IMCI Integrated Management of Childhood IllnessBy: Apple G. Alvarez, RN, MN

Started in

1992 particularly by the UNICEF,WHO, DOH and AUSAID

Strategy Reducing

Childhood Illnesses Mortality Morbidity

Mortality Death of large numbers Number of deaths in a given place or locality

Morbidity Rate of incidence of disease

Integrated Management of Childhood Illness (IMCI)Birth 1 week 2 monthsPregnancy

5 years

IMCI case management guidelines

Why 1 week to 2 months up to 5 years? First week of life Labor and Delivery

Special Management

IMCI again... CASE MANAGEMENT PROCESS

First-level facility

Guidelines How to? Care brought to a clinic Illness Scheduled follow up visit to check the childs progress.

Guidelines INCLUDES:1. Instructions (routine assessment) 2. Treatment 3. Basic Activities Illness Prevention

4. Do not describe management of trauma Other acute emergencies due to accidents or injuries

4. If sought an untrained provider Too late for assessment Death! Teaching IMPORTANT > Case Process

TAKE NOTE: Understandable terms In shaking the child - GENTLE

Second hand watch.

UNDRESS the child LongitudinalPinching of the abdomen

2 months SPOON 6 months with acup

If sunken eyes - ASK if USUAL

Malaria Risk Area Davao Del Norte Davao Oriental Sarangani Sultan Kudarat

Petechiae Folds Thigh

Use pediatric cuff tourniquettest

New EPI Administrative Order BCG Hepatitis B 1st dose Before Discharge

Iodine Deficiency = Iodized Salt Anemic Pregnancy= Iron Supplement

Vit. A Deficiency =Micronutrients

Second Line =Availability of drug

Oresol Home made solution 1 teaspoon of salt 4 teaspoons of sugar 1 liter of water

Fully Immunized before 12 months of age BCG 1 DPT 1 DPT 2 DPT 3 OPV 1 OPV 2 OPV 3 HB 1 HB 2 HB 3 Measles

Problems why IMCI exist?1. The under five population is the most vulnerable group 2. Child mortality remains UNACCEPTABLY HIGH 3. Many of these deaths had no medical attendance or being seen by first level health facilities

4. First-level facilities: - undermanned/underpaid - HWs are not appropriately TRAINED - drug supply inadequate/not properly managed - inaccessible - poor laboratory support

5. Family and community profile/ practices - late help seeking behavior - poor utilization of health facilities - literacy - traditional beliefs/traditions - economic - large families - crowded, dense, polluted environment

IMCI - OBJECTIVES1. To reduce SIGNIFICANTLY global

mortality and morbidityassociated with the major causes of disease in children

2. To contribute to healthy growth and development of children

A must to take note:

TRAINING DESIGN toteach integrated management of sick infants and children to first level HWs in primary care settings that have NO laboratory support and only a limited number of essential drugs.

Action oriented CLASSIFICATIONS , rather than EXACT DIAGNOSES, are used.

A careful balance has been struck between SENSITIVITY and SPECIFICITY

Using FEW CLINICAL SIGNS as possible which health workers of diverse background can be trained to recognize

The IMCI guidelines rely on detection of cases based on SIMPLE CLINICAL SIGNS, without laboratory tests, and offer EMPIRIC TX

COLOR CODING

PINK

Severe URGENT PRE REFERRAL Hospital/Treatment

YELLOW

With

Moderate Needs

Management Rural Health Unit Specific Medical Treatment Advice

GREEN

Mild

Home Care Simple Advice

5 steps in IMCI case management1. 2. 3. 4. 5. Assess and Classify Identify Treatment Treat Counsel the Mother Follow Up

ASSESS Left side column how to take a history and do a physical examination

CLASSIFY Decision

severity of

ILLNESS

IDENTIFY TREATMENT To quickly identify treatment for the classifications Written on your case recording form.

Case Recording Form

Documentation! At the back of the form After assessment

IMPORTANT BEFORE ASSESSMENT st 1

Know which the child age belongs 1 week up to 2 months 2 months up to 5 years

nd 2 Name Age in months Weight in kilograms Temperature and etc.

Remember! Mothers knows best!

3rd

Initial Follow Up

Initial visit 1st

VISIT

Episode of Illness

Follow up visita few days ago for the same illnessCondition improved or still the same Seen

THE CASE PROCESS

I. Assess for the 4 GENERAL DANGER SIGNS Not able to drink Severe Vomiting Convulsions Abnormally Sleepy

Not able to drink If the child is: Too weak to drink Not able to suck/swallow when offered a drink/breastfeed

If the nurse is not sure upon assessment ASK THE MOTHER to offer a child to drink (clean water/breast milk) IMPORTANT: Check if the childs nose is

blocked! POOR SUCKING

Severe Vomiting EVERTHING!!

Convulsions DURING THE ILLNESS Arms and legs stiffening! Jerky Movements Loss of consciousness even if eyes are open SHIVERING !!! not a convulsion

Abnormally Sleepy Drowsy Not interested with surroundings Stares blankly No response - - even when TOUCH, SHAKEN or SPOKEN to.

If child is asleep and has COUGH or DIFFICULT Breathing, it is essential to: Count the number of breaths BEFORE waking up the CHILD Why? So it is easier to get the accurate breathing rate.

In cases, there are presences of ANY danger signs - - as in ANY...

Complete

Assessment Form

Pre referral treatment immediately! REFERRAL is not delayed!

II. Assess for COUGH / DIFFICULTY in BREATHING1. In breathing LOOK and LISTEN to STRIDOR Harsh noise when the child BREATHS IN

2. In cough HOW LONG? Chronic? More than 30 days

Rules 1-4 Count

BREATHS per minute

CHILD - - quiet and calm Do not count . . . .! Ask the mother - -> Lift the childs shirt

Fast BreathingIf the child is Fast breathing is:

1 months -12 months 50 breaths/minute or more 12 months- 5 years 40 breaths/minute or more

Is there breathing IN or OUT?NORMAL The whole chest wall and abdomen move OUT when the child breaths IN CHEST INDRAWINGThe LOWER CHEST WALL goes IN when the child BREATHS IN

Best Position to Check Lying down

Stridor means.. Harsh Noise Breathing IN Swelling of the: Larynx Trachea

Epiglottis

How to check for STIDOR?

The nurse must PUT her ear near the childs MOUTH While breathing IN and OUT Harsh noise while BREATHING OUT NOT A STRIDOR!

III. Assess for DIARHEA

IMCI definition : DIARRHEA 3 or more loose or watery stools in a 24 hour period

Questions to ask.. How long? Blood in the STOOL? Signs of DEHYDRATION?

If there is DIARRHEA Further assessment includes: Dehydration Persistent Diarrhea 14 days or more

Dysentery

Dysentery Infection of the intestine marked by severe diarrhea , usually of the lower intestinal tract

If suspected DEHYDRATIONCheck if there are signs like:

Abnormally sleepy/difficult to awaken Restless and irritable ALL THE TIME! AS IN

Sunken eyes

If the nurse is not sure, please ask the MOTHER if the manifestation is usual to the childs appearance.

Offer the child fluid - - with a CUP or a SPOONNot able to drink Not able to take fluid in mouth and swallow

Drinking poorly

If weak and cannot drink without help

Drinking eagerly, thirsty

Reaches out for the water offered

Pinch the skin of the abdomen

Skin goes back VERY SLOWLY Skin goes back SLOWLY

Longer than 2 seconds Stays for a BRIEF TIME after release

IV. Assess for FEVER

IMCI definition : FEVER History of fever no present fever but had fever within 72 hours

Feels HOT Axillary temperature =

37.5c

Checking on Malaria Risk Been in places with malaria in the past 4 weeks Look/feel for STIFF NECK If child bends/moves neck easily as he looks around Draw the childs attention to his TOES

Gently support BACK and BEND the HEAD forward to his CHIN Look for RUNNY NOSE not HISTORY of runny nose! Look for SIGNS Of MEASLES

Signs of Measles Generalized rash Any: cough, runny nose, red eyes Measles rash - behind the EARS, NECK, spreads to the face and to the rest of the BODY No vesicles or pustules no itchiness!

And if there was MEASLES now or WITHIN the last 3 months

ASSESS FOR:1. Mouth ulcers painful (inside of the mouth, lips or tongue) 2. PUS draining from the eye 3. Clouding of the cornea (hazing of the cornea)

Assess for DENGUE HEMORRHAGIC FEVER1. Only to those who are 2 months of age or older

2. Look for signs of BLEEDING/SHOCK: Bleeding from the nose & gums Skin petechiae Small hemorrhages in the skin Small dark spots/patches in the skin Not raised Not tender Not lose its color when the skin is stretched

3. Cold and clammy extremities Check for slow capillary refill (longer than 3 seconds)

4. Tourniquet Test! Done: when there are no signs in the ASK/LOOK and FEEL Is 6 months Fever is present more than 3 days

How is tourniquet test done? Rumpel-Leede CapillaryFragility Test Based on counting petechiae in a given area of the arm A blood pressure cuff is applied and inflated to a point between the systolic and diastolic blood pressures

Positive more than 20 petechiae per square inch - - caused by a minor hemorrhage). After application of the rubber cuff sphygmomanometer 5 minutes.

IV. Assess for EAR PROBLEM