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10 Steps to Recovery

10 Steps to Recovery. Steps 1-2. Treat/prevent hypoglycemia and hypothermia. STEP 1: Treat Hypoglycemia STEP 2: Treat Hypothermia. Usually occur together Associated with some severe illnesses and infection Frequent feeding is important Hypoglycemia: blood sugar < 3mmol/l

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10 Steps to Recovery

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  1. 10 Steps to Recovery

  2. Steps 1-2 Treat/prevent hypoglycemia and hypothermia

  3. STEP 1: Treat Hypoglycemia STEP 2: Treat Hypothermia • Usually occur together • Associated with some severe illnesses and infection • Frequent feeding is important • Hypoglycemia:blood sugar < 3mmol/l • Signs and symptoms: • Confusion, abnormal behavior, visual disturbances • Heart palpitations, tremor, anxiety, sweating, hunger

  4. STEP 1: Treat Hypoglycemia • If confirmed, give through mouth or NGT tube: • 50 ml of 10% glucose solution or sugar water (1 rounded teaspoon of sugar in 3.5 tablespoon water) • Feed every 2 hours, day and night. Start straightaway or rehydrate first, if needed.

  5. STEP 1: Treat Hypoglycemia • Check for the blood sugar again: • After 30 minutes and again after 2 hours • If it is low on either occasion, repeat the 50 ml glucose solution or sugar water. • If unable to test, assume all severely malnourished children have hypoglycemia.

  6. STEP 2: Treat Hypothermia • Hypothermia • Temperature: 35 C (axillary), 35.5 (rectal) • Children lose heat faster than adults do. • There is sympathetic nervous system excitation • shivering, hypertension, tachycardia, tachypnea, and vasoconstriction

  7. STEP 2: Treat Hypothermia • Feed straightaway • Make sure the child is warm • Put the child on the mother’s bare chest or abdomen and cover them • Clothe the child and cover with a warmed blanket • Place a heater or lamp nearby

  8. STEP 2: Treat Hypothermia • Check: • the rectal temperature every 2 hours until it rises above 36.5 C • The child is covered all times, especially at night • For hypoglycemia • Assume the child has hypothermia when the thermometer does not measure low temperatures and the child’s temperature is too low to register.

  9. STEP 1: Treat Hypoglycemia STEP 2: Treat Hypothermia • To prevent hypothermia and hypoglycemia: • Feed the child every 2 hours, start straightaway • Always feed during the night • Keep the child covered and away from draughts • Avoid exposure

  10. Step 3 Treat/Prevent Dehydration

  11. STEP 3: Treat/ Prevent Dehydration • Do not use the standard WHO oral rehydration salt solution • Give modified solution instead. • Do not use IV route except in shock, and then do so with care.

  12. New ORS Formulation

  13. STEP 3: Treat/ Prevent Dehydration • Monitor progress of rehydration • every 30 minutes for the first 2 hours • every hour for the next 6-12 hours • Check pulse, respiratory rates, input and output (urine, stool, vomitus)

  14. Signs of TOO much Rehydration • Increase RR • Increase PR • Edema • Puffy eyelids * If these signs occur,STOP fluids immediately and reassess the child’s condition after 1 hour.

  15. STEP 3: Treat/ Prevent Dehydration • When a child has watery diarrhea: • Start feeding straightaway • Replace the approximate volume of stool losses with the modified rehydration solution. • Encourage continued breastfeeding if the child is breastfed

  16. Body Weight Method for Daily Maintenace Fluid Volume

  17. Hourly Maintenance Rate

  18. Step 4 Correct Electrolyte imbalance

  19. STEP 4: Correct Electrolyte imbalance • All severely malnourished children have TOO much sodium in their bodies. • They also have potassium and magnesium deficiencies which may take at least 2 weeks to correct. • Edema is partly due to this deficiencies

  20. STEP 4: Correct Electrolyte imbalance • Give • Extra potassium 2-4 mmol/kg/day • Extra magnesium 0.3-0.6 mmol/kg/day • Modified ORS solution (see step 3) • Prepare food without salt • Extra potassium and magnesium can be prepared in liquid form and added directly during preparation

  21. IVF Composition

  22. Step 5 Treat Infections

  23. STEP 5: Treat Infection • Severe malnutrition: No Fever • Given routinely to ALL admission: • Broad spectrum antibiotics • Measles vaccine to unimmunized • Metronidazole (7mg/kg tid for 7 days)* • Mebendazole: Children > 2 years

  24. Treat Infections: Antibiotics • No complications Co-trimoxazole • Given for 5 days, twice daily • If < 4 kg, give 2.5 ml • If > 4kg, give 5 ml

  25. Treat Infections: Antibiotics • If severely ill + complications (lethargic, hypoglycemic, hypothermic, skin lesions) Gentamicin + Ampicillin • Gentamicin: 3.5 mg/kg IM or IV q12h for 7 days • Ampicillin: 50 mg/kg IM or IV q6h for 2 days then shift to oral for 5 days

  26. Treat Infections: Antibiotics • If fails to improve within 48hGentamicin + Ampicillin+ Chloramphenicol • Gentamicin: 3.5 mg/kg IM or IV q12h for 7 days • Ampicillin: 50 mg/kg IM or IV q6h for 2 days then shift to oral for 5 days • Chloramphenicol: 25mg/kg IM q6h for 5 days

  27. STEP 5: Treat Infection • Poor appetite continues after 5-7 days of antibiotic, complete 10 day course. • If still anorexic, fully RE-ASSESS the patient

  28. Step 6 Correct Micronutrient deficiencies

  29. STEP 6: Correct micronutrient deficiencies • Give • Multivitamin supplement • Folic acid 1mg/day • Zinc 2mg/kg/day • Copper 0.2 mg/kg/day • Do NOT give Iron (3mg/kg/day) until the child starts gaining weight (2nd week of treatment

  30. Step 7 Start cautious feeding

  31. STEP 7:Start Cautious feeding Start cautious feeding in the stabilization phase (days 1-7) The amount and type of food given is important. Feeds should be started as soon as possible and provide just sufficient energy and protein to maintain basic physiological processes.

  32. STEP 7:Start Cautious feeding Give: Small, frequent feeds of a milk-based starter formula 100kcal/kg/day 1-1.5g protein/kg/day 130mL/kg/day (100mL/kg/day if the child has edema) If the child is breastfed, encourage continued breastfeeding (give starter formula first)

  33. STEP 7:Start Cautious feeding Very weak children may be fed by spoon, dropper, syringe (remove needle) or nasogastric tube During this phase, diarrhea should gradually diminish and children with edema should lose weight

  34. STEP 7:Start Cautious feeding A typical schedule for feeding is:

  35. Step 8 Rebuild Wasted Tissues

  36. STEP 8: Rebuild Wasted Tissues • Rebuild wasted tissues

  37. Frequent feeds (every 4 hours) of a catch-up diet with unlimited amounts 150-220kcal/kg/day 4-6g protein/kg/day

  38. Step 9 Provide TLC

  39. Step 9: TLC • Stimulation, play, and loving care

  40. Starting from admission, provide: 1. tender, loving care 2. structured play and physical activity as soon as the child is well enough 3. a cheerful, stimulating environment 4. mother’s involvement

  41. Step 10 Preparation for follow up after discharge

  42. Some pointers: Involve parents in feeding and playing with their child Child= 90% weight-for-length can be considered to be ready for discharge Good feeding practices and stimulation should continue at home

  43. The family should… Give energy and nutrient dense foods at least 5x per day Establish play time with the child so that mental development may improve

  44. Thank you!!

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