بروتكول imci مهم جدا

[الطبيب العام]

السلام عليكم ورحمة الله وبركاته
تحيه الى الجميع ,,
الموضوع هنا يخص الاطباء بالدرجه الاولى اولئك الذين يعملون في العيادات
موضوعنا اليوم يتحدث عن
برنامج العلاج الكامل والمثالي للاطفال
هذا البرنامج هو عباره عن برنامج توصي به منظمه الصحه العالميه
ويتم تعليمه لكافه الاطباء العاميين وكذلك اخصائي الاطفال
البرنامج يعطى على شكل دورات لمده لاتزيد عن 11 يوما
الهدف من البرنامج
- هو حصر الامراض الخطيره للاطفال في العيادات ومتى يتم تحويل الحاله الى المستشفى
- علاج الاطفال في كافه العيادات بنفس الطريقه مما يوفر الجهد والوقت لدى الاطباء في العيادات والمستشفيات.
ينقسم البرنامج الى اربعه اجزاء
- الجزء الاول : تصنيف وتقيم حالات الاطفال المرضى من عمر اسبوع وحتى شهرين
- الجزء الثاني : تصنيف وتقيم حالات الاطفال المرضى من عمر شهرين وحتى عمر الخمس سنوات
- الجزء الثالث : معرفه العلاج
- الجزء الرابع : طريقه العلاج
الجزء الخامس : المتابعه لحاله الطفل بعد العلاج
الموضوع من منظمه الصحه العالميه تجدوه على هذا الرابط
http://www.who.int/child_adolescent_health/documents/9241546441/en/index.html
Integrated Management of Childhood Illness (IMCI)
والكتب الي بنتعلم منها هنا هما 7 كتب
Introduction
Assessand classifythe cick child from 2 mounth up to 5 years
Identify treatment
Treat the child
advise to mother
Manegment of sick young infant age up to 2 mounth
Follow up
والبروتوكول خاص بالاطفال تحت خمس سنين
وبيركز علي اهم الامراض الي بيتعرض لها الاطفال في الفئة العمرية
وبتبقي الاساس في الفحص والمقارنة
زي الpnumonia
Diarrhea
وال dehydration
و الthroat problem
بسبب الrhumatic fever
و الmeasels
وكمان من اساسيات البروتوكول الfever
Ear problems
Amaemia
Feeding problem
يعني نقريبا بيغطي 80 في المية من حالات الاطفال واي شكوي اخري بتتكتب في
مشاكل اخري
الاهداف
من اهمها المحافظة علي صحة الطفل
الوصول لاصح وافضل توصيف لحالة الطفل
الفحص الشامل للطفل
الترشيد في استخدام الادوية والمضادات الحيوية
متابعة الطفل
توعية الام
وبنمشي عليها في الشغل وفحص الاطفال
واي كتابة في الاستمارات بتبقي بالرصاص
وليها قواعد
زي مثلا سن الاطفال من شهرين لخمس سنين بيحسب بالشهر
والشهور الكاملة فقط
وزن الطفل بيتكب لاقرب 100 جرام
درجة الحرارة axilarry
وبتتكتب زي ماهي
اسم الطفل ثلاثي
وشكوي الطفل علي حسب كلام الام فقط
وبيبقي سؤالنا اية مشكلة الطفل ونكتب الي بتقولة فقط
من غير ما نسال بس فية تاني وغيرة من الاسئلة الي ملهاش لازمة
ولو سالت علي حاجة من الشارت وطلعت الام مش فاهماها بعتبرها مش موجودة
يعني مثلا هل الطفل اتشنج اثناء فترة المرض لو قالت اية او يعني اية
او مش عارفة تبقي زي ماهي بالضبط
نحكي بالانجليزي علشان نفهم
This is an innovative approach which was started in 1995 by WHO and UNICEF with the aim of introducing a comprehensive
and timely management of the 5 most common causes of ill health and death among the under-fives.
These illnesses are:
Pneumonia;
Diarrhoea;
Malaria;
measles;
malnutrition.
2.2 WHY DO WE NEED TO HAVE AN INTEGRATED APPROACH?
The evidence that a large proportion of childhood morbidity and mortality in the development world is caused by just five conditions is really not enough justification for an integrated approach. However, most sick children present with signs and symptoms related to more than one of these conditions.
This overlap means that a single diagnosis may neither be possible nor appropriate (see Table 1.1).
Treatment of childhood illness may also be complicated by the need to combine therapy for several conditions. An integrated approach to managing sick children is, therefore, indicated, as is the need to go beyond single diseases and address the overall health of a child.
Therefore, the IMCI strategy combines improved management of childhood illnesses with aspects of nutrition, immunization, and several other important influences on child health, including maternal health. The IMCI strategy aims at reducing death, and frequency and severity of illness and disability, by integrating treatment and prevention of major childhood illnesses, to contribute to improved growth and development.
Table 1.1 Diagnosis of common childhood diseases
For many sick children a single diagnosis may not be apparent or appropriate.
Presenting complaint
Possible cause or associated condition
Cough and / or fast breathing
Pneumonia
Severe anaemia P.Falciparum malaria
Lethargy or unconsciousness
Cerebral malaria
Meningitis Severe dehydration Very severe pneumonia
Measles rash
Pneumonia
Diarrhoea Ear infection
Very sick young infant
Pneumonia
Meningitis Sepsis
IMCI Case Management
IMCI case management requires you to have a well-defined set of knowledge and skills so that you can accurately assess, classify, and treat ill children and, thereby, reduce mortality and avert significant disability (Figure 2.1). Case management relies on case detection using simple clinical signs and empirical treatment. As few clinical signs as possible are used; these signs strike a careful balance between sensitivity and specificity.
الى جديد ان شاء الله في القريب العاجل
تقبلوا تحياتي

[الطبيب العام]

The complete IMCI case management process involves the following:
The health worker assesses a child by checking first for danger signs, asking questions about common conditions (cough or difficult breathing, diarrhoea, fever, and ear problems), examining the child, and checking the nutrition and immunization status. The health worker also assesses the child for other health problems.
The health worker classifies a child’s illnesses using a classification chart. Many health workers are familiar with this system from experience with the WHO case management guidelines for diarrhoea and acute respiratory infections. Because children often have more than one condition, the health worker classifies each illness according to whether it requires urgent pre-referral treatment and referral, specific medical treatment and advice, or simple advice on home management.
After classification, the health worker identifies specific treatments and develops an integrated treatment plan for each child. If a child requires urgent referral, the health worker gives essential treatment before the patient is transferred. If a child needs treatment at home, the health worker
gives the first dose of drugs to the child.
The health worker provides practical treatment instructions, including advising the caretaker on how to give oral drugs, how to feed and give fluids during illness, and how to treat local infections at home. The health worker asks the caretaker to return for follow-up on a certain date, and teaches them how to recognize signs that indicate that the child should return immediately to the health facility.
If a child is underweight, the health worker identifies treatment or refers the child, when appropriate. The health worker also provides counselling to solve feeding problems, including assessment of breastfeeding practices. If a child should be immunized, the health worker gives immunizations.
When a child is brought back to the clinic as requested, the health worker gives follow-up care and, if necessary, reassesses the child for new problems.
Remember, in order to apply IMCI case management process properly you need to learn the skills from a trained IMCI facilitator.
Attached to this unit, is the IMCI chart booklet. This booklet gives guidelines on the following:
assessment,
classification,
identification of treatment of sick under fives and
treatment
Counselling of caretakers.
I am sure you have seen posters with these guidelines in your health facility. It is important to have these guidelines nearby so that you can apply them correctly in the management of childhood illnesses in your health facility.
Various modes of training health workers in IMCI have been adopted by the MOH. These include:
Regular 11 day training as stated above.
On job training. This is done in a health facility by a trained health worker transferring skills to untrained colleagues. This is the method you should use to acquire skills by learning from someone already trained.
Distance learning using computer based training modules. When taking a distance learning course, you will still need to contact the person in charge of IMCI in the district headquarters or in your hospital to help you acquire practical skills on IMCI case management.
During this training, health workers are taught how to assess children using the IMCI strategy.
How do we assess children using IMCI strategy?
In IMCI we assess children for a number of things:
1. In IMCI all children are assessed first for the following danger signs:
lethargic or unconscious
Convulsing now
History of convulsions
Vomiting everything
Not able to drink or breastfeed
If you find a child with any of these danger signs, you should managed them quickly and if necessary refer after giving them pre-referral treatment.
2. After the danger signs, children are then assessed for four main symptoms. These are:
Cough and difficult breathing
Diarrhoea
Fever
Ear problem
3. Following these, all children are assessed for malnutrition and anaemia, and for possible HIV infection.
4. Finally all children’s immunization and vitamin A supplementation status is checked. Any missed vaccines are given for children who do not have severe classifications.
This is explained further in Charts 1 to 6 which are attached at the end of this Unit as

[الطبيب العام]

Improvement of Health Systems


The IMCI strategy requires that the health system is strengthened to support the strategy in the following ways:
Ensuring the availability of essential drugs and supplies.
Organization of the hospital emergency area to support rapid evaluation and management of sick children.
Training of health workers in Emergency Triage Assessment and Treatment(ETAT)
Adherence to National policies for standards of care
Availing job aides in critical areas


The next critical step in this component of IMCI is the organisation of the hospital emergency area to support rapid evaluation and management of sick children. Let us briefly look at how this should be done.


Organisation of Hospital Emergency Area

As you are well aware, district, sub-district and provincial hospitals act as referral centres for peripheral health facilities. It is therefore critical that their emergency area is organized to respond to the needs of sick children. The following are important points in the organization of an emergency receiving area:
Triage of sick children should be done by a designated person who may be a health worker, records clerk or even a trained guard. Triaging is a system of sorting out or identifying sick children who need urgent attention so that they can receive prompt management. It can save a life.
Essential emergency drugs e.g. anticonvulsants, dextrose, oxygen; bronchodilators must be available at all times. These should be accessible without the patient having to pay first;
Essential supplies like cannulas, ambu bags, oxygen delivery equipment should be available;
Critically ill children must be attended to without having to undergo registration or any such formality that can cause a delay;
Newborn babies should not be made to wait in queues.
Referrals should always be seen urgently
What is Emergency Triage Assessment and Treatment (ETAT).

As I mentioned earlier, ‘Triage’ simply means sorting out. That is, assigning a person to see that very sick children are seen first and emergencies dealt with immediately. ETAT demands that very sick children should not have to be registered first before they are seen. Also newborn babies who are less than 2 months old should be seen quickly, as sometimes they may die quietly in the queue. Anyone can be trained to do triage, even an askari or records clerk. Having staff trained in ETAT helps to also ensure that the essential drugs and equipment are always available in the emergency area. This way, the scenario depicted in Case study 2 can be avoided.
Another important thing to have in emergency areas is wall charts which give staff instructions on what to do. Examples of these wall charts are:
Charts on resuscitation of children which should be displayed in all emergency areas including wards;
Newborn resuscitation charts which should be in labour ward, nursery, maternity theatre;
Fluid management plans;
Dosages and routes of administration of drugs.
‘

In its efforts to improve the health care of sick children in hospitals, our government has developed a number of policies following the IMCI guidelines. The specific policies that should be followed include the following:
Children should be allowed to stay with a caretaker in the ward;
All children admissions should be given Vitamin A unless they have received a dose within the last one month. Malnourished children with eye signs should receive repeated doses;
All newborn admissions aged less than 14 days should get Vitamin K unless it has already been given;
Newborns should be given Vitamin K and eye prophylaxis at birth;
Immunizations should be given daily to avoid missed opportunities;
Missed immunizations should be given before a child is discharged from the ward;
It is Ministry of health policy that under-fives should not pay for health services.

Policies on the Hospital Environment
Within the hospital environment when children are hospitalised, the following aspects of in-patient care are important:
A child should stay with the mothers or caretaker;
Breastfed children should get breast milk and breastfeeding should be promoted. This means that babies below 6months of age should be exclusively breastfed. Hospital staff should not give these babies any other food. Have you found 3month old baby being given porridge in the hospital? You should discourage this and encourage the mother to practice exclusive breastfeeding;
Children should get feeds that are appropriate and commensurate with their age;
Caretakers should be counselled and educated on their children’s illness;
As much as possible, admissions should receive diagnostic counselling and testing for HIV. Those children who are eligible for ART should be able to access this service;
Psychosocial stimulation is important for children recovering from illness. It is therefore important that children’s wards have a designated, safe play area. This is especially so for malnourished children;
As a health worker, you have an important role to play in the implementation of these policies which are crucial in improving the health of children.


3. Improvement of Family and Community Practices
The 3rd component of IMCI addresses the household and community. As you maybe aware most sick children die in the community. Also, most of the causes of ill health can be prevented. If communities and households observed some positive practices, it would go a long way in reducing child deaths. In this component called community IMCI (cIMCI), 16 important practices have been adapted internationally. In addition, Kenya’s Ministry of Health has added 4 more practices. These practices have been grouped into the following 4 broad areas:
A. Growth Promotion and Development
Exclusive breastfeeding for 6m
Appropriate complementary feeding from 6m whilst continuing BF up to 24m
Adequate micronutrients through diet or supplementation
Promote mental and psychosocial development
B. Disease Prevention
Proper disposal of faeces, hand washing etc
Child sleeps under ITN
Prevention and care of HIV/AIDS
Prevent child abuse/neglect & taking appropriate action
C. Home Management
Continue to feed and offer more food & fluids when child sick
Give child appropriate home treatment for infections.
Take appropriate actions to prevent and manage child injuries and accidents
D. Care seeking and compliance
Take child to complete full course of immunization before 1st birthday
Recognize when child needs treatment outside home and take to HW
Follow Health Worker’s advice about treatment, Follow Up and referral
ANC attendance and TT vaccination during pregnancy
Active participation of men in childcare and reproductive health activities
In addition to the above 16 practices, Kenya has added the following:
Birth registration and issuance of birth certificate
Growth monitoring
Household water safety
Control of indoor air pollution
In the current National Health Sector Strategic Plan II (2005-2010), the Ministry of Health has stated that health care strategies will start at the community level. The plan has also underlined the important role that will be played by community owned resource persons (CORPS) in the achievement of its objective. In the area of IMCI, CORPS will play a key role in promoting the above practices to improve the health of children and communities. Apart from that, they will be involved in other health aspects as will be decided by the various programs in the Ministry of Health.

Let us consider the importance of the practices in the first 4 broad areas we first listed.
A) Growth Promotion and Development
Exclusive breastfeeding for 6months
Appropriate complementary feeding from 6m whilst continuing BF up to 24m
Considering the above 2 practices, it has been shown that exclusive breastfeeding (no food or water except medicine for the first 6 months) protects infants from pneumonia and diarrhea. However many babies in our communities are weaned as early as 2 weeks. The Kenya Demographic and Health Survey 2003 shows only 2.6% of babies are exclusively breastfed at 6 months. As health workers, we should promote breastfeeding. All mothers, unless medically indicated, should breastfeed their babies exclusively for the first 6 months.

Adequate micronutrients through diet or supplementation
One of the important micronutrients which is supplemented is Vitamin A. This is given to children aged between 6 months to 5 years. As most mothers stop taking their children to the clinic after they get the last vaccine (Measles at 9 months), it is important for them to bring their children who are under 5 years s to the clinic for weighing and vitamin A supplementation every 6 months.
B) Disease Prevention Diarrhoea and malaria are the important causes of disease and death. It is therefore important to prevent them. Safe disposal of faecal material and hand washing need to be promoted. Whereas families may have and use pit latrines, sometimes babies’ stools are not disposed off safely as mothers may not think it is an important cause of infection. You need to educate mothers on the need for proper disposal of all waste including the baby’s stool.
To prevent malaria in vulnerable groups ( that is children under 5 years and pregnant women) it is very important to promote the use Insecticide Treated Nets (ITNs). These groups are required to sleep under ITNs every night. Recently the Ministry of health distributed 3.4 million ITNs to pregnant women and under-fives in those districts where malaria is a problem.
The other practice under this group is the prevention and care of HIV infection in children. This is approached by:
Prevention of HIV infection in the general population. This includes women of child bearing age;
Prevention of pregnancy in HIV positive women;
Prevention of mother to child transmission of HIV;
Care, treatment and support of HIV infected women, children and families;
Prevention of mother to child transmission (PMTCT) of HIV is being carried out in many health facilities. It is important to ensure that all pregnant women have access this service. This will reduce the number of children who get infected with HIV. Almost 60% of admissions in Kenyatta National Hospital have HIV as underlying condition. You will learn more about the management of children with HIV/AIDS in Unit 14.

It is also our responsibility as health workers to prevent child abuse and neglect by taking appropriate action. We have a great role to play in recognising and managing children who are abused or neglected. You should report these incidences to the children’s officers so that they can take the appropriate action.
C) Home Management
The practices under this area include the need to continue feeding and offering fluids to sick children as well as giving sick children the appropriate home treatment for infections. As you are well aware, this is a good principle of home care. Sick children often have a very poor appetite and it is our responsibility as health worker to educate the caretakers to continue feeding the child. You should also counsel them on the danger signs so that they can bring their children back if they get worse. This is especially so in diseases like diarrhoea. This prevents both dehydration and malnutrition. In the case of diarrhoea, there are three rules of home treatment which you should teach them. These are:
more fluids
continue feeding
when to return immediately.
These will be covered in more detail in Unit 11 on diarrhoeal diseases. In addition, the Ministry of health, Division of Child Health has developed guidelines for home management of diarrhoea as well as guidelines for community health workers.

D) Care seeking and compliance
This group of practices emphasise the importance of Immunization of babies and pregnant women. It is the most effective method of preventing diseases like polio, measles and neonatal tetanus. Involving all family members in ensuring that this is done will prevent outbreaks of disease. Early care seeking is crucial in preventing morbidity and mortality

[القلب الطفولي]

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تقبــــــل مروري.

[د.جيهان]

بارك الله بك اخي الطبيب العام
مشاركة قيمة

[Miss..Nurse]

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