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Community Survey

Community survey is a method of gathering information and data about a specific community.

Facts or Profile to be obtained during a Community Survey

1. Population Size: The survey collects data on the total number of individuals living in the community. This information helps in understanding the scale of the population and its implications for planning and resource allocation.

2. Location: The survey identifies the geographical location of the community, including its specific geographical boundaries. This information is important for mapping, resource allocation, and understanding the community’s environmental status.

3. Climate Conditions: Data on the climate conditions of the community, such as temperature, rainfall patterns, and prevailing weather conditions, are collected. This information helps in understanding the environmental status and can have implications for various sectors, including agriculture, health, and infrastructure.

4. Ethnicity: The survey gathers information on the ethnic composition of the community, including the major ethnic groups residing in the area. Understanding the ethnic diversity of a community is important for cultural sensitivity, equitable service provision, and promoting social cohesion.

5. Economic Status: Information on the economic status of the community is obtained during the survey. This includes factors such as income levels, poverty rates, employment opportunities, and economic indicators. Understanding the economic status helps in addressing socio-economic differences and designing targeted interventions.

6. Education: The survey collects data on the education levels and literacy rates within the community. This information provides insights into the educational needs, availability of educational resources, and potential barriers to accessing education.

7. Standard of Living: Data on the standard of living are obtained to assess the overall quality of life within the community. This may include housing conditions, access to basic needs (such as clean water, sanitation, and electricity), and indicators related to health and well-being.

8. Occupation: The survey gathers information on the types of occupations and employment patterns within the community. This data helps in understanding the community’s economic activities, labor markets, and potential skill gaps or opportunities.

9. Religion: Information on religious affiliations and practices within the community is collected during the survey. This helps in understanding the religious diversity and cultural practices that may influence various aspects of community life.

Questions to Address during Community Survey

What are the major problems or challenges faced by the community?
How well is the existing health facility addressing these problems or challenges?
What are the strengths and weaknesses of health workers in their roles and responsibilities?
What are the perceived problems and needs of health workers in delivering healthcare services?
What are the perceived problems and needs of community members regarding their healthcare?
Are community members satisfied with the quality and accessibility of healthcare services?
What are the barriers or challenges community members face in accessing healthcare?
Are there specific health issues or diseases prevalent in the community that need attention?
Are community members aware of preventive healthcare measures and health promotion activities?
Are there any specific groups within the community (e.g., children, elderly, marginalized populations) that require targeted healthcare interventions?
Are there any cultural or social factors that influence healthcare-seeking behaviors in the community?
Are there any existing community-based healthcare initiatives or programs? How effective are they?
What are the community’s perceptions and attitudes toward healthcare providers and services?
Are there any gaps in healthcare infrastructure or resources within the community?
How does the community perceive the affordability and availability of healthcare services?

Importance of conducting a Community Survey

1. Identification of the community’s needs and problems: A community survey helps to systematically identify the specific needs, challenges, and issues faced by the community. It provides valuable data and insights that inform decision-making and resource allocation.

2. Provision of data for planning, implementation, and evaluation: The data collected through a community survey serves as a foundation for planning, implementing, and evaluating community-based health and development programs. It ensures that interventions are evidence-based, targeted, and aligned with the community’s needs.

3. Development and decision-making for community involvement: A community survey helps in developing strategies to involve the community actively in the planning and implementation of programs. It fosters participatory approaches, ownership, and empowerment within the community.

4. Community self-awareness and problem-solving: By conducting a survey, the community becomes more conscious of its existing problems, challenges, and potential solutions. It creates an opportunity for the community to reflect on its own strengths and weaknesses and take collective action to address the identified issues.

5. Matching project organization and services to community needs: The data from a community survey helps in aligning project organizations and services with the specific needs and priorities of the community. It ensures that resources and interventions are tailored to the unique characteristics of the community.

6. Understanding social, cultural, and environmental characteristics: A community survey provides insights into the social, cultural, and environmental aspects of the community. It helps in understanding the way in which interventions will be implemented and tailoring strategies to the community’s specific characteristics.

7. Creating opportunities for inter-sectoral collaboration: A community survey facilitates the identification of opportunities for collaboration among different sectors, such as healthcare, education, social services, and environmental agencies. It promotes coordination among stakeholders to address the multifaceted needs of the community.

How to Conduct a Community Survey

When planning a survey, consider the following;

Time
What information will be collected
Community health problems
Competencies of the health workers
Community attitude towards health workers
Health resources in the community
Environmental sanitation as in H2O, housing, nutrition, hygiene
Where will the data be collected?
How will the data be analyzed?
How will the data be used?

Process of community survey

Planning:

Clearly define the purpose and objectives of the survey.
Consult individuals with relevant experience and expertise in survey design and implementation.
Visit the community to gather information about the population, culture, and specific health issues.
Determine the key questions or observations to be included in the survey and ensure they are standardized.
Design the survey instrument or questionnaire and finalize its format and presentation.
Select an appropriate sample size and sampling method.
Allocate resources required for the survey, including personnel, equipment, and funding.

Organizing:

Obtain cooperation and involvement from local community members who can assist in organizing and conducting the survey.
Recruit and train survey staff or volunteers who will administer the survey.
Arrange for necessary laboratory facilities or equipment if required for data collection.
Develop a detailed plan outlining the tasks, responsibilities, and timeline for each phase of the survey.
Prepare all the required resources, such as survey materials, data collection tools, and logistics.

Implementation:

Provide supervision to the survey staff to ensure they have the necessary equipment and resources for data collection.
Supervise and coordinate with senior members of the local community who are assisting with the survey.
Ensure that the survey is administered properly, and participants receive satisfactory service.
Monitor data collection to maintain data quality and accuracy.

Evaluation and Feedback:

Analyze the collected survey data using appropriate statistical methods.
Discuss the results with medical staff and members of the community to gain additional insights and perspectives.
Prepare a brief report summarizing the findings, including recommendations for action.
Share the report and recommendations with relevant stakeholders, such as the Ministry of Health or community leaders.
Provide feedback to the community, sharing the survey results and engaging in a dialogue about potential interventions and next steps.

Roles of a nurse in a community survey

1. Planning and Design: Nurses play a crucial role in the planning and design phase of a community survey. They contribute their knowledge and expertise in identifying relevant health indicators, designing appropriate survey questions related to health, and ensuring that the survey instrument captures important health data.

2. Data Collection: Nurses actively participate in the data collection process during a community survey. They administer surveys, conduct interviews, and engage with community members to gather accurate and reliable health-related information. Nurses ensure that data collection is conducted in an ethical and culturally sensitive manner.

3. Health Education and Promotion: Nurses have an opportunity to provide health education and promotion messages during the community survey. They can disseminate information about preventive measures, health behaviors, and available healthcare services to community members. This role helps to raise awareness and promote positive health practices.

4. Health Assessment: Nurses contribute to the health assessment component of the community survey. They assess the health status of individuals, families, and the community as a whole. They may conduct physical assessments, collect vital signs, and screen for common health conditions. This assessment helps in identifying prevalent health issues and planning appropriate interventions.

5. Collaboration and Networking: Nurses actively collaborate with other healthcare professionals, community leaders, and organizations involved in the community survey. They work together to ensure the smooth execution of the survey, share health-related insights, and collaborate on follow-up actions, such as referrals for healthcare services or interventions.

6. Data Analysis and Interpretation: Nurses participate in the analysis and interpretation of health-related data collected during the survey. They apply their clinical knowledge and expertise to analyze health indicators, identify patterns or trends, and draw meaningful conclusions. Nurses contribute to the interpretation of data to inform healthcare planning and decision-making.

7. Reporting and Documentation: Nurses play a vital role in documenting survey findings, outcomes, and recommendations. They contribute to the preparation of reports summarizing the health-related data, observations, and identified health needs. Nurses ensure accurate documentation and communication of the survey results to relevant stakeholders, including healthcare teams and community leaders.

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Community Entry

Community entry refers to the process of engaging and integrating into a specific community or local area in order to work collaboratively with its members.

A process where one gets to know the status of the community and learns how best one can help the community following the normal steps.

It involves establishing relationships, building trust, and understanding the social, cultural, and economic dynamics of the community. This follows Community Approach.

Steps involved in Community Entry.

1. Preliminary study of the community: Conduct a comprehensive study to gather information about the community’s location, population size, climate conditions, education levels, ethnicity, economic status, standard of living, occupations, and religious affiliations. This information will provide a foundation for understanding the community’s needs and priorities.

2. Contact the community leaders: Reach out to influential individuals in the community, such as local councilors (L.Cs) or community representatives(CORPS), to establish initial contact. Introduce yourself, explain the purpose of your engagement, and express your interest in working collaboratively with the community.

3. Sensitization meeting: Organize a sensitization meeting with key community leaders and stakeholders. During this meeting, present your intentions, objectives, and proposed initiatives to seek their commitment, support, and feedback. This helps to create awareness about your presence and builds a foundation for collaboration.

4. Identification of potential partners: Identify potential partners within the community who share similar objectives or have experience working on related issues. This could include local NGOs, community-based organizations, or government agencies. Collaborating with established partners increases the likelihood of success and ensures a more comprehensive approach to community development.

5. Design a social map of the community: Develop a social map of the community, which outlines the key institutions, organizations, and influential individuals within the community. This map acts as a guideline for navigating the community and understanding the social status and power structures at play.

Factors to Consider when entering a Community

1. Community Structures: Understand the existing community structures and institutions, such as local councils, community-based organizations, or traditional leadership systems. Engage with these structures to utilize their knowledge, networks, and resources for effective community entry and collaboration.

2. Proper Timing: Consider the timing of your entry into the community. Be aware of significant cultural or religious events, agricultural seasons, or any other factors that may affect community members’ availability or presence to new initiatives. Choosing an appropriate time enhances acceptance and engagement.

3. Appropriate Target: Clearly define your target audience or beneficiaries within the community. Identify the specific group or individuals who will benefit from your interventions or initiatives. Tailor your approach, messaging, and activities to meet their specific needs and aspirations.

4. Approach Methodologies: Determine the most suitable approach and methodologies for engaging with the community. This could include participatory methods, community mobilization, workshops, focus group discussions, or one-on-one interactions. Choose methods that facilitate active community participation, ensure inclusivity, and encourage meaningful engagement.

5. Resource Assessment: Assess the available resources within the community, including human resources, infrastructure, and local expertise. Identify potential assets and strengths that can be utilized or built upon for community development initiatives. This promotes sustainability and maximizes local ownership.

6. Power Status: Understand the power dynamics within the community, including social hierarchies, gender roles, and decision-making structures. Be sensitive to these dynamics and ensure inclusivity and equity in your engagement. Empower marginalized groups and ensure their voices are heard.

7. Local Knowledge and Expertise: Respect and value the community’s local knowledge, traditional practices, and expertise. Collaborate with community members to integrate their knowledge into your initiatives. This fosters mutual respect and ensures the relevance and effectiveness of interventions.

8. Community Priorities: Identify and align your initiatives with the community’s priorities and aspirations. Conduct needs assessments or consultations to understand their most pressing concerns and work together to address them. This increases community buy-in and ownership.

9. Monitoring and Evaluation: Establish mechanisms for ongoing monitoring and evaluation of your initiatives. Involve community members in the evaluation process to assess the impact, identify areas for improvement, and ensure accountability.

Importance of Community Entry

1. Conducting a Preliminary Study: Community entry allows for conducting a comprehensive preliminary study of the community. This study involves gathering information about the community’s demographics, socio-economic conditions, cultural practices, and other relevant factors. It provides a foundation for understanding the community’s unique characteristics, needs, and priorities.

2. Identifying Potential Partners: Through community entry, potential partners within the community can be identified. These partners can be local NGOs, community-based organizations, or other stakeholders who have experience working in the community. Collaborating with these partners enhances the effectiveness and sustainability of interventions by leveraging their local knowledge, resources, and networks.

3. Meeting Influential Community Members: Engaging with influential members of the community, such as community leaders or key stakeholders, is an essential aspect of community entry. These interactions allow for proper planning, establishing rapport, and gaining support from individuals who hold influence within the community. Their involvement contributes to the success and acceptance of initiatives.

4. Reviewing Community Health Data: Community entry provides an opportunity to review existing data about the community’s health status and problems. This data review helps in understanding the prevailing health issues, disease prevalence, healthcare utilization, and the specific health needs of the community. It enables the development of targeted interventions and strategies to address these health challenges effectively.

Roles of a Nurse in Community Entry

Conducting a Preliminary Study: Nurses gather information about the community’s demographics, health indicators, existing health services, and healthcare utilization patterns. This information helps in understanding the community’s specific health needs and designing appropriate interventions.
Engaging Community Leaders: Nurses establish relationships with influential community leaders, such as local council members or community health workers, to gain their support and involvement in community health initiatives. Collaboration with community leaders enhances the acceptance and effectiveness of healthcare interventions.
Collaborating with Local Healthcare Providers: Nurses collaborate with local healthcare providers, such as doctors, midwives, VHT’s or community health workers, to ensure seamless coordination and continuity of care. This collaboration improves access to healthcare services and promotes comprehensive and integrated healthcare delivery.
Mobilizing Community Resources: Nurses identify and mobilize community resources that can support health promotion activities. They may involve local organizations, volunteers, or community members in implementing health initiatives and leveraging available resources to address health challenges.
Advocating for Community Health: Nurses serve as advocates for the community’s health needs and rights. They raise awareness of health disparities, facilitate access to healthcare services, and advocate for policies and interventions that promote the well-being of the community.

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Introduction To Community Based Health Care (CBHC)

TECHNIQUES USED TO ESTABLISH COMMUNITY HEALTH ACTIVITIES

Below are the steps taken to establish community health activity.

∙ Community approach
∙ Community entry
∙ Community Assessment
∙ Community situation analysis (Diagnosis)
∙ Community mobilization
∙ Community participation
∙ Community organization
∙ Community empowerment
∙ Community based rehabilitative services for disabled and disadvantaged groups

Community Approach

Community approach refers to a comprehensive and participatory approach to addressing health issues and promoting well-being within a specific community or geographic area.

It emphasizes the active involvement and engagement of community members in identifying, prioritizing, and solving health challenges.

A community approach involves recognizing the unique characteristics, cultural beliefs, and social dynamics of a particular community. It seeks to understand the community’s needs, resources, and strengths, and collaboratively develop and implement interventions that are appropriate and sustainable. This approach recognizes that communities are not passive recipients of healthcare services but active partners in their own health promotion.

Elements of Community Approach

Community participation and ownership: The community is actively engaged and empowered to take ownership of their health. This includes involving community members in decision-making processes, mobilizing community resources, and fostering a sense of collective responsibility for health outcomes.
Needs Assessment: Conducting a thorough needs assessment is an integral part of the community approach. This involves gathering information about the community’s health challenges, existing health infrastructure, socio-economic factors, cultural beliefs, and practices. It helps identify priority health issues and tailor interventions to the specific needs of the community.
Community Mobilization, Health Education and Awareness: Community mobilization activities are carried out to raise awareness and engage community members. This may include community meetings, workshops, door-to-door campaigns, and the use of various communication channels to disseminate health-related information. The aim is to educate community members about health issues, prevention strategies, and available services.
Capacity Building and Training: Building the capacity of community members, including community health workers and volunteers, is crucial for effective implementation of the community approach. Training programs are conducted to equip them with the necessary knowledge, skills, and resources to deliver health services, health promotion activities, and community mobilization efforts. Training may cover areas such as health education, disease prevention, first aid, data collection, and management.
Integration with existing systems: The community approach strives to integrate community-based health services with the existing formal healthcare system. This coordination ensures seamless referral mechanisms, effective collaboration with health facilities and professionals, and alignment with national health policies and guidelines.
Collaboration and partnerships: Successful community-based health programs in Uganda often involve partnerships and collaborations between community organizations, non-governmental organizations (NGOs), government agencies, and other stakeholders. These partnerships help leverage resources, expertise, and support for sustainable implementation and scaling up of interventions.
Monitoring and evaluation: Regular monitoring and evaluation are essential components of the community approach. They enable the assessment of program effectiveness, identification of challenges, and adjustment of strategies as needed. Monitoring and evaluation also facilitate accountability and learning within the community and among program implementers.

What is involved in Community Approach?

1. Site identification and location of the community:
– These activities can be considered as part of the needs assessment stage in the community approach. They involve identifying the specific site or area where the community is located and understanding its geographical area.

2. Request community members:
– This step aligns with community participation and engagement. Requesting community members’ involvement indicates the intention to actively engage them in the community approach, seeking their input, and involving them in decision-making processes.

3. Get data from other sources:
– Gathering data from other sources helps in understanding the community’s health challenges, existing infrastructure, and socio-cultural factors that influence health. This activity is related to the needs assessment element of the community approach.

4. Site Investigations:
– Accessibility to health facilities: This aligns with the goal of assessing the community’s existing health infrastructure and understanding the availability and proximity of health facilities, which is important for planning interventions.
– Community interest: Evaluating the community’s interest and receptiveness towards health programs is an important part of community mobilization and engagement.
– Availability of health facilities: Assessing the availability and functionality of health facilities relates to the needs assessment and resource mapping components of the community approach.

5. Other Resources: LCS, clan leaders, chiefs, community residents:
– These mentioned resources represent key stakeholders in the community who play a significant role in the community approach:
– LCS (Local Council Systems): They are local government structures that can provide support and collaboration in implementing community-based health programs.
– Clan leaders and chiefs: These community leaders are important influencers who can facilitate community mobilization, engagement, and collaboration with health initiatives.
– Community residents: Community members’ active participation and involvement are crucial for the success of the community approach, as they are the primary beneficiaries and contributors to their own health outcomes.

How to Carry Out Community Approach

1. Go through their gatekeepers:
– Engage with gatekeepers to gain access to the community and seek their support and collaboration. Gatekeepers may include community leaders, local authorities, respected individuals, or community-based organizations.

2. Understand the culture and norms of the community:
– Take the time to learn about the community’s culture, traditions, values, and social norms. This understanding helps build trust, respect, and effective communication with community members. It enables you to adapt interventions to align with community practices and preferences.

3. Assess the needs of the community:
– Conduct a comprehensive assessment of the community’s health needs, challenges, and assets. Engage community members through surveys, interviews, focus groups, and observations to gather information. This assessment provides a foundation for planning interventions that are responsive to the community’s specific needs.

4. Prioritize the community needs with them:
– Collaborate with community members to prioritize the identified needs. Engage in dialogue and discussions to understand their perspectives, values, and priorities. Together, determine which needs are most critical and align with the community’s goals and resources.

5. Plan with them:
– Facilitate a participation-planning process that involves community members at every stage. Engage them in setting goals, defining strategies, and developing action plans. Encourage their active participation, ownership, and leadership in the planning process.

6. Implement with them:
– Work together with community members to implement the planned interventions. Assign roles and responsibilities, and involve community members in the execution of activities. Ensure that the implementation aligns with the community’s cultural setting, resources, and capacities.

7. Evaluate with them:
– Conduct evaluations in collaboration with community members to assess the impact and effectiveness of the interventions. Use participatory evaluation methods, such as surveys, focus groups, and community feedback sessions. Involve community members in data collection, analysis, and interpretation. This process promotes transparency, accountability, and shared learning.

Reasons for Community Approach

1. Ownership, Sustainability, and Community Engagement: The community approach promotes community ownership and involvement in health initiatives. When community members actively participate in decision-making, planning, and implementation, they feel a sense of ownership and responsibility for the success of the interventions. This leads to increased sustainability as the community is more likely to continue and maintain the initiatives even after external support diminishes.

2. Maintenance of Equipment and Infrastructure: By engaging community members in the upkeep and maintenance of health facilities, equipment, and resources, the longevity and functionality of these assets are improved. Community members take pride in their health facilities, ensuring they are well-maintained and available for use when needed.

3. Accessibility: The community approach focuses on improving access to healthcare services. By bringing healthcare services closer to the community, barriers such as distance, transportation costs, and lack of infrastructure are reduced. This results in increased accessibility to healthcare, particularly for marginalized and underserved populations who may face significant challenges in accessing formal healthcare facilities.

4. Support in Terms of Resources: The community approach taps into the resources available within the community. This can include community members’ skills, knowledge, traditional practices, and local resources. By leveraging these community resources, the community approach reduces dependence on external resources and fosters self-reliance. It also ensures that interventions are culturally relevant, aligned with local practices, and utilize resources that are readily available within the community.

5. Local Knowledge and Expertise: Communities possess valuable knowledge about their specific health challenges, local setting, and traditional practices. The community approach acknowledges and values this local knowledge, involving community members as experts in their own health. By incorporating local knowledge and expertise, interventions can be more effective, culturally appropriate, and responsive to the unique needs of the community.

6. Trust and Relationship Building: Implementing the community approach helps build trust and relationships between community members and healthcare providers or organizations. Working directly with the community and involving community members in decision-making builds trust, credibility, and mutual understanding. This strengthens the relationship between healthcare providers and the community, leading to improved collaboration and better health outcomes.

Challenges in Community Approach

1. High Expectations: Community members may have high expectations regarding the outcomes and impact of community-based interventions. Managing these expectations and ensuring realistic goals can be a challenge, especially when resources and capacity are limited.

2. Difference in Priorities: Community members may have distinct priorities, and their perspectives on what constitutes a priority, may vary. Balancing and addressing different priorities within the community can be challenging, requiring careful negotiation and consensus-building processes.

3. Communication Barriers: Effective communication is crucial for the success of the community approach. However, communication barriers such as language differences, cultural variations, or limited literacy levels can hinder effective information sharing, understanding, and engagement with community members.

4. Wrong Perceptions: Misconceptions or wrong perceptions about the purpose, goals, or benefits of community-based interventions can exist within the community. Overcoming these misconceptions and fostering accurate understanding can be challenging, requiring targeted communication and education efforts.

5. Lack of Community Participation: Limited community participation or engagement in the planning and implementation of interventions can hinder the success of the community approach. Encouraging and sustaining community involvement requires continuous efforts to build trust, address barriers, and promote active participation.

6. Lack of Political Commitment and Support: Political commitment and support at various levels are crucial for the success of community-based approaches. However, a lack of political will, limited allocation of resources, or inconsistent support can undermine the implementation and sustainability of interventions.

7. Negative Attitudes: Negative attitudes or resistance from community members, key stakeholders, or even healthcare providers can pose challenges. These attitudes may be due to cultural beliefs, fear of change, mistrust, or previous negative experiences. Addressing and changing negative attitudes requires targeted communication, education, and relationship-building efforts.

Nurses Roles in Community Approach

1. Health Promotion and Education: Nurses are involved in health promotion activities to educate and empower individuals and communities to make informed decisions about their health. They provide health education on various topics such as preventive measures, healthy lifestyles, disease management, and the importance of regular screenings.

2. Disease Prevention and Management: Nurses actively participate in community-level disease prevention efforts. They conduct screenings, immunizations, and health assessments to identify and manage health conditions. They also collaborate with other healthcare professionals to develop and implement disease prevention strategies, such as awareness campaigns and community-wide interventions.

3. Community Assessment and Needs Identification: Nurses contribute to community assessments by gathering data, identifying health needs and priorities, and determining the resources and assets available within the community. They use this information to design and implement tailored interventions that address the specific health challenges of the community.

4. Community Engagement and Collaboration: Nurses build relationships and collaborate with community members, community organizations, and key stakeholders to facilitate community engagement. They actively involve community members in the planning, implementation, and evaluation of healthcare initiatives, ensuring that interventions are culturally appropriate, relevant, and accepted by the community.

5. Care Coordination and Case Management: Nurses play a crucial role in coordinating care and providing case management services to individuals within the community. They assess individual health needs, develop care plans, and collaborate with other healthcare providers, social workers, and community resources to ensure continuity and comprehensive care.

6. Advocacy and Empowerment: Nurses advocate for the health and well-being of individuals and communities. They address health differences, social determinants of health, and systemic issues that impact community health. They empower individuals to become active participants in their own healthcare decisions, promoting self-care and self-advocacy.

7. Health System Navigation: Nurses assist community members in navigating the healthcare system, providing guidance on accessing healthcare service, and available resources. They act as a bridge between the community and healthcare facilities, ensuring that individuals receive appropriate and timely care.

8. Data Collection and Evaluation: Nurses contribute to data collection and evaluation efforts within the community approach. They collect and analyze health data, monitor health outcomes, and assess the effectiveness of interventions. This information guides decision-making, helps identify areas for improvement, and supports evidence-based practice.

TECHNIQUES USED TO ESTABLISH COMMUNITY HEALTH ACTIVITIES Read More »

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (IMCI)

Integrated Management of Childhood Illnesses is a child management process where care/treatment of a sick child is done in totality.

IMCI stands for Integrated Management of Childhood Illness is an approach developed by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) to improve the health and well-being of children under the age of five.

IMCI is an integrated approach to child health that focuses on the well-being of the whole child.

IMCI aims to reduce death, illness, disability, and to promote improved growth and development among children under five years of age.

IMCI aims to reduce preventable mortality, minimize illness and disability, and promote healthy growth and development in young children.

IMCI guidelines help to interview caretakers accurately and recognize clinical signs, choose appropriate treatments, provide counseling and preventive care of children aged unto 5 years.

Goals of IMCI

Identify key causes of childhood mortality.
Explain the meaning and purpose of integrated case management.
Describe the major steps in the IMCI strategy.
Introduce use of IMCI tools including chart booklet, wall posters and case management sheets.

Key Components of IMCI

IMCI aims at three (3) main components of health care.

Improving case management skills of healthcare providers.
Improving health systems to provide quality care.
Improving family and community health practices for health, growth, and development.

CHILD HEALTH AND MORTALITY

In 2015, approximately 5.9 million children under the age of five died worldwide, which translates to nearly 16,000 deaths every day. The leading causes of death in this age group are infections, neonatal conditions, and nutritional issues. Alarmingly, the majority of these deaths are preventable.

Uganda has been reported to have a high child mortality rate. According to the World Health Organization (WHO), Uganda ranks 168th out of 188 countries in terms of infant mortality rates.

The under-five mortality rate in Uganda was reported at 53 deaths per 1,000 live births in 2016, according to the World Bank.

Seventy five percent (75%) of the common causes of child mortality in developing countries include:

Infectious Diseases: Acute respiratory infections, diarrhea diseases, malaria, and measles are leading causes of death among children under five years old. These diseases can be severe and life-threatening, especially in resource-constrained settings where access to healthcare and preventive measures may be limited.
Malnutrition: Malnutrition is a significant contributor to child mortality in developing countries. Children who are malnourished have weakened immune systems, making them more susceptible to infectious diseases and less able to recover from illness.

It is important to note that these causes often overlap, and children may suffer from a combination of these conditions. The clinical presentations of these diseases can be similar, which may lead to challenges in diagnosing and treating children effectively.

WHY IMNCI? (Need for IMCI)

Multiple Conditions:

Children often present with multiple potentially deadly conditions at the same time. IMCI takes a holistic approach, considering all the conditions that may affect a child and put them at risk of preventable mortality or impaired growth and development. By facilitating an integrated assessment and combined treatment of these conditions, IMCI focuses on effective case management and prevention of diseases, contributing to healthy growth and development.

Lack of Diagnostic Tools:

In many healthcare settings, there is a lack of diagnostic tools such as laboratory tests or radiology. IMCI recognizes this challenge and provides clinical algorithms that rely on patient history, signs, and symptoms for diagnosis. By training healthcare providers in IMCI, they can effectively assess and manage childhood illnesses even in resource-limited settings.

Reliance on Patient History:

IMCI acknowledges the importance of patient history in diagnosing and managing childhood illnesses. Healthcare providers are trained to gather comprehensive information about the child’s symptoms, medical history, and other relevant factors. This information, combined with the IMCI clinical algorithms, helps providers make accurate diagnoses and provide appropriate treatment.

Need for Referrals:

In cases where a child has a serious illness that requires specialized care, IMCI emphasizes the need for timely referrals to a higher level of care . By identifying severe illnesses and facilitating prompt referrals, IMCI ensures that children receive the necessary treatment and support from specialized healthcare providers.

IMCI PROCESS

The IMCI (Integrated Management of Childhood Illness) process is a comprehensive approach to the identification and management of childhood illnesses in outpatient settings.

It aims to improve the quality of care for children under the age of five by providing standardized guidelines and interventions.

Here is an overview of the IMCI process and the interventions included in the IMCI guidelines:

IMCI Process:

List of Conditions: The IMCI process involves checking for a list of conditions in children and infants to ensure comprehensive assessment and treatment.
Assessment and Treatment: Children are assessed and treated for all conditions that are present, following standardized algorithms that guide management decisions.
Decision to Transfer: If necessary, the IMCI guidelines provide guidance on when to transfer a child to higher levels of care for further management.

Interventions Included in the IMCI Guidelines:

The IMCI guidelines include both curative and preventive interventions for various childhood conditions.

Curative Interventions:

Acute Respiratory Infections (ARI) including pneumonia
Anaemia
Diarrhoea (dehydration, persistent, dysentery)
Ear infections
HIV/AIDS
Local bacterial infections
Meningitis and sepsis
Malnutrition
Wheeze
Malaria
Measles
Neonatal jaundice

Preventive Interventions:

Breastfeeding support
Immunization
Nutrition counseling
Periodic deworming
Vitamin A supplementation
Zinc supplementation

Who Can Use IMCI:

The IMCI process can be used by all doctors, nurses, and other health professionals who provide care for young infants and children under the age of five. It is primarily designed for first-level facilities such as clinics, health centers, or outpatient departments of hospitals.

The Case Management Process

IMCI classifies children into two categories:

Sick young infants who range from 1 week to 2 months. Less than 1 week infants are not managed under IMCI, mainly because their illnesses are usually related to antenatal, labour and delivery.

Sick child who range from 2 months to 5 years.

IMCI is designed for health workers (doctors, nurses etc) who treat sick children and infants in a first level health facility e.g. clinic, health center or OPD in a hospital.

In the management process the following steps are taken:

Assessing the child/young infant.
Classify the illness.
Identify treatment.
Treating the child/ young infant.
Give counseling to the mother.
Give follow up care.

Assessing the child means taking the history and performing a physical examination.
Classifying the illness implies making a decision on the severity of illness i.e. you select a category of classification which corresponds with the severity of the disease.

Note that, classifications are not specific diagnoses but can be used to determine treatment e.g. severe febrile disease is a classification for a child who could be having cerebral malaria, meningitis, septicemia etc, but treatment for this classification covers for all the possible causes of the problem.

Steps in Integrated Case Management according to IMCI guidelines:

STEP 1: ASSESS

The assess column in the chart booklet describes how to take history and do a physical exam.

Establish good communication with the mother of the child.
Screen for general danger signs, which would indicate any life-threatening condition.
Specific questions about the most common conditions affecting a child’s health (diarrhea, pneumonia, fever, etc).
If the answers are positive, focus on a physical exam to identify life-threatening illness.
Evaluation of the child’s nutrition and immunization status.
The assessment includes checking the child for other health problems.

STEP 2: CLASSIFY

The classify (signs and classify) column of the chart lists clinical signs of illnesses and their classification. “Classify” in the chart means the health worker has to make a decision on the severity of the illness.

Classify the child’s illnesses based on the assessment using a specially developed color-coded triage system.
Because many children have more than one condition, each condition is classified according to whether it requires:

COLOUR	CLASSIFICATION
PINK	Severe classification needing admission or pre-referral treatment and referral.
YELLOW	Classification needing specific medical treatment and advice.
GREEN	Not serious, and in most cases, no drugs are needed. Simple advice on home management given.

STEP 3: IDENTIFY TREATMENT

The identify treatment column helps the healthcare workers to quickly and accurately identify treatments for the classifications selected. If a child or young infant has more than one classification, the healthcare worker must look at more than one table to find the appropriate treatments.

COLOUR	CLASSIFICATION
PINK	If a child requires urgent referral, determine essential treatment to be given before referral.
YELLOW	If a child needs specific treatment, develop a treatment plan and identify the drugs to be administered at the clinic. Also, decide on the content of the advice to be given to the mother.
GREEN	If no serious conditions have been found, provide appropriate advice to the mother on the actions to be taken for the child’s care at home.

STEP 4: TREAT

The treat column shows how to administer the treatment identified for the classifications. Treat means giving the treatment in the facility, prescribing drugs or other treatments to be given at home and also teaching the mother/caregiver how to administer treatment at home.

The following rules should be adhered to.

COLOUR	CLASSIFICATION
PINK	If a child or young infant requires admission or referral, it is important the essential treatment is offered to the child or young infant before admission or referral.
YELLOW	If the child or young infant requires specific treatment, develop a treatment plan, administer drugs to be given at the facility and advise on treatment at home and counsel the mother/caregiver accordingly.
GREEN	If no serious conditions have been found (green classification), advise the mother/caregiver on care of the child at home.

STEP 5: COUNSEL

If follow up care is indicated, teach the mother/caregiver when to return to the clinic. Also teach the mother/ caregiver how to recognize signs indicating that the child or young infant should be brought back to the facility immediately.
Assess feeding, including breastfeeding practice, and provide counseling to solve any feeding problems found. This also includes counseling the mother about her own health.

STEP 6: FOLLOW-UP

Some children or young infants need to be seen more than once for a current episode of illness. Identify such children or young infants and when they are brought back, offer appropriate follow up care as indicated in the IMNCI guidelines and also reassess the child or young infant for any new problems.

The guidelines also aim to empower healthcare workers to:

Identify children who require additional follow-up visits.
Provide appropriate follow-up care as indicated in IMCI guidelines.
Correctly counsel the mother about her own health.
Provide counseling for appropriate preventative and treatment measures.
If necessary, reassess the child for any new problems.

Assessing and Classification of a Sick Child and General Danger Signs.

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INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (IMCI) Read More »

Autism Spectrum Disorder

AUTISM

Autism, also known as autistic spectrum disorder, is a childhood psychiatric disorder characterized by communication impairment, social interaction impairment, and restricted and repetitive activities.

Causes of Autism

IDIOPATHIC The exact cause of autism is still unknown,

But it is believed to result from a combination of genetic and environmental factors.

Genetic Factors: Genetic factors are believed to play a significant role in autism. Numerous studies have shown that there is a higher risk of developing autism if a family member has the condition. Certain genes have been identified as potential contributors to the development of autism, although no single gene has been identified as the sole cause. It is likely that multiple genes, in combination with other factors, contribute to the development of ASD.
Neurotransmitter Imbalances: Imbalances in neurotransmitters, the chemical messengers in the brain, have been implicated in autism. Specifically, abnormalities in the levels or functioning of neurotransmitters such as serotonin, dopamine, and gamma-aminobutyric acid (GABA) have been observed in individuals with ASD. These imbalances may affect brain development and the regulation of mood, behavior, and social interactions.
Brain Development and Connectivity: Research has shown that individuals with autism may have atypical brain development and connectivity. Studies using various neuroimaging techniques have revealed differences in brain structure, function, and connectivity in individuals with ASD. These differences may affect the development and organization of neural networks involved in social interaction, communication, and sensory processing.
Environmental Factors: While genetic factors play a significant role, environmental factors may also contribute to the development of autism. Prenatal and early-life exposures, such as maternal infections during pregnancy, exposure to certain chemicals or medications, complications during birth, and prenatal factors like advanced parental age, have been studied as potential environmental contributors to ASD. However, the specific environmental factors and their interactions with genetic factors are still being explored.
Immune System Dysfunction and Inflammation: Some research suggests that immune system dysfunction and chronic inflammation may be involved in the pathophysiology of autism. Abnormal immune responses, including alterations in cytokine levels and the presence of certain autoantibodies, have been observed in individuals with ASD. It is hypothesized that immune dysregulation and inflammation may affect brain development and contribute to the behavioral and cognitive symptoms of autism.

Classifications of Autism

According to Severity

Based on the degree of severity and level of support ASD are classified into 3 types.

Severity level		Social communication	Restricted, repetitive behaviors
Level 3	Requiring very substantial support	Severe deficits in verbal and non-verbal communication skills Severe impairment in functioning Very limited initiation of social interactions Minimal response to social overtures from others	Inflexibility of behavior Extreme difficulty in coping with change Repeated behavior markedly interferes with functioning in all spheres Great distress/difficulty changing focus or action
Level 2	Requiring substantial support	Marked deficits in verbal and non-verbal communication skills Marked impairment in functioning Limited initiation of social interactions	Difficulty in coping with change Distress/difficulty changing focus or action Repetitive behaviors occur frequently
Level 1	Requiring support	Without support, deficits in verbal and non-verbal communication skills Atypical and unusual social responses	Interference with functioning in one or more context Problems of organization and planning hamper independence

According to Diagnostic Criteria

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Autistic Disorder (Classic Autism): Autistic disorder, also known as classic autism, is the most severe and well-known type of autism. Individuals with this type of autism typically exhibit significant social, communication, and behavioral challenges. They may have delayed language development, difficulty with social interactions, repetitive behaviors, and a limited range of interests.
Asperger’s Syndrome: Asperger’s syndrome is considered a milder form of autism. Individuals with Asperger’s syndrome generally have average or above-average intelligence but struggle with social interactions and nonverbal communication. They may have intense interests in specific subjects and may exhibit repetitive behaviors or routines.
Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS): PDD-NOS is a classification used when an individual displays some, but not all, of the characteristics associated with autism. People with PDD-NOS may have difficulties with social communication, interaction, and behavior, but the symptoms may not fully meet the criteria for autistic disorder or Asperger’s syndrome.
Childhood Disintegrative Disorder (CDD): Childhood disintegrative disorder is a rare condition in which children develop typically for a period of time but then experience a significant loss of previously acquired skills. These skills may include language, social abilities, and motor functions. CDD usually occurs between the ages of 2 and 4, and the cause is not well understood.
Rett Syndrome: Rett syndrome is a genetic disorder that primarily affects females. It is characterized by normal development in early childhood, followed by a regression in skills and the emergence of specific symptoms such as loss of purposeful hand skills, repetitive hand movements, and difficulties with language and social interactions.

Signs and Symptoms

Social interaction impairment:

Failure to respond to the name
Preference for playing in isolation
Reduced interest in other people
Lack of eye contact
Physically aggressive behavior
Self-injurious behaviors due to frustration (e.g., biting oneself)

Communication impairment:

Poor language development
Lack of communication gestures
Mute
Issues with combining words in speech
Failure to respond to their name

Repetitive and restricted behaviors:

Preoccupation with certain objects and mannerisms
Resistance to change
Overreaction or underreaction to one or more senses

Management of Autism

Aims of management

Promoting Communication and Social Interaction
Reducing Challenging Behaviors
Supporting Cognitive and Behavioral Development

Early Intervention: Early identification and intervention are important in optimizing outcomes for individuals with autism. Nurses and medical team do evaluations, and initiate appropriate interventions as early as possible.
Behavioral Therapies: Behavioral therapies, such as Applied Behavior Analysis (ABA), are often utilized in the management of autism. These therapies focus on modifying behaviors, teaching new skills, and promoting positive interactions. Nurses may collaborate with behavior analysts and therapists to implement and monitor these interventions.
Speech and Language Therapy: Communication difficulties are common in individuals with autism. Speech and language therapy can help improve language development, communication skills, and social interaction. Nurses may provide support and resources to families to ensure consistent follow-up and participation in therapy sessions.
Medications: In some cases, medications may be prescribed to manage specific symptoms associated with autism, such as hyperactivity, anxiety, or aggression. Nurses play a role in monitoring medication effectiveness, side effects, and educating families about proper administration.
Family Support and Education: Providing support and education to families is crucial in the management of autism. Nurses can offer guidance on coping strategies, community resources, and access to support groups. They can also provide families with accurate and up-to-date information about autism and advocate for their needs within healthcare and educational settings.
Individualized Care Plans: Individualized care plans are essential in managing autism. Nurses collaborate with families, educators, and therapists to develop personalized plans that address the unique strengths and challenges of each individual. These plans may include specific goals, strategies, and accommodations to optimize the individual’s functioning and well-being.
Continue with,
Use simple and short sentences during conversations when interviewing the patient and the parents.
Develop a trusting relationship with the child and convey acceptance of the child separate from the unacceptable behavior.
Develop a symptom management plan for the child, including obtaining developmental milestones, improving communication skills, promoting good social interaction skills, enhancing the child’s interests, and reducing repetitive behaviors.
Create tasks with a high chance of success, such as guided play and introducing stimulative activities with rewards.
Train social skills and reward positive behaviors like good eye contact, smiling, and helping others.
Introduce one activity at a time and be specific while teaching skills.
Ensure the child’s attention by calling their name and establishing eye contact before giving instructions.
Repeat instructions, provide explanations and clarifications, and avoid assuming understanding.
Simplify activities and teaching techniques when necessary.
Provide assistance during task performance.
Be patient and tolerant.
Gradually decrease assistance and the number of assistants, while assuring the patient that assistance is still available when necessary.
Coordinate overall treatment plans with schools, collateral personnel, the child, and the family.
Assess parenting skill levels, considering intellectual, emotional, physical strengths, and limitations.
Be sensitive to parents’ needs as they often experience exhaustion of parental resources due to prolonged coping with the child.
Provide information and materials related to the child’s disorder and effective parenting techniques to the parents or guardians, using written or verbal step-by-step explanations.
Educate the child and family on the use of psycho stimulants and practice strategies for dealing with the child’s behaviors.

Nursing Interventions when caring for a child with Autism.

Promote Communication Skills: Encourage and support the development of communication skills by using visual aids, augmentative and alternative communication (AAC) devices, and social stories. Provide a communication-friendly environment and use simple and concise language to facilitate understanding.
Implement Structure and Routine: Establish consistent routines and visual schedules to provide predictability and reduce anxiety. Help the child understand and follow daily routines through visual cues and verbal prompts.
Manage Sensory Sensitivities: Create a sensory-friendly environment by reducing excessive noise, bright lights, and other sensory triggers. Offer sensory breaks or provide sensory tools like fidget toys or weighted blankets to help the child self-regulate.
Support Social Interaction: Facilitate social interactions by creating opportunities for the child to engage with peers, such as structured play activities or social groups. Teach and reinforce appropriate social skills, such as sharing, taking turns, and making eye contact.
Provide Emotional Support: Recognize and address the emotional needs of the child with ASD. Use calming techniques, such as deep breathing exercises or sensory input, to help manage anxiety or emotional distress.
Collaborate with the Multidisciplinary Team: Work closely with the child’s healthcare team, including therapists, psychologists, and educators, to ensure coordinated and comprehensive care. Share relevant information and collaborate on treatment plans and interventions.
Educate the Family: Provide education and support to the child’s family, including information about ASD, available resources, and strategies for managing challenges at home. Help them access support groups or connect with other families in similar situations.
Assist with Medication Management: If medications are prescribed, educate the family about the purpose, potential side effects, and proper administration of medications. Monitor the child’s response to medication and communicate any concerns to the healthcare provider.
Facilitate Self-Care Skills: Teach and encourage age-appropriate self-care skills, such as grooming, dressing, and feeding. Use visual cues and step-by-step instructions to assist the child in developing independence and promoting self-confidence.
Advocate for the Child: Serve as an advocate for the child with ASD and ensure their needs are met in various settings, such as school, community, and healthcare settings. Communicate with teachers, caregivers, and other professionals to promote understanding and inclusion.

Nursing Diagnosis

You can formulate nursing diagnosis from the following issues.

Impaired Social Interaction: This nursing diagnosis reflects difficulties in initiating or maintaining social interactions, limited eye contact, and challenges in understanding social cues and norms.
Impaired Verbal Communication: Many individuals with autism experience delays or difficulties in speech and language development, which may lead to impaired verbal communication. This diagnosis addresses challenges in expressing needs, understanding and using language, and engaging in effective communication.
Impaired Nonverbal Communication: Individuals with autism may struggle with nonverbal communication skills, such as body language, facial expressions, and gestures. This diagnosis focuses on difficulties in understanding and utilizing nonverbal communication.
Risk for Injury: Individuals with autism may engage in repetitive or self-injurious behaviors, pose safety risks due to sensory-seeking or sensory-avoiding behaviors, or have difficulty recognizing and responding to potential dangers. This diagnosis addresses the increased risk of injury or harm.
Anxiety: Many individuals with autism experience anxiety and heightened levels of stress due to difficulties with communication, social interactions, and sensory sensitivities. This diagnosis focuses on the individual’s feelings of apprehension, restlessness, and increased stress levels.
Impaired Coping: This nursing diagnosis addresses challenges in effectively managing stress, regulating emotions, and adapting to changes or transitions. Individuals with autism may exhibit maladaptive coping mechanisms or have difficulty adjusting to new situations.
Disturbed Sleep Pattern: Sleep disturbances, including difficulties with falling asleep, staying asleep, or having irregular sleep patterns, are common among individuals with autism. This diagnosis relates to disruptions in the normal sleep-wake cycle.
Impaired Self-Care: Some individuals with autism may require assistance with various aspects of self-care, including grooming, dressing, and feeding. This diagnosis addresses difficulties in performing activities of daily living independently.
Parental Role Conflict/Stress: This nursing diagnosis acknowledges the potential challenges and stress experienced by parents or caregivers of individuals with autism. It encompasses the emotional, physical, and psychological impact on parents or caregivers in managing the care of a child with ASD.

Autism Spectrum Disorder Read More »

Self study questions for nurses and midwives

Questions and Answers

Medicine

Hyperglycemia

Mrs. Loyce a thirty three year old female patient has been admitted with signs and symptoms of hyperglycemia.

(a). Manage Loyce from the time of her admission up to discharge.

(b) Differentiate between hyperglycemia and hypoglycemia.

SOLUTIONS

a). Hyperglycemia– refers to chronically high blood glucose level .it is usually over 240mg/dl.

Hypoglycemia– refers to dangerously low blood glucose levels that drop below 70mg/dl

However the sign and symptoms of hyperglycemia includes:-

Blood glucose over 240mg/dl
More urine output than normal
Increased thirst (polydipsia)
Dry skin and mouth (dehydration)
Nausea and vomiting
Decreased appetite
Easy fatiquability ,drowsiness or no energy

Management of Loyce from the time of admission up to discharge

Aims of management

To reduce blood glucose level to normal
To prevent further complication
To provide basic nursing care
To alley anxiety

ACTUAL MANAGEMENT

Mrs. Loyce is received in female medical ward given a seat and rapport created to alley anxiety
Brief history taking of the patient’s condition including the demographic data

Admission

The patient is admitted in female medical ward in a clean admission bed with clean linens in a well lit room free from dust and well ventilated

Position

The patient adopts any comfortable position under nurse’s supervision

Observations

Vital observations .temperature, pulse respiration and blood pressure of the patient are taken and recorded in the observation chart. So that incase of any deviation from normal, it can be managed appropriately.
Specific observations .this includes observing the patient for jaundice, anemia ,cyanosis, clubbing, oedema, lymphadenitis, dehydration, urine colour and smell. Findings recorded and reported to the doctor.

General observation

This is done from head to toe to rule out any abnormalities.

Inform the doctor: As soon as the observations are done the doctor is informed who will come and carry out his assessments (confirm the nurses findings) and may order for the following investigations

Investigations

Specific investigations

Haematology

-Blood for random blood sugar

– Renal function test

– Complete blood count

– Blood electrolytes

Urinalysis to rule out presence of acetone & ketones, urine protein, blood in urine etc

b) General investigations

– HIV serology

– When results are out, the doctor makes a diagnosis and may prescribe the following supportive treatment

Intravenous fluids normal saline 3 liters while monitoring blood pressure until blood glucose level is lowered to normal
Insulin administered intradermal .it can be pre-breakfast or pre- supper depending on doctor’s prescription
Antibiotics e.g. ceftriaxone 2g in case of any sign of infections

Specific nursing care

Diet. -The patient is given low sugar diet ,low fats diet and diet rich in vitamins
Elimination. – Bladder is monitored for urine output using the fluid balance chart (FBC) and recorded on the chart.
Bowel. Patient is encouraged to empty the bowel whenever necessary
Exercise:- passive exercise in acute state eg massaging the patients toes and fingers to aid circulation
Active exercise e.g. deep breathing exercise to prevent hypostatic pneumonia, lower limbs to prevent DVT, the patient is encouraged to move around the ward

General nursing care

Rest and sleep by restricting number of visitors and noise in the room should be minimized
Personal hygiene e.g. skin care, oral care and bed linens changed whenever it is soiled.
Environmental hygiene of the ward .the ward should be maintained clean and free from horrible dour that may discomfort the patient
Psychotherapy e.g. the nurse allows relatives to stay with the patient and also may invite religious leaders who may update the patients spiritually

Investigations before discharge.

When the patient’s condition has improved, the doctor may order for investigations like:-

Urinalysis
Blood for blood sugar & CBC
Renal function test

When the results are satisfactory, the doctor writes a discharge form and the patient is discharged

Advice on discharge

Take medications as prescribed
Come back for review on the schedule date
Avoid injuries that can cause damage to the skin
The patient is advised on diet as follows

Food with reduced sugar
Fatty food should be limited
Diet should contain vitamins
Improve on life style for example cessation of smoking ,alcoholism etc.

Differences between hyperglycemia and hypoglycemia

Hyperglycemia	Hypoglycemia
High blood glucose level more than 240mg/dl	Low blood glucose level
The onset is gradual over few days	Onset is sudden over minutes
Urine contains large amount of sugar and acetone	Urine has no sugar and acetone

Insulin is administered in most cases	Glucose is given
The skin is worm and dry	The skin is pale, cold and sweaty
Patients become gradually drowsy and lethargic	Patient is confused ,restless and anxious
Breath is deep and fast in most cases	Shallow breath
Fruity smell of the breath due to acetone	No fruity smell, acetone absent
Rapid pulse rate	Normal pulse rate

Prevention of diabetic foot

Diabetic foot is a neurological condition that occurs during diabetes. However, it can be prevented from occurring through the following ways:-

Maintain and keep the blood glucose level low in a target range to prevent complications by administering insulin and advising on diet for example reduce on intake of sugar and fatty foods
Examine and screen the patient’s feet daily for senses, colour, cuts, swelling, pain and temperature for early interventions incase of any.
Wash and dry feet paying much attention between the toes.
Turn the patient 2 hourly to prevent excessive pressure on the pressure areas of the foot to prevent pressure sores
Wash and dry feet paying much attention between the toes.
Turn the patient 2 hourly to prevent excessive pressure on the pressure areas of the foot to prevent pressure sores
Wear for the patient shoes and stockings to prevent injury to the feet .the shoes should be of appropriate size. Always check the shoes before wearing.
Trim the patients nail. This is done using the nail file to prevent under growing nails that can cause infections.
Keep the skin soft and smooth by rubbing the skin with lotion over the top and bottom to prevent cracks
Massage the feet to maintain blood circulation and the patient is encouraged not to cross the legs for long time because this can cut off circulation for the feet
Protect the feet from cold and hot water since this can impair the senses
Exercise the foot by moving it for about 5 minutes and teach the patient how to do it (physiotherapy)

Health educate the patient (Loyce) on the following;

Importance of wearing a well fitting pair of shoes
Not to move bare foot
Check her foot before putting on shoes
Seek medical assistance in case of any injury
Put on gumboots incase of farming activities

Pulmonary Tuberculosis

2. Joseph an adult patient has been diagnosed with pulmonary tuberculosis.

(a) Outline ten signs and symptoms of PTB.

(b) Describe his management using nursing process from the time of admission up to discharge.

SOLUTIONS

Tuberculosis (TB)

This is a chronic lung disease caused by a bacillus called mycobacterium of the genus mycobacterium tuberculosis.

It can also occasionally be caused by other strains of mycobacteria including mycobacterium bovis which is found in animals.

TB is of two types;

Pulmonary TB
Extra pulmonary TB

PULMONARY TB:

Type of TB that affects mainly the lungs and is the most common type of TB.

SIGNS AND SYMPTOMS.

Fever and chills
Night sweats
Productive or non productive cough
Weight loss
Fatigue
Cough for more than 3 weeks.
Coughing up blood (Haemoptysis)
Chest pain
Significant figure clubbing may occur
Lymphdenopathy which is a sign of bacterial infection.
Aneroxia
Insomnia

ASSESSMENT	NURSING DIAGNOSIS	PLAN/GOAL∕EXPECTED OUTCOME	INTERVENTION OR IMPLEMENTATION	RATIONALE	EVALUATION
Chest Pain	A cute chest pain related to inflammatory response secondary to disease process as evidenced by patient coughing out blood and reporting pain.	Relieve pain within 24 hours. Patient will be free from pain until discharge.	Admit the patient on the medical ward specifically the TB unit. Take vital observations i.e. TPRIBP and weight. Position the patient in sit up position. Re-assure the patient. Inform doctor to prescribe drugs and order for investigations. Administer prescribed analgesics like 1m diclofenac 75mg stat then later tabs paracetamol 1g tds x 3/7.	For proper management As baseline and for future reference. To relieve pressure of the abdominal organs onto the diaphragm. To allay the patient’s anxiety For proper assessment and management of the patient. To relieve pain.	Goal met, patient was relieved from pain after 24 hours and patient was free from pain at discharge.
Cough	Altered respiratory patterns related to disease process as evidenced by patient having cough for more than 3 weeks.	Patient will have normal respiratory patterns until discharge.	Maintain the patient in the sit up position. Do investigations as ordered. Do sputum analysis and chest x – ray, erythrocyte sedimentation rate (ESR). Complete blood count (CBC) Administer prescribed anti TB drugs and give the right regimen (6EHRZ + 2EH) Administer prescribed supportive drugs like multi-vitamins i.e. Folic acid	For comfortibility. To confirm the causative agent and to rule out the involvement of other organs like the heart and complications. To help in the re-epithelialisation and boost the patient’s appetite. To destroy the causative organism	Goal met, patient reports normal respiratory patterns until discharge.
Fever	Altered thermoregulation / body temperature related to disease process as evidenced by the patient hot on touch also the patient reporting fevers for the last 3 weeks.	To normalize the body temperatures wit in 24 hours and maintain within normal ranges until discharge.	Expose the patient. Tepid sponge the patient. Maintain the already prescribed antipyretics. Take temperature 4 hourly until discharge.	To allow cool air to reach the patient’s skin. To cool the external body. To act on the temperature regulating centres in the brain. As baseline and for future comparison.	Goal met, patient’s temperatures normalized after 24 hours and the patient’s temperatures were maintained with in the normal ranges till discharge.
Weight loss	Altered nutrition less than body requirements related to loss of appetite as evidenced by the patient reporting having lost weight for the last 3 weeks or months.	To nourish the patient throughout his stay on the ward.	Encourage nourishing diet. Encourage oral care and continue with prescribed multi-vitamins.	To nourish the patient. To boost the patient’s appetite.	Goal met, patient was well nourished at discharge.
Fatigue	Activity intolerance related to disease process as evidenced by patient unable to perform activities of daily life.	Patient will perform activities of daily living throughout his stay on the ward.	Encourage patient to carryout activities of daily living such as bathing, eating, toileting, oral care and going to the urinals by himself	To improve on patient’s general hygiene and improve on the appetite To avoid complications that may arise as a result of over staying in bed.	Goal met, patient is able to perform activities of daily living at discharge.
Insomnia	Altered sleeping patterns related to night sweats and irritating cough secondary to disease process as evidenced by the patient reporting not sleeping well.	Patient will have normal sleeping patterns during his stay on the ward.	Minimize noise and visitors on the ward. Switch off light (bright lights) Administer prescribed sedatives like tabs diazepam 5mg OD or PRN Continue re-assuring the patient.	To enable the patient have enough rest. To induce sleep. To alley patient anxiety

COMPLICATIONS ARE;

Plueral effusion
Pericardial effusion
Empyema (pus in the pleural cavity)
Pneumothorax
Lung fibrosis
Lung collapse (Atelectasis)
Extra TB due to spread of the infection to other organs.

Nephrotic Syndrome

3. An adult male patient has been brought to medical ward with features of nephrotic syndrome

(a) List five cardinal signs and symptoms of nephrotic syndrome

(b) Describe his management from admission up to discharge.

SOLUTIONS

(a) NEPHROTIC SYNDROME.

Is a syndrome caused by many diseases that affect the kidney characterized by severe and prolonged loss of protein in urine especially albumen, retention of excessive salts and water, increased levels of fats.

FIVE CARDINAL SIGNS AND SYMPTOMS.

Massive protenuria.
Generalized edema.
Hyperlipidemia.
Hypoalbuminemia.
Hypertension.

(b) MANAGEMENT.

Aims of management

To prevent protein loss in urine.
To prevent and control edema.
To prevent complications.

ACTUAL MANAGEMENT.

Admit the patient in medical ward male side in a warm clean bed in a well ventilated room and take the patients particulars such as name, age, sex, religion, status.
General physical examination is done to rule out the degree of oedema and other medical conditions that may need immediate attention.
Vital observations are taken such as pulse, temperature, blood pressure recorded and any abnormality detected and reported for action to be taken.
Inform the ward doctor about the patient’s conditions and mean while the following should be done.
Position the patient in half sitting to ease and maintain breathing as the patient may present with dyspnoea due to presence of fluids in the pleural cavity.
Weigh the patient to obtain the baseline weight and daily weighing of the patient should be done to ascertain whether edema is increasing or reducing which is evidenced by weight gain or loss.
Monitor the fluid intake and output using a fluid balance chart to ascertain the state of the kidney.
Encourage the patient to do deep breathing exercises to prevent lung complications such as atelectasis.
Provide skin care particularly over edematous area to prevent skin breakdown.
On doctor’s arrival, he may order for the following investigations.
Urine for culture and sensitivity to identify the causative agent.
Urine analysis for proteinuria and specific gravity.
blood for;
Renal function test, it will show us the state of the kidney function.
Cholesterol levels; this will show us the level of cholesterol in blood.
Serum albumen; this will show us the level of protein or albumen in blood.
The doctor may prescribe the following drugs to be administered;
Diuretics, such as spirinolactone 100-200mg o.d to reduce edema by increasing the fluid output by the kidney.
Antihypertensives such as captoril to control the blood pressure.
Infusion albumen 1g/kg in case of massive edema ascites and this will help to shift fluid from interstitial spaces back to the vascular system.
Plasma blood transfusion to treat hypoalbuminemia.
Cholesterol reducing medication to have the cholesterol levels in blood such as lovastatin.
Anticoagulants to reduce the blood ability to clot and reduce the risk of blood clot formation e.g. Hepanine.
Immune suppressing medications are given to control the immune system such as prednisolone if the cause is autoimmune.
Antibiotics such as ceftriaxone to treat secondary bacterial infections.
The doctor may order for renal transplant if the chemotherapy fails.

Routine nursing care.

Continuous urine testing is done to see whether proteinuria is reducing or increasing.
Encourage the patient to take a deity rich in carbohydrates and vitamins but low in protein and salts.
Ensure enough rest for the patient as this will reduce on body demand for oxygen and hence prevent fatigue.
Promote physical comfort by ensuring daily bed bath, change of position, oral care and change of bed linen.
Re-assure the patient to alley anxiety and hence promote healing.
Ensure bladder and bowel care for the patient.

ADVICE ON DISCHARGE

The patient is advised on the following:

To take a deity low in salt and protein.
Drug compliance.
Personal hygiene.
Stop using drugs like heroin, NSAID’s.
Screening and treating of diseases predisposing or causing the disease.
To come back for review on the appointment given.

COMPLICATIONS.

Acute kidney failure.
Kidney necrosis.
Ascites.
Pyelonephrosis.
Cardiac failure
Pulmonary embolism.
Atherosclerosis.
Deep venous thrombosis.

Surgical Nursing

Fractures

Josephine a thirty year old female patient has been involved in a road traffic accident and sustained a compound fracture.

(a) Outline ten signs and symptoms of fracture.

(b) Discuss the negative factors that can influence healing of a bone.

(d) Mention ten complications of fractures.

SOLUTIONS

a) History from the patient or the on lookers.

Pain aggravated by movement
Tenderness over the fractured limb
Loss of function of the affected part or the whole limb
Deformity
Shortening of the limb
Abnormal mobility at the affected area
Creepers or grating of the bone ends as they move each other
Swelling of the affected part
Shock may occur
The bone may be seen out if it’s a compound fracture

Tissue fragments between bone ends; Splinters of dead bone (sequestrate) and soft tissue fragments not removed by phagocytosis delay healing.
Deficient blood supply; this delays growth of granulation tissue and new blood vessels. Hypoxia also reduces the number of osteoblasts and increases the number of chondrocytes that develop from there common parent cells. This may lead to cartilaginous union of fracture which results in a weaker repair.
Poor alignment of bone ends: This may result in the formation of a callus that heals slowly and often results in permanent disability
Continued mobility of bone ends; Continuous movement results in fibrosis of the granulation tissue followed fibrous union of the fracture.
Miscellaneous; this include

Infection; pathogens enter through broken skin, although they occasionally be blood borne, healing will not occur until infection resolves
System illness
Malnutrition
Drugs e.g. Corticosteroids
Aging

Following a fracture the broken ends of a bone a joined by the deposition of a new bone. This occurs in several stages

Hematoma forms between the ends of the bone and in the surrounding soft tissues.
There follows development of acute inflammation and accumulation of inflammatory exudates, continuing microphages that phagocytosis the hematoma and small fragments of a bone without blood supply(this takes place about five days). Fibroblasts migrate to the site, granulation tissue and the new capillaries develop.
New bone forms as large numbers of osteoblasts secretes spongy bone, which unit the broken ends, and is protected by the outer layer of the bone and cartilage, this new deposits of bone and cartilage are called callus.
Over the next few weeks, the callus matures and the cartilage is gradually replaced by new bone
Reshaping of the bone continues and gradually the medullary canal is re –opened through the callus (in weeks or month). In time the bone heals completely with callus tissue replaced with mature compact bone. Often the bone is thicker and stronger at the repair site that originally, and the second is more likely to occur at a different site.

d) Complications of fractures are divided in to two.

General complications.

Local complications
General complications are;
Hemorrhage which may lead in to shock.
Fat embolism
Infections
Hypostatic Pneumonia
Damage to the nearby structures

Local complications

Keloids
Loss of function
Damage to the nerves
Necrosis
Delayed union of bones; this may be as a result of incomplete reduction, inadequate immobilization, lack of blood supply to areas, infection which disrupt formation
Malunion of the bones; this when there’s failure of bone fragments to unit. This as a result of a big gap between the fragment

Hyperthyroidism

1.Define:

(a) Hyperthyroidism:

(b)Hypothyroidism

2. Outline the differences between hyperthyroidism and hypothyroidism

3. Describe the management of a patient with hyperthyroidism.

4. Mention seven complications which are likely to occur following a thyroidectomy.

SOLUTIONS

The hub of excellence

a) Hyperthyroidism: this is a condition in which there is high circulating thyroid hormone in blood.
b) Hypothyroidism-this a condition in which there are low circulating thyroxin hormone in blood.
c) Thyrotoxicosis– it is a state of hyper secretion of thyroxin by the thyroid gland.

2. Differences between hyperthyroidism and hypothyroidism

Hyperthyroidism	Hypothyroidism
It is characterized by excessive thyroxin production.	Characterized by insufficient thyroxin production.
Characterized by weight loss with increased appetite and diarrhea	Characterized by weight gain
More commonly caused by an auto immune response to specific anti bodies	Can be of congenital cause
T4( thyronine ) levels are elevated	The serum Thyroid stimulating hormone is elevated in an attempt to produce more thyroxin
Commonly occurs in women than men, usually at age of 20 to 40 years	Common in women of ages 30 to 60 years
Surgery is always indicated incase medication and radio therapy has failed	Primarily managed by hormonal replacement therapy

3. Management

Patient is admitted on a medical ward for complete bed rest.
Reassure patient and relatives.
Vitals are taken and doctor informed
Thorough physical assessment is done

Pre operative tests are ordered by the doctor and blood taken for the following tests;

Serum thyroxin estimation- which levels are elevated in hyperthyroidism
Serum tri-thyroxin(T3)
TSH estimation –to rule out hypothyroidism
Thyroid antibody measurement in cases of autoimmune thyroidism
Radio active iodine uptake and scan for both diagnosis and treament.
FNAC- for cytology to rule out any malignancy
Fibre optic laryngoscopy-to view the vocal cords

Pre operative preparation(immediate)

Patent’s HB is checked
Cross match and book 2 units of blood
x-ray chest thoracic inlet
Shaving of the neck skin, upper part of the chest, the axilla and the upper arms

Pre operative drugs are also given as ordered by the doctor to bring patient to euthyroid state including;

Carbimazole 10-20mg start 8hourly,several weeks then stopped 10days to surgery
Propranolol 120-160 mg daily in divided doses. this is continued up to operation day
Lugol’s iodine 0.3-0.9mls T.D.S. for 10 days-to reduce vascularity
Diazepam 5mg 12 hourly to sedate the patient
Digitalis incase of atrial fibrilation

Meanwhile, specific pre operative nursing care includes;

Daily measuring of the neck circumference to monitor progression of thyroid enlargement
Monitor serum electrolyte levels and check for hyperglycaemia
Monitor for signs of heart failure e.g date dyspnoea
Ensure nutritious diet with adequate calorie, proteins
Minimize physical and emotional stress
Re assure patient and family that mood swings will disappear with Rx.
Monitor frequency and characteristic of stool and give anti diarrhaels as ordered

Post operative management

Post operative bed is prepared and patient put in lateral position till recovery, then propped up supported by back rest.
Monitor vitals including BP, Respirations. Give oxygen incase respirations are fast, shallow
Report any respiratory difficulty for prompt management
Ensure little fluid intake to clean the mouth.

Specific nursing care

Ensure constant drainage in a drainage bottle or dressing
Intubation if there is respiratory edema.
Closely observe for hemorrhage.
Ensure a calm environment, and possibly give drugs to encourage sleep.
Care of drain and sutures; change drainage 24 hourly and sutures removed on third day or fourth day.
Minimize patient’s neck movement to minimize neck pain.
Give analgesics 1g start to reduce pain.
2 hourly vitals’ taking including temperature, respiration and blood pressure to monitor for any complications like thyroid storm or infections.
Give antibiotics; ceftriaxone 2g 24 hourly

4. Complications of thyroidectomy

Hemorrhage due to hyper ventilation of the thyroid gland
Thyroid crisis (thyroid storm); characterized by rapid pulse, raised temperature, profuse, sweating, and confusion.
Tetany; due to removal or trauma to parathyroid glands- it’s characterized by tingling and numbness of the face, lips and hands.
Soreness of the throat.
Hoarseness –due to damage to the recurrent laryngeal nerve
Hypothyroidism due to thyroid removal
Recurrent thyrotoxicosis
Respiratory obstruction –due to laryngeal edema.
Wound infection

Shock

1.An adult male patient has been brought to S.O.P.D with featured of shock.

(a)Define shock

(b) Explain seven types of shock that you know.

SOLUTIONS

a). shock.

Is the failure of the circulatory system to maintain adequate tissue perfusion of the vital organs like the heart and kidney, brain?

PATHOPHYSIOLOGY

Heart:-due to the reduced fluid volume in the body(blood) caused by vaso constriction leads to inadequate blood supply to the heart which decreases cardiac output hence less amount of blood reach the brain leading to hypoxia eventually shock occurs.

B) . seven types of shock.

Hemorrhagic shock.

It occurs due to severe blood loss causes are as follows:- Obstetric emergencies e.g. post partum heamorrhage, abortion etc, Trauma i.e. RTA, gun shot

Septic shock

It occurs as result of bacteria multiplying in the blood and releasing toxins in the circulation leading to pooling of blood in the capillaries and blood vessels. It occurs in diabetic wounds, crutch wounds, burns.

Carcinogenic shock ; this is when the heart fails to maintain tissue perfusion leading to shock. It results from the following; Heart attack, Myocardial infarction

Neurogenic shock.

This is generalized vasodilatation due to stimulation of Vegas nerve e.g. due to strong pain.

Anaphylactic shock.

This is due to hypersensitivity reaction which results from exposer to allergens leading to sudden cardiac arrest or respiratory distress. It can be due to reaction to drugs, foods.

Hypovolemic shock.

This is due to loss of body fluids through diarrhea, vomiting, burns etc.

Ologenic shock.

This is due to either receiving of good or bad news: – emotional upset

C). management

It’s a surgical emergency that requires immediate intervention

Aims of management

To maintain functions of the vital organs like the brain and heart
To improve circulation
To prevent complications
To promote patients comfort

Admission

The patient is received and quickly admitted in surgical ward in warm well ventilated room
The relatives of the patient are reassured
Patient is put in semi porn Position with the head turned to one side for easy drainage of secretions and to prevent the tongue from falling back
The foot of the bed is elevated to aid return of blood to the circulatory center
Quick assessment done

Assess the consciousness of the patient using Glasgow coma scale. This is performed as follows .

PARAMETERS

SCORE

Eye opening

Spontaneously
To speech
To pain
None

Best verbal response

Oriented
Disoriented
Inappropriate
Incompressible
No response

Best motor response

Obeys command
Localized pain
With draw or flexion
Extension with rigidity
None response

Total response for 3 is 15

Observations i.e.

Vital observations like temperature, pulse, respiration and BP (blood pressure).
General observations such as level of dehydration, skin color for cyanosis.
Doctor is informed

Specific management

Air way:-

Artificial air way is put in position and sanction is done whenever necessary to avoid blockage of the air way with secretion and falling back tongue
Air way piece is insitu to prevent back flow of the tongue.

Breathing:–

Patient is administered oxygen 5-8 liters per minute in order to ventilate the lungs and increase tissue perfusion.

Circulation:-

Plan c of management of dehydration applies
An intravenous line is established to re hydrate patient with intravenous fluids like normal saline 0.9% and ringers lactate(se) allows it to run faster at a drop /rate of 40drops per minute
Continue monitoring the patient’s condition for over flow

Investigations

Doctor orders for the following investigations below.

Blood

Hb, grouping and cross matching
CBC (complete blood count, Ph of the blood showing decreased Ph (acidic Ph)

ECG (Electrocardiogram)

To check for the activities of the heart.

EEG (.electro encephalogram):-

To check for the activities of the brain.

Urinalysis: –

To determine kidney function

Specific nursing care

Patient is provided with warmth by adding additional blanket but not to overheated transfuse the patient incase patient is anemic with whole blood and to improve blood volume in the circulation
Foot of the bed is elevated to aid return of blood into the circulatory center.
Continue monitoring vitals that is TPR/BP, to detect deviation from the normal.

General nursing care

Hygiene:-

Ensure patient s hygiene by daily oral care, care of the skin , finger nails, patients hair, daily bathing of patient if able and if patient unable to bath by self carry out bed bath for patient as well much attention is on the pressure areas.

Diet:-

The patient is feed on well balanced diet and light diet which can digest easily. Feeding is done using naso gastric tube, when patients condition improves give patient food orally.

Rest and sleep:-

Adequate rest is ensured by limiting visitors; minimize noise in the room or ward etc.

Psychotherapy:-

This includes care of mind by counseling, give adequate information about the illness to the patient and the relatives or family members

Physiotherapy: –

This is done by helping and encouraging the patient to carry out some light exercise that is passive and active exercise such as deep breathing exercise.

Elimination

Care of the bladder and bowel check if patient is passing urine out normally and avoid constipation by encouraging plenty of fluids and light diet is suitable
Pass catheter incase of incontinence to prevent wetting of the bed or soiling of the bed linen
Give bed pan to the patient if passing out stool normally.
Establish fluid balance chart in order to monitor fluid input and output.

Tracheostomy

A male patient aged 40 yrs has been brought to S.O.P.D with features of an airway obstruction, upon assessment the surgeon recommended for a tracheotomy.

Define tracheotomy.
Mention 10 indications of a tracheotomy.
Describe the pre and post operative management of the patient up to discharge.
Mention 5 likely complications which may occur following a tracheotomy.

SOLUTIONS

Tracheotomy is the artificial opening through the neck into the trachea to relieve sudden airway obstruction

Indications of a tracheotomy

These are divided into two i.e. obstructive conditions of the larynx and paralysis or spasm of the respiratory muscles or respiratory failure.

Obstructive conditions of the larynx
Acute laryngitis e.g. in diphtheria
Carcinoma of the larynx
A cute oedema of the glottis
Foreign body in the airway
Trauma to the trachea
Severe burns of the mouth or involving the larynx
Severe neck or mouth injuries
Paralysis or spasms of the respiratory muscles failure
Paralysis of the respiratory muscles
Respiratory failure
Tetanus
Following thyroidectomy
Surgery around the box (larynx) that prevents normal breathing and swallowing

Pre-operative management of the patient for tracheostomy

Aims

To relieve sudden airway obstruction
To alley patient’s anxiety
To prevent likely complications to occur .

Admission: The patient is admitted to the surgical ward in a well ventilated room and all procedures are done within this time.

Nurse patient relationship / rapport: A positive nurse patient relationship is created to alley patients, anxiety; explain the nature of condition is having to the patient and what is going to be done.

Observation: Both general and vital observations are done to know the state of condition in which the patient is in starting with general observations then vital observations that is temperature, tube, respiration and pressure monitor patients conditions

Investigation: The doctor will order for investigation i.e. Hb, biopsy

Consent form: It’s obtained from the patient after through explanation towards what is going to be done in theatre to relieve airway obstruction

Shaving: This is done immediately before the patient being taken to theatre for operation

Theatre gown: The patient is offered with a theatre gown before going in for operation, all other items like bangle and dentures are removed there and then

Premedication: Will be administered to the patient if any was prescribed by the doctor

Informing of theatre staffs: They are informed before the patient is taken for theater for the operation

Patient taken of theatre: The patient will then be taken to theatre for operation by two nurses who will handle the patient to theatre staff

Post – operative bed: After the nurses have handled over the patient in theatre they will come and make a postoperative bed and all its accompaniments

In theatre : A patient well be positioned in a supine position with the neck hyper extended over the shoulder which brings the tracheal orifice closer to the surface. An incision is made on the trachea and the tracheal tube inserted into the opening and secured in position with tapes tied around the neck

Post operative management

Prepare an emergency tray at the bed side with tapes tied around the neck

Sterile tracheal dilators,
Sterile suction catheters
Sterile gloves
Suction machine with half an inch of savlon in the suction bottle
Bowl of savlon
Gallipot with saline to act as a lubricant

After completion of the operation, the theatre team will inform ward nurse s to come all collect the [patent taken to the ward

On the ward

Position: The patient should lie flat in bed had turned on one side hourly for easy drainage, when patient a wakens he should be probed up and kept in this position for 48 hours

Observations: Vital observations are done ½ hourly for ½ hourly for 2 hours , 1 hourly , 2 hourly for 6b hours then when the patient stabilizers they are done twice a day , much emphasis is put on the respiration rates , observe the tube to see if its not blocked.

Medication: Drugs like antibiotics to treat or prevent any infections like – IV ceftriaxone1-2 gms o.d for 5-7 days

Analgesics e.g. in diclofenac 75 mg IM 8hry for 24 hours then paracetamol tablets 1gm tds for 3 days

Oxygen may be administered via the tracheotomy mask or tube

Care of the tubes: Frequent suction is very important at least 2 hourly then later PRN , it’s done by anesthetist and a nurse , the inner tube is washed with sodium bicarbonate , sterilized and replaced as required a supply of sterile tubes be readily available

Keep the tube covered loosely with gauze to prevent entry of cockroaches and other insects especially at night

Care of the incision wound: It should be cleaned daily using a suitable antiseptic and new dressings replaced, key hole dressing is used

Exercises: Deep breathing exercises are carried out under the direction by a physiotherapist, suction must be readily available for the nurse to suck the secretions

Provide a bell, book and pen for easy communication in acute phase

Diet: Swallowing may be very difficult especially in the acute phase but small amounts of fluids can usually be taken and if the patient fails to tolerate intravenous fluids are given , when the condition improves they are stopped

Hygiene : Is should be observed throughout to prevent respiratory infections, hands scrubbed and worn to prevent cross infection. Tubes must be stylized before re use

Psychological care: This is maintained throughout the patient’s stays on the ward to alley anxiety

Bowel and bladder care: By taking of plenty of oral sips and roughages to prevent constipation

Rest and sleep: Ensure that the patient facts enough reset a sleep by minimizing noise, dimming lights during the night and covering the tube to prevent entry of insects into the tube

Discharge : When the patient’s condition is satisfaction will be discharged home and follow up date given

N.B

In case the tracheostomy is permanent like in cases of career , the patient will be returning for reviews and increase where its temporarily when the obstruction has resolved the tube is removed and the wound left to close

Advice on discharge

Take drugs as prescribed
Maintain proper hygiene
Maintain / keep follow up dates

Complications

Haemorrhage
Shock
Infections
Respiratory failure
Emphysema
Nerve injury including paralysis
Scarring
Damage to the thyroid gland

Pharmacology

Malaria

Opio aged 10 years with a body weight of 18 kg was diagnosed with severe malaria. The doctor prescribed IV artesunate and requested the nurse to calculate the right dose.

State any four cardinal symptoms of severe malaria.
Calculate the dose of IV artesunate you would give to Opio.
Outline the steps you would take as you administer IV artesunate.
Mention any 3 drugs used in the prevention of malaria.

SOLUTIONS

Malaria: Is an acute illness characterized by fever and other clinical features which is caused by infection with the malaria parasites of the genus anopheles mosquito.

TRANSMISSION: Malaria is transmitted from one person to another through the bite of an infected anopheles mosquito.

Plasmodium species

P. Falciparum
P. Malarie
P. Vivax
P. Ovale

No.1

Altered mental state / confusion.
Convulsions.
Severe anemia.
Prostration.
Difficulty in breathing.

No.2

Artesunate dosage =3.0mg × body weight

=3mg ×18

= 54mg

Therefore: The dosage of Artesunate to be given to Opio is 54mg.

No. 3

Identify the patient.
Create a rapport and weigh the patient.
Identify the drug and check for the expiry date.
Reconstitute the drug by mixing Sodium bicarbonate with Artesunate powder.
Shake approximately for 2 minutes until the dissolved solution will be cloudy.
The reconstituted solution will be clear in about 1 minute. Discard if not clear.
Insert the needle to remove air.
Inject the required volume of saline in to the reconstituted solution.
Artesunate solution is now ready for use.
With draw the required dose in m/s according to the route of administration.
Give slow IV injection 3-4 minutes per minute or injection in the appropriate site by deep IM.

No.4

Chloroquine
Sulphurdoxine.
Doxycycline.
Mefloquine.

Hypertension

MN, a 44 year old truck driver was diagnosed with hypertension by his doctor after registering a BP of 160/ 95 mmhg on 3 separate clinic visits. MN weighs 107 kgs and his height is 1.7 M tall. He smokes an average of 16 cigarettes per day and drinks 4 bottles of beer every evening. The doctor prescribed Nifedipine 20mg 12 hourly for 30 days.

To which class of anti hypertensive does Nifedipine belong?
Name any other 3 drugs that belong to the same class as Nifedipine.
Give 4 common side effects associated with the use of Nifedipine.
Besides drug treatment, give any 5 advices you would give to Opio in order to effectively control his blood pressure.
Mention any 4 complications associated with poorly managed hypertension.

SOLUTIONS

Nifedipine belongs to a group of antihypertensive called calcium channel blockers

Calcium channel blockers act by decreasing calcium uptake into cardiac and smooth muscles by blocking slow calcium channels which reduces on the vascular tone that results into reduction in peripheral resistance thus controlling blood pressure

2. Examples of other calcium channel blockers

Amlodipine Tablets 10mg, 5mg
Nicardipine Capsules 20mg, 30mg
Felodipine Tablets 2.5mg, 5mg, 10mg
Nimodipine Tablets 30mg

3. Side effects associated with the use of Nifedipine

Peripheral edema
Flushing
Hypotension
Visual disturbances
Headache
Dizziness
Fatigue
Fast heart rate

4. Advises which can be given to Mr. Opio to effectively control his blood pressure

Health educating Opio about dangers of smoking
Health educating him about the dangers of excessive alcohol consumption
Eating much less than usual to reduce the weight
Eating fat free foods
Doing enough exercises
Visiting the clinic regularly for blood pressure checking
Teaching him about the warning signs of elevated blood pressure

5. Complications of poorly managed hypertension

Renal failure
Glomeronephritis
Heart failure
Retinopathy
Un explained abortions
Intra uterine growth retardation i.e. in pregnant mothers
Cerebral vascular accident
Hypertensive encephalopathy
Impotence
Brain damage

Mental Health

Causes of Mental Illnesses

Mental illness is very common in Uganda, Write down the general causes of mental illness.

SOLUTIONS

CAUSES OF MENTAL ILLNESS.

The chief cause of mental illness is unknown i.e. it is idiopathic.

However research states a number of factors responsible for causing mental illness.

These factors are either;

Predisposing factors
Precipitating factors
Perpetuating factors.

PREDISPOSING FACTORS

These factors determine an individual’s susceptibility to mental illness. They interact with triggering factors resulting into mental illness. Examples include; Genetic risk factor, physical damage to the central nervous system (the brain and spinal cord).

PRECIPITATING FACTORS.

These are events that occur shortly before the onset of the disorder. I.e. they trigger the onset of the disease. Examples include; physical stress and psychosocial stress.

PERPETUATING FACTORS.

These factors are responsible for aggravating or prolonging the disease already existing in an individual. Examples include; psychosocial stress.

Thus, etiological factors of mental illness can be;

Biological factors
Physiological factors
Psychological factors
Social factors

BIOLOGICAL FACTORS

- Genetic risk factor; According to research individuals born in families with parents and relatives who have suffered from mental illness, are susceptible to developing mental illness once exposed stressful conditions. This is because the predisposition gene is passed on from the parents to the offspring.
- Biochemical; This regards the neurotransmitters (provide medium for transmission of impulses). Any imbalances in the levels of the neurotransmitters in the brain may result into mental illness as shown below.

Neurotransmitter related state	Mental disorder
Increased in dopamine level	Schizophrenia
Decrease in nor epinephrine level	Depression
Decrease in serotonin level	Alzheimer’s disease
Decrease in gamma amino butyric acid	Anxiety
Decrease in glutamate level	Psychotic thinking

Brain damage; This may be as a result of;

Infections e.g. HIV infection, neurosphilis, encephalitis etc.
Injury that involves loss of the brain tissue.
Intoxication; toxins that can damage the brain tissue e.g. alcohol.
Vascular damage; damage to blood vessels leading to poor blood supply to the brain, subdural hemorrhage, intracranial hemorrhage, etc.
Tumors; brain tumors
Degenerative diseases; dementia.

Physiological factors; The functioning of the body changes at certain critical periods in life i.e., puberty, pregnancy, menstruation, peurperium and delivery. Coupling these physiological changes with maladaptive psychological capacity makes an individual susceptible to mental ill health.
Psychological factors;

Personality; It has been observed that specific personality types are more prone to certain psychological disorders, e.g. Schizoid personality (unsocial and reserved) are vulnerable to schizophrenia under stressful situations.
Strained interpersonal relationships at home, school and work.
Childhood insecurity due to parent’s over strictness, rejection and unhealthy comparisons.
Social and recreational deprivation; which may result into boredom, isolation and alienation.
Marriage problems e.g. forced bachelorhood, childlessness and many children.
Sexual difficulties.
Stress and frustrations.

Social factors;

Poverty.
Unemployment.
Injustice.
Insecurity.
Migration.
Urbanization.
Gambling.
Alcoholism.
Prostitution.
Divorce.
Religions.
Traditions.

Psychiatric Emergencies

Psychiatric emergencies are very common in the community.

Mention all the psychiatric emergencies.
How can we prevent psychiatric emergencies?
Nakimbugwe, a psychiatric patient has completely refused to eat food and she wants to starve herself to death, How can you manage such a patient?

SOLUTIONS

The psychiatric emergencies.

1. Aggression and violence; Aggression is an intended behavior that can cause pain, harm directly to one self or others either physically or verbally whereas violence is an intention to use physical force/power to threatened action against one’s self, other person or group resulting into injury.
2. Suicidal attempts; This is a type of deliberate self-harm and is defined as an intentional human act of killing oneself.
3. Delirium tremens; A type of delirium caused by abrupt withdraw from excessive taking of alcohol or substance of abuse
4. Status Epilepticus; This is said to occur when a seizure lasts too long or when seizures occur close together and the person doesn’t recover between seizures.
5. Catatonic stupor; This refers to decreased motor activity or being emotionless or being unresponsive to the environment stimuli although he or she is conscious
6. Hysterical attacks; This personality disorder due to the upbringing. Individual of this category present with exaggeration, attention seeking, want over protection, very sensitive to pain and also want to be cared about
7. Furor Epilepticus; The sudden unprovoked attacks of intense anger and violence to which individuals with psychomotor epilepsy are occasionally subject.
8. Panic attacks; This is a psychiatric emergency characterized by periods of intensive fear, which occurs suddenly without accompanying danger but person thinks or perceives that there is danger
9. Total insomnia; Sleeping disorder characterized by loss of sleep of an individual
10. Food refusal; Psychiatric eating disorder characterized by abandoning of oneself to eat food
11. Severe depression; Excessive type of depression characterized by persisted low mood or sadness

2. How we can prevent psychiatric emergencies.

Psychiatric emergencies are life threatening and therefore they should be attended to urgently to prevent complications and save life. I.e. the ways include;

Proper counseling and guidance of patients with stress disorders
Proper management of psychiatric conditions
Early diagnosis and treatment of psychiatric conditions
Health education of the people about the predisposing factors to severe mental illness
Equipping heath skilled workers on how to manage the psychiatric conditions by regular CME’s.
Ensuring drug compliance to prevent relapses and progression to severity

3. Management of food refusal

On admission

Patient is hospitalized in a psychiatric unit and a rapport is created in order to gain confidence of the patient in the health unit and the healthy worker

Assessment

Subjective data; Here history is obtained of any chronic illness, and any history about mental illness in the family
Objective data; physical examination from head to toe and general appearance of the patient to rule out any underlining conditions
Mental data; This involves the emotional response, concentration, orientation , memory and perception.

Investigation

Do an FBC to rule out any infection
VDL test to rule out syphilis
Do an RBS to check the amount of sugar levels of the patient
Do a urinalysis for ketones

Nursing care

Daily weighing of the patient is paramount
Monitor status of skin and mucous membranes
Encourage the patient to verbalize feelings of not wanting food.
Maintenance of a strict output and input chart
Avoid discussions that focus on food and weight gain
Allow patient to take packed foods and fluids
Encourage family to participate in education regarding connection between family process and the patient’s disorders
Control vomiting by making the bathroom inaccessible for at least 2hours
Eating must be supervised by the nurse and a balanced diet of atleast 3000 calories should be provided in 24hours

Drugs

Give appetite stimulants like multivitamins
Give antidepressants like Amitriptyline 25mg-75mgs

Family therapy; Educate and counsel the family to accept the patient

Psychotherapy; If the patient’s condition improves, assist the patient to sit and move around and encourage her by respecting her suggestions

Individual therapy; Talk politely to the patient and make him aware that she is important by respecting her decisions

Bi-Polar

Bipolar Affective Disorder is one of the common conditions patients present with.

What is bipolar affective disorder?
Mention the signs and symptoms of Bipolar Affective Disorder?
How would you manage a patient with bipolar affective disorder?

SOLUTIONS

1. Bipolar affective disorder– is an affective/ mood disorder characterized by alternating attacks of Mania and Depression separated by episodes of normal mood
Signs and symptoms of Bipolar affective disorder

Manic episode

Persistently elevated mood
Increased psychomotor activity
Flight of ideas
Poor judgement
Pressure of speech
Lack of insight
Delusions of grandeur and persecution
Decreased food intake due to over activity
Dressed in flamboyant clothes. In severe cases, there is poor self care
Decreased need for sleep (less than 3hrs)
Increased libido
Decreased attention and concentration
High risk activity
Irritability
Increased sociabilities
Impulsive behavior
High risk activities e.g. reckless driving, foolish business investment, distributing money or articles to unknown people

Depressive episode

Decreased psychomotor activity
Persistent low mood/ sadness
Social withdrawal
Loss of energy
Hopelessness, unworthlessness and powerlessness
Fatigue
Delusion of persecution, sin, control, unworthiness, hypochondriasis
Decreased food intake due to lack of appetite
Auditory hallucinations
Avolition i.e. lack of will to act
Ambivalence i.e. two opposing ideas
Anhedonia i.e. inability to experience pleasure
Insomnia
Physiological symptoms e.g. headache, backache, chest pain, amenorrhea, decreased libido, abdominal pain
Tearfulness
Pessimistic
Recurrent thoughts of death
Slow speech/ poverty of ideas
Negativism

3. Management of Bipolar affective disorder

Manic phase

Aims of management

To alleviate delusions and hallucination
To alleviate hyperactivity
To prevent possible injury and aggression
To calm down the patient
To restore normal food intake
To restore normal sleep pattern

Management

Assessment to obtain baseline data and the basis for evaluation. It focuses on the severity of the disorder, causes, patients’ resources, mood and affect, thinking, perceptual ability, sleep disturbance, changes in energy level.

Obtain both objective and subjective data from the patient

Objective data

Disturbed speech
Rapid speech
Loud pressured speech
Over activity
Mood lability
Weight changes

Subjective data

Feelings of joy
Rapid mood swing
Sleep disturbance
Delusions and hallucinations

Admit the patient on an acute non-storeyed psychiatric ward with minimum furniture, free from harmful objects with reduced environmental stimuli to prevent possible harm to self or others.
Form a positive nurse-patient relationship to win the patients’ trust and confidence
Encourage patient to verbally express his feelings to relieve tension and hostility
Have sufficient staff to show strength to the patient and convey contrl over the situation
Reassure patients and relatives to allay anxiety
Encourage performance of planned activities to channel excess energy into socially acceptable behaviours
Formulate a contract and set limits on manipulative behavior, explain the consequences if limits are violated
Stay with the patient as hyperactivity increases to offer support and provide a feeling of security
Keep the patient occupied most of the time during day, discourage day sleep eliminate uncomfortable stimuli at bed time, avoid caffeine containing drinks at bed time, administer prescribed hypnotics to promote sleep and rest of the patient
Teach the patient relaxation techniques e.g. deep breathing exercise, diversion techniques e.g. listening to music to cope with anxiety
To restore normal food intake:

Serve the patient meals on time
Involve patient in food preparation
Serve meals in clean and attractive dishes
Fruits should be provided unpeeled
Provide patients with foods that the patient can eat while moving
Encourage patient to sit down and eat
Provide a balanced diet
Ensure adequate fluid intake
Monitor fluid intake and output
Weigh the patient regularly

12. Encourage the patient to interact with others to promote communication

13. Positive reinforcement for desired behaviours

14. Involve family members in the management of this patient

15. Administer prescribed drugs i.e.

Major tranquilizers such as Chlorpromazine 100-600mg daily in divided doses, Haloperidol 5-60mg daily
Mood stabilizers such as carbomazepine200-1000mg daily, Lithium carbonate300-1500mg daily in divided doses, Sodium valporate600-2600mg daily
Anxiolytics and sedatives such as Diazepam 5-20mg daily in divided doses

16. Monitor side effects of drugs

17. ECT

18. Health educate patient and family members about side effects and how to manage them, increased fluid intake, drug compliance

19. Advice on discharge

Depressive episode

Aims of management

To promote possible harm self and others
To restore normal nutritional status
To restore normal sleep pattern
To restore normal communication

Interventions

Assessment to obtain baseline information and determine the basis for evaluation. It focuses on severity, risk for suicide, causes, resources available, Mood, affect, thinking, somatic complaints. Obtain both objective and subjective data

Objective data

Alteration of activity
Poor personal hygiene
Apathy
Altered social interaction
Impaired cognition
Delusions

Subjective data

Anhedonia
Worthlessness, hopelessness, helplessness
Suicidal idea

Admit the patient on a non-stored open psychiatric ward with limited furniture, free from dangerous objects to prevent possible harm to self
Form a therapeutic nurse- patient relationship to win patients’ trust and confidence
Closely supervise the patient during meals and medication time
Form a contract with the patient not to harm self. This gives a degree of responsibility of his safety
Explore feelings of anger and help the client direct them towards intended object
Accept the clients’ feelings, spend time with the patient, focus on the strengths and accomplishments and minimize failures to build patients’ self esteem
Teach patient assertive and communication skills to promote self esteem
Allow the patient to participate in goal setting and decision making regarding own core to increase his or her feelings of control
Positive reinforcement for desired behavior
Close supervision is always required when recovering from the disease
Involve patient in groups as he improves to promote communication
Ensure quiet and peaceful environment, give warm bath to the patient, do not allow patient to sleep during day, sedatives, plan day activities basing on patients’ interest to improve night sleep
Closely monitor food and fluid intake, maintain input and output chart, record patients’ weight regularly, serve patient with the food he likes, feed the patient on small but frequent meals, encourage more fluid intake to restore normal nutrition. Feed patient on roughage diet and green vegetables to prevent constipation
Administer prescribed drugs i.e.

Antidepressants such as

SSRI’s e.g. Fluoxetine 20-60mg daily, Paroxetine, Sertraline, Citalopram
Tricyclic antidepressants e.g. Amitriptyline 25-75mg Nocte, Imipramine 25-150mg
MAOIs’ e.g. Phenelzine
Others e.g. Maprotiline

Mania

Nakibirye, a mentally ill is presenting with a provisional diagnosis of mania.

Define the term mania.
What are the causes of mania?
Mention the signs and symptoms of mania.
What medical treatment will be given to this patient with mania?

SOLUTIONS

Mania is a mood disorder characterized by self important ideas, mood changes consisting of elation, irritability and over activity sustained over a long period of time

2. Causes of mania

The actual cause is idiopathic but however there are factors that are believed to contribute to its occurrence.

They include:

Predisposing factors
Precipitating factors
Perpetuating factors/ maintaining factors

(I) PREDISPORSING FACTORS

These are factors that may operate from early life or people are born with them.

Hereditary: Mania is believed to have been passed on from the parents/ relatives who suffered from it to children
Uterine environment: This includes factors like maternal drug abuse while pregnant which can be transplacental and causes effect to the fetus
Personality: People with difficult personalities like the paranoid are predisposed to mania due to their irritative mood
Biochemical factor: This includes the abnormal secretion of neuro transmitters and hormones like over secretion of serotonin, dopamine, acetylcholine, adrenaline hormone stimulates the hyperactivity of the body.

(II) PRECIPITATING FACTOR

These are factors which occur shortly before the onset of the illness and appear to have induced the disorder for example:

Physical and social factors like upbringing of children: Which can be due to too much freedom/ permissiveness given to children by parents when growing up?
Maternal deprivation: This creates a depressive mood at early childhood due to inadequate maternal love provided to the child but later mania may be developed as denial to the depression.
Anxious parents: For example parents who expect much from the child and hence drive child’s mind to go for bigger positions (like in leadership if at school) in order to sustain the parents.
Physical stressors: These include changes that which occur for example during adolescents
Psychological situations: Financial achievements like acquiring a job, winning money/prizes. Fulfilled goals in life like education at higher levels like masters degree, PHD.
Marriage and partnership: Being wedded/ introduced especially among women by their husbands. Becoming pregnant for example among women once pronounced infertile by community.
Drug abuse like alcohol abuse marijuana, khaki etc: Trauma to the brain for example through accidents involving the head. Brain tumor like brain cancer can precipitate mania. Infections like syphilis, meningitis that affect the brain tissues may precipitate mania .

(iii) PERPECUATING FACTOR

Continuous drug abuse during the illness.
Poor drug compliance during the illness.
Loss of a job due to the disorder.
Difficulty personality maintaince for example psyclothemic who have mood swing

4. What medical treatment will be given to this patient with mania?

Mania can be managed with/ without treatment depending on the cause.
The patient is admitted on psychiatric ward in a side room with no furniture’s, open sealing or an y other metals to avoid injuries to the patient.
She is given the following medical treatment as prescribed by the psychiatric doctor.
Anti-psychotic drugs- to control psychotic features like hallucination for example chlorpromazine initially 100-200mg 8hourly,then daily doses of up to 300mg are given as a single dose at night.

OR.

Iv sterazine 5-10mg every 12hours;then adjust according to the response up to 40mg or more daily may be required in severe or persistent cases..

OR.

IV haloperidol 5-10mg for every 12 hours; then assessment is made according to response.
An additional dose of diazepam 5-20mg 12hourly for 3/7 its given with chlorpromazine (above)
If patients condition improves is given tablets diazepam 10mg once at night to allow patient rest.
She can also be given a mood stabilizer for example.
Carbamezapine 200mg once a day until a condition stabilizers

Tabs: sodium valporate 200-500mg 12 hourly

Tabs: lithium carbonate 300mg once a day till condition stabilizers.
In case of extra pyramidal side effects, tablets artane is given 2mg-5mg once daily.

Supportive treatment

Family planning is initiated for example IM depoprouera 150mg for every 3 months since she has a high libido.
I.V fluids like normal saline/ dextrose 10% for rehydrating the patient.
A nutritious diet is provided to the patient to boast the immunity.
Psychotherapy like counseling incase patient gains insight.
And investigations are carried out to find out the underlying cause for example rapid plasma reagent (RPR) to R/O for syphilis , serology to R/O HIV/AIDS , and a CT-scan to R/O brain tumors.

Pediatrics

Immunisation, Cold chain

Define the term immunization.
Outline the current immunization schedule.
Describe the cold chain system.

SOLUTIONS

Definition.

Immunization is the process of introducing a weakened or killed vaccine into the body in an attempt to increase the body’s ability to fight against immunizable diseases.

UGANDA NATIONAL EXPANDED PROGRAMME ON IMMUNIZATION (UNEPI)

Vaccine

Doses

No of dosage

Interval between dosage

Minimum age to start.

Route of administration.

Site of administration.

Storage temperature.

Remark

BCG

-0.05mls up to 11months

-0.1mls after 11months.

None

-At birth

-At 1st contact.

I M

-Right upper arm.

+2-+8

-Use diluents provided for BCG ONLY.

Not to be given to children with symptomatic HIV/AIDS.

-Discard reconstituted vaccine after 6 hrs.

Use sponge method.

DPT+ Hep B – Hip

0.5mls

1 month

At 6 weeks.

I M

-Outer aspect of the left thigh.

+2-+8

-Don’t freeze

-Don’t place directly on ice.

Use sponge method.

PCV

0.5mls

1 month

At 6 weeks.

I M

-Outer aspect of the thigh.

+2-+8

-Don’t freeze

Use sponge method.

Polio O.P.V

3 drops

0+3

1 month

-At birth OPV

-First contact.

Orally

Mouth

+2-+8

-Use diluents provided.

-Discard used vial.

Use sponge method.

Measles

0.5mls

None

At 9 months

1st contact.

S/C

-Left upper aspect of the arm.

-Outer aspect of the thigh.

+2-+8

-Use diluents provided.

Use sponge method.

Tetanus toxoid

0.5mls

TT1-TT2=1mnth

TT2-TT3=6mnth

TT3-TT4=1yr

TT4-TT5=1yr.

-At child bearing age 1st contact

Pregnant mother

I M

-Upper arm or

-Outer aspect of the thigh.

+2-+8

-Don’t freeze

-Don’t place vial directly on the ice pack.

Use sponge method.

HPV

0.5mls

HPV 1:At first contact with a girl in primary 4 or aged 10 years for those in the community

HPV2; 6 months after HPV1.

Girls in primary 4 or 10 years old girls who are out of school.

Left upper arm.

+2 to 8

Don’t freeze

Use conditioned ice packs

Use sponge method

IPV

0.5mls

None

At 14 weeks (or first contact after that age)

Outer upper aspect of right thigh2.5cm from PCV injection site.

+20c to +80c

-Do not freeze

-Use conditioned ice packs.

-Use sponge method.

b). Cold chain – Refers to the set of equipments or containers in which vaccines are stored at specified temperatures and transported from the moment of manufacture to the time of administration. It is essential to ensure an unbroken cold chain for vaccines right from the manufacturer (producer) to the person being vaccinated. The specified temperature range is 35° F (2°C) to 45°F (8°C),the system involves personnels, equipments, vaccines, supplies and procedures.

If the vaccines get warm, their potency (effectiveness) is lost, especially those containing live organisms such as polio and measles. On the other hand, vaccines made from toxoids such as Tetanus and diphtheria, and suspended dead organisms such as whooping cough (pertussis) must not be frozen as this will make them loose potency. Vaccines must be stored at their own correct temperatures all the time. The cold chain must not be broken. If the cold chain is broken, Vaccines may loose potency and become useless.

DIAGRAMATIC REPRESENTATION OF THE COLD CHAIN.

Manufacturer of vaccines

Airport

Central vaccine store

Regional or District store
		Mobile or Outreach post

Health centre

Immunization post

Recipient (Mothers, children)

The chain travels in this way;

From the manufacturer to the airport, vaccines are carried in deep freezers in the aeroplane.
From the airport, to the general medical vaccines stores and they are carried in freezers or cold boxes.
From the general medical vaccines stores to the regional (Districts). They are carried in a refrigerated van, in a refrigerator, cold boxes or vaccine carriers.
From the district to the health units, they are carried in the vaccine carriers or cold boxes.
From the health unit to the outreach site, the vaccine should be wrapped in black polythene bags and carried in a well packed vaccine carrier with ice packs.

In the chain vaccines should be separated into those that can be frozen and those that must not be frozen.

The temperature monitoring devices used in the cold chain are; Thermometers and vaccine vial monitors (VVMS).

The equipments used in the cold chain are;

Cold rooms
Freezers and Refrigerators
Vaccine carriers
Ice packs.
Thermometers.

COLD ROOMS

Cold rooms are large, specially constructed rooms or self- contained buildings located at national and in some cases regional levels for storage of large quantities of vaccines that last for 12 months or more.

They have a 24-hour temperature monitoring system with an alarm, a recorder, and a back up generation that will turn on automatically when the regular power is interrupted.

FREEZERS AND REFRIGERATORS

Freezers and refrigerators are used at the district, regional and central stores.

Freezers are used for freezing icepacks and storing some vaccines, particularly OPV that need to be kept at temperatures below 0°c. Other vaccines are stored in refrigerators, which are also used for chilling diluents before mixing with freeze- drained Ice lined refrigerations, which are used at the central and regional levels, are capable of maintaining temperatures below =8°c even when electricity fails as many as 16 of every 24 hours, day after day.

HOW TO CARE FOR REFRIGERATORS.

COLD BOXES

Cold boxes are insulated containers that are lined with icepacks to keep vaccines and diluents cold. They are normally used to transport vaccines from the central level to the regions, regions to districts, and sometimes from districts to the service delivery levels (immunization posts). In some developing countries, Refrigerated vehicles are used instead of cold boxes.

However, these vehicles are expensive to buy, and are subject to frequent mechanical breakdowns, a good cold box works as well, or even better.

Cold boxes are used for temporary storage of vaccines when a refrigerator is out of order, or being defrosted.

VACCINE CARRIERS

These are insulated containers that are lined with icepacks to keep vaccines and diluents cold. They are more portable, are commonly used to transport vaccines from distinct stores to smaller health facilities and to outreach sessions (immunization posts).

ICE PACKS

An icepack is a flat rectangular plastic container designed to be filled with clean water, frozen and then used to keep vaccine. Icepacks must be placed in a cold box or vaccine carrier in a precise way, So their size is important. One extra set of ice packs should be available so that while one set is being frozen at a temperature of (-) 25°C, the other is being used. Freezing icepacks is a process that usually takes at least 24 hours. The icepacks are different from vaccine carriers and should be as per the guide of the manufacturer.

THERMOMETERS

Health unit staffs use alcohol thermometers to monitor the temperature of vaccines in refrigerators, cold boxes and vaccine carriers.

VACCINES

It is stored at a temperature of +2°C to+8°C.
Restricted BCG and Measles vaccine should not be used beyond 6 hours.

Only use the diluents supplied and packaged by the manufacturer with the vaccine since the diluents is specifically designed for the needs of that vaccine, with respect to volume, HP level and chemical properties.

The diluents may be stored outside the cold chain as it may occupy the space of the fridge but keep diluents for at least 24 hours before use in the fridge to ensure that the vaccine and diluents are at +2°C to 8°C when being reconstituted. Otherwise, it can lead to thermal shock that is, the death of some or all the essential live organisms in the vaccine. Store all the diluents and droppers with the vaccine in the vaccine carrier during transportation. Diluents should not come in contact with the ice packs.

Any vials that are expired or frozen or with VVMS beyond the discard point, should not be kept in the cold chain.

Questions and Answers Read More »

Male Involvement in Reproductive Health Services

MALE INVOLVEMENT IN REPRODUCTIVE HEALTH SERVICES

Male involvement is having men participating more in Reproductive health matters as clients and partners.

This can be in the form of seeking and sharing reproductive health information and services with their partners and friends. Sharing domestic chores and child rearing responsibilities is another form of male involvement, joint decision-making between men and their partners will improve the utilization of family planning, STI and EMTCT services.

Male involvement is embedded in the International Conference on Population and Development Program of Action which includes male responsibilities and participation as critical aspects for improving reproductive health outcomes, achieving gender equality, equity and empowering women. This mandate contributes to broadening the concept of gender so that it now includes men.

Male involvement is critical in the reduction of maternal and infant mortality and morbidity in Uganda. Culturally men are the decision-makers in Uganda. Many women are not empowered (decision and economically) to seek health care without consulting their spouses. Some recognize danger signs during or puerperium but wait for their spouses to return home and consent to their seeking for health care. The decision on where to seek care primarily depends on the spouse and his relatives. Evidence from maternal death audits shows that this delay has contributed to the high maternal and infant mortality and morbidity rates in Uganda.

Decisions to keep the family healthy and seek care involve gender power roles
Where men control household resources indirect costs of care seeking are at their discretion
Control of STDs/HIV is a key R.H issue for men, who are often involved in high risk behaviour
Decision on number of children is often dictated by men
SRH issues involve an emotional journey and both men women need the emotional support
Since men control the resources, women often have to explain why they have go to facilities
Preventive services are often harder to justify than emergencies that men need in equal measures are inaccessible to them

Men have sexual and reproductive health problems which need to be addressed. Conditions of the male reproductive system including; – HIV/AIDs, fertility problems, midlife concerns, such as andropause and sexual dysfunction. Serious conditions include non- malignant genitor-urinary conditions and malignancies of prostate, testicles and genitor-urinary organs.

Vulnerability of males to SRH problems, their roles and responsibilities in prevention and care, including the prevention of gender based violence, are important aspects of a gendered approach to prevention interventions. Empirical and anecdotal evidence indicates that often, cultural beliefs and expectations of manhood or masculinity encourage risky behaviour in men. Masculinity requires males to play brave by not seeking help or medical treatment if they are faced with ailments including HIV/AIDs. Violence against women is more common and arises from the notion of masculinity based on sexual and physical domination over women. Gender based violence is a cross-cutting issue in all the sectors, exists within family and community spaces, and is entrenched within the existing ethno-cultures and its consequences are grave.

In the past, men\’s involvement has sometimes been opposed by women\’s health advocates, who understandably fear that adding these services will damage the quality of women\’s services and create additional competition for already scarce resources. However, adding programs for men can enhance rather than deplete existing programs if the designers of these programs carefully integrate them into the existing health care structure in a way that benefits both women and men.

Both the 1994 International Conference on Population and Development in Cairo and the 1995 Fourth World Conference on Women in Beijing endorsed the incorporation of reproductive health services that include men, mandating that men\’s constructive roles be made part of the broader reproductive health agenda.

In fact, neglecting to provide information and services for men can detract from women\’s overall health. For example, men who are educated about reproductive health issues are more likely to support their partners in decisions on contraceptive use and family planning, support that may be essential if women are to practice safe sex or avoid unwanted pregnancy. Moreover, if men are knowledgeable about reproductive health issues and can communicate about them with their partners, they are more likely to be supportive during pregnancy and may make better health care decisions: for example, by ensuring that their partner receives emergency obstetric services when needed, rather than delaying recourse to such care. The effect of men\’s attitudes and behavior on women\’s health is perhaps most obvious in regard to the pandemic of AIDS and other STDs. Programs that educate, test and treat only one partner will not be effective in safeguarding the continued health of both. Men need to share the responsibility of disease prevention, as well as the risks and benefits of contraception.

Importance of Male Involvement

Involving men in reproductive health services benefits men and women, community and the service provider

Reasons for Involving Men in Reproductive Health

Provides male support for female actions related to reproduction and respect for women’s reproductive and sexual rights
Increases access to male contraceptive methods and hence helps on expanding the range of contraceptive options
Promotes responsible and healthy reproductive and sexual behavior in young men
Involves men with their spouses during counseling and other FP/RH information
Helps in preventing the spread of HIV/AIDS and STDs
Helps inform men of the ill effects of men’s risky sexual behaviour on the health of women and children
men approve of family planning and hence supporting women’s contraceptive use
men make decisions that affect women and men’s health
demands from women for more involvement
involving men in reproductive health is to use the forum of reproductive health programmes to promote gender equity and the transformation of men’s and women’s social roles

Factors limiting male participation in reproductive health

Primary health center (PHC) programs not geared to meet men’s needs
Unfavorable social and cultural climate. Cultural factors have limited men’s abilities to take an active role in family planning practice and reproductive health decision making.
Services aimed at women and children. Most family planning and reproductive health services are designed to meet women‘s or children‘s needs and, as a result, men often do not consider them as a source of information and services. Many may be inconvenient or unwelcoming to men, and providers may not have the training or skills necessary to meet men‘s reproductive health needs. Men also may be embarrassed about visiting a facility that primarily serves women.
Limited number of male contraceptives available. As mentioned above, available male methods are limited to condoms, natural family planning, vasectomy, and withdrawal. Like contraceptives for women, each of these methods has advantages and disadvantages and each potential client will have to decide for himself whether a particular method will meet his needs. While research is ongoing on new methods for men (including hormonal injections and implants), it is unlikely that a new method will be widely available for several years.
Rumors and misinformation. Because of the general lack of access to accurate information about male contraceptive methods, many men and women may not know how to use them correctly or may have misperceptions and fears that prevent them from using the methods. For instance, men may be un- willing to consider using vasectomy because they equate it with castration or believe that it leads to impotence; similarly, they may be unwilling to use condoms because they believe condoms will reduce sexual satisfaction or cause an allergic reaction.
Provider bias against male methods. Providers also may have misconceptions or biases about male methods or men‘s roles in family planning. As a result, they may not present information about male methods or assume that men are not interested. Concerns about the lower effectiveness of some male methods can be addressed through counseling about correct and consistent use as well as by offering emergency contraceptive pills to users as a backup in case condoms are not used properly or break.
Unfavorable social or religious climate. In societies where sexual matters are not discussed openly, men may feel uncomfortable talking about their family planning needs and sexual concerns with their partners and with health educators. Young men may face particularly strong social pressures that prevent them from seeking reproductive health information and services. In addition, some men may believe that practicing
contraception is contrary to the teaching of their religion. Priority given to women‘s health services. Many programs are reluctant to invest time and money to reach men with information and services when their female clients have significant unmet health and family planning needs.
PHC service providers are mostly female
Priorities to women and child care services
Health workers attitude were some Providers have bias against male involvement
Lack of information and knowledge
Limited communication between spouses about FP needs
Health centre resource constraints such as lack of enough male H/W, lack of male clinics
Psychological factors (mindset and shyness of men)
Difficult reaching couple with health information before pregnancy

Reproductive Health Needs and Services for Men (Male reproductive health needs)

Information:

1. - Basic sexual and reproductive health education
  - Genital health and hygiene
  - Healthy relationships
  - Pregnancy prevention
  - STI including HIV
  - Fatherhood
  - Where and how to obtain other services (violence, sexual abuse, genetic counseling etc.)
  - Contraception
  - Reproductive physiology
  - Sexuality
  - Pregnancy
  - Birth preparedness
  - Male reproductive cancers
  - Sexual and gender based violence
  - Fertility and infertility

Skills:

1. - Pregnancy and STI prevention and sex/sexual skills
  - Fatherhood skills

Preventive health care services:

1. - Sexual and reproductive history
  - Cancer screening
  - Substance abuse screening
  - Mental health assessment
  - Physical examination
  - Links to other services, if needed

Clinical diagnosis and treatment

- Testing for STIs, including HIV
- Diagnosis of and treatment for sexual dysfunction
- Fertility evaluation
- Contraceptive services (vasectomy) treatment of urologic disease: vasectomy reversal

Social and Reproductive Health Responsibility of Men

Discussing contraceptive with the partner
Discussing and utilizing STI/HIV screening services with partners
Escorting partners to antenatal care, delivery and postnatal care services
Men should only marry partners who are 18 years and above
Abstain from sex until marriage
Use condoms to prevent STI/HIV and unwanted pregnancies
Have good relationship with partner especially during pregnancy, labor and puerperium
Provide moral and financial support to the partners during pregnancy, child birth and postnatal
Provide support to the partner for infant feeding choices
Help bringing up children

Social Norms, Beliefs, Practices and Taboos:

Promiscuity
Power imbalances where male dominance is the norm
Inadequate dialogue(lack of communication between spouses)
Inadequate participation of men in child care
Assigned roles due to gender biases example men do not cook therefore cannot assist their wives during pregnancy
Early marriage is culturally accepted
Wife inheritance
Polygamy
Competition among wives
Poverty

Strategies to Increase Male Involvement in Reproductive Health

Working with young men to influence gender biases for better reproductive health (e.g. in school)
Integrate the desired services to address needs of men in the existing services
Improved services at existing clinics.
Sensitize the general community to re-address gender biases which have negative impacts on reproductive health
Build capacity of health workers to involve men in reproductive health services
Develop information, education and communication and advocacy materials, address male involvement/responsibilities in reproductive health services.
RH information and services should focus the couple rather than the individual.
Remove myths about condom and vasectomy.
Service providers to be sensitized for men’s reproductive health needs.
In RH health clinics, a arrangement health services may increase the male clientele.
Separate clinic for males.
Workplace services.
Community-based services.
Commercial and social marketing.
Increase contraceptive choice for men.
Train providers about male FP/RH needs.
Culturally appropriate messages
Male health workers
Engaging different institutions such as MoH and NGOs
Develop guidelines on male involvement in RH

Male Involvement in Reproductive Health Services Read More »

Infertility

INFERTILITY

Infertility is the inability of a couple to conceive or to get a child after one year of regular coitus without having used any form of contraception.

Infertility refers to failure to conceive in spite of regular unprotected sex during the child bearing age that is 15-49 years without any contraception for at least one year.

Types of infertility

Primary infertility

Primary infertility is the inability to conceive in a couple that has had no previous pregnancies.
Primary infertility is the term used for a couple who have never achieved a pregnancy at any time after 1 year of unprotected sex.

Secondary infertility

Secondary infertility is where one has ever conceived but then stops to produce when she is not on any method of family planning.
Secondary Infertility also refers to a couple who have previously succeeded in achieving at least one pregnancy even if this ended in spontaneous abortion being unable to conceive again.

Forms of Infertility

Male Infertility

Male infertility means a man is not able to start a pregnancy with his female partner.

Female Infertility

Female infertility is defined as not being able to get pregnant (conceive) after one year (or longer) of unprotected sex.

Causes of infertility

In males

Depression: Mental health conditions, such as depression, can affect the ability of a man to engage in sexual intercourse since it can affect sustaining an erection. Stress and emotional factors may contribute to the release of immature or abnormal sperm.
Poor Sperm Movement: Factors like extreme heat, prolonged fever, or exposure to excessive heat can reduce sperm count, impair movement, and increase the number of abnormal sperm in semen.
Ejaculation Issues: Difficulties in ejaculation, including poor or failed ejaculation, can contribute to male infertility.
Hydrocele: Excessive fluid collection in the scrotum (hydrocele) can hinder proper sperm production, impacting fertility.
Varicocele: Varicose veins in the scrotum can affect blood supply and drainage, leading to increased temperatures and reduced sperm production. It may also impact ejaculation.
Drug-Induced Erectile Dysfunction: Certain medications, such as amebicides, anti-hypertensives (e.g., aldomet), and diabetic drugs, may cause erectile dysfunction, contributing to infertility.
Diseases like Mumps: Mumps can lead to orchitis, an inflammation of the testes, affecting sperm production.
Hormonal Imbalance: Inadequate production of testosterone hormone can result in the production of immature sperm.
Degenerative Changes in Sperm: Nitrofurantoin, a medication, can cause degenerative changes in sperm.
Lifestyle Factors: Excessive smoking, alcohol consumption, and obesity can negatively impact sperm quality and fertility.
Retrograde Ejaculation: Ejaculation into the bladder can occur, affecting fertility. This can be assessed through urinalysis after ejaculation.
Exposure to Toxins: Exposure to toxic chemicals or radiation can adversely affect spermatogenesis.
Genetic Factors: Genetic conditions like Klinefelter’s syndrome (XXY chromosomes) and Turner’s syndrome (45XO chromosomes) can lead to infertility in males.

Causes/factors in females

Are best discussed under the following headings;

Defective Implantation
Endocrine Disorders
Ovarian Disorders
Defective Transport
Physical / Psychological Disorders
Systemic Disorders

DEFECTIVE IMPLANTATION

Major cause is tubal blockage due to PID (in Uganda especially). This contributes to 60 – 70%.

Salpingitis caused by infection after abortion or delivery by gonorrhoea, chlamydia or tuberculosis or by pelvic peritonitis from acute appendicitis may damage the tubal epithelium and in severe cases bring about tubal blockage.
When the tubes are not completely blocked, fertilization of the ovum may still take place but because of the damage to the ciliated epithelium the fertilized ovum may not be carried down the tube to the uterus and an ectopic pregnancy results.
Abnormalities of the uterus. Some people are born with no uterus or with a bicornuate uterus or Didelphys uterus with 2 horns).
Tubal factors eg tubal blockage due to adhesions resulting from STIs.eg gonorrhoea
Uterine fibroids: Large uterine fibroids can cause irregular implantation surfaces.
Endometrial Abnormalities: Severe inflammation (endometritis) or intrauterine adhesions can affect implantation.
Endometriosis: Presence of endometrial-like tissue outside the uterus can cause inflammation, scarring, and infertility.
Over curettage of the uterus or surgery of the uterus i.e. Hysterectomy, Stenosed Cervix due to trauma or injury due to dilatation and curettage. May be acquired or congenital Gynatresia i.e. a very small hole with a blind end of the vagina.

ENDOCRINE DISORDERS

Hormonal Inefficiency: Alterations in hypothalamic function due to stress, drugs, or weight changes can lead to anovulation.
Prolactin Hormone Issues: Pituitary tumours causing excessive prolactin production can lead to anovulation.
Thyroid and Adrenal Function: Changes in thyroid or adrenal function can result in anovulation.
Age-Related Factors: Fertility declines with age, impacting women during menopause.

OVARIAN CAUSES

Ovary Malfunction: Absence of FSH receptors or disturbances in FSH-follicle interaction can lead to anovulation or polycystic ovarian syndrome.
Premature Menopause: Early cessation of ovarian function can result in infertility.
Surgery and Infection: Surgical removal of ovaries or infections like PID can damage ovarian tissue.

DEFECTIVE TRANSPORT

Allergy to the man’s sperms/cervical hostility – This is a condition in which the cervical mucus is unreceptive to spermatozoa either preventing their progressive advance or actually killing them. It may be due to infection or to the presence of sperm antibodies.
Vaginal Ph: Acidic environment in the vagina destroying the motility of the sperms.

PHYSICAL/ PSYCHOLOGICAL CAUSES

Other conditions preventing union of ova and sperm in female are;

Dyspareunia and Vaginismus: Painful intercourse (dyspareunia) or psychological conditions like vaginismus can affect conception.
Physical Abnormalities: Physical abnormalities like a retroverted uterus can impact fertility.
Psychological Factors: Stress, depression, and wrong timing of intercourse can influence fertility.

SYSTEMIC CAUSES

Systemic Diseases: Diseases like diabetes, hypertension, and renal failure can affect reproductive health.

Conditions that should be fulfilled for implantation to occur.

For successful implantation to occur, the following conditions must be fulfilled:

Two individuals engaging in unprotected sexual intercourse must be actively involved and share a mutual desire to conceive.
The sexual intercourse should involve the right sexual route, with the male ejaculating healthy semen containing normal spermatozoa into the female’s vagina.
Both individuals should be within the age range of conception, ranging between 14 to 49 years, to optimize the chances of successful fertilization and implantation.
The female partner must release a normal, healthy ova from her ovary during her menstrual cycle.
The released ovum must be fertilized by the sperm to form a zygote.
The fertilized ovum, or zygote, must then successfully implant itself in the lining of the uterus to initiate pregnancy.

NOTE: It is important to note that the term “sterility” should only be used when there is no available treatment to enable a couple to conceive, such as in cases where a man lacks testes or a woman lacks a uterus.

GENERAL INVESTIGATIONS

All couples who complain of infertility should be investigated but the length to which the investigations should be carried out will vary.
Both partners should be seen for the initial interview.

Female Investigations	Male Investigations
1. History Taking	1. General Physical Examination
2. Urinalysis	2. Medical History
3. Full Blood Count	3. Semen Analysis
4. Pelvic Ultrasound Scan	4. Scrotal Ultrasound
5. Hysterosonography	5. Hormone Testing
6. Laparoscopy	6. Post-Ejaculation Urinalysis
7. Cervical Mucus Analysis	7. Genetic Tests
8. Endometrial Biopsy	8. Testicular Biopsy
9. Testing for Tubal Patency	9. Specialized Sperm Function Tests
– Tubal Insufflation/Rubin Test	10. Transrectal Scan
– Hysterosalpingography
10. Ovarian Reserve Testing
11. Post Coital Test (Sims Huhner Test)

Evaluation in Women (Females):

History:

Menstrual History: Menarche and length of menstrual periods.
Gynaecological History:

Previous contraceptive use and outcomes.
History of procedures like dilatation and curettage, salpingectomy.
Any history of abortions or suggestive Pelvic Inflammatory Diseases (PID).
Previous obstetric history, including pregnancies and children fathered.

Pelvic Infection History: History of pelvic infections.
General Health and Nutrition: Assess general health and nutritional status.
Age and Weight: Age of both partners and consider weight; very lean or obese women may face fertility challenges.
Visual Examination: Assess hair distribution, including pubic hair and general body hair.
Vaginal Examination: Confirm vaginal normality through visual examination and ultrasound.
Hormonal Investigations:

Check progesterone levels on day 21 of a 28-day cycle to assess ovulation.
Serial ultrasound for ovulation.
FSH and LH levels, especially in cases of premature menopause or ovary removal.

Special Tests:

Hysterosalpingogram to check tubal patency.
Post-coital test to assess sperm allergy.
Basal body temperature charting for ovulation confirmation.
Examination of cervical mucus for ovulation characteristics.
Blood progesterone level testing.

Histology: Premenstrual endometrial biopsy to show secretory changes after ovulation.
Laparoscopy: Tubal patency test, with methylene blue injection to observe spillage.
Tubal Insufflation: Carbon dioxide test via the vagina, coupled with X-rays to assess blockages.
Hysterosalpingogram: Radiographic test with opaque radio aqueous solution to check patency.
Post-Coital Test (Huhner’s Test): Conducted around ovulation to assess sperm motility and quantity.
Prolactin Tests: Conducted when prolactin levels are elevated.
Endometrial Biopsy: Performed 10-12 days after ovulation.
Transvaginal Ultrasound (TVS): Used for evaluation with certain contraindications and risks.

Evaluation in Men (Male):

Obesity Assessment: Check for associations with diabetes mellitus, hypertension, and infertility.
Hair Distribution and Genitalia Development: Assess hair distribution and genitalia development.
Undescended Testis: Check for undescended testes, with corrective surgery before puberty if necessary.
Breast Examination: Check for breast enlargement indicating increased oestrogen levels.
Testes Examination: Assess testis size and position.
Blood Tests: Sperm Count/Seminal Fluid Analysis:

Normal count is ≥20 million/ml; below 10 million may indicate an issue (oligospermia).
Decreased androgen levels may indicate infertility.

Normal Findings in Semen Analysis:

Volume: Normal volume is ≥2 ml or 2.5ml.
pH: 7-8.
Total Sperm Count: More than 20 million/ml.
Liquefaction: Complete in 1 hour.
Motility: ≥50% with forward motility.
Morphology: 30% or more with normal shape.
Concentration: ≥20 million/ml.

Note:

Azoospermia: Lack of sperms in semen.
Oligospermia: Few sperms, less than 20 million/ml.
Asthenospermia: Decreased sperm motility.
Teratospermia: Excessive abnormality of sperms in semen.

MANAGEMENT AND TREATMENT OF INFERTILITY.

Treatment In Females

Management of infertility involves a range of strategies, including

Medication,
Surgery,
Artificial insemination, or advanced reproductive technologies.

The choice of treatment depends on factors such as;

The cause of infertility,
Age of the individual,
Duration of infertility, and individual preferences.

Medical Management(Chemotherapy): This Involves stimulating ovulation using fertility drugs. Fertility drugs regulate or stimulate ovulation. Fertility drugs are the main treatment for women who are infertile due to ovulation disorders.

Fertility drugs generally work like the natural hormones — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — to trigger ovulation. They’re also used in women who ovulate to try to stimulate a better egg or an extra egg or eggs. Fertility drugs may include:

Clomiphene citrate:

Clomiphene is taken by mouth and stimulates ovulation by causing the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg.
Dose: Clomiphene Citrate (Clomid): 50mg daily for 5 days, with potential second course.
The treatment is usually started on the fifth day of your menstrual period. But can still be taken at any time.
If ovulation does not occur a second course of 100 mgs daily for 5 days may be given starting as early as 30 days after the previous one, In general 3 courses of therapy are adequate to assess whether ovulation is obtainable. Clomiphene induces ovulation by stimulating the Hypothalamic pituitary system.

Gonadotropins:

Instead of stimulating the pituitary gland to release more hormones, these injected treatments stimulate the ovary directly to produce multiple eggs.
Gonadotropin medications include human menopausal gonadotropin or hMG (Pregonal) or Pure FSH (Metrodin) may be used if clomiphene has failed.
Another gonadotropin, human chorionic gonadotropin is used to mature the eggs and trigger their release at the time of ovulation.
Administered via syringe pump every 90 minutes to trigger ovulation. 10-25 micrograms released via a syringe pump every 90 minutes. It’s given intravenously or subcutaneously.
The treatment is continued throughout the menstrual cycle
The success rate of 60-70% has been shown.
Concerns exist that there’s a higher risk of conceiving multiples and having a premature delivery with gonadotropin use.

Metformin:

Metformin is used when insulin resistance is a known or suspected cause of infertility, usually in women with a diagnosis of Polycystic ovary syndrome (PCOS). Metformin helps improve insulin resistance, which can improve the likelihood of ovulation.

Letrozole:

Letrozole belongs to a class of drugs known as aromatase inhibitors and works in a similar fashion to clomiphene.
Letrozole may induce ovulation. However, the effect this medication has on early pregnancy isn’t yet known, so it isn’t used for ovulation induction as frequently as others.
One study found that 27.5% of women who took letrozole achieved a successful birth. Other studies suggest that compared to women who took Clomid, women who took letrozole had higher rates of ovulation, pregnancy, and live birth.

Bromocriptine:

Bromocriptine(also called parlode lactodel, dopagon or Brameston), a dopamine agonist, may be used when ovulation problems are caused by excess production of prolactin (hyperprolactinemia) by the pituitary gland.
Initially 1.25 mgs at bed time which is increased gradually to the usual dose of 2.5mgs 3 times a day with food. Increased if necessary to a maximum dose of 30 mgs daily.

Tamoxifen:

Tamoxifen Is in the same class of medication as Clomiphene and works in a similar fashion. It has been shown to effectively induce ovulation in 65-75 percent of women, a rate similar to that of Clomid.
Give Tamoxifen 20 mgs daily on days 2, 3, 4 and 5 of the menstrual cycles. Dose may be increased to 40 mgs the 80mgs.

Surgery

Tubal Blockage:
Surgery is performed in an attempt to unblock them and remove adhesions. Success rate is low.

Salpingolysis: This is when peritubal adhesions around the ampullary ends of the tubes are divided and
function restored.
Salpingostomy: This is when the fimbriae are turned back to produce a new opening of the tube.
Tubal Anastomosis and Repair: This is usually done when the blockage is at the Isthmus. The blocked segment is incised and cut ends are anastomosed.
Laparoscopic or hysteroscopic surgery: These surgeries can remove or correct abnormalities to help improve your chances of getting pregnant. Surgery might involve correcting an abnormal uterine shape, removing endometrial polyps and some types of fibroids that misshape the uterine cavity, or removing pelvic or uterine adhesions.
Uterine, Cervix, or Vaginal Issues: Corrective surgeries, e.g., Myomectomy for uterine fibroids.

TREATMENT IN MALE

Surgical Interventions:

Varicocele Correction: Surgical correction of varicoceles, common dilations of the spermatic veins, is a viable option.
Vas Deferens Repair: Surgical procedures can address obstructions in the vas deferens, facilitating the passage of sperm.
Vasectomy Reversal: Reversal procedures can be performed for individuals who had previously undergone vasectomies.
Sperm Retrieval Techniques: In cases of absent sperm in ejaculate, direct retrieval from the testicles or epididymis using specialized techniques may be employed.

Management of Infections:

Antibiotic treatments are considered to address reproductive tract infections, aiming to restore fertility. However, efficacy varies.

Addressing Sexual Dysfunction:

Conditions like erectile dysfunction or premature ejaculation impacting fertility can be managed with medications or counseling.

Hormone Therapies and Medications:

Hormone Replacement: In cases of hormonal imbalances affecting fertility, hormone replacement therapy may be recommended.
Human Gonadotropin Therapy: Clomiphene citrate might be administered to stimulate sperm production.
Testosterone Treatment: Prescribed to stimulate sexual desire, caution is exercised in cases of impaired spermatogenesis. It is administered subcutaneously or intramuscularly 2 to 3 times per week at doses of 2,000 to 3,000 international units (IU).

Surgical Measures:

Reproductive Tract Obstruction Relief: Surgical procedures aim to alleviate obstructions in the reproductive tract.
Inguinal Hernia Repair: Surgical correction is performed for inguinal hernias.
Assisted Reproductive Technology (ART): ART involves various methods to obtain sperm, including normal ejaculation, surgical extraction, or from donor individuals.

Lifestyle Modifications:

Diet and Exercise: Encouraging a healthy lifestyle with a balanced diet and regular exercise can positively impact sperm quality.
Avoidance of Environmental Hazards: Minimizing exposure to environmental factors like toxins and excessive heat can contribute to improved fertility.
Increase frequency of sex. Having sexual intercourse every day or every other day beginning at least 4 days before ovulation increases your chances of getting your partner pregnant.
Have sex when fertilization is possible. A woman is likely to become pregnant during ovulation — which occurs in the middle of the menstrual cycle, between periods. This will ensure that sperm, which can live several days, are present when conception is possible.
Advise the patient to avoid the use of lubricants. Products such as Astroglide or K-Y jelly, lotions, and saliva might impair sperm movement and function. Supplements with studies showing potential benefits on improving sperm count or quality include: Herbal supplements, Chewing dry coffee, Eating plenty of ground nuts, Chewing roots of herbal plants e.g. Mulondo.

Medications for Specific Conditions:

Depending on the underlying causes, specific medications targeting conditions affecting fertility, such as anti-inflammatory drugs, may be prescribed.

OTHER CONSIDERATIONS FOR BOTH PARTNERS

In Vitro Fertilization (IVF):

Developed in 1978, by Robert Edwards who received the nobel prize in Physiology for development of IVF. It is a type of Assisted reproductive technology.
IVF is an infertility treatment for women unable to conceive naturally.
Involves retrieving a healthy ovum from the woman or a donor, fertilizing it with sperms, and implanting the embryo in the uterus.
Often results in multiple pregnancies due to transferring several fertilized ova to enhance implantation chances.

Intrauterine insemination (IUI).

During an intrauterine insemination (IUI) procedure, sperm is placed directly into the uterus using a small catheter.
The goal of this treatment is to improve the chances of fertilization by increasing the number of healthy sperm that reach the fallopian tubes when the woman is most fertile.
During IUI, millions of healthy sperm are placed inside the uterus close to the time of ovulation.

Surrogate Parents:

In situations where the woman lacks a uterus, her ova can be fertilized with the husband’s sperms and implanted in another woman’s uterus.
As soon as the baby is born the surrogate mother hands over the child to the rightful parents.

Adoption of Children:

If still eager to have children, they can visit an adoption centre, fill in forms and apply for adoption of a child of choice.

Artificial Insemination by a Sperm Donor (AID):

Artificial insemination is often used by couples who have tried to conceive naturally for at least one year without success.
Treatment for couples struggling with male fertility problems, including low sperm counts, decreased sperm motility, or ejaculation dysfunction disorders.

NURSING DIAGNOSES

Anxiety and fear related to unknown procedures, treatment and outcome evidenced by the patient’s verbalization.
Low self esteem related to inability to conceive evidenced by low mood, negative attitude and social isolation.
Knowledge deficit related to the process of ovulation, pregnancy and sexual relationship evidenced by inadequate verbalization of correct sexual behavior information.
Knowledge deficit related to sexual anatomy and physiology/ causes of infertility evidenced by inadequate verbalization of related information.

Nursing Interventions

Assessment: Conduct a thorough assessment of the patient’s medical history, reproductive health, and lifestyle factors influencing fertility.
Emotional Support: Provide empathetic support to address the emotional distress associated with infertility. Offer counseling or refer to mental health professionals when needed.
Educational Guidance: Offer education about the various causes of infertility, available treatments, and assisted reproductive technologies (ART) to empower patients with knowledge.
Lifestyle Modification: Collaborate with patients to identify and modify lifestyle factors that may impact fertility, such as smoking cessation, reducing alcohol intake, and maintaining a healthy diet.
Medication Education: Educate patients on the proper administration, potential side effects, and expected outcomes of fertility medications prescribed..
Fertility Monitoring: Instruct patients on methods of monitoring fertility, such as tracking ovulation cycles and recognizing fertile periods.
Assistive Reproductive Technologies (ART): Explain the processes and options associated with ART, including in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and other advanced techniques.
Infection Prevention: Emphasize the importance of preventing and treating reproductive infections that may contribute to infertility.
Nutritional Counselling: Collaborate with a dietitian to provide nutritional counselling, ensuring patients are aware of the impact of diet on fertility and overall reproductive health.
Sexual Health Education: Offer guidance on maintaining a healthy sexual relationship and addressing any concerns related to sexual dysfunction or discomfort.
Monitoring Medication Adherence: Regularly assess and monitor the patient’s adherence to prescribed medications and treatments, addressing any concerns or challenges.
Facilitate Support Groups: Arrange or recommend participation in support groups where patients can share experiences, coping strategies, and emotional support with others facing similar challenges.
Referral to Specialist: Collaborate with fertility specialists, reproductive endocrinologists, or other healthcare professionals to ensure a multidisciplinary approach to care.
Advocacy: Advocate for patients’ needs and ensure they have access to comprehensive fertility care, addressing any barriers or challenges they may face during the diagnostic and treatment process.

Prevention of Infertility

Cease Smoking: Smoking is associated with reduced fertility in both men and women. Quitting smoking enhances reproductive health by improving sperm quality and reducing the risk of reproductive complications in women.
Moderate Alcohol Consumption: Excessive alcohol intake can adversely affect fertility. Limiting alcohol consumption promotes overall reproductive well-being. It is advisable for both partners to maintain moderation.
Adopt a Nutrient-Rich Diet: A well-balanced diet rich in essential nutrients supports reproductive health. Key elements include antioxidants, vitamins, and minerals that contribute to optimal hormonal balance and overall fertility.
Timed Intercourse: Understanding the menstrual cycle and engaging in timed intercourse during the fertile window increases the chances of conception. Regular sexual activity throughout the menstrual cycle is encouraged.
Stress Reduction Techniques: Chronic stress can impact fertility. Incorporating stress-reduction practices such as meditation, yoga, or mindfulness can contribute to a healthier reproductive environment.
Maintain a Healthy Weight: Both obesity and being underweight can affect fertility. Maintaining a healthy weight through regular exercise and a balanced diet supports hormonal balance and reproductive function.
Safe Sex Practices: Protecting against sexually transmitted infections (STIs) is crucial. STIs can lead to pelvic inflammatory diseases (PID) that may result in infertility. Consistent and correct use of barrier methods, like condoms, helps prevent STIs.
Regular Health Check-ups: Routine health check-ups for both partners can detect and address potential reproductive health issues early on. Identifying and managing health conditions timely contributes to fertility preservation.
Avoid Exposure to Environmental Toxins: Limit exposure to environmental pollutants and toxins, such as certain chemicals and radiation, which may impact fertility. Precautions in the workplace and living environment are essential.
Manage Chronic Health Conditions: Proper management of chronic conditions like diabetes, hypertension, and thyroid disorders is crucial. Uncontrolled health conditions may negatively impact fertility.

Complications of Infertility

Depression: Experiencing infertility can lead to emotional distress and, in some cases, clinical depression. The frustration, disappointment, and uncertainty about the future can contribute to mental health challenges.
Strain on Relationships: Marital Challenges and Divorce: Infertility may strain relationships, leading to conflicts and challenges. The pressure to conceive can create emotional distance, and, in extreme cases, contribute to marital strain and even divorce.
Sexual Morality: The stress of infertility might impact the couple’s intimate life, leading to challenges in maintaining a healthy sexual relationship.
Polygamy: Cultural or societal expectations, combined with the desire for children, may lead some individuals to consider polygamy as a solution, introducing additional complexities to relationships.
Social Stigma: Societal attitudes towards fertility and parenthood can contribute to stigmatization, causing individuals or couples to feel isolated or judged.
Financial Strain: Economic Impact: Fertility treatments can be financially demanding. The cost of various procedures, medications, and assisted reproductive technologies may contribute to economic stress.
Health Risks and Treatment Complications: Health Concerns: Fertility treatments, especially hormonal interventions, may pose certain health risks.
Treatment Complications: Some fertility treatments carry risks and potential complications that individuals and couples need to be aware of.

Image References: https://www.invitra.com/en/female-sterility/

Infertility Read More »

Ectopic Pregnancy

ECTOPIC PREGNANCY

Ectopic pregnancy is a condition in which a fertilized egg implants and grows outside the uterus. Instead of the fertilized egg traveling to and implanting in the uterus as it should during a normal pregnancy, it implants in a location where it cannot develop properly.

Ectopic pregnancy is when the fertilized ovum embeds outside the uterine cavity.

Causes of Ectopic Pregnancy.

Fallopian tube damage: Scarring or blockage in the fallopian tubes, caused by previous infections, surgeries, or conditions like endometriosis, can interfere with the the movement of the fertilized egg through the tube and increase the likelihood of implantation outside the uterus. Congenitally long tubes which are liable to kink, Congenital narrowing of the fallopian tube also increases the risk.
Hormonal factors: Certain hormonal imbalances or abnormalities can affect the movement and implantation of the fertilized egg, increasing the risk of ectopic pregnancy.
Previous ectopic pregnancy: Women who have had an ectopic pregnancy in the past are at a higher risk of experiencing another ectopic pregnancy in the future.
Reproductive system abnormalities: Structural abnormalities of the reproductive system, such as a misshapen uterus or an abnormally located fallopian tube, can contribute to the occurrence of ectopic pregnancy.
Pelvic inflammatory diseases.eg salpingitis. This cause destruction or erosion of Cilia, formation of adhesions interfering with peristalsis in the tubes.
Tumours: pressing on adjacent sides of the tube causing partial or complete blockage of the tube.
Endometriosis ie development of the endometrium in other places other than the uterus.
Repeated induced abortions
Tubal surgery ie surgical procedures on the fallopian tubes may cause intraluminal or extraluminal adhesions.
Intra Uterine Devices. This can interfere with implantation of the fertilized ovum.

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SITES OF ECTOPIC PREGNANCY

The commonest is the uterine tube but can also occur in the broad ligament, ovary and abdominal cavity.

Fallopian tubes(commonest)
Ovary
Intraperitoneal abdominal cavity
Cervix

Tubal pregnancy

This is when a fertilized ovum embeds it self in the fallopian tubes.

Sites for tubal pregnancy

Ampulla(commonest)
Isthmus (e most dangerous because it has tendency to rupture
very early sometimes even before the mother realizes she is pregnant)
Fimbriated end(infundibulum) – rare
Interstitial part(rare)

POSSIBLE OUTCOMES OF TUBAL PREGNANCY

Tubal mole: The zygote dies but it is retained in the fallopian tubes surrounded by a blood clot. This may result into a slow leaking ectopic pregnancy
Tubal abortion: The zygote separates from the fallopian tube lining and it is expelled through the fimbriated end. It may die out or continue to survive on abdominal organs resulting into abdominal pregnancy which can go up to term.
Tubal rapture: The tube becomes too small for the growing zygote so it raptures causing internal bleeding into the abdominal cavity.
It is one of the obstetric emergencies since it causes a lot of internal bleeding and thus shock.
Tubal erosion: The zygote erodes the fallopian tube lining causing bleeding in to the abdominal cavity.

Signs and symptoms ectopic pregnancy (tubal rapture)

On history taking

History of amenorrhea 6 – 10 weeks
Patient complains of a feeling of fainting, dizziness, thirsty and vomiting.
Patient complains of acute abdominal pain localized in the iliac fossa which is colicky in nature. It can be referred to the shoulder especially on lying down due to blood irritating the diaphragmic nerve and peritoneum.

On examination

Signs of pregnancy are present. eg darkening of areolar.
Signs of shock i.e. cold, clammy skin, rapid and thread pulse, low blood pressure and temperature.
Patient is anxious and restless.
Pallor of the mucous membrane.

On palpation

Abdominal tenderness especially on the affected side
Abdominal muscles become rigid due to mother guarding against pain.
Abdominal distension due to presence of blood in the abdominal cavity

On vaginal examination

Amount of bleeding doesn’t correspond to the mother’s condition.
Tenderness on movement of the cervix and a mass is felt in the lateral fornix of the vagina.
Painful mass in the pouch of Douglas
Dark brown blood on the examining finger.

Investigations

Ultra sound scan will reveal the rupture and collection of blood on the affected side. Ultrasound scan will confirm the diagnosis
Blood for Hb, grouping and cross match.
On CBC, Haemoglobin level will be low
Pregnancy test is positive
In an emergency if scan is not available a puncture into the Pouch of Douglas fresh blood will be found on aspiration

Differential diagnosis

Salpingitis if associated with irregular menses
Appendicitis
Abortion
Twisted ovarian cyst
Urinary tract infection

Management of Ectopic Pregnancy

In health centre.

This is an emergency and everything must be done as quickly as possible to save life of the mother.

Aims

To prevent shock
To relieve pain
To reassure the patient

Admission: Mother is admitted temporarily on gynaecological ward. Histories are taken, general examination, observations, abdominal and vaginal examination done. A diagnosis is then made.
Histories: these are taken including personal, social, surgical, medical, obstetrical history, how the condition started etc
Examination: This is carried out from head to toe to rule out anaemia, dehydration, shock etc
Observation: Temperature, pulse, respiration and blood pressure are taken and recorded to assess functioning of vital organs.
Resuscitation: A drip of normal saline is put up and morphine 15 mg given intramuscularly. The foot of the bed should be raised to allow blood to move to vital centers.
Transport: Send for transport as soon as possible and inform the patient and relatives about the decision made and why it is necessary.
Transfer: The decision is explained to the patient and relatives, a well written note made stating time of admission, treatment given condition on arrival and leaving. Transport is arranged then the mother is transferred to hospital. The midwife escorts the mother and hands her over to the hospital staff.
Treatment: Put up intravenous infusion of normal saline to prevent or treat shock. This is to elevate the low blood pressure. Administer morphine or pethidine to relieve pain as prescribed.
Nursing care: The vulva is swabbed and a clean pad is applied. Send the patient to hospital with a written note stating when the patient reported to the center, condition on admission and at time leaving and treatment given.

Hospital Management

In the hospital

It is a gynecological emergency, so everything must be done quickly as possible and all nurses must work as a team to see that the patient is taken for operation as soon as possible.

Aims

To treat anaemia
To prevent or treat shock
To reassure the patient
To prevent complications
Admission: Admit the patient in a well-ventilated room and warm admission bed. Establish a good nurse patient relationship.
Histories :Histories are taken from the patient if able or from the relatives if patient is unable (collateral history).These will include social, medical, surgical, obstetrical, gynaecological histories. More emphasis is put on history of the presenting complaint i.e. when the condition started, amount of bleeding, site of pain, any vomiting or if any treatment has been given. Weeks of amenorrhoea are estimated.
The doctor is then informed
General examination: This carried out from head to toe to rule out anemia, shock, dehydration etc
Observations: Vital observations like temperature, pulse, respiration and blood pressure.
Investigations: On arrival of the doctor, he orders for the following investigations;
> Haemoglobin estimation to rule out malaria
> Blood group and cross matching because blood transfusion may be necessary
> Pregnancy test to confirm that the mother was pregnant and the pain is not due to other conditions
> Ultra sound scan to confirm the diagnosis
> Urinalysis to rule out urinary tract infection
Resuscitation: Intravenous Normal saline is started to prevent or treat shock. Morphine 15 mg I.M. will be given as ordered by doctor. If mother is in shock it is also managed. Intravenous fluids eg normal saline are put up and fluid balance chart is maintained.
Blood transfusion: This carried out depending on the haemoglobin results.
Pain relief: Analgesics such as morphine is administered to relieve pain as prescribed by the doctor.

Pre-operative care

The doctor will determine the operation.

Preparation for theatre

Nursing care

A bed bath is given, theatre gown offered, observations done and recorded, all charts collected then the patient is wheeled to theatre.
Explain the nature of operation to the patient and obtain an informed consent.
Reassure the patient to allay anxiety
Theatre staffs are informed
Pass an intravenous line for infusion
Vulva swabbing is done to minimize infections
Catheterization is done and a fluid balance chart is started.
Pass a naso-gastric tube for aspiration gastric or stomach contents or an anti-acid like magnesium trisilicate is given to make the stomach contents alkaline. This prevents aspiration of acidic contents into the lungs.
Pre- medication is given like atropine to dry the secretions.
Repeat vital observations and compare with the baseline observations and record.
Compile the clinical charts and notes, dress the patient in gown and transport her carefully to theatre.
In theatre give a full report to the theatre nurse about the patient.
Book about 1-2 units of blood.
The patient is handed over to the theatre staff and if possible the ward nurse stays with the patient until she is anesthetized. The nurse goes back to the ward and makes a post-operative bed with all its requirements.

In theatre

Laparatomy and salpingectomy is done to remove the ruptured portion and repair the area to control bleeding. The other tube is examined for patency and unblocked if possible. If the rupture was acute and the blood is fresh it may be collected, sieved into an anticoagulant (sodium citrate) and re-transfused into the patient. This is known as auto transfusion. If this is not possible cross matched blood is transfused.

Post- operative care

Post-operative bed should be made with all its accessories such as a drip stand, oxygen machine, vital observation tray, emergency tray, resuscitation tray e.t.c. ready to receive the patient.
When the operation is complete, the ward staff are informed and two qualified nurses go to theatre to collect the patient.
In theatre, receive a full report from the anesthetic and the theatre nurse in a recovery room should report the condition of the patient.
Confirm the report while patient is still in the recovery room by;

Checking airway, breathing and circulation.
Taking vital observations
Observing the site of operation for bleeding
Observe the catheter to see if it is draining well and in good position.

After confirming, the patient is gently wheeled to ward in a recumbent position with the head turned to one side meanwhile observing the airway.

On ward

The patient is lifted from the trolley with care to a well made post-operative bed with all its accessories close to the nurse’s station for close observations.
The patient is put in a recumbent position with the head turned to one side to allow drainage of secretions and also to prevent falling back of the tongue.

Observations and records

Vital observations of temperature, respiration, blood pressure and pulse are taken1/4 ,1/2, 1, 2 hourly according to surgeon’s instructions and duration is increased as the patient stabilizes.

These observations are continued until the patient is discharged.

Observe the site of operation for bleeding
Observe the catheter if it is draining well, colour and the quantity of urine passed.
Maintain a fluid balance chart and balance it every 24 hours to rule out renal failure.
On gaining consciousness, the patient is welcomed from theatre, face is sponged, theatre gown changed, mouth wash is done to remove anesthetic smell and a pillow is offered.

Fluid/hydration

Intravenous fluid.eg 0.9% are continued to replace lost fluids.
Observation of IV infusion are done such as observing the cannular site for swelling, drip rate and incase of anything it should be corrected.
Keep monitoring fluid intake and out put to avoid over hydration.
IV fluids are stopped when bowel sounds are heard and the patient is able to take by mouth.
Cannula is also removed when necessary.eg if patient has completed intravenous drugs.

Drug therapy

Administer prescribed antibiotics to counteract infections and administer prescribed strong analgesics for pain relief.

Antibiotics
> Ampicillin 500 mg 6 hourly for 5 days
> Ceftriaxone 2 gm o.d. for 5 days
> Metronidazole 500 mg 8 hourly for 5 days
> Gentamycin 160 mg o.d. for 5 days
Analgesics
> Pethidine 100mg 8 hourly for 3 doses
> Diclofenac 75 mg 8 hourly for 12 hours
> Panadol 1 gm 8 hourly to complete 5 days as soon as patient can take orally.
Monitor the patient for side effects of the drugs given.
Supportive drugs such as ferrous and folic acid are given to prevent anaemia.

Wound care

Observe the wound for bleeding and if so add more dressing if soiled change the dressing. Also check signs of infections.
Carry out daily wound dressing.
Stitches are removed on the 7th and 8th day alternatingly.

Physiotherapy.

Encourage the patient to do deep breathing exercise to prevent chest complications like hypostatic pneumonia.
Also encourage the patient to start with passive exercises such as limb movement then active exercises like walking around to prevent deep vein thrombosis.

Psychotherapy

In addition to the psychological care given to the patient pre-operatively, she is continuously reassured to allay anxiety.

Diet

First carryout digestion test and if positive the bowel sounds are heard, start the patient on small sips of water. Soft foods are introduced and given according to the tolerance and should be rich in;

Proteins to help in tissue repair
Roughages to prevent constipation
Carbohydrates for energy

NB: The nasal gastric tube is removed as long as the patient can take orally without any complaint.

Hygiene

Carryout bed bath on the first day of operation when the patient is still weak and later assist her to the bathroom.
Carryout mouthcare to prevent neglected mouth complaints like stomatitis, halitosis e.t.c.
Ensure that the patient’s clothing, bed linen and the surrounding environment are clean.

Bowel and bladder care

If urine is clear in 24-48 hours, the urethral catheter is removed and patient is encouraged to pass urine.
The patient is encouraged to pass stool, offered privacy and also given foods rich in roughages to prevent constipation.
Incase of constipation and conservative measures have failed, give purgatives such as bisacodyl 5-10mg O.D or NOCTE.

Rest and sleep

The patient is kept in a quiet well-ventilated room, visitors restricted, bright light avoided so as to create a conducive environment for the patient to sleep and rest.

Advice on discharge

When the patient is fit for discharge advise on the following;

Should have enough rest at home
Avoid heavy lifting so as to avoid straining the abdominal muscles.
To come back for review on appointed dates
To attend ANC clinics when pregnant
To bring the husband for treatment if the cause of ectopic pregnancy was PIDs.
To complete the prescribed medications

Complications of ectopic pregnancy

Immediate complications

Shock
Peritonitis
Dehydration

Long term complications

Sepsis
Anaemia
Fibrosis
Adhesions following surgery
Recurrence

Ectopic Pregnancy Read More »

Under water seal drainage

UNDER WATER SEAL DRAINAGE

Under water seal drainage is a system that allows drainage of the pleural space using an airtight system to maintain sub-atmospheric intrapleural pressure.

It’s used when air or fluid gets trapped in the pleural space.

Pleural Space: This is the space between the two layers of pleura, which are thin membranes lining the lungs and the inside of the chest wall. Normally, this space has negative pressure, which helps the lungs stay inflated.

Purpose: The water seal drainage system has two main jobs:

To remove air and fluid: It allows air and fluid that have accumulated in the pleural space to escape out of the chest. Under water seal drainage is used to remove blood, air, pus, or serous fluid from the pleural cavity after thoracotomy, chest injury, pleural effusion, or pneumothorax.
To prevent backflow: It stops air and fluid from going back into the pleural space, especially when you breathe in (inhale). This one-way system is nice for proper lung function.

In simpler terms: Imagine a bottle with a straw dipped in water. When you blow into the straw, bubbles escape, but water doesn’t come back up the straw into your mouth. Water seal drainage works on a similar principle for your chest.

The underwater seal acts as a one-way valve.

Conditions necessitating Underwater Seal Drainage

Traumatic Pneumothorax: This happens when an injury to the chest (like a car accident or stab wound) causes air to leak into the pleural space, collapsing the lung.
Hemopneumothorax: This is a combination of air and blood in the pleural space. It can also be caused by trauma.
Spontaneous Pneumothorax: Sometimes, a lung can collapse on its own, without an obvious injury. This is more common in tall, thin young adults or people with lung diseases.
Iatrogenic Pneumothorax: This occurs unintentionally as a result of a medical procedure, such as inserting a central line or during a lung biopsy.
Broncho-pleural Fistula: This is an abnormal connection between an airway in the lung (bronchus) and the pleural space, causing air to leak into the pleural space.
Emphysema: A chronic lung disease where air sacs in the lungs are damaged. In some cases, it can lead to air leaks into the pleural space.
Malignancy: Lung cancers or other cancers in the chest can sometimes cause fluid buildup in the pleural space (pleural effusion).
Pleural Effusion: This is the buildup of excess fluid in the pleural space. It can be caused by various conditions like heart failure, pneumonia, or cancer.
Thoracic or Thoraco-abdominal Surgeries: After surgeries in the chest or upper abdomen, chest tubes are often placed to drain air and fluid and prevent complications.

In short: Any condition that causes air or fluid to accumulate in the pleural space and disrupt normal lung function may require water seal drainage.

Indications of Water Seal Drainage

The goals of water seal drainage are to:

Permit Drainage of Air and Fluid: The most direct purpose is to remove unwanted air, blood, or fluid from the pleural cavity. This helps to relieve pressure and allow the lung to re-expand.
Establish Normal Negative Pressure: The pleural space normally has a negative pressure, which is essential for keeping the lungs inflated. Water seal drainage helps to restore this negative pressure. Think of it like sucking air out of a balloon to make it inflate inside a jar.
Promote Lung Expansion: By removing air and fluid and restoring negative pressure, water seal drainage allows the collapsed lung to re-inflate and function properly.
Equalize Pressure on Both Sides of the Thoracic Cavity: Conditions like pneumothorax can disrupt the pressure balance in the chest. Water seal drainage helps to restore this balance.
Prevent Tension Pneumothorax: In a tension pneumothorax, air keeps getting trapped in the pleural space and cannot escape, leading to dangerous pressure buildup that can compress the heart and major blood vessels. Water seal drainage prevents this life-threatening situation by providing an escape route for the air.
Provide Continuous Suction (if needed): In some cases, gravity alone may not be enough to drain the air or fluid, or to re-expand the lung quickly. In these situations, gentle suction may be added to the water seal drainage system to assist the process.

In essence: Water seal drainage aims to bring the lung back to its normal, healthy state by removing obstacles and restoring the necessary pressure for it to function.

Site for Chest Tube Insertion

Where is the Chest Tube Inserted? The location of the chest tube depends on the reason for drainage:

For Thoracic Surgery (usually two tubes):

Anterior Chest Tube (Front):

Location: Usually placed in the upper and front part of the chest wall.
Intercostal Space: Inserted in the 2nd intercostal space (the space between the 2nd and 3rd ribs).
Purpose: Primarily to remove air. Air rises, so placing the tube high in the chest helps to drain air that has collected in the upper pleural cavity.

Posterior Chest Tube (Back):

Location: Placed in the back of the chest.
Intercostal Space: Inserted in the 8th or 9th intercostal space at the mid-axillary line (roughly in line with the middle of your armpit).
Purpose: Primarily to remove fluid (like blood or serous fluid). Fluid tends to settle at the bottom of the pleural cavity due to gravity, so a lower tube placement is effective for drainage.
Tube Diameter: Tubes for fluid drainage (posterior tubes) are often wider or longer than tubes for air drainage (anterior tubes) to facilitate better fluid removal.

For Pneumothorax (usually one tube for air removal):

Location: In the front or side of the chest.
Intercostal Space: Usually placed in the 2nd or 3rd intercostal space along the mid-clavicular line (in line with the middle of your collarbone) or anterior axillary line (front of your armpit).
Purpose: To remove air from the pleural space, allowing the lung to re-expand. Since air rises, a higher placement is effective for pneumothorax.

Types of Drainage Systems

Water seal drainage systems can be categorized based on the number of bottles (or chambers in modern systems). The basic principle remains the same, but complexity increases with more bottles.

One-Bottle Drainage System (Simple System)

Components:

Drainage Bottle: A single sterile bottle containing a specific amount of sterile water or saline solution.

Two Tubes:

Patient Tube (A): Connects to the chest tube from the patient. This tube is submerged underwater in the bottle, creating the water seal.
Vent Tube (B): A shorter tube that vents to the atmosphere (or suction). This allows air to escape from the bottle.

How it Works:

Air and fluid drain from the patient’s pleural space through tube A into the bottle.
The underwater seal prevents air from being sucked back into the pleural space during inhalation.
Air from the pleural space bubbles through the water and escapes out through vent tube B.
Drainage fluid collects in the bottle.

Limitations:

As drainage collects in the bottle, the water level rises, increasing the positive pressure needed to push out more fluid. This can slow down drainage if a large amount of fluid needs to be removed.
Not ideal for large amounts of drainage or when suction is needed.

Two-Bottle Drainage System (Improved Drainage and Collection)

Components:

Trap Bottle (Collection Bottle): The first bottle to receive drainage from the patient. It’s simply a collection container and doesn’t contain water.
Underwater Seal Bottle: The second bottle, containing sterile water and acting as the water seal, similar to the one-bottle system.

How it Works:

Drainage from the patient first goes into the Trap Bottle, which collects the fluid.
Air then passes from the Trap Bottle to the Underwater Seal Bottle.
The Underwater Seal Bottle functions exactly as in the one-bottle system, providing the water seal and venting air.
The collection of drainage in a separate bottle prevents the increasing water level issue of the one-bottle system.

Advantages over One-Bottle System:

More efficient drainage, especially for larger volumes, as the water seal is not affected by the amount of drainage.
Allows for more accurate measurement of drainage as it’s collected in a separate bottle.

Three-Bottle Drainage System (Suction Control Added)

Components:

Trap Bottle (Collection Bottle): First bottle, collects drainage.
Underwater Seal Bottle: Second bottle, provides the water seal.
Manometer Bottle (Suction Control Bottle): Third bottle, controls the amount of suction applied to the system. It also contains sterile water.
Adjustable Vent Tube: A tube in the Manometer Bottle that is open to the atmosphere.

How it Works:

Drainage flows through the Trap Bottle and Underwater Seal Bottle as in the two-bottle system.

Suction Control: The Manometer Bottle regulates the suction.

The depth of the vent tube in the water in the Manometer Bottle determines the amount of negative pressure (suction). For example, if the tube is submerged 20 cm underwater, the suction will be approximately -20 cm H₂O.
When suction is applied, air is drawn in through the adjustable vent tube and bubbles through the water in the Manometer Bottle. This bubbling indicates that the suction is working and is being controlled at the desired level.
Excess suction is vented to the atmosphere, preventing excessive negative pressure from being applied to the patient’s pleural space.

Advantages of Three-Bottle System:

Controlled Suction: Allows for the application of gentle suction to aid in lung re-expansion and drainage, especially when gravity drainage is insufficient.
Safety: Prevents excessive suction, which could damage lung tissue.
More efficient drainage: Especially useful for persistent air leaks or when rapid lung re-expansion is needed.

Modern Systems: Today, many systems use pre-assembled, disposable plastic units that combine the functions of these bottles into chambers within a single unit. These are often referred to as multi-chamber drainage systems and are more convenient and easier to manage, but the underlying principles are the same as the bottle systems.

Factors Affecting Water Seal Drainage

Several factors can influence how well a water seal drainage system works. Knowing these factors is key for effective nursing care and management.

1. Proper Placement of Chest Catheter (Chest Tube): Rationale: Correct placement is key for effective drainage. As discussed earlier, tubes placed high are for air, and tubes placed low are for fluid.

Considerations:

Intercostal Space: Using the correct intercostal space (e.g., 2nd for air, 8th-9th for fluid).
Anterior/Posterior: Anterior for air, posterior for fluid in surgical cases with two tubes.
Single Tube: If only one tube is used, it’s often placed lower for general drainage of both air and fluid, although its effectiveness for air drainage alone might be less optimal than a higher placed tube in pneumothorax.
Separate Bottles: If multiple tubes are placed, they should be connected to separate drainage bottles to manage drainage from different areas effectively.

2. Proper Placement of Chest Drainage Apparatus: Rationale: Gravity is key. The drainage system must be lower than the chest for drainage to occur effectively and to prevent backflow.

Considerations:

Below Chest Level: Always ensure the drainage unit is consistently below the patient’s chest level, whether the patient is in bed, sitting, or walking.
Gravity Assist: This helps gravity to pull drainage from the pleural space into the collection system.
Prevent Backflow: Keeping it low prevents fluid in the drainage system from flowing back into the pleural space, which could cause infection or other complications.
During Transfer: When moving the patient (e.g., to another bed or for transport), the drainage unit should be held or placed carefully below chest level. It’s also advisable to briefly clamp the tubing (as instructed by protocol or physician order) during transfer to prevent accidental spillage or backflow, but clamping should be brief and tubing must be unclamped immediately after.

3. Length of Drainage Tubing: Rationale: Tubing length affects drainage efficiency and patient mobility.

Considerations:

Not Too Short: Tubing that is too short can restrict patient movement, potentially dislodge the chest tube, or cause tension on the insertion site.
Not Too Long: Tubing that is too long can create loops that impede drainage flow due to increased resistance and potential fluid collection in loops.
Straight Line: Tubing should ideally run in a relatively straight line from the chest to the drainage system, avoiding kinks or dependent loops.
No Loops: Avoid creating loops in the tubing, as these can trap fluid and air, obstructing drainage.

4. Patency of Chest Tubing: Rationale: The chest tube must be open and clear for drainage to flow.

Considerations:

Frequent Checks: Regularly check the tubing for kinks, clamps, or pressure points that might obstruct flow.
No Kinks or Pressure: Ensure the patient is not lying on the tubing, and that bedding or clothing is not pressing on it.
Mucus Plugs/Clots: Clots or mucus plugs inside the tubing can block drainage.
Milking the Tube: If clots or plugs are suspected, gently “milking” or stripping the tubing (following hospital protocol and physician orders) can help to dislodge them and maintain patency. However, routine stripping/milking is generally discouraged as it can create excessive negative pressure and potentially damage lung tissue. Gentle manipulation to maintain patency is preferred.
Avoid Clamping: Never clamp the chest tubing routinely, as this can lead to tension pneumothorax if air is still leaking into the pleural space. Clamping is generally only done briefly in specific situations, such as changing the drainage system, assessing for air leaks, or prior to removal, and should be done per physician order or hospital protocol.

5. Maintenance of Air Tight Drainage System: Rationale: The system must be airtight to maintain the water seal and suction (if used) and prevent air from entering the pleural space.

Considerations:

Air Tight Seals: Ensure all connections in the drainage system (tubing connections, bottle stoppers, connections to the chest tube at the insertion site) are airtight.
Taping Connections: Tape all tubing connections securely to prevent accidental disconnections and air leaks.
Stoppers and Seals: Make sure bottle stoppers (if using bottle systems) are firmly in place and that any seals in modern systems are intact.
Check for Leaks: Regularly check the system for air leaks. Continuous bubbling in the water seal bottle (when not expected) may indicate an air leak in the system rather than from the patient. To check for system leaks, briefly and sequentially clamp sections of the tubing starting close to the patient. If bubbling stops when you clamp a certain section, the leak is likely in that section or closer to the patient. If bubbling continues even when clamped near the patient, the leak is likely from the patient (e.g., lung air leak) or the chest tube insertion site.

6. Position of the Client: Rationale: Patient position can affect drainage, especially fluid drainage.

Considerations:

Fowler’s Position (Semi- or High-Fowler’s): Elevating the head of the bed (Fowler’s position) is often recommended.
Fluid Localization: Fowler’s position helps to localize fluid in the lower pleural space, making it easier to drain through a lower placed chest tube.
Lung Expansion: It can also improve lung expansion and breathing mechanics.
Regular Repositioning: Encourage the patient to change position regularly (within activity limitations) to promote drainage from different areas of the pleural space and prevent fluid from settling in one area.

7. Application of Mechanical Suction: Rationale: Suction, when used appropriately, can enhance drainage but must be applied correctly.

Considerations:

Continuous and Gentle: Suction should be continuous and gentle, not intermittent or high pressure.

When to Use Suction: Suction is typically used when:

Gravity drainage alone is not enough (e.g., persistent air leak, slow lung re-expansion).
The patient’s respiratory effort and cough are weak.
There’s a fast or significant air leak into the pleural space.
Speedier removal of air or fluid from the pleural space is needed.

–

Physician Order: Suction should always be applied based on a physician’s order.
Proper Setting: Ensure the suction is set to the prescribed level (often indicated by the water level in the suction control bottle or the setting on a modern drainage unit).
Bubbling in Suction Chamber: Gentle, continuous bubbling in the suction control chamber (Manometer Bottle) is a sign that suction is being applied correctly. Vigorous bubbling is usually unnecessary and can increase water evaporation and noise.

8. Activity of the Client: Rationale: Patient activity can promote drainage and lung function.

Considerations:

Movement on Bed: Encourage gentle movement in bed (turning side to side, repositioning). Movement helps to shift fluid and air within the pleural space, promoting drainage.
Coughing and Deep Breathing: Encourage the patient to cough and deep breathe regularly.
Intrapleural and Intrapulmonary Pressure: Coughing and deep breathing help to increase intrapleural and intrapulmonary pressure, which can assist in expelling air and fluid from the pleural space and promote lung expansion.
Walking (if appropriate): If medically appropriate and ordered by the physician, ambulation (walking) can also be beneficial, as it encourages deeper breathing and overall lung function.

Requirements for Under Water Seal Drainage (UWSD)

STERILE TROLLEY – Top Shelf

A trocar and cannula, intercostal tubing, and an introducer

Artery forceps in a receiver

Scalpel

Suturing material

Safety pin

A large Winchester bottle containing water or normal saline to a level of about 6cm

A rubber cork pierced by a short and long glass tube or by rigid plastic tubes

Bottom Shelf

A pair of gloves

Chest X-ray investigations and ultrasound scan results

A dressing pack

A patient’s file

Bedside

Hand washing equipment

Suction machine

Screen

Patient’s file

Emergency tray

Procedure for Underwater Seal Drainage (UWSD)

Step	Action	Rationale
Preparation of equipment
1	Preferably a graduated bottle is used	For correct reading of the drainage fluid
2	Assist Doctor to submerge the long tube in the water at 2 to 3 cm but must not touch the bottom of the bottle. The short tube acts as an escape route for air in the vacuum space in the bottle.	To prevent air from going to pleural cavity
3	Assist the Doctor to connect the tube to the top of the under-water to the patient’s intercostal drainage tube.	To drain fluid from the pleural cavity
Procedure
1	Explain the procedure carefully to the patient; to understand the importance of limited movements during the period of UWSD.	Explanation encourages patients cooperation and relieves anxiety
2	Take the trolley to the bedside, screen the bed and close nearby windows.	To provide privacy
3	Wash and dry hands and be ready to assist the doctor.	Promote hygiene measures
4	Position the patient leaning over the bed table supported by pillows. The patient’s arm which is on the side where the tube will be inserted must be placed forward and supported by a nurse.	This position gives best access to the second or third intercostal space
5	Observe the patient’s colour, pulse and respirations throughout the procedure.	To detect any change in patient condition and manage accordingly
6	The doctor cleans the patient’s skin, places a drape in position and injects local anaesthesia. A scalpel is used to make an incision through the skin and muscle of the intercostal space. Using the introducer, the tubing is inserted and secures it with a stitch.	Local anaesthesia helps to relieve pain
7	The nurse connects the tube to the UWSD bottle once the introducer is removed, then clamps the tube with two pairs of clamps until all the connections of the apparatus are sealed.	To be able to clip the tube so as to prevent air going to the lungs
8	Remove the clamps and check the functioning of the apparatus by noting if the fluid in the tube rises and falls in rhythm with the patient’s respirations.	To ensure that the system is air tight and no air leakages and no risk of emphysema.
9	Apply a dressing to the wound.	A dressing makes an airtight seal at the incision site and prevents infection.
10	Wash hands, clear away the equipment and leave the patient comfortable.	To prevent spread of infections
Changing the bottle
11	• Securely clamp off the drain with two clamps but for a short time. • Disconnect the tubing and put used apparatus to one side. • Connect new tubing and bottle and remove the clamps.	Minimise re-infection of the patient.
12	Monitor the fluid in tubing whether it is moving up and down in rhythm with the patient’s respiration rate.	To ensure that the tube is in situ and functioning.
13	Record the amount of drainage on the fluid balance chart and note any abnormalities.	For effective assessment of progress of therapy and the patient
	Wash hands, Clear away and clean the used apparatus and equipment.	To prevent spread of infections

Points to remember

Make sure that all connections are secure to avoid leakages
Check that the patient is not compressing or kicking any part of the drainage system, to avoid obstructing the tube.
The bottle must always remain below the level of the patient’s chest and should preferably be in a stand to avoid being easily knocked over, to prevent back flow of fluid from drainage chamber to pleural cavity and to maintain the water seal.

Under water seal drainage Read More »