Standard Treatment Protocol (STP) For Basic Health Services (BHS) Package 2078 PDF

STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 Ministry of Health and Population Department of Health Services Curative Service Division Kathmandu, Nepal STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICE...

STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 Ministry of Health and Population Department of Health Services Curative Service Division Kathmandu, Nepal STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 Ministry of Health and Population Department of Health Services Curative Service Division Kathmandu, Nepal STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 I STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 III STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 V STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 VII STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 IX STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 TECHNICAL WORKING GROUP (TWG) MEMBERS 1. Director, Curative Service Division (CSD), DoHS – Coordinator 2. Representative, Policy, Planning and Monitoring Division, MoHP – Member 3. Representative, Quality Standard and Regulation Division, MoHP – Member 4. Representative, Health Coordination Division, MoHP – Member 5. Representative, Deputy Secretary, Law Section, MoHP – Member 6. Representative, Family Welfare Division, DoHS – Member 7. Representative, Epidemiology and Disease Control Division, DoHS – Member 8. Representative, Management Division, DoHS – Member 9. Representative, National Public Health Laboratory – Member 10. Representative, National Health Training Center – Member 11. Representative, Department of Drugs Administration (DDA) – Member 12. Representative, World Health Organization (WHO), Nepal – Member 13. Representative, Nepal Health Sector Support Programme (NHSSP) – Member 14. Representative, GIZ, Nepal – Member 15. Section Chief, Basic and Emergency Service Management Section, CSD DoHS - Member Secretary CORE WORKING TEAM CONTRIBUTED REGULARLY TO THE DEVELOPMENT OF THE BHS-STP A. Curative Service Division, Department of Health Services 1. Dr. Madan Kumar Upadhaya, Director 2. Dr. Taranath Pokhrel, (Immediate Director, CSD) 3. Dr Pawanjung Rayamajhi, Director, CSD 4. Dr. Pomawati Thapa, Senior Consultant Medical Generalist 5. Dr. Narendra K. Khanal, Senior Consultant Medical Generalist 6. Dr. Prakash Budhathoki, Senior Consultant Dental Surgeon 7. Mr. Bharat Mani Marhatta, Senior Pharmacy Officer 8. Ms. Uma Kumari Rijal, Nursing Officer 9. Ms. Nilam Kumari Singh, Nursing Officer 10.Mr. Kamlesh Mishra, Public Health Inspector 11.Bijay Raj Chapagain. Pharmacy Officer, B. Nepal Health Sector Support Programme (NHSSP) 1. Dr. Maureen Dar Iang, Coverage and Quality Thematic (Former) Team Leader 2. Dr. Binamra Rajbhandari, Coverage and Quality Thematic(Current) Team Leader 3. Ms. Kamala Shrestha, Coverage and Quality Specialist (Access) 4. Dr. Rajendra Gurung, Sexual and Reproductive Health and FP Specialist 5. Dr. Paras Chipalu, Coverage and Quality Specialist (Quality) 6. Dr.Geetha Rana, Chief Consultant for BHS-STP 7. Dr. Binod Dangal, Consultant for BHS-STP 8. Mr. Prakash Ghimire, Health Assistant, Consultant for BHS-STP X  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 CONTENTS PART ONE: GENERAL INFORMATION 1 Chapter I – People-Centred Care And Rational Prescribing 2 1. People-Centred Care 2 2. Principles Of Appropriate Prescribing 3 3. Rational Use Of Antibiotics 5 4. Prescription And Its Contents 5 5. Infection Prevention And Control And Waste Management At Basic Health Care Centres 6 PART TWO: COMMON EMERGENCIES 11 Chapter II– Common Emergency Conditions 12 1. Surgical Skills – Dressing, Suturing, Incision And Drainage 12 2. Shock 15 3. Unconscious Patient 18 4. Convulsions 19 5. Primary Trauma Care (Ptc) 21 6. Management Of Fracture And Dislocation In Trauma Patients 22 7. Burns And Scalds 23 8. Drowning 25 9. Snake Bite 26 10. Poisoning 27 11. Common ENT and Eye Emergency Conditions 29 Chapter III – Common Symptoms 30 1. General Considerations On Pain 30 2. Chest Pain 31 3. Breathlessness/Shortness Of Breath 32 4. Cough 33 5. Abdominal Pain 34 6. Nausea And Vomiting 35 7. Headache 37 8. Fever 39 9. Dizziness Or Vertigo 41 10. Syncope (Sudden Collapse Or Loss Of Consciousness) 43 11. Itching (Pruritus) 44 12. Fatigue And Weakness (Generalised) 45 PART THREE: PREVENTIVE AND PROMOTIVE HEALTH SERVICES 47 Chapter IV – National Immunization Program 48 1. /fli6«o vf]k sfo{qmd 48 2. Case Surveillance for Vaccine Preventable Diseases 56 Chapter V – Integrated Management Of Neonatal And Childhood Illness 58 1. Management Of Children Under 2 Months 59 2. Management Of Children 2 Months To 5 Years 73 Chapter VI – National Nutrition Programme And Nutrition Disorders 85 1. Causes Of Malnutrition 85 2. Acute Malnutrition 86 3. Growth Monitoring And Promotion (GMP) Of Under 2 Years 92 4. Infant And Young Child Feeding 92 5. Micronutrient Supplementation And Deworming 95 6. Body Mass Index, Overweight, Obesity 97 XI  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 Chapter VII – Safe Motherhood, Safe Abortion Care and PMTCT 100 1. Antenatal Care 100 2. Anaemia In Pregnancy 102 3. Normal Labour And Birth 104 4. Postpartum Care of The Mother and Immediate Newborn Care 106 5. Management of Complications: Emergency Obstetric and Newborn Care 107 6. Obstetric First Aid and Referral 108 7. Safe Abortion Services 116 8. Prevention of Mother-To-Child Transmission of HIV (PMTCT) 120 9. Referral and Emergency Response System 122 Chapter VIII – Family Planning and Reproductive Health Services 123 1. Family Planning 123 2. Uterine Prolapse/Pelvic Organ Prolapse 130 3. Fistula 131 4. Cervical Cancer – VIA, Counselling And Referral 132 5. Breast Lumps And Cancer 133 PART FOUR: CURATIVE SERVICES 135 Chapter IX – Communicable Diseases 136 1. HIV/AIDS 136 2. Tuberculosis 139 3. Animal Bite and Rabies 143 4. Malaria 145 5. Leprosy 149 6. Kala-Azar 150 7. Dengue 151 8. Lymphatic Filariasis 152 9. Gastrointestinal Infections 153 10. Respiratory Infections 159 11. Eruptive Skin Lesions 162 12. Genitourinary Infections 165 13. Urinary Tract Infection (UTI) 173 Chapter X – Non-Communicable Diseases (NCD) 174 1. Hypertension (HTN) 174 2. Diabetes Mellitus (DM) 175 3. Asthma And Chronic Obstructive Pulmonary Disease 177 4. Musculoskeletal Pain 179 5. Acid Peptic Disease 182 6. Disability 183 7. Mental Health Disorders: Common Neurotic And Psychotic Disorders And Idiopathic Epilepsy 184 8. Adolescent Health Services 198 9. Health of the Elderly, Physiotherapy & Rehabitation 200 Chapter XI – Common Eye, ENT, Oral, Skin Conditions 206 1. Eye Disorders 206 2. Ear, Nose and Throat Disorders 212 3. Oral Health Problems 220 4. Skin And Soft Tissue Infections 224 PART FIVE: AYURVEDA AND ALTERNATIVE MEDICINE 231 Chapter XII –Ayurved Medicine 232 != k"j{ k+rsd{ 232 @= :tgkfoL cfdfsf] nflu ztfjf/L r'0f{ ljt/0f 234 #= of]u 234 XII  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 Chapter XIII – Homeopathic Medicine 236 1. kl/ro 236 2. Diseases 237 PART SIX: HEALTH PROMOTION 243 Chapter XIV– Health Promotion 244 1. Health Education: 245 2. Information, Education and Communication (IEC): 246 3. Behavioral Change Communication (BCC): 246 4. Public Awareness: 247 PART SEVEN 249 Chapter XV – Investigations And Drugs In Basic Health Care Facilities 250 1. Basic Investigations At BHS Facilities 250 2. Drug List and Dosage Charts 251 3. Adverse Drug Reactions (ADRS), Prevention and ADR Reporting Form 273 REFERENCES 273 ANNEXES 277 Annex 1 Pediatric Cardiac Arrest Algorithm 280 Annex 2 Adult Cardiac Arrest Algorithm 281 Annex 3 RTH for growth Monitoring for Under 5 Girls and Boys 282 Annex 4 BMI Chart for Boys and Girls (Age: 5-19 years) 283 XIII  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 ABBREVIATIONS ABCDE Airway, Breathing, Circulation, Disability, Exposure ADR Adverse Drug Reaction AEFI Adverse Events Following Immunisation AES Acute Encephalitic Syndrome AFB Acid-fast Bacilli AFHC Adolescent-friendly Health Clinic AFP Acute Flaccid Paralysis AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care ANM Auxiliary Nurse Midwife APD Acid Peptic Disease APH Antepartum Haemorrhage ARI Acute Respiratory Tract Infection ART Anti-retroviral Treatment ARV Anti-Retro Virus ASOM Acute Suppurative Otitis Media ASRH Adolescent Sexual and Reproductive Health ASV Anti-snake Venom ATT Anti-tubercular Therapy AVPU Alert, Responds to Verbal, Responds to Pain and Unresponsive BCC Behavioral Change Communication BCG Bacillus Calmette Guerin BD Twice a day BEONC Basic Emergency Obstetric and new-born Care BHS Basic Health Services BHSC Basic Health Services Centre BLS Basic Life Support BMI Body Mass Index BP Blood Pressure BTL Bilateral Tubal Ligation BW Body Weight CBE Clinical Breast Examination CCF Congestive Cardiac Failure CD4 Cluster of Differentiation 4 CEONC Comprehensive Emergency Obstetric and New-born Care CHD Coronary Heart Disease CHX Chlorhexidine CIN Cervical Intraepithelial Neoplasia CL Cutaneous Leishmaniasis XIV  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 CNS Central Nervous System COC Combined Oral Contraceptive COPD Chronic Obstructive Pulmonary Disease CPR Cardiopulmonary Resuscitation CPT Cotrimoxazole Prophylactic Therapy CRT Capillary Refill Time CS Caesarean Section CSF Cerebrospinal Fluid CSOM Chronic Suppurative Otitis Media CVA Cerebrovascular Disease CVD Cardiovascular disease CXR Chest X-Ray D&E Dilatation and Evacuation DBP Diastolic Blood Pressure DBS Dried Blood Sample DDA Department of Drug Administration DEC Diethylcarbamazine DHO District Health Officer DM Diabetes Mellitus DMPA Depot-Medroxyprogesterone Acetate DNA Deoxyribonucleic Acid DoHS Department of Health Services DPT Diphtheria, Pertussis and Tetanus DST Drug Sensitivity Test DUB Dysfunctional Uterine Bleeding EAC External Auditory Canal EC Emergency Contraception ECG Electrocardiogram ECP Emergency Contraceptive Pill EDCD Epidemiology and Disease Control Division EDD Expected date of delivery EMTC Early Management of Trauma Course ENT Ear Nose and Throat EONC Emergency Obstetric and new-born Care EPI Expanded Program on Immunization EPS Extrapyramidal Symptoms EPTB Extra-pulmonary Tuberculosis ET Eustachian Tube EWARS Early Warning and Reporting System F/U Follow Up FBF Fortified Blended Food FBMNCI Facility-Based Integrated Management Of Neonatal And Childhood Illness FBS Fasting Blood Sugar XV  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 FHR Foetal Heart Rate fIPV Fractional Injectable Polio Vaccine FP Family Planning G6PD Glucose 6-phosphate Dehydrogenase GAM Global Acute Malnutrition GBS Guillain-Barré Syndrome GCS Glasgow Coma Scale GERD Gastroesophageal Reflux Disease GI Gastrointestinal GIT Gastrointestinal Tract GMP Growth Monitoring and Promotion GPP Good Pharmacy Practice GTCS Generalised Tonic Clonic Seizure GUD Genital Ulcer Disease Hb Haemoglobin HBV Hepatitis B Virus HCV Hepatitis C Virus HHE Hypotonic Hyporesponsive Episode HiB Haemophilus Influenzae Type B HIV Human Immunodeficiency Virus HLD High-level Disinfection HMIS Health Management Information System HP Health Post HPF High-power Field HPV Human Papilloma Virus HR Heart Rate HRZE isoniazid (H), rifampin (R), pyrazinamide (Z), and ethambutol (E) HTN Hypertension I&D Incision and Drainage I/O Input/Output ID Intradermal IDA Iron Deficiency Anaemia IEC Information, Education and Communication IFA Iron and Folic Acid ILI Influenza-like Illness ILR Ice-lined Refrigerator IM Intramuscular IMNCI Integrated Management on Neonatal and Childhood Illness IPC Infection Prevention and Control IPT Isoniazid Preventive Therapy IUCD Intrauterine Contraceptive Device IUGR Intrauterine Growth Restriction IV Intravenous XVI  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 IYCF Infant and Young Child Feeding JE Japanese Encephalitis JVP Jugular Venous Pressure KMC Kangaroo Mother Care KUB Kidney, Ureter and Bladder LAM Lactational Amenorrhoea Method LF Lymphatic Filariasis LMP Last menstrual period LNG Levonorgestrel LPA Line Probe Assay LRTI Lower Respiratory Tract Infection LSCS Lower Segment Caesarean Section MA Medical Abortion MAM Moderate Acute Malnutrition MB Multibacillary MCL Mucocutaneous Leishmaniasis MDI Metred-dose Inhaler MDR Multi-drug-resistant MDT Multi Drug Treatment MEC Medical Eligibility Criteria MI Myocardial Infarction MMR Measles, Mumps and Rubella MNP Micronutrient Powder MoH/MOHP Ministry of Health/ Ministry of Health and Population MoH/MOHP Ministry of Health/ Ministry of Health and Population MR Measles-Rubella MSM Men who have Sex with Men MTB Mycobacterium tuberculosis MUAC Mid-upper Arm Circumference MVA Manual Vacuum Aspiration NCD Non-communicable Disease NG Nasogastric NHTC National Health Training Centre NLEM National List of Essential Medicines NS Normal saline NSAID Non-steroidal Anti-inflammatory Drug NSV No-scalpel Vasectomy NT Neonatal Tetanus NTC National Tuberculosis Centre NVP Nevirapine OD Once a day OPD Outpatient Department OPV Oral Polio Vaccine XVII  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 ORS Oral Rehydration Salts OTC Outpatient Treatment Centre OTP Outpatient Therapeutic Programme PA Per Abdomen PB Paucibacillary PCI Percutaneous Coronary Intervention PCR Polymerase Chain Reaction PEP Post-exposure Prophylaxis PHCC Primary Health Care Centre PHD Provincial Health Directorate PID Pelvic Inflammatory Disease PKDL Post Kala-azar Dermal Leishmaniasis PLHIV People Living with HIV PMTCT Prevention of Mother-to-child Transmission PNC Postnatal Care PO Per Oral POCs Product of Conceptions PPE Personal Protective Equipment PPFP Postpartum Family Planning PPH Postpartum Haemorrhage PPV Positive Pressure Ventilation PR Per Rectum PrHO Provincial Health Office PRN When necessary/occasionally PS Per Speculum PTC Primary Trauma Care PUD Peptic Ulcer Disease PUO Pyrexia of Unknown Origin PV Per Vagina PWID People Who Inject Drugs QDS/QID Four times a day R/E Routine Examination RBS Random Blood Sugar RDT Rapid Diagnostic Test RF Rheumatic Fever RH Reproductive Health RHD Rheumatic Heart Disease RIG Rabies Immunoglobulin RL Ringer’s Lactate RR Respiratory Rate RTH Road to Health RUTF Ready-to-Use Therapeutic Food SAM Severe Acute Malnutrition XVIII  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 SARI Severe Acute Respiratory Infection SAS Safe Abortion Services SBP Systolic Blood Pressure SC Subcutaneous SDM Standard Days Method SFP Supplementary Feeding Programme SLE Systemic Lupus Erythematosus SMO Surveillance Medical Officer SN Staff Nurse SNCU Sick New Born Care Unit SOPs Standard Operating Procedures SOS When necessary SPO2 Oxygen Saturation SSD Silver Sulphadiazine STD Sexually Transmitted disease STI Sexually Transmitted Infection STP Standard Treatment Protocols TB Tuberculosis TBM Tuberculous Meningitis TD Tetanus Diphtheria TDS/TID Three times a day TIA Transient Ischaemic Attack TSS Toxic Shock Syndrome TT Tetanus Toxoid UD Urethral Discharge URTI Upper Respiratory Tract Infection UTI Urinary Tract Infection VDRL Venereal Disease Research Laboratory VIA Visual Inspection with Acetic Acid VPD Vaccine Preventable Diseases VVM Vaccine Vial Monitor VZV Varicella Zoster Virus WHO World Health Organiztion XIX STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 of] pkrf/ k4lt k'l:tsf s;/L k|of]u ug]{< of] :t/Lo pkrf/ k4lt k'l:tsfsf] k|of]u ;DaGwdf k|of]ustf{sf] ;'ljwf tyf o;sf] clwstd pkof]usf] nflu oxfF ;fdfGo hfgsf/L k|:t't ul/Psf] 5. o; k'l:tsfsf] ;Dk"0f{ ljifo–;"rLnfO{ @ efudf ljeflht u/L ;f] sf] k|of]u ;DaGwdf lgDgfg';f/ hfgsf/L ul/Psf] 5. efu !M ;fdfGo hfgsf/L -General Information_M  pkrf/sf vf; k4ltaf/] o; k'l:tsfsf] ljifo ;"rLdf -Table of Contents_ pNn]lvt cWofox? x]/L kQf nufpg ;lsG5.  x/]s Chapter nfO{ Introduction, Diagnostic Features, Management Sections dful/Psf] 5. Divide Management Sections df Treatment, Advice, Counselling / Coordination and Notification Section df k'g Divide ul/Psf] 5 / s'g} ;?jf /f]u x?sf] Joj:yfkgf eg] Provincial Health Office, Local Health Unit sf] Coordination df Notification ug{ h?/L 5, h:t} M Scrub Typhus, Cholera, Rabies, Dengue, cflb.  g]kfn kmfd]{;L kl/ifbaf6 Go"gtd Pharmacy Practice -GPP ;DaGwdf d:of}bf tof/ ul/Psf] 5 h;df cf} iflw pkrf/ ;DaGwdf ;d"lrt k'hf{ n]vg -Rational Prescribing_ cf}iflw ljt/0f, e08f/0f / lj/fdL;+u ljdz{ -Patient Communication_ af/] hfgsf/L lbOPsf] 5. o;af6 cf}iflwsf] ;d"lrt k|of]u -Rational Use of Medicine_ / lj/fdLaf6 cg'z/0f Patient Compliance af/] ;xof]u k'Ug] ljZjf; ul/Psf]5.  o; k'l:tsfdf pNn]v ul/Psf ;/sf/L :jf:Yo ;]jf cGtu{tsf ljleGg :jf:Yo sfo{qmdx? tyf /fli6«o sfo{qmdx? cGtu{tsf pkrf/ k4ltx? ;DalGwt dxfzfvf tyf s]G›x?af6 kl/dfh{g tyf cBfjlws ul/Psf 5g\  olb lj/fdL JolQm kfFr aif{ pd]/ eGbfsdsf] ePdf afn :jf:Yo dxfzfvfsf] IMNCI sfo{qmd, /fli6«o kf]if0f sfo{qmd / /fli6«o vf]k sfo{qmdaf6 yfxf kfpg ;lsG5.  ;fdfGo Abbreviations tyf Symbol cf}iflw k'hf{ -Prescription_ df pNn]v ul/g] Abbreviations/Symbol af/] hfgsf/L lbO{Psf 5g\. efu–@M pkrf/ k4ltx? -Treatment Protocol_M cf}iflw ;]jf – (Pharmaceutical Care) sf] ;DaGwdf dxTjk"0f{ hfgsf/Lx? lgDgfg';f/ lbOPsf 5g\.  pNn]lvt k4ltdf cf}iflwsf] agfj6 -Dosages Form_, dfqf -dose_, Frequency and Duration, Route of Administration, Dosages Form af6 yfxf kfpg ;lsG5.  cf}iflw;+usf] cGt/lqmof -Drug Interaction_ cf}iflw ;+u x'g ;Sg] ;Defljt cGtlqmofaf/] pNn]v ul/Psf 5g\ h;af6 o:tf ;d:ofaf6 /f]Sg ;lsG5.  cf}iflwsf] gsf/fTds c;/ / k|lts'n c;/x? cf}iflwx?af6 x'g ;Sg] ;Defljt k|ltlqmofx? -Side Effects_ / cf}iflwsf] k|lts'n c;/x?af/] hfgsf/L lbOPsf 5g\. ;Defljt cf}iflwsf] gsf/fTds c;/af/] ;DalGwt lgsfodf hfgsf/L k7fpg cfjZos Format o;} k'l:tsfdf ;+nUg ul/Psf]5. pQm kmf/d o;}k'l:tsfaf6 Photocopy u/L cfjZos hfgsf/Lsf ;fy k7fpg ;lsG5. pQm 9fFrf cf}iflw Joj:yf ljefusf] web site : www.dda.gov.np af6 klg k|fKt ug{ ;lsG5. pQm kmf/ddf cfjZos hfgsf/L e/L :jf:Yo sfof{no dfkm{t cf}iflw Joj:yf ljefusf] ;"rgfzfvfsf] National Pharmacovigilance Center df k7fpg ;lsg]5. XX  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 PART ONE GENERAL INFORMATION 1 CHAPTER I STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 PEOPLE-CENTRED CARE AND RATIONAL PRESCRIBING 1. PEOPLE-CENTRED CARE People-centred care is a care that is focused and organised around people, rather than diseases. Within a people-centred approach, disease prevention and management are seen as important, but are not sufficient to address the needs and expectations of people and communities. The central focus is on the person in the context of his or her family, community, and culture (see Table below). People-centred care is broader than a closely related concept, patient-centred care. Whereas patient-centred care is commonly understood as focusing on the individual seeking care — the patient — people-centred care encompasses these clinical encounters and also includes attention to the health of people in their communities and their crucial role in shaping health services. Distinguishing features of conventional health care and people-centred care: Conventional care People-centred care Focus is on illness and cure Focus on health needs Relationship limited to the moment of consultation Enduring personal relationship Episodic curative care Comprehensive, continuous and person-centred care Responsibility limited to effective and safe advice to Responsibility for the health of all in the community the patient at the moment of consultation along the life cycle; responsibility for tackling determinants of ill-health Users are consumers of the care they purchase People are partners in managing their own health and that of their community Core principles of people-centred care include the following: Dignity and respect: Patients’, families’, and communities’ perspectives and choices are sought, heard, and respected. Their knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care. Focus on the whole person: People-centred care views people as more than their diseases. It sees them in the context of their daily lives, as part of a family and a community, and over the life course from childhood to old age. People’s health and well-being are considered from a biopsychosocial perspective, and maximising quality of life is a paramount treatment objective. Partnership: Within a people-centred approach, power and responsibility are shared among patients, health workers and communities. People are enabled to participate, to their level of ability and preference, as partners in their own health and that of their community. Continuity of care is an important aspect of people-centred care and primary health care teams providing Basic Health Care Services (BHCS) are best positioned to coordinate and facilitate referral and coordination between different levels of care. The ultimate goal of primary health care is better health for all. Organising health services around people’s needs and expectations is key to achieving that goal, along with moving towards universal coverage. 2  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 People-Centred Care and Rational Prescribing 2. PRINCIPLES OF APPROPRIATE PRESCRIBING The following aspects should be considered before prescribing a drug: Appropriate prescribing depends on accurate diagnosis, knowledge about drugs available for treatment, proper prescribing of the correctly selected drugs and proper understanding and compliance of patients about how to use each prescribed drug. Unless it is necessary, avoid prescribing multiple drugs (polypharmacy). Never prescribe any drug just to please the patient. Try to resist any demand from the patient for certain products, e.g., injectable preparation, vitamin products. Antibacterials, e.g., Amoxicillin or Cotrimoxazole, are only effective for treating bacterial infections. Do not misuse or overuse them in conditions that are not caused by bacterial infections, like influenza, acute non-specific diarrhoea, etc. Essential medicines are those effective, safe and economical drugs that are selected to satisfy the needs of the majority of the population. The drugs recommended in these treatment protocols are only those that belong to the National List of Essential Medicines (NLEM). Prescriptions should always be confined to the essential medicines. Always prescribe by generic names, e.g., Paracetamol, and not by brand names, e.g., Cetamol. Every medication may bear a risk for adverse reactions. In every case, the likely benefit should be weighed against the potential risk. Some conditions cannot be treated in Health Posts (HPs) or community health units (CHU) or urban health centres (UHC). Patients who cannot be treated at the local health facility should be referred to a higher-level facility without delay. Prescribing for children is not the same as that for adults. Calculation of dose for children and neonates requires special care and monitoring. Children’s doses may be calculated using age, weight, body surface area or a combination of these as prescribed in standard texts. Prescribing in elderly patients and the immunosuppressed also needs special care and monitoring. Elderly patients are different from younger adults as they may suffer from multiple disease or conditions, have reduced body mass and volume of drug distribution, reduced hepatic and renal function and manifestations of normal aging, etc. Patients should be counselled on: how to take drugs, the timing, duration and completion of prescribed dosage, what to do if side effects occur and when to return, and interaction with other drugs/food etc. Therefore, to achieve a safe, effective and economical use of drugs, prescribing should be based on some basic principles, as follows: Appropriate indication: Prescribing of drugs should be based on a real medical need consistent with accurate diagnosis, and critical evidence indicating that drug therapy is the best alternative for treating the patient's health problem. Prescribing of drugs should not be made for other reasons, for instance, because of demands from the patient, or to please the patient. Appropriate drug: If a patient requires drug treatment, only those drugs that are most effective, safe, suitable, and economical should be prescribed. The recommended drugs for all common conditions here in Nepal are given in this book. Providers are advised to follow the treatment recommendations in this guide. Appropriate for the patient: The selected drug that is considered best to treat the problem can only be given to an individual patient if there is no contraindication. If a contraindication exists, a safer alternative should be chosen. For example, Cotrimoxazole cannot be given to patient with history of allergy to Sulfa drugs. 3 STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 Appropriate administration, dosages and duration: How the drug will be administered, in which formulation, what dosage, how often, and for how long, should be decided before prescribing a drug to an individual patient. For most drugs that are used to treat commonly occurring problems in HPs and community health units/urban health centres/units’ information about dosages, administration, and duration of treatment is included in this guideline. Use of steroid and NSAIDs: NSAIDs and Steroids are frequently prescribed drugs. Use of these drugs needs proper consultation in long term. Appropriate information: Providing proper information regarding the disease and the medication is an integral part of the prescribing process. Patients should be well informed, to ensure the correct and safe use of drugs as well as the compliance of the patients. Appropriate follow-up: Every medication should be properly followed up and evaluated. Expected effects or unintended side effects should be properly communicated to patients, and should be evaluated during follow-up examinations. The patients should be informed properly when they should come back for follow-up. Reporting of adverse effects to the national reporting system is encouraged at all levels of the health care system. 3. RATIONAL USE OF ANTIBIOTICS Increasing antimicrobial resistance today poses a significant threat to public health in Nepal. A safe and effective strategy for antibiotic use involves prescribing an antibiotic only when it is needed and selecting an appropriate and effective agent at the recommended dose, with the narrowest spectrum of antimicrobial activity, fewest adverse effects and lowest cost. Good antibiotic prescription practices include: 1. Prescribing empiric antibiotics for suspected bacterial infections only if: Symptoms are significant or severe, There is a high risk of complications, The infection is not resolving or is unlikely to resolve. 2. Using first-line antibiotics first. 3. Reserving broad spectrum antibiotics for specifically indicated conditions. 4. When starting antimicrobials, using full therapeutic doses, paying close attention to dose, frequency, and route of administration and duration of treatment. 5. Stopping antimicrobials if the cause of initial symptoms is found to be non-infectious. 6. Whenever possible using diagnostic tests such as culture and sensitivity to determine the appropriate antibiotic. 7. Reassessing the patient after 48 hours of antibiotic use if possible. 4. PRESCRIPTION AND ITS CONTENTS A prescription is a legal document. It is a direct means of communication between the doctor/other authorised prescriber and the pharmacist/other authorised dispenser regarding drug therapy of the patient. A prescription should be written clearly, legibly, correctly and completely. This will enable the dispenser to understand the contents fully, to dispense drugs correctly to the patients avoiding significant or even life-threatening errors. 4  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 People-Centred Care and Rational Prescribing A prescription should contain information on three aspects: patient, therapy, and prescriber. Information about the patient includes the name, address, age, sex, and diagnosis. Information about therapy includes the name of the prescribed drug (always include generic name), dosage form and strength and quantity of drug. The patient should be told how to take the drugs, including dosage, route of administration, and frequency and duration of administration. Information identifying the prescriber includes the name, address and Nepal Medical Council or other professional council registration number. Whenever necessary, special instructions for taking the drugs need to be given to patients. This should be clearly written, e.g. ‘to be taken before meals’ or ‘after meals.’ The prescriber must sign a prescription. The date of the prescription should also be given. An example of the prescription is given below. Remember to check whether any family members have similar problems. If so they should also be treated. Prescription sample: Date: 2075-9-15 Patient name: Ram Bahadur Tamang, Age/Sex: 7 years old, Male, Address: Wada No. 2, ABC Municipality, Dailekh Diagnosis: Helminthiasis-Pinworm infestation Rx: Albendazole 400mg chewable tablet. One tablet at bedtime. Repeat one tablet of Albendazole after two weeks. Hand washing before every meal and cleaning of underwear and bed clothes. Follow-up: Any time if not well. Signature Hari Raj, HPC no. 123456 Patient communication Providing information to patients is an obligation for health care providers. Sufficient time should be spent with the patient to allow an effective two-way communication between health worker and patient (and/or carer) regarding the health problem s/he is suffering from, and the treatment that is required. The primary aim of patient communication is to educate patients towards good and desired behaviour for their health, and to ensure that they comply with the medication. The information that should be provided and shared with the patients and should therefore cover some essential components: The health problem from which the patient is suffering. What are the cause, prognosis, and necessary preventive and promotive measures in the future? The treatment that is required, both drug and non-drug treatment Information about drug treatment, including the name of the drugs, how to take the drugs and anticipated adverse effects that patients need to know. Reassurance should be given to patients, to help them comply with the treatment When the patients might need to come back for follow-up, if required. 5 STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 5. INFECTION PREVENTION AND CONTROL AND WASTE MANAGEMENT AT BASIC HEALTH CARE CENTRES 5. A. INFECTION PREVENTION AND CONTROL (IPC) Infection Prevention and Control (IPC) is a scientific approach and practical solution designed to prevent harm caused by infection to patients and health workers. Standard Precautions include: Hand washing and antiseptics (hand hygiene) Use of personal protective equipment when handling blood, body fluids, excretions and secretions Appropriate handling of patient care equipment and soiled linen Prevention of needle stick/sharp injuries Environmental cleaning and spills management Waste management. Hand Hygiene: This minimises contamination of microorganisms. Hand washing is recommended: Before and after examining any client (direct contact) After removing gloves because gloves may have holes in them After exposure to blood or any body fluids (secretions and excretions), even if gloves were worn. Steps of hand washing: Use a plain or antiseptic soap Vigorously rub lathered hands together for 10–15s, taking care to clean backs of hands, between fingers, under nails, and wrists Rinse with clean running water from a tap or bucket. Dry hands with a clean towel or air-dry them. Alcohol solution for surgical hand-scrub: Add 2ml glycerine to 100ml 60-90% alcohol solution. Use 3–5ml for each application and continue rubbing the solution over the hands for about 2–5 minutes, using a total of 6–10ml per scrub Close the tap (long body bibcock) with elbow. Use of Personal Protective Equipment (PPE): This provides a barrier between microorganisms and the wearer. Equipment includes - gloves, eyewear, masks, aprons, gowns, boots/shoe covers/caps. Wear Gloves: When performing a procedure in the clinic or operating room When handling soiled instruments, gloves and other items When disposing of contaminated waste items (cotton, gauze or dressings). Wear protective goggles, face-masks and aprons: If splashes and spills of any body fluids are likely. Patient care equipment: Any equipment that is used for a patient, and touches only their intact skin, such as surgical instruments, should be sent for different methods of infection prevention (e.g. decontamination, cleaning, High-level Disinfection (HLD), sterilisation). 6  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 People-Centred Care and Rational Prescribing Effectiveness of methods for processing instruments: Methods Effectiveness (removal) End point Decontamination Kills Hepatitis B Virus (HBV), 10 min soak in 0.5% chlorine Human Immunodeficiency Virus solution or equivalent (HIV) Cleaning (water only) Up to 50% Until visibly clean Cleaning (detergent with rinsing water) Up to 80% Until visibly clean Sterilisation 100% Autoclave, dry heat or chemicals (for recommended time) HLD 95% (does not inactivate some Boiling, steaming or chemical for 20 endospores) minutes Processing soiled instruments and other items: Decontamination Thoroughly wash and rinse Preferred Acceptable methods methods Sterilisation HLD Chemical Autoclave Dry Heat Boil Steam Chemical Cool Decontamination: Process that makes inanimate objects safer to be handled by staff before cleaning (i.e., kills or inactivates HBV, HIV, Hepatitis C Virus (HCV) and reduces, but does not eliminate, the number of other contaminating microorganisms). How to decontaminate instruments: Place instruments and reusable gloves in 0.5% chlorine solution after use, soak for 10 minutes and rinse immediately. How to make 0.5% chlorine solution: To make 0.5% chlorine solution from 35% chlorine powder, mix 14.2g powder in 1 litre of water. 7 STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 Cleaning: Refers to removal of organic material on soiled surfaces; generally done by clean water, mechanical action or detergents, later rinsing with clean water and drying. Ensure all visible soil is removed. This must be done for sterilisation and HLD to be effective. How to clean instruments: Wash with detergent and water Scrub instruments until visibly clean Thoroughly rinse with clean water. Sterilisation: Process that eliminates all microorganisms (bacteria, viruses, fungi and parasites) including bacterial endospores from inanimate objects by high-pressure steam (autoclave), dry heat (oven), chemical sterilising agent or radiation. This is used for instruments and items that are in direct contact with blood or tissue. Practice of sterilisation: Autoclave (steam sterilisation): 121°C, 106kPa pressure or 15lb pressure/square inch (15psi), 15min for unwrapped items and 30min for wrapped items. Dry heat (oven): 170°C for 1 hour or 160°C for 2 hours Chemical sterilisation: Soak items in 2% glutaraldehyde for 8–10 hours or formaldehyde for 24 hours and then rinse with sterile water. HLD: Process that destroys all microorganisms except endospores from inanimate objects. This is only acceptable alternative when sterilisation equipment is not available. HLD practice: Boiling: Boil instruments and other items for 20min, start time when water begins to boil, air-dry before use Steaming: Steam instruments for 20min, start time when steam begins to come, air-dry and store in covered steamer pans Chemicals: Soak in 0.5% chlorine/2% glutaraldehyde/formaldehyde solution for 20min, rinse with boiled water and air-dry before use. 5. B. HEALTH CARE WASTE MANAGEMENT Hospital waste is a potential reservoir of pathogenic microorganisms and requires appropriate, safe and reliable handling. Steps in the management of HP waste include waste minimisation, segregation/separation, collection, transportation, storage and final disposal. Types Non-risk health care waste: Also called general health care waste, this type of waste does not pose any biological, physical, chemical or radioactive hazard. It contains waste like paper, plastic, food waste, metal etc. It can be categorised as follows: Biodegradable waste (compostable): Leftover food, fruit, plants etc. Non-biodegradable waste (recyclable): Plastic, bottles, cans, metals, glass, paper, rubber etc. Other non-risk waste: Waste that cannot be composted or recycled (low-grade plastic). 8  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 People-Centred Care and Rational Prescribing Risk health care waste: This type of waste poses various environmental and health risks. Its classification includes: Sharp waste: Needles, blades, knives, scalpels, broken glass etc. Infectious waste: Waste contaminated with blood and body fluids, laboratory culture etc. Pathological waste: Body parts, human tissue, organs, blood product, placenta etc. Pharmaceutical waste: Expired and unused drugs Chemical waste: Laboratory reagents, disinfectant, film developer, batteries, and mercury thermometers. Purpose of waste management: To protect people who handle waste items from accidental injury To prevent the spread of infection to workers who handle waste To prevent the spread of infection to the local community To protect the surrounding environment from pollution (soil, water, air) To safely dispose of hazardous materials. Basic steps are considered essential for proper waste management: Waste minimisation Waste segregation Waste collection and storage Waste transportation Waste treatment, and Recycling, Reuse and disposal of the rest in sanitary landfill. Proper segregation at the source itself: Waste segregation at Basic Health Care Centres (BHCCs) with different colour-coded buckets (separation) before disposal: 1. Green: Non-risk biodegradable waste, such as leftover food, fruit peel, leaves, flowers etc. 2. Blue: - Non risk recyclable waste (non-biodegradable), such as recyclable plastic bottles, cans, metal, glass, plastic, paper, rubber - Other non-risk waste that does not belong to biodegradable or recyclable categories 3. Red: - Infectious waste, such as syringes, bandages, gauze, cotton, content with body fluids etc. - Pathological waste, containing human body parts and placenta - Sharp waste such as all types of glass bottles and broken glass articles, and discarded medicines. 4. White: Waste sharps (needle, blades) including metals- puncture proof containers. 5. Yellow: Chemical waste 6. Black: Hazardous radioactive waste. Methods of waste management: Non-risk biodegradable waste: Food, garden waste, fruit peel, plant residue can be composted to produce compost and also can produce biogas if the volume of waste is sufficient for anaerobic digestion Infectious waste: Bandages, cotton, dressing materials, syringes etc. should be autoclaved, with non- recyclable waste safely disposed of through sanitary landfill 9 STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 Pathological waste: Human tissue and placentas should be disposed of in placenta pits that are compliant to standards Non-biodegradable recyclable waste: Plastic, paper, rubber and metals should be reused or recycled Pharmaceutical waste: Waste is disposed of in secured landfill after encapsulation Sharp waste: Waste is at first disinfected with 0.5% chlorine solution and disposed of by encapsulation or septic vault. Placenta pits are prepared in all HP Birthing Centres for disposal of placenta; they measure about 4m deep and 1.5m wide. 5. C. NEEDLE STICK INJURIES Needle stick injuries are wounds caused by needles that accidentally puncture the skin. These injuries are a hazard to health workers and can occur any time while using hypodermic syringes or related needle equipment. Body fluids which are proven to be more infective in causing infections are blood, semen and vaginal secretions. Similarly, CSF, synovial, pleural, peritoneal fluids are also considered to be potentially infectious. The major pathogens of concern in such occupational body fluid exposure via needle stick injuries and their risks of seroconversion due to sharps injury from a known positive source are: 1. HIV: 0.3% 2. Hepatitis B: 6-30 % 3. Hepatitis C: 2% General Measures: 1. Wash with soap and water for 10-15 seconds. Alcohol can also be used in case of small punctures since it is virucidal to HIV, HBV and HCV. 2. If mucosa is involved, irrigate with clean running water or normal saline. REFERRAL Immediate referral for Post Exposure Prophylaxis (PEP) in cases of high-risk patient source. Refer patient for testing if the status is not known. 10  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 PART TWO COMMON EMERGENCIES 11 CHAPTER II STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 COMMON EMERGENCY CONDITIONS 1. SURGICAL SKILLS – DRESSING, SUTURING, INCISION AND DRAINAGE Traumatic injuries can range from simple isolated wounds to complex injuries as in cases of polytrauma involving multiple organ systems. Below is a description of simple dressing and suturing procedures at BHSCs. 1. A. DRESSING AND SUTURING DRESSING is a set of procedures for treating a wound, using an aseptic technique. The objective of dressing is to prevent contamination from the external environment, to favor tissue regeneration, to destroy pathogenic organisms and to stop hemorrhage. Equipment needed for simple dressing: - 1 dressing tray - 1 dissecting forceps with no teeth - 1 Kocher forceps with teeth - 1 pair of scissors - 1 drum of sterile gauze pads - 1 kidney dish - Cotton wool to disinfect the tray - Adhesive tape - Antiseptic: povidone iodine, normal saline, sterile water. TECHNIQUE of sterile dressing Use Standard Precautions (see Chapter I, Section 5) Wash hands thoroughly with soap and water, then dry with a clean towel and wear sterile gloves Open the sterile dressing tray Clean the wound and surrounding skin with cotton balls soaked in povidone iodine or Normal Saline (NS) in a circular, inside-to-outside motion or a straight up-to-down motion. Use each cotton ball for one wipe each: DO NOT rub back and forth. Dispose of soiled cotton balls Gently dry the wound using gauze Place sterile dressing pad over the wound o The pad should extend to cover the skin at least a few centimetres around the wound o The part of the dressing that will be in contact with the wound should never be touched o If blood/fluid seeps through the first bandage, do not remove it – instead, place another dressing over the top o If blood seeps through the second dressing, take off both dressings and apply a fresh dressing and put firm pressure on the wound to help stop the bleeding Cover wound with sterile gauze and a sterile compressor such as a rolling bandage Secure with adhesive tape or gauze bandage Dispose of all soiled items in the proper container; remove gloves and wash hands Change dressing every two to three days, with daily dressing if the wound is infected with pus formation. 12  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 SUTURING Sutures are appropriate when the depth of the wound would lead to excess bleeding or scarring if the wound edges were not properly opposed. Equipment needed for suturing: - 1 dressing tray - 1 dissecting forceps with no teeth - 1 needle holder for suture material EMERGENCY CONDITIONS - Suture material: catgut (for mucus membrane), nylon/silk (for skin) - 1 Kocher forceps with teeth - 2 pairs of scissors (one tissue cutting and one suture cutting) - 1 drum of sterile gauze pads - 1 kidney dish - Cotton wool to disinfect the tray - Adhesive tape - Solution of antiseptics: povidone iodine, normal saline, sterile water - Local anaesthesia: 1% or 2 % lignocaine. TECHNIQUE: Wash hands properly, put on sterile gloves, and make equipment ready for suturing Initial cleaning using NS or sterile water Disinfect the wound with povidone iodine Infiltrate local anaesthetic (1% lignocaine 5–10ml) around the edges of wound and wait for at least for two minutes In adults, the maximum dose of Lignocaine is 20ml of 1% solution (child 0.4ml/kg BW of 1% solution) or 10ml of 2% solution (child 0.2ml/kg BW for 2% solution); this may not be sufficient in patients with very large or multiple wounds; refer such patients Proceed carefully from the superficial to deepest parts of the wound to explore the extent of wound Look for any other injury to underlying structures: fracture, nerve injury, tendon injury, arterial injury Primary suturing: immediate suturing performed only after cleaning, exploration and satisfactory excision for simple wounds, no more than 6–24 hours old with no contused tissue Delayed suturing is performed for contaminated wounds, dog bites and bullet injuries. If after 72 hours there are no signs of local infection, the wound can be sutured Suturing: Plan where you are going to put your sutures. It is often better to start with the middle of the wound, with a “placer suture”, even if you cannot approximate the edges completely, so that you can get the right parts together While suturing, ensure that the needle passes through the Subcutaneous (SC) tissue, not just the superficial skin. The sutures should not normally be closer together than 1cm apart, and if it is difficult to get the edges together, use “mattress” sutures Tying sutures: Loop the suture around the needle holder in one direction and remember the direction of the loop; grasp the loose end with the needle holder and pull it through the loop to make the first knot, then lower the knot so that it closes the wound. The second loop should be in the opposite direction. At least three knots are required to make a suture, alternating from one direction to other. Close deep wounds in layers, using absorbable sutures for the deep layers Place a drain in deep oozing wounds to prevent haematoma formation Ask patients with clean wounds to come for dressing in two three days’ time, and those with infected wounds to attend daily Remove suture in five to ten days (five to seven days for face and hands, seven to ten days for legs and trunk). 13 STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 MANAGEMENT Drug treatment Preventing Tetanus Inj.Tetanus Toxoid (TT) 0.5ml IM administration over the deltoid muscle in any kind of wound is of utmost importance Refer for Tetanus Immunoglobulin to higher centre if the wound is contaminated and deep. Antibiotics: As a rule, systemic antibiotics should not be prescribed routinely; even topical antibiotics are optional. However, in some situations, systemic antibiotics are needed: Deep and soiled wounds, especially bite wounds To prevent abscess formation in infected wounds Infected burns. Cap cloxacillin 500mg orally (PO) four times a day (QDS) for five days, or amoxicillin 500mg PO three times a day (TDS) for five days, and Tab metronidazole 400mg PO TDS for five days. REFERRAL Wound with bleeding vessels (apply pressure dressing before referral) Tendon injury, nerve injury Deep lacerated wounds needing tetanus immunoglobulin Bone fractures (wash wound with NS, apply sterile dressing and stabilise fracture by application of a splint; give antibiotics before referral) and polytrauma. 1. B. ABSCESS A skin abscess is a collection of pus within the dermis or subcutaneous space. Predisposing factors for abscess formation are trauma, skin inflammation, oedema due to impaired lymphatic drainage and venous insufficiency, obesity, immune-suppression, and haematogenous spread of infection. The most commonly identified organism in abscess is Staphylococcus aureus. DIAGNOSIS Painful, fluctuant, erythematous nodule with or without surrounding cellulitis. INCISION AND DRAINAGE (I&D) FOR ABSCESS Equipment needed for I&D: - Sterile scalpel blade and handle - Surgical gloves - Plain curved forceps without teeth (Kelly forceps), scissors - Antiseptic solution, e.g., povidone iodine - 5 or 10ml syringe - Packing material: plain gauze - Mosquito forceps 14  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 Anaesthesia: Most of the time, local anaesthesia for abscess drainage is not effective For superficial abscesses, the skin can be briefly infiltrated with Lignocaine 1%, 5–10ml. Procedure: Clean the abscess area with povidone iodine, wait for 30 seconds, wipe off with sterile gauze Give local anaesthesia at the skin over and around the abscess where the incision will be made. Wait for three minutes. For bigger abscess, refer to higher centre for drainage. If you are not sure about whether it is an abscess, first take a syringe with an 18gauge needle and insert it into EMERGENCY CONDITIONS the area you suspect. Attempt to aspirate the pus. If blood and pus are removed, then proceed with the I&D. Hold the skin and use the scalpel blade (usually #11) to make a quick stabbing cut into the abscess. The direction of the cut should be in the same direction of the skin folds if possible. Make sure the incision is at least 1cm or larger (based on the size of the abscess) After incision, probe the abscess cavity with a haemostat forceps to break up loculations and ensure proper drainage. Use your fingers to express any pus and blood that comes out. Use a gauze pad to help soak the pus and blood Make sure that the abscess has been drained and that there are no other pockets of infection that have not been incised, to prevent recurrence Irrigate the abscess cavity copiously with isotonic saline solution until visible pus is removed Pack the abscess cavity with sterile gauze, a tail of 1cm of packing can serve as a wick for drainage and facilitate subsequent removal of the packing material Re-evaluate the wound after 24–48 hours. Generally, the pack can be removed after this time and the wound cleaned and dressed every one to two days until healed (may take one to three weeks, depending on size of abscess). MANAGEMENT Drug treatment: Antibiotics: for single abscess >2cm, multiple lesions, systemic signs of toxicity (fever >100.5°F/38°C, tachycardia, hypotension), extensive surrounding cellulitis, associated with other comorbidity etc. Inadequate clinical response to I&D alone: o Cloxacillin – 500mg QDS for five days OR o Doxycycline 100mg – twice a day (BD) on Day one, followed by once a day (OD) for four days 2. SHOCK Shock is the failure of the circulatory system to carry blood and oxygen to the heart, brain and other vital organs. It is life-threatening and requires immediate and intensive treatment by fluid replacement. DIAGNOSTIC FEATURES Important symptoms: History of blood loss, diarrhoea, serious burn or other injury, high fever, snake bite, allergy, poisoning or other serious disease Patient may feel very anxious and cold Patient may be confused or drowsy and hard to wake There may be shortness of breath/fast breathing. 15 STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 Important signs: Pulse fast (tachycardia) and weak Raised Respiratory Rate (RR, >25/minute in an adult) Skin pale or grey and clammy (sweaty, cold to touch) Blood Pressure (BP) f]]_ -! d'vdf ufnfsf] leqL efudf /f]6f efO/;af6 x'g] emf8fkvfnf l6pa_ kf]lnof] (2 Drops) d'vdf kf]lnof] -bf]>f]f]_ lk=l;=le= (0.5 ml) bfofF lt3|fsf] aLr aflx/L efu lgdf]lgof -bf]>f]_ df;'df l8=lk=l6=–x]k aL=– afFof lt3|fsf] dWo aflx/L efu Eofu't] /f]u nx/]vf]sL, wg'i6ª\ Preventive And Promotive Health Services lxj= (0.5 ml) -bf]>f]]_ df;'df sf/ x]kf6fOl6;–aL, x]df]lkmn; OGkm'n'OGhf–aL -lgdf]lgof_ $ !$ xKtf kf]lnof] (2 Drops) d'vdf kf]lnof] -t]>f] Pkm=cfO{=lk=le= (0.1 bfofF kfv'/fsf] dflyNnf] efu kf]lnof] ml) -bf]>f]]_ 5fnf leq (Intradermal) l8=lk=l6=–x]k aL=– afFof lt3|fsf] dWo aflx/L efu Eofu't] /f]u nx/]vf]sL, wg'i6ª\ lxj= (0.5 ml) -t]>f]]_ df;'df sf/ x]kf6fOl6;–aL, x]df]lkmn; OGkm'n'OGhf–aL -lgdf]lgof_ % ( dlxgf bfb'/f–?a]nf (0.5 ml) afofF kfv'/fsf] dflyNnf] efu bfb'/f / ?a]nf -klxnf]_ 5fnf / df;' aLr lk=l;=le= (0.5 ml) bfofF lt3|fsf] aLr aflx/L efu lgdf]lgof -t]>ff]_ df;'df ^ !@ dlxgf hfkflgh OG;] bfofF lt3|fsf] dflyNnf] aflx/L Hffkflgh OG;]kmnfO{l6; kmnfO{l6; (0.5 ml) efu 5fnf / df;' aLr (Subcutaneous) & !% dlxgf bfb'/f–?a]nf (0.5 ml) afofF kfv'/fsf] dflyNnf] bfb'/f / ?a]nf -bf];|f]_ efu 5fnf / df;' aLr (Subcutaneous) * ue{jlt dlxnf l6=l8= (0.5 ml) afofF kfv'/fsf] dflyNnf] efu wg'i6ª\sf/–Eofu't] /f]u df;'df olb dfly lbOPsf] tflnsf cg';f/ afnaflnsfx? s]lx sf/0fa; lgoldt vf]k nufpg 5'6 ePsf 5g] eg], g]kfn ;/ sf/n] cf=j= @)&&/&* af6 % jif{;Ddsf afnaflnsfnfO{ vf]k lbg] tflnsf ;fj{hlgs u/]sf] 5. 49 STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 -v_ lgoldt vf]k tflnsf cg';f/ lgoldt vf]k 5'6 ePsf % jif{;Ddsf afnaflnsfnfO{ vf]k lbg] tflnsf lgoldt vf]k tflnsf cg';f/ 5'6 ePsf] afnaflnsf dfqf, ;'O{ nufpg] lgoldt vf] !@ dlxgf;Ddsf] pd]/ !@ b]lv @# @$ b]lv %( vf]k :yfg / dfWod k tflnsf dlxgf;Ddsf] dlxgf;Ddsf] pd]/ pd]/ la=l;=lh= )=)% ld=ln= bfofF ! dfqf pd]/ ! jif{;Ddsf] nflu ! jif{ jf ;f] eGbf dflysf] nflu kfv'/fsf] dflyNnf] M hlGdg] )=)% ld=ln= )=! ld=ln=sf] Ps dfq lbg]. efu 5fnf leq (ID) ljlQs} )=! ld=ln= vf]k lbFbf Pkm=cfO{=lk=le= lbg] l;l/~h k|of] u ug]{. /f]6f ! 6\o"a -ufnfsf] @ dfqf M ! dlxgfsf] km/sdf @ dfqf @ jif{ dflysf pd]/ leqL efu_ ^ / !) lbg]. ;d"xsf]nfO{ /f]6f xKtfdf vf]k lbg' x'b}g. kf]lnof] d'vdf b'O{ yf]kf # dfqf M ^, ! dlxgfsf] km/sdf # dfqf lbg]. !) / !$ xKtfdf Pkm=cfO{= )=! ld=ln=, afofF @ dfqf M ! dlxgfsf] km/sdf @ dfqf lbg]. lk=le= kfv'/fsf] dflyNnf] ^ / !$ efu 5fnf leq (ID) xKtfdf lk=l;=le= )=% ld=ln=, bfofF # dfqf M ^ & dlxgf d'lgsf] ePdf klxnf] ! dlxgfsf] @ dlxgfsf] km/sdf lt3|fsf] aLr aflx/L xKtf, !) km/sdf bf];|f] dfqf lbg] / @ dfqf lbg]. efu df;'df (IM) xKtf / ( ( dlxgfdf t];|f] dfqf lbg]. dlxgfdf & b]lv ! dlxgf;Ddsf]nfO{ !÷! dlxgfsf] km/sdf # dfqf lbg]. l8=lk=l6=–x]k )=% ld=ln=, afofF # dfqf M ^, !÷! dlxgfsf] km/sdf # !÷! dlxgfsf] km/sdf @ dfqf / aL=–lxj= -k] lt3|fsf] aLr aflx/L !) / !$ dfqf lbg]. bf];|f] dfqf nufPsf] ^ dlxgfkl5 G6fEofn]06_ efu df;'df (IM) xKtfdf t];|f] dfqf lbg]. bfb'/f–?a]nf )=% ld=ln=, afofF @ dfqf M ( b]lv !% dlxgf d'lgsf] ePdf klxnf] dfqf !% b]lv %( lt3|fsf] dflyNnf] ( / !% nufPsf] slDtdf ! dlxgf km/sdf t/ !% dlxgf;Ddsf] ePdf aflx/L efu 5fnf / dlxgfdf dlxgfdf bf];|f] dfqf lbg]. !÷! dlxgfsf] km/ df;' aLr (SC) sdf @ dfqf lbg]. hfklgh OG;] )=% ld=ln=, bfofF ! dfqf M ! dfqf lbg]. kmnfO{l6; lt3|fsf] dflyNnf] !@ dlxgfdf aflx/L efu 5fnf / df;' aLr (SC) gf]6 M 5'6 ePsf vf]kx¿ lbFbf klxn] lbPsf vf]ksf dfqf bf]x¥ofpg' x'b}g. 50  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 -u_ /fli6«o vf]k sfo{qmddf ;dfj]; x'g] cGo vf]kx¿sf] ;+lIfKt hfgsf/L != Xo"dg Koflknf]df efO/; lj?4sf] vf]k (Human Papilloma Virus Vaccine- HPV Vaccine) ;+;f/sf ljleGg b]zx¿df ul/Psf cWoog cg';f/ kf7]3/sf] d'vsf] SofG;/sf] k|d'v sf/0f Pr=lk=eL= gfds efO/; xf]. Pr=lk=eL=(HPV) sf] k"0f{¿k (Human Papilloma Virus) xf]. Pr=lk=eL= efO/; !)) eGbf w]/} k|sf/sf x'G5g\. kf7]3/sf] d'vdf x'g] SofG;/dWo] &) k|ltzt SofG;/ Pr=lk=eL=n] u/fpF5. Pr=lk=eL= efO/; lj?4df k|of]u ul/g] vf]knfO{ Pr=lk=eL= vf]k elgG5. of] vf]kn] Pr=lk=eL=sf] ;+qmd0faf6 ;'/lIft u/fpF5 / bL3{sfnLg ?kdf tL dlxnfsf] kf7]3/sf] d'vsf] SofG;/ x'gaf6 arfpg ;S5. g]kfndf lzIff dGqfno;Fusf] ;xsfo{df sf:sL / lrtjg lhNnfdf cf=j= @)&@–&# df of] vf]k ;]jf ;~rfng ul/ Psf] lyof]. /fli6«o vf]k ;Nnfxfsf/ ;ldltn] of] vf]knfO{ /fli6«o vf]k sfo{qmddf ;dfj]; u/L sIff ^ df cWoogug]{ 5fqfx¿ / ljBfno ghfg] !) jif{ pd]/sf lszf]/Lx¿nfO{ ^ dlxgfsf] km/sdf @ dfqf vf]k lbg l;kmfl/; u/]s]f 5. @= 6fOkmfO8 lj?4sf] vf]k Preventive And Promotive Health Services g]kfndf 6fOkmfO8 /f]u ;a} 7fpFdf AofKt /x]s]f s'/f o;;DaGwL ljleGg cWoogn] b]vfPsf] 5. of] /f]u h'g;'s} pd]/sf dflg;nfO{ x'g;S5 t/ of] /f]uaf6 ;a}eGbf a9L hf]lvd kfFrjif{ d'lgsf afnaflnsfx¿ /x]sf 5g\. /fli6«o vf]k ;Nnfxsf/ ;ldltn] of] vf]knfO{ /fli6«o vf]k sfo{qmddf ;dfj]; u/L k|f/Dedf !% dlxgf b]lv !% jif{;Ddsf afnaflnsfx¿nfO{ cleofgsf]?kdf vf]k ;]jf k|bfg u/L tt\ kZrft sf afnaflnsx¿nfO{ lgoldt vf]k ;]jf dfkm{t !% dlxgfdf bfb'/f–?a]nf bf]>f] dfqf ;+u} vf]k lbg l;kmfl/; u/]s]f 5. -3_ P=O{=Pkm=cfO{= ;le{n]G; / P=O{=Pkm=cfO{= vf]k nufPkl5 x'g] s'g} klg :jf:Yo ;DaGwL cgk]lR5t 36gf (AEFI- Adverse Event Following Immunizaton) xf], h'g vf]ksf] sf/0fjf6 gePsf] klg x'g;S5. o:tf cgk]lR5t 36gfx¿ vf]k nufPkl5 ck|Toflzt\ lrGx, nIf0f, c;fdfGo k|of]uzfnf k/LIf0f kl/0ffd (Abnormal Lab Test Result) jf /f]usf] ?kdf b]vf kb{5g\. vf]k kZrft x'g] w]/}h;f] cgk] lR5t 36gfx¿ Vff]k;Fu ;DalGwt x'b}gg\ / tL 36gfx¿ ;+of]uj; x'g] 36gfx¿ x'g. o;/L vf]k nufPkl5 x'g;Sg] cgk]lR5t 36gfsf] vf]hk8tfn tyf lgu/fgLnfO{ P=O{=Pkm=cfO{= ;le{n]G; elgG5. P=O{=Pkm=cfO{=sf] k|sf/ M vf]k kZrft x'g] lrGx, nIf0f / /f]usf] cj:yfsf] cfwf/df P=O{=Pkm=cfO{=nfO{ d'Vou/L @ efudf juL{s/0f ul/G5 M != ;fdfGo k|sf/sf P=O{=Pkm=cfO{=, @= ulDe/ k|sf/sf P=O{=Pkm=cfO{= != ;fdfGo k|sf/sf P=O{=Pkm=cfO{= (Minor or Non-serious AEFI) vf]k nufPkl5 ;'O{ nufPsf] 7fFpdf b'Vg], ;'lGgg], /ftf] x'g], ;fdfGo Hj/f] cfpg], 6fpsf] b'Vg], ysfO{ nfUg] / cfn:o dxz'; x'g], jfsjfs nfUg] h:tf ;fdfGo c;/x¿ x'g ;S5g\ h;nfO{ ;dfGo k|sf/sf P=O{=Pkm=cfO{= elgG5. ;fdfGo lsl;dsf P=O{=Pkm=cfO{=n] vf]k lng] JolQmsf] :jf:Yodf ulDe/ c;/ kfb}{gg\ / of] cfkm} la:tf/} 7Ls x'G5. @= ulDe/ k|sf/sf P=O{=Pkm=cfO{= (Serious AEFI) vf]k nufPkl5 x'g;Sg] ulDe/ k|sf/sf P=O{=Pkm=cfO{= eGgfn] vf]k kZrft ePsf] s'g} klg ;d:ofsf] sf/0fn] d[To' x'g], Hofg} hfg;Sg] hf]lvd x'g], c:ktfn nfdf] ;do;Dd egf{ eP/ pkrf/ ug'{kg]{ cj:yf x'g], ckfË jf czQmtf x'g], hGdhft ljsª\ntf jf ckfË hGdg] h:tf 36gfx¿ kb{5g\. t/ ulDe/ k|sf/sf cgk]lR5t 36gfx¿ cToGt} Go"g ;+Vofdf jf lj/n} dfq x'G5. Hofg} hfg;Sg] hf]lvdx¿df ljz]ifu/L a]xf]; x'g], PgfkmfOn]lS;; jf ulDe/ k|sf/ sf] k|ltlqmof b]vfkg]{ cj:yfnfO{ lng ;lsG5. vf]k kZrft x'g] a]xf]; / PgfkmfOn]lS;; sf] pkrf/ Pjd\ Aoj:yfkg km/s x'g] ePsf]n] lrGx / nIf0fx¿sf] cfwf/df tL cj:yf 5'6\ofpg h?/L x'G5. 51 STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 a]xf]; (Faint) / PgfkmfOn]lS;; (Anaphylaxis) 5'6\ofpg] cfwf/x¿ lrGx / nIf0f a]xf]; (Fant) PgfkmfOn]lS;; (Anaphylaxis) z'?df b]lvg] ;"O{ b]Vg] ljlQs}, ;"O{ nufpFb} ubf{ jf ;"O{ vf]k nufPsf] % b]lv #) ldg]6 leq b]lvg], oBlk nufpg] ljlQs} xg] ! 306f jf ;f] eGbf kl5 klg b]lvg] 5fnfdf b]lvg] z/L/ k'm;|f] (Pale) x'Fb} hfG5 / z/L/ x'Fb} hfg] ;"O{ nufPsf] efudf jl/k/L /ftf] x'g], ;'lgg], cg'xf/ ;'lgg], cfFvf ;'lgg] Zjf; k|Zjf;df ;fdfGo jf nfdf]–nfdf] ;f; km]g]{ vf]sL nfUg], ;f; km]g{ ufx|]f x'g], ;f; km]bf{ £of/– £of/ jf :jfF :jfF cfjfh cfpg], ;f; km]g{ ufx|f] eP/ xft / v'6\6f lgnf] x'g] /Qm ;~rf/df d'6'sf] w8sg sd x'g], /Qmrfk sd x'g], t/ d'6'sf] w8sg a9\g] / /Qmrfk sd x'g] o; k|sf/sf] lrGx Ifl0fs x'g] / pQfgf] kf/]/ ;'Tbf 7Ls x'g] kfrg k|0ffnLdf jfsjfsL nfUg[, jfGtf x'g] k]6 jfpl8g], k]6 b'Vg], jfsjfsL nfUg], jfGtf x'g] :gfo' k|0ffnLdf Ifl0fs a]xf]; x'g], pQfgf] kf/]/ ;'tfPkl5 jf w]/} lrGtf, 8/ / ufx|]f ePh:tf] x'g], k"/} a]xf]; 6fpsf] tn kf/]/ ;'tfPkl5 xf];df cfpg] x'g], pQfgf] jf 6fpsf] tn kf/]/ ;'tfpbf klg xft v'6\6fdf em6\sf cfPh:tf] x'g] / cfFvf s'g} lsl;dsf] k|ltlqmo glbg] kN6fpg] h:tf nIf0f b]lvg] h'g sDkg cfpFbf h:tf] b]lvg] t/ of] sDkg eg] xf]Og. PgfkmfOn]lS;;sf] pkrf/ tyf Aoj:yfkg k|yflds pkrf/ ug{sf] nflu cGo :jf:YosdL{ jf :jo+;]jsx¿sf] ;xof]u lng]. lj/fdLnfO{ pQfgf] kf/]/ ;'tfP/ /fVg] h;df v'6\6f dly / 6fpsf] tn x'g] u/L /fVg]. :jf; k|Zjf; dfu{ ;kmf ug{] jf ;kmf ePsf] Plsg ug{] (Clear Airway). lj/fdLnfO{ Gofgf] kf/]/ /fVg]. lj/fdLsf] :jf; k|Zjf; dfu{, :jf;–k|Zjf;sf] cj:yf / d'6'sf] w8sg (ABC: Airway, Breathing and Circulation) hfFr ug{]. cfjZos ePdf CPR (Cardipulmonary Resuscitation) z'? ug]{. k|f/lDes pkrf/ ug]{ – Injection Adrenaline (1:1000 Solution, 1 mg/ml) df;'df (IM) lbg], – lj/fdLsf] cj:yfdf ;'wf/ gePdf jf nIf0fx¿ To:t} /x]df Adrenaline sf] dfqf % b]lv !% ldg]6sf] km/sdf # k6s;Dd lbg]. t/ Ps k6sdf )=% ld=ln eGbf w]/} glbg]. lj/fdLsf] k|f/lDes pkrf/kl5 lj/fdLsf] cj:yf l:y/ eO;s]kl5 lj/fdLnfO{ tf]lsPsf] k|]if0f s]Gb|df k|]if0f ug{]. vf]k sf8{df P=O{=Pkm=cfO{= ePsf] jf/] k|i6;Fu pNn]v ug{]. vf]k lbg] :jf:YosdL{n] tTsfn :jf:Yo ;+:yf k|d'v, gu/klnsf :jf:Yo zfvf k|d'v / lhNnf l:yt :jf:Yo sfo{fno k|d'vnfO{ hfgsf/L lbg]. 52  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 pd]/ cg';f/ Adrenaline (1:1000 Solution, 1 mg/ml) sf] dfqf ( dlxgf b]lv @# dlxgf;Ddsf] aRrfnfO{ M )=!) ld=ln= @$ dlxgf b]lv $& dlxg;Ddsf] aRrfnfO{ M )=!% ld=ln= $* dlxgf b]lv %( dlxgf;Ddsf] aRrfnfO{ M )=@) ld=ln= Wofg lbg'kg]{ s'/fx? Pl8«gflng ;"O{ yf]/} dfqfdf lbg'kg]{ x'Fbf pko'Qm k|sf/sf] l;l/~hsf] k|of]u ug{'k5{. l;l/~hsf] k|of]u ubf{ 7Ls dfqf lbg ;lsof];\ eGgfsf] nflu ! ld=ln=sf] l;l/~h k|of]u ug{' k5{ h;df !) 7'nf wsf{ -k|lt 7'nf] wsf{ a/fa/ )=! ld=ln=_ / !)) ;fgf] wsf{ -k|lt ;fgf] wsf{ a/fa/ )=)! ld= ln=_ x'G5g\. Pl8«gflngsf] dfqf Ps pkrf/ calwdf tLg k6seGbf al9 lbg' x'b}g. P=O{=Pkm=cfO{=sf] k|ltj]bg -s_ ;dfGo k|sf/sf] P=O{=Pkm=cfO{=sf] nflu – lgoldt vf]k ;]jfsf] qmd ePsf] eP, :jf:Yo ;+:yfsf] dfl;s k|ltj]bgdf pNn]v ug]{. Preventive And Promotive Health Services – cleofgsf] qmddf ePsf] eP, 6\ofnL l;6 / k|ult k|ltj]bgdf ;FVof pNn]v ug]{. lgldt k|ltj]bgdf ;d]6\g' kg]{ P=O{=Pkm=cfO{=x¿ M vf]k lbPsf] z/L/sf] efudf s8f lsl;dsf] k|ltlqmof b]lvPdf. vf]k lbPsf] z/L/sf] efudf 3fp ePdf jf lkk hd]sf] ePdf. aL=;L=hL= vf]k nufPkl5 sfvL j/Lk/L ufF7f–uF'7L ;'lgPsf] ePdf jf 3fp ePdf. zf/Ll/s n'nf]kgf / tftf], lr;f], 5f]Psf] sd yfxf ePdf (Hypotonic, Hyporesponsive Episode) t'?Gt k|ltj]bg ug'{kg]{ k|sf/sf P=O{=Pkm=cfO{=x¿ -v_ ulDe/ k|sf/sf] P=O{=Pkm=cfO{=sf] nflu – P=O{=Pkm=cfO{= ePsf] @$ 306f leq lj:t[t ljj/0f ;lxt k|ltj]bg k7fpg] -tf]lsPsf] kmf/ddf pNn]lvt ljj/0f ;a} eg'kg]{_ @$ 306fleq k|ltj]bg ug'{kg]{ P=O{=Pkm=cfO{=x¿ M :jf:YosdL{ jf÷/ hg;d'bfon] vf]ksf] sf/0faf6 g} d[To' jf hLjg g} hf]lvdk"0f{ cj:yfdf k'u]sf] -h:t}M PgfkmfOn] lS;;\, cr]t cj:yf x'g', :gfo'k|0ffnL;Fu ;DalGwt cGo u+lDe/ c;/x? b]lvg' cflb_ eGg] ljZjf; u/]sf] P=O{=Pkm=cfO{= ePdf, :jf:YosdL{ jf÷/ hg;d'bfon] vf]ksf] sf/0faf6 g} la/fdL eO{ c:ktfndf egf{ eO{ pkrf/ ul/Psf] xf] eGg] ljZjf; u/]df, :jf:YosdL{ jf÷/ hg;d'bfon] ue{jtL 5Fbf lbOPsf] vf]ksf] sf/0faf6 hGdhft lasnfË aRrf hlGdsf] ljZjf; u/]df, Ps} 7fpFdf w]/} ;+Vofdf ;fdfGo k|sf/sf P=O{=Pkm=cfO{= b]vf k/]df. :jf:YosdL{ jf÷/ hg;d'bfon] vf]ksf] sf/0faf6 g} lgDg lsl;dsf s8f lsl;dsf c;fdfGo 36gfx¿ ePsf] xf] eGg] ljZjf; u/]df. gf]6M lhNnf l:yt :jf:Yo sfof{nosf] AEFI Investigation Team n] P=O{=Pkm=cfO{=sf] cg';Gwfg u/]/ To;sf] k|ltj]bg kl/jf/ sNof0f dxfzfvfdf k]z ug'{kb{5. o;}sf] cfwf/df x/]s ulDe/ k|sf/sf] P=O{=Pkm=cfO{=sf] yk cg';Gwfg /fli6«o:t/ df ul7t P=O{=Pkm=cfO{+ ;ldltaf6 x'G5. 53 STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 P=O{=Pkm=cfO{=sf sf/0fx¿ sf/0fx¿ kl/efiff vf]k pTkfbg;Fu ;DalGwt EoflS;g pTkfbg ubf{ vf]kdf lglxt tTj (inherent properties) sf] sf/0faf6 k|ltlqmof pTkGg x'g] cgk]lR5t 36gf. (Vaccine product related gf]6 M ;a} EoflS;gx¿ ;'/lIft x'G5g\ t/ vf]kdf lglxt u'0fn] ubf{ slxn] sfFxL reaction) cgk]lR5t 36gf x'g] ;Defjgf x'G5. h:t}– PgfkmfOnflS;;\ vf]ksf] u'0f:t/;Fu ;DalGwt pTkfbsn] vf]k / vf]k lbg k|of]u ug]{ ;fdu|Lsf] pTkfbg, e08f/0f / 9'jfgL ubf{ k|ltlqmof x'g] q'6Lsf] sf/0faf6 x'g] cgk]lR5t 36gf. h:t}– u'0f:t/df sdL ePsf] vf]k, (Vaccine quality defect ljlu|sf] vf]k, ;+qmldt÷b'lift ePsf] ;fdu|Lsf] k|of]u. related reaction) gf]6 M vf]ksf] /Ë kl/jt{g ePsf], hd]/ lju|g] vf]k hd]s]f, 9';L hd]s]f, 3f]Ng] vf] k /fd|f];Fu g3'lng] ePsf], 3f]nsdf 9';L b]lvPsf], l;l/~h lgl8n b'lift ePsf] z+sf nfu]s]f, l;l/~h lgl8nsf] vf]n RofltPsf] ePdf k|of]u ug'{ x'b}g. vf]k sfo{qmd ;~rfngsf] vf]k e08f/0f / 9'jfgL, 3f]Ng] / l;l/~hdf lgsfNg] tyf nufpg] k|lqmofdf x'g] qmddf x'g] q'l6af6 x'g] q'6Laf6 pTkGg x'g] cgk]lR5t 36gf. k|ltlqmof (Immunization h:t}– vf]k nufPsf] s]xL 306fleq Hj/f] cfpg], jfGtf x'g] / kftnf] lbzf x'g,] lzlyn error related reaction) x'g,] cw{rt] x'g] / cr]t cj:yfdf hfg], ;'O{ lbPsf] 7fFpdf ;'lGgg], kfSg], cflb. gf]6 M vf]k e08f/0f / 9'jfgL, 3f]Ng] / l;l/~hdf lgsfNbf ;fjwfgL ckgfP/ / vf]k nufpFbf ;'/lIft ;"O{sf lgodnfO{{ clgjfo{ ?kdf kfngf u/]/ o; k|sf/sf] 36gfnfO{ z'Godf Nofpg' kb{5. ;'O{ k|ltsf] 8/, lrGtf vf]k k|ltsf] 8/ jf ;"O{sf] 8/, lrGtfaf6 pTkGg x'g] k|ltlqmof :j?k x'g] cgk] (Immunization anxiety lR5t 36gf. o; k|sf/sf] 36gf vf]k glbFb} jf lbFbf lbF+b} tTsfn j]xf]; x'g] jf a] related reaction) xf]; ePsf] h:tf] x'g] b]lvG5. o; k|sf/sf 36gfx? Go"g ;FVof dfq b]lvG5g. gf]6 M vf]k ;]jf k|bfg ubf{ vf]ksf] dxTj / vf]k nufPkl5 x'g;Sg] ;fdfGo c;/ jf/] vf]k lng] JolSt / cleefjsnfO{ /fd|f];Fu k/fdz{ lbg' kb{5. vf]k lbg] :yfg ;kmf, v'Nnf / ;]jfu|fxLnfO{ kv{g], cf/d ug]{ :yfgsf] Aoj:yf ug'{ kb{5. ;fy} vf]k nufPkl5 ;]jfu|fxLnfO{ cfwf 306f a:g nufpg' kb{5. olb s'g} AolQm lrlGtt / cflQPsf] h:tf] ePdf ljz]if lgu/fgL ug'{ kb{5. ;+of]ua; x'g] 36gf (Co- vf]ksf] sf/0fn] geO{ ;+of]ujz x'g] 36gf. h:t}– vf]k nufPkl5 lgdf]lgof x'g] incidental event) jf cGo s'g} lj/fdL kg]{. gf]6 M vf]k lng] JolQmnfO{ klxn] g} /f]usf] ;+qmd0f ePsf] x'g ;S5 t/ To;sf] lrGx / nIf0f vf]k nufPsf] s]xL ;dokl5 b]lvg] a]nf k/]s]f x'g;S5. 54  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 dfly pNn]lvt sf/0fx¿ / b]vfkg]{ cgk]lR5t 36gfx¿dWo] w]/}h;f] 36gfx¿ ;fdfGo k|sf/sf x'G5g / tL cfkm}+ 7Ls x'G5g jf ;fdfGo pkrf/af6 lgsf] x'G5g\. t/ la/n} x'g] / eO{xfn]df Hofg} hf]lvddf kg]]{ s8f 36gf h:t}– PgfkmfOn] lS;; klg x'g;S5. To;}n] vf]klbg] :jf:YosdL{n] PgfkmfOn]lS;;sf] klxrfg / tTsfn pkrf/ Pjd\ Aoj:yfkg jf/] kof{Kt 1fg / ;Lk xfl;n u/]s]f x'g'k5{ / vf]k s]Gb|;Dd P=O{=Pkm=cfO{= ls6 /flvPsf] x'g'kb{5. -ª_ sf]N8 r]g tyf vf]k Aoj:yfkg;DaGwL s]xL cfwf/e"t hfgsf/L ;a} vf]kx¿ ;"o{sf] k|sfz / tfkaf6 lalu|G5g\. s]xL vf]kx¿ w]/} lr;f] -)) ;]= eGbf sd tfkqmd_df hD5g\ / lalu|G5g\. w]/} lr;f]af6 lalu|g] vf]kx¿ l8=lk=6L=–x]kla=–lxj, lk=l;=le=, Pkm=cfO{=lk=le, /f]6f, l6=8L= x'g\. hd]/ lau|g] vf]kx¿ Ps k6s hd]kl5 ;w}sf] nflu ljlu|G5g\. s'g} vf]k tftf]af6 l56f] lalu|G5g\ eg] s'g} vf]k tftf]af6 l9nf] lalu|G5g\. tftf]af6 vf]k lau|]sf] 5 ls 5}g egL yfxf kfpgsf] nflu vf]ksf] efonsf] n]andf le=le=Pd= (VVM : Vaccine Preventive And Promotive Health Services Vial Monitor) /flvPsf] x'G5. lgoldt vf]k ;]jfdf k|of]u x'g] ;a} vf]k le=le=Pd=ePsf] g} k|of]u ul/G5. lhNnf l:yt :jf:Yo sfof{no, :jf:Yo ;+:yf / vf]k s]Gb|df ;a} k|sf/sf vf]kx¿ ;fdfGotofM Pp6} tfkqmd -@) ;]= b]lv *) ;]=_ sfod x'g] u/L e08f/0f / 9'jfgL ul/G5. k|b]z:t/Lo vf]k e08f/af6 lhNnf l:yt vf]k e08f/df, To;kl5 :jf:Yo ;+:yf / vf]k s]Gb|df vf]k 9'jfgL ubf{ sf] N8 aS; jf EoflS;g Sofl/o/ k|of]u ul/G5. sf]N8 aS; jf EoflS;g Sofl/o/df vf]k 9'jfgL ubf{ cfO; Kofs /flvPsf] x'G5. k"/} hd]s]f cfO; Kofs /fVbf tfkqmd )) ;]= eGbf sd tfkqmd x'G5 h;n] ubf{ hd]/ lau|g] vf]k lalu|G5g\. o;sf] nflu cfO; KofsnfO{ sl08;lgË ug'{k5{. cfO; KofsnfO{ sl08;lgË ug{ hd]s]f cfO; KofsnfO{ lk|mhaf6 lgsfn]/ s]xL ;do;Dd aflx/L jftfj/0fdf /fv]/ klUng lbg'k5{. cfO; KofsnfO{ xNnfpFbf leq kfgLsf cfjfh ;'lgPdf sl08;lgË ePsf] a'‰g'k5{. cfO; Kofs leq kfgL / a/ kmsf 6'qmf x'g' eg]s]f @) ;]= b]lv *) ;]= tfkqmd /x]s]f 5 eGg] xf]. sf]N8 aS; jf EoflS;g Sofl/o/df vf]k 9'jfgL ubf{ ;w} g} sl08;lgË u/]s]f cfO; Kofs dfq k|of]u ug'{k5{. k"/} hd]s]f cfO; Kofs /fVbf tfkqmd )) ;]= eGbf sd tfkqmd x'G5 h;n] ubf{ hd]/ lau|g] vf]k lalu|G5g\. -r_ vf]khGo kmf]x/–d}nfsf] lj;h{g vf]khGo kmf]x/–d}nf eGgfn] vf]k ;]jf;Fu ;DalGwt kmf]x/nfO{ a'emfpF5. h:t}– vf]ksf] efon, 3f]nssf] PDk'n jf efon, vf]ksf] 6o"a / 9sgL, l;l/~h / lgl8n, lgl8n 5f]k]s]f Sofk, l;l/~h lgl8n Kofs u/]sf] vf]n, vf]k, 3f]ns / l;l/~h lgl8n Kofs u/]s]f aS;, vf]k nufPkl5 k|of]u x'g] skf;, k|of]udf gcfpg] lk|mh, /]lkmh]/]6/, sf]N8 aS;, EoflS;g sofl/o/. o; k|sf/sf kmf]x/nfO{ :jf:Yo ;]jfhGo cGo kmf]x/–d}nfnfO{ h:t} tf]lsPsf] pko'Qm ljlwaf6 lj;h{g ug'{k5{. vf]k ;]jfdf k|of]u ul/Psf l;/~h lgl8nx¿ ;]km\6L aS;df ;++sng u/]/ :jf:Yo ;+:yfdf NofP/ lj;h{g ug'{kb{5. kfFr ln6/ Ifdtfsf] Pp6f ;]km\6L aS;df a9Ldf !)) j6f;Dd l;l/~h lgl8n /fVg ;lsG5. kftnf] a:tL ePsf, b'u{d kxf8L jf lxdfnL e]usf] ;Gbe{df Pp6f ;]km\6L aS;df !)) eGbf sd l;l/~h lgl8n ;+sng ul/Psf] cj:yfdf klg dlxgfsf] cGTodf pQm ;]km\6L aS;df lj;h{g ug{ ;lsG5. 55 STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 2. CASE SURVEILLANCE FOR VACCINE PREVENTABLE DISEASES WHO programme for Immunization Preventable Diseases (IPD)- Nepal, in collaboration with Family Welfare Division (FWD), is doing surveillance of vaccine preventable diseases (VPD)- Measles, Rubella, Poliomyelitis, Japanese encephalitis and Neonatal Tetanus (NT). Stool sample, CSF sample, Serum collection done only with WHO’ guidance, not covered by BHS. Vaccine Preventable Surveillance case definition Key Surveillance methods Diseases (VPD) Measles and Rubella Suspected measles: Any person Report immediately to nearby health institutions/ with fever and maculopapular WHO IPD field office. rash or any person in whom a Collect blood at first contact/visit. clinician suspects Measles. Collect blood in a tube that does not contain any chemicals or anticoagulants. Collect 5ml of whole blood for older children and adults and 1ml for small children. Prepare serum from collected blood, transfer serum in cold box, maintaining temperature of 2-8-degree temperature, as soon as possible Poliomyelitis Acute Flaccid Paralysis (AFP): Report immediately to nearby health institution/ Sudden onset of weakness WHO IPD field office. and floppiness in any part of Stool specimens are collected from each AFP case the body in a child < 15 years within 14 days of paralysis onset ideally but can also of age or paralysis in a person be done up to 60 days. of any age in which polio is Specimens are taken at least 24 hours apart. suspected. Each stool specimen should be at least 8 grams. This excludes adults, spastic (approximately the size of an adult thumb) paralysis, cases with obvious Keep stool specimen in specimen carrier box with causes (trauma). ice packs. Specimens will be forwarded to the Polio reference lab (Bangkok) by surveillance unit for culture 56  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 Japanese Acute encephalitis syndrome Report immediately to nearby health institution/ Encephalitis (JE) (AES): Clinically, a case of WHO IPD field office. acute encephalitis syndrome First specimens (blood and CSF) should be collected (AES) is defined as a person of on admission to hospital or when patient first seen. any age, at any time of year, As JE IgM may take up 10 days to develop after with the acute onset of fever onset of symptoms, a second serum sample should and a change in mental status be collected on the 10th day of illness onset or at (including symptoms such the time of discharge. as confusion, disorientation, Sample should be stored and transported to lab coma, or inability to talk) AND/ maintaining proper cold chain. OR new onset of seizures Sample should be tested for malaria plasmodium at (excluding simple febrile the hospital. seizures). Neonatal Tetanus Suspected neonatal tetanus: Report immediately to nearby health institution/ (NT) Any neonatal death between WHO IPD field office. Preventive And Promotive Health Services 3-28 days of age in which No sample collection is needed. the cause is unknown or any Diagnosis of neonatal tetanus is entirely clinical neonate reported as having through verbal autopsy. suffered from NT between Case Investigation Form (CIF) is filled up to come to 3-28 days of age and not clinical diagnosis. investigated. 57 CHAPTER V STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS IMNCI materials (Ministry of Health and Population (MoHP), are for use by paramedics, nurses and doctors who see children aged under five years. They facilitate the case management process and the charts describe the sequence of all case management steps. The chart booklet should be used by all health professionals providing care to sick children during the process of clinical care. The Chapter is divided into two main parts: 1. Sick young infant aged up to two months 2. Sick child aged two months to five years Chapter Outlines: 1. Children aged less than two months: Immediate newborn care, Head-to-toe examination, Management of birth asphyxia, Neonatal resuscitation, Convulsion management, Prematurity and low birth weight, Bacterial infection and classification, Jaundice, Hypothermia, Dehydration, Breastfeeding and feeding problems, Drug dosage (ampicillin, gentamicin, amoxicillin), Follow-up care 2. Children aged two months to five years: Triage of sick children, Pneumonia classification, Dehydration and diarrhoea, Malaria, Ear infections, Anaemia, Malnutrition, Immunisation status, Prevention of Mother-to-child Transmission (PMTCT), Drug dosage (amoxicillin, ciprofloxacin, erythromycin, cotrimoxazole, antimalarial, vitamin A & iron, albendazole, diazepam), Hypoglycaemia assessment and management, Classification of dehydration and management, Follow-up care 58  STANDARD TREATMENT PROTOCOL (STP) FOR BASIC HEALTH SERVICES (BHS) PACKAGE 2078 IMNCI clinical guidelines are based on the Principle of Integrated Case Management All sick children up to five years of age are assessed forA combination of individual signs leads to a general danger signs and all young infants for signs of very child’s classification within one or more symptom severe disease. These signs indica