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Full text of "NURSING AND MIDWIFERY A GUIDE FOR TRAINERS"

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A TOPICAL OUTLINE FOR THE 
TEACHING OF FAMILY HEALTH 

A LIFE-CYCLE APPROACH 
(NURSING AND MIDWIFERY) 




prepared by the 
AFRICAN HEALTH TRAINING INSTITUTIONS PROJECT 

1977 



THE VtilVJBRS. IT? OF NORTH CAROLINA AT CHAPEL HILL 
Carolina Population Center 

and 

The Medical School - Office of Medical Studies 
Chapel Hill, N.C. 2?514> U.S.A. 



publication of this volume has been made possible through the 
of the United States Agency for International Development, Bureau 
-ion and Humanitarian Assistance, Washington, D.C. 

Project No. AID-PHA/CM/C-73-33 



A Topical Outline . . . ACKNOWLEDGEMENTS 

Nursing and MidDifery page j 



A CKNOWLEDGEMENTS 



Many individuals have contributed their time, interest and support to 
various parts of the Topical Outline for the Teaching of Family Health - 
Nursing and Midwifery. There were many authors, all of whom are identified 
on the list of contributors. 

Appreciation is extended to the AHTIP Consultative Group for Nursing, 
Midwifery and Allied Health Professions, who have reviewd this volume in 
various stages of completion and who have given many valuable recommendations 

Special recognition goes to Dr. Raymond Isely who has reviewed and 
critiqued most of the modules, and has given his support and encouragement 
throughout the writing of this volume. Ms. Linda Staurovsky also has made 
significant contributions through her interest, recommendations and actual 
content review of all modules relating to maternity. 

Appreciation is extended to Ms. Betty Rose Johnson, Ms. Dorothy Burford, 
and Ms. Ella Oliver for review of specific modules and to Ms. Marjorie Kupper 
and Ms. Catherine Murphy for their steady support and for supplying the list 
of resources for teaching aids. 

Many AHTIP staff members have assisted with the typing and proofreading 
of this manuscript. Ms. Herml Rojahn, In particular, deserves special commen- 
dation for her ability and patience in coordinating the components of this 
book and for managing its production. 



Elizabeth M. Edmands 
General Editor 



Chapel Hill, September 1977 



A Topical Outline ... WOT OF CONTRIBUTORS 

and Midwifery page ** 



LIST OF CONTRIBUTORS 



ENAAM Y. ABOU-YOUSSEF, R.N.,B.SC., M.S., ED.D. 

Adjunct Associate Professor, Public Health Nursing, School of Public 
Health; Nurse-Midwife Educator, African Health Training Institutions 
Project, University of North Carolina, Chapel Hill, N.C., U.S.A. 

ELIZABETH M. EDMANDS, R.N., B.S.P.H.N., M.A. 

Associate Professor, Public Health Nursing, Maternal and Child Health, 
School of Public Health; Public Health Nurse Educator, African Health 
Training Institutions Project, University of North Carolina at Chapel 
Hill, Chapel Hill, N.C., U.S.A. 

RAYMOND B. ISELY, M.D., M.P.H., D.T.M. 

Clinical Assistant Professor of Paediatrics, The Medical School; 
Adjunct Assistant Professor of Health Education, School of Public 
Health; Medical Advisor, African Health Training Institutions Project; 
University of North Carolina at Chapel Hill, Chapel Hill, N.C., U.S.A. 

JAMES W. LEA, PH.D. 

Assistant Professor, Department of Family Medicine/Office of Medical 
Studies; Associate Director, Clinical Cancer Education Program; The 
Medical School; Director, African Health Training Institutions Project; 
University of North Carolina at Chapel Hill, Chapel Hill, N.C., U.S.A. 

ROBERT D. STONE, PH.D. 

Assistant Professor, Department of Family Medicine; Assistant Professor, 
School of Education; Faculty Member, Office of Medical Studies; The 
Medical School, University of North Carolina at Chapel Hill, Chapel 
C., U.S.A. 



A Topical Outline . . , LIST OF CONTRIBUTORS 

Nursing and Midwifery p age 



FRANK T. STRITTER, PH.D. 

Associate Professor, Department of Family Medicine; Associate Professor, 
School of Education; Associate Professor of Health Education, School 
of Public Health; Faculty Member, Office of Medical Studies, The 
Medical School, University of North Carolina at Chapel Hill, Chapel 
Hill, N.C. , U.S.A. 



Members of AHTIP Consultative Group for Nursing, Midwifery and 
Allied Health Professions: 

AYODELE AKIWUMI 

Head, Post-Basic Nursing Department 
University of Ghana 
Legon, Accra, Ghana 

HIBA HASSANI 

Head of Professional Training 
Ministry of Public Health 
Rabat, Morocco 

EUNICE MURINGO KIEREINI 
Chief Nursing Officer 
Ministry of Health 
Nairobi, Kenya 

MOHGA LUTFI 

Midwifery Tutor 

Omdurman Midwifery Training School 

Omdurraan, Sudan 

SOHEIR MOKABEL 

Director, Higher Institute of Nursing 
University of Alexandria 
Alexandria, Egypt 



LIST OF CONTRIBUTORS 

A Topical Outline ... jy 

Hursing and Midwifery r y 



DAMARIS MOUNLOM 
Director 
National School of Nursing and Midwifery 

Yaounde, Cameroon 

MARGARET OSEI-BOATENG 

Nursing Tutor, Post-Basic Nursing Department 
University of Ghana 
Legon, Accra, Ghana 

AWATIF OSMAN 
Director 

College of Nursing 
Khartoum, Sudan 

OLIKOYE RANSOME-KUTI 

Professor and Head, Department of Paediatrics 
Director, Institute of Child Health 
University of LBROS 
Lagos, Nigeria 

STELLA 0. SAVAGE 

Chief Nursing Education and Training Officer 
Federal Ministry of Health 
Lagos, Nigeria 



A Topical Outline , . . TABLE OF CONTENTS 

Nursing and Midtiifevy page V 



TABLE OF CONTENTS 

page 



CHAPTER 1: 1 

THE ORIGINS AND DEVELOPMENT OF THE TOPICAL OUTLINE 
James W. Lea 

CHAPTER 2: 3 

DEVELOPMENT OF THE LIFE-CYCLE APPROACH TO THE TEACHING 
OF FAMILY HEALTH 

Frank T. Stritter and Raymond B. Isely 
adapted for Nursing and Midwifery Education by 
Elizabeth M. Edmands 

CHAPTER 3: 21 

A GUIDE TO USING THE TOPICAL OUTLINE 
Raymond B. Isely and Elizabeth M. Edmands 

CHAPTER 4: 2 ? 

TEACHING MODULES FOR FAMILY HEALTH: THE TOPICAL OUTLINE 
Elizabeth M. Edmands 

Module A - NATURE OF THE COMMUNITY 29 

Section I: Assessment of the Community 

Section II: Methods of Collecting Data About a Community 36 

Section III: Evaluation of Data and Determination of Health 38 

Need Priorities 
Section IV: The Planning of Health Activities Based on 39 

Community Assessment 

Module B - THE FAMILY AS A UNIT 43 

Section I: Definition and Cultural/Social Determinants of the 45 

Nature of Families 

Section II: Family Structure and its Relevance to Function 47 

Section III: Intervention by Nurses or Midwives 50 

Module C - CONCEPTION AND INFERTILITY 55 

Section I: Social and Cultural Attitudes and Practices Toward 57 

Conception and Infertility 
Section II: Anatomy and Physiology of Male and Female Repro- 59 

ductive Systems 

Section III: Conception 60 

Section IV: Incidence and Causes of Infertility 2 



A Topical Outline . . . TABLE OF CONTENTS 

Nursing and Midtiife-py page VI 







page 


Section V: 


Procedures Performed for Diagnosis and 


64 




Treatment of Infertility 




Section VI: 


Role of Nurse/Midwife in Care and Counseling 


66 




of Infertile Couples 




Module D - 


PREGNANCY, BIRTH AND PUERPERIUM 


71 


Section I: 


Cultural Attitudes and Practices 


73 


Section II: 


Normal Pregnancy 


77 


Section III 


: Care of Pregnant Women 


82 


Section IV: 


Foetal Growth and Development 


86 


Section V: 


Labour and Delivery 


89 


Section VI: 


Care of the Woman During Labour and Delivery 


93 


Section VII 


: The Puerperium 


98 


Section VIII: Care of the Woman During the Puerperium 


101 


Section IX: 


Deviations From Normal 


104 



Module E - LACTATION AND WEANING (by Enaam Abou-Youssef) 113 

Section I: Anatomy of the Breast and Physiology of Lactation 115 

Section II: Breast-Feeding 116 

Section III: Bottle-Feeding 119 

Section IV: Weaning 12i 

Module F - GROWTH AND DEVELOPMENT (Birth to Puberty) 125 

Section I: Normal Growth and Development Patterns 127 

Section II: Major Factors Affecting Growth and Development 129 
Section III: Diagnostic and Assessment Tools to Measure Growth 131 

and Development 
Section IV: Counseling and Education of Parents and Children - 133 

Nursing Intervention 

Module G - PUBERTY AND ADOLESCENCE 139 

Section I: Definitions of Terms and the Steps Leading to 142 

Maturity 

Section II: Traditional and Current Attitudes Surrounding 147 

Adolescent Life in Community 

Section III: Major Needs of Adolescents 149 

Section IV: Nursing Intervention 152 

Module H - THE ADULT 159 

Section I: The Productive Years 161 

Section II: Cultural Attitudes and Practices 163 

Section III: Needs of Adults 167 

Section IV: Problems Encountered by Adults 170 

Section V: Nursing Intervention .172 

'. - OLD AGE (45 years and over) 179 

T : Life Expectancy 182 

r .: Traditional Attitudes 184 

!I: Physical and Psychological Changes of Aging 186 

r : Needs and Problems 188 

Role of Nursing in Preventive, Curative, and 192 

Long-Term Care of the Older Person 



A Topical Outline . . . 
Nursing and Midwifery 



TABLE: OF CONTENTS 

page VII 



page 



Module J 



COMMON DISEASES AND ACCIDENTS AFFECTING FAMILY HEALTH 
(b.y Raymond B. Isely) 



Section I: 
Section II: 
Section III 
Section IV: 
Section V: 
Section VI: 



Concepts and Definitions 

Diseases and Accidents of Childhood 

Diseases of Adult Women 

Diseases and Accidents of Adult Males 

Diseases and Accidents Occurring in all Age Groups 

Nursing Intervention 

Module K - FAMILY PLANNING 



Section I: 
Section II: 
Section III: 

Section IV: 
Section V: 
Section VI: 
Section VII: 

Section VIII; 
Section IX: 



Introduction 

Benefits of Family Planning 

Criteria for Assessing Appropriateness of a 

Contraceptive Method 

Behavioral Methods 

Mechanical and Chemical Methods 

Systemic Methods 

Nursing and Midwifery Care and Counseling 

in Family Planning 

Abortion 

Sterilization 



Module L - THE HEALTH WORKER AND THE COMMUNITY 



Section I: 
Section II: 

Section III: 



Various Categories of Health Workers 

Community Health Programmes - Goals, Objectives 

and Component Parts 

Nursing/Midwifery Activities and Contributions 

to Community Health Programmes 



197 

200 
203 

206 
208 
211 

214 

223 

226 
228 
230 

231 
232 
233 
234 

238 

240 

245 

248 
251 

254 



CHAPTER 5: 

INSTRUCTIONAL STRATEGIES 
Frank T. Stritter 

CHAPTER 6: 

GUIDELINES FOR THE SELECTION AND UTILIZATION OF EVALUATION 
METHODS IN THE TEACHING OF FAMILY HEALTH 

Robert D. Stone 



261 



271 



APPENDIX I: 

Addresses of Publishers 

APPENDIX II: 

Sources of Teaching Aids 



277 



281 



A Topical Outline . . . CHAPTER 1 

Nursing and Midwifery 



CHAPTER 1 : 

THE ORIGINS AND DEVELOPMENT OF THE TOPICAL OUTLINE 
James W. Lea 



The development of A_ Topical Outline for the Teaching of Family Health: 
Nursing and Midwifery has been a process of nearly two years of International 
study and cooperation. The process began in 1975 when the staff of The African 
Health Training Institutions Project (AHTIP) realized the need for an organiza- 
tional format which would help to group the self-instructional family health 
teaching materials being produced in significant numbers by African nursing 
and midwifery faculty in AHTIP-conducted workshops. Such an organizational 
format, it was felt, should have several characteristics: 

1. It should allow participants in future AHTIP workshops to identify 
those topics upon which instructional units had already been developed, 
so that they might more wisely choose their own topic for authoring 
units . 

2. It should allow faculty who use it to see what teaching materials were 
available for their students, 

3. It should relate realistically to existing African nursing and midwifery 
curricula and to those new curricular areas in which family health 
teaching programs were being, or could be, developed. 

It was immediately clear that such a document could only be produced through 
the mutual efforts of a cross sectional group of professionals representing nursing 
and midwifery education in Africa. Such a group already existed in the AHTIP 
Consultative Group for Nursing, Midwifery and the Allied Health Professions, 
whose eight members represented seven African countries. So a preliminary draft 
of a conceptual curriculum outline for family health teaching in nursing and 
midwifery was presented to the Consultative Group at their July, 1975, meeting 



A Topical Outline ... CHAPTER 1 

Nursing and Midwifery page 2 



in Nairobi. The Group agreed upon Che usefulness of such an outline and devoted 
several sessions to analyzing, editing and revising the draft. They sent their 
revisions back to the AHTIP staff for further study and incorporation into a 
second draft. 

For the next year, Ms. Elizabeth M, Edmands, the General Editor of the 
document, continued to develop it, with consultation from individual members 
of the Consultative Group and other professional colleagues. During this time, 
it began to appear that "curriculum outline" was a misnomer for the document, 
for with inputs from several African professionals it was taking more the form 
of an organized compendium of teaching topics, with rationale, objectives and 
related materials, appropriate to structuring Family Health teaching components. 
Hence, it became known as A Topical Outline. Along with a companion volume 
being developed for medical teaching, the Topical Outline adopted the family 
life-cycle approach as its organizational basis. 

In September 1976, a much more detailed draft of A Topical Outline 
was submitted to the Consultative Group at their meeting in Alexandria. 
At this time, The Group did further editing and individually recommended resource 
lists and other helpful additions. These contributions, along with further 
editorial effort, make up the completed Topical Outline. 

This volume, then, is the product of great efforts by a great number of 
nursing and midwifery education professionals. It Is the hope of everyone who 
contributed to it that A Topical CKitline will be helpful as a family health 
curriculum and course planning guide, as a reference for assessing current 
teaching programs and as a stimulus to more focus upon family health as a thrust 
In health professional training and practice, in Africa and elsewhere. 



A Topical Outline . .. CHAPTER 2 

Nursing and Midwifery page 3 



CHAPTER 2 : 

DEVELOPMENT OF THE LIFE-CYCLE APPROACH 
TO THE TEACHING OF FAMILY HEALTH 

Frank T, Stricter and Eaymond B, Isely 

adapted for Nursing and Midwifery Education by 
Elizabeth W. Edmonds 



This chapter will describe how the concepts which gave rise to the ideas 
discussed in the previous chapter were developed. It assumes the viewpoint of 
the curriculum builder: whether that person be a course instructor, a depart- 
ment chairman, or the person in charge of an entire institution. It poses a 
set of theoretical questions to which will be given general answers, followed 
by specific responses taken from the experience of developing the particular 
approach of this volume. There will thus be constructed simultanously both a 
general conceptual framework for the curriculum builder in any institution, 
and a specific one for the life-cycle approach to teaching family health. 



I. A CONCEPTUAL FRAMEWORK FOR THE CURRICULUM BUILDER 
A. WHAT IS A CURRICULUM? 

A curriculum by definition Includes two major components. The first is 
a set of logical and sequential educational goals. These goals are broad 
statements of what students are expected to achieve as a result of partici- 
pation in the curriculum. They may be applied to as short a programme as a 
course of one term (e.g. a curriculum in paediatric nursing within the entire 
nursing school programme) or to one as long aa the entire preparation for a 
career (e.g. a four year baccalaureate programme in nursing.) They serve both as 
a planning guide for the developers and evaluators and as a study guide for the 
student participants in the curriculum. The second component is a series of 



A Topical Outline ... CMPTFP 9 

Nursing and Mi&ifery pa e / 

learning experiences through which students are helped to achieve the various 
goals. These activities are experiences in which students participate to varic* 
degrees. They can be courses, required or optional, taken on a group basia, or 
they can be instruction organized individually. The Instruction may be didactic 
or experiential. A curriculum, then, is composed of both the goals and expert 
of a specific instructional programme. 

B. WHAT ARE THE TASKS OF THE CURRICULUM PEVET.OPFB? 

The curriculum developer can be a single Individual or a committee. One 
or more individuals can be responsible for presenting the curriculum or an 
organization can be responsible for administration of the programme, such 
a Ministry of Health or Education, a dean or director of a faculty or a 
faculty committee on educational policy. Whoever or whatever the developer Is, 
several responsibilities or ta 8 ks must be accomplished if a curriculum Is to 
be useable. The first task is to select a curriculum framework, that is some 
type of overriding philosophy or structure into which all the goals and ex- 
periences can be fitted. A second responsibility is to determine the baaic 
behaviors, skills, knowledge and attitudes or feelings which the program ' a 
graduates should possess as a result of- participating in the curriculum. Tha 
general outcomes of a curriculum will often be specified by some higher 
political authority or may be ascertained by the developer from studies of 
what a society or profession expects. A third responsibility is to design a 
series of instructional experiences or activities for students that will enabli 
them to meet the desired outcomes, i.e. to evaluate the students and the 
programme. Once that evaluation is accomplished, the faculty can certify that 
the students have in fact achieved a standard suitable for entry into a 
particular profession or occupation, and they can be graduated. 

C. WHAT OPTIONS ARE AVAILABLE TO THE CURRICULUM DEVELOPER IN THE 
CONSTRUCTION OF A TEACHING PROGRAMME? 

Decisions affecting curriculum organization are frequently made on the 
basis of pressure by government, by faculty groups or other influential in- 
dividuals, on the basis of hunches or on the basis of expediency, Instead of 
clear-cut theoretical considerations or assumptions. In many institutions , 
this manner of developing curriculum has resulted in a cafeteria array of 



A Topical Outline ... CHAPTER 2 

Nursing and Midwifery P a 9 e 5 

unrelated topics through which the student is expected to proceed in a 
sequence determined by a faculty group. The student must sort out all the 
concepts and information presented and then put it all together in some 
meaningful arrangement for future use. This type of curriculum development 
is of obviously little benefit to the student and questionable from an 
educational standpoint. 

A framework that makes better educational sense can be developed if the 
needs of one of the constituent groups affected by the curriculum being 
developed are considered. Some of these groups are the faculty or instructors, 
the students, or the recipients of the services provided by the graduates. 

The needs of a department or a faculty lead a developer to the familiar 
subject-oriented curriculum from which most instructional programmes have 
evolved and which characterizes the majority of programmes today. The assump- 
tion made is that because the major subjects, such as anatomy and psychiatry, 
provide a logical and efficient way of organizing existing and new knowledge, 
they constitute, therefore, an effective way of learning it. A curriculum 
so organized Is characterized by compartmentalization of knowledge and re- 
sources, by deficient or absent communication between the individuals respon- 
sible for the various subjects and by an overwhelming assortment of material 
for the student to memorize, some of which is redundant. The advantage of 
such a curriculum is that It is more easily planned and taught than most 
other approaches, simply because of the common discipline and the proximity 
of the individuals responsible for teaching. It is, after all, much easier 
to discuss curriculum matters with one's peers than with those of different 
disciplines. This approach thus provides a more efficient structure for 
development and presentation of facts and preserves faculty time and effort. 

The needs of the students form another possible guide for developing a 
curriculum. For example, students frequently have problems in identifying 
and integrating the important concepts presented In a compartmentalized 
currlcular approach. Interdisciplinary or interdepartmental approaches have 
been suggested as solutions. Several specific, items can be combined in a dis- 
cussion of larger unifying principles, problems and themes. Such an approach helps 
to break down the logical fences that specialists have, for convenience, built' 
up between their subject areas and to stimulate the unification of knowledge. 
For example, nursing students frequently have difficulty relating a clinical 
problem or entity to Its relevant factual material from the basic sciences. 



A Topical Outline . . . CHAPTER 2 

and Midwifery page 6 



A curriculum organization designed to address this problem may be or- 
ganized on the basis of organ systems, wherein all aspects of a given system: 
the anatomy, physiology, pharmacology, pathology, and therapeutics are taught- 
as a single unit. Another organizational framework might be furnished by 
clinical problems, e.g. hypertension, diabetes, or respiratory tract infec- 
tions. 

A curriculum could also be baaed on the needs of a societal group such 
as a defined community or the recipients of health care. A curriculum of 
this type would be organized around the functions , activities, events or 
problems which constitute the significant features of life in a culture or 
society. This organizational pattern would be responding to human needs 
rather than to the needs of a particular group, i.e. faculty or students. 
In addition to forming a basis for the integration of knowledge, such an 
organization would be of value in outlining a practitioner's responsibilities, 
Thus a patterned relationship between the curriculum, the skills of the 
practitioner and lives of the practitioner's constituents would be provided. 
A combination of societal needs, learner's needs, and the life situations of 
the recipients of health care would be emphasized. A curriculum of this 
nature however is difficult to organize and even more difficult ot implement. 
An example Is found in a curriculum based on the life-cycle or life-events 
of the development of an individual or a family. This approach is the theme 
of this volume. 

D * ARE THERE CRITERIA THAT CAN GUIDE THE CURRICULUM BUILDER'S TASK OR BY 
WHICH A COMPLETED CURRICULUM PROPOSAL CAN BE ASSESSED? 

If a set of standards or guidelines is used by the curriculum builder 

as the curriculum is developed, then it Is likely that a more logical and 

useable plan will result. The following list includes several categories 
that constitute a set of criteria. 

1. SCOPE 

A curriculum should be limited to a specific area of concern rather than 
a large amorphous body of knowledge that does not appear to have inner connec- 
tions . It should present concepts and content which are directly related 



A Topical Outline , , , CHAPTER S 

Nursing and Midwifery page ? 



to that area of concern. If concepts happen to be interrelated, the 
connections should be identified so that the students will grasp them. 

2 . COMPREHENSIVENESS 

A curriculum should cover all the relevant topics within the specific 
area chosen. There will often be too much material to include in any one 
curriculum and the developer will have to establish priorities for selecting 
the most important topics. When that task is undertaken, however, it should 
be done empirically to assure the best choices . 

3. SEQUENCE 

The curriculum should be arranged in some logical order to facilitate 
meaningful learning. Some possibilities are a world r6lat_ed_ sequence, i.e. 
the way phenomena exist or occur naturally in the world either spatially, 
temporally or phyaicallly; a concepj^ jrej.atej3 sequence, i.e. the way contents 
relate conceptually; inquiry related sequence, i.e. a sequence derived from 
the nature of generating, discovering, or verifying knowledge; learning 
rel.at.ed , i.e. a sequence derived from the psychology of learning or the way 
individuals learn; and ^i^lzation. relatedi, i.e. a sequence based on the way 
information or concepts are used either procedurally or according to anticipated 
frequency of use. 

4. CUMULATIVE LEARNING 

The curriculum should be built up in a meaningful way, such as proceeding 
from the acquisition of factual knowledge to the application of concepts t or 
from the aetiology of a condition to its treatment and prevention. What is 
expected of students should also increase in difficulty and intensity as the 
programme progresses, 

5. INTEGRATION 

A curriculum should show how facts and principles from one topic or area 
of concern relate to elements of other topics within the scope of the curriculum 



A Topical Outline ... CHAPTEE 2 

Nursing and Midwifery vaae ** 



6. FLEXIBILITY 

Curricula must often be adaptable, I.e. useable in different settings by 
different instructors or by different students. A curriculum designed to be 
used in several different Institutions should be general and not too specific 
To assure its flexibility it should be tested in a variety of locations and 
should be found useable in those settings by different instructors. Not all 
curricula will necessarily have the same degree of flexibility but in some 
cases it will be an important criterion. 

7. UTILITY 

The curriculum should be practical and useable. It should undergo constant 
testing. Parts found unuseable should be revised or discarded. 

A curriculum which receives a systematic evaluation based on the foregoing 
criteria will be better designed than one that has not. The reviewer or 
developer, of course, will make individual decisions aa to whether the curri- 
culum meets his standards in these criteria, but the criteria nonetheless 
provide a guide for such decisions. 

E. IS THERE AN ORGANIZATIONAL STRUCTURE FROM WHICH A CURRICULUM CAN BE 
DEVELOPED? 

An organizational structure provides a format by which an instructor or 
a committee can develop a curriculum. It aids in assuring that all relevant 
areas are considered for inclusion and in a logical sequence. One such 
structure is a two-dimensional grid or matrix which provides an interrelated 
system of premises or guidelines for making the various curriculum-related 
decisions about objectives, topic headings, content, learning experiences 
and evaluation. The matrix has two principal components. One is the vertica. 
axis or ordinate which details curricular goals or outcomes expressed aa the 
broad skills or abilities which a competent health practitioner should exhibi- 
at the conclusion of an Instructional programme. The horizontal axis or 
abscissa is labelled Curriculum Organization. It corresponds to the curricul 
framework referred to earlier, in which the organizational elements are the 
needs of one or more of the constituent groups. If the axes are extended, 



A Topical Outline . . , 
ing and Midwifery 



CHAPTER 2 
page & 



both vertically form the elements in the Curriculum Organization, and horizon- 
tally from the curricular goals, these lines will bisect each other forming 
cells which provide an additional focus (Figure 1) . 



Figure 1: 

A HYPOTHETICAL CURRICULUM 
PLANNING MATRIX 



Curricular 
Goals 


Curriculum Organization 


Elements based on societal needs, tor example 


A 


B 


C 


D 


E 


F 


G etc. 


1 
2 
3 
4 
5 
6 





































































































A. Topical Outline . . . CHAPTER 2 

and Miduifery page 20 



II. DEVELOPMENT OF THE LIFE-CYCLE APPROACH 
A, PRELIMINARY CONSIDERATIONS 

The first problem encountered was to devise a working concept of 
family health to guide curriculum building efforts. It needed to be made 
quite clear that family health does not mean ipso facto family planning or 
population control. It is not a euphemistic way of talking about birth 
control. Family health, rather, refers to the health status of the family 
however family may be defined. Whether the family is made up of four people 
or an entire hamlet of fifty or sixty people, then, is immaterial. The 
health status of that social unit is what concerns family health. 

The concept of family health embodies the concerns expressed above 
but also includes emphasis on the family as the unit of practice for 
health services and on the community context where the health of the family 
is determined. Family health requires successful adaptation to the total 
environment. The major family health concerns encompass: the reproductive 
process, child rearing, nutrition, infectious diseases, health education, 
and environmental hygiene. 

These concepts of family health serve as a good introduction to the 
problems faced by the curriculum builder in designing a programme for 
teaching in African health science institutions. What are the problems? 

1. The programme must be broad enough to capture all the important 
aspects of family health. At minimum it should include family 
sociology, family planning, maternal and child health, nutrition, 
major diseases and accidents, occupational hazards, and some 
elements of community health. It should emphasize the major types 
of intervention made by health personnel both curative and pre- 
ventive . 

2. At the same time it must be focused enough to avoid encompassing 
all of the health sciences. Criteria need to be developed for de- 
limiting what is important to family health and what is less 



A Topical Outline ... CHAPTER 2 

Nureing and Midwifery page 11 



4. A serious attempt should be made to emphasize the practice 
of family health more than a theory. As important as proper 
theoretical base is, the goal of teaching family health is 

to equip students to practice it. The programme must care for 
this delicate balance between understanding and skill In 
accordance with professional role expectations that are 
nationally defined. 

5. The programme must seek ways of linking the teaching of family 
health, paediatric nursing, midwifery, medical/surgical nursing, 
and other speciality areas without attempting to supplant these 
programmes . 

6. Opportunity should be given for the interrelated problems of 
fertility regulation, control of infections, and nutrition to 
emerge as priorities. 

Taking a general concept of curriculum and combining it with the specific 
needs of a family health curriculum, the curriculum builder, then, has his 
task - the construction of a teaching programme. The life-cycle approach 
represents the results of such an effort. 

B. THE LIFE-CYCLE MATRIX 



1. THE CURRICULAK GOALS OR OUTCOMES 

The following abilities are chosen: They range along the vertical 
side of the matrix (aee Fig. 1): 

1. Interpret the given culture 

2. Describe normal structure and function, whether of an Individual, 
a family or a community. 

3. Make appropriate assessments. 

4. Discuss important deviations from normal 

5. Describe and apply appropriate preventive, therapeutic and 
nursing care measures 

6. Educate individuals and families in prevention of and care 
for accidents and illnesses. 

7. Provide emotional support to individuals and families during 
family crises . 

8. Correlate the many aspects of health services. 

9. Give and receive consultation 

10. Function with limited resources 

11. Participate in simple research 



A Topical Outline ... CHAPTER 2 

Nursing and Midwifery a8 



12. See health problems In a total environment 

13. Collaborate with other health workers 

14. Continue a process of self-instruction and self-evaluation 

15. Behave in a professionally ethical manner. 

2. THE CONSTITUENT GROUP 

The group chosen in this approach is composed of the individuals, families 
and communities whom the practitioner will serve. The events and processes 
in the life of the family serve as delimiting factors. Health care needs re- 
lated to these events and processes were chosen aa the specific foci. The 
rationale for this choice is discussed in C. below. What are the components 
and events of the life-cycle? They range from conception to old age in 

c. Conception and Infertility 

d. Pregnancy, Birth and Puerperium 

e. Lactation and Weaning 

f. Growth and Development 

g. Puberty and Adolescence 
h. The Adult (Age 21-44) 

i. Old Age (45 years and older) 

j. Common Diseases and Accidents Affecting Family Health 

Four additional areas which could not be classified as either events or pro- 
cesses in the cycle were thought necessary to include, to understand the cycle. 
These areas provide the student with the context within which to view the cycle, 
They are: 

a. The Nature of the Community 

b. The Family as a Unit 
k. Family Planning 

1. The Health Worker and the Community 



A Topical Outline . . . 
Nursing and Midwifery 



CHAPTER 2 
page 13 



3. CELLS DEFINED 

By the intersection of the secondary vertical and horizontal axes 
cells (see Fig. 2) which represent the interaction of practitioner skills 
with the events and processes of the life cycle are defined. For example, 
one cell (C.2) specifies that the normal structure and function of the 
family and its members should be recognized by the practitioner with respect 
to matters of conception and infertility occuring in the family life-cycle. 
One would reason that in this case the normal structures of the male and 
female genital systems, the normal physiologic processes of spermatogenesis 
and oogenesis, and the factors affecting fertility, among other matters, 

should be covered. 

In another example, cell 1.3 calls for the practitioner to assess the 
major medical, social and psychological problems of the elderly. Considerations 
of all these various cells of the matrix provides the topical details for the 
curriculum. 

Figure 2: THE LIFE-CYCLE MATRIX 





A. 


B 


C 


D 


E 


r 





H 


I 


J 


K 


L 



























o 






















8 


e 


' 












a 










rj u 










t 


* 


l! 


a 


S 








U C 






































*1 


u C 
















i *' 
























































H 5 










r-H 


t 


: 


< 




-* 






i n 

IS 


Tt > 

1 *" 


B 


, -a 

c 
0, n 


U It 

33 


II 


o 

c 


u 


o 


i T) 
O E 
U 


e 
,n 


H 

I C 
IE U 


1 Culture 


























Normal Structure 
2 and Function 






.2 






































1 








3 AitBoent 


























, Deviations from 


























Prevent, Treat, 


























Educate Individual 




















































7 EtBotlonal Support 




















































8 Services 


























1 Consultation 


























Function With 


























. Fartleipatn is 






















1 




,, Health and Envlrun- 




















































., Collaborate With 


























14 Self-instruction 















































































A Topical Outline . . . CHAPTER 2 

Nursing and Midwifery page 14 



C. RATIONALE FOR THE LIFE- CYCLE APPROACH 

How does this approach meet the proposal outlined In B.I.? 

1. It offers a framework for orienting teaching to the health needs of the 
people. 

The decision to use the so-called life-cycle approach to the teaching of 
family health was influenced first of all by the recent movements in medical 
and nursing education worldwide, toward more relevance in health training 
programmes. For the first time in modern history, medical, nursing and midwifery 
schools have taken up the issues of equal access to medical care, distribution 
of health manpower, and cost-benefit evaluations of health programmes. They 
have assumed responsibility, not just for academic treatment of these issues 
but for seeking solutions. 

In the United States the number of medical students remained relatively 
stationary between 1945 and 1965. The number of medical schools increased 
only slightly during these years. The study of medicine as late as the early 
1960s was a largely academic pursuit with practice confined to the wards and 
clinics, mostly the wards of large university teaching hospitals. Nearly 70 % 
of medical school graduates decided to specialize. Community practice, public 
health, and preventive medicine took decidedly low positions in the hierarchy 
of specialities. The ideal of the average medical student of the post-war era 
and until 1965 was the professor with a long white coat with one foot in the 
laboratory and the other in the ward. 

Nursing education during this period was still largely hospital-centered. 
However, several things had already happened to nursing service and education 
before and during this time. Nursing had moved out into the community and be- 
came a highly respected branch of the core profession, long before comparable 
status was achieved in medicine, University education was initiated due to the 
demands of nurses working in the community, for more knowledge of administration, 
epidemiology, school health and sanitation. From this beginning the universlly 
took on the additional responsibility of educating nurses to be teachers 



A Topical Outline .... CHAPTER 2 

Nursing and Mi&tifery page 25 



privileges and the hospital consultant who centered his attention on acute, 
catastrophic illness. In an even greater isolation were the local authorities 
who managed preventive, midwifery, and other peripheral services. 

British nursing education tended to be hospital-based and hospital- 
focused also. Only recently did they have graduates from a university 
degree granting programme in nursing. 

Medical and nursing education in much of the rest of the world, including 
Africa and the Peoples Republic of China, had been influenced by the patterns 
established in the United States and the United Kingdom. Much of what was 
accomplished from 1945 - 1965 was of enormous benefit. The fault lay in the 
failure either to make the advances in medicine and nursing accessible to the 
mass of the population or to lay proper stress on the social and economic 
aspects of health and disease. Events since 1965 have brought about some needed 
changes . 

The most remarkable change in medical and nursing education has taken 
place in China. Since the Cultural Revolution of 1968-69 the curricula have 
been shortened, more time has been given to field training in rural areas 
in keeping with the national policy, and most importantly the base of recruit- 
ment (Horn: 1969:124-146) has been considerably broadened. With a firm commit- 
ment to serve the rural areas as a priority, to integrate theory and practice, 
and to infuse the health delivery system with political Ideology, working and 
living with the peasant and worker populations has been deemed as important 
as theoretical knowledge of medicine (Sidel and Sidel: 1973), 

Of the African countries to embark in similar policies Tanzania and 
Mall have made the most notable progress, but awareness of the Chinese example 
Influences policy-making In many other African countries. 

During the latter part of the nineteenth century and Into the early 
twentieth there was a rising concern for preventable illnesses and deaths. 
Pioneers In medical research, public health and social welfare made some of 
their most dramatic contributions during this period of time. The whole. public 
health movement concerned itself with organization for the control of epidemics, 
the enforcement of sanitary regulations, and a variety of services for mothers 
and children. Leaders emerged in the United States and Europe; yet it was still 
true that medical aspects of public health and the practice of medicine were 
separate entities. It was a rise of social consciousness among students in 
the mid 1960s that particularly led to many action-programmes directed to 
underserved segments of the population in the United States, Government policy 



. , ^ j., CHAPTER 2 

A Topical Ou.tli.ne ... 16 

Nursing and Midwifery 

changes meanwhile released hitherto unavailable funds to medical schools to 
launch community health action programmes as vehicles, of service and education. 
Departments of community medicine arose, followed by departments of family 
practice and federal funds began to determine recruitment policies and distribution 
of physicians. Nursing schools have been encouraged to develop "family nurse 
practitioner" programs in order to meet the increasing needs and demands of the 
people. Schools for nurse-midwifery education have increased in number and size. 
Demands for nurse-midwifery services exceed the supply of qualified graduatea. 
In the United Kingdom there has been a similar movement to create depart- 
ments of social and preventive medicine or community medicine and to try to 
direct students to community practice and stem the tide of emigration of 
British physicians. One proposal which seems to have found favor is to 
develop the community practitioner as an age group specialist: for children, 
for women of child-bearing age, for adult males 20-65, and for the elderly. 
Educational programmes would center on the health needs of particular age 
groups, which tend to be rather homogenous. 

The life-cycle idea is first and foremost, a response to the need 
for a people-oriented approach to training health personnel. Because it 
focuses on families and what happens to them as they pass through the events 
and processes o life and offers students an opportunity to look at health 
and illness in the people's perspective, it bears a distinct advantage over 
a subject-oriented or an organ system-oriented approach. It thus helps to 
meet the fourth need expressed in II.A.i to train health workers capable of 
service to families. 

2 It makes a serious attempt at orienting care to cultural values. 
Any medical or nursing education programme .t in the future try to integrate 
traditional cultural values into the curriculum. Much of the medical, nursing 
and midwifery care in African countries is still carried on by shamans, 
healers, and village midwives. Only an estimated 15-20% of the rural population 
ever use modern medical facilities and 70-80 % of the African population are 
rural. As a minimum, students should be permitted to value and understand thei, 

own cultural background. 

Most cultural belief systems attempt to interpret to people the events and 
processes of life, and practices are developed to help people cope with them. 
What are these events and processes? Conception, pregnancy, birth, breast- 
feeding, weaning, growth, maturation, psycho-motor development, puberty, 



m . , , - . CHAPTER 2 

A Topical Outline ... 1? 

Nursing and Midwifery " g 



circumcision, adolescence, marriage, parenthood, disease, old age, and death 
are important ones for most ethnic groups. These events and processes are the same 
ones chosen by the life-cycle approach to teach family health to medical and 
nursing students. 

In summary, there are two main reasons for choosing the life-cycle approach: 

1. Its focus on people and how they experience health and disease 
in families and communities 

2. Its natural orientation toward organizing the teaching of family 
health around the events and processes in the life-cycle that 
considers traditional beliefs and practices 

Thus, needs 3. and 4. in II. A. can be met. But what of the other needs? 
It is hypothesized, but remains to be verified, that the life-cycle approach 
can meet them, too, namely: 

Wggd . 1: Coverage of the entirety of the subject of family health 
It is reasoned that a conception to old age approach cannot fail 
to cover every Important point. 

Need 2: A focua on what is important 

The events and processes chosen are those deemed important by the 
cultures in African peoples. They can serve adequately as nodal points 
around which to concentrate teaching emphases. 

Need 5: Integration of various specialities 

The treatment of the events and processes of life almost without exception 
requires the efforts of more than one speciality area. For example, birth 
is not the exclusive province of obstetrics, nor is growth only a concern of 
paediatrics, when these phenomena are seen in their family context. 

Need 6; Emphasis on the interrelatedneas of fertility regulation, 
nutrition, and control of infection 

This need should be met as the teaching focuses on the family and what 
is happening to the people rather than the disease and what is happening 
to the organism or the tumor. In the arena of caring for families these 
three big concerns will have a decided interplay. 



. ^ ^ . CHAPTER 2 

A Topical Outline . . . 18 

Uursing and Midwifery ^ F 



All of this reasoning, however, requires validation. The next section 
will discuss a first attempt at validating these suppositions: the deaign 
of a topical outline. 



A Topical Outline ... CHAPTER 2 

Nureing and Midwifery page -2^ 



REFERENCES 

HORN, JOSHUA S. 

Away With^All Pests. London: Monthly Review Press, 1969. 
MECHANIC, DAVID 



Medical BocJ.oio^y^ A Selective View. New York: The Free Press, 
1968. 

REINHARDT, ADINA M. and MILDRED D. QUINN (Eds.) 

Family Centered Community^ jjurjaing! ;_ A . Socio-Cultural ^Framework. 
St. Louis, C.V. Mosby, 1973. 

SIDEL, VICTOR W. and RUTH SIDEL 



the^ People: '. <3b8e,rvat ion . .on^Medicine in the People's 
Republic of China. New York: Joshia Macy Foundation, 1973. 



A Topical Outline , . . CHAPTER 3 

Nursing and Midwifery P a< 3 e 21 



CHAPTER 3: 

A GUIDE TO USING THE TOPICAL OUTLINE 
Raymond S. laely and Elizabeth V* Edmands 

I. INTRODUCTION 

The aim of this hook Is to help the instructor and the curriculum 
planner in a variety of settings to formulate a programme for the 
teaching of family health. Various institutional and other constraints 
will determine the kind of setting in which this volume will be used. 
These constraints will also determine the commitments which institutions, 
departments and individual instructors can make to change toward the 
family and community focus in their teaching. 

At the level of an Individual course, the change called for will be 
in the content and teaching methods. Information from the chapters to 
follow will be useful in making that change. 

At a more complex level, a department chairman or a nursing school 
director may need the cooperation of several faculty members to change 
their teaching programme. Use of the suggestions in this book may require 
a philosophic as well as a methodologic commitment. 

At the institutional level, family health can be taught only by an 
integrated approach, requiring the cooperation of several sections or 
departments. The degree of necessary commitment to both a change of 
philosophy and of methods of teaching will obvioualy be the greatest 
in this setting. 

Whatever his/her setting, the curriculum planner who is interested 
in the teaching of family health should find this Topical Outline of 
interest. 



A Tovical Outline . . . CHAPTER 3 

and Midwifery 



II, TYPES OF INFORMATION SUPPLIED 
The information included is of four different .types: 

A. THE DEVELOPMENT OF THE LIFE-CYCLE APPROACH - CHAPTER 2 

The concepts leading to the development of this approach 

B. AN OUTLINE IN DETAIL OF EACH OF THE TWELVE MODULES IN CHAPTER 4 
OF THE TOPICAL OUTLINE 

Topics A, B and L cover background material on community and family; 
C through I correspond to stages in the family life-cycle from conception 
to old age; J and K represent entities that affect family and community 
life at different stages of the life-cycle. Each topic is organized 
into a teaching module which consists of: 

1. A RATIONALE which points out the relevance of the content for 
the nursing or midwifery students and delineates the scope of information 
covered; 

2. A list of OVERALL BROAD LEARNING OBJECTIVES: both cognitive, 
(information acquisition) and behavioral (skills development). 

3. A list of SPECIFIC OBJECTIVES, which are grouped by sections 
corresponding to aspects of the overall topic of the module. There 
are several sections for each module, e.g.: 

a. Cujlturajl T a sheets - where the belief and practice systems 
related to the subject are discussed. 

b. Aspects ^of norjaaj^ ^structure and function whether of the 
community, the family at a particular stage of the life- 
cycle, or an individual. 

c. Deviations, from normal - the important problems of a health, 
social or psychological nature occurring at a stace of the 
life-cycle. 



A Topical Outline ... CHAPTER 3 

Nursing and Midwifery page 23 

d. Assessment measures useful for the problems occurring at a 
stage of the life-cycle. 

e. Nursing and midwifery Intervention - the types of responsi- 
bilities appropriate to the problems raised under the topic. 

4. A detailed outline of ORGANIZATION OF CONTENT for each section 
of each module, In effect the scope of what should be taught under each 
topic in the outline. 

5. A BIBLIOGRAPHY, useful for planning course content, is to be 
found at the end of each module. The list includes self-Instructional 
units from the AHTIP library and books judged helpful by AHTIP staff 
and African nursing and midwifery educators. 

c - CRITERIA FOR SELECTING TEACHING METHODS - CHAPTER 5 

Criteria for selecting teaching methods are presented, with guide- 
lines as to how to choose from among multiple approaches to subject 
matter, objectives, student levels, and available resources. 

D. DIFFERENT WAYS OF EVALUATING STUDENT LEARNING - CHAPTER 6 

Different ways of evaluating student learning and how to select 
them appropriately are shown. 



III. HOW TO USE THE INFORMATION 

The objectives of curriculum planning in an individual Institution 
will determine how information will be used. Planning objectives may 
include one or more of the following: 

A. TO DESIGN A COURSE, e.g. a course in labour and delivery. 



A Top-leal Outline ... CHAPTER 3 

and Midwifery page 24 



B. TO PLAN OR CHANGE THE PROGRAMME OF A DEPARTMENT, e.g. obstetrical 
and gynaecological nursing or midwifery, 

C. TO BUILD AN INSTITUTION-WIDE CURRICULUM, e.g. a nursing curriculum 
focused on the family as the unit of practice and the community 

as the setting. 



***** 



A. THE DESIGN OF A COURSE 

In the first example, the curriculum planner is a course instructor 
who wants to Improve his/her teaching of labour and delivery, refocusing 
the birth event in the family life-cycle. 

The instructor will first turn to Module D. entitled "Pregnancy, 
Birth and Puerperium" and read the rationale and the overall objectives , 
paying especially close attention to those parts dealing with labour and 
delivery. He would compare these overall objectives with hie own if he 
has developed them. If not, he would take the relevant objectives from 
the module and adapt them to his own course, perhaps later adding others 
of his own. Then he would turn to the specific ob.1 actives and go through 
the same process. 

Once he was comfortable with both the overall and specific objective! 
he would proceed to the organization of content, reviewing each of the 
sections for items dealing with labour and delivery. The instructor 
would compare the resulting outline with his own, make the necessary 
modifications and develop detailed notes on those sections not adequately 
covered. In doing so, he may make uae of the references found at the 
end of the module. He may want to order some of the self-instructional 
units. Before deciding on self-instruction, he should also refer to 
the discussion of various teaching methods in Chapter 5. He may wish 



A Topical Outline ... CHAPTFR 

Nursing and Mi&rifery page 25 



Finally, he would turn to Chapter 6, where the evaluation of student 
learning is discussed. Using the criteria developed there for various 
evaluation methods, he would choose those that seem most appropriate for 
his particular circumstances. 

B. PLANNING A SCHOOL-WIDE PROGRAMME 

In this example, a school of nursing or midwifery seeks to use the 
Topical Outline to improve the teaching programme in obstetrics and 
gynaecology. An approach similar to that of the first example would 
be useful. First, the nursing director or the curriculum committee 
would review the rationales and overall objectives for each module 
which appears relevant to their programme. Modules A, B, C, D, E, 
G, H and K all contain material relevant to obstetrics and gynaecology. 
The rationales and overall objectives of these eight modules could be 
compared with those of the existing curriculum and necessary modification 
would be made to arrive at general agreement. For example, Che existing 
programme may not include any teaching of community or family aspects, 
so that the material in modules A and B would have to be added. On 
the other hand, the programme on pregnancy, birth and the puerperium 
may be more complete than module D and would need no modification. 
From modules C. "Conception and Infertility", E. "Lactation and Weaning", 
G. "Puberty and Adolescence", H. "The Adult", and R. "Family Planning" 
the committee may want to select certain parts to supplement existing 
teaching . 

When agreement has been reached on rationales and overall obj actives > 
the committee would then review the specific objectives and organization 
of content of each module section by section. They may wish to ask 
the rest of the faculty to review their proposal. During the review, 
the objectives and content would again be compared with existing courses 
and modifications made in the programme to correct deficiencies and to 
expand inadequately covered subjects. 

After these modifications had been made, lecture notes coulrl be 
developed, self-instructional units written, clinical experiences planned 



A Topical Outline ... CHAPTER 3 

and Midwifery 



and learning sequences designed using the references and guidelines 
contained in this book (see end of each module In Chapter 4 and Chapters 
5 and 6). 

C. OTHER APPROACHES TO BUILDING A FAMILY HEALTH CURRICULUM IN A NURSING 
OR MIDWIFERY SCHOOL 

The faculty would need to react with the Topical Outline as a whole 
before dealing with individual modules. It would be necessary to come 
to terms with not only the material covered In Chapter 4, but the philo- 
-sophical bases discussed in Chapter 2, since this latter determines the 
way In which the outline is organized. 

If agreement can be reached, then the next step is to determine how 
the content In the modules might be taught. It may be that a series of seminars 

on family health held monthly throughout the year will provide the 
best format. A coordinator would need to be appointed. Individual 
course instructors would make their contributions as appropriate. This 
approach would be a modest attempt at change toward a more family- 
focused teaching programme. Adding planned clinical experiences, case 
conferences, field activities, projects, and papers In which tutors 
Join in collaborative efforts would advance further the process of change. 

Whatever the position or point of view of the curriculum planner 
reading this volume, some of the Information in the ensuing chapters 
should be useful to him. Whether it be objectives, content, references, 
teaching methods, evaluation techniques, combinations of these or all 
of them, the hope is that this Topical Outline will find its way Into 
multiple curriculum and course planning activities in African schools 
of nursing and midwifery. 



A Topical Outline ... CHAPTER 4 

Nursing and Midtfifery page %7 



CHAPTER 4 ; 

TEACHING MODULES FOR FAMILY HEALTH 
THE TOPICAL OUTLINE 

Elisabeth M. Edmands 



A Topical Outline ... MODULE A: NATURE OF THE COMMUNITY 

Nursing and Micfoifery page 29 



MODULE A : 
NATURE OF THE COMMUNITY 



I. RATIONALE 

In order to teach nursing and midwifery students about the health of 
families, it Is important to realize that all families belong to some kind 
of a community. These communities may vary in size from a small hamlet to a 
large metropolitan city, or may even be considered in the context of an entire 
nation. How Individual families function and the resources available to them 
will often depend on the size and nature of the community in which they live. 

It is, therefore, important for students to know what factors in the 
community are most likely to influence the health of Individual families and 
how to assess their impact. Among the more obvious factors are: 

1. Safe water supplies 

2. Waste disposal 

3. Food supplies (quantity and quality) 

4. Access to preventive and curative health, including 
the traditional 

5. Transportation systems 

6. Educational facilities 

7. Employment opportunities 

8. Climatic conditions 

Other factors which also have a profound effect include: 

1. The size and make-up of the population 

2. The level and quality of its leadership 

3. Cultural beliefs and practices 

4. Internal and external political and economic influences 

5. Topography of the land 

6. Formal and Informal communication systems 

7. Laws by which the people are governed 

For most students in the health professions (nursing and midwifery as 
well as medical), a logical approach to determining the health needs of a 
community is to gather data in a similar manner to that used in history 
taking and examination of a patient, in order to develop a working diagnosis. 



A Topical Outline ... MODULE A: NATURE OF THE COMMUNITY 

Nursing and Midwifery page 30 



It is important, however, to point out that even in the care of an individual 
patient the health professional is dependent upon the patient's desire to be 
cared for, willingness to supply information, assent to the diagnostic and 
treatment plan, and cooperation in the care plan. A community is no different. 
At the very outset the health worker must explain the rationale for his or 
her presence in the community, gain the acceptance of a network of community 
leaders, and reach agreement with the community leadership on objectives as 
well as a tentative plan of action. When the health problems of the community 
are identified, they can be ranked by priority and decisions made about 
appropriate action. 



A Topical Outline ... MODULE A: NATURE OF THE COMMUNITY 

Nursing and Midwifery page 31 



II. OVERALL OBJECTIVES 

At the completion of this module, students should be able to: 

1. Determine what information is needed to assess a community. 

2. Select and use appropriate tools to collect information (or 
use available data) . 

3. Evaluate data and determine health need priorities of the 
community. 

4. With others, plan and coordinate activities. 



A Topical Outline ... MODULE A: NATURE OF THE COMMUNITY 
Nitreing and Midwifery P a 9 e s2 



Section I ; As see amen t o f the Communi t y _ 

Specific Objectives: 

1. Define a community and list characteristics which are common to 
any community. 

2. For a given community, determine what data are needed to understand 
the composition and nature of the population. 

3. Describe the interrelationships of factors that determine the nature 
of the community. 

4. Explore the relationship of factors as they affect the health of 
the community. 

Organization of Content _. , . 



A. A working definition of a community 

1. Circumscribed area 

2. Groups of people 

3. Common goods and practices 

4. Some form of laws 

5. Some form of leadership 
B. Demographic data 

1. Size of population 

2. Breakdown by 

a. Age 

b. Sex 

c. Marital status and number of families 

d. Ethnic groups 

e. Social class 

f. Religion 

3. Birth and death rates 

4. Infant mortality rate 

5. Growth rate 

6. Migration rate 

7. Dependency ratio - number of dependents per breadwinner 

8. life expectancy 



A Topical Outline ... MODULE A: NATURE OF THE COMMUNITY 

Nursing and Midwifery page 33 



Section I : Assessment of the Community 
Organization of Content - c on t ._.__. 



C. Environmental aspects of the community 

1. Land space 

a. Amount 

b. Urban vs. rural 

c. Ownership (land tenure) 

2. Land quality 

a. Fertile or arid 

b. How utilized - crops 

c. Adequacy of food supplies 

3. Drinking water 

a. Sources 

b. Safety 

c. Adequacy 

4. Waste disposal 

a. Kinds 

b. Safety 

c. Adequacy 

5. Climate 

a. Temperature 

b. Seasonal variation 

c. Rainfall (drought, flooding) 

6. Transportation and communication 

a. Roads - quality, seasonality 

b . Telephone 

c. Radio (TV) 

d. Other means of transportation 

e. Other means of communication 



7. Economic 

a. Industry 

b. Agriculture 

c. Employment vs. unemployment 

d. Employment for women 

e. Average cash income and range 

8. Housing 

a. Kinds 

b. Adequacy 



A Topical Outline... MODULE A: NATURE OF THE COMMUNITY 

Nursing and Midwifery page 34 



Section I: Assessment of .. T the, Community 
Qraanlzatipn of J3ontj3nt - cont. . . 



D. Resources for health and social welfare 

1. Hospitals and/or health centers 

a. Location 

b. Size 

c. Services offered 

d. Organizational system 

e. Adequacy to meet community needs 

f. Financial support 

2. Agricultural and environmental services 

3. Religious structure (or services) 

4. Educational (schools) 

5. Social and recreational resources 

6. Manpower for these services 

E. Customs - heritage 

1. History of the community 

a. New or established 

b. Origin of various families 

2. Established customs, beliefs or taboos 

a. Puberty - rites, eexual attitudes and behavior 

b. Marital - roles, relationships, types of marriages 

c. Traditional fertility regulation 

d. Child bearing and rearing 

e. Meaning of children - including social value 

f . Family customs or habits - including value systems 

g. Clan or tribal loyalties 
h. Food habits, taboos, etc. 

3. Traditional "medical" practices 

a. Beliefs 

b. Manpower - "medicine man", "healers" etc. 

c. Practice based on magic, spells, voodoo, herbs, etc. 

d. Coordination (or cooperation) with modern scientific medicine 

F. Health problems in the community 

1. Leading causes of death 

2. Leading causes of morbidity 



A Topical Outline ... MODULE A: NATURE OF THE COMMUNITY 

Nursing and Midwifery page 35 



.Section I ;_ ^Assessment of the Community 



Organization qf_^ojite^nt - cont . .. 



3. Nutritional status 

4. Vectors 

5. Varying susceptibility to change (by leaders or the people) 

6. Lack of effective communication 

a. Between health and social welfare agencies 

b. Between these agencies and the people 

G. Leadership 

1. Identification and selection 

2. Nature of leadership 

a. Networks of leadership 

b. Decision making 
c , Communication 

d. Delegation of responsibilities 

3. Community response 

a. Cooperation vs. opposition 

4. Political influences 

a. National 

b. Regional and local 

H. The Community 

1. Interrelationship of above factors 

2. Exploration of how all the preceding factors affect health of 
the community 

3. Uniqueness of each community 



A Topioal Outline ... MODULE A: NATURE OF THE COMMUNITY 

Nursing and Midwifery T?a<3 3S 



Section II: Methods of Collecting Data About a Community . 

Specific Objectives! 

1. Using the content presented In Section I, select items for assess- 
ment that are pertinent to the area of concern or interest. 

2. Determine what data are already collected and discuss plans for 
further investigation. 

3. With guidance, select and use available data or appropriate tools 
to obtain information. 

Organization of Content 

A. Survey methods 

1. Review - previously collected data, if any 

2. Identification of objectives in gathering information 

3. Selection of design for data collection 

a. Questionnaire 

b. Interview 

c. Observation 

d. Combination 

4. Betermination of sample size - random, clusters, or systematic 

a. Feasibility 

b. Cost 

c. Time 

5. Selection of survey personnel 

a. Number - self only (?) 

b. Criteria 

c. Estimate of time involved 

d. Volunteers or paid workers 

B. Problems in data collection 

1. Accuracy of the instrument 

2. Appropriateness of the instrument 

3. Misunderstanding of questions by survey personnel or by respondent 

4. Faulty transmission of data 

5. Purpose of inquiry not always fully explained or understood 

6. Too much or too little data requested 

7. Miscalculation in estimated cost 



A Topical Outline . .. MODULE A: NATURE OF THE COMMUNITY 

Nursing and Midwifery page 3? 



Section II: Methods of Collecting Data .About a Community 
Organization of Content - cont... 

C. Training of survey personnel 

1. Planning 

2. Conducting 

3. Approach 

4. Role playing 

5. Variety of interviewing techniques 

6. Confidentiality (in some types of surveys) 

7. Recording 

8. How findings will be used 

D. Supervision and management of data collection 

1. Completeness 

2. Estimate of accuracy (reasonableness) 

3. Time schedule 



A Topical Outline . . , MODULE A: NATURE OF THE 

Nursing and Midwifery page 30 



Section III: Evaluation of Data and Determination of Health Need Priorities 

Specific Objectives: 

1. Determine what data to evaluate and how to do it. 

2. From data collected, determine what seems to be the priorities 
in the health needs of the community. 

Organization of ...Content ^_. r ^... r ^ -^-^- 

A. Organization of collected data 

B. Synthesis of information 

C. Analysis of data 

1. Statistical measurements 

2. Consistency of data 

3. Relevance of findings to community needs and resources 

D. Determining with community leaders the priorities in health needs 

1. Implications of findings in setting priorities 

2. Preception of community leaders 

3. Coordinating perceived needs with survey findings 

a. Similarities 

b. Differences 

c. Compromise 

4. Matching priorities to resources available 

a . Economic 

b. Manpower 

c. Leadership support 

d. Technology 



A Topical Outline ... MODULE A: NATURE OF THE COMMUNITY 

Nursing and Midwifery page 39 



Section IV: The Planning of Health Ac tivi u-ies Based on Community Assessment 
Specific Objectives: 

1. Develop a plan to bring about change in one or more health activities 
in the community. 

2. If the plan involves health workers other than nurses (or midwives) , 
describe how to plan and coordinate with them 

Organization of Content __ 

A. Planning 

1. Setting of objectives based on priorities as determined in Section III 

2. Re-examine the reality of resources 

a . Human 

b. Material 

3. Constant sharing of ideas of community leaders and health personnel 

a. Feasibility of plan 

b. Practicality of plan 

c. Organization 

4. Other factors in decision making 

a. Policy 

b. Financial support 

c. Can leaders get support of significant others in community 

d. A sponsoring agency of indicated 

5. The nature of the change 

a. Gradual 

b. Integration of new service into on-going program or 

c. A new service/program 

6. Personnel 

a. Selection 

b. Coordination of activities 

c. Training for a new service 

B. Implementation and evaluation 

1. Although most of the content on implementation and evaluation will 
be presented in Module L, "The Interaction Between the Health Worker 
and the Community", it is relevant to outline plans at this stage 
of development . 



A Topical Outline ... MODULE A: NATURE OF THE COMMVttFf? 

Nursing and Midwifery page 40 



BIBLIOGRAPHY 



I. SELF- INSTRUCTIONAL UNITS 

available from the African Health Training Institutions Project 



Community Diagnosis to De termine the^ Needs for Health Servicea, 
JAMES KHACHINA (Kenya) 

Assessing Health Services to Determine Staffing Needs 

WINIFRED NYOIKE (Kenya) 

Food Customs^ and^Taboos i^ln ^ j.ela.tion to the Family Health 
in __a : Commun i ty_ 

SARA W. KAVITI (Kenya) 

Factors Affecting the Patient's Health 
AMAL F. GARAS (Egypt) 

I n an t Mo rb id i ty and Mo r t al i t y - r D.ata Collection , C aus e anc[ 
Prevention. 

DOROTHY MULONGA NASAH (Cameroon) 

Family P 1 anning as a Me ans of P romo ting Hea 1th 
MOKOWA BLAY ADU-GYAMFI (Ghana) 

The Use of Health Examination Surveys to Measure Disease 
Control Programs 

DONALD W. BELCHER (Ghana) 

The A. B.C. of Communication in Health and Medical Work 
MATILDA E. PAPPOE (Ghana) 

Influence of Environmental and Cultural Factors on Child 
Care and Development 

PAULINE MELLA (Tanzania) 

The Training of Voluntary Rural Health Workers in Developing 
Countries 

AFIYA H. YAHYA (Kenya) 

The Role of Family Planning in Family Health and Community 
Development 

VUYELWA N. NGCONGCO (Botswana) 

Vital Rates in Family Health 
SAMUEL OFOSU-AMAAH (Ghana) 

The Community Organization Process and its Relevance to 
Community Health Practice 

E.K. QUARTEY-PAPAFIO (Ghana) 



A Topical Outline . . . MODULE A: NATURE OF THE COMMUNITY 

Nursing and Midwifery page 41 



II. BOOKS 

BYRNE, MONICA and F.J. BENNETT 

Community Nursing in Developing Countries , a Manual for the 
Auxiliary Public Health Nurse. London: Oxford University Press 
1973. 

DIVINCENTI, MARIE 

Administering Nursing Services. Boston: Little, Brown, 1972. 
FOSTER, GEORGE M. 

Traditional Societies and Technological Change! 2nd edition. 
New York: Harper and Rowe, Inc., 1973. 

FREEMAN, RUTH B. 

Community Health Nursing Practice. Philadelphia: Saunders, 1970. 
GARRETT, ANNETTE 

Interviewing. Its Principles and Methods. New York: Family Service 
Association of America, 1972. 

JELLIFFE, DERRICK, B. 

The Assessment of Nutritional Status of the Community. Geneva: 
World Health Organization, 1966. 

LEAHY, KATHLEEN M. and MARGUERITE COBB 

Community Health Nursing. 2nd edition. New York: McGraw Hill, 1972. 
LEEDAM, ELIZABETH J. 

Community Nursing Manual; A Guide for Auxiliary Public Nurses. 
Singapore: McGraw-Hill International Book Co., 1972. 

LEININGER, M.M. 

Nursing and Anthropology: Two Worlds to Blend. New York: John Wiley. 
1970. ~~ 

LINTON, RALPH 

The Cultural Background of Personality. New York: Prentice Hall, 
1961, 

MACLEAN, UNA 

Magical Medicine: A Nigerian Caae-Study. London: Penguin, 1971. 



A Topical Outline ... MODULE B: THE FAMILY AS A UNIT 

Nursing and Midwifery page 44 



II. OVERALL OBJECTIVES 

At the completion of this module students will be able to: 

1. Define the various meanings of the word "family," 

2. Describe the cultural and social influences that determines the nature 

of families. 

3. Describe family structure and its relevance to its function. 

4. Discuss appropriate nursing and/or midwifery intervention in relation 
to the health of the family. 



A Topical Outline ... MODULE B; THE FAMILY AS A UNIT 

Nursing and M-iduifery page 45 



Section I. Definition and cultural/social determinants o the nature of families 

Specific Objectives: 

1. Define the terra "family" and give examples of the various types in the 
local community. 

2. Describe the problems of families that affect its structure. 

3. Discuss the prevalent beliefs and attitudes that influence the individual 
roles of family members. 

4. Describe how attitudes and customs in the community determine the position 
and status of families. 

Organization of Content 

A. Common definition of the family unit 

1. Mother and father 

2 . Children 

3. Significant others 

a. Blood relatives 

b. Relatives by marriage 

B. Concept of classification of families 

1. Nuclear vs. extended 

2. By type of marriage 

3. By lines of authority and inheritance 

a. Matrilineal 

b. Patrilineal 

4. Polygamous 

C. Problems affecting the structure 

1. Death of one or both parents 

2. Separation (divorce) 

3. Desertion of one parent 

A. Childless couples (infertility) 

5. Temporary disruption caused by environmental factors 

a. Catastrophe - flooding, fire, drought, famine 

b. Illness of one parent (physical or mental) 

c. Unemployment 

d. Migration 



A Topical Outline ... MODULE B: THE FAMILY AS A UNIT 

Nwc*8-i,ng and Miduifery page 46 



Section I; Definition and cultural/social determinants of the nature of families.. 
Organization of Content - :. .cont_._i_. _._... 

D. Cultural attitudes toward roles of family members 

1. Traditional 

2. Forces of change 

a. Factors involved 

b. Nature of change 

3. Role ot the adult male 

a. Traditional 

b . Current 

4. Role of the adult female 

a. Traditional 

b . Current 

5. Changing role of parents as family life cycle progresses 

6. Evolving roles of children (by age and development) 

1. Role of grandparents and other relatives - see Module I -Sections 
II + IV 

8. Role of single adults 

a. separated 

b. widowed 

c. never married 

E. The status of families 

1. Position in the community 

2. Determinants - background, attitudes and customs 

3. Mobility or fixed status 

A. Social class, prestige, wealth, occupation 

5. Health, heredity 

6. Intellect, education 

7. Politics 

8. Religion 



A Topical Outline . . . MODULE B: THE FAMILY AS A UNIT 

Nursing and Midwifery page 4? 



Section II: Family structure and ita relevance to function 

S pec i fie Ob j e c t i ve s : 

1. Describe factors Influencing family structure. 

2. Discuss the basic needs of families. 

3. Describe the tasks of a family unit as they relate to function 
Organisation of Content 



A. Structure of the family 

1. Individual members 

2. Roles of individuals 

a. Nature of leadership, authority, and family decision-making 

b. Nature of compliance 

3. Role behavior and interpersonal relationships with other family members 

B. Factors influencing structure of the family 

1. Biological 

a. Heredity 

b. Congenital or acquired defects 

c. Intellectual capacity 

d. Nutritional status 

e. Reproductive capacity 

2. Cultural (described in Section I) 

3. Psychosoclal 

a. Coping ability 

b. Acceptance by peers or other neighboring families 

4. Educational 

a. Accessibility 

b. Quantity - levels 

c. Quality 

d. Family attitude toward educational achievement 

e. Attitude toward education of females 

5 . Economic 

a. Employment - availability 

b. Minimum standards - housing, food, clothing 

c. Employment of women and children 

d. Fair wage and labor laws 



A Topical Outline 
and 



MOVVI& B: Mffi FAMILY AS A UNIT 
page 



Tamilv structure and its relpvanr.e to function 



Organization of Content - cont. 




C. Basic needs of families 

1. Survival 

2. Continuity 

a. Biological 

b. Values, traditions 

c. Philosophy 

3. Growth 

D. Tasks involved to meet basic needs 

1. Reproduction 

a. Planning number of children 

b. Child-spacing 

2. Physical maintenance 

a. Food 

b. Clothing 

c. Shelter 

d. Medical care 

e. Recreation 

3. Socialization of offspring 

a. Sexual identity 

b. Values 

c . Language 

d. Security and acceptance (love) 

e. Acceptable aocial behavior 

f . Orientation to adult roles - work, family responsibilities 

4. Resources and responsibilities 

a. Allocation of authority : 

b. Decisions regarding income and spending 

c. Designation of household (or community) tasks 

d. Decisions regarding family life events - marriages, naming ceremonies 
allocation of land and belongings, care for illness, etc. 

5. Communication and relationships 

a. Between individual family members 

b. Between family and community 

c. Between families in same clan. 



A Topical Outline . .. MODULE B: THE FAMILY AS A UNIT 

Nursing and Midwifery P<z$ e 4 



Se c 1 1 on II : Family stjr u c tu re and^its^ re le van ce to unc, t ion 

Organization of Content - cont . . . 

6. Maintenance of order 

a. Through conforming to societal or cultural requirements or norms 

b. By respecting taboos 

c. By supporting the laws 

7. Maintenance of family ties 

a. Morale and motivation 

Acceptance 
Encouragement 
. Affection 

b. Loyalties 

Ceremonies 
. RitualB 
Festivals 

c. Support during crises 

8. Acceptance of change 

a. Incorporation of new family members 
. Birth 

Marriage 

b. Releasing family members 
. Work 

. Marriage 

c. Coping mechanisms for stress 



A Topical Outline ... WDUEB B: THE FAMILY AS A WXT 

Nursing and Mid&ifery page ^ 



Section III: Intervention by Nurses or Midwlves 



Specific Ob.lectivflB; 

1. Determine kinds of family data needed to approach a health problem. 

2. Interview and observe a family to obtain data. 

3. Analyze family resources to determine a nursing care plan. 

4. Counsel families on health related problems. 

Organization of Content , 

A. Collection of data 

1. Family history 

2. Presenting problem 

3. Family and community resources 

4. Medical records 

B. History taking 

1. Approaches and techniques 

2. Use of information 

C. Observation in home, clinic or hospital 

1. Interaction of family members 

2. Identifying family decision maker 

3. Attitudes toward health problems 

4. Impressions of resources, strengths, liabilities 

D. Formulating the nursing care plan 

1. Synthesis of history, observations and presenting health problems, 
needs and diagnosis 

2 . Resources 

a . Family 

b . Community 

3. Setting objectives for intervention 

4. Formulating guidelines of approach 

5. The actual plan 



A Topical Outline ... MODULE B: THE FAMILY AS A UNIT 

Nursing and Midwifery page >! 



Section III: Intervention by Nurses or Midwives 

Q_rj5anlzatipn..jjf Content - cont . . . 

6. Points where intervention can be evaluated 

E. The nature of health-related problems in the family (physical, mental and 
social) which are appropriate for intervention 

1. Pregnancy 

a. Maternal health 

b. Health of child 

c. Family 

2. Child care 

3. Growth and development 

a. Deviations from normal - growth failure, mental deficiency, behavior 
problems 

b. Significance 

4. Cost and/or lack of resources for medical care 

5. Nutritional education 

a. Basic needs 

b . Food values 

c. Sources 

d. Cost 

6. Prevention of illness 

a. Immunizaiton 

b. Environmental hygiene 

c. Personal care 

d. Health Instruction 

7. Assessment of illness of any family member 

a. Nature of symptoms 

b. Pain 

c. Disability 

d. Resources for care - traditional vs. modern 

e. Contagion 

8. Stress (and/or mental Illness) 

a. Neurosis 

b. Psychosis 

c. Addictions - alcohol, drugs, etc. 

d. Marital problems 

e. Coping ability of individuals and families 

9. Family planning (see Module K. - Family Planning) 

a. Element of choice 

b. Education and counseling 

c. Service resources 



A Topical Outline 
Nursing and 



MODVU B: THE FAMILY AS A UNIT 
page 52 




10. Infertility (see Module C - Conception and Infertility) 

a. Knowledge 

b. Beliefs and attitudes 

c. History J . 

d. Resources available for investigation 

e. Counseling 
Counseling techniques 

1. Approach and timing 

2. Privacy and confidentiality 

3. Detection of areas of sensitivity 

4. Problem-solving 

5. Family focus and responsibilities 

6. Use of other resources 

a. Coordination of efforts 
. Medical 

, Educational 

. Social 

. Agricultural 

b. Consultation 

c. Referral 

d. Traditional healers 

e. Authority figure in family 

7. The nature of communication 

a. Verbal 

b. Body language 

c. Terminology 

d. Interpretation 



8. Evaluation of progress 



MODULE B: THE FAMILY 



BIBLIOGRAPHY 



I. SKT.F-TNSTRUCTIONAL UNITS 

- available from the African Health Training Institutions Project 

Relation of Child Spacing to the Mental Health of the Family 
D.B. WANGA (Kenya) 

Social* Psychological and Educational Aspects Related to Family 

Planning 

KORAY NAGALI (Ghana) 



Th.? SQciallzation Prof-eas o Children and Tf.fl T.rnporf,fmf.e 
Health 



EDITH FORDJOR CGhana) 

Introduction to Family Planning, Contraception and the IUCD 

GRACE DELANO (Nigeria) 
Lonft-Term Nursing Intervention with Malnourished Children and, 

Their Families 

SUZAN H. BANOUB (Egypt) 

Maternal Nutritional Needs 
ELIZABETH MUTURI (Kenya) 

Mental Illness In Children 
E. OLU ADELOWO (Nigeria) 

The Rn1 P of Family Planning in Family Health and Community Development 
VUYELWA N. NGCONGCO (Botswana) 

Family Planning: Its Implication on Health 
GRACE NNENNA NZERIBE (Nigeria) 

Food Customs and Taboos in Relation to Family Health in a Community 
SARA W. KAVITI (Kenya) 

Influence of Environmental and Cultural Factors on Child Care and, 
Development 

PAULINE MELLA (Tanzania) 

Feeding Practices -and the Health of Children 
A.O. OBARISIAGBON (Nigeria) 



MODULE B: THE FAMILY 

***#* ** 



II. BOOKS 

FOSTER, GEORGE M. 

Traditional Societies and Technological Change. 2nd edition- 
New York: Harper and Rowe, Inc., 1973. 

FREEMAN , RUTH B. 

Community Health Nursing Practice, Philadelphia: Saunders, 1970. 

HYMOVICH, D.P. and M. BARNARD 

Family Health Care. New York: McGraw Hill, 1973. 
KING, MAURICE and DAVID MORLEY 

Nutrition for Developing Gountriea with Special Reference to Maize,, 
Cassava and Millet. London: Oxford University Press, 1972. 

LEININGER, M.M. 

Nursing and Anthropology: Two Worlds to Blend. New York: 
John Wiley, 1970. 

LINTON, RALPH 

The Cultural Background of Personality. New York: Prentice-Hall, 
1961. 

OMRAN, ABDEL 

Health Theme in Family Planning. Chapel Hill. North Carolina: 
Carolina Population Center Monograph, 1971. 

REINHARDT, ADINA M. and MILDRED D. QUINN (ede.) 

T^lTy Cantered Community Nurslnp; A Socio-Cultural Framework, 
Saint Louis: Mosby, 1973. 

SPOCK, BENJAMIN 

Babv and Child Care . New York: Simon and Schuster, Inc., 1974. 



A Topical Outline ... MODULE C: CONCEPTION AND INFERTILITY 
Nwaing and Micbrifery P a 9 e 55 



MODULE C : 
CONCEPTION AND INFERTILITY 



I. RATIONALE 

In most societies, the ability of the woman to conceive is considered an 
essential achievement. When this event takes place, the woman has proved that 
she is fertile and, therefore, deserving of all the social attributes of womanhood. 

Conception, the union of the ovum and sperm, marks the beginning of a 
complex series of changes in the physiology and psychology of the woman. In 
order to understand how conception occurs, the student must have knowledge and 
understanding of the following: 

1. Anatomy and physiology of the reproductive systems (male and female). 

2. The menstrual cycle, particularly the significance and timing of 
ovulation . 

3. Maturation of the human organism - spermatogenesis and oogenesis. 

4. Sexual Intercourse. 

These components will be Integrated to form the basis of nursing and midwifery 
teaching and counseling about maternity care, contraceptive methods and infertility. 

Infertility and sterility are terms used to describe the inability of a couple 
to produce a child. This inability is particularly tragic for the African woman, 
for traditionally her adult life has been centered around the production and nurture 
of children. In addition, many beliefs, superstitions, and rituals have focused on 
the female responsibility to reproduce and until recently there has been little 
recognition that the male factors contribute to about a third of the causes of in- 
fertility. 

Medical science has developed many new ways to diagnose and treat infertility. 
However, some of the procedures are highly sophisticated and not readily available 
to those who need them. It is also known that there is a psychological component 
to infertility which produces stress in the individual and in the couple. Wise 
counseling by physicians, nurses and midwlves should help to release this tension 
and in some cases where there are no medical or mechanical barriers, conception 
may occur. 



A Topical Outline^ 
and 



MODI/IE C, COHCEFIJON AND 
page 66 



II. OVERALL OBJECTIVES 



At the collation of this module, the student should be able to: 



1. Discuss social and cultural attitudes toward conception and 

2. Describe the anatomy and physiology of the .ale and female reproductive 

systems. 

3. Describe the process of conception. 

4 Describe the incidence and causes of infertility 

5. State the kinds of procedures performed for diagnosis and treatment 

of infertility. - 

6. Describe the role of the nurse and/or midwife in care and counselling 

the infertile couple, including follow-up. 

7. Demonstrate competence in counseling the female partner of an infertile 
union or preferably the couple together. 



A Topical Outline ... MODUL& C: CONCEPTION AND INFERTILITY 

Nursing and Midwifery page 5? 



Section I: Social and Cultural Attitudes and Practices Toward Conception and 
Infertility _ 

Specific Objectives; 

1. Describe the attitudes and practices in most African societies, 
surrounding the reproductive capacity of women, 

2. Compare these attitudes with those found in the local community. 
Organization of Content ~ 

A. Cultural background 

1. Role of woman in the family, in the community 

a. Traditional (urban and rural) 

b. Modern (urban and rural) 

c. Transitional 

2. Importance of reproduction 

a. Social 

b. Familial 

c. Individual status (particularly female) 

d. Survival of species, tribe, family 

B. Formation of attitudes toward reproductive ability of women 

1. Belief system supporting attitude 

2. Basic needs 

a. Proof of womanhood 

b. Place in society 

c. Role fulfillment 

d. Care of children 

3. Influences 

a. Religion 

b. Education 

c. Economic status 

d. Type of marriage 

e. Family pressures 

4. Process of change 

a. Effect of industrialization 

b. Mobility 

c. Education 

d. Standards of living 

C. Practices 

1. Fertility rites 



A Topical Outline . . . MODULE C: CONCEPTION AND INFERTILITY 

Nursing and Aft 



Section I: Social and Cultural Attitudes and Practices Toward Conception and 

Infertility 

Organization of Content - cont... 

C. 2. Action based on beliefs or factors affecting conception 

a. Taboos 

b. Foods 

c. Ritual 

d. Circumcision (male and female) 

3. Premarital conception as proof of fecundity 

4. Effect of polygamy or monogamy on sexual exposure 

5. Religious aspects - blessing of marriage to produce children 



A Topical Outline . . . MODULE C: CONCEPTION AND INFERTILITY 

and Midwifery page 69 



Section II: Anatom^jmd PhysipJLjpj^ of _Male ijarid ir Female Reproductive . Sy sterns^ 

Specific Qb j.ectiyes^ 

1, Describe the anatomy and physiology of the female reproductive 
eystem including the menstrual cycle and ovulation. 

2. Describe the anatomy and physiology of the male reproductive system, 
Organization of. Content 

A. Organs involved (female) 

1. Identification 

2. Description 

3. Function 

4 . Interrelationships 

B. Maturation (also see Module G - Puberty) 

1. Stages 

2. Hormones and their influence 

3. The menstrual cycle 

4. Readiness for sexual performance and reproduction (oogenesia) 

5. Abnormalities 

C. Organs Involved (male) 

1. Identification 

2. Description 

3. Function 

4 . Interrelationships 

D. Maturation (also see Module G - Puberty) 

1. Stages 

2. Hormones and their influence 

3. Readiness for sexual performance and reproduction (spermatogenesis) 

4. Abnormalities 



A Topical Outline ... MODULE C: CONCEPTION AND INFERTILITY 

Nursing and Midtifery page 60 



Section III; Conception ___ _. 

Specific Objectives; 

1. Describe the process of gametogenesls 

2. Describe fertilization and Implantation* 

3. Differentiate the three main germ layers of the growing embryo. 
A. Identify three components of the fetal environment. 

5. Trace size of growing fetus and relate structural development to 
viability. 

6. Describe the signs and symptoms of pregnancy. 

Organization of Content 

A. Physiology of conception and development of fertilized ovum 

1. Gametogeneais 

a. Spermatozoon 

. Spermatogenesis - formation - minute - head, neck, tail 
. Mature before discharge from tubules in teatis 
. Undergoes meiotic process 
. Ready for fertilization 

. Chromosomes 

b. Ovum 

. Oogenesis - large, round, veaclcular 

. Rests In ovary before discharge to Fallopian tube 

(usually one a month) 

. Process of melosis - maturity 

. Ready for fertilization 

. Transport through Fallopian tubes 

. Chromosomes 

2. Fertilization 

a. Time - at ovulatlon 

b. Union of sperm and ovum 

c. Retention in Fallopian tube about 3 days 

e. In uterine cavity about 4 days before Implantation 

3. Implantation 

a. Imbedding of fertilized ovum 

b. Deep into lining epithelium of uterus-decidua 

c. Now called trophoblast (or chorion) 

Lng embryo 

Lfferentiate into three main germ layers 

Ectoderm - from which the following structures arise: 

skin, hair, nails, sebaceous glands, epithelium of nasal and 

oral passages, tooth enamel and the nervous system 



A Topical Outline . . . MDWLE C: CONCEPTION AND INFERTILITY 

Nuveing and Midwifery page SI 



Section III: Conception ___ 

Organization of Content - cont . . . _ 

A. 4. a. . Meaoderm - derive muscles, bone cartilage, dentln of teeth, 
ligaments, tendons, kidneys, ureters, ovaries, testes, heart 
and blood vessels etc. 

. Entoderm - derive epithelium and glands of the digestive tract, 
respiratory tract, bladder, urethra, thyroid and thymus. 

b. Environment for growth in pregnant uterus 

. Amnlon 

. Chorion 

. Placenta - true placental circulation established 

approximately 17 days after fertilization 
. Hormones - names, site of production and function 

5. Size and development of the fetus - see Module D, Section IV 

a. Weight and length at each month of pregnancy 

b. Viability 

c. Structural development 

d. Duration of pregnancy - see Module D, Section II 

B. Signs and Symptoms of Pregnancy 

1. Presumptive signs 

a. Menstrual suppression or amenorrhea 

b. Nausea, vomiting, "morning sickness" in about half of pregnant women 

c. Frequency of micturition 

d. Tenderness and fulness of breasts - nipple pigmentation 

e. "Quickening" 

f . Chadwlck's sign - dark blue discoloration of vaginal mucous membrane 

g. Pigmentation (skin) and abdominal striae 
h. Fatigue - early months 

2. Probable signs 

a. Enlarged abdomen - appropriate for length of pregnancy 

b. Fetal outline - after 6th month 

c. Changes in size, shape and consistency of uterus - Hegar s sign 

d. Changes in cervix - softening 

e. Braxton Hicks contractions 

f. Positive pregnancy tests 

g. Internal balottement 
h. Uterine souffle 

3. Positive signs 

a. Fetal heart sounds 

b. Fetal movements 

c. X-ray shows outline of fetus 



A Topical Outline . . . MODULE C; CONCEPTION AND INFERTILITY 

and Midwifery ppge 62 



Section IV: Incidence and Causes of Infertility 



Sp e ci f^tc Ob j e c t lyes : 

1. Define and distinguish between the terms infertility and sterility. 

2. State the incidence of infertility. 

3. Identify the major causes of infertility. 

4. Identify the factors that contribute to infertility. 

Organization of Content _ _ ___ _ 

A. Definitions 

1, Infertility 

a. Primary - no pregnancy has occured 

b. Secondary - pregnancy has occured at one time, buf-currently no 
pregnancy or repeated spontaneous abortion. 

2. Sterility - Incapacity to reproduce 

B. Incidence 

1. 15 X of all couples experience difficulty in producing a child 

a. Found in all races and nations 

b. Found in all socio-economic groups 

2. Medical and environmental factors affecting incidence and causes. 

a. Accessibility of resources for care of Infection, malnutrition 
and abortion 

b. Socio-economic conditions 

C. Major causes 

1. Cervical factor (20X) - lacerations, malpositions and Impenetrable 
mucus 

2. Tubal factor (30-35X) - Salpingitia, malformations and anything else 
causing obstruction 

3. Hale factor (30-35X) - any condition preventing the passage of 
sufficient, mobile, viable sperm 

4. Hormonal factor (15X) - any endocrine abnormality in either partner 
which prevents production of normal ova or sperm. 

5. Unknown factors (5-10Z) 

D. Contributing factors 

1. Age of female partner (peak is about 24 years) 



A Topical Outline... MODULE C: CONCEPTION AND INFERTILE 

Nursing and Midwifery page S3 



V^ ^Incidence and Causes of Infertility 

Organization of Content - cont . . . 

D. 2. Age of male partner (peak is about 24-25 years) 

3. Frequency and timing of intercourse 

4. Length of exposure 

a. Normal cohabitation over period of one year (without contra- 
ceptives) should produce a pregnancy in monogamous marriage, 

b. Polygamous marriage - plural wives - may cut frequency of 
intercourse 



A Topical Outline . . . MODULE C: CONCEPTION AND INFERTILITY 

and Midwifery 



Section V! Procedures Performed for Diagnosis and Treatment of Infertility 

Specific Objectives: 

1. Explain why the couple should be diagnosed and treated as a unit. 

2. Describe components of evaluation and treatment in the male. 

3. Describe components of evaluation and treatment in the female. 

Organization of Content . .. __ 

A. Importance of diagnosis and treatment of couple as a unit 

1. Basic premise of fertility 

a. Viable, normal, mobile sperm 

b. Deposited in female - moves to Fallopian tubes at appropriate 
time In cycle to unite with ovum 

c. Normal, fertllizable ovum enters Fallopian tube and after 
fertilization moves to uterus, is implanted in the endometrlum 
where conceptua undergoes development 

2. Complexity- psychological as well as physical factors 

3. Concept of fertility threshold 

a. In most couples, combinations of factors produce fertile threshold 
t>. Usually not one factor involved, but many 

B. The evaluation and treatment of the male partner 

1. History 

2. Examination 

3. Laboratory studies 

a. Semen analysis 

b. Standards - seminal fluid 

c. Other lab work as indicated 



4. Treatment 



ra'l health 

'nation of external factors - heat, radiation, fumes etc. 

cal treatment of abnormalities may be .possible (rare) 
Durance, Instruction about timing of Intercourse may be helpful 
Cations 

neral, treatment of male not encouraging 

ion and treatment of the female partner 



Lon 

ate physical 
igh pelvic 



A Topical Outline ... HOWS C: CONCEPTION AND IMTERILIW 
Nursing and Midwifery page 65 ^ 



Section V: Procedures Performed for Diagnosis and Treatment of Infertility 

Or Rani zat ion, of Content - cont . . ._ ... _ 

C. 3. Laboratory studies 

a. Basal body temperature chart 

b. Slide penetration test 

c. Sims-Buhner test - post coital mucous test 

. Spinnbarkeit 
. Arborization 

d. Endometrial biopsy (test for ovulation) 
c. Tubal insufflation (Rubin) 

f . Othdr labwork as indicated and as equipment and manpower available 

. Hysterosalpinogram 
. Thyroid studies 
. Hormonal studies 

4. Treatment 

a. Basal body temperature 

b. Medications 

. Oestrogen 

. Clomid 
. Perganol 

. Antibiotics for inflammation 

c. Surgical intervention 

. Remove barrier to flow of semen 
. Lysis of adhesions 
. Tuboplaaty 
. Laparascopy 

d. Reassurance - if indicated 

e. Support for individual outcome of tests 

f. Artificial insemination - husband or donor 

g. In general, treatment of female more encouraging 



A Topical Outline ... MODULE C: CONCEPTION AND INFERTILITY 

Nursing and Midwifery page 66 



Section VI: Role of Nurse/Midwife in Care arid Counseling of Infertile Couples 

Specific Objectives; 

1. Describe factors which are basic to understand the meaning of infertility, 

2. State factors to be considered in case-finding. 

3. Describe the factors in the histories of both partners that will 
influence intervention. 

4. List and describe components of referral, care and support. 

5. Interview a couple (or woman) who has not produced a child and report 
on your conference. 

6. Provide care during clinical diagnostic procedure (for female) 

Qrjiani zation of Content 

A. Understanding of 

1. Woman's role 

2. Motherhood 

3. Parenthood 

4. Meaning of children (social, economic and personal values) 

5. Meaning of infertility to male and female 
E. Case-finding 

1. Likely sources 

2. Factors influencing approach 

3. Need for privacy (sensitivity of subject) 

4. Liaito imposed by lack of resources 
C. History 

1. Factors influencing the nature of intervention 



A Topical Outline . . . MODULS C; CONCEPTION AM) INFERTILITY 

Nursing and Midwifery page 6? 



Section VI; Role of Nurse/Midwife in Care and Counseling of Infertile Couple 
Organization of Content - cont... ^^,_..- 

D. Initial Gynecology Examination (PAP amear etc.) 

E. Referral, Care, Support and Follow-up 

1. Resources - kinds, costs, criteria 

2. Referral procedures 

3. Care of the client (male or female) during clinical diagnostic 
procedures 

a. Equipment 

b. Preparation 

c. Support 

4. Need for sustained support and counseling 

a. Stress factors 

b. Interpretation of findings 

c. Tedious, long procedures 

5. Alternatives if no conception 

a. Help couple to avoid blaming each other 

b. Explanation of artificial Insemination by husband's semen (AIH) 
and artificial insemination by donor's semen (AID) - sometimes 
successful, but not generally available in Africa yet. 

c. Adoption of children 

6 . Follow-up 

a. Kinds 

b . Appropriate referral 



A Topical Outline . . . WDVI? C: CONCEPTION AND 

Nursing and Midwifery Bibliography 68 



BIBLIOGRAPHY 



I. SELF-INSTRUCTIONAL UNITS 

available from the African Health Training Institutions Project 



Anatomy and Physiology of the Uterus 
FREDA OJWANGH (Kenya) 

DlaertoaiB of Pregnancy 
CATHERINE FOGEL (USA) 

The Endocrine System (Hormonal Influence on Human Reproduction) 
ANNE N. HORACE (Kenya) 

Fertilization and Development of the Ovum 
MARGARET OSEI-BOATENG (Ghana) 

Family Planning 

JANE ROSAMUND HAYFRON (Ghana) 

The Normal Menstrual Cycle Related to Human Reproduction 
MERCY MUJOMBA (Kenya) 

Infertility in the Female 

MARCY I. AISUEBEOGUN (Nigeria) 

Male Infertility 

ELIZABETH OGWJDA (Nigeria) 

Pelvic Examination 

HAGDA YOUSSEF HELMI MOURAD (Egypt) 

Traditions, Beliefs and Practices Related to Infertility 
MAVIS B. AMONOO-ACQUAH (Ghana) 

Social Aspects of Female Infertility In Nigeria 
H.O. BANJOKO (Nigeria) 

Foetal Development up to 40 Weeks 
REGINA IPOPO (Kenya) 

Pelvic Tuberculosis 

MICHAEL I. ASUEN (Nigeria) 



A Topical Outline ... MODULE C: CONCEPTION AND INFERTILITY 

Nursing and Midwifery Bibliography 69 



II. BOOKS 



HURT, J.J. and LINDA A. BROWER 

Education for Sexuality; Concepts and Programs for Teaching, 
Philadelphia: Saunders, 1970. 

CLAUSEN, J.P., M.H.. FLOOR and B.FORD 

Maternity Nursing Today. 2nd edition. New York: McGraw-Hill Book 
Co., 1977. 

FORMAN, ALICE M. , et al. (eds.) 

New Horizons in Midwifery , 1972. Proceedings of the 16th Triennial 
Congress of the International Confederation of Midwivas held in 
Washington DC. October 28 - November 3, 1972. 

New York: International Confederation of Midwives and the American 
College of Nurse-Midwives, 1973. 

MYLES, MARGARET 

A Textbook for Midwlves. 7th edition, London: Longman, 1972. 
ROPER, NANCY 

Man's Anatomy. Physiology. Health and Environment. 4th edition. 
Edinburgh, Scotland: Churchill, Livingstone, 1973. 

REEDER, S.R., L. MASTROIANNI, L.L. MARTIN and E. FITZPATRICK 

Maternity Nursing. 13th edition, Philadelphia: J.B. Lippincott, 
1976. 



WHELAN, ELIZABETH M. and MICHAEL C. QUADLAND 

Human Reproduction and Family Planning: A Programmed Text. 
Palo Alto: Syntex Laboratories, 1972. 



A Topical Outline . . . MODULE D: PREGNANCY* BIRTH AND PUEKPERIUM 

Nursing and Midwifery page 71 



MODULE D : 
PREGNANCY, BIRTH AND 

PVERPEEIUM 
I. RATIONALE 

In all countries and In all cultures, pregnancy and birth have signif- 
icant meaning to individuals, families and communities. The practice of 
obstetrics in the last half century has emerged as an art and a highly 
developed medical science. Needless to say, scientific skills are not 
available to all women on an equal basis, nor do all women need sophisti- 
cated procedures in order to enjoy a healthy pregnancy and a safe delivery. 

The purpose of this module is to outline the social, cultural and emotional 
aspects of pregnancy and birth, as well as the basic clinical knowledge needed 
to guide women through the childbirth experience. Knowledge, understanding 
and the development of nursing and midwifery skills in this basic area of 
family health are critical parts of the foundation of these two professions. 

Obviously, the midwife will need competency in the clinical management of 
patients far beyond that needed by nursing personnel. The framework will be 
presented here but the depth of knowledge, and the degree of skills to be 
taught, will have to be determined by the institution and the specific tutors. 



MODULE D: PHBGNANCX, BIRTH AND 
A Topical Outline ... 
Nursing and Midwifery 



II. OVERALL OBJECTIVES 

1. Describe the cultural attitudes, customs and practices as they 
affect pregnancy and birth, including the role of the traditional 
birth attendant. 

1. Explain the anatomical, physiological, endocrine and emotional 
changes in a pregnant woman. 

3. Describe the components of preventive, medical and supportive care 
needed by pregnant women, including the educational component, 

4. Discuss foetal growth and development at various months of gestation 

5. Explain the various stages of labor aftd delivery. 

6. Describe the care needed by the woman In labor and at the tinrn of 
delivery. 

7. Relate the changes that take place during the puerperlum. 

8. Describe the care needed by the woman after delivery. 

9 . Describe the deviations from normal conditions encountered in 
mother and baby during pregnancy, labor, delivery and puerperlum. 

10. Give pertinent data regarding the causes and incidence of maternal 
and newborn morbidity and mortality. 



A Topical Outline ... MODULE D: PRJWNANCY, BIRTH AND PU8PPEPIUM 

timing and 



Section I! Cultural Attitudes and Practices 



Specific Objectives! 

1. Describe the traditional attitudes and practices of most African 
cultures toward chlldbearlng. 

2. Describe the characteristics and role of the traditional birth 
attendant (traditional midwife) . 

3. Discuss points to be considered by health professionals in 
training traditional birth attendants. 

Organization of Content _ _ - - 

A. Attitudes and practices In pregnancy and birth 
1. Beginning of life and continuity of family 
2 A visible sign of success and achievement 

3. For the female 

a. Status 

b. Proof of fertility 

c. Justification for existence 

d. Satisfaction and pride 

e. Promise of fulfillment of lifetime occupation 

. Child bearing 
. Child rearing 

f. Security against divorce 

4. For the male 

a. Prestige In community 

b. Proud sign of male virility and potency 

5. For both 

a. Continuation of lineage 

b. Gift of God 

c. Hope of descendent to honor departed 

d. Labour and economic potential 

e. Hope for security in old age 

f. Hope for social power 

g. Importance of male child 

6. Restraints on childbearing 

a. Lactatlng women . . . . 

b. Abstinence - prescribed by cultural, religious or social practices 

c. Late marriage - especially for men 

d. Taboos - sexual related 

e. Misinformation about fertile days 

f. Infertility 



A Topical Outline . . . -MODULE D: PREGNANCY, BIRTH AND 

Nursing and Midwifery page ?4 



Section I: Cultural Attitudes and Practices 

OrRanlzation of Content - cont . . . 

B. Customs and practices in relation to pregnant women 

1. Personal care and hygiene 

2. Rituals and behavioral taboos 

3. Food 

a. Selection 

b . Taboos 

4. Work and exercise 

5. Sexual relations 

6. Birth attendant 

a. Selection 

b. Availability 

c. Engagement of services 

7. Prenatal care 

8. Preparation for baby 

C. Customs and practices in relation to birth 

1. Place of confinement 

a . Home 

b. Exclusion (privacy?) 

c. Maternity homes 

2. Beliefs about birth process 

a. Influences and external symbols 

b. Taboos - labor and delivery 

c. Blood loss 

d. Cord 

e. Placenta 

f . Position of child at delivery 

3. Attitude toward child 

a. Name 

b. Confinement or isolation 

c. Ceremonies and rituals 

d. Effect of high infant mortality 



A Topical Outline . . . MODULF! D: PPRtTNANCY, RTWN AND 

Nursing and Midwifery page 75 



Section I: Cultural Attitudes and Practices 



Organization of Content - cont 



D. Characteristics of traditional birth attendants 

1. Usually illiterate 

2. Usually aged 

3. Daughter of a traditional birth attendant 

4. Little or no training 

5. Superstitions 

a. Myths 

b. Tales and legends 

c. Spells 

6. Status in community 

a. Respect 

b. Wisdom accorded older people 

E. Role of the traditional birth attendant (TBA) 

1. Varies by background of TBA 

2. Varies by access to health professionals 

3. Varies by rural/urban setting 

4. Management of pregnancy, labour, delivery and puerperium 

5. In addition, cares for older children, gets meals, launders 
a total process 

6. Counsels and instructs new mother in care of self and baby 

7. Cultural influences on role 

F. Training of traditional birth attendant 

1. Authority 

2. Approach 

3. Planning programme - content 

4. Teaching methodology 

a. Simple 

b. Repetitive 

c. Visual 

5 . Examination 
6. Supervision 



A Topical Outline ... MODULE D: PPEGNANCZ, BIRTH AND FUERPB 
Ni&sing and Midwifery page ?6 ^__ 



ion I: Cultural Attitudes and Practices 
nizatlon of Content - cont... 



F. 7. Communication and referral to health professionals 

8. Family planning 

a. Introduction of concept 

b. Enlisting support of TBA 

c. Referrals 



A Topical Outline . . . MODULE D: PRBMWCY, BXPTH AND PWMPERIUM 
tfi&eing and Midwifery page ?? 



II: Normal P: 



Specific Objective.8i 

1. Discuss the duration of pregnancy and how the expected date of 
confinement is calculated. 

2. Describe the anatomical and physiological changes of normal pre- 
gnancy, including endocrine changes. 

3. Describe the changes in the various body systems which are caused 
by pregnancy. 

4. Discuss the nutritional needs of a pregnant woman. 

5. Discuss the emotional aspects of pregnancy. 

6. Describe the common minor discomforts of pregnancy. 



Organization 


of 


Conte 


nt ~~ 



A. Duration of pregnancy 

1. Average duration 

2. Naegele's Rule - estimate date of delivery 

3. Length of time varies 

a. normal variations 

b. irregular ovulation 

c. prolonged pregnancy 

B. Anatomical and physiological changes 

1. Reproductive system and mammary glands 

a. Uterus 

, Changes in size and shape 

. Fundal height at approximate weeks of gestation 

. Uterine contractility 

. Changes in blood flow 

. Effects of enlarging uterus on other pelvic organs 

. Development of the decidua 

b. Cervix 

. Softening 

. Cyanosis 

. Increase in cervical mucus 

c. Ovaries and Fallopian Tubes 

. Corpus luteum 

. Quiescent or cessation of ovulation 

. Little change in Fallopian tubes 

d. Vagina 

, Violet color in pregnancy (Chadwick's Sign) 
. increased vaginal secretion 
. Change in cells 



A Topical Outline . . . MODULE D: PREGNANCY, BIRTH AND 

Nureing and Midwifery page ^ 



Section II; Normal Pregnancy 

Organization of Content - coat... 

B. e. Perineum 

. Effects on ligaments and muscles 
. Increased vascularity 

f. Breasta 

. Enlargement 

. Pigmentation of areola 

. Tingling sensation 

. Colostrum 

. Glands of Montgomery 

g. Pregnancy related structures 

. Placenta 

. . Development 

, . Fetal and maternal circulation 

. Placental hormones 

, . Functions 
. Amnion and Chorion 
. Umbilical cord 

C. Endocrine glands 

1. Pituitary body - master gland 

a. Secretion of anterior lobe 

b. Secretion of posterior lobe 

2. Thyroid 

3. Adrenal cortex 

D. Changes In the various body systems 

1. Cardiovascular system 

a. Heart 

. Change in position 
. Murmurs in pregnancy 
. Cardiac output 

b. Hematologic changes 

. Increase in volume 

. Increase in red blood cells 

. Hematocrit changes 

stasis 

ry system 

displacement of diaphragm 
kg of thoracic cage 
iry function 



A Topical Outline . . . MODULE D; PREGMANC> BIRTH AND PUERPER 

Nursing and Mi&tf,f e ry page 79 



Section II; Normal Pregnancy 
Organization of Content-. - cont 



D. 3. 'Gastrointestinal system 

a. Displacement of stomach and intestines 

b. Decrease of motility and tone 

c. Muscle relaxation 

d. Changes in gums 

4. Urinary system 

a. Dilatation and elongation of ureters 

b. Changes in kldney-glomerular filtration rates 

c. Bladder dianges 

5. Musculoskeletal system 

a. Postural changes 

b. Gait 

c. Mobility of pelvic Joints 

d. Shift In center of gravity 

e. Diastasls of rectl muscles 

6 . Skin (Integumentary System) 

a. Striae 

b . Chloasma 

c. Llnea nigra 

7. Metabolic changes 

a. Weight gain 

. Distribution 

. Range of average weight gain 

. Patterns of weight gain by trimester 

b. Water metabolism 

c* Protein, carbohydrate and fat metabolism 

d. Mineral metabolism 

E. Nutritional needs of pregnancy 

1. Xntake related to pregnancy outcome 

a. Prematurity 

b. Stillbirths 

c. Low birth weight babies 

d. Neonatal mortality 

e. Weight gain in relation to size of fetus 

2. Calories 

a. Additional 200-300 cal. per day needed 

b. Well balanced diet - meat, vegetables, fruit el 



A Topical Outline . . . 
Nursing and Midwifery 



MODULE, D; PREGNANCY, BIRTH AND PV&RPERTM 
page 80 



Section II; Hormal Pregnancy 



Organization of 



E. 3. Protein 

a. Increase of 10 gm per, day 

b. Provision of amlno acids and nitrogen 

c. Good sources 

4. Minerals 

a. Calcium 

b. Phosphorus 

c. Iron 

d. Sodium 

5. Vitamins 

a. Vitamin A 

b. Vitamin D 

c. Follc acid 

d. Other essential vitamins 

6. Iron and Vitamin Supplements 
F Emotional aspects of pregnancy 

1. Concept of "pregnant couple or family" 

2. Change in sexual attitudes 

a. Fears 

b. Desires 

c. Practices 

3. The moods of pregnancy 

a. Lability 

b. Variations by personality 

c. Variations by circumstances 

d. Ambivalence of being pregnant 

e. Relation of psycho somatic symptoms 

f. Self-centeredness 

. Protective mechanism 
. Concern for own needs 

g. Introversion and passivity of the pregnant woman 

4. Body image changes 

a. Self-image 

b. Attitude of husband and family 

Anxieties related to pregnancy 

a. Labor and delivery 

b. Concerns about baby 



A Topical Outline . . . MODULE D: PREGNANCY, BIRTH AND PUERPERIUM 

Nursing and Midwifery page SI 



Section II: Normal Pregnancy 

Or eaniz a t ion of c on t en t^ n - con t . . ,.. 

F. 6. Taking on maternal role 

a. Mother-child relationship 

b. Responsibilities 

c. Support systems available 

G. Common minor discomforts of pregnancy 

1. Definition 

2. Gastrointestinal 

a. Morning sickness 

b. Heartburn 

c. Food idiosyncrasis 

. Dislikes 

. Pica or cravings 

d. Constipation 

e. Haemorrhoids 

f. Ptyallsra 

3. Musculoskeletal 

a. Backache 

b. Muscle cramps 

c. Fatigue and somnolescence 

4. Other common discomforts 

a. Frequent urination 

b. Dyspnea 

c. Edema 

d. Varicositles 

e. Syncope and dizziness 

f. Headache 

g. Leukorrhea 



A Topical Outline . . . MODULE D: PKEGNANCY, BIETti AND 

Nursing and Midwifery page 82 



Section III: Care of Pregnant Women 

Specific Objectives; 

1. Discuss the objectives of antenatal care. 

2. Describe the components of preventive care. 

3. Describe the components of medical care 

4. Describe the components of supportive care. 

5. Describe the elements of the educational component 

6. Interview a prenatal patient to obtain base-line data. 

7. Provide nuraing care during medical and obstetrical examination. 

8. Conduct an educational session for an individual and for a group 

Organization of Content ~ 

A. Objectives of antenatal care 

1. Prevention 

2. Medical care 

3. Supportive care 

4. Education 

B. Prevention 

1. Early detection of those in high-risk category 

a. Maternal 

b. Infant 

2. Periodic observation of woman's progress 

3. Appropriate immunizations 

4. Dental care 

5. Nutrition counseling 

6. Early planning 

a. Antenatal care 

b. Attendant 

c. Place of delivery 



7- Extra care needed by early teen-aged patient 
8, Motivation in obtaining best care available 



A Topical Outline ... MODULE D: PHSGNAlfCY, BIRTH AND PUERPERIUM 

Nursing and M^dJ J )^feyy page 33 



Section III: Care of Pregnant Women 
Organization of Content - cont . . . 



C. Medical care 

1. Establish base-line data 

a. Medical history 

b. Obstetrical history 

c. History of this pregnancy 

d. Family history 

2. The medical examination 

a. Height/weight 

b. Blood pressure 

c. Complete physical examination 

d . General appearance 

3. Obstetric examination 

a. Breast examination 

b. Palpation and auscultation of the abdomen 

c. Pelvic examination 
. speculum 

. bimanual 

d. Pelvic measurements 

4. Laboratory tests 

a. Urinalysis, Including test for glucose and albumen 

b. Haemoglobin - Haematocrit 

c. Tests for Rh and blood type 

d. Blood test for syphilis 

e. Papanicolaou smear 

f. Smear for gonorrhea 

g. Pregnancy test if indicated 

5. Minimum equipment 

a. For prenatal care 

b. For laboratory procedures 

D. Supportive care 

1. Establishment of relationships 

a. Physician 

b. Midwife 

c. Nurse 

d. Auxiliaries 

e. Traditional birth attendant 

2. The art of interviewing 

3. The purpose of interviewing 



A Topical Outline . . . MODULE D: WSOaOICI. BIRTH Am PUERPERB 

flursing and Midwifery page 84 



tion III: Care of Pregnant Women 
anization of Content - cont... 

4. Kinds of support needed 

a. Knowledge 

b. Understanding and caring 

. By family 
. By professional 
By attendant 



c. Availability of assistance 

d. Material needs - economic 



E. Educational component 

1. Points to consider 

a* Uniqueness of opportunity 

b. Need 

c. Group or individual 

d. Techniques 

e. Planning a teaching program 

f. Evaluation 

2. General hygiene 

a. Rest 

b * Exercise 

c* Employment 

d. Care of skin 

e. Care of breasts 

. Preparation for breast feeding 
. Support 

f. Clothing 

g. Teeth 
h. Bowels 

i. Sexual relations 

j . Smoking 

k. Alcohol and other drugs 

3, Nutrition 

a. Diet history 

b. Analysis of current diet to determine adequacy 

c. Estimate of needs 

d. Determine foods available 

e. Review basic nutritional needs 

. For family 

. For pregnant women 

. For lactating women 

f. Relation of nutrition to 

. Anaemia 

. Weight 

. Well-being of mother and infant 



A Topical Outline ... MODULE D: PREGNANCY, BIRTH AND PUERPERIVM 

Nursing and Midwifery page S5 



III: Care of Pregnant Women 

Organization of ^Content , - cont^. 

4. Danger signals 

a. Vaginal bleeding 

b. Abdominal pain 

c. Severe headache 

d. Swelling of hands, feet or face 

e. Visual disturbances 

f. Escape of amnlotic fluid 



E. 5. Labor and delivery 

a. Signs of labor 

b. Timing - primapara vs. multipara 

c. Process and stages 

d. Contractions - pain 

e. Use of relaxation exercises 

f. The climax of delivery 

g. Expulsion of placenta 

6. Immediate post-par turn 

a. Control of bleeding 

b. Care of breasts 

c. Care of bladder 

d. Care of perineum 

7. The newborn 

a. Description 

b. Vital signs 

c. Preparation for arrival 

d. Immediate care 



8. Supplies and equipment 

a. Clothing, bedding, bathing and feeding equipment 

b. Influence by climate, economic factors and tradition 

c. Importance of cleanliness 



9. Family planning 

a. Concept of spacing 

b. Basic information 

c. Resources 



A Top-Coal Outline . . . **&* * fflMK?r, BOTH ASD PUBUWI& 
Nursing and Midtifery page 86 



"Sp^nn TV: Foetal Growth and Development _ _ __ 

Specific Objectives: 

1. Describe the size and development of the foetus at various months. 

2. (For advanced etudents:) Trace the development of each body system 
from conception to birth, 

Organization of Content , 

A. Development of the embryo and fetus 
(see Module C Section III, A. 4-5) 

B. Size and development by month*) 

1. End of first lunar month 

a. Embryo 1/4 inch long 

b. Curved backbone and "tail" 

c. Head prominent - development of lobes of forebrain 

d. Rudiments of eyes, ears and nose 

e. Tube-formed which will become heart 

f. Rudiments of digestive tract 

g. Arm and leg buds present 

2, End of second lunar month 

a. Called a foetus 

b. Assumes human form 

c. Head disproportionately large due to brain development 

d. Human face 

e. Arms, legs, fingers, toes 

f . Measures one inch from head to buttocks 

g. Weighs 1/30 of an ounce 

h. External genitalia but cannot yet determine sex 

3, End of third lunar month 

a. Length 3 inches 

b. Weight one ounce 

c. Sex can be determined 

d. Ossification of most bones starting to occur 

e. Tooth' buds 

f. Rudimentary kidneys 

g. Weak movements beginning 

h. Fingernails and toenails start to form 

4. End of the fourth lunar month 

a. Length 6 1/2 inches 

b. Weight four ounces 

c. External genital development well distinguished 

5. End of fifth lunar month 

a. Length 10 inches 

b. Weight 8 ounces 

*)Most of this material has been extracted from: FTTZPATRICK, REEDBK 
MSTROIANNI "Maternity Nursing", 12th edition, Philadelphia, J.P. 

nnH- 10 71 tin A9-ftfi. 



A Topical Outline . . . MODULE D: PFtEGNANCy, BIRTH AND PUERPERIUM 

Nursing and Midwifery page 87 



Section IV; Foetal Growth and Development 
.Organization of Content - cont... 



B. 5. c. Appearance of fine downy hair-"lanugo" . 

d. Mother feels fluttering movements - called "quickening" 
e- Foetal heart can be heard 

6. End of the sixth lunar month 

a. Length 12 inches 

b. Weight 1 1/2 pounds 

c. Resembles baby 

d. Skin red - no fat 

e. Development of protective covering of skin - "vernix caseoaa" 

7. End of the seventh lunar month 

a. Length - 15 Inches 

b. Weight - 2 1/2 pounds 

c. Survival possible but risky 

8. End of eighth lunar month 

a. Length - 16 1/2 inches 

b. Weight - 4 pounds 

c. Appearance resembles "little old man" 

d. Under excellent conditions and care survival about 3 out of 4 

9. End of ninth lunar month 

a. Length - 19 Inches 

b. Weight - 6 pounds 

c. Body more rotund 

d. Skin less wrinkled 

e. Rapid weight gain 

10. Middle of tenth lunar month 

a. Length - about 20 Inches 

b. Weight - 7 - 7 1/2 pounds 

c. Skin pink - coated with vernix 

d. Fingernails firm and protrude beyond tips of fingers 

C. The body systems 

1. Cardio-vascular 

2. Respiratory 

3. Renal 

4. Digestive 

5. Reproductive 

6. Central nervous 



A Topical Outline ... 
Nursing and 



MODULE D: PKEGNANCY, BIETH AND PUERPBRm 

ftf\ 

page 




D. Teratogenic Disorders 

1. Environmental 

2. Chromosomal 

3. Drug-induced 

4. Congenital Abnormalities 



A Topical Outline . . . MODULE D: PREGNANCY > BIRTH AND 

Nttreing and Midwifery page 89 



and Delivery 

In thes.e particular sections V and VII of Module D, only the minimum outline of contei 
is presented. It is obvious that the nurse specializing in obstetrics or the midwife 
will need details in greater depth and the development of skills to a greater de- 
gree than can be suggested here. Instructors are referred to their texts for such 
details. 

Specir^ic Objectives : 

1. Discuss the premonitary signs of labour 

2. Describe the first stage of labour 

3. Describe the second stage of labour 

4. Describe the third stage of labour 

5. Describe the fourth stage of labour 

Organization of Content 

A. Premonitary signs of labour 

1. Lightening (in the primipara) 

a. About 10 - 14 days before delivery 

b. Shift in uterine contents 

c. Settling of foetal head In pelvis 

2. False labour 

a. May begin 3-4 weeks before delivery 

b. No dilatation of cervix 

c. Braxton-Hicks contractions 

d. Do not increase in intensity, frequency. 

3. "Show" 

a - Discharge 

b. Blood-tinged mucous 

4. Rupture of membranes 

a. In some women 

b. Should be watched 

B. Normal labour 

1. Definition 

2. Factors effecting labour 

a. Passenger 

b. Passage 

c. Powers 

d. Personality 



A Topical Outline . , . MODULE D; PREGNANCY, BIRTH AND PUEKPERIW 

Nursing and MicbHfery page 90 



gection V: Labour and Delivery _ _____ 

Organization of Content - cont... _ _ _____ 

C. The mechanism of labour and delivery 
1 . Engagement 

2. Descent 

3. Flexion 

4. Internal Rotation 

5. Extension 

6. Expulsion 

7. Restitution 

8. External rotation 

D. The first stage of labour 

1. Definition 

a. Begins with onset of regular rhythmic contractions, ends with full 
cervical dilatation 

b. Average length of time 

2. Cause of onset 

a. Not really known 

b. Number of theories 

c. Usually "Just right" for mother and baby 

3. Description of a contraction 

a. Phases 

b. Intermittent 

c. Involuntary 

d. Universally called "pain" 

e. Intensity varies 

4. Contractions 



- Pai Ynr 8 ^ 8 ? "f*** contrac ^on fl throughout labour 
aual increase in intensity and duration 
dual decrease in intervals 



wnt 



;tening and obliteration of cervical canal 
ix becomes a circular 9 rifice 



A Topical Outline . . . MODULE D: PREGNANCY, BIKTH AND PUERPERIUM 

Nursing and Midwifery page 92 



jje.cj:ion V: Labour and Delivery 
Organization of Content - cont 



6. Dilatation of the cervical os 

a. Closed circular muscle becomes progressively dilated to 
10 cm or full dilatation 

b. Permits passage of foetus 

E. Second stage of labour 

1. Definition 

a. Prom full dilatation to expulsion of the >^aby 

b. Average length of time 

2. Contractions 

a. At 2-3 minute intervals 

b. Lasting 50-70 seconds 

c. Strong Intensity 

3. Usually membranes rupture 

4. Muscles of abdomen and diaphragm begin to function (voluntary powers) 

a. Urge to bear down 

b. Overcome resistance of vagina and perineum 

c. Pressure on perineum and rectum 

5. Delivery 

a. Precautions for mother 

b. Precautions for infant 

F. The third stage of labour 

1. Definition 

a. From birth of baby to expulsion of placenta 

b. Average length of time 

2. Placental separation 

a. Mechanism of separation 

b. Signs of separation 

3. Placental expulsion 

a. Schultze's mechanism - 80% 

b. Duncan's mechanism - 20% 

c. Average blood loss 250-300 cc 

G. The fourth stage of labour 

1. Definition 

a. First critial 2 hours after delivi 

b. Stabilization of mother's conditii 



-4 Topical Outline . . . MODULE D; PREGNANCY, BIRTH AND 

Nursing and Mifoifevy P a 3 e &s 



Section V: Labour and Delivery 



Organization of Content - cont . . . 



G. 2. Uterus 

a. Continues to contract and relax 

b. Size 

c. Condition 

3. Vagina and perineum 

4. Urinary system 
5* Abdomen 

6. Emotional factors 
H. Analgesia and Anesthesia 

1. General principles 

2. Methods 

3. Availability 

4. Need 



A Topical Outline MODULE D: PREGNANCy, BIRTH AND 

Nursing and Midwifery page 93 



Section VI i Care of the Woman During Labour_ and 
SPJJ cjj: c^Qbj jac t iye s : 

1. Discuss the objectives of care during labor and delivery. 

2. Describe the care needed during the premonitary and first stage of laboi 

3. Describe the care needed during the second stage of labour. 

4. Describe the care needed during the third stage of labour. 

5. Describe the care needed during the fourth stage of labour. 

6. Provide the care needed during each of the four stages of labour. 

Organization of Content , . 

A. Objectives of care 

1. Comfortable, safe experience for mother 

2. The delivery of a normal infant 

a. Unharmed by the birth process 

b. Able to breath and function independently at birth 

3. Understanding, satisfaction and fulfillment of the parents 

B. Care during premonitary and first stage of labour 

1. Premonitary signs 

a. Explanation of process 

b . Reassurance 

c. Differentiating signs from true labour 

2. First stage of labour 

a. Data obtained or reviewed 

b. Preparation for delivery 

. Bath 

. Clean environment 

. Supplies and equipment for mother and baby 

c. Monitoring of physical parameters 

. Contractions - frequency, intensity, duration 
. Vital signs - temperature, pulse, respiration, blood pressure 
. Bleeding - normalcy as it relates to progression of labour 
. Spontaneous or artificial rupture of membranes 

d. Evaluation of bladder and bowel activity 

e. Monitoring of foetal heart rate 

f. Guidance 

. Activity 
. Fluids 
. Diet 

g. Pain relief 

h. Assessment of emotional status 



A Topical Outline . . . MODULE D; PREGNANCY, BIRTH AND PUERPEIHW 

fti&sing and Midwifery 



Section VI: Care of the Woman During Labour and Delivery 



Organization of Content - cont... 



2. i. Monitoring of transitional phase 

. Cervix fully dilated (8-10 cm dilatation) 

. Bloody show increases 

. Woman may become nauseated with vomiting 

. Acute restlessness, apprehension 

. Perineum flattens and rectum bulges 

j . Supportive care 

. Attitudes of personnel 

. Interpretation 

. Encouragement and reassurance 

. Need Increases in proportion to length of labour 

. Coach on methods of relaxation 

k. Comfort measures 

. Frequent cleansing 

. Removal of wet or soiled pads 

. Back rubs 

. Effleurage 

. Cold cloths to head 

. Sips of water or ice if tolerated 

. Analgesics as indicated 

3. Communication 

a. With others involved 

b. By accurate recording 

C. Care during the second stage of labour 

1. Event marked by intensity of activity 

2. Continuation of monitoring maternal blood pressure, fetal heart tonoa 
and uterine contractions 

3. Coaching 

a. Guidance in pushing and relaxation 

b. Reassurance of progress 



A Topical Outline . . . MODULE D: PREGNAHC3, BIRTH AND PUERPEHIUM 

and Midwifery page 95 



Section VI: Care of the Woman During Labour and Delivery 
Organization of Content - cont . . . 



7. Contact with "significant others" 

a. Physician 

b. Midwife 

c. Others 

D. Immediate care of the newborn 

1. Clear air passage 

a. Head down position 

b. Suctioning of mucous 

2. Promotion of crying 

3. The umbilical cord 

a. Clamp after pulsation ceases 

b. Tying 

c. Cutting 

d. Dressing 

4. Apgar scoring system and interpretation 

a. Heart rate 

b. Respiratory effort 

c. Muscle tone 

d. Reflex irritability 

e. Colour 

5. Care of the eyes 

6. Identification (if hospital delivery) 

7. Physical assessment 

a. Systematic, orderly approach 

b. Referral or consultation for Immediate problems 

c. Record of findings 

E. Care during the third stage of labour 

1. Explanation and guidance in expelling placenta 

2. Observe blood loss 

a. Nature of bleeding 

b. Estimate amount if possible 

3. Blood pressure 



ection VI: Care of the Woman During Labour and Pali 
rganization of Content - cont... " 



4. Pulse 

a. Quality 

b. Rate 

c. Irregularity 

5. Inspection of placenta 

a. Maternal side 

b. Foetal side 

c. Amniotic membranes 

d. Umbilical eord 

6. 'Comfort measures 

a. Appropriate or needed bathing only 

b. Clean bedding 

c. Fluids if tolerated 

7. Special attention to the anesthetized patient 

a. Vital signs 

b. Protection 

c. Recovery 

F. Care during the fourth stage of labour 

1. Assessment 

a. Tone and size of fundus 

b. Bladder dlstention 

c. Bleeding 

d. Perineum 

e. Deviations in pulse, blood pressure and temperature 

f. Pain 

2. Continuous monitoring 

a. For one/ two hours 

b, To assure normalcy of postpartum status 

3. Evaluation 



A Topical Outline ... MODULE D: PfiEGNANCY, BIRTH AND PUERPERIUM 

Nursing and Midaifery 



Section VI: Care^of^the Woman During Labour and Deliver 



Organization of Content - cont 



4. Conifort measures 

a. Need for quiet and rest 

b. Reassurance 

c. Support if temporarily emotionally upset 

d. Knowledge of contact with husband or family 

e. Encourage dietary intake and fluids 

f. Promote urination 

g. General hygiene 

h. Analgesics as indicated 



.A Topioal Outline ... MODULE D: PREGNANCY* BIRTH AND PUEKPERIUM 

Nursing and Midaifery page 98 



Section VII; The Puerperium 



Specific Objectives: 

1. Describe the anatomical changes that take place during the puerperium, 

2. Describe the clinical manifestations that are evident during the 
puerperlum. 

3. Discuss the phases of developing the maternal role. 

r gani za t i on of C on tea t .... 

A. Definition 

1. Time after fourth stage of labor 

2. Up to six weeks postpartum 

B. Anatomical changes 

1. Involution of the uterus 

a. The process 

b. Progress - time 

c. Involution of placental site 

2. Cervical changes 

a. Rapid closure 

b. Differences in external os 

3. Lochia 

a. Lochia rubra 

b . Lochia aeroaa 

c. Lochia alba 

d. Quantity 

e. Cessation 

4. The pelvis 

a. Vagina 

b . Ligaments 

5. Abdominal wall 

a. Still soft and flabby 

b. Striae remain 

c. Time period to return to normal 

6. The breasts 

a. Secretion of colostrum 

b. Breast milk "comes in" between 3rd and 4th day 

c. Congestion or engorgement 

d. See Module E, Section I 



-4 Topical Outline ... MODULE D: PREGNANCY > BIRTH AND PUERPERIW 

Mursing and Midwifery P a 9 e " 



Section VII: The Puerperium 

Organization of Content - cont... 

7. Other systems 

a. Gastro-intestinal 

b . Urinary 

c. Cardio-vascular 

C, Clinical manifestations 

1. Temperature 

a. Mild elevation usually normal 

b. May signal complications 

2. Pulse 

3. After-pains 

4. Digestion 

5. Loss of weight 

6 . Urinary 

a. Increased output 

b. Urine content 

7. Intestinal 

a. Constipation 

b . Haemorrhoids 

8. Blood parameters 

a. Leukocytosis 

b. Haematocrit 

c. Blood volume 

9. Skin 

a. Excess perspiration 

b. Elimination of waste products 

10* Menstruation 

D, Post-partum evaluation 

1* At least 4-6 weeks after delivery 

2. Early detection of any abnormalities 

3. Family planning 

E, Developing the maternal role 



A Topical Outline ... MODULE D: PREONASC!, BIRTH AND PUERPERIUM 
Nursing and MiMfery page I'OO 



Section VII: The Puerperium 

Organization of Content - cont ,..._._ _ J- ., - 

*) 

1. Phases 

a. "Taking in" 

. Lasts 2-3 days 

. Concerned with own needs (sleep, food) 

. Need to talk about delivery 

b. "Taking-hold" 

. Begins to organize 

. Wants to be "in charge 11 

. Underlying fears and anxiety repressed 

. Frustration of less than perfect performance - self and baby 

c. "Letting-go" 

. Accepting baby as a separate person 

. Establish new ways for self, baby and family. 

2. Conflicts 

a. Dependence vs. independence 

b. Idealism and reality 

c. Love and resentment of infant 

d. Self-fulfillment and motherhood 

e. Time must be divided 

f . Post-partum "blues 



*) RUBIN, Reva. "Puerperal Change", Nursing Outlook 9 (12), 753-755, 
December, 1961. 



A Topical Outline . . . MODULE D; PREGNANCY, BIRTH AND PVERPRPIJW 

and Midwifery page 101 



Section VIII; Care of the Woman _ Pur ing_^the .Pu_er per ium 

Specific Objectives: 

1. Discuss the objectives of care during the puerperiura. 

2. Describe the physical care needed 

3. Describe the educational needs for mother and baby. 

4. Describe the emotional support needed by the mother. 

5. Provide the care, teaching, and emotional support needed by 
family, mother, and baby. 

Organization of Content 

A. Objectives 

1. Return of the mother to her pre-pregnancy physical state 

a. Minimum discomfort 

b. No residual complications 

2. Functioning mother-child relationship 

a. Mutually beneficial and enjoyable 

b. Integration into family 

B. Physical care needed 

1 . Early needs 

a. Sleep 

b. Food - usually good appetite 

c. Resources for detection of early symptoms of complications 

d. Help with breast-feeding 

2. Later 

a. Resumption of self-care 

b. Adequate diet for self and for lactation 

c. Exercise 

3. Care of body 

a. Skin 

b. Breasts and nipples 

c. Perineum 

d. Urination 

e. Bowels and Haemorrhoids 

f. Vital signs 
h. Smoking 

i. Alcohol and drugs 

4. Nutrition 

a. Importance of well-balanced diet 

. Proteins 

. Fats 

. Carbohydrates 



A Topical Outline ... MODULE D: PREGNANCY 3 BIRTH AND PUERPERTUM 

Nursing and Midwifery page 102 



Section VIII: Care of the Woman During the Puerperium 
jjrgani z a t i o n of Con tent - c ont . . . 



4. b. Increased needs of lactating mother 
c. Use of local foods 

5. Early care of baby 

a. Provision for sleep 

b. Feeding 

c. Burping 

d. Bathing 

e. Care of cord 

f. Care of genital area 

6. Feelings 

a. Physical baals 

b. Psychological baais 

c. Maturatlonal basis 

d. Understanding reactions 

C. Educational needs 

1. Planning 

a. Levels of learning 

b. Selection of content 

c. Place and timing 

d. Individual 

e. Groups 

. Size 

. Frequency 

. Discussion 

2. General 

a. Review of birth experience 

b. Changes taking place in the puerperium 

c. Benefits of breast-feeding 

. For mother 
. For baby 

d. Bottle feeding (if necessary) 

* How to prepare 

. Simulating breast milk 

. Precautions 

.. Refrigeration 
.. Clean bottles and nipples 
ling for feeding 

rest 

exercise 

to work outside home 



A Topical Outline . , . MODULE D: PREGNANCY, BIXTH AND PUERPERIUM 

and M^doifer t y page 103 



lection VIII ! Care of the Woman During the Puerperium 
[rganigation of Content - cont . . . 



D, 



.2. f . Exercise 

. Kinds 

. Importance 

g. Family Planning (see Module K) 
. Selection of method 
. Resumption of sexual relations 

Emotional Support (aUp include content in teaching) 

X ' mood S swings ^ attendantS f ""^r'a psychological changes or 

a. Manifestations 

b. Their normalcy 

2. Mother's needs 

a. To talk of experience 

b. Reassurance 

c. Confidence in her own ability 

d. Knowledge 

. of self 
. of baby 

e. Understanding of mood swings 

f. Approval 

. Husband 
. Family 
. Attendant 

3. Mother's needs in relation to family 

a. Recognition 

b. Understanding of process of developement of mother-child relationship 

c. Sharing p 

d. Supporting 

4. Baby's needs 

a. Immediate gratification 

. Food 
. Love 
. Handling (touch) 

b. Developing a sense of trust 

c. Security to take on next growth tas 



A Topical Outline ... MODULE D: PREGNANCY, BIRTH AND 

Nursing and Midwifery page 104 ___ 



g e ction IX: Deviations from Normal . ,___-- 

Specific Objectives: 

1. Cite the major factors that contribute to high-risk for the 
mother during pregnancy. 

2. Describe the kinds of high-risk factors in the infant. 

3. Describe the complications of pregnancy which are related to the 
pregnancy itself. 

4. Describe the medical conditions in the mother that may be aggravated 
by pregnancy. 

5. Describe the complications occurring during labour and delivery. 

6. Discussthe complications of the puerperium. 

7. Provide nursing care to mothers who are experiencing deviations 
from normal pregnancy. 

8. Discuss the cauaes and incidence of maternal, foetal and neonatal 
morbidity and mortality. 

Organization of Content _ 

A. Major maternal factors in high risk pregnancy 

1. Age - < 16 and > 40 years 

2. Grandmultiparity and short intervals between pregnancies 

3. Poor lifetime nutrition 

4. Medical history of chronic illness 

5. Poor obstetrical history 

6. Drug abuae 

7. Unwanted pregnancy 

8. Psychiatric illness or psychological problems 

B. Infants at high-risk 

1. Premature by gestational age 

2, Low birth weight 

3, Rh factor - hemolytic disease 

4. Respiratory problems 

5, Neonatal jaundice 

6. Prolonged or difficult labor and delivery 



A Topical Outline . . . MODULE D: PREGNANCY, BIRTH AND PUERPERIUM 

Nursing and Midwifery page 105 



Section IX: Deviations^ _fro_m_ Normal _ 

Organization of Content - cont . . . 

B. 7. Syphilis 

8. Congenital anomalies 

9. Infant whose mother was on drugs during pregnancy, including 
alcohol and smoking 

10. Rubella in mother 

C. Complications related to pregnancy itself 

1 . Toxemia 

2. Polyhydramnlos 

3. Rh-f actor 

4. Hyperemesis gravldarum 

5. Threatened and spontaneous abortion 

6. Hydatidiform mole 

7. Ectopic pregnancy 

8. Spontaneous abortion or miscarriage 

9. Multiple pregnancy 

10, Haemorrhage 

11. Abnormalities of genital tract 

D. Medical conditions aggravated by pregnancy 

1. Cardiac condition 

2. Diabetes 

3. Hypertension 

4. Anemias 

5. Renal disorders 

6. Tuberculosis 

7. Thyroid 

8. Infections of the urinary tract 



A Topical Outline ... MODULE D: PREGNANCY, BIRTH AND 

Ni&sing and Miduifery page 106 



Section IX: Deviations from Normal 
Organisation of Content - cont . . . 



9. Other infections 

a. Malaria 

b. Syphilis 

c . Bilharziasis 

d . Hookworm 

e. Gonorrhea 

f. Viral hepatitis 

g. Rubella 

h, Herpes virus 



E. Complications occurring during labour and delivery 

1. Premature labour 

2. Dysfunctional labour 

a. Inertia 

b. Precipitate 

3. Foetus 

a. Size disproportional to pelvis (Cephalo-pelvic disproportion) 
a. Abnormal position 

4. Multiple pregnancy 

5. Placenta praevia 

6. Abruptio placentae 

7. Umbilical cord 

8. Cephalo-pelvic disproportion (CPD) 

9. Uterine rupture 

10. Lacerations of the soft tissue 

11. Forceps delivery 
10 ""isarean 

lacenta 

of the puerperium 
any 



A Topical Outline . . . 
Nursing and Midwifery 



MODULE D: PREGtfAMCY, BIRTH AND PUERPERIUM 
page 10? 



Section IX: Deviations from Normal 



Organization of Content - cont . . . 




3. Infection 

4. Subinvolution 
5* Breaat problems 

6. Bladder atony 

7. Thrombo-phlebltis 

8. Difficult mother-child relationship 

9. Family disruption 
10. Postpartum psychosis 

G. Care of mother and baby at high risk 

1. Prevention 

2. Prompt diagnosis 

3. Appropriate medical and nursing care 

4. Education 

5. Emotional support 

H. Causes of maternal, foetal and neonatal morbidity and mortality 

1. (Obtain local information) 

2. Classify by: 

a. Preventable 

b. Non-preventable 

I. Incidence of maternal, foetal and neonatal morbidity 

1. (Obtain local information) 

2. Compare incidence 

a. To "like communities" 

b. To national statistics 

c. To statistics from other countries 



A Topical Outline . . . fiCBULE D: PREGNANCY, BIRTH AND PUERPRRHIH 

Nursing and Midwifery 



BIBLIOGRAPHY 



I. SELF-INSTRUCTIONAL UNITS 

available from the African Health Training Institutions Project 



Abdominal Examination of a Pregnant Woman^ at the Antenatal Clinic 
KATE AGVEI-SACKEY (Ghana) 

Ae phy xi a Ne ona t orum 

LUCY OSEI-KOFI (Ghana) 

Bleeding in Early Pregnancy 
AYODELE AKIWUMI (Ghana) 

Common Minor Discomforts of r Pregnancy 
MARY MBABALI (Uganda) 

DiabetjBS in Prjjgnjancy^- Its Effects on ^he Mother and her Infant 
IAN WHITLOCK and CATHERINE FOGEL (USA) 

The Female Bony gelvia 
THEODORA POBEE (Ghana) 

Major Factors Influencing the ^ Out come of Pregnancy 
AGNES SEKABUNGA (Uganda) 

Management of the Second Stage, of Normal Labour 
CHRYSOLITE JOYCE PRAH (Ghana) 

Maternal Nutritional Meeds 
ELIZABETH MUTURI (Kenya) 

Multiple Pregnancy 

ANGELA HASSALY (Sierra Leone) 

Midwife's First Examination of the Newborn Baby 
JOLA OLOFINBOBA (Nigeria) 

Nursing Care of the Premature Infant 
ADEBIMIPE OKUNADE (Migeria) 

Nutrition in Pregnancy 
LOIS M. NJIRI (Kenya) 

The Physiology of the First State of Normal Labour 
SARAH ABADOO (Ghana) 

The Premature Baby 

ADUKE SANNI (Nigeria) 

Ppst-partum Haejporrhage 
MONICA RODGERS (Kenya) 



A Topical Outline . . . MODULE D: PREGNANCY, BIRTH AND PUBRPEHIVM 

Nursing and Midwifery P a 3 e 



Routine Newborn Skin Care 
HARVEY HAMRICK (USA) 

Tetanus Neonatorum 

HELEN NANYAMA KUKUBO (Kenya) 

The Third Stage of Labour 
VICTORIA AJAYI (Nigeria) 

Breech Presentation and^ Management 
UDUAK E. AKPAN (Nigeria) 

Anaemia in Pregnancy 

PATRICIA OLUYOMI BAKARE (Nigeria) 

Fet a 1, Dl s t res s in Lab our 
NANCY E. EKONG (Nigeria) 

P ue r p e r aJL JCnj: eji tljm 

MARIE L. MASON (Liberia) 

Prolapse of m the Umbilical^Cord 
H.G. MEHEUX (Nigeria) 

Placenta 1 Deye logmen t 

ADEBIMPE ALAYODE OGUNLANA (Nigeria) 

Rup tared Uterus 

ABIMBOLA OLUFUNMILOLA PAYNE (Nigeria) 

The Modified Obstetric Flying Squad: A Method oF Reducing Maternal 
Mortality and Morbidity Rate in Developing Countries 
GLORIA K. ZUBAIRU (Nigeria) 

The Clinical Course and Management of the First Stage of Labour 
MOHGA LUTFI (Sudan) 

Immediate Care of the Newborn 

SOHAIR HUSSEIN KAMEL SHAWKY (Egypt) 

Preparation for 



MOUSHERA MOSTAFA EL GENEIDY (Egypt) 

The Role of the Nurse in. the Detection of Neonatal Abnormalities 
FAYZA ABDEL HAKIM KAMEL and GAMALAT EL-SAYED MANSY (Egypt) 

Examination oj:^ the Placenta 
ASMAA ABD EL-HAMID ASHMAWY 



A Topiaal Outline ... MODULE D; PREGNANCY, BIRTH AND PVERPEttTUM 

Nursing and Midwifery page 



The Physiological Changes of Pregnancy 
FATMA OSMAN KILLA (Sudan) 

Home Confinement 

E.O. ADEWALE (Nigeria) 

Neonatal Jaundice in the Troplca 
OLU C. NWANA (Nigeria) 

Preparation of the Mother ^ f or Premature Infant Home Care 
SOHEIR ABDEL HAMID DEBASH (Egypt) 

To xaem la In P r e j^ia ncy 

MARIAN ABOAGYE-AKYEA (Ghana) 

Uterine Pregnancy 



^^ 

G.A.C.B. ANTESON (Ghana) 

Soclo-Cultural Influences on the Prevention of Tetanus Neonatomm 
REXFORD ODUR& AiJANTE (Ghana) - ' - ~~ - 

Anaemia In Pregnancy 
DORIS CHARWAY (Ghana) 

Fertilization and Development of the Ovum 
MARGARET OSEI-BOATENG (Ghana) 

Breast Care 

LYDIA WANJUM CEGE (Kenya) 

Prenatal Nutrition and Fetal Growth 
NEBIAT TAFARI (Ethiopia) 

Diet In Horinal Pregnancy 
MOHAMED M. OSMAN (Egypt) 

The Endocrine System - Hormonal Influence on Human Reproduction 
ANNE M. MURAGE (Kenya) 

Flacental Insufficiency 
GAMAL I. SEROUR (Egypt) 

Antepartuip Haemorrhage 

TSIGERIDA TEGASHAW (Ehtlopia) 

Nutritional Anemia 

EMILY 0. DUKE ( Nigeria) 

Infant Morbidity and Mortality - Data Collection, Causes and Prevention 
DOROTHY MULONGA KASAH (Cameroon) 

Pelvic Examination 

MAGDA YOUSSEF HELMI MOURAD (Egypt) 



A Topical Outline . . . MODULE D: PREGNANCY, BIRTH AND PUERPERIUM 

Nursing and Midwifery page 212 



The Normal Menstrual Cycle Related to Human Reproduction 
MERCY MUJOMBA (Kenya) " 

Foetal Development up to 40 Weeks 
REGINA IPOPO (Kenya) 

Vital Rates in Family Health 
SAMUEL OFOSU-AMAAH (Ghana) 

Anatomy and Physiology of the Uterus 
FREDA OJWANGH (Kenya) 

Premature Labour 

WALTHER GRUBER (Austria) 

VeBico-VaRinal Fistula 
HAMID RUSHWAN (Sudan) 



A Topical Outline . . . MODULE D: PREGNANCY BIRTH MD 

Nursing and Midwifery page 



II. BOOKS 

CLARK, ANN L., and DYAHHE D. AFFONSO 

ChUdbearlng: A Nuralnp Prospective. Philadelphia: F.A. DaviH 
Co., 1976. 

CLAUSEN, J.P., M.H. FLOOR and B. FORD 

Maternity Nursing Today_._ 2nd edition. New York: McGraw-Hill, 1977. 

KENDALL, N.R.E. 

Auxiliaries in Health Care: Programs in Developing Countries.. 
Baltimore: The Johns Hopkins Press for the Joslah Macy, .Tr. 
Foundation, 1972. 

FORMAN, ALICE M., et al (eda . ) 

New Horizons in Midwifery, 1972. Proceedings of the 16th triennial 
Congress of the International Confederation of Midwivea hold.. in, 
Washington. DC, October 28 -November 3. 1972. New York: 
International Confederation of Mldwives and the American Col to K" 
of Nurse-Midwives, 1973. 

HYMOVICH, D.P, and M. BARNARD 

Family Health Care. New York: McGraw-Hill, 1973. 

HYLES, MARGARET 

A Textbook for Mldwivee. 8th edition, London: Churchill and 
Livingston, 1975. 

NATIONAL RESEARCH COUNCIL. FOOD AND NUTRITION BOARD. COMMITTEE ON 
MATERNAL NUTRITION. 

Maternal Nutrition and the Course of Pregnancy. Washington I 
National Academy of Sciences, 1970. 

PILLITERI , ADELE 

Nursing Care of the Growing Familyi A Maternal/Newborn Text:. 
Boston: Little, Brown and Co., 1976. 

PRITCHARD, J.A. and B.C. MacDONALD 

editon ' Netf York: Appleton-Century- 



REEDER, S.R., L. MASTROIANNI, L.L. MARTIN, and E. FITZPATRICK 

Maternity Nurelnfl. 13th edition. Philadelphia: J.B. LlpplncoU , 
1976. 



A Topical Outline MODULE E: LACTATION AND UBANIN 

Nursing and Midwifery p age 



MODULE E : 
LACTATION AND WEANING 



I. RATIONALE 



The physiological process of lactation permits a woman to nurse her child b; 
breast-feeding during a critical period in his/her life. Weaning is the event 
which terminates this process. Customs, beliefs, and values, play a significant 
role in determining the pattern of lactation and weaning in a given society. 

The success of both breast-feeding and weaning may determine whether or not 
the Infant survives. If he survives, it may determine what kind of survival it 
will be; i.e., one of continued growth and well-being or of progressive malnutri- 
tion, physical and psychological impairment, and susceptibility to infection. 
For the mother, too, the process of lactation and the time of weaning will have 
a bearing on her future physical and emotional well-being. Proper management of 
the process of. lactation and the event of weaning, coupled with child spacing is 
of capital importance, in assuring reduced infant mortality and morbidity rates 
and better maternal health. 

Nursing and midwifery students need to understand these phenomena as they 
work individually with families and in their communities. Such understanding is 
needed to help these future nurses and midwives in their roles as assessors, 
planners, educators, and promoters in maternal and child health. 



A Topical Outline MODULE E: LACTATION AND 

and Midwifery p a g e 214 



II. OVERALL OBJECTIVES 

Upon completion of thla module, the student will be able to: 

1. Discuss the anatomy of the female breast and the physiology of the 
lactation process. 

2. Develop personal awareness of own attitudes, beliefs and values 
related to lactation and weaning. 

Z. Recognize cultural, psychological and physical factors related to the 
process of infant feeding (breast and artificial) and weaning. 

4. Recognize and manage both maternal and infant problems related to 
infant feeding and weaning. 

5. Provide counseling' and health teaching to women. related to lactation, 
infant feeding, and weaning. 



A Topical Outline 

and Midwifery 



MODULE E: LACTATION AND 
page Us 




Section 

.Specific Objectives: 

1. Describe the anatomical structure of the female breast. 

2. Explain the process of milk secretion. 

3- Identify the hormones which control t he process of m il k secretion ln 

the human female, 

4. List the factors which influence the process of lactation. 
Organization of Conte^T 

A. Anatomy of the Breast 

1. External morphology 

a- Size, location and division 
b. Nipple and different types 

2. Internal Structure 

a. Lobes, tubules and acini cells 

b. Ducts 

c. Ampullae 

B. Milk Secretion 

1. Site of manufacture, mechanism of production and ejection (let-down) 

2. Hormonal influences 



b. The process of milk secretion - prolactin 

of coioatruffi 



Factors affecting milk production 

a. Vigor and constancy of sucking by infant 

b. Nutrition of mother, including fluid - 

c. Physical condition of mother (gener, 

d. Psychological condition of mother 

Absence of stress 
. Desire to breast feed 

e. Stimulative or repressive efft 



* m - 7 n ^- E: LACTATION AND WEANIBG 

A Topical Outline 

Nursing and Midwifery P 



Section II: Breast-feeding 

Specific Objectives: 

1. Identify the social and cultural factors; e.g., beliefs, values, etc,, 
which have a bearing on breast-feeding in the community. 

2. List the dietary requirements of a lactating woman. 

3. Advise a lactating woman on preparation for and management of breast- 
feeding. 

4. Develop simple aids to be used in health teaching of lactating 
mothers about breast-feeding. 

5. Compare the advantages --and disadvantages, indications and contrain- 1 
dications of both breast and artificial feeding. 

6. Recognize and manage both maternal and infant problems interfering with 
breast-feeding. 

7. Recognize and manage problems of over-feeding and under-feeding In 
the infant who is breast-fed. 

8. Identify and recommend contraceptive methods to be used by lactating 
women, 

9. Identify one's own attitudes toward feeding patterns and verbalize 
through a group discussion. 

Organization of Content ____ , 

A. Social and cultural factors affecting patterns of breast-feeding 

1. Religion 

2. Industrialization - urban vs. rural society 

3. Education 

a. General 

b. Specifically in relation to values of breast-feeding 

4. Cultural beliefs and values 

5. Taboos 

6. Influence of family members and peers 

7. Employment of women 

8. Publicity and influence of mass media 

9. Attitudes of health workers toward breast-feeding 

10. Use of local herbs and medicaments 



A Topical OutMn* MODULE E: LACTATION AND UEANI 

and Midwifery page 117 



Section II: Breast-feeding 
Organization of Content: - c 



B. Advantages of breast-feeding 

1. For mother 

a. Convenience 

b. Economic 

c. Nutritional 

d. Psychological 



Satisfaction of accomplishment 
Warmth of close relation with baby 



e. Physical 

. Anovulation - various periods of time-serves as contraceptive 
. Reproductive organs involute more rapidly 

2. For baby (newborn) 

a. Normal response to sucking need 

b. Milk appropriate content, consistency 

c. Immunological protection for approximately 6 months 

d. Protection against allergy 

e. Infant bonding 

f. Sterility of breast milk 

g. Availability 

C. Dietary requirements of a lactating woman 

1. Need for increasing dietary requirements 

2. Dietary allowance for the lactating woman 

3. Local foods which have affect on the lactation process (increase, 
decrease, and milk flow) 

D, Managment of breast-feeding 

1. Significance of breast care 

2. Process of feeding - frequency and duration of feeding, burping, etc. 

3. Teaching mothers the art of breast-feeding 

E. Maternal health problems interfering with breast-feeding 

1. Minor - not an indication to stop but needing remedial assistance 

a. General ill health, anaemia 

b. Flat, small or large, or sore nipples 

c. Inadequate milk flow 



A Topical Outline MODULE E: LACTATION AND 

and Miduifery page 118 



Section II; Breast-feeding 



Organization of Content - cont. 



2. Major 

a. Physical, e.g., tuberculosis, heart failure 

b. Psychological, e.g., neurosis, psychosis 

3. Pregnancy 

4. Cracked nipples, mastitis and breast abscess, inverted nipples 

a. Mild - remediable 

b. Severe - probably not remediable 

F. Infant related problems which interfere with breast-feeding 

1. Congenital abnormalities 

2. Prematurity 

3. Over-feeding and underfeeding 

G. Relationship between breast-feeding and family planning 

1. Value of avoiding pregnancy to promote breast-feeding for benefit 
of infant 

2. Specific methods of contraception that do not affect breast milk. 

H. Impact of attitudes of nurses, midwives, doctors, and other health 
workers on feeding practices 

1. On the mother 

2. On patterns of infant feeding (breast vs. bottle) 

3. On weaning 



A Topical Outline 
Nursing and Midwifery 



MODULE E: LACTATION AND 
page 119 



Section III; Bottle Feedin 



Specific Objectives: 




2 - 



of bottle 



Dions' otbotae'fe^int 



' *""> - -train. 



4. Prepare bottle feedings following scientific principles 



s: L r r ure for 



b'otnffeeding? 88 



follo - u P P roblems "suiting fro. improper 



Organization of Content 




A. Different types of bottle feeding and the prevalence of each 

1. Supplementary 

2 . Comp lemen tary 

3. Complete artificial feeding 

B. Factors affecting the use of bottle feeding 

C. Common nutrients used in bottle feeding 

1. Different types of milk and other mixes 

2. Compare chemical compositions of breast and bottle milk 

D ' feeding 68 ' dlsadvantases ' indications and contraindications of bottle 

E. Preparation of bottle feeding 

1. Principles to follow 

2. Techniques of preparation and sterilization (single feed, feeds for 
2.f\ hours) 

3. Storage of feeds 

4. Use of previously prepared feed 



A Topical Outline MODULE : LACTATION AND WBANItiS 

NwBing and Miditiifery P a 9 e 



Section III! Bottle Feeding (Artificial Feeding) 



Organization of Content - cont.*. 



F. Teaching mothers about bottle feeding 

1. When to begin 

2. What to include in teaching 

3. How Co approach a single mother and/or group of mothers 

4. Value of developing teaching aids in discussing of bottle feeding to 
mothers 

G. Problems associated with bottle feeding 

1. Economic problems 

2. Health problems of infants 

a. Over-feeding 

b. Under-feeding 

c. Infection (prevention, early detection and management) 

d. Allergies (referral and follow-up) 

e. Malnutrition 

f. Electrolyte disturbance 



A Topical Outline 
Nursing and Midwifery 



MODULE E: LACTATION AND WEANING 
page 121 



Section IV: Weanin 




Specific Objectives; 

1. Discuss the beliefs, cu-to-, and practlce8 relating tQ 

Se and'th ""IT "^^^ f the ^t during the first year of 
life and the need and value of each one, 

3. Identify the principles to be followed during the weaning proems. 

3. List in a sequential manner by month or week the food Items to be 
introduced to the baby during the weaning process. 

4. Provide instructions to the mother of infante on the process of weaning. 

haa:ard8 whlch could affecc the infant 



6. Provide necessary nursing management for the prevention and treatment 
of complication resulting from improper weaning. treatment 



Organization of Content 




Beliefs, customs and practices pertaining to weaning 

1. Indications to start weaning 

2. What foods to be introduced 

3. Methods of weaning 
Foods 

1. Available foods in the community for infants and their nutrient value 

2. Dietary requirements during the first year of life 

Guiding principles for promotion of successful weaning 

1. Sound health of the Infant 

2. Age of starting 

3. Gradual process 

4. Proper selection of food Items 



f lmpr per ***, (^r each of the following: the 
nursing care) S68> *"* SymPt0mB ' "**, Prevention? health and 



1. Nutritional deficiencies 

a . Marasmus 
b . Kwashiorkor 
c. Anaemias 



A. Topiaal Outline MODULE E: LACTATION AND 

Nursing and Afteiii/ery page 222 



Se,ctlgn, IV v Weaning 



Organization of Content - cont... 



2. Infections 

3. Gastrointestinal disorders 

4. Psychological trauma 
E. Nursing management 

1. Physical 

2. Educational (mother) 

a. Prevention 

b. Remedial 

3. Psychological 



BIBLIOGRAPHY 

I. SELF-INSTRUCTIONAL UNITS 

available from the African Health Training Institutions Project 

Breast Care 

LYDIA WANJUM CEGE (Kenya) 

Breast-Feeding 

COMFORT ASEM (Ghana) 

Breast-Feeding 

J.W. MAINA (Kenya) 

Education to Mothers About Basic Nutritional Food Values 
LILIAS N. MURIITHI (Kenya) ~~ 

Infant Weaning 

AGNES D. EMELIFE (Nigeria) 

Artificial Feeding 

MAGDA MOHAMED EL-SAYED YOUSSEF AND GAMALAT EL-SAYED MANSY (Egypt) 

Preparation of Mother for Premature Infant Home Care 
SOHEIR ABDEL HAMID DEBASH (Egypt) 

Breast Examination 

SOHEIR HUSSIEN AHMAD ELEBRIARY (Egypt) 

Nutrition Classes for Mothers in Child Health Clinics 
MODUPE OLUBUNMI OSIBINI (Nigeria) 

Traditional Beliefs and Practices Regarding Lactation and Weanine 
HUTTON AYIKWEI ADDY (Ghana) ~~~~ & 

Effect of Lactation on Fertility 

JASWANT S. BAL (Zambia) 

Rural Weaning Diets 

JOHN K. LUBEGA (Uganda) 



A Topical Outline . . . MODULE E: LACTATION AND 

and Midwifery Bibliography 1S4 



II. BOOKS 



CLARK, ANN L. and DYANNE D. AFFONSO 

Chlldbearing: A Nuraina Prospective, Philadelphia: F.A. Davis Co, 
1976. 

CLAUSEN, J.P., H.H. FLOOR and B. FORD 

Maternity Nursing Today. 2nd edition. New York: McGraw-Hill 
Book Co., 1977. 

FORMAN, ALICE M., et al. (eds.) 

New Horizons in Midwifery, 1972. Proceedings of the 16th triennial 
.Congress of the International Confederation of Midwivee held in 
Washington, DC. October 28 - November 3. 1972. New York: 
International Confederation of Midwives and the American College 
of Nurae-Midwives, 1973. 

KING, MAURICE and D. MORLEY 

Nutrition for Developing Countries with Special Reference to Maise. 
Cassava and Millet. London: Oxford University Press, 1972. 

MYLES, MARGARET 

A Textbook for Midvivea. 7th edition. London: Longman, 1972. 

NATIONAL RESEARCH COUNCIL. FOOD AND NUTRITION BOARD. COMMITTEE ON 
MATERNAL NUTRITION. 

Maternal Nutrition and the Courae of Pregnancy. Washington : 
National Academy of Sciences, 1970. 

REEDER, S.R. , L. MASTROIANNI, L.L. MARTIN and E. FITZPATRICK 

Ma_ternity Nurainfl. 13th edition. Philadelphia: J.B. Lippincott, 

Ly /t> i 



WAECHTER, EUGENIA and FLORENCE G. BLAKE 

Nursing Care of Children, Philadelphia: J.B. Lippincott, 1976. 



A Topical Outline . . . MODULE F: GROWTH AND DEVELOPMENT 

Nursing and Midwifery p age 



MODULE F : 

GROWTH AND DEVELOPMENT 
( B i p t h to Pubert 



I. RATIONALE 

The study of child growth and development Includes knowledge and 
observation of its continuity, marked by critical physical and psycho- 
logical landmarks from birth to puberty. It is essential to understand 
this process, for it is against this background that the effects of mal- 
nutrition, infectious disease and social deprivation can best be measured, 
and the impact of preventive measures estimated. 

Nurses, especially, need this knowledge and understanding, for many 
of their activities involve assessment and interpretation of the status 
of child health. In addition, nurses must be skilled in describing the 
limits of normalcy to parents and guiding them in preventing or correcting 
impediments to growth and development. This involves helping parents to 
recognize and meet the individual needs of their children. 



A Topical Outline . . . 
Nursing and Midwifery 



MODULE F-: GROWTH AND DEVELOPMENT 
page 126 



II. OVERALL OBJECTIVES 



At the completion of this module, students should be able to: 



1. Describe the process of growth and development In terms of 
continuity and significant landmarks (both physical and psycho- 
social) . 

2. Describe the major factors affecting growth and development. 

3. Indicate diagnostic and assessment tools to aid In determining 
the progress of growth and development. 

4. Plan for the counseling and education of parents whose chlld(ren) 
are showing signs of failure to achieve recognized landmarks. 



Specific Objectives^ 

1. Describe the concept of the continuum In the process of 
growth and development. 

2. Relate the significance of physical and psychosocial landmarks 

3. Identify developmental tasks in relation to critical landmarks 

4. Apply concept of normalcy to growth and development. 



on or Content 



A. Continuum, of growth and development 

1. Physical 

a. Somatic growth 

b. Motor development 

. gross 
. fine 

c. Immunologlc development 

d. Development of senses: sight, hearing 

2. Intellectual 

a . Language 

b. Conceptual 

c. Memory functions 

3. Emotional and psychological 

4. Social 

B. Concept of a pattern 

1. Relationship of components 

2. Constant integration and interdependency 

C. Significant landmarks of growth and development in each category above 

1. Infancy (0 - 11 months) 

2. Toddler (12 - 35 months) 

3. Pre-school (3-5 years) 

4. School age (5-8 years) 

5. Pre-adolescence (9 - 13 or 15 years) 



A Topical Outline . . . MODULE F: GROWTH AND DEVELQPflfENT 

and Micfaif&ry page 128 



Section I; Normal Growth and Developmental Patterns 

Organization of Content - cont... 

D. Developmental tasks 

1. .Identity of tasks for each landmark 

2. Achievement as preparation for next task 

3. Maturity - mastery of each component and integration of whole 
person 

E. Deviations from normal 

1, Mild to severe 

2. Significance of deviation 

3 The limits of normalcy - concept of variation 

4. Condition static or progressive 

5. Condition correctable or fixed 



A Topical Outline ... MODULE F: GKQWH AND DEVELOPMENT 

Nw?a^ng and Miauife-py page 129 



Section II: Major Factors Affecting Growth and Development 

Spec! fie Ob J e c t i ve 8 _:_ 

1. Relate the role of heredity In determining individual patterns of 
growth and development. 

2. Describe how nutrition supports or impedes growth and development 

3. Describe the effect of disease on growth. 

4. Describe the need for stimulation. 

r gani za t ioii of Content """ " ~~ ~ 

A. Genetics or heredity 

1. Uniquness of the individual 

2. Biological make-up 

3. Potentialities - predictions 

4. Interrelation with environment 

B. Nutrition 

1. Requirements by age and developmental task 

2. Needs 

a. Calories 

b. Proteins 

c. Carbohydrates 

d. Fats 

e. Vitamins and minerals 

f. Fluids 

3. Evaluation of nutritional status 

a. Tests, haemoglobin 

b. Measurements, especially weight and arm circumference 

4. Effects of deprivation (see Module J - Section II) 

a. Acute 

b. Chronic 

c. Relation to time of deprivation 

5. Food preferences and taboos 

C. Disease (see Module J - Section II) 

1. Infection 

2. Relation of disease and nutrition 



A Topical Outline . . . MODULE F: GROWTH AND 

Nwsing and Midwifery P<*9 e 



Section II: Malor Factors Affecting Growth and Development 

Organization of Content - cont... 

C. 3. Relation of disease to intellectual, emotional and social development 

a. Severity 

b. Timing 

4. Crippling effects of chronic or repeated acute illness 

D. Stimulation 

1. Constant universal need 

2. Components 

a. Physical 

b . Intellectual 

c. Emotional 

d. Social 

3. Manifestations 

a. Healthy body 

b. Curiosity and eagerness to learn 
c. Love and affection 

d> Security and belonging 

e* Re- assurance and encouragement 

f . Parental and peer approval 

g. Satisfaction with accomplishment 

4. Effects of deprivation 

a. Failure to thrive (physical) 

b. Withdrawal 

c. Failure to accomplish tasks of development 

d. Poor language development 

e. Dissatisfaction and unhapplneas 



A Topical Outline . . . MODULE F: GROWTH AND DEVELOPMENT 

Nt&sing and Midwifery page 131 



Section III; Diagnostic and Assessment Tools Co Measure Growth and Development 
S-JJgci f 1 c Ob j e c_t_ iye_3_!_ 

1. Describe available teats for diagnosing and assessing growth and 
development, 

2. Select and perform (under guidance) appropriate assessment measures. 

3. For a selected age, develop a check-list of components for assessment 

f Content ~ """ 

A. Observation 

1. General appearance 

a. Body habitus 

b. Affect 

c. Obvious signs of disease or disability 

d. Level of activity 

2. Gait and coordination 

3. Skin and hair 

a. Texture 

b. Color 

4. Facial expression 

a. Alertness 

b. Apathy 

5. Maternal-child interaction 

6. Reaction of child to environment 

B. History 

1, General 

a. Medical 

b. Social 

c. Family medical 

2, Specific episode or condition 

a. What is wrong? 

b. How long? 

c. Any treatment? 

3, Condition of 

a. Parents 

b. Other children 

c. Other family members 



A Topical Outline . . . MODULE F: GROWTH ADD DEVELOPMENT 

Nursing and Midwifery po#e 13S 



Section Illi Diagnostic and Assessment Tools to Measure Growth and Development 
Organization of Content - cont.. ,., , _ 

C. Physical examination 

1. Appropriate for age 

2. Partial or complete, as appropriate 

D. Laboratory tests 

1. Urinalysis 

2. Haemoglobin 

3. Tuberculin 

4. Stool 

5. Thick amear for parasites 

6. Others, as Indicated 

E. Screening tests 

1. Height and weight 

2. Vision 

3. Hearing and speech 

4. Developmental (e.g. Denver) 

5. Dental 

F. Recording 

1. Observations 

2. History 

3. Physical findings 

4. Test findings 

G. Correlation of findings 

1. Interpretation 

2. Usefulness 



A Topical Outline . . . MODULE F: GROWTH AND DEVELOPMENT 

fluvsing and Midwifery page 133 



Section IV: Counseling and Education ^ oJ^Parent: and Children -^ Nursing 

^ Intervention 

Specific Objectives; 

1. Identify what children need to promote normal growth and development 

2. Indicate protective measures Chat will prevent impediments to growth, 

3. Plan with and counsel a parent. 

4. Plan with and counsel an older child. 

Organizaiton of Content 

A. The needs of children to promote normal growth and development 

1. Good nutrition 

2. Functional hearing, sight and ambulation 

3. Protection 

a. Accidents 

b. Illness 

c. Freedom from anxiety 

4. Parental love and stimulation 

a. Praise 

b. Acceptance and encouragement 

c. Limits 

5. Safe environment 

a. Home 

b . Play 

c. School 

B. Protective Measures 

1. Adequate Diet 

2. Immunizations 

3. Early physical and mental assessment of individual child 

4. Medical care 

a. Accessible 

b. Available 

c. Compassionate 

d. Competent 

5. Elimination of environmental hazards 

6. Early assessment of problem areas with prompt intervention 



A Topical Outline MODULE F: GROUTH .AND 

Nursing and Midwifery P a 3 e 1U 



Section IV t Counseling and Education of Parent and Children - Nursing 
_ Intervention _ __ _ _ - 

Organization of Content - cont. . . _ ___ - 

C. Techniques of nursing intervention 

1. Utilization of available screening tools 

2. Evaluation of findings 

3. Developing a plan of action 

4. Emphasis on helping parent and ch4,ld understand reason for action 

5. Involving family members In setting priorities and deciding course 
of action. 

6. Attempt to remove barriers to desired action 

7. Motivation for self-development or self-reliance 

8. Confer with other available personnel on problem areas 

a. Medical 

b. Social 

c. Psychology 

d. Education 

e. Community leaders 

f. Religious 

9. Interpret and correlate suggestions or activities 

10. Refer child with marked developmental deviations to appropriate 
^resources for help, 

11. Constantly support and reinforce parental action 

D. Use of and coordination with Community Resources 

1. Health centers (or honpltals) 

2. Clinics 

3. Nutrition rehabilitation centers 

4. Educational institutions 

5. Recreational facilities 

6. Other 



A Topical Outline . . . MODULE F . 5Im TQ PUBE/?Ty 

and Mvdnfery Bibliography 135 



BIBLIOGRAPHY 

I. SELF-INSTRUCTIONAL UNITS 

available from the African Health Training Institutions Project 

Growth, Development and Care of Normal Infants from Birth to One Year 
CECILIA KING (Ghana) ~ ~~~ 

Introduction to Kwashiorkor: Its Nature, Causation and Manifeatations 
ALICE N. AKITA (Ghana) ~ ~~ ~~" 

Kwashiorkor and Pre-Kwashiorkor ; Identification and Treatment 
SOPHIE WALTER-HOLTZ (Ghana) ' ~ 

The Relationship Between Nutrition and Growth and Development (0-5 years') 
REMI IGUN (Nigeria) ~~ *- 

Influence of Environmental and Cultural Factors on Child Care and 
Development 

PAULINE MELLA (Tanzania) 

Protein-Calorie Malnutrition 
FITZROY JOSEPH (Kenya) 

Vitamina^ 

DORIS CHARWAY (Ghana) 

Factors Contributing to the Normal Growth and Development of a Child 
ANU ADEGOROYE (Nigeria) ' 

Feeding Practices and the Health of Children 
A.O. OBARISIAGBON (Nigeria) 

Preparation of Mother for Premature Infant Home Care 
SOHEIR ABDEL HAMID DABASH (Egypt) 

Examination of a 6-Month-Old Infant in a Family Health Clinic 
E.O. AKINNIBOSUN (Nigeria) 

Interpretation of the Weight Chart and its Significance in Child Health 
ADESOLA TINUBU (Nigeria) 

.School Meals in Lagos 

PEJU ABODERIN (Nigeria) 

Nutrition Classes for Mothers in Child Health Clinics 
MODUPE OLUBUNMI OSIBINI (Nigeria) 

Education to Mothers About Basic Nutritional Food Values 
LILIAS N. MURIITHI (Kenya) 



A Topical Outline . . . MODULE F: BIRTH TO PUBEfiT 

Nursing and Midtoifery Bibliography 136 



Long-Term Nursing Intervention with Malnourished Children 
and Their Families 

SUZAN H. BANOUB (Egypt) 

N.eg.hrj^tis 

ALHAJI KASIHU ALIYU (Nigeria) 

Advice to Mothers on Symptoms of Childhood Diseases 
CECILIA 0. ADEDOYIN (Nigeria) 

Proteins^ in the Weaning Diet 
CHRISTINA NARTEY (Ghana) 

Midwife's First Examination of the Newborn Baby 
JOLA OLOFINBOBA (Nigeria) 

Nursing Care of the Premature Infant 
ADEBIMIPE OKUNADE (Nigeria) 

Food Customs and Taboos In Relation to the Family Health in a CommunU 
SARA W. KAVITI (Kenya) 

Prenatal^ Nu tr^y v g - n_jand Fetal Growth 
NEBIAT TAFARI (Ehtlopia) 

Pellagra 

SAMIR KAMAL ELDIB (Egypt) 

Energy Protein Malnutrition 

EBD EL-HAMU) GUINEA (Egypt) 

Effect of Malnutrition on Growth , and AdoleBcence 
NABILA M. HIDAYET (Egypt) 

Caloric Requirement and Adequa t e Pie t 
MOHYI ELDIN ABDEL-WAHAB (Egypt) 

The Contribution of a School Health Programme to Family Health 
ERNESTINE A. GYEBI-OFOSU (Ghana) 

The Detection of Neonatal Abnormalities 
FAYZA ABDEL HAKIM KAMEL (Egypt) 

Nutrition Education and Counselling 
KADRIA M. MOUSTAFA (Egypt) 

Immediate Care of the Newborn 

SOHEIR HUSSEIN KAMEL SHAWKY (Egypt) 

Mental Illness in Children 
OLU ADELOWO (Nigeria) 

Traditional Belief and Practi^e_s_ Regarding Lactation and Weanlna 
HUTTON AYIKWEI ADDY (Ghana) 



A Topical Outline . . . MODULE F: BIRTH TO PUBERTY 

Nursing and Midwifery Bibliography 13? 



Family Planning: Its Implication on Health 
GRACE NENNA NZERIBE (Nigeria) 

The Socialization Process of Children and Its Importance 
to Public Health 

EDITH FORDJOR (Ghana) 

Thg__Mgtor_ Development of Infants^ 
G.I. ODIA (Nigeria) 



A Topical Outline ... MODULE F: BIRTH TO 

Nursing and Miduifery Bibliography 138 



II. BOOKS 

BURT, J.J. and LINDA A. BROWER 

Education for Sexuality; Concepts and- Programs for Teaching. 
Philadelphia; Saunders, 1970. 

HYMOVICH, D.P. and M. BARNARD 

Family Health Care. New York: McGraw-Hill Book Co., 1973. 
JELLIFFE, DERRICK, B. 

The Assessment of Nutritional Status of the Community. Geneva : 
World Health Organization, 1966. 

KILIMANJARO CHRISTIAN 'MEDICAL CENTRE 

Child Health: Rural Health Series #1. A Manual for Medical 
Assistants and Other Rural Health Workers. Kenya: African 
Medical and Research Foundation, 1975. 

KING, MAURICE and D. MORLEY 

Nutrition for Developing Countries with Special Reference to Maize. 
Cassava and Millet. London: Oxford University Press, 1972. 

MORLEY, DAVID 

Pediatric Priorities in Developing Countri M *. London: Butterworthe, 

PILLITTERI, ADELE 

Nursing Care of the Growing Family: A Maternal/Newborn Text. 
Boston: Little, Brown and:Co., 1976. 

ROPER, NANCY 

Man r a Anatomy, Physiology, Health and Environment. 4th edition. 
Edinburgh, Scotland: Churchill, Livingstone, 1973. 

SPQCK, BENJAMIN 

Baby and Child Care. New York: Simon and Schuster, Inc., 1974. 
STONE, L. and J. CHURCH 

Childhood and Adolescence t A Psychology of the Growing Person 
New York: Random House, 1973^ ~~ '' 

WAECHTER, EUGENIA and FLORENCE G. BLAKE 

Nursing Care of Children. 9th edition. Philadelphia: 
J.B. Lippi ncott( 1976 



MODULE G 



PUBERTY AND ADOLESCENCE 



I . RATIONALE 



Puberty is the point of development at which the biological changes of 
pubescence reach a climax marked by indicators of sexual maturity. Adolescence 
is the entire period starting approximately two years prior to puberty and 
ending when the individual has reached full physical, mental, emotional, and 
social maturity - approximately ages 11 through 20 years. 

Adolescence is a time of rapid growth. In modern times it is usually 
regarded as a period of stress and turmoil, for social maturity does not 
always keep pace with physical growth and development. However, in many 
cultures and religious groups there is considerable ceremony attached to 
certain events that are marked by physical changes or chronological maturity. 

Adolescents as a group have had difficulty in fitting into the practice 
of medicine. They are not children and not yet adults. They have some 
pressing medical and social needs which are often neglected or ignored. Because 
of their growth spurt, they have special nutritional needs. In general they are 
a healthy group, for they have survived the hazards of childhood and are not 
old enough to have acquired chronic debilitating disease. During adolescence* 
sexual maturity is taking place, therefore, there is the ever-present possibility 
that pregnancy and the accompanying responsibilities of parenthood can occur. 
Pregnancy in adolescence is in the high risk category for the mother as well 
as the infant. 



A Topical Outline ... MODULE G: PVBEKTY AMD ADOLESCED 

and Midrifery page 



Well-prepared student nurses or recent graduates can do an excellent Job o 
counseling adolescents. They are not too far removed from the peer group. Vet 
they have had time to gain the perspective knowledge and skills that are 
mandatory in the counseling situation. 



A Topical Outline ... MQDVIE G: PUBERTY AND ADOLESCENCE 

and Midwifery page 141 



II. OVERALL OBJECTIVES 

AC the completion of this module, students should be able to: 

1. Define basic terminology. 

2. Describe the steps from pubescence to sexual maturity (physical, 
emotional and social.) 

3. Describe the traditional and current attitudes of the culture and 
society as well as the characteristics of adolescent life in the 
local community. 

4. Correlate the major needs of adolescents with the changes that are 
taking place in their bodies and their social environment. 

5. Designate and explore areas of interest to adolescents where the 
nurse can provide counseling, 

6. Provide appropriate counseling to adolescents and/or their parents 



A Topical Outline ... MODULE G: PUBERTY AND ADOLESCEffCl 

Nursing and Midwifery page 14S 



Section I: Definitions of terms and the steps leading to maturity 
Specific Objectives! 

1. Define the terms pubescence, puberty and adolescence. 

2. Describe the physical changes that take place from pubescence to 
maturity. 

3. Describe the emotional changes and social demands that develop 
from pubescence to maturity. 

Or g an iz a t lo n of C on ten t " T " ~~ 



A. Pubescence 

1, Period of approximately two years preceding puberty 

2. Beginning of growth 

B, Puberty 

1. Point of development 

2. Changes reach a climax 

3. Indicators of sexual maturity 

C. Adolescence 

1. The entire period 

2. Approximately 6-9 years 

D, Physical changes 

! Influences 

a. Heredity 

b. Nutritional status 

c. Hormonal changes and interactions 

d. General state of health 

2. Growth spurt 

a. Weight 

b. Height 

. Centered on extremities - arms, legs, neck 

. Unevenness of growth may cause temporary motor incoordination 

. Intensity tnay cause fatigue and loss of energy 



c. Girls 

Broadening of hips 

Increase of subcutaneous fat 

. Appearance of breast buds - usually one of first outward signs 
(see 6a below) & 

d. Boys 

. Broadening O f shoulders 

. Development of muscles and bone 

3. Growth of body hair 

a. Pubic an3 axillary (boys and girls) 

b. Facial and chest in boya 

c. Extremities 

4. Skin 

a. Courser, with larger pores 

b. Sebaceous glands produce an oily secretion 

c. Perspiration altered - increase in amount and odor 

5. Changes in pulse rate and basic metabolic rate (BMR) 

6. Breast changes 

a. Girls -.areolas elevated, conical, larser in diameter, increase 
in fat, increasingly mounded, pigmentation of nipple 

b. Boys - temporary - may vary from slight to significant enlargement 

7. Genitalia 

a. Girls - slight external enlargement but menstruation evidence 
of internal changes 

b. Boys - enlargement first of penis, then testes, and scrotum - 
pendulous - change in nature of erection - nocturnal emissions 

8. Menstruation 

a. Age of onset - variations 

b. Cyclic nature 

c . Phases 

d. Interval between onset of menstruation and ovulation 

e . Characteristics 

Bleeding 

. Cramping - dyaraanorrhea 
. Pre-menstrual tension 

f. Interaction of hormonal changes 

. Affect emotional development 

. May cause temporary malaise and/or depression 



Topical Outline 
and 



MODULE G: 
page 144 



AND ADOLESCED 



TT^J^^^^^^^^^I:::. 




Pathology 

Dysfunctional bleeding 
Prolonged anovulation 
Imperforate hymen 
. Scarring from clitorectomy 



9. Voice changes 



a. 

b. 



uoya ~ uMOkie,- - - 
fluctuations characteristic 

10. Asynehrony - split growth 



a. 

b. 



c. At puberty - end up in balance 
11. Deviations in rate of maturing 



a. 
b. 



puberty and approximate size 



parental history 

birth weight 

size at age 2 

nutrition 

bone oBBlfiaation 



c. 



E. 



Emotional changea and social demands 

1. Period of transition (reorganisation of personality) 

t * 1 I 



a. Neither adult nor^chUd 

b, " LJ "" 



2. External awkwardness 

a adjustment to new size 

b! adaptation to rapidly changing body 

3. Search for new identity 



a. "Who am H" 

b. "What is expected of 

c. "What do I want?" 

d. "What will I become? 
e Search for role model 



A Topical Outline . . . MODULE G: PUBEXK AND ADOLESCED 
Nursing and Mifoifery P Q e I* 5 

Section I; Definitions of terms and the steps leading to maturity 

Organization of Content - cont ... __ 

4. Demands for achievement 

a. Parents, teachers, religious leaders, peers 

b. Expectations va . reality 

c. Compliance vs. rebellion 

5. Development of interest in opposite sex 

a. Task of heterosexual development 

b. Worry about sexual attractiveness and performance ability 

c. Internal feelings (stirrings) 

strangeness 

lack of understanding 

d. Curiosity vs. modesty 

e. Cultural standards and taboos 

f. Differences in boy and girl perspectives 



6. Development of new interpersonal relationships 

Psychosocial 
Instability - 
ship to others 



a. Psychosocial 

b. Instability - love/hate relation with :ael, reflected in relati 



c. Learning to handle idealism as well as hostilities 

d. Search for "sincerity" and dependability in others 

e. Need for friends - peers and adults 

Concern about health related problems 

a. Normality of new body image 

b. Apprehension about minor symptoms 

c. Temporary obesity 

d. Psychosomatic symptoms 

e. Illness and death 

. Self 
. Parents 
. Others 

f. Depression - Inability to cope 

g. Ambivalence of feelings about dependency on parents 

. Need to be protected and loved 
. Isolation and loneliness 
. Constant fluctuation 
h. Veneral disease 

. Cause 
. Cure 
i. Masturbation 

. Prevalence 
. Normalcy 
1. Excellent time to teach preventive hea 



A Topiaal Outline ... AND 

and Mifoifery 



Section I: Definitions of terms and the steps leading to maturity 
Organization of Content - cont . . .. ___ _ __ 

8. Concern about preparation for career and marriage 

a. Ability to support self and family 

b. Career-rewarding interest and remuneration 

c. Marriage responsibilities 

d. Child-bearing and child-rearing responsibilities 



A Topical Outline ... MODULE G: PUBERTY AND ADOLESCENCE 

Nursing and Midwifery page 



Section II: Traditional and current attitudes surrounding adolescent life 
Lif ___^ in community , 

jaecific Objectives: 

1. Identify and traditional attitudes or rites in relation to puberty, 
and preparation for marriage. 

2. Determine the current attitudes in the community. 

3. Describe the resources in the community to meet adolescent nee da . 

Organization of Content . 

A. Traditional beliefs 

1. Place of adolescent in a specific culture 

2. Puberty rites 

3. Responsibilities - premarital, marital 

4. Taboos 

5. Criteria governing choice of marital partner 

B. Current attitudes 

1. Sources of information 

a. Teachers 

b. Religious leaders 

c. Community leaders 

d. Parents 

e. Adolescent groups 

2 . Dependency 

3. Orientation to 

a. Education 

b. Occupations 

c. Working women 

4. Sexual activity 

a. Pre-marital activity 

b. Pre-marital pregnancy 

c. Venereal disesease 

d. Family planning 

e. Sexual deviations 

f. Infertility 

5. Age of marriage 

a. Bride price or bride wealth 

b. Responsibility to family 



MQDVI& G; 
page 148 



AND ADOlESt 







C. 



6. Current taboos 

Conmmity resources to meet adolescent needs 

1. Schools 

2. Religious groups 

3. Hospital, health centers 

4. Extended families - clana, tribes, etc, 

5. Work opportunities 

6. Recreational opportunities 

7. Mobility - transportation 

8. Communication 



A Topical Outline ... MODULE G: PUBERTY AND ADOiBSCEWt 

Nuwing and Midwifery page 



Section III; Major Needa of Adolescents _ 

Specific Objectives: 

1. Describe the nutritional needs of adolescents. 

2. Explore the various educational needs. 

3. Describe the broad aspects of health needs. 

4. Describe the need for understanding and acceptance by parents, adult 
and peers. 

Organization of Content - . 

A. Nutritional needs 

1. Accommodate to growth spurt 

2. Accommodate to increased activities - sports, manual labor 

3. Regular - adequate in quantity and quality 

4. Protein, fat, carbohydrates 

5. Vitamins and minerals 

6. Special needs of adolescent pregnancy 

B. Educational needs 

1. Literacy - Adult life demands ability to read and write 

a. Ability to get a Job 

b. Ability to understand structure and functioning of modern 
communities 

c. Aid to Independence 

2. Level of education 

a. Higher level - higher standard of living 

b. Value of knowledge and skills 

c. Satisfaction and stimulation 

3. General education 

a. Orientation to responsible citizenship 

b. Status - personal as well ae community 

4. Good schools 

5. Well-prepared teachers 

6. Vocational or job-oriented preparation 



A Topical Outline ... 
and Midtifery 



MODULE G: PUBERTY AND ADOLESCENCE 
page 150 



Ma-lor Needs of Adolescent a 



Organization of Content - coat 




7. University education for preparation of community leaders and 
professional personnel 

8. Sex education 

9. Family-life education 

a. Preparation for marriage 

b. Economic aspects of marriage 

c. Human reproduction 

d. Responsibilities of parenthood 

e. Child-spacing and family planning 

10. Health education (See Health needs "C" below) 

11. Community programs 

a. Agriculture 

b. Care of livestock 

c. Environmental hygiene 

d. Development of local crafts 

C, Health Needs 

1. Knowledge of preventive measures 

a. Immunization 

b. Safe water 

c. Disposal of wastes 

d. Communicable diseases including eyphilis and gonorrhea 

2. Basic requirements for good health 

a. Food - quantity and quality 

b. Rest 

c. Cleanliness 

d. Shelter 

e. Love and security 

f. Protection 

3. Health services 

a . Adequacy 

b. Suitable and acceptable to adolescents 

b. Special services for 

a. Recreation 

b. Psycho-social disorders 

c. Adolescent maternal health program 

d. Family-planning 



A Topical Outline ... MODULE G: PUBERTY AND ADOLESCENCE 

Nursing and Midwifery page 151 



Section III: Ma.lor Needs of Adolescents 

Organization of Content - cont ... . __ 

D. Need for understanding and approval 

1. By parents, adults, and peers 

2. Personal interest 

a. Someone to depend upon 

b. Experience in establishing rapport (give and take) 

3. Counseling programs 

a. Adolescents only 

b. Parents and/or significant others 

A. Resources to make achievements visable - sports, crafts, etc 



A Topical Outline 
Nursing and 



MODULE G: PUBERTY AND ADQLES'CSNCE 
page 



Spe r.lfic Objectives 




C. 



11 of cogent previously listed * ** ). -tl. I, 
and E and Section III. 

Tech ni q ue S i n counseUns .ere ob^tive is t. b.1, adolescents solve 
own problems 

1. Non-threatening approach 

a. Select time 

b. Provide privacy 

2. Explain reason for questions 

3. Confidentiality of information 

a. What la and what IB not 

b . Reasons 

4. Determine readiness of adolescent 

a. To give information 
b'. To receive information 

5. Expreea Interest in understanding and supporting 

6. Recognize limitations 

7. Allow expression, of frustration, hostility and anfcivalence 

8. Individual and/or group sessions 

9. Total effort toward helping adolescent problem solve 
Intervention in major problem of adolescence 

1. School problems 

a. Achievement (possible learning disabilities) 
b . Behavior 
c. Attitude 



A Topical Outline ... MODULE G: PUBERTY AND ADQLBSCENCL 

Nuveing and Midwifery page 153 



:tion IV= Nursing Intervention 
anization of Content - cont ..... 



2 . Family 

a. Pressures 

b. Responsibilities 

c. Approval 

d. Permission 

e. Assistance to parents 

f. Importance of communication 

3. Peers 

a. Critical needs for approval 

b. Involvement in group activities 

c. Boy/girl relationships 

d. Smoking, alcohol, drugs 

A. Career opportunities 

a. Preparation needed 

b. Appropriateness for individual 

c. Feasibility 

5. Marriage customs 

a. Premarital rites including sexual practices 

b. Parental choice of marital partner 

c. Bride price 

d. Monogomy vs. polygamy 

6. Conflicts between dependence and independence 

a. Meeds 

b . Reality 

D. Counseling needs of pregnant adolescent 

1. Acceptance by counselor 

2. Determine marital status 

a. Married - attitudes of family menbers 

b. Unmarried - cultural attitudes and practices in relation to 
pregnancy and child support 

3. Nutrition education 

a. Importance of diet components 

b. Relation to changes of pregnancy 

c. Relation to physical well-being 

d. Relation to growth of baby 



MODUZE G: PUBERTY AND ADOLESCENCE 
A Topical Outline 

Nursing and 



Section IV: Nurginjz Intervention , . 

Organization of Content - cont .-. . . . ...... 

4. Medical care - determining category or risk 

a. Resources - physician, midwife, nurse 

b. Place of delivery 

c. Preparation for labour and delivery 

d. High risk factors 

e. Early detection of abnormalities 

f. Criteria for referral 

g. Supports and costs 

5. Prenatal education 

a. Body changes and their meaning 

b. Common discomforts of pregnancy 

c. Importance of medical/midwifery supervision 

d. Personal hygiene 

e. Sexual activity during pregnancy 

f. Signs of labour 

g. Process of delivery 
h. Puerperium 

1. Follow-up care Including family planning 

6. Preparation for baby 

a. Breast feeding 

b. Discussion of abilities and needs of babies 

c. Total dependence 

d. Clothing - as appropriate for culture and climate 

e. Discussion of local taboos, myths or customs related to the 
newborn 

f. New responsibility for adolescent mother 

7. Unwanted pregnancy (if so indicated) 

a. Interruption to school 

b. Change of way of life 

c. Alternatives to carrying pregnancy to term (probably extremely 
limited) 

d. Learning to cope 

e. Introduction to contraception 

E, Referrals 

L, Other health team members 

2. Social or welfare 

3. Educational 

4. Recreational 

E . Charting 

1. Importance for continuity of care and counseling 



A Topical Outline ... MODULE G: PUBERTX AND ADOLESCENCE 

Nursing and Midwifery page 



Section IV: Nursing Intervention 

Organization of Content - cont . , . 

2 . Format 

a. Anecdotal 

b. Check list 

3. Observations 

4. Discussions 

5. Recommendations and/or nursing care plan 

6. Follow-up 
F. Group sessions 

1. Techniques 

a. Discussion 

b. Role-playing 

c. Adult leader 

d. Adolescent leadership 

2. Timing and place 

3. Size of group 

4. Importance of "food and talk" sessions for adolescents 

5. One time or series 

6. Orientation 

a. Crisis 

b. Education 

c . Both 

7. Pre-planning and group Involvement 

8. Evaluation 



A Topical Outline . 
Nursing and Midwifery 



MODULE G: PVBEPT7 AND ADOLESCENCE 
Bibliography 156 



BIBLIOGRAPHY 



Nutritional Needa of **e Adolescents 
SARATU 0, AKU (Nigeria) 

Pelvic Examination 

- MAGDA YQJJSSEF HELKI MOURAD (Egypt) 

Physical Changes in Puberty 

ZEINAB MOHAMMED ABD-EL-FATAH (Egypt) 

Health Problems of Adolescents 

BENEDICTA MONICA ABABIO (Ghana) 



Beliefs qn^| Pract^ftff fr n Ghana 



ELLEK BORTEI-DOKU (Ghana) 



A M eBBent of Growth and Nuitional Statua of NiRerian Children 



M, DUGGAH (Nigeria) 



of Kalniitrltion 0" Growth at Adolescence 



NABILA M. HIDAYET (Egypt) 




nric Requirement and Adequate Diet 
MOKYI ELDIN ABDEL-WAHAB ^Kgyp t ) 



- Hormonal Influence on Huiaan Reproduction 



ANNE N. MURAGE (Kenya) 




> Normal Menstrual Cycle Related to Human Reproduction 

"MERCY MUJOMBA (Kenya) 



A Topical Outline . . . MODULE G: PUBERTY AND ADOLESCENCE 
Hursing and Midwifery Bibliography 15? 



II . BOOKS 

BURT, J.J. and LINDA A. BROWER 

Education for Sexuality; Concepts and Programs for TeachinR. 
Philadelphia: Saunders, 1970. 

CLARK, ANN L. and DYANNE D. AFFONSO 

Childbearing: A Nursing Prospective. Philadelphia: F.A. Davis 
Co., 1976, 

KING, MAURICE and D. MORLEY 

Nutrition for Developing Countries with Special Reference to Maize, 
Cassava and Millet, London: Oxford University Press, 1972. 

SPOCK, BENJAMIN 

Baby and Child Care.. New York: Simon and Schuster, Inc., 1974. 

STONE, L. JOSEPH and JOSEPH CHURCH 

Childhood and Adolescence: A Psychology of the Growing Person. 
New York: Random House, 1973. 

WAECHTER, EUGENIA and FLORENCE G. BLAKE 

Nursing Care of Children. Philadelphia: J.B. Lippincott. 1976. 
WHELAN, ELIZABETH M. and MICHAEL C. QUADLAND 

Hunan Reproduction and Family Planning A Programmed Text. 
Palo Alto: Syntex Laboratories, 1972. 



A Topical Outline ... MODULE H: THE ADULT (AGE 21- 

Nursing and Midwifery page 159 



MODULE 



THE ADULT 



I. RATIONALE 

After many years of growth and development, the human organism reaches 
physical and psychological maturity at the approximate age of. 21 years. 
Characteristics of this mature adult are dependent on all that has gone 
before. However, it is also recognized that in many cultures, courtship, 
marriage and childbearlng have already begun for the female. In general 
the male is 4-5 years older than his female partner. 

The years from 21 to 44 In African countries might also be called the 
"productive years." It is during this time that families are formed, 
children are reared, occupations are developed, and the major responsibility 
for caring for and supporting self and dependents is dominant, 

In order to maintain healthy families, this age group must be kept 
active and mobile. It is from this maintenance level that communities can 
call upon their citizens to promote community development. Most of the 
morbidity and mortality in this age group comes from conditions which are 
preventable. For example, accidents, childbirth complications, excess 
weight gain, dental problems and venereal disease are all conditions in 
which early detection and treatment can prevent the severe complications 



A Topical Outline ... 
Nursing and Midwifery 



MODULE H: THE ADULT (AGE 21-44) 
page 160 



II. OVERALL OBJECTIVES 

At the completion of this module, students should be able to: 

1. Describe the major responsibilities of the adult during the productive 
years. 

2. Enumerate and discuss the cultural attitudes and expectations in 
relation to this age group. 

3. Describe the needs of adults in this group. 

4. Discuss the problems including illnesses that are common to this 
group. 

5. Identify ways in which nuraing intervention may care for, educate 
and support these adults. 



A Topical Outline ... MODULE H: TM ADULT (AGE 27- 

Nursing and Midwifery page 162 



Section I: The Productive Years 



Specific _0b jec_tive_s : 

1. Define maturity and factors that influence its development 

2. Explain why the years 21-44 are considered the "productive years" 
in most African cultures. 

3. Discuss the kinds of responsibilities normally encountered by indi- 
viduals in this age group. 

Organization of Content r . .. , _- T ... ,..,-., 

A. Maturity 

1. Definition - A state of full development 

a. Physical 

b. Intellectual 

c. Emotional 

2. Variations in age of achievement 

3. Variations in degree of achievement 

4. Influences 

a. The physical and mental health of the adult body 

b. Opportunity for education 

. Type 

. Quality 

. Achievement 

c. Parental Guidance In Youth 

d. Quality of previous parent - child relationship 

e. Role models - in family or community 

f. Environmental factors - climate, hardships, availability of food 

g. Affluence or poverty 

5. Ability to assume responsibility for own actions 

a. Making value Judgments 

b. Guiding others 

c. Ability to accept mistakes as well as successes 

6. See Module G, Section I 



B, Factors affecting 

a. Adolescent experience - preparation for productive years 

b. Life expectancy averages 45 years in Africa (see Module I, 
Section I) 



A Topical Outline 
Nursing and 



MODULE H: THE ADVLT (AGE 21-44} 
page 162 



T: The Productive Years 



of Content - cont . . 




2. Characteristics 

a. Responsibilities - many kinds occurlng at the same time 

b. Intensity of living 

c . Ac comp lishmen ts 

d. Hazards 

occupational 
, obstetrical 

Kinds of responsibilities 

a. Family - three or more generations 

b. Children - bearing and rearing 

c. Older parents 

d. Civic (community) 

e. Occupational and financial 
. Food production 

g. Food "preparation" 

h. Prevention of illness and accidents 

1. Health care 

j. Housing 

k. Clothing 

1. Education 

B. Family mores and customs 

n. Adherence to religious observance and practices 



A Topical Outline ... MODULE H: THE ADULT (AGE 2t 

Nursing and Midwifery page 163 



Section II: Cultural Attit:ud_e_s_an.d Practices 



S p e c 1 f 1 c^_Qbj e i_cti_ves : 

1. Describe the variety of patterns of courtship in the country. 

2. Describe the variety of wedding ceremonies or marriage contracts. 

3. Discuss attitudes toward women, pregnancy, infertility and family 
planning. 

4. Describe the female and male parental roles in the nurture of 
children. 

5. Discuss dependence of older parents. 

6. Describe traditional and modern attitudes and practices relating 
to illness . 

Organization^ pjf Content , . ..._.._ 

A, Courtship 

1. Patterns 

a. Customs 

b . Taboos 

2. Criteria for mate selection 

3. Premarital pregnancy as proof of fertility 

4. Attitudes toward virginity 

5. Ceremonies 

6. Bride price or bride wealth 

a. Traditional articles and their significance 

. Cattle as an example 
. Modern substitutes 

b. Contract 

7. Differences by 

a. Country 

b . Region 

c. Rural-urban 

d. Tribe or clan 

e. Family 

B. Wedding Ceremonies or Marriage Contracts 

1. Influences 

a. Tribe or clan 

b. Custom 

c. Religion 



A Topical Outline 
Nursing and 



MODULE H: THE ADULT (AGE 21-44} 
page 



Cultural AttJ-'"te" and Practices 



' I - 

of Content - eont.y. 




C. 



e . 
. 
g. 
h. 



Expediency - time factor 

Family 

Legal aspects 

Urban/rural 

Economic status 



Kinds 

a. Religious ceremony 

b. Civil ceremony 

c. Tribal ceremony 

d. No ceremony - cohabitation 

e. Mutual agreement 

f. Polygamy 

Attitudes and practices related to marriage 
Double standard of sexual behavior 
Infertility 

Promiscuity or prostitution 
Venereal disease 
Abortion 

Determining family size 
Serious illness or death of marital partner 



a. 
b. 
c. 
d. 
e. 
f . 
S* 



Traditional vs Current Attitudes 
1, Toward women 



a. 

b. 



Position in family 
Subservience 



, Supremacy of 

. Control 

. Relationships to others 

Matrillneal vs. patrillneal 

. Kinds of power 

. Determinants of pattern 

Divorce 

Education 

Work outside home (for pay) 

Influences 

. Tribal 

, Custom 

. Religion 

. Government decree 



2. Toward pregnancy 

a. Expectations 

b. Fulfillment 

c. See Module D, Section I 



A Topical Outline ... MODULE H: THE ADULT (AGE 21-44) 

Nursing and Midwifery ~ age 



Section II: Cultural Attitudes and Practices 



Organization of^ Content - cont 



3. Toward Infertility 

a. Female usually blamed 

b. Consequences for female 
. Isolation 

. Desertion - divorce 

. No position In society 

. Implication of punishment for sins 

c. General Ignorance or reluctance to acknowledee malp 

d. See Module C, Sections IV and VI 

4. Toward family planning 

a. Desire and potential for large families 

b. Concept of fewer children not easily accepted 

c. Changes taking place 

. Most in urban areas 
Among educated adults 

d. See Module K, Section II 

D. Adult Roles in the Nurture of Children 

a . Female 

, Child bearing 
, Suckling 
. Feeding 

. Daily care and "mothering" 
Care in illness 

b . Male 

. Provider - food, housing, education 

"Fathering" - according to custom 
. Authority figure 
. Guidance In decision making - economic, educational 

c. Both 

Role models 
. Protectors 
. Imparting of values, standards and religious concepts 

Love and pride _ 

. Decisions regarding education and marital partners of 

children 
E. Dependence of Older Parents 

1. Expectations 

a. Parents 

b . Children 

c. Grandchildren 

2. Roles ~ see Module I, Section II 



A Topical Outline ... 
Nursing and Midwifery 



MODULE H: THE ADULT (AGE 21-44 
page 166 



Attitudes and Practices 




F. Illness 



1, Traditional beliefa and practices 

a. Aetiology 

b. Home or tribal remedies 

c. Roles of traditional healers 

2. Modern concepts of Illness 

a. Prevention 

b . Aetiology 

c. Treatment 

d. Care 

a. Use of medical facilities 
f 4 Role of health education 

3. Death 

a. Religious aspects 

b . Funeral or burial ceremonies 

c. Beliefs about causation 

. Evil eye 

, Punishment 

. Casting spells 



A Topical Outline ... MODULE tt: THE ADULT (AGE 27-44) 

Nursing and Midwifery page 



Section III; Needs of Adults 

Sjiecif ic Objectives : 

1. Describe the biological and psychological needs of the adult. 

2. Discuss the kinds of activities that promote social and peer 
relationships . 

3. Discuss the relationship of work and remuneration to family 
functioning. 

4. Describe the kinds of environmental essentials needed for health. 

Organization of^ Content , ,.._. ..._ 

A. Biological and psychological needs 

1. Nutritional 

a. Adequate in quantity and quality 

b. Variations in needs by male and female 

c. Variations in needs by occupation 

d. Special needs of pregnant and lac tat ing women 

2. Physical health 

a. Early detection of illness 

b. Prevention of accidenta and handicaps 

c. Appropriate immunizations 

d. Access to medical and dental care 

e. Assurance of care and counseling for a safe child bearing 
experience 

f. Education in relation to the prevention of degenerative diseases 

g. See Module J, Sections III, IV and V 

3. Psychological 

a. Means to handle stress 

b. Ability to cope 

c. Concepts of how to be a parent 

d. Positive feedback In relation to tasks 

e. Avoidance of drugs and alcohol (addiction) 

f. Access to counseling and support - health, social, religious 

B. Activities that promote social and peer relationships 

1. Occupation 

2. Community organizations to promote: 

a. Health 

b. Social action 

c. Education 

d. Agriculture 

e. Political movements 



MODULE H: THE ADULT (AGE 

Topical Outline ... e 168 

uraing and 



ion Hit Needs of Adults 



ization of Content - cont 



f. Religious functions 

g, Parent groups - discussion 

3. Supervision 
A. Family of clan gatherings 
C. Work and remuneration irt relation to family functioning 

1. Work 

a. Availability and continuity 

b v Kinds 

c. Suitability 

d. Satisfaction 

2 . Remuneration 

a. Appropriate and adequate 

b. Money or goods 

3. Support of family 

a. Responsibility 

b. Single source - husband 

c. Multiole sources - including wife and other family members 

4. Effect of unemployment 

a. Chronic 

b . Seasonal 

c, Planning needed 

5. Supplemental income 

a. Cash crops 

b. Two jobs 

D. Environmental essentials 

1 . Hous Ing 

. Safe 
. Adequate 
Protection 



2 . Water 



Safety 
Adequacy 



3. Waste disposal 

. Sanitary conditions 

. Prevention of contamination of soil 

, Protect food and water supply 



A Topical Outline ... MODULE H: THE ADULT (AGE: 21-4 

Nursing cmd Midwifery page 169 



Section III: Needs of Adults 
Organization of Content - cont, 



4. Food supplies 

Home gardens 
. Markets 

Protection from spoilage and pests 

5. Clothing 

Protection 
Status symbol 



jpiaal Outline 
ling and Midwifery 



MODULE H: Tffi ADUltf (AGE 21-44) 
page 170 




Specific Objectives: 

! List the a 3 or illnesses and accidents that affect this age group 

2 ' Discuss the problems co^only related to marital disruption 

3 Discuss the proble frequently encountered in the care of children 



Or a an izat lonofContent 




Illnesaes and accidents 

1. See Module J, Sections III. IV and V 

2. Other dleeaae or conditions of local prevalence 

3. General health status of this age group in local co^unity 
Problems related to marital disruption 

1. Interpersonal relationships 

2 . Family interference 

3. Financial and inadequate support 

4. Mixed tribal or religloua background 

5 . Chronic illness 

6. Infertility 

7. Contention among wives in polygamous marriages 

8. Prostitution 

9. Venereal disease 

10. Alcoholism or drug addiction 

11. Sexual incompatibility 

12. Anti-social behavior and mental illness 

13 . Separation or desertion 

14. Death of one partner 



A Topical Outline ... MODULE H: THE ADULT (AGE 21-44) 

Cursing and Midwifery page 



Section IV: Problems Encountered by Adults 



Organization of Content - cont. 



C. Problems encountered in the care of children 

1. Inadequate food supplies 

2. Inability to breast feed 

3. Acute and chronic Illness of child 

A. Handicapped child 

Physical 
. Mentally retarded 

5. Failure of child to thrive and dpvelon 

6. Learning disabilities 

7. Hyperactivity or lethargy 

8. Naming customs 

9. Non-conforming behavior 

10. Dependence vs. independence 

11. Educational opportunities 

12. Available medical care 

. Accessibility 
. Cost 
. Quality 

13. Economic aspects of child-rearing 

14. Teaching basic values, customs, heritage 

15. Handling emotional problems 

16. Decisions regarding selection of marital partner 

. Traditional vs. modern 
. Bride wealth 



MODULE H: THE ADULT (AGE 22-44) 
page 272 



Specific Objectives: 




2. 
3. 

4. 



Define the basic elements to be considered in assessing the health 

of an individual adult. 

Describe the kinds of nursing care and counseling commonly needed 

by the female adult. 

Describe the kinds of nuraing care and counseling commonly 

needed by the male adult. 

Itemize points of ^phasis in a planned health education program 

for adults of this age group 



5. Plan and conduct a aeries of at least three health education classes 

for adults 

6. Describe nursing and midwifery roles in relation to service and 
education of this group. 



OrEanlzationofContent 




A. Asaesaing health of individual adults 

1. Observation 

2, Chief complaint (if any) 

a. Symptoms 

b. Duration ujm- 

c. Severity of symptoms, pain or disability 

d. Remedies already tried 

3. History 

a. Individual 

b . Family 



Screening techniques within nursing competence and appropriateness 



Temperature taking 

Blood pressure 

Assessment of nutritional status 

External palpation 

Inapection of bleeding sites, if 

Estimate o emotional status 

Estimate of coping ability 

Laboratory tests as authorized 

Other diagnostic measures as appropriate 



any 



5. 



a. 
b. 

c. 

d. 
e . 
f, 
g- 

h, 

i, 

Screening techniques within midwifery competence and 
appropriateness 

a. Stages of pregnancy, delivery, puerperium 

b, See Module D, Sections II, V, VII and IX 



A Topical Outline ... MODULE H: THE ADULT (AGE 21-4* 

Hursing and Midwifery P a Q e 173 



Section V: Nursing Intervention 
Organization of Content - cont. . 



6. Decisions 

a. Needed care within realm of nursing or midwifery 

b. First aid 

c. Consultation needed 

d. Direct referral to medical resources 

B. Nursing care of female adult 

1. Prevention 

a. Early case-finding 

b. Promotion of good nutrition 

c. Immunization as indicated 

d. Health education 

2. Care of the acute and chronically ill 

a. Nursing as appropriate for illness 

b. In hospital or home 

c. Prevention of complications 

d. Teaching others 
Emotional support 



e . 



3. Care of the pregnant woman 

a. Pregnancy 

b. Labor 

c. Delivery 

d. Post-partum 

e. See Module D, Section III 

A. Counseling needs 

a. Listening 

b. Teaching problem-solving techniques 

c. Support and reassurance 

d. Understanding 

e. Referral, if indicated 

5. Follow-up as indicated 
C. Nursing care of male adult 

1. Prevention 

a. Same as B-l above 

b. Protection from on-the-job injuries 

2. Care of the acute and chronically ill 

Si LTaMU^n STccident case, and those .1th long-tar lllne, 



>piaal Outline 
jing and 



MODULE 8: 
page 174 



THE ADULT (AGE 22-44) 



Section V! Nursing Intervention 



n rfff . n -ifiMnn nf Content - cont. 




3. Teaching family members 

a. "Nursing" care 

b. Nutrition 

4. Counseling needs 
a. Same as in B-4 

5. Follow-up as indicated 

D. Planned health education program 

1. Procedures 

a. Determine needs and interest 

b. Select site 

c. Leadership from group if possible 

d. Determine methods and techniques 

e. Plan orientation session 

f. Plan series of sessions 

g. Invite participation 

h. Build in evaluation methods 

2. Probable topics for presentation and discussion 



a. 
b. 
c. 

d. 
e. 

f , 

8- 

h. 
i. 

J. 

k. 

1. 

m, 

n . 

o. 
P- 

q- 

r. 

s , 
t. 
u, 



Health and nutrition 

Health and the environment 

Health and early case-finding 

Preventive measures - Immunisation 

Contagious diseases 

Dental care 

Handicapped children 

Accident prevention 

Child rearing 

Normal growth and development 

Behavior problems 

Concept of "parenting" 

Parents as role models 

Parents as teachers - hygiene, nutrition, sex education, family 

values and traditions, etc. 

Problems of adolescents 

Premarital and marital counseling 

Childbirth 

Fetal growth 

Care of newborn 

Breastfeeding 

Family planning 



A Topical Outline ... MODV18 H: THE ADULT (AGE 22-44 

Nursing and Midwifery page 175 



Section V: Nursing Intervention 

Organization of Content - cont . . . . 

E. Nursing and midwifery roles 

1. Place of work 

a. Hospital 

b. Clinics 

c. Health centers 

d. Community 

2 . Tasks 

a. By need 

b. By competence 

c. By appropriateness 

d. By policy 

3. Concept of combining service and education 

a. Rich potential in this age group 

b. Opportunities 

c. Values 

4. Dependent and independent activities 

a. Relationships and communications 

b. Coordination 

c. Management 

d. Supervision of auxiliaries 



A Topical Outline 
Nursing and - 



MODULE H: ADULTHOOD 
Bibliography 



BIBLIOGRAPHY 



T SELF-INSraUCTIONALUNITS 

available from the Atrican Health Training Institutions Project 



Factors Afgactinfe thg Patient's Health 
AMAL F. GARAS (Egypt) 

Pelvic Examination 

YOUSSEF HELMI MOURAD (Egypt) 



Nutritional Anaemia 

EMILY 0. DUKE (Nigeria) 

Education to Mothers About Basic Nutritional Food Values 
LILIAS N. MURIITHI (Kenya) 

Vitanina 

BORIS CHARWAY (Ghana) 

Nephritis 

ALHAJI KASIMU ALIYU (Nigeria) 

Proteins 

CHRISTINA NARTEY (Ghana) 

Fnnd Custom and Taboos in Region to the Family Health in a Co^unlt] 
SARA W. KAVITI (Kenya) 

Nutrition Education and Counselling 
KADRIA M. MOUSTAFA (Egypt) 

Causes, Treatment and Prevention of Malaria 
BENSON B, MANGERA (Kenya) 

Sickle Cell Disease 

PETER OLASUNKANMI AJAYI (Nigeria) 

Sygptoms, Treataent and Prevention of Hookworm Infestation 
M.R. OLAN (Nigeria) 

Nursing Management of Viral Hepatitis 
LAYLA I. KAMEL (Egypt) 

Pulmonary Tuberculosis in Adults 
ISAAC M. DOWARA (Egypt) 

Malaria! Diagnosis and Treatment 
F.O. AFONJA (Nigeria) 



A Topical Outline ... MODULE H: ADULTHOOD 

Nursing and Midwifery Bibliography 17? 



Malaria: Methods of Control 

ABIGAIL IYABODE AWOTESU (Nigeria) 

Management and Control of Urinary Schietosomiasis 
GILFORD A. ASHITEY (Ghana) 

Food Polnsoning 

B.M. ODUYOYE (Nigeria) 

Onchocerciasis 

OLAYINKA DICKSON (Ghana) 



A Topical Outline . . . * : 

Uursing and Midrtfiry Bibliography 178 



II. BOOKS 

ANTHONY, E. J. and TH. BENDER 

Parenthood. Boston: Little, Brown and Co., 1970. 
BEACHAM, D.H. and W.D. BEACHAM 

Synopsis of Gvnecology. 8th edition. St. Louis: C.V. Mosley Co., 
1972. 

BETAND, I.L. and J.Y. PASSOS 

Clinical Nursing: Pathophvsiological and Psychosocial Approaches... 
3rd edition. New York: MacMillan Co., 1975. 

HOOLE, A.J., R.A. GREENBERG and C.G. PICKARD (Eds.) 

Patient Care Guidelines for Family Nurse Practitioners. 
Boston: Little, Brown and Co., 1976. 

HUDAK, C.M., P.M. REDSTONE, N.L. HOKANSON and J.E. SUZAKI 

Clinical Protocols - A Guide for Nurses and Physicians. 
New York: J.B. Llppincott Co., 1976. 

LINTON, R. 

The Cultural Background of Personality.,. New York: Prentice Hall, 
1961. 

SEWARD, G. and R. C. WILLIAMSON 

Sex Roles in Changing Society. New York: Random House, 1970. 
SMITH, D.E. and C.P.H. GERMAIN 

Care of the Adult Patient. Philadelphia: J.P. Lippincott Co., 1975, 



A Topical Outline ... MODULE I: OLD AGE 

and Midwifery page 179 



MODULE I : 

OLD AGE 
(45 y s a y a and over) 



I. RATIONALE 

Life expectancy at birth has undergone a radical change upward 
in the past 25 years. This change first became noticeable in the highly 
industrialized countries, where the developments in medical science 
provided immunizations and many other aspects of preventive health care. 
Now the effect of these achievements are also becoming evident in many 
of the developing countries. In particular these preventive aspects have 
enabled more children to survive the first five years of life, there is 
better nutrition, there are better medical services - especially 
obstetric and paediatrlc - and more people have been educated to seek 
these services. 

In general, in African society, elderly people are accorded deep 
respect for their wisdom and their longevity. 

In 1976 in Africa, the average life expectancy at birth was 45, 
with a range of 38 to 66 in the various countries. This does not mean 
that there are no people who live beyond these stated years. It means 
there are few. In all probability life expectancy at age 5 or even at 
age 20 would give a clearer picture of the potential for those who survive 
the hazards of birth, and early and late childhood. These figures are 
difficult to obtain but in some parts of Africa statistics may be avail- 
able from which more practical data can be extracted. 



. t n. *T : OLD AGS 

A Topical Outline ... w 

fluraing and Midwifery ___ 

Physicians and nurses have an excellent base on which to build 
their knowledge and skills of how to handle the health problems of 
the older groups of people. In the next two decades, the probability 
of excessive numbers of very elderly people is quite remote. In all 
probability the early aged (45 - 55 years) will constitute the bulk of 
the older population. For this reason, health resources can concentrate 
on preventive and educational aspects of care. It is important, there- 
fore, for nursing to recognize that it has a major responsibility for the 
promotion of health in older people 



A Topical Outline ... MODULE I: OLD AGE 

Nursing and Midwifery P a 9 e 



II. OVERALL OBJECTIVES 

At the completion of this module, students should be able to: 

1. State the average life expectancy for Africa and for their 
own country. 

2. Describe the reasons for changes in the past 25 years. 

3. Describe traditional attitudes toward older people in most 
African societies. 

4. Describe the aging process and the physical and psychological 

changes of aging. 

5. Describe the needs and problems of the older age groups - 
including common diseases. 

6. Define the nursing roles in preventive, curative and long- 
term care of the older person. 



A Topical Outline ... mULE I: OLD AGE 
Nursing and Midwifery P a $ e 182 



Section I: Life Expectancy. 



Specific Ob1ectives_:_ 

1. State the average life expectancy at birth for the continent of Africa 

2. Compare data from students' own country with that of Africa in general 
and neighbouring countries. 

3. Describe some of the specific reasons why life expectancy has increased 
throughout the world and in Africa. 

Organization of Content ___.__, '_...,.-.. 

A. The terminology "life expectancy at birth". 

1. Meaning 

2. Significance as a measurement 

B. Presentation of available data 

1. World 

2. Africa 

3. Country of residence 
A. Neighbouring countries 

C. Reasons for increase In life expectancy during past 25 years 

1. Medical science 

a. Preventive measures 

b. Immunization 

c. New knowledge of disease 

d. Improved diagnostic tools 

e. Research 

2. Health services 

a. More hospitals, health centers, dispensaries 

b. Preventive programs 

c. More health personnel 

d. Better education of health personnel 

e. Improvement most evident in maternal and child health services 

3. Nutrition 

a. Improved agriculture 

. Planting 

. Fertilizers 

b. Knowledge of food values 



A Topical Outline ... MODULE I: OLD AGE 

Nursing and Midwifery page 183 



Section I: Life Expectancy _ 

Organization of Content - cont ....... , 

3. c. Supplemental food programs 

. Individuals 
. Families 
. Communities 

d. Distribution of food 

4. Education 

a. Less illiteracy (selected countries) 

b. Improved communication 

c. Health teaching 

. Schools 

. Health Centers 

5. Transportation 

a. Roads 

b. Vehicles 

c. Public vs. private 

d. Increased availability of health resources 



4 Topical Outline 
Nursing and 



MODULE I: OLD AGE 



Traditional Attitudes 



Specific Objectives; 




page 



284 



Describe traditional attitudes of most African societies toward 
older persona. 

2. Describe roles assigned to them. 

3. Discuas potential changes in attitude and role in present-day 
society. 

4. Describe the local beliefs and practices surrounding the death of 
a family member". 




A. Traditional attitudes toward aged 

1. Respect for 

a. Survival 

b. Experiences 

c. Wisdom 

2. Authority 

a. Earned place in family* community 

b. Equating of longevity and wiadom 

3. Pride and affection 

a. Achievement of family members 

b. Love and warmth of family relations 

4. Tolerance 

a. Accepting of limitations 

b. Deserving of help and support 

B. Roles assigned to older persons 

1. Males 

a. Decision makers 

b. Traditional judges In village and tribal politics 

c. Guardians of family practices, taboos, folklore 

d. Ceremonial and religious leaders 

e. Advisers of the young 

f . Continued but reduced work load 

2. Females 

a. Educators of the young in relation to marriage and 
family responsibility 

b. "Wise mother" role in relation to family, pregnancy, child- 
birth and child rearing 

c. Participation, supervision and direction of household taaka 



A Topical Outline ... MODULE I: OLD AGE 

Nursing and Midwifery 



Section II: Traditional Attitudes 



Organization of Content - cpnt 



2. d. Protector of young children. 

. Love 

. Approval 

. Discipline 

e. Continued but reduced workload 
C. Potential change 

1. Increase in number of older persons 

2. Increase in reverse dependency 

3. Trends toward urbanization 

a. Quickening pace 

b. More nuclear families 

c. Less living space 

d. Cost of living 

4. Modern concept of prolonged education postpones marriage and 
beginning of family life 

5. Roles of older person become ill-defined 

6. In all of above changes, the older person may become a burden 
D. Concepts of death 

1. Influenced by 

a. Tradition 

b. Religion 

c. Blending of old and new beliefs 

d. Fatalism 

2. Meaning of death 

a. Belief In after life 

b. Continuation of the "soul" with descendents 

c. Practical aspects of division of property 

d. Passing on of authority 

3. Family practices 

a. Ceremonies 

b. Role of family members 

c. Burial vs. cremation 

4. Role of mourning and other ceremonies 

a. Acceptance 

b. Release 

c. Acknowledgement of reality 

d. Grieving 

e. Paying respect to deceased and family 



A Topical Outline . . . 
and Midwifery 



MODULE I: OLD AGE 
page 186 



and Psychological Changes of Agin 





1 Describe the aging process and factors that influence it. 

2. Describe the physical changes which normally occur in the older person. 

3. Describe the psychological changes. 

Organization of Content 

A. The process and its continuity 

1. Process has no sharp beginning, but is gradual 

2. Individual differences 

3. Male/female differences 

/4. Maturation 

5. The rate of change and/or deterioration may be uneven in same 
individual 

a. Physical may precede mental 

b. Mental may precede physical 

6. Theories of aging 

7. Influences 

a. General health 

b. Nutritional status 

c. Severe chronic illness 

d. Ambulation , , AT.T \ 

e. Ability to care for self (Activities of daily living - ADL) 

f. Attitudes 

. Self 

. Family 
. Society 

g. Stimulation 

h. Love and belonging 

B. Physical changes (by system) 

1. Cardio-vascular 

2. Respiratory (including nose, and throat) 

3. Sensory changes 

a. Auditory 

b. Sight 



4, Dental (including periodontal) 



A Topical Outline . . . MODULE I: OLD AGE 

Nursing and Midwifery P a 9 e 



Section III: Physical and PavcholoRical Changes of Aging 
Organization of Content - cont... 

B. 5. Muscular-skeletal 

6. Gastro-intestlnal 

7. Genlto-urinary 

8. Reproductive 

9. Endocrine 

10. Nervous 

11. Skin 

G. Psychological changes 

1. Feelings about change 

a. Environmental 

b. Social 

2. Gradual disengagement 

a. Retirement 

b. Diminished physical and mental abilities 

3. Less confidence in self 

a. Feelings of uselessness 

b. Memory loss 

c. Body image 

d. Sexuality 

4. Desire to maintain dignity and respect of self 

5. Relationships with family and society 

a. May be more critical 

b. May be more tolerant 



. t . *7 - MODULE I: OLD AGE 

A Topical Outline ... 

Nursing and Midwifery * tf 



Section IV: Needs and Problems _ , 

Specific Objectives: 

1. Relate some of the general health and social needs of older people. 

2. Describe the degenerative diseases of the aged and their complications, 

3. Describe the neoplastic diseases and their complications. 

4. Describe the most commonly occurring accidents in this age group. 

5. Describe the physical and psychological aspects of the menopause. 

6. Describe the, more prominent paychiatric disorders of the aged. 



A. Needs of older people 

1. Nutritional 

a. Balanced diet 

b. Reduced caloric intake 

2. Medical and/or nursing supervision 

a. Early detection of abnormalities 

b Prevention of handicapping conditions 

c. For severe illness - remedial, supportive or long-term care 

d. For non-disabled - health education and emotional support 

3. Socio-economic 

a. Independence (financial and social) 

b. Dependence without stigma 

c. Defined role in family /community 

d. Adequate housing 

e. Means of obtaining medical or health care 

. Money 

, Transportation 
. Availability 

4. Mental- intellectual 

a. Stimulation 

b. Participation in decisions 

. Self 

. Family 
. Community 

c. Companionship and communication 

. Peers 
. Children 

, Grandchildren 

d. Responsibility 



A Topical Outline ... WWLE I: OLD AGE 

Nursing and Midwifery P a 9# 



Section IV: Needs and Problems ___ 

Organization of Content - cont,.. __ 

B. Degenerative diseases - symptoms, diagnosis, treatment, prognosis, and 
complications (see Module J, Sections III, IV and V) 

1. Arteriosclerosis 

2. Osteoarthritls 

3. Hypertension 

4. Cardlo-vascular disease 

5. Renal disease 

6. Diabetes mellltus - late outset 

7. Syphilis - tertiary 

8. Gonorrhea - late 

9. Prostatic disease 

10. Skin problems 

11. Hearing loss 

12. Diminished sight or blindness 

C. Neoplastic diseases - symptoms, diagnosis, treatment , prognosis, 
and complications 

1. Chronic leukemia 

2. Primary hepatoma 

3. Carcinoma of stomach 

4. Carcinoma of bladder 

5. Carcinoma of large intestine 

6. Carcinoma of cervix 

7. Carcinoma of endometrlum 

8. Carcinoma of breast 

9. Carcinoma of skin (cysts, moles) 



A Topical Outline ... 
and Midwifery 



MODULE I: OLD AGE 
page 



Section IV: Needs and Problems 



of Content - cont... 




D. Common accidents - aetiology, diagnosis, treatment, prognosis, and 
complications 

1. Burns 

2. Falls - frar.tures 

3. Traffic (automobile) 

E. Menopause - age, symptoms, treatment and complications 

1. Stages of menopause 

a. Loss of fertility 

b. Irregular or absent menses 

c. Circulatory instability 

d. Anatomical atrophy 

2. Loss of estrogen may cause physical signs 

a. Hot flashes 

b. Arthritis - osteo 

c. Artherioscleroflis 

d. Vaginal dryness 

3. Psychological aspects 

a. Irritability - agitation 

b. Damage to self-image 

c. Depression 

d. Change in sexual desire 

7. Psychiatric disorder*! - symptoms, diagnosis, treatment, prognosis and 
complications 

1. Psychoses 

a. Functional disordera 

b. Organic disorders 

2. Depression 

a. Mild 

b. Severe - leading to suicide 

3. Chronic anxiety 

4. Senile dementia 

a. Memory loss 

b. Disorientation 



5. Reversible brain syndrome 



A Topical Outline . . . MODULE I: OLD AGE 

Nursing and Midwifery page 191 



Section IV: Needs and Problems 
Organization of Content - cont 

F. 6. Alcoholism - chronic 
7. Drug addiction 



A Topical Outline 
Nursing and 




MODULE I: OLD AGE 
page 192 



Section V: Role of Nursing in Preventive, Curative and Long-term Care 



of the Older Person 




Specific Objectives ! 

1 Describe the special components and techniques of taking a 
* medical/aocial history from an older person. 

2. Discuss physical and health education aspects of nursing 
Intervention In preventive care. 

3. Describe the physical, psychological, rehabilitation , and 
follow-up needs for curative care. 

4. Describe long-term care and the nursing role. 

5. Demonstrate simple nursing care of a chronically 111 patient 
to the caretaker in the home. 



if Content 



A. History and observation 

1. Basically Includes elements of history-taking in any age group 

2. Seek out "chief complaints" 

a. Direct and Indirect questioning 

b. Observation 

3. Question in detail responses of pain, discomfort, bleeding, 
disfunction and anxiety 

a. Length of time symptoms present 

b. Degree of severity 

c. Patient's reaction 

4. Question especially 

a. Nutrition and food preparation 

b. Current abilities 

c. Patient's problems 

d. Identity of closest family members (person responsible) 

e. Housing 

5. Techniques 

a. Use person's language or use an Interpreter 

b. Consider cultural influences 

c. Approach - warm, unhurried 

d. Emphasis - desire to help 

e. May need to get Information from others 

f . Exercise patience when data is not coherent 

g. Gently probe for accuracy 

B. Preventive care 

1. Physical 

a. Early case-finding 

b. Evaluation of assets and handicaps 



A Topical Outline ... MODULE I: OLD AGE 

Nursing and Midwifery P&d e 



Section V: Role of Nursing In Preventive, Curative and Long-term Care of 

the Older Person ^ 

Organization of Content - cont... .__.. 

1. c. Rehabilitation 
d. Good nutrition 

2. Health education 

a. Group discussions 

. Peers 
. Family 

b. Individual Counseling 

c. Content 

. Nutrition 

. Food preparation 

. Accident prevention 

. Early reporting of symptoms 

, Alcohol consumption 

. Drugs - use and precautions 

. Importance of physical and mental activity 

C, Curative Care 

1. Physical needs 

a. Early diagnosis 

b. Referral to available resources 

c. Actual nursing care 

. Appropriate for illness or injury 
. Need to teach others 

d. Medications 

e. Special diagnostic procedures and treatment 

2. Psychological needs 

a. Ease of pain and discomfort 

b. Understanding of condition 

c. Re-assurance 

d. Family Involvement 

3. Follow-up 

a. When 

b. Where 

c. By whom 

d. Why 

D. Long-term care 

1. Location 

a. Majority in home 

b. May need occasional hospitalization for acute medical condition 



A Topical Outline 
Nursing and 



MODULE I: OLD AGE 
page 194 



Section V: Role of Nursing In Preventive. Uirative and Long-terta Care 



of the Older Person 



of Content - cont... 




D. 2. Care-takers 

a. Usually family member 

b. occasionally neighbours 

3. Identifying patient's needs 

a. Ambulation or bed-faat 

b. Food and fluid 

c. Skin care 

d. Urination and defecation 

e. Medications 

. Analgesics 

. Sedatives 

. Cardiac drugs 

. Diuretics 

. Antibiotics 

. Anti-hypertensive drugs 

. Chemotherapeutic drugs 

. Laxatives 

f. Activities (as appropriate) 

g. Companionship 
h. Family 

1. Religious aspects 
j . Financial aspects 

4. Nursing intervention 

a. Teaching and demonstration of physical care to patient 
and family 

. Hone visits 
. Group meetings 
. Health centers 

b. Education (of othera) 

. Process of aging 

. Heeds of aged 

. Understanding of assets and limitations 

. Simple nursing care 

c. Referral to social or other community services 

d. Communication and interpretation 

. Patient 

. Family 

. Medical resources 

e. Comfort and support at time of death 

, Patient 
, Family 



A Topical Outline . . . MODULE I: OLD AGE 

Nursing and Midwifery Bibliography 195 



BIBLIOGRAPHY 



I. SELF- INSTRUCTIONAL UNITS 

available from the African Health Training Institutions Project 



Factors Affecting the Patient's Health 
AMAL F. GARAS (Egypt;) 

Nutrition Education and Counselling 
KADRIA M. MOUSTAFA (Egypt) 

Nursing Care Plans 

WINIFRED MODUPE OGUNDEYIN (Nigeria) 



. 7 , - . MODULE I: OLD AffS 

A Topical fotUne . ,. Bibliography 

and a r 



II. BOOKS 



ANDERSON, J.E. (Ed.) 

Psychological Aspects of Aging. Washington, D.C.: American 
Psychological Association, 1955. 

BURNSIDE, J.M. 

Nursing and the Aged. New York: McGraw-Hill, 1976. 
CAIRD, F.I. and T.G. JUDGE 

Assessment of the Elderly Patient. (Thirs impression) . London: 
Pitman Medical Publishing Co., 1977. (Also: Sir Isaac Pitman and 
Sons, Nairobi, Kenya) 

HIRSCHBERG, G.E., L. LEWIS and P. VAUGHAN 

Rehabilitation: A Manual for the Care of the Disabled and Elderly.. 
2nd edition. Philadelphia: J.B. Lippincott, 1976. 

HOOLE, A.J., R.A. GREENBERG and C.G. PICKARD (eds.) 

Patient Care Guidelines for Family Nurse Practitioners. 
Boston: Little, Brown and Co., 1976. 

HUDAK, C.M., P.M. REDSTONE, N.J. HOKANSON and I.E. SUZAKI 

Clinical Protocols - A Guide for Nurses and Physicians. 
Philadelphia: J.B. Lippincott, 1976 

PFEIFFER, E. (ed.) 

Successful Aging. Durham, N.C. : The Center for the Study of Aging 
and Human Development, 1974. 

SCHWARTZ, D., B. HENLEY, L. ZEITZ 

The Elderly Ambulatory Patient. Hew York: MacMillan Co., 1964. 
SIMPSON, I.H, and J.C. McKINNEY (eds.) 

Social Aspects of Aging. Durham, N,C.: Duke University Press, 1966. 



A Topical Outline ... MODULE J: COMMON DISEASES AND ACCIDENTS 

Nursing and Midwifery page 19? 



MODULE J : 

'COMMON DISEASES AND ACCIDENTS 
AFFECTING FAMILY HEALTH 

I. RATIONALE 

As Che family life cycle turna through normal events and processes 
from conception to old age, its course is shaped by the numerous stresses 
and strains of disease and injury. It is impossible to, predict when dis- 
ease or accident will occur in a given family. These events have been 
grouped together in this module, the unifying theme being their impact 
on the family unit. That impact may be economic, nutritional or social. 
Whether a disease or accident occurs principally during childhood or 
adulthood, it will be discussed here. 

First of all, certain concepts and definitions will be discussed: 
definitions of family and of family health will be reviewed; then a concept 
of how the impact of disease or injury on the family can be measured will 
be developed. The conceptual framework will also include the Influence of 

environmental factors. 

In the second section, specific diseases and accidents will be outlined. 
Every African ethnic group possesses a system of beliefs and practices by 
which it attempts to explain the aetiology of diseases and how to cope with 
them. Many of the conditions to be discussed below are known to traditional 
healers. These cultural attitudes will be discussed first of all. 

The range of perspectives needed by nursing and midwifery personnel 
will be brought to bear on each condition: 

1. Aetiology 

2. Epidemiology - Including social and economic impact 

3. Pathogenesis 

4. Diagnosis 

5. Treatment, including nursing care and follow-up 

6. Complications 

7. Prevention 



A Topical Outline . . . ^DVLE J; COMMON DISEASES AND 

Nursing and Midwifery 



In all some thirty to thirty-five conditions will be covered. The Indi- 
vidual instructor, however, should feel free to add or delete conditions 
according to his or her local circumstances. They are grouped into 
four sections. 

1. Those whose impact on family health is largely through the children. 

2. Those which affect family health mainly through women. 

3. Those concentrated in. adult males. 

4. Those which affect family members irrespective of sex or age. 

With this approach nurses and midwives should be equipped to consider 
each illness or injury encountered not only in the technical sense of diag- 
nosis and treatment, but in terms of the impact of the condition on family 
equilibrium and the influence of family factors on the cauae of the dlseaae, 
Then they should be able to anticipate these effects in practice 
and other effective and appropriate counseling, referral, and follow-up 

services. 



A Topical Outline ... MODULE J: COMMON DISEASES AND ACCIDENTS 

and Miefoifery page 199 



II. OVERALL OBJECTIVES 

At the completion of this module students should be able to: 

1. Define the family and a concept of family health. 

2. Describe the various ways in which illness or injury effect 
family health. 

3. Describe the influence of environmental factors on disease or 

injury. 

4. Describe the aetiology, epidemiology, pathogenesis and compli- 
cations of the major conditions affecting family health. 

5. Participate in a diagnosis and treatment plan for selected 
conditions . 

6. Develop a nursing care plan and carry out the nursing care and 
follow-up for selected conditions. 

7. Implement preventive measures for selected conditions as 
appropriate. 



A Topieal Outline . , . MOVUI& J: COMMON DISEASES AND ACCIDENTS 
Nursing and MiMfery P*ge 200 



Section I- Concepts and Definitions ___ 

Specific Objectives: 

1. Define the various types of family structure and organisation. 

2. Define a working concept for family health. 

3. Describe the economic Impact of illness or injury on the family. 

4. Discuss the. impact of illnea.8 on the nutrition of a family. 

5. Discuss the social Impact of illness on family health. 

6. Discuss the Influence of environmental conditions on the impact 
of illness on family health. 

Organization "of Content 

A. Family structure and organization (review - see Module B) 

1. Types 

a* Nuclear or extended 

b. Monogamy or polygamy 

c. Single parents families 

d. Matrlllneal or patrlllneal 

e. Patrilocal or matrllocal 

2. Roles of the family 

a. Support 

. Physical - material 
, Psychological 
, Spiritual 

b. Socialisation of members 

c. Reproduction - implications for continuity 

B. Family health - elements of a concept 

1. Equilibrium 

a. Biologic 

b. Social 

c. Economic 

2. Factors affecting 

a. Environment 

. Climatic e.g. drought, flood 

. Biologic e.g. waste disposal, water, disease vectors 
. Socio-economic e.g. migration, unemployment, urbanization, 
divorce 

b. Size: number of children and adults 

c. Educational level of family members 

d. Accessibility and quality of medical care and other health services 



A Topical Outline .. . MODULE J; COMMON DISEASES AND ACCIDENTS 

Nursing and Midwifery page 201 



Section I: Concepts and Definitions 
Organization of Content - cont . . . 



C. Economic impact of disease or injury on family health 

1. Drain on family financial resources 

a. Medical and dental care costs 

b. Hospital costs 

c. Costs of drugs and appliances 

d. Transportation costs 

2. Reduced income 

a. Disability of income earner 

b. Death of income earner 

D. Nutritional impact 

1. Reduced food supply 

a. Disability or death of food producer 

b. Disability or death of food purchaser 

2. Food preparation 

a. Effect of disorganization within family unit 

b. Illness of the food preparer (usually the mother) 

E, Social impact 

1. Emotional support 

a. Short-term loss due to family disruption caused by acute 
illness 

b. Long-term loss due to chronic disease or debilitating Injury 
of key family members 

2. Security 

a. Chronic illness or death of children 

b. Parental anxiety - current and future 

c. Concerns 

. Family continuity 

. Support by children of parents In old age 

. Prestige 

. Prosperity 

F, Environmental factors 

1. Climatic Influences 

a. Relation of drought to protein calorie malnutrition (PCM) 

b. Relation of flood conditions to malaria 



A Topical Outline 
Nursing and 



MODULE J: COMMON DISEASES AND ACCIDENTS 
page 202 



T ; mncets and Definitions 




F. 2. Migration and urbanization 

a Relation to the social system of the community and family 
b. Effect of disruption of family system by occupational in- 
juries, chronic illnesses 

3. Physical and biological factors such as housing, water supply, 
waste disposal, vector infestation, e.g. 

a Effect of overcrowding on tuberculosis 
b. Relation of inadequate waste disposal on the impact ol 
btlharziasis 



Topical Outline . . . MODULE J; COMMON DISEASES AND ACCIDENTS 

and Midwifery page 203 



Section II: Diseases and Accidents of Childhood 



Specific Objectives: 

1. Name the major infections, inherited diseases and accidents of 
childhood having an impact on family health. 

2. Discuss the aetiology, epidemiology, pathogenesis and complications 
of each one. 

3. Participate in the assessment of selected cases as available. 

4. Describe and implement preventive measures aimed at each condition. 



Organization of Content, 



A. Catalogue of childhood conditions 
1. Infections 



. Diarrhea and dysentery e.g. salmonella 

. Acute respiratory infections e.g. staphlococcus and streptococcus 



. Pharyngitis 
. Otitis 
. Pneunomia 

c. Measles 

d. Pernicious "cerebral" malaria 

e. Pertussis 

. Hook worm infection 

g. Round worm infection 

h. Typhoid fever 

i. Tuberculosis 

J. Leprosy 

k. Meningitis and encephalitis 

1. Urinary tract infection 

m. Trachoma and other eye infections 

n. Smallpox 

o. Chicken pox 

p. Impetigo and pyoderma 

q. Poliomyelitis 

r. Rheumatic fever 

s. Glomerulonephritis 

2. Haematologic Disorders 

a. Haemolytic anaemia 

b. Leukemia 

c. Lymph oma 

3. Inherited disease 

a. Sickle cell anaemia 

b. Glucose-6-phosphate dehydrogenaae deficiency 

4. Perlnatally related diseases 

a. Cerebral palsy 

b. Congenital infections, e.g. syphilis 



A Topical OutHne 
Nursing and 



MODULE J: 
page 204 



COMMON DISEASES AND ACCIDENTS 



""" <* Accidents of Childhood 



of Content - cont . . 




4. c. Birth injuries 

d. Growth retardation 

5. Mental illness 



a. Childhood 

b. Emotional instability 

6. Handicapping conditions 

a. Sense organs 

. Blindness 

. Deafness 

b. Gait and physical disfunction 

c. Mental deficiencies 

d. Learning disabilities 

7. Congenital abnormalities 

a. Spina blfida 

b. Heart abnormalities 

c. Other 

8. Nutritional problems 



a. Growth failure 

b. Protein calorie malnutrition - kwashiorkor 

c. Protein calorie malnutrition - marasmlc type 

d. Dehydration 

e. Iron deficiency anaemia 



9. Accidents 

a. Bums 

b. Eye injuries 

c. Head injuries 

d. Falls from heights 

m accidents 



ractices related to selected 



A Topical Outline . . . MODULE J: COMMON DISEASES AND ACCIDENTS 
Nursing and Midwifery page 205 



Section II: Diseases and Accidents of Childhood _ 

QrRanization of Content - corit... ... , 

C. Aetiology of each of the above 

1. Primary cause where possible 

2. Contributing factors, principally environmental (see Section I,F.) 

D. Epidemiology (selected conditions) 

1. Mode of transmission 

2. Natural history of the condition 

3. Associated nutritional, economic and social effects of the 
condition on family health 

E. Pathogenesis of selected conditions, i.e. how symptoms are produced 

F. Complications for the child and/or the family 

1. Physical/nutritional 

2. Psychological or social 

3. Economic 

G. Diagnosis of selected conditions 

1. Case-finding methodology 

2. History 

3. Physical signs 

A. Laboratory and X-ray signs 

5. Elements of the definitive diagnosis where possible 
H. Preventive measures, e.g. 

1. Primary: immunisation for measles 

2. Secondary: tuberculin testing 

3. Tertiary: prompt treatment of severe fractures 



A Topical Outline 
Nursing and 



MODULE J: COMMON DISEASES AND ACCIDENTS 
page 206 



Specific Objectives; 

1. Name the diseases which have their impact on family health largely 
through their occurrence in women. 

2. Discuss the aetiology, epidemiology, pathogenesis and complications 
of each one. 

3. Participate in the assessment of a case of each one. 

4. Describe and implement preventive measures aimed at each condition. 



itent 



cont 



A. Catalogue of diseases occurring chiefly in women 

1. Infections 

a. Pelvic inflammatory diseases 
b. -Mastitis 

c. Pelvic tuberculosis 

d. Urinary tract infections 

e. Acute and chronic pyelonephritis 

f. Sexually transmitted diseases 

g. Endome trios is 
h. Endometritis 

2. Malignancies 

a. Breast 

b. Dysplasia 

c. Reproductive system 

. Cervical 

. Uterine 

. Ovarian 

, Vaginal 

. Fallopian Tubes 

3. Benign tumor 

a. Uterine fibroids 

b. Cystic breast masses 

c. Polyps 

4. Cardio-vaacular 

a. Hypertension 

b . Thrombo-phlebitis 

5. Nutritional problems 

a. Iron deficiency anaemia 

b. Obesity 

c. Malnutrition 



4 Topical Outline ... ARMWLff J: COMKW ZJJffffASffS 4ff> ACCIDENTS 
'iursing and Midwifery page SO? 



Section III: Diseases of Adult Women 



ilzation of Content - cont 



B. Prevalent cultural beliefs and practices 

1. Beliefs about aetiology 

2. Traditional methods of diagnosis 

3. Traditional treatment and prevention 

C. Aetiology of conditions listed in A. 

1. Primary cause where possible 

2. Contributing factors, principally environmental (see Section I.F.) 

D. Epidemiology 

1. Mode of transmission 

2. Natural history of the condition 

3. Associated nutritional, economic, and social effecta of the 
condition on family health 

E. Complications for the woman (and/or the family) 

F. Complications for the child and/or the family 

1. Physical-nutritional 

2. Psychological or social 

3. Economic 

G. Diagnosis or assessment of selected conditions 

1. Case-finding methodology 

2. History 

3. Physical signs 

4. Laboratory and X-ray signs 

5. Elements of the definitive diagnosis where possible 
H. Preventive measures 

1. Primary: e.g. nutrition education for iron deficiency anaemia 

2. Secondary: e.g. screening and prompt treatment of urinary tract 

infections 

3. Tertiary: e.g. surgical removal of cervical carcinoma 



A Topical Outline ... MODVLE J: COMMON DISEASES AND ACCIBBKCS 



and e 208 



loti IV: Diseasea and Accidents of Adult Males 



Specific Oblectivesl 

1. Name the diseases and accidents which exert their impact on 
family health primarily through their occurrence in adult males . 

2. Discuss the aetiology, epidemiology, pathogenesis, and complicatlona 
of selected cases. 

3. Participate in the diagnosis or assessment of selected cases. 

4. Describe and implement preventive measures aimed at these conditions. 

Organization of Content _ __ _ __ - - - 

A. Catalogue of diseases and accidents occurring primarily in adult males 

1. Infections 

a. Amoebiasis 

b. Onchocerclasls 

c. Sexually transmitted diseases 

2. Cardlo-vascular diseases 

a. Hypertension 

b. Cerebral vascular accident 

3. Malignancy 

a. Primary hepatoma 

b. Prostate 

4. Behavioral conditions 

a. Alcoholism 

b. Drugs 

5. Accidents 

a. Eye injuries 

b. Head Injuries 

c. Transportation accidents - as chauffeurs, lorry drivers 

d. Snakebite 

e Other occupational hazards 

. Agriculture: Insecticides, herbicides 

. Mining: crushing Injuries 

. Factory work: crushing injuries, toxins 

. Road construction: heat prostration, crushing injuries 

. Other construction: falls, crushing injuries 

B. Prevalent cultural beliefs and practices related to selected conditions 

1. Beliefs about aetiology 

2. Methods of diagnosis 

3. Treatment and prevention 



A Topical Outline . . . MODULE <T; COMMON DISEASES AND ACCIDENTS 

Nursing and Midwifery page BOG 



Section IV; Diseases and Accidents of Adult Males ___ 

Organization of Content - cont ... ,^_ , 

C. Aetiology of each of the *Hove 

1. Primary cause where possible 

2. Contributing factors principally environmental (see Section I.F.) 

D. Epidemiology 

1. Mode of transmission 

2. Natural history of the condition 

3. Associated nutritional, economic, and social effects of the 
condition on family health 

E. Complications for the man 

1. Loss of earning capacity 

2. Loss of prestige of being the wage earner 

3. Physical pain and incapacity 

4. Dependence on others 

5. Discouragement and depression 

F. Complications for the child and/or the family 

1. Physical - nutritional 

2. Psychological or social 

3. Economic 

G. Diagnosis or assessment of selected conditions 

1. Case finding methodology 

2. History 

3. Physical signs 

A. Laboratory and X-ray signs 

5. Elements of the definitive diagnosis where possible 
H. Preventive measures 

1. Primary: e.g. safety measures for occupational hazards 



A Topical Outline ... MODULE J: COMMON DISEASES AND ACCIDENTS 

Nursing and Midwifery page 210 



Section IV: Diseases and Accidents in Adult Males 
Organization of Content - cont... 

H. 2. Seconday: e.g. screening for hypertension 

3. Tertiary: e.g. prompt treatment for head injuries 



A Topical Outline . . . MODULE J: COMMON DISEASES AND ACCIDENTS 

Nursing and Midwifery 



Section V: Diseases and Accidents Occurring in all Age Groups 

Specific Objectives: 

1. Name the diseases and accidents which have their impact on family 
health through their occurrence in family members irrespective of 
age. 

2. Discuss the aetiology, epidemiology, pathogenesis, and complications 
of selected conditions. 

3. Participate in the diagnosis or assessment of selected casea. 

4. Describe and implement preventive measures aimed at selected con- 
ditions. 

Organi za t ion of Con t en t^ m _ n ^ ,_^ .,.., -.-.-,... . 

A. Catalogue of diseases occurring in all age groups of the family 

1. Infections 

a. Malaria 

b. Bilharziasis 

c. Trypanosomlasis 

d . Tuber culos is 

e. Bancrofti filarsiasls 

f. Schistosomiasis 

g. Typhoid fever 

h. Infectious hepatitis 

i. Syphilis 

j . Gonorrhea 

k. Cholera 

1. Leprosy 

m. Relapsing fever 

n. Trachoma 

o. Others 

2. Inherited diseases 

a. Diabetes ae 11 it us 

b. Down ayndrone 

3. Cardlo-vascular/renal diseases 

a. Chronic renal disease 

b. Hypertension 

4. Nutrition problems 

a. Pellagra 

b . Anaemia 

c. Skin conditions 

5. Accidents 

a . Burns 

b. Fractures 



A Topical Outline ... MODULE J: COMMON DISEASES AW ACCIDENTS 

Nursing and Midwifery page 



Section V; Diseases and Accidents Occurring in All Age Groups 

Organization of Content - cont... 

A. 6. Mental Illness 

a. Psychosis 

b. Disfunction 

7. Handicaps 

a. Blindness 

b. Deafness 

c. Disfunction of extremities 

8. Malignancies 

a. Neoplasms 

b. Leukemias 

B. Prevalent cultural beliefs and practices related to selected diseases 
and injuries 

1. Beliefs about aetiology 

2. Methods of diagnosis 

3. Treatment and prevention 

C. Aetiology of each of the above 

1. Primary cause where possible 

2. Contributing factors principally environmental (see Section I.F.) 

D. Epidemiology 

1. Mode of transmission 

2, Natural history of the condition 



A Topiaal Outline . . . MODULE J; COMMON DISEASES AND ACCIDENTS 

Ihwsing and Mictoifery page 313 



Section V: Diseases and Accidents Occurring in all Age Groups 
Organization of Content - cont . 

G. 3* Physical signs 

4. Laboratory and X-ray atgns 

5. Elements of the definitive diagnosis where possible 
H. Preventive measures 

1. Primary: e.g. BCG immunization -for tuberculosis 

2. Secondary: e.g. screening for syphilis by doing blood tests 

3. Tertiary: e.g. treating trypanosomiasis in the first stage 



A Topical Outline ... MODULE J: COMMON DISEASES AND ACCIDENTS 

Nursing and Midwifery 



Section VI: Nuraing Intervention 



Sepcific Objectives: 

1. Describe the basic elements of simple assessment of the individual 
patient. 

2. Review the principles of nursing care of acute and chronic diseases 
and accidents. 

3. Discuss the needs for emotional support and counseling. 

A. Discuss the educational components of nursing care, including the 
need for follow-up. 

5. Make a nursing plan and give care to patients with acute chronic 
illnesses . 

6. Plan and lead an educational session instructing a group of mothers 
on home nursing care. 

Organization of Content _ _____ _ - - 

A. Assessing the health needs of individuals 

(see Module H, Section V. A. 1-6 - Assessing health of individual adults.) 

1. Above principles apply equally to children 

2. Parents or mother chief source of information 

B. Nursing care 

1. Early case-finding 

2. Care as appropriate for illness 

a. Hospital 

b. Clinic or health center 

c. Home 

3. Nutrition guidance 

4. Comfort measures 

5. Prevention of complications 

a. Through observation 

b. Through knowledge 

c. Through skilled nursing care 

6. Teaching of others 

7. Recording 

8. Communication with medical and nursing authorities 

a. For direction 

b. For exchange of vital information 

c. For consultation 

d. For support 



Top-teal Outline . . . MODULE J; COMMON DISEASES AND ACCIDENTS 

and MCdtfifery page 



Section VI: Kurelnp, Intervention 



of Content - cont... 



. Heeds for emotional support and counseling 

1. Anxiety generated by Illness or accident 

2. Coping ability - Individual and fiamily 

a. Organization 

b. Resources 

c. Need for constructive activity 

3. Concerns 

a. Prognosis 

b. Disability or pain 

c. Loss of earning power 

d. Effect on family 

4. Reassurance 

5. Understanding 

D. Educational Components 

1. Teaching as part of all nursing care 

a. Opportunities 

b. Importance 

2. Settings 

a. Individual contacts 

b. Family contacts 

c. Group contacts 

d. Classrooms, meetings, clinics, etc. 

3. Planning 

a* What to teach - content 

b. Level of understanding 

c. Goals and purposes 

d. teaching aids 

. Films 

, Slides 

. Pamphlets 

. Posters 

. Demonstrations 

4. Content in relation to diseases and accidents 

a* Known causes 

b. Preventive measures 

. Early case-finding 
. Immunization 



A Topioal Outline . . . MODULE J: COWON DISEASES AND ACCIDENTS 

Nursing and Mid&ifery page 216 



Section VI; Nursing Intervention 

Organization of Content - cont... 

4. b. . Elimination of accident hazards 

. Good nutrition 

. Safe water 

. Clean environment 

c. Care of the ill or injured 

. Medications 

* Pood 

. Bedside care 

. Ambulatory care 

. Rehabilitation 

. Stimulation 

d. Hoed for follow-up 

. Specific to Illness or accident 

. Importance and benefits 

. Resources and referral 

. Short-term vs. long-term 



A Topical Outline ... MODULE J: COMMON DISEASES AW ACCIDENTS 

tfursing and Midwifery Bibliography 217 



BIBLIOGRAPHY 



I. SELF- INSTRUCTIONAL UNITS 

available from the African Health Training Institutions Project 



Causes T Treatment and Fr event ion of Malaria 
BENSON B. MANGERA (Kenya) 

Gaatro-Enteritis 

FLORENCE (Kenya) 

Immunization 

KATHLEEN CHINTU (Zambia) 

The Management o f Simple plar rhe a in Infants 
HARVEY HAMRICK (USA) 

The Care of the Child with Measles (Rubeola) 
JOYCE MPINDA KIRUKI (Kenya) 

Pert us s i s (Wh o op ing jfough ) : Ae t i o logy , Tjrea tmen t ^ _ Nur s ing Care , 
an d P r ey en t ion 

SARAH ADDISON, (Ghana) 

Prevention oj^ Roundwprm InfeS ta^tj^on 
MAVIS AKUTTER (Ghana) 

Epidemic Cerebro- Spinal Meningitis 
ALHAJI MOHAMMADU ADAMU (Nigeria) 

Broncho-Pneunoraia in Children 
JULIUS B. ADENIYI (Nigeria) 

Sickle Cell Disease 

PETER OLASUNKANMI AJAYI (Iligeria) 

The Causes and Prevention, of Fireburn In Children 
JORJOH CHAM-KINTEH (Gambia) 

Symptoms. Treatment and Prevention of Hookworm Infestation 
M.R. DOLAN (Nigeria) 

Nutritional Anaemia 

EMILY DUKE (Nigeria) 

Dehydration: Diagnosis and Treatment 
D.Y. KUTEYI (Nigeria) 

Factors Affecting the Patient's Health 
AMAL F. GARAS (Egypt) 



A Topical Outline . . . M* J: COMMON DISEASES AND ACCIDENTS 
Nursing and Mifaifery BibUogwpty 218 



Nursing Management of Viral Hepatitis 
LAYLA I. KAMEL (Egypt) 

Accidents in the Home 

SUZAN ATTEYA ABED EL-SAYED (Egypt) 

Pulmonary Tuberculosis in Adults 
ISAAD M. DOWARA (Egypt) 

BCG Vaccination 

OLIKOYE RANSOME-KUTI (Nigeria) 

Immunizations 

LYNN H. GILBERT (Nigeria) 

Malaria; Diagnosis and Treatment 
F.O. AFONJA (Nigeria) 

Malaria; Methods of Control 

ABIGAIL TYABODE AWOTESU (Nigeria) 

Pelvic Examination 

MAGDA YOUSSEF HELMI MOURAD (Egypt) 

Tuberculosis in Children 

R. AMONOO-LARTSQN (Ghana) 



Kerosene Poisoning in Children 
S. HAGAN ANNOBIL (Ghana) 

Management and Control of Urinary SchlatosomiaBis 
Gilford A. Ashitey (Ghana) 

Haemoglobin Analysis 
O.A. AJAYI (Nigeria) 

Nephritis 

ALHAJI KASIMU ALIYU (Nigeria) 

Food Poisoning 

B.M. ODUYOYE (Nigeria) 

Advice to Mothers on Symptoms of Childhood Diseases 
CECILIA 0. ADEDOYIN (Nigeria) 

Onchocerciasis 

OLAYINKA DICKSON (Ghana) 

Introduction to Kwashlorkor: Its Nature* Causation and Manifestation 
ALICE N; AKITA (Ghana) 

Kwashlorkor and Pre-Kwashiorkor ; Indent if icat ion and Treatment 
SOPHIA WALTER-HOLTZ (Ghana) 



ieal Outline ... MODULE J: COMMON DISEASES AND ACCIDENTS 

'.r,g and Midwifery Bibliography 219 



Food Customs and Taboos in Relation to the Family Health 
in a Community 

SARA W. KAVITI (Kenya) 

Maternal Nutritional Needs 
ELIZABETH MUTURI (Kenya) 

The Relationship Between Nutrition and Growth and Development (0-5 years) 
PAULINE MUHUHU (Kenya) 

Relation of Child Spacing to the Mental Health of the Family 
D.B. WANGA (Kenya) 

Pellagra 

SAMIR KAMAL ELDIB (Egypt) 

Energy-Protein Malnutrition 

EBD EL-HAMID GUINENA (Egypt) 

Effect of Malnutrition on Growth and Adolescence 
NABILA M. HIDAYET (Egypt) 

Caloric Requirement and Adequate Diet 
MOHYI ELDIN ABDEL-WAHAB (Egypt) 

Infant Morbidity and Mortality: Data Collection. Causes and Prevention 
DOROTHY MULONGA NASHA (Cameroon) 

Neonatal Jaundice in the Tropics 
OLU C. NWANA (Nigeria) 

Feeding Practices and the Health of Chiidren 
A.O. OBARISIAGBON (Nigeria) 

Breast Examination 

SOHEIR HUSSEIN AHMAD ELEBRIARY (Egypt) 

Tetanus Neonatorum 

HELEN NANYAMA KUKUBO (Kenya) 



MODULE J: COMMON DISEASES AND ACCIDENTS 
A Topical Outline ... Bibliography 22(3 

Nursing and Miduifery 



II . BOOKS 



BENENSON, A.S. 

Control of Communicable Diseases in Man. 12th edition, Washington: 
American Public Health Association, 1975. 

BRENNER, L.S. and D.S.. SUDDARTH 

The Llppincott Manual of Nursing Practice. Philadelphia: 
J.B. Ltpplncott Co., 1974. 

FENDALL, N.R.E. 

Auxiliaries in Health Care: Programa in Developing Countries. 
Baltimore: The Johns Hopkins Press for the Josiah Macy, Jr. 
Foundation, 1972. 

HYMDVICH, D.P. and M. BARNARD 

Family Health Care. New York: McGraw-Hill, 1973. 
JELLIFFE, DERRICK B. 

Child Health in the Tropics. 7th edition, London: Edward 
Arnold f 1975. 

KILIMANJARO CHRISTIAN MEDICAL CENTRE 

Child Health! Rural Health Series II. A Manual for Medical 
Assistants and Other Rural Health Workers.. Kenya : African 
Medical and Research Foundation, 1975. 

KING, MAURICE 

Medical Care in Developing Countries. London: Oxford University 
Press, 1966. 



A Topioal Outline 
and 



MODULE K: FAMILY PLANNING 



page 



223 



MODULE X. 



FAMILY 



I. RATIONALE 

a rletv of customs based on social, 

d - f tir : fl ; i :-" - - 

religious and economic factors. ^ 11true for children bring 

children as V of God." This concept is t - 

joy , love and enrich^, to people's lives and^e ^ ^ 

no re than ever, carried couples are ^^ J^, fuli ll 
their children will survive and how they, P 

t r: ir: 






o two y eare and 



couples to determine vhat their - 

planning include those related to h.1th .oci-1, accompanylog thi8 

^e desire for chiXdren 1. nearly universa 1. v ^ 

desire is the hope that each child 111 h ,, > - e E opportunlty M receive 

lth enoush to eat, freedom f.o. chron ic Hn -. - " 

enough education to ^e hi, or er a j-^^ 
.ociety. By spacing the interval of child bearing 
. *. of five years, *. -other has ^^ 
lf.t is .t. Itoly to have adequate nutrition and the 
needed for optimm growth and development 

Hedical personnel. 

families through p*.vntive, curative and 
.bo U t what happens to fa^ies ^ 
iafomed about the relationship of child 
ta counseling -d delivering the services that are needed. 



lnvolved wlth 






adequately 
d 



-4 Topical Outline .. . MODULE K: FAMILY PLANNING 

and Midwifery p a g e 224 



Methods of postponing or preventing conception have been known since 
ancient times, practiced by royal tribes and peasants alike. Many of these 
ancient methods consi8ted of efforts to prevent the "fluid of the man" from 
entering the "womb of the woman" or in modem terminology, to provide a barrier 
so that the sperm could not meet to unite with the ovum. Other methods and 
beliefs had to do with magic potions imbibed or rituals performed around the 
time of coitus. 

Today some of these principles are still used in the design of modern 
contraceptives or in the recognition of a fertile period in the menstrual cycle. 
Traditionally In some cultures there ia separation of the man and woman for 
certain periods of time such as during the period of lactation following 
child birth. This is child spacing for the benefit of each member of the family 

Modern contraceptives may be classified In three distinct ways: 

1. Behavioral methods 

2. Mechanical and chemical methods 

3. Systemic methods 

In addition, therapeutic abortion may be considered as one aspect of child 
spacing, and sterilization may be a part of family planning when a couple de- 
cides that their family is complete. Infertility (see Module C) is of major 
concern to those who want children and is also considered a component of family 
Planning. All of these components are important to nursing and midwifery 
education, for they will be part of the services to people in clinical settings 
as well as in the community. 



Outline . . . MODULE K: FAMILY PLANNING 

and ffafoifery page SS5 



II. OVERALL OBJECTIVES 

At the completion of this module students should be able to: 

1. Define family planning and explain historical development 
of the concept. 

2. Describe the health and socio-economic benefits of family 
planning. 

3. Describe the responsibilities of nursing/midwifery personnel 
in counseling for family planning. 

A. List criteria for assessing the appropriateness of a family 
planning method. 

5. Describe the behavioral, mechanical and systemic methods of 
contraception. 

6. Describe the nursing/midwifery care needed by patients with 
various types of abortion. 

7. Describe sterilization procedures for female and male and 
points of nursing/midwifery intervention. 

8. When appropriate, evaluate a non-pregnant pelvis and prescribe, 
fit or insert an appropriate contraceptive. 



Topical Outline ... MODULE K: FAMILY PLANNING 

i&eing and Midwifery page 226 



Section I; Introduction to Family Planning 

Specific Objectives: 

1. Define family planning concepts and describe their historical devel- 
opment . 

2. Describe how government policies are determined and their impact on 
services, 

3. Describe how services are organized at different governmental levels 

4. Describe manpower resources needed for family planning services and 
education. 

5. Discuss the role of non-governmental organizations. 

Organization of Content _ _ r 

A. Definition and the development of concept of family planning 

1, Concept of freedom to choose 

a. Number of children 

b. Frequency of child-bearing (spacing) 

2. Assistance for those experiencing difficulty in conceiving 

a. Infertility 

b. Sterility 

c. Alternatives to child bearing 

B. The historical background 

1. From antiquity 

2. Scientific advances in last 25 years 

a . Knowledge 

b. Techniques 

3. Personalities and their contributions 

4. Resources for research and dispersal of knowledge 

a. Local 

b. National 

c. International 

5. Development of national and local policies 
C. Philosophy and Objectives 

1. Overall 

2. Differences by country 



A Topical Outline . . . MODULE K: FAMILY PLANNING 

and Micfoifery page 22? 



Section _Ij_ Introduction to Family Planning 



Organization of Content - cont... 



D. Role of government In family planning 

1. Policies 

a. How development takes place 

b. Influences 

. Tradition 

. Religion 

. Resources 

. Politics 

. Attitudes and understanding of policy-makers 

2. Organization of services 

a. National 
b . Regional 

c. Local 

3. Financial support 

E. Role of non- government organizations (international, national, etc.) 

1. Educational 

a. Health and welfare organizations 

b. Universities 

c. Professional schools 

d. Public schools 

e. Newspaper and journal articles 

2 . Research 

a. Medical 

b. Social 

c. Economic 

3 . Service 

a. Implement new programs 

b. Supply contraceptives 

c. Coordination with other services 

d. Some staffing 

F. Manpower for services and education 

1. Categories 

2. Selection 

3. Training or preparations 

4. Utilization 



A Topical Outline^ ... MODULE K; FAMILY PLANNING 

Nursing and Mid&ifery page 228 



Section II: Benefits of Family Planning 

Specific Objectives; 

1. Identify at least 5 health benefits of family planning. 

2. Identify at least 5 socio-economic benefits of family planning. 

Organization of Content ~~ 

A. Health and socio-economic benefits of family planning 

1. To individuals 

2. To families 

3. To communities 

B. Health benefits 

1. Decrease in mortality 

a. Maternal 

b. Perinatal 

c. Childhood 

2. Decrease in complications of pregnancy and delivery 

a. Prevention of grand miltiparity 

b. Prevention of pregnancy In timea of illness or family stress 

3. Concept of spacing 

a. Maternal replenishment 

b. Care and breast feeding of Infant 

4. Concept of age of minua reproductive risk 

5. Prevention of genetic diseases 

6. Prevention of communicable diseases 

a. Morbidity 
b; Mortality 

7. Inprovaent of nutritional status 

a. Prevention of kwashiorkor, marasmus, and growth failure by prolong- 
ing breast feeding 

b. Appropriate and sufficient food for growth and development 

c. Prevention of low birth weight for gestational age 

8* Improvement of mental health and family adjustment 



A Topical Outline ... MODULE K; FAMILY PLANKING 

and Mtdw-fery P a ff e 



Section II: Benefits of Family Planning. 



Organization of Content - cont 



C. Socio-economic benefits 

1. Decrease in unwanted pregnancies, therefore fewer Illegal abortions 

2. Improvment in financial potential for families 

3. Improvement in educational potential for children 

4. Improvement in intellectual development in children (more individual 
stimulation) 

5. Improvement in work opportunities for 

a. Heads of families 
b , Women 

6. Less drain on community resources 

7. Improved nutrition and quality of life 

a. Caloric and protein intake 

b. Supply and distribution 

c. Quality of food 

d. More land area per person 



Topical Outline . . . MODULE K: FAMILY PLANNING 

weing and Midwifery page 230 



SeiCtion in III^ _C^ a Contraceptive Method 

Specific Objectives: 

1. Describe criteria for assessing the appropriateness of a family 
planning method. 

Organization of. Content 

A. Availability 

B. Mode of action 

C. Indications and contra-indications 

D. Suitability for couple 

E. Side-effects or complications 

F. Effectiveness (reliability) 

G. Cost 

H. Technical aspects 

I. Specific guidance and counseling needed for the method 



A Topiaal Outline ... MODULE K; FAMILY PLANNING 

and Midwifery page 231 



Section IV: Behavioural Methods 



Hoter In the teaching and discussion of the family planning methods that 
follow (Section V through IX) in addition to the specific techniques , 
demonstrations or practice of a particular method, the outline of the 
preceding Section (IV) should be followed. 

Specific Objectives! 

1. Describe behavioral methods. 

2. Assess behavioral methods using suggested criteria. 

3. Counsel clients on behavioral methods as appropriate. 

Organization of Content _ __________ 

A. Rhythm and Basal Body Temperature 

1. Review of phases and timing of menstrual cycle 

a. Concept of the "safe period" 
b . Individual variations 

2. Ovulation 

a. Methods of detecting 

b. Length of time in relation to fertilization 

B. Withdrawal 

1. Definition 

2. Difficulties 

a. Mechanical 
b . Individual 

C* Traditional local pratices 

1. Beliefs and taboos concerning sexual activity and conception 

2. Abstinence 

3. Lactation 

4. Separation of Bother and child from family (usually specified 
period of time) 

5. Polygamy 



A Top-ioal Outline . , . MODULE K: FAMILY PLANNING 

Nuraing and Midwifery page 232 



SectjLgn V; Mechanical^ and_ Chemical Methods 

Specific Oblectives: 

1. Describe available mechanical and chemical jnethods. 

2. ABBESS mechanical and chemical methods using suggested criteria. 

3. Teach or apply mechanical and chemical methods where appropriate. 

Or ga n i z a t ion of Con ten t 

A. Condom 

1. Male contraceptive 

2. Kinds 

3. Also provides some V.D. protection 

B . Diaphragm 

1. Material - sizes 

2. Requires fitting by professional - teach student when appropriate 

3. Insertion and length of time in place 

4. Removal, cleansing, and care 

C. Foams, Jellies, tablets and suppositories 

1. Method of application 

2. Length of time effective 

3. Allergic reactions 
D> IUD 

1. Kinds 

2. Insertion and/or removal by professional - teach student when 
appropriate 

3. Coitus can be spontaneous 



\Topical Outline ... MODULE K: FAMILY PLANNING 

teaing and Midwifery page S33 



Section VI: Systemic Methods 

Specific Objectives: 

1. Describe available systemic methods. 

2. Assess systemic methods by using suggested criteria. 

3. Recommend systemic methods where appropriate. 

Organization of Content , - 

A. Oral Contraceptives (Kinds) 

1. Combined 

2. Sequential 

3. Low- level supplement 

B. Injections and silastic capsules 

1. Techniques of treatment and/or insertion 

2. Timing 

C. General considerations 

1. Controversy on distribution. 

a. Should they be M.D. prescribed? 

b. Should they be para-medical prescribed? 

c. Should over-the-counter sales be permitted commercially? 

2. Long-term studies 

a. Retrospective 

b. Prospective 

c. Findings and implications 

3. Follow-up 

a. Routine 

b. Resources for emergency medical care 



A Topical Outline MODULE K: FAMILY PLANNING 

Nursing and Midwifery P<*g e 



S a c t_ion_ Vj _!_*_. N u r a ing an d Mi dwi f e ry Care an d^ , _ Couns el in g^ in^ _F amily P 1 ann In g 
Specific, 



1. State where and how case-finding for family planning should 
be done. 

2. Do family planning case-finding and report on the experience. 

3. Describe the nursing care needed during the first visit to 
family planning clinic, 

4. Interview, take history and care for a client during her first 
clinic visit. 

5. Conduct a group session for "first-time" clients. 

6. Name the four laboratory procedures usually done in a family 

planning clinic. 

7. Describe return visit responsibilities . 

8. Make an actual referral of a client to an outside resource, 
under supervision of physician or instructor. 

9. Discuss sensitive areas confronting nurses and midwlves in 
caring for the family planning client. 



Organization of Content . 

A. Case-finding 

1 , Where 

2, How to approach 

a. Individuals (differences) 

b. Groups 

3. Motivation 

a. Assisting clients to understand concepts 

b. Addressing health, social and economic benefits 

4. Interviewing 

a. Factors in selection of appropriate Information 

. Readiness to learn 

. Educational level 

. Degree of critical need 

. Potential health or socio-economic problems 

, Previous knowledge 

, Resources and methods available 

b. Timing and privacy for discussion 

c. Opportunity for questions from clients 

. Appreciation of potentially sensitive areas 
. Rapport in nurse/client relationship 



-' Topical Outline MODULE K; FAMILY PLANNING 

Sudsing and Midwifery page 235 



Section VII; Nursing and Midwifery Care and Counseling in Family Planning 
Organization of Content - cont . . . 

B. Nursing and midwifery concerns during first clinic visit 

1, Importance of first contact 

a. Warm 

b. Meaningful 

2. The clinic interview 

a. Determine reason for coming 

b. Discussion of basic values 

c. Evaluate knowledge 

. Reproductive anatomy and physiology 
. Menstrual cycle including ovulation 
. Process of fertilization 
. Contraceptive methods 

d. History 

. General medical 

. Obstetrical (and/or gynaecological) 

. Living children 

e. Determine attitudes 

. Spouse 

. Significant others (family, peers) 

f. Explanation of clinic prodecures 

. Laboratory 

. Physical examination including pelvic area 

. Choice of contraceptives 

. Follow-up 

3. The group interview 

(In many situations nearly all of the above can be done in 
group sessions) 

a. Advantages 

. Tine-saving for staff 

, Clients get answers to questions without revealing 

lack of knowledge 
. Peer group with same needs 

b . Disadvatages 

. May miss pertinent Individual problems and questions 
. May overlook shy or frightened clients needing special 
attention 

4. Laboratory tests (usual) 

a. Urinalysis 

b. Blood for haematocrit 



A Topical Outline MODULE K: FAMILY PLANNING 

Nursing and Midwifery page 336 



Section VII; Nursing and Midwifery Care and Counseling in Family Planning 
Organization of Content - cont... 



B. 4. c. Papanicolaou smear 

d. Smear for gonococcuB 

5. Physical examination including pelvic 

a. By physician, midtirife or specially prepared nurse 

b. Nursing support 

c. General physical 

. Heart 

. Lungs 

. Breast 

. Varicosities 

. Other, based on history 

d. Pelvic 

. Early detection of pregnancy 

. Evidence of Inflammation, discharge, lesions 

. Evidence of neoplasms 

e. Evaluation 

6* Selection of contraceptive 

a. Availability 

b. Client's choice if medically appropriate 

c. Explanation of use 

d. Supply 

7. Plan for follow-up 

a. Usual intervals 

b. Resources for emergency care 

C. Return visit responsibilities 

1. Schedule 

2, Often seen only by nurse or midwife 



idicated 



Lsit 



A Topical Outline MODULE K; FAMILY PLANNING 

Nursing and MidiOifery page 237 



Section VII; Nursing and Midwifery Care and Counseling in Family Planning 
Organ.! za t Ion of Content -^:ont .^. 



D. Referral to outside resources 

1. What Is available? 

a Consultation 

b . Other clinics 

c. Welfare agency 

2. Methods of referral 

a. Physician initiated 

b. Nurse-midwife initiated 

c. Actual mechanics of referral 

3. Communication of need to client 

4. Communication between resources 

a. Telephone 

b . Papers 

c. Transfer of Information 

5. Costs 

6. Transportation 
H. Sensitive areas 

1 . Decisions 

a. Nurse informs, client makes Informed decision 

b . Avoid coercion 

c. Client problems - her own desire and attitudes of others 

2. Impartial care (problems in some countries) 

a. Care of unwed mother 

b. Care of abortion or sterilization patients 

3. Attitudes of nurse/raldwives in relation to family planning, 
infertility, abortion, and sterilization 

4. Infertility counseling as a component of family planning 
(see Module C) 



A Topical Outline ... MODULE K: FAMILY PLANNING 

Nuvaing and Midtiifexnj page 238 



.Section VIII ; Abortion 



Specific Objectives: 

1. Describe national abortion policy and how determined. 

2. Classify the types of abortion 

3. Identify socio-cultural factors that influence the practice of abortion 

4. Assess methods and techniques by suggested criteria. 

5. Describe care of an abortion patient. 

6. Give nursing care and guidance to an abortion patient. 

Organizaitign^gf Content _ ________ 

A. National Policy 

1. Why a policy? 

2. Who determines? 

3. How are decisions made? 

4. Policy statement of local country 

B. Classification of abortion 

1. Spontaneous 

2. Illegal 

3. Therapeutic (medical reasons) 

4. Legal on demand no restrictions 

C. Legal and therapeutic considerations 
1 . Emergency measure 

2. Method by time of gestation 

D. Social, cultural factors 

1. Attitudes (pro-con) 

2. Religious positions 

3. Historical background 

4. Legality - government policy 

E. Methods 

1. Dilatation and curettage 



Topiaat Outline . . . MODULE K: FAMILY FLAMING 

and Midwifery page 239 



Section VIII: Abortion 

Organization of Content - cont... __ 

2. Aspiration by vacuum 

3. Hysterotomy 

4. Hysterectomy (rare) 

5. Saline induction - intra-amniotic injections 

6. Prostaglandlns 

7. Abortifacients - drugs 

B. Traditional beliefs and illegal methods; miscellaneous methods - 
some effective, many ineffective, dangers and precautions 

F . Complications 

1. Infection 

2 . Uterine perforation 

3. Haemorrhage 

4 . Retaine d tissue 

G. Nursing care of the abortion patient 

1. Physical 

a. Control bleeding 

b. Assess pain and provide appropriate reliet 

c. Assist in management 

d. Comfort measures 

2 . Education 

a. Explain what is happening 

b. Explain procedures to be followed 

c. After abortion provide information 

. Personal care 
. Contraceptives 

3. Supportive and emotional 

a. Observe closely 

v, (inane-Inn attitudes and feelings 

c! Provide factual data and reassurance where appropriate 



A Topical Outline ... MODULE K: FAMILY PLANNING 

Nursing and Midwifery page 240 



Section IX: Sterilization , 

Specific Objectives:. 

1. Describe how national policy is formulated and what factors in- 
fluence it. 

2. Identify kinds of sterilization procedures for males and females, 

3. Assess sterilization techniques by using suggested criteria, 
describing pros and cons of each. 

4. Describe nursing care of a sterilisation patient. 

5. Give nursing care to a sterilization patient. 

r gani za t i_on_ o f Con , t en t .._. 

A. National policy 

1. Who determines 

2. How decisions made 

3. Contributing factors 

B. Kinds of sterilizations 

1 , Female 

a. Tubal ligation (variety of surgical techniques) 

b . Hysterectomy 

c. Radiation (rare) 

2. Male: vasectomy 



A Topical Outline ... M?mF K: FAMILY PLANNING 
Nweing and Midwifery Bibliography 241 



BIBLIOGRAPHY 



I. SELF- INSTRUCTIONAL UNITS 

available from the African Health Training Institutions Project 



Family Planning 

JANE ROSAMOND HAYFRON (Ghana) 

Insertion of the IUGP (Lippes Loop) 
GRACE DELANO (Nigeria) 

Introduction to Family Planning, Contraception and the IUCD 
GRACE DELANO (Nigeria) 

Nursing Responsibilities for Family Planning Case Finding 
ANNA L.A. OKUMU (Kenya) 

Relation of Child-Spacing and the Mental Health of he Family 
D.B. WANGA (Kenya) 

Social, Psychological, and Educational Aspects Related to 
Family Planning 

KORAY NAGALI (Ghana) 

Family Planning! Its Implication on Health 
GRACE NNENNA NZERIBE (Nigeria) 

Contraindications of and Instructions Before and After the 
Insertion of lUCD's 

SEHAM S. RAGHEB (Egypt) 

Contraceptive Methods 

AMIRA MOHAMMED ANWAR EL MALATAY (Egypt) 

Benefit of Child Spacing for Family Health 
FERIAL ABDEL AZIZ ALY (Egypt) 

The Role of Family Planning in Family Health and Community Development 
VUYELWA N. NGCONGCO (Botswana) 

Family Planning as a Meane of Promoting Health 
MOKOWA BLAY ADU-GY.AMFI (Ghana) 

Contraceptive Methods 

DAPHNE THERESA ROACH (Sierra Leone) 

Clinical Use of Oral Contraceptives 
MAGDI RAMZY (Sudan) 

Effect of Lactation on Fertility 
JASWANT S. BAL (Zambia) 



A Topical Outline ... MODULE K: FAMILY PLANNING 
Nursing and Midji-fepy Bibliography 



The__ Role of Child-Spacing in the Promotion of Maternal. and 
Child Health 

HASSAN 0. OMER (Sudan) 

Dellye r ing^ Faml ly P lann ing Co unselln g 
JOSEPHINE M. NAMBOZE (Uganda) 

Abortign 

ABDEL HAMID BADAWY (Egypt) 

Conventional ^Methods of Contraception and their Evaluation 

BASSIOUINI AHMED BASSIOUNI (Egypt) 

Pelvic^ Examination 

MAGDA YOUSSEF HELMI MOURAD (Egypt) 

Breast 



SOHEIR HUSSEIN AHMAD ELEBRIARY (Egypt) 



. - ,, . MODULE K: FAMILY PLANNING 

Topical Outline ... 

and Midwifery Bibliography 243 



II . BOOKS 

BOYER, MICHELINE and ELIZABETH M. EDMANDS 

Guide lines for the Integration of Family Planning into the Nursing 
School Curriculum. Chapel Hill. North Carolina: Carolina Population 
Center Publication Series, 1973. 

CLARK, TOM L. 

Patient Servian Training Manual. Alameda, California: Planned 
Parenthood/World Population, 1973. 

DOWNSTATE MEDICAL CENTER 

F M ilv Planning Procedure Manual for Nurses and Midwivea . New York: 
Downstate Medical Center, 1975. 

FENDALL, N.R.E. 

Auxiliaries in Health Care; Programs in Developing Countries , 
Baltimore: The Johns Hopkins Press for the Josiah Macy, Jr. 
Foundation, 1972. 

HATCHER, R.A. et al. 

Contraceptive Technology. 8th rev. edition. New York; Irvington 
Publishers, Inc.: Haleted Press, 1976. 

INTERNATIONAL PLANNED PARENTHOOD FEDERATION 

Family Planning for M^Yf-fl And Nurses. London! International 
Planned Parenthood Federation, 1971. 

KILIMANJARO CHRISTIAN MEDICAL CENTRE 

Child 
gVn 
Foundation, 1975. 

KLEINMAN, RONALD L. 

Male and Female Sterilization. London: International Planned 
Parenthood Federation, 1973. 

MANISOFF, MIRIAM 

F fl milv Planning! A Teaching Guide for Nurses. New York: 
Planned Parenthood/World Population, 1971. 

OMRAN, ABDEL 

Mefl1 th Theme in Family Planning. Chapel Hill, North Carolina: 
Carolina Population Center Monograph, 1971. 



"""I- Health Series rfl. A Manual for MP.dlcal Assistants 



"- . 

Health Workers. Kenya: African Medical and Research 




A Topical Outline ... MODULE K: FAMILY PLANNING 

Nursing and MidDif&ry Bibliography 244 



II . BOOKS 

TURNBULL, LILY and HELEN PIZARKI (eds.) 

Family Planning in the Education of Nurses and Midwives. P.H. Papers tf 53 
Geneva: World Health Organization, 1973. 

WHELAN, ELIZABETH M. arid MICHAEL C. QUADLAND 

Human Reproduction and Family Planning: A Programmed Text. 
Palo Alto: Syntex Laboratories, 1972. 



A Topical Outline . . . MODULE L: THE HEALTH WORKER AND THE COMMUNITY 

tfwsing and Midwifery P a 9 & 24S 



MODULE L : 
THE HEALTH WORKER 

AND THE 
COMMUNITY 



I . RATIONALE 



Health workers In a community come from a variety of backgrounds to bring 
their knowledge and skills to meet the health needs of the community. The kinds 
and number of these workers will vary according to the size of the community, as 
well as the wealth, political influence, location and other community reeources . 
In a large city or political division one might find many categories of health 

workers. 

In smaller communities there are fewer kinds of workers BO that a single 
worker may need to do the work of others as well as his or her own. 

The goals and objectives of a community health program are to provide service 
and education to meet the health needs of the people. These components are con- 
stant, although their activities may shift to meet changing conditions within the 
community: 

1. Control of communicable disease including immunization 

2. Provision of care for illnesses and accidents 

3. Maternal and child health services including family planning 

4. Nutrition education and services 

5. School health education and services 

?! ProgrLa a to provide safe water, waste disposal, vector control and to 
prevent air pollution 

Health workers may function Independently, or as employees of the governiaent , 
or as representatives of local/national private health agencies. This pointa out 
the need for a local health team to coordinate the functions and activities of 
various types of individuals and programs , 

Nurses and .idwives are involved In community health practive at many levels. 
Their roles may shift from assessing to planning, to implementing, to evaluating, 
to coordinating, to providing service, to educating, to being a resource person, 



Gal Outline . . . MODULE L: THE HEALTH WORKER AND THE COMMUNITY 

g and Midwifery page 246 



Realistically In Africa, the nurse or midwife or auxiliary may find him/ 
erself Co be the only health representative in many of the rural communities. 
herefore, it is important to emphasize to students, in their educational programs, 
he importance of developing a broad competence and to learn how to organize and 
nvolve the community in their own efforts toward health promotion. Students 
hould become aware of national and regional rural development goals, to enable 
hem to contribute from the health standpoint. 



Topical Outline ... MODULE L: THE HEALTH WORKER AND THE COMMUNITY 

and Midwifery p age 24? 



II. OVERALL OBJECTIVES 

At the completion of this module, students should be able to: 

1. Identify various categories of health workers. 

2. Describe the goals and objectives of community health programs. 

3. Describe the component parts of health service and education programs 
in a community. 

4. Describe the role of nursing/midwifery in community programs. 

5. Participate in the planning and execution of a community health service 



I Outline . . . MODULE L; TEE HEALTH WORKER AND THE COWIVftZTY 

and Midwifery page 248 



ion Ii Varioua Categories of Health Workers 

cific Objectives! 

1. Identify the broad categories of health workers, 

2. Determine the categories of health workers in a given community, their 
background, skills and activities. 

3. Interview representatives of two categories of health workers (other 
than nursing/midwifery) and focus on determining their goals. 

;anization of Content _____ 



Categories of health workers 

1. Physicians 

2. Nurses - all levels 

3. Midwives - all levels 

4. Aides or auxiliaries (dressers) 

5. Dentists 

6. Social workers - all levels 

7. Pharmacists 

8. Health educators 

9. Technicians 

10. Sanitation workers 

11. Statisticians 

12. Lay leaders and workers 

13. Volunteers 

14. Traditional birth attendants or healers 
Background 

1. Professional schools 

2. Training programs 

3. On-the-job training 

4. Levels of education 

5. Levels of performance 



A Topioal Outline ... MODULE L: THE HEALTH WORKER AND THE COMMUNITY 

Cursing and Midwifery page 



Section I: Various Categories of Health Workers 

Organization of Content - cont... 

C. Skills 

1. Health or medically oriented 

2. Technically oriented 

3. Administrative - management 
A. Custodial 

5. Therapeutic care 

6. Rehabilitative care 

7. Educational (preventive) 
D< Activities 

1. Health services 

a. Hospital 

b . Health center 

c. Dispensary 

d. Community 

2. Education 

a. Health institutions 

b. Schools 

c. Community groups 

3. Social Welfare 

a. Kinds of service available 

b. Eligibility 

c. Funding 

4. Supportive services in community 

a. Education re: water, waste disposal, crops, etc 

b. Investigation of problem areas 

c. Advice or consultation 

d. Planning and maintenance of basic services 

e. Extension services - agriculture and sanitation 

f. Religious groups 

g. Maintenance of order 

5. Statistical 

a. Assessment 

b. Evaluation 



'.cat Outline ... MODULE L; THE HEALTH WORKER AND THE 

iff and Midwifery page 250 



iectionl: Various Categories of Health Workers. 
hrganization of Content - c on t_ ._.__. 



6. Lay workers and volunteers 

a . Education 

b. Promotion and support 

c. Special interest groups 

. Handicapped children 
. Heart disease 
. Cancer 



A Topical Outline ... MODULE L: HEALTH WORKER AND COMMUNITY 

and Midwifery page 



JS e c t i on II ! Conmiuni t y He a 1th Prog r ama - Goa Is , ObJ ! act iyee and Comp onen t Parts 

.Specific Objectives; 

1. Identify goals and objectives of health programs in the community. 

2. Describe the component parts of health service and education programs. 

3. Determine the components of a program in your community. 

4. Using data on "Assessment of the community" (Module I-Section I), 
identify areas of need in a community for which no services are provided, 

Organization of Content - _____ 

A. Goals and objectives of health programs in the community 

1. To meet health needs of the people 

a. As perceived by health workers 

b. As perceived by the people of the community 

2. Provision of Services 

a . Preventive 

b. Diagnostic 

c. Therapeutic 

d. Restorative 

3. Resources (availability) 

a. Hospitals 

b. Health Centers 

c. Dispensaries 

d. Supplies 

e. Manpower 

f . Finances 

4. Provision of education 

a. Goals or purpose 

, For factual and informational data 

. For emphasis on preventive aspects of health and the environment 

. To promote action by the community and its leaders 

b. Location 

. In schools 

. In health-related facilities 

. In community groups 

. In the home (where Indicated) 

, Component parts of a community health prog 

1. Control of communicable disease 

a. Case finding 

b. Diagnosis and treatment as needed 



"apical Outline 
*sing and 



MODULE ; THE HEALTH WRKBR AND THE COMMUNITY 
page 252 



Health ProBramg^_Ggalg.,. Objectives, and Component 



Organization of Content - cont- . , . 




1. 



c. 
d. 
e . 



Nursing care 

Teaching and activating preventive aspects 
Immunization 



2. Care of Illnesses and accidents 



a 

b 

c, 

d, 

e . 

f , 



Case-finding 

Diagnosis and treatment as needed 

Nursing care 

Acute vs. chronic care 

Complications 

RehabiUtation rt ^ "" handicapped topical, mental and social) 



Maternal and child health services including family planning 



Prenatal services 

Delivery 

Post-partum 

Family planning - education and service 

Child health services 

Crippled and handicapped children services 



4. Nutrition 



a 
b 

c, 
d, 

e . 

f . 



Assessment (early case-finding) 

Education 

Supplemental feeding including iron and vitamins 

Advise on crops and their production 

Prevention of malnutrition 

Rehabilitation 



5. School Health 



a 
b, 
c, 
d. 

e . 

f . 



Screening programs 

Medical services 

Counseling services 

Psychological services 

Social welfare 

Educational - prevention 

Educational - Personal and environmental health 



6. Adult health education and services 



a , 
b. 



Nutrition 

Disease prevention 

c. Parenting - child care 

d. Family planning - education and services 



A topical Outline ... mffis "" D THE COMMUNm 

tfuyai-ng and Midwifery P&ge 253 



Section II: Community Health Programs - Goals, Oblectives and Component: Farts 

Organization^f Content - cont. . . _, . 

7. Environmental programs 

a. Safe water - wells, storage, protection, sterilization, etc. 

b. Waste disposal - principles, latrine building and maintenance 

c. Vector and rodent control - insecticides, netting, trash, etc. 

d. Housing 

e. Schools - safety, hygiene, design 

f. Hospitals - safety, hygiene, efficiency, design 

g. Other public buildings 

h. Prevention of damage from floods, fire 

i. Storage and protection of food supplies 

j. Prevention of air pollution 



A Topical Outline ... MODULE L: HEALTH WORKER AND COMMUNITY 

Nwsing and Midwifery page 854 



Section III: Nursing/Midwifery Activities and Contributions to Community 
Health Programs 

Specif ic JDbj ectiyes : 

1. List the categories of nursing/midwifery personnel that may be 
found in the community. 

2. Describe the various roles these personnel may assume. 
Organization of Content ^ 

A. Categories of nursing/midwifery personnel (terminology may vary by country) 

1. Registered level 

a. Nurses 

b. Midwives 

c. Public Health nurses 

d. Tutors 

e. Administrators - head nurses, matrons, supervisors 

f. Private practice 

2. Enrolled level 

a. Nurses 

b. Midwives 

c. Administrators (see e above) 

d. Community nurses (in some countries) 

3. Aides - auxiliaries 

4. Traditional birth attendants and healers 

5. Dressers 

6. Other classifications 

B. Various roles 

1. Care of the sick 

2. Promoter of health care, physical and psychological 

a . Prenatal 

b. Child health 

c. Screening programs 

d. Counselor - in school health, health centers, family planning 
centers and home visits J * 6 

3. Community organizer 

a. Assessment of needs 

b. Assessment of resources 

c. Identification of community leaders 

d. Assessment of priorities (with leaders) 

e. Group organization - community involvement 

f. Definition of program objectives 



A Topical Outline . . . MODULE L: HEALTH WORKER AND COMMUNITY 

Nursing and Midwifery page 255 



Section III: Nursing/Midwifery Activities and Contributions to Community 

Health Programs 

Organization of Content - cont... 

B. 3. g. Determination of manpower needs 

h. Training program (if needed) 

i. Coordination of efforts with other health, social, 

educational workers 

j. Implementation and support of program 

k. Promotion of community leadership and independence 

1. Exploration of costs and funding 

m. Evaluation of efforts 

4. The broad role of the educator 

a. General 

b. Integration of education and nursing service 

c. Development of teaching skills 

d. Adaptation of teaching skills 

5. Areas of need and nursing competence in education 

a. Mother and child care 

b. Nutrition - basic needs and prevention of malnutrition 

c. Family planning - child spacing 

d. Human reproduction 

e. Nursing skills 

f. Child growht and development 

g. Stimulation of learning 

h. Parental observation and assessment 

i. Prevention of accidents 

j . Environmental hazards 

k. Other (by individual competence) 

6 . The nurse/midwife as conmunity leader 

a. Influences - community respect for knowledge and performance 

b. Source of information 

c. Interpreter of medical diagnosis and technology 

d. Adviser 

e. Source of referral 

f. Nurse/midwife's respect for individual - 
compassion, understanding, concern 



A Topical Outline . . . MODULE L: HEALTH WORKER AND COMMUNITY 

Nursing and Midwifery Bibliography 256 



BIBLIOGRAPHY 



I. SELF- INSTRUCTIONAL UNITS 

available from the African Health Training Institutions Project 



The Training of Voluntary Rural Health Workers in Developing 

Countries 

AFIYA H. YAHYA (Kenya) 

NurBinR Care Plans 

WINIFRED MODUPE OGUNDEYIN (Nigeria) 

The Modified Obstetric Flying Squad; A Method of Reducing Maternal 
Mortality and Morbidity Rate in Developing Countries 
GLORIA K. ZUBAIRU (Nigeria) 

Introduction to Leadership Training 
LAILA MOHAMED ABDOU (Egypt) 

Education and Counsellin 



KADRIA M. MOUSTAFA (Egypt) 

The Role of the Professional Nurse in Planning for Health Education 
to Promote Family and Community Health 
MARY KELABA HARMINA (Egypt) 

Nutrition Classes for Mothers In Child Health Clinics 
MODUPE OLUBUNMI OSIBINI (Nigeria) 

The Role of Family Planning in Family Health and Community Development 
VUYELWA N. NGCONGCO (Botswana) 

Infant Morbidity and Mortality - Data Collection. Causes and Prevention 
DOROTHY MULONGA NASAH (Cameroon) 

The Contribution of a School Health Programme to Family 
Health - 

OTESTINE A. GYEBI-OFOSU (Ghana) 

Food Poisoning 

B.M. ODUYOYE (Nigeria) 

Immuniz a t ions 

LYNN H. GILBERT (Nigeria) 

Major Factors Influencing the Outcome of Pregnancy 
AGNES SEKABUNGA (Uganda) 

Nursing Responsibilities for Family Planning Case Finding 
ANNA L.A. OKUMU (Kenya) 

Nutritional Needs of Adolescents 
SARATU 0. AKU (Nigeria) 



A Topical Outline . . . MODULE L; HEALTH WORKER AND COMMUNITY 

and Midwifery Bibliography 25? 

Dehydration: Diagnosis and Treatment 
D.Y. KUTEYI (Nigeria) 

School Meals in Lagos 

PEJU ABODERIN (Nigeria) 

Home Confinement 

E.G. ADEWALE (Nigeria) 

Malaria: Methods of Control 

ABIGAIL IYABODE AWOTESU (Nigeria) 

Immunization 

KATHLEEN CHINTU (Zambia) 

Planning Community Health Examination Surveys 
FRED K. WURAPA- (Ghana) 

The Community Organization Process and Its Relevance to Community 
Health Practice ~ " ~ "~~~ 
E.K. QUARTEY PAPAFIO (Ghana) 

Long-Term Nursing Intervention with Malnourished Children and Their 
Families 

SUZAN H. BANOUB (Egypt) 

Community Diagnosis to Determine the Needs for Health Services 
JAMES KHACHINA (Kenya) 

Assessing Health Services to Determine Staffing Needs 
WINIFRED NYOIKE (Kenya) 

.The A. B.C. of Communication in Health and Medical Work 
MATILDA E. PAPPOE (Ghana) 

Preparation for Public Health Nursing Home Visit 
CECILIA DEFIE-MENSAH (Ghana) 



Topical Outline . . . MODULE L; HEALTH WORKER AND COMMUNITY 

waing and Midiifevy Bibliography 258 



II. BOOKS 

BYRNE, MONICA and F.J. BENNETT 

Community Nursing in Developing Countries, a Manual for the Auxiliary 
Public Health Nurse. London: Oxford University Press, 1973. 

DIVINCENTI, MARIE 

Administering Nursing Services. Boston: Little, Brown & Co., 1972. 
FREEMAN, RUTH B. 

Community Health Nursing Practice. Philadelphia: W.B. Saunders, 1970, 
FOSTER, GEORGE M. 

Traditional Societies and Technological Change, 2nd edition 
New York: Harper and Rowe, Inc., 1973. 

JELLIFFE, DERRICK B. 

The Assessment of Nutritional Status of the Community. Geneva : 
World Health Organization, 1966, 

LEAHY, KATHLEEN M. and MARGUERITE COBB 

Community Health Nursing. 2nd edition. New York: McGraw-Hill 
Book Co., 1972. 

LEEDAM, ELIZABETH J. 

Community Nursing Manual! A Guide for Auxiliary Public Nurses. 
Singapore: McGraw-Hill International Book Co., 1972. 

MACLEAN, UNA 

Magical Medicine: A Nigerian Case-Study. London: Penguin, 1971. 
PAUL, BENJAMIN DAVID and WALTER B. MILLER 

Health. Culture and Community ; Case Studies of Public Reactions 
to Health Programs, New York: Russell Sage Foundation, 1955, 

REINHARDT, ADINA M. and MILDRED D. QUINN (eds.) 

Family Centered Community Nursing: A Socio-Cultural Framework. 
St. Louis: C.V. Mosby, 1973, 

ROSS, MURRAY G. 

Community Organization: Theory, Principles and Practice. 
New York: Harper and Rowe, 1967. 



A Topical Outline . . . MODULE L: HEALTH WORKER AND COMMUNITY 

Cursing and Midwifery Bibliography 259 



II. BOOKS 



SHIFTMAN, M.A. and S. EAJAGOPALAN 



Gu 1 de t o Simgjle^S aii 1 1 ar ^J^a^^^ ^g^ t he C on, t r o 1 ^o f En. t e r 1 c 
Pi Be ages. Geneva: World Health Organization, 1974. 



A Topical Outline ... CHAPTER 5 

fti&eing and Midwifery page 261 



CHAPTER : 

INSTRUCTIONAL STRATEGIES 

Fronfc T. Stritter 



An instructional strategy can be very simply defined as a plan of 
learning activities designed to enable students to achieve a particular 
educational goal. 

I. FACTORS INFLUENCING THE EFFECTIVENESS OF INSTRUCTION 

Two important considerations influence the instructor's use of strategies 
for his/her instructional responsibilities. The first consideration is a 
workable set of programme/course goals or objectives defined as indications 
of what the students are expected to know, to do, or to feel as a result of 
instruction. Goals are general, often expressed in broad or abstract terms, 
and apply to an entire programme or course. An example of a goal is, "Students 
will develop an awareness of the needs of the elderly in relation to biological, 
sociological and psychological changes in the process of aging. 11 An objective 
IB more specific and might relate to a smaller segment of the instruction. 
An example might be> "Students will be able to describe the stages of psycho- 
logical development in late life and be able to indicate the stage of a par- 
ticular patient." The instructor can use goals and objectives as a guide in 
preparing a meaningful and cpnsistent program and in selecting and organizing 
appropriate strategies. 

A second important consideration influencing choice and use of strategies 
Is an understanding of how people learn, A series of factors or variables 
should be considered regardless of the particular instructional strategy that 
one chooses. The more that one can attend to each factor in the development 
of instruction, the more he/she can be assured that optimal conditions for 
learning have been provided. Significant factors, described with specific 



Topical Outline ... CHAPTER 5 

and Midwifery po.ge 262 



illustrations taken from the teaching of care for the aged, 
are the following: 

A. MEANINGFULNESS 

Students tend to learn more if they know why they are studying a 
particular topic, subject or skill - that is, what meaning it has for them. 
By carefully outlining the relative importance of the subject matter, its 
relation to what has been studied previously and to what will be studied in 
the future and its possible utility in the student's future, the meaningfulness 
of the subject can be enhanced. 

"It ia recognized by practitioners in rural areas of Africa 
that many of the symptoms suffered by the elderly are either caused 
by or exacerbated by emotional factors. Understanding the psycho- 
logical aspects of aging now will enable you to better deal with the 
care of elderly persons." 

B. EXPECTATIONS 

Students tend to learn better if they know what is expected of them, 
than If they do not know. Teachers should therefore inform students what 
they should be able to do as a result of the Instruction and how well they 
should be able to do it. It is not necessary to be overly specific, but 
students do benefit fron a guide for organizing their learning. 

"You should b* able to Illustrate the Impact of 1) loss of self-image, 
2) loss of fanily support, 3) dirainished sexual ability, on the 
health status of the elderly by citing specific clinical examples, 
and then generalize your examples to the population of the elderly 
as uch as you can justifiably." 

C. PLEASANT CONDITIONS 

A comfortable congenial setting is important to learning. If students 
like what they are doing and are not distracted by unpleasant characteristics 
in the environment, their learning will be likely to be effective and 
efficient. 



A Topioat OutHm ,., CHAPTER 6 

and ttidtifery page 



"An introduction to the psychology of aging might be to have the students 
interview a variety of elderly men and women in their homes in both 
urban and rural settings and then to present and discuss the findings 
in a aeries of student conferences in the student lounge," 

P. ACTIVE FRACTICl 

The instruction ahould include opportunities for students to use the 
knowledge and/or skills which they are expected to learn in exercxse. Such 
practice might be in the form of self-test, oral quizzes, simulated or 
practical exercises and should be provided for all students relatively fre- 
quently during the learning sequence. Requiring that students use the in- 
fo-mation actively - in ways that are consistent with one's objectives - 
is one of the most important learning principles that a teacher can apply 
in his/her teaching. 

"Illustrate the impact of psychological factors on the health problene 

of the aged by analysing, the results of one of your interviews. 

Generalise your findings Co the extent justified by the quality of 
your findings." 

E. ..FEEDBACK 

After students participate in practice exercises, they should be able 
to determine the results of their practice. Only cnrougn reecoack or cms 
nature can a student try out hia understanding of the concepts being taught 
and correct any misunderstandings or deficiencies, chat may be present:. 
Faadba-ck should provide a<M discussion of the appropriate respoas,e and 
indicate what can t done to achieve a better result. 

"You have obviously understood the psychodyuamics o the health sit- 
uation of the widow y.oti interviewed. You should be able to give tear 
good me-dical care. Your generalizations however, are weak. After 
all,, not all widows ar* efoi Idlers as in the case you discussed. H ' 



odT reward o>r iacerttive Sen: aaa 
ap-jMro-riate response or behavior. A positive re in force man t of this nature 
will b*a likely to. 3.trag..eha, th bhayloc that producas it aad inuc.reaff 



A Topical Outline . . . CHAPTER 5 

Nweing and Mic&ifery page 264 



the probability that It will re-occur. The best reinforcement comes through 
the task itself, that is when the student is correct and can make that 
determination. Other forms of reinforcement include attention, recognition, 
praise and/or confirmation of correct answers from the Instructor, free time 
at the conclusion of a successful performance, time for social Interaction 
with peers, grades and other awards. Whenever possible, be positive. 

"I intend to take the interview schedule you used In the rural setting 
and use It as an illustration for next year's course." 



II. CATEGORIES OF INSTRUCTIONAL STRATEGIES* 



Instructional strategies can be divided into two categories, one is 
instructional formats, which IB the activity through which Instruction 
occurs, or the manner in which It is organized. The other is instructional 
media, which is the manner in which information is communicated to a student. 
Representative types of media are diagrams or illustrations, printed language 
in books, self-instructional materials, films, slides or the Individual 
teacher lecturing to the students. The following section will focus on a 
description of the principal Instructional formats, indicate the major uses 
of each and list representative advantages and disadvantages . 

A. LECTURE/DISCUSSION 

This approach is most often used with large groups of students where 
the instructor is the primary source of information and normally communicates 
to students in a one way manner at a specific time and place, usually a 
lecture setting. Sons students may have an opportunity to participate, but 
their interaction is generally limited and not planned. Lectures are effi- 
cient ways of communicating factual information and students generally find 
this approach adequate when recall of that information is tested at a later 
time. 



*) Material In this section is based on a typology developed by 

Charles P. Friedmann, of the Office of tedlcal Studies, University 
of North Carolina, School of Medicine, 



A Topical Outline , . , CHAPTER 5 

Nursing and Midwifery p age 285 



In addition, the lecture often serves a modeling function, allowing students 
the opportunity to observe scholars and professionals in their roles. There 
are some disadvantages, however. 

1. The learning needs of individual students cannot be accommodated 
easily, 

2. The students' role is generally passive, and 

3. Students do not generally acquire higher level intellectual abil- 
ities and attitudes as well as with some other formats. 

Some important points should be remembered when lecturing; 

1. The purpose and objectives of the lecture and their importance 
to learners should be communicated, 

2. Any "ground rules" for audience participation should be set. 

3. The material and its message should be organized and presented 
logically and sequentially. 

4. Attention should be drawn to or focus upon the main points. 

5. Specific examples should be used to Illustrate main points. 

6. The presentation should be paced so that students can take notes. 
Consider distributing outlines which will guide note taking, 

7. Transitions should be made between different segments of the 
lecture . 

8. Evidence sJu-uliI be cited to support: sta^e:nen!:& , av,J f?.:i:s should 
be separated from opinion. 

9. The Instructor should work with only one medium at a time. 

10. Supplementary resources should be prepared and presented and 
authorities should be cited when appropriate. 

11. The instructor's own viewpoint should be presented along with 
divergent viewpoints for contrast and comparison, 

12. New and/or technical terminology should be clarified. 

13. Student questions and comments should be stimulated, responded 
to and reinforced. 

14. Summaries should be made periodically to reinforce important 
points and to achieve closure on issues. 



B. SMALL GROUP INSTRUCTION 

This approach Promotes extensive peer interaction. It is organized 
around a specific task and utilizes small groups of less than 13 students. 



4 Topical Outline ... CHAPTER S 

and 



The se8sions are student-centered and controlled, with the Instructor serving 
only as a resource. Studies have shown that groups tend to generate more 
and better information and that the members are more inclined to accept the 
results when they have an opportunity to discuss it in a group than if they 
merely accept it from a teacher or work it out individually. Group members 
in addition are more likely to apply correct concepts, develop appropriate 
attitudes, increase their motivation, and develop collaborative akills as a 
result of participation in small student centered groups. 

Student-centered or small group discussion should have a task as its 
basis, not so specific that it will stifle creativity and student desired 
directions, but specific enough to provide some direction for the group. To 
begin the discussion, one might use a common experience followed by a "Why- 
did 7" question, a problem without a specific solution or one that is 
controversial. For students to learn effectively through student-centered 
discussions, they should develop certain skills: 

1. Clarifying what the group is trying to do, 

2. Developing a willingness to talk about one's ideas openly 
and to listen and respond to the ideas of others, 

3. Planning effectively and efficiently so that Issues can 

be formulated and out-of-clasa assignment can be determined 
before the group breaks up, 

4. Reinforcing the ideas of others so that their motivation to 
participate will be Increased rather than decreased, 

5. Sensitivity to the feelings of other group members, 

6. Evaluating the various aspects and outcomes of the discussion. 

C. SEMINARS 

Like the previous approach, this one Is based on group learning and active 
student participation, but in contrast each session is led by the instructor. 
In small group instruction, the instructor acts only as a resource and does 
not interfere unless asked by the students. In the seminar, the group leader 
adopts a democratic method of conduct. Policies and decisions are a matter of 
group discussion, but he facilitates, encourages and assists the process. By 
selecting the stimulus that sets the group in motion and by outlining the goals 
and procedural rules, he defines the group task. He establishes a model for 
behavior of other group members. He is the chief facilitator of communication 



A Topical Outline .... CHAPTER 5 

ftiweing and Midwifery page 26? 



and Interaction and is prepared to assume the role of expert when he feels 
it appropriate. 

There are several seminar/discussion processes that can be used in a 
classroom setting: 



1. Get-acquainted activities which facilitate group members' getting to 
know each other before significant discussion is undertaken. Each 
participant might be responsible for finding out something signifi- 
cant about another participant and then describe him/her to the 
group . 

2. Individuals might work in pairs to undertake specific tasks or to 
provide each other feedback on the results of a task, 

3. Discussions can be started with questions to specific people about 
problems, opinions, etc., which the leader knows that individuals 
hold. 

4. Different participants and observers can be designated from meeting 
to meeting so that roles will be distributed and large groqpa can 
be broken into a manageable size for discussion. 

5. Tasks can be organized so that groups compete against each other 
for results. 

6. Cooperative tasks can be developed in which groups work together 
to complete a project or produce a product. 

7. Paper and pencil exercises or questionnaires can be completed by 
Individuals and then responses compared as a stimulus for discussion. 

8. Case studies may be used in which students read background informa- 
tion prior to discussion and then arrive at a solution or recommen- 
dation. The group is asked the question - "Now what to do?" 

9. In role playing students act out a particular situation or inter- 
action, using clearly defined roles as a discussion stimulus. 

10. Games can be used, usually involving two or more persons. Specific 
information on rules opposing interests or conflict, constraints, 
goals or expected conslusions may be provided. 



D. INDIVIDUALIZED INSTRUCTION 

In this approach the individual student works to accomplish specific 
learning tasks at his own rate. It has several unique characteristics. 
First, the content is organized into a series of sequential units. Second, 
each unit has objectives, i.e., statements describing what the learner is 
expected to know, do or feel as a result of the instruction. Third, each 
unit includes a learning activity provided In any of a variety of forms which 
can be pursued individually. Fourth, through a readiness test after each unit, 



A Topical Outline ... CHAPTER 5 

Nursing and Midwifery po.ge 268 



the student demonstrates that he can perform the objectives of the present 
unit before he/she can begin to work on the next one. Finally, the whole 
process has to be accomplished at the student's own individual rate. Students 
move step by step through each unit of the course or prqgranme, ending only 
when they have completed all objectives. Contact with the instructor can be 
much or little, depending on the way instruction is organized. A course 
organized in this manner is designed to maximize success and reduce failure 
by permitting some students to finish before and others after the regularly 
scheduled completion time. 

E. EXPERIENTIAL LEARNING 

Through thia approach a student or group of students learn independently . 
The Instructor usually helps the students formulate problems, find answers 
and evaluate their own progress. Through an apprenticeship the students assume 
some portloiuof the role of a professional and endeavour to determine the 
"real world" relevance of the material, information or skills that they have 
been learning In the formal academic portion of the programme. Alternatively, 
the students may design, initiate or carry out their own projects. Here the 
students generally have complete responsibility for a project with a finite 
beginning and ending. For example, the student might carry out a survey and 
write the report. A final option for the student is to participate in an 
Instructor- led project or team as a participant. He/she participates relative- 
ly autonomously, but nevertheless is definitely a junior colleague contri- 
buting only to the extent of his knowledge and experience. 



III. ONE IMPORTANT POINT TO STRESS 

One well-known fact about instruction is that there probably Is no one 
best teaching strategy for all teachers to use with all students in all 
situations. There are ways for the teacher to make a decision, however. First 
a teacher may, on the basis of educational philosophy and personal preference, 
choose the strategy that beet suits the needs of his students. Students learn 
differently; consequently this consideration may well be the most important. 



A Topical Outline ... 

and Midoifery page 



More than one format or approach should be used whenever possible. Finally, 
a teacher must make a choice, yet be prepared Co test and modify the decision 
Thus, he must collect information on how well and how much students learn, 
how well they like it, how costly it is in time and money and how well the 
instructors like it. Using this information, the instructor can revise his 
programme to provide a better experience the next time it is offered. 



A Topical Outline ... CHAPTER 6 

Nursing and Midwifery page 271 



CHAPTER 8 ; 

GUIDELINES FOR THE SELECTION AND UTILIZATION OF 
EVALUATION METHODS IN THE TEACHING OF FAMILY HEALTH 

Robert D. Stone 



I. PURPOSES OF EVALUATION 

In planning programmes of instruction, evaluation, la usually the last 
step to be considered, if it is considered at all. Evaluation is frequently 
con due te d after teaching ,has been designed and implemented, yet if It is to 
achieve its primary goals, it must be planned bef o re the teaching takes place 
In order to be maximally effective. If the teacher seriously thinka about 
what students should learn and .how they can best learn it, he will have already 
laid a firm foundation upon which to base useful and productive evaluation 
efforts. In essence the three basic evaluation questions will have been 
posed: 

1. Did the students learn what they should have learned? 

2. How effective was the teaching in helping the students to learn 
what they ahould have learned 1 ? 

3. What changes must be made in the teaching so that students will 
learn more effectively? 

It is the task of evaluation to answer these questions. To do BO the 
evaluation design should have: 

1. diagnosed shortcomings in student learning, 

2. established which skills and competencies students have acquired, 

3. provided a solid base for assigning grades to students, and 

4. detected areas of Instruction that need revision, as well as 
those that are already effective in bringing about the desired 
learning outcomes. 



I Topical Outline . . . 
Jursing and Mii&ifery 



CHAPTER 6 
page 2? 2 



This last point is extremely important since it suggests that much of the 
responsibility, and consequently, much of the credit or discredit for 
student learning rests in the hands of the teacher. Aa the designer, control- 
ler, and frequently, deliverer of instruction, the teacher must also be 
willing to share the consequences of his or her instructional actions. 
Students are not absolved of their responsibility for learning the material; 
on the contrary, learning is one of their major roles. But the teacher as 
the person who is a professionally recognized authority in a given field of 
learning must identify, define, and teach what is to be learned, and evaluate 
finally what Is learned. If students are not sufficiently motivated to learn 
the material, the expert teacher cannot fault the students without first ask- 
ing how he or she, as a teacher, can better motivate them to learn. 

Instructional evaluation focuses on the teaching program designed and 
presented to the students. It la useful to conceptualize an instructional 
programme as a system for producing student learning. Although the components 
of instructional systems may differ according to the needs of a particular 
school, department, course, or teaching programme, there are generalizations 
which can be made . The Topical Outline for the Teaching of .Family Health 
and its accompanying chapters illustrate the general categories of component 
parts. Such an instructional system is presented below, featuring the role 
of evaluation in relation to each component. 



Figure 1* THE MAJOR COMPONENTS OF AN INSTRUCTIONAL SYSTEM AND THE 
ROLE OF EVALUATION IN PROVIDING REVISIONARY INFORMATION 
FOR IMPROVING THE SYSTEM 



Topical Outline 
(Organization 
of Content) 



Available 
Resources 




Overall and 
Specific 
Objectives 




Teaching 
Methods 


\ 


' / ^ 



Evaluation Methods 
and Instruments 



Revisionary Data 



A Topical Outline . , . CHAPTER 6 

Nursing and Midwifery p age 



In the diagramme, the revisionary information is obtained from the 
evaluation methods and accompanying instruments that are utilized. Eval- 
uation itself is also one of the major components in this instructional 
system. Although it generally occurs last In a sequence of components, it 
serves a controlling function over all of the other components , Including 
Itself, Evaluation provides the Information necessary to improve each 
component in the system and to Improve the interrelationships among compon- 
ents, 

II. EVALUATION BASED UPON OBJECTIVES 

A fundamental strategy is to evaluate on the basis of instructional 
objectives. That is, to start with the behavioral objectives of the in- 
structional programme and determine through appropriately designed evaluation 
if they were, in fact, attained. These instruments must be so designed as to 
help the instructor detect which parts of the instructional system need im- 
provement to provide more effective learning. Since the relationships among 
components of an Instructional system are dynamic, a modification In one 
component will usually affect the other component, too, Thus, the evaluation 
plan should examine relationships among components while examining the indi- 
vidual components . 

The specific instructional objectives are the keys to any instructional 
system. In measurable terms, they indicate precisely the skills 
the student must demonstrate. If these skilled behaviors cannot be performed, 
the student has probably not learned, or at least not very well, and the 
instructional system in one or more of its components is likely to need re- 
vision. 

For example, If a number of students are unable to achieve a given 
instructional objective, one or more problems may be present: 

1. Evaluation methods inaccurately measure results 

2. Resources are Inappropriate or inadequate 

3. Teaching methods are ineffective 

4. Specific objectives are too difficult to attain - unrealistic 

5. Curricular topics are irrelevant to the achievement of objectives 



Topical Outline ... 
u^a ing and Midwifery 



CHAPTER 6 
page 274 



The first problem to consider is the quality of the evaluation methods. 
Do they provide useful information on student learning and the effectiveness 
of the instructional programme? Fortunately, this problem can be minimized 
fairly easily, If instructional objectives are specified, since they Indicate 
observable, measurable skills that students must exhibit. The success of 
student learning or instructional programmes is based on the performance of 
the skills specified in the objectives. The challenge for faculty therefore 
Is: a. to specify the conditions under which the behavior must be demonstrated 
and measured, and b. the degree to which or how well it must be performed. 

These questions having been settled, evaluation methods can be devised. 
Once they provide valid, consistent, and objective information, the remaining 
components of the instructional system can be assessed and revised accordingly. 

III. EVALUATION PROBLEMS, CRITERIA. AND METHODS 

Teaching faculty are likely to be the best judges of what evaluation 
conditions (situation in which students demonstrate learning) and criteria 
(how well they must perform) are most representative of the professional 
context in which their students will eventually practice. They should identify 
these conditions and criteria, therefore, and Incorporate them Into each 
performance objective as the faculty see fit. 

Out of a general pool of evaluation techniques, those that are appropriate 
for measuring and teaching certain kinds of student skills can be selected. 
These techniques are presented in. the table below. 



EVALUATION OF STUDENTS 


Skill Area 


Evaluation Criteria 


Evaluation Methods 


1, Clinical Procedures 


Quality of student perfor- 
mance 


Observation checklists , 
case studies, simula- 
tions, rating scales, 
patient records, 
patient interviews, 
student Interviews 


2. Clinical knowledge 
of science material 


Quality of student perfor- 
mance 


Written and oral exami- 
nations, problem solv- 
ing, case studies 



A Topical Outline 
Nursing and 



CHAPTEK 6 
page 275 



EVALUATION OF TEACHING 


Skill Area 


Evaluation Criteria Evaluation Methods 


1. Motivation 
of students 


Quality of student per- 
formance, degree of 
student effort 


All types of examinations, 
interviews, perception of 
content relevance 


2. Evaluation 
Methods 


Consistency and useful- 
ness of results 


Questionnaires or inter- 
views with checklists, 
rating scales , open-ended 
items related to specific 
problem areas, observation 
forms 


3. Teaching 
Methods 


Instructional charac- 
teristics, logical 
consistency with ob- 
jectives and resources 
cost-benefit 


Interviews with students 
and colleagues, observa- 
tion checklists, cost 
analysis 


4. Resources 


Cost-benefit of Instruc- 
tional materials, aids 
or personnel, logical 
consistency between ob- 
jectives and teaching 
methods 


Observation forms, cost 
calculations , document 
examination 


5. Objectives 


Degree of student 
achievement 


Test scores, interviews 
and questionnaires to 
students or colleagues 


6. Topics 


Agreement of experts 


Professional literature, 
survey of colleagues 



IV. CONTINUOUS EVALUATION 



Evaluation of students and instruction should occur continuously from 
the planning stages, through the teaching Itself, and finally, after it has 
been completed. Just as each of these stages in necessary, so are evaluation 
data regarding the success of each one. The sooner a component is evaluated, 
the sooner It can be improved. 

The sooner a student's behavior is assessed, the sooner he or she can 
correct it if necessary. For example, student abilities and Interests can 
be assessed before the curriculum is Implemented; resources and constraints 



A Topical Outline ... CHAPTER 6 

Nursing and Midwifery P a 9 e 



can be identified early. So can teaching and evaluation methods. By the 
same token, all of these can be monitored throughout the design and implemen- 
tation of the course and after it has been completed. 

V. IMPLICATIONS OF THE EVALUATION STRATEGY 

Evaluation by objectives can be an extremely powerful strategy for im- 
plementing A Topical Outline for the Teaching of. Family. Health_:_A Life-Cycle 
Approach since it provides continuous valid, consistent and objective data 
regarding student achievement and instructional effectiveness. The evaluation 
by objectives strategy is of particular value with respect to the Topical 
Outline because the objectives have already been defined by a group of health 
practitioners and educators who are familiar with the kinds of skills needed 
in the practice of family health care in the African context. The evaluation 
by objectives strategy gives primary consideration to the professional 
judgment of each faculty member by drawing on his or her expertise in the 
specification of the conditions and criteria that should be employed in 
assessing student competence in important skill areas. 



A Topical Outline ... APPENDIX I 

Nursing and Midwifery 



ADDRESSES OF PUBLISHERS 



Addison-Wesley Publishing Company Inc. 

Jacob Way 

Reading, Massachusetts 01867 

USA 

African Medical and Research Foundation 

Wlleon Airport 

P.O.B. 30125 

Nairobi 

Kenya 

Edward Arnold & Son 
25 Hill Street 
London, W1X 8LL 
England 

Butterworth's Publ. Ltd. 
88 Kingsway 
London, WC2B 6AB 
England 

Carolina Population Center 

University of North Carolina at Chapel Hill 

University Square 

Chapel Hill, N.C. 27514 

USA 

Churchill & Livingstone 

Division of Longman Inc. 

72 Fifth Avenue 

New York, N.Y. 10011 

USA 

F.A. Davis & CO 

1915 Arch Street 

Philadelphia, Pennsylvania 19103 

USA 

Dickinson Publishing Co., Inc. 
16250 Ventura Boulevard 
Encinco, California 91436 
USA 

Downstate Medical Center 

P.O.B. 24 

Brooklyn, New York 11203 

USA 



, n, i n.4.f APPENDIX I 

A Topical Out^^ne ... 

Nursing and Midwifery F y 



Family Service Association of America 
44 East 23rd Street 
New York, N.Y. 10016 

USA 

Fearon Publishers Inc. 

Division of Pitman Publishing Corp. 

6 Davis Drive 

Belmont, California 94002 

USA 

Halsted Press 

Division of John Wiley & Sons, Inc. 

605 Third Avenue 

New York, N.Y. 10016 

USA 

Hamlyn Publishing Group 

Astronaut House 

Hounslow Road 

Feltham, Middlesex TWI 49AR 

England 

Harper & Rowe Publishers Inc. 
10 East 53rd Street 
New York, N.Y. 10022 
USA 

International Confederation of Midwives 
47 Victoria Street 
London SW1H OEQ 
England 

International Planned Parenthood Federation 
18-20 Lower Regent Street 
London, SW1Y 4PW 
England 

Johns Hopkins University 
615 N. Wolfe Street 
Baltimore, Maryland 21205 
USA 

J.B. Lippincott & CO 
521 Fifth Avenue 
New York, N.Y. 10017 
USA 

Little, Brown & CO 

34 Beacon Street 

Boston, Massachusetts 02106 

USA 



APPENDIX I 
page 2? 9 



Longman Publishers Inc. 

19 West 44th Street, Suite Iol2 

New York, N.Y. 10036 

USA 

McGraw Hill Book CO 

1221 Avenue of the Americas 

New York, N.Y. 10036 

USA 

C.V. Mosby & Sons 

11830 West Line Industrial Drive 

Saint Louis, Missouri 63141 

USA 

National Academy of Sciences 
Printing and Publishing Office 
2102 Constitution Avenue 
Washington, D.C. 30418 
USA 

Oxford University Press 

200 Madison Avenue 
New York, N.Y. 10016 
USA 

Penguin Books Inc. 
625 Madison Avenue 
New York, N.Y. 10022 
USA 

Prentice Hall Inc. 

Englewood Cliffs, New Jersey 07632 

USA 

Random House 

201 East 50th Street 
New York, N.Y. 10022 
USA 

Russel Sage Foundation 

230 Park Avenue 

New York, N.Y. 10017 

USA 

W.B. Saunders 

West Washington Square 

Philadelphia, Pennsylvania 19105 

USA 

University of Chicago Press 
5801 Ellis Avenue 
Chicago, Illinois 60637 
USA 



Topical Outline 
wsing and Midwifery 



APPENDIX I 
page 280 



World Health Organization 

Q Corporation 

49 Sheridan Avenue 

Albany, New York, 12210 

USA 

John Wiley and Son 
605 Third Avenue 
New York, N.Y. 10016 
USA 



A Topical Outline . . . APPENDIX II 

Nuroinrj and Midwifery page 282 



SOURCES OF TEACHING AIDS 



The following In a partial Hat of organizations where various types 
of touching materials on topics In family health may be obtained. These 
organisations produce und/or distribute printed materials, films, slides, 
noHtorn, flip charts, and multi-media packages. Moet materials must be 
purchnHcd; however some sources can offer their media free of cost. By 
writing to the addressed below, information or catalogues listing types 
of media, content areaa , Intended students, cost, and descriptions of their 
nudio-vlBunl materials can be obtained. 

African Medical and Research Foundation 

Wilson Airport 

P.O.D. 30125 

Nairobi 

Kenya 

Hwrcou d 1 Etudes et de Recherches Pour la Promotion de la Sante 

Kangu-Mayumbe 

Republlque du Zaire 

(hofl materials In French and English) 

Carolina Population Center 
Educational Materials Program 
University of North Carolina 
401 University Square 
Chapel Hill, N.C. 27514 
U.S.A. 

Catholic Relief Fund 
11 Rue de Cornavin 
CH-1201 Geneva 
Switzerland 

ENI Communication Centre 
P.O.B, 2361 
Addis Ababa 
Ehtlopla 

Foundation for Teaching Aids at Low Cost (TALC) 

Institute for Child Health 

30 Gullford Street 

London, WC1N 1KH 

England 



APPENDIX II 

A Topical Outline ... page 252 

Nursing 'and 



international Audio-Visual Resource Service 

Borland House 

18-20 Lower Regent Street 

London, SW1Y 4PW 

England 

mternational Planned Parenthood Federation: 

Headquarters : 

18-20 Lower Regent Street 
London, SW1Y 4PW 
England 

Regional Office: 
IPPF 

p.O.B. 30234 
Nairobi 
Kenya 

African Regional Council Sub-Office: 
IPPF 

P.O.B. 7699 
Accra Worth 
Ghana 
Planned Parenthood Federation of America, Inc. 

The Alan Guttmacher Institute 

151 Madison Avenue 

New York, N.Y. 10022 

U.S.A. 

National Food and Nutrition Commission 

P.O.B. 2669 

Lusaka 

Zambia 

The Pathfinder Fund 
850 Boylston Street 
Boston, Massachusetts 02167 
U.S.A. 

Population Reference Bureau 
1755 Massachusetts Avenue H.W. 
Washington, B.C. 20036 
U.S.A. 

Royal Tropical Institute 

Department of Tropical Hygiene 

63 Mauritskade 

Amsterdam 

The Netherlands 

World Council of Churches 
Christian Medical Commission 
150 Route de Ferney 
CH-1211 Geneva 20 
Switzerland 



Since 1961 when the Peace 
zens have served as 

'' 



A3UA mien me re ace Corn 
have served as Volunteers iU*5 Cir eated, R, re than 80,000 U.S cltl 

PCvl Sre P nvolvpd% rd Wo?!^* 1 ^^ C0untr1 * s > I1v1n 9 "d working 
* L5 lnv 76d 1n Programc \j S , co11ea 9 ues a "d co-workers. Today 
J HP^I SS S i! h funda ^ntal r dest 9ned to help strengthen loca clpa- 
y development, nutrition and h^ C ^u S ? s food Production, water supply, 
Coros . .... HeaUh educat1on and Deforestation. 



city to 
energy deve 



Peace Corps overseas offices- 



BELIZE 

P.O. fox 4B7 

Belize City 

.BENIN 

FFT71 

Cotonou 



BOTSWANA 
T.6. 6 ox 93 
Gaborone 

BURKINA FASO 
BP 537-Samandln 
Ouagadougou 

BURUNDI 

c/o American 

Embassy 

Bujumbura 

CAMEROON 
IF~BT7~~ 
Yaounde 

CENTRAL AFRICAN 

SMEE 
ITTuW" 

Bangui 

COSTA RICA 
Apartado Po s t a 1 
1266 
San Jose 

DOMINICAN REPUBUC 
Apartado Postal 
1412 

Santo Domingo 




Box "94 






GHANA 



ox 5796 
(North) 



HATM 



Port -u.p r1ncc 

HONDURAS 

Postal 




EASTERN 
Inc 



CARIBBEAN 
Antigua, 



uding 

Barbados, Grenada, 
Montserrat, St, 
Kltts-Nevls.St, 
Lucia, St. Vincent, 
Dominica *EMn 
Court" Bishops 
Court Hill 
P.O. Box 696-C 
Bridgetown, Barbados 



Avenue 
ngston 10 



- 30518 



554 



Monrovia 



MALI 
W^5 
Box 564 

MAURITANIA 
feP 222 
Nouakchott 

MICRONESIA 
P.O. Box 9 
Kolonla, Ponape 
F.S.M. 96941 

MOROCCO 
1 , Z a n q u a t 
Benzerte 
Rabat 

NEPAL 

KO. Box 613 

Kathmandu 

NIGER 

TTTCI537 

Niamey 

PAPUA NEW GUINEA 

r\0. Box 1790 

Boroko 

Port Moresby 

PARAGUAY 
c/o American 
Embassy 
Asuncion 

PHILIPPINES 
'P.O. Box 7613 
Manila 

RWANDA 

c/o American 

Embassy 

Kigali 

SENEGAL 
BP 254 
Dakar 

SEYCHELLES 
BP 697 

Victoria 
SIERRA LEONE 



SOLOMON 
?.~0. Box" 
Honiara 



SRI 'LANKA 
sU/5 Sir 1 pa 
Colombo 5, 
Sr1 Lanka 



ISLANDS 



Roac 



SUDAN 

ffjbdi Deutsch 

Administrator/PC 

c/o American Emt 

Khartoum 



SWAZILAND 
F."0. Box 
Mbabane 

TANZANIA 

Box 

Dar 



362 



es Salaam 



THAILAND 
42 Sol 

Somprasong 2 
Petchburl Road 
Bangkok 4 

TOGO 

ITO194 

Lome 

TONGA 



Nukualofa 



TUNISIA 

BP 96 

1002 Tunis- 
Belvedere 
Tunis 

WESTERN SAMOA 
Private Mall Bag 
Apia 

YEMEN 

FTffTBox 1151 
Sana'a 

ZAIRE