imci-2010 back up
TRANSCRIPT
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IMCI – Integrated Management of Childhood Illness
By: Apple G. Alvarez, RN, MN
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Started in
• 1992 particularly by the UNICEF, WHO, DOH and AUSAID
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• Strategy• Reducing
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Childhood Illnesses
• Mortality• Morbidity
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Mortality
• Death of large numbers
• Number of deaths in a given place or locality
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Morbidity
• Rate of incidence of disease
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Integrated Management of Childhood Illness (IMCI)
Birth 1 week 2 months 5 years
Pregnancy
IMCI case management guidelines
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Why 1 week to 2 months up to 5 years?
• First week of life• Labor and Delivery
• Special Management
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IMCI again...
• CASE MANAGEMENT PROCESS
• First-level facility
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Guidelines – How to?
• Care brought to a clinic
• Illness• Scheduled
follow up visit to check the child’s progress.
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Guidelines INCLUDES:
1. Instructions (routine assessment)
2. Treatment3. Basic
Activities – Illness Prevention
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4. Do not describe management of trauma
• Other acute emergencies due to accidents or injuries
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4. If sought an untrained provider
• Too late for assessment
• Death!• Teaching –
IMPORTANT > Case Process
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TAKE NOTE:• Understandable
terms • In shaking the child -
- GENTLE
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• Second hand watch.• UNDRESS the child
• Longitudinal – Pinching of the abdomen
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• 2 months – SPOON
• 6 months – with a cup
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• If sunken eyes - - ASK if USUAL
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• Malaria Risk Area– Davao Del Norte– Davao Oriental– Sarangani– Sultan Kudarat
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• Petechiae – Folds– Thigh
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• Use pediatric cuff –tourniquet test
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• New EPI Administrative Order– BCG– Hepatitis B– 1st dose– Before Discharge
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• Iodine Deficiency = Iodized Salt
• Anemic Pregnancy = Iron Supplement
• Vit. A Deficiency = Micronutrients
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• Second Line = Availability of drug
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• Oresol• Home made solution
– 1 teaspoon of salt– 4 teaspoons of sugar– 1 liter of water
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Fully Immunized – before 12 months of age
• BCG 1• DPT 1• DPT 2• DPT 3• OPV 1• OPV 2• OPV 3• HB 1• HB 2• HB 3• Measles
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Problems why IMCI exist?
1. The under five population is the most vulnerable group
2. Child mortality remains UNACCEPTABLY HIGH
3. Many of these deaths had no medical attendance or being seen by first –level health facilities
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4. First-level facilities: -
undermanned/underpaid
- HW’s are not appropriately TRAINED
- drug supply inadequate/not properly
managed - inaccessible - poor laboratory
support
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5. Family and community profile/ practices
- late “help seeking” behavior
- poor utilization of health facilities
- literacy - traditional
beliefs/traditions - economic - large families - crowded, dense,
polluted environment
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IMCI - OBJECTIVES
1. To reduce SIGNIFICANTLY global mortality and morbidity associated with the major causes of disease in children
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• 2. To contribute to healthy growth and development of children
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A must to take note:
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“TRAINING DESIGN to teach integrated management of sick infants and children to first level HW’s in primary care settings that have NO laboratory support and only a limited number of essential drugs.”
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“ Action oriented CLASSIFICATIONS ,
rather than EXACT DIAGNOSES, are used.”
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“ A careful balance has been struck
between SENSITIVITY and SPECIFICITY
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“Using FEW CLINICAL SIGNS as
possible which health workers of diverse background can be trained
to recognize”
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“ The IMCI guidelines rely on detection of cases based on SIMPLE CLINICAL SIGNS,
without laboratory tests, and offer EMPIRIC TX “
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COLOR CODING
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PINK
• Severe• URGENT PRE REFERRAL
• Hospital/Treatment
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YELLOW
With Moderate Needs
Management – Rural Health Unit
Specific Medical Treatment
Advice
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GREEN
Mild
Home Care
Simple Advice
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5 steps in IMCI case management
1. Assess and Classify
2. Identify Treatment3. Treat4. Counsel the
Mother5. Follow Up
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ASSESS
Left side column how to take a history and do a physical examination
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CLASSIFY
Decision severity of ILLNESS
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IDENTIFY TREATMENT
To quickly identify treatment for the classifications
Written on your case recording form.
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Case Recording Form
Documentation!At the back of the form
After assessment
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IMPORTANT BEFORE ASSESSMENT –
1st
• Know which the child age belongs– 1 week up to 2
months– 2 months up to 5
years
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2nd
– Name– Age in
months– Weight in
kilograms– Temperatur
e and etc.
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Remember!
• Mothers knows best!
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3rd
• Initial• Follow
Up
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Initial visit
1st VISIT
Episode of Illness
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Follow up visit
Seen a few days ago for the same illness
Condition – improved or still the same
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THE CASE PROCESS
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I. Assess for the 4 GENERAL DANGER
SIGNS• Not able to
drink• Severe Vomiting • Convulsions • Abnormally
Sleepy
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Not able to drink …• If the child is:
–Too weak to drink–Not able to
suck/swallow when offered a drink/breastfeed
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»If the nurse is not sure upon assessment – ASK THE MOTHER to offer a child to drink (clean water/breast milk)
»IMPORTANT: Check if the child’s nose is blocked!
» POOR SUCKING
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Severe Vomiting …
• EVERTHING!!
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Convulsions …
DURING THE ILLNESS
Arms and legs – stiffening!
Jerky Movements
Loss of consciousness – even if eyes are open
SHIVERING !!! – not a convulsion
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Abnormally Sleepy …Drowsy
Not interested with surroundings
Stares blankly
No response - - even when TOUCH, SHAKEN or SPOKEN to.
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If child is asleep and has COUGH or DIFFICULT
Breathing, it is essential to:– Count the number
of breaths BEFORE waking up the CHILD
– Why? So it is easier to get the accurate breathing rate.
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In cases, there are presences of ANY danger signs - - as in
ANY...
Complete Assessment Form
Pre referral treatment immediately!
REFERRAL is not delayed!
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II. Assess for COUGH / DIFFICULTY in
BREATHING
1. In breathing• LOOK and LISTEN
to STRIDOR• Harsh noise when
the child BREATHS IN
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2. In cough• HOW LONG?• Chronic?• More than 30
days
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Rules 1-4
Count BREATHS per minute
CHILD - - quiet and calm
Do not count . . . .!
Ask the mother - -> Lift the child’s shirt
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Fast Breathing
If the child is Fast breathing is:
1 months -12 months
50 breaths/minute or more
12 months- 5 years
40 breaths/minute or more
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Is there breathing IN or OUT?
NORMAL CHEST INDRAWING
The whole chest wall and abdomen move OUT when the child breaths IN
The LOWER CHEST WALL goes IN when the child BREATHS IN
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Best Position to Check
• Lying down
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Stridor means..
• Harsh Noise Breathing IN
• Swelling of the:– Larynx– Trachea
–Epiglottis
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How to check for STIDOR?
• The nurse must PUT her ear near the child’s MOUTH
• While breathing IN and OUT• Harsh noise while BREATHING OUT –
NOT A STRIDOR!
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III. Assess for DIARHEA
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IMCI definition : DIARRHEA
3 or more loose or watery stools
in a 24 hour period
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Questions to ask..
• How long?• Blood in the STOOL?• Signs of
DEHYDRATION?
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If there is DIARRHEA
• Further assessment includes:– Dehydration– Persistent
Diarrhea• 14 days or more
– Dysentery
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Dysentery
– Infection of the intestine marked by severe diarrhea , usually of the lower intestinal tract
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If suspected DEHYDRATION
Check if there are signs like:
• Abnormally sleepy/difficult to awaken
• Restless and irritable AS IN ALL THE TIME!
• Sunken eyes If the nurse is not sure, please ask the MOTHER if the manifestation is usual to the child’s appearance.
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Offer the child fluid - - - with a CUP or a SPOON
Not able to drink Not able to take fluid in mouth and swallow
Drinking poorly If weak and cannot drink without help
Drinking eagerly, thirsty
Reaches out for the water offered
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Pinch the skin of the abdomen
Skin goes back VERY SLOWLY
Longer than 2 seconds
Skin goes back SLOWLY
Stays for a BRIEF TIME after release
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IV. Assess for FEVER
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IMCI definition : FEVER
– History of fever – no present fever but had fever within 72 hours
– Feels HOT
– Axillary temperature
= 37.5’c
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Checking on Malaria Risk• Been in places with malaria in
the past 4 weeks– Look/feel for STIFF NECK
• If child bends/moves neck easily as he looks around
• Draw the child’s attention to his TOES
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• Gently support BACK and BEND the HEAD forward to his CHIN
• Look for RUNNY NOSE – not HISTORY of runny nose!
• Look for SIGNS Of MEASLES
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Signs of Measles• Generalized rash• Any: cough, runny nose,
red eyes• Measles rash -
behind the EARS, NECK, spreads to the face and to the rest of the BODY
• No vesicles or pustules –no itchiness!
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And if there was MEASLES now or WITHIN the last 3 months
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ASSESS FOR:
1. Mouth ulcers –painful (inside of the mouth, lips or tongue)
2. PUS draining from the eye
3. Clouding of the cornea (hazing of the cornea)
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Assess for DENGUE HEMORRHAGIC FEVER
1. Only to those who are 2 months of age or older
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2. Look for signs of BLEEDING/SHOCK:
• Bleeding from the nose & gums
• Skin petechiae– Small
hemorrhages in the skin
– Small dark spots/patches in the skin
– Not raised– Not tender– Not lose its color when
the skin is stretched
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3. Cold and clammy extremities
– Check for slow capillary refill (longer than 3 seconds)
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4. Tourniquet Test!– Done:
» when there are no signs in the ASK/LOOK and FEEL
» Is 6 months» Fever is present more
than 3 days
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How is tourniquet test done?• Rumpel-Leede Capillary-
Fragility Test• Based on counting
petechiae in a given area of the arm
• A blood pressure cuff is applied and inflated to a point between the systolic and diastolic blood pressures
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• Positive more than 20 petechiae per square inch - - caused by a minor hemorrhage).
• After application of the rubber cuff - sphygmomanometer
• 5 minutes.
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IV. Assess for EAR PROBLEM
• Palpate• Look• Smell
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Only assessed the following:
1. Ear pain
2. Ear Discharge3. Tender swelling
behind the ear
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IF:
Present less than 2 weeks
Acute EAR infection
Present 2 weeks or more
Chronic EAR infection
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MASTOIDITIS
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ACUTE EAR INFECTION
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CHRONIC EAR INFECTION
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NO EAR INFECTION
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V. Assess for MALNUTRITION & ANEMIA
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MARASMUSVisible Severe Wasting
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KWASHIORKOREdema of both feet
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ANEMIAPalmar Pallor
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Weight for ageBasis for Nutrition
Imbalanced
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Treating Local Infections @ HOME
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Eye Infection – Tetracycline Ointment
• 3 times• Inside - lower lid
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Dry the EAR by WICKING
• 3X daily• Roll – tissue paper in a wick• Ear• Remove wick when wet• Repeat until dry
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Mouth Ulcers – gentian violent
• Half strength• 0.2 %
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Soothe the THROAT – Relieve COUGHSAFE REMEDY
• Breast milk – for exclusively breastfed
• Tamarind• Calamansi• Ginger• Harmful Remedies:
– Codeine Cough Syrups– Oral and Nasal
Decongestants
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Prevent low blood sugar
• If the child not able to BREASTFEED
• 30 ml of milk• SUGAR WATER
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To make sugar water
• 4 level of teaspoons of SUGAR (20 grams)
• 200 ml clean cup water
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• If the child – not able to swallow
• 50 ml – milk / sugar water
• NGT
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