Sud 2

WORK INSTRUCTIONS
HEALTH AND WELLNESS CENTRE

SUDDEKUNTE
DIST TUMKURU
SUDDEKUNTE
Doc No:WI/NQAS/HWC SUDDEKUNTE

WORK INSTRUCTIONS 1st Issue date:21/05/2023
Rev. date:
Issue No.:01
Next revision : 20/11/2024
DOCUMENTCONTROL SHEET
DOCUMENT NAME : WORK INSTRUCTIONS
EFFECTIVE FROM : 21.05.2023
QUALITY TEAM HEALTH AND

PREPARED AND REVIEWED, BY :
WELLNESSCENTRE, SUDDEKUNTE
APPROVED AND ISSUED BY AMO PHC

MUDDENAHALLI
QUALITY TEAM, HEALTH AND

RESPONSIBILITY OF UPDATING WELLNESS CENTRE, SUDDEKUNTE
DOCUMENT AMENDMENT SHEET
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SL DATE AMENDMENT REASON PAGE

NO MADE NO
Page
Table of Content
No.
1. INSTRUCTIONS FOR USING RDK 5
2. WORK INSTRUCTION FOR RMNCHA SERVICES 10
3. WORK INSTRUCTIONS FOR SCREENING, MANAGEMENT AND APPROPRIATE 14
REFERRAL OF NCDS
4. WORK INSTRUCTIONS FOR SCREENING, MANAGEMENT AND APPROPRIATE 26
REFERRAL OF COMMUNICABLE DISEASE
5. WORK INSTRUCTIONS FOR SCREENING AND REFERRAL OF PATIENTS WITH 41
MENTAL DISORDERS
6. WORK INSTRUCTIONS FOR SCREENING OF COMMON OPHTHALMIC PROBLEMS 46
7. WORK INSTRUCTIONS FOR SCREENING OF ENT PROBLEMS 48
8. WORK INSTRUCTIONS FOR SCREENING OF COMMON ORAL PROBLEMS 51
9. WORK INSTRUCTION FOR SCREENING OF COMMON ELDERLY & PALLIATIVE CARE 53
Prepared by:HWC QUALITY TEAM Approved: AMO PHC UKKALI

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10. WORK INSTRUCTION FOR MANAGEMENT OF EMERGENCY MEDICAL SERVICES 56

11. WORK INSTRUCTIONS FOR INFECTION PREVENTION & BIO MEDICAL WASTE 65
MANAGEMENT
Work instructions
A work instruction is a written document that provides clear and precise steps to carry out a
single instruction.
PURPOSE
To provide clear and precise guidelines to carry out screening, to provide treatment and
referral services.
By creating work instructions, staff ensure that the best way of doing a specific task is clearly
communicated, understood, and implemented.
SCOPE
Community and the patients coming to Health and wellness centre
RESPONSIBILITY
Community Health Officer, Primary Health Care Officer, Health Inspecting Officer and
ASHAs.
1. INSTRUCTIONS FOR USING RDK
A rapid diagnostic test (RDT) is a medical diagnostic test that is quick and easy to perform.
RDTs are suitable for preliminary or emergency medical screening and for use in medical
facilities with limited resources.
RAPID DIAGNOSTIC TEST FOR HIV/AIDS
Prepared by:HWC QUALITY TEAM Approved: AMO PHC MUDDENAHALLI

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RAPID DIAGNOSTIC TEST FOR HEPATITIS B
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RAPID DIAGNOSTIC TEST FOR SYPHILIS
Prepared by: HWC QUALITY TEAM Approved: AMO PHC MUDDENAHALLI

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RAPID DIAGNOSTIC TEST (RDT) FOR MALARIA

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2. WORK INSTRUCTION FOR RMNCHA SERVICES
RMNCHA - Reproductive Maternal Neonatal Child Health and Adolescent
Care in pregnancy and child birth
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Family planning, contraceptive services and other reproductive care services
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3. WORK INSTRUCTIONS FOR SCREENING, MANAGEMENT AND APPROPRIATE

REFERRAL OF NCDS
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Non-Communicable Diseases (NCDs), also known as chronic diseases, are not passed
from person to person. They are of long duration and generally slow progression. NCDs
do not result from an (acute) infectious process and hence are not communicable. They
have a prolonged course and does not resolve spontaneously.
The 4 main types of Non Communicable Diseases are cardiovascular diseases (like heart
attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive.
Every individual will be screened annually for Hypertension (High Blood Pressure) and
Diabetes. For common Cancers, the screening will be done once in 5 years.
Screening for Hypertension, Diabetes, oral cancer and breast cancer can be offered in
the outreach services at the village level, while cervical cancer screening requires privacy
and facilities for sterilization of equipment.
Cancer
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Cancer is a disease caused by uncontrolled division of cells in any part in the human
body. Normally the cell growth is kept under control by the body’s immune system. It is
only when these cells start to divide uncontrollably, forming lumps or growths, that
Cancer is caused.
Cervical Cancer
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Cervical cancer is a cancer arising from the cervix. It is due to the abnormal growth of
cells that have the ability to invade or spread to other parts of the body.
Visual Inspection using Acetic acid (VIA)
Screening using acetyl salicylic acid
Naked-eye visual inspection of the uterine cervix, after application of 5% acetic acid
(VIA) provides simple tests for the early detection of cervical precancerous lesions and
early invasive cancer. The results of VIA are immediately available and do not require
any laboratory support.
Acetic acid caused intracellular dehydration and coagulation of protein within abnormal
cervical cells. So the abnormal cells will turn white after application of acetic acid.
Instruments and materials required

• Examining table.
• Light source.
• Bivalve speculum (Cusco).
• Instrument tray or container.
• Bottles with normal saline.
• 5% acetic acid (freshly prepared).
• Cotton-tipped - swab sticks.
• Disposible gloves.
• 0.5% chlorine solution for decontaminating.
• Forms and registers for recording the findings.
Preparation of 5% acetic acid: Acetic acid is to be freshly prepared everyday:
Ingredients Quantity
1 Glacial acetic acid 5 ml
2 Distilled water 95 ml
Preparation: Carefully add 5 ml of glacial acetic acid into 95 ml of distilled water and mix
thoroughly.
Storage: Unused acetic acid should be discarded at the end of the day.
Procedure of VIA examination
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• Explain the screening in detail to the woman. The woman should be reassured that
the procedure is painless, and every effort should be made to ensure that she is fully
relaxed and remains at ease during testing.
• Written informed consent should be obtained before screening.
• The woman is invited to lie down in a modified lithotomy position on a couch with
leg rests or knee crutches or stirrups.
• Gently introduce the speculum and open the blades of the speculum to view the
cervix in the presence of good light source.
• Identify the external os, columnar epithelium (red in colour), squamous epithelium
(pink) and the squamocolumnar junction.
• Proceed to identify the transformation zone, the upper limit of which is formed by
the squamocolumnar junction. (Cervical neoplasias occur in the transformation zone
nearest to the squamocolumnar junction).
• Gently, but firmly, apply 5% acetic acid using a cotton swab soaked in acetic acid.
The secretions should be gently wiped off. The swabs after use should be disposed of
in the waste bucket.
• The curdy-white discharge associated with candidiasis is particularly sticky, and if
particular care is not taken to remove it properly, it may mimic an acetowhite lesion,
thus leading to a false-positive result.
• After removing the swab, carefully look at the cervix to see whether any white
lesions appear, particularly in the transformation zone close to the squamocolumnar
junction, or dense, non-removable acetowhite areas in the columnar epithelium.
• The results one minute after application of acetic acid should be reported. Note how
rapidly the acetowhite lesion appears and then disappears.
Carefully observe
• The intensity of the white colour of the acetowhite lesion: if it is shiny white,
cloudy white, pale-white or dull-white.
• The borders and demarcations of the white lesion: distinctly clear and sharp or
indistinct diffuse margins; raised or flat margins; regular or irregular margins.
• Whether the lesions are uniformly white in colour, or the colour intensity varies
across the lesion, or if there are areas of erosion within the lesion.
• Location of the lesion: is it in, near or far away from the transformation zone? Is
it abutting (touching) the squamocolumnar junction? Does it extend into the
endocervical canal? Does it occupy the entire, or part of, the transformation
zone? Does it involve the entire cervix (which usually indicates early preclinical
invasive cancer)?
• Size (extent or dimensions) and number of the lesions
Reporting the Outcome of VIA
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VIA negative (-)
• VIA screening is reported as negative in the case of any of the following

observations:
• No acetowhite lesions are observed on the cervix.
• Polyps protrude from the cervix with bluish
• White acetowhite areas.
• Nabothian cysts appear as button-like areas, as whitish acne or pimples.
• Dot-like areas are present in the endocervix, which are due to grapelike
columnar epithelium staining with acetic acid.
• There are shiny, pinkish-white, cloudywhite, bluish-white, faint patchy or
doubtful lesions with ill-defined, indefinite margins, blending with the rest of the
cervix.
• Angular, irregular, digitatingacetowhite lesions, resembling geographical regions,
distant (detached) from the squamocolumnar junction (satellite lesions).
• Faint line-like or ill-defined acetowhitening is seen at the squamocolumnar
junction. ™ Streak-like acetowhitening is visible in the columnar epithelium.
• There are ill-defined, patchy, pale, discontinuous, scattered acetowhite areas.
VIA positive (+)
The VIA test outcome is reported as positive in any of the following situations:
• There are distinct, well-defined, dense (opaque, dull- or oyster-white) acetowhite
areas with regular or irregular margins, close to or abutting the squamocolumnar
junction in the transformation zone or close to the external os if the
squamocolumnar junction is not visible.
• Strikingly dense acetowhite areas are seen in the columnar epithelium. ™ The entire
cervix becomes densely white after the application of acetic acid.
• Condyloma and leukoplakia occur close to the squamocolumnar junction, turning
intensely white after application of acetic acid.
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Breast cancer
Breast cancer, disease characterized by the growth of malignant cells in the mammary
glands.
Screening
Screening for breast cancer Breast cancer is the commonest cancer among women all
over the world. Some of the risk factors for breast cancer are:
• Reproductive and hormonal factors – The older a woman is when she has her
first child, the greater her chance of having breast cancer. Early menarche
(before age 12), late menopause (after age 55) or never had children are also at
greater risk. Women who take menopausal hormone therapy (oestrogen and
progesterone) for five years or more after menopause also appear to have an
increased risk.
• Family History: Risk of Breast cancer increases in women with a first-degree

relative with breast cancer
• Other factors:
➢ Being obese after menopause
➢ Physical inactivity.
➢ Alcohol intake: some studies suggest that the risk of breast cancer increases with
increased intake of alcoholic beverages.
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Oral Cancer
Oral cancer, also known as mouth cancer, is cancer of the lining of the lips, mouth, or
upper throat
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Diabetes
Diabetes is a disease in which the body does not produce or cannot properly use the
hormone insulin. The body needs insulin to convert sugar, starches and other foods into
energy. Impairment of insulin secretion and action in the body leads to abnormally
elevated levels of glucose in blood, a condition classically termed as Diabetes.
Algorithm for screening and management of diabetes
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Hypertension
Abnormally elevated blood pressure is a pathological condition which increases the work
load on the heart. This condition is termed as high blood pressure or hypertension.
Algorithm for management of hypertension
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4. WORK INSTRUCTIONS FOR SCREENING, MANAGEMENT AND APPROPRIATE

REFERRAL OF COMMUNICABLE DISEASE - MALARIA , DENGUE, TB, LEPROSY, HIV-
AIDS AND HEPATITIS
HIV-AIDS
Human immunodeficiency virus (HIV) is an infection that attacks the body's immune
system, specifically the white blood cells called CD4 cells.
Screening/ Diagnosis
HWC is provided with rapid kits for screening of HIV. This is not a confirmatory test and
those persons who are screened positive must undergo confirmatory test that is
available at block TH or district hospital level in HIV/AIDS counselling and testing
Services facilities. Those persons with negative test results from rapid test assured of not
having active HIV infection. The persons with negative result showing high risk behaviors
followed up regularly for early detection.
Some groups of people who are at a high risk of HIV infection should undergo routine
HIV screening:
➢ All pregnant women
➢ Babies born to HIV-positive women
➢ Children of women living with HIV
➢ Children presenting with suboptimal growth or severe acute malnutrition, delay
in developmental milestones, oral thrush, severe pneumonia and sepsis
➢ Patients who present with signs and symptoms suggestive of HIV/AIDS
➢ Individuals who have faced sexual assault
➢ Anyone (including hospital staff) who had needle prick injury or blood contact
with HIV positive person
➢ All patients with TB or presumptive TB, Kala-azar, hepatitis B or C, or STI/RTI
➢ STI/RTI clinic attendees
➢ Sexual partners/spouses of PLHIV (People Living with HIV)
➢ Prison Inmates
➢ Persons who have undergone sexual assault
➢ Injecting Drug Users (IDU)
➢ Adolescents (age groups 10–19 years) with high risk behavior
➢ Needle sharing partners of HIV positive IDU
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Prevention of HIV at HWC Level
Following activities are to be undertaken as preventive measures at HWC level:
➢ Promotion of use of Condoms:

➢ Screening of all pregnant women: It is possible to prevent transmission of infection
from pregnant woman to her child; thus, all pregnant women should be screened
and those found HIV positive should be referred to nearest HCTS Centres for further
confirmation of diagnosis.
➢ All staff at SHC - HWC know how to prevent oneself from needle stick injuries and
correct techniques of handling instruments, blood stained surfaces etc. All staff
should follow proper Bio Medical Waste Management guidelines.
Through ART (Anti-Retroviral Therapy) centres, link-ART centers and Care and support
Centers. These treatment services offer free standardized Anti-Retroviral Therapy (ART)
for all diagnosed people living with HIV (PLHIV) as well as comprehensive management
of opportunistic infections.
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TUBERCULOSIS
Tuberculosis (TB) is a bacterial infection spread through inhaling tiny droplets from the
coughs or sneezes of an infected person.
Screening
➢ All people living with HIV (PLHIV), malnourished, diabetics, cancer patients,
patients undergoing dialysis, patients on immunosuppressant or maintenance
steroid therapy, chronic smokers.
➢ Enhanced case finding and contact screening should be undertaken in high
priority populations listed in the table given below:
➢ Early identification of presumptive TB patients through screening for cough, fever,

weight loss, blood in sputum, or night sweat should be undertaken during OPD and
during Population Enumeration using the CBAC form or its updation, or during any
other population-based activities by the HWC.
➢ Periodic TB screening (preferably once in a quarter) shall be undertaken among
identified vulnerable population including diabetic patients, patients on
immunosuppressants, smokers, etc.
Type of TB Case Doses in IP Doses in CP#

New and Previously 56 doses (8 weeks x 7 112 doses(16 weeks x 7
treated days/week) or 28*2 days/week) or 28*4
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Leprosy
Leprosy is a chronic infectious disease caused by Mycobacterium leprae.
Management at SHC-HWC Level Any suspected case of leprosy, either presenting to the
SHC-HWC or detected during Active Case Detection and Regular Surveillance (ACDRS) should
immediately be referred to the Medical Officer at the PHC-HWC. The following signs should
be carefully looked for to suspect a leprosy case:
1. Any change in the skin color (Pale or Reddish patches on skin) with partial or complete
loss of sensation 2. Thickened skin on the patches
3. Shiny or Oily face skin
4. Nodules on skin
5. Thickening of ear lobe(s)/ Nodules on earlobe(s)/ nodules on face
6. Inability to close eye(s)/ watering of eye(s)
7. Eyebrow loss
8. Nasal infiltration (saddle nose deformity)
9. Thickened peripheral nerve(s)
10. Pain and/ or tingling in the vicinity of the elbow, knee or ankle
11. Inability to feel cold or hot objects.
12. Loss of sensation in palm(s)
13. Numbness in hand(s)/ foot/ feet
14. Ulceration in hand(s)/ painless wounds or burns on palm(s)
15. Weakness in hand(s) when grasping or holding objects; inability to grasp or hold objects
16. Difficulty in buttoning up shirt/ jacket etc.
17. Tingling in fingers(s)/ toe(s) 18. Tingling in hand(s)/ foot/feet
19. Ulceration in foot/ feet; painless wounds or burns on foot/feet
20. Clawing/ bending of finger(s)/ toe(s)
21. Loss of sensation in sole of foot/ feet
22. Weakness in foot/ feet/ footwear comes off while walking
23. Foot drop/ dragging the foot while walking
If ASHA suspects that a person screened is a “Suspect case”, she/ he will issue a Referral Slip
to the Suspect with the advice to immediately visit the nearest SHC-HWC for final diagnosis
by the CHO. A copy of the said Referral Slip shall also be handed over by the ASHA to the
MPW F/M of the SHC-HWC/PHC-HWC/UPHC-HWC concerned within a day of screening of
such Suspect. The CHO should diagnose the Suspect where a HWC is established. If,
however, the CHO fails to make a final diagnosis, the Suspect should be referred to the MO-
PHC for final diagnosis. The MO-PHC will confirm the diagnosis (based on clinical
examination and slit-skin smear if available) and initiate the treatment (Multidrug
therapy/MDT). CHO should follow up with the patient to find out their diagnosis and
management advised at PHC-HWC to ensure treatment compliance.
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After confirmation of a new case of leprosy, the CHO/PHC/UPHC Medical Officer will inform
the concerned MPW F/M and ASHA and shall ensure screening of all the close contacts of
such index case following Guidelines for Post Exposure Chemoprophylaxis shared earlier
with all States/UTs. The close contacts of every ‘Index Case’ of leprosy shall be screened for
signs or symptoms of leprosy by a regular trained health worker, under the overall
supervision of the CHO/MO- PHC/UPHC. If a confirmed case of leprosy is found in the
contacts, the treatment needs to be immediately initiated with MDT. For the remaining
contacts, Single Dose of Rifampicin (SDR) is required to be administered as Post Exposure
Chemoprophylaxis (PEP).
Following four key messages are suggested to generate awareness regarding leprosy in the
community:
1. Leprosy is Curable: The disease is caused by leprosy germs and can be cured with
medicines (MDT) that are available free of charge in all the health facilities.
2. Early Symptoms of Leprosy: Leprosy usually starts as a skin patch with loss of sensation
or as numbness and tingling in hands and/ feet. Consult health worker on occurrence of any
of these.
3. Disabilities can be Prevented: Early detection with appropriate treatment helps
prevention of disability due to leprosy.
4. No Place for Segregation: Leprosy is treatable and once on treatment patient does not
infect others and hence there is no place for segregation of Persons affected by leprosy.
5. Accept Persons Affected by Leprosy: Persons affected by leprosy, once on treatment
needs compassion and empathy.
Discrimination of patients is in human Interventions for reducing stigma may be required at
five levels –Viz. intrapersonal, interpersonal, community, organizational/institutional and
governmental level.
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Role of HWC-SHC Level in Delivering Services under NLEP
1. Implementation of Active Case Detection and Regular Surveillance (ACD&RS) for leprosy
in the villages under the jurisdiction of HSC-HWC as per ACD&RS Operational Guidelines
2020
2. Implementation of Post Exposure Prophylaxis for the close contacts of index cases in
coordination with MO and in compliance with the PEP guidelines.
3. Refer all the suspect cases of leprosy to MO-PHC for confirmation of diagnosis and
initiation of treatment
4. Dispensation of Multi Drug Therapy (MDT) to the confirmed leprosy cases as prescribed
by MO PHC
5. Follow up the on MDT (on-treatment) cases and identify the early signs of reactions (Type
I and II) /Neuritis and referral to MO-PHC for management
6. Maintain and update line list of Grade I and Grade II disability cases and new /old cases
7. Identification of eligible grade II disability cases for Reconstructive surgery and their
referral to higher facility
8. Identification of early signs of disability and referral for physiotherapy and treatment to
the higher facility.
9. Follow-up of Under Treatment (UT) and Released From Treatment (RFT) leprosy cases
10. Retrieval of Defaulters/dropout cases
11. Distribution of MCR to the eligible cases twice a year
12. Distribution of self-care kits to the eligible cases twice a year
13. Counseling of Persons Affected with Leprosy, and their family members
14. Active participation in Sparsh Leprosy Awareness Campaigns (SLAC) and awareness
generation among general population regarding leprosy through appropriate IEC/BCC/
awareness generation tools
15. Supportive supervision of ASHAs and MPWs
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Dengue
Dengue is a vector-borne viral infection transmitted by female Aedesaegypti mosquito,

which is also responsible for spread of other viral diseases like Chikungunya, Yellow fever
and Zika virus infection.
Dengue MANAGEMENT AT SHC-HWC LEVEL
➢ In mild DF, only symptomatic care is recommended. Paracetamol tablets as

antipyretics, good hydration with plenty of fluids in different forms of home
remedies as rice-water, fresh fruit juices, nimbupani, ORS, etc. are advised.
➢ Aspirin/NSAIDs (non-steroidal anti-inflammatory drugs) like Ibuprofen, Diclofenac,
etc. should be avoided since it may cause gastritis, vomiting, and severe bleeding
complications in patients with dengue infection.
➢ Patients should be monitored for 24–48 hours in DHF endemic areas for warning
signs even after they become afebrile. They should be explained about danger signs
and symptoms and clearly instructed to return to SHC-HWC for follow up.
➢ Any person, confirmed with rapid kit tests to have dengue infection should be
referred to higher center for treatment, if he/she shows following danger
symptoms/signs
• hypotension (systolic BP<90 mmHg)
• signs of severe dehydration
• altered sensorium (confusion, irrelevant talk, slurring of speech, etc.)
or unconsciousness
• breathing difficulty
• bleeding gums
• decreased urine production or complete absence
• jaundice
• bluish-black patches over skin
➢ When a patient is brought to SHC-HWC in shock, as in DHF or DSS; then initial
stabilization with IV fluids should be done before and during referral from SHC-HWC.
During referral of DSS patients, carefully follow these principles:

i. First thing to do is hemodynamic stabilization of patient with reference to
vitals; this includes treatment of hypotension for a patient in shock. About
10–20 ml/kg of IV fluids (preferably Ringer’s lactate RL or Normal saline NS)
should be given in first one hour. Additional 10 ml/kg of fluids may be given if
patient is still hypotensive during referral.
ii. Confirm the diagnosis using rapid test kits and discuss with the relatives,
attendants about severity of illness, and required level of facility care, plan of
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referral including place, accompanying persons, vehicle, possible requirement

for arrangement of blood and blood donors, etc.
iii. Provide a good referral note mentioning briefly details of first clinical
assessment and treatment given. Call and inform the referral center in
advance about the concerned patient.
Preventive Measures
Integrated vector management and personal protective measures are the most
important steps for prevention and protection from dengue virus infection, similar to
other vector borne diseases and this has been adopted as a strategic plan of
NVBDCP. Early identification of all cases, timely referral of all sick persons, and
increased community awareness are among the other activities to be carried by SHC-
HWC staff at community level
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Malaria
Malaria is a protozoal disease caused by Plasmodium and transmitted from person to

person thorough bite of female Anopheles mosquito.
In endemic areas where there is high burden of the disease, malaria should be routinely
suspected in any febrile person. Suspicion for malaria should be kept high for those persons
from non- endemic area with acute febrile illness, who have history of recent travel to a
malaria endemic zone.
Any case suspected for malaria is confirmed by a laboratory diagnosis. Microscopic

examination of thick and thin blood smears and visualization of malarial parasite in the
slides confirms the diagnosis. Rapid diagnostics kits are available at SHC-HWC level, which
are reliable, easy to use and give results within minutes.
Presumptive treatment of malaria is not recommended routinely. Treatment is
recommended only after confirmation of diagnosis of suspected malaria case is done.
Treatment is based on three main factors:
1. The infecting malaria parasite (Plasmodium or Vivax) species

2. The clinical status of the patient
3. The drug susceptibility of the infecting parasites as advised for the geographic area
Uncomplicated Malaria
Treatment of Uncomplicated P. vivax Cases
i. Chloroquine: 25 mg/kg body weight divided over three days, i.e. 10 mg/kg on day
1, 10 mg/kg on day 2 and 5 mg/kg on day 3. (For adults above 60 kg, maximum
dose is 600 mg)
ii. Primaquine: 0.25 mg/kg body weight daily for 14 days with maximum dose for
adults 15 mg/day
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Treatment of Uncomplicated P. falciparum Cases and Mixed Infections (Pv+Pf)
➢ Artemisinin based Combination Therapy (ACT): Artesunate tablets 4 mg/kg body

weight daily for 3 days (Caution: ACT is not to be given in 1st trimester of pregnancy)
➢ Sulfadoxine (25 mg/kg body weight) and Pyrimethamine (1.25 mg/kg body weight):
As a single dose on first day
➢ Primaquine: Single dose of 0.75 mg/kg body weight on day 2 only
Note: Primaquine is contraindicated during pregnancy and should not be given
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in either Pv, Pf or Mixed Pv+Pf infection. For pregnant women in first trimester, tablet
Quinine (10 mg/kg three times a day for 7 days) is recommended for uncomplicated
malaria infection insteadof artesunate combination therapy.
MANAGEMENT OF PATIENT’S SYMPTOMS AND HIS/HER CLINICAL STATUS
After the diagnosis of malaria is confirmed, CHO assess whether the patient has signs of
severe malaria or any complications or not and which are the presenting complaints
reported by the patient.
In Addition to Antimalarial Drugs, Give Treatment for Patient’s Presenting Complaints
Fever and Pain:Paracetamol tablet/ syrup is effective to treat these symptoms.

In adults and pregnant women, give PCM 500mg 4 times a day for 3–5 days or till symptoms
are resolved. In children, give PCM syrup/ tablet 15mg/kg 4 times a day till symptoms are
resolved.
Vomiting: Metoclopramide syrup and tablets may be used. If vomiting occurs within 30
minutes of intake of medicines, repeat the dose.
Avoid giving antimalarial drugs on empty stomach. Counsel the patient to take full course of
medicines. Ask the patient to report back to HWC, if symptoms are not resolved after 3 days
of medicines or if danger signs as bleeding from gums, nose or urine, black-reddish round
patches or rash appears anywhere over the skin.
Complicated Malaria
Patients with severe malaria may present with different combination of red flag signs;
therefore, every case of severe malaria may be different than the other. Overall
management should be based on specific findings in an individual patient.
For example, all 3 of the following features are seen in three different patients with malaria.
i. Fever of 3 days with acute onset seizures, or
ii. Fever from 2–3 days and severe shock and respiratory distress, or
iii. Patient with high grade fever and severe vomiting with splenomegaly.
Assessment of A-B-C (Airway, Breathing, Circulation) done first as per basic life support
protocols and necessary steps be taken accordingly. All sick patients with severe malaria
should receive 1st dose of antimalarial drugs as well as required resuscitation at HWC level
itself, before referral to higher center.
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PREVENTIVE MEASURES
➢ In malaria endemic areas, all front lines workers including ASHA and MPW are
undertake fortnightly house to house visits in village to identify any person with
fever. They prepare blood smears of febrile patients and send them to PHC-HWC
laboratory for confirmation of diagnosis of malaria. If suspicion of malaria is high as
in high risk areas or when the patient is sick, the SHC-HWC team may confirm the
diagnosis using rapid diagnostic kits and start the treatment with first dose of
antimalarial drugs immediately and then refer the patient to PHC-HWC.
➢ ASHAs counsel individuals and families to adopt self-protection measures and to

maintain cleanliness in and surrounding houses. All the staff of HWC conduct
awareness sessions for community regarding malaria prevention.
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Viral Hepatitis
MANAGEMENT AT SHC- HWC LEVEL
Prevention Awareness generation & outreach activities regarding preventive measures need
to be carried out at the SHC-HWC and community level
Hepatitis A and E
➢ Promote and advocate safe water, hygiene and sanitation: washing hands after using
the toilet and before eating food; safe drinking water–boiled/ filtered/ packaged/
safe portable etc., ensure safe disposal of human excreta, avoid open defecation
➢ Promote and advocate for safe food: ensuring that eating well cooked and
appropriately stored food items; avoiding or peeling fruits and vegetables that may
have been washed or grown in contaminated water etc.
Hepatitis B and C
Vaccination
➢ Ensure hepatitis B birth dose to all newborn (within 24 hours of birth), followed by
three doses at 6, 10 and 14 weeks to complete the schedule
➢ Vaccination of all healthcare workers with hepatitis B vaccine at 0,1 & 6 months
Safety of Blood and Blood Products

➢ Promote information regarding availability of safe blood at licensed blood banks
Harm Reduction in High Risk Groups

➢ Prevention package is similar to that under NACP i.e. behavioural change
communication, condom promotion, community mobilization and enabling
environment, and linkages to TC/MTC for further management
➢ Screening of pregnant women for hepatitis B using Rapid Diagnostic Test kits
➢ Screening of HBV and HCV of high-risk groups e.g. Intravenous Drug Users, recipients
of multiple blood transfusions, commercial sex workers, etc. using Rapid Diagnostic
Test kits
Injection Safety and Infection Control

➢ Limit use of unnecessary injections and promotion for use of Reuse prevention
syringes when needed.
➢ Safe injections practices while respecting the socio-cultural practices like tattooing,
religious ceremonies (e.g. mundans), ear/body piercing etc
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DIAGNOSIS AND MANAGEMENT
Approach to a Patient
Viral hepatitis B & C are usually a silent disease (asymptomatic). A patient may present at a
healthcare setting with or without jaundice. Ensure testing of all pregnant women or
persons in the high-risk categories. After the patient has been tested & found positive for
viral hepatitis, s/he will be referred to MO for further evaluation and management. In case
of the treatment initiation by the MO, the drugs for hepatitis B and C may be dispensed
monthly after ensuring compliance at SHC-HWC as per national guidelines. The patient is to
be followed for treatment adherence and any side effects of the drugs.
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5. WORK INSTRUCTIONS FOR SCREENING AND REFERRAL OF PATIENTS WITH MENTAL

DISORDERS
A mental disorder is characterized by a clinically significant disturbance in an individual's

cognition, emotional regulation, or behaviour.
Community Health Officers (CHO) will provide the primary level care at the Health and
Wellness Centres, including screening and primary management, and will enable adherence
to treatment protocols.
Interventions delivered at this level will include:
a. Awareness and stigma reduction activities at an individual level and psychoeducation for
all groups of MNS conditions.
b. Promotion of mental health through family enrichment programs, school health

programs, positive parenting, and physical activities initiative including yoga.
c. CMDs (Common Mental Health Disorder)– Screening/identification, psychosocial

interventions (basic counselling, psychological first aid, problem solving, behavioural
activation, cognitive behavioural techniques, stress management, life-skills training, lifestyle
modification, simple multimodal multisensory stimulation techniques for developmental
disorders, sleep hygiene counselling), referral, and follow-up for CMDs, including for post-
partum depression.
d. SMDs (Common Mental Health Disorder) – Screening/Identification, referral to PHC and

follow-up, communitybased rehabilitation, family-based interventions, and organising
meetings of self-help groups
e. C&AMHDs (Childhood & Adolescent Mental Health Disorder) – Screening/Identification,

referral to PHC and follow-up.
f. SUDs (Childhood & Adolescent Mental Health Disorder)– Screening/Identification, brief

intervention/management (including relapse prevention), harm reduction counselling, first
aid response to overdose/intoxication, referral to PHC or addiction/ dependence treatment
centres such as OST centres, and follow-up
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6. WORK INSTRUCTIONS FOR SCREENING OF COMMON OPHTHALMIC PROBLEMS
Screening of the eye will be undertaken by ASHA for all adult community members using
finger counting method, 6/18 Snellen vision chart (E chart) and risk assessment through
Community Based Assessment Checklist (CBAC);
Screening of 0-18 years children and adolescents through the RBSK team in schools and
Anganwadi centres, screening for children during Village Health, Sanitation and Nutrition
Day (VHSND) by primary healthcare team, school health check-up programmes, organising
eye screening camps, etc. for early identification of blindness and refractive errors with
timely referral.
Regular monitoring of blood pressure, blood sugar, heart diseases, etc. of the target
community members done. Besides these opportunities, special eye screening camps for
older populations. At the end of the screening activities, the ASHA and ANM/MPW will
update the registers and records.
Screening for Cataract
In order to screen for cataract, you need to examine the eye of the patient with the help of
a torch. In normal cases, the pupils get constricted and appear jet black. However, in
patients suffering from cataract, due to the opacity of the lens, light gets reflected and the
pupil appears to be white (as depicted in the above image).
Screening for Refractive Errors/Testing of Vision
Testing of the Vision of an individual is done using certain vision charts. Separate charts are
used for testing the distant and near vision. You along with the MPW/ANM will be
responsible for screening for blindness and refractive errors using Snellen’s chart and near
vision card/chart at the AB-HWCSHC.
In addition to identifying high-risk individuals through filling of CBAC, ASHA will also identify
adult individuals at community level with blindness and visual impairment by the finger
counting method and 6/18 Vision Chart (Snellen E chart), respectively.
Steps to be undertaken by CHO at AB-HWC-SHC for testing Distant Vision
➢ Ask the person to stand at the distance of 6 meters or 20 feet away from the chart. If
there is shortage of space, a mirror can be used and a distance of 3 meters or 10 feet
can be recorded. The Snellen vision chart (E chart) should be at the same level as the
person’s eyes.
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➢ If the person normally wears spectacles/glasses to see in the distance, tell them to
put their glasses on during the test.
➢ Ask the person to cover his/her left eye with the palm of their left hand properly and
see the chart with right eye. Do not squeeze the eye as it may lead to error in
reading, the person should read normally.
➢ Stand beside the vision chart. The person should speak aloud/point the direction of
the open end of the “E” letter of each row beginning from the top.
➢ Ensure that the person stands straight and does not lean forward.
➢ The lower most line which the patient is able to read clearly, corresponds to the
vision of the patient.
➢ Now ask the person to cover the right eye properly with the palm of their right hand
and repeat the test with the left eye.
➢ Any patient with a vision < 6/9 (less than) needs to be referred to the OA at Vision
Centre/ Eye Specialist/Eye Doctor at higher health facilities for further evaluation
and management.
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7. WORK INSTRUCTIONS FOR SCREENING OF ENT PROBLEMS
The most important ENT condition which is widely screened for is deafness or hearing
loss. Hearing loss is a condition which is prevalent in all age groups. Hearing loss may be
congenital (present at birth) or acquired later in life. Both the types of hearing loss are
preventable.
Screening the population regularly done for hearing loss. Early diagnosis of deafness by
means of screening can find out its cause and provide treatment at the earliest.
• National Programme for Prevention and Control of Deafness (NPPCD) –

Screening for deafness in hospitals and health camps.
• National Programme for Health Care of the Elderly (NPHCE) – Screening of
geriatric population for deafness in primary health care facilities as well as
specialised geriatric clinics.
• RashtriyaBalSurakshaKaryakram (RBSK) – Screening of children and adolescents
using platforms like anganwadi centres and schools for congenital deafness and
other birth defects related to ENT problems.
ASHA - She will identify individuals with hearing loss while filling up the CBAC form. She
will mobilise people for screening camps, mobilise mothers/caregivers for getting their
children screened through RBSK.
PHCO -PHCO will support the ASHA in carrying out screening and awareness generation
activities in the community. PHCO will support the ASHA in carrying out screening and
awareness generation activities in the community.
Community based New born screening at home through PHCOs for new-borns till six
weeks of age, during home visits/immunization sessions.
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8. WORK INSTRUCTIONS FOR SCREENING OF COMMON ORAL PROBLEMS
World Health Organization has defined ‘Oral Health’ as a state of being free from mouth
and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum)
disease, tooth decay, tooth loss, and other diseases and disorders that limit an
individual’s capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing
(WHO, 2012)
• Opportunistic dental screening done by CHO for individuals (18-29 years) who are
not covered under CBAC for NCD screening.
• Oral screening is part of routine health care examination of CHO.
• CHO Coordinate and participate into the outreach activities of PHC. Supportive
supervision or dental care through joint visits with ASHA, where required in order to
motivate people to attend the dental screening days.
• CHO coordinate and participate into the outreach activities of PHC. Supportive
supervision or dental care through joint visits with ASHA, where required in order to
motivate people to attend the dental screening days.
• ASHA Co-ordinate and participate in the outreach activities of PHC/CHC/ District
Mobile dental clinic. Mobilization of community members to attend dental screening
camps or use of Village Days to raise awareness and provide screening services.
• Population based screening for 0-18 years (under RBSK) and those 30 years and
above (through Community Based Assessment Checklist) could serve as an entry
point strategy for identifying common dental problems.
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9. WORK INSTRUCTION FOR SCREENING OF COMMON ELDERLY & PALLIATIVE CARE
Palliative care
As per WHO, Palliative care is an approach that improves the quality of life of patients
and their families facing the problems associated with life-threatening illness, through
the prevention and relief of suffering by means of early identification and impeccable
assessment and treatment of pain and other problems, physical, psychosocial and
spiritual.
Elderly
As per Ministry of Health & Family Welfare, citizens above the age of 60 years are
considered to be elderly.
Screening
Screening for geriatric syndromes an elderly undergoes screening for depression, risk of
falls, urinary incontinence and memory recall.
CHO undertakes the screening with respect to vision, hearing, and change in weight,
constipation and insomnia.
ASHA creates awareness about palliative care, First level screening of patient/families
for potential palliative care needs
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Palliative Care Screeing tool for Community Health Officer/Staff nurse/Medical Officer
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10. WORK INSTRUCTION FOR MANAGEMENT OF EMERGENCY MEDICAL SERVICES
Definition - Emergency medical services
The group of conditions which need immediate medical care and intervention, called as
emergencies, are non-discriminatory as well as time bound; non-discriminatory in the sense
that it can happen to anyone irrespective of age, gender, economic status etc. and time
bound in the sense that most of the emergencies require intervention within one hour also
called as the golden hour. Emergencies that are commonly encountered in the community
may span from accidents and trauma to emergencies arising out of chronic diseases of the
heart or lungs.
Activity at AB HWC
• Conducting initial assessment of the patient to arrive at probable diagnosis and

assess the need for referral
• Provide first-aid care and stabilization before referral to appropriate centers of care
• Administer life-saving drugs/interventions, as appropriate, in acute cases
• Counsel the patient/ caregivers about the presenting condition and probable line of
management
• Timely referral of patients in emergency
• Community follow up of patients discharged after emergency care in referral centers
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11. WORK INSTRUCTIONS FOR INFECTION PREVENTION & BIO MEDICAL WASTE
MANAGEMENT
Infection Prevention
1. Hand washing facilities are available - Washbasin with functional drainage pipe, tap,
running water, Soap (Soap bar/liquid), AHR are available
2. Hand washing poster (Pictorial- Local language) displayed
3. Soap and Alcohol Hand rub available for outreach
4. Staff is trained and adheres to hand washing practices - Five Moments of hand
washing , Six Steps of Hand washing
5. Adequate number of required gloves, mask & apron etc is available & used
6. Disposable Gloves, Cap, Mask are not reused,
7. Staff is aware of method of donning and doffing the PPE
8. Staff is trained for the decontamination and cleaning procedure
9. Staff know how to make chlorine solution
10. Decontamination and cleaning of instruments and surfaces done as per guidelines -
decontamination of instruments is done with 0.5% of chlorine solution for 10 min.
Instrument are cleaned thoroughly with soap or detergent and water.
11. Staff adhere to the process of high level disinfection (HLD) and records are
maintained
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HLD by boiling
Boiling is a simple method of HLD that can be performed in any location that has access to
clean water and a heat source. Using this method, instruments and other items are placed in
a boiler and the water is heated to boiling for 20 minutes.
Steps of HLD by Boiling
Step 1- Decontaminate and clean all instruments and other items to be high-level
disinfected.
Step 2 - Open all hinged instruments and other items and disassemble those with sliding or
multiple parts. Place any bowls and containers upright, not upside-down, and fill with water.
Because water must touch all surfaces for HLD to be achieved, completely submerge all
instruments and other items in the water in the pot or boiler. (Adjust the water level so that
there is at least 2.5 cm (1 inch) of water above the instruments.)
Step 3- Cover the pot or close the lid on the boiler and bring the water to a gentle, rolling
boil.
Step 4 - When the water comes to a rolling boil, start timing for 20 minutes. Use a timer or
make sure to record the time that boiling begins. From this point on, do not add or remove
any additional water, instruments, or other items.
Step 5 - Lower the heat to keep the water at a gentle, rolling boil; too vigorous a boil will
cause the water to evaporate and may damage the instruments and other items if they
bounce around the container and hit the sidewalls and other instruments or items.
Step 6 - After 20 minutes, remove the instruments and other items using dry, high-level
disinfected pickups (lifters, cheatle forceps). Place the instruments and other items on a
high-level disinfected tray or in a high-level disinfected container, away from insects and
dust and in a low-traffic area. Allow to air-dry before use or storage. Never leave boiled
instruments and other items in water that has stopped boiling; they can become
contaminated as the water cools down.
Step 7 - Use instruments and other items immediately or keep in a covered, dry, high-level
disinfected container and use within 72 hours.
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Biomedical Waste Management
1. Adequate number of bins and non-chlorinated plastic bags are available

2. BMW segregation chart displayed at the point of waste generation.
3. Needle/hub cutter & puncture proof boxes are available
4. Segregation of BMW done as per guidelines
5. BMW is not stored for more than 48 hours
6. Sharp waste is stored in puncture proof container
7. Post exposure prophylaxis is available and staff is aware what to do in such condition
8. HWC is mercury free
9. HWC waste is collected & transported in close container
10. No burning of any category of waste within/outside HWC
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WORK INSTRUCTIONS

HEALTH AND WELLNESS CENTRE

Doc No:WI/NQAS/HWC SUDDEKUNTE

DOCUMENT NAME : WORK INSTRUCTIONS

EFFECTIVE FROM : 21.05.2023

QUALITY TEAM HEALTH AND

APPROVED AND ISSUED BY AMO PHC

QUALITY TEAM, HEALTH AND

DOCUMENT AMENDMENT SHEET

SL DATE AMENDMENT REASON PAGE

7. WORK INSTRUCTIONS FOR SCREENING OF ENT PROBLEMS 48

8. WORK INSTRUCTIONS FOR SCREENING OF COMMON ORAL PROBLEMS 51

9. WORK INSTRUCTION FOR SCREENING OF COMMON ELDERLY & PALLIATIVE CARE 53

Prepared by:HWC QUALITY TEAM Approved: AMO PHC UKKALI

10. WORK INSTRUCTION FOR MANAGEMENT OF EMERGENCY MEDICAL SERVICES 56

1. INSTRUCTIONS FOR USING RDK

RAPID DIAGNOSTIC TEST FOR HIV/AIDS

Prepared by:HWC QUALITY TEAM Approved: AMO PHC MUDDENAHALLI

RAPID DIAGNOSTIC TEST FOR HEPATITIS B

RAPID DIAGNOSTIC TEST FOR SYPHILIS

Prepared by: HWC QUALITY TEAM Approved: AMO PHC MUDDENAHALLI

RAPID DIAGNOSTIC TEST (RDT) FOR MALARIA

Prepared by: HWC QUALITY TEAM Approved: AMO PHC MUDDENAHALLI

Prepared by: HWC QUALITY TEAM Approved: AMO PHC MUDDENAHALLI

2. WORK INSTRUCTION FOR RMNCHA SERVICES

RMNCHA - Reproductive Maternal Neonatal Child Health and Adolescent

Care in pregnancy and child birth

Care in pregnancy and child birth

Care in pregnancy and child birth

Family planning, contraceptive services and other reproductive care services

3. WORK INSTRUCTIONS FOR SCREENING, MANAGEMENT AND APPROPRIATE

Visual Inspection using Acetic acid (VIA)

Screening using acetyl salicylic acid

Instruments and materials required

Preparation of 5% acetic acid: Acetic acid is to be freshly prepared everyday:

Procedure of VIA examination

Reporting the Outcome of VIA

VIA negative (-)

• VIA screening is reported as negative in the case of any of the following

VIA positive (+)

• Family History: Risk of Breast cancer increases in women with a first-degree

Algorithm for screening and management of diabetes

Algorithm for management of hypertension

4. WORK INSTRUCTIONS FOR SCREENING, MANAGEMENT AND APPROPRIATE

Prevention of HIV at HWC Level

Following activities are to be undertaken as preventive measures at HWC level:

➢ Promotion of use of Condoms:

➢ Early identification of presumptive TB patients through screening for cough, fever,

Type of TB Case Doses in IP Doses in CP#

Leprosy is a chronic infectious disease caused by Mycobacterium leprae.

Role of HWC-SHC Level in Delivering Services under NLEP

Dengue is a vector-borne viral infection transmitted by female Aedesaegypti mosquito,

Dengue MANAGEMENT AT SHC-HWC LEVEL

➢ In mild DF, only symptomatic care is recommended. Paracetamol tablets as

During referral of DSS patients, carefully follow these principles:

referral including place, accompanying persons, vehicle, possible requirement

Malaria is a protozoal disease caused by Plasmodium and transmitted from person to

Any case suspected for malaria is confirmed by a laboratory diagnosis. Microscopic

Treatment is based on three main factors:

1. The infecting malaria parasite (Plasmodium or Vivax) species

Treatment of Uncomplicated P. vivax Cases

Treatment of Uncomplicated P. falciparum Cases and Mixed Infections (Pv+Pf)