Basic needs of clients according to Maslow's hierarchy

Abraham Maslow arranged human needs in a five-level pyramid, from the most basic (lower level) to the highest. In nursing, this hierarchy guides the prioritisation of client care — lower-level needs are met first because they are essential for survival.

1. Physiological needs (first level / base of the pyramid) The most basic needs for survival: oxygen, food, water, elimination, sleep and rest, temperature regulation, shelter, and pain relief. In a client, these include maintaining a patent airway, adequate breathing and circulation, nutrition and hydration, bladder and bowel elimination, and freedom from pain. These are given the highest priority in nursing care.

2. Safety and security needs (second level) The need to be free from physical and psychological harm — protection from injury, infection, falls, and hazards; freedom from fear, anxiety, and uncertainty; and the need for physical and emotional security (e.g., a safe environment, financial and job security, health insurance). For a client, this means a safe hospital environment, proper identification, side rails, and reassurance.

3. Love and belonging needs (third level) The need for affection, acceptance, companionship, and a sense of belonging to family, friends, and community. Clients need emotional support, visits from family, and a caring nurse–client relationship. Loss of these needs leads to loneliness, rejection, and depression.

4. Esteem needs (fourth level) The need for self-respect, self-confidence, achievement, recognition, and respect from others. Clients need to feel valued, to be addressed by name, to have privacy and dignity maintained, and to take part in their own care decisions. Illness often lowers self-esteem, so the nurse must promote independence and praise progress.

5. Self-actualisation needs (fifth / highest level) The need to reach one's full potential, to grow, and to use one's abilities to the maximum. In a client, this may mean returning to work, resuming roles, or achieving personal goals after recovery. It is met only when all lower needs are satisfied.

Application in nursing: Maslow's hierarchy helps the nurse decide priority of care — for example, a client with difficulty in breathing (physiological) is attended before one who feels lonely (love and belonging). Needs are met in order from the base upward, though a client may have needs at several levels at the same time.

Specific Instructions for Colonoscopy Preparation

Colonoscopy is an endoscopic procedure to visualise the entire colon and rectum. Adequate bowel preparation is essential for clear visualisation and a successful procedure. The nurse should provide the following specific instructions:

1. Dietary Instructions

• Low-residue diet should be started 2–3 days before the procedure.
• Avoid high-fibre foods such as fruits, vegetables, seeds, nuts, whole grains, and legumes.
• On the day before the procedure, take only clear liquids — water, clear broth, clear fruit juice (without pulp), tea/coffee without milk, and clear gelatin.
• Avoid red or purple coloured liquids (they can be mistaken for blood).
• Nil by mouth (NPO) from midnight before the procedure, or as instructed (usually 6–8 hours fasting).

2. Bowel Cleansing (Laxative/Bowel Preparation)

• Take the prescribed bowel-cleansing solution (e.g., polyethylene glycol / PEG) as scheduled — usually in split doses (evening before and morning of the procedure).
• Drink the solution slowly over the recommended time; do not gulp.
• Stay near a toilet after taking the laxative, as frequent loose stools will occur.
• The bowel is considered clean when the stool is clear, light yellow liquid without solid particles.

3. Medication Instructions

• Inform the doctor about all medicines, especially blood thinners (aspirin, warfarin, clopidogrel), iron tablets, and antidiabetic drugs — these may need to be stopped or adjusted as advised.
• Diabetic patients should consult the doctor about insulin/oral hypoglycaemic dose on the day of fasting.

4. Other Instructions

• Arrange someone to accompany the patient home, as sedation may be given.
• Do not drive or operate machinery for 24 hours after sedation.
• Remove jewellery, dentures, contact lenses before the procedure.
• Report immediately if severe abdominal pain, bleeding per rectum, or vomiting occurs.

Conclusion: Clear dietary restriction, adequate bowel cleansing, medication adjustment, and safety precautions ensure a successful and safe colonoscopy.

Routes of drug administration (5 marks)

Routes of drug administration refer to the path by which a drug is introduced into the body. They are broadly classified into three main groups:

1. Enteral routes (drug enters through the gastrointestinal tract)

• Oral (PO): Swallowed by mouth; most common, convenient and economical route.
• Sublingual: Placed under the tongue for rapid absorption, bypassing the liver (e.g. nitroglycerin).
• Rectal: Inserted into the rectum, useful when the patient is vomiting or unconscious (e.g. suppositories, enemas).

2. Parenteral routes (drug given by injection, bypassing the GIT)

• Intravenous (IV): Directly into a vein — fastest onset, 100% bioavailability.
• Intramuscular (IM): Into muscle mass (e.g. deltoid, gluteal) for moderate-rate absorption.
• Subcutaneous (SC): Into subcutaneous tissue (e.g. insulin).
• Intradermal (ID): Into the dermis (e.g. BCG, Mantoux test).
• Intrathecal / Intra-articular / Intra-arterial: Into subarachnoid space, joint cavity or artery respectively.

3. Topical / local routes (applied to body surfaces for local action)

• Skin (cutaneous): Ointments, creams, lotions, transdermal patches.
• Mucous membranes: Ocular (eye drops), nasal, otic (ear drops), buccal, vaginal.
• Inhalation: Through the respiratory tract for rapid systemic absorption (e.g. salbutamol, general anaesthetics).

Conclusion: The choice of route depends on the drug's properties, the desired speed of action, the site of action, and the patient's condition.

Labelled diagram of the gastrointestinal (GI) system

┌──────────────────────────────┐
│         ORAL CAVITY          │
│    (mouth, teeth, tongue,    │
│       salivary glands)       │
└──────────────────────────────┘
                │
                ▼
┌──────────────────────────────┐
│           PHARYNX            │
└──────────────────────────────┘
                │
                ▼
┌──────────────────────────────┐
│          OESOPHAGUS          │
│         (food pipe)          │
└──────────────────────────────┘
                │
                ▼
┌──────────────────────────────┐
│           STOMACH            │
│    (cardia, fundus, body,    │
│           pylorus)           │
└──────────────────────────────┘
                │
                ▼
┌──────────────────────────────┐
│       SMALL INTESTINE        │
│           Duodenum           │
│           Jejunum            │
│            Ileum             │
└──────────────────────────────┘
                │
                ▼
┌──────────────────────────────┐
│       LARGE INTESTINE        │
│            Caecum            │
│Colon (ascending, transverse, │
│     descending, sigmoid)     │
│            Rectum            │
│          Anal canal          │
└──────────────────────────────┘
                │
                ▼
┌──────────────────────────────┐
│             ANUS             │
└──────────────────────────────┘

ACCESSORY ORGANS (pour secretions into the duodenum):
┌────────────────────┐  ┌────────────────────┐  ┌────────────────────┐
│       LIVER        │  │    GALL BLADDER    │  │      PANCREAS      │
│    (makes bile)    │  │   (stores bile)    │  │ (pancreatic juice) │
└────────────────────┘  └────────────────────┘  └────────────────────┘

The GI tract is a continuous muscular tube about 9 metres long, running from the mouth to the anus. The liver, gall bladder and pancreas are accessory organs: they pour their secretions into the small intestine but are not part of the tract itself.

Menstrual Cycle

The menstrual cycle is the regular, cyclical series of changes in the female reproductive system, controlled by hormones of the hypothalamus, pituitary and ovary, that prepares the uterus for possible pregnancy. It begins at puberty (menarche) and continues till menopause, except during pregnancy and lactation. Its average duration is 28 days (normal range 21–35 days).

Phases of the menstrual cycle

1. Menstrual phase (Days 1–5): If fertilization does not occur, the corpus luteum degenerates, progesterone and estrogen levels fall, and the endometrium breaks down and is shed as menstrual blood (about 50–80 ml) along with mucus and unfertilized ovum. This is the period of bleeding.

2. Follicular / Proliferative phase (Days 6–13): Under the influence of FSH from the anterior pituitary, a Graafian follicle develops in the ovary and secretes estrogen. Estrogen causes the endometrium to proliferate and thicken again (repair and regeneration).

3. Ovulatory phase (About Day 14): A sudden rise (surge) of LH from the anterior pituitary causes rupture of the mature Graafian follicle and release of the ovum — this is ovulation. The ovum remains viable for about 24 hours.

4. Luteal / Secretory phase (Days 15–28): The ruptured follicle changes into the corpus luteum, which secretes progesterone. Progesterone makes the endometrium thick, vascular and secretory (rich in glycogen) to receive the fertilized ovum. If fertilization occurs, the corpus luteum persists and pregnancy continues; if not, it degenerates, hormone levels fall, and the next menstrual cycle begins.

Hormonal control: The cycle is regulated by the hypothalamo-pituitary–ovarian axis — GnRH from the hypothalamus → FSH and LH from the anterior pituitary → estrogen and progesterone from the ovary, operating through feedback mechanisms.

Significance: It prepares the uterus for implantation, makes pregnancy possible, and its regular occurrence indicates normal reproductive and endocrine function.

Primary Health Care: Principles and Elements

Principles of Primary Health Care (2 marks)

Primary Health Care (PHC), as defined at the Alma-Ata Conference (1978), rests on the following principles:

1. Equitable distribution — Health services should be accessible to all people equally, with priority given to the underserved (rural, poor, marginalized).
2. Community participation — People should be actively involved in planning, implementing and evaluating their own health care.
3. Intersectoral coordination — Health cannot be achieved by the health sector alone; agriculture, education, water supply, housing and other sectors must work together.
4. Appropriate technology — Methods and equipment should be scientifically sound, affordable, acceptable and usable by the local people.
5. Focus on prevention — Emphasis is placed on health promotion and disease prevention rather than curative care alone.
6. Affordability and self-reliance — Services should be within the economic reach of the country and community.

Elements of Primary Health Care (3 marks)

The Alma-Ata Declaration lists eight essential elements:

1. Education concerning prevailing health problems and the methods of preventing and controlling them.
2. Promotion of food supply and proper nutrition.
3. Adequate supply of safe water and basic sanitation.
4. Maternal and child health care, including family planning.
5. Immunization against the major infectious diseases.
6. Prevention and control of locally endemic diseases.
7. Appropriate treatment of common diseases and injuries.
8. Provision of essential drugs.

Additional (supportive) elements in the Nepali context include: mental health, dental health, care of the elderly, and rehabilitation of the disabled.

Conclusion: In Nepal, PHC is delivered mainly through Health Posts, Primary Health Care Centres and Female Community Health Volunteers (FCHVs), making these principles and elements the backbone of the national health strategy.

(a) Respiratory failure [2]

Respiratory failure is a condition in which the respiratory system fails in one or both of its gas-exchange functions — oxygenation and carbon dioxide elimination — resulting in inadequate oxygen supply to the tissues and/or inadequate removal of carbon dioxide.

It is defined on the basis of arterial blood gas (ABG) values:

• Type I (hypoxaemic) respiratory failure: PaO₂ < 60 mmHg with PaCO₂ normal or low (≤ 45 mmHg), i.e. failure of oxygenation.
• Type II (hypercapnic) respiratory failure: PaO₂ < 60 mmHg together with PaCO₂ > 50 mmHg, i.e. failure of ventilation.

Both types occur when the patient is breathing room air (FiO₂ 0.21) at sea level.

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(b) Causes of respiratory failure [2]

1. Causes of Type I (hypoxaemic) failure

• Pneumonia, pulmonary oedema, acute respiratory distress syndrome (ARDS)
• Pulmonary embolism, atelectasis
• Pulmonary fibrosis, interstitial lung disease
• Asthma, bronchospasm
• Chest injury — flail chest, pulmonary contusion, pneumothorax, haemothorax (as in Mr. Shanker's case)

2. Causes of Type II (hypercapnic) failure

• Depression of the respiratory centre — head injury, sedatives/opioids, anaesthesia
• Neuromuscular diseases — Guillain–Barré syndrome, myasthenia gravis, poliomyelitis, spinal cord injury
• Chest wall disorders — flail chest, kyphoscoliosis, obesity hypoventilation
• Airway obstruction — COPD, severe asthma, foreign body, laryngeal oedema
• Post-operative effects of anaesthesia and muscle relaxants

3. Common precipitating factors

• Road traffic accidents with chest trauma, major surgery, prolonged immobilisation, smoking, pre-existing lung disease.

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(c) Nursing care of Mr. Shanker in maintaining the airway [6]

Mr. Shanker is an ICU patient with chest injury who has been taken for emergency surgery; after anaesthesia and with chest trauma, his airway is at high risk. The nurse maintains the airway as follows:

1. Assessment of the airway and breathing

• Assess patency of airway — look for secretions, blood, vomitus, foreign body, tongue fall-back, stridor or gurgling.
• Monitor respiratory rate, rhythm, depth, chest expansion (symmetry), use of accessory muscles, and signs of respiratory distress (restlessness, cyanosis, nasal flaring).
• Monitor SpO₂ continuously with pulse oximetry and ABG values (PaO₂, PaCO₂, pH) as ordered.
• In an unconscious patient, use the Glasgow Coma Scale and cough/gag reflexes to judge the ability to protect the airway.

2. Positioning

• Keep the patient in a semi-Fowler's or upright position (if not contraindicated) to promote lung expansion and drainage.
• If unconscious and no cervical spine injury is suspected, place in lateral or recovery position to prevent aspiration; if spinal injury is suspected, use a log-roll with manual in-line immobilisation of the neck.

3. Airway clearance measures

• Suction oropharyngeal and endotracheal secretions using sterile technique, only when needed, for not more than 10–15 seconds at a time.
• Perform chest physiotherapy — postural drainage, chest percussion and vibration, and encourage deep breathing and coughing exercises (splinting the chest with a pillow to reduce pain).
• Encourage use of an incentive spirometer and provide adequate hydration (unless fluid-restricted) to liquefy secretions.
• Administer nebulisation, humidified oxygen and prescribed bronchodilators/mucolytics.

4. Oxygen therapy and ventilatory support

• Administer oxygen as prescribed (nasal cannula, mask, or mechanical ventilation) and never withhold oxygen in a hypoxaemic patient.
• Check that the endotracheal tube is patent and properly secured, note its marking, and monitor cuff pressure.
• Assist with endotracheal intubation/tracheostomy if required and provide tracheostomy care.
• Maintain the ventilator settings, alarms and tubing; keep a manual resuscitator (Ambu bag) and suction apparatus at the bedside.

5. Prevention of aspiration and infection

• Keep the head of the bed elevated 30–45° during and after feeding; check residual gastric volume before enteral feeds.
• Provide oral care every 2–4 hours to prevent ventilator-associated pneumonia.
• Follow strict hand hygiene and aseptic technique for suctioning and tube care.

6. Documentation and coordination

• Record respiratory rate, SpO₂, ABG reports, amount and character of secretions, suctioning done and patient's response.
• Report immediately to the physician any deterioration — falling SpO₂, rising PaCO₂, inability to clear secretions, or absent breath sounds.
• Keep emergency drugs, oxygen and resuscitation equipment ready at the bedside.

By these measures the nurse keeps Mr. Shanker's airway patent, ensures adequate oxygenation and ventilation, and prevents complications such as hypoxia, atelectasis and infection during his ICU stay.

Health Indicators: Parameters and Significance in Improving Health Status

Meaning

Health indicators are quantitative or qualitative variables that measure and summarise the health status of a population, the performance of the health system, and the factors that determine health. They are the basic tools used by planners, managers and policy makers to assess, compare and monitor the health situation of a community, district, province or country.

Parameters (Types) of Health Indicators

Health indicators are broadly grouped as follows:

1. Mortality Indicators

• Crude Death Rate (CDR)
• Infant Mortality Rate (IMR)
• Under-5 Mortality Rate (U5MR)
• Neonatal and Perinatal Mortality Rate
• Maternal Mortality Ratio (MMR)
• Life Expectancy at Birth
• Proportional Mortality Rate

2. Morbidity Indicators

• Incidence and Prevalence of diseases (TB, HIV, malaria, NCDs)
• Notification rates of communicable diseases
• Hospital admission, discharge and attendance rates
• Attack rate and case fatality rate

3. Natality (Fertility) Indicators

• Crude Birth Rate (CBR)
• General Fertility Rate
• Total Fertility Rate (TFR)
• Adolescent Fertility Rate

4. Nutritional Indicators

• Prevalence of underweight, stunting and wasting in under-5 children
• Anaemia prevalence in women and children
• Low Birth Weight (LBW) proportion
• Iodine deficiency and vitamin A deficiency rates

5. Morbidity/Disability and Quality of Life Indicators

• Disability-adjusted Life Years (DALYs)
• Quality-adjusted Life Years (QALYs)
• Healthy Life Expectancy (HALE)

6. Health Care Delivery Indicators

• Doctor–population ratio, nurse–population ratio
• Health facility density per 10,000 population
• Bed occupancy rate, average length of stay
• Immunisation coverage (BCG, DPT, measles, etc.)
• Antenatal care (ANC) visits, institutional delivery rate
• Contraceptive Prevalence Rate (CPR)

7. Environmental and Socio-economic Indicators

• Access to safe drinking water and improved sanitation
• Indoor air pollution, solid waste management
• Literacy rate, female literacy, per capita income
• Poverty rate and food security

8. Health Policy and System Indicators

• Total health expenditure as % of GDP
• Out-of-pocket expenditure on health
• Health service coverage index, UHC service coverage index
• Catastrophic health expenditure

Significance in Improving Health Status

1. Assessment of health situation: Indicators reveal the actual health problems of a community, e.g. high IMR points to poor maternal and child health services.
2. Identification of priority problems: By comparing indicators, planners can identify high-risk groups and priority diseases for intervention.
3. Planning and policy formulation: National health plans, SDG targets and Nepal's Health Sector Strategy are framed on the basis of indicator data.
4. Resource allocation: Indicators help in equitable distribution of budget, manpower and equipment to needy areas.
5. Monitoring and evaluation: Regular measurement shows whether programmes (e.g. immunisation, safe motherhood) are achieving targets.
6. Comparison and benchmarking: Indicators allow comparison between districts, provinces and countries, and with national/international targets (SDG 3).
7. Measuring equity: Disaggregated indicators (by sex, caste, geography) expose disparities and guide pro-poor policies.
8. Raising public awareness and advocacy: Published indicators create public pressure and political commitment for health improvement.
9. Evidence-based decision making: Reliable indicators replace guesswork with scientific planning, leading to better health outcomes.
10. Quality assurance: Indicators such as bed occupancy rate and case fatality rate help maintain quality of health services.

Conclusion

Health indicators are the mirror of a nation's health. Their proper collection, analysis and use enable the health system to plan scientifically, allocate resources rationally, monitor progress and correct weaknesses in time. In Nepal, indicators such as IMR (currently around 28 per 1,000 live births), MMR (around 151 per 100,000 live births) and TFR (around 2.0) guide national health programmes. Thus, health indicators are indispensable for improving the health status of the people.

Special instructions to the mother and family when the mother is Rh-negative and the baby is Rh-positive

The key issue is Rh incompatibility: an Rh-negative mother whose baby is Rh-positive may become sensitised (form anti-D antibodies) if even a small amount of fetal blood enters her circulation at delivery. This sensitisation does not harm this baby, but it can cause haemolytic disease of the newborn (erythroblastosis fetalis) in future pregnancies. Therefore the nurse must give the following instructions:

1. Anti-D immunoglobulin (Anti-D injection) is essential.

   • Explain that the injection must be given to the mother within 72 hours of delivery (ideally as early as possible).
   • Stress that this is not optional — it prevents her from forming antibodies that would harm the next baby.
   • If the injection is not available at the health facility, she must be sent to a centre where it is available, without delay.

2. Do not delay or miss the injection.

   • Warn the family that after 72 hours the injection becomes ineffective, so they must not wait for relatives, money or transport.
   • If she goes home before the injection, give her a written slip with the date and time of delivery and the injection due, and tell her to return immediately.

3. Blood group testing of the baby.

   • The baby's blood group and Rh type must be tested (cord blood) to confirm whether the baby is Rh-positive. If the baby is Rh-negative, the injection is not needed.
   • Also test the mother's antibody screen (indirect Coombs test) as advised.

4. Watch the baby for danger signs.

   • Instruct the mother to bring the baby to the health facility immediately if she notices yellow colouration of skin or eyes (jaundice), paleness, poor feeding, excessive sleepiness, or dark urine.
   • Explain that these may appear within the first few days and need urgent check-up.

5. Information for future pregnancies.

   • Tell her to inform every health worker in future pregnancies that she is Rh-negative.
   • Anti-D is also given at 28 weeks of pregnancy and after any abortion, miscarriage, or invasive procedure — so she must attend all antenatal check-ups.
   • Family planning advice: spacing of pregnancies should be discussed, and she should not conceive again without medical advice if Anti-D was missed.

6. General postnatal care.

   • Continue breastfeeding — Rh incompatibility is not a reason to stop breastfeeding.
   • Maintain hygiene, adequate diet (iron-rich), rest, and take iron and folic acid tablets as prescribed.
   • Attend the postnatal check-up at 6 weeks (and earlier if any problem).
   • Report heavy bleeding, foul-smelling discharge, fever, or breast problems.

7. Reassure the family.

   • Tell them that the present baby is normal and healthy, and that with timely Anti-D injection the risk to future babies can be prevented.
   • Remove any misconception that the mother or baby is "diseased" or that the baby should be separated from the mother.

Summary: The most important instruction is to give Anti-D immunoglobulin within 72 hours of delivery, keep the baby's Rh status and jaundice under watch, and inform all health workers in future pregnancies that the mother is Rh-negative.

Essential Care of Newborn Baby

Essential newborn care (ENC) is a set of basic, cost-effective interventions provided to every newborn immediately after birth and during the first 28 days of life to promote survival, growth and development.

1. Immediate care at birth (first few minutes)

• Clear the airway: Wipe the mouth and nose with a clean cloth; suction only if secretions obstruct breathing.
• Dry and warm the baby: Dry the whole body with a clean, dry, warm cloth and discard the wet cloth.
• Assess breathing: Observe for spontaneous crying and regular respiration; initiate resuscitation if not breathing.
• Skin-to-skin contact (Kangaroo Mother Care): Place the naked baby prone on the mother's bare chest immediately after birth.
• Delayed cord clamping: Clamp and cut the cord after 1–3 minutes using a sterile, clean instrument; apply nothing to the stump.
• Early initiation of breastfeeding: Put the baby to the breast within 1 hour of birth.

2. Thermal protection (prevention of hypothermia)

• Maintain room temperature at 25–28°C; keep the baby well wrapped, with a cap and socks.
• Avoid unnecessary bathing; first bath only after 24 hours when temperature is stable.
• Use skin-to-skin contact and rooming-in to keep the baby warm.

3. Feeding

• Exclusive breastfeeding for the first 6 months — no water, honey, ghee or prelacteal feeds.
• Feed on demand, at least 8–12 times in 24 hours, day and night.
• Ensure correct positioning and attachment (whole nipple and areola in the mouth) to prevent nipple trauma and poor intake.
• Give vitamin K 1 mg IM at birth to prevent haemorrhagic disease of the newborn.

4. Infection prevention (cord, eye and skin care)

• Cord care: Keep the cord clean and dry; apply nothing; fold the nappy below the cord; watch for redness, discharge or bleeding.
• Eye care: Clean eyes with sterile cotton swabs from inner to outer canthus; apply tetracycline/erythromycin eye ointment if indicated.
• Skin care: Keep skin clean and dry; avoid harmful traditional applications; use clean clothes and bedding.
• Hand hygiene: Insist that all caregivers wash hands before handling the baby.
• Immunisation: BCG and OPV-0 (Hep B-0 where applicable) at birth as per the national schedule.

5. Monitoring and assessment

• Check temperature (normal 36.5–37.5°C), respiratory rate (normal 40–60/min), heart rate (120–160/min) and weight (normal 2.5–4 kg).
• Observe for danger signs: poor feeding, lethargy, grunting, chest indrawing, jaundice, convulsions, hypothermia or fever.
• Record and report the first passage of urine and meconium.

6. Follow-up and counselling

• Advise follow-up visits at 3, 7 and 28 days, and danger-sign recognition.
• Counsel on birth spacing, family planning and maternal nutrition.
• Ensure newborn screening (e.g., congenital hypothyroidism, hearing screening) as per national protocol.

Conclusion: Essential newborn care — warmth, clean delivery, early and exclusive breastfeeding, cord and eye care, infection prevention and early detection of danger signs — is the simplest and most effective measure to reduce neonatal mortality and ensure healthy growth of the newborn.

Clinical features of Gonorrhoea

Gonorrhoea is a sexually transmitted infection caused by Neisseria gonorrhoeae. The incubation period is usually 2–7 days (range 2–14 days).

In males:

• Urethral discharge — profuse, purulent, yellow-green, and thick
• Dysuria (burning pain during micturition)
• Urgency and frequency of micturition
• Red, oedematous urethral meatus
• Complications: epididymo-orchitis, prostatitis, urethral stricture

In females:

• Often asymptomatic (about 50% of cases)
• Increased vaginal discharge (mucopurulent)
• Dysuria and frequency
• Intermenstrual bleeding or postcoital bleeding
• Pelvic pain if pelvic inflammatory disease develops
• Complications: PID, salpingitis, infertility, ectopic pregnancy, Bartholinitis

In both sexes:

• Anorectal infection — rectal discharge, pain, tenesmus (common in men who have sex with men)
• Pharyngeal infection — usually asymptomatic sore throat
• Disseminated gonococcal infection — fever, arthralgia, skin rash (pustular lesions on extremities), septic arthritis
• Ophthalmia neonatorum in newborns born to infected mothers — purulent conjunctivitis, which may lead to blindness

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Management

1. General measures:

• Reassurance and health education about safe sex practices
• Advice to abstain from sexual intercourse until both partners are treated and cured
• Screening and treatment of sexual partners (contact tracing)
• Screening for other STIs, including HIV and syphilis

2. Antibiotic therapy (as per national STI guidelines):

• Uncomplicated gonorrhoea:
  • Ceftriaxone 500 mg IM single dose (or 250 mg IM in some protocols), plus
  • Azithromycin 1 g orally single dose (to cover possible co-infection with Chlamydia trachomatis)
  • Alternative: Cefixime 400 mg orally single dose plus azithromycin 1 g orally single dose
• Disseminated gonococcal infection: Ceftriaxone 1 g IV/IM once daily for 7 days
• Ophthalmia neonatorum: Ceftriaxone 50 mg/kg IM single dose (maximum 125 mg)

3. Follow-up:

• Test of cure by culture or NAAT after 1–2 weeks in resistant or complicated cases
• Re-evaluation if symptoms persist

4. Prevention:

• Condom use
• Early diagnosis and treatment of both partners
• Antenatal screening and prophylactic eye care of the newborn

Prevention of Vesicovaginal Fistula (VVF) — 5 marks

Vesicovaginal fistula is an abnormal communication between the urinary bladder and the vagina, causing continuous leakage of urine per vaginam. In Nepal, most cases are obstetric (obstructed labour) in origin. Since prevention is far easier and cheaper than surgical repair, it is given top priority in nursing and public health practice.

1. Prevention of prolonged/obstructed labour (primary prevention)

• Early registration of pregnancy and at least four ANC visits, with identification of high-risk mothers (short stature, previous difficult delivery, malpresentation, big baby).
• Promotion of institutional delivery with skilled birth attendants (SBA) and use of the partograph to detect labour crossing the alert and action lines.
• Timely referral to a well-equipped centre (CEONC/ BEONC) when labour is prolonged, membranes have ruptured for long, or the head is not descending.
• Avoidance of harmful traditional practices such as fundal pressure, application of force on the abdomen, and unskilled instrumental delivery.
• Active management of the third stage and careful, gentle handling of tissues during delivery to avoid bladder injury.

2. Prevention of surgical and traumatic VVF (secondary prevention)

• Careful technique during caesarean section, hysterectomy, and other pelvic surgeries; proper identification and protection of the bladder and ureters.
• Adequate bladder emptying (continuous or intermittent catheterisation) before and after pelvic surgery, and removal of the catheter only after confirming free voiding.
• Prompt repair of any bladder injury recognised during surgery, with an indwelling catheter for 7–14 days.
• Prevention of sexual violence and female genital mutilation, and early treatment of pelvic trauma.

3. Prevention of recurrent fistula and disability (tertiary prevention)

• Early detection of continuous urine leakage after delivery or surgery and immediate referral to a fistula treatment centre (e.g., Kathmandu Model Hospital, BPKIHS, and mobile camps).
• Post-repair care: adequate bladder drainage, avoidance of heavy lifting and intercourse for at least three months, and treatment of anaemia and infection.
• Counselling and rehabilitation of affected women to reduce stigma, and family planning advice to prevent another pregnancy too soon.

4. Health education and community awareness

• Educating mothers, families, and TBAs about danger signs of obstructed labour (labour > 12 hours, dribbling of urine, foul discharge) and the need for immediate hospital care.
• Promoting girl-child education, delaying early marriage and early pregnancy, and improving nutrition to prevent stunted pelvis.
• Strengthening the referral system, transport, and 24-hour emergency obstetric care so that no woman labours at home for days.

Conclusion: VVF is almost entirely preventable through quality maternity care, skilled attendance, use of the partograph, timely referral, and safe surgical practice. The nurse's role in ANC, intranatal care, and community education is central to its prevention.

Six Major Killer Diseases

The six major killer diseases (as identified in public health, especially in the context of child and community health) are:

1. Tuberculosis (TB)
2. Malaria
3. HIV/AIDS
4. Diarrhoeal diseases
5. Pneumonia (Acute Respiratory Infection)
6. Measles

(Note: In some Nepali public health contexts, the six major killer diseases of childhood are listed as: Diarrhoea, Pneumonia, Measles, Malaria, Malnutrition, and Neonatal conditions. The above list is the commonly accepted general answer.)

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Nursing Management of a Patient with Tuberculosis

A. Assessment

• Assess for cough lasting more than 2 weeks, fever (especially evening rise), night sweats, weight loss, loss of appetite, chest pain, haemoptysis, fatigue and breathlessness.
• Take history of contact with a TB patient, previous TB treatment, and any chronic illness (e.g., HIV, diabetes).
• Record vital signs, weight, and sputum examination (AFB smear/GeneXpert) findings.

B. Nursing Diagnosis

• Ineffective airway clearance related to excessive tracheobronchial secretions.
• Imbalanced nutrition: less than body requirements related to anorexia and increased metabolic demand.
• Activity intolerance related to weakness and breathlessness.
• Risk for infection transmission related to coughing and poor hygiene.
• Knowledge deficit regarding disease and treatment.

C. Nursing Interventions

1. Airway clearance and breathing

• Place the patient in a semi-Fowler's position to ease breathing.
• Encourage coughing and deep breathing exercises; teach effective coughing to clear secretions.
• Provide a sputum mug with lid and tissue paper; collect sputum for AFB testing as ordered.
• Administer oxygen if there is breathlessness/hypoxia, as prescribed.

2. Medication (DOTS) management

• Administer anti-TB drugs (as per national protocol — e.g., 2HRZE/4HR regimen) strictly under DOTS (Directly Observed Treatment, Short-course).
• Ensure the patient swallows the drugs in front of the health worker; never leave medicines with the patient.
• Monitor for side effects: hepatotoxicity (INH, RIF), peripheral neuritis (INH — give pyridoxine), orange urine (RIF), optic neuritis (ethambutol), ototoxicity (streptomycin).
• Emphasize completion of the full course (6–8 months) and never stopping drugs on feeling better, to prevent MDR-TB.

3. Nutrition

• Provide a high-calorie, high-protein, vitamin-rich diet; give small frequent feeds.
• Encourage oral fluids; record intake and output; weigh the patient regularly.

4. Rest and activity

• Provide adequate rest and a well-ventilated room; gradually increase activity as tolerated.

5. Infection prevention

• Isolate the patient in a separate, well-ventilated room during the infectious period.
• Teach the patient to cover the mouth and nose while coughing/sneezing.
• Use a mask while handling the patient; practice hand hygiene.
• Ensure proper disposal of sputum and soiled articles; disinfect them.

6. Psychological support and health education

• Reassure the patient and family to reduce stigma and anxiety.
• Educate about the cause, mode of spread, importance of DOTS, follow-up sputum tests, and BCG immunization for children.
• Advise screening of family members and contact tracing.

C. Evaluation

• Patient maintains a patent airway and breathes comfortably.
• Weight and nutritional status improve.
• Patient adheres to DOTS and completes the full course.
• No further transmission to family/community members.

Causes of Mental Illness

Biological (organic) factors

• Heredity/genetic predisposition — family history of mental illness
• Brain injury, trauma, or damage (head injury, birth asphyxia)
• Neurochemical imbalance — disturbance of neurotransmitters (serotonin, dopamine, noradrenaline)
• Physical illness — hypothyroidism, epilepsy, brain tumour, infections (meningitis, encephalitis)
• Substance abuse — alcohol, cannabis, opioids, amphetamines
• Hormonal changes — puberty, pregnancy, postpartum period, menopause

Psychological factors

• Childhood trauma — physical, sexual, or emotional abuse; neglect
• Faulty upbringing — overprotection, rejection, inconsistent discipline
• Low self-esteem, poor coping skills, unresolved grief
• Chronic stress, academic or occupational pressure
• Personality disorders

Social/environmental factors

• Poverty, unemployment, financial crisis
• Family conflict, broken family, domestic violence
• Social isolation, lack of social support
• Discrimination, stigma, and social rejection
• Stressful life events — death of a loved one, divorce, failure, disaster
• Peer pressure and substance abuse in adolescence

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Signs and Symptoms of Mental Illness

Emotional (affective) symptoms

• Persistent sadness, hopelessness, or excessive worry and fear
• Irritability, anger outbursts, mood swings
• Loss of interest and pleasure in usual activities (anhedonia)
• Feelings of guilt, worthlessness, and helplessness

Cognitive (thinking) symptoms

• Difficulty concentrating, poor memory, indecisiveness
• Delusions — false fixed beliefs (e.g., persecution, grandeur)
• Hallucinations — hearing/seeing things not present
• Disorganized or incoherent speech and thinking
• Suicidal or homicidal thoughts

Behavioural symptoms

• Social withdrawal and avoidance of people
• Neglect of personal hygiene and appearance
• Changes in sleep — insomnia or hypersomnia
• Changes in appetite — overeating or loss of appetite
• Restlessness, agitation, or slowed movements
• Aggressive, violent, or self-harming behaviour
• Poor work/study performance and absenteeism
• Substance abuse, repeated unexplained physical complaints

Key point: A symptom is considered a sign of mental illness when it is persistent, causes significant distress, and impairs daily functioning (personal, social, and occupational).

Definition of Leadership

Leadership is the process of influencing, guiding, motivating and directing the behaviour of individuals or a group towards the achievement of a common goal. It involves the ability to inspire others to work willingly and enthusiastically to accomplish organisational objectives. In the health service context, leadership is the art of mobilising health workers, resources and the community to deliver quality health care.

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Leadership Style Appropriate for Managing Health Service Effectively

Among the various leadership styles — autocratic, democratic (participative), laissez-faire, transactional and transformational — the democratic (participative) leadership style is the most appropriate for managing health services effectively.

Justification

1. Health service is a teamwork-based system Health care delivery involves a multidisciplinary team — doctors, nurses, paramedics, lab technicians, pharmacists and support staff. A democratic leader consults team members, values their input and coordinates their efforts, which is essential for smooth, integrated patient care.

2. Promotes job satisfaction and motivation When health workers are allowed to participate in decision-making, they feel valued and respected. This raises morale, reduces staff turnover and absenteeism, and improves retention — a critical issue in Nepal's health sector where staff shortages are common.

3. Encourages professional accountability and creativity Nurses and other health workers are professionally trained and competent. A participative leader taps this expertise, encourages initiative and innovation (e.g., improving infection-control practices or patient-flow systems) rather than suppressing it through rigid orders.

4. Improves quality of care and patient safety Democratic leadership promotes open communication. Staff feel safe to report errors, near-misses and problems without fear. This transparency is the foundation of patient safety and continuous quality improvement.

5. Builds trust and commitment Involving staff in goal-setting (e.g., reducing hospital-acquired infections) creates ownership of those goals. People support what they help create, so compliance is voluntary and genuine rather than forced.

6. Adaptable to changing health needs Health emergencies (epidemics, disasters, pandemics) demand quick, flexible responses. A democratic leader can consult the team, pool ideas and adapt strategies rapidly, whereas a purely autocratic leader may stifle the very feedback needed in a crisis.

7. Community participation is central to public health Nepal's health system relies heavily on community involvement — FCHVs, health committees, mothers' groups. Democratic leadership is essential to engage these stakeholders, ensure cultural appropriateness of services and improve health-seeking behaviour.

Why Other Styles Are Less Suitable

• Autocratic style: Though useful in emergencies for quick decisions, it suppresses feedback, lowers morale and causes resentment among skilled professionals, leading to poor teamwork and higher staff turnover.
• Laissez-faire style: Gives too much freedom with little guidance. In a setting where protocols, standards and accountability are vital, this leads to chaos, inconsistent care and poor outcomes.
• Transactional style: Based only on rewards and punishments. It may achieve short-term targets but does not build the commitment, innovation and shared vision needed for sustained quality improvement.
• Transformational style: Highly effective and complementary, but it works best when combined with participative practices; on its own it depends heavily on a charismatic leader and may not ensure day-to-day staff involvement.

Conclusion

The democratic (participative) leadership style is most appropriate for managing health services effectively because it harnesses the expertise of the multidisciplinary team, raises morale and retention, ensures patient safety through open communication, and enables flexible, community-responsive care. In practice, the best nurse leader uses the democratic style as the default, switching briefly to autocratic decision-making only in emergencies where immediate action is essential.

Role of the Nurse in Reducing Child Mortality in Nepal
(10 marks)

Nepal has significantly reduced under-five mortality, yet preventable deaths from pneumonia, diarrhoea, malnutrition, neonatal complications and vaccine-preventable diseases still occur, especially in rural and remote districts. Nurses, being the largest and closest health workforce to families and communities, play a decisive role in further reducing child mortality. Their major roles are as follows:

1. Antenatal, Intranatal and Postnatal Care
Nurses provide early registration of pregnancy, at least four ANC visits, iron–folic acid and tetanus–diphtheria immunization, and detection of high-risk pregnancies. During delivery they ensure safe, clean delivery, immediate newborn care (drying, warming, skin-to-skin contact, delayed cord clamping) and early initiation of breastfeeding. These measures directly reduce neonatal deaths, which form the largest share of child deaths in Nepal.

2. Newborn and Neonatal Care
Nurses identify and manage birth asphyxia, low birth weight, hypothermia, sepsis and jaundice; they promote Kangaroo Mother Care (KMC) and essential newborn care, and refer sick newborns in time. This lowers neonatal mortality, especially in remote districts.

3. Immunization and Prevention of Communicable Diseases
As EPI service providers, nurses administer BCG, OPV, DPT–HepB–Hib, PCV, MR and other vaccines, maintain the cold chain, trace defaulters and conduct outreach/mobile immunization camps. Full immunization prevents deaths from measles, pertussis, tetanus, diphtheria and pneumonia.

4. Management of Childhood Illnesses (IMCI/CBIMCI)
Nurses assess and treat pneumonia, diarrhoea, fever, ear problems and malnutrition using IMCI protocols; they give ORS and zinc for diarrhoea, antibiotics for pneumonia, and treat severe cases or refer them. They also train and supervise FCHVs under CBIMCI, extending care to the community level.

5. Nutrition Promotion
Nurses counsel on exclusive breastfeeding for six months, complementary feeding, growth monitoring, vitamin A supplementation, deworming and management of severe acute malnutrition. Malnutrition is an underlying cause of about half of child deaths, so this role is crucial.

6. Health Education and Awareness
Nurses teach mothers and families about hygiene, hand washing, safe drinking water, sanitation, home care of sick children, danger signs requiring immediate care, and family planning (birth spacing). This changes health-seeking behaviour and prevents deaths at home.

7. Early Identification and Referral
By recognizing danger signs — fast breathing, chest indrawing, convulsions, inability to feed, lethargy, severe dehydration — nurses refer children promptly to higher centres, preventing deaths that occur due to delay.

8. Maternal Health and Family Planning
Reducing maternal deaths and promoting birth spacing indirectly reduces child mortality, as children born after short intervals and to unhealthy mothers are at higher risk.

9. School Health and Adolescent Services
Nurses conduct school health programmes, screening, deworming and health education, improving child survival and well-being at school age.

10. Data Recording, Reporting and Advocacy
Nurses maintain registers (births, deaths, immunization, growth charts), report to HMIS, identify local causes of child deaths and advocate for resources and programmes such as FCHV, nutrition and immunization campaigns.

Conclusion
Through safe motherhood, newborn care, immunization, IMCI, nutrition counselling, health education and timely referral, nurses directly reduce neonatal, infant and under-five mortality in Nepal. Strengthening the number, skill and deployment of nurses, especially in rural and remote areas, is therefore essential to achieve SDG target 3.2 of ending preventable child deaths.