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UNIT I Nursing Foundation.pptx

beminaja
4. Nov 2022
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UNIT I Nursing Foundation.pptx

  1. UNIT I : INTRODUCTION CONCEPTS OF HEALTH Prepared By :Mrs Bemina JA Assistant Professor ESIC College of Nursing Kalaburagi
  2.  By the end of the lectures on the Concept of Health and Disease you should know and understand the following  • Changing concepts of Health;  • Definitions of Health; New Philosophy of Health;  • Dimensions of Health; Positive Health;  • Concept of Wellbeing; Physical Quality of Life Index (PQLI); By the end of the lecture the students should know and understand the following  • Determinants of Health; Ecology of Health; Responsibility for Health; Health and Development;  • Indicators of Health
  3.  Biomedical Concept (Health has been viewed as an “absence of disease”, and if one was free from disease the person was considered healthy)  Ecological Concept (Health implies the relative absence of pain and discomfort and a continuous adaptation and adjustment to the environment to ensure optimal function)  Psychosocial Concept (Health is both a biological and social phenomenon)  Holistic Concept (A sound mind in a sound body, in a sound family, in a sound environment; All sectors of society like agriculture, animal husbandry, food, industry, education, housing, public works, communication & other sectors have an effect on health)  It recognizes the strength of social, economic, political and environmental influences on health. Implies that all sectors of society have an effect on health Ancient view: Sound mind, in a sound body, in a sound family, in sound environment Emphasis is on promotion and protection of health
  4.  WHO Definition: “ Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity and the ability to lead a socially and economically productive life”.  Operational Definition of Health: “ A condition or quality of the human organism expressing the adequate functioning of the organism in given conditions, genetic or environmental”.  Thus Health means  (a) No obvious evidence of disease and that the person is functioning normally  (b) Several organs of the body are functioning adequately as well as in relation to one another (Equilibrium or Homeostasis).
  5.  • Health is a fundamental Human Right  • Health is the essence of productive life  • Health is inter sectorial  • Health is an integral part of development  • Health is central to the concept of quality of life  • Health involves individuals, state and international responsibility  • Health & its maintenance is a major social investment  • Health is a worldwide social goal
  6.  • Health is multidimensional,  WHO definition envisages three (3) specific dimensions, however there are many more dimensions: •  Physical What does physical health mean?  Perfect functioning of the body in which each organ is working in harmony with the maximum capacity How is it achieved?  By exercise, healthy diet, adequate rest & sleep, and no addictions. What are the signs of good physical health?  A healthy skin texture  Bright eyes  Not too thin or fat  A good appetite  Regular bowel and bladder activities  Smooth and easy coordinated movements  The resting, pulse rate, blood pressure and exercise tolerance are all within the range of "normality" for the individual's age and sex.  Steady gain in weight till 25 years and constant thereafter
  7.  i) Self assessment of overall health  ii) Inquiry into symptoms of ill health and risk factors  iii) Inquiry into medications  iv) Inquiry into level of activity  v) Inquiry into use of medical services  vi) Standardized questionnaires for cardiovascular diseases vii) Standardized questionnaires for respiratory diseases viii) Clinical examination  ix) Nutrition and dietary assessment and  x) Biochemical and laboratory investigations  Community Assessment: At the Community Level, state of health may be assessed by such indicators as:  • Death Rate; Infant Mortality Rate and Expectation of Life
  8.  What is good mental health? The ability to respond to the many varied experiences of life with flexibility and a sense of purpose  Definition: "A state of balance between the individual and the surrounding world, a state of harmony between oneself and others, a coexistence between the realities of the self and that of other people and that of the environment"  Psychological factors can induce all kinds of illness not simply mental ones which may include:  Essential Hypertension;  Peptic Ulcer and Bronchial Asthma • Some major Psychiatric Illnesses like Depression and Schizophrenia have biological component
  9.  A) Free from internal conflicts, is not at war with him or herself  B) Well adjusted: Is able to get along well with others. Accepts criticism and is not easily upset  C) Searches for Identity  D) Has a strong sense of self esteem  E) Knows oneself, ones needs, problems and goals (this is known as self actualization)  F) Has good self control, balances rationality and emotionality  G) Faces problems and tries to solve them intelligently, i.e., coping with stress and anxiety One of the keys to good health is Positive Mental Health.
  10.  Harmony and integration within the individual, between each individual and other members of society and between individuals and the world in which they live  Definition: "Quantity and quality of an individual's interpersonal ties and the extent of involvement with the community"  • Social health takes into account that every individual is a part of a family and a wider community and focuses on social and economic conditions and well being of the “Whole Person” in the context of his social network.  • Social Health is rooted in “Positive material environment” (focusing on financial and residential matters) and “Positive human environment” which is concerned with social network of the individual.
  11.  It includes integrity, principles and ethics, the purpose in life, commitment to some higher being and belief in concepts that are not subject to "state of the art" explanation  (Spiritual health in this context, refers to that part of the individual which reaches out and strives for meaning and purpose in life)
  12.  Mental health can be seen as "knowing" or "cognition" while emotional health relates to "feeling"  (Initially mental and emotional dimensions were seen one in the same thing but as more research becomes available a definite difference is emerging.
  13.  When work is fully adapted to human goals, capacities and limitations, work often plays a role in promoting both physical and mental health the culmination of the efforts of other dimensions as they function together to produce what the individual considers life "success"  (Importance of this dimension is exposed when individuals suddenly loose their jobs or are faced with mandatory retirement.  For some this dimension may merely be a source of income but for others it may be source of self worth and life success.  Goal achievement and self realization in work are source of satisfaction and enhanced self esteem)
  14.  Philosophical,  Cultural,  Socioeconomic,  Environmental,  Educational,  Nutritional,  Curative  Preventive.
  15.  A variable which helps to measure changes , directly or indirectly (WHO,1981).  The health indicators are defined as those variables which measures the health status of an individual and community.  Mortality Indicators: Crude Death rate, Life Expectancy, Infant mortality rate, Child mortality rate, Under five mortality rate, Maternal mortality ratio, Disease specific mortality, proportional mortality rate etc.  Morbidity Indicators: Incidence and prevalence rate, disease notification rate, OPD attendance rate, Admission, readmission and discharge rate, duration of stay in hospital and spells of sickness or absence from work or school.
  16.  Nutritional Status Indicators: Anthropometric measurement of preschool children, Prevalence of low birth weight etc.  Health Care Delivery Indicators: Doctor- population ratio, Bed-nurse ratio, Population- bed ration, Population per health facility etc.  Utilization Rates: immunization coverage, ANC coverage, % of Hospital Delivery, Contraceptives prevalence rate, Bed occupancy rate, average length of stay in hospital and bed turnover rate etc. 16
  17.  Indicators of social and mental health: Rates of suicides, homicides, violence, crimes, RTAs, drug abuse, smoking and alcohol consumption etc.  Environmental indicators: Proportion of population having access to safe drinking water and improved sanitation facility, level of air pollution, water pollution, noise pollution etc.
  18.  Socio Economic Indicators: rate of population increase, Per capita GNP, Dependency ratio, Level of unemployment, literacy rate, family size etc.  Health policy Indicators: proportion of GNP spent on health services, proportion of GNP spent on health related activities including safe water supply, sanitation, housing, nutrition etc. and proportion of total health resources devoted to primary health care.  • Indicators of Quality of Life: PQLI physical quality of life index , IMR, Literacy rate, Life Expectancy at age one etc.
  19.  WHO definition of health introduces the concept of “well being”.  It has both subjective and objective components.  Standard of Living (Spiritual , educational, recreational and other services may be used individually as measures of socioeconomic status and collectively as an index of the standard of living”.  The standard of living depends on the per capita GNP)
  20.  It consists of nine components: health, food consumption, education, occupation and working conditions, housing, social security, clothing, recreation and leisure and human rights.  These objective characteristics are believed to influence human well being  Quality of Life  It is a subjective component and is defined by WHO as “ The condition of life resulting from the combination of the effects of the complete range of factors such as those determining health, happiness (including comfort in the physical environment and a satisfying occupation, education, social and intellectual attainments, freedom of action, justice and freedom of expression.”)
  21.  According to Betty Newman (1990) "Health on a continuum is the degree of client wellness that exists at any point in time, ranging from an optimal wellness condition with available energy at its maximum to death, which represents total energy depletion.  “ According to Health-illness continuum model,  'Health is a dynamic state that continuously alters as a person adapts to changes in the internal and external environments to maintain a state of physical, emotional, intellectual, social, developmental and spiritual well-being. Illness is a process in which the functioning of a person is diminished or impaired in one or more dimensions when compared with the person's previous condition'.
  22.  Because health and illness are relative qualities existing in varying degrees it may be more useful to consider health and illness in terms of a point on a scale or continuum rather than a absolute state.  High level of wellness and sever illness are at opposite ends of the continuum  A nurse can determine a clients level of health at any point of time on the health illness continuum  Center to health illness continuum model are risk factors
  23.  The health illness continuum is a graphic illustration of a well being , concept first proposed by John. W. Travis in 1972.  It describes how wellbeing is more than simply an absence of illness , but also incorporates the individuals mental and emotional health.  Travis believed that the standard approach to medicines , which assumes a person is well when there are no signs or symptoms of disease , was insufficient.
  24.  Composed of two arrows pointing in opposite direction and joined at a neutral point.  Movement to the right to the arrows (toward the high level of wellness) equals an increase in level of health and wellbeing  • Achieved in three steps , • Awareness • Education • Growth  Movement to the left to the arrows (towards premature death) equates a progressively decreasing state of health.  • Achieved in three steps, • Signs • Symptoms • Disability
  25.  Most important is the direction is the individual facing on the pathway  A. If towards high level of health , a person has genuinely optimistic or positive out look despite his/ her health status.  B. If towards premature death , a person has a genuinely pessimistic or negative out look about his or health status.
  26.  Compares treatment model with a wellness model, If treatment model is used , an individual can move right only to the neutral point.  Eg: A hypertensive client who only takes his medications without making any other life style changes.  If wellness model is used , an individual can move right past the neutral point.  Eg : As hypertensive client not only takes medications but stops smoking , looses weight , starts an exercise programme etc
  27.  – To help the client to identify their place on the health- continuum.  – To assist the clients to adopt some measures in order to reach a well state of health.
  28.  The factors determining health are many  Some factors are inside the body genetics and some fact are out side the body environment .  Genetic  Environment  Biological  Social  Psychological  Others
  29.  Genetic Influences Race Sex Genetically Transmitted Diseases  Behavioral Influences Tobacco use Unhealthy diet Inadequate activity Alcohol and drug use Risky sexual behaviors Behaviors leading to intentional/unintentional injury Personal hygiene
  30.  Internal environment (organs )  External environment (air ,water, soil ,climate )  Indirect Health Risks Adequate housing Family composition Education level of parents Economic status of parents Direct Health Risks Infectious disease exposure Toxic substance exposure Radiation exposure Violence exposure
  31.  Biological Plants and Animals and pathogenic microorganism  Social Cultural Beliefs Traditions Psychological Mental disorder Psychological symptoms Personality trait Coping styles Maladaptive health behavior Stress related physiological response
  32.  Others Life style Socio economic conditions Education Occupation Income Health services Exercise Rest and sleep Posture Clean home environment Safety measures at play and work
  33. INTRODUCTION  Illness : An illness is the response ,the person has to disease .  It is an abnormal process in which the persons level of functioning is changed compared with a previous level.  Persons physical ,emotional, intellectual , social, developmental or spiritual functioning is diminished.  Illness is highly subjective ; only the individual person can say he or she is ill.
  34.  ILLNESS BEHAVIOR A coping mechanism , involves ways individual describes ,monitor ,interpret their symptoms ,take remedial actions , and the use of health care system.  DETERMINANTS OF ILLNESS BEHAVIOR  Recognisability of illness symptoms.  The extent the person perceives symptoms as serious.  Information, knowledge and cultural assumption.  Disruption in family work and social activity.  Frequency of appearance.  Toleration level.  Physical proximity of treatment resources
  35.  Biological factors [infection /pathogenic organisms ]  Physical factors [cold heat radiation pollution]  Psychological factors [stress, tensions,fear, anxiety and emotions]  Genetic /heredity factor  Idiopathic [unknown factors]  Traumatic [falls,injuries,accidents]  Iatrogenic [hospital induced ]  Neoplastic [cancers]  Congenital [by birth ,development of embryo growth of fetus]  Community causes  Epidemic [sudden out break of disease in a particular population ]eg Nipah,SARS  Endemic  Pandemic  Sporadic
  36.  Any condition that increases the chances of developing a diseases  Family history  Age  Gender  Lifestyle practices  Habits  Sedentary life style  Physical inactivity  Diet  Culture  Beliefs  Religious
  37.  Impact on family  Family dynamics is the process by which the family functions, makes decision, give support to individual members and copes with everyday changes and challenges which were reluctant to assume the ill role or responsibilities due to frequent hospitalization ,economic problems.
  38.  Family factors such as member of the family who is ill  Serious and length of illness  Cultural and social customs the family follows  Roles changes  Task reassignment and increased demands on time  Stress  Financial problems  Loneliness  Change in social customs
  39.  Impact on clients  Leads to behavioral and emotional changes such as  Irritable  Anger  Withdrawal  Denial  Hopelessness  Powerlessness  Lack of energy  Fear  Anxiety  Change in body image /physical appearance depending on the type of change Short term [they will accept] permanent [show reactions ]  Shock  Withdrawal  Acknowledgement  Acceptance  Rehabilitation  Use of prosthesis  Change in life style [diet ,exercise ,activity rest and sleep ]
  40.  Body defense or immunity is defined as action produced against infection may be local, systemic, non specific, specific, humoral and cellular.  Any antigen entering in body may stimulate single or generally multiple defense mechanisms.  It is a specific protective antibodies or cellular immunity as a result of previous infection  ACTIVE IMMUNITY: Individual naturally resistant to certain microorganisms  PASSIVE IMMUNITY: Individual develops as a result of previous contact with an organism
  41. Active Immunity  • Humoral Immunity  • Cellular Immunity  • Combination of humoral and cellular immunity Passive Immunity  • Normal human Ig  • Specific human Ig  • Animal antigen
  42. VACCINES  Live Vacine  Inactivated Vaccine  Toxoids IMMUNOGLOBULINS:  IgG IgM IgA IgD IgE ANTISERA OR ANTITOXINS
  43.  Currently health care system has five levels of care for which health care providers offers services:  Disease Prevention  Health Promotion  Primary Care  Secondary Care  Tertiary Care
  44.  It is defined as main social targets of governments and WHO in the coming decades should attainment of all citizens of the world by the year of 2000 of a level of health that will enable every individual to lead a socially and economically productive life
  45.  Realization of highest possible of health  Attainment of minimum level of health  Removal of obstacles to health such as unemployment, ignorance, poor living conditions, malnutrition etc  Health care services are within the reach of all in the country
  46.  The Alma Ata Declaration called for global strategy to provide guidelines for member countries to refer.  In 1981, Who global strategy for HFA is based on the following principles:  Health is a fundamental human right People have right and duty of participate individually and collectively in the planning and implementation of their health care  Existing gross inequality in the health strategies concern of all countries and must be drastically reduced  Government has responsibility for the health of their people  Countries and people must become self reliant in health matters  Governments and health professionals have the responsibility of providing health information  Equitable distribution of resources should be allocated most to those who need most  Primary health care would be the key to the success of HFA  Development and application of appropriate technology to health care system  Research in the field of biomedical and health care services
  47.  Reduction of infant mortality from the level of 125 to below 60  To raise the expectation of life at birth from the level of 52 years to 64  To reduce the crude death rate from the level of 14 per 1000 population to 21  To reduce the crude birth rate from the level of 33 per 1000 population to 21  To achieve a net production rate of one rural population
  48.  Health promotion refers to efforts are focused on promoting self actualization and integrated functioning among individuals, families, groups and communities  Health promotion programme lower the over all costs of health care by reducing the incidence of disease, minimizing complications and thus reducing the need to use more expensive health care resources.
  49.  DEFINITION: Health promotion is a process of helping people improve their health to reach an optimal state of physical, mental and social well being.
  50.  ACTIVE STRATEGIES OF HEALTH PROMOTION: Individuals are motivated to adopt specific health programme such as weight reduction and smoking cessation programme to improve the present & future level of illness while decreasing risk of disease  PASSIVE STRATEGIES OF HEALTH PROMOTION: Individuals gain from the activities of others with out acting themselves.  Eg: Fluoridation of municipal drinking water and fortification of homogenized milk with vitamin-D
  51.  Wellness is given in form of education teaches people how to care themselves in a healthy way and it can be achieved by awareness education, stress management and self responsibility.  Preventive care is more disease oriented and focused on reducing and controlling risk factors for disease through activities such as immunization and occupational health programmes  It means avoiding or removal or elimination of single known essential cause which produce illness
  52.  Primary prevention  Secondary prevention  Tertiary prevention Primary prevention  It can be defined as action taken prior to the onset of disease which removes the possibility that a disease will ever occur.  It includes health promotion and specific protection
  53.  HEALTH PROMOTION: First level of prevention is by promoting and maintaining the health of the host by nutrition, health education, good heredity and other health promotion activities  SPECIFIC PROTECTION: May be directed towards the agent like disinfection of contaminated particles, materials, water, food and other particles on the assumption that the agent has escaped into these vehicles or environment Specific protection can be achieved by immunization
  54.  Secondary prevention done by early diagnosis and treatment  It can be defined as action which halts the progress of the disease at its incipient stage and prevents complication.  Early detection of the disease ensures prompt treatment so that the disease will not progress further  Early detection of the disease is possible by periodic examination of population groups like antenatal mothers, growing children, industrial workers
  55. DIAGNOSIS  It can be defined as the detection of disturbances of homeostatic and compensatory mechanism while biochemical, morphological and functional changes are still reversible – WHO TREATMENT  It means measures directed at removing or relieving the cause of a disease  TYPES OF TREATMENTS:  Causal Treatment  Conservative Treatment  Curative Treatment  Empirical Treatment  Heroic Treatment  Palliative Treatment  Radical Treatment  Rationale Treatment  Specific Treatment  Symptomatic Treatment
  56.  It can be defined as all measures available to reduce or limit impairment and disabilities, minimize suffering caused by existing departures and disabilities, minimize suffering caused by existing departures from good health and to promote the patients adjustments to irremedial conditions.  Activities are directed at rehabilitation rather than diagnosis and treatment
  57. Rehabilitation  It has been defined as the combined and co ordinated use of medical, social, educational and vocational measures for training and retraining the individual to the highest possible level of functional ability – WHO AIMS:  To reduce the impact of disability and handicapping condition  To achieve social integration  Rehabilitation occurs in many health care settings including special rehabilitation agencies, out patient settings and home Rehabilitation services includes physical, occupational, speech therapy and social services  Specialized rehabilitation services such as cardiovascular, neurological, musculoskeletal, pulmonary and mental health rehabilitation programmes help patients and families adjust to necessary changes in life style and learn to function with the limitations of their disease  It restores a person to the fullest physical, mental, social, vocational and economic potential
  58.  MEANING: The word hospital comes from “hospes” which means host or guest Hospitals are organized institution for the care of the sick and injured  It is defined as an integral part of the social and medical organization, the function of which is to provide for the population, complete health care, both curative and preventive and whose outpatient services reach out to the families and its environment; the hospital is also a centre for the training of health workers and biosocial research - WHO
  59. Based on the ownership  Public hospitals  Voluntary hospitals  Private/ charitable/ nursing homes  Corporate hospitals Based on the length of stay  Short term stay – acute illness  Long term stay – chronic illness Based on the license to treat  General hospitals  Specialty hospitals  Based on the size  Teaching hospitals – 500 beds  District hospitals - 200 beds  Taluka hospitals -50 beds  Primary health centers – 4 – 30 beds Based on the system Allopathic Ayurvedic Homeopathic Unani Sidha Naturopathy Yoga
  60.  RECEPTION: it receives patients with illness and directs to OPD  Members: receptionist and nurse  Functions:  clarify the enquiry –  Guide the patients to various departments  Maintain various registers and records
  61. OUTPATIENT DEPARTMENT:  Registration  History collection and physical examination  Consultation with the doctor  References  Referral system  Initial admission procedures INPATIENT DEPARTMENT:  Admission and discharge of patients  Provision of medical and nursing care  Investigations  Health education  Infection control  Material management  Staff development
  62.  DIAGNOSTIC: Provide the diagnostic services for the early and prompt diagnosis of illness  THERAPEUTIC: Provide the curative services to the sick people  EMERGENCY CARE: Provide the emergency care to the patients for acute illness  CRITICAL CARE SERVICES: Provide the advanced tertiary care for the patients suffering from life threatening illness  REHABILITATION: Provides facilities for rehabilitative services such physical, occupational and speech therapy  PREVENTIVE SERVICES: Provide preventive services such as antenatal care, immunization, well baby clinic etc  HEALTH PROMOTION: Should actively participate in health promotion activities such as health education and family welfare clinics  EDUCATION AND TRAINING: Provide platform to offer the education for medical, nursing and paramedical students  RESEARCH: Research carried out to expand body of knowledge in the field of health sciences
  63. ADMINISTRATIVE DEPARTMENT:  Administrative officer  Assistant officers  Manager  Secretary  Treasury  Clerks  Accountants  Class IV workers Functions Staffing Maintenance of the hospital building Budgeting for the hospital Supervision Controlling and coordination among various functionaries Medical and nursing audit Performance appraisal Patient welfare activites Quality assurance Accreditation Reporting
  64.  Health care team work has been defined as a dynamic process involving two or more health care professionals with complementary backgrounds and skills, sharing common health goals, exercising concerted physical and mental effort in assessing, planning or evaluating patient care  Physicians  Nurses  Dieticians  Pharmacists  Laboratory Technician  Radiology Technician  Respiratory Technologist  Physiotherapist  Occupational Therapist  Social Workers  Psychiatrist  paramedical workers  health educators  health visitors  public health engineers
  65. DEFINITION: Activities directed toward increasing the level of well being – PENDER (1996)   HEALTH EDUCATION: A large number of diseases could be prevented through proper health education and awareness programme. Eg: Aids awarness programme, hygienic measures, cancer prevention, cessation of smoking, tobacco prevention, prevention of water borne diseases  ENVIRONMENTAL MODIFICATION: A comprehensive approach to health promotion requires environmental modification. Eg: Provision of safe water, Installation of sanitary latrines, Control of insects and rodents, Improvement of housing  NUTRITIONAL INTERVENTIONS: These comprises of food distribution and nutrition improvement of vulnerable groups such as under five children's and women's. Eg: Child feeding programme, Mid day meal programme, Prevention of anemia and vitamin – A deficiency  LIFESTYLE AND BEHAVIORAL CHANGE: It can be achieved through health education programme. Eg: Cessation of smoking, Tobacco prevention, Stress reduction programme Make changes in life style and attitude of people towards health related activities Facilitate patients involvement in the assessment, implementation and evaluation of health goals
  66.  Primary health care is an essential health care made universally accessible to individuals and families in the community, by means acceptable to them, through their full participation and at a cost that the community and country can afford  Health education  Maternal and child health care  Prevention of illness  Prevention and control of epidemic diseases  Treatment of minor illness and injuries  Adequate safe water and supply  Promotion of mental health  Adequate nutrition  Provision of essential drugs Immunization
  67.  ACCESSIBILITY: Permeates uniformly reach equitably to all segments of population  ACCEPTABILITY: Achieves accepts through cultural assimilation of its policies and programs  ADAPTABILITY: PHC system is highly flexible and adaptable  AFFORDABILITY: Affordable to consumer as well as providers  AVAILABILITY: Always to ready to respond to any demand at any time  APPROPRIATENESS: Evolves from the socio economic conditions, social values and health situation of a community  CLOSENESS: Health centre is close at hand to people at their door steps  CONTINUITY: Continuous service which extends from womb to tomb  COMPREHENSIVENESS: Comprehensive and curative needs of the community  COORDINATIVENESS: Dependent on inter sectoral coordination and community participation
  68.  EQUITABLE DISTRIBUTION: Shared equally by all peoples irrespective of their ability to pay (rich, poor, urban or rural)  COMMUNITY PARTICIPATION: Involvement of community in planning, implementation and maintenance of health services  COVERAGE AND ACCESSIBILITY: Cover the entire population and acceptable within easy reach of them  INTERSECTORAL COORDINATION: Requires joint efforts with other sectors such as agriculture, animal husbandry, housing, social welfare, public works, communication and other sectors
  69.  APPROPRIATE HEALTH TECHNOLOGY: Scientific adaptable to local need and socially acceptable instead of costly methods, equipment and technology  HUMAN RESOURCE: Very essential to make full use of all the available resources including human potential of the entire community  REFERRAL SYSTEM: Desirable to develop referring from one level to another with laid down procedures and policies  LOGISTICS TO SUPPLY: Include planning and budgeting for the supplies required manufacture, storage distribution and control  PHYSICAL FACILITIES: Need to be simple and clean, should have specious waiting area with toilet facility  CONTROL AND EVALUATION: Assess the relevance, progress, efficiency, effectiveness and impact of the services
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