FEVER IN IMCI
FEVER
According
to IMCI, a child with fever may have Malaria,
Meningitis, Measles or another severe disease.
Causes of Malaria
Ø Plasmodium
vivax
Ø Plasmodium
Malariae
Ø Plasmodium
Falciparum (more severe)
Ø Plasmodium
Ovale.
Transmission of Malaria
Malaria is transmitted by the bite of infected female
Anopheles mosquito, which is found in dumpy, swampy, watery areas.
CLINICAL PICTURE
Ø Fever
Ø Headache
Ø Abdominal
pains
Ø Nausea
and Vomiting
Ø General
body pains and body weakness.
NURSING MANAGEMENT
Nurse will ask the parent or caretaker for a history of
fever or if the child’s body feels hot. The child has a history of fever if
child has had any fever with this illness. Measure the body temperature of all
sick children or child in this case.
Find out if the child:
Ø Has
history of fever.
Ø Feels
hot, nurse should feel the child‘s stomach or under arm and determine if child
feels hot.
Ø Has a
temperature of 37.5 or above.
If child does not have fever by history or does not feel
hot or temperature is not 37.5 or above, do not assess the child for signs of
related fever. If caretaker reports that the child has had fever with this
illness, and then assess the child for signs of related fever, even if the
child does not have a temperature of 37.5 or does not feel hot. Ask for how long has the fever been? Is it
more than 7 days? Has the fever been present everyday? Thereafter, look or feel
for stiff neck.
Draw the child’s head to his umbilicus or toes. For
example, you can tickle his toes to encourage the child to look down. Look to
see if the child can bend his neck when he looks down at his umbilicus or toes.
If you still have not seen the child bend his neck himself, asks the caretaker to
help you lay the child, gently support his back and shoulders with one hand.
With the other hand, then carefully bend the head forward towards his chest. If
the neck bends easily, the child does not have a stiff neck. If the neck feels
stiff and there is resistance to bending the child the child does have a stiff
neck.
CLASSIFICATION OF FEVER
There are two possible classifications of fever;
Ø Very
severe febrile disease
Ø Malaria
Classification and Treatment of the Child with Fever
1. Very Severe Febrile Disease
Signs are
any general danger sign for example, stiff neck, and convulsions.
Treatment
1. Give a first dose of injection Quinine e.g. 1 year of 8
kg give 0.8mls-loading dose, then 0.4mls for maintenance dose. For a 5 years
child weighing15kg, give 2.4mls loading dose then 1.2 maintenance dose. Treat
the child to prevent low blood sugar (preventing low blood sugar is an urgent
pre-referral treatment for children very severe febrile disease) by giving some
breast milk, breast milk substitutes or sugar water all provide glucose to
treat and prevent low blood sugar. Give 50% Dextrose or Ringers lactate. Give a
first dose of an appropriate antibiotic e.g. co-trimoxazole. Do tepid sponging
and give one dose of Paracetamol for fever of 38.5 or above. Then refer
urgently to the hospital.
2. Malaria
Signs are: Any
history of fever or temperature of 37.5 or above.
Treatment
First line treatment using the new government policy is
Coartem or Atermether-lumefantrine.
Fansidar will be used in the transition period as first
line drug for malaria treatment, given in a single dose. Under 1 year give ¼
tablets, 1-3 years give ½ tablet, 4-6 years give 1 tablet.
Then Quinine will be used as the second line
treatment. If the child has already been treated with Fansidar during this
episode of fever, treat with oral Quinine. Do tepid sponging.
Give one dose of Paracetamol for fever of 38.5 or above.
Advise the caretaker when to return immediately or for review. Ask the
caretaker to return in 2 days time if fever persists. If fever is present
everyday for 7 days, re-assess and refer to the hospital.
MENINGITIS
It is one of the causes of fevers in children. Acute
bacterial meningitis is a bacterial infection of the meninges and the cerebro
spinal fluids, which results in meningeal inflamation, obstruction of the
circulation of cerebral spinal fluid caused by purulent exudate, cerebral edema
and local necrosis of nerve fibres and cerebral vessels.
Diagnosis
Ø Look for
history of:
Ø Vomiting
Ø Inability
to drink and breastfeed
Ø A
headache or pain in back of neck
Ø A recent
head injury
Ø Convulsions
and irritability.
On examination, look for:
Ø A stiff
neck
Ø Repeated
convulsions
Ø Lethargy
Ø Irritability
Ø Bulging
fontanelle
Also look for signs of increased intracranial
pressure:
Ø Unequal pupils
Ø Rigid
posture
Ø Focal
paralysis in any of the limb or trunk
Ø Irregular
breathing
Lab investigations
Lumbar puncture
Ø CSF
microscopy will reveal the presence of meningitis
Ø White
cell count is above 100/mm3
Ø CSF
glucose lower than 1.5
mmol/litre
Ø CSF protein
higher than 0.4g/litre
Treatment
If the CSF is obviously cloud, treat immediately with
antibiotics before results of lab CSF are available. If the child has signs of
meningitis and lumbar puncture is not possible treat immediately.
Antibiotic treatment
Choose one of the two regimes
1. Chloramphenicol 25mg/kg IM (IV) qid Plus Ampicillin 50mg/kg IM (or IV) qid
2. Chloramphenicol 25mg/kg IM (or IV) qid Plus Benzylpenicillin 60mg/kg IM or IV
qid
In case of resistant the third generation drugs are
used:
Ceftriaxone 50mg/kg IV, over 30- 60 minutes every 12
hours or Cefotaxime 50mg/kg IM or IV, every 6 hrs.
NURSING MANAGEMENT OF A CHILD WITH MENINGITIS
Assessment of activities of living (Roper, Logan and Tierney model)
Maintenance of safe environment
The child will have altered level of consciousness and is
at risk of falls.
The child will have seizures and will be photophobic.
Child will have communication difficulties due to severity of the illness. The
child may not communicate due to coma or due to unfamiliar hospital
environment. Child may be fearful and cry continuously resulting into
communication problems with the caretaker.
Breathing
Child will have difficulties in breathing due to paralysis
of respiratory muscles. Altered respiratory pattern i.e. chenny strokes,
hypoventilation due to hypoxia will be another problem causing difficulty in
breathing to the child.
Eating and drinking
Child will be vomiting, unable to tolerate food due
confusion and restlessness and unable to take food orally due paralysis of the
muscles of mastication and altered level of consciousness..
Eliminating
Child will be unable to micturate and defecate or
constipated due to reduced food intake.
The child’s urine will be concentrated and the
specific gravity will be raised.
Personal cleansing and dressing
The older child may not be able to bath him or herself due
to altered level of consciousness. Mother or caretaker may be unable to bath
the child due to unconsciousness.
Controlling body temperature
Child will have fever due to presence of infection in the
body (trauma to hypothalamus)
Mobilizing
Child may be unable to move due to restlessness,
unconsciousness, pain, bed rest and weakness.
Work and play
The child will be unable to play due to strange
environment, altered level of consciousness and anxiety.
Expressing sexuality
Sexuality in children is usually expressed in play.
Therefore, the child will be unable to express it due to hospitalization, pain
and weakness.
Sleeping
Child is unable to sleep due to fever, disorientation,
pain and anxiety.
Dying
This issue is discussed depending on the age of the sick
child and the condition.
In younger children it is discussed with the caretaker.
NURSING DIAGNOSES
- Altered body temperature related to the
stimulation of the thermal regulatory centre in the brain by the
endogenous pyrogens evidenced by a fever of 38*c
- Altered nutrition less than body requirements,
related to reduced oral intake and vomiting as evidenced by weight loss.
- Risk for trauma like falls related to restlessness,
unconsciousness and disorientation.
- Headache related to irritation of the meninges
exhibited by patient being restless.
- Self care deficit related to inability to
maintain body hygiene as evidenced by patient’s unkemptness. (In older
children)
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