TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N Integrated Management of Childhood Illness ● ● Developed by WHO and UNICEF Combined delivery of essential interventions at Community health systems level. Objectives: 1. Reduced death and frequency of severity of illness 2. And disability. 3. Improved growth and development. Components: 1. Improving case mgt skills of health workers. 2. Overall health systems. 3. Family & Community health practices. Child covered by IMCI: 1. Birth up to 2 months (sick young infant) 2. 2 months up to 5 years old (sick young child) Basis for classifying child’s admission Pink - Urgent Hospital Referral/Admission. 1. Give first dose of antibiotic Ampicillin - q6 if referral isn’t available Gentamicin 2. Treat low blood sugar Breastfeeding 4 teaspoons of sugar 200ml of clean water. 3. Refer Explain the need for referral, to agree Calm fears Write referral note for mom to take the child in hospital Give mother instructions/supplies needed. Yellow - Outpatient Treatment (May go home) 1. 2. 3. 4. Treat local Infection - Amoxicillin, Cotrimoxazole Treat specific - Tetracycline (eye ointment) , Violet Gentian (mouth ulcers) , Quinolone (for ear drops) Advise the mother. Follow up care. Green - Supportive Home Care 1. Counsel mother/Advise Mother - When to return to the health center, What food and fluids to give on the child. 2. Follow up care - Reassess children for new problems. TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N STEPS ON IMCI CASE MANAGEMENT PROCESS Ask the mother what the problem is (child) - 1st Step. 1. Assess/child infant - History Taking/Physical Exam, General Danger signs, Nutrition & Immunization stats, Finish All Q’s even if step you answer that. 2. Classify the illness - Pink/Red, Yellow, Green 3. Identify specific treatments for children - Color classification 4. Treat a child. 5. Counsel mother - When to return to the health center, What food and fluids to give on the child. 6. Give follow up care - reassess the child. General Danger Signs 1. Vomits everything - even breastmilk or little water. 2. Unable to eat/drink. 3. Lethargy/unconscious/unresponsive/abnormally sleepy 4. Convulsions - History of convulsions is not classified as severe. Coughing or Difficult Breathing 1. Any General danger signs 2. Stridor in a calm child 1. Severe pneumonia 2. Very severe pneumonia 1. Give the first dose of antibiotic ampicillin or gentamicin. 2. Refer Urgently to hospital 1. Chest indrawing 2. Fast Breathing <2 mos - 60 breaths/min 2-12 mos - 50 breaths/min 12mos-5yrs - 40 breaths min Pneumonia 1. Give oral amoxicillin for 5 days. 2. Give inhaled bronchodilator for 5 days if wheezing. 3. If coughing for more than 14 days recurrent wheeze, refer for possible TB or Asthma Assessment. 4. Follow up in 3 Days 1. No signs of pneumonia or very severe disease. Cough or cold 1. If wheezing (or disappeared after rapidly acting bronchodilator for 5 days). 2. Soothe the throat and relieve cough with a safe remedy. 3. If coughing/recurrent wheezing refer. 4. Follow up 5 days if not improving. Practice: 1. Any danger signs 2. Stridor in calm child 3. RR of child 12 mos to 5 years 4. Yellow classification 5. Green classification 6. Antibiotic for pneumonia - TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N 7. Antibiotic for severe pneumonia 8. Fast breathing 9. Refer urgently to hospital Classify Diarrhea or Dehydration Two of the following signs: ● ● ● ● Severe dehydration Give fluid for severe DHN PLAN C or ● If a child has Severe classification. Refer urgently to the hospital with mother giving frequent ors otw Advise mother continue BF ● If a child is 2 years old and there’s cholera in your area, give antibiotics for cholera. Some dehydration ● Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly. Skin pinch goes back very slowly. Two of the following signs: ● ● ● ● Restless, Irritable Sunken eyes Drinks Eagerly, Thirsty Skin pinch goes back slowly. ● ● ● ● Not enough signs to classify as some or severe dehydration. No dehydration ● ● Practice: 10. Some dehydration 11. No dehydration 12. Unconscious 13. Plan C 14. Drinks eagerly 15. Sunken eyes 16. Skin pinch goes back slowly 17. Skin pinch goes back very slowly 18. Plan A 19. Not enough signs 20. Pink classification 21. restless/irritable 22. Refer - Give fluid, Zinc supplements and food for some DHN PLAN B If a child also has a severe classification Refer and give him ORS on the way. Continue breastfeeding. Follow up in 5 days if not improving. Give fluid, Zinc supplements and food to treat diarrhea at home PLAN A Follow up in 5 days if not improving. TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N If Diarrhea 14 days or more ● Dehydration present Severe persistent diarrhea ● ● ● No Dehydration Persistent Diarrhea ● ● ● ● Blood in the stool Dysentry ● ● Treat dehydration before referral unless the child has another classification. Refer to the hospital Advise mother on feeding a child who has persistent diarrhea Give multivitamins and minerals including zinc for 14 days Follow up in 5 days. Give ciproflaxacin for 3 days oral Follow-up in 3 days Classify Fever: High or Low Malaria Risk ● ● Any danger signs convulsions, vomits, lethargy or unable to eat. Stiff neck ● Malaria Test positive Very severe Febrile Disease ● ● Malaria ● ● ● ● ● Malaria test negative Other cause of fever present Fever: No malaria ● ● ● ● ● Treat dehydration before referral unless the child has another classification. Refer to the hospital Advise mother on feeding a child who has persistent diarrhea Give multivitamins and minerals including zinc for 14 days Follow up in 5 days. Give one dose of paracetamol Give appropriate antibiotic (culture) Advise mother Follow up in 3 days if you have a fever. If fever is present everyday for 7 days, Refer. TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N If Measles now or Within last 3 months Classify ear problem Classify for anemia Classify for Nutritional status TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N COMMUNICABLE DISEASE - Caused by infectious agents whether bacteria /virus spread from person to person. Contagious - easily transmitted can be airborne/droplet Infectious - not easily transmitted can be blood borne, food borne, STD’s gonorrhea or chlamydia “All contagious diseases are infectious but not all infectious are contagious” Pathogenicity - ability of pathogen to cause a disease. Virulence - Ability to damage a host. TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N CHAIN OF INFECTION Mode of transmission: ● ● ● ● ● ● Vehicle route - Food, water, Blood or non living thing Vector borne - infections transmitted by the bite of infected arthropod species, such as mosquitoes, ticks, triatomine bugs, sandflies, and blackflies. Example: Aedes mosquito - zika - chikungunya virus Example: Anopheles mosquito- filariasis, malaria Example: Culex mosquito - Japanese Encephalitis Airborne - Droplet nuclei, Remain long in air heavy (small particles at 5mm) Droplet - large and short distances (up to 6 ft/2 meters) Thru sneezing for a long period of time on the surface. Direct contact - tissues or fluids, physical transfer through mucous membranes (eyes and mouth) open wounds abraded skin. Indirect - contaminated objects (fomites), unclean hands. TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N Communicable Diseases DIPHTHERIA Causative agent: Corynebacterium diphtheria or Klebbs- loffler Mode of transmission: Droplet especially secretions from mucous membranes of the nose and nasopharynx and from skin and other lesions; Milk has served as a vehicle. Incubation Period: 2 – 5 days SIGNS AND SYMPTOMS: ● Respiratory Diphtheria Ex: Sore throat, Fever Difficulty swallowing Bull neck appearance ● Pathognomonic sign: Pseudomembrane (A thick, gray membrane covering the throat and tonsils.) ● Laryngeal Diphtheria Ex: Gradually increasing hoarseness, cough, stridor Nasal Diphtheria Ex: Clear nasal discharge but every becomes blood stained Cutaneous Diphtheria Skin ulcers commonly in the legs. ● Diagnostic test: ● ● ● Nose/throat swab Moloney’s test – a test for hypersensitivity to diphtheria toxin Schick’s test – determines susceptibility to bacteria Interventions: 1. Isolate the child until two negative nose and throat culture are negative (24 hours apart) 2. Bed rest is necessary (except for nasal diphtheria) 3. Oral hygiene (warm mouth wash, NEVER TOOTHBRUSH) Prevention: ● Active immunization: DPT immunization ● Passive immunization: Anti-toxin Drug-of-Choice: Erythromycin 20,000 - 100,000 units IM once only Complication: MYOCARDITIS, Respiratory, Airway obstruction. TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N PERTUSSIS (WHOOPING COUGH) Three stages: 1. Catarrheal or Prodromal stage: ● 7-14 days ● Mild fever, headache, colds ● Persistent cough 2. Paroxysmal stage (Spasmodic or whooping stage) ● 14-28 days ● Paroxysmal cough (Several sharp coughs in one expiration, followed by deep inspiration, which ● may be accompanied by. Whoop) ● Cough is worse at night ● Anorexia 3. Convalescent stage: ● Lasts 21 days ● Less cough and vomiting Diagnostic Test: Bordet-gengou agar test - is an enriched, casein peptone medium with potato infusion and glycerol to supply the nutrients necessary to support the growth of B. pertussis. Defibrinated sheep blood supplies additional nutrients and enables the detection of hemolytic reactions, which aid in the identification of B. Management: ● Drug of choice: Erythromycin or Penicillin 20,000 - 100,000units ● Isolation and complete bed rest ● For paroxysmal stage: Avoid dust pollutants, oxygenation, calm atmosphere ● Watch out for airway obstructions Prevention: • Active immunization: DPT immunization • Booster: 2 years and 4-5 years • Patient should be segregated until after 3 weeks from the appearance of paroxysmal cough • Passive immunization: Gamma globulin IgG No toxins TETANUS “Lockjaw” ● ● ● ● Etiologic agent: Clostridium tetani – anaerobic spore-forming heat- resistant and lives in soil or intestine Neonate: umbilical cord Children: dental caries Adult: puncture wound; after septic abortion Mode of transmission: Indirect contact – inanimate objects, soil, street dust, animal and human feces, puncture wound Incubation Period: Varies from 3 days to 1 month, falling between 7– 14 days Signs and symptoms ● Convulsion is the first warning symptom among children ● Restlessness and irritability TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N ● ● ● ● ● Muscular stiffness progresses Trismus : Tight jaw, inability to open mouth Stiff arm and legs, then whole body Resus sardonicus: Facial muscle spasm Opisthotonus: Backward arching of the back as a result of dominance of extensor muscles of the spine, head draws back. No specific test, only a history of puncture wound Treatment: ● Antitoxin anti tetanus serum (ATS) ● Tetanus immunoglobulin (TIG) (if the patient has allergy, should be administered in fractional doses) ● Antibiotics (Penicillin G) ● Diazepam – for muscle spasms Prevention: ● Active immunization: DPT immunization ● Tetanus toxoid (artificial active) immunization among pregnant women ● Passive immunization: Tetanus immuno-globulin or antitoxin Poliomyelitis “Infantile paralysis” ● ● ● ● Causative agent: Poliovirus (Legio debilitans) Man is the only reservoir Mode of transmission: Fecal – oral Incubation period: 5-14 days Signs and symptoms: Abortive Poliomyelitis ● Upper respiratory tract infection symptoms ● Fever, Headache, Vomiting Non-Paralytic polio ● Stiffness of neck, back and limbs ● Nausea and vomiting ● Increase protein in CSF Paralytic Polio ● Spinal: Paralysis appear within a day or two after above manifestations; Limb paralysis most common; chest, diaphragm, bladder and bowel paralysis may also occur. Bulbar Polio ● Life threatening; swallowing problem and regurgitation; aspiration may occur; Encephalitis Diagnostic test: CSF analysis / lumbar tap Management: ● Rehabilitation involves ROM exercises ● Symptomatic Prevention: ● Active immunization: OPV, IPV vaccination (Trivalent poliovirus vaccine) Sabin: Attenuated; Orally Salk: Killed virus; Injection TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N ● Passive immunization: Gamma Globulin MEASLES “Morbilli Rubeola” ● ● ● ● Causative agent: RNA containing paramyxovirus Period of Communicability: 4 days before the appearance of rash to 5 days after rash appearance Mode of transmission: Airborne -droplet secretions from nose and throat Incubation period: 10 days – fever ;14 days – rashes appear (8-13 days) Coryza Common colds and occur before rash appearance Fever (Highest just before the appearance of the rash) Barking cough Conjunctivitis and photophobia; Enlarged posterior cervical lymph nodes Koplik’s spots: Appear on day before rash. Whitish spots with reddish base on the inside of the mouth Rash: Appears on 2nd to 5th day and remain about a week Appears first on the face, behind the ears, on the neck, forehead or cheeks then spread downwards over the rest of the body (Trunk, arms, legs) Itchy rash No specific diagnostic test Management: • Isolation and bed rest. • Supportive and symptomatic • Eye care with warm saline solution • Antipyretics for fever; Encourage fluids • Mouth care for Koplik’s spots Prevention: • Active immunization: Live attenuated vaccine • Passive immunization: Newborn through the mothers; Gamma globulin • Disinfection of soiled articles Isolation of cased from diagnosis until about 5-7 days after onset of rash MUMPS ● ● ● ● Etiology: Paramyxovirus Incubation Period: 14-21 days Communicability Period: One to six days before the first symptoms appears until swelling disappears Mode of transmission: Droplet; Direct or indirect contact Prodromal Phase: ● Coryza ● Low grade fever ● Vomiting, headache, malaise TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N Acute Phase: ● Pain in or behind ears; Pain on swallowing or chewing ● Swelling and pain in glands (unilateral or bilateral) ● Orchitis and mastitis may occur Complication: Sterility Management: ● Symptomatic treatment ● Isolation and bed rest until swelling disappears ● Encourage fluids and soft foods ● Apply hot or cold compress for swelling. ● Orchitis: Support scrotum, use cold compress for 20 minutes. Prevention: ● Active immunization: Live attenuated vaccine ● Passive immunization: Gamma-globulin CHICKEN POX ● ● ● ● Etiologic agent: Varicella-zoster virus Period of Communicability: From as early as 1 to 2 days before the rashes appear until the lesions have crusted. Mode of transmission: Airborne Incubation Period: 2-3 weeks, commonly 13 to 17 days Prodromal stage: ● Mild fever, anorexia, headache Acute Phase: Vesiculo-pustular rashes ● Centrifugal appearance of rashes – rashes which begin on the trunk and spread peripherally and more abundant on covered body parts Pruritus No specific diagnostic exam ● Treatment is supportive. ● Drug-of-choice: Acyclovir / Zovirax ® (orally to reduce the number of lesions; topically to lessen the pruritus) ● To relieve itching, antihistamine, or calamine lotion. ● Cool sponge bath. Mittens may be used to avoid scratching ● Keep in isolation until lesions have been crusted. ● NEVER give ASPIRIN. Aspirin when given to children with viral infection may lead to development of REYE’S SYNDROME. TOP RANK REVIEWER SUMMARY BY RESURRECCION, CRYSTAL JADE R.N GERMAN MEASLES “Rubella” ● ● ● ● ● Causative agent: Rubella virus or RNA containing Togavirus (Pseudoparamyxovirus) Teratogenic infection can cause congenital heart disease and congenital cataract. Mode of transmission: Droplet, Direct/ Indirect contact Incubation Period: 14-21 days Communicable Period: During Prodromal period and 5 days after the rash. Prodromal stage: ● Mild fever (Disappears when rash appear) ● Malaise, headache, anorexia ● Runny nose, sore throat ● Forscheimer spots – red pinpoint patches on the oral cavity ● Faint maculopapular rashes. Small pinpoint pink or pale red macules which fades on pressure. ● Enlargement of posterior cervical and postauricular lymph nodes Diagnostic Test: Rubella Titer (Normal value is 1:10); below 1:10 indicates susceptibility to Rubella. ● Instruct the mother to avoid pregnancy for three months after receiving the MMR vaccine. ● MMR is given at 15 months of age and is given intramuscularly. Prevention: ● MMR vaccine (live attenuated virus) - Derived from chick embryo ● Contraindication: Allergy to eggs