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

DYSENTERY
After 2 days: Assess the child for diarrhea. 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?

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

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.

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

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

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

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

Take a blood smear and conduct a blood smear test. Give the second-line antimalarial without waiting for the results of the 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 blood smear for reassessment. If the fever has been present for 7 days, 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, treat him or her as having a VERY SEVERE FEBRILE DISEASE/MALARIA.

If malaria is the only apparent cause of the fever:

Take a blood smear and conduct a blood smear test.

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. If the fever has been present for 7 days, refer the child to a hospital for assessment.

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

Treatment:
If there has been travel to a malaria-risk area and the blood smear is positive or there is no blood smear, classify the child as having fever with malaria risk, and treat him or her accordingly. 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, treat him or her as having a VERY SEVERE FEBRILE

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

Measles with Eye or Mouth Complications

After 2 days:

Look for red eyes and pus draining from the eyes. Look for mouth ulcers. Smell the mouth

Treatment for Eye infection:

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

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.

Treatment:
If the child has any sign of bleeding, including skin petechiae, or a positive tourniquet test, 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 childs fever, provide the appropriate treatment.

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

Ear Infection
After 5 days: Measure the childs temperature.

Treatment:
If there is tender swelling behind the ear or a high fever (38.5 degree C or above), treat the child as having MASTOIDITIS. Acute ear infection: If the ear pain or discharge persists, treat the child with the same antibiotic for 5 more days. Continue wicking the childs ear to dry it. Follow up in 5 days.

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

FEEDING PROBLEM After 5 days: Reassess the childs feeding.

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, ask her to bring the child back to the health center for follow up.

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 childs weight gain.

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

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 childs feeding.

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

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

FOOD
Assess the Childs 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?

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, has the childs feeding changed? If yes, in what way has it changed?

COUNSEL THE MOTHER ABOUT THE CHILDS FEEDING PROBLEMS

If the child is not being fed as prescribed in the above recommendations, counsel the mother accordingly. In addition:

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

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. 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.

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

If the mother is using a bottle to feed the child:

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

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

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

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

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

For a child with diarrhea:

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

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 childs problems.

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

ASSES, CLASSIFY, AND TREAT THE SICK YOUNG INFANT AGED 1 WEEK TO 2 MONTHS

ASSESS: Ask the mother what the young infants problems are Determine if this is an initial or followup visit for this problem.
If follow-up visit, use the follow-up instructions in the follow-up section. If the initial visit, assess the young infant follows:

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

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?

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

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 (37.5 degree C, 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.

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?

LOOK AND FEEL:

Look at the young infants general condition. Is the infant: -abnormally sleepy or difficult to awaken?

-restless and irritable?

Look for sunken eyes Pinch the skin of the abdomen. Does it go back to its original state: -very slowly (longer than 2 seconds)?

-slowly?

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

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, 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.

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.) If the infant has a possible serious Bacterial infection or Dysentery: -refer the infant URGENTLY to a hospital, with the mother giving the infant frequent sips of ORS on the way. -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, treat the dehydration before referral to a hospital unless the infant has a POSSIBLE SERIOUS BACTERIAL INFECTION. Refer the infant to a hospital

IF THERE IS BLOOD IN THE STOOL

Signs: Blood in the stool Classification: Dysentery Treatment: Refer the infant URGENTLY to a hospital, with the mother giving the infant frequent sips of ORS on the way. Advise the mother to continue breastfeeding the infant

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.

To Treat Skin PustulesThe mother should: Wash her hands. Gently wash off the pus and crusts with soap and water Dry the infected area. 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 infants umbilicus. It is red or draining pus? Does the redness extend to the skin? Look for skin pustules. Are there many or severe pustules?

To Treat Oral Thrush (ulcers or white patches in the mouth)The mother should:

Wash her hands. Wipe the infants mouth with a clean, soft cloth wrapped around her (the mothers) finger and dipped in water. Paint the infants mouth with halfstrength Gentian Violet Wash her hands again.

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

Show the mother now to help the infant attach, She should:

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

Advise the mother Regarding How to Give Home Care to the Young Infant
Food Fluid

When to Return Note: Breastfeed frequently, as often and for as long as the infant wants to be breastfed, day and night, during sickness and health

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

Local Bacterial Infection

After 2 days: Look at the infants umbilicus. It is red or draining pus? Does the redness extend to the skin? Look for skin pustules. Are there many or severe pustules?

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 infants 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 infants weight gain. Exception: If you do not think that the infants 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 infants 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 infants immunization.

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

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