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Unit 7 - Assisting Individuals and Families to Promote and Maintain Their Health

Community Health Nursing I | 5th Semester B.Sc. Nursing (INC Syllabus)

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Overview

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A. Assessment of Individuals and Families

• Children
• Women
• Adolescents
• Elderly

• Identify health needs and problems
• Plan need-based, appropriate care
• Prioritize referrals
• Monitor progress over time

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B. Assessment of Children

1. Monitoring Growth and Development

• Growth = physical changes (increase in height, weight)
• Development = skill/milestone progression (speaking, walking, social skills)

• Growth charts (WHO/National standards)
• Height boards, infantometers
• Weighing scales

• Measure growth parameters during home/clinic visits
• Educate parents about nutrition and developmental stimulation
• Identify delays or abnormalities early

2. Anthropometric Measurements

• Height / Length
• Weight
• BMI (Body Mass Index)
• Head circumference (in infants)
• Mid-Upper Arm Circumference (MUAC) - for malnutrition screening

3. Developmental Milestones

• Assess gross motor, fine motor, language, and social milestones
• Use standard milestone charts
• Refer if delay is noted

4. Social Development

• Observation of interaction with family, peers
• Assess school attendance and behavior

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C. Assessment of Women

1. Nutritional and Reproductive Health Screening

• High prevalence of iron deficiency anemia, underweight, and obesity in Indian women

• Hemoglobin levels (to detect anemia)
• Height / Weight / BMI
• Dietary patterns and food habits
• Obstetric history (number of pregnancies, abortions, living children)
• Use of contraception and menstrual regulation methods

2. Menstrual Cycle Assessment

• Regularity, duration, flow
• Identify dysmenorrhea, menorrhagia, or absence of menses
• Counsel on menstrual hygiene and self-care
• Identify and refer cases of anemia or hormonal disorders

3. Breast Self-Examination (BSE)

• Teach women how to perform BSE monthly
• Identify any lumps, discharge, or skin changes
• Refer suspicious findings for further evaluation

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D. Providing Primary Care at Home / Health Centres

Routine Check-ups

• Covers all age groups: children, pregnant women, elderly, those with chronic conditions

1. Measure vital signs (BP, temperature, pulse, respiration)
2. Conduct visual inspections (skin, eyes, wounds)
3. Monitor weight, height, BMI
4. Record findings and plan further care or referrals

Immunization

• Goal: prevent vaccine-preventable diseases
• Nurse's role:
  • Check immunization status of children and pregnant women
  • Administer vaccines as per the Universal Immunization Programme (UIP)
  • Educate about the immunization schedule
  • Maintain cold chain and records

Health Counseling

• Dietary counseling (balanced diet, breastfeeding)
• Hygiene and sanitation
• Family planning counseling
• Counseling for chronic disease management (diabetes, hypertension)
• Antenatal and postnatal counseling

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E. Therapeutic Procedures at Home and in the Community

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F. Records and Reports

• Family folder / Family health record
• Antenatal and postnatal registers
• Immunization records
• Growth monitoring records
• Daily / Weekly activity reports
• Field practice reports

• Continuity of care
• Monitoring trends
• Planning interventions
• Legal documentation

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G. Care for Specific Groups

Adolescents

• Physical growth assessment (height, weight, BMI)
• Menstrual health (girls)
• Nutritional assessment (anemia screening)
• Mental health screening
• Counseling on sexual and reproductive health
• Prevention of substance abuse

Elderly

• Assessment of activities of daily living (ADL)
• Screening for hypertension, diabetes, COPD
• Fall risk assessment
• Mental status evaluation (dementia, depression)
• Social support assessment

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H. Nurse's Role - Summary

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Key Learning Outcomes (as per INC)

1. Assess and interpret health status of individuals and the community correctly
2. Organize and provide need-based health services
3. Perform primary care at home/health centres using approved standing orders and protocols
4. Develop skill in maintenance of records and reports
5. Appreciate the importance of teamwork and inter-sectoral coordination

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Quick Revision Points

• Unit 7 = 10 theory hours (one of the longest units in CHN-I)
• Focuses on all age groups: children, women, adolescents, elderly
• Key tools: growth charts, anthropometric measurements, vital signs
• Key activities: monitoring growth & development, immunization, health counseling, therapeutic procedures
• Always follow MoH&FW / INC approved protocols and standing orders
• Nurse's role: assessor, educator, care provider, coordinator, record keeper, advocate

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Unit 7 - Detailed Notes

Community Health Nursing I | 5th Semester B.Sc. Nursing

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TOPIC 1: MENSTRUAL CYCLE

Definition

• Average cycle length: 28 days (counted from Day 1 of one period to Day 1 of the next)
• Normal range: 21-35 days
• Cycle days are numbered starting from the first day of menstruation

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Phases of the Menstrual Cycle

Phase 1 - Menstrual Phase (Day 1-5)

• Shedding of the endometrial lining
• Estrogen and progesterone levels fall
• Normal blood loss: 30-80 mL
• Duration: 3-7 days

Phase 2 - Follicular / Proliferative Phase (Day 1-14)

• Dominated by Estrogen (17β-Estradiol)
• FSH stimulates several primordial follicles to grow; one becomes the dominant (Graafian) follicle
• Endometrium thickens (proliferates) - glands and stroma grow, spiral arteries elongate
• Cervical mucus becomes copious, watery, elastic - shows "ferning" pattern on a glass slide
• Channels form in the mucus creating openings for sperm

Phase 3 - Ovulation (Day 14)

• LH surge triggers rupture of the dominant follicle
• Ovum is released into the abdominal cavity and picked up by the fimbriated ends of the uterine tubes
• Minor bleeding from follicle may cause brief lower abdominal pain = Mittelschmerz
• The ruptured follicle fills with blood = Corpus hemorrhagicum

Phase 4 - Luteal / Secretory Phase (Day 14-28)

• Dominated by Progesterone
• Granulosa and theca cells proliferate to form the Corpus luteum (yellowish, lipid-rich)
• Endometrial changes:
  • Proliferation slows
  • Uterine glands become tortuous, accumulate glycogen
  • Stroma becomes edematous
  • Spiral arteries become more coiled
• Cervical mucus becomes thick, non-elastic, does not fern (blocks sperm entry)
• Progesterone has a mild thermogenic action - raises basal body temperature (basis of rhythm method of contraception)
• If no fertilization: corpus luteum regresses → estrogen and progesterone fall → menstruation begins

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Hormonal Control Summary

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Normal Menstrual Parameters (for Assessment)

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Common Menstrual Disorders to Identify & Refer

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Nurse's Role in Menstrual Health (Community Setting)

1. Assessment - Ask about cycle regularity, duration, flow, pain, last menstrual period (LMP)
2. Counseling on menstrual hygiene:
   • Use clean absorbent material (sanitary pads/cloth)
   • Change pads every 4-6 hours
   • Wash genitalia with clean water
   • Avoid using unclean materials (risk of infection/toxic shock)
3. Identify abnormalities - Refer cases of heavy bleeding, severe pain, absent periods
4. Screen for anemia - Check conjunctiva, pallor; refer for hemoglobin testing if suspected
5. Educate about normalcy - Reduce myths and taboos around menstruation
6. Document - Record LMP, cycle details in family health record

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TOPIC 2: BREAST SELF-EXAMINATION (BSE)

Definition

Purpose

• Early detection of breast lumps or changes
• Increases awareness of normal breast feel and appearance
• Helps identify signs that need medical attention

When to Perform BSE

• Premenopausal women: Monthly, 7-10 days after the onset of menstruation (when breasts are least tender and least swollen)
• Postmenopausal women: Monthly on a specific calendar date (easier to remember)
• Frequency: Once a month

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The 7 Ps of Breast Examination (Essential Components)

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Step-by-Step BSE Technique

Step 1 - Inspection (Looking)

• Asymmetry in size or shape
• Skin dimpling or puckering
• Nipple retraction or discharge
• Redness, swelling, or rash

1. Arms at sides (normal relaxed position)
2. Arms raised over head
3. Hands pressed on hips (contracts pectoralis muscles - highlights dimpling)
4. Bend forward and lean - check for any hanging irregularity

Step 2 - Palpation (Feeling) - Standing/Sitting

• Use fingers of the opposite hand
• Palpate each breast and axilla (armpit)

Step 3 - Palpation - Lying Down

• Lie flat on back
• Place a small pillow under the shoulder of the side being examined
• Use the pads of the three middle fingers of the opposite hand
• Apply three pressures:
  1. Light - skin surface
  2. Medium - mid breast tissue
  3. Deep - near the chest wall (ribs)

Step 4 - Pattern of Search

• Top to bottom: Clavicle to inframammary fold
• Side to side: Sternum to latissimus dorsi (armpit)

• Move fingers in vertical overlapping columns from top to bottom
• Better than concentric circular or radial methods (those miss the edges)

Step 5 - Nipple Examination

• Gently squeeze the nipple
• Note any discharge (clear, milky, bloody)

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What to Look/Feel For (Abnormal Signs - REFER Immediately)

• A new lump or thickening (especially if hard, painless, irregular border)
• Skin dimpling or puckering
• Nipple retraction (turning inward) that is new
• Bloody or unusual nipple discharge
• Redness, swelling, or warmth that doesn't resolve
• Change in breast size or shape

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Nurse's Role in BSE Education

1. Teach the technique during home visits, ANM clinics, health camps
2. Demonstrate using a breast model or diagram
3. Educate about the importance of monthly BSE
4. Counsel women not to panic - most lumps are benign
5. Ensure follow-up referral for any suspicious finding
6. Document BSE education and findings in the family health record

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TOPIC 3: MAINTENANCE OF RECORDS AND REPORTS

Definitions

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Purposes / Importance of Records and Reports

For Patient Care:

1. Communication - ensures continuity of care between health workers
2. Coordination - links different levels of care (sub-centre → PHC → CHC)
3. Planning - helps nurses plan future visits and care
4. Evaluation - track progress of individual and family health

For Administration:

1. Statistical information - helps management make decisions on resource use
2. Supervision - helps supervisors evaluate services rendered
3. Legal protection - proof of care given

For Education:

1. Teaching/learning - case studies and outcomes educate nursing staff
2. Research - data from records used for community health research

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Types of Records in Community Health Nursing

1. Cumulative / Continuing Records

• Systematic account of an individual's total history over time
• Time-saving and economical
• Allows review of long-term progress

2. Family Records - The Family Folder

• All health records of a family kept together in one folder
• Gives a complete picture of the family's health status
• Contains:
  • Family demographic details (name, address, age, occupation)
  • Socio-economic information
  • Health status of each member
  • Services received (immunizations, antenatal visits, treatments)

3. Registers (at Sub-Centre / PHC level)

4. Diaries

• Diary of Health Worker Male (HWM) and Health Worker Female (HWF)
• Diary of Health Assistant (HA) Male and Female
• Record of daily field activities and visits

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Types of Reports

A. Based on Format:

B. Reports Used in Community Setting (Returns):

1. Monthly Report of HW (Male and Female)
2. Complication Report of HW
3. PHC Monthly Report

C. Reports Used in Hospital Setting:

1. Change-of-Shift Report - nurse handover at shift change
2. Transfer Report - when patient moves between wards/hospitals
3. Incident Report - any unusual event (fall, medication error)
4. Legal Report - for medico-legal cases
5. 24-hour Report - overall ward summary
6. Census Report - daily patient count
7. Birth and Death Report - vital statistics
8. Anecdotal Report - narrative account of specific observation

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Principles of Good Record Keeping

1. Accurate - factual, no guesses
2. Complete - all relevant details included
3. Clear - legible, no ambiguous abbreviations
4. Concise - brief but containing all important information
5. Timely (Prompt) - written as soon as possible after the event
6. Confidential - not shared with unauthorized persons
7. Dated and signed - with name and designation of the nurse

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Principles of a Good Report

• Prompt - given at the right time
• Clear - easy to understand
• Concise - to the point
• Complete - includes all pertinent details
• Objective - based on facts, not opinions

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Record Maintenance at Sub-Centre / PHC Level - Summary

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Quick Revision - Key Points

• Menstrual cycle: Average 28 days; 4 phases - menstrual, follicular (estrogen), ovulation (LH surge), luteal (progesterone)
• BSE: Monthly, 7-10 days after period starts; use 7 Ps; vertical stripe pattern preferred
• Records vs Reports: Record = permanent written document; Report = communication of current findings
• Family folder = most important record in community health nursing
• Good records: Accurate, complete, clear, concise, prompt, confidential, signed

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