IMCI-ppt (1) Integrated Management of Childhood Illnesses PDF

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES PREPARED BY: FRANCHEZKA CASRTO, RN, MSN F.CASTRO What is IMCI? Integrated Management of Childhood Illnesses (IMCI) is a strategy for reducing the mortality and morbidity associated with the majo...

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES PREPARED BY: FRANCHEZKA CASRTO, RN, MSN F.CASTRO What is IMCI? Integrated Management of Childhood Illnesses (IMCI) is a strategy for reducing the mortality and morbidity associated with the major causes of childhood illness. It is an integrated approach to child health that focuses on the well- being of the whole child’s. IMCI aims to reduce death, illness and disability, and to promote improved growth and development among children under five years of age. It includes both preventive and curative elements that are implemented by families and communities, as well as by the  Principles of the Integrated Clinical Case Management Guidelines The IMCI Clinical Guidelines are based on the following principles:  All sick children aged up to five years of age are examined for general danger signs and all young infants are examined for signs of very severe disease. These signs indicate the need for immediate referral or admission to hospital.  Principles of the Integrated Clinical Case Management Guidelines  The children and infants are then assessed for main symptoms. For older children the main symptoms include cough or difficulty of breathing, diarrhea, fever, and ear infection. For young infants, the main symptoms include local bacterial infection, diarrhea, and jaundice. In addition, all sick children are routinely assessed for nutritional and immunization status, and other potential  Principles of the Integrated Clinical Case Management Guidelines A combination of individual signs leads to a child’s classification within one or more symptom groups rather than a diagnosis. The classification of illness is based on a color-coded triage system: “pink” indicates urgent hospital referral or admission, “yellow” indicates initiation of specific outpatient treatment such as an appropriate antibiotic and “green” indicates supportive home care.  Case Management Process SICK CHILD AGED 2 MONTHS TO 5 YEARS. This part contains all the necessary guidelines, information and instructions on how to provide care to sick children aged 2 months to 5 years brought to the attention of a health-care provider. SICK YOUNG INFANT AGED 1 WEEK UP TO 2 MONTHS. This part includes case management clinical guidelines for the care of a young infant aged up to 2 months. GENERAL DANGER SIGNS  Care for Child aged 2 months to 5 years Assess and classify the child Ask the mother about the child's problems  Check for general danger signs  Assess main symptoms: o Cough or difficulty breathing o Diarrhea o Fever o Ear problem Check for General Danger Signs Always check ALL sick children for general danger signs. General danger signs are:  the child is not able to drink or breastfeed  the child vomits everything  the child has had convulsions during the present illness or has convulsions now  the child is lethargic or unconscious  Check for General Danger Signs A child with a general danger sign has a serious problem. All children with a general danger sign need urgent referral to hospital. If during assessment you found presence of a general danger sign you should complete the rest of assessment immediately. If the child is to be referred, you should give urgent pre-referral treatment.  How to check for general danger signs? ASK: Is the child able to drink or Abreastfeed? child who is not able to suck or swallow when offered a drink or breast milk because he or she is too weak or cannot swallow has the danger sign not able to drink or breastfeed. Ask the mother if the child is able to drink or breastfeed. Make sure that the mother understands the question. If she says that the child is not able to drink or breastfeed, ask her to describe what How to check for general danger signs? ASK: Does the child vomit everything? A child who is not able to hold anything down at all has the danger sign "vomits everything” What goes down comes back up. A child who vomits everything will not be able to hold down food, fluids or oral drugs. A child who vomits several times but can hold down some fluids does not have this  How to check for general danger signs? LOOK: Is the child having convulsions During now?a convulsion, the child's arms and legs stiffen because the muscles are contracting. The child may lose consciousness or not be able to respond to spoken directions. Convulsions may be the result of fever. In this instance, they do little harm beyond frightening the mother. But convulsions may be associated with meningitis, cerebral Convulsions considered a life threatening danger sign are:  Any convulsions in children aged less than 6 months.  More than one episode of convulsions during the present illness or convulsions lasting for more than 15 minutes in One episode  children agedof6generalized months or convulsions more. during the current febrile illness in a child aged 6 months or more lasting for less than 15 minutes are considered simple febrile convulsions, NOT a general danger sign.  How to check for general danger signs? ASK: Has the child had convulsions during the present illness? Ask the mother of a child aged 6 months or more: How many times has the child had convulsions during this current illness? Just once or more than once? How many minutes had the convulsions lasted? Has the child had the convulsions for a few minutes or for a long time - more  How to check for general danger signs? LOOK: Is the child is unconscious or lethargic? A lethargic child is not awake and alert when he or she should be. The child is drowsy and does not take any notice of his or her surroundings or does not respond normally to sounds or movement. Often the lethargic child does not look at his or her mother or watch your face when you talk. The child may stare blankly and appear not to notice what is going on around him or her.  How to check for general danger signs? LOOK: Is the child is unconscious or lethargic? An unconscious child cannot be wakened. The child does not respond when he or she is touched, shaken or spoken to. Ask the mother if the child seems unusually sleepy or if she cannot wake the child. Look to see if the child wakens when the mother talks or shakes the child or when you clap your hands.  Classification  A child who is not able to drink or breastfeed, or vomits everything, or has had convulsions during the present illness or has convulsions now, or is lethargic or unconscious or is not able to drink or breastfeed has a danger sign and is classified as VERY SEVERE DISEASE Any general VERY SEVERE DISEASE danger sign  Classification Treatment. A child classified as VERY SEVERE DISEASE has a severe problem and needs URGENT attention. There must be no delay in treatment. Give diazepam if the child is convulsing now. Before the child leaves, give the child breast milk or sugar water to treat or prevent low blood sugar and advise the mother how to keep her child warm on the way to hospital. All sick children should be routinely checked for general danger signs  If you have found during the assessment that the child has a general danger sign, complete the assessment IMMEDIATELY.  Remember that a child with any general danger sign has a Exercise No: 1 Case Scenario #1 Mara is 3 years old. She weighs 14 kg. Her height is 95 cm. Her temperature is 38°C. The health worker asks about the child's problems. Mara’s parents say, “she is coughing and has ear pain." This is his initial visit for this problem. The health worker asks, "Is your child able to drink or breastfeed?" The parents answer, "Yes." "Does Mara vomit everything?" he asks. The parents say, "No." The health worker asks, "Has he had convulsions?" Does Mara have any General Danger signs? If yes, please They say, "No." The health worker looks at Mara. The child sits calmly in enumerate. his mother's lap and looks at the health worker. Exercise No: 1 Case Scenario #2 Cassy is 5 months old. She weighs 6 kg. She is 61 cm in length. Her temperature is 38.5°C. The health worker asks, "What are the child's problems?" The mother says, "Cassy has had a cough for 3 days, and she is very weak." This is The health Cassy's worker initial checks visit for Cassy for general danger signs. He asks, "Is this problem. Cassy able to drink or breastfeed?" The mother says, "No. Cassy does not want to breastfeed. She will not take any other drinks I offer her." The health worker offers Cassy some water. She is too weak to drink. Next he asks the mother, "Is she vomiting?" The mother says, "No." Exercise No: 1 He sees that Cassy does not have convulsions now, so he asks, "Has she had convulsions?" The mother says, "Yes, but it was less than a 3 minutes." The health worker looks to see whether Cassy is lethargic or unconscious. Cassy's eyes are open, but when the health worker and her mother are talking Does she does Cassy have not anylook at Danger of the them. When the Signs? health If yes, worker touches her, please enumerate. she does not respond. PNEUMONI A F.CASTRO Assess cough or Difficulty of breathing A child with a cough or difficulty breathing may have pneumonia or another severe respiratory infection. Pneumonia is an infection of the lungs. Children with bacterial pneumonia may die from hypoxia (too little oxygen) or sepsis (generalized infection).  Assess cough or Difficulty of breathing CLINICAL ASSESSMENT Difficulty breathing means any unusual pattern of breathing. Mothers describe this in different ways. They may say that their child's breathing is "fast" or "noisy" or "interrupted." When you ask the mother if the child has a cough or difficulty breathing and the mother answers "NO", see if you think the child has a cough or difficulty breathing. Assess cough or Difficulty of breathing ASK: For how long has the child had a cough or difficulty breathing? A child who has had a cough or difficulty breathing for more than 2 weeks has a chronic cough. This may be a sign of tuberculosis, asthma, whooping cough or another problem. Assess cough or Difficulty of breathing Child's age: Fast breathing: Note: A child who is exactly 12 months old has fast breathing if you count 40 or more breaths per minute.  Look for Chest Indrawing Lower chest wall indrawing (the inward movement of the bony structure of the chest wall when the child breathes in) is an indicator of pneumonia. It is more specific than intercostal indrawing, which concerns the soft tissue between the ribs without involvement of the bony structure of the chest wall. Chest in- drawing is when the lower chest wall (lower ribs) goes in when the Look for Chest Indrawing Chest indrawing occurs when the effort the child needs to breathe in is much greater than normal. In normal breathing, the whole chest wall (upper and lower) and the abdomen move out when the child breathes in. When chest indrawing is present, the lower chest wall goes in Look for Chest Indrawing  Look and Listen for Stridor Stridor is a harsh noise made when the child breathes in. Stridor happens when there is a swelling of the larynx, trachea or epiglottis. These conditions are often called croup. This swelling interferes with air entering the lungs. It can be life- threatening when the swelling causes the child's airway to be blocked. A child who has stridor when calm has a dangerous condition.  Look and Listen for Stridor To look and listen for stridor, look to see when the child breathes in. Listen for stridor when the child breathes in. Put your ear near the child's mouth because stridor can be difficult to hear. Sometimes you will hear a wet noise if the child's nose is blocked. Clear the nose, and listen again. A child who is not very ill may have stridor only when crying or upset. Be sure to look and  Look and Listen for Wheezing Wheezing is a soft musical noise made when the child is breathing out. Wheezing is caused by a narrowing of the air passages in the lungs. Breathing out takes longer than normal and requires effort. Look and listen for wheezing when the child breathes Hold your ear near the child's mouth because the out. wheezing noise can be difficult to hear. Sometimes so little air moves that there is no noise. Look to see if the breathing out phase requires great effort and is longer than normal. Classify the Child’s cough or difficulty breathing Based on the clinical signs found during the clinical assessment, the child's condition can be classified into one of three categories for: pre-referral treatment; specific treatment; or home care. Classify the Child’s cough or difficulty breathing SEVERE PNEUMONIA OR VERY SEVERE DISEASE A child with any general danger sign or stridor when calm is classified as having SEVERE PNEUMONIA OR VERY SEVERE DISEASE.  Any general danger SEVERE PNEUMONIA sign or OR  Stridor in calm child VERY SEVERE DISEASE Classify the Child’s cough or difficulty breathing Treatment A child classified as having SEVERE PNEUMONIA OR VERY SEVERE DISEASE is seriously ill. He or she needs to be urgently referred to a hospital for treatment, such as oxygen, a bronchodilator, or injectable antibiotics. Before the child leaves, give the first dose of an appropriate antibiotic. The antibiotic helps prevent severe pneumonia from becoming worse. It also helps treat other serious bacterial infections, such as sepsis or meningitis.  Classify the Child’s cough or difficulty breathing A child with a cough or difficulty breathing who has chest indrawing or fast breathing and NO general danger signs and NO stridor when calm is classified as having PNEUMONIA.  Chest indrawing or PNEUMONIA  Fast breathing Classify the Child’s cough or difficulty breathing Treatment A child with pneumonia needs treatment with Amoxicillin. A child with wheezing should receive inhaled bronchodilator for 5 days. A child who has a chronic cough (a cough lasting more than 2 weeks) may have tuberculosis, asthma, whooping cough or another problem. A child with a chronic cough needs to be referred to hospital for further assessment. Classify the Child’s cough or difficulty breathing COUGH OR COLD  A child with cough or difficult breathing who has no general danger signs, no stridor when calm, no chest indrawing, and no fast breathing is classified as having COUGH OR COLD. No signs of pneumonia or very severe disease COUGH OR COLD Classify the Child’s cough or difficulty breathing Treatment A child with COUGH OR COLD does not need an antibiotic. The antibiotic will not relieve the child's symptoms. It will not prevent the cold from developing into pneumonia. If the child is wheezing, give an inhaled bronchodilator or, if not available, oral salbutamol for 5 days. If the wheezing is recurrent, refer the child for assessment. SUMMARY Exercise No: 2 Case Scenario #1 Kara is 6 months old. She weighs 5.5 kg. Her length is 63 cm. Her temperature is 38°C. Her mother says she has had a cough for 2 days. The health worker checks for general danger signs. The mother says that Kara is able to breastfeed. She has not vomited during this illness. She has not had convulsions. Kara is not lethargic or unconscious. The health worker says to the mother, "I want to check Kara's cough. You said she has had a cough for 2 days now. I am going to count her breaths. She will need to remain calm while I do this." Exercise No: 2 The health worker counts 58 breaths per minute. She does not see chest indrawing. She does not hear stridor or wheezing. 1.How long has Kara had a cough or difficulty of breathing? 2. Does Kara have General Danger Signs?  If yes, please enumerate the danger sign seen to Kara. 3. Does Kara have Fast Breathing? 4. How would you Classify Kara’s cough? Exercise No: 2 Case Scenario # 2 Monique is 8 months old. She weighs 6 kg. her length is 69 cm. Her temperature is 39°C. Her father tells the health worker, "Monique has had a cough for 3 days. She is having trouble breathing. She is very weak." The health worker says, "You have done the right thing to bring your child today. I will examine her now." The health worker checks for general danger signs. The mother says, "Monique will not breastfeed. She will not take any other drinks I offer her." Monique does not vomit everything and has not had convulsions. The health care worker assess Monique if she is alert. She does not look at the health worker or her parents when they talk. Exercise No: 2 The health worker counts 55 breaths per minute. He sees chest indrawing. He decides that Monique has stridor because he hears a harsh noise when she breathes in. He does not hear wheezing. 1. For how long has Monique had a cough or difficulty of breathing? 2. Does Monique have danger signs?  If yes, please enumerate the Danger Signs seen to Monique 3. What signs associated with cough or difficulty breathing does Monique have? 4. How would you classify Monique’s cough? Exercise No: 2 Case Scenario # 3 Pedro is 18 months old. He weighs 9 kg, his length is 70 cm, and his temperature is 37°C. His mother says he has had a cough for 3 days. The health worker checks for general danger signs. Pedro's mother says that Pedro is able to drink and has not vomited anything. He has not had convulsions. Pedro looks at her mother and the health care worker when they are talking and responded when called by his name. The health worker counts the child's breaths. He counts 38 breaths per minute. The mother lifts the child's shirt. The health worker does not see chest indrawing. He does not hear stridor or wheezing when he listens to the child's breathing. Exercise No: 2 For how long has Pedro had a cough? Does he have fast breathing? How would you classify Pedro’s cough? DIARRHEA & DEHYDRATIO N  Assess for PERSISTENT DIARRHEA Clinical Assessment ASK: Is there blood in the stool?  Ask the mother if she has seen blood in the stools at any time during this episode of diarrhea. Assess for Dehydration CLINICAL ASSESSMENT Assess all children with diarrhea for the following signs of dehydration:  General condition  Sunken eyes  Thirst  Reaction to skin pinch  Assess for Dehydration LOOK at the child's general condition When a child becomes dehydrated, he or she is at first restless and irritable. If dehydration continues, the child becomes lethargic or unconscious (this is also a general danger sign).  Assess for Diarrhea – Dehydration LOOK at the child's general condition A child has the sign "restless and irritable" if the child is restless and irritable all the time, or every time he or she is touched and handled. If a child is calm when breastfeeding but again restless and irritable when he or she stops breastfeeding, the child has the sign  Assess for Diarrhea – Dehydration LOOK for Sunken eyes As the child's body loses fluids, the eyes may look sunken.  Decide if you think the eyes are sunken.  Then ask the mother if she thinks her child's eyes look unusual. Her opinion helps you confirm that the child's eyes are sunken.  Assess for Diarrhea – Dehydration OFFER the child fluid  Is the child not able to drink?  Is the child drinking poorly?  Is the child drinking eagerly, thirsty? A child is not able to drink if he or she is not able to take fluid in his or her mouth and swallow it. For example, a child may not be able to drink because he or she is lethargic or unconscious.  Assess for Diarrhea – Dehydration A child is drinking poorly if he or she is weak and cannot drink without help. The child may be able to swallow only if fluid is put in his or her mouth. A child has the sign drinking eagerly, thirsty if it is clear that the child wants to drink. Notice if the child reaches out for the cup or spoon when you offer him or her water. When the water is taken away, see if the child is unhappy because he or she wants to drink more. Assess for Diarrhea – Dehydration PINCH the skin of the abdomen. Does it go back very slowly (longer than 2 seconds)? Slowly? Ask the mother to place the child on the examining table so that the child is flat on his or her back with arms at sides (not over head) and legs straight. Or ask the mother to hold the child so he or she is lying flat in her lap. Locate the area on the child's abdomen halfway between the umbilicus and the side Assess for Diarrhea – Dehydration PINCH the skin of the abdomen. Does it go back very slowly (longer than 2 seconds)? Slowly? To do the skin pinch, use your thumb and first finger. Do not use your fingertips because this will cause pain. Place your hand so that when you pinch the skin, the fold of skin will be in a line up and down the child's body and not across the child's body.  Classifications of Dehydration There are three possible classifications of dehydration in a child with diarrhea: severe dehydration; some dehydration; no dehydration. SEVERE DEHYDRATION If the child has two or more of the following signs - lethargic or unconscious, not able to drink or drinking poorly, sunken eyes, skin pinch goes back very slowly - classify the child as having SEVERE DEHYDRATION. Two or more of the following signs:  Lethargic or unconscious SEVERE  Sunken eyes  Not able to drink or drinking poorly DEHYDRATION  Skin pinch goes back very slowly Classifications of Dehydration. Treatment Children have severe dehydration if they have a fluid deficit of 10 per cent or more of their body weight. They need fluids quickly. Treat with intravenous (IV) fluids. Plan C on the TREAT THE CHILD chart describes how to give fluids to severely dehydrated children.  Classifications of Dehydration. SOME DEHYDRATION  If the child has two or more of the following signs - restless, irritable; drinks eagerly, thirsty; sunken eyes; skin pinch goes back slowly - classify the child as having SOME DEHYDRATION. Also, if a child has one sign in the pink (top) row and one sign in the yellow (middle) row, classify the child as having SOME DEHYDRATION. Two of the following signs:  Restless, irritable  Sunken eyes SOME DEHYDRATION  Drinks eagerly, thirsty  Skin pinch goes back slowly. Classifications of Dehydration. Treatment Children with some dehydration have a fluid deficit of 5 to 10 per cent of their body weight. A child who has SOME DEHYDRATION needs fluids, zinc supplement, and foods. Treat the child with oral rehydration salts (ORS solution). Breastfed children should continue breastfeeding. Other children should receive their usual milk or some nutritious food after 4 hours of treatment with ORS. This treatment is described in Plan B on the TREAT THE CHILD chart.  Classifications of Dehydration. NO DEHYDRATION  A child who does not have two or more signs in the pink (top) or yellow (middle) row is classified as having NO DEHYDRATION. Not enough signs to classify as some or NO DEHYDRATION severe dehydration. Classifications of Dehydration Treatment Children with diarrhea but no signs of dehydration usually have a fluid deficit, but equal to less than 5 percent of their body weight. These children need more fluid than usual to prevent dehydration. A child who has NO DEHYDRATION needs home treatment described in Plan A on the TREAT THE The four rules of home treatment are: CHILD chart.  Give extra fluid  Give zinc supplements  Continue feeding When to return Assess for Diarrhea - Dehydration Diarrhea is also called loose or watery stools. It is common in children, especially those between 6 months and 2 years of age. It is more common in babies aged under 6 months who are drinking cow's milk or infant formulas. Frequent passing of normal stools is not diarrhea. The number of stools normally passed in a day varies with the diet and age of the child. In many regions diarrhea is defined as three or more loose or watery stools in a 24-hour period.  Assess for Diarrhea - Dehydration Types of Diarrhea Acute Diarrhea – episode of diarrhea lasts less than 14 days. Acute watery diarrhea causes dehydration and contributes to malnutrition. The death of the child with acute diarrhea is usually due to dehydration.  Assess for Diarrhea - Dehydration Types of Diarrhea Persistent Diarrhea – diarrhea lasts 14 days or more. Persistent diarrhea often causes nutritional problems that contribute to deaths in children who have diarrhea.  Assess for Diarrhea - Dehydration Types of Diarrhea Dysentery – Diarrhea with blood in the stool, with or without mucus. The most common cause of dysentery is Shigella Bacteria. Amoebic dysentery is not common in young children. A child may have both watery stool and dysentery.  Assess for PERSISTENT DIARRHEA Clinical Assessment ASK: For how long has the child had diarrhea?  Diarrhea which lasts 14 days or more is persistent diarrhea.  Give the mother time to answer the question. She may need time to recall the exact number of days.  Classifications Persistent Diarrhea SEVERE PERSISTENT DIARRHEA  If a child has had diarrhea for 14 days or more and also has SOME or SEVERE DEHYDRATION, classify the child as having SEVERE PERSISTENT DIARRHEA. Dehydration present. SEVERE PERSISTENT DIARRHEA Classifications Persistent Diarrhea  Classifications Persistent Diarrhea PERSISTENT DIARRHEA  A child who has had diarrhea for 14 days or more and who has no signs of dehydration is classified as having PERSISTENT DIARRHEA. No dehydration. PERSISTENT DIARRHEA  Classifications Persistent Diarrhea Treatment Children with PERSISTENT DIARRHEA and no signs of dehydration can be safely managed in the outpatient clinic, at least initially. Special feeding is the most important treatment for most children with persistent diarrhea.  Classification of DYSENTERY DYSENTERY  A child is classified as having DYSENTERY if the mother reports blood in the child's stool. It is not necessary to examine the stool or perform laboratory tests to diagnose dysentery. Stool culture, to detect pathogenic bacteria, is rarely possible. Also, at least two days are required to obtain the results of a  Classification of DYSENTERY Blood in the stool. DYSENTERY Treatment All children with bloody diarrhea should be treated with an antibiotic effective against Shigella because:  bloody diarrhea in children under 5 years of age is caused much more frequently by Shigella than by any other pathogen. SUMMARY Exercise No: 3 Determine if the child’s photos are with sunken eyeballs Exercise No: 3 Case 1: Anna has had diarrhea for five days, has no blood in the stool, is irritable, has sunken eyes, drinks eagerly when offered water, has a skin pinch that goes back slowly. What is Anna’s classification? Exercise No: 3 Case 2: Jane has had diarrhea for 3 days, has no blood in the stool, is not lethargic or unconscious, is not irritable or restless, has sunken eyes,is able to drink, but is not thirsty, has a skin pinch that goes back immediately. What is Jane’s classification? Exercise No: 3 Case 3: Gretel has had diarrhea for 2 days, does not have blood in the stool, is restless and irritable, has sunken eyes, is not able to drink, has a skin pinch that goes back very slowly. What is Gretel’s classification? Exercise No: 3 Case 4: Rana is 14 months old. She weighs 12 kg. She is 87 cm in length. Her temperature is 37.5°C. Rana's mother says the child has had diarrhea for 3 weeks. Does not have any general danger sign, does not have a cough or difficulty breathing, has had diarrhea for 21 days, does not have blood in the stool, is irritable throughout the visit, does not have sunken eyes, drinks eagerly when offered fluid, has a skin pinch that goes back immediately. What is Rana’s classification? END