fracture, the requirement
for vitamin D is increased from 200 IU/day to 400 in individuals of 51–70 years
of age and to 600 IU/day for those over 70 years of age. The equivalent of three
glasses of milk is needed to meet calcium requirement in older adults. Calcium
supplements may be necessary to achieve the recommended amount. Other
nutrients important for bone health include vitamin A, vitamin K, magnesium, vitamin
C, and phytoestrogens.
Older adults need to obtain their Recommended Dietary Allowance (RDA) for
vitamin B12 from the synthetic form found in supplements or fortified foods. The
dietary Reference Intakes (DRIs) for sodium decreases due to the decrease in
calorie requirement. The RDA for iron in women decreases when menses stops.
Generally, older adults do not consume enough vitamin E, magnesium, fiber,
calcium, potassium, and probably vitamin D. They should be encouraged to eat
more whole grains, dark green and orange fruits and vegetables, legumes, and milk
and milk products.Screening for nutritional problems is appropriate for all older adults and in all settings.
Screening is essential so that timely nutrition intervention can be instituted. Weight
loss is the most effective dietary strategy against osteoarthritis. The benefits of
weight loss and exercise combined are greater than when either method is used
alone. Benefits include improvements in physical function and quality of life.
Even interventions begun late in life can slow or stop bone loss characteristic of
osteoporosis.
Sarcopenia is the loss of muscle mass and strength that occurs with aging. It is
not inevitable and can be reversed with resistance training and adequate protein
intake. To build muscle in older adults, more protein than the RDA may be required.
The treatment of obesity in older adults is not without risk. Weight loss can be
counterproductive if it comes from a loss of muscle and bone, not fat. For many
older adults, malnutrition presents more of a risk than overweight. A heart healthy
diet may help reduce the risk of Alzheimer disease (AD) and coronary heart disease
(CHD).
Pressure ulcers increase the need for calories, protein, and other nutrients.
Increasing nutrient density without increasing the volume of food served may be the
most effective method of delivering additional nutrients. Between-meal supplementsmay also be needed to maximize intake.
Self-assessment 1.8
1. What are the negative effects that result from poor nutrition practices of
older people?
2. Why older adults are at risk for nutritional problems?
3. Discuss the food components and their sources that should be emphasized
in the diets of older Adults.
1.9. Food security and availability
Learning activity 1.91.9.1.Introduction to Food security and availability
The concept of food security means that the need for households to have both
physical and economic access to the national food supply is fulfilled. The household
food security exists when all the people living in the household have physical,
social and economic access to sufficient, safe and nutritious food at all times. Itshould meet their dietary needs and food preferences for an active and healthy life
Food security is more than simply access to enough food to prevent death by
starvation. The current understanding of food security accordingly emphasizes the
quality of the diet – on the need for dietary diversity and for food that supplies the
micronutrients necessary to create and sustain health.1.9.2. Levels of food and nutrition security
An individual’s food security – at house level, is the final step in a sequence of food
production and distribution, from the availability of food globally and nationally to
access to food at the household level. Global food availability refers to the total
amount of food that is produced globally. Currently, global food availability would
be more than adequate to meet the energy needs of the entire world’s people if theprovision of food was equally distributed.
National food availability refers to the amount of food available for consumption
by a country’s population. This supply of food consists of total agricultural production
(cash crops, livestock, and food crops), net food imports (imports minus exports),
food aid, and food stocks. A country is self-sufficient if it is able to produce 100% (ormore) of its national food requirements
1.9.3. Household Food Security:
Sufficient amounts of food may be available at the national level, but people must
have both physical and economic access to this food. Unless they are able to
generate enough food on their own to provide a balanced diet, they must be able
to reach a place where food is available. National food security is a prerequisite
but no guarantee of household food security. Household food security includes thefollowing:
(1) Households need physical access to a place where food is available.
Households typically obtain food through producing their own crops or livestock for
consumption, purchasing from markets, receiving food as a transfer from relatives,
members of the community, the government, or foreign donors, and gathering in the
wild. Physical availability of food relates to local production, agricultural productivity,
and the ability of markets to deliver food to consumers and agricultural inputs to
farmers. In developing countries, availability through local food production is often
affected by low agricultural productivity, seasonality, and inadequate adoption ofappropriate technologies.
(2) Regardless of the source of food, households must have the means to acquire
appropriate foods. Economic access therefore refers to the affordability of food
to the consumer. The majority of people worldwide, including those in low-income
countries, obtain at least part of their food through markets. Households’ ability topurchase food depends on the households’ income and the price of food.
The factors that affect either food prices or household income influence the people’s
ability to buy food.
(3) Socio-political access: Various social and political factors affect household
food security. Households in developing countries may, for example, have unequal
access to food because of unequal social conditions and exclusionary practices.Social conflict can also threaten the food access of affected people.
The causes of food and nutrition insecurity all relate to either insufficient national
food availability or insufficient access to food by households and individuals.
Several global risks can potentially impact the availability of food at the national level.
These include high and volatile food prices, financial and economic shocks, climate
change, and epidemic outbreaks of human disease and crop and livestock disease.
Other factors may be: the general social, economic, and political environment
prevailing at national level; the presence of natural shocks or conflict; the quality of
commercial and trade policies; the commitment of the political leadership to hunger
reduction; and the prevalence of institutions that enable participation of women
and marginal groups in decision-making processes that affect their future. The
food insecurity at the household level include shocks in production (e.g., harvest
failure), market (e.g., lost employment), or household expenditure (e.g., emergencymedical costs resulting in less money available for food).
Other factors may include, but not limited to the following reasons: rapid
population growth (It is not always easy to purchase food for large numbers of
family members), conflict and/or civil war (interfere with production, marketing
and distribution), and extreme production fluctuation. They include also limited
or lack of employment, lower level of saving, high rate of natural erosion and/
or natural disasters, poor health and sanitation which may lead to the increased
morbidity, mortality and reduced productivity due to illness, deforestation leads
to high top soil erosion and poor soil fertility. It will lead to decreased rainfall anddryness.
1.9.5. Consequences of household food insecurity
The body’s response to chronic hunger and malnutrition is a decrease in body size.
In small children this is known as stunting, or stunted growth, and is indicated by
low weight for height. This process starts as the baby is growing in the uterus, if the
mother is malnourished, and continues until approximately the third year of life. It
leads to higher infant and child mortality, with rates increasing significantly duringfamines.
Once stunting has occurred, improved nutritional intake later in life cannot reverse
the damage. Premature failure of vital organs occurs during adulthood.
For example, a 50-year-old individual might die of heart problems because their
heart suffered structural defects during early development. Stunted individuals
suffer a far higher rate of disease and illness than those who have not undergone
stunting. Severe malnutrition in early childhood often leads to defects in mental
development. Chronic food insecurity will lead to poor growth, slower development,
low educability, school absenteeism or dropout, and increased morbidity and
decreased survival impacting on the socioeconomic development through severalgenerations.
1.9.6. Community-based Actions to address food and nutritioninsecurity
Community-based interventions to improve household food availability and dietary
diversity are considered sustainable solutions to address household food and
nutrition insecurity in developing countries. In these interventions, household
food availability is increased through local production, thereby increasing the
household’s access to diverse and micronutrient-rich foods. Such programs can
also lead to reduced household poverty, improved nutritional status of household
members, and potentially empower women.
Food-based strategies at the community level generally focus on the production
of nutritious food for household consumption. These strategies have the potential
for income generation, provided that households produce a surplus and have easy
access to markets at which to sell their harvest. Economically viable post-harvest
products could further enhance market possibilities for locally produced crops.
To ensure that the gardening activities translate into improved dietary quality,
home-gardening projects need to include a strong nutrition education and behavior
change component. Various entry points can be used for nutrition education
and promotions. The best choice of intervention depends on the nature and
the magnitude of the problem. A situation assessment prior to the intervention
will indicate which elements of food insecurity are involved and who is affected.
Analysis of the underlying causes of food and nutrition insecurity should be the core
of any sustainable intervention that aims to prevent recurrence and does not createdependency.
Self-assessment 1.9
1. Identify the levels of food security.2. What are the causes of food insecurity?
1.10. Food contamination and spoilage
Learning activity 1.10
1. Name the items in the pictures A, B, C, D, E and F and indicate the place
where they are
2. What is happening on picture C and F? What do you think will be theresult?
Bacteria are a major source of microbial contamination of food (i.e., the undesired
presence in food of harmful microorganisms or the harmful substances they
produce). Viruses, parasites and fungi are also able to contaminate food and causefoodborne illnesses in humans
1.10.1.Routes for food contamination
Microorganisms can enter food through different routes including the followings:
Air and dust: Microorganisms are found everywhere in our environment. Many
types of microbes can be found in air and dust, and can contaminate food at any
time during food preparation or when food is left uncovered.
Soil, water and plants: Many microorganisms present in soil and water may
contaminate foods. Microorganisms also grow on plants and can contaminate food
if care is not taken to remove them by washing or inactivate them by cooking.
Gastrointestinal tract: The intestines of all humans and animals are full of
microorganisms, some of which are beneficial but others are pathogenic. Bacterial
pathogens such as Salmonella, Campylobacter and Escherichia coli are common
examples.
Animals: Many foodborne microorganisms are present in healthy animals raised
for food, usually in their intestines, hides, feathers, etc. Meat and poultry carcasses
can be contaminated during slaughter by contact with small amounts of intestinal
contents. For example, in animals slaughtered in rural communities without any
safety measures, microorganisms present in the animals’ intestines can easily
contaminate the meat.
Food handlers: The term food handler can be applied to anyone who touches or
handles food, and this includes people who process, transport, prepare, cook and
serve food. The presence of microorganisms on the hands and outer garments
of food handlers reflects the standard of hygiene in the environment and the
individuals’ personal hygiene.
Food utensils: Food utensils are cutting boards, knives, spoons, bowls and other
equipment used in food preparation, which may become contaminated during food
processing and preparation. For example, in families where there is no access to
running water, the food utensils may not be properly cleaned, stored and handled,
and may become a major route of food contamination.
Cross-contamination of food is the transfer of harmful microorganisms between
food items and food contact surfaces. Prepared food, utensils and surfaces may
become contaminated by raw food products and microorganisms. These can be
transferred from one food to another by using the same knife, cutting board or other
utensil without washing it between uses.
A food that is fully cooked can become re-contaminated if it touches raw foods or
contaminated surfaces or utensils that contain pathogens.
Unsafe temperature: An unsafe temperature for food storage is a major factor in
food contamination. Many microorganisms need to multiply to a very large numberbefore enough are present in food to cause disease in someone who eats it.
Poor personal hygiene: Poor personal hygiene of food handlers is another major
factor in food contamination. The most important contaminants of food are the
microorganisms excreted with faeces from the intestinal tract of humans. These
pathogens are transferred to the food from faecal matter present on the hands.
Pests: Foods can be damaged and also contaminated by pests. Many stored
grains are lost through the damage done by pests, including termites (mist), beetles,
locusts, cockroaches, flies and rodents such as rats and mice. Pests can damage
and contaminate foods in various ways, such as boring into and feeding on theinsides of grains, or tunneling into stems and roots of food plants.
1.10.2. Prevention of food contamination
To prevent contamination, food production and preparation operations need to be
carefully controlled, in order to avoid exposing them to microbial, chemical and /orphysical food contamination.
In order to prevent microbial food contamination people have to have a habit of
hand washing before and during food preparation. Attention also needs to be given
to possible chemical contamination of food. Food can be contaminated through
the misuse or mistaken handling of chemicals, including pesticides, bleach and
other cleaning materials. All chemicals (detergent, disinfectant, sanitiser) used in
the food preparation area should be removed before food preparation begins, to
prevent any chemical contamination of the food. Physical contaminants include
stones, pieces of glass, and metal. Physical contamination can occur at any stage
of the food chain: for example, stones, bones, twigs, pieces of shell or foreign
objects can enter food during handling and preparation. These materials should
be removed, if possible, for example by sieving or picking out the items with cleanfingers.
1.10.3. Food spoilage
Microbial spoilage is caused by microorganisms like fungi and bacteria. They spoil
food by growing in it and producing substances that change the color, texture and
odor of the food. Eventually the food will be unfit for human consumption. Spoilage
may be physical or chemical.
Physical spoilage is due to physical damage to food during harvesting, processing
or distribution. The damage increases the chance of chemical or microbial spoilage
and contamination because the protective outer layer of the food is bruised or
broken and microorganisms can enter the foodstuff more easily.
Chemical spoilage: in this case chemical reactions in food are responsible for
changes in the color and flavor of foods during processing and storage. Foods are
of best quality when they are fresh, but after fruits and vegetables are harvested,
or animals are slaughtered, chemical changes begin automatically within the foods
and lead to deterioration in quality. Fats break down and become rancid (smell
bad), and naturally-occurring enzymes promote major chemical changes in foodsas they age
1.10.4.Factors influencing food spoilage
The factors that can increase or delay the process of food spoilage include its water
content, environmental conditions, packaging and storage. The amount of water
available in a food can be described in terms of the water activity. No matter whether
food is fresh or processed, the rate of its deterioration or spoilage is influenced by
the environment to which it is exposed. The exposure of food to oxygen, light,
warmth or even small amounts of moisture can often trigger a series of damaging
chemical and/or microbial reactions. Changing the environment can help to delay
spoilage (e.g. storing foods at low temperatures).
Packaging helps to protect food against harmful contaminants in the environment
or conditions that promote food spoilage including light, oxygen and moisture. The
type of packaging is a key factor in ensuring that the food is protected. Packaging
of foods in cans, jars, cartons, plastics or paper also serves to ensure food safety if
it is intact, because it provides protection against the entry of microorganisms, dust,dirt, insects, chemicals and foreign material.
General measures for keeping food safe and clean in the household
Safe food-preparation practices should be respected. People have to observe the
following measures for keeping food safe and clean in the household:
1. Hands should always be clean whenever food is handled. Hot water and
soap should be used to wash hands after going to the bathroom, beforehandling cooked foods, and after handling raw food.
2. A person who is ill should not prepare food.
3. During food preparation, contact between hands and the mouth, nose, or
hair should be avoided. Likewise, coughing and sneezing over foods are
forbidden. Tissues or handkerchiefs should be used to prevent contamination.
4. Tasting food with fingers and utensils used during preparation is not advised,
even if the cooking temperature is very hot.
5. Buy fresh foods on the day of consumption when possible, or use before the
expiry date (if indicated).
6. Do not buy foods with any of the danger signs
7. Frozen food should be thawed in a refrigerator, not put in warm water or left
out to thaw.
8. Store foods at the right temperature and covered.
9. Eat meals as soon as possible after preparation.
10. Use clean covered containers for fetching water.
11. Use a safe water supply, or else boil all water before use.
12. Wash hands with soap and water before food preparation, before eating
meals, and after touching animals, dirty areas, or soil or after visiting the
bathroom.
13. Keep food covered.
14. Cook food thoroughly or to the correct internal temperature.
15. Wash all food preparation and eating utensils thoroughly with water and
soap before use.
16. Wash all fruit and vegetables before peeling or eating.
17. Do not cough, spit, or touch the body during food preparation.
18. Keep rubbish bins closed at all times.19. Keep animals away from food preparation areas.
Self-assessment 1.1 0
1. Describe at least 5 routes of contamination of foods2. Identify the general measures for preventing food spoilage?
1.11. Food preservation and storage
Learning activity 1.11
Observe the pictures below:
1. What do pictures A and B communicate to you?2. What do you expect to learn from this lesson?
1.11.1. Food preservation
Food preservation refers to the different techniques that are applied to food to
prevent it from spoiling. The science behind food preservation involves either: (1) the
destruction of micro-organisms responsible for causing food spoilage; (2) reducing/
eliminating the water (moisture) content from food; and (3) altering the temperature
and other conditions that favor the growth of food microorganisms, and thereby
retarding microbial growth and replication (thus delaying food spoilage). Simple
household food preservation techniques are the following:
a. Drying
A number of foods (fruits, vegetables, tubers-cassava, and potatoes) which cannot
be stored for long in their fresh state without spoiling can be preserved by drying.
Before drying, there should be enough sunshine and foods should be sliced in
small pieces for them to dry faster. Dried fruits can be eaten in their dry state (e.g.
dried jackfruit), vegetables and potatoes need to be cooked by boiling in waterwhile dried cassava can be ground into flour and used later
b. Smoking
Smoking meat and fish is a highly recommended method for prolonging their
storage life. The fish is first cooked over a high fire and then smoke-dried in one to
five days (and nights) over a low fire. Fresh-dried fish keeps for up to a week, while
hard-dried fish (keeping fish in salt for several weeks) keeps for several months.
c. Salting
Salting is a simple food preservation method that can be used to prolong the shelf
life of food for a few days. When added to foods, salt takes out moisture and retards
microbial growth and replication.
d. Boiling
Boiling of foods kills food microbes. Perishable foods can be boiled, cooled andkept in clean containers and then used within a day.
1.11.2. Food storage
Storing food in the right way can be a great help in ensuring a household’s food
security. Food storage broadly refers to the different means through which food can
be kept for longer periods without the food spoiling. The shelf life of a food is the
length of time a food remains safe and fit for human consumption. It is essential to
store food properly to ensure the following: food remains in good condition for as
long as possible. Food is protected from flies, dust and other organisms that can
spoil and/or contaminate food. Food is protected from organisms like insects andrats that eat and spoil food.
a. Category of foods
Foods should be stored differently on the basis of how fast they will spoil. Foods
can be categorized into 3 groups:
• Perishable foods (e.g., eggs, milk, and cream, fresh meat and raw fish) have
the shortest shelf life and must be used within a few days. These should be
stored in a clean cool place. In the absence of refrigerators, such foods can
be placed in clean containers, saucepans or pots. The containers can then
be placed in a basin of cold water covered with a clean piece of cloth. In all
circumstances, milk and meat should be consumed within 2 days.
• Semi-perishable foods (e.g., bread, cakes, grain, fresh fruit and vegetables):
Breads and cakes should be stored in a bread bin or tin. Fruit and vegetables
may be stored in a rack or basket. When put in storage, care should always
be taken to remove and discard the particular foods that start showing signs
of spoilage so as to avoid cross-contamination.
• Non-perishable foods: e.g., dry, bottled and tinned foods can be stored in acupboard on their own or in airtight containers.
The recommended storage conditions for foods often vary; the variations even
differ for the same foods depending on the freshness or dryness of the particular
food. The following are the further food categories and their storage methods:
b. Storage of cereals, bread, flour, and rice:
Bread needs to be stored in its original package at room temperature. It should
be used within 5 to 7 days or else it will grow moulds (a sign of spoilage). Cereals
- depending on the quantities and level of dryness - may be stored at room
temperature in tightly closed containers to keep out moisture and insects. Properly
dried cereals packaged in sacs can be stacked on racks in a dedicated food store.
Due attention should be taken to keep out rats that normally feed on stored food.
Grain raw rice can be stored in closed containers at room temperature and used
within one year. Once cooked, rice should be eaten immediately in the absence of
refrigeration.
c. Storing fresh vegetables:
Proper storage of fresh vegetables helps to maintain their quality and retain nutrient
value. Most fresh vegetables need to be stored under low temperatures in areas
which are neither humid nor damp. If available, fresh vegetables can be stored in
a clay pot fridge.
d. Storing fresh fruits:
All fresh fruits generally need to be stored in a cool area, preferably in a clay pot
fridge. Fruits have a tendency to either be contaminated by other foods and or to
absorb odors from other foods. They therefore need to be kept separately.
e. Storing milk and milk products:
Milk is a highly perishable food and yet very nutritious. To prolong its shelf life, milk
should never be left at room temperature for a long time as it spoils quickly. Care
must be taken to keep milk in clean covered containers that should be left to stand
in a cool place. Unrefrigerated milk should be used within a day.
f. Storing meat and fish:
Meat (including poultry), fish, eggs and milk are the best sources of proteins in
the human diet. Given their high protein and moisture content, these products are
highly perishable. It is for this reason that these products will spoil faster than others
- however well prepared and stored. One big contributor to the faster spoilage of
fresh cuts of meat is the fact that these usually contain spoilage bacteria on the
surface that can grow quickly, producing slime and causing spoilage after a few
days. Meat should be prepared and eaten within 24 hours of purchase/slaughter.
Thinly cut pieces of meat are more susceptible to spoilage given the larger surface
area for bacterial action. Meat and meat products should be used within a few days.
If the meat cannot be used within a day, it is advisable to dry, smoke or salt it beforestoring it
Like meat, fresh fish should be eaten immediately. Never store fish in water as this
leads to loss of nutrients from the fish. In order to store fish for longer, it should be
smoked.
g. Storing Root Tubers (Cassava, Sweet Potatoes):
Most root tubers may not be stored well for long after harvest; however, root tubers
keep longer than other vegetables, fruits, meat, milk, etc. When tubers will not be
prepared within a few days, care should be taken to avoid bruising them.
Cassava tubers can also be piled into plenty and watered daily to keep them fresh
or coated with a paste of mud to preserve their freshness. They can keep for about
4-7 days.
Un-bruised sweet potatoes can be kept in a cool, dry place for up to 4-7 days. Care
should be taken to remove any developing buds.Self-assessment 1.11
1. Describe 4 simple household food preservation techniques
2. Explain the storage methods of the following food categoriesa) Storage
of cereals, bread, flour, and rice; (b) Storing fresh vegetables (c) Storing
fresh fruits (d) Storing milk and milk products (e) Storing meat and fish (f)Storing Root Tubers (Cassava, Sweet Potatoes).
1.12. Food habits
Learning activity 1.12
Observe the pictures below:
As humans need to fit into society, it follows naturally that people often adopt a
dietary practice to demonstrate a sense of belonging. For example, people of the
African diaspora may choose to eat African foods on certain occasions or at parties
as an expression of ethnic identity. Food can be linked to status, and this is plainly
seen when people’s dietary habits change as they move up the socio-economic
hierarchy. They tend to go beyond mere consumption of basic essential items
for survival to the purchase and intake of more expensive and indeed unusual
forms of diet that are prestigious and can adequately “match” their status. Foods
that are considered within their own culture as “food for the poor” are consciously
excluded from the daily diet as these could “taint” their achieved social position. In
general, eating with particular people connotes social equality with those people –
many societies regulate who can dine together as a means of establishing class.
Moreover, a gendered dimension is seen in some cultures where women andchildren eat apart from men.
1.12.1.Conservatism of Cuisine
Another aspect of the culture-food interaction is the concept of “conservatism of
cuisine.” Although what people eat is based in part on what has traditionally been
available to them, food habits are also culturally defined. Thus, some food items,
although edible and nutritious, remain taboo among certain population groups. In
essence, what determines consumption of a particular food is not only its availability(and our ability to purchase it) but, importantly, its cultural acceptability
Food preferences, while sometimes purely personal, are strongly determined by
culture and tradition: what is considered acceptable as food is dictated to a large
extent by cultural norms. This explains why people are often reluctant to try foods
that are unfamiliar to them and why they tend to be conservative in their choice ofcuisine.
1.12.2. Food Taboos
A food taboo refers to the act of abstaining from certain foods by reason of culture
or religion. Food taboos dictate what may or may not be eaten, and by whom, at
what periods certain foods may or may not be eaten, and which foods can or cannot
be eaten together. Cultural guidelines may also exist regarding how a particular
crop is to be harvested or how a certain type of animal is to be slaughtered, cooked,
and served. For example, in most Western cultures, the idea of eating dog or horse
meat is unacceptable, as is the thought of eating insects, which are considered a
delicacy in some cultures.
Food taboos can also be tied to the reproductive cycle. Pregnant women, for
example, may be allowed to eat certain foods but not others. Cultural values and
beliefs can also affect infant feeding practices, including the practice of breast
feeding, in ways that may have either a positive or negative impact on a child’s
nutritional status. For example, in some cultures, mothers are told that a child with
diarrhoea should abstain from food in order to “cleanse” the belly. Another widely
held belief in some cultures is that colostrum is “dirty” and should be discarded, and
a baby should therefore not be suckled until the “white milk” appears.
1.12.3. Etiquette
Proper etiquette for serving and eating food also shows great variation between
different cultures. In many cultures, only the right hand may be used for eating,
because the other hand (the left) is, culturally, not suitable, as it is designated for
sanitation purposes. While meals must be eaten silently in some cultures, in others
mealtimes are looked forward to as a period for family discussion and interaction. In
considering all these possibilities, it should be accepted that there are no absolute
right or wrong food habits, as conclusions can only be made within the perspective
of one’s own culture – provided that the food habits in question are of nutritionalbenefit to the consumers.
Self-assessment 1.12
1. What does a food taboo refer to?2. Give 2 examples of food etiquette
1.13. Factors affecting the choice of food
Learning activity 1.13
Observe the following pictures and answer the questions mentioned below
1. What do pictures A and B communicate to you?
2. How would you organize your meal plate in order to be healthy?
3. Use library books of nursing nutrition or internet and write short notes on the
physical/environmental, physiological, social, economic, psychological,religious and cultural factors influencing food choices
Why do people eat what they eat? Food is necessary to sustain life and health, but
people eat certain foods for many reasons other than good health and nutrition,
although these are important factors. Eating behaviors develop from cultural,
societal, and psychological patterns. These patterns, reflecting food habits that
have been transmitted from preceding generations, are the heritage of any given
ethnic group. They may be influenced by interactions with other groups, so that
some intermingling of patterns is inevitable, but modifications are worked into
the total structure over long periods of time and are acceptable only if they fit the
existing customs.
Food patterns reflect a people’s social organization, including their economy,
religion, beliefs about the health properties of foods, and attitudes about family.
Great emotional significance is attached to the consumption of certain foods.
1.13.1.Biological food needs
The biological food needs of a person throughout the life cycle have one requirement.
The food consumed must provide essential chemical substances – nutrients which
the body can digest, absorb, and metabolize. To maintain life and health, the
nutrients must reach the cells.
Adequate nutrient intake depends on many factors, including age, sex, activity,
size, and individual variations. The amounts of required nutrients may vary, but the
types and kinds of nutrients established as being essential to life and health will
remain the same throughout life. Research may add other, as yet unrecognized,essentials as scientific investigation progresses.
1.13.2. Cultural development of food habits
Each particular society that identifies itself with a common denominator (e.g.,
ethnicity, religion, geographic location, and lifestyle) has its own unique cultural
food pattern.
Culture involves much more than the major and historic aspects of a person’s
communal life (e.g., language, religion, politics, location). It also develops from all
of the habits of everyday living and family relationships, such as preparing and
serving food. In a gradual process of conscious and unconscious learning, cultural
values, attitudes, customs, and practices become a deep part of individual lives.
Although part of this heritage may be revised or rejected as adults, people are
ultimately responsible for shaping their own lives and passing traditions on to thesubsequent generations as they see fit.
Food habits are among the oldest and most deeply rooted aspects of a culture. An
individual’s cultural background largely determines what is eaten as well as when
and how it is eaten. All types of customs, whether rational or irrational or beneficial
or injurious, are found in every part of the world. Many foods take on symbolic
meanings related to major life events (e.g., birth, death, weddings). From ancient
times, ceremonies and religious rites involving food have surrounded certain
events and seasons. Food gathering, preparing, and serving have followed specific
customs, many of which remain intact today.
Many different cultural food patterns are part of family and community life. These
patterns have contributed special dishes or modes of cooking to people eating
habits. Older members of the family use traditional foods more regularly, with
younger members of the family using them mainly on special occasions or holidays.
Nevertheless, traditional foods have strong meanings and bind families and cultural
communities in close fellowship. Individual tastes and geographic patterns will vary,
but general food patterns are connected with culture and have a strong influence
on how people eat.
Assumptions about dietary patterns cannot be made, but knowledge of the variety
of unique traditional foods provides a rudimentary understanding of the range of
possible food choices. Such an understanding of various cultural food patterns isvaluable when providing dietary guidance as a health care professional.
1.13.3. Religious Aspects
Food plays different, important roles in many religious faiths and practices. These
roles are usually rigid and tenaciously held by the adherents of the faiths. Then again,
these roles may vary within a faith or philosophy. For instance, most Buddhists are
vegetarians so as to avoid killing animals. Some Buddhists avoid meat and dairy
products, while others only avoid beef.
Many Hindus are vegetarian but this is not obligatory. Muslims follow a list of
foods that are allowed (halal, Arabic for “permitted” or “lawful”) and those that are
prohibited (haram), such as pork and alcohol.
Christian practices vary by denomination and sect. While Catholic and Orthodox
Christians observe several feast and fast days during the year, most Protestants
observe only Easter and Christmas as feast days and don’t follow ritualized fasting.
Some Christians do not drink alcohol, including many members of various Protestant
churches. Seventh Day Adventists avoid both caffeinated and alcoholic beverages,and they are vegetarians.
1.13.4. Social effects
In any society, social groups are largely formed by factors such as economic status,
education, residence, occupation, and family. Accordingly, values and practices
differ among groups. Subgroups also develop on the basis of region, religion, age,
sex, social class, health issues, special interests, ethnic backgrounds, politics, and
other common traits such as group affiliations.
Food habits, like any other form of human behavior, are gradually established with
influences from every direction.
Food is a symbol of acceptance, warmth, and friendliness in social relationships.
People tend to accept food or food advice readily from friends, acquaintances, and
people who they view as trusted authorities. This guidance is especially strong in
family relationships.
Food habits that are closely associated with family sentiments often stay with
people throughout their lives. During adulthood, certain foods may even trigger a
flood of childhood memories and are valued for reasons apart from any nutritional
importance.
1.13.5. Psychological influences
Understanding dietary patterns begins with the recognition of the psychological
influences that are involved. Many of these psychological factors are rooted in
childhood experiences. For example, when a child is hurt or disappointed, parents
may offer a cookie or a piece of chocolate to distract the child. Then, when adults
feel hurt, they may turn to similar comfort foods to help them cope. Certain foods,
especially sweets and other pleasurable flavors, stimulate “feel good” body
chemicals in the brain called endorphins that give a mild “high” that may actually
help ease pain.
1.13.6.Food and psychosocial development
From infancy to old age, emotional maturity grows along with physical development.
At each stage of human growth, food habits are part of both physical and psychosocial
development. For example, a 2-year-old toddler who is taking his first steps toward
eventual independence from his parents may learn to control his parents through
food by refusing to eat at meal times or otherwise being a demanding eater.
Psychologists believe that food neo-phobia may also be involved. This normal
developmental trait may be an instinct from the evolutionary past that protected
children from eating harmful foods when they were just becoming independent fromtheir mothers.
1.13.7. Marketing and environmental Influences
Food habits are also manipulated by television, radio, magazines, and other media
messages. Influences from peers, availability of convenience items, marketing
at the local grocery store, and many other factors of persuasion may sway the
decision-making process for food choices throughout life. Advertising strategies
that make use of brand mascots and cartoon media characters on food packages
greatly impact children’s eating patterns by increasing the preference for products.
Marketing trends and media also influence what a culture views as beautiful and
such provocations may dictate food choices, meal composition, lifestyle, and bodyimage expectations.
1.13.8.Economic Influences
Economics is a very strong factor in the determination of food consumption. The
costs of producing, transporting, and distributing food determine how much and
what types of food are available. Lack of money affects not only the prices that
people can pay for food but also the kinds of storage facilities they can afford
to have within the household. Poor people often must buy cheap foods in small
quantities and purchase items that do not require special storage facilities such as
freezers or refrigerators.
The cost of transportation may prohibit going to a large market, where volume
purchases permit cheaper prices. Poverty is sometimes classified as a subculture
in our society, and different attitudes and adaptations about foods emerge from
this class than those found in the middle or upper classes. Nurses should have anextensive knowledge of these differences.
Self-evaluation 1.13
Analyze your eating patterns. Be as objective as possible. Answer the following
questions about your behaviors.
1. What are the determining factors in the way you eat?
2. What are the determining factors in the amount you eat?3. What determines your likes and dislikes?
1.14. Protein-energy malnutrition
Learning activity 1.14
See the following images and attempt the questions that follows
1. Differentiate the persons in picture A and B based on their physical
characteristics?
2. Describe the hair of the person in Picture B
3. What do you expect to learn from this lesson?
1.14.1. Introduction
An appropriately nourished individual is well equipped to resist disease, recover
from illness, reach an optimal fitness level and enjoy a better quality of life.
Malnutrition is a common problem worldwide. Malnutrition encompasses the
inadequacy of any nutrient in the diet. It includes under–nutrition (in people with
a limited or restricted food intake) and over-nutrition associated with excessive
food intake.
The consequences of malnutrition include an increased risk of diseases and
death, poor productivity of the malnourished individuals as well as poor academic
performance and loss of attendance of children from school. Other consequences are
poverty perpetuation (a vicious circle) and an intergenerational cycle of malnutrition.
Death from protein-energy malnutrition and other nutritional deficiencies occurs
within 60 to 70 days of total starvation in normal weight adults, but over a shorter
period of time in those who are already malnourished. Depletion of nutrient storesalso occurs more rapidly in the ‘metabolically stressed patient’.
1.14.2.Protein-energy malnutrition
Protein-energy malnutrition (PEM) is the inadequate intake of protein, mainly seen
in developing countries. Within a hospital setting in developed countries, protein
energy malnutrition may be due to poor nutritional intake in alcohol misusers or in
those suffering from anorexia nervosa. It may be seen in some conditions, because
of an inability either to adequately absorb nutrients, such as with Coeliac disease,
or to utilize that which is absorbed, such as in cirrhosis. Protein loss can occur
following excessive losses of protein in the urine, such as in nephritic syndrome or
other renal disorders, and in acute surgical trauma or burns, owing to catabolism.
Finally, increased utilization and therefore protein intake requirements occur in
fevers and hyperthyroidism.
Malnutrition can occur in the hospital setting, particularly in older patients who are in
hospital for a number of weeks, owing to poor attention to their nutritional needs, for
example lack of nutrition screening, food left out of the patient’s reach, not providing
appropriate assistance to eat or drink etc.
Kwashiorkor and Marasmus are serious diseases of Protein Energy Malnutrition
(PEM) which develop in young children between 1-3 years of age. They are due to
(a) an inadequate diet, that is a diet lacking in proteins and calories and (b) Infectionssuch as diarrhea, measles, bronchitis which lead the child into malnutrition.
1.14.3. Kwashiorkor
Kwashiorkor is a form of malnutrition caused by protein deficiency in the diet,
typically affecting young children.
a. Causes of Kwashiorkor
The main cause of kwashiorkor is not eating enough protein or other essential
vitamins and minerals.
b. Sign and symptoms
The Signs and symptoms of kwashiorkor are: change in skin and hair color (to
a rust color) and texture, fatigue, diarrhea, loss of muscle mass, failure to grow
or gain weight, edema (swelling) of the ankles, feet, and belly; damaged immune
system, which can lead to more frequent and severe infections; irritability; flaky
rash and shock.
c. Prevention and treatment
Prevention, is mainly done through health education of the parents about nutrition
and breastfeeding; exclusive breastfeeding for the first 6 month is the best; children
should breastfeed up to at least 2 years and the food is introduced slowly from
6 months starting from the soft ones; Immunization, family planning and earlytreatment of any disease.
Curative:
a) Hospitalization.
b) Rehydration: by oral fluids & solution to maintain electrolytes. In severe cases
blood transfusion (10ml/kg) may be prescribed.
d. Complications
Kwashiorkor results in: muscle wasting, a low serum albumin resulting in peripheral
edema (which may make the muscle wasting less obvious) and fatty liver with
hepatomegaly. There is also a reduction in immunity and infections may also be
present. It is usually seen in children and so there is also growth retardation. All
these features are reversible with an adequate protein intake:
1. Secondary immune deficiency.
2. Sever water & electrolytes disturbances.
3. Hypoglycemia.
4. Hypothermia.
5. Heart failure: due to severe anemia, septicemia or due to over hydration
during treatment.
6. Bleeding tendency: due to low vit. K.
7. Blindness due to sever vit.A deficiency.
8. Mental retardation: if Kwashiorkor occurs before 6 months of life.
1.14.4.Marasmus
Definition
It is due to both protein and energy deficiencies; it can occur in anyone with severe
malnutrition but usually occurs in children.
Clinical manifestations: it is characterized by the classic features of starvation,
including: growth reduction, absence of body fat (loss of sub-cutaneous fat, and
marked wasting of muscles (the child is reduced to “skin and bones”).
Treatment:
1) Preventive: as mentioned in Kwashiorkor.
2) Curative:
• Treatment of causes. b) Treatment of complications.
• Diet: Increase calories & protein (of high biological value).
• Increase vitamins & minerals. Vegetables & fruit.• Parental fluid & blood transfusion.
• Antibiotics & anti diarrhea drugs.
Complications:
• Hypothermia.
• Hypoglycemia.
• Infection.
• Gastro enteritis & dehydration.
• Edema: Marasmic Kwashiorkor.
• Bleeding tendency• Congestive heart failure.
1.14.5.Marasmus Kwashiorkor
Definition: This form of edematous Protein Energy Malnutrition (PEM), combines
clinical characteristic of Kwashiorkor and Marasmus.
Clinical signs
The main features are the edema of Kwashiorkor, with or without its skin lesions,
and muscle wasting, loss of subcutaneous fat of Marasmus. Biological features
of both Marasmus and kwashiorkor are seen, but alterations of severe portion
deficiency usually predominate.
Kwashiorkor and marasmus affect not only the physical growth but also mental
development of the child. They can also cause death.
Protein Energy Malnutrition need to be prevented by means of:
• Proper antenatal care of mothers, because a healthy mother give birth to a
healthy baby.
• Promotion of breast feeding.
• Proper weaning of the child.
• The child should be given nutrition supplement starting around the age 6
months as breast milk alone is not sufficient to sustain the growth of the child.
Nutritional supplements can be easily prepared at home using low-cost foods
that are locally available. They are foods such as cereals, millets, ground nuts
and sugar. Proper use of these supplements helps in preventing malnutrition
during the weaning period.
• Nutrition education of the mother.
• Immunization of the child against child hood diseases.
• Food hygiene practices to prevent infections.• Economic development to decrease poverty.
• Improved environmental sanitation.
• Nutrition and health education.
• Family planning.
Main three lines in treatment of Protein Energy Malnutrition (PEM):1) Rehydration 2) Medication 3) Provide of adequate nutrition.
Nursing care plan to PEM:
Nursing diagnosis:
1. Imbalanced nutrition less then body requirements related to lack of parents
knowledge, economic factors, and inability to absorb nutrition or inadequate
food intake.
2. Deficit fluid volume related to diarrhea & vomiting.
3. Subnormal body temperature caused by loss of body heat related to loss
subcutaneous fats.4. Risk for infection related to malnutrition, decrease immunoglobulin.
The usual approach to treatment
1. First phase is the stabilization phase (24-48 Hours): correction of dehydration
and antibiotic therapy to control infection
2. Second phase (an additional week to 10 days): continued antibiotic therapy
And initial diet administration: to provide maintenance requirements of
energy and protein (75 cal/ kg/24hrs and 1 gm /kg /24hrs). Lactose free milk
may be initially given, followed by humanized milk. Correct the electrolyte &
vitamin deficiency
3. Third phase: The child’s appetite is returning and the infections are usually
under control. A diet provide up to 150 kcal/ kg/24hrs and 4 gm /kg /24hrs
of protein. Iron therapy. Blood transfusion is required in case of anemia,serious infection and bleeding tendency (15- 20 ml/kg).
Self-assessment 1.14
1. Differentiate Kwashiorkor from Marasmus in terms of their clinical features,prevention and nursing management
1.15. Specific vitamin deficiencies
Learning activity 1.15
Observe the image below
Vitamins and minerals are essential nutrients in human body because they act in
concert, they perform hundreds of roles in the body. They help shore up bones,
heal wounds, and bolster your immune system. They also convert food into energy,
and repair cellular damage. Their deficiencies affect the whole-body function. Their
main food sources include vegetables and fruits, food from animals (eggs, meat,milk, etc).
1.15.1.Vitamin A deficient
The absorption of vitamin A is related to fat absorption in the gut, and requires
protein for synthesis. Therefore, a deficiency of fat, protein or a gut-related illness
can result in vitamin A deficiency. Deficiency results in growth reduction and visual
problems. Xerophthalmia may occur in vitamin A deficiency and is characterized
by conjunctivitis, abnormal and severe dryness of the surface of the cornea and
conjunctiva.
Bitot’s spots (white, soft deposits on the conjunctiva) and night blindness may also
occur. Where a deficiency exists, there may be a reduction in immunity.
In a previously adequately nourished individual, there are usually enough stores of
vitamin A within the liver to last approximately nine months, so it is not unusual forpatients to present late in chronic illness.
Good dietary sources of vitamin A (and beta-carotene, a precursor to vitamin
A) include: carrots, oily fish, liver and liver products. They also include fortified
margarine and fat spreads, fish liver oils, dairy products (milk, cheese, cream and
butter), egg yolks, peaches, apricots and mangoes, tomatoes and red peppers anddark-green leafy vegetables (such as spinach).
1.15.2.Vitamin B1 (thiamine) deficiency
Vitamin B1 deficiency may be seen in individuals who abuse alcohol, although it is
present in many foodstuffs, vitamin B1 is not present in alcohol. In addition, the body
does not store vitamin B1, as it is a water-soluble vitamin. Thiamine is mainly required
during the metabolism of carbohydrates, fat and alcohol. Diets high in carbohydrate
require more thiamine than diets high in fat. The deficiency is commonly known as
beriberi. ‘Dry beriberi’ refers to the development of neurological problems, such as
Wernicke’s encephalopathy (ataxia, confusion, nystagmus and sixth cranial nerve
palsy), peripheral and motor neuropathy. ‘Wet beriberi’ refers to the development
of neurological problems with additional heart failure. The problems are reversible
if sufficient thiamine is given, intravenously if necessary.
Sources of thiamine: Thiamine is not evenly distributed in cereal grains – most of
it is present in the outer ‘germ’ layer. Other good sources include: yeast and yeast
extract, wholegrain cereal foods, pork, nuts and pulses.Many breakfast cereals are fortified with thiamine.
1.15.3.Vitamin B2 (riboflavin)
Vitamin B2 is water-soluble and is found in small amounts in many foods. However,
levels rapidly decrease under serious illness or with the intake of some drugs,
for example amitriptyline, imipramine, chlorpromazine or oral contraceptives. A
deficiency of riboflavin results in lesions on the muco-cutaneous surfaces of the
mouth (angular stomatitis, atrophic lingual papillae and magenta tongue), cracked,
bleeding lips and glossitis. Itchy perineum and hair loss may be seen. There may
also be neurological sequelae with photophobia and ataxia.
Riboflavin deficiency is often accompanied by iron deficiency – possibly as a result
of impaired absorption.
Good dietary sources of riboflavin include: yeast and yeast extract, liver and offal
meats, green, leafy vegetables, eggs, milk and dairy products and cereals andcereal products.
1.15.4.Vitamin C (ascorbic acid)
Vitamin C is water-soluble and easily destroyed in cooking. It is biochemically activein collagen synthesis, iron absorption and in immunologic function. Therefore, not
surprisingly, a deficiency in vitamin C, better known as ‘scurvy’, is characterized by
swollen, bleeding gums, wiry hair, anaemia and a predisposition to infections, and
easy bruising. People with poor diets devoid of fresh food, and those with increased
vitamin C requirements, such as cigarette smokers or post-operative patients, are
likely to have suboptimal levels. Owing to its role in collagen synthesis, adequate
vitamin C is essential for wound healing.
Good dietary sources of vitamin C include:
• Fruits and fruit juices (particularly citrus fruits, strawberries, kiwi fruit, berries,
currants and guava)
• Some green vegetables (such as green peppers, broccoli, cabbage and springgreens); however, significant losses can occur during storage and cooking
Self-assessment 1.15
1. Discuss the physical characteristics of the people with the following
vitamin deficiency: Vitamin A, B1 (thiamine), B2 (riboflavin) and C
2. What are the good dietary sources of the following vitamins: Vitamin A,B1 (thiamine), B2 (riboflavin) and C
1.16. Specific mineral deficiencies
Learning activity 1.16
See the picture A and B mentioned below:
1. Find out the types of foods displayed in picture A
2. Characterize the health status of the lady in picture B
3. What do you think may be the consequences of lacking the foods inpicture A in human body organism?
1.16.1. Folic acid
Folic acid is the parent molecule of a large number of derivatives collectively known
as ‘folates’. The role of folic acid is also known in preventing neural tube defects
in early pregnancy. In deficiency states, it causes megaloblastic anaemia, atrophic
tongue and growth retardation.
Deficiency is most likely to occur as a result of:
• Mal absorption (e.g., in coeliac disease): The use of certain drugs interferes
with folic acid metabolism (notably methotrexate to treat rheumatoid arthritis
and anticonvulsants used in the treatment of epilepsy).
• Cell proliferation: Some disease states can cause an increase in cell
proliferation (e.g., leukaemia).
Good dietary sources of folates include: liver, green vegetables, yeast extract,pulses and some fruits (oranges and orange juice).
1.16.2.Zinc
A deficiency in zinc may occur in patients who require long-term administration of
parenteral or enteral feeding, if they have high requirements, with only standard
amounts being provided. There are very small body stores of zinc; so, problems
can arise if it is not present within the diet on a regular basis. Conditions which
predispose people to zinc deficiency are related to:
• Reduced intake (perhaps associated with an eating disorder)
• Reduced absorption/bioavailability (owing to an inhibitor, such as a highphytate diet)
• Increased losses (such as in diarrhoea or excessive vomiting)
• Increased requirement associated with growth (also in pregnancy/lactation)
and are Secondary to conditions such as alcoholism.
Deficiency results in poor hair quality and hair loss. Changes in the skin result
in crusty lesions around the nose and mouth, followed by fingers, toes and the
perineal area. The patient may go on to develop diarrhoea, mental confusion and
depression. There is also an increased susceptibility to infections, as zinc has a
critical role in immune-competence.
Zinc deficiency in childhood results in stunted growth. Zinc is also thought to play a
role in taste acuity, and a loss of taste (hypogeusia) may result from zinc deficiency.
Zinc has a critical role in protein synthesis and in structural proteins; hence, a
deficiency may impair wound healing. It has been postulated that zinc is related
to appetite, as it is not unusual to have a loss of appetite with subclinical zincdeficiency.
Good dietary sources of zinc include: red meat, fish and shellfish, milk and milk
products, poultry, and eggs. Other sources of zinc include bread and cereal products,green, leafy vegetables and pulses, although these all have a lower bioavailability.
1.16.3.Iron
Iron is an essential component of haemoglobin and myoglobin, with its major
function being that of carrying oxygen. Many enzymes contain or require iron,
and it is required for many metabolic processes. In contrast to other minerals, no
mechanism exists in the body to excrete iron, therefore body levels of iron are
regulated by absorption. Iron deficiency results in a reduced ability to transport
oxygen around the body. This can have many harmful effects on cardiovascular
and respiratory systems, brain and muscle function, and wound healing.
Both a deficiency and excess of iron are associated with an increased susceptibility
to infection. Iron deficiency, with or without anemia, results in a wide range of
defects in immune function.
Good dietary sources of iron include:
• Red meat, liver and offal, poultry and fish (contain smaller amounts)
• Cereal products and fortified breakfast cereals; these can contribute significant
amounts of non haem iron, but this is less well absorbed than iron from meat
products (haem iron).
• Other good sources of non-haem iron include green leafy vegetables, dried
fruit, pulses, nuts and seeds.
Having a good source of vitamin C (for example fruit or fruit juice) with foods that
contain non haem iron can enhance the absorption of iron. Tannins and phytates
can inhibit the absorption of non-haem iron.
Iron and zinc compete for absorption, which is why it can be a disadvantage for
people to self-supplement with either of these nutrients unless there is a provendeficiency and they are under medical supervision.
Self-assessment 1.16
1. Discuss the consequences resulting from the lack of the following minerals
in human body: folic acid, zinc, and iron2. What are the good dietary sources of (a) folic acid, (b) zinc and (c) iron
1.17. Over-nutrition conditions
Learning activity 1.17
Observe the pictures below:
1. What does each of the pictures A, B, C, and D communicate to you?
2. Identify the groups of foods included in picture A and their importance.3. What do you expect to learn from this lesson?
Over-nutrition overview
Over-nutrition is a growing health problem globally. Obesity often coexists with
under-nutrition in developing countries and is a complex condition, with serious
social and psychological dimensions, affecting virtually all ages and socio-economicgroups.
The reproductive risks of over-nutrition or obesity include infertility or difficulty with
conception, gestational diabetes, hypertension (pregnancy-induced), premature
birth, and increased rates of caesarean section, as well as a birth weight of greater
than 4000 grams. Overweight and obesity are important risk factors for most of
the chronic disorders. Indeed, there is a strong interrelationship between many of
chronic disorders and risk factors.
Early identification by means of nutritional screening, dietary treatment, and
monitoring of obese pregnant women as part of standard prenatal care may affectoutcomes for the mother and infant.
Overweight is defined as having a BMI that is more than 25. It is related to an
excessive body weight, not necessarily excessive body fat. Muscle, bone, fat, and
water all contribute to body weight. Obesity, on the other hand, is defined as having
a BMI ≥30, a condition characterized by excess accumulation of body fat.
Overweight and obesity are important risk factors for most of the chronic disorders.
Indeed, there is a strong interrelationship between many of chronic disorders andrisk factors.
1.17.1.The Causes of Obesity
Obesity is a completely unnatural human condition. Dozens of studies from around
the world have convincingly shown that obesity is absent when people eat the
traditional diet for their region. The disorder appeared when people began to adopt
a more modern, Westernized lifestyle.
A major factor leading to obesity is reduced physical activity. This occurs as a
result of the combination of urbanization and labor-saving machinery. A few decades
ago, the majority of people in developing countries lived in villages and engaged in
agricultural work or other occupations that require much physical labor. Over recent
decades, many tens of millions have relocated to cities. Most jobs today require far
less expenditure of energy. At the same time, thanks to the availability of cars andbuses, people today typically walk much less than people used to.
Another major cause of obesity is the widespread availability of highly palatable,
energy-dense food (i.e., high quantity of kcal per gram). A large amount of
accumulated evidence demonstrates how such food leads to excess intake of food
energy – in other words, over-nutrition. Such foods have four key features: a high
fat content, high refined sugar content, low fiber content, and a high energy density.
These features of the modern, Western diet should not be viewed singly: they act
synergistically.
Let us start with dietary fat. The majority of human studies indicate that a high-fat
diet induces excessive energy intake and hence weight gain. The next heavy factorin the obesity epidemic is sugar. In particular, sugar-sweetened beverages have a
similar effect on energy balance as does dietary fat: consuming these drinks leads
to spontaneous overconsumption of food. With respect to weight control fruit juices,
as far as is known, have no advantage over soft drinks.
Another important dietary component with respect to obesity is fibre. Fibre has the
opposite action in the body of sugar and fat; the presence of fibre in foods tends to
induce satiation (a feeling of fullness), thereby bringing about a halt to eating. This
can be illustrated by comparing a slice of whole wheat bread, a slice of white bread,
and 170 mL of cola drink (about half a tin). They each have 170 kcal. Compared
with whole wheat bread, the white bread has only half as much fiber, and cola is
lacking of fiber altogether. This difference is clear when these foods are eaten:
white bread can be eaten more quickly than whole wheat bread and produces less
satiation. The cola can be consumed even more quickly and produces minimal
satiation.
The role of fiber in retarding the development of obesity is supported by strong
epidemiologic evidence. Detailed comparisons have been made between the
satiating effects of the major components of food. In general, fat has the least
satiating action, next is carbohydrate, then protein, while fiber has the most.
An important factor that determines the satiating ability of a particular food is its
energy density. Foods with more concentrated energy (more kcal per gram) have
less satiating power (i.e., little appetite satisfaction relative to energy consumed),
and they are therefore more likely to lead to overconsumption of food energy. This
may be a major reason why food fat causes weight gain: because fat has more
than twice as much energy per gram as either protein or carbohydrates, fat-rich
foods tend to be energy dense. Conversely, foods with high water content have a
low energy density and can therefore satiate the appetite before much food energy
has been consumed. Many types of fruit and vegetables, such as apples, melon,
carrots, and cabbage, have high water content and are therefore particularly good
at satisfying the appetite.
We can summarize as follows: Doughnuts and biscuits (cookies) are a mixture of
fat, sugar, and refined flour, with a minimal content of water and fiber. They are the
type of food that readily causes people to overeat and become overweight. In stark
contrast, no one ever became overweight by eating too many carrots or by drinking
too much tomato soup!
One more factor deserves mention in a discussion of the causes of obesity is portion
sizes. These have been steadily expanding for the past 40 years. For example,
plates in restaurants are significantly larger now than they were a few decades ago.
In the case of bottle sizes for cola drinks, these are now three or four times larger.This is potentially important because evidence shows that when people have more
food placed in front of them, they eat more. This problem appears to be additive
when combined with increased energy density.
An accepted wisdom concerning obesity is that most people who try to lose weight
fail, and of those that do lose weight, most regain it. By comparison, avoiding obesityin the first place is a much easier goal to accomplish.
1.17.2.Complications of Obesity
Obesity significantly increases mortality and morbidity. It is associated with a wide
variety of comorbidities, including diabetes, hyperlipidemia, fatty liver disease,
obstructive sleep apnea, gastro-esophageal reflux disease, vertebral disk disease,
osteoarthritis, and increased risk of certain cancers. Abdominal obesity, part of
the metabolic syndrome, increases the risk of coronary heart disease and type
2 diabetes. Obesity increases the risk of complications during and after surgery
and the risk of complications during pregnancy, labor, and delivery. Higher body
weights are associated with higher mortality from all causes. Obesity increases the
risk of complications during and after surgery and the risk of complications during
pregnancy, labor, and delivery. Higher body weights are associated with higher
mortality from all causes.
Obesity presents psychological and social disadvantages. In a society that
emphasizes thinness, obesity leads to feelings of low self-esteem, negative self
image, depression, and hopelessness Negative social consequences include
stereotyping; prejudice; stigmatization; social isolation; and discrimination in social,
educational, and employment settings.
1.17.3.The Treatment of Obesity
A lifestyle approach that includes nutrition therapy, physical activity, and behavior
modification is the basis of comprehensive weight management. Pharmacotherapy
and surgery may be used in conjunction with lifestyle interventions, based on the
individual’s body mass index (BMI) and the presence of comorbidities.
Attempts to lose weight (i.e., body fat) usually achieve little success. It is important
that people wishing to lose weight have realistic goals. An appropriate goal is to
lose between 200 and 900 grams per week, or 10% of body weight over 6 months.
Setting more ambitious goals is a recipe for disappointment. Moreover, rapid weight
loss increases the probabilities of later regaining the weight. Many overweight people
dream of achieving a shape that requires losing 30% of their weight. When they fail
to achieve this, they feel they have failed. In reality, losing 10% of body weight is a
success because it results in significant improvement to long-term health, such as
a decrease in blood pressure or blood cholesterol, or an improvement in ability to
walk quickly.
The first step in losing weight is the adoption of an energy-reduced diet. Anappropriate target is to cut energy intake by 500 to 1000 kcal per day.
It is of prime importance to recognize the major causes of obesity and put these
into reverse. In other words, a person should follow a healthy lifestyle that includes
a diet that has a generous content of fiber-rich foods, is moderate in fat, is low
in sugar, and has a low energy density.
Exercise is especially important. There is much evidence that achieving weight
loss – and long-term avoidance of weight regain – requires around 60 or 90 minutes
of exercise every day, such as walking at a brisk pace. If the intensity is greater,
as in the case of jogging for example, then the time required is reduced to 30
to 45 minutes per day. One of the secrets for losing weight is to engage in high
levels of physical activity (approximately 1 hour per day), eating a low-calorie, low
fat diet, eating breakfast regularly, self-monitoring weight, and maintaining a
consistent eating pattern across weekdays and weekends. Moreover, weight
loss maintenance may get easier over time; after individuals have successfully
maintained their weight loss for 2 to 5 years, the chance of longer-term success
greatly increases.Here are additional rules that are helpful for people trying to lose weight:
1. Eat small portions.
2. Eat breakfast every day.
3. If a person wishes to have sweet-tasting beverages, then replace sugar with
synthetic sweeteners.
4. Avoid buying foods that encourage overeating, and don’t have the “wrong”
foods easily accessible. If you can’t resist chocolate, then keep chocolate
out of easy reach.
5. Stay away from buffets or other locations where overeating is made easy.
6. Try to identify factors that trigger overeating. For example, many people
react to stress by overeating. Reducing stress is one example of changing
behavior so that overeating is avoided.
7. Buy a pedometer. These devices count the number of steps walked. An
appropriate goal is 10,000 steps per day.
8. Join a group that actively supports weight loss, increased fitness, and
healthful eating. This could be, for example, a commercial organization or a
group of friends.
9. Eating at regular, frequent intervals may help prevent extreme hunger and
reduce the risk of binge eating. Meal patterns should be individualized.
10. Measure weight frequently,
11. Watching TV for a limited period of time,
12. Nletting a small weight gain become a big weight gain, and13. Pharmacotherapy is adjunctive therapy in the treatment of obesity. Drugs
are not effective in all people, and they are only effective for as long as they
are used.
14. Surgery to promote weight loss therapy involves limiting the capacity of the
stomach. Gastric bypass also circumvents a portion of the small intestine to
cause mal absorption of calories. Both types effectively promote weight loss
but are tools, not magic strategies.
15. Bariatric surgeries require lifelong changes in eating behaviors to ensure
continued success. The postsurgical diet progresses from clear liquids to
pureed food to a soft diet. Small, frequent meals are necessary to avoid
overstretching the pouch. Sugars are avoided to decrease the risk of dumping
syndrome. Nutritional deficiencies are a lifelong risk, requiring preventative
supplementation.16. Perhaps most important of all: be determined!
Self-assessment 1.17
1. What are the complications that result from obesity?2. Discuss the dietary management of obesity?
1.18. Assessment of nutritional status of a client
Learning activity 1.18
Observe the pictures below:
Nutritional assessment is a systematic process used for collecting client’s nutrition
information, interpreting them in order to make decisions about the nature and cause
of nutrition related health issues that affect the person. Nutritional assessment
focus on the interpretation of anthropometric, biochemical (laboratory), clinical and
dietary data to determine whether a person or groups of people are well nourished
or malnourished (over-nourished or undernourished). Nutritional assessment can
be done using the ABCD methods. These refer to the following:
A: Anthropometry; B. Biochemical methods; C: Clinical methods; D: Dietary methods
The type of data needed for health and diet history is subjective and involves
interviews and food records. The accuracy of both approaches depends on the
skill of the interviewer and the client’s memory, perception, and cooperation. It
is important that the interviewer learn something about the client’s life and the
factors that influence his or her eating habits (such as money, storage facilities,transportation, and ethnicity).
1.18.1.Anthropometric assessment
Anthropometry is the measurement of the size, weight, and proportions of the body.
Common anthropometric measurements include weight, height, MUAC, head
circumference, skinfold and body mass index (BMI).
a. Weight
Weighing is usually the first step in anthropometric assessment and a prerequisite
for finding weight-for-height z-score (WHZ) for children and BMI for adults. Weight
is strongly correlated with health status. Unintentional weight loss can mean
poor health and reduced ability to fight infection. Low pre-pregnancy weight andinadequate weight gain during pregnancy are the most significant predictors of
intrauterine growth retardation and low birth weight.
b. Height
Measuring length or height requires a height board or measuring tape marked in
centimeters (cm). Measure the length for children who are under 2 years of age
or less than 87 cm long. Measure height for children of 2 years and older who are
more than 87 cm tall and for adults.
c. The head circumference (HC)
HC is the measurement of the head along the supra orbital ridge (forehead)
interiorly and occipital prominence (the prominent area on the back part of
the head) posterior. It is measured to the nearest millimeter using flexible, non
stretchable measuring tape around 0.6cm wide. HC is useful in assessing chronic
nutritional problems in children under two years old as the brain grows faster during
the first two years of life.
d. Mid-Upper Arm Circumference (MUAC)
MUAC is the circumference of the left upper arm measured at the mid-point between
the tip of the shoulder and the tip of the elbow, using a measuring or MUAC tape.
MUAC measurements in millimeters (mm) are more accurate than measurements
in cm. Use MUAC to measure all pregnant women and women up to 6 months
postpartum. MUAC is not currently recommended for infants under 6 months and
should not be used to assess nutritional status in people with edema.
e. Skinfold measurement
Skinfold measurement is a technique to estimate how much fat is on the body. It
involves using a device called a caliper to lightly pinch the skin and underlying fat in
several places. This quick and simple method of estimating body fat requires a high
level of skill to get accurate results. The seven skin sites for skinfold measurement
are the followings: triceps, chest/pectoral, midaxillary, subscapular, suprailiac,
abdominal, and thigh.
f. Body Mass Index (BMI)
BMI is an anthropometric indicator based on weight to-height ratio. It is used to
classify malnutrition in non-pregnant/non-postpartum adults. BMI is not an accurate
indicator of nutritional status in pregnant women or adults with edema.BMI=Weight (Kg)/Height2 (m)
1.18.2. Clinical methods
In this part the nurse will assess clinical signs and symptoms that might indicate
potential specific nutrient deficiency. Special attention is given to organs such as
skin, eyes, tongue, ears, mouth, hair, nails, and gums. Clinical methods of assessing
nutritional status involve checking signs of deficiency at specific places on the body
or asking the patient whether they have any symptoms that might suggest nutrientdeficiency.
1.18.3.Biochemical assessment
Biochemical assessment means checking levels of nutrients in a person’s blood,
feces, urine or other tissues that have a relationship with the nutrient. Laboratory
test results provide to health care professionals useful information about medicalproblems that may affect appetite or nutritional status.
Table 1.18 3 Blood tests useful for determining nutritional status
Many parameters are useful in assessing nutrition status, including anthropometric,
laboratory, physical, and historical data. These data form the basis for interpreting
nutrient needs and determining how they will be met. Each client’s individual needs
in all the areas must be considered. The Needs can change as people change—
aging, recovering from diseases, or adopting different lifestyles are some of the
important changes that require different nutritional patterns.
1.18.4.Dietary methods
Assessing food and fluid intake is an essential part of nutrition assessment. It
provides information on dietary quantity and quality, changes in appetite, food
allergies and intolerance, and reasons for inadequate food intake during or after
illness.
The first methods use is called 24-hour recall. This technique is used to quantify
or assess the average dietary intake. The patient is asked to remember in detail
every food and drink consumed along the previous 24 hours. It may be repeated
on several occasions in order to count day to-day variation in intake. The nurse will
ask the patient to remember what they ate or drank for a specified period of time
or activities.
The second method for dietary assessment is food frequency questionnaire which
provide information that establishes usual dietary intake. It is designed to obtain
information on overall dietary quality rather than nutrient composition and intake.
The food frequency questionnaire examines how often someone eats certain foods,
and sometimes the size of the portions. It consists of a list of foods and a selection
of options relating to the frequency of consumption of each of the foods listed (e.g.,
times per day, daily, weekly, monthly).
Another way to do dietary assessment is called food group questionnaire which
focus on showing clients’ pictures of different food groups (often available from
national nutrition authorities) and ask whether they ate or drank any of those foods
the previous day.
a. Weighed food records
The 7-day weighed food record is frequently regarded as the “gold standard” against
which other methods are compared, because it uses many days of recording –
which is more likely to capture the usual intake of an individual – and provides
exact measures for portion sizes. Prior to consumption, subjects or investigators
are required to weigh each item of food and drink. A detailed description of the food
(individual ingredients, brand name, method of preparation, etc.) and its weight are
recorded.
b. Estimated food records
Estimated food records are similar to weighed food records, the difference being the
way in which individuals or investigators quantify food intake. Intake is estimated,
rather than weighed, and then converted into amounts that can be used to calculate
food and nutrient intake
c. Household food surveys
A number of surveys are meant to collect information about dietary intake at the
household level. This method has been used to monitor long-term dietary intake
and provide information on food expenditure and food and nutrient intake trendsover a period of time.
Examples of questions that are used for nutrition history
1. How many meals and snacks do you eat each day?
Meals------------- Snacks-----------------
2. How many times a week do you eat the following meals away from home?
Breakfast-------- Lunch---------- Dinner
What type of eating places do you frequently visit? Fast food Diner?cafetaria
Restaurant---- other---------
3. On average, how many pieces of fruit or glasses of juice do you eat or drink
each day?
Fresh fruit-----------------juice ---------------
4. On average, how many servings of vegetables do you eat each day? ------
----
5. On average, how many times a week do you a high-fiber breakfast cereal?
------
6. How many times a week do you eat red meat (beef, lamb, veal) or pork?---
-------
7. How many times a week do you eat chicken or turkey?-------
8. How many times a week do you eat or shellfish?--------
9. How many hours of television do you watch every day?---------
Do you usually snack while watching television? Yes----No----
10. How many times a week do you eat desserts and sweets?------11. What types of beverages do you usually drink? How many servings of each
do you drink a day?
Water---- Milk: Alcohol:
Juice---- Whole milk:---- Beer-----------
Soda------ 1%milk---------- Wine----------
Diet soda ------ skim milk-------- hard liquor---
Sports drinks .......
Ice tea-------Iced tea with sugar------
Self-assessment 1.18
1. What are the common anthropometric measurements?
2. Identify the clinical signs and symptoms of nutritional deficiencies based
on physical examination of the following organs:
a. Skin, hair, and mucous membranes
b. Eyes
c. Abdomen
3. What are the laboratory tests and acceptable limits that are useful for
determining malnutrition problems relating to the following nutrients?
a. Carbohydrate
b. Ironc. Calcium
1.19. Oral feeding
Learning activity 1.19
1. What do you see on pictures A and B?
2. Differentiate pictures A and B in terms of the activities that are being
performed.3. What do you expect to learn from this lesson?
Nutrition is a basic component of health that affects a patient’s rate of recovery
from short-term and chronic illness, surgery, and injury. The lack of attention to a
patient’s nutritional status leads to malnutrition.
Associate nurse collaborates with a variety of health care professionals regarding
the nutritional health of patients and participate in nutritional screenings and
assessments. He/she also assess and help patients with feeding and identify
patients at risk for difficulty swallowing and aspiration during feeding.
Nutritional screening must be completed within 24 hours of admission to a hospital,
within 14 days of admission to a long-term care facility, or within a facility-defined
period of time in ambulatory and home care settings.
Hospitalized patients receive a number of different oral diets that require a health
care provider’s order. A therapeutic diet treats many illness and disease states. A
regular diet can be modified in two ways: quantitatively or qualitatively. Qualitative
diets include modifications in consistency, texture, or nutrients such as clear or full
liquid. Quantitative diets include modifications in number or size of meals served or
amounts of specific nutrients such as six small feedings or calorie diets. You can
supplement any diet with oral nutrition supplements. You prepare a patient so he or
she can be comfortable and not interrupted during a meal.
Helping adults with oral nutrition requires time, patience, knowledge, and
understanding. Most people eat without assistance. For other people assistance
is required to get food from the plate and into the mouth. When they are ill, many
patients require assistance either to feed themselves or, if necessary, to be fed by
another person if unable to eat independently.
Altered dentition, improperly fitted dentures, oral lesions or infections, or diseases
causing impaired digestion limit the types and consistencies of foods tolerated.
Hemiplegia, fractured arm, quadriplegia, debilitating illness, or generalized
weakness limits self-feeding ability and appetite.
Equipment for oral feeding:
• Stethoscope and tongue blade for assessment
• Washcloths and towels• Tongue blade
• Adaptive utensils as necessary for self-feeding
• Oral hygiene suppliesTable 1.19 1 Implementation of oral feeding
Self-assessment 1.19
1. What is the rational for putting the patient in high-Fowler’s position during
oral feeding?
2. Why should the associate nurse or family talk with patient during meal?3. What is the required equipment for oral feeding?
1.20. Nasogastric tube feeding
Learning activity 1.8
Observe the pictures below:
1. What information do you get from the above pictures?
2. Describe the activities that are being done in pictures B, C, and D
mentioned above.3. What do expect to be the today’s lesson?
In order to help patients who are not able to swallow, a nasogastric tube is required.
Nasogastric tube feeding is a method for providing nutrients to patients who are not
able to meet their nutritional requirements orally. As a rule, candidates for enteralnutrition must have a sufficiently functional gastrointestinal (GI) tract to absorb nutrients.
1.20.1. Indications for Nasogastric tube feeding
Indications for Nasogastric tube feeding include the following:
• Situations in which normal eating is not safe because of high risk for aspiration:
Altered mental status, swallowing disorders, impaired gag reflex, dependence
on mechanical ventilation, certain esophageal conditions (strictures, or
dysmotility), and delayed gastric emptying – inability to safely and adequately
consume oral intake.
• Clinical conditions that interfere with normal ingestion or absorption of
nutrients or create hypermetabolic states: Surgical resection of oropharynx,
proximal intestinal obstruction or fistula, pancreatitis, burns, and severe
pressure ulcers.
• Short-term feeding (< 6 weeks) with functional gastrointestinal tract
• Conditions in which disease or treatment-related symptoms reduce oral
intake: Anorexia, nausea, pain, fatigue, shortness of breath, or depression.
1.20.2.Advantages and disadvantages for Nasogastric tube
feeding
Advantages
It is easy to place and remove tube. It uses stomach as reservoir. It can use
intermittent feedings. Dumping syndrome is less likely than with naso-intestinal (NI)
feedings.
Disadvantages
It is contraindicated for clients at high risk for aspiration. It is potentially irritating
to the nose and esophagus. It may be removed by uncooperative or confused
patients. It is not appropriate for long-term use. It is unaesthetic for patient.
1.20.3. Technique of nasogastric feeding
a. Preparation
Before starting feeding procedure, the nurse will have to prepare him/herself as
follow:
• Wear clean uniform (dress or gown)
• Tie hair properly
• Remove watch and jewelry
• Wash hands
• Be aware of food reactions, its side effects and its interactions with the
treatment at hand.• Check patient’s medical prescription
The next step will be the assessment:
• Identify the patient.
• Assess patient’s clinical status to determine potential need for tube feedings,
decreased level of consciousness, nutritional deficits, head or neck surgery,
facial trauma, or impaired swallow, patient’s ability to understand and cooperate,
physical and psychological condition.
• Assess patient for food allergies.
• Perform physical assessment of abdomen, including auscultation for bowel
sounds before feeding.
• Obtain baseline weight and review serum electrolytes and blood glucose
measurement.
• Assess patient for fluid volume excess or deficit, electrolyte abnormalities,
and metabolic abnormalities (e.g., hyperglycemia).
• Verify health care provider’s order for type of formula, rate, route, and
frequency.
• Check expiration date of feed and check for damage
The preparation of patient will focus on:
• Respect of patient’s privacy
• Evaluate the patient’s ability to understand and co-operate
• Inform and explain the patient/family: objective, procedure, etc. of care
• Get patient’s consent
Equipment
• Trolley or disinfected tray
• A container with liquid or semi liquid food at room temperature or a disposable
feeding bag, tubing, or ready-to-hang system
• 50-60mL or larger “Janet” Syringe
• Clean gloves
• Protection for the patient
• A cup of clean water to rinse the catheter
• Clean gauze / tissue to wipe the patient’s mouth, if necessary
• Stethoscope
• Kidney dish
• Enteral infusion pump for continuous feedings if applicable
• pH indicator strip (scale 0.0 to 11.0)
• Document (file) for recording the frequency and administered quantity
• Prescribed enteral formulab. Implementation
1. Identify patient using two identifiers (i.e., name and birthday or name and
account number) according to agency policy. Compare identifiers with
information on patient’s identification bracelet.
2. Perform hand hygiene. Apply clean gloves
3. Obtain formula to administer: Verify correct formula and check expiration
date; note condition of container. Provide formula at room temperature.
4. Prepare formula for administration:
a) Use aseptic technique when manipulating components of feeding system
(e.g., formula, administration set, connections).
b) Shake formula container well. Clean top of canned formula with alcohol swab
before opening it.
c) For closed systems, connect administration tubing to container. If using open
system, pour formula from brick pack or can into administration bag (see
illustration).
5. Open roller clamp and allow administration tubing to fill. Clamp off tubing
with roller clamp. Hang container on intravenous (IV) pole.
6. Place patient in high-Fowler’s position or elevate head of bed at least 30
degrees (preferably 45 degrees). For patient forced to remain supine, place
in reverse Trendelenburg’s position.
7. Verify tube placement. Observe appearance of aspirate and note pH
measure.
8. Check gastric residual volume (GRV) before each feeding (for bolus and
intermittent feedings) and every 4 to 6 hours (for continuous feedings):
– Draw up 10 to 30mL air into syringe and connect to end of feeding tube.
– Inject air into tube. Pull back slowly and aspirate total amount of gastric
contents.
– Return aspirated contents to stomach unless volume exceeds 250mL.
– Do not administer feeding when a single GRV measurement exceeds 500mL
or when two measurements taken 1 hour apart each exceed 250mL.
– Flush feeding tube with 50mL of water
9. Before attaching feeding administration set to feeding tube, trace tube to itspoint of origin. Label administration set, “Tube Feeding Only.”
Intermittent gravity drip:
– Pinch proximal end of feeding tube and remove cap. Connect distal end of
administration set tubing to feeding tube and release tubing.
– Set rate by adjusting roller clamp on tubing or attach tubing to feeding pump.
Allow bag to empty gradually over 30 to 45 minutes.
Label bag with tubefeeding type, strength, and amount. Include date, time, and initials.
– Change bag every 24 hours.
Continuous drip method:
a) Connect distal end of administration set tubing to feeding tube as in Step 10a.
b) Thread tubing through feeding pump; set rate on pump and turn on.
10.Advance rate of tube feeding gradually, as ordered.
11. Flush tubing with 30mL water every 4 hours during continuous feeding, before
and after an intermittent feeding. Have registered dietitian recommend total
free water requirement per day and obtain health care provider’s order.
12. When patient is receiving intermittent tube feeding, cap or clamp end of
feeding tube when not being used.
13. On completion of feed, flush the tube with 10-20 CC of water or until the tube
is clear (or volume as recommended on dietetic regimen). The plunger must
be used for flushing to achieve optimum flushing of the tube and prevent
blockage.
14. Close the clamp on the NG tube then disconnect the syringe and recap the
feeding port.
15. Wipe the mouth
c. Completion of the procedure
• Position the patient comfortably and appropriately
• Arrange personal effects of the patient and put them within reach.
• Thank the patient for his or her collaboration
• Eliminate waste
• Dispose of supplies and perform hand hygiene
• Provide a health education related to the patient’s health condition
• Wash hands
• Record and sign the administration of food on the monitoring document by
providing clear specifications as follows: feeding hour, administered quantity,patient’s reactions, and possible residues.
Self-assessment 1.20
1. What are the indications for nasogastric tube feeding?
2. Within the skills laboratory, prepare the material for nasogastric tube
feeding. By using simulation mannequin (model), perform nasogastricfeeding with respect of all recommended steps.
End unit assessment 1
1) Recommendation for protein during pregnancy is:
a. 60 g daily
b. 14 g daily
c. 32 g daily
d. 75 g daily
2) It is recommended that pregnant women get at least 1000mgs/day of ...,
to help build healthy bones for mother and baby.
a. Calcium
b. Folic acid
c. Iron
d. Thiamine
3) Reduces the risk of birth defects of the brain and spinal cord; referred to
as the “neural tube”
a. Calcium
b. Folic Acid
c. Potassium
d. Fiber
4) Which supplement helps prevent anemia and supports the baby’s growth
and development
a. zinc
b. vitamin Dc. DHA
d. iron
5) Discuss the factors that influence eating habits to promote a healthy
lifestyle
6) Discuss the different nutritional disorders found in children aged less thanfive years and their management
7) Explain the specific diets for management of the adolescents with
Anorexia nervosa and Bulimia
8) Explain how to prevent iron deficiency anemia to an infant?
9) What nutrients should be mostly recommeded for promoting the growth
of children
10) What will you discourage to eat or drink to a lactating Woman?
11) Discuss the food components and their sources that should be emphasized
in the diets of older Adults.
12) What are the causes of food insecurity?
13) Identify the general measures for preventing food spoilage
14) Describe 4 simple household food preservation technique
15) Explain the storage methods of fruits; vegetables; cereals, milk, sweet
and potatoes.
16) Discuss shortly the food habits
17) What are the cultural factors affecting food choices
18) Differentiate Kwashiorkor from Marasmus in terms of their clinical features,
prevention and management.
19) What are the clinical characteristics of the people with the following
vitamin deficiencies: vitamin A and C
20) What are the good dietary sources of the following vitamins: Vitamin A;
B1 (thiamine); and C
21) What are the good dietary sources of (a) folic acid (b) iron (c) Zinc?
22) Discuss the dietary management of obesity
23) What are the common anthropometric measurements?
24) What is the rational for putting the patient in high fowler’s position during
oral feeding?25) What are the indications for nasogastric tube feeding?
UNIT2:HUMAN NUTRITION AND DIETETICS
Introductory activity 2
Introductory activity 2
Observe the picture above and answer the following questions:
1) What do you see on the picture above?
2) On your point of view, what is the role of each part mentioned on the
picture above?
3) You receive a patient suspected of having endocrine disorder. What isgeneral assessment you are going to perform
2.1. Specific History Taking on Endocrinology System
Learning activity 2.1
Observe the picture above and answer below questions:
1) What do you see on the picture above?
2) What are history to collect when suspecting a problem arising from the
endocrine system?2.1.1. Overview of history taking of endocrine system
The endocrine system is a series of glands and tissues that produce and secrete
hormones, which are used by the body to regulate and coordinate vital bodily
functions, including growth and development, metabolism, sexual function and
reproduction, sleep and mood.
At the time of taking history of the patient focusing on endocrine system, the history
regarding illness, personal history, family history and social history will be asked to
patient. Furthermore, both subjective and objective data are assessed. Endocrine
disorders and diseases usually manifest according to which endocrine hormone is
being overproduced and secreted, or under-produced, at any given age.
History taking in endocrine system follows the general client history and focus on
history regarding illness, personal history, family history, social history as well assubjective and objective data
a. History regarding illness
The health care professional asks the patient how and when the disease started.
What are aggravating factors and what are alleviating factors of the disease.
b. Personal history
A personal history in endocrinology system is similar like other assessment and
may include information about allergies, illnesses, surgeries, immunizations, andresults of physical exams, tests, and screenings.
c. Family history
Family history is crucial in endocrinology system because a mutated gene
causes different endocrine glands in the body to develop benign and cancerous
neuroendocrine tumors. Endocrine glands secrete hormones, so tumors arising
from these glands may also overproduce hormones that result in symptoms. Hence
it can provide insight into a patient’s risk for developing certain cancers or even
give a hint as to how aggressively a particular patient’s cancer might behave.
Furthermore, many endocrinology systems develop along with a family because
some families are exposed to develop a given disease example of diabetes. Health
care provider asks a patient on history of the endocrinology disease in a given
family.
d. Social history
The social history covers the patient’s lifestyle, such as marital status, occupation,
education, and hobbies. It may also include information about the patient’s diet, use
of alcohol or tobacco, and sexual history. Along with the chance to connect with the
patient as a person, the social history can provide vital early clues to the presence
of disease, guide physical exam and test-ordering strategies, and facilitate theprovision of cost-effective, evidence-based care.
2.1.2. Subjective and objective data
After taking patient history, continue with subjective data and objective data
Ask the patient symptoms he /she is feeling and the patient can accuse one or
more of the following symptoms: dizziness, fatigue or lethargy, weight gain or loss,
changes in vision, feelings of depression, irritability, or anxiety, decreased libido,
change in appetite, pain, nausea and vomiting, changes in urinary or bowel habits,
intolerance to heat or cold.
Objective data will focus on endocrinology system which will be discussed in this
unit. Always assess patient from head to toe.
Note:A patient with one endocrine disease (e.g., Hashimoto’s thyroiditis) is at greater
risk for the development of other endocrine disorders (e.g., adrenal, testicular, orovarian failure).
Self-assessment 2.1
1) The key to discovering the nature of the symptoms found during
assessment is lying in understanding of the functions of the endocrine
hormones.
a. True
b. False
2) Which sign will indicate a health professional to assess the endocrine
system?
a. Fever
b. Bleeding
c. Frequent urinationd. Abdominal pain
2.2. General Survey in Endocrinology System
Learning activity 2.2
The general appearance of a patient may provide diagnostic clues to the illness,
severity of disease, and the patient’s values, social status, and personality. By
gathering general survey in a person with endocrine system observing and focusing
carefully on facies, features and expression, build & stature, nutrition, decubitus,
neck vein, neck glands, anemia, cyanosis, clubbing, jaundice, edema, pulse,respiration, Temperature, BP, generalized skin & nail and extremities.
Note: stature and habitus: observe the patient’s body build. Very short stature
will be seen in dwarfism, pseudo hypoparathyroidism, Turner’s syndrome, or
prepubertal steroid therapy. Very tall and lanky people with long, thin extremities
suggest Marfan’s syndrome.Self-assessment 2.2
1) What should you focus more while conducting general survey on
endocrine system?
2) You receive a 30-year-old male with 90cm of height, what is the firstdisorder you think on your first sight?
2.3. Physical exam of endocrine system
Learning activity 1.9
Physical examination techniques in a focused endocrine assessment follows
the same steps used in a general exam and it made of inspection, auscultation,
percussion and palpation.
2.3.1. Inspection
During inspection, a health professional inspect overall patient and note any
abnormalities. He/she looks for generalized appearance, skin color, any lesion and
its location, bruises or rashes, body shape and symmetry, size of body parts, any
abnormal sounds, any abnormal odors, inspect the neck from the front.
2.3.2. Auscultation
Auscultation is done before palpation and percussion.
2.3.3. Palpation
Palpation is done to assess endocrine system on the area where the organs linked
to endocrine system are located. It can be light or deep palpation. Palpation helps
health care professional to assess for texture, tenderness, temperature, moisture,
pulsations, masses, and internal organs.
When palpating the neck where located thyroid gland, the patient sits with the neck
muscles relaxed and stand behind him. Health care provider palpate gently the
thyroid on the front of the patient’s neck, with index fingers just touching lateral to
the trachea where the thyroid is located. In normal conditions, thyroid gland is not
palpable.
Shape and surface: Simple goiter is relatively symmetrical in their earlier stages
but often become nodular with time
Mobility: Most goiters move upwards with swallowing. Very large goiters may be
immobile, and invasive thyroid cancer may fix the gland to surrounding structures.
Consistency: Nodules in the substance of the gland may be large or small, and
single or multiple, and are usually benign. A very hard consistency suggests
malignant change in the gland.
Large: firm lymph nodes near a goiter suggest thyroid cancer.
Tenderness: Diffuse tenderness is typical of viral thyroiditis, whereas localized
tenderness may follow bleeding into a thyroid cyst.
Thyroid bruit: This can be found during auscultation and indicates abnormally high
blood flow and can be associated with a palpable thrill. It occurs in hyperthyroidism.
A thyroid bruit may be confused with other sounds. A bruit arising from the carotid
artery or transmitted from the aorta will be louder along the line of the artery.
Transient gentle pressure over the root of the neck will interrupt a venous hum fromthe internal jugular vein.
Endocrine organs namely testes and thyroid glands are the only endocrine glandsthat may be accessible for physical examination.
2.3.4. Percussion
Percussion helps to produce tenderness or sounds that point to underlying problems.
When percussing directly over suspected areas of tenderness, monitor the patient
for signs of discomfort.
Examples of area to percuss in endocrine disorder: enlarged pancreas, a pleural
effusion associated with specific endocrine abnormalities, or a hormone-secretingtumor
Self-assessment 2.3
1) Outline 2 examples of organs that can be assessed during palpation in
endocrine system.2) Name other endocrine organs of the human body
2.4. Interpretation of specific findings in endocrinesystem
Learning activity 10
Observe the image below
1) The image above shows a male patient, what are particularities seen on
this patient?
A comprehensive physical examination and its interpretation is required in endocrine
system. Symptoms of endocrine disturbance are varied and non-specific, and affect
many body systems.
The main endocrine glands are the pituitary, thyroid, parathyroid, pancreas, adrenals
and gonads (testes and ovaries). These glands synthesize hormones which are
released into the circulation and act at distant sites.
Examination sequence
The initial greeting may suggest a diagnosis. Inspect the face for a ‘spot’ endocrine
diagnosis
Observe the patient behavior: if the patient restless and agitated (hyperthyroidism)?
or slow and lethargic (hypothyroidism)?
Examine the entire skin surface, looking for abnormal pallor (hypopituitarism),
vitiligo, plethora (Cushing’s or carcinoid syndrome) or pigmentation (Addison’s
disease).
If the patient is obese, is the adiposity centrally distributed (Cushing’s syndrome
and growth hormone deficiency)?
Observe the body hair in quality and amount: look for hirsutism in females with
menstrual disturbance, especially on the face, chest and abdomen
Examine the hands for excessive sweating, soft tissue overgrowth (acromegaly),
skin crease pigmentation (Addison’s disease) and wasting of the thenar muscles
due to carpal tunnel syndrome. Assess the pulse rate, rhythm and volume. Record
the blood pressure because hypertension is a feature of several endocrine
conditions. Check for postural hypotension with lying and standing blood pressures
if you suspect adrenal insufficiency.
Examine the eyes in all thyroid patients for external inflammation, proptosis, diplopia
and visual function. Assess visual acuities and fields in patients with suspected
pituitary tumors, to detect bitemporal hemianopia due to compression of the optic
chiasm. Examine the fundi for optic atrophy in patients with longstanding optic
pathway compression.
Examine the patient face and note any hirsutism (Hirsutism results in excessive
amounts of stiff and pigmented hair on body areas where men typically grow
hair, including the face, chest and back, Hirsutism can result from excess male
hormones, called androgens.
Examine the neck for goiter. If this is present, record its size, surface and consistency.Look for gynaecomastia (enlargement of a men’s breasts, usually due to hormone
imbalance or hormone therapy) and for evidence of milk production in a man or non
breastfeeding woman (galactorrhoea). Inspect the axillae for acanthosisnigricans
or loss of axillary hair
Examine the male external genitalia. Inspect the amount of pubic hair and make
a pubertal staging of all adolescents. Record testicular consistency and volume.
Inspect the legs for evidence of pretibial myxoedema (Graves’ disease), proximalmuscle wasting and weakness (Cushing’s syndrome and hyperthyroidism).
Self-assessment 2.4
1) Hypertension is a feature of several endocrine conditions
a. True
b. False
2) The initial greeting of a patient suffering from endocrine system may
suggest a diagnosis.
a. True
b. False3) Differentiate hirsutism from gynecomastia
2.5. Identification of client problem
Learning activity 2.5
Common endocrine disorders are: diabetes mellitus (a disease in which the
body’s ability to produce or respond to the hormone insulin is impaired, resulting
in abnormal metabolism of carbohydrates and elevated levels of glucose in the
blood),acromegaly(overproduction of growth hormone), addison’s disease
(decreased production of hormones by the adrenal glands), cushing’s syndrome
(high cortisol levels for extended periods of time), graves’ disease (type of
hyperthyroidism resulting in excessive thyroid hormone production), hashimoto’s
thyroiditis (autoimmune disease resulting in hypothyroidism and low production
of thyroid hormone), hyperthyroidism (overactive thyroid), hypothyroidism
(underactive thyroid), prolactinoma(overproduction of prolactin by the pituitary
gland). The Treatments depend on the specific disorder but frequently focus onregulating hormone balance using synthetic hormones.
Serious symptoms that might indicate a life-threatening condition
In some cases, endocrine disorders can be life threatening. The patient can have
symptoms/signs like: confusion or loss of consciousness for even a brief moment,
dangerously low blood pressure (extreme hypotension), dangerously slow heart
rate, dehydration, depression or anxiety, difficulty breathing, eye problems, including
dryness, irritation, pressure, pain or bulging severe fatigue or weakness, severe,
unexplained headache, severe vomiting and diarrhea, sleep disturbances.
Self-assessment 2.5
1) Define the term acromegaly
2) Outline five Serious symptoms that might indicate a life-threateningendocrine condition
2.6. Nursing intervention based on client problem
Learning activity 2.6
A 35 years old patient, was admitted in medical word complaining of
generalized body weakness, increased sensitivity to cold, constipation, dry
skin, weight gain, puffy face, hoarseness, muscle weakness, pain, stiffness
or swelling in joints, slowed heart rate, depression, impaired memory and
enlarged thyroid gland (goiter).
1) What is the suspected diagnosis (problem) for this patient?2.6.1. Interventions
Nursing intervention in endocrine system depends the client disorder.
For diabetic patient, Monitor the patient’s signs of hyperglycemia and
hypoglycemia and intervene accordingly. Monitor the patient weight to avoid
obesity and help assess the adequacy of nutritional intake and vitals signs
monitoring
Education the importance of physical activity. Education on how to self inject insulin
if any and how to take other medications. Physical activity helps lower blood glucose
levels. Regular exercise is a core part of diabetes management and reduces therisk for cardiovascular complications.
Monitor patient for evidence of excess physical and emotional fatigue because
hyperthyroidism results in protein catabolism, over activity, and increased
metabolism leading to exhaustion.
Monitor cardiorespiratory response to activity (e.g., tachycardia, other dysrhythmias,
dyspnea, diaphoresis, pallor, blood pressure [BP], and respiratory rate) because
decompensation of cardiopulmonary function can occur with hypermetabolism.
Assist with regular physical activities (e.g., ambulation, transfers, turning, and
personal care) to make certain patient’s daily needs are met.
Assist the patient to understand energy conservation principles (e.g., the requirement
for restricted activity or bed rest) to avoid fatiguing patient.
Assist the patient to schedule rest periods and avoid care activities during scheduledrest periods to promote adequate rest.
2.6.2. Nutrition Management
Determine, in collaboration with the dietitian, the number of calories and type of
nutrients needed to meet nutrition requirements.
Ascertain patient’s food preferences to determine extent of the problem and plan
appropriate interventions.
Provide patient with high-protein, high-calorie, nutritious finger foods and drinks
that can be readily consumed because hyperthyroidism increases metabolic rate
with resulting need to prevent muscle breakdown and weight loss.
Offer snacks (e.g., frequent drinks, fresh fruits/juice) to maintain adequate caloric
intake.
Monitor recorded intake for nutritional content and calories to evaluate nutritional
status.
Weigh patient at appropriate intervals to evaluate effectiveness of nutritional plan.
Provide appropriate information about nutritional needs and how to meet them topromote self-care.
Assist the patient in receiving help from appropriate community nutritional programs.
2.6.3. Weight Management
Discuss with individual the medical conditions that may affect weight to reassure
patient that optimal weight can be maintained with treatment of hypothyroidism.
Discuss with individual the relationship between food intake, exercise, weight gain,
and weight loss to promote understanding of weight management.
Determine the individual’s ideal body weight to plan weekly weight loss goals.
Assist in developing well-balanced meal plans consistent with level of energy
expenditure.
Develop with the individual a method to keep a daily record of intake, exercise
sessions, and/or changes in body weight to promote progress toward final goal.
2.6.4. Constipation/Impaction Management
Encourage increased fluid intake (e.g., 2-3 L of fluids per day) to maintain soft stool.
Instruct patient/family on high-fiber diet to increase knowledge of how to increase
fecal mass.
Monitor bowel movements, including frequency, consistency, shape, volume, and
color, to plan appropriate interventions.
Suggest use of laxatives/stool softeners to stimulate bowel evacuation.
Teach patient/caregivers about timeframe for resolution of constipation because
elimination patterns will improve with treatment of hypothyroidism.
2.6.5. Reality Orientation
Monitor for changes in orientation, cognitive and behavioral functioning, and quality
of life to determine appropriate interventions.
Inform patient of person, place, and time to decrease confusion.
Provide a low-stimulation environment for patient in whom disorientation is increased
by overstimulation.
Speak to patient in slow, distinct manner with appropriate volume to allow patient
to understand.
Avoid requests that exceed the patient’s capacity (e.g., abstract thinking when
patient can think only in concrete terms, decision making beyond preference or
capacity) to decrease frustration and loss of self-esteem.Use environmental cues (e.g., signs, pictures, clocks, calendars) to maintain
orientation to time and day.
2.6.6. Infection Protection
Monitor for systemic and localized signs and symptoms of infection so infection can
be detected early and treatment initiated promptly.
Provide private room.
Maintain asepsis for patient at risk.
Screen all visitors for communicable diseases to reduce the risk of infection
exposure.
Monitor absolute granulocyte count, WBC count, and differential results to detect
infection and plan treatment.
Obtain cultures as indicated to identify and treat infectious organisms.
Inspect skin and mucous membranes for redness, extreme warmth, or drainage
because other signs and symptoms of infection may be minimal or absent.
Teach patient and family members how to avoid infections (e.g., hand washing).
Teach the patient and family about signs and symptoms of infection and when to
report them to the health care provider.
2.6.7. Self-Esteem Enhancement
Encourage patient to identify strengths to promote awareness of capabilities.
Reinforce the personal strengths that patient identifies.
Make positive statements about the patient to boost morale by providing positive
feedback.
Encourage increased responsibility for self to improve patient’s appearance and
self-esteem.
2.6.8. Teaching: Disease Process
Provide reassurance about patient’s condition (e.g., explaining physical and
emotional changes will resolve with hormonal balance) to increase their
understanding and assist with coping.
2.6.9. Skin Surveillance
Observe extremities for color, warmth, swelling, pulses, texture, edema, and
ulcerations for early detection of skin impairment.
Monitor for sources of pressure and friction to prevent injury to easily traumatized
tissue.
Monitor skin for rashes and abrasions to promote early treatment.
Monitor skin and mucous membranes for areas of discoloration, bruising, and
breakdown to provide early treatment.
Document skin or mucous membrane changes to provide early intervention.
2.6.10.Skin Care: Topical Treatments
Provide support to edematous areas to promote circulation to edematous areas.Use devices on the bed (e.g., sheepskin) that protect the patient.
Self-assessment 2.6
1) Outline 5 action of nurse in prevention of infection for the patient with
endocrine disorders.
2) The nurse should ensure skin Surveillance in order to
a. Maintain skin color
b. Detect early signs of skin impairment.c. Keep the skin clean
End unit assessment 2
1) Explain the hormones produced by each gland in the diagram above and
its role in human body.
2) What is the result of overproduction and hypo production of each gland
shown in this diagram in human body?
3) Explain the component of history taking in endocrine assessment4) Observe the table below and match a disease with its cause
UNIT3:NURSING ASSESSMENT OF NEUROLOGICAL SYSTEM
Key Unit Competence
Take appropriate action based on findings of nursing assessment of neurological
system
Introductory activity 3
Neurological assessment is a sequence of questions and tests to check brain,
spinal cord, and nerve function. The exam checks a person’s mental status,
coordination, ability to walk, and how well the muscles, sensory systems, and
deep tendon reflexes work.Observe the pictures below and answer the asked questions:
1) What do you see on picture A?
2) What do you see on picture B?
3) On your point of view, what are connections between picture A and theaction which is being done on picture B?
3.1. Specific history taking on Neurological system
Learning activity 3.1
Observe the picture below:
1) Based on the picture above, what is problem does have this person?
2) What are possible questions can you ask to this person to know wellabout that problem?
Taking the patient’s history is habitually the first step in practically every clinical
meeting. Taking a detailed history and performing a careful examination can help
the health care provider to determine the site of a specific neurological lesion and
reach a diagnosis.
Always start with demographic data such as name, age, sex, educational background,
marital status, religion and address. Ask the patient history of the presenting illness
or chief complaint should include the following information: Symptom onset (acute,
sub-acute, chronic, insidious), duration, course of the condition (static, progressive,
or relapsing and remitting), associated symptoms (other features of neurological
disease): Headache, Numbness, pins and needles, cold or warmth, Weakness,
unsteadiness, stiffness) nausea, vomiting, vertigo, numbness, weakness, and
seizures.
Firstly, observe the patient’s gait as he/she enters the room. Note any abnormalities
in gait and any involuntary movement.
Ask about the symptoms: What are they? Which part of the body do they affect?
Are they localized or more widespread? When did they start? How long do they last
for? Were they sudden, rapid or gradual in onset? Is there a history of trauma? Ask
about any associated symptoms (other features of neurological disease): Headache,
Numbness, pins and needles, cold or warmth, Weakness, unsteadiness, stiffness)Self-assessment 3.1
1) Outline at list 5 questions you can use to ask patient about his/hersymptoms
3.2. Specific physical examination of neurological
system
Learning activity 3.2
Observe the image below and answer the questions
1) What do you see on image above?
2) What steps to follow in performing specific physical assessment for theabove patient?
A complete neurological assessment consists of seven steps which are mental
status exam, cranial nerve assessment, reflex testing, motor system assessment,
sensory system assessment, coordination and Gait.
3.2.1. Mental Status
Changes in memory or mood, ability to care for oneself, ability to balance a
checkbook, difficulty with language, geographical orientation,
3.2.2. Cranial nerve assessment
Abnormalities in vision, hearing, smell, taste, speech or swallowing, Facial weakness
or numbness.
3.2.3. Reflex testing
Reflex testing occurs when an initial test result meets pre-determined criteria (e.g.,
positive or outside normal parameters), and the primary test result is inconclusive
without the reflex or follow-up test. It is performed automatically without theintervention of the ordering physician.
3.2.4. Motor system assessment
History of muscular weakness, tremor, difficulty in initiating movements, loss of
muscle bulk.
3.2.5. Sensory system assessment
Numbness, tingling, or altered sensation in any limbs.
3.2.6. Coordination
Clumsiness, difficulty with hand writing or carrying out coordinated tasks.
3.2.7. Gait and station
Abnormalities of gait, frequent falling, difficulty maintaining balance.
3.3. Interpretation of specific findings on Neurologicalsystem
Learning activity 3.3
Observe the image below
1) The picture above shows a patient with facial palsy with asymmetrical
facial muscle tone. What is the most probable cranial nerve being moreaffected?
Interpretation of specific finding in neurological system is a very crucial step to
guide diagnosis and treatment. It is necessary to assess each of the seven itemsassessed as discussed in previous lesson.
3.3.1. Mental status
The patient’s attention span is assessed first; an inattentive patient cannot cooperate
fully and hinders testing. Any hint of cognitive decline requires examination of
mental status which involves testing multiple aspects of cognitive function. Assess
the patient orientation to time, place, and person.
Assess the patient attention and concentration, memory, verbal and mathematical
abilities, judgment and reasoning
3.3.2. Cranial nerve assessment
Each cranial nerve has a well-defined function and any abnormality in cranial nervesystem should be assessed, reported and treated accordingly.
Table 3.3 1 Cranial nerves
3.3.3. Reflextesting:
A reflex is an involuntary and nearly instantaneous movement in response to a
stimulus. The reflex is an automatic response to a stimulus that does not receive or
need conscious thought as it occurs through a reflex arc.
The muscle contraction should be seen and felt and compared side-to-side. If
reflexes are diminished or absent, try reinforcing the reflex by distracting the patient
or having the patient contract other muscles (e.g., clench teeth). Note, however, that
symmetrically brisk, diminished, or even absent reflexes may be found in normal
people. The muscle stretch reflexes that are the most clinically relevant and that
you should know how to obtain include the biceps, triceps, knee, and ankle. The
superficial (cutaneous) reflexes are elicited by applying a scratching stimulus to the
skin. The only superficial reflex that you need to know other than the corneal is the
plantar reflex. An abnormal plantar reflex (extension of the great toe with fanningout of the other toes upon stimulation of the plantar surface of the foot) is a specific
indicator of corticospinal tract dysfunction and may be the only sign of ongoing
disease or the only residual sign of previous disease.
3.3.4. Motor system assessment
The motor exam is affected not only by muscle strength, but also by effort, coordination,
and extrapyramidal function. Tests of dexterity and coordination are most sensitive
to picking up upper motor neuron and cerebellar abnormalities, whereas direct
strength testing is more sensitive to lower motor neuron dysfunction. Other aspects
of the motor exam include (1) patterns of muscle atrophy or hypertrophy, (2)
assessment of muscle tone (e.g., spastic or clasp knife, rigid or lead pipe, flaccid)
with passive movement of joints by the examiner, (3) disturbances of movement
(e.g., the slowness and reduced spontaneity of movement in parkinsonism), (4)
endurance of the motor response (e.g., the fatigability of myasthenia gravis), and
(5) whether any spontaneous movements are present (e.g., fasciculation or brief
twitches within the muscle).
3.3.5. Sensory system assessment
Explain to the patient what you are going to do and what you expect of them, then
have them close their eyes for the testing. Be aware of the fact that patients may
report differences in sensation in the presence of normal sensory function because
of actual differences in the stimulus intensity applied.
3.3.6. Gait
Since walking requires integration of motor, sensory, cerebellar, vestibular, and
extrapyramidal function, assessment of gait can provide important information to
guide the focus of the rest of the exam and can obviate the need for specific testing.
It is for this reason that health care provider should watch the patient walk at the
very beginning of the exam.
Pay attention to the following;
• Posture of body and limbs (Is the patient stooped over or leaning to one side?
Is a limb held in a funny position?);
• Symmetry of arm swing (Is one side decreased?);
• Length, speed, and rhythm of steps (does the patient lurch? Are the legs stiff
and scissoring?); 4) base of gait (Are the legs held far apart because the
patient is unstable?);
• Steadiness; and
• Turns (How many steps does the patient take to turn?). More informative stillis if the patient can run and hop on one foot.
Self-assessment 3.3
1) During assessment of mental health status, a nurse should assess the
patient orientation on three aspects. What are they?
2) Give names and function of the following cranial nerves
a. 1st Cranial nerve
b. 2nd Cranial nerve
c. 4th cranial nerve
d. 11th cranial nervee. 12th cranial nerve
3.4. Identification of client problems
Learning activity 3.4
You receive a 36 years old female with balance difficulties; eyesight changes;
weakness of face muscles; left arm weakness and difficult in speech since 5
hours ago.What do you suspect?
Identification of client problem in neurological system is a key action very necessary
to lead an appropriate diagnosis and treatment. The following are six common
neurological disorders
3.4.1. Headaches
Headaches are one of the most common neurological disorders and can affect
anyone at any age. The sudden onset of severe headache as well as headache
associated with a fever, light sensitivity and stiff neck are all red flags of something
more serious such as intracranial bleeding or meningitis.
3.4.2. Epilepsy and Seizures
Epilepsy is a common neurological disorder involving abnormal electrical activity in
the brain that makes a patient more susceptible to having recurrent, unprovoked
seizures. Unprovoked means the seizure cannot be explained by exposure to or
withdrawal from drugs or alcohol, as well as not due to other medical issues such
as severe electrolyte abnormalities or very high blood sugar.
3.4.3. Stroke
A stroke is usually due to a lack of blood flow to the brain, oftentimes caused by
a clot or blockage in an artery. Many interventions can be done to stop a stroke
these days, but time is brain (not money) in this case. The B.E. F.A.S.T. mnemonic
is helpful to remember to recognize the signs of a stroke: B: Balance difficulties; E:
Eyesight changes; F: Face weakness; A: Arm weakness; S: Speech; and T: Time.
These signs and symptoms don’t always mean someone is having a stroke, but it’s
very important to request help right away.
3.4.4. Amyotrophic Lateral Sclerosis (ALS)
Amyotrophic Lateral Sclerosis, also known as Lou Gehrig’s disease, is a somewhat
rare neuromuscular condition that affects the nerve cells in the brain and spinal
cord. The cause is not well known, but factors that may cause ALS include genetics
and environmental factors. Symptoms include muscle weakness and twitching,
tight and stiff muscles, slurred speech, and difficulty breathing and swallowing.
Unfortunately, this condition is difficult to diagnose and often requires the evaluation
of a neuromuscular neurologist.
3.4.5. Alzheimer’s disease and Dementia
Memory loss is a common complaint, especially in older adults. A certain degree of
memory loss is a normal part of aging. For example, walking into a room and forgetting
why may be totally normal. However, there are signs that may indicate something
more serious, such as dementia or Alzheimer’s disease. These symptoms may
include getting lost, having difficulty managing finances, difficulties with activities of
daily living, leaving the stove on, forgetting the names of close family and friends
or problems with language. Behavioral changes along with these memory changes
could also raise concerns. Dementia is a slowly progressive condition. While there
is no cure, there are medications and therapies that can help manage symptoms.
3.4.6. Parkinson’s disease
Parkinson’s disease is a progressive nervous system disorder that primarily affects
coordination. Generally, it becomes more common as a patient get older.
Symptoms of Parkinson’s disease usually get worse over time. Patient may
experience changes in posture, walking and facial expressions early on in the
disease, and cognitive and behavioral problems could develop later in the disease
Self-assessment 3.4
1) Memory loss is a common complaint:
a. True
b. False
2) Parkinson’s disease is a progressive nervous system disorder that
primarily affects coordination
a. True
b. False
3) State six common neurological disorders
3.5. Nursing intervention based on patient’s problem.Learning activity 3.5
You have received a 27years old male with epileptic disorder. He is seizing.
1) What are your interventions after seizure stop?
Nursing interventions in patient with neurological disorders are very crucial to
alleviate the client discomforts. Any client complaints should be monitored andtreated accordingly.
3.5.1. Interventions for Headache
• Encourage the client to rest in a quiet, dark room.
• Avoid noises
• Encourage relaxation techniques
• Collaborate with other health professionals to identify and treat the cause of
headache
3.5.2. Interventions for Epilepsy/Seizure
The patient will be placed in a horizontal plane and care will be taken that he does
not receive trauma to the skull, with the head tilted and the clothing lopsided.
Control and assess in the patient: assess the duration of the seizure, type of seizure,
the level of consciousness, the coloring of the skin and mucous membranes.
Monitor vital signs Heart rate, breathing frequency, blood pressure, O2
saturation…), perform capillary blood glucose.
a. Tonic-clonic onset seizures
In those patients with previous epileptic seizures or with significant risk factors
in treatment with antiepileptic drugs, severe brain injury, exposure to drugs and
hallucinogens, etc.:
• Maintain the necessary material for oxygen therapy and aspiration, in optimal
conditions.
• Facilitate the accessibility of calls to the nursing staff, especially if there are
prodromes.
• Provide a suitable and safe environment, free of furniture and objects that can
cause harm during the epileptic seizure.
• Protect the patient from all potentially harmful objects.
• Maintain a patent venous line if necessary.
• Inform the patient and the family about the action before the appearance of
prodromes:
• Remove the teeth or other objects from the mouth.
• Remove the eye lenses.
• Lay him down on the floor or in bed.
b. During tonic-clonic onset epileptic seizures
• Keep calm and serenity as much as possible and we will transmit it to the
patient, relatives.
• Identify that it is a tonic-clonic epileptic seizure.
• Alert: Notify the doctor on duty.
• Protect the patient:
• If the patient is out of bed, help him to lie down if possible, or lay him on the
floor; avoiding as much as possible the fall.
• Do not leave the patient alone under any circumstances and monitor him.
• Remove nearby objects and / or furniture with which it may hit.
• Loosen clothing that is tight.
• Remove the glasses if you wear them.
• Do not immobilize or restrain the patient by force during the epileptic seizure,
but control and guide their movements to avoid injuries.
• Protect the head by placing a pillow or a towel underneath.
c. Guarantee the patency of the airway:
• Remove, if possible, dentures and dental implants that are not permanent.• Remove food from the mouth in case this process is carried out.
• Aspirate secretions, if necessary.
• Perform other nursing intervention are necessary such as oxygen
administration, a peripheral line should be installed as soon as the seizures
stop, monitoring of vital signs: (temperature, blood pressure, heart rate,
breathing frequency), carry out the complementary tests as requested by the
doctor.
• It is very important to control and assess the duration of the tonic-clonic phase,
type of epileptic seizure, where does the movement or begin contracture, eye
position and / or eye movements, the pupils (relationship between them, size
and reactivity) and time the patient is unconscious. Assess any urinary and
fecal incontinence. When the epileptic seizures cease, place the patient in the
recovery position.
• Do not administer anything by mouth.
• If after the crisis he is excited, calm him down and reassure him.
• Administer the drug directed by the doctor.
• If there is any bleeding lesion, press with a sterile compress until the bleeding
stops.
• Ensure that the environment is quiet and safe, without excessive lighting or
noise.
• Carry out a new check of vital signs and serum glycemia.
• In case of incontinence, proceed to clean the patient.
• In case of drowsiness, let him rest.
• When he wakes up, redirect and reassure him.
• Carry out the complementary tests requested by the doctor.
• Control and assess: Duration of the post-seizure phase, assessment of the
level of consciousness (GLASGOW SCALE), degree of confusion, if he is
drowsy, let him sleep and do not wake him up or shake him, color of the skin
and / or mucous membranes, whether he speaks or not. If there is paralysis
or weakness in the arms and / or legs.
3.5.3. Interventions for stroke
• When a patient is having stroke, immediately call for ambulance because
as he/she delays to get appropriate treatment, more serious complications
develop
• Note the time the first symptom occurs
• Provide appropriate positioning.
• Prevent flexion and adduction• Monitor closely vital signs
3.5.4. Interventions for Amyotrophic Lateral Sclerosis (ALS)
• Assess motor strength; presence of spasticity, flaccidity and presence
contracture.
• Assess skin daily, especially those areas susceptible to breakdown.
• Promotion of activity and exercise.
• Encourage continuation of daily routines and activities.
• Range-of-Motion (ROM) exercises to prevent contracture and pain in joints;
first Active ROM, then passive.
• When weakness in the extremities begins to compromise mobility, safety,
or independence in Activities of daily living (ADL), refer to a physical or
occupational therapist.
• Promotion of proper positioning to prevent decubitus ulcers. Use as many
different positions as possible when in bed. Change positions every two
hours, or on skin tolerance. After each change of position, check for redness
over bone prominences, and provide an eggshell or circulating mattress when
immobility prevents independent repositioning.
• Repositioning in the wheelchair based on the patient’s skin tolerance. Use of
a wheelchair cushion to prevent skin breakdown.
• Proper positioning when ambulating or in a wheelchair, i.e., use of a sling for
a weak upper extremity.
• Promote adequate nutritional intake.
3.5.5. Interventions for Alzheimer’s disease and Dementia
• Frequently orient client to reality and surroundings.
• Encourage caregivers about patient reorientation.
• Enforce with positive feedback and discourage suspiciousness of others.
• Avoid cultivation of false ideas
• Monitor client closely
3.5.6. Interventions for Parkinson’s Disease
• Improving functional mobility and independence in performing activity of daily
living.
• Assess bowel elimination and encourage patient on good diet to avoid
constipation
• Improve and maintaining acceptable nutritional status,• Promote effective communication and developing positive coping mechanisms.
Self-assessment 3.5
1) When the epileptic seizures cease, what is the best position to give to the
patient?
2) Give 2 primary nursing interventions for each of following
a. Headache
b. Epilepsy/Seizurec. Stroke
End unit assessment 3
1) Memory loss is a common complaint:
a. True
b. False
2) Parkinson’s disease is a progressive nervous system disorder that
primarily affects coordination
a. True
b. False
3) State six common neurological disorders
4) Give 2 primary nursing interventions for each of following
a. Headache
b. Epilepsy/Seizure
c. Stroke
5) Outline at list 5 questions you can use to ask a neurological patient about
his/her symptoms.6) List 7 steps of complete neurological assessment
UNIT4:NURSING ASSESSMENT OF SENSORY SYSTEM
Take appropriate action based on findings of nursing assessment of Sensorysystem
Introductory activity 4
1) How many images do you see in the picture A? List them
2) What is the role of each image in the picture A?
3) Which relationship between the image in the center of picture A and the
surrounding images?
4) Which image in picture A corresponding to the action of nurse in picture B
A sensory system is a part of the nervous system consisting of sensory receptors
that receive stimuli from the internal and external environment, neural pathways
that conduct this information to the brain and parts of the brain that processes this
information. We have 5 senses (vision, hearing and equilibrium, taste, smell, touch)and related sensory organs (eye, ear, tongue, nose and skin)
4.1. Specific history taking on sensory system
Learning activity 4.1
Observe the image above and respond to the following question
1) Describe people presented on the above figure.
2) What may be wrong with a person touching his head?
3) Enumerate the steps of a patient- health professional interaction duringconsultation
4.1.1. Assessment of the head
In clinical settings, health assessment of a patient is made of history taking and
physical examination. It is up to clinicians to develop empathetic listening, ability
to interview patients of all age, technique to assess different body part and ability
to sum up the information obtained to identify the patient’s health problem. A well
done health history should follow a chronological order as follow: identifying data,
chief complaints, history of presenting illness, past health related history, family
history, personal and social history and review of systems.
Usually, the assessment of the head goes together with the neck as the share
together the important structures such as cranial nerves, sensory organs and major
blood vessels. Headache is a very common symptom presented by patient during
the assessment of the head. Other common symptoms the head and neck are
change or loss of vision, eye pain, redness, tearing, double vision, hearing loss,
earache, ringing in the ears, dizziness, vertigo, nosebleed, Sore throat, hoarseness,swollen cervical glands and enlarged thyroid gland.
Headache is defined as the pain in any region of the head. A patient complaining
about headache will be asked to clarify on its location, severity, character,
circumstances in which it occurs, remitting or exacerbating factors, associated
manifestations and duration. Headache is subdivided into two main categories
which are primary headache and secondary headache. The primary headache is
said when it comes by its own, not a symptom of any diseases whereas secondary
headache happens as a symptom to an underling medical condition. In fact, primary
headache originates from over-activity of the structures of the head and the neck
such as nerves, muscles, blood vessels and specific areas of the brain. The causes
of secondary headache may be pregnancy, stroke, brain tumor, hypothyroidism
and systemic infections. If a patient is complaining about headaches, we have to be
careful and collect detailed information because it may be a sign of a very serious
health conditions. Migraine is a form of on side headache with a severe pulsating
sensation. Other types of primary headache include cluster, tension and chronic
daily headache. A headache which is severe, persistent, occur regularly, does
not improve with medication, accompanied with other clinical manifestations such
as fever, confusion, sensory changes and neck stiffness need to seek for medicalattention
Interview guide when taking history of the head
• Ask the patient to allocate the area of pain or discomfort. Location and
radiation patterns will allow the examiner to classify and to guide his or her
diagnosis
• Is the headache severe and of slow or sudden onset? Guide the patient to
rate the pain by explaining the rational of pain score from 0 to 10.
• How long does it last?
• Is it episodic? Does the headache recur at the same time every day?
• Chronic and recurring? Is there a recent change in pattern?
• Any associate factors such as nausea, vomiting, fever, confusion and so on?
Nausea and vomiting are common in migraine but may be seen in brain tumor
and subarachnoid hemorrhage.
• Ask about any unusual feeling before the occurrence of a headache.
Weakness, dizziness, vision changes are some of the preliminary signs for
some form of headache.
• Get to know about aggravating and alleviating factors. Sneezing, coughing,
changing position may aggravate headache in case of acute sinusitis.
– Ask about personal means to manage the headache. If a patient is using
medications for more than 2 days a week as a symptomatic treatment of a
chronic headache, consider this situation as medication overuse.
Family history is another important key to ask for to compare the patient’s
situation to his or her family member. Migraine is a good example of headachethat runs in families.
The physical assessment of the head involves the inspection and palpation of the
parts of the head which in turn are named in accordance to the bone of the skull.
We also assess the salivary glands: a pair of parotid glands located superficial
to behind the mandible and submandibular sited deep to the mandible. The
assessment of the head includes palpation of superficial temporal artery passing in
front of the ear, it is easily identified to its pulsation.
To assess the head, we systematically follow this order: hair, scalp, skull, face
and the skin. Remember to always ask the patient to remove head covers and
hair pieces should be removed. You may note movable fragments of dandruff.
Fine hair is observable during hyperthyroidism whereas coarse hair is seen during
hypothyroidism. The tiny ovoid granules adhere to the hair may be lice eggs. For
the scalp, displace the hair in several directions and search for scars, lumps, nevi
and any other particularity. The redness and scaling may suggest seborrheic
dermatitis or psoriasis whereas nevi that raises indicate melanoma. On the skull,
observe the contour and its size. Microcephaly is an abnormally small head while
macrocephaly is an abnormally large head. Consider any deformity, depression,
lump or tenderness. Get to know normal irregularity of the skull such presence of
fontanelles and sutures in infancy. The enlarged skull indicates hydrocephalus orPaget disease of the bone. Tenderness while palpating the skull suggests possible
trauma. For the face, check for patient’s facial expression and contour. Note any
identified asymmetry, involuntary movement, edema and mases. Look at the skin
of the face and the head to objectivate any change in color, texture, thickness, hairdistribution and lesions.
Self-assessment 4.1
1) What are the physical assessment techniques used to assess the head?
2) Name possible abnormalities which can be seen on the face during
physical examination.
3) Conduct an history taking for a patient complaining about a headache.
4) Mr. M was riding a bicycle, abruptly he loses control and hits the border
of the road. His neighbor took him to the nearest health center. During a
complete physical assessment, the nurse realizes tenderness on the left
parietal region.
a. What does tenderness mean?
b. Briefly list other important point to be assessed on the head.
5) An 18-year-old male college student wake up this morning complain
about headache, weakness and perspiration which prevent him to attend
class today. We took him to the school clinic for treatment, the nurse
conducted an assessment and blood smear collection and realize that
these symptoms are linked to malaria. She then provided a dose of
analgesic and anti-malarial medication.
a. Which type of headache is appropriate for the above situation?
b. What are the possible causes of a headache depending on their types?
c. What will be your focal points when conducting an interview for someonewith a headache?
4.2. Assessment of the eye
Learning activity 4.2
Observe image A, B and C and respond the following question
1) Describe the images A, B and C
2) Compare the eyes seen on the image B and C3) What is the meaning of the letters illustrated on the picture C?
4.2.1. Overview of the assessment of the eye
The eye is our organ of sight. The visual system consists of the external tissues and
structures surrounding the eye, the external and internal structures of the eye, the
refractive media, and the visual pathway. The external structures are the eyebrows,
eyelids, eyelashes, lacrimal system, conjunctiva, cornea, sclera, and extraocular
muscles. The internal structures are the iris, lens, ciliary body, choroid, and retina.The entire visual system is important for visual function. Light reflected from an
object in the field of vision passes through the transparent structures of the eye
and, in doing so, is refracted (bent) so that a clear image can fall on the retina. From
the retina, the visual stimuli travel through the visual pathway to the occipital cortex,
where they are perceived as an image.
4.2.2. Taking history
An eye assessment is a series of tests performed to assess vision and ability to
focus on and discern an object. Failure to take eye history can lead to missing vision
or life-threatening conditions. The structure of ophthalmological history taking is no
different than for other systems; however, it is important to take particular note of
the following:
Demographic data: Ask patient’s name, age, sex, religion, disability, Patient’s
occupation, daily tasks and hobbies. During the initial observation, observe the
patient’s overall facial and ophthalmic appearance. The eyes should be symmetric
and normally placed on the face. The globes should not have a bulging or sunken
appearance.
Chief complaints: watering/discharge from the eyes, redness, pain, itching, burning
sensation, foreign body sensation, loss of vision, double vision or swelling of an
eyelid all are the common reasons for consultation.
History of present illness- mode of onset, Sudden or gradual. Eg: Sudden visual
loss suggests retinal detachment, vitreous hemorrhage, or occlusion of the central
retinal artery, duration, severity and progression of eye disease.
a. Past eye history
Ask for detail about any previous eye problems such as:
• History of similar eye complaints in the past. This is important in recurrent
conditions such as herpes simplex keratitis, allergic conjunctivitis, uveitis and
recurrent corneal erosions.
• History of eye surgery or trauma. It is important to ask about any ocular
surgery in the past such as cataract extraction, muscle surgery, glaucoma, or
retinal surgery
• Other symptoms. Ask whether the patient has any other specific eye
symptoms.
b. General medical history
Ask about any current and past medical conditions such as diabetes, hypertension,
arthritis, HIV, syphilis, asthma and eczema.
Family history: ask patient about familial predisposition of inheritable ocular
disorders
It is important to ask the patient whether any other member of the family has a
similar
condition or another eye disease. This can help to establish familial predisposition
of inheritable ocular disorders like glaucoma, retinoblastoma or congenital eyediseases, diabetes and hypertension
c. Medication history
Ask about present and past medications for both ocular and medical conditions as
some medications are important in the etiology of ocular conditions.
It is also helpful to ask whether the patient has been able to use the medication
as prescribed (their compliance). If a medication is ineffective, you want to know
whether the patient is actually using the medication as prescribed. find out if access
to medication prescribed is easy. Assess whether a cost or other concerns are a
potential reason for non-compliance. There could also be practical issues, such as
difficulty instilling eye drops or forgetting to do so. Do not forget to ask in a non
judgmental way about traditional/herbal medication use. Consider that many cold
preparations contain a form of epinephrine (e.g., pseudoephedrine) that can dilate
the pupil. Note the use of any antihistamine or decongestant, since these drugs
can cause ocular dryness. In addition, specifically ask whether the patient uses
any prescription drugs such as corticosteroids, thyroid medications, or agents such
as oral hypoglycemics and insulin to lower blood glucose levels. Long-term use
of corticosteroid preparations can contribute to the development of glaucoma or
cataract.
d. Other history
Ask about any allergies to medications or other substances. Social history- ask the
patient about smoking habit, illegal substances and alcohol. For children, the birth
history (prematurity) and immunization status can be important.
4.2.3. Inspection of the eye
To maintain optimum vision, people need to have their eyes examined regularly
throughout life. It is recommended that people under age 40 have their eyes
tested every 3 to 5 years, or more frequently if there is a family history of diabetes,
hypertension, blood dyscrasia, or eye disease (e.g., glaucoma). After age 40, an
eye examination is recommended every 2 years. Examination of the eyes includes
assessment of the external structures, visual acuity (the degree of detail the
eye can discern in an image), extraocular muscle movement, and visual
fields (the area an individual can see when looking straight ahead). Most eye
assessment procedures involve inspection.
Eye should be examined from outside to inside in systematic approach as follow
a. External structure inspection
After the inspection, palpation of the orbital rim may also be desirable, depending on
the presenting signs and symptoms. The sclera and conjunctiva are the only parts
to be easily assessed. Vision tests and ophthalmoscopic test need an advanced
level of practice. Ophthalmoscope is used to examine the anterior chamber, lens,vitreous and internal surface of the retina.
Below are the images illustrating some common features of the eyes
Table 4.2 1 Common features of the eye problems
b. . Visual acuity examination
Visual acuity is the eye ability to detect fine details and is the quantitative measure
of the eye’s ability to see an in-focus image at a certain distance. The commonly
used tool for visual acuity is the Snellen Chart. Document the patient’s visual acuity
before the patient receives any ophthalmic care. Position the person on a mark
exactly 20 feet or 6 meters away from the Snellen eye chart. If the person wears
glasses or contacts, leave them on. Cover one eye at a time during the test. Ask
the person to read down the lines of the chart to the smallest line of letters possible.
Record the result using the numeric fraction at the end of the last successful line
read. Indicate whether any letters were missed and if corrective lenses were worn
(e.g., “Left eye, 20/30- 2, with contacts”). Next ask the patient to cover the other
eye, and repeat the process. Normal visual acuity is 20/20. The numerator indicates
the distance the person is standing or sitting from the chart; the denominator is
the distance at which a normal eye can read the particular line. The larger the
denominator the poorer the vision. A vision poorer than 20/30 need to be referred
to the ophthalmologist. Legal blindness is defined as the best-corrected vision inthe better eye of 20/200 or less.
Self-assessment 4.2
1) In which condition a patient may manifest yellow eyes?
a. Bacterial conjunctivitis
b. Liver diseases
c. Trauma of the eyes
d. Congenital defect of the eyes
2) The normal finding of the pupil examination is:
a. Pupil should be equal, round, reactive to light and accommodate
b. Pupil should be equal, square, reactive to light and accommodate
c. Pupil are white, dry, reactive to light and accommodate
d. Pupil is intact, pink, ovoid and reactive to light
3) Increased intraocular pressure may occur as a result of
a. Edema of the corneal stroma.
b. Dilation of the retinal arterioles.
c. Blockage of the lacrimal canals and ducts.
d. Increased production of aqueous humor by the ciliary process
4) What are the normal findings when assessing the eyebrows?
5) Which parts of the eyes can we assess by using inspection?
6) Why do we ask for other health conditions to a patient consulting for eyeproblem?
4.3. Assessment of the ear
Learning assessment 4.3
Observe the image A and B and respond the following questions
1) What is the attitude of person in image A and what do you think may be
the cause
2) Give the similarities of image A and B3) What is the name and importance of material used by Doctor in image B?
4.3.1. Overview of the assessment of the ear
The auditory system is composed of the peripheral auditory system and the central
auditory system. The peripheral system includes the structures of the ear itself: the
external, middle, and inner ear. This system is concerned with the reception and
perception of sound. The inner ear functions in hearing and balance. The central
system integrates and assigns meaning to what is heard. This system includes the
vestibulocochlear nerve (Cranial nerve 8) and the auditory cortex of the brain. The
brain and its pathways transmit and process sound and sensations that maintain
a person’s equilibrium. The role of the external and middle portion of the ear is to
conduct and amplify sound waves from the environment. This portion of sound
conduction is termed air conduction. Problems in these two parts of the ear may
cause conductive hearing loss, resulting in a decrease in sound intensity and/or a
distortion in sound. Disturbances in equilibrium can impair coordination, balance,
and orientation. Damage to or an abnormality of the inner ear or along the nerve
pathways results in sensorineural hearing loss. Sensorineural hearing loss may
affect the ability to understand speech or cause complete hearing loss. Impairment
within the auditory pathways of the brain causes central hearing loss. This type of
hearing loss causes difficulty in understanding the meaning of words that are heard.
4.3.2. History taking
An ear history taking it is done to screen for ear problems, such as hearing loss,
ear pain, discharge, lumps, or objects in the ear. These problems may be due to
infection, too much earwax, or an object like a bean or a bead.
The following issues should be included:
• Classic symptoms of ear disease: deafness, tinnitus, discharge (otorrhoea),
pain (otalgia) and vertigo.
• Previous ear surgery, or head injury.
• Family history of deafness.
• Systemic disease (eg., stroke, multiple sclerosis, cardiovascular disease).
• Ototoxic drugs (antibiotics (eg, gentamicin), diuretics, cytotoxics).
• Exposure to noise (eg, pneumatic drill or shooting).
• History of atopy and allergy in children.
4.3.3. Inspection of the ear
a. Inspecting the external ear
Inspect the external ear before examination with an otoscope/auriscope. Swab any
discharge and remove any wax. Look for obvious signs of abnormality.
• Size and shape of the pinna.
• Extra cartilage tags/pre-auricular sinuses or pits.
• Signs of trauma to the pinna.
• Suspicious skin lesions on the pinna, including neoplasia.
• Skin conditions of the pinna and external canal.
• Infection/inflammation of the external ear canal, with discharge.
• Signs/scars of previous surgeryb. Inspecting the ear canal and eardrum
The inspection of the ear canal and the tympanic membrane need anotoscope/
auriscope with its own light source to examine the ear. The examination technique
involves grasping the pinna and pulling it up and backwards (posteriorly and
superiorly), which helps to straighten the ear canal and for inspection of the tympanic
membrane. For the infants, only pull the pinna downwards and backwards to be
able to visualize into the ear. Enter the ear gently to avoid possible trauma, select a
correct size of speculum to achieve the best view and detach it from the otoscope
after examination for appropriate cleaning.
Note the condition of the canal skin, and the presence of wax, foreign tissue,
or discharge. The mobility of the eardrum can be evaluated using a pneumatic
speculum, which attaches to the otoscope. The drum should move on squeezing
the balloon.
For the inspection of the ear drum, move the otoscope in order to see several
different views of the drum. The drum is roughly circular (~1 cm in diameter).
The normal drum is translucent with light-gray color or a shiny pearly-white. The
common pathological conditions related to the ear include: perforations of the drum
(note size, site and position), tympanosclerosis, middle-ear effusion, retractions of
the drum, and hemotympanum (blood in the middle ear).
Check facial nerve function if ear pathology is serious.
4.3.4. Physical exam: Palpation
Palpate the pinna to looking for swelling or nodules and check for tenderness.
Press the tragus towards the ear canal. Palpate around the ear for pre and post
auricular, suboccipital and superior jugular lymph nodes and parotid glands.
4.3.5. Basic hearing test: Tuning fork tests: Weber’s test and
Rinne’s testA patient with normal hearing should hear equally as well in both ears.
a. Weber ‘s test
This test is performed to assess bone conduction by examining the lateralization
(sideward transmission) of sounds. The vibrating fork is placed in the middle of the
forehead and the patient is asked whether any sound is heard and, if so, whether
it is equally heard in both ears or not. In a patient with normal hearing, the tone is
heard centrally (Weber negative). If the patient has unilateral hearing loss and the
sound is louder in the weaker ear, this suggests a conductive hearing loss mostly
happening in otosclerosis, otitis media, perforation of the eardrum, and cerumen. If
the sound is louder in the better ear, it is more likely to be a sensorineural hearing
loss (Weber positive). (See Figure 4.3 1)
b. Rinne’s test
Rinne’s test used to compare air conduction to bone conduction: Hold the handle of
the activated tuning fork on the mastoid process of one ear, A until the client states
that the vibration can no longer be heard. Immediately hold the still vibrating fork
prongs in front of the client’s ear canal. Making sure that it is not touching any hair.
Ask whether the client now hears the sound. Sound conducted by air is heard more
readily than sound conducted by bone. The tuning fork vibrations conducted by
air are normally heard longer. This is a positive Rinne’s test. If the Rinne’s test is
positive and there is hearing impairment, it is a sensorineural hearing loss and not
a conductive problem. If there is a negative Rinne’s test with hearing loss, then theproblem is a conductive. (See Figure 4.3 2 and Figure 4.3 3)
4.3.6. Special population
a. Infant
To assess gross hearing, ring a bell from behind the infant or have the parent call
the child’s name to check for a response. Newborns will quiet to the sound and may
open their eyes wider. By 3 to 4 months of age, the child will turn head and eyes
toward the sound.
b. Children
To inspect the external canal and tympanic membrane in children less than 3 years
old, pull the pinna down and back. Insert the speculum only 0.6 to 1.25 cm. Perform
routine hearing checks and follow up on abnormal results.
In addition to congenital or infection-related causes of hearing loss, noise-induced
hearing loss is becoming more common in adolescents and young adults as a
result of exposure to loud music and prolonged use of headsets at loud volumes.
Teach that music loud enough to prevent hearing a normal conversation can
damage hearing.
4.3.7. Identification of client’s problems
While most people know about hearing loss, many other conditions can affect the
ears too. Some are just irritating, but others can cause discomfort. What’s more,
these diseases can have a knock-on effect on your hearing or exacerbating any
existing hearing loss that you may have.
a. Hearing loss
Conductive hearing loss is the result of interrupted transmission of sound waves
through the outer and middle ear structures. Possible causes are a tear in the
tympanic membrane or an obstruction, due to swelling or other causes, in theauditory canal.
Sensorineural hearing loss is the result of damage to the inner ear, the auditory
nerve, or the hearing center in the brain.
Mixed hearing loss is a combination of conduction and sensorineural loss.
b. Otalgia (ear pain)
Pain that originates from the ear is called primary otalgia, and the most common
causes are otitis media and otitis externa. Examination of the ear usually reveals
abnormal findings in patients with primary otalgia. Pain that originates outside the ear
is called secondary otalgia, and the etiology can be difficult to establish because of
the complex innervation of the ear. The most common causes of secondary otalgia
include temporomandibular joint syndrome and dental infections because the
nerves innervating the ear have a shared distribution to include the head, neck,
chest, and abdomen. The ear is innervated by several sensory nerves. The auricle
is affected by cranial nerves V, VII, X, the external auditory meatus and canal by
cranial nerves V, VII, and X; the tympanic membrane by cranial nerves VII, IX, and
X; and the middle ear by cranial nerves V, VII, and IX. Irritation of any portion of
these nerves can result in otalgia.
Primary otalgia is more common in children, whereas secondary otalgia is more
common in adults. History and physical examination usually lead to the underlyingcause.
c. External ear problem
Among the external ear problem, atresia defined as absence or closure of
external ear canal being a birth defect, and accompanied by auricle malformation
which is characterized by Conductive hearing loss. On clinical examination, usually
the auricle is malformed and the external auditory canal is not patent or significantly
narrowed.
Necrotizing external otitis
Infection involving primarily bony and cartilaginous external auditory canal and
adjacent structures. It occurs usually in immunocompromised persons, especially
elderly patients with diabetes mellitus, and is often initiated by self-inflicted or
iatrogenic trauma to the external auditory canal. Clinically, patients complain of
severe otalgia that worsens at night, and otorrhea. Otoscopic findings include
granulation tissue in the external auditory canal, particularly at the bony-cartilaginous
junction. On audiology there is conductive hearing loss.
d. Middle ear problem
• Traumatic opacified middle ear
Trauma to the temporal bone is usually the result of a blunt head injury. Patients
with temporal bone fracture may present at the time of trauma with evidence ofbasilar skull fracture, such as battle sign, raccoon eyes, or hemotympanum. In
addition, they may complain of hearing loss or dizziness. If a temporal bone fracture
initially goes unrecognized, delayed presentation may involve cerebrospinal fluid(CSF) otorrhea, hearing loss, or symptoms related to cranial nerve VII dysfunction.
• Non-traumatic opacified middle ear: Eustachian tube dysfunction (secretory
otitis)
Persistent mucoid or serous middle ear effusion, in the absence of acute inflammation.
Eustachian tube dysfunction is well known to be related in the pathogenesis of
secretory otitis. Secretory otitis is the most common disease in children, sometime
it can be seen in adults. In children, this can occur purely from enlarged adenoids,
with no pain or bacterial infection. In adults, secretory otitis may be found when a
growing tumor in the nasopharynx blocks Eustachian tube opening.
It is manifested by fluid filling the middle ear cavity causes tympanic membrane
bulging with no signs of acute infection (redness, pain, oedema). Over time, middle
ear fluid can become very thick and glue-like (“glue ear”), which increases thelikelihood of conductive hearing loss.
• Non-traumatic opacified middle ear: acute inflammation/infection
Acute middle ear infection (acute otitis media) usually presenting with typical clinical
image and in most cases not requiring imaging.Clinical manifestation include
earache, fever, pain, otorrhea, conductive hearing loss. On otoscopy tympanic
membrane is red and bulging.Both from clinical and radiological points of view, it is
important to differentiate between acute otitis media and secretory otitis.
Secretory otitis means fluid in the middle ear cavity without signs or symptoms of
infection; this is usually caused when the Eustachian tube patency is compromised
and fluid is trapped in the middle ear. Signs and symptoms of acute otitis media
occur when effusion in the middle ear becomes infected.
• Non-traumatic opacified middle ear: chronic inflammation/infection
When the inflammation persists at least 6 weeks and is associated with otorrhea
through a perforated tympanic membrane, chronic otitis media (COM) is diagnosed.Symptoms include conductive hearing loss, sometimes pain, vertigo, otorrhea.
Self-assessment 4.3
1) Enumerate possible signs and symptoms of a patient with ear problem
2) Which interview questions will you as to a patient with otalgia?
3) Distinguish conduction hearing loss to sensorineural hearing loss.
4) Elaborate possible clinical manifestations of acute otitis media.5) Which tests used to measure hearing capacity of a patient
4.4. Assessment of the nose
Learning activity 4.4
4.4.1. Nose assessment overview
The nose is an organ for olfactory sense. Mostly, the assessment of the nose goes
together with sinuses but our emphasis will be on the nose. The most common
patients’ presenting signs and symptoms of the nose are rhinorrhea, nasal
congestion, loss of smell, pain, itching and epistaxis. Rhinorrhea is a drainage
from the nose while nasal congestion is sense of obstruction within the nose. These
two symptoms can be followed by sneezing, watery eye, throat discomfort and
itching of the eyes, nose and throat. They are caused by viral infection or rhinitis
more precisely; itching is due to allergic causes. Periodic occurrence and presence
of environmental factors of these symptoms suggest allergic rhinitis. Bleeding from
the nose known as epistaxis can be confused to the bleeding from paranasal and
nasopharynx but the latter passes in the throat and continue to the mouth or in the
esophagus.
4.4.2. History taking
To conduct patient history on the nose, here are guiding questions:
• Do symptoms occur when colds are prevalent and last for less than sevendays?
• Do the symptoms keep coming in the same period of the year (e.g: when
pollen is in the air)?
• Are symptoms triggered by a specific animal (e.g: pet) at home or environmental
exposure (e.g: dust)
• Ask about remedies, how long is it? And its effectiveness.
• Ask if any drug was used to control these symptoms.
• Get to know if nasal congestion comes after upper respiratory infection? In
this condition the patient will experience purulent nasal discharge, loss of
smell, facial pain aggravated by bending forwards, ear pressure, cough and
fever.
• Ask if the patient is taking any medication including oral contraceptives,
alcohol and cocaine
• Get to know if nasal congestion is only on one side or both. Sometimes,
deviated nasal, nasal polyp, foreign body or cancer in that area.
• In case of epistaxis, ask the patient to pinpoint the source of bleeding
and differentiate coughing of blood (hemoptysis) to vomiting of blood
(hematemesis) because they all have different causes. The local causes of
epistaxis are from trauma, inflammation, drying of nasal mucosa, tumor and
foreign body in the nose.
• Ask the patient if epistaxis is a recurrent issue, and if there is easy bruising or
bleeding elsewhere. Some medications such as anticoagulants, non-steroid
anti-inflammatory drugs as well as diseases of coagulation and vascular
diseases contribute to epistaxis.4.4.3. Physical assessment of the nose
In the normal condition the breathing process starts when air enters the anterior
naris on both sides then reaches the vestibule and continues to the pharynx and
larynx to the trachea down to the lung. The physical assessment of the nose
involves inspection and palpation. Inspect the external parts of the nose for skin
status, sign of inflammation and symmetry. Consider any asymmetry or deformity
of the nose. It is common to find a deviated lower septum and it is easily detected
during inspection. With a gentle pressure on the tip of the nose, palpate lightly in
the normal condition the nostrils will widens. In case of tenderness on the tip of the
nose, be gentle to manipulate the nose as little as possible.
To check for nasal obstruction, press the ala nasi towards the nasal septum and
ask the patient to breathe in, and repeat he same to the other side then note any
degree of obstruction. To visualize the inner parts of the nose, use an otoscope with
the largest ear speculum. Ask extend his or her neck and introduce the speculum
into the vestibule each nostril and avoid touching the sensitive nasal septum. Enterthe otoscope posteriorly then upwards in short steps to inspect the inferior and
middle turbinate and nasal septum. Normally the nasal mucosal lining the septum
and turbinate is redder than oral mucosa. During examination, indicates the color,
swelling, bleeding and exudate.
In case of exudate reports related characteristic such as clear, mucopurulent or
purulent. In viral rhinitis the mucosa will be increasingly red and swollen whereas
in allergic rhinitis the mucosa will be pale, blue or red. The epistaxis commonly
originates to the lower anterior of nasal septum, so assess for any deviation,
inflammation, perforation and ulceration. Inspect may objectivate fresh blood or
clots while septal perforation may be due to trauma, surgery and intranasal use of
cocaine or amphetamine. The latter two medications are also responsible for septal
ulceration.
The saclike growth made of inflamed tissue which inhibit normal flow of air is known
as nasal polyps sometimes are seen during inspection. Nasal polyps are identified
in case of allergic rhinitis, aspirin sensitivity, asthma and chronic sinus infection.
Rarely, the cancerous tumors found in the nasal cavity are linked to tobacco
exposure or long-term toxin inhalation.
Remember to discard or clean and disinfect used speculum appropriately as per
your institutional policy. Palpate the frontal sinuses on both sides under the bony
brows while doing so, do not apply pressure on the eyes. Palpate also the maxillary
sinuses located below the orbits downwards to the length of the nose. In case
of tenderness in these sinuses associated with facial pain, pressure or fulness,
purulent nasal discharge, nasal obstruction, smell difficulties suggest an acute
bacterial rhinosinusitis involving frontal and maxillary sinuses.Self-assessment 4.4
1) List 5 common causes of consultation of the nose
2) Which finding can we have while assessing the nose using otoscope?
3) State the questions you will ask a patient with rhinorrhea as chief
complain?4) Mention the causes of epistaxis
4.5. History taking of the mouth and pharynx
Learning activity 4.5
1) Which parts of the body here illustrated?
2) Enumerate at least 5 common consultation problems of the mouth.
3) Which technique of physical assessment will you use to assess the mouthand pharynx?
4.5.1. Review of anatomy and physiology of the mouth and
pharynx
The mouth is considered as organ of taste. In anatomical position the lips made
as muscular folds around the mouth, they are the only part of the mouth seen
outside. When the lips are opened, we immediately see the teeth surrounded by
the gingiva. The teeth are connected to maxillary and mandible bones in form of
arch. The gingiva is pale in light skinned people; it is influenced by the individual
level of melamine pigmentation which makes it brown to darker in black people.
In the oral cavity seen when mouth is open, there is the tongue, hard and soft
palate, uvula and two tonsils. The upper surface of the tongue present papillae
which gives a rough surface, some of the papillae are a bit red than others. In
normal circumstance, the tongue may be covered by a thin layer of white coat. On
the lower surface of the tongue, there are no papillae. Just looking at that surface,
we find midline lingual frenulum which attach the tongue to the floor of the mouthand the ducts of submandibular.
The paired sublingual glands lie just under the floor of the mouth mucosa.
Above and behind the tongue, there is an arch formed by anterior and posterior
pillars, the soft palate and uvula. The posterior pharynx is visible behind the soft
palate and the tongue. The uvula known as a hanged lobe in the middle of the
posterior border of the soft palate. Tonsils are often smaller even absent in adults.
The buccal mucosal covers the internal surface of the cheeks. The parotid ductsopen onto the buccal mucosal near the upper second molar
4.5.2. Physical examination of the mouth and pharynx
The physical assessment of the mouth and pharynx involve inspection and
palpation. The examiner observes the lips for color, moisture, ulcers, cracking
or trauma and note any deviance from normal anatomy. By using a new tongue
depressor and bright light in hand, ask the patient to open the mouth widely. Inspect
the gums for bleeding, ulcers, or swelling, and check to see if any teeth are missing,
discolored, abnormal shaped, or loose. Redness of the gingiva and swelling of the
interdental papillae are observed during gingivitis. Carefully inspect the buccal
mucosa for ulcers, nodules, or white patches. To inspect the tongue, ask the patient
to protrude the tongue and move it from side to side, assessing for symmetry, and
inspect the color and texture of its dorsal surface. Asymmetric protrusion of the
tongue suggests the lesion of hypoglossal nerve. Oral cancers most commonly
develop on the sides and base of the tongue. Men of greater than 50 years, smokers
and alcohol consumer are at high risk of tongue and oral cavity cancers. Have the
patient touch the tongue to the hard palate, and carefully inspect its undersurface
and the floor of the mouth. Using a gloved hand, gently grasp the tip of the tongue
with a square piece of gauze and move it from side to side, inspecting carefully forulcerations, plaques, masses, or discoloration.
To inspect the pharynx, the tongue will be back inside, have the patient open wide
and say “ah” or yawn. If the pharynx cannot be seen clearly, have the patient
repeat this maneuver while you firmly press down on the tongue with the tongue
depressor. Take care not to gag the patient. Observe for the soft palate rise because
it indicates the normal functioning of vagus nerve. Inability to rise the soft palate
and deviated uvula are the signs of vagus nerve paralysis. Inspect the uvula,
anterior and posterior pillars, tonsils (if present), and pharynx. When the patient is
saying “Ah” Check for symmetry, discoloration, ulcerations, swelling, masses, ortonsillar exudate.
Self-assessment 4.5
1) While making oral cavity assessment, which findings will indicate you that
the patient has gingivitis?
2) Mention at least 3 risk factors to develop oral cancer
3) Which features will you note on the patient’s lips during inspection?4) Draw an illustration of the oral cavity with all the parts
4.6. Skin assessment
Learning activity 4.6
Observe the images below and respond the questions that follow
1) Compare the images A, B and C
2) Do you think the skin in image b is normal? Explain your answer3) What are the characteristics of a normal skin?
Assessment of the skin involves inspection and palpation. The entire skin surface
may be assessed at one time or as each aspect of the body is assessed. In some
instances, the nurse may also use the olfactory sense to detect unusual skin odors.
4.6.1. History taking of the skin
Ask if the client has any history of the following: pain or itching; presence and
spread of lesions, bruises, abrasions, pigmented spots; previous experience with
skin problems; associated clinical signs; presence of problems in other family
members; related systemic conditions; use of medications, lotions, home remedies;
excessively dry or moist feel to the skin; tendency to bruise easily; association
of the problem to season of year, stress, occupation, medications, recent travel,
housing, and so on; recent contact with allergens (e.g., metal paint).
4.6.2. Physical examination of the skin
The entire skin surface should be examined as well as hair, nails and mucosal
surfaces. Explain the necessity of complete examination to the patient. Use an
appropriate light source and magnification. Identify the presenting complaint and
incidental skin conditions. Always patient privacy should be respected during
examination. Assess distribution, morphology and arrangement i.e. the number,
size and color of skin lesions, which sites are involved, their symmetry, shape and
arrangement. What types of lesions are present?
4.6.3. Inspection
• Inspect skin color, (Pallor, cyanosis, jaundice, erythema) (best assessed
under natural light and on areas not exposed to the sun).
• Inspect uniformity of skin color. Generally, the skin must be uniform except
in areas exposed to the sun; areas of lighter pigmentation (palms, lips,
nail beds) in dark-skinned people. Areas of either hyperpigmentation or
hypopigmentation indicate some abnormalities.
• Assess edema, if present (i.e., location, color, temperature, shape, and the
degree to which the skin remains indented or pitted when pressed by a finger).
Measuring the circumference of the extremity with a millimeter tape may be
useful for future comparison.
• Inspect, palpate, and describe skin lesions. Apply gloves if lesions are open
or draining. Palpate lesions to determine shape and texture. Freckles, some
birthmarks that have not changed since childhood, and some longstanding
vascular birthmarks such as strawberry or port-wine hemangiomas, some flat
and raised nevi; no abrasions or other lesions.
• Touch the skin to palpate individual lesions and more diffuse rashes, noting
surface and deep characteristics. Does the lesion involve epidermis, dermis?If scaly, does the surface flake off easily? If crusted, what is underneath?
• Look carefully for signs of systemic disease, such as xanthomas
(hyperlipidaemia), café-au-lait macules (neurofibromatosis),
acanthosisnigricans (insulin resistance) etc.
• Various interruptions in skin integrity; irregular, multicolored, or raised
nevi, some pigmented birthmarks such as melanocystic nevi, and some
vascular birthmarks such as cavernous hemangiomas. Even these deviations
from normal may not be dangerous or require treatment.
• Observe and palpate skin moisture. Moisture in skin folds and the axillae
(varies with environmental temperature and humidity, body temperature, and
activity) Excessive moisture (e.g., in hyperthermia); excessive dryness (e.g.,
in dehydration).
• Palpate skin temperature. Compare the two feet and the two hands, using the
backs of your fingers. Generalized hyperthermia (e.g., in fever); generalized
hypothermia (e.g., in shock); localized hyperthermia (e.g., in infection);
localized hypothermia (e.g., in arteriosclerosis)
• Note skin turgor (fullness or elasticity) by lifting and pinching the skin on an
extremity or on the sternum. When pinched, skin springs back to previous
state (is elastic); may be slower in older adults Skin stays pinched or tented
or moves back slowly (e.g., in dehydration). Count in seconds how long the
skin remains tented.
• Examine the hair and nails.
• Document findings in the client record using forms or checklists supplemented
by narrative notes when appropriate. Draw location of skin lesions on body
surface diagrams.
Common causes of skin disorders include: bacteria trapped in skin pores and hair
follicles, fungus, parasites, viruses, a weak immune system, contact with allergens,
irritants, or another person’s infected skin, genetic factors, sun exposition, systemic
conditions with skin effect such as thyroid, immune system, kidneys and so on.
4.6.4. Lifespan considerations
a. Infants
Physiological jaundice may appear in newborns 2 to 3 days after birth and usually
lasts about 1 week. Pathologic jaundice, or that which indicates a disease, appears
within 24 hours of birth and may last more than 8 days. Newborns may have
milia (whiteheads), small white nodules over the nose and face, and vernixcaseosa
(white cheesy, greasy material on the skin). Premature infants may have lanugo, a
fine downy hair covering their shoulders and back.
In dark-skinned infants, areas of hyperpigmentation may be found on the back,
especially in the sacral area. Diaper dermatitis may be seen in infants. If a rash ispresent, inquire in detail about immunization history
Assess skin turgor by pinching the skin on the abdomen.
b. Children
Children normally have minor skin lesions (e.g., bruising or abrasions) on arms and
legs due to their high activity. Lesions on other parts of the body may be signs of
disease or abuse, and a thorough history should be taken. Secondary skin lesions
may occur frequently as children scratch or expose a primary lesion to microbes.
With puberty, oil glands become more productive, and children may develop acne.
Most persons ages 12 to 24 have some acne.
Measles is a highly infectious, airborne caused by morbilivirus. It is very prevalent
in babies who are too young to be vaccinated, pregnant people, and others who did
not get vaccine. One symptom of measles is a red or brown rash that spreads down
the body. Other symptoms include a fever, watery eyes and a runny nose, a cough,
and small reddish spots inside the mouth. There is no cure, but treatment tend to
address the symptoms and monitor to prevent complications.
Impetigo defined as a contagious bacterial infection is one of the most common
skin infections in young children. It usually causes itchy sores and blisters to appear
around the mouth and elsewhere on the face. These sores then burst and leave a
crust. The crust dries and leaves a red mark that fades without scarring. Treatment
usually involves an antibiotic.
Cellulitis is a bacterial infection in the deeper layers of the skin. It develops quickly
and can spread rapidly throughout the body. The affected skin may be red, swollen,
hot, and painful or tender. Cellulitis is most common in the legs but can occur
anywhere in the body. Severe cellulitis may be life threatening, and the treatment
generally involves antibiotics.
Acne, the most common skin disorder, can be a source of anxiety for every teen,
caused by blocked hair follicles and sebaceous glands of the skin, often triggered
by hormonal changes. Acne affects mostly the face and sometimes the back and
chest. Acne needs to be treated by a dermatologist because untreated forms cause
permanent scars and dark facial spots.
Atopic dermatitis is one of the most common forms of eczema seen in children.
The exact cause of atopic dermatitis is not known, possibly it involves genetics, the
environment, and/or the immune system. Atopic dermatitis can appear on the face
especially in infants, hands, feet and folds of the skin. Clinically, the skin looks dry,
scaly and itchy skin are the norm, and constant scratching may lead to a thickened
area. Topical steroids are often used to control the symptoms.
Cutaneous candidiasis caused by overgrowth of the Candida albicansis
manifested as lesions or small pustules. Candidiasis typically develops in skinfolds, such as the armpit or around the groin, sometimes affect the face. People
can usually prevent Candidiasis by improving their skin hygiene and avoiding
the overuse of antibiotics. The treatment consist of antifungal and corticosteroidcreams.
c. Older adults
Changes in white skin occur at an earlier age than in black skin. The skin
loses its elasticity and develop wrinkles. Wrinkles first appear on the skin of the
face and neck, which are abundant in collagen and elastic fibers. The skin appears
thin and translucent because of loss of dermis and subcutaneous fat.
The skin is dry and flaky because sebaceous and sweat glands are less active. Dry
skin is more prominent over the extremities. The skin takes longer to return to its
natural shape after being tented between the thumb and finger. Due to the normal
loss of peripheral skin turgor in older adults, assess for hydration by checking skin
turgor over the sternum or clavicle. Vitiligo tends to increase with age and is thought
to result from an autoimmune response which trigger loss of skin pigmentation.
Vitiligo generally causes white patches to appear on the skin, usually in areas
exposed to sunlight, it is more remarkable in dark skinned people and currently nocure for vitiligo.
Shingles or Herpes Zoster results in a red, blistered rash that may wrap around
the trunk or appear anywhere on your body. Other signs and symptoms include
fever, fatigue and headache. Shingles is caused by the same virus that causes
chickenpox - the varicella-zoster virus. People who suffered from chickenpox are
at risk for shingles as the chickenpox virus lies dormant in their nervous system
for years. The treatment of measles is symptomatic, the preventive measure is a
vaccine called measles, mumps, rubella (MMR) vaccine.
Skin cancer involves uncontrollable skin cells growth. We have several types of
skin cancer but common ones are basal cell carcinoma, squamous cell carcinoma
and melanoma. Early recognition of cancer may allow its effective treatment. These
cancers tend to occur after prolonged exposure to the sun. Darker skin produces
more melanin, which gives the skin more protection from harmful sun rays. The
Basal cell carcinoma which is the most common skin cancer. It typically develops
on the neck, arms, or head but can affect any area of the body. In a person with
lighter skin, basal cell carcinoma may appear as a pink, round bump or patch. In
someone with darker skin, the bump may be brown or black and may look like a
common mole.
Squamous cell carcinoma is the second most common type of skin cancer. The
skin appears dry, scaly, patches called actinic keratoses. The late diagnostic will let
it grow deeper into the skin and cause disfigurement. People with lighter skin tend
to develop this cancer in areas often exposed to the sun whereas in darker skinned,it affects the legs, genitals, and anus. It is a good idea to consult for any lesion that
grows, changes, bleeds or looks unusual in any other way.
Melanoma is the most serious of the skin cancers because it spreads most easily
to other parts of the body. It is can develop from a mole or another pigmented
area of skin. If any mole is asymmetrical, has ragged edges or an uneven color, or
changes in size, there is a need for medical attention. Melanoma may be harder to
identify in darker skinned people, so checking carefully is important. Remember to
include the toenails and fingernails, as this type of cancer is more common in these
areas for People of color. The treatment of cancer involves radiotherapy, surgery,and chemotherapy.
4.6.5. Specific test of the skin
Specialized techniques used in examination of the skin include:
• Dermoscopy for pigmented lesions to diagnose melanoma.
• Skin biopsy for histology and direct immunofluorescence.
• Patch tests to identify type 4 contact hypersensitivity reactions.
• Skin scrapings or nail clippings for mycology (fungal infections).
• Wood’s light (long wave UVA) examination for pigmentary changes and
fluorescence resulting from certain infections.
Table 4.6 1How to describe a skin lesion
4.6.6. Preventing skin disorders
Certain skin disorders aren’t preventable, including genetic conditions and some
skin problems due to other illnesses. However, it’s possible to prevent some skin
disorders by:
• Washing hands with soap and warm water frequently.
• Avoid direct contact with the skin of other people who have an infection.
• Clean things in public spaces, such as gym equipment, before using them.
• Don’t share personal items, such as blankets, hairbrushes, or swimsuits.
• Sleep for at least seven hours each night.
• Drink plenty of water.
• Avoid excessive physical or emotional stress.
• Eat a nutritious diet.
• Get vaccinated for infectious skin conditions, such as chickenpox.
Noninfectious skin disorders, such as acne and atopic dermatitis, are sometimes
preventable. Prevention techniques vary depending on the condition. Here are
some tips for preventing some noninfectious skin disorders:
• Wash face with a gentle cleanser and water every day.
• Use moisturizer.
• Avoid environmental and dietary allergens.
• Avoid contact with harsh chemicals or other irritants.
• Sleep for at least seven hours each night.
• Drink plenty of water.
• Eat a healthy diet.• Protect your skin from excessive cold, heat, and wind.
Self-assessment 4.6
1) What are the skin characteristics to note during physical examination?
2) What are the causes of acne?
3) Enumerate common skin conditions in children
4) Which physical assessment technique used to examine the skin5) List the element of education for the prevention of skin conditions?
End unit assessment 4
1) List 5 infectious diseases of the skin
2) Why do old adults lose skin elasticity and develop wrinkles?
3) Why do we insert the otoscope differently in children and adult patients?
4) What does a deviated uvula present during buccal cavity assessment?
5) What are the inspectional findings of the lips?
6) Enumerate the signs and symptoms of tonsillitis7) Which sinuses are palpable during physical examination?
UNIT5:INTRODUCTION TO COMMUNITY HEALTH NURSING
Key Unit Competence:
Provide basic community interventions
Introductory activity 5
Observe the pictures A, B, C, and D
1) Describe the pictures A, B, C and D2) According to you, what do you think is the focus of this unit 5?
Introduction
As a specialty field of nursing, community health nursing adds public health
knowledge and skills that address the needs and problems of communities
and aggregates and focuses care on communities and vulnerable populations.
Community health nursing is grounded in both public health science and nursing
science, which makes its philosophical orientation and the nature of its practice
unique. It has been recognized as a subspecialty of both fields.
5.1. Overview of community health Nursing:
This sub-unit of overview of community health nursing discusses the Concepts
definition, History of community health nursing, and objectives of Community health
nursing. It also argues on characteristics of community health nursing, principles ofcommunity health nursing and community Health in Rwanda
5.1.1. Concepts definition
Learning activity 5.1.1
With use of student text book of fundamentals of nursing (senior six) or the
library text books of community health nursing / public health nursing, define
the following terms/concepts: health, a community, an aggregate, social
determinants of health, community health nursing, public health, primaryprevention, secondary prevention, and tertiary prevention.
a. Health
Health is defined in the WHO constitution of 1948 as: A state of complete physical,
social and mental well-being, and not merely the absence of disease or infirmity.
Here below, there discussion of each of those components of health (that is physical,
mental (or psychological), and social well-being).
Defining physical health
Physical health, which is one of the components of the definition of health, could
be defined as the absence of diseases or disability of the body parts. Physical
health could be defined as the ability to perform routine tasks without any physical
restriction. The following examples can help you to understand someone who is
physically unhealthy:
• A person who has been harmed due to a car accident
• A farmer infected by malaria and unable to do their farming duties
• A person infected by tuberculosis and unable to perform his or her tasks.Psychological health
Sometimes it can be really hard from the outside to tell if the person is struggling
with mental health issues, but at other times they show symptoms that suggest a
lack of self-awareness or personal identity, or an inability of rational and logical
decision-making.
At other times it might be apparent that they are not looking after themselves and
are without a proper purpose in their life. They may be drinking alcohol and have a
non-logical response to any request. You may also notice that they have an inability
to maintain their personal autonomy and are unable to maintain good relationships
with people around them. So how do we recognize a mentally healthy adult? The
mentally healthy adult shows behavior that demonstrates awareness of self, who
has purpose to their life, a sense of self understanding, self-value and a willingness
to perceive reality and cope with its difficulties.
The mentally healthy adult is active, hardworking and productive, persists with tasks
until they are completed, logically thinks about things affecting their own health,
responds flexibly in the face of stress, receives pleasure from a variety of sources,
and accepts their own limitations realistically. The healthy adult has a capacity
to live with other people and understand other people’s needs. It is sometimes
considered that the mentally healthy person shows growth and maturity in three
areas: cognitive, emotional and social. The next part will help you understand
these three components of psychological health:
Cognitive component
The cognitive component of mental health is really to do with thinking and being
able to work things out. It includes the ability of an individual to learn, to have
awareness (consciousness) and to perceive reality. At a higher level it also involves
having a memory and being able to reason rationally and solve problems, as well
as being able to work creativity and have a sense of imagination.
Emotional component
When you are implementing a health extension program, you may encounter
various feelings or emotions in households in your community such as happiness,
anger or sadness. People might cry or laugh. The emotional component of health
is the ability and skill of expressing emotions in an ‘appropriate’ way. The word
“appropriate” means that the type of response should be able to match the problem.
In the previous section you have learned something about the physical and mental
components of health. Social health is also an important component of overall
health and in the next section you will consider the definition and some examplesof social health.
Social component
A social role can be developed while taking part in communal activities such as
harvesting or other activities where teamwork is important.
The social component of health is considered to be the ability to make and
maintain ‘acceptable’ and ‘proper’ interactions and communicate with other people
within the social environment. This component also includes being able to maintain
satisfying interpersonal relationships and being able to fulfill a social role. Having
a social role is the ability that people have to maintain their own identity while
sharing, cooperating, communicating and enjoying the company of others. This is
really important when participating in friendships and taking a full part in family and
community life.
The following examples could be considered to contribute to social health:
1. Mourning when a close family member dies
2. Going to a football match or involvement in a community meeting
3. Celebrating traditional festivals within your community
4. Shopping in the market
5. Creating and maintaining friendship.
In reality all these events could have a social component and help towards building
people’s social view of health. They all involve interacting with others and gaining
support, friendship and in many instances joy from being with other people.
b. Community
The definitions of community are numerous and variable. Before 1996, definitions
of community focused on geographic boundaries combined with social attributes of
people.
In recent nursing literature, community has been defined as “a collection of people
who interact with one another and whose common interests or characteristics form
the basis for a sense of unity or belonging”.
Maurer and Smith (2013) further addressed the concept of community and
identified three defining attributes: people, place, and social interaction or common
characteristics, interests, or goals. Combining ideas and concepts, in this text,
community is seen as a group or collection of individuals interacting in social
units and sharing common interests, characteristics, values, and goals.
Maurer and Smith (2013) noted that there are two main types of communities:
geopolitical communities and phenomenological communities. Geopolitical
communities are those most traditionally recognized or imagined when the
term community is considered. Geopolitical communities are defined or formed
by natural and/or manmade boundaries and include cities, counties, states, and
nations. Other commonly recognized geopolitical communities are school districts,
census tracts, and neighborhoods.
Phenomenological communities, on the other hand, refer to relational, interactive
groups. In phenomenological communities, the place or setting is more abstract,
and people share a group perspective or identity based on culture, values, history,
interests, and goals. Examples of phenomenological communities are schools,
colleges, and universities; churches, synagogues, and mosques; and various
groups and organizations, such as social networks.
A community of solution is a type of phenomenological community. A community of
solution is a collection of people who form a group specifically to address a common
need or concern. The Sierra Club, whose members lobby for the preservation of
natural resource lands, and a group of disabled people who challenge the owners
of an office building to obtain equal access to public buildings, education, jobs, and
transportation are examples. These groups or social units work together to promote
optimal “health” and to address identified actual and potential health threats and
health needs.
c. Aggregate
It is a population group with common characteristics. Aggregates are subgroups or
subpopulations that have some common characteristics or concerns.
Depending on the situation, needs, and practice parameters, community health
nursing interventions may be directed toward a community (e.g., residents of a
small town), a population (e.g., all elders in a rural region), or an aggregate (e.g.,
pregnant teens within a school district).
d. Community-based nursing
Community-based nursing is setting-specific, and the emphasis is on acute and
chronic care and includes such practice areas as home health nursing and nursing
in outpatient or ambulatory settings. Community-based nursing practice refers to
application of the nursing process in caring for individuals, families and groups
where they live, work or go to school or as they move through the health care
system.
At present, community-based nursing is defined as minor acute and chronic care
that is comprehensive, coordinated, and delivered where people work, live, or
attends school. Community-based nursing is an extension of illness care provided
to clients and their families outside the acute care setting. Although the client’s
individual needs are met, the nurses may not be paying attention to family dynamics,
environmental health, health education, and health promotion.
For the past few decades, the title community health nurse has been used todesignate nursing care in community settings that combines the practice of
community-based nursing and public health nursing. The practice of community
health nursing is the use of systematic processes to deliver care to individual
people, families, and community groups with a focus on promoting, preserving,
protecting, and maintaining health. In doing so, the care directed to the individual
person, family, or community group contributes to the health of the population as a
whole.
e. Community health nursing
It is the use of systematic processes to deliver care to individuals, families,
and community groups with a focus on promoting, preserving, protecting, and
maintaining health.
Community-based nursing and community health nursing have different goals.
Community health nursing emphasizes preservation and protection of health, and
community-based nursing emphasizes managing acute or chronic conditions.
In community health nursing, the primary client is the community; in community
based nursing, the primary clients are the individual and the family. Finally, services
in community-based nursing are largely direct, but in community health nursing,
services are both direct and indirect.
f. Epidemiology
It is the study of the distribution and determinants of states of health and illness in
human populations.
g. Evidence-based nursing
It is the integration of the best evidence available with clinical expertise and the
values of the client to increase the quality of care.
h. Healthcare disparities
Gaps in healthcare experienced by one population compared with another.
i. Health information technology
It is comprehensive management of health information and its secure exchange
between consumers, providers, government and quality entities, and insurers.
j. Public health
Contrasting with “medical care,” which focuses on disease management and
“cure,” public health efforts focus on health promotion and disease prevention.
Health promotion activities enhance resources directed at improving well-being,
whereas disease prevention activities protect people from disease and the effects
of disease.
C. E. Winslow is known for the following classic definition of public health: Public
health is the Science and Art of (1) preventing disease, (2) prolonging life, and(3) promoting health and efficiency through organized community effort for: (a)
sanitation of the environment, (b) control of communicable infections, (c) education
of the individual in personal hygiene, (d) organization of medical and nursing services
for the early diagnosis and preventive treatment of disease, and (e) 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
k. Public health nursing
Population-based practice, defined as a synthesis of nursing and public health
within the context of preventing disease and disability and promoting and protecting
the health of the entire community.
l. Social determinants of health:
These are the social conditions in which people live and work. The health status of
a community is associated with a number of factors, such as health care access,
economic conditions, social and environmental issues, and cultural practices, and it
is essential for the community health nurse to understand the determinants of health
and recognize the interaction of the factors that lead to disease, death, and disability.
Indeed, individual biology and behaviors influence health through their interaction
with each other and with the individual’s social and physical environments. Thus,
policies and interventions can improve health by targeting detrimental or harmful
factors related to individuals and their environment.
Community and public health nurses should understand social determinants of
health and appreciate that health and illness are influenced by a web of factors,
some that can be changed (e.g., individual behaviors such as tobacco use, alcohol
consumption, diet, physical activity) and some that cannot (e.g., genetics, age,
gender). Other factors (e.g., physical and social environment) may require changes
that will need to be accomplished from a policy perspective. Community health
nurses must work with policy makers and community leaders to identify patterns of
disease and death and to advocate for activities and policies that promote health at
the individual, family, and population levels.
m.Preventive Approach to Health
Leavell and Clark (1958) identified three levels of prevention commonly described in
nursing practice: primary prevention, secondary prevention, and tertiary preventionas illustrated in the following figure:
Primary prevention relates to activities directed at preventing a problem before it
occurs by altering susceptibility or reducing exposure for susceptible individuals.
Primary prevention consists of two elements: general health promotion and specific
protection. Health promotion efforts enhance resiliency and protective factors and
target essentially well populations. Examples include promotion of good nutrition,
provision of adequate shelter, and encouraging regular exercise. Specific protection
efforts reduce or eliminate risk factors and include such measures as immunization
and water purification.
Secondary prevention refers to early detection and prompt intervention during
the period of early disease pathogenesis. Secondary prevention is implemented
after a problem has begun, but before signs and symptoms appear. It targets
those populations that have risk factors. Mammography, blood pressure screening,
scoliosis screening, and Papanicolaou smears are examples of secondary
prevention.
Tertiary prevention targets populations that have experienced disease or injury
and focuses on limitation of disability and rehabilitation. Aims of tertiary prevention
are to keep health problems from getting worse, to reduce the effects of disease
and injury, and to restore individuals to their optimal level of functioning. Examples
include teaching how to perform insulin injections and disease management to a
patient with diabetes, referral of a patient with spinal cord injury for occupational
and physical therapy, and leading a support group for grieving parents.
Much of community health nursing practice is directed toward preventing the
progression of disease at the earliest period or phase feasible using the appropriate
level(s) of prevention. For example, when applying “levels of prevention” to a client
with HIV/AIDS, a nurse might perform the following interventions:
• Educate students on the practice of sexual abstinence or “safer sex” by using
barrier methods (primary prevention)
• Encourage testing and counseling for clients with known exposure or who are
in high-risk groups; provide referrals for follow-up for clients who test positive
for HIV (secondary prevention)
• Provide education on management of HIV infection, advocacy, case
management, and other interventions for those who are HIV positive (tertiaryprevention).
Self-assessment 5.1.1
1) Give at least 4 social determinants of health
2) Differentiate a community from an aggregate
3) Differentiate community-based nursing from community health nursing.
4) With examples, differentiate physical health from psychological health
5) With examples, differentiate the three levels of prevention commonlydescribed in nursing practice
5.1.2. History of community health Nursing
Learning activity 5.1.2
By the use of community health nursing books and internet resources, found
out at least three key periods of the history of community health nursing andexplain them.
Traditionally, historians believed that organized public health efforts were eighteenth
and nineteenth-century activities associated with the Sanitary Revolution. However,
modern historians have shown that organized community health efforts to prevent
disease, prolong life, and promote health have existed since early human history.
Public health efforts developed slowly over time. The following sections briefly tracethe evolution of organized public health and highlight the periods of prerecorded
historic times (i.e., before 5000 BCE), classical times (i.e., 3000 to 200 BCE), the
Middle Ages (i.e., 500 to 1500 CE), the Renaissance (i.e., fifteenth, sixteenth, and
seventeenth centuries), the eighteenth century, and the nineteenth century, and
into the present day.
a. Prerecorded Historic Times
From the early remains of human habitation, anthropologists recognize that early
nomadic humans became domesticated and tended to live in increasingly larger
groups. Aggregates ranging from family to community inevitably shared episodes
of life, health, sickness, and death. Whether based on superstition or sanitation,
health practices evolved to ensure the survival of many aggregates. For example,
primitive societies used elements of medicine (e.g., voodoo), isolation (e.g.,
banishment), and fumigation (i.e., use of smoke) to manage disease and thus
protect the community for thousands of years.
Classical Times
In the early years of the period 3000 to 1400 BCE, the Minoans devised ways
to flush water and construct drainage systems. Circa 1000 BCE, the Egyptians
constructed elaborate drainage systems, developed pharmaceutical preparations,
and embalmed the dead. Pollution is an ancient problem. The Biblical Book of
Exodus reported that “all the waters that were in the river stank,” and in the Book of
Leviticus (believed to be written around 500 BCE), the Hebrews formulated the first
written hygiene code. This hygiene code protected water and food by creating laws
that governed personal and community hygiene such as contagion, disinfection,
and sanitation.
Greece
Greek literature contains accounts of communicable diseases such as diphtheria,
mumps, and malaria. The Hippocratic book On Airs, Waters and Places, a treatise
on the balance between humans and their environment, may have been the only
volume on this topic until the development of bacteriology in the late nineteenth
century. Diseases that were always present in a population, such as colds and
pneumonia, were called endemic. Diseases such as diphtheria and measles,
which were occasionally present and often fairly widespread, were called epidemic.
The Greeks emphasized the preservation of health, or good living, which the
goddess Hygeia represented, and curative medicine, which the goddess Panacea
personified. Human life had to be in balance with environmental demands; therefore
the Greeks weighed the importance of exercise, rest, and nutrition according to
age, sex, constitution, and climate.
Rome
Although the Romans readily adopted Greek culture, they far surpassed Greekengineering by constructing massive aqueducts, bathhouses, and sewer systems.
For example, at the height of the Roman Empire, Rome provided its 1 million
inhabitants with 40 gallons of water per person per day, which is comparable to
modern consumption rates. Inhabitants of the overcrowded Roman slums, however,
did not share in public health amenities such as sewer systems and latrines, and
their health suffered accordingly. The Romans also observed and addressed
occupational health threats. In particular, they noted the pallor of the miners, the
danger of suffocation, and the smell of caustic fumes. The ancient Romans provided
public health services that included the following:
• A water board to maintain the aqueducts
• A supervisor of the public baths
• Street cleaners
• Supervision of the sale of food
For protection, miners devised safeguards by using masks made of bags, sacks,
membranes, and bladder skins. In the early years of the Roman Republic, priests
were believed to mediate diseases and often dispensed medicine. Public physicians
worked in designated towns and earned money to care for the poor. In addition,
they were able to charge wealthier patients a service fee.
Much as in a modern health maintenance organization (HMO) or group practice,
several families paid a set fee for yearly services. Hospitals, surgeries, infirmaries,
and nursing homes appeared throughout Rome. In the fourth century, a Christian
woman named Fabiola established a hospital for the sick poor. Others repeated this
model throughout medieval times.
b. Middle Ages
The decline of Rome, which occurred circa 500 CE, led to the Middle Ages.
Monasteries promoted collective activity to protect public health, and the population
adopted protective measures such as building wells and fountains, cleaning streets,
and disposing of refuse. The commonly occurring communicable diseases were
measles, smallpox, diphtheria, leprosy, and bubonic plague. Physicians had little
to offer in the management of diseases such as leprosy. The church took over by
enforcing the hygienic codes from Leviticus and establishing isolation and leper
houses, or leprosaria.
A pandemic is the existence of disease in a large proportion of the population. One
such pandemic, the bubonic plague, ravaged much of the world in the fourteenth
century. This plague, or Black Death, claimed close to half the world’s population at
that time. For centuries, medicine and science did not recognize that fleas, which
were attracted to the large number of rodents inhabiting urban areas, were the
transmitters of plague. Modern public health practices such as isolation, disinfection,and ship quarantines emerged in response to the bubonic plague.
During the Middle Ages, clergymen often acted as physicians and treated kings and
noblemen. Monks and nuns provided nursing care in small houses designated as
structures similar to today’s small hospitals. Medieval writings contained information
on hygiene and addressed such topics as housing, diet, personal cleanliness, and
sleep.
c. The Renaissance
Although the cause of infectious disease remained undiscovered, two
events important to public health occurred during the Renaissance. In 1546,
GirolamoFracastoro presented a theory that infection was a cause and epidemic
a consequence of the “seeds of disease.” Then, in 1676, Anton van Leeuwenhoek
described microscopic organisms, although he did not associate them with disease.
The Elizabethan Poor Law, enacted in England in 1601, held the church parishes
responsible for providing relief for the poor. This law governed health care for the
poor for more than two centuries and became a prototype for later U.S. laws.
d. Eighteenth Century
Great Britain
The eighteenth century was marked by imperialism and industrialization. Sanitary
conditions remained a huge problem. During the Industrial Revolution, a gradual
change in industrial productivity occurred. The industrial boom sacrificed many
lives for profit. In particular, it forced poor children into labor. Under the Elizabethan
Poor Law, parishes established workhouses to employ the poor. Orphaned and
poor children were wards of the parish; therefore the parish forced these young
children to labor in parish workhouses for long hours.
At 12 to 14 years of age, a child became a master’s apprentice. Those apprenticed
to chimney sweeps reportedly suffered the worst fate because their masters forced
them into chimneys at the risk of being burned and suffocated. Vaccination was
a major discovery of the times. In 1796, Edward Jenner observed that people
who worked around cattle were less likely to have smallpox. He concluded that
immunity to smallpox resulted from an inoculation with the cowpox virus. Jenner’s
contribution was significant because approximately 95% of the population suffered
from smallpox and approximately 10% of the population died of smallpox during the
eighteenth century. Frequently, the faces of those who survived the disease were
scarred with pockmarks.
e. Nineteenth Century
Europe
During the nineteenth century, communicable diseases ravaged the population
that lived in unsanitary conditions, and many lives were lost. For example, in themid-1800s, typhus and typhoid fever claimed twice as many lives each year as
the Battle of Waterloo. Edwin Chadwick called attention to the consequences of
unsanitary conditions that resulted in health disparities that shortened life spans of
the laboring class in particular. Chadwick contended that death rates were high in
large industrial cities such as Liverpool, where more than half of all children born
of working-class parents died by age 5. Laborers lived an average of 16 years. In
contrast, tradesmen lived 22 years, and the upper classes lived 36 years.
In 1842, Chadwick published his famous Report on an Inquiry Into the Sanitary
Conditions of the Laboring Population of Great Britain. The report furthered the
establishment of the General Board of Health for England in 1848. Legislation for
social reform followed, addressing prevailing concerns such as child welfare, factory
management, education, and care for the elderly, sick, and mentally ill. Clean water,
sewers, fireplugs, and sidewalks emerged as a result.
In 1849, a German pathologist named Rudolf Virchow argued for social action—
bettering the lives of the people by improving economic, social, and environmental
conditions—to attack the root social causes of disease. He proposed “a theory
of epidemic disease as a manifestation of social and cultural maladjustment”. He
further argued that the public was responsible for the health of the people; that
social and economic conditions heavily affected health and disease; that efforts to
promote health and fight disease must be social, economic, and medical; and that
the study of social and economic determinants of health and disease would yield
knowledge to guide appropriate action. In 1849, these principles were embodied
in a public health law submitted to the Berlin Society of Physicians and Surgeons.
According to this document, public health has as its objectives: (1) The healthy
mental and physical development of the citizen, (2) the prevention of all dangers to
health, and (3) the control of disease.
It was pointed out that public health cares for society as a whole by considering
the general physical and social conditions that may adversely affect health and
protects each individual by considering those conditions that prevent the individual
from caring for his or her health. These “conditions” may fit into one of two major
categories: conditions that give the individual the right to request assistance from
the state (e.g., poverty and infirmity) and conditions that give the state the right and
obligation to interfere with the personal liberty of the individual (e.g., transmissible
diseases and mental illness).
A very critical event in the development of modern public health occurred in 1854,
when an English physician, anesthetist, and epidemiologist named John Snow
demonstrated that cholera was transmissible through contaminated water. In a large
population afflicted with cholera, he shut down the community’s water resource by
removing the pump handle from a well and carefully documented changes as thenumber of cholera cases fell dramatically
f. Advent of Modern Health Care
Early public health efforts evolved further in the mid-nineteenth century.
Administrative efforts, initial legislation, and debate regarding the determinants
of health and approaches to health management began to appear on a social,
economic, and medical level. The advent of “modern” health care occurred around
this time, and nursing made a large contribution to the progress of health care.
The following sections discuss the evolution of modern nursing, the evolution of
modern medical care and public health practice, the evolution of the community
caregiver, and the establishment of public health nursing.
Evolution of Modern Nursing
Florence Nightingale, the woman credited with establishing “modern nursing,”
began her work during the mid-nineteenth century. Historians remember Florence
Nightingale for contributing to the health of British soldiers during the Crimean War
and establishing nursing education. However, many historians failed to recognize her
remarkable use of public health principles and distinguished scientific contributions
to health care reform The following review of Nightingale’s work emphasizes her
concern for environmental determinants of health; her focus on the aggregate
of British soldiers through emphasis on sanitation, community assessment, and
analysis; the development of the use of graphically depicted statistics; and the
gathering of comparable census data and political advocacy on behalf of the
aggregate.
Nightingale was from a wealthy English family, was well educated, and traveled
extensively. Her father tutored her in mathematics and many other subjects.
Nightingale later studied with Adolphe Quetelet, a Belgian statistician. Quetelet
influenced her profoundly and taught her the discipline of social inquiry. Nightingale
also had a passion for hygiene and health. In 1851, at the age of 31 years, she
trained in nursing with Pastor Fliedner at Kaiserswerth Hospital in Germany. She
later studied the organization and discipline of the Sisters of Charity in Paris.
Nightingale wrote extensively and published her analyses of the many nursing
systems she studied in France, Austria, Italy, and Germany.
In 1854, Nightingale responded to distressing accounts of a lack of care for wounded
soldiers during the Crimean War. She and 40 other nurses traveled to Scutari,
which was part of the Ottoman Empire at the time. Nightingale was accompanied
by lay nurses, Roman Catholic sisters, and Anglican sisters. Upon their arrival, the
nurses learned that the British army’s management method for treating the sick
and wounded had created conditions that resulted in extraordinarily high death
rates among soldiers. One of Nightingale’s greatest achievements was improving
the management of ill and wounded soldiers. Nightingale faced an assignment inThe Barrack Hospital, which had been built for 1700 patients. In 4 miles of beds,
she found 3000 to 4000 patients separated from each other by only 18 inches
of space. During the Crimean War, cholera and “contagious fever” were rampant.
Equal numbers of men died of disease and battlefield injury. Nightingale found
that allocated supplies were bound in bureaucratic red tape; for example, supplies
were “sent to the wrong ports or were buried under munitions and could not be
got”. Nightingale encountered problems reforming the army’s methods for care of
the sick because she had to work through eight military affairs departments related
to her assignment. She sent reports of the appalling conditions of the hospitals to
London. In response to her actions, governmental and private funds were provided
to set up diet kitchens and a laundry and provided food, clothing, dressings, and
laboratory equipment Major reforms occurred during the first 2 months of her
assignment. Aware that an interest in keeping social statistics was emerging,
Nightingale realized that her most forceful argument would be statistical in nature.
She reorganized the methods of keeping statistics and was the first to use shaded
and colored coxcomb graphs of wedges, circles, and squares to illustrate the
preventable deaths of soldiers. Nightingale compared the deaths of soldiers in
hospitals during the Crimean War with the average annual mortality in Manchester
and with the deaths of soldiers in military hospitals in and near London at the time.
Through her statistics she also showed that, by the end of the war, the death rate
among ill soldiers during the Crimean War was no higher than that among well
soldiers in Britain.
Indeed, Nightingale’s careful statistics revealed that the death rate for treated
soldiers decreased from 42% to 2%. Furthermore, she established community
services and activities to improve the quality of life for recovering soldiers. These
included rest and recreation facilities, study opportunities, a savings fund, and a
post office. She also organized care for the families of the soldiers.
After returning to London at the close of the war in 1856, Nightingale devoted her
efforts to sanitary reform. At home, she surmised that if the sanitary neglect of
the soldiers existed in the battle area, it probably existed at home in London. She
prepared statistical tables to support her suspicions.
In one study comparing the mortality of men aged 25 to 35 years in the army
barracks of England with that of men the same age in civilian life, Nightingale found
that the mortality of the soldiers was nearly twice that of the civilians. In one of her
reports, she stated that “our soldiers enlist to death in the barracks”. Furthermore,
she believed that allowing young soldiers to die needlessly of unsanitary conditions
was equivalent to taking them out, lining them up, and shooting them. She was
very political and did not keep her community assessment and analysis to herself.
Nightingale distributed her reports to members of Parliament and to the medical and
commanding officers of the army. Prominent male leaders of the time challengedher reports. Undaunted, she rewrote them in greater depth and redistributed them
In her efforts to compare the hospital systems in European countries, Nightingale
discovered that each hospital kept incomparable data and that many hospitals used
various names and classifications for diseases. She noted that these differences
prevented the collection of similar statistics from larger geographic areas. These
statistics would create a regional health-illness profile and allow for comparison
with other regions. She printed common statistical forms that some hospitals in
London adopted on an experimental basis. Nightingale also stressed the need to
use statistics at the administrative and political levels to direct health policy. Noting
the ignorance of politicians and those who set policy regarding the interpretation
and use of statistics, she emphasized the need to teach national leaders to use
statistical facts. Nightingale continued the development and application of statistical
procedures, and she won recognition for her efforts. The Royal Statistical Society
made her a fellow in 1858, and the American Statistical Association made her an
honorary member in 1874.
In addition to her contributions to nursing and her development of nursing education,
Nightingale’s credits include the application of statistical information toward an
understanding of the total environmental situation. Population-based statistics
have marked implications for the development of public health and public health
nursing. Grier and Grier (1978) recognized Nightingale’s contributions to statistics
and stated, “Her name occurs in the index of many texts on the history of probability
and statistics, in the history of quantitative graphics, and in texts on the history of
science and mathematics.” It is interesting to note that the paradigm for nursing
practice and nursing education that evolved through Nightingale’s work did not
incorporate her emphasis on statistics and a sound research base. It is also curious
that nursing education did not consult her writings and did not stress the importance
of determining health’s social and environmental determinants until much later.
Establishment of Modern Medical Care and Public Health Practice
To place Nightingale’s work in perspective, it is necessary to consider the
development of medical care in light of common education and practice during
the late nineteenth and early twentieth centuries. Goodnow (1933) called this
time a “dark age.” Medical sciences were underdeveloped, and bacteriology was
unknown. Few medical schools existed at the time, so apprenticeship was the path
to medical education. The majority of physicians believed in the “spontaneous
generation” theory of disease causation, which stated that disease organisms grew
from nothing.
Typical medical treatment included bloodletting, starving, using leeches, and
prescribing large doses of metals such as mercury and antimony. Nightingale’s
uniform classification of hospital statistics noted the need to tabulate the classification
of diseases in hospital patients and the need to note the diseases that patients
contracted in the hospital. These diseases, such as gangrene and septicemia,
were later called iatrogenic diseases. Considering the lack of surgical sanitation in
hospitals at the time, it is not surprising that iatrogenic infection was rampant. For
example, Goodnow (1933) illustrates the following unsanitary operating procedures:
Before an operation, the surgeon turned up the sleeves of his coat to save the coat,
and would often not trouble to wash his hands, knowing how soiled they soon would
be! The area of the operation would sometimes be washed with soap and water,
but not always, for the inevitability of corruption made it seem useless. The silk or
thread used for stitches or ligatures was hung over a button of the surgeon’s coat,
and during the operation a convenient place for the knife to rest was between his
lips. Instruments used for lancing abscesses were kept in the vest pocket and often
only wiped with a piece of rag as the surgeon went from one patient to another.
During the nineteenth century, the following important scientists were born: Louis
Pasteur in 1822, Joseph Lister in 1827, and Robert Koch in 1843. Their research
also had a profound impact on health care, medicine, and nursing. Pasteur was
a chemist, not a physician. While experimenting with wine production in 1854, he
proposed the theory of the existence of germs. Although his colleagues ridiculed
him at first, Koch applied his theories and developed his methods for handling and
studying bacteria. Subsequently, Pasteur’s colleagues gave him acknowledgment
for his work.
Lister, whose father perfected the microscope, observed the healing processes of
fractures. He noted that when the bone was broken but the skin was not, recovery
was uneventful. However, when both the bone and the skin were broken, fever,
infection, and even death were frequent. He found the proposed answer to his
observation through Pasteur’s work. Something outside the body entered the
wound through the broken skin, causing the infection. Lister’s surgical successes
eventually improved when he soaked the dressings and instruments in mixtures of
carbolic acid (i.e., phenol) and oil.
In 1882, Koch discovered the causative agent for cholera and the tubercle bacillus.
Pasteur discovered immunization in 1881 and the rabies vaccine in 1885. These
discoveries were significant to the development of public health and medicine.
However, physicians accepted these discoveries slowly. For example, TB was
a major cause of death in late nineteenth century America and often plagued its
victims with chronic illness and disability. It was a highly stigmatized disease, and
most physicians thought it was a hereditary, constitutional disease associated with
poor environmental conditions.
Hospitalization for TB was rare because the stigma caused families to hide their
infected relatives. Without treatment, the communicability of the disease increased.
The common treatment was a change of climate. Although Koch had announcedthe discovery of the tubercle bacillus in 1882, it was 10 years before the emergence
of the first organized community campaign to stop the spread of the disease.
The case of puerperal (i.e., childbirth) fever illustrates another example of slow
innovation stemming from scientific discoveries. Although Pasteur showed that
Streptococcus caused puerperal fever, it was years before physicians accepted
his discovery. However, medical practice eventually changed, and physicians no
longer delivered infants after performing autopsies of puerperal fever cases without
washing their hands.
Debates over the causes of disease occurred throughout the nineteenth century.
Scientists discovered organisms during the latter part of the century, supporting the
theory that specific contagious entities caused disease. This discovery challenged
the earlier, miasmic theory that environment and atmospheric conditions caused
disease.
The new scientific discoveries had a major impact on the development of public
health and medical practice. The emergence of the germ theory of disease focused
diagnosis and treatment on the individual organism and the individual disease.
State and local governments felt increasingly responsible for controlling the spread
of bacteria and other microorganisms. A community outcry for social reform forced
state and local governments to take notice of the deplorable living conditions in the
cities.
Community Caregiver
The traditional role of the community caregiver or the traditional healer has nearly
vanished. However, medical and nurse anthropologists who have studied primitive
and Western cultures are familiar with the community healer and caregiver role.
The traditional healer (e.g., shaman, midwife, herbalist, or priest) is common in non
Western, ancient, and underdeveloped societies. Although traditional healers have
always existed, professionals and many people throughout industrialized societies
may overlook or minimize their role. The role of the healer is often integrated into
other institutions of society, including religion, medicine, and morality. The notion
that one person acts alone in healing may be foreign to many cultures; healers can
be individuals, kin, or entire societies.
Societies retain folk practices because they offer repeated success.
Most cultures have a pharmacopoeia and maintain therapeutic and preventive
practices, and it is estimated that one fourth to one half of folk medicines are
empirically effective. Indeed, many modern drugs are based on the medicines of
primitive cultures (e.g., eucalyptus, coca, and opium).
Since ancient times, folk healers and cultural practices have both positively and
negatively affected health. The late nineteenth and early twentieth century practiceof midwifery illustrates modern medicine’s arguably sometimes negative impact on
traditional healing in many Western cultures. For example, traditional midwifery
practices made women rise out of bed within 24 hours of delivery to help “clear” the
lochia. Throughout the mid-1900s, in contrast, “modern medicine” recommended
keeping women in bed, often for fairly extended periods.
Establishment of Public Health Nursing
Public health nursing as a holistic approach to health care developed in the late
nineteenth and early twentieth centuries. Public and community health nursing
evolved from home nursing practice, community organizations, and political
interventions on behalf of aggregates.
Twentieth Century
In 1902, Wald persuaded Dr. Ernest J. Lederle, Commissioner of Health in New
York City, to try a school nursing experiment. Henry Street lent a public health nurse
named Linda Rogers to the New York City Health Department to work in a school
(Dock and Stewart, 1925). The experiment was successful, and schools adopted
nursing on a widespread basis. School nurses performed physical assessments,
treated minor infections, and taught health to pupils and parents. In 1909, Wald
mentioned the efficacy of home nursing to one of the officials of the Metropolitan
Life Insurance Company. The company decided to provide home nursing to its
industrial policyholders, and soon the United States and Canada used the program
successfully. The growing demand for public health nursing was hard to satisfy. In
1910, the Department of Nursing and Health formed at the Teachers College of
Columbia University in New York City. A course in visiting nursing placed nurses
at the Henry Street settlement for fieldwork. In 1912, the newly formed National
Organization for Public Health Nursing elected Lillian Wald its first president. This
organization was open to public health nurses and to those interested in public
health nursing. In 1913, the Los Angeles Department of Health formed the first
Bureau of Public Health Nursing (Rosen, 1993). That same year, the Public Health
Service appointed its first public health nurse. At first, many public health nursing
programs used nurses in specialized areas such as school nursing, TB nursing,
maternal-child health nursing, and communicable disease nursing. In later years,
more generalized programs have become acceptable. Efforts to contain health care
costs include reducing the number of hospital days. With the advent of shortened
hospital stays, private home health agencies provide home-based illness care
across the United States. The second half of the century saw a shift in emphasis to
cost containment and the provision of health care services through managed care.
Traditional models of public health nursing and visiting nursing from home health
agencies became increasingly common over the next several decades, but waned
toward the end of the century owing to changes in health care financing.g. Twenty-First Century
New Causes of Mortality
Since the middle of the twentieth century, the focus of disease in Western societies
has changed from mostly infectious diseases to chronic diseases. Increased food
production and better nutrition during the nineteenth and early twentieth centuries
contributed to the decline in infectious disease–related deaths. Other factors were
better sanitation through water purification, sewage disposal, improved food handling,
and milk pasteurization. According to McKeown (2001) and Schneider (2011), the
components of “modern” medicine, such as antibiotics and immunizations, had little
effect on health until well into the twentieth century. Indeed, widespread vaccination
programs began in the late 1950s, and antibiotics came into use after 1945. The
advent of chronic disease in Western populations puts selected aggregates at risk,
and those aggregates need health education, screening, and programs to ensure
occupational and environmental safety. Too often modern medicine focuses on the
single cause of disease (i.e., germ theory) and treating the acutely ill. Therefore
health providers have treated the chronically ill with an acute care approach even
though preventive care, health promotion, and restorative care are necessary and
would likely be more effective in combating escalating rates of chronic disease.
This expanded approach may develop under new systems of cost containment.
Hygeia versus Panacea
The Grecian Hygeia (i.e., healthful living) versus Panacea (i.e., cure) dichotomy still
exists today. Although the change in the nature of health “problems” is certain, the
roles of individual and collective activities in the prevention of illness and premature
death are slow to evolve.
Formerly, Health care has been for those living near enough to a hospital or a
doctor in times of need and for those who could spend money for medicines and
treatment. The great majority of people stayed in the village when sick and even
today many suffer and die without proper help.
The shorter length of stay in acute care facilities, as well as the increase in ambulatory
surgery and outpatient clinics, has resulted in more acute and chronically ill people
residing in the community who need professional nursing care. Fortunately, these
people can have their care needs met cost effectively outside of expensive acute
care settings. As a result, demand has increased for nurses in ambulatory clinics,
home care, care management, and case management.
Public and community health, ambulatory care, and other non-institutional settingshave historically had the largest increases in Registered Nurse employment.
Self-assessment 5.1.2
1) In which centuries was public health nursing developed as a holistic
approach to health care?
2) Who is the woman credited with establishing modern nursing?
3) Discuss the prerecorded historic times of community health nursing
5.1.3. Objectives, purposes and principles of community healthnursing
Learning activity 5.1.3
1) Use the books of community health nursing and internet resources and
found out the purposes and principles of community health nursing
a. Objectives of community health nursing
The goals and objectives of Community Health Nursing are the following:
• To assess the need and priorities of vulnerable group like pregnant mother,
children and old age persons;
• To provide health care services at every level of community including health
education, immunization,
• To make community diagnosis;
• To evaluate the health programs and make further plans;
• To prevent disabilities and providing rehabilitation services;
• To provide referral services at various health care levels;
• To increase life expectancy;
• To enhance the standard of nursing profession through:
– Conducting nursing research.
– Provide quality assurance in community health nursing.
– Performing the role of nurse epidemiologist.
• To improve the ability of the community to deal with their own health problems
• To strengthen the community resources
• To prevent and control communicable and non-communicable diseases
• To provide specialized services
b. Purpose of community health nursing
Purposes / Aims of Community Health Nursing are:
• To promote health and efficiency;
• Prevention and control diseases and disabilities;
• Need based health care to prolong life.
c. Principles of Community Health Nursing
The following are the principles of community health nursing:
• Health services should be based on the needs of individuals and the
community.
• Health services should be suitable to the budget; workers and the resources.
• Family should be recognized as a unit and the health services should be
provided to its members.
• Health services should be equally avail¬able to all without any discrimination
of age, sex, caste religion, political leaning and social or economic level etc.
• Health education is an important part of community health nursing. It should
be preplanned, suitable to conditions, scientifically true and effective.
• Community health nursing should be provided continuously, without any
interruption.
• Preparation and maintenance of records and reports is very important in
com¬munity health nursing.
• Community health nurses and other health workers should be guided and
supervised by highly educated and skilled professionals.
• Community health nurse should be responsible for:
– Responsible for professional development.
– Should continuously receive in-service training and continuing education.
– Should follow professional ethics and standards in her work and behaviour.
– Should have job satisfaction.
• Must have effective team spirit while working in the community.• Timely evaluation is must for community services.
Self-assessment 5.1.3
1) Identify the objectives of community health nursing
2) What are the principles of community health nursing?5.1.4. Characteristics of community health nursing
Learning activity 5.1.4
In the last holiday Mrs. K. and her parents went to visit their grandparents in
Masimbi village. One day two community health nurses came to visit this village
and took sufficient time meeting pregnant women and lactating mothers. They
discussed together about pregnant women health and some issues during
pregnant and lactation. The next day they hold a meeting talking about children
nutrition. These events reminded her the day nurses came to their school and
teach about malaria prevention.
Mrs. K admired the way those nurses use for helping people. Returning to their
home town, she sat down with her mother and asked many questions in order to
know more about the career of those nurses who work with people in their own
villages.
Some of those questions are the followings:
1) Do community health nurses are the same as those who work in hospitals
and clinics?
2) How do you characterize community health nursing?
3) After reading the related text in community health nursing textbooks, helpthe mother to offer responses to Mrs. K
Eight characteristics of community health nursing are particularly most important to
the practice of this specialty:
a. The client or “unit of care” is the population.
Community health nursing is population-focused, meaning that it is concerned for
the health status of population groups and their environment. A population may
consist of the elderly, scattered group with common characteristics, such as people
at high risk of developing heart disease, battered women living throughout a county.
It may include all people living in a neighborhood, district, census tract, city, state,
or province. Community health nursing’s specialty practice serves populations and
aggregates of people.
b. The primary obligation is to achieve the greatest good for the greatest
number of people or the population as a whole.
Community health nurses are concerned about several aggregates at the same
time, service will, of necessity, be provided to multiple and overlapping groups; theethical theory of utilitarianism promotes the greatest good for the greatest number.
c. The processes used by public health nurses include working with the
client(s) as an equal partner.
In order to achieve the goal of community health which is” “to increase quality
and years of healthy life and eliminate health disparities”, clients’ health status and
health behavior will change if people accept and apply the proposals (developed in
collaboration with clients) presented by the community health nurse.
d. Primary prevention is the priority in selecting appropriate activities.
In community health nursing, the promotion of health and prevention of illness are
a first-order priority. It focuses also on positive health, or wellness. These include
services to mothers and infants, prevention of environmental pollution, school health
programs, senior citizens’ fitness classes, and “workers’ right-to-know” legislation
that warns against hazards in the workplace. Less emphasis is placed on curative
care.
e. Selecting strategies that create healthy environmental, social, and
economic conditions in which populations may thrive is the focus.
The wish of community health nursing is to create healthy environments for our
clients, so that they can thrive and not simply survive.
f. There is an obligation to actively reach out to all who might benefit from
a specific activity or service.
We know that some clients are more prone to develop disability or disease because
of their vulnerable status (e.g., poverty, no access to health care, homeless).
Outreach efforts are needed to promote the health of these clients and to prevent
disease. In acute care and primary health care settings, like emergency rooms or
physician offices, clients come to you for service. However, in community health,
nurses must “focus on the whole population and not just those who present for
services” and seek out clients wherever they may be.
g. Optimal use of available resources to assure the best overall improvement
in the health of the population is a key element of the practice.
It is vital that community health nurses ground their practice in research, and use
that information to educate policy makers, and population about best practices.
They have to put more effort on the utilization of the available personnel and
resources effectively and prudently in order to assure the best overall improvement
in the health of the population for a long time.
h. Collaboration with a variety of other professions, organizations, and
entities is the most effective way to promote and protect the health of
people.
Community health nurses must work in cooperation with other team members,
coordinating services and addressing the needs of population groups. This inter
professional collaboration among health care workers, other professionals and
organizations, and clients is essential for establishing effective services and
programs. Individualized efforts and specialized programs, when planned inisolation, can lead to fragmentation and gaps in health services
Self-assessment 5.1.4
1) Explain eight characteristics of community health nursing
5.1.5. Community Health in Rwanda
Learning activity 5.1.5
Using internet and other resources like National Community Health Strategic
Plan, Community Health policies; read about community health in Rwanda and
respond to the following questions:
1) Discuss the importance of community health program in the community
and its implementation.
2) How Community health workers (CHWs) are selected, their responsibilities
and reporting?3) Discuss about CHWs supervision
In Rwanda, community health services started in 1995 as Rwanda Community
Health Worker (CHW) Program, aiming at increasing uptake of essential maternal
and child clinical services through education of pregnant women, promotion of
healthy behaviors, and follow-up and linkages to health services.
When the Ministry of Health (MOH) endorsed the program in 1995, there were
approximately 12,000 CHWs. By 2005, the program had grown to over 45,000
CHWs. From 2005, after the decentralization policy had been implemented
nationally, the MOH increased efforts to train and provide supplies to CHWs to
deliver maternal and child health (MCH) services. Between 2008 and 2011, Rwanda
introduced integrated community case management (ICCM) of childhood illness (for
childhood pneumonia, diarrhea, and malaria). In 2010, the Government of Rwanda
introduced Family Planning as a component of the national community health
policy. The program has since grown to include an integrated service package that
includes malnutrition screening, treatment of tuberculosis (TB) patients with directly
observed therapy (DOT), prevention of non-communicable diseases (NCDs),community-based provision of contraceptives, and promotion of healthy behaviors
and practices including hygiene, sanitation, and family gardens.
Program implementation
In each village of approximately 100–150 households, there is one CHW in
charge of maternal health, called an ASM (Agent de Sante Maternelle) and two
multidisciplinary CHWs called Binômes(one man and one woman working as a
pair) providing basic care and integrated community case management (ICCM) of
childhood illness. CHWs are full-time, voluntary workers who play a very key role
in extending services to Rwanda’s village communities. The CHWs are supervised
most directly by the cell coordinator and the in-charge of community services at
the catchment-area of the health center. CHWs now use Rapid SMS to submit
reports and communicate alerts to the district level and to hospitals or health
centers regarding any maternal or infant deaths, referrals, newly identified pregnant
women, and newborns in the community.
In 2010, the Government of Rwanda introduced FP as a component of the national
community health policy, and CHWs were trained not only to counsel but also to
provide contraceptive methods including pills, injectables, cycle beads (for use with
natural FP), and condoms. This program was first piloted in three districts and later
scaled nationwide.
Responsibilities of Community Health Workers
Three CHWs, with clearly defined roles and responsibilities, operate in each village
of approximately 100–150 households. ASMs have been trained to identify pregnant
women, make regular follow-ups during and after pregnancy, and encourage
deliveries in health facilities where skilled health workers are available. In addition
to following up pregnant women and their newborns, the ASM also screens
children for malnutrition, provides contraceptives (pills, injectables, cycle
beads, and condoms), promotes prevention of Non-Communicable Diseases
(NCDs) through healthier lifestyles, preventive and behavior change activities
and carries out household visits.
Between 2008 and 2011, Rwanda introduced ICCM of childhood illness (for
childhood pneumonia, diarrhea, and malaria) nationwide. Binômes were trained
and equipped to: (a) provide ICCM (assessment, classification, and treatment
or referral of diarrhea, pneumonia, malaria, and malnutrition in children younger
than 5 years of age; including treatment with antibiotics, zinc, and antimalarials) (b)
malnutrition screening (c) community-based provision of contraceptives, (d) DOT
for TB, (e) prevention of NCDs, (f) preventive and behavior change activities and
(g) household visits. They are in charge to detect cases of acute illness in need ofreferral, and to submit monthly reports
Supervision
There are two community health workers, called “cell coordinators”, who are heads
of all CHWs at the cell level, and whose aim is to follow up, and thereby strengthen,
CHWs’ activities.
The specific roles and responsibilities of the cell coordinator at the cell level include
the following:
1) Visiting of community health workers in order to monitor their activities on a
monthly basis.
2) Follow up and verify if CHW has patient registers, and if they are correctly
filled out and well-kept.
3) Monitor if drugs are distributed correctly and if these drugs are not expired
and well-kept
4) Compilation of reports of drugs that have been used by CHW in that cell and
requisition of drugs at health centers
5) Supervision of the binome and a household that was recently attended to
by a CHW
6) Check if CHW does post-visit for children she/he recently treated
7) Supervise CHW on how well she/he is able to sensitize the community on
family planning usage
8) Verification of reports brought for compilation if they have been sent by
telephone
(m’Ubuzima)
The cell coordinator is aided by an assistant cell coordinator, who is responsible for:
• Monitor if the ASM has registers and these registers are filled correctly
• Follow up and see if the ASM refers pregnant women for ANC visits at the
health center (HC)
• Follow up and verify if the ASM has sent RapidSMS reports for pregnant
mothers confirmed by health provider
• Verify if the ASM has Misoprostol drugs and the drugs are not expired
Place of CHWs in the health system
Health services are provided at different levels of the health care system – in
communities, at health posts (HP), health centers (HC), district hospitals (DH),
and referral hospitals – and by different types of providers – public, confessional,
private-for-profit and NGO. At all levels, the sector is composed of administrative
structures and implementing agencies. The area of CHW’s activities is the village.At the lowest level, those in charge of community health activities at the health
centers administratively supervise CHWs.
At the sector level, there are Health Center Committees that provide oversight on
the work from various units in the health center, its outreach, supervision activities,
and general financial controls.
At the district level, one finds district hospitals (DH), district pharmacies, community
based health insurance (CBHI) committees, and HIV/AIDS committees.
Financial support to CHWs
The CHWs receive financial compensation through performance based financing,
or PBF, for delivering a certain number of health services. Thirty percent of the
total PBF funds are shared among CHW members while 70% is deposited in the
collective funds of CHW cooperatives.
Selection, training, and retention of Community Health Workers
CHWs come from the villages in which they live. They must be able to read and write
and be between the ages of 20 and 50 years. They also must be willing to volunteer
and be considered by their peers to be honest, reliable, and trustworthy. They are
elected by village members in a process that involves gathering the volunteers
and villagers on the last Saturday of the month (Umuganda, or community service
day) and voting “with their feet” in a literal sense. The process has been described
(in conversation) as one that involves community members lining up in front of the
person they support. The individual with the most support is recruited.
Within each of the villages (Umudugudu), Binômes are trained in community-based
integrated management of childhood illnesses (IMCI) by preparing them to be first
responders to a number of common childhood illnesses, including pneumonia,
diarrhea, and malaria. The CHWs are also trained on when and how to refer
severe cases to the health facility. IMCI refresher training is provided through a
supportive supervision model, where the supervisor conducts training to strengthen
the CHW’s knowledge and skills in providing quality case management services in
their communities.
Another example of program-specific training is the ten-day training for community
based provision of FP services.
In 2009, the MOH introduced Community Performance-Based Funding (CPBF) as
a way to motivate CHWs. Community Health worker Cooperatives are organized
groups of CHWs that receive and share funds from the MOH based on the
achievement of specific targets established by the MOH. Each health center in
Rwanda supervises the CHWs that make up one CHW cooperative. By linking
incentives to performance, the MOH hoped to improve quality and utilization of
health services.Impact of Community Heath Program and challenges
The most important achievements in the health sector include an increase in facility
based deliveries, the introduction of maternal and child death audits at all health
facilities, an increase in vaccination coverage. CHW follow-up of all pregnant
women, and provision of community-based FP services. CHWs are currently testing
all suspected cases of malaria with a rapid diagnostic test and providing treatment
when indicated to children younger than 5 years of age who have malaria within 24
hours.
The challenges faced by the Rwanda CHW program are similar to challenges
faced by CHW programs in other countries. These include (1) the financial and
administrative difficulties in supporting and continuing to build the capacity of
CHWs as they increase in number and as the scope of their work expands; (2) the
challenge of supervising and effectively equipping CHWs to perform their duties;
and (3) low community participation in the health sector and the strong influence of
traditional beliefs and traditional medicines.
As the number of CHWs has risen rapidly in Rwanda and as their tasks have
increased, the Government of Rwanda faces a constant battle to increase the
capacity of CHWs and to provide them with the equipment and supplies they need.
Refresher trainings are too few and provision of essential equipment is delayed due
to insufficient financial resources. Field supervision of CHWs and the transfer of skills
and knowledge to the communities to foster ownership and enhance sustainability
is a continuing challenge. Each CHW is supposed to be supervised by either the
In-Charge of Community Health or the cell coordinator on monthly basis. However,recent findings show that supervisory visits occur only quarterly, if that.
Self-assessment 5.1.5
1) Discuss the responsibilities of an ASM
2) Explain the main activities of Binômes
3) How are CHWs selected?
4) Identify the coverage area of CHW activities.
5) Discuss the issues encountered by CH program in our country5.1.6. Characteristics of a community
Learning activity 5.1.6
Observe the images below and answer to the questions:
Human beings are social creatures. All of us, with rare exception, live out our lives
in the company of other people. Communities are an essential and permanent
feature of the human experience. The communities in which we live and work have
a profound influence on our collective health and well-being.
The community is a territorial group with shares a common soil as well as shared
way of life. People living in the same locality come to have a distinctive community
life. The community is more than the locality it occupies. It is also sentiment. They
share common memories and traditions, customs and institutions. Today none of
us belong to one inclusive community. Under modern conditions attachment to local
community is decreasing.
Meaning of community can be better understood if we analyze its characteristics
or elements. These characteristics decide whether a group is a community or not.
However, generally, community has the following 13 most important characteristicsor elements:
1) A group of people
A group of people is the most fundamental or essential characteristic or element
of community. This group may be small or large but community always refers to a
group of people. Because without a group of people we can’t think of a community,
when a group of people live together and share a common life and binded by a
strong sense of community consciousness at that moment a community is formed.
Hence a group of people is the first pre-requisites of community.
2) A definite locality
It is the next important characteristic of a community. Community is a territorial
group. A group of people alone can’t form a community. A group of people forms
a community only when they reside in a definite territory. The territory need not be
fixed forever. A group of people like nomadic people may change their habitations.
But majority community are settled and a strong bond of unity and solidarity is
derived from their living in a definite locality.
3) Community Sentiment
It is another important characteristic or element of community. Without community
sentiment a community can’t be formed only with a group of people and a definite
locality. Community sentiment refers to a strong sense of awe feeling among the
members or a feeling of belonging together. It refers to a sentiment of common
living that exists among the members of a locality. Because of common living
within an area for a long time a sentiment of common living is created among the
members of that area. With this the members emotionally identify themselves. This
emotional identification of the members distinguishes them from the members of
other community.
4) Naturality
Communities are naturally organized. It is neither a product of human will nor
created by an act of government. It grows spontaneously. Individuals became the
member by birth.
5) Permanence
Community is always a permanent group. It refers to a permanent living of individuals
within a definite territory. It is not temporary like that of a crowd or association.
6) Similarity
The members of a community are similar in a number of ways. As they live within
a definite locality they lead a common life and share some common ends. Among
the members similarity in language, culture, customs, and traditions and in many
other things is observed. Similarities in these respects are responsible for thedevelopment of community sentiment.
7) Wider Ends:
A community has wider ends. Members of a community associate not for the
fulfilment of a particular end but for a variety of ends.
These are natural for a community.
8) Total organized social life:
A community is marked by total organized social life. It means a community includes
all aspects of social life. Hence a community is a society in miniature.
9) A Particular Name:
Every community has a particular name by which it is known to the world. Members
of a community are also identified by that name. For example, people living in
sector of Nkombo is known as “Abanyenkombo”.
10) No Legal Status:
A community has no legal status because it is not a legal person. It has no rights
and duties in the eyes of law. It is not created by the law of the land.
11) Size of Community:
A community is classified on the basis of its size. It may be big or small. Village is an
example of a small community whereas a nation or even the world is an example of
a big community. Both the type of community is essential for human life.
12) Concrete Nature:
A community is concrete in nature. As it refers to a group of people living in a
particular locality we can see its existence. Hence it is concrete.
13) A community exists within society and possesses distinguishable
structure which distinguishes it from others.
Specifically, different types of community exist and they have their particular
characteristics including the ones described below:
a. Characteristics of village/rural Community:
The village people have a sense of unity. The relationship between people is
intimate. They personally know each other; structurally and functionally the village
is a unit.
In the village, people assist each other and thus they have close neighborhood
relations. In the village the joint family system is retained. The agricultural occupation
requires the cooperation of all the family members.
The People in the villages have deep faith in religion and duties. The village peoplelead a simple life. Their behavior is natural and not artificial. They are free from
mental conflicts. They are hard-working; their level of moralities is high. Social
crimes are less.
Ancient village community was a very small group of ten or twenty families. The
feeling of familiarity was so great that if a child wandered off from the home, the
parents had nothing to worry because there are numerous relatives in the village.
They laid a common property. Due to lack of communication and transport the
members of the community were separated due to distance.
In the modern village community, there is a rise of industrialism. Now urban group
began to dominate civilization. Urbanization is increasing and dominant rural. Social
forms are changing rapidly.
Rural people follow the urban forms of life. Kinship bond is broken due to increased
size and mobility of population. Land is no longer cultivated jointly. They continue
to work the land but then try to live in the mode of the city. Rural social forms are
changed due to urbanization.
Rural communities may have their specific major Problems such as:
• Health problems, the most common being: Malnutrition, especially in under
– five-year children; communicable diseases and infection and child deaths
and maternal deaths and clean water accessibility.
• Education problems – the problems of illiteracy, school dropouts, few
teachers, also lack of equipment and insufficient buildings or in need of repair
child labor etc.
• Problems related to transport and communications – lack of good roads,
especially in rainy season, causes problems of supplies, marketing and
taking the sick to hospital, etc. The problem of villages being cut off from other
communities and urban facilities, results in slow progress and development.
• Problems concerning agriculture – the farmer may have problems such as
insufficient water supply, especially in failure of monsoon, electricity cuts, and
repair of pump-sets, tractors etc. Delay in getting supplies of seed, fertilizers,
especially if he has no capital reserves.
• Labor problems – laborers may not be available when needed, or coolly
demands are high. Procurement price given by Government may be too low,
or demand for products is low. Sickness and death of flocks and herds (sheep
and cattle).
• Population and employment problems– Agriculture can no longer provide
enough for the growing population in rural areas. Some rural communities
have taken up handloom weaving or other small industries, but these are
not without many problems. Young men leave the village for urban areasin search of jobs. Sometimes whole groups of families migrate to a distant
place to work for a contractor (building, mining and other project). They get
advances from the contractor to buy food, and soon may become ‘bonded
laborers’ and never get bat to their own village.
b. Characteristics of urban Community:
Home decreasing is a disturbing feature of city community. The home problem in a
big city is very acute. The middle class have insufficient accommodation. The child
doesn’t get any play space. Energy and speed are the traits of a city. The people
work at a speed, day and night which stimulates other to work. People indulge in too
many activities. Cities are consumers of population. Facilities for preserving health
such as hospitals and medical specialist are many and excellent. City has more
heterogeneous than the village. It is most favorable propagation ground of new
biological and cultural hybrids. The personal traits, the occupations, the cultural and
the ideas of the members of the urban community vary widely.
Class extremes characterize urban community. In a city, the people rolling in
luxury and living, in grand mansion as well as people live in street. The best forms
of ethical behavior and the worst racketeering are both to be bound in cities.
Superior creativeness and chronic unemployment are similar. The city is the home
of opposites. In some cities, residents may treat the strangers they meet as not
human beings. They meet with speak without knowing each other’s name. A citizen
may live for several years in a city and may not know the names of one-third of the
people who live in the same city area.
Life is quite different in towns and cities than in the village. Traditions, customs and
modes do not have much influence over those living in urban areas. Family life is
less disciplined, and there is no community support. There is much more mixing
among people of very different backgrounds. This brings about changes in habits
and attitudes. Family conflicts are common. For the individuals, and for families
coming to live in the urban area, conscious efforts need to be made to form good
friendships and to live in harmony with others. There are many opportunities for
joining social groups for various activities. People need to take up the challenge
for forming a new community even in the city, for mutual help and action to solve
problems.
The main urban problems may be listed as follows:
a) Growth of slums
b) Lack of employment, leading to poverty, under – nutrition, disease, and
anti-social activities. Failure of people to adjust, causing mental illness or
delinquency.
c) Crime and delinquency, begging and prostitution.
d) Overcrowding in dwellings, buses and streets.
e) Failure in administration (e.g. public services such as refuse collection and
disposal) to cope with the rapid growth of the population.
f) Road accidents.
g) Health problems due to overcrowding and to stress of urban living.
h) Political and industrial unrest and conflicts.
c. Characteristics of common-interest Community
A community also can be identified by a common interest or goal. A collection
of people, even if they are widely scattered geographically, can have an interest
or goal that binds the members together. This is called a common-interest
community. The members of a church in a large urban area, the members of a
national professional organization, and women who have had mastectomies are
all common-interest communities. Sometimes, within a certain geographic area, a
group of people develop a sense of community by promoting their common interest.
Disabled individuals scattered throughout a large city may emerge as a community
through a common interest in promoting adherence to federal guidelines for
wheelchair access, parking spaces, toilet facilities, elevators, or other services for
the disabled.
The residents of an industrial community may develop a common interest in air or
water pollution issues, whereas others who work but do not live in the area may not
share that interest. Communities form to protect the rights of children, stop violence
against women, clean up the environment, promote the arts, preserve historical
sites, protect endangered species, develop a smoke-free environment, or provide
support after a crisis. The kinds of shared interests that lead to the formation of
communities vary widely.
Common-interest communities whose focus is a health-related issue can join with
community health agencies to promote their agendas. A group’s single-minded
commitment is a mobilizing force for action. Many successful prevention and health
promotion efforts, including improved services and increased community awareness
of specific problems, have resulted from the work of common-interest communities.
d. Community of Solution
A type of community encountered frequently in community health practice is a group
of people who come together to solve a problem that affects all of them. The shape
of this community varies with the nature of the problem, the size of the geographic
area affected, and the number of resources needed to address the problem. Such
a community has been called a community of solution. Example: club against HIV/AIDS
Self-assessment 5.1.6
1) Identify 13 most important characteristics of a community in general2) Discuss the characteristics of urban people
5.1.7. Characteristics and functions of a healthy community
Learning activity 5.1.7
With use of community health text books taken from library or internet, ready,
understand, discuss and write brief notes on: characteristics of healthy
community, roles and responsibilities of a community health nurse; and corefunctions of community health nursing
This sub-unit discusses the following four points: characteristics of healthy
community, roles and responsibilities of a community health nurse, qualities of a
community health nurse and functions of community health nursing.
a. Characteristics of a Healthy Community
A healthy community is one in which all residents have access to a quality education,
safe and healthy homes, adequate employment, transportation, physical activity,
and nutrition, in addition to quality health care. Unhealthy communities lead to
chronic disease, such as cancers, diabetes, and heart disease.
Just as health for an individual is relative and will change, all communities exist in
a relative state of health. A community’s health can be viewed within the context
of health being more than just the absence of disease, and including things that
promote the maintenance of a high quality of life and productivity.
Just as there are characteristics of healthy individuals, so are there characteristics
of healthy communities. These include the following:
• The healthy community ensures that community resources are available to
all members and groups within the community. It ensures there is access to
appropriate health care services that focus on both treatment and prevention
for all members of the community; a clean and safe physical environment;
and roads, schools, playgrounds, and other services to meet the needs of the
people in that community
• Emergency preparedness: a healthy community has a well-organized base of
community resources available to meet the needs and to intervene in a crisisor natural disaster
problems and collaborates and coordinates a response among members and
groups to meet their identified needs.
• Communication through open channels. It ensures that communication
remains open and information flows among all members and groups in every
direction within the community.
• Resolution of disputes through legitimate mechanisms
• The healthy community ensures there is participation by citizens in
decision making and subgroups participate in community affairs. It provides
opportunities for and encourages participation of individuals and groups in
decision making related to issues affecting the community.
• A high degree of wellness among its citizens: the healthy community focuses
on promoting a high level of wellness and health among all members and
populations within the community.
• A healthy community has an awareness of its members, populations, and
subgroups as being part of the community.
• The historical and cultural heritage is promoted and celebrated.
• There is a diverse and innovative economy.
• There is a sustainable use of available resources for all.
b. Roles and Responsibilities of Community Health Nurse:
Some key roles and responsibilities of community health nurse are discussed below:
A community health nurse performs various functions while she works in any
defined community health setting. In general, the community health nurse performs
the following functions according to her roles:
a) Clinician Role or Direct care provider
She provides a continuous and comprehensive care to the family, group of people
and community at large. She emphasizes more on promotive and preventive health
care. The community health nurse approaches the family and persuades them to
implement promotive and preventive measures. Care during illness is beneficial
gaining acceptance, trust and confidence.
She also provides care during illness for which usually the family members come
forward to seek help. As care is given, the nurse educates and helps the family
members to develop their abilities and overcome their barriers so that they can take
care of their health and nursing needs, promote their health and prevent illness.
The care is provided at home, clinic, school, work place etc.
b) Health educator:
The community health nurse educates the individual, family, groups of people and
the community at large. Health education thus given focuses on promoting health,
preventing illness and aspects related to care during illness and rehabilitation &
disability prevention. The nurse conducts planned health education sessions for
organized community groups e.g., school children, antenatal mothers, eligible
couples, elderly etc. Health education for the family is planned and implemented
as part of the family care plan. The community nurse assesses the knowledge,
attitudes, values, beliefs, behaviours, practices, stage of change, and skills of the
community people and provides health education according to knowledge level.
The community health nurses are involved in giving incidental/casual/spontaneous
health education according to the situation. (Washing of hands before a child eats).
c) Counselor:
The community health nurse helps individual, families and the community at large
to recognize and understand their problems to be solved, find solutions with-in
resources and implement feasible and acceptable solutions.
d) Resource person:
The community health nurse explores community resources in terms of money,
manpower, material, agencies etc. She makes use of these resources in helping
individual, family groups and community to meet their health and nursing needs.
e) Care manager/Managerial Role:
The community health nurse implements the care which is planned for the family
and community. She directly provides the care with the active participation of family
and community members. She makes use of family and community resources.
She guides the family and community and refers when required. She maintains
a record of the care given to families and the community. The community health
nurse evaluates the effectiveness of care given in terms of change in health status,
health behavior, reduction in illness, improvement in clinic attendance-immunization
& rate of utilization of the community health services.
As a manager the nurse exercises administrative direction towards the
accomplishment of specified goals by assessing clients’ needs, planning and
organizing to meet those needs, directing and controlling and evaluating the
progress to assure that goal are met.
f) Planner:
The community health nurse while giving comprehensive care to family and
community, she/he makes a plan on the basis of identified health problems
and health & nursing needs. She/he plans with other team members to provide
appropriate care.g) Research Role:
In the researcher role community health nurses engage in systematic investigation
of any untoward change in health behavior and health status of the community,
people, their surroundings, and unusual occurrence of disease. She/he carries out
collection, and analysis of data to solve problems and enhance community health
nursing practice. Based on the research results, a community nurse improve their
service quality and improve their health accordingly, for examples by providing
information, health education to people to improve their behavior and health status,
working with the family and providing direct care during illness, notification to health
authority about communicable disease.
h) Advisor:
The community health gives some suggestions on practical situation which requires
immediate actions and where there is little scope of health education. For example,
in case of a client with diabetes mellitus, the community health nurse advices with
concern on the foods to be included and avoided according to the socio –economic
condition of the individual & family.
i) Advocate Role:
The issue of clients’ rights is important in health care today. Every patient or client
has the right to receive just equal and humane treatment. A community health nurse
is an advocate of patient’s rights about their care. They encourage the individuals
to take the right food for maintaining health, the right drugs for the treatment, and
the right services at the right place where ever needed. They provide sufficient
information to make necessary health care decisions, promote community
awareness of significant health problems.
j) Collaborator Role:
Community health nurses seldom practice in isolation. They must work with
many people including clients, other nurses, physicians, social workers, and
community leaders, therapists, nutritionists, occupational therapists, psychologists,
epidemiologists, biostatisticians, legislators, etc. as a member of the health team.
k) Leader Role:
Community health nurses are becoming increasingly active in the leader role. As a
leader, the nurse instructs influences or persuades others to effect change that will
positively affect people’s health. The leadership role’s primary function is to use a
change of health policy based on community people’s health; thus, the community
health nurse becomes an agent of change.
c. Qualities of a community health nurse
A best community health nurse is characterized by the following qualities:
1. Interest in community health nursing.
2. Good interpersonal relationship skills.
3. Interested in people.
4. Emotional stability.
5. Good communicability.
6. Guiding & helping nature.
7. Sensitive observation.
8. Good listener.
9. A friendly disposition.
10. Initiative/creativity
11. Resource fullness.
12. Endurance & patience.
d. Functions of community health nursing
The four core functions of community health nursing practices are displayed below:
1. Identification of community culture and resources that lead as a key factor in
the community health care delivery system.
2. Evaluate community health conditions, health risks, and problems to identify
the health-care demands of the people.
3. Plan and implementation of comprehensive community health interventions,
care, services, and programs.
4. Develop health policy at the local community level to drive policies/
agreements at the state and national levels for collaborative endeavors andactions.
Self-assessment 5.1.7
1) Give the four core functions of community health nursing practice
2) Mention any 4 characteristics of a healthy community
3) Explain any 2 roles and responsibilities of a community health nurse.
5.2. Determinants of health and the factors affectingcommunity health
Learning activity 5.2
Get community health nursing books and/or internet resources and provide the
answers to the following questions:
1) Explain any 2 determinants of health
2) Write a short description on each of the following factors affecting the
community health nursing: Physical factors, Social/Cultural factors,Community organization, and Individual behavior
5.2.1. Determinants of health
Determinants of Health and Disease: The health status of a community is associated
with a number of factors, such as health care access, economic conditions,
social and environmental issues, and cultural practices, and it is essential for the
community health nurse to understand the determinants of health and recognize
the interaction of the factors that lead to disease, death, and disability. Indeed,
individual biology and behaviors influence health through their interaction with each
other and with the individual’s social and physical environments. Thus, policies and
interventions can improve health by targeting detrimental or harmful factors related
to individuals and their environment. Some causes of death resulting from individual
behavior are: tobacco, poor diet and physical inactivity, alcohol consumption and
its association with accidents, suicides, homicides, and cirrhosis and chronic liver
disease. Other leading causes of death are microbial agents, toxic agents, motor
vehicle crashes, firearms, sexual behaviors and illicit use of drugs.
Although all of these causes of mortality are related to individual lifestyle choices,
they can also be strongly influenced by population-focused policy efforts and
education. For example, the prevalence of smoking may be fallen dramatically,
largely because of legal efforts (e.g., laws prohibiting sale of tobacco to minors
and much higher taxes), organizational policy (e.g., smoke-free workplaces), and
education. Likewise, concerns about the widespread increase in incidence of
overweight and obesity may lead to population-based measures to address the
issue (e.g., removal of soft drink, regulations prohibiting the use of certain types of
fats in processed foods).
Indeed, at the population level, better health can be attributed to higher standards
of living, good nutrition, a healthier environment, and having fewer children.
Furthermore, public health efforts, such as immunization and clean air and water, and
184 Fundamental Of Nursing - Senior 6 - Student's Book
medical care, including management of acute episodic illnesses (e.g., pneumonia,
tuberculosis) and chronic disease (e.g., cancer, heart disease, diabetes mellitus),
may also contribute significantly to the increase in life expectancy. Community
and public health nurses should understand these concepts and appreciate that
health and illness are influenced by a web of factors, some that can be changed
(e.g., individual behaviors such as tobacco use, diet, physical activity) and some
that cannot (e.g., genetics, age, gender). Other factors (e.g., physical and social
environment) may require changes that will need to be accomplished from a policy
perspective. Community health nurses must work with policy makers and community
leaders to identify patterns of disease and death and to advocate for activities and
policies that promote health at the individual, family, and population levels.
5.2.2. The factors affecting community health
The factors affecting community health can be grouped into: Physical factors,
Social/Cultural factors, Community organization, and Individual behavior
a. Physical factors
• Industrial development: Communities that are industrially developed are more
likely to be affected by numerous diseases due to the toxic waste products
from the industries that are released into water bodies and the atmosphere
and due to congestion of settlement leading to slum development hence
contagious diseases compared to areas that are not industrially developed.
Water contamination from industrial discharge and air pollution may be ones
of the consequences of industrial development.
• Community size: A densely populated or over populated community can
easily be attacked by communicable diseases
• Geographical location: Some communities are more prone to diseases due
to the geographical location. For example, some communities located in
swampy areas are more prone to diseases, especially during heavy rains
these communities are affected by floods which can lead to manipulation of
organisms causing disease. If the water is stagnant, there is risk of spread of
organisms which cause diseases such as malaria and diarrhea disease.
• Environment: A clean environment is very vital to the proper health of a
community which minimizes the occurrence and transmission of diseases,
unlike a dirty environment which easily leads to outbreak of diseases.
b. Social/cultural factors
• Traditions Beliefs: Beliefs or traditions such as female genital mutilation
(FGM) possessed by communities greatly affect the health of its people.
• Economy: A community that is economically well off has low chances of
suffering from disease breakouts because they have proper health care andwater drainage systems unlike a poor community.
• Government: since the government involves planning, implementing and
provision of community services such as water supply, medical supplies and
other needs which can directly affect the community health
• Educational factors: poor education or illiteracy affects the health of a community
when people don’t have education on how they can prevent themselves from
diseases. For example, health education on the use of mosquito treated nets
to prevent malaria, health education on the environmental hygiene so as to
prevent diseases such as cholera and trachoma.
c. Community organization
This is about the ways in which communities organize their resources such as
taxes which can be very helpful in control of diseases and supply of sufficient and
efficient medical care, even in times of crisis. Unlike communities without proper
accountability of their taxes which can partly be allocated to the health sector, may
suffer from lack of adequate resources to prevent diseases, protect and promote
the health of its citizens.
d. Individual behavior
Community health is greatly influenced by individuals, their personal health, habits,
etc.
In order to achieve a healthy community, it requires a team work for example in the
following in activities:
• Proper disposal of waste products from individuals’ compound,
• Clearing all stagnant water in the compound to prevent harboring of
mosquitoes,
• Active smokers to quit smoking to avoid passive smokers thus preventing lung
cancer, Abstinence from sexual activities and for sexually active individuals to
use protection to prevent the spread of HIV/AIDs and STDs etc.
Thus proper individual healthy living can greatly promote a healthy communitySelf-assessment 5.2
1) Describe the 4 factors that affect the health of the community
2) Explain the issues related to biology and individual behavior asdeterminants of health
5.3. Community health needs assessment
Learning activity 5.3
Using internet and Community Health Nursing Textbooks; read about community
health needs assessment and respond to the following questions
1) What is the meaning of community health assessment?
2) Discuss types of community assessment.
3) Describe the methods of community assessment
4) Identify the sources of data in community assessmentThe primary concern of community health nurses is to improve the health of the
community. This process involves using demographic and epidemiological methods
to assess the community’s health and diagnose its health needs.
After considering the importance of community partnerships and coalitions, the
community health nurse is ready to determine the community’s needs. Assessment
is the key initial step of the nursing process. Assessment for nurses means collecting
and evaluating information about a community’s health status to discover existing
or potential needs and assets as a basis for planning future action.
Assessment involves two major activities. The first is collection of pertinent data,
and the second is analysis and interpretation of data. These actions overlap
and are repeated constantly throughout the assessment phase of the nursing
process. While assessing a community’s ability to enhance its health, the nurse
may simultaneously collect data on community lifestyle behaviors and interpret
previously collected data on morbidity and mortality.
Community needs assessment is the process of determining the real or perceived
needs of a defined community. In some situations, an extensive community study
may be the first priority; in others, all that is needed is a study of one system or even
one organization. At other times, community health nurses may need to perform
a quick examination or “windshield survey” to familiarize them with an entire
community without going into any depth.
The next text discusses the types of community needs assessment, the methods of
community health assessment, and sources of data.
a. Types of Community Needs Assessment
Although it is difficult to determine the type of assessment needed in advance,
understanding the various types of community assessment in advance helps to
facilitate your decision. Here below there is a short description of the types ofcommunity needs assessment.
Familiarization or Windshield Survey
A familiarization assessment is a common starting place in evaluation of a community.
It involves studying data already available on a community, then gathering
a certain amount of firsthand data in order to gain a working knowledge of the
community. Such an approach may utilize a windshield survey—an activity often
used by nursing students in community health courses and by new staff members
in community health agencies. Nurses drive (or walk) around the community of
interest; find health, social, and governmental services; obtain literature; introduce
them-selves and explain that they are working in the area; and generally, become
familiar with the community and its residents. This type of assessment is needed
whenever the community health nurse works with families, groups, organizations,
or populations. The windshield survey provides knowledge of the context in which
these aggregates live and may enable the nurse to better connect clients with
community resources.
Problem-Oriented Assessment
A second type of community assessment, problem-oriented assessment, begins
with a single problem and assesses the community in terms of that problem.
The problem-oriented assessment is commonly used when familiarization is
not sufficient and a comprehensive assessment is too expensive. This type of
assessment is responsive to a particular need. The data collected will be useful in
any kind of planning for a community response to the specific problem. Data should
address the magnitude of the problem to be studied (e.g., prevalence, incidence),
the precursors of the problem, information about population characteristics, along
with the attitudes and behaviors of the population being studied.
Community Subsystem Assessment
In community subsystem assessment, the community health nurse focuses on a
single dimension of community life. For example, the nurse might decide to survey
churches and religious organizations to discover their roles in the community. What
kinds of needs do the leaders in these organizations believe exist? What services
do these organizations offer? To what extent are services coordinated within the
religious system and between it and other systems in the community? Community
subsystem assessment can be a useful way for a team to conduct a more systematic
community assessment. If five members of a nursing agency divide up the ten
systems in the community and each person does an assessment of two systems,
they could then share their findings to create a more comprehensive picture of thecommunity and its needs
Comprehensive Assessment
Comprehensive assessment seeks to discover all relevant community health
information. It begins with a review of existing studies and all the data presently
available on the community. A survey compiles all the demographic information on
the population, such as its size, density, and composition.
Key informants are interviewed in every major system—education, health, religious,
economic, and others. Key informants are experts in one particular area of the
community or they may know the community as a whole. Examples of key informants
would be a school nurse, a religious leader, key cultural leaders, the local police
chief or fire captain, a mail carrier, or a local city council person. Then, more detailed
surveys and intensive interviews are performed to yield information on organizations
and the various roles in each organization. A comprehensive assessment describes
the systems of a community, and also how power is distributed throughout the
system, how decisions are made, and how change occurs.
Because comprehensive assessment is an expensive, time-consuming process, it
is not often undertaken. Performing a more focused study, based on prior knowledge
of needs is often a better and less costly strategy. Nevertheless, knowing how to
conduct a comprehensive assessment is an important skill when designing smaller,
more focused assessments.
Community Assets Assessment
The final form of assessment presented here is assets assessment, which focuses
on the strengths and capacities of a community rather than its problems. The
type of assessment depends on variables such as the needs that exist, the goals to
be achieved, and the resources available for carrying out the study.
Assets assessment begins with what is present in the community. The capacities
and skills of community members are identified, with a focus on creating or rebuilding
relationships among local residents, associations, and institutions to multiply power
and effectiveness. This approach requires that the assessor looks for the positive.
Assets assessment has three levels:
1. Specific skills, talents, interests, and experiences of individual community
members such as individual businesses, cultural groups, and professionals
living in the community.
2. Local citizen associations, organizations, and institutions controlled largely
by the community such as libraries, social service agencies, voluntary
agencies, schools, and police.
3. Local institutions originating outside the community controlled largely outsidethe community such as welfare and public capital expenditures.
The key, however, is linking these assets together to enhance the community from
within. The community health nurse’s role is to assist with those linkages.
b. Community Assessment Methods
Community health needs may be assessed using a variety of methods. The choice of
assessment method varies depending on the reasons for data collection, the goals
and objectives of the study, and the available resources. It also varies according to
the theoretical framework or philosophical approach through which the nurse views
the community. In other words, the community health nurse’s theoretical basis for
approaching community assessment influences the purposes for conducting the
assessment and the selection of methodology.
Regardless of the assessment method used, data must be collected. Data collection
in community health requires the exercise of sound professional judgment, effective
communication techniques, and special investigative skills. Four important methods
are discussed here: surveys, descriptive epidemiologic studies, community forums
or town meetings, and focus groups.
Surveys
A survey is an assessment method in which a series of questions is used to collect
data for analysis of a specific group or area. Surveys are commonly used to provide
a broad range of data that will be helpful when used with other sources or if other
sources are not available.
To plan and conduct community health surveys, the goal should be to determine
the variables (selected environmental, socioeconomic, and behavioral conditions
or needs) that affect a community’s ability to control disease and promote wellness.
The nurse may choose to conduct a survey to determine such things as health
care use patterns and needs, immunization levels, demographic characteristics, or
health beliefs and practices.
The survey method involves self-report, or response to predetermined questions,
and can include questionnaires, telephone or in person interviews. It can also be
combined with other measures.
The process of gathering data consists to interview key informants in the community.
These may be knowledgeable residents, elected officials, or health care providers.
It is essential that the community health nurse recognize that the views of these
people may not reflect the views of all residents.
Descriptive Epidemiologic Studies
A second assessment method is a descriptive epidemiologic study, which
examines the amount and distribution of a disease or health condition in a populationby person (Who is affected?), by place (Where does the condition occur?), and by
time (When do the cases occur?).
In addition to their value in assessing the health status of a population, descriptive
epidemiologic studies are useful for suggesting which individuals are at greatest
risk and where and when the condition might occur. They are also useful for health
planning purposes and for suggesting hypotheses concerning disease etiology.
Geographic Information System Analysis
The geographic information systems (GIS) “mapping and visualization of health
disparities and their relationship to the geographical location of health care services
can allow for better resource allocations to disparate and underserved populations”.
It is now commonly used in community health assessment, in general, and for
specific populations and problems. For example, GIS has been useful in identifying
air pollutant risk exposure, planning or rapid public health response during a
natural disaster, and identification of colorectal screening resources for medically
underserved communities.
GIS data are often combined with field observation or census data and other survey
results to provide powerful visualizations of data for analysis and intervention.
Community Forums or Town Hall Meetings
The community forum or town hall meeting is a qualitative assessment method
designed to obtain community opinions. It takes place in the neighborhood of the
people involved, perhaps in a school gymnasium or an auditorium. The participants
are selected to participate by invitation from the group organizing the forum.
Members come from within the community and represent all segments of the
community that are involved with the issue. For instance, if a community is
contemplating building a swimming pool, the people invited to the community
forum might include potential users of the pool (residents of the community who do
not have pools and special groups such as the Girl Scouts, elders, and disabled
citizens), community planners, health and safety personnel, and other key people
with vested interests. They are asked to give their views on the pool: Where should
it be located? Who will use it? How will the cost of building and maintaining it be
assumed? What are the drawbacks to having the pool? Any other pertinent issues
the participants may raise are included. This method is relatively inexpensive, and
results are quickly obtained. A drawback of this method is that only the most vocal
community members, or those with the greatest vested interests in the issue, may
be heard.
This format does not provide a representative voice to others in the community who
also may be affected by the proposed decision. This method is used to elicit public
opinion on a variety of issues, including health care concerns, political views, and
feelings about issues in the public eye, such as gangs.
Focus Groups
This fourth assessment method, focus groups, is similar to the community forum
or town hall meeting in that it is designed to obtain grassroots opinion. However,
it has some differences. First, only a small group of participants, usually 5 to 15
people, is present. The members chosen for the group are homogeneous with
respect to specific demographic variables. For example, a focus group may consist
of female community health nurses, young women in their first pregnancy, or retired
businessmen.
Leadership skills are used in conjunction with the small group process to promote
a supportive atmosphere and to accomplish set goals. The interviewer guides the
discussion according to a predetermined set of questions or topics. The best use
of focus group data includes not only analysis of individual communications, but of
the interactions between participants.
Nurses who conduct focus groups must carefully select participants, formulate
questions, and analyze recorded sessions. These sessions can produce greater
interaction and expression of ideas than surveys and may provide more insight
into an aggregate’s opinions. In addition to encouraging community participation
in the identification of assets and needs, focus groups may lay the groundwork for
community involvement in planning the solutions to identified problems.
Major advantages of focus groups are their efficiency and low cost, similar to the
community forum or town hall meeting format. A focus group can be organized to be
representative of an aggregate, to capture community interest groups, or to sample
for diversity among different population groups. One example is a research study
involving youths and adults. Eight focus groups were held to determine perceptions
of healthy diet and exercise among parents and children. Whatever the purpose,
however, some people may be uncomfortable expressing their views in a group
situation.
c. Sources of Community Data
The community health nurse can look in many places for data to enhance and
complete a community assessment. Data sources can be primary or secondary,
and they can be from international, national, or local sources.
Primary and Secondary Sources
Community health nurses make use of many sources in data collection: Community
members, including formal leaders, and informal leaders. The community members
can frequently offer the most accurate insights and comprehensive information.
Information gathered by talking to people provides primary data, because the
data are obtained directly from the community. Secondary sources of data
include people who know the community well and the records such people create
in the performance of their jobs. Specific examples are health team members,
client records, community health (vital) statistics, census bureau data, reference
books, research reports, and community health nurses. Because secondary data
may not totally describe the community and do not necessarily reflect community
self-perceptions, they may need augmentation or further validation through focus
groups, surveys, and other primary data collection methods.
International Sources
International data are collected by several agencies, including the World Health
Organization (WHO) and its six regional offices and health organizations. In
addition, the United Nations and global specialty organizations that focus on certain
populations or health problems, such as the United Nations Children’s Fund, are
major sources of international health-related data. The WHO publishes an annual
report of their activity, and international statistics for diseases and illness trends can
be found on the Internet.
Information from these official sources can give the nurse in the local community
information about immigrant and refugee populations he serves.
National Sources
Community health nurses can access a wealth of official and nonofficial sources
of national data. Official sources develop documents based on data compiled by
the government. Example of national data sources: National Institute of Statistics
of Rwanda, Ministry of Health, Rwanda through its department like Rwanda
Biomedical Center, etc.
d. Steps of community health needs assessment
The following are the required steps in conducting a needs assessment:
1) Identify aggregate for assessment
2) Identify required information
3) Select method of data gathering
4) Develop questionnaire or interview questions
5) Develop procedures for data collection
6) Train data collectors
7) Arrange for a sample representative of the aggregate
8) Conduct needs assessment
9) Tabulate and analyze data
10) Identify needs suggested by data11) Develop an action plan
Self-assessment 5.3
1) Discuss the Sources of data for community health needs assessment.
2) Describe different methods used for community health assessment.3) What are the steps in conducting community health needs assessment?
5.4. Basic community interventions
5.4.1. Community education
Learning activity 5.4.1
Using Community Health Nursing Textbooks and internet; read about community
education and respond to the following questions:
1) Discuss different methods used for providing a community health
education.
2) What do you understand for the factors that affect readiness to learn
among community health members?
3) Discuss any four teaching materials used for providing a community
health education session.a. Overview on community health education
Health education is an integral part of the nurse’s role in the community for
promoting health, preventing disease, and maintaining optimal wellness. Moreover,
the community is a vital link for the delivery of effective health care and offers
the nurse multiple opportunities to provide appropriate health education within the
context of a setting that is familiar to community members.
At the core of health education is the development of trusting relationships based
on nurturing and healing interactions, the use of community-based participatory
methods that highlight community strengths, and the creation of sustainable
collaborations and partnerships
Health education is any combination of learning experiences designed to predispose,
enable, and reinforce voluntary behavior conducive to health in individuals,
groups, or communities. Its goal is to understand health behavior and to translate
knowledge into relevant interventions and strategies for health enhancement,
disease prevention, and chronic illness management. Health education aims toenhance wellness and decrease disability; attempts to actualize the health potential
of individuals, families, communities, and society; and it includes a broad and varied
set of strategies aimed at influencing individuals within their social environment for
improved health and well-being.
Aim of health education is not just about giving health information, but also involves
the process of changing a person or community towards favorable healthy behaviors
and maintaining optimum health.
The most important goal of health teaching in community-based care is to assist the
client and family in achieving independence through self-care.
When client learning needs are considered within the context of the client, family
and community, care is improved.
Likewise, staff satisfaction improves when teaching results are positive. It is
professionally satisfying to prepare a client for discharge and receive subsequent
feedback that the discharge was satisfactory. Likewise, it is professionally satisfying
for the home care nurse to prepare a client to successfully manage self-care at
home. On the other hand, it is stressful when a nurse sees a client with inadequate
preparation trying to manage home care unsuccessfully.
Quality health education provides continuity between settings of care. Providing
information about diet, activity, medications, equipment, and follow-up appointments
enhances self-care capacity.
Community health education is especially a matter of working with community
organizations, voluntary bodies, and groups. Informal leadership based on respect
and not on the office holdings, is often very influential. Political leadership is
usually the most powerful, but professional and voluntary leadership also need
understanding and collaboration.
Studying the community: it means especially studying those who have leadership
positions in the community, and then the organizations, bodies, and groups through
which their influence is spread. To build co-operation with those who have authority
can make difference between success and failure in disease control or a health
improvement campaign. Informal leadership is of those people who, though holding
no offices, are nevertheless respected by particular groups. Such groups may meet
for drinking and the exchange of news and gossip. Those who are respected and
listened to in these groups can powerfully influence many people’s thinking and
attitudes, and the co-operation they give to, or withhold from, health staff. The official
leadership of greatest importance is the political leadership. Mutual understanding
with those who carry the responsibility for the administration is very essential.
Professional leadership in the village is found not only in the agricultural extensionservice, in education, rural or community development, social welfare, etc. but also
in the churches, and sometimes other voluntary bodies. It is necessary to work
together closely with all these agencies. For example, a health education campaign
which succeeds in persuading people to eat more eggs will lead to a quick rise in
the price of eggs unless the agricultural staff also works successfully persuading
farmers to produce more eggs.
Schools, Farmers’ clubs, literacy programs, Scouts and Guides, Red Cross,
women’s progress movements, etc. are all interested in health improvement. They
can help in health education in substantial and effective way. Their co-operation
with programs of the health services can be valuable and fruitful.
No opportunity should be missed to explain health programs to these agencies and
to enlist support for particular health education campaigns.
A community health education program needs to Centre upon a recognized
problem and be well planned. Rumors can do great damage and need to be
systematically and quickly contradicted.
The community health nurses need to study and seek to understand their community,
its hopes and fears, its personalities and power structure, its priorities and methods
of decision making, and also the problems involved in implementing the decisions
made.
Working in the community: it depends upon developing and maintaining good
working relationships with official leaders, informal opinion leaders, and voluntary
leaders. All must be kept informed, taken into our confidence, and have a clear
understanding of our plans and objectives. Regular meetings providing for cross
representation on their committees can help. Health education is not confined to
formal activities but goes an all the time as people meet. Our aim must be to work
from within the community.
In planning community health education: it is better to start with a problem
and to choose one which has widespread importance and which the community
recognizes and wants to reduce or eliminate. Scabies, worms, colds, or nuisance
pests like rats and flies, can all be important in the thinking and life of a community.
Then co-operation and confidence can be built up by actively following the five
steps scheme:
• Recognition of the problem
• Analysis of the problem-educational diagnosis
• Educational prescription
• Educational treatment
• Recording and review of results, with evaluation.
Mobilizing the community for action: is the road to success. Community healthnurse set targets, to be reached as the work progresses. The community members
should be involved in the solving of the community health problems, and wherever
it is possible the use of community available resources is advised.
Divisions, rival groups, and damaging rumors are the chief dangers. As health
education program moves to success, the confidence created should give rise to
growing interest in tackling more serious problems. These can range from maternal
and infantile mortality to tuberculosis, measles, or other causes of high morbidity
and mortality. Some problems are however so tied to deep-rooted habits and
customs that are very difficult to make much headway. Smoking and the resulting
respiratory conditions, alcoholism, venereal disease and malaria are examples.
Where a sustained long term health education program is needed it is wise to be
sure you have the experience, the resources and the staff to get deeply involved
before commencing such program. Skilled advice from a health education specialist
can be a substantial help.
b. Factors that affect readiness to learn
Factors that affect readiness to learn are the followings:
Physiologic factors: Age, gender, disease process currently being treated,
intactness of senses (hearing, vision, touch, and taste), and preexisting condition.
Psychosocial factors: Sociocultural circumstances, occupation, economic stability,
past experiences with learning, attitude toward learning, spirituality, emotional
health, self-concept and body image, sense of responsibility for self.
Cognitive factors: Developmental level, level of education, communication skills,
primary language, motivation, reading ability, learning style, problem-solving ability.
Environmental factors: Home environment, safety features, family relationships/
problems, caregiver (availability, motivation, abilities), other support systems.
Developmental considerations: It is helpful for the nurse to understand various
theories of development. Just as the need to learn will be different at various age
levels, the cognitive domain will differ and life experiences will differ. For example,
teaching a 6-year-old girl about insulin administration will be different from teaching
a 24-year-old woman, which would in turn be different from teaching a 69-year-old
woman.
The nurse must consider these factors when developing teaching plans.
c. Learning domains
Teaching and learning occur in three learning domains: cognitive, affective, and
psychomotor. All three domains must be considered in all aspects of the teaching
and learning process. Thus, the nurse must assess the client’s need, readiness,and past experience in the cognitive, affective, and psychomotor domains
Cognitive learning involves mental storage and recall of new knowledge and
information for problem solving. Sometimes this domain is referred to as the critical
thinking or knowledge domain. An example of cognitive learning is seen in the client
who has recently been diagnosed with insulin-dependent diabetes. Not only will
this client need information about diet, insulin, and exercise, but he or she will also
need to use the information to formulate menus and an exercise plan. In addition,
as blood sugar levels fluctuate, a client with diabetes must alter food intake and
exercise. All this requires cognitive learning.
Affective learning involves feelings, attitudes, values, and emotions that influence
learning. This is also referred to as the attitude domain.
In the last decade the role emotion plays in learning has been speculated to be the
most influential of all the domains in impacting motivation, thus the first domain that
educators should assess. For example, the client who has just been identified as
having diabetes may have to talk about his or her feelings about having diabetes
before being ready to learn about insulin. Some of the client’s feelings may stem
from his or her prior knowledge and preconceived ideas about diabetes.
Psychomotor learning consists of acquired physical skills that can be demonstrated.
This may be referred to as the skill domain. For example, the client with newly
diagnosed insulin-dependent diabetes must learn to give self-injections, which will
require learning the skill of using syringes.
d. Teaching and levels of prevention
Teaching, whether it is in the acute care or community-based setting, occurs
at all levels of prevention. An important goal of teaching is to prevent the initial
occurrence of disease or injury through health promotion and prevention activities.
The examples of primary prevention: A nurse teaching a nutrition class to parents
an example of health promotion. A school nurse teaching parents about preventing
malaria, childhood injuries focusing on health protection. Teaching parents about
the importance of immunization, promotion of healthy lifestyle, food hygiene, weight
control, growth and development of children, are also primary prevention.
Secondary prevention teaching is targeted toward early identification and
intervention of a condition. A home care nurse teaching the parents of a ventilator
dependent child about early signs of upper respiratory infection and when to contact
the health facility, breast self-examination and treatment of cancer, is focusing on
secondary prevention.
Tertiary prevention: Most teaching in the home setting addresses tertiary
prevention because most home care clients have chronic conditions or are
postsurgical. Tertiary prevention arises from teaching that attempts to restore healthand facilitate coping skills. Examples: skill of self-care for rehabilitation at centre or
home (e.g., post stroke, palliative care, care of wound, care for special needs child).
e. Methods of health education
Description of certain methods of health education and their uses
a. Illustrated lecture:
It is a teaching method in which the teacher delivers information through an
interactive oral presentation, often using visual aids to support the presentation.
Because you may present information formally in a classroom or informally during
a clinical practice session, the term “interactive presentation” is used rather than
illustrated lecture. No matter where you are presenting information, remember the
following keys to a successful presentation:
Define learning objectives: Decide what the learners should know or be able to do
after this presentation.
Plan your presentation: Create an outline based on your objectives to help
organize the content and keep focused. The outline should include key points,
questions, reminders of activities and visual aids, and summary points.
Introduce each presentation: A good introduction grabs attention and clearly
communicates the objectives of the session. Vary introductions used in different
presentations to maintain learners’ interest.
Use effective presentation skills. Involve learners by asking questions, moving
around the room when possible, and maintaining eye contact. Provide clear
transitions between topics and summaries.
Use questioning techniques. Asking questions is essential to maintaining learners’
interest, checking their understanding, and developing their problem-solving skills.It helps learners assess information and learn to make appropriate choices.
Summarize your presentation. A good summary supports the presentation’s main
points and reinforces the most important information.
Note: Use this check list to assess your presentation skills. Check each skill was
performed. Which areas need improvement?
Planning the presentation:
1) Review the objectives.
2) Prepare an outline of key points and presentation aids such as visual
materials
3) Note questions for students
4) Note reminders for planned activities
5) Note reminders to use specific visual aids.
6) Note summary questions or other activities
Introducing the presentation:
1) State the objective(s) of the presentation as part of the introduction.
2) Use a variety of introductions to capture interest, make learners aware of the
objectives, and create a positive learning climate.
3) Relate the content to previously covered and related topics
Using effective presentation skills:
1) Follow a plan and use an outline
2) Communicate clearly with students. Project your voice, move about the
room, provide clear transitions between topics, and maintain eye contact.
3) Interact with learners by asking and responding to questions, using their
names, and providing feedback.
4) Use visual materials to illustrate and support main points.
Using questioning techniques during a presentation:
1) Target questions to the group and to individuals.
2) Provide feedback and repeat correct responses.
3) Use students’ names.
4) Redirect questions that are typically or totally incorrect until the correct
answer is revealed.
Summarizing the presentation:
1) Stress the main points
2) Relate information to the objectives.
3) Provide an opportunity for questions.
b.Creation and facilitation of role play
The steps to be followed in creating a role play:
To create a role play, follow these steps:
• Decide what the students should learn from the role play (the objectives).
• Select an appropriate situation: it may be drawn from students ‘experiences,
your experiences, or clinical records. The situation should be relevant and
similar to situations that students will encounter during their professional
careers. Keep the situation simple; the interaction is more important than the
content. Because the same role play may be used with a number of students
in various learning settings, keep the situation as general as possible.
• Identify the roles that students will act out during the role play. In most clinical
learning situations, there will be a clinician and a patient. Specify any specific
roles or points of information that students should cover. For example, if
the student acting the role of the patient should resist advice, ask certain
questions, or give certain answers, clearly explain the desired “patient”
behavior in the role play.
• Determine whether the role play will be informal, formal, or a clinical
demonstration. These are defined as:
– Informal: the teacher gives the role players a general situation and asks
them to “act it out” with little or no preparation time. For example, if a question
about a patient counseling session comes up in class, you may ask two of
the students to take a few minutes to plan and present a brief role play that
addresses the situation. This type of role play is not prepared in advance.
– Formal: The teachers give the role players a set of instructions that outline
the scope and sequence of the role play. Using the counseling example, the
students would be given a situation with specific roles they are to act out,
often with specific points of information to cover.
– Clinical demonstration: this type of role play is often part of a clinical
simulation. The clinical demonstration role play, which is similar to the
formal role play, typically uses an anatomic model, simulated patient, or
real patient, and often occurs as part of a coaching session. For example,
you demonstrate a pelvic examination using a pelvic model, or demonstrate
counseling a woman about oral contraceptives. Following the demonstration,
you ask two of the students to role play the procedure. One student assumes
the patient or caretaker role, while the other assumes the role of the clinician.
If an anatomic model is used, the student playing the patient sits or stands bythe model and speaks as a patient would, asking questions and responding
to the clinician. The student playing the clinician will not only perform the
physical examination but also will verbally interact with the “patient”.
– Determine whether students will report the results of their discussion of the
role play in writing or orally to entire group.
Facilitation of a role play:
To facilitate a role play:
• Explain the nature and purpose of the exercise (the objectives).
• Define the setting and situation of the role play.
• Brief the participants of their roles.
• Explain what the other students should observe and what king of feedback
they should give. Tell students what to look for and how to document their
questions or feedback. Should they observe for verbal communication skills?,
The use of questioning?, Nonverbal communication?
• Provide the students with questions or activities that will help them to focus
on the main concept (s) being presented.
• Keep the role play brief and to the point. Be ready to handle unexpected
situations that might arise (confusion, arguments, etc.).
• Engage students in a follow-up discussion. Discuss important features of the
role play by asking questions of both the players and observers.
• Provide feedback, both positive and suggestions for improvement.
• Summarize what happened in the session, what was learned, and how it
applies to the skill being learned.
Note: A role play will be effective only if it is clearly related to the learning objectives.
Explain the objectives of the role play before beginning the activity. When the role
play is completed, summarize and discuss the results of the role play and relate the
role play to the learning objectives.
c.Facilitating a brainstorming session
Brainstorming is generating a list of ideas, thoughts, or alternative solutions that
focus on a specific topic or problem. Brainstorming is a teaching method that
stimulates thought and creativity and is often used along with group discussions.
Brainstorming sessions should not be interrupted to discuss or criticize ideas. The
compiled list may be used as the introduction to a topic or form the basis for a group
discussion.
Once the brainstorming process has been completed, the group can organize the
ideas into themes. The key to successful brainstorming is to separate the generationof ideas, or possible solutions to a problem, from the evaluation of these ideas or
solutions.
Plan for brainstorming by determining the objectives of the activity and making sure
that there is a way to record responses and suggestions.
Brainstorming is useful to:
• Stimulate interest in a topic.
• Encourage broad or creative thinking.
Facilitation of a Brainstorming session:
• Share the objective of the brainstorming session.
• Explain the ground rules before the session. There are three basic rules: all
ideas will be accepted, discussions of suggestions are delayed until after the
activity, and no criticism of suggestions is allowed.
Example: “During this brainstorming session, we will be following three basic rules.
All ideas will be accepted; Peter will write them on the flipchart. At no time will we
discuss or criticize any idea. Later, after we have our list of suggestions, we will go
back and discuss each one. Is there any question? If not,”
• State the topic or problem. Clearly state the focus of the brainstorming session.
Example: During the next few minutes we will be brainstorming and will follow our
usual rules. Our topic today is “Benefits of Family Planning.” I would like your full
participation. Janet will write these on the board so that we can discuss them later.”
• Maintain a written record on a flipchart or writing board of the ideas and
suggestions. This will prevent repetition, keep learners focused on the topics,
and be useful when it is time to discuss each item.
• Provide opportunities for anonymous brainstorming by giving the learners
cards on which they can write their comments or questions. Post the cards
and use them for a later discussion. This technique allows learners to share
thoughts or questions without revealing their identities.
• Involve all of the students and provide positive feedback in order to encourage
more input. Avoid allowing a few learners to monopolize the session, and
encourage those not offering suggestions to do so.
• Review written ideas and suggestions periodically to stimulate additional
ideas.
• Conclude brainstorming by summarizing and reviewing all of the suggestions,
and by placing ideas in categories, if this is useful and possible.
d. Facilitating a discussion
A discussion is an opportunity for learners to share their ideas, thoughts, questions,and answers in a group setting with a facilitator.
A discussion that relates to the topic and stays focused on the learning objectives
can be a very effective teaching method. Guide the learners as the discussion
develops and keep it focused on the topic at hand.\Group discussion is used to
support other teaching methods, particularly to:
• Conclude a presentation.
• Summarize the main points of a videotape.
• Check students’ understanding of a clinical demonstration.
• Examine alternative solutions to a case study.
• Explore attitudes exhibited during a role play.
• Analyze the results of a brainstorming session.
Considerations when preparing for a discussion:
When preparing for a discussion, consider the following:
• What are the objectives of this discussion? How long should it last?
• Do learners have some knowledge of or experience with the topic? Attempting
a group discussion when students have limited knowledge or experience in
the topic will often result in little or no interaction.
• Is there enough time available? Discussion requires more time than a
presentation because of the interaction among students.
• Are you prepared to direct or control the discussion? A poorly directed
discussion may move away from the subject and never accomplish the
learning objectives. If the teacher does not maintain control, a few students
may dominate the discussion while others lose interest.
Key points to be followed to ensure successful group discussions
How do you choose a topic for discussion? Group discussions are best planned
ahead of time, although sometimes they arise spontaneously from the students.
The following key points should be followed to ensure successful group discussions:
• Have a very clear idea in mind of what the group will discuss and what you
hope to gain through the discussion. State the topic as part of the introduction.
Example: “To conclude this presentation on counseling the sexually active
adolescent, let’s take a few minutes to discuss the importance of confidentiality.”
• Shift the conversation to the learners. Allow the learners to discuss the topic
and ensure that the discussion stays on the topic at hand. Encourage shy
learners to speak up so that everyone has a chance to share their thoughts.
Examples:
– “James, would you share your thoughts on…?”– “Mary, what is your opinion?”
– “Luck, do you agree with my statements that…”
• Allow the group to direct the discussion; act as a referee and intercede only
when necessary.
Example: “It is obvious that Peter and Rose are taking opposite sides in this
discussion. Peter, let me see if I can clarify your position. You seem to feel that…”
• Summarize the key points of the discussion periodically. Provide feedback on
learners’ comments when appropriate.
Example:
– Let’s stop here for a minute and summarize the main points of our discussion.”
– “Actually, confidentiality is essential for counseling and testing for HIV. Can
anyone tell me why?”
• Ensure that discussion stays on the topic.
Examples:
– “Sandra, can you explain a little more clearly how that situation relates to our
topic?”
– “Monica, would you clarify for us how your point relates to the topic?”
– “Let’s stop for a moment and review the purpose of our discussion.”
• Use the contributions of each learner and provide reinforcement. Point out
differences or similarities among the ideas presented by different people.
Examples:
– “That is an excellent point, John. Thank you for sharing that with the group.”
– “Alex has a good argument against the policy. Mark, would you like to take
the opposite position?”
• Encourage all learners to get involved.
Example: “Sylvia, I can see that you have been thinking about these comments.
Can you give us your thoughts?”
• Ensure that no one learner dominates the discussion.
Example: “Paul, you have contributed a great deal to our discussion. Let’s see if
someone else would like to offer…”
Note: your role as the discussion facilitator is to keep the discussion focused,
ensure that all students have equal opportunity to participate, and to intervene
when the discussion moves away from the objectives. Conclude the discussion
with a summary of the main ideas and how they relate to the objectives presentedduring the introduction.
e. Demonstration
Note that giving a good demonstration is worth a thousand words. There are four
steps to a demonstration:
1. Explaining the ideas and skills that you will be demonstrating
2. Giving the actual demonstration
3. Giving an explanation as you go along, doing one step at a time
4. Asking one person to repeat the demonstration and giving everyone a
chance to repeat the
Qualities of a good demonstration
For an effective demonstration you should consider the following features: the
demonstration must be realistic, it should fit with the local culture and it should use
familiar materials. You will need to arrange to have enough materials for everyone
to practice and have adequate space for everyone to see or practice. People need
to take enough time for practice and for you to check that everyone has acquired
the appropriate skill.
f. Traditional means of communication
Traditional means of communication exploit and develop the local means, materials
and methods of communication, such as poems, stories, songs and dances, games,
fables and puppet shows.
g.Preparation and using the teaching / learning materials (aids)
After completing this sub-session, you will be able to prepare and use a variety of
the following teaching/learning materials:
• A writing board
• A flipchart
• A video
• Slides and a computer to prepare and project a presentation
• Leaflets
1) A writing board:
A writing board is the most commonly used visual aid. It can display information
written with chalk (chalkboard or blackboard) or special pens (whiteboard). You
can use a writing board for announcements, informal discussions, brainstorming
sessions, and note taking. A writing board is also an excellent tool for illustrating
subjects like anatomy and physiology and for outlining procedures.
Some possible uses of a writing board:
• Document ideas during discussions or brainstorming exercises,
• Draw a sketch of anatomy or a physiological response,
• Note points you wish to emphasize,
• Diagram a sequence of activities for working through the process of making
a clinical decision,
Tips (instructions, guidelines) for using a writing board:
Most teachers use a writing board of some kind. Sometimes the board will look
messy at the end of a presentation, with untidy diagrams and no pattern to the
words. For using a writing board, follow the following guidelines:
• Before you start, decide what you will illustrate on the board.
• During the presentation, write the key words or phrases in order, according to
the structure of the presentation.
• Remember that learners tend to copy the words and the layout as they appear
on the board, so make sure that what you write on the board is what you want
the learners to write in their notes.
• Keep the board clean
• Use chalk or pens that contrast with the background of the board so the
learners can see the information clearly.
• Make text and drawings large enough to be seen in the back of the room.
• Underline headings and important or unfamiliar words for emphasis
• Do not talk while facing the board.
• Do not block the learners’ view of the board; stand aside when you have
finished writing or drawing.
• Allow sufficient time for learners to copy the information from the board.
• Summarize the main points at the end of the presentation.
2) A flipchart
A flipchart is a large tablet or pad of paper, usually a tripod or a stand. You can use
a flipchart for displaying prepared notes or drawings as well as for brainstorming
and recording ideas from discussions. You can also use flipcharts before and after
clinical practice visits to introduce objectives and group exercises, or to summarize
the experience.
The possible uses of a flipchart are the same as those listed for the writing board,
but also include the following:
• Note objectives or outcomes before or after clinical practice sessions.
• Create flowcharts to work through clinical decision-making in different
situations, such as during a complicated labor and childbirth.
• Record discussions or ideas during small group exercises.
Tips for using a flipchart:
• Make it easy to read. Use bullets (*) to highlight items on the page. Leave
plenty of white space, and avoid putting too much information on one page.
Print in block letters using wide-tipped pens or markers.
• Make the flipchart page attractive. Use different colored pens to provide
contrast, and use headings, boxes, cartoons, and borders to improve the
appearance of the page.
• Have masking tape available to hang flipchart pages on the walls during
brainstorming and problem-solving sessions.
• To hide a portion of the page, fold up the lower portion of the page and tape
it; when you are ready to reveal the information, remove the tape and let the
page drop.
• Face the learners, not the flipchart, while talking.
• When you finish with a flipchart page, tape it to the wall where you and the
learners can refer to it.
Note: When you use the flip chart in health education you must discuss each
page completely before you turn to the next and then make sure that everyone
understands each message. At the end you can go back to the first charts to review
the subject and help people remember the ideas.
3) Preparation and using computer generated slides
When preparing slides:
• Limit each slide to one main idea; detailed information should be put into a
handout, not on a slide.
• Make sure slides support the text or objectives. Slides should clearly
demonstrate their objective.
• Be sure that the material on the slide is legible. A good rule is that if a slide
can be read by the naked eye-without a projector- it will be legible to learners
in the back of the room when it is projected.
• When using a computer to develop a presentation, keep the presentation
simple and clear.
• Be consistent, Use the same general style and tone throughout.
• Proofread. You are more likely to catch errors if you proofread before creating
slides.
• Limit the information on each slide to one idea that can be grasped in 5-10
seconds.
• State the main idea in the title.
• Use about three to five bullets per slide. Use no more than seven lines of text.
• Limit a bulleted item to six to eight words.
• Whenever possible, use pictures, or graphs to support or replace text. Bar
graphs and line graphs are effective tools to show trends and statistics.
Photographs and line drawings are foe example useful for showing clinical
signs and symptoms and demonstrating clinical procedures.
• Make graphics and drawings large enough to be seen easily in the back of the
room. Use large lettering (at least 5 mm tall, preferably larger if printing, or 18
point or larger if using a computer).
• If you are using a computer to prepare slides use only one typeface (font) per
slide. Use italics or bold to emphasize points rather than using another font.
• Make sure that technical assistance is available to deal promptly with
problems. Practice the computer program for creating and projecting your
presentation until you are comfortable with it.
• Avoid busy or confusing background. Use a color for the text that has a very
high contrast with the background. A simple white background with dark
lettering is very effective.
• I you are preparing a projected presentation, minimize the transition between
slides. Use sound effects sparingly and only to emphasize a point. If there is
animation, it should be used consistently throughout the presentation.
• Remember that your slides should highlight your key points. They should not
contain the full text of the presentation.
• Charts and tables should be large and simple for the message to be clear.
• Always save the presentation on the computer’s hard drive and on other USB
like flash disk or CD-Rom in case something happens to the computer (e.g.
sometimes computers “crash” or “freeze” and information can be lost if not
saved.
The following are some instructions for using a slide projector:
• Arrange the room so that all learners can see the screen; make sure that
there is nothing between the projector and the screen.
• Set up and test the slide projector and computer before the learners arrive
• Once the projector is on, move away from the projector to avoid blocking the
learners’ view of the screen.
• Face the learners, not the screen, while talking.
• Allow plenty of time for the learners to read what is on the screen and takenotes, if necessary
• Determine if all or some of the lights can be left on during the slide presentation;
this will help learners pay attention and make taking notes easier.
• During presentation, avoid rushing through a series of slides. This can be
very frustrating for learners, take time to view and discuss each slide. When
appropriate, ask learners questions about what they are seeing on a slide.
4) Use Video
Videos can be very versatile visual aids. Videos can be used by a single learner
for individual learning, by a group of learners for independent learning, or by the
teacher for involving learners in a discussion. One of the most important aspects
of teaching a skill is showing how an expert would perform it. Video is particularly
useful for this purpose. A bank for prerecorded videos provides a valuable resource
for demonstrating various aspects of clinical practice. When the resources are
available, you can use video to record individual learners’ performances and provide
valuable feedback on their acquisition of clinical skills.
Note: Video can also be recorded on a CD-ROM to be played on a computer and
on a DVD to be played on a DVD player. Video from a CD-ROM or DVD can also be
projected onto a screen, allowing a large group of learners to see the video. When
this approach is used, external speakers may be needed so that all learners can
hear the audio portion of the video.
Possible uses for video:
• Provide an overview or introduction to a topic to stimulate interest and
discussion.
• Allow the teacher to model a technique or procedure, such as how to counsel
adolescents about reducing their HIV risks, assess breastfeeding attachment,
or insert an Intra-uterine Device (IUD), in a clear, step-by-step manner.
• Allow learners to practice identifying clinical signs such as sunken eyes and
fast breathing.
Tips for using Videos:
• In the classroom, use several short video segments with pauses in between
for explanation or discussion, rather than one long video.
• Preview the videotape to ensure that it is appropriate for the learners and
consistent with the course objectives.
• Make sure that the information presented in the video is up-date with current
practices and standards. If there are some differences, be sure to tell the
learners about them before showing the video. If there are considerable
differences, do not show the video.
• Before the classroom session, check to be sure that the video is compatiblewith the video player. Run a few seconds of the tape to ensure that everything
is functioning properly. Cue the video to the beginning of the program or to the
section of the video that you will show.
• Arrange the room so that all learners can see the video monitor or screen and
hear the video.
• Prepare the learners to view the video:
• State the objective
• Give the learners an overview of the content they will see on the video.
• Focus learners ‘attention by asking that they look for a number of specific
points as they watch the video.
Remember: Use videos as an interactive tool. When appropriate, stop the video
to point out things the learners should notice, or ask questions to check their
understanding. Discuss the video after it has been shown. Review the main points
that the learners were asked to watch for as they viewed the video. This will make
the video a much more effective teaching tool than if the learners watch it without
your guidance.
Summary for using visual aids: No matter which visual aids you use, remember
the following:
• Keep it simple: each flipchart or slide should present only one main point,
with supporting information in a bulleted list. This will help learners remember
important information.
• Keep it relevant: Use up-to date videos and slides. Present information and
demonstrate skills in a manner consistent with best practices.
• Keep it focused: prepare or use visual aids that support the learning
objectives and highlight main points.
• Practice using visual aids in advance
• Set up or prepare your visual aids in the room before the learners arrive
• Check that all audiovisual equipment is working before the learners arrive
• Make sure that all learners can see the writing board, flipchart, screen, and
video monitor.
• Prepare any copies of handouts related to the visual aids in advance and
have them in the room when the learners arrive.
• When appropriate, have questions or exercises (e.g. case studies, role plays)
prepared for use after using the visual aids.
• Make notes about how effective the visual aids were in helping the learners
and how you might use the visual aids in future presentations.
5) Leaflets
Leaflets are the most common way of using print media in health education. They
can be a useful reinforcement for individual and group sessions and serve as a
reminder of the main points that you have made. They are also helpful for sensitive
subjects such as sexual health education. When people are too shy to ask for
advice, they can pick up a leaflet and read it privately.
In terms of content, leaflets, booklets or pamphlets are best when they are brief,
written in simple words and understandable language. A relevant address should
be included at the back to indicate where people can get further information.
Notes: Visuals materials are one of the strongest methods of communicating
messages, especially where literacy is low amongst the population. They are good
when they are accompanied with interactive methods. It is said that a picture tells a
thousand words. Real objects, audio and video do the same. They are immediate
and powerful and people can play with them!
You might take with you real visual materials to a health education meeting. We’ve
already mentioned bed netting for demonstrating prevention of malaria, but there
are other real objects too. Think about family planning, nutrition, hygiene and so on.
If your display is on ‘family planning methods’, display real contraceptives, such as
pills, condoms, diaphragms, and foams. If your display is on weaning foods, display
the real foods and the equipment used to prepare them.
Audio material includes anything heard such as the spoken word, a health talk
or music. Radio and audio cassettes are good examples of audio aids. As the
name implies; audio-visual materials combine both seeing and listening. These
materials include Television (TV), films or videos which provide a wide range of
interest and can convey messages with high motivational appeal. They are good
when they are accompanied with interactive methods. Audio-visual health learning
materials can arouse interest if they are of high quality and provide a clear mental
picture of the message. They may also speed up and enhance understanding or
stimulate active thinking and learning and help develop memory.
f. fScheme of health education
Identification:
Names of health educator:
Topic name:
Duration (in minutes):
Time: from: ….. to: …..
Place:
Audience (or target population/group/person):
Objectives/learning outcomes:
g. Barriers to Successful Teaching
It is helpful to be aware of some of the potential obstacles to successful teaching.
Conditions and barriers to successful teaching differ between the acute care setting
and community setting. Likewise, there may be barriers to successful teaching that
differ between community-based settings. In the next section barriers to successful
teaching are presented and followed by characteristics of successful teaching.
These barriers have the potential to interrupt the coordination of and consistency in
teaching and communication with the care giving team.
Nursing students and novice home care nurses often express dismay over their
diminished control of client behavior when providing care in settings other than the
acute care setting. For instance, teaching in the home often requires adaptation to
the particular home environment, where the client is in control. Further, the nurse
is faced with accommodating the specific needs of the client and family within their
own schedule and circumstances.
Another barrier relates to difficulty in coordinating client teaching among multiple
providers. Often, many care providers are involved with the client’s care.
Other professionals may include other nurses, physical therapists, social workers,
home health aides, nurse practitioners, and physicians. Each provider may teach a
procedure, treatment, or process in a different way, confusing the client. It is difficult
to maintain ongoing communication among multiple caregivers in several diverse
settings.
Lack of time is a barrier to home care teaching. The time factor in acute care
settings may prohibit teaching, and many home care referrals come from clinics or
physicians’ offices. As a result, the first teaching, in many cases, may be done in the
home. Home care nurses are often pressed for time. It may be difficult for the home
care nurse to feel teaching is ever complete or even adequateSelf-assessment 5.4.1
1) Explain 5 factors that affect the readiness to learn
2) Explain 3 domains of learning
3) Describe how the following teaching methods should be used during
health education session: Lecture, demonstration, role play
4) Describe how the following teaching materials/aids should be used during
health education session: a writing board, a video and slides & a computer
to prepare and project a presentation5.4.2. Advocating for the community
Using Community Health Nursing Textbooks and internet; read about
advocating for the community and respond to the following questions:
1) Discuss the purpose of advocacy, advocacy methods, and principles of
advocacy
2) What do you understand about approaches used in advocacy?3) Discuss the advocacy strategies.
Advocacy is the act of ‘‘taking a position on an issue, and initiating actions in a
deliberate attempt to influence private and public policy choices’’. It is an act of
delivering an argument so that you can gain commitment from your political and
community leaders, and help your community organize itself to face a particular
health issue.
Advocacy involves the selection and organization of information to make sure that
your argument is convincing. Advocacy is not just one thing or one way of doing
things; it can be delivered through a variety of interpersonal and media channels.
Advocacy also includes organizing and building alliances across a wide variety of
stakeholders.
Advocacy is strategic and it should be geared to using well-designed and organized
activities in order to influence policy or decision makers about all the important
issues that you think will affect the health of your community. This might include
a wide range of possible issues, including health policy, laws, regulations, and
programmes or funding from the public and private health sectors.
A community health advocate (or CHA) works to ensure that members of a particular
community are treated fairly and adequately in all health care matters. Community
health advocates generally work for a government agency or an independent
nonprofit organization.
Advocacy can address single or multiple health issues, during which time-limited
campaigns as well as ongoing work may be undertaken on a range of health issues.
Community advocacy efforts can be implemented on a group, local, national,
transnational basis or at all levels at the same time.
The level at which advocacy is conducted is often determined by a number of
factors, including the scope of the issue, the short term and/or long term nature of
the issue, and the availability of resources. Many issues are amenable to, but donot necessarily require, advocacy efforts at multiple levels.
a. Purpose of advocacy
The main purpose of advocacy is to bring about positive changes to the health
of your population. Sometimes advocacy will address health issues through the
implementation of a national health policy, or through the implementation of public
health policy — and it can also address health issues related to harmful traditional
practices. Moreover, advocacy could help to meet the goals of health extension
programme policies, where specific resource allocation and service delivery models
are formulated for advocacy campaigns.
Advocacy is about helping you to speak up for your community; to make sure that
the views, needs and opinions of your community are heard and understood. It
should always be an enabling process through which you, as a Health Extension
Practitioner, together with individuals, model families and others in your community
— take some action in order to assist the community to address their health needs.
Advocacy is person-centered and people-driven. It is always community-rights
based. That is to say that advocacy is dealing with what your community needs to
improve its health. You could also say that advocacy is the process of supporting
people to solve health issues. It includes single issues and time-limited campaigns,
as well as ongoing, long-term work undertaken to tackle a range of health issues
or health problems.
Remember, advocacy is your opportunity to influence polices or programs of
health. It also means putting important health problems on the agenda. Advocacy
may be able to provide a solution to specific health problems, and build support
and networks that can tackle health issues that are affecting the health of your
community
b. The goals and objectives of advocacy
The goals and objectives of advocacy are to facilitate change and the development
of new areas of policy, in order to tackle unmet health needs or deal with emerging
health needs in a given community.
Here the goal means the desired result of any advocacy activity. An advocacy goal
will usually be a long-term result, and it may take three to five years of advocacy
work to bring about the desired result. It is unlikely that your advocacy network can
achieve a goal on its own; it will probably require other allies to bring about the
required change. It is vital to know what you are trying to do before you start your
advocacy work. This involves developing a goal that applies to the situation that
needs to change.
Important points to note about goals are as follows:
• A goal is the overall purpose of a project. It is a broad statement of what you
are trying to do.
• A goal often refers to the benefit that will be felt by those affected by an issue.
• A goal is long term and gives direction — it helps you know where you are
going. It needs an accompanying route map or strategy to show you how to
get there.
• Without a goal, it is possible to lose sight of what you are trying to do.
• A goal needs to be linked to the mission and vision of your organization.
An objective is the intended impact or effect of the work you are doing, or the
specific change that you want to see. The word ‘objective’ often refers to the
desired changes in policy and practice that will be necessary to help you and your
community meet that goal. It is the most important part of your strategy, and is the
next step after developing the goal itself. It is worth spending time writing clear
objectives, because you will find you are able to write the rest of the advocacy
strategy much more clearly — and you are likely to be more effective in achieving
change.
When you set an advocacy objective, always consider or keep in mind the
resources available in your locality. It is important that an advocacy objective
identifies the specific policy body in the authority that should be approached to
fulfil the objective, as well as detailing the policy decision or action that is desired.
For example, if you want to overturn the ban on community-based distribution of
contraceptives, then the right target to direct your advocacy towards would be the
Ministry of Health.
In contrast to a goal, an advocacy objective should be achievable by the network
on its own. It is a short-term target, which means it should be achievable within the
next one or two years. The success of your advocacy objectives should always be
measured.
SMART objectives
‘SMART’ is a way of reminding you that your objectives should be:
S: Specific — by this we mean that you need to set a specific objective for each of
your health programmes.
M: Measurable — your objective should be measurable.
A: Achievable — the objective should be attainable or practicable.
R: Realistic — which also means credible.
T: Time-bound — and should be accomplished and achieved within a certain
amount of time
c. The advantages of advocacy
The success of advocacy as a method of problem solving or resolution is tied in
part to the advocates’ philosophy of searching for solutions rather than problems.
As a health worker acting as an advocate, you may be able to find ways to resolve
the community’s health-related problems. In some situations, you may have to
act as a health advocate and provide ongoing representational advocacy for your
community. Advocates should be particularly good at identifying the strengths of
their own community, and should help them find ways of solving health-related
problems.
There are several benefits of advocacy:
• Advocacy helps your community’s voice to be heard
• It provides you with information, support, and services to help you make
choices.
• It helps you to get people to understand your point of view
• Makes it easier for you to get information in a way that you can understand
• Helps you to see what other services are available
• Helps you choose what you want to do
• Helps with expressing your views effectively
• Represents your community’s views faithfully and effectively
• Helps influential people understand the issues.
d. Advocacy methods
Before starting advocacy, the community health nurse has to choose a method(s)
which will be used in order get the desired results. These methods are:
1) Lobbying, this means influencing the policy process by working closely with
key individuals in political and governmental structures, together with other
decision makers.
2) Meetings, usually it is used as part of a lobbying strategy or negotiation, to
reach a common position.
3) Project visits are another useful tool of advocacy to demonstrate good
practice and information, education and communication as various means
of sensitizing the decision makers.
4) Community organizing is another important tactic that can be used.
e. Principles of advocacy
The use of the following principles may help you to get a common understanding
and get support for your advocacy activities:• Use several tools for advocacy to reach a wide audience
• (for example, not only the public, but also officials and decision makers), and
be sure to form good relationships with your local media representatives.
• Have good relations with the private sector and all the NGOs working in the
area around you. Collaborate with them and all the people who can help your
advocacy work.
• Have good strategic planning.
• Use effective monitoring tools.
f. Approaches to advocacy
The advocacy approach uses many different methods of reaching people. Inter
personal meetings or face-to-face approaches with the decision makers are the
most effective advocacy approaches for those people. However, with the limited
availability of advocates in the field, the potential number of people reached is limited
using this form of communication, and further work like that may be expensive. As
mentioned in earlier sessions, you can also use other channels for reaching the
public, for example newsletters, flyers/leaflets, booklets, fact sheets, posters, video
and dramas.
As an advocacy coordinator, you will need support and technical assistance, and
possibly extra personnel to carry out your advocacy activities. You may need
help in the areas of identifying health issues, planning, and message or material
production. Some organizations that can help you carry out an advocacy campaign
will have expertise in conducting advocacy campaigns, or be able to help you carry
out needs assessment and issue identification. Other organizations may help with
advocacy activities such as message development and broadcast work. Some
will have expertise in audio-visual and media message production, while others
may have expertise in training field workers for developing their advocacy and
networking skills.
Here below certain advocacy approaches are described:
1) ‘‘Grassroots’’ or ‘‘bottom-up’’ approaches to advocacy are based on the
identification of needs and goals by community members themselves. It is
defined as efforts by which groups sharing a common interest are assisted
in identifying their specific needs and goals, mobilizing resources within their
communities, and in other ways taking action leading to the achievement of
the goals they have set collectively.
2) top-down models emphasize the identification of needs or goals by
experts outside of the community or by only the community leaders. These
advocates may be professional staff of non-profit organizations, or national
or international professional health organizations.
Organizing is critical to the success of advocacy efforts, whether they are
conducted from a bottom-up or top-down approach. For instance, a non-
profit or non-governmental organization that is spearheading efforts to
improve health related services in a particular locale or to prohibit smoking
must organize, at a minimum, its staff and constituents to further/promote
these goals.
3) Community organizing has been defined as ‘‘the process of organizing
people around problems or issues that are larger than group members’ own
immediate concerns’’. As such, it is relevant to bottom-up advocacy efforts.
Community readiness is a prerequisite for mobilization for a specific goal. The
stronger the community’s sense of identity, cohesion, and connectedness,
the more likely it is that the community is ready to mobilize and to address
a specific issue.
Organizing efforts using a bottom-up approach may rely on indigenous community
organizers, that is, community leaders who are able to influence and represent the
larger constituency of the community.
Other mechanisms used in bottom-up advocacy efforts include reliance on small
groups, often called the locus of change because they help to create a group
identity and a sense of purpose, and town hall meetings, which are used to inform
the relevant community and to consider a variety of solutions.
Organizing and mobilizing a community is often a cyclical process that comprises
assessment, research, action, and reflection. As an example, an advocacy group
may find that there are multiple issues to deal with and that each of these issues
falls within its mission or vision. Because each issue demands an allocation of time
and resources, it would be impossible to begin all of them simultaneously with the
same degree of attention and intensity. One option open to the organization is to
survey its membership about which issues or activities the members feel are most
critical.
Alternatively, an organization may choose to conduct a needs assessment and,
from the information gathered through this assessment, prioritize the needs to be
addressed, and the activities to be pursued.
Assessment, then, is the process by which members identify and define the
critical issues that affect their community. Although ‘‘needs assessment’’ has been
variously defined, it is frequently viewed as a systematic process that is ‘‘designed
to determine the current status and unmet needs—sometimes, both the present
and future needs—of a defined population group or geographic area with regard
to a specified program or subjects area’’. This process is often founded upon
research, which is the examination of causes and correlates of issues identified
in the assessment phase: the nature of the issue, including any barriers to access
and/or limitations of current policies and how the allocation of community resources
relates to it; political influences, how organizations or other players exercise social
power around it; and solutions.
A community needs assessment that is both valid and credible is characterized by:
1) A multidisciplinary team that includes individuals with expertise in community
assessment procedures, knowledge about strategies relevant to the issue
under study, and members of the population to be affected;
2) Broad agreement on the objectives focus, and scope of the needs
assessment;
3) A study design that uses both primary and secondary data effectively;
4) A realistic study design, time frame, and allocation of resources;
5) A process for regular reviews and input by community representatives; and
6) a plan for the utilization of the findings.
This, in turn, raises yet another issue: How do we define ‘‘need’’?
A need is a difference between ‘‘what is’’ and ‘‘what should be.’’ Some researchers
have defined need as ‘‘a gap—between the real and ideal conditions—that is both
acknowledged by community values and potentially amenable to change’’.
The values mean an idea about what is good, right, and desirable; values are
central to judgment and to behavior.
Before embarking on this process, however, it is critical that the community to be
assessed be clearly defined.
Geographical, health, social, and/or demographic characteristics may provide the
basis for this decision. The research question that the needs assessment is to
answer must then is clearly defined. These two elements will provide the basis for
the design of the needs assessment process. During the first phase of the needs
assessment process, the pre-assessment, those conducting the assessment will
conduct all preliminary planning and background research activities.
This requires the identification of the data to be collected, the sources of the data,
the methods for collecting and analyzing the data, and the use of the data after
its collection and analysis. The pre-assessment phase provides those conducting
the assessment with an opportunity to consider such key issues as the cost of
conducting the assessment; any special needs of the target population that may
have an impact on the methods to be used to collect the data, such as literacy
levels or primary language; and the timeline for completion of the assessment.
The assessment phase is the second phase of the needs assessment process.
The focus of this stage is the collection of data and its analysis. The methods
used for data collection should permit triangulation, defined as the use of different,
independent approaches to address research questions. Data collection strategies
may include, for instance, survey instruments, structured interviews, and secondary
data from existing databases. Triangulation strengthens the basis for conclusions
to be drawn from the study. The post-assessment phase is often referred to as an
action phase because it requires that the results of the data analysis be put into
action. This phase is used to determine how the information gathered through the
needs assessment process can best be put to use.
g. How to get supporters
During these activities a community health nurse need support to form an advocacy
network because of the amount of work and the number of activities that may be
involved. She/he may need help in order to design effective messages, to form a
task force, to decide the strategy, and for fundraising, as well as for calculating the
cost of the activities.
As advocator you also need to identify potential supporters. This can be achieved by
attending local events, enlisting the support of the media, holding public meetings,
and talking to all the influential people in your community. To do these things
effectively, you will also need to do a community diagnosis and get to understand
the resources in your community or locality. To get good support for advocacy
campaigns, you need to form a cooperative team for your advocacy activities, and
you need to know the stages to go through in order to achieve the best results.
It is indicated to implement the following stages in order to build the capacity of the
team which will help you in the advocacy activities. These stages are called the
stages of team growth.
• Stage 1 Team forming
When a team or network is forming, you need to explore the boundaries of
acceptable group behavior as the people change from individuals to gain member
status. At this stage, the members of the team may feel excitement, anticipation
and optimism, as well as possibly suspicion, fear and anxiety about the advocacy
activities ahead. Members attempt to define the task at hand and decide how it will
be accomplished. They also try to determine acceptable group behavior and how
to deal with group problems. Because so much is going on to distract members’
attention, the group may only make a little progress. However, be aware that a slow
start is a perfectly normal phenomenon.
• Stage 2 Storming
At the storming stage, the team members begin to realize that they do not know
the task, or may consider it is more difficult than they imagined. They may become
irritable or blameful, but are still too inexperienced to know much about decision
making. Team members argue about what actions they should take, even when
they agree on the issues facing them. Their feelings include sharp fluctuations
in attitude about the chance of success. These pressures mean that membershave little energy to spend in meeting common goals, but they are beginning to
understand each other.
• Stage 3 Norming
During the norming stage, members reconcile competing loyalties and
responsibilities. They accept the team ground rules or norms, their roles, and the
individuality of each member. Emotional conflict is reduced. There is increased
friendliness as members begin to trust one another. As members begin to work out
their differences, they have more time and energy to spend on their objectives, and
to start making significant progress.
• Stage 4 Performing
At the performing stage, members begin diagnosing and solving problems, and
implementing changes. They have accepted each other’s strengths and weaknesses
and learnt their roles. They become satisfied with the team’s progress and feel a
close attachment to one another. The team or network is now an effective support,
and ready to help you in your health advocacy work.
h. The role of community advocator
The main role in advocacy will be to secure the resources necessary to meet
the health needs of the communities. To do this effectively requires, undertaking
several key tasks, such as understanding the health needs of the communities and
identifying the government officials and stakeholders with the power to determine
health policy. The advocator also needs to be able to identify fundamental barriers
and their solutions as well as identify the main problems or issues to be addressed.
There is also a need to develop effective messages. So find a support group, or
form a network and collaborate with them. To do this you need to develop your
advocacy leadership skills.
i. Advocacy strategies
Advocacy requires action, which requires that the social power of the organizations
be exercised through public events that are intended and formulated to demonstrate
that power. Multiple strategies through which that power can be exercised and
demonstrated include advocacy through media, through courts, through legislative
bodies, and through regulatory processes.
1) Advocating through the media
Media advocacy, one of the most common advocacy strategies used to advocate
on health-related issues, requires the identification of issues and concerns
related to the community wellbeing, an emphasis on the broader context of those
concerns, the maintenance of media attention to those concerns, and the provision
of ‘‘entertainment’’ to the audience hearing of those concerns.The issues that provide the focus of the media advocacy must be appropriately
framed using sound bites, which are brief, quotable statements; visual images; and
social math, which explains statistical data while placing it in a relevant context.
Various strategies can be used to prepare for contact with the media including:
• The development of a Fact Sheet, that briefly conveys the message to be
made;
• A Source List or roster of people who are available to speak competently on
the issue to be discussed;
• Talking Points, which is a listing of the main messages to be conveyed;
• A Question and Answer Sheet, which addresses in question and answer
format the most commonly raised issues associated with the matter to be
discussed; and
• A Press List comprised of all media outlets in a specific geographical area.
Press releases, meaning a written pitch for a particular issue, should be released to
all media contact. The press release consists of no more than one page and includes
the name and contact information of the media contact person on a particular issue.
Other strategies that can be used to engage the media include letters to the editors
of newspapers and journals, op-ed columns, interviews with reporters, the staging
of media events, paid advertising, and public service announcements.
2) Using the courts
The courts system provides yet another avenue for advocacy efforts. The process
of filing a lawsuit (claim) differs across countries. The system in use in the USA is
used as an example here because it may be relevant in an international, as well
as national, context, as exemplified by the following situation. In 1996, after an
outbreak of meningitis in Kano, Nigeria that resulted in 109 580 cases of illness
and 11 717 deaths, the international pharmaceutical company Pfizer provided
supplies, medical staff, and ‘‘treatment.’’ This ‘‘treatment,’’ however, consisted of
Trovan (trovafloxacin), an experimental drug for the treatment of meningitis. After
the departure of Pfizer’s personnel from Kano, local residents reported severe
health problems. Investigations conducted by news reporters raised questions
about the validity of company research documents, the apparent lack of oversight
and approval of research procedures, and the failure to give effective treatment
to ill people. In August 2001, the families of the children who were given Trovan
(trovafloxacin) in Kano brought a lawsuit in US courts, alleging that Pfizer had
violated international and national laws in carrying out its research with Trovan.
This advocacy effort represented the first lawsuit in US history of non-US residents
bringing a lawsuit against a private corporation for wrongful experimentation in
violation of US and international law. In this lawsuit against Pfizer, the families of
the children claiming injury or harm to the children by Pfizer (plaintiffs) started their lawsuit through the filing in court of a complaint, which states the nature of the claim
that one party is bringing against another, the facts to support the claim, and the
amount in controversy. The defendant Pfizer (the party being sued) was served
with a copy of the complaint, together with a summons. The summons indicated
that the defendant was required to respond to the complaint in a specified period
of time or the plaintiff will win the lawsuit by default. The defendant must, in some
way, respond to the complaint. Each allegation/accusation in the complaint may be
admitted or denied or the plaintiff may plead ignorance. Pfizer also had the option
of filing a countersuit, that is, a lawsuit against the plaintiff or another third party.
Alternatively, Pfizer could have sought dismissal of the plaintiff’s lawsuit, claiming
that the court has no jurisdiction (authority to hear the case) or that the plaintiff
failed to state a cause of action. In fact, Pfizer actually did attempt to have the court
dismiss the lawsuit. After the filing of the lawsuit and the answer by the defendant,
the plaintiff and defendant will have a period of discovery, during which they will
each have an opportunity to discover facts about the other side’s case, the identity
of expert witness being used by the other side, and weaknesses in the other side’s
case. The forms of discovery that are most commonly used in cases involving
advocacy efforts include depositions, the questioning under oath of individuals who
will be testifying for the other party, including that party; a request for the production
of documents, so that one side can review documents it deems relevant but that
are in possession of the other party; a request for a mental or physical examination,
such as when members of a community might be claiming that they have been
injured by a toxic exposure; and a request for admissions.
3) Legislative and regulatory advocacy
Regulatory and legislative advocacy are strategies that are often used by
organizations seeking to have their voices heard. Although the specific procedures
vary depending upon the legal jurisdiction, the strategies are common across
countries. As an example, in Australia, the Coalition on Food Advertising to Children
is seeking more severe protection of children from food advertising. In Ireland, the
Broadcasting Commission of Ireland is seeking consultation from interested entities
in the development of an advertising code that will provide additional protections for
children. In the USA, the National Association of Social Workers has been engaging
in regulatory and legislative advocacy in an attempt to establish parity for mental
health care and to promote child welfare.
4) Using coalitions
Regardless of which strategies are ultimately used, the development of a coalition
may be critical to the success of the advocacy effort. ‘‘Coalitions are sets of groups
with a shared goal and some awareness that ‘united we stand, divided we fall’’’.
Accordingly, coalitions may consist of groups of community members, groupsof organizations, or both. Groups participating in a coalition must have a shared
vision and mission, or intentionality that is clear to all of the participants and that
is directly related to their goals and objectives. Organizations participating in the
coalitions must have the structure or organizational capacity that will support such
efforts, that is, the staff, volunteers, task forces, membership, and leadership, as
well as a clear allocation of roles and responsibilities. Technical assistance, such
as consultation, training, and support for advocacy efforts, may be necessary to
enable organizations to build and participate in coalitions.
j. Evaluation of advocacy efforts
A formative evaluation, also known as formative research, is conducted at the
beginning of a program and focuses on research that must be done to develop
a program or intervention. The focus of a process evaluation is to examine the
procedures and tasks involved in implementing an effort or program. In contrast,
an outcome evaluation focuses on an examination of the value of the program or
effort and whether short term objectives have been achieved. An impact evaluation
focuses on an examination of whether long term change has resulted from the
program or effort; this is the most comprehensive type of evaluation effort. The
data that are used in an evaluation may be qualitative, resulting from ‘‘nonnumeric”
observations collected systematically through established social science methods,’’
or quantitative, meaning ‘‘numeric variables which are either discrete or continuous’’
k. Challenges in advocating for health
Community health advocates may encounter significant obstacles in attempting to
effectuate their goals. One of the major challenges of community health advocacy
is finding a way to engage the public in a specific issue. Mothers Against Drunk
Driving (MADD) in the USA has been notably successful in engaging the media,
the public, and legislators in its campaigns to eliminate plea bargaining for drunken
driving offences, institute mandatory jail sentences for drunk driving, reclassify
alcohol related injuries and death accidents to felonies (major crimes), institute
‘‘dram shop’’ laws holding proprietors of restaurants and bars liable for accidents
resulting from serving alcohol to excess, and increase the minimum legal drinking
age. To MADD’s successes are attributable to a number of factors.
In addition to difficulties that may be encountered in garnering understanding and
support for a particular position, community health advocates may face additional
barriers and attacks on a systemic level. The difficulties encountered by Brazil
exemplify the types of obstacles that may confront advocates in the political and
legal domains. As an example, Brazil was forced to defend against a complaint
filed against it by the USA, which claimed that Brazil’s efforts to make antiretroviral
drugs more widely available to HIV infected people in that country through its
patent laws discriminated against US imports of antiretroviral drugs. The World
Trade Organization ultimately commissioned a legal dispute panel in an attempt toresolve the grievance
Self-assessment 5.4.2
1) Describe briefly the approaches to advocacy
2) Discuss the advocacy strategies.3) Identify the advocacy principles
5.4.3. Home based car
Learning activity 5.4.3
Using internet and Community Health Nursing Textbooks; read about Home
Based Care and respond to the following questions:
1) What is the meaning of home-based care?
2) Who needs home based care?
3) Who may be in-charge for providing home-based care?
4) Discuss the principles and objectives of home-based care?5) Discuss the types of home-based care?
Home care is defined as the provision of health services by formal and informal
caregivers in the home in order to promote, restore and maintain a person’s
maximum level of comfort, function and health including care towards a dignified
death.
Home care services can be classified into preventive, promotive, therapeutic,
rehabilitative, long-term maintenance and palliative care categories.
It is an integral part of community-based care. Community-based care is the care
that the consumer can access nearest to home, which encourages participation by
people, responds to the needs of people, encourages traditional community life and
creates responsibilities.
HBC is also defined as any professional care given to sick people in their homes,
which includes physical, psychosocial, palliative, and spiritual activities.
a. Who needs home based care?
Home based cares are services that may be provided to:
Health people, someone who is aging and needs assistance to live independently;
or managing a chronic health issue; recovering from a medical condition in need
of assistance e.g. post deliveries or after specific treatment.; at risk people with
moderate to severe functional disabilities. It includes also terminally ill persons;
persons living with HIV/AIDS or any other debilitating disease and/or conditions
e.g. mental illness, substance abusers; any other disadvantaged group/person in
need of such care e.g. people in crisis.
b. Who are the caregivers?
Families; caregivers from the formal system e.g. professionals like nurses,
physicians, therapists; caregivers from the non-formal system e.g. NGOs; caregivers
from the informal system e.g. community health worker (CHW), volunteers, other
community caregivers and church groups provide short-term or long-term care in
the home, depending on a person’s needs.
c. Principles of home-based care and community-based care
Home-based care and community-based care are:
• Holistic: they involve together physical, social, emotional, economic and
spiritual aspects. Community needs, to be addressed, but integrated into
existing systems.
• Person- centered: the provision of care should be sensitive to culture,
religion and value systems to respect privacy and dignity (community-driven,
customer-centered).
• Comprehensive, interdepartmental and all-encompassing; preventative,
promotive, therapeutic, rehabilitative and palliative (multi-sectoral
involvement).
• Empowering and allows capacity building to promote the autonomy and
functional independence of the individual and the family or caregivers.
Leadership is from within the community.
• Ensure access to comprehensive support services.
• Cover total lifespan.
• Sustainable and cost-effective resource responsibilities to be identified and
shared.
• Promote and ensure quality of care, safety, commitment, cooperation and
collaboration.
• Allow choice and control over to what extent partners will participate.
• Recognize diversity.
• Promote and protect equal opportunities, rights and independent living.
• Specific in what needs to be done and achieved.
• Focus on a basic and essential component of PHC.
• Adhere to a basic principle in health care and development, namely community
involvement.
d. Purposes
Community-Based Care (CBC) provides complete quality health services at home
and in communities to help restore and maintain people’s health standards and a
way of living by providing health services, supported self-care and health education
at home.
e. Goals and objectives of home-based care
• To move the emphasis of care to the beneficiaries (care are given in the
comfort and familiarity of home, in the community)
• To ensure access to care and follow-up through a functional referral system.
• To integrate a comprehensive care plan into the informal, non-formal and
formal health system.
• To empower the family and/or community to take care of their own health.
• To empower the client, the caregivers and the community through appropriate
targeted education and training.
• To reduce unnecessary visits and admissions to health facilities.
• To eliminate duplication of activities and enhance cost-effective planning and
delivering of services.
• Be pro-active in approach
f. Advantages of the home-based care and community-based care
• Reduce the pressure on hospital beds and other resources at different levels
of service.
• Reduce and share the cost of care within the system.
• Feelings of ownership and accountability are evoked.
• Allow people to spend their days in familiar surroundings and reduce isolation.
• Enable family members to gain access to support services.
• Promote a holistic approach to care and ensure that health needs are met.
• Create awareness of health in the community
• Bring care providers in touch with potential beneficiaries.
• Intervention is pro-active rather than reactive.
• Right to decide about care within own environment.
• Commonly occurring diseases/conditions can be effectively managed at
home.
• Promotes job creation especially in non-formal system.
• Decision making is inclusive
• Beneficial to family and friends as it allows more direct time with clients and
involvement in care giving
• Care will be individualistic and person centered.
• Avoid unnecessary referrals to and from higher levels.
• Avoid unnecessary and/or prolonged admission to health care facilities or
institutions.
• Ensure that partners in caregiving know and play their roles to avoid
duplication.
• Ensure that caregivers and all key role players are well informed
(knowledgeable), received adequate skills training and utilize other partners
in care.
• Caregivers are fully involved and informed about the individual care plans.
• Ensure adequate documentation and encourage proper use of recorded
information.
• Ensure continuity and consistency in service, quality assurance and
management.
g. Challenges of home-based care
While providing home-based care some caregivers or clients may have some of the
following challenging problems which may be a barrier to an appropriate provision
of care.
• Social environment is restricted because of a set believes and customs,
ideologies and local conflicts, inappropriate housing.
• Caregivers may experience emotional and physical strain and stress.
• Caregivers and clients may lack sufficient empowerment regarding care or
resources and diagnosis.
• Uncertainty about the duration of the situation.
• Inadequate support structures for the caregiver.
• Social isolation, related to confinement of the person to bed and the home.
• Emotions such as rejection, anger and grieving.
• Economic constraints and exhaustive care needs.
• Focus too often on health service activities only – no common vision.
• Fear or mistrust of the primary caregivers.
• Barriers to access-built environment, communication and information.
• Poor resource allocation, e.g., respite centers/care, equipment.
• Lack of and confusion around volunteerism.
• Negative past experiences.• Programs are not community driven and fragmented.
• Emphasis on “sick” role and “disabilities” rather than on “quality of life” and
“abilities”.
• Self-neglect - often refusal of intervention/care.
• Level of readiness of communities to accept their roles and functions.
• The concept of partnerships is misunderstood e.g., government is the one
and only provider.
• Confidentiality of diagnosis - unwillingness to disclose.
• HIV/AIDS epidemic may decrease caregiver pool
h. Types of Home-Based Care
a) Personal care and companionship
Those are the care related to help with everyday activities like bathing and dressing,
meal preparation, and household tasks to enable independence and safety. Those
cares are also known as non-medical care, home health aide services, senior
care, homemaker care, assistive care, or companion care.
It may include but not limited to the following:
• Assistance with self-care, such as grooming, bathing, dressing, and using the
toilet,
• Enabling safety at home by assisting with ambulation, transfer (e.g., from bed
to wheelchair, wheelchair to toilet), and fall prevention,
• Assistance with meal planning and preparation, light housekeeping, laundry,
medication reminders, and escorting to appointments,
• Companionship and engaging in hobbies and activities,
• Supervision for someone with dementia or Alzheimer’s disease
• Personal care and companionship does not need to be prescribed by a doctor.
They are the cares provided on an ongoing basis on a schedule that meets
a client’s needs.
b) Private Duty Nursing Care
This type of care includes long-term, hourly nursing care at home for adults
with a chronic illness, injury, or disability. They are also known as home-based
skilled nursing, long-term nursing care, catastrophic care, tracheostomy care,
ventilator care, nursing care, shift nursing, hourly nursing, or adult nursing
Examples of Private Duty Nursing Care services:
• Care for diseases and conditions such as Traumatic brain injury and /or Spinal
cord injury
• Ventilator care
• Tracheostomy care
• Monitoring vital signs
• Administering medications
• Ostomy/gastrostomy care
• Feeding tube care
• Catheter care
Private duty nursing care needs to be prescribed by a professional health care
specialized in the concerned domain. Those are the cares which should be provided
and monitored every day 24 hours over 24 hours.
c) Home Health Care services
They are short-term, physician-directed care designed to help a patient to prevent or
to recover from an illness, injury, or hospital stay. They are also known as Medicare
certified home health care, intermittent skilled care, or visiting nurse services. They
may include:
• Short-term nursing services
• Physical therapy
• Occupational therapy
• Speech language pathology
• Medical social work
• Home health aide services
Home health care needs to be prescribed by a professional health care specialized
in the concerned domain. The care is provided through visits from specialized
clinicians or other health care provider specialized in the related domain, on a
short-term basis until individual goals are met
Self-assessment 5.4.3
1) Identify people who need home based care?
2) Describe the types of home-based care.3) What are the principles of home-based care and community-based care
End unit assessment 5
1) Geopolitical communities are defined or formed by:
a. Natural and/or manmade boundaries
b. A group perspective or identity based on culture
c. A group specifically to address a common need
d. Are subgroups or subpopulations that have some common characteristics
2) Primary prevention:
a. Relates to activities directed at preventing a problem before it occurs
b. Is implemented after a problem has begun, but before signs and symptoms
appear
c. Focuses on limitation of disability and rehabilitation
d. Refers to early detection and prompt intervention during the period of early
disease pathogenesis
3) The objectives of community health nursing include the following, except:
a. To assess the need and priorities of vulnerable group like pregnant mother,
children and old age persons;
b. To provide health care services at every level of community including
health education, immunization,
c. To prevent and control communicable and non-communicable diseases
d. To deliver health services as determined by the private stakeholders
4) The principles of community health nursing include the following, EXCEPT:
a. The health workers should be elected by the multidisciplinary health care
team.
b. Health services should be based on the needs of individuals and the
community.
c. Health services should be suitable to the budget; workers and the resources.
d. Family should be recognized as a unit and the health services should be
provided to its members.
5) The types of Community Needs Assessment are identified here below,
EXCEPT:
a. Familiarization or Windshield Survey
b. Problem-Oriented Assessment
c. Community Subsystem Assessment
d. Geographic Information System Analysis6) The following examples describe someone who is physically unhealthy,
EXCEPT:
a. A person who has been harmed due to a car accident.
b. A farmer infected by malaria and unable to do their farming duties.
c. A person who has an inability of rational and logical decision-making.
d. A person infected by tuberculosis and unable to perform his or her tasks.
7) ____________ is one of the characteristics of the person who is
psychologically healthy
a. Having a memory and being able to reason rationally and solve problems,
b. Going to a football match or involvement in a community meeting,
c. Celebrating traditional festivals within your community,
d. Having an ability to perform routine tasks without any physical restriction,
8) Which of the following activities should be considered as secondary
prevention?
a. Preventing an established disease such as hypertension from becoming
worse
b. Breast self-examination for early diagnosis and prompt treatment of cancer
c. Distributing insecticide treated bed nets to prevent people from getting
infected with malaria
d. Immunizing less than five years children against an infectious disease like
Tuberculosis
9) ___________________is an interactive process in which learners share
their ideas, thoughts, questions, and answers in a group setting with a
facilitator.
a. Demonstration
b. Role play
c. Discussion
d. Lecture
10) Which one of the following teaching methods is more appropriate for
teaching the diabetic patient a skill like “injecting insulin?”
a. Brainstorming
b. Discussion
c. Interactive presentationd. Demonstration
11) As a facilitator who is introducing a teaching session using an interactive
presentation (illustrated lecture) as teaching method, the first step to
consider is the following:
a. Relate the content to previously covered and related topics.
b. State the objective(s) of the presentation.
c. Provide an opportunity for asking questions.
d. Use visual materials to illustrate and support the main points.
12) Deliberate on the confirmations given below. What is real about the writing
board as a teaching / learning material?
a. When using the writing board, the text and drawings should be little enough.
b. The facilitator (health educator) should talk while facing the writing board.
c. The board can be used to document ideas during discussions or
brainstorming exercises.
d. The writing boards are expensive and require more electricity for displaying
information.
13) The following affirmations are true about flipchart, EXCEPT:
a. The flipchart may be used to note objectives or outcomes before or after
clinical practice sessions.
b. The pages of information can be prepared in advance and revealed at
appropriate points in the presentation.
c. When you use the flip chart in health education you must discuss each
page completely before you turn to the next.
d. The teacher should use the same colored pens to provide contrast for
making the flipchart page attractive.
14) Among the options presented below, what the health educator / teacher
should do when preparing computer generated slides?
I. Limit the information on each slide to one idea that can be grasped in 5-10
seconds.
II. Use about six to eight bullets per slide and limit a bulleted item to three to
five words.
III. Use no more than seven lines of text per each slide.
IV. Use several typefaces (fonts) per slide to emphasize points.
a. I and III
b. I and IV only
c. II and IVd. II and III only
15) The following are the instructions for health educator/teacher, who is using
a slide projector, excluding:
a. Making sure that there is nothing between the projector and the screen so
that all learners can see.
b. Setting up and testing the slide projector and computer before the learners
are present.
c. Rushing through a series of slides for allowing learners enough time to
study during presentation.
d. Allowing plenty of time for the learners to read what is on the screen and
take notes, if necessary.
16) The assertions mentioned below are TRUE about videos as health
education material, with the exception of one of them. Which one?
a. Commercially developed videos are often outdated and may show
techniques that are inconsistent with currently approved practices.
b. Preferably, using one long video should be encouraged rather than several
short video segments with pauses in between for explanation or discussion.
c. The teacher should preview the videotape to ensure that it is appropriate
for the learners and consistent with the course objectives.
d. The teacher should make sure that the information presented in the video
is up-date with current practices and standards.
17) Decide which one of the following declarations is TRUE about the role
play?
a. The clinical demonstration role play is similar to the informal role play, and
often occurs as part of a coaching session.
b. In informal role play, the teachers give the role players a set of instructions
that outline the scope and sequence of the role play.
c. Clinical demonstration role play is often part of a clinical simulation. It
typically uses an anatomic model, simulated patient, or real patient,
d. In formal role play, the teacher gives the role players a general situation
and asks them to “act it out” with little or no preparation time.
18) The following are classified as traditional means of communication,
EXCEPT:
a. Lecture and discussion,
b. Poems and stories,
c. Songs and dances,d. Games and fables.
19) Tips for a better use of a flipchart are the following EXCEPT:
a. Leave plenty of white space, and avoid putting too much information on
one page.
b. Print in block letters using wide-tipped pens or markers.
c. Use different colored pens to provide contrast, and use headings, boxes,
cartoons, and borders to improve the appearance of the page.
d. Face the learners, not the flipchart, while talking.
e. When you finish with a flipchart page give it to the group for better
understanding.
20) Explain any 4 characteristics of community health nursing
21) Discuss the responsibilities of an ASM (Agent de Santé Maternelle).
22) Discuss the challenges faced by Rwanda community health program
23) Explain any 5 important characteristics of a community
24) Characterize the different types of a community
25) Describe the factors affecting community health
26) Discuss any four Characteristics of a Healthy Community
27) Outline the required steps in conducting community health needs
assessment?
28) Describe the methods used for conducting an advocacy for a community.
29) You are appointed to do advocacy for the people living near Kabeza
industrial zone because of toxic waste coming from the industries.
Describe any two advocacy approaches to be used.
30) Outline the principles of home-based care
31) Explain the types of Home Based Care
32) Identify any 4 factors that contributed to the decline in infectious disease–
related deaths during the nineteenth and early twentieth centuries.UNIT6: PRIMARY HEALTH CARE (PHC)
Key Unit Competence:
Apply the principles and components of health promotion to prevent diseases andpromote health of communities.
Introductory activity 6
1) What do you think as actions to be done in order to optimize the health of
people in each of the sections of the image above?
2) Read this page: https://www.who.int/news-room/fact-sheets/detail/primary-health-care and think about why Primary Health care is necessary.
6.1. Primary Health Care Overview
6.1.1. Concept of primary health care
Self-assessment 6.1.1
Using library books or Internet, read on Primary Health Care and try to explain
the following concepts:
1) Primary health care2) Objectives of the primary health care
Primary Health Care “is essential health care made universally accessible to
individuals and families in the community by means acceptable to them, through
their full participation and at a cost that the community and country can afford. It
forms an integral part both of the country’s health system of which it is the nucleus
and of the overall social and economic development of the community”.
Primary health care is essential (promotive, preventive, curative, rehabilitative, and
supportive) care that focuses on preventing illness and promoting health. It is both
a philosophy of health care and an approach to providing health care services.
Primary health care is what happens when someone who is ill (or who thinks
he or she is ill or who wants to avoid getting ill) consults a health professional
in a community setting for advice, tests, treatment or referral to specialist care.
Such care should be holistic, balanced, personalized, rigorous and equitable, and
delivered by reflexive practitioners who recognize their own limitations and draw
appropriately on the strengths of others.
Types of primary health care
• Selective PHC -Health promotion initiatives aimed at certain groups or
specific issues
• Comprehensive PHC -Health promotion initiatives aimed at the health and
wellness for the whole community
• Primary care -Initial decisions on managing a health issue e.g. general
practice decisions about managing chronic conditions
a. Primary care and primary nursing
Primary health care should not be confused with primary care or primary nursing.
Primary care is provider driven and is the entry point to the health care system.
Primary nursing is a system of delivering nursing services whereby a nurse is
responsible for planning the 24-hour care of a specific patient. Both these conceptsare illness-oriented concepts
b. Objectives of the primary health care
The objectives of the primary health care are: to increase the programs and services
that affect the healthy growth and development of children and youth; to boost
participation of the community with government and community sectors to improve
the health of their community; To develop community satisfaction with the primary
health care system; to support and advocate for healthy public policy within all
sectors and levels of government; to support and encourage the implementation
of provincial public health policies and direction; to provide reasonable and timely
access to primary health care services; to apply the standards of accountability in
professional practice; to establish, within available resources, primary health care
teams and networks ; and to support the provision of comprehensive, integrated,
and evidence-based primary health care services.
c. Role of the Nurse in primary health care
The goal of nursing is to improve the health of clients through partnerships with
clients, other health care providers, related community agencies, and government.
Nursing practice involves a variety of roles, including direct care provider, educator,
administrator, consultant, policy adviser, and researcher.
• Care giver: The caregiver role has traditionally included those activities that
assist the client physically and psychologically while preserving the client’s
dignity. The required nursing actions may involve full care for the completely
dependent client, partial care for the partially dependent client, and
supportive–educative care to assist clients in attaining their highest possible
level of health and wellness.
• Communicator: Communication is integral to all nursing roles. Nurses
communicate with clients and their support people, other health care
professionals, and people in the community. The quality of a nurse’s
communication is an important factor in nursing care. The nurse must be able
to communicate clearly and accurately so that a client’s health care needs
are met.
• Educator: As a health teacher, the nurse helps clients learn about health and
the health care procedures they need to perform to restore or maintain health
• Client Advocate: A client advocate acts to protect the client. In this role,
the nurse may represent the client’s needs and wishes to other health care
professionals, such as relaying the client’s request for information to a
member of the health care team.
• Counsellor: Counselling is the process of helping a client recognize and
cope with stressful psychological or social problems, develop improved
interpersonal relationships, and promote personal growth. It involves providingemotional, intellectual, and psychological support.
In contrast to the psychotherapist, who counsels individuals with identified
problems, the nurse counsels primarily healthy individuals who are
experiencing normal adjustment difficulties.
• Change Agent: The nurse acts as a change agent when assisting clients to
make modifications in their own behavior.
• Leader: The leadership role can be employed at different levels: individual
client, family, groups of clients or colleagues, or the community.
• Manager: Every nurse manages the nursing care of individuals, families, or
communities. The nurse manager, a formal leadership role, also delegates
nursing activities to ancillary workers and other nurses, and supervises andevaluates their performance.
Self-assessment 6.1.1
1) Explain the difference between primary nursing and primary care
2) Explain importance of primary health care
3) Explain different role of the nurse in the primary health care
4) Which of the following statements best illustrates the difference between
primary health care and primary care?
a. Primary health care is a theoretical approach to health care, whereas
primary care is a system of delivering services.
b. Primary health care is illness focused, whereas primary care is health
promotion focused.
c. Primary health care is a set of government standards for world health care,
whereas primary care provides a set of principles for delivering care.
d. Primary health care is a philosophical approach to providing health care,whereas primary care provides an entry point to the health care system
6.1.2. History and Evolution of PHC.
Learning activity 6.1.2
Using the library books on “Primary Health Care” or internet, read on the
evolution of primary health care. Focus on Alma-Ata Declarations and respond
to the following questions;
1) Identify different issues that have pushed the World to establish primary
health care?
2) Reading the information available on following link: https://www.euro.
who.int/en/health-topics/Health-systems/primary-health-care/primary
health-care/questions-and-answers-understanding-primary-health-care.
What can be done to make quality PHC accessible and affordable foreveryone, everywhere?
Deep concern for the health of the world’s population, specifically short life
expectancies and high mortality rates among children, led to the formation of
the global health strategy of primary health care. All members of the WHO were
encouraged to take actions toward the attainment of “health for all by the year
2000” through ensuring adequate food supply, safe water, adequate sanitation,
maternal and child health care, immunization, prevention and control of endemic
diseases, provision of essential drugs, health education, and treatment of common
diseases and injuries.
a. Alma-Ata declarations
From September 6 to September 12, 1978, delegates from 134 countries and
representatives from 67 nongovernmental organizations, agencies, and United
Nations (UN) organizations gathered in the city of Alma-Ata at the invitation of the
USSR under the aegis of the World Health Organization (WHO) and United Nations
International Children’s Emergency Fund (UNICEF). The purpose of the conference
was to exchange experience about something called primary health care.
The Declaration of Alma-Ata (WHO & UNICEF, 1978) emphasized health, or well
being, as a fundamental right and a worldwide social goal. It was an attempt
to address inequality in the health status of persons in all countries and to target
governments that needed to be responsible for policies that would promote economic,
social, and health development, which were considered basic to the achievement
of “health for all.” The following are declarations that have been agreed:
Declaration one: The Conference strongly reaffirms that health, which is a “stateof complete physical, mental, and social well-being, and not merely the absence
of disease or infirmity”, is a fundamental human right and that the attainment
of the highest possible level of health is a most important worldwide social goal
whose realization requires the action of many other social and economic sectors inaddition to the health sector
Declaration two: The existing inequality in the health status of people particularly
between developed and developing countries as well as within countries is politically,
socially, and economically unacceptable and is, therefore, of common concern to
all countries.
Declaration three: Economic and social development, based on a New International
Economic Order, is of basic importance to the fullest attainment of health for all
and to the reduction of the gap between the health status of the developing and
developed countries. The promotion and protection of the health of the people is
essential to sustained economic and social development and contributes to a better
quality of life and to world peace
Declaration four: The people have the right and duty to participate individually and
collectively in the planning and implementation of their health care.
Declaration five: Governments have a responsibility for the health of their people
which can be fulfilled only by the provision of adequate health and social measures.
A main social target of governments, international organizations, and the whole
world community in the coming decades should be the attainment by all peoples of
the world by the year 2000 of a level of health that will permit them to lead a socially
and economically productive life. Primary health care is the key to attaining this
target as part of development in the spirit of social justice.
Declaration Six: Primary health care is essential health care based on practical,
scientifically sound, and socially acceptable methods and technology made
universally accessible to individuals and families in the community through their full
participation and at a cost that the community and country can afford to maintain at
every stage of their development in the spirit of self-reliance and self-determination.
It forms an integral part both of the country’s health system, of which it is the central
function and main focus, and of the overall social and economic development of the
community. It is the first level of contact of individuals, the family and community
with the national health system bringing health care as close as possible to where
the people live and work, and constitutes the first element of a continuing health
care process.
Declaration Seven: Primary health care:
1) reflects and evolves from the economic conditions and sociocultural and
political characteristics of the country and its communities and is based
on the applications of the relevant results of social, biomedical, and healthservices research and public health experience;
2) addresses the main health problems in the community, providing promotive,
preventive, curative, and rehabilitative services accordingly;
3) includes at least education concerning prevailing health problems and the
methods of preventing and controlling them; promotion of food supply and
proper nutrition; an adequate supply of safe water and basic sanitation;
maternal and child health care, including family planning and immunization
against the major infectious diseases; prevention and control of locally
endemic diseases; appropriate treatment of common diseases and injuries;
and provision of essential drugs
4) involves, in addition to the health sector, all related sectors and aspects
of national and community development, in particular agriculture, animal
husbandry, food, industry, education, housing, public works, communications,
and other sectors, and demands the coordinated efforts of all those sectors;
5) requires and promotes maximum community and individual self-reliance and
participation in the planning, organization, operation and control of primary
health care, making the fullest use of local, national, and other available
resources; and to this end develops through appropriate education the
ability of communities to participate;
6) should be sustained and integrated, functional and mutually supportive
referral systems, leading to the progressive improvement of comprehensive
healthcare for all, and giving priority to those most in need;
7) relies, at local and referral levels, on health workers, including physicians,
nurses, midwives, auxiliaries, and community workers as applicable, as
well as traditional practitioners as needed, suitably trained socially and
technically to work as a health team and to respond to the expressed health
needs of the community.
Declaration Eight: All governments should formulate national policies, strategies,
and plans of action to launch and sustain primary health care as part of a
comprehensive national health system and in coordination with other sectors.
To this end, it will be necessary to exercise political will, to mobilize the country’s
resources and to use available external resources rationally.
Declaration Nine: All countries should cooperate in a spirit of partnership and
service to ensure primary health care for all people since the attainment of health
by people in any one country directly concerns and benefits every other country. In
this context, the joint WHO/UNICEF report on primary health care constitutes a solid
basis for the further development and operation of primary health care throughout
the world.
Declaration Ten: An acceptable level of health for all people of the world by theyear 2000 can be attained through a fuller and better use of the world’s resources,
a considerable part of which is now spent on armaments and military conflicts.
A genuine policy of independence, peace, detente, and disarmament could and
should release additional resources that could be devoted to peaceful aims and in
particular to the acceleration of social and economic development of which primaryhealth care, as an essential part, should be allotted its proper share
Self-assessment 6.1.2
1) Summarize the declarations from the Alma-Ata
6.1.3. Characteristics of Primary Health Care
Learning activity 6.1.3
Using library books or internet, read on characteristics of primary health care
and respond to the following question.
1) What do you think are the pillars of the primary health care?
2) What do you think as the primary health care being client (patient/Family)centered?
Good primary health care aims at safeguarding, promoting and restoring health.
However, health is not an aim in its self, but a condition for human development
and well-being. Health services should thus be developed in harmony with other
aspects of society; education, social and economic infrastructure etc. and use only
a reasonable share of the total financial and human resources available.
Indeed, “the possibility that the direct positive effects of health care on health may
be outweighed by its negative effects through its competition for resources with
other health-enhancing activities. A society which spends so much on health that
it cannot or will not spend adequately on other health-enhancing activities may
actually be reducing the health of its population through increased health spending”.
To produce a maximum of health with these limited resources, health services must
be rationalized to function in an effective and efficient way.
Characteristics of PHC include:
• Patient/family centeredness, self-reliance and participation: the
involvement of the patient/Family makes the PHC interventions more effective
and sustainable.
• Community engagement and participation: Community are engaged to
take initiations in identifying their own health and social problems therefore,
integration of promotive, preventive and curative health services are given ina unified way by the participation of the local population
• Health workers collaborating in inter-disciplinary teams: the primary
health care approach does not only involve one profession. Multidisciplinary
teams and multisectoral involvement is the key to achieve PHC objectives.
• Proactive Prevention Focus: the primary health care services includes
promotion, prevention and restoring health, however, early intervention before
the population health is endangered is the main focus.
• Accessibility: the services delivered within the primary health care should
be easily available and meeting the primary health needs of the population
• Better Management of Chronic Conditions
• Localized set of choices,
• Sustainability
• Multi-sector alignment and involvement: the PHC ideal require good
planning and allocation of resources. Multisectoral involvement makes the
PHC services more available, accessible and affordable but putting neededresources
a. Pillars of primary health care
Primary health care consists of an integrative group of health care professionals
coordinating to provide basic health care services to a particular group of people
or population. The Primary Health care outline is built on four key pillars which are
reinforcement for the delivery of safe health care.
The four major pillars of primary health care are as follows: Community Participation,
Inter-sectoral Coordination, Appropriate Technology and Support Mechanism Made
Available.
• Community Participation: Community participation is a process in which
community people are engaged and participated in making decisions about
their own health. It is a social approach to point out the health care needs
of the community people. Community participation involves participation of
the community people from identifying the health needs of the community,
planning, organizing, decision making and implementation of health programs.
It also ensures effective and strategic planning and evaluation of health care
services. In lack of community participation, the health programs cannot
run smoothly and universal achievement by primary health care cannot be
achieved.
• Inter-sectoral Coordination: Inter-sectoral coordination plays a vital role in
performing different functions in attaining health services. The involvement of
specialized agency, private sectors, and public sectors is important to achieve
improved health facilities. Intersectoral coordination will ensure different
sectors to collaborate and function interdependently to meet the health careneeds of the people.
• It also refers to delivering health care services in an integrated way. Therefore,
the departments like agriculture, animal husbandry, food, industry, education,
housing, public works, communication, and other sectors need to be involved
in achieving health for all.
• Appropriate Technology: Appropriate healthcare technologies are an
important strategy for improving the availability and accessibility of healthcare
services. It has been defined as ‘’technology that is scientifically sound,
adaptable to local needs and acceptable to those who apply it and to whom it
is applied and that can be maintained by people themselves in keeping with
the principle of self-reliance with the resources the community and country
can afford.’’
Appropriate technology refers to using cheaper, scientifically valid and
acceptable equipment and techniques. It is also necessary to ensure that
the technology is: Scientifically reliable and valid, Adapted to local needs,
Acceptable to the community people and Accessible and affordable by the
local resources.
• Support Mechanism Made Available: Support Mechanism is vital to health
and quality of life. Support mechanism in primary health care is a well-known
process focused to develop the quality of life. Support mechanism includes that
the people are getting personal, physical, mental, spiritual and instrumental
support to meet goals of primary health care. Primary health care depends on
adequate number and distribution of trained physicians, nurses, community
health workers, allied health professions and others working as a health teamand supported at the local and referral levels.
Self-assessment 6.1.3
Read the following scenario and attempts questions asked:
Scenario 1: A dentist finds a suspicious white lesion while doing a routine check
up of a 72-year-old woman smoker and offers to refer her urgently to an oral
surgeon.
Scenario 2: A multi-disciplinary community team including doctors, nurses,
social workers and health advocates provides a ‘health bus’ offering a range of
services to refugees and asylum seekers on an inner city estate
1) What primary health care does the scenarios above represent and why?
2) Among the following, one is not the component of the primary health care
a. Community participation
b. Support mechanism made available
c. Appropriate technologyd. Sustainability
6.1.4. Structure and Functioning of Health Care system
Learning activity 6.1.4
Using library books or other available resources on the health sector, Read on
Health system organization and answer the following questions;What do you think are the components of the health system and why?
a. Overview of the health system
Health system consists of all the activities whose primary purpose is to promote,
restore and maintain health. It is also defined as the people, institutions and
resources, arranged together by established policies, to improve the health of the
population they serve, while responding to people’s legitimate expectations and
protecting them against the cost of ill-health through a variety of activities whose
primary intent is to improve health. (WHO, 2017).
b. Principles of health system
The following are the principles of a health system:
• People-centered: when it is people centered, equity and fairness are ensured.
• Results-oriented: Quality management system for continual quality
improvement.• Evidence-based: Technocrats, academicians, politicians, community or local
context and change are key divers of the health system.
• Community-driven: Leadership, governance accountability, transparency
and sustainability.
• Context-specific: context is synonymous with resource-constrained
environment.
• Ethically sound: Human rights and dignity, safety for the client, community
and environment
• Systems thinking: Holistic view of the health system
c. Components of health system
For the health system to work, it has components, these are: Service delivery, Health
workforce, Information, Medical products, vaccines and technologies, Financing
and Leadership and governance
Leadership and governance: Each country’s specific context and history shapes
the way leadership and governance is exercised, but common ingredients of good
practice in leadership and governance can be identified. These include:
• Ensuring that health authorities take responsibility for steering the entire
health sector and for dealing with future challenges (including unanticipated
events or disasters) as well as with current problems
• Defining, through transparent and inclusive processes, national health
policies, strategy and plan that set a clear direction for the health sector
Health information systems: good governance is only possible with good
information on health challenges, on the broader environment in which the health
system operates, and on the performance of the health system. This specifically
includes timely intelligence on:
• Progress in meeting health challenges and social objectives (particularly
equity),including but not limited to household surveys, civil registration
systems and epidemiological surveillance
• Health financing, including through national health accounts and an analysis
of financial catastrophes and of financial and other barriers to health services
for the poor and vulnerable
• Trends and needs for HRH; on consumption of and access to pharmaceuticals;
on appropriateness and cost of technology; on distribution and adequacy of
infrastructure
• Access to care and on the quality of services provided.
Health financing: Health financing can be a key policy instrument to improve
health and reduce health inequalities if its primary objective is to facilitate universal
coverage by removing financial barriers to access and preventing financial hardshipand catastrophic expenditure. The following can facilitate these outcomes:
• A system to raise sufficient funds for health fairly
• A system to pool financial resources across population groups to share
financial risks
• A financing governance system supported by relevant legislation, financial
audit and public expenditure reviews, and clear operational rules to ensure
efficient use of funds.
Human resources for health: The health workforce is central to achieving health.
A well performing workforce is one that is responsive to the needs and expectations
of people, is fair and efficient to achieve the best outcomes possible given available
resources and circumstances. Countries are at different stages of development
of their health workforce but common concerns include improving recruitment,
education, training and distribution; enhancing productivity and performance; and
improving retention.
Essential medical products and technologies: Universal access to health
care is heavily dependent on access to affordable essential medicines, vaccines,
diagnostics and health technologies of assured quality, which are used in a
scientifically sound and cost-effective way. Economically, medical products are the
second largest component of most health budgets (after salaries) and the largest
component of private health expenditure in low- and middle-income countries
Service delivery: Health systems are only as effective as the services they provide.
These critically depend on:
• Networks of close-to-client primary care, organized as health districts or
local area networks with the back-up of specialized and hospital services,
responsible for defined populations
• Provision of a package of benefits with a comprehensive and integrated
range of clinical and public health interventions, that respond to the full
range of health problems of their populations, including those targeted by the
Millennium Development Goals
• Standards, norms and guidance to ensure access and essential dimensions of
quality: safety, effectiveness, integration, continuity, and people -centeredness
• Mechanisms to hold providers accountable for access and quality and to
ensure consumer voice
d. Institutional overview of the health sector in Rwanda
The healthcare sector is a complex system made up of people, facilities, laws and
regulations. It addresses current health, tries to ensure wellness, treats medical
problems; creates new medication and medical devices; manages the health bothindividuals and populations; and helps determine regulations for safety, privacy, the
environment, and healthcare delivery itself.
The Rwandan health sector is a pyramidal structure and consists of three levels: the
central level, the intermediary level, and the peripheral level. (More details lesson
6.1.7Levels of Healthcare Essential components of PHC.)
The Central Level: The central level comprises: Ministry of Health, Rwanda
Biomedical Center and national referral and teaching hospitals.
The Intermediary Level: the intermediate level comprises of regional (within
country) referral hospitals, provincial referral hospitals and other private practices.
The peripheral level: the peripheral level comprises of administrative offices at
health district, the District hospitals, Health centers and health posts
e. Stakeholders of the health sector
There are many types of stakeholders in the healthcare sector. The space covers
everyone from the general public – who have a stake in their own health and the
health of those around them for issues like infectious disease – to the individual
researchers who investigate current healthcare problems. The high-level groups of
stakeholders include:
• The general public;
• Healthcare providers (such as doctors, nurses, clinics, and hospitals);
• Payers (such as insurance companies);
• Public health organizations;
• Researchers, scientists, and corporations in the pharmaceutical industry;
• Medical device manufacturers;
• Policy makers (particularly those with interest in public health, healthcare
safety or privacy policies);
• Healthcare information technology technicians and organizations; and
• Professional organizations and societies relevant to the various aspects of
the spaceSelf-assessment 6.1.4
1) Explain the principals of the health system
6.1.5. Elements of PHC.
Learning activity 6.1.5
1) What are the elements of the primary health care?
The Alma Ata declaration put forward 8 essential components of primary healthcare.
They are:
1) Education about prevailing health problems and methods of preventing
and control them
Ill health inhibit access to opportunities in education, work, income earning, political
and cultural participation and other value dimensions of human life. Health education
is important element to communicate with the facts that help to promote the ways of
healthy livings and solve basic health problems.
2) Prevention and control of Locally endemic diseases
The other aspect of the primary health care is to establish measures to prevent and
control the diseases that may attack and spread rapidly throughout the community.
3) Provision of Essential drugs
PHC also emphasize on the availability of essential medicine such as drugs against
diarrhea, fever, pain, malaria, etc. free of cost.4) Maternal and child health, Family planning
With the world population increasing and women’s health in danger as they have to
work for their families and still get pregnant; the primary health care also focuses
on improvement of the maternal and child health by ensuring trained staffs to help
mother while pregnant, giving birth and after birth and to care for the babies and
also by availing the family planning methods to all people in need.
5) Expanded Immunization against major infectious diseases
Most people, especially in the developing world, due to lack of proper knowledge of
health, poor economic status, lack of sophisticated curative health services are not
in position to afford the costs of treatment, therefore, Immunization is the only major
preventive measure against various communicable diseases such as Tuberculosis,
tetanus, Diphteria, Whopping cough, etc.
6) Promotion of Food supply and proper Nutrition
A balanced diet is highly necessary to live healthy lives. Sufficient supply of food
and management of proper nutrition is necessary to get balanced diet. People suffer
from malnutrition due to lack of balance in diet and various related health problems
emerge along with malnutrition. Therefore, food supply and proper nutrition is one
of the important aspects of PHC.
7) Treatment of common infections
In the absence of proper and time treatment on communicable diseases various
rural people have died immature death. Treatment of various such disease can be
managed at the local level with short training preparation.
8) Adequate supply of safe water and basic Sanitation
Safe water supply and sanitation are close related: without water, the sanitary
conditions are automatically affected. Without safe drinking water and poor
sanitation, we are exposed to the gastrointestinal diseases such as diarrhea,
cholera, typhoid, round worm, amoeba, dysentery, etc. therefore, good supply of
safe drinking water is and ensuring good sanitation are critically important for ourgood health.
Self-assessment 6.1.5
1) Explain the elements of the primary health care
6.1.6. Principles of PHC.
Learning activity 6.1.6
Look at the diagram above which represents the six primary principles. Reading
the books that talk about the primary health. Respond to the following questions1) Explain each of the above point in the above image
Attributes of primary health care
The following are attributes of primary health care: Essential healthcare,
Universally accessible, Acceptable, Community bases, First point of contact,
Affordability, Adaptability, Appropriateness, Community participation, Continuity,
Comprehensiveness, Continuity, and coordination
a. Core principles of primary health care
The primary health care principles, are:
Equitable distribution: inequitable access to the health care services is a major
concern especially in the marginalized and poor community. One author Julian
Tudor Hart described the health inequality as the “inverse care law” where by the
care is mostly availed to those who are in need of it whilst the people in need
cannot access. The first key principle in primary healthcare is that individuals with
more compromised health should receive more health services. Commitment to
health equity does not only focus only on ensuring program inputs but also reducing
differences in health outcomes. Aspects of health and health care are: equity in
access to healthcare, equity in health and effective coverage.
Community participation: refers to the involvement of individuals, families
and community, determine the collective needs and priorities. Universal health
coverage cannot be achieved without involving the local community. They are two
types of community participation: Active community participation; this involves the
cooperation of the community with the health administration with the community
share the financial implications; and Passive community participation; the
community and the administration are working cooperatively but community is not
actually required to have certain financial involvement.
The following are advantages of community participation: increases program
acceptance and leadership, ensures that the program meets the local needs, cost
of implementing the program may be reduced by using the local resources, use
local/familiar organizations and hence problem solving is efficient, commitments to
the decisions is facilitated and the community is key to sustainability.
Intersectoral communication: primary health care involves in addition to the health
sector, all related sectors and aspects of national and community development.
It includes sustainable participation that combine inter-organizational cooperative
working alliances. Here are the pre-requisites of the Intersectoral coordination:
proper orientation of policies and program, formation of joint coordination committee
at each level. Defining role and responsibilities of participatory agencies and
participatory decision making.
Use of appropriate technology: the use of technology that is scientifically sound,adaptable to local needs and acceptable to those for whom it is used and is
maintained by the people themselves in keeping with the principle of self-reliance
with the resources the country and the community can afford. The technology
should be designed to meet the specific health needs and it should be selected
with reference to the magnitude of the population affected the health condition.
The use of technology is effective only when it is accompanied by the following:
Knowledgeable and skilled users, clear practice guidelines and policies, effective
financing and distribution to make them available, community efforts to bring clientsinto contact with health services in timely way.
Self-assessment 6.1.6
1) Explain the following principles of primary health care according to the
Alma-Ata declarations
a. Bottom-up and community engaged
b. Priority to those in needc. Involving many counterparts
6.1.7. Levels of Healthcare Essential components of PHC.
Learning activity 6.1.7
1) Illustrate the public health care service delivery in Rwanda
a. Back ground of health system in Rwanda
Following the African regional committee of the World Health Organization held
at Lusaka in 1985, Rwanda has adopted a health development strategy based
on decentralized management and district-level care. The decentralization process
began with the development of provincial-level health offices for health system
management. Progress was made toward decentralizing management to the
province and, ultimately, to the district level.
During the Genocide against Tutsi in 1994, the health system has been disrupted;
infrastructures, equipment, personnel and the health system itself, have been
destroyed. In February 1995, the government has issued a new policy for health
system reconstruction; district health offices have been established and started to
work as autonomous entities and providing services to a well-defined population.
b. Institutional overview of the health sector in Rwanda
The Rwandan health sector is a pyramidal structure and consists of three levels:the central level, the intermediary level, and the peripheral level.
The Central Level
The central level comprises (i) Ministry of Health (MOH), (ii) Rwanda Biomedical
Center (RBC) and the (iii) national referral and teaching hospitals.
• The responsibility of the MOH at central level is to formulate policies and
strategies, ensure monitoring and evaluation, facilitate capacity building and
mobilization of resources. The central level organizes and coordinates the
intermediary and peripheral levels of the health system and provides them
with administrative, technical and logistical support.
• The RBC’s mission is to provide quality affordable and sustainable health
care services to the population through innovative and evidence based
interventions and practices, guided by ethics and professionalism. The core
functions of the RBC include coordination and improvement of biomedical
research activities, coordination of various activities geared towards the
fight against communicable and non-communicable diseases, provide high
level technical expertise in the health realm, ensure availability of medicines
and medical supplies at all times in health facilities, and establish strategic
relations with regional and international institutions, so as to achieve the
strategic health goals.
• The mission of the national referral and teaching hospitals is to provide tertiary
care to the population. These include King Faisal Hospital (KFH), Rwanda
Military Hospital, Kigali University Hospital (CHUK), Butare University Hospital
(CHUB) and Ndera Hospital for mental health and psychiatric care. King
Faisal hospital was created to provide a higher level of technical expertise
than that available in the national referral hospitals to both the private and
public sector and to reduce the number of patients being referred abroad for
complex medical interventions.
The Intermediary Level
To decrease the pressure of demand for services in the national referral hospitals,
3 district hospitals were upgraded to referral hospital level (Ruhengeri, Kibuye
and Kibungo hospitals) and four other district hospital were upgraded to provincial
hospital level (Rwamagana, Bushenge, Ruhango and Kinihira) in order to form
an intermediary level of referral hospitals. In addition, there are private practices
operating in most of these cities.
The Peripheral Level: DHs, HCs and HPs
The peripheral level is represented by the health district and consists of an
administrative office; District Health Unit (DHU), a district hospital (DH), and a
network of health centers and health posts (HCs /HPs). As part of the decentralized
structure of the GOR, the District Health Unit (DHU) is an administrative unit in
charge of coordination of the provision of health services (including the private
The Central Level
The central level comprises (i) Ministry of Health (MOH), (ii) Rwanda Biomedical
Center (RBC) and the (iii) national referral and teaching hospitals.
• The responsibility of the MOH at central level is to formulate policies and
strategies, ensure monitoring and evaluation, facilitate capacity building and
mobilization of resources. The central level organizes and coordinates the
intermediary and peripheral levels of the health system and provides them
with administrative, technical and logistical support.
• The RBC’s mission is to provide quality affordable and sustainable health
care services to the population through innovative and evidence based
interventions and practices, guided by ethics and professionalism. The core
functions of the RBC include coordination and improvement of biomedical
research activities, coordination of various activities geared towards the
fight against communicable and non-communicable diseases, provide high
level technical expertise in the health realm, ensure availability of medicines
and medical supplies at all times in health facilities, and establish strategic
relations with regional and international institutions, so as to achieve the
strategic health goals.
• The mission of the national referral and teaching hospitals is to provide tertiary
care to the population. These include King Faisal Hospital (KFH), Rwanda
Military Hospital, Kigali University Hospital (CHUK), Butare University Hospital
(CHUB) and Ndera Hospital for mental health and psychiatric care. King
Faisal hospital was created to provide a higher level of technical expertise
than that available in the national referral hospitals to both the private and
public sector and to reduce the number of patients being referred abroad for
complex medical interventions.
The Intermediary Level
To decrease the pressure of demand for services in the national referral hospitals,
3 district hospitals were upgraded to referral hospital level (Ruhengeri, Kibuye
and Kibungo hospitals) and four other district hospital were upgraded to provincial
hospital level (Rwamagana, Bushenge, Ruhango and Kinihira) in order to form
an intermediary level of referral hospitals. In addition, there are private practices
operating in most of these cities.
The Peripheral Level: DHs, HCs and HPs
The peripheral level is represented by the health district and consists of an
administrative office; District Health Unit (DHU), a district hospital (DH), and a
network of health centers and health posts (HCs /HPs). As part of the decentralized
structure of the GOR, the District Health Unit (DHU) is an administrative unit incharge of coordination of the provision of health services (including the private
sector) and responsible for planning, monitoring and supervision of the decentralized
implementing agencies. The DHU is part of the DHMT and reports to the Vice
Mayor in charge of social affairs.
The functions of the DHU include organization and coordination of health services
in the Health Facilities (DH, HCs and HPs) and the Community. Health facilities
deliver the approved healthcare packages (annex 6), provide administration,
manage logistics supplies and supervise Community Health Workers (CHWs).
Generally, the service package at a district hospital (DH) includes inpatient /
outpatient services, surgery, laboratory services, gynecology-obstetrics, radiology,
mental health, dental and eye services. The HCs provide preventive services,
primary health care, in-patient care, referrals, and basic maternity services, while
the HPs provide services such as immunization, family planning, growth monitoring,
and antenatal care.
At the village level, Community Health Workers (CHWs) provide prevention,
promotion and some curative health services. Community health services are
integrated into the community development services and administrative structures.
There are 499 HCs spread-out all over the country.
c. Level of services provided within the public healthcare system in
Rwanda
Regarding the healthcare services provision, it is offered into levels whereby each
level works in complementarity to the other levels. It starts by the community health
workers, working closely with the health posts and health centers. These are
primary level. The secondary level is composed by the district hospitals located in
each district. The tertiary level is composed by the provincial referral hospitals and
the national referral hospitals and University teaching hospitals.Table 6.1 1 Existing Administrative Structures and related health facilities (HSSP4 2018-
2024)
d. Package of the health services
Most common illnesses in Rwanda are transmissible diseases that are preventable
through improved hygienic measures and changes in individual health behavior (cfr
Rwanda Health statistics). A package of activities directed toward these, as well
as common preventive interventions, has been defined for each level of the health
system. Here below are different package of activities according to levels:
i. Health center level, the minimum package of activities (MPA)
• Promotional activities: including information, education, and communication
(IEC); psychosocial support nutritional activities related to small farming and
food preparation; community participation; management and financing ofhealth services; home visits; and hygiene and sanitation in the catchment
area around the health center
• Preventive activities: premarital consultation, Ante Natal Care (ANC)
services, postpartum care for the mother and child, family planning counseling
and services, school health, and epidemiologic surveillance activities
• Curative activities: including consultations, management of chronically
ill patients, nutritional rehabilitation, curative care, observation before
hospitalization, normal deliveries, minor surgical interventions, and laboratory
testing
ii. District hospitals, complementary package of activities
The complementary package of activities (CPA) for district hospitals includes almost
all activities of the MPA for the peripheral level, but emphasizes treating referred
case. Additional activities under the CPA include the following:
• Prevention, including preventive consultations for referred cases and ANC
consultations for at-risk pregnancies. Family planning, with the provision of all
methods for referred cases, including female and male sterilization.
• Curative care, including management of referred cases, referrals for tertiary
level care, management of difficult labor, medical and surgical emergencies,
minor and major surgical interventions, inpatient care, laboratory testing, and
medical imaging;
• Management, including the training of paramedical personnel in district
schools and collaboration with the district work group for continuing education
and supervision activities.
iii. Complementary package of activities for national referral hospitals
Although the national referral hospitals provide the highest level of service and
should function almost solely as referral centers from district hospitals, in reality,
there is an overlap of the activities of the district and national referral hospitals.
This is because there is still an unclear delineation of responsibilities for the central
level national referral hospitals, and there are not enough functioning district
hospitals, especially in urban areas. This results in national referral hospitals often
assuming the responsibilities of district hospitals.
e. Standards of functioning health system
A well-functioning health system responds in a balanced way to a population‘s
needs and expectations by: Improving the health status of individuals, families and
communities, Defending the population against what threatens its health, Protecting
people against the financial consequences of ill-health, Providing equitable access
to people-centered care and Making it possible for people to participate in decisions
affecting their health and health system
Self-evaluation 6.1.7
1) What are the levels of health care delivery in Rwanda?2) What are the characteristics of the well-functioning health system?
6.2. Health Promotion6.2.1. Background of health promotion
Learning activity 6.2.1
Read this link below about background of health promotion and briefly give an
overview, strategy and focus of health promotion according to WHO.https://www.who.int/health-topics/health-promotion#tab=tab_1
The first International Conference on Health Promotion was held in Ottawa in 1986,
and was primarily a response to growing expectations for a new public health
movement around the world. It launched a series of actions among international
organizations, national governments and local communities to achieve the goal
of “Health For All” by the year 2000 and beyond. The basic strategies for health
promotion identified in the Ottawa Charter were: advocate (to boost the factors
which encourage health), enable (allowing all people to achieve health equity) and
mediate (through collaboration across all sectors).
Since then, the WHO Global Health Promotion Conferences have established
and developed the global principles and action areas for health promotion. Most
recently, the 9th global conference (Shanghai 2016), titled ‘Promoting health in
the Sustainable Development Goals: Health for all and all for health’, highlighted
the critical links between promoting health and the 2030 Agenda for Sustainable
Development. Whilst calling for bold political interventions to accelerate country
action on the SDGs, the Shanghai Declaration provides a framework through which
governments can utilize the transformational potential of health promotion.Self-assessment 6.2.1
1) Where was the first International Conference on Health Promotion held?
2) Which was the goal of the first International Conference on Health
Promotion?
3) What are the basic strategies for health promotion identified in the OttawaCharter?
6.2.2. Concept definition of “Health promotion”
Learning activity 6.2.2
1) What is the relationship between these components (physical activity,
health eating, stop smoking, community development, health schools,and health trainers) and health promotion?
The most well-known definition of health promotion is that of the World Health
Organization’s Ottawa Charter (1986): Health promotion is the process of enabling
people to increase control over, and to improve, their health. This definition was
slightly modified in 2005, in WHO’s Bangkok Charter for Health Promotion in a
Globalized World to: Health promotion is the process of enabling people to increase
control over their health and its determinants, and thereby improve their health.
To reach a state of complete physical, mental and social well-being, an individual
or group must be able to identify and to realize aspirations, to satisfy needs, and to
change or cope with the environment. Health is therefore, seen as a resource for
everyday life, not the objective of living. Health is a positive concept emphasizing
social and personal resources, as well as physical capacities. Therefore, health
promotion is not just the responsibility of the health sector, but goes beyond healthy
life-styles to well-being.
Health promotion is the process of enabling people to exert control over the
determinants of health and thereby improve their health. (WHO, 2009)Purpose of health promotion
The purpose of this activity is to strengthen the skills and capabilities of individuals
to take action and the capacity of groups or communities to act collectively to exert
control over the determinants of health and achieve positive change.
Health promotion and determinants of health.
Many factors combine together to affect the health of individuals and communities.
Whether people are healthy or not, is determined by their circumstances and
environment.
To a large extent, factors such as where we live, the state of our environment,
genetics, our income and education level, and our relationships with friends and
family all have considerable impacts on health, whereas the more commonly
considered factors such as access and use of health care services often have lessof an impact
Self-assessment 6.2.2
1) What is health promotion according to WHO?
2) What must an individual/ group be able to do in order to reach a state of
complete physical, mental and social well-being?
3) List five determinants of health.
6.2.3. The scope of health promotion.
Learning activity 6.2.3
Open one of the following links and read about the scope of health promotion,
describe briefly five health promotion actions.
https://www.euro.who.int/__data/assets/pdf_file/0004/129532/Ottawa_Charter.
pdf
https://bsahely.com/2018/09/12/the-ottawa-charter-for-health-promotionwho-1986/
a. Developing personal skills
Youth organizations, through the broad range of programmes and activates delivered
to young people, including health education and health information, positively
influence the development of personal skills, for example self-esteem, self-efficacy,
communication, negotiation, life skills and motivation. The development of these
skills has a positive impact on health.b. Creating supportive environments
Through creating safe and secure physical and social environments, youth
organizations provide young people and staff with opportunities to discuss and
explore health issues and practice health-enhancing behaviors, thus supporting
health education and ‘making the healthier choice the easier choice’; for example
providing healthy food options in the tuck shop; providing healthy snacks for after
schools clubs; providing a smoke free environment, implementing an anti-bullying
policy, providing an adolescent friendly health service.
c. Strengthen community action
Through developing partnerships and alliances with other organizations and
sectors in the community, youth organizations can build capacity and positively
influence health within the wider community, which in turn, can continue to support
the health of their target groups who live in the community, for example delivering
parent programmes, working in partnership with healthy towns’ initiatives.
d. Delivering health public policy
Through the development of health-related policy internally, youth organizations
demonstrate evidence-based practice indicating the importance of having policy in
place to support practice, for example sexual health policy; substance use policy.
Additionally, youth organizations have a key role to play in raising awareness and
advocating for public policy development and change in order to support their
health-related work and the health of their target groups, for example national
alcohol policy.
e. Reorient the health services
Advocating for the development and provision of health services that can respond
to the health needs of young people is a key role of youth organizations, for
example youth organizations have a role in creating awareness and advocating forthe provision of an adolescent friendly health service for young people.
Self-assessment 6.2.3
Consider each of the following activities and decide whether you think each is,
or is not, health promotion.
1) Using TV advertisements to encourage people to more physically active.
2) Campaigning for smoking cessation programs such as ‘quit’ activities and
‘brief interventions.
3) Explaining the mother how to breastfeed his child.
4) Setting up a self-help group for people who have been sexually abusedas children.
5) Providing schools with a crossing patrol to help children across the road
outside schools.
6) Raising awareness on how poverty affect health.
7) Giving people information about the way their bodies work.
8) Immunizing children against infectious diseases such as measles.
9) Protesting about a breach in the voluntary code of practice for alcohol
advertising.
10) Running low-cost gentle exercise classes for older people at local leisure
centres.
11) Proving healthier menu choices at workplace canteens.
12) Teaching a programme of personal and social education in a secondary
education.
13) Proving support to people with learning disabilities living in the community.
14) Using social marketing tools to ensure behavioral change in a group of
smokers.
15) Campaigning for increasing tax on tobacco.
What were your reasons for saying “yes” or “no”? Can you identify the criteriayou are using for deciding whether an activity is “health promotion’?
6.2.4. Principles of health promotionLearning activity 6.2.4
Open the link below and read about Principles of health promotion and briefly
give an overview of health promotion principles.https://www.youth.ie/articles/principles-of-health-promotion/
a. Principles of health promotion
Empowerment: a way of working to enable people to gain greater control over
decisions and actions affecting their health.
Participative: where people take an active part in decision making.
Holistic: taking account of the separate influences on health and the interaction of
these dimensions
Equitable: ensuring fairness of outcomes for service users.
Intersectoral: working in partnership with other relevant agencies/organizations.
Sustainable: ensuring that the outcomes of health promotion activities are
sustainable in the long term.Multi Strategy: working on a number of strategy areas such as programmes, policy
Self-assessment 6.2.4
6.2.5. Main approaches to health promotion.
Learning activity 6.2.5
Open the link below and read about approaches to health promotion and
describe briefly each approach.
https://repository.canterbury.ac.uk/download/
e5b13fb82eb016e6c2bae128f962f54291a459571e774b8ec99c0b0d6d2
7f297/298377/Effective%20approaches%20to%20health%20promotion%20in%20nursing%20-%20Nursing%20Standard%20Oct%202018.pdf
a. Medical or Preventive Approach
The medical or preventive approach aims to reduce premature death by targeting
the whole population or groups who are at higher risk of developing disease. This
approach can operate at three levels:
• Primary prevention – preventing the onset of disease
• Secondary prevention – attempting to prevent disease progressing
• Tertiary prevention level – seeking to mitigate harm in people who have
already developed disease. Nurses who work within this approach to health
promotion may be involved in immunization programmes, screening for
diseases such as cancers, or administering medicine to patients in palliative
care settings.
b. Behavioral Approach
The behavioral approach, also known as the behavior change approach, makes
the fundamental assumption that healthy lifestyles are crucial to maintaining
good health. Some behavior change attempts have been targeted at the whole
population, for example, ‘Stoptober’, the annual 28-day stop smoking campaign that
was initiated by the Department of Health in 2012. Healthcare professionals who
adopt the behavioral approach in their practice seek to provide individual patients
with information concerning their unhealthy lifestyle behaviors and motivate them
to change.
c. The Educational Approach
The educational approach to health promotion assumes that increasing people’s
knowledge about their health will lead to healthier behavior. Nurses who adopt an
educational approach provide people with knowledge and information about their
health. This differs from the behavior change approach in that it does not seek to
attempt to motivate the individual to change their behavior in a specific direction
decided by the professional, for example, to quit smoking, reduce alcohol intake or
consume more fruit and vegetables.
The focus of the educational approach is on learning and comprises three aspects
• Cognitive -addresses people’s understanding concerning a health topic.
• Affective -considers an individual’s feelings and attitudes towards a health
topic.
• Behavioral -concerned with people’s skills, for example, their ability to cook.
One important outcome of the educational approach is ‘health literacy’, which
refers to “the personal, cognitive and social skills which determine the ability
of individuals to gain access to, understand and use information to promote
and maintain good health”
d. The Empowerment Approach
Within the context of health promotion, empowerment can be understood as “a
process through which people gain greater control over decisions and actions
affecting their health” (WHO, 1998, p. 6). An empowerment approach seeks to
enable individuals and social groups to express their health-related needs and
have greater involvement in decision-making regarding their health. It can be used
when working directly with individual patients or whole communities. Since nurses
have an understanding of the needs and socio-cultural challenges within the local
communities in which they work, it has been suggested that there is scope within
some nursing roles, for example school nursing, to support whole families and
collaborate with other healthcare professionals to achieve joint, local health goals.
One example of the empowerment approach being used to successfully promote
patient health has been demonstrated within a hospice setting that specializes in
cancer care. By improving open dialogue with patients and their families, nursing
staff were able to elicit expressed needs and subsequently develop patient-centred
care plans that promoted patients’ autonomy
e. The Social Change Approach
The social change approach focuses on making changes to the physical, social and
economic environment to increase their health promoting capacity. This approach
assumes that if the healthier choice is made the easier choice, it will become
increasingly realistic for individuals to make decisions to improve their health and
wellbeing. Therefore, health promotion is therefore ‘a social and political process’
that regards health as a human right and considers the maintenance of populationhealth to be a prerequisite for social progress.
Self-assessment 6.2.5
1) List five approaches to health promotion.
2) With supportive examples, describe briefly the aims of each approach to
health promotion listed in question 1.
3) This approach to health promotion is based on the assumption that
humans are rational decision-makers, this approach relies heavily upon
the provision of information about risks and benefits of certain behaviors.
a. behavior change approach
b. community development approach
c. biomedical approach
d. none of these
4) This approach to health promotion is synonymous with health education
as it aims to increase individuals’ knowledge about the causes of health
and illness.
a. behavior change approach
b. community development approach
c. biomedical approachd. none of these
6.2.6.Basic strategies of health promotion
Learning activity 6.2.6
Open the link below and read about basic strategies of health promotion,
describe briefly each strategy. https://www.betterhealth.vic.gov.au/health/
servicesandsupport/ottawa-charter-for-health-promotion
Learning activity 6.2.6
The Ottawa Charter identifies three basic strategies for health promotion:
• Advocate – good health is a major resource for social, economic and personal
development, and an important dimension of quality of life. Political, economic,
social, cultural, environmental, behavioral and biological factors can all favour
or harm health. Health promotion aims to make these conditions favorable,
through advocacy for health.
• Enable – health promotion focuses on achieving equity in health. Health
promotion action aims to reduce differences in current health status and
to ensure the availability of equal opportunities and resources to enable all
people to achieve their full health potential. This includes a secure foundation
in a supportive environment, access to information, life skills and opportunities
to make healthy choices. People cannot achieve their fullest health potential
unless they are able to control those things that determine their health. This
must apply equally to women and men.
• Mediate – the prerequisites and prospects for health cannot be ensured by
the health sector alone. Health promotion demands coordinated action by
all concerned, including governments, health and other social and economic
sectors, non-government and voluntary organizations, local authorities,industry and the media.
Self-assessment 6.2.6
1) Outline three basic strategies for health promotion.
6.3. Health Education
6.3.1. Concept definition of health education.Learning activity 1.9
Look at the images above and attempt the following questions
1) What do you see in the image A and B?
2) When observing carefully the image B, what should be going on?3) Why do you think health education is important?
a. Definition of health education
Health education is defined as a process by which people learn about their health
and more specifically, how to improve their health. It can also be defined as a
development of individual, group, institutions, community and systemic strategies
to improve health knowledge, attitudes, skills and behaviour.
The WHO defined health education as comprising of consciously constructed
opportunities for learning involving some form of communication designed to
improve health literacy, including improving knowledge, and developing life skills
which are conducive to individual and community health.
Health education as a tool for health promotion is critical for improving the health of
populations and promotes health capital.
Health literacy is the degree to which people are able to access, understand,
appraise and communicate information to engage with the demands of different
health contexts in order to promote and maintain good health across the life-course.
b. Relationship between health education and health promotion
Health promotion and health education are easily confused because both concepts
are closely related and work together to help people make wise decisions about
their health. Health education is one aspect of promoting a healthy lifestyle and it
only aims to inform people and give them knowledge about health. Health promotion
is more general and broader of an area and it involves government policy-making in
addition to education. Health promotion also includes areas such as cultural, socialand political factors, in addition to education.
Table 6.3 1 Table comparing health promotion and health education
Self-assessment 6.3.1
1) Define the term ‘Health education’.2) Is health education important in the community? Justify your answer
6.3.2. Objectives of health education
Learning activity 6.3.2
Referring to the definition of Health education as a process by which people
learn about their health and more specifically, how to improve their health; and
also considering the above topics, answer the following questions:
1) What should be the relationship between health education and nutrition?2) Give at least 2 objectives of health education.
Health education programs help empower individuals and communities to live
healthier lives by improving their physical, mental, emotional and social health by
increasing their knowledge and influencing their attitudes about caring for their wellbeing.
Health education focuses on prevention, increasing health equity, and decreasing
negative health outcomes such as availability and accessibility of health services,
benefiting all stakeholders.The following are the some of the main objectives of health education:
• To provide information about health and its value as community asset:
Health education aims at acquainting the etchers with the rules of health and
hygiene. Functioning of Precautionary measures to ward off diseases and to
provide good disease-free working conditions.
• To maintain norms of good health: The authorities should provide hygienic
environment in the form of adequate ventilation proper temperature, good
sanitation and all-round cleanliness. It helps the authorities to keep certain
norms of health.
• To take precautionary and preventive measures against communicable
diseases. Its aim is to take adequate precautions against contamination
and spread of diseases. Thus, good sanitary arrangements are made.
Precautionary and preventive measures. If they are properly adopted can
help in improving the health standards of society.
• To render assistance to the school going children an understanding
of the nature and purpose of health services and facilities – It aims
at discovering physical defects and other abnormalities in the child and
promoting their reduction if they are easily curable.
• To develop and promote mental and emotional health – Mental and
emotional health are also equally important along with physical health. While
physically health makes a pupil physically fit mental and emotional health
enables him to maintain an even temper and a happy disposition.
• To develop a sense of civic responsibility. School is a miniature society
Responsibility of skill health does not lie on any one’s shoulders. Even some
cause of skill health has their origin in social conditions which require action
on the part of community as a whole in order to eradicate them. It aims at
realizing the people to make combined efforts and work for community health.
Factors affecting learning
The nurse should be aware of the following factors that can facilitate or hinder
optimal learning by a client:
• Age and developmental stage: three major developmental stage factors
associated with clients’ readiness to learn include physical, cognitive, and
psychosocial maturation.
• Motivation: Motivation to learn is the desire to learn. Motivation is generally
greatest when a person experiences a need and believes the need will be
met through learning
• Readiness: Readiness to learn refers to demonstrated behaviors that reflect
not only the client’s willingness to learn but also his or her ability to learn at
a specific time. For example, a client may want to learn self-care during a
dressing change, but when experiencing pain he may not be able or ready to
learn.
• Active involvement: When the learner is actively involved in the process of
learning, learning becomes more meaningful and faster, and retention is better.
Active learning promotes more effective problem solving and application of
learning to the clients’ own situations
• Relevance: The client can learn more easily if he or she can connect or relate
the new knowledge or skills to what he or she already knows.
• Feedback: Feedback is information regarding a person’s performance
in meeting a desired goal; it needs to be meaningful and given in a timely
manner. Feedback that accompanies the practice of psychomotor skills helps
the person learn those skills.
• Nonjudgmental support: People learn best when they believe they
are accepted and not being judged. Once learners have succeeded in
accomplishing a task or understanding a concept, they gain self-confidence
in their ability to learn. This confidence reduces their anxiety about failure and
can motivate further learning.
• Simple to complex: Learning is facilitated by material that is logically
organized and proceeds from the simple to the complex. Such organization
enables the learner to comprehend new information, assimilate it with previous
learning, and form new understandings
• Repetition: Repetition of key concepts and facts facilitates retention of newly
learned material
• Timing People retain information and psychomotor skills best when the time
between learning and active use of the learning is short; the longer the time
interval, the higher the chances of the learning being forgotten
• Environment An optimal learning environment with reduced distractions
facilitates learning. Noise can distract the learner and interfere with listening
and thinking.
• Emotions: Emotions, such as high anxiety, fear, anger, and depression, can
impede learning. Clients or families who are experiencing extreme emotional
states may retain only part of the communication.
• Physiological events Physiological events, such as a critical illness, pain, or
sensory deficits, inhibit learning
• Cultural barriers Cultural barriers to learning include language, beliefs,
and values. Western medicine may conflict with cultural healing beliefs and
practices. Nurses need to be competent in providing culturally safe and
sensitive care; otherwise, the client may be partially or totally noncompliant
with recommended treatments
• Psychomotor ability Nurses must be aware of a client’s psychomotor skillswhen planning teaching. Motor abilities can be affected by health status.
Self-assessment 6.3.2
1) List the main objectives of health education.2) List factors that can affect learning during health education
6.3.3. Principles of Health education.
Learning activity 6.3.3
1) Read through the link below and list the principles of health educationhttp://nursingexercise.com/health-health-education-overview/
The following are principles of health education: Credibility, Interest, Participation,
Motivation, Comprehension, Reinforcement, Learning by doing, Known to unknown,
Setting an example, Good human relations, Feedback and Leaders. They are
discussed below:
1. Interest: Health teaching should be related to the interests of the people.
Health programmers should be based on the “FELT NEEDS”, so that it
becomes “people’s programme. Felt needs are the real health needs of the
people that is needs the people feel about themselves.
2. Participation: A high degree of participation tends to create a sense of
involvement, personal acceptance and decision –making and provides
maximum feedback. The Alma- Ata Declaration states “The people have a
right and duty to participate individually and collectively in the planning and
implementation of their health care”. Health programmers are unlikely to
succeed if community participation is not an integral part. Health educators
should include clients from the identification of the problems, planning,
implementation, and evaluation.
3. Known to unknown: We must proceed “from the concrete to the abstract”,
“from the particular to the general”, “from the simple to the more complicated”,
“from the easy to more difficult” and “from the known to unknown” Here
health communicator uses the existing knowledge of the people as pegs on
which to hang new knowledge
4. Reinforcement: Repetition of message at intervals is necessary; if the
message is repeated in different ways, people are more likely to remember
it.
5. Motivation: In every person, there is a fundamental desire to learn.
Awakening this desire is called motivation. Two types of motives are: primary
motives-are driving forces initiating people into action; and secondary
motives –are created by outside forces or incentives. Need for incentives is
a first step in learning to change and incentives may be positive or negative.
Main aim of motivation is to change behavior and motivation is contagious:
one motivated person may spread motivation throughout a group.
6. Comprehension: Health educator must know the level of understanding,
education and literacy of people to whom the teaching is directed. Always
communicate in the language people understand and consider the mental
capacity of the audience when
7. Communication: Communication is very important. Health educator should
know any barrier to communication like language, cultural background of the
community. Health educator has to know the group for whom he/she has to
give health education.
8. Needed-based: Any health-related education should focus on community
health needs. It should be purposeful, ascertain, specific and relevant to the
problems and available solutions.
9. Change behavior: Health educator should know the prior behavior of the
community to educate. The purpose of health education is to change their
behavior and adopt a healthier one. Therefore, multidisciplinary approach is
necessary to understand human behavior as well as for an effective teaching
process.
10. Scientific based knowledge: Health-related education must be scientific
and current knowledge-based. Therefore, a health educator should have the
recent scientific knowledge to provide health education.
11. Rapport relationship: The health educators are not teachers; they are
facilitators, enablers. They need to be accepted by the community members;
they have to win the confidence of their clients.
12. Compare and upgrade knowledge: It must be remembered that people
have no information or ideas about health. The health educators are not only
passing information but also allow clients to analyses old ideas with new
ones, compare with experience, and take decisions that are found favorable
and beneficial.
Targets people for health education:
• Individuals such as clients of services, patients, healthy individuals.
• Groups E.g. groups of students in a class, youth club.
• Community e.g. people living in a village.
Self-assessment 6.3.3
1) List at least five principles of health education2) Who are the target people for health education?
6.3.4. Process of Health education
Learning activity 6.3.4
Referring to the books that talks about the health education and using the link
below, give the steps that are involved in the teaching-learning process
Books on teaching content for a variety of health care conditions
• Nurse’s Handbook of Patient Education, by Shirin F. Pestonjee (2000,
Springhouse).
• Mosby’s Handbook of Patient Teaching, by Mary Conobbio (2000, Harcourt
Health Services).
Link:
https://www.euromedinfo.eu/process-of-patient-education-introduction.
html/#:~:text=Developing%20learning%20objectives,Documenting%20
patient%20teaching%20and%20learning
Learning activity 6.3.4
The process of patient teaching refers to the steps you follow to provide teaching
and to measure learning. The steps involved in the teaching-learning process are:
• Assessing learning needs
• Developing learning objectives
• Planning and implementing patient teaching
• Evaluating patient learning
• Documenting patient teaching and learning
a. Assessing learning needs
The first step in the process of patient teaching is assessing the patient’s learning
needs, learning style, and readiness to learn. Assessment includes finding out what
patients already know, what they want and need to learn, what they are capable of
learning, and what would be the best way to teach them.
Begin the process by interviewing the patient. First, find out more about the patient
as an individual and what his life is like. Questions you might ask include:• Tell me what an average day is like for you
• How has your average day changed since you’ve been sick?
• What do you like to do in your spare time?
• Tell me about your family
• Tell me about your work
Second, start assessing the patient’s learning needs. Questions you might ask
include:
• What are you most concerned about?
• What are your goals for learning how to take care of yourself?
• What do you feel you need to know to achieve your goals?
• What specific problems are you having?
• What do you know about your condition?
• What are you most interested in learning about?
• How will you manage your care at home?
Third, find out what the patient’s learning style is so you can match teaching
strategies as closely as possible to the patient’s preferred learning style. Questions
you might ask to determine the patient’s learning style are:
• What time of day do you learn best?
• Do you like to read/what types of books or magazines do you enjoy reading?
• Would you prefer to read something first, or would you rather have me explain
information to you?
• Do you learn something better if you read it, hear it, or do it hands on yourself?
Forth, gather information about the patient’s readiness to learn. Questions you
might ask include:
– How do you feel about making the changes we’ve discussed?
– What changes would you like to work on now?
– Are there any problems that would prevent you from learning right now?
Forth, gather information about the patient’s readiness to learn. Questions you
might ask include:
• How do you feel about making the changes we’ve discussed?
• What changes would you like to work on now?
• Are there any problems that would prevent you from learning right now?
After you’ve talked with the patient, interview the family. Conversations with the
patient’s family can fill in missing information, change your understanding of what
you’ve heard from the patient, or affect your view of what the patient’s home situation might be. Do family members ask to be present during teaching, and when teaching
occurs, do they actively participate? Do they seem supportive of the patient’s need
to change health behaviors and to learn new tasks and skills?
You can also consider using checklists and questionnaires to obtain information
about learning needs, learning style, and learning readiness. Written materials
also help you determine the patient’s literacy level and ability to understand written
information. Confer with other health care team members. Each health care team
member has valuable information about the patient and his or her learning needs
and abilities. Collaborating with others who care for the patient can give you-and
them-a better picture, allowing all of you to design more effective teaching strategies.
In some instances, there are differences between the patient’s and the health
professional’s view of the need to know. The health professional may perceive the
need for information when the patient does not. For example, a pharmacist tries
to give the patient information when filling a prescription. The patient’s response
is: „Oh, I don’t need to know that-I trust my doctor. Whatever he ordered is fine.
There’s no reason I should know all the details. “ In this example, the best approach
may be for the pharmacist to start with why the information is important and explain
that the physician depends on the patient to know the information.
Determining learning style involves assessing how patients learn best, when
they learn best, and how able they are to learn what they need to know. Finding
out whether the patient learns best by hearing, reading, or hands-on learning is
relatively straightforward. However, factors such as the patient’s educational and
literacy levels also need to be considered. Sometimes patients and families may
seem uninterested in learning because they don’t know what to ask or don’t yet
realize that they will need information. For example, family members of a patient
with a stroke may have never known anyone else with a stroke and thus may have
no idea of what to plan for or what to ask. In some instances, nurses and other health
professionals may take it for granted that patients have a better understanding of
their condition and treatment than they actually do.
During the acute phase of an illness, patients are dependent on health care
professionals. Dependency may be a realistic and necessary condition because
of physical and psychosocial demands caused by the illness. Available energy is
invested in coping with the physiological and psychosocial demands of the illness
and the person’s focus may be on survival. Readiness to learn, therefore, is limited.
Not only is energy diminished, but other distractors such as pain and fatigue are
usually present. Learning needs at this time usually focus on diagnostic tests and
treatments. These needs are considered short-term learning-the material being
learned relates to the present situation and once the situation is over, it is usually no
longer necessary to retain it. As the person recovers and independence increases,
he or she progresses to the post-acute or resolution stage of illness. For most
patients, an improving physical condition and the desire to return to normalcy acts
as an incentive to learn how to recognize, prevent, and manage complications. Due
to short hospital stays, much of the patient’s learning readiness for management
and prevention of further problems will take place in an out-patient or a home setting.
b. Developing learning objectives
To develop objectives, you need to define the outcomes you and the patient expect
from the teaching-learning process. Unlike goals, which are general and long
term, learning objectives are specific, attainable, measurable, and short-term. For
example, for a newly diagnosed diabetic patient, the overall learning goal may be to
learn how to maintain blood glucose levels between 70 and 150 mg/dl at all times.
Reaching such a goal may be overwhelming unless it’s broken down into specific,
short-term behavioral objectives that lead up to the overall goal. For this patient, an
objective such as „After this session, the patient will be able to list five symptoms of
hypoglycemia “is one step on the way to the larger goal.
A simple and practical way of developing learning objectives is to start with the
words WHO, DOES, WHAT, HOW, and WHEN. For example, the objective “The
patient will list five signs of hyperglycemia by time of discharge” could be broken
down this way:
• WHO-the patient
• DOES-will list
• WHAT-five signs of hyperglycemia
• HOW-accurately or by stating out loud
• WHEN-by discharge
Make sure in writing objectives that you use action words that are measurable such
as list, state, explain, and demonstrate. Avoid using terms that cannot be measured
or observed easily, such as understand or appreciate.
c. Planning and implementing teaching
The next step in the process is to plan and implement an individualized teaching
plan. Your teaching plan should include what will be taught, when teaching will
occur, where teaching will take place, who will teach and learn, and how teaching
will occur.
Patient/clients should be involved in what will be taught/learnt from the beginning
up to the end. Nurse as educator should identify the needs of the client and engage
the client in the whole learning process.
Plan when and where the teaching/learning will take place considering what is best
for the client; ensure that the clients inform you what works for them and offer as
many as possible realistic options available. Consider the time and the length and
depth of the session that is good for the client.
d. Evaluating teaching and learning
Evaluation, the last phase of the teaching process, is the ongoing appraisal of the
patient’s learning progress during and after teaching. The goal of evaluation is to
find out if the patient has learned what you taught.
Here are some ways you can evaluate learning:
• Observe return demonstrations to see whether the patient has learned the
necessary psychomotor skills for a task
• Ask the patient to restate instructions in his or her own words
• Ask the patient questions to see whether there are areas of instruction that
need reinforcing or re-teaching,
• Give simple written tests or questionnaires before, during, and after teaching
to measure cognitive learning
• Talk with the patient’s family and other health care team members to get
their opinions on how well the patient is performing tasks he or she has been
taught
• Assess physiological measurements, such as weight and blood pressure,
to see whether the patient has been able to follow a modified diet plan,
participate in prescribed exercise, or take antihypertensive medication
• Review the patient’s own record of self-monitored blood glucose levels, blood
pressure, or daily weights
• Ask the patient to problem solve in a hypothetical situation
e. Documenting patient teaching
Your documentation of patient teaching should take place throughout the entire
teaching process. Documentation is done for several purposes. Documentation
promotes communication about the patient’s progress in learning among all health
care team members. Good documentation helps maintain continuity of care and
avoids duplication of teaching. Documentation also serves as evidence of the
fulfillment of teaching requirements for regulatory and accrediting organizations
such as the JCAHO, provides a legal record of teaching, and is mandatory for
obtaining reimbursement from third party payers. Documentation of patient teaching
can be done via flow-charts, checklists, care plans, traditional progress notes, or
computerized documentation. Whatever the method, the information must become
a part of the patient’s permanent medical record. Table 6 shows suggestions onwhat to document and how
Sample Teaching Plan: Wound Care
Assessment of Learner: A 24-year-old male university student suffered a 7-cm
laceration on the lower anterior part of the left leg during a hockey game.
The laceration was cleaned, sutured, and bandaged. The client was given an
appointment to return to the health clinic in 7 days for suture removal. Client
states that he lives in the university dormitory and is able to care for the wound if
given instructions. Client is able to understand and read English.
• Nursing diagnosis: Lack of knowledge of wound and suture care
• Long-term goals: Client’s wound will heal completely without infection or
other complications.
• Intermediate goal: At clinic appointment, client’s wound will be healing
without signs of infection, loss of function, or other complication.
• Short-term goals: Client will (a) correctly list three signs and symptoms of
wound infection and (b) correctly perform a return demonstration of wound
cleansing and bandaging.
Behavioral outcomes.
On completion of the instructional session, the client will do the following:
• Describe normal wound healing
• Describe signs and symptoms of wound infection
• Demonstrate wound cleansing and bandaging
Content outline
• Normal wound healing
• Infection:
– Signs and symptoms
– Signs of systemic infection.
• Wound care equipment
– Cleansing solution
– Dressing materials
• Demonstration of wound cleansing and bandaging on the client’s wound
• Resources available for client’s questions• Follow-up treatment plan
Teaching methods
• Describe normal wound healing with the use of audiovisuals.
• Discuss the mechanism of wound infection. Use audiovisuals to
demonstrate infected wound appearance.
• Demonstrate the equipment needed for cleansing and bandaging wound.
• Demonstrate wound cleansing and bandaging on the client’s wound.
• Discuss available resources.
• Provide a handout of the procedure and frequently asked questions (FAQs)
Evaluation
The client will do the following:
• Correctly describe normal wound healing and signs and symptoms of
wound infection
• Return demonstration of wound cleansing and bandaging
• State contact person and telephone number to obtain assistance• State date, time, and location of follow-up appointment
Documenting Patient Teaching
What to document
• The patient’s learning needs
• The patient’s preferred learning style and readiness to learn
• The patient’s current knowledge about his or her condition and health care
management
• Learning objectives and goals as determined by both you and the patient
• Information and skills you have taught
• Teaching methods you have used, such as demonstration, brochures, and
videos.
• Objective reports of patient and family responses to teaching
• Evaluation of what the patient has learned and how learning was observed
to occur
How to document
• Record the patient’s name on every page of your documentation.
• Include the time and date on all entries.
• Sign each entry.
• Write in black or blue ink, for legal and reproduction purposes.
• Write legibly.
• Be accurate and truthful when discussing facts and events.
• Be objective-don’t show personal bias or let others influence what you
write.
• Be specific.
• Be concise-record information succinctly, without compromising accuracy.
• Be comprehensive-include all pertinent information.
• Record events in chronological order.
Source: Rankin, S.H., & Stallings, K.D. (1996). Patient Education: Issues,Principles, Practices, 3rd ed. Philadelphia: Lippincott-Raven, 233-236
Self-assessment 6.3.4
1) List the steps used in the teaching learning process2) What to document in patient teaching
End unit assessment 6
1) Selective Public Health Care is:
a. Client is a passive recipient
b. Service provision is not holistic, equitable or sustainable
c. Health achieved through medical interventions
d. All of the above
2) Comprehensive PHC is?
a. Holistic understanding and implementation of healthcare and wellbeing
that is equitable, empowering and sustainable.
b. Health achieved through medical interventions
c. Client is a passive recipient and Service provision is not holistic, equitable
or sustainable
d. All of the above
3) Health is best described as a resource that allows a person to have
a. A social and spiritual life
b. A productive social and economic life
c. Economic well being
d. Physical capacity
4) What distinguishes primary healthcare from primary care
a. A focus on primary, secondary, and tertiary intervention
b. Provision of interventions specific to the health need
c. Works within a multidisciplinary framework
d. Planning and operation of services is centralized
5) Primary prevention is concerned with
a. Preventing disease or illness occurring
b. Delaying the progress of an existing disease or illness
c. Maintaining current health status
d. Treatment of existing disease or illness
6) Which of the following approaches to health promotion aims to reduce
premature death by targeting the whole population or groups who are at
higher risk of developing disease?
a. Medical/preventive
b. Behavioural
c. Educational
d. Empowerment
7) A home health nurse who provides skin care and repositioning of a client
on bedrest is conducting activities in:
a. Health promotion
b. Health protection
c. Health prevention
d. Rehabilitation
8) The public health nurse who does Blood Pressure screening and related
health education is conducting activities in the level of :
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Focused prevention
9) The major goal of health promotion includes all of the following Except:
a. optimizing health
b. focusing on subacute diseases
c. staying health
d. creating new health environment
10) Which of the following is the core principle of health promotion?
a. one or two strategies
b. inequity
c. sustainability
d. disempowerment
11) A person’s health and wellbeing are dependent on a good, good future,
good care, and support. These influences, social, economic, physical,
and environmental factors, are known as:
a. Health care
b. Health promotion
c. Public health
d. Determinants of health.
12) The scope of health promotion in which developing partnerships and
alliances with other organizations and sectors in the community to build
capacity and positively influence health within the wider community is ….
a. Developing personal skills
b. Creating supportive environments
c. Strengthen community action
d. Delivering health public policy
13) The principle of health promotion where people take an active part in
decision making is:
a. Empowerment
b. Participative
c. Holistic
d. Equitable
14) 14) Which audience comment best demonstrates self-efficacy?
a. I believe I can learn to do this.
b. I think the nurse is a real expert in this stuff.
c. Those computer graphics really make it clear how people can do this.
d. Wow. The nurse really expects us to do this
15) Which of the following would be the best question for a nurse to ask to
determine whether an educational intervention had any effect?
a. Are you interested in any other topics for me to teach?
b. Did you find this program useful to you?
c. Do you understand the material I presented?
d. How are you going to apply these ideas at home?
16) In preparing to give a presentation on breast self-examination, a nurse
went to the Rwandan Cancer Center and obtained a variety of handouts
to use during the presentation. Which possibly erroneous assumption is
the nurse make?
a. Handouts are the best technique for emphasizing important points.
b. Handouts will be easily read by people in the audience.
c. People will appreciate the brochures and freebies such as shower hook
reminders.
d. People will use the reminders and put them in their bathrooms
17) Principles of health education includes all except:
a. Participation
b. Motivation
c. Reinforcement
d. Punishment
18) What are the key elements of health promotion?
19) What is the Purpose of health promotion?UNIT7:INTROUCTION TO ENVIRONMENTAL SANITATION
Key unit competence
Apply house and environmental sanitation
Introductory activity 7
1) Observe and think about the environmental aspects of image A, B, and
C
2) Does the status of the above images have an impact on people’s health?
Yes or No? Explain your answer.3) What can you do to maintain a good sanitation in this environment?
7.1. Introduction to environmental health
Learning activity 1.8
1) Identify image(s) that reflect on good environmental health and explain
why.
2) Identify image(s) that reflect on poor environmental health and outline thethree possible health risks for people who live in that area.
7.1.1. Concepts definition
Environment
The term environment refers to “the complex of physical, chemical, and biotic
factors (as climate, soil, and living things) that act upon an organism or an ecologicalcommunity and ultimately determine its form and survival.
The term environment captures the notion of factors that are external to the
individual.
Environment also refers to ssurroundings in which an organization operates,
including air, water, land, natural resources, flora, fauna, humans and their
interrelationships.
Environmental aspect
Element of an organisation’s activities, products or services that interacts or can
interact with the environment – the activity
Environmental condition
A state or characteristic of the environment as determined at a certain point in time.
Environmental impact
Change to the environment (adverse or beneficial), wholly or partly resulting from
the organisation’s environmental aspects – potential change or harm.
The environment has a major impact on the risk of chronic diseases such as
cancers, chronic lung disease, and birth defects and on the risk of acute illnesses
such as viral gastroenteritis, respiratory infections, and such vector-borne diseases
as malaria.
Ecological System (Ecosystem)
An ecosystem is a dynamic complex of plant, animal, and microorganism
communities and the nonliving environment interacting as a functional unit. Humans
are an integral part of ecosystems.
Survival of the human population depends upon ecosystems, which aid in supplying
clean air and water as part of the earth’s life support system. Ecosystems are being
degraded with increasing rapidity because of human environmental impacts such
as urbanization and deforestation. Degradation of ecosystems poses environmental
dangers such as loss of the oxygen-producing capacity of plants and loss of
biodiversity.
Environmental Health
Environmental health comprises those aspects of human health, including quality of
life, that are determined by physical, chemical, biological, social and psychosocial
factors in the
environment. It also refers to the theory and practice of assessing, correcting,
controlling, and preventing those factors in the environment that can potentially
affect adversely the health of present and future generations.” (World HealthOrganization)
Environmental pollution
Pollution is the introduction of contaminants into the natural environment that
causes adverse change. Pollution can take the form of chemical substances
or energy, such as noise, heat or light. Pollutants, the components of pollution,
can be either foreign substances/energies or naturally occurring contaminants.
Environmental pollution is one of the most serious problems facing humanity and
other life forms on our planet today.
“Environmental pollution is defined as “the contamination of the physical and
biological components of the earth/atmosphere system to such an extent that
normal environmental processes are adversely affected.” Pollutants can be naturally
occurring substances or energies, but they are considered contaminants when in
excess of natural levels. Any use of natural resources at a rate higher than nature’s
capacity to restore itself can result in pollution of air, water, and land.
Environmental pollution is of different types namely air, water, soil, noise and
light-weight. These cause damage to the living system. How pollution interacts
with public health, environmental medicine and the environment has undergone
dramatic change.
Environmental health Prevention
Prevention lies at the core of environmental public health. It includes not only the
control of hazards but also health promotion through environmental strategies.
Prevention in environmental health extends upstream to the root causes of
environmental change and to the resulting environmental pressures that eventually
have an impact on human health and well-being.
Actions to reduce or control the hazards (or to promote environmental health) can
be taken at all points in this chain of events. In this three-level model:
Primary prevention involves interventions prior to the development of any signs of
ill health. In the case of environmental health, strategies directed toward modifying
driving forces, pressures, and state of the environment are primary prevention
efforts.
Secondary prevention is early detection of a health problem, prior to the onset of
disease, for the purpose of intervening at an early stage to prevent the development
of the disease. In environmental health this is usually a preventive effort targeting
the phase when exposure has begun to occur but prior to the development of any
health impacts.
Tertiary prevention involves early identification and treatment of people with
a disease, to prevent or forestall disability and/or death. An example of tertiary
prevention is the effort to ensure that patients with asthma follow recommended
guidelines for medical treatment and environmental remediation in order to reducethe frequency and severity of asthma attacks.
7.1.2. Essential Services of Environmental Health
1. Monitor environmental and health status to identify and solve community
environmental health problems.
2. Diagnose and investigate health problems and health hazards in the
community.
3. Inform, educate, and empower people about health issues.
4. Mobilize community partnerships and action to identify and solve health
problems.
5. Develop policies and plans that support individual and community
environmental health efforts.
6. Enforce laws and regulations that protect environmental health and ensure
safety.
7. Link people to needed environmental health services and assure the
provision of health care when otherwise unavailable.
8. Assure a competent public health and personal health care workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and population
based environmental health services.
10. Research for new insights and innovative solutions to environmental healthproblems.
Self-assessment 7.1
1) What is the difference between environment and environment health?
2) What are the environment impacts that degrade the Ecosystem?
3) Why is it important to assess and control environmental factors?
4) Explain environmental pollution and outline its types.
5) Enumerate 4 essential services of Environmental Health7.2. Sanitation
Learning activity 7.2
7.2.1. Definition
Sanitation is the hygienic means of promoting health through prevention of human
contact with the hazards of wastes. Hazards can be physical, microbiological,
biological or chemical agents of disease. Wastes that can cause health problems
are human and animal feces, solid wastes, domestic wastewater (sewage, sullage,
greywater), industrial wastes, and agricultural wastes.
Sanitation generally refers to the provision of facilities and services for the safe
disposal of human urine and faeces.
7.2.2. Objectives of Sanitation
a. Protect and promote Health
Keeping disease carrying waste and insects away from the people, toilets and
home, break the spread of disease, prevent spreading of waterborne diseases,and improve the health and quality of life.
b. Protect environment against pollution
Keeping disease carrying waste and insects away from the environment prevent
environment from pollution (air, soil and emission) and prevent contamination ofwater resources (surfaces and ground water)
7.2.3. Types of Sanitation
Basic sanitation: refers to the management of human feces at the household
level.
On-site sanitation: the collection and treatment of waste is done where it is
deposited. Examples are the use of pit latrines, septic tanks, and imhoff tanks.
Off-site sanitation: A sanitation system, in which waste is collected, transported
away from the plot where it was generated and treated.
Food sanitation: refers to the hygienic measures for ensuring food safety.
Environmental sanitation: the control of environmental factors that form links
in disease transmission. Subsets of this category are solid waste management,
water and wastewater treatment, industrial waste treatment and noise and pollution
control.
Ecological sanitation: a concept and an approach of recycling to nature the
nutrients from human and animal wastes. Ecological sanitation is based on
composting or vermicomposting toilets where an extra separation of urine and
feces at the source for sanitization and recycling has been done. It thus eliminates
the creation of backwater and eliminates fecal pathogens from any still presentwastewater (urine).
7.2.4. Poor sanitation
Poor sanitation is linked to transmission of diseases such as cholera, diarrhea,
dysentery, hepatitis A, typhoid, polio and stunting. Poor sanitation reduces human
wellbeing, social and economic development. Poor sanitation also is a major cause
of neglected tropical diseases such as intestinal worms, schistosomiasis and
trachoma. Poor sanitation contributes to malnutrition.
a. The main causes of poor sanitation and solutions
The biggest cause of poor sanitation globally is simply lack of education. Even the
simple act of washing hands regularly can have a huge impact on the overall health
of a community. There are many causes of poor sanitation, let’s explore a few ofthese.
Open defecation
This is an area we focus on as Ecoflo-WASH has the capacity to help communities
with composting toilets that will alleviate many of the issues surrounding open
defecation. Put simply, open defecation fouls surrounding environments and is a
major cause for the spread of preventable diseases.
Unsafe drinking water
Unsafe, untreated and contaminated drinking water is estimated to cause more
than 500,000 diarrhoeal deaths each year. Many of these could be prevented
with simple sanitary practices and clean drinking water. Diseases like diarrhoea,
cholera, dysentery, typhoid and polio are rife in areas where clean drinking water
isn’t available.
High density living
In areas where informal or temporary / semi-permanent settlements crop up, the
high-density nature of these areas along with less access to sanitation programs
and products means there’s a high likelihood of sewage and waste not being dealt
with properly.
Lack of education
This is a relatively easy issue to combat as education starts typically in the form of
school programs teaching children the importance of healthy habits when it comesto sanitation, waste control, clean drinking water and washing their hands.
7.2.5. Benefit of improving sanitation
Benefits of improved sanitation extend well beyond reducing the risk of diarrhea.
These include: reducing the spread of intestinal worms, schistosomiasis and
trachoma, which are neglected tropical diseases that cause suffering for millions;
reducing the severity and impact of malnutrition; promoting dignity and boosting
safety, particularly among women and girls; promoting school attendance: girls’
school attendance is particularly boosted by the provision of separate sanitary
facilities; and potential recovery of water, renewable energy and nutrients fromfaecal waste.
Self-assessment 7.2
1) Define sanitation
2) Explain the objectives of sanitation?
3) Explain 2 factors that may contribute to poor sanitation4) What are the benefits of improving Sanitation?
7.3. Environmental Sanitation
Learning activity 7.3
In the previous lessons we learnt about environment and sanitation, Please
think more on that lesson and respond to the following questions:
1) What do you think is environmental sanitation?
2) What do you think as characteristics of good environment sanitation?3) What can you do to maintain a good environmental sanitation?
7.3.1. Definition of environmental sanitation
Environmental sanitation is a set of interventions that reduce peoples’ exposure to
disease by providing a clean environment in which to live, with measures to break
the cycle of disease. This usually includes hygienic management of human and
animal excreta, solid waste, wastewater, and storm water; the control of disease
vectors; and the provision of washing facilities for personal and domestic hygiene.
Environmental Sanitation involves both behaviors and facilities that work togetherto form a hygienic environment
7.3.2. Importance of environmental Sanitation
There are so many reasons why sanitation and hygiene are crucial.
a. Protecting from illnesses and diseases
The lack of sanitation in water and nutrition kills many people. Eating contaminated
food has been shown to be one of the leading causes of worm infections. Individuals
who live in neglected houses suffer from asthma conditions, experience more fall
and slip injuries, and can get microbial infections from germs growing up in their
bathrooms and kitchens. Maintaining a good environmental sanitation enhance the
prevention of illness and diseases.
b. Maintaining mental health
Maintaining good sanitation and hygiene also plays an essential role in nourishing
mental health. Researchers have long linked mental stress and anxiety to messy
environments and lack of organization. Mental health also comes hand-in-hand
with physical health, and each of them will always impact the other in turn. A healthy
body will nurture a healthy mind, and the opposite holds true as well.
c. Improving self-image and self confidence
By ensuring the house, nutrition, and lifestyle are sanitary and by guiding population
through proper personal hygiene care, are empowering them to be the best
versions of themselves. As a result, their self-image improves and they gain more
self-confidence.
d. Improving population social status
Good environmental sanitation improve social status of the population, because the
people are clean, no skin rashes or other pathology their sociability will increase.
e. Increasing population focus and productivity
Providing the optimum environment for them, both physically and mentally, will help
them grow. They’ll grow as balanced individuals who strive to achieve the best
versions of themselves, and they’ll have an adequate environment that helps in
achieving that. They’ll be able to focus more on their work or studies without any
distractions or limitations. As a result, their productivity will increase, allowing them
to achieve more growth and nourishment.
f. Providing a better quality of life
By maintaining proper sanitation and ensuring good hygiene, create the perfect
environment for the community. Making the most out of living conditions, and, in
doing so, it provides a better quality of life. The quality of life provided can be
measured by the lack of illnesses and diseases, the lack of psychological issues,and the growth they experience while living under your roof.
7.3.3. Characteristics of environmental sanitation
7.3.4. Strategies to improve environmental sanitation
The improved sanitation shall be promoted through a combination of measures:
Awareness campaigns related to visible and non-visible health impacts of poor
sanitation and aiming at behavior change;
Marketing the sanitation offer, targeting on people’s expectations and preferences
such as comfort, status, health benefits, value or safety;
Education and training in schools and universities; Urban and rural population about
the maintenance of environmental sanitation
Provision of limited material incentives or subsidies to accelerate the improvement,
construction or replacement of sanitary facilities; using the provision of water supply
services as an incentive and opportunity to improve sanitation facilities.Self-assessment 7.3
1) In which way good environmental sanitation can improve population
social status: Choose the correct answer
a. If the people are clean, no skin rashes or other pathology their sociability
will rise
b. If the people are clean, with skin rashes or other pathology their sociability
will rise
c. If the people are clean, no skin rashes or other pathology their sociability
will decrease
d. If the people are dirty, no skin rashes or other pathology their sociability
will rise
2) Define Environmental sanitation
3) Outline two strategies that my enhance environmental sanitation
improvement
4) Explain how environmental sanitation increase population focus andproductivity
7.4. Human excreta management
Learning activity 7.4
Observe the above image A and B respond to the following questions:
1) What are the sanitation problems do you observe?
2) What do you think as consequences of the sanitation problems observed
for human health?
3) What advices can you give to that people in order to resolve the observed
problems
7.4.1. Introduction
Human excreta are the wastes products of the human digestive system, menses
and human metabolism including urines and feces.
Human excreta should be disposed safely in order to avoid contamination of the
environment, food or hands. Safe disposal of excreta is crucial to ensure a health
environment and for protecting personal health; is one of the principal ways ofbreaking the fecal -oral disease transmission cycle.
Bacterial, viral and parasitic zoonotic pathogens that transmit via the fecal-oral
route have a major impact on global health. A well-established sanitation system is
a key barrier to disease transmission.7.4.2. Sanitation system
A sanitation system is a combination of different functional units and technologies
for safe collection, transport, treatment or disposal of human waste in order toprotect people and environment.
Safe sanitation is essential for health; for preventing infection, improving and
maintaining mental and social well-being. The lack of safe sanitation systems leads
to infection and disease, including: Diarrhea, a major public health concern and a
leading cause of disease and death among children under five years in low- and
middle-income countries, neglected tropical diseases such as soil-transmitted
helminth infections, schistosomiasis and trachoma that cause a significant
burden globally and Vector-borne diseases such as West Nile Virus or lymphaticfilariasis through poor sanitation facilitating the proliferation of Culex mosquitos.
7.4.3. Components of a sanitation system
Figure 7.4 2 Components of sanitation system
A sanitation system has five components: User interface, Collection and storage,
Conveyance, Treatment, Use and /or Disposal
a. User interface
The user interface is the way in which the sanitation system is accessed. The user
interface strongly influences the technological choices of subsequent processes.
The following should be considered while siting the on-site systems:
• An on-site sanitation system must not be located over a surface water body
and should be at 30 m from the edge of the flood plain of a surface water
body.
• Onsite systems should be sited away from trees to prevent obstruction of
their features such as ventilation pipes.
• On-site system should be constructed with enough space for easy access
and movement during desludging.
• Soil conditions such as rocky outcrops, unstable ground and depressions
with shallow water table should be avoided as much as possible.
They are two types of toilets depending on operational modes:
Dry toilets: A dry toilet refers to a toilet that operates without flushing water. The
design for dry toilets requires careful judgment and considerations for the following
features:
• The slab or pedestal (user can sit on) base should be well sized to the pit so
that it is both safe for the user and prevents storm water from infiltrating thepit (which may cause it to overflow).
• For smooth emptying, the slab should provide a hole for desludging with
cover,
• Slab should be at least 150 mm above the ground level with a hole covered
with a lid when not in use.
• The hole should be closed with a lid to prevent unwanted intrusion from
insects or rodents entering the containment technology. The lid also controls
odours and flies from the toilets.
• The pit should be lined with stones or burnt clay bricks to prevent the collapse
of the earth.
• The superstructure should be designed and constructed so that it prevents
intrusion of rainwater, storm water, animals, rodents or insects. It should also
provide maximum level of privacy. Features of the superstructure include:
– Roof should be waterproof to ensure user comfort (protection against the rain
and sun)
– Ventilation should be provided between the walls and roof for aeration,
– Door with a locker.
• Accessible handwashing facilities with soap and water should be available
nearby in a location that encourages use.
Operation maintenance of dry toilets
The following practices should be respected in operation and maintenance for dry
toilets:
• Operation and maintenance of the interface (toilet) should be practiced to
avoid risk of illness to public health.
• Cleanliness: The toilet and all surfaces of the room (e.g. bathroom, washroom,
rest room, cubicle, etc.) should be kept clean and free of excreta.
• Cleaning arrangements: Locally-available cleaning materials should be
safely stored and used, and all people carrying out cleaning should observe
safe working practices.
• Where dry toilets are used as public ones, the following should be specifically
catered for operation and maintenance:
– Safety (adequate lighting, no slippery grounds or surface, firm construction
and cleaning agents), privacy (doors with lockers) and accessibility should be
ensured,
– Public toilets should be placed again with a visible sign for visitors’ convenience,
– Each public toilet should have at least one toilet for the people with disability.
They should have bigger doors for wheel chair access, and railing for support
near the latrines.
– Each public toilet should also be well designed to meet the needs of the
children and pregnant women.
Water-based toilet: flush toilets; toilets that uses water.
The design of water-based toilets should consider the following minimum
requirements to ensure safely managed sanitation across the service chain.
• The water seal at the bottom of the pour flush toilet or plan should have a
slope of at least 25o.
• Water seal should be made out of plastic or ceramic to prevent clogs and to
make cleaning easer (concrete may clog super easily if it is rough or textured),
• The s shape of the water seal determines how much water is needed for
flushing and optimal depth of the water seal head should be approximately 2
cm to minimize the water required to flush the excreta,
• The trap should be approximately 7 cm in diameter
• For public toilets, the design should mention clear sign boards for visitors and
at least one door for disabled (with big door with wheel chair access) and
railing for support near accessible,
• Appropriateness: Pour flush toilet is appropriate for those who sit or squat
(pedestal or slab) as well as for those who cleanse with water. It is also
appropriate when there is a constant supply of water
Operation and maintenance
• Pour flush toilets rarely require repair. However, it should be cleaned regularly
to maintain hygiene and prevent the build-up of stains.
• To reduce water requirements for flushing and to prevent clogging, it is
recommended that dry cleansing materials and products used for menstrual
hygiene be collected separately and not flushed down the toilets.
• For pour flush toilets used as public toilets, priority should be given to efficientflush toilets5 which can reduce each full flush, from 11 to 3 litres per flush.
b. Collection and storage
The products generated at the user interface need to be collected and stored safely.
In the case of extended storage, some treatment may be provided, though it is
generally minimal and dependent on storage time.
Where groundwater is used as a drinking-water source, a risk assessment should
ensure that there is sufficient vertical and horizontal distance between the base
of a permeable container, soak pit or leach field and the local water table and/or
drinking-water source (allowing at least 15 m horizontal distance and 1.5 m vertical
distance between permeable containers and drinking-water sources is suggested
as a rule of thumb).
When any tank or pit is fitted with an outlet, this should discharge to a soak pit,
leach field or piped sewer. It should not discharge to an open drain, water body or
open ground. Where products from storage or treatment in an on-site containment
technology are handled for end use or disposal, risk assessments should ensureworkers and/or downstream consumers adopt safe operating procedures.
Table 7.4 1 Examples of Collection and storage technologies
c. Conveyance of wastes products
Consist of empting and transport of products from one functional group to another.
Full latrines must be either emptied or moved to a new location. Latrines should
be emptied in a safe and hygienic manner by well trained, equipped and protected
workers (e.g., gloves, masks, hats, full overalls and enclosed waterproof footwear)
who transport the sludge to a treatment, use or disposal site.
For septic tanks, a common rule is that they should be emptied when the solids’component of the waste fills between one-half and two-thirds of the. Based on the
most common sizes, septic tanks should be cleaned, at the least, every five to
seven years.
The choice of the technology for emptying and transportation depends on different
factors including types and quantity of products to be transported, distance to cover,
accessibility, topography, soil and ground characteristics, financial resources and
availability of the service provider
They are two types of emptying and transportation of Feacal sludge:
• Human powered emptying technologies:
Human powered emptying technologies have been innovatively developed in
recent years. These technologies are appropriate for areas that are not served or
not accessible by vacuum trucks, or where vacuum truck emptying is too costly.
They are well suited to dense, urban and informal settlements. The most common
types of human powered emptying equipment including Sludge Gulper, Diaphragm
pump, Nibbler and semi-manual pit emptying technology.
• Fully motorized emptying and transportation technologies
Fully motorized emptying and transport technologies refer to a vehicle equipped
with a motorized pump and a storage tank for emptying and transporting faecal.
The pump is connected to a hose, which is lowered down into the tank or pit, and
the sludge is sucked up into the holding tank of the vehicle. These technologies are
powered by the electricity, fuel or pneumatic systems. Provide an essential service
to unsewered areas. They are more used in urban areas with good road and to
containments that are easily accessible. They can also be used to empty schools,
public places and public institutions.
d. Treatment of Fecal sludge
Treatment helps to protect the environment and public health from fecal pathogens
and other contaminants. The treatment facility should be designed and operated
according to the specific end use/disposal objective and operated using a risk
assessment and management approach to identify, manage and monitor risk
throughout the system.
Generally, faecal sludge treatment plants treat faecal sludge in three steps: (i) solid/
liquid separation, (ii) dewatering and (iii) stabilization of further treatment.
From the technical performance, investment needed for installation, operation
and maintenance (O&M) perspective for different systems, the following treatment
systems for faecal sludge are most appropriate in Rwanda:
• Imhoff tanks: Can treat high organic loads and are resistant to organic shock
loads. Space requirements are low and Imhoff tanks can be used in warm
and cold climates. As the tank is very high, it can be built underground if thegroundwater table is low and the location is not flood-prone.
• Settling/thickening tank: It is a low-cost technology for treating faecal
sludge, low operating costs can be built and repaired with locally available
materials and no energy is required.
• Unplanted drying beds: Have low operating costs, can be built and repaired
with locally available materials, no energy is required and good dewatering
efficiency.
• Anaerobic digestion (for biogas production): It is a net energy-producing
process which produces renewable energy in the form of biogas. The liquid
digestate is a better fertilizer in many ways than normal chemical fertilizers.
The digestate produces fewer odours when it is spread on farmland, and is
less likely cause pollution of local rivers and streams and spreading untreated
manure.
• Solar drying beds: Solar greenhouse is the use of renewable energy
sources, reduces the cost of drying. The dried sewage sludge is characterized
by a smaller volume and a ceramic structure, which facilitates storage and
transport.
• LaDePa (Latrine Dehydration and Pasteurization): Converts raw FS
from pit latrine, public toilets and households’ septic tanks into enriched and
pelletized compost, low-cost technology with limited energy requirement.
• Co-composting: Enriches soil, helping retain moisture and suppress plant
diseases and pests, reduces the need for chemical fertilizers, encourages the
production of beneficial bacteria and fungi that break down organic matter to
create humus, a rich nutrient-filled material
e. Disposal / Reuse
Excreta should be disposed or used in ways that are the least harmful to people
and environment. Workers handling effluent or faecal sludge (FS) should be trained
on the risks and on standard operating procedures and use personal protective
equipment. A multi-barrier approach (i.e., the use of more than one control measure
as a barrier against any pathogen hazard) should be used.
There are different options for FS use, particularly as a soil conditioner (land
application in raw form or as compost or co-compost), building material (cement
mixture), biofuel (gas, char briquettes) and in the production of protein (e.g., animal
feed and via the black soldier fly). Inappropriate disposal in soils and leach field are
discouraged.
In Rwanda, faecal sludge is mostly used as a soil conditioner for agriculture
purposes especially in rural areas to schools and prison farms. However, the end
products should be well treated to avoid illness that may occur once in contact with
them. The dewatered solid content seen with no viable reusable option is disposedin either dumpsite or sanitary landfill.
Self-assessment 7.4
1) Family of X live in rural area where it is difficult to access water, which kind
of toilet will you advise them to use and why? Enumerate the features to
consider while designing that toilet.
2) Enumerate and explain three components of a sanitation system?
3) What are benefits of safe excreta disposal?
4) Talk about a urine diverting toilet?
5) Differentiate Cistern Flush toilet from a flush pour toilet6) Define a septic tank and give its class in a sanitation system component
7.5. Animal Excreta management
Learning activity 1.8
Observe carefully the above image and respond to the following questions
1) Think about the practices observed on image A
2) What may be the consequences of practices on image A?
3) What do you think will be good practices can you advise to the people on
image A.
4) Think about image B, what is your observation?
7.5.1. Definition
Animal excreta consist of animal feces and urines; also called manure. Animal
manure contains significant number of micro-organisms such as bacteria, virus and
parasites, responsible of many diseases in humans.
7.5.2. Importance of Animal excreta management
Animal excreta may cause pollution of air and water. If animal excreta are well
managed; it can be beneficial to the population.
Management of animal excreta has a great importance on environment, health and
economy:
• Environment: Reduce detrimental environmental effects; prevent the
environment impacts on air, soil, wildlife and the marine, reduces greenhouse
gas emission from waste, reduces liter and odor and prevent the risks of
flood.
• Economy: Increases business opportunities, provides savings to
business, especially in resources extraction and use, by waste prevention
actions recovery and/or recycling activities, achieves economic saving
by improvements in human health and the environment leading to higher
productivity, lower medical costs, better environmental quality and the
maintenance of ecosystem services. Capturing methane as biogas provides
cooking fuel and lighting that can replace firewood and charcoal.
• Agriculture: used as fertilizer, promote sustainable agriculture and increase
crop production.
• Public Health: Protects human health and safety in community and at waste
management facilities, minimize the risks associated with the wastes, and
improves occupational health. Prevent transmission of zoonotic diseases that
be transmitted through manure.
7.5.3. Animal excreta management practices
Safe and effective animal excreta management practices are key to prevention of
disease transmission from animal excreta to human.
Animal excreta management is done into four steps: Collection, storage, treatmentand reuse or application.
a. Excreta collection or manure collection
Manure collection is very dependent on livestock housing.
Zero –grazing system that consist of confinement of animals in housing with open
sheds with roofing, sloping, concrete floor , slurry pit and manger. Frequent dung
removal is recommended and if possible separate urine collection and drainage
to limit Nitrogen loss. Remove manure as frequent as possible, locally available
materials such tridents, hoe and basket may be used to handle manure.
Deep litter system: these are system where layers of bedding material are
repeatedly spread on older layers as the get soiled. Deep litter poultry ensure a
collect moisture balance in the litter. Prevent any water spills from drinker and addlitter when necessary.
c. Treatment of animal excreta
They are three most common ways of treating manure:
• Drying: urines and feces captured using bedding materials
• Composting: is the natural process of decomposition of organic matter by
micro -organism under aerobic condition.
• Anaerobic digestion: anaerobic digestion is biological process that produces
biogas.
d. Manure application
Consist of safe use of manure in agriculture as fertilizer.
Manure application rates vary according to the type of animal, Collection and
storage method available soil nutrient content and the crop cultivated.General rule; apply two handfuls of solid manure (cattle, goat, sheep etc) or one
handful of poultry manure per hole/plant.
7.5.4. Animal manure, potential pathogens and illnesses Caused
in humans
Animal excreta can cause many illnesses if handled inappropriately.
The table below summarizes potential pathogens and illness caused in humans
7.5.5. Different ways to block transmission of pathogen fromanimal excreta
• Treat your water to make it safe to drink
• Wash your hands
• Prepare food well (e.g., washing vegetables with safe water)
• Cover food and water to prevent contact from animals and flies
• Fence or tether animals
• Fence gardens to prevent animals from accessing them
• Wear protective footwear to prevent soil-transmitted helminth infections
• Remove excreta from the living environment and treat/dispose in a safelocation
Self-assessment 7.5
1) What is the collect sequence of animal excreta management:
a. Collection, storage, treatment and application
b. Collection, treatment, reuse and storage,
c. Storage, Collection, treatment and application
d. Treatment, reuse, Collection, and storage,2) Match the following items:
7.6. Solid waste management overview
Self-assessment 7.6
In your community you have various waste resulted from home activities,
community population activities, industries, and medical waste.
Based on observed waste in your community, respond to the following questions:
1) What types of solid wastes do you observe in your community?2) What do you do to manage them?
7.6.1. Introduction
Waste in general is defined as materials, which have lost their value to their first
owners. In other words, the term waste is used to describe materials that are
perceived to be of negative value.
“Solid Waste” is defined as a solid material possessing a negative economic
value, which suggests that it is cheaper to discard than to use.
Solid waste is another type of human wastes, which refers to the solid or semi-solid
forms of wastes that are discarded as useless or unwanted. It includes food wastes,
rubbish, ashes and residues, etc.
Solid wastes generated from human activities include those from residential,
commercial, street sweepings, institutional and industrial categories. Solid waste
can create significant health problems and a very unpleasant living environment if
not disposed of safely and appropriately. If not correctly disposed of, waste may
provide breeding sites for insect-vectors, pests, snakes and vermin (rats) that
increase the likelihood of disease transmission. It may also pollute water sources
and the environment. All generated solid waste must be managed to minimize
environmental impact and to protect human health.
7.6.2. Classification of solid waste
Solid waste can be classified into two categories by its characteristics. These are:
Organic solid waste and Inorganic Solid waste
Organic solid waste: Wastes that are generally biodegradable and decompose in
the process of which emits offensive and irritating smell when left unattended.
Putrescible wastes e.g., Garbage
Inorganic solid waste: Solid matter that does not decompose at any rat. This
category of waste matter may be combustible depending on the type of the nature
of the material they constitute. Non-putrescible wastes e.g., Rubbish7.6.3. Solid Waste Management
The most environmentally preferred strategy consists of reduction of waste
production. Through source reduction, the volume of solid waste that must be
deposited in landfills is limited, e.g: Improved packaging designs that reduce the
number of materials that must be discarded (e.g., the use of smaller packages for
products); design products, such as refillable bottles, that can be reused.
Solid waste management consists of four steps: storage, collection, transportation,
and disposal.
a. Storage
Storage is a system for keeping materials after they have been discarded and prior
to collection and final disposal. Where on-site disposal systems are implemented,
such as where people discard items directly into family pits, storage may not be
necessary. In emergency situations, especially in the early stages, it is likely that
the affected population will discard domestic waste in poorly defined heaps close to
dwelling areas. If this is the case, improved disposal or storage facilities should be
provided fairly quickly and these should be located where people are able to use
them easily. Improved storage facilities include:
• Small containers: household containers, plastic bins, etc
• Large containers: communal bins, oil drums, etc.
• Shallow pits: is larger-diameter sewer that carry both solid and liquid wastes.
• Communal depots: walled or fenced-in areas
In determining the size, quantity and distribution of storage facilities the number
of users, type of waste and maximum walking distance must be considered. The
frequency of emptying must also be determined, and it should be ensured that allfacilities are reasonably safe from theft or vandalism.
b. Collection
Collection simply refers to how waste is collected for transportation to the final
disposal site. Any collection system should be carefully planned to ensure that
storage facilities do not become overloaded. Collection intervals and volumes of
collected waste must be estimated carefully. Waste collection services are provided
by private operators or companies based on door-to-door collection. Waste is
collected using specific trucks which are dominated by used roll-on-trucks owned
by private operators.
c. Transportation
This is the stage when solid waste is transported to the final disposal site. There
are various modes of transport which may be adopted and the chosen method
depends upon local availability and the volume of waste to be transported. Types of
transportation can be divided into three categories:
• Human-powered: open hand-cart, hand-cart with bins, wheelbarrow, tricycle
• Animal-powered: donkey-drawn cart
• Motorized: tractor and trailer, standard truck, tipper-truck
d. Disposal
The final stage of solid waste management is safe disposal where associated risks
are minimized. There are four main methods for the disposal of solid waste: Land
application (burial or landfilling), compositing, Burning or incineration and recycling.
i. Land application: burial or landfilling
A landfill is an engineered pit, in which layers of solid waste are filled, compacted
and covered for final disposal. It is lined at the bottom to prevent groundwater
pollution.
Advantages
Effective disposal method if managed well
Sanitary disposal method if managed effectively
Energy production and fast degradation if designed as a bioreactor landfill
Disadvantages
Fills up quickly if waste is not reduced and reusable waste is not collected separately
and recycled
A reasonably large area is required
Risk of groundwater contamination if not sealed correctly or the liner system isdamaged
High costs for high-tech landfills
If not managed well, there is a risk of the landfill degenerating into an open dump
Once the landfill site is shut down Operation, Maintenance (O&M) and monitoring
must continue for the following 50 to 100 years.
ii. Composting
Defined as “the aerobic biological decomposition of organic materials (e.g., leaves,
grass, and food scraps) to produce a stable humus-like product. A natural process
that breaks down organic material (material that once came from a living thing) to
create a valuable soil amendment.
Items that can be composted include: vegetable scraps, fruit scraps, nuts,
nutshells, eggshells, coffee grounds, tea leaves, yard trimmings, grass clippings,leaves, twigs, woodchips and straw
Figure 7.6 1 Organic waste compositing at the landfill
Benefits of composting
• Supports healthy soil structure and plant growth
• Creates valuable resource for agriculture, including a home garden
• Reduces the amount of waste to be collected and transported
• Eliminates the need for chemical fertilizers by serving as a homemade organic
fertilizer
• Soil holds water better
• Reduces methane emissions from landfills
• Costs very little to get started and nothing to operate, can be done at home
How to Use the Compost
• Place it around the plant that requires extra attention
• Cover the compost layer with soil
• Add extra compost on top by scooping out a small proportion of the soil from
around the plant
• Create a shallow dip to make watering easy and for runoff to not occur
Wait a few weeks so that the plants have time to grow. Hopefully, when they’re
grown, you will be able to see the effect compost has on your plants.
iii. Burning or incineration
Incineration is defined as the controlled burning of solid, liquid, or gaseous wastes.
In other words; incineration is a treatment technology involving the destruction ofwaste by controlled burning at high temperatures.
Burning wastes at home is dangerous to public health and environment; chemicals
released into the air cause serious air pollution and are related to illnesses such as
cancer. Smoke from burning is hazardous to human health, especially lungs. Also
bothers eyes, nose, and throat. Plastics are especially dangerous than wood, paper
and some construction debris.
Benefits of Waste Incineration
Proper and responsible waste incineration provides various benefits:
Some progressive countries use modern waste treatment and incineration facilities
to convert heat used in the burning of trash to electric power.
The incinerator bottom ash can be used as an aggregate in creating lightweight
blocks, pavement concrete, bulk fill, and more. Environment conscious entities are
using novel technologies to create bricks, tiles, shingles, and other construction
materials from ash.
Incineration can decrease the solid mass of the original waste, which is already
compacted by garbage trucks, to a further 80 to 85%. It can also reduce the volume
of trash up to 95%.
The reduction of solid waste by incineration drastically reduces the amount of trash
that ends up in a landfill.
Incineration can also be used to treat hazardous waste (such as materials
contaminated with hazardous chemicals) or medical waste (such as hospital waste
contaminated with blood or other potentially infectious materials). The high heat of
incineration can destroy these hazards. Hazardous and medical wastes can only
go to special incinerators that are permitted to treat these types of wastes.Safety precautions of burning and burying solid waste
• Combustible waste should always be separated from non-combustible waste
before being loaded into the burn chamber.
• The incinerator should have had sufficient air pollution controls, meets specific
air emission standards
• If burning and incineration is used, the equipment chosen should be designed
and sized to accommodate the waste produced, minimize fire hazard and
result in the complete combustion of the waste.
• Burn waste as far away as possible from people and items that can catch fire,
such as your house
• Burn it in a pit or a barrel to prevent fire spreading
• Bury ashes in a pit or landfill; they may have dangerous substances in them
• Locate the site at least 500 meters away and downhill from drinking water
sources.
• Ensure that there is at least 2 meters between the bottom of the disposal pit
and the highest annual groundwater level. The more distance between the
bottom of the pit and the groundwater, the lower the risk of contamination.
• Do not dispose waste in an area susceptible to flooding.
• Locate the site in clay-like soil if possible. The smaller the soil grain size, the
lower the risk of soil and groundwater contamination. Do not dispose waste
in sandy areas.
• Cover waste with 0.1 meters of soil or ash regularly (e.g., daily or weekly) to
reduce smells and pests, and prevent waste from blowing away.
• Construct a fence to keep animals and children out of the disposal site.
iv. Recycling
Recycling is defined as the process of “collecting and reprocessing a resource
so it can be used again,” e.g: collecting aluminum cans, melting them down, and
using the aluminum to make new cans or other aluminum products.” Recycling is
taking a product, breaking it down from its current form and making something new
from the same material
Items that can be recycled are: Papers, metal, plastics and glass.
Benefits of recycling
• Reduces emissions of greenhouse gases
• Prevents pollution generated by the use of new materials,
• Decreases the number of materials shipped to landfills, thereby reducing theneed for new landfills,
• Recycling companies often pay for materials, income can be generated
• Preserves natural resources, opens up new manufacturing employment
opportunities and Saves energy
Self-assessment 7.3
1) Wastes that are generally biodegradable and decompose in the process
of which emits offensive and irritating smell when left unattended. These
wastes are known as:
a. Inorganic wastes
b. Organic wastes
c. Metal Wastes
d. Paper Wastes
2) One of the following items is the benefit of waste composting
a. Supports healthy soil structure and plant growth
b. Eliminates the need for chemical fertilizers by serving as a homemade
inorganic fertilizer
c. Increase methane emissions from landfills
d. Discourage household because composting consume much time3) Match each concept with its definition
4) define the following terms
a. waste
b. solid waste5) outline 5 safety precautions of burning and burying solid waste
7.7. Hazards waste management
Learning activity 7.7
Observe the above images and respond to the following questions
1) What do you consider as difference or similarities between images in row
A?
2) Illustrate the difference between images in row A and B
3) What to do you think as risks to the environment or Human health can beresulted from Images in row A if are not well handled?
7.7.1. Definition
Hazardous waste: is a contaminant that is a dangerous good and is no longer
wanted or is unusable for its original intended purpose and is intended for storage,recycling, treatment or disposal
Hazardous waste is waste that is dangerous or potentially harmful to our health
or the environment. Hazardous wastes can be liquids, solids, gases, sludge’s,
discarded commercial products (e.g., cleaning fluids or pesticides), or the by
products of manufacturing processes.
7.7.2. Categories of hazardous waste
a. Radio-active substance
Radioactive waste is the type of hazardous waste that contains radioactive
material. Radioactive waste is a by-product of various nuclear technology
processes, industries based on nuclear medicine, nuclear research, nuclear power,
manufacturing, construction, coal and rare-earth mining and nuclear weapons
reprocessing. Any substances capable of emitting ionizing radiation are said to
be radioactive and are hazardous because prolonged exposure often results in
damage to living organisms.
b. Chemicals
The hazardous chemical wastes can be categorized into five group’s namely
synthetic organics, inorganic metals, salts, acids and bases, and flammables and
explosives. Some of the chemicals are hazardous because they threaten human
lives.
c. Bio-medical wastes
The main sources of hazardous biological wastes are from hospitals and biological
research facilities. The biological waste has the capability of infecting other living
organisms and has the ability to produce toxins. Biomedical waste mainly includes
malignant tissues discarded during surgical procedures and contaminated materials,
such as hypodermic needles, bandages and outdated drugs.
d. Flammable wastes
The hazardous waste category also includes flammable wastes. This grouping is
necessary because of risk involved in storage, collection and disposal of flammable
wastes. The flammable wastes may be of solid, liquid or gaseous form. Examples
of flammable waste include organic solvents, oils, plasticizers and organic sludge’s.
e. Explosives
Explosive hazardous wastes are mainly ordnance (artillery) materials. Explosives
also involve high potential for hazard in case of storage, collection and disposal.
These types of wastes may exist in solid, liquid or gaseous form.
7.7.3. Risks of hazardous waste
Hazardous waste presents a danger to the environment, or to people in the nearby
vicinity if it is not handled correctly. Inhalation, ingestion, or dermal exposure to
hazardous materials can cause significant harm to humans, animals and plantswhilst the environment can and has been damaged by improper disposal. Hazardous
waste presents a serious danger if:
It’s released into the air, water, or land and can contaminate the surrounding
environment
A large amount is released at one time, or if small amounts are released frequently
at the same location
It comes into contact with humans via skin contact, ingestion, or breathing in
hazardous materials
Improper storage or disposal leading to spills and leaks which can lead to fires
Hazardous wastes can cause dermatitis to the skin, some cause asthma on long
exposure, and others cause the eyes to smart and run and also tightening of the
chest
7.7.4. Principles of hazardous waste management
a. Requirement for Environmental Impact
No person shall engage in any activity likely to generate any hazardous waste
without a valid Environmental Impact Assessment Certificate issued by a competent
Authority.
b. Collection of hazardous waste
Any generator of hazardous waste shall ensure that all hazardous waste generated
are collected in appropriate manner.
c. Segregation of hazardous waste
The segregation for hazardous waste must meet the following requirements:
• All hazardous waste must be segregated to prevent incompatible mixtures;
• The segregation can be done by hazard class
d. Packing material for hazardous waste
The packing materials of hazardous waste shall be: inert and not react with the
hazardous waste the materials which can be used include: Steel; Aluminium;
Natural Wood; Plywood; Reconstituted wood.
e. Types of containers for hazardous waste packing
The hazardous waste containers shall be in the following types: Bags; Boxes;
Drums; Jerrycans; Combination packaging; Composite packaging.
f. Characteristics of containers
The containers when used for packaging of hazardous wastes shall meet the
following requirements:
Container shall be of mild steel with suitable corrosion-resistant coating and roll-on
roll-off cover or plastic drums, cardboard cartons for a variety of wastes. However,
all such containers should hold up mechanical handling; the containers for liquid
hazardous waste should be completely closed, in fact sealed. Container should
be easy to handle during transportation and also emptying. Manual handling of
containers should be minimized to the extent possible.
g. Packaging of hazardous waste
The containers of hazardous waste must be able to withstand normal handling
and retain integrity for at least six months. In general, packaging for hazardous
waste must meet the following requirements: All packaging material shall be of
such strength, construction and type that they would not break or become defective
during transportation; Packaging material should be such that there will be no
significant chemical or galvanic action among any of the material in the package.
h. Labeling of hazardous waste
All hazardous waste containers must be clearly labeled showing all its contents.
The labels must be waterproof and firmly stuck to the containers so that they cannot
be removed. Containers storing hazardous waste shall be labeled with the words
“HAZARDOUS WASTE” in official language or Warning or caution statements
which may include any of the following as appropriate: the words “WARNING” or
“CAUTION”. The information on the label must include the waste type, origin (name,
address, telephone number of generator), hazardous property (flammable), and the
symbol for the hazardous property (The red square with flame symbol).
i. Transportation for hazardous waste
The following are requirements pertaining to the transportation of hazardous wastes:
• The transportation vehicles and containers shall be suitably designed to
handle the hazardous wastes and must be closed at all times;
• Vehicles shall be painted preferably in blue color to facilitate easy identification;
• Vehicle should be fitted with mechanical handling equipment for safe handling
and transportation of wastes;
• The words “HAZARDOUS WASTE” shall be displayed on all sides of the
vehicle in one of the officials’ languages;
• Transporter shall carry documents of manifest for the wastes during
transportation;
• The trucks shall be dedicated for transportation of hazardous wastes and
they shall not be used for any other purpose;
• Each vehicle shall carry first-aid kit, spill control equipment and fire
extinguisher;
• Driver(s) shall be properly trained for handling the emergency situations and
safety aspects involved in the transportation of hazardous wastes;
• The design of the trucks shall be such that there is no spillage duringtransportation.
j. Storage facilities for hazardous waste
The following are requirements pertaining to the storage of hazardous waste
facilities:
• The storage area should have a proper containment system. The containment
system should have a collection area to collect and remove any leak, spill or
precipitation;
• No open storage is permissible and the designated hazardous waste storage
area shall have proper enclosures, including safety requirements;
• Proper stacking of drums with wooden frames shall be practiced; d. In case of
spills/leaks, cotton shall be used for cleaning instead of water;
• Signboards showing precautionary measures to be taken in case of normal
and emergency situations shall be displayed at appropriate locations;
• Manual operations within storage area are to be avoided to the extent possible.
In case of personnel use, proper precautions need to be taken, particularly
during loading/unloading of liquid hazardous waste in drums.
k. Treatment of Hazardous Waste
Any person who generates hazardous waste shall treat or cause to be treated
such hazardous waste using the classes of incinerators manner. Any products
treated shall be disposed of or treated in accordance with the conditions set by the
Regulatory Authority in consultation with the concerned stakeholders.
Do not dispose hazardous waste in latrines, drainage channels, water sources or
on the ground.
Dispose hazardous waste in a separate landfill site from general household waste
l. Exportation permit
No person shall export hazardous wastes without a valid permit issued by a nationalcompetent Authority.
Self-assessment 7.7
1) Define hazardous waste
2) Talk about hazardous Bio-medical wastes
3) Give the typical information should appear on label of hazardous waste?
4) Explain 2 requirements pertaining to the storage of hazardous waste
facilities5) Discuss the hazardous waste treatment
7.8. Domestic waste water management
Learning activity 7.8
Observe carefully the above image and respond to the following questions
1) Think about the names the waste water A and B?
2) Do you think that there is a difference between the waste water A and
waste water B. If yes what is the difference between them.3) What do you think as the importance of managing waste A and waste B
7.8.1. Definition
Domestic waste water is the wastewater that is produced due to human activities in
households. They are three types of domestic water:
• Black water: A mixture of urine, faeces and flush water along with anal
cleansing water (if water is used for cleansing) and/or dry cleansing materials.
Black water contains pathogens of faeces and the nutrients of urine that are
diluted in flush water.
• Grey water: Water generated from domestic activities; such as laundry,
dish washing, bathing, cleaning and in the kitchen except water from toilets.
Usually has low levels of pathogens, especially compared to black water.
Any pathogens are usually from cross-contamination with excreta. Fecal
pathogens can end up in grey water through hand washing after defecation,
washing children after defection, and washing children’s diapers. Grey water
may also have other contaminants like oil, grease, soap, detergent or other
household chemicals.
• Overflow water: Waste water that has spilled from wells or water points.
Normally it has very low levels of pathogens. However, overflow water can
quickly become contaminated with pathogens from human and animal feces
when it is not well managed and causes standing water.
Domestic wastes water have a negative impact on the environment and public
health if is not well managed. The table below summarizes the domestic wastewater components and its environmental effect
Table 7.8 1 Domestic waste water pollution
7.8.2. Importance of domestic waste water management
Domestic waste water management aims to remove the wastewater pollutants in
other to protect the environment and protect public health.
• Environment: Prevent pollution of surface or ground water sources such as
ocean, lakes, rivers and streams. It prevents euthrophication and pollution
of sensitive aquatic systems (surface water, groundwater, drinking water
reservoirs) as well as terrestrial systems (irrigated soil). It preserves aquatic
life from toxics and biological decomposition of pollutants that may kills fishes
and other aquatic livings.
• Public health: management of domestic waste water aim to protect public
health by eliminating waterborne diseases. It creates an effective physical
barrier between contaminated wastewater and user, as well as avoid odor
emissions and stagnant water leading to breeding sites for mosquitoes.
• Infrastructure: It prevents erosion of shelter and facilities such roads, bridges
etc.
• Agriculture: well, treated domestic water may be used in agriculture to
irrigate crops.
• Economic: Treatment of domestic water aim to prevent the use of excessive
water as treated water may be recycled and reused thus by reducing the costof water.
7.8.3. Management of Domestic waste water
Management of domestic waste water may be done in two ways: on site management
and off-site management
Off-site safely managed sanitation: A sanitation system, in which domestic waste
water is collected, transported away from the plot where it was generated and treated.
Following this, remaining products are either disposed or re-used. Currently, there
are few safe treatment options for off-site faecal sludge management in Rwanda.
On-site safely managed sanitation: A sanitation system or technology in which
faecal sludge is contained, collected, stored, emptied and treated on the institutionalor household plot where it was generated.
a. Management of black water
Methods and processes to manage fecal sludge (The settled contents of pit latrines
and septic tanks) and sewage (Untreated wastewater which contains feces and
urine) were discussed previously in five components of a sanitation system; through
collection, transport and treatment of faecal sludge from pit latrines, septic tanks or
other on-site sanitation systems.
b. Management of grey water
The amount of grey water produced depends on how much water a person uses in
a day. A household with no water shortages and a piped supply typically produces
about 90–120 liters/person/day. But this can be much less, especially in water
scarce areas where people must fetch their water and use only 20–30 litres/person/
day.
The most main step in management of grey water is to control the source by
reducing the amount of grey water contamination in the first place.
i. Collection and containment
Grey water may be managed by on site system by collecting and containing water
using soak pits, grease trap and septic tanks.
ii. Treatment of grey water
The grey water may be treated using different methods:
Physical treatment: In this stage, physical methods are used for cleaning the
wastewater. Processes like screening, sedimentation and skimming are used to
remove the solids. No chemicals are involved in this process.
One of the main techniques of physical wastewater treatment includes sedimentation,
which is a process of suspending the insoluble/heavy particles from the wastewater.
Once the insoluble material settles down at the bottom, you can separate the pure
water.
Another effective physical water treatment technique includes aeration. This process
consists of circulating air through the water to provide oxygen to it. Filtration, the
third method, is used for filtering out all the contaminants. You can use special
kind of filters to pass the wastewater and separate the contaminants and insoluble
particles present in it. The sand filter is the most commonly used filter. The grease
found on the surface of some wastewater can also be removed easily through this
method.
Biological water treatment:
This uses various biological processes to break down the organic matter present in
wastewater, such as soap, human waste, oils and food. Microorganisms metabolize
organic matter in the wastewater in biological treatment. It can be divided into three
categories:
• Aerobic processes: Bacteria decomposes the organic matter and converts
it into carbon dioxide that can be used by plants. Oxygen is used in this
process.
• Anaerobic processes: Here, fermentation is used for fermenting the waste at
a specific temperature. Oxygen is not used in anaerobic process.
• Composting: A type of aerobic process where wastewater is treated by mixing
it with sawdust or other carbon sources.
Chemical waste water treatment
Secondary treatment removes most of the solids present in wastewater, however,
some dissolved nutrients such as nitrogen and phosphorous may remain
As the name suggests, this treatment involves the use of chemicals in water.
Chlorine, an oxidizing chemical, is commonly used to kill bacteria which decompose
water by adding contaminants to it. Another oxidizing agent used for purifying
the wastewater is ozone. Neutralization is a technique where an acid or base is
added to bring the water to its natural pH of 7. Chemicals prevent the bacteria from
reproducing in water, thus making the water pure.
c. Reuse and disposal of grey water
Reuse grey water to irrigate household gardens and agricultural crops
Reuse grey water as toilet flush water.
Dispose of grey water into the ground using a soak pit or infiltration trench
Discharge grey water into a surface water body (e.g., pond, stream, river, lake)
7.8.4. Overflow water management
Over flow water should be channeled away so that it does not cause standing water.
Overflow water that does not drain away from water points could backflow into the
water source and possibly contaminate the drinking water. Or the overflow water
can cause the soil to erode away and damage the water point structure. Overflow
water may be used as irrigation water for agriculture. It may be infiltrated into the
ground using soak pits and infiltration trenches. Over flow water may be released
directly to surface waters (e.g., lakes, rivers or ponds). Overflow water does not
normally require treatment before it can be used, infiltrated or disposed.
Self-assessment 7.8
1) What is blackwater and where does it come from?
2) What is greywater and where does it come from?
3) What is overflow water and where does it come from?
4) What are options to manage greywater?
5) What are options to manage overflow water?
7.9. Environmental sanitations inspections
Learning activity 7.9
In the previous lessons, you leant about sanitation and environmental sanitation,
human and animal excreta management, solid waste water management and
domestic waste water management. Based on these covered lessons:
1) What do you think as environmental inspection?
2) What can you think as benefits and purpose of an environmental sanitationinspection?
7.9.1. Environmental sanitations inspections overview
An environmental sanitation inspection is onsite inspection of environmental
sanitation practices and technologies, to identify potential source and transmission
of diseases related to unsafe water, poor sanitation and poor hygiene. Community
representatives, government officers such as environmental health inspectors,
or field officers from national and international organizations, may use sanitary
inspections.
Environmental sanitation inspection focuses on Domestic wastewater, excreta
management, and public facilities. Solid waste and vector control.
7.9.2. The benefits and purpose of an environmental sanitation
inspection.
Environmental sanitations inspection helps to:
• Provide a simple and fast means of assessing and identifying hazards
associated with unsanitary practices
• Observation and inspection of community and household practice• Identify potential and actual risks
• Useful in assessing small community upgrading options
• Identify WASH practices: excreta management, hygiene, domestic wastewater
• Management, animal excreta management, vector control and solid waste
management.
• Identify potential sources of microbiological (fecal) contamination
7.9.3. Environmental sanitations inspections data collection
methods
During Data, collection different method of data collection may be used such as
Observation and Interview.
Observation can be used for observing the presence or absence of things and
their condition. It may also indicate some behavioral practices. For example, you
can directly observe solid waste in drainage ditches, or the lack of a latrine facility,
or animal excreta management practices.
Interview may be necessary to collect information about practices and behavior,
as they are hard to observe directly. For example, defecation practices, hygiene
practices, and the presence or absence of vectors.
7.9.4. Environmental sanitation inspection forms
Environmental sanitation inspection uses standardized environmental sanitation
inspection forms to ensure consistent assessments. Inspectors use appropriate
forms for the situation being assessed. Questions on the form are designed in asimple way by open-ended question by Yes or No to reduce subjectivity
a. Environmental sanitation Inspection Form: Animal Excreta management
b. Environmental Sanitation Inspection Form: Domestic waste water
Management
C.Environmental Sanitation Inspection Form: Human Excreta Management
d. Environmental sanitation inspection forms: Public facilitiesSelf-assessment 7.9
1) Why do we use environmental sanitation inspection forms?
2) During inspection, you find that the goats and cows lives in the same
house with the family member. What will be you recommendation to the
family and why?
3) Is it dangerous for pregnant women to live with cats in the household?
Yes or No , explain you answer.
4) What data gathering methods could you use to learn about excreta
management practices in a community?
5) What is environmental inspection?End unit assessment 7
1) A dynamic complex of plant, animal, and microorganism communities
and the nonliving environment interacting as a functional unit is:
a. Environment
b. Ecosystem
c. Environmental health
d. Environmental sanitation
2) The contamination of the physical and biological components of the
earth/atmosphere system to such an extent that normal environmental
processes are adversely affected is:
a. Environmental pollution
b. Environmental health Prevention
c. Primary prevention
d. Tertiary prevention
3) The biggest cause of poor sanitation globally is:
a. Lack of education
b. Lack of hand washing
c. Lack of pure water supply
d. Lack of food industry
4) The below items are benefits of improved sanitation except;
a. Reducing the spread of intestinal worms
b. Reducing the severity and impact of malnutrition
c. Promoting dignity and boosting safety
d. Curing the intestinal worms
5) Sanitation system is:
a. Essential for health; for boosting virus vaccination, improving and
maintaining mental and social well-being
b. A combination of different functional units and technologies for safe
collection, transport, treatment or disposal of human waste.
c. Water seal made out of plastic or ceramic to prevent clogs and to make
cleaning easer
d. Well designed to meet the needs of the children and pregnant women.
6) The name of Water generated from domestic activities; such as laundry,
dish washing, bathing, cleaning and in the kitchen except water from
toilets is:
a. Overflow water
b. Black water
c. Grey water
d. No correct answer
7) Explain the importance of disposing safely the human excreta
8) Give difference between dry toilet and wet toilet
9) Explain the way of treating the Manure
10) Explain the ways of using compost
11) Outline 5 safety precautions of burning or burying solid waste
12) Give 3 benefits of recycling solid waste
13) Explain 5 Precautions of transporting hazardous waste
14) Discuss the importance of domestic wastewater management to public
health
15) Enumerate 2 methods used in data collection during environmental
sanitations inspections.
UNIT8:INTRODUCTION TO PALLIATIVE CARE
Apply the principles of palliative care to alleviate pain, support psychologically and
spiritually the individuals, families and community during life threatening illnessesand during end-of-life period
Introductory activity 8
1) What do the pictures A, B, C, D, and E have in common?2) What do you think is the focus of this unit 8?
Definition:
The World Health Organization (WHO) defined Palliative care “as an approach
to care which improves quality of life of patients and their families facing life
threatening illness, through the prevention, assessment and treatment of pain and
other physical, psychological and spiritual problems.”
The primary goal of palliative care:
It is to help patients and families achieve the best possible quality of life.
The goals of palliative care:
For patients with active, progressive, far-advanced disease, the goals of palliative
care are
• To provide relief from pain and other physical symptoms
• To maximize the quality of life
• To provide psychosocial and spiritual care
• To provide support to help the family during the patient’s illness and
bereavement
Scope of palliative care:
Although it is especially important in advanced or chronic illness, it is appropriate
for patients of any age, with any diagnosis, at any time, or in any setting.
Patients who have complex serious illnesses often benefit from palliative care
throughout the course of their illness, even while seeking treatment for their disease.
As the goals of care change and cure for illnesses becomes less likely, the focus
shifts to more palliative care strategies. Palliative care interventions are not only
appropriate at the end of life. Making this distinction is important because some
patients, family members, or health care professionals refuse helpful palliative careinterventions, believing that palliative care is only for the dying.
to care which improves quality of life of patients and their families facing life
threatening illness, through the prevention, assessment and treatment of pain and
other physical, psychological and spiritual problems.”
The primary goal of palliative care:
It is to help patients and families achieve the best possible quality of life.
The goals of palliative care:
For patients with active, progressive, far-advanced disease, the goals of palliative
care are
• To provide relief from pain and other physical symptoms
• To maximize the quality of life
• To provide psychosocial and spiritual care
• To provide support to help the family during the patient’s illness and
bereavement
Scope of palliative care:
Although it is especially important in advanced or chronic illness, it is appropriate
for patients of any age, with any diagnosis, at any time, or in any setting.
Patients who have complex serious illnesses often benefit from palliative care
throughout the course of their illness, even while seeking treatment for their disease.
As the goals of care change and cure for illnesses becomes less likely, the focus
shifts to more palliative care strategies. Palliative care interventions are not only
appropriate at the end of life. Making this distinction is important because some
patients, family members, or health care professionals refuse helpful palliative careinterventions, believing that palliative care is only for the dying.
8.1. Historical background of palliative care
Self-assessment 8.1
1) Shortly explain at least 4 timeline of important events in the history of
palliative care
At the end of the Second World War in 1945, people in Western societies were tired
of death, pain, and suffering. Cultural goals shifted away from war-centered activities
to a focus on progress, use of technology for better living, and improvements in
the health and well-being of the public. Guided by new scientific knowledge and
new technologies, health care services became diversified and specialized andlifesaving at all costs became a powerful driving force.
End-of-life care was limited to postmortem rituals, and the actual caregiving of
dying patients was left to nursing staff. Palliative nursing in those days depended
on the good will and personal skills of individual nurses, yet what they offered was
invisible, unrecognized, and unrewarded.
Thanks to the efforts of many people across the years, end-of-life care is
acknowledged today as an important component of integrated health care services.
Much knowledge has accrued about what makes for good palliative care, and
nurses have been in the forefront of efforts to improve quality of life for patients and
families throughout the experience of illness.
The nurse gives attention to the physical, psychological, social, spiritual, and
existential aspects of the patient and family—whole person care.Below is a brief timeline of important events in the history of palliative care:
• 1967: Palliative care was born out of the hospice movement. Dame
Cicely Saunders is widely regarded as the founder of the hospice movement.
She had degrees in nursing, social work, and medicine. She introduced
the idea of “total pain,” which included the physical, emotional, social, and
spiritual dimensions of distress. Saunders opened St. Christopher’s Hospice
in London in 1967.
• 1969: Elisabeth Kübler-Ross published her book On Death and Dying. In
this book, she defined the five stages of grief through which many terminally
ill patients progress: denial, anger, bargaining, depression, and acceptance.
Although we now believe dying patients do not necessarily go through these
phases and that these phases do not necessarily occur in a set order, Kübler
Ross’s book and lectures raised public consciousness about care for patients
at the end of life.
• 1974: Florence Wald, the dean of Yale School of Nursing, was so inspired by
a lecture by Dr. Saunders at Yale that she went to visit St. Christopher’s in
1969. Florence Wald then founded the first hospice in the United States, in
Branford, Connecticut, in 1974. At the start of the hospice movement in the
United States, most hospices were home based and volunteer led.
• 1974: Dr. Balfour Mount, a surgical oncologist from McGill University, coined
the term “palliative care” to distinguish it from hospice care. While hospice
falls under the umbrella of palliative care, palliative care can be provided from
the time of diagnosis of a serious illness and concurrently with curative or life
prolonging treatment.
• 1990: The World Health Organization recognized palliative care as a
distinct specialty dedicated to relieving suffering and improving quality of life
for patients with life-limiting illness.
• 1997: The Institute of Medicine report “Approaching Death: Improving
Care at the End of Life” noted discrepancies between what the American public
wanted for end-of-life care and how Americans were experiencing end of life
in the United States. With tremendous support from multiple philanthropic
foundations, multifaceted efforts were made to promote palliative care.
• 2006: The American Board of Medical Specialties (ABMS) and the
Accreditation Council for Graduate Medical Education (ACGME) recognized
hospice and palliative care as its own specialty.
• 2010: The New England Journal of Medicine published a study by Dr.
Jennifer Temel and colleagues that showed that people with lung cancer
who received early palliative care in addition to standard oncologic care
experienced less depression and increased quality of life and survived 2.7months longer than those receiving standard oncologic care.
Self-assessment 8.1
1) What did world Health Organization do in 1990 as regards to palliative
care?
2) What are the five stages of grief according to Elisabeth Kübler-Ross 1969
book on death and dying?
3) How did Dr. Balfour Mount distinguish hospice care from palliative carein1974?
8.2. Components of palliative care
Learning activity 8.2
Use the following link and watch the video on palliative care: https://www.youtube.
com/watch?v=TZCI25C8tEQ
With use of student text book of fundamentals of nursing or any relevant book,
discusses the components of palliative care
Palliative care incorporates the whole spectrum of care—medical, nursing,
psychological, social, cultural and spiritual. A holistic approach, incorporating these
wider aspects of care is essential in palliative care.
The following table illustrates the components of palliative care, or the aspects of
care and treatment that need to be addressed, follow logically from the causes of
suffering. Each has to be addressed in the provision of comprehensive palliativecare, making a multidisciplinary approach to care a necessity.
Treatment of pain and physical symptoms are addressed first because it is not
possible to deal with the psychosocial aspects of care if the patient has unrelieved
pain or other distressing physical symptoms.
The various causes of suffering are interdependent and unrecognized or
unresolved problems relating to one cause may cause or exacerbate other aspects
of suffering.
Unrelieved pain can cause or aggravate psychosocial problems. These psychosocial
components of suffering will not be treated successfully until the pain is relieved.
Pain may be aggravated by unrecognized or untreated psychosocial problems.
No amount of well prescribed analgesia will relieve the patient’s pain until the
psychosocial problems are addressed.
Palliative care nursing reflects a “whole-person” philosophy of care implemented
across the lifespan and across diverse health care settings.
Relieving suffering and enhancing quality of life include the following: providing
effective pain and symptom management; addressing psychosocial and spiritual
needs of the patient and family; incorporating cultural values and attitudes into the
plan of care; supporting those who are experiencing loss, grief, and bereavement;
promoting ethical and legal decision-making; advocating for personal wishes and
preferences; using therapeutic communication skills; and facilitating collaborative
practice.
In addition, in palliative nursing, the “individual” is recognized as a very important
part of the healing relationship. The nurse’s individual relationship with the patient
and family is seen as crucial. This relationship, together with knowledge and skills,
is the essence of palliative care nursing and sets it apart from other areas of nursing
practice.
Palliative care as a therapeutic approach is appropriate for all nurses to practice. It
is an integral part of many nurses’ daily practice, as is clearly demonstrated in work
with the elderly, the neurologically impaired, and infants in the neonatal intensivecare unit.
The palliative care nurse frequently cares for patients experiencing major
stressors, whether physical, psychological, social, spiritual, or existential.
Many of these patients recognize themselves as dying and struggle with this role.
To be dying and to care for someone who is dying are two sides of a complex social
phenomenon. There are roles and obligations for each person. To be labeled as“dying” affects how
Self-assessment 8.2
1) Identify the aspects of care and treatment that need to be addressed in
palliative care2) Explain how the various causes of suffering are interdependent
8.3. Principles of palliative care
Learning activity 8.3
Use the following link and watch the video on palliative care: https://www.youtube.
com/watch?v=TZCI25C8tEQ
With use of student text book of fundamentals of nursing or any relevant book,
discusses the principles of palliative care
The following principles have been informed by research-based evidence:
• A caring attitude
• Consideration of individuality
• Care is patient, family and carer centered
• Care provided is based on assessed need
• Cultural considerations: linking the principles of ethics, humanities, and
human values into every patient- and family-care experience
• Consent
• Choice of site of care
• Effective communication
• Clinical context: Appropriate treatment
• Comprehensive inter-professional care / Multidisciplinary care
• Care excellence
• Consistent medical care
• Coordinated care
• Care should be integrated
• Continuity of care
• Crisis prevention
• Caregiver support
• Continued reassessment
• Advance Care Planning
• Patients, families and carers have access to local and networked services to
meet their needs
• Care is evidence-based, clinically and culturally safe and effective
• Care is equitable
• Scope of care
• Timing of palliative care
• Holistic care
Here below, each of the principles of palliative care is explained:
A caring attitude:
It involves sensitivity, empathy and compassion, and demonstrates concern for the
individual. There is concern for all aspects of a patient’s suffering, not just the medical
problems. There is a non-judgmental approach in which personality, intellect, ethnic
origin, religious belief or any other individual factors do not prejudice the delivery of
optimal care.
Consideration of individuality:
There are psychosocial features and problems that make every patient a unique
individual. These unique characteristics can greatly influence suffering and need to
be taken into account when planning the palliative care for individual patients.
Care is patient, family and career centered:
Patient, family and carer centered care requires that they be actively involved in all
aspects of care, including care planning and setting holistic goals of care. Patients,
families and careers are ‘partners’ in the decision making regarding the provision
of their healthcare. This results in care that aims to ensure ‘patients receive
comprehensive health care that meets their individual needs, and considers the
impact of their health issues on their life and wellbeing. It also aims to ensure that
risks of harm for patients during health care are prevented and managed through
targeted strategies. Comprehensive care is the coordinated delivery of the total
health care required or requested by a patient. This care is aligned with the patient’s
expressed goals of care and healthcare needs, considers the impact of the patient’shealth issues on their life and wellbeing, and is clinically appropriate
Patient, family and carer centered care is an historical cornerstone of end of life
and palliative care. When patients, families and carers are supported by the health
system to actively participate, research has shown that it can lead to increased
patients’ satisfaction with health care services, improved patients’ self-perceptions,
reduced stress and increased empowerment.
Care provided is based on assessed need:
Making care available on the basis of assessed need ensures that every patient,
family and carer gets access to care that is individualised based on their goals,
wishes and circumstances.
A key learning from consultations is that “people’s needs change.” The needs of
the patient, family and carer will vary with time and across care settings during their
palliative and end of life journey.
Needs-based care requires services be available with skilled staff to meet
the needs of patients, families and carers. Regular assessment of need allows
patients, families and carers to describe their changing needs over time and helps
services be responsive, coordinated and flexible in meeting these changing needs
including reassessing care plans and goals of care. Needs-based assessment
drives effective referral and clinical handover therefore, clinical staff must have the
skills to undertake holistic needs assessments as people in their care approach
and reach the end of life helping to ensure that people get the right care in the right
place at the right time.
Cultural considerations: linking the principles of ethics, humanities, and
human values into every patient- and family-care experience:
Ethnic, racial, religious and other cultural factors may have a profound effect on a
patient’s suffering. Cultural differences are to be respected and treatment planned
in a culturally sensitive manner.
Good palliative care is significant in the manner, in which it embraces cultural, ethnic,
and faith differences and preferences, while interweaving the principles of ethics,
humanities, and human values into every patient- and family-care experience
Consent:
The consent of a patient, or those to whom the responsibility is delegated, is
necessary before any treatment is given or withdrawn. In most instances, adequately
informed patients will accept the recommendations made
Choice of site of care:
The patient and family need to be included in any discussion about the site (place/
setting) of care.
The patients with a terminal illness should be managed at home whenever possible.
Effective communication:
Good communication between all the health care professionals involved in a
patient’s care is essential and is fundamental to many aspects of palliative care.
Good communication with patients and families is also essential. Healthcare
providers should develop communication skills including listening, providing
information, facilitating decision making and coordinating care.
Important and potentially difficult discussions are frequently necessary with palliative
care patients, who have active, progressive, far-advanced disease, regarding:
• Breaking bad news
• Further treatment directed at the underlying disease
• Communicating prognoses
• Admission to a palliative care program
• Artificial nutrition
• Artificial hydration
• Medications such as antibiotics
• Do-not-resuscitate orders
• Decisions must be individualized for each patient and should be made in
discussion with the patient and family.
Clinical context: Appropriate treatment:
All palliative treatment should be appropriate to the stage of the patient’s disease and
the prognosis. Over-enthusiastic therapy that is inappropriate and patient neglect
are equally deplorable. Care must be taken to balance technical interventions
with a humanistic orientation to dying patients. The prescription of appropriate
treatment is particularly important in palliative care because of the unnecessary
additional suffering that may be caused by inappropriately active therapy or by lack
of treatment.
When palliative care includes active therapy for the underlying disease, limits should
be observed, appropriate to the patient’s condition and prognosis. Treatment known
to be useless, given because you have to do something’, is unethical.
Where only symptomatic and supportive palliative measures are employed, all
efforts are directed at the relief of suffering and the quality of life, and not necessarily
at the prolongation of life.
Comprehensive inter-professional care / Multidisciplinary care:
The provision of total or comprehensive care for all aspects of a patient’s suffering
requires an interdisciplinary team.
A multidisciplinary team approach is essential to address all relevant areas of
patient care. In order to facilitate a family in crisis to establish and then achieve
mutually agreed upon goals, the palliative care team integrates and coordinates the
assessment and interventions of each team member and creates a comprehensive
plan of care.
A multidisciplinary approach to assessment and treatment is mandatory. Failure to
do this often results in unrelieved pain and unrelieved psychosocial suffering.
Successful palliative care requires attention to all aspects of a patient’s suffering,
which requires input or assistance from a range of medical, nursing and allied
health personnel—a multidisciplinary approach. Established palliative care
services work as a multidisciplinary or inter-professional team.
Multidisciplinary is the term that used to be applied to palliative care teams, but if
the individuals work independently and there are no regular team meetings, patient
care may become fragmented and conflicting information given to patients and
families.
Inter-professional is the term now used for teams that meet on a regular basis to
discuss patient care and develop a unified plan of management for each patient,
and provide support for other members of the team.
Where palliative care services have not yet been established, it is important for
the few professionals providing such care to work as a team, meeting regularly,
planning and reviewing care, and supporting each other.
The patient may be considered a ‘member’ of the team (although they do not
participate in team meetings), as all treatment must be with their consent and in
accordance with their wishes.
The members of the patient’s family can be considered ‘members’, as they have
an important role in the patient’s overall care and their opinions should be included
when formulating a plan of management.
The ideal multidisciplinary team involves:
• Medical staff,
• Nursing staff,
• Social worker
• Physiotherapist
• Occupational therapist
• Dietician
• Psychologist (or liaison psychiatrist)
• Chaplain (or pastoral care worker)
• Volunteers
• Other personnel, as required
• Family members
• Patient
Volunteers play an important role in many palliative care services
Care excellence:
Palliative care should deliver the best possible medical, nursing and allied health
care that is available and appropriate.
Palliative care is active care and requires specific management for specific
conditions. It requires health care providers equipped with quality knowledge and
skills.
Consistent medical care:
Consistent medical management requires that an overall plan of care be established,
and regularly reviewed, for each patient. This will reduce the likelihood of sudden or
unexpected alterations, which can be distressing for the patient and family.
Coordinated care:
It involves the effective organization of the work of the members of the inter
professional team, to provide maximal support and care to the patient and family.
Care planning meetings, to which all members of the team can contribute, and at
which the views of the patient and the family are presented, are used to develop a
plan of care for each individual patient.
Care should be integrated:
Integration of care is an approach that aims to deliver seamless care within the
health system and its interface with social care. It laces people at the centre of care,
providing comprehensive wrap around support for individuals with complex needs
and enabling individuals to access care when and where they need it.
Palliative care is integral to all healthcare settings (hospital, emergency department,
health clinics and homecare).
A more integrated healthcare system is easy to use, navigate and access. It is
responsive to the specific health needs of local communities, providing them with
more choice and greater opportunities to actively engage with the health system.
For service providers and clinicians, integrating care supports them to collaborate
more effectively across health and with social care.
Healthcare providers and patients, families and carers at times describe health
services as being siloed / isolated in their care and in the systems they use to
support that care. This results in care that is delayed and or fragmented and not
supported with timely, transferable data that works across agencies and jurisdictions.
Integrating care is vital to improving outcomes for vulnerable and at-risk populations
and people with complex health and social needs.
Continuity of care:
The provision of continuous symptomatic and supportive care from the time the
patient is first referred until death is basic to the aims of palliative care. Problems
most frequently arise when patients are moved from one place of care to another
and ensuring continuity of all aspects of care is most important.
Crisis prevention:
Good palliative care involves careful planning to prevent the physical and emotional
crises that occur with progressive disease. Many of the clinical problems can be
anticipated and some can be prevented by appropriate management. Patients and
their families should be forewarned of likely problems, and contingency plans made
to minimize physical and emotional distress
Caregiver support:
The relatives of patients with advanced disease are subject to considerable
emotional and physical distress, especially if the patient is being managed at home.
Particular attention must be paid to their needs as the success or failure of palliative
care may depend on the caregivers’ ability to cope
Continued reassessment:
This is a necessity for all patients with advanced disease for whom increasing and
new clinical problems are to be expected. This applies as much to psychosocial
issues as it does to pain and other physical symptoms.
Advance Care Planning:
Advance care planning is a means for patients to record their end-of-life values
and preferences, including their wishes regarding future treatments (or avoidance
of them)
Advance care planning involves a number of processes:
• Informing the patient
• Eliciting preferences
• Identifying a surrogate decision maker to act if the patient is no longer able to
make decisions about their own care
It involves discussions with family members, or at least with the person who is to be
the surrogate decision maker.
The principle of advance care planning is not new. It is common for patients aware
of approaching death to discuss with their carers how they wish to be treated.
However, these wishes have not always been respected, especially if the patient
is urgently taken to hospital and if there is disagreement amongst family members
about what is appropriate treatment. There is less conflict between patients and
their families if advance care planning has been discussed.
Patients, families and carers have access to local and networked services to meet
their needs
Providing care as close to home as possible means that people have access
to high quality, services and supports required to meet their needs, wishes and
circumstances. Home can include a residential aged care facility or a relative’s
home.
Decisions about how close to home it is possible to provide care will start with a
detailed understanding of the patient, family and carer wishes combined with good
clinical judgement and decision-making about safe and practical options. As always
in a patient-centred model of care these options need to be negotiated and agreed
with the patient, family and carer.
Care is evidence-based, clinically and culturally safe and effective
This means that: people receive health care without experiencing preventable harm.
People receive appropriate evidence-based care. There are effective partnerships
between consumers and healthcare providers and organizations at all levels of
healthcare provision, planning and evaluation. Ensuring clinical, cultural and
psychological safety means patients; families and carers experience no negative
consequences.
All people in need should have equitable access to quality care based on assessed
need as they approach and reach the end of life. Ensuring that care provided is in
accordance with best practice recommendations, is organized for quality and is
driven by the collection and reflection of appropriate and meaningful clinical data
are all necessary components of quality systems. Quality and safety in palliative and
end of life care is eroded when there are gaps in resourcing and support available
to those providing such care.
Care is equitable:
We know that some population groups and clinical cohorts do not have equitable
access to care or experience care that is sub-optimal and or culturally unsafe or
inappropriate.
Equity in relation to health care means that patients, families and carers have equal
access to available care for equal need; equal utilization for equal need and equal
quality of care for all.
Evidence shows that care to people approaching and reaching the end of life is
often fragmented and under-utilized by identified population groups or clinical
cohorts. These included Aboriginal people, people under the age of 65, people who
live alone, and people of culturally and linguistically diverse backgrounds, people
with a non-cancer diagnosis, people living with dementia and people living with a
disability.
There is a growing body of evidence indicating that given a choice, patients would
prefer to die at home or as close to home as possible. However, a lack of services
to support that care means that many people die in acute care settings or for people
in rural and remote areas, death occurs far from their local community. A lack of
after-hour support services particularly inhibits carers and family members’ ability
to provide home care.
The next text discusses the principles of palliative care management:
Scope of care:
It includes patients of all ages with life-threatening illness, conditions or injury
requiring symptom relief from physical, psychosocial and spiritual suffering.
Timing of palliative care:
Palliative care should ideally begin at the time of diagnosis of a life threatening
condition and should continue through treatment until death and into the family’s
bereavement.
Holistic care:
Palliative care must endeavor to alleviate suffering in the physical, psychological,
social and spiritual domains of the patient in order to provide the best quality of lifefor the patient and family
Self-assessment 8.3
Explain the following principles of palliative care:
1) Care is integrated and coordinated
2) Care is equitable
3) Holistic care
4) Multidisciplinary care5) Effective communication
8.4. Non-pharmacological Pain management techniques
Learning activity 8.4
Observe the pictures below and answer the asked questions:
1) What are you seeing on the image above?2) Describe the importance of this action on patient pain
8.4.1. Advantages and disadvantages of non-pharmacologicalinterventions
Non-pharmacological pain managements are ways to decrease pain without
medicine. Non-pharmacological pain management interventions are a set of
psychological and physical pain management methods that play a vital role and
can be used both complementarily and independently
a. Advantages of non-pharmacological interventions
Non pharmacological interventions lower medical costs, greater availability to
patients, diversification and ease of use and greater patient satisfaction. They also
reduce the likelihood of dependence on drug interventions by facilitating pain relief
as the first line of treatment.
b. Disadvantages
Disadvantage of non-pharmacological pain management include time consuming,
may request advanced technology such as network in case of video, need the
patient cooperation and understanding its benefits for both nurses and patients in
order to be a successful method.
8.4.2. Non-pharmacological pain management approaches
Non-pharmacological approaches to the relief of pain may be classified as follows 1)
psychological interventions, (2) acupuncture and acupressure, (3) transcutaneous
electrical nerve stimulation, (4) physical therapies
a. Psychological interventions
Psychological interventions include distraction, stress management, hypnosis,
and other cognitive-behavioral interventions. For patients dealing with chronic pain,
psychological interventions plans are designed often involves teaching relaxation
techniques, changing old beliefs about pain, building new coping skills and
addressing anxiety or depression that may accompany pain.
b. Transcutaneous electrical nerve stimulation (TENS)
TENS is a therapy that uses low voltage electrical current to provide pain relief. A
TENS unit consists of a battery-powered device that delivers electrical impulses
through electrodes placed on the surface of your skin.
c. Acupuncture and acupressure
Acupuncture is a traditional Chinese technique that involves the insertion of
extremely fine needles into the skin at specific called acupoints. This may relieve
pain by releasing endorphins, the body’s natural pain-killing chemicals, and by
affecting the part of the brain that governs serotonin, a brain chemical involved with
mood.
Acupressure is a traditional Chinese medicine therapy in which pressure is applied
to a specific point on the body. It is done to free up energy blockages said to cause
health concerns from insomnia to menstrual cramps.
d. Physical therapies
Physical therapies include massage, heat and cold application, physiotherapy,
osteopathy ( a system of complementary medicine involving the treatment of medical
disorders through the manipulation and massage of the skeleton and musculature.
osteopath aims to restore the normal function and stability of the joints to help the
body heal itself.) and chiropractic which is a healthcare profession technic that
cares for a patient’s neuromusculoskeletal system like the bones, nerves, muscles,
tendons, and ligaments. A chiropractor helps manage back and neck pain throughthe use of spinal adjustments to maintain good alignment.
Self-assessment 8.4
1) What is non-pharmacological pain management?
2) Differentiate osteopath and chiropractic
3) What are advantages and disadvantages of non-pharmacological painmanagement
8.5. Additional methods of non-pharmacological painmanagement
Learning activity 8.5
Observe the following picture and answer the questions below:
1) What are you seeing on the image above?2) Describe the importance of the video images on this patient condition
Relaxation Techniques for non-pharmacological pain management
Relaxation exercises calm the mind, lower the amount of stress hormones in the
blood, relax muscles, and elevate the sense of well-being. Using them regularly can
lead to long term changes in the body to counteract the harmful effects of stress.
There is no best relaxation technique for natural pain relief. Just choose whatever
relaxes you, like music, prayer, gardening, going for a walk, or talking with a friend
on the phone. Relaxation techniques can include:
• Aromatherapy is a way of using scents to relax, relieve stress, and decrease
pain. Aromatherapy uses oils, extracts, or fragrances from flowers, herbs, and
trees. They may be inhaled or used during massages, facials, body wraps,
and baths.
• Foursquare breathing. Breathe deeply so that your abdomen expands and
contracts like a balloon with each breath. Inhale to a count of four, hold for a
count of four, exhale to a count of four, then hold to a count of four. Repeat
for ten cycles.
• Tense your muscles and then relax them. Start with the muscles in your
feet then slowly move up your leg. Then move to the muscles of your middlebody, arms, neck and head
• Meditation and yoga may help your mind and body relaxes. They can also
help you have an increased feeling of wellness. Meditation and yoga help you
take the focus off your pain.
• Guided imagery teaches you to imagine a picture in your mind. You learn to
focus on the picture instead of your pain. It may help you learn how to change
the way your body senses and responds to pain.
• Music may help increase energy levels and improve your mood. It may help
reduce pain by triggering your body to release endorphins. These are natural
body chemicals that decrease pain. Music may be used with any of the other
techniques, such as relaxation and distraction.
• Heat helps decrease pain and muscle spasms. Apply heat to the area for 20
to 30 minutes every 2 hours for as many days as directed. Remember to be
cautious in order to avoid to burn the patient
• Ice helps decrease swelling and pain. Ice may also help prevent tissue
damage. Use an ice pack, or put crushed ice in a plastic bag. Cover it with a
towel and place it on the area for 15 to 20 minutes every hour, or as directed.
• Massage therapy may help relax tight muscles and decrease pain.
• Physical therapy teaches you exercises to help improve movement and
strength, and to decrease pain.
• Comfort therapy: Comfort therapy may involve companionship, exercise,
heat/cold application, lotions/massage therapy, meditation, music, art, or
drama therapy, pastoral counseling and positioning.
• Physical and occupational therapy: Physical and occupational therapy
may involve aquatherapy, tone and strengthening and desensitization
• Psychosocial therapy/counseling: Psychosocial therapy/counseling may
involve individual counseling, family counseling and group counseling
• Neurostimulation: Neurostimulation may involve Transcutaneous electricalnerve stimulation (TENS), acupuncture and acupressure.
Self-assessment 8.5
1) What is non -pharmacological pain management?
2) Outline three examples non pharmacological pain management3) What is the best relaxation techniques in pain management?
8.6. Pain evaluation in palliative care
Learning activity 8.6
Watch this picture provide the answers to the questions presented below it:
The above patient is hospitalized in a district hospital and he was diagnosed with
pancreatic cancer at advanced stage. He is experiencing irresistible pain, crying
for help. You give painkiller and after 1 hour he told you that he still experiences
pain and requests additional painkiller.
1) How are you going proceed in managing this patient?
2) What are possible complications that can arise if the pain is not treated?
The pain evaluation should encompass physical, psychological, social and spiritual
components as they all interact upon one another. Untreated chronic pain can cause
different complications including decreased mobility, decreased concentration,
depression, anorexia, sleep disturbances and impaired immunity with all associated
complications that can arise from impaired immune system. Adequate management
of pain will alleviate the complications of pain.
Pain causes distress and suffering for people and their loved ones. Pain can also
increase blood pressure and heart rate, and can negatively affect healing. Pain
keeps people from doing things they enjoy. It can prevent them from talking and
spending time with others. It can affect their mood and their ability to think. Managing
the pain is very important as it helps ease suffering, improving patient comfort and
therefore patient satisfaction. Pain control can facilitate early ambulation, adequate
oxygenation and nutrition and reduce the stress. This helps the speed up the
recovery time and may reduce the risk of developing depression.
The first principle of managing pain is an adequate and full assessment of where
the underlying pain is coming from. Patients may have more than one area of pain
and different pains have different causes. The acronym SOCRATES is used toassess pain:
• Site: Where is the pain? The maximal site of the pain.
• Onset: When did the pain start, and was it sudden or gradual? Include also
whether it is progressive or regressive.
• Character: What is the pain like? An ache? Stabbing?
• Radiation: Does the pain radiate anywhere?
• Associations: Any other signs or symptoms associated with the pain?
• Time course: Does the pain follow any pattern?
• Exacerbating/relieving factors: Does anything change the pain?• Severity: How bad is the pain?
Self-assessment 8.6
1) Using SOCRATES, describe how you can assess pain
2) What is importance of managing of patient pain?3) What are complications associated with pain?
8.7. Psychosocial support
Learning activity 8.7
Mr. F aged 35 is a married with 3 children. The first born is 6 years old; the
second is 4 years old while the last is one year old. He is the chief of his family
and he was working to satisfy his family’s basic needs, his wife is a nurse at
one District hospital. Mr. F has been informed that he has stage IV Metastatic
Melanoma since 6 months ago. He has been receiving chemotherapy over the
duration of his illness. Chemotherapy can cause side effects such as nausea,
vomiting depression, tiredness and thinning or loss of hair. His family cared for
him at home until two weeks ago. He has now moved to a hospice for respite
care. Mr. is a pastor in one protestant church and therefore he receives many
visitors.
1) What do you think could be the psychological impacts of Mr. F’s disease?
2) If you are nurse caring M.r F what do you think as nursing actions that
could help Mr.F alleviate his discomfort other than medication.
End of life is a difficult time for patients and their relatives and careers. It is important
that psychosocial care is provided to palliative patients and their families in various
ways through a range of medical, nursing and allied healthcare professionals. It is
imperative for nurses in palliative care to know about any specific cultural practices,
spiritual and psychosocial conditions of the patients.
The term psychosocial denotes both the psychological, spiritual and social aspects
of a person’s life and may describe the way people make sense of the world.
Psychological characteristics include emotions, thoughts, attitudes, motivation, and
behavior, while social aspects denote the way in which a person relates to and
interacts with their environment.
Psychosocial support is care concerned with the psychological and emotional well
being of the patient and their family or careers, including issues of self-esteem,
insight into an adaptation to the illness and its consequences, communication,
social functioning and relationships. It is a form of care that encourages patients
to express their feelings about the disease while at the same time providing ways
by which the psychological and emotional well-being of such patients and their
caregivers are improved.
In most cases, palliative patients have severe functional and cognitive limitations
requiring support in basic needs, such as hygiene, food, money, medication and
mobility, relying on others for daily life activities, with increasing dysfunction andpsychological repercussions.
8.7.1. Consequences of diagnosis
The psychological and social consequences of a diagnosis of life-limiting illness on
the patient need to be considered. A diagnosis of this kind may provoke a range of
emotional responses in the patient or family member. These include:
• Fear of physical deterioration/ dying; pain/suffering; losing independence; the
consequences of illness or death on loved ones
• Anger at what has happened or what may have caused/ allowed it to happen;
unsuccessful treatment Sadness at approaching the end of life; restriction of
activities due to illness
• Guilt/regret for actions; in some cases for contributing to the development of
the illness
• Changes in sense of identity, adjusting to thinking of themselves as unwell/
dependent
• Loss of self-confidence, sometimes related to loss of physical functioning/
changes in appearance Confusion about what has happened; the future andchoices available.
8.7.2. Importance of psychosocial support
Psychosocial support is very important for patients in palliative care by reducing
both psychological distress and physical symptoms through increasing quality of
life, enhancing coping and reducing levels of pain and nausea with a consequentreduction on demands for hospital resources.
8.7.3. Components of psychosocial support
Psychosocial support and services may include any or all of the following:
• Emotional support, including social activities, companionship and befriending
• Personal care, help with bathing or providing massage and other
complementary therapies
• Assistance in securing financial support
• Help inside and outside the home; for example, cleaning and shopping
• Supplying practical aids such as wheelchairs and other equipment
• Offering counseling and psychological support to help people come to terms
with dying religious/spiritual support, whatever a person’s beliefs
• Practical support in preparing for death, including saying farewell, makingend-of-life decisions and arranging funerals.
8.7.4. Features of psychosocial care
The care taken to address the psychological and social concerns of patients in
palliative care might involve:
Communication
Good communication is at the core of positive end of life experiences. Communication
underpins every aspect of care and is a conduit to psychosocial aspects of care.
Unmet communication needs of people with life limiting illnesses and of carers
can undermine the coordination of care and compromise the provision of relevant
information and subsequent decision-making.
Effective communication and meaningful ongoing conversations during care can
help facilitate knowledge about the palliative patients, their life experiences and
needs of care. Through this increased understanding of the person, it assists in
identifying any emotional, or spiritual concerns they may have which in turn can
improve physical and emotional wellbeing.
Allowing adequate time for communication to occur improves the quality of the
interaction with the person, with research showing a reduction in care time is
achieved due to greater engagement, cooperation and a reduction in distress.
Conversely, poor communication can lead to poor understanding of a person’s
concerns which has a known association with the development of depression and
anxiety.
From the perspective of the family of the person receiving palliative care, their
information needs are critical. Families often wish to be kept informed of their
relative’s condition and value open and timely communication from staff. Deficiencies
in conversations, particularly around changes in their relative’s health status, often
result in family members experiencing feelings of abandonment, anxiety, distress
and fear of the unknown. Fully engaging family members in information sharing
and decision making with honest, open communication can allow them to make
decisions around how best to spend their remaining time with their family member.
Other features:
• Helping patients understand their illness and/or symptoms
• Helping patients to understand their options and plan for the future
• Advocating on behalf of patients/those close to them to ensure they have
access to the best level of care and services available
• Enabling patients and those close to them to express their feelings and
worries related to the illness, listening and showing empathy, providing
comfort through touch as/ when it is appropriate, e.g. holding a patient’s hand
or putting a hand on his or her shoulder. Also, complementary therapies such
as massage
• Helping the patient or family member access any financial aid they may
be entitled to (including benefits, but also charitable trusts/grants where
applicable)
• Practical help with daily activities like grocery shopping
• Arranging personal/social care and organising aids for daily living — setting
up a care package, installing hand rails or other adaptations
• Career support such as making arrangements for respite
• Signposting the patient/those close to them to relevant resources like local
support groups
• Exploring spiritual issues and ensuring the patient is able to continue his or
her religious practices
• Referring the patient or family member to specialist psychological/socialsupport where appropriate
Self-assessment 8.7
1) Psychosocial support is defined as….
a. Means actions that address both the psychological and social needs of
individuals, families and communities
b. Means interventions aimed at curing mental health problems
c. Aims to enhance the self-promoted recovery and resilience of the affected
individual, group and community
d. Means interventions offered to the cadaver after death
2) What are the consequences of deficiency communication to the family
which has a patient under palliative care?
3) Explain the importance of psychosocial support
4) Enumerate three consequences resulting from emotion to palliativepatient or his/her family
8.8. Spiritual support
Learning activity 8.8
Observe the image below and answer the following questions
1) What do you see on the above picture?
2) Describe the importance of the actions which are being done on the
above picture
It is very crucial for nurses in palliative care to know about any specific cultural
practices, spiritual and religious conditions of the patients. Spiritual variables havean important effect mediating physical symptoms and suffering.
8.8.1. Importance of spiritual support in palliative care
Spiritual care has positive effects on individuals’ stress responses, spiritual well
being (such as the balance between physical, psychosocial, and spiritual aspects
of self), sense of integrity and excellence, and interpersonal relationships. Spiritual
care improves people’s spiritual well-being and performance as well as the quality
of their spiritual life.
spiritual status of patient impact the patient decision-making at the end-of-life and
high levels of spiritual wellbeing have been associated with improved quality of life,
improved coping with disease, improved adjustment to diagnosis, better ability to
cope with symptoms and protection against depression, hopelessness and desire
of hastened death. Therefore, improving spiritual support in patients’ palliative care
is a valuable task.
8.8.2. Where to get spiritual support services
In health care system, the spiritual support services can be available either as
pastoral care workers (or spiritual care workers) or be invited from outside of the
health care system and are available to support palliative care team. Pastoral care
workers are trained professionals who can help people work through their feelings.
They can also arrange visits from spiritual leaders such as ministers, priests, rabbis
and imams. Where necessary, they can also educate and support others in caring
roles in providing culturally sensitive spiritual care.
If the person is religious, possible spiritual interventions might include (1) visits from
or referrals to chaplains, pastoral care workers or traditional healers, (2) spiritual or
religious counseling and (3) taking part in religious services.
If the person is not religious, possible spiritual interventions might include (1)
creating a life review, (2) support groups, (3) listening to music, (D) creating artwork,(E) enjoying nature, (F) enjoying other leisure activities.
Self-assessment 8.8
1) Case study: You are at hospital where you have a patient suffering from
liver cancer in advanced stage. She is catholic and the family members
need a sacrament for their patient. Where can you find that spiritual
support?2) What is the importance of spiritual support for a palliative care patient?
8.9. Legal and Ethical issues in Palliative care
Learning activity 8.9
Mr. X is hospitalized for 3 months; he was diagnosed of advanced cancer of the
lungs with metastasis in the liver. The treating team has decided to treat him as
palliative care as there is no curative treatment for his advanced lung cancer.
Mr. X has difficulty in breathing and experience severe pain; he is on strong pain
killers and oxygen via face mask. This morning during the ward round he called
the doctor in front of his wife and said that if he had a cardiac arrest he doesn’t
want to be resuscitated and that if he fails in respiratory failure he doesn’t want
any other mean of advanced respiratory support such as mechanical ventilation.
The doctor asked you to give a paper To Mr. X and to sign for his preferences atend of life.
1) Do you think that it is acceptable to accept such request? Explain your
answer2) By respecting Mr. X request which ethical principles are respected.
Learning activity 8.9
Ethics refer to the moral principles that guide behavior and decision making, and
the branch of knowledge and inquiry that deals with moral principles. Guiding moral
principles arise from a variety of beliefs about right and wrong and behavior.
Bioethics is ethics as applied to human life or health (such as decisions about
abortion or euthanasia).
Palliative and end of life issues are often delicate and controversial and require
skilled, insightful interdisciplinary care. Health care providers encounter many
challenges and ethical dilemmas; ethical principles and code conduct guide them
in decision making.
8.9.1. Ethical principles in palliative care/ end of life care
Ethical principles guide decision making in end of life/palliative care. The following
principles should be applied while providing palliative care and end of life care.
Understanding the principles underlying ethics is important for health care providers
and their patients to solve the problems they face in end of life care. The ethical
principles are autonomy, beneficence, no maleficence, fidelity, justice and veracity.
a. Autonomy
Autonomy refers to the right to make one’s own decisions. It is patient’s right to
self-determination. Everyone has the right to decide what kind of care they should
receive and to have those decisions respected. Respecting patient autonomy is
one of the fundamental principles of nursing ethics. This principle emphasizes on
protection of the patients’ right to self-determination, even for patients who havelost the ability to make decisions. This protection can be achieved by using advance
care directives.
Advance care directives (ADs): ADs are derived from the ethical principles of
patient’ autonomy. They are oral and/or written instructions about the future medical
care of a patient in the event he or she becomes unable to communicate, and loses
the ability to make decisions for any reason. ADs completed by competent person
ordinarily include living wills, health care proxies, and “do not resuscitate” (DNR)
orders.
A living will is a written document in which a competent person provides instructions
regarding health care preferences, and his or her preferences for medical
interventions such as feeding tubes that can be applied to him or her in end-of-life
care. A patient’s living will take effect when the patient loses his or her decision
making abilities.
A health care proxy (also called health care agent or power of attorney for health
care) is the person appointed by the patient to make decisions on the patient’s
behalf when he or she loses the ability to make decision. A health care proxy is
considered the legal representative of the patient in a situation of severe medical
impairment. The responsibility of the healthcare proxy is to decide what the patient
would want, not what the proxy wants.
ADs help ensure that patients receive the care they want and guide the patients’
family members in dealing with the decision-making burden. Another reason for
ADs is to limit the use of expensive, invasive, and useless care not requested by
patients. Researches show that ADs improve the quality of end-of-life care and
reduce the burden of care without increasing mortality.
In many countries, the right of people to self-determination is a legal guarantee.
Each patient’s “right to self-determination” requires informed consent in terms of
medical interventions and treatment. A patient has both the “right to demand the
termination of treatment” (e.g. the discontinuation of life support) and the “right to
refuse treatment altogether”; the exercise of these rights is strictly dependent on
the person. ADs can be updated yearly and/or prior to any hospitalization.
In many countries, the right of competent individuals to express their treatment
preferences autonomously in end-of life care should be met with ethical respect,
taking into account the use of advanced treatments and the prognosis of their
disease. However, this autonomy has some limitations. The decisions made by
a patient should not harm him or her. It is important for healthcare providers to
respect the autonomy of their patient and fulfill their duties to benefit their patientswithout harming them.
b. Non-maleficence
Non-maleficence is the duty to ‘do no harm’. Although this would seem to be
a simple principle to follow, in reality it is complex. Harm can mean intentionally
causing harm, placing someone at risk of harm and unintentionally causing harm.
However, placing a person at risk of harm has many facets. A person may be at risk
of harm as a known consequence of a nursing intervention intended to be helpful.
For example, an individual may react adversely to a medication. Unintentional harm
occurs when the risk could not have been anticipated.
Although some of the nursing interventions might cause pain or some harm, non
maleficence refers to the moral justification behind why the harm is caused. Harm
can be justified if the benefit of the nursing intervention is greater than the harm to
the patient and the intervention is not intended to harm the patient.
c. Beneficence
Beneficence means ‘doing good’. Nurses are obligated to do good; that is, to
implement actions that benefit individuals. However, doing good can also pose
a risk of doing harm. Beneficence requires physicians to defend the most useful
intervention for a given patient. Often, patients’ wishes about end-of-life care are
not expressed through ADs, and the patients’ health care providers and family
members may not be aware of their wishes about end-of-life care.
If a patient is not capable of decision-making, or if the patient has not previously
documented his or her wishes in the event he or she becomes terminally ill, the
end-of-life decision is made by the patient’s Health care provider as a result of
consultations with the patient or the patient’s relatives or the patient’s health care
proxy. In this situation, the responsibility of the Health care provider in the care of
the dying patient should be to advocate the approaches that encourage the delivery
of the best care available to the patient.
d. Justice
Justice is often referred to as fairness. Nurses face decisions where a sense of
justice should prevail. Healthcare providers have an ethical obligation to advocate
for fair and appropriate treatment of patients at the end of life. This can be achieved
through good education and knowledge of improved treatment outcomes.
e. Fidelity
Fidelity means to be faithful to agreements and promises. By virtue of their standing
as professional caregivers, nurses have responsibilities to people in their care,
employers and society, as well as to themselves. Nurses often make promises such
as ‘I’ll be right back with your pain medication’ or ‘I’ll find out for you’. Individuals
take such promises seriously and nurses are obliged to respond within appropriate
time frames. Fidelity principle requires Health Care providers to be honest with their
dying patient about the patients’ prognosis and possible consequences of patients’
disease.
f. Veracity
Veracity refers to telling the truth. Although this seems straight forward, in practice
choices are not always clear. Should a nurse tell the truth when it is known that it will
cause harm? Does a nurse lie when it is known that the lie will relieve anxiety and
fear? Lying to sick or dying people is rarely justified. The loss of trust in the nurse
and the anxiety caused by not knowing the truth usually outweigh any benefits
derived from lying. Truth telling is fundamental to respecting autonomy.
Most patients want to have full knowledge of their disease and its possible
consequences, but this desire may decrease as they approach the end of their life.
Some patients may not want information about their disease. Health care providers
should be skilled in determining their patients’ preferences for information and,
honestly yet sensitively, provide their patients with as much accurate information
as the patients want. Having effective patient-centered communication skills helps
Health Care providers learn and meet the demands of their patients.
8.9.2. Ethical issues in end of life and Palliative care
In the end of life care of a patient, the decision to implement practices to prolong the
patient’s life or to comfort the patient may be difficult for the Health care providers,
patient, family members or health care proxy. The following topics relate to some
situations where difficulty in decision making regarding end of life is encountered:
Cardiopulmonary resuscitation (CPR), advanced respiratory support such as
Mechanical ventilation (MV), artificial nutrition and hydration (ANH), terminal
sedation, withholding and withdrawing treatment, euthanasia and physician
assisted suicide (PAS).
a. Cardiopulmonary resuscitation(CPR)
Although CPR is valuable in the treatment of heart attacks and trauma, sometimes
the use of CPR may not be appropriate for dying patients and may lead to
complications and
Worsen the patients’ quality of life. For some terminally ill patients, CPR is an
undesired intervention. The decision not to perform CPR on a dying patient can
be difficult for healthcare personnel. The decision to administer CPR to a patient
depends on many factors such as patient preferences, the estimated success rate,
the risks of the procedure, and the perceived benefit.
A competent patient may not want to undergo CPR in the event of cardiopulmonary
arrest. This decision is called the” Do not attempt CPR” (DNR decision). Despite
this request, the patient’s family members may ask the Health Care provider to
perform CPR. In this case, if the patient is conscious and has the ability to make
decisions, the patient’s decision is taken into account. Physicians must learn the
CPR demands of patients at risk of cardiopulmonary arrest. DNR decision can be
considered for the following patients
• Patients who may not benefit from CPR;
• Patients for whom CPR will cause permanent damage or loss of consciousness;
• Patients with poor quality of life who are unlikely to recover after CPR.
b. Advanced respiratory support: Mechanical ventilation
Approximately 75% of dying patients experience difficulty breathing or dyspnea.
This feeling can be scary for patients and those who witness it. In end-of-life care,
mechanical ventilation is applied not to prolong the lives of patients but to reduce
their anxiety and to allow them to sleep better and eat more comfortably.
If Mechanical ventilation support does not provide any benefit to the patient or no
longer meets its intended goals, or if the outcome is not optimal, or the quality of
life is not acceptable according to the patient’s or family’s wishes, support can be
terminated. The timing of the device separation should be chosen by the patient’s
family members.
c. Advanced Nutrition and Hydration(ANH)
Nutrition and hydration are essential parts of human flourishing. ANH involves
giving food and water to patients who are unconscious or unable to swallow.
Artificial nutrition can be given through enteral feeding by tube or parenteral feeding.
Nutrition and hydration decisions are among the most emotionally and ethically
challenging decisions in end-of-life care. Many medical associations suggest that
feeding and hydration treatments are forms of palliative care that meet basic human
needs and must be given to patients at the end of life.
ANH may improve the survival and quality of life of some patients. It may improve
the nutritional status of patients with nutritional problems. ANH is associated with
considerable risks such as the aspiration pneumonia, diarrhea, and gastrointestinal
discomfort.
For these reasons, the benefits and possible harms of the intervention should be
explained to the patient or to the other decision-makers in detail before making the
ANH decision.
If a patient is incompetent, his or her proxy decision-maker can refuse artificial
feeding and hydration on behalf of the patient.
d. Terminal Sedation
Terminal sedation is a medical intervention used in patients at the end of life, usually
as a last effort to relieve suffering when death is inevitable. Sedatives are used forterminal sedation. People have some concerns about terminal sedation because
the treatment of an unconscious patient is sensitive and risky. The purpose of
terminal sedation is not to cause or accelerate death but to alleviate pain that is
unresponsive to other means.
There are four criteria for evaluating a patient for terminal sedation:
• The patient has a terminal illness.
• Severe symptoms are present, the symptoms are not responsive to treatment,
and the symptoms are intolerable to the patient.
• A “do not resuscitate” order is in effect.
• Death is imminent (hours to days).
e. Withholding and Withdrawing treatment
Withdrawing is a term used to mean that a life-sustaining intervention presently
being given is stopped. Withholding is a term used to mean that life-sustaining
treatment is not initiated or increased.
The decision to withhold or withdraw interventions or treatment is one of the
difficult decisions in end-of-life care that causes ethical dilemmas. If a patient and
physician agree that there is no benefit in continuing an intervention, the right action
is withholding or withdrawing the interventions.
In most countries, the legal opinion is that patients cannot seek treatment that is
not in their best interest and, that physicians should not strive to protect life at all
costs. However, if there is doubt, the decision must be in favor of preserving life. All
healthcare professionals should be able to define an ethical approach to making
decisions about withholding and withdrawing treatment that takes into account the
law, government guidance, evidentiary base, and available resources.
f. Euthanasia
Euthanasia, is a Greek word meaning ‘good death’, Euthanasia is applied in two
ways as active or passive euthanasia.
Active euthanasia involves actions to bring about an individual’s death directly. In
active euthanasia, a person (generally a physician) administers a medication, such
as a sedative and neuromuscular relaxant, to intentionally end a patient’s life at the
mentally competent patient’s explicit request.
Passive euthanasia: Passive euthanasia occurs when a patient suffers from
an incurable disease and decides not to apply life-prolonging treatments. More
commonly referred to now as withdrawing or withholding life-sustaining therapy,
involves the withdrawal of extraordinary means of life support, such as removing
a ventilator or withholding special attempts to revive an individual (e.g. a ‘not for
resuscitation’ status) and allowing the individual to die of the underlying medicalcondition.
Euthanasia is not accepted legally and ethically in many counties worldwide
including Rwanda.
8.9.3. Strategies to enhance ethical decisions and practice
Several strategies help nurses overcome possible organizational and social
constraints that may hinder the ethical practice of nursing and create moral distress.
As a nurse, the following should be taken into consideration:
• Become aware of your own values and the ethical aspects of nursing.
• Be familiar with nursing codes of ethics.
• Seek continuing education opportunities to stay knowledgeable about ethical
issues in nursing.
• Respect the values, opinions and responsibilities of other health care
professionals that may be different from your own.
• Where possible, participate in or establish ethics rounds. Ethics rounds use
hypothetical or real cases that focus on the ethical dimensions of the care of
the individual rather than the individual’s clinical diagnosis and treatment.
• Serve on institutional ethics committees.
• Strive for collaborative practice in which nurses work effectively in cooperation
with other health care professionals.
Other patients’ rights
All patients have a right to dignity throughout their life, especially when the end of
life is near. Provide privacy when bathing or caring for a patient. Encourage the
person to make choices and control their own life. If they want to wear a certain
dress, let them wear it. If they want their bath in the evening instead of the morning,
let them have their bath in the evening. Allow the person to be as independent as
possible, speak to the person with respect and call the patient by their name.
All patients that are capable of making a decision must be able to do so, even when
the end of life is near. Patients have a right to have their medical information secret
and private. Never discuss a patient or their condition with friends, neighbors, other
patients or residents. Do not discuss any information about the patient unless the
patient asks you to.
Keep patient information confidential. It is against the law to tell your family member
or neighbor that a patient named x, my patient is dying with AIDS.
Nursing care does not stop when the end of life comes. All members of the health
care team play a very important role in the end-of-life care. This care meets the
person’s physical, mental, social, spiritual and financial needs. Nurse and others
health team must be able to meet these needs. Care at the end of life is a veryrewarding part of nursing care.
Furthermore, the patient has right to be treated as a living human being until He/she
die, right to maintain a sense of hopefulness, the right to express the feelings and
emotions about the approaching death in the patient own way, right to participate
in decisions concerning his care, right to expect continuing medical and nursing
attention even though cure goals must be changed to comfort goals, right not to die
alone, right to be free from pain, right to have questions answered honestly, right
to die in peace and dignity, right to discuss and enlarge patient religious and or
spiritual experiences, whatever these may mean to others and right to expect thatthe sanctity of the human body will be respected after death.
Self-assessment 8.9
1) What are advance care directives? What is its purpose in end of life care?
2) Cardiopulmonary resuscitation (CPR) is lifesaving intervention; however
in some circumstances a decision of Do not attempt Resuscitation (DNR)
may be made; for which patients a DNR may be considered?
3) In end of life care; termination sedation may be administered to
patients; What are criteria should the health care provider assess before
administration of termination sedation.
4) Define euthanasia and explain its main types
5) In caring patient in palliative care nurses may encounter constraints that
may hinder the ethical practice of nursing and create moral distress. Give4 strategies that will help the nurse to overcome those constraints?
8.10. Communication in palliative care
Learning activity 8.10
1) In which context may you encounter image A and B?
2) Which message pictures A and B communicate to you?
In situations of serious illness, communication is one of the most important tools
which the health care professionals use in giving the patient the information that
they need to know. This creates a sense of trust and security for both the patient
and the family.
Communication is the exchange of information, thoughts and feelings among
people using speech or other means. In healthcare, it is approaching every patient
interaction with the intention to understand the patient’s concerns, experiences,
and opinions.
Communication is a vital basic pre-requisite for all health care providers to provide
effective quality of care for all patients and not just in the palliative care; however
Palliative care requires excellent communication skills because at this time
communication can be particularly challenging due to patient clinical situations
where suffering, fear, and confusion can be considerable. Communication in
palliative care involves the conversation between patient, family and health care
provider about goals of care, transitions in care, progress of disease and providing
social, psychological & spiritual support. Communication can never be neutral; it is
either effective or ineffective, stress relieving or stress inducing.
The approach in communicating information, predictions, and prognoses to patients
and loved ones will have a crucial effect on their current and future behavior, as well
as potentially on treatment and illness outcomes.
Communication should be done in sense of Sensitive, honest and empathic in order
to relieve the burden of difficult treatment decisions, and the physical and emotional
complexities of death and dying, and lead to positive outcomes for people nearing
the end of life and their companions.
Effective and efficient communication is crucial for providing care and support to
people affected by life-limiting illness. However, some people are not familiar to
discussing personal psychological issues and can find these conversations difficult
Importance of communication in palliative care
Good communication between healthcare professionals and patients can lead to a
greater sense of well-being, decreasing feelings of distress commonly experienced
by those diagnosed with a terminal illness and their families.
Communication in palliative care help patients to understand their disease,
outcomes, patient behavior, ability to cope, both physical and psychological health,
as well as patient satisfaction with care, and compliance with treatment.
Also, good communication in palliative care was found to be effective in prevention
of depression and other stress related, helps patient to participate in decisionmaking during care and improve psychological and physical well-being.
Open communication is an important aspect of death and dying and of a good death
and it is thought to contribute to effective symptom control and end of life planning.
By contrast, poor communication is associated with distress, complaints and
can result in the patient -family having significant misunderstanding of end-of-life
processes.
Behavior of nurse in palliative care
During communication, the health care provider should possess the following
behavior in order to contribute in patient’s sense of hope including being present
and taking time to talk; giving information in a sensitive and compassionate manner,
answering questions and being nice, friendly and polite.
Showing empathy to the patient is a key for both verbally and nonverbally
communication. Non-verbal communication is vital as the way we interact impacts
on the relationships with our patients, as we constantly give out signals through ourbody language in the way we sit and the gestures we make
Self-assessment 8.10
1) What is communication?
2) What are factors that can influence the communication in palliative care?3) Who can be involved in communication with the patient?
8.11. Communication strategies used in palliative care
Learning activity 8.11
Observe the following pictures and respond to the related questions
1) What is the attitude of health care provider observed in the images A, B,
and C?
2) What are the similarities of the above images?3) What is the importance of the nurse‘s attitude in the image A, B, C?
Interpersonal communication in the area of health and palliative care is understood
as a complex process that involves the perception, comprehension and transmission
of messages in the interaction between patients and health-care professionals.
This process has two dimensions: the verbal, which occurs through the expression
of spoken or written words, and the nonverbal, characterized by the manner and
tone of voice with which words are said, by gestures that accompany the speech,
by looks and facial expressions, by the body posture, and by the physical distance
that people maintain with each other.
Communication in the context of palliative care consists of verbal and nonverbal.
Verbal communication strategies include interrogative nature and were related to
the expectations and knowledge of the patients about their disease and treatment,
as well as statements of concern and interest in the multidimensional aspects of
the patient. Nonverbal consist of communication five signals or strategies including
affective touch, the look, the smile, physical proximity and active listening. It is
essential for the care of the patient undergoing the process of dying that healthcare
professionals adequately perceive, comprehend and employ verbal and nonverbal
communication.
The nonverbal communication makes it crucial in the context of terminality because
it allows the perception and comprehension of the feelings, doubts and anxieties of
the patient, as well as the understanding and clarification of gestures, expressions,
looks and symbolic language typical of someone who is experiencing a phase in
which a cure for their disease is no longer possible.Verbal communication strategies consist of asking what the patients know about
their condition, ask the patients how they feel, to encourage them to talk about
their feelings, verbalize willingness to help, talk and/or clarify doubts, ask about
the expectations of the patients regarding the treatment, ask about the interests
and preferences of the patients in order to establish pleasant conversations. The
strategies or techniques of verbal communication can be classified into three
groups: expression, clarification and validation.
The strategies allocated to the expression group were those that they allow verbal
expression of thoughts and feelings, facilitating their description and enabling the
exploration of problematic areas for the patient. In the clarification group, there
were the strategies that help to comprehend or clarify the messages received,
enabling the correction of inaccurate or ambiguous information. The validation
group contained the expressions that make the ordinary meaning of what is
expressed, certifying the accuracy of the comprehension of the message received.
Nonverbal communication strategies include:
1) Affectionate touch that refers to the physical contact that conveys messages
of an emotional nature. Several actions mentioned by the professionals that
were grouped under this denomination were: a hug, a kiss on the cheek, a
caress of the hair, a firm handshake, touching hands, arms and shoulders
and greeting with physical contact.
2) Establish/maintain eye contact and smiling: Eye contact and smiling are
facial signals that denote interest and, therefore, facilitate the interaction with
the patients. In addition to portraying emotions, the look has an important
function: to regulate the flow of the conversation. The interruption of eye
contact may denote a lack of interest in continuing the conversation, causing
the interaction to be interrupted or impaired. Thus, both show essential
signals for the approach and establishment of a bond of trust with the
patients.
3) Physical proximity: The distance that people maintain with each other
during the interaction also transmits messages.
4) Active listening: Active listening involves the therapeutic use of silence, the
conscious emission of nonverbal facial signals that denote interest in what
is being said (maintaining eye contact, positive head nods), the physical
proximity and orientation of the body with the trunk facing toward the person,
and the use of short verbal phrases that encourage continuation of thespeech, such as: and then..., and I hear you.
Self-assessment 1.1
1) Discuss non-verbal communication strategies2) Explain the groups of verbal communication
8.12. Principles of communication in palliative care
Learning activity 8.12
Observe the following images A and B:
What are your observations toward the image A and B?
8.12.1.Overview of principles of communication in palliative care
There are some general communications principles that help facilitate discussion
about existential and psychological concerns, and demonstrate respect for the
person’s individuality. thus, including PREPARED and The SPIKES communicationframework
The PREPARED communication framework outlines key strategies that can be used
when communicating with a person with a life-limiting illness, their family and cares.
The PREPARED communication frameworkP) Prepare for discussion, (R) Relate
to person, (E) Elicit preferences from the person and their caregivers, (P) Provide
information tailored to the needs of both the person with a life limiting illness and
their families and carers, (A) Acknowledge emotions and concerns, (R) Realistichope, (E) Encourage questions and further discussions and (D) Document.
a. The PREPARED communication framework in clinical practice
P: Prepare for the discussion:
Ensure facts about the person’s clinical circumstances are correct, ensure privacy
and uninterrupted time for the discussion, mentally prepare yourself for the
conversation and negotiate who should be present during the discussion eg, “Is
there anyone else
you would like to be here with you while we talk?”
R: Relate to the person:
Develop a rapport, show empathy, care and compassion during the entire
conversation, propose the topic in a culturally appropriate and sensitive manner,
make eye contact (if culturally appropriate), and Sit close to the person (if culturally
appropriate). Use culturally appropriate body language and allow silence and time
for them to express feelings.
E: Elicit personal preferences:
Identify the reason for this conversation and establish the person’s expectations,
clarify their understanding of the situation and establish how much detail they want
to know and consider cultural and contextual factors that can influence information
preferences.
P: Provide information that is tailored to the personal needs of all parties
Offer to discuss what to expect, in a sensitive manner, giving the person the
option not to discuss it, provide information in small amounts at the person’s step,
engage in active listening such as attend to the person completely, reflecting and
repeating back what you think they have said. Explain the uncertainty, limitations
and unreliability of prognostic and end-of-life information, ensure consistency of
information and approach and use the words ‘death’ and ‘dying’ where appropriate.
A: Acknowledge emotions and concerns
Explore and acknowledge fears, concerns and emotional reaction and be willing
to initiate and engage in conversations about what can happen in the future and
during the dying process and respond to distress where applicable.
R: Realistic hope
Be honest without being blunt or giving more detailed information than desired. Do
not provide misleading or false information that artificially influences hope. Reassure
the person that support, treatment and resources are available to control pain and
other symptoms but avoid premature reassurance. Explore and facilitate realisticgoals, wishes and ways of coping on a day-to-day basis, where appropriate.
E: Encourage questions
Encourage questions and information clarification. Be prepared to repeat
explanations, check understanding of what has been discussed and whether the
information provided meets personal needs and Leave the door open for topics to
be discussed again in the future.
D: Document
Write a summary in the medical record of what has been discussed and speak or
write to other key healthcare providers involved in the person’s care.
b. The SPIKES communication framework in clinical practice
The SPIKES Protocol was developed to assist healthcare professionals with
breaking bad news. Effective communication when dealing with bad news can
enhance the understanding of prognosis and treatment options, and the person’s
adjustment to their situation.
THE SPIKES steps can complement the PREPARED framework by assisting with
the four most important objectives of breaking bad news which are (1) Gathering
information, (2) Transmitting medical information (3) Providing support and (4)
eliciting the person’s collaboration in developing a strategy or treatment plan for
the future.
Although some of the steps of SPIKES are similar to the steps in PREPARED,
SPIKES concentrates on delivering bad news (such as the initial diagnosis), while
PREPARED focuses on the holistic support of the person and their family throughout
their illness and can be used to frame discussions in a range of palliative contexts.
SPIKES stand for:
Setting up: organize an interview with the patient
Perception: Find out what the patient knows about his or her condition
Invitation: Get patient’s permission to impart bad news
Knowledge: Convey bad news at the level of the patient’s comprehension
Emotions: Physician must acknowledge and respond to patient’s emotions
Strategy and Summary: Summarize areas discussed, and formulate strategy and
follow-up plan.
S: Setting up the conversation
Choose a setting with privacy and without interruptions, ensuring that you have a
private space, phones turned to silent, turned pagers off, allowed sufficient time forthe conversation, help the person to understand what they are hearing by confirming
and explaining medical facts, check the accuracy of all available information –
including test results and that you have the right person. Plan what you will say,
decide on general terminology to be used, consider your own emotional reaction
to providing the distressing news. Find out in advance if the person wants anyone
else to be present.
P: Assessing the Person’s perception
Find out how much the person knows already, in particular, how serious they think
the illness is and how much it will affect the future. This helps you gauge how close
to the medical reality their understanding is or if they are in denial. This information
helps you to decide on the pacing and content of the conversation.
I: Obtaining the Person’s invitation
Find out what the person wants to know, you must be committed to honesty and
respecting their wishes if they do not want to be informed.
K: Providing knowledge and Information to the Person
The health care provider should decide on the objectives for the conversation and
consider what the person knows and needs to know. The patient should be clear
on how to manage their illness about diagnosis, treatment Plan, prognosis and
support. The health care provider should be clear and direct. He should use plain
language and avoid jargon, complex medical terminology and acronyms. Whenever
necessary, use diagrams, written messages and booklets as an aid and respond to
patient concerns and questions.
E: Addressing the person’s emotion with empathic responses
The health care provider should observe the person and give them time to react and
comprehend the news and acknowledge any emotional response without criticism
or blame. Ask the person what they are thinking or feeling; listen and explore if
you are unclear about what they are expressing; resist the temptation to make the
distressing news better than it is and allow time for silence.
S. Strategy and Summary
Demonstrate a genuine understanding of the person’s concerns, distinguish the
fixable from the unfixable, make a plan or strategy and explain it by providing
information on tests, treatment options, referrals and other aspects of care and
prepare for the worst and hope for the best and schedule a follow up appointmentso that they have the opportunity for further questions.
Self-assessment 8.12
1) Briefly discuss the communications framework used in palliative care
communication and give the difference between them.
2) Respond with True or False to the following statement:
“While providing knowledge and information to the person with end of lifecondition, it is better to ask him about what he/she knows about transport.”
8.13. End of life and nursing care
Learning activity 8.13
See the pictures below
1) Explain the similarities in the images A and B2) In which context you can see the images above?
Dying is a process of deterioration of the vital system, which ends with clinical
death. One of the most important things we can do for patients who are dying is to
provide the best possible care for them and their families during the last phase of
life through death. This is particularly important during the “imminent” phase. This
is the phase that precedes the actual death, and is also the time when the patient
typically loses consciousness. The care the nurse provides during this phase will
affect the family’s memories of their loved one’s final days and hours on earth. It is
vital that the nurse performs thorough assessments, rapid response to changes in
status, rapid titration of medications, and timely discontinuation and introduction ofinterventions aimed to promote comfort.
8.13.1.Diagnosis dying
Making a diagnosis that the patient is dying can be a complex process. In the
hospital setting where the treatment emphasis is generally “cure” orientated,
potentially useless investigations and treatments may continue at the expense of
patient comfort if the diagnosis of dying is not made.
The advantages of diagnosing dying are that emphasis of care to become comfort
based and ceasing unnecessary interventions, improving the awareness of dying,
can enhance communication for the patient and family, enable discussion about
place of care and assist the patient with their final wishes.
The following criteria generally support the diagnosis of dying: (1) A progressive
deterioration in the responsiveness of the patient (e.g. their ability to respond to
surroundings, decreased energy levels, becoming semi-comatose), (2) Reduced
ability to swallow (e.g. able to only take sips of fluid, unable to take oral medication),
(3) Deteriorating physical function (e.g. the patient has become bed-bound).
In other chronic incurable diseases predictability of the dying phase is not always
as clear. A range of factors will need to be considered including diagnosis of a life
threatening illness, no further curative treatment options, cause of deterioration
(infection, hypercalcemia, etc).
According to Kübler-Ross, there are 5 stages which precede dying and they are
widely known in the acronym DABDA (Denial, Anger, Bargaining, Depression and
Acceptance):
1. Denial: "I feel fine."; "This can't be happening, not to me. Denial is usually
only a temporary defense for the individual. This feeling is generally replaced
with heightened awareness of possessions and individuals that will be left
behind after death. Denial can be conscious or unconscious.
2. Anger: Why me? It's not fair!"; "How can this happen to me?"; '"Who is to
blame?” Once in the second stage, the individual recognizes that denial
cannot continue. Because of anger, the person is very difficult to care for due
to misplaced feelings of rage and envy. Anger can manifest itself in different
ways.
3. Bargaining: "I'll do anything for a few more years."; "I will give my life
savings if..." The third stage involves the hope that the individual can
somehow postpone or delay death. Psychologically, the individual is saying,
"I understand I will die, but if I could just do something to buy more time..."
People facing less serious trauma can bargain or seek to negotiate a
compromise.
4. Depression: "I'm so sad, why bother with anything?"; "I'm going to die
soon so what's the point?"; "I miss my loved one, why go on?" During the
fourth stage, the dying person begins to understand the certainty of death.
Because of this, the individual may become silent, refuse visitors and spend
much of the time crying and grieving. This process allows the dying person
to disconnect from things of love and affection. It is not recommended to
attempt to cheer up an individual who is in this stage. It is an important time
for grieving that must be processed.
5. Acceptance: "It's going to be okay."; "I can't fight it; I may as well prepare
for it."
In this last stage, individuals begin to come to terms with their mortality, or that of
a loved one, or another tragic event. This stage varies according to the person's
situation.
8.13.2.Phases of dying
Dying process has 3 phases including: actively dying, Transitioning, and Imminent.
a. Active phase
In active dying phase there are two typical roads to death that can occur during
the actively dying process which are the usual road or the difficult road. The
usual road is the best we can hope for when caring for persons at the end of life.
It begins with sedation and lethargy and progresses to a comatose state and then
death. The difficult road includes restlessness and confusion that often progresses
to unpleasant hallucinations and delirium. Myoclonus and seizures can also
accompany the difficult road.
Physical signs and symptoms associated with both roads including: pain, dyspnea,
fatigue, cough, constipation or diarrhea, incontinence, anorexia, cachexia, nausea
and vomiting, depression and seizures
The role of the nurse during the active dying phase is to support the patient and
family by educating them on what they might expect to happen during this time,
addressing their questions and concerns honestly, being an active listener, and
providing emotional support and guidance.
b. Transition phase
Transitioning phase describe the period of time in between the actively dying
phase and the imminent phase. In this phase, patients begin to withdraw from the
physical world around him in preparation for their final journey. Some examples of
this could include: decreased interest in activities of life, less frequent and shorter
interactions with others, this is referred to as “nearing death awareness” and
often documented by clinicians as “hallucinations.” Possible explanations of this
phenomenon from the medical community are as a result of hypoxia, acidosis, or
alterations in metabolic processes. Patients will generally not exhibit any signs orsymptoms of distress with this awareness, whereas patients whose dying is taking
the difficult road might show signs of distress or agitation with their awareness.
During transitioning, it is important to keep the patient’s area as comfortable and
peaceful as possible. Common lights and noises can contribute to restlessness and
agitation; therefore, it is advisable to keep lights soft, shades closed if possible, and
external noises limited to a minimum.
c. Imminent phase
Imminent phase is defined as what is about to happen. The patient has transitioned
into this last phase of the dying process and death can occur at any point now. Not
all individuals will present with every sign or symptom, and the symptoms will occur
in no particular order. During this phase, the body is in the process of shutting down.
Multi-system organ failure often occurs and will result in some typical symptoms. In
cardiological or circulatory system the patient may have Cool and clammy skin, cold
extremities and rapid or irregular pulse. In musculoskeletal system, the patient may
present inability to ambulate, inability to move/turn in bed and increased lethargy.
In neurological system, the patient may present more difficulty to arouse, confusion
and restlessness, in respiratory system, the patient may present periods of apnea
or Cheyne stokes respiration pattern, increased respiratory rate, inability to cough
or clear secretions and presence of increased secretions (death rattle). In urinary
system, the patient may present decreased and/or dark urine output
During this phase, the patient becomes unresponsive to those around him and
may appear to be sleeping. Sometimes the patient’s eyes will be partially open as
they are resting. The patient can still hear or sense the activity and loved ones
around them and so nurse has to teach the families to continue to talk to and gently
touch their loved ones in this phase.
8.13.3. Nursing management of dying person
a. Assessment
To gather a complete database that allows accurate analysis and identification of
appropriate nursing diagnoses for individuals who are dying and their families, the
nurse first needs to recognize the states of awareness manifested by the person
and family members. In cases of terminal illness, the state of awareness shared
by the dying person and the family affects the nurse’s ability to communicate freely
with individuals and other health care team members and to assist in the grieving
process. Three types of awareness:
• Closed awareness, the individual is not made aware of impending death.
The family may choose this because they do not completely understand why
the person is ill or they believe that they will recover. The doctor may believe it
is best not to communicate a diagnosis or prognosis to the individual. Nursing
staff are confronted with an ethical problem in this situation.
• Mutual pretence, the individual, family and health professionals know that
the prognosis is terminal but do not talk about it and make an effort not to
raise the subject. Sometimes the person refrains from discussing death to
protect the family from distress. Mutual pretence permits the person a degree
of privacy and dignity, but it places a heavy burden on them because there is
no one in whom they can confide.
• Open awareness, the individual and others know about the impending death
and feel comfortable discussing it, even though it is difficult. This awareness
gives them an opportunity to finalize affairs and even participate in planning
funeral arrangements
Clinical manifestations impending clinical death
Loss of muscle tone, characterized by the following:
• Relaxation of the facial muscles (e.g. the jaw may sag).
• Difficulty speaking.
• Difficulty swallowing and gradual loss of the gag reflex.
• Decreased activity of the gastrointestinal tract, with subsequent nausea,
accumulation of flatus, abdominal distension and retention of faeces,
especially if narcotics or tranquillisers are being administered.
• Possible urinary and rectal incontinence due to decreased sphincter control.
• Diminished body movement.
Slowing of the circulation, characterized by the following:
• Diminished sensation.
• Mottling and cyanosis of the extremities.
• Cold skin, first in the feet and later in the hands, ears and nose (the person,
however, may feel warm if there is a fever).
• Slower and weaker pulse.
• Decreased blood pressure.
Changes in respirations, characterized by the following:
• Cheyne–Stokes respirations (rhythmic waxing and waning of respirations
from very deep breathing to very shallow breathing with periods of temporary
apnoea).
• Noisy breathing, referred to as the ‘death rattle’, due to collecting of mucus
in the throat.
• Mouth breathing, dry oral mucous membranes.Sensory impairment, characterized by the following:
• Blurred vision.
• Impaired senses of taste and smell.
b. Diagnosing
A range of nursing diagnoses, addressing both physiological and psychosocial
needs, can be applied to the dying person, depending on the assessment data.
Diagnoses that may be particularly appropriate for them are Fear, Hopelessness
and Powerlessness. In addition, Risk of caregiver role strain and Interrupted family
processes are not uncommon diagnoses for caregivers and family members.
c. Planning
Major goals for individuals who are dying are (a) maintaining physiological and
psychological comfort, and (b) achieving a dignified and peaceful death, which
includes maintaining personal control and accepting declining health status.
People facing death may need help accepting that they have to depend on others.
Some people who are dying require only minimal care; others need continuous
attention and services. People need help, well in advance of death, in planning for
the period of dependence. They need to consider what will happen and how and
where they would like to die. If the dying person wishes to be at home and family or
others can provide care to maintain symptom control.
d. Implementing
The major nursing responsibility for individuals who are dying is to assist them to a
peaceful death. More specific responsibilities are the following:
• To minimize loneliness, fear and depression
• To maintain the individual’s sense of security, self-confidence, dignity and
self-worth
• To help the individual adapt to losses
• To provide physical comfort.
i. Helping people die with dignity
Nurses need to ensure that the person is treated with dignity; that is, with honor and
respect. People who are dying often feel they have lost control over their lives and
over life itself. Helping them die with dignity involves maintaining their humanity,
consistent with their values, beliefs and culture
ii. Meeting the physiological needs of the dying person
The physiological needs of people who are dying are related to a slowing of body
processes and to homeostatic imbalances. Interventions include providing personal
hygiene measures; controlling pain; relieving respiratory difficulties; assisting with
movement, nutrition, hydration and elimination; and providing measures related to
sensory changes
Table 8.13 1 Physiological need of dying peopleiii. Providing spiritual support
Spiritual support is of great importance in dealing with death.
Although not all people identify with a specific religious faith or belief, most have a
need for meaning in their lives, particularly as they experience a terminal illness.
The nurse has a responsibility to ensure that the individual’s spiritual needs are
attended to, either through direct intervention or by arranging access to individuals
who can provide spiritual care.
Specific interventions may include facilitating expressions of feeling, prayer,
meditation, reading and discussion with appropriate clergy or a spiritual advisor.
It is important for nurses to establish an effective interdisciplinary relationship with
spiritual support specialists
iv. Supporting the family
The most important aspects of providing support to the family members of a dying
individual involve using therapeutic communication to facilitate their expression of
feelings. When nothing can reverse the inevitable dying process, the nurse can
provide an empathetic and caring presence. The nurse also serves as a teacher,
explaining what is happening and what the family can expect. Due to the stress of
moving through the grieving process, family members may not absorb what they
are told and may need to have information repeated. The nurse must have a calm
and patient demeanor.
Family members should be encouraged to participate in the physical care of the
dying person as much as they wish to and are able. The nurse can suggest the family
assist with bathing, speak or read to the person and hold their hand. The nurse must
not, however, have specific expectations of family members’ participation. Those
who feel unable to care for or be with the dying person also require support from
the nurse and from other family members. They should be shown to an appropriatewaiting area if they wish to remain nearby
e. Evaluating
To evaluate the achievement of the goals of the dying person, the nurse collects
data in accordance with the desired outcomes established in the planning phase.
Evaluation activities may include the following:
• Listening to the individual’s reports of feeling in control of the environment
surrounding death, such as control over pain relief, visitation of family and
support people, or treatment plans.
• Observing the individual’s relationship with significant others
• Listening to the individual’s thoughts and feelings related to hopelessness orpowerlessness.
Self-assessment 8.13
1) Which criteria should generally support the diagnosis of dying?
2) List the 5 stages which precede dying according to Kübler-Ross?
3) Briefly explain 3 phases of dying process
4) What are the major responsibility and specific responsibilities of nurse
while caring a dying patient?
5) Outline three nursing diagnoses which can be formulated while caring adying patient
8.14. Death and post mortem care
Learning activity 8.14
Ms. G is a female with 23 years old hospitalized in hospice setting since 6 months
ago due to metastatic uterine cancer. Today in morning when a nurse is coming
to do morning assessment, she found the following signs: Ms.G was too cold,
the neck is stiff, and the orbits of the eyes are fixed (do not move), she doesn’t
do any body movement. The nurse monitors vital signs, she doesn’t find any
values of results (the all vital signs are not marked). Family members of Ms. G
are crying, but the surround population doesn’t know what happen
1) What do you think was happened to Ms.G?
2) What do you think could be the nursing management to Mr. G8.14.1.Death
a. Definitions and signs of death
Death is defined as a state of the total disappearance of life or irreversible cessation
of the functions of organs that are necessary for life including heart, lungs and brain.
In modern medicine death is indicated by the flat line in the record of
electroencephalography (EEG) or lack of brain function, however traditional clinical
signs of death are cessation of the apical pulse, respirations, and blood pressure
which is referred to as heart-lung death.
When patient is on assisting equipment of respiration and blood pressure death
acknowledgement is difficult but can be indicated by total lack of response to
external stimuli, no muscular movement especially breathing, no reflexes
and flat encephalogram (brain waves).
Cerebral death or higher brain death occurs when the higher brain center, the
cerebral cortex, is irreversibly destroyed. In this case, there is “a clinical syndrome
characterized by the permanent loss of cerebral and brainstem function, manifested
by absence of responsiveness to external stimuli, absence of cephalic reflexes, and
apnea.
b. Body status after death
After death, the body undergoes many physical changes, including Algor mortis,
Livor mortis and Rigor mortis..
Algor mortis is the gradual decrease of the body’s temperature after death.
When blood circulation terminates and the hypothalamus ceases to function,
body temperature falls about 1°C per hour until it reaches room temperature.
Simultaneously, the skin loses its elasticity and can easily be broken when removing
dressings and adhesive tape.
Livor mortis is characterized by cease of blood circulation, the red blood cells
break down, releasing hemoglobin, which discolors the surrounding tissue.
Rigor mortis is the stiffening of the body that occurs about 2 to 4 hours after death.
It results from a lack of adenosine triphosphate (ATP), which causes the muscles to
contract, which in turn immobilizes the joints. Rigor mortis starts in the involuntary
muscles (heart, bladder and so on), then progresses to the head, neck and trunk,
and finally reaches the extremities.
8.14.2. Post mortem care
Nurses are responsible for care of a body after death. Postmortem care should be
carried out according to the policy of the hospital or organization. Because care of
the body may be influenced by religious law, the nurse should check the deceased’sreligion and make every attempt to comply. If the deceased’s family or friends wish
to view the body, it is important to make the environment as clean and pleasant as
possible and to make the body appear natural and comfortable.
Postmortem care should be provided as soon as possible to prevent tissue damage
or deformity. Post mortem care is defined as the care given once death has occurred
through transfer to a funeral provider.
Because the deceased person’s family often wants to view the body and because
it is important that the deceased appear natural and comfortable, nurses need
to position the body, place dentures in the mouth and close the eyes and mouth
before rigor mortis sets in. Because of the reduction in body temperature and loss
of skin tone (algor mortis) after death, it is important to gently remove all tape and
dressings to prevent tissue damage.
The skin or body parts should never be pulled on. The head of the bed should be
elevated and a clean pillow placed under the head immediately after death before
beginning other activities in order to prevent purplish discoloration (livor mortis) of
the face.
Tissues after death become soft and eventually liquefied by bacterial fermentation:
the hotter the temperature, the more rapid the change. Therefore, bodies are often
stored in cool places to delay this process. Embalming prevents the process through
injection of chemicals into the body to destroy the bacteria.
8.14.3.Special consideration in end life and post mortem care
a. Pediatric considerations
Arrange for family members, especially parents, to be with the child throughout the
dying process and at the time of death, if they wish. Allow family members to hold
their child’s body after death. Make every effort to honor family members’ requests
per the organization’s practice. Family members of deceased newborns may want
a memento of their infant (picture, article of clothing, footprint, or lock of hair).
b. Older adult considerations
It is important to consider that some older adults have small families and small
circles of surviving friends. Health care team members may be the only human
presence during death. Arrange for someone to be with the person when death is
imminent.
c. Home care considerations
Consider the type of support family members need at the time of death and assist
with arrangements. After death in the home setting, follow the organization’s practice
for body preparation and transfer and for disposal of durable medical equipment
(e.g., tubing, needles, and syringes), soiled dressings or linens, and medications.
Instruct family members regarding safe and proper handling and disposal ofmedical waste.
Self-assessment 8.14
1) The loss of skin elasticity and change in body temperature which occurs
after death is better referred as:
a. Algor mortis
b. Livor mortis
c. Rigor mortis
2) What is the main reason for storing the deceased body in cool place?
3) Differentiate heart-lung death from brain death4) What should the nurse do as nursing care before rigor mortis develops?
8.15. Resilience and self-care
Learning activity 8.15
Observe the following images:
1) Discover the activities that are being done by the persons in images A, B,
C, D and C presented above.2) What could be the importance of those activities to human health?
8.15.1. Self-care
Self-care refers to activities and practices that we can engage in on a regular
basis to reduce stress, maintain and enhance our short/long-term health and well
being. Self-care is necessary for your effectiveness and success in honoring your
professional and personal commitments. Thus help to reduce stress, cope with the
challenges of work, enhance subjective sense of well-being, and replenish energylevels.
A key point for supporting one’s self-care lies in the ability to identify and manage
the general challenges that personnel face, such as the potential for stress
and burnout or interpersonal difficulties; to be aware of your own personal
vulnerabilities, such as the potential for re-traumatization; and as well as striving
for balance in your life, by maintaining and enhancing the attention you pay to thedifferent domains of your life in a way that makes sense to you.
c. Strategies to support self-care
The following are some strategies/tips for taking care of your-self:
1. Physical self-care
Get enough sleep. Regularly do physical activity that you enjoy. Eat regularly, well
balanced meals. Reduce alcohol and caffeine consumption.
Access medical care when needed (both preventative and acute). Take time off
when sick. Calm the body. Release tension in healthy ways. Practice healing
through movement and music.
Take deep breaths. Limit or eliminate exposure to media. Balance work, play, andrest.
2. Emotional self-care
Know your vulnerabilities. Engage socially to avoid feeling isolated. Spend time with
non-work friends, family and acquaintances. Set limits, if necessary, when others
are too overwhelmed demanding of your time or energy (Give yourself time to heal
and renew). Stay in contact with important people in your life.
Use relaxation skills that work best for you. Acknowledge when you have done
well. Value yourself. Identify energizing /positive activities, people and places, and
actively seek them out.
Reestablish a routine, if possible- allow your-self to cry or be upset. Find things that
make you laugh. Express your opinion on social issues outside of work. Listen to
music that soothes you.
3. Psychological self-care
Take time out (trips out of town, to the beach or a weekend away). Take time away
from telephones, email, social media and the internet. Make time for self-reflection.
Notice your inner dialogue (listen to your thoughts and feelings). Have your own
personal development and/or external supervision.
4. Spiritual self-care
Do some forms of reflective practice (meditate, pray or reflect). Spend time in
natural environments. Connect to a community or network with shared values. Beopen to feeling inspiration, awe and other positive emotions. Nurture your optimism
and hope. Be open to not knowing. Identify what is meaningful to you and notice
its place in your life. Contribute to causes in which you believe in outside of work.
5. Interpersonal self-care
Schedule regular time with significant others (e.g. partner, kids, friends, family). Stay
in contact with friends and networks. Make time to reply to personal correspondence.
Allow others to do things for you (meet new people; ask for help when you need it).
Share your feelings: good, bad or other with someone you trust.
6. Self-care in personal settings
Effective self-care strategies used outside of the workplace settings included a
range of health behaviors, including, meditation and spiritual practice, a healthy
diet, adequate sleep, and moderation of alcohol intake were considered important.
In addition to exercising for fitness, other physical activities such as yoga and
massage were found to be effective self-care strategies. Rest and relaxation
at home in a bath were described as effective self-care strategies when feeling
overwhelmed or needing to wash away thoughts of the workplace and socializing
and maintaining positive relationships with friends and family, finding harmony
between personal and professional roles was consistently described as an effective
self-care strategy and establishing and maintaining boundaries between home and
the workplace was considered an effective self-care strategy.
7. Self-care in workplace settings
Self-regulation of workload is important, but often difficult to achieve. It involves
being assertive about one’s capacity in relation to workload and wellbeing.
Take breaks during the work day for example during lunch or between meetings;
taking meal breaks, taking recreation leave for regular holidays, and taking personal
leave during illness were also considered effective self-care strategies. For some,
choosing to work part-time was an effective self-care strategy that provided ongoing
regulation of workload in relation to other competing demands. Having a cohesive
team was important and this contributed to a supportive working environment.
Mindfulness exercises were an effective self-care strategy in the workplace, both
in individual and group contexts. A sense of allowing oneself to be human, in the
context of displaying emotion in the clinical setting, was also part of effective self
care practice.
Take time to chat with colleagues. Create uninterrupted time to complete tasks. Set
boundaries with clients and colleagues. Balance your workload so that you are not
overwhelmed. Arrange your work space so that it is comfortable and comforting.
B. Barriers to self-care
Multiple impediments to self-care were identified in the workplace including busyness.
Workplace culture: in some workplace cultures there is a stigma associated with
self-care, making it difficult for individuals to engage in self-care practice without
feeling judged as being selfish. Bringing work home can be described as a barrier
to self-care, and related to workplace culture and expectations. Self-worth was also
discussed as a common concern for effective self-care, where self-criticism and a
lack of self-worth undermined self-care as an important priority and lack of planning
for self-care.
C. Factors facilitating Self-care
Several factors were described as facilitators of effective self-care including
recognizing the importance of self-care. Some became conscious of this through
previous experiences of illness or being unwell after having initially neglected selfcare.
Prioritizing self-care was an important enabler which correlated with noticeable
benefits. Adopting a preventative approach to self-care was important, Positive
workplace cultures supportive of self-care were described as vital to effective self
care practice. Leadership and positive role models were considered key enablers
to effective self-care. This also related to the allocation of reasonable workloads.
Other facilitators of effective self-care were more intrapersonal. These included
having a positive outlook, self-awareness and positive emotions. Self-awareness
was described as central to effective self-care practice. Gratitude and taking
a positive perspective, even in the face of negative circumstances enable self
care. Self-compassion was considered essential to self-care, and relational to
compassion for others.
Authenticity and courage were also described as self-care enablers. These
encompassed self-advocacy and self-acceptance – in terms of being realistic about
limitations; and being, in the words of one participant, authentically human.
8.15.2. Resilience
Resilience has been defined by the American Psychological Association as the
human ability to adapt in the face of tragedy, trauma, adversity, hardship, and
ongoing significant life stressors. Resilience is the ability to cope under pressure
and recover from difficulties. A person who has good resilience copes well under
pressure and can bounce back more quickly than someone whose resilience is less
developed.
a. Behaviors associated with resilience
A person who has a good resilience exhibit understanding and valuing the meaning
of what he/she do, greeting new situations, people and demands with a positive
attitude. He/ she is doing what you can to get on with other people, taking a problem
-solving approach to difficulty, keeping a sense of perspective when things go wrong.
Furthermore, he is being flexible and willing to adapt to change, drawing on a rangeof strategies to cope with pressure, recognizing your thoughts and emotions, and
managing them, asking for help when you need it.
Several attributes are common in resilient people: Resilient people have a positive
image of the future. That is, they maintain a positive outlook, and envision brighter
days ahead. Resilient people have solid goals, and a desire to achieve those goals.
Resilient people are empathetic and compassionate; however, they don't waste
time worrying what others think of them. They maintain healthy relationships, but
don't bow to peer pressure. Resilient people never think of themselves as victims –
they focus their time and energy on changing the things that they have control over.
How we view adversity and stress strongly affects how we succeed, and this is one
of the most important reasons that having a resilient mindset is so important. The
fact is that we're going to fail from time to time: it's an inevitable part of living that
we make mistakes and occasionally fall flat on our faces.
b. Signs of Resilience
Based on years of research into those who tend to be more resilient after hardship,
these six abilities represent some of the core skills in bouncing back:
• Ability to think clearly and flexibly in changing and challenging situations
• Ability to regulate one’s emotions (including stress) and remain emotionally
composed
• Ability to problem-solve, make sensible decisions and mobilize the right
resources that we need
• Ability to maintain positive connections and relationships with others who
support us
• Ability to maintain self-belief and persist in the face of challenging
circumstances (also called grit; ability to face up and continue after a set
back; a positive sense of one’s ability to manage things)
• Ability to maintain a state of wellbeing where we feel well fit and energized
enough to tackle life’s demands (including the demands of work, study, and
home-life and balancing all of our chosen activities/priorities)
c. factors that build resilience
Factors influencing resilience include personality, past experience, current
circumstances and the people around. Other factors contributing to resilience
include having the capacity to make realistic plans, setting goals and taking steps
to carry them out – no matter how small. Resilience is as well influenced by the
capacity to be connected with others and staying social. This is important to have
caring and supportive relationships within and outside the work, family, and in the
community. Resilience is moreover influenced by ability to have a sense of purposein life. Resilient people should be physically stronger. They should monitor their
selves and have mindfulness and the capacity to manage effectively their strong
feelings and impulses in a healthy manner. To be resilient you should focus on
learning and have good communication skills and confidence in your strengths and
abilities.
d. Importance of resilience
Being resilient will help to manage stressful situations, protect from mental illness
and improve health and wellbeing. At work, this ensures that you can continue to
do your job well, and deliver high quality care and support. It can also support in
personal life.
e. Tips of resilience
Tip 1 Focus: Don’t try and do everything. Focus on your priorities. Go back to your
assessments and tools and see what you could be doing at this point.
Tip 2: Find a change partner: Find a colleague you can bounce ideas off inside
or outside your organization. Most people will provide a sounding board to help you
work through an issue or change. It’s ok to talk about your fears – it helps reduce
them.
Tip 3: Know what helps you: You should be aware of what helps you manage
your stress or bring you back to ground or centre. Release the negative self-talk
around making time to decompress. Tip 4: Pragmatist or perfectionist: Sometimes
we care too much and expect too much. Beware of your inner perfectionist and
what purpose it serves. A perfect solution is often not possible. Focus on what you
can actually achieve.
Tip 5: Keep your perspective: We need to live to fight another day - in the end;
some changes are just not going to go well. Do your best and take care of yourself
- both mentally and physically. Take time out to rest and refresh over the break. Set
your work or life boundaries.
f. Pathways to building resilience
Self-care practices help us to build resilience. Even by choosing to put in place
some simple and reliable activities such as exercise, hobbies and catching up with
friends, we’re making a real difference to our minds and bodies – releasing happy
hormones, reducing stress and building healthy self-belief and habits that can
support us when the ‘chips are down’. Choose self-care activities and routines that
include and build on these things:
i. Wellbeing
Maintain basic health: healthy lifestyle routines such as exercise, good nutrition,
sleep and recreation. Practice self-reflection: regularly take time to think and identify
what you honestly need in order to thrive. Choose your attitude: adopt a deliberateand constructive attitude toward life and life’s challenges. Connect to positives:
recall and reconnect to your values, accomplishments and sources of gratitude/joy.
Flex your strengths: identify your strengths and use these more in work and life;
engage in interests/hobbies. Purposeful activity: do things that provide a sense of
purpose, connection and meaning in your life.
ii. Stress management
Social support: spend quality time talking with mates, family and others who can
support you when needed. Recognize stress: acknowledge that stress is normal
and know your early signs of stress (checklists, feelings). Regulate stress: develop
ways to relax and calm yourself on cue, e.g. relaxation exercises, positive thinking.
Problem-solve: adopt a problem-solving approach to life’s hassles – create a written
action plan with options. Manage energy: work around your energy cycle (dips and
peaks); use breaks and healthy energizer activities.
iii. Grit
Develop self-belief: focus on what you can do; visualize success; rehearse
your approach; give things a go. Reframe perspective: be realistic, identify and
‘reframe’ crooked/unhelpful thinking – review your thoughts. Bounce back: (growth
mindset) be open to feedback, learn from mistakes and try again; revise your
approach. Practice Grit: one mental toughness training activity is to persist longer
with uncomfortable or boring tasks. Develop mindfulness: the ability to pay calm
attention, on purpose in the present moment, non-judgmentally.
Professional help and coaching are good ways to proactively build self-care and
resilience, by developing a personalized plan, around the barriers and towards one’s
objectives. Remember that resilience levels change over time and require active
maintenance. You can be hassled or stressed– even if you’re normally resilient and
unbothered by things. In this way we caution that having some ‘resilience’ is not
enough on its own to cope with some very significant events. In these cases, othertools, actions and help will fill the gap.
Self-assessment 8.15
1) Differentiate self-care from resilience
2) Discuss the strategies for physical and psychological self-care3) Discuss the factors that build up resilience
8.16. Practice (return demonstration) of post mortemnursing procedures in skills lab
Learning activity 8.16
This activity should be done by associate nurse learners in simulation
laboratory, under the following instructions:
1) Identify the materials/equipment required for post mortem nursing care2) Use the following check list and practice post –mortem nursing skills
Table 8.16 1 Check list for practicing post mortem nursing technique
Self-assessment 8.16
In simulation laboratory use the check list presented above and score yourselfafter practicing post mortem care
End unit assessment 8
This end unit assessment 8 includes theoretical assessment of knowledge
acquired evaluation of practical skills which involves the organization of Objective
Structured Clinical Evaluation (OSCE) in skills laboratory.
Theoretical questions
1) Explain any 10 principles of palliative care
2) Explain the components of palliative care
3) Explain the importance of psychosocial support
4) Explain any 5 methods/techniques of non-pharmacological pain
management in palliative care
5) Explain ethical aspects in palliative care
6) Explain the strategies of communication in palliative care
7) Explain any 6 strategies for self-care 8) Explain any 5 ways of
building up resilience
Objective Structure Clinical Evaluation in skills laboratory
After you have practiced palliative care skills, the OSCE in simulation lab should
be organized on the following nursing care: nursing care to the dying patient andpost mortem nursing technique.
REFERENCES
Patricia A. Potter, Anne Griffin Perry, Patricia A. Stockert (2021). Fundamentals of
Nursing, Tenth edition, Elsevier.
Oxford University Press (2002). Essentials of Human Nutrition, SECOND EDITION
Susan G. Dudek (2014).NutritionEssentialsfor NursingPractice, seventh edition,
Lippincott Williams & Wilkins.
Patricia Williams (2016). Basic Geriatric Nursing Sixth edition, Elsevier.
Patricia A. Potter, Anne Griffin Perry, Patricia A. Stockert, Amy M. Hall, (2013).
Fundamentals of nursing, Eighth edition, Mosby, Elsevier.
Berman, Audrey T.; Snyder, Shirlee; Frandsen, Geralyn (2018).Kozier and Erb’s
Fundamentals of Nursing. Concepts, Process and Practice, fourth edition, Pearson
austrarian group.
Peggy S. Stanfield and Hui Y. H., (2010). Nutrition and Diet Therapy, Self
Instructional Approaches, Jones and Bartlett Publishers, LLC
Nix, Staci, (2017).Williams’Basic Nutrition and Diet Therapy, fifteen edition, Elsevier
Inc.
John Wiley & Sons (20080.Nutrition: A Handbook for Nurses, Wiley-Blackwell.
Norman J. Temple and NeliaSteyn (2016).Community nutrition for developing
countries, AU Press, Athabasca University, Canada.
Anne Griffin Perry, Patricia A. Potter, Wendy R. Ostendorf (2014). Clinical Nursing
Skills & Techniques, p790, 8th Edition, Mosby, Inc., an imprint of Elsevier Inc.
Jayne Marshall and Maureen Raynor (2014).Myles Textbook for Midwives, sixteenth
edition, Churchill Livingstone, Elsevier.
Bevan, J. S. (2009). The endocrine system. Macleod’s Clinical Examination. 12th
ed. London: Elsevier Health Sciences, 88-104.
Johnstone, C., Hendry, C., Farley, A., &McLafferty, E. (2014). Endocrine system:
part 1. Nursing Standard, 28(38).
Chaney, D., & Clarke, A. (2014). Nursing care of conditions related to the endocrine
system. s of related interest. Bickley, L. S., & Szilagyi, P. G.(2017) Bates’ Guide for
Physical Examination and History Taking
Lewis S.L. et al (2014) Medical-Surgical Nursing: Assessment and Management of
Clinical Problems
Luis, F., & Moncayo, G. (2018). Health systems policy, Finance and Organization
(G. Carrin, K. Buse, H. K. Heggenhougen, & S. R. Quah (eds.)). World health
Organisation Redional Office of the Eastern Mediterranean.
Takusewanya, M (2019) How to take a complete eye history.community y eye
health journal.32,107
Fotedar -Dr, D. (2018, April 2). Difference Between Myopia and Hypermetropia.
Difference Between Similar Terms and Objects. http://www.differencebetween.net/
science/health/difference-between-myopia-and-hypermetropia/.
Gwenhure T, Shepherd E (2019) Principles and procedure for eye assessment and
cleansing. Nursing Times [online]; 115: 12, 18-20.
Valerie Watson, V(2021)What is ear pain?
Knott,L,Willacy,H, (2021) Ear, Nose and Throat Examination
Prasad, A., Hasan, S., &Gartia, M. R. (2020).Optical Identification of Middle Ear
Infection.Molecules (Basel, Switzerland), 25(9), 2239.https://doi.org/10.3390/
molecules25092239
Earwood, O, S; Rogers, S, T, E Rathjen, N, A, DO, Dwight D (2018)Ear Pain:
Diagnosing Common and Uncommon Causes. Eisenhower Army Medical Center,
Fort Gordon, Georgia
Anderson, L, A, (2021)10 of the Most Common Skin Conditions: Photos and
Treatments
Gail A. Harkness, Rosanna F. DeMarco (2012). Community and Public Health
Nursing, EVIDENCE FOR PRACTICE, Wolters Kluwer Health | Lippincott Williams
& Wilkins.
Hunt, Roberta. (2009). Introduction to community-based nursing, 4th ed. Wolters
Kluwer Health | Lippincott Williams & Wilkins.
Judith A. Allender, Cherie Rector, Kristine D. Warner (2010). Community health
nursing : promoting and protecting the public’s health 7th ed. Wolters Kluwer Health
| Lippincott Williams & Wilkins.
Judith A. Allender, Cherie Rector, Kristine D. Warner (2014).Community &Public
health nursing: Promoting the Public’s Health 8th ed. Wolters Kluwer Health |
Lippincott Williams & Wilkins.
Loue, Sana (2006). Community health advocacy.Journal of epidemiology and
community health 60(6):458-63 DOI:10.1136/jech.2004.023044, retrieved from
https://www.researchgate.net/publication/7082449_Community_health_advocacy
Mary A. Nies, Melanie McEwen (2015). Community/Public Health Nursing:
Promoting the Health of Populations, 6th edition, Elsevier Inc. Saunders.
Matt Vera (2018). Principles of Community Health Nursing, Nurseslabs, Retrieved
from https://nurseslabs.com/community-health-nursing-principles/
Moana M. (2015). Community Nurses Role in Health Promotion. Nursing Exercise
http://nursingexercise.com/community-health-nursing-overview/
National Institute of Statistics of Rwanda (NISR) [Rwanda], Ministry of Health
(MOH) [Rwanda], and ICF International.(2015). Rwanda Demographic and Health
Survey 2014-15. Rockville, Maryland, USA: NISR, MOH, and ICF International.
National Institute of Statistics of Rwanda (NISR) [Rwanda], Ministry of Health (MOH)
[Rwanda], and ICF.(2020). Rwanda Demographic and Health Survey 2019-20 Key
Indicators Report. Kigali, Rwanda, and Rockville, Maryland, USA: NISR and ICF.
Rwanda Ministry of Health (2008).National Community Health Policy.
Rwanda Ministry of Health (2013).National Community Health Strategic Plan, July
2013–June 2018.
Taylor & Francis (2018). A Textbook of Community Nursing, second edition,
Routledge.
WHO (2002). Community home-based care in resource-limited settings, a framework
for action, retrieved from: https://www.who.int/chp/knowledge/publications/comm_
home_based_care.pdf
Wiley Blackwell (2013).Community and Public Health Nursing, 5th edition, John
Wiley & Sons, Ltd.
World Health Organization (1998).Health promotion glossary, World Health
Organization (2005).Effective teaching, A Guide for Educating Healthcare Providers
Bishai, D., & Schleiff, M. (2020). Achieving Health for All Primary Health Care in
Action (Vol. 4). Johns Hopkins University Press.
Donev, D., Kovacic, L., & Laaser, U. (2013). The Role and Organization of Health
Care Systems. In B. G & Z.-K. L (Eds.), Health: Systems – Lifestyles – Policies (2nd
editio, Issue October, pp. 3–14). https://www.researchgate.net/publication/http://
www.seejph.com/category/books/
Greenhalgh, T. (2007). Primary health care Theory and Practice. Blackwell
Publishing Inc.
Przybylska, D., Borzęcki, A., Drop, B., Przybylski, P., & Drop, K. (2014). Health
education as an important tool in the healthcare system. Journal of Public Health
Policy, 124(3), 145–147. https://doi.org/10.2478/pjph-2014-0032
WHO. (2008). Public policies for the public’s health. In World Health Report: Primary
Health Care - Now More Than Ever (pp. 63–77).
WHO. (2017). Primary health care systems ( Primasys ): Case study from Rwanda.
Alliance for Health Policy and Systems Research, 1–16. http://apps.who.int/iris.
Luis, F., & Moncayo, G. (2018). Health systems policy, Finance and Organization
(G. Carrin, K. Buse, H. K. Heggenhougen, & S. R. Quah (eds.)). World health
Organisation Redional Office of the Eastern Mediterranean.
Amadi CC, Okeke OC, Amadi DC, State I. Hazardous Waste Management: a
Review of Principles and Methods. Int J Adv Acad Res | Sci Technol Eng [Internet].
2017;3(8):12. Available from: https://www.ijaar.org/articles/Volume3-Number8/
Sciences-Technology-Engineering/ijaar-ste-v3n6-jn17-p3.pdf
Aime T. Guidelines for Faecal Sludge management [Internet]. KIGALI:
RwandaUtilities Regulatory Autholoty; 2018. Available from: https://rura.rw/
fileadmin/Documents/Water/RegulationsGuidelines/Draft_Guidelines_for_Faecal_
Sludge_Management_for_Rwanda.pdf
Gabriel Adebayo M, Bolu Aliyu SM, Abiodun S. Sustainable Animal Manure
Management Strategies and Practices. Intech [Internet]. 2012;13. Available from:
http://dx.doi.org/10.1039/C7RA00172J%0Ahttps://www.intechopen.com/books/
advanced-biometric-technologies/liveness-detection-in-biometrics%0Ahttp://
dx.doi.org/10.1016/j.colsurfa.2011.12.014
Skibinski K, Smith P, Cross D, Skidmore B. Introduction to Wastewater Management.
Handb Wastewater Manag [Internet]. 2015;1–18. Available from: http://efc.syr.edu/
wp-content/uploads/2015/03/Chapter1-web.pdf
Maeda K, Nitta H. Environmental health. Vol. 6, Journal of Epidemiology. 1996.
Theodore L, Dupont RR. Environmental Health and Hazard Risk Assessment:
Principles and Calculations [Internet]. Taylor & Francis Group. 2012. 636 p. Available
from: https://books.google.com/books?id=d5gyMbKPUXYC&pgis=1
Howard G. Excreta disposal. Heal villages a Guid communities community Heal
[Internet]. 2002;38–47. Available from: https://www.who.int/water_sanitation_
health/hygiene/settings/hvchap4.pdf
MININFRA. National sanitation policy. Development [Internet]. 2006;(March):1–12.
Available from: https://www.mininfra.gov.rw/water-and-sanitation
WHO. Guidelines on sanitation and health. [Internet]. World Health Organization.
2018. 1–220 p. Available from: http://www.who.int/water_sanitation_health/
publications/guidelines-on-sanitation-and-health/en/
Sen S, Roy S, Sarkar A, Chaki N, Debnath NC. Wastewater management. J
Comput Sci [Internet]. 2014;5(4):675–83. Available from: https://www.unwater.org/
app/uploads/2017/05/UN-Water_Analytical_Brief_Wastewater_Management.pdf
Oladoja NA. Appropriate technology for domestic wastewater management in
under-resourced regions of the world. Appl Water Sci. 2017;7(7):3391–406.
Naughton C, Mihelcic J. Introduction to the Importance of Sanitation. Water Sanit
21st Century Heal Microbiol Asp Excreta Wastewater Manag (Global Water Pathog
Proj [Internet]. 2019; Available from: https://www.pseau.org/outils/ouvrages/unicef_
introduction_to_the_importance_of_sanitation_2017.pdf
A UMF, Nhapi I, Wali UG, Banadda N. Assessment of Wastewater Management
Practices in Kigali City , Rwanda. 2010;21–8.
Delahoy MJ, Wodnik B, Mcaliley L, Penakalapati G, Swarthout J, Freeman MC, et al.
International Journal of Hygiene and Pathogens transmitted in animal feces in low
and middle-income countries. Int J Hyg Environ Health [Internet]. 2018;221(4):661–
76. Available from: https://doi.org/10.1016/j.ijheh.2018.03.005
Kennedy, Lloyd-Williams. M (2006) Maintaining Hope: Communication in Palliative
Care.
Manopriya ,V. Renuka, K(2018) Communication Skills in Palliative Care. Pondicherry
journal of nursing.vol.11
Clayton, J., Hancock, K., Butow, P., Tattersall, M. & Currow, D. (2007). Clinical
practice
guidelines for communicating prognosis and end-of-life issues with adults in the
advanced stages of a life-limiting illness, and their caregivers. MJA, 186 (12),
S77-S108.
PCC4U Implementation Guide I (2020) Communication principles
Caissie A, & Zimmermann C (2017). Communication skills for end-of-life care.
McKean S.C., & Ross J.J., & Dressler D.D., & Scheurer D.B.(Eds.), Principles and
Practice of Hospital Medicine, 2e. McGraw Hill. https://accessmedicine.mhmedical.
com/content.aspx?bookid=1872§ionid=14698719 Archer,W, Latif,A & Faull,C
(2017) Communicating with palliative care patients nearing the end of life, their
families and cares
Woogara,N. (2021)Communicating at the end of life.
Kozier, B et al, 2008, Fundamentals of Nursing: Concepts, process and practice,
first publication, Pearson Education Limited
Kozier & Erb’s, 2008, Fundamentals of Nursing: Concepts, Process and Practice,
8th Edition, Pearson Education, Inc, page 850
Kerig, P. (2020). Strengthening your resilience: Take care of yourself as you care
for others. Los Angeles, CA,and Durham, NC: National Center for Child Traumatic
Stress.
Mills, J., Wand, T. & Fraser, J.A. Exploring the meaning and practice of self-care
among palliative care nurses and doctors: a qualitative study. BMC Palliat Care 17,
63 (2018). https://doi.org/10.1186/s12904-018-0318-0
Huggard P., Huggard J. (2019) Self-Care and Palliative Care. In: MacLeod R.,
Van den Block L. (eds) Textbook of Palliative Care. Springer, Cham. https://doi.
org/10.1007/978-3-319-77740-5_44
Austin health (2016) guidelines for care of the dying patient
Marianne M., Deborah W. S., (2010). Palliative Care Nursing, Quality Care to the
End of Life, Springer Publishing Company, LLC.
Margaret O’C., Sanchia A., Susie W., (2003). Palliative Care Nursing, A Guide to
Practice, Second Edition, Taylor and Francis group.
Robert Wood Johnson Foundation (2010).PALLIATIVE CARE, Transforming the
Care of Serious Illness, Jossey-Bass, Sanfrancisco.
Oxford University Press (2010). Oxford Textbook of Palliative Nursing, third edition,
New York.
Derek D.,Roger W. (2008).International Association for Hospice & Palliative Care,
Promoting Hospice & Palliative Care Worldwide, The IAHPC Manual of Palliative
Care
2nd Edition
Kia, Z., Allahbakhshian, M., Ilkhani, M., Nasiri, M., & Allahbakhshian, A. (2021).
Nurses’ use of non-pharmacological pain management methods in intensive care
units: A descriptive cross-sectional study. Complementary Therapies in Medicine,
58, 102705.
Khalil, N. S. (2018). Critical care nurses' use of non-pharmacological pain
management methods in Egypt. Applied Nursing Research, 44, 33-38.
Lewis, M. J. M., Kohtz, C., Emmerling, S., Fisher, M., & Mcgarvey, J. (2018). Pain
control and nonpharmacologic interventions. Nursing2020, 48(9), 65-68
Rego, F., Pereira, C., Rego, G., & Nunes, R. (2018). The psychological and spiritual
dimensions of palliative care: a descriptive systematic review. Neuropsychiatry,8(2), 484-494
Cerit, E., & Özkan, B. (2021). The Importance of Spiritual Care in Nursing. Turkish
Journal of Science and Health, 2(2), 33-39.
Shipman C, Levenson R, Gillam S. Psychosocial Support. King’s fund [Internet].
2009;66(8):828–37. Available from: https://www.kingsfund.org.uk/sites/default/
files/PsychosocialSupport.pdf
Anderson L. Psychosocial Support for the Palliative Care Patient. Wound Essentials.
2011;6:84–6.
Bouleuc C, Burnod A, Angellier E, Massiani MA, Robin ML, Copel L, et al. Early
palliative care in oncology [Internet]. Alt-Epping B, Nauck F, editors. Vol. 106,
Bulletin du Cancer. New york: Springer-Verlag Berlin Heidelberg; 2019. 796–804 p.
Available from: https://usa1lib.org/book/2528204/959e1