Community File 1st Year

KRISHNA INSTITUTE OF NURSING
SCIENCE & RESEARCH
COMMUNITYHEALTH NURSING
PRACTICAL FILE
SUBMITTED TO- SUBMITTED BY-

MRS. VIMLA SHARMA PRIYANKA SINGH
ASSOCIATE PROFEESOR OF COMMUNITY
COMMUNITY HEALTH NURSING MSC NURSING 1 ST YEAR
K.I.N.S.R. KANPUR K.I.N.S.R. KANPUR
INTERNAL EXAMINER EXTERNAL EXAMINER

SIGNATURE SIGNATURE
INDEX
ANGANWADI VISIT.................................................................................................................................4
NURSING CARE PLAN ON ACUTE RHEUMATIC FEVER (UNDER FIVE CARE PLAN).....................................8
BAG TECHNUQUE.................................................................................................................................18
BAG TECHNUQUE – SPECIMEN COLLECTION.........................................................................................23
BAG TECHNUQUE (TOOL MAKING).......................................................................................................28
BAG TECHNUQUE – URINE TEST...........................................................................................................33
BAG TECHNUQUE – WOUND DRESSING...............................................................................................38
SET UP OF COMMUNITY HEALTH CENTRE.............................................................................................43
CARDIO PULMONARY RESUCITATION..................................................................................................48
NURSING CARE PLAN ON DIARRHOEA..................................................................................................58
CASE STUDY ON FAMILY.......................................................................................................................70
CASE STUDY ON APPENDICITIS.............................................................................................................74
FAMILY CASE STUDY.............................................................................................................................79
NORMAL PUERPERIUM........................................................................................................................89
FAMILY WELFARE PROGRAMME..........................................................................................................98
HEALTH CARE DELIVERY SYSTEM IN INDIA..........................................................................................104
HEALTH TALK ON BALANCE DIET........................................................................................................123
HEALTH-TALK ON DIET IN DIABETIES MELLITUS AND FOOT CARE IN DIABETIC PATIENT.....................128
ASSIGNMENT ON HYGIENE.................................................................................................................137
NURSING CARE PLAN ON JAUNDICE...................................................................................................142
JAUNDICE...........................................................................................................................................149
KANGAROO MOTHER CARE................................................................................................................153
LESSON PLAN ON COMMUNITY COUNSELLING...................................................................................161
CASE STUDY ON PLUERAL EFFUSION..................................................................................................167
CASE STUDY ON RTA...........................................................................................................................198
NATIONAL MALARIA CONTROL PROGRAMME...................................................................................248
NATIONAL TUBERCULOSIS CONTROL PROGRAMME...........................................................................253
HEALTH EDUCATION ON NUTRITIONAL FOOD....................................................................................259
CASE STUDY ON POSTNATAL MOTHER...............................................................................................263
ASSIGNMENT ON PRIMARY HEALTH CENTRE......................................................................................284
SCHOOL HEALTH PROGRAMME..........................................................................................................291
ASSIGNMENT ON SUB CENTRE...........................................................................................................295
ASSIGNMENT ON WATER PURIFICATION............................................................................................299
KRISHNA INSITUTE OF NURSING SCIENCES & RESEARCH
VILLAGR AMILIHA POST – TATIYAGANJ KANPUR NAGAR 209217
ANGANWADI VISIT

DATE OF SUBMISSION-
ANGANWADI VISIT
An Anganwadi normally covers a population of 1000. This Anganvadi was in a government

building attached to school but now new building is in construction so they are in private building, which
is small. This Anganvadi has one worker; her name is Mrs. Seema who is handicapped, and a helper, Mrs
Chandamma. There totally 45 students in this anganwadi.
Objectives of Anganwadi:
The main aim of Anganwadi is to reduce maternal and infant mortality rate, for which they have
following objectives.
1. Supplementary nutrition.
2. Immunization.
3. Health check-up.
4. Referral services.
5. Nutrition and health education.
6. Non-formal educational services.
Objectives of Anganwadi visit:
1. Understand the organization pattern of ICDS.

2. Understand the staffing of ICDS.
3. Studies functions of Anganvadi.
4. Studies the roles and responsibilities of Anganvadi workers.
5. Knows the maintenance of records and reports of Anganvadi.
Functions of Anganwadi:
 Daily check up of personal hygiene.

 Health check up.
 Nutrition and health education program.
 Immunization program.
 Immunization program.
 Informative services.
 Antenatal mother and postnatal services.
Under fives:
Total number of under fives
0-5years – 45
Records and reports maintained at Anganvadi:
 Survey book
 Attendance/Beneficiaries register.
 Birth register.
 Death registers.
 Health check up book
 Home visit book
 Visitors register.
 Drugs stock register.
 Immunization book.
 Daily stock register.
 Immunization book.
 Daily routine book.
 Staple items maintenance book.
 Growth chart book.
 Suggestion book.
 Expenditure book.
 Antenatal register.
 Post natal register.
Care given:
 Recorded anthropometric measurement.

 Assessed the general condition of the child.
 Assessed the degree of malnutrition.
 Education about the importance of growth chart.
 Education about the importance of immunization.
 Advised the parents to give a well balanced diet.
Time table:
9:30AM – 10:30AM: personal hygiene and prayer.
10:30AM – 11:00AM: outdoor games.
11:00AM – 11-10AM: Leisure.
11:10AM – 11-40AM: Introduction to New topic.
11:40AM – 12:00PM: storytelling, action song, Language development.
12:00PM – 12:45PM: Exercise.
12:45PMLunch
KRISHNA INSTITUTE OF NURSING SCIENCES & RESEARCH
VILLAGE- AMILIHA POST- TATIYAGANJ KANPUR NAGAR- 209217
UNDER FIVE YEAR CARE PLAN

ON
REHUMATIC FEVER

DATE OF SUBMISSION_-
NURSING CARE PLAN ON ACUTE RHEUMATIC FEVER (UNDER FIVE CARE PLAN)
IDENTIFICATION DATA OF THE CLIENT
NAME Ms Neelam
AGE/SEX 14 yrs/female
WARD NO. Pediatrics
IPD NO 179
DIAGNOSIS Acute rheumatic fever
RELIGION Hindu
ADDRESS Saharanpur
DATE OF ADMISSION 5/06//22
VITAL SIGN
HR- 96 /min
BP-100/68 mm hg
RR- 24/min
Temp- 101.6F
Weight- 35 kg
RBS- 120mg/dl
CHIEF COMPLAINTS
Child was admitted with complaints of :
 Fever since 10 days

 Palpitations since 1 week
 Swelling and pain in knee joint since 2 days
HISTORY OF PRESENT ILLNESS
 Patient was apparently asymptomatic 2 ½ months back when she developed generalized
weakness followed by fever which was not associated with chills and rigor.
 Patient also had achymotic patches appear first on hands which were bluish or black in color × 1
month and more in number.
 Patient is a known case of acute rheumatic fever.
PAST HISTORY
At the age of 6 yrs patient had severe dyspnea for which she was admitted in the hospital. Therapeutic
management is done after which fever subside.
FAMILY HISTORY
Not significant
(31 yrs Father) (28 yrs Mother)
(14 yrs Patient) (4 yrs brother)
BIRTH HISTORY:
 Full term delivery With LSCS

 Cried immediately
 Birth weight =3.5kg
 No H/o of birth asphyxia and any birth injury
IMMUNISATION HISTORY :
 BCG scar mark present

 Complete immunized for age
DEVELOPMENT HISTORY
Physical development:
Height: 4 feet
Weight: 34kg
Linguistic development: Child is well communicating with children of same age group.
PERSONAL HISTORY:
HYGIENE : well maintained
SLEEP : she takes around 16-18 hrs sleep

ELIMINATION : Patient has normal pattern
Of bowel and bladder elimination
.
SOCIAL RELATION : Patient is active and interaction is
Good with others
ACTIVITIES : normal
FAMILY HISTORY:
TYPE OF FAMILY : Nuclear family
SOCIO ECONOMIC STATUS OF FATHER/MOTHER
Education: 10th Pass/ illiterate
Occupation Labour/housewife
Total income/monthly Rs 5000/-approx
Housing: 2 room kaccha house
Sanitation: Poor
Disposal of refuse: Open disposal system
HISTORY OF ANY HEREDITARY DISEASE
No any history of any hereditary disease
VITALS SIGNS & SUGAR CHARTING:
DATE TIME TEMP PULSE RESP B.P.
6-11-2019 10:00am 98.86F 120/min 24/min 100/50 mm hg
7-11-2019 9:00am 98.6°F 116/min 24/min 100/60 mm hg

8-11-2019 9:30 am 98.6.°F 120/min 26/min 98/60mm hg
9-11-2019 9:30 am 98.6.°F 120/min 26/min 98/60mm hg
INVESTIGATION
Echocardiography
LV=Normal, LA=enlarged, RV=normal
Electrocardiogram
Results: Chronic rheumatic heart disease/mitral value thickened, dilated left atrium, severe mitral
regurgitation( jet area=1sq cm), mild aortic regurgitation and normal LV systolic function.
Hematology
 Hb- 11.78 mg/dl

 RBC – 1.24 million/cumm
 TLC - 7.46 thous/ cumm
 PCV - 10.74%
Bilirubin= 0.68 mg/dl
DLC
 Neutrophil - 05%
 Lymphocyte – 94%
 Eosinophil - 0.06%
 Monocyte - 01%
 S.creatinine - 0.32 mg/dl
 Aspartate amino transferase – 20U/L
General blood picture -- Severe anemia with mild leucopenia and relative lymphocyte
Bone marrow report – It shows hypo plastic marrow and shows lymphocytosis
TREATMENT
 Inj cefotaxime 2gm IV BD

 Tab omnacortil 30 mg BD with meals
 Tab lasilactone BD
 Syp mulmin
 Syp lactulose
 Inj penidura 12 Lac IV
PHYSICAL EXAMINATION
General appearance - looking active
Child is conscious, active
Nutritional status of child is inadequate
Head to toe examination
Head = no any scar and fracture
Eyes = corneal reflex is present, No discharge
Face= having petechie marks on face
Neck = pain during movement of neck
Limbs = petechie is present

CHEST EXAMINATION
Inspection
 Symmetry- normal
 Bilateral symmetry- normal
 No edema, erythma, no retraction or wrinkling
 No looking for localized buldge.
 Movement of chest-B/L equal chest movement
Palpation
 No tenderness
 Normal movement on two sides of chest
 No presence of any vibration during breathing
Percussion
 Equally resonant on both sides
 No dullness in sound
 Normal expansion of lungs on both sides
Auscultation
 Vesicular sound is normal , loud, high pitched
 Bronchial is low in intensity, high pitched, loud and prolonged
 Intensity of breath sound is normal
 No crepitation in sound and no added sounds
ABDOMEN
 Abdomen is non-distended, soft, non tender
Systemic examination
CNS: Tone normal in all 4 limbs
B/L knee movement present
Knee jerk reflex present .
GI: few episode of vomiting per day
Cardiovascular system
Electrocardiogram is done (color Doppler) which confirms the diagnosis.
Pansystolic murmur is heard 5th intercoastal spaces radiating to axilla, clubbing of fingers were also
present and enlarged left atrium is evident.
Musculoskeletal system
Knee pain is present

Swelling is also evident
Chorea(lower limbs) are involved.
RESPIRATORY SYSTEM:
 Chest B/L symmetrical.

 Air entry B/L equal.
 No added sounds.
 No webbing.
 Resp-26/mt
GROWTH AND DEVELOPMENT
Motor – developed
Language - developed
Social – developed
Intellectual development= preoperational stage
Cognitive development = preoperational stage
Psychosocial development = intiative Vs guilt
Spiritual development = intuitive Vs projective

NURSING CARE PLAN
NURSING NURSING GOAL PLANING/RATIONALE IMPLEMENTATION EVALUATION

ASSESSMENT DIAGNOSIS
1.
Subjective data Imbalanced nutrition: To maintain nutritional 1.Assess the nutrition 1.Assessed the condition and Dietary intake is
Patient having less than body level of child pattern of the patient nutrition pattern of child increased
2-3 episode of requirements related
vomiting to recurrent episode 2. Determine the intake and 2. Intake output chart maintained
of vomiting output of the patient Nutritional level is
Objective data evidenced by 3.Monitored weight of the maintained
1.Weight loss weakness of body 3. To monitor weight of the patient – 17kg
2.nausea, patient
vomiting 4. small frequent balanced diet is
3. Lack of 4. nutritional supplement to given to patient
appetite be given
5. IV fluid I-sope is
5.IV fluids to be given administered
6. provide medication to 6. inj perinorm is provided to

child patient
Risk for bleeding

2. related to disease To maintain complication 1.Assess general condition 1. vital taken and general
Subjective data condition as from bleeding of patient condition was assessed Risk for bleeding was
1.Patient is evidenced by blood reduced.
lethargy, reports CHC 2. tell patient to do mouth 2. provide mouth wash
decreased ( decreased platelet wash
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activity counts) 3. sample was sent for platelet
and having 3.tell parents to check for counts
marks on body any complication
5 .administer antibiotics as
4. send blood for platelet prescribed by doctor
Objective data count
1.patient is
having low 4. vital signs to be
platelets count monitored
Risk for infection 1. Child’s condition is assessed.

related to decreased To minimize the risk for 1. Assess condition of child Risk for infection
resistance and infection 2.vital signs are monitored was reduced
3. increased 2. vital signs to be
susceptibility as monitored 3. hand washing was done by all
Subjective data evidenced by care givers before touching
1patient is leucopenia 3. proper hand washing patient
weak , lethargy technique by care giver
4. aseptic technique was
4. maintain aseptic followed during procedure
Objective data technique during procedure
1.low Hb,
pallorness of
body
2. increased
WBC
14
1. to assess knowledge of 1. educated the parents and
family regarding disease encouraged them to interact with
Knowledge deficit condition child Knowledge of parents
related to treatment To clear doubt regarding increase regarding
and disease condition treatment and prognosis 2. clear all doubts of family 2. all doubts of family member disease and care of
as evidenced by member were cleared child
frequent asking
4. question 3. educate parent regarding 3. Educated family member Interaction of parents
care of child and diet of regarding care and diet of child. with child increased.
Subjective data child
Asking question
related disease
Objective data
anxiety of
parents
PARENT KNOWLEDGE DEFICIT AREAS AND HEALTH EDUCATION
 Family member as educated about the hygiene maintenance

 Family member educated regarding proper hydration maintenance
 Family member was educated regarding diet of patient and care of child
Family member were educated regarding observation of sign of bleeding.
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BAG TECHNUQUE

DATE OF SUBMISSION-
16
BAG TECHNUQUE
Definition
Bag technique – a tool making use of public health bag through which the nurse, during his/her
home visit, can perform nursing procedures with ease and deftness, saving time and effort with the end
in view of rendering effective nursing care.
Public health bag – is an essential and indispensable equipment of the public health nurse which
he/she has to carry along when he/she goes out home visiting. It contains basic medications and articles
which are necessary for giving care.
Rationale
To render effective nursing care to clients and /or members of the family during home visit.
Principles
1. The use of the bag technique should minimize if not totally prevent the spread of infection from
individuals to families, hence, to the community.
2. Bag technique should save time and effort on the part of the nurse in the performance of nursing
procedures.
3. Bag technique should not overshadow concern for the patient rather should show the
effectiveness of total care given to an individual or family.
4. Bag technique can be performed in a variety of ways depending upon agency policies, actual
home situation, etc., as long as principles of avoiding transfer of infection is carried out.
5. Special Considerations in the Use of the Bag
 The bag should contain all necessary articles, supplies and equipment which may be used to
answer emergency needs.
 The bag and it’s contents should be cleaned as often as possible, supplies replaced and ready for
use at any time.
 The bag and it’s contents should be well protected from contact with any article in the home of
the patients. Consider the bag and it’s contents clean and /or sterile while any article belonging
to the patient as dirty and contaminated.
 The arrangement of the contents of the bag should be the one most convenient to the user to
facilitate the efficiency and avoid confusion.
 Hand washing is done as frequently as the situation calls for, helps in minimizing or avoiding
contamination of the bag and its contents.
 The bag when used for a communicable case should be thoroughly cleaned and disinfected
before keeping and re-using.
Contents of the Bag
 Paper lining
 Extra paper for making bag for waste materials (paper bag)
 Plastic linen/lining
 Apron
 Hand towel in plastic bag
 Soap in soap dish
 Thermometers in case [one oral and rectal]
 2 pairs of scissors [1 surgical and 1 bandage]
 2 pairs of forceps [ curved and straight]
17
 Syringes [5 ml and 2 ml]
 Hypodermic needles g. 19, 22, 23, 25
 Sterile dressings [OS, C.B]
 Sterile Cord Tie
 Adhesive Plaster
 Dressing [OS, cotton ball]
 Alcohol lamp
 Tape Measure
 Baby’s scale
 1 pair of rubber gloves
 2 test tubes
 Test tube holder
 Medicines
 betadine
 70% alcohol
 ophthalmic ointment (antibiotic)
 zephiran solution
 hydrogen peroxide
 spirit of ammonia
 acetic acid
 benedict’s solution
Note: Blood Pressure Apparatus and Stethoscope are carried separately.
Steps/Procedures
Weight measurement
Weight should be measured in all participants, except pregnant women, wheelchair bound individuals,
or persons who have difficulty standing steady.
Setting up scale at the examination site
The scale should be placed on a hard-floor surface (not on a floor which is carpeted or otherwise
covered with soft material). If there is no such floor available, a hard wooden platform should be placed
under the scale. A carpenter's level should be used to verify that the surface on which the scale is placed
is horizontal.
Calibration of scale
Calibration should occur at the beginning and end of each examining day.
The scale is balanced with both sliding weights at zero and the balance bar aligned. The scale is checked
using the standardized weights and calibration is corrected if the error is greater than 0.2 kg. The results
of the checking and the recalibrations are recorded in a log book.
Weighing procedure for heavily overweight persons
If the participant is heavily overweight, i.e. weighs more than the upper limit of the scale, this fact
should be noted in the data collection form, together with the upper limit of the scale.
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Self-reported weight
Self-reported weights are not acceptable, even if the participant is immobile or refuses to be weighed.
Height measurement
Height should be measured in all participants, except wheelchair bound individuals, persons who have
difficulty standing steady or straight, and participants with hairstyle (e.g. Afro or Mowhawk) or head
dress (e.g. turban) that prevents proper use of the height measuring equipment.
Setting up stadiometer at the examination site
If the height is measured with the measuring rod attached to the balanced beam scale no further set-up
procedures are required, if the scale has been placed properly for weighing. However, it should be
verified that the upper part of the measuring rod is straight and vertical (i.e. not bend or curved).
If the height is measured by stadiometer, the height rule is taped vertically to the hard flat wall surface
with the base at floor level. The wall may not have a baseboard molding. A carpenter's level is used to
check the vertical placement of the rule.
The floor surface next to the height rule must be hard. If no such floor is available, a hard wooden
platform should be placed under the base of the height rule. Using the carpenter's level, the surface on
which the height rule rests should be checked to be horizontal.
Calibration of height rule
At the beginning and end of each examination day, the height rule should be checked with standardized
rods and corrected if the error is greater than 2 mm. The results of the checking and recalibrations are
recorded in the log book.
After Care
1. Before keeping all articles in the bag, clean and alcoholize them.
2. Get the bag from the table, fold the paper lining ( and insert), and place in between the flaps and
cover the bag.
Evaluation and Documentation
3. Record all relevant findings about the client and members of the family.
4. Take note of environmental factors which affect the clients/family health.
5. Include quality of nurse-patient relationship.
6. Assess effectiveness of nursing care provided.
REFERENCES
1. Williams, Martin (2016-03-30). "Scots assisted death and abortion pioneer dies, aged 89". The
Herald. Retrieved 2016-04-18.
19
2. Jump up ^ Ogden RD, Hassan S (2011). "Suicide by oxygen deprivation with helium: a
preliminary study of British Columbia coroner investigations". Death Studies. 35 (4): 338–64.
doi:10.1080/07481187.2010.518513. PMID 24501824.
3. ^ Jump up to: a b Schön CA, Ketterer T (December 2007). "Asphyxial suicide by inhalation of
helium inside a plastic bag". The American Journal of Forensic Medicine and Pathology. 28 (4):
364–7. doi:10.1097/PAF.0b013e31815b4c69. PMID 18043029.
4. ^ Jump up to: a b Auwaerter V, Perdekamp MG, Kempf J, Schmidt U, Weinmann W, Pollak S
(August 2007). "Toxicological analysis after asphyxial suicide with helium and a plastic bag".
Forensic Sci. Int. 170 (2–3): 139–41. doi:10.1016/j.forsciint.2007.03.027. PMID 17628370.
(subscription required)
5. ^ Jump up to: a b Ogden RD, Wooten RH (September 2002). "Asphyxial suicide with helium
and a plastic bag" (PDF). Am J Forensic Med Pathol. 23 (3): 234–7.
6. http://nursingcrib.com/nursing-notes-reviewer/community-health-nursing/bag-technique/
20
BAG TECHNUQUE – SPECIMEN

COLLECTION

DATE OF SUBMISSION-
21
BAG TECHNUQUE – SPECIMEN COLLECTION
Definition
Rationale
Principles
procedures.
use at any time.
Contents of the Bag
 Paper lining
 Apron
22
 Alcohol lamp
 Tape Measure
 Baby’s scale
 2 test tubes
 Medicines
 betadine
 70% alcohol
 acetic acid
Steps/Procedures
Collect the specimen as follows:
• Urinate before collecting the stool so that you do not get any urine in the stool sample. Do
not urinate while passing the stool.
• Stool can contain material that spreads infection, so wash your hands before and after you
collect the specimen.
• Pass stool (but no urine) into a sterile cup. You may also tape cling or plastic wrap across the
toilet to catch the stool, please see picture below.
• Either solid or liquid stool can be collected.
• If you have diarrhea, a plastic bag taped to the toilet seat may make the collection process
easier; the bag is then placed in a sterile cup.
• Do not collect the sample from the toilet bowl.
• Do not mix toilet paper, water, or soap with the sample.
• Place the lid on the container and label it with your name and the date the stool was
23
collected.
• Deliver your stool specimen the same day you collect it to your county health department.
Wash the TT, TT holder and droppers with soap and water. Drain,place them in the work area.
Disinfect the kidney basin, TT, TT holder and droppers with 3 pieces of CR with alcohol, Discard 2CB.
Place the articles inside the kidney basin(Save the last CB with alcohol)
With one CB with alcohol, disinfect the lamp and the plastic lining.
Discard the waste receptacle.
Do thorough hand washing. Dry Hands with the towel.
Return all articles in their proper places in the bag.
Remove apron away from the body, folding contaminated part in. Place over the flaps of the bag.
Fold the plastic lining contaminated part in. Place over the flaps of the bag.
Hold the bag with one hand, and with the other hand fold the paper lining , contaminated part in. Place
over the plastic lining.
Close the bag.
After Care
cover the bag.
REFERENCES
doi:10.1080/07481187.2010.518513. PMID 24501824.
364–7. doi:10.1097/PAF.0b013e31815b4c69. PMID 18043029.
24
25
BAG TECHNUQUE (TOOL MAKING)

DATE OF SUBMISSION-
26
BAG TECHNUQUE (TOOL MAKING)
Definition
Rationale
Principles
procedures.
use at any time.
Contents of the Bag
 Paper lining
 Apron
27
 Alcohol lamp
 Tape Measure
 Baby’s scale
 2 test tubes
 Medicines
 betadine
 70% alcohol
 acetic acid
28
After Care
cover the bag.
REFERENCES
29
doi:10.1080/07481187.2010.518513. PMID 24501824.
364–7. doi:10.1097/PAF.0b013e31815b4c69. PMID 18043029.
30
BAG TECHNUQUE – URINE TEST

DATE OF SUBMISSION-
31
BAG TECHNUQUE – URINE TEST
Definition
Rationale
Principles
procedures.
use at any time.
Contents of the Bag
 Paper lining
 Apron
32
 Alcohol lamp
 Tape Measure
 Baby’s scale
 2 test tubes
 Medicines
 betadine
 70% alcohol
 acetic acid
Steps/Procedures
Using the urine specimen in a community health setting can be beneficial in determining the sugar level.
This is done using the Benedict’s Method for those with history of diabetes.
Materials:
Benedict’s qualities reagent
Test tube
Alcohol lamp
Droppers (2pieces)
Urine (Early morning, mid stream flow)
Match
Procedure:
Place the paper lining clean side out on a table or any clean, flat surface away from the client.
33
Spread the plastic lining over the paper lining, clean side in.
Place the bag in the area away from the client, tucking handles beneath the bag.
Open the bag; take out soap in dish, towel and apron.
Do thorough hand washing. Dry hands, place soap/dish and towel near the bag.
Put on apron, right side out.
Take out the kidney basin and place 3 CB with alcohol.
Take out 2 droppers, a test tube and holder, and place these in the kidney basin. Take out the alcohol
lamp, match .Benedict’s sol’n and place them on the work area.
Place the waste receptacle at one corner of the work area.
Light the lamp.
Place 6-8 drops of urine in the test tube.
Add 3-5 ml. Of Benedict’s sol’n to the urine
Used droppers should be placed near the waste receptacle.
Pass the test tube with mixture over the flame, mouth of the TT should be away from you and the client.
Remove from flame and stand for one minute. Put off flame.
Interpret:
1. Clean blue to marked cloudygreen———–negative

2. Bluish green—————————————-+
3. Yellowish green————————————++
4. Yellow————————————————-+++
5. Orange————————————————++++
Wash the TT, TT holder and droppers with soap and water. Drain,place them in the work area.
Disinfect the kidney basin, TT, TT holder and droppers with 3 pieces of CR with alcohol, Discard 2CB.
Place the articles inside the kidney basin(Save the last CB with alcohol)
With one CB with alcohol, disinfect the lamp and the plastic lining.
Discard the waste receptacle.
Do thorough hand washing. Dry Hands with the towel.
Return all articles in their proper places in the bag.
Remove apron away from the body, folding contaminated part in. Place over the flaps of the bag.
Fold the plastic lining contaminated part in. Place over the flaps of the bag.
Hold the bag with one hand, and with the other hand fold the paper lining , contaminated part in. Place
over the plastic lining.
Close the bag.

34
After Care
cover the bag.
REFERENCES
doi:10.1080/07481187.2010.518513. PMID 24501824.
364–7. doi:10.1097/PAF.0b013e31815b4c69. PMID 18043029.
35
BAG TECHNUQUE – WOUND DRESSING

DATE OF SUBMISSION-
36
BAG TECHNUQUE – WOUND DRESSING
Definition
Rationale
Principles
procedures.
use at any time.
Contents of the Bag
 Paper lining
 Apron
37
 Alcohol lamp
 Tape Measure
 Baby’s scale
 2 test tubes
 Medicines
 betadine
 70% alcohol
 acetic acid
Steps/Procedures
Removing an old dressing
Wash your hands and put on non-sterile gloves (to protect yourself) before removing an old dressing.
Dispose of this dressing in a separate dirty clinical waste bag.
Complete a wound assessment. This includes a visual check and comparing and evaluating the smell,
amount of blood or ooze (excretions) and their colour, and the size of the wound.
If the site has not improved as expected, then the treating physician or senior charge nurse must be
informed so they too can evaluate it and consider changing the care plan.
Cleaning and dressing the wound
Make sure that you have selected the correct dressing type and materials to provide full and appropriate
coverage of the type, size and location of the wound as per the care plan or the physician or senior
charge nurse's recommendations.
Wash your hands and put on sterile gloves. If the gloves become desterilised, remove them, re-wash
your hands and put on new sterile gloves. This is best practice, but where resources are not available,
safe modifications to this process can be made, for example by using non-sterile gloves to protect the
nurse while removing the dressing and then washing the hands with gloves on and using alcohol gel on
the gloves to make them clean enough to clean the wound and redo the dressing. This then protects both
the nurse and the patient.
38
Start from the dirty area and then move out to the clean area. Be very careful when doing this as the
tissue or skin may be tender and there may also be sutures in place. Clean the area without causing
further damage or distress to the patient.
Make sure you do not re-introduce dirt or ooze by ensuring that cleaning materials (i.e. gauze, cotton
balls) are not over-used. Change them regularly (use once only if possible) and never re-introduce them
to a clean area once they have been contaminated.
Make sure that you have selected the correct dressing type and materials needed to provide full and
appropriate coverage for the type, size and location of the wound, according to the care plan or the
physician's or senior charge nurse's recommendations.
Dress the wound as per instructions.
Note: Ensure that the materials and dressing pack are only used for one eye at a time to prevent cross-
contamination. If, for some reason, another part of the face or the other eye also needs a dressing
change, then open another pack and start on the other side with clean hands and gloves.
After Care
cover the bag.
REFERENCES
doi:10.1080/07481187.2010.518513. PMID 24501824.
364–7. doi:10.1097/PAF.0b013e31815b4c69. PMID 18043029.
39
40
SET UP OF COMMUNITY HEALTH

CENTRE

DATE OF SUBMISSION-
41
SET UP OF COMMUNITY HEALTH CENTRE
Introduction
Health care delivery in India has been envisaged at three levels namely primary, secondary and
tertiary. The secondary level of health care essentially includes Community Health Centres(CHCs),
constituting the First Referral Units(FRUs) and the district hospitals. The CHCs were designed to provide
referral health care for cases from the primary level and for cases in need of specialist care approaching
the centre directly.
4 PHCs are included under each CHC thus catering to approximately 80,000 populations in tribal
/ hilly areas and 1, 20,000 populations in plain areas. CHC is a 30-bedded hospital providing specialist
care in medicine, Obstetrics and Gynecology, Surgery and Pediatrics.
Objectives of Indian Public Health Standards (IPHS) for CHCs:

• To provide optimal expert care to the community
• To achieve and maintain an acceptable standard of quality of care.
• To make the services more responsive and sensitive to the needs of the community.
Service delivery in CHCs: Every CHC has to provide the following services which can be known as the
Assured Services:
 Care of routine and emergency cases in surgery:
o This includes Incision and drainage, and surgery for Hernia, hydrocele, Appendicitis,
haemorrhoids, fistula, etc.
o Handling of emergencies like intestinal obstruction, haemorrhage, etc.
 Care of routine and emergency cases in medicine:
o Specific mention is being made of handling of all emergencies in relation to the National
Health Programmes as per guidelines like Dengue Haemorrhagic fever, cerebral malaria, etc.
Appropriate guidelines are already available under each programme, which should be
compiled in a single manual.
 24-hour delivery services including normal and assisted deliveries
 Essential and Emergency Obstetric Care including surgical interventions like Caesarean Sections and
other medical interventions
 Full range of family planning services including Laproscopic Services
 Safe Abortion Services
 New-born Care
 Routine and Emergency Care of sick children
 Other management including nasal packing, tracheostomy, foreign body removal etc.
 All the National Health Programmes (NHP) should be delivered through the CHCs.
 Integration with the existing programmes like blindness control, Integrated Disease Surveillance
Project, is vital to provide comprehensive services.
o RNTCP
o HIV/AIDS Control programme:
o National Vector
o National Leprosy Eradication Programme:
o National Programme for Control of Blindness:
o Under Integrated Disease Surveillance Project
 Others:
o Blood Storage Facility
o Essential Laboratory Services
o Referral (transport) Services
42
Minimum requirement for delivery of the above-mentioned services:
The following requirements are being projected based on the assumption that there will be
average bed occupancy of 60%. The strength may be further increased if the occupancy increases with
subsequent up gradation.
Staffing pattern of CHC
Doctors 4
Nurses 7
Dresser 1
Pharmacist 1
Laboratory assistant 1
Radiographer 1
Ward boy 2
Sweepers 3
Dhobi 1
Mali 1
Chowkidar 1
Ayah 1
4th class servant 1
Total 25
*1 ANM and 1 PHN for family welfare will be appointed under the ASHA scheme
** Ophthalmic assistant may be placed wherever it does not exist through redeployment or contract
basis.
*** Flexibility may rest with the state for recruitment of personnel as per needs.
Investigative facilities at the CHC:
 In addition to the lab facilities in the CHC, ECG should be made available in the CHC with
appropriate training to a nursing staff.
 All necessary reagents, glass ware and facilities for collecting and transport of samples should be
made available.
Physical Infrastructure:
The CHC should have 30 indoor beds with one Operation theatre, labour room, X-ray facility
and laboratory facility. In order to provide these facilities, following are the guidelines:
 Location of the centre: To the extent possible, the centre should be located at the centre of the
block head quarter in order to improve access to the patients. This may be applicable only to
centres that are to be newly established.
However, priority is to be given to operationalise the existing CHCs. The building should have
areas/ space marked for the following:
 Entrance zone:
 Prominent display boards in local language providing information Regarding the services
available and the timings of the institute
 Registration counters
 Pharmacy for drug dispensing and storage
 Outpatient department:
 Clinics for Various Medical Disciplines –These clinics include general medicine, general
surgery, dental (optional), obstetric and gynaecology, paediatrics and family welfare
 Room shall have, for the admission of light and air, one or more apertures, such as windows and
fan lights, opening directly to the external air or into an open verandah. The windows should be
in two opposite walls
 Family Welfare Clinic – The clinic should provide educative, preventive, diagnostic and
curative facilities for maternal, child health, school health and health education
 Waiting room for patients
43
 The Drug Dispensary should be located in an area conveniently accessible from all clinics
 Emergency Room/ Casualty:-The emergency cases may be attended by OPD during OPD
hours and in inpatient units afterwards.
 Treatment Room:
 Minor OT
 Injection Room and Dressing Room
 wards: Separate for males and females
 Nursing Station– The nursing station shall be centered such that it serves all the clinics from
that place.
 Patient Area:
 Enough space between beds.
 Toilets; separate for males and females.
 Separate space/ room for patients needing isolation
 There should be an area separating OPD and Indoor facility.
 Operation theatre/ Labour room:
 Patient area:
 Pre-operative and Post-operative(recovery)room
 Staff area:
 Changing room separate for males and females
 Storage area for sterile supplies
 OT/ Labour room area:
 Operating room/ labour room
 Scrub area
 Instrument sterilization area
 Disposal area
 Public utilities: Separate for males and females
 Physical infrastructure for Support services:
 CSSD: Sterilization and Sterile storage
 Laundry:
 Storage: separate for Dirty linen and clean linen
 Outsourcing is recommended after appropriate training of washer man regarding
separate treatment for infected and non-infected linen.
 Services: Electricity/ telephones/ water/ civil engineering: May be Outsourced.
 Training of all cadres of worker at periodic intervals is an essential component.

 Multi-skill training for paramedical workers
FUNCTIONS OF CHC:
1. Care of routine & emergency cases in surgery also, medicine, obstetrics /gynaecology
2. Full range of family planning services including laproscopic services.
3. Safe abortion services.
4. New born care.
5. Routine and emergency care of sick children.
6. Other management including nasal packing foreign body, Tracheostomy.
7. All national programme delivered from CHC conducted others
8. Caring and supervision of concerned PHCs
9. Providing consultancy /referral services to PHCs
10. Referring patient to district hospital and teaching hospitals
11. Implementation of all national health programmes with active participation in them
12. Providing RCH services including family planning
1) Blood storage facility.
2) Essential laboratory services.
3) Referral services.
CONCLUSION
44
Community health centre provides secondary level of health care in rural health services.These were
designed to provide referral as well as specialist health care to the rural population.In order to provide
quality care in CHCs now Indian public health standards are being prescribed.
BIBLIOGRAPHY
1.Essentials of community health nursing,K Park,6th edition,466,467
2.Essentials in community health nursing practice,S.kamalam,2 nd edition,171
3.Basic concept of community health nursng,I Clement,2nd edition,203,204
4.Swarnakar`s Community health nursing,3rd edition,607-610
45
CARDIO PULMONARY RESUCITATION

46
CARDIO PULMONARY RESUCITATION
CPR is a lifesaving procedure that is performed when someone's breathing or heartbeat has stopped, as
in cases of electric shock, drowning, or heart attack. CPR is a combination of:
 Rescue breathing, which provides oxygen to a person's lungs.
 Chest compressions, which keep the person's blood circulating.
Permanent brain damage or death can occur within minutes if a person's blood flow stops. Therefore,
you must continue these procedures until the person's heartbeat and breathing return, or trained medical
help arrives.
Considerations
CPR can be lifesaving, but it is best performed by those who have been trained in an accredited
CPR courseTime is very important when dealing with an unconscious person who is not breathing.
Permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 -
6 minutes later.
When a bystander starts CPR before emergency support arrives, the person has a much greater chance
of surviving. Nevertheless, when most emergency workers arrive at a cardiac arrest, they usually find no
one giving CPR.
Machines called automated external defibrillators (AEDs) can be found in many public places, and are
available for home use. These machines have pads or paddles to place on the chest during a life-
threatening emergency. They use computers to automatically check the heart rhythm and give a sudden
shock if, and only if, that shock is needed to get the heart back into the right rhythm.
When using an AED, follow the instructions exactly.

Causes
In adults, major reasons that heartbeat and breathing stop include:
 Drug overdose
 Excessive bleeding
 Heart disease (heart attack or abnormal heart rhythm)
 Infection in the bloodstream (sepsis)
 Injuries and accidents

Symptoms
 No breathing or difficulty breathing (gasping)
 No pulse
 Unconsciousness
First Aid
The following steps are based on instructions from the American Heart Association.
1. Check for responsiveness. Shake or tap the person gently. See if the person moves or makes a
noise. Shout, "Are you OK?"
47
2. Call 911 if there is no response. Shout for help and send someone to call 911. If you are alone,
call 911 and retrieve an AED (if available), even if you have to leave the person.
3. Carefully place the person on their back. If there is a chance the person has a spinal injury, two
people should move the person to prevent the head and neck from twisting.
4. Open the airway. Lift up the chin with two fingers. At the same time, tilt the head by pushing
down on the forehead with the other hand.
5. Look, listen, and feel for breathing. Place your ear close to the person's mouth and nose.
Watch for chest movement. Feel for breath on your cheek.
6. If the person is not breathing or has trouble breathing:
o Cover their mouth tightly with your mouth.
o Pinch the nose closed.
o Keep the chin lifted and head tilted.
o Give two rescue breaths. Each breath should take about a second and make the chest
rise.
7. Perform chest compressions:
o Place the heel of one hand on the breastbone -- right between the nipples.
o Place the heel of your other hand on top of the first hand.
o Position your body directly over your hands.
o Give 30 chest compressions. These compressions should be FAST and hard. Press
down about 2 inches into the chest. Each time, let the chest rise completely. Count the
30 compressions quickly:
o "1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,
off."
8. Give the person 2 more breaths. The chest should rise.
9. Continue CPR (30 chest compressions followed by 2 breaths, then repeat) until the person
recovers or help arrives. If an AED for adults is available, use it as soon as possible.
If the person starts breathing again, place them in the recovery position. Periodically re-check for
breathing until help arrives.
Do Not
 If the person has normal breathing, coughing, or movement, DO NOT begin chest
compressions. Doing so may cause the heart to stop beating.
 Unless you are a health professional, DO NOT check for a pulse. Only a health care
professional is properly trained to check for a pulse.
Prevention
To avoid injuries and heart problems that can lead to cardiac arrest:
48
 Eliminate or reduce risk factors that contribute to heart disease, such as cigarette smoking, high
cholesterol, high blood pressure, obesity, and stress.
 Get plenty of exercise.
 See your doctor regularly.
 Always use seat belts and drive safely.
 Avoid using illegal drugs.

Technique
 For an unconscious adult, CPR is initiated using the head-tilt chin-lift maneuver to open the
airway and determine if the patient is breathing.
 Before beginning ventilations, rule out airway obstruction by looking in the patient’s mouth for
a foreign body blocking the patient’s airway. CPR in the presence of an airway obstruction
results in ineffective ventilation/oxygenation and may lead to worsening hypoxemia.
 Effective mouth-to-mouth ventilation is determined by observation of chest rise during each

exhalation. Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion.
Two such exhalations should be given in sequence after 30 compressions (the 30:2 cycle of
CPR). When breaths are completed, compressions are restarted.
o If available, a barrier device (pocket mask or face shield) should be used.
o More commonly, health care providers use a positive pressure bag-valve-mask (BVM),
which forces air into the lungs when the bag is squeezed.
o Several adjunct devices may be used with a BVM, including oropharyngeal and
nasopharyngeal airways.
 If the patient is not breathing, 2 ventilations are given using the provider’s mouth or a BVM.
 Delivery of mouth-to-mouth ventilations. The rescuer has lifted the chin to ensure an open
airway and has pinched the nostrils shut to assist with an airtight seal. Two breaths should be
given, followed 30 compressions, as shown below.
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o The mouth-to-mouth technique is performed as follows:
 The nostrils of the patient are pinched closed.
 The provider puts his mouth completely over the patient’s mouth.
 The provider gives a breath for approximately 1 second with enough force to
make the patient’s chest rise.
o The BVM or invasive airway technique is performed as follows:
 The provider ensures a tight seal between the mask and the patient’s face.
49
 The bag is squeezed with one hand for approximately 1 second, forcing at least
500 mL of air into the patient’s lungs.
 Next, the provider checks for a carotid or femoral pulse.
 If the patient has no pulse, chest compressions are begun, as shown below.
Delivery of chest compressions. Note the overlapping hands placed on the center of the sternum,
with the rescuer's arms extended. Chest compressions are to be delivered at a rate of 100
compressions per minute.
o The heel of one hand is placed on the patient’s sternum and the other hand is placed on
top of the first, fingers interlaced.
o The elbows are extended and the provider leans directly over the patient.
o The provider presses down, compressing the chest 1.5 to 2 inches.
o The chest is released and allowed to recoil completely.
o Keeping the hands in place, the compressions are repeated 30 times at a rate of 100
compressions per minute.
 After 30 compressions, 2 breaths are given.
 This entire process is repeated until a pulse returns or the patient is transferred to definitive
care.
 Chest compressions can become quickly tiring. Another bystander should be prepared to take
over if the initial rescuer becomes fatigued.
 Care should be taken to not lean on the patient between compressions, as this prevents chest
recoil and worsens blood flow.
 Of note, an intubated patient should receive continuous compressions while ventilations are
given 8-10 times per minute.
 The above techniques refer specifically to CPR as prescribed by the basic cardiac life support
(BCLS) guidelines. In the in-hospital setting, or when a paramedic or other advanced provider
is present in the out-of-hospital setting, Advanced Cardiac Life Support (ACLS) guidelines call
for a more robust treatment of cardiac arrest including drug interventions, ECG monitoring,
defibrillation, and invasive airway procedures.
50
Pearls
 The key thing to keep in mind when doing chest compressions during CPR is to push fast and
hard.
 Chest compressions can become quickly tiring. Another bystander should be prepared to take
over if the initial rescuer becomes fatigued.
 Care should be taken to not lean on the patient between compressions, as this prevents chest
recoil and worsens blood flow.
 A key determinant of survival is the rapid delivery of high-quality CPR (within minutes of
cardiac arrest).
 Attempting to perform CPR is better than doing nothing at all, even if the provider is unsure if
he or she is doing it correctly. This especially applies to many people’s aversion to providing
mouth-to-mouth ventilations. If one does not feel comfortable giving ventilations, chest
compressions alone are still better than doing nothing.
Complications
 Performing chest compressions may result in the fracturing of ribs or the sternum, though
the incidence of such fractures is widely considered to be low.
 Artificial respiration using noninvasive ventilation methods (eg, mouth-to-mouth, BVM) can
often result in gastric insufflation. This can lead to vomiting, which can further lead to airway
compromise or aspiration. This problem is eliminated by inserting an invasive airway, which
prevents air from entering the esophagus.
 When done properly, CPR can be quite fatiguing for the provider. If possible, in order to give
consistent, high-quality CPR and prevent provider fatigue or injury, new providers should
intervene every 2-3 minutes (ie, providers should swap out, giving the chest compressor a rest
while another rescuer continues CPR).
American Heart Association CPR Guidelines
In 2005, the American Heart Association Emergency Cardiovascular Care Committee (ECC)
released their newest set of guidelines for CPR. In these guidelines, the compression/ventilation ratio
was changed from 15:2 to 30:2, reflecting a greater emphasisoncompressions.
Several recent studies have looked at the quality of CPR being performed in hospitals and EMS
systems and found that providers often did not perform CPR up to the standards of the ECC guidelines ,
Specifically, they found that providers were often deficient in both rate and depth of chest compressions
and often provided ventilations at too high a rate. Other studies have demonstrated the impact of
inadequate rate and depth on survival.
Another active controversy in the world of CPR research is the question of whether ventilations
should be given at all during bystander CPR in the out-of-hospital setting. Several studies have
concluded that stopping compressions in order to give ventilations may be detrimental to the patient’s
outcome .While a bystander halts compressions to give 2 breaths, blood flow also stops and leads to a
quick drop in the blood pressure that had been built up during the previous set of compressions.
Beforeyoubegin
Before starting CPR, check:
 Is the person conscious or unconscious?
 If the person appears unconscious, tap or shake his or her shoulder and ask loudly, "Are you OK?"
51
 If the person doesn't respond and two people are available, one should call 911 or the local emergency
number and one should begin CPR. If you are alone and have immediate access to a telephone, call 911
before beginning CPR — unless you think the person has become unresponsive because of suffocation
(such as from drowning). In this special case, begin CPR for one minute and then call 911.
 If an AED is immediately available, deliver one shock if instructed by the device, then begin CPR.
Remember the ABCs
Think ABC — airway, breathing and circulation — to remember the steps explained below. Move
quickly through airway and breathing to begin chest compressions.
Airway: Clear the airway
1. Put the person on his or her back on a firm surface.
2. Kneel next to the person's neck and shoulders.
3. Open the person's airway using the head-tilt, chin-lift maneuver. Put your palm on the person's
forehead and gently tilt the head back. Then with the other hand, gently lift the chin forward to
open the airway.
4. Check for normal breathing, taking no more than five or 10 seconds. Look for chest motion, listen
for normal breath sounds, and feel for the person's breath on your cheek and ear. Gasping is not
considered to be normal breathing. If the person isn't breathing normally and you are trained in
CPR, begin mouth-to-mouth breathing. If you believe the person is unconscious from a heart
attack and you haven't been trained in emergency procedures, skip mouth-to-mouth rescue
breathing and proceed directly to chest compressions.
Breathing:
Breathefortheperson
Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing if the mouth is seriously
injured or can't be opened.
1. With the airway open (using the head-tilt, chin-lift maneuver), pinch the nostrils shut for mouth-
to-mouth breathing and cover the person's mouth with yours, making a seal.
2. Prepare to give two rescue breaths. Give the first rescue breath — lasting one second — and
watch to see if the chest rises. If it does rise, give the second breath. If the chest doesn't rise,
repeat the head-tilt, chin-lift maneuver and then give the second breath.
3. Begin chest compressions to restore circulation.
Circulation: Restore blood circulation with chest compressions
1. Place the heel of one hand over the center of the person's chest, between the nipples. Place your
other hand on top of the first hand. Keep your elbows straight and position your shoulders directly
above your hands.
52
2. Use your upper body weight (not just your arms) as you push straight down on (compress) the
chest 2 inches (approximately 5 centimeters). Push hard at a rate of 100 compressions a minute.
3. After 30 compressions, tilt the head back and lift the chin up to open the airway. Prepare to give
two rescue breaths. Pinch the nose shut and breathe into the mouth for one second. If the chest
rises, give a second rescue breath. If the chest doesn't rise, repeat the head-tilt, chin-lift maneuver
and then give the second rescue breath. That's one cycle. If someone else is available, ask that
person to give two breaths after you do 30 compressions. If you're not trained in CPR and feel
comfortable performing only chest compressions, skip rescue breathing and continue chest
compressions at a rate of 100 compressions a minute until medical personnel arrive.
4. If the person has not begun moving after five cycles (about two minutes) and an automatic
external defibrillator (AED) is available, apply it and follow the prompts. Administer one shock,
then resume CPR — starting with chest compressions — for two more minutes before
administering a second shock. If you're not trained to use an AED, a 911 operator may be able to
guide you in its use. Use pediatric pads, if available, for children ages 1 to 8. Do not use an AED
for babies younger than age 1. If an AED isn't available, go to step 5 below.
5. Continue CPR until there are signs of movement or until emergency medical personnel take over.
To perform CPR on a child
The procedure for giving CPR to a child age 1 through 8 is essentially the same as that for an adult. The
differences are as follows:
 If you're alone, perform five cycles of compressions and breaths on the child — this should take about
two minutes — before calling 911 or your local emergency number or using an AED.
 Use only one hand to perform heart compressions.
 Breathe more gently.
 Use the same compression-breath rate as is used for adults: 30 compressions followed by two breaths.
This is one cycle. Following the two breaths, immediately begin the next cycle of compressions and
breaths.
 After five cycles (about two minutes) of CPR, if there is no response and an AED is available, apply it
and follow the prompts. Use pediatric pads if available. If pediatric pads aren't available, use adult pads.
Continue until the child moves or help arrives.
To perform CPR on a baby
Most cardiac arrests in babies occur from lack of oxygen, such as from drowning or choking. If you
know the baby has an airway obstruction, perform first aid for choking. If you don't know why the baby
isn't breathing, perform CPR.
To begin, examine the situation. Stroke the baby and watch for a response, such as movement, but don't
shake the baby.
If there's no response, follow the ABC procedures below and time the call for help as follows:
53
 If you're the only rescuer and CPR is needed, do CPR for two minutes — about five cycles — before
calling 911 or your local emergency number.
 If another person is available, have that person call for help immediately while you attend to the baby.
Airway: Clear the airway
1. Place the baby on his or her back on a firm, flat surface, such as a table. The floor or ground also
will do.
2. Gently tip the head back by lifting the chin with one hand and pushing down on the forehead with
the other hand.
3. In no more than 10 seconds, put your ear near the baby's mouth and check for breathing: Look for
chest motion, listen for breath sounds, and feel for breath on your cheek and ear.
If the infant isn't breathing, begin mouth-to-mouth rescue breathing immediately. Compressions-only
CPR doesn't work for infants.
Breathing: Breathe for the infant
1. Cover the baby's mouth and nose with your mouth.
2. Prepare to give two rescue breaths. Use the strength of your cheeks to deliver gentle puffs of air
(instead of deep breaths from your lungs) to slowly breathe into the baby's mouth one time, taking
one second for the breath. Watch to see if the baby's chest rises. If it does, give a second rescue
breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second
breath.
3. If the baby's chest still doesn't rise, examine the mouth to make sure no foreign material is inside.
If the object is seen, sweep it out with your finger. If the airway seems blocked, perform first aid
for a choking baby.
4. Begin chest compressions to restore blood circulation.
Circulation: Restore blood circulation
1. Imagine a horizontal line drawn between the baby's nipples. Place two fingers of one hand just
below this line, in the center of the chest.
2. Gently compress the chest to about one-third to one-half the depth of the chest.
3. Count aloud as you pump in a fairly rapid rhythm. You should pump at a rate of 100
compressions a minute.
4. Give two breaths after every 30 chest compressions.
5. Perform CPR for about two minutes before calling for help unless someone else can make the call
while you attend to the baby.
Continue CPR until you see signs of life or until medical personnel arrive.
54
55
CASE STUDY ON MUTLIGRAVIDA

WITH FULL TERM PREGNANCY

DATE OF SUBMISSION_
56
NURSING CARE PLAN ON DIARRHOEA
HISTORY TAKING
IDENTIFICATION DATA
 Name : Mr. Rajesh Yadav

 Age : 10 years
 Sex : male
 Father : Mr. Radhey Shyam Yadav
 Address : Gonda
 Education : 5th std
 Fathers Occupation : business man
 Fathers Income annual : 250000/year
 Religion : Hindu
 Diagnosis : Diarrhoea
History of present illness
Patient has been admitted in krishnachild ward with the complaints of severe diarrhoea.
History of past illness
There is no history of past illness.
Family history
Mr.radheyshyam yadav
68 years, healthy Ms.Sarojini Yadav
60 years, healthy Ms.Suman
yadav
39 years,
healthy
Ms.anil yadav
Ms.lata yadav 42years,
34 years, healthy healthy
Ms.Rajesh Yadav
10 years, diarrhoea
Educational history
Seema
10 years, healthy
 Age at beginning of formal education : 6th year
 Academic performance : average
 Relationship with peer and teacher : often fought with students and teachers
Play history
 Games played : hide and seek, carrom, chese

 Relationship with team work : present
57
Treatment history
s.no Name of the drug Action Route/dose Side effects Nurses

responsibility
1 lactated Ringer IV/250 ml - -Maintain the flow
solution of the IV fluid as
per doctor’s order
-Inform the patient
to contact the near
by person or
nurses, if he feels
any discomfort
2 Cefixime Antibiotics IV/5mg Constipation, Monitor the
headache patient till he get
comfort.
3 Paracetamol Antipyretics 50mg tab Constipation Monitor the
, abdominal patient till he get
discomfort. comfort.
58
Personal history
Perinatal history
 Antenatal period : Normal

 Intranatal period : Normal
 Delivery : normal
 Birth : full term
 Birth Defects : Not
 Postnatal complication : not significant
Childhood History
 Primary caregiver : Mother

 Feeding : Breast feed
 Developmental milestones : Normal
 Behavior and emotional problems : Temper tantrum in school going age
 Child hood illness : not significant
Head to foot assessment
Head: dandruff present
Hairs
Color: brown
Normally distributed
Eyes
Colour of eyeball – black
No infection
No discharges
Mouth
No foul smell
No infection
Dental cares present
Nose
DNS – absent
No abnormal discharges
No infection
Neck
No abnormal bulges
59
No thyroid problems
Chest
Irregular expansion
Increased heart rate
Extremities
Normal
Bladder and bowel movement
Bladder activity normal
Bowel movement – excessive watery stool
Gas formation
Nursing care plan on diarrhea
Nursing diagnosis
 Diarrhea related to side effects of antibiotics as evidence by frequent lose, liquid stools, and
reports of abdominal pain.
 Altered nutrition, less than body requirement related to inability to take food.
 Fluid and electrolyte imbalance related to diarrhoea
 Impaired social interaction related to weakness
60
Nursing Nursing
Planning Implementation Evaluation
assessment diagnosis
Subjective data: Diarrhea related to -The nurse will -The nurse Diarrhoea has
Patient is telling infection. assess the patient assessed the been reduced
he is so tired. report of diarrhea patient report of
Having frequent Objective: every shift. diarrhea every
loose motion. Reduce the -The nurse will shift.
diarrhoea assess the patients -The nurse
Objective data stool consistency assessed the
Patient is going to daily according to patients stool
pass stool more the Bristol stool consistency daily
than five times. chart. according to the
-The nurse will Bristol stool chart.
keep track of how -The nurse kept
many bowel track of how many
movements the bowel movements
patient has daily. the patient has
-The nurse will daily.
encourage and -The nurse
provide the patient encouraged and
with clear liquids provide the patient
every two hours with clear liquids
while awake. every two hours
-The nurse will while awake.
educate the patient -The nurse
and parents on educated the
what clear liquids patient and parents
to consume and on what clear
avoid. liquids to consume
-The nurse will and avoid.
and parents about educated the
the contributing patient and parents
factor that is about the
causing her contributing factor
diarrhea. that is causing her
diarrhea.
Subjective data: Fluid and -provide ORS -provided ORS Fluid and
Patient is telling electrolyte -allow him to take -allow him to take electrolyte
that he mouth is imbalance related plenty of fluid. plenty of fluid. balanced.
getting dry. to diarrhoea -provide -provided
Objective data Objective: medications as per medications as per
Patients mouth is Maintain normal doctors order. doctors order.
getting dry. Skin fluid and Moisture the -Moistured the
also getting dry. electrolyte mouth with water mouth with water
balance. to relieve from to relieve from
dryness. dryness.
Subjective data: Altered nutrition, Provide high Provide high Nutritional status
Patient is telling less than body protein , high protein , high has been
he is very week. requirement caloric nutritious caloric nutritious maintained.
Objective data related to inability food, food,
Patients is very to take food. -Find out patients -Found out
week and to able dislikes and likes patients dislikes
to stand also. Objective: -Provide 6-8 and likes
Maintain normal glasses of fluids -Provided 6-8
nutritional status per day glasses of fluids
-Maintain record per day
61
Nursing Nursing
of intake and -Maintained
output. record of intake
-Supplement diet and output.
with vitamin and -Supplemented
minerals. diet with vitamin
and minerals.
62
Diarrhoea
Definition
Diarrhea is an increase in the frequency of bowel movements or a decrease in the form of stool
(greater looseness of stool). Although changes in frequency of bowel movements and looseness of
stools can vary independently of each other, changes often occur in both.
Health effects
Diarrheal disease may have a negative impact on both physical fitness and mental development. "Early
childhood malnutrition resulting from any cause reduces physical fitness and work productivity in
adults," and diarrhea is a primary cause of childhood malnutrition. Further, evidence suggests that
diarrheal disease has significant impacts on mental development and health; it has been shown that,
even when controlling for helminth infection and early breastfeeding, children who had experienced
severe diarrhea had significantly lower scores on a series of tests of intelligence.
Classification:
 Acute diarrhea is short-lasting - between several hours and a number of days, and for less than 2
weeks or 14 days. World guidelines further say that acute diarrhea is the presence of 3 or more
abnormally loose or watery stools in the preceding 24 hours. Acute diarrhea includes cholera. If
the acute diarrhea is bloody, it is called dysentery
 Persistent diarrhea lasts for longer than 2 weeks but less than 4 weeks
 Chronic diarrhea lasts more than 4 weeks.
Causes
 Poverty is a good indicator of the rate of infectious diarrhea in a population. This association
does not stem from poverty itself, but rather from the conditions under which impoverished
people live.
 One of the most common causes of infectious diarrhea, is a lack of clean water. Often, improper
fecal disposal leads to contamination of groundwater. This can lead to widespread infection
among a population, especially in the absence of water filtration or purification. Human feces
contains a variety of potentially harmful human pathogens
 Proper nutrition is important for health and functioning, including the prevention of infectious
diarrhea. It is especially important to young children who do not have a fully developed
immune system.
Signs and symptoms
Book picture Patient picture

 Loose, watery stools  Loose, watery stools
 Abdominal cramps  Abdominal pain
 Abdominal pain  Fever
 Fever  Nausea
 Blood in the stool  Urgent need to have a bowel movement
 Bloating
 Nausea
 Urgent need to have a bowel movement
63
Pathophysiology
According to two researchers, Nesse and Williams, diarrhea may function as an evolved
expulsion defense mechanism. As a result, if it is stopped, there might be a delay in recovery. They cite
in support of this argument research published in 1973 that found that treating Shigella with the anti-
diarrhea drug (Co-phenotrope, Lomotil) caused people to stay feverish twice as long as those not so
treated. The researchers indeed themselves observed that: "Lomotil may be contraindicated in
shigellosis. Diarrhea may represent a defense mechanism.
Diagnostic approach
 In infants
 Moderate or severe diarrhea in young children
 Associated with blood
 Continues for more than two days
 Associated non-cramping abdominal pain, fever, weight loss, etc.
 In travelers
 In food handlers, because of the potential to infect others;
 In institutions such as hospitals, child care centers, or geriatric and convalescent homes.
 A severity score is used to aid diagnosis in children
Prevention
 Numerous studies have shown that improvements in drinking water and sanitation (WASH)
lead to decreased risks of diarrhoea.[42] Such improvements might include for example use of
water filters, provision of high-quality piped water and sewer connections.
 Basic sanitation techniques can have a profound effect on the transmission of diarrheal disease.
The implementation of hand washing using soap and water, for example, has been
experimentally shown to reduce the incidence of disease by approximately 42–48%
 Given that water contamination is a major means of transmitting diarrheal disease, efforts to
provide clean water supply and improved sanitation have the potential to dramatically cut the
rate of disease incidence. In fact, it has been proposed that we might expect an 88% reduction in
child mortality resulting from diarrheal disease as a result of improved water sanitation and
hygiene.
 Immunization against the pathogens that cause diarrheal disease is a viable prevention
strategy, however it does require targeting certain pathogens for vaccination. In the case of
Rotavirus, which was responsible for around 6% of diarrheal episodes and 20% of diarrheal
disease deaths in the children of developing countries, use of a Rotavirus vaccine in trials in
1985 yielded a slight (2-3%) decrease in total diarrheal disease incidence, while reducing
overall mortality by 6-10%. Similarly, a Cholera vaccine showed a strong reduction in
morbidity and mortality, though the overall impact of vaccination was minimal as Cholera is
not one of the major causative pathogens of diarrheal disease.
 Dietary deficiencies in developing countries can be combated by promoting better eating
practices. Supplementation with vitamin A and/or zinc. Zinc supplementation proved successful
showing a significant decrease in the incidence of diarrheal disease compared to a control
group.[55][56] The majority of the literature suggests that vitamin A supplementation is
advantageous in reducing disease incidence
 Breastfeeding practices have been shown to have a dramatic effect on the incidence of diarrheal
disease in poor populations. Studies across a number of developing nations have shown that
64
those who receive exclusive breastfeeding during their first 6 months of life are better protected
against infection with diarrheal diseases.
Management
 Oral rehydration solution (ORS) (a slightly sweetened and salty water) can be used to prevent
dehydration. Standard home solutions such as salted rice water, salted yogurt drinks, vegetable
and chicken soups with salt can be given. Home solutions such as water in which cereal has
been cooked, unsalted soup, green coconut water, weak tea (unsweetened), and unsweetened
fresh fruit juices can have from half a teaspoon to full teaspoon of salt (from one-and-a-half to
three grams) added per liter. Clean plain water can also be one of several fluids given.
 Eating: WHO recommends a child with diarrhea continue to be fed. Continued feeding speeds
the recovery of normal intestinal function. In contrast, children whose food is restricted have
diarrhea of longer duration and recover intestinal function more slowly. A child should also
continue to be breastfed. The WHO states "Food should never be withheld and the child's usual
foods should not be diluted. Breastfeeding should always be continued.
Medications
While antibiotics are beneficial in certain types of acute diarrhea, they are usually not used except in
specific situations. There are concerns that antibiotics may increase the risk of hemolytic uremic
syndrome in people infected with Escherichia coli O157:H7. In resource-poor countries, treatment with
antibiotics may be beneficial.[72] However, some bacteria are developing antibiotic resistance,
particularly Shigella. Antibiotics can also cause diarrhea, and antibiotic-associated diarrhea is the most
common adverse effect of treatment with general antibiotics.
While bismuth compounds (Pepto-Bismol) decreased the number of bowel movements in those with
travelers' diarrhea, they do not decrease the length of illness. Anti-motility agents like loperamide are
also effective at reducing the number of stools but not the duration of disease. These agents should only
be used if bloody diarrhea is not present.
Bile acid sequestrants such as cholestyramine can be effective in chronic diarrhea due to bile acid
malabsorption. Therapeutic trials of these drugs are indicated in chronic diarrhea if bile acid
malabsorption cannot be diagnosed with a specific test, such as SeHCAT retention.
Bibliography
1. Basem Abdelmalak; John Doyle, eds. (2013). Anesthesia for otolaryngologic surgery.
Cambridge University Press. pp. 282–287.
2. Curtis V, Cairncross S (May 2003). "Effect of washing hands with soap on diarrhoea risk in the
community: a systematic review". The Lancet infectious diseases. 3 (5): 275–81.
3. http://www.mayoclinic.org/diseases-conditions/diarrhea/symptoms-causes/dxc-20232937
4. http://www.medicinenet.com/diarrhea/article.htm
https://en.wikipedia.org/wiki/Diarrhea CHILD MORTALITY RATE
Child mortality, also known as under-5 mortality or child death, refers to the death of infants and
children under the age of five or between the age of one month to four years depending on the
definition. A child's death is emotionally and physically hard on the parents. Many deaths in the
majority of the world go unreported since many poor families cannot afford to register their babies in
the government registry.
65
The leading causes of death of children under five include:
1. Diarrhea
2. Malaria
3. Malnutrition
4. Pneumonia
5. Preterm birth conditions
Prevention and child survival
Child survival is a field of public health concerned with reducing child mortality. Child survival
interventions are designed to address the most common causes of child deaths that occur, which include
diarrhea, pneumonia, malaria, and neonatal conditions. Of the portion of children under the age of 5
alone, an estimated 9.2 million children die each year mostly from such preventable causes. According
to an estimate by UNICEF in 2008, one million child deaths could be prevented annually at a cost of
$US 1 billion per year (an average of $US 1000 for each child)
Low-cost interventions
Two-thirds of child deaths are preventable.[6] Most of the children who die each year could be
saved by low-tech, evidence-based, cost-effective measures such as vaccines, antibiotics, micronutrient
supplementation, insecticide-treated bed nets, improved family care and breastfeeding practices,[7] and
oral rehydration therapy.[8] Empowering women, removing financial and social barriers to accessing
basic services, developing innovations that make the supply of critical services more available to the
poor and increasing local accountability of health systems are policy interventions that have allowed
health systems to improve equity and reduce mortality.
The Lancet Child Survival Series
The British medical journal The Lancet has published a widely quoted series of five articles outlining
the current child survival situation, include challenges and feasible solutions, commonly referred to as
"The Lancet Child Survival Series". The series outlines a number of child survival interventions which
have been scientifically proven to reduce mortality, include oral rehydration therapy, sleeping under
insecticide-treated mosquito nets, vitamin A supplementation, and community-based antibiotic
treatment for pneumonia. Agencies promoting and implementing child survival activities worldwide
include UNICEF and non-governmental organizations; major child survival donors worldwide include
the World Bank, the British Government's Department for International Development, the Canadian
International Development Agency and the United States Agency for International Development. In the
United States, most non-governmental child survival agencies belong to the CORE Group, a coalition
working, through collaborative action, to save the lives of young children in the world's poorest
countries.
Global trends
The child survival rate of nations varies with factors such as fertility rate and income distribution; the
change in distribution shows a strong correlation between child survival and income distribution as well
as fertility rate where increasing child survival allows the average income to increase as well as the
average fertility rate to decrease.
66
BIRTH RATE
Birth rate: 19.3 births/1,000 population (2016 est.)
Definition: This entry gives the average annual number of births during a year per 1,000 persons in the
population at midyear; also known as crude birth rate. The birth rate is usually the dominant factor in
determining the rate of population growth. It depends on both the level of fertility and the age structure
of the population.
Some activists believe India's 2011 census shows a serious decline in the number of girls under
the age of seven – activists fear eight million female foetuses may have been aborted between 2001 and
2011.[42] These claims are controversial. Scientists who study human sex ratios and demographic
trends suggest that birth sex ratio between 1.08 and 1.12 can be because of natural factors, such as the
age of mother at baby's birth, age of father at baby's birth, number of babies per couple, economic
stress, endocrinological factors, etc.[43] The 2011 census birth sex ratio in India, of 917 girls to 1000
boys, is similar to 870–930 girls to 1000 boys birth sex ratios observed in Japanese, Chinese, Cuban,
Filipino and Hawaiian ethnic groups in the United States between 1940 and 2005. They are also similar
to birth sex ratios below 900 girls to 1000 boys observed in mothers of different age groups and
gestation periods in the United States
2.72 children born/woman (2009 est.), although more up-to-date statistics indicate that India's
TFR was 2.6 in 2008[63]
The TFR (total number of children born per women) according to religion in 2001 was: Hindus
2.4, Muslims 2.8, Sikhs 2.1, Christians 2.1, Buddhists 2.1, Jains 1.4, animists and others 2.99, tribals
3.16, scheduled castes 2.89
REFERENCES:
1. GBD 2013 Mortality and Causes of Death, Collaborators (17 December 2014). "Global,
regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of
death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.". Lancet.
385 (9963): 117–71. doi:10.1016/S0140-6736(14)61682-2. PMC 4340604Freely accessible.
PMID 25530442.
2. Liu, Li; Oza, Shefali; Hogan, Dan; Chu, Yue; Perin, Jamie; Zhu, Jun; Lawn, Joy E; Cousens,
Simon; Mathers, Colin. "Global, regional, and national causes of under-5 mortality in 2000–15:
3. UNICEF STATISTICS. Retrieved 14 June 2015.
4. UNICEF Facts on Children - May 2008
5. UNICEF - Young child survival and development.
6. "UNICEF - Goal: Reduce child mortality". Retrieved 14 June 2015.
7. "WHO - New formula for oral rehydration salts will save millions of lives". Retrieved 14 June
2015.
8. Levels & Trends in Child Mortality Report 2014
9. Curtis, Val; Cairncross, Sandy (May 2003). "Effect of washing hands with soap on diarrhoea
risk in the community: a systematic review". The Lancet Infectious Diseases. 3 (5): 275–281.
doi:10.1016/S1473-3099(03)00606-6. PMID 12726975.
10. "UNICEF STATISTICS". Retrieved 14 June 2015.
67
CASE STUDY ON FAMILY

DATE OF SUBMISSION_
68
CASE STUDY ON FAMILY
Introduction
General information
 House number: 48
 Name of the head of the family : Mr.Raghu Ram
 Type of family: Joint family
 Caster : Yadav
 Mother tongue : Hindi
 Language known : Hindi
Family composition
s.n Name of the Relationship Age/ Marital Educat Occupatio Health

o Family Members with HOF sex status ion n status
8TH
1 Mrs.Manjula Wife 50/F Married agriculture Healthy
STD
2 Mr.Deepak Son 27/M Married PUC agriculture Healthy
S.S.L.
3 Mrs.Manisha Daughter 25/F Married House wife Healthy
C
LAB Private Appedis
4 Mr. Dhurgesh Son 20/M Not married
TECH hospital ectomy
Mrs.manjula
50 yrs, 8th std,
Healthy
Mrs.Raghu Ram
Head of the family
53 yrs, 8th std,
Healthy
Mr. Dhurgesh 20
yrs, LAB TECH,
Appendectomy
Mr.Deepak
27 yrs, Agriculture, Mrs.Manisha 25
Healthy yrs, S.S.L.C,
Healthy
69
Present Health History
Mr. Dhurgesh affected undergone appendectomy. He is having little abdominal pain. And fever.
Past Health History
Past history of jaundice was there. He took treatment also for that. It was Ayurvedic treatment.
Housing conditions:
 Well-furnished house
 There are 4 rooms
 The house is adequately ventilated
 Properly lightened
 Kitchen made it perfect and cleanliness maintained
 They are using LPG
 There was proper water supply
 The surrounding area is not clean
Nutritional status
 There are eating veg types of foods only

 They are well aware of nutritional diets
Physical assessment of the client
 Name: Mr. Dhurgesh

 Age:20 years
 Sex:Male
 Height:150 cm
 Weight:52 kg
Vital signs
 Temperature – 37 degree celcius

 Pulse: 71 beats/min
 Respiration: 23 breaths / min
 Blood pressure: 120/90 mm of hg
General appearance
 Active
 Dull in face
 Worrying about the illness
Physical examination
Head to foot examination
Head
 Dandruff present
 No infections or wound in head
 Hair is black and white mixed
70
 Hair falling is there
Eyes
 Eye brows present

 Eye ball is black in colour
 No infection
Ears
 No discharge
 No infection
Nose
 No DNS
 No discharges
 No bleeding
Mouth
 Foul smell is there

 Teeth are absent
Neck
 Not find any abnormalities

 No lymph node enlargement
Chest
 Symmetrical expansion
 Abnormal breathing sound
Abdomen
 No cancer tissue
 Bowl sound present
Extremities no abnormalities
Genitalia
 Constipation present
 Urinary incontinence absent
 regular bladder and bowl movement
71
CASE STUDY ON APPENDICITIS

72
CASE STUDY ON APPENDICITIS
Definition
Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to
its other parts. It is caused by obstruction of the appendiceal lumen from a variety of causes.
Obstruction is believed to cause an increase in pressure within the lumen.
Appendicitis is inflammation of the appendix. It may be acute or chronic.
An appendectomy (sometimes called appendisectomy or appendicectomy) is the surgical removal of the

vermiform appendix
causes of appendicitis
 Appendicitis occurs most often between the ages of 10 and 30

 Symptoms include pain around the bellybutton, loss of appetite, nausea, abdominal swelling,
and low grade fever.
 enlarged lymphoid follicles
 worms
 trauma
 tumors
Pathophysiology
Tradition holds that once the appendix becomes obstructed, bacteria trapped within the appendiceal
lumen begin to multiply, and the appendix becomes distended. The increased intraluminal pressure
obstructs venous drainage, and the appendix becomes congested and ischemic.
The combination of bacterial infection and ischemia produce inflammation, which progresses to
necrosis and gangrene. When the appendix becomes gangrenous, it may perforate. The progression from
obstruction to perforation usually takes place over 72 hours.
One study noted that appendiceal perforation is more common in children, specifically younger
children, than in adults. A substantial risk of perforation within 24 hours of onset was noted (7.7%) and
was found to increase with duration of symptoms. While perforation was directly related to the duration
of symptoms before surgery, the risk was associated more with prehospital delay than with in-hospital
delay.
During the initial stage of appendicitis, the patient may feel only periumbilical pain due to the T10
innervation of the appendix. As the inflammation worsens, an exudate forms on the appendiceal serosal
surface. When the exudate touches the parietal peritoneum, a more intense and localized pain develops.
Perforation results in the release of inflammatory fluid and bacteria into the abdominal cavity. This
further inflames the peritoneal surface, and peritonitis develops. The location and extent of peritonitis
(diffuse or localized) depends on the degree to which the omentum and adjacent bowel loops can
contain the spillage of luminal contents.
If the contents become walled off and form an abscess, the pain and tenderness may be localized to the
abscess site. If the contents are not walled off and the fluid is able to travel throughout the peritoneum,
the pain and tenderness become generalized.
Signs and symptoms
73
 pain around the bellybutton
 lower right side abdominal pain
 loss of appetite
 nausea
 vomiting
 diarrhea
 constipation
 inability to pass gas
 abdominal swelling
 low grade fever
 a sense you might feel better after passing stool
Diagnostic findings
 A physical exam for appendicitis looks for tenderness in the lower right quadrant of your
abdomen. If you’re pregnant, the pain may be higher. If perforation occurs, your stomach may
become hard and swollen.
 A swollen, rigid belly is a symptom that should be discussed with a doctor right away.
 Urinalysis can rule out a urinary tract infection or kidney stone.
 Pelvic exams can make certain that women don’t have reproductive problems. They can also
rule out other pelvic infections.
 Pregnancy tests can rule out a suspected ectopic pregnancy.
 Abdominal imaging can determine if you have an abscess or other complications. This may be
done with an X-ray, ultrasound, or CT scan.
 Chest X-ray can rule out right lower lobe pneumonia. This sometimes has symptoms similar to
appendicitis.
Medical Management
 In rare cases, appendicitis may get better without surgery. Treatment might involve only
antibiotics and a liquid diet.
 In most cases, however, surgery will be necessary. The type of surgery will depend on the
details of your case.
 If you have an abscess that hasn’t ruptured, you may receive antibiotics first. Your doctor will
then drain your abscess using a tube placed through your skin. Surgery will remove your
appendix after you’ve received treatment for the infection.
 If you have a ruptured abscess or appendix, surgery may be necessary right away. Surgery to
remove the appendix is known as an appendectomy.
 A doctor can perform this procedure as open surgery or through a laparoscopy. Laparoscopy is
less invasive, making the recovery time shorter. However, open surgery may be necessary if
you have an abscess or peritonitis.
Nursing management
 Self-care deficit related to health condition

 Impaired nutritional status related to difficulty to take food as evidenced by pain while taking
food.
 Knowledge deficit related to disease condition
74
Nursing Nursing
Nursing planning Implementation Evaluation
Subjective data Self-care deficit -assess the -assessed the severity Self-care has
Patient telling no related to health severity of the of the patient’s been
interest on self- condition patient’s condition condition maintained
care activities. Objectives -educate the -educated the patient
Objective data Improve self-care patient the the importance of the
Patient shows no activities importance of the proper hygiene
interest on personal proper hygiene -provided health
hygiene -provide health education.
education. -medicated as per
-medications as doctors order
per doctors order
Subjective data Impaired -Assess the -Assess the severity Nutritional
Patient says she nutritional status severity of the of the nutritional status has been
couldn’t take any related to loss of nutritional level. level. maintained.
food. She feels no interest to take -Educate the -Educate the
taste in food food. nutritional value nutritional value of
Objective data of food on health. food on health.
Patient show no Objective -The food which -The food which is
interest for food Maintain normal is very important very important for
intake. nutritional status. for DM should be DM should be
explained to them explained to them
-Tell them to take -Tell them to take
periodical food periodical food
intake. intake.
-Medications as -Medications as per
per doctor’s order. doctor’s order.
Subjective data Knowledge deficit -Assess the -Assessed the Knowledge has
Patient says she related to disease severity of the severity of the been improved
couldn’t take any condition. patients. patients Knowledge regarding DM
food. She feels no knowledge deficit. deficit. care.
taste in food Objective -Provide health -Provided health
Objective data education. education.
Patient show no Improve -Explain about the -Explained about the
interest for food knowledge on diet need to diet need to maintain
intake. DM. maintain to keep to keep the sugar
the sugar level level normal.
normal. -Explained the
-explain the important of the
important of the personal hygiene.
personal hygiene. -Medications done as
-Medications as per doctor’s order.
per doctor’s order.
Comparison of Book picture and patient picture
Signs and Symptoms present in book Signs and Symptoms present in Patient
• pain around the bellybutton • pain around the bellybutton
• lower right side abdominal pain •
• loss of appetite •
• nausea • nausea
• vomiting • vomiting
• diarrhea •
75
• constipation •
• inability to pass gas •
• abdominal swelling • abdominal swelling
• low grade fever • low grade fever
• a sense you might feel better after passing
stool
76
FAMILY CASE STUDY

DATE OF SUBMISSION-
77
FAMILY CASE STUDY
PERSONAL DATA
1. NAME:
2. CLASS: M.sc nursing1st year
3. COLLEGE: K.I.N.S.R. KANPUR
4. AREA POSTED: kanpur
5. CARE STARTED: 25-06-22
6. CARE ENDED: 30-06-22
FAMILY DATA
1. NAME: Mrs. Rama

2. AGE: 22 years
3. SEX: female
4. DIAGNOSIS: Postnatal mother
5. ADDRESS: Mrs.Rama W/o Mr.Suresh Gonda
SOCIO-ECONOMIC
1. Background of the village

2. Community setting:
3. Name of the area: haripur
4. Urban/rural: rural
5. Name of the taluk / district: -
6. Population : 5000
7. Main caste group: sc and st
8. Religion: hindu
9. Administration of panchayat: panchayat president elected by community people
10. Main occupation: coolie
11. Methods of recording births/ deaths: village health nurse
OTHER FACILITIES
Community people have no transportation facility:. They go to market on every Friday, they
have a small temple in the community. Most of the people have their house. All the houses have electric
facility, they are getting water from common pipe, they are practicing open air defecation, there is no
library facilities.
COMMUNITY HEALTH PROGRAMMES
Community nurse is often visiting the community and giving treatment for minor ailments and
the health worker is doing blood smear to detect malaria cases and leprosy cases. In the sub centre they
are providing treatment for TB, malaria, leprosy, maternal and child health facilities, immunization and
family planning services
INFLUENTIAL PERSONS IN THE AREA
The influential person is the president, he stays in the community area itself , if any problem
they can approach him at any time. The village health nurse visits once in a week to every house.
FACILITIES AVAILABLE
 Medical :
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o Govt hospitals- present
o Private nursing home- nil
o Health center – nil
o Indigenous practitioner – present
 SOCIAL AGENCIES: NIL
 EDUCATIONAL FACILITIES
Some of the people are educated: in this village one primary school is present,
where the children are getting their primary education
 COMMUNITY SANITATION
Community sanitation is inadequate, they don’t have latrine facilities, most of the
people use open air defecation, and there are no proper drainage facilities in the houses.
SOCIOECONOMIC BACK GROUND OF THE FAMILY
 Family set up
Nuclear family,
Sl.no Name of the family Education occupation Marital Remarks of

Member status health
1 Suresh 10 Coolie married healthy
Rama
2 10 House wife married postnatal
mother
1. EXPENDITURE OF MONTH
Total income of the family is 3000 rupees per month
2. Food: 20%
3. Vegetables: 10%
4. Ration :20%
5. Milk: 10%
6. Non-veg: 5%
7. Clothing :5%
8. Medical:10%
9. Festival :10%
10. Others : 5%
11. Saving: 5%
Details about the property
House: own house
Land: no land
Animal: there is a cow in their house
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12. Family and social relationships
o Attitude among family members and neighbors
Family members have good understanding between them, they maintain good relationship with the
neighbors, they spend atleast some time to discuss and take important decision
o Attitude towards people of other community and religion
They mingle with the people of all the religion, they also attend the functions of other religion also
13. Description of house and surroundings

 Roof: cemented
 Walls: walls are made up of cement and bricks
 No of rooms : 2 rooms
 Lighting : lighting is available in all the rooms
 Ventilation: proper ventilation is available in all the rooms
 Water supply: they get water from the common pipe
 Bathing area: they have bathroom inside the house itself
 Latrine : they don’t have latrine, they are practicing open field defecation
 Disposal of waste: they have common drainage but it is not clean and clear
 Surroundings: the surrounding is not clean and it is not hygienic
14. Leisure time activities

During leisure time they speak with the neighbors and watch television
POSTNATAL ASSESSMENT
Patient profile:
Name : Mrs. Rama
Age : 22yrs
Sex : Female
Husband’s name : Mr Rama
Address : KANPUR
Religion : Hindu
Marietal status : Married
Education : PUC, passed
Occupation : housewife
Family income : 3000 / month
G1P 1 L 1 A 0
Date of registration : 4. 12. 2021
Date and time of delivery: 03 -04 -2022 and 8.15 pm
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LMP : 26. 11.2021
Chief complains:
She has a complaint of pain in the perineum.
Personal history:
She has a moderate body built. She sleep 8-9 hrs per day. She does not have any bad habits like
chewing betels leaves, smoking etc. she has a hobbies of cooking , , listening music etc.
Socio economic history
Her husband is the bread winner of the family. They are living in their own house. Their house is
of kutcha type and there are only 2 rooms in their house. They have enough ventilation inside the room
from 3 windows and 2 doors. Adequate electric and water facilities is there. They have close drainage
system. There is no pet animals in their house. They maintain good relationship with their neighbours.
Family history:
Their family member does not have any
 maternal and paternal history of breech delivery

 history of twin delivery
 history of Hypertension , Heart disease, Diabetes or any other Congenital malformation
 Past medical history
She has no past medical diseases like diabetes mellitus, hypertension, heart diasease etc.
Past surgical history
No significant surgical history in her past
Menstrual history:
 She attain her puberty at the age of 15 year

 Last menstrual period date – 26 .11..2021
 Duration of each period is 30 days
 She has a history of dysmenorrhoea
Contraceptive history:
No history of using any contraceptive in her past.
Past obstetric history:
No past obstetric history
Notes on admission for labour:
Present pregnancy :
 Full term
 Date of admission : 02.08. 2021
 Period of gestation : full term
 Presentation and the position : vertex and LOA
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 Date of delivery : 03.07.2022
 Time of delivery : 8.15pm
Labor note
 Membrane rupture spontaneously at 8.00pm

 Expulsive contraction commenced at : 9am
 Time and onset of labor :8pm
 Type of labor : full term normal vaginal delivery with
episiotomy
 Mode of delivery : vaginal
Length of labor:
 1st stage :30min

 2nd stage :30min
 3rd stage :15min
 Total hrs :11hrs
Condition of the mother after delivery:
 Temperature - 98.8◦F
 Pulse - 78beats per min
 Respiration -20 breath per min
 BP -110/70mm Hg.
 Fundal height -10cm
 Uterus -hard
 Vaginal bleeding -normal
 Condition of the baby -alive
 Sex of the baby -male
 Wt of the baby -2.8gm
 Ht -40cm
Immediate care of the baby:
 Apgar score checked and it is good

 Eye care and cord care given.
 vital signs checked,
 Baby bath given.
 Baby passed meconium immediately after delivery.
 Baby is fed with breast milk
Immediate care of the mother:
 Vitals sign checked.

 Administered the ordered drugs.
 Episiotomy care given.
 Observed for the vaginal discharge.
 Recorded the number of pad.
 Encourage the mother to ambulate in an early.
 She voided freely. Her general condition is good..
Drugs given:
Inj methergen 1 ampoule given.
82
83
PHYSICAL EXAMINATION:
Anthropometric measurement:
Height :151cm
Weight :50kg
General appearance : she looks inactive
Facial appearance : normal , no edema , no puffiness.
Body built : moderate body built
Head and face:
Scalp : clean, no inflammation, or no any pediculi
Nose :
No nasal septum deviation
No nasal polyps
No inflammation in the nostrils.
Mouth:
Lips :No angular stomatitis,
Tongue :No glossitis , no coated tongue, no fissures in the tongue
Teeth :no dental caries, no pyorrhea.
Gums :no gingivitis, no swollen gums, and no bleeding gum.
Neck:
No lymph node enlargement, all range of motion is possible.
Chest:
Heart S1 and S2 sound, no cardiac murmur sound heart.
Lungs:
Symmetrical lungs expansion
No whistling sound
No stridor sound
Breast:
Inspection:
Symmetrical in shape and size
Presence of Montgomery tubercles

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Presence of primary and secondary areola
No crack nipple and no visible discharge.
Palpation:
breasts are enlarged, soft, warm, and contain only a small amount of colostrum.
Nipples: nipples is intact without redness, tenderness, cracks or blisters. Colostrum is expressed.
Abdominal examination:
Uterus:
Inspection:
Presence of striae gravida
Presence of linea nigra
Absence of scar mark
Umbilicus is inverted
Uterus size—9cm
Uterus shape—ovoid
Palpation:
Fundal height:-- 9cm
Lower limbs—ROM is normal, no varicose vein, no edema
Homan’s sign--- negative
Genitalia:
Vulva: visible blood dots while inspection
No abnormal foul smelling
No veneral infection
Present of lochia rubra.
NEW BORN ASSESSMENT
Vitals sign,
Temperature :98.6F
Pules :130 beats per min.
Respiration :26 breath per min
Length / height of the baby : 42cm

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Weight : 2.6kg
Head circumference : 33cm
Chest circumference : 32cm
General appearance:
 Activity :active
 Posture :well flexed
 Cry : good cry.
Skin:
Colour :pink in colour.
Texture :good texture.
Lanugo :present
Vermix caseosa :present
Mongolian spot :present in the sacrum area of the baby
Head:
Hair : equally distribution.
Skull : no injury, or anything during birth.
Shape :normal shape, no abnormal shape like hydrocephaly,

anencephaly, microcephaly , macrocephaly etc.
Fontanelle :anterior fontanelle – open
posterior fontanelle.--open.
Face : no puffiness
Eyelids : eyelids may be slightly edematous.
Eyes : no discharge, no congenital cateract.
Nose : no nasal septum deviation
Nostrils : no choanal atresia or stenosis.
Flaring : no nasal flaring.
Mouth:
Lips : pink in color, no bluish discoloration which indicate

cyanosis.
Cleft : no cleft lip and cleft palate.
Neck :possible all range of motion
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Chest:
Inspection : breast is symmetrically enlarged, no abnormal

infection like breast abcess.
Symmetry : ribs are horizontal and equally expanded.
Movements : symmetric movement of the chest is present.
Respiration is 42 breath per min.
Nipple :no inflammation , no witch milk.
Auscultation :no abnormal sound.like grunting sound
Abdomen:
Inspection : no congenital hernia like omphalocele, cord is

clean no discharge from the cord.
Palpation : liver is palpable 2 cm.no spleenomegaly and no

hepatomegaly.
Shape : round in shape
Auscultation : heart bowel sound.
Stools( meconium):
Stool passed, no abnormality like fistula
External genitalia:
The testes is descended.
The extremities:
No malformation like polydactyly or syndactyly , no congenital dislocation of the hip.
NEONATAL REFLEXES:
1) Moro reflex :present

2) Startle reflex : present
3) Rooting reflex : present
4) Swallowing and suckling reflex : present
5) Placing reflex : present
6) Doll’s eyes reflex : present
7) Glabella reflex :present
8) Bibinski’s reflex : present
9) Symmetrical head reflex :present
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NORMAL PUERPERIUM

DATE OF SUBMISSION-
NORMAL PUERPERIUM
INTRODUCTION:
88
Puerperium is defined as the time from the delivery of the placenta through the first few weeks
after the delivery. This period usually is considered to be 6 weeks in duration. By 6 weeks after
delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted
to the nonpregnant state.
DEFINITION:
"The puerperium, or postpartum period, generally lasts 6–12 weeks and is the period of adjustment after
delivery when the anatomic and physiologic changes of pregnancy are reversed, and the body returns to
the normal nonpregnant state. The postpartum period has been arbitrarily divided into the immediate
puerperium—the first 24 hours after parturition—when acute postanesthetic or postdelivery
complications may occur: the early puerperium, which extends until the first week postpartum: and the
remote puerperium, which includes the period of time required for involution of the genital organs and
return of menses, usually by 6 weeks in nonlactating women, and the return of normal cardiovascular
and psychological function, which may require months...."
An overview of the relevant anatomy and physiology in the postpartum period is as follows:
Uterus
The pregnant term uterus (not including baby, placenta, fluids, etc) weighs approximately 1000 grams.
The uterus recedes to a nonpregnant state, with a weight of 50-100 grams, during the 6 weeks after
delivery.
Immediately after delivery, the uterus can be palpated at or near the umbilicus. Most of the reduction in
size and weight occurs in the first 2 weeks, at which time the uterus has decreased enough in size to be
located in the true pelvis.
The endometrial lining rapidly regenerates, so that by the seventh day the endometrial glands already
are evident. By day 16, the endometrium is restored throughout the uterus, except at the placental site.
The placental site goes through a series of changes in the postpartum period. Immediately after delivery,
the contractions of the arterial smooth muscle and compression of the vessels by contraction of the
myometrium result in hemostasis. The size of the placental bed decreases by half, and the changes in the
placental bed result in the quantity and quality of the lochia that is experienced.
Initially postpartum, a large amount of red blood comes from the uterus as the contraction phase rapidly
occurs. The volume rapidly decreases. The duration of this discharge (lochia), known as lochia rubra, is
variable. The red discharge changes to a brownish-red color, with a more watery consistency, which is
known as lochia serosa. Over a period of weeks, the discharge continues to decrease in amount and
color and changes to a yellow discharge, which is known as lochia alba. The amount of time the lochia
can last varies, averaging about 5 weeks, with a waxing and waning amount of flow and color.
Each woman will have her own pattern, with the various phases of the lochia lasting for different
lengths of time. Fifteen percent of women have lochia at 6 weeks?postpartum. Often, women
experience an increase in the amount of bleeding at 7-14 days secondary to the sloughing of the eschar
on the placental site.
Cervix
The cervix also begins to rapidly change back to a nonpregnant state, but it never returns to the
nulliparous state. By the end of the first week, the external os is closed to the extent that a finger could
not be easily introduced.
Vagina
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The vagina, which was distended to accommodate the baby, diminishes in size to a non pregnant state,
but it does not completely return to its prepregnant size. There is resolution of the increased vascularity
and edema by 3 weeks, and the rugae of the vagina begin to reappear in the woman who is not
breastfeeding. At this time, the vaginal epithelium appears atrophic on smear. This is restored by weeks
6-10: however, it is further delayed in the breastfeeding mother because of the persistently decreased
estrogen levels.
Perineum
The perineum has been stretched and traumatized, and sometimes torn or cut, during the process of
labor and delivery. The swollen and engorged vulva rapidly resolves, and swelling and engorgement are
completely gone within 1-2 weeks. Most of the muscle tone is regained by 6 weeks, with more
improvement over the following few months. The muscle tone may or may not return to normal,
depending on the extent of injury that was experienced.
Abdominal wall
The abdominal wall remains soft and poorly toned for many weeks. The return to a prepregnant state
depends greatly on exercise.
Ovaries
The resumption of normal function by the ovaries is highly variable. It is greatly influenced by the
mother decision whether to breastfeed the infant. The woman who decides to breastfeed has a longer
period of amenorrhea and anovulation than does the mother who chooses to bottle-feed the infant. The
non-breastfeeding mother may ovulate as early as 27 days after the delivery. Most women have had a
menstrual period by 12 weeks, with a mean time to first menses being 7-9 weeks. In the breastfeeding
woman, this resumption of menses is highly variable and depends on a number of factors, including
how much and how often the baby is fed and whether the baby 旧 food is supplemented with formula.
The delay in the return to normal ovarian function in the lactating mother is caused by the suppression
of ovulation due to the elevation in prolactin. One half to three fourths of women who breastfeed return
to periods within 36 weeks of delivery.
Breasts
The changes to the breasts that prepare the body for breastfeeding occur throughout the pregnancy. By
16 weeks?gestation, lactation can occur. Lactogenesis is triggered initially by the delivery of the
placenta, which results in falling levels of estrogen and progesterone, with the continued presence of
prolactin. If the mother is not breastfeeding, the prolactin levels decrease and return to normal within 2-
3 weeks.
The colostrum is the liquid that is initially released by the breasts during the first 2-4 days after delivery.
It is high in protein and is very protective for the newborn. The colostrum, which the baby receives in
the first few days postpartum, already is present in the breasts, and suckling by the newborn triggers its
release. The process, which started out as an endocrine process, switches to an autocrine process: the
removal of milk from the breast stimulates more milk production. Over these first 7 days, the milk
matures and has all of the necessary nutrients that the baby needs in this neonatal period. The milk
continues to change throughout the period of breastfeeding to meet the changing demands of the baby.
Lactation
Breast-feeding should be encouraged for several reasons. First and foremost, breast milk is the ideal
source of nutrients for the neonate. Breast milk also provides some degree of immunologic protection
for the neonate. Nursing is contraindicated in patients with certain viral infections such as CMV,
hepatitis B, and HIV infection.
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The breast and nipples of a woman who is nursing her infant require little attention in the puerperium
other than attention to cleanliness and fissures. Some parturients may request lactation suppression
during the postpartum period. Lactation is suppressed in 60-70% of women who wear a fight brassiere
and avoid stimulation of the nipples. Althoughbreast engorgement may occasionally cause a
temperature elevation of short duration, any rise in temperature during the puerperium might be a sign
of infection.
LACTOGENESIS
One distinguishing characteristic of mammals is their capacity to nourish their young with secretions
from the mammary glands. On the basis of studies in animals, lactogenesis can be arbitrarily divided
into two stages. During the first stage, which occurs during the third trimester of pregnancy, the lobular-
alveolar complex is stimulated to differentiate such that there are increases in synthesis of enzymes
necessary for the production of milk components. These special constituents of human milk include
major proteins such as a-lactalbumin, [3-1actoglobulin, and casein, as well as triglycerides and lactose.
The second stage is characterized by secretion of colostrum, followed by significant milk secretion
approximately 5 days after delivery.
In concert with cortisol, insulin, estrogen, progesterone, and placental lactogen, prolactin stimulates
growth and development of the milk-secreting apparatus of the mammary gland. Prolactin is the
principal hormone that stimulates lactogenesis, and levels increase progressively throughout pregnancy
from a mean of less than 20 ng/mL in a nonpregnant woman to an average of 250-300 ng/mL during the
third trimester. Prolactin exerts its principal action by binding to specific membrane receptors on
mammary tissue to stimulate gene transcription of messenger RNA and subsequent synthesis of lactose,
casein, milk fat, and a-lactalbumin. During pregnancy, the high estrogen levels produced by the fetal-
placental unit stimulate an increase in circulating puerperium, lactation , breast-feeding, breast feeding,
breastfeeding, postpartum, postpartum depression, postpartum hemorrhage, uterine infection, mastitis,
episiotomy infection prolactin: however, the high estrogen-progesterone levels also suppress the number
of available prolactin-binding sites in mammary tissue so that lactogenesis is delayed until placental
separation leads to a rapid decline in these steroid levels. After delivery, prolactin concentrations remain
elevated and increase further during suckling. Because higher prolactin levels lead to more prolactin-
binding sites, prolactin can induce an up-regulation of its own receptors, thereby further increasing its
biologic activity.
Although both human placental lactogen and growth hormone are structurally similar to prolactin and
have intrinsic lactotrophic properties, their role in lactogenesis in humans is unclear. During pregnancy,
growth hormone is suppressed to very low levels, whereas placental production of human placental
lactogen is parallel to the increase in placental growth during the second half of pregnancy. In animal
models, human placental lactogen can mimic the biologic action of prolactin by binding to the prolactin
receptor. Because levels of human placental lactogen decline rapidly and become undetectable 24 hours
after delivery, a role for human placental lactogen in the maintenance of lactation is unlikely.
In mammary tissues, cortisol induces the development of the rough endoplasmic reticulum and Golgi
membranes that are necessary for increased synthesis of milk proteins. Thus, cortisol appears to be
essential for prolactin stimulation of casein production.
During pregnancy, estrogens promote ductal development while progesterone stimulates lobular-
alveolar maturation of the mammary gland. In addition, the high levels of estrogens present during
pregnancy augment the release of prolactin from the pituitary gland, and the high levels of progesterone
act to suppress lactogenesis by reducing the ability of prolactin to up-regulate its own receptors.
Progesterone also exerts other anti-lactogenic effects by reducing estrogen binding to mammary tissue.
Thyroid hormones appear to play a permissive role in lactogenesis because administration of T 4

augments mammary development and milk production.
ROUTINE POSTPARTUM CARE 　

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The immediate postpartum period occurs most often in the hospital setting, where the majority of
women remain in the hospital approximately 2 days after a vaginal delivery and 3-5 days after a
cesarean section. During this time, women are recovering from their delivery, as well as beginning to
care for the newborn. This period is used both to make sure the mother is stable and to educate her in
the care of her baby, especially the first-time mother. While still in the hospital, the mother is monitored
for blood loss, signs of infection, abnormal blood pressure, contraction of the uterus, and the ability to
void.
It is customary to check the blood type of the baby and to administer the RhoGAM vaccine to the Rh-
negative mother if her baby 旧 blood type is Rh positive. Usually, the mother has at least her hematocrit
level checked on the first postpartum day. Women are encouraged to ambulate and to eat a regular diet.
Vaginal delivery
After a vaginal delivery, most women experience swelling of their perineum and pain. This is
intensified if the woman has had an episiotomy or a laceration. Routine care of this area includes ice
applied to the perineum to reduce the swelling and help with pain relief. Conventional treatment is to
use ice for the first 24 hours after delivery and then switch to warm sitz baths. However, there is little
evidence to support this method over other methods of treatment of the postpartum perineum. Pain
medications are very helpful both systemically as nonsteroidal anti-inflammatories (NSAIDs) or
narcotics, as well as local anesthetic spray to the perineum.
Another postpartum issue that is likely to affect the women who have vaginal deliveries is hemorrhoids.
Symptomatic relief is the best treatment during this immediate postpartum period, because often the
hemorrhoids will resolve as the perineum recovers. This can be achieved by the use of corticosteroid
creams, witch hazel compresses, and local anesthetics.
Tampon use can be resumed when the patient is comfortable inserting the tampon and it is comfortable
to wear. This will take longer for the woman who has had an episiotomy or a laceration than for one
who has not. The vagina and perineum should be fully healed, which takes about 3 weeks. It also is
important to change the tampons frequently to prevent infection.
Cesarean section
The woman who has had a cesarean section does not usually have the pain and discomfort from her
perineum, but rather from her abdominal incision. This, too, can be treated with ice to the incision, as
well as with the use of systemic pain medication. Often, women who have had a cesarean section are
slower to begin ambulating, eating, and voiding. However, they should be encouraged to resume these
and other normal activities quickly.
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Sexual intercourse
Sexual intercourse may resume when there is no bright red bleeding, the vagina and vulva are healed,
and the woman is physically comfortable, as well as emotionally ready. The physical readiness usually
takes about 3 weeks. Birth control is important to protect against pregnancy, as the first ovulation is
very unpredictable.
Patient education
Substantial education takes place during the hospital stay, especially for the mother who has just had her
first child. The mother, and often the father, is taught routine care of the baby, feeding, diapering, and
bathing, as well as what can be expected from the baby in terms of sleep, urination, bowel movements,
and eating.
The mother who is breastfeeding should receive education, support, and guidance with the
breastfeeding. Breastfeeding is neither easy nor automatic. It requires much effort on the part of the
mother and her support team. Breastfeeding should be initiated as soon after delivery as possible: in a
normal, uncomplicated vaginal delivery this can be done almost immediately after the birth. The mother
should be encouraged to feed the baby every 2-3 hours (at least while she is awake during the day) to
stimulate mild production. Feedings do not need to be long, but they should be frequent. The milk
production should be well established by 36-96 hours.
In women who choose not to breastfeed, the care of the breasts is quite different. Care should be taken
not to stimulate the breasts in any way to try to prevent milk production. Ice packs applied to the breasts
and the use of a tight bra or a binder also can help to prevent breast engorgement. Acetaminophen or
NSAIDs can help with the symptoms of breast engorgement (eg, tenderness, swelling, fever) if it does
occur. At one time, bromocriptine was administered to suppress milk production. However, its use has
diminished because it requires 2 weeks of administration, does not always work, and can produce
adverse reactions.
Discharge instructions
It is important to give the mother discharge instructions. The most important information is who and
where to call if she has problems or questions. She also needs details about resuming her normal
activity. Instructions vary, depending on whether the mother has had a vaginal delivery or a cesarean
section.
The woman who has had a vaginal delivery may resume all physical activity as long as she is
comfortable and without pain or discomfort with the activity. This includes using stairs, riding in a car,
driving a car, or doing muscle-toning exercises. The caveat to resuming normal activity is not to overdo
activity on one day to the point that the mother is completely exhausted the next day. Pregnancy, labor,
and delivery, as well as care for the newborn, are strenuous and stressful, and the mother needs
sufficient rest to recover. The woman who has had a cesarean section needs to be more careful about
resuming some of her activities. It is important for her to prevent overuse of her abdomen until her
incision is well healed to prevent an early dehiscence or a hernia later on.
Women conventionally return for their postpartum visit at about 6 weeks after delivery. There is no
sound reason for this: the time probably has become the standard so those women who are returning to
work can be medically cleared to return. There is nothing that should be or needs to be done at a
postpartum visit that cannot be done earlier or later than 6 weeks. Often, an earlier visit can aid a new
mother in resolving problems she may be having or provide a time to answer questions that she might
have.
It is very important to counsel the mother about birth control options before she leaves the hospital. She
may not be ready to decide about a method, but she needs to know what her options are. Her decision
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will be based on a number of factors, including her motivation in using a particular method, how many
children she has, and whether she is breastfeeding. There are many available options.
 Natural methods can be used in highly motivated couples. This includes the use of
monitoring the basal body temperature and the quality and quantity of the cervical
mucus to determine what phase of the menstrual cycle the woman is in and if it is safe
to have intercourse.
 Barrier methods of contraception like condoms are widely available, as are vaginal spermicides.
Condoms are available over-the-counter, while diaphragms and cervical caps need to be fitted.
 Hormonal methods of contraception are numerous. There are combined estrogen-progestin
agents that are taken daily by mouth or monthly by injection. Progestin-only agents are
available for daily intake or by long-acting injection that are effective for 12 weeks.
 Intrauterine devices can be placed a few weeks after delivery.
 Permanent methods of birth control (ie, tubal ligation, vasectomy) are best for the couple that
have more than one child and are sure that they do not want any more.
Lochia :
It is the vaginal discharge for the first fortnight during puerparuim. It comes from uterus, cervix &
vagina. It has a fishy smell. Depending up the colour its divided into-
 Lochia rubra-red and lasts for 1-4 days.

 Lochia serosa yellowish or pink and lasts for 4-10 days.
 Lochia alba-pale white and lasts for 10-15 days.
 It may be seen up to 3 weeks.
Clinical Importance:
It's smell, colour, amount & duration give an idea of infection, retained bits, subinvolution or other
lesions.
Common puerperal problems
 Perineum:
o If the perineum has been damaged and repaired it may cause considerable pain,
requiring analgesics, and women may prefer to sit on a rubber ring.
o If the perineum is painful, it is important to check the sutures and check for any signs of
infection. Occasionally sutures may need to be removed.
 Micturition:
o May be difficult in first 24 hours and may occasionally require catheterisation.
o Around 1 in 10 women have urinary incontinence and this usually takes the form of
stress incontinence. For most women this has resolved after a few weeks. Pelvic floor
exercises should be taught and encouraged.
 Bowel problems:
o Constipation may be a problem for a short time and stool softeners may be useful.
o Haemorrhoids may be more painful after the birth than before. These can occasionally
appear for the first time perinatally and these normally disappear within a few weeks.
 Mastitis:
o May be due to failure to express milk from one part of the breast: can treat by ensuring
all milk is expressed and cold compresses.
o May be complicated by infection with Staphylococcus aureus and require treatment
with flucloxacillin.
o Very occasionally a breast abscess develops and requires incision and drainage.
 Backache:
o This may persist after the birth and affects approx. a quarter of women - 50% of these
women suffered backache before pregnancy.
o Pain may be considerable and last for several months.
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 Psychological problems:
o 'Third day blues': on days 3-5, a large proportion of women become temporarily sad
and emotional: approximately 10% of women suffer from postnatal depression which
may present at any time during the first year after delivery.
o The precise cause of this is unknown and may involve hormonal changes, reaction to
excitement of childbirth and doubts by the mother about her ability to care for the child.
o Management consists of talking to the mother and explaining what is happening.
Serious maternal health problems
 Postnatal psychosis:
o Affects 1-3/1000 women and usually appears as mania or depression but women
sometimes present with apparent schizophrenia.
o Usually begins abruptly at 5-15 days, initially with confusion, anxiety, restlessness and
sadness.
o There is rapid development of delusions e.g. baby has died or is deformed or
hallucinations with deepening melancholia.
o The woman must be admitted to hospital, preferably with her baby.
o There is limited evidence for the effectiveness of treatment specifically for puerperal
psychosis. Treatments used for affective psychoses in general are also appropriate for
puerperal psychosis, e.g. one or more drugs from the antidepressant, mood stabilising or
neuroleptic groups and occasionally ECT. 1,2
 Postpartum haemorrhage:
o Primary postpartum haemorrhage is defined as loss of more than 500 ml of blood
during first 24 hours.
 Normally 200-600 ml blood is lost before myometrial retraction plus strong
uterine contractions stop flow.
 80% of cases are associated with either an atonic uterus or placental remnants.
Rest of cases are associated with laceration of the genital tract, rarely uterine
rupture or blood coagulation defect.
 Treatment in situations where placenta is still in uterus is combining controlled
cord traction with fundal pressure. If this fails, manual removal of the placenta
under general anaesthetic.
 If the placenta has already been expelled, treatment includes massaging the
uterus, IV ergometrine or syntocinon, or misoprostol, blood transfusion,
correction of coagulation defects, bimanual compression of the uterus: urgent
transfer to theatre for surgery may be required.
o Secondary postpartum haemorrhage is abnormal bleeding after 24 hours up until 6
weeks postpartum.
 Usual causes are:
 Poor epithelialisation of placental site (80% cases).
 Retained placental fragment and/or blood clots (usually detected by
ultrasound).
 Uterus is often found to be bulky and tender with cervix open.
 Initially treated with ergometrine IM plus antibiotics. Curettage is only
necessary if bleeding persists despite this.
 Postnatal anaemia is common and may easily be overlooked.
 Puerperal pyrexia:
o Defined as temperature 38 °C or above during the first 14 days after delivery.
o Now occurs in only 1-3% of all births.
o Most cases are due to anaerobic streptococci that normally inhabit the vagina. Initially,
infect placental bed and then spread either into parametrium or via uterine cavity to
Fallopian tubes and occasionally pelvic peritoneum.
o Alternatively may be breast infection or UTI, or non-infective cause such as
thrombophlebitis or deep vein thrombosis.
 Thromboembolism:
95
o Now occurs in <1/1000 births and more likely to occur in women who are overweight,
over the age of 35 or have had a caesarean section. 3
o Deep vein thrombosis: indicated by low-grade fever, raised pulse rate and feeling of
uneasiness. Calf muscles are tender and painful on firm palpation. Clinical signs are
unreliable and need confirmation with colour Doppler ultrasound. Treatment is with IV
heparin plus oral warfarin continued for 6-12 weeks.
o Pulmonary embolus: dyspnoea and pleural pain and cyanosis may develop later.
Friction rub heard on chest. Diagnosis confirmed by lung perfusion scan performed
urgently as women may die within 2-4 hours. Treatment is with IV heparin bolus
followed by infusion.
CONCLUSION:
Puerperium is the period following child birth during which the body & the organs involved in
pregnancy & child birth, revert back to approximately the pre-pregnant state both anatomically &
physiologically.
BIBLIOGRAPHY:
1. Pilliteri Adele., Maternal and Child Health Nursing., Philadelphia: J.B. Lippincott Company.P:
2. Park k: Park’s Textbook of Preventive and Social Medicine: 17 th edition: Banarsidas Bhanot
Publicatios: 2002. P:
3. Annamma Jacob, A Comprehensive Textbook Of Midwifery, Edition: 2 nd, published by: Jaypee
Brothers. P: 684-92.
4. Novak Julie C., Broom Betty L., Maternal And Child Health Nursing. Edition: 8 th, Published
by: Mosby Publication. P: 9-13.
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FAMILY WELFARE PROGRAMME

DATE OF SUBMISSION-
97
FAMILY WELFARE PROGRAMME
Introduction
Looking to the need of population planning,national family planning programme was started in India in
1952.India is the first country in the world to implement family planning programme.In 1977 the name
of this programme was changed to family welfare programme.National family welfare programme is
completely sponsored by union government.National family welfare programme is run by family
planning division of ministry of health and family welfare.The objectives of family welfare alsohonour
the commitments of the govt. of India,which includes International conference on population and
development and millanium development goals and others.
Objectives
1. To reduce growth rate of population so as to achieve stable population at the earliest

2. To ensure good reproduction and childhood status
Contributory objectives
 To bring about wanted conceptions

 To develop the wanted conception in to healthy newborn
 To rear wanted newborn in to healthy children
 To avoid unwanted birth and to regulate the interval between the pregnancies
 To adopt the small family norm
Basic principles of NFWP
Right from the beginning the basic principles of family welfare programme have remained as
follows
 Family welfare services are voluntary

 Family welfare programme will provide comprehensive MCH services and also family planning
services.
Family Welfare Programmes Mainly include:
1. Family planning information, counselling and services to women for healthy reproduction.
2. Education about safe delivery and post delivery of the mother and the baby and the treatment of
women before pregnancy.
3. Health care for infants immunization against preventable diseases.
4. Prevention and treatment of sexually and Reproductive Tract infection.
Organization/Functionaries of NFWP
98
At centre level: Ministry of health and family welfare,Family planning division,Central family welfare
council,National population commission,DGHS,National institute of health and family welfare and all
departments concerned with the human resources and development
NIHFW : It is the apex institute for the promotion of health and family welfare programme in
the country.It is an autonomous organization which has established in the year 1977.Its
functions are preparing modules for training ,training of trainers.mid term evaluation of
ASHA,development of curriculum.
1. At state level : State ministry of health and family welfare,Directorate of state health and family
welfare and other concerning department.State institute of health and family welfare is the main
organ of family welfare programme at state level.It runs various progarmmes,educational
activities and training for health personnel at state level.
2. At district level : Chief health and medical officer,district family welfare bureau,urban family
welfare centers,urban health post etc.
3. At block and village level : Block CMO,Medical officer incharge of
CHC/PHC,subcenter,ANM/FHW,village health guide,ASHA etc.
Contraceptive services under NFWP
 Councelling,access to provision of good quality services and follow up care are

emphazised in all contraceptive services
 GOI is promoting fixed day static services approach in sterilization services with in the
public health system with the aim of increasing access to sterlizationservices.
 Increasing male participation in planned parenthood including vasectomy
 Camp approach for male sterilization
 Providing wide range of contraceptive services at various levels of health system.
Elements of success in family welfare programming
 Make services accessible and affordable

 Offer client centered care
 Rely on evidence based technical guidance
 Communicate effectively
 Assure contraceptive security
 Work for supportive policies
 Coordinate among implementing partners
 Build a high performing staff
 Secure adequate budget use it well and properly
 Base decisions on evidence
 Lead strongly and manage well
99
 Integrate service appropriately
National family planning insurance scheme
Govt. of India launched the National Family Planning Insurance Scheme in November 2005 to
compensate for the acceptors of sterilization or his/ her nominee in the unlikely event of failure or
complication ,death following sterilization operation
Funding for family welfare programme
The resources made available for this programme were always less than the need because of
this the objective of population stabilization could only be partially achieved.In addition to central govt.
world bank,United Nation Fund For Population Activities,WHO,USAID also provide technical and
financial help for family welfare programme.
Key challenges for family welfare programme : Demographic challenges
Service delivery challenges
Future strategies for family welfare programme
 Advocacy for repositioning the FP programme at all level

 Ensuring the fixed day static services round the year for delivery of FP services
 Increasing the thrust on postpartum family planning services
 Promoting community based distribution of contraception through ASHAs
 Organizing state family planning workshops countrywide with focus on family planning
services
 Statewise spread of IEC/BCC and advocacy materials
 Ensuring adequate supply of contraceptives to all the states
Activities of nurse in family welfare
 Antenatal care
 Intranatal care
 Postnatal care
 Immunization
 Contraceptive services
 Medical termination of pregnancy
 Guide
 Health educator
 Follow up activities
Role of a nurse in family welfare programme

100
Role of a nurse in family welfare will be governed by the policy of the govt. or the health institution
employing them.
1. Administrative role
The community health nurse has to participate and organize family welfare programmes at
national,regional and community level as an administrator.
2. Functional role
Community health nursing function include assisting doctor in pparentral,postnatal
examination and with various clinical and biological test.Also help in family planning and
provide opportunity to choose suitable methods of contraception.
3. Supervisory role
As a supervisor community health nurse should encourage their staff to participate actively
in family welfare programme.The community health nurse will organize in service programme
to other health workers ,professionals and other persons.
4. Education role
As a basis for counselling in family planning nurse must have sound knowledge of the
biology of human reproduction.The nurse play as effective educator for the individual ,family
and community
5. Role in research
The community health nurse is a primary member of multidisciplinary research team.She has
to extend directly or indirectly to cooperate,participate and motivate all research activities on
family welfare activities.
6. Evaluation role
The community health nurse evaluate all the activities of welfare programme.
Conclusion
The family planning programme is not merely intended for population stabilization now but it has much
larger perspective in holistic approach towards Reproductive and child health. Services, family
planning, Immunization, training etc. comprise a comprehensive health care package.The Family
welfare activities are guided as per the policies, guidelines and funding by Govt. of India. To ensure
qualitative healthy delivery and population control the Reproductive and child Health programme has
been implemented in every state with community needs assessment approach. To boost the health care
delivery, each State Govt. has formulated health reforms and implemented the same to give better
autonomy to the health institutions.
BIBLIOGRAPHY
1.Preventive and social medicine,K Park,4th edition,516-517
2.Essentials in community health nursing practice,S.kamalam,2 nd edition,122
101
3.Basic concept of community health nursng,I Clement,2nd edition,189-192
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HEALTH CARE DELIVERY SYSTEM IN

INDIA

DATE OF SUBMISSION-
103
HEALTH CARE DELIVERY SYSTEM IN INDIA
Introduction:
India is a union of 28 states and 7 union territories. States are largely independent in matters relating to
the delivery of health care to the people. Each state has developed its own system of health care
delivery, independent of the Central Government.
The Central Government responsibility consists mainly of policy making, planning, guiding, assisting,
evaluating and coordinating the work of the State Health Ministries. The health system in India has 3
main links
1. Central
2. State and
3. Local or peripheral
(1) At the central
The official “organs” of the health system at the national level consist of
1. Ministry of Health and Family Welfare
2. The Directorate General of Health Services
3. The Central Council of Health and Family Welfare
1. Union Ministry of Health and Family Welfare.
Organization Pattern
Cabinet Minister
Department of Health Department of Family Welfare
Joint Secretary Additional Secretary
Deputy Secretary Commissioner
Administrative staff Joint Secretary
Administrative staff
Functions: (1) Union list
1. International health relations and administration of port quarantine
2. Administration of Central Institutes such as All India Institute of Hygiene and Public Health,
Kolkata.
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3. Promotion of research through research centers
4. Regulation and development of medical, pharmaceutical, dental and nursing Professions
5. Establishment and maintenance of drug standards
6. Census and collection and publication of other statistical data
7. Immigration and emigration
8. Regulation of labor in the working of mines and oil fields
9. Coordination with states and with other ministries for promotion of health
(2) Concurrent list
The functions listed under the concurrent list are the responsibility of both the union and state
governments.
1. Prevention and extension of communicable diseases
2. Prevention of adulteration of food stuffs
3. Control of drugs and poisons
4. Vital statistics
5. Labor welfare
6. Ports other than major
7. Economic and social planning
8. Population control and Family Planning
9. Preparation of health education material for creating health awareness through Central Health
Education Bureau.
10. Collection, compilation, analysis, evaluation and dissemination of information Through the
Central Bureau of Health Intelligence
11. National Medical Library
2. Directorate General of Health Services Organization Pattern
Directorate General of health services
Director General of health services
Additional Director General of health service
Deputy Directorate General of health services
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I
Functions:
1. International health relations and quarantine of all major ports in country and International
airport
2. Control of drug standards
3. Maintain medical store depots
4. Administration of post graduate training programmes
5. Administration of certain medical colleges in India
6. Conducting medical research through Indian Council of Medical Research
7. Central Government Health Schemes.
8. Implementation of national health programmes
9. Preparation of health education material for creating health awareness through Central Health
Education Bureau.
10. Collection, compilation, analysis, evaluation and dissemination of information through the
Central Bureau of Health Intelligence
11. National Medical Library
3. Central Council of Health Organization Pattern
Chairman (Union health Minister)
Members (State health Minister)
Functions
1. To consider and recommend broad outlines of policy regard to matters
Concerning health like environment hygiene, nutrition and health education.
2. To make proposals for legislation relating to medical and public health matters.
3. To make recommendations to the Central Government regarding distribution of Grants-in-aid
II. At the State level
The health subjects are divided into three groups: federal, concurrent and state. The state list is the
responsibility of the state, including provision of medical care, preventive health services and
pilgrimage within the state.
State health administration
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At present there are 28 states in India, each state having its own health administration Organization
Pattern
(1) State Ministry of Health & family welfare
Deputy Minister of Health and Family Welfare
Health Secretary
Deputy Secretaries
State Director of health
(2)
Director of Medical Education Director of Health Services
I I
Additional Director of Health Services
Dean of medical college
I I
State nursing superintendent Deputy Director of Health Services
I I
Regional
Functional
MCH, TB, Leprosy, Immunization
Hospital Education
I I
Nsg Superintendent Nsg Officer
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Incharge
Ward
Senior tutor
Junior tutor
Nsg Staff
Functions of state health Director:
(1) Studies in depth the health problem and needs in the state and plans scheme to Solve them
(2) Providing curative &preventive services
(3) Provision for control of milk and food sanitation
(4) Prevention of any outbreak of communicable diseases
(5) Promotion of health education
(6) Promotion of health programmes such as school health, family planning, Occupational health
(7) Supervision of PHC
(8) Establishing training courses for health personnel
(9) Co-ordination of all health services with other minister of state such as minister of education,
central health minister &voluntary agency
III. At the district level
T here are 593 ( year 2001 ) districts in India. Within each district, there are 6 types of
administrative areas.
1. Sub -division
2. Tehsils( Taluks )
3. Community Development Blocks
4. Municipalities and Corporations
5. Villages and
6. Panchayats
> Most district in India are divided into two or more subdivision, each incharge of an Assistant
Collector or Sub Collector
> Each division is again divided into taluks, incharge of a Thasildhar. A taluk usually comprises
between 200 to 600 villages
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> The community development block comprises approximately 100 villages and about 80000 to
1,20,000 population, in charge of a Block Development Officer.
> Finally, there are the village panchayats, which are institutions of rural local self-government.
> The urban areas of the district are organized into
> Town Area Committees (in areas with population ranging between 5,000 to 10,000
> Municipal Boards (in areas with population rangingbetween 10,000 and 2,00,000)
> Corporations (with population above 2,00,000)
> The Town Area Committees are like panchayats.They provide sanitary
services.
> The Municipal Boards are headed by Chairmen /President, elected by members.
The functions of Municipal Board:
> Construction and maintenance of roads
> Sanitation and drainage
> Street lighting
> Water supply
> Maintenance of hospitals and dispensaries
> Education and
> Registration of births and deaths etc
> The Corporations are headed by Mayors, elected by councillors, who are elected from
different wards of the city. The executive agency includes the
commissioner, the secretary, the engineer and the health officer.
The activities are similar to those of municipalities, on a much wider scale.
> Panchayat Raj -
The panchayat raj is a 3-tier structure of rural local self-government in India linking the village to the
district.It includes
> Panchayat (at the village level)
> Panchayat Samiti( at the block level)
> Zila Parishad(at the district level)
(1) Panchayat (at the village level):
> The Panchayat Raj at the village level consists of
> The Gram Sabha

109
> The Gram Panchayat
The Gram Sabha:
It is the assembly of all the adults of the village, which meets at least twice a year.The gram sabha
considers proposals for taxation,and elect members of The Gram Panchayat.
The Gram Panchayat
It is the executive organ of the gram sabha and an agency for planning and development at the village
level. The population covered varies from 5000 to 15000 or more.The members of panchayat hold
offices for a period of 3to4 years. Every panchayat has an elected president (Sarpanch or Sabhapati or
Mukhia), a vice president and panchayat secretary. It covers the civic administration including
sanitation and public health and work for the social and economic development of the village
(2) Panchayat Samiti (at the block level):
The block consists of about 100 villages and a population of about 80,000 to 1,20,000. The panchayat
samiti consists of Sarpanch, MLAs, MPs residing in block area, representative of women, SC, ST and
cooperative socities. The primary function of The Panchayat Samiti is the execute the community
development programme in the block. The Block development Officer and his staff give technical
assistance and guidance in development work.
(3) Zila Parishad (at the district level):
The Zila Parishad is the agency of rural local self governmen at the district level . The members of Zila
parishad include all heads of panchayat samiti in the district,MPs, MLAs, representative of SC, ST and
women and 2 persons of experience in administration,public life or rural development. Its functions and
powers vary from state to state.
Health care system:
(1) At village level
(2) At sub center level
(3) At PHC level
(4) At CHC level
(1) At village level:
At the village level, elementary services are rendered by
(a) Village health guides
(b) Local dais
(c) Anganwadi workers
(d) ASHA
(a) Village health guides:
Village health guide is a person with an aptitude for social service and is not full time govt. functionary.
Village health guides scheme was introduced on 2nd oct. 1977.
110
Guidelines for their selection:
(1) They should be permanent resident of the local community, preferably women
(2) They should be able to read and write, having minimum formal education at least up to the VI
std.
(3) They should be acceptable to all sections of community
(4) They should be able spare at least 2 to 3 hours every day for community health work.
After selection the health guide undergo a short training in primary health care. The training is arranged
in the nearest PHC, subcenter or other suitable place for the duration of 200 hours, spread over a period
of 3 months. During the training period they receive a stipend of Rs. 200 per month.
Functions of Village health guides:
(1) Provide treatment for common minor ailments
(2) First aid during accidents and emergency
(3) MCH care
(4) Family planning
(5) Health education
(2) Local dais:
Most deliveries in rural areas are handled by untrained dais. Th e training for dais given for 30 working
days. Each dai is paid stipend of Rs. 300 during the training period.The training is given at
PHC,subcenters or MCH center for 2 days in a week and on the remaining four days of the week they
accompany the health worker(female) to the village. During her training each dai is required to conduct
at least 2 deliveries under the supervision and guidance of health worker (female), ANM,health assistant
(female).
Functions of dais:
(1) MCH care
(2) Family planning
(3) Immunization
(4) Education about health
(5) Referral services
(6) Safe water and basic sanitation
(7) Nutrition
(3) Anganwadi worker:
Under the ICDS scheme there is an anganwadi worker for a population of 1000.There are about 100
such workers in each ICDS project. The anganwadi worker is selected from the community and she
111
undergoes training in various aspect of health, nutrition and child development for 4 months. She is a
part time worker and paid an honorarium of Rs.200-250 per month for the services.
Functions of anganwadi worker:
(1) MCH care
(2) Family planning
(3) Immunization
(7) Supplementary nutrition
(8) Nonformal education of children
Accredited Social Health Activist (ASHA)
One of the key components of the National Rural Health Mission is to provide every village in the
country with a trained female community health activist - 'ASHA' or Accredited Social Health Activist.
Selected from the village itself and accountable to it, the ASHA will be trained to
work as an interface between the community and the public health system. Following are the key
components of ASHA:
SELECTION OF ASHA
□ The general norm will be ‘One ASHA per 1000 population’. In tribal, hilly, desert areas the
norm could be relaxed to one ASHA per habitation, dependant on workload etc.
□ The States will also need to work out the district and block-wise coverage/phasing for selection
of ASHAs.
□ It is envisaged that the selection and training process of ASHA will be given due attention by
the concerned State to ensure that at least 40 percent of the ASHAs in the State are selected and given
induction training in the first year as per the norms given in the guidelines. Rest of the ASHAs can
subsequently be selected and trained during second and third year.
Criteria for Selection
□ ASHA must be primarily a woman resident of the village ‘ Marri ed/Wi dow/Di vorced’ and
preferably in the age group of 25 to 45 yrs.
□ ASHA should have effective communication skills, leadership qualities and be able to reach
out to the community. She should be a literate woman with formal education up to Eighth Class. This
may be relaxed only if no suitable person with this qualification is available.
□ Adequate representation from disadvantaged population groups should be ensured to serve

such groups better.
Roles and responsibilities of ASHA:
112
□ ASHA will take steps to create awareness and provide information to the community on
determinants of health such as nutrition, basic sanitation & hygienic practices, healthy living and
working conditions, information on existing health services and the need for timely utilization of health
& family welfare services.
□ She will counsel women on birth preparedness, importance of safe delivery, breastfeeding and
complementary feeding, immunization, contraception and prevention of common infections including
Reproductive Tract Infection/Sexually Transmitted Infection (RTIs/STIs) and care of the young child.
□ ASHA will mobilize the community and facilitate them in accessing health and health related
services available at the village/sub-center/primary health centers, such as Immunization, Ante Natal
Check-up (ANC), Post Natal Check-up (PNC), ICDS, sanitation and other services being provided by
the government.
□ She will work with the Village Health & Sanitation Committee of the Gram Panchayat to
develop a comprehensive village health plan.
□ She will arrange escort/accompany pregnant women & children requiring treatment/ admission
to the nearest pre-identified health facility i.e. Primary Health Centre/ Community Health Centre/ First
Referral Unit (PHC/CHC /FRU).
□ ASHA will provide primary medical care for minor ailments such as diarrhea, fevers, and first
aid for minor injuries. She will be a provider of Directly Observed Treatment Short-course (DOTS)
under Revised National Tuberculosis Control Programmed.
□ She will also act as a depot holder for essential provisions being made available to every
habitation like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet (IFA), chloroquine,
Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc. A Drug Kit will be provided to each
ASHA. Contents of the kit will be based on the recommendations of the expert/technical advisory group
set up by the Government of India.
□ Her role as a provider can be enhanced subsequently. States can explore the possibility of
graded training to her for providing newborn care and management of a range of common ailments
particularly childhood illnesses.
□ She will inform about the births and deaths in her village and any unusual
health problems/disease outbreaks in the community to the Sub-Centers/Primary Health Centre.
□ She will promote construction of household toilets under Total Sanitation Campaign.
□ Fulfillment of all these roles by ASHA is envisaged through continuous training and up-
gradation of her skills, spread over two years or more
Comparison of health care delivery system in Rajasthan and Maharashtra:
(1) Subcenter:
Topics Maharashtra Rajasthan
(1) Population covered
(2) Functions 5000 in general
3000 in tribal & hilly areas

113
(1) MCH care
(2) Family planning
(3) Immunization
(5) Referral services 3600 in general
2800 in tribal & hilly areas
(1) MCH care
(2) Family planning
(3) Immunization
(6) Prevention and control of locally endemic diseases
Designation Maharashtra Rajasthan
(3) Staffing pattern Health worker female 1 Health worker male 1 Voluntary worker 1 (paid Rs 100
per month as Honorarium Health worker female 1 Health worker male 1 ANM 1
(2) Primary health center:
(2) Functions
(3) Staffing pattern 30.0 rural population in plains
20.0 population in hilly, tribal
(1) MCH care
(2) Family planning
(3) Immunization
(8) Collection and reporting of vital statistics
(9) National health programmes
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(10) Training of health guides, health workers, local dais and health assistant
(11) Basic laboratory services
Medical officer 2 Pharmacist 1 Nurse midwife 1 Health worker female 1 Block extension educator 1
Health assistant (female) 1 Health assistant male 1 U.D.C 1 48000 population in plains
30000 population in tribal and hilly
(1) MCH care
(2) Family planning
(3) Immunization
(7) Prevention and control of
locally endemic diseases
(8) Collection and report in
Of vital statistics
(9) National health programmes
(10) Training of health guides, health workers, local dais and health assistant
(11) Basic laboratory services
Medical officer 1 Pharmacist 1 Nurse midwife 1 Health worker female 1 Health worker male 1 Block
extension educator 1 Health assistant (female) 1 Health assistant male 1 U.D.C 1
L.D.C 1 L.D.C 1
Driver 1 Driver 1
ClassIV4 ClassIV2
(3) Community health center:
(2) Bed capacity
(3) Specialty
(3) Functions 80,000 to 1.20 lakhs 30 Beds
Surgery, medicine, obstetrics and gynecologist and pediatrics with X-ray and lab facilities.
• Care of routine and emergency cases in surgery

115
• Care of routine and emergency cases in medicine
• 24 hours delivery services including normal and assisted deliveries
• Essential and emergency obstetric care including caesarean sections and other Medical
interventions.
• Full range of family planning services including laparoscopic services
• Safe abortion service
• Newborn care
• Routine and emergency care of children
• Other management including 74,000 to 1.5 lakhs 24 Beds
Surgery, medicine, obstetrics and gynecologist and pediatrics with X-ray and lab facilities.
(1) MCH care
(2) Family planning
(3) Immunization
(8) Collection and report in of vital statistics
(9) 24 hours delivery services including normal and assisted deliveries
Nasal (10) Essential and emergency
packing,tracheostomy,foreign obstetric care including
body removal caesarean sections and other
• (10) All national Medical interventions.
health programmes (11) Full range of family
delivered through planning services including
CHC laparoscopic services
• Other services (12) Safe abortion service
(a) Blood storage (13) Newborn care
facility (14) Routine and emergency
(b) Essential lab. care of children’s.
116
Services (15) ) All national health
(c ) Referral programmes delivered through
(transport) services CHC
Existing clinical manpower Existing clinical manpower
(4) Staffing pattern General surgeon 1 G en e ral su rgeo n 1
Physician 1 Physi ci an 1
Obstetrics/ gynecologist 1 Obstetrics/ gynecologist 1
Pediatrician 1 Pediatrician 1
Proposed clinical man Proposed clinical man
power power
Anesthetics 1 Eye surgeon 1 An esthet ic 1
Public health programme 1 Public health programme 1
manager manager
Existing support manpower Existing support manpower
Nurse midwife 9 Nurs e mi dwife 12
Dresser 1 Dresser 1
Pharmacist 1 Pharmaci st 2
Lab. Technician 1 Lab . Technician 1
Radiographer 1 Radiographer 1
Ophthalmic 1 Ophthalmic 1
Ward boy 2 W ard b oy 2
Sweeper 3 Sw e e p er 3
Chowkidar 1 Chowki dar 2
OPD attendant 1 OPD attendant 1
Statistical assistant 1 S tati sti cal assistant 1
OT attendant 1 O T attendant 1
Registration clerk 1 R e gi str ati o n clerk 2
Job description of the members of the health team: (1) Medical officer:
• He is the captain of the health team at the primary health center.
117
• He devotes the morning hours attending to patients in the out-door,in the afternoon and
supervises the field work.
• He visits each subcenter regularly on fixed days and hours and provides guidance, supervision
and leadership to the health team.
• He spends one day in each month organizing staff meetings at PHC to discuss the problems
and review the progress of health activities.
• He ensures that national health programmes are being implemented in in his area properly
• The success of PHC depends largely on the team leadership which the medical officer is able to
provide.
• The medical officer must be a planner, the promoter, the director, the supervisior, the
coordinator as well as the evaluator.
(2) Health worker male and female:
Under the multipurpose worker scheme, one health worker female and one male are posted to each sub-
centers and are expected to cover 5000 of population (3000 in tribal and hilly areas) health worker
female limits her activities among 350-500 families.
Health worker female:
• She will register pregnant women from three months of pregnancies onwards.
• Maintain maternity record, register of antenatal cases, eligible couple register, children register
up to date.
• She will provide care to pregnant women especially registered mother throughout the period of
pregnancy;
• Give advice on nutrition to expectant and nursing mothers about storage, preparation and
distribution of food.
• Immunize pregnant mothers with tetanus toxoid.
• Conduct about 50% of total deliveries at home.
• Supervise deliveries conducted by Dais and whenever call in.
• Spread the message of family planning to the couples; motivate them for family planning
individually and in groups.
• Distribute conventional contraceptives to the couples.
• Assess the growth and development of the infant and take necessary action.
• Records and reports births and deaths in her area.
• Test urine for albumin and sugar and do Hb during her home visit.
• Arrange and help M.O and health assistant in conducting MCH and family planning clinics at
subcenters.
• Maintain the cleanliness of subcenter.

118
• Attend staff meetings at PHC, CD block or both.
Health worker male:
• He will survey all the families in his area and collect all the information about each village/
locality in his area.
• Identify the cases of communicable diseases and notify the health assistant male and M.O PHC
immediately.
• Educate the community about importance of control and preventive measures against
communicable diseases.
• Assist the village health guide in undertaking the activities under TB programme properly.
• Educate community on the method of liquid and solid waste, home sanitation, advantage and
use of sanitary latrines.
• Assist the health assistant male in the school health programme.
• Utilize the information from the eligible couple and child register for the family planning
programme.
• Spread the message of family planning to the couples; motivate them for family planning
individually and in groups.
• Distribute conventional contraceptives to the couples.
• Provide follow-up services to male family planning acceptors.
Health assistant male and female:
Health assistant male and female will supervise 4 health workers each of the corresponding
category.
Health assistant female:
• Supervise and guide the health workers in the delivery of health care services to the
community.
• Carry out supervisory home visiting.
• Guide the health workers (female) in Distribution of conventional contraceptives to the

couples.
Visit each of the 4 subcenters at least once in a week on fixed days.
• Respond to urgent calls from the health workers and trained dais and render necessary help.
• Organize and utilize the mahila mandal, teachers etc., in the family welfare programme.
• Provide information on the availability of services for MTPs and refer suitable cases to the
approved institution.
• Supervise the immunization of all pregnant women and children (0-5 years)
119
• Collect and compile the the weekly reports of births and deaths occurring in his area.
• Educate the community regarding the need of registration of vital events. .
Health assistant male:
• Supervise the work of Health worker male during concurrent visit.
• Check minimum 10% of houses in village.
• Supervise the spraying of insecticides during local spraying along with the health worker
(male).
• Conduct immunization of all school going children with the help of health worker (male).
• Supervise the immunization of all children’s (0-5 years).
• Assist M.O.PHC in organization of family planning camps and drives. .
• Provide information on the availability of services for MTPs and refer suitable cases to the
approved institution.
• Ensures follow-up of all cases of vasectomy, tubectomy IUD and other family planning
acceptors.
• Ensure that all the cases of malnutrition infants and young childrens (0-5years) are given the
necessary treatment and advice and refer serious cases to PHC.
• Ensure that Iron and folic acid and Vitamin A are distributed to the beneficiaries.
Conduct MCH and family planning clinics and carry out educational activities.
Organize and conduct training for dais women leaders with the help of health workers
• Collect and compile the the weekly reports of births and deaths occurring in his area.
• Educate the community regarding the need of registration of vital events.
REFERENCES
(1) k. Park, Text book of preventive and social medicine, Bhanot publication, 18th edition, Page
no.674-699.
(2) B.T.Basvanthappa, Community health nursing, Jaypee, Publication, 6th edition, Page no.584-
605.
rd
(3) K.K. Gulani, Community health nursing, Kumar Publication, 3 edition, Page no.591-593.
(4) Dr. Sr. Mary Lucita, Public health and Community Health, Nursing, B.I. publication, 1st
edition, Page no.25-34.
(5) John M. Cookfair, Nursing care in the community, Mosby, Publication, 2nd edition, Page no.
65-81.
(6) www.google. com.
120
121
HEALTH TALK ON BALANCE DIET

DATE OF SUBMISSION-
122
HEALTH TALK ON BALANCE DIET
TOPIC : Balance Diet
DATE : 06/07/22
TIME : 11:00am
PLACE : Kanpur
MEDIUM : Hindi
NO. OF PEOPLE : 25
A.V. AIDS : Flip Chart
GENERAL OBJECTIVE : At the end of the session the

group will be able to
understand the balance Diet

and it’s importance in life.
SPECIFIC OBJECTIVE : At the end of the session the

group will be able to:-
1. Define balance diet

2. Explain the classification of
food
3. Explain about the
classification of food group.
4. Explain about the importance
of balance diet.
5. Plan a menu for adult group.
TIM SPECIFIC CONTENT TEAHI A. EVALUATIO
E NG V. N
OBJECTIV LEARN A
E ING I
ACTIVI D
TY S
3 mnt INTRODUCTION
All individuals in the world

have the same body functions. For the
regulation of these functions, The
requirement is very essential. The
123
amount of the nutrient is vary according
to age and daily activity. For the
maintenance of the health, the balance
diet is very essential.
DEFINITION Lecture Flip- Stat the

A balance diet is a type of diet which cum Chart definition
To define discussio of balance
contain different type of food stuff in
balance diet n diet.
2 mnt such quantity and preparation according
to need for calories. Nutrients are
amounted in order to live normal healthy
life
Lecture Flip- What is the

cum Chart classificati
CLASSIFICATION discussio on of food
To explain The classification of food is as follows:- n
the
classification 1. Carbohydrates
5 mnt
of food 2. Protein
3. Fat
4. Vitamin
5. Mineral
6. Water
1. Carbohydrate: - The main function
is to provide energy.
2. Protein: - It plays role in tissue
building and growth.
3. Fat: - They are concrete source of
energy and carriers of vitamins
4. Vitamins:- Vitamins does not
provide energy but enables the body
to utilize other nutrients. They are
required by the body in small
amount.
5. Minerals :- They helps in
maintenance of electrolytes.
CLASSIFICATION OF FOOD
GROUPS
Energy serving foods:- Cereals, Rice,

Wheat, Gyegre, Potato, Sugar-cane,
Explain
fruits, banana etc. Flip-
Lecture about the
Chart
cum classificati
discussio on of food
Body building foods:- Milk and milk n groups.
products, Pulses, gram, legumes, eggs,
124
paneer, etc.
To explain
about the
classification CEREALS→ rice, Wheat Flore, Juwar,
of food millets are the major sources of the
15 energy contain both carbohydrate and
group.
mnt protein. Lecture Flip-
cum Chart
discussio
PULSES→ They are the source of the n
protein. They do not contain fat but are
the major sources of protein. They also
contain Vit-B and Vit- B complex in
some amount.
NUTS AND OIL SEEDS→ Nuts and oil

seeds are the sources of both protein and
fats.
GEEN LEAFY VEGETABLES →

Green leafy vegetables are the sources of
minerals, carbohydrates, protein and it
also contain vitamins.
FRUITS→ Fruits are the sources of

minerals and vitamins. They also contain
energy in addition.
MILK AND MILK PRODUCT → Milk

and milk products are good sources of
protein, fats and minerals specially
calcium.
FISH AND MEAT→ Fish is the protein

sources and also have biological value as
it contain vitamin- B complex. Meat and
chicken are the Chief sources of Protein.
IMPORTANCE
Food is the prime requirement of the life.

Many people maintain their heath only
by the maintenance of the diet. Physician What is the
and health agency also indicate the importance
importance of diet in the daily life. A of balance
125
balance diet is prepared to meet for Flip- diet
maintaining of health, vitality and
general well-being. A balance diet is Lecture Chart
accepted mean of safeguard the cum
To explain discussio
population from nutritional deficiency.
about the n
10 importance
mnt of balance
diet. FUNCTIONS OF BALANCE DIET
1. It provide energy for daily

activity.
2. It has food stuff which help in
body growth and regeneration
and repairing of body tissue.
3. It helps in the regulation of body
functions.
MENU PLAN FOR ADULT PERSON
BREAK FAST
 Bread Toast - 3 Slices

 Boiled egg - 1
 Milk - 1 glass
 Fruit - 1
LUNCH How will
you
To prepare  Chapattis with butter - 5-6 prepare a
menu plan  Salad - ½ Cup menu- plan
Flip-
 Dal - 1 Cup for adult
for adult
 Rice - 1 Cup Lecture group
group. Chart
 Vegetable - 1 Cup cum
15
.  Curd - 1 Cup discussio
mnt
TEA TIME n
 Tea - 1 cup
 Biscuit - 3-4
DINNER
 Chapattis with butter - 5-6

 Salad - ½ Cup
 Dal - 1 Cup
 Rice - 1 Cup
 Vegetable - 1 Cup
BED TIME
 Milk - 1 Glass
126
HEALTH-TALK ON DIET IN DIABETIES

MELLITUS AND FOOT CARE IN
DIABETIC PATIENT

DATE OF SUBMISSION-
HEALTH-TALK ON DIET IN DIABETIES MELLITUS AND FOOT

CARE IN DIABETIC PATIENT
S. Specific Durat Subject matter Teachin Evalua
127
No objective ion g- A. tion
. Learnin V.
g Ai
ds
Activity
1 State the INTRODUCTION Discuss
introductio diabetes mellitus commonly known as about
n diabetes . It is a disorder of carbohydrate the
metabolism characterized by high blood sugar Diabete
level diet for (hyperglycemia) and high level s
of sugar in urine . it can be kept well under
2 controls reasonably managed with proper care
Define the through it cannot be cured once it occurs. What
diabetes do you
mellitus Lecture mean
DEFINITION on the by
Diabetes is a metabolic disorder that definiti diabet
3 prevents the body to utilize glucose completely on of es
Causes of or partially. diabetes
diabetes What
Lecture are the
CAUSES on causes
 Infection causes of
 Acute stress of diabet
 Immunologic factor disturbance diabetes es
4  Genetics
symptoms  Obesity
SYMPTOMS
Initial observation
 Increased thrist (polydipsia)
Lecture What
 Increased urination (polyurea)
on are the
 Increased hunger
Sympto sympt
 Weight loss or obesity ms of oms of
 Weakness diabetes diabet
 Decreased healing capacity es
 Skin irritation or infection
 Blurred vision
Management
5.  Patient education
MANAGE  Insulin therapy-oral hypo glycaemia
MENT drug
 Diet management
 Exercise
6. Diet in Diabetes
Diet in Diabetes should not be a Manage
Diet in complete deviation from the normal diet. The ment of
diabetes nutritional requirements of the person with diabetes
diabetes are same as for non-diabetic.
Generally, in Indian diets, carbohydrates
contribute most of the total calories of the daily
intake.
What
Carbohydrates: It is recommended that 60% of are the
the calories should be obtained from food
carbohydrates. Since the blood sugars levels That
128
depends mainly on the intake of carbohydrates, must
it is important to distribute the intake of avoide
carbohydrates as per the daily needs. d for
diabeti
Proteins: It is recommended that 15-20% of c
the total calories be derived from proteins. patient
Meat and meat products, milk, pulses legumes
and nuts are all rich in proteins.
Fats: It is recommended that 15-25 % of the

calories be derived from fat. People with What
diabetes, should consume less of saturated fats are the
(ghee, butter, vanaspati etc.), as compared to caloric
PUFA –poly-unsaturated oils (sunflower, requri
safflower oils) and MUFA- mono-unsaturated ment
oils (palm oil, olive oil etc.) for
diabeti
Vitamins and Minerals: These are protective c
factors which in small amounts are essential for patient
the body. They are available in green leafy
vegetables, fresh fruits, milk, cereals, nuts etc.
Dietary Fibre: It is an important part of a

diabetes diet and is present in cereals, legumes,
fruits and vegetables. Intake of 25 g of fibre
per 1000 calories is considered to be optimum
for a diabetes diet. Long-term consumption of
insoluble fibre (present in cereals) also
improves glucose control.
Choosing healthy foods The Food Guide

Pyramid is a good basic guide to choosing
healthy foods. It shows various kinds of food
EVERYONE needs. The best choices for the
rest of the family are also the best choices for
people with diabetes.
 Eat a variety of food from the different food
groups.
 Eat plenty of vegetables and fruits. All

fruits and most vegetables contain
carbohydrates, but their high content of
vitamins, minerals, and fiber make them great
choices.
 Choose a diet low in fat, saturated fat, and

cholestersol. For best health , these should
make up only a small portion of overall food
choices.Saturated fats (animals fats
shortcoming, for example) tend to raise blood
cholesterol levels and are bad for the health of
your heart
 Use salt (sodium) in moderation. most

people eat more salt than they really need.For
some people , extra salt adds to their risk for
high blood pressure. High blood sugar is more
129
common in people with diabetes.And
uncontrolled blood pressure (greater than
130/85) greatly increase the risk for health
problems.Here are ways to cut down on salt:
 Choose foods " close to nature."Less

processed foods have less salt.
 Avoid foods canned, boxed or frozen with

extra salt. Try the " no-salt added varieties.
 Use herbs , spice, and salt- free seasoning

mixes for added flaver, instead of salt.
 Use sugar in moderation High sugar foods
should make up only a small part of the
diet.However , small amounts of sweet foods
can be a part of a healthy diet ,even for people
who have diabetes.Learn how to fit the sweets
you enjoy into your overall plan.
Nutritional supplements
7.  Biotin – It helps the body in

metabolizing carbohydrates,
Food proteins and fats.
avoided  Vitamin C – It prevents sugar
from getting attached to
proteins. Insulin deficiency
hinders effective metabolism
and transport of Vitamin C, Lecture
making its increased intake all on food
the more important. Here, to be
ascorbates like Emergency is avoided
more preferred as compared to
ascorbic acid.
 Chromium – It aids the
metabolism of glucose. It is
most effective if consumed as
niacin.
 Vitamin E – It helps in
improving insulin sensitivity.
 Magnesium – It helps in
lowering blood pressure and Lecture
reducing heart-attack risks by on
relaxing the muscle tissues. calorie
 CLA – It helps in protecting requrim
cells from becoming diabetic ent
or getting damaged by
atherosclerosis, colon cancer
and chronic inflammation.
 Omega 3 and Alpha Lipoic
Acids - They are effective
building blocks and anti-
8. oxidants respectively. They
reduce the risks associated
with nerve damages by aiding
Exchange balancing of blood sugar.
130
list  Vitamin B6 – It helps in
preventing neuropathy.
 Vitamin D – It helps in reducing
insulin resistance and averting
the risks of cataract.
 Zinc – It helps in improving the
action of insulin.
ood avoided
 Sugar cane ,sweets, jam candies etc.
 Alcohol and soft drinks
 Concentrated milk preparation ,mawa
preparation, such as pedha ,rabdi,
cream, gulabjamun, and other sweets
 Nuts and oil seed such as groundnut
etc
 Vanaspati ghee ,cream etc
 Bakery products
9.
Calorie requirement
Menu plan
for a diet  Total calorie 1125
 Carbohydrate 118 g(443 calorie)
 Protein 45g (180 calorie)
 Fat 52 g (473 calorie)
Exchange list
Items No. Cal carboh pro f

S. of orie ydrate tein a
No exch t
. ange
1 Milk 3 300 13 15 1
5
2 Legu 2 200 30 12 -
me
and
3 Flesh 1 100 - 30 -
food
4 Veget 4 - - - -
able
A
5 Veget 1 50 10 - -
able-
B
6 fruits 1 50 1o - -
7 Cerea 3 300 60 6 -
l
8 fats 2 200 - - -
Menu plan
131
Tea
1cup tea or coffee without sugar
Breakfast
 1 exchange milk
 1 egg (flesh food ½ exchange)
 1 exchange fruit
 1 exchange cereals,fat
Total calorie-300
10. CHO-35g
Lunch
 1 exchange cereals
 2 exchange veg A
Some tips
 1exchange veg B
for diabetic
 1 exchange legumes and pulses
patient
 1 exchange fat
Total calorie-400
CHO-35 g
Tea Lecture
1 cup skimmed milk CHO-45 g without on tips
sugar
Dinner
 1 exchange cereals
 2 exchange veg A
 1 exchange legumes
 1 exchange veg B, 1 egg
Bed time
1 glass skimmed milk without sugar CHO
-45 g
Some tips for diabetic patient

11.
 Eat food at fixed hours
 Do not overeat
Foot care  Do not eat immediately after a workout
of D.M.  Make sure you have three proper meals
patients & light snacks in between
 Eat about the same amounts of food each
day
 Eat your meals and snacks at about the
same times each day
 Make sure the gaps between your meals
are short Discuss
 Do not eat fast; masticate and munch on
your food well before you swallow diabetes
 Drink a lot of water that will help flush foot
the toxins off your system care.
 Avoid fried foods and sweetmeats
 Include fresh vegetable salad in every
meal
132
 Include sprouts in the diet
 Take your medicines at the same times
each day
 Exercise at about the same times each
day
 Avoid smoking. Smoking leads to heart
disease and poor circulation
 Check your feet for cuts, blisters, and
swelling which are likely to result from
diabetes-related nerve damage
 Take good sleep daily
 Check your blood sugar level regularly
 Try to stick up to the plan made up for
sugar control
 Check the other tests such as kidney
function, liver function, heart function,
ketone level etc
 Check your weight periodically and
maintain ideal body weight
Diabetes Foot Care

When you have diabetes, proper foot care is
very important. Poor foot care with diabetes
can lead to serious health problems, including
possibly having to remove the foot or leg
(amputation).
It's important to understand the connection
between diabetes and foot care. As a person
with diabetes, you are more vulnerable to foot
problems because diabetes can damage your
nerves and reduce blood flow to your feet.
Wash and Dry Your Feet Daily
 Use mild soaps.
 Use warm water.
 Pat your skin dry; do not rub.
Thoroughly dry your feet.
 After washing, use lotion on your feet
to prevent cracking.
toes.
Examine Your Feet Each Day

 Check the tops and bottoms of your
feet. Have someone else look at your
feet if you cannot see them.
 Check for dry, cracked skin.
 Look for blisters, cuts, scratches, or
other sores.
133
 Check for redness, increased warmth,
or tenderness when touching any area
of your feet.
 Check for ingrown toenails, corns, and
calluses.
 If you get a blister or sore from your
shoes, do not "pop" it. Apply a
bandage and wear a different pair of
shoes.
Take Care of Your Toenails
 Cut toenails after bathing, when they
are soft.
 Cut toenails straight across and smooth
with a nail file.
 Avoid cutting into the corners of toes.
 You may want a podiatrist (foot
doctor) to cut your toenails.
Be Careful When Exercising
 Walk and exercise in comfortable
shoes.
 Do not exercise when you have open
sores on your feet.
Protect Your Feet With Shoes and Socks
 Never go barefoot. Always protect

your feet by wearing shoes or hard-
soled slippers or footwear.
 Avoid shoes with high heels and
pointed toes.
 Avoid shoes that expose your toes or
heels (such as open-toed shoes or
sandals). These types of shoes increase
your risk for injury and potential
infections.
 Try on new footwear with the type of
socks you usually wear.
 Do not wear new shoes for more than
an hour at a time.
 Look and feel inside your shoes before
putting them on to make sure there are
no foreign objects or rough areas.
 Avoid tight socks.
 Wear natural-fiber socks (cotton, wool,
or a cotton-wool blend).
 Wear special shoes if your health care
provider recommends them.
 Wear shoes/boots that will protect your
feet from various weather conditions
(cold, moisture, etc.).
 Make sure your shoes fit properly. If
you have neuropathy (nerve damage),
Footwear Test
134
 Use this simple test to see if your shoes
fit correctly:
 Stand on a piece of paper. (Make sure
you are standing and not sitting,
because your foot changes shape when
you stand.)
 Trace the outline of your foot.
 Trace the outline of your shoe.
 Compare the tracings: Is the shoe too
narrow? Is your foot crammed into the
shoe? The shoe should be at least 1/2
inch longer than your longest toe and
as wide as your foot.
Proper Shoe Choices
The following types of shoes are best for
people with diabetes:
 Closed toes and heels.
 Leather uppers without a seam inside.
 At least 1/2 inch extra space at the end
of your longest toe.
 Inside of shoe should be soft with no
rough areas.
 Outer sole should be made of stiff
material.
 Shoe should be at least as wide as your
foot.
Tips for Foot Care in Diabetes
 Don't wait to treat a minor foot

problem if you have diabetes. Follow
your health care provider's guidelines
and the first aid guidelines.
 Report foot injuries and infections to
your health care provider immediately.
 Check water temperature with your
elbow, not your foot.
 Do not use a heating pad on your feet.
 Do not cross your legs.
 Do not self-treat your corns, calluses,
or other foot problems. Go to your
health care provider or podiatrist to
treat these conditions.
135
KRISHNA INSTITUTE OF NURSING SCIENCE & RESEARCH
Village – amiliha Post- Tatiyaganj Kanpur nagar 209217
ASSIGNMENT ON HYGIENE

DATE OF SUBMISSION-
ASSIGNMENT ON HYGIENE
Hygiene is a set of practices performed for the preservation of health. According to the World Health
Organization (WHO), "Hygiene refers to conditions and practices that help to maintain health and
prevent the spread of diseases.
136
Background
Hygiene is a concept related to cleanliness, health and medicine, as well as to personal and
professional care practices related to most aspects of living. In medicine and in home (domestic) and
everyday life settings, hygiene practices are employed as preventative measures to reduce the incidence
and spreading of disease. In the manufacture of food, pharmaceutical, cosmetic and other products,
good hygiene is a key part of quality assurance i.e. ensuring that the product complies with microbial
specifications appropriate to its use. The terms cleanliness (or cleaning) and hygiene are often used
interchangeably, which can cause confusion. In general, hygiene mostly means practices that prevent
spread of disease-causing organisms. Since cleaning processes (e.g., hand washing) remove infectious
microbes as well as dirt and soil, they are often the means to achieve hygiene. Other uses of the term
appear in phrases including: body hygiene, personal hygiene, sleep hygiene, mental hygiene, dental
hygiene, and occupational hygiene, used in connection with public health. Hygiene is also the name of a
branch of science that deals with the promotion and preservation of health, also called hygienic.
Hygiene practices vary widely, and what is considered acceptable in one culture might not be acceptable
in another.
Home and everyday life hygiene
 Home hygiene pertains to the hygiene practices that prevent or minimize disease and the
spreading of disease in home (domestic) and in everyday life settings such as social settings,
public transport, the work place, public places etc.
 Hygiene in home and everyday life settings plays an important part in preventing spread of
infectious diseases. It includes procedures used in a variety of domestic situations such as hand
hygiene, respiratory hygiene, food and water hygiene, general home hygiene (hygiene of
environmental sites and surfaces), care of domestic animals, and home healthcare (the care of
those who are at greater risk of infection).
 Good home hygiene means targeting hygiene procedures at critical points, at appropriate times,
to break the chain of infection i.e. to eliminate germs before they can spread further.[8] Because
the "infectious dose" for some pathogens can be very small (10-100 viable units, or even less
for some viruses), and infection can result from direct transfer from surfaces via hands or food
to the mouth, nasal mucosa or the eye, 'hygienic cleaning' procedures should be sufficient to
eliminate pathogens from critical surfaces. Hygienic cleaning can be done by:
 Mechanical removal (i.e. cleaning) using a soap or detergent. To be effective as a hygiene
measure, this process must be followed by thorough rinsing under running water to remove
germs from the surface.
 Using a process or product that inactivates the pathogens in situ. Germ kill is achieved using a
"micro-biocidal" product i.e. a disinfectant or antibacterial product or waterless hand sanitizer,
or by application of heat.
 In some cases combined germ removal with kill is used, e.g. laundering of clothing and
household linens such as towels and bedlinen.
Hand hygiene
Hand hygiene is defined as hand washing or washing hands and nails with soap and water or
using a waterless hand sanitizer. Hand hygiene is central to preventing spread of infectious diseases in
home and everyday life settings.
In situations where hand washing with soap is not an option (e.g. when in a public place with no
access to wash facilities), a waterless hand sanitizer such as an alcohol hand gel can be used. They can
also be used in addition to hand washing, to minimize risks when caring for "at risk" groups. To be
137
effective, alcohol hand gels should contain not less than 60%v/v alcohol. Hand sanitizers are not an
option in most developing countries. In situations with limited water supply, there are water-conserving
solutions, such as tippy-taps. (A tippy-tap is a simple technology using a jug suspended by a rope, and a
foot-operated lever to pour a small amount of water over the hands and a bar of soap.) In low-income
communities, mud or ash is sometimes used as an alternative to soap.
The World Health Organization recommends hand washing with ash if soap is not available in
emergencies, schools without access to soap and other difficult situations like post-emergencies where
use of (clean) sand is recommended too. Use of ash is common and has in experiments been shown at
least as effective as soap for removing bacteria.
Respiratory hygiene
Correct respiratory and hand hygiene when coughing and sneezing reduces the spread of germs
particularly during the cold and flu season.
 Carry tissues and use them to catch coughs and sneezes

 Dispose of tissues as soon as possible
 Clean your hands by hand washing or using an alcohol hand sanitizer.
Food hygiene at home
Main article: Food hygiene
Food hygiene is concerned with the hygiene practices that prevent food poisoning. The five key
principles of food hygiene, according to WHO, are:
 Prevent contaminating food with mixing chemicals, spreading from people, and animals.
 Separate raw and cooked foods to prevent contaminating the cooked foods.
 Cook foods for the appropriate length of time and at the appropriate temperature to kill
pathogens.
 Store food at the proper temperature.
 Use safe water and raw materials
Household water treatment and safe storage
Methods for treatment of drinking water include:
 Chemical disinfection using chlorine or iodine

 Boiling
 Filtration using ceramic filters
 Solar disinfection - Solar disinfection is an effective method, especially when no chemical
disinfectants are available.
 UV irradiation - community or household UV systems may be batch or flow-though. The lamps
can be suspended above the water channel or submerged in the water flow.
 Combined flocculation/disinfection systems – available as sachets of powder that act by
coagulating and flocculating sediments in water followed by release of chlorine.
 Multibarrier methods – Some systems use two or more of the above treatments in combination
or in succession to optimize efficacy.
Hygiene in the kitchen, bathroom and toilet
138
Routine cleaning of (hand, food, & drinking water) sites and surfaces (such as toilet seats and
flush handles, door and tap handles, work surfaces, bath and basin surfaces) in the kitchen, bathroom
and toilet reduces the risk of spread of germs. The infection risk from the toilet itself is not high,
provided it is properly maintained, although some splashing and aerosol formation can occur during
flushing, particularly where someone in the family has diarrhea. Germs can survive in the scum or scale
left behind on baths and wash basins after washing and bathing.
Laundry hygiene
Laundry hygiene pertains to the practices that prevent or minimize disease and the spreading of
disease via soiled clothing and household linens such as towels. Items most likely to be contaminated
with pathogens are those that come into direct contact with the body, e.g., underwear, personal towels,
facecloths, nappies. Cloths or other fabric items used during food preparation or for cleaning the toilet
or cleaning up material such as faeces or vomit are a particular risk.
Medical hygiene at home
Medical hygiene pertains to the hygiene practices that prevents or minimizes disease and the
spreading of disease in relation to administering medical care to those who are infected or who are more
"at risk" of infection in the home. Across the world, governments are increasingly under pressure to
fund the level of healthcare that people expect. Care of increasing numbers of patients in the
community, including at home is one answer, but can be fatally undermined by inadequate infection
control in the home. Increasingly, all of these "at-risk" groups are cared for at home by a carer who may
be a household member who thus requires a good knowledge of hygiene. People with reduced immunity
to infection, who are looked after at home, make up an increasing proportion of the population
(currently up to 20%).
Body hygiene
Personal hygiene involves those practices performed by an individual to care for one's bodily
health and well being, through cleanliness. Motivations for personal hygiene practice include reduction
of personal illness, healing from personal illness, optimal health and sense of well being, social
acceptance and prevention of spread of illness to others. What is considered proper personal hygiene
can be cultural-specific and may change over time. In some cultures removal of body hair is considered
proper hygiene. Other practices that are generally considered proper hygiene include bathing regularly,
washing hands regularly and especially before handling food, washing scalp hair, keeping hair short or
removing hair, wearing clean clothing, brushing one's teeth, cutting finger nails, besides other practices.
Some practices are gender-specific, such as by a woman during her menstrual cycle. People tend to
develop a routine for attending to their personal hygiene needs. Other personal hygienic practices would
include covering one's mouth when coughing, disposal of soiled tissues appropriately, making sure
toilets are clean, and making sure food handling areas are clean, besides other practices. Some cultures
do not kiss or shake hands to reduce transmission of bacteria by contact.
Reference
 Bloomfield SF, Exner M, Fara GM, Nath KJ, Scott, EA; Van der Voorden C. The global burden
of hygiene-related diseases in relation to the home and community. (2009) International
Scientific Forum on Home Hygiene.
 Bloomfield, SF, Aiello AE, Cookson B, O’Boyle C, Larson, EL, The effectiveness of hand
hygiene procedures including hand-washing and alcohol-based hand sanitizers in reducing the
risks of infections in home and community settings" American Journal of Infection Control
2007;35, suppl 1:S1-64
139
 Baker et al. 2014 Association between Moderate-to-Severe Diarrhea in Young Children in the
Global Enteric Multicenter Study (GEMS) and Types of Handwashing Materials Used by
Caretakers in Mirzapur, Bangladesh. Am J Trop Med Hyg 2014 vol. 91 no. 1 181-189
140
NURSING CARE PLAN ON JAUNDICE

Submitted To-
141
NURSING CARE PLAN ON JAUNDICE
HISTORY TAKING
IDENTIFICATION DATA
 Name : Mr. Varun

 Age : 12 years
 Sex : male
 Father : Mr. Radhey Shyam Yadav
 Address : Kanpur
 Education : 7th std
 Fathers Occupation : business man
 Fathers Income annual : 150000/year
 Diagnosis : Jaundice
History of present illness
Patient has been admitted in krishnachild ward with the complaints of severe vomiting.
History of past illness
There is no history of past illness.
Family history
Mr.Jijendar yadav
60 years, healthy Ms.Meena Yadav
55 years, healthy
Ms.anil yadav
Ms.lata yadav 42years,
34 years, healthy healthy
Ms.Varun Yadav
12 years, Janundice
Educational history
 Age at beginning of formal education : 6th year

 Academic performance : average
 Relationship with peer and teacher : often fought with students and teachers
Play history
 Games played : cricket

 Relationship with team work : present
Treatment history
142
s.no Name of the drug Action Route/dose/ Side effects Nurses
frequency responsibility
1 lactated Ringer IV/250 ml - -Maintain the
solution flow of the IV
fluid as per
doctor’s order
-Inform the
patient to contact
the near by
person or nurses,
if he feels any
discomfort
2 Erythromycin Antibiotics IV/300mg /bd Constipation, Monitor the
headache patient till he get
comfort.
3 Paracetamol Antipyretics 50mg tab/td Constipation , Monitor the
abdominal patient till he get
discomfort. comfort.
143
Personal history
Perinatal history
 Antenatal period : Normal

 Intranatal period : Normal
 Delivery : normal
 Birth : full term
 Birth Defects : Not
 Postnatal complication : not significant
Childhood History
 Primary caregiver : Mother

 Feeding : Breast feed
 Developmental milestones : Normal
 Behavior and emotional problems : Temper tantrum in school going age
 Child hood illness : not significant
Head to foot assessment
Head: dandruff present
Hairs
Color: brown
Normally distributed
Eyes
Colour of eyeball – black
No infection
No discharges
Mouth
No foul smell
No infection
Dental cares present
Nose
DNS – absent
No abnormal discharges
No infection
Neck
No abnormal bulges
144
No thyroid problems
Chest
Irregular expansion
Increased heart rate
Extremities
Normal
Bladder and bowel movement
Bladder – painful micturation
Bowel movement – constipation
Abdominal discomfort
Nursing care plan on diarrhea
Nursing diagnosis
 Diarrhea related to side effects of antibiotics as evidence by frequent lose, liquid stools, and
reports of abdominal pain.
 Altered nutrition, less than body requirement related to inability to take food.
 Fluid and electrolyte imbalance related to severe vomiting
 Impaired social interaction related to weakness
145
Nursing Nursing
Subjective data: Diarrhea related to -The nurse will -The nurse Diarrhoea has
Patient is telling antibiotic side assess the patient assessed the been reduced
he is so tired. effects. report of diarrhea patient report of
Having frequent every shift. diarrhea every
loose motion. Objective: -The nurse will shift.
Reduce the assess the patients -The nurse
Objective data diarrhoea stool consistency assessed the
Patient is going to daily according to patients stool
pass stool more the Bristol stool consistency daily
than five times. chart. according to the
-The nurse will Bristol stool chart.
keep track of how -The nurse kept
many bowel track of how many
movements the bowel movements
patient has daily. the patient has
-The nurse will daily.
encourage and -The nurse
provide the patient encouraged and
with clear liquids provide the patient
every two hours with clear liquids
while awake. every two hours
-The nurse will while awake.
and parents on educated the
what clear liquids patient and parents
to consume and on what clear
avoid. liquids to consume
-The nurse will and avoid.
and parents about educated the
the contributing patient and parents
factor that is about the
causing her contributing factor
diarrhea. that is causing her
diarrhea.
Subjective data: Fluid and -provide ORS -provided ORS Fluid and
Patient is telling electrolyte -allow him to take -allow him to take electrolyte
that he mouth is imbalance related plenty of fluid. plenty of fluid. balanced.
getting dry. to diarrhoea -provide -provided
Objective data Objective: medications as per medications as per
Patients mouth is Maintain normal doctors order. doctors order.
getting dry. Skin fluid and Moisture the -Moistured the
also getting dry. electrolyte mouth with water mouth with water
balance. to relieve from to relieve from
dryness. dryness.
Subjective data: Altered nutrition, Provide high Provide high Nutritional status
Patient is telling less than body protein , high protein , high has been
he is very week. requirement caloric nutritious caloric nutritious maintained.
Objective data related to inability food, food,
Patients is very to take food. -Find out patients -Found out
week and to able dislikes and likes patients dislikes
to stand also. Objective: -Provide 6-8 and likes
Maintain normal glasses of fluids -Provided 6-8
nutritional status per day glasses of fluids
-Maintain record per day
146
Nursing Nursing
of intake and -Maintained
output. record of intake
-Supplement diet and output.
with vitamin and -Supplemented
minerals. diet with vitamin
and minerals.
147
JAUNDICE

DATE OF SUBMISSION-
148
JAUNDICE
Jaundice, also known as icterus, is a yellowish or greenish pigmentation of the skin and whites of the
eyes due to high bilirubin levels.
Signs and symptoms
The main symptom of jaundice is a yellowish discoloration of the white area of the eye and the
skin. Urine is dark in colour. Slight increases in serum bilirubin are best detected by examining the
sclerae, which have a particular affinity for bilirubin due to their high elastin content. The presence of
scleral icterus indicates a serum bilirubin of at least 3 mg/dL. The conjunctiva of the eye is one of the
first tissues to change color as bilirubin levels rise in jaundice. This is sometimes referred to as scleral
icterus. However, the sclera themselves are not "icteric" (stained with bile pigment) but rather the
conjunctival membranes that overlie them. The yellowing of the "white of the eye" is thus more
properly termed conjunctival icterus. The term "icterus" itself is sometimes incorrectly used to refer to
jaundice that is noted in the sclera of the eyes, however it’s more common and more correct meaning is
entirely synonymous with jaundiceComplications.

yellowish discoloration of the white area of the yellowish discoloration of the white area of the
eye eye
Severe vomiting Vomiting
Complications
Hyperbilirubinemia, more precisely hyperbilirubinemia due to the unconjugated fraction, may

cause bilirubin to accumulate in the gray matter of the central nervous system, potentially causing
irreversible neurological damage leading to a condition known as kernicterus. Depending on the level of
exposure, the effects range from clinically unnoticeable to severe brain damage and even death.
Newborns are especially vulnerable to hyperbilirubinemia-induced neurological damage and therefore
must be carefully monitored for alterations in their serum bilirubin levels.
Pathophysiology
Jaundice itself is not a disease, but rather a sign of one of many possible underlying
pathological processes that occur at some point along the normal physiological pathway of the
metabolism of bilirubin in blood.
When red blood cells have completed their life span of approximately 120 days, or when they
are damaged, their membranes become fragile and prone to rupture. As each red blood cell traverses
through the reticuloendothelial system, its cell membrane ruptures when its membrane is fragile enough
to allow this. Cellular contents, including hemoglobin, are subsequently released into the blood. The
hemoglobin is phagocytosed by macrophages, and split into its heme and globin portions. The globin
portion, a protein, is degraded into amino acids and plays no role in jaundice. Two reactions then take
place with the heme molecule. The first oxidation reaction is catalyzed by the microsomal enzyme heme
oxygenase and results in biliverdin (green color pigment), iron and carbon monoxide. The next step is
the reduction of biliverdin to a yellow color tetrapyrol pigment called bilirubin by cytosolic enzyme
biliverdin reductase. This bilirubin is "unconjugated," "free" or "indirect" bilirubin. Approximately 4
mg of bilirubin per kg of blood is produced each day. The majority of this bilirubin comes from the
breakdown of heme from expired red blood cells in the process just described. However approximately
20 percent comes from other heme sources, including ineffective erythropoiesis, and the breakdown of
other heme-containing proteins, such as muscle myoglobin and cytochromes.
149
Diagnostic approach
Most patients presenting with jaundice will have various predictable patterns of liver panel
abnormalities, though significant variation does exist. The typical liver panel will include blood levels
of enzymes found primarily from the liver, such as the aminotransferases (ALT, AST), and alkaline
phosphatase (ALP); bilirubin (which causes the jaundice); and protein levels, specifically, total protein
and albumin. Other primary lab tests for liver function include gamma glutamyl transpeptidase (GGT)
and prothrombin time (PT).
Some bone and heart disorders can lead to an increase in ALP and the aminotransferases, so the
first step in differentiating these from liver problems is to compare the levels of GGT, which will only
be elevated in liver-specific conditions. The second step is distinguishing from biliary (cholestatic) or
liver (hepatic) causes of jaundice and altered laboratory results. The former typically indicates a surgical
response, while the latter typically leans toward a medical response. ALP and GGT levels will typically
rise with one pattern while aspartate aminotransferase (AST) and alanine aminotransferase (ALT) rise
in a separate pattern. If the ALP (10–45 IU/L) and GGT (18–85) levels rise proportionately about as
high as the AST (12–38 IU/L) and ALT (10–45 IU/L) levels, this indicates a cholestatic problem. On
the other hand, if the AST and ALT rise is significantly higher than the ALP and GGT rise, this
indicates an hepatic problem. Finally, distinguishing between hepatic causes of jaundice, comparing
levels of AST and ALT can prove useful. AST levels will typically be higher than ALT. This remains
the case in most hepatic disorders except for hepatitis (viral or hepatotoxic). Alcoholic liver damage
may see fairly normal ALT levels, with AST 10x higher than ALT. On the other hand, if ALT is higher
than AST, this is indicative of hepatitis. Levels of ALT and AST are not well correlated to the extent of
liver damage, although rapid drops in these levels from very high levels can indicate severe necrosis.
Low levels of albumin tend to indicate a chronic condition, while it is normal in hepatitis and
cholestasis.
Lab results for liver panels are frequently compared by the magnitude of their differences, not
the pure number, as well as by their ratios. The AST:ALT ratio can be a good indicator of whether the
disorder is alcoholic liver damage (above 10), some other form of liver damage (above 1), or hepatitis
(less than 1). Bilirubin levels greater than 10x normal could indicate neoplastic or intrahepatic
cholestasis. Levels lower than this tend to indicate hepatocellular causes. AST levels greater than 15x
tends to indicate acute hepatocellular damage. Less than this tend to indicate obstructive causes. ALP
levels greater than 5x normal tend to indicate obstruction, while levels greater than 10x normal can
indicate drug (toxic) induced cholestatic hepatitis or Cytomegalovirus. Both of these conditions can also
have ALT and AST greater than 20× normal. GGT levels greater than 10x normal typically indicate
cholestasis. Levels 5–10× tend to indicate viral hepatitis. Levels less than 5× normal tend to indicate
drug toxicity. Acute hepatitis will typically have ALT and AST levels rising 20–30× normal (above
1000), and may remain significantly elevated for several weeks. Acetaminophen toxicity can result in
ALT and AST levels greater than 50x normal
References
1. Buttaro, Terry Mahan; Trybulski, JoAnn; Polgar-Bailey, Patricia; Sandberg-Cook, Joanne

(2012)
2. Winger, J; Michelfelder, A (September 2011). "Diagnostic approach to the patient with
jaundice.". Primary care. 38 (3): 469–82
3. Maisels, MJ (17 March 2015). "Managing the jaundiced newborn: a persistent challenge".
CMAJ : Canadian Medical Association journal (Journal de l'Association medicale canadienne).
187 (5): 335–43
150
4. Winger, J; Michelfelder, A (September 2011). "Diagnostic approach to the patient with
jaundice.". Primary care. 38 (3): 469–82
151
KANGAROO MOTHER CARE

DATE OF SUBMISSION-
152
KANGAROO MOTHER CARE
Subject : Child Health Nursing
Unit : IV
Topic : Kangaroo Mother Care
Place : Basic B Sc Nursing3 rd year
.Group : Basic B Sc Nursing3rd year
Method of Teaching : Lecture cum discussion
Instructional Aids : Chalk board , transparencies
Student Prerequisites : Students having previous knowledge of

Kangaroo Mother Care.
General objective : Student gain in depth knowledge on Kangaroo Mother Care
Specific objective : At the end of the class student will able to
1) Define Kangaroo Mother Care
2) State the brief history
3) Explain the working of K M C
4) Explain the benefits of K M C
153
TIM CONTRIBUTOR CONTENTS TEACHIN A.V.AID EVALUATIO
E Y G- S N
OBJECTIVE LEARNING
ACTIVITE
S
154
1 min To introduce the Self introduction Teacher
Topic introduce the
topic with
life
experiences
2 min To recapitulate the
previous Review of previous
knowledge knowledge CHALK What do you
Teacher asks BOARD mean by
1 min student Rooming in
Introduction of topic respon
To develop mental
readiness of the
learner
15
min OHP
Define
a)DEFINTION: Kangaroo
A universally available Mother Care
and biologically sound
method of care for all
To define the newborns, but in
Kangaroo Mother particular for premature
care babies, with three
components ... Teacher
1 Skin-to-skin Contact defines
2 Exclusive Kangaroo
breastfeeding Mother Care
3 Support to the mother with the help
infant dyad. of
transparency
Skin-to-skin contact is
between the baby front
and the mother's chest.
The more skin-to-skin,
the better.
Exclusive
breastfeeding means
that for an average
10 mother, expressing
Min from the breasts or OHP
direct suckling by the
baby is all that is
needed.
For very premature
babies, supply of some
essential nutrients may
be indicated.
Support to the dyad

means that whatever is
needed for the medical, Tell about brief
emotional, history of K M
psychological and C
To State the brief physical well being of
history mother and baby is
155
provided to them, Teacher state
without separating the brief
them. This might mean history with
adding ultramodern help of O H
equipment if available, P
or purely intense
psychologial support in
contexts with no
resources.
b) BRIEF HISTORY:-
15 1979 - Dr Rey and chalk
Min Martinez started board
programme in Bogota,
Colombia, in response
to shortage of
incubators and severe
hospital infections.
• 1983 - UNICEF
brought attention to
programme, Spanish!
• 1985 - Number of
visits from USA, UK
and Scandinavia, first
English report
published in The Lancet
by Whitelaw and
Sleath, May 1985.
• 1986 onwards -
Research in Europe and
USA. Implementation Teacher state Explain the
widespread in the process working of
Scandinavia and with the help K M C?
To explain the Germany. Early of chalk
working of K M C implementation in board
Mozambique and other
African countries.
• 1991 - First review of
research published by
10 Gene Cranston
min Anderson.
• 1996 - First
International OHP
Workshop, Trieste,
Italy, hosted by
Adreano Cattaneo and
team. Noted over thirty
different terms used,
agreed to use KMC
(Kangaroo Mother
Care), defining the
programme of skin-to-
skin contact,
breastfeeding and early
discharge. The term “K
156
C” refers only to
intervention
“intrahospital maternal-
infant skin-to-skin
contact”.
• 1998 - First
International
Conference on Teacher
Kangaroo Care, explain the
Baltimore, Maryland, benefits with
USA, arranged by help of
Susan Ludington-Hoe transperancy
• 1998 - Second
International Explain the
To explain the Workshop, Bogota, benefits of
benefits of K M C Colombia, arranged by KMC?
Nathalie Charpak and
team; focus on research
and implementation.
• 2000 - Third
International
Workshop, Yogyakarta,
Indonesia.
c)
Workin
g of
Kangar
oo
Mother
Care means skin to skin
2 min contact between mother
and her newborn baby,
this contact has
remarkable effects.
Breastfeeding is
essential for the baby,
2min from the first hour of
life and onwards. The
key message is :
NEVER SEPARATE
MOTHER AND HER
NEWBORN. The
benefits are even more
2 min crucial for a premature
baby.
Dr Nils Bergman was

the Doctor who
introduced Kangaroo
Mother Care (KMC) to
South Africa. He has
recently published the
results of a strict
scientific trial (in Acta
Paediatrica) comparing
skin to skin
157
immediately after birth
to incubator care . What Teacher
he found was that skin summarize
to skin care was much the topic
better for the newborn with help of
than the incubator. chalk board
Babies were warmer
and calmer, breathed
To summarize the better and had a more
Topic stable heart rate with
skin to skin care. Teacher asks
Surprisingly, the the question
smaller the baby was- student
down to 1200grams- the responds
To evaluate the more stable they were,
knowledge of and the more unstable
students in the incubator! This is
opposite to what people
think! Teacher
dictate and
In fact there is other students
research suggesting that copies it
To reinforce the the incubator is
learning harmful! Babies’ brain
development requires
skin to skin contact and
being held and carried,
and eye to eye contact
to form the right brain
d)Benefits of
Kangaroo Mother
Care
Benefits of the
KangaCarrier
The KangaCarrier shirt

is designed to be safe
for premature babies
and is designed for the
first eight weeks of full
term babies life before
they have neck control.
Benefits for the baby:
The baby in the
KangaCarrier with the
wrapper has its airway
stabilized and the neck
supported. The
KangaCarrier provides
security and
containment for the
baby while providing
the full physiological
benefits of skin-to-skin
care including a stable
158
temperature, heart rate,
breathing and
metabolism. The skin-
to-skin contact reduces
stress hormones in the
baby. In a calm baby,
food can be properly
absorbed in the
stomach, so the baby
grows faster. The
baby’s temperature
stabilizes much faster
on the mother’s chest
than in an incubator.
The Kanga Carrier
enables early bonding
of the mother and baby
so the baby will receive
better long-term care
and emotional stability.
The Kanga Carrier also
protects babies from the
harmful effects of
incubators.
Benefits for the baby:
The baby in the Kanga
Carrier with the
wrapper has its airway
stabilized and the neck
supported. The Kanga
Carrier provides
security and
containment for the
baby while providing
the full physiological
benefits of skin-to-skin
care including a stable
temperature, heart rate,
breathing and
metabolism. The skin-
to-skin contact reduces
stress hormones in the
baby. In a calm baby,
food can be properly
absorbed in the
stomach, so the baby
grows faster. The
baby’s temperature
stabilizes much faster
on the mother’s chest
than in an incubator.
The Kanga Carrier
enables early bonding
of the mother and baby
so the baby will receive
better long-term care
and emotional stability.
159
The KangaCarrier also
protects babies from the
harmful effects of
incubators.
for the mother, as she
knows that her baby is
with her and safe, and
that she is giving the
best care to her baby.
The shirt is convenient
as it leaves both of the
mother’s arms free to
carry on with the
normal business of life
and walking around.
The shirt is comfortable
and made from
polycotton, which does
not need ironing. The
KangaCarrier is safe
enough for the mother
and baby to sleep
together without fear of
rolling on the baby and
this is soothing for both
Mum and baby, so they
get more rest.
e)Summary:-chalk
board
summary
f)Evaluation
g)Assignment
write an assignment on
Rooming in
160
LESSON PLAN ON COMMUNITY

COUNSELLING

DATE OF SUBMISSION-
161
LESSON PLAN ON COMMUNITY COUNSELLING
GENERAL OBJECTIVES :
This course is designed to help students gain knowledge of the concept and nature of measurement and
evaluation, meaning, process, purposes, techniques and role of nurse in counseling.
SPECIFIC OBJECTIVE:
Upon completion of the course, the student shall be able to:
1. Describe in general the concept and principles of counseling.
2. Describe in detail the purpose and techniques of counseling used in community.
3. Describe in detail the areas and components for counseling in the community sector.
4. Describe in detail the role of counselor.
5. Describe in detail the role of ANM nurse in community counseling.
6. Describe in detail female health worker as counselor in community sector.
S.NO LEARNIN CONTENT TIME TEACHING ASSESSMEN

G LEARNNG T
OBJECTI ACTIVITY METHODS
VE
Concept and principle of counseling :

1. Describe in Guidance & counseling are twin concepts &
general the have emerged as essential elements of every SHORT
concept educational activity.  Guidance & 10 MIN Lecture cum ANSWER
and counseling are not synonymous term. discussion TYPE
principles Counseling is a part of guidance.  Guidance,
of in educational context, means to indicate,
counseling. point out, show the way, lead out & direct.
Counseling is a specialized service of Essay type
guidance. It is the process of helping questions
individuals learn more about themselves &
their present & possible future situations to
make a substantial contribution to the society
162
DEFINITION OF COUNSELING
:
Counseling is essentially a process in which
the counselor assists the counselee to make
interpretations of facts relating to a choice,
plan or adjustment which he needs to make. -
Glenn F. Smith  Counseling is a series of
direct contacts with the individual which aims
to offer him assistance in changing his attitude
& behaviors. - Carl Rogers
PURPOSES OF GUIDANCE AND

2. Describe in COUNSELLING :
detail the • Providing the needed information & 10 min Lecture cum SHORT
purpose assistance discussion ANSWER
and • Helping in individual to make wise choices TYPE
techniques • Improve the understanding of self
of • Facilitate the adjustment
counseling • Helps in adapting to the changes or new Essay type
used in environment
community • Making self-sufficient & independent
. • Efficient use of capabilities & talent
• Promote the optimal personal & professional Objective type
development
• Balanced physical, psychological,
emotional, social & spiritual growth
• Helps in overall development & to live
productive life
TYPES OF COUNSELLING
APPROACHES
:
1. Directive counseling approach
2. Nondirective counseling approach
3. Eclectic counseling approach
163
I. Directive Counseling
Approach :
It is also known as prescriptive
counseling or counsellor-centred
approach of counseling.  This
approach of counseling is
advocated by E.G. Williamson, a
professor at University of
Minnesota. In directive
counseling, the counselor plays a
leading role & uses a variety of
techniques to suggest appropriate
solutions to the counselee's
problem.  This approach also
known as authoritarian or
psychoanalytic approach.  The
counselor is active & help
individuals in making decisions &
finding solution to their problems.
 The counselor believes in the
limited capacity of the patient.
II. Nondirective Counseling

Approach :
The chief exponent of this
counseling approach, Carp R.  It
is also known as the permissive
counseling approach where the
counselor's role is passive & the
counselee’s role is active.  It is
a counselee-centered or patient-
centered humanistic approach. 
The counselee makes the final
decisions as individuals are
thoughts to have full right to
make final decisions for the self
& solve their problems.  The
counselor has to accept the
counselee’s capacity to make
adjustment & adapt.
III. Eclectic Counseling Approach :

This approach is based on the fact
that all individuals are different
from one another.  The
techniques are elective in nature
because they have been derived
from all sources of counseling. 
This approach is based on
selecting the best & leaving out
what is least required.  The
basic assumption related to
164
eclectic counseling approach: 
There is objectivity & co-
ordination between counselor &
the patient during the counseling
experience.  The patient is
active & the counselor remains
passive in the beginning. …
components of community counseling:

Provide advice and consultation to a 10 MIN Lecture cum SHORT
3. Describe community's caregivers to increase access to discussion ANSWER
the mental health care. TYPE
component Identify high-risk populations.
s of Reduce the incidence of mental disorders at Objective type
community an individual level.
counseling Develop preventive services to reduce
relapses.
Recognize the value of the community and its Essay type
ability to bolster positive mental health and
develop effective programs.
4. Describe in ROLE OF THE COUNSELLOR

detail the : 10 MIN Lecture cum SHORT
role of Arrange orientation programs for the other discussion ANSWER
counselor support staff to enlist their cooperation. TYPE
in  Prepare an up-to-date list of resources,
community information, referral & energy available to Explain using Objective type
him.  Organize the guidance committee.  Charts ,
Set up an educational & occupational formative and
information center.  Display the information summative
collected in an attractive way.  Disseminate evaluation Essay type
information through educational & career
talks, group discussion & so on.  Arrange
talks by expert from different fields. 
Organize career days, career weeks, career
conferences, parents day & so on.
ROLE OF ANM NURSE IN

5. COMMUNITY :
Describe in detail 1. To conduct survey 10 Lecture cum SHORT
the role of ANM 2. Evaluate and gather the MIN discussion ANSWER
nurse in population and needs for TYPE
community counseling in the community
counseling 3. Prioritize the needs in the Objective type
community.
4. Prepare community based
setting and tools for
counseling Essay type
165
5. Prepare individual and group
counseling session in
community
6. Conduct / or assist in
community counseling
7. Note down the process
recording of counseling
8. Evaluate the effectiveness of
counseling in community.
6. .THE ROLE OF ANM NURSE IN

Describe in detail COUNSELLING 10 Lecture cum SHORT
the role of ANM : MI discussion ANSWER
NURSE in Counselling involves two individuals- N TYPE
counseling one seeking help & the other a
professionally trained person who can Objective type
help the first. There should be a
relationship of mutual respect between
the two individuals. Counselling is
aimed at bringing about desired Essay type
changes in the individual for self-
realization & providing assistance to
solve problems through an intimate
personal relationship. The counselor
discovers the problems of the
counselee & help him to set up
realistic goals
166
CASE STUDY ON PLUERAL EFFUSION

DATE OF SUBMISSION-
167
CASE STUDY ON PLUERAL EFFUSION
Introduction
As part of our advanced nursing practice clinical posting, I had been posted to krishnahospital.
Mrs.Lakshmamma got admitted in to krishnahospital with the complaints of, dyspnoea, cough, chest
pain, wheezing, since 1 week. I have posted in female ward and observed the client and physician
diagnosed as Plueral effusion.
Patient bio-data:
NAME : Mrs.Lakshmamma
AGE/SEX : 64 years/ Female
MARITAL STATUS ; Married
OCCUPATION ; Housewife
RELIGION : Hindu
HOSP NO : 87658
BEDNO :4
DATE OF ADDMISSION : 16-06-2022
WARD : female Medical ward
ADDRESS : lucknow
DIAGNOSIS : pleural effusion
SOURCE OF INFORMATION : patient, record, relatives.
PRESENTING COMPLAINTS ; cough,chest pain, dyspnea, trachy cardia, wheezing, since 1 week.
APPLICATION OF OREM'S SELF-CARE DEFICIT THEORY IN NURSING PRACTICE
OBJECTIVES
 To assess the patient condition by the various methods explained by the nursing theory
 to identify the problems of the patient and to select a theory for the application according to the
need of the patient
 To demonstrate an effective communication and interaction with the patient.
 to apply the theory to solve the identified problems of the patient
 To evaluate the extent to which the process was fruitful.
168
Areas Patient details
 Name  Mrs. Lakshmamma

 Age  64 years
 Sex  Female
 Education  10th std
 Occupation  Housewife.
 Marital status  Married
 Religion  Hindu
 Diagnosis  Pleural effusion.
 Theory applied  Orem’s theory of self care deficit.
DATA COLLECTION ACCORDING TO OREM’S THEORY OF SELF CARE DEFICIT
BASIC CONDITIONING FACTORS
Age 64 years
Gender Female
Health state Disability due to health condition, therapeutic self care demand
Development state
Sociocultural orientation 10th standard, Indian, Hindu
Health care system Institutional health care
Family system Married, Husband working
Patterns of living At home with children
Environment Rural area, items for ADL not in easy reach, no special precautions to
prevent infections
Resources Husband,And Son.
2. UNIVERSAL SELF-CARE REQUISITES:
Air patient is suffering with dyspnea
169
Water Fluid intake is sufficient
Turgor normal for the age
Food Hb -11gm%, BMI = 14.Food intake is not adequate or the diet is not
nutritious.
Elimination Voids and eliminates bowel with difficulty.
Activity/ rest Frequent rest is required due to inability to move

Activity level has come down.
Social interaction Communicates well with neighbors and calls the children by phone
Need for medical care is communicated to the husband.
Prevention of hazards Need instruction prevention of infection. Need instruction on

improvement of nutritional status.
Promotion of normalcy Has good relation with sister.
3. DEVELOPMENTAL SELF-CARE REQUISITES:
Maintenance of Not able to walk alone,

developmental environment
Prevention/management of the Feels that the problems are due to her own behaviours and discusses
conditions threatening the normal the problems with husband.
development
4. HEALTH DEVIATION SELF CARE REQUISITES
Adherence to medical regimen Reports the problems to the physician when in the hospital. Cooperates
with the medication, Not much aware about the use and side effects of
medicines
Awareness of potential problem Not aware about the actual disease process.
associated with the regimen No compliant with the diet and prevention of hazards. Not aware about
the side effects of the medications
Modification of self image to Has adapted to limitation in mobility.

incorporates changes in health The adoption of new ways for activities leads to deformities and
status progression of the disease.
Adjustment of lifestyle to Adjusted with the problems.

accommodate changes in the
170
health status and medical
regimen.
5. MEDICAL PROBLEM AND PLAN:

Physician’s perspective of the condition:
Diagnosed as pleural effusion and is on the following medications:
Inj. Dexamethasone
Inj. Theophylline
Inj. Rantac
Inj. Ampiccilin
Medical Diagnosis: pleural effusion
SOCIO-ECONOMIC STATUS OF THE FAMILY;

Mrs.Lekshmamma, 64yrs, is from a middle class family. Their monthly income is Rs.6000. they
are staying in rented house, rent is 2000/month religion is hindu. They have 1 private hospital near by
their house, They uses toilet for defecation. Water supply is from tap water. They have electricity
supply in their house.
Mother tongue-Kannada
Language Known; Kannada
Cultural group; Friends.
Mood; Social.
HISTORY OF ILLNESS (MEDICAL & SURGICAL)
Present medical/surgical history:
Mrs.Lekshmama got admitted in krishnahospital with the complaints of cough,chest pain,

dyspnea, trachy cardia, wheezing, since 6 days. Patient was taken some home remedies like taking
steam, but symptom is persistent. So she was brought to the hospital for further management.
Past medical/surgical history:
There was no history of past medical illness .pt was undergone tubectomy 25yrs back. History
of dust allergies.
Personal history:
171
Mrs.Lekshmamma looks thin in body build. she is a house wife. She looks anxious; she is
having the habit of chewing pan and betel leaves. she does not have the habit of alcoholism,. Her hobby
is watching T.V. She is not taking food regularly since 2 month due to health problem. Her bladder
pattern is normal she is not sleeping properly due to dyspnea. she sleeps daily 4-5 hours / daily. she
believes in allopathic treatment.
Family history:
Relationshi
p with
Name of the family Age(yea sex patient education Occupation Marital Health
members rs) status status
Mr.Ramayya 68yrs M Husband 10th std farmer Married Healthy
MrsLehshmamma 64yrs F client Nil House wife Married Asthma
Mr.sajesh business
38yrs M Son B.com Married Healthy
Mrs.sangeetha nil
32yrs F D-in-law T.C.H Married Healthy
Mr.santhosh factory
34yrs M Son I.T.I Unmarri Healthy
Nutritional history;
She is non-vegetarian. She takes food, whenever she wants. She is maintaining good
nutritional status.
PHYSICAL EXAMINATION;
Date :16/07/2020
Time : 10.30 am
General observation:
172
Body built ; Lean
Nutritional status ; well nourished
Personal appearance; Anxious
Posture; Good
Emotional stage; Anxious.
Cooperativeness; Cooperative.
Activity ; dull not active
Height: 149cm
Weight: 48kg
Vital signs;
Temperature: 98.6’F
Pulse: 80 b/mints
Respiratory rate: 22 breath/ mints
BP: 120/80 mm hg
Skin;
Presence of rashes: no rashes, no abscess
Color of the skin: Black
Texture of the skin: normal
Nails: normal capillary filling present
Pruritis: no pruritis
Edema; absent
Head;
Skull; No abnormality noted
Hair; Black hair, hair distribution normal.
Movements of the head; full range of movement.
173
Forehead; No scars or lesions.
Face; Anxious
Eye:
Eye set is normal, symmetry
Vision: normal
Eye brows: Equal
Eye lids; no lesion
Lacrimation; clear fluid.
Use of glasses: no
Use of contact lenses: no
Pupils: react to light
Conjunctiva: no conjunctivitis
Sclera: no discoloration, white.
Ear:
Appearance of ear: normal
Hearing : normal
Use of hearing aids: not using any aids
External ear: no discharges.
Nose;
Appearance; no septal deviation.
Discharge; no
Patency; both nostrils are patent
Sense of smell; good
Mouth and throat;
174
Lips; Dry.
Tongue; Normal
Teeth; Intact in upper and lower jaw, no caries,
Gums; Pink and moist.
Buccal mucosa; no lesion
Tonsil; not enlarged
Taste; normal
Speech : normal
Neck;
General appearance; Normal
Lymph node; No enlargement.
Thyroid gland; Feel smooth and firm.
Cyst and tumor; Absence
Respiratory system:
Inspection: cough, dyspnoea, chest pain is present. chest is symmetry in shape, no abnormal
configuration.
Palpation: absence of enlargement of lung present.
Auscultation: wheezing present.
Percussion: fluid collection present.
RR: 22/mt
Circulatory system:
Clubbing: absent, no cyanosis, normal capillary filling present
Heart sounds: S1, S2 normal, no gallop. No murmur, chest pain present.
Gastrointestinal system:
Inspection: no abdomen distention, no rashes,
Palpation; No organomegally
175
Percussion; No fluid filled spaces.
Auscultation; peristalsis present.
Back;
Spine and curvature; no abnormalities is noted.
Movements; all range of movements is normal.
Tenderness; no tenderness noted.
Upper and lower Extremities;
Normal movement.
No deformities.
Genitalia;
Normal-no discharges.
Central nervous system:
GCS: 15/15
Cerebral function: normal, he is conscious, oriented with place person
Cerebellar function: normal, motor function normal
Reflexes: normal
Cranial nerves: normal
Motor function: normal
Sensory function: normal
Reflexes: all reflex present, normal
INVESTIGATIONS
Investigations normal values Patient Values
176
Hemoglobin (13-19g/dl) 11g/dl
WBC (4000- 12000 cells/cm

11000 cells/cumm)
Neutrophil (40-75%) 78%
Lymphocyte (25-45%) 11%
Monocyte (2-10%) 5.6%
Eosinophil (0-10%) 3.5%
Basophil (0-2%) .4%
Platelet (150000-400000 cells/cumm) 350000cell/cumm
ESR (0-10mm/hr) 88mm/hr
RBS (60-150 mg/dl) 145mg/dl
Urea (8-35mg/dl) 29mg/dl
Creatinine (0.6-1.6 mg/dl) 1.9mg/dl
Sodium (130-143 mEq/L) 139meq/l
Potassium (3.5-5 mEq/L) 4meq/l
Blood group A+
HIV Negative
HCV Negative
HBsAg Negative
Urine Protein (negative) Negative
Urine WBC (0-5 cells/hpf) Nil
RBC (nil ) Nil
Epithelial cell (0-5) 4-5
Anatomy & Physiology of the Respiratory System
177
The respiratory system is situated in the thorax, and is responsible for gaseous exchange between the
circulatory system and the outside world. Air is taken in via the upper airways (the nasal cavity,
pharynx and larynx) through the lower airways (trachea, primary bronchi and bronchial tree) and into
the small bronchioles and alveoli within the lung tissue.
Move the pointer over the coloured regions of the diagram; the names will appear at the bottom of the
screen)
The lungs are divided into lobes; The left lung is composed of the upper lobe, the lower lobe and the
lingula (a small remnant next to the apex of the heart), the right lung is composed of the upper, the
middle and the lower lobes.
Mechanics of Breathing
To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The
diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are
held to the thoracic wall by the pleural membranes, and so expand outwards as well. This creates
negative pressure within the lungs, and so air rushes in through the upper and lower airways.
Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held
against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space
(pneumothorax).
Physiology of Gas Exchange
Each branch of the bronchial tree eventually sub-divides to

form very narrow terminal bronchioles, which terminate in
the alveoli. There are many millions of alveloi in each lung,
and these are the areas responsible for gaseous exchange,
presenting a massive surface area for exchange to occur over.
Each alveolus is very closely associated with a network of

capillaries containing deoxygenated blood from the
pulmonary artery. The capillary and alveolar walls are very
thin, allowing rapid exchange of gases by passive diffusion
along concentration gradients.
CO2 moves into the alveolus as the concentration is much
lower in the alveolus than in the blood, and O2 moves out of
the alveolus as the continuous flow of blood through the
capillaries prevents saturation of the blood with O 2 and
allows maximal transfer across the membrane.
178
Introduction
Normally, very small amounts of pleural fluid are present in the pleural spaces, and fluid is not
detectable by routine methods. When certain disorders occur, excessive pleural fluid may accumulate
and cause pulmonary signs and symptoms. Simply put, pleural effusions occur when the rate of fluid
formation exceeds that of fluid absorption. Once a symptomatic, unexplained pleural effusion occurs, a
diagnosis needs to be established.
Definition
Pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid-filled space that
surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of
the lungs during inhalation.
Pathophysiology
Pleural effusion is an indicator of an underlying disease process that may be pulmonary or

nonpulmonary in origin, acute or chronic.
 Normal pleural fluid has the following characteristics:

o Clear ultrafiltrate of plasma that originates from the parietal pleura
o pH 7.60-7.64
o Protein content less than 2% (1-2 g/dL)
o Fewer than 1000 WBCs per cubic millimeter
o Glucose content similar to that of plasma
o Lactate dehydrogenase (LDH) less than 50% of plasma
o Sodium, potassium, and calcium concentration similar to that of the interstitial fluid
 The following mechanisms play a role in the formation of pleural effusion:
o Altered permeability of the pleural membranes (eg, inflammation, malignancy,
pulmonary embolus)
o Reduction in intravascular oncotic pressure (eg, hypoalbuminemia, cirrhosis)
o Increased capillary permeability or vascular disruption (eg, trauma, malignancy,
inflammation, infection, pulmonary infarction, drug hypersensitivity, uremia,
pancreatitis)
o Increased capillary hydrostatic pressure in the systemic and/or pulmonary circulation
(eg, congestive heart failure, superior vena cava syndrome)
o Reduction of pressure in the pleural space, preventing full lung expansion (eg,
extensive atelectasis, mesothelioma)
o Decreased lymphatic drainage or complete blockage, including thoracic duct
obstruction or rupture (eg, malignancy, trauma)
o Increased peritoneal fluid, with migration across the diaphragm via the lymphatics or
structural defect (eg, cirrhosis, peritoneal dialysis)
o Movement of fluid from pulmonary edema across the visceral pleura
o Persistent increase in pleural fluid oncotic pressure from an existing pleural effusion,
causing further fluid accumulation
The net result of effusion formation is a flattening or inversion of the diaphragm, mechanical
dissociation of the visceral and parietal pleura, and a restrictive ventilatory defect.
Clinical Manifestations
179
History
A detailed medical history should be obtained from all patients presenting with a pleural
effusion, as this may help to establish the etiology. For example, a history of chronic hepatitis or
alcoholism with cirrhosis suggests hepatic hydrothorax or alcohol-induced pancreatitis with effusion.
Recent trauma or surgery to the thoracic spine raises the possibility of a cerebrospinal fluid (CSF) leak.
The patient should be asked about a history of cancer, even remote, as malignant pleural effusions can
develop many years after initial diagnosis. An occupational history should also be obtained, including
potential asbestos exposure, which could predispose the patient to mesothelioma or asbestos pleural
effusion. The patient should also be asked about medications they are taking.
The clinical manifestations of pleural effusion are variable and often are related to the
underlying disease process. The most commonly associated symptoms are progressive dyspnea, cough,
and pleuritic chest pain.
 Dyspnea
o Dyspnea is the most common symptom at presentation and generally indicates the
presence of a large effusion.
o It is reported to occur in 50% of patients with malignant pleural effusions.
o Other factors (eg, underlying lung disease, cardiac dysfunction, anemia) may also
contribute to the development of dyspnea.
 Chest pain
o Chest pain in this setting results from pleural irritation, which can aid in determining
the etiology of the effusion, since most transudative effusions do not cause direct
pleural irritation. Its presence raises the likelihood of an exudative etiology such as
pleural infection, mesothelioma, or pulmonary infarction.
o Pain may be mild or severe. It is typically described as sharp or stabbing and is
exacerbated with deep inspiration.
o Pain may be localized to the chest wall or referred to the ipsilateral shoulder or upper
abdomen, usually because of diaphragmatic involvement.
o Pain often diminishes in intensity as the pleural effusion increases in size.
 Other symptoms occurring with pleural effusions are associated with the underlying disease
process.
o Increasing lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea may
all occur with congestive heart failure.
o Night sweats, fever, hemoptysis, and weight loss should suggest tuberculosis (TB).
o Hemoptysis also raises the possibility of malignancy, other endotracheal or
endobronchial pathology, or pulmonary infarction.
o An acute febrile episode, purulent sputum production, and pleuritic chest pain may
occur in patients with an effusion associated with pneumonia.
Physical
Physical findings are variable and depend on the volume of the pleural effusion. Generally, there
are no physical findings for effusions smaller than 300 mL. With effusions larger than 300 mL,
findings may include the following:
 Dullness to percussion
 Decreased tactile fremitus
 Asymmetric chest expansion, with diminished or delayed expansion on the side of the effusion:
Dullness to percussion, decreased tactile fremitus, and asymmetric chest expansion are the most
reliable physical findings of pleural effusion.
 Diminished or inaudible breath sounds
 Egophony ("e" to "a" changes) at the most superior aspect of the pleural effusion
 Pleural friction rub
 Other findings that provide clues to the etiology of the effusion include the following:
180
o Peripheral edema, distended neck veins, and S 3 gallop, suggestive of congestive heart
failure
o Edema may also be a manifestation of nephrotic syndrome; pericardial disease; or,
combined with yellow nails, the yellow nail syndrome.
o Cutaneous changes with ascites, suggestive of liver disease
o Evidence of malignancy such as lymphadenopathy or palpable mass
Types of fluids
Four types of fluids can accumulate in the pleural space:
 Serous fluid (hydrothorax)

 Blood
 Chyle (chylothorax)
 Pus (pyothorax or empyema)
Causes
Transudative
The most common causes of transudative pleural effusions in the United States are left ventricular
failure, and cirrhosis (causing hepatic hydrothorax). Pulmonary embolisms were once thought to be
transudative but have been recently shown to be exudative
Exudative
Pleural effusion Chest x-ray of a pleural effusion. The arrow A shows fluid layering in the right pleural
cavity. The B arrow shows the normal width of the lung in the cavity
Once identified as exudative, additional evaluation is needed to determine the cause of the excess fluid,
and pleural fluid amylase, glucose, pH and cell counts are obtained.
 Pleural fluid amylase is elevated in cases of esophageal rupture, pancreatic pleural effusion,
or cancer.
 Glucose is decreased with cancer, bacterial infections, or rheumatoid pleuritis.
 Pleural fluid pH is low in empyema (<7.2) and may be low in cancer.
 If cancer is suspected, the pleural fluid is sent for cytology. If cytology is negative, and
cancer is still suspected, either a thoracoscopy, or needle biopsy of the pleura may be
performed.
 The fluid is also sent for Gram staining and culture, and, if suspicious for tuberculosis,
examination for TB markers (adenosine deaminase > 45 IU/L, interferon gamma > 140
pg/mL, or positive polymerase chain reaction (PCR) for tuberculous DNA).
The most common causes of exudative pleural effusions are bacterial pneumonia, cancer (with
lung cancer, breast cancer, and lymphoma causing approximately 75% of all malignant pleural
effusions), viral infection, and pulmonary embolism.
181
Other/ungrouped
Other causes of pleural effusion include tuberculosis (though pleural fluid smears are rarely positive for
AFB, this is the most common cause of pleural effusion in some developing countries), autoimmune
disease such as systemic lupus erythematosus, bleeding (often due to chest trauma), chylothorax (most
commonly caused by trauma), and accidental infusion of fluids.
Less common causes include esophageal rupture or pancreatic disease, intraabdominal abscess,
rheumatoid arthritis, asbestos pleural effusion, Meigs syndrome (ascites and pleural effusion due to a
benign ovarian tumor), and ovarian hyperstimulation syndrome.
Pleural effusions may also occur through medical/surgical interventions, including the use of
medications (pleural fluid is usually eosinophilic), coronary artery bypass surgery, abdominal surgery,
endoscopic variceal sclerotherapy, radiation therapy, liver or lung transplantation, and intra- or
extravascular insertion of central lines.
Diagnostic Evaluation:
Noninvasive Diagnostic Techniques
When the presence of a pleural effusion is suspected by physical examination, confirmation with a chest
x-ray is necessary. With some pleural effusions, especially when subpulmonic in location (layering
below the lung but above the hemidiaphragm), a lateral decubitus film usually confirms the presence of
fluid. Pleural space ultrasound is extremely helpful to locate small amounts or isolated loculated pockets
of fluid. Thoracentesis can be performed simultaneously using ultrasound guidance. Chest CT is most
helpful to distinguish between parenchymal and pleural disease and may demonstrate pleural
thickening, pleural calcification, a pleural based mass, or loculated collections of fluid.
Thoracentesis and Pleural Fluid Analysis
To establish the etiology, a thoracentesis usually needs to be performed. Fifty to 100 ml of fluid are
usually removed and sent for analysis . Not every effusion needs to be tapped, but when the patient has
no obvious clinical cause for the effusion, is febrile, or has pulmonary compromise, fluid should be
removed. The first step is to determine if the fluid is a transudate or an exudate. Transudative effusions
occur when systemic factors that influence the formation and absorption of pleural fluid are altered
(e.g., low serum proteins and increased pulmonary venous pressure). Exudative effusions occur when
local factors that influence the formation and absorption of fluid are altered (e.g., infection and
malignancy). The lactate dehydrogenase (LDH), protein levels or specific gravity of the fluid can
distinguish these two. Most agree that exudates must meet one or more of the following criteria,
whereas transudates meet none:
 Pleural fluid/serum protein > 0.5 or absolute value > 3 g/dl.

 Pleural fluid/serum LDH > 0.6 or absolute value > 0.45 upper normal serum limit
 Pleural fluid specific gravity > 1.018
Once an effusion is categorized as transudative or exudative, etiologic considerations narrow.

Additional pleural fluid studies that help to establish a diagnosis include glucose, amylase, white blood
cell counts with differential, and cytologic and microbiologic examination.
Treatment
182
The free end of the Chest Drainage Device is usually attached to an underwater seal, below the level of
the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning
to the chest.
Treatment depends on the underlying cause of the pleural effusion.
Therapeutic aspiration may be sufficient; larger effusions may require insertion of an intercostal drain
(either pigtail or surgical). When managing these chest tubes it is important to make sure the chest tubes
do not become occluded or clogged. A clogged chest tube in the setting of continued production of fluid
will result in residual fluid left behind when the chest tube is removed. This fluid can lead to
complications such as hypoxia due to lung collapse from the fluid, or fibrothorax, late, when the space
scars down. Repeated effusions may require chemical (talc, bleomycin, tetracycline/doxycycline) or
surgical pleurodesis, in which the two pleural surfaces are scarred to each other so that no fluid can
accumulate between them. This is a surgical procedure that involves inserting a chest tube, then either
mechanically abrading the pleura, or inserting the chemicals to induce a scar. This require the chest tube
to stay in until the fluid drainage stops. This can be days to weeks and can require prolonged
hospitilizations. If the chest tube becomes clogged fluid will be left behind and the pleurodesis will fail.
Pleurodesis fails in as many as 30% of cases. An alternative is to place a Pleurex or Aspira Drainage
Catheter. This is a 15Fr chest tube with a one way valve. Each day the patient or care givers connect it
to a simple vacuum tube and remove from 600 cc to 1000 cc. This can be repeated daily. When not in
use, the tube is capped. This allows patients to be outside the hospital. For patients with malignant
pleural effusions, it allows them to continue chemotherapy, if indicated. Generally the tube is in about
30 days and then it is removed when the space undergoes a spontaneous pleurodesis.
CAMPARISION WITH THE PATIENT PICTURE AND BOOK PICTURE
CAUSES:
Transudative
The most common causes of transudative pleural

effusions in the United States are left ventricular
failure, and cirrhosis (causing hepatic
hydrothorax). Pulmonary embolisms were once
thought to be transudative but have been recently
shown to be exudative
Exudates
Other/ungrouped
Other causes of pleural effusion include

tuberculosis (though pleural fluid smears are rarely
positive for AFB, this is the most common cause of
pleural effusion in some developing countries),
autoimmune disease such as systemic lupus
erythematosus, bleeding (often due to chest
trauma), chylothorax (most commonly caused by
trauma), and accidental infusion of fluids.
183
Less common causes include esophageal rupture or
pancreatic disease, intraabdominal abscess,
rheumatoid arthritis, asbestos pleural effusion,
Meigs syndrome (ascites and pleural effusion due
to a benign ovarian tumor), and ovarian
hyperstimulation syndrome.
Pleural effusions may also occur through

medical/surgical interventions, including the use of
medications (pleural fluid is usually eosinophilic),
coronary artery bypass surgery, abdominal surgery,
endoscopic variceal sclerotherapy, radiation
therapy, liver or lung transplantation, and intra- or
extravascular insertion of central lines.
CLINICAL MANIFESTATION
Dyspnea
Dyspnoea, cough,wheezing present
o Dyspnea is the most common
symptom at presentation and
generally indicates the presence of
a large effusion.
o It is reported to occur in 50% of
patients with malignant pleural
effusions.
o Other factors (eg, underlying lung
disease, cardiac dysfunction,
anemia) may also contribute to the
development of dyspnea.
 Chest pain
o Chest pain in this setting results
from pleural irritation, which can
aid in determining the etiology of
the effusion, since most
transudative effusions do not cause
direct pleural irritation. Its
presence raises the likelihood of an
exudative etiology such as pleural
infection, mesothelioma, or
pulmonary infarction.
o Pain may be mild or severe. It is
typically described as sharp or
stabbing and is exacerbated with
deep inspiration.
o Pain may be localized to the chest
wall or referred to the ipsilateral
shoulder or upper abdomen,
usually because of diaphragmatic
involvement.
o Pain often diminishes in intensity
as the pleural effusion increases in
size.
184
 Other symptoms occurring with pleural
effusions are associated with the
underlying disease process.
o Increasing lower extremity edema,
orthopnea, and paroxysmal
nocturnal dyspnea may all occur
with congestive heart failure.
o Night sweats, fever, hemoptysis,
and weight loss should suggest
tuberculosis (TB).
o Hemoptysis also raises the
possibility of malignancy, other
endotracheal or endobronchial
pathology, or pulmonary
infarction.
o An acute febrile episode, purulent
sputum production, and pleuritic
chest pain may occur in patients
with an effusion associated with
pneumonia.
 Dullness to percussion
 Decreased tactile fremitus
 Asymmetric chest expansion, with
diminished or delayed expansion on the
side of the effusion: Dullness to
percussion, decreased tactile fremitus, and
asymmetric chest expansion are the most
reliable physical findings of pleural
effusion.
 Diminished or inaudible breath sounds

 Egophony ("e" to "a" changes) at the most
superior aspect of the pleural effusion
 Pleural friction rub
 Other findings that provide clues to the
etiology of the effusion include the
following:
o Peripheral edema, distended neck
veins, and S 3 gallop, suggestive of
congestive heart failure
o Edema may also be a
manifestation of nephrotic
syndrome; pericardial disease; or,
combined with yellow nails, the
yellow nail syndrome.
o Cutaneous changes with ascites,
suggestive of liver disease
o Evidence of malignancy such as
o lymphadenopathy or palpable mass
Diagnostic Evaluation:
Noninvasive Diagnostic Techniques-
X-Ray, physical examination, routine blood

investigation.
185
Thoracentesis and Pleural Fluid Analysis X- ray, physical examination, routine blood
investigation.
Treatment
Water seal drainage, antibiotic, pleural aspiration.
Antibiotic therapy
Nursing diagnosis:
1. Impaired breathing pattern related to pleural congestion as evidenced by dyspnea

2. Activity intolerance related to dyspnea as evidenced by decreased walking
3. Fluid volume deficit related to less intake of fluid
4. Impaired sleeping pattern related to dyspnea as manifested by disturbed sleep
5. Fear related to disease prognosis as evidenced by anxious depression
6. Imbalanced nutritional status less then body requirement related to less intake of
food a manifested by eight lo, refused to take food
7. Deficient knowledge related to treatment, follow up a evidenced by lake of
awareness
Nursing care plan according to Orem’s theory of self-care deficit
Nursing diagnosis Outcome and plan Implementation Evaluation
(diagnostic (Prescriptive (control operations) (regulatory operations )

operations ) operations)
186
Based on self care Outcome Nurse- patient actions to 1. Effectiveness of the nurse patient
deficits action to
Nursing goal and - Promote patient as self
objectives care agent -Promote patient as self care agent
Design of nursing - Meet self care needs - Meet self care needs
system
- Decrease the self care - Decrease the self care deficit.
Appropriate method deficit.
of helping 2. Effectiveness of the selected
nursing system to meet the needs.
Thus in the patient Mrs. Lekshmamma the areas that need assistance were…
1. Air
2. Water
3. Food
4. Elimination
5. Activity/ Rest
6. Solitude/ Interaction
7. Prevention of hazards
8. Promotion of normalcy
9. Maintain a developmental environment.
10. Prevent or manage the developmental threats
11. Maintenance of health status
12. Awareness and management of the disease process.
13. Adherence to the medical regimen
14. Awareness of potential problem.
15. modify self image
16. Adjust life style to accommodate health status changes and medical regimen
187
APPLICATION OF OREM’S THEORY;
Developmental Self care deficit;

Health deviation self care deficits;
Universal Self Care Deficits -Unable to breath properly by self.
Assess self care activity
-Assess breathing pattern of the pt. Assess breathing pattern
-Assess the fluid intake/output. Assess coping strategies
-Assess the nutritional status of the
patient. Self care
Impaired activity
-Husband Impaired breathing pattern
-Son Impaired nutritional status
-Nurse Self care agency Impaired fluid intake.
Self care demands
Conditioning Factors; Supportive Compensatory

Age-55 years. System;
Developmental Status- Nursing agency -Explain about disease
Adult. condition and treatment
Health care delivery- regimen.
Supportive health care -Teach breathing/
system coughing exercise.
-Education about
Partially Compensatory System; nutrition.
Prevent infection.
Provide high protein diet.
Administer medication
Administer fluid.
188
Nursing care plan according to Orem’s theory of self-care deficit
Nursing diagnosis Outcome and plan Implementation Evaluation
(diagnostic operations ) (Prescriptive operations) (control operations) (regulatory operations )
Impaired breathing pattern dyspnoea  Client will maintained  Assessed the breathing pattern  Client maintained normal
breathing pattern
related to broncheotrachial normal breathing pattern  Comfortable, position provided
obstruction.  Comfort devices provided
 positioned the patient with the help of
Cardiac patient.
 Administered the oxygen
 Nebulization given.
 Bronco dilators given.
 Provided good ventilation.
 calm and quiet environment provided.
189
Imbalanced nutritional status less than  Client will maintain  Assess the nutritional status of the patient.  Improved the nutritional
body requirement related to anorexia, normal nutritional status  Assess the likes & dislikes status
less intake of food, vomiting as  Assess the food pattern of the patient
evidenced by, weight loss  Provide high calorie diet
 Give low fat diet
 Provide carbohydrate rich diet
 Maintain I/O chart
 Recheck the weight daily
 Provide low frequent diet.
 Increase the palatability of the food.
 Serve the food according to patients
comfort.
 Advised the patient to drink more water
 Antiemetic given (inj. Emeset)
Fluid volume deficit related to  Client will maintain  Assessed the dehydration level of the patient  Normal fluid balance
subsequent vomiting as evidenced by normal fluid balance  advised the patient to drink more water maintained
dehydration  i/o chart maintained
 administered more IV fluid
 provided the more fluid diet
 adviced the client to drink more liquid diet
190
 added more fluids in food
 humidified oxygen administered
 petroleum jelly applied to prevent dry and
coated lips and toungue.
Client gained knowledge
 Assessed the knowledge level of patient

 Listen to the client.
 Ask questions related to care
 Allow the expression of doubts
 Inform about the hazards of lack of
 Client will impart cleanliness, various portal of entry of
knowledge regarding microbes, maintenance of healthy home

atmosphere
diet, use of health services,  Inform to cultivate hygienic practices,
environmental sanitation importance of balanced nutrition to build up

immune system.
 Inform about the importance of follow up
care and continuation of drugs
 Ask the patient to avoid exposing to dust
and cold
191
Knowledge deficit regarding diet, use
of health services,
environmental sanitation
192
Medication
Date Drugname Dos Route Action Side effects Nurses responsibility
193
Inj.Theophyl 200g IV/TID Adirect bronchial muscle Cardiacarrithmias, -assess the patients vital signs
ine m relaxant.&relaxessmooth neurotoxicity, seizure,
-check the o2 saturation
muscle in pulmonary blood anorexia,nausea,tremorshypers
vessels ensitivity, hyperglycemia. -watch for reaction
IV/BID A synthetic analogue of -check the vital signs

Inj. 4mg naturallyoccurring
Growth retardation, -Watch for any complication
dexamethaxo glucocorticoid. Action is
osteoporosis, peptic ulcer,
ne primarilyantiinflammatory with -close monitoring of the
glaucoma, increased appetite,
very little sodium retain patient.
obesity
property.
-none reported, other:
H2 receptor antagonist, blokes
headache, dizziness, -it should be given in empty
the histamine h2
rarely,hepatitis,confusion,hype stomach
50m receptors,&prevents
Inj.Rantac IV/BID rsensitivity
g histaminemediate gastric acid Watch for any allergic
secretion reaction
194
EVALUATION OF THE APPLICATION OF SELF CARE DEFICIT THEORY
The theory of self-care deficit when applied could identify the self care requisites of
Mrs.Lekshmamma from various aspects. This was helpful to provide care in a comprehensive manner.
Patient was very cooperative. The application of this theory revealed how well the supportive and
educative and partly compensatory system could be used for solving the problems in a patient with
Fracture.
HEALTH EDUCATION
DATE TOPIC HEALTH EDUCATION
COMPONENTS
NUTRITION
 Advised the patient to take high calorie diet.
 Advised to take small frequent diet.
 Advised to take plenty of oral fluid.
 Advised to take food rich in vitamin ‘c’ to promote healing.
 Advised the family member to increase the palatability of
the food.
 Advised to take high fiber diet.
 Advised the family members to feed the patient according
to his comfort.
 Advised the pt to avoid cold foods.
 Advised the pt about treatment and its continuation,

 Advised about timings of medicine intake.
TREATMENT  Advised to take full course of medicine.
 Advised the importance of medicine intake and harms if
discontinued.
 Explained about the side effects of the medicine and the
remedies for that.
 Advised to have plenty of oral fluids with the medicine to
prevent constipation and side effects.
 Advised to avoid dust and allergens.
 Teached about the use of inhalers.
 Advised to take nebulisation in case of dyspnea.
 Advised the patient to maintain good personal hygiene.

 Advised the patient to take daily bath and wear clean cloth.
 Advised to keep the Niles short, and keep the ears clean.
 Advised the family members to maintain good hygiene
during food preparation & serving.
PERSONAL  Advised the pt about the importance of personal hygiene
HYGIENE and how it influence on health.
195
EXERCISE  Advised the patient to do deep breathing and coughing
exercise.
 Advised the patient to do postural drainage exercises.
 Advised the pt to avoid vigorous exercises.
 Advised the patient to avoid vigorous coughing .
 Advised about the importance deep breathing and coughing
exercises.
 Advised, not to lift heavy objects .
 Advised to avoid stress.
 Advised the pt about treatment and follow up care.

 Advised to take treatment continuously.
FOLLOW UP  Advised to come for follow-up checkups.
 Advised to seek immediate medical attention in case of any
problem.
 Advised to inform to the doctor about the problems.
 Advised to keep all the records of health for further
reference.
Prognosis
Patient is recovering from dyspnea, she is able to take care herself and carrying all her daily
activities by herself. Taking medicines in time.. No breathing difficulties. Food and fluid intake is
good, no dehydration. And the patient is ready to go home
Summary
196
Ms. Lekshmamma got admitted on 16/05/2022 in krishnahospital with the complaints of
cough,chest pain, dyspnea, trachy cardia, wheezing, since 6 days and diagnosed as pleural effusion.
As part of my clinical posting I have posted in female medical ward and observed the patient.
BIBLIOGRAPHY:
1. Merck Manual Home Edition

2. http://content.nejm.org/cgi/content/full/360/10/1002 Asthma, Christopher H. Fanta, N Engl J
Med, 360:123-124, March 5, 2009
3. ^ AAAAI article on avoiding respiratory symptoms symptoms
4. ^ George Schiffman, MD, FCCP (12/18/2009). "Chronic Obstructive Pulmonary Disease /
COPD". MedicineNet/WebMD.
http://www.medicinenet.com/chronic_obstructive_pulmonary_disease_copd/article.htm.
Retrieved 27 January 2010.
5. ^ http://www.nhlbi.nih.gov/guidelines/pleural effusion /03_sec2_def.pdf Retrieved March
197
CASE STUDY ON SPINAL CORD

INJURY

DATE OF SUBMISSION-
198
CASE STUDY ON SCI
Introduction:
Mr.Imran got admitted in krishna hospital with SCI, he met with an accident at Kanpur and
admitted to emergency ward, and he was complaint of dyspnoea, cough, not able to walk, acute pain
in the neck and stiffness of neck. I have posted in emergency ward and observed the patient,
Mr.Imran was suffering with severe injuries at the back and small injuries to other parts of the
body.physician examined him thoroughly and diagnosed him as spinal cord injury.
Patient profile
NAME : Mr.Irshan
AGE/SEX : 36years/ male
HOSP NO : 886637
BED NO :7
DATE OF ADDMISSION : 15.4.2022
EDUCATION ; PUC
MARITAL STATUS ;married
RELIGION : muslim
WARD :Male medical ward, (67 th&68th)
ADDRESS :kanpur
DIAGNOSIS : SPINAL CORD INJURY
SOURCE OF INFORMATION : patient, record, relatives.
APPLICATION OF OREM'S SELF-CARE DEFICIT THEORY IN NURSING PRACTICE
OBJECTIVES
 To assess the patient condition by the various methods explained by the nursing theory
 to identify the problems of the patient and to select a theory for the application according to
the need of the patient
 To demonstrate an effective communication and interaction with the patient.
 to apply the theory to solve the identified problems of the patient
 To evaluate the extent to which the process was fruitful.
199
Areas Patient details
 Name  Mrs. Irshan

 Age  36 years
 Sex  male
 Education  puc
 Occupation  Business
 Marital status  Married
 Religion  Muslim
 Diagnosis  Spinal Cord injury.
 Theory applied  Orem’s theory of self care deficit,
myra Enstrin four conservation
model. So I plan to give care to this
patient in Myra Enstrin Levein
model.
DATA COLLECTION ACCORDING TO OREM’S THEORY OF SELF CARE DEFICIT
BASIC CONDITIONING FACTORS
Age 36 yrs
Gender Male
Health state Disability due to health condition, therapeutic self care demand
Development state
Sociocultural orientation PUC, Indian, Hindu
Health care system Institutional health care
Family system Married, Wife is house wife, one child
Patterns of living At home with children
Environment Rural area, items for ADL not in easy reach, no special precautions to
prevent infections
Resources wife, And relatives
2. UNIVERSAL SELF-CARE REQUISITES:
200
Air
Water Fluid intake is sufficient

Turgor normal for the age
Food Hb -12.4gm%, BMI = 14.Food intake is not adequate or the diet is not
nutritious.
Elimination Voids and eliminates bowel with difficulty.
Activity/ rest Frequent rest is required due to inability to move

Activity level has come down.
Social interaction Communicates well with neighbors and calls the children by phone
Need for medical care is communicated to the husband.
Prevention of hazards Need instruction prevention of infection. Need instruction on

improvement of nutritional status.
Promotion of normalcy Has good relation with others.
3. DEVELOPMENTAL SELF-CARE REQUISITES:
Maintenance of Not able to walk alone,

developmental environment
Prevention/management of the Feels that the problems are due to her own behaviours and discusses
conditions threatening the normal the problems with wife.
development
4. HEALTH DEVIATION SELF CARE REQUISITES
Adherence to medical regimen Reports the problems to the physician when in the hospital. Cooperates
with the medication, Not much aware about the use and side effects of
medicines
Awareness of potential problem Not aware about the actual disease process.
associated with the regimen No compliant with the diet and prevention of hazards. Not aware about
the side effects of the medications
201
Modification of self image to Has adapted to limitation in mobility.
incorporates changes in health The adoption of new ways for activities leads to deformities and
status progression of the disease.
Adjustment of lifestyle to Adjusted with the problems.

accommodate changes in the
health status and medical
regimen.
Chief complaints;
Not able to walk, not able to do self care activities, pain all over the body.
Present medical/surgical history:
Mr.Irshan got admitted in hospital with SCI Not able to walk, not able to do self care
activities, dyspnoea, severe neck pain. He got an accident. There was no history of past medical
illness .no past surgical history.
Personal history:
Mr. Irshan looks thin in body build. He is a garment worker. He looks anxious; he is having
the habit of smoking 1 pack per day. He does not have the habit of alcoholism, chewing betel leaves.
His hobby is playing cricket. He is not taking food regularly since 2 month due to job tension. He use
to take from fast food contents with high spicy. His bladder pattern is normal he is not sleeping
properly due to duty schedule. He sleeps 5-6 hours / day. He believes allopathic treatment.
Family history:
Relationshi
p with
Name of the family Age(yea Sex patient Education Occupation Marital Health
members rs) status status
Mr.Irshan 36 Male Client PUC Garment Married Spinal cord

injury
Mrs.Laila
Healthy
202
30 Femal Wife PUC House wife Healthy
e
Married
male
Mast. Shahul 6 Son UKG -
Psycho-social History;
Economic History; Mr.Irshan is a breadwinner of the family. He earns Rs.4500/month. His

occupation is garment worker. They live in a rented house. They uses toilet for defecation. Water
supply is from boring well. He has electricity supply in his house.
Mother tongue-Kannada
Language Known; Kannada, English
Cultural group; Friends.
Mood; Social.
Nutritional history;
He is non-vegetarian . He takes food, whenever he wants. He is maintaining good nutritional

status and no history of allergy.
Elimination pattern;
Bowel- he has irregular bowel movement, constipation present.
Bladder- urinary retention present.
Environmental history;
He lives in a concrete house, which has one room and a kitchen. They use toilet for
defecation. Water supply is obtained from boring well. They have electricity in their house and have
closed drainage system.
PHYSICAL EXAMINATION;
General observation:
Constitution ; Moderate
Stature ; Normal
State of Nutrition ; Moderate
Personal appearance ; Anxious
Posture ; not able to stand
Emotional stage ; Anxious.
203
Cooperativeness ;Cooperative.
Height : 150cm
Weight : 65kg
Vital signs;
Temperature : 98.6’F
Pulse : 80 b/mints
Respiratory rate : 22 breath/ mints
BP : 120/80 mm hg
Skin;
Presence of rashes : no rashes, no abscess
Color of the skin : Black
Texture of the skin : normal
Nails : normal capillary filling present
Pruritis : no pruritis
Edema ; absent
Head;
Skull ; No abnormality noted
Hair ; Black hair, hair distribution normal.
Movements of the head ; Range of movement limited because he complaints
severe neck pain.
Forehead ; No scars or lesions.
Face ; Anxious
Eye:
Vision ; normal
204
Expression ; anxious and fear
Eye brows : Equal
Eye lids ; no lesion
Lacrimation ; clear fluid.
Eye set ; is normal, symmetry
Use of glasses : no
Use of contact lenses : no
Pupils : react to light
Conjunctiva : no conjunctivitis
Sclera : no discoloration, white.
Ear:
Appearance of ear : normal
Use of hearing aids : not using any aids
Limitation to hearing : no restriction for hearing
External ear : no discharges.
Nose;
Appearance ; no septal deviation.
Discharge ; no
Patency ; both nostrils are patent
Sense of smell ; good
Ear:
Appearance of ear : normal
Use of hearing aids : not using any ear aids
Limitation to hearing : no restriction for hearing
External ear : no discharges
205
Mouth and throat;
Lips ; Dry.
Tongue ; Normal
Teeth ; Intact in upper and lower jaw
Gums ; Pink and moist.
Buccal mucosa ; no lesion
Tonsil ; not enlarged
Taste ; normal
Speech:
Ability to talk : no difficulty for speaking
Level of orientation : he is oriented with time, place, and person.
Language : Kannada, Tamil.
Content of thought : relevant
Neck;
General appearance ;pain present.
Trachea ; normal in position.
Lymph node ; No enlargement.
Thyroid gland ; Feel smooth and firm.
Cyst and tumor ; Absence
Respiratory system:
Inspection : chest is symmetry in shape, no abnormal

configuration, cough and dyspneoa present.
Palpation : absence of enlargement of lung present.
Auscultation : normal breath sound, no rhonchi.
Percussion : normal resonance in both lungs.
Circulatory system:
Clubbing : absent, no cyanosis, normal capillary filling

present
206
Heart sounds : S1, S2 normal, no gallop. No murmur
Gastrointestinal system:
Inspection : no abdomen distention, no rashes,
Palpation ; No organomegally
Percussion ; No fluid filled spaces.
Auscultation ; peristalsisabsent, patient complaints of constipation.
Back;
Spine and curvature ; injury at L1,L2, abnormalities is noted.
Movements ; range of movements is limited.
Tenderness ; tenderness noted at L1,L2.region.
Upper and lower Extremities;
Normal movement in upper extrimities, but in lower, paraplegia present.
No deformities.
Genitalia;
Catheter present. No sign of infection.
Central nervous system:
GCS : 15/15
Cerebral function : normal, he is conscious, oriented with place

person
Cerebellar function : normal, motor function impaired
Reflexes :impaired
Cranial nerves : normal
Motor function : impaired
Sensory function : lower extrimities sensation impaired.
Investigation:
CT- fracture in L1L2 , Injury,MRI
Date Type Patient value Normal valve Remarks
29.08.09 Sodium 138meq/dl 135-145meq/dl Normal
Potassium 4.9meq/dl 3.5-5meq/dl Normal
207
Chloride 103meq/dl 97-107meq/dl Normal
ESR 20meq/dl <30mm/hr Normal
Urea 12mg/dl 10-20mg/dl Normal
Creatinine 0.7mg/dl 0.5-1.5mg/dl Normal
RBS 92mg/dl 80-130mg/dl Normal
HB 13.8GM 13-18mg Normal
BT 1’30 1.5-9.5 min Normal
CT 4’45 4-8min normal
Anatomy of the Spinal Cord
Gross Anatomy
The spinal cord is part of the central nervous system (CNS), which
extends caudally and is protected by the bony structures of the vertebral
column. It is covered by the three membranes of the CNS, i.e., the dura
mater, arachnoid and the innermost pia mater. In most adult mammals it
occupies only the upper two-thirds of the vertebral canal as the growth of
the bones composing the vertebral column is proportionally more rapid
than that of the spinal cord. According to its rostrocaudal location the
spinal cord can be divided into four parts: cervical, thoracic, lumbar and
sacral, two of these are marked by an upper (cervical) and a lower (lumbar) enlargement. Alongside
208
the median sagittal plane the anterior and the posterior median fissures divide the cord into two
symmetrical portions, which are connected by the transverse anterior and posterior commissures. On
either side of the cord the anterior lateral and posterior lateral fissures represent the points where the
ventral and dorsal rootlets (later roots) emerge from the cord to form the spinal nerves. Unlike the
brain, in the spinal cord the grey matter is surrounded by the white matter at its circumference. The
white matter is conventionally divided into the dorsal, dorsolateral, lateral, ventral and ventrolateral
funiculi. Each half of the spinal grey matter is crescent-shaped, although the arrangement of the grey
matter and its proportion to the white matter vary at different rostrocaudal levels. The grey matter can
be divided into the dorsal horn, intermediate grey, ventral horn and a centromedial region surrounding
the central canal (central grey matter) The white matter gradually ceases towards the end of the spinal
cord and the grey matter blends into a single mass (conus terminalis) where parallel spinal roots form
the so-called cauda equina
The dorsal roots leave the dorsal horn and dorsolateral white matter, coalesce into two bundles and
enter the dorsal root ganglion (DRG) in the intervertebral foramen. Immediately distal to the ganglion,
the dorsal and ventral roots unite and form a trunk, the spinal nerve. The spinal nerves, which are now
outside the vertebral column, converge and form plexuses and from these emerge the peripheral
nerves. The number of spinal nerves and spinal segments largely corresponds to the number of
vertebrae with a few exceptions: there are eight cervical, 12 thoracic, five lumbar, five sacral and one
coccygeal spinal segments in humans. The number of these segments varies slightly in different
species.
Fine Organization of the Spinal Cord
The fine structure of the mammalian spinal cord was studied mainly on rodents, cats and primates.
The most important results were those of Rexed and Scheibel and Scheibel on the cat spinal cord.
Although the overall organization of the human spinal cord is similar to that of other mammals, there
are some differences both in the cyto- and myeloarchitecture. In the past few years several studies
made an effort to describe the structure of the human spinal cord and gave a detailed account of its
features. Here we give a short description of the human spinal cord and where necessary refer to the
important differences between human and other mammalian species (monkey, cat, rat and mice).
Cyto- and Dendroarchitecture
The laminar distribution of spinal neurons has been widely accepted. Its main advantage is its simple
and comprehensive scheme of spinal cord organization and physiological properties can also be
correlated to this structural arrangement.
a) Cross section of the lumbar portion of the rat spinal cord showing the layered arrangement of the
hemicord. The white matter is separated from the grey matter by a broken line. LSN= lateral spinal
nucleus which takes place outside the grey matter in the dorsolateral funiculus. Cresyl violet stain.
Scale bar = 50 μm. b) Higher magnification photograph shows a group of lumbar motoneurons. Note
the rough and intensely stained Nissl substance which actually fills the cytoplasm. Cresyl violet stain.
Scale bar = 20 μm.
Cytoarchitectural laminae are characterized by the density and topography of spinal neurons in the
grey matter and can usually be identified on thick cross sections . In addition, each lamina has its own
characteristics which are particularly distinct at the level of cervical and lumbar enlargements. Most
of the information about dendritic territories has been obtained by using Golgi impregnation methods.
In addition to the laminar arrangement in the coronal plain, in the ventral horn the cervical and lumbar
motoneurons form rostrocaudal motor columns.
209
Lamina I is the dorsalmost lamina which covers the tip of the dorsal horn. It has a loosely packed
neuropil and a low neuronal density with neurons of variable size and distribution. The most typical
neuron is the so-called Waldeyer cell: large, fusiform neuron with disk-shaped dendritic domain.
However, in cat and rat also small and medium-sized pyramidal neurons were identified in this lamina
and characterised as fusiform, pyramidal and multipolar cells.
Lamina II appears as a darkly stained band in Nissl-stained sections due to its high neuronal density
(substantia gelatinosa, Rolando, 1824). In cat and rodents the inner and outer zones can be
distinguished although in humans there is not a clear separation between these zones. The neuronal
population consists of small fusiform neurons. There are two main cell types which form the majority
of the population of lamina II: the islet cells with a rostrocaudal axis and the stalked cells with a
dorsoventral dendritic tree. Other types of neurons have been described such as arboreal, curly,
border, vertical, filamentous and stellate cells. It is possible, however, that some of these latter
neurons correspond to each other or to the two main cell types. Islet cells contain GABA therefore
they are considered as the inhibitory cells of this lamina.
Lamina III can be easily distinguished from lamina II by its lower neuronal density and by the
presence of intermediate size neurons. This layer has a mixed population of antenna-like and radial
neurons. These cells have a simpler dendritic morphology than those in layer II. Many of the above
cells contain inhibitory neurotransmitters: GABA or glycine.
Lamina IV in man and cat has a variety of antenna-like cells and the so-called transverse cell. Most of
their dendrites originate dorsally on the cell body and spread towards lamina II and III. In animals, the
axons of lamina IV neurons mainly enter the spinocervical tract, which is vestigial in humans. Most
probably human lamina IV neurons project to the spinothalamic tract. Laterally from this lamina there
is a small group of neurons embedded in the lateral funiculus: the lateral spinal nucleus. Its neurons
project to the midbrain and brainstem and send processes to lamina IV itself.
Lamina V-VI have a similar cyto- and dendroarchitecture. The medial part contains fusiform and
triangular neurons. The lateral part is not clearly separated from the dorsolateral funiculus. This part
corresponds to the reticular formation in the brainstem and consists of medium-sized multipolar
neurons.
Lamina VII occupies the intermediate zone of the grey matter and is formed by an homogeneous
population of medium-sized multipolar neurons. In the appropriate segments it contains some well-
defined nuclei, such as the intermediolateral nucleus (T1-L1; medially) and the dorsal nucleus of
Clarke (T1-L2; laterally). The intermediolateral nucleus plays a role in the autonomic sensory and
motor functions and the axons of neurons from the dorsal nucleus of Clarke form the ascending fibres
of the dorsal spinocerebellar tract.
Lamina VIII has, unlike laminae I-VII a dorsoventral extension. It contains a variety of neurons with
dorsoventrally polarized dendritic tree. The largest multipolar neurons can be distinguished from
motoneurons only by their finer Nissl bodies by using conventional morphological techniques.
The ventromedial motoneurons (IX-vm) form vertical and longitudinal dendritic branches (not
hown), motoneurons in the ventrolateral (IX-vl) and central (IX-c) columns tend to form dendritic
bundles in the longitudinal and transverse planes. Motoneurons in these columns have long
overlapping areas. On the contrary, dorsolateral motoneurons (IX-dl) have no such a dendritic bundle
formation and their branches mostly branch out in the transverse plane. WM: white matter; DF=
dorsal funiculus; DH= dorsal horn; CC= central canal.
Lamina IX is made up of groups of cells that form motor nuclei. Motoneurons have a unique position
in this lamina, being the only spinal cord neuron which has its axon almost entirely in the peripheral
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nervous system. The α-motoneurons have the largest somata in the cord (50 x 70 μm) whilst the γ-
motoneurons are smaller. Motoneurons can be easily recognized by the abundance of Nissl bodies in
their cytoplasm and their multipolar shape . Their dendrites extend for long distances, dorsally as far
as lamina VI. Small neurons at the medial border of the motor nucleus are identified as the short-
axoned inhibitory interneurons, the Renshaw cells. Although Rexed's classification did not
differentiate between motoneuron groups in lamina IX, these neurons can be divided into four
separate columns in the human cord: the ventromedial, ventrolateral, dorsolateral and central columns.
Motoneurons projecting to the axial muscles are found in the ventromedial column, those innervating
proximal musculature of the limbs occupy medial and ventral position while neurons innervating
distal limb muscles are located in dorsal and lateral positions. In all but one (dorsolateral) motoneuron
column the dendritic polarization is longitudinal and dendritic trees overlap for a long distance. Such
a dendritic organization favours synchronization and synergy for axial, proximal and calf muscles. , In
contrast to these columns, motoneurons in the dorsolateral column have radially oriented dendritic
trees without much overlap of their dendrites). This dendritic arrangement favours precise contacts
with segmental afferents and may contribute to a more precise control of movements of distal
muscles.
Lamina X
This lamina corresponds to the substantia grisea centralis, the grey matter around the central canal.
Two cell types can be recognized: (1) Bipolar cells with fan-shaped dendritic tree (dorsal portion of
lamina X) and (2) bipolar cells with poorly ramified longitudinal dendrites (ventral portion).
Interneurons in the Spinal Cord
Interneurons are probably the most important modulating cell types in the spinal cord. The importance
of spinal interneuronal networks has only recently been acknowledged although the flexibility of these
networks became apparent as early as in the 1950s.
Initially only electrophysiological approaches were used, later the precise location, morphology and
immunohistochemical features helped to distinguish special interneuronal classes.
The very first morphologically and physiologically identified interneurons were the Renshaw cells
and Ia interneurons (Renshaw cells project on motoneurons and thus establish the recurrent inhibition,
whereas Ia interneurons are activated by Ia afferents of agonist muscles and inhibit antagonistic
motoneurons). Renshaw cells, Ia and Ib inhibitory interneurons, interneurons in disynaptic and
polysynaptic reflex pathways and interneurons mediating descending commands were the “classical
interneurons” and their function was thoroughly analyzed in a series of studies. Recently a number of
new interneurons modulating special functions were described, e.g.,interneurons involved in the
clasp-knife reflex, bladder function, control of respiration and last-order premotor interneurons, etc. It
is expected that the number of these highly specialized interneurons will further increase with time
(for recent reviews and references see Jankowska 2001, Edgley 2001.
Most interneuron types have also been characterised by their neurochemical features. Renshaw cells,
for example, express not only glycine, their characteristic inhibitory neurotransmitter, but they
reportedly synthesize calcium binding proteins calbindin-D28k and parvalbumin.
This short description of spinal interneurons suggests that the fine control of spinal functions mostly
depends on the integrity of spinal interneuronal networks. It should be noted that interneurons named
after their characteristic input (Ia, Renshaw, etc) receive a variety of multisensory inputs of different
origins and these inputs together determine what the interneuron actually will do.
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Glial Cells of the Spinal Cord
The central nervous system contains numerous nonneuronal, nonexcitable cells. The largest class of
these cells is neuroglia or “nerve glue” a name taken from the Greek. The main glial cell types are
astrocyte, oligodendrocyte, ependyma and microglia. Astrocytes together with oligodendrocytes and
ependyma develop from the neuroectoderm whilst microglia is considered to be derived from blood
monocytes.
a) Fluorescent photograph of oligodendrocytes present in the spinal cord visualized with carbonic
anhydrase II immunostaining. Scale bar = 50 μm. b) High magnification photograph shows two
oligodendrocytes stained by using carbonic anhydrase enzyme histochemistry. Note the long, parallel
branching processes. Scale bar = 10 μm. c) Distribution of myelinated tracts in the dorsal part of the
spinal cord. Myelin sheaths are immunostained for myelin basic protein (MBP), a major protein
present in normal myelin. DF: dorsal funiculus. Scale bar = 50 μm. d) Ramified microglial cells
(arrows) in the grey matter of intact spinal cord. Note the faint staining and fine ramifications. Scale
bar = 20 μm. Immunostaining to complement receptor type 3 (OX-42). e) Astrocytes in the intact
spinal cord visualized by immunostaining to glial fibrillary acidic protein (GFAP). Scale bar = 20 μm.
f ) Reactive astroglial cells in an injured spinal cord (seven days after injury). Note the increased
GFAP content and the thicker processes of the reactive cells (arrows). Scale bar = 20 μm. g) Low
magnification photograph of the ventral part of spinal cord. The Schwann cells are immunostained
with the Rat-401 antibody which is specific to Schwann cells in the adult CNS. Note that no
immunostaining can be seen in the spinal cord (sc) only in the attached ventral roots (vr). Scale bar =
20 μm.
Astrocytes are large cells with a stellate morphology. These very numerous fine processes radiate in
all directions and contain a specific form of cytoskeletal intermediate filament, the glial fibrillary
acidic protein .Astrocytes come in two main forms: fibrous astrocytes are primarily found in white
matter and protoplasmic astrocytes in the grey matter. The latter subtype has long thin processes
containing much less GFAP than the fibrous astrocytes, but can be characterized by the presence of
glutamine synthase. Although these types of astrocytes differ anatomically, the developmental,
functional and biochemical differences between them are not fully understood.
During embryonic development astrocytes guide the migration of neurons while in the mature CNS
they form a structural scaffolding for other cells. Astrocytic foot processes form perivascular cuffs
around CNS capillaries thus contributing to the formation of blood-brain barrier and similar processes
protect the CNS from external influences at the pial surface (glial limitans externa). Apart form many
other metabolic functions astrocytes are thought to transport ions and fluid from the extracellular
space to vessels and they can release a number of factors which promote axonal growth. Astrocytes
are able react to many deleterious effect to the CNS. Morphologically this process is characterized by
the appearance and proliferation of so-called reactive astrocytes . Although this astrocytic healing
process is often called glial repair the proliferation of astrocytes can lead to the formation of glial scar
which is considered as the impediment of axonal growth and regeneration in the CNS.
Oligodendrocytes produce myelin within the CNS. One oligodendrocyte is able to myelinate several
adjacent axons . The myelin is formed by these cells wrapping spiral layers of cell membrane around
the axon. The inner surfaces of the cell membranes fuse and form the so-called major dense line. The
myelin contains special lipids and proteins, for example the glycolipid galactocerebroside and the
myelin basic protein . The myelin in the CNS is the target of several serious diseases such as multiple
sclerosis and leukodystrophies. Outside the CNS myelin is formed by Schwann cells which myelinate
only a single axon. Schwann cells normally are not present in the CNS and in the case of the spinal
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cord and brainstem there is a distinct junction between the PNS- and CNS-type myelin called
transitional zone and characterized by a complex glial structure.
The CNS has its unique set of immune cells the brain macrophages. The most important and
characteristic CNS macrophages are the microglial cells. The phenotype of microglia suggests that
they are dendritic antigen-presenting cells expressing class II (I-A) major histocompatibility antigens.
Under pathological circumstances microglial cells become activated, increase in size and number and
are usually supplemented by blood-born monocytes.
Connections of the Spinal Cord with Other Parts of the CNS
The spinal cord has its own intrinsic pathways which are called propriospinal connections. The rest of
the fibre tract system connects the spinal cord to other parts of the CNS and are described here as
descending and ascending pathways. There are, of course, marked species differences, the most well
known are those of the corticospinal system.
Intrinsic Pathways
These tracts not only establish connections between different neuronal groups and segments of the
spinal cord but also act as relays between descending pathways and intrinsic spinal neurons.
Accordingly, well defined ascending and descending white matter bundles are committed to
propriospinal functions.
The Lissauer's tract tract can be localized between the entering dorsal roots and lamina I. It is mainly
composed of unmyelinated descending and ascending fibres and both types extend a few segments.
The majority of these fibres originate from the dorsal roots whilst the rest is intrinsic in nature
terminating on marginal and substantia gelatinosa cells. The comma tract is a comma-shaped thin
fibre bundle in between the fasciculi cuneatus and gracilis. It contains descending fibres from the
cervical dorsal roots. The septomarginal tract is situated in the dorsal white matter and its position
varies at the level of different segments. It consists of descending dorsal root and intrinsic fibres. The
cornucommissural tract can be found along the dorsal commissure and contains ipsilaterally running
descending and ascending propriospinal fibres. The anterior and lateral ground bundles are present
throughout the spinal cord being most developed at the levels of enlargements. They contain both
ascending and descending long and short fibres. They originate in the ipsilateral hemicord and
terminate throughout the grey matter.
Ascending Pathways
The ascending pathways are formed by the central axons of dorsal root ganglion cells entering the
spinal cord via the dorsal roots. They either enter an ascending fibre tract (dorsal column pathways) or
terminate in the spinal grey matter. About two-third of these fibres are fine, unmyelinated, slowly-
conducting C fibres. The myelinated fibre components can be classified as fast-conducting, large,
myelinated Aβ, and slower-conducting, thinly myelinated Aδ fibres. Primary sensory fibres either
terminate in the dorsal column nuclei of the medulla or in the superficial dorsal horn according to a
segregated pattern. Thin fibres related to temperature and pain terminate in laminae I and II, whereas
coarse fibres terminate in deeper layers (laminae III-V) and in the ventral horn as well (proprioceptive
afferents). Furthermore, primary afferents coming from cutaneous receptors terminate almost
exclusively in lamina II in rat and cat whilst visceral and muscle afferent terminals are mainly
confined to laminae I and V.
The dorsal column pathways include the medially located fasciculus gracilis (Goll) and the laterally
situated fasciculus cuneatus (Burdach). The fasciculus gracilis contains dorsal root afferents from the
lower limbs and lower part of the body, the fasciculus cuneatus from the upper limb and upper part of
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the trunk. The fibres synapse on neurones of the nucleus gracilis and nucleus cuneatus, respectively.
These pathways play role in discriminative sensory tasks, such as two-point discrimination, detection
of speed and direction of movements and judging of cutaneous pressure. The spinothalamic tract
originates from neurons in laminae I,V,VII and VIII,however the distribution of spinothalamic
neurons shows significant species differences. In humans the axons cross to the ventrolateral column
and terminate in the ventral posterolateral and in the central lateral nuclei of the thalamus. In other
mammals they terminate mainly in the posterior thalamic nuclear complex. Functionally, this tract
conveys the accurate localization of pain and thermal stimuli. Ventrolateral cordotomies presented
evidence that other tracts may also transmit pain stimuli. The spinoreticular tract originates from cells
situated bilaterally throughout the spinal grey matter. The ascending fibres in the ventral and lateral
funiculi terminate in several nuclei of the reticular formation. Many spinothalamic ascending fibres
also give collaterals to reticular nuclei. This pathway is responsible for carrying a variety of sensory
information. The spinocervicothalamic tract uses an intermediate nucleus in the spinal cord, the lateral
cervical nucleus, which is consistent in lower mammals but often absent in human spinal cords.
Afferent fibres to this nucleus arise from the ipsilateral lamina IV in all cord segments. Neurons from
the lateral cervical nucleus project to the contralateral thalamus via the medial lemniscus. This system
is involved in tactile conditioned reflexes, tactile and proprioceptive placing and size discrimination.
The spinocerebellar tracts (dorsal and ventral) carry information primarily arising from the lower
extremities. The dorsal spinocerebellar tract is formed by axons of the ipsilateral nucleus dorsalis of
Clarke (present in Th1-L2 segments in humans) and projects to the vermis and the paravermal regions
of the cerebellum. It conveys information from muscle spindles, Golgi tendon organs, joints and
mechanoreceptors of the lower extremities. Axons of cells situated in laminae V and VII in the
lumbosacral spinal cord form the ventral spinocerebellar tract. It projects to the vermis and
paravermal region of the cerebellum and probably carries information about the interrelationship of
different muscle groups. Equivalent information from the upper extremities are conveyed by the
cuneocerebellar and the rostral spinocerebellar tracts of the spinal cord.
Descending Pathways
The corticospinal tract is most developed in higher primates and species differences are most
pronounced for this tract. The cells of origin are located in the motor cortex and their axons form the
pyramidal tract. In most mammals fibres from neurones in the postcentral gyrus also contribute to this
tract. In humans the bulk of the fibres cross in the lower medulla and form the lateral corticospinal
tract whereas uncrossed fibres remain in the ventral funiculus and then cross in the ventral
commissure. In some species the organization of this tract is different Functionally, the corticospinal
pathway exerts a fine and amplified motor control by influencing other descending pathways. Fibres
of the reticulospinal tracts originate from the dorsal and central parts of the medulla and the pontine
tegmentum. The terminal distribution of medial reticulospinal fibres is very dense in the ventral horn
of the enlargements while the lateral reticulospinal tract fibres terminate in laminae I and V. Fibres of
the vestibulospinal tract originate from the lateral and medial vestibular nuclei. Both lateral and
medial tract fibres terminate ipsilaterally in laminae VII and VII and form mono- or polysynaptic
inhibitory connections with motoneurons, especially with those of neck and back muscles. The
rubrospinal tract is well developed in lower mammals and less developed in humans. Its fibres
originate from the caudal magnocellular part of the red nucleus and project according to a somatotopic
pattern contralaterally to laminae V-VII. In cat there is a direct rubrospinal connection to
motoneurons. The tract exerts excitatory effects on flexor motoneurons and inhibits extensor
motoneurons. The tectospinal tract tract originates from the superior colliculus and terminates
contralaterally in the ventral horn of the upper cervical cord where its fibres establish multisynaptic
connections with motoneurons of neck muscles.
Apart from the major descending tract, there are many minor fibre bundles originating from the
interstitial nucleus of Cajal, solitary and retroambiguous nuclei, and the paraventricular nucleus of the
hypothalamus. Noradrenergic fibres descend from the locus coeruleus and the lateral pontine nuclei to
the grey matter and to the intermediolateral nucleus, respectively. Serotonergic projections arise from
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the raphe magnus and raphe pallidus and obscurus nuclei terminate either in laminae I and V (raphe
magnus fibres) or in the ventral horn (rest of the fibres).
Function of the Spinal Cord
The spinal cord is a highly organized and complex part of the central nervous system. Its complexity
is due to the role it plays in the 3 most important functions of the individual: sensation, autonomic and
motor control. If it was to simply report to the brain the information that it receives from the large
number and variety of afferent inputs and relay back to the motoneurons and preganglionic neurons
the outcome of processing performed by the supraspinal centres the situation would be more straight
forward. However, as is well established, this is not the case and the spinal cord has, in addition to
relaying information from the rest of the body to the brain and receiving efferent commands from
varied portions of the brain the ability to integrate and modify both afferent signals from the
periphery, and efferent signals from segmental afferents and supraspinal centres. Thus there is a
complicated network of neurons that normally operates in conjunction with the rest of the CNS to
allow perfect control of sensory, autonomic and motor functions. This complex circuitry is critically
dependent on its connections with the brain and it can not function appropriately when it is either
completely or even partially disconnected from it. It is rather regrettable, that we understand so little
of the potential of the complex intrinsic circuitry of the spinal cord that when it looses connection
with the brain we are unable to exploit its' potential function and restore deficits caused by spinal cord
lesions.
In spite of the fact that the physiology of the spinal cord has been intensively investigated for at least a
century it keeps revealing new surprising phenomena.
In this chapter only a brief account will be given of its main functions.
Sensory Processing
In an oversimplified manner it can be stated that the somatic afferent functions that are processed in
the spinal cord constitute the following: (a) pain and temperature, (b) touch, and (c) proprioception.
Different sense organs in the peripheral structures initiate these sensory modalities, but the processing
of them is usually carried out by a network of neurons in the spinal cord that are common to several of
these different modalities of sensation.
Pain and Temperature
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.
a) and b) illustrates schematically the types of sensory nerve endings in peripheral tissues innervated
by sensory nerves (peripheral processes). It also shows the central processes and their lamination in
the spinal cord and medulla. The insert on the left shows the location of the Clarke's nucleus in
relation to the ventral and dorsal spinocerebellar tract and dorsal columns. Modified from ref. Pansky
and Allen, 1980, Review of Neuroscience.
The peripheral receptors for various modalities of sensation are specialised sense organs that are
contacted by axons from dorsal root ganglion neurons. These neurons have a peripheral process and a
central branch that enters the spinal cord where they branch. These neurons that are directly linked
with the peripheral structures are called first order neurons, and their role in processing of sensory
information is largely determined by their branching pattern.
216
illustrates some of the sense
organs of the first order neurons that are involved in pain and temperature sensation and also shows
that the main target of the branches of the central portion of this first order neuron terminates and
synapses on neurons in the substantia gelatinosa. It is from this part of the dorsal horn where the
second order neurons give rise to their processes which convey the information to other parts of the
spinal cord and brain. However, there are ascending and descending branches of the second order
neurons that synapse on cells in different segments of the spinal cord and on more ventral
interneurons that are concerned with control of movement and integration of somatic afferent inputs
with those from other parts of the central nervous system.Thus these second order neurons play a
crucial role in the processing of sensory information within the spinal cord. Not only somatic afferent
fibres converge into the neurons in the substantia gelatinosa, but visceral sensation and pain also
converges onto this group of second order neurons. In addition there is a strong input from various
structures of the brain that impinge upon neurons in the substantia gelatinosa modify the input from
the periphery and in this way the outcome of sensation (for further reading see Brown 1991,
Schomburg 1990. It is partly because of this convergence of inputs to this part of the spinal cord that
sensation is not simply the result of particular peripheral inputs.
Touch and Tactile Discrimination
The sensation of light touch is initiated from specialized sense organs in the skin or connective tissue
or from free nerve endings in the dermis. The sense organs are contacted by axons from the cells of
dorsal root ganglia and the information reaches the spinal cord via the central branch of the neurons of
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the dorsal root ganglion cells. These central branches form long tracts which give off branches to
interneurons of the posterior horn in laminae VI and VII. The second order neurons within the spinal
cord that process information about touch are thus in lamina VI and VII.
The same structures that are involved in the sensation of touch are also contributing to more
sophisticated sensory functions such as two point discrimination, awareness of movement of body
parts, as well as the position of various body parts in relation to each other. However these functions
are also critically dependent on proprioception.
Proprioception
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Figure 5
a) and b) The sensory and motor innervation of the mammalian muscle

spindle is illustrated in a. This figure also shows the schematic
picture of the cross section of the spinal cord with the various inputs
to γ-motoneurons (left) and α-motoneurons (right). In b reciprocal
inhibition of antagonistic msucles during a monosynaptic stretch
reflex is shown. Modified from ref. Pansky and Allen, 1980, Review
of Neuroscience.
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b) The sense organs that convey this modality of sensation are located in muscles, tendons and
joints (Fig and 5
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). The structure of these is
rather complex and indicate their important function in conveying the initial signal. In the muscle
the annulospiral and flower spray endings of the spindles are monitoring muscle length and this
task is complicated by the fact that the spindles are themselves a group of muscle fibres
ensheathed in a connective tissue capsule and contacted by 2 types of sensory fibres. In addition
to their sensory innervation the muscle fibres within the spindle receive their own motor
innervation from small motoneurons and axons referred to as gamma efferents. Thus by relaxing
or contracting the muscle fibres within the spindle the message about the state of the muscle is
modified even before it reaches the spinal cord. In muscle tendons there are organs (Golgi
tendon organs) which monitor the stretch imposed upon the tendon, and the Pacinian corpuscules
within joints and close to bony structures monitor the pressure exerted upon these structures. The
axons of sensory nerves that carry the information from the spindles towards the spinal cord are
among the largest and fastest conducting nerves in the body. The central branch make up the
medial division of the dorsal root as it enters the spinal cord. The central branch splits after
entering the spinal cord and some of these enter the anterior horn where they synapse directly
onto motoneurons to initiate a monosynaptic reflex, or onto interneurons to exert via
interneurons more sophisticated control over locomotor activity. These monosynaptic
connections are rather unique in that there is a high degree of specificity and muscle spindle
afferents from a given muscle contact only motoneurons that innervate the muscle of the origin
of this afferent input. Other branches enter the posterior funiculus and ascend towards Clarke's
nucleus in the posterior grey horn. Some descending and ascending branches synapse on
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interneurons in laminae V, VI, and VII. Axons of these cells cross the mid line and ascend in the
ventral cerebrovascular tract to communicate with the cerebellar-bolivar system.
Thus the various parts of the sensory system inform the brain about the external and internal stimuli
impinging onto the extremities and trunk. However this information undergoes considerable
processing by the circuitry of the spinal cord and is continuously modified by it.
Motor Control
Reflexes
Our understanding of spinal cord physiology has until recently been dominated by observations of
Harrington (1910) and his colleagues that the structures of the spinal cord are able to produce
stereotyped responses to external stimuli. These responses were referred to as reflexes and carefully
defined and observed. The simplest of these reflexes is the mono-synaptic stretch reflex, elicited by
activation of the IA afferent fibers that originate from the muscle spindle, and when activated
produces contraction of the synonymous muscle. However even the study of this simple reflex
revealed a great degree of complexity in the spinal cord circuitry. The strength of muscle contraction
in response to the same stimulus was not always the same and was influenced by preceding activity of
the spinal cord. In order to explain some of the findings associated with the variability of reflex
activity it was necessary to consider events such as temporal and spatial summation of excitation
inputs, and inhibitory influences from other sources.Thus even the simplest “reflex” turned out to
display considerable variability. Nevertheless the information about the behaviour of the structures
that mediate the responses to various stimuli in the spinal cord obtained by the study of reflex activity
was of immense importance. It taught us that the observation of temporal and spatial summation of
excitation inputs is caused by the ability of neurons to add up excitation postsynaptic potentials
(Epson) and therefore when 2 inputs, each of which is too weak to produce a response on its own,
impinge upon a neuron simultaneously, or with a slight delay, they can produce a response since the
depolarization of the cell reaches a threshold level which fires off an action potential. These rules
apply even in the case of the simplest reflex response such as the stretch reflex, which is mono
synaptic and the integration is carried out by only one cell, the motoneuron. All other reflexes are poly
synaptic, and therefore each neuron involved in the response can contribute to the final outcome i.e.,
the motor response to a particular stimulus . The study of these relatively simple spinal reflexes
revealed other features of the system, i.e., that neurons are not only excited, but can be inhibited by
particular inputs. Such inhibition is either postsynaptic so that the membrane potential of the
postsynaptic neuron increases and thus the same excitation input fails to depolarize the neuron
sufficiently to initiate an action potential, or inhibition can be synaptic, by which the amount of
excitation transmitter released from the synaptic terminal is reduced.
Patterned Movements Organised by the Circuitry of the Spinal Cord
In addition to the mono synaptic stretch reflex the circuitry of the spinal cord can generate patterned
responses that involve movement of several joints. The best explored reflex of this type is the flexor,
or withdrawal reflex in response to various sensory stimuli, and in particular in response to pain.
During this reflex the extremity is withdrawn from the site of the stimulus. The flexor reflex is a
complex movement which involves a highly organized sequence of activation and inhibition of
motoneuron to particular muscles. It affects muscles of the contra lateral limb so that the animal is
supported during the time when the limb is involved in the flexor reflex and is lifted off the ground.
Another patterned response that can be organized by the spinal cord is stepping. In acutely spindled
animals Brown (1911) showed that the spinal cord could trigger rhythmic walking movements. These
movements are of interest, since they do not depend entirely on sensory inputs and are generated by
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neurons located in the spinal cord. The group of neurons responsible for the organization of this
movement has been referred to as central pattern generator (CPG).
Most of the information on spinal cord Cp Gs in mammals has been obtained on experimental animals
such as rats or cats. However, whether the spinal cord of primates and humans is able to produce the
same responses when disconnected from the brain is less well documented. So far the available
information suggests that the isolated spinal cord of primates or humans is unable to generate such
primitive stepping movements as those described for the cat. Nevertheless some spinal reflex
responses are preserved after complete spinal cord lesion in humans. These include the stretch reflex,
which is often exaggerated and the flexor reflex. However, these responses are not stereotyped and
change when they are elicited repetitively. Thus even the human spinal cord is able to generate
complex responses, which are influenced by repeated activity, by mechanisms that we do not
understand.
The localisation of supraspinal locomotor regions is well established in the sense that electrical
stimulation of such regions can elicit walking, or even galloping in decorticate cats suspended above a
treadmill belt. Stimulation of these areas in primates prepared in a similar manner as cats, also elicited
walking and trotting. However the monkeys walked on all 4 limbs. Thus like in cats the
mesencephalic locomotor centre was able to activate the locomotor function of the primate spinal
cord, but without the connection with this centre the stimuli that induced locomotor activity in the
spinal cat were unable to do so in the spinal monkey
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Figure 6
The scheme illustrates the various structures involved in the control of locomotor function.
Until now this section described the potential of the spinal cord to produce integrated responses
without depending on the influences from the brain. However it is important to emphasize that this
situation is rare and even after spinal cord injury in man the separation of the spinal cord from the
brain is rarely complete. It is therefore important to consider spinal cord function in relation to the
control systems that normally regulate its performance.
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summarizes the various
influences from the higher centres that may influence the performance of the spinal cord circuitry.
Since this book is concerned with the possibility that neuronal or glial transplants will either replace
damaged parts of the spinal cord, or encourage existing structure to regenerate or resume their
function it seems pertinent to mention observations that concern the importance of various descending
pathways for recovery of locomotor activity. It appears that in patients with spinal cord injuries the
preservation of the ventral funiculi is best correlated with recovery of gait, while patients with well
preserved sensation of touch and position, but severe damage to the anterior part of the cord have a
poor chance to regain the ability to walk. In monkeys trained to walk on a treadmill return of
locomotor performance after spinal cord injury was critically dependent on the preservation of at least
one ventrolateral funiculus. Retrograde labelling of the preserved funiculus showed that the axons in
the preserved funiculus originates in the vestibular, reticular and raphe nuclei. Thus it appears that
these structures are of critical importance for the control of the spinal cord central pattern generator.
In the context of the topic discussed in this book this finding is of utmost importance, for it indicates
that for successful restoration of motor function efforts should be made to reconnect particular
structures, rather then haphazardly investigate indiscriminate growth of axons that may not be able to
contribute to improvement of function.
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Autonomic Function
The figure illustrates the location of the sympathetic neurons in the spinal cord and the targets they
innervate. Modified from ref. Pansky and Allen, 1980, Review of Neuroscience.
There are important structures within the mammalian spinal cord that regulate various autonomic
functions of the body and can be severely affected when the spinal cord is disconnected from the
brain. Generally the autonomic nervous system is divided into sympathetic and parasympathetic
components. The cells that control these two separate divisions occupy a typical position within the
spinal cord of mammals. The figure shows that the preganglionic neurons of the sympathetic system
are localised in the thoracic and lumbar part of the spinal cord, while neurons that control the
parasympathetic ganglia originate in the sacral
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s
a) The location of the sympathetic and parasympathetic neurons in the lumbosacral cord, and the
targets they innervate is shown. Modified from ref. Pansky and Allen, 1980, Review of
Neuroscience. b) Illustrates a scheme that could explain the control of bladder function, where the
CNS can initiate the transition of the bladder from a storage to a voiding state.
These cells that regulate important autonomic functions are closely controlled and integrated by
segmental afferent inputs, and by supraspinal inputs. Following disruption of these the autonomic
control of functions such as bladder control, or control of defecation as well as sexual arousal can be
seriously altered and it is an important consideration that these bodily functions be restored. Much of
the information on the control mechanisms exerted by the spinal cord centres over these functions is
concerned with those involved in micturition. The central pathways controlling lower urinary tract
function are organized as simple on-off switch circuits summarized in
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. The main
control is concerned with the switch from the storage of urine mode to the micturition mode.
This switching is normally accomplished by supraspinal structures, but after spinal cord injury
involuntary reflex voiding can be achieved (for details see de Groat et al, 19936
Regarding other autonomic functions the information is less complete and beyond the scope of this
brief summary of spinal cord physiology.
Neurotransmitters and Receptors in the Spinal Cord
The communication between the neurons of the central and peripheral nervous system and between
neurons and their nonneuronal targets is established by using a variety of chemical messengers, the
neurotransmitters. There are other molecules, the so-called neuromodulators which coexist with the
neurotransmitters and probably regulate their function. All these molecules are different in their
chemical nature as they belong to the families of amino acids, monoamines, peptides, opiates etc. The
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mapping of neurotransmitters involves the histochemical localization of synthesizing and degradating
enzymes of the transmitter as well as recent methods, such as immune cytochemistry, receptor
autoradiography, in situ hybridization, the stimulated cobalt uptake method and topobiochemistry. All
these recent investigations led to the better understanding of spinal mechanisms of outstanding
importance, for example spinal motor functions and pain. However, it should be noted that
remarkably more information is available on the mechanisms of neurotransmission in the dorsal horn
and intermediate grey matter than in the ventral horn. This short overview is not intended to provide a
detailed account of neurotransmitters and receptors in the spinal cord. Therefore for more information
on these systems see recent reviews including those by Todd and Spike 1993, Coggeshall and Carlton
1997 and Budai 2000.
Acetylcholine
Cholinergic neurotransmission plays an outstanding role in the function of the spinal cord and
therefore has been extensively studied. Although acetylcholine (Ach) was the first neurotransmitter
discovered in the PNS its localization in the CNS is far not as simple as it was thought in the early
1960s. It is relatively easy to detect histochemically acetylcholinesterase, the degradative enzyme for
acetylcholine but it is present in both cholinergic and cholinoceptive neurons, the latter only receiving
cholinergic innervation. Cholinacetyltransferase, the enzyme synthesizing acetylcholine, is more
specific for cholinergic neurons. Histochemically detected acetylcholinesterase levels as well as
enzymatic levels of cholinacetyltransferase are highest in laminae I and III, motor columns and in
autonomic nuclei.70 Nicotinic acetylcholine receptors are preferentially found in dorsal horn laminae
III and IV. A significant number of dorsal horn muscarinic and nicotinic receptors are thought to be
located on the primary afferent terminals. Muscarinic acetylcholine receptors (M1 and M2) are most
abundant in laminae II and IX and this fact suggests the presence of cholinergic inputs on
motoneurons. Indeed, acetylcholinesterase- and cholinacetyltransferase-positive terminals were found
on motor nerve cells and on Renshaw cells.This important cholinergic input arises from recurrent
axon collaterals from adjacent motoneurons as well as supra- and propriospinal fibres. Renshaw cells
receive cholinergic afferents from motoneuron axon collaterals, though they possess nicotinic
cholinergic receptors (for review see refs.
In addition to the well-established roles of Ach in spinal motor performance, both muscarinic and
nicotinic receptors are thought to mediate antinociceptive effects.
Monoamines
The spinal cord receives an abundant monoaminergic innervation from the brainstem nuclei.
Noradrenergic fibres descend from the lateral tegmentum and locus coeruleus and subcoeruleus to the
dorsal and ventral horn. Serotonergic (5-HT) fibres innervate the dorsal horn (from nucl. raphe
magnus) and the intermediate grey matter and ventral horn (from nucl. raphe obscurus and pallidus),
whereas dopaminergic fibres from the A11 cell group of the diencephalon invade the dorsal horn (for
review see: Lindvall and Björklund 1983. 5-HT may be colocalized with substance P, CGRP,
enkephalins and somatostatin in the raphe nuclei and their terminals.
Seven distinct 5-HT receptor subtypes have been identified (5-HT 1-7), 3 of which (5-HT1-3) are
associated with dorsal horn somatosensory processing. The activation of 5-HT receptors produce
multiple physiological events as 5-HT receptors families either activate or inhibit second messenger
systems.
Dopamine D2 receptors are mainly found in dorsal horn laminae II-III. Accordingly, focal stimulation
of the A11 cell group results in selective suppression of nociceptive responses originating from
multireceptive rat spinal cord neurons.
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There is more noradrenalin than dopamine in the spinal cord. This abundance of noradrenergic
innervation is accompanied by a dense concentration of α 2-adrenergic receptors in the dorsal horn.The
clinical significance of noradrenergic neurotransmission is indicated by the finding that activation of
α2-adrenergic receptors in the dorsal horn induces analgesia in humans and experimental animals.
Amino Acids
Excitatory amino acids (EAAs), such as aspartate and glutamate are released by some interneurons
(aspartate), Ia afferents and corticospinal fibres (glutamate). EAAs induce their excitatory actions via
two broad categories of receptors: ionotropic and metabotropic glutamate receptors. Ionotropic
receptors directly regulate the opening of ion channels and three subtypes of have been distinguished:
NMDA, AMPA and kainic acid (KA) receptors. Metabotropic glutamate receptors are coupled to the
G-protein and their action increases the turnover of polyphosphoinositides and induces the release of
intracellular Ca++. EAA receptors have a relatively widespread distribution in the CNS, although some
distinguished cell types display high density of certain specific receptors. Glycinergic neurons are
mainly concentrated in the ventral horn: Renshaw cells and Ia interneurons are thought to use this
inhibitory neurotransmitter. Glycine receptors are either strychnine-sensitive or -insensitive ones. The
activated strychnine-insensitive receptor is colocalized with the NMDA receptor complex and it plays
a major role in the regulation of NMDA-mediated synaptic events. GABA (γ-amino butyric acid) is
abundant throughout the spinal cord and GABA- as well as its synthesizing enzyme, glutamic acid
decarboxylase-immunoreactive neurons are present in the ventral horn and lamina II.GABA A and
GABAB receptor subtypes have been localized on primary afferent terminals and therefore GABA is
thought to participate in the presynaptic modulation of nociceptive primary afferent inputs.
Neuropeptides
A wide variety of neuropeptides is present throughout the spinal cord. The list of peptides includes
somatostatin, substance P, enkephalins, calcitonin gene-related peptide (CGRP), neuropeptide Y,
oxytocin, opioid peptides, nociceptin, nocistation and some others. Most of the immunoreactivity is
due to fibres entering the dorsal horn of the spinal cord but also numerous various cell types contain
neuropeptides. The peptidergic immunoreactivity in dorsal horn fibres is only in part due to
descending fibres from brainstem neurons, whereas many somatostatin and CGRP reactive fibres
enter the dorsal horn via the dorsal root ganglia. The most intense immunoreactivity is always
confined to the dorsal horn laminae where they probably play an important role in modulation of
nociception. Functionally, CGRP expressed by motoneurons may have a trophic action on skeletal
muscle cholinergic receptors but its role is obscured by the finding that some, but not all motoneurons
contain this peptide. CGRP was found in most of the α-motoneurons innervating fast muscles while
less motoneurons supplying slow muscles contained CGRP. In contrast, γ-motoneurons were only
weakly stained for CGRP or totally devoid of CGRP labelling.
DISEASE CONDITION
INTRODUCTION:
The spinal cord is the largest nerve in the body, and it is comprised of the nerves which act as the
communication system for the body. The nerve fibers within the spinal cord carry messages to and
from the brain to other parts of the body. Thus, the spinal cord can be compared to a telephone cable
which connects the central office (brain) to the individual homes. Because of its important role in the
nervous system, the spinal cord is surrounded by protective bone segments, called the vertebral
column. The vertebral column is comprised of seven cervical vertebrae, twelve thoracic vertebrae, 5
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lumbar vertebrae and five sacral vertebrae. As the body grows, the vertebral column grows more in
length than the spinal cord, causing a discrepancy between the location of the spinal cord segments
and the vertebral column segments, particularly in the lower part of the spinal system. For this reason,
there is often a discrepancy between the level of vertebral fracture and the level of spinal cord injury.
DEFINITION:
The term spinal cord injury refers to any injury of the neural elements within the spinal canal. Spinal
cord injury can occur from either trauma or disease to the vertebral column or the spinal cord itself.
Most spinal cord injuries are the result of trauma to the vertebral column causing a fracture of the
bone, or tearing of the ligaments with displacement of the bony column producing a pinching of the
spinal cord. The majority of broken necks and broken backs, or vertebral fractures, do not cause any
spinal cord damage; however, in 10-14% of the cases where a vertebral trauma has occurred, the
damage is of such severity it results in damage to the spinal cord.
COMMON CAUSES:
The most common causes of spinal cord injuries in the United States are:
 Motor vehicle accidents. Auto and motorcycle accidents are the leading cause of spinal cord
injuries, accounting for more than 40 percent of new spinal cord injuries each year.
 Acts of violence. As many as 15 percent of spinal cord injuries result from violent
encounters, often involving gunshot and knife wounds, according to the National Institute of
Neurological Disorders and Stroke.
 Falls. Spinal cord injury after age 65 is most often caused by a fall. Overall, falls cause about
one-quarter of spinal cord injuries.
 Sports and recreation injuries. Athletic activities, such as impact sports and diving in
shallow water, cause about 8 percent of spinal cord injuries.
 Alcohol. Alcohol use is a factor in about 1 out of every 4 spinal cord injuries.
Diseases. Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal
cord injuries
SIGHNS AND SYMPTOMS:
 Complete. If all sensory (feeling) and motor function (ability to control movement) is lost
below the neurological level, your injury is called complete.
 Incomplete. If you have some motor or sensory function below the affected area, your injury
is called incomplete.
Additionally, paralysis from a spinal cord injury may be referred to as:
 Tetraplegia or quadriplegia. This means your arms, trunk, legs and pelvic organs are all
affected by your spinal cord injury.
 Paraplegia. This paralysis affects all or part of the trunk, legs and pelvic organs.
Your health care team will perform a series of tests to determine the neurological level and
completeness of your injury.
Spinal cord injuries of any kind may result in one or more of the following signs and symptoms:
 Loss of movement
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 Loss of sensation, including the ability to feel heat, cold and touch
 Loss of bowel or bladder control
 Exaggerated reflex activities or spasms
 Changes in sexual function, sexual sensitivity and fertility
 Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord
 Difficulty breathing, coughing or clearing secretions from your lungs
Emergency signs and symptoms

Emergency signs and symptoms of spinal cord injury after an accident may include:
 Extreme back pain or pressure in your neck, head or back

 Weakness, incoordination or paralysis in any part of your body
 Numbness, tingling or loss of sensation in your hands, fingers, feet or toes
 Loss of bladder or bowel control
 Difficulty with balance and walking
 Impaired breathing after injury
 An oddly positioned or twisted neck or back
CLASSIFICATION:
The American Spinal Injury Association (ASIA) defined an international classification based on
neurological responses, touch and pinprick sensations tested in each dermatome, and strength of ten
key muscles on each side of the body, i.e. shoulder shrug (C4), elbow flexion (C5), wrist extension
(C6), elbow extension (C7), hip flexion (L2). Traumatic spinal cord injury is classified into five
categories by the American Spinal Injury Association and the International Spinal Cord Injury
Classification System:
 A indicates a "complete" spinal cord injury where no motor or sensory function is preserved
in the sacral segments S4-S5.
 B indicates an "incomplete" spinal cord injury where sensory but not motor function is
preserved below the neurological level and includes the sacral segments S4-S5. This is
typically a transient phase and if the person recovers any motor function below the
neurological level, that person essentially becomes a motor incomplete, i.e. ASIA C or D.
 C indicates an "incomplete" spinal cord injury where motor function is preserved below the
neurological level and more than half of key muscles below the neurological level have a
muscle grade of less than 3, which indicates active movement with full range of motion
against gravity.
 D indicates an "incomplete" spinal cord injury where motor function is preserved below the
neurological level and at least half of the key muscles below the neurological level have a
muscle grade of 3 or more.
 E indicates "normal" where motor and sensory scores are normal. Note that it is possible to
have spinal cord injury and neurological deficits with completely normal motor and sensory
scores.
In addition, there are several clinical syndromes associated with incomplete spinal cord injuries.
 The Central cord syndrome is associated with greater loss of upper limb function compared to
lower limbs.
 The Brown-Séquard syndrome results from injury to one side with the spinal cord, causing
weakness and loss of proprioception on the side of the injury and loss of pain and thermal
sensation of the other side.
 The Anterior cord syndrome results from injury to the anterior part of the spinal cord, causing
weakness and loss of pain and thermal sensations below the injury site but preservation of
proprioception that is usually carried in the posterior part of the spinal cord.
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 Tabes Dorsalis results from injury to the posterior part of the spinal cord, usually from
infection diseases such as syphilis, causing loss of touch and proprioceptive sensation.
 Conus medullaris syndrome results from injury to the tip of the spinal cord, located at L1
vertebra.
 Cauda equina syndrome is, strictly speaking, not really spinal cord injury but injury to the
spinal roots below the L1 vertebra.
The Location of the Injury
Determining the exact level of injury is critical in making accurate predictions about the specific parts
of the body that may be affected by paralysis and loss of function.
The symptoms observed after a spinal cord injury differ by location (refer to the spinal cord map on
the right to determine location). Notably, while the prognosis of complete injuries are generally
predictable, the symptoms of incomplete injuries span a variable range. Accordingly, it is difficult to
make an accurate prognosis for these types of injuries.
Cervical injuries
Cervical (neck) injuries usually result in full or partial tetraplegia (Quadriplegia). However,
depending on the specific location and severity of trauma, limited function may be retained.
 C3 vertebrae and above : Typically results in loss of diaphragm function, necessitating the
use of a ventilator for breathing.
 C4 : Results in significant loss of function at the biceps and shoulders.
 C5 : Results in potential loss of function at the shoulders and biceps, and complete loss of
function at the wrists and hands.
 C6 : Results in limited wrist control, and complete loss of hand function.
 C7 and T1 : Results in lack of dexterity in the hands and fingers, but allows for limited use of
arms. C7 is generally the threshold level for retaining functional independence.
Thoracic injuries
Injuries at or below the thoracic spinal levels result in paraplegia. Function of the hands, arms, neck,
and breathing is usually not affected.
 T1 to T8 : Results in the inability to control the abdominal muscles. Accordingly, trunk
stability is affected. The lower the level of injury, the less severe the effects.
 T9 to T12 : Results in partial loss of trunk and abdominal muscle control.
Lumbar and Sacral injuries
The effects of injuries to the lumbar or sacral regions of the spinal cord are decreased control of the
legs and hips, urinary system, and anus.
Central Cord and Other Syndromes
Central cord syndrome (picture 1) is a form of incomplete spinal cord injury characterized by
impairment in the arms and hands and, to a lesser extent, in the legs. This is also referred to as inverse
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paraplegia, because the hands and arms are paralyzed while the legs and lower extremities work
correctly.
Most often the damage is to the cervical or upper thoracic regions of the spinal cord, and
characterized by weakness in the arms with relative sparing of the legs with variable sensory loss.
This condition is associated with ischemia, hemorrhage, or necrosis involving the central portions of
the spinal cord (the large nerve fibers that carry information directly from the cerebral cortex).
Corticospinal fibers destined for the legs are spared due to their more external location in the spinal
cord.
This clinical pattern may emerge during recovery from spinal shock due to prolonged swelling around
or near the vertebrae, causing pressures on the cord. The symptoms may be transient or permanent.
Anterior cord syndrome (picture 2) is also an incomplete spinal cord injury. Below the injury, motor
function, pain sensation, and temperature sensation is lost; touch, proprioception (sense of position in
space), and vibration sense remain intact. Posterior cord syndrome (not pictured) can also occur, but is
very rare.
Brown-Séquard syndrome (picture 3) usually occurs when the spinal cord is hemisectioned or injured
on the lateral side. On the ipsilateral side of the injury (same side), there is a loss of motor function,
proprioception, vibration, and light touch. Contralaterally (opposite side of injury), there is a loss of
pain, temperature, and deep touch sensations
Complications spinal cord injury
At first, changes in the way your body functions may be overwhelming. However, you can learn new
skills and ways to adapt old skills to deal with the physical effects of a spinal cord injury. Possible
difficulties you may encounter include:
 Bladder control. Your bladder will continue to store urine from your kidneys. However, your
brain may no longer be able to control bladder emptying, as the message carrier (the spinal
cord) has been injured. The loss of bladder control increases your risk of urinary tract
infections. It may also cause kidney infection and kidney or bladder stones. Drinking plenty
of clear fluids may help. And during rehabilitation, you'll learn new techniques to empty your
bladder.
 Bowel control. Although your stomach and intestines work much like they did before your
injury, your brain may no longer be able to control the muscles that open and close your anus.
This may cause fecal incontinence. A high-fiber diet may help regulate your bowels, and
you'll learn techniques to better control your bowels during rehabilitation.
 Impaired skin sensation. Below the neurological level of your injury, you may have lost part
or all skin sensations. Therefore, your skin can't send a message to your brain when it's
injured by things such as prolonged pressure, heat or cold. This can make you more
susceptible to pressure sores, but changing positions frequently — with help, if needed — can
help prevent these sores. And, you'll learn proper skin care during rehabilitation, which can
help you avoid these problems.
 Circulatory control. A spinal cord injury may cause circulatory problems ranging from
spinal shock immediately following your spinal cord injury to low blood pressure when you
rise (orthostatic hypotension) to swelling of your extremities throughout your lifetime. These
circulation changes may increase your risk of developing blood clots, such as deep vein
thrombosis or a pulmonary embolus. Another problem with circulatory control is a potentially
life-threatening rise in blood pressure (autonomic hyperreflexia). Your rehabilitation team
will teach you how to prevent autonomic hyperreflexia.
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 Respiratory system. Your injury may make it more difficult to breathe and cough if your
abdominal and chest muscles are affected. These include the diaphragm and the muscles in
your chest wall and abdomen. Your neurological level of injury will determine what kind of
breathing problems you may have. If you have cervical and thoracic spinal cord injury you
may have an increased risk of pneumonia or other lung problems. Medications and therapy
can treat these problems.
 Muscle tone. Some people with spinal cord injuries may experience one of two types of
muscle tone problems: spastic muscles or flaccid muscles. Spasticity can cause uncontrolled
tightening or motion in the muscles. Flaccid muscles are soft and limp, lacking muscle tone.
 Fitness and wellness. Weight loss and muscle atrophy are common soon after a spinal cord
injury. However, limited mobility after spinal cord injury may lead to a more sedentary
lifestyle, placing you at risk of obesity, cardiovascular disease and diabetes. A dietitian can
assist you in attaining a nutritious diet to sustain an adequate weight. Physical and
occupational therapists can help you develop a fitness and exercise program.
 Sexual health. Sexuality, fertility and sexual function may be affected by spinal cord injury.
Men may notice changes in erection and ejaculation; women may notice changes in
lubrication. A spinal cord injury may cause decreased or absent sensation and movement
below the level of injury, but a person may notice a heightened sensitivity in areas above the
level of injury. Doctors, urologists and fertility specialists who specialize in spinal cord injury
can offer options for sexual functioning and fertility.
There's usually no physical change in women with a spinal cord injury that inhibits sexual
intercourse or pregnancy. Most women with a spinal cord injury can experience labor, have a
normal delivery and breast-feed.
 Pain. Some people may experience pain, such as muscle or joint pain from overuse of
particular muscle groups. Nerve pain, also known as neuropathic or central pain, can occur
after a spinal cord injury, especially in someone with an incomplete injury
Tests and diagnosis
In the emergency room, a doctor may be able to rule out a spinal cord injury by careful inspection,
testing for sensory function and movement, and asking some questions about the accident. But if the
injured person complains of neck pain, isn't fully awake, or has obvious signs of weakness or
neurological injury, emergency diagnostic tests may be needed.
These tests may include:
 X-rays. Medical personnel typically order these tests on all people who are suspected of
having a spinal cord injury after trauma. X-rays can reveal vertebral (spinal column)
problems, tumors, fractures or degenerative changes in the spine.
 Computerized tomography (CT) scan. A CT scan may provide a better look at
abnormalities seen on an X-ray. This scan uses computers to form a series of cross-sectional
images that can define bone, disk and other problems.
 Magnetic resonance imaging (MRI). MRI uses a strong magnetic field and radio waves to
produce computer-generated images. This test is extremely helpful for looking at the spinal
cord and identifying herniated disks, blood clots or other masses that may be compressing the
spinal cord.
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 Myelography. Myelography allows your doctor to visualize your spinal nerves more clearly.
After a special dye is injected into your spinal canal, X-rays or CT scans of your vertebrae
can suggest a herniated disk or other lesions. This test is used when MRI isn't possible or
when it may yield important additional information that isn't provided by other tests.
If your doctor suspects a spinal cord injury, he or she may prescribe traction to immobilize your spine.
A few days after injury, when some of the swelling may have subsided, your doctor will conduct a
neurological exam to determine the level and completeness of your injury. This involves testing your
muscle strength and your ability to sense light touch and a pinprick.
Treatments and drugs
Unfortunately, there's no way to reverse damage to the spinal cord. But, researchers are continually
working on new treatments, including innovative treatments, prostheses and medications that may
promote nerve cell regeneration or improve the function of the nerves that remain after a spinal cord
injury.
In the meantime, spinal cord injury treatment focuses on preventing further injury and empowering
people with a spinal cord injury to return to an active and productive life.
Emergency actions
Urgent medical attention is critical to minimizing the effects of any head or neck trauma. So treatment
for a spinal cord injury often begins at the scene of the accident.
Emergency personnel typically immobilize the spine as gently and quickly as possible using a rigid
neck collar and a rigid carrying board, which they'll use to transport you to the hospital.
Early (acute) stages of treatment
In the emergency room, doctors focus on:
 Maintaining ability to breathe

 Preventing shock
 Immobilizing your neck to prevent further spinal cord damage
 Avoiding possible complications, such as stool or urine retention, respiratory or
cardiovascular difficulty, and formation of deep vein blood clots in the extremities
You may be sedated so that you don't move and sustain more damage while undergoing diagnostic
tests for spinal cord injury.
If you do have a spinal cord injury, you'll usually be admitted to the intensive care unit for treatment.
You may even be transferred to a regional spine injury center that has a team of neurosurgeons,
orthopedic surgeons, spinal cord medicine specialists, psychologists, nurses, therapists and social
workers with expertise in spinal cord injury.
 Medications. Methylprednisolone (Medrol) is a treatment option for an acute spinal cord

injury. If methylprednisolone is given within eight hours of injury, some people experience
mild improvement from their spinal cord injury. It appears to work by reducing damage to
nerve cells and decreasing inflammation near the site of injury. However, this is not a cure for
a spinal cord injury.
 Immobilization. You may need traction to stabilize your spine, to bring the spine into proper
alignment or both. Sometimes, traction is accomplished by securing metal braces, attached to
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weights or a body harness, to your skull to keep your head from moving. In some cases, a
rigid neck collar also may work. A special bed also may help immobilize your body.
 Surgery. Often, surgery is necessary to remove fragments of bones, foreign objects, herniated
disks or fractured vertebrae that appear to be compressing the spine. Surgery may also be
needed to stabilize the spine to prevent future pain or deformity.
 Experimental treatments. Scientists are trying to figure out ways to stop cell death, control
inflammation and promote nerve regeneration. Ask your doctor about the availability of such
treatments.
Ongoing care
After the initial injury or disease stabilizes, doctors turn their attention to preventing secondary
problems that may arise, such as deconditioning, muscle contractures, pressure ulcers, bowel and
bladder issues, respiratory infections and blood clots.
The length of your hospitalization depends on your individual condition and what medical issues
you're facing. Once you're well enough to participate in therapies and treatment, you may transfer to a
rehabilitation facility.
Rehabilitation. Rehabilitation team members may begin to work with you while you're in the early
stages of recovery. Your team may include a physical therapist, occupational therapist, rehabilitation
nurse, rehabilitation psychologist, social worker, dietitian, recreation therapist and a doctor who
specializes in physical medicine (physiatrist) or spinal cord injuries.
During the initial stages of rehabilitation, therapists usually emphasize maintenance and strengthening
of existing muscle function, redeveloping fine motor skills and learning adaptive techniques to
accomplish day-to-day tasks. You'll be educated on the effects of a spinal cord injury and how to
prevent complications, as well as be given advice on rebuilding your life and increasing your quality
of life. You'll be taught many new skills, and will use equipment and technology that can help you
live on your own as much as possible. You'll be encouraged to resume your favorite hobbies,
participate in social and fitness activities, and return to school or the workplace.
Medications. Medications may be used to manage some of the effects of spinal cord injury. These
include medications to control pain and muscle spasticity, as well as medications that can improve
bladder control, bowel control and sexual functioning.
New technologies. Inventive medical devices can help people with a spinal cord injury become more
independent and more mobile. Some devices may also restore function. These include:
 Modern wheelchairs. Improved, lighter weight wheelchairs are making people with a spinal
cord injury more mobile and more comfortable. For some, an electric wheelchair may be
needed. Some wheelchairs can even climb stairs, travel over rough terrain and elevate a
seated passenger to eye level to reach high places without help.
 Computer adaptations. For someone that has limited hand function, computers can be very
powerful tools, but they're difficult to operate. Some examples of computer adaptations range
from simple to complex, such as key guards or voice recognition.
 Electronic aids to daily living. Essentially any device that uses electricity can be controlled
with an electronic aid to daily living (EADL). Devices can be turned on or off by switch or
voice-controlled and computer-based remotes.
 Electrical stimulation devices. These sophisticated devices use electrical stimulation to
produce actions. They're often called functional electrical stimulation (FES) systems, and they
use electrical stimulators to control arm and leg muscles to allow people with a spinal cord
injury to stand, walk, reach and grip.
Prognosis
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It's often impossible for your doctor to make a precise prognosis right away. Recovery, if it occurs,
typically starts between a week and six months after an injury. However, some people experience
small improvements for up to one year or longer
Coping and support
An accident that results in paralysis is a life-changing event. The sudden presence of disability can be
frightening and confusing. After all, adapting to life with a disability — often in a wheelchair — is no
easy task. You may wonder how your spinal cord injury will affect your everyday activities, job,
relationships and long-term happiness.
Recovery from such an event takes time, but many people who are paralyzed move on to lead
productive and fulfilling lives. It's essential to stay motivated and get the support you need.
Grieving
If you're newly injured, you and your family will likely experience a period of mourning and grief.
Although the grieving process is different for everyone, it's common to experience denial or disbelief,
followed by sadness, anger, bargaining and, finally, acceptance.
The grieving process is a common, healthy part of your recovery. It's natural — and important — to
grieve the loss of the way you were. But it's also necessary to set new goals and find a way to move
forward with your life.
You'll likely experience many thoughts and emotions. And you'll probably have concerns about how
your injury will affect your lifestyle, your financial situation and your personal relationships. Grieving
and emotional stress are normal and common. However, if your grief and sadness are affecting your
personal care, causing you to isolate yourself from others, or prompting you to abuse alcohol or other
drugs, you may want to consider talking to a social worker, psychologist or psychiatrist. Or, you
might find a support group made up of people with spinal cord injuries to be helpful. Talking with
others who truly understand what you're going through can be very encouraging, and members of the
group may also have good advice on adapting areas of your home or workspace to better
accommodate your current needs. Ask your doctor or rehabilitation specialist if there are any support
groups in your area.
Taking control
One of the best ways to regain control of your life is to educate yourself about your injury and your
options for reclaiming an independent life. A wide range of driving equipment and vehicle
modifications is available today. The same is true of home modification products. Ramps, wider
doors, special sinks, grab bars and easy-to-turn doorknobs make it possible for you to live more
autonomously.
Because the costs of a spinal cord injury can be overwhelming, you may want to find out if you're
eligible for economic assistance or support services from the state or federal government or from
charitable organizations. Your rehabilitation team can help you identify resources in your area.
Talking about your disability

Your friends and family may respond to your disability in different ways. Some may be unfazed by
your injury. Others may be uncomfortable and unsure if they're saying or doing the right thing.
Being educated about your spinal cord injury and willing to educate others is helpful. Children are
naturally curious and sometimes adjust rather quickly if their questions are answered in a clear,
straightforward way. Adults can also benefit from learning the facts. Explain the effects of your injury
and what your family and friends can do to help. At the same time, don't hesitate to tell friends and
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loved ones when they're helping too much. Although it may be uncomfortable at first, talking about
your injury often strengthens your relationships with family and friends.
Dealing with intimacy, sexuality and sexual activity

Your spinal cord injury may affect your body's response to sexual stimuli. However, you're a sexual
being with sexual desires. A fulfilling emotional and physical relationship is possible, but requires
communication, experimentation and patience. A professional counselor can help you and your
partner communicate your needs and feelings. Your health care provider can provide the medical
information you need regarding sexual health. You can have a very satisfying future complete with
intimacy and sexual pleasure.
Looking ahead
By nature, a spinal cord injury has a sudden impact on your life and the lives of those closest to you.
When you first hear your diagnosis, you may start making a mental list of all of the things you can't
do anymore. However, as you learn more about your injury and your treatment options, you may be
surprised at all of the things you can do.
Thanks to new technologies, treatments and devices, people with a spinal cord injury play basketball
and participate in track meets. They paint and take photographs. They get married, have and raise
children, and have rewarding jobs.
Today, advances in stem cell research and nerve cell regeneration give hope for a greater recovery for
people with spinal cord injuries. At the same time, new medications are being investigated for people
with long-standing spinal cord injuries. No one knows exactly when new treatments will become
available, but you can remain hopeful about the future of spinal cord research, while living your life to
the fullest today.
Prevention
Following this advice may reduce your risk of a spinal cord injury:
 Drive safely. Car crashes are one of the most common causes of spinal cord injuries. Wear a
seat belt every time you drive or ride in a car. Make sure that your children wear a seat belt or
use an age- and weight-appropriate child safety seat. To protect them from air bag injuries,
children under age 12 should always ride in the back seat. Don't drive while intoxicated or
under the influence of drugs.
 Be safe with firearms. Lock up firearms and ammunition in a safe place to prevent
accidental discharge of weapons. Store guns and ammunition separately.
 Prevent falls. Use a stool or stepladder to reach objects in high places. Add handrails along
stairways. Put nonslip mats on tile floors and in the tub or shower. For young children, use
safety gates to block stairs and consider installing window guards.
 Take precautions when playing sports. Always wear recommended safety gear. Check
water depth before diving to make sure you don't dive into shallow water. Avoid leading with
your head in sports. For example, don't slide headfirst in baseball, and don't tackle using the
top of your helmet in football. Use a spotter for new moves in gymnastics.
COMPARISON OF BOOK PICTURE AND PATIENT PICTURE:
PATIENT PICTURE
BOOK PICTURE
239
COMMON CAUSES:
Motor vehicle accident

The most common causes of spinal cord injuries
in the United States are:
 Motor vehicle accidents. Auto and

motorcycle accidents are the leading
cause of spinal cord injuries, accounting
for more than 40 percent of new spinal
cord injuries each year.
 Acts of violence. As many as 15 percent
of spinal cord injuries result from violent
encounters, often involving gunshot and
knife wounds, according to the National
Institute of Neurological Disorders and
Stroke.
 Falls. Spinal cord injury after age 65 is
most often caused by a fall. Overall, falls
cause about one-quarter of spinal cord
injuries.
 Sports and recreation injuries. Athletic
activities, such as impact sports and
diving in shallow water, cause about 8
percent of spinal cord injuries.
 Alcohol. Alcohol use is a factor in about
1 out of every 4 spinal cord injuries.
Diseases. Cancer, arthritis, osteoporosis and

inflammation of the spinal cord also can cause
spinal cord injuries
SIGHNS AND SYMPTOMS:

Cant able to walk. Pain , swallowing
 Complete. If all sensory (feeling) and
difficulty.quadriplegia.
motor function (ability to control
movement) is lost below the neurological
level, your injury is called complete.
 Incomplete. If you have some motor or
sensory function below the affected area,
your injury is called incomplete.
Additionally, paralysis from a spinal cord injury

may be referred to as:
 Tetraplegia or quadriplegia. This

means your arms, trunk, legs and pelvic
organs are all affected by your spinal
cord injury.
 Paraplegia. This paralysis affects all or
part of the trunk, legs and pelvic organs.
Your health care team will perform a series of

tests to determine the neurological level and
240
completeness of your injury.
Spinal cord injuries of any kind may result in one

or more of the following signs and symptoms:
 Loss of movement
 Loss of sensation, including the ability to
feel heat, cold and touch
 Loss of bowel or bladder control
 Exaggerated reflex activities or spasms
 Changes in sexual function, sexual
sensitivity and fertility
 Pain or an intense stinging sensation
caused by damage to the nerve fibers in
your spinal cord
 Difficulty breathing, coughing or clearing
secretions from your lungs
Emergency signs and symptoms

Emergency signs and symptoms of spinal cord
injury after an accident may include:
 Extreme back pain or pressure in your

neck, head or back
 Weakness, incoordination or paralysis in
any part of your body
 Numbness, tingling or loss of sensation
in your hands, fingers, feet or toes
 Loss of bladder or bowel control
 Difficulty with balance and walking
 Impaired breathing after injury
An oddly positioned or twisted neck or back
Tests and diagnosis

CT, MRI done.
CT, MRI, Myelography, blood investigation.
MANAGEMENT
Emergency actions
Urgent medical attention is critical to minimizing
the effects of any head or neck trauma. So
treatment for a spinal cord injury often begins at Emenrgency actions taken,
the scene of the accident.
Immobilise the client
Emergency personnel typically immobilize the
spine as gently and quickly as possible using a
rigid neck collar and a rigid carrying board,
which they'll use to transport you to the hospital.
Early (acute) stages of treatment
241
In the emergency room, doctors focus on:
 Maintaining ability to breathe

 Preventing shock
 Immobilizing your neck to prevent
further spinal cord damage
 Avoiding possible complications, such as
stool or urine retention, respiratory or
cardiovascular difficulty, and formation
of deep vein blood clots in the
extremities
 Medications. Methylprednisolone
(Medrol) is a treatment option for an
acute spinal cord injury. If
methylprednisolone is given within eight
hours of injury, some people experience
mild improvement from their spinal cord
injury. It appears to work by reducing
damage to nerve cells and decreasing
inflammation near the site of injury.
However, this is not a cure for a spinal
cord injury.
 Immobilization. You may need traction
to stabilize your spine, to bring the spine
into proper alignment or both.
Sometimes, traction is accomplished by
securing metal braces, attached to
weights or a body harness, to your skull
to keep your head from moving. In some
cases, a rigid neck collar also may work.
A special bed also may help immobilize
your body.
 Surgery. Often, surgery is necessary to
remove fragments of bones, foreign
objects, herniated disks or fractured
vertebrae that appear to be compressing
the spine. Surgery may also be needed to
stabilize the spine to prevent future pain
or deformity.
 Experimental treatments. Scientists are
trying to figure out ways to stop cell
death, control inflammation and promote
nerve regeneration. Ask your doctor
about the availability of such treatments.
THEORY APPLY
242
Mr. Irshan 36 years, male person, admitted in hospital as the complaints of not able to walk, pain,
weakness, etc. ( accident)
In this case we can apply the following theories:
 Myra Enstrin Levine four conservation model

 Dorothy Johnson, Behavioral system model
 Roy’s adaptation model
 Bet Neuman’s model
 Peplau interpersonal theory
These theories can apply for Mr. Irshan, because the problems of client are,
- Impaired physical mobility

- Impaired nutrition less than body requirement
- Knowledge deficit
- Risk for infection and dehydration
So I plan to give care to this patient in Myra Enstrin Leveine four conservation models.
MYRA ENSTRIN LEVINE- FOUR CONSERVATION PRINCIPLE:
1. CONSERVATION OF ENERGY:
The individual require a balance of energy and renewal of energy to maintain life
activities. That energy is challenged by process such as healing and ageing. Levine identifies these as
those activities involved in growth, transport, biochemical and bioelectrical change.
Nursing intervention called to the individual ability is dependent upon providing care
that makes the least additional demand possible.
2. CONSERVATION OF STRUCTURAL INTEGRITY:
The principle focuses on the healing process through multiple experience with scraped
knees and such that heal with no scaring, nurse support structural integrity through efforts to limit
injury and thus limit scaring through proper position and range of motion to prevent skeletal
deformity.
3. CONSERVATION OF PERSONAL INTEGRITY:
The principle focus on a self (Levine 1980) and Gold Stein’s (1963) self actualization.
Nurses can show patient’s respect by calling them by name.
Levine describes Gold Stein’s (1969) identification of self- actualization as observed in

afford of to retain their personal identity.
The most generous psychosocial approach would be limit the recording of confidence to
only those generalizations that actually make a difference in choice of treatment plans.
243
4. CONSERVATION OF SOCIAL INTEGRITY:
To function successfully in this wide variety of social environment require a broad

behavioral repertoire the ultimate direction for social integrity is derived from ethical values of the
social system.
The health care system is a vast social order with its own rule but is an instrument of
society and must guarantee previous personhood and respect as moral imperatives.
APPLICATION OF THEORY IN TO NURSING PRACTICE:
According to Levine the focus of nursing care is the maintenance of wholeness(integrity,

oneness) and the promotional adaptation.
Challenges to Mr. irshan internal environment:
Challenges to reduce Mr.Irshan energy resources muscle weakness, quadriplegia, changed

his internal environment.
Challenges to Mr. Irshan external environment:
He is a only one person breadwinner of his family and earns 4, 000/ month. Now financial
problem and altered family coping mechanism.
Assessment:
Energy conservation: challenges that result in an energy again of Mr. Irshan include inability to
walk, difficult in taking food, , he can’t walk too much distance also.
Structural integrity:
Mr. Irshan structural threateneded he is unable to walk, difficult to communicate with. Include
lack of knowledge on the disease condition, treatment modalities and follow up care.
Personal integrity:
Mr.Irshsan feel as he cannot earn money and to take care of his family members and cannot
involve in decision- making process of family.
Social integrity:
Mr. Irshan comes from Muslim family ha has lot of relatives from his side and his wife side and
have good relationship with them. He feels that his disease condition will not allow him to be social,
and he may have refused from him because of illness.
Hypotheses:
244
Using conservation model the following are the proposed hypotheses about Mr. Irshan need to
develop a plan of care with her.
1. Providing Mr.Irshan with nutritional consultant will that he can tolerate to take food himself
and food that will provide his with energy strength and healing.
2. Mr. Irshan can able to walk without assistance.
3. Encouraging Mr.Irshan able to talk about what the disease condition means to high and his
concerns and his help to resolve fear.
4. Teach about his discharge medicine and activities should be provided.
EVALUATION OF THE APPLICATION OF THEORY
The theory when applied could identify the self care requisites of Mr. Irshan from various aspects.
This was helpful to provide care in a comprehensive manner. Patient was very cooperative. The
application of this theory revealed how well the supportive and educative and partly compensatory
system could be used for solving the problems in a patient with spinal cord injury.
HEALTH EDUCATION
DATE TOPIC HEALTHEDUCATION

COMPONENTS
NUTRITION
 Advised the patient to take high calorie diet.
 Advised to take small frequent diet.
 Advised to take plenty of oral fluid.
 Advised to take food rich in vitamin ‘c’ to promote healing.
 Advised the family member to increase the palatability of
the food.
 Advised to take high fiber diet.
 Advised the family members to feed the patient according
to his comfort.
 Advised the pt about treatment and its continuation,

 Advised about timings of medicine intake.
 Advised to take full course of medicine.
TREATMENT  Advised the importance of medicine intake and harms if
discontinued.
 Explained about the side effects of the medicine and the
remedies for that.
 Advised to have plenty of oral fluids with the medicine to
prevent constipation and side effects.
 Advised to avoid dust and allergens.
 Teached about the use of inhalers.
PERSONAL  Advised to take nebulisation in case of dyspnea.
HYGIENE
 Advised the patient to maintain good personal hygiene.

 Advised the patient to take daily bath and wear clean cloth.
245
 Advised to keep the Niles short, and keep the ears clean.
 Advised the family members to maintain good hygiene
during food preparation & serving.
 Advised the pt about the importance of personal hygiene
and how it influence on health.
EXERCISE  Advised the patient to do deep breathing and coughing

exercise.
 Advised the client to passive and active exrcises.
 Advised the pt to avoid vigorous exercises.
 Advised the patient to avoid vigorous coughing .
 Advised about the importance deep breathing and coughing
exercises.
FOLLOW UP
 Advised the pt about treatment and follow up care.
 Advised to take treatment continuously.
 Advised to come for follow-up checkups.
 Advised to seek immediate medical attention in case of any
problem.
 Advised to inform to the doctor about the problems.
 Advised to keep all the records of health for further
reference.
CONCLUSION:
One can have spine injury without spinal cord injury. Many people suffer transient loss of
function ("stingers") in sports accidents or pain in "whiplash" of the neck without
neurological loss and relatively few of these suffer spinal cord injury sufficient to warrant
hospitalization. In the United States, the incidence of spinal cord injury has been estimated to
be about 40 cases per million per year. In China, the incidence of spinal cord injury is
approximately 60,000 per year.
The prevalence of spinal cord injury is not well known in many large countries. In some
countries, such as Sweden and Iceland, registries are available. According to new data
collected by the Christopher and Dana Reeve Foundation, in the US, there are currently 1.3
million individuals living with spinal cord injuries- a number five times that previously
estimated in 2007. 61% of spinal cord injuries occur in males, and 39% in females. The
average age for spinal cord injuries is 48 years old. There are many causes leading to spinal
cord injuries. These include motor vehicle accidents (24%), work-related accidents (28%),
sporting/recreation accidents (16%), and falls (9%).
BIBILIOGRAPHY:
1. Brunner and suddarths. Text book of medical and surgical nursing. Walters’ klewer.
Lippincott Williams and willkins; 11(1):1285-305.
2. Joice M black, medical and surgical nursing. Saunders Company; 6(1):987-90.
246
3. Watsons, text book of medical and surgical nursing and related pathology, Joan A royle,
mikes Walsh. ELBS .4: 499- 510.
4. Saunders manual of medical and surgical nursing, Joan luckmann, Sounders Company. 389-
920.
5. CIMS. Updated prescriber hand book, 2002; Jan: 76, 74, 206, 306.
NURSING DIAGNOSIS:
1. Impaired gas exchange related to retained secretions.
2. Constipation related to inadequate fluid intake
3. Risk for impaired skin integrity related to prolonged bed ridden
4. Impaired urinary elimination related to limited fluid intake.
5. Impaired physical mobility related to spinal cord injury.
6. Impaired nutrition: less than body requirement related to inability to eat
independently
7. Anxiety related to disease condition
247
NATIONAL MALARIA CONTROL

PROGRAMME

DATE OF SUBMISSION-
248
NATIONAL MALARIA CONTROL PROGRAMME
Introduction – the national control programme was launched in 1953 to reduce the enidence of
malaria in our country. In 1958 the NMCP was converted in to NMEP. The initial success against
malaria had been commendable and the incidence of malaria was brought down.
Activities casued out in NMEP
1. Case detection & prompt Treatment

2. Blood slides are elected through active surveillance by basic health workers during home visit
3. Passive surveillance in outpatient department of PHC and presumptive Treatment is given
4. Radical tx for all positive cases immediately
5. Fogging operation
6. Surveillance by male and temale workers at the doorstep.
7. Spraying work and anti larval operation in the infected villages.
8. Health education to the community
9. Notification to the district level officers for immediate.
10. Supervision of weekly and monthly reports to the PHC medical officer by the field function
arias
11. Periodical collection and consolidation of report
National Malaria eradication Programme
An expert committee formed by govt of india in 1994 identified malaria as a problems and
recommended the adoption of special measures against it. Malaria action plan was implemented on
the basis of these recommendations. The committee has identified cities, towns, metropolises and
state sealing un des the problem of malaria
Objectives of MAP
- Management of clinical and complicated cases of malaria
- Checking date due to malaria in high-risk group
- Reducing morbidity rate
- Checking the malaria endemic
- Limiting the cases of drug resistant malaria and falciparum
The working policy under NMEP includes

- Finding and treating the case of malaria controlling parasite
- Taking anti larva measures and identifying the primary aria taking the problem
- In urban aria malaria eradication pgm is coupled with health education.
249
Surveillance system malaria control
This is the component of modified plan of operation (MPO) under this malaria surveillance worker
and malaria inspectors are given the responsibility for timely collection & examination of blood
slides and also providing radical Treatment to such cases with are found positive.
Active surveillance : malaria surveillance workers goes home to home in his aria for collecting the
blood slides for all fever cases and after examination of these at PHC, the radical Treatment is
provided by worker to malaria TV cases He also give chloroquine to fever cases
Passive Surveillance: The detection of malaria cases done by hospital or health centers and local
doctors. Blood smear is made here of all fever cases sent for diagnosis and a single dose Treatment
for malaria is given & the case is tound tv msg is send to local surveillance worker for providing
radical
Enhanced malaria control Project (EMCP) : This was launched in 1977 with the financial
support of world bank EMCP is being run in 100 districts of & states which are more affective with
malaria.
Components of EMCP
 Early detection & prompt Treatment
 Selective vector control and individual pretention
 Information, education and communication
 Developing capacity against infection
 Epidemic planning and sapid response

To create awareness among people to control malaria, other than he progrmmes 7 th of may is
celebrated as malaria week. Fever treatment centers and medicine distribution centers have also been
setup in rural areas.
In 1999 the name of Programme was changed from NMEP to national anti malaria programme now
govt. of india is sponsoring this programme under a major head vector bone disease control
programme.
The national health policy 2002 has set the good of reduction in mortality an account of malaria up to
50% by 2010.
250
STAFFING PATTERN IN ANTI MALARIAL PROGRAMME
State level Director of malaria and filarial
Senior entomologist
Supportive staff / technicians

District level
Supportive staff
Entomologist / technicians
assistant
Health inspectors
District level
Block health supervisor
Health Inspectors Grade B

Health Inspectors Grade A
Mazdoors
251
Role of Nurse in anti malarial Programme
1. Detection of fever cases through active & passive surveillance

2. Taking blood smears to rule out malaria parasite.
3. Presumptive treatment for fever cases.
4. Examination of blood smear slides in PHC laboratories
5. Radical treatment for TB cases at the doorstep
6. Blood smear for all contacts.
7. Spray work in TB cases area in and around 50 KM radius
8. Notification to the healthy authority
9. Active surveillance by male health workers in the field
10. Supervision
11. Health Education
12. Follow up
13. Submission of report
World malaria day is 25 April and recognizes global efforts to control malaria
World malaria day was established in may 2007 by the 60 th session of the world health assembly. The
day was established to provide “education and understanding of malaria and spread information to all
peoples.”
2016 theme in malaria day
The theme for 2016 is “End malaria for Good” following the great progress made under the
millennium development goals.
The world malaria day theme provides a common platform for countries to show case their success in
malaria control.
252
NATIONAL TUBERCULOSIS CONTROL

PROGRAMME

DATE OF SUBMISSION-
253
NATIONAL TUBERCULOSIS CONTROL PROGRAMME
Introduction
National TB control Programme was launched in 1962. TB is one of the major community
health problem of the major community cause not only physical handicap but produce emotional and
social distress esto,ated 1.5% of the population suffering from radiological active TB . TB is more
prevalent in India compared to other developing countries due to emergence of HIV infection
Low socio comomic status & unhygienic living condition
Components of NTCP
 BCG campaign constituted one of the component
 Increase bed strength
 Domiciliary statement
 Establishment of TB clinics, training centers and research activities
District Tuberculosis programme
The district TB control Programme started in 1963 each TB center has a team of medical &
paramedical persons. The persons are
 District TB officer
 Treatment organizer
 X-ray technician
 Non medical team leader
 BCG technician
These members are trained at the national TB institute and team is equipped with a static 100 mm
x-ray unit, fitted with odelea camera for miniature radiography and laboratory equipment for direct
sputum smear microscopy
The DTCP function as a referral center for the entire TB control programme of the district.
254
Activities of DTCP
- Case finding & case holding
- Microscopic examination of the sputum
- Radiological examination should be restricted
- For whose sputum is repeatedly negative
- BCG vaccination
- Monitoring and evaluation
- Supervision and follow up
- Control of defaulter’s rate
- Involvement of primary health centers, SC, and private practitioners.
Revised National Tuberculosis control Programme
RNTCP –
RNTCP is the run TB control initiative of the government of India. As per the National
strategic plan 2012-17 the programme has a vision of achieving a “TB free India” and aims to achieve
universal access to TB control services. The programme provides various free of cost, quality TB
diagnosis and Treatment services across the country through government health system.
The treatment success rate of NTCP ware unacceptably low and he death rate semaining
high. In view of this the govt of India, who and world bank together reviewed RNTCP formulated in
the year 1992. This programme adopted the internationally recommended directly observed treatment
short course (DOTS)
The objectives of RNTCP are -
1. Achievement of 85% cure rate of infectious cases through supervised shoot course
chemotherapy
2. Case finding activities through quality sputum microscopy
255
3. Involvement of NGOs, information education and communication and improved operational
research
The revised strategy was introduced in the country as a pilot project since 1993 in a phased
manner pilot project since 1993 in a phased manner pilot phase I, II by the end of 1998 only 2%
of the total population of India was covered by RNTCP large scale implementation began in 1998.
The RNTCP has expanded rapidly over the years and since march 2006 it covers the whole
country.
Program strategy
The programme initially adopted the WHO DOTS strategy which consisted of the five
components
1. Political will and administrative commitment
2. Diagnosis by quality assured sputum smear microscopy
3. Adequate supply of quality assured short course chemotherapy deluges
4. Directly observed treatment
5. Systematic monitoring & accountability
In 2006 stop TB strategy was announced by who and adopted by RNTCP. With progress in achieves
in the DOTS therapy, the plan hopes to achieve detection of at least 90% the total estimated cases in
the country the components are
Case finding & Diagnosis
- Early identification of all infectious TB cases
- Improved interdiction with the general health system
- Staff for home based case finding
- Improve communication and outreach
- Screening clinically and socially vulnerable risk group for TB
- Develop improve sputum collection & transportation systems.
- Development of higher-sensitivity diagnostic test for TB suspects
256
- Catch pts already diagnosed though notification
- Improvement referral for Treatment mechanism
Patient Friendly Services
- Promptly & appropriately treating TB

- Making & appropriately treating through increased communication with peoples
- Help pts complete Treatment and better monitoring though information technology
- Improving partnership b/w public and private sector
- Research will guide improvements in regiments and delivery systems
- National Treatment committee for regular review of regimens & all Treatment related to TB
Integration with health system-
- Integrating the RNTCP with the overall health system
- In rural areas the RNTCP can focus integration through the NRHM
- In urban areas the RNTCP can integrate through the private sector and the evolving national
urban health mission
257
Organization of RNTCP -
State TB officer State TB officer
State TB Training & Director

demonstration center
District TB Center District TB Officer
TB Unit
Medical officer TB control
Senior Treatment supervisor
Senior TB laboratory supervisor
Microscopy centers
Treatment centrs
Dots Providers
Conclusion: Tuberculosis is a major public health problem in India. India accounts for one-fifth
of the global TB incidence and is estimated to have the highest number of active TB cases
amongst all the countries of the entire World. Overall performance of the RNTCP for the country
has been excellent with cure/treatment completion rate consistently above 85% and death rate
among patients registered for treatment reduced to less than 5%.
Bibliography:
1. S.kamalam ,Essentials in community health nursing practice, ,2 nd edition,104-106

2. I Clement ,Basic concept of community health nursing, ,2 nd edition,231-232
3. Swarnakar`s Community health nursing,3rd edition,726-727.
4. K Park ,Preventive and social medicine, ,4th edition,473-475.
258
HEALTH EDUCATION ON
NUTRITIONAL FOOD
SUBMITTED TO SUBMITTED BY-

DATE OF SUBMISSION-
HEALTH EDUCATION ON NUTRITIONAL FOOD
259
To maintain a healthy heart, active brain and optimally working muscles, you must take care
to eat a balanced diet that provides proper nutrients to your body. These nutrients provide you with
energy as well as stronger bones, muscles and tendons. Nutrients also aid in the regulation of bodily
processes, like blood pressure and digestion. What nutritious foods to eat for all these amazing
benefits?
The Importance of Eating Nutritious Foods
1. Weight Control
A diet that is full of fruits, vegetables, lean proteins and whole grains can help you lose,
maintain or control your weight. Replace high-fat and high-calorie foods with nutrient rich items. The
fiber in fruits, vegetables and whole grains will keep you fuller for longer while proteins will provide
you with cellular support.
2. Blood Sugar Control
Sugary foods cause spikes in your blood sugar. If you consume too many sugary foods like
white breads and concentrated fruit juices, over time you can develop Type 2 diabetes. Complex
carbohydrates, like those in oatmeal, can help reduce and regulate blood sugar.
3. Heart Health
High-fat foods cause high cholesterol and a buildup of plaque in your arteries. It’s a known
fact that this can lead to stroke, heart attack or heart disease. Eat healthy fats, like those found in nuts
and avocados, to get the fat you need without the plaque buildup.
4. Deceased Cancer Risk
Fruits and vegetables are full of antioxidants that help neutralize the damaging cells known as
free radicals. Free radicals are highly unstable and can lead to cancerous cells. Antioxidants create a
stable cell environment.
5. More Benefits
 Greatly reduce your risk of heart and coronary artery disease.

 You can decrease bone loss and reduce your overall risk of developing kidney stones.
 Most fruits and vegetables are naturally low in fat and calories. Plus, they have no cholesterol.
 Potassium rich diets can help to maintain healthy blood pressures.
 Dietary fiber has been found to help reduce blood cholesterol levels and might actually lower
your risk for heart disease. Fiber is also important to maintaining proper bowel functions.
Fiber-rich vegetables can help you feel fuller for longer and consume less calories in a meal.
 Folic acids, or folates, are an important part of helping the body form red blood cells. This is
particularly good for women who are or may become pregnant. They will need folic acid
during pregnancy so supplements and foods with folates are needed.
 Vitamin A found in nutritious foods keeps your eyes and skin healthy while also protecting
from infections.
 Vitamin C is needed for healthy skin as well, aiding to heal cuts and keep teeth and gums
healthy. It is also a part of iron absorption in the blood.
Tips for Healthy Diet
260
The following information is key to a balanced and healthy diet:
Be sure you are eating the correct number of calories per day based on your level of activity. This
balances the energy you consume and the energy you use. On average men need about 2,500 calories
(10,500 kilojoules) per day and women need about 2,000 calories (8,400 kilojoules) per day to
maintain a healthy diet.
Most of us eat more calories than we need on daily basis, so the intake of energy is greater than the
output of it. The excess is stored as fat. Make sure you eat a variety of nutritious food. This ensures
you have a regular, balanced diet, and your body is receiving the proper nutrients.
Reference:
 http:// www. newhealthguide.org/ The-Importance-Of-Eating-Nutritious-Food.html

 https://www.google.co.in/url?sa=t&rct=j&q
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CASE STUDY ON POSTNATAL MOTHER

DATE OF SUBMISSION-
262
CASE STUDY ON POSTNATAL MOTHER
FAMILY DATA
1. NAME: Mrs. Rukmani
2. AGE: 22 years
3. SEX: female
4. DIAGNOSIS: Postnatal mother
5. ADDRESS: kanpur
1. Background of the village
2. Community setting:
3. Name of the area: haripur
4. Urban/rural: rural
5. Name of the taluk / district: -kanpur
6. Population : 5000
7. Main caste group: sc and st
8. Religion: hindu
9. Administration of panchayat: panchayat president elected by community people
10. Main occupation: coolie
11. Methods of recording births/ deaths: village health nurse
OTHER FACILITIES
Community people have no transportation facility:. They go to market on every Friday, they have a
small temple in the community. Most of the people have their house. All the houses have electric
facility, they are getting water from common pipe, they are practicing open air defecation, there is no
library facilities.
COMMUNITY HEALTH PROGRAMMES
Community nurse is often visiting the community and giving treatment for minor ailments and the
health worker is doing blood smear to detect malaria cases and leprosy cases. In the sub centre they
are providing treatment for TB, malaria, leprosy, maternal and child health facilities, immunization
and family planning services
INFLUENTIAL PERSONS IN THE AREA
The influential person is the president, he stays in the community area itself , if any problem they can
approach him at any time. The village health nurse visits once in a week to every house.
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FACILITIES AVAILABLE
• Medical :
o Govt hospitals- present
o Private nursing home- nil
o Health center – nil
o Indigenous practitioner – present
• SOCIAL AGENCIES: NIL
• EDUCATIONAL FACILITIES
Some of the people are educated: in this village one primary school is present,
where the children are getting their primary education
• COMMUNITY SANITATION
Community sanitation is inadequate, they don’t have latrine facilities, most of the people use open air
defecation, and there are no proper drainage facilities in the houses.
SOCIOECONOMIC BACK GROUND OF THE FAMILY
• Family set up
Nuclear family,
1. EXPENDITURE OF MONTH
Total income of the family is 3000 rupees per month
2. Food: 20%
3. Vegetables: 10%
4. Ration :20%
5. Milk: 10%
6. Non-veg: 5%
7. Clothing :5%
8. Medical:10%
9. Festival :10%
10. Others : 5%
11. Saving: 5%
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Details about the property
House: own house
Land: no land
Animal: there is a cow in their house
12. Family and social relationships
o Attitude among family members and neighbors
Family members have good understanding between them, they maintain good relationship with the
neighbors, they spend atleast some time to discuss and take important decision
o Attitude towards people of other community and religion
They mingle with the people of all the religion, they also attend the functions of other religion also
13. Description of house and surroundings
• Roof: cemented
• Walls: walls are made up of cement and bricks
• No of rooms : 2 rooms
• Lighting : lighting is available in all the rooms
• Ventilation: proper ventilation is available in all the rooms
• Water supply: they get water from the common pipe
• Bathing area: they have bathroom inside the house itself
• Latrine : they don’t have latrine, they are practicing open field defecation
• Disposal of waste: they have common drainage but it is not clean and clear
• Surroundings: the surrounding is not clean and it is not hygienic
14. Leisure time activities
During leisure time they speak with the neighbors and watch television
POSTNATAL ASSESSMENT
Patient profile:
Name : Mrs. Rama
Age : 22yrs
Sex : Female
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Husband’s name : Mr Rama
Address : Kanpur
Religion : Hindu
Marietal status : Married
Education : PUC, passed
Occupation : housewife
Family income : 3000 / month
G1 P 1 L 1 A 0
Date of registration : 4. 07. 2022
Date and time of delivery: 03 -04 -2022 and 8.15 pm
LMP : 26. 06.2021
Chief complains:
She has a complaint of pain in the perineum.
Personal history:
She has a moderate body built. She sleep 8-9 hrs per day. She does not have any bad habits
like chewing betels leaves, smoking etc. she has a hobbies of cooking , , listening music etc.
Socio economic history
Her husband is the bread winner of the family. They are living in their own house. Their
house is of kutcha type and there are only 2 rooms in their house. They have enough ventilation inside
the room from 3 windows and 2 doors. Adequate electric and water facilities is there. They have close
drainage system. There is no pet animals in their house. They maintain good relationship with their
neighbours.
Family history:
Their family member does not have any
• maternal and paternal history of breech delivery
• history of twin delivery
• history of Hypertension , Heart disease, Diabetes or any other Congenital malformation
• Past medical history
She has no past medical diseases like diabetes mellitus, hypertension, heart diasease etc.
Past surgical history
No significant surgical history in her past
266
Menstrual history:
• She attain her puberty at the age of 15 year
• Last menstrual period date – 26 .06.2021
• Duration of each period is 30 days
• She has a history of dysmenorrhoea
Contraceptive history:
No history of using any contraceptive in her past.
Past obstetric history:
No past obstetric history
Notes on admission for labour:
Present pregnancy :
• Full term
• Date of admission : 04.07. 2022
• Period of gestation : full term
• Presentation and the position : vertex and LOA
• Date of delivery: 05.03 .2020
• Time of delivery : 8.15pm
Labor notes:
• Membrane rupture spontaneously at 8.00pm
• Expulsive contraction commenced at : 9am
• Time and onset of labor :8pm
• Type of labor : full term normal vaginal delivery with

episiotomy
• Mode of delivery : vaginal
Length of labor:
 1st stage :30min
 2nd stage :30min
 3rd stage :15min
 Total hrs :11hrs
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Condition of the mother after delivery:
• Temperature - 98.8◦F
• Pulse - 78beats per min
• Respiration -20 breath per min
• BP -110/70mm Hg.
• Fundal height -10cm
• Uterus -hard
• Vaginal bleeding -normal
• Condition of the baby -alive
• Sex of the baby -male
• Wt of the baby -2.8gm
• Ht -40cm
Immediate care of the baby:
• Apgar score checked and it is good
• Eye care and cord care given.
• vital signs checked,
• Baby bath given.
• Baby passed meconium immediately after delivery.
• Baby is fed with breast milk
Immediate care of the mother:
• Vitals sign checked.
• Administered the ordered drugs.
• Episiotomy care given.
• Observed for the vaginal discharge.
• Recorded the number of pad.
• Encourage the mother to ambulate in an early.
• She voided freely. Her general condition is good..
Drugs given:
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Inj methergen 1 ampoule given.
PHYSICAL EXAMINATION:
Height :151cm
Weight :50kg
General appearance : she looks inactive
Facial appearance : normal , no edema , no puffiness.
Body built : moderate body built
Head and face:
Scalp : clean, no inflammation, or no any pediculi
Nose :
No nasal septum deviation
No nasal polyps
No inflammation in the nostrils.
Mouth:
Lips :No angular stomatitis,
Tongue :No glossitis , no coated tongue, no fissures in the tongue
Teeth :no dental caries, no pyorrhea.
Gums :no gingivitis, no swollen gums, and no bleeding gum.
Neck:
No lymph node enlargement, all range of motion is possible.
Chest:
Heart S1 and S2 sound, no cardiac murmur sound heart.
Lungs:
Symmetrical lungs expansion
No whistling sound
No stridor sound
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Breast:
Inspection:
Symmetrical in shape and size
Presence of Montgomery tubercles
Presence of primary and secondary areola
No crack nipple and no visible discharge.
Palpation:
breasts are enlarged, soft, warm, and contain only a small amount of colostrum.
Nipples: nipples is intact without redness, tenderness, cracks or blisters. Colostrum is expressed.
Abdominal examination:
Uterus:
Inspection:
Presence of striae gravida
Presence of linea nigra
Absence of scar mark
Umbilicus is inverted
Uterus size—9cm
Uterus shape—ovoid
Palpation:
Fundal height:-- 9cm
Lower limbs—ROM is normal, no varicose vein, no edema
Homan’s sign--- negative
Genitalia:
Vulva: visible blood dots while inspection
No abnormal foul smelling
No veneral infection
Present of lochia rubra.
NEW BORN ASSESSMENT
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Vitals sign,
Temperature :98.6F
Pules :130 beats per min.
Respiration :26 breath per min
Length / height of the baby : 42cm
Weight : 2.6kg
Head circumference : 33cm
Chest circumference : 32cm
General appearance:
• Activity :active
• Posture :well flexed
• Cry : good cry.
Skin:
Colour :pink in colour.
Texture :good texture.
Lanugo :present
Vermix caseosa :present
Mongolian spot :present in the sacrum area of the baby
Head:
Hair : equally distribution.
Skull : no injury, or anything during birth.
Shape :normal shape, no abnormal shape like hydrocephaly, anencephaly, microcephaly ,

macrocephaly etc.
Fontanelle :anterior fontanelle – open
posterior fontanelle.--open.
Face : no puffiness
Eyelids : eyelids may be slightly edematous.
Eyes : no discharge, no congenital cateract.
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Nose : no nasal septum deviation
Nostrils : no choanal atresia or stenosis.
Flaring : no nasal flaring.
Mouth:
Lips : pink in color, no bluish discoloration which indicate cyanosis.
Cleft : no cleft lip and cleft palate.
Neck :possible all range of motion
Chest:
Inspection : breast is symmetrically enlarged, no abnormal infection

like breast abcess.
Symmetry : ribs are horizontal and equally expanded.
Movements : symmetric movement of the chest is present.
Respiration is 42 breath per min.
Nipple :no inflammation , no witch milk.
Auscultation :no abnormal sound.like grunting sound
Abdomen:
Inspection : no congenital hernia like omphalocele, cord is clean no discharge

from the cord.
Palpation : liver is palpable 2 cm.no spleenomegaly and no hepatomegaly.
Shape : round in shape
Auscultation : heart bowel sound.
Stools( meconium):
Stool passed, no abnormality like fistula
External genitalia:
The testes is descended.
The extremities:
No malformation like polydactyly or syndactyly , no congenital dislocation of the hip.
NEONATAL REFLEXES:
1) Moro reflex :present
2) Startle reflex : present
3) Rooting reflex : present
4) Swallowing and suckling reflex : present
5) Placing reflex : present
6) Doll’s eyes reflex : present
7) Glabella reflex :present
8) Bibinski’s reflex : present
9) Symmetrical head reflex :present
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ASSESMEN DIAGNOSIS GOALS PLANNING RATIONALE IMPLEMENTATION EVALUATIO
T N
Subjective Ineffective The mother  Promote -It prevents the growth of Breast is cleaned with clear She was
data: breast feeding will breast microorganisms. water and dried with soft feeding her
related to lack demonstrate hygiene. towel. baby on 5th day
She says that of knowledge effective  Encourag after delivery
e mother
evidenced by breast feeding without
my breast is to feed -Baby sucking release
increased independently her baby assistance and
painful. oxytocin and prolactin Comfortable position is given
body . regularly. engorgement is
which helps in milk to mother then breast is
temperature.  Apply relieved next
production and reduces cupped with hands
warm day.
tenderness underneath. Baby is turned
compress
toward mother’s body and
es to the
Objective engorged strokes the baby’s cheek for
data: breast rooting reflex. With hand
-It dilates the distended
tissue. some milk is expressed into
veins and improves
Inspection  Provide infant’s mouth. Nipples are
circulation.
education rolled to bring them out
Veins are on breast before feeding and placed in
dilated. Its feeding
infant’s mouth. Baby’s
enlarged. Its technique
s. sucking reflex is assed.
shiny.
 Advised
Palpation to wear
snug
Sitting, lying and cradle hold
Skin is warm fitting bra
or positions are demonstrated to
to touch, taut
commerci mother.
and hard and
tender. Its al breast Determine physiological
binder. Feeding is given for 10 min
painful and
each side.
psychologicaldisturbances
. Warm, moist compresses are
273
applied 15 to 20 min before.
Regulate body temp by

conduction, radiation.
Prevent the risk of

Altered body dehydration due to fluid
temperature loss.
related to
ineffective
temperature
Subjective regulation Her body
data: evidenced by temperature It maintains metabolic
breast will be Vital signs are monitored.
functions during fever.
The mother engorgement. maintained in These are as follows:
says that she 24 to 48 Provide record of
is feeling Temp.101 F
hours. Monitor vital variance vital signs. The mother’s
warmness and signs Pulse..90/ min temp is
heat is decreased to
producing Res-24/min 99.6F after 6
from body hours.
and have Ventilation at 9 o’ clock in the morning.
headache should be
also. maintained.
Air conditioning is provided.
Doors and windows opened.
Objective
data: Hydrotherapy
should be Excess clothes are removed .
On given.
assessment
274
Temp. is
101F and
pulse 90/ Fluid and
electrolyte
balance Cold sponging is done and
should be ice packs are applied
maintained. especially on the forehead,
arms, abdomen and feet for
every 30 min. Its given every
2 hrly.
It promote muscle tonicity

Well balanced which help in fecal It
diet should be increases fecal bulk and
provided. enhances water absorption Oral fluids are given to her
into stool. including juices.
Calorie rich diet is given to

her which includes
Maintain vital carbohydrates which include
signs chart. rice, cereals, pulses and she
It promotes stool
consistency. has taken bread with with
milk. Proteins, fats, vitamins
and minerals are also given
to her in diet which includes
green, leafy vegetables, deep
It increases fecal bulk and yellow color veg and fruits
enhances water absorption including juices also.
into stool.
She is encouraged to take 8
Constipation to 10 glasses of water.
275
related to
inadequate
intake of diet. Prevent the risk of genital Vital signs are monitored at 2
tract infections. o’ clock in the evening which
are as follows
Temp.99.6F
Pulse.84/min
Res.22/min
Her Vital signs chart is

constipation maintained.
Subjective will be
data: relieved in 2
to 3 days.
She says that Pt is assisted in frequent
I didn’t pass She has passed
moderate physical exercise.
stool after the stool on 4th
delivery. day and bowel
movements are
visible with
observation.
Objective Ambulation is provided by
data: assisting in walking and
activities of daily living like
dress changing etc.
On
assessment
Exercises are demonstrated
Auscultation: to increase abdominal muscle
Regular
tone which are as follows:
276
Hypoactive physical 1. Contract abdominal
bowel sounds activity is to muscles several
are present. be promoted. times throughout
day.
These are
weak and A well
infrequent balanced diet As it can give a sense of 2. Do sit-ups, keeping
and 2 to 3 in which is rich heels on floor with
control which enhances
2 min. with fibers or knees slightly flexed.
coping ability.
roughage is to
be provided.
3. While supine, raise
It helps to clarify and lower limbs, keeping
verbalize fears and knees straight.
Plenty of 4. Deep breathing
allowing the nurse to give
fluids should exercises also.
realistic feedback and
be given in 5. Turn and change
reassurance. positions in bed,
diet.
lifting hips.
6. Lift knees
alternatively to the
It provides opportunity to
Perineal care chest, stretching
correct misconceptions. arms out to side and
should be
up over the head.
given. Dietary preferences of
the patient are discussed
It enhances patient’s
with patient.
sense of control over the
body’s response to stress.
Diet is provided which is

high in bulk like fresh fruits
and vegetables with skins,
bran, nuts and seeds, beans,
whole grain breads and
cereals, beans( kidney, lima
277
and navy) cooked fruits and
vegetables and fruit juices.
800 gm of fruits and

vegetables about four pieces
of fresh fruit and large salads
for normal daily movements
are provided.
She is suggested to take

moderate use of bran at first
and moderately increase it as
it may irritate GI tract.
She is advised to include

time for defecation as part of
daily routine.
She is advised to attempt to

defecate about 1h or so after
meals and that remaining in
the bathroom for a suitable
length of time may be
necessary.
278
Client is assisted to normal
semi squatting position to
allow optimum use of
abdominal muscles and effect
of force of gravity.
Perineal care is given and

sterile pad is applied after
care.
Reassurance and comfort is

provided to the patient.
Breathing exercises are

demonstrated.
Pt is encouraged to recall and

to analyze similar instances
of anxiety.
To reduce anxiety
interruptions, patient is
279
taught to
Look up.
Anxiety Control breathing.

related to
ineffective Lower extremities.
breast feeding Slow thoughts.
patter and
other Alter voice.
puerperal
complications Exercise.
.
Scruff face.
Anxiety will Emotional support is given

be relieved and pt. is encouraged to share
after 3 to 4 thoughts. She started to
days and will participate in
be decrease care and
on anxiety anxiety is
Subjective
scale. reduced to
data:
level 3 at
The mother anxiety scale.
said: I feel
worried as
my baby is
not feeding
properly”.
280
Objective
Data
On
assessment Encourage the
patient to
She is participate in
looking sad decision
and anxious making.
and its 5 on
anxiety scale. Provide
emotional
support and
encourage to
share
thoughts.
Encourage the
patient to
verbalize the
feelings.
Demonstrate
relaxation
techniques.
BIBLIOGRAPHY:
5. Pilliteri Adele., Maternal and Child Health Nursing., Philadelphia: J.B. Lippincott Company.P:
6. Park k; Park’s Textbook of Preventive and Social Medicine; 17 th edition; Banarsidas Bhanot Publicatios; 2002. P:
7. Annamma Jacob, A Comprehensive Textbook Of Midwifery, Edition: 2 nd, published by: Jaypee Brothers. P: 684-92.
8. Novak Julie C., Broom Betty L., Maternal And Child Health Nursing. Edition: 8 th, Published by: Mosby Publication. P: 9-13.
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ASSIGNMENT ON PRIMARY HEALTH

CENTRE

DATE OF SUBMISSION-
282
ASSIGNMENT ON PRIMARY HEALTH CENTRE
SET UP OF PRIMARY HEALTH CENTRE
Introduction
The concept of Primary Health Centre (PHC) is not new to India. The Bhore Committee in 1946
gave the concept of a PHC as a basic health unit to provide as close to the people as possible, an integrated
curative and preventive health care to the rural population with emphasis on preventive and promotive
aspects of health care.
The health planners in India have visualized the PHC and its Sub-Centres (SCs) as the proper
infrastructure to provide health services to the rural population. The Central Council of Health at its first
meeting held in January 1953 had recommended the establishment of PHCs in community development
blocks to provide comprehensive health care to the rural population. These centres were functioning as
peripheral health service institutions with little or no community involvement.
The 6th Five year Plan (1983-88) proposed reorganization of PHCs on the basis of one PHC for
every 30,000 rural population in the plains and one PHC for every 20,000 population in hilly, tribal and
backward areas for more effective coverage. Since then, 23,109 PHCs have been established in the country
(as of September 2004).
Objectives of Indian Public Health Standards (IPHS) for Primary Health Centres:
The overall objective of IPHS is to provide health care that is quality oriented and sensitive to the
needs of the community.
The objectives of IPHS for PHCs are:
 To provide comprehensive primary health care to the community through the Primary
Health Centers
 To achieve and maintain an acceptable standard of quality of care.
 To make the services more responsive and sensitive to the needs of the community.
Minimum Requirements (Assured Services) at the Primary Health Centre for meeting the IPHS:
Assured services cover all the essential elements of preventive, promotive, curative and
rehabilitative primary health care. This implies a wide range of services that include
1.OPD services:
4 hours in the morning and 2 hours in the afternoon / evening. Time schedule will vary from
state to state. Minimum OPD attendance should be 40 patients per doctor per Stabilization of the condition
of the patient before referral, Dog bite/snake bite/scorpion bite cases, and other emergency conditions
Referral services
In-patient services (6 beds)
2. Maternal and Child Health Care including family planning:

a) Antenatal care:
 Early registration of all pregnancies ideally in the first trimester (before 12th week of pregnancy).
However, even if a woman comes late in her pregnancy for registration she should be registered
and care given to her according to gestational age.
 Minimum 3 antenatal checkups and provision of complete package of services. First visit as soon
as pregnancy is suspected/between 4th and 6th month (before 26 weeks), second visit at 8th
month (around 32weeks) and third visit at 9th month (around 36 weeks). Associated services like
providing iron and folic acid tablets, injection Tetanus Toxoid etc.
 Minimum laboratory investigations like haemoglobin, urine albumin, and sugar, RPR test for
syphilis
 Nutrition and health counselling
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 Identification of high-risk pregnancies/ appropriate management
 Chemoprophylaxis for Malaria in high malaria endemic areas as per NVBDCP guidelines.
 Referral to First Referral Units (FRUs)/other hospitals of high risk pregnancy beyond the
capability of Medical Officer, PHC to manage.
b) Intra-natal care:(24-hour delivery services both normal and assisted)

 Promotion of institutional deliveries
 Conducting of normal deliveries
 Assisted vaginal deliveries including forceps / vacuum delivery whenever required.
 Manual removal of placenta
 Appropriate and prompt referral for cases needing specialist care.
 Management of Pregnancy Induced hypertension including referral
 Pre-referral management (Obstetric first-aid) in Obstetric emergencies that need expert
assistance(Training of staff for emergency management to be ensured)
c) Postnatal Care:
 A minimum of 2 postpartum home visits, first within 48 hours of delivery, 2nd within 7 days
through Sub-centre staff.
 Initiation of early breast-feeding within half-hour of birth
 Education on nutrition, hygiene, contraception, essential new born care
 Others: Provision of facilities under Janani SurakshaYojana (JSY)
d) New Born care:

 Facilities and care for neonatal resuscitation
 Management of neonatal hypothermia / jaundice
e) Care of the child:
 Emergency care of sick children including Integrated Management of Neonatal and Childhood
Illness (IMNCI)
 Care of routine childhood illness
 Essential Newborn Care
 Promotion of exclusive breast-feeding for 6 months.
 Full Immunization of all infants and children against vaccine preventable diseases as per
guidelines of GOI.
 Vitamin A prophylaxis to the children as per guidelines.
 Prevention and control of childhood diseases, infections, etc.
f) Family Planning
 Education, Motivation and counselling to adopt appropriate Family planning methods.
 Provision of contraceptives such as condoms, oral pills, emergency contraceptives, IUD
insertions.
 Permanent methods like Tubal ligation and vasectomy / NSV.
 Follow up services to the eligible couples adopting permanent methods (Tubectomy/Vasectomy).
 Counseling and appropriate referral for safe abortion services (MTP) forthose in need.
 Counseling and appropriate referral for couples having infertility.
3. Medical Termination of Pregnancies using Manual Vacuum Aspiration (MVA) technique.

(wherever trained personnel and facility exists)
4. Management of Reproductive Tract Infections / Sexually Transmitted
284
Infections:
a) Health education for prevention of RTI/ STDs
b) Treatment of RTI/ STDs
5. Nutrition Services (coordinated with ICDS)
a) Diagnosis of and nutrition advice to malnourished children, pregnant women and
others.
b) Diagnosis and management of anaemia, and vitamin A deficiency.
c) Coordination with ICDS.
6. School Health: Regular checkups, appropriate treatment including deforming, referral and follow ups
7. Adolescent Health Care: Life style education, counselling, appropriate treatment.
8. Promotion of Safe Drinking Water and Basic Sanitation
9. Prevention and control of locally endemic diseases like malaria, Kala azar, Japanese, Encephalitis,
etc.
10. Disease Surveillance and Control of Epidemics
11. Collection and reporting of vital events
12. Education about health/Behaviour Change Communication (BCC)
13. National Health Programmes including Reproductive and Child Health Programme (RCH),
HIV/AIDS control programme, Non communicable disease control programme.
14. Referral Services
15. Training
 Health workers and traditional birth attendants
 Initial and periodic Training of paramedics in treatment of minor ailments
 Training of ASHAs
 Periodic training of Doctors through Continuing Medical Education, conferences, skill
development training, etc. on emergency obstetric care
 Training of ANM and LHV in antenatal care and skilled birth attendance.
16. Basic Laboratory Services: Essential Laboratory services including:
 Routine urine, stool and blood tests
 Bleeding time, clotting time,
 Diagnosis of RTI/ STDs with wet mounting, Grams stain, etc.
 Sputum testing for tuberculosis (if designated as a microscopy centerunder RNTCP)
 Blood smear examination for malarial parasite.
 Rapid tests for pregnancy / malaria
 RPR test for Syphilis/YAWS surveillance
 Rapid diagnostic tests for Typhoid
 Rapid test kit for fecal contamination of water
 Estimation of chlorine level of water using ortho-toludine reagent.
17. Monitoring and Supervision.
18. AYUSH services as per local people’s preference (Mainstreaming of AYUSH)

19. Rehabilitation: Disability prevention, early detection, intervention and Referral.
20. The PHCs would provide 24 hour delivery services and new born care, all seven days a week in order
to increase the institutional deliveries which would help in reducing maternal mortality.
21. Selected Surgical Procedures: The vasectomy, tubectomy (including laparoscopic tubectomy),
MTP, hydrocolectomy and cataract surgeries as a camp/fixed day approach have to be carried out in a
PHC having facilities of O.T. During all these surgical procedures, universal precautions will be adopted
to ensure infection prevention.
22. Record of Vital Events and Reporting.
a) Recording and reporting of Vital statistics including births and deaths.Maintenance of all the
285
relevant records concerning services provided inPHC.
Essential Infrastructure: The PHC should have a building of its own. The surroundings should be clean.
The details are as follows:
PHC Building
Location: It should be located in an easily accessible area. The building should have a prominent board
displaying the name of the Centre in the local language.
Entrance: It should be well-lit and ventilated with space for Registration and record room, drug
dispensing room, and waiting area for patients.
The doorway leading to the entrance should also have a ramp facilitating easy access for
handicapped patients, wheel chairs, stretchers etc.
Waiting area:
a) This should have adequate space and seating arrangements for waiting clients / patients.
b) The walls should carry posters imparting health education.
c) Booklets / leaflets may be provided in the waiting area for the same purpose.
d) Toilets with adequate water supply separate for males and females should be available.
e) Drinking water should be available in the patient’s waiting area.
f) The surroundings should be kept clean with no water-logging in and around the centre and vector
breeding places.
Outpatient Department:
a) The outpatient room should have separate areas for consultation and examination.
b) The area for examination should have sufficient privacy.
Wards 5.5x3.5 m each:
a) There should be 4-6 beds in a primary health centre. Separate wards/areas should be earmarked for
males and females with the necessary furniture.
b) There should be facilities for drinking water and separate and clean toilets for men and women.
Operation Theatre:
To facilitate conducting selected surgical procedures (e.g. vasectomy, tubectomy,
hydrocelectomy, Cataract surgery camps)
a. It should have a changing room, sterilization area operating area and washing area.
b. Separate facilities for storing of sterile and unsterile equipments /instruments should be available in the
OT.
c. The Plan of an ideal OT has been annexed showing the layout.
d. The OT should be well-equipped with all the necessary accessories and equipment.
Labour Room (3800x4200mm):
a) There should be separate areas for septic and aseptic deliveries.
b) The LR should be well-lit and ventilated with an attached toilet and drinking water facilities. Plan has
been annexed.
Minor OT/Dressing Room/Injection Room/Emergency:

a) This should be located close to the OPD to cater to patients for minor surgeries and emergencies after
OPD hours.
b) It should be well equipped with all the emergency drugs and instruments.
Laboratory (3800x2700mm):
a) Sufficient space with workbenches and separate area for collection and screening should be available.
b) Should have marble/stone table top for platform and wash basins
General store:
286
a) Separate area for storage of sterile and common linen and other materials/ drugs/ consumable etc.
should be provided with adequate storage space.
b) The area should be well-lit and ventilated and should be rodent/ pest free.
Dispensing cum store area: 3000x3000mm
Infrastructure for AYUSH doctor: Based on the specialty being practiced,appropriate arrangements
should be made for the provision of a doctor’sroom and a dispensing room cum drug storage.
Immunization/FP/counseling area: 3000x4000mm
Office room 3500x3000mm
Dirty utility room for dirty linen and used items
Residential Accommodation:
Other amenities:
a. Electricity with generator back-up
b. Adequate water supply
c. Telephone: at least one direct line
d. Wherever possible garden should be developed preferably with theinvolvement of community.
STAFFING PATTERN OF PHC;- At present in each community development block, there are one or
more PHCs each of which cover 30’000 rural population. In the new set up each PHC will have the
following staff.
S.No. Staff Number

1 Medical officer 1
2 Pharmacist 1
3 Nurse mid -wife 1
4 Health worker (f) ANM 1
5 Block extension (male) 1
6 Health assistant (M &F) 2
7 U.D.C. 1
8 L.D.C. 1
9 Lab. Technician 1
10 Driver 1
11 Class IV 4
TOTAL 15
FUNCTION OF PRIMARY HEALTH CENTER:
The functions of the primary health centre in India cover all the 8 “essential” elements of primary health
care as outlined in the Alma-Ata declaration. They are-
1. Medical care.
2. MCH including family planning.
3. Safe water supply and basic sanitation.
4. Prevention & control of local endemic disease.
5. Collection & reporting of vital statistics.
6. Education about health.
7. National health programme as relevant.
8. Referral services.
9. Training of health guides, health worker, local dais and health assistant.
10. Basic laboratory services.
CONCLUSION
287
Primary Health Centre (PHCs) sometimes referred to as public health centres, are state-owned rural health
care facilities in India.They are essentially single-physician clinics usually with facilities for minor
surgeries, too. They are part of the government-funded public health system in India and are the most
basic units of this system. Presently there are 25,308 PHCs in India.
BIBLIOGRAPHY
1.Essentials in community health nursing practice,S.kamalam,2 nd edition,170,171
2.Basic concept of community health nursng,I Clement,2nd edition,204,205
3.Essentials of community health nursing,K Park,6th edition,465,466
4.Swarnakar`s Community health nursing,3rd edition
288
SCHOOL HEALTH PROGRAMME

DATE OF SUBMISSION-
289
SCHOOL HEALTH PROGRAMME
INTRODUCTION
School health services at providing a package of preventive promotive and curative health services
directed towards improvement of current health status of the school age children.
Objectives
 To improve the health

 To promote the health
 Prevention of disease
 Early diagnosis treatment and follows of defects
 Awaking health consciousness in children
 Provision of good environment
 To provide adequate nutrition of school age children.
 Improvement of health level of the school age children.
Health problems of school childrens
 Malnutrition
 Anemia
 Eye disease
 Diarrhea
 Dental carries
 Intestinal parasites
 Acute respiratory tract infection
 Skin disease
Role of nurse in school health programme
 Initiations and implementations

 Activities
 Coordination
 Evaluation
 Training and guidance
Active participation
Conducting primary health checkup identifying children at risk providing treatment. Providing
follow-up services, conducting and nutritional programs protects children from infections disease
maintain school health records conduction health education activities. Supporting total sanitation
campaign.
 Date of visit; 13/9/2021

 Name of the school: Kishan primary school
 No of students admitted 200
290
 No of students present 150
 School environment : well environment
 It is situated in the center of the city
 It is having 5 acre site
 40 students could be accommodated in a room
 Adequately ventilated rooms
 Proper lighting present
 Eating facility also available
1 The school is monitoring the nutritional status of each and every child.
2 They are having the services of guidance and counseling
3 They are maintaining the proper disposal methods in proper area.
4 The school includes the regular checkup of the following
a. School health cards.
b. First aid kit
c. Immunization particulars
d. Health education programmes
e. Malaria program
f. Hand washing technique
Kitchen
Cleanliness of the following has been maintained.
- Surrounding
- Utensils
- Personal
- Children
Food stuffs
- Stored properly
- Adequate vegetables added in the food
- The school personals knows the following
 How to weight a child
 Personal hygiene
 Environmental hygiene
The children were not having any major problems. The deducted minor problems are as follows
- Eye problems – 2%
- Ear problems – 1%
- Dental problems – 8%
- Others - 2%
The school is maintaining the following
291
- Anecdotal record
- Cumulative record
- Progress record
- Immunization record
- Some other records also.
292
ASSIGNMENT ON SUB CENTRE

DATE OF SUBMISSION-
293
ASSIGNMENT ON SUB CENTRE
SET UP OF SUB CENTER
Introduction
In the public sector, a Sub-health Centre (Sub-centre) is the most peripheral and first contact
point between the primary health care system and the community. As per the population norms, one Sub-
centre is established for every 5000 population in plain areas and for every 3000 population in
hilly/tribal/desert areas. It is the lowest rung of a three-tier set up consisting of the Sub-centre established
for every 3000-5000 population with referral linkage to the Primary Health Centre (PHC) for 20,000 –
30,000 population, and the Community Health Centre (CHC) for 80,000 to 1,20,000 population.
A Sub-centre provides interface with the community at the grass-root level, providing all the
primary health care services. Of particular importance are the packages of services such as immunization,
antenatal, natal and postnatal care, prevention of malnutrition and common childhood diseases, family
planning services and counselling. They also provide elementary drugs for minor ailments such as ARI,
diarrhoea, fever, worm infestation etc. and carryout community needs assessment. Besides the above, the
government implements several national health and family welfare programmes which again are
delivered through these frontline workers.
Objectives of Indian Public Health Standards (IPHS) for Sub-centres

The overall objective of IPHS is to provide health care that is quality oriented and sensitive to the
needs of the community. The objectives of IPHS for Sub-Centres are:
i. To provide basic Primary health care to the community.
ii. To achieve and maintain an acceptable standard of quality of care.
iii. To make the services more responsive and sensitive to the needs of the community.
Services to be provided in a Subcentre:

Sub-centres are expected to provide promotive, preventive and few curative
primary health care services as below:
Maternal and Child Health:
 ANTENATAL CARE:
 Early registration of all pregnancies
 Minimum three antenatal check-ups
 Associated services like general examination such as height, weight, B.P.,anaemia,
abdominal examination, breast examination, Folic AcidSupplementation in first trimaster,
Iron & Folic Acid Supplementation from 12 weeks, injection tetanus toxoid, treatment of
anaemia etc.,
 Minimum laboratory investigations like haemoglobin estimation, urine foralbumin and
sugar, and referral to PHC for blood grouping.
 Identification of high-risk pregnancies and appropriate and prompt referral.
 Malaria prophylaxis in malaria endemic zones as per the guidelines of
 Counselling on diet & rest, pre birth preparedness and complicationreadiness, delivery kit
for home deliveries, danger signs, infant & young child feeding, initiation of breast
feeding, exclusive breast feeding for 6 months, demand feeding, supplementary feeding
(weaning and starting semi solid and solid food) at 6 months, contraception, advice on
institutional deliveries, clean and safe delivery at home, postnatal care & hygiene,
nutrition, care of newborn and registration of birth.
294
 INTRA-NATAL CARE:
 Promotion of institutional deliveries
 Skilled attendance at home deliveries when called for
 Appropriate and prompt referral
 POSTNATAL CARE:
 A minimum of 2 postpartum home visits, first within 48 hours of delivery, 2 ndwithin 7 to
10 days.
 Initiation of early breast-feeding within half-hour of birth
 Counselling on diet & rest, hygiene, contraception, essential new born care,infant and
young child feeding. (As per Guidelines of GOI on Essential newborncare) and STI/RTI
and HIV/AIDS
 OTHERS:
 Provision of untied fund to the Sub-centres (currently Rs.10,000 per Sub centre is
provided under NRHM) for facilitating the service management at the Sub-Centre.
 Provision of facilities under JananiSurakshaYojana (JSY)
 CHILD HEALTH:
 Essential Newborn Care (maintain the body temperature and prevent hypothermia,
maintain the airway and breathing, the baby should be breast fed by the mother within
half-an-hour, take care of the cord, and take care of the eyes, as per the guidelines for
Ante-Natal Care and Skilled Attendance at Birth by ANMs and LHVs.)
 Promotion of exclusive breast-feeding for 6 months.
 Full Immunization of all infants and children against vaccine preventable diseases as per
guidelines of GOI (Current Immunization Schedule.
 Vitamin A prophylaxis to the children as per guidelines.
 Prevention and control of childhood diseases like malnutrition,infections, ARI,
Diarrhoea, Fever, etc.
 FAMILY PLANNING AND CONTRACEPTION

 Education, Motivation and counselling to adopt appropriate Family planning methods
 Provision of contraceptives such as condoms, oral pills, emergency contraceptives, IUD
insertions (Wherever the ANM is trained on IUD insertion)
 Follow up services to the Eligible couples adopting permanent methods(Tubectomy /
Vasectomy)
 COUNSELING AND APPROPRIATE REFERRAL FOR SAFE ABORTION

SERVICES (MTP)
 CONTROL OF LOCAL ENDEMIC DISEASES

 DISEASE SURVEILLANCE
 WATER QUALITY MONITORING:
 DISINFECTION OF WATER SOURCES
 TESTING OF WATER QUALITY USING RAPID TEST (BACTERIOLOGICAL)
 PROMOTION OF SANITATION INCLUDING USE OF TOILETS AND
APPROPRIATE
 TRAINING, COORDINATION AND MONITORING:
295
 NATIONAL HEALTH PROGRAMMES:
 RECORD OF VITAL EVENTS
STAFFING PATTERN
S.No. Staff Number

1 Health Worker Male 1
2 Health Worker Female 2
3 Voluntary worker to keep the SC clean 1
Total 4
Supervision of sub centers
Supervision of 6 female health workers that is 6 sub centres is done by female health assistant.Financial
aid or support for the sub centers are made by union ministry of health and family welfare.Centers are
also financially assisted by the state governments under minimum need programme.Male health workers
are paid by state government.
Main functions of sub centers

1. MCH and RCH services
2. Family planning services
3. Immunization services
4. Primary treatment and referral services
5. School health
6. Field activities
7. Disease surveillance
8. Promotion of sanitation
9. Records and reports
10. National health programmes
11. Co-ordinating and monitoring village
Conclusion
The subcentre is the most peripheral health care facility. Sub-Centres are assigned tasks relating to
interpersonal communication in order to bring about behavioral change and provide services in relation to
maternal and child health, family welfare, nutrition, immunization, diarrhoea control and control of
communicable diseases programmes. The Sub-Centres are provided with basic drugs for minor ailments
needed for taking care of essential health needs of men, women and children.
BIBLIOGRAPHY
2.Essentials of community health nursing,K Park,6th edition,465
296
ASSIGNMENT ON WATER
PURIFICATION

ASSIGNMENT ON WATER PURIFICATION
Introduction
297
Water purification is the process of removing undesirable chemicals, biological contaminants,
suspended solids and gases from contaminated water. The goal is to produce water fit for a specific
purpose. Most water is disinfected for human consumption (drinking water), but water purification may
also be designed for a variety of other purposes, including fulfilling the requirements of medical,
pharmacological, chemical and industrial applications. The methods used include physical processes such
as filtration, sedimentation, and distillation; biological processes such as slow sand filters or biologically
active carbon; chemical processes such as flocculation and chlorination and the use of electromagnetic
radiation such as ultraviolet light.
Purifying water may reduce the concentration of particulate matter including suspended particles,
parasites, bacteria, algae, viruses, fungi, as well as reducing the amount of a range of dissolved and
particulate material derived from the surfaces that come from runoff due to rain.
The standards for drinking water quality are typically set by governments or by international
standards. These standards usually include minimum and maximum concentrations of contaminants,
depending on the intended purpose of water use.
Visual inspection cannot determine if water is of appropriate quality. Simple procedures such as
boiling or the use of a household activated carbon filter are not sufficient for treating all the possible
contaminants that may be present in water from an unknown source. Even natural spring water –
considered safe for all practical purposes in the 19th century – must now be tested before determining
what kind of treatment, if any, is needed. Chemical and microbiological analysis, while expensive, are the
only way to obtain the information necessary for deciding on the appropriate method of purification.
According to a 2007 World Health Organization (WHO) report, 1.1 billion people lack access to
an improved drinking water supply, 88% of the 4 billion annual cases of diarrheal disease are attributed to
unsafe water and inadequate sanitation and hygiene, while 1.8 million people die from diarrheal diseases
each year. The WHO estimates that 94% of these diarrheal cases are preventable through modifications to
the environment, including access to safe water. Simple techniques for treating water at home, such as
chlorination, filters, and solar disinfection, and storing it in safe containers could save a huge number of
lives each year. Reducing deaths from waterborne diseases is a major public health goal in developing
countries.
Purification of water at domestic level can be achieved by the following methods:
298
1. Distillation
2. Boiling
3. Filtration
4. Chemical method of sterilization.
1. Distillation:
In the process of distillation water is heated and evaporation takes place, whereby water changes
back to water when cooled; this process is called condensation. The condensed water is the purest form of
water, free from microbes, and impurities.
But it loses its taste and odor. Through aeration or passing oxygen through it the water becomes
consumable.
This method is quite expensive and time - consuming. But in place like laboratories, on sea-ships
or places where pure water is not available, this method is found to be very useful.
2. Boiling:
For water purification and in sterilization, boiling is the best and simplest method to purify and disinfect.
After straining the water twice through clean muslin cloth, it is boiled for ten minutes lo kill the microbes
present in it and also remove the temporary hardness of water.
If the water is still unclean then small amount of aluminum sulphate or fitkari is added and left
for a few hours. The impurities will collect at the bottom of the pan. This water should be boiled again
before use.
3. Filtration:
Different varieties of filters are used to purify the water at domestic level. Filter rods (candies) are
installed in the upper chamber. These rods are made of china porcelain and it is porous and hollow from
the centre. When water is filled in the upper chamber it purifies and drips in the lower chamber. This
water is free of any suspended matter but still has microbes in it
4. Chemical Methods for Water Sterilization
299

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KRISHNA INSTITUTE OF NURSING

SCIENCE & RESEARCH

SUBMITTED TO- SUBMITTED BY-

INTERNAL EXAMINER EXTERNAL EXAMINER

SUBMITTED TO- SUBMITTED BY-

An Anganwadi normally covers a population of 1000. This Anganvadi was in a government

Objectives of Anganwadi visit:

1. Understand the organization pattern of ICDS.

 Daily check up of personal hygiene.

Total number of under fives

Records and reports maintained at Anganvadi:

 Recorded anthropometric measurement.

UNDER FIVE YEAR CARE PLAN

SUBMITTED TO- SUBMITTED BY-

IDENTIFICATION DATA OF THE CLIENT

WARD NO. Pediatrics

DIAGNOSIS Acute rheumatic fever

DATE OF ADMISSION 5/06//22

Child was admitted with complaints of :

 Fever since 10 days

HISTORY OF PRESENT ILLNESS

(31 yrs Father) (28 yrs Mother)

(14 yrs Patient) (4 yrs brother)

 Full term delivery With LSCS

 BCG scar mark present

HYGIENE : well maintained

SLEEP : she takes around 16-18 hrs sleep

TYPE OF FAMILY : Nuclear family

SOCIO ECONOMIC STATUS OF FATHER/MOTHER

Education: 10th Pass/ illiterate

Total income/monthly Rs 5000/-approx

Housing: 2 room kaccha house

Disposal of refuse: Open disposal system

HISTORY OF ANY HEREDITARY DISEASE

No any history of any hereditary disease

VITALS SIGNS & SUGAR CHARTING:

DATE TIME TEMP PULSE RESP B.P.

6-11-2019 10:00am 98.86F 120/min 24/min 100/50 mm hg

7-11-2019 9:00am 98.6°F 116/min 24/min 100/60 mm hg

LV=Normal, LA=enlarged, RV=normal

 Hb- 11.78 mg/dl

Bilirubin= 0.68 mg/dl

 Inj cefotaxime 2gm IV BD

General appearance - looking active

Child is conscious, active

Nutritional status of child is inadequate

Head to toe examination

Head = no any scar and fracture

Eyes = corneal reflex is present, No discharge

Face= having petechie marks on face

Neck = pain during movement of neck

Limbs = petechie is present

 Abdomen is non-distended, soft, non tender

CNS: Tone normal in all 4 limbs

B/L knee movement present

Knee jerk reflex present .

GI: few episode of vomiting per day

Electrocardiogram is done (color Doppler) which confirms the diagnosis.

Knee pain is present

Chorea(lower limbs) are involved.