Master the 3rd Year GNM Community Health Nursing-II syllabus at RGUHS, Bengaluru, Karnataka. Covers Epidemiology, Health Planning, National Health Programs, and Disaster Nursing.

SYLLABUS
UNIT I. HEALTH SYSTEM IN INDIA
UNIT II. HEALTH CARE DELIVERY SYSTEM
UNIT III. HEALTH PLANNING IN INDIA
UNIT IV. SPECIALIZED COMMUNITY HEALTH SERVICES AND NURSES ROLE
UNIT V. NATIONAL HEALTH PROBLEMS
UNIT VI. NATIONAL HEALTH PROGRAMS
UNIT VII. DEMOGRAPHY AND FAMILY WELFARE
UNIT VIII. HEALTH TEAM
UNIT IX. HEALTH INFORMATION SYSTEM
UNIT X. HEALTH AGENCIES
TAB: SYLLABUS

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COURSES

GNM

B.SC NURSING

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Learn essential growth monitoring methods for B.Sc Nursing students in community areas. This includes anthropometric measurements and Gomez classification. It also involves measuring vital signs, menstrual cycle tracking, and testicular self-examination (TSE).

Methods of Growth Monitoring

Growth monitoring is essential for assessing a child’s development and identifying malnutrition early. Various methods are used, including growth charting and anthropometric measurements.

1. Growth Charting

Growth charts were initially designed by David Morley and later modified by the World Health Organization (WHO). Also known as the “road-to-health” chart, they visually represent a child’s growth and development.

• Under the Integrated Child Development Services (ICDS), a Mother and Child Protection Card is used separately for boys and girls.
• This card includes information on family identification and birth record. It also covers pregnancy details, immunization schedules, nutrition, and milestones. There are special care requirements under schemes like Janani Suraksha Yojana.

Basic Features of Growth Charts:

• Weight-for-age chart does not consider height.
• Weight is a more sensitive indicator of growth than height.
• Deviation from normal growth curves signals potential health issues.
• A child can lose weight but not height due to malnutrition.
• When plotted correctly, growth charts provide early detection of growth failure, especially Protein-Energy Malnutrition (PEM).

Uses of Growth Charts:

• Growth Monitoring: Helps track child health in a simple, cost-effective way.
• Diagnostic Tool: Identifies high-risk children, especially those with malnutrition.
• Planning and Policy-Making Tool: Supports health programs and decision-making.
• Educational Tool: Helps uneducated parents understand child growth patterns.
• Intervention Tool: Guides health workers in planning appropriate actions.
• Teaching Tool: Used in health education about feeding, nutrition, and illnesses.
• Evaluation Tool: Measures the impact of health interventions.

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2. Anthropometric Measurements

These measurements help assess a child’s growth and nutritional status by comparing them to standard reference values.

Key Measurements:

1. Weight: A primary indicator of physical growth. Periodic weight checks (especially in ages 1-5 years) help detect growth faltering.
2. Height: Indicates long-term growth trends. Low height-for-age is called nutritional stunting, a sign of past malnutrition.
3. Head and Chest Circumference: At birth, head circumference (HC) is larger than chest circumference (CC). In severe malnutrition, CC may take longer (3-4 years) to surpass HC due to poor thoracic growth.
4. Mid-Arm Circumference (MAC): Reflects muscle mass and nutritional status. A decrease signals malnutrition.

Interpretation of Anthropometric Data:

• Mean or Median: A variation of ±2 standard deviations is considered normal.
• Percentile or Centiles:
  • Below the 3rd percentile or above the 97th percentile is unusual but not necessarily abnormal.
• Weight-for-Height/Length:
  • <70% of expected weight-for-height indicates severe malnutrition.
  • WHO standards guide weight assessments.

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3. Grading Malnutrition

Several classifications assess malnutrition severity:

1. Waterlow’s Classification (Stunting & Wasting)

Category	Stunting (Height-for-Age %)	Wasting (Weight-for-Height %)
Normal	>95%	>90%
Mild	87.5-95%	80-87.5%
Moderate	80-90%	70-80%
Severe	<80%	<70%

2. Gomez Classification (Weight-for-Age %)

Category	Reference Weight %
Normal	90-110%
Mild Malnutrition (Grade I)	75-89%
Moderate Malnutrition (Grade II)	60-74%
Severe Malnutrition (Grade III)	<60%

3. Indian Academy of Pediatrics (IAP) Classification

• Grade I: 70-80% of standard weight-for-age
• Grade II: 60-70%
• Grade III: 50-60%
• Grade IV: <50%

4. WHO/UNICEF Malnutrition Criteria

• Moderate Acute Malnutrition (MAM): Weight-for-Height Z-score <-2 but >-3.
• Severe Acute Malnutrition (SAM):
  • Weight-for-Height Z-score <-3.
  • Mid-Upper Arm Circumference (MUAC) <11.5 cm.
  • Bilateral pitting edema (Marasmic-Kwashiorkor).

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4. Measuring Weight Using Salter Scale

The Salter scale is a spring hanging scale used for weighing preschool children. It measures up to 25 kg with 100 g accuracy.

Steps for Measuring Weight:

1. Hook the scale securely at eye level.
2. Hang the weighing pants on the lower hook.
3. Set the scale to zero before weighing.
4. Undress the infant and place them in the weighing pan.
5. Ensure the child hangs freely without support.
6. Record weight only when stable, to the nearest 100 g.
7. Inform the parent of the child’s weight and compare with previous records.

Purpose of Weighing:

• Assess growth and health status.
• Calculate drug dosages.
• Determine BMI for underweight/obesity screening.

Articles Required:

• Weighing scale.
• Health card and pen to record weight.

Steps Involved:

1. Establish rapport with parent and child.
2. Explain the procedure.
3. Check previous weight records.
4. Place the scale on a firm, level surface.
5. Remove shoes and heavy clothing.
6. Ensure the child stands properly on the scale.
7. Record weight to the nearest decimal fraction.
8. Inform the parent about the child’s weight progress.

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Measuring Vital Signs

Oral Temperature Using Community Health Nursing Bag

Steps Involved

1. Preparation:
   • Spread a newspaper or a plastic square on a flat surface and place the community health nursing bag on it.
   • Obtain a newspaper. Use it to make a paper bag for discarding soiled cotton. Place the bag at one corner of the spread-out newspaper.
   • Explain the importance of the paper bag to the family and keep it standing in one corner.
2. Hand Hygiene:
   • Remove your watch and pin it securely (e.g., on a sari or salwar kameez).
   • Identify a suitable washing area with the help of a family member.
   • Wash hands thoroughly with soap and water for 3-5 minutes, following proper handwashing techniques.
   • Be mindful of water usage, especially in areas with water scarcity.
   • Dry hands using air or a towel.
3. Setting Up Equipment:
   • Return to the working area where the bag is placed.
   • Lift the unzipped outer covering of the upper compartment using the elbow.
   • Open the inner cardboard lining by pulling the attached small cloth piece.
   • Take out the necessary items for checking oral temperature. These include an oral thermometer, two cotton balls, a long layer of cotton for disinfection, and spirit. Place these on the newspaper.
   • Close the inner cardboard lining to prevent contamination.
4. Cleaning and Measuring Temperature:
   • Take the oral thermometer to the wash area.
   • Wash it under running cold water or pour water over it.
   • Use a cotton ball from the newspaper to wipe the thermometer from bulb to stem.
   • Explain the procedure to the patient, obtain consent, and place the thermometer under the tongue.
   • Ask the patient to close their mouth carefully and hold the thermometer in place with their lips.
   • Wait for three minutes.
   • Remove the thermometer. Read the temperature at eye level. Wipe it from stem to bulb with the used cotton ball.
   • Discard the used cotton into the paper bag.
5. Post-Procedure Care:
   • Wrap the thermometer in a long cotton strip soaked with soap and leave it for 10-15 minutes.
   • Use this time to collect patient history, provide health education, or conduct physical/nutritional assessments.
   • After 10-15 minutes, remove the thermometer. Clean it using a spiral motion with a fresh cotton ball. Rinse it with water and dry it. Disinfect with spirit. Lastly, place it back in its case.
   • Wash hands thoroughly.
   • Securely dispose of the soapy cotton swab in the paper bag and give it to a family member for safe disposal (e.g., burning).
   • Repack all items in the bag and zip it properly.
   • Fold the newspaper, ensuring the side that touched the floor remains inside.
   • Dry the towel upon returning to the health center.

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Measuring Blood Pressure

Purpose:

To assess systolic and diastolic arterial blood pressure.

Equipment Needed:

• Sphygmomanometer with cuff
• Stethoscope
• Antiseptic solution
• Paper bag for disposal

Procedure:

1. Preparation:
   • Explain the procedure to the patient or their relative.
   • Arrange the equipment in a convenient workspace.
   • Expose the patient’s arm above the elbow and ensure they are relaxed.
2. Cuff Placement:
   • Position the compression bag over the inner aspect of the arm, approximately 1 inch above the elbow.
   • Before application, squeeze and expel excess air from the cuff.
   • Secure the strap firmly using the Velcro sleeve band.
   • Adjust the manometer to eye level.
3. Palpation and Inflation:
   • Locate the brachial artery by palpation at the antecubital area.
   • Tighten the screw on the inflation bulb.
   • Inflate the cuff until the brachial pulse is no longer palpable.
   • Increase pressure by an additional 20-30 mmHg beyond the point where the pulse disappeared.
4. Auscultation and Reading Blood Pressure:
   • Place the diaphragm or bell of the stethoscope over the brachial artery.
   • Insert the stethoscope earpieces correctly, pointing forward.
   • Slowly release the pressure valve, allowing the mercury to fall at 2-3 mmHg per second.
   • Listen for the first pulse sound (systolic pressure).
   • Continue releasing pressure until the last pulse sound is heard (diastolic pressure).
   • Rapidly release the remaining pressure and remove the cuff.
5. Post-Procedure Care:
   • Clean the stethoscope’s bell or diaphragm with antiseptic solution.
   • Discard the used swab in the paper bag for safe disposal.

Menstrual Cycle

Definition & Basics

• Menstruation: Shedding of the uterus lining if no pregnancy occurs.
• Menarche: First menstrual period, marking puberty onset.
• Cycle Duration: Typically 28 days (can range from 21-42 days).
• Menstrual Flow: Lasts about 4-5 days, with 50-60mL blood loss.

Hormones Involved

• Estrogen: Develops & maintains female reproductive system.
• Progesterone: Produced by corpus luteum, supports pregnancy.
• FSH (Follicle-Stimulating Hormone): Stimulates estrogen & ovulation.
• LH (Luteinizing Hormone): Triggers ovulation & progesterone production.
• GnRH (Gonadotropin-Releasing Hormone): Regulates FSH & LH release.

Phases of the Menstrual Cycle

1. Proliferative Phase (Before Ovulation)
   • FSH rises → Estrogen secretion → Uterine lining thickens.
2. Ovulatory Phase (Day 14 in a 28-day cycle)
   • LH surge → Ovulation (release of egg).
3. Secretory (Luteal) Phase
   • Progesterone rises → Endometrium thickens for pregnancy.
   • If fertilization occurs → Hormones remain high.
   • If no fertilization → FSH & LH drop → Menstrual bleeding starts.

Psychological & Physical Changes

• Breast tenderness, fatigue, mood swings.
• Mild pain/discomfort in lower back, legs, pelvis.
• Important to normalize menstruation as a natural process.

Role of Community Health Nurse

• Educates girls & women about menstrual health.
• Ensures cultural sensitivity in discussions.
• Encourages hygiene, proper nutrition, and exercise.

Menstrual Hygiene Tips

• Use clean cotton pads or sanitary napkins.
• Change pads frequently based on flow.
• Wash perineal area & hands with soap and water.
• Dispose of used pads properly, avoiding toilet blockage.
• Maintain clean clothing & undergarments.

Pain Management

• Regular exercise & low-fat diet.
• Heating pads for cramps.
• NSAIDs for excessive pain (consult doctor if severe).

Breast Self-Examination (BSE)

• Check for lumps, skin changes, or nipple discharge monthly.
• Best done 7-10 days after period starts.
• Women aged 20-39: BSE monthly & clinical check every 1-3 years.
• Women 40+: BSE monthly & yearly clinical breast exam.

Testicular Self-Examination (TSE)

Why Perform TSE?

• Helps detect testicular cancer early.

How to Perform TSE?

1. Choose Privacy: Stand undressed in front of a full-length mirror.
2. Check for Swelling: Look for any changes in size or shape.
3. Palpate the Testis:
   • Use both hands.
   • Roll the testis gently between the thumb and fingers.
   • Feel for lumps or abnormalities.
4. Check the Epididymis & Spermatic Cord:
   • Epididymis is a soft cord-like structure at the top and back.
   • The spermatic cord runs from the testis upward.
   • Do not mistake them for lumps.
5. Repeat on the Other Side: One testis may be slightly larger – this is normal.
6. Consult a Doctor If:
   • You feel a small lump.
   • The testis is swollen or painful.

How Often?

• Perform TSE once a month.

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COURSES

GNM

BSC NURSING

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Explore the concept of Primary Health Care with an epidemiological approach and evidence-based practice. Learn how empowering people to care for themselves is key in community health nursing.

Epidemiological Approach

Key Highlights

1. Historical Foundation:
   • Florence Nightingale (1820–1910) was a statistician. She used epidemiological approaches during the Crimean War. She represented preventable deaths among soldiers through statistical methods.
2. Definition of Epidemiology:
   • “The study examines the distribution and determinants of health-related states or events in specified populations. It applies this study to the prevention and control of health problems.” (Last, 1988)
3. Core Components of Epidemiology: a. Distribution
   • Frequency: Relationship between the number of health events and population size (e.g., cases of diabetes per population size).
   • Pattern: Study of occurrence based on:
     • Time: Annual, seasonal, or hourly trends.
     • Place: Geographic variations, urban/rural differences.
     • Person: Demographics (age, gender, socioeconomic status) and behaviors.
   b. Determinants
   • Factors or root causes influencing health events (e.g., environmental exposures, behaviors).
   • Analytical epidemiology helps identify these determinants.
   c. Health-Related States or Events
   • Initially focused on communicable diseases, now includes non-communicable diseases and overall well-being.
4. Focus on Populations:
   • Specified Populations:
     • Physicians focus on individuals, while epidemiologists focus on communities or populations.
     • The epidemiologist’s “patient” is the community.
5. Applications:
   • Community-Based Practice:
     • Diagnosis of community health forms the basis for public health interventions.
     • Aim: To prevent and control diseases through feasible, relevant, and acceptable measures.

Importance of Epidemiology in Nursing:

• Provides tools for scientific inquiry and public health foundations.
• Combines biostatistics, informatics, and social sciences to assess health states/events.
• Facilitates designing effective health programs and interventions.

Using Epidemiological Approach in Community Health Nursing

Key Highlights

1. Surveillance of Disease and Health Status:
   • Importance of Surveillance:
     • Provides insight into the health status of the community.
     • Helps identify new, emerging, and re-emerging diseases.
     • Aids in planning, prioritization, and budgeting for health programs.
   • Role of Surveillance Data:
     • Estimates the magnitude of health problems.
     • Tracks the natural history and unusual presentations of diseases.
     • Identifies endemic diseases and detects epidemics for timely action.
   • Sources of Surveillance Data:
     • Records, registers, government reports, and management information systems (MIS).
2. Search for Etiology:
   • Audits and Reviews:
     • Perinatal, maternal, and under-five mortality audits provide insights into underlying causes.
     • Data sources include government and private agencies.
3. Evaluating Care:
   • Explores the effectiveness of care at facilities like sub-centers and primary health centers (PHCs).
4. Descriptive Epidemiological Approach in Nursing:
   • Defining the Population:
     • Study either the entire population or a representative sample.
   • Defining the Disease:
     • Describe the disease in terms of:
       • Time: When the disease occurs (e.g., year, season, hour).
       • Place: Where it occurs (e.g., geographic zones, urban/rural areas).
       • Person: Who is affected (e.g., age, sex, social status).
   • Analyzing Patterns:
     • Compare present patterns with past trends or across regions/countries.
   • Formulating Hypotheses:
     • Use descriptive data to hypothesize causes, later tested through analytical epidemiology.
5. Investigating Food Poisoning:
   • Steps in Investigation:
     • Identify affected individuals and gather details on food consumption:
       • What, where, and when they ate.
       • Symptoms experienced and their onset.
       • Other affected individuals in the group or region.
     • Check for events or travel histories that may explain exposure.
   • Outcome:
     • Helps pinpoint the source and cause of food poisoning.

Importance of Epidemiological Approach

• Provides data-driven insights for community health improvement.
• Enhances early detection and prevention of outbreaks.
• Supports evidence-based decision-making in public health nursing.

Problem-Solving Approaches in Nursing

Key Highlights

1. Definition and Importance:
   • Problem-solving involves applying a structured theoretical model for decision-making.
   • Decision-making, a critical part of problem-solving, relies on critical-thinking skills.

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Traditional Problem-Solving Approach

• Widely recognized and involves 7 sequential steps:
  1. Identify the problem.
     • Gather data to analyze causes and consequences.
     • Explore alternative solutions.
     • Evaluate alternatives.
     • Select the appropriate solution (decision-making).
     • Implement the solution.
     • Evaluate the results.
• Weakness: Lacks an explicit goal-setting step.

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Managerial Decision-Making Process

• An enhanced version of the traditional model, addressing its limitations.
• Steps include:
  1. Set objectives.
  2. Search for alternatives.
  3. Evaluate alternatives.
  4. Choose a solution.
  5. Implement the solution.
  6. Follow-up and control.

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Nursing Process as a Decision-Making Model

• A widely used approach in nursing for problem-solving and decision-making.
• Similar to the managerial decision-making process but incorporates a feedback mechanism for continuous improvement.

Steps:

1. Assessment:
   • Collect data and identify the problem.
2. Planning:
   • Identify criteria and explore alternatives.
3. Implementation:
   • Implement the selected alternative.
4. Evaluation:
   • Evaluate the outcomes and make adjustments.

• Key Advantage:
  • The feedback mechanism ensures ongoing assessment and improvement, setting it apart from traditional and managerial models.

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Evidence-Based Practice (EBP) Approach in Community Health Nursing

Definition

• Evidence-Based Practice (EBP) is the conscientious, explicit, and judicious use of current best evidence to make informed decisions about patient care.
• Integrates clinical expertise, patient values, and research evidence for decision-making (Sackett, 1996).
• In community health nursing, clinical expertise equates to the nurse’s experience, education, and skills, while patient values include preferences, concerns, and expectations.

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Elements of EBP

1. Best Research Evidence: From rigorously conducted studies.
2. Clinical Expertise: The knowledge and skills of community health nurses.
3. Patient Values: Preferences, expectations, and value systems.
4. Improved Patient Outcomes: The ultimate goal of EBP.

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Steps in Evidence-Based Practice

1. Develop a Clinical Question:
   • Construct a well-defined question based on observations or gaps in knowledge.
2. Assess Existing Evidence:
   • Determine if sufficient evidence exists or if further exploration is needed.
3. Apply Methodology (e.g., PICO):
   • Use structured approaches like PICO to guide research and interventions.

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PICO Method

A systematic approach to defining and answering clinical questions:

• P: Patient/Population of interest (e.g., infants, pregnant women, high-risk groups).
• I: Intervention of interest (e.g., a specific treatment or practice).
• C: Comparison of interest (e.g., no treatment, placebo, or standard care).
• O: Outcome of interest (e.g., reduced malnutrition rates, improved health).
• T: Time frame (e.g., duration of the intervention).

Example Question Using PICO:
“Does the incidence of protein-energy malnutrition among infants (P) in village A decrease (O) with the administration of nutritious balls (I) for 6 months compared to infants in village B (C)?”

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Other Methods

• PICOT: Adds “Time” as a component to PICO.
• PESICO: Includes Person, Environment, Stakeholders, Intervention, Comparison, and Outcome (Schlosser & Costello, 2007).

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Advantages of EBP in Community Health Nursing

• Promotes individualized care by integrating evidence with patient preferences.
• Helps community health nurses question outdated practices and adopt scientifically validated approaches.
• Drives innovation and improves health outcomes in populations.

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Empowering People to Care for Themselves: Community Health Nursing Perspective

Definition and Importance of Community Empowerment

• Community Empowerment: A process enabling communities to gain greater control over their lives (Laverack, 2008).
• Promotes shared values, concerns, and identities within communities.
• Empowers individuals to take ownership of their health, making them assets in their own care.

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People’s Ownership of Their Own Health

• Encourages self-reliance in health management.
• Role of External Agencies: Serve as catalysts to guide and support communities in gaining control over their health.
• Community Health Nurses (CHNs):
  • Use participatory approaches to enhance knowledge and encourage self-responsibility.

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Role of Health Literacy in Empowerment

• CHNs strive to improve access to health information and help communities use it effectively.
• Health Literacy vs. Health Education:
  • Health literacy addresses behavioral, environmental, political, and social determinants of health, going beyond traditional education.

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Resilient Health Systems

• Characteristics of a resilient health system:
  1. Universal reach
  2. Adequate workforce
  3. Community participation mechanisms
  4. Strong financial and leadership base
• Strengthening health systems is a key strategy for health promotion.

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Health Care Concepts in India: A Timeline

1. Comprehensive Health Care (1946)

Introduced by the Bhore Committee, focusing on integrated services.

Features:

• Preventive, curative, and promotive services.
• Accessibility to all beneficiaries, especially vulnerable groups.
• Close provider-beneficiary cooperation.
• Focus on healthy environments at home and workplaces.

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2. Basic Health Services (1965)

Concept introduced by UNICEF and WHO, emphasizing coordinated efforts between peripheral and intermediate health units.

Key Features:

• Assurance of competent professionals and auxiliary staff.
• Similar to comprehensive health care but lacked community participation and intersectoral coordination.

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Concept of Primary Health Care

The Primary Health Care (PHC) approach was established in 1978 during the Alma-Ata Conference in the USSR. It emphasizes equitable, universal health care accessible to all individuals, irrespective of their socioeconomic status. The conference defined PHC as:

“Essential health care is made universally accessible to individuals. It is acceptable to them through their full participation. This is achieved at a cost that the community and country can afford.”

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Core Elements of Primary Health Care

1. Health Education: Focus on preventing and controlling health issues.
2. Nutrition Promotion: Ensuring proper food supply and nutrition.
3. Safe Water and Sanitation: Provision of clean water and basic sanitation.
4. Maternal and Child Health: Including family planning services.
5. Immunization: Protection against major communicable diseases.
6. Control of Endemic Diseases: Measures to prevent and manage local outbreaks.
7. Treatment of Common Illnesses and Injuries.
8. Access to Essential Drugs.

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Principles of Primary Health Care

1. Equitable Distribution

• Health services must be accessible to all, regardless of wealth or location.
• Addresses social injustice, ensuring equal distribution of resources, especially to underserved rural and urban slum populations.

2. Community Participation

• Encourages involvement of individuals, families, and communities in planning, implementing, and evaluating health services.
• Examples:
  • Village health guides in India.
  • Barefoot doctors program in China.

3. Multisectoral Coordination

• Collaboration among various sectors like agriculture, housing, education, and public health to ensure comprehensive care.
• Examples of Coordination:
  • Maternal care: Involves health departments, family welfare, and community nurses.
  • Communicable diseases: Requires cooperation among sanitation, agriculture, urban development, and healthcare sectors.

4. Appropriate Technology

• Technology should be:
  • Scientifically sound
  • Adaptable to local needs
  • Affordable and maintainable by the community.
• Promotes self-reliance and aligns with the philosophy of “health by the people.”

5. Focus on Prevention

• Prevention is the cornerstone of PHC, with activities targeted at all levels of disease progression:

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Levels of Prevention in Primary Health Care

Primary Prevention

• Focus: Health promotion and disease prevention.
• Purpose: Reduce exposure to health risks before disease onset.
• Examples:
  • Immunizations against communicable diseases like polio.
  • Educating young adults on healthy lifestyles.
  • Promoting safety measures for the elderly.

Secondary Prevention

• Focus: Early detection and intervention.
• Purpose: Limit the progression of existing health issues.
• Examples:
  • Cervical cancer screening (Pap smears).
  • Hypertension and cholesterol checks.

Tertiary Prevention

• Focus: Rehabilitation and restoring optimal function.
• Purpose: Minimize disability and improve quality of life.
• Examples:
  • Post-stroke rehabilitation to reduce impairment.
  • Exercise programs post-mastectomy.

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COURSES

GNM

BSC NURSING

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