Peripartum Depression

Risks from untreated major depression during pregnancy

Decreased prenatal care
Insufficient weight gain
Increased use of addictive substances
Increased risk of being a victim of violence
Decision to abort due to depression
Suicide (although risk may be lower than in non-pregnant women

Obstetric & neonatal complications of depression
Fetal growth retardation
Pre-eclampsia
Premature labor
Placental abruption
Newborns more inconsolable (independently of addictive substance use, weight gain, length of labor, method of delivery and Apgar scores)


Types of postpartum mood disorders
Postpartum “blues”
Postpartum depression
Postpartum psychoses

Postpartum “blues”
Central features: tearfulness, lability, reactivity
Peaks 3-5 days after delivery
Present in 50-80% of women
Present in all cultures studied
Unrelated to environmental stressors
Unrelated to psychiatric history

Postpartum “blues” : hormone withdrawal hypothesis
Ovarian steroid receptors in CNS are heavily concentrated in the limbic system
The magnitude of the postpartum drop in estrogens and progesterone correlates with presence of “blues”; absolute levels don’t
Neuroactive steroids (pregnanolone, allopregnanolone) decrease postpartum, affecting GABA

Postpartum “blues”: biological attachment hypothesis
Neurobiological systems foster attachment between mammalian mothers & infants
Oxytocin activates limbic structures (e.g. the ACG) that mediate the interface between attention & emotion
Postpartum reactivity may stem from this
With stressors, depression may result

“I couldn’t snap out of it. I was so down. I had a knot in my stomach. I kept wringing my hands. Sometimes I held my head, knowing that at any second, it was going to explode. I was petrified to get up with my baby. I would cry at the drop of a hat. I was afraid I’d lose my temper. I felt guilty because I couldn’t control myself. I couldn’t bring myself to eat. I had to force myself to chew. I couldn’t sleep even though I was exhausted.” (from Dalton)

Clinical features of postpartum depression
Despondency
Sleep disturbance, fatigue, irritability
Anorexia
Poor concentration
Feelings of inadequacy
Ego-dystonic thoughts of harming the baby

Characteristics of postpartum depression
Begins within 4 weeks of baby’s birth
Clinical presentation peaks 3-6 months after delivery
Present in 10% of new mothers in U.S.
Much less prevalent in some cultures
Related to psychiatric history
Related to environmental stressors

Consequences of untreated postpartum depression
Disturbed mother-infant relationship (elevated cortisol found in both)
Psychiatric morbidity in children later (depression, conduct disorder, lower IQ)
Marital tension
Vulnerability to future depression
Suicide/homicide

Postpartum cultural influences
Ceremonies
Cleansing rituals
Seclusion
Rest
Solicitude
Return to home of origin

Postpartum psychoses
Usually related to a mood episode
More disorientation, agitation, lability
Peaks within 3 weeks of birth
Affects 1/1000 women overall, but 25 - 35% of women with bipolar diathesis
Predicted by absence of depression/anxiety in third trimester
Unrelated to environmental stressors

Treating postpartum mood disorders
Psychotherapy
Interpersonal psychotherapy
Couples therapy
Somatic treatments
Antidepressant medication
Hormone therapy
ECT
Self help networks

Interpersonal psychotherapy for postpartum depression
Focus on role transition
Integrate new role with established roles
Explore feelings & ambivalence about roles
Assess satisfaction with relationships
Define patient’s expectations of others
Renegotiate relationships
Maintain specific problem focus

Couples therapy for postpartum depression: evaluation
Evaluation begins with family, then each parent individually, then couple together
Relevant history
parents’ families of origin
history of parents’ relationship
parents’ expectations about the baby
circumstances surrounding becoming pregnant, pregnancy, labor, delivery, postpartum

Couples therapy for postpartum depression
Create accepting atmosphere
Educate about wide range of normal feelings postpartum
Establish common ground
Articulate “ideal family”
Find compromises to approximate the ideal and replace fantasies with a real family

Antidepressants: teratogenicity
Morphologic: none for SSRI’s, tricyclics & venlafaxine; not enough systematic data about newer agents (e.g. nefazodone, bupropion, mirtazapine)
Behavioral
none for fluoxetine, tricyclics
fluoxetine protects against brain effects of maternal separation in rats

Antidepressants: fetal & neonatal side effects
SSRI’s: “colic”, decreased weight gain; tremor; tachypnea; motor automatisms; increased bleeding diathesis
Tricyclics: tachycardia; (rare) tachyarrhythmia, urinary retention
All antidepressants:
neonatal withdrawal
questionable association with prematurity

Guidelines for antidepressants during pregnancy
Consider better-studied agents
Agents to avoid during pre-eclampsia: bupropion, maprotiline
Vitamin C with SSRI’s
Dosing considerations
increase sometimes needed in 2nd trimester
consider reduction during last month

Postpartum pharmacotherapy: side effect concerns
Sedation
Insomnia
Weight gain
Decreased sexual desire
Effects on breastfeeding infant

Antidepressants & lactation: relative doses to nursing
Sertraline: 0.4% - 1.0%
Fluvoxamine 0.5% - 1.6%
Paroxetine: 0.1% - 4.3%
Fluoxetine: 1.2% - 12.0%
Venlafaxine: 5.2% - 7.4%
Citalopram: 0.7% - 9.0%
(% of weight-adjusted maternal doses)

Antidepressants & lactation: reported side effects
Usually none
Fluoxetine case report of “colic” -- e.g. crying, restlessness, decreased sleep, vomiting, watery stools
Citalopram case report of uneasy sleep
Doxepin case report of pallor, hypotonia, respiratory depression

Prescribing during lactation
Explain potential risks & benefits, ideally to both parents
Obtain description of baby’s baseline behavior
For possible infant side effects, check serum level & confer with pediatrician
Some mothers pump breast milk prior to each dose & use pumped milk after dose

Postpartum estrogen treatment
Effective in placebo-controlled studies
Dose: 200 micrograms as transdermal patch, changed twice weekly, or sublingual 1mg QID
Contraindications: breast cancer, hypercoagulability, pregnancy
Efficacy & safety relative to antidepressants not yet established

Preventing peripartum depression
Discuss family planning & reproduction
Identify women at risk during pregnancy
Psychosocial prevention
Mood stabilizer prophylaxis for bipolar disorder
Antidepressant prophylaxis for depression
Estrogen prophylaxis (experimental)

BEHAVIORAL SYSTEM MODEL

BEHAVIORAL SYSTEM MODEL
INTRODUCTION
Theory and models provide knowledge to improve practice, guide research and nursing curriculum and identify the goals of nursing practice. Theory provides common ground for communication and professional autonomy and accountability. Theory also provides the nurse with goals for assessments, diagnosis, implement and intervention.
The behavioural system model was developed in 1868 by Dorothy E. Johnson. Her theory of nursing focuses on how the client adapts to his illness and how actual or potential stress can offer the clients ability to adapt. For Johnson the goal of nursing is to reduce stress so that the client can move more easily through the recovery process. Johnson’s theory focuses on basic needs interms of seven subsystem of behaviour.
Under normal conditions the client is able to function fairly effectively in his environment. When stress disrupts normal adaptation, however the clients behaviour becomes erratic and less purposeful. The nurse identifies the clients inability to adapt and provides nursing care to resolve problems in meeting the clients needs.
CREDENTIALS AND BACKGROUND OF THE THEORIST
On August 21, 1919 Dorothy E. Johnson was born in Savannah, Georgia.
In 1942, received her Bachelor of science in Nursing from Vanderbilt university in Nashville, Tennessee.
1943-1944, worked as staff nurse at Chatham Savannah Health Council.
In 1948, received her masters degree in public health from Harvard.
From 1949, her teaching career as professor of nursing was at the university of California, Los Angles.
In addition, From 1955 to 1967 she was a pediatric nursing advisor assigned to the Christian Medical College School of Nursing in Vellore, South India.
Her publications about nursing include many books, articles in periodicals and many reports.
In 1968, she proposed her behavioural system model.
She has received many honors such as 1975 faculty award from graduate students and many more.
On 1st Jan 1978, she retired as professor.
In 1980, she published her behavioural system model in “Conceptual Models for Nursing Practice”.
Assumptions
1.Behaviour is the sum total of physical biological, emotional and social factors / behaviours.
2.Behaviour of an individual evident at any given point in time is the product of the net aggregate of consequences of these factors over time and that point in time.
3.When these regularities and constancies are disturbed, the integrity of the person is threatened and the functions. Served by such order are less than adequately fulfilled.
4.Man is a system of behaviour characterized by repetitive, regular, predictable and goal directed behaviours that always strive toward balance.
5.There are different levels of balance and stabilization. Levels are different at different time periods.
6.Balance is essential for effective and efficient functions of the individual (a minimum of energy expenditure, maximum satisfaction and survival)
7.Balance is developed and maintained within the subsystem or the system as whole inorder to maintain adaptation and environment.
8.Changes in structures / function of a behavioural subsystem is related to dissatisfied drive, lack of functional requirement or changes in environmental conditions.
MAJOR CONCEPTS OF JOHNSON’S BEHAVIOURAL SYSTEM MODEL
1. Human Beings 3. Health
2. Society 4. Nursing
Human Beings
Johnson views human beings as having 2 major systems, the biological system and the behavioural system. It is the role of medicine to focus on the biological system, where as nursing focus is the behavioural system.
Society
It relates to the environment in which an individual exists. According to Johnson, an individuals, behaviour is influenced by all the events in the environment.
Health
It is a purposeful, adaptive response, physically, mentally, emotionally and socially, to internal and external stimuli in order to maintain stability and comfort. Johnson’s is attempting to maintain some balance / equilibrium.
Nursing
It has a primary goal that is to faster equilibrium within the individual. Johnson focused nursing on maintaining a balance in the behavioural system when illness occur in the individual.
JOHNSONS SEVEN BEHAVIOURAL SUBSYSTEMS
Johnson believes each individual has patterned, purposeful, repetitive ways of acting that comprise a behavioural system specific to that individual. Johnson identifies seven subsystems with in the behavioural system model. The seven subsystems are considered to interrelated and changes in one subsystem affect all the subsystem.
The following are the seven subsystems
1.Affiliative / Attachment Subsystem
Forms the base for all social inclusion, intimacy and social bonds or provide a sense of security.
2.Dependency Subsystem
“Succoring” behaviour that elicits a nurturing response or self dependence and interdependence.
3.Ingestion Subsystem
Involves food intake, results in appetite satisfaction or taking in nourishment in socially and culturally acceptable ways.
4.Elimination Subsystem
Involves behaviour surrounding the excretion of waste from the body or ridding system of waste in socially and culturally acceptable ways.
5.Sexual Subsystem
Involves behaviour associated with procreation and sexual gratification.
6.Aggressive Subsystem
Involves behaviour related to self protection and preservation of the self and society.
7.Achievement subsystem
Involves behaviour related to manipulation of the environment to gain mastery. Includes intellectual, physical creative, mechanical and social skill.
Behaviour is linked with each subsystem in response to the subsystem components, goals, set, choices and action. The components of each subsystem provide its structure.
Goal : is the drive or motivational aspect of the system
Set : is the predisposition to act with reference to the goal.
Choices : are the repertoire of a available alternatives.
Action : leads to the behavioural output of the system
The structural components of each subsystem give direction for nursing assessment, analysis planning, intervention and evaluation.

Health history

INTRODUCTION:

The health history is a chronologic and detailed record of the client. Its purpose is to elicit information regarding the variables that may affect the client’s health status. These data are then used to develop nursing diagnosis and subsequent plans for individual care. For the ill client health history serves as a back ground material related to the development of present symptoms and associated difficulties. A nurse utilizes health history to provide individualized care to determine the impact of illness on the client and the family, to determine health teaching needs and to begin discharge planning. The nursing health history is different from medical history. A physician takes a medical history to assist in diagnosis and treatment of an illness.

PURPOSES

1.To elicit information about all the variables that may affect the client’s health status.
2.To obtain data that helps the nurse to understand and appreciate client’s life experience.
3.To initiate a non judgemental, trusting interpersonal relationship with the client.

GUIDELINES FOR THE HEALTH HISTORY INTERVIEW

The health history interview process is affected by external and internal factors that affect the health history. Data quality and quantity are enhanced by sensitivity of the client and by one’s skill level with the interview process.

1.Preparation of the environment

a) When possible conduct the interview in a comfortable setting, using a quiet room with a closed door which decreases interruption.
b) Reduce or eliminate distractions and inform colleagues to avoid interruptions.
c) Use comfortable chairs to establish rapport. Adjust the distance between chairs to the client’s preference and sense of personal space.
d) Ensure a moderate room temperature to promote comfort.
e) Provide indirect lighting to prevent glare and strong shadows that may distort observations of non verbal clues.

2.Preparation of the client

a) After introduction explain the nature and purpose of the health history interview.
b) Speak in a moderate tone of voice, calmly and patiently.
c) Ask no probing, client centred questions, which help to put the client at ease. as the interview progress focused questions and therapeutic communication technique help to identify problem areas.
d) Alternate between open ended and closed questions depending on the data being collected.
e) Through out the interview observe non verbal communication for signs pf discomfort with the topic under discussion.
f) Respect the clients wish to decline discussing a topic.
g) Be aware of interview style and skills. Non verbal behaviour can either facilitate or inhibit client responses and affect the quality of the historical data.
3. Preparation of the Interviewer

a) Reduce repetition questioning and proceed in a structured and flexible manner. Until the nurse is comfortable with the interview format, use a pocket sized outline o0f the history format as an aid.
b) Take brief notes and inform the client in advance that you will be taking notes so as not to disrupt the flow of the interview. Avoid extensive notes taking, because it suggests that you are not listening attentively.
c) Compile the written history after interview.
d) Terminate the interview by summarizing highlights and allowing the client to add or clarify information.
e) Inform the client about how the physical examination will proceed.


COMPONENTS OF THE HEALTH HISTORY

The health history includes subjective data regarding the following
1.Biographical and demographic information
2.Physical Health history including review of system
3.Past health history
4.Family health history
5.Personal history
6.Psychosocial history
7.Environmental history
8.Review of system
9.Appraisal of the clients health maintenance and health promotion behaviour to asses health risks

1. BIOGRAPHICAL AND DEMOGRAPHIC INFORMATION

The extent and type of biographical and demographic information may vary depending on agency protocol. Include the date of interview because the information gathered constitutes baseline assessment. If the clients health status changes, the health history and physical examination reflect the extent of the change over the time. These provide clues about personal health risk. some risks may be ascribed to age, sex, family history, location of residence. Various health screening procedures are recommended based on age, gender, and background data. For e.g. periodical pelvic examinations for women’s and screening of visual acuity and testing for glaucoma for aged persons.


Biographical and demographic data;

Full name
Age
Sex
Address
Date and time of admission
Nationality
Religion
Primary language
Date and place of birth
Educational status
Marital status
Occupation
Income (per month)
Significant others
Phone number
Emergency contact
Legal guardian
Source of information
Diagnosis

2. PHYSICAL HEALTH HISTORY

Chief complaints
It begins with the client’s subjective statement of reason for seeking health care. It reveals the clients perception of the present health problem. The client may talk about what the problem means and how he is coping. When the client reports a health problem, either past or current, the nurse proceeds with a symptom analysis.

Symptom analysis
It is the client’s description of the health problem characteristics. In addition to assessing these characteristics, ask the client to provide an opinion about the cause of the manifestations or problem. Clients often have insight as to the nature and the cause of their problems. Explore fears and concerns to identify and treat their responses to health problems.
Areas included are
a)Timing;
It includes onset, duration, and frequency.
-Onset-refers to when a manifestation was first noticed. (Hours, days, months ago)
- Duration-is how long the manifestation lasts. (Minutes, hours, days, weeks)
-Frequency is how often a manifestation occurs (daily, weekly, and monthly)
.
b) Quality;
Ask the client to discriminate manifestation quality with adjectives such as sharp, stabbing, dull aching, cramping, cold, searing, burning, numb,
Tingling, loose, solid, soft, hard, and tight or crushing.

c) Quantity;
Severity of the pain is qualified by asking the client to rate the symptom on a scale such as 1-5 or 1-10. Assist the client in describing the size, amount and number or extent of manifestation as well as the severity or intensity. Assess the manifestations effect by asking how usual daily activities have been affected.
.
d) Location;
Ask the client to show where a symptom is located on the body, and whether it moves or is stationary.
.
e) Precipitating factor;
Ask the client does he know what may have led to the manifestation s occurrence? Ask what the client was doing at the time the manifestation noticed.

f) Aggravating and relieving factors;
Ask the client to recall whether any factor alleviate the symptom or make it worse.
.
g) Associated manifestations;
Inquire whether the client has noticed anything in conjunction with the manifestation.


Past health history

It may be important for determining both current and future health risk status.
It includes information about

Growth and development;
Any known problems with growth and development including prenatal or birth history or delay in language speech motor skills.

Immunization
Record childhood immunization and whether kept up to date, note last of T.T booster and influenza vaccination.

Past illness;
Ask spout measles, mumps, rubella, chicken pox, whooping cough, rhematic fever, poliomyelitis, asthma, T.B.


Serious or chronic illness;
Note the presence of DM, heart disease,
Hypertension, kidney problem, ulcers, thyroid problem, migraine head aches, seizure, stroke, arthritis, cancer, anamia, HIV etc.


Hospitalisation
Date and reason for each admission
Summary of treatment, length of hospitalisation
Name of primary care physician
Reaction to these events and their out comes

Surgeries
Date and time of procedure performed
Name of the surgeon
Note whether performed on inpatient or outpatient basis
Client’s reaction to the procedure and out come

Serious injuries or accidents
Date and type of injuries or accidents
Ask specifically about head injuries, fractures, burns, or other trauma
Note client’s reaction to each and their outcome.


Obstetric history
For completed pregnancies; number, course of each pregnancy,
Labour, delivery, post partum period, delivery date, birth weight, sex,
Infant’s health.
For uncompleted pregnancies; number, duration of pregnancy, date
And circumstances
Complications

Last visit to health care providers
Record most recent dates for dental, physical, vision, hearing
Examination
Date and results of screening or diagnostic tests performed.

Allergies
Description of allergies and reactions
Include medications, food, contact agents, environmental agent


Medications
Ask about common medications such as aspirin, vitamins, antacids,
Birth control pills, topical creams and lotions
Ask about dose, route, frequency, time of the day, reason for taking,
Are there problems with taking, who prescribed each drug and when


4. FAMILY HEALTH HISTORY

The family health history helps to identify family linked diseases that affect health status and risk for potential health problems

1.Inquire about relationship of family members, their ages (if living), the age at which they died the cause of death, the presence of other health problem.
2.Include a statement summarising health problems in the family.
3.Ask specifically about heart disease, hypertension, stroke , epilepsy, mental illness,T.B,DMthyroidproblems,arthritis,cancer, obesity,alcoholism,alzeimer’s disease, HIV, anaemia, haemophilia, migrains,allergies, asthma.
4.Diagram the data as a visual display to track health risk status.



4 .PERSONAL HISTORY
The next component is aimed at determining the kind of environment the client is accustomed to. Information is obtained related to occupational history, financial status, personal habits, daily activities, diet, sleeping pattern, recreation
.
Occupational history;
Inquire whether client is presently employed or unemployed. It helps to asses stress level and mental status of the client. Ask about the occupational hazards of the client’s job. Knowing that a client who is complaining of chest pain and cough has worked with industry for some years may help to pinpoint the contributing factor to the illness. Inquire about the geographical location of the work place. If the employment area is in pollutant region they may aggravates the existing condition.

Personal habits;
Information must be obtained regarding the use of cigarettes, alcohol

Diet;
A clients eating pattern s may be the clue to a problem of obesity or malnutrition. the clients eating habits may also direct to areas for further assessment; for example the adolescent who exist on fad food may develop skin problems, obesity or anaemia while the elderly person subsisting on te and toast may be in fluid and electrolyte imbalance and malnourished.
Inquire about the typical diet on a normal day, how much he eats how many meals he consumes per day? Who prepares the food? Does he eat and then vomit? Does he think he is too fat? Does the client is on special diet? Has he had any disturbances in digestion, chewing or swallowing?

Sleeping pattern;
The most common disorder is insomnia. Clients with psychosis and neurosis suffer from insomnia. Sleep and rests clearly affect the total well being. The more prevalent physical conditions disposes to insomnia are chronic pain, DM, gastric ulcer, angina pectoris, and respiratory disorders. Some physical characteristics that may indicate troubled sleeping pattern are dark circles, under eyes, puffy eyelids, irritability, headache, fatigue, and decreased attention span.
Inquire about total hours of sleep, when do they sleep and wake up?, have they experienced any difficulty in sleeping?, if they have experienced difficulty what remedies they tried? Has anything happened recently that might attribute to their sleeping difficulty? Do they have trouble fall asleep? Do they wake up during the night? Do they wake up morning feeling fatigued? Do they experience nightmares, sleepwalking bedwetting?


Activities of daily living;
When assessing daily activities, we will gather information about difficulties he might have experienced in the basic activities. We should also determine whether the client is independent in performing daily activities or whether he needs supervision or assistance?
Inquire whether he has any difficulty with feeding, grooming, brushing, bathing, dressing? Can he get out of bed? Can he get into a chair? Is he unable to carry out certain activities? How much assistance does he need? Does he require adaptive devices to perform activities?

Recreation / hobbies;
Discussion might include such things like exercise, hobbies and other interests and even time spent with family and friends.

Sexuality;
If the client is sick energy, enthusiasm and interest for sexual activity are generally decreased. Keeping in mind the nursing goal of promoting and maintaining health status and having background knowledge of sexuality will enable the nurse to pursue this area of health assessment with clients.


5. PSYCHOSOCIAL HISTORY

Psychosocial assessment assists the nurse in understanding a client’s response to circumstances and events which intern influences the client’s ability to function. It encomposses gathering information about psychological pattern and social experiences. It requires sensitivity and interpersonal skills by the nurse.
The term psychosocial denotes the melding of the 2 dimensions because it is impossible to separate the effects of psychological factors from those of social factors.

Psychosocial risk factors
During the health history interview, nurse will assess for risk factors which indicates that the client is at risk for psychosocial problem.
Those factors are
Social history
Personal history
Level of stress
Usual coping pattern

If these risk factors are present, proceed with a detailed assessment.


Psychological history

It encompasses gathering information about thoughts, feelings, motivation, mood, personal strengths, weakness, stressors, values and beliefs and spirituality, motor activity, behaviour, mental status, level of consciousness, attention span, orientation, speech and communication, memory, general knowledge, calculations, abstract thinking, insight, judgement. Record subjective data in health history and objective data in the physical assessment form.


Sociologic history
It includes information about psychosocial development, social network, socioeconomic status, and culture.

Psychosocial development;
It refers to a person’s level of growth and development. It occurs across the life span and includes physical, emotional, psychological, social and cognitive components. An understanding of human growth and development provides a foundation from which to asses the client.

Social network;
It is the group of people that surrounds, interacts, with, and sustains a person with intimacy, special integration, nurturing, reassurance, and assistance. The nurse becomes the part of a client’s social network when the client enters the health delivery system.
Collect social network data by observing the client during interactions with family members, visitors. Do not assume that only family members are the most important people. When planning care include significant others.

Socioeconomic status;
An individual’s economic position in the society is referred as socioeconomic status. For persons in the lower income areas may not get adequate clothing which may decrease the protection and opens 5the individual to illness. And they give importance to shelter than food so they are often weak, anaemic and malnourished.


5. ENVIORNMENTAL HISTORY
Ask about
Location of house (urban or rural)
Type of house
Whether client owns or rents the home
Environmental sanitation
Type of water supply
Method of sewage disposal
Drainage
Lavatory facilities
Lighting
Ventilation





6. REVIEW OF SYSTEM

General condition
Inquire about fever, chills, sweats, night sweats, weakness, weight loss, fatigue, malaise, nausea, vomiting, and he

Skin
Inquire about past skin problems like scars, birth marks, burns, purities, rashes, a change in skin colour, temperature, bruising, psoriasis, eczema, sun exposure, skin care habits, and a sore that does not heal presence of any tattoos.
.
Hair
Is there any problem with alopecia, dryness, brittleness, dandruff?

Nails
Are there any problems with brittleness, cracking, or splitting? Is there any change in nail texture? Does the client bite his nails?

Haematopoietic
Inquire about fatigue, unusual bleeding, easy bruising, ecchymosed, anaemia, leukaemia, exposure to radiation, any blood transfusion.

Endocrine
Inquire about the presence of DM, thyroid problem or goitre, impotence, hirsutism, hormone treatment.

Head
Inquire about trauma, or blow, injury to the head, headaches, dizziness, syncope, vertigo, seizures.

Eyes
Inquire about the eye infections, chalazion, glaucoma, cataract, detached retina, strabiscus, vision problem, blindness, redness, itching, and lacrimation, discharge, swelling around eyes, photophobia, and last eye examination, wearing of lens or eye glasses.


Nose and sinuses
Ask if there is any history of frequent colds, sinus infection, nasal stuffiness, allergies, nasal trauma or fracture, sneezing, runny nose, pain over sinuses, epistaxis, breathing difficulty, use of nasal sprays or other cold, sinus medications.

Ears
Inquire about past problems with ear infections, loss of hearing, tinnitus, buzzing, ear pain, discharge, vertigo.

Mouth and pharynx
Inquire about a history of sore throats, or oral infections, such as cold sores, thrush, bleeding gums, and dry mouth, difficulty in chewing or swallowing, oral surgery, voice change, last dental examination, dental hygiene practices, presence of any denture.



Neck
Ask about neck injury, goitre, pain, limited neck movement, presence of lumps, or tenderness or swelling in the neck.

Breast and axillae
Ask the client about a history of fibrocystic breast disease, cancer, gynacomastia breast pain, swelling, pruritis, nipple discharge, lumps, breast surgery, taking of estrogens and corticosteroid.

Lungs
Inquire about a past history of breathing problem like asthma, emphysema, wheezing, pleurisy, bronchitis, T.B, smoking habit, chronic cough, haemoptysis, night sweats, dyspnoea, orthopnea, pain with breathing, cyanosis, taking chest x-ray.

Heart
Ask the client about a history of rheumatic fever, congenital heart disease, heart murmur, MI, cardiac surgery, hypertension, thyroid problem. Are there current problem with; chest pain, syncope, vertigo, palpitation, paroxysmal noctural dyspnoea, orthpnea, sudden weight gain, edema of hands, or feet, hyper lipidemia. Has the client ever had any cardiac tests, such as ECG, coronary angiogram, echocardiogram?

Gastro intestinal
Inquire about history of ulcer, indigestion, heart burn, hernia, liver disease, hepatitis, pancreatic disease, appendicitis, use if alcohol, cancer ,unusual bowel pattern,diarrhea, constipation, bowel incontinence, flatulence, rectal pain or itching, pain abdomen, use if laxatives or enemas, or suppositories.

Urinary
Does the client have a history of bladder infection, kidney problems,
urinary tract stones, STD, UTI if there are any problems with urinary
frequency, dysuria, pyuria, urgency, incontinence, nocturia, polyuria,
oligouria, flank or low back pain, change of the urine, foam in the urine,
And discharge from the urethra?
Has the client had tests of the urinary system such as urinalysis,
Cystoscopy, IVP?

Genitoreproductive
Is there any history of genital lesions, sores, ulcers, urethral discharge, odour, pain, pruritis, STD, infertility, pelvic diseases, endometritis.? History of age at menarche, menopause. In case of males inquire about inguinal hernia, prostate problem, impotence, reproductive cancer, testicular pain.

Musculoskeletal
Ask about problems with sprains, stains, fractures, dislocations, arthritis, gout, back ache, bursitis, osteomyelitis, scoliosis, spinal deformity, limited movement, muscle twitches, cramps, spasms, pain, weakness, muscle atrophy, stiffness, redness, and swelling.


Neurologic
Is there any history of loss of consciousness, fainting, seizures, paralysis, parasthesia, trauma to the nervous system, cerebral vascular accident? Are there current problem with vertigo, syncope, tremors, spasms, speech problem, headache, loss of balance.

Psychiatric
Ask about history of depression, bipolar disease, OCD, sleeping problems, eating disorder, memory problem, anxiety attacks, using of psychotropic substances. Does the client currently have problem with mood swings, sleeping problem, anxiety, change in appetite, memory lapses, inability to concentrate, phobias, delusions, hallucination


7. HEALTH PROMOTION AND HEALTH RISK APPRAISAL

Health risk appraisal examines factors that affect potential for developing a particular health problem.
Risk factors are
-Genetic or biologic
-Behavioural
-Environmental
Determining health risk status identifies high risk clients who may benefit from timely interventions. In health risk appraisal assess the client’s willingness and motivation to modify or reduce risk factors.
Health risk factors are categorised for assessment purpose.

Risk factors include the following
Race and genetic or family related factors
Age related factors
Biologic factors
Personal factors
Life style factors
environmental and occupational factors
socioeconomic factors
Awareness of health risk factors may motivate a client to seek a screening procedures and to practice health promotion behaviours , particularly for health promotion that are treatable or manageable through timely interventions. A client with multiple risk factors linked to health problems is at greater risk for development of those problems than the client with fewer or no risk factors.
After assessing the risk profile, evaluate the client’s health risk status. Examine each identified risk factors with the client to determine whether its effects can be modified. If the client is interested in reducing health risks, intervene either directly or indirectly.
Health promotion needs change with age and gender. Specific screening procedures are performed during health assessment to determine potential and actual health problems. For health maintenance and prevention, specific health management behaviours are recommended based on age.
Screening procedures help to assess for a health problem or for risk of future health problem. They can be used to asses’ health status and to recommend further follow up or screening procedures.



RECORDING THE HEALTH HISTORY INTERVIEW

Record interview data in the health record according to agency protocol. The format is organised and all positive and negative findings must be recorded. Data are clear, concise, comprehensive, and consistent with no gaps. Use approved agency abbreviations and terminology, when possible to promote communication among health care team members.
In health assessment seeks to gather as much data about the client as possible, both subjective and objective.


HEALTH ASSESSMENT FORMAT

1. Biographical and demographic data;

Full name
Age
Sex
Address
Phone number
Date and time of admission
Nationality
Religion
Primary language
Date and place of birth
Educational status
Marital status
Occupation
Income (per month)
Significant others
Emergency contact
Legal guardian
Source of information
Diagnosis

2. Physical health history

Chief complaints( current symptoms or reason for seeking health care)


Symptom analysis
a) Timing;
Onset-
Duration-
Frequency-
.
b) Quality;

c) Quantity;
.
d) Location;
.
e) Precipitating factor;

f) Aggravating and relieving factors;
.
g) Associated manifestations;

3. Past health history

a) Developmental history

b) Immunization

c) Past illnesses

d) Serious or chronic illness

e) Hospitalisation

f) Surgeries

g) Serious injuries or accidents

h) Obstetric history

i) Last visit to health care provider
j) Allergies

k) Medications

4. Family health history


5. Personal history

- Occupational history

- Sexuality

-Personal habits

-Diet

-Sleeping pattern

-Activities of daily living

6. Psychosocial history

- General appearance
- Motor activity
-Behaviour
-Mental status
-Level of consciousness
-Orientation to person, time and place
-Mood and Affect
-Speech and Communication
-Thought process and content
-Attention span
-Memory
-General knowledge
-Calculations
- Abstract reasoning
-Perceptual distortion
- Judgement
- Insight
- Motivation
- Personal strengths
- Values and beliefs
-Spirituality
- Psychosocial development
-Social network
- Socioeconomic status

7. Environmental history

8. Review of system

General

Integument

Haematopoietic

Endocrine

Head

Eyes

Ears

Nose and sinuses

Mouth and pharynx

Neck

Breasts and axillae

Lungs

Heart

Gastrointestinal

Urinary

Genitoreproductive

Musculoskeletal

Neurologic

Psychiatric


COLLECTING HISTORY FROM PATIENTS OF DIFFERENT AGES

1. Talking with parents;
To obtain histories on infants and children under 5years of age, gather information from parents, third party, or from guardian.


2. Talking with children;
Children of 5 years or older are able to add significantly to the history and can describe more accurately the severity of the symptoms and their own level of concern regarding them. It’s better to begin such interviews by discussing an interesting, no threatening subjects.

3. Talking with adolescents;
Adolescents tend to open up when the focus of the interview is on themselves and their problems. Then a good way to begin the interview with adolescents is to chat informally about their friends, school, hobbies, family etc.




5.Talking with aged client;
Give an elderly person extra time to respond to the questions and speak slowly and in a low voice. Do not try to accomplish everything in one visit. Multiple visits may be less fatiguing and more productive.



CONCLUSION

The health history interview is the first part of the assessment of the client’s health status and is usually carried out before the physical examination. A nurse utilizes health history to provide individualized care, to determine health teaching needs and to begin discharge planning.

PROGRESSIVE PATIENT CARE

PROGRESSIVE PATIENT CARE;

Progressive patient care is one of the nursing care concepts. The concept began to take shape in the middle of 1950`s, the over all aim of this concept was to organize hospital services in such way that the patient receives optimum care according to his medical and nursing needs.

Definition:
Progressive patient care is described as the organization of the hospital facilities services and staff around the changing medical and nursing need of the patient.
Progressive patient care is the area where patient are nursed in different units according to the illness suffered by them.

Description:
Under progressive patient care system, the patient is classified and place in different units of the hospital according to his need and not according medical diagnosis. The patient may need intensive care or long-term care and accordingly he is admitted to the appropriate unit irrespective of his medical diagnosis. The concept has under gone some changes over the years with the trend towards specialization, a variety of progressive patient care elements have been established under a decentralized set up in major department of large hospitals.

Principle elements of progressive patient care:
a)Intensive care – for critically ill patients who receive the intensive care around the clock, who need constant attention is admitted to intensive care unit. The purpose of this unit is life saving.
b)Intermediate care – when the patient no longer needs the close attention by the nurses they are transferred to the intermediated care unit when condition improves and vital function are stabilized.
c)Self-care – for the ambulatory patient who are mostly self sufficient in terms and need daily care requirement. Self care patient patients require minimal nursing care .self care patient are not ready for discharge, as they may need few more days to adjust to activities of daily living, particularly if they have been transferred to this unit from an intensive care unit. Example; patient recovering from acute poisoning.
d)Long-term care – for chronically ill patients or disabled patient who require nursing care for a prolonged period. Rehabilitation are occupational therapy and physical therapy may be needed for these patients. Patient teaching is emphasized with a view to help these patients learn how to adjust to their illness and disabilities.
Example; Paraplegia client, Cancer client.
e)Home care – for the patients who can be adequately cared for in the home through the extension of certain services. A hospital care based care programme provides staff, equipment and supplies for of the patient.
Example; Tuberculosis client.
f)Out patient care – for the ambulatory patient requiring simple diagnostic, curative preventive and rehabilitative services.

Advantages of progressive patient care:
To the client;
Clients receive specialized attention when they need it.
Get assistance in making adjustment to the hospital and later to home and community.
To the nursing personnel;
Can make effective use of special skills and capabilities.
Placement can be made according to skills and competencies of nursing staff.
Team can include semi skilled staff to extend the nursing services to low risk patients, can be under the guidance of qualified registered nurses.
Can deliver increased and improved quality of nursing services.
To the hospital;
Can enhance the quality of patient care as a result of effective and efficient use of personnel.
Can maintain continuity of care and co – ordinate home care services.
Disadvantages;
There may be discomfort to client who is moved often.
Long-term nurse client relationships are difficult to arrange.
There is often timely difficulty in meeting administrative need of the organization staffing, evaluation and accreditation.

NATIONAL RURAL HEALTH MISSION

NATIONAL RURAL HEALTH MISSION

The National Rural Health Mission (NRHM) has been launched with a view to bringing about dramatic improvement in the health system and the health status of the people, especially those who live in the rural areas of the country. The Mission seeks to provide universal access to equitable, affordable and quality health care which is accountable at the same time responsive to the needs of the people, reduction of child and maternal deaths as well as population stabilization, gender and demographic balance. In this process, the Mission would help achieve goals set under the National Health Policy and the Millennium Development Goals.

To achieve these goals NRHM will:
Facilitate increased access and utilization of quality health services by all.
Forge a partnership between the Central, state and the local governments.
Set up a platform for involving the Panchayati Raj institutions and community in the management of primary health programme and infrastructure.
Provide an opportunity for promoting equity and social justice.
Establish a mechanism to provide flexibility to the states and the community to
promote local initiatives.
Develop a framework for promoting inter-sectoral convergence for promotive
and preventive health care.

The Vision of the Mission
To provide effective healthcare to rural population throughout the country with
special focus on 18 states, which have weak public health indicators and/or
weak infrastructure.
18 special focus states are Arunachal Pradesh, Assam, Bihar, Chattisgarh,
Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur , Mizoram,
Meghalaya, Madhya Pradesh, Nagaland, Orissa , Rajasthan, Sikkim, Tripura,
Uttaranchal and Uttar Pradesh.
To raise public spending on health from 0.9% GDP to 2-3% of GDP, with
improved arrangement for community financing and risk pooling.
To undertake architectural correction of the health system to enable it to
effectively handle increased allocations and promote policies that strengthen
public health management and service delivery in the country.
To revitalize local health traditions and mainstream AYUSH into the public
health system.
Effective integration of health concerns through decentralized management at
district, with determinants of health like sanitation and hygiene, nutrition, safe
drinking water, gender and social concerns.
Address inter State and inter district disparities.
Time bound goals and report publicly on progress.
To improve access to rural people, especially poor women and children to
equitable, affordable, accountable and effective primary health care.

The Objectives of the Mission
Reduction in child and maternal mortality
Universal access to public services for food and nutrition, sanitation and hygiene and universal access to public health care services with emphasis on services addressing women’s and children’s health and universal immunization.
Prevention and control of communicable and non-communicable diseases, including locally endemic diseases.
Access to integrated comprehensive primary health care.
Population stabilization, gender and demographic balance.
Revitalize local health traditions & mainstream AYUSH.
Promotion of healthy life styles.

The core strategies of the Mission
Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and manage public health services.
Promote access to improved healthcare at household level through the female health activist (ASHA).
Health Plan for each village through Village Health Committee of the Panchayat.
Strengthening sub-centre through better human resource development, clear quality standards, better community support and an untied fund to enable local planning and action and more Multi Purpose Workers (MPWs).
Strengthening existing (PHCs) through better staffing and human resource
development policy, clear quality standards, better community support and an
untied fund to enable the local management committee to achieve these
standards.
Provision of 30-50 bedded CHC per lakh population for improved curative care to a normative standard. (IPHS defining personnel, equipment and management standards, its decentralized administration by a hospital management committee and the provision of adequate funds and powers to enable these committees to reach desired levels).Preparation and implementation of an inter sector District Health Plan prepared by the District Health Mission, including drinking water, sanitation, hygiene and nutrition.
Integrating vertical Health and Family Welfare programmes at National, State,
District and Block levels.
Technical support to National, State and District Health Mission, for public health management Strengthening capacities for data collection, assessment and review for evidence based planning, monitoring and supervision.
Formulation of transparent policies for deployment and career development of
human resource for health.
Developing capacities for preventive health care at all levels for promoting healthy life style, reduction in consumption of tobacco and alcohol, etc.
Promoting non-profit sector particularly in underserved areas.

Programmes
Reproductive and Child Health Programme – II (RCH-II) and the Janani
Suraksha Yojana (JSY) launched.
Polio eradication programme intensified – cases reduced from 134 in 2004-05 to 63 (up to now).
Sterilization compensation scheme launched.
Accelerated implementation of the Routine Immunization programme taken up. Catch up rounds taken up this year in the States of Bihar, Jharkhand and Orisaa.
Ground work for introduction of JE vaccine completed.
Ground work for Hepatitis vaccines to all States completed.
Auto Disabled Syringes introduced throughout the country.
State Programme Implementation Plans for RCH II appraised by the National
Programme Coordination Committee set up by the Minstry. Funds to the
extent of 26.14% i.e. Rs. 1811.74 crore have been released under NRHM
Outlay.


Mission on nursing education:
The Mission would support strengthening of Nursing Colleges wherever required, as the demand for ANMs and Staff Nurses and their development is likely to increase significantly. This would be done on the basis of need assessment, identification of possible partners for building capacities in the governmental and non governmental sectors in each of the States/UTs, and ways of financing such support in a sustainable way. Special attention would be given to setting up ANM training centres in tribal blocks which are currently para-medically underserved by linking up with higher secondary schools and existing nursing institutions

Primary Health Care in India.

Primary Health Care in India.

In 1977 government of India launched a rural health scheme, based on the principles of “Placing people’s health in people’s hands’
As a signatory to Alma-Ata Declaration, the government of India is committed to achieving the goal of Health care approach which seeks to provide universal health care at a cost which is affordable.
Keeping in view the WHO goal of “Health for All” by 2000 AD, the government of India evolved a National Health Policy in 1983.
Keeping in view the Millennium Developmental Goals, the government of India revised the draft of National Health Policy in 2001.

Principles of primary Health Care.
1.Equitable distribution
2.Community participation
3.Intersectoral coordination
4.Appropriate technology
5.Preventive in Nature
6.Man power development.

Primary Health Centre

Primary Health Centers are the cornerstone of rural health services- a first port of Call to a qualified doctor of the public sector in rural areas for the sick and those
Who directly report or referred from Sub-centers for curative, preventive and
promotive health care.

A typical Primary Health Centre covers a population of 20,000 in hilly, tribal, or difficult areas and 30,000 populations in plain areas with4-6 indoor/observation beds. It acts as a referral unit for 6 sub-centres and refer out cases to CHC (30 bedded hospital) and higher order public hospitals located at sub-district and district level.

Standards are the main driver for continuous improvements in quality. The
Performance of Primary Health Centers can be assessed against the set
Standards.
In order to provide optimal level of quality health care, a set of standards are
being recommended for Primary Health Centre to be called Indian Public Health
Standards (IPHS) for PHCs. The launching of National Rural Health Mission
(NRHM) has provided this opportunity.

Assured services or Functions of Primary health canters:
Assured services cover all the essential elements of preventive, promotive,
Curative and rehabilitative primary health care. This implies a wide range of
Services that include:

1.Medical care:
OPD services: minimum 4 hours in the morning and 2 hours in the evening.
24 hours emergency services
Referral services
In-patient services (6 beds)
2.Maternal and Child Health Care including family planning:
Antenatal care: Early diagnosis, minimum three antenatal check up, identification and management of high risk pregnancies, nutrition and health counseling, minimum laboratory investigation urin albumin, test ofr syphilis, chemoprophylaxis for malaria in high endemic area as per NVDCP.
Intra-natal care. (24-hour delivery services both normal and assisted)
Postnatal Care.( Janani Suraksha Yojana (JSY)) Minimum 2 postpartum visit, initiation of breast feeding health education on hygiene, contraception etc,
New Born care.
Care of The Child.
Family Planning
.
3.Medical Termination of Pregnancies using Manual Vacuum Aspiration
(MVA) technique. (Wherever trained personnel and facility exists)

4. Management of Reproductive Tract Infections / Sexually Transmitted
Infections:

5.Nutrition Services (coordinated with ICDS)

6.School Health

7.Adolescent Health Care

8.Promotion of Safe Drinking Water and Basic Sanitation

9.Prevention and control of locally endemic diseases like malaria, Kalaazar,
Japanese Encephalitis, etc

10. Disease Surveillance and Control of Epidemics

11.Collection and reporting of vital events

12.Education about health/Behaviour Change Communication (BCC)

13.National Health Programmes including Reproductive and Child HealthProgramme (RCH), HIV/AIDS control programme, Non communicable
disease control programme etc

14.Referral Services.

15.Training: ASHA, ANM, LHV

16.Basic Laboratory Services

17.Monitoring and Supervision:

18.AYUSH services as per local people’s preference (Mainstreaming of
AYUSH)

19.Rehabilitation

20.Selected Surgical Procedures

21.Record of Vital Events and Reporting

SUBCENTRE

In the public sector, a Sub-health Centre (Sub-centre) is the most peripheral and first contact point between the primary health care system and the community. As per the population norms, one Sub-centre is established for every 5000 population in plain areas and for every 3000 population in hilly/tribal/desert areas. A Sub-centre provides interface with the community at the grass-root level, providing all the primary health care services. As sub- centre are the first contact point with the community, the success of any nation wide programme would depend largely on well functioning sub-centre providing services of acceptable standard to the people. The current level of functioning of the Subcentresare much below the expectations.

There is a felt need for quality management and quality assurance in health care delivery system so as to make the same more effective, economical and accountable. No concerted effort has been made so far to prepare comprehensive standards for the Sub-centre. The launching of NRHM has provided the opportunity for framing Indian Public Health Standards.

Objectives of Sub-centres:

i. To provide basic Primary health care to the community.
ii. To achieve and maintain an acceptable standard of quality of care.
iii. To make the services more responsive and sensitive to the needs of
the community.

Assured services or Functions of Primary health centres:
Assured services cover all the essential elements of preventive, promotive,
curative and rehabilitative primary health care. This implies a wide range of
services that include:

1.Maternal and Child Health Care including family planning:
Antenatal care: Early diagnosis, minimum three antenatal check up, identification and management of high risk pregnancies, nutrition and health counseling, minimum laboratory investigation urine albumin, test for syphilis, chemoprophylaxis for malaria in high endemic area as per NVDCP.
Intra-natal care: Promotion of institutional deliveries, skilled reference at home deliveries. Minimum 2 postpartum visit, initiation of breast feeding health education on hygiene, contraception etc,
Others: Provision of facilities under Janani Suraksha Yojna and NRHM.
Postnatal Care:
Child health: Essential New born care, promotion of exclusive breast feeding, immunization of all children, prevention and control of all childhood disease.
.
2.Family planning and contraception: Education motivation and counseling to adopt family planning motheds, provision of contraception.
3.Counseling and appropriate referral for safe abortion services for those in need.
4.Adolescent health care:
5.Assistance to school health services.
6.Control local endemic diseases such as Malaria, filariasis etc.
7.Disease surveillance
8.Water quality monitoring: Disinfection of water sources
9.Promotion of sanitation including use of toilets and appropriate garbage disposal.
10.Field visits
11.Community needs assessment
12.Curative services: Provide treatment for minor ailments, referral service, organizing health day once in month at anganvadi.
13.Training coordination and monitoring: Training of traditional birth attendants ASHA community health volunteers, monitoring of water quality.
14.National Health Programme.
15.Record of Vital Events.

The staff of the Sub center will have the support of ASHA (Accredited Social Health Activists) wherever the ASHA scheme is implemented / similar functionaries at village level in other areas. ASHA is primarily a trained woman volunteer, resident of the village-married/widow/divorced with formal education up to 8th standard preferably in the age group of 25-45 years. The general norm is one ASHA per 1000 population. The job functions of ANM, Male Health worker, ASHA and AWW in the context of coordinated functions under NRHM.

HOSPITALS AND HEALTH CENTRES

Community Health Centres.

Health care delivery in India has been envisaged at three levels namely primary, secondary and tertiary. The secondary level of health care essentially includes,Community Health Centres(CHCs), constituting the First Referral Units(FRUs) and the district hospitals. The CHCs were designed to provide referral health care for cases from the primary level and for cases in need of specialist care approaching the centre directly. 4 PHCs are included under each CHC thus catering to approximately 80,000 populations in tribal / hilly areas and 1, 20,000 populations in plain areas. CHC is a 30-bedded hospital providing specialist care in medicine, Obstetrics and Gynaecology, Surgery and Pediatrics. These centres are however fulfilling the tasks entrusted to
them only to a limited extent. The launch of the National Rural Health Mission (NRHM)gives us the opportunity to have a fresh look at their functioning.

NRHM envisages bringing up the CHC services to the level of Indian Public Health Standards. Although there are already existing standards as prescribed by the Bureau of Indian Standards for 30-bedded hospital, these are at present not achievable as they are very resource-intensive. Under the NRHM, the Accredited Social Health Activist
(ASHA) is being envisaged in each village to promote the health activities. With ASHAin place, there is bound to be a groundswell of demands for health services and the system needs to be geared to face the challenge. Not only does the system require up gradation to handle higher patient load, but emphasis also needs to be given to quality aspects to increase the level of patient satisfaction. In order to ensure quality of services, the Indian Public Health Standards are being set up for CHCs so as to provide a yardstick to measure the services being provided there.

Objectives of Indian Public Health Standards (IPHS) for CHCs:
To provide optimal expert care to the community
To achieve and maintain an acceptable standard of quality of care
To make the services more responsive and sensitive to the needs of the
community.

Functions of CHCs:
Every CHC has to provide the following services which can be known as the Assured
Services:
1.Care of routine and emergency cases in surgery:
This includes Incision and drainage, and surgery for Hernia, hydrocele,
Appendicitis, haemorrhoids, fistula, etc.
Handling of emergencies like intestinal obstruction, haemorrhage, etc.
2. Care of routine and emergency cases in medicine:
Specific mention is being made of handling of all emergencies in relation to the National Health Programmes as per guidelines like Dengue Haemorrhagic fever, cerebral malaria, etc. Appropriate guidelines are already available under each programme, which should be compiled in a single manual.
3.24-hour delivery services including normal and assisted deliveries
4.Essential and Emergency Obstetric Care including surgical interventions like Caesarean Sections and other medical interventions
5. Full range of family planning services including Laproscopic Services
6.Safe Abortion Services
7. New-born Care
8.Routine and Emergency Care of sick children
9.Other management including nasal packing, tracheostomy, foreign body removal etc.
10.All the National Health Programmes (NHP) should be delivered through the CHCs.Integration with the existing programmes like blindness control, Integrated Disease Surveillance Project, is vital to provide comprehensive services.
11.Others
Blood storage facility
Essential laboratory services
Referral (transport) facility.

Hospitals.
India’s Public Health System has been developed over the years as a 3-tier system, namely primary, secondary and tertiary level of health care. District Health System is the fundamental basis for implementing various health policies and delivery of healthcare, management of health services for defined geographic area. District hospital is an essential component of the District health system and functions as a secondary level of health care which provides curative, preventive and promotive healthcare services to the people in the district.
Every district is expected to have a district hospital linked with the public hospital/health centres down below the district such as Sub-district/Sub-divisional hospitals, Community Health Centres, Primary Health Centers and Sub-centres. As per the information available, 609 districts in the country at present are having about 615 District hospitals.

However, some of the medical college hospitals or a sub-divisional hospital is found to serve as a district hospital where a district hospital as such (particularly the newly created district) has not been established. Few districts have also more than one district hospital.

Objectives for district hospitals:
The overall objective of IPHS is to provide health care that is quality oriented and sensitive to the needs of the people of the District. The specific objectives of IPHS for DHs are: 
i.To provide comprehensive secondary health care (specialist and referral services) to the community through the District Hospital.
ii.To achieve and maintain an acceptable standard of quality of care.
iii.To make the services more responsive and sensitive to the needs of the people of the district and the hospitals/centres from which the cases are referred to the district hospitals.

 
Definition .
The term District Hospital is used here to mean a hospital at the secondary referral level responsible for a District of a defined geographical area containing a defined population.  
Grading of district hospitals:  
The size of a district hospital is a function of the hospital bed requirement, which in turn is a function of the size of the population it serves. In India the population size of a district varies from 35,000 to 30,00,000 (Census 2001). Based on the assumptions of the annual rate of admission as 1 per 50 populations and average length of stay in a hospital as 5 days, the number of beds required for a district having a population of 10 lakhs will be around 300 beds. However, as the population of the district varies a lot, it would be prudent to prescribe norms by grading the size of the hospital as per the number of beds. 
Grade I: District hospitals  norms for 500 beds
Grade II: District hospitals norms for 300 beds
Grade III: District hospitals  norms for 200 beds
Grade IV: District hospitals  norms for 100 beds
The disease prevalence in a district varies widely in type and complexities. It is not possible to treat all of them at district hospitals. Some may require the intervention of highly specialist services and use of sophisticated expensive medical equipments. Patients with such diseases can be transferred to tertiary and other specialized hospitals. A district hospital should however be able to serve 85-95% of the medical needs in the districts. It is expected that the hospital bed occupancy rate should be at least 80%.
 
Functions 
District hospital has the following functions: 
1.It provides effective, affordable healthcare services (curative including specialist services, preventive and promotive) for a defined population, with their full participation and in co-operation with agencies in the district that have similar concern. It covers both urban population (district headquarter town) and the rural population in the district.
2.Function as a secondary level referral centre for the public health institutions below the district level such as Sub-divisional Hospitals, Community Health Centres, Primary Health Centres and Sub-centres. 
3.To provide wide ranging technical and administrative support and education and training for primary health care. 

Essential Services 
Services include OPD, indoor, emergency services. 
Secondary level health care services regarding following specialties will be assured at hospital: 

Consultation services with following specialists: 
General Medicine
General Surgery
Obg & Gyne
Paediatrics including Neonatology
Emergency (Accident & other emergency) (Casualty)
Critical care (ICU)
Anaesthesia
Ophthalmology
ENT
Dermatology and Venerology including STI/RTI
Orthopaedics
Radiology
Dental care
Public Health Management 

 Paraclinical services 
Laboratory Services
X-Ray Facility
Sonography (Ultrasound)
ECG
Blood transfusion and storage facilities
Physiotherapy
Dental Technology (Dental Hygiene).
Drugs
Pharmacy
 
 Support Services 
Medico-legal/postmortem
Ambulance services
Dietary services
Laundry services
Security services
Counseling services for domestic violence, gender violence, adolescents, Gender and socially sensitive service delivery be assured. 
Waste management
Ware housing/central store
Maintenance and repair
Electric Supply (power generation and stabilization)
Water supply (plumbing)
Heating, ventilation and air-conditioning
Transport
Communication
Medical Social Work
Nursing Services
Sterilization and Disinfection
Horticulture (Landscaping)
Lift and vertical transport
Refrigeration 

Health System in China.

Great advances in public health have been hallmark of the People’s Republic of China since it was founded in 1949. Examples of public health advances that were made in china including controlling contagious disease such as cholera, typhoid etc. These accomplishments in public health were credited to a political system that was and is largely socialistic terms as collective.

The collective health care system was owned and controlled by the state and was characterised by the use of barefoot doctors who were medical practioners trained at the community level and who could provide a minimal level of health throughout the country.

This system was financed by co operative insurance plan.
Barefoot doctors combined western medicine with traditional techniques such as acupuncture, herbal remedies.

Today health care in china is managed by the Ministry of Public Health, which sets national health policy.

Chinas health care system is modified by the introduction of primary health care system in community health clinics (CHC) based on the health care system in Canada. With this system, a family practice physician is assigned 500 or more individuals for whom to provide health care.