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Published by: Richard S. Roxas on Sep 11, 2013
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COMMUNITY HEALTH NURSING

IMCI PART 3
Prepared by: Ms. Josephine De Leon, RN

PNEUMONIA:
After 2 days: Check the child for general danger signs. Assess the child for cough or difficulty in breathing Ask: Is the child breathing slower? Has the child’s temperature gone down? Is the child eating better?

Treatment:
If there is chest in drawing or a general danger sign, give a dose of the second-line antibiotic or intramuscular chloramphenicol. Then, refer the child URGENTLY to a hospital. If the child’s breathing rate, fever, and eating are the same, change to the second-line antibiotic and advise the mother to return in 2 days, or refer the child to a hospital. (if the child had measles within the last 3 months, refer him or her to the hospital.)

If the child’s breathing is slower, his or her temperature has gone down, or the child is eating better, consume the 5-day dosage of the antibiotic.

Ask: Are there fewer loose stool evacuations? Is there less blood in the stool? Has the temperature gone down? Is there less abdominal pain? Is the child eating better? .DYSENTERY After 2 days: Assess the child for diarrhea.

treat the dehydration If the number of loose stool evacuations. Advise the mother to return to the health center in 2 days. or eating are the same or worse: Change to the second-line antibiotic recommended for shigella in your area. Give it for 5 days. fever. .Treatment: If the child is dehydrated. abdominal pain. the amount of blood in the stool.

.Exceptions-if the child: -is less than 12 months old -was dehydrated in the first visit or -had measles within the last 3 months *refer the child to a hospital.

and the child is eating better. . the temperature has gone down.If there are fewer loose stool evacuations. there is less blood in the stool. continue giving the same antibiotic until the 5day dosage has been consumed. there is less abdominal pain.

Persistent Diarrhea After 5 days: Ask: Has the diarrhea stopped? How many times does the child evacuate loose stool per day? .

Give him or her any treatment he or she needs. If the diarrhea has stopped (the child evacuates loose stool less than 3 times per day). conduct a full assessment of the child. refer the child to a hospital. Then. tell the mother to follow the usual recommendations for the child’s age. .Treatment: If the diarrhea has not stopped (the child still evacuates loose stool 3 or more times per day).

or returns within 14 days: Treatment: If the child has any general danger sign or a stiff neck.Malaria If the fever persists after 2 days. provide the appropriate treatment. If malaria is the only apparent cause of the fever: . treat him or her as having a VERY SEVERE FEBRILE DISEASE/MALARIA If the child has any cause of fever other than malaria.

Take a blood smear and conduct a blood smear test. . Advise the mother to return in 2 days if the fever persists If the fever persists after a 2-day treatment with the second-line oral antimalarial. refer the child to a hospital. Give the second-line antimalarial without waiting for the results of the blood smear test. If the fever has been present for 7 days. Give the blood smear for reassessment. refer the child to a hospital for assessment.

Fever: Malaria Unlikely If the fever persists after 2 days: Assess the child for other possible causes of his or her fever. .

Treatment: If the child has any general danger sign or a stiff neck. If malaria is the only apparent cause of the fever: Take a blood smear and conduct a blood smear test. . treat him or her as having a VERY SEVERE FEBRILE DISEASE/MALARIA.

refer the child to a hospital for assessment. If the fever has been present for 7 days.Treat the child with the first-line oral antimalarial. . Advise the mother to return to the health center in 2 days if the fever persists.

.FEVER: NO MALARIA If the fever persists after 2 days: Make sure that there has been no travel to a malaria risk area. if possible. If there has been travel to a malariarisk area. take a blood smear.

treat him or her as having a VERY SEVERE FEBRILE .Treatment: If there has been travel to a malaria-risk area and the blood smear is positive or there is no blood smear. If there has been no travel to a malaria risk area of the blood smear is negative: *If the child has any general danger sign or a stiff neck. and treat him or her accordingly. classify the child as having fever with malaria risk.

advise the mother to return to the health center in 2 days if the fever persists.DISEASE *if there is any apparent cause of the child’s fever. *If there is no apparent cause of the fever. provide the appropriate treatment. * if the fever has been present for 7 days. . refer the child to a hospital for assessment.

Look for mouth ulcers. Smell the mouth .Measles with Eye or Mouth Complications After 2 days: Look for red eyes and pus draining from the eyes.

. If the mouth ulcers are the same or better.Treatment for Eye infection: If the mouth ulcers have become worse. continue using half-strength Gentian Violet for a total of 5 days. or there is a very foul smell coming from the mouth. refer the child to a hospital.

Fever: Dengue Hemorrhagic Fever Unlikely If the fever persists after 2 days: Conduct a tourniquet test. . Assess the child for other possible causes of his or her fever.

or signs of shock or persistent abdominal pain or vomiting. treat him or her as having SEVERE DENGUE HEMMORRHAGIC FEVER. . If there is another apparent cause of the child’s fever. provide the appropriate treatment. including skin petechiae. or a positive tourniquet test.Treatment: If the child has any sign of bleeding.

refer the child to a hospital for assessment. Advise the mother to make sure that the child is given more fluids and is eating well. advise the mother to return to the health center daily until the child has had no fever for at least 48 hours.If the fever has been present for 7 days. . If there is no apparent cause of the child’s fever.

Ear Infection After 5 days: Measure the child’s temperature. .

Acute ear infection: If the ear pain or discharge persists. treat the child as having MASTOIDITIS. . Continue wicking the child’s ear to dry it. treat the child with the same antibiotic for 5 more days. Follow up in 5 days.5 degree C or above).Treatment: If there is tender swelling behind the ear or a high fever (38.

If there is no ear pain or discharge. praise the mother for her careful treatment of the child. tell her to make sure they are consumed.Chronic ear infection: Check that the mother is wicking the child’s ear correctly. . Encourage her to continue doing this. If the 5-day dosage of the antibiotic has not been consumed.

ask her to bring the child back to the health center for follow up. Ask about any feeding problem found in the initial visit. Counsel the mother about any new or continuing feeding problem of the child. If you will counsel the mother to implement significant changes in feeing.FEEDING PROBLEM After 5 days: Reassess the child’s feeding. .

.If the child has a very low weight for age. ask the mother to return to the health center in 30 days after the initial visit so you could determine the child’s weight gain.

. refer him or her to a hospital for assessment. Continue giving iron every day for 2 months. Advise the mother to return to the health center in 14 days. with follow-up every 14 days. If the child has any palmar pallor after 2 months.ANEMIA After 5 days: Give iron.

VERY LOW WEIGHT FOR AGE After 30 days: Weigh the child and determine if he or she still has a very low weight for age. Reassess the child’s feeding. .

or until he or she no longer has a very low weight for age. praise the mother and encourage her to continue feeding the child well. If the child still has a very low weight for age. Continue to see the child monthly until he or she is already feeding well and gaining weight regularly.Treatment: If the child no longer has a very low weight for age. counsel the mother about any feeding problem found. .

ALSO.Exception: If you do not think that the child’s feeding will improve. refer the child to a hospital. . TELL THE MOTHER WHEN TO RETURN IMMEDIATELY TO THE HEALTH CENTER. or if the child has lost weight.TELL THE MOTHER WHEN THE NEXT FOLLOW-UP VISIT WILL BE. IF ANY MORE FOLLOW UP VISITS ARE NEEDED BASED ON THE INITIAL VISIT OR THIS VISIT.

FOOD Assess the Child’s Feeding: Ask: Do you breastfeed your child? -How many times do you do so during the day? -Do you also breastfeed during the night? Does the child take in any other food or fluid? .

has the child’s feeding changed? If yes.What food or fluid does the child take in? How many times per day does the child take in this food or fluid? What do you use to feed the child? If the child has a very low weight for age: How large are his or her servings? Is the child given his or her own serving? Who feeds the child and how? During this illness. in what way has it changed? .

counsel the mother accordingly. In addition: .COUNSEL THE MOTHER ABOUT THE CHILD’S FEEDING PROBLEMS If the child is not being fed as prescribed in the above recommendations.

and gradually reducing the child’s intake of other kinds of milk or foods. day and night. . longer breastfeeds. If the child is less than 4 months old and is taking other kinds of milk or foods: Build the mother’s confidence by telling her that she can produce all the breastmilk that her child needs. assess the child’s breastfeeding.If the mother reports difficulty with breastfeeding. Suggest giving the child more frequent.

Make sure that the other kind of milk to be given to the child is locally appropriate breast milk substitute . and give it to the child only when necessary.If the child intake of other kinds of milk needs to be continued. counsel the mother to: Breastfeed the child as other as possible. including at night. .

and give it to the child only when necessary.Make sure that the other kind of milk to be given to the child is correctly and hygienically prepared. if any. . Prepare only an amount of milk that the child can consume within an hour. Discard leftover milk.

Show the mother how to feed the child using a cup. .If the mother is using a bottle to feed the child: Recommend substituting a cup for a bottle.

and encourage him or her to eat. counsel the mother to: Sit with the child while the latter is eating. . Give the child an adequate serving in a separate plate or bowl.If the child is not being fed actively. Observe what the child likes and consider these in the preparation of his or her food.

. small feedings. Give the child soft. if possible. and for a longer time at each feed. to encourage him or her to eat as much as possible. and offer the child frequent. as well as the child’s favorite foods. and appetizing foods.If the child is not feeding well during illness. varied. counsel the mother to: Breastfeed the child more frequently.

Follow up any feeding problem in 5 days.Clear the child’s blocked nostrils if they interfere with his or her feeding Expect the child’s appetite to improve as he or she gets better. .

. buko juice. or clean water. For any sick child: Breastfeed the child more frequently and for a longer time at each feed. rice.Advise the Mother to Increase the Child’s Fluid Intake during Illness. Increase the child’s fluid intake. For example: give the child soup. water.

Give the child fluid according to Plan A or Plan B on the TREAT THE CHILD CHART.For a child with diarrhea: Giving the child extra fluid can save his or her life. .

.WHEN TO RETURN? Advise the mother regarding When the Return to the Health Center Follow up visit: Advise the mother to come for followup at the earliest time indicated for the child’s problems.

.

.

COUNSEL THE MOTHER ABOUT HER OWN HEALTH If the mother is sick. If she has a breast problem (such as engorgement. Advise her to eat well to maintain her own strength and health Check the mother’s immunization status. and give her tetanus toxoid if needed. Make sure she has access to: Family planning. provide care for her or refer her for help. provide care for her. or refer her for help. and Counseling on STD and AIDS prevention . breast infection). sore nipples.

CLASSIFY. use the follow-up instructions in the follow-up section. If the initial visit. AND TREAT THE SICK YOUNG INFANT AGED 1 WEEK TO 2 MONTHS ASSESS: Ask the mother what the young infant’s problems are Determine if this is an initial or followup visit for this problem.ASSES. If follow-up visit. assess the young infant follows: .

Repeat the count if the infant is elevated.CHECK FOR POSSIBLE BACTERIAL INFECTION Ask: Has the infant had convulsions? Look. Listen. Look for severe chest indrawing Look for nasal flaring . Feel: Count the infant’s breath in one minute.

Look and listen for grunting Look and feel for bulging fontanelle Look for pus draining from the ear Look at the umbilicus. Is it red or draining pus? .

Look at the infant’s movements.Does the redness extend to the skin? Measure the infant’s body temperature (or feel for fever or low body temperature). Are they not normal? . Look for skin pustules. Are there many or severe pustules? See if the infant is abnormally sleepy or difficult to awaken.

SIGNS: Convulsions or Fast breathing (60 breaths or more per minute) or Severe chest indrawing or Nasal flaring or Grunting or Bulging fontanella or Pus draining from the ear or .

Fever (37. or feels cold)or Many or severe skin pustules or Abnoramally sleepy or difficult to awaken or Abnormal movement Classification: Above is classified as possible serious bacterial infection. .5 degree C.

Treatment: Give the infant the first dose of intramuscular antibiotics Treat the infant to prevent the lowering of his or her blood sugar Advise the mother regarding how to keep the infant warm on the way to the hospital Refer the infant URGENTLY to a hospital. .

Signs: Red umbilicus or draining pus or Skin pustules Classification: Classified as Local Bacterial infection .

Treatment: Give an appropriate oral antibiotic Treat the local infection in the health center. and teach the mother to treat local infections at home. Advise the mother regarding how to give home care to the infant. Follow up in 2 days .

ASK DOES THE YOUNG INFANT HAVE DIARRHEA? If yes Ask: For how long has the child had it? .

Does it go back to its original state: -very slowly (longer than 2 seconds)? -slowly? . Is the infant: -abnormally sleepy or difficult to awaken? -restless and irritable? Look for sunken eyes Pinch the skin of the abdomen.LOOK AND FEEL: Look at the young infant’s general condition.

Severe Dehydration Two or more of the following signs: Abnormally sleepy or difficult to awaken.Classification of Diarrhea 1. Sunken eyes Pinched skin goes back to its original state very slowly .

. with the mother giving the infant frequent sips of ORS on the way. Advise the mother regarding how to keep the infant warm on the way to the hospital.Treatment: If the infant does not have a possible serious BACTERIAL INFECTION OR DYSENTERY: Give the infant fluid for severe dehydration (plan C) Or If the infant has a POSSIBLE SERIOUS BACTERIAL INFECTION OR DYSENTERY: Refer the infant urgently to a hospital.

2. Some Dehydration Two of the following signs: Restless. irritable Sunken eyes Pinched skin goes back to its original state very slowly .

Treatment: Give the infant fluid and food for some dehydration (Plan B. . with the mother giving the infant frequent sips of ORS on the way.) If the infant has a possible serious Bacterial infection or Dysentery: -refer the infant URGENTLY to a hospital. -advise the mother to continue breastfeeding the infant.

3. No Dehydration Not enough signs to allow classification as some or severe dehydration Treatment: Give the infant fluid to treat the diarrhea at home (Plan A). .

IF THERE HAS BEEN DIARRHEA FOR 14 DAYS OR MORE: Signs: Diarrhea lasting for 14 days or more Classification: Severe Persistent Diarrhea Treatment: If the young infant has dehydration. Refer the infant to a hospital . treat the dehydration before referral to a hospital unless the infant has a POSSIBLE SERIOUS BACTERIAL INFECTION.

Advise the mother to continue breastfeeding the infant . with the mother giving the infant frequent sips of ORS on the way.IF THERE IS BLOOD IN THE STOOL Signs: Blood in the stool Classification: Dysentery Treatment: Refer the infant URGENTLY to a hospital.

.

Immunization .

TABLE 2 .

Table 3 .

Teach the Mother How to Treat Local Infections at Home. . Explain how the treatment should be given Watch her as she does the first treatment in the health center Tell her to do the treatment twice daily. and that she should return to the health center if the infection worsens.

Gently wash off the pus and crusts with soap and water Dry the infected area.To Treat Skin PustulesThe mother should: Wash her hands. . Paint the infected area with Gentian Violet Wash her hands again.

To Treat Umbilical InfectionThe mother should: Wash her hands Clean the infected area with 70% ethyl alcohol. . Paint the infected area with Gentian violet. Wash her hands again.

Local Bacterial Infection After 2 days: Look at the infant’s umbilicus. It is red or draining pus? Does the redness extend to the skin? Look for skin pustules. Are there many or severe pustules? .

Paint the infant’s mouth with halfstrength Gentian Violet Wash her hands again. soft cloth wrapped around her (the mother’s) finger and dipped in water. . Wipe the infant’s mouth with a clean.To Treat Oral Thrush (ulcers or white patches in the mouth)The mother should: Wash her hands.

not just his or her neck and shoulders .Teach the Correct Positioning and Attachment For Breastfeeding Show the mother how to hold the infant: With the infant’s head and body straight Facing her breast with the infant’s nose opposite her nipple With the infant’s body close to her body Supporting the infant’s whole body.

. aiming the infant’s lower lip well below the nipple »Look for signs of good attachment and effective suckling.Show the mother now to help the infant attach. She should: » Touch the infant’s lips with her nipple » Wait until the infant’s mouth is opening wide and »Move the infant quickly onto her breast. try again. She should: Show the mother now to help the infant attach. If the attachment or suckling is not good.

during sickness and health . as often and for as long as the infant wants to be breastfed. day and night.Advise the mother Regarding How to Give Home Care to the Young Infant Food Fluid When to Return Note: Breastfeed frequently.

Follow up visit: .

When to Return Immediately: Advise the mother to return to the health center immediately if the young infant has any of these signs: Is the breastfeeding or drinking poorlyIs becoming sicker Has developed a fever Has fast breathing Has difficulty in breathing Has blood in the stool .

Are there many or severe pustules? . It is red or draining pus? Does the redness extend to the skin? Look for skin pustules.Local Bacterial Infection After 2 days: Look at the infant’s umbilicus.

Treatment: If the pus or redness remains or has become worse, refer the infant to a hospital. If pus and redness have improved, tell the mother to continue giving the antibiotic to the infant until the 5-day dosage has been consumed, and to continue treating the local infection at home.

Feeding Problem
After 2 days: Reassess the infant’s feeding Ask about any feeding problem found on the initial visit. Counsel the mother about any new or continuing feeding problem. If you will counsel the mother to make significant changes in feeding, ask her to bring the infant back to the health center for follow-up.

If the infant has a low weight of age, ask the mother to return in 14 days after the initial visit so you could determine the infant’s weight gain. Exception: If you do not think that the infant’s feeding will improve, or if the infant has lost weight, refer the infant to the hospital.

Low Weight for age:
After 14 days: Weigh the infant and determine if he or she still has a low weight for age. Reassess the infant’s feeding If the infant no longer has a low weight for age, praise the mother. Ask her to come again within a month or when she returns for the infant’s immunization.

If the infant still has a low weight for age and still has a feeding problem. Exception: If you do not think that the infant’s feeding will improve. if this is within 2 weeks). refer the infant to a hospital. . or until the infant no longer has a low weight for age. or if the infant has lost weight. Continue to see the infant every few weeks until the infant is feeding well and gaining weight regularly. Ask the mother to return again in 14 days (or when she returns for the infant’s immunization.

continue the treatment with half-strength Gentian Violet for a total of 5 days. and if the infant is feeding well. If the thrush is the same or has become better.Oral Thrush After 2 days: Look for ulcers or white patches in the mouth (Thrush) Reassess the infant’s feeding. If the thrush gets worse. refer the infant to a hospital. or if the infant has problems with attachment or suckling. .

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