Topic outline

  • General

  • UNIT1:HUMAN NUTRITION AND DIETETICS

     

     

    Key Unit Competence
    Assist adequately in preparation of a balanced diet to community, family and 

    individuals.

    Introductory activity 1.1

    Observe the Pictures below (A, B, C, D and F) and answer the questions that 

    follow:


    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 of 

    breast 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 12 

    months 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 first 

    day 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 the 

    refrigerator.

    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 to 

    manoeuvre 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 with 

    breastfeeding 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, and 

    ergotamine 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 and 

    whey) 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 iron 

    formulas 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 previous 

    breast 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 of 

    stock 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 the 

    baby.

    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 amounts 

    of 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 months 

    of 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 during 

    weaning 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 childhood 

    may 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 milk 

    takes 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 growth 

    of children

    1.5. Special considerations and nutritional disorders in 

    adolescence

    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. For 

    achieving 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 confronted 

    throughout 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 every 

    day 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 with 

    low 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 recommend 

    to 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 quantity 

    while 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 and 

    vomiting, 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 mercury 

    completely.  

    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 she 

    should 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 meet 

    activities 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 less 

    accurate 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 supplements 

    may 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 1.9

    1.9.1.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. It 

    should 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 the 

    provision 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% (or 

    more) 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 the 

    following:

    (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 of 

    appropriate 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 to 

    purchase 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., emergency 

    medical 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 and 

    dryness.

    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 during 

    famines. 

    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 several 

    generations.

    1.9.6. Community-based Actions to address food and nutrition 

    insecurity

    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 create 

    dependency.

    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 the 

    result?

    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 cause 

    foodborne 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 number 

    before 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 the 

    insides 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 /or 

    physical 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 clean 

    fingers.

    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 foods 

    as 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, before 

    handling 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 foods

    2. 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 water 

    while 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 and 

    kept 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 and 

    rats 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 a 

    cupboard 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 before 

    storing 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 categoriessada) 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 and 

    children 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 of 

    cuisine.

    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 nutritional 

    benefit 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 the 

    subsequent 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 is 

    valuable 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 from 

    their 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 an 

    extensive 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 stores 

    also 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) Infections 

    such 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 early 

    treatment 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 for 

    patients 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 and 

    dark-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 and 

    cereal products.

    1.15.4.Vitamin C (ascorbic acid)
    Vitamin C is water-soluble and easily destroyed in cooking. It is biochemically active 

    in 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 spring 

    greens); 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 in 

    picture 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 zinc 

    deficiency.

    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 proven 

    deficiency 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 iron

    2. 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-economic 

    groups.

    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 affect 

    outcomes 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 and 

    risk 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 and 

    buses, 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 factor 

    in 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 obesity 

    in 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. An 

    appropriate 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, and

    13. 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 and

    inadequate 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 nutrient 

    deficiency.

    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 medical 

    problems 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 trends 

    over 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. Iron

    c. 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 supplies

    Table 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 enteral 

    nutrition 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 formula

    b. 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 its 

    point 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 nasogastric 

    feeding 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 D

    c. 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 than 

    five 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 is 

    general 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 as 

    subjective 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, and 

    results 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 the 

    provision 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, or 

    ovarian 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 urination

    d. 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 first 

    disorder 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 from 

    the internal jugular vein.

    Endocrine organs namely testes and thyroid glands are the only endocrine glands 

    that 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-secreting 

    tumor

    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 endocrine 

    system

    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), proximal 

    muscle 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. False

    3) 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 on 

    regulating 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-threatening 

    endocrine 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 the 

    risk 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 scheduled 

    rest 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 to 

    promote 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 assessment

    4) 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 the 

    action 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 well 

    about 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/her 

    symptoms

    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 the 

    above 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 the 

    intervention 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 Neurological 

    system

    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 more 

    affected?

    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 items 

    assessed 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 nerve 

    system 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 fanning 

    out 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 still 

    is 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 nerve 

    e. 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 and 

    treated 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 sad 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/Seizure

    c. 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

     

    Key Unit Competence
    Take appropriate action based on findings of nursing assessment of Sensory 

    system

    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 during 

    consultation

    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 medical 

    attention

    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 headache 

    that 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 or 

    Paget 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, hair 

    distribution 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 someone 

    with 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 C

    3) 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 eye 

    diseases, 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 in 

    the 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 eye 

    problem?

    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 B

    3) 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 surgery

    b. 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 test

    A 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 the 

    problem 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 the 

    auditory 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 underlying 

    cause.

    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 of 

    basilar 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 the 

    likelihood 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 seven 

    days?

     • 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. Enter 

    the 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 mouth 

    and 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 mouth 

    and 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 ducts 

    open 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 for 

    ulcerations, 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, or 

    tonsillar 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 answer

    3) 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 is 

    present, 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 skin 

    folds, 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 corticosteroid 

    creams.

    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 no 

    cure 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 skin

    5) 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 tonsillitis

    7) 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 D

    2) 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 of 

    community 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, primary 

    prevention, 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 examples 

    of 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 to

    designate 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 prevention 

    as 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 (tertiary 

    prevention).

    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 commonly 

    described 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 and 

    explain 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 trace 

    the 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 Greek 

    engineering 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 the 

    mid-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 the 

    number 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 in 

    The 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 challenged 

    her 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 announced

    the 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 practice

    of 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 settings 

    have 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 health 

    nursing

    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, help 

    the 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; the 

    ethical 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 in 

    isolation, 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 of 

    referral, 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 country

    5.1.6. 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 characteristics 

    or 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 the 

    development 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 people 

    lead 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 areas 

    in 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 general

    2) 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 core 

    functions 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 crisis 

    or 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 and 

    actions.

    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 affecting 

    community 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 and 

    water 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 community

    Self-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 as 

    determinants 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 assessment

    The 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 of 

    community 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 the 

    community 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 outside 

    the 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 population 

    by 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 data 

    11) 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 to

    enhance 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 extension 

    service, 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 health

    nurse 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 health 

    and 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 by 

    the 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 generation 

    of 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 presented 

    during 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 take 

    notes, 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 compatible 

    with 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 adequate

    Self-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 presentation

    5.4.2. 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 do 

    not 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 members 

    have 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, groups 

    of 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 to 

    resolve 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 Analysis

    6) 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 presentation

    d. 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 IV

    d. 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 and 

    promote 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 care

    2) 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 concepts 

    are 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 providing 

    emotional, 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 and 

    evaluates 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 for 

    everyone, 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 “state 

    of 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 in 

    addition 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 health 

    services 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 the 

    year 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 primary 

    health 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 in 

    a 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 needed 

    resources

    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 care 

    needs 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 team 

    and 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 technology

    d. 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 hardship 

    and 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 both 

    individuals 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 space

    Self-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 our 

    good 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 questions

    1) 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 clients 

    into 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 need

    c. 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 in 

    charge 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 of 

    health 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 Promotion

    6.2.1. 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 Ottawa 

    Charter?

    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 less 

    of 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 for 

    the 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 abused 

    as 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 criteria 

    you are using for deciding whether an activity is “health promotion’?

    6.2.4. Principles of health promotion

    Learning 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 population 

    health 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 approach

    d. 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, social 

    and 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 skills 

    when 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 education

    http://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 education

    2) 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 on 

    what 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 process

    2) 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 the 

    three 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 ecological 

    community 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 Health 

    Organization)

    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 reduce 

    the 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 health 

    problems.

    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 Health

    7.2. 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 of 

    water 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 present 

    wastewater (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 of 

    these.

    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 comes 

    to 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 from 

    faecal waste.

    Self-assessment 7.2 

    1) Define sanitation
    2) Explain the objectives of sanitation?
    3) Explain 2 factors that may contribute to poor sanitation

    4) 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 together 

    to 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 and 

    productivity

    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 of 

    breaking 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 to 

    protect 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 lymphatic 

    filariasis 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 the 

    pit (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 efficient

    flush 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 ensure 

    workers 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 the 

    groundwater 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 disposed 

    in 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 toilet

    6) 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, treatment 

    and 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 add 

    litter 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 from 

    animal 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 safe 

    location

    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., Rubbish

    7.6.3. 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 all 

    facilities 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 is 

    damaged 

    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 of 

    waste 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 the 

    need 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 time 

    3) Match each concept with its definition

    4) define the following terms
    a. waste
    b. solid waste

    5) 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 be 

    resulted 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 plants

    whilst 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 during 

    transportation.

    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 national 

    competent 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 
    facilities

    5) 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 waste 

    water 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 cost 

    of 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 institutional 

    or 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 sanitation 

    inspection?

    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 a 

    simple 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 facilities













    Self-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 illnesses 

    and 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 care 

    interventions, 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 care 

    interventions, 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 and 

    lifesaving 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 2.7 

    months 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 care 

    in1974?

    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 palliative 

    care, 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 intensive 

    care 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 care

    2) 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’s 

    health 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 life 

    for 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 care

    5) 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-pharmacological 

    interventions

    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 sad1) 
    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 through 

    the 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 pain 

    management

    8.5. Additional methods of non-pharmacological pain 

    management

    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 middle 

    body, 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 electrical 

    nerve stimulation (TENS), acupuncture and acupressure.

    Self-assessment 8.5

    1) What is non -pharmacological pain management?
    2) Outline three examples non pharmacological pain management 

    3) 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 to 

    assess 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 and 

    psychological 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 and 

    choices 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 consequent 

    reduction 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, making 

    end-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/social 

    support 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 palliative 

    patient 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 have 

    an 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 at 

    end of life.

    1) Do you think that it is acceptable to accept such request? Explain your 
    answer

    2) 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 have 

    lost 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 patients 

    without 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 for 

    terminal 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 medical 

    condition.

    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 very 

    rewarding 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 that 

    the 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. Give 

    4 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 decision 

    making 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 our 

    body 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 the 

    speech, such as: and then..., and I hear you.

    Self-assessment 1.1 

    1) Discuss non-verbal communication strategies 

    2) 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 communication 

    framework

    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 frameworksadP) 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) Realistic 

    hope, (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 realistic 

    goals, 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 for 

    the 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 appointment 

    so 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 life 

    condition, 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 B

    2) 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 of 

    interventions 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 or 

    symptoms 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 people

    iii. 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 appropriate 

    waiting 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 or 

    powerlessness.

    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 a 

    dying 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. G

    8.14.1.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’s 

    religion 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 of 

    medical 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 death

    4) 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 energy 

    levels. 

    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 the 

    different 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, and 

    rest.

    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. Be 

    open 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 range 

    of 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 purpose 

    in 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 deliberate 

    and 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, other 

    tools, 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-care

    3) Discuss the factors that build up resilience

    8.16. Practice (return demonstration) of post mortem 

    nursing 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 care

    2) 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 yourself 

    after 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 and 

    post mortem nursing technique.

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  • Topic 10

  • Topic 11

  • Topic 12