FIRST PART

HOSPITAL GUIDELINESCottolengo Mission Hospital, Chaaria (Kenya)

FOREWORD

Cottolengo Mission Chaaria was founded in 1984 by the congregation of the St. Joseph Cottolengo brothers under supervision of brother Lodovico Novaresio

In the beginning it was a home for disabled boys, together with a busy dispensary. After the arriving of brother and doctor Giuseppe Gaido, the mission grew over time to a hospital where nowadays the patients find it worth, to travel far for.

The developing and maintenance of the hospital did not only depend on the contribution of sponsors, the Cottolengo congregation and the local staff but the most contributing factor of this all is the endless dedication of the missionaries.

LOVE BELONGS TO THOSE WHO THINK OF OTHERS..Claire Nolte

TABLE OF CONTENT

General information: Glossary of Abbreviations:Frequently used medication:Laboratory:

INTRODUCTION

The manual is intended to provide guidelines for the treatment of common diseases and problems seen at Cottolengo Mission Hospital, to set out hospital treatment policy, and to establish standards of care. But as there will always continue to be changes and developments in the practice of medicine, comments and suggestions are welcome.

This is not a textbook; reference books must be consulted for further information.

All the drug dosages listed have been checked, but these should be confirmed before use.

PRESCRIBING GUIDELINES:

The drug formulary at Cottolengo Mission Hospital is based on the use of essential drugs, a limited number of safe, effective and cost-effective medications for the treatment of the common diseases seen here.

Oral medication should be used whenever possible; both the cost and the risks are greater with parenteral drugs. Injections should be reserved for patients unable to take oral medicines, and changed to oral as soon as possible.

WEEKLY ACTIVITIES: Thursday at 8 AM: Lesson by Dr. Gaido Sunday at 9 AM: Mass for staff and patients Every 1st Wednesday of the month at 8 AM: Mass for staff

GLOSSARY OF ABBREVIATIONS:

ARV = Anti-retroviral drugsATT = anti-tetanus toxoidCXR = Chest X-rayBPH = Benign Prostate HyperplasiaCCF = congestive cardiac failureCO review = Clinical officer to reviewCS = Caesarean sectionD = DischargeDD = Differential DiagnosisDIB = Difficulty in BreathingDr’s review = doctor to review the patientEUA = Examination under AnesthesiaGBM = General Body MalaiseHOB = Hotness of BodyHSD = Half strength Darrows solutionHTN = HypertensionI&D = Incision and drainageIPD = In Patient DepartmentMU = Mega Unit

LOCATION INFORMATION

Room 26: Female Room 28: Male Room 19: Pediatric Room 20: Maternity Room 23: post-operation Male Room 22: Post-operation Female Room 9: Clinical Officers Laboratory: Down the hall Discharge: Down The premises HIV/TB clinic: Down the premises Physiotherapy: Center

STAFF INFORMATION:

Dr. Gaido (Beppe) Dr. Ogembo Anesthetist: Jesse Head Nurses: Sr Florence Clinical officer: Kaberia Clinical officer: Nyaga HIV/TB Counselor: Mutthuri Store manager: Kathira Theater manager: Makena Laboratory manager:

Mugambi & Justus Maintenance: Br Lorenzo

PUD = Peptic Ulcer DiseasePID = Pelvic Inflammatory DiseaseNGT = Naso-Gastric TubeOGD = Gastro-scopyOPD = Out Patient DepartmentPOP = PlasterPCP = Pneumocystis PneumoniaPMCT = prevention of mother to child transmission of HIVPOD = Post Operation DayUS =UltrasoundUTI = Urinary Tract infectionWHO = World Health organization

FREQUENTLY USED MEDICATION

SCHEDULE:OD Once Daily (1x)BD Twice Daily (2x)TDS Tree times Daily (3x)QID Four times Daily (4x)STAT One time / Right nowx/7 X 7 daysx/52 X weeksx/12 X 1 month

Some Antibiotics availableAmoxicillin 500 mgAmpiclox 500 mgCAF 250 mgCloxacillin 250 mgDapsone 100 mgDoxicyclin 100 mgErytromycin 250 mgFlagyl 200 mgNitrofurantoin 100 mgSeptrin 960 mgTetracycline 250 mg

Some Cardio-vascularAldactone 25 mgAldomet 250 mgCardiasa 100 mgDigoxin 0.250 mgFrusemide 40 mg

HCTZ 50 mgNifedipine 20 mgPropranolol 40 mg

Pain managementBrufen 400 mgBuscopan 10 mgB-complexDiclofenac 50 mgParacetamol 500 mg

SteroidsDexamethasone 0.5 mgPrednisolon 5 mg

BronchodilatorsAminofillin 100 mgPhenobarbitone 30 mgVentolin 4 mg

Sedatives/anti-histaminesDiazepam 5 mgPrometin 25 mgPirition 4 mgLaroxil 25 mgLargactil 100 mgSerenase 1.5 mgAmitryptiline 25 mg

SupplementsFerrous 200 mgFolic acid 5 mgMulti-vitaminPyridoxine (Vit B6)

DiverseLoperamide 4 mgOmeprazole 20 mgPlasil 10 mg

Oral Anti-malarialsAl (coartem) TabsQuinine 200 mg Tabs

ARVLamivir (stavudine, lamivudine)Trio (stavudine, lamivudine, nevirapine)

NVP (nevirapine) 200 mgEfavirenz 600 mg

IV/IM MEDICATION

Diclofenac 75 mg (to be given IM) Quinine 600 mg (in dextrose 5%) NB Diabetes Mellitus in NS Lasix 20 mg Buscopan 10 mg Plasil 10 mg (to be given in 100 ml H2O) Zantac 50 mg (to be given in 100 ml H2O) Dexamethasone 4 mg Hydrocortisone 100 mg Diazepam 10 mg Phenobarbitone 60 mg Gentamicin 80 mg Aminophilline 250 mg Ceftriaxone 1 gr CAF = Cloramphenicol Sodium Succinate X PEN = Benzylpenicillin Sodium PPF = Fortified Procaine Penicillin 4 MEGA UNITS (to be given IM)

COMMON LABORATORY TEST:AAFB (2x) Sputum for TBkIDNEY Creat, UreaBrucella test BrucellosisBS for MPS MalariaElectrolytes Na, K, ClFHG Full HaemogramHb HaemoglobinLiver function tests SGOT, SGPT, Billirubine (T&D)No3 HIVRBS Random Blood sugarRF Rheumatoid factorStool for O/C Stool-testUrine analysis Urine analysisWidal Typhoid-test

NORMAL LABORATORY VALUES

HaematologyWBC (white blood cells) 3.5-10.5 (x 103 ul)SW (LYMPH) 1 – 3 (x 103 ul) 20 – 40 %MW (MONO) 0.2 – 1 (x 103 ul) 2 – 10 %LW (GRAN) 2.5 – 7.5 (x 103 ul) 41 – 85 %

RBC (red blood cells) 4.5 – 5.5 (x 103 ul)

HB (Haemaglobine) 11.5 – 16.5 (g/dl) 12.5 – 17.5 %HCT (Haematocrit) 40 – 54 % 37 – 47 %MCV 80 – 110 FLMCH 27 – 32 pgMCHC 31.5 – 34.5 g/dlRDW 11.5 – 15 %lPLT 140 – 440 (x 103 ul)

BiochemistryBLOOD SUGAR (Random) 6.5– 11.1 mmol/lUREA 35 – 125 mmol/lCREATININE 1.7 – 8.3 mmol/l

ElectrolytesCHLORIDE (CL) 90 -105 mmol/lPOTASSIUM (K) 3.5 5.5 mmol/lSODIUM (NA) 135 – 150 mmol/l

Liver function test:BILIRUBINE (TOTAL) < 1.1 mg/dlBILIRUBINE (DIRECT) <0.3 mg/dlSGOT <37 iu/lSCPT <45 iu/l

CARE OF THE SURGICAL PATIENT

Pre-operative care: Take complete history, examination. Check:

o Hbo RBSo No3o BP

Anemia: Transfuse two units if below 8 g/dl Correct dehydration and acid/base balance Inform Anaesthesist (Jesse) Consent Fasting from Midnight Ceftriaxone 1 gr STAT Green blannula 1 Litre NS Shaving + Catheter

Post-operative care: IV X-pen (QID) 2/7 IM PPF (OD) 5/7 IM Gentamicin 160mg (OD) 7/7 Pain management:

o 5% Dextrose 500ml + Pethidine 50mg 2/7 (NOCTE)o NS 500ml + Pethidine 50mg 2/7 (DAY)o Voltaren 150 mg PRN

In most cases stitches to be removed alternate on the 7th POD, and all on the 9th POD

A GENERAL APPROACH TO SYNDROMES/SYMPTOM COMPLEXES

Gastrointestinal presentations

Dysphagia:Significant recent-onset dysphagia should always raise the possibility of oesophageal carcinoma.Oesophageal candidiasis (AIDS-related) is also a common cause.

Abdominal Pain: Abdominal tuberculosis Typhoid Hydatid cyst rupture Amobiec colitis Amoebic liver abscess Intestinal obstruction Sickle cell crisis Splenic rupture

Malabsorption:Malabsorption can be a feature of infection with giardia lablia, strongyloides stercoralis, intestinal TB infection, as well as AIDS

ASCITES No tapping, unless there is pulmonary failure

o Don’t exceed > 2 Liters of tapping.

o Albumine infusion not available

DRESSING

Amputation:The dressing treatment consists first in a wash out with Normal Saline solution, putting sterile gauzes with Betadine and than a semi compressive closure with elastic bandages.

Not infective ulcerarations: Rains with Normal Saline solution Rains with Betadine solution Removal of the dead tissue In absence of special creams that stimulate the vascular and tissue regeneration, test the

effectiveness of sugar used in association with Betadine

ANAEMIASymptoms: Tachycardia General body malaise / weakness Pale looking Splenomegaly

Diagnosis: Malaria Malignancy Chronic disease Acute bleeding Hookworm

Treatment: Hb < 5.5 g/dl OR symptomatic:

o Transfusion Hb > 5.5 g/dl:

o Ferrous 200 mg TDS 1/12o Folic acid 5 mg OD 1/12

TREAT THE CAUSE

BRUCELLOSIS

Symptoms: Chronic fever Sweating Joint pain / backache Splenomegaly

Diagnosis: Brucella (BAT = Brucellosis agglutination test) Rule out: Malaria, TB, HIV/AIDS

Treatment: Doxycline 100mg BD 6/52 Streptomycin (20mg/kg) OR gentamycin (7mg/kg) 2/52 In pregnant females treat with:

o Septrin 960 mg BD 3/52o Streptomycin (20mg/kg) OR Gentamycin (7mg/kg) OR Rifampicin (300mg BD) 3/52

Grazie a Claire Nolte

(continueremo la pubblicazione di queste brevi note che speriamo siano utili come pocket manual, sia agli infermieri che ai medici che si preparano al volontariato a Chaaria)

Fr Beppe