CHN

1. Diarrhoea
Presented by
Deepa Manandhar
Lecturer
Community Health Nursing

2. Acute diarrhoeal disease
• Diarrhoea is defined as the passage of loose, liquid or watery stools.
These liquid stools are usually passed more than three times a day.
• However, it is the recent change in consistency and character of stools
rather than the number of stools that is more important.

3. Clinical types of diarrheal disease
1.Acute Watery Diarrhoea
2. Acute Bloody diarrhoea
3. Persistent diarrhoea
4. Diarrhoea

4. Acute watery diarrhoea
• Lasts several hours to days; the main danger is dehydration, weight
loss
• V. cholerae or E. coli bacteria, as well as rotavirus.

5. Acute bloody diarrhoea
• It is marked by visible blood in the stools.
• The most common cause of bloody diarrhoea is shigella, a bacteria
that is also a most common cause of severe cases.
• The main dangers are damage of the intestinal mucosa, sepsis and
malnutrition.

6. Persistant diarrhoea
• Lasts 14 days or longer.
• The main danger is malnutrition and dehydration.
• Persons with other illness, such as AIDS, are more likely to develop
persistent diarrhoea.

7. Diarrhoea with severe malnutrition
(kwashiorkor vs marasmus)
The main dangers are severe systemic infection, dehydration, heart
failure, and vitamin and mineral deficiency.

8. agent
• Virus :A great many diarrhoeal diseases are caused by viruses.
ROTAVIRUSES: The rotavirus, first discovered in 1973, has emerged
as the leading cause of severe, dehydrating diarrhoea in children aged
<5 years globally.
• Bacteria: infection occurs through water and food contaminated with
bacteria such as E.coli, Shigella and Salmonella.

9. agent
• Others: some diarrheas may be protozoal or parasitic in origin. Such as
E.histolytica, Giardia intestinalis, Trichuriasis, Intestinal worms.
• Amoebiasis, giardiasis and other intestinal parasitic infections are
associated with diarrhea

10. Reservoir of infection
• For some enteric pathogens, man is the principal reservoir and thus
most transmission originates from human factors ; examples E. coli,
shigella spp, V. cholerae
• For other enteric pathogens, animals are important reservoirs and
transmission originates from both human and animal faeces

11. Host factors
• most common in children especially those between 6 months and 2
years. Incidence is highest in the age group 6-11 months, when
weaning occurs.
• more common in persons with malnutrition.

12. Environmental factors
• In temperature climates, bacterial diarrhoea occur more frequently
during the warm season, whereas viral diarrhoea, particularly
diarrhoea caused by rotavirus peak during the winter.

13. thansmission
• Faecal-oral route

14. Clinical features
 Frequent loose stools
 Restlessness
 Dehydration
 Thirst
 Loss of elasticity of the skin
 Depending on the type of diarrhea other features like pain in the
abdomen, fever, blood or mucous in the stool may be present.

15. Preventive statergies
1. Sanitation
2. Health education
3. Immunization
4. Fly control

16. Time for discussion

17. CONTROL OF
DIARRHOEAL
DISEASE IN
NEPAL
Prepared by:
Deepa Manandhar
Lecturer
Community Health Nursing

18. History of Programme
• In Nepal, Child survival intervention began when
Control of Diarrhoeal Disease (CDD) Program was
initiated in 1983.
• Further, Acute Respiratory Infection (ARI) Control
Program was initiated in 1987

19. History….
• In 1997/98, ARI intervention was combined with
CDD and named as CB-AC (Community Based ARI
and CDD) program.
• One year later two more components, nutrition and
immunization, were also incorporated in the CBAC
program.

20. History….
• IMCI program was piloted in Mahottari district and
was extended to the community level as well.

21. History….
• Finally, the government decided to merge the CBAC
into IMCI in 1999 and named it as Community-Based
Integrated Management of Childhood Illness (CB-
IMCI).

22. History….
• CB-IMCI included the major childhood killer diseases
like pneumonia, diarrhoea, malaria, measles, and
malnutrition.

23. History….
• The strategies adopted in IMCI were improving
knowledge and case management skills of health
service providers, overall health systems
strengthening and improving community and
household level care practices.

24. History….
• After piloting of low osmolar ORS and Zinc
supplementation, it was incorporated in CB-IMCI
program in 2005.
• Nationwide implementation of CBIMCI was
completed in 2009 and revised in 2012 incorporating
important new interventions.

25. History….
• ‘Community-Based New Born Care Program (CB-
NCP)’ was designed in 2007, and piloted in 2009

26. History….
• Considering the management of similar kind of two
different programs, MoH decided to integrate CB-
NCP and IMCI into a new package that is named as
CB-IMNCI.

27. History….
• CB-IMNCI is an integration of CB-IMCI and CB-
NCP Programs as per the decision of MoH on
2071/6/28 (October 14, 2014).

28. History….
• This integrated package of child-survival intervention
addresses the major problems of sick newborn such as
- birth asphyxia,
- bacterial infection,
- jaundice,

29. History….
- hypothermia,
- low birth weight,
- counseling of breastfeeding.

30. History….
• It also maintains its aim to address major childhood
illnesses like
- Pneumonia,
- Diarrhoea,
- Malaria,
- Measles and
- Malnutrition
among under 5 year’s children in a holistic way.

31. Goal
• Improve newborn and child survival and healthy
growth and development.

32. Elements
• Assess
• Classify
• Identify
• Treatment
• Counsel
• Follow up care

33. IMNCI CASE MANAGEMENT
PROCESS
• Assess a child
• Classify a child’s illnesses
• Identify treatments for the child.
• Treatment instructions

34. IMNCI CASE MANAGEMENT
PROCESS….
• Counsel the mother to solve any feeding problems and her own health.
• When a child is brought back to the clinic give follow-up care and if
necessary reassess the child for new problems

35. 1.Assess
• A child by checking first for danger signs (or possible bacterial
infection in a young infant), asking questions about common
conditions, examining the child, and checking nutrition and
immunization status.
• Assessment includes checking the child for other health problems

36. 2. Classify
• A child’s illnesses using a colour-coded triage system. Because many
children have more than one condition, each illness is classified
according to whether it requires:
- urgent pre-referral treatment and referral (red), or

37. 2. Classify….
- specific medical treatment and advice (yellow), or
- simple advice on home management (green).

38. 3. Identify
• Specific treatments for the child.
• If a child requires urgent referral, give essential treatment before the
patient is transferred.

39. 3. Identify….
• If a child needs treatment at home, develop an integrated treatment
plan for the child and give the first dose of drugs in the clinic.
• If a child should be immunized, give immunizations

40. 4.Treatment
• Provide practical treatment instructions, including teaching the
caretaker
- how to give oral drugs,
- how to feed and give fluids during illness, and
- how to treat local infections at home.

41. 4.Treatment….
• Ask the caretaker to return
- for follow-up on a specific date, and
- teach her how to recognize signs that indicate the child should return
immediately to the health facility

42. 5. Counsel
• Assess feeding, including assessment of breastfeeding practices, and
counsel to solve any feeding problems found.
• Then counsel the mother about her own health.

43. 6. Give follow-up care
• When a child is brought back to the clinic as requested, give follow-up
care and, if necessary, reassess the child for new problems.

44. 6. Give follow-up care….
• The case management process for sick children age 2 months up to 5
years is presented on three charts titled:
- ASSESS AND CLASSIFY THE SICK CHILD
- TREAT THE CHILD
- COUNSEL THE MOTHER

45. 6. Give follow-up care….
• If the child is not yet 2 months of age, the child is considered a young
infant.
• Management of the young infant age up to 2 months is somewhat
different from older infants and children.

46. 6. Give follow-up care….
• It is described on a different chart titled:
- ASSESS, CLASSIFY AND TREAT THE SICK YOUNG INFANT

47. Management of diarrhoea based on
CBIMNCI
For young infants
The steps to assess and classify during an initial visit are
• Rapidly appraise all waiting infants.
• Ask the mother what the young infants problem are.

48. Management of diarrhoea based on
CBIMNCI….
• Check for possible serious bacterial infection, very severe disease,
pneumonia or local bacterial infection
• Then, check for jaundice

49. Management of diarrhoea based on
CBIMNCI….
• Ask about diarrhoea. If the infant has diarrhoea, assess for related
signs.
• Classify the young infants for dehydration
• Also classify for persistent diarrhoea and dysentery if present.

55. Management of Persistent Diarrhoea
• If there is diarrhoea for 14 days or more then it is classified as severe
persistent diarrhoea. Treat the young infant as follows:
- If there is no bacterial infection then treat dehydration before referral
- Refer to the hospital.

56. Management of dysentery
• If there is presence of blood in stool then:
- Administer first dose gentamycin (IM) and ampicillin (IM).
- Referral to health facilities
- Continue breastfeeding and maintain temperature of the infant.

57. Follow up care

58. Management of diarrhoea based on
CBIMNCI
For older child (2 months- 5year)
• Ask the mother what the child's problems are.
• Determine if this is an initial or follow-up visit for this problem. If
follow-up visit, use the follow-up instructions.

59. Management of diarrhoea based on
CBIMNCI….
• If initial visit, assess the child as follows:
• Check for general danger signs.
- Ask about presence of cough or breathing difficulty.
- Ask about diarrhoea.

60. Management of diarrhoea based on
CBIMNCI….
- Ask about fever.
- Ask about ear problem
- Check for malnutrition

61. Management of diarrhoea based on
CBIMNCI….
- Check for anemia
- Check for HIV infection
- Check for immunization, vitamin A and deworming status.

72. Follow up care

74. • Second line
- Add metronidazole (Syp 200 mg per 5 ml). Give for 5 days TDS(1 yr-
3 yrs:2.5ml, 3 yrs- 5yrs:5 ml).
- Advise the mother to return in 3 days