Joyce Rev

Chest Tube Care and Monitoring TERMINAL LEARNING OBJECTIVE Given a scenario in a holding or ward setting, involving a patient with a chest tube, identify procedures for chest tube care and monitoring IAW the Textbook of Basic Nursing, Lippincott Introduction Trauma, disease, or surgery can interrupt the closed negative-pressure system of the lungs, causing the lung to collapse. Air or fluid may leak into the pleural cavity. A chest tube is inserted and a closed chest drainage system is attached to promote drainage of air and fluid. Chest tubes are used after chest surgery and chest trauma and for pnuemothorax or hemothorax to promote lung re-expansion Terms and definitions a.

Pneumothorax – collection of air in the pleura space

b.

Hemothorax – an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleurae, usually as the result of trauma

c.

Chest tubes – a catheter inserted through the thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and intrapulmonic pressures

Chest Tube Systems a.

b.

c.

Pleur-Evac chest drainage system (1)

One-piece molded plastic unit that duplicates the three-chambered system

(2)

Cost effective

(3)

There must be bubbles flowing in the suction control portion of the unit to provide suction to the patient

Pleur-Evac Set Up (1)

Fill water seal chamber

(2)

Fill suction control chamber

(3)

Attach tube to suction source

(4)

Tape all the connections

(5)

Provide sterile tube for connection to patient

Procedure for Proper Usage of the Heimlich Valve (1)

Heimlich valve is a plastic, portable one-way valve used for chest drainage, draining into a vented bag

(2)

Equipment

(3)

(a)

Heimlich valve

(b)

Kelly clamps - 2 (rubber-tipped)

(c)

Vented drainage bag or ostomy bag

(d)

Ostomy tape or rubber band

(e)

Suction setup (if applicable)

(f)

Clean scissors

Procedure Steps (a)

Gather equipment and bring to patient area

(4)

(b)

Wash hands

(c)

Don gloves. Nonsterile gloves are acceptable as long as sterile technique is maintained while the connection is being made.

Heimlich Valve To Chest Tube (a)

Place rubber-tipped Kelly clamps in opposite directions on the proximal end of the chest tube as near to the patient as possible

(b)

Connect the chest tube to the blue end of the Heimlich valve using sterile technique

CAUTION: Only the blue end of the Heimlich valve can be connected to the chest the wrong position and no drainage will take place. (c) CAUTION:

tube. If the clear end is connected, the one-way valve will be in

Tape the connection site at both ends of the valve using 2 inch cloth tape.

When two chest tubes are present, two Heimlich valves must be used to ensure proper functioning of chest tubes. (d)

CAUTION: (e)

Monitor and record character of drainage and patency of valve in nursing progress notes.

Measure all drainage in a calibrated cylinder for accurate readings. Record drainage output on I & O graphic every 8 hours. If conditions permit.

Care of patients with chest tubes a.

Assess patient for respiratory distress and chest pain, breath sounds over affected lung area, and stable vital signs

b.

Observe for increase respiratory distress

c.

Observe the following:

d.

e.

f.

g.

(1)

Chest tube dressing, ensure tubing is patent

(2)

Tubing kinks, dependent loops or clots

(3)

Chest drainage system, which should be upright and below level of tube insertion

Provide two shodded hemostats for each chest tube, attached to top of patient’s bed with adhesive tape. Chest tubes are only clamped under specific circumstances: (1)

To assess air leak

(2)

To quickly empty or change collection bottle or chamber; performed by soldier medic who has received training in procedure

(3)

To change disposable systems; have new system ready to be connected before clamping tube so that transfer can be rapid and drainage system reestablished

(4)

To change a broken water-seal bottle in the event that no sterile solution container is available

(5)

To assess if patient is ready to have chest tube removed (which is done by physician’s order); the solider medic must monitor patient for recreation of pneumothorax

Position the patient to permit optimal drainage (1)

Semi-Flower’s position to evacuate air (pneumothorax)

(2)

High Flower’s position to drain fluid (hemothorax)

Maintain tube connection between chest and drainage tubes intact and taped (1)

Water-seal vent must be without occlusion

(2)

Suction-control chamber vent must be without occlusion when suction is used

Coil excess tubing on mattress next to patient. Secure with rubber band and safety pin or system’s clamp

h.

Adjust tubing to hang in straight line from top of mattress to drainage chamber. If chest tube is draining fluid, indicate time (e.g., 0900) that drainage was begun on drainage bottle’s adhesive tape or on write-on surface of disposable commercial system (1)

Strip or milk chest tube only per MD/PA orders only

(2)

Follow local policy for this procedure

Problems solving with chest tubes a.

Problem: Air leak (1)

(2)

Warning: (3)

(a)

Locate leak

(b)

Tighten loose connection between patient and water seal

(c)

Loose connections cause air to enter system.

(d)

Leaks are corrected when constant bubbling stops

Problem: Bubbling continues, indicating that air leak has not been corrected (a)

Cross-clamp chest tube close to patient’s chest, if bubbling stops, air leak is inside the patient’s thorax or at chest tube insertion site

(b)

Unclamp tube and notify physician immediately!

(c)

Reinforce chest dressing

Leaving chest tube clamped caused a tension pneumothorax and mediastinal shift

Problem: Bubbling continues, indicating that leak is not in the patient’s chest or at the insertion site

(4)

b.

Problem: Continuous bubbling is seen in water-seal bottle/chamber, indicating that leak is between patient and water seal

(a)

Gradually move clamps down drainage tubing away from patient and toward suction-control chamber, moving one clamp at a time

(b)

When bubbling stops, leak is in section of tubing or connection distal to the clamp

(c)

Replace tubing or secure connection and release clamp

Problem: Bubbling continues, indicating that leak is not in tubing (a)

Leak is in drainage system

(b)

Change drainage system

Problem: Tension pneumothorax is present (1)

(2)

Problems: Severe respiratory distress or chest pain (a)

Determine that chest tubes are not clamped, kinked, or occluded. Locate leak

(b)

Obstructed chest tubes trap air in intrapleural space when air leak originates within patient

Problem: Absence of breath sounds on affected side (a)

(3)

Notify physician immediately

Problems: Hyperresonance on affected side, mediastinal shift to unaffected side, tracheal shift to unaffected side, hypotenstion or tachycardia (a)

Immediately prepare for another chest tube insertion

(4)

(5)

(6)

(7)

(b)

Obtain a flutter (Heimlich) valve or large-guage needle for short-term emergency release or air in intrapleural space

(c)

Have emergency equipment (oxygen and code cart) near patient

Problem: Dependent loops of drainage tubing have trapped fluid (a)

Drain tubing contents into drainage bottle

(b)

Coil excess tubing on mattress and secure in place

Problem: Water seal is disconnected (a)

Connect water seal

(b)

Tape connection

Problem: Water-seal bottle is broken (a)

Insert distal end of water-seal tube into sterile solution so that tip is 2 cm below surface

(b)

Set up new water-seal bottle

(c)

If no sterile solution is available, double clamp chest tube while preparing new bottle

Problem: Water-seal tube is no longer submerged in sterile fluid (a)

Add sterile solution to water-seal bottle until distal tip is 2 cm under surface

(b)

Or set water-seal bottle upright so that tip is submerged

SUMMARY Caring for a patient with a chest tube requires problem solving and knowledge application. Remember, a chest tubes is a catheter inserted through the thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and intrapulmonic pressures. When caring for and maintaining a patient with a chest tube, it is important to note the patency of chest tubes, presence of drainage, presence of fluctuations, patient's vital signs, chest dressing status, type of suction, and level of comfort. What is HIV? What is AIDS? HIV (human immunodeficiency virus) is a virus that attacks the immune system, the body’s natural defense system. Without a strong immune system, the body has trouble fighting off disease. Both the virus and the infection it causes are called HIV. White blood cells are an important part of the immune system. HIV invades and destroys certain white blood cells called CD4+ cells. If too many CD4+ cells are destroyed, the body can no longer defend itself against infection. The last stage of HIV infection is AIDS (acquired immunodeficiency syndrome). People with AIDS have a low number of CD4+ cells and get infections or cancers that rarely occur in healthy people. These can be deadly. But having HIV does not mean you have AIDS. Even without treatment, it takes a long time for HIV to progress to AIDS—usually 10 to 12 years. If HIV is diagnosed before it becomes AIDS, medicines can slow or stop the damage to the immune system. With treatment, many people with HIV are able to live long and active lives. What causes HIV? HIV infection is caused by the human immunodeficiency virus. You can get HIV from contact with infected blood, semen, or vaginal fluids.

• • •

Most people get the virus by having unprotected sex with someone who has HIV. Another common way of getting the virus is by sharing drug needles with someone who is infected with HIV. The virus can also be passed from a mother to her baby during pregnancy, birth, or breast-feeding.

HIV doesn't survive well outside the body. So it cannot be spread by casual contact such as kissing or sharing drinking glasses with an infected person. What are the symptoms? HIV may not cause symptoms early on. People who do have symptoms may mistake them for the flu or mono. Common early symptoms include:

• • • • • •

Fever. Sore throat. Headache. Muscle aches and joint pain. Swollen glands (swollen lymph nodes). Skin rash.

Symptoms may appear from a few days to several weeks after a person is first infected. The early symptoms usually go away within 2 to 3 weeks. After the early symptoms go away, an infected person may not have symptoms again for many years. But during this time, the virus continues to grow in the body and attack the immune system. After a certain point, symptoms reappear and then remain. These symptoms usually include:

• • • • •

Swollen lymph nodes. Extreme tiredness. Weight loss. Fever. Night sweats.

A doctor may suspect HIV if these symptoms last and no other cause can be found. How is HIV diagnosed? The only way to know for sure if you have HIV is to get a blood test. If you have been exposed to HIV, your immune system will make antibodies to try to destroy the virus. Blood tests can find these antibodies in your blood. Most doctors use two blood tests, called the ELISA and the Western blot assay. If the first ELISA is positive (meaning that HIV antibodies are found), the blood sample is tested again. If the second test is positive, the doctor will do a Western blot to be sure. It may take as long as 6 months for HIV antibodies to show up in a blood sample. If you think you have been exposed to HIV but you test negative for it:

• •

Get tested again in 6 months to be sure you are not infected. Meanwhile, take steps to prevent the spread of the virus. If you are infected, you can still pass HIV to another person during this time.

Some people are afraid to be tested for HIV. But if there is any chance you could be infected, it is very important to find out. HIV can be treated. Getting early treatment can slow down the virus and help you stay healthy. You can get HIV testing in most doctors’ offices, public health clinics, hospitals, and Planned Parenthood clinics. You can also buy a home HIV test kit in a drugstore or by mail order. But be very careful to choose only a test that has been approved by the U.S. Food and Drug Administration (FDA). If a home test is positive, see a doctor to have the result confirmed and to find out what to do next. How is it treated? The standard treatment for HIV is a combination of medicines called highly active antiretroviral therapy (HAART). Antiretroviral medicines slow the rate at which the virus multiplies. Taking these medicines can reduce the amount of virus in your body and help you stay healthy. It may not be easy to decide the best time to start treatment. There are pros and cons to taking HAART before you have symptoms. Discuss these with your doctor so you understand your choices. To find out how much damage HIV has done to your immune system, a doctor will do two tests:

• •

CD4+ cell count, which shows how well your immune system is working. Viral load, which shows the amount of virus in your blood.

If you have no symptoms and your CD4+ cell count is at a healthy level, you may not need treatment yet. Your doctor will repeat the tests on a regular basis to see how you are doing. If you have symptoms, you should consider starting treatment, whatever your CD4+ count is. After you start treatment, it is important to take your medicines exactly as directed by your doctor. When treatment doesn't work, it is often because HIV has become resistant to the medicine. This can happen if you don't take your medicines correctly. Ask your doctor if you have questions about your treatment. Treatment has become much easier to follow over the past few years. New combination medicines include two or three different medicines in one pill. Many people with HIV get the treatment they need by taking just one or two pills a day. To stay as healthy as possible during treatment:

• • • •

Don't smoke. People with HIV are more likely to have a heart attack or get lung cancer.1, 2 Smoking can increase these risks even more. Eat a healthy, balanced diet to keep your immune system strong. Get regular exercise to reduce stress and improve the quality of your life. Don't use illegal drugs, and limit your use of alcohol.

Learn all you can about HIV so you can take an active role in your treatment. Your doctor can help you understand HIV and how best to treat it. Also, consider joining an HIV support group. Support groups can be a great place to share information and emotions about HIV infection. How can you prevent HIV? HIV can be spread by people who don't know they are infected. To protect yourself and others:

• • • • • •

Practice safe sex. Use a condom every time you have sex (including oral sex) until you are sure you and your partner are not infected with HIV. Don't have more than one sex partner at a time. The safest sex is with one partner who has sex only with you. Talk to your partner before you have sex the first time. Find out if he or she is at risk for HIV. Get tested together and retested 6 months later. Use condoms in the meantime. Don't drink a lot of alcohol or use illegal drugs before sex. You might let down your guard and not practice safe sex. Don't share personal items, such as toothbrushes or razors. Never share needles or syringes with anyone.

THYROIDECTOMY & MINIMALLY INVASIVE VIDEO-ASSISTED THYROID SURGERY Frequently Asked Questions (FAQ) What is thyroidectomy? Thyroidectomy is an operation in which one or both lobes of the thyroid gland are removed. The most common indications for thyroidectomy include a large mass in the thyroid gland, difficulties with breathing related to a thyroid mass, difficulties with swallowing, goiter, suspected or proven cancer of the thyroid gland and hyperthyroidism (overproduction of the thyroid hormone, Graves' disease). The need for thyroidectomy is based on your history, the results of a physical examination and tests. The most common tests to determine whether a thyroidectomy is necessary include a fine needle aspiration biopsy, thyroid scan, ultrasound, x-rays and/or CT scan, and assessment of thyroid hormone levels. The procedure is usually done under general anesthesia. The extent of surgery (removal of one or both lobes) may sometimes be determined in the course of surgery after microscopic examination of tissue removed during the surgery. What is minimally-invasive video-assisted thyroidectomy (MIVAT)? What is endoscopic thyroidectomy? MIVAT or Minimally-invasive video-assisted thyroidectomy (also called endoscopic thyroidectomy) is a new surgical technique which allows the surgeon to perform thyroid surgery through a very small incision in the neck. This technique which has been used in Europe since 1998 has recently gained popularity in the USA. The combined use of fiberoptic endoscopic telescopes and harmonic scalpels has made it possible to remove parathyroid tumors as well as small and medium sized thyroid glands from incisions as small as one inch. Obviously, the smaller incisions are less invasive, less painful and result in smaller finer scars. This operation is safe, achieves esthetically pleasing scars and requires shorter recovery periods. What happens before surgery? We will schedule a pre-operative visit during which the doctor will fill-out hospital forms, go over your medical history, current medications, allergies etc. and perform a complete physical examination. You will also be given the opportunity to ask questions about the procedure, hospitalization, complications, etc. You will sign the pre-operative surgical consent form and receive your post-operative instructions, and prescriptions for antibiotics, pain killers and other medications you may need after surgery. What is pre-operative assessment? After you finish with the doctor, you will then go to the hospital for pre-operative registration and assessment. This is where pre-operative blood tests, EKG, chest x-rays, etc. are carried out. You will also have the opportunity to talk to the anesthesiologist and ask questions or express concerns about anesthesia. Here also, you will be informed of the time of the operation and given instructions about when to take your medications and what to wear. You may also be asked to sign consent forms for surgery, anesthesia and blood transfusions. Sometimes, this assessment may not be necessary and may be carried out on the telephone. What time do I show up on the day of surgery? The assessment nurse will tell you the exact time of your operation and when to come to the hospital. In general, you are expected to be in the hospital, an hour and a half prior to your scheduled procedure. What happens on the day of surgery? If you have been assigned a room and have been admitted to a hospital bed, then you will be transported to the pre-operative holding area about 30 minutes prior to your operation. Your family may remain in your room or wait in the Surgery waiting area on the second floor. It would be helpful if family members or friends notify the nurses’ desk or the waiting room receptionist of their whereabouts, so that we can find them to let them know that your surgery is over. If you have not been assigned a room, you would be asked to go to the second floor registration and from there, you would be directed to Day Surgery pre-op holding. In pre-op holding, the nurses will start an IV line and review your history and medications. They will ask you questions to make sure you understand what is going to be done and that you have consented. They may make you sign the consent forms if you have not signed them during assessment. They will also mark the operative site with ink and if applicable, write on your neck LEFT or RIGHT so that there will be no confusion as to which side is being operated on. You may request a tranquilizer if you are very anxious. What is recurrent laryngeal nerve monitoring? Recurrent laryngeal nerve monitoring and mapping using EMG (electromyography) is the latest in technological innovation in thyroid and parathyroid surgery. A special endotracheal tube with right and left electrodes is placed near the muscles of the vocal cords which are innervated by the recurrent laryngeal nerve. These electrodes are connected to a computer that analyzes the electric activity and displays the electro-

myographic (EMG) activity of the vocal cords ( muscle electrical potentials) on a screen. During the operation, the electrical activity (EMG response) of the nerve is continuously monitored. If the recurrent laryngeal nerve is stimulated or disturbed, an electrical impulse is detected by the monitoring technician who alerts the surgeon. What happens during surgery? When the thyroid is removed, it is sent for frozen section. This means that they freeze a piece of the gland, slice it very thin and color it for the pathologist to examine it under the microscope. Most often, the pathologist is able to determine if it is a cancer or a benign lesion. If there is cancer, the remaining thyroid tissue is removed and sometimes, the lymph nodes of the neck are removed as well (neck dissection). In rare instances, the pathologist may be unable to make a diagnosis on frozen section and the diagnosis is postponed until the tissue has been permanently processed in the laboratory. This may take a few days. It is therefore possible for a patient to go home and be called back for more surgery if a cancer is discovered in the permanent preparation. What happens after surgery? When you wake up from surgery, you will be transported to the recovery room (PACU), where would spend about 30 minutes to an hour, until you are fully awake and stable for transportation to your room. You will be asked to speak to find out if your voice is hoarse. Many patients, especially smokers, have a raspy or hoarse voice when they wake up from anesthesia. Smokers have a tendency to cough. You will notice that the wound is not covered with a dressing; it is just sealed with acrylic glue (Dermabond). Occasionally, however, dressings or drains are needed and you may notice a dressing wrapped around your neck and drain tubes attached to your clothes or a necklace. These are usually removed the next day. Please do not pull on them or try to empty the attached plastic bulbs. For 2 – 3 days after the surgery, it is not unusual to have pain or difficulty on swallowing. The nurses have standing orders to give you antibiotics, pain killers, thyroid replacement hormone and medications for nausea and vomiting. If there are no contraindications, you will also receive your usual home medications. Most patients develop a transient hypocalcemia (low calcium) in the immediate post-operative period. That is why your calcium, phosphorus and magnesium levels will be monitored every six hours and sometimes more frequently. If you develop hypocalcemia, you will be given calcium by mouth and / or intravenously. Tingling around the mouth and face, muscle spasms of the hands and feet, involuntary grimacing and sometimes difficulty in breathing and gasping for air (stridor) are signs of hypocalcemia. If you feel up to it, you are allowed to stand up, walk and go to the bathroom, with assistance and always, with someone present in the room. Do not attempt at walking or going to the bathroom if you are alone in the room. You may be too groggy from the pain killers or you may passout and fall down. In general, the wound is sealed with a thin clear acrylic layer (Dermabond) and the sutures are buried under the skin. There is no need to apply antibiotic ointment on the wound. You are allowed to take a shower without covering the wound. This acrylic film will peal off in a couple of weeks. When you go home, please keep the wound exposed and do not hide it with a dressing or scarf. A little antibiotic ointment may be used at the site of the drains for a day or two. In general the drain wound heals and stops oozing in 24 hours. When do I go home? Most patients are discharged the day after the operation. By then, they should be able to eat, walk and go to the bathroom. Occasionally, however, some patients may run a temperature or continue to have hypocalcemia, nausea or excessive drainage. It is not uncommon for older men, especially those with large prostates, to develop urinary retention after general anesthesia. In all these instances, discharge is delayed a day or two, until the problem is resolved. Complications Bleeding or infection are possible short term complications. Although rare in thyroid surgery, some patients may develop a thick scar or keloid. Two complications specific to thyroid surgery are hypocalcemia and vocal cord weakness or paralysis. Hypocalcemia, or low blood levels of calcium, may occur after complete removal of both thyroid lobes. This condition is caused by interference with four tiny glands called parathyroid glands, which are located within or very close to the thyroid gland. Hypocalcemia is usually temporary, but sometimes may require calcium supplements if sufficiently pronounced. Permanent hypocalcemia is fortunately rare. Vocal cord weakness or paralysis may be caused by swelling, stretching, or injury to the recurrent laryngeal nerve which passes very close to the thyroid gland. Temporary hoarseness may result. Again, this is an uncommon, usually temporary complication. Permanent vocal cord paralysis is rare COLOSTOMY What is a colostomy? A colostomy is an incision (cut) into the colon (large intestine) to create an artificial opening or "stoma" to the exterior of the abdomen. This opening serves as a substitute anus through which the intestines can eliminate waste products until the colon can heal or other corrective surgery can be done. The bowel movements fall into a collection pouch. Our ostomy nursing staff will teach you skin care and how to change the bag. When is a colostomy needed? A colostomy may be needed to divert intestinal contents in conditions such as necrotizing enterocolitis ( an acute inflammatory disease of the bowel), imperforate anus (absence of anal opening) or Hirschsprung's Disease (a condition in which the nerves controlling bowel function are abnormal). Each one of these conditions will be explained in detail by your pediatric surgeonHow is a colostomy created? 1. 2. 3. 4.

an abdominal opening is created the intestines are brought out through the skin the intestine is sutured to the skin the stoma is complete

How is a colostomy cared for?

There are many products available for colostomy care. You will be carefully instructed about colostomy care before discharge from the hospital. Many stomas are temporary and can later be closed. INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) Steps in the IMCI Case Management Process: 1.Assess and Classify 2.Identify Treatment 3.Treat 4.Counsel the Mother 5.Follow-Up A. Assess and Classify Sick Children 2 months up to 5 Years 1. Determine which age group the child belongs: 1 week up to 2 months 2 months up to 5 years 2. Record the child’s data : Name, Age in months, Weight in kg., temperature, etc. 3. Ask the mother what the child’s problems are. 4. Determine if this is an initial or follow – up visit: Initial visit – 1st visit for this episode of an illness or problem Follow-up visit- the child has been seen a few days ago for the same illness - if the child’s conditions improved, still the same or is getting better 4. Check for general danger signs: a. Not able to drink or breastfeed •too weak to drink and is not able to suck or swallow when offered a drink or Breast-feed •if not sure: ask mother to offer child a drink of clean water or breast milk •A child may have difficulty sucking when his nose is blocked. If the nose is blocked, clean it. b. Vomits everything •a child is not able to hold anything down at all •if in doubt, offer the child water c. Convulsions (during this illness) •arms and legs stiffen because muscles are contracting •the child may lose consciousness or not be able to respond to spoken directions or handling, even if eyes are open •“fits” or “spasms” or “jerky movements” Note: Shiver is not convulsion. There is no loss of consciousness. d. Abnormally sleepy or difficult to awaken •drowsy and does not show interest in what is happening around him •stare blankly and appear no to notice what is going on around him •does not respond when touched, shaken or spoken to Note: 1. If the child is asleep and has cough or difficult breathing, counts the numbers of breaths first before you try to wake the child. 2. If there is any general danger sign, complete the assessment and any pre-referral treatment immediately so referral is not delayed. 5. Assess and classify cough or difficult breathing •2 Common Causes of Pneumonia 1.Stretococcus pnemoniae 2.Hemophilus influenzae •2 Causes of Death 1.hypoxia – too little oxygen 2.sepsis – generalized infection •Health workers can identify almost all causes of pneumonia by checking for 2 clinical signs: 1. fast breathing – body’s response to stiff lungs and hypoxia 2. chest indrawing Assess cough or difficult breathing: Does the child have cough or difficult breathing? “fast” or “noisy” or “interrupted”? * If the answer is NO, look back to see if you think the child has cough or difficult breathing. •how long? chronic cough – more than 30 days - may be sign of tuberculosis, asthma, whooping cough or another problem •fast breathing a. Count the breaths in one minute 1.child must be quiet and calm 2.no feeding, crying or angry ∗ Ask the mother to lift the child’s shirt. If you are not sure about the number of breaths you counted, repeat the count. b. cut-off for fast breathing: if the child is: fast breathing is: 2 months up to 12 months 50 breaths/ minute or more 12 months up to 5 years 40 breaths/ minute or more

∗Determine if the child is breathing IN or breathing OUT •chest indrawing – the lower chest wall goes IN when the child breaths IN NORMAL: the whole chest wall and abdomen move OUT when the child breaths IN Best position: lying down Conditions: clearly visible Note: intercostals indrawing or intercostals retractions and subcostal indrawing are not chest indrawing. •Look or listen for stridor. Stridor – harsh noise made when the child breaths IN -- happens when there is swelling of the larynx, trachea, or epiglottis ∗Put your ear near the child’s mouth and look at the movement of the abdomen to determine if child is breathing IN or OUT wet noise - blocked nose wheezing - harsh noise while breathing OUT; not stridor CLASSIFY COUGH OR DIFFICULT BREATHING 6. Assess and classify diarrhea diarrhea – loose or watery stool-defined as 3 or more loose or watery stools in a 24 – hour period Assess: •how long? •blood in stool •signs of dehydration If YES, asses for: •dehydration •persistent diarrhea – 14 days or more •Dysentery Asses for dehydration: •Abnormally sleepy or difficult to awaken •Restless and irritable: (all the time) •Sunken eyes: If not sure, ask the mother if the child’s eyes look unusual. •Offer the child fluid: *Not able to drink - if he is not able to take fluid in his mouth and swallow it Drinking poorly – if the child is weak and cannot drink without help. Drinking eagerly, thirsty – reaches out for the cup or spoon when you offer water. •Pinch the skin of the abdomen: Goes back very slowly – longer than 2 seconds Goes back slowly – the skin stays up for even a brief time after release. CLASSIFY DIARRHEA FOR; DEHYDRATION PERSISTENT DIARRHEA DYSENTERY 7. Assess Fever A child has the main symptom fever if: --the child has history of fever – no fever now but had fever within 72 hours or --the child feels hot or --the child has an axillary temperature of 37.5 C or above Decide malaria risk: -child lives in malarious area or -has been in a malaria risk area in the past 4 weeks. Look or feel for stiff neck: -look to see if the child moves and bends his neck easily as he looks around or -draw the child’s attention to his toes or -gently support his back and bend the head forward toward hid chest. Look for runny nose ( not history of runny nose) Look for signs of Measles: generalized rash and any one of the following: cough, runny nose, or red eyes. Measles rash: begins behind the ears and on the neck, spreads to the face, and to the rest of the body; does not have vesicles or pustules; does not itch. If the child has measles now or within the last 3 months, assess for: -mouth ulcers – painful open sore on the inside of the mouth and lips or tongue -pus draining from the eye -clouding of the cornea – hazy area in the cornea Assess for Dengue Hemorrhagic Fever all children two months of age or older. - Look and feel for signs of bleeding and shock:-bleeding from the nose and gums -skin petechiae – small hemorrhages in the skin; look like small dark red spots or patches in the skin; not raised, not tender; if you stretch the skin they do not lose their color. -Cold and clammy extremities -If with cold and clammy extremities, check for slow capillary refill ( longer than 3 seconds) -Perform the tourniquet test if: there are no signs in the ASK or LOOK and FEEL, the child is 6 months or older, and the fever is present for more than 3 days. CLASSIFY FEVER 8. Assess Ear Problem Assess the child for: -Ear pain -Ear discharge; Present less than 2 weeks – Acute ear infection Present 2 weeks or more – Chronic Ear Infection -Tender swelling behind the ear CLASSIFY EAR PROBLEM 9. Check for malnutrition and anemia: *Look for visible severe wasting – a child with visible severe wasting has marasmus, a form of severe malnutrition.. A child has this sign if he is thin, has no fat, and looks like skin and bones. Look for palmar pallor – a sign of anemia Some palmar pallor – the skin on the child’s palm is pale Severe palmar pallor – the palm is very pale or so pale that it looks white

•

Look and feel for edema of both feet – the child may have kwashiorkor, a form of severe malnutrition.

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Determine weight for age: Very low weight for age – child’s weight is below the bottom curve of a weight for age chart. CLASSIFY NUTRITIONAL STATUS 10. Check the child’s immunization status. 11. Check the child’s Vitamin A status. 12.Assess other Problems. B.Management of the Sick Young Infant Age 1 Week Up to 2 Months 1. Assess the sick young infant Check the young infant for possible bacterial infection. 1. Ask if the child had convulsion at any time after birth. 2. Count the number of breaths in one minute. Fast breathing is 60 breaths per minute or more. 3. Look for severe chest indrawing. Mild chest indrawing is normal in a young infant or young child. Severe chest indrawing is very deep and easy to see. 4. Look for nasal flaring – widening of the nostrils when the young infant breaths in. 5. Look and listen for grunting – soft, short sounds when breathing out. 6. ‘Look and feel for bulging fontanelle. Fontanelle is the soft spot on the top of the young infant’s head, where the bones of the head have not formed completely. 7. Look at the umbilicus – is it red or draining pus? 8. Measure temperature or feel for fever or low body temperature. Fever (axillary) temperature 37.5 C or more; rectal temperature 38 C or more). Hypothermia ( axillary0temperature below 35.5 C; rectal temperature below 36 C). 9. Look for skin pustules – red spots or blisters which contain pus. A severe pustule is large of has redness extending beyond the pustule. 10. LOOK: See if the child is abnormally sleepy or difficult to awaken. 11.LOOK at the young infant’s movement. Are they less that normal? CLASSIFY ALL SICK YOUNG INFANT FOR BACTERIAL INFECTION Assess Diarrhea -- For how long? -- Is there blood in the stool? -- Look at the young infant’s general condition. Is it “Abnormally sleepy or difficult to awaken” or “Restless and irritable”? --Look for sunken eyes.-Pinch the skin of the abdomen. Does it go back very slowly? Or slowly? CLASSIFY DIARRHEA Check for feeding problem or low weight. Assess Breastfeeding. 4 Signs of Good Positioning; --with infant’s head and body straight --facing her breast, with infant’s nose opposite her nipples --with infant’s body close to her body --supporting infant’s whole body, not just neck and shoulders 4 Sign of Good Attachment: --Chin touching breast --Mouth wide open --Lower lip turned outward --More areola visible above than below the mouth. * Suckling effectively – the infant suckles with slow, deep sucks and sometimes pauses. You may see or hear the infant swallowing.

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Not suckling effectively – he is taking only rapid, shallow sucks. You may see indrawing of the cheeks. You do not see or hear swallowing.

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Not suckling at all – not able to suck breastmilk into his mouth and swallow.

Look for ulcers or white patches in the mouth (thrush). Thrush looks like milk cuds on the inside of the cheek, or thick white coating of the tongue. Try to wipe it off. Milk curds will be removed but thrush will remain. Check the Young Infant’s Immunization Status Assess Other Problems