LESSON PREVIEW/REVIEW (5 minutes)

Community Health Nursing 1 - Lecture BS NURSING /

STUDENT ACTIVITY SHEET
SECOND YEAR
Session # 18

Materials:
Pen, paper, index card, book, and class List
LESSON TITLE: Integrated Management of Childhood
Illnesses (IMCI)
LEARNING OUTCOMES: Reference:
Upon completion of this lesson, the nursing student can: Famorca, Z. U., Nies, M. A., & McEwen, M. (2013).
Nursing Care of the Community. Elsevier
1. Define IMCI; Gezondheidszorg.
2. Discuss the IMCI case management process; and, 3.
Outline disease based on presenting signs and symptoms.

Instruction: Enumerate the six preventable diseases were initially included in the EPI.
1. _______________
2. _______________
3. _______________
4. _______________
5. _______________
6. _______________

MAIN LESSON (30 minutes)

Definition
⎯ IMCI is an integrated approach to child health that focuses on the well-being of the whole child. ⎯ IMCI strategy is
the main intervention proposed to achieve a significant reduction in the number of deaths from communicable diseases
in children under five

Goal
⎯ By 2010, to reduce the infant and under five mortality rates at least one third, in pursuit of the goal of reducing it by
two thirds by 2015.

Aim
⎯ To reduce death, illness and disability, and to promote improved growth and development among children under 5
years of age.
⎯ IMCI includes both preventive and curative elements that are implemented by families and communities as well as by
health facilities.

IMCI Objectives
⎯ To reduce significantly global mortality and morbidity associated with the major causes of disease in children ⎯ To
contribute to the healthy growth & development of children

IMCI Components of Strategy

⎯ Improving case management skills of health workers
⎯ Improving the health systems to deliver IMCI
⎯ Improving family and community practices
**For many sick children a single diagnosis may not be apparent or appropriate

Presenting complaint:
⎯ Cough and/or fast breathing
⎯ Lethargy/Unconsciousness
⎯ Measles rash

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Education (Department of Nursing) 1 of 11
⎯ “Very sick” young infant

Possible course/ associated condition:

⎯ Pneumonia, Severe anemia, P. falciparum malaria
⎯ Cerebral malaria, meningitis, severe dehydration
⎯ Pneumonia, Diarrhea, Ear infection
⎯ Pneumonia, Meningitis, Sepsis

Five Disease Focus of IMCI:

⎯ Acute Respiratory Infection
⎯ Diarrhea
⎯ Fever
⎯ Malaria
⎯ Measles
⎯ Dengue Fever
⎯ Ear Infection
⎯ Malnutrition

The IMCI Case Management Process

⎯ Assess and classify
⎯ Identify appropriate treatment
⎯ Treat/refer
⎯ Counsel
⎯ Follow-up

The Integrated Case Management Process

1. Check for General Danger Signs:
A general danger sign is present if:
⎯ The child is not able to drink or breastfeed
⎯ The child vomits everything
⎯ The child has had convulsions
⎯ The child is lethargic or unconscious

2. Assess Main Symptoms

⎯ Cough/DOB
⎯ Diarrhea
⎯ Fever
⎯ Ear problems

3. Assess and Classify Cough of Difficulty of Breathing

⎯ Respiratory infections can occur in any part of the respiratory tract such as the nose, throat, larynx, trachea, air
passages or lungs.

4. Assess and classify PNEUMONIA

⎯ Cough or difficult breathing
⎯ An infection of the lungs
⎯ Both bacteria and viruses can cause pneumonia
⎯ Children with bacterial pneumonia may die from hypoxia (too little oxygen) or sepsis (generalized infection).

** A child with cough or difficult breathing is assessed for:

⎯ How long the child has had cough or difficult breathing
⎯ Fast breathing
⎯ Chest indrawing
⎯ Stridor in a calm child.

Remember:
⎯ ** If the child is 2 months up to 12 months the child has fast breathing if you count 50 breaths per minute or more

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⎯ ** If the child is 12 months up to 5 years the child has fast breathing if you count 40 breaths per minute or

more. Color Coding

PINK OUTPATIENT HEALTH FACILITY✔ Advise parents

(Urgent Referral) ✔ Refer child
GREEN
(Home management)

OUTPATIENT HEALTH FACILITY

YELLOW
HOME REFERRAL FACILITY
(Treatment at Outpatient Health
✔ Pre-referral treatments ✔ Emergency Triage and Treatment
(Facility)
(ETAT)
✔ Diagnosis, Treatment
✔ Monitoring, follow-up
✔ Any general danger sign or
✔ Chest indrawing or
✔ Treat local infection
✔ Give oral drugs
✔ Advise and teach caretaker
✔ Follow-up
✔ Stridor in calm child
PNEUMONIA
✔ Fast breathing
NO PNEUMONIA: COUGH OR
COLD
Education (Department of Nursing) 3
Classify DYSENTERY
⎯ Child with diarrhea and blood in the ✔ Abnormally sleepy or difficult to
stool
SEVERE PNEUMONIA OR ✔ Treat the child to prevent low blood
VERY SEVERE DISEASE sugar
✔ Caretaker is counseled on: ✔ Refer urgently to the hospital ✔ Give
✔ Home treatment/s paracetamol for fever > 38.5oC
✔ Feeding and fluids
✔ When to return immediately
✔ Follow-up
✔ ✔ Give an appropriate antibiotic for 5
days
✔ Give first dose of an appropriate
antibiotic
✔ Give Vitamin A
✔ No signs of pneumonia or very
severe disease
Assess and classify DIARRHEA
A child with diarrhea is assessed for:
⎯ How long the child has had diarrhea
⎯ Blood in the stool to determine if the child has dysentery
⎯ Signs of dehydration.
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of PHINMA
✔ Soothe the throat and relieve cough with a safe remedy
✔ Advise mother when to return immediately
✔ Follow up in 2 days
✔ Give Paracetamol for fever > 38.5oC
✔ If coughing more than more than 30 days, refer for
assessment
✔ Soothe the throat and relieve the cough with a safe
remedy
✔ Advise mother when to return immediately
✔ Follow up in 5 days if not improving
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Two of the following signs? ✔ Skin pinch goes back very slowly
awaken
✔ Sunken eyes
✔ Not able to drink or drinking poorly
 SEVERE
DEHYDRATION
✔ If child has no other severe
classification: ⎯ Give fluid for severe
dehydration (Plan C) OR
✔ If child has another severe
classification: ⎯ Refer URGENTLY to
hospital with mother giving frequent
sips of ORS on the way
⎯ Advise the mother to continue
breastfeeding ✔ If child is 2 years or
older and there is cholera in your area,
give antibiotic for cholera

Two of the following signs: No dehydration

PERSISTENT DIARRHEA
✔ Restless, irritable
✔ Sunken eyes
✔ Drinks eagerly, thirsty Blood in the stool
✔ Skin pinch goes back slowly Not enough signs to DYSENTERY

Does the child have fever?

**Decide:
classify as ✔ Malaria Risk
✔ No Malaria Risk
✔ Measles
✔ Dengue

SOME DEHYDRATION ✔ Give fluid and food for some Malaria Risk
dehydration (Plan (Plan A)
✔ Advise mother when to return immediately ✔ Follow up
B) in 5 days if not improving
✔ If child also has a severe classification: ✔ Treat dehydration before referral unless the child has
⎯ Refer URGENTLY to hospital with mother another severe classification
giving frequent sips of ORS on the way ✔ Give Vitamin a
⎯ Advise mother when to return immediately ✔ Refer to hospital
✔ Follow up in 5 days if not improving ✔ Advise the mother on feeding a child who has persistent
diarrhea
✔ Home Care ✔ Give Vitamin A
✔ Give fluid and food to treat diarrhea at home ✔ Follow up in 5 days
some or severe dehydration NO DEHYDRATION ✔ Treat for 5 days with an oral antibiotic recommended for
Shigella in your area
✔ Follow up in 2 days
✔ Give also referral treatment
Dehydration present
SEVERE PERSISTENT DIARRHEA

✔ Any general danger sign or
✔ Stiff neck
VERY SEVERE FEBRILE DISEASE /
MALARIA
✔ Give first dose of quinine (under
medical supervision or if a hospital is
not accessible within 4hrs)
✔ Give first dose of an appropriate
antibiotic ✔ Treat the child to prevent
low blood sugar
✔ Give one dose of paracetamol in
health center for high fever (38.5oC) or
above
✔ Send a blood smear with the patient

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✔ Blood smear (+)
If blood smear not done: ✔ NO runny nose, and ✔ NO
measles, and ✔ NO other causes of fever
✔ Give one dose of paracetamol in health center for high
fever (38.5oC) or above
✔ Advise mother when to return immediately
✔ Follow up in 2 days if fever persists
✔ If fever is present every day for more than 7 days, refer
for assessment

✔ Blood smear (–), or

✔ Refer URGENTLY to hospital
✔

MALARIA ✔ Treat the child with an oral antimalarial

✔ Runny nose, or ✔ No signs of very severe ✔ Advise mother when to return

✔ Measles, or Other causes of fever FEVER: MALARIA UNLIKELY immediately ✔ Follow up in 2 days if
fever persists
✔ If fever is present every day for more
than 7 days, refer for assessment

No Malaria Risk

✔ Any general danger sign or

✔ Stiff neck ✔ Give first dose of an appropriate
antibiotic ✔ Treat the child to prevent
low blood sugar ✔ Give one dose of
VERY SEVERE FEBRILE DISEASE
✔ Give one dose of paracetamol in paracetamol in health center for high
o
health center for high fever (38.5 C) or fever (38.5 C) or above
o

above ✔ Refer URGENTLY to hospital

febrile disease FEVER: NO MALARIA ✔ Give one dose of paracetamol in health center for high
fever (38.5oC) or above
✔ Advise mother when to return immediately
✔ Follow up in 2 days if fever persists
✔ If fever is present every day for more than 7 days, refer
for assessment

Measles

✔ Clouding of cornea or ✔ Deep or ✔ Measles now or within antibiotic ✔ If clouding of the cornea or
extensive mouth ulcers SEVERE COMPLICATED MEASLES pus draining from the eye, apply
tetracycline eye ointment
✔ Refer URGENTLY to hospital

✔ Pus draining from the eye or ✔ Give Vitamin A

✔ Mouth ulcers MEASLES WITH EYE OR MOUTH ✔ If pus draining from the eye, apply
COMPLICATIONS tetracycline eye ointment
✔ Give Vitamin A ✔ If mouth ulcers, teach the mother to
✔ Give first dose of an appropriate treat with gentian violet

the last 3 months MEASLES ✔ Give Vitamin A

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Dengue Fever ✔ Bleeding from nose or gums or ✔ Black stools or vomitus or
✔ Bleeding in stools or vomitus or ✔ Skin petechiae or ✔ Cold clammy
extremities or FEVER: DENGUE ✔ DO NOT GIVE ASPIRIN
✔ Capillary refill more than 3 seconds HEMORRHAGIC UNLIKELY ✔ Give one dose of paracetamol in
or health center for high fever (38.5oC) or
✔ Abdominal pain or ✔ Vomiting above
✔ Tourniquet test (+) ✔ Follow up in 2 days if fever persists
✔ If skin petechiae or Tourniquet test,
or child shows signs of bleeding
are the only positive signs give ORS
✔ If any other signs are positive, give ✔ Advise mother when to return
fluids rapidly as in Plan C immediately
✔ No signs of severe dengue ✔ Treat the child to prevent low blood
hemorrhagic sugar ✔ DO NOT GIVE ASPIRIN
fever ✔ Refer all children Urgently to hospital
SEVERE DENGUE
HEMORRHAGIC FEVER

Does the Child have an Ear Problem?

✔ Tender swelling behind

the ear MASTOIDITIS ✔ Give first dose of appropriate antibiotic
✔ Give paracetamol for pain
✔ Refer URGENTLY

✔ Pus seen draining from the ear and discharge is ✔ Follow up in 5 days
reported for less than 14 days or
✔ Ear pain

✔ Pus seen draining from the ear and discharge is CHRONIC EAR INFECTION ✔ Dry the ear by wicking ✔
reported for less than 14 days Follow up in 5 days
ACUTE EAR INFECTION ✔ Give antibiotic for 5 days

✔ Give paracetamol for pain

✔ Dry the ear by wicking
✔ No ear pain and no pus seen NO EAR INFECTION ✔ No additional treatment
draining from the ear

Check for Malnutrition and Anemia

Give an Appropriate Antibiotic:

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Education (Department of Nursing) 6 of 11
A. For Pneumonia, Acute ear infection or Very Severe BID FOR 5 DAYS
disease AMOXYCILLIN BID FOR 5 DAYS

COTRIMOXAZOLE

Age or Weight Adult Tablet

Syrup Tablet Syrup
2 months up to 12 months (4 – < 9 kg) 1 / 2 5 ml 1 / 2 5 ml 12 months up to 5 years (10 – 19kg) 1 7.5 ml 1 10

ml
B. For Dysentery
COTRIMOXAZOLE BID FOR 5 DAYS
AMOXYCILLIN BID FOR 5 DAYS

AGE OR WEIGHT TABLET SYRUP SYRUP 250MG/5ML

2 – 4 months (4 – < 6kg)

1
4 – 12 months (6 – < 10 kg) 1 – 5 years old (10 – 19 kg)

C. For Cholera
½
5 ml 1.25 ml (¼ tsp)

7.5 ml (1 tsp)

5 ml 2.5 ml (½ tsp)

TETRACYCLINE QID FOR 3 DAYS COTRIMOXAZOLE BID FOR 3 DAYS

AGE OR WEIGHT Capsule 250mg Tablet Syrup

2 – 4 months (4 – < 6kg) ¼ 1 / 2 5ml 4 – 12 months (6 – < 10 kg) ½ 1 / 2 5 ml 1 – 5 years old (10 – 19 kg) 1 1 7.5ml

Give an Oral Antimalarial

Sulfadoxine +

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Education (Department of Nursing) 7 of 11
CHOLOROQUINE AGE TABLET (150MG) center for P. Falciparum Give daily for 14 days for P.
Vivax
Give for 3 days DAY1 DAY2 DAY3 TABLET

Primaquine (15MG) TABLET

Primaquine
Give single dose in health (15MG)
Pyrimethamine Give single dose TABLET (15MG)

2 months – 5 months ½ ½ ½ ¼ 5 months – 12 months ½ ½ ½ 1/2

12 months – 3 years old 11½½¼¾

3 years old – 5 years old 1 ½ 1 ½ 1 3/4 1/2 1

Give Vitamin A
AGE VITAMIN A CAPSULES 200,000 IU 6 months – 12 months 1/2

12 months – 5 years old 1

Give Iron
AGE or WEIGHT Iron/Folate Tablet - FeSo4 200mg + (6 – <10kg)
250mcg Folate (60mg elemental iron) Iron Syrup - FeSo4 150 mg/5ml (6mg elemental iron per
ml)
2months-4months
(4 – <6kg) 2.5 ml

4months – 12months
4 ml

12months – 3 years (10 – <14kg) 3years – 5 years (14 – 19kg)

1/2 5 ml 1/2 7.5 ml

Give Paracetamol for Fever Higher (38.5oC or more) or Ear Pain

AGE OR WEIGHT TABLET (500MG) SYRUP (120MG / 5ML)

2 months – 3 years (4 – <14kg) 3 years up to 5 years (14 – 19 kg)

¼ 5 ml 1/2 10 ml

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Education (Department of Nursing) 8 of 11
Give Mebendazole
⎯ Give 500mg Mebendazole as a single dose in health center if:
✔ hookworm / whipworm is a problem in children in your area, and
✔ the child is 2 years of age or older, and
✔ the child has not had a dose in the previous 6 months

CHECK FOR UNDERSTANDING (20 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 20 minutes for this activity:

Multiple Choice

1. You can classify that a child aged 2 years has fast breathing if he has a respiratory rate of A. 60 bpm or more
B. 50 bpm or more
C. 40 bpm or more
D. Any of the above
ANSWER: ________
RATIO:_________________________________________________________________________________________
_
_______________________________________________________________________________________________
__ ______________________________________________________________

2. Baby Yuki, 4 months old is not able to breastfeed and chest indrawing is present. This can be classified as A.
Pneumonia
B. Severe Pneumonia
C. No Pneumonia: cough or cold
D. Mild Pneumonia
ANSWER: ________
RATIO:_________________________________________________________________________________________
_
_______________________________________________________________________________________________
__ ______________________________________________________________

3. These are all possible treatments for severe pneumonia except:

A. Giver first dose of an appropriate antibiotic
B. Soothe the throat and relieve the cough with a safe remedy
C. Give vitamin A
D. Treat the child to prevent low blood sugar
ANSWER: ________
RATIO:_________________________________________________________________________________________
_
_______________________________________________________________________________________________
__ ______________________________________________________________

4. What color is "NO PNEUMONIA: COUGH OR COLD" classified as?

A. Green
B. Pink
C. Yellow
D. Red
ANSWER: ________
RATIO:_________________________________________________________________________________________
_
_______________________________________________________________________________________________
__ ______________________________________________________________

5. If the child has wheezing and either fast breathing or chest indrawing present, the nurse should: A. Refer
URGENTLY to hospital
B. Give a trial acting inhaled bronchodilator for up to 3 times

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Education (Department of Nursing) 9 of 11
C. Assess vital signs
D. Give Vitamin A
ANSWER: ________
RATIO:_________________________________________________________________________________________
_
_______________________________________________________________________________________________
__ ______________________________________________________________

6. Dysentery is classified if:

A. There is Dehydration
B. Stools are watery
C. Fast breathing is present
D. There is blood in the stool
ANSWER: ________
RATIO:_________________________________________________________________________________________
_
_______________________________________________________________________________________________
__ ______________________________________________________________

7. All are signs of severe dehydration except

A. Restlessness
B. Sunken eyes
C. Skin pinch goes back very slowly
D. Abnormally sleepy
ANSWER: ________
RATIO:_________________________________________________________________________________________
_
_______________________________________________________________________________________________
__ ______________________________________________________________

8. Which type of plan would the nurse instruct to a child who was classified with severe dehydration? A. Plan A
B. Plan B
C. Plan C
D. Plan D
ANSWER: ________
RATIO:_________________________________________________________________________________________
_
_______________________________________________________________________________________________
__ ______________________________________________________________

9. If child has not enough signs to classify as some or severe dehydration, the child will be classified as what? A.
Severe Dehydration
B. Mild Dehydration
C. Some Dehydration
D. No Dehydration
ANSWER: ________
RATIO:_________________________________________________________________________________________
_
_______________________________________________________________________________________________
__ ______________________________________________________________

10. Patient Tifa, 5 months old has diarrhea for already 16 days. You also notice that dehydration is present. This could
be classified as?
A. Severe Dehydration
B. Severe Persistent Diarrhea
C. Some Dehydration
D. Persistent Diarrhea
ANSWER: ________
RATIO:_________________________________________________________________________________________
_
_______________________________________________________________________________________________
__ ______________________________________________________________

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Education (Department of Nursing) 10 of 11
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE-TO-FACE INTERACTION) The instructor
will now rationalize the answers to the students. You can now ask questions and debate among yourselves. Write the
correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

10. ANSWER: ________

RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

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Education (Department of Nursing) 11 of 11
You are done with the session! Let’s track your progress.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

AL Activity: Muddiest Point:

In today’s session, what was least clear to you?
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