Textbook of Nursing Foundation I Clement
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IntroductionCHAPTER 1

 
TERMINOLOGY
  1. Acute illness: Illness characterized by symptoms that are of relatively short duration, are usually severe and affect the functioning of the clients in all dimensions.
  2. Adaptation: Process by which changes occur in any of a person's dimensions in response to stress.
  3. Etiology: Identification of the cause of a problem. The cause may be direct or a contributing factor in the development of client problem or need.
  4. Health: Dynamic state in which an individual adapts to internal and external environments so that there is a state of physical, emotional, intellectual, social and spiritual well-being.
  5. Health behavior: Activities through which a person maintain, attains or regains behavior as an expression of personal health beliefs.
  6. Health-belief model: Conceptual framework that predicts a person's health behavior as an expression of personal beliefs.
  7. Health-illness continuum: Scale by means of which a personnel's level of health can be described, ranging from high level wellness to severe illness. The scales take in to account the presence of risk factors.
  8. Health promotion: Activities directed toward maintain or enhancing the health and well-being of clients.
  9. Health promoting behavior: Considered a third subcategory of health behavior and through assessment, reveal needs for vehicular safety, home safety, domestic violence recognition, recreational safety, occupational safety and health.
  10. Holistic health: A system of compressive or total care that considers the physical, emotional, social, economical and spiritual needs of the person the response to the illness, and the effect of the illness on the person's ability to meet self-care needs.
  11. Models: Models are graphic or symbolic representations of phenomena that objectify and present certain perspectives or points of view about nature or function or both.
  12. Concept: Concepts are the elements or components of a phenomenon necessary to understand the phenomenon and derived from impressions the human mind receives about phenomena through sensing the human environment.
  13. 2Philosophy: A philosophy is statement of belief and values about human being and their world.
  14. Theory: Theory refers to a set of logically interrelated concepts, statement, proposition and definitions which have been derived from philosophical beliefs of scientific data and from which questions or hypothesis can be deduced, tested and verified.
  15. Health: A state of physical, mental and social well-being, and the absence of disease or other disorders. It involves constant change and adaptation to stress.
  16. Community: Community as a group of inhabitants living together in a somewhat localized area under the same general regulations and having common interests, functions, needs and organizations.
  17. Nursing: Nursing is an art, science and profession by which we render, serve to human being to help him to regain or to keep a normal state of body and mind and when it cannot accomplish this, it help him for the relief from physical pain, mental anxiety or spiritual discomfort.
  18. Community health: Community (public) health is a science and art of preventing disease, prolonging life and promoting health and efficiency through organized effort.
  19. Community health nursing: Community health nursing is a synthesis of nursing and public health practice applied of promoting and preserving the health of people. The practice is general and compressive. It is not limited to a particular age group or diagnosis, and continuing, not episodic.
  20. Profession: A profession is an occupation with moral principles that are devoted to the human and social welfare. The service is based on specialized knowledge and skill developed in a scientific and learned manner.
  21. Quality care: The degree of which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
  22. Health care team: Health care team refers to all of the personal in all of the departments of a health care facility, who provides health care services. They are doctors, nurses, technicians and paramedical staff.
  23. Primary nursing: In primary nursing, a professional nurse has total responsibility for a particular patient or group of patients. The model's purpose is to provide continuity and coordination of care.
  24. Primary health care: It is a essential health care based on practical, scientifically sound and socially accepted methods and technology, made universally acceptable to individuals and families in the community involving their full participation and at a cost that the community and country can afford to maintain at every stage of their development.
  25. Health center: It is defined as an institution for the promotion of health and welfare of the people in a given area, which seeks to achieve health work through coordination with welfare and relive organization.
  26. Comprehensive health care: Comprehensive health care is the combined (integrated) curative, preventive, promotive and restorative care made available to the people without distinctions of caste, creed or economic status from birth to death (from womb to tomb).
  27. Primary health center: Primary health center is an institution for providing comprehensives health care, e.g. preventive, promotive and curative services, to the people living in a defined 3geographical area. It seeks to achieve its purpose by grouping under one roof or coordinate all the health work of that area.
  28. Health for all: Health for all has been defined as attainment of a level of health that will enable every individual to lead a socially and economically productive life.
  29. Community development block: Community development is a process which is designed to promote better living of the whole community, with the active participation by the community itself along with governmental efforts.
  30. Community health nurse: Community health nurse is person plays important role in helping people learn to care themselves and to work with other community residents to develop the capacity or infrastructure needed to ensure essential health care for everyone.
  31. Disease: Any deviation from or interruption of the normal structure or function of any part, organ or system of the body, manifesting with a characteristic set of signs and symptoms.
 
INTRODUCTION
  1. Health in its broadest sense is a dynamic state in which the individual adapts to changes in internal and external environments to maintain a state of well-being. The internal environment includes many factors that influence health, including genetic and psychological variables, intellectual and spiritual dimensions and disease processes.
  2. The external environment includes factors outside the person that may influence health, including factors outside the person that may influence health, including the physical environment, social relationships, and economic variables because both environments continuously change, the person must to maintain a state of well-being.
  3. Health and illness therefore must be defined in terms of individual. Health can include conditions that the client or nurse may have previously considered to be illness. Health is also closely related to an individual's work place and home life and stressors can be the result of those environments.
 
CONCEPT OF HEALTH
Health is considered by many as the opposite of illness or disease. For some, it means a well- developed or adequately nourished body, capable of various activities and able to withstand physical stress. All communities have their concepts of health integrated as a part of their culture. Widely differing culture groups share the concept of health as a state of balance and harmony.
The WHO has defined health as a “state of complete physical, mental, social, spiritual well-being, and not merely absence of disease or infirmity”. The concept of positive wholeness or completeness is emphasized and health is seen as more than a physical state. An individual's health is never static and is always in a dynamic equilibrium with his environment.
Physical well-being is measurable although it is varying ranges and validity. As regards mental well-being, measurable standards vary from culture to culture and hence the criteria for mental wellbeing may differ from one country to another or from place to place within the same country. There is also difference of opinion as to what is precisely meant by social well-being. Social well-being may be regarded as a state of predisposing condition of health.
 
4DIMENSIONS OF HEALTH
Traditionally health has been defined in terms of the presence or absence of disease. Nightingale defined health as a state of being well and using every power the individual possess to the fullest extent. It reflects concern for the individual as a total person functioning physically, psychologically and socially (Fig. 1.1).
  1. Environmental determinants: Environment has the direct impact on the health of individual, family or community. Internal or external and physical, biological and psychosocial components of environment influence the mental, social, spiritual and physical well-being of individuals. Environmental pollution has become a global threat. We must find the ways to reduce and manage the pollution as well as waste. It is worth mentioning that Florence Nightingale had also given importance to environmental factors in the maintenance of the health and care of the sick. Air, water, noise, radiation, housing, waste-management, etc. all affect the health status and quality of life.
    zoom view
    Fig. 1.1: Dimensions of health
  2. Political system: Political system has a great effect on the social climate in which we live. Political influences have the power and authority to regulate much of our surroundings in that, health care is also included. Implementation of any health program cannot be conducted properly without the strong political will. In our country health is a subject of concurrent list, so there is a need of coordination between the union and state governments in the health-related matters.
  3. Behavioral determinants: Health is the mirror of a person's lifestyle because faulty and ill habits have the adverse effect on the health of the individual. It is an established fact that culture and ethnic heritage shape much of our lifestyle including the health care.
  4. Socioeconomic determinants: Socioeconomic conditions have the major impact on the health status of any country. Education, economy, occupational opportunities, housing, nutritional level, per capita income, etc. determine the health care system and health resources.
  5. Health care delivery system determinants: The health care delivery system plays a great role in the field of health, this is considered as a disease-oriented system, but in our country which has the second largest population in the world, providing health care services at the grass-roots level is a difficult task. Besides the above-mentioned determinants women's issue, 5ageing population, agriculture, social welfare, rural development, urban improvement, etc. also have a major impact on the health of the nation, its families and individuals.
 
MULTIPLE FACTS OF HEALTH—WHO (WORLD HEALTH ORGANIZATION)
  1. Health a tridimensional state: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.
  2. Health a fundamental right: “The enjoyment of the highest attainable standards of health is one of the fundamental rights of every human being, without distinction of race, religion, and political belief, and economic and social condition”.
  3. Health for peace and security: “The health for all people is fundamental to the attainment of peace and security and is dependent upon the fullest cooperation of individuals”.
  4. Health a government responsibility: “Government have a responsibility for the health of their people, which can be fulfilled only by the provision of adequate health and social measures”.
  5. Health and health information: “The extension to all people of the benefits of medical, psychological, and related knowledge is essential to the fullest attainment of health”.
  6. Health and people cooperation: “Informed opinion and active cooperation on the part of the public are of the utmost importance in the improvement of health of the people”.
  7. Health and health care: “Unequal development in different countries in the promotion of health and control of disease, especially communicable disease is a common danger”.
  8. Health and child development: “Healthy development of the child is of basic importance the ability to live harmonically in changing total environment is essential to such development”.
  9. Health gain for all: “The achievement of any state in the promotion and protection of health is of value to all.
 
CONCEPTIONS OF HEALTH MODELS
Smith (1983) describes the various conceptions of health in four models. These are the clinical, role performance, adaptive and eudemonistic models. Each of these models can be defined by the characterization of the extremes of health-illness continuum (Fig. 1.2).
  1. Clinical Model
    • Health extreme: Absence of signs or symptoms of disease or disability as identified by medical science.
    • Illness extreme: Conspicuous presence of these signs and symptoms.
      zoom view
      Fig. 1.2: Model of health and illness
  2. 6Role Performance Model
    • Health extreme: Performance of social roles with maximal expected output.
    • Illness extreme: Failure in performance role.
  3. Adaptive Model
    • Health extreme: Flexible adaptation of the person to the environment and interaction with it to the maximal advantage.
    • Illness extreme: Alienation of the person from the environment and failure of self-corrective responses.
  4. Eudemonistic Model
    • Health extreme: Exuberant well-being.
    • Illness extreme: Enervation, languishing debility.
 
FACTORS INFLUENCING HEALTH
Health influenced by various factors which interact with each other and determine the health status of many individual, family and community at large at any given point of time. These factors known as determinants of health. According to WHO expert committee on community health nursing. Technical report series 558 (1974) and Blum, these factors are categorized as human biology, environment, lifestyle, health and health allied resources.
 
Human Biology
  1. Genetic inheritance: Hereditary or genetic predisposition to specific illness is a major physical risk factor. For example, a person with a family history of diabetes mellitus is at risk for developing the disease later in life. Other documented genetic risk factors include family his histories of cancer, coronary disease and renal disease.
  2. Age: Age increases susceptibility to certain illness. For example, the risk of cardiovascular disease increases with age for both sexes. The risk of birth defects and complications of pregnancy increase in women bearing children after age 35. Age risk factors are often closely associated with other risk factors such as family history and personal habits.
  3. Race: Race increases susceptibility to certain illness. For example, the risk of sickle cell anemia is more common in Africans and Mediterranean people.
  4. Self-concept: Self-concept implies individual's perception of his or physical, intellectual and social abilities.
 
Environment
  1. Physical environment: The physical environment includes atmospheric pressures, gravity, light and sound waves, temperature, humidity, wind velocity, solar radiation, electromagnetic fields and seasonal variations, etc. The variety of pollutants are found to pollute air, water, food and soil, and are the cause of various acute and chronic diseases, e.g. gastrointestinal, respiratory, skin cancer, cardiovascular diseases, etc.
  2. Biological environment: Most of the plants and animals are useful to human being to promote health but are the same time, they human being to promote health but are the same time, the produce diseases like malaria, insect bites and allergic reactions.
  3. Social environment: The social environment include other people and social institutions, sociocultural events, religious beliefs, moral and ethical values and social rules and regulations, pertaining to living society, socioeconomic support system.
  4. 7Lifestyle: Many activities, habits and practices involve risk factors, the stresses of life crises and frequent life changes also risk factors. Health practices and behaviors can have positive or negative effects in health. Practices with potential negative effects are risk factor these include overeating or poor nutrition, insufficient rest and sleep and poor personal hygiene. Other habits that put a person at risk for illness include smoking alcohol or drug abuse, and activities involving a threat of injury such as skydiving or mountain climbing. Some habits are risk factors for specific diseases. For example, excessive sunbathing increases the risk of skin cancer, and being overweight increases the risk of cardiovascular disease.
Prolonged emotional stress may increase the chance of illness. Emotional stress may occur with events such as divorce, pregnancy and arguments. Job related stresses, e.g. many overtax a person's cognitive skills and decision making ability leading to mental overload or burnout.
 
Health and Health Allied Resources
  1. Health services: Health services are directly concerned with improvement of health status of people. Health services can also contribute on socioeconomic development of people because sound health can improve and increase the physical, intellectual and emotional capacity of people to get educated, work and earn for their livelihood improve their lifestyle which will further reinforce their health.
  2. Socioeconomic conditions: Socioeconomic conditions have significant influence on community health. In developed countries like America, UK and Canada, there has been significant reduction in the morbidity and mortality rates and increases in longevity at birth because of socioeconomic, developments. Socioeconomic conditions include economic status, education, occupation and living standards.
  3. Political system: The political system has a very strong role in health promotion of people in the country. The health care delivery system is determined by the political system though there is constitutional control. Decisions pertaining to health policy, allocation of funds, programs, manpower development, infrastructure, health technology and delivery of health services are made by the ruling party within the parliament system.
  4. Health related services: The health related services include education governmental policies; social welfare developmental programs food and agriculture, industry, communication and broadcasting rural and urban development and transportation facilities. The health related services needs to have balanced approach between National Health Policy and voluntary health promotes active participation.
 
CONCEPT OF DISEASE
Disease can be considered as something more than mere deviation from health, each disease being a distinct entity, with distinguishing qualities in its pathologic process, its typical clinical appearance and often its characteristic epidemiologic pattern of distribution in terms of time, place and person. The concept of disease also may vary from one society to another society. There will be no difficulty in distinguishing an illness which is severe enough to necessitate bed rest and treatment. But milder condition of disease and in apparent or subclinical conditions which do not make these individual take to bed are likely to be missed or ignored. Just like the border-line health conditions, diseases of mild nature and in apparent or subclinical conditions are supposed to lie in the middle of a spectrum. At one end of this spectrum is “optimal health” and at the other end “serious disease” and in between those two ends, various grades of health 8and disease are located. The milder the disease or the more border-line the health, the more difficult it is to differentiate between health and disease.
 
CULTURAL FACTORS IN HEALTH AND DISEASE (FIG. 1.3)
The member of a particular society quite unconsciously agrees upon a common pattern of living. It includes basic rules for living together. These rules could be understood as the culture of the society. The behavior pattern of a particular culture are not biologically inherited but socially acquired through learning. Concept of etiology and cure—Supernatural causes like wrath of god and goodness, breach of to boo, past sins, evil eye and spirit or ghost intrusion. Physical causes include the effects of weather, water and impure blood.
  1. Environmental sanitation: Sanitation is the science of safe-guarding health. It is the quality of living that is exposed in the clean home, the clean farm, the clean business, the clean neighborhood and the clean community. Environmental sanitation is nothing but the introduction of such methods which bring about control of all the factors in the physical environment.
  2. Food habits: Food habits have deep psychological roots and are associated with love, affection, warmth, self-image and social prestige. The diet of the people is influenced by local conditions, religious customs and beliefs. Vegetarians and Hindus believes these food habits have a religious sanction from early daily.
  3. Mother and child health: Mother and child health is surrounded by a wide range of customs and beliefs all over the world. MCH care and good customs such as prolonged breastfeeding, oil bath, massage and exposure to sun. MCH care and bad customs are the child is not put to breast during the first 3 days of birth because of the belief that colostrums might be harmful.
  4. Personal hygiene: Hygiene is the science of health and includes all factors which contribute to healthful living. Personal hygiene includes all those personal factors which influence the health and well-being of an individual. The practice of an oil bath is a good Indian custom. Circumcision is a prevalent custom among Muslims which has a religious sanction.
    zoom view
    Fig. 1.3: Factors affecting health
  5. 9Sex and marriage: Sexual customs vary among different social, religious and ethnic groups. Orthodox Jews are forbidden to have intercourse for seven days after the menstruation ceases, these custom have an important bearing in family planning. Marriage is sacred. It is the usual social custom in India to perform marriages early at about the age of puberty. Child marriages are fortunately disappearing. The high rate of venereal diseases in Himachal Pradesh is attributed to the local marriage customs.
 
CAUSES AND RISK FACTORS FOR DEVELOPING ILLNESS
 
Internal Variables
  1. Developmental stage: A person's thought and behavior patterns change throughout life.
  2. Intellectual background: Knowledge about body functions and illnesses, educational background and past experiences, all influence the health beliefs and practice of patients.
  3. Emotional and spiritual factors: The patient's degree of calm or stress can influence health beliefs and practices. Spiritual beliefs also influence whether and how a patient seeks or avoids healthy behavior
    zoom view
    Fig. 1.4: Factors affecting health
 
External Variables
  1. Family practices: The way that patient's families use health care services, their perceptions of the seriousness of diseases and their preventative care behaviors can influence the health beliefs and practice.
  2. Socioeconomic factors: Social relationships, economic level and psychosocial factors influence health beliefs and practice.
  3. Cultural background: It influences beliefs, values and customs. It influences the approach to the health care system, personal health practices and nurse-patient relationship.
 
10Factors Affecting a Patient's Health Status
  1. Smoking
  2. Nutrition
  3. Alcohol use
  4. Habituating drug use
  5. Driving
  6. Exercise
  7. Sexuality and contraceptive use
  8. Family relationships
  9. Risk factor modification
  10. Coping and adaptation.
 
BODY DEFENCE: IMMUNITY AND IMMUNIZATION
Immunity is the resistance produced by the body against microorganisms and their products. Immunity is the ability to tolerate the presence of material indigenous to the body (self) and to eliminate foreign (nonself) material. This discriminatory ability provides protection from infectious diseases, since most microbes are identified as foreign by the immune system. Immunity to microbe is usually indicated by the presence of antibody to that organism. Immunity is generally specific to a single organism or group of closely related organism.
Application of immunity: Immunity is the resistance of the body against the damage caused by microorganisms and microbial products. There are two basic mechanism, they are active and passive immunity. Application of immunity:
  1. It helps us to understand etiology and pathogenesis of diseases, e.g. rheumatic fever, asthma, acute glomerulonephritis, etc.
  2. Diagnosis of disease is possible using ELISA, etc.
  3. Development of vaccines
  4. Treatment using antibodies
  5. Transplantation and blood transfusion
  6. Surveillance, i.e. immune surveillance
  7. It helps to find out possible future susceptibility a person to diseases with the help of HLA typing system.
 
Innate Immunity
It is the inborn resistance of the body against infectious agents. It exists prior to exposure to microbes and is non-specific. It is genetically and physiologically mediated. The functions of innate immunity are to kill or inhibit infectious agents and to activate the acquired immune mechanisms.
 
Meaning of Innate Immunity
  1. Is the basic resistance to disease that an organisms or individual has as a function of birth. It is the initial immune defense system.
  2. Is non-specific.
  3. 11At the species level it refers to the immune response that all members show to a pathogen.
  4. Within a species there exists subgroups such as race, gender, etc. that may exhibit differences in immunity to pathogens.
  5. Individual immunity refers to differences in an individual's response to a pathogen within a given race.
  6. Four types of barriers to infections: Anatomic, physiologic, phagocytic and inflammatory. Examples of these barriers: Temperature, pH, enzymes and chemical, skin, mucous membranes, phagocytic or endocytic barriers, inflammatory barriers.
 
Organs involved in Innate Immunity
  1. Eyes: Tears wash away pathogens and have bactericidal enzymes.
  2. Skin: Difficult for a pathogen to penetrate, sweat creates high salt conditions; oil layer makes an inhospitable environment.
  3. Stomach: Acid kills pathogens and sterilizes food.
  4. Nose: Mucus traps pathogens which are swallowed or blown out.
  5. Mouth: Natural microbiota prevents growth of opportunistic pathogens.
  6. Lungs: Mucus lining of lungs traps pathogens and cilia move particles out to throat and it is swallowed.
  7. Large intestine: Natural microbiota prevents growth of opportunistic pathogens.
  8. Reproductive system: Acid conditions and natural microbiota.
 
Mechanisms
 
Skin
  1. Intact skin with its keratin layer acts as a mechanical barrier against bacteria and other organisms.
  2. Skin secretions such as sebum and sweat are anti-bacterial and antifungal in nature.
  3. Normal flora of skin protects against infection by competing for receptors and nutrients and breakdown of toxins; they also produce toxic metabolites.
 
Respiratory Tract
  1. Anatomy of respiratory tract prevents entry of microorganisms.
  2. The mucus lining of the epithelium, the cough reflex and the cilia lining the respiratory tract prevent the entry of microorganisms.
  3. Phagocytic cells such as the alveolar macrophages engulf and destroy the micro-organisms that enter the lungs.
 
Gastrointestinal Tract
  1. Gastric pH which is around 1.5 destroys most ingested pathogens.
  2. Saliva and other secretions in the oral cavity have an inhibitory effect on many microorganisms; lysozyme in saliva has antibacterial action.
  3. Peristaltic movements of the intestine remove infectious agents from the intestinal tract.
  4. Normal flora of the intestinal tract competes for receptors and nutrients with potential pathogens and also produces toxic metabolites.
  5. Defecation removes infectious agents from intestine.
 
12Genitourinary Tract
  1. Flushing action of urine and its acidic pH, vesicoureteric valves prevent the establishment of infection.
  2. The acidic pH of the vagina is unfavorable for pathogenic organisms.
Conjunctiva: The flushing action of lachrymal secretions along with lysozyme protects the eye from infectious agents.
 
Acquired Immunity
It is the resistance that the body develops after exposure to an agent like bacteria, viruses or toxins. It improves after repeated exposure to the agent and is specific. It is mediated by antibody and T- lymphocytes (helper and cytotoxic). Acquired immunity is broadly classified into (i) Active immunity, (ii) Passive immunity.
  • Active immunity- is of two types
    • Natural- by exposure to infection
    • Artificial- by use of vaccines.
 
Mechanisms of Acquired Immunity
Development of acquired immunity involves both a humoral and cell-mediated immune response
  1. Humoral immunity: It is immunity produced by the activation of B lymphocytes which provide resistance against infectious agents by producing antibodies. It brings about immunity by (i) Neutralization of infectious agents, (ii) Opsonization, (iii) Complement activation, (iv) Antibody dependent cellular cytotoxicity. It is important particularly in defense against capsulated and toxic bacterial infections and viral infections.
  2. Cellular immunity: It is also called as cell mediated immunity. It begins with activation of T- lymphocytes which destroy the infectious agents entering the body of the host. This type of immunity is an important and major defense mechanism of the host against infections caused by viruses, fungi, parasites and certain intracellular bacteria like tubercle bacilli. It also has a role to play in delayed hypersensitivity reactions and rejection of foreign tissue transplants.
 
ACTIVE IMMUNITY
Active immunity can be either cell-mediated or humoral. In cell-mediated immunity, cells such as cytotoxic T cells hunt down and kill specific invaders by using the antigens on their cell membranes as identifying markers. With humoral immunity, B cells produce antibodies that bind to specific invaders, again using the antigens on their cell membranes as identifying markers. These antibodies make it easier for white blood cells to either destroy the microbes or neutralize their negative effects. In both natural and artificial forms, the body produces all the cells and materials to perform both cell-mediated and humoral immune functions. Active immunity is protection, that is produced by the person own immune system. This type of immunity is usually permanent.
 
13Types of Active Immunity
  1. Natural acquired immunity: It occurs following exposure to infection and may be short lasting (e.g. common cold) or long lasting (e.g. small pox).
  2. Artificial acquired immunity: It develops after administration of vaccines which may contain live or killed organisms or toxins.
Process of active immunity: The active immune system usually kicks in through a series of chain reactions. All invading microbes have certain proteins on their surfaces called antigens. When a specialized cell of the immune system called a phagocyte eats the microbe, it delivers the antigen to a white blood cell called a helper T-cell. Helper T-cells then activate other cells of the immune system, which together help to destroy the infection. This process also creates memory cells-cells that become activated to fight in the event the same microbe strikes again.
 
VACCINES
They are preparations containing nonpathogenic immunogens which when introduced into a host induce protective immunity against a specific infection. Active immunization is done by use of vaccines. Vaccines may be live attenuated, killed or in the form of toxoids.
Types of vaccines are:
  1. Live attenuated vaccines, e.g. BCG for tuberculosis
  2. Killed vaccines, e.g. salk vaccine for poliomyelitis
  3. Bacterial products, e.g. tetanus toxoid for tetanus
  4. Other vaccines, e.g. subunit vaccines, recombinant DNA vaccines.
    • Live attenuated vaccines: A single dose of live vaccine is sufficient for immunization. The attenuated organism can multiply in the body to provide a continuous antigenic stimulus and thus serves both as primary and booster dose.
      The attenuated organisms are the suspensions of living organisms with reduced virulence. These mimic natural infection with antibody production but without symptoms. Examples of some live vaccines are : oral polio vaccine (OPV); mumps, measles and rubella (MMR) and yellow fever.
    • Killed (inactivated) vaccines: These vaccines possess antigens common to the original pathogen but do not replicate. With killed vaccine, usually three doses of vaccines are required to have effective immune response. Booster doses are necessary. Killed vaccines include typhoid, cholera, rabies, hepatitis B, influenza, pertussis and pneumococcal vaccines.
    • Toxoids: Toxoids are modified toxins which have lost toxigenicity but retained the antigenicity. These are usually prepared by treating the toxins with formalin (formal toxoids). Toxoids are used for prophylaxis against those infections in which pathogenesis is attributable to a toxin. In DPT (diphtheria, pertussis, tetanus) vaccine, tetanus toxoid and diphtheria toxoid are mixed with a pertussis vaccine. Pertussis vaccine acts as an adjuvant. Tetanus toxoid (TT) and diphtheria toxoid (DT) are two widely used toxoids for immunization.
 
PASSIVE IMMUNITY
Passive immunity is protection by an animal or human and transferred to human, usually by injection. Passive immunity often provides effective protection, but this protection disappears 14with time, usually within a few weeks or months. Passive immunity is immunity acquired by an individual during life in ready form, i.e. antibodies. It is of two types: (a) Natural, (b) Artificial.
 
Types of Passive Immunity
Passive immunization is used when it is considered necessary to give immediate protection to an anticipated infection. Immunity produced is short-lasting. Human sera and animal sera are used for passive immunization.
  1. Human sera: Two types of normal human immunoglobulin are available, pooled immunoglobulins and specific (hyper immune) immunoglobulins.
    • Pooled immunoglobulins
      It is prepared from pooled normal human serum containing high levels of appropriate antibody. Human normal immunoglobulin is used for short-term prophylaxis of hepatitis A and measles after contact with a case.
    • Specific (hyper immune) immunoglobulins: It is prepared from sera of patients who are recovering from infection (convalescent sera) or from persons who have been actively immunized against a specific infection. Specific immunoglobulins are available for passive immunization against.
      • Tetanus (human tetanus immunoglobulin, HTIG)
      • Hepatitis B (hepatitis B immunoglobulin, HBIG)
      • Rabies (HRIG).
        Human sera are administered by intramuscular injection. However, in case of rabies, half dose is given around the bite wound and the other half is administered intramuscularly.
  2. Antiserum: The term antiserum is applied to antibodies prepared in animals. These sera are raised in horses by active immunization. The equine antisera were previously used widely but current trend is in favor of using human sera as far as possible.
  3. Combined passive and active immunization: In some diseases (tetanus, diphtheria, rabies) passive immunization is often undertaken in conjunction with inactivated vaccines to provide both immediate (but short-lasting) passive immunity and slowly developing active immunity. Both injections should be administered at separate sites.
  4. Individual immunization: Vaccines offered under national immunization schedule are limited by economic considerations. Some important vaccines are omitted because they are costly. These include hepatitis B vaccine, MMR, vaccine, varicella vaccine and typhoid vaccine. These may be supplemented by individual initiative, whenever possible.
    • Hepatitis B vaccine: Three doses of killed vaccine are given at 0, 1 and 6 months. It is given intramuscularly into the deltoid or, in infants into the anterolateral aspect of the thigh.
    • MMR vaccine: A single dose of measles-mumps-rubella (MMR) vaccine is given at 16–24 months or later. It is live attenuated vaccine and given by subcutaneous route.
    • Varicella vaccine: The vaccine is given as a single subcutaneous dose in children 9 months to 12 years of age, and as two doses at an interval of at least 6 weeks, in those older. It is live attenuated vaccine. It is contraindicated in pregnancy.
    • Typhoid vaccine: Two recent typhoid vaccines, the live oral Gal-E mutant vaccine and the injectable purified Vi polysaccharide vaccine are recommended for immunization of those five years old or above.
 
Uses of Passive Immunization
  1. It provides immediate short lasting immunity
  2. 15Treatment of severe infections
  3. To suppress active immunity, e.g. Rh positive baby born to Rh negative mother.
TABLE 1.1   Differences between active and passive immunity
Active immunity
Passive immunity
  1. It develops actively in the host
  2. Requires prior contact with organisms
  3. Immunity usually long lasting
  4. Immunological memory is present
  5. Not of use in immunodeficient persons
  6. Lag period is present
  1. Host receives in the form of preformed antibodies
  2. Prior contact not required
  3. Brief but effective immunity
  4. Immunological memory is absent
  5. Useful in immunodeficient persons
  6. Lag period is absent
 
Miscellaneous
  1. Combined immunization: It is the simultaneous use of active and passive immunization. Passive immunity provides early protection till active immunity takes effect.
  2. Local immunity: It is the local immunity present on mucosa usually due to secretory IgA. It may be induced by natural infections or oral vaccines. For example, oral polio vaccine.
  3. Herd immunity: It is the overall resistance of individuals in the community against infection. When herd immunity is good, it protects against epidemics of infection. For example, oral polio vaccine gives good herd immunity.
 
CONCEPTS OF HEALTH, ILLNESS AND SICK BEHAVIORS
  1. It is useful for the nurse to be aware of the behavioral components of health, illness and sick role behavior.
  2. Every person develops a system of health beliefs and attitudes, and these tend to fall within the framework provided by society or cultural heritage.
  3. Health behavior activities a person engages in, when feeling well, to take measures to prevent disease and illness or to detect them before symptoms occur.
  4. Illness behavior activities a person engages, when feeling ill, that will lead to the defining of the state of health and that will gain help.
  5. Sick-role behavior, activities a person engages in believing himself ill. For any individual the level of health behavior is determined by the significance of symptoms—danger value, visibility, ambiguity, fear of unknown, the expectations of those from whom help is sought, feeling about dependence and fear of loss of control, the expectorations of the illness position, including past experiences with illness.
 
ILLNESS BEHAVIOR
  1. Illness is not merely the presence of disease process. Illness is a state in which a person's physical, emotional, intellectual, social, developmental or spiritual functioning is diminished or impaired compared with that person's previous experiences.
  2. Illness behavior involves the ways persons monitor their bodies, definite and interpret their symptoms, take remedial actions, and use their health care system.
  3. The important internal values influencing the way clients behave when they are ill are their perceptions of symptoms and the nature of the illness. A client's illness behavior can also be affected by the nature of the illness.
  4. 16Acute illness involves symptoms of relatively short duration that are usually severe and may affect functioning in any dimension.
  5. Chronic illnesses persist, usually longer than 6 months, and can affect functioning in any dimension.
  6. External variables influencing a client's illness behavior include the visibility of symptoms, social groups, cultural background, economic variables, accessibility of the health care system and social support.
 
Stages of Illness Behavior (Fig. 1.5)
 
Symptom Experience
  1. During the initial stage, a person is aware that something is wrong. A person usually recognizes a physical sensation or a limitation in functioning but does not suspect a specific diagnosis.
  2. The person's perception of symptoms includes awareness of a physical change such as pain, a rash, or a lump.
 
Assumption of the Sick Role
  1. The assumption of the sick role results in emotional changes, such as withdrawal or depression, and physical changes.
  2. Emotional changes may be simple or complex, depending on the severity of the illness, the degree of disability and anticipated length of the illness.
    zoom view
    Fig. 1.5: Stages of illness behavior
 
17Medical Care Contact
  1. If symptoms persist despite home remedies, become severe or require emergency care, the person is motivated to seek professional health services.
  2. In this stage the client seeks expect acknowledgement of the illness, as well as treatment in addition, the client seeks an explanation of the symptoms, the cause of the symptoms, the course of the illness for future health.
  3. Client's illness can be validated at any point on the health illness continuum. A health professional may determine that they do not have an illness or that illnesses are present and may belief threatening.
 
Dependent Client Role
  1. After accepting the illness and seeking treatment, the client enters the fourth stage of illness behavior.
  2. In this stage, the client depends on health care professionals for relief of symptoms. The client accepts care, sympathy and protection from the demands and stresses of life.
  3. It is socially permissible for clients in the dependent role to be relieved of normal obligations and tasks.
 
Recovery Stage
  1. The final stage of illness behavior-recovery and rehabilitation-can arrive suddenly, such as when a fever subsides.
  2. The recovery is not prompt, long-term care may be required before the client is able to resume an optimal level of functioning.
  3. In the case of chronic illness, the final stage may involve an adjustment to a prolonged reduction in health and functioning.
 
Impact of Illness on Family
 
Behavioral and Emotional Changes
  1. People react differently to illness. Individual behavioral and emotional reactions depend on the nature of the illness, the client's attitude toward's it, the reaction of others to it, and the variables of illness behavior.
  2. Severe illness, particularly one that is life threatening, can lead to more extensive emotional and behavioral change, such as anxiety, shock, dental, anger and withdrawal.
 
Impact of Family Roles
  1. When an illness occurs, the roles of client and family may change. Such a change may be subtle and short-term or drastic and long-term.
  2. An individual and family generally adjust more easily to subtle, short-term changes in most cases they know that the role change is only temporary.
  3. Long-term changes, however, require an adjustment process similar to the grief process. The client and family often require specific counseling and guidance to assist them in coping with role changes.
 
18Impact on Body Changes
  1. Some illnesses result in changes in physical appearance, and client's and families react differently to these changes.
  2. When changes in body image occur, such as results from a leg amputation, the client generally adjusts in the following phases: Shock, withdrawal, acknowledgment, acceptance and rehabilitation.
  3. Withdrawal is an adaptive coping mechanism that can assist the client in making the adjustments.
 
Impact of Self-concepts
  1. Self-concept is individual's mental image of themselves, including how they view their strengths and weaknesses in all aspects of their personalities.
  2. Self-concepts depend on parts of body image and roles but also include other aspects of the psychological and spiritual self.
  3. Self-concept changes because of illness may no longer meet the expectations of the family, leading to tension or conflict.
 
Impact of Family Dynamics
  1. Family dynamics is the process by which the family functions, makes decisions, give support to individual members, and copes with everyday changes and challenges.
  2. If a parent in a family becomes ill, family activities and decision making often come to a habit as the other family members wait for the illness to pass, or they delay action because they are reluctant to assume the ill person's roles or responsibilities.
 
HEALTH–ILLNESS CONTINUUM
  1. According to Neuman (1990), health on a continuum is the degree of client wellness that exist at any point in time ranging from an optimal wellness condition, with available energy at its maximum, to death, which represents total energy depletion (Fig. 1.6).
  2. According to health-illness continuum model, health is a dynamic state that continuously alters as a person adapts to changes in the internal and external environments to maintain a state of physical, emotional, intellectual, social, developmental and spiritual well-being.
  3. The continuum is thought of a complex, dynamic process that includes physical, psychological and social components. There are adoptive or maladaptive behavioral responses to internal and external stimuli.
    zoom view
    Fig. 1.6: Health-illness continuum
  4. 19Health and illness tend to merge but may represent patter s of adoptive change along the continuum the direction of change may be reversible, depending on the quality of the individual's adoptive efforts.
  5. The individual at the illness end of the continuum is characterized by feeling of uncertainty, helplessness, loss of control, loss of identity and incapacity for problem solving.
  6. As the patient is in the sick role, there is incapacity to meet other social roles, the person has sought diagnosis and get treatment.
  7. Less far along the illness end of the continuum, as illness behavior are brought in to play, the person may be tired, rundown and irritable with complains of loss of sleep, appetite, dependence, self-absorption, minor illnesses such as colds, infections, headaches and backaches.
  8. Between illness and wellness there is the ambiguous area where no symptoms are present and the person is neither especially well nor especially ill.
  9. At the health end of the continuum, as health behaviors are utilized, the persons are not only unaware of disease and without pain, fatigue or somatic complications but also tend to be resistant to infections, industrious, vigorous and physically agile, with a strong sense of identity and autonomy, caring out usual social roles and needing no health care.
  10. The goal in preventive health care is to maintain equilibrium between health and illness, with balance in favor of maximum wellness for the individual.
 
MODELS OF HEALTH AND ILLNESS
 
Health–wellness Model
  1. It was developed by Dunn (1997), the high level wellness model is oriented toward maximizing the health potential of an individual.
  2. This model requires the individual to maintain a continuum of balance and purposeful direction within the environment.
  3. It involves progress toward a higher level of functioning open-ended and expanding challenges to live at the fullest potential
 
Agent-host-environmental Model
  1. The agent-host-environmental model of health and illness originated in the community health work of level, etc.
  2. According to this approach the health or illness of an individual or group depends on the dynamic relationship of the agent, host and environment.
  3. The agent is any internal or external factors that its presence or absence can lead to disease or illness or disease.
  4. The host is the person or persons who may be susceptible to a particular illness or diseases.
  5. The environment consists of all factors outside of the host. It includes physical environment, social environment and biological environment.
 
Health Belief Model (Fig. 1.7)
  1. Rosenstoch's (1794) and Bakerand Maiman's (1975) health belief model addresses the relationship between a person's belief and behavior.
  2. 20It provides a way of understanding and predicating how clients will behave in relation to their health and how they will comply with health care therapies.
  3. The first component in this model involves the individual's perception of susceptibility to an illness.
    zoom view
    Fig. 1.7: Health belief model
  4. The second component is the individual's perception of the seriousness of the illness. This perception is influenced and modified by demographic and sociopsychological variables, perceived threats of the illnesses, and cues to action.
  5. The third component: The likelihood that a person will take preventive action- is the person's perception of the benefits of taking action.
 
Health Promotion Model
  1. The health promotion model proposed by pender (1996). It was designed to be a complementary counterpart to models of health protection.
  2. Health promotion is directed at increasing a client's level of well-being. The model focuses on three functions.
  3. The model also organizes cues into a pattern to explain the likelihood of a client's participation in health-promotion behavior.
  4. The focus of this model is to explain the reasons that individuals engage in health activities. It is not designed for use with families or communities.
 
BIOPSYCHOSOCIAL ASPECTS OF HEALTH AND ILLNESS (FIG. 1.8)
Physical, social, cultural and psychological factors interact dynamically and have an important influence on patient care needs there are needs common to everyone, no matter their sociocultural background, so-called human needs. These needs when they are not met create tensions and these tensions may give rise to anxiety that can hamper recovery if not relived.
21
zoom view
Fig. 1.8: Biopsychosocial model
 
Developmental Needs
  1. Prenatal: This stage determines many characteristics of the person and to some extend the requirements for use of adaptive resources throughout life.
  2. Neonatal: Developmental tasks are mostly physical, foundations are begun at this time for later personality responses.
  3. Infancy: This is a time of much physical, but foundations are begun at this time for later personality reponses.
  4. Childhood: Marked physical growth continues during this time. There is the beginning of role identification and moving out from the family to the peer group and community.
  5. Adolescence: Many physical and emotional changes occur as growth and maturation continues, changing hormonal activity and search for identity are major stresses for the adolescent.
  6. Young adulthood: Physical maturation is completed. There are many psychosocial stresses related to family and community roles during this stage.
  7. Middle adulthood: Developmental tasks are mostly psychosocial, reacting to reassessment of goals, physical stamina and hormone output beginning to decline.
  8. Older years: Physical conditioning is generally declining, and decreased sensory acuity may be noticeable. Developmental takes are related to sharing accumulated experiences and evaluating achievements.
 
Cultural Influences
  1. Culture may be thought of as the total way of life of a people, the social legacy the individuals acquire from his or her groups.
  2. The culture concept is cardial to an understanding of ourselves and our world.
  3. Custom and group habits are referred to as folkways and mores. Folkways are the accustomed and time-honored ways of doing things, the social habits that become routine and that are often performed without thinking.
  4. The patient's cultural background helps to determine the way the relationship with the physician or nurse in perceived and facilitates or impedes interaction or communication.
 
Religious Aspects
  1. Religion traditionally has focused on a god beyond the individual and has concentrated itself with relating the individual and has concerned itself with relating the individual to that god.
  2. 22Religious beliefs are seldom held to oneself but are part of group processes, so that there is immediate family or group support for the patient.
  3. It helps the patient's own attitude or belief that recovery is possible and that there are forces available to facilitate the healing process.
  4. It is important if the nurse is to be of help, to understand not only the spiritual needs of the patient but also the means and methods that organized religion has for meeting those needs.
 
HEALTH CARE DELIVERY SYSTEM IN INDIA (FIG. 1.9)
The health care system is intended to deliver the health care services. It constitutes the management sector and involves organizational matters. It operates in the context of the socioeconomic and political framework of the country. The health care delivery system in India has different components to it and the diagram below explains the existing pattern.
zoom view
Fig. 1.9: Health care delivery system in India (Existing)
 
Health Problems
  1. Communicable disease problem.
  2. Nutritional problems.
  3. Environmental and sanitation problem.
  4. Medical care problems.
  5. Population problems.
 
Resources
  1. Health manpower.
  2. Money and material.
 
Health Care Services
  1. Comprehensive care.
  2. Accessible care.
  3. Acceptable care.
  4. Provide scope for community participation.
  5. Available at a cost community and country can afford.
 
23Health Care System
  1. Public sector.
  2. Private sector.
  3. Indigenous system of medicine.
  4. Voluntary health agencies.
  5. National health programs.
 
Public Sector
  1. Primary health center (PHC)
  2. Hospitals.
    1. Community health center.
    2. Rural hospital.
    3. Strict hospital.
    4. Specialist hospital
    5. Teaching hospitals.
  3. Health Insurance Schemes- ESI (1948), Central Government Schemes (1954).
  4. Other agencies-Defensive and railways.
 
Private Sector
  1. Private hospitals, polyclinics, nursing homes and dispensaries.
  2. General practitioners and clinics.
 
Indigenous Systems of Medicine
  1. Ayurveda and Siddha.
  2. Unani and Tabbi.
  3. Homeopathy.
  4. Unregistered practitioner.
 
Voluntary Health Agencies
  1. Indian Red Cross Society (1920).
  2. Hindu Kusht Nivaran Sangh (1950).
  3. Indian Council for Child Welfare (1952).
  4. Tuberculosis Association of India (1939).
  5. Bharat Sevak Samaj (1952).
  6. Central Social Welfare Board (Aug 1953).
  7. Kasturba Memorial Fund (1944).
  8. Family planning Association of India (1949).
  9. All India Women Conference (1929).
  10. All India Blind Relief Society (1946).
  11. Professional Bodies (CMAI, TNAI).
  12. International Agencies.
 
Health Programs in India
  1. National Malaria Eradication.
  2. 24National Filaria Eradication.
  3. National Tuberculosis Program.
  4. National Leprosy Eradication.
  5. Guinea Worm Eradication.
  6. National Blind Control.
  7. National Diabetes Control.
  8. National Mental Illness Control.
  9. Iodine Deficiency Control.
  10. Diarrheal Disease Control.
  11. STD Control.
  12. Minimal Needs Program.
  13. MCH and Family Planning.
  14. Universal Immunization.
  15. Cancer Control Program.
 
HEALTH FOR ALL
  1. The World Health Assembly in its 30th meeting in 1977 decided the goal of HFA and defined that main social targets of Governments and WHO in the coming decades should be the attainment of all citizens of the world by the year 2000 of a level of health that will permit them to lead socially and economically productive life.
  2. Attainment of a level of health that will enable every individual to lead a socially and economically productive life.
 
Health for All Goals
  1. Realization of highest possible of health which includes physical mental and social well-being.
  2. Attainment of minimum level of health that would enable to the economically productive and participate actively in social life of community in which they live.
  3. Removal of obstacles to health such as unemployment, ignorance, poor living conditions, standards and malnutrition, etc.
  4. Health care services are within the reach of all in the country.
 
Strategies for Health for All
The Alma Ata declaration called for global strategy to provide guidelines for member countries to refer. In 1981, the WHO after consultations with member countries developed a global strategy for health for all. The global strategy provides common broad frame work which can be modified and adopted by countries according to their needs. The global strategy for HFA is based on the following principles.
  1. Health is a fundamental human right and a worldwide social goal and an integral part of social and economic development of the communities.
  2. People have right and the duty of participate individually and collectively in the planning and implementation of their health care.
  3. The existing gross inequality in the health strategies is of common concern of all countries and must be drastically reduced.
  4. 25Government has responsibility for the health of their people.
  5. Countries and people must become self-reliant in health matters.
  6. Governments and health professionals have the responsibility of providing health information to people.
  7. There should be equitable distribution of resources within and among the countries but should be allocated most to those who need most.
  8. Primary health care would be the key to the success of HPA and it has to be the integral part of the country's health system.
  9. Development and application of appropriate technology according to health care system of the nation.
  10. Research in the field of biomedical and health services must be conducted and findings should been applied soon.
The National Health Policy echoes the WHO a call for HFA and the Alma Atta declaration. It had laid down specific goals in respect of various health indicators by different dates such as 1990 and 2000 AD.
  1. Reduction of infant mortality from the level of 125 (1978) to below 60.
  2. To raise the expectation of life at birth from the level of 523 years to 64.
  3. To reduce the crude death rate from the level of 14 per 1000 population to 21.
  4. To reduce the crude birthrate from the level of 33 per 1000 population to 21.
  5. To achieve a net reproduction rate of one rural population.
 
HEALTH CARE SERVICES
  1. Health promotion
    1. Prenatal classes
    2. Nutrition counseling
    3. Family planning
    4. Stress management
  2. Illness prevention
    1. Screening programs (e.g. hypertension, breast cancer)
    2. Immunization
    3. Occupational health and safety measures
    4. Mental health counseling
    5. AIDS control program.
  3. Primary care
    1. School health units
    2. Routine physical examination
    3. Follow up for chronic illnesses (e.g. diabetes, epilepsy)
  4. Diagnosis
    1. Radiological procedure (e.g. CT scans, X-ray studies)
    2. Physical examination
    3. Laboratory investigations
  5. Treatments
    1. Surgical intervention
    2. Laser therapies
    3. Pharmacological therapy
  6. 26Rehabilitation
    1. Cardiovascular programs
    2. Sports medicine
    3. Mental illness program.
 
HEALTH CARE TEAM
Health team consists of a group of people who coordinate particular skills in order to assist a patient or his family. The personnel who comprises a particular team will depend upon the needs of the patient.
TABLE 1.2   Members of healthcare team
Sl. No.
Team
Description
1.
The physician
In hospital setting, the physician is responsible for the medical diagnosis and for determining the therapy required by the person who is ill or injured. A physician is a person who is legally authorizes to practice medicine in particular jurisdiction
2.
The nurse
A nursing team composed of personnel who provide nursing services to the patient and family. The team leader head nurse is responsible for delegation of duties to members of her team and care given to the patients
3.
Dietitian
Dietitian designs special duties and they supervise the preparation of meals according to doctor's prescription
4.
Physiotherapist
The physiotherapist provides assistance to a patient who has problem related to his musculo-skeletal system
5.
The social worker
The patient and his/her family are assisted by social worker with such problems as finances, rest home accommodation, counseling or marital problems, adaptation of children
6.
The occupational therapist
The occupational therapist assists patients with some impairment of function to gain skills as they relate to activities of daily living-ADL and helping with a skill that is therapeutic
7.
Paramedical technologist
It includes laboratory technologist and radio-logic technologists
Laboratory technologists: examines and study specimen such as urine, faces, blood and discharges from wound
Radio-logic technologists: Assist in wide variety of X-ray procedures, from simple chest radio-graphy to more complex fluoroscopy. Through use of radioactive materials, nuclear medicine technologists can provide diagnostic information about functioning of the patients liver, etc.
8.
The pharmacist
The pharmacist prepares and dispenses pharmaceuticals in hospital and community settings. The role of pharmacist in monitoring and evaluating the actions and side effects of medications on patients are becoming increasingly prominent
9.
Respiratory therapist
Respiratory technologist is skilled in therapeutic measures used in care of patients with respiratory problems. These therapist are knowledgeable about oxygen therapy devices, intermittent positive pressure breathing respirators, artificial mechanical ventilators and accessory devices used for inhalation therapy
 
HEALTH CARE AGENCIES
Types of Health Care agencies: Health care is provided in various settings.
  1. Outpatient services: Patients who don't require hospitalization can receive health care in a clinic. An outpatient setting is designed to be convenient and easily accessible to the patient. Hospital settings (to get the material) outpatient services are generally directed at primary and secondary health centers.
  2. 27Clinics: Clinics involve a department in a hospital where patients not requiring hospitalization, receive medical care.
  3. Institutions: Hospitals – Hospital have been the major agency of health care system. Hospitals are classified as 1. Public, 2. Private, 3. Military
A public hospital are financed and operated by the government agency at the local, state or national level. Hospitals provide services at free of cost.
Private hospitals are owned and operated by churches, corporations, individuals and charitable organizations. Private hospitals are operated on a for-profit-basis.
Military hospitals provide medical care for the armed forces and their families.
 
Health Care Organizations
TABLE 1.3   Organizations involves in healthcare
Sl. No.
Team
Description
1.
World Health Organization (WHO)
The World Health Organization is a specialized agency of the United Nations. It was organized in 1948 to achieve the highest possible level of health for all people. More than 150 countries are members of WHO and help to finance the financial requirement the health care activities around the world. The WHO is also active in nursing education and practice in a number of ways in India:
  1. It has offered guidance in setting up program of nursing education
  2. It has promoted training for auxiliary nursing personnel
  3. The WHO promotes public health in many ways around the world
2.
The International Red Cross Society
The International League of Red Cross was formed in 1919 after World War I. It was closely with national societies during times of national disasters, providing expertise and conducting seminars to help these societies to improve their administrations and services. A super global body made up of the above league and national societies is the International Conference of Red Cross‘s activities. The body meets once in four years. It supports unity in the work of all of these originations and promotes governmental support of the Red Cross Activities
3.
The Indian Red Cross Society
The Indian Red Cross Society was established in 1920, with major aims of helping others from a neutral point. It gives relief to needy and suffering people at times of major disasters and in times of wars
Aims: Prevention of disease, promotion of health and care of the sick in any kind of situation
Functions
  1. Gives financial aid to social welfare institutions
  2. Operates blood banks throughout India
  3. It teaches first aid
4.
United Nations International Children's Educational Fund (UNICEF)
UNICEF is an agency of the United Nations. It was founded in 1946 for the purpose of helping mothers and children in country affected by World War II. Now it offers services in all underdeveloped countries
UNICEF in India has provided teaching equipments for nursing education, textbooks and visual aids for schools and colleges of nursing and training for personal to help with the health of mothers and children
5.
USAID (United States Agency for International Development)
USAISD was started in 1961. It provides grants and loans for a number of projects designed to improve the health of the people. The US government presently extends aid to India through three agencies
Agencies of United States: (1) United States agency for International Development (USAID), (2) The public law-food for peace program, (3) The US export – import Bank
USAID on Health in India: (1) Malaria eradication program, (2) Medical education, (3) Nursing education, (4) Health education, (5) Water supply and sanitation, (6) Control of communicable diseases, (7) Nutrition, (8) Family planning
6.
UNDP (United Nations Development Program)
The United Nations Development programme was established in 1966 contributes towards increasing the pace of development in the Third World countries. It supports all phases of socio-economic development including agriculture, industry, education, health and social welfare. It is the main source of funds for technical assistance. The basics objective of the UNDP is to help poorer nations develop their human and natural resources more fully
 
28HOSPITAL: TYPES, ORGANIZATION AND FUNCTIONS
The English word ‘Hospital' originates from the Latin word “HOSPILE” and also some viewed that it comes from the French word ‘Hospitale' as do the words ‘Hostel' and ‘Hotel'. The three words hospital, hostel, hotel, all are derived from same source, are used in different sense but basically the meaning of the word will be the same. For example, in hotel, hotel authorities take care of the clients, who wish to stay there and client will receive the hospitality according to their ability. In hostel also, the hostel authorities are expected to treat their clients by providing basic amenities and other facilities as needed by their clients. In the same, hospital authorities also receive their clients as their guests and are expected to show hospitality than those of hotel or hostel. Likewise, all these three institutions are meant treating their clients but style of treatment will be different. Now, the term ‘Hospital' means an establishment temporary space occupied by the sick or injured. In other words, the hospital is an institution in which sick or injured persons are treated.
 
Definition
  1. According to WHO, “The hospital is an integral part of a social and medical organizations, the function of which is to provide for the population complete health care, both ‘curative' and ‘preventive' and whose outpatient services reach out to the family and it's environment; the hospital is also a center for the training of health workers and biosocial research”.
  2. According to Steadman's Medical Dictionary, “Hospital is an institution for the care, cure and treatment of the sick and wounded, for the study of diseases and for the training of doctors and nurses”.
  3. According to Blakiston's New Could Medical Dictionary, “Hospital is an institution for medical facility primarily intended, appropriately staffed, and equipped to provide diagnostic and therapeutic service in general medicine and surgery or in circumscribed field or fields of restorative medical care, together with bed care nursing care and dietic service to the patients requiring such care and treatment”.
 
Objectives of the Hospital
As stated in the definition and philosophy of the hospital, its main objective is to:
  1. Provide optimum health services to all people irrespective of race, color, caste and creed, and regardless of socioeconomical status.
  2. Provide care, cure, and preventive services to all people irrespective of race, color, caste, creed and economic and social status.
  3. Protect the human rights of clients while taking care in its jurisdiction in all areas of its services.
  4. Provide training for professional's, i.e., doctors, nurses, pharmacists, dentists and others technical personnel who are involving in health care services.
  5. Provide in-service/continuing education in all discipline professional/technical personnel involving health care. For updating their knowledge, skills, etc.
  6. Participate/conduct research and investigations in basic and applied biomedical, social and technological sciences that will benefit patient care, improve the community health 29status, the management of hospital services and the education of individual who perform the required service.
  7. Define its leadership role in the community and possibly the region depending upon its size, type and facilities in relation to regional area planning of hospital.
 
Scope of Hospital
As stated in the objectives of the hospital, an optimum health care service have the basis of scientific method and should be applied in a personalized manner with full recognition and attention to personal dimensions in client, needs and are carried out within a framework of social responsibility. It should be available and accessible to everyone who needs it through his own community. The optimum health services consist of following elements.
  1. Team approach: The care of the needy person will be taken by the team of professional members (Doctors, Nurses, etc.) arid paraprofessionals, technicians under the leadership of medically qualified persons with integration and co-ordination.
  2. Contents of service: A spectrum of services that includes diagnosis, specific treatment, rehabilitation, education and prevention.
  3. Co-ordination: Clients' care will cover the co-ordinated efforts of all agencies which have the required facilities at all levels.
  4. Continuity of care: Continuity of client care will be available and rendered by the particular agency with specific services whenever needed.
  5. Integration: Organization of the hospital care of both ambulatory and non-ambulatory patients into a continuum with common integrated services.
  6. Evaluation and research: Periodic evaluation program and provision of conducting research included in the optimum health services for adequacy in meeting needs of the patients and the community.
 
Functions of the Hospital
  1. Patient care: Care of the sick and injured, and restoration of the health of a diseased person without any discrimination.
  2. Diagnosis and treatment of disease: There are diagnosis and treatment services to in-patients. Within this broad function there are many subdivisions of medical, surgical, obstetrical, gynecic, pediatric, psychiatric and other forms of care and rehabilitation. Involved in the entire inpatient services are various modalities, including nursing, dietics, pharmaceutical skills, laboratory and X-ray services and varying refinement of diagnosis and therapy.
  3. Out-patient services: There are services to out-patients with an equally wide range of specialties and technical modalities.
  4. Medical education and training: Hospital provides professional and technical education for many classes of health personnel. They must work in hospital to receive proper training of their choice, i.e. medical, nursing, pharmacy, dental, laboratory technicians, X-ray technicians etc.
  5. Medical and nursing research: Since accumulation of different types of patients, the hospital provides the basis for scientific investigation into causes, diagnosis, treatment and nursing management of diseases and hospital administration, ward/unit administration in hospitals.
  6. Prevention of disease and promotion of health: Hospital provides services to surrounding populations that may be preventive care and promoting their health. There are many ways 30that hospitals as centers for technical skills can offer services to people before they are sick or can protect patients from the hazards of disease beyond that for which they have come to the hospital.
 
CLASSIFICATION OF HOSPITALS
Hospitals have been classified in many ways. Each hospital is distinct in its characteristic as it differs in structure, functions, performance and the community it serves. However, we can classify the hospitals into different types, depending upon different criteria. The most commonly accepted criteria for classification of the modern hospital are according to:
  1. Length of stay of patient (long-term and short-term)
  2. Clinical basis
  3. Ownership/control basis
  4. Objectives
  5. Size
  6. Management
  7. System of medicine
Classification according to length of stay of patient: A patient stays for a short-term in a hospital for treatment of disease that is acute in nature, such as pneumonia, peptic ulcer, gastroenteritis, etc. A patient may stay for a long-term in a hospital for treatment of diseases that are chronic in nature, such as tuberculosis, leprosy, cancer, psychosis. The hospital according to long-term and short-term also known as chronic-care hospital and acute care hospitals respectively.
Classification according to clinical bases: These are hospitals licensed as general hospital; treat all kinds of diseases but major focus on treating speed disease or conditions such as heart disease, or cancer, or ophthalmic or maternity, etc.
Classification according to ownership control: On the basis of ownership or control, hospitals can be divided into four categories:
  1. Public hospitals
  2. Voluntary hospitals
  3. Private/charitable/nursing homes
  4. Corporate hospitals.
  1. Public hospitals: Public hospitals are those run by the central or state governments or local bodies on noncommercial lines. These may be general hospital or specialized hospitals or both.
  2. Voluntary hospitals: Voluntary hospitals are those which are established and incorporated under the Societies Registration Act 1860; or Public Trust Act 1882 or any other appropriate Act of Central or State Governments. They are run with public or private funds on a noncommercial basis.
  3. Private nursing hospitals/nursing homes: Private nursing hospitals/nursing homes are generally owned by an individual doctor or a group of doctors. They run the hospital or nursing home on a commercial basis. They accept patient suffering from infirmity, advanced age, illness, injury, chronic, disability, etc. But do not admit patient suffering from communicable disease, alcoholism, drug addiction or mental illness. Usually they prefer patient from wealthy families.
  4. Corporate hospitals: Corporate hospitals are hospitals which are public limited companies formed under the Companies Act. They are normally run on commercial lines. They can be 31either general or specialized or both (e.g. Hinduja hospital, Mallya hospital, Apollo Group of Hospitals).
Classification according to the objectives: According to the objectives, hospitals can be classified into three categories:
  1. Teaching-cum-research hospitals
  2. General hospitals
  3. Specialized hospitals.
  4. Isolation hospitals.
  1. Teaching-cum-research hospital: Teaching cum research hospital is a hospital to which a college is attached for medical nursing/dental/pharmacy education. The main objective of these hospitals is teaching based on research and the provision of health care is secondary, e.g. AIIMS, New Delhi, PGIMER, Chandigarh, JIPMER, Pondicherry, KR Hospital, Mysore, Victoria hospital, Bangalore belong to this type.
  2. General hospitals: General hospitals are those which provide treatment for common diseases and conditions. All establishments permanently staffed by at least two or more doctors which can offer inpatient accommodation and provide active medical and nursing care for more than one category of medical discipline such as general medicine, general surgery, obstetrics and gynecology, pediatrics, etc. The main objective of these hospitals is to provide medical care to the people. While teaching and research is secondary and incidental, e.g. all district and taluk or PHC or rural hospitals belong to this type.
  3. Specialized hospitals: Specialized hospitals are hospitals providing medical and nursing care primarily for only one discipline or a specific disease or condition of one system. In other words, these hospitals concentrate on a particular aspect or organ of the body and provide medical and nursing care in that field, e.g. tuberculosis, ENT, ophthalmology, leprosy, orthopedics, pediatrics, cardiology, mental health psychiatric, oncology, STDs, maternal, etc. The specialized department, administration attached to a general hospital will not be considered as specialized hospital.
  4. Isolation hospitals: Isolation hospital is a hospital in which the persons are suffering from infections/communicable diseases requiring isolation of the patients, e.g., Epidemic Diseases Hospital, Bangalore.
Classification according to size: On the basis of health committee report, it is recommended that the following pattern of development of hospitals to be adopted according to size, i.e. bed strength.
  1. Teaching hospital 500 (bed to be increased according to the number of students).
  2. District hospital 200 (may be raised up to 300 beds depending upon population).
  3. Taluk hospital 50 (may be raised depending upon population to be served).
  4. Primary health centers 6 (may be increased up to 10 depending upon needs).
Classification according to management
  1. Union government/government of India: All hospitals administered by the government of India, e.g. hospital run by the railways, military/defense, or public sector undertakings of the central government.
  2. State governments: All hospitals administered by the state/union territory. Government authorities and public sector undertaking operated by the state/union territories including the police, prison, irrigation department and, etc.
  3. Local bodies: All hospitals administered by local bodies, i.e. municipal corporation, municipality, zila parishad, panchayat, e.g. corporation maternity homes.
  4. 32Autonomous bodies: All hospitals established under special act of parliament or state legislation and founded by the central/state government/union territory, e.g. AIIMS, New Delhi, PGIMER, Chandigarh, NIMHANS, Bangalore, KMIO, Bangalore.
  5. Private: All private hospitals owned by an individual or by a private organization, e.g. MAHE, Manipal, Manipal Hospital, Bangalore, Hinduja hospital, Mumbai.
  6. Voluntary agencies: All hospitals operated by a voluntary body/a trust/charitable society registered or recognized by the appropriate authority under central/state government laws. This includes hospitals run by missionary bodies and cooperatives.
Classification according to system: According to the system of medicine, we can classify the hospital as follows:
  • Allopathic hospitals.
  • Ayurvedic hospitals.
  • Homeopathic hospitals.
  • Unani hospitals.
  • Hospitals of other systems of medicine.
 
LEVELS OF DISEASE PREVENTION
The disease process, in many instances is susceptible to interruption in order to limit its further progress or the speed of its progression. As disease involves interaction of host, agent and environment prevention can be achieved by altering one or more of these three elements so that interaction does not take place or is interrupted in favor of the host. Effective preventive measure requires that the disease process be interrupted as early in its course as possible.
The interaction between the agent and the host can be avoided either by the elimination of the agent in the environment or by converting the human host susceptible or immune to the attack of the agent. Those attempts to bring about changes in the three elements before the disease stimulus is produced are grouped under one type of prevention namely primary prevention. When the disease stimulus has already been practiced and the disease process has crossed over to the period of pathogenesis two types of prevention, namely secondary and tertiary prevention.
  1. Primary prevention: Primary prevention can be defined as “action taken prior to the onset of disease which removes the possibility that a disease will ever occur”. It signifies intervention in the prepathogenesis phase of a disease or health problem or other departure from health.
    Primary prevention is applied at the prepathogenic period; it includes health promotion and specific protection.
    1. Health promotion: The first level of prevention is by promoting and maintaining the health of the host by nutrition, health education, good heredity and other health promotion activities.
    2. Specific protection: It may be directed towards the agent like disinfection of contaminated particles, materials, water, food, and other particles on the assumption that the agent has escaped into these vehicles or environment. Specific protection can also be achieved by immunizations to increase the resistance of the host so that the host will be able to withstand the onslaught of the agent. This is done by the active and passive immunizations.
  2. Secondary prevention: Secondary prevention can be defined as “action” which halts the progress of a disease at its incipient stage and prevents complications. The specific interventions 33are early diagnosis, e.g. screening tests, case finding programs and adequate treatment. The secondary prevention done by early diagnosis and treatment. Early diagnosis and prompt treatment comes under secondary prevention. If primary prevention fails or when suitable measures are not available (as in cancer) the disease stimulus is bound to be produced. Early detection of the disease is possible by periodic examinations of population groups who are at special risks like antenatal mothers, growing children, industrial worker, etc.
    Monitoring of persons middle age and above is one of the modern methods of early detection of cancer. In many instances, this detection of the diseases condition is possible only after the onset of the signs and symptoms. Early detection of the disease ensures prompt treatment so that the disease will not progress further.
  3. Tertiary prevention: When the disease process has advance beyond its early stages, it is still possible to accomplish prevention by what might be called “tertiary prevention”. It signifies intervention in the late pathogenesis phase. Tertiary prevention can be defined as “all measures available to reduce or limit impairment and disabilities, minimize suffering caused by existing departures and disabilities, minimize suffering caused by existing departures from good health and to promote the patient's adjustments to irremediable conditions”. Tertiary prevention includes disability limitation and rehabilitation.
Disability limitation: It is necessary that the disability that is caused by limited by active medical or surgical treatment so that there is no further deteoriation of the disease process.
Rehabilitation: Those with permanent disability as in the case of leprosy, tuberculosis, polio, mental retardation, etc. will not be able to lead an independent life unless they are rehabilitated. This level will be needed only when have failed in the application of previous levels of prevention.
 
PRIMARY HEALTH CARE (FIG. 1.10)
Primary health care is essential health care made universally accessible to individuals and families in the community, by means acceptable to them, through their full participation and at a cost that the community and country can afford.
zoom view
Fig. 1.10: Primary health care
34It forms an integral part both of the country's health system of which it is the nucleus and the overall social and economic development of the community (Alma Ata 1978).
 
Highlights of this Definition
This definition highlights several attributes of primary health care. It stresses on:
  1. Its essentiality by observing that primary health is essential health care.
  2. Its ‘accessibility' by observing “made universally accessible to individuals and families in the community.
  3. Its ‘acceptability' by observing by means acceptable to them.
  4. Its ‘patricianly' by observing acts a cost that the community and country can afford.
  5. Its ‘affordability' by observing it forms an integral part both of the country's health system of which it is the nucleus and the overall social and economic development of the community.
  6. Its integrality by observing it forms an integral part both of the country's health system of which it is the nucleus and the overall social and economic development of the community.
 
Attributes of Primary Health Care
  1. Accessibility: Primary health care permeates uniformly to reach equitably to all segments of population.
  2. Acceptability: Primary health care achieves acceptability through cultural assimilation of its policies and programs.
  3. Adaptability: Primary health care system is highly flexible and adaptable. It believes in ‘adaptation' rather than ‘adaptation'.
  4. Affordability: Primary health care is affordable to consumer as well as providers.
  5. Availability: Primary health care is always ready to respond to any demand at any time.
  6. Appropriateness: Primary health care system evolves from the socio-economic conditions, social values and health situation of a community, it is quite appropriate from all angles.
  7. Closeness: Primary health center is close at hand to people at their door steps.
  8. Continuity: Primary health service is a continuous service which extends from ‘womb' to tomb and addresses the changing needs of an individual in all situations of health and disease.
  9. Comprehensiveness—Primary health care is comprehensive and the curative needs of the community.
  10. Coordinativeness: Primary health care is dependent on inter-sectoral coordination and community participation.
 
Elements of Primary Health Care
As per Alma Ata declaration primary health care includes.
  1. Education concerning prevailing health problems and methods of identifying, preventing and controlling them.
  2. Promotion of food supply and proper nutrition.
  3. An adequate supply of water and basic sanitation.
  4. Maternal and child health care including family planning.
  5. Immunization against the major infectious disease.
  6. 35Prevention and control of locally endemic diseases.
  7. Appropriate treatment of common diseases and injuries.
  8. Promotion of mental health.
  9. Provision of essential drugs.
 
Principles of Primary Health Care
  1. Equitable distribution: Primary health care services must be shared equally by all people irrespective of their ability to pay (rich, poor, urban or rural).
  2. Community participation: Primary health care must be a continuing effort to secure meaningful involvement of the community in the planning, implementation and maintenance of health services.
  3. Coverage and accessibility: Primary health care implies providing health care services to all which are required by them. The care has to be appropriate and adequate in content and in amount to satisfy the essential health needs of the people and has to be provided by methods acceptable to them.
  4. Intersectoral coordination: Primary health care requires joint efforts of other health related sectors such as agriculture, animal husbandry, food, industry, housing, social welfare, public works, communication and other sectors.
  5. Appropriate health technology: The technology that is scientific, adaptable to local need and socially acceptable instead of costly methods, equipment and technology.
  6. Human resource: Health resource is very essential to make full use of all the available resources including the human potential of the entire community.
  7. Referral system: Referral system would be desirable to develop referring from one level to another with laid down procedures and policies.
  8. Logistics of supply: The logistic of supply include planning and budgeting for the supplies required procurement or manufacture, storage distribution and control.
  9. The physical facilities: The physical facilities for primary health care need to be simple and clean. It should have a specious waiting area with toilet facility.
  10. Control and evaluation: A process of evaluation has to be built into assess the relevance, progress, efficiency, effectiveness and impact of the services.
 
Role of Nurse in Primary Health Care
An extent committee on community health nursing was concerned by WHO executive Board in July 1974 to recommend way in which nursing could have critical impact on the urgent health problems throughout the world. The committee made specific recommendations.
  1. The development of community health nursing services, responsive to community health needs that would assure primary health care coverage for all.
  2. The reformulation of basic and post basic nursing education as to prepare all nurses for community health nursing.
  3. The inclusion of nursing in national development plans in a way that would ensure the rational distribution and the appropriate utilization and support of nursing personnel.
 
Role of Nurse in PHC
  1. Community health nurse work with population, community, family, individual. The focus is multiple or promoting health maintaining a degree of balance toward health.
  2. 36Community health nurse focus on assessment of the impact of the socioeconomical and cultural factors affecting health measures the must constantly be dealt with and take priority in order to make family assume health measures.
  3. The community health nurse works with entire spectrum of health and illness conditions from optimal health to minor or severe conditions from acute to chronic illness.
  4. The community health nurse works in all kinds of setting such as home, school, clinic, industry, etc.
  5. The community health nurse works in school where primary goal is health education and disease prevention.
  6. The community health nurse works in industry is to improve the production and employees safety.
  7. The community health nurse is responsible for assisting patients and families to coordinate health care, which necessitates contact with personnel from health, welfare and other significant community agencies.
  8. Community health nurse has responsibilities in education an training of individuals, auxiliaries and others.
  9. The community health nurse involves in provision of direct services to patients both preventive and curative at the outpatient, inpatient clinics and community.
 
Major Role of CHN in PHC
  1. Facilitative role.
  2. Developmental role.
  3. Supportive role.
    • Training
    • Management
    • Supervision
    • Program implementation
    • Program evaluation
    • Policy making
    • Program planning
  4. Clinical role.
 
CONCLUSION
Health of an individual or group affects its work output and efficiency, good health is not only essential for a normal life and activities, but it is the basic factor for a happy life. Nurses care for individuals who are healthy and ill, of all ages and cultural backgrounds, and who have physical, emotional, psychological, intellectual, social and spiritual needs. The profession combines physical science, social science, nursing theory, and technology in caring for those individuals. Health promotion concerns are those activities directed towards maintaining or enhancing the health and well-being of individuals and their families. The student learns the role of patient advocate as he/she provides information needed to make health care decisions and then supports the patient in that decision. The student learns and teaches health practices that promote and enhance optimum functional levels of wellness. Such practices include, but are not limited to, nutrition, diet, exercise, drug therapy and complementary therapies.
37BIBLIOGRAPHY
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