KENYA METHODIST UNIVERSITY

NRSG 364: Pediatrics Nursing

Assignment: 3rd Trimester 2015

Assignment
marks)

(40

1.
Discuss five (5) differences between Integrated Management of Childhood Illness (IMCI)
and Emergency Triage Assessment and Treatment (ETAT) (25 mks)

IMCI is an integrated approach to child health that focuses on the well-being of the whole child;
the innovative approach that was started in 1995 by WHO and UNICEF has the aim of
introducing a comprehensive and timely management of the five most common causes of ill
health and death among the under-fives targeted diseases are namely Pneumonia; Diarrhea;
Malaria; measles; malnutrition these conditions differ with these tackled by Emergency Triage
Assessment and Treatment (ETAT) which is a set of guidelines adapted from the Advanced
Pediatric Life Support guidelines used in western countries, the simplified guidelines is used for
the emergency care of children to improve the triage and rapid initiation of appropriate
emergency treatments for children presenting to hospitals in developing countries by identifying
children with immediately life-threatening conditions which are most frequently seen in
developing countries, here the emergency conditions targeted are namely obstruction of the
airway and other breathing problems caused by infections, shock, severely altered central
nervous system function coma or convulsions, and severe dehydration.
In management IMCI the clinical guidelines are based on the following principles examining all
sick children aged up to five years of age for general danger signs and all young infants for signs
of very severe disease. These signs indicate severe illness and the need for immediate referral or
admission to hospital. The children and infants are then assessed for main symptoms,In older
children the main symptoms include:Cough or difficulty breathing,Diarrhoea,Fever, and Ear
infection.In young infants, the main symptoms include:Local bacterial infection, Diarrhoea, and
Jaundice,Then in addition, all sick children are routinely checked for: Nutritional and
immunization status, HIV status in high HIV settings, and Other potential problems. Only a
limited number of clinical signs are used that are selected on the basis of their sensitivity and
specificity to detect disease through classification where as in ETAT the steps followed in
emergency triage assessment and treatment are summarized as first, checking for emergency
signs in three steps initial Step is to check whether there is any airway or breathing problem; and
start immediate treatment to restore breathing by managing the airway and give oxygen. Second
Step involve Quick check of whether the child is in shock or has diarrhoea with severe
dehydration managed by giving oxygen start IV fluid resuscitation. In trauma, if there is external
bleeding, compress the wound to stop further blood loss. The third step is a quick determining of
whether the child is unconscious or convulsing resolved by Giving IV glucose for
hypoglycaemia and or an anti-convulsant for convulsing.

In IMCI a combination of individual signs leads to a child's classification within one or more
symptom groups rather than a diagnosis. The classification of illness is based on colour -coded

triage system "PINK" indicates urgent hospital referral or admission,YELLOW indicates

initiation of specific outpatient treatment. "GREEN" indicates supportive home care, where as in
etat the the triage process rapidly screen sick children soon after their arrival in hospital, and
identify those with EMERGENCY SIGNS, who require immediate emergency treatment, those
with PRIORITY SIGNS, who should be given priority in the queue so that they can be
assessed and treated without delay; and NON-URGENT CASES, who have neither emergency
nor priority signs.
IMCI management procedures use a limited number of essential drugs and encourage active
participation of caregivers in the treatment of their children.at An essential component of IMCI is
the counselling of caregivers regarding home care: Appropriate feeding and fluids, When to
return to the clinic immediately, and When to return for follow-up where as in ETAT
management procedure are complex and employ use of medical apparatus like equipment
oropharyngeal (guedel) airways: at least 3 different sizes electric (or foot) suction pump suction
catheters: size 15 f.g. oxygen concentrator or oxygen cylinder with regulator, pressure gauge and
flow meter oxygen tubing, nasal prongs or catheters consumables cardboard to make splints iv
infusion sets scalp vein needles (size 21 or 23 g) iv cannula (size 22 or 24 g) needles for
intraosseous insertion (size 21g) tuberculin syringes test strips and scale for blood sugar.
IMCI has a strategy that includes three main components: Improving case management skills of
health-care staff, improving overall health systems & improving family and community health
practices. Implementation of etat has a single strategy aiming improve the assessment and
treatment of critically children associated with improved patient outcomes particularly in
mortality at before 48 hours in the developing world to improve acute inpatient and outpatient
pediatric care.

2.

Discuss the classification of dehydration according to World Health organization (5 mks)

According to world health organization the hydration status should be classified as severe
dehydration, some dehydration, or no dehydration in children with conditions that alter hydration
status, like diarrhea and vomiting. In a child with diarrhea, classification is achieved through
assessing the general condition, looking for sunken eyes, making a skin pinch, and offering the
child fluid to see if he or she is thirsty or drinking poorly.
Severe dehydration; the child is classified so when he/she has two or more of the following
signs, unable to drink or drinks poorly, sunken eyes, return of skin pinch goes back very slowly
longer than two seconds, child has movement only when stimulated or no movement even when
stimulated. Any child with dehydration needs extra fluids. Severely dehydrated children need to
have water and salts quickly replaced. Intravenous (IV) fluids are usually used for this purpose.
Rehydration therapy using iv fluids or using a nasogastric (ng) tube is recommended only for
children who have severe dehydration. The treatment of the severely dehydrated child depends
on the type of equipment available at your clinic or at a nearby clinic or hospital, the training you
have received, and whether the child can drink.
Some dehydration; here the child is able to drink adequately but has two or more of: sunken
eyes, return of skin pinch takes one to two seconds, restlessness or irritability. A child who has
some dehydration needs fluid and foods. Treat a child who has diarrhea and some dehydration
with plan b. this plan includes an initial treatment period of 4 hours in the clinic. During the 4
hours, the mother or caretaker slowly gives a recommended amount of ORS solution. The
mother gives it by spoonfuls or sips. A child who has a severe classification and some
dehydration needs urgent referral to hospital. Do not try to rehydrate the child before he leaves.
quickly give the mother some ors solution. Show her how to give frequent sips of it to the child
on the way to the hospital. the exception is a child who has a single severe classification of
severe persistent diarrhoea. this child should first be rehydrated and then referred. if a child who
has some dehydration needs treatment for other problems, you should start treating the
dehydration first. then provide the other treatments.after giving ors for 4 hours, reassess and
classify the child for dehydration using the assess and classify chart. if the signs of dehydration
are gone, the child is put on plan a. if there is still some dehydration, the child repeats plan b. if
the child now has severe dehydration, the child would be put on plan c.
No dehydration, not enough signs to classify as some dehydration or severe dehydration here the
child has diarrhea with fewer than two of the signs of dehydration the child is able to drink
adequately but may have two or more of Sunken eyes, Return of skin pinch takes one to two
seconds, Restlessness or irritability. Treat a child who has diarrhoea and no dehydration with
plan a. With the 3 rules of home treatment are: give extra fluid (as much as the child will take),
continue feeding, when to return . children with diarrhoea who come to a health facility with no
dehydration will be put on plan a. children with some or severe dehydration need to be
rehydrated on plan b or c, and then put on plan a. eventually, all children with diarrhoea will be

on plan a. plan a involves counselling the childs mother or caretaker about the 3 rules of home
treatment.

3. Master P, four years old is admitted with sickle cell disease crisis. Discuss the health messages
you would share with master Ps parents.
(10marks)
The health messages will be aimed to help in promoting home and community-based care of the
child during his admission time and even after discharge from hospital emphasis will be on
teaching on the patients care and Self-Care, but because patients with sickle cell anemia are
typically diagnosed as children, parents will participate in the initial education. The complexity
of education will be based on the parents education, literacy, socioeconomic level, and interest.
My teaching will focus on the disease process explaining Sickle cell anemia as a severe
hemolytic anemia that result from inheritance of the sickle hemoglobin gene. The gene causes
the hemoglobin molecule to be defective. The sickle hemoglobin acquires a crystal-like
formation when exposed to low oxygen tension. The oxygen level in venous blood can be low
enough to cause this change; consequently, the RBC containing loses its round, very pliable,
biconcave disk shape and becomes deformed, rigid, and sickle-shaped. These long, rigid RBCs
can adhere to the endothelium of small vessels; when they pile up against each other, blood flow
to a region or an organ may be reduced. If ischemia or infarction results, the patient may have
pain, swelling, and fever. Symptoms of sickle cell anemia vary and are only somewhat based on
the amount of HbS. Symptoms and complications result from chronic hemolysis or thrombosis.
The sickled RBCs have a shortened life span. Sickly child is always anemic, usually with
hemoglobin values of 7 to 10 g/dL. Jaundice is characteristic and is usually obvious in the sclera.
Bone marrow expands in childhood in a compensatory effort to offset the anemia, sometimes
leading to enlargement of the bones of the face and skull. The chronic anemia is associated with
tachycardia, cardiac murmurs. Virtually any organ may be affected by thrombosis, but the
primary sites involve those areas with slowed circulation, such as the spleen, lungs, and central
nervous system. All the tissues and organs are constantly vulnerable to microcirculatory
interruptions by the sickling process and therefore are susceptible to hypoxic damage or true
ischemic necrosis. Patients with sickle cell anemia are unusually susceptible to infection,
particularly pneumonia and osteomyelitis. Complications of sickle cell anemia include infection,
stroke, renal failure, impotence, heart failure, and pulmonary hypertension.
Explain the acute pain management during a sickle cell crisis, that it can be severe and
unpredictable. The patients subjective description and rating of pain on a pain scale must guide
the use of analgesics, which are valuable in controlling the acute pain of a sickle crisis. Any joint
that is acutely swollen should always be supported and elevated until the swelling diminishes.
Relaxation techniques, breathing exercises, and distraction are alternative but helpful for master
ps pain management. After the acute painful episode has diminished, aggressive measures should
always be implemented to preserve function. Physical therapy, whirlpool baths, and
transcutaneous nerve stimulation are examples of such measures.
Explain to parents on lifestyle changes needed to prevent crisis to the parents with emphasis on
the importance of warmth, adequate hydration, and prevention of infection in preventing crisis

and the steps they can take to prevent or diminish such crises. Like always ensure master-p is
keeping warm and maintaining adequate hydration as that can be very effective in diminishing
the occurrence and severity of attacks. Avoiding stressful situations is more challenging but
options on corporal punishment at school and home will minimize attacks. Group education may
be more effective if it is carried out by members of the community who are from the same ethnic
group as those with the disease to help parents of and child with sickle cell anemia to benefit
from understanding what situations can precipitate a sickle cell crisis and the steps they can take
to prevent or diminish such crises.
Parents will help in preventing and managing infection by closely monitoring the child patient
for signs and symptoms of infection and report them when noted. Prescribed antibiotics should
be initiated promptly, and the patient should be assessed for signs of dehydration. If the child
patient is to take prescribed oral antibiotics at home, emphasis should be for parents to
understand the need to complete the entire course of antibiotic therapy and must be able to
identify a feasible administration schedule.
Parents should assist in monitoring and managing potential complications, parents will be
equipped with knowledge of potential complications like Leg ulcers require careful management
and protection from trauma and contamination and require early referral to a wound care
specialist to facilitate healing and assist with prevention. Priapism leading to Impotence Male
patients may develop sudden, painful episodes of persistent penile erection. The parents are
taught to monitor and supervise, as the child is taught to empty his bladder at the onset of the
attack, exercise, and take a warm bath. If an episode persists longer than 3 hours, medical
attention is recommended. Repeated episodes may lead to extensive vascular thrombosis,
resulting in impotence. Chronic pain and substance abuse many patients have considerable
difficulty coping with chronic pain and repeated episodes of sickle crisis. Those who feel they
have little control over their health and the physical complications that result from this illness
may find it difficult to understand the importance of complying with a prescribed treatment plan.
Being nonjudgmental and actively seeking involvement from the patient in establishing a
treatment plan are useful strategies.
Explain to the parents that the patients with sickle cell anemia may develop problems with
substance abuse. For many, this abuse results from inadequate management of acute pain during
episodes of crisis may result from prescribing inadequate amounts of opioid analgesics for an
inadequate time. The patients pain may never be adequately relieved, promoting mistrust of the
health care system and (from the patients perspective) the need to seek care from a variety of
sources when the pain is not severe. This cycle is best managed by prevention. Receiving care
from a single provider over time is much more beneficial than receiving care from rotating
physicians and staff in an emergency department. Once the pattern of substance abuse is
established, it is very difficult to manage, but continuity of care and establishing written
contracts with the patient can be useful management strategies. Remind the parents that as the

child ages, educational interventions with the child will help prepare the child to assume more
responsibility for self-care.

Please note that:

1. This assignment is due before or on 23rd October, 2015 by 5.00pm.
2. Late submission (within 1 week after deadline) will be deducted 5 marks. No
submission after this will be accepted.
3. All assignment should be submitted on soft copy (Gladys.machira@kemu.ac.ke).
4. For any assignment submitted I shall send an email of acknowledgement.
5. If you do not receive an email from me within 5 working days of submitting your
assignment you need to confirm with me.
6. The assignment should be 8-10 pages well typed and correct format used.

Prepared by: Gladys Machira-Maripet

Date: 16th September, 2015