December 2013, Volume 63, Issue 12

Case Reports

Women's Health: An achievable goal for public health nursing in Pakistan

Samina Subzali Vertejee  ( School of Nursing and Midwifery, Aga Khan University, Karachi, Pakistan. )
Noureen Nasruddin Karamali  ( School of Nursing and Midwifery, Aga Khan University, Karachi, Pakistan. )


Monsoons of 2010; left devastated effects in Pakistan; it wiped away thousands of houses and damaged health infrastructure. The national and international communities rescued Internally Displaced People (IDP). Alongside the other health professionals\' Public health nurses (PHN) were instrumental in assisting IDPs.
This is a case study of a 30 year old postnatal woman; who sustained an injury on her right breast and developed an abscess in IDP camp. The client was assisted by the team of public health nurses by timely referral to undergo incision and drainage for appropriate management. Moreover, post procedure follow-up assisted the woman in wound management and neonate care, especially the breast feeding. The family was also involved in client\'s care to ensure their empowerment in managing the case. Thus, the efforts of PHN and their health assessment saved the life of one family by saving the life of a woman in that IDP camp.
Keywords: Public Health Nurse (PHN), Internally Displaced People (IDP), Breast Abscess, Wound Care, Nursing students, Faculty.


Monsoons in 2010; left devastated effects in Pakistan; it wiped away thousands of houses and damaged health infrastructure. The national and international communities rescued Internally Displaced People (IDP) and about 15 million people were affected. Many people suffered from post disaster health issue at the same time the accessibility was a challenge due to damage to health infrastructure.1,2 The situation has also impacted women's health particularly amongst IDPs.
People were brought to roads with no food, shelter and sanitation; in addition floods also abandoned over 200 hospitals, making health services inaccessible to people,3 whereas at least six million people needed lifesaving assistance. Nevertheless, people faced all the challenges yet they struggled to survive under the given scenario, hoping and aiming for food supplies, safe shelter and security.4 Despite the rescue efforts by individuals and organizations yet the suffering continued.
Amongst many, a private institution also contributed in rehabilitations of IDPs at different sites; several interventions were executed including the selection of IDP camp as a clinical placement for undergraduate nursing students enrolled in "Advanced Concepts in Community Health Nursing" (ACCHN). This established a win-win platform for both the IDPS and students. Nursing students proved to be extended arms for service provisions while meeting their course and clinical objectives. This continued for the period of four months to assist nursing students to understand and demonstrate the role of a public health nurse while working with communities. These roles have its own importance while working for the community development to integrate all the principles of Primary Health Care.5 To address the needs of IDPs the students along with their faculty participated in services provision and rehabilitation of IDPs.

Case Report

This report discusses the role of PHN in helping flood victims and making a difference by timely addressing their needs. Amongst many cases; was a 30 year old woman who lived in a relief camp along with her family. She was pregnant when she moved to the flood relief camp in November 2011 and after four and half months she delivered a baby boy. During the weekly visits from January-May 2011; student nurses screened and managed several at risk cases in IDP camps including this woman.
On the first visit in March 2011, students found her with painful expression on her face and tears in her eyes while breast feeding the new-born. The woman reported that she had pain in her breasts but could not visit the doctor due to cultural restriction and poverty; she stated that according to her mother in law the pain is normal for a nursing mother. However, she herself finds it a very agonizing experience, compared to her past experiences of breastfeeding. She further reported that she delivered her child after moving to IDP camp, and she never received any antenatal care.
Like other IDPs her family also lost their home and business in the floods and were surviving on food, clothing and shelter provided by NGOs and philanthropists. She further reported that she was injured while collecting the food aid. When the truck came to distribute supplies she also accompanied her husband to collect supplies. Unfortunately, she could not reach the distribution spot as she was knocked down by someone unknowingly. She fell down and sustained several injuries on her body including the right breast. Being a flood victim she could not visit the doctor; therefore managed the injuries with home remedies and local herbs, other injuries gradually healed; except the injury on the right breast.
After four and a half months history of injuries she delivered a child in March 2011 in IDP camp by a local woman; unfortunately due to the injury the right breast discomfort continued even in the postnatal period. On physical examination by PHN team including faculty and students, they identified that the woman had untreated right breast injuries. She had hard, tender to touch, black and shiny skin bilaterally, with a small infected wound on the right breast. The nursing mother with the history of breast injury, having the typical signs of breast abscess, reveals the causal relationship between breast feeding leading to mastitis and development of breast abscess.6,7 Breast abscess is a painful condition which can prohibit breast feeding.8 The woman also presented with the classic signs of breast abscess including shiny reddish to black skin of the breast, pain, tenderness and discomfort on feeding the new born.9
Moreover, the management depends on the accuracy of the diagnosis.10 This was observed in this case where the woman was identified by the team of PHN, and referred to an appropriate centre which was both technically and financially convenient for the patient. The delayed diagnosis caused extensive suffering to the patients.
Immediate hospitalisation was not possible as finances had to be arranged for transporation and a family member had to take charge of the baby. These challenges have been reported in literature for working mothers when they fall sick11 or suffer from chronic disorders.12
It was the efforts of the PHN which organised the hospitalisation and the breast abscess was incised and drained. The patient returned to the camp after the procedure and was followed up by the nursing students.
The woman had a big challenge of poverty and scarce resources on discharge from hospital. The CHN team of faculty and students were concerned about the home care of the incised breast in IDP camp with additional challenges of inadequate food, poor shelter and unhygienic living conditions. To prevent the woman from any complication especially infection, the team ensured that the dressing was done in a clean and hygienic condition. The family was taught about proper hand washing before and after handling of the incised wound, use of clean dressing, and appropriate clothing.


The presented case shows the miseries of the Internally Displaced People due to floods in Pakistan. The suffering of this population was relieved to a large extent by the voluntary services of Public Health Nurses who provided health care at the source. They could also educate the IDPs on personal hygiene as handwashing and cleanliness which was essential for protection against infections and other diseases.


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12. Antle BJ, Wells LM, Goldie RS, DeMatteo D, King SM. Challenges of parenting for families living with HIV/AIDS. Soc Work 2001; 46: 159-69.

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