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Paediatric nursing

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  • 1. PAEDIATRICNURSINGFIVE YEAR PLANSNATIONAL GOALSNATIONAL HEALTH PROGRAMMES RELATEDTOCHILD HEALTHwww.drjayeshpatidar.blogspot.com
  • 2. INTRODUCTION In 1950’Planning commission was constitutedto help government to plan out integrateddevelopment plan for the entire country. The Govt. of India &the planning commissiongive considerable importance to health in fiveyear plans. The constitution of India had considered healthas human beings right and an asset for over allsocio economic development.www.drjayeshpatidar.blogspot.in
  • 3. OBJECTIVES OF THE “FIVE YEARPLANS” Control &eradication of various communicablediseases, deficiency diseases, chronic diseases. Strengthening of medical basic health services byestablishing district health units, primary healthcentres&sub centers. Population control. Development of health manpower resources & research. Development of indigenous system of medicine. Improvement of environmental sanitation. Drug control. www.drjayeshpatidar.blogspot.in
  • 4. FIRST FIVE YEAR PLAN (1951-1956) AIMS: To fight against diseases, malnutrition and unhealthyenvironment & to build up health services for ruralpopulation for mother &children in order to improvegeneral health status of people. PRIORITIES: Health care of rural population. Health services for mother &children. Safe water supply & sanitation - Control of malaria. Family planning & population control. Education, training & health education.www.drjayeshpatidar.blogspot.in
  • 5. SECOND FIVE YEAR PLAN (1956-1961)AIMS: To expand existing health services to bring them within thereach of all people so as to promote progressive improvementof Nations health.PRIORITIES: Establishment of institutional facilities for rural as well as forurban population. Development of technical man power. Control of communicable diseases. Water supply & sanitation. Family planning &other supporting programmes.www.drjayeshpatidar.blogspot.in
  • 6. THIRD FIVE YEAR PLAN(1961-66) -68AIMS: To remove the shortages & deficiencies which were observed at theend of the second five year plan in the field of health. These werepertaining to intuitional facilities especially in rural areas, shortagesof trained personnel & supplies lack of safe drinking water in ruralareas & inadequate drainage system.PRIORITIES: Safe water supply in villages & sanitation especially the drinageprogramme in the urban areas. Expansion of intuitional facilities to promote accessibility especiallyin the rural areas. Eradication of malaria , smallpox & control of various otherdiseases. Family planning & other supporting services for improving healthstatus of people. Development of manpower.www.drjayeshpatidar.blogspot.in
  • 7. FOURTH FIVE YEAR PLAN (1969-1974)AIMS: To strengthen primary health center network in the rural areasfor preventive , curative & family planning services & to takeover the maintenance phase of communicable diseases.PRIORITIES: Family planning programme. Strengthening of primary health centers. Strengthening of sub divisional & district hospitals to provideeffective referral support to primary health centers. Intensification of control programmers. Expansion of medical & nursing education training of Paramedical personnel to meet the minimum technical manpowerrequirements. www.drjayeshpatidar.blogspot.in
  • 8. FIFTH FIVE YEAR PLAN (1974-79)AIMS:To provide minimum level of well integrated health,MCH &FP, nutrition & immunization services toall the people with special reference to vulnerablegroups especially children, pregnant women &nursing mothers, through a network of infrastructurein all the blocks & well structured referral system .The emphasis of the plan was on removingimbalance in respect of medical facilities &strengthening the health infrastructure in the rural &tribal areasPRIORITIES:Priorities were based on the minimum needprogramme.- increasing accessibility of health services in ruralareas.www.drjayeshpatidar.blogspot.in
  • 9. SIXTH FIVE YEAR PLAN (1980-1985)AIMS: To workout alternative strategy & plan of action for primary health care as part ofnational health system which is accessible to all section of society & especiallythose living in tribal, hilly, remote rural areas & urban slums.PRIORITIES: Rural health services. control communicable & other diseases. development of rural & urban hospitals dispensaries. improvement in medical education & training. medical research. drug control & prevention of food adulteration. population control & family welfare including MCH. water supply & sanitation. Nutrition.www.drjayeshpatidar.blogspot.in
  • 10. SEVENTH FIVE YEAR PLAN (1985-1990)AIMS: To plan & provide primary health care & medical services to all with specialconsideration of vulnerable groups & those who are living in tribal, hilly andremote rural areas so as to achieve the goal of health for all (HFA) by 2000A.D. The plan emphasized on community participation, inter sectoral co-ordination & co-operation.PRIORITIES: health services in rural, tribal & hilly areas under minimum need programme. medical education & training. control of emerging health problems especially in the area of noncommunicable diseases. MCH & family welfare. medical research. safe water supply & sanitation. standardization, integration & application of Indian system of medicine.www.drjayeshpatidar.blogspot.in
  • 11. EIGHTH FIVE YEAR PLAN (1992-1997)AIMS:To continue reorganization & strengthening ofhealth infrastructure & medical service accessibleto all especially to vulnerable groups & thoseliving in tribal, hilly, remote rural areas etc.PRIORITIES:- Developing rural health infrastructure- Medical education & training- Control of communication diseases- Strengthening of health service- Medical research- Universal immunization- MCH & family welfare- Safe water supply & sanitation.www.drjayeshpatidar.blogspot.in
  • 12. NINTH FIVE YEAR PLAN (1997-2002) Due to same political reason the ninth five year plan couldn’t commence on 1st ofApril 1997 at could commence on 19th of February 1999.AIMS: The ninth plan continued with the same aim as that of right plan which wasmainly concerned with reorganization & heightening of infrastructure so as toprovide health care services accessible to all especially those living in remoterural, hilly & tribal areas.OBJECTIVES: To tackle both communicable & non-communicable diseases effectively so thatthere is sustained improvement in the health status of the population To further intensity the efforts to improve the health status of the population byoptimizing coverage & quality care by identifying the critical gaps ininfrastructure, manpower, essential diagnostic reagents & drugs etc.www.drjayeshpatidar.blogspot.in
  • 13. NINTH FIVE YEAR PLAN (1997-2002)PRIORITIES: control of communication & non- communicable diseases. Efficient primary health care system as part of basic healthcare services to optimize accessibility & quality care. strengthening of existing infrastructure. improvement of referral linkages. development of human resources, meeting increasing demandsnurses in specially & super specialist & super specialty areas. strengthening of existing national vertical programmers. involvement of practitioners from indigenous system ofmedicine, voluntary & private organizations. inter sector co-ordination.www.drjayeshpatidar.blogspot.in
  • 14. TENTH FIVE YEAR PLAN (2002-2007) Today India has a vast network of governmental, voluntary and privatehealth infrastructure manned by large number of medical & paramedicalpersons . During the tenth plan, efforts will be further intensified toimprove the health status of the population by optimizing coverage &quality of care by identifying & rectifying the critical gaps ininfrastructure, manpower, equipment, essential diagnostic reagents &drugs.AIMS: To improve access to and enhance the quality of primary health care inurban & rural areas by providing on optimally functioning primary healthcare system as a part of basic minimum services & to improve theefficiency of existing health care infrastructure at primary, secondary &tertiary care settings through appropriate institutional strengthening &improvement of referral linkages.www.drjayeshpatidar.blogspot.in
  • 15. TARGET1] Reduction of poverty ratio by 5 percent points by 2007, andby 15 percent points by 2012;2] All children in school by 2003; all children to complete 5year of schooling by 2007;3] Reduction in gender gaps in literacy and wage rates by atleast 50% by 2007.4] Reduction in the decadal rate of population growth between2001 & 2011 to 16.2 percent5] Increase in literacy rate to 75% within the plan period6] Reduction of infant mortality rate to 45 percent 1000 livebirth by 2007 & to 28 by 2012.7] Reduction of maternal mortality ratio to 2 percent 1000 livebirth by 2007 & to 1 by 2012.8] All villages to have sustained access to potable drinkingwater within the plan period.www.drjayeshpatidar.blogspot.in
  • 16. ELEVENTH FIVE YEAR PLAN (2007-2012) The 10th plan aimed at providing essential primary healthcare, particularly to the underprovided & underservedsegments of our population it also sought to devolveresponsibilities & funds for health care to PRIS.However, progress to words these objectives has been slow &targets on MMR & IMR hare been missed. Accessibility remains a major issue especially in areas wherehabitations are scattered & women & children continue to dieen route to hospitals. Rural health care in most states is marked by absenteeism ofdoctor/health providers, law level of skills, shortage ofmedicines, inadequate supervision an/monitoring & callousattitudes. There are neither rewards for service providers nor punishmentfor defaulters. As a results, health outcomes in India are adverse compared toothers countries. www.drjayeshpatidar.blogspot.in
  • 17. ELEVENTH FIVE YEAR PLAN (2007-2012) A comprehensive approach which encompasses individual healthcare, public health, sanitation, clean drinking water, access to food &knowledge about hygiene & feeding practice is needed. With concerted action including enabling pregnant women to hareinstitutional deliveries & receive nutritional supplements, connecting PHCs& CHCs by all weathers roads so that they can be reached quickly inemergencies; (accessibility to hospital should be measured in terms oftravel time, not just distance from nearest PHC); providing home-basedneonatal care including emergency life saving measures etc; it would bepossible to achieve the millennium development goals for IMR, MMR andfor combating diseases by the end of the 11th plan.www.drjayeshpatidar.blogspot.in
  • 18. The 11th plan will first lay emphasis on Integrated district health plan and second on block specifichealth plans, Involvement of all health sectors & emphasize partnershipwith NGOS ensure quality health care in rural areas & specialneeds of people who are HIV positive, in particular women. Plan will continue to advocate fertility regulation, specialhealth care needs of the elderly. Following areas are to be strengthened: 1] National Rural Health Mission 2] Disability and mental health 3] Financing health services 4] Clean water for all 5] Sanitation.www.drjayeshpatidar.blogspot.in
  • 19. NATIONAL RURAL HEALTH MISSIONOBJECTIVES: Provision of trained & supported village healthactivities, in under severed areas as per needensuring quality and close supervision of ASHA. Preparation of health action plans by panchayats asmechanism for involving community in health. Strengthening SC/PHC/CHC by developing Indianpublic health standards. Institutionalizing &substantially strengtheningdistrict level management of health. Increase utilization of first referral units from lessthan20%to more than75%by2010. Strengthening sound local health traditions & localresource based health practices related to PHC &public health.www.drjayeshpatidar.blogspot.in
  • 20. TARGET IMR reduced to 30/1000 live births by 2012. MMR reduced to 100/1,00,000live births by 2012. TFR reduced to2.1by 2012. Malaria mortality reduction rate 100% by 2010 &additional 10% by 2012. Kala-Azar mortality reduction rate 100%by 2010 &sustainining elimination thereafter. Filarial reduction rate 70% by 2010, 80% by 2012& eliminated by 2012. Dengue mortality reduction rate-50%by2010&sustaining it at that level till 2012. Cataract operations increasing to 46lakh perannum. Leprosy prevalence rate-reduce from 1.8per 10,000in 2005 to less than 10,000 thereafter. TB DOTS Series-maintain 85%care throughmission period.www.drjayeshpatidar.blogspot.in
  • 21.  DISABILITY&MENTAL HEALTH: Coping with challenges of living in a rapidlydeveloping society & increasing exposure to aviolent world has led to a perceptible increase inmental stress. 11th plan should recognize the importance ofmental health care &should concentrate onproviding counseling, medical services&establishing help lines for all-especially peopleaffected by calamities, riots &violence. The 2001 census reveals that 2.13%of Indianpopulation or approximately 2.19 crore people inIndia suffer from severe disability.www.drjayeshpatidar.blogspot.in
  • 22. BHART NIRMAN Bharat Nirman is time –bound business plan for actionin rural infrastructure over the four year period [2005-2009] under bharat nirman action is proposed in theareas of: 1] Irrigation –To create 10 million hectares ofadditional irrigation capacity. 2] Rural roads-To connect all habitations withpopulation above 1000 [500 in hilly/tribal areas] withall roads. Rural housing-To construct 60 lakh houses for ruralpoor. Rural water supply- Rural electrification Rural telephony www.drjayeshpatidar.blogspot.in
  • 23. FINANCING HEALTH SERVICES Emerging health systems involves additional government expenditure. Theexisting level of government expenditure on health in India is just under 1%which is unacceptably low &efforts should be made to increase the totalexpenditure at the center & the states to 2-3% of GDP. Clean water for all. Waterborne infections hamper absorptions of food even when intake issufficient. Clean drinking water is therefore vital to reduce the incidence of disease&to check malnutrition. The 10th plan target of providing potable drinking water to all villages hasnot been achieved. Sanitation. Rural health sanitation is covered 35%by the end of the plan.www.drjayeshpatidar.blogspot.in
  • 24. MILLENIUM DEVELOPMENT GOALS INTRODUCTION The new century opened with newtechnology, scientific development,resources, political stability, cooperation but withwide disparity between rich & poor in terms ofdistribution of food,shelter,environmentalresources,& problems such asilliteracy, unemployment, poor health services, poorwater supply &sanitation etc. These new developments & challenges have beenrecognized by the world community with anunprecedented declaration of solidarity &determination to rid the world of poverty. In 2000 the UN Millennium declaration theworld leaders promised to work together to meetwww.drjayeshpatidar.blogspot.in
  • 25. GOAL Eradicate poverty & hunger. Universal primary education. Promote gender equality & empower women. Reduction of child mortality. Improve maternal health. Combat HIV/AIDS, Malaria & other diseases. Ensure environmental sustainability. Development of a global partnership for development.www.drjayeshpatidar.blogspot.in
  • 26. NATIONAL HEALTH PROGRAMMES RELATEDTO CHILD HEALTH Reproductive & child health programme. School health programme in India. Polio eradication pulse polio programme Diarrhea control programme &ORS programme. Prevention & control of Vitamin A deficiency among children. Universal Immunization programme. National immunization schedule. IMNCI Special nutrition programme Balwadi nutrition programme ICDS Scheme Mid day meal programme Prophylaxis against nutritional anemia Pilot project against micronutrient malnutrition. National nutritional anemia prophylaxis programme RNTCP (Pediatric tuberculosis) National HIV/AIDS control programmewww.drjayeshpatidar.blogspot.in
  • 27. REPRODUCTIVE & CHILD HEALTHPROGRAMME INTRODUCTION The programme was formally launched on 15th October1997. The International conference of population &development1994 established an international consensus on a newapproach to policies to achieve population stabilization. It is realized that reproductive & child health programme shouldfocus the needs of actual & potential clients, not only for limitingbirths but also for healthy sexuality& child bearing. DEFINITION:- Reproductive & child health has been defined as“People have the ability to reproduce & regulate theirfertility, women are able to go through pregnancy & child birthsafely, the outcome of pregnancies is successful in terms ofmaternal &infant survival and well being, & couples are able tohave sexual relations free of fear of pregnancy & of contractingdisease.” The aim of programme is to improving the health status of youngwomen & children.www.drjayeshpatidar.blogspot.in
  • 28. COMPONENT OF RCH Family planning. Child survival & safe motherhood. Clint approach to health care. Prevention/management of RTI/STD/AIDS.www.drjayeshpatidar.blogspot.in
  • 29. HIGHLIGHTS OF RCH PROGRAMME The programme integrates all interventions of fertilityregulation, maternal& child health with reproductivehealth for both women & men. The services to be provided are client oriented, demanddriven, high quality &based on needs of community. Upgradation of the level of health services forproviding various interventions & quality of care. FRUare set up at sub-district level providing emergencyobstetric& new born care. RCH facilities OF PHCs areupgraded. Facilities of obstetric care, MTP& IUD insertion in thePHCs level are improved.IUD insertion are alsoavailable at sub-centers. Specialist facilities for STD&RTI are available at alldistrict hospitals.www.drjayeshpatidar.blogspot.in
  • 30. RCH PHASE (I) INTERVENTIONS Child survival interventions :immunization, prevention&control of vitamin A, oral rehydration therapy &prevention of death due to pneumonia. Safe motherhood interventions: antenatal checkup, immunization for tetanus, safe delivery, anemiacontrol programme. Implementation of target free approach. High quality training at all levels. IEC activities. RTI/STD clinics at district hospitals. Facility for safe abortions at PHCs by providingequipment, contractual doctors etc. Community participation through panchayats, womensgroup &NGOs. Adolescent health &reproductive hygiene.www.drjayeshpatidar.blogspot.in
  • 31. RCH PHASE (II) INTERVENTIONS RCH phase II start from 1st April,2005 The focus of the programme is to reduce maternal & childmorbidity &mortality &emphasis on rural health care. Strategies : EssentialObstetric care a) institional delivery b) skilled attendance atdelivery c) ANM/LHV/SNs now been permitted to use drugsin specific emergency situations to reduce maternal mortality. Emergency obstetric care a) Operationalising FRU b)Operationalising PHCs/CHCs for round the clock deliveryservices. Strengthening referral system.www.drjayeshpatidar.blogspot.in
  • 32. SCHOOL HEALTH PROGRAMME OF INDIA School health programme is an important branch ofcommunity health. First time medical examination of school children was carriedout in Baroda city. In1960 the GOVT. of INDIA Renuka ray committee was setup to assess the standards of health & nutrition of schoolchildren &suggest ways &means to improve them. The committee submitted report in 1961 during five year planwith useful recommendations. then many state startedproviding school health &school feeding programme. Modern concept, school health services is an economical &powerful means of raising community health & moreimportant ,in future generations. According to that to providecomprehensive care of the heath & well-belling of childrenthroughout the school year &start school health services.www.drjayeshpatidar.blogspot.in
  • 33. OBJECTIVES The promotion of positive health. The prevention of disease. Early diagnosis, treatment & follow-up of defects. Awakening health consciousness in children. The provision of healthful environment. INDICATORS FOR ASSESSMENT OF SCHOOL HEALTHPROGRAMME Indicators of childrens health status. Indicators of ability to learn & learning achievement. Indicators of heath behavior. Indicators of the quality of school health programme & Policy Indicatorswww.drjayeshpatidar.blogspot.in
  • 34. COMPONENTS OF SCHOOL HEALTHPROGRAMME School health care services include preventive, curative & referralservices focusing on not only on student but also school staff. Health appraisal:-a) Regular periodic medical examination. b) Dailyinspection of students by the school teacher. c) A health record cardmaintained by the teacher. School health education includes academic skills &knowledgedevelopment. School health environment (physical & psychosocial) School community projects &outreach. Nutrition & food safety. Physical education & recreation. Mental health, counseling & social support. First aid & emergency care Dental health, eye health, education to handicapped children. Prevention of communicable diseases, remedial measures &follow-up.www.drjayeshpatidar.blogspot.in
  • 35. STRATEGIES Vision building &strategic planning Advocacy Networking & planning Resource mobilization &allocation Capacity building Operations researchwww.drjayeshpatidar.blogspot.in
  • 36. SCHOOL MENTAL HEALTH PROGRAMME School plays a crucial role in the development ofcognitive, linguistic, social, emotional& moral functions&competencies in child. Common stress in children. Mental health &learning go hand-in-hand. Psychosocial issues in schools Comprehensive life skills education.www.drjayeshpatidar.blogspot.in
  • 37. POLIO ERADICATION PULSE POLIOPROGRAMME INTRODUCTIONThe world assembly passed a resolution in May 1988to eradicate the dreaded polio from the face of theearth by the end of year2000. In 1995India took a step closer to eradicating polio,through the strategy of National Immunization Days-Pulse Polio Immunization . Polio can be caused by three types of wild polioviruses-Type I, Type II &Type III. Type I polio virus is predominantly isolated in childrenwith paralysis. It is estimated that for every child with paralytic polio,at least 100 other children are affected who have eitherno symptoms or have only nonspecific symptoms of amild illness. Oral polio vaccine (Trivalent) is considered to beeffective in preventing polio.www.drjayeshpatidar.blogspot.in
  • 38. STRATEGIES FOR POLIO ERADICATION IN INDIA Conduct Pulse Polio Immunization days every year for 3-4years or until poliomyelitis is eradicated. Sustain high levels of routine immunization coverage. Monitor OPV coverage at district level & below. Improve surveillance capable of detecting all cases of AFP dueto polio & non-polio etiology. Ensure rapid case investigation, including the collection ofstool samples for virus isolation. Arrange follow-up of all cases of AFP at 60 days to check forresidual paralysis. Conduct outbreak control for cases confirmed or suspected tobe poliomyelitis to stop transmission.www.drjayeshpatidar.blogspot.in
  • 39. CURRENT FOUR BASIC STRATEGIES TO ERADICATEPOLIO 1)Routine Immunization –Immunize every child with at least 4 doses of oral poliovaccine (Trivalent vaccine) 2)National Immunization Days/Pulse Polio Immunization program/Sub-NationalImmunization Days 3)Surveillance of Acute Flaccid Paralysis-To find places with circulation of wildpoliovirus. ----Components--- -Establishment &maintenance of reporting units. -AFP case notification. -AFP case investigation. -Stool specimen collection & transportation. -Outbreak response immunization -Active case search in the community. 60-days follow up examination Cross notification &tracking of cases. Data management &analysis. Case classification Feedback.www.drjayeshpatidar.blogspot.in
  • 40. CURRENT B. S. 4)Conduct extensive house to house immunization mopping-up campaigns -Mopping Up -Operationalization – Macro planning & micro planning New initiativeswww.drjayeshpatidar.blogspot.in
  • 41. DIARRHEA CONTROL PROGRAMME &ORSPROGRAMME The best treatment for dehydration is Oral Rehydration therapyby Oral Rehydration salt solution. The latest studys findings suggest that using the low-sodium, low-glucose& reduced osmolarity ORS formulationreduces the need for intravenous fluids by33% The effect of this reduction could result in fewer childrenrequiring hospitalization, fewer secondary infections, adiminished need to handle blood with its potentially dangerousconsequences, & lower health care costs.www.drjayeshpatidar.blogspot.in
  • 42. TREATMENT PLAN-A Age Amount of ORS given after each loose stool Above2yr. 50-100ml 2-10yr. 100-200ml 10-above As much as wanted TREATMENT PLAN-B Age Above4month 4-11month 12-23month 2-4yr. 5-14yr. Weight 5kg. 5-7kg 8-10kg 11-15kg 16-29kg AMT.ml.200-400 400-600 600-800 800-1200 1200-2200 15yrs or above 30 or more kg 2200-4000www.drjayeshpatidar.blogspot.in
  • 43. Composition of ORS FOR 1LITER Constituents Composition g/l 1)Sodium Chloride 2.6 2)Potassium chloride 1.5 3)Sodium citrate 2.9 4)Glucose anhydrous 13.5 Total Weight is 20.5 TREATMENT PLAN-C Age First give 30ml/kgin Then give70ml/kg in Infant One hour Five hours Older 30Minutes Two & a half hourswww.drjayeshpatidar.blogspot.in
  • 44. Prevention & control of Vitamin A deficiency amongchildren The signs & symptoms are: 1)Nightblindness 2)Xerophthalmia:drying of conjunctiva &cornea 3)Bitots spot: accumulation of foamy, cheesy material on theconjunctiva. Corneal Xerosis /Ulceration Keratomalacia: melting or wasting of the cornea on 1/3 of thecornea &2/3 of the cornea Corneal scar Xerophthalmic funduswww.drjayeshpatidar.blogspot.in
  • 45. PROPHYLAXIS Vitamin A, schedule recommended under the NationalProgram for Prophylaxis against Blindness in Children causeddue to Vitamin A deficiency that is now integrated with RCHProgram, starting at 9 months. Five doses of vitamin A are given to all children under threeyears of age. The first dose 1lakh units is given at nine months of age alongwith measles vaccination. The second dose2lakh units along with DPT/OPV doses&three doses are given 6months interval(2lakh units each).www.drjayeshpatidar.blogspot.in
  • 46. TREATMENT Two doses of 2 lakh IU vitamin A are given 4weeks apartaccording to program. Nutritional Counseling –Vitamin A rich food.www.drjayeshpatidar.blogspot.in
  • 47. RNTCP (Pediatric tuberculosis) Pediatrics & TB culminated in a national workshop on the“Management of pediatric TB under RNTCP.” This workshop resulted in modification of the RNTCPguidelines for the diagnosis & treatment of pediatric patients. A major recommendation was that the drugs for pediatric TBcases under RNTCP should be supplied in patient-wise boxes. Treatment will be based on the childs body weight &there willbe two PWBs One for the 6-10kg weight band,& the second for the 11-17 kgweight band. DOTS programme in the world is not available for children. Children weighing less than 6kg will be treated with loose anti-TB drugs.www.drjayeshpatidar.blogspot.in
  • 48. National HIV/AIDS control programme The project using Nevirapine, single dose, to the mother &child has been started from 1st October 2001 at 11 centersviz.Maharashtra(5),Chennai(3),Bangalore(1),Hyderabad(1)&Imphal(1). School AIDS Education Programme-www.drjayeshpatidar.blogspot.in
  • 49. ROLE OF NURSE IN NATIONAL HEALTHPROGRAMME Administrative role Supervisory role Educator role Implementer role Advisor rolewww.drjayeshpatidar.blogspot.in
  • 50.  THE ENDwww.drjayeshpatidar.blogspot.in

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