1child Healh.

NMT 05112
Child Health
NTA Level 5 Facilitator Guide
for Certificate in Nursing
September 2013
NMT 05112 Child Health NTA Level 4-6, Semester 1
i United Republic of Tanzania

Ministry of Health and Social Welfare
Ministry of Health and Social Welfare
Department of Human Resources Development
Nursing Training Section
© Ministry of Health and Social Welfare 2013
Table of Contents
Acknowledgement ................................................................................................................... iii
Background v
Goals and Objectives of the Training Manual ..........................................................................vi
Overall Goal for training manual ........................................................................................vi
Objectives for training manual............................................................................................vi
Introduction vii
Module Overview ..............................................................................................................vii
Who is the Module For? ....................................................................................................vii
How is the Module Organized? .........................................................................................vii
How Should the Module be Used? ....................................................................................vii
Module Sessions
Session 1: Human Growth and Development......................................................................1
Session 2: Growth and Developmental Milestones of One Month to Two Month Old
Infant ………. ............................................................................................................................9
Session 3: Growth and Development in Infant from Three Months to Six Months ......14
Session 4: Average Achievements of Children Aged 7 Months to 9 Months ...............22
Session 5: Average Achievements of Children Age 10 Months to 12 Months .............27
Session 6: Average Achievements and General Needs of a Toddler.................................35
Session 7: Average Achievements of a Preschooler..........................................................51
Session 8: Developmental Achievements of School Aged Children.............................61
Session 9: Developmental Achievements in Adolescents ................................................71
Session 10: Common Cold and Bronchitis ..........................................................................79
Session 11: Pneumonia ........................................................................................................84
Session 12: Asthma..............................................................................................................92
Session 13: Oral Thrush.......................................................................................................97
Session 14: Diarrheal Diseases ..........................................................................................101
Session 15: Rectal Prolapses..............................................................................................108
Session 16: Anaemia..........................................................................................................111
Session 17: Fractures .........................................................................................................117
Session 18: Burns and Scalds ............................................................................................123
Session 19: Urinary Tract Infection ...................................................................................128
NMT 05112 Child Health NTA Level 5, Semester 1

i
Session 20: Convulsions ....................................................................................................131
Session 21: Meningitis.......................................................................................................135
Session 22: Measles ...........................................................................................................140
Session 23: Whooping Cough (Pertussis)..........................................................................145
Session 24: Diphtheria .......................................................................................................149
Session 25: Tetanus............................................................................................................152
Session 26: Hepatitis..........................................................................................................156
Session 27: Poliomyelitis...................................................................................................160
Session 28: Tuberculosis....................................................................................................164
Session 29: Introduction of Accidents in Children ............................................................172
Session 30: Management of Accidents in Children ...........................................................177
Session 31: Background and Purpose of IMCI..................................................................183

ii
Acknowledgement
The development of the training manuals for Certificate and Diploma in Nursing (NTA Level
4 to 6) has been possible and accomplished through involvement of different stakeholders.
The Ministry of Health and Social Welfare (MoHSW) through the Director of Human
Resources Development sends sincere gratitude to the stakeholders including the
coordinating team (Department of Nursing and Midwifery Training), TNI, through AIHA and
the WINONA state University for funding the activity.
The MOHSW would like to thank all those involved during the process for their valuable
contribution to the development of these training materials. The ministry of Health would like
to thank the Assistant Director for Nursing Training section Mr. Ndementria Vermand, and
Ms. Vumilia B.E Mmari (Coordinator for Nursing and Midwifery Training) who tirelessly led
this important process.
Sincere gratitude is expressed to main facilitator: Mr. Golden Masika, Tutorial Assistant
University of Dodoma for his tireless efforts and Mr. Nicolaus Ndenzako Programme
consultant of AMCA inter consultant in guiding participants through the process. Special
thanks go to the team of contributors representing the Health Training Institutions, hospitals
and Universities. Their participation in meetings and workshops and their inputs in the
development of the content for each module have been invaluable. It is the commitment of
these participants that has made this product possible.
These participants are listed with our gratitude below:
SN Name Title Institution

1. Mary S. Matembo Nurse Tutor Korogwe NTC
2. Elialilia M. Herman Nurse Tutor MT. Meru Hospital
3. Alice Chifunda Nurse Tutor Mbulu NTC
4. Lilian Wilfreda Nurse Tutor KCMC
5. Aselina Milinga Nurse Tutor KCMC
6. Veronica Mahela Nurse Tutor Kahama
7. Samwel Mwangoka Nurse Tutor Mbeya SOTM
8. Hamza S. Matagira Nurse Tutor Kahama NTC
9. Elikana Wallace Nurse Tutor Kolandoto S/Nursing
10. Anna Sangito Pallangyo Nurse Tutor Kahama NTC
11. David Abincha Nurse Tutor Bukumbi NTC
12. Leon S. Mgohamwende Nurse Tutor Tosamaganga NTC
13. Crescent D. Ombay Nurse Tutor Haydom S/Nursing
14. Kizito B. Tamba Nurse Tutor Ndanda S/N
15. Robert E. Moshi Nurse Tutor IMTU college of Nursing
16. Oresta Ngahi Nurse Tutor Muhimbili S/N
17. Aloyce Ambokile Nurse Tutor Kondoa District Hosp.
18. Helma A. Shimbo Nurse Tutor Mwambani NTC
19. Elizabeth G. Chezue PNO N Tutor MOHSW HIS & QAS
20. Hinju Januarius Obstetrian Dodoma Regional Hosp.
21. Manase Nsunza Principal HLT Singida HLTC
22. Ezekiel Amata IMC Facilitator Mpwapwa Hosp.
23. Sostenes D. Ntambuto HLT Tutor SMLS MUHIMBILI
iii
24. Anna Sangito Pallanyo N/Tutor Kahama SN
25. Naomi Kagya NT Muhimbili
26. Aloyce Amboikile Nurse Kondoa
27. Golden Masika Lecturer UDOM
28. Vumilia B.E. Mmari CD-NT MOHSW
29. Upendo kilume Nurse PHN
30. Fatuma Iddi Librarian MOHSW
31. Shango Nasania Nurse Newala
32. George Laisser C/Analyst MOHSW
33. Anande Mungure Nurse Tutor Mbulu NTC
34. Robert Masano Nurse Tutor Nkinga NTC
35. Ambokile Dodoma General Hospital
36. Nolasca Mtega Nurse Tutor Tukuyu School of Nursing
37. Asteria Ndomba Senior Lecturer CUHAS
38. Alfreda Ndunguru
39. Elizabeth Chezua MOHSW
40. Magwaza Charles
41. Ellen Mwandemele
42. Robert Mushi IMTU
43. Anna Mangula Nurse Tutor Mirembe NTC
44. Cesilia Mallya Nurse tutor Newala NTC
45. Helma Shimba
46. Kapaya Andrew TNMC
47. Ntambuto Sostenese
48. Joseph Nkungu
49. Anastazia Dinho
50. Eliaremisa Ayo Nurse Tutor MOHSW
51. Grace Mallya Paediatrician RCHS/GBV/VAC-MOHSW
52. Dr. Tecla Kohi Senior Lecturer MUHAS
53. Dr. Lilian Msele Lecturer MUHAS
Supporting staff:
Daniel Muslim Driver, Ministry of Health and Social Welfare
Fatuma Mohamed Health Librarian, Ministry of Health and Social Welfare
Mbaruku A. Luga Driver, Morogoro School of Public Health Nursing
Roselinda RugemaliraAdm. Secretary, Tanzania Nursing & Midwifery Council
Veronica Semhando Secretary Ministry of Health & Social Welfare
George Laizer System Analyst Ministry of Health & Social Welfare
Silvanus Ilomo System Analyst Ministry of Health & Social Welfare
Violet Mrema Adm. Secretary, Ministry of Health and Social Welfare
Walter Ndesanjo System Analyst, Ministry of Health and Social Welfare
Dr. Gozbert Mutahyabarwa

Ag: Director of Human Resource and Development,

iv
Background
In 2007 the Ministry of Health and Social welfare (MOHSW) started the process of
reviewing the nursing curricula at Certificate and diploma level. In 2008 refined and
developed NTA Level 4 to 6 Nursing Curricula and in the same year 2008 started the
implementation. The intention was to comply with the National Council for Technical award
(NACTE) Qualification framework which offers a climbing ladder for higher skills
opportunity. Advanced Diploma awards are not among the awards of the council and do not
conform to NACTE framework. Therefore, institutions offering Advanced Diploma in
nursing are required to either offer Ordinary Diploma (NTA Level 6) or develop its capacity
to offer Bachelor’s Degree (NTA Level 7&8).
These programs have been developed in line with the above consideration aiming at
providing a room for Nurses to continue to a higher learning and achieve advanced skills
which will enable them to perform duties competently. In addition, WHO advocates for
skilled and motivated health workers in producing good health services and increase
performance of health systems (WHO World Health Report, 2006). Moreover, Primary
Health Care Development Program (PHCDP) (2007-15) needs the nation to strengthen and
expand health services at ALL levels. This can only be achieved when the Nation has
adequate, appropriately trained and competent work force who can be deployed in the health
facilities to facilitate the provisions of quality health care services.
In line with these new curricula, the MOHSW supported tutors by developing quality
standardized training materials to accompany the implementation of the developed curricula.
These training materials will address the foreseen discrepancies in the implementation of the
new curricula. NTA level 8 training materials have been developed after Curricula validation
and verification.
This training material has been developed through writers’ workshop (WW) model. The
model included a series of workshops in which tutors and content experts developed training
materials, guided by facilitators with expertise in instructional design and curriculum
development. The goals of Writer’s Workshop were to develop high-quality, standardized
teaching materials and to build the capacity of tutors to develop these materials. This product
is a result of a lengthy collaborative process, with significant input from key stakeholders
(NACTE, MOHSW, AIHA and WINONA University) and experts of different organizations
and institutions. The new training package for NTA Level 4-6 includes a Facilitator Guide
and Student Manual. There are 28 modules with approximately 520 content sessions

v
Rationale
The vision and mission of the National Health Policy in Tanzania focuses on establishing a
health system that is responsive to the needs of the people, and leads to improved health
status for all. Skilled and motivated health workers are crucially important for producing
good health through increasing the performance of health systems (WHO, 2006). With
limited resources (human and non-human resources), the MOHSW supported tutors by
developing standardized training materials to accompany the implementation of the
developed CBET curricula. These training manuals address the foreseen discrepancies in the
implementation of the new curricula.
Therefore, this training manual for Certificate and Diploma program in Nursing (NTA Levels
4-6) aims at providing a room for Nurses to continue achieving skills which will enable them
to perform competently. These manuals will establish conducive and sustainable training
environment that will allow students and graduates to perform efficiently at their relevant
levels. Moreover, this will enable them to aspire for attainment of higher knowledge, skills
and attitudes in promoting excellence in nursing practice.
Goals and Objectives of the Training Manual

Overall Goal for training manual
The overall goal of these training manual is to provide high quality, standardized and
competence-based training materials for Diploma in nursing (NTA level 4 to 6) program.
Objectives for training manual

 To provide high quality, standardized and competence-based training materials.
 To provide a guide for tutors to deliver high quality training materials.
 Enable students to learn more effectively.

vi
Introduction
Module Overview
This module content has been prepared as a guide for tutors of NTA Level 5 for training
students. The session contents are based on the sub-enabling outcomes of the curriculum of
NTA Level 5 Certificate in Nursing.
The module sub-enabling outcome as follows:
2.2.1 Describe the process of human growth and development
2.2.4 Identify and manage common medical disorders in children
2.2.7 Describe the concepts and principles of Integrated Management of Childhood Illness
(IMCI)
Who is the Module For?

This module is intended for use primarily by tutors of NTA Level 4 to 6 in nursing schools.
The module’ sessions give guidance on the time and activities of the session and provide
information on how to teach the session to students. The sessions include different activities
which focus on increasing students’ knowledge, skills and attitudes.
How is the Module Organized?

The module is divided into 31 sessions; each session is divided into sections. The following
are the sections of each session:
 Session Title: The name of the session.
 Learning Tasks – Statements which indicate what the student is expected to learn at the
end of the session.
 Session Content – All the session contents are divided into steps. Each step has a heading
and an estimated time to teach that step. Also, this section includes instructions for the
tutor and activities with their instructions to be done during teaching of the contents.
 Key Points – Each session has a step which concludes the session contents near the end
of a session. This step summarizes the main points and ideas from the session.
 Evaluation – The last section of the session consists of short questions based on the
learning objectives to check the understanding of students.
 Handouts are additional information which can be used in the classroom while teaching
or later for students’ further learning. Handouts are used to provide extra information
related to the session topic that cannot fit into the session time. Handouts can be used by
the participants to study material on their own and to reference after the session.
Sometimes, a handout will have questions or an exercise for the participants. The answers
to the questions are in the Facilitator Guide Handout, and not in the Student Manual
Handout.
How Should the Module be Used?

Students are expected to use the module in the classroom and clinical settings and during
self-study. The contents of the modules are the basis for learning Child Health. Students are
therefore advised to learn each session and the relevant handouts and worksheets during class
hours, clinical hours and self-study time. Tutors are there to provide guidance and to respond
to all difficulty encountered by students.

vii
viii
Session 1: Human Growth and Development
Total Session Time: 120 Minutes
Prerequisites
 None
Learning Tasks
By the end of this session, students are expected to be able to:
 Define growth and development
 Explain the process of human growth and development
 Describe factors influencing growth and development
Resources Needed
 Flip charts, marker pens, and masking tape
 Black/white board and chalk/whiteboard markers
 Computer and LCD
 Overhead projector
SESSION OVERVIEW
Step Time Activity/ Method Content
Presentation of Session Title and Student

1 05 Minutes Presentation
Learning Task
2 15 Minutes Presentation Definitions of growth and development
Presentation/
3 45 Minutes Process of human growth and development
Brainstorm
Factors influencing human growth and
development
5 05 Minutes Presentation Key points
6 05 Minutes Presentation Evaluation
NMT 05112 Child Health

NTA Level 5, Semester 1 1
SESSION CONTENT
Step 1: Presentation of Session Title and Learning Tasks (5 minutes)
READ or ASK students to read the Learning Tasks and clarify
ASK student if they have any question before continuing
Step 2: Definitions of Growth and Development (15 minutes)

Growth and development
 Are terms often used interchangeably, each depends upon the other and in a normal child
they parallel each other, but the terms are not the same.
Growth
 Refers to an increase in physical size of the whole body or any of its parts and can be
measured in centimeters and kilograms. (Weight and height)
o It causes quantitative change in a child’s body.
o The most common cause of concern is a sudden slowing not typical for the age in any
aspect of growth.
Development
 Refers to a progressive increase in skill and capacity to function.
 Development is orderly, not haphazard; there is a direct relation between each stage and
the next.
Step 3: Process of Human Growth and Development (45 minutes)
Activity: Brainstorming (5 minutes)
ASK students to brainstorm on the fetus development and conception
ALLOW few students to provide responses and let others provide unmentioned response
WRITE their responses on the black board or flip chart
CLARIFY their responses using the information below
The fetus development

 It is convenient to regard pregnancy as beginning at the last normal menstrual period
because this is usually the only definitive date available.
 Some individual woman may know the exact date of conception.
 For the first 3 weeks following conception, the term fertilized ovum or zygote is used.
 From 3-8 weeks after conception, it is known as the embryo.
 From 8 weeks, it is known as the fetus until birth when it becomes a baby.

0-4 weeks after conception
 Rapid growth
 Formation of the embryonic plate
 Primitive central nervous system
 Heart develops and begins to beat
 Limb buds form
4-8 weeks
 Very rapid cell division
 Head and facial features develop
 All major organs laid down in primitive form
 External genitalia present but sex not distinguishable
 Early movements
 Visible on ultrasound from 6 weeks
8-12 weeks
 Eye lids fuse
 Kidneys begin to function and the fetus passes urine from 10 weeks
 Fetal circulation functioning properly
 Sucking and swallowing begin
 Sex apparent
 Moves freely (not felt by mother)
 Some primitive reflexes present
12-16 weeks
 Rapid skeletal development-visible on x-ray
 Meconeum present in gut
 Lanugo appears
 Nasal septum and palate fuse
16-20 weeks
 Quickening-mother feels fetal movements
 Fetal heart heard on auscultation
 Vernix caseosa appears
 Finger nails can be seen
 Skin begins to be renewed
20-24 weeks
 Most organs become capable of functioning
 Periods of sleep and activity
 Responds to sound
 Skin red and wrinkled
24-28 weeks
 Survival may be expected if born
 Eyelids reopen
 Respiratory movements

28-32 weeks
 Begins to store fat and iron
 Testes descend into the scrotum
 Lanugo disappears from face
 Skin becomes paler and less wrinkled
32-36 weeks
 Increased fat makes the body more rounded
 Lanugo disappears from body
 Head hair lengthens
 Nails reach tips of fingers
 Ear cartilage soft
 Plantar creases visible
36-40 weeks after conception (38-42 weeks after LNMP)

 Term is reached and birth is due
 Contours rounded
 Skull firm
Step 4: Factors Influencing Human Growth and Development (45 minutes)
 Heredity
o Heredity determines the extent of growth and development that is possible but
environment determines the degree to which the potential is achieved.
o The relatively typical pattern of growth and development is influenced by heredity
and environment.
o The heredity of a man and a woman determines that of their children.
o Before the largeness or smallness of a child is evaluated the size of the parents should
first be observed.
 Sex
o Sex is determined at conception.
o After birth the male infant is both longer and heavier than the female infant.
o Boys maintain this superiority until 11 years of age.
o Girls mature earlier and reach the period of accelerated growth earlier than boys and
then taller on the average.
o During the prepubertal spurt of growth thereafter boys again are taller than girls.
o The sex of children determines not only their physical attributes and patterns of
growth but also the manner in which others react to them.
o In all cultural groups, family and friends have different attitudes towards and
expectations of a child dependent on the child’s sex.
 Race
o Distinguishing characteristics called racial or sub racial development in prehistoric
humans.
o As to height, tall and short examples exist among all races and sub races.

o Among civilized groups, intermarriage has produced mixed racial types.
o The racial factor has a great influence on height, weight, colour, features, and body
constitution. A child of white race will be white and tall, even hair and eye colour,
facial structure are governed by the same race.
 Environment
o Although each human being at birth has a gene determined physical, mental, and
biochemical potential, the potential may not be reached because of the influences of
the environment.
o The influence of heredity and environment are so interrelated that they are practically
inseparable.
 Prenatal environment
o The influence of intrauterine environment on the child’s future development is great
particularly since the uterus shields the fetus from the full impact of external adverse
conditions.
o Harmful prenatal factors.
o Insufficient mother’s diet in terms of quality and quantity.
o Endocrine disturbances such as diabetes mellitus may affect the fetus.
o Infectious disease may affect the child.
o Radiation for cancer or any other condition may also affect the fetus.
o Any infectious disease that a mother suffers during pregnancy may affect the fetus.
o For example, Rubella (German measles) during the first trimester may lead to
abnormal development of the fetus.
o Other infections that can affect the fetus include:
 Toxoplasmosis
 Syphilis
 Herpes
 Malaria
 HIV
o Rhesus incompatibility may cause erythroblastosis fetalis.
o Faulty placental implantation or malfunction may lead to nutritional impairment.
o Drugs, smoking, and alcohol may lead to abnormalities or prematurity.
 Postnatal Environment
o External environment
 Cultural influences
 Social economic status of the family
 Nutrition
 Climate and season
 Deviation from positive health (for example Dwarfism)
 Long term chronic illness
 Congenital anomalies (cardiac etc.)
 Exercise
 Exercise by increasing the circulation promotes physiologic activity and
stimulates muscular development.
 Fresh air and moderate sunshine favour health and growth.
 Ordinal position in the family
 The behaviour of the parents towards and their expectations of each child are
different, yet predictable according to the child’s position in the family.
 The 1st born child in the family receives all the parental attention until the 2nd
child is born.
 Parents may be overly concerned about care giving especially if they have the
knowledge of growth and development. Therefore, the child may be raised rigidly
and with anxiety.
 The child develops a more anxious perfectionist personality than do the later
siblings and is more conforming, intelligent, and achievement oriented.
 The 1st born may learn at an early age to control and organize behavior of others.
The only child develops more rapidly. The middle child gets less attention from
parents. The youngest child tends to be more peers oriented.
 These generalizations apply to many children. However, each child is different.
o Internal environment
 Intelligence-this influences mental and social development.
 Hormonal influences
 The important hormones which affect growth are:
 Somatotrophic
 Thyroid
 Those that stimulate the gonads.
 Emotions
 Relationship with significant other persons, mother, father, siblings, peers, and
teachers among others play a vital role in the emotional, social, and intellectual
development of the child.
 Parents provides food, warmth, love, and protection as child develops.
 Siblings are child’s earliest peers.
 The way the child relates to playmates and classmates depends largely on the
parent child relationship in the home.
 As the child grows, other people such as teachers, neighbor, and shopkeepers have
great influence on emotional, social, and personality development.
 If the child is not given the necessary care and love that promotes healthy
development, growth and development are retarded.
Step 5: Key Points (5 minutes)
 Growth and development are terms often used interchangeably. They depend upon each
other but they are not the same.
 Human growth and development starts as soon as the male and female gametes fuse.
Therefore, there is growth and development which takes place when the fetus is in utero
which continues when the child is born.
 Human growth and development are influenced mainly by heredity and environment.
There is prenatal and postnatal environment.
 All children go through a normal sequence of growth but not at the same rate.
 Adults who have a clear understanding of the stages of growth and development can
apply the knowledge when caring for children.

Step 6: Evaluation (5 minutes)
 What is growth?
 What is development?
 List the stages of growth and development.
 Mention the factors which influence growth and development.
References
London, M. L., Ladewig, P. W., Ball, J. W., & Bindler, R. C. (2007). Maternal and child
nursing care (2nd ed.). London: Pearson.
Marlow, D. R., & Redding, B. A. (1988). Textbook of pediatric nursing (6th ed.). London:
W. B. Saunders Company.
Pillitteri, A. (2003). Maternal and child health nursing: Care of the childbearing and
childbearing family (4th ed.). London: Lippicott.
Stanfield, P., & Nimrod, B. (2005). Child health: A manual for medical and health workers
in health centers and rural hospitals (3rd Ed.). Nairobi: African Medical and
Research Foundations.

Session 2: Growth and Developmental Milestones of
One Month to Two Month Old Infant
Total session time: 120 minutes
Prerequisites
 None
Learning Tasks
By the end of this session, students are expected be able to:
 List the stages of growth and development
 Describe the average achievement of a one month old infant
 Describe the average achievement of a two month old infant
Resources Needed:
 LCD and computer
SESSION OVERVIEW
Step Time Activities/Method Content
Presentation of the session title and Student
Learning Tasks
Presentation/
2 15 Minutes List the stages of growth and development
Brainstorm
3 50 Minutes Presentation Average achievement of a one month infant
Presentation/
4 40 Minutes Average achievement of a 2 month infant
Group discussion
SESSION CONTENT
Step 1: Presentation of Session Title and Student Learning Tasks

(5 minutes)
ASK students if they have any questions before proceeding

NTA Level 5, Semester 1 9 Session 2: Growth and Development
Milestones of One to Two Month Old Infant
Step 2: Stages of Human Growth and Development (15 minutes)
ACTIVITY: Brainstorming (5 minutes)
ASK students to mention the stages of human growth and development
WRITE the answers on the board/flip chart
SUMMARIZE using the content below
 All children go through a normal sequence of growth but not at the same rate.
 The rate is also not the same in all areas.
 There is positive correlation between physical growth and mental, emotional, and sexual
development. This may not be true in individual children. Therefore, we should not
attempt to force a child into a standard pattern of growth.
 There are many variations in genetic traits and in the environment to make this possible.
 The strain upon the child may affect the child’s personality and even the child’s physical
health.
 Adults who have a clear understanding of the stages of growth and development can
apply their knowledge when caring for children.
 The stages are as follows:
o From birth to 4 weeks -a neonate or a newborn
o From 1 month (4 weeks)-12 months (1year) - an infant
o From 1 year-3 years –a toddler
o From 3-5 years - a preschooler
o From 6-12 years - a school child
o From 12 -13 years - a pubescent.
o From 14-21 years – an adolescent
Step 3: Average Achievements of a One Month Infant (50 minutes)
 Physical
o Weight 4.4 + 0.8 kg
o Gains 150-210 gm per week during the first 6 months
o Length 53 + 2.5 cm per month during the first 6 months
o Head circumference increases about 1.5 cm per month during the first 6 months
o Pulse 130 + 20 beats per minute
o Respiration 35 + 10 per minute
o Blood pressure 80/50 + 20/10 mm/hg
o Well developed sucking, rooting, swallowing, extrusion, Moro, and asymmetric tonic
neck reflex (head turned to one side, one arm and leg extended on the same side, the
other arm flexed to the shoulder with the leg on the same side flexed)
o Dance and dolls eye reflexes fading
o Still breathing through the nose

 Motor
o Lies in flexed position
o When prone, pelvis is elevated but knees are not beneath abdomen as they were after
birth
o Head lags when baby is pulled from a supine to a sitting position
o Head sags forward when baby is held in sitting position
o May lift head periodically when held over adult’s shoulder or placed in prone
positions
o Cervical curve begins to develop as infant learn to hold head erect
o Turns head to one side when prone
o Makes crawling movements when prone on flat surface
o Pushes with the feet against a hard surface to move forward
o Holds hand in tight fists
o Can grasp an object placed in the hand but drops it immediately (palmar grasp reflex)
 Sensory
o Startled by sounds (Moro reflex)
o Attentive to speech of others
o Indefinite stare at surrounding
o Fixates on objects brought in front of eyes
o Notices faces and bright objects which are in line of vision.
o Blinks in response to bright light
 Psychosocial
o Beginning development of sense of trust versus mistrust
o Totally egocentric (self-centered)
 Psychosexual
o Complete dependence on caregiver usually the mother
o Activity diminishes when a human face can be seen
o Establishes eye contact
o Smiles briefly
o Quiets, cuddles and molds when held
o Perceives self and parents as one
o Oral stage-oral dependence, need for suckling pleasure
 Spiritual
o Undifferentiated (0-1 year)
o Feelings of trust warmth and security forms the foundation for the latter development
of faith
 Intellectual
o Can make association between an act and a sequential response
o Cannot distinguish self from environment
o Begins to repeat actions of own body voluntarily, hand to mouth movement permits
sucking

 Moral
o Pre-conventional morality
 “The good is what I like and want”
 Language and speech development
 Responds to human voices
 Opens and closes mouth as adults speak
 Utters small throaty sounds
 Utters sounds of comfort when feeding
 Cries when hungry or uncomfortable
 Begins to coo
 Play Stimulation
o Hold, touch, rock infant gently
o Talk and sing to infant softly
o Call infant by name at close range
o Encourage mutual eye contact
o Provide pacifier for sucking pleasure
o Place large bright pictures on crib or wall
o Repeat noises made by infant
o Coo to infant
o Respond to crying signals
o Have ticking clock, radio, television, or music nearby
o Provide soft toys too large to swallow
o Swaddle to soothe infant
o When awake, place infant where household activities are in progress
o Take child for a walk
o When infant is alert and responsive, provide periods of affectionate play
Step 4: Average Achievement of a Two Months Infant (40 minutes)
Activity: Group Discussion (15 Minutes)
DIVIDE the students into manageable group
ASK a group of student who has assessed a two month infant to present
ALLOW the other students to contribute to the presentation
FACILITATE a brief discussion and then
SUMMARIZE the discussion using the information below
 Physical
o Posterior fontanelle closes at 6-8 weeks of age
 Motor
o Less fixed prone position
o No head droop when suspended in prone position
o Lifts head almost 450 above a flat surface when lying prone

o Holds head erect in midposition
o Holds head erect when held upright
o Turns from side to back
 Fine Motor
o Hands may be open
o Holds a rattle briefly when placed in the hand
 Sensory
o Turns head to side when a sound occurs at ear level
o When on back, follows a dangling object or a moving light beyond the midline of
vision
o Eyes follow moving person nearby
 Psychosocial
o Sense of trust
o Distinguishes mother or primary caregiver from others and is more responsive to that
person
o Eye to eye contact – orientation, smiling, and vocalization are the evidences of
attachment between infant and parents especially the mother
o Smiles back in response to another’s smile
o This is the beginning of social behavior
o Has learned that crying brings attention
 Psychosexual
o Oral stage 0-1 year
 Spiritual
o Undifferentiated (0-1 year)
 Moral
o Pre-conventional morality
 Receptive Language
o Alert expression when listening
o Direct definite regard
o Soothed by caregivers, mothers voice
 Expressive Language
o Cry patterns develops
o They vary with the reason for crying
 For example, hunger, sleepiness or pain
o The pitch and intensity vary
o Responds vocally to caregivers voice -“ah”, “eh”, “uh”
o Coos

o Offer a rattle
o Pull from supine to sitting position
o Hold or dangle toy in front of infant to encourage eye movement
o Change patterns of objects from bright and shinny to dull and dark for further
stimulation
o Go outing with the child
 In order to know if the child is achieving as expected consider the following parameters:
o Physical growth, motor, sensory, psychosocial, psychosexual, spiritual, and
intellectual development and include his/her receptive and expressive language.
 The caregiver/parents should be encouraged to provide what the infant needs at a specific
age so that growth and development of the child is enhanced.
Step 6: Session Evaluation (5 minutes)
 When do you expect the posterior fontanel to close?

 Infants doubles their birth weight at how many months?
 The lower central incisors normally erupt at how many months?
 Psychosexually the infant is at which stage?
References

Session 3: Growth and Development in Infant from
Three Months to Six Months
Total session time: 120 minutes
Prerequisites
 None
Learning Tasks
 Describe the average achievement of a three month to six month infant
Resources Needed:
SESSION OVERVIEW
Step Time Activities/Method Content
Learning Tasks
2 20 Minutes Presentation Average achievement of a 3 month infant
SESSION CONTENT
Step 1: Presentation of Session Title and Student Learning Task

(5 minutes)
READ or ASK the students to read the students Learning Tasks and clarify

NTA Level 5, Semester 1 14 Session 3: Growth and Development in
Infant from Three Months to Six Months
Step 2: Average Achievements of a Three Months Infant (20 minutes)
Activity: Buzzing (5 minutes)
ASK students to buzz in pairs on what are the average achievements of a three month
infant
ALLOW few students to respond
SUMMARIZE the achievements using the content below:
 Physical
o Weight 5.7 + 0.8 kilogram
o Length 60 + 2 cm
o Pulse 130 + 20 beats per minute
o Respirations 35 + 10 per minute
o Blood pressure 80/50 +20/10 mm/hg
 Reflexes
o Palmar reflex absent
o Landau reflex appears
 Motor
o Very slight head lag
o Sits back rounded, knees flexed when supported in sitting position
o Raises chest usually supported on forearms when in prone position
o Hold head erect and steady
o Hands open or closed loosely
o Holds hands in front of face and stares at them
o Holds objects put in hand with active grasp
o Carries hand or object to mouth at will
o Reaches for bright objects
 Sensory
o Turns hand to locate sound
o Turns eyes to objects
o Blinks at objects that threaten the eyes
 Psychosocial
o Sense of trust
o Smile in response to mothers smile
o Stops crying when familiar faces approaches
 Language
o Looks in direction of speaker
o Cries less
o Shows pleasure in making many sounds
o Vocalizes in response to others
o May laugh aloud

NTA Level 5, Semester 1 15 Session 3: Growth and Development in
 Play and Stimulation
o Provide greater variety of toys
o Take on daily outing
o Bounce on bed
o Play with infant during feeding
Step 3: Average Achievements of a Four Months Infant (30 minutes)
 Physical Growth
o Drools between three and four months
o This indicates increased production of saliva. As the infant is unable to swallow it all,
it runs from mouth.
 Reflexes
o Tonic neck, Moro, suckling, and rooting when awake are absent
o Extrusion reflex fading
 Motor Growth
o Sits with adequate support
o Enjoys being propped up
o Holds head erect and steady when placed in sitting position
o Lifts head and shoulders at a 900 angle
o When on abdomen and looks around
o Attempt to roll or actually rolls over from front to back
o Sustains small portion of own weight when held in standing position
o Activates arms at sight of preferred toy
 Fine Motor
o Holds hand predominantly open
o Brings hands together in midline
o Plays with fingers
o Grasps object held near hand
o Cannot pick object when dropped down
o Grasps object with both hands
o Attempts to reach objects with hands but overshoots them
o Objects are carried to mouth
 Sensory
o Follows moving object well with eyes
o Even the most difficult types of eye movement are present
o Fairly good binocular vision
o Looks briefly for toy that disappears
o Accommodation begins to develop
o Can accommodate to nearby objects
o Can focus on small objects
o Stares at rattle placed in hand and takes it to the mouth
o Recognizes familiar objects such as feeding bottle and toys
o Beginning hand-eye coordination
o Comforts self by sucking thumb or pacifier
NTA Level 4-6, Semester 1 16 Session 3: Growth and Development in
 Psychosocial
o Sense of trust
 Smiles in response to smiles of others when appear nearby
 Initiates social play by smiling or vocalizing
 Shows evidence of wanting social attention and of increasing interest in other
family members
 Shows interest in new stimuli
 Fusses if left alone or bored thereby demanding attention from others
 Shows eagerness when feeding bottle (cup and spoon) appears
 Breathes heavily when excited
 Psychosexual
o Oral stage
 Spiritual
o Undifferentiated
 Intellectual
o Repeats actions that affect an object to get a response e.g. shaking a rattle
o Experiments with old or new responses to produce environmental changes or to reach
a goal
 Moral
o Preconventional morality
 Receptive Language
o Responds differently to pleasant or angry noises
o Does not cry when scolded
 Expressive Language
o Laughs aloud
o Vocalizes socially coos and gurgles when spoken to
o Very talkative to self, people, or toys
o Talking and crying follow each other quickly
o Can vocalize consonants b,g,h,k,n,p.
o Hold, touch and rock infant gently
o Smile when talking and singing to infant
o Encourage mutual eye contact
o Laugh when infant laughs
o Echo sounds that infant makes
o Observe subtle clues from infant’s body language and respond to them
o Light tickling stimulates laughter
o Provide variety of small multitexured (fuzzy, smooth) and colored objects that infant
can hold but not swallow
o Shake rattle placed in infant’s hand
o Offer toys for grasping

o Move rattles around the infant so that it can be followed visually and grasped
 This helps develop hand–eye coordination and improve head control
o Provide floating toys for bath
o Encourage splashing in bath water
o Help infant sit up with support and roll over
o Help infant learn balance when sitting by tilting the body from an erect position to
one side
o Hold child in standing position
o Use infant seat, swing, and stroller
o Provide safe area for periods of solitary play
o Place infant when awake where household activities are in progress
o Include infant in family’s television viewing and activities
Step 4: Average Achievements of a Five Months Infant (25 minutes)
 Physical
o At least twice the birth weight
o Mean age for doubling birth weight is 3.8 months
o Physical growth is slowing down
o Can breathe through mouth when nose is obstructed
 Motor growth
o Sits with slight support
o Balances head well when sitting
o Hold back straight when pulled to a sitting position
o Pushes whole chest off a flat surface when prone
o Rolls from back to front
o Sustains more of own weight when held in standing position
o Pulls feet up to mouth when supine
o Uses thumb in partial position to fingers more skillfully
o Tries to obtain objects independently to direct stimulation of palm of the hand
o Grasps objects with whole hand either right or left
o Holds one object while looking at another
 Sensory
o Localizes sounds made below the ear
o Looks for a dropped object
o Inspects objects visually for a lengthening period of time
o Can fixate an object more than 3 feet away
 Psychosocial
o Sense of trust
 Smiles at self in mirror
 Begins to discriminate family members from strangers
 Accept an object from another person
 Play enthusiastically, shows displeasure when toy is lost
 Plays with own feet

 Psychosexual
o Oral stage
 Spiritual
o Undifferentiated
 Receptive language
o Responds when own name is called
 Expressive language
o Squeals when happy or excited
o Vocalizes displeasure when a desired object is taken away
o Consonant sound increase
o Sounds like vowels appear with consonants such as “goo”
o Begin to mimic sounds
 Play stimulation
o Provide sufficient different objects for play
o Provide small objects that are too large to swallow
o Make various sounds near ear
o Hold infant in standing position and bounce to exercise legs and develop balance
Step 5: Average Achievements of a Six Months Infant (30 minutes)
 Physical
o Weight 7.4 + 1 kg. Gains about 340 gm every month
o Length 65.5 + 3 cm
o Head circumference 43 cm
o Pulse 120 + 20 beats/minute
o Respirations 31+ 9 per minute
o Teething two lower central incisors erupt-6+ 2 months
o Begins to bite and chew
 Motor
o Sits alone briefly if placed in a favorable leaning position on hard surface
o Holds arm out
o Back is straight when sitting in high chair
o Pulls to a sitting position
o Springs up and down when sitting
o Lifts chest and upper abdomen when prone putting the weight on arms and hands
o Turns completely over with rest periods during the turn so the infant must be
protected from falling
o Sustains most of own weight when held in standing position
o Hitches- that is moving backward when in a sitting position by using the arms and
hands
o Grasp with simultaneous flexion of fingers
o Begins to use fingers to feed self a cracker
o Retains transient hold on two objects one in each hand

o Drops one object when another is offered
o Begins to bang objects that are held (rattles, spoons, toys)
o Hold own bottle but may prefer for it to be held
 Sensory
o Localizes sound made above the ear
o Retrieves a dropped object that can be seen and reached
o Enjoys more complex visual stimuli
o Moves in order to see an object
 Psychosocial
o Sense of trust
 Recognizes strangers as different from family members
 Begins to extend arms to be picked up
 Thrashes arms and legs when frustrated
 Imitation of others is beginning
 Sticking tongue out
 Knows what is liked and disliked
 Psychosexual
o Oral stage
 Spiritual
o Undifferentiated
 Intellectual
o Beginning of object permanence when infant briefly searches for dropped object
o Recognizes familiar words
o Actively vocalizes pleasure with cooing or crowing
o Cries easily on slight or no provocation (withdrawal of a toy)
o Vocalizes several well defined syllables
o Lallation or imperfect imitation begins (6-9 months)
o Shows enjoyment in hearing own vocalization
o Talks to own image in mirror
o May pat image of self if close to mirror
o Encourage infant to look in mirror
o Repeat names of parts of face such as mouth, nose, and eyes
o Make funny faces for infant to imitate
o Paint out people, food, objects and repeat their names.
o Talk to infant about own and surrounding activities
o Repeat infant’s name
o Encourage response to simple commands
o Use the word “no” only when necessary

o Provide more complex soft cuddy toys
o Provide hard large toys possibly with moving parts such as a set of measuring spoons,
bows, pots and so on
o Provide fabrics or food with different textures for infant to feel
o Provide sound making toys
o Encourage infant to search for lost objects and obtain those out of reach.
o Help infant sit up while leaning forward for support
o Begin to place infant in walker
o Provide a limited area on floor where the infant can move safely for sitting, crawling,
rolling over
 In order to know if the child is achieving as expected consider the following parameters:
o Physical growth, Motor, sensory, psychosocial, psychosexual, spiritual, and
intellectual development and include his/her receptive and expressive language
 The caregiver/parents should be encouraged to provide what the infant needs at a specific
age so that growth and development of the child is enhanced
 When do you expect the posterior fontanel to close?

 Infants doubles their birth weight at how many months?
 The lower central incisors normally erupt at how many months?
 Psychosexually the infant is at which stage?
 Psychosocially the infant has which sense?
References

Session 4: Average Achievements of Children Aged
7 Months to 9 Months
Prerequisites
 None
Learning Tasks
By the end of this session, students will be able to:
 Describe the average achievement of a seven months to nine months infant
Resources Needed
 Flipcharts, marker pens, masking tape
 Black / whiteboard and chalk/white board markers
 Projector
 Computer
SESSION OVERVIEW
Step Time Activity/Method Content

Learning Tasks
2 40 minutes Presentation Average achievements of an infant 7 months
3 35 Minutes Presentation Average achievements of an infant 8 months
5 05 Minutes Presentation Key Points
SESSION CONTENT
Step 1: Presentation of Session Title and Student Learning task
(5 minutes)
READ or ASK the student to read the Student Learning Tasks and clarify.
ASK students if they have any questions before proceeding.

NTA Level 5, Semester 1 22 Session 4: Average Achievements of Children
Aged 7 Months to 9 Months
Step 2: Average Achievement of a Seven Month Infant (40 minutes)
 Physical growth
o Sucking and rooting reflexes disappears at seven to eight months when asleep
o Parachute reflex appears between seven to nine months
 Teething
o Upper central incisors erupt 7.5+ 2 months
o Lower lateral incisors erupt 7+ 2 months
o Ultimate color of iris is established
 Motor
o Sits alone on hard surface leaning forward on hands
o Lifts head as if trying to sit up when supine control trunk is more advance
o Rolls more easily from back to abdomen
o Sustains all weight on feet when held in standing position
o Bounces actively when held in standing position
o Grasps a toy with one hand
o Transfers a toy from one hand to another successfully
o Imitates simple acts of others
o Bangs objects that are held
o Holds cup
 Sensory
o Fixates on very small objects and details
o Has preference in taste for foods
 Psychosocial
o Sense of trust
 Shows increasing fear of strangers (7-8 months)
 Actively clings to a familiar person when distressed
 Unhappy when caregiver disappears
 Responds socially to own name
 Rapidly changes from crying to laughing (emotional instability)
 Closes lips tightly when disliked food is offered
 Psychosexual
o Oral aggressiveness is evidenced by biting and chewing
o Discovers genitalia
o Recognizes own name
o Responds with gestures to words such as come
o Vocalizes m-m-m when crying
o Imitates simple noises and speech sounds
o Vocalizes da, ma, ba

 Play and stimulation
o Place toy under blanket and encourage him to find it
o Repeat simple sounds dada, mama
o Provide objects or foods that can be chewed and beaten safely
o Encourage playing in water
o Encourage banging of toys
Step 3: Average Achievement of Eight Months Infant (35 minutes)
ASK students to brainstorm on average achievements of a eight months infant
ALLOW students to respond
 Physical
o Begins a pattern in bowel elimination
 Motor
o Pulls self to standing position with help
o Perfect hand-eye coordination
o Holds two things while looking to a third
o Release objects from hand voluntarily
o Drinks from cup with assistance (7-9 months)
 Psychosocial
o Greeting strangers with shyness (coy) or even crying or screaming
o Refuses strangers
o Affection for family members by stretching arms to them
o Dislikes changing clothes
 Intellectual
o Can search hidden things
o Problem solving begins to develop
 Language
o Stops activity when own name is spoken
o Understands no
o Shouts for attention
o Imitates sound sequences
o Continue mama, dada
o Can vocalize consonants d,t,w

o Hold, touch and rock infant gently
o Continue talking and singing to the child
NTA Level 4-6, Semester 1 24 Session 4: Average Achievements of Children
o Place infant in a sitting position against something and encourage to lean forward to
improve balance
o Push gently from a sitting position to improve balance.
Step 4: Average Achievements of a Nine Months infant (30 minutes)
 Physical
o Plantar grasp absent
o Upper lateral incisors erupt (9+2)
 Motor
o Raises to a sitting position alone with good coordination
o Sits steady for a long time
o Crawls-can start at 4 months average 8-9 months
o Can also creep
o Begins to pull self to standing position alone by holding on to furniture
o Bangs two objects together
o Pokes objects with fingers
o Has preference for the use of one dominant hand
o Drinks from cup with some spilling (9-12 months)
o Attempts to use a spoon but spills contents
 Psychosocial
o Begins to play simple games with adults e.g. bye- bye
o Wants to please caregiver
o Fears when left alone
o Doesn’t want his face to be washed so cover it with hands
 Language
o Responds to no by stopping what he is doing
o Begins to respond to simple commands
o Responds to adult anger
o Cries when scolded
o Says mama dada as names of persons
o Encourage crawling and creeping by playing with wheel barrow
o Provide a larger environment for crawling safely
Step 5: Key points (5 minutes)
 An infant has a sense of trust

 At 7 months starts to have preference in food tastes
 Average age for crawling is 8-9 months
 Place child in a walker to encourage him/her to walk.

 Infant is supposed to have a pattern of bowel movement at how many months?

 When do you expect the upper central incisors to erupt?
 An infant can say “mama” at which age?
 Infant can walk while holding furniture at which age?
 Birth weight is normally tripled at how many months?
References
Research Foundations..

Session 5: Average Achievements of Children Age
10 Months to 12 Months
Prerequisites
 None
Learning Tasks
By the end of this session, students are expected to be able to
 Describe the average achievement of a ten months to 12 months infant
Resources Needed:
 PowerPoint projector and computer
 Handout 5.1. General Needs of the Infant
SESSION OVERVIEW

Learning Tasks
SESSION CONTENT
Step 1: Presentation of Session Title and Student Learning task
(5 minutes)
READ or ASK the student to read the Learning Tasks and clarify

Step 2: Average Achievements of a Ten Months Infant (40 minutes)
ACTIVITY: Group Discussion (15 minutes)
DIVIDE students into manageable groups
ASK students to discuss in their groups on average achievements of a ten months old
infant
ALLOW several students to respond
 Macula is well developed so that fine visual discriminations can be made
 Motor
o Moves from prone to sitting position
o May sit by falling down from sitting position
o Does not want to lie down unless sleepy
o Pulls to standing position well
o Making stepping movements when supported
o Can pick small objects with index finger and thumb
o Releases an object after holding it
o Brings the hands together
 Sensory
o Has marked interest in very small objects
o Searches for a lost toy with greater persistence
 Psychosocial
o Expresses recognizable emotions such as:
 Anger
 Sadness
 Jealousy
 Anxiety
 Pleasure
 Excitement
 Affection
o Objects away from being away from parents
o Can imitate facial expressions
o Shows preference in toys
o Offers a toy to another but may not release it
o Can look at pictures
o Attracts the attention of others by pulling their clothes
o Repeats actions that attract attention
 Language
o Understands simple commands
o Vocabulary increases can now say “no”

o Understanding meaning of bye bye and waves
o Imitates sounds of animals
o Obtain his attention on request
o Make facial expression for imitation
o Show pictures
o Continue games
o Place in a jumper to encourage jumping
Step 3: Average Achievements of an Eleven Months Infant (25 minutes)
 Motor
o Stands erect with minimal support and lifts one foot to take a step
o Walks holding furniture
o Explore toys and other objects carefully
o Removes covers from boxes
o Take toys out of box or cup and put them back without letting them
o Can start marking on paper
 Sensory
o Tilts head backwards to see upwards
 Psychosocial
o Shows pleasure when a desired act is accomplished
o Becomes frustrated when restricted
o Seeks approval and avoids disapproval
 Language
o Responds to simple questions when asked for something she can point to it
o Imitates specific speech sounds of others
o Jargon well established (unintelligible words)

o Encourage play
o Encourage to stand alone- decrease support
o Place him in a walker
Step 4: Average Achievement of a Twelve Months Infant (40 minutes)
ACTIVITY: Buzzing (5 minutes)
ASK students to buzz in pairs on the average achievements of a twelve months infant
ALLOW the students to respond

 Physical
o Weight is 10+ 1.5 kg
o Has tripled birth weight
o Length 74.5+ 3cm. It has increased almost 50% from birth
o Head circumference 46 cm (the head has increased by 1/3)
o Brain weight has increased rapidly since birth resulting in significant achievements
o Head and chest are almost equal in circumference
o Anterior fontanel closes between 12-18 months
o Pulse 115 +20
o Respirations 30+ 10
o Blood pressure 96/66 +30/24
 Reflexes
o Babinski’s reflex disappear
o Landau reflex disappear between 12 and 24 months
o Have 6-8 deciduous teeth
o Physiologic stability achieved and maintained during the first year of life
 Motor
o Stands alone for a length of time
o Sits down from standing position alone
o Walks a few steps alone
o Picks small bits of food and transfer them to mouth
o Enjoys eating with fingers
o Releases object inside another object
o Attempts to put one block on top of another without success
o Turns pages in a book
o Drinks from a cup
o Eats from a spoon although he still needs help
 Sensory
o Listens to recurring sounds
o Follows fast moving objects with eyes
 Psychosocial
o Attachment developed to primary care giver
o Clings to care giver when fearful
o Responds to request for affection such as a kiss or a hug
o Views himself as a separate person
o Cooperates in dressing
o Drops objects on purpose for someone else to pick
 Intellectual
o Develops object permanence
o Can solve a problem but has not learned to think per se

 Language
o Responds with gestures to more complex verbal requests e.g. please give it to me
o May speak more than two words
o Understanding meaning of more words and names of objects even though he can’t
speak
o Intonation becoming like adult speech
o Indicates no by shaking head
o Can control responding to voice
o Walking increase
o Vocalization decreases
o Provide something to use in drawing
o Encourage walking
 An infant has a sense of trust

 At 7 months starts to have preference in food tastes
 Average age for crawling is 8-9 months
 Place child in a walker to encourage him/her to walk.
 General needs includes discipline leading to self control, development of self esteem,
feeding, exercise, accident prevention
 Infant is supposed to have a pattern of bowel movement at how many months?

 When do you expect the upper central incisors to erupt?
 An infant can say “mama” at which age?
 Infant can walk while holding furniture at which age?
 Birth weight is normally tripled at how many months?
References

Handout 5.1. General Needs of the Infant
 Emotional social needs include:
o Love and security
 The most important emotional need of infants and children of all ages is to be
loved and feel secure in that love
 Love is communicated to them through action and words
 They eventually learn that they are loved just because they exist and not because
of what they do
 A sense of security and beginning sense of self esteem develop from such
unconditional love
 Thus, they can move from total dependence to gradual independence and can be
disciplined so that eventually they can adjust to their social roles in life
 Also they are able to cope with minor and major problems in growing up
 If parents have been raised by loving parents themselves, they already know how
to express their love
 If parents have not experienced parental love, they may not be able to
communicate it to their infants even though they believe that they express love
 If infants do not have a loving intimate warm and continuous relationship with
their parents or parent substitutes, they may develop feelings of excessive anxiety
 These feelings of insecurity may form the basis for less than optimal physical,
emotional and mental health later in their life times
 Dependence progressing to independence

o Neonates are totally dependent at birth
o During the first year of life, their beginning independence is seen in attempting to
feed themselves and in cooperating in dressing
 Discipline leading to self control

o During the first year the concept of discipline is simply that of guidance and limit
setting to help infants with their development and provide for their safety
o Infants who are not assisted and encouraged in their development may be considered
spoiled by their parents
 Developing self esteem

o Self esteem develops gradually through the appraisals of significant others and the
infants achievements of developmental milestones
o Infants with loving parents who can communicate their deep feelings of love through
actions and words and encourage their children to develop their abilities have already
begun towards developing healthy self esteem
 Biological Needs
o Sleeping and waking
o Feeding
o Exercise
o Although the parents have scheduled activities, the infants’ schedule also should be
considered to provide some consistency in routines

 Health promotion and anticipatory guidance
o Nutrition
 0-6 months exclusive and sustainable breast feeding
 6-7 months introduction of solid foods although breast milk remain to be the main
source of nutrition
 Infants enjoy bland foods with no added salt with slight sweet taste
 7-8 months –pureed or strained food
 8 months onwards -mashed
 At twelve months they can eat well cooked adult foods
 They prefer moderate temperatures that is not too hot not too cold
 Sequence of introduction at weekly interval
 Cereals
 Fruits and vegetables
 Meat
 Accidents prevention
o Accidents are important causes of injury and death during the first year of life
o This is due to rapid advances in motor and sensory development and the
overwhelming curiosity about their surroundings
o Therefore, parents should be on the alert to the potential dangers that are in the
environment constantly
o The potential dangers are:
 Falls
 Suffocation
 Aspiration or swallowing of foreign materials
 Motor vehicle accidents
 Injuries to the body
 Drowning
 Burns
 Poisoning
o Parents should be informed of these various accidents then they can decide on
themselves how to prevent them in relating to their individual environment
 Health Supervision
o The goals of health supervision
 To reduce the morbidity and disability rates
 To reduce the mortality rates
 To promote growth and development to their optimal potential
 Through the promotion of wellness to assist them to have fuller and more
productive lives
 The above goal will be met by:

o Early detection of disease before irreparable damage has occurred
o Preventive health measures such as
 Immunization
 Health education
 Anticipatory guidance
 Counseling
 Continuity of care

 The above can be achieved by:
o A complete history of family and infant or child and a home visit to understand the
family and identify potential problem areas
o Recognizing and identify defects or illness through complete physical assessment and
guiding parents to sources in the community where these conditions can be treated
o Helping parents understand the physical growth and development of their children
and how serious problems can be averted if they know what to expect of an infant or
child at various ages
o Providing protection against certain communicable diseases by immunization
o Guidance about nutrition and accident prevention and other parental concerns
o Assistance with problem behaviors and help for the family in their overall relations
with the child
o Establishing sound child-health team–parent relations and attitudes towards medical
treatment

Session 6: Average Achievements and General Needs of
a Toddler
Prerequisites:
 None
Learning Tasks
 Define a Toddler
 Describe the average achievement of a toddler from 15 months to 30 months of age
Resources Needed:
 Handouts 6.1: General needs of a toddler
SESSION OVERVIEW
Step Time Content
Activity/Method
Presentation of session title and Learning
Tasks
Brainstorm/
2 10 Minutes Definition of a toddler
Presentation
3 15 Minutes Presentation Achievements of a toddler 15 months
4 20 Minutes Presentation Achievements of a toddler at 18 months
5 35 Minutes Presentation Achievement of a toddler at 24 months
6 25 Minutes Presentation Achievements of a toddler at 30 months
SESSION CONTENT
Step 1: Presentation of Session Title and Student Learning Task (5

minutes)
READ or ASK student to read the Student Learning task and clarify
ASK student if they have any question before proceeding

NTA Level 5, Semester 1 35 Session 6: Average Achievements and
General Needs of a Toddler
Step 2: Definition of a Toddler (10 minutes)
ASK students the definition of a toddler
ALLOW student to answer, write the responses on the flip chart or board
SUMMARIZE using the content below
Definition
 A toddler is a child between one year and approximately three years
 The child emerges from the total dependency of infancy into beginning independency or
autonomy
 The toddler uses his trust in exploration and investigation of a world beyond parent’s
arms
Step 3: Average Achievements of a 15 Months Toddler (15 minutes)
 Physical
o Legs appear bowed
 Motor
o Walks without support
o Kneels without support
o Creeps upstairs
o Has ability to release object from grasp
o Builds a tower of 2-3 cubes
o Open boxes
o Pokes finger in holes
o Scribbles spontaneously
o Makes line with crayon (pen)
 Self care
o Holds a cup with all fingers
o Grasp a spoon and inserts it into a dish but cannot fill it well
o Enjoy finger feeding
o Leaves dish on tray when fed
o Helps in dressing
o Removes socks
o Indicates when nappy is wet or soiled
 Sensory
o Looks at pictures intently for prolonged period of time
 Psychosocial
o Sense of autonomy versus shame and doubt
o Egocentric still

o Can tolerate some separation from care giver
o Can cope in unfamiliar environment
o Less fearful of strangers
o Hugs and kisses parents
o Kisses pictures
o Begins to imitate parents doing house keeping
o Very early temper tantrums
 Psychosexual
o Anal stage (1-3 years)
 Moral
o The good is what I like and want
 Language
o Recognizes various parts of the body and names
o Responds to familiar simple commands
o Still uses jargon unintelligible words
o Says 2-6 words
o Names familiar pictures
o Vocalizes wants and points to
o Shakes head to communicate no
o Communicates no even when following a request
o Encourage walking as a form of play
o Provide:
 Balls
 Staffed animals
 Dolls
 Musical toys
 Picture books
 Discs or blocks
Step 4: Average Achievements of a 18 Months Toddler (20 minutes)
 Physical
o Anterior fontanel closed-may be closed as early as 12 months
o Abdomen protrudes
o Physiological anorexia due to decreased growth
o Has sphincter control
 Motor
o Walks, seldom falls, sideways and backward
o Can walk upstairs holding with one hand
o Can attempt jumping
o Sits self in small chair
o Climbs on furniture
o Gets into everything, explores drawers even waste baskets

o Pushes light furniture around room
o Throws ball overhead without falling
o Scribbles vigorously
o Turns pages in a book
o Can put things into a hole
 Self care
o Holds cup with both hands and can hand it to care giver, put it down or drops it
o Eats with spoon and turns spoon in mouth
o Spills frequently
o May play with food
o Negativism and high activity level
o May interfere with eating
o Removes and unzips simple garments
o Complains when wet
o May indicate need to toilet
o Increased readiness for bowel and bladder control
o May control bowel movement
o May smear feces
 Sensory
o Intense interest in pictures
o Identifies various shapes
 Psychosocial
o Sense of autonomy (a feeling of independence)
o Egocentric
o Autonomous behavior increasing
o Negativism and dawdling predominant
o Have temper tantrums
o Aware of strangers
o Seeks help when in trouble
o May resist to sleep for sometime
o Bed rituals begins
o Imitates parents behavior
o Possessiveness begins
o Gender identity begins
 Intellectual
o Is comfortable when hearing parents voice
o Short attention span
o Begins sense of time and anticipation of events
o Begins to think
o Beginning traces of memory
o Experiments actively to achieve goals
 Language
o Speaks an average of 10 real words
o Name pictures

o Uses words than gestures to express desire
o About 25% of vocalization is intelligible
o Enjoys solitary play or watching activities of others
o Has a favorite toy
 Provide for motor play

o Large hollow wooden blocks
o Balls
o Pull toys
o Low swing with arms and back
o Low slide
o Rocking chair or horse
o Low wheeled toys to ride
o Small chair and table
o Running and chasing games
 Provide creative play

o Container with openings into which blocks of different shapes can be placed
o Blocks, bowls, tumblers
o Finger paints
o Large crayon
o Clay
o Bells around wrist or ankle
o Sand toys (shovels, pail)
o Stuffed animals and dolls to drug, sit upon or hug
o Imitates parental actions in play
Step 5: Average Achievements of a Toddler 24 Months (2 Years)

(25 minutes)
 Physical
o Weight approximately 11.8-12.7 kg
o Height approximately 82.5 -85 cm
o Gained 10 -12 cm in second year
o Adult height is about twice height at 2 years
o Chest circumference exceeds head circumference
o Anterior posterior diameter less than lateral diameter
o Head circumference 49-50 cm
o Pulse 110 + 20 –average 100 beats/minute
o Respiration 26-28/minute
o Blood pressure 99/64 + 26/24
o Landau reflex completely disappeared
o Approximately has 16 temporary teeth
o Physiologic function is mature except endocrine and reproductive
o Abdomen protrudes less than in 18 months
o May control daytime bowel and bladder

 Motor
o Can walk with heel toe gait
o Walks backwards in imitation
o Runs more quickly with few falls
o Jumps
o Kicks large ball
o Builds tower of 6-7 cubes
o Makes cubes into a train
o Turns pages of a book one at a time
o Opens door by turning knob
o May run away
o Unscrews lid or jar
o Folds paper once (imitating)
 Self care
o Drinks well from a small glass held in one hand
o Puts spoon in mouth occasionally with one hand
o Plays with food
o Can use a straw
o May request certain foods
o Pulls on own simple garments
o Removes most of own clothing
o Verbalizes toilet needs
o Usually bowel trained with occasional accidents
o Usually urinates when taken to toilet
o Toilet trained in day time
o May still smear stool
o May brush teeth with help
o Attempts to wash self in tub or shower
 Sensory
o Accommodation well developed
o Inserts square objects into its appropriate place or hole
o May develop strabismus (squint)
 Psychosocial
o Sense: Has sense of autonomy
 Still egocentric in both thought and behavior
 Separation anxiety continues
 Shows early signs of individuality
 Independent from care giver
 Is possessive (mine not yours)
 Does want to share possessions
 May push other children as if they are objects out of his way
 May want to make friends but doesn’t know how
 Pulls other persons to show them something
 Does not want to sleep so has many demands before bed time
 Upset by changes in routine
 Thumb sucking decreased

 Focuses on own wishes
 Violent temper tantrums decreasing
 Psychosexual
o Anal stage
 Intellectual or cognitive
o Attention span is longer
o Memory increases
o Starts to understand past present and future
o Increased sense of time-can anticipate events and can wait for them
o Can pretend
 Language
o Understands more complex sentences
o Can obey 2 commands given at the same time
o Enjoys stories with pictures
o No longer use jargon
o Knows about 300 words
o Refers to self by first name
o Uses pronouns “I”, “me”, “mine”
o Asks what’s, who’s that
o Tells about immediate experiences
o Identifies familiar objects
o Verbalizes need for drink, food, and toileting
o May use the word now meaningfully
o About 66% of vocalization are intelligible
 Play and Stimulation

o Little social interaction with other children
o Begins to learn to replace toys in their proper place
o Frequently idle (dawdles)
o Pulls wagon
o Manipulates play materials such as clay, finger paints, brush paints
o Sings songs
o Needs large puzzles and toys to take apart
o Enjoys hearing stories with pictures
o Takes favorite toys to bed
o Mimic domestic activities of parents
o Enjoys playing with dolls
Step 6: Average Achievements of a Toddler at 30 Months (25 minute)
 Physical
o Weight–gains about 5kg between 1 and 3 years
o Weight is quadrupled
o Height increases about 6-8 cm during the third year
o Has a full set of 20 temporary teeth
o Daytime bowel and bladder control possibly established

 Motor
o Can stand on one foot momentarily
o Walks on tiptoe for few steps upon request
o Walks up and down stairs one foot on a step alternating feet
o Jumps well in place with both feet off the floor
o Jumps from step or low chair
o Can throw a large ball 4-5 feet
o Can ride a walker or pedal car
o Builds a tower of 8 cubes
o Adds chimney to train or cubes
o Imitates circular strokes
o Holds crayon with fingers instead of entire hand
o Good hand-finger coordination
 Self-care
o Can feed himself with occasional spilling
o Pours from a jug often spilling
o Gets a drink without assistance
o Distinguishes between finger and spoon food
o Chews with mouth closed
 Dressing
o Puts arm through large arm hole
o Buttons a large front button
o Unbuttons large front buttons
o Helps to put things away
 Toilet and grooming

o Mastery of daytime bowel and bladder control
o May go to the toilet himself
o Control bowel at 26 months
o Controls urination 30 months
o Needs assistance with wiping
o Attempts to wash hands adequately
o Can partially dry hands upon reminder
 Sensory
o Recalls visual images
 Psychosocial
o Sense of autonomy (1-3 years)
 Theoretically autonomy is achieved at the end of toddler period. If it is not
achieved a sense of shame and doubt predominates
 Still egocentric
 Learns to cope with separation anxiety
 Independent behavior increases
 Achieves some self control based on self esteem rather than fear
 Reluctant to go to bed
 Negativism and dawdling continue

 Temper tantrums may or may not decrease
 Imitates sex role behavior of adults
 Knows own sex
 Psychosexual
o Anal stage (1-3 years)
 Intellectual
o Concept of time still limited
o Begins causal thinking
o Problem solving through trial and error
 Language
o Identifies five body parts when named
o Gives full name (first and last) if asked
o Uses appropriate pronoun when referring to self “I”
o Uses plurals and past tense of verbs
o Talks constantly
o Asks why
o Uses 4-5 word sentences
o About 75 % of vocalizations are intelligible
o Helps to put things away
o Pretends in play
 Motor play
o Pushes and steers toys well
o Needs:
 Large cars
 Trucks
 Cardboard boxes
 Block trains that interlock
 Carries breakable objects
 Creative play
o They need:
 Clay
 Finger paints
 Large crayons
 Large wooden puzzles
 Sand box toys
 String to string beads or lace large shoes
 Bright colored construction
 Paper to fold or cut with blunt scissors
 Quiet play
o Cloth or cardboard books
o Toys for water play

 Dramatic play
o Baby doll and doll equipment
o Toys for housekeeping such as small broom and dust cloth
o Play telephone
 The toddler’s curiosity may lead the child into danger for example:
o Motor vehicle accidents
o Bath tub drowning
o Hot fluid scalding
o Electric shock leading to death
o Poisonous substances can kill the toddler
o Drugs can also kill or overdose
o Kerosene can kill
o Try as much as possible that all these are out of reach of children
 A toddler is a child between 1 year and approximately 3 years

 Anterior fontanel is closed from 12-18 months
 A toddler can sing songs at 2 years
 Controls bowel at 26 months and urination at 30 months
 Relation of growth, development and accidental injury
o Increased mobility and ease of locomotion
o Improved fine motor control
o Heightened curiosity about the environment
o Increased sensitivity to the emotional climate of the home
 Define a toddler.
 Anterior fontanel is supposed to close at how many months?
 What is the psychosexual stage of a toddler?
 Mention the psychosocial stage of a toddler
 Mention the basic needs of a toddler.
 List common accidents which are likely to occur to toddlers.
References

Handout 6.1: The General Needs of a Toddler
 The basic needs of a toddler are:

o Love and security
o Discipline leading to self control
o Progression to independence
o Achievement of control of bodily functions
o Nutrition
o Accident prevention
 Love and security

o Parental love should be constant, unconditional and openly expressed even when the
child is misbehaving
o This type of love enables the toddler to grow and to reach out for more mature goals
since the child feels loved and secure, the frustrations everyone endures in the process
of maturation can be handled
o Both boys and girls give their first love to their primary caregiver usually the mother.
When the father gives the same care as the mother, the toddler generally feels
attached to and secure with both parents.
o Toddlers may develop separation anxiety if the primary caregiver leaves them alone
e.g. in a nursery school or hospital
o This is evidenced by:
 Restlessness
 Hyperactivity
 Depression manifested by crying and withdrawal
 Regression to earlier modes of behavior. (Regression is returning to an earlier or
former state or type of behavior.)
o The parents should understand that such behaviors are normal
o Toddlers who are attempting to achieve autonomy may become overwhelmed by
separation anxiety when the parents attention is diverted from them to a new sibling
or when they enter nursery school or are admitted to a hospital thus they regress
o They may return to earlier behaviors such as demanding to drink from a nursery
bottle, refusing to cooperate in toilet training and loosing the various skills that they
tried so hard to achieve
o The best way to handle a child’s regression is simply to ignore it.
 Discipline leading to self-control

o Proverbs 22: 6
“Teach a child to choose the right path and when he is older he will
remain upon it.”
o Discipline means establishing and adhering to standards of behavior for the toddler
with the goal of self-control
o It includes:
 Setting of limits (rules and guidelines)
 These must be set on the daily behavior of children if they feel secure

 Reinforcement of approved behavior by deepening this trusting bond between
parents and child is preferred over material rewards.
 Constructive discipline helps the child to better behaved and happier
 Qualities of constructive discipline

o Consistency
o Clarity
o Firmness-parents must mean what they say and say what they mean
o Immediacy
o Encouragement of independence
 Disciplinary action
o A loving reward is more consistently effective in disciplining a child than punitive
actions BUT:
o Punishment is a useful tool if used with discretion
o Punishment should be given privately and with respect
o Examples of punishment
 Physical punishment
 Explaining or reprimanding
 Disregarding or ignoring. This should be avoided if there is danger of physical
harm to the child
 Taking time out. This means that the child is removed from any positive
reinforcement when misbehavior occurs
o Instead of the parents giving a scolding or spanking for unwanted behavior, the child
is placed in a boring situation for a specified period of time. No playing is permitted
o This will be perceived as a punishment
o The toddler ultimately gives up the misbehavior in order to return to the family group
 Outcomes of discipline
o Parents must define reality for their children and through guidance and discipline,
help them in their striving for maturity
 Types of parents who fail in this period

o Those that are over demanding and insist upon perfection in behavior
o This causes intense anxiety and guilt in their children
o Those who set no limits or over permissive
o Those fail to provide security and help to their children to learn to live harmoniously
in society
o Those who provide inconsistent discipline
o These make their children to find difficulties to develop stable behavioral control and
values
o Among the procedures for discipline the safest is the use of time out or isolation
o Disciplinary action may sometimes be necessary but remember children still need
compassion, understanding and respect for their developing independence
 Dependence progressing to independence in self care

o By the time children reach 3 years of age they are beginning their journey to
independence in self care
o Children learn to care for themselves initially by attempting to imitate the actions of
their parents and siblings
o The achievements in self care includes:
 Feeding
 Dressing
 Toilet
 Grooming
 Achieving control of bodily functions

o Achieving control of bodily functions of defecation and urination is one of the major
tasks of the toddler period
o The relative importance of this achievement depends on the culture and the
socioeconomic status of the child’s family
o In some groups, toddlers do not wear nappies or pants and are permitted to move
through the home and environment excreting at will. In these families, toilet training
is not emphasized so the children in effect must train themselves.
 Process of toilet training

o The parents record the times the child eliminates for several days
o This record provides the toddlers own schedule for training that is when it is
appropriate to place the child on a comfortable child sized toilet sit or potty chair
o The potty chair should be used only in the toilet room or bathroom so that the act of
excretion is associated with this one location
o The parents take the child to the bathroom and calmly explain in simple language
what is to be done
o Specific words that are widely understood to indicate the acts of defecation and
urination are used
o The parents stay with the toddler during the entire process.
o Do not allow the child to play at this time
o The accidents that occur during the process of toilet training should be ignored
o A two year old toddler is generally toilet trained in the day time
o The 21/2 years old may have begun to master night time bladder control. However,
accidents are common.
o Night time bladder control may not be complete until the child is 4-5 years of age
 Fecal smearing
o This behavior occur between the ages 15-18 months
o The desire to smear may be sublimated by providing clay, damp sand, and mud
o Later, they may enjoy smearing with finger paints using bright light colors on large
sheets of paper
o After the child has learned to use potty chair, smearing is usually no longer a great
problem
 Developing self-esteem
o Self-esteem is a belief in oneself or self-respect
o Self-esteem is based on appraisals repeated several times
o Therefore, avoid shaming and ridicule
o A young child who is categorized as being “good” or “bad” usually lives up to the
appropriate expectation
o The child’s own effort also promotes or reduces self-esteem
o Patience and persistence are necessary in helping children develop self-esteem as they
become able to cope with life in their world
o Functions of play:
 Play during the toddler period stimulates all areas of growth and development
 The social importance of play increases as the child grows
 Active play encourages gross and fine muscle development. Surplus energy is
worked off.
 When playing besides and watching others, they seem to want to be friendly but at
this time their social skills are inadequate so adult supervision is necessary
 Play assist the toddler to fully develop the concept of object permanence
 They develop very early understanding of moral values
 They learn differentiate between right and wrong when they are taught not to hurt
others in play
 They develop language and speech when they talk to toys, pets, or others parents
 Reading and singing to child helps
 Negative feelings and tensions can be released in an approved way. Fpr example,
an angry child can find relief by pounding soft balls or begs through holes in a
board or tossing bean bags.
 Play responses
o In early toddler period play is free and spontaneous
o They are in most cases destructive
o They normally claim their own toys by saying “mine, mine”
o They learn sharing later
o Do not encourage them to give up their toy until later on.
 Safety and the care of playing things

o Toddlers need safe toys
o No sharp or rough edges or small removable parts
o No beads, marbles, or coins which could be swallowed or aspirated
o They should not be flammable
o They should not be coated with lead paint which can lead to lead poisoning
 Nutrition
o Nutritional intake include the essential nutrients in the amount necessary for
maintenance, replacement, and growth of tissue and for energy
o They are usually three well-spaced small meals with in-between nutritious snacks
each day
o Toddlers need less food per unit of body weight during the second year of life than
infants because the growth rate is less rapid
o At about 18 months, toddlers develop what is known as physiological anorexia
o If inadequate amounts of vitamins and minerals especially iron are not obtained in the
diet because of the anorexia, supplements can be prescribed
o Children may prefer playing than eating so take care of the meal times

 Accident prevention
o Accidents are the largest single cause of mortality and disability between the ages of
1-4 years
o Accidents include:
 Motor vehicle accidents
 Drowning
 Burns
 Suffocation
 Falls
 Poisoning
 Other injuries e.g. cuts
o When parents understand their child’s level of growth and development, they can
predict the hazardous situations that may result in an accident then judge how much
responsibility the child can assume for self-protection
o If the child is injured accidentally, point to the child the cause of the accident and it
will be a lesson to the child

Session 7: Average Achievements of a Preschooler
Prerequisites
 None
Student Learning Tasks

 Define a preschooler
 Describe the average achievement of a preschooler from 3 to 5 years
 Explain the general needs of a preschooler
Resources Needed
 PowerPoint projector
 computer
 Handout 7.1: General Needs of a Preschooler
SESSION OVERVIEW
Presentation of session title and

Brainstorm/
2 05 Minutes Definition of a preschooler
Presentation
Achievements of a preschooler 3
years
Achievements of a preschooler 4
years
5 30 Minutes Presentation Achievement of a preschooler 5 years
SESSION CONTENT

NTA Level 5, Semester 1 51 Session 7: Average Achievements of a
Preschooler
Step 2: Definition of a Preschooler (5 minutes)
ASK the students to brainstorm on definition of a preschooler
ALLOW few students to respond and let others to provide unmentioned responses
WRITE their responses on the flip chart/ board
CLARIFY and summarize using the content below
 A preschooler is a child from 3 -5 years
Step 3: Average Achievements of a three years preschooler (35 minutes)
 Physical or biologic
o Weight 12.5-16.5 kg (approximately)
o Height 90.5-1001 cm (gained 8 cm in 3rd year)
o Pulse 105+ 15 (average beats 95 beats /minute)
o Respirations 25+ 5/minute
o Blood pressure 10/65+24/25
o Motor walks a straight line
o Walks backwards
o Walks on tiptoes
o Runs without looking at feet
o Catches ball with extended arms
o Kicks a ball
o Jumps from height of several centimeters
o Rides tricycle using pedals, turns wide corners
o Builds a tower of 9-10 blocks
o Copies a circle
o Uses blunt scissors with one hand to cut
o Shows preference for handedness
o Puts beads on strings
o Can help with simple household tasks
 Self care
o Dressing skills
 Can put on a coat without assistance
 Can undress self in most instances
o Toileting and grooming
 Can pull pants up and down
 Can go to toilet alone
 Brushes teeth with help

Preschooler
 Psychosocial
o Beginning development of sense of initiative (3-5 years)
o Still egocentric in thought and behavior
o Alternates between reality and imagination
o Able to share but expresses idea of “mine”
o Less dependent on parents but needs reassurance and help
o Tolerates short separation from parents
o Fears the dark
o May have dreams and night mares
o Knows own sex
 Psychosexual
o Phallic stage (3-6 years)
 This is also known as the oedipal period (family romance)
 Childhood sexuality reaches a peak
 They grow more aware of their sex organs
 Boys and girls experience a period of initial attachment to the parents of opposite
sex and hostility towards the parent of the same sex
 Boys encounter the Oedipus complex in which they desire their mothers sexually
while experiencing an increased hostility towards their father
 The girls encounter what is known as the Electra complex in which they want
their fathers and find their mothers in the way
 The feelings may be hidden but sometimes they can speak it out by saying “I hate
you”
 Children have feelings of both love and hate at the same time to both parents
(Ambivalence)
 Channel the curiosity of the children to other direction such as other activities to
avoid masturbation because they discover that touching and manipulation of the
genitals result in a pleasurable sensation
 Spiritual development
o Intuitive–projective faith
 Children follow religion because it is expected of them
 They are influenced mostly by parents
 Intellectual or cognitive moral development (2-4 years)

o This is a period of language acquisition
o Egocentric and bases problem solution on only one aspect
o Tries to please and conforms to requests
o Characteristic of thought include animism and realism
o Able to follow directional commands
o Has a beginning of understanding of time
 Language
o Can obey two prepositional commands such as on or under
o Uses four word sentences
o Asks why
o Uses plurals
o Gives sex and full names
o Names figures in a picture
Preschooler
o Has vocabulary of 800-1000 words
o Child is intelligible 90% of time
o Like things that squish, move, talk make noise such as:
 Books about known things like animals, fruits, etc.
 Crayon paints, climbing apparatus, transportation toys, tricycle wagons, dump
trucks, doll carriage
 Play telephone, music, record player, and toy dishes
 Try to answer their questions relating to sex accurately according to age
 Train your child in your faith (religion)
 Never keep your children neutral
Step 4: Average Achievements of a 4 Years Preschooler (35 minutes)
 Physical
o Has gained 2.27 kg during the fourth year
o Height approximately 95-109 cm
o Has increased 8 cm in the 4th year
o Has doubled birth length
o Pulse 100+10 beats per minute
o Average 92 beats/minute
o Respirations 24+4/minute
o Blood pressure 100/66+ 20mm/hg
 Motor
o Runs on tip toes
o Balances on one foot 3-5 seconds
o Jumps from greater heights
o Pedal a tricycle quickly and can turn sharp corners
o Catches ball with extended arms and with hands
o Hops on preferred foot
o Climbs ladders, trees, playground equipment
o Alternates feet when descending stairs
o Copies a square
o Draws a simple face
o Cuts around pictures with scissors
 Self-care
o Manages spoon with little spilling
o Can eat with fork held in fingers
o Dressing skills
o Buttons side buttons and small buttons
o Can put on socks with help
o Put on shoes (not laces) without help
o Knows back from front of clothes

Preschooler
 Toilet and grooming skills
o May bath self with assistance
o Washes and dry hands without supervision
o Usually dry at night
 Psychosocial
o Sense of initiative (3-5 years)
 Egocentric-is unable to see other’s point of view and cant understand why others
don’t see children
 Tends to be impatient and selfish
 Usually separates easily from parents
 Physically and verbally aggressive
 Still have fears
 Dreams and night mares continues
 Sexually curious
 Demonstrates strong attachment for parents of opposite sex
 Jealousy of siblings may be evident
 More cooperative in play although remind others of ownership
 Psychosexual and spiritual (same as 3-6 years)
 Classifies objects according to one characteristic
 Not able to conserve matter
 Continue to believe that thoughts cause events
 Obeys because parents set limits, not because of understanding between right and
wrong
 Highly imaginative
 Concept of time improving especially in relation to sequence of daily routines
 Use alibis to excuse behavior
 Moral
o Preconventional morality (4-7 years)
o “You do it for me” “I’ll do it for you”
o Understands directives (on, under, in, back, front)
o Name one or more colors correctly
o Uses “I”
o Counts to five
o May use profanity for attention
o Uses 3-7 word sentence
o Has a vocabulary of 1500 words

o Plays cooperatively with others
o Interested in the world
o Provide:
 Hand puppet, dolls, blackboard, chalk, paper, scissors, clay, finger paints, swings,
work bench, blocks, garden toys to encourage imagination, creativity, and motor
activities
Preschooler
Step 5: Average Achievements of a 5 years Preschooler (30 minutes)
Physical
o Weight 15.4-21.4 kg
o Has gained 2.27 kg during the fifth year
o Height 103- 115 cm. Gained 8 cm in fifth year
o Pulse 95 + 15 (average 90 beats/ minute)
o Respiration 22 + 3/minute
o Head size-adult head size nearly reached
o Anticipates immediate toilet needs
 Motor
o Skips alternate feet
o Jumps rope and over objects
o Walks a balance beam
o Imitates dance steps, if taught
o Catches a ball smoothly with hands
o Balances on one foot 8-10 seconds
o Copies a triangle
o Crosses vertical lines
o Copies letters, may be able to print own name
o Draws a three part man
 Self-Care
o Feeding skills
 Select fork over spoon when appropriate
o Dressing skills
 May be able to lace shoes
 Manages zippers in back
o Toilets and grooming skills
 Wipes self independently
 Flushes toilet after each use
 Bathes self
 Combs hair with help
 Can blow nose when asked
 Psychosocial
o Sense of initiative (3-5 years)
 Continues to be egocentric
 Separates easily from parents
 Independent and trustworthy
 Has fantasies and day dreams
 Looks for parental encouragement and support
 Engages in cooperative play
 Very industrious
 Appropriately relates to adults outside family

Preschooler
 Psychosexual
o Phallic stage (3-6 years)
 Spiritual
o Intuitive–projective faith
 Preoperational thought
o Classifies objects according to relationships that are similar
o Accurately describes events
o Aware of cultural differences in others
o Has time orientation
o Improving using words with increased meaning
o Very curious
o Carries out instructions with three suggested tasks such as wash hands, dry them and
sit down
o Names primary colors
o Asks meaning of words
o Names penny, nickel, etc.
o Repeats sentences of 12 or more syllables
o Counts to 10
o Plays competitive exercise games
o Loves to transport things in trucks, cars, and wagons
o Therefore provide:
 Simple games for competitive and team play
 Jump rope for motor activity
 Constructive toys, paper dolls
 Opportunities for collecting nature specimens for creative activity
 Color sets, books, puzzles for quiet play
 Children at this stage have a sense of initiative psychosocially; they are in the phallic
stage psychosexually
 They need to go to nursery school
 They should continue to attend under five clinics for health supervision
Step 7: Evaluation 5 (minutes)
 Mention the needs of a preschooler

 Mention reasons why accidents are likely to occur at this period

Preschooler
References

Preschooler
Handout 7.1. Needs of a Preschooler
 Preschoolers have emotional social needs and physiologic biologic needs

 The needs are influenced by accomplishments during infancy and the toddler period
 Emotional Social Needs

o Love and security
 Love and security continues to be essential
 They begin to develop a preference for one parent
 Guidance
o Adults should respect the individuality of children and through guidance help them to
expand their skills, develop their potential and master self control
o Parents should set limits to children’s behaviors which give children a feeling of
security
o Suggestions, not commands, are made in positive form
o Commands are seldom necessary but are more effective when given in positive rather
than negative form
o Children are reassured when their parents help them to solve problems as they arise
o Give choices when possible
 Dependence progressing to independence

o They strive to become independent in self-care activities desiring to please their
parents and significant others
o They also have a sense of delight with each new skill
 Nursery school
o The schools offer for experimentation, exercising the imagination, creative activity,
problem solving, and socializing
o The schools also increase the capacity for independent action, self confidence, and
feelings of security in a variety of situations
 Separation
o Five year olds should be prepared to enter the world of their peers as well as
developing a sense of self as an individual
 Discipline leading to self control

o A positive approach to discipline involves reinforcement and consistency in the
socialization process of which the end goal for the child is self-control
 Problems which should be dealt with are:

o Bed time problem-sleep
 All children are likely to experience sleep problems
 Dreams or nightmares may be due to fairy tales or television
 Find the cause and deal with it accordingly

Preschooler
o Selfishness
 Children are not born with ability to share with others what is theirs
 Slowly they learn the joy of giving and of sharing with others
 Development of ownership is necessary before they can learn to be generous with
others
 Help children to learn to share with others
o Hurting others
 This can happen accidentally and therefore ignored
 The child who hurt the other purposely can be helped
 Identifying with the group, accepting them and being loved by them
 Physical outlets should be provided enabling the child to work off excess energy
and relieve feelings of frustration
 Praise should be given for achievements in the group and solitary play and for
those kind acts the child does for others
o Destructiveness
 Parents should learn to differentiate between accidental and intentional destruction
of objects that may value highly
 Accidental destruction may be due to:
 Boundless energy
 Endless curiosity
 To avoid accidental destruction:

o Remove valuable objects
o Provide space for the child to play without danger of breakage or harm to house
furnishings
o Children should be helped to direct their energy into appropriate activities
 Developing self esteem

o Preschoolers need to be encouraged to develop self esteem by family members,
teachers, and peer opinions regarding adequacies, acquisition of motor, language, and
self-care skills
Physiological- Biologic Needs

 Control of bodily functions
o By the end of the preschool period children are adequately independent in toileting
skills
o Accidents may still happen during periods of stress or illness or if children are
involved in play activities
o The child may be helped by giving less fluid in the evening
o If there is no physiologic cause and the child continues to have uncontrolled stool
passage beyond the time the bowel control is expected about 3-4 years, the child is
said to have encopresis (incontinence of feces)
o The general causes of enuresis and encopresis may be:
 Too rigid toilet training
 Too early training
 Overtraining
 Lack of training
 An organic problem such as diarrhea or megacolon
 Poor parent child relationship
o Parents should find the cause and deal with it accordingly
Preschooler
 Health Promotion and Anticipatory Guidance
o Nutrition
 Preschoolers enjoy five meals a day to keep up with energy demands
 Take care of the child’s likes and dislikes
o Accident prevention
o Some reasons why accidents occur at this stage are:
 Children explore outside the home and into the neighborhood
 They play with peers
 Rides bicycles
 Play activities become rougher
 Forgets rules for safety at the height of play
o Therefore:
 Adults (parents) should discuss with children safety in the home and at play
 Discuss about fire prevention
 Teach how to roll on the ground to smoother flames should their clothes catch fire
 If they participate in water activities swimming lessons should be provided
 Teach safety when crossing streets
 Parents should know where their children play and the potential dangers in the
neighborhood
 Health supervision
o Is by a physician or nurse.
 Therefore parents should be encouraged to continue to bring their preschoolers to
the under fives clinic
o Parent education
 Health care providers should share information on the developmental needs of the
preschooler so that parents can use the information in care giving and supervision

Preschooler
Session 8: Developmental Achievements of School
Aged Children
Prerequisites
 None
Learning Tasks
 Define a school child
 Describe the average achievement of a school child from 6 to12 years
 Explain the roles of parents in school aged children
Resources Needed
 Black/white board
 Flipcharts
 Marker
 Computer/lap top and LCD
Handout 8.1.: Roles of Parents in School aged Children
SESSION OVERVIEW

Presentation of The Session Title and
2 05 Minutes Presentation Definition of A School Child
Brainstorm/ Achievements of A School Child 6-8
3 35 Minutes
Presentation Years
Achievements of A School Child 8-10
Years
Achievement of A School Child 10-
12 Years
SESSION CONTENT
READ or ASK student to read the Learning task and clarify

NTA Level 5, Semester 1 61 Session 8: Developmental Achievements of
School Aged Children
Step 2: Definition of a School Child (5 minutes)
A school child is a child from 6-12 years of age
Step 3: Average achievements of a 6-8 years school child (35 minutes)
ASK student to brainstorm on the average achievements of a six to 8 years scholar
ALLOW the students to contribute to the presentation
 Physical
o Weight: Approximately 17.5-25.5 kg
o Gains 3.8 kg yearly
o Height 110-124 cm. Gains 1.13 cm yearly
o Pulse 90 +15 beats/minute
o Respiration 21 +3/minute
o Blood pressure 100/60 +16/10mm/hg
o Dentition: Starts to loose temporary teeth
o Acquires 1st permanent molars, medial incisors, lateral incisors
o Tires easily
 Motor
o Rides bicycle without training wheels
o Runs, jumps, climbs hops
o Constantly in motion
o Clumsy and awkward
o Eye-hand coordination improving
o Knows right from left hand
o Draws a person with 12-16 parts
o Prints words
 Self-care skills
o Feeding skills
 Like to eat with fingers
 Stuffs food into the mouth
 Talkative while eating
 More interested in eating at beginning of meal
 At 7 years, has improved table manners, less talking, may bolt food (gulp un-
chewed food)
o Grooming and dressing skills
 Self-care managed
 Has a tendency to dawdle in bathtub
 Needs to be reminded to wash hands
 May need some help with dressing
 Wears whatever is selected by parents

 Leaves clothes where they are removed
 Can brush and comb hair
 Psychosocial
o Beginning of development of sense of industry (6-12 years)
o Sense of industry versus inferiority
o Continuous to be egocentric
o Bossy
o Has a “know it all” attitude
o Craves attention
o Insists on being first in everything
o Returns to temper - may use verbal, physical attack
o Uses tensional releases
o Wiggling, chewing on hair and nose picking
o Has good days and bad days
o Wants other children to play with
o Jealous of siblings
o Fear injury to body
 Psychosexual
o Latency stage (6-12 years)
 Spiritual
o Mythical - literal faith
 Preoperational thought
o Attention span increasing
o Can describe objects in picture and knows their use
o Concept of cause and effect developing
o Can see differences more than similarities
o Can tell time
o Knows date month and season
o Is learning to read
o Follows rules to avoid punishment
o Takes small objects from others
 Moral
o Conventional Morality (7-9 years)
o “Am I a good person?”
 Perceptive language
o Follow series of 3 commands
o Response depends on mood
o Responds to praise and recognition
o Can repeat sentences of 10-12 words
o Uses all forms of sentence structure
o Knows number combination up to 10
o Develops a sense of humor
o Enjoys telling jokes
o Likes rough and tumble play
o Loves active play
o Prefers group play
o Adults influence present
o Doll play at a height
o Provide:
 Table games
 Board games for competitive and team play
 Bicycle jump ropes, punching bags
 Balls dolls, clay, musical instruments, books
Step 4: Average Achievements of 8-10 years School child (35 minutes)
 Physical
o Weight 22-32 kg - Gains 3.8 kg yearly
o Height approximately 121.5-136.5 cm.
o Respiration 20 + 3/minute
 Motor
o Performs tricks on bicycle races
o Begins to participate in organized sports
o Likes football or netball
o Throws a ball skillfully
o Uses both hands independently
o Prints fluently, writing improved
 Self-care
o Feeding
o Handles eating utensils skillfully
o Dresses self completely
o Enjoys selecting own clothes
o Unaware of dirty clothes
o Needs to be reminded to brush teeth
o Visual acuity 20/20 (This is adult value and it is from 3 years)
 Psychosocial
o Sense of industry (6-12 years))
o Is ready for anything
o Curious about everything
o Concerned about relationship with others
o Becoming peer oriented
o Easy to get along with at home
o Begins hero worship

o Considers peer opinions more important than parents
o Enjoys running errands helping when mother is busy
o Relation with sibling improved
o Have fears that are reasonable
o Aware of appropriate sexual role
 Psychosexual
 Spiritual
o Mythical - literal
 Concrete operational thought

o Shows interest in causal relationship
o Understands explanations and tries to follow through
o Ashamed of failures
o Interested in school work
o Memory span increasing
o Is usually punctual
o Rebels against authority - may complain or withdraw
o Makes alibis for own fault
 Moral
o “We need law and order”
o Follow suggestions better than commands
o Is gregarious (fond of company)
o Begins to use shorter and more compact sentences
o Prefers companionship in play
o Likes to compete
o Continue to require supervision in play as fights may occur
o Enjoys dramatic play
o Hobbies begin to develop
o Enjoys making things
o Toys/activities as for 6-8 years

Step 5: Average Achievements of a 10-12years School child (30 minutes)
ACTIVITY: Group Discussion (15 minutes)
ASK a group of student who has assessed a ten to 12 years school child to present
ALLOW the other students to contribute to the presentation
FACILITATE a brief discussion and then
 A ten years school child

 Gains 3.8 kg yearly
o Pulse
 10 years 90+20 beats per minute
o Respiration 19 + 3 per minute
o Blood pressure
 10 years 109/58 + 16/10 mm/hg
 A twelve years school child

o Weight
 Boys 30-48 kg
 Girls 30-50 kg
o Height
 Boys 142-158 cm
 Girls 144-160 cm
o Pulse - 12 years
 Boys 90 + 20 beats/minute
 Girls 88 + 20 beats/minute
o Blood pressure - 12 years
 113/58 + 18/10 mm/hg
 Dentition
o Acquires canines (cuspids)
o First and second premolars
o Secondary sex characteristics may begin to develop
 Motor
o Enjoys physical activities
 Self-care
o Feeding skills
 Criticizes table manners of parents
o Dressing and grooming skills
 May wear some clothes continually
 Leaves clothes where they fall
 Enjoys wearing current styles of clothes

 Needs constant reminding of personal hygiene (10 years)
 Bathes frequently–prefers showers (12 years)
 Psychosocial
o Sense of industry (6-12 years) that is doing purposeful activity-useful work
o Congenial, sincere, and confident
o Has greater self-control
o Respects parents and their role
o Have short bursts of anger (10 years)
o Able to control anger (12 years)
o Joins groups–formal and informal
o Hero worship of adult continues
o Still fears the dark
o Knows about sexual intercourse
 Psychosexual
 Spiritual
o Mythical – literal faith
 Intellectual or cognitive
o Formal operational thought
o 11 years–adulthood
o Uses problem solving method
o Interested in the why and how
o Short interest span
o Collects facts for future use
o Begins to think about vocation
o Preoccupied with right and wrong
o Ethical sense more realistic than idealistic (12 years)
 Moral
o Conventional morality (10-12 years)
o Follow suggestions better than requests
o Is obedient
o Oral vocabulary 7200 words
o Reading vocabulary 50,000 words
o Uses part of speech correctly
o Able to give precise dictionary definition of words
o Uses numbers beyond 100 with meaning
o Enjoys riddles

o 10 years enjoys large muscle activity and outdoor activities such as:
 Bicycle riding
 Reading
 Collecting
 Construction
o 12 years enjoys
 Parties with supervision
 Athletic sports
 Reading mystery and love stories
 Talking on telephone
o Parents less involved with providing toys and play equipment
o Difference in sex noticed in plan
 A school child has a sense of industry so should be guided to be useful in the family
 School children should be given time for organized play which should be guided
 Secondary sexual characteristics can occur by age 12 years especially in girls. Adults
should teach them what to expect and what to do at that time.
 Adults should know their children friends and what type of material they are reading or
watching
 Explain the role of parents in school children

 List the main topics to be included in giving health education to school children
References

Handout 8.1: Roles of Adults in School Children
 Roles are as follows:
o Teach children the rules of safety to crossing street, play in water and correct use of
matches
o Assist in learning the rules of organized sports
o Help the child learn to work e.g. assisting with duties in and around the house
o This takes parent’s time but help children to develop their sense of industry
o Help them to decide what they would like to do and how they can get started with the
money if they have earned
o The attitude they develop towards work in these early years will influence how they
view work as adults.
 Health promotion and anticipatory guidance

o The health of the school child is influenced by the health supervision received from
parent specifically
o The parents are still responsible for information giving and explaining physiologic
changes that occur during school years and also do all the health teaching.
o It is good to do a preschool health examination with the purpose to identify whether
there are any physical problems which need correct or if any treatment is needed
o Dental examination is important to preserve the permanent teeth
 School health program

o This is an important part in the National Health programs
o Purpose is to maintain, improve and promote the health of every school child
o This includes:
 Nutrition
 Recreation and physical education
o Preventive services which includes:
 Tooth decay and dental carries
 Accidents
 Eyes
 Poor nutrition
 Infectious diseases
 Unhygienic environment
 Insufficient care after illness
 Drug addiction
 Emotional disorders
 Areas of health education

o Nutrition
 Because these children are busy with school and other activities, they may forget
to eat
 Breakfast is crucial to perform in school and after school snacks are needed to
supplement energy needs
 Good eating habits and table manners are learned largely through imitation of
adults in the child’s environment

 A friendly atmosphere and enjoyment of the meal are the best aids to stimulate
appetite
 School children have well-defined food preferences and dislikes
 They prefer large amounts of sugar and starches while avoiding vegetables and
protein foods
 This may result into obesity. If they hate obesity, they may end up in anorexia
nervosa and bulimia.
 Dental health
o Provide foods with adequate fluoride, Vitamin A and D, calcium, ascorbic acid and
phosphorus
o Avoid raw sugar and candies
 Sleep and rest

o They experience night terrors or nightmares which prevent peaceful sleep
o Therefore, sleeping time should be made as quiet as possible and a prayer should be
said as it happens in many families
o Parents must ensure that children get sufficient sleep
o 6 years: 11-12 hours sleep
o 12 years: 10 hours sleep
 Activities
o Activities of children must be known and controlled
 Common accidents
o Motor vehicle
o Drowning
o Children should be reminded of these accidents every time so that they can take extra
care
 Sex education
o Older school children, both girls and boys, need to be told about physical changes
they will experience at puberty so that they may not be terrified when they occur
 Prevention of sexual molestation

o Children must understand about the existence of sexual molestation
o Children should be aware of the undesirability of accepting favors from and
accompanying strangers
o They should be told to avoid adults who want to befriend them
o They should be taught to report unusual occurrences with other people to parents
 Smoking and drugs

o Education in relation to smoking tobacco and drug abuse should be taught to school
children
o The main aim is to teach them the dangers and how to stop from smoking and using
abusive drugs thus prevention

Session 9: Developmental Achievements in Adolescents
Prerequisites
 None
Learning Tasks
 Define an adolescence
 Describe the average achievement of adolescence
 Explain the general physical changes of adolescence
 Explain the roles of parents in adolescence
Resources Needed
 Projector
 computer
Handout 9.1.: Roles of Parents in adolescents
SESSION OVERVIEW
Step Time Activity/method Content
Presentation of Session Title and
Brainstorm/
2 10 Minutes Definition of An Adolescent
Presentation
Achievements of Early Adolescence
12-13 Years
Achievements of Middle Adolescence
14-16 Years
Achievements of Late Adolescence17-
21 Years
SESSION CONTENT

NTA Level 5, Semester 1 71 Session 9: Developmental Achievements in
Adolescents
Step 2: Definition of Adolescence (10 Minutes)
ASK students to brainstorm on definition of an adolescent
ALLOW few students to respond and let others provide unmentioned responses.
WRITE the responses on the flip chart or board
An adolescent is a child who is in a period between puberty and maturity, normally ranging
from 12-21 years. Because the onset of puberty and maturity is a gradual process and varies
among individuals, it is not practical to set exact age or chronological limits in defining the
adolescent period.
Step 3: Achievements in Early Adolescence 12-13 years (30 minutes)
 Physical or biological
o Weight
 Male approximately 38-60 kg
 Female approximately 40-60 kg
o Height
 Male approximately 154-172 cm
 Female approximately 152-167 cm
o Pulse 65 + 8 beats /minute
o Respirations 19 + 3/minute
o Blood pressure
 Male 114/68 + 10/14 mm/hg
 Female 112/66 + 10/12 mm/hg
 Dentition
o Eruption of second molars 12-13 years
o Secondary sex characteristics develop
 Motor
o Clumsiness occurs due to rapid physical growth
o Motor function comparable to adult
o Eye-hand coordination at adult level
o Possesses manual dexterity
 Psychosocial
o Beginning of development of sense of identity (at 13-18 years start to ask “who am
I?”)
o Negative counterpart: self-diffusion
o Egocentric world centers on child
o Has intense loyalty to peer groups
o Shows mood swings and extremes of behavior
Adolescents
o Experiences sense of loss as begins to separate from parents
o Day dreams over heroes
o Continuous same-sex friendships
 Psychosexual
o Genital stage
o Masturbation occurs
 Spiritual
o Synthetic - conventional faith
 Intellectual or cognitive moral development

o Formal operational thought (11 years-adulthood)
o Generates hypothesis
o Uses the scientific method for problem-solving
 Moral
o Post conventional stage (13+ years)
o The individual conforms to maintain others respect
 Language, speech development

o Uses slang within and outside peer group
o Uses distinct meanings for words

o Recreational activities
o Chooses activities according to interests
o Parties, conversations, helping others, interest in world affairs, hobbies, crafts, social
drinking and drugs
Step 4: Achievements in Middle Adolescence 14-16 Years (25 minutes)
 Physical
o Weight: Intensified appetite related to accelerated growth
 Male approximately 50-60 kg
 Female approximately 42-64 kg
o Blood pressure
 Male 116/70 + 12/14 mm/hg
 Female 114/70 + 14/12 mm/hg
 Motor and Self-Care

o Motor function same as adults
o Eye-hand coordination at adult level
o Possesses manual dexterity
 Psychosocial
o Sense of identity (13-18 years)
 “WHO AM I” versus self-diffusion
 Egocentrism diminishes

Adolescents
 Separation from parents continues
 Heterosexual relationships and interest common
 Verbally attacks parents’ beliefs and values.
 Psychosexual
o Genital stage
 Spiritual
o Synthetic – conventional faith

o Expresses concern for education versus vocational choice
o Engages in organized competitive play such as football or netball
Step 5: Achievements in Late Adolescence 17-21 years (20 minutes)
 Physical
o Weight:
 Male-approximately 56-80 kg
 Female-approximately 48-72 kg
o Height
 Male-approximately 163-182 cm
 Female-approximately 156-170 cm
o Respiration 17 +3/minute
 Dentition
o Eruption of 3rd molar (wisdom teeth) 17-21 years
 Motor and self-care

o As adults
 Psychosocial
o Sense of identity
o Sense of intimacy versus isolation
o Severs ties with parents
o Establishes interdependent relationship with parents
o Have fewer but closer friends
o Heterosexual relationships are the rule
 Psychosexual
o Genital stage
 Spiritual
o Individuating - reflecting faith

Adolescents
o Pursues further education or enters the job market
 Moral
o Orientation toward decisions of conscience
o Universal ethical principles
 Recreational activities
o Chooses more passive spectator sports
Step 6: General Physical Changes of Adolescence (20 minutes)
 In boys:
o Increase in the size of the genitalia
o Swelling of the breasts
o Growth of pubic, axiliary, facial and chest hair
o Voice changes
o Production of spermatozoa
o Shoulder broadening (about the age of 13 years)
o They can be disturbed by nocturnal emissions and the loss of seminal fluid during
sleep
o They should be told that this is normal as it is due to the activity of the sexual glands
and occasional release of spermatic fluid during sleep so should cause no concern.
 In girls:
o Increase in the transverse diameter of the pelvis
o Development of the breasts
o Changes in the vaginal secretions
o Growth of pubic and axillary hair
o Menstruation begins between the appearance of pubic hair and that of axillary hair
o Average age of menarche (first menstrual period) is 12.5-12.8 years
o Girls’ hips begin to broaden from about the age of 12 years
o Before puberty and adolescence, children should be well-oriented to the anatomic and
functional differences between sexes
o Girls should have a clear understanding of:
 Ovulation
 Menstruation
 Fertilization
 Pregnancy
 Childbirth
 Adolescents are in the genital stage psychosexually

 In relation to adolescents, boys and girls should be taught to say “no” in order to prevent
them from sexual transmitted diseases including HIV/AIDS and adolescent pregnancy
 The recommended method of contraception is abstinence and if they find this impossible,
they should be advised to use condom

Adolescents
 Explain the physical changes that can observed on a female in middle adolescence
 Explain the physical changes that can be observed on a male in late adolescence
 List 4 major roles of parents in adolescent
References

Adolescents
Handout 9.1.: Parents Role in Adolescents
 Nutrition
o They need extra 12-14% of the recommended basic requirements due to the dramatic
growth and development
 Accident prevention
o Motor vehicle accidents are the leading cause of death in the adolescent years
o Adolescents must be taught to discipline themselves to become safe drivers to save
their own lives as well as those of others
o Accidents are due to young drivers who use alcohol, bhang and other addictive drugs
while driving
 Prevention of addictive behavior

o Parents and health care givers must make information available concerning the risk in
using addictive substances
 Sex education
o Most parents don’t have the knowledge of what to teach their children as far as the
subject is concerned so the nurse should be in a position to answer any questions
adolescents may wish to ask or discuss
o The nurse is one of the most likely adult outside the home to be asked about sex by
adolescents
o Nurses are known to be non-judgmental and have no disciplinary role as teachers
o Inform adolescents about sexually transmitted diseases, recognizable symptoms,
treatments, and the follow up of contacts and prevention
o Inform them of their rights of using family planning services with no need of parent
consent and that this is given with high confidentiality
o In all aspects of contraceptive counseling, adolescents must be assisted in choosing a
method that is not only safe and effective but also one they can be comfortable with
for a long period of time
o The best method for adolescents is abstinence and condom
o They should be taught to be able to say “NO”
o Adolescent girls should learn to examine their breasts monthly during the week
following menstruation
o If a young woman learns how her breasts look and feel like in their normal state, she
should be able to recognize easily a thickening or a lump
o Parents should stress that menstruation is a normal phenomenon
o Pimples may occur if the pores of sebaceous glands of the back, chest and face are too
small for the sebaceous material to escape
o Heart and lungs grow more slowly leading to feeling of constantly tired
o Usually by 15-16 years, the secondary sex characteristics have developed fully and
adolescents are capable of reproduction
o During the first year of menstruation, periods are frequently missed or are irregular
o Adolescent boys should be taught to examine their testicles monthly to screen for
lumps

Adolescents
o The examination should be done after a warm bath when the scrotal skin is more
relaxed
o By incorporating concepts of nutrition, environment, genetics and human growth, and
development, children and adolescents should develop awareness and acquire
knowledge about parenting and all its responsibilities

Adolescents
Session 10: Common Cold and Bronchitis
Total Session Time: 120 minutes
Prerequisite
 None
Learning Tasks
 Define common cold and bronchitis
 List the causative organisms of common cold and bronchitis
 State the diagnosis of common cold and bronchitis
 Explain the signs and symptoms of common cold and bronchitis
 Describe the Nursing care and management of a child with common cold and bronchitis
 Explain the preventive measures of common cold and bronchitis
Resources Needed
 Projector
 computer
SESSION OVERVIEW
Presentation/ Definition and Causative Organism of
2 15 Minutes
Brainstorm Common Cold
Signs, Symptoms and Diagnosis of
Common Cold
Nursing Care Management and
prevention of Common Cold
Definition and causative organisms of
Bronchitis
Buzz/Lecture/ Signs, Symptoms and Diagnosis of
6 15 Minutes
Discussion Bronchitis
Nursing Care Management and
Prevention of Bronchitis
8 20 Minutes Presentation Chronic Bronchitis

SESSION CONTENT
Step 1: Presentation of session title and Student Learning Tasks
(5 minutes)
Step 2: Definition and Causative Organisms of Common Cold (15 minutes)
ACTIVITY: Brain storming (5 minutes)
ASK students to brainstorm on definition of common cold
ALLOW few students to respond and let others provide unmentioned responses
Common cold is an acute virus infection of nasal and pharyngeal mucosa.
Causative organism
 Most colds are caused by:
o rhinovirus
o adenovirus
o corona virus
o coxsackie viruses
o Influenza viruses or respiratory syncytial viruses
Step 3: Signs, Symptoms and Diagnosis of Common Cold (15 minutes)
 Sneezing
 Watery purulent nasal discharge
 Sore throat
 Coughing
 Sometimes fever
 Nasal discharge due to a cold may be serious in young babies because they cannot breathe
through the mouth
 Sometimes infection spreads to the bronchi causing bronchitis or bronchiolitis in infants
or even in the alveoli causing pneumonia
 Secondary bacterial infection can occur
 Diagnosis of common cold is through signs and symptoms

Step 4: Nursing Care management and Prevention of Common cold
(10 minutes)
 Clean the nose with a piece of cloth

 If blockage of the nose interferes with suckling or drinking
 Give ephedrine 0.5 % nose drops. One in each nostril t.i.d for 5 days
 Do not give antibiotics to prevent resistance among bacterial flora as it does not kill the
virus
 Prevent exposure from dust, fumes and cold weather.
Step 5: Definition and Causative Organisms of Bronchitis (15 minutes)
Definition
Bronchitis is inflammation of the mucous membrane of the bronchial airways caused by
irritation or infection or both, by pathogen. It can be acute or chronic.
Causative organisms:
 Virus
 Mycoplasma
 Chlamydia
 Streptococcus
 Haemophillus
 Staphylococcus
 It may be caused by exposure to various physical and chemical agents such as dust,
fumes, and pollens
 Allergens and pre-existing conditions such as asthma or chronic obstructive lung disease
may be important co-factors
Step 6: Signs, Symptoms and Diagnosis of Bronchitis (15 minutes)
ASK the students what are the clinical manifestation of bronchitis
ALLOW students to respond and write their responses on board or flip chart
CLARIFY and summarize by using the information below
 Fever
 Barking cough (hard and later become bubby and productive)
 Cough is worse at night when is lying down
 Some audible whistles and wheezes
 No obstructive symptoms
 The condition clears up rapidly but in malnourished children it may persist
Diagnosis
 Diagnosis is through signs and symptoms
 X-ray chest
Step 7: Nursing Care Management and Prevention of Bronchitis
(15 minutes)
 Give bed rest to the child

 Ensure a clear airway by suction if there is blockage by mucus
 Increase fluid intake
 Give prescribed antipyretics and analgesic
 Antibiotic is given if the cough persists for more than 10 days or if the child begins to
cough up yellow purulent sputum or there is associated malnutrition or anemia
 Avoid any allergens and any other irritants
Step 8: Chronic Bronchitis (20 minutes)
 This normally follows after an infection such as whooping cough or bronchopneumonia

 The walls of the bronchi may become weakened especially if the lung tissue beyond is
collapsed and the bronchi dilate: a condition known as bronchiectasis
 The condition is suspected after a severe respiratory infection or whooping cough or
sometimes after the removal of a foreign body from the bronchial tree.
 If the cough persists with the production of a lot of purulent yellow sputum sometimes
blood stained
 The cough usually is worse when lying down at night
Diagnosis
 History
 Signs and symptoms
 Chest X-ray to rule out tuberculosis or lung abscess
Treatment
 Treatment is like any other upper respiratory tract infection
 Antibiotics should only be used if the condition persists and the child begins to cough up
yellow purulent sputum or there is associated malnutrition or anemia
 Common cold is an acute virus infection of nasal and pharyngeal mucosa

 There five signs and symptoms of common cold namely Sneezing, Watery purulent nasal
discharge, a sore throat, coughing, and fever
 There are two types of bronchitis namely acute and chronic bronchitis
 Chronic bronchitis normally follows after an infection such as whooping cough or
bronchopneumonia

 What is common cold
 Mention the causative organism of common cold
 Explain the nursing care and management of common cold
 List the signs and symptom of acute bronchitis
 Explain the nursing care and management of chronic bronchitis

References
Bunker Rosdahl, C. (1999). Textbook of basic nursing (7th ed.). Philadelphia: Lippincott.
Fraser D. M., & Cooper M. A. (2003). Myles’ textbook for midwives (14th ed.). St. Louis:
Churchill Livingstone.

Session 11: Pneumonia
Prerequisites
 None

 Define Pneumonia
 List the causes of Pneumonia
 Identify the common signs and symptoms of Pneumonia
 Explain the classification of Pneumonia
 Explain the nursing care and management of a child with Pneumonia
 Explain the preventive measures of Pneumonia
Resources Needed
 Projector
 computer
SESSION OVERVIEW
Presentation/ Definition and causative organisms of
2 15 Minutes
Brainstorm Pneumonia
3 10 Minutes Presentation Classification of Pneumonia
4 15 Minutes Presentation Non Severe Pneumonia
5 30 minutes Presentation Severe Pneumonia
6 25 minutes Presentation Very Severe Pneumonia
7 05 Minutes Presentation Complications of Pneumonia
8 05 Minutes Presentation Prevention of Pneumonia

SESSION CONTENT
Step 2: Definition and Causative Organisms of Pneumonia

(15 minutes)
ASK students to brainstorm on definition of Pneumonia
Definition
 Is an infection or inflammation of the lungs involving not only the bronchi but also the
alveoli.
 May occur as a primary disease, as a complication of other diseases, or by aspiration of a
foreign body
 Causative organisms
o Neonates
 Group B Streptococci
 Gram negative enteric bacteria-E.Coli
o Infants
 Respiratory Syncytial Virus (RSC)
 Parainfluenza and Influenza virus
 Streptococci pneumoniae
 Staphylococcus aureus
 Haemophilus influenza
 Mycobacterium tuberculosis
o Preschool Children
 Streptococci pneumoniae
 Staphylococcus aureus
 Haemophilus influenza
 Mycobacterium tuberculosis
 Respiratory Syncytial Virus (RSC)
 Parainfluenza and Influenza virus

o School aged children
 Chlamydia Pneumoniae
 Mycoplasma pneumonia
 Respiratory viruses
 Mycobacterium Tuberculosis
o Causative organisms in immunosuppressed children
 Chlamydia trachomatis
 Pneumocystis Jirovecii
Step 3: Classification of Pneumonia (10 minutes)
 Pneumonia can be classified due to severity as:

o Non severe
o Severe
o Very severe
 Infectious pneumonia is classified in anatomical distribution as:

o Lobar
o Lobular pneumonia/bronchopneumonia
o Interstitial pneumonia
 Can also be classified according to causative organism:

o Viral pneumonia
o Bacteria such as:
 Pneumococci - Pneumococcal pneumonia
 Streptococci - Streptococcal pneumonia
 Staphylococci - Staphylococcal pneumonia
Step 4: Non Severe Pneumonia (15 minutes)
 Signs and symptoms

o Cough
o Difficult breathing
o Fast breathing
 Age <2 months: >60/minute
 Age 2-12 months: > 50/minute
 Age 12 months to 5 years: > 40/minute
o Other signs on auscultation
 Crackles
 Reduced breath sounds or an area of bronchial breathing
 Treatment
o The child is treated as an outpatient with:
 Amoxicillin (25 mg/kg 2 times a day) for 5 days
 Give the first dose at the clinic and teach the mother how to give the other doses at
home

 Follow-up
o Encourage the mother to feed the child.
o Advise her to bring the child back after two days or earlier if the child becomes more
sick or is not able to drink or breastfeed
 When the child returns

o If the breathing has improved (slower), there is less fever, and the child is eating
better, complete the five days of antibiotic treatment
o If the breathing rate, fever, and eating have not improved, change to the second-line
antibiotic and advise the mother to return again in two days
o If there are signs of severe or very severe pneumonia, admit the child to hospital and
treat according to the guidelines
Step 5: Severe Pneumonia (30 minutes)

Signs and Symptoms
o Cough
o Difficult breathing
o Fast breathing
o Plus one of the following signs:
 Lower chest wall indrawing
 Grunting in young infants
Chest auscultation signs

o Decreased breath sounds
o Bronchial breath sounds
o Crackles
o Abnormal vocal resonance (decreased over a pleural effusion, increased over lobar
consolidation)
o Pleural rub
 Exclude signs of very severe pneumonia such as:

o Central cyanosis
o Inability to breastfeed or drink
o Vomiting everything
o Convulsions, lethargy or unconsciousness
o Severe respiratory distress
 Nursing Care Management

o Admit or refer the child to hospital
o Antibiotic therapy
 Benzylpenicillin (50000 units/kg IM or IV every 6 hours) for at least 3 days.
 When the child improves, switch to oral amoxicillin (15 mg/kg 3 times a day)
o The total cause of treatment is 5 days
o If the child does not improve within 48 hours or deteriorates, switch to
chloramphenical (25 mg/kg every 8 hours IM or IV) until the child has improved.
o Continue the treatment orally for a total course of 10 days
o Oxygen therapy
 If readily available, give oxygen to any child with severe lower chest wall
indrawing or a respiratory rate of > 70/ minute
o Supportive care
 If the child has fever (> 39° C) which appears to be causing distress, give
paracetamol.
 If wheeze is present, give a rapid-acting bronchodilator
 Remove by gentle suction any thick secretions in the throat which the child cannot
clear
 Ensure that the child receives daily maintenance fluids appropriate for the child’s
age but avoid over hydration
 Encourage breastfeeding and oral fluids
 If the child cannot drink, insert a nasogastric tube and give maintenance fluids in
frequent small amounts
 If the child is taking fluids adequately by mouth, do not use a nasogastric tube as
it increases the risk of aspiration pneumonia
 If oxygen is given by nasopharyngeal catheter at the same time as nasogastric
fluids, pass both tubes through the same nostril
 Encourage the child to eat as soon as food can be taken.
 Monitoring
o The child should be checked by nurses at least every 6 hours
o The child should be checked by a doctor at least once a day
o Check and record vital signs
o Note the child’s level of consciousness
o Check the child’s ability to breastfeed or drink
o In the absence of complications, within 2 days there should be signs of improvement
that is:
 Slower breathing
 Less chest indrawing
 Less fever
 Improved ability to eat and drink
Step 6: Very Severe Pneumonia (25 minutes)
 Signs and symptoms

o Cough or difficult breathing
o Fast breathing:
o Lower chest indrawing
o Plus at least one of the following:
 Central cyanosis
 Inability to breastfeed or drink or vomiting everything
 Convulsion, lethargy or unconsciousness
 Severe respiratory distress (head nodding)
o Chest auscultation signs are:
 Decreased breath sounds
 Bronchial breath sounds
 Crackles
 Abnormal vocal resonance
 Pleural rub
o If possible take chest X-ray to identify:
 Pleural effusion
 Empyema
 Pneumothorax,
 Pneumatocele
 Interstitial pneumonia
 Pericardial effuse
 Treatment
o Admit the child
o Give Antibiotic therapy
 Chloramphenicol (25 mg/kg IM or IV every 8 hours) until the child has improved
 Then continue orally 3 times a day for a total course of 10 days
 If chloramphenical is not available, give benzylpenicillin (50 000 units/kg IM or
IV every 6 hours) and Gentamycin (7.5 mg/kg IM once a day) for 10 days
 If the child does not improve within 48 hours:
 Switch to Gentamycin (7.5 mg/kg IM once a day) and cloxacillin (50 mg/kg
IM or IV every 6 hours
 When the child improves, continue cloxacillin (or dicloxacillin) orally for a total
course of 3 weeks
o Oxygen therapy
 Give oxygen to all children with severe pneumonia
 Continue with oxygen therapy until the signs of hypoxia such as chest indrawing,
breathing rate of > 70/minute, head nodding or cyanosis are no longer present
 The nurse should check every 3 hours that the catheters are not blocked with
mucus and are in the correct place and that all connections are secure
o Supportive care
 If the child has fever (> 39° C) which appears to be causing distress, give
paracetamol.
 If wheeze is present, give a rapid-acting bronchodilator
 Remove by gentle suction any thick secretions in the throat which the child cannot
clear
 Ensure that the child receives daily maintenance fluids appropriate for the child’s
age but avoid over hydration
 Encourage breastfeeding and oral fluids
 If the child cannot drink, insert a nasogastric tube and give maintenance fluids in
frequent small amounts.
 If the child is taking fluids adequately by mouth, do not use a nasogastric tube as
it increases the risk of aspiration pneumonia
 If oxygen is given by nasopharyngeal catheter at the same time as nasogastric
fluids, pass both tubes through the same nostril
 Encourage the child to eat as soon as food can be taken.

 Monitoring
o The child should be checked by nurses at least every 3 hours and by a doctor at least
twice a day
o In the absence of complications, within two days there should be signs of
improvement that is breathing not so fast, less indrawing of the lower chest wall, less
fever, and improved ability to eat and drink
Step 7: Complications (5 minutes)
 Empyema
 Pyopneumothorax
 Tension pneumothorax
 Secondary bacterial infection; e.g Tuberculosis
 Atelectasis
 Heart failure
Step 8: Prevention of Pneumonia (5 minutes)
 Immunization all preventable diseases.

 Proper nutrition including breastfeeding and Vitamin A rich food are able to decrease the
number of children dying from pneumonia.
 Teach mothers how to recognize difficult and fast breathing as symptoms of early
pneumonia.
 All children born to HIV positive mothers should be give cotrimoxazole 5mg/kg once a
day to reduce the incidence and severity of pneumocystis pneumonia
 Pneumonia is an inflammation of the lungs

 Classification of pneumonia includes non-severe, severe and very severe or it can be
classified according to anatomical distribution
 What is pneumonia?
 List the signs and symptoms of severe pneumonia
 Outline the nursing care and management of the patient with very severe pneumonia

References
Bunker Rosdahl, C. (1999). Textbook of basic nursing (7th ed.). Philadelphia Lippincott.

Session 12: Asthma
Prerequisites
 None
Learning Tasks
 Define Asthma
 State the causes of Asthma
 List signs and symptoms of Asthma
 Explain the Nursing care and management of Asthma
 Outline the Complications of Asthma
 Describe the Prevention of Asthma
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Brainstorm/
2 10 Minutes Definition and causes of Asthma
Presentation
Presentation/
3 10 Minutes Signs and symptoms of Asthma
Buzzing
Nursing care and management of
Asthma
5 05 Minutes Presentation Complication of Asthma
6 05 Minutes Presentation Prevention
7 05 Minutes Presentation Key Points of Asthma
8 05 Minutes Presentation Evaluation of Asthma

Session 12: Asthma
SESSION CONTENT
Step 2: Definition of and Causes of Asthma (10 minutes)
Definition
o Asthma is a chronic inflammatory condition with reversible airways obstruction. It is
characterized by recurrent episodes of wheezing, often with cough which respond to
treatment with bronchodilators and ant-inflammatory drugs.
o Antibiotics should be given only when there are signs of pneumonia
Causes of Asthma
o Foreign proteins called allergens
o Viral respiratory infection
o Vigorous exercise producing increased respiratory rate and depth
o Cold air
o Smoke
o Emotional stress
o Parasitic larvae travelling through the lungs
Step 3: Signs and Symptoms of Asthma (10 minutes)
TELL students to pair up and list the signs and symptoms of Asthma
ALLOW few students to respond and let other pairs to provide unmentioned responses
 History of recurrent episodes of wheezing often with cough.

 On examination:
o Hyperinflation of the chest
o Lower chest wall indrawing
o Prolonged expiration with audible wheeze
o Reduced air intake when obstruction is severe
o Absence of fever
o Good response to treatment with a bronchodilator
 If the diagnosis is uncertain, give a dose of a rapid-acting bronchodilator

Session 12: Asthma
Step 4: Nursing care Management (15 minutes)
 A child with the first episode of wheezing and no respiratory distress can usually be
managed at home with supportive care only
o A bronchodilator is not necessary
 If the child is in respiratory distress or has recurrent wheezing, give salbutamol (in what
ever route available)
o If salbutamol is not available give subcutaneous epinephrine
o Reassess the child after 30 minutes to determine subsequent treatment
o If respiratory distress has resolved and the child does not have fast breathing, advise
the mother on home care with oral salbutamol syrup or tablets
o If respiratory distress persists admit to hospital and treat with oxygen, rapid-acting
bronchodilators and other drugs as prescribed
 If the child has central cyanosis or is unable to drink, admit to hospital and treat with
oxygen, rapid-acting bronchodilators and other drugs prescribed
 In children admitted to hospital, give oxygen, a rapid-acting bronchodilator, and a first
dose of steroids (oral or IV) promptly.
o A positive response to these should be seen in 30 minutes that is less respiratory
distress and better entry of air on auscultation
o If this does not occur, give the rapid-acting bronchodilator at up to hourly intervals
o If there is no response after 3 doses of rapid acting bronchodilator, add IV
aminophylline.
 Oxygen
o Give oxygen to all children with asthma who’s difficult breathing interferes with
talking, eating or breastfeeding
 Antibiotics
o Antibiotics should not be given routinely for asthma or to a child with asthma who
has fast breathing without fever. It should be given only when there is persistent fever
and other signs of pneumonia
 Supportive care
o Ensure that the child receives daily maintenance fluids appropriate for his age
o Encourage breastfeeding and oral fluids
o Encourage adequate complementary feeding for the young child as soon as food can
be taken
 Monitoring
o Check and record vital signs at least every 3 hours
o Ensure the child is seen by the doctor daily
o Observe for signs of respiratory failure
o Observe for drug effectiveness. If poor, salbutamol can be given up to once every 60
minutes
o If Salbutamol (Ventolin) is not effective give Aminophylline
o Give and monitor oxygen as prescribed

Session 12: Asthma
Step 5: Complications (5 minutes)
 Pneumothorax
 Infections: bronchiectasis, pneumonia, bronchiolitis
 Atelectasis
 Emphysema
 Emotional and behavioral problems
 Dehydration
 Hypotention and/or hypertension
 Infants (up to two years) serious respiratory failure due to the stage of development of
their anatomical structures and physiological mechanisms.
Step 6: Prevention (5 minutes)
 Limiting exposure to indoor inhalants such as:

o House dust
o Cockroach antigen
o Dander
o Molds
o Tobacco smoke
o Strong odors
 If affected by cold weather, can benefit from change of climate so transfer to an area with
warm climate and vice versa
 Avoid any physical exertion that causes wheezing or excessive shortness of breath
 Avoid using irritating ointments on chest or in nose
 Avoid carbonated drinks such as ginger ale and colas especially when wheezing
 Asthma is a chronic inflammatory condition with reversible airways obstruction

 It is characterized by recurrent episodes of wheezing, often with cough which respond to
bronchodilators and anti-inflammatory drugs
 A child with the first episode of wheezing and no respiratory distress can usually be
managed at home with supportive care only
 List the signs and symptoms asthma

 Explain how you will manage a patient with asthma

Session 12: Asthma
References

Session 12: Asthma
Session 13: Oral Thrush
Prerequisites
 None
Learning Tasks
 Define Oral thrush

 Identify the risk factors of oral thrush
 List signs and symptoms of oral thrush
 Explain nursing care and management of oral thrush
 Describe prevention of oral thrush
 State the complication of oral thrush
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Presentation of session title and Student
Learning Tasks
Presentation/
2 05 Minutes Definition oral thrush
Brainstorm
3 05 Minutes Presentation Risk factors of oral thrush
4 05 Minutes Presentation Signs and symptoms of oral thrush

Buzzing/
5 30 Minutes Nursing care and management of oral thrush
Presentation

SESSION CONTENT
READ or ASK students to read the Student Learning Tasks and clarify
ASK student if they have any question before you proceed
Step 2: Definition of Oral Thrush (5 minutes)
ASK student to brainstorm on definition of oral thrush
WRITE their responses on the flip chart/ board
CLARIFY and summarize their responses by using the information below
Oral thrush
 Is infection of the mucosa of the mouth caused by Candida albicans, yeast-like fungus
that is part of the normal flora of the oral cavity
Step 3: Risk Factors (10 minutes)
 Major risk factors:

o Immunosuppression
o Decreased level of some normal oral flora due to prolonged use of antibiotics
o Use of corticosteroids
o Diabetes
 Candidiasis commonly occur in critically ill client with prolonged intubation
 Prophylactic treatment is often started for these high risk clients
 Candidiasis is a secondary infection resulting from either an immunodeficiency or
prolonged use of antibiotics
 When the normal flora is disrupted, an overgrowth of the candida organism may occur
Step 4: Signs and Symptoms (5 minutes)
 White patches
o On the tongue, palate, and buccal mucosa
o The lesions adhere firmly to the tissues and are difficult to remove
o When rubbed off, it leaves erythematous and often bleeding base
o The lesions are often referred as milk curds because of their appearance
o Clients describe the lesions as dry and hot
o Clients with recurrent candidiasis infections should be examined for a possible
systemic cause

Step 5: Nursing care and Management (30 minutes)
TELL students to pair up and list the nursing care and management of oral thrush
ALLOW a few students to respond and let other pairs to provide unmentioned responses
CLARIFY and summarize using the information below
 Give antifungal medication such as Nystatin (mycostatin), amphotericin B, clotrimazole

or ketoconazole
 The antifungal may be in pill form or as suspension
 When used as suspension, instruct patient to swish vigorously for at least 1 minute and
then swallow
 Relieve pain by use of analgesics such as aspirin
 Mouth washes with warm saline or warm water with half hydrogen peroxide as part of
oral hygiene
 Gauze pads may replace toothbrushes
 Use prophylactic antifungal for those with high risk
 In suspected infection take oropharyngeal culture
Evaluation
 The infection should clear up within a few days to a week in most clients
 Assess the client for other risk factors if re-infection occurs
 Educate the patient about the signs of infection and what to report to the health care
practitioner
 Oral thrush is infection of the mucosa of the mouth caused by Candida albicans
 Major risk factors oral thrush includes immunosuppressant, decreased level of some
normal oral flora due to prolonged use of antibiotics, use of corticosteroids and diabetes
 Give antifungal medication such as Nystatin (mycostatin), amphotericin B, clotrimazole
or ketoconazole.
 What is the term oral thrush

 List the signs and symptoms oral thrush
 Explain how you will manage a patient with oral thrush

References

Session 14: Diarrheal Diseases
Prerequisites
 None
Learning Tasks
 Define Diarrhoea
 List the types of diarrhoea
 List signs and symptoms of oral thrush
 Explain nursing care and management of oral thrush
 Describe prevention of oral thrush
 State the complication of oral thrush
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Definition, Etiology and Types of
2 30 minutes Presentation
diarrhea
Presentation/
3 75 Minutes Nursing care and Management
Group Discussion
READ or ASK students to read the Student Learning Tasks and clarify
ASK student if they have any question before you proceeding
Step 2: Definitions, Etiology and Types of Diarrhoea (30 minutes)
Definition
o Is passing of unusual loose or watery stools, with or without blood, for three or more
times within 24 hours

Etiology
 Pathogens that cause gastrointestinal diseases are transmitted by:
o The fecal oral route
o From person to person
o Through ingestion of fecal contaminated food and water
 Gastrointestinal infections are often referred to as “food poisoning” because food is
frequently the vehicle for transmission of actively growing microbes or their toxins
 Common bacterial source of contaminated foods are eggs (salmonella), raw or
undercooked meat (E. coli), and chicken (campylobacter)
 Unpasteurized milk, fruit juice, and ice creams are also sources of food-borne infections
 Other causative organisms are Vibrio cholera (cholera), Shigella bacilli (dysentery),
staphylococcus aureus (staphylococcus food poisoning), and Viruses.
 The incubation period for all viral and bacterial infections ranges from 6 hours to 3 or 4
days
Types of Diarrhoea
o Acute watery diarrhoea
 More than 3 loose or watery stools per day
 No blood in stools
 Less than 14 days
o Persistent diarrhea
 Diarrhea lasting 14 days or longer.
o Dysentery
 Blood in stool (seen or reported)
o Diarrhoea with severe malnutrition
 Any diarrhea with signs of severe malnutrition
 There are many causes of acute diarrhea in children, vomiting is often an
associated symptom
 Early detection and treatment with fluids and electrolytes is critical to prevent death and
disability
 Other treatments will depend on the causative organisms
 For all children with diarrhea, hydration status should be classified as severe dehydration,
some dehydration and no dehydration and appropriate treatment given.
Severe dehydration
o Children with severe dehydration require rapid IV rehydration with close monitoring
which is followed by oral rehydration once the child starts to improve sufficiently.
o In area where there is cholera outbreak, give an antibiotic effective against cholera
 Diagnosis of severe dehydration
o If two of the following signs are present, severe dehydration should be diagnosed:
 Lethargy or unconsciousness
 Sunken eyes
 Skin pinch goes back very slowly (2 seconds or more)
 Not able to drink or drinks poorly

 Treatment
o Start IV fluids immediately. While the drip is being set up, give ORS solution if the
child can drink.
o The best IV fluid solution is Ringer’s lactate solution (also called Hartmann’s
Solution for injection.) If Ringer’s lactate is not available normal saline solution (0.9
% NaCl) can be used. 5% glucose (dextrose) solution on its own is not effective and
can be dangerous if given quickly.
 Monitoring
o Reassess the child every 15-30 minutes until strong radial pulse is present
o If hydration is not improving, give the IV solution more rapidly. Therefore, reassess
the child by checking skin pinch, level of consciousness, and ability to drink at least
every hour in order to confirm that hydration is improving.
o Sunken eyes recover more slowly than other signs and are less useful for monitoring
o When the full amount of IV fluid has been given, reassess the child’s hydration status
fully
o If signs of severe dehydration are still present, repeat the IV fluid infusion
o Persistent severe dehydration after rehydration is unusual, it usually occurs only in
children who pass large watery stools frequently during the rehydration period
o If the child is improving but still shows signs of some dehydration, discontinue IV
treatment and give ORS solution for 4 hours
o If there are no signs of dehydration, follow diarrhea treatment plan A
o Observe the child for at least 6 hours before discharge to confirm that the mother is
able to maintain the child’s hydration by giving ORS solution
o All children should start to receive some ORS solution (about 5ml/kg/hour) by cup
when they can drink without difficulty (usually within 3-4 hours for infants, or 1-2
hours for older children)
o This provides additional base and potassium which may not be adequately supplied by
the IV fluid
Administration of IV fluid (100 ml) to a severely dehydrated child

First give 30ml/kg in Then give 70ml/kg in
<12 months old 1 hour a 5 hours
a
> 12 months old 30 minutes 21/2 hours
a
Repeat again if the radial pulse is still very weak or not detectable
Some Dehydration
 Care of Children with some dehydration
o In general, children with some dehydration should be given ORS solution for the first
4 hours at a clinic while the child is monitored and the mother is taught how to
prepare and give ORS solution
o If the child has another non-severe illness in addition to the diarrhea, start treatment
for dehydration before the other illness is treated
o However if the child has severe illness in addition to diarrhea, assess and treat this
illness first

 Diagnosis of some dehydration
o If the child has two or more of the following signs, the child has some dehydration:
 Restlessness/irritability
 Thirsty and drinks eagerly
 Sunken eyes
 Skin pinch goes back slowly
o If the child has one of the above signs and one of the signs of severe dehydration e.g.
restless/ irritable and drinking poorly then that child also has some dehydration
 Treatment
o In the first 4 hours, give the child the following approximate amounts of ORS)
solution according to the child’s weight (or age if the weight is not known)
o However if the child wants more to drink, give more
o Show the mother how to give the child ORS solution, a teaspoon 1-2 minutes if the
child is under 2 years, frequent sips from cup for an older child
o Check regularly to see if there are no problems
o If the child vomits, wait 10 minutes, then resume giving ORS solution more slowly
(E.g. a spoonful every 2-3 minutes)
o If the child’s eyelids become puffy, stop ORS solution and give plain water or breast
milk
o This child can be considered rehydrated and the mother should be taught the rules for
home treatment
o Advise breastfeeding mothers to continue breastfeeding whenever the child wants.
o Infants under 6 months who are not breastfed should be given 100-200 ml clean water
in addition to ORS solution during the first 4 hours
o If the mother has to leave before 4 hours, show her how to prepare ORS solution and
give her enough ORS packets to complete rehydration at home plus for 2 more days
o Reassess the child after 4 hours, checking for signs of dehydration
o Reassess the child before 4 hours if the child is not taking the ORS solution or seems
to be getting worse
o If there is no dehydration, teach the mother the three rules of home treatment:
 Give extra fluid
 Continue feeding
 Return if the child develops the following signs:
 Drinking poorly or unable to drink or breastfeed
 Become more sick
 Develops a fever
 Has blood in the stool
o If the child has some dehydration, repeat treatment for another 4 hours with ORS
solution as above and start to offer food, milk, or juice and breastfeed frequently
o If signs of severe dehydration have developed, manage accordingly:
Administration of ORS in the first 4 hours to a child with some dehydration
Weight Age Amount of ORS in the first 4
hours
<5 kg <4 months 200-400 ml
5<8 kg 4<12 months 400-600 ml
8<11 kg 12 months<2years 600-800 ml
11<16 kg 2<5 years 800-1200 ml
16-50 kg 5-15 years 1200-2200 ml

 Feeding
o Continuation of nutritious feeding is an important element in the management of
diarrhea
o In the initial 4 hour rehydration period, do not give any food except breastmilk
o Breastfed children should continue to breastfeed frequently throughout the episode of
diarrhea
o After 4 hours, if the child still has some dehydration and ORS continues to be given,
give food every 3-4 hours
o All children over 4-6 months old should be given some food before being sent home.
This helps to emphasize to caregivers the importance of continued feeding during
diarrhea.
o If the child is not normally breastfed, explore the feasibility of relactation (restarting
breastfeeding after it was stopped) or give the usual breast milk substitute.
o If the child is 6 months or older or already taking solid food, give freshly prepared
foods-cooked, mashed or ground
o The following are recommended:
 Cereal or another starchy food mixed with pulses, vegetables and meat or fish, if
possible with 1-2 teaspoons of vegetable oil added to each serving
 Any complementary food recommended available in that area
 Fresh fruit juice or mashed banana to provide potassium
 Encourage the child to eat by offering food at least 6 times a day. Give the same
food after the diarrhea stops and give extra meal a day for 2 weeks
 No Dehydration
o Children with diarrhea but no dehydration should receive extra fluids at home to
prevent dehydration
o They should continue to receive appropriate diet for their age including continued
breastfeeding
 Diagnosis
o Diarrhea with no dehydration should be diagnosed if the child does not have two or
more of the following signs which characterize some or severe dehydration:
 Restlessness/irritability
 Lethargy or unconsciousness
 Not able to drink or drinks poorly
 Thirsty and drinks eagerly
 Sunken eyes
 Skin pinch goes back slowly or very slowly
 Treatment
o Treat the child as an outpatient
o Counsel the mother on the three rules of home treatment
 give extra fluid
 continue feeding
 give advise on when to return
 give zinc suppliments
o Give extra fluid as follows:
 If the child is being breastfed, advise the mother to breastfeed frequently and for
longer periods at each feed
 If the child is exclusively breastfed, give ORS solution or clean water in addition
to breast milk
o After the diarrhea stops, exclusive breastfeeding should be resumed if appropriate to
the child’s age
o In non-exclusive breastfed children, give one or more of the following:
 ORS solution
 Food-based fluids (such as soup, rice water, and yoghurt drinks)
 Clean water
o To prevent dehydration from developing, advise the mother to give extra fluids-as
much as the child will take:
 For children < 2 years, about 50-100ml after each loose stool
 For children 2 years or over, about 100-200ml after each loose stool
o Tell the mother to give small sips from a cup if the child vomits, wait 10 minutes and
then give more slowly. She should continue giving extra fluid until the diarrhea stops
o Teach the mother how to mix and give ORS solution and give her two packets of ORS
to take home
o Continue feeding the child
o Advise the mother on when to return
 Follow-up
o Advise the mother to return immediately to the clinic if the child becomes sicker, or is
unable to drink or breastfeed, or drinks poorly, or develops a fever, or shows blood in
the stool
o If the child shows none of these signs but is still not improving, advice the mother to
return for follow-up at 5 days
o Also explain that this same treatment should be given in the future as soon as diarrhea
start
 Diarrhoea means passing of three or more watery stools, with or without blood within 24
hours.
 Gastroenteritis (diarrhea diseases) is an inflammation of the stomach and intestinal tract
that primarily affect the small bowel
 Major sources of infection are contaminated food and water and it is a cause of many
deaths
 List the types of diarrhoea

 List the main causative organ m gastroenteritis

References

Session 15: Rectal Prolapses
Prerequisite
 None
Learning Tasks
 Define rectal prolapse
 List the predisposing factors to rectal prolapsed
 State the diagnosis of rectal prolapse
 Explain nursing care and management of rectal prolapse
 Describe prevention of rectal prolapse
 State the complication of rectal prolapse
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Step Time Activity/Method Contents
Learning Tasks
Presentation/
2 05 Minutes Definition of Rectal Prolapsed
Brainstorm
3 10 Minutes Presentation Predisposing Conditions
4 05 Minutes Presentation Diagnosis of rectal prolapsed

Nursing Care And Management of Rectal
Prolapse
SESSION CONTENT

Step 2: Definition of Rectal Prolapse (10 minutes)
ASK students to Brainstorm on definition of Rectal Prolapse for 2 minutes
ALLOW few students to respond and let others to provide unmentioned responses
CLARIFY and summarize their responses using the information below
 Protrusion of the rectal mucosa or full thickness of the rectum. It is diagnosed by seeing a
smooth, red, rounded mass coming out of the anus
 This is a common condition but troublesome problem seen in pediatric practice
 The children affected are often between 1 and 5 years. The child may have no other
problem
Step 3: Predisposing Conditions (10 minutes)
 Age between 1 and 5 years

 Chronic Cough
 Constipation
 Phimosis
 Torn perineum
 Threadworms/whipworm
 Whooping cough during the paroxysmal coughing
 Neurological conditions e.g. spinal bifida
 Relatively straight anorectal canal found at this age
 Malnutrition with absorption of the peri-anal fat
 Polyps
 Prolonged diarrhea
Step 4: Diagnosis of Rectal Prolapse (5 minutes)
 Rectal prolapsed is diagnosed by seeing a smooth, red, rounded mass coming out of the
anus
 The prolapsed occurs on defecation
 Initially, the prolapsed section reduced spontaneously but later may require manual
reduction
Step 5: Nursing Care and Management (25 minutes)
 Incomplete prolapse usually seen in infants

 The mucus only prolapses
o Regulation of the bowel is necessary
o Reduce the prolapse by employing gentle but firm pressure with a moist cloth
o Keep the child in bed with the feet raised. Strap the buttocks together with plaster for
2-3 days

o Improve nutrition with appropriate diet
o Treat the predisposing factor
 Rectal prolapsed is protrusion of the rectal mucosa or full thickness of the rectum.
 It is diagnosed by seeing a smooth, red, rounded mass coming out of the anus
 Explain the nursing care and management of rectal prolapsed

 List the predisposing condition of rectal prolapse
References

Session 16: Anaemia
Prerequisite
 None
Learning Tasks
 Define Anaemia
 List the main causes of Anaemia
 Describe hookworm anaemia
 Describe Anaemia due to malaria
 Describe Aplastic anaemia
 Describe sickle cell anaemia
 Explain management of sickle cell anaemia
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Presentation of session Title and Student
Learning Tasks
2 05 Minutes Presentation Definition of Anaemia
Buzzing/
3 10 Minutes Main Causes of anaemia
Presentation
4 20 Minutes Presentation Hookworm Anaemia
5 15 Minutes Presentation Anaemia due to malaria
6 10 Minutes Presentation Aplastic anaemia
7 35 Minutes Presentation Sickle cell anaemia
8 10 Minutes Presentation Management schedule for anaemia in children
10 05 minutes Presentation Evaluation

Session 16: Anaemia
Step 2: Definition of Anaemia (5 minutes)
 A reduction in the mass of circulating red blood cells and/or hemoglobin concentration
compared with normal values for age
 Anemia is not a disease but rather a symptom of other illnesses
 Anaemia weakens the child resistance to infection for example pneumonia, gastroenteritis
and malaria
 Anaemias are the most common hematologic disorders of infancy and childhood
Step 3: Main Causes of Anaemia (10 minutes)
TELL students to pair up and list the main causes of Anaemia
 Inadequate production of RBC components e.g. deficiency of raw materials-iron, folic

acid
 Increased destruction of RBCs e.g. infections-malaria, sepsis, sickle cell anaemia
 Excessive loss of RBCs through haemorrhage e.g. Hookworm infestation
Step 4: Hookworm Anaemia (20 minutes)
 Hookworm infection is a soil-transmitted helminthiasis caused by the nematode

parasites Necator americanus (N. americanus) and Ancylostoma duodenale (A.
duodenale).
 Is the leading cause of anemia and protein malnutrition in developing nations
 Pathophysiology
o Hookworm infection is associated with iron-deficiency anemia due to blood loss is
often associated with
o Hookworm-associated blood loss results from the destruction of capillaries in the
intestinal mucosa
o Level of iron deficiency and anemia depends on three major factors:
 worm burden
 type of hookworm (A. duodenale causes more blood loss than N. americanus)
 Patient nutritional status

Session 16: Anaemia
 Signs and Symptoms
o Pallor of conjunctiva, lips, fingernails, palms, and tongue
o Tiredness
o Rapid pulse
o Iron deficiency signs will be found in a host with a high load of hookworms and
include fatigue, poor concentration, and shortness of breath
o Signs of heart failure in severe anaemia
 Diagnosis
o In general, hookworm is clinically diagnosed
o Hookworm infection definitive diagnostic is established by identifying hookworm
eggs in feces under light microscopy
 Management
o Treat the anaemia with extra iron and extra protein
o If Hb is below 5g/dl, treat anaemia first and hookworm disease later otherwise treat
simultaneously
o Regiments with mebendazole and albendazole are the treatment of choice for adult
hookworms.
o Hookworm infection is treated with a single dose of 500 mg of mebendazole or 100
mg of mebendazole twice a day for 3 consecutive days
o Albendazole is given at a single dose of 400 mg. Associated iron-deficiency anemia
should be detected and treated adequately.
o Hookworm infection control is achieved through the sanitary disposal of feces and
educational campaigns about the proper use of latrines.
Step 5: Anaemia Due To Malaria (15 minutes)
 Where malaria is endemic, there is widespread anaemia due to destruction of red blood
cells by malaria parasites (Hemolytic Anaemia)
 The anaemia may develop in a matter of days or even hours during an acute attack of
malaria with fever and rigors, or it may develop slowly when chronic malaria is present
without acute attacks.
 Treatment
o Treat the malaria
o Assume that at least part of the anaemia is due to iron deficiency and treat as such
o Send children with Hb less than 5g/dl immediately to hospital for blood transfusion
 Prevention
o Prevent the child from getting malaria
o Promote normal nutrition to prevent added occurrence of iron deficiency anaemia

Session 16: Anaemia
Step 6: Aplastic Anaemia (10 minutes)
 Anaemia caused by deficient red cell production due to bone marrow disorder
 The bone marrow can be inactive because of:
o Leukaemia cells replacing the normal red bone marrow
o Chloramphenicol or other drugs depressing the bone marrow cells
o Idiopathic (unknown causes)
Step 7: Sickle Cell Anaemia (35 minutes)
 Sickle cell anaemia is an inherited disorder transmitted as an autosomal recessive trait

that causes an abnormality of the globin genes in haemoglobin.
o Sickle cell anaemia is an inherited disease where the haemoglobin is abnormal
 The abnormal red blood cells are broken very easily
 In certain circumstances, these cells undergo deformation-sickling which is the tendency
of red blood cells to be sickle shaped
 The result is an increased breakdown of blood cells and obstruction of the blood vessels
by elongated sickle shaped erythrocytes
 The bone marrow becomes hyperactive and tries to keep up with the increased breakdown
 This occurs only in children who have abnormal genes (SS) in each cell
 They are unable to produce normal Hb which is HbA, making the abnormal sickle cell
Hb (=HbS) only
 Normal individuals on the contrary have two normal genes (AA) and produce HbA only
 Parents of sickle cell children carry both the normal A-gene enabling them to produce
HbA, and the abnormal S- gene causing production of HbS
 25 % of children from such marriage will be unlucky enough to inherit the abnormal S-
gene from both sides
 SS = a patient with sickle cell disease
 Another 25 % of the children on the other hand inherit normal genes from both sides AA.
 50% just like parents carry both the A and the S gene “AS”
 They are carriers of the disease, have a positive sickle cell test but no disease and are said
to have the “sickle cell trait”
Clinical features
 Signs and symptoms related to haemolysis
o Anaemia
 This is due to increased breakdown of the red cells e.g. infection
o Jaundice
o This is usually slight but intensified during haemolytic crisis
 Hepatosplenomegaly
 Hyperactive bone marrow
o This is shown by reticulocytosis and X-ray changes in the bones (bossing of the skull)

Session 16: Anaemia
 Signs and symptoms related to the sickling
o Smear
o In sickle cell anaemia, usually sickle cells can be seen in the blood smear
o In both sickle cell trait and sickle cell disease, sickling can be provoked in the
laboratory by hypoxia-“sickle cell test”
o Intravascular sickling (sequestration crises)
o These are triggered by hypoxia or other factors
o They cause vascular obstruction which gives rise to further hypoxia which in turn
increases the sickling and so on
o The hypoxia and ischaemia causes considerable pain
o In children, pain and swelling of hands and feet are most marked (hand-foot
syndrome=dactylitis)
o In older children, pains are mostly localized in the long bones and abdomen
o If the conditions triggering off the intravascular sickling, infection, anaemia, cold, and
hypoxia are quickly dealt with then the process is reversible
o If not dealt with, actual infarction results leading to necrosis usually in the bones
o In sickle cell anaemia, osteomyelitis caused by salmonella bacilli is often seen
 Management Of Sickle Cell Crises

o During crises the Haemoglobin may become as low as to warrant a blood transfusion
o If possible, avoid transfusion because its effect is temporary and there is danger of
iron overload
o In sequestration crises, the patient is kept comfortable
o Give strong analgesic for bone pain
o Treat concurrent infections
 Prevention
o The disease itself cannot be prevented
 Carriers should not marry each other
 Parents with sickle cell trait should be advised especially if they have a few
healthy children not to have more children
o Acute crises can partly be prevented by:
 Malaria prophylaxis
Step 8: Management Schedule for Anaemia in Children (10 minutes)
 Ask about diet and recent infections

 Examine especially for jaundice (indicating a haemolytic anaemia, splenomegaly,
malaria, haemolytic anaemia, and leukaemia) and for signs of heart failure (dyspnoea and
oedema) indicating severity of the condition
 Hemoglobin, malaria slide, and stool specimen for hookworm
 If no cause for anaemia can be found in this way, treat for six weeks with oral iron
medication and repeat Hb 3 weeks later
 If insufficient response has occurred (less than 3 g% rise), repeat the stool examination
for hookworm and try Imferon
 If haemoglobin is below 5 g% or if insufficient response to above mentioned
management, send to hospital
 In case of splenomegaly without any other explanation for the anaemia, give a full course
of antimalaria followed by prophylaxis

Session 16: Anaemia
 Anaemia is a reduction in the mass of circulating red blood cells and is not a disease but
rather a symptom of other illnesses
 List the main causes of anaemia

 List the signs and symptoms of sickle cell anaemia
 Explain the management of anaemia in children
References

Session 16: Anaemia
Session 17: Fractures
Prerequisite
 None
Learning Tasks
 Define fracture
 List the causes of fractures
 Outline the signs and symptoms of fractures
 Explain nursing care and management of fractures
 Describe prevention of fractures
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
2 20 minutes Presentation Definition and Causes of Fractures
Brainstorm/
3 10 minutes Signs and Symptoms of Fractures
Presentation
Group Discussion/ Nursing Care and Management of
4 75 minutes
Presentation Fractures
5 05 minutes Presentation Key Points
READ and ASK students to read the Learning task
NMT 05112 Child Health 1

Step 2: Definition and Causes of Fractures (20 minutes)
Fractures
o A fracture is a break in the continuity of a bone
 Causes of fractures
o Pathological
 This is in certain diseases such as osteomalacia, syphilis, and osteomyelitis where
bones break without trauma.
o Trauma
 Direct violence - the bone is broken directly at the point where the force was
applied as in fracture of the tibia by being run over
 Indirect violence - the bone is fractured by a force applied at a distance from the
site of a fracture and transmitted to the fractured bone as fracture of the clavicle
by falling on an outstretched hand
 Muscular contraction - the bone is broken by a sudden violent contraction of the
muscles
 Traumatic fracture is the most common
 Injuries may be closed that is the injury to the bone or joint does not communicate
with the outside
 It may be compound that is the broken bone or injured joint is accessible to
outside pollution and therefore more likely to become infected
 Anatomical types of fracture:

o If the bone ends are jammed together, it is known as impacted fracture
o If the bone ends are splintered, it is a comminuted fracture
o Fracture of a young child which normally is partially fractured is known as a
greenstick fracture
o If the fractured bone damage the nearby
 Stress fracture
o This occurs when there is undue and repetitive stress placed upon them
Step 3: Signs and Symptoms of Fracture (10 minutes)
ASK students to brainstorm to list the signs and symptoms of fractures
ALLOW few students to respond and let others students to provide their responses
CLARIFY and summarize using the contents below
 Pain aggravated by movement

 Tenderness over the fracture line
 Swelling
 Deformity
 Shortening of the limb
 Loss of function
 Abnormal mobility at the fracture site
 Occasional crepitus or grating of the bone ends as they move on each other.
 Principles of treatment
o Reduction
 This is done mainly in complicated fractures
o Rest until healed
 Methods of splintage to ensure rest
 Sling or a collar and cuff
 Plaster of Paris (POP)
o The following may indicate that a plaster of Paris is too tight:
 Pain which is increasing and persistent
 Numbness of the extremities indicating cut of blood and nerve supply
 Whiteness, paleness and duskiness of the extremities due to circulatory
interference
 Increasing swelling of hand or foot
 If these signs are seen, the POP must be removed as quickly as possible and
reapplied
 Therefore, close observation is very important
 The plaster must be well applied and smooth to avoid causing damage to the skin
o Splints
o The common used splint is Thomas splint
 Restoration of function
o This is the most important principle
o There is no need to have a perfect healed fracture but the limb cannot be used
o This should begin as soon as the primary treatment has been done by the nurses and
by the physiotherapist if available
o Fractures and dislocations account for the greatest proportion of accidental injuries
during childhood caused mainly by sporting activities or by road traffic accidents
o The mostly affected bones are:
 Femur
 Humerus
 Tibia
 Radius
 Ulna
 Spine and pelvic girdle are less affected
 Principles applied in diagnosis and management of paediatric fractures and dislocations:
o Healing occurs faster in children than in adults
o The younger the patient, the sooner the fracture will heal
o Non-union and joint stiffness rarely complicate pediatric factures
o Physiotherapy is normally not necessary in under-five year olds as they resume their
normal activities as soon as possible once healing has occurred
o Proper reduction is necessary in order to prevent malunion with deformity which
impede functional recovery

o Bones of children are still growing so use of metallic appliances should be
discouraged as they will interfere with the growth and development of the affected
part of the skeleton. If used they should be use, only temporary during the critical
phase of the fracture healing
o Conservative management for most pediatric fractures is recommended
o If operative treatment is necessary, strict aseptic techniques must be adhered to avoid
septic complications.
o Fracture of the femur in infants and young children is managed by what is known as
gallows traction only
 Head Injuries
o The importance of head injury lies in the fact that there has occurred some damage to
the brain and other intracranial structures
o Therefore, the state of unconsciousness is the most important indicator of the degree
of brain damage sustained.
 Diagnosis and management

o All children suspected of having sustained a head injury should be admitted for at
least 24 hours observation
o Other admission criteria include:
 Evidence of concussion or vomiting or unexplained state of unconsciousness
 The presence of scalp wounds, depressed skull fractures or bleeding through the
ear, nose, and mouth
 Evidence of multiple injuries
 Management
o Admit the child
o Maintain a clear airway
o Assess for any additional injuries in particular those of the chest, abdomen, limbs, and
spine
o Treat hypovolemic shock, if present
o Monitor the vital signs
o Monitor the level of unconsciousness
o Recognize and treat any complications such as intracranial hemorrhage, convulsions,
and infection
o Rehabilitate the child after the acute effects of injury have resolved
o Manage any late complications such as epilepsy that may occur.
o Prognosis of head injury depends on the extent of brain damage and complications
that has occurred
 Important Points About Particular Fractures

o Shoulder girdle
 Fractures of the clavicle are treated by 2-3 weeks rest in a broad arm sling or
figure of 8 bandage followed by mobilization
 Fracture of the scapula requires rest in a sling until the pain and swelling subsides
 No particular treatment other than this is necessary
o Fracture of the Humerus

 A fracture of the greater tuberosity of the humerus is commonly associated with a
dislocation of the shoulder joint
 Treatment
o Reduction of the dislocation as early as possible
o Rest in sling for 3-6 weeks
o Fracture around the elbow
o These are common fractures in children.
o A supracondylar fracture of the humerus in children should be reduced by
manipulation under general anaesthetic and supported in a collar and cuff with the
elbow flexed beyond the right angle.
 Complications
o Compression of the brachial artery
o The nurse must check for radial pulse
o If the pulse disappears, the flexion at the elbow must be lessened
o As a general rule, fractures around the elbow joint do not need to be immobilized in
plaster but some complicated fractures do need open reduction and internal fixation.
 Fractures of the forearm bones

o Treatment
o Manipulative reduction followed by a plaster slab for four-five weeks
 Fracture of the wrist and hand

o This bone has a poor blood supply
o Treatment of a fracture needs scaphoid plaster for many weeks to ensure union
o Fracture of the metacarpals heal with no problem even without immobilization
o Fracture of the fingers are important because, if badly treated, may give rise to
permanent deformities and limitation of movement
 Fracture of the spinal column

o If there is no involvement to the spinal cord, the patient is rested in bed until pain
settle down.
o When the pain has diminished, the patient is allowed up and down
o In case of a stable dislocation with no neurological involvement, reduction is done
and rest in bed till pain settles
o If the spinal cord is involved thus there is paralysis, nursing care is all that is needed
o Patient will most likely be confined to bed or in wheel chair so patient is likely to
develop pressure sores due to the fact that there is no sensation on the skin
o The patient therefore needs to be turn every two hours
o Care of the bladder is another important aspect
o Breathing exercise is also important
 Fracture of the ribs

o For the fracture, no local treatment is needed
o Problem with this fracture is that the fractured ends may pierce the lungs, giving rise
to a haemothorax and pneumothorax.
o If it is a tension pneumothorax, it requires urgent treatment otherwise the patient will
die
o If many ribs are damaged leading to a flail chest a ventilator is necessary to aid
respiration.
o Fractured ribs may also damage the spleen, kidney, stomach and liver.
o In this case laparatomy is necessary.
 Fractures of the pelvis

o Problem from this fracture is the damage of underlying organs which are the urethra,
urinary bladder, and the bowels
o Urgent surgical treatment is necessary for these damaged organs
o Fractures of the pelvis which do not pass through the weight bearing area of the pelvis
are treated merely by rest until the painful symptoms subside
o Fractures of the pelvis involving the acetabulum or the sacroiliac joints require much
longer periods of bed rest and sometimes need open reduction and fixation
 Fractures and dislocations account for the greatest proportion of accidental injuries during
childhood caused mainly by sporting activities or by road traffic accidents
 A fracture is a break in the continuity of a bone.
 The mostly affected bones includes femur, humerus, tibia, radius, ulna, spine, and pelvic
girdle are less affected
 Proper reduction is necessary in order to prevent malunion with deformity which impede
functional recovery
 All children suspected of having sustained a head injury should be admitted for at least 24
hours observation
 Define the term fracture

 Mention the causes fracture
 Describe the nursing care of the child with fracture
 List the complication of the fracture of the humerus
References

Session 18: Burns and Scalds
Prerequisite
 None
Learning Tasks
 Define Burns and scalds
 List the classification of burns
 Outline the clinical features of burns
 Explain the investigations of burns
 Explain nursing care and management of burns
 Describe preventive measures of burns.
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Presentation of the Session Title and Student

Learning Tasks
Presentation/
2 05 minutes Definition of Burns And Scalds
Brainstorm
3 15 minutes Presentation Classification of Burns
Presentation/
4 10 minutes Clinical Features of Burns
Buzzing
5 05 minutes Presentation Investigation of Burns
6 60 minutes Presentation Nursing Care and Management of Burns
7 10 minutes Presentation Prevention of Burns

SESSION CONTENT
Step 2: Definition of Burns and Scalds (5 minutes)
ASK students to brainstorm on definition of burns and scalds
ALLOW few students to respond and let the others provide their responses
 A burn is a tissue injury resulting from excessive exposure to thermal, chemical, electrical
or radioactive agents.
 Scald is to burn with hot liquid. A burn of the skin or flesh caused by moist heat and hot
vapors such as steam.
 To cause a burn with hot liquid or steam.
 Sometimes a scald is deeper than a burn from dry heat. Healing is slower and scar
formation is greater in scalds.
Step 3: Classification of Burns (15 minutes)
 Burns are usually classified as:

o First degree
 A superficial burn in which damage is limited to the outer layer of the epidermis
and is marked by redness, tenderness, and mild pain
 Blisters do not form and the burn heals without scar formation. A common
example is sunburn.
o Second degree
 A burn that damages epidermal and some dermal tissue but does not damage the
lower lying hair follicles, sweat, or sebaceous glands. The burn is painful and red;
blisters form and wounds may heal with scars.
o Third degree
 A burn that extends through the full thickness of the skin layer and often into
underlying tissues. The skin has pale brown gray or blackened appearance. The
burn is painless because it destroys nerves in the skin. Scar formation is likely.
o Small children are quite likely to get burned or scalded as they often play close to
fires and cooking pots and have not learned wisdom through experience

Step 4: Clinical Features and Diagnostic Approach (10 minutes)
ASK students to pair up and list the clinical features of Burns and scald they know
 History which includes:

o The cause
o Time and date it happened
o Is the child epileptic?
o Treatment given
 General examination
o Is the child shocked? This will be characterized by weak thready pulse and cold skin
on his nose and fingers
o Rule out pain so that you can give analgesic promptly
Step 5: Investigation (5 minutes)
 Examination of the burn

o Extent of the burn
o A blister is a sign of only a superficial burn
o Black charred skin, or if it is hard and feels like leather, means a deep burn that will
need grafting
o Examine for signs of infection which includes temperature and obvious pus around
the burn area.
 Laboratory test:
o Haemoglobin (or haematocrit)
o Areas of burns as percentage of body surface
o Front and back of head about 20%
o Front and back of neck only 2%
o One upper limb10%
o Front of chest and abdomen about 15%
o Back of chest and abdomen 15%
o Buttocks 3% each
o One lower limb about 15%
Step 6: Nursing Care and Management of Burns (60 minutes)
 First-aid in the home

o Deep immediately in clean cold water within 10 minutes of the burn to prevent
development of deep burn
o Cover the area with a clean cloth
o Take the child to the nearest health facility
o Do not put anything on the burnt area
o Do not remove any burnt cloth that is in place as it acts as a temporary sterile dressing
until formal burn dressing is done.
 Pain relief
o Give pain relief quickly e.g. pethedine 1mg/kg prn or morphine 0.25mg/kg prn 6
hourly.
o Paracetamol may be sufficient in mild burns
o Restoration of fluid loss
o Extra fluid is important to replace the fluid loss
o It may be orally or intravenously or both
o Breast milk is preferred if it is known to be sufficient. No need of calculation.
o Fluid replacement in burns
% OF BODY SURFACE EXTRA FLUIDS TO BE TYPE OF FLUID AND

BURNED GIVEN (ML/KG) HOW GIVEN
10 or less 20 Can be given as homemade
Electrolyte solution by
mouth
20 40 I.V. saline or preferably
30 60 Ringer’s lactate
40 80 Ideally every other bottle
50 100 should be plasma
 Local treatment
o While pethedine or morphine is working:
 Gently wash the burnt area with warm soapy water
 Remove any dirt or dead skin and gently dry. For burns of the body, limbs,
genitals, face, and neck, air dry so use no dressings or medicines. This is called
exposure treatment. Use bed cradle to keep clothes off the area.
 For burns of the hands or feet, closed treatment is better
 After washing, dress with Vaseline gauze if it is available then bandage the limb
in good functional position and elevate it on pillows or in a sling
 Each finger should be bandaged separately
 The burns are soaked in warm soapy water every day and surgical toilet carried
out
 Antibacterial treatment
o Sterile techniques are essential
o To prevent streptococcal infection give penicillin
o Give Tetanus prophylaxis-if not vaccinated more than two years ago, boost with
tetanus toxoid 0.5 IM stat
 Treatment of anemia
o Keep a check once weekly on the haemoglobin
o Give a blood transfusion if it falls below 7g/dl in the first week
o Give a course of ferrous sulphate for less severe anaemia

 Transfer to hospital
o All severe burns should be transferred to centers with experienced staff and special
facilities
o Severe burns
 Extensive burns (more than 25% of body area)
 Deep burns that have not healed in 14-17 days
 Flame burns to the face and eyelids
 Contractures following untreated burns
 Elevate fire place to be out of reach of children

 Children should never be close to fire while grownups are not around
 Epileptic children should never be allowed to lie near fires
 A burn is a tissue injury resulting from excessive exposure to thermal, chemical, electrical
or radioactive agents
 There are three classification of burns namely first, second and third degree
 What is burns?
 Describe the three classification of burn
References

Session 19: Urinary Tract Infection
Prerequisite
 None
Learning Tasks
By the end of this session, students are expected to be able to
 Describe urinary tract infection
 Outline the signs and symptoms of urinary tract infection
 Explain the diagnosis of urinary tract infection
 Explain nursing care and management of urinary tract infection
 Describe preventive measures of urinary tract infection
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Learning Tasks
2 10 Minutes Presentation Descriptive Definition of urinary tract infection
Buzzing/
3 10 Minutes Signs and symptoms of urinary tract infection
Presentation
4 05 Minutes Presentation Diagnosis of urinary tract infection
Small Group Nursing care and Management of urinary tract
5 20 minutes
Discussion infection

Step 2: Descriptive Definition of Urinary Tract Infection (10 minutes)
 Infection of the kidney, ureter, bladder, and urethra is generally called urinary tract
infection
 The infection may mainly affect the lower urinary tract that is the urethra and the bladder
especially in girls due to ascending infection from the vulva
 A lower urinary tract infection may spread upwards to the ureter and kidneys if not
treated properly. The infection may spread by the blood stream to the kidneys
 Urinary tract infections are more common in girls than in boys because of their short
urethra and the increasing risk of ascending infection
 They are also more common in any congenital abnormality of the renal tract especially if
the abnormality causes obstruction of the flow of urine such as in hydrophoresis where
the obstruction may be due to a congenital narrowing of the ureter in congenital urethral
valves which rarely occur in infant boys or in chronic unrecognized Phimosis
 Urinary tract infection also may occur where there is paralysis of the bladder as in a
spinal injury with paraplegia or a congenital meningomyelocele
Step 3: Clinical features (signs and symptoms) (10 minutes)
ASK students to pair up and list the clinical features of urinary tract infection
 In small children, the diagnosis is very difficult because fever, failure to thrive and
vomiting may be the only signs
 Local symptoms of pain or discomfort on passing urine (dysuria) may be due to a vulvitis
in girls or less commonly a balanitis or inflammation of the prepuce in uncircumcised
boys. They can also be due to injury to the urethra from little children inspecting their
urethral openings and inserting needles or other foreign bodies, or in younger and older
children from sexual abuse.
 Older children may complain of frequency of micturition with scalding on passing urine
and abdominal pain or pain over the kidney area.
Step 4: Investigation and Diagnosis (5 minutes)
 Microscopic examination of a midstream specimen of urine

 Clean the vulvae or prepuce with cotton wool soaked in clean water or saline to avoid
contamination. Get the mother to assist. The urine specimen should be really fresh.
 Bacteria seen in fresh urine signify infection
 Culture and sensitivity test are important if service is available

 Make sure the child is well-hydrated and is drinking an adequate amount of fluid
 The child is treated as an outpatient except when there is high fever and systemic upsets
such as vomiting everything or inability to drink or breastfeed
o Give oral Cotrimoxazole
o Alternatives include Ampicillin, amoxicillin depending on local sensitivity patterns of
E. coli and other Gram negative bacilli that cause UTI and on antibiotic availability
o If there is poor response to the first line antibiotics or the child’s condition
deteriorates, give Gentamycin plus Ampicillin
o Consider complications such as pyelonephritis if there is tenderness in the costo-
vertebral angle and high fever or septicaemia
o Treat young infants below two months with Gentamycin until the fever has subsided
then continue with oral treatment
o After treatment, the urine should be examined to ensure that the infection has been
adequately treated.
o If the urine is still infected, a further course of treatment is necessary
o Chronic urinary tract infection will damage the kidneys permanently. If urinary tract
infections have not cleared up after 2 weeks of treatment, refer the child to hospital.
o Cases which do not clear may be due to congenital abnormality which can be
diagnosed by x-ray. Another reason is drug resistance.
 Urinary tract infections are more common in girls than in boys because of their short
urethra and the increasing risk of ascending infection
 In small children, the diagnosis is very difficult because fever, failure to thrive and
vomiting may be the only signs
 Make sure the child is well-hydrated and is drinking an adequate amount of fluid
 Define urinary tract infection

 Mention the signs and symptoms of tract infection
 Explain the nursing care and management of tract infection
References

Session 20: Convulsions
Prerequisite
 None
Learning Tasks
 Define convulsion
 List causes of convulsion
 Outline the signs and symptoms of convulsion
 Explain the investigation of convulsion
 Explain nursing care and management of convulsion
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Brainstorm/
2 10 minutes Definition of Convulsions
Presentation
3 25 minutes Presentation Causes of Convulsions
4 15 minutes Presentation Investigation of Convulsions

Nursing care and Management of
Convulsions
SESSION CONTENT

Step 2: Definition of Convulsion (10 minutes)
ACTIVITY: Brainstorm (5 minutes)
ASK the students to brainstorm on definition of convulsions for 2 minutes
WRITE their responses on the board/flip chart
CLARIFY and summarize using the information below.
 Convulsion is a paroxysm of involuntary muscular contractions and relaxations

 In the neonate it can become stiff and rigid with arching of the back or clonic in nature
with repetitive movement and may be focal or generalized.
 Other signs are:
o Apnoea
o Cyanosis
o Bradycardia
 Sometimes there is no other sign or symptom except abnormal eye movements and
sucking movement.
Step 3: Causes of Convulsions (25 minutes)
 A high fever can cause a convulsion in infants and young children aged 6 months to 6
years.
o The fever may be due to any infection such as:
 Otitis media
 Pneumonia
 Urinary tract infection
 Malaria
 A benign febrile convulsion can only be the diagnosis if:

o The convulsion lasted less than 10 minutes
o No residual paralysis was detected afterwards
o It is in a child from 6 months -6 years
o There is a high fever
o There is a normal CSF
 The condition is rather common. If more than one convulsion occurs, send to hospital for
further investigations.
o Cerebral malaria
o Meningitis, encephalitis, and brain abscess
o Tumour and bleeding to the brain tissue and head injury
o Functional disturbances to the brain cells such as:
 Asphyxia
 Hypoglycemia
 Poisoning such as insectside poisoning
 Electrolyte disturbances such as dehydration
 Hypoglycemia convulsions are particularly likely in severe malnourished children, low
birth weight newborns and diabetics who have received too much insulin
 Glomerulonephritis due to high blood pressure
 Kernicterus
 Congenital malformation
 Drug withdrawal
 Idiopathic
Step 4: Investigations (15 minutes)
 Blood glucose
 Plasma electrolytes
 Plasma calcium and magnesium
 Haemoglobin
 White blood count and differential blood culture
 Lumbar puncture and check the cerebral spinal fluid.
 If the above investigations don’t give the diagnosis, do:
o X-ray skull
o Cranial ultrasound
o CT scan
o Electroencephalogram (EEG)
 Fits normally differ in length and severity
Step 5: Nursing Care and Treatment of Convulsions (55 minutes)
ASK students to pair up and discuss the management of convulsion
 Turn child to the semi-prone position

o This will prevent the tongue from falling back and obstruct the airway
 Gently do oral suction-remove mucus and milk from mouth and pharynx
 If cyanosed, give oxygen
 Secure medical aid
 Estimate capillary glucose to exclude hypoglycemia
 Allow child to rest
 Nurse child unclothed, if possible, to be able to observe and maintain neutral thermal
environment.
 Keep a convulsion chart. The format of the chart see below
Date Time Type(clonic,tonic) Region(s)involved Apnea Cyanosis Duration

 Initial drugs
o Anticonvulsants
 Give an anticonvulsant drug diazepam 0.15 mg/kg as a slow blood injection IV or
diazepam 0.5-1.0mg /kg per rectum
 Draw the IV of diazepam preparation into a small syringe and remove the needle
 Insert 5 cm of a nasogastric tube into the rectum. Inject the diazepam into the
nasogastric tube and flush it with 5 ml of water. If a nasogastric tube is not
available, use a syringe without a needle. If convulsions persist after 10 minutes,
repeat rectal diazepam treatment as above. Should convulsions continue despite a
second dose, give a further dose of rectal diazepam
o Restore correct levels if there is low blood sugar, electrolytes, calcium, or magnesium
o Treat the underlying cause if detected
o Give adequate explanation and support to the parents
 It is important to find out the cause of a convulsion, treat it to prevent reoccurrence just
after managing the convulsion
 Parents should be educated about the causes of convulsions and they should be told that
the convulsions can be managed well in health facilities
 Define a convulsion
 List causes of convulsions
 Explain how you will give diazepam per rectum
References

Session 21: Meningitis
Prerequisite
 None
Learning Tasks
 Define meningitis
 List causes of meningitis
 Outline the clinical features of meningitis
 Explain the investigation of meningitis
 Explain nursing care and management of meningitis
 Describe complications of meningitis
 Describe Tuberculosis meningitis
 Explain viral meningitis
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Presentation/
2 15 Minutes Definition and Causes of meningitis
Buzzing
3 20 Minutes Presentation Clinical Features of meningitis
4 10 Minutes Presentation Investigations

meningitis
6 5 Minutes Presentation Complication of meningitis
7 15 Minutes Presentation Tuberculosis meningitis
8 15 Minutes Presentation Viral meningitis
9 5 minutes Presentation Prevention

Step 2: Definition and Causes of Meningitis (15 minutes)

Definition
 It is an inflammation of the meninges, the membranes that cover the brain.
ACTIVITY: Buzz (5 minutes)
ASK students to pair up and list the causes of meningitis
Causes of meningitis
 Bacteria.
 Tubercle bacilli
 Viruses
 Fungi and parasites in immunosuppressed children
 Purulent Meningitis
o This is a very serious disease caused by meningococci, pneumococci or other bacteria
entering the meninges either from blood stream or as a complication of mastoiditis or
meningomyelocele (spinal bifida)
Step 3: Clinical Features (20 minutes)
 Sudden onset
 Fever
 Headache
 Loss of appetite
 Vomiting
 Drowsiness
 Neck stiffness
 Kerning’s sign
 Convulsions
o In children under 2 years there is no neck stiffness or kerning’s sign
o Child will present with:
 Fever
 Drowsiness
 Vomiting
 Irritability
 Convulsions
 A startled expression
 A bulging fontanel

o In younger babies, signs may be:
 Fever
 Cyanosis
 Vomiting
 High pitched cry
 Drowsiness
 Inability to suckle
 Convulsions
 Full fontanel
 Neck retraction
 Examination of the cerebral spinal fluid (CSF) obtained by lumbar puncture to isolate the
causative organism
 In purulent meningitis, CSF is cloudy
 Clear CSF should also be examined to rule out early TB or viral meningitis
 Culture and sensitivity is done if resources are available
 Perform blood slide for malarial parasites to rule out Malaria
 Perform random blood glucose to rule out hypoglycaemia
 Admit the child

 Treatment should be started immediately as soon as diagnosis is made
 Notify the DMO in case of meningococcal meningitis
 Give X-Penicillin 300 mg (500,000 units)/kg/day in 3 hourly doses till the temperature is
stable and normal and thereafter in 6 hourly doses for 14 days
 Plus Chloramphenicol 100mg/kg/day IM in 6 hourly doses until the child has no fever
and looks well usually in 3-5 days then change to oral Chloramphenicol for a total of 14
days
o In neonatal meningitis the three best combinations are:
 Chloramphenicol plus penicillin,
 Ampicillin plus Gentamycin
 Ampicillin plus cefotaxime
 Phenobarbitone 5mg/kg/day in three divided doses with a minimum of 10 mg 3
times a day is given to children who have had a convulsion in order to prevent
recurrence
 Fluids
o If the child cannot drink, an intragastric tube should be passed and fluid ORS should
be given
o If the child is very sick or vomiting, give maintenance IV fluid
o Treat purulent meningitis for 2 weeks

Step 6: Complications of Meningitis (5 minutes)
 If treatment was delayed or antibiotic dose was too low, the following may arise:
o Hydrocephalus
o Subdural effusion
o Blindness
o Deafness
o Death
Step 7: Tuberculosis Meningitis (15 minutes)
 Onset is gradual
 Headache at first
 Drowsiness
 Constipated
 Vomiting
 Loss of appetite
 Neck stiffness
 Kerning’s sign positive
 Finally child becomes spastic and get convulsions
 The child can die in coma if treatment is not given
 Investigation
o CSF is clear or slightly cloudy
o Examination under microscope shows increased cells mainly lymphocytes
o CSF glucose is low
o CSF protein is moderately raised.
o Mantoux test is positive or will become positive
 Management
o All suspected cases should be referred to hospital
Step 8: Viral or Aseptic Meningitis (15 minutes)
 Clinically, it is the same as purulent meningitis but less severe

o On investigation
 CSF is almost clear
 CSF shows some cells often mainly lymphocytes
 CSF glucose is normal
 Treatment
o Give Fluids
o Do observation
o Avoid injections in case the disease is poliomyelitis in which case injections may
precipitate paralysis
o If in doubt, treat as TB meningitis until proved otherwise
o Tuberculin test remains negative
o Child should be referred to hospital

 Vaccination to all children – Pneumococcal vaccine and Haemophilus Influenzae type B

vaccine
 Avoid overcrowding (especially when there is an outbreak)
 In any child with convulsions, rule out meningitis

 Find out the cause of meningitis before starting treatment because treatment will depend
on the cause
Step 11: Evaluation
 Define meningitis
 What are the causes of meningitis
 What are the differences between purulent meningitis and viral meningitis
References

Session 22: Measles
Prerequisite
 None
Learning Tasks
 Define Measles
 Identify the incubation period of Measles
 Explain measles in relation to nutrition
 Outline the signs and symptoms of Measles
 Explain nursing care and management of Measles
 Describe complications of Measles
 Describe the prognosis of Measles
 Explain the preventive measures of Measles
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Teaching
Step Time Content
activities
Brainstorm/
2 15 minutes Descriptive Definition of Measles
Presentation
3 10 minutes Presentation Measles and Nutrition
4 15 minutes Presentation Clinical Features of Measles

measles
6 10 minutes Presentation Complication of measles
7 05 minutes Presentation Prognosis of measles
8 10 minutes Presentation Prevention of measles

Session 22: Measles
Step 2: Descriptive Definition of Measles (15 minutes)
ASK the students to brainstorm on definition of measles
 Measles is a very dangerous general infection caused by a virus

 It is extremely contagious
 It is spread from one person to another by fine invisible droplets which contain viruses
 It occurs usually in epidemics among children from nine months
 Before that age, the infant is fairly well protected by antibodies from the mother.
 During the time of entering school, all children have been in contact with the measles
virus
 Mortality is high particularly in malnourished children due to complications, mainly in
the respiratory tract.
 If a child survives the infection, there will be a life-long immunity and the child will not
get measles again.
 Incubation period for measles is 10-14 days
 The duration of infectivity is from the eighth day of the incubation period (before the
typical symptoms occur) until one week after the onset of the rash
Step 3: Measles and Nutrition (10 minutes)
 The course of measles is more severe in children with malnutrition and complications
occur more frequently, causing many deaths
 Measles interferes with food intake particularly when there is a sore mouth or the child is
too sick to take enough food and fluids
 Children usually loose quite a lot of weight as a result of this infection and it often takes
them weeks to regain their former weight
 Frank kwashiorkor or marasmus often develops after measles infection
 Measles is an excellent demonstration of the interaction of nutrition and infection in
children
 Measles is very severe in malnourished children so prevent measles by vaccination

Session 22: Measles
 The illness starts as a severe cold with high fever, cough, watery red eyes, and nasal
discharge
 Early in the disease before the typical rash appear, you can find white spots of red
background on the mucus membranes of the mouth inside the cheeks (koplik’s sports)
 About the fourth day after onset the rash appears. The rash is dark red slightly raised and
irregular and spreads all over the body
 The rash is difficult to see on dark skin and may appear almost black
 The temperature starts to fall a few days later and the rash begins to fade away.
 Desquamation and depigmentation of the skin usually follow
 There is no drug that affects the measles virus

 The priority in treatment is appropriate food intake and fluid supply such as
breastfeeding, milk products, protein and energy-rich foods, vitamins, and home made
solutions.
 Keep eyes wet and clean
 Give antipyretic such as Paracetamol.
 Treat complications as they appear
 Give antibiotics as prescribed especially in malnourished children
 Follow-up the child in the under-fives clinic to control weight and check up.
Management schedule
 Uncomplicated measles
o Symptoms
 The child will be well nourished or mildly under-weight
 Fever
 Conjunctivitis
 Rhinitis
 Cough
 Koplik’s Spots
 Rash
o Nursing care and Management

 Treat this child as outpatient
 Ensure proper fluid intake and good food
 Give antipyretic
 Follow-up daily
 If you cannot follow up give antibiotics as will be prescribed
 Complicated measles
o Symptoms
 Child will be malnourished
 Dyspnoea
 Nasal flaring
 Hoarseness, barking cough, and inspiratory stridor

Session 22: Measles
 Sore mouth inside and around
 Inability to suck
 Diarrhea and vomiting
 Convulsions
 Dry eyes
 Photophobia
 Hazy cornea
 Red eardrum and ear discharge
 Persistent pneumonia
o Management
 Treat as inpatient with balanced diet, protein and energy-rich food
 Manage the child as having pneumonia or Laryngo-tracheo-bronchitis by giving
prescribed antibiotics and close observation
 Replace fluid and electrolyte loss accordingly
 Exclude malaria
 Do lumbar puncture to exclude encephalitis
 Give vitamin A 10000 i.u IM stat then 5000 i.u/day orally for one week.
 Give Chloramphenicol or tetracycline eye ointment
 Treat the child for otitis media
 Rule out tuberculosis
Step 6: Complications of Measles (10 minutes)
 Gastroenteritis–watery diarrhea, sometimes with blood and mucus, vomiting

 Stomatitis-sore mouth inside and around
 Laryngotracheobronchitis–horse voice, barking cough and inspiratory stridor
 Pneumonia-breathing difficulty nasal flaring
 Otitis media-red eardrum, discharge from ear
 Keratitis and corneal ulcer-photophobia, hazy cornea, dry eyes
 Encephalitis-vomiting convulsions and coma
 Pyodermia-extensive desquamation, secondary bacterial infection
 Complications of measles are more common and more severe in a malnourished child
Step 7: Prognosis (5 minutes)
 Mortality is high
 A period of ill-health sometimes several months
 Child may develop malnutrition, recurrent diarrhea, and tuberculosis
 Epidemics are prevented by vaccinating all children when exactly nine months.
 Note:
o Measles vaccine contains a live virus
o Therefore, it must be kept in a refrigerator
o It should not be exposed to sunlight to avoid inactivating the virus

Session 22: Measles
 Prevention of hospital infection
o All children admitted should be vaccinated within 24 hours if not vaccinated
o If this is not possible, isolate all children suspected of incubating measles
 Measles is a very dangerous general infection caused by a virus

 The course of measles is more severe in children with malnutrition
 The illness starts as a severe cold with high fever, cough, watery red eyes, and nasal
discharge
 The priority in treatment is appropriate food intake and fluid supply such as
breastfeeding, milk products, protein and energy-rich foods, vitamins, and homemade
solutions
 Follow-up the child in the under-fives clinic to control weight and check up
 What is measles?
 What is the incubation period for measles?
 What are the complications of measles?
References

Session 22: Measles
Session 23: Whooping Cough (Pertussis)
Prerequisite
 None
Learning Tasks
 Define Whooping cough
 List the causative organisms of Whooping cough
 Identify the incubation period of Whooping cough
 List the signs and symptoms of Whooping cough
 Describe the Nursing care and Management of Whooping cough
 Explain the complication of Whooping cough
 Explain the preventive measures of Whooping cough.
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Teaching
Step Time Content
activities
Brainstorm/ Definition and Causative organisms of
2 10 minutes
Presentation whooping cough
3 10 minutes Presentation Clinical features of Whooping cough
whooping cough
5 05 minutes Presentation Complications of whooping cough
6 05 minutes Presentation Prevention of whooping cough
8 05 minutes Discussion Evaluation

READ or ASK the students to read the students learning tasks and clarify
ASK students if they have any question before proceeding
Step 2: Definition and Causative Organisms of Whooping cough

(10 minutes)
ASK the students to brainstorm on definition of measles for 2 minutes
 Whooping cough (Pertussis) is an acute, infectious disease characterized by a catarrhal

stage, followed by a peculiar paroxysmal cough, ending in a whooping inspiration
o Incubation period is 7-10 days
o Infectivity duration is from 2 days before onset of the cough for three weeks
Causative organism
 A small non motile, negative bacillus, Bordetella pertussis
 The bacteria produce an inflammation of the mucus membranes of the nose, pharynx,
larynx, trachea, and bronchi.
 A thick mucus is produced which the child wants to get rid off by coughing
 The cough is characteristic of the disease
 It spreads rapidly from person to person by the droplet from coughing
 There is no protection through antibodies of the mother in these young children
 There is a slow onset of cough and fever with the same signs as a cold
 The cough gets more severe and comes in attacks with spasms followed by a long
inspiratory crowing or whoop
 In babies, atypical whoop may be missing
 Young babies may be very ill and have attacks of not breathing and become cyanosed
 The coughing attacks are often associated with vomiting strings of mucus usually hang
down the sides of the mouth
 Attacks are more frequent at night
 The cough can last several weeks
 High WBC

 Uncomplicated whooping cough

o No need of antibiotics because it cannot change the course in uncomplicated cases
o Tetracycline or Chloramphenicol as per prescription
o Heavy sedation is contraindicated because the cough reflex will be suppressed ad the
child cannot get rid of the mucoid secretions. Pneumonia will be the result.
o Mild sedation such as phenobarbitone or a cough mixture e.g. mist expect sedative
can be given but will not modify the course
o Give plenty enough fluids
o Feed again after vomiting
o Care should be taken in relation to nutrition of the child
 Complicated whooping cough

o Treat the pneumonia accordingly
o Penicillin is the antibiotic of choice
o Do suction to remove mucus
 Encephalopathy
o When there is convulsions treat accordingly
o Lumbar puncture releases increased intracranial pressure
Step 5: Complications of Whooping cough (5 minutes)
 Pneumonia
 Encephalopathy
 Hemorrhages e.g. epistaxis and conjuctival hemorrhage
 Inguinal hernia
 Rectal prolapse
Step 6: Prevention of Whooping cough (5 minutes)
 Immunize with DTP-HEP-B-HIB early in infancy

 Give full vaccination that is three injections starting four weeks after birth at four weeks
interval
 Do not vaccinate children over five years old.
 Whooping cough is a viral infection

 Whooping cough can be eradicated by vaccination of all under fives

 Mention the causative organism of whooping cough
 What is the other name for whooping cough?
 Mention the vaccine which is given to prevent whooping cough

References

Session 24: Diphtheria
Prerequisite
 None
Learning Tasks
 Define Diphtheria
 List causative organisms of Diphtheria
 Outline the signs and symptoms of Diphtheria
 Explain nursing care and management of Diphtheria
 Describe complications of Diphtheria
 Describe the prognosis of Diphtheria
 Explain the preventive measures of Diphtheria
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
1 05minutes Presentation
Definition and causative organism of
diphtheria
Buzzing/
3 10 minutes Clinical features of diphtheria
presentation
diphtheria
5 05 minutes Presentation Complication diphtheria
6 05 minutes Presentation Prognosis of diphtheria
7 05 minutes Presentation Prevention of diphtheria

SESSION CONTENT
Step 2: Definition and Causative Organism (10 minutes)
 Diphtheria is a rare bacterial infectious disease marked by the formation of a membrane

over the tonsils, uvula, soft palate, and posterior pharynx and occasionally on the skin.
The membrane is created by thick inflammatory exudates.
 Air-borne droplets transmit the organisms causing diptheria from person to person
 Incubation period is 2-5 days
 Causative organism
o Corynebacterium diphtheria a non-motile, non-spore forming, club-shaped
bacillus.
ASK students to pair up and list the clinical features of Diphtheria
 The child has fever and is acutely ill-toxic

 Grayish-white patches, diphtheritic membranes, are seen on examination of the throat
 Blood stained purulent nose discharge sometimes
 Diphtheritic membranes on the skin mainly on pre-existing wounds
 The lesions are extremely painful
 If larynx is affected, there will be respiratory problems with crowing inspirations
 Neck may be enormously swollen.
 Membranes can grow further down the trachea and pneumonia occurs especially in young
children
 There are mild forms or asymptomatic carriers.
 Give any suspect Penicillin according to prescription and urgently refer the patient to
hospital
 Give diphtheria antitoxin as early as possible to neutralize the circulating toxins
 Nurse patient in a strict bed rest
 Administer corticosteroids
 Sometimes tracheostomy may be necessary

Step 5: Complications of Diphtheria (5 minutes)
 Due to toxins from the local lesions

o Myocarditis-the toxins attacks the heart muscles causing signs of cardiac failure
o Paralysis-due to damage to the peripheral nerves
 To the palatal muscles-difficult in swallowing
 To the ocular muscles-ptosis, strabismus, unequal pupils
 Death due to local action of bacteria causing airway obstruction, toxaemia, Myocarditis,
nerve paralysis
 Depends on:
o Severity
o How early was the antitoxin given
o Always think of diphtheria in any case of sore throat
 A full course DPT HepB-HiB prevents the disease

 Examine contacts of diphtheria patients and treat them with penicillin
 Diphtheria is a very serious bacterial infectious disease but it is rare

 It can be prevented by giving vaccination
 Define diphtheria
 How can you prevent diphtheria?
References

Session 25: Tetanus
Prerequisite
 None
Learning Tasks
 Define Tetanus
 Describe clinical features and management of Tetanus
 Explain Nursing care and management of Tetanus
 Discuss the prognosis of Tetanus
 Explain prevention of Tetanus
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
1 05minutes Presentation
Presentation/
2 10 minutes Descriptive Definition of Tetanus
Brainstorm
3 05 minutes Presentation Clinical features of Tetanus
Nursing care and management of
Tetanus
5 05 minutes Presentation Prognosis of Tetanus
6 05minutes Presentation Prevention of Tetanus
7 05minutes Presentation Key points
8 05minutes Presentation Evaluation

Session 25: Tetanus
Step 2: Descriptive Definition of Tetanus (10 minutes)
ASK the students to brainstorm on definition of Tetanus
 Tetanus is an acute life threatening illness caused by a toxin tetanospasmin produced in

infected wounds by the bacillus clostridium tetani.
 Tetanus infection in the newborn is acquired during or after delivery and has a very high
mortality.
 The tetanus bacteria gain entrance to the newborn’s body through the stump of an
umbilical cord which has been cut by an unsterile instrument or treated in an unclean
manner.
 Tetanus bacteria can only grow in anaerobic conditions (without oxygen)
 Incubation period is 3-10 days
 Portals of entry of tetanus in older children are wounds or punctures in the limbs e.g.
injuries, jiggers, burns, unsterile vaccinations or injections
 Tetanus should be considered in children without wounds
Step 3: Clinical Features of Tetanus (5 minutes)
Clinical features in neonates

 Gradual onset with inability to suck due to spasm of the masseter muscles trismus
 Typical generalized tetanus spasms follow within 36 hours
 There may be difficult in breathing (laryngospasm) with cyanosis
 Fever
 Local signs of umbilical infection.
Clinical features in older children

 Clinical features
o The same as in newborns
o Inability to open the mouth
o Painful muscle spasms without convulsions
o Arching of the back raised heels and neck (called opisthotonos)

Session 25: Tetanus
 ATS (anti- tetanus serum) 10000 i.u IM or IV stat

 Antibiotics mainly penicillin
 Note:
o ATS is only effective against still circulating tetanus toxins
o Penicillin is only effective against still present bacteria
o Neither of these conditions may be present by the time the patient is seen
General measures
o Intensive and careful nursing care is the most important part in the management
 Clean the umbilicus with methylated spirit or savlon and keep it dry
 Keep children under careful supervision in a quite room and avoid noise, bright
light, and unnecessary handling as much as possible as these can precipitate
spasms
 Prevent pneumonia
 Turn child every three hours into another position but never onto the back because
of the danger of aspiration
 Suck out mucus and secretions from mouth as necessary
 Keep a special intensive care charts
o Sedation–the principle should be:
 Enough to control the spasms but not so much as to increase the danger of
pneumonia and kill the baby
 Start with diazepam (valium) 2.5-5 mg IM
 Reduce the sedation when the spasms become less severe
o Nasogastric tube:
 Pass a tube after primary sedation and give expressed breastmilk (EBM) and oral
medications by the tube
 This will be a minimal irritation for the child and keep the mother’s breasts going
 Remember: Do not over-sedate tetanus children
 Treatment in Older Children

o ATS 50000-100000 u IM stat after test dose
o Tetanus toxoid 0.5ml IM stat
o Antibiotics mainly penicillin as per prescription
o Surgical debridement of the wound
o Sedation with valium 5-10 mg prn
o Phenobarbitone 5mg/kg/day adjusted according to the severity of spasms
 Lower the frequency and dose of sedation as spasms become less severe
 The prognosis depends on:
o Quality of nursing care
o Prevention of aspiration of secretions
o Prevention of pneumonia

Session 25: Tetanus
 Short incubation period leads to severe infection so prognosis is worse
 Mortality rate in many places is 100%
 If child survives, the child may be sick for two weeks to one month
NOTE:
 Children who survive neonatal tetanus do not develop immunity against tetanus infection
 They have to be vaccinated with triple or tetanus vaccine after one to two months
 Give a full course of DTP-HepB-Hib

 Encouragement of delivery in a health facility
 Proper training of traditional birth attendants (TBAs)
 Health education campaigns towards proper and clean handling of the umbilical cord
stump, postnatal visits and check the cord
 Check up of equipments and method used in handling the umbilical cord
 Immunization of women of child bearing age (from 15-49 years) 5 doses of T.T 0.5 ml
IM
 All pregnant woman if they have not completed the 5 doses should be vaccinated at least
3 doses (even one dose is better than nothing.)
 Every child seen after the fourth day of delivery should ideally be given 1500 u of ATS.
The drug is expensive and in most cases not available
 Children who survive neonatal tetanus do not develop immunity against tetanus infection
 All children have to be vaccinated with triple or tetanus vaccine after 1-2 months
 Define tetanus
 Mention the causative organism of tetanus
 Explain how a new born baby can get tetanus infection
 Explain the prevention of tetanus
References

Session 25: Tetanus
Session 26: Hepatitis
Prerequisite
 None
Learning Tasks
 Define Hepatitis
 List causative organisms of Hepatitis
 Outline the signs and symptoms of Hepatitis
 State the diagnosis of Hepatitis
 Explain nursing care and management of Hepatitis
 Explain the preventive measures of Hepatitis
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Brainstorm/
2 10 Minutes Definition and Causes of Hepatitis
Presentation
Clinical Manifestation of Hepatitis A
and B
Hepatitis
5 05 Minutes Presentation Prevention of Hepatitis


Step 2: Definition and Causes of Hepatitis (10 Minutes)
ACTIVITY: Brainstorm (5 minutes)
ASK the students to brainstorm on definition of Hepatitis for 2 minutes
 Is an acute or chronic inflammation of the liver that can result from several different
causes
Causes of Hepatitis
 Viral Infections such as:
o Hepatitis A virus (HAV), hepatitis B (HBV), Hepatitis C virus (HCV), Hepatitis D
virus (HDV), Hepatitis E virus (HEV), Hepatitis G virus (HGV)
o Epstein-Barr Virus (EBV)
o Cytomegalovirus (CMV)
o Human Immunodeficiency virus (HIV)
 Non-viral causes such as: Abscess, Amoebiasis
 Autoimmune
 Metabolic
 Chemical
 Neoplastic
 Idiopathic
Step 3: Clinical Manifestation of Hepatitis A and B Viruses (15 minutes)
Hepatitis A Virus
 Is very common in areas with poor living conditions, inadequate sanitation, crowding,
and poor personal hygiene practices
 Spreads directly or indirectly by fecal-oral route by ingestion of contaminated material or
direct exposure to infected faecal material or close contact with an infected person
 Virus is excreted in stool and urine from 3 weeks to 1 week after the onset of clinical
symptoms
 Average incubation period is about 4 weeks with a range of 15-50 days
 Clinical features
o Rapid acute onset
o Commonly there is fever, anorexia, jaundice, nausea and vomiting
o Rarely there is rash, arthralgia, pruritus
Hepatitis B virus
 Mode of Transmission
o Blood or serum from a scratch of one child to another child with scratch

o Blood transfusion
o Contaminated syringes and needles
o Vertical transmission that is from mother to child through placenta
o Incubation period is 45-60 days with average of 120 days
o It may be mild and last for several weeks
o Kidneys may also be affected and unexpected symptoms may appear
o In the liver, it may persist for many years even for life time
o It causes slow destruction of liver cells and later in life can cause liver cirrhosis or
hepatoma.
 Therefore, infection should be prevented as far as possible
 Clinical Features
o Onset is Insidious
o Less frequently there is fever
o There is mild to moderate anorexia
o Commonly there is rash, arthralgia
o Sometimes, there is pruritus
o Jaundice is present

Diagnosis
 Is based on History and Physical examination
 Serological markers for Hepatitis viruses
 Serum bilirubin (increase of mainly direct bilirubin)
 Liver function tests
 Histological evidence
Treatment
 Most cases get better without treatment
 Bed rest when jaundice is obvious
 Hygienic disposal of stools and urine
 Hand washing after contact with patient
 Low fat diet
 Refer patient to hospital if:
o Jaundice is very severe
o Vomiting persists
o Confusion, coma of bleeding tendency occur
 Vaccine is available for contacts or give Hepatitis Immunoglobulin
Nursing Care
 Encourage a well-balanced diet
 Provide health education on use of drugs and hand washing
 Educate parents and children on mode of transmission of Hepatitis, and universal
recommendations for Hepatitis immunization
 In young people who are suspected to have illicit drug use, educate the parents and the
youth on dangers associated with

 Prevent transfusion and syringe transmitted infection

 Screen blood donors for the virus
 Take care in any minor operations such as circumcision to prevent any contamination of
the wound with an infected person’s serum
 Every child should get a full course of DPT-HepB-Hib vaccine
 Hepatitis is inflammation of the liver caused by viruses

 There are many types of hepatitis but the common ones are hepatitis A and B
 There is no routine vaccine for Hepatitis A
 Define hepatitis
 List the mode of transmission of hepatitis B
 Mention the vaccine given against Hepatitis
References

Session 27: Poliomyelitis
Prerequisite
 None
Learning Tasks
 Define Poliomyelitis
 State the predisposing factors of Poliomyelitis
 List clinical features of Poliomyelitis
 Identify the diagnostic measures of Poliomyelitis
 Explain the Nursing care and management of Poliomyelitis
 Explain preventive measures of Poliomyelitis
Resources Needed
 Projector
 Computer
SESSION OVERVIEW

Learning Tasks
2 05 Minutes Presentation Definition of poliomyelitis
3 05minutes Presentation Predisposing factors of poliomyelitis
4 05 Minutes Presentation Mode of spread of poliomyelitis

Presentation/
5 10 minutes Signs and symptoms of poliomyelitis
Buzz
6 05 minutes Presentation Investigation poliomyelitis
poliomyelitis
9 05Minutes Presentation Prevention of Poliomyelitis
11 05Minutes Presentation Evaluation

Step 2: Descriptive Definition of Poliomyelitis (5 minutes)
 Poliomyelitis is inflammation of the gray matter of the spinal cord and sometimes the
lower part of the brain (medulla oblongata)
 It is an acute viral disease characterized by:
o Fever
o Sore throat
o Headache
o Vomiting
o Stiffness of the neck
o Backache
o Lately-atrophy of a group of muscles ending in contraction and permanent deformity
Step 3: Predisposing Factors (5 minutes)
 Muscle exhaustion
 Injections damaging small nerve endings
 Tonsillectomy
Step 4: Mode of spread (5 minutes)
 The virus is mainly spread through faeces

 Most infective stage lasts for 2 weeks
ASK students to pair up and list the signs and symptoms of Poliomyelitis for 2 minutes
 The child starts with:

o Fever
o Malaise
o Vomiting
o Headache

 This is followed a few days later by:
o Weakness and paralysis of one or more limbs
o The paralysis may extend to all limbs and even to the respiratory muscles
o Paralysis may develop without any preceding illness in some children
o There is no sensory loss the paralysis affecting only the muscles
o It is a flaccid paralysis
 Lumbar puncture to exclude meningitis

 Lymphocytes and polymorphs in the CSF may be present.
 CSF is not cloudy as in purulent meningitis
 No specific treatment is available

 Strict rest in bed. Activity in the acute stage of the illness that is the first 2 weeks often
increases the paralysis
 During the acute stage, affected limbs should be mobilized in splints to prevent flexion
deformities and to make the child rest
 No injections. These may precipitate paralysis.
 When the acute stage has settled, gentle exercise of the affected limbs should be
commenced
 After discharge from hospital, the child should be seen at regular intervals to ensure that
flexion deformities are not occurring
 If they do not occur, the patient will require plaster back-slabs to strengthen the limbs
 Special shoes and calipers may help severely affected children to walk again
 If polio occurs in your area, notify the DMO immediately

 Give Sabin oral vaccine from birth and then 3 other doses from when the child is 4 weeks
old at a monthly interval.
 Poliomyelitis is a notifiable disease

 Vaccination to all children is mandatory to prevent this condition which leads to
permanent deformity if child is affected
 Define poliomyelitis
 Mention the signs and symptoms of poliomyelitis
 Explain how to give vaccination against poliomyelitis

References

Session 28: Tuberculosis
Prerequisite
 None
Learning Tasks
 Define Tuberculosis
 List causative organisms of Tuberculosis
 List the mode of Transmission of Tuberculosis
 State the incubation period of Tuberculosis
 Outline the signs and symptoms of Tuberculosis
 Explain the sites affected by Tuberculosis
 State the diagnosis of Tuberculosis
 Explain nursing care and management of Tuberculosis
 Explain the preventive measures of Tuberculosis
Resources Needed
 Projector
 Computer

SESSION OVERVIEW
Learning Tasks
Brainstorm/
2 05 Minutes Definition of Tuberculosis
Presentation
3 05 Minutes Presentation Causative Organism of Tuberculosis
4 05 Minutes Presentation Mode of Transmission Tuberculosis
5 05 Minutes Presentation Incubation Period of Tuberculosis
6 10 Minutes Presentation Signs And Symptoms of Tuberculosis
7 15 Minutes Presentation Sites Affected by Tuberculosis
8 10 Minutes Presentation Diagnosis of Tuberculosis

Nursing Care and Management of
Tuberculosis
10 05 Minutes Presentation Prevention of Tuberculosis
SESSION CONTENT


Step 2: Definition of Tuberculosis (5 minutes)
ASK the students to brainstorm on definition of Tuberculosis for 2 minutes
 Tuberculosis (TB) is a disease of poverty, overcrowding, poor housing, and lowered

immunity such as in a child with malnutrition or HIV/AIDS. It is one of the main causes
of illness and death in children
Step 3: Cause of Tuberculosis (5 minutes)
 It is caused by the organism Mycobacterium Tuberculosis which is transmitted through

the air in infectious particles called droplet nuclei
Step 4: Mode of Transmission (5 minutes)
 Adults with laryngeal or pulmonary tuberculosis may transmit the disease by coughing,
sneezing, speaking and singing. These adults have positive or open tuberculosis as
compared with children who are very rarely infectious.
 Rarely children can be infected by milk contaminated with bovine tubercle bacilli
Step 5: Incubation Period (5 minutes)
 Skin test becomes positive 2 to 8 weeks after exposure (median 3-4 weeks)
 Risk of developing disease is highest in the first 6 months but remain high for two years.
Many years may elapse between infection and disease. Infection progresses to disease in
around 10% of cases.
 General symptoms:
o Loss of weight
o Loss of appetite
o Low grade fever
o In primary tuberculosis, these sign may be so minimal as to be missed completely. In
progressive tuberculosis, the child will usually have more pronounced general
symptoms.
 Respiratory signs and symptoms

o Irritating cough in hilar lymph gland Tb, or productive in advanced pulmonary Tb.
Coughing up blood is rare in a child.
o No physical abnormalities of the lungs in primary Tb
o Collapse of lung (atelectasis), pleural fluid or cavitations can be seen in progressive
Tb
o A child with Pneumonia or chronic cough who does not respond within 2 weeks of
adequate treatment should be suspected of having PTB especially in the presence of
fever loss of weight and chest signs
Step 7: Sites Affected by Tuberculosis (15 minutes)
 Bone and joint tuberculosis

o Bones mostly affected are the vertebrae (Pott’s disease). They present with collapse
of the vertebrae leading to a hump backed deformity of the spine and abscess
formation
o The above may lead to pressure on the spinal cord with bladder and rectal
incontinence and leg paralysis.
o The abscess may track down and present as a lump in the groin
o The joints mostly affected are the knee and hip. The patient will complain with a
limp and pain in the hip or knee.
 Cervical gland tuberculosis

o Enlarged cervical lymph glands
o Tuberculin test will be positive and biopsy result will confirm the diagnosis
 Tuberculosis meningitis
o Gradual onset of headache, fever and neck stiffness. Diagnosis is confirmed by
lumbar puncture and typical cerebral spinal fluid (CSF) findings, that is increased
lymphocytes and low CSF glucose. Tubercle bacilli may be seen on staining the CSF.
 Military tuberculosis
o It is diagnosed by the mottled appearance of the chest x-ray of a sick child
o Enlargement of the liver and spleen
o Fever
o Wasting
 The following presentations should be remembered:

o Persistent pneumonia often following measles or whooping cough that has not been
cleared up on one or more courses of antibiotics
o Wasting often with cough, fever, diarrhea, abdominal distension loss of appetite, or
anaemia
o Lethargy progressing to semi-consciousness and coma often with fits or local central
nervous system signs and a stiff neck
o Local signs in an unwell child, either due to reaction (allergy to tuberculin) e.g. skin
rash, phyctenular conjunctivitis, joint swellings, or due to local tuberculous infection
e.g. a gibbus deformity of the spine, rubbery glands in the neck, swollen abdomen or a
“cold” abscess. Cold abscesses filled with cheesy (caseous) material often present in
the groin or in the neck from an osteitis of the spine.
o Malnourished child who does not respond to adequate nutritional rehabilitation
o A child with HIV/AIDS

Step 8: Investigations/diagnosis (10 minutes)
 Diagnosis of Tuberculosis in children is more difficult than in adults because children

unlike adults, do not readily produce sputum, which is required for laboratory
investigation. Diagnosis, therefore, depends on the following factors often considered
singly or in combination
 Family history
o Contact with an adult with known Tb will increase our suspicion of tuberculosis
o Primary Tb in a child apart from infection from milk should lead us to an adult
contact that may also have infected other children in the family or neighbouring
community
 Tuberculin test
o With a few exceptions (during malnutrition, measles, in miliary Tb and within 8
weeks after the onset of the tuberculous infection), the tuberculin test becomes
positive. A positive tuberculin test indicates that either the child has had tuberculosis
and has recovered, that the child has active tuberculosis, or that the child has had
BCG. A positive tuberculin test is not at all uncommon especially in older children.
 Sputum
o In primary tuberculosis, the sputum rarely contains tubercle bacilli unless the focus
has extended into a bronchus because children swallow their sputum thus difficult to
obtain
o A swab can be taken from the back of the pharynx after provoking the cough reflex by
touching the soft palate with a spatula.
o Collection of gastric contents. Gastric contents aspirated early in the morning will
contain sputum swallowed during the night and offer the best chance of finding AFB
(acid fast bacilli i.e. tubercle bacilli that stain red with Ziel-Neelsens’s stain and
cannot be decolourized with acid)
o In older children, sputum usually can be collected and examined for tubercle bacilli
o If negative, repeat twice more
o During treatment, repeat the sputum examination every 6 months
 Laboratory
o A low Hb
o High erythrocyte sedimentation rate (ESR)
o Chest x-ray may show abnormalities highly suggestive of Tb-enlarged hilar lymph
glands cavities
 Note on the diagnosis of pulmonary tuberculosis

o In the acutely ill marasmic child, the tuberculin test is negative; AFBs are often not
found in the sputum or gastric contents and the x-ray picture is often rather non-
specific
o Such children should be referred to the hospital as quickly as possible. High calorie
nutrition diet and antibiotics should be started immediately.
o BCG can be used not only as vaccine but also as tuberculin test
o BCG test should not be used in known HIV positive children

o The diagnosis of Tb in children depends on a combination of history of disease,
history of contact, physical examination, tuberculin reaction, x-ray studies, and
response to a trial of anti-tuberculosis treatment.
 Effective treatment of all identified Tb cases is very important in the control and
prevention of Tb as this reduces or eliminates the reservoir of infection
 Current anti-Tb treatment involves short course therapy usually in two phases
o An initial phase/intensive phase of 2-3 months and the use of at least 3 drugs with the
purpose of reducing the tubercle bacilli population in the body rapidly and of
preventing resistance to the drugs
o A combination phase of 4-6 months in which fewer drugs are used for the elimination
of the remaining bacteria and to prevent recurrence
 Directly observed treatment in a short course (DOTS) is essential in both phases for the
purpose of ensuring compliance and is a comprehensive strategy used around the world to
promote compliance and cure rates of Tb patients
 Directly observed treatment Short course (DOTS) works as follows:

o Directly-Tb patients are identified and put on treatment
o Observed-health workers or trained volunteers or other responsible members of the
family or community observe the patient swallowing the drugs
o Treatment is monitored to assess response and progress until the patient is cured
o Short course–correct combinations of anti TB drugs are used for the correct length of
time
o The mother is the key person in all long term treatment of children and time taken to
discuss the importance of not giving up on the treatment is never wasted. Make sure
that health centre or hospital keeps a stock of antituberculous drugs and does not run
out of them.
 Five drugs are used in the treatment namely:

o Isoniazid(H)
o Rifampicin (R)
o Pyrazinamide(Z)
o Streptomycin (S)
o Ethambutol (E)
 These drugs are used in various combinations as part of the recommended Tb treatment
regimes.
 Change of drug treatment is considered only if the patient failed to respond after five
months of DOTS
 HRZ are components of all the anti Tb drug regimes recommended by WHO

 Standard abbreviations are used in the prescription of the different drug combinations e.g.
2HRZ/4HR the letters representing standard abbreviations for drug names. The numbers
show the duration of each phase in months. The stroke or t slash shows the division
between the two phases
 The national programme treatment regimes should always be followed
 The treatment depends on the severity and extent of the infection, the response, or
sensitivity of the tubercle bacilli to the drugs and the availability of the drugs
 Children who need chemoprophylaxis

o A healthy newborn with mother who is sputum positive for tubercle bacilli
 Make sure the mother is taking treatment (examine sputum)
 Encourage her to continue breastfeeding
 Give baby Isoniazid for 3-4 months then carry out a tuberculin test (Mantoux or
Heaf)
 If test is negative give BCG (whether or not the baby is HIV positive)
 If mother is HIV positive and her sputum is still positive for tubercle bacilli,
continue isoniazid for 9 months and make sure mother is being treated
o Healthy child, tuberculin negative, in close contact with adult with active Tb
 Make sure the adult is taking treatment (examine sputum)
 Give BCG and repeat tuberculin test in 2-3 months which should be Grade 2-3
positive
 If Grade 4 positive (strong/very strong) but the child is still healthy, give Isoniazid
for 6 months
 Follow-up
o Patient should be properly followed as outpatients
o Pay attention to nutrition
o Correct anaemia
o Treat any other disease
o Carefully record the weight of the child on the growth chart at each visit
o Ensure that there is no defaulter
Step 10: Prevention of Tuberculosis (5 minutes)
 Early detection and treatment of all Tb cases

 Making sure patients are compliant with their treatment
 Contact tracing by investigating the family members and other close contacts
 Isolating of all sputum–positive open Tb cases as far as possible
 Avoiding overcrowding and improving housing conditions
 Child spacing advice to mothers with active open Tb.
 Drinking only pasteurized or boiled milk
 Ensuring BCG immunization for all children under five years of age
 Improving the nutritional status of all children
 Improving the socio-economic status of families and communities
 Teaching and sharing how to avoid the spread of TB in the community

 Children with persistent lung consolidation or hilar lymphadenopathy should be

investigated for tuberculosis
 Diagnosis in a child should always trigger the search for an adult source of infection
 If the child is immunocompromised or has meningitis, a positive skin test is useful but a
negative does not exclude the diagnosis
 Define tuberculosis
 Mention the general signs and symptoms of tuberculosis
References
MoHSW. (2008). National Tuberculosis and Leprosy programme annual report 2007. Dar
es salaam National Tuberculosis and Leprosy.

Session 29: Introduction of Accidents in Children
Prerequisite
 None
Learning Tasks
 Define accidents in children
 List the predisposing factors of accidents in children
 Describe the common types of accidents in children
 Explain nursing care and management of accidents in children
 Explain the preventive measures of accidents in children
 Describe road accidents in children
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Learning Tasks
2 05 minutes Presentation Definition accidents in Children
Buzzing/
3 15minutes Predisposing factors of accident in children
Presentation
4 15 minutes Presentation Common types of accidents in children
Nursing care and Management of accidents in
children
6 05 minutes Presentation Prevention of accidents in children
Group discussion/
7 50 minutes Road traffic accident
Presentation


NTA Level 5, Semester 1 172 Session 29: Introduction of Accidents in
Children
Step 2: Definition (5 minutes)
 Accidents are defined as something unexpected and hence difficult to anticipate and
prevent
Step 3: Predisposing factors (15 minutes)
ASK students to pair up and list the predisposing factors for 2 minutes
 Factors predisposing to child’s accidents are:

o Environmental factors
o Factors in the child
o Environmental factors
 Arrangement of furniture, chairs and tables can be in the way of the playful child
and cause accidents
 Poor stairs, unprotected balcony, open windows are some other factors
 Ladders, pools of water such as ponds, accumulated water in unfilled quarries,
rivers and lakes
 Trees including fruit trees
o Childhood factors include:

 Young age
 Sex of the child
 Lack of experience
 The growing and developing child with an urge to explore and experiment and
imitate while learning about his surroundings because of curiosity, urge to touch
and put things in his mouth
 Uncoordinated movement of the child
 An abnormal child with inability to balance
 A mentally retarded child with inability to make judgments
 A child with epilepsy, when at height or in front of fire he gets an epileptic attack
 A blind child not able to see precarious circumstances
 Accidents in children are related to their age and development
 The younger the child the higher the risk of getting accidents
 Boys and girls suffer accidents that may vary depending upon their normal gender
activities
 Boys for instances are often outdoors while girls are often indoors and at the
cooking place
 Lack of supervision of the child is a very important factor

Children
Step 4: Types of accidents (15 minutes)
 Common types of accidents
o Falls
o Burns
o Cuts
o Bites and stings e.g. insect stings, spiders, bees, snake, and dog
o Punctures
o Road traffic accidents
o Drowning
 Injuries from accidents

o Accidents are associated with injuries to the child
o Falls
 Falls are the most common type of accidents in children
 They affect more boys than girls
 Falls result from falling from a height, chairs, tables, stairs, fence, roof, trees, and
bicycles
 They may fall in a hole, pit latrine, and construction sites.
 Injuries from falls may be mild or severe and may be fatal
o Injuries include:
 Bruises
 Cut wounds
 Fractures
 Dislocations
 Injury to soft tissue may cause bleeding and severe blood loss
 Injury may lead to infection and tetanus
 Fractured limb may shorten leading to deformity
Step 5: Management of injuries (15 minutes)
 Surgical cleaning, suturing if needed and possible, and dressing wounds

 Relieving pain by administration of analgesics/referral for treatment of fractures, more
extensive and deeper wounds and suspected internal injuries
 Referral for treatment of fractures, more extensive and deeper wounds and suspected
internal injuries
 Referral where there is actual or suspected serious blood loss or continued bleeding for
assessment of blood loss and blood replacement
Step 6: Prevention of accidents (5 minutes)
 Careful supervision of young children

 Proper arrangement of furniture in the houses
 Reduction of environmental hazards in the compound

Children
Step 7: Road Traffic Accidents (50 minutes)
ACTIVITY: Small Group discussion (20 minutes)
DIVIDE students into small manageable groups
ASK students to discuss in groups on the Road traffic accidents
AFTER small group discussion, ask students to provide their responses
 Road traffic accidents are more common in urban areas than in rural areas they are related
with:
o Number of vehicles
o Poor roads
o Poorly maintained vehicles
o Poor visibility
o Undisciplined, drunk or unqualified drivers
o Children playing near the road carelessly or cycling on the road are at risk
o Children may also be involved in traffic accidents as passengers in a vehicle
 Types of injuries in road traffic accidents include:

o Limb fractures
o Head injuries
o Injury to internal organs such as brain, ruptured spleen, liver lungs, and heart.
 First aid management include:

o Splinting fractured limbs
o Stopping any bleeding
o Administering pain killers if authorized
o If there is suspected head injury, give pain killers with great care and note
o Refer the child to hospital for urgent definitive surgery management
 Prevention of road traffic accident

o Vehicles should follow regulations
o Drivers should be well trained and adhere to use road signs
o Drivers and passengers (including children) should wear seat belts
o Young children should be accompanied by adults when going to school if there is
road crossing
o Roads should be in a good state of repair
 Accidents are defined as something unexpected and hence difficult to anticipate and
prevent but as a rule accident should be prevented
 Every parent or caregiver should study his/her environment to anticipate accident which
might occur so that they can be prevented.
Children
 Define an accident
 Mention common types of accidents
 Mention ways which can be used to prevent accidents.
References

Children
Session 30: Management of Accidents in Children
Prerequisite
 None
Learning Tasks
 Describe management of common accidents in children
Resources Needed
 Projector
 Computer
SESSION OVERVIEW
Learning Tasks
Presentation/
2 15 Minutes Management a child with Snake bites
Brainstorm
3 05 Minutes Presentation Management of a child with dog bites
Group discussion/
4 50 Minutes Management of a child taken Poison
Presentation
5 10 minutes Presentation Management of a drowned child
6 25Minutes Presentation Management of a child with foreign body
Step 1: Presentation of Session Title and Learning Task (5 minutes)

NTA Level 5, Semester 1 177 Session 30: Management of Accidents in
Children
Step 2: Snake Bites (15 minutes)
ASK the students to brainstorm on poisonous snakes for 2 minutes
 Poisonous snakes in Africa include:

o Vipers
o Cobras
o Black mambas
 Snake bites cause:

o Pain and swelling or blisters at the site of the bite
o Bleeding
o Discoloration of the skin
o Systemic symptoms due to the venom which include:
 Vomiting
 Headache
 Weakness
 Collapse
 Shock
 Breathing difficulties
 Paralysis
 Difficult in talking or swallowing
 Bleeding from gums
o A child who suddenly becomes ill while playing outdoors should be suspected of
having been bitten by a snake and the site of the bite looked for to confirm
o Nursing care and Management
 Management should be quick
 The site of the bite should be cleaned thoroughly with clean water to reduce
absorption of the venom and bandaged. The child should be reassured to reduce
anxiety.
 Refer the child urgently to hospital where anti-venom can be administered
 If the snake is killed, it is better to take it with the child to hospital for
identification
 Administer Tetanus Toxoid for prophylaxis
Step 3: Dog Bite (5 minutes)
 The serious risk of dog bite is that the saliva may contain the rabies virus
 The injured part may bleed and be painful

Children
 Management:
o Clean and dress the wound
o Refer the child to hospital for anti rabies vaccine
o Give Tetanus Toxoid for prophylaxis
Step 4: Poisoning (50 minutes)
ACTIVITY: Small Group discussion (20 minutes)
DIVIDE students into small manageable groups (6-8 students)
ASK students to discuss in groups on common poisons taken by children.
AFTER small group discussion, ask students to provide their responses
 Children may drink poisonous substances or drugs accidentally
 Kerosene (Paraffin) Poisoning

o Young children often drink kerosene by accident
o It is kept in the house as fuel for lamps or primus stoves and often is kept in an old
squash, soda or beer bottle
o A child usually does not drink more than a mouthful because of the unpleasant taste
o Clinical features
 Bronchopneumonia caused by aspiration so to avoid aspiration never induces
vomiting.
 Acute pulmonary oedema
 Coma due to its narcotic effect
o Management
 Do not induce vomiting
 Do not wash out the stomach
 Instead, give 5 ml milk of magnesia as a laxative
 Start pneumonia treatment immediately.
 Insecticide Poisoning (Parathion, Malathion)

o These are organophosphates which if ingested are absorbed into the body
o Signs and symptoms
 Tremors of the muscles
 Sweating
 Copious secretions of saliva
 Pinpoint pupils-this guide diagnosis and treatment
 In later stages:
 Convulsions
 Coma and/or paralysis

Children
o Treatment
 Wash the skin with soap and water if there has been exposure to reduce absorption
 Give atropine sulphate intramuscularly.
 Children under five: 0.5 mg intramuscularly
 Older children: 1mg atropine sulphate intramuscular every 15-30 minutes until
pupils become dilated
 Refer child to hospital
 Other common poisons

o Iron tablets
o Aspirin
o Chloroquin
o Daraprim
o Antihistamine
o Management
 Induce vomiting (unless the poison is kerosene or poisons that burn the mouth
such as acids and alkalis)
 Place a spatula at the back of the child’s throat
o Prevention
 All drugs should be kept out of reach of children, preferably in a locked cupboard
and clearly labeled
 This includes such common drugs as aspirin tablets and antimalarials
 Kerosene should be kept high up on a shelf where children cannot reach it or,
better still locked up
 Shops should sell kerosene in bottles that are clearly labeled as containing
kerosene
 Health education is needed to teach parents of the risks of poisons for children
 Note: Coloured and sugar coated tablets (such as iron tablets) and tasteless
tablets (e.g. Daraprim) are particularly dangerous. They must be kept out of
reach.
 Accidents should be prevented
 If it occurs, find out why
 Parents should understand why it occurred so that it will not happen again
 As a guiding principle, the young child should be protected from accidents
 Local medicines, herbs and accidentally ingested berries or seeds
 It is well known that strong laxatives may sometimes give rise to intussusception
 Other unidentified herbs may cause liver damage, vomiting blood, or coma
 It must also be admitted that some doctors tend to blame any symptom they
cannot explain on local medicines

Children
Step 5: Drowning (10 minutes)
 Drowning is defined as an immersion injury where the patient sinks in water inhaling the
water into the lungs and also swallowing large of water
 Causes of drowning
o Infants can drown in water in a bathing basin
o Young children can fall in a pond and drown if left unsupervised
o Big children go swimming in rivers and lakes and if not skilled will drown
o Children who may have been submerged in water for more than 3-8 minutes may not
recover
 Management
o Removing water from the lungs by holding him upside down and suction if possible
o Mouth to mouth breathing and artificial respiration by pressure on the chest if not
breathing
o Keeping the child warm and monitoring body temperature
o Monitoring vital signs
o Feeding by IV fluid
 Prevention
o Small children should be supervised all the time
o Children should be instructed on swimming.
Step 6: Foreign Bodies (25 minutes)
 Nose
o Foreign bodies in the nose can cause pain and chronic purulent discharge. Children
love to put things in their noses
o Health workers like taking them out so everyone can be happy
o Often a foreign body can be sneezed out. If this fails a gentle trial with small forceps
or small hook.
o Always work under direct vision with the otoscope and never try just to poke in the
nose blindly
o If this fails, refer to hospital for removal with adequate equipment
 Ear
o Foreign bodies like small beads can be put into the outer ear and insects can also
enter.
o A chronically draining ear especially attracts flies and the resulting obstruction will
prevent the ear from healing
o If syringing fails to remove the wax or parts of insects, a small hook will be needed
under direct vision through the otoscope
 Larynx
o A foreign body in the larynx will cause severe inspiratory stridor

Children
 Management
o Quickly inspect the mouth for foreign objects large enough to be removed with
forceps
o Turn the child upside down while firmly squeezing the chest
o If this does not help and the child is desperately dyspnoeic, try to remove the foreign
body with fingers or forceps
o If possible, transfer to hospital for laryngoscopy
 Bronchial tree
o Foreign bodies such as groundnuts or peas in the bronchial tree present as pneumonia
or recurrent pneumonia
o History will be acute onset of dyspnoea and severe coughing
o This is sufficient reason to suspect a foreign body in any recurrent treatment resistant
pneumonia
o Ask specifically about this when taking the history
o Diagnosis is by x-ray or bronchoscopy
o Therefore, refer the child to hospital

 Poisonous snakes include: Vipers, Cobras and Black mambas
 The serious risk of dog bite is that the saliva may contain the rabies virus
 The injured part may bleed and be painful.
 Manage by cleaning, dressing the wound and refer the child to hospital for anti-rabies
 Drowning is defined as an immersion injury where the patient sinks in water inhaling the
water into the lungs and also swallowing large of water
 Children who may have been submerged in water for more than 3-8 minutes may not
recover
 Small children should be supervised all the time
 Children should be instructed on swimming
 Foreign bodies in the nose can cause pain and chronic purulent discharge. Children love
to put things in their noses

 Define the term drowning
 Explain systemic symptoms due to the venom of snake
 Explain the management of dog bites
References
Children
Session 31: Background and Purpose of IMCI
Prerequisite session
 None
Learning Tasks
 Define IMCI
 Explain the historical background of IMCI
 List the purpose of IMCI
 Discuss the objective of IMCI
SESSION OVERVIEW
Learning Tasks
2 05 Minutes Presentation Definition of IMCI
3 15 minutes Presentation Historical background
4 20 minutes Presentation Purpose of IMCI
5 05 minutes Presentation Objectives of IMCI
Step 1: Presentation of Session Title and Student Learning Tasks

(5 minutes)
ASK students if they have any question before proceeding
Step 2: Definition of IMCI (5 minutes)
 IMCI is an integrated approach to child health that focuses on the well-being of the whole
child
 IMCI includes both preventive and curative elements that are implemented by families
and communities as well as by health facilities

NTA Level 5, Semester 1 183 Session 31: Background and Purpose of
IMCI
 IMCI is an integrated strategy, which takes into account the variety of factors that put
children at serious risk. It ensures the combined treatment of the major childhood
illnesses, emphasizing prevention of disease through immunization and improved
nutrition.
 In health facilities, the IMCI strategy promotes the accurate identification of childhood
illnesses in outpatient settings, ensures appropriate combined treatment of all major
illnesses, strengthens the counseling of caretakers, and speeds up the referral of severely
ill children.
 In the home setting, it promotes appropriate care seeking behaviours, improved nutrition
and preventative care, and the correct implementation of prescribed care.
Step 3: Historical background of IMCI (15 minutes)
 Every day, millions of parents seek health care for their sick children, taking them to
hospitals, health centres, pharmacists, doctors and traditional healers. Surveys reveal that
many sick children are not properly assessed and treated by these health care providers,
and that their parents are poorly advised. At first-level health facilities in low-income
countries, diagnostic supports such as radiology and laboratory services are minimal or
non-existent, and drugs and equipment are often scarce. Limited supplies and equipment,
combined with an irregular flow of patients.
 In Tanzania, diarrhoea, malaria and pneumonia are the main causes of illness and deaths in
young children. Together they account for over 50% of all causes of childhood morbidity
(Health Statistics abstract, Ministry of Health, 1995). Measles is the number one killer
among the vaccine-preventable diseases in children. Malnutrition is also a major problem
in Tanzania. Over one third of children suffer from moderate or severe malnutrition
(DHS, 1992) and most of them are chronically malnourished as a result of repeated
episodes of infection, along with continued deficits in food and micronutrients intake. In
turn, malnutrition increases the severity and the risk of death from most frequent
infectious diseases. Taken together, diarrhoea, malaria. Malnutrition, measles and
pneumonia cause more than 70% of the deaths in children under five years of age.
 Increasingly HIV/AIDS has become one of major causes of under five morbidity and
mortality. Illness and causes of death associated with HIV infection in children are the
same target diseases of the IMCI strategy. However, HIV/AIDS has to be specifically
addressed to identify those who are symptomatic so that appropriate management and
follow up care will be provided.
 There are feasible and effective ways that health workers in clinics can care for children
with these illnesses and prevent most of these deaths. WHO and UNICEF used updated
technical findings to describe management of these illnesses in a set of integrated
(combined) guidelines, instead of' separate guidelines for each illness. They then
developed this training package which has been adapted to the technical policies of the
Tanzania Ministry of Health and the national conditions to teach the integrated case
management process to health workers who take care of sick children in dispensaries,
health centres and other outpatient services.

IMCI
 Health workers have experience treating common childhood illnesses. They are often
trained using separate. Disease-specific guidelines, such as guidelines for treating
malaria, or guidelines for managing diarrhoea. However, they may have difficulty
combining different guidelines when caring for a sick child with several problems. They
may not know which problems are most important to treat. With limited time and drugs,
health workers may not be able to identify and treat all of a sick child's problems. There
are important relationships between the illnesses. For example, repeated diarrhoea
episodes often lead to malnutrition; diarrhoea, which often accompanies or follows
measles, is particularly severe. Therefore, effective case management needs to consider
all of a child's symptoms.
 A health worker can follow the integrated case management process and quickly
consider all of a child's symptoms and not overlook any problems. The health worker can
determine if a child is severely ill and needs urgent referral. If not, the health worker can
follow the guidelines to treat the child's illnesses. The guidelines also describe
counselling for mothers and other caretakers.
 The case management guidelines incorporate existing national guidelines, such as those
for managing diarrhoea disease, acute respiratory infections, malaria, immunisation, care
and treatment for HIV/AIDS.
 The case management guidelines describe how to care for a child who presents at a clinic
with an illness for the first time or for a scheduled follow-up visit to cheek the child's
improvement. They address most but not all of the major reasons a child is brought to a
clinic for illness. A child returning with chronic problems or less common illnesses may
require special care, which is not described in this course. The course does not describe
the management of trauma or other acute emergencies due to accidents or injuries.
 Case management can be effective only to the extent that families bring their sick
children to a trained health worker for care in a timely way. If a family waits to bring a
child to a clinic until the child is extremely sick or takes the child to an untrained
provider, the child is more likely to die from the illness. Therefore, teaching families
when to seek care for a sick child is an important part of the case management process.
Step 4: Purpose of IMCI (20 minutes)
 IMCI aims to reduce death, illness and disability, and to promote improved growth and
development among children under five years of age.
 This IMCI session is designed to teach the case management process to, nurses and other
health workers who see sick children and infants. It is a case management process for a
first-level facility such as a clinic, a health centre or an outpatient department of a
hospital. The course uses the word "clinic" throughout to mean any such setting.
 You will learn to manage sick children according to the case management charts,
including:
o Assessing signs and symptoms of illness, and nutritional and immunization status,
o Classifying the illness,
o Identifying treatments for the child's classifications and deciding if a child needs to be
referred,

IMCI
o Giving important pre-referral treatments (such as a first dose of an antibiotic, vitamin
A, quinine injection, and treatment to prevent low blood sugar) and referring the
child,
o Providing treatments in the clinic, such as oral rehydration therapy, vitamin A, and
immunization,
o Teaching the mother to give specific treatment at home, such as an oral antibiotic or
antimalarial.
o Counselling the mother about feeding and when to return.
o When a child comes for scheduled follow-up, reassessing the problem and providing
appropriate care.
Step 5: Objectives of IMCI (5 minutes)
 Reducing infant mortality

 Reducing the incidence and seriousness of illnesses and health problems that affect boys
and girls
 Improving growth and development during the first five years of a child's life
 IMCI is an integrated approach to child health that focuses on the well-being of the whole
child. IMCI includes both preventive and curative elements that are implemented by
families and communities as well as by health facilities
 Objectives of IMCI Reducing infant mortality
 Define IMCI
 List the purpose of IMCI
Refer students to IMCI guidelines: Major Diseases Covered in IMCI
References

IMCI
IMCI

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NMT 05112

NMT 05112 Child Health NTA Level 4-6, Semester 1

i United Republic of Tanzania

NMT 05112 Child Health NTA Level 5, Semester 1

NMT 05112 Child Health NTA Level 5, Semester 1

These participants are listed with our gratitude below:

SN Name Title Institution

Dr. Gozbert Mutahyabarwa

NMT 05112 Child Health NTA Level 5, Semester 1

NMT 05112 Child Health NTA Level 5, Semester 1

Goals and Objectives of the Training Manual

Objectives for training manual

NMT 05112 Child Health NTA Level 5, Semester 1

Who is the Module For?

How is the Module Organized?

How Should the Module be Used?

NMT 05112 Child Health NTA Level 5, Semester 1

Presentation of Session Title and Student

6 05 Minutes Presentation Evaluation

NMT 05112 Child Health

Step 1: Presentation of Session Title and Learning Tasks (5 minutes)

READ or ASK students to read the Learning Tasks and clarify

ASK student if they have any question before continuing

Step 2: Definitions of Growth and Development (15 minutes)

Step 3: Process of Human Growth and Development (45 minutes)

Activity: Brainstorming (5 minutes)

ASK students to brainstorm on the fetus development and conception

WRITE their responses on the black board or flip chart

CLARIFY their responses using the information below

The fetus development

NMT 05112 Child Health

NMT 05112 Child Health

36-40 weeks after conception (38-42 weeks after LNMP)

Step 4: Factors Influencing Human Growth and Development (45 minutes)

NMT 05112 Child Health

Step 5: Key Points (5 minutes)

NMT 05112 Child Health

NMT 05112 Child Health

6 05 Minutes Presentation Evaluation

Step 1: Presentation of Session Title and Student Learning Tasks

READ or ASK students to read the Learning Tasks and clarify

ASK students if they have any questions before proceeding

NMT 05112 Child Health

ACTIVITY: Brainstorming (5 minutes)

ASK students to mention the stages of human growth and development

WRITE the answers on the board/flip chart

SUMMARIZE using the content below

Step 3: Average Achievements of a One Month Infant (50 minutes)

NMT 05112 Child Health

NMT 05112 Child Health

Step 4: Average Achievement of a Two Months Infant (40 minutes)

Activity: Group Discussion (15 Minutes)

DIVIDE the students into manageable group

ALLOW the other students to contribute to the presentation

FACILITATE a brief discussion and then

SUMMARIZE the discussion using the information below

NMT 05112 Child Health

NMT 05112 Child Health

Step 5: Key Points (5 minutes)

Step 6: Session Evaluation (5 minutes)

 When do you expect the posterior fontanel to close?

NMT 05112 Child Health

3 30 Minutes Presentation Average achievement of a 4 month infant