Community Health Nursing 1 - Lecture

STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR

Session # 18

LESSON TITLE: Integrated Management of Childhood Materials:

Illnesses (IMCI)
Pen, paper, index card, book, and class List
LEARNING OUTCOMES:
Upon completion of this lesson, the nursing student can:
Reference:
1. Define IMCI;
2. Discuss the IMCI case management process; and, Famorca, Z. U., Nies, M. A., & McEwen, M. (2013).
3. Outline disease based on presenting signs and symptoms. Nursing Care of the Community. Elsevier
Gezondheidszorg.

LESSON PREVIEW/REVIEW (5 minutes)

Instruction: Enumerate the six preventable diseases were initially included in the EPI.
1. _ _ _
2. _ _ _
3. _ _ _
4. _ _ _
5. _ _ _
6. _ _ _

MAIN LESSON (30 minutes)

Definition
 IMCI is an integrated approach to child health that focuses on the well-being of the whole child.
 IMCI strategy is the main intervention proposed to achieve a significant reduction in the number of deaths from
communicable diseases in children under five

Goal
 By 2010, to reduce the infant and under five mortality rates at least one third, in pursuit of the goal of reducing it by two thirds
by 2015.

Aim
 To reduce death, illness and disability, and to promote improved growth and development among children under 5 years of
age.
 IMCI includes both preventive and curative elements that are implemented by families and communities as well as by health
facilities.

IMCI Objectives
 To reduce significantly global mortality and morbidity associated with the major causes of disease in children
 To contribute to the healthy growth & development of children

IMCI Components of Strategy

 Improving case management skills of health workers
 Improving the health systems to deliver IMCI
 Improving family and community practices
**For many sick children a single diagnosis may not be apparent or appropriate

Presenting complaint:
 Cough and/or fast breathing

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 1 of 11
 Lethargy/Unconsciousness
 Measles rash

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 2 of 11
 “Very sick” young infant

Possible course/ associated condition:

 Pneumonia, Severe anemia, P. falciparum malaria
 Cerebral malaria, meningitis, severe dehydration
 Pneumonia, Diarrhea, Ear infection
 Pneumonia, Meningitis, Sepsis

Five Disease Focus of IMCI:

 Acute Respiratory Infection
 Diarrhea
 Fever
 Malaria
 Measles
 Dengue Fever
 Ear Infection
 Malnutrition

The IMCI Case Management Process

 Assess and classify
 Identify appropriate treatment
 Treat/refer
 Counsel
 Follow-up

The Integrated Case Management Process

1. Check for General Danger Signs: A
general danger sign is present if:
 The child is not able to drink or breastfeed
 The child vomits everything
 The child has had convulsions
 The child is lethargic or unconscious

2. Assess Main Symptoms

 Cough/DOB
 Diarrhea
 Fever
 Ear problems

3. Assess and Classify Cough of Difficulty of Breathing

 Respiratory infections can occur in any part of the respiratory tract such as the nose, throat, larynx, trachea, air passages
or lungs.

4. Assess and classify PNEUMONIA

 Cough or difficult breathing
 An infection of the lungs
 Both bacteria and viruses can cause pneumonia
 Children with bacterial pneumonia may die from hypoxia (too little oxygen) or sepsis (generalized infection).

** A child with cough or difficult breathing is assessed for:

 How long the child has had cough or difficult breathing
 Fast breathing
 Chest indrawing
 Stridor in a calm child.

Remember:
 ** If the child is 2 months up to 12 months the child has fast breathing if you count 50 breaths per minute or more

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 3 of 11
 ** If the child is 12 months up to 5 years the child has fast breathing if you count 40 breaths per minute or more.

Color Coding

YELLOW
PINK GREEN
(Treatment at Outpatient Health
(Urgent Referral) (Home management)
(Facility)

OUTPATIENT HEALTH FACILITY OUTPATIENT HEALTH FACILITY HOME

 Pre-referral treatments  Treat local infection  Caretaker is counseled on:
 Advise parents  Give oral drugs  Home treatment/s
 Refer child  Advise and teach caretaker  Feeding and fluids
 Follow-up  When to return immediately
 Follow-up


REFERRAL FACILITY  Give first dose of an appropriate

 Emergency Triage and Treatment SEVERE PNEUMONIA OR VERY antibiotic
(ETAT) SEVERE DISEASE  Give Vitamin A
 Diagnosis, Treatment  Treat the child to prevent low blood
 Monitoring, follow-up sugar
 Refer urgently to the hospital
 Give paracetamol for fever > 38.5oC

 Any general danger sign or  Give an appropriate antibiotic for 5

 Chest indrawing or days
 Stridor in calm child  Soothe the throat and relieve cough
PNEUMONIA
with a safe remedy
 Advise mother when to return
immediately
 Follow up in 2 days
 Give Paracetamol for fever > 38.5oC

 Fast breathing  If coughing more than more than 30

days, refer for assessment
 Soothe the throat and relieve the
NO PNEUMONIA: COUGH OR
cough with a safe remedy
COLD  Advise mother when to return
immediately
 Follow up in 5 days if not improving

 No signs of pneumonia or very

severe disease

Assess and classify DIARRHEA

A child with diarrhea is assessed for:
 How long the child has had diarrhea
 Blood in the stool to determine if the child has dysentery
 Signs of dehydration.

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 4 of 11
Classify DYSENTERY
 Child with diarrhea and blood in the stool

Two of the following signs?  If child has no other severe classification:

 Abnormally sleepy or difficult to  Give fluid for severe dehydration (Plan C)
awaken SEVERE OR
 Sunken eyes  If child has another severe classification:
DEHYDRATION
 Not able to drink or drinking poorly  Refer URGENTLY to hospital with mother
 Skin pinch goes back very slowly giving frequent sips of ORS on the way
 Advise the mother to continue breastfeeding
 If child is 2 years or older and there is cholera in
your area, give antibiotic for cholera

Two of the following signs:
 Restless, irritable
 Sunken eyes
 Drinks eagerly, thirsty
 Skin pinch goes back slowly
 Give fluid and food for some dehydration (Plan B)
SOME DEHYDRATION  If child also has a severe classification:
 Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way
 Advise mother when to return immediately
 Follow up in 5 days if not improving

 Home Care
Not enough signs to classify as  Give fluid and food to treat diarrhea at home
some or severe dehydration NO DEHYDRATION (Plan A)
 Advise mother when to return immediately
 Follow up in 5 days if not improving
 Treat dehydration before referral unless the child
Dehydration present has another severe classification
SEVERE PERSISTENT  Give Vitamin a
DIARRHEA  Refer to hospital
 Advise the mother on feeding a child who has
No dehydration persistent diarrhea
PERSISTENT  Give Vitamin A
DIARRHEA  Follow up in 5 days
 Treat for 5 days with an oral antibiotic
Blood in the stool recommended for Shigella in your area
DYSENTERY  Follow up in 2 days
 Give also referral treatment

Does the child have fever?

**Decide:
 Malaria Risk
 No Malaria Risk
 Measles
 Dengue

Malaria Risk

 Any general danger  Give first dose of quinine (under medical supervision or if a
sign or VERY SEVERE FEBRILE hospital is not accessible within 4hrs)
 Stiff neck DISEASE / MALARIA  Give first dose of an appropriate antibiotic
 Treat the child to prevent low blood sugar
 Give one dose of paracetamol in health center for high
fever (38.5oC) or above
 Send a blood smear with the patient

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 5 of 11

 Blood smear (+)
If blood smear not done:
 NO runny nose, and
 NO measles, and
 NO other causes of
fever
 Blood smear (–), or
 Runny nose, or
 Measles, or Other
causes of fever
No Malaria Risk
 Any general danger sign
or
 Stiff neck
 No signs of very severe
febrile disease
Measles
 Clouding of cornea or
 Deep or extensive
mouth ulcers
 Pus draining from the
eye or
 Mouth ulcers
 Measles now or within
the last 3 months
This document and the information thereon is the property of PHINMA
Education (Department of Nursing)
 Refer URGENTLY to hospital
 Treat the child with an oral antimalarial
MALARIA  Give one dose of paracetamol in health center for high
fever (38.5oC) or above
 Advise mother when to return immediately
 Follow up in 2 days if fever persists
 If fever is present every day for more than 7 days, refer for
assessment

 Give one dose of paracetamol in health center for high
FEVER: MALARIA fever (38.5oC) or above
UNLIKELY  Advise mother when to return immediately
 Follow up in 2 days if fever persists
 If fever is present every day for more than 7 days, refer for
assessment
 Give first dose of an appropriate antibiotic
VERY SEVERE FEBRILE  Treat the child to prevent low blood sugar
DISEASE  Give one dose of paracetamol in health center for high
fever (38.5oC) or above
 Refer URGENTLY to hospital
 Give one dose of paracetamol in health center for high
FEVER: NO MALARIA fever (38.5oC) or above
 Advise mother when to return immediately
 Follow up in 2 days if fever persists
 If fever is present every day for more than 7 days, refer for
assessment
 Give Vitamin A
SEVERE COMPLICATED  Give first dose of an appropriate antibiotic
MEASLES  If clouding of the cornea or pus draining from the eye,
apply tetracycline eye ointment
 Refer URGENTLY to hospital
 Give Vitamin A
MEASLES WITH EYE OR  If pus draining from the eye, apply tetracycline eye
MOUTH COMPLICATIONS ointment
 If mouth ulcers, teach the mother to treat with gentian
violet
 Give Vitamin A
MEASLES
6 of 11
This document and the information thereon is the property of PHINMA
Education (Department of Nursing) 7 of 11
Dengue Fever

 Bleeding from nose or  If skin petechiae or Tourniquet test, are the only positive
gums or signs give ORS
 Bleeding in stools or  If any other signs are positive, give fluids rapidly as in
vomitus or Plan C
 Black stools or vomitus SEVERE DENGUE  Treat the child to prevent low blood sugar
or HEMORRHAGIC FEVER  DO NOT GIVE ASPIRIN
 Skin petechiae or  Refer all children Urgently to hospital
 Cold clammy extremities
or
 Capillary refill more than
3 seconds or
 Abdominal pain or
 Vomiting
 Tourniquet test (+)

 No signs of severe  DO NOT GIVE ASPIRIN

dengue hemorrhagic FEVER: DENGUE  Give one dose of paracetamol in health center for high
fever HEMORRHAGIC UNLIKELY fever (38.5oC) or above
 Follow up in 2 days if fever persists or child shows signs of
bleeding
 Advise mother when to return immediately

Does the Child have an Ear Problem?

 Tender swelling behind  Give first dose of appropriate antibiotic

the ear MASTOIDITIS  Give paracetamol for pain
 Refer URGENTLY

 Pus seen draining from the  Give antibiotic for 5 days

ear and discharge is ACUTE EAR INFECTION  Give paracetamol for pain
reported for less than 14  Dry the ear by wicking
days or  Follow up in 5 days
 Ear pain

 Pus seen draining from the  Dry the ear by wicking

ear and discharge is CHRONIC EAR INFECTION  Follow up in 5 days
reported for less than 14
days

 No ear pain and no pus  No additional treatment

seen draining from the ear NO EAR INFECTION

Check for Malnutrition and Anemia

Give an Appropriate Antibiotic:

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 8 of 11
A. For Pneumonia, Acute ear infection or Very Severe disease

COTRIMOXAZOLE AMOXYCILLIN
BID FOR 5 DAYS BID FOR 5 DAYS

Adult Tablet Syrup Tablet Syrup

Age or Weight

2 months up to 12 months (4 – < 9 kg) 1/2 5 ml 1/2 5 ml

12 months up to 5 years (10 – 19kg) 1 7.5 ml 1 10 ml

B. For Dysentery
COTRIMOXAZOLE AMOXYCILLIN
BID FOR 5 DAYS BID FOR 5 DAYS

AGE OR WEIGHT TABLET SYRUP SYRUP 250MG/5ML

2 – 4 months ½ 5 ml 1.25 ml (¼ tsp)

(4 – < 6kg)

4 – 12 months ½ 5 ml 2.5 ml (½ tsp)

(6 – < 10 kg)

1 – 5 years old 1 7.5 ml (1 tsp)

(10 – 19 kg)

C. For Cholera
TETRACYCLINE COTRIMOXAZOLE
QID FOR 3 DAYS BID FOR 3 DAYS

AGE OR WEIGHT Capsule 250mg Tablet Syrup

2 – 4 months (4 – < 6kg) ¼ 1/2 5ml

4 – 12 months (6 – < 10 kg) ½ 1/2 5 ml

1 – 5 years old (10 – 19 kg) 1 1 7.5ml

Give an Oral Antimalarial

Sulfadoxine +

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 9 of 11
 CHOLOROQUINE Primaquine Primaquine Pyrimethamine

Give for 3 days Give single dose in Give daily for 14 Give single dose
health center for P. days for P. Vivax
Falciparum

TABLET TABLET TABLET

AGE TABLET (150MG) (15MG) (15MG) (15MG)

DAY1 DAY2 DAY3

2 months – 5 months ½ ½ ½ ¼

5 months – 12 months ½ ½ ½ 1/2

12 months – 3 years old 1 1 ½ ½ ¼ ¾

3 years old – 5 years old 1½ 1½ 1 3/4 1/2 1

Give Vitamin A
AGE VITAMIN A CAPSULES 200,000 IU

6 months – 12 months 1/2

12 months – 5 years old 1

Give Iron
AGE or WEIGHT Iron/Folate Tablet - FeSo4 200mg + 250mcg Iron Syrup - FeSo4 150 mg/5ml
Folate (60mg elemental iron) (6mg elemental iron per ml)

2months-4months 2.5 ml
(4 – <6kg)

4months – 12months 4 ml
(6 – <10kg)

12months – 3 years 1/2 5 ml

(10 – <14kg)

3years – 5 years 1/2 7.5 ml

(14 – 19kg)

Give Paracetamol for Fever Higher (38.5oC or more) or Ear Pain

AGE OR WEIGHT TABLET (500MG) SYRUP (120MG / 5ML)

2 months – 3 years ¼ 5 ml
(4 – <14kg)

3 years up to 5 years 1/2 10 ml

(14 – 19 kg)

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 10 of
11
Give Mebendazole
 Give 500mg Mebendazole as a single dose in health center if:
 hookworm / whipworm is a problem in children in your area, and
 the child is 2 years of age or older, and
 the child has not had a dose in the previous 6 months

CHECK FOR UNDERSTANDING (20 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct answer and
another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You are given 20 minutes
for this activity:

Multiple Choice

1. You can classify that a child aged 2 years has fast breathing if he has a respiratory rate of
A. 60 bpm or more
B. 50 bpm or more
C. 40 bpm or more
D. Any of the above
ANSWER: _ _
RATIO:____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ __

2. Baby Yuki, 4 months old is not able to breastfeed and chest indrawing is present. This can be classified as
A. Pneumonia
B. Severe Pneumonia
C. No Pneumonia: cough or cold
D. Mild Pneumonia
ANSWER: _ _
RATIO:____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ __

3. These are all possible treatments for severe pneumonia except:

A. Giver first dose of an appropriate antibiotic
B. Soothe the throat and relieve the cough with a safe remedy
C. Give vitamin A
D. Treat the child to prevent low blood sugar
ANSWER: _ ___
RATIO:____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ __

4. What color is "NO PNEUMONIA: COUGH OR COLD" classified as?

A. Green
B. Pink
C. Yellow
D. Red
ANSWER: _ _
RATIO:____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ __

5. If the child has wheezing and either fast breathing or chest indrawing present, the nurse should:
A. Refer URGENTLY to hospital
B. Give a trial acting inhaled bronchodilator for up to 3 times

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 11 of
11
C. Assess vital signs
D. Give Vitamin A
ANSWER: _ _
RATIO:____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ __

6. Dysentery is classified if:

A. There is Dehydration
B. Stools are watery
C. Fast breathing is present
D. There is blood in the stool
ANSWER: _ _
RATIO:____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ __

7. All are signs of severe dehydration except

A. Restlessness
B. Sunken eyes
C. Skin pinch goes back very slowly
D. Abnormally sleepy
ANSWER: _ _
RATIO:____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ __

8. Which type of plan would the nurse instruct to a child who was classified with severe dehydration?
A. Plan A
B. Plan B
C. Plan C
D. Plan D
ANSWER: _ _
RATIO:____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ __

9. If child has not enough signs to classify as some or severe dehydration, the child will be classified as what?
A. Severe Dehydration
B. Mild Dehydration
C. Some Dehydration
D. No Dehydration
ANSWER: _ _
RATIO:____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ __

10. Patient Tifa, 5 months old has diarrhea for already 16 days. You also notice that dehydration is present. This could be classified
as?
A. Severe Dehydration
B. Severe Persistent Diarrhea
C. Some Dehydration
D. Persistent Diarrhea
ANSWER: _ _
RATIO:____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ __

This document and the information thereon is the property of

PHINMA Education (Department of Nursing) 12 of
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE-TO-FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves. Write the correct
answer and correct/additional ratio in the space provided.

1. ANSWER: _ _
RATIO:___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _

2. ANSWER: _ _
RATIO:___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ __ _ _ _ _

3. ANSWER: _ _
RATIO:___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _

4. ANSWER: _ _
RATIO:___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _

5. ANSWER: _ _
RATIO:___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
__ _ _ _ _ _ _ _ _ _ _ _ _ _

6. ANSWER: _ _
RATIO:___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _

7. ANSWER: _ _
RATIO:___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _

8. ANSWER: _ _
RATIO:___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ ___ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _

9. ANSWER: _ _
RATIO:___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _

10. ANSWER: _ _
RATIO:___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ __ _ _ _ _

LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you track
how much work you have accomplished and how much work there is left to do.

This document and the information thereon is the property of

PHINMA Education (Department of Nursing) 13 of
You are done with the session! Let’s track your progress.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

AL Activity: Muddiest Point:

In today’s session, what was least clear to you?
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ ___ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

This document and the information thereon is the property of

PHINMA Education (Department of Nursing) 14 of